James Chan @jameschanuk
Global Emergency Care Fellow, ST5 in Emergency Medicine, Leeds Teaching Hospitals NHS Trust
Anisa Jafar @EmergeMedGlobal
NIHR Academic Lecturer and ST5 in Emergency Medicine, University of Manchester/Manchester Royal Infirmary
There are a number of sound-bytes which have been cropping up recently such as “in this together” and “One world: together at home” alongside COVID-19. The irony of course is that there is no more of a universal “seat at the table” than there ever was prior to the pandemic. In fact, it would be fair to say that for some people, who beforehand might at least have been a few proverbial towns away from said “table”, now find themselves (proverbially of course) on a separate continent1.
In emergency care we, along with our colleagues in the community, have the unique speciality-privilege of seeing the unfettered outside world at our front door2. We see the sharp end of social inequality sitting in our waiting rooms as we manage its direct and indirect consequences on both physical and mental health.
These inequalities are stark enough in high-income countries (HICs), however the situation in low-middle income countries (LMICs) and other weak health systems is even more urgent3. There are many specialist resources (we’ve tried to link to as many as we can in this blog e.g AFEM, IFEM, LSHTM, LSTM, WHO, Africa CDC, Irish Global Health Network) where you can read in more detail about what is going on across the world and more specifically how COVID-19 is being managed in the global south. What we’re going to try to do is highlight just a few international insights to begin with, follow up with some ways in which it is in fact the LMICs who have afforded the UK some benefit in managing COVID-19 and then conclude with some food for thought as to “what next?” when it comes to working with those experiencing the very harshest of realities.
Further afield: a window into COVID-19
Tuning into the traditional media outlets in the UK would have us believe that the only difference between our shores and the rest of the world is how strictly the same version of lockdown is being enforced and comparatively how far along the lockdown continuum we have progressed. In fact there are vast differences, because there are many parts of the world with a greater degree of societal fragility. Hand-in-hand with this come poorly-resourced health systems that remain inaccessible to many. Already they are burdened with challenges such as Ebola, HIV, tuberculosis (TB) and, malaria, and now they face disruption of vital public health programmes4. COVID-19 may yet trigger a humanitarian crisis on an unprecedented scale as a result of the widespread socioeconomic collapse, adversely affecting the most vulnerable populations5, especially those already affected by war5,6, food insecurity6,7 and climate breakdown6.
As the health systems in LMICs turn to face COVID-19, with examples of non-governmental organisations taking time to respond with specific guidance, already scarce resources will be diverted from the multitude of challenges which continue to threaten the global community. Certainly the new kid on the respiratory infection block has quickly overshadowed its long-standing neglected cousin, TB8. Notably there has been a big increase in critical care capacity in Europe and as we see signs of the spread of the pandemic to Africa, we can understand why many would feel that donating ventilators to a continent where there are 5 ICU beds per million people would be a welcome response. However, we must remember that current data suggests a UK mortality of just under two-thirds of those with COVID-19 receiving advanced airway support9. Given that there is an extreme shortage of healthcare professionals with the appropriate skills across Africa, it is quite clear that higher-tech interventions will not play as prominent a role in LMICs compared to HICs. Context-appropriate public health measures are primarily what is needed.
Social and health inequalities change the emphasis of outbreak control measures depending where you sit along the scale of privilege. The poorest may face difficulties in acquiring hygiene products and PPE but more pressingly in accessing simple soap and water. Those that subsist and depend on street or market trading, or rely on precarious employment; social distancing becomes a luxury they can ill-afford. For those who face financial barriers to healthcare, government subsidies have been used in some places to ensure healthcare remains accessible10. There simply may not be capacity for this to be an option in many LMICs.
COVID-19 is not the only infectious disease that Brazil faces11. Within an already deeply deprived population, migration patterns and lowered rates of vaccination have seen a rise in measles, whilst endemic vector-borne disease continues to add to a heavy burden of ill health.
