In these times, healthcare systems around the world are being stretched to capacity and challenged in unanticipated ways. The need for preparedness training, access to Personal Protective Equipment (PPE), and equipment has been an issue for even the most well-funded and well-equipped healthcare institutions. How, then, will low-income countries be able to prepare for their fight against COVID-19?

Karoline Myklebust Linde, CEO for the not-for-profit company, Laerdal Global Health talks about the impact of Covid-19 on developing countries and lessons learned that can be applied to help.

Q.

We know that the COVID-19 pandemic is developing more quickly, but what is your impression of the status of coronavirus in low-income countries?

A.

We’re just not sure yet. In the best-case scenario, it is not hitting as bad in lower-income countries as in other places and we don’t know why. Or, more likely, it just hasn’t reached there yet. The numbers reported are not as high as expected. We haven’t seen the massive influx of COVID-19 patients that we’ve seen in some other countries. The speculation is that it is delayed or it could be that they don’t know the true cope of the situation due to lack of testing. But many African countries have implemented restrictions – travel, closures. Ethiopia has been a positive case – early with soc distance, travel.

Q.

How do you predict it will develop in the immediate future (and beyond)?

A.

While we don’t know how the specific coronavirus will impact these countries, we are seeing the implications of it in the form of disruption to healthcare services. To me, this is the most pressing concern right now. In a recent study, it was reported that more than half of them were experiencing severe disruption. Disruption means interference with ordinary healthcare treatment for example childbirth. For instance, one of the large hospitals in Nairobi has reported 40% fewer childbirths – and we know babies are still being born – it means that many more are being born without the help of a skilled birth attendant or midwife. Most prenatal care appointments have been stopped as well, which is when you can detect problems related to pregnancy. It could be that transportation is an issue or fear of contacting COVID-19. It could be that more healthcare workers are moved to different wards to prepare for COVID-19 patients or become quarantined themselves. So, the COVID-19 crisis and the repercussions have a ripple effect on healthcare.

Q.

Now, more than even healthcare inequity is apparent. The WHO estimates that in some low-income countries,  like Tanzania, there is one doctor for every 40,000 people. How will healthcare workers in low-income countries cope with COVID-19?

A.

Access to healthcare is a big problem in these countries. At the beginning of the crisis, we were very focused on access to ventilators, how to produce and distribute them to these countries, but ventilators are really only useful in high functioning healthcare settings. That’s not to say these don’t exist in low-income countries – certainly in Nairobi and the capital cities -- where they can provide this level of care.

But in general, the standard of healthcare is low. Not only do they not have ventilators, but the healthcare workers are not trained to use them. So, the focus in these places is triage, detection, isolation, and oxygen treatment to try to save those who can be saved. There is now a big push to have oxygen treatment available in healthcare settings. And this is good news because even before COVID-19 there was a great need for this – newborns or patients with other conditions who need oxygen. The World Bank is contributing a lot of funding to this together with some major United Nations non-profit organizations with help from local partners.

Q.

According to Unicef, 116 million babies will be born during the COVID-19 pandemic. What are some of the challenges low-income countries will face?

A.

Personal Protective Equipment (PPE). There is a shortage of this in high-income countries, but in low-income countries, the lack is extreme. It is not only not available, they have no experience in how to use it properly which is critical to avoid infection. Right now, the focus has been on trying to secure enough PPE, but really that won’t help unless we can also ensure healthcare workers are trained to use it.

Q.

What have we learned that can be used to help healthcare workers – and others – to better prepare?

A.

I think previous outbreaks has enabled low-income countries to have a greater understanding and to know what to expect and what measures need to be taken. The SARS outbreak in East and Southeast Asia from 2002-2004 and the Ebola outbreak in West Africa from 2014-2016 gave these countries experience that can be harnessed to learn from. I think the countries that we affected by SARS were very quick to act and contain the coronavirus. It will be interesting to see how it is handled by the countries that experienced Ebola. But the healthcare systems of these countries are still weakened from the Ebola outbreak that was only 5 years ago.

Q.

What is your greatest concern?

A.

My greatest concern right now is healthcare disruption – of course, this will change if there is a major spike in COVID-19 cases in low-income countries. Healthcare disruption is something we have learned more about from previous outbreaks. For example, estimations modeled after the Ebola outbreak showed the disruption in healthcare in the maternal and newborn sector can result in additional deaths – an estimated 30,000 additional maternal deaths and 400,000 additional newborn deaths as a result of lack of access to care. Many people don’t know this, but during the Ebola crisis, there were as many mothers who died due to lack of healthcare as there were people who died of Ebola.  (link to model reference) It’s quite frightening, in fact, one model from Johns Hopkins University predicts that if these disruptions are maintained and severe over 12 months, the worst-case scenario could mean 130,000 additional maternal deaths.

Another major concern is vaccination – COVID-19 and otherwise. I hope there will be a COVID-19 vaccination in the not-too-distant future – but low-income countries are often the last to have access to vaccines. And the distribution of vaccines during the crisis is a major concern. Most vaccine programs for measles and polio have been suspended right now. These are diseases that we have been nearly able to eradicate due to mass vaccinations in these countries. It is alarming that we can possibly see a resurgence of these diseases.

Q.

How is Laerdal Global Health positioned to help?

A.

One of the first things we thought about was How can we help the midwives – who are the end-users of our products - -to better face this situation. And we realized we didn’t have the platform for this. We’ve only reached our users through our partners, those who are delivering the training. So we partnered with a Danish organization called the Maternity Foundation (link) that makes an app that is used in 40 countries and they are “in the hand” of many midwives already. So together, we developed some COVID-19 specific e-Learning modules, videos, and even simulation scenarios. And we quickly tested it with 60 midwives in Tanzania and got very positive feedback. Just running through scenarios of how to receive a patient with COVID-19, how to treat them, how to use PPE, how to maintain respectful care, and more. Practicing all of these things in a team-based simulation setting was very valuable for them.

Another thing we did once we learned that many of our partners have had to cancel their face-to-face maternal and newborn training, we quickly began the major effort to digitalize our Helping Mothers Survive and Helping Babies Survive training programs. We’ve really had to learn how to work differently for delivering a course virtually. We’re using animations, integrating videos, adding quizzes and interactive elements, etc. So, we’ve found that this digital material can also complement the face-to-face training when it resumes. I think this will result in better training in the end. So in this way, COVID-19 is a catalyst for developing better solutions.

Q.

Yale medical historian, Frank Snowden, has said that “pandemics serve like looking-glasses in which societies see their own reflections.” What do you think would be reflected in low-income countries? And is there anything, in particular, you are hopeful about?

A.

I hope that the reflection they would see would be resilience. These communities have been through so much. Many people have been able to get out of poverty in the past 10 years. I am worried that this crisis will be pushed back into poverty, but I also want to believe that they might have a shorter bounce back because they’ve been there before and they know they have the power to rise again.