J www.jogh.org •doi:10.7189/jogh.11.03077 2 1 Andy APearson Central and America Panama The puzzle of COVID-19 in © T E City UniversityofNewYork,USA INCAE BusinessSchool,Alajuela,CostaRica O he onlineversionofthisarticlecontainssu l 2021THEAUTHOR(S) G ectronic material: supplementary dices, andpoliticalinterests. schism, culturalbeliefsandpreju- testing, apronouncedurban-rural data. Problemsstemfromlackof country themoreproblematic are notreliable,andthepoorer Data aboutCOVID-19intheregion H
© 2021ISoGH ofeconomic development shape each countries’ exposure to the virus and ability to mitigate its reach. For – ditions thatshapetheregion’s vulnerabilitytoCOVID-19.Politics,urbandensity,andthe level–andkind itisinstructivetoexplorethepolitical,economic, andsocialcon Given thatthepandemicisso pervasive, data aboutfatalitiesbymeasuring themagnitudeofunderestimationdeathsinofficial COVID-19data. views tocomplementthesestatistics. Inaddition,itisusefultoassessthepotentialunreliability ofCOVID-19 shortcomings insomecountries’ officialdata,itishelpfultodiscussthemandsharehealth careprofessionals’ democracies, aremoreaccountabletocitizensandoffer completeandreliableinformation.Despitethese case mortalityratesthanthosewithweakerhealthsystems. Perhaps governments,particularlyinprosperous At the same time, these countries might be better positioned to treat COVID-19 patients and achieve lower countries with better health systems are more likely to notice (through testing) and record infections and deaths. Variables thatmightinfluencethescarcityandshortcomings ofthedataarenumerous[1 from eachcountryintheregionrevealsthatsixcoutrieshavesufferedunequallypandemic. sharing arelativelycommonhistoryandculture.Nonetheless,theofficialdataasofApril2021onCOVID-19 These sixcountriesarenotonlytuckedtogetherintoacorneroftheworld,buttheyallsmall countries (whichwereonceasinglepoliticalunit)andPanamawasformerlyprovinceofColombia). policies’ effectivenesstocontrolthevirus.TheCentralAmericanisthmusembracesfive regions, withvaryingintensity,raisingquestionsaboutwhatmakespopulationsvulnerableandpublic T 1 and destructivelyitspreadthroughouttheworld.However, thediseasehasstruckcountries,andeven the WorldHealthOrganization (WHO)inMarch2020tobeapandemic. Itisalarminghowquickly he novelcoronavirus,SARS-CoV-2, whichcausestheinfectiousdiseaseCOVID-19,wasdeclaredby , Andrea MPrado
pplementary material. compare outcomesamongcountries. assess themagnitudeofchallenge,tomakepublicpolicy decisions,andto tries oftheregionaboutreliabilityCOVID-19data,hindering effortsto than others.Inparticular, therearewidespreaddoubts in thenortherncoun in theregionislikelytobeunreliableandmisleading–some countriesmore deaths permillioninhabitants,notsoinmortalityrate.OfficialCOVID-19data ern Hemisphere,hasinsteadfaredthebestintermsofnumbercasesand of casesresultingindeath).Nicaragua,thesecondpoorestcountryWest cases and deaths permillioninhabitants, not sointhe mortality rate(percentage ment –CostaRicaandPanamahavefaredtheworstintermsofnumber According totheofficialdata,countrieswithhighesteconomicdevelop 1 , Forrest DColburn 1
1,2 in CentralAmericaandPanama.JGlobHealth2021;11:03077. Cite as:PearsonAA;PradoAM,ColburnFD.ThepuzzleofCOVID-19 2021 •Vol. 11 • 03077 ]. Perhaps wealthier - - - -
