Haiti, the Coronavirus, and the Obligation to Care--March 2020
Anse-a-Pitres Refugee Camp (Photo by John Carroll–September 19, 2015)
Le Nouvelliste, a Haitian newspaper, reported on March 24 that Haitian doctors were fleeing the General Hospital in Port-au-Prince due to fear of coronavirus.
The newspaper interviewed a young doctor at the hospital who decried the fact that a functional quarantine room did not exist at the hospital. He stated that the hospital staff does not think they can protect themselves from the virus and this is why physicians have deserted the hospital which is the largest hospital in the country.
The same doctor described the fact the HUEH has water and soap stations throughout out the hospital but lacked Personal Protective Equipment (PPE). He stated that resident physicians are simply not going to come to the hospital to work if adequate means are not taken to protect them.
“Before the disease was introduced into the country, services were operating at a slower pace. After confirmation of the virus in the country, nothing works here,” said the physician.
In another article several weeks ago, Haitian nurses stated that if coronavirus were to hit Haiti and they had no PPE, they would not risk their lives to care for patients.
So are these Haitian caregivers being responsible?
During the past 39 years, I have worked with hundreds of Haitian doctors and nurses in outpatient and inpatient settings. Most of them have done their very best under very trying circumstances. Medical supplies are frequently lacking which demands innovation and persistence on their part to deliver care. The cholera tents were stifling hot and it was very difficult to assess patients lying on their cots. But caring for coronavirus patients seems over the top if protective gear is not available for the caregivers.
It just so happens that the United States and other “developed countries” are having their own problems with material to care for coronavirus patients.
From the New England Journal of Medicine today (3/27/2020)–
“Equally worrisome is the lack of adequate PPE for frontline health care workers, including respirators, gloves, face shields, gowns, and hand sanitizer. In Italy, health care workers experienced high rates of infection and death3 partly because of inadequate access to PPE. (In the hard-hit Italian region of Lombardy, 20% of the healthcare workers have been infected by COVID-19.) Every time another one of them falls ill, that’s one fewer person to treat sick patients. And recent estimates here in the United States suggest that we will need far more respirators and surgical masks than are currently available.”
And from the New York Times today (3/27/2020)–
“The United States Conference of Mayors questioned officials in 213 municipalities and found serious shortages that underscored the “scope and severity” of the crisis. The organization, a nonpartisan association of mayors from across the country, urged the federal government to provide more support.
“More than 90 percent — or 192 cities — said they did not have an adequate supply of face masks for police officers, firefighters and emergency workers. In addition, 92 percent of cities reported a shortage of test kits and 85 percent did not have a sufficient supply of ventilators available to local health facilities.
“Roughly two-thirds of the cities said they had not received any emergency equipment or supplies from their state, the report said. And of those that did receive state aid, nearly 85 percent said it was not enough to meet their needs.
“The survey included municipalities from 41 states and Puerto Rico, with populations ranging from under 2,000 to 3.8 million. Across the board, local officials said they were not getting the support and supplies they need.
“It is abundantly clear that the shortage of essential items such as face masks, test kits, personal protective equipment, ventilators and other items needed by health and safety personnel has reached crisis proportions in cities across the country,” Tom Cochran, the chief executive of the conference said in a letter accompanying the survey’s findings.
“The result is that the safety of city residents and the health workers and first responders protecting them is being seriously compromised.”
If the most wealthy country in the history of the world is deficient in material to keep its health workforce safe, can you imagine what Haiti may experience in the near future as coronavirus spreads?
So should a health care provider anywhere be forced to care for a patient with COVID symptoms if the appropriate PPE is not available?
Justin Morgenstern, MD has a blog called “First 10 EM” and he recently published an article called Covid Ethics. He asks the question whether providers should be required to take care of Covid patients without adequate protection. His conclusion is that clinicians should not see patients without appropriate PPE.
He explains that there is a large grey zone attached to this very sensitive topic but his rationale is as follows:
“However, if we take a moment to step back from the emotions of the situation, it will quickly become clear that seeing a patient without appropriate PPE results in tremendous harm in a pandemic situation. Without PPE, I am very likely to spread the infection to other patients, staff members, family, and friends. I am likely to make the pandemic worse. Furthermore, after treating a patient without PPE, I am very likely to become ill myself, and I will be unable to work. If everyone followed my actions, the emergency department would rapidly run out of staff, and our patients would suffer. Our efforts to save a single patient would end up harming thousands.”
Morgenstern also gives the official stance of multiple organizations below–
The American Medical Association: “Whether physicians can ethically decline to provide care if PPE is not available depends on several considerations, particularly the anticipated level of risk. In some instances, circumstances unique to the individual physician, or other health care professional, may justify such a refusal—for example, when a physician has underlying health conditions that put them at extremely high risk for a poor outcome should they become infected.” (Ie, vague legalese that doesn’t actually help us when trying to make a decision in the moment.)
The Candian Medical Protective Association: “Physicians may be permitted in exceptional circumstances to refuse to practice if they reasonably believe that the work environment creates a legitimate unacceptable hazard that is not inherent to their ordinary work. A refusal to work due to inadequate protective gear could put a physician at risk of a College or hospital complaint, the success of which will depend upon the context of the situation. The CMPA is aware that the Colleges are taking into account the current COVID-19 situation and would assess any College complaint in that context. Hospitals and clinics also generally have an obligation to provide a safe work environment for their staff pursuant to occupational health and safety legislation.” (Again, some not so helpful legalese.)
The Ontario Medical Association (in an email to members): “If you have run out of PPE, and legitimately can no longer safely practice, you are not legally required to risk your life. Society needs health-care workers to try to protect themselves to ensure a healthy workforce.”
The National Academy of Medicine does not address this issue specifically, but provides some pragmatic advice about rationing PPE and altering standard PPE practices.
The College of Nurses of Ontario: “You should only conduct clinical assessments and collect specimens from at-risk patients in compliance with PPE guidelines and the latest guidance from Public H
ealth or the Ministry of Health.”
John A. Carroll, MD
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