Under One Roof: A new approach to health care in Nicaragua

By Sarah Kramer

On a hill overlooking a steep mountain valley dappled with tropical greens and dry scrub brush, wire fences and a small dirt footpath lead to the main road and the town center of Boaco.

Above all this sits the home of Milagro Solano Lira, 29, and her 4-year-old daughter, Yosmiling. She is a single mother, having separated from Yosmiling’s father three years ago, and works as a lavandera, washing clothes. Her home is just two rooms, built of concrete and corrugated metal, with hardly enough chairs to seat the half-dozen visitors who come to visit on a windy afternoon in February. Outside her modest home is a panoramic view of mountains worthy of a palatial villa. She has no electricity or potable water and keeps chickens. She grows fruit and herbs in a small yard fenced by barbed wire wound around thick branches.

On the day the visitors came, Yosmiling, a sweet toddler in a pink dress, had a cough and a fever. After work, Lira said, she’ll take her to the clinic where her sister, Yessica Solano, works as a nurse. She has been going to this clinic for two years, and though she has to pay for consults and travel an hour each way on the public bus, she far prefers it to the free public clinics run by the Ministry of Health. It’s faster, she said, and the staff is more attentive. She has to save to pay the 30 córdobas, roughly $1.20, a suggested donation the clinic asks for each consult. Still, she said, the treatment she receives is worth it.

Welcome to Clínica Verde .

The gold and green building stands against a backdrop of farmland, with the rough, verdant hills of central Nicaragua in the distance. A large sign sits in front of the landscaped breezeway, complete with pharmacy window and a small wooden swing. Double doors lead to a lobby where patients, mostly women and children, wait for their appointments. Clínica Verde, however, is trying to be something more than a doctor’s office. Clínica Verde is trying to change how we view health care, starting in a small corner of Nicaragua, the second poorest country in Latin America.


Susan Dix Lyons, founder of Clínica Verde, has always felt a connection with Nicaragua. Her journalist grandfather traveled the country in the 1970s, meeting Pedro and Violeta Chamorro while Pedro was the editor of la Prensa. The Chamorros were outspoken critics of the Somoza family, who ruled Nicaragua with an iron fist for over 40 years. In 1978, Pedro’s assassination by unknown gunman sparked riots in Managua. The following year, the Sandinista National Liberation Front overthrew the Somoza regime and the small country plunged into a decade of revolution and turmoil.

In 1990, Dix Lyons was a reporter for the Tico Times in Costa Rica. She traveled to Nicaragua to report on the presidential election—the second since the first Somoza, Anatasio, seized power in a coup on New Year’s Day, 1937. Violeta Chamorro, the widow of the assassinated journalist, won narrowly over incumbent Daniel Ortega. Dix Lyons’ connection to Nicaragua and the Nicaraguan people had been reinvigorated.

Then life took over. Dix Lyons moved back to the U.S. at the end of 1990. She moved to Chicago and then to Tampa, Florida, working her way up the ranks of a local alternative weekly, then back to California in 2001; to raise her sons with her husband, Tim. She went back to graduate school for a master’s degree in art history and in the process became fascinated with sustainable urban design.  She also gave birth to a daughter in 2003.

After graduating in 2005, Dix Lyons said, she was “looking for purpose. In 2006, she returned with a group of volunteers to Nicaragua. The poverty, especially among young women, ignited her passion. She had found her purpose.

“I met a lot of people who had a clear and significant need,” Dix Lyons said of her return to Nicaragua. She remembered Joselin in particular: a small girl, 9 or 10 years old, with warm brown eyes and wavy, chin-length hair.

“I looked at Joselin and said, this could be my daughter,” Dix Lyons said. To the journalist and mother of three, it seemed Joselin was suffering because of the “grave injustice” of being born into poverty. Dix Lyons saw in this little girl the stark reality of a life that was severely limited by external circumstances—the likelihood of a next meal, the need for adequate shelter.

“Joselin, in my mind, became a point of inspiration,” Dix Lyons recalled. “I starting thinking about what we could do to make her life a little better, to give her more options: a life of dignity, possibility, hope.”

This drive is what led Dix Lyons to start working on the idea of Clinica Verde: a place where even the most impoverished could receive not only health care, but true compassion. In 2007, she asked Cristiana Chamorro, the daughter of Violeta and Pedro, to join her in creating Clinica Verde.

“We wanted to create a place for health and well-being from the ground up. What would that look like, what would that feel like?” Dix Lyons asked.

