As I walk into work each morning, I wonder what the day will bring. Life, as we know it, has changed with the presence of the COVID-19 pandemic. Each day, as we turn on the news, we wait to hear what restrictions will be placed on the state or county that we reside in. Is eating at a restaurant allowed, or are we mandated to stay at home? Do we go into work at the office, or are we working from afar? Is a mask required to go into a store to buy groceries? Is it required all the time or just some of the time?
In my work for a nonprofit mission organization that serves developing nations, we have also been directly affected by the COVID virus. Every part of mission work encompasses travel to other nations and serving crowds of people. With the restrictions that are in place, travel for us is not possible. In the last 7 months, we have had many teams scheduled to fly to Cambodia, Nepal, and Guatemala. Our mission is to provide much-needed health care to the unreached people of these nations. Every one of our trips has had to be canceled.
Cambodia has recently lifted some of the restrictions but has placed a $3,000 USD deposit to travel there. Upon arrival, each visitor is placed into quarantine for 14 days in a designated hotel for foreigners. The deposit monies are used for room, meals, COVID testing, and other necessities that may be needed during those 2 weeks. If there is any money left after the 14 days, it will be returned to the person traveling into the country.
Quarantine is presently required to arrive in the developing nations and then also upon returning to the United States. This means extra monies and time to travel; therefore, our organization has placed a hold on the planned medical mission trips. So, how are we serving these nations that we so desperately want to provide healthcare to when we are faced with these limitations?
If our mission was in the United States, we could ask the patient to log onto a computer, and a telemedicine appointment could be completed. Another option would be to come to the outpatient office in a staggered appointment fashion with proper cleaning in between each person. Unfortunately, this luxury is not available in the nations that we serve. The people we work with have minimal access to vehicles or bikes and may even have to walk many hours to reach a town that can provide any medical assistance.
To offer some minimal care to the patients in these nations, we have had to be creative with the limited communication tools available. We have had some success with direct on-the-ground cooperation. We have developed relationships between these unreached people and missionaries living there. Some local churches have agreed to allow us to set up “clinics” for health care delivery in their buildings. The mission is equipped with a cell phone and some minimal first aid supplies. As patients come into the church, they are asked a series of questions to assess what may be worrying them. This information is relayed via text message and a photo, if needed, to a team of volunteer physicians and nurses in the United States. The team in the United States triages the patient and provides medical care via instructions to the missionary. Although this may not be an ideal way to provide care, using the available resources is the only way to provide medical care to these unreached people.
Another way that support has been provided to these nations during the pandemic is through donations of medical supplies. The lack of access to the much-needed personal protective equipment has been verbalized by several countries that we work with. We have received requests for help with masks, face shields, gowns, gloves, and many other supplies. One hospital in Guatemala reported that the frontline workers were being exposed to the COVID-19 daily, and many wear their soiled work clothing home. This has placed their families at risk of exposure. It has been reported from our contacts that we have many frontline workers who have lost their lives because of exposure while working.
We have been able to work with some contributors in the United States to obtain some of the supplies and funds to allow the nations to purchase the supplies locally. Some of the nations will not allow anything to be shipped from other countries, so this has been a more significant challenge to provide resources to them. Even our limited assistance to health care colleagues who live in such poverty is a significant contribution.
The issue of ventilators is complex. Although the United States has sent ventilators abroad, this has been critiqued (Torbati, 2020) by some who feel that there are not enough personnel in developing nations to operate these ventilators and no one who knows how to repair them. Barsky and Sayeed (2020) have written about how poverty-stricken nations deal with a medical crisis such as respiratory arrest. They describe the use of long-term manual hand-bag ventilation. According to Barsky and Sayeed, in low-income countries, some families perform manual hand-bag ventilation on their children during times of medical crisis and lack of ample medical personnel. This creates an ethical dilemma for medical providers. Teaching the task is simple, but complications such as “under or over ventilation, pneumothorax, dislodgement of the endotracheal tube and provider fatigue” (Barsky & Sayeed, 2020) can occur. If a complication occurs while the family provides the ventilation, this can place a great deal of guilt and stress on the family. These authors question whether it is appropriate to put this type of pressure on families. In the United States, this is not a task given to a family, but in the poverty-stricken countries, families perform much of a child's care while in the hospital setting. Unless the country has adequate medical and support staff, these families will continue to do what is needed to try to ensure that their child lives. Would you do the same?
Barsky and Sayeed have developed an algorithm to be used in these cases to help medical professionals decide if manual hand-bag ventilation is suitable for a patient. One of the deciding factors is if this is a bridge to equipment becoming available. Hand-bag ventilation is appropriate, they state, if a ventilator will be available in 6–8 hours. If this is not possible, then the manual ventilation should not be initiated. Although manual hand-bag ventilation may seem like an extreme measure for a family to perform, this is a risk and task that these families are willing to take on for their loved ones.
In these times of uncertainty, we in all countries of the world are uncertain what measures to take to ensure our loved ones stay healthy. Many people continue to quarantine in their homes, and do not venture out, avoiding contact with others. American Pediatric Surgical Association members continue to serve at work while caring for both family at home and those far away. We look forward to the end of this medical disaster (the “new normal”) for the next chapter in all of our lives.
Barsky E., Sayeed S. (2020). Parental manual ventilation in resource-limited settings: An ethical controversy. Journal of Medical Ethics
, 46(7), 459–464.