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Medical News & Perspectives
June 12, 2020

Latin America and Its Global Partners Toil to Procure Medical Supplies as COVID-19 Pushes the Region to Its Limit

JAMA. 2020;324(3):217-219. doi:10.1001/jama.2020.11182

Three and a half months after coronavirus disease 2019 (COVID-19) breached Latin America’s borders, a bit of optimism emerged in hard-hit Brazil, where case numbers have surpassed 700 000. Brazilian regulatory authorities on June 2 approved the country’s participation in the University of Oxford’s severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine trial supported by AstraZeneca. Two days later, the Lemann Foundation, which supports public education in Brazil, announced that it would fund half of the country’s 2000 volunteers participating in the initial round of trials.

As the first nation outside of the UK to test the Oxford vaccine, Brazil’s involvement is “an important milestone,” the foundation’s executive director, Denis Mizne, said in a statement. Yet even though Latin America’s largest country is playing a vital role in the worldwide quest for a safe, effective vaccine, the pandemic is further stressing a part of the world that’s already vulnerable from rising levels of poverty and inequality, as well as outbreaks in recent years of Zika virus, chikungunya, measles, and several other infectious diseases.

Less than a week after Lemann’s announcement, officials at the Pan American Health Organization (PAHO) discussed Latin America’s increasing COVID-19 cases and supply issues during a media briefing. “Many areas are reporting exponential rises in cases and deaths,” PAHO Director Carissa Etienne, MBBS, MSc, told reporters. “We are concerned by data showing that the virus is surging in new places, places that had previously seen a limited number of cases.” As of June 9, more than 1.2 million COVID-19 cases and 52 000 deaths had been reported in Latin America.

“In Mesoamerica, case counts are rising in Mexico, Panama, and Costa Rica, where we are seeing increased transmission around the Nicaraguan border. In South America, the virus continues to spread aggressively in Brazil, Peru, and Chile. We’re also seeing in Venezuela that cases are now mounting faster than at any point during the country’s outbreak. In the Caribbean, cases are on the rise in Haiti,” Etienne said. And as they confront the novel coronavirus, Latin American countries, like so many others, face an international shortage of personal protective equipment (PPE) for health workers and other medical supplies.

Four Percent Is Not Enough

Latin America’s shortages are compounded by a fundamental lack of preparedness and a lack of manufacturing resources to make PPE or ventilators, according to James Seifert, MPH, JD, a project manager at the Center for Infectious Disease Research and Policy at the University of Minnesota. “Their supply chain generally relies on foreign manufacturing and that has completely broken down,” he said in an email.

A recent report from the Economic Commission for Latin America and the Caribbean (ECLAC), part of the United Nations (UN), found that the region is highly dependent on PPE, mechanical ventilators, test kits, medicines, and other medical supplies that are imported from the rest of the world. Only 4% of these products are sourced from within the region.

Latin America’s reliance on medical imports has left it endangered by trade bans during the pandemic, according to ECLAC Economics Affairs Officer Sebastián Herreros. “Export restrictions—some of which have lapsed since the publication of the report—have hampered the supply of products essential for fighting the pandemic in the region, compounding the vulnerability of national health systems,” Herreros said in a June email.

In fact, by the time the report was released in early May, more than 70 countries had restricted medical supply exports in response to the pandemic, including the US, Latin America’s main supplier of products essential for combating COVID-19. When calculated by monetary value, 58% of N95 and similar respirators imported to the region in 2018 came from the US, which also was its main supplier of mechanical ventilators.

In April, the Trump administration restricted US exports of N95 and other respirators, surgical masks, and gloves, directing the Federal Emergency Management Agency to review shipments of those products and determine whether they should be allowed to leave the country. One manufacturer affected was 3M, which currently produces 35 million N95 respirators monthly in the US. The company sends a critical supply of respirators to Latin America, which the administration wanted to halt.

However, 3M officials said in a statement that such a stoppage would create “significant humanitarian implications.” Days later, 3M and the administration came to an agreement that allowed continued export of the company’s US-produced respirators to Latin America. But as countries continue their struggles to find supplies, China may be filling some of the gaps. The ECLAC report found that the country has not restricted medical product exports and is “sharply increasing” its shipments of masks, ventilators, and other goods.

Creating a Supply Chain

As the pandemic began to grip Latin America, Etienne told reporters that the World Health Organization, UN agencies, and international stakeholders established an “unprecedented global supply chain” that helped PAHO distribute nearly 30 tons of supplies containing 1.4 million essential PPE items to 25 countries. The supplies came from PAHO’s own regional emergency warehouse in Panama.