VIEWPOINTS VIEWPOINTS 2021 •Vol. 11 • 03077 Throckmorton FineArt,NewYork. a motherandchildbeinghelpedbydoctors.Circa 1928.Courtesyof Photo: PhotographbyTina Modotti,viewofaMexicanmural,showing of CostaRicaandPanama,thetwosoutherncountriesthathavebyfarhighestpercapitaincomes,sta The sixcountriesoftheCentralAmericanisthmushavelongbeenplacedinthreegroups.Onegroupconsists are notjudgedreliable,especiallyinNicaragua,ElSalvador, Honduras,andGuatemala(fourofthesixcases). always remainunknown.Eventhenumberofcasesanddeathsfromdiseaseweredeemedunclear;data in reachingconclusions.Timeandtimeagain,itwasstatedthatmuchnotonlyunknownbutwould werecautious officials fromtheMinistriesofHealthorSocialSecurityAdministration.Thoseinterviewed fessionals workingatthecommunitylevelinnon-governmentalorganizations, andcurrentorformerpublic includeddoctorsatthe“frontline”ofhospitalsandclinics,healthpro believe ishappening.Thoseinterviewed to beacomplementthestatisticaldataandprovideinsightsintowhatprofessionalsinfieldperceiveor sought medical professionareawareofwhattheircolleaguesintheregionconfronting.Theseinterviews with health professionals in each of the six countries are illuminating, revealing that those in the Interviews the region,when presentedwiththedata,inevitably questionitsreliability. Thereareanumberofconcerns. that Hondurasisthe country inthe Northern Triangle hardest hit by the pandemic. Health professionals in most fromCOVID-19,bothin thenumberofcasesanddeathspermillioninhabitants. Itisalsosurprising What ismostnotableaboutthe datapresentedin cause theyscarethepopulation) [ the government’sdismissalof the epidemic(topointofaskingdoctorsandnursesnot towearmasksbe in theisthmusfromCOVID-19.Thatoutcomeisnotableand counterintuitivegiventhecountry’s povertyand group’s activity,perhaps becauseits higherfiguresnonethelesssuggestthatNicaraguahassufferedtheleast lieved tobe caused byCOVID-19.Somewhat surprisingly,theNicaraguangovernmenthasnotsuppressed in Nicaragua to report weekly data on infections and deaths be ganized theCOVID-19 Citizen Observatory fooling anyone completely unreliable[ from thegovernmentsofeachcountry,withexception Nicaragua.OfficialdatafromNicaraguaisjudged Table 1 DATA of theirinhabitants. tocombatthepovertythatconfrontsalargehave nevermadesustainedinvestmentsinsocialservices share isthmus isthe“NorthernTriangle”: Guatemala,ElSalvador, andHonduras.Thesethreecountriesarepoor Haiti). Nicaraguaalsocontinuestobemarredbypoorgovernanceandpoliticalstrife.Thethirdgroupinthe 1979 thatledtoacollapseinpercapitaincome(thecountryisnowthepoorestAmericasafter The secondgroupconsistsofonlyNicaragua,aparticularcase.countrywastornapartbyrevolutionin notablyeducationandhealthcare. ble democracies,anddecadesofcontinuousinvestmentinsocialservices,
shows the incidence of COVID-19 in the five Central American countries and Panama. The data are showstheincidenceofCOVID-19infiveCentralAmerican countriesandPanama.Thedataare ” (personalcommunication,October22,2020).Inresponse, agroupofdoctorsandcitizensor 6 ]. AsoneNicaraguandoctorquipped,“ 7 ]. parities in COVID-19 infection rates among neighboring countries. ingly, eventhemediainthisisthmushasgivenscantcoveragetodis have yettostudysystematicallyCOVID-19intheregion.Surpris International organizations, such as the WHO or the World Bank, many countries,thisdatadoesnotyetexist. and extensivedatatogeneratetesthypotheses.Unfortunately,for in others?”[ Why doesthepandemicseemfardeadlierinsomecountriesthan appreciation forwhathasbeennamed“theCOVID-19conundrum: vulnerabilities toCOVID-19.Indeed,thereis,worldwide,agrowing Throughout theworldtherearechallengesinunderstandingnational for furtherresearch. care practitionersareilluminatingandcan,perhaps, asaguide serve is difficult, but such discussions are necessary. The views of health sions aboutthesekindsofvariablesintheCentralAmericanisthmus manipulate dataforpoliticalexpediency.Reachinghard-fastconclu economic activity.However, suchregimesmightalsobetemptedto gimes mightfinditeasiertorestrict,abruptly,socialmovementand different socialandeconomiccircles.Conversely,authoritarianre ercise their liberties, including continually moving in and out ofmany example 2
