A year of COVID-19 in El Salvador

On March 11, 2020, the president of El Salvador, Nayib Bukele issued his first emergency decree to respond to the emerging COVID-19 pandemic.   This week Thursday, exactly one year later, El Salvador received its second shipment of vaccines and finally plans to partially reopen schools closed by that first decree.  Today we look back at the past year with its lockdowns and quarantines, its conflicts among branches of government, and the ups and downs of a pandemic which still afflicts the country.

That first executive decree on March 11 also prohibited the entry into El Salvador of anyone who is not a Salvadoran citizen or permanent resident, effective that same day. Any Salvadoran or resident who returned to the country following the decree was subject to a thirty day quarantine, which did not depend on the country from which the person came or whether the person was exhibiting symptoms of COVID-19.

The decree suspended classes in all public and private schools and universities. Gatherings of more than 500 people were prohibited by the March 11 decree.

The lockdown

Ten days later on March 21, Bukele ordered a strict lockdown of the country confining everyone to their homes except certain essential workers.  On May 5, that lockdown was tightened with only one person per household allowed to go out to buy food, medicine, or to bank, and only twice per week depending on the person’s identity card number.  In a country where 40% or more of people work in the informal economy, and don't eat if they don't go out to work, the lockdown was painful.  Some families resorted to waving white flags by the street to show there was a household without food.

President Bukele at a press conference

At one point, Bukele sent troops to the coastal town of Puerto La Libertad to lock it down and enforce a total quarantine after he was angered by persons being found in the streets. In a tweet, he ordered the city to be cordoned off by the military with no one allowed to enter or leave. Residents were confined to their houses without permission to leave even to buy food or medicine. The military blocked all access to the city, and patrolled it wearing masks and toting semi-automatic weapons.

Contention centers

One of the most controversial parts of the early lockdown phase was the use of “contention centers.”  The contention centers held persons who entered the country from abroad, or persons who were found to be away from their homes in violation of the lockdown order.  Ultimately almost 17,000 persons spent time confined in the centers because they entered the country from abroad or for being found out in public in violation of the lockdown orders.

The confinement of people who had no symptoms of disease for 30 days under guard, often without timely COVID-19 tests or delivery of results raised numerous questions of what level of violation of human rights could be tolerated in the name of slowing the pandemic. Especially in the early days, the conditions in the contention centers were poor, although gradually the government contracted the use of hotels around the country for this purpose.  El Salvador’s Supreme Judicial Court would ultimately prohibit the use of contention centers for people who exhibited no risk of contagion and had not received due process.

Los varados   

On March 17, Bukele ordered the international airport closed to arriving passenger flights. No exceptions were made for Salvadoran citizens or residents of El Salvador caught outside of the country on that date to allow them to return.  Hundreds of Salvadorans were stranded outside of the country, “los varados” -- the stranded ones, often without resources for lodging, clothing, etc.  There were countless stories of people who had been out of the country with a suitcase for only a week or 10 days, only to find themselves without a way to come home.  The government would only gradually start repatriation flights on May 11 after people had been stranded for two months, but the process would stretch on for months longer for some who had been marooned in foreign countries around the world.   

Confrontation with other branches of government

On April 15, Bukele went on a twitter rampage to declare that his government would not comply with rulings of the Constitutional Chamber of El Salvador's Supreme Judicial Court. The conflict arose out of a series of rulings by the Chamber which rejected extremes of Bukele's measures against the novel coronavirus, especially the domestic quarantine, or stay at home order.

The Chamber ruled that Bukele exceeded his authority as he has been ruling by decree without laws passed by the Legislative Assembly supporting those actions.  The Chamber declared that persons found outside their houses cannot be arrested and carried off to quarantine centers if they are not symptomatic; the police cannot impound cars of persons who violated the quarantine; the government must have a plan to allow Salvadorans stranded abroad to return home.

One hundred days into the pandemic's spread through El Salvador, the complete breakdown of cooperation between the executive and legislative branches of government continued.  President Bukele continued to rule by decrees which vary from laws passed by the Assembly, and although the Assembly passed laws to address the pandemic, Bukele vetoed those laws because they do not contain all the provisions which he demands.  The Assembly then overrode the vetoes, but when a veto is based on Bukele's claim that the laws violate the Constitution, the Constitutional Chamber then must rule on whether the law can go into effect.

Bukele showed little interest in working with the Legislative Assembly throughout the pandemic, instead berating them on Twitter and in Facebook addresses, asserting at one point that the other branches of government were guilty of genocide.