Dix Lyons began raising funds for Clinica Verde in 2007. The following year, the Clinica Verde board of directors met for the first time in Managua, Nicaragua’s capital city. Then the mayor of Boaco, Vivian Orozco, donated the land for the clinic, a lengthy a complex process. Dix Lyons and the board then spent two years designing the clinic, drawing on the expertise of doctors, engineers and architects from both countries.

Dix Lyons acknowledges that the process was, at times, frustrating, but the lengthy design and building process “gave us the time to establish meaningful relationships; get to know the community better and signal our unflagging commitment to the vision.

The clinic is a laboratory of sorts, constantly building new programs and partnerships and adapting to challenges. “We have to be flexible and adaptive,” Dix Lyons said. “We’re trying to evolve and grow and become better all the time.”

A prototype

The Nicaraguan Ministry of Health provides health care to all Nicaraguans through a system of health outposts, clinics and hospitals throughout the country. Health posts are small and give generalized medical care. For those who can afford upper-tier medical care, there are private clinics. Everyone else relies on government facilities. Even these, however, are subdivided into clinics for those with insurance, and clinics for those without.

As in the U.S., insurance can be provided by an employer or bought in a la carte packages, the main difference being that the government is the sole insurance provider in the market. Most Nicaraguans, however, are poor, with 76 percent living on less than $2 per day. In the department of Boaco, where Clínica Verde is located, just over 5,000 patients have insurance in an estimated population of 171,000. In addition, an estimated 37 physicians serve every 100,000 Nicaraguans, and there’s roughly one hospital bed for every 10,000. (In the U.S., there are 245 physicians per 100,000 people and 30 beds per 10,000.)

Compounding these issues, said Rafael Morales, general manager at Clínica Verde, is the fact that Nicaraguan society remains segregated by class. Morales, who grew up in Nicaragua but lived in the U.S. for much his adult life, said that the customer service model of care is somewhat different in Nicaragua, especially when economic class comes into play. But Clínica Verde, he said, aims to add a special touch: a kind word, a smile, an affirmation of dignity for every patient, no matter what.

“I feel strongly that being loved, being touched on a personal level, being looked at with compassion and care, is the first step to well being,” Dix Lyons said.

La clínica

Clínica Verde requests that patients make a 30 cordoba ($1.20) donation for a consult—a pittance by U.S. standards, but the equivalent of more than half a day’s wages for most Nicaraguans. If the price is too steep, however, the clinic won’t turn a patient away. Of 44 patient consults on a single day in February, 12 patients paid nothing at all. The requested donation, said Betsy Dankenbring, the clinic’s interim medical coordinator, is a new policy, intended to promote the idea of Clínica Verde as an investment for the community. One of Clínica Verde’s goals, Morales said, is eventually to become self-sustaining, rather than reliant on the U.S.-based fundraising efforts that currently fund clinic operations.

The clinic can test blood samples and pap smears, and recently received a colposcope, a machine physicians use to examine the cervix, a key tool in the battle against cervical cancer, the most common form of cancer among Nicaraguan women. Dankenbring said the clinic has the ability to provide the vast majority of common diagnostic tests. The clinic is also expanding into dentistry, with two dental chairs and the first panoramic X-ray machine in Boaco.

La farmacia

To the left of the lobby entrance, a small pharmacy window provides medication to patients. Some are free, but others are sold at what Morales calls an “ethical markup,” That is, the minimum Clínica Verde can charge while not losing money. Any medicine Clínica Verde receives for free is redistributed without charge, said Dankenbring. Implanon, for example, a contraceptive implant, is available for about $15—far less than the $100 price tag at a private clinic. Childhood vaccinations are free, thanks to a USAID program.

The question of financial independence can sometimes strain the clinic’s ability to compete with the single-payer model of the government clinics. While Clínica Verde runs its pharmacy on very slim margins, Lira said she can’t always afford to pay Clínica Verde prices for medications. However, she pointed out, government clinics are often out of certain medicines. When she can’t afford pharmaceuticals, Lira treats her and her daughter’s ailments with herbal folk remedies from her garden.

El huerto

Behind the clinic, roughly three dozen garden beds burst with squash flowers, bean tendrils, bright amaranth blossoms and desiccated sunflowers, ripening chili peppers and rich green kale, with tawny bursts of marigolds providing natural pest protection. The garden, the result of a partnership with sustainable agriculture nonprofit Global Student Embassy, is biointensive.