, democraciesmightbemorevulnerablebecausecitizensex Table 1 2 ]. Answering this all-important question requires good ]. Answeringthisall-importantquestionrequiresgood is that Costa Rica and Panama have suffered the isthatCostaRicaandPanama havesufferedthe The data the government is publishing are not The datathegovernmentispublishingarenot www.jogh.org • doi: 10.7189/jogh.11.03077 ------www.jogh.org • as wellcontrolthepandemic. complicated effortstounderstand cal calculations of governors, has and inparticularthenarrowpoliti ty toCOVID-19infection.Politics, region toexacerbatevulnerabili held byhealthprofessionalsinthe combined withpoverty,issimilarly Urban density, especially when doi: 10.7189/jogh.11.03077 VID-19 Citizen Observatory data[ VID-19 CitizenObservatory *Sources: JohnsHopkinsCoronavirusResourceCenter[ ing available for the poor. And countries that are democratic (which is defined to include freedom of the press), Wealthier countries,suchasCostaRicaandPanama,aremorelikelytotestforthedisease–have Table 1. count alone[ tality, a more comprehensive measure of the total impact of the pandemic on deaths than the COVID-19 death substracting theaveragenumber ofdeathsinthelastfivenormalyears(2015-2019),one can getexcessmor By takingacountry’s totalnumber ofdeathsfromallcausesreportedfortheyear2020(a pandemicyear)and in fact,itwasfromCOVID-19. stigma toCOVID-19,resulting indeathsbeingreportedbyfamilymembersasa“stroke”or “diabetics”when, public orprivate.Sometimesthereisnowheretoseekassistance. Addingtodifficulties,thereisawidespread is noalternative:inruralareas,wheremanyCentralAmericans live,thereisapaucityofhealthcarefacilities, “ tors andlittlemedicine commonly, asadoctorinHondurasreports,“ Guatemala, aprohibitivecostformostGuatemalans.There issometimesafearofenteringhospital.More essary resourcesforcomprehensivetesting.Privatetestingis expensive,reportedlyashighUS$165.00in do not have the nec American isthmus. They include prominently insufficient testing. Public health services Explanations varyforalikelyunder-reporting ofCOVID-19casesinthenortherncountriesCentral communication, October23,2020). He adds,“ tor whoasserts,“ Still,many healthcareprofessionalsintheisthmusacceptconclusionofaPanamaniandoc care services. InPanama,thereareisolatedruralcommunitiesthatmaybebeyondthereachofadequatehealth services. the population),andmanydonothavelegalresidencysoarehesitanttoavailthemselvesofpublichealth infections iscomplete[ it istrustedbyCostaRicans.Still,therearedoubtseveninRicaandPanamaofwhetherreporting nication, January12,2021).InCostaRica,theMinistryofHealthhasapresencethroughoutcountry,and to receive multiple tests, a desired practice but one not followed elsewhere in the isthmus (personal commu throughout thecountry.AdoctorinPanamalikewisestressesthatpatientswithpositivetestresultsarelikely es. Panama is praised foritsGorgas Institute for Health Studies and its decentralized capacity to perform tests such as,again,CostaRicaandPanama,arelesslikelytoengageinmanipulationofdataforpoliticalpurpos Panama Costa Rica Nicaragua Honduras El Salvador Guatemala Country People attendtothemselvesathome COVID-19 cases,deaths,andtestsreportedforCentralAmericatoApril2021* The casesthatareregisteredonlyforthemostseriouscases,thoserequiringhospitalization 9 ]. However, asthepandemic hasdiscouragedpeople fromseekinghealthcare, includingvisit 361 678 233 498 203 359 216 329 13 806 68 007
