What COVID-19 is Teaching Us About Healthcare Around the World

The authors perform surgery in a Ugandan hospital. Photo courtesy Tamara Fitzgerald

By Tamara Fitzgerald and Danielle Ellis

At this time last year, our binational surgical team was removing a cancerous tumor from a four-year-old child in Kampala, Uganda. Seemingly angry that we had threatened its existence, this tumor was oozing blood from every surface. In the U.S., we would have handled this by continuing the operation and giving the child blood products, followed by a stay in the intensive care unit.

In Uganda, the single unit of blood we had reserved for this patient had been given to another and there was no pediatric ICU for recovery. To make matters worse, there was a problem with the ventilator — the oxygen tank was empty and could not be exchanged because the bolt was stripped. At least ten maintenance men flooded into the operating room with pliers and wrenches and saws to try to loosen the bolt. It wouldn’t budge.

The child was steadily losing blood, and the tumor was only halfway out. Our team began to discuss if we should stop the operation. This would leave the tumor in place but avoid additional blood loss. Stella, our Ugandan surgical colleague, met our eyes from across the operating table and said, “If we do not remove this tumor, nobody else is going to try later and this patient will die.”

She was right, of course. Given the limited healthcare resources available to Ugandans, most of those who need surgery don’t get even one chance at it. So we continued with the procedure. One of the maintenance men was able to loosen the empty oxygen tank and swap in a full one. We controlled the bleeding and a family member donated a unit of blood.

Our patient spent the night in the pediatric ward, crammed in with 15 other patients and their caregivers in an area the size of a single-patient room in many U.S. hospitals. Fortunately, the child beat the odds and made a full recovery. But when healthcare providers are forced to improvise with limited resources, we are not always so lucky.

A crowded pediatric ward in a Ugandan hospital. Photo courtesy Tamara Fitzgerald

During the COVID-19 pandemic, we are finding that the U.S. is “under-resourced” — a term that we often assign to low-income countries. Doctors and nurses are struggling to provide care with shortages of personal protective equipment, ventilators, essential medicines, and other medical supplies.

The difference is that in the U.S., these shortages are likely temporary, whereas they are the everyday reality in low-income countries. In many parts of the world, nine in 10 people cannot access basic surgical care. We have seen three to four children occupy one hospital bed because there is not enough space. Family members provide nursing care because there are not enough nurses.

As we confront the overwhelming stresses of this pandemic, we should remember that for much of the world, this is normal. This experience can be instructive, because there are certainly things to learn from the challenges of delivering healthcare when resources are scarce. But ultimately, it should be a wake-up call to us all that these conditions should not be anyone’s daily reality.

This is what scarcity feels like

In the U.S., waste accounts for 30% of our country’s healthcare costs. Most surgical teams are generally unaware of the cost of supplies; thus many supplies are opened, but never used. It is standard to dispose of three large bags of medical waste after a surgical procedure.

Surgery in Uganda, by contrast, generates only about as much waste as fits in a shoebox. There, as in many low-income countries, equipment considered disposable in the U.S. is sterilized and reused, including endotracheal tubes, gloves, surgical gowns and cautery pencils.

As practitioners in the U.S. consider both the cost and value of personal protective equipment and other items in short supply, hospitals are now sterilizing and reusing them. In the future, when our medical resources are no longer in shortage, many of us will have a greater awareness that they are far from infinite or free. These supplies will continue to be desperately needed and valued by healthcare systems elsewhere. This realization should catalyze our nation to reduce healthcare waste, and to spend that money on improving access to care — both in our country and around the world.

When the technology we need doesn’t exist

In low-income countries, innovation is an integral part of providing healthcare. Low cost alternatives have been developed in lieu of expensive treatments. Medical equipment is often jury-rigged when a broken part can’t be replaced or to expand its usefulness, such as when a single ventilator is modified to support two patients.

We’ve seen similar innovation in the U.S. response to Covid-19. Pharmaceutical companies, universities, and government agencies are collaborating to develop a Covid-19 vaccine, non-medical corporations have designed ventilators, and students have devised novel ways to make face masks.

Post-pandemic, we should channel our ingenuity to make our technology more efficient and develop innovations that address the needs of low-income countries.

Drs. Tamara Fitzgerald, left, and Danielle Ellis. Photo courtesy Tamara Fitzgerald

This is what well-intentioned, uncoordinated help feels like

During the pandemic, a 1,000-bed Navy hospital ship was sent to Manhattan to ease pressure on New York City hospitals as cases surged. But only 20 patients were cared for on the ship. The captain was given orders to treat only patients with non-Covid conditions, while the health systems on the ground were completely overwhelmed with needs of patients suffering from Covid-19. If the local health systems had been asked where they most needed help, they likely would have said the greatest need was treating patients with Covid-19.

This mismatch of resources and needs is all too familiar to healthcare providers in low-income countries. For decades, missions and military endeavors have arrived on their shores and airstrips to provide care. These medical brigades have been well-intentioned, and many patients have benefitted from this kind of outreach. However, many times these brigades leave behind patients with surgical complications that local doctors are left to manage.

True partnership requires asking local stakeholders what they need. If we were to ask these countries how we can help, they may favor medical and surgical training of their citizens to strengthen their own health systems and access to care. Going forward, we should commit to sustained partnerships with our colleagues in low-income countries to improve the health systems of the world — including our own.

This is what it means to move forward

When we think back to the child in Uganda, we are reminded of how health systems affect the lives of individuals. Whenever we saw the boy’s mother after that, she would hug us and say, “Thank you. Thank you.” She was able to leave the hospital with her son.

During this pandemic, not everyone in the U.S. has left the hospital with their loved ones. As we emerge, let us remember that life under these terms was not okay for us, and it is not okay for the rest of the world going forward. This pandemic has shown that the health of all people around the world is deeply interconnected. So too are our health systems. We can improve health systems around the world through appropriate allocation of resources, investment in sustainable technologies and continued partnerships with our colleagues in low-income countries. Now is the time to invest in global health initiatives. No day, anywhere, should feel like a pandemic.

Tamara Fitzgerald is an assistant professor of pediatric surgery and global health at Duke University. Danielle Ellis holds an M.D. from the University of North Carolina-Chapel Hill and is an incoming general surgery resident at the Massachusetts General Hospital.

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