Interview with Dr. Roberto López, Executive President of the INSS, with Alberto Mora
Live Magazine, Channel 4 April 1st 2020
Alberto Mora : We welcome Dr. Roberto Lopez of the Nicaraguan Institute of Social Security. Thank you, Doctor, for being with us this morning.
We want to talk about the coordination already established between the Ministry of Health and the other health institutions in the country to face the Coronavirus. Thank God it has not affected us like other countries, including our neighbors; El Salvador already had more than 30 cases and reported a first death from this cause; not to mention the situation in Panama and Costa Rica, which differ quite a bit from the figures in Nicaragua.
In this sense, how are these coordination efforts going? The measures that have been put into practice have been quite effective in preventing the spread of the disease, so that it doesn't spread.
Dr. Roberto López: Thanks for having me on the program. In fact, from the start of the epidemic in China, at the beginning of January, the Ministry of Health here started to review what was happening so as to establish what Measures should be taken to avoid an epidemic in the country.
Already when the World Health Organization declared the Pandemic, which simply means an epidemic in many countries; it is not that a pandemic is something worse than an epidemic... a pandemic is an epidemic in many countries. Then, the World Health Organization declared that all countries should prepare themselves to prevent this disease.
So from that moment the Ministry of Health, which is our National Health Authority, activated something called the International Health Regulations, which states that in situations where there is an epidemic there is only one National Health Authority in the country, which is the Ministry of Health in this case, and the Ministry began to meet with the various SILAIS local health authroities, and these SILAIS met with the Social Security Institute and with the private sector, with the various doctors concerned, to establish the prevention measures which are the most important thing, and the prevention measures are clear: hand washing must be guaranteed, people who are ill with colds must adequately protect others when sneezing, and people who have respiratory symptoms, whether colds or coughs, must go to the nearest Health Unit to be identified and diagnosed.
This mechanism is also accompanied, within the already established strategy, by community work, because the community organization, both in mainland China and in Taiwan, showed that this Community Organization where everyone is watching, identifying cases and supporting them to go to the Health Units and get treated promptly, is what determines the success in reducing the number of cases that may occur in this epidemic.
Here the important thing, as in all countries of the world, is that the cases do not occur all at once, that everyone gets sick at once, but that the epidemic, which is in effect a cold that in most cases is not complicated, occurs gradually, and the National Health System can attend to all possible cases that occur.
So there has been a work of prevention and preparation to care for cases, but the most important thing is always prevention and timely detection. This work has been activated in phases that are called "scenarios". When there were no cases in Nicaragua, what happened was a process of information and preparation work, organization of the hospitals where we could attend to cases, in case more cases occurred, and also work on communication between all the health personnel of the hospitals, health centers, health posts, social security clinics, and even with the private sector.
In addition, the Ministry of Health, in the only laboratory trained in this country to perform the tests, obtained the tests or the tests that come from the Pan American Health Organization, which are the only ones that detect 100% of the cases. And the mechanism was established so that the suspicious cases, either in the health posts, in the health centers, in the Hospitals of the MINSA, or in the Social Security clinics, would be sent those tests properly, to detect the cases.
Obviously, the first five cases we had were detected through that mechanism; some were detected in private clinics, others in hospitals of the Ministry of Health, and the important thing now in this next phase is that there should be no dissemination, all at once, of this disease, and that we should all protect ourselves.
That is to say, the important work is the work in the community, the work in the family, the individual work, which is, to wash your hands continuously, to protect others properly when you sneeze, and the third thing, to go to the doctor at the moment you have symptoms of cough and fever, or some kind of cold symptoms. The physician, according to the patient's circumstances, can determine whether or not testing is required.
This work will continue along with the work of informing our population, because we have already spent several weeks where the Multisectoral Brigades, where the Ministry of Health, the Police and other institutions are, are out giving information in the markets, in houses, what these prevention measures are and what to do in case of a potential case.