Cases The dataofCostaRicaandPanamaarecredible ” (personal communication, October 27, 2020). Hence, as a Nicaraguan doctor says, ” (personalcommunication,October27,2020).Hence,as aNicaraguandoctorsays, 8 - - ]. CostaRicahasalarge immigrantpopulationofNicaraguans(judged tobe10%of COVID-19 # deaths 5 6196 3115 3055 7309 4981 2089 ]. most populouscountryintheisthmus:“ October 21,2020).AcolleagueinGuatemalawasbluntaboutthedatafor know ifitisbeingmanipulatedornot,butincorrect In ElSalvador, adoctorreports,“ double ortriplewhatisreported ing casesday-after-day, wecanseethatofficialfiguresofCOVID-19casesshould be the numberofcasesinHonduras ports thatbecauseofinsufficienttesting,“ that hehimselfhadCOVID-19butnevertookatest.InHonduras,doctorre (personal communication,October22,2020).Surprisingly,thedoctorreports ing fromthedisease.Buttheydonotseekmedicalattention;remainanonymous COVID-19. InNicaragua,adoctorreports,“ Guatemala where there are widespread doubts about the reliability of data about It isinthepoornortherncountriesofNicaragua,Honduras,ElSalvador, and ” (personal communication, October 22, 2020). Sometimes, though, there ” (personal communication, October 22, 2020). Sometimes, though, there
2 321435 1 187042 919 324 567 813 894 988 Tests – 3 3 People donotseekpublichealthservicesbecausetherearefewdoc
], Worldometers[ Case fatality 22.1% 1.7% 1.3% 2.4% 3.4% 3.1% rate ” (personal communication, October 27, 2020). ” (personalcommunication,October27,2020). .” Headds,“ 4 ” (personalcommunication,January12,2021). ], April22,2021.ExceptforNicaragua:NicaraguanCO 1M pop The datathatisreportednotcorrect: Idonot Cases/ 85 172 46 260 20 866 10 538 13 029 2109
The dataforGuatemalaisnotcorrect. We do not have an accurate diagnosis of We donothaveanaccuratediagnosisof For thoseofusdoctorswhoareattend Deaths/ 1M pop There aremanypeopleheresuffer 1 459 617 467 511 324 440 ” (personal communication, ” (personalcommunication,
2021 •Vol. 11 • 03077 1M pop 546 678 182 132 138 681 58 260 71 491 Tests/ –
(in millions) Population ” (personal ” (personal 16.6 4.2 5.0 6.5 9.7 6.5 ” ” ------
VIEWPOINTS VIEWPOINTS 2021 •Vol. 11 • 03077 Doubts aboutthereliabilityofCOVID-19dataweredominantconcernhealthcareprofessionalsinter portrayed asunnecessaryillnessanddeath. late data,withastrongtendencytowardsunderreporting.Nopoliticianwantstobeblamedforwhatmight dor, andGuatemala–thereisaconvictionamonghealthcareprofessionalsthatpoliticalauthoritiesmanipu reason forthelackofreliabledata:innortherncountriesisthmus–Nicaragua,Honduras,ElSalva and thus,itmightnotbepossibletoconfirmthecauseofdeath.Second,thereisafinal,distinctsuggested the ruralpoor, notalldeathsarecorrectlyregisteredastheymighthaveaccesstoahealthprofessional, more conditionsmightinfluencetheunder-reporting ofCOVID-19deaths.First,amongthepoor, especially Honduras doesnothavethedatafortotaldeaths2020,soitwasimpossibletoincludein their excessdeathsfor2020asCOVID-19,representingapotential90%under-estimation ofCOVID-19cases. of theirexcessdeathsin2020notreportedasCOVID-19.ElSalvadorstandsoutforonlyreporting10% Panama seemtohavethemostreliabledatainregion,whilenortherncountriesmorethan60% Under theseestimations,differencesamongcountries’potentialunder-reporting areevident.CostaRicaand the sametimespan. †Excess deathsincludedataforJanuarytoAugust,2020.Forcomparisonpurposes,COVID-19(2020)bothcountriesinclude *Source: Giattinoetal.