Why Honduras?

Honduras is currently suffering the worst dengue epidemic in its history. Faced with this, some important questions must be asked:

1. What are the causes of the epidemic? 2. Is this simply an unavoidable natural disaster? 3. Are other countries in Central America suffering similarly? 4. Why has Honduras seen such high levels of dengue fever?

Statistics indicate that Hondurans are suffering far worse than their International neighbors. Countries which share its vulnerability and levels of poverty are not being affected to the same extent. The following figures illustrate the problem:

Country	Cases of classic dengue 2010		Country	Cases of hemorrhagic dengue 2010		Country Deaths caused by dengue in 2010 Honduras 56 Guatemala 15 Nicaragua   3 El Salvador   1 Panamá   0 Belice   0 Costa Rica   0
Honduras	44,866		Honduras	1299
Costa Rica	17,342		El Salvador	115
El Salvador	17,182		Guatemala	104
Guatemala	7,478		Nicaragua	98
Nicaragua	6,261		Belice	59
Panamá	705		Costa Rica	10
Belice	697		Panamá	1

Compared to other Central American countries, Honduras has suffered:

• THREE times as many cases of classic dengue; • TEN times as many cases of hemorrhagic dengue; • FOUR times as many deaths caused by dengue than Guatemala; • TWENTY times as many deaths caused by dengue than Nicaragua; and • SIXTY times as many deaths caused by dengue than El Salvador.

How can these figures be explained?

Why Tegucigalpa?

Another important question must be asked: why is Tegucigalpa the area of Honduras most affected by dengue? Inhabitants of Tegucigalpa are not isolated, they are educated and fumigation trucks can reach most areas of the city…
In its August 2010 bulletin, the Pan-American Health Organization ("OPS") revealed that:

"In terms of the number of cases reported in each national region, the most affected are: the City of Tegucigalpa (23,719 cases – 53%), the City of San Pedro Sula (4,432 cases – 10%), Olancho (4,329 cases – 10%), Choluteca (2,229 cases – 5%), El Paraiso (1,763 cases – 4%)."

Why have 53% of dengue cases been reported in the Capital compared to 10% in Olancho and San Pedro Sula? Tegucigalpa is one of the most developed cities in Honduras and it is the city with the best access to healthcare and fumigation. The city should, therefore, be the area best protected against an epidemic which is both preventable and treatable.

How can this be explained?

It was expected that Honduras, like its neighbors, would see a higher number of dengue cases in 2010 than 2009. But why has Honduras suffered so much worse than its International neighbors despite sharing their vulnerabilities? Furthermore, why has Tegucigalpa, the area of the country with best access to preventative and combative support, been worst hit by the epidemic?

Experts indicate that dengue is a preventable disease. It has been eradicated in Bolivia, the poorest country in South America. Experts also say that if treated swiftly and adequately, dengue should cause few if any fatalities (as is the case in neighboring countries). How, therefore, can Honduras' dengue epidemic be explained?

The most likely explanation is that this epidemic, with its thousands of cases and dozens of deaths, is a result of management and administrative failures within the Ministry of Health. Although the blame for an epidemic cannot be attributed to a sole individual, the Secretary of Health is responsible for directing national health policy. With this in mind, we must ask ourselves whether the authorities have made best use of the information and resources available to them?

Transformemos Honduras (Let's Transform Honduras) has carried out a series of investigations into the dengue epidemic. These investigations reveal that since February 2010, the Honduran Health Minister (Dr. Bendaña) had reliable information regarding the imminent dengue epidemic. Instead of doing all possible to prevent the epidemic, Dr. Bendaña's management of the matter has been characterized by extreme inefficiency.

We believe the Honduran people deserve more.

In the analysis that follows we outline the chronology of events. In addition, we highlight evidence which supports our hypothesis.

I. The Health Minister had sufficient notice of the impending dengue epidemic

a.	On 4 February 2010, Dr. Bendaña received a special report from the OPS warning of the impending dengue epidemic.
	On 4 February 2010, the Pan-American Health Organization published a special report. The report warned that the number of cases of dengue in Honduras had increased by 297% between January 2009 and January 2010. This was a clear indicator of the increasing danger of an epidemic. Since 4 February 2010, the OPS has repeatedly advised Honduras to implement stronger preventative measures Download: Actualización Regional Dengue: Programa Regional de Dengue (04 de febrero de 2010) pdf
b	Doctor Elsa Palou, specialist in internal medicine and infectious diseases, and ex-Minister of Health, stated the following:
	"In October 2009 we began to see an increase in dengue cases. We have therefore known since then that our focus should be on preventative measures. From July to December 2009 nothing was done to prevent dengue. A massive educational campaign should have been started in January as well as a campaign to destroy the breeding sites of adult mosquitoes. Once an epidemic has begun, it is necessary to fumigate but the effects of fumigation only last 4 to 5 days. In this case we fumigated but then nothing, we didn't do anything."
c	In February / March 2010, Dr. Bendaña also received a written report from the Head of the National Health Watchdog
	Dr. Marco Antonio Pinel. The report warned of the problems that dengue was likely to pose to Honduras.