Alberto Mora : In the case of the preparation that you were talking about, which was the first scenario, when we did not have any cases, 19 hospitals were set up, which were defined at the time, care rooms were also set up for the people, staff were trained; in the case of the tests I understand that it was not overnight, but that there was preparation there, training, and above all securing equipment that was not available in the country at the time; an emergency line 132 was also set up where people can call, that as an emergency number. But in that sense, although our resources are limited, so far, and avoiding the early spread of the virus, we have been able to cope with it have we not?
Dr. Roberto López : We have a very important resource, one that is unlimited, it is community organization, community information, and the community work with families. That is to say, the epidemic can be addressed, resolved and prevented if each family complies with hand washing, protects others adequately when people sneeze, and goes to its health unit with symptoms. If that happens then cases from the epidemic will not occur all at once, which is the important part, but rather they will occur gradually and then we will be prepared.
In fact, in addition to what was mentioned, the Ministry of Health already has a lot of experience in handling tests for viruses with this treatment that is called Polymerase Chain Reaction; additional machines were acquired and staff have been trained appropriately. In addition, we have been ensuring that doctors and health unit personnel are trained in the detection of this type of case, and we have been acquiring the necessary medicines to deal with any additional cases that may occur.
In particular, we have already bought Interferon, from Cuba, and more doses of Interferon are coming, which is one of the treatments that has been used successfully, as it was used successfully in the epidemic in China, and other antiviral drugs, as well as antibiotics, serums and all the things that are required for those cases that could become complicated.
But the important thing here is always preventive work; in all phases preventive work is fundamental, and preventive work is individual. What happens is that sometimes there are some ill-intentioned people here who deliberately set out to provoke consternation.
It is true that the United States has an epidemic, but conditions in the United States these are not the same as conditions in Nicaragua, so we have to move forward calmly, gradually, dealing with each situation as it arises. Let's hope that the infection passes without major difficulties here in Nicaragua, but this is the moment to be prepared, to take individual responsibility and to organize ourselves. That is why we are acting as a health system, where there are 19 hospitals that are already prepared with trained personnel, with the necessary resources, and those hospitals have rooms that have been conditioned to attend the first cases that are presented.
The Nicaraguan Institute of Social Security continues to provide its services normally, as does the Ministry of Health, but we prepare for the occurrence of some other cases, and we have the necessary coordination so that care is orderly. We are not going to activate all the country's hospitals to attend only to the epidemic, because every day in the hospitals children are born in Nicaragua, every day there are patients with normal ailments, every day there are problems with accidents that have to be attended to in the hospitals. So, both the INSS, the INSS Social Security Clinics, and the Ministry of Health continue to provide normal services and be prepared for other cases.
Alberto Mora : Doctor, your Social Security Institute has a vulnerable population, because we are talking about insured people, pensioners, and in that sense they are the ones who are most at risk. There has been a campaign here too, to say "let's take care of our old people", because the elderly are more vulnerable and if they have chronic diseases they can get complicated.
As far as the supply of this medicine, to guarantee it to the pensioners, how are we, can we avoid that an increasing number of vulnerable cases, Doctor?
Dr Roberto López : The fact is that the virus does not distinguish whether you are an insured or not, whether you are a ensioner or not. In this country there are approximately 600,000 people over 60 years of age, that is to say, those who, when they have illnesses, can be at greatest risk and are the ones we have to take care of.
Some of us are already reaching 60 years old, and in real life there are always diseases that are those one normally suffers at this age, and they always put you at greater risk for any other infection, not only for this disease. There are many cases of older people dying from normal pneumonia, pneumonia caused by bacteria, not by viruses like these, so we always have to take care of them.
So the INSS pensioners are not at special risk, they are at risk just like all people over 60, that is why the work we have to do has to be comprehensive; that is, Ministry of Health, Nicaragua's Institute of Social Security, the Social Security Clinics, to protect everyone.
