The Latin American Experience with the COVID-19 Pandemic
José Antonio Soriano Sánchez1, José Alberto Israel Romero Rangel2, Andrés M. Rubiano3
1President of the Mexican Society of Neurological Surgery
Vice president of the Latin American Federation of Neurosurgical Societies
Chairman of the Spine Clinic, Neurological Center, The American-British Cowdray Medical Center IAP
Professor of Minimally Invasive Spine Surgery, National Autonomous University of Mexico
2Executive Secretary of the Mexican Society of Neurological Surgery
Neurosurgeon and Minimally Invasive Spine Surgeon, The American-British Cowdray Medical Center IAP
Assistant Professor of Minimally Invasive Spine Surgery, National Autonomous University of Mexico
3President Elect, Colombian Association Of Neurosurgery
President Trauma and Intensive Care Chapter, Latin American Federation of Neurosurgical Societies
Chairman, Neurological Surgery Service, Vallesalud Clinical Network, Cali (Colombia)
Professor of Neurosciences and Neurosurgery, Universidad El Bosque, Bogotá (Colombia)
May 30th, 2020
In times of crisis, only imagination is more important than knowledge
The first clinical case of COVID-19 was reported in Wuhan, China, on December 8th, 2019, according to the World Health Organization (WHO) [1,2]. The Brazilian Ministry of Health confirmed the first case in Latin America on February 26th, 2020, a 61 years old man from Sao Paulo, who had recently returned from Italy [3,4]. He presented clinically with a dry cough, fever, sore throat, and nasal secretion; the test for COVID-19 was positive. After the announcement, the Brazilian stock market fell 5% , showing the immediate effect that the epidemic event can produce, in both the health and the economy of countries. In the next few days, the entire world witnessed the rapid spread of this infectious disease whose causative agent was identified as a SARS-2 coronavirus. In February also, the first case of COVID-19 was diagnosed in Mexico in a 35 years old male arriving from Italy. On March 6th the first case was diagnosed in Colombia in a 61 years old female arriving from Milano, Italy.
On March 11th, Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO), declared a state of pandemic. At that moment, 114 countries reported more than 118,000 cases and 4,291 deaths . On that day, Dr. Carissa F Etienne, Director of the Pan American Health Organization (PAHO), highlighted that "although all actions are important, countries should focus on five key areas: detecting cases early, saving lives, reducing transmission of the disease, working with all other sectors to maintain basic services, informing the public so that action can be taken at each stage. Public health recommendations will help to contain or reduce the spread of the disease so that health services are not saturated and can provide the care that people need" .
Up to now, we have reached 5,991,102 million infected people around the world . Almost 366,875 people have died from COVID-19 and comorbidities . Countries with most infected people are United States (1,758,304), Brazil (465,166), Russia (396,575), United Kingdom (274,219), and Spain (239,228) . In Latin America the five countries with most affected people are Brazil (465,166 infected / 27,878 deaths), Peru (148,285 / 4,230), Chile (94,858 / 997), Mexico (84,627 / 9,415) and Ecuador (38,571 / 3,334) . The global loss of working hours has risen to 4.5%, equivalent to 130 million full-time jobs lost in the first quarter of 2020, according to International Labour Organization (ILO), and is expected to grow even further.
The Americas are expected to have the most working hours lost at 12.4 percent, equivalent to 347 million full-time jobs loss . Almost 436 million enterprises representing global employers and own-account workers are at high risk of severe disruption . The informal market earnings have fallen 60% globally. Latin America, together with Africa, is one of the most affected regions, having a reduction of 81% in their economies . This income-group represents 82% of our population, resulting in an increase of 34% of the relative poverty reaching almost 56%, according to ILO .
In neurosurgery, we have reported a 79% reduction of consultation and surgery performance, with almost 80% of the neurosurgeons receiving just partial reimbursement for their work in the private and public healthcare systems . This economic restriction poses a significant risk for unsustainability, even for healthcare providers. For various reasons, many of our colleagues are working without appropriate personal protective equipment (PPE). Different media report the pandemic is worsening, and healthcare workers' exposure to infected patients has increased as a result of our profession. Therefore, an increasing number of healthcare providers are expected to contract COVID-19 infection, with possible loss of life depending on different complex factors.