The highly controversial attitude toward COVID-19 displayed by President Jair Bolsonaro in his disregard for lockdown and making light of the pandemic, has compounded a volatile scenario where the social and health impacts are deeply intertwined. Brazil’s indigenous peoples face the ‘multiple’ jeopardy of self-imposed lockdown to prevent what would be catastrophic community spread, which then puts their community at further risk as it exposes them to ongoing battles over territory which will be taken advantage of12. The poorest inhabitants of the densely-populated favelas face rapid spread of COVID-19 which in the main, has been imported by their rich counterparts who could afford international travel13.
The Democratic Republic of the Congo (DRC)
The first case of COVID-19 was confirmed in DRC on 10th March 202014, almost a month before the latest Ebola outbreak was to be declared over, and which continues to transmit15. Experience has taught that surveillance and testing is vital for bringing Ebola under control. With only 100 tests a day for 80 million people, and a 1 week wait time for results16, COVID-19 surveillance in DRC will be even more challenging than in the UK where there still isn’t any mass surveillance. The dependence on cross border traffic for day-to-day supplies and for transit of humanitarian staff is making the situation far worse now that borders are closed16.
In a country prone to natural disasters, with already poor healthcare infrastructure, and notably inadequate capacity to mitigate further health system pressures; COVID-19 will pose an unprecedented challenge17. Bordered by China and Iran, with a great deal of cross-border movement in the early days of the pandemic, it comes as no surprise that the scale of spread in Pakistan will likely rival those countries worst affected18. The international community have already highlighted overcrowded prisons19, which, much like care homes in the UK, will be dangerous reservoirs for spreading infection.
Urban informal settlements/slums pose a specific challenge in the generic national planning to control and manage COVID-19 in Kenya20. The complexity of approaching and addressing the pandemic in such settings will rely upon existing knowledge and understanding of pre-existing health challenges within slums21, as well as learning from past outbreaks. Health in this context will require specific medical guidance, however it simply cannot be addressed without direct community engagement and policies which go hand in hand with addressing social need as well as the glaring paucity of basic nutrition, water and sanitation.
Every country will share some common experiences of the pandemic, regardless of socio-demographics, however there are certain specific circumstances which will render a population more vulnerable. It has been noted in South Africa that the unique combination of already having experienced the trauma of apartheid restriction, the stigma of highly prevalent HIV, increased avoidance of seeking healthcare and an increased rate of post-lockdown domestic violence, will render HIV positive older females at a specifically higher risk of mental ill health22. Then add into the mix informal settlements, where some of those most vulnerable live in such close quarters that the requirements of social distancing during lockdown would render it impossible to leave home23. Even within sub-Saharan Africa’s potentially strongest country when it comes to tackling COVID-19, these and a multitude of other deep running societal and healthcare challenges have been highlighted by this ongoing crisis24.
One country who did not escape the mainstream media gaze, especially at the beginning of the lock-down period has been India. There has been widespread criticism of the way in which social distancing measures were hastily implemented: mass exit from densely populated cities into rural areas have seen informal workers without the means to afford food25. A huge 1.3 billion country with enormous health inequalities and simmering cultural and religious tensions has seen an upsurge in misinformation26, attacks against healthcare workers27, COVID-19 stigma28 and deepening ethnic divides.
Probably one of the most striking examples of the way in which geopolitics directly impacts national healthcare has been front and centre of the COVID-19 pandemic. Economic sanctions on Iran have directly impeded the country’s ability to manage the healthcare of its population29. Despite calls from the international community to recognise the need to support all countries in this pandemic, cynically it may be the notion that a nidus of uncontrolled disease in any country poses a threat beyond its borders, which eventually forces a way out of the sanctions30.
Less visible (in the UK media at least), is the current situation in Iraq. Alex Dunne (Humanitarian Affairs Officer for Médecins Sans Frontières (MSF) in Iraq) reflects that whilst at the time of writing, cases remain relatively low and transmission is slow, there are three major concerns facing the country with respect to COVID-19. Firstly the high volume of Iraqi internally displaced persons and Syrian refugees within camps – as well as those in informal settlements and urban centres – represent a dangerously high risk for outbreaks which would easily overwhelm the repurposed COVID-19 public health care capacity and lead to high mortality. Secondly, demonstrating direct and devastating economic impacts: low oil prices have already resulted in a monthly federal budget shortfall of $2 billion31 – this will most likely impact on public spending, including that on healthcare services. Finally, bureaucratic impediments facing humanitarian organisations globally, nationally and locally will directly impact on the supply chain of medications, personal protective equipment (PPE) and indeed the healthcare workers themselves32,33.
