Opinion: The long wait — how COVID-19 impacts surgical services in Peru

With COVID-19 cases continuing to rise in Latin America, Peru is currently one of the 10 countries in the world with the highest numbers of cases, with more than 280,000 confirmed infections.

Despite the fact that it was among the first countries in the region to declare a lockdown by March 16 — as part of its main public health policy to mitigate the impact of COVID-19 — it is now one of the worst hit. And after 107 days of national lockdown, many health care services have been affected, including surgical care. During the first three months of the pandemic, an estimated 7,478 elective surgeries were canceled each week.

In April, the national entity in charge of advanced medical training in Peru, CONAREME, announced that the admission process for doctors seeking specialization training, which usually takes place in May, would be postponed to October. This important decision impacts all specialties, including surgery from now until October, as no new residents — doctors in specialty training — will be entering the health system.

Building capacity during the crisis

To mitigate the high demand for medical staff, the government has adapted the Pan American Village, originally constructed for the Pan American Games in 2019, as the biggest hospital for COVID-19 patients with newly hired, exclusive medical staff.

Additionally, to support critical areas that are experiencing an overload of patients and work, many surgeons have been transitioned from the operating room to the emergency room.

Dr. María Cáceres, a hepatobiliary surgeon at a hospital in Lima and member of the American College of Surgeons, told us in an interview that “we [as surgeons] have joined the COVID triage of suspected cases to contribute because this is not just a problem for pulmonologists and internists — it is a problem for everyone.”

Furthermore, with the intention to create scientific evidence in surgical patients, a recently formed group of Peruvian surgeons and trainees, called Siray, has joined a worldwide collaborative initiative, CovidSurg. The project intends to report outcomes of surgical patients with COVID-19 and describe high-risk factors — such as being male, being over 70 years old, and having a history of cancer or emergency procedures.

This multinational project, led by the NIHR Global Health Research Unit on Global Surgery in the U.K., will provide information for decision-making for the post-coronavirus era — not only for Peru but worldwide.

Peruvian society has stepped up during the pandemic. Many businesses, charity organizations, and independent individuals have contributed donations to health care providers. The group Medicos Solidarios has been able to launch campaigns to get donors and reach out to hospitals around the country to provide personal protective equipment, hospital beds, and mechanical ventilators.

Obstacles remain in a fragmented system

But despite the action already taken to support access to health care, there are challenges within the highly fragmented health system. How are the five systems of the Ministry of Health, the Ministry of Labor and Employment Promotion, the army, the police, and the private sector communicating effectively and how can the health system get prepared for surgeries?

Communication is essential, and the central government committee has taken the lead. It has gathered experts from different fields such as infectiology, epidemiology, mathematics, and research to inform decision-making and share information with the general public.

Measures by the Ministry of Health are already taking place, including the relocation of surgical services in coronavirus-free areas, the opening of specific operating rooms for COVID-19 patients, and the purchase of surgical supplies that ensure appropriate safety of staff.

While there is a lack of PPE for all the hospitals in the country, a budget has been assigned for surgical and staff supplies, according to the economic resources of each institution. The process is slow, but it is being implemented.

Despite the transition into a focalized lockdown on July 1, the number of suspended surgeries continues to rise. Because of this, national directions to assess the risks and benefits of surgical management are very much needed.

Tools are now available for clinical risk stratification of patients that might have an important role, especially in rural areas where medical technology is scarce. Prioritization must be considered if the benefits overcome the risk of exposure to intrahospital contagion and complications.

Lessons learned and best practices

Like Peru, many other middle- and lower-income countries are struggling to provide continuity of essential surgical care.

One of the biggest lessons learned from the pandemic is that despite fast initial efforts, they weren’t enough to solve the underlying socioeconomic conditions that were linked to a fragile health system before the pandemic. However, the actions taken might serve other members of the global health community.

Update, July 1, 2020: This op-ed was updated to reflect that Dr. María Cáceres was interviewed by the authors.