How COVID-19 exposed crevices in Uganda’s health workforce

 

At the outset of the SARS-CoV-2 outbreak in December 2019, the magnitude and impact of the current global pandemic was inconceivable. As it ravaged one country to another, trepidation grew in Uganda. Locally, we wondered whether we could mount and coordinate an effective response: how would we cope with inextricably high patient loads, access and use rare equipment like ventilators, and ration an already overwhelmed workforce? In addition, could our fellow health care workers endure the risks involved in care provision?

Like neighbouring countries in the region, we have lived through previous viral hemorrhagic fever (VHF) epidemics, which have been disastrous to heath workers. We remember our grief on 5th December 2000, at the height of one Ebola epidemic, when our highly trained and respected colleague Dr. Matthew Lukwiya died of Ebola after bravely treating infected patients. Countless others have succumbed during subsequent outbreaks of VHFs, and more recently from COVID-19. In fact, COVID-19 has been even more worrisome given its global reach and mode of infection.

When facing highly contagious diseases in places like Uganda, whether VHF or COVID-19, health workers make do with just the basic equipment and skills. Usually, providing care takes resolve, courage, and sometimes accepting the inevitability of one’s fate – literally turning to God in lieu of tangible medical alternatives. Those who “soldier on” with the meager resources use innovatively risky solutions to try and save countless lives, from polythene bags in place of unavailable personal protective equipment during VHF outbreaks, to unproven herbal remedies for COVID-19.

While pandemic responses in resource-rich settings grapple with deficiencies in bed space and equipment, in Uganda we contend with similar deficiencies and even more; the most critical being the need for skilled health workers. Even before COVID-19, Uganda had fewer than 2 physicians and 13 nurses or midwives for every 10,000 people; well below targets set by the Sustainable Development Goals. Facing a novel deadly virus without sufficient protections, instances of health workers abandoning suspected infected patients were recorded at some health centers during the early days of the COVID-19 pandemic, exacerbating staffing challenges even further. An equitable global health response cannot proceed with such workforce as has previously been observed during the West African Ebola epidemic.

Typically, the World Health Organization and other multilaterals define minimum standards and requirements for infection control and prevention. These ‘minimum requirements’, e.g., access to a vaccine, should be applied to all humans equally and equitably, but have so far differed significantly based on the economic status of the geographical area of reference. While 96% of American physicians are fully immunized against COVID-19, only 34% of Ugandan health workers like us have been similarly vaccinated.

These ‘double standards of care’ applied to COVID-19 vaccines – reminiscent of the inequities we previously faced while calling for scale up of effective antiretroviral therapy against HIV – only increase the challenges we face in trying to care for COVID-19 patients. We watch in real time as the number of infected patients in our hospitals is once again rising. Without increased access to vaccines for both providers and community members, our already strained and under-protected health workforce could be easily overwhelmed by another wave of COVID-19 cases, just as we witnessed earlier this summer and during previous VHF outbreaks. “Vaccine nationalism” simultaneously increases our risk to the emergence of breakthrough viral strains (e.g., the delta variant) in the unvaccinated that can affect both vaccinated and unvaccinated alike. As our institutions diligently sequence virus genotypes from patients, we fear that an even more transmissible or deadly COVID-19 variant may once again leave us with no options but to call on God.

While global health has come a long way in improving health equity, especially for childhood vaccinations, COVID-19 is not giving us the luxury of time. As our health workforce in Uganda prepares to ride wave after wave of a pandemic that could be stopped with existing vaccines, how much more must we endure before the world decides to act?

About the Authors:

Dr. Stephen Asiimwe is Program Director of the Global Health Collaborative at Mbarara University of Science and Technology and Principal Investigator at Kabwohe Clinical Research Center.

Dr. Edith Nakku-Joloba is Senior Lecturer of Epidemiology at Makerere University School of Public Health and Sexually Transmitted Infections Specialist and Consultant with the Uganda Ministry of Health.

Dr. Francis Bajunirwe is Epidemiologist and Senior Lecturer in the Department of Community Health at Mbarara University of Science and Technology.

Dr. Aggrey Semeere is a Senior Physician at the Infectious Diseases Institute at Makerere University and Principal Investigator at the East African International Databases to Evaluate AIDS.

Dr. Louise C. Ivers is Executive Director of the Massachussetts General Hospital Center for Global Health and a Professor at Harvard Medical School.

Competing Interests: None

Handling Editor: Neha Faruqui

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