'Hard Times, Difficult Measures': Lessons on COVID-19 From Low-Income Countries

Bishal Gyawali, MD, PhD


March 26, 2020

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It's taken for granted that lower-income countries learn regularly from high-income countries. Having lived and worked as a physician in Nepal, Japan, the United States, and Canada, however, I know that high-income countries have much to learn from their lower-income brethren as well. And now the COVID-19 pandemic is providing a very tangible and palpable opportunity to observe this in real time.

In high-income countries, we hear that "difficult times call for difficult measures," but this has always been the case in low- and middle-income countries.

In countries like Nepal, where I was born, patients often travel upwards of 12 hours to receive care at a cancer clinic. Most patients must make do with only the bare minimum number of visits. Because they typically don't have a place to stay in Kathmandu, we try to provide chemotherapy and an office visit in the same day so that they can return home that night. They get their lab work and imaging done at their local center and only then come to Kathmandu, where these results are checked by an oncologist and a clinical decision is made.

Likewise, most patients in lower-income countries can't afford cancer medicines, so we make do with bare-minimum drugs. Many also cannot afford scans, so we get by with as few as possible. Between visits, oncologists in these cancer centers often provide remote follow-up via WhatsApp, Viber, or Facebook Messenger. I can see my colleagues in Canada, the US, and other high-income countries shuddering at the potential loss of patient privacy. But there is implied consent when a patient uses WhatsApp to send me their scan reports or blood work. No doubt, privacy cannot be ensured. But it is simply a question of balance: the potential loss of patient privacy versus the hardship of a patient traveling 12 hours on a public bus and then waiting in line at the clinic only to have an oncologist say, "The report looks fine. Come back in 3 months."

This is exactly what we are now learning to do in high-income countries, although for very different reasons. With the COVID-19 pandemic escalating globally, many oncologists around the world are doing these same things—reducing patient visits, transitioning to telemedicine, and avoiding low-value drugs and other interventions as much as possible.

Jugaad Culture

In Nepal and India, the two lower-income countries with which I am most familiar, making do with the bare minimum is ingrained. We call it jugaad in both Nepali and Hindi; it is an integral part of our culture. It is basically a less-than-ideal solution to a problem but one that solves it nonetheless. In scientific literature, it's called frugal innovation.

Thus far in the pandemic, the best example of jugaad culture has been a colleague from Sudan illustrating how a stethoscope can be repurposed as an oxygen socket.

Other examples of successful jugaad in medicine include:

  • An origami paper-based "foldscope" microscope

  • Water or cola plastic bottles as spacers for asthma inhalers

  • Sari cloth for water filtration to prevent cholera

  • Motorcycles used as ambulances in Nepal and other countries to immediately transport victims to the hospital

Such concepts will become more and more relevant as the patient load in this pandemic continues to overwhelm our healthcare delivery resources.

I am not suggesting that low- and middle-income countries will get through this pandemic easily. In truth, it will create extreme challenges in places that are already resource constrained to begin with. The virus could be even more devastating in these countries if appropriate measures are not taken in a timely manner.

Lower-income countries will also have a lot to learn from high-income countries that have faced the pandemic early on, including identifying the control strategies that worked versus those that did not, and incorporating results from the many trials currently underway in high-income countries to test treatments for this disease.

A Lesson in Mutual Respect and Learning

Like cancer, a pandemic respects no boundaries. Yet, it is heartening to see the whole world coming together to fight against this virus. The World Health Organization is demonstrating the leadership we expect of it.

Trials have been conceived and launched in a matter of weeks, which suggests that much of the red tape in trials may be unnecessary. Multiple clinical trials are being conducted internationally and in collaboration so as not to duplicate efforts. A randomized controlled trial of lopinavir-ritonavir from China has already been published. Resources related to COVID-19 are open-access in nearly all journals and other media.

If we continue this togetherness in medicine after the pandemic has settled down, we will have walked a long way. And if the "not-invented-here" syndrome is replaced with a spirit of "we did this together," we will have made incredible progress.

Bishal Gyawali, MD, PhD, is an assistant professor in the Department of Public Health Sciences, a scientist in the Division of Cancer Care and Epidemiology, and a clinical fellow in the Department of Medical Oncology at Queen's University in Kingston, Canada, and is also affiliated faculty at the Program on Regulation, Therapeutics, and Law in the Department of Medicine at Brigham and Women's Hospital in Boston. His clinical and research interests revolve around cancer policy, global oncology, evidence-based oncology, financial toxicities of cancer treatment, clinical trial methods, and supportive care.

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