Economic relief

The first attempt at providing economic relief to Salvadorans impacted by the shutdown of the country was through a $300 cash payment per household. This process had enormous challenges as websites and call centers crashed, and desperate people crowded together in long lines at banks and government offices. The effort was improvised, and it showed. In addition, the government suspended Salvadorans' obligations to make many kinds of utility and loan payments during the crisis.   

Soldiers delivering food packets

Subsequently, the government turned to delivering packets of food supplies to households across the country as a relief measure. A year end poll by foundation FundaUngo found that 95% of respondents in the country said their household had received food packets in this way.  In many parts of the country, the government has been using the military to deliver the food relief.

Hospital El Salvador

One of the Bukele’s high profile initiatives was to convert the convention center in San Salvador into a new large new hospital dedicated to treating COVID-19 patients.   Although Bukele has consistently overstated the capacity of this hospital in terms of beds and ICU units, the hospital did significantly expand El Salvador’s capacity to treat COVID patients needing hospitalization.   The government published a description of Hospital El Salvador in the medical journal The Lancet.   A response printed in the medical journal pointed out the lack of data to allow assessment of the effectiveness of this response to the pandemic. 

Hospital El Salvador

There is a valid question whether El Salvador needed a facility as large as Hospital El Salvador solely devoted to treating COVID-19 patients.   Although the government does not disclose patient counts, anecdotally it appears that the facility has never been close to its capacity. While one can say that it is a benefit to have a facility that could theoretically handle a large surge in COVID-19 in El Salvador, one could also say that resources are better used on public health measures to prevent a surge and to improve other health metrics throughout the country.  

The course of the pandemic   

By the middle of June, the stay at home quarantine order was no longer in effect.   Persons could leave their homes, but most businesses, churches, schools and gathering spots were still not open.  On June 15, the government announced it had reached a plan with the business sector to gradually reopen the economy in phases.  But with daily cases and hospitalizations surging, Bukele pushed out the start time of the plan until July.  

Cadavers line a hospital hallway at peak of first wave

At the beginning of July, the large wave of COVID-19 cases was hitting its peak.  Reports in the press described the hospital system as "collapsed," and Hospital El Salvador was only omitting a few dozen patients in its early weeks.  Shortly after Hospital El Salvador came online, the great mid-year surge of cases in El Salvador suddenly declined starting the second week of August.   Ironically this was exactly the opposite of what Nayib Bukele was asserting at the time.  Bukele was arguing for a strict two week re-lockdown as cases were surging.   No lockdown was imposed, but in the government statistics, starting August 10, daily cases suddenly started to drop. 

The steep decline from the late July/early August peak continued until the middle of September. On September 19, the airport began reopening to passenger flights and was fully open by October 5, with arriving passengers required to show proof of a negative COVID test. From mid-September onward, daily cases gradually moved higher in a steady fashion towards the end of the year as Salvadorans returned to work and shopping and then gathered with family and friends for Christmas and year end festivities.   This second wave peaked in the middle of January, but the country was better able to handle the load of cases and hospitalizations than in mid-2020.   Case rates have been falling steadily since mid-January through today.        

 Undercounting cases and deaths and refusal to be transparent  

The government displays the progress of the pandemic at the website COVID19.gob.sv.  The website has an important limitation, however.   It only depicts the number of infections and deaths for persons who have received a COVID-19 test administered by the Ministry of Health and tested positive.  Since May 19, the government has been producing results for approximately 2500 tests each day.  The statistics do not include test results from tests performed by private labs, who were allowed to start testing in the latter half of 2020.        

As a consequence, the official number of cases is useful to indicate trends by showing the percentage of 2500 tests which are positive on any given day and whether that percentage is increasing or decreasing.  But it does not provide a tool for knowing the total number of infections.  

Similarly, the death toll only includes persons who had a positive COVID test before they died.   Even if a person was in the hospital being treated for COVID when they passed, if there had not been a test performed that person is not included in the official statistics.   Numerous questions have been raised about how to determine mortality rates.  A survey of municipalities in El Salvador indicated they had buried 5,563 persons in their cemeteries during 2020 suspected of having COVID-19, but for the same period the national government only listed 1785 deaths.   Minister of Health Francisco Alabi has acknowledged there has been an undercounting but refuses to estimate by how much.

The government refuses to provide greater details about the progress of the pandemic and withholds information such as who is tested and the locations of testing.   Similarly, information on the number of people entered into the COVID facility at Hospital El Salvador and their mortality rate is not released.   As such, academics and public health experts outside of the government are unable to assess and assist with the government’s planning.     