International overseas work: reversing the benefit
Those who have had experience in resource-poor healthcare environments frequently report the benefits arising for healthcare practitioners and health systems in HICs34. This benefit is becoming more widely recognised in the UK NHS. Therefore it may come as no surprise that the COVID-19 pandemic has brought this crossover learning into sharp focus.
UK healthcare professionals use Ebola experience to bolster response to COVID-19
Hooi-Ling Harrison is a consultant in emergency medicine at Princess Royal University Hospital in London. She worked in the Connaught Hospital isolation unit in Freetown (Sierra Leone) during the 2014 Ebola outbreak. Richard Lowsby similarly worked in Freetown in 2015 in both an isolation unit and a government referral hospital emergency department. He now works as a consultant in emergency medicine at Mid-Cheshire Hospitals Foundation Trust. Cécile Gaunt, currently a palliative care nurse in the UK, was an MSF Paediatric A&E Supervisor in post-Ebola Monrovia, Liberia in 2015.
They reflect on how their experience managing Ebola has directly influenced their preparation for COVID-19 within their current UK hospitals:
- Screening: when managing Ebola, case definitions were used to screen patients and so adopting this approach early and being responsive to Public Health England updates allowed case streaming to a respiratory department from the outset and reduced the chance of potentially positive cases ending up elsewhere in the hospital.
- Personal protective equipment: experience of donning and doffing was invaluable in being able to teach colleagues the correct procedure and develop them into experts – but also small key things to remember like using the buddy system, avoiding face touching and ensuring adequate breaks were established early. Also remembering to put ‘PPE before the patient’ which, at times, such as in cardiac arrest, is a tough ethical decision however reminding healthcare staff that in order to be well enough to care for others, they must remain healthy.
- Multi-professional team approach: the Ebola response taught the value of every member of the team and daily working involved everyone from domestic colleagues, technicians, oxygen engineers through to community colleagues. Again, within the COVID-19 response, from the beginning we have appreciated the whole team’s contribution to the response throughout our approach and planning.
- Data management: instead of recognising a few weeks into the COVID-19 response that data collection would need to change focus, from the outset, experience in Ebola drew attention to such things as highlighting the impact on non-COVID-19 attendances and measuring triage effectiveness.
- Impact on health-care workers: Ebola saw many healthcare workers lose their lives in the line of duty and along with that came a great deal of anxiety and sadness. Quarantine and the separation of families and communities had an adverse effect on people’s mental health. Pre-empting these eventualities, whilst never making it easier, has allowed support systems and coping strategies to be explored from the first moment.
Richard, considering the benefit of his previous Ebola experience, reflects:
“I have no doubt that early recognition [of this] at my Trust has saved lives”.Dr Richard Lowsby, consultant in emergency medicine, Mid-Cheshire Hospitals Foundation Trust
These are just a handful of insights of the many other healthcare professionals, who have not only cared for patients with Ebola, but also SARS and MERS and whose experience has directly influenced the UK-wide approach even at policy level.
Broader lessons for the UK from the Ebola outbreaks
Lessons are being learned by the humanitarian sector reflecting on their own response to the Ebola outbreaks in West Africa in 2014 and in The Democratic Republic of Congo in 201835. Unlike the UK context, many of the communities that were affected by Ebola did not have an inherent trust of healthcare providers which led to widespread suspicion and disengagement, and ultimately greater transmission. Misinformation and dangerous rumours about COVID-19, combined with existing stigma will make the lives of those affected more miserable16 and the epidemic more difficult to control. Community engagement is vital in ensuring control can be established and maintained. This is something which will be integral to the UK in the coming weeks as we ease lockdown.
