As Wealthy Countries Flatten the Curve, COVID-19 Could Flatten the Healthcare Workforce in Poorer Countries

In many low- and middle-income countries, a new generation of healthcare workers is leading their country’s response to COVID-19. Many are the distinguished alumni of training programs funded by the US and other high-income countries. Through our careers devoted to health system strengthening in places like Haiti, Rwanda, and Peru, many of these are our friends and colleagues with whom we’ve celebrated gains achieved in health education, care delivery, and improvements in overall health indices. Now, these colleagues are reporting critical shortages of masks, gloves, and gowns, even in the earliest stages of their own expanding COVID-19 epidemics.

As high-income countries with significant global health budgets scramble to source personal protective equipment (PPE) for their own workforces, they risk leaving similar healthcare workers in poorer countries in dire straits. If they cannot be properly protected as they respond to the pandemic, the consequences will be catastrophic. The global community must urgently intervene to protect this health workforce as well as the gains it has achieved.

In the last decade, donor governments, nongovernmental organizations, and academic institutions have financed partnerships to strengthen the health workforce in many LMICs. In 2018, nearly $39 billion was spent on global health programs, with increasing emphasis on addressing deficits in human resources for health in LMICs. Between 2010 and 2015, the US Medical Education Partnership Initiative invested $130 million in training all levels of the Sub-Saharan African healthcare workforce. The ambitious Human Resources for Health Program in Rwanda brought together more than 25 US academic institutions to help rebuild the Rwandan health education system and increase the numbers of physicians and nurses by 50% or more. Rwanda and other LMICs have also seen a proliferation of training partnerships and programs led by nongovernmental organizations, universities, and other groups.

These efforts have expanded the ranks of healthcare personnel and contributed to sustained gains across a range of health priorities, including the control and treatment of infectious disease. Yet, despite these advances, many LMICs lack the capacity to cope with the surge of critical care patients that have overwhelmed even the health systems of high-income countries. And experience tells us that the greatest risk to the population in LMICs is not the lack of ventilators (which has become a focal point in higher income settings), but rather the potential devastation of their national healthcare workforces as a consequence of COVID-19.

Data from the cities and countries first hit by the pandemic show that healthcare workers face high rates of infection with COVID-19. More than 3,300 healthcare workers in China were infected, with more than 22 deaths. 20% of Italy’s infections were in healthcare workers, to date and over 100 of them have died. Moreover, reports suggest that healthcare workers are susceptible to more severe forms of the disease.

Critical shortages have led to calls on the American government to invoke wartime production powers and have set off a global procurement frenzy for respirators, diagnostics, and other essential supplies. LMICs are now being shut out of the global market for PPE items that have seen a twenty-fold increase in price. The latest blow against their attempts to procure PPE came in the form of a draft presidential memorandum that would limit US foreign aid spending on PPE unless it is produced in that country.

Without access to PPE for their frontline healthcare workers, poorer countries, especially those with fragile health systems, will sustain far more devastating losses than their counterparts in higher resource settings. One of the hardest learned lessons from the 2014 Ebola epidemic in West Africa was how in just over three months, Liberia lost 8% and Sierra Leone 7% of their critically small healthcare workforces due to contracting Ebola while caring for their patients.[10] This led to estimated losses of over 4000 lives per year from maternal mortality in the three most affected countries and set back much of the progress gained across a region recovering from prolonged civil conflicts.

Multiplied across other disease areas and geographic regions, loss of the health workforce will result in increased mortality rates far beyond the current pandemic. Donor countries and institutions must take urgent action to ensure equitable access to PPE. Funding must be available for critical supplies, and donor countries must act to ensure the stability of supply chains for PPE and other essentials. Learning the lessons from the Ebola outbreak means we need not be condemned to repeat them.

Dr. Adams and Ms. Sosin are the Director and Program Director for the Center for Global Health Equity at Dartmouth.