March 21, 2020
Written by Marnie Jakab
Much like some of you, I’ve spent the last week at home practicing social distancing. Each day I am immersed in the current public health crisis the world is experiencing and spend my time learning more and more about COVID-19. When I describe my daily activities, on the surface they seem normal – running, yoga, cooking, and catching up with friends over the phone. However, the feeling of my daily habits are clouded by an unsettled feeling due to the weariness within the global context. Thus far, I am thankful to report that I have minimally been affected by the virus much like the majority of Canadians at the moment. Currently, I am studying to become a doctor at Queen’s University School of Medicine, in Kingston, Ontario, Canada. I have been given an extra break to support social distancing measures and assist in preventing the spread of the Coronavirus, with classes scheduled to resume online next week. As part of developing our core competencies as physicians, those in the medical school program participate in hands-on clinical learning. These placements have been put on hold and it is uncertain when we will be resuming our regular clinical duties. Nevertheless, I can remain more relaxed than some given the current economic climate, as I have the security of knowing that one day I will be a doctor; my financial situation, my career and my future are stable.
I could write about the feeling of helplessness and what it’s like for my classmates and I to be on the sidelines of the pandemic. Situations like this are part of the reason we go to medical school in the first place. We want to help people and their families who are suffering. We want to help our colleagues as they become overrun with an increasing caseload. Unfortunately, for now, we must wait patiently and complete our academic assignments, while the number of confirmed cases increases exponentially, so does the feeling of selfishness in doing so as we spectate safely. I digress.
While listening to the New York Times podcast, “The Daily” and their interview with New York Governor, Andrew Cuomo, I heard some unsettling, but somewhat familiar statistics that struck me as poignant. In New York State, over the next 45 days, it is expected that the COVID-19 pandemic will reach its peak. It is anticipated that the state will need 110,000 hospital beds, while only having 50, 000. They will need 37, 000 Intensive Care Unit (ICU), beds having only 3 000. This large and concerning gap will be costly.
The goal of social isolation and social distancing is to flatten the curve, as not to overwhelm our healthcare system. Because COVID-19 affects the respiratory system, those who have severe symptoms from the virus will need ICU beds and machines to assist with breathing, ventilators. It has become clear over the last few weeks that, globally, we do not have enough ventilators for everyone who will require ventilatory support- a sobering thought, I know.
In 2015, before embarking upon medical school I was fortunate to assist in a research project based out of Uganda. It would be inappropriate for me to pretend I was an expert on the topic and situation there or that I was able to provide extensive experience or insight. The entire research project lasted approximately six months and I was only in Uganda for ten days, but the lessons I learned were impactful and during this crisis I am reminded of them. Travellers, myself included, worry about culture shock on the way into a low resource country, but paradoxically my greatest shock was coming back. When I returned home I was working at St. Joseph’s Hospital in Hamilton, Ontario, Canada, conducting clinical research in the intensive care unit. It is a tertiary ICU, meaning we had 21 ICU beds, all equipped with extensive ventilatory and dialysis capabilities. We even had technology to measure the difference between abdominal and pulmonary pressures to achieve personally titrated ventilatory settings. We measure the abdominal pressure because it is one of the pressures preventing the patient from being able to inflate their own lungs. The purpose of calculating the difference between the lung and abdominal pressures is to gauge how much pressure the ventilator would need to ideally inflate the lungs for the individual in question. Few ICUs in Canada have this technology or the training to implement this intra-abdominal pressure monitoring technique.
Contrasting the resource rich environment of the Canadian system with Uganda, a sub-Saharan African country, sharing a similar population size with Canada (~36 million) there are immediate stark differences with the level of care they are able to provide. At the time, the entire country of Uganda had 33 critical care beds, 12 qualifying as ICU beds and a measly 12 functional ventilators. In the unfortunate circumstance that you needed ventilatory support in Uganda, you would hope your family was large enough to be able to ventilate you manually. If a patient needed assistance breathing, they would have a breathing tube hooked up to a football shaped bag that family members would take turns compressing in organized succession to inflate their lungs. This would go on for days until either the family was unable to continue to ventilate, or they recovered. In Kampala, the capital of Uganda, within the main hospital there are two staff serving the four ICU beds, each accompanied with a ventilator. However, to complicate things, the hospital experiences constant, almost daily, electrical blackouts. At each moment doctors working in the ICU have to be prepared to manually ventilate if the power goes out, and when it inevitably does, they have a calculated plan to determine who will receive manual ventilation. I’m sure you can do the math.
As you may have gathered from the example above, Uganda is consistently short on supplies, personnel and beds. This creates a recipe for disaster for families when their loved ones are sick. I vividly remember people camped out in the courtyards because there were no beds available inside as they waited for their family members to receive care. Due to the lack of personnel, and more dire situations requiring nurse and doctor expertise, families usually provide what would be routine nursing care in the Western world. Nurses and doctors are in a constant struggle deciding who they have time to see and who they can allocate time and resources to, in order to save lives. As of 2019, the country was equipped with 55 ICU beds and 35 beds with ventilator capabilities indicating an improvement of service capabilities since my time there, but leaving the country at a ratio of 1.3 ICU beds per million population.
I realized back then and upon my arrival home that healthcare personnel in Uganda make decisions everyday that we in Canada have the privilege to never have to make… As time passes during this pandemic it’s becoming more and more apparent that we will temporarily lose that luxury. Essentially, our healthcare system has become akin to a low resource setting. Our Canadian hospitals are taking extreme measures in hopes of preparing, but nonetheless, our fellow citizens will be the victims as they exceed their capacities. Hospitals in Hamilton, Ontario have put a call out to retired doctors and nurses as COVID-19 is diverting health care workers from other services, such as family medicine, and those in emergency rooms. Countries across the world have done the same for their health services. We, in Canada, are already feeling the effects of an ill equipped health care system as we have already begun to run low on personal protective equipment. Hospitals have resorted to locking up their surgical and specialized N95 masks for hospital personnel only.
Globally, we are all trying to acquire more ventilators. Much like Uganda experiences everyday, we will have more people requiring ventilatory support than ventilators available. Just yesterday, Elon Musk announced on Twitter that his companies would also commence manufacturing ventilators, while Justin Trudeau unveiled new measures to support companies in Canada to produce medical supplies to fight the spread. Our governments are collaborating with many manufacturing companies that are generously repurposing their assembly lines to reduce the impact of the ventilator shortage. Unfortunately, it’s not as simple as just acquiring more ventilators. Those ventilators need rooms that can accomodate them with available power outlets and appropriate gas lines. They also need trained respiratory therapists, doctors and nurses to use them. Just like in Uganda, we need more resources and we will have to decide who gets what we have available and who does not. In addition to looking inward at our own policies and practices we should look outwards to low resource settings like Uganda. This is a concept termed reverse innovation and it often is unexplored in the western world. It requires organizations to make radical changes, and look down a different path to troubleshoot a problem they’ve never seen before. Countries like Uganda have been faced daily by the challenges ours is anticipating. This is their only reality. They are the experts and if our countries are smart enough, humble enough, they will consult our low resource counterparts. They have lived this and will continue to live this long after the COVID-19 pandemic has stabilized.
Marnie is currently completing her MD in Kingston, Ontario, Canada and spends most of her time offline, working on accomplishing her goal of cycling around the world.