COVID-19 and global health: Influences and implications for education and training support in low- and middle-income countries

The past 6 months of the COVID-19 pandemic have changed nearly all aspects of medical care in countries around the world and this includes education and training. This has major foreseeable and unforeseeable implications for medical and healthcare training, especially in low- and middle-income countries (LMICs) already challenged by poorly resourced health systems.

Australia and New Zealand, via the tripartite support of Fellows and members of the Australian and New Zealand College of Anaesthetists, the Australian Society of Anaesthetists and the New Zealand Society of Anaesthetists and also via the World Federation of Societies of Anaesthesiologists, have a long history of anaesthesia training, education and support to the Pacific Island Countries, Federated States of Micronesia, Papua New Guinea, Timor-Leste, parts of Southeast Asia, Mongolia and some African nations. However, existing programmes, support and initiatives are all on hold while we wait to see what happens next with the pandemic as it evolves in different regions and countries.

Effects of COVID-19 on LMIC health systems

COVID-19 is subverting many of the goals achieved in global health in recent years. So far, more than 96% of deaths have been in ‘affluent’ countries, including Brazil, China and Iran. ¹ LMICs have different age, population density and other demographic factors to consider when trying to predict the effect of the pandemic in these countries. The disease is still spreading and increasing. Globally there are now around a million new cases per week at the time of writing (early July 2020).

In the western Pacific region numbers are relatively low to date, with over 300 cases and only seven deaths across Guam, Fiji, French Polynesia, Papua New Guinea, New Caledonia, Northern Mariana Islands and Timor Leste. ² Countries such as the Cook Islands, Kiribati, Nauru, Marshall Islands, Samoa, Tonga, Palau, Tuvalu, Vanuatu and the Solomon Islands have had no cases at the time of writing. This has been attributed to early country lockdown and border closures. However, Indonesia is seeing a marked increase in cases, and accurate detection and data collection can be challenging or impossible in many remote areas of LMICs.

There is significant potential for this to change, with many factors that could make any LMIC the next potential disaster like Italy, Brazil and the United States. ³ Living, working and travelling in close physical proximity, lack of testing (due to limited availability of appropriate tests) and under-resourced health systems with already overcrowded and under-staffed hospitals all contribute. A recent major global modelling study of populations at increased incidence of severe COVID-19 due to underlying health conditions had several significant estimates. ⁴ Firstly, 1.7 billion people (22% of the global population) have an underlying condition that will increase their risk of severe COVID-19, ranging from less than 1% of those under 20 years old to 66% in those over 70 years of age. Additionally, the population at increased risk has been highest in countries with older populations, African countries with high HIV/AIDS prevalence and small island nations with high diabetes prevalence. ⁴

Several of the factors determined by the Lancet Commission regarding safe surgery and anaesthesia will be particularly impacted: these include access, volume of surgery, patient financial viability and numbers of surgeons, anaesthetists and obstetricians. ⁵

Closure of national and provincial/state borders, lockdowns and curfews will severely impact the ability of patients to access the bellwether surgical procedures within the recommended 2 h. Recent modelling has shown an estimated 28 million surgical operations will be cancelled or postponed due to the pandemic. ⁶ This will strike at LMICs the most, where many are already performing emergency surgery only. Postoperative mortality in surgical patients who are diagnosed with SARS-CoV-2 is high. ⁷ , ⁸

Health care workers (HCWs) are a critical resource in LMICs with physician and non-physician anaesthetists being at high risk due to their expertise in airway management in ill patients. In the United Kingdom, the incidence of COVID-positive HCWs rose from 5% to 20% as the pandemic increased, ⁹ and a similar trend could decimate numbers in LMICs for generations.

Recently published data has indicated the risk to HCWs following tracheal intubation of patients with proven or suspected COVID-19 is potentially high. The magnitude of this risk is yet to be accurately defined but, in a prospective international multicentre cohort trial, approximately 1 in 10 healthcare workers involved in tracheal intubation under these circumstances subsequently reported a COVID-19 outcome. ¹⁰ This outcome was defined as either COVID-positive, or new symptoms where the HCW had to isolate or were admitted to hospital. These initial estimates come from high-income country (HIC) hospitals where staff were appropriately protected with personal protective equipment (PPE) whilst performing the intubations – the implications for HCWs from LMICs who may not have reliable access to appropriate PPE, and the potential impact on their workforce, is of major concern. Ensuring appropriate preparation for increasing patient numbers, infection control techniques and training and reliable, high quality PPE supply is imperative.

In LMICs, scarce health resources may be redirected to COVID control so already existing disease entities with significant mortality will be ignored. Roberton et al. reported on a recent modelling study on a potential rise in maternal and child mortality in LMICs if health services already under duress are impacted in any way by COVID-19. ¹¹ This study projected an additional 1.16 million child deaths and 56,700 maternal deaths in 118 countries if coverage of essential services decreases by around 50% for 6 months. Data in 2019 showed that 45 countries spent more on external debt repayments than on healthcare, further impacting health resources. ¹² In April 2020, G20 finance ministers announced a debt service suspension initiative that applied to 77 countries.