The Latin American neurosurgeons have not been the exception; sadly, six of our dear colleagues have passed away as a result of COVID-19. We mention their names and nationalities in order according to their date of death just to eternally honor their memory (Table 1).
Most of the Latin American Neurosurgical Associations concerned about the problematic situation, have prepared and disseminated protocols, recommendations, and guidelines for the performance of safe neurosurgery for both patients and neurosurgeons . All agree on fundamental aspects: to consider all the patients as COVID-19 positive until they have a negative test; to use operating rooms with adequate specifications whenever possible; to organize neurosurgical teams into a few groups to do duties; to reduce the number of participants during surgery; to stay outside of the surgical room during the intubation process; to strictly use the appropriate PPE (even some of the Societies, for example, the Mexican Society of Neurological Surgery, managed and invested in equipment to guarantee the care of its associates); to avoid as possible the trans-nasal and trans-oral approaches; to separate in specific controlled units the positive COVID-19 patients; to operate primarily on emergencies only.
During this pandemic, one of the most affected aspects of neurosurgery is the praxis itself. Most neurosurgical outpatient consultation has been performed by telemedicine, while assuming this type of practice can increase the risk of errors and increase legal implications. Increased legal protection for healthcare providers should be sought to implement telemedicine programs in a regular and standardized fashion.
Regarding neurosurgical education, practical training has been dramatically reduced. It is difficult to calculate the final impact on quality of performance or number of well-completed learning curves at the end of the current year's courses, specifically among senior Neurosurgery residents. This situation will undoubtedly accelerate the design and promotion of new methods to practical training (even at a distance), such as sophisticated true-trainers, virtual and augmented reality simulators, and robotics - helping to avoid the increasing difficulties of availability and the health-legal risk of training in cadaveric specimens. It will be the neurosurgical associations' responsibility and commitment to participate in its design, acquisition, and increased use as an innovative approach. Paradoxically, the lack of medical praxis and the teaching spirit of neurosurgeons have increased online scientific activities in Latin America with massive connections around the world; not surprisingly, the compulsory use of media has been well accepted by all neurosurgeons. No matter what generation we belong to, all are witnessing an era without frontiers or barriers to educating and to being educated; we do not need to travel long distances to acquire and share neurosurgical knowledge. In our opinion, there will be no return; too many days have passed from the daily activity that became a habit. Is also evident that neurosurgeons in the region are improving the organization and design of neurosurgical care through multiple scientific articles on clinical and organizational aspects, and trying to evaluate the impact of COVID-19. For example, the Latin American Federation of Neurosurgical Societies has recently published the results of a survey that demonstrates the profound impact of COVID-19 on Latin American neurosurgical practice . In this survey information came from 21 Latin American countries. Sixteen society presidents reported having suspended regular activities, and differing local scheduled congresses; fourteen reported mandatory isolation by government; four instituted a telemedicine project. Four-hundred eighty-six colleagues, mean age 49 years, reported a mean 79% reduction in their neurosurgical praxis. Seventy-six percent of neurosurgeons had savings to self-support for 3-6 months, if restrictions are long lasting, showing a general trend of COVID-19 implications in our practice.
In this pandemic, neurosurgeons as human beings are required daily to resolve chaotic situations, and are also characterized by their high level of intelligence, creativity, and talent to develop positive thoughts and actions in favor of humanity. As a proof, neurosurgeons from around the world by initiative of Latin American neurosurgeons have produced a book with philosophical thoughts and positive advice, including poetry, during this pandemic, entitled “LOVE FOR NEUROSURGERY IN TIMES OF COVID-19” (to be published in the coming days) .
In summary, neurosurgeons of the Latin American Region, even in the middle of this critical situation, have been able to be quickly organized, react with order and intelligence – demonstrating to the world that there are opportunity areas for the benefit of humanity during this difficulty.
Table 1. Latin American neurosurgeons who have lost their lives in the war against COVID-19