[ Table 2. by country( obtains anapproximationofthemaximumrangeCOVID-19deathsthatmighthavebeenunder-estimated attributable toCOVID-19andcomparesthisnumberwiththetotaldeathsreportedin2020,one to diseasesotherthanCOVID-19.Nevertheless,ifoneassumestheexcessnumberofdeathsin2020areall ing hospitals,andalsomadeitharderfordoctorstotreatallpatients,someexcessdeathsmightbeattributed having beenspeaking ofCostaRica,wherethe opennessandlaxityofsociety isnotfarbehindthatofPanama. the fatherthatleadsway carnivals andparties.Panamais liketheUnitedStates,andthisrelationshipwillneverchange.The UnitedStatesislike of Panama,“ ample, institutedinElSalvador) eveniftheyhadbeensoinclined.Anaccomplisheddoctor inCostaRicasaid reasons. Governmentswouldhave founditdifficulttoimplementdraconian“lockdowns” (of thekind,forex ulations areaccustomedtopersonallibertiesandtheopportunities tomovefreelyaboutforanynumberof The democraciesofCostaRicaandPanamamayhavebeenmore vulnerabletoCOVID-19becausetheirpop batter theircountry. caragua.) Nooneintheisthmuswaspreparedforinfectious disease,orevenhadanideaofhowitwould care. (CostaRica’spercapitaincome,forexample,isbetween sixandeighttimesthepercapitaincomeofNi other hand,theirhigherGrossNationalProducts(GNP)translate intomuchhigherexpendituresforhealth population oversixty-fiveyearsofage,andsufferingfromdiabetics, highbloodpressure,andobesity.Onthe nently diabetics,elevatedbloodpressure,andobesity.Costa RicaandPanamahavehigherpercentagesofthe of doctors,beds,andthepresencediseasesthatareassociated withseverecasesofCOVID-19,promi to confront the crisis. Local governmentshadlittlechanceofstrengtheningtheirhealthsystemsorobtainingthenecessarysupplies The first casesofCOVID-19 emerged inCentral Americashortly after thoseregistered inAsia andEurope. NATIONAL VULNERABILITIESTOCOVID-19 ditions, andpoliticalrealitiesframe–shapethedynamicsofCOVID-19inregion. though, also stress that need to understand the demographic, socio-economic con viewed. Those interviewed, Panama Costa Rica Nicaragua† El Salvador† Guatemala Country
COVID-19 andnon-COVID-19-relateddeathsinCentralAmericancountries,2015-2020* Table 2 Panamanians areabsolutelyirreverent; theythoughtthepandemicwas afable;theycontinuedwiththeir Average #deaths (2015-2019) per year 9 19 320 22 983 15 706 28 064 82 159 ], March31,2021. ). Table 3 ” (personalcommunication,October 19,2020).Thedoctor, though,mightaswell offers an overview of each country’s offers an overview investment in health care, the availability Total #deaths (2020) 23 876 26 209 23 581 35 368 94 798 4
average 2015-2019 Excess #deaths (2020) vis-à-vis 12 639 4556 3226 7875 7304 COVID-19 #deaths www.jogh.org • (2020) 3975 2185 2565 4813 717 doi: 10.7189/jogh.11.03077 % ofexcess deaths not COVID-19 reported as Table 2 12.8 32.3 67.4 90.2 61.9 . Two ------www.jogh.org • doi: 10.7189/jogh.11.03077 “lockdown,” which was vigorously enforced. (El Salvador is also believed by doctors to be the country in the “lockdown,” whichwasvigorouslyenforced.(ElSalvadorisalsobelievedbydoctorstobethecountryin have ledtoahigherCOVID-19infectionrate,butthegovernmentofcountryhadanearlyandextended six million,twohundredthousand.Perhaps thedensityofElSalvador, andofSanSalvadorinparticular, would dorans liveinthegreatermetropolitanareaofcapital,SanSalvador;totalpopulationcountryis The mostdenselypopulatedcountryintheregionisElSalvador. Two million,fourhundredthousandSalva ‘home’ istenbymeterswitheightpeople about the average level of contact among individuals in each country, but here too it is hard to believe there about theaverage levelofcontactamongindividuals ineachcountry,but here tooitishardtobelievethere and familystructureliving arrangementsdonotvarysignificantly.Itcouldbeusefulto haveinformation