Contingency plans are required for the post-pandemic phase. ¹³ The COVID-19 pandemic could potentially reduce progress on global poverty by 20–30 years and increase those living in extreme poverty (income less than US$1.90/day) from 700 million to 1.1 billion in the next few years. ¹⁴

Effects of the COVID-19 pandemic on medical training and education in LMICs

In many countries, there has been a reduction in surgical workload and clinics and, with social/physical distancing, there is less contact between teachers and trainees and smaller group teaching has been required for medical students. Medical student and advanced specialist training have also been impacted. Remote learning can only partly address this deficit. This will affect the quality of training, with less clinical exposure and practice-based learning, but some countries will aim for earlier graduation of medical students to boost the healthcare workforce. ¹⁵ With the paucity of PPE in many countries, there is the increased potential for the loss of part of a generation of HCWs from COVID-19. This is particularly challenging in LMICs where staffing at all levels is always critical. This could include senior clinicians, who carry a significant load of clinical teaching and training.

There are many clinical and educational programs around the world undertaken by professional medical organisations, charities and non-government organisations (NGOs) that will be severely impacted by the pandemic. Volunteers undertaking teaching or clinical work in LMICs will need to have had either COVID-19 with a good immune response, be effectively immunised (which may be several years away) or have access to emergency repatriation via medical evacuation if they become seriously ill. This is very expensive, and the availability of insurance to cover these events is highly unlikely.

Closure of borders in some countries means there may be no travel, in or out, until 2021 and perhaps later. This will be dependent on when borders will reopen and the costs of airline tickets may also increase dramatically. The need for quarantining at either end of a mission will need to be taken into consideration and, in addition to the extra expense, may make these missions unduly long and untenable for many with other clinical and personal commitments in their home country. This will also affect travel in the other direction for scholarships and advanced training in HICs, attendance at major conferences in either country and the core clinical activities of many NGOs. Challenged affluent economies with increasing unemployment will have less funding from government, donations to NGOs will decrease and professional medical bodies may be less financially able to support LMIC initiatives.

Where do we go from here?

Up to 15% of COVID positive patients will need hospitalisation and oxygen therapy. LMICs often have minimal intensive care capacity so tracheal intubation and ventilation will not be a viable treatment option for the severely ill, who will probably perish. These countries may have minimal supplies of oxygen, simple mask delivery systems and pulse oximetry to monitor their patients, and the appropriate provision and monitoring of oxygen therapy will be life saving for many patients in LMICs. ¹⁶ At current COVID-19 rates, the World Health Organisation estimates the world needs an additional 620,000 m³ of medical oxygen/day (about 88,000 large cylinders), and many countries have major difficulties attaining adequate numbers of oxygen concentrators. ¹⁷ HCWs’ skills in using oxygen may also be low, and oxygen-related patient fees may be unaffordable in some LMICs. ¹⁸

‘Hypoxia packages’ consisting of pulse oximetry (e.g. Lifebox™, Acare Technology, New Taipei City, Taiwan), oxygen concentrators, oxygen masks or nasal prongs and clinical bedside guidelines will be extremely useful. ¹⁹ Concentrators require a regular power supply, and other methods of oxygen supply may be appropriate. In a pandemic situation, supply of these are best coordinated at an international level through national agencies, e.g. Australia’s Department of Foreign Affairs and Trade, and facilitated by professional medical organisations where relevant. There must be a responsible and informed approach that any equipment sent is clinically relevant to that LMIC, with appropriate documentation and servicing capability available.

We have already seen a new reality in online education, especially for LMICs. ²⁰ However, in low resource environments, this education needs to have reliable access for trainees that is cost effective. Internet access in many LMICs is very expensive for many HCWs. New frontiers in design and implementation of online medical education are already appearing, ²¹ and we will need to be innovative and comprehensive to allow activities such as high-level interaction, polling, involvement of multiple instructors and breakout sessions. A need for fair and effective online examination for advanced trainees has appeared quickly that must be addressed very soon. This may involve in-country and external examiners with appropriate candidate supervision and conditions.

Physical distancing has placed an increased emphasis on simulation in LMICs that needs to be lightweight, portable, robust, inexpensive and practical. This will need to be tied with appropriate online supervision and assessment of practical skills. All of this provides new challenges to medical educators both within and outside LMICs that needs to be addressed urgently.

Our colleagues will also need psychological support. A study in Hubei in China showed half of 493 physicians and 764 nurses had symptoms of depression and anxiety, with many reporting insomnia and psychological distress. ²² Digital learning packages can be very helpful in providing some support. ²³

Highly successful courses such as Essential Pain Management (EPM), Safe Anaesthesia From Education (SAFE – Obstetrics, Paediatrics and Operating Room) and Vital Anaesthesia Simulation Training (VAST) will need trained local in-country champions to continue these courses in LMICs until safe travel becomes possible. Funding for other support such as educational resources, academic prizes and specific equipment, e.g. PPE, Lifebox™ pulse oximeters and oxygen delivery systems should continue.

Currently, we have no idea how long the ramifications of the COVID-19 pandemic will persist and how extensive these effects will be. This may well affect personal travel for several years and we may never go back to pre-pandemic levels of in-country LMIC medical education and training support. It has never been more important to maintain support and relationships with our colleagues in LMICs. We will need to quickly build better communication and remote education techniques.