In an April 25 statement, UNICEF said that it would ship 220 000 face masks and tens of thousands of face shields and gowns to Latin America and the Caribbean in the coming weeks and months. A UNICEF humanitarian shipment delivered in early April to Caracas, Venezuela, contained almost 100 tons of critical health supplies, including PPE kits and emergency treatment kits for patients with severe respiratory problems due to COVID-19.

“Both globally and locally, our teams are searching for hygiene products and personal protective equipment to reach families and health workers with essential supplies as soon as possible,” Bernt Aasen, UNICEF regional director for Latin America and the Caribbean, said in the statement.

Even so, Doctors Without Borders, or Médecins Sans Frontières (MSF), struggles to maintain an adequate supply of PPE for its staff in Brazil, according to Vitoria Ramos, an MSF humanitarian affairs and advocacy officer there. “We have seen places where PPE was [rationed] and used to the limit, especially N95-grade masks,” she said in an email. “There are difficulties to import ventilators and delays on their delivery.”

Ramos also pointed out statistics from Brazil’s Federal Nursing Council indicating that as of June 10, 18 354 nurses had been infected with SARS-CoV-2 and 182 had died. The figures, she noted, “show that Brazil has the world’s highest number of nurses that died from COVID-19.”

As trouble obtaining supplies persists, some scientists in Latin America have tried to gather resources themselves. Amilcar Tanuri, MD, PhD, of the Federal University of Rio de Janeiro, told The New York Times that he called private companies on 3 continents to procure chemical reagents needed to process hundreds of health workers’ SARS-CoV-2 tests in the public laboratories that he runs. The companies’ response? The US and Europe had gotten there first.

In Colombia, the tests themselves are hard to come by, and inadequate diagnostic testing is a major problem. “The molecular technology is not simple [to obtain] around the country,” Bogotá infectious disease specialist and epidemiologist Carlos Arturo Alvarez Moreno, MD, PhD, said in an interview. What’s more, he added, Colombia also hasn’t been able to compete with the US and Europe in trying to buy polymerase chain reaction tests from China and Korea.

Testing is also limited in Brazil, according to Ramos. “This has been an obvious bottleneck that is compromising the adoption of more specific policies by the local authorities,” she said.

In Peru, a group of physician friends launched Médicos Solidarios in April to raise funds to buy PPE for workers at Lima’s Cayetano Heredia Hospital, a national hospital run by the country’s Ministry of Health.

Lima general internist Germán Málaga, MD, MPH, told JAMA that, having raised US $800 000 so far, they’ve also been able to buy PPE for the rest of the city’s hospitals as well as medical centers around the country. In addition, some of the funds have paid for patients’ diagnostic imaging and laboratory tests that haven’t been available at national hospitals.

Since Médicos Solidarios was created, Málaga noted, prices for some products essential for treating COVID-19 have soared in Peru. At first, he said, N95 respirators cost US $5 apiece, but now they’re US $25 each. A large bottle of oxygen, which used to cost US $100, has skyrocketed to as much as US $1800, he said. “Some days we don’t have enough oxygen for patients,” Málaga explained.

“Peru is not a poor country now,” he said, noting that the economy has been growing for the last 20 years. Unfortunately, he noted, logistics are lacking. For example, the national government has bought hundreds of thousands of masks, “but nobody knows where those masks are,” Málaga said. “They don’t have the capability to send the masks or the PPE to every corner of the country.”

“In the rural areas, with supposedly a public health care system, there is no PPE or ventilators to speak of,” Seifert said. “The NGOs [nongovernmental organizations] are doing their best to provide a basic supply with varying success.” Many villages make their own PPE based on designs from the internet, he added.

The continent and particularly the rural areas have little capability to care for COVID-19 patients, except by isolation, Seifert said. Guatemala had planned to consolidate care for patients with COVID-19 in the outlying areas by moving them to Guatemala City. But urban hospitals were soon overwhelmed. “[N]ow the strategy is to just have COVID patients stay in the villages,” he noted.

Increasing Capacity, if Possible

In Brazil, which has the second-largest number of COVID-19 cases behind the United States, the Oswaldo Cruz Foundation built an emergency hospital for patients with the disease in less than 2 months. The foundation, also known as Fiocruz, is one of the world’s leading public health research institutions. Its new 195-bed hospital in Rio de Janeiro, outfitted with negative air pressure rooms and x-ray, ultrasound, echocardiography, and computed tomography equipment, began treating patients on May 19.

Tent hospitals also have gone up in Brazil, MSF’s Ramos said. “[They] have physical structures ready but lack more sophisticated equipment, such as ventilators, and are not able to hire professionals because there are not enough doctors available or they don’t want to work in certain regions.”