II. Bendaña failed to take advantage of valuable resources and available expertise. Instead he dismissed officials who were experts on dengue and replaced them with inexperienced individuals as political favors.

a.	As previously mentioned, Dr. Bendaña received a report from Dr. Pinel about the risk of a dengue epidemic in February 2010. In an interview, Dr. Palou told us about the Health Minister's response to this report:
	"...Bendaña's response to the report was to fire Dr. Pinel. They transferred him without any consultation and in doing so broke the law. Political appointees were then placed in key positions." Spotting a valuable asset, the Pan-American Health Organization contracted Dr. Pinel and sent him to Ecuador as a technical advisor in the field of surveillance and vectors. By removing Dr. Pinel, Honduras lost one of its top dengue experts.
b	Dr. Bendaña also dismissed the Director of the National Dengue Program
	Dr. Roxana Araujo. Dr. Araujo is a specialist in epidemiology who had occupied the position for three years. Dr. Araujo is currently covering the current holder of her former position during her maternity leave.
c.	Arguably Dr. Bendaña's most irresponsible decision, however, was to name Dr. Karla Yadira Rosales Pavon as Director of the National Dengue Program
	on 20 February 2010. Dr. Pavon has no expertise or experience of dengue and only graduated 3 months before her appointment as a general medical practitioner. This was confirmed by the National University of Honduras ("UNAH") which recorded her graduation as having taken place on 3 December 2009 UNAH Graduation Certificates, december 2009 In an interview, Dr. Palao confirmed the above: The new Director of the National Dengue program was appointed when levels of dengue were rising and it was clear an epidemic was starting. In February or March 2010 they appointed the recently graduated general practitioner, Dr. Karla Pavón. She is a general practitioner who left medical college 6 months ago. How could such a person be appointed in the middle of an epidemic?

III. Dr. Bendaña invested 15 million Lempiras in a large scale media campaign. This campaign has been widely criticized and has done little to prevent dengue in Honduras.

a.	The Health Minister began a campaign on 9 March using the slogan "this is how to kill mosquitoes".
	The slogan was a reference to a catchy song that was popular at the time. The campaign was, however, ineffective as it failed to change people's practices and attitudes. The Ministry of Health was fiercely criticized for the campaign and criticism was not limited to those outside the government. The Minister of External Relations, Mario Canahuati, made the following comments about the campaign: We must ask ourselves whether this campaign, and the slogan "this is how to kill mosquitoes", is putting across the correct message. The fight against dengue should be carried out in a serious and responsible manner - it's about saving lives after all.
b	This widely criticized and ineffective campaign was also very costly.
	The campaign used newspapers, radio and television and cost the State 15,166,673 Lempiras (around US$800,000). This money could have been invested in a preventative program in the cities most affected by dengue thereby avoiding many cases of illness and death. To put it into perspective, the campaign cost five times more than the amount invested by any other Ministry or Mayoral Department from January to August 2010. Inversión hecha en televisión,radio y prensa
c.	Unfortunately the Ministry of Health did not begin to back up the campaign with actual preventative measures until the epidemic was already in full swing
	What was most needed was fumigation, eradication of mosquito breeding grounds, training of the population and training in schools and colleges. The adverts were the only preventative strategy adopted.
d	With the epidemic in full swing, plains and helicopters were hired to fumigate, but why? Dr. Palao said the following:
	"Why hire a plane? How much does it cost to hire a plane and fill it with gas? Mosquitoes don't fly at altitudes higher than a few meters. This is a mosquito, an animal that once inside a house will stay on the ground floor and will probably be found in a closet or under a table."
e	It is also worth repeating comments made by the presidential appointee of the National Anti-Dengue Front, Victor Hugo Barnica, as reported in the National press:
	In Honduras there is no uniform method for combating the Aedes aegypti (the mosquito that transmits dengue). The Presidential Appointee responsible for the National Anti-Dengue Front condemned politicians and departmental heads of the Ministry of Health for failing to contribute to the preventative campaign and increasing public confusion. (see Annex No. 7, El Heraldo newspaper, 3 August 2010) The Minister of Health should have developed and effected a uniform plan to combat dengue. There are many national dengue experts and international support is readily available to prevent the disease. For these reasons there is no justification for failing to transmit a clear message and carry out a coherent plan.

