Written by Rebecca Alcock //
On June 3rd, 2018, a volcano erupted in the heart of Guatemala. Its ash plume was visible from space, and its name, Fuego, suddenly stung with honesty. The eruption delivered the deadliest volcanic byproduct: pyroclastic flow, a high-speed surge of lava, rock, ash, and gas. Pyroclastic flows reach temperatures up to 1000°C and hurtle down volcanoes’ slopes as fast as commercial airplanes fly. It is the type of event that suits science fiction novels, but experiencing the ash fall first-hand and witnessing the extent of devastation for what, and who, lay in its course brings the phenomenon into harsh reality.
At the time of the eruption, I was living and working in Guatemala. I served as a field intern for the non-profit Engineers Without Borders (EWB), supporting the pre- and post-implementation site assessments for infrastructure projects. Less than 20 miles from the volcano, my friend and fellow intern Tabatha Davis and I navigated a city blanketed in ash, trying to learn the cause of the chaos and confusion. We secured a Wi-Fi connection at a McDonald’s and watched as the death and missing person counts climbed. In the following days and weeks, numerous disaster response efforts crystallized, from local donation drives to World Central Kitchen’s emergency food assistance program. Within the EWB organization, the Engineering Service Corps entered a collaboration with Rotary International and the Guatemalan government’s emergency response bureau. The team mobilized to rebuild crucial infrastructure in the communities surrounding the volcano and had the foresight to formally establish a response framework that would allow them to act quickly in future disaster scenarios. In fact, these partnerships would pave the way for the substantial COVID-19 response efforts underway today.
COVID-19. As the pandemic ravaged New York City and began its first assault on the American Midwest, our team wondered how the clinics in Guatemala would fight the virus once it reached their shores. We imagined the difficulty of mitigating transmission without access to water or providing patient care without proper protection and medical equipment. To investigate the veracity of our intuition, we engaged with local stakeholders on the front lines, and these conversations confirmed our hypotheses. As a result, our response objectives became threefold: to improve hospital and clinic infrastructure, enable local production of personal protective equipment (PPE), and repair ventilators that were broken due to flawed donation or maintenance systems. In some cases, ventilator donations were not accompanied by replacement parts, or importing their specialized components was cost-prohibitive. In others, proper training was not provided to local technicians to conduct preventive maintenance, or the owners of leased ventilators let their units fall into disrepair.
The work to achieve our three aims matured in several stages, starting with rapid assessments of needs and existing manufacturing capacity. No domestic PPE production was afoot at the outset, but thanks to our EWB and Rotary partners on the ground, many facilities were identified as potential candidates based on their capital equipment and pre-pandemic capabilities. For example, apparel shops converted to mask and gown production. In another case, an industrial sign manufacturer repurposed its facilities for face shield production. With a handful of committed companies, we moved on to the next stages: prototype development, evaluation, and finally mass production. Over 75,000 units of PPE were distributed to 11 hospitals within the first four weeks. To date, seven manufacturers and hundreds of workers have been mobilized to produce nine different products, including face shields, reusable masks, and coveralls. Simultaneously, a local biomedical equipment technician from the NGO Engineering World Health traveled to clinics throughout Guatemala and diagnosed the broken ventilators. He worked with our team to secure the necessary parts and brought 50 ventilators back to life. Additionally, several members of our team in America and Guatemala collaborated with local engineers and contractors to improve water, sanitation, and hygiene infrastructure at over 15 healthcare facilities. Ultimately, the scale and speed of the response in Guatemala led to partnerships between the University of Wisconsin–Madison and the United Nations Development Programme (UNDP) to expand the work to other parts of the world.
Over the past eight months, our interinstitutional team, with members from the UNDP Crisis Bureau, EWB, and UW–Madison, has learned that responding to COVID-19 is different than responding to “ordinary disasters,” like tropical storms and earthquakes. The most notable distinction is that disasters are typically localized to a community, country, or region. For example, when a hurricane hits the Gulf Coast, construction materials from unaffected neighboring states can be reallocated until damaged infrastructure is restored. COVID-19’s global expanse has largely eliminated this type of resource sharing, which strengthens the case for a community-driven response like that undertaken in Guatemala. Our mission to increase the resiliency of the Guatemalan healthcare system to the virus’s myriad challenges held steadfast throughout the response, always grounded in local needs and capabilities. However, our strategy to achieve that goal evolved each week as we gained new insights into international pandemic response.
Field Note #1: Thoughtful prioritization is key to an effective response. In the early days of the pandemic, many conversations focused on ventilators. COVID-19, in the most severe cases, can cause respiratory distress that requires mechanical ventilation. Naturally, people questioned if hospitals were equipped with enough ventilators, especially in low- and middle-income countries (LMICs), to meet the rising demand. We learned that there were only 60 known functioning ventilators throughout the entire country of Guatemala and were tempted to concentrate on this issue. However, through conversations with clinicians and faculty experts on lung biomechanics, we soon realized that ventilation as a treatment is not as simple as making new ventilators available. For instance, it requires the patient to be sedated, but a consistent supply of anesthetics may not be readily available. There are similar logistical challenges for oxygen supplies and filters. Further, the ventilators must be fail-safe to unreliable power sources, and respiratory therapists or other trained personnel must be on site for safe operation.
Lastly, the ugly truth is that ventilators’ track record of saving lives is less than confidence-inducing. A patient may spend weeks on a ventilator only to lose their battle to the virus, which decreases its value in the context of disaster response. For example, with an investment of $90,000, one could purchase three new ventilators and save 1-2 lives over the timeframe of a month or more. The same investment could repair hundreds of existing ventilators, buy 450 non-invasive ventilation helmets — a mid-level medical intervention for patients under respiratory distress — or even purchase 45,000 face shields. Such investments have the potential to save many more lives over a shorter period of time than buying new ventilators. For these reasons, our team opted to repair broken ventilators sitting idle at clinics and focus the rest of our efforts on local PPE production and infrastructure development, despite the early popularity of ventilator procurement.
Disaster response often requires practitioners to compare strategies with difficult cost-benefit analyses like these and make prudent, sometimes uncomfortable, decisions. This is particularly true when funding is scarce or spread thinly between initiatives. In considering these trade-offs, context of implementation must also be considered. The best use of resources in Guatemala may not be the same in Kyrgyzstan or Malawi, depending on factors like stakeholder involvement and types of local industries. Overall, prioritization serves as a useful tool for ensuring that no investment is wasted and that those responsible for directing the response have confidence in their choices.
Field Note #2: A health system’s capacity to mitigate COVID-19 is largely determined by external factors. To non-experts, health is narrowly defined as one’s physical and mental wellbeing and attributed to exercise, nutrition, and genetics. However, this interpretation excludes the latent contributions to an individual’s or population’s health, such as environment, education, and economic stability. These are examples of the social determinants of health, which are not only instrumental to one’s health but also to health systems. A hospital’s relative vulnerability to COVID-19 and its capacity to manage an effective response and care for its patients hinges on these factors.
In Yemen, for example, how do you conceive of responding to a pandemic when your health system is largely a bootstrapped humanitarian effort? When your society is suffering from ongoing conflict and teetering on the brink of economic collapse and famine? The country was already navigating multiple crises when COVID-19 knocked on its door. The mere thought of addressing the virus within a nonexistent healthcare infrastructure is overwhelming, and to actually execute a response strategy is fraught with complexity. Subsequently, the pandemic’s direct toll on the health of Yemenis, as well as its implicit consequences on their economic stability and food security has and will continue to disproportionately affect those living in Yemen versus other parts of the world.
To put it simply, this case demonstrates that the deck is stacked against health systems situated in LMICs. Of course, these types of external factors and others, such as leadership and support of local or national governments, influence health systems all over the world and even cause significant variation in the quality of healthcare available within a country’s borders. However, one in four healthcare facilities worldwide lacks access to water, and 1 billion people obtain healthcare in clinics without electricity. Circumstances like these place upper limits on the quality and quantity of care that can be provided at health systems in LMICs and contribute to their current capacity to mitigate a pandemic. Response strategies in these environments require creativity and resilience, which makes the success of the UNDP program in Yemen all the more impressive.
The situation in Yemen called for exceptional ingenuity, which is precisely what the young engineers with whom we worked manifested. All other options exhausted, they took into their own hands the task of increasing the country’s manufacturing capacity in the face of the numerous, seemingly insurmountable obstacles. The team designed and constructed an automated surgical mask production machine using locally-available hardware components and limited engineering resources. Now, their solution is being deployed at small and medium enterprises throughout Yemen with the help of the UNDP country office. Despite all odds, the project has high prospects of generating a sustainable supply of quality face masks. Without the engineers’ resolve and innovative vision, the promise of local production in Yemen may have never been realized.
Field Note #3: We must work to make our supply chains more resilient and more equitable. In March and April, headlines bounced between rising case counts and product shortages. Photos of healthcare providers dressed in inadequate PPE were shared on social media, and discussions about our global supply chains became mainstream. We learned that decades of maximizing efficiency and profits had left the network of raw materials producers and PPE manufacturers concentrated among few businesses and that the supply chains had been made so lean there was little slack to handle increases in demand. Both of these factors left the world’s medical supplies vulnerable to depletion. Additionally, governments implemented policies to prevent the export of these products, and key links in these business chains shut down for weeks at a time as COVID-19 swept through their employee base.
When global supply chains are disrupted in this way, procurement in LMICs becomes nearly impossible. These countries, already strapped for funding, often have weak currencies and less overall leverage for negotiation, making it harder to acquire materials than in wealthier countries. This is exacerbated by the fact that institutions around the globe were panicking and vying to purchase all the PPE they could for their healthcare providers. Further, the inaccessibility of quality PPE through traditional channels increases these countries’ susceptibility to fraudulent schemes and perpetuates the lack of confidence that both providers and patients have in their health systems. It is clear that these shortcomings must be addressed to adequately and equitably prepare for another pandemic. For example, web platforms that offer transparency of inventory and coordination of PPE distribution at the national or international level could help healthcare organizations make more informed decisions on their procurement and conservation strategies, while also expediting the movement of these products from stockpiles, distributors, and producers to the hands of those that need them most. Calls to rethink the PPE supply chains have been met with solidarity from healthcare professionals and administrators, policy makers, and supply chain experts, and efforts to enact such changes are already underway.
In closing. These field notes represent only a small sampling of the lessons I have learned since March. Every day there are new observations to record and every week a discussion to be had re-evaluating what was learned the week before. The one characteristic of the response to COVID-19 that has remained the same, however, is that it differs greatly from responding to the more “ordinary disasters.” The virus’s grips have spanned the globe, rendering traditional response strategies futile, and spurred innovation in mitigation approaches and medical technologies. We have seen massive community mobilization, and an unprecedented degree of interest and involvement in disaster response. People everywhere have offered their time, talent, and financial resources to ensure our healthcare providers are protected, whether sewing reusable masks to extend the lifespan of N95s when no others are available or donating to EWB’s initiative to repair broken ventilators in Guatemala. As we emerge on the other side of COVID-19 over the next months or even years, I hope we maintain our current ethic of global collectivism and advance its influence into actual policies. Here’s to a shared path forward.
Special thanks to Elise Ahn, Dana Cook, Yuko Hirose, Mike Paddock, Jessica Thayer, and the many others with whom I have had the pleasure of working on international COVID-19 response over the past eight months. The early-morning conversations and brainstorming sessions we shared inspired many of the themes presented in this piece.