As the pandemic took off in Peru—the country’s first reported case was March 6—the 400-bed Cayetano Heredia Hospital expanded its intensive care unit (ICU) from 20 beds to 50 beds and designated 250 beds for COVID-19 patients, Málaga said. But, he noted, other cities in Peru don’t have the capability to handle the growing number of cases. By the second week in June, Peru had nearly 200 000 cases, trailing only Brazil among Latin American countries. Outside of Lima, hospitals also lack physicians and nurses with experience in caring for patients on ventilators.

“The problem is that Peru is like several countries,” Málaga said. Thirty percent of Peru’s population live in Lima, but 80% of the country’s ICU beds are there, he said. The coast of Peru is home to other large cities, such as Trujillo, population 750 000, that lack Lima’s resources, Málaga said.

Then there is Iquitos and the rest of the jungle, which has few ventilators and no oxygen, leading to the deaths of several physicians and patients from COVID-19, he said. In the country’s highlands, however, which include the popular tourist destination of Cuzco, “the impact of the pandemic is very low,” with perhaps 8 or 10 deaths, Málaga said. “Nobody knows why,” although he speculated that physiological adaptations to living at high altitudes—Cuzco sits at 11 152 feet above sea level—might be a reason.

The main reason for COVID-19 cutting a wide swath across Peru, Málaga said, is that many people don’t have the luxury of staying home. “They have to work.”

According to the National Institute of Statistics and Informatics of Peru, 72.5% of the employed population work in the informal economy. Their jobs aren’t taxed or regulated and are frequently characterized by unsafe and unhealthy working conditions and long hours. Many both work and shop at traditional food markets, which have become hubs of SARS-CoV-2 transmission. Half the households in Peru don’t have a refrigerator, so “they have to go shopping at least 3 times a week,” Málaga noted.

Complicating the situation is Peru’s 3 tiers of hospitals. About two-thirds of the population receive care at the national hospitals, which are the worst-equipped. “We don’t have MRI [magnetic resonance imaging], for example,” Málaga said. About a quarter of the people—workers in the formal economy who have health benefits—receive care at the middle-tier “social security” hospitals, he said, and the remainder can afford top-of-the-line private hospitals.

Throughout Latin America, each country has monitored its availability of hospital beds and ICU beds during the pandemic, Ciro Ugarte, MD, PAHO’s director of health emergencies, said during the June 9 media briefing. Ugarte noted that, like Brazil and Peru, other countries also expanded their capacity to care for patients with COVID-19 by adding beds or establishing modular hospitals as their cases increased.

Although Latin America has faced a persistent shortage of PPE and ventilators since the pandemic began, Ugarte said more supplies were expected in mid-June. Among the first to receive critical equipment will be Ecuador, Nicaragua, Peru, and Venezuela, he noted. Efforts were underway to transport more than $100 million worth of goods including gloves, surgical masks, N95 respirators, surgical gowns, goggles, and face shields from Asia to PAHO’s emergency warehouse in Panama for distribution in Latin America and the Caribbean, Etienne told reporters.

“We are especially grateful to the global support that we have received,” she said. “[W]e are looking to help member states to procure the supplies that they very much need.”

The supplies may become even more critical as South America heads into winter and influenza season, while North and Central America and the Caribbean face the onslaught of a hurricane season predicted to be one of the worst on record. Both, Etienne said, are expected to compound the growing public health emergency. “The COVID-19 pandemic has pushed our region to the limit,” she said.

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    1 Comment for this article
    Latin America: A region in two hemispheres
    Carlos Alvarez, MD, PhD, FIDSA | Professor of Medicine at Infectious Diseases and Tropical Medicine. Universidad Nacional de Colombia; Clinica Universitaria Colombia, Clinica Colsanitas
    Latin America is a region in two hemispheres. Although we share culture and language, there are marked contrasts in socioeconomic conditions and health systems among countries, which can make a difference when dealing with a crisis such as the one generated by COVID -19. Furthermore, within each state, there are also discrepancies between the quality of health care between rural and urban areas. In the large cities of Latin America, the level and quality of health care may be like that of the United States. By contrast, in rural areas, difficulties in accessing molecular diagnosis and specialized services in intensive care, and local lack of skilled human resources and infrastructure can make it challenging to confront and mitigate the epidemic. Besides, limitations obtaining adequate supplies on time and at a fair value added to the high informal employment as described by Rubin R et al. can complicate the mitigation and self-care strategies of the general population. Finally, the situation of Brazil, Argentina, and Chile in May and June, could be the right mirror for what could happen in the northern hemisphere in October-December.