El Salvador

Health and Welfare

Nurse in rural health post administering an injection
Courtesy Inter-American Development Bank

Insufficient income had a serious adverse effect on the general health and vitality of the rural population. In the mid1980s , El Salvador was among the countries of the Western Hemisphere most seriously affected by malnutrition. During the 1970s, the poorer 50 percent of the population consumed, on average, only 63 percent of required calories and 56 percent of required protein according to accepted international guidelines for adequate nutrition; the overall population averaged 77.2 percent of the minimum standard for caloric consumption and 83.6 percent of the standard for protein consumption. Anemia, riboflavin deficiencies, and vitamin A and other vitamin deficiencies were widespread among the population.

Malnutrition was particularly prevalent among young children. Even before the upset caused by civil conflict during the 1980s, approximately 48.5 percent of children under five years of age suffered from mild malnutrition, 22.9 percent from moderate malnutrition requiring medical attention to cure, and 3.1 percent from severe malnutrition requiring hospitalization for adequate recovery. Stated differently, 80 percent of children suffered from at least first-degree malnutrition--10 to 24 percent underweight--and 5 percent suffered from third-degree malnutrition--over 40 percent underweight. Because pregnant women usually lacked proper nutrition as well, many children were born underweight and undernourished.

The poverty responsible for inadequate nourishment among campesinos was also reflected in substandard homes and living conditions. In some regions, land for housing and domestic life was limited to an absolute minimum by the expansion of private estates. Some closely crowded groups of huts were strung along the remaining narrow strips of public lands bordering highways and rivers or erected on narrow peripheries between the fenced boundaries of estates closed to resident laborers and the nearest public road, in an arrangement called "fence housing."

Rural homes typically sheltered four or more persons. They usually had one, sometimes two, rooms, dirt floors, walls of adobe brick or bahareque (wood frame with a mud or rubble fill) or of poles and straw, and thatched or tiled roofs. The kitchen commonly was in a separate shelter or located under an extension of the main roof. Even in the 1980s, almost none of the rural population had access to sewage systems. Some 12 percent had latrines or septic tanks, but 80 percent had no sanitation facilities. Surface water was seriously polluted by agriculture and industry, yet 60 percent of the rural population depended on rivers and streams and/or rainwater and 22 percent on wells for their water needs. Some 93 percent were without electricity and used kerosene lamps or candles for light and wood or charcoal for cooking and heat.

Conditions such as these, combined with malnutrition, produced high rates of chronic illness and high mortality, especially in infants and young children. Although families of three to four children were considered the most desirable size, rural women actually had an average of six to eight children and, given the high infant death rate (about 120 to 125 per 1,000 live births) often had twice as many pregnancies. In general, about 30 percent of all deaths per year were of children under the age of one, and with another 14 percent occurred in the age-group from one to four.

Several diseases posed particularly serious problems. Malaria was of major concern in rural departments, with morbidity ranges between 4,100 and 1,800 per 100,000 inhabitants in the 1980s. Water-borne diseases were also particularly common and one of the major factors affecting mortality. In the 1970s and 1980s, the leading causes of death included enteritis and other diarrheal diseases, as well as pneumonia and other respiratory diseases, such as bronchitis, emphysema, and asthma. Nutritional insufficiencies, perinatal complications, infections, and parasitic diseases also took a high toll, especially among children (see table 3, Appendix). As of 1987, El Salvador had reported sixteen cases of acquired immune deficiency syndrome (AIDS), the lowest total of any Central American country except Belize. Of the sixteen, six victims had died.

High mortality rates reflected the fact that health care itself was limited and medical facilities for the general population inadequate. This condition was aggravated by the civil disturbances of the 1980s. The 1971 census indicated that there were three doctors and seventeen hospital beds for every 10,000 persons. In 1984 ten general hospitals and twelve health centers, in addition to several hundred other community posts and dispensaries, provided between 0.5 and 1.5 beds per 1,000 inhabitants outside the San Salvador metropolitan area. Some rural regions did not have any hospital facilities. Where rural hospitals existed, health care personnel frequently were hampered in their work by limited equipment and supplies and unsanitary conditions. These conditions made it difficult to meet even the ordinary medical needs of the rural population. For example, most births took place at home, sometimes with the assistance of relatives or neighbors, but often unassisted.

Rural areas were deprived of sufficient government-financed social programs in part because of a longstanding governmental preference to keep taxes low and to concentrate the provision of services in San Salvador. The situation was exacerbated by increased military spending during the 1980s, as the budget allocations for the Ministry of Public Health and Social Services declined in real terms. Similarly, the number of medical personnel available to work in rural areas declined drastically after the Medical School of the National University was closed in 1980, ending the flow of interns, who had provided much of the medical care in the countryside. In addition, many doctors and other health workers in rural areas either relocated or abandoned their efforts as a result of the intensifying civil conflict in the 1980s.

The government, particularly through the Ministry of Public Health and Social Services, recognized as national priorities the need for improvement of health services, control of malaria, improved sanitation and drinking water quality, and increased child survival. It pledged to follow various lines of action toward these ends.

Social security was another government benefit to which rural Salvadorans had far less access than urban dwellers. The social security system was administered by the Salvadoran Social Security Institute, an autonomous institution first established in 1949. Its medical benefits and pension system, implemented in 1969, covered employees in industry and commerce but excluded agricultural workers, domestics, casual employees, and civil servants. The latter were covered by a different system. The institute also administered a number of hospitals throughout the country. Individuals (and their spouses) covered by the system were entitled to sickness and maternity benefits, care for workrelated injuries, and pensions on the basis of old age or disability. The system was funded by payroll deductions from the insured, as well as by employer and government contributions.

Data as of November 1988

El Salvador - TABLE OF CONTENTS