demand for Brigadistas trained in first aid and acute emergency care. By July 1984 some 20,000 BAPS had been trained, but the training of Mother--Child Brigadistas had lagged. Training of school and work Brigadistas had yet to begin in earnest. Meanwhile, in some areas of the country, increased civilian and military casualties contributed, in part, to the allocation of more resources to acute than to primary care. In Region II ( Léon-Chinandega) fully 60 percent of the 1983 regional budget went to an acute care hospital (35). Yet, the labor- intensive nature of the primary care program allowed that region to reach 104 percent of its goal of prenatal encounters (35, Table 3.1). The Sub-Division of Education and Popular Communications in Health reported that in 1983, 89.6 and 93 percent of children were vaccinated against polio in two campaigns and 87 percent in an anti-measles vaccination program (36).
The undeclared war of the United States against Nicaragua had created some 120,600 internal refugees by May of 1984 (37) and absorbed $66 million in relief and relocation costs (37, p. 9, Table 3). By mid-1984 the damages inflicted on the health infrastructure by the former Somoza Guardsmen amounted to $1 million (37, p. 12). Twenty health centers had been closed in the Special Zone of North Zelaya and in Region I (Esteli) near the Honduran border (37, pp. 12-13). On the other hand, the popular health model is proving its vitality even in the face of these difficult circumstances. A Brigadista from Cinco Pinos near the border with Honduras was going house to house as part of his vaccination schedule. Several families in one isolated hamlet were especially grateful, remarking that it was the first time they had ever been visited by a health worker. The Brigadista then learned that he had strayed into Honduras.
In July 1984 there was an outbreak of polio in Honduras. The Honduran Ministry of Health accepted an initial 50,000 doses of oral vaccine from the Nicaraguan Ministry of Health with another 500,000 to follow. The Hondurans welcomed, as consultants, the Nicaraguan chief epidemiologist and the national director of DECOPS (38).
Several conclusions can be drawn from the discussion. The first concerns the relevance of the conflict between models of primary care delivery to the issue which Segall raises about defining health care systems as "capitalistic," "nationalized" or "socialized" (3). The ascendancy of the Division of Popular Education model of primary care and the role of the Popular Health Councils suggest that the Nicaraguan health system is moving toward a model of primary health care which is decentralized and orientated to local needs, especially in the rural areas. Yet, within the ministry itself there are interests which could direct the health care system more to urban and professional demands. The training of large numbers of Nicaraguan physicians and the presence of many physicians in Nicaragua from other countries suggest that a medical