The medicine that has been acquired is not just for INSS pensioners; the medicine is being acquired in coordination with the Ministry of Health to cover all the cases required. We have guaranteed care for all persons who may be affected.
Alberto Mora : Doctor, I was referring to their chronic disease medication, not the virus treatment.
Dr. Roberto Lopez : All that goes on. We have, for example, approximately 2,833 people who areir receiving cancer treatment these days. That work continues. There are 4,700 people on hemodialysis who are at greater risk because they have CKD, which lowers their immunity, so in those places where hemodialysis is done every day, there is a Treatment Protocol, not now, but always, where the temperature is monitored, infections are checked, and protective measures are used to prevent the spread of infections in all Hemodialysis Units.
So the Institute continues to provide normal care through itsSocial Security Clinics; the supply of medicines continues exactly the same across the country, no product has been out of stock, and we are guaranteeing that care, while preparing in an organized way for the possibility of other cases.
Because here the secret of our System has always been organization, from communty organization to the organization of the health centers, and the appropriate relationship between the Social Security Clinics, the private sector clinics and with the National Health Authority which is the Ministry of Health. At this moment what we have to do is follow the leadership and recommendations of what the Ministry of Health tells us, and the Ministry of Health has established that the most important thing at this moment is to wash your hands, protect yourself properly when you are sneezing so as not to infect other people, and go promptly to your Health Unit in case you have a respiratory problem, i.e., a cold, a cough.
Alberto Mora : This means that, as it is a single Health System, any person who is detected in a Social Security centre must follow the Protocol that has been established and go to the places that are prepared for this crisis, for this pandemic.
Dr. Roberto López : Well it's not like you're going to that place. You have your own Social Security Clinic, you go there, you are attended to, and if you are detected there because you are tested there, the INSS and the Ministry of Health guarantee that the patient will be transferred to the appropriate unit. It's not that we are going to send you... "go, take the bus to..." It's already detected if the patient has already reached a Health Unit.
What I am trying to say is that people must have the confidence that we are working in a coordinated manner, and if a clearly suspicious case appears, the patient is moved to the appropriate place and the prevention measures are taken in the Social Security Clinic, because then the medical personnel who were in contact with this patient, will have to comply with the follow-up measures in their home, as has been proposed, to check that they have not been infected.
This follow-up work that the Ministry of Health has been doing, visiting the homes of people who have had contact with the positive cases, with these patients, is what guarantees that the spread of the virus will be reduced and that many cases will not appear, all at once, and this is what we have to be fighting for every day in each of our homes.
Alberto Mora : Speaking a little about Cuban Solidarity with the Brigade that has arrived in the country, we also saw you visiting laboratories where they could begin to manufacture the medicines that the Cubans have put into practice and which have yielded good results. In that sense, when could we be ready, Doctor?
Dr. Roberto López : Interferon has been produced by Cuba for many years, in China too; that is why in China they had the availability of this drug that against viruses, and particularly against this virus it is very useful.
We have already been in discussion, in the first visit that was made a year ago probably, we had been talking with the Cubans about producing some of the things that they have there in Cuba, in our vaccine plant. The vaccine plant has been producing around 5 million doses of influenza vaccine, which is the one available in the world and has been applied in Nicaragua for more than 4 years. We are applying the vaccine and it has been applied in other Latin American countries.
So there are options for that plant to produce more vaccines, and other products that can be processed in this plant. The work will require some months; we would like by the end of this year to be able to bring the product to Nicaragua and that the company called BioCubaFarma would be producing in our Mechnikov plant, so the product could be available to more countries, not only for this epidemic, but also for other treatments that are required.
Nicaragua had already been buying Interferon for years, and in particular the Social Security Institute had been guaranteeing Interferon for several years for the treatment of, for example, viral hepatitis, multiple sclerosis, and other diseases, for which Interferon is required.
