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Coronavirus

This Is How a Pandemic Buckles a Health System

In developing countries, frontline workers get hit hard. Guatemala is a struggling example. Latest in a series.

Emi Sasagawa 11 Sep 2020 | TheTyee.ca

Emi Sasagawa is an award-winning journalist who has reported on issues including housing and homelessness, mental health and marijuana legalization. She graduated with a master’s in journalism from the University of British Columbia in 2015.

As British Columbia invests another $1.6 billion to prepare for a COVID-19 second wave, the virus is causing health systems to buckle in smaller, poorer countries. In Guatemala, for example, it’s now month eight of the pandemic. There, the numbers of cases and deaths are underreported, continue to rise, and casualties among health workers are leaving an already weak line of defence frayed. The government, meanwhile, struggles to maintain the narrative that everything is under control.

Recorded cases in Guatemala have risen from a total of 263 in mid-April to 77,684 earlier this week. That’s a 300-fold increase since April, when The Tyee started following the country’s efforts to deal with COVID-19, our reporting done in partnership with TulaSalud, an initiative of the Tula Foundation, which funds rural public health work in that Central American country.

During their battle, health workers have lacked armour, causing many to fall. The government has largely failed, even now, to provide appropriate personal protective equipment to doctors and nurses.

Before the first Guatemalan was diagnosed with COVID-19, the nation’s health system was already stretched thin. By March, the pandemic had been sweeping parts of the globe for nearly two months. That’s when health-care providers like Claudia Tut, an auxiliary nurse in the municipality of San Juan Chamelco, in the northern province of Alta Verapaz, began complaining about lack of access to PPE, as The Tyee has reported.

Many are still waiting. “Three weeks ago, they gave us five KN95 masks,” Tut told The Tyee early in September. “Since then we haven’t gotten anything. Hats and gowns, I have to buy with my own money. You can’t find PPE in our community. Sometimes when my relatives travel, they bring some back. And nowadays, I hardly leave, so I have to reuse the masks many times to make them last. I know this is not good, but what choice do I have?”

What’s behind the hold-up on PPE? After months of hesitation, the Guatemalan government found itself struggling to negotiate purchases in a market with inflated prices. Then, in late June, two days prior to the initial deadline for offers by providers, the Ministry of Public Finance requested that the Ministry of Health postpone by almost a month the date when bidding companies would need to provide the equipment.

According to the Ministry of Public Finance, the extension was a result of changes to technical specifications for these health supplies. Whatever the cause for delay, it meant an ongoing shortage in Guatemala of face shields, KN95 and N95 masks, three-layer surgical masks, disposable caps, shoes for the surgical area, biosafety suits, gloves, protective glasses and gowns.

The lack of protection has cost the lives of some life-protectors, and sidelined others.

At a news conference in June, the Ministry of Health announced that 108 health-care professionals were infected with COVID-19 — including 35 doctors, 32 nurses, 22 auxiliary nurses, five laboratory technicians and 14 people in administrative positions.

A month later, on July 20, the vice-minister of hospitals said health-care professionals with the virus included 207 doctors, 295 nurses and 250 administrative personnel with a total of 752 health-care workers infected. The government later announced 19 health-care workers had died due to COVID-19.

Five days later, a communique from the College of Doctors presented different numbers, reporting 32 doctors and two nurses had died of the virus.

Experts say pronouncing an accurate infection rate for health-care professionals is virtually impossible in Guatemala due to lack of transparency at high levels. “There is no co-ordination or management of information. The data being shared is not reliable. They don’t know who of their personnel is infected, and no one guarantees these numbers,” said Wilson Boche, a Guatemalan economic analyst who specializes in health.

The lack of protections for health-care workers and resulting infections had caused a domino effect. In the province of Guatemala alone, the closure rate for health posts and health centres has surpassed 60 per cent, due to health workers contracting COVID-19.

Without a plan in place to replace sick doctors and nurses, it’s likely things will get much worse, noted Boche. The process of hiring new employees can be lengthy. Even if enough qualified professionals were available, it could take months to replace those hit by the virus.

Early in the pandemic, Guatemala’s congress decreed the replacement process for health workers who fall ill be sped up. The initiative included a commitment to spend 396 million quetzales, about C$67 million, on smoothing procedures. Of this allowance, less than $4 million have been put to use, under six per cent of what was allotted.

Dr. Rubén Gonzalez, former vice-minister of health, cautioned against attributing such problems to just the coronavirus. Instead, COVID-19 has laid bare symptoms deeply rooted in the nation’s health bureaucracy, he said.

Gonzalez is a leading voice for alternative COVID-19 responses and wider reform of the health system in his country. “The pandemic has brought to light the state of the health system. This crisis is making known the health issues in the country — the inefficiency of the state, the low technical capacity of public health service providers, and the inadequate administration of resources by the government,” he said.

Since May, Gonzalez said, he has watched eight of his colleagues die as a result of the pandemic.

851px version of GirlOnlineGuatemalaCityRooftop.jpg
A young woman in Guatemala City takes courses online due to COVID-19 measures. Her country, which has half the population of Canada but 1/20th the wealth, is hampered in its pandemic fight by corruption, poor planning and low investment in health care, say Guatemalan experts, who hope the crisis will trigger reforms. Photo via Shutterstock.

Compared to Canada, Guatemala has about half as many people (17.5 million), but only 1/20th the gross domestic product. Just British Columbia’s GDP is 2.5 times as large as Guatemala’s, yet the province has less than one-third Guatemala’s population.

The World Health Organization’s most recent statistics, from 2014, show Canada spending C$6,121 per person on health compared to C$624 by Guatemala.

