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The Oxygen Divide

Ventilators for Europeans, Soap for Africans?

One of the more common platitudes about Covid-19 is the myth of the Coronavirus as ‘the great leveler’, infecting world leaders and bus drivers alike. As if we are reassured to find something in our increasingly unequal societies to show our common shared humanity: a deadly virus. But this assertion is not holding up well to scrutiny. Whilst lawyers and bankers work from the safety of their homes, low paid professions like care home staff, hospital cleaners and delivery drivers are clearly more at-risk. Self-isolating is not an option for vulnerable communities such as refugees or the homeless. In the US state of Louisiana, 70% of the Covid-19 deaths are African American, whilst being only 33% of the population. As the pandemic takes hold in the Southern Hemisphere, the supposed equality of all in the face of Covid-19 will be decisively exposed for the lie it always was.

We have seen footage of intensive care units (ICU) buckling under pressure in China, Europe and the United States. However, across large parts of Latin America, Central Asia, the Middle East and Africa the world is facing a different scenario. Gaza has about 40 mechanical ventilators for a population of two million people; the Central African Republic has three ventilators for the whole country of five million; and Burkina Faso a grand total of nine critical care beds for its 21 million citizens.

We could hope that a younger demographic will help mitigate the total impact of COVID-19 in most of these countries, but in MSF we know that many already have comorbidities such as TB, HIV/AIDS, unmedicated uncontrolled non-communicable diseases and common infections such as Cholera, Measles, Malaria. Catching Covid-19 on top of of these infections will prove a deadly combination.

For that reason, MSF’s working assumption is that morbidity patterns will match those seen so far in Asia and Europe: eighty percent of those infected with COVID-19 may not require hospitalisation, but some twenty percent will. Most of these patients will need oxygen therapy, a full quarter of them mechanical ventilation. For those without such care death by asphyxiation is inevitable.

Oxygen and ventilators will be the dividing line between North and South just as access to antiretrovirals drugs (ARVs) were at the beginning of the HIV/AIDS pandemic in the 90s. MSF scaled-up over a few years ARV treatment projects in South Africa to demonstrate this divide was neither necessary nor acceptable. MSF, and others, refused to accept the denial of the severity of the crisis and the fatal indifference toward the fate of people without the resources to afford quality care. We should refuse to accept the oxygen divide now. But we don’t have the time to scale up the response we had with the slower-moving HIV pandemic. Covid-19 moves fast. The virus is highly transmissible and the time between infection and mortality is often less than a month. This time we have weeks to scale up.

Seemingly unprecedented challenges for wealthy countries can seem insurmountable in resource-poor settings. Under-resourced Ministries of Health will inevitably bear the brunt of the difficulties.

The existing humanitarian system, severely limited by global lock-downs and shortages of protective equipment (PPE) and almost everything else, cannot plug the gap.

First, the gulf between the offer of services and the potential demand is massive. In high-income countries we take medical oxygen for granted, it just comes out of the walls into each hospital room via sophisticated in-built piping systems. In the hospitals where we work this is just not the case at all. Each time MSF has to bring in oxygen concentrators that demand stable electricity supplies or source bottled oxygen – not a practical solution for a disease that requires patients to be on oxygen for days or weeks. In many places there are simply no supplies of medical-grade oxygen.

Second, very few humanitarian organisations have the knowledge or logistics required to provide high-end medical services. We have seen this in recent Ebola epidemics in West Africa and DRC. MSF found itself in the unusual position in the West African 2014/2015 Ebola epidemic of having to train international and national NGOs on how to organise effective treatment responses. A significant number of NGOs stepped up to the challenge and deployed successfully in West Africa alongside MSF and in support of MoH efforts. But that outbreak was not global, and supplies were not running out before it even started.

The aid system will have some capacity to implement complex but less technical interventions focused on community strategies, health promotion, provision of safe water and the distribution of hygiene material. MSF will contribute where it can to these activities with a focus on protection of medical staff and outbreak control measures. When it comes to the sharp end of hospital care, expertise and real capacity lies outside of the aid system. Even for MSF, an organisation specialised in medical emergencies and epidemic response, we rarely provide intubation for more than a few hours or days to trauma patients in our warzone hospitals. Intubation at-scale over several weeks for each patient is a highly specialized skill, in short supply even in well-resourced countries.

Still, MSF plans to provide essential care of critical cases with oxygen therapy and, in a few settings, deliver intensive care with mechanical ventilators. We need to challenge the divide, this socio-economic triage where minorities, vulnerable groups, slum dwellers, and in some cases entire populations, will have no access to care and oxygen.

None of this will be possible unless current obstacles are surmounted. Freedom of movement across borders for medical and humanitarian staff should be facilitated. Bans on exporting medical supplies to particularly vulnerable countries should be lifted. Newly produced medical equipment, drugs and PPE need to be made available beyond national borders.

There is some light at the end of the tunnel. In a few months, as the centre of the epidemic shifts, there may be a surplus of mechanical ventilators, oxygen delivery apparatus and other vital equipment, along with doctors and staff who have become experienced in treating COVID-19. Medical personnel will have acquired invaluable experience in treating this virus in Asia and Europe, and some will want to share that expertise – as we have seen with doctors from China supporting the Italian Ministry of Health. Although this prospect may be months away, this transfer of equipment and expertise will eventually save lives.

Hopefully COVID will ultimately be defeated by science and control measures. In the meantime, MSF and other humanitarian agencies have to aim to cover the full range of epidemic response, from prevention to critical care, everywhere. We must denounce all policies that leave half of the world’s patients to face the pandemic without any access to the oxygen and ICUs available in the North. We should reject policies that expect those living in the South to settle for soap and leaflets telling them to wash their hands. We should not accept that many amongst the unfortunate 20% who will fall very sick will die for want of a few litres of oxygen.

Photo by Maya Abu Ata © MSF, 2020.

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