COVID-19; Reflecting on a Globalized Response

COVID-19; Reflecting on a Globalized Response

As I write this is, it has been 200 days since the first reports in China came out regarding an unspecified viral illness in Wuhan, China. What is now the pandemic of COVID-19 has spread around the world, and in history books and our collective memory, the year 2020 will forever be closely associated with this virus. There have been nearly 14 million confirmed cases around the world and nearly 600,000 known deaths from COVID-19. Some countries have done incredibly well with containment measures, while others continue to see case counts grow every day.

It has been fascinating to see how the outbreak has had different impacts in communities around the world, including how local and global responses have efficiently controlled or been unable to contain this novel public health problem. Prevention and mitigation strategies continue to form the foundation of public health management of this outbreak. The capacity for any country or locality to provide the most invasive supportive care is widely variable, and even when it is available mechanical ventilation is certainly not a panacea as COVID-19 case-survival rates in those being mechanically ventilated have been low (from 14% to 25%).

At the core of the variable outcomes seems to be a mix of sociological issues: a mix of personal beliefs, geography, politics, socio-economics and health infrastructure which lead to vastly different outcomes around the globe.

The accumulation of more epidemiological data over the past 200 days has improved our collective understanding of the COVID-19 virus, as today we have improved models and a better understanding of the rates of asymptomatic carriers (estimated at 40%) and mortality rates (1.4%-15.4%). Yet still, uncertainties and local variability (even within countries) have made an accurate calculation of the COVID-19 basic reproductive number (R0; the number of people who are infected by a single disease carrier) difficult. In the early stage of the outbreak in Wuhan, R0 calculation ranged from 1.4-5.7, and some have suggested that instead of single R0 value, modellers should consider using ongoing contact tracing to gain a better range of transmissibility values.

We have seen how prevention strategies such as hand-washing, face-masking, and physical distancing can impact local and disseminated disease spread. While many communities have come together through a collective approach to lock-downs and universal masking measures, other localities have struggled to get adequate levels of citizen compliance. Others have struggled with obtaining testing supplies. Certain political systems allow for streamlined and unified directives while others have made it difficult to provide adequate centralized coordination.

As the COVID-19 pandemic has spread to almost every country in the world, outbreaks are smoldering in much of the global south. While the United States continues to see rising numbers of cases with numerous states confronting ongoing daily record high incident cases, other countries such as Brazil are seeing similar upward trends. At the global level, the curve of daily incident cases seemed to have “flattened” and held steady through much of April and into May with aggressive seemingly worldwide measures. However, since the last days of May, global incident cases have been again steadily increasing. This is likely due to a variety of reasons but is linked, at least in part, to efforts to reopen economies and return to pre-pandemic routines and lifestyles.

covid-19 daily cases
Source: Johns Hopkins University Coronavirus Resource Center https://coronavirus.jhu.edu/map.html, accessed July 17, 2020

As an American citizen and a physician with training in public health, it has been both interesting and frustrating to see the how some countries (including my own) have had deficiencies in dealing with testing and basic prevention (such as mandatory universal masking). While I don’t want to engage in political rhetoric or cast blame in any one place, I do think it is instructive to point out that in the United States (or anywhere else for that matter) the sociological factors of personal preferences and autonomy, geography, and local politics have had an overwhelming influence in determining the progress of the pandemic.

Quarantining has always been a unique problem that sits at the intersection of personal autonomy and communal wellbeing, and is implemented and respected by citizens in different ways around the world. It would seem, at least anecdotally, that cultures with an emphasis on personal independence and autonomous choice have had greater difficulty with containment or in obtaining high levels of compliance with masking and distancing measures, even when compared to other localities with similar socio-economic situations.

These sociological factors are key to responding to and managing any epidemic health concern. We have come to see that in our globalized world, our ability and desire to work together towards a common goal, even at the cost of personal sacrifice, will determine our ability to control both the COVID-19 pandemic and the next health crisis of the future.

Public health education and communication, it would seem, is at the crux to getting collective buy-in and global participation.

Unfortunately, as with so many things these days, such issues can be easily politicized and cause fractured and disparate approaches to response. In our globalized world, this coronavirus outbreak is unlikely to be the last public health crisis we must face as a worldwide community.

As thoughts turn towards what is to come, from vaccine development and distribution to numerous long-term economic impacts, we are not nearing the end of this outbreak yet.

The incidence curve is growing, and there is much work left to be done. My hope is that as we move into the second half of 2020, our global community can continue to find ways to improve communication and coordination in order to come together to approach and control this pandemic collectively. The fate of this outbreak, and likely the next, hangs in the balance.

Cite this article as: J. Austin Lee, USA, "COVID-19; Reflecting on a Globalized Response," in International Emergency Medicine Education Project, August 3, 2020, https://iem-student.org/2020/08/03/covid-19-reflecting-on-a-globalized-response/, date accessed: July 3, 2022

A Medical Student’s Encounter with Disaster

a medical student's encounter with disaster

25th April 2015

A 7.8 magnitude earthquake struck Nepal on 25th April 2015, affecting 35 of the 77 districts of Nepal and causing a death toll of over 8000 lives with 22,309 people reported as injured and an estimated 2.8 million displaced. The following article is based on the first-hand experience of a then fourth-year medical student from Patan Academy of Health Sciences, a tertiary care center in Lalitpur District, one of the worst-hit districts in Nepal.

Rescue work following 7.8 Richter scale earthquake. Image by Omar Havana via https://www.theatlantic.com/photo/2015/04/nepal-after-the-earthquake/391481/
Rescue work following 7.8 Richter scale earthquake. Image by Omar Havana via https://www.theatlantic.com/photo/2015/04/nepal-after-the-earthquake/391481/

Reflection

25th April 2015, started off as a casual Saturday morning. At the boy’s hostel, everyone was preparing for the inter-medical college football tournament which was to start off that day, until the first jolt changed plans for the whole day and many more days to come. Our first response was to rush out of the hostel and make sure our family members and friends were okay. Just as all of us were frantically, unsuccessfully so, trying to contact our families, a friend of mine came running and informed that all medical students were to go to the hospital with their aprons. We had not even considered going to the hospital until my friend arrived; maybe because none of us had faced such a situation before or because we were yet to come back to our right state of mind.

Students ready to receive disaster victims. Image by Online Khabar via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Students ready to receive disaster victims. Image by Online Khabar via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/

As we reached the hospital, it was already flooded with injured patients from the disaster. Everyone started doing what they could. Some started giving analgesics to people who were agonized by the pain, some started talking and trying to calm down people who were on the verge of hyperventilation, some took gauge pieces and pressed it against the bleed on people’s head and some helped in patient transportation. There were a lot of people doing a lot of things, but neither was I in very observant state of mine nor could I recall enough now to mention the minute details. One thing I remember with absolute clarity is that me and my friends (as I found out in the after talks) forgot that we were trying to contact our families when we were called.

Medical students providing Tetanus Toxoid injection to victims. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Medical students providing Tetanus Toxoid injection to victims. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/

A lady was lying on the floor, covered with mud, she wasn’t moving at all. My friend and I suspected she was seriously injured but didn’t see any obvious wound from where we were standing. We went near and tried to feel the carotid pulse. Never in my life had I even remotely imagined that one day I will confuse whether or not the carotid pulse is present. But there I was. I didn’t feel the pulse, but I was reluctant to admit that she didn’t have one; so we decided to ask one of our teachers. We did and got the obvious answer. Now we were to put the black tag on her and take her to the black area. She was the first to be taken to the black triage. Before putting her down from the stretcher, we took the pulse again. It was one of my first encounters with death declaration.

I came out of the front door and was among a lot of injured patients; nerve wrecked students and doctors trying to help people in the best possible way. It was then that most of us remembered that we hadn’t contacted out families yet; maybe sadness had taken over our survival instinct or maybe we were learning to keep our professional duties up ahead. This continued for the day and the next day was nearly the same; only a little more organized. Basically, the name of the game for the couple of days that followed was help in all that you are capable of.

Apart from being the most traumatizing experience of our life until now, this earthquake also taught us some lessons and profoundly so. I knew that survival instinct takes over everything at first when you perceive a threat to our life; however, once you are just out of the instinct and see before you, the circumstance that you are trained to deal with, you prioritize things and work in the line of your training.

Survival instinct takes over everything at first when you perceive a threat to our life...

Students raising awareness to prevent possible outbreaks. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Students raising awareness to prevent possible outbreaks. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/

a need for disaster curriculum to be rigorously taught to every medical student.

One thing that I realized while trying to help the casualties that will help me every time I sit to study is: no matter how much you memorize stuff until you really understand something well, you won’t be able to use the knowledge when it is most needed. The disaster drill that we performed a few months before the disaster helped us make sense of triage, proper transportation and of what was happening. I realized the importance of training and keeping myself updated on skills that we need at times when we are less likely to think rationally. Also, I felt a need for disaster curriculum to be rigorously taught to every medical student. Medical students formed an important workforce during this disaster. Having occurred on the weekend, medical students were the most readily and adequately available resource. However, with limited knowledge and skill, medical students left to work unsupervised are prone to cause harm to themselves and patients; hence proper training and work delegation are required so that they can become a better-skilled workforce.

This was yet another example for me to ponder and reinforce upon myself that not everything will go on as planned; hence, I need to keep myself updated and work on my improvising skills. This event as devastating as it was also made me feel proud of what I am training to become and instilled in me more passion towards my profession.

Further Reading

  • World Health Organization, Regional Office for South-East Asia. Nepal earthquake 2015: an insight into risks: a vision for resilience. New Delhi, India: World Health Organization, SEARO; 2016. Available from: https://apps.who.int/iris/handle/10665/255623
  • Sheppard PS, Landry MD. Lessons from the 2015 earthquake (s) in Nepal: implication for rehabilitation. Disability and Rehabilitation. 2016 Apr 23;38(9):910-3.
  • Nepal earthquake of 2015 – link
Cite this article as: Sajan Acharya, Nepal, "A Medical Student’s Encounter with Disaster," in International Emergency Medicine Education Project, August 5, 2019, https://iem-student.org/2019/08/05/a-medical-students-encounter-with-disaster/, date accessed: July 3, 2022