We are reminded that COVID-19 is not merely an isolated health emergency. Too narrow a focus on one disease risks disruption and neglect of other health programmes and systems36: the ramifications of this are potentially enormous. As the UK public were told to ‘Stay at Home, Protect the NHS, Save Lives’, we have seen a drop in emergency department attendances, sparking concern that many are avoiding seeking help for their serious health problems37. A comparison can be made with the Ebola outbreak in Sierra Leone where people sought to avoid healthcare facilities which were associated with Ebola infection, leading to a fall in engagement of community healthcare programmes38. Equally, in countries where malaria is endemic, the focus shift to COVID-19 with similar symptomatology may see an increasing burden of morbidity and mortality from missed early cases of malaria39. There is a strong lesson here that engagement with the population is needed to ensure an appropriate use of health services for both acute and chronic illness40, and to help dispel any dangerous rumours that could hamper outbreak control efforts.
Further learning from the wider humanitarian setting
A group of UK healthcare workers, several in emergency medicine, who have NHS experience as well as experience in resource-constrained settings have come together since the beginning of the COVID-19 pandemic to form Frontline Collaboration Against COVID-19. They have pooled resources and shared expertise with a view to bringing some of this crossover learning together. They have directly briefed the Health and Social Care committee as to the need for this shared learning41. Specific guidance documents have for example focused on safe reuse of PPE, support for those bereaved during a pandemic and template situation reports for hospital use which have been adapted from field hospital settings. Even at central government level there has been some recognition of the value of field experience, given that many of the healthcare professionals involved in managing and developing the NHS Nightingale hospitals have extensive experience in humanitarian response. The natural next step for the UK will of course be the transition from crisis to steady-state. Business as usual, especially for our emergency departments, is a long way off, however, some level of routine functioning will be paramount to meet the healthcare needs of our population. This step-change is part and parcel of humanitarian response and can be illustrated in one way by the disaster management cycle42. There are many models to adopt, and the humanitarian and development sector are potential sources of guidance.
What COVID-19 means for humanitarian work
International volunteers: where are they now?
It has long been the very appropriate narrative of global health that encouraging “voluntourism” can perpetuate inequity43. Along the spectrum of this is the concept of healthcare professionals spending time committing to short international projects. However, the current status quo wherein LMICs rely upon HICs, as unsatisfactory as it may be in exposing fragile health systems, is unfortunately what some communities have come to rely upon. So we find ourselves in a rather desperate situation when it comes to COVID-19. Consider all those HIC healthcare professionals who cannot travel to low-resource settings; all those who were working in such settings and who left before lockdown set in; and all those healthcare workers who have become unwell because of inadequate PPE in the face of rapidly spreading disease. And so with that uncomfortable feeling of “it’s not right, but it’s ok” we may quickly find ourselves as a global community in desperate need of skilled international ‘voluntourists’ to not only get through the pandemic, but to somehow pull the healthcare provision back from near-collapse. We might compare this to the compromising position akin to sending an alcoholic home to drink. It is never the real solution, but oftentimes it is all we can offer to avoid the even more deleterious outcome of acute withdrawal. HIC advocacy for keeping this at the top of the international agenda will become critical as will the maintenance of professional standards in the face of the pandemic emergency44. It would be wholly ethically unacceptable to use this unprecedented situation as an excuse for healthcare practitioners to work at a lower standard, and without scrutiny.
COVID-19 in complex humanitarian settings
Prisons and care homes have been highlighted as dangerous environments in terms of viral spread. What then of refugee camps often forgotten in national planning45? Already overcrowded and under-resourced: COVID-19 equates to a catastrophe. Consider then such camps within the context of civil unrest and political uncertainty: the situation becomes much more challenging46. Cox’s Bazaar is one of the most appropriate examples of this scenario and as the pandemic was taking its hold globally, there was no facility for testing there47. The community, reliant on international aid workers (who, in a cruel twist, are also highly likely to be the vectors of COVID-19 in Cox’s Bazaar), can be offered very little supportive care other than attempts at isolation zones to limit spread48. When we consider complex humanitarian settings, there is one unfortunate advantage of course: outbreaks are nothing new. There are measures which have been adopted in the recent past and there is a body of experience as to what works best and these include very generic approaches which highlight:
- Maintenance of essential health services49
- Access to infection prevention and control, testing and treatment to avoid camps becoming a reservoir49
- Community engagement and trust49
There is one message HICs must both say and hear loud and clear: migrant and refugee health simply must not become an afterthought, it needs to be front and centre46.
