By Telmo E. Fernandez-Cadena, Intensive Care, Guyaquil, Ecuador; Manuel Jibaja, director, Intensive Care Unit, Hospital Eugenio Espejo, Quito, Ecuador; Nelson Maldonado, MD, Neurocritical Care, Universidad San Francisco de Quito (USFQ); Miguel Andrade, MD
Perspectives from Guayaquil, Ecuador
On Feb. 29, 2020, the first case of SARS-CoV-2 in Ecuador was announced in Guayaquil. What we saw as a distant problem in Wuhan and New York had finally arrived. A city hospital was enabled with 24 intensive care beds for COVID-19, and the opening of a hospital under construction was brought forward, which made us feel prepared.
It turned out that this was not the case. The key issue in those months was that our intensive care units were filled at 100% occupancy in both the public and private sectors, but the most shocking matter was that the first patients, and, therefore, the first deaths, were our colleagues. Intensivists with whom we recently had coffee or shared a conversation about some controversial case were in intensive care being intubated and struggling to survive.
There are more than 150 colleagues whom we will not see or consult any more. This led to a very serious problem: a shortage of trained personnel. This greatly limited the capacity to expand services in terms of the number of beds. This led to an unmet demand for health services resulting in deaths outside the hospital, abandoned corpses on the streets and rooms in houses converted into intermediate care units. As the demand for portable oxygen was so large, it did not matter if the oxygen tanks were for medicinal or industrial purposes. As long as it was oxygen, it worked.
Demoralized and depleted health personnel faced the pandemic. The protection equipment existed, but it was scarce and sold at triple the price relative to normal circumstances. President Trump's ban on exporting N95 masks (manufactured by 3M) to Latin America unleashed hoarding and speculation that is currently being sold informally at eight times its pre-pandemic price. In view of the abandonment of the United States government, we were forced to look toward China, and now the most used protective equipment in the country has the KN95 standard.
When the epidemic broke out in the city, it was at that stage that we tried everything that seemed to be appropriate at least in theory. We went through the stage of replication inhibition, depleting hydroxychloroquine (HCQ) and azithromycin stocks in pharmacies within hours, leaving patients with autoimmune disease without HCQ and the ones on antiretroviral therapy without lopinavir/ritonavir. Then to the immunomodulation stage with corticosteroids and tocilizumab to finally offer plasma from convalescent people, all with the aim of limiting mortality from severe COVID-19.
Saying that an intensive care service has a mortality attributed to COVID-19 of 40% can be interpreted as good performance. However, in the context of an unmet demand for medical care that results in an excess mortality of 15,000 people resulting in the world’s highest per capita mortality rate, it is disgraceful.
In conclusion, the city of Guayaquil and its authorities were and have been unable to handle the epidemic. The flattening of the curve is attributed to the herd immunity that has been achieved with a very high price from the number of deaths. That immunity group death is the result of collapsed emergencies, the dead bodies on the street, lost bodies, mass and hurried burials. There is no way the decrease in cases can be attributed to the non-existent success of null management. We, in the intensive care units, had limited capability to expand our services in terms of the number of beds due to the lack of both human and financial resources. Half of our medical staff was infected, and this affected the availability of beds. We have learned that in a disaster situation, the city of Guayaquil has a lot to learn and develop, but it has been a lesson with too high a price, a lesson that will remain with us, tormenting us for a long time.
While the storm is easing in Guayaquil, it is raging in other Ecuadorian regions, so the city extends its hand. Today, intensive care units are at a 100% occupancy with patients from other regions. Guayaquil people will continue helping because we have tasted that bitter drink of losing family, friends and coworkers and because we know decisions to control the pandemic were made with political calculation instead of science-based evidence.
Perspectives from Quito, Ecuador
It has been months since the first description of the novel SARS-CoV-2 back in January, the continuous spread from its epicenter, how it took over China, Italy, Spain, The United States and now, South America.
Since the first case was reported in Guayaquil, Ecuador, an impressive number of cases were registered, overtaking health services response capacity. They asserted an enormous workload on the medical services, especially the intensive care units.
Furthermore, Guayaquil City and the Guayas Province became recognized around the world by the press, some even referring to it as “Latin America’s Wuhan.”
At the same time, I was working in the ICU at Hospital Eugenio Espejo in Quito, Ecuador. It is the country's largest public health hospital. We became first-hand witnesses to the events developing in Guayaquil, foolishly thinking that our fate was different.
Sadly, this unprecedented sanitary crisis presented itself at the country's worst economical situation in the past decades. As revealed by the World Bank Group data, Ecuador holds the seventh position for income per capita in South America.
It was not until March 9, 2020, that the first COVID-19 case was reported in Quito. The patient was hospitalized in our ICU with a severe case of ARDS and shock state. Since then, the case report incidence has progressively risen in a worrisome manner.
The attention given to ICU patients in a medium income country conforms a peculiar scenario, requiring the development of a certain set of skills that would not be necessary in places of wealthier resources. Specifically, the quantity of ICU beds available per 100,000 habitants are abysmally different. For example, at the beginning of the pandemic, Germany and the United States disposed of 33 and 30 beds, respectively, while Ecuador held seven.
Today, ICUs in Quito are reaching maximum capacity, and some are even overflowing due to COVID-19. Hospital Eugenio Espejo provides service to the economically challenged population who have no health insurance. The hospital expenses are covered by the state’s budget. Adversely, the state’s main source of income is oil, which is at its lowest cost in history. It is obvious we are not only fighting COVID-19.
Nevertheless, I have worked nearly three decades in critical medicine. To the date, I cannot remember a more hostile environment from what we are experiencing today. A gigantic amount of information is transmitted every minute, scientific publications have set an alarming and suspicious record. Mechanical ventilators now are as mainstream as football, and the quantity of COVID-19 experts is overwhelming.
The main lesson government authorities of developing countries have to learn during this pandemic is that we must channel resources to public health immediately. Regardless of the political party in power, hospitals, especially those treating the most vulnerable, must be in top condition to perform if we want to avoid unprecedented catastrophes.