country. However, median agesaresimilarinthesixcountries,populationpyramid isnotsodifferent, haps, forexample,thereareexplanations hiddeninthe“demographicstructure”ofpopulations ofeach There areotherpossiblehypotheses toexplainnationaldifferencesinCOVID-19infections anddeaths.Per entails exposuretoaninfectious virus. in the“informalsector,” whichusually entailssellingsomethinginthestreet[ America, theymayliveindensesettlementsandbeforcedto ventureoutdailytoearnamiserablelivelihood However, whenthepoorabandon rural lifeandmovetourbanareas,astheyhavedonefordecadesinCentral not travel; they work in their communities and there is no tourism little risk.AsaGuatemalandoctorputit,“ Conversely, subsistencefarminginthewesternhighlands of GuatemalaorineasternNicaraguamayentail settings andtoenjoyawidevarietyofexperiences,many whichcanentailexposuretoaninfectiousvirus. foreign exchangeforthecountry).Thosewhoareprosperous intheisthmusaremostlikelytoliveurban nal, sometobankingorotherbusiness)andtheinternational tourismofCostaRica(thelargest generatorof economic developmentbringsrisks,suchaswiththebusiness travelinPanama(sometiedtotheCa judged by health care professionals in the Central American isthmus to be complex. A relatively high level of A third proposition for explaining national vulnerability to COVID-19, level of economic development, is with apopulationverydispersed Nicaragua havingthelowestincidenceofCOVID-19infectioninisthmusbystating,“ gua, iswidelyspreadout,withapaucityofofficetowersorapartmentblocks.ACostaRicandoctorexplained In contrast,Guatemala,Honduras,andNicaraguaaredecidedlymorerural.AndNicaragua’scapital,Mana region withthemostgovernmentmanipulationofdata.) Table 3. are oftendense[ Panama City’s metropolitanareaishometonearlyhalfofPanama’sfourmillionpeople.Urbanneighborhoods but wellovertwomillionCostaRicansliveinthegreatermetropolitanareaofcapital,SanJosé.Likewise, isthmus have a majority of their population living in urban settings. Costa Rica’s population is five million, A secondvulnerabilitycouldcomefromtheregion’sdenseurbanneighborhoods. Allofthecountries *Sources: WorldHealthOrganization [ GDP –grossdomesticproduct,BMIbodymassindex,SBPsystolicbloodpressure,DBPdiastolicpressure estimate, %) mmol/L oronmedication)(2014,crude Raised fastingbloodglucose(≥ ≥ 140ORDBP Prevalence ofraisedbloodpressure(SBP (2016, crudeestimate,%) adultsBMI≥ Prevalence ofoverweight % oftotal) Population 65yofageandover(2019, people) Hospital beds(2015,per1000 people) Medical doctors(2018,per10 (2017, US$) Current healthexpenditurepercapita GDP) Current healthexpenditure(2017,%of Health careexpenditures,resources,andprevalenceofselectdiseasesinCentralAmerica* 90) (2015,18+years,%)
12 ]. AsaCostaRicandoctorexplained,“ 000 000 7.0 7.0
” (personalcommunication,October19,2020). 10 25 25 ], WorldBank[ Guatemala 474.8 17.0 51.4 7.5 4.9 0.6 3.5 5.8 ” (personalcommunication,October22,2020). Isolated rural communities have been the least affected. There people do Isolated ruralcommunitieshavebeentheleastaffected.Therepeople do 5 11
El Salvador ]. 582.7 16.8 56.8 15.7 8.8 8.5 1.3 7.2 Everyone says to stay in your home, but no one notes that Everyone saystostayinyourhome,butnoonenotesthat ” (personal communication, October 20, 2020). ” (personalcommunication,October20,2020). Honduras 395.8 17.3 51.9 7.2 4.8 0.7 3.1 7.9 Nicaragua 506.2 17.2 54.8 8.1 5.5 0.9 9.8 8.6 13 ]. This kind of poverty also ]. Thiskindofpovertyalso 2021 •Vol. 11 • 03077 Costa Rica 1,262.2 18.2 61.5 28.9 8.5 9.9 1.2 7.3 It is a rural country, It isaruralcountry, Panama 1,794.8 19.3 58.5 15.7 9.0 8.3 2.3 7.3 - - - -