IV. There was a shortage of national saline solution stock when it was most needed.

a.	According to both the mass media and Dr. Palao, an expert in epidemiology, there was a lack of saline solution in Tegucigalpa, San Pedro Sula and even San Lorenzo. The shortage of saline solution, the most effective means of preventing death by dengue, lasted for weeks.
	i. 21 de July: ii. 5 de July: iii. Dr. Palao: "In Tegucigalpa there was a period at the end of April and beginning of May when we had no saline solution at the hospital."

V. The new National Health Plan does not include prevention of dengue.

a.

Whilst Honduras is the Central American State with most cases of Dengue, it still has no national dengue policy despite the fact that a new national health plan has just been drawn up. This is a clear sign of the lack of interest shown and efforts dedicated to dengue by the Minster of Health. Health Minister Bendaña and other senior ministers within the Ministry of Health drew up the National Health Plan 2010 – 2014. The Health Plan outlines various health policies:

i. Sexual and reproductive health policy ii. Maternal and infant health policy iii. Medicine policy iv. Mental health policy v. Nutrition policy vi. Women policy vii. Blood policy The following question therefore arises: why do we have all these policies but nothing relating to the control of dengue? El Salvador, a country very similar to Honduras in terms of its vulnerabilities, has a complete plan dedicated to dengue. The country has only had a single dengue related death in 2010.

VI. Results

a.	According to Dr. Pavon, since 11 May 2009 the number of dengue cases has risen by 1000% (One thousand percent).
	In May 2009, 244 cases of dengue were recorded. 2,594 cases were recorded in one week of May 2010. The problem should have been categorized as a national emergency by May 2010.
b	There is still a high risk that the epidemic may worsen in the interior regions of Honduras. Dr. Palou recently expressed her worries:
	"The figures show that in Choluteca, Olancho and El Paraíso (regions of Honduras) we are currently (as at July 2010) experiencing a full-scale epidemic. Are we working as hard at prevention in these regions as we are in Tegucigalpa or are we only working in Tegucigalpa? If we don't work hard in these regions we are going to see the same problems as we saw recently in the capital."
c.	In addition to the cost in terms of lives and human suffering (see above), the epidemic has had an extremely high economic cost. Dengue related government expenditure is detailed below:
	• The Teaching Hospital ("Hospital Escuela") reports an expenditure of 60 million Lempiras. • Expenditure in the Honduran Institute for Social Security exceeded 24 million Lempiras according to Mario Zelaya, director of the center where people are attended. • 70 million have been spent by the National Government on this epidemic, including 30 million specifically for the Ministry of Health's anti-dengue program. • 20 million Lempiras were donated by the United National Development Program ("PNUD") and the rest was approved as additional funds by the Finance Ministry. These figures do not, however, tell the whole story. There are additional hidden costs associated with the current dengue epidemic: the cost of private health care, the economic cost of thousands of work days missed through illness and the cost to families of the loss of a bread winner to name a few. In summary, the cost of the epidemic both in economic terms and in terms of human suffering is incalculable. Once more, Transformemos Honduras must emphasize that comparing our experiences to those of our international neighbors, it is clear that Hondurans have been let down by both the Health Authorities and more specifically by the Minister of Health Dr. Bendaña.

Conclusión

Although the responsibility for an epidemic can not be placed on the shoulders of one individual, Transformemos Honduras believes Dr. Bendaña has made key errors in the handling of the current dengue crisis. As shown above, Bendaña has had access to reliable information regarding the proximity of a dengue epidemic since February 2010. Instead of acting on this information to prevent the epidemic, Bendaña removed key dengue experts from office and appointed a new head of the national dengue program who lacked experience. In addition, Bendaña began a costly advertising campaign which did little to avoid the current situation. These advertising funds could have been spent on a mass educational and preventative campaign focused on the most vulnerable regions of Honduras.

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Transformemos Honduras therefore requests that the authorities of the Republic of Honduras name those responsible for:

• the current epidemic and rising levels of dengue; • the lack of space, and cramped conditions in hospitals; and • the general anxiety of the population caused by fear of contracting dengue.