Still, Guatemala has one of the largest economies in Central America, and some question its dependence on privatized medicine. An analysis of Guatemala’s health system conducted by the United States Agency for International Development in 2015 shows that most health spending goes to the private sector and most health care — 83 per cent — is purchased by Guatemalans out of pocket rather than through insurance or public funds. Total spending by all government agencies towards health amount to just 1.2 per cent of Guatemala’s GDP.

Combining private and public sectors, the country spends 6.3 per cent of its GDP on health care, compared to Canada, which spends 11.6 per cent of its GDP.

Political analyst Fredy Argueta believes what made Guatemala’s health system so vulnerable in the face of the pandemic is not so much a lack of funds, but poor strategic planning and too much corruption. In July 2019, prosecutors in Guatemala started investigating a multimillion-dollar graft scheme within the federal public health ministry. Prosecutors said that the kickbacks for repairs to refurbish damaged hospitals after a 2012 earthquake totalled at least 17 million quetzales (around $2.9 million), while those received as part of the construction of new hospitals amounted to 36 million quetzales (around $6.1 million).

The network, prosecutors say, also purchased unnecessary medical equipment in exchange for bribes, and doled out 450 jobs as “political favours.” About 100 of these jobs were “ghost” positions.

Entering the pandemic, Guatemala’s health-care workers were already scarce compared to countries with similar profiles. The WHO recommends that for each 10,000 inhabitants, there be 34.5 health workers. In Guatemala, the average is 12.5, making it the country with the lowest number of health workers per 10,000 inhabitants in Central America. According to Statistics Canada, B.C. has 134 doctors and 854 registered nurses per 100,000 inhabitants, nearly three times Guatemala’s numbers.

Rural Guatemala bears the brunt. Three out of four health workers in the country are concentrated in the more urban province of Guatemala, where Guatemala City is located. In the nation’s cities, on average, there are 26 health workers for every 10,000 inhabitants. In the countryside the corresponding number is three.

As a result, rural health workers like Claudia Tut faced daunting tasks. She is one of three auxiliary nurses to service three communities spread over a wide area requiring over an hour of travel from village to village on foot. Four out of 10 Guatemalans are Indigenous, most living in rural areas and speaking a range of languages. Health workers must not only be able to communicate across such barriers, they face severe public health issues. Compared to the wider population, in Guatemala’s Indigenous communities, nutrition levels are lower, and women are two times more likely to die giving birth.

851px version of RuralGuatemalanWomen.jpg
COVID-19 is now penetrating Guatemala’s rural areas, already facing severe public health issues. Indigenous women in the countryside are two times more likely to die giving birth than the nation’s overall population. Photo via Shutterstock.

Add to such challenges the job insecurities health-care providers face, said Gonzalez. “More than half of people working in health care are hired as short-term contracts — this contributes to high rotation, instability and lack of transparency in hiring, promotions and compensation. The drop-out rate for nurses is high, at 69 per cent, so there’s a chronic lack of nurses.” Ideally there would be nearly three nurses per doctor, he said, but now there are fewer nurses than doctors in Guatemala.

Like cracks in tree branches before a powerful storm, these weaknesses in Guatemala’s health system made it fragile in the face of the pandemic, experts told The Tyee.

The lack of strategic planning has resulted in problems in the provision of supplies, inadequate levels of testing, and slow replacement protocols for health-care workers who’ve fallen ill.

The low numbers of doctors and nurses in place before the pandemic has meant health professionals must now work extraordinarily long shifts and remote communities are left to fend for themselves, without sufficient infrastructure and support.

Corruption has compounded purchasing delays, put health workers at risk, and eroded faith in government officials.

By early August, Guatemala blasted past a “best case” scenario for COVID-19 the government had charted using a mathematical model. The pandemic is picking up speed moving into rural communities. Experts predict a second wave will hit the countryside hard in months to come.

“If we continue in this way, we will reach the peak of the curve, but we won’t come down. In rural areas, we are facing a different reality. Measures to contain COVID-19 need to be adapted to this setting where the same infrastructure and resources aren’t present or available,” said Gonzalez.

In the northern region of Guatemala where Tut works as a nurse, the statistics might not seem very foreboding to people in Canada who have seen far larger numbers. In June, when The Tyee previously spoke with Tut, she had yet to see her first COVID-19 case. Since then, in the communities she serves, there have been 14 cases and two deaths.

But Tut is deeply concerned. “When I heard that we had a case in the community, I became very worried because I knew things were going downhill from here, and we weren’t prepared for this,” she said.

In San Juan Chamelco, the municipality where Tut is based, she and two colleagues must work to control the spread, keep up with new cases, and make sure they and other health professionals stay virus-free.

And still they are waiting for the basics of protective equipment and good data. “We are not kept informed. People are always trying to hide the number of cases, and when you don’t know what’s going on, you feel like you can’t protect others or yourself. It’s a really stressful time. I’m working long hours and when I get home I can’t relax because I know this is just the beginning,” said Tut.

Gonzalez places Tut’s fears in a larger context — and grasps for hope in what a pandemic can teach. “COVID didn’t make things worse, because they were already pretty bad. If we see it this way, the pandemic came to give social consciousness about how bad things are in our health system. It came to illustrate the reality of the Guatemalan health system with the loss of lives.”

From his vantage as a policy expert and former health minister, Dr. Rubén Gonzalez sees an opportunity for Guatemala to key off its current health crisis in reforming its approach to primary health care.

But for Tut and others on the frontline of this fight, just making it day to day is the immediate challenge. “As health workers, we are putting our lives on the line every day we leave for work. Two health workers from a nearby community became infected,” she said. “The threat is very real. I could be next.”

This article is part of a continuing series, found here.  [Tyee]

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