VIEWPOINTS VIEWPOINTS 2021 •Vol. 11 • 03077 REFERENCES
11 10 8 7 6 5 4 3 2 1 9 ry/ www.nacion.com/el-pais/salud/vertiginosa-caida-en-tasa-de-contagio-de-covid-19/7M77NATFQRFQZFLNNMO27ES764/sto Ávalos Á.Vertiginosacaídaentasadecontagiocovid-19intrigaa especialistas. LaNaciónCostaRica.2021.Available: line:32612814 Pearson AA,PradoAM,ColburnFD.Nicaragua’ssurprisingresponse toCOVID-19.JGlobHealth.2020;10:010371. Accessed: 18January2021. Available: Romero KT. Másde7500muertosporcovid-19:Minsaoculta98ciento defallecidos.ElConfidencialNicaragua.2020. rioni.org/15-al-21-de-abril-2021/ Informe Semanal del 15 al 21 de abril 2021. 2021. Available: Nicaraguan COVID-19 Citizen Observatory. virus/ Worldometers. ReportedCasesandDeathsbyCountryorTerritory. 2020.Available: https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 Johns Hopkins University. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE). 2020. Available: does-the-pandemic-seem-to-be-hitting-some-countries-harder-than-others Mukherjee S.TheCOVIDconundrum.NewYorker. 2021.Available: so-unreliable and CenterforHealthJournalism.Available: Heisel W. WhyCOVID-19casecountsaresounreliable.2020.UniversityofSouthernCaliforniaSchoolforCommunication development-indicators&preview=on The WorldBank.development indicators.2020.Available: imr World HealthOrganization. indicator views.2020.Available: Globalhealthobservatory Our WorldinData.Available: Giattino C, Ritchie H, Roser M, Ortiz-Ospina E, Hasell J. Excess mortality during the coronavirus pandemic (COVID-19). 2020. . Accessed:24February2021. . Accessed:3October2020. responding author)anddeclarednoconflictofinterest. Competing interests: Authorship contributions: Funding: a strengtheningofhealthcaresystems,includingtheircapacitytocollectdetailedanduncompromiseddata. are nowbeingoffered,andthereishopethatsufferingwillease.However, alegacyofCOVID-19shouldbe The novelcoronaviruspandemichaswreakedhavoconaregionthatlongconfrontedmisfortune.Vaccines that thepandemichasbeencontained,andcertainitnotyetunderstood. notbelieving motivation seemsdrivenbypoliticalcalculations.Wearyhealthcareprofessionalsarenervous, region havereducedeffortsatconfinement,allowingaresumptionofeconomicandevensocialactivities.The to thepeople.Ifpeoplewanttakecareofthemselves,theywillcare”[ issue nowtobeablereturntheofgoverningcountry.Todaywearetransferringresponsibility 2020, in which hesaid,“Wehave been busy allthis time with thecoronavirus.I thank God I am leaving this responsibility totackleCOVID-19.InGuatemala,PresidentAlejandroGiammatteigaveaspeechonAugust6, pandemic. Increasingly in the region, governments are shifting their responsibility to citizens taking personal An alarmingturn-of-eventsisofpoliticalleadersabandoningtheirresponsibilitytoleadeffortscontrolthe CONCLUSION to theworldwideepidemiologicalmysteryofCOVID-19. testing, and, in any case, the reach and reliability of data are sorely limited. The Central American isthmus adds erable tradeandmovementofpeopleamongcountries.Therearenocompellinghypothesesthatcryoutfor pandemic. However, theCentralAmericanisthmusisbothrelativelysmallandhasalwayswitnessedconsid helpful levelofimmunity,thenthespecificgeographytheirreachcouldexplaindisparitiesincurrent ID-infections anddeaths,researchershavewonderedifcertainpreviouslycirculatingpathogenscaninducea would besignificantnationalvariations.Insearchingforexplanations for theworldwidedivergence inCOV . Accessed:22April2021. https://confidencial.com.ni/nacion/mas-de-7500-muertos-por-covid-19-minsa-oculta-98-por-ciento-de-fallecidos/
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