So this is a new opportunity to reinforce these ties that the government of Comandante Daniel and the Compañera Rosario have been strengthening with all the nations of the world, and particularly with our Cuban sisters and brothers who have a very important technological development. So, if everything goes well and we are pass the relevant procedures. because we have to obtain the appropriate permits, do the necessary tests and guarantee get the product approved by the Ministry of Health, then we will also be able to sell it in Nicaragua, and export it.
There is a normative process for all manufacturing of medicines, particularly these medicines that are biological, so they have to be more secure. That is what we are thinking of doing, logically we all would like there to be a vaccine against the coronavirus but this is a new virus, and we already know that it is going to take some time until they manage to develop it, and that it is safe. So eventually, when the vaccine is developed, we will probably be able to produce it in our factory as well. But, still, that's a process that takes a long time, there are people who talk about 18 months, there are people who talk about 1 year, there are people who talk about 2 years.
Since it's a new virus, everybody has many opinions and they try to give an opinion, or a quick solution... No! The process of creating vaccines is a very long process and you have to be sure that the vaccine that you inject into a person is not going to make them sick instead of saving them; that's why you have to be sure of what you're doing.
Likewise, with Interferon, we will be working with the necessary protocols to guarantee safety; meanwhile, Cuba has made available to us a number of products that they already have.
We have received the inventories that we have at the Ministry of Health, at the Social Security clinics, and what is being bought at the moment and Cuba has offered us the amount that we need, is Interferon, which is probably one of the 3 most important products for the care of patients, depending on the severity of the infection.
Of course, if the patient gets worse, then we have the normal treatments that are used with patients that have respiratory insufficiency, oher antibiotics, other medicines, the treatment with life support for patients, intensive care treatment that is the normal treatment used with any serious Patient. We have all those drugs in Nicaragua.
Alberto Mora : Speaking of the tests, Doctor, only the Ministry of Health that has a laboratory for this purpose able to determine this type of Coronavirus, but I heard, someone told me, that some hospitals have offered their patients a test that tells them that it is Coronavirus, but it does not identify that it is CODIV-2, that is, SARS 2 or CODIV-19, and it has a very high cost, more than 300 dollars, I think. In that sense, so that people do not fall into a trap, they should know that it is the only Ministry of Health that can determine accurately.
Dr. Roberto López : I'll tell you something I read in a newspaper on the Internet. The Minister or Governor of the Northern Italy Zone of Lombardy in an interview a few days ago, said that he is surprised because there are a lot of scammers out there. He explained how they went out to look for ventilators and the companies concerned refused to sell them th ventilators. In Spain a Spanish distributor sold the auhtorities some tests for the coronavirus, which were not useful. Spain did what they had to do, once they bught the tests, they started checking them, and found they didn't work.
So, on this issue we must be very careful not to get caught out, and we must act rationally. That is to say, there are 3 types of things that are detected when one has a viral disease: the first one is, that you can detect if the virus exists; the second thing that you can detect is an antibody that is called immunoglobulin M, immunoglobulin M is an antibody that the person produces in the first days after they get a viral infection. And then there are the G-immunoglobulins that you get or that your body starts producing days later, probably 3 to 4 weeks after the infection occurs. These are the responses the body has.
So we have either the virus that infected us, or we detect the response to the virus, which can be immunoglobulin M in the first few days, or immunoglobulin G in the later days. Therefore, usually the only test you can be sure of is one that detects the virus. What happens? In the test that is done via the nose and pharynx, that sample is put in a special machine which replicates the genetic load of the virus that is there, and makes it possible to detect if the virus is there, or not, because there is a sequence of nucleic acids that are the ones that determine that the virus is there, which is the composition of the virus.
The others are the reactions to the virus, which are antibodies. So the rapid tests for other diseases is when the antibodies are already there, they are already reacting and there has been a response; so there are rapid tests for other diseases. In the case of this rapid test, first of all we have to be sure that the pharmaceutical company or that the manufacturer is genuine; and secondly, it has to have had the antigens necessary to be able to develop this test, and what is happens is that it takes five days after the symptoms have already appeared before the body can produce these Immunoglobulins.
