Massachusetts General Hospital Vincent Program in Global OB/GYN
Even as we struggle to understand the safest and most appropriate ‘return to normal’ after our initial wave of Covid-19 infections here in Boston, our departure from our normal should not blind us to the privileges we enjoy living and working. Our colleagues Dr. Joy Muhumuza and Ms. Courtney Steer-Massaro remind of two stark truths of the Covid-19 crisis in sub-Saharan Africa. First, resources are scarce and there is no margin for error in public health decisions. Second, the health and welfare of poor and working class women is not always the highest priority, and they disproportionately suffer when society is placed under threat.
-Thomas Randall, MD
Division of Gynecologic Oncology, MGH
Dr. Randall is a gynecologic oncologist at MGH. He has an interest in capacity building for cervical cancer prevention, treatment and other women’s health services in low resource settings. Tom is co-Chair of the International Gynecologic Cancer Society’s Global Curriculum program, that supports gynecologic oncology fellowships in 12 low- and middle-income countries, and he has active projects in Uganda and Rwanda through the MGH Center for Global Health and the Department of Global Health and Social Medicine at Harvard Medical School.
Notes from the Field
The Challenges of COVID-19 lockdown in Mbarara, Uganda Joy Muhumuza, MBChB, MMed email@example.com
Late night, at 1 am, I received a call from a resident at Mbarara Regional Referral Hospital (MRRH) regarding pregnant mother at 31 weeks who had gone into shock. I was told she was having antepartum hemorrhage. She needed at least 4 units of blood and emergency surgery, but the hospital’s blood bank carried only one unit of blood. The lockdown imposed by the government as a measure against the COVID-19 pandemic prohibited me from driving and reaching the hospital immediately. While an ambulance, permitted to run during the countrywide lockdown, would have to transport me to the hospital, the demand for picking up patients makes that difficult. All I could do to help was consult the resident over the phone, staying up the entire night - afraid of the worst-case scenario, hoping for God to do His wonders.
Before arriving at MRRH, the mother had walked a long distance to reach another health center, bleeding all along, only to be told her case was too complicated and had to be referred to another health facility. The second facility required an additional 20-kilometer walk to reach. After enduring a long, painful journey, on her arrival at the second health facility, she found the medical staff unable to operate because there was no electricity and the generator had run out fuel. Only then was she referred to Mbarara Regional Referral Hospital, where I work.
Luckily, MRRH could deploy an ambulance to pick her up, which took an additional hour. She suffered a tragic stillbirth followed by life-threatening postpartum hemorrhage that necessitated a hysterectomy. She was admitted to the intensive care unit for four days. In a culture where men and women derive joy from their children, this 28-year-old lady with only four children now had her uterus removed. This may have a dramatic impact on her future domestic security.
In low-resource settings like Mbarara, the COVID-19 pandemic has made obstetric care more inaccessible. The Ugandan government has shut down the public transportation system including commonly used motorcycle taxis, locally known as ‘boda bodas’. In a setting where government-provided emergency transport is insufficient, banning private vehicles creates an additional barrier to maternity care for pregnant women and service providers. This situation is worsened by the mandate that pregnant women must ask permission from the Resident District Commissioners (RDC) to be allowed to use private transport, further delaying care for these women. How they are supposed to go to seek permission while they are laboring is another nightmare.
In limited-resource settings like this one, it is imperative that pregnant women are systematically treated as emergencies, given that labor and complications occur unexpectedly. Resources such as transport, hospital labs, blood banks, and operating theatres must be designed and supported well enough to handle all obstetrical emergencies at any time. Currently, there are frequent shortages of sterile sets in theatre because of the high number of patients. This shortage is worsened when several emergencies occur simultaneously and teams have to wait for equipment to be made available. In an unequal world where women’s rights are often neglected, places with few resources often see their healthcare systems fall apart, and women suffer disproportionately.
Dr. Muhumuza has nine years of diverse experience in clinical practice and the health-related nongovernmental organization sector. In her practice as a Medical Officer in Marie Stopes Uganda, 30% of her time is spent in seeing outpatients and 70% spent in providing a full range of Family Planning (FP) services, especially in the communities in the Southwestern Region of Uganda. She trains students and health workers on modern Family Planning Techniques. At Mbarara University of Science and Technology/ Mbarara Regional Referral Hospital, 80% of her time is spent with outpatient clients, operating room, and inpatient rounds and 20% devoted to teaching medical students, residents, and supervision of postgraduate research projects. She is the Attending Gynecologist to a Cervical Cancer Prevention (CCP) Clinic.
Developing A COVID-19 Task Force At Motebang Hospital In Lesotho Courtney Steer-Massaro, CNM, FNP-C, RN, MPH firstname.lastname@example.org
I live in a country with 12 confirmed COVID-19 cases as of June 21, 2020. Lesotho, a small, mountainous, enclave country in Southern Africa, did not have a documented COVID-19 case until May 13th. This, however, doesn’t mean that I believe there are really so few cases, particularly given South African has over 92,000 cases, it just means that the 2,000 people who have been tested so far (in a country of about 2 million) have mostly all tested negative.
My husband (an OBGYN) and I (a Certified Nurse-Midwife) moved to Lesotho in February from Boston. My husband is now employed by the Ministry of Health (MOH), and works at the country’s largest public hospital (Motebang Hospital) as an OBGYN consultant and faculty to the Lesotho Boston Health Alliance’s (LeBoHA) Family Medicine Specialty Training Program, the country’s only residency program. I was planning on getting a teaching position at a Nursing/Midwifery school nearby, though that has been put on hold due to the pandemic so I’ve been volunteering with LeBoHA for the short-term.
Lesotho has had the advantage of seeing how COVID-19 has debilitated wealthier and better-resourced countries. Despite that, the MOH response has been slower than many of us would like. Even before the countrywide lockdown and the MOH writing country-specific guidelines, and organizing Training of Trainers conferences, key staff in our hospital had mobilized and formed a COVID-19 task force. This task force is wonderfully interdisciplinary; we have doctors, nurses, interns, pharmacists, kitchen staff, and cleaners amongst the team. Since I don’t have any official clinical duties I have been helping spearhead this task-force and have worked to implement the measures the group decides are needed to help keep the hospital, its patients, and its staff as safe as possible.
The task force, like all healthcare institutions around the country, has faced an uphill battle; Motebang has some liquid soap, but not enough for all our wards at this point. We have approximately 10 oxygen cylinders, but those have to last us indefinitely. There are no ventilators in the hospital and are fewer than a dozen in the entire country. But even if Motebang had ventilators, there isn’t an ICU to house them or anyone who can safely use them long term. The District’s 26 health centers are even worse off; they have no oxygen, more limited PPE supply, and many days don’t have running water.
Because of these limitations, the task force started at the basics: triage and infection prevention control. We developed a screening system for the front gate (where all patients/staff/cars pass through). We worked with the District Health Management Team (public health department) to build tip-taps for low-cost, touch-less hand washing stations around the hospital. These, unfortunately, aren’t being used as much recently due to it being winter and people not wanting to wash their hands with cold water. (Lesotho lies entirely above 1,000 meters, and it’s average winter temperatures at night are below freezing, so it does get very cold here). We have had a number of staff education sessions in English and Sesotho (most peoples’ first language), members have talked on the local radio, and we’ve had a simulation to test our screening system (we didn’t do very well). We have prohibited visitors, worked to implement physical distancing in queues, and mandated mask wearing for all patients and providers. Apart from all those changes, we are also trying to ensure that primary health services are still maintained and supported. We don’t want the hospital staff to get too focused on COVID-19 and forget about the many important services that they need to offer Motebang’s patients. It is a continuous process of assessing the hospital’s changing needs and trying to disseminate information and motivate those people who are needed to help with the updates. We hope that all of these interventions will prepare us for the cases that we know will inevitably come.
Author's biography: Courtney C. Steer-Massaro, CNM, FNP-C, MPH, RN is a Certified Nurse-Midwife currently working for the Lesotho Boston Health Alliance in Hlotse, Lesotho. She received her MPH with a focus on International Maternal Child Health from Tulane University School of Public Health and Tropical Medicine. She completed her RN certificate and Master of Science in Nursing, with certification as both a Certified Nurse-Midwife and Family Nurse Practitioner, at Vanderbilt University School of Nursing. She is a volunteer Assistant Professor at Boston University School of Medicine, and the former Director of the Refugee Women's Health Clinic at Boston Medical Center. She has worked internationally in Africa, Asia, and the Caribbean.
Seed Global Health has put together the COVID Content Hub: www.c19hub.io. The Hub is a community-sourced platform that includes more than 700 different clinical and training resources for practitioners responding to the pandemic in resource-limited settings. Please send any COVID-19 care protocols, guidelines, or country-specific documents, especially those focused on resource-limited settings toContentHub@seedglobalhealth.org.
International Gynecologic Cancer Society holds monthly gynecologic oncology tumor board meetings including gynecologic oncologists and GYN-ONC trainees all over the globe. Interested fellows and residents, please email Thomas Randall (email@example.com) or Ak Goodman (firstname.lastname@example.org).