Corruption in government contracting 

As was true the world over, the Salvadoran government suddenly needed to find medical and other supplies in the spring to address the pandemic.   Personal protective equipment (“PPE”), ventilators, alcohol gel, masks, supplies for food kits, all needed to be acquired and quickly.   With tens of millions of dollars in purchases needed in many sectors, the possibilities for fraud and corruption were widespread.   

Investigators from the office of the Attorney General of El Salvador ("FGR" for its initials in Spanish) raided the offices of various government ministries between November 9 and 12 to gather documents and computer files. The investigators held a judicial order in an investigation of possible corruption in pandemic-related contracting by the government.   The transactions in question total as much as $155 million according to reporting by RevistaFactum.    Reportedly two thirds of the contracts used to purchase medical supplies during the pandemic are under investigation.

While the Ministry of Health was the primary focus, investigators also showed up at the Ministry of the Treasury, the Ministry of Agriculture and the water authority ANDA, as well as several businesses tied to government officials or their families. 

 Status of the pandemic today

In November, Bukele announced the signing of a contract to purchase 2 million doses of Astra-Zeneca vaccine.  The first batch of 20,000 doses of a COVID-19 vaccine arrived to great fanfare in the country on February 17.   These doses were purchased from AstraZeneca and manufactured in India.  A second shipment arrived on March 11, 2021 acquired through the UN sponsored COVAX global initiative.  

 But the pandemic continues to claim lives in El Salvador.  25.4% of Salvadorans indicated that they or someone in their household had contracted COVID-19 during 2020 according to the FundaUngo poll

 The government currently displays this map showing levels or risk of community transmission of the disease: 

Map from COVID19.gob.sv

Assessing El Salvador’s response

After one year, the public’s approval of Bukele’s management of the pandemic remains very high.  A CID-Gallup poll released by the government showed 98% of respondents rating Bukele’s handling of the crisis very good (88%) or good (10%).   An independent poll by the FundaUngo Foundation showed 88% of Salvadorans rating the president’s actions good or very good.    

The government of Nayib Bukele should probably get a mixed grade for its response to the pandemic.   In the early months of the pandemic, through the middle of August, there were many stumbles.  The contention centers were arbitrary, deprived people of their freedom for weeks with no medical necessity (and potentially exposing them to greater risk of contracting the virus). The three branches of government were incapable of working together. Thousands of people were stranded outside of the country.

Those conflicts largely ended as the economy re-opened.  The contention centers have been closed and persons with symptoms are told to self-quarantine and given support to do so.   Salvadorans and foreigners can arrive through the international airport upon showing a negative COVID test.  The economy has reopened even to the point where there are fans in the stands for soccer matches.  Only schools and universities remain closed, although there are  plans to reopen on a semi-in-person basis on April 6.        

The most favorable aspect of El Salvador's response to the pandemic, and for which Nayib Bukele deserves credit, is that public health messaging never became a political issue.  El Salvador avoided the tragedies created by the horrible messaging of Trump in the US, Lopez Obrador in Mexico and Bolsonaro in Brazil.   In El Salvador, lockdowns and contention centers were an enormous political issue, but this was never the case for the basics of personal preventive measures.  Salvadorans received a uniform message from the president on down to the local level, of the need to wear a mask, wash your hands, and exercise social distancing.  Temperature checks, alcohol gel, and other measures are part of entering any enclosed building.   And while Salvadorans, living in the most densely populated country in the Americas, have definitely been challenged by social distancing, mask wearing is accepted and widespread.  

Still, it is not possible to verify Bukele's claim that he has done the best job managing the pandemic in Latin America.   His government hides too much of the data to assess the credibility to this assertion.   Just the fact that we do not know the mortality rate of people who are admitted to the prize Hospital El Salvador should make us pause and ask more questions.  We cannot tell if the official death toll is understated by 100, 200 or 300%.

The pandemic is far from over in El Salvador. More people are dying, and the government's 2500 COVID tests are still identifying more than 130 new cases each day.  Rich countries in the world will insist on vaccinating their citizens before El Salvador sees significant quantities of vaccine.   While El Salvador is currently  on a downward trajectory in cases following its second wave of cases, that could easily reverse. 

Recent elections and public opinion polling shows large majorities of Salvadoran listen to Nayib Bukele.  He can keep El Salvador on the right path with his public health messaging and promotion of vaccine use as soon as it arrives.