Hospital El Salvador: broader questions remain – Authors' reply
Authors: Manuel Bello, Víctor Segura, Luis Camputaro, William Hoyos, Mauricio Maza, Xochitl Sandoval, Magdalena Serpa, Craig M Coopersmith
Journal: The Lancet Global Health (2021)

We thank Amaral Arevalo and Clare Wenham for their interest in our Comment.1Bello M Segura V Camputaro L et al.Hospital El Salvador: a novel paradigm of intensive care in response to COVID-19 in central America.Lancet Glob Health. 2020; (published online Dec 23.)https://doi.org/10.1016/S2214-109X(20)30513-1PubMed Google Scholar Hospital El Salvador is part of the network of public sector hospitals of the Ministry of Health. In our role as physicians and scientists involved in the design and operation of Hospital El Salvador, we were not part of national public policy discussions. Despite this, by our training and by analysing pandemic behaviour,2Ng Y Li Z Chua YX et al.Evaluation of the effectiveness of surveillance and containment measures for the first 100 patients with COVID-19 in Singapore - January 2–February 29, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 307-311Crossref PubMed Scopus (0) Google Scholar, 3Han E Tan MMJ Turk E Sridhar D Leung GM Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe.Lancet. 2020; 396: 1525-1534Summary Full Text Full Text PDF PubMed Scopus (217) Google Scholar we understand the importance of public health measures such as disease surveillance, prevention, containment, and mitigation in slowing outbreaks. Such measures are recommended by the Pan-American Health Organization and WHO, and El Salvador's national COVID-19 preparedness and response plan4Ministry of HealthEl Salvador's Government2020. Plan nacional de preparación y respuesta ante el Novel Coronavirus (2019 – nCov), El Salvador.http://asp.salud.gob.sv/regulacion/pdf/planes/Plan-nacional-de-preparacion-y-resp-eventos-provocados-virus-resp-potencial-pandemico-svl-2020_v2.pdfDate: 2020Date accessed: January 19, 2021Google Scholar follows these global health recommendations.5WHOCountry and Technical Guidance - Coronavirus disease (COVID-19).https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidanceDate accessed: January 19, 2021Google Scholar Although preventive public health measures are crucial to pandemic response, management of patients at the bedside is equally crucial. We do not view these as competing priorities but rather believe there is a complementary role for both. Our role as clinicians is to treat patients affected by disease. As highlighted in our Comment,1Bello M Segura V Camputaro L et al.Hospital El Salvador: a novel paradigm of intensive care in response to COVID-19 in central America.Lancet Glob Health. 2020; (published online Dec 23.)https://doi.org/10.1016/S2214-109X(20)30513-1PubMed Google Scholar the intensive care unit (ICU) bed capacity of public hospitals before the pandemic was dangerously low. Had trends in the growth of COVID-19 continued, the demand could have rapidly surpassed the supply. This situation necessitated urgent action. Multiple medical professional associations—including intensive care, internal medicine, and palliative care—were consulted during initial planning for Hospital El Salvador's development. Additionally, public policy experts, engineers, and architects provided input to the design. A hallmark of democracy is that citizens can agree or disagree with a government's policies. As such, some scientists and clinicians agreed with the construction of Hospital El Salvador while others did not. Public discourse related to health care is ultimately beneficial to progress in society, and multiple voices were heard before and after the construction of Hospital El Salvador. As COVID-19 spread in El Salvador, many physicians who initially disagreed with the construction of the hospital now refer their patients to this hospital due to the shortage of ICU beds in the private sector. We appreciate the opportunity to highlight the gender diversity of providers at Hospital El Salvador. Currently, 10 female and 13 male intensive care physicians work at the Hospital El Salvador monitoring centre, while six female and two male intensive care residents are part of the staff. More than half of the 297 general physicians working directly with COVID-19 patients at the ICU are female (166 [55%]). Most nurses in El Salvador are female, and consistent with this, of the 256 nursing staff currently working at ICU, 193 (75%) are female, and 63 (25%) are male (data as of Feb 8, 2021). We are proud that Hospital El Salvador has expanded access to health care for patients suffering from COVID-19 in El Salvador and welcome further rigorous scientific analysis of our actions. MS reports personal fees from Hospital El Salvador during the conduct of this Correspondence. By virtue of their roles within a public hