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 Table of Contents  
EDITORIAL
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 49-53

What's New in Academic International Medicine? Academic International Medicine and life after COVID-19


1 Division of International Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York, NY, USA
2 Division of Emergency Ultrasound, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
3 Division of International Emergency Medicine, Louisiana State University, New Orleans, Louisiana, USA
4 Department of Emergency Medicine, Weill Cornell Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
5 Family Medicine, Elitra Health, New York, NY, USA
6 Division of Trauma and Critical Care, Rutgers-NJMS, Newark, NJ, USA

Date of Submission27-May-2020
Date of Acceptance16-Jun-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
Dr. Christina Bloem
Division of International Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York, NY
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_70_20

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How to cite this article:
Bloem C, Butts C, De Wulf A, Garg M, Garg S, Sifri Z. What's New in Academic International Medicine? Academic International Medicine and life after COVID-19. Int J Acad Med 2020;6:49-53

How to cite this URL:
Bloem C, Butts C, De Wulf A, Garg M, Garg S, Sifri Z. What's New in Academic International Medicine? Academic International Medicine and life after COVID-19. Int J Acad Med [serial online] 2020 [cited 2020 Nov 29];6:49-53. Available from: https://www.ijam-web.org/text.asp?2020/6/2/49/287971



Although some controversies continue regarding the identification and management of the early spread of COVID-19 since it was first recorded in Wuhan, China, efforts were made to contain the disease. A cordon sanitaire, a restriction of movement into and out of a defined area, was instituted in January 2020 by the Chinese government; weeks after initial cases were noted. Fifty million people in Hubei province were affected by bans on transit and a lockdown on gatherings. To attend to the steady increase in COVID-19 cases, the Chinese government allocated the United States (US) $145 million to rapidly construct new hospitals.[1] At the same time, China was also criticized for possible underreporting of cases. Modeling based on known transmissibility of the coronavirus indicated that there would have been up to ten times as many cases as officially reported.[2] This discrepancy has significant implications, as thousands of unrecognized cases could have been spreading disease undetected.

Individual countries and regions approached the pandemic with varying approaches and with variable success, highlighting the strengths and weaknesses of individual health systems. Public health crises require a uniform response, particularly when they are of pandemic proportions. Countries with a long history of highly valuing individual freedoms, such as the US and the United Kingdom (UK), experienced struggles with instituting vast limitations of freedom of movement. The political climate of our world and the polarization that results also informed the response to the virus. Although a pandemic of this size and scope has not been seen for decades, many countries have experienced smaller scale outbreaks that gave them experience and resources to better combat this test.

South Korea focused on testing early, with early use of accessible testing and containment measures for infected or suspected infected. Although the country did not impose formal lockdowns, they used countrywide text messaging to spread information and to promote social distancing.[3] These aggressive and coordinated efforts resulted in an early “flattening of the curve,” although periodic outbreaks continue.

New Zealand's aggressive early lockdown measures helped to mitigate coronavirus and built on an elimination strategy. When New Zealand had 102 confirmed coronavirus cases, Jacinda Ardern, the Prime Minister, increased the alert level of the country to 3. Two days later, New Zealand was on complete lockdown and the alert level was increased to 4. To date, New Zealand has had 1500 infections and only 21 deaths, with a population of 4.8 million people.[4] Although testing capability may have been somewhat limited, the early lockdown and low death rates have proved successful.[5] As of May 25, there have been no new cases of coronavirus and the country is slowly decreasing lockdown measures.

Iran was also impacted early in the pandemic. Cases were noted in the country in January, but the existence of the virus was not publicly acknowledged until February. Iran suffered from a lack of testing supplies and this, in conjunction with allegations of secrecy regarding the severity of the outbreak, has led to charges of intentional underreporting of prevalence in Iran.[6]

Italy represented one of the hardest hit countries in Europe and a harbinger of things to come outside of Asia. The approach by the Italian government was disjointed, resulting in step-wise increases in containment protocols rather than uniform guidelines. Testing, tracing, and containment procedures were instituted at varying times and were not uniform from region to region, resulting in some regions, such as Lombardy, being hit much harder than others.[7] Italy also demonstrated to the world the danger of finite health-care resources being overwhelmed by large numbers of critically ill patients.[8]

The US exhibited similar challenges to Italy, with inconsistent guidelines regarding distancing and closure of public spaces. As the US is composed of 50 semi-autonomous states, policies and timelines varied and some areas experienced more severe outbreaks than others. New York State, in particular, was greatly affected early on, with more than 28,000 deaths attributed to COVID-19 by mid-May. The availability of testing continues to be a major issue, with some areas having little access. As of this writing, the US has almost 1.5 million documented cases but is likely missing thousands of cases due to a lack of availability of testing. It is nearly 100,000 deaths that represent the largest death toll in the world.[9]

As in many countries, Brazil's response has been characterized by confusion and political motivations.[10] COVID-19 did not substantially affect the country until late February, but transmission has outpaced countries of similar size and now has the most cases in South America. The country faces multiple challenges in its response, an interesting combination of challenges seen in both high- and low-income countries. Despite its high-income economy, the striking poverty and densely populated favelas more closely mirror low-income countries and represent a significant challenge to physical distancing. Brazil's indigenous population is of particular concern in light of the lack of support from its central government. As in many other countries, politicization of information has been evident, with a lack of consistent and science-based guidance.

The UK suffers from many of the same challenges as other similar high-income countries, with access to testing and protective equipment an ongoing problem. A delay in mandating public health procedures such as the closure of public spaces, initiation of physical distancing, and community testing added to a chorus of criticism for the government's response.[11] The prime minister of the UK, Boris Johnson, tested positive for coronavirus and required hospitalization. Although the effect of this development remains to be seen, it perhaps made the situation more real for those both in the government, as well as for regular UK citizens.

Politics certainly has influenced the response to the pandemic, as noted above in Iran, China, and the US. Many see a worsening outbreak as a threat to their political power and chance of reelection. Tanzania's president, John Magufuli, has publicly stated that the rate of positive cases in his country is due to false-positive tests created to make him look bad.[12]

Tracking the outbreak throughout low- and middle-income countries (LMICs) has been particularly challenging. Testing, as in the countries listed above, has been a challenge, and certainly, the number of cases is likely underreported. However, even accounting for this difficulty, the number of expected deaths has not risen at a rate consistent with a widespread outbreak in these countries. This is, in many ways, surprising, as the public health support systems needed to combat a pandemic (testing, capacity to isolate or physically distance, health-care infrastructure, and economic support) are often limited. This may represent an incomplete picture, an early snapshot of a possibly worsening outbreak, or another factor yet to be determined.

Conversely, experience with prior epidemics, specifically Ebola, has left several lower resourced countries with valuable public health lessons. The Democratic Republic of Congo reported its first case of COVID-19 in early March and has since grown to over 700 cases. The country has instituted hygiene stations in hard hit areas and sought assistance in isolating positive cases that otherwise would not be able to self-quarantine.[13] Liberia instituted a robust contact tracing program, as a result of lessons learned during its own Ebola outbreaks.[14] Perhaps, the most striking example of applying the lessons of prior epidemics was seen in Sierra Leone, one of the hardest hit nations in the Ebola epidemic. Building on its prior public health response, the nation took early action, developing a preparedness plan 3 weeks prior to its first case. This enabled the country to identify cases quickly and place them into quarantine, minimizing the spread of disease. To date, the country reports 338 cases with only 19 deaths, in a nation with a population of just over 7 million.[15]

Similarly, Vietnam relied on its experiences during the severe acute respiratory syndrome outbreak. Early travel restrictions, border closures, school closures, and health checks were instituted in late January. Intensive contact tracing allowed the country to focus on and isolate areas where pockets of positive cases were found. This allowed testing to be focused on areas with high prevalence. Although there are concerns regarding the authoritarian response to the pandemic, the results are striking. Out of a population of 97 million people, the country has recorded 300 cases of COVID-19 and no deaths.[16]


  Toll on Providers Top


Mental health effects of disasters on health-care workers (HCW) have been traditionally underrepresented in discussions of international health and disasters. The COVID-19 pandemic has however exposed the tremendous need for a focus on robust mental health responses for health-care providers in disaster preparedness and mitigation. The toll of the pandemic on HCWs will have enduring physical and mental health consequences. According to recent Centers for Disease Control and Prevention data, HCWs accounted for 11% of all COVID-19 infections in the US, although this percentage likely represents an underestimation. Of HCWs who were infected, 8%–10% were hospitalized, 2%–5% were admitted to an intensive care unit, and 0.3%–0.6% died despite a young median age of 42.[17]

In addition to frequent high-risk exposures to infected patients, the risk for acquiring COVID-19 is related to the lack of access to personal protective equipment (PPE). This left many HCWs questioning safety initiatives put forth by hospitals and health systems. The consequence of this feeling of insecurity, either propagated by lack of planning, disruptions in the supply chain, resource-poor institutions, or leadership miscalculations has long-lasting ripple effects on the physical health and psyche of HCWs. HCWs in LMICs will likely continue to be disproportionately affected by inadequate PPE, a noted deficiency in previous assessments of preparedness during the Ebola crisis in Ghana.[18]

Particularly in regions of high COVID-19 prevalence, repeated exposure to dying patients, being the sole interface during end-of-life discussions with families who are not allowed at the bedside, and lack of evidenced-based ethical and clinical guidelines have resulted in clear negative impacts on mental health. Many HCWs know someone personally who has been ventilated or has died from the disease. The risk of bringing the virus home to one's family has caused many HCWs to self-isolate and/or live apart from their loved ones when they need them the most. The impact of quarantine and self-isolation can negatively impact HCWs and lead to mistakes at work, erratic behavior, and cognitive function decline.

There are a number of ways to help address the mental health of HCWs. Proper mentorship and effective leadership are essential to preventing burnout. Hospitals providing proper PPE, creature comforts (food, lodging, transportation, and gifts), and psychiatric support have also been suggested to relieve mental health distress. Hospitals and organizations implementing a “hear me, protect me, prepare me, support me, care for me” model may ease some of the stress of the pandemic.[19] Mental health resilience of HCWs will require a sizeable cadre of professionals skilled with navigating posttraumatic stress disorder, grief, depression, and burnout.

It is imperative that we learn from these lessons and are prepared to navigate future pandemics and disasters. These lessons are not being learned for the first time. As noted by HCWs in Sierra Leone during the Ebola epidemic, isolation from family and communities, inadequate PPE, watching colleagues die, and increased stress and workload all contributed to negative mental health effects of HCWs.[20] Having HCWs that are physically safe and mentally stable as well as health systems with leadership that can adapt and support their HCWs is the foundation of this preparedness.


  Academic International Medicine and Emerging Lessons Top


Academic International Medicine (AIM) has been challenged on multiple fronts during the COVID-19 pandemic. Aside from the obvious limitations on travel, all person-to-person interactions currently carry significant risk for spreading disease. This must be considered, particularly in regions ill-equipped to handle everyday health emergencies, letalone the large patient loads associated with a pandemic. As international programs are dependent on effective collaborations with local stakeholders, maintaining close relationships is critical. International travel is imperative to maintaining effective communication, in particular, when language or cultural barriers exist or when access to communication platforms are hampered by cost or infrastructure limitations. With severely restricted travel, this key component of international programming has been compromised.

The challenges inherent to limited-resource settings, such as unreliable or unavailable Internet for the use of virtual platforms, as well as countries' attention currently turned toward managing the pandemic, have necessitated that many programs be put on hold. Organizations have had to consider alternative methods to remain connected with partners to keep forward momentum with previous projects and to support international partners through the pandemic itself. These pauses in program implementation and international medical research have been further challenged by uncertain timelines and funding, particularly given the severe economic impact of the pandemic and an anticipated shifting focus of funders shift toward pandemic-related priorities. Academic international conferences have been canceled, with some choosing virtual formats in place of in-person gatherings. Without face-to-face networking enabling collaboration, the sharing of best practices, and emerging data surrounding AIM topics, opportunities can be lost.

At the same time, this period represents an opportunity to evaluate and improve health-care systems, infrastructure, and to train personnel to treat large numbers of acutely ill patients. Telemedicine and telecommunication may offer potential opportunities to continue and expand AIM projects while limiting person-to-person contact.

The COVID pandemic is irrefutable proof of the interconnectedness of health and populations around the world. Largely due to online access to medical literature and the willingness of medical providers to share preliminary information about their experiences with this novel illness, a lot has collectively been learned about COVID-19 in a short period of time. Furthermore, as different health systems have coped with the influx of ill patients, current health systems have been challenged in new ways, exposing weaknesses and other areas for improvement.

Knowledge acquired from these experiences must be shared with our colleagues worldwide to improve global preparedness. Lessons learned about PPE supply chains, infectious disease command centers, surging hospital capacity to meet a rapidly growing number of patients, therapeutic interventions and protocols, HCW protection guidelines, and community containment strategies are just a few examples of valuable lessons learned that should be disseminated. Previous mistakes resulting in increased patients as well as HCWs, infections, and deaths cannot be repeated. Lessons learned from our partners in high-income countries as well as LMIC should be shared, as we seek novel containment strategies and cost-effective solutions for care in light of the resource limitations that have emerged.

AIM is well suited to addressing the challenges of COVID-19. With clinical knowledge gained through experience with the virus, a long-standing history of collaboration with international partners, academic backgrounds and institutional support systems to evaluate and share data, we, as practitioners of AIM, have the imperative to develop and share what we believe at this time are best practices for the care of the COVID patients, the protection of HCWs, and to mitigate the damage caused by the virus. We play an important role in bidirectional communication to develop strategies for the pandemic response, to share knowledge, and to lend expertise and human resources to areas with already overstretched health systems. Alternate methodologies for executing these functions during the pandemic will prove useful moving forward, as the landscape of international work will likely be altered for some time to come.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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