Where does UK emergency medicine fit in?
There has been a growing movement within the UK emergency medicine community over the past few years to consolidate engagement in the broad term “global health”. The Royal College of Emergency Medicine (RCEM) has a global emergency medicine committee (GEM) which has been encouraging the development of regional UK global health hubs. One such hub which was in its development stages in the months just prior to the COVID-19 pandemic was the Global Emergency Care Collaborative (GECCo) which seeks to raise the profile of global health within emergency medicine, especially demystifying any barriers to engagement and finding ways for those with an interest to work together. The RCEM GEM committee have highlighted to its members the impact of COVID-19 on LMICs50 and have shared their concerns over future UK support to weaker health systems with the Department for International Development51. Thinking outwardly from the outset of this pandemic, and continuing advocacy for those communities hit hardest will be essential for our work both internationally and nationally. And whilst weak health systems internationally will expose the most vulnerable, such as is being seen in the United States, equally in the UK our most vulnerable will experience COVID-19 the hardest52,53. In April we saw a letter to The Times newspaper with nearly 600 signatories, including the RCEM, to lift charges for overseas migrants, an already disadvantaged group, who otherwise will have even more reason to avoid healthcare.
Jane Stratton is a UK trainee in anaesthetics, she also works as a medico-legal report writer for Freedom From Torture (FFT). Although there have been obvious changes, the UK government continues decision-making over asylum applications and, amidst some controversy, detention centres continue to operate, serving as another potential reservoir of infection54. Therefore Jane’s work continues, however, without the face to face interviewing. She reflects on the heavy toll that social isolation is having on her clients who already often rely upon food banks; may be suffering PTSD, which is likely to be much worse whilst in isolation; and frequently know limited English, making public information about COVID-19 inaccessible:
“Amidst the COVID lockdown, I encountered a FFT client whilst working clinically. I’d spent nine hours with them previously, detailing their experiences, much of which had never before been shared, and yet my ED consultation with a phone interpreter for only a few minutes, starkly reminded me how small a window we ordinarily get into complex lives.”Dr Jane Stratton, anaesthetic trainee, North West England, UK
Now more than ever in our emergency practice we have the opportunity to ease a great deal of invisible suffering: even simple measures such as directing patients to the Doctors of the World multi-lingual resource of up to date COVID-19 information55. Also, recognising both under-use and advocating for local availability and utilisation of interpretation services56 with a view to improving patient experience57. Taking this further, the Australian College of Emergency Medicine’s Global Emergency Care Committee (in conjunction with colleagues in nearby LMICs) have developed a guidance document for LMICs preparing for a COVID-1958. As a speciality we might use this moment in time to reevaluate the shape of our training and how deeply we invest in our global health engagement. We have quite clearly demonstrated the benefits to our own practice and undoubtedly there will be international settings, where having experienced emergency practitioners willing to support local infrastructure, will provide reciprocal benefit.
We recognise there is little by way of “good news” at this stage in the pandemic especially for those with weaker health systems. However there are guidelines, tools and practical steps which we know can make a positive difference. Richard Lowsby sums up where this leaves us:
“There have been some dark moments but there will be positives to come, as there were in West Africa, such as innovative ways of working, a focus on health system strengthening and a greater sense of community. This should occur on a global scale and as we reach the end of the first phase in the UK, we should give thought as to how we can support and advocate for our colleagues facing the pandemic in resource limited settings that have taught many NHS workers so much, myself included, in recent times.”Dr Richard Lowsby, consultant in emergency medicine, Mid-Cheshire Hospitals Foundation Trust
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