By Beryne Odeny (Washington University in St. Louis, Department of Surgery) and Julia Robinson (PLOS Global Public Health) The first in-person CUGH…
By guest contributor Irene Torres, PhD
There are many ways to describe the impact of COVID-19 in a small country such as Ecuador.
Similar to high-income countries such as the UK and the US, there is the inaction of the government and the mixed scientific messages (including from WHO), which appeared to have been processed selectively. There is also the human despair derived from having one of the highest excess death rates in the word amid general indifference even after confronted with the images of corpses lying on the streets of Guayaquil, a major Ecuadorian city. By the end of 2020, 41,000 more people had compared to 2019; and, even though the government estimates only 23,800 died of COVID-19, this number equals 21% of all deaths last year.
Since the onset of this pandemic, I have been trying to understand where decision makers in Ecuador may have tended to or ignored the basics of human wellbeing. A heightened focus on vaccination shows we have not looked towards our own capacity to tackle the pandemic and continue to misinterpret the promises of adopting external technology and models. While Ecuador could use structural, socioeconomic transformations, maybe some minimal changes would better ease our way out of the pandemic while setting a foundation for a better health system. Using WHO’s “building blocks” framework, I analyze here the (limited) evidence available reflecting on the potential usefulness of basic tactics in the country to support 1) service delivery, 2) the health workforce, 3) health information systems, 4) access to essential medicines, 5) financing and 6) leadership and governance.
The image of “building blocks” may evoke a health system that is composed of equally important elements coupled together with the help of policy carefully placed between them like mortar, i.e., a modern construction pre-designed for success. It is more difficult to imagine an Inca structure with loose-fitting, non-uniformly cut stones, which are quite resistant to shock but defy what could be considered technically conceived or efficient. Without the unique discernment required to forecast how conjoining stones go together like in Sacsayhuaman, I only offer small stones to fill the crevices, as we wait for larger slabs to be readjusted.
Ecuador has a quite limited diagnostic capacity for Sars-CoV-2. By the time the pandemic made its first international headlines, at the end of April 2020, only 8 out of 24 provinces had laboratories that could process COVID-19 PCR samples and not all were doing so. More than 12% of samples took 10 or more days between healthcare attention and notification of results. The price cap for private tests was set so high, at US$120 for an RT-qPCR assay, that few could afford one in a country where less than 40% are formally employed and the minimum wage is US$400. The government did such few tests that for months the positivity rate read like the flip of a coin: 1 out of 2 came out positive.
The government did such few tests that for months the positivity rate read like the flip of a coin: 1 out of 2 came out positive.– Author Irene Torres, on the early days of the COVID-19 crisis in Ecuador
Limited testing has implied that COVID-19 surveillance information is similarly limited; in consequence, contacts are inadequately traced, or not at all. In a country where less than half of people in the poorest quintile use social media, the government-created app requiring patients to have a smart phone was doomed to fail. While classic community surveillance efforts have been successful at a small scale, the idea of having private companies and industries report outbreaks has not been embraced – yet. Because employees report whether they are sick with COVID-19 and may also get free tests at work, such anonymized data could allow for more expedient and relevant decision making. Even though the formally employed add to only about 40% of the economically active population, health authorities would still have better knowledge of the location of outbreaks than currently.
Ecuador’s primary health system for the uninsured (roughly 60% of the population) largely depends on the compulsory service year of medical doctors after graduation, i.e., minimally trained personnel, with limited access to updated and timely health literature in Spanish. When my husband had COVID-19, he was prescribed ivermectin, which is unsurprising given that the Vice Minister of Health had announced hydroxychloroquine would be freely distributed to medical doctors as a “prophylactic” measure. The romanticized depiction of mandatory service makes it difficult for the very doctors involved to reconsider a different career pathway for entry-level personnel. As an example, when the newly elected government insisted on vaccinating using the pressured and understaffed primary health level, no one complained this would take away attention from regular health prevention, promotion and care.
Due to the absence of individual health records, Ecuador does not have a common information system in place across the different public and private providers. Without being able to link records automatically, the country continues to wait for a more accurate account of the impact of COVID-19, which in addition means that decisions continue to be rather intuitive. In contrast, neighboring Peru has at least made COVID-19 deaths more transparent by linking different types of records based on improved criteria to categorize cases. Just the excess death factor (EDF) in Ecuador shows the dramatic inequality of impact until September 2020: 2.2 in indigenous populations compared to 1.36 in the predominant mestizo group. Moreover, the EDF in indigenous women is higher than in men in all age groups between 20 and 50 years. It would be strategic to produce more knowledge on all 2020 deaths, and their wider social determinants –hopefully with the advice of the Peruvian experts instead of starting from scratch– to make any (not just health) plans.
Access to essential medicines has been mired by widespread corruption, making government purchases look at the least dodgy. When compared to the previous year, prices paid by public hospitals for medical supplies increased of up to 1,307% in April 2020, which was the month that saw the highest spike in deaths in Ecuador. Outdated and incomplete regulation policy obstructing scientific production in the country has reinforced its dependency on importing medicines and medical supplies, making Ecuador vulnerable to global shortages and related price speculation. In a country where out-of-pocket health expenditures add to more than 40% of the total health budget, limited scientific autonomy can draw the line between life and death more than the coronavirus itself. It would not take much for Ecuador to adapt regulations drafted by agencies such as FDA in the United States, which consider many different scenarios and types of supplies and devices that need to be approved.
I can only hope some change can come out of these lessons.
Although I will be the first to say that research and scientific debate should not covidized, there is still much to learn from Ecuador’s response to the pandemic, and for Ecuador to learn from its own mistakes. I can only hope some change can come out of these lessons. One by one, small stones can be made to fall into place, while we continue to work on finding the best way in which the larger stones can be arranged together.
Irene Torres works from Fundacion Octaedro in Ecuador, where she is board member of the Ecuadorian Society of Public Health. Her research focuses on school-based health promotion, migration and health, and more recently COVID-19. Twitter: @lairene