So what happens? With some of these rapid tests you get what's called a "false negative" which is, you had the rapid test, it came back negative, and since it came back negative you think you don't have the disease, and that's where you could be transmitting it.
That's why the clinic, the investigation of the contacts and the test where the virus is found in the body of the person, is the only thing that guarantees a secure diagnosis. And what has happened? Here all kinds of phonies have arrived at the Social Security Clinics, I am not going to mention names, some who arrive with a 7 dollar rapid test, and others who are selling a 300 dollar rapid test.
So the question is: Are we going to let tests come in here so that people can get confused and think that they are being detected with the test? No! There's even one confidence tickster saying their test is like a pregnancy test, that you take it and that's it.... Unfortunately, they're looking for a way to fool people. So we have to be responsible.
The World Health Organization and the Pan American Health Organization have not said: OK, these tests can be used. So before we agree to use any of these tests, they would have to have been properly tested, both in Nicaragua and in other countries.
We have already found, for example, that in Korea where thousands of tests were done, 96% were negative. So how do we know if they were negative or not? That is, the polymerase chain reaction test was not done, which is the test where you find the virus particle. You find the virus particle inside the person's body.
So, for other diseases that are more chronic, that give time to detect them, that develop a faster immune response, rapid tests can be helpful, but in this case the usefulness is not clear.
Alberto Mora : So basically, don't let people take advantage of you when they say “I'm going to do a quick test here, I'll tell you if you're affected”.
Dr. Roberto López : You can meet any kind of trickster, and you just don't know. So what makes most sense, buying some quick tests that we don't know if they're going to work, or getting prepared so as to receive proper treatment? You have to have the right medication. And the diagnosis... Always, always, in all diseases the most important thing is the clinical diagnosis; because all of a sudden we have come to believe that technology is the most important thing at the time of a diagnosis. Technology does help, technology does help solve things, technology in some things does offer indications, but in the end it is the clinical experience of doctors, nurses and organizations that guarantee cases are detected properly.
There are many cases that we have found, with other diseases, that an x-ray seems to say one thing, while the laboratory tests say another thing, and it is the experience of the doctor that ensures the diagnosis will be the correct one and that in the end the treatment is the correct one. We have very good infectologists in Nicaragua, and all the infectologists in Nicaragua work either in the Social Security clincis or in the Ministry of Health, and we have been working together with the pneumonologists, with the intensive care specialists and the infectologists, preparing the protocol for this virus which was ready a couple of months ago.
We have been adjusting it, just as they have been adjusting it everywhere, based on the experience of other countries, and this protocol has been applied, which is clearly defined and has been applied by our medical professionals.
Nor is it a matter of beginning to say now that everyone has to take medicine X... No! Medicines have their positive effects and their negative effects, that is why any treatment must be supervised by qualified personnel, doctors and nurses who are working on the front line in the Ministry of Health, in our Social Security clinics, and who are seeing patients every day, and that accumulated experience is the most important thing to detect the cases.
Alberto Mora : And the pensioners, retired people, have their money ready, right?
Dr. Roberto López : Absolutely! On the 4th we are paying the reduced pension in the banks and in our payment centers, as well as the INSS payments. And on the 14th we will be making bank transfers to people who receive bank transfers, and on the 20th we will be paying approximately 150,000, 170,000 pensioners who arrive at our payment centers and who have their payments guaranteed there in cash.
Obviously, all our centers have also been working on prevention, because they have been giving talks inside the payment centers, as part of this work of the Ministry of Health, to ensure that each of these people can take care of themselves and their families. Here each one of us has to take care of ourselves and others, and it is very simple: Wash your hands, protect others properly when you sneeze, and go to the nearest Health Unit when you find symptoms of a cold, or cough, or respiratory diseases.
Alberto Mora : I thank you, Doctor; thank you for joining us.