Biointensive agriculture focuses on producing as much food as possible in a relatively small area while improving soil quality and minimizing negative impacts. The gardens are organic and serve as teaching tools for the surrounding communities. Global Student Embassy, a California-based environmental education non-profit, and Clinica Verde have also brought small gardens to nearby schools, with the goal of growing produce for the schools’ cafeterias. In March, Clinica Verde announced plans to launch a 10-week prenatal and early childhood nutrition program, using the garden as a teaching tool for nutrition and cooking classes. An estimated 23 percent of children in Nicaragua are undernourished, and need is even greater in rural areas. The clinic hopes to use the biointensive garden and spacious kitchen facilities to combat malnutrition.

Just outside the kitchen, a small greenhouse provides a safe space for seedlings, while a black tank collects rainwater. A few feet from the tank stands one of Clinica Verde’s most ambitious and challenging moves toward sustainability projects: the transition to solar panels for free energy and a smaller carbon footprint.

Los paneles solares

The solar panels are the result of another partnership, this time with Portland, Oregon-based Green Empowerment and its local affiliate, Asociación Fenix. A mutual donor interested in helping Clínica Verde lower steep electricity bills supported the partners and project. Caitlyn Peake, Green Empowerment’s regional director for Latin America, said the organizations knew of other solar projects that had been given permission to connect to the Nicaraguan grid, and were encouraged to go ahead with the project to demonstrate commitment. One year later, and the solar panels are up and running, supplying 30 percent of the clinic’s electricity.

“They’re basically just producing electricity that they’re using for themselves at any one moment, but what they’re not doing is offsetting electricity they use at night” or during other sunless periods, Peake said.

Peake is confident that legislative change will soon require Nicaraguan utility companies to allow solar energy systems to connect and send excess power back to the grid. When this happens, Peake estimated, the clinic will be 70 percent powered by solar panels. Despite the sense that tropical climes are best suited to the solar revolution, the experience of Clínica Verde shows the need for legal and physical infrastructure to support alternative energies.
Green Empowerment, like Clínica Verde, works in conjunction with local nonprofits to create innovative, sustainable projects that improve the lives of the community members.

Organizations outside of Nicaragua are also starting to take notice of the huge benefit solar energy can bring to developing nations. “By powering a community, you can definitely improve health outcomes,” said Katharine McCormick author of the recent Natural Resources Defense Council paper, “Bridging the Clean Energy Divide.” Solar, she said, also subverts the argument that communities must choose between clean environments and the improved standard of living electricity provides.

In places where utilities and legislation are ready for solar connections, the renewable resource has great potential to expand access to power in the developing world, said Dick Co, assistant professor of chemistry at Northwestern University and director of outreach at Argonne-Northwestern Solar Energy Research Center, said word. “It’s really an abundant source of energy that we know how use,” he said, pointing out that the cost of panels has decreased significantly as technology has improved. In addition, the small-scale and localized nature of solar power means that the effects of severe weather events on the power supply are mitigated, McCormick said. When one panel goes, the system can continue to function.

Asociación Fenix has been operating in Nicaragua for over a decade. Local partners, Peake said, are critical to the success of any long-lasting project because of the individualized historical and cultural knowledge each brings.

“I would have never gone in as an American without strong partners,” Dix Lyons said. “I knew they had answers and understanding that I never could.” Also like Clinica Verde, Green Empowerment asks that communities make small investments to establish the community’s commitment.

Roughly two hours from Boaco, the small, arid village of el Bálsamo has experienced major changes as a result of the AsoFenix/Green Empowerment partnership. Prior to the groups’ collaboration, which began in April 2013, residents drew all their water from the nearby river, walking over a mile to gather drinking water, wash clothing and water livestock.

After seeing AsoFenix’s work in a neighboring village, the community of el Balsamo decided to partner with the nonprofits, contributing local labor and supplies to install a solar-powered pump system to draw clean groundwater up from over 35 feet underground. The water is pumped to a large, bright blue tank that sits on a hilltop overlooking the village. The water powers the village’s first communal running-water bathroom and laundry sinks. El Balsamo residents contributed not only labor and materials, but gave a small financial contribution to cover between 20 or 30 percent of the cost of project. Now families pay a usage fee of 10 cordobas per liter, roughly 37 cents.

Eusebia Campos Rodriguez, a member of the community council tasked with maintaining the project, said the former water supply, from a small river nearby made children and adults ill and gave them skin infections when they bathed. More than 2.8 million people in Nicaragua lack access to adequate sanitation, according to the nonprofit WaterAid. The families in the village had neither running water nor electricity, and relied on latrines.

Most communities, Peake said, hear about AsoFenix’s work by word-of-mouth. “They know what their neighbors have done and invested. They get a better sense of what it would be like to develop it,” she said.

While all the council members agree clean water has been the greatest contribution to the community, AsoFenix is also empowering the community with improved nutrition. The nonprofit partners helped start 32 small huertos, or backyard gardens, so families can grow fresh produce—mangoes, bananas, herbs, beans, squash and more— a boon for a village without access to refrigeration. The food produced in the garden is then prepared on improved cook stoves, designed as an alternative to the traditional wood-fired stoves that caused respiratory and eye infections for families. These problems were even greater in women and children, who spend the most time at home.

“It’s so bright now!” joked Rodrigues, mimicking the women wiping smoke from their eyes after the introduction of the new stoves. The cleaner burning stoves use less wood, diminishing the need to haul heavy firewood, and offer the safety of an enclose frame and chimneys.

In some ways, el Balsamo is a perfect laboratory for these small scale but deeply impactful projects. Because massive, centralized energy infrastructure isn’t yet in place, developing areas have a chance to start fresh. “They don’t have to undo decades and decades of investment in dirty energy,” McCormick said. “They can kind of a start with a clean slate.”

Co said that solar energy could help equalize not only health outcomes, but even deeper disparities:

“It’s not just watts you’re putting out; it’s a domino effect,” Co said. “If you bring power and electricity to the developing world you can allow children, men and women especially to learn.”

La salud de las mujeres

“Women are the backbone of society,” Dix Lyons said. “They care for, teach and support the next generation.” The health of women is a major component of Clinica Verde’s work. Of the over 10,134 patients seen at Clínica Verde in 2014, women accounted for 7,174. Nearly 2,000 of these women were between 20 and 34 years old. According to the Guttmacher Institute, roughly half of Nicaraguan women give birth before the age of 20. By providing low- or no cost contraception, pap smears and colposcopies, the clinic promotes good sexual health practices in a deeply Catholic country.

As part of Clínica Verde’s model of not just healing, but uplifting community members, the clinic has partnered with Latin American youth empowerment organization JovenSalud, or TeenSmart, to run an after-school program that teaches teenagers about sexual health, personal safety and communication skills. Both sexes are encouraged to attend, but the goals of the program are undeniably geared toward a society where women often have little or no autonomy.

The program coaches teens to counsel their peers with the same lessons they learn at the clinic. Yessica Solano, Milagro Lira’s sister, runs the sessions, which might include instructional videos, internet questionnaires, role playing scenarios or frank discussions about contraception. Even the youngest teens will soon start seeing pregnancy in their peer groups.

One teen counselor, Marcela, said the goal is breaking free of the linked cycles of teen pregnancy, lack of education and domestic violence that plagues Nicaraguan women.

Dix Lyons understands the struggle of Nicaraguan women acutely, especially for mothers like Lira: “A lot of the households are led by single women who work very hard to scrape by, to have enough food for their children, to have enough money,” Dix Lyons said. “Women don’t have the opportunities that we have in the States.” Again, it is the profound injustice of circumstance that drives Dix Lyons’ passion to help the people of Boaco.

She credits Joselin as a source of inspiration for her work with Clínica Verde, adding fuel to her deeply felt “mission” to help the world’s most needy. After four years of hard work to get Clínica Verde off the ground, Dix Lyons found Joselin
again—a young mother, selling food by the side of the road.

“ I walked away, behind this building, and I just cried.” She remember. “I felt like we weren’t good enough. We weren’t fast enough.”

Joselin still visits the clinic. “We’re not going to be able to save everybody,” Dix Lyons said, but is indefatigable in her optimism. “I feel that I’m doing work that I was intended to do.”

Dix Lyons aims to build a replicable prototype that could bring the same form of compassionate care to communities around the globe, including to the U.S. She admitted she will never be finished with the grand project that is Clinica Verde, the compassionate care model. She wakes up in the middle of the night, sometimes, in her home in California’s Napa Valley, wondering:

“How do I make this sure this lasts well beyond me? How do I keep this going?”

She wants Clinica Verde to have the widest impact possible, to save always more people, to lift them out of poverty, to show them individual kindnesses.

And how does she respond to the skeptics and the isolationists, to those who don’t share or understand her dedication to Clinica Verde?

“One of the first things I always say is, will you come?”

Photo at top: Yosmiling plays outside her mother’s home with her cousin in Boaco, Nicaragua. Boaco’s hillside setting divides the city into Upper and Lower Boaco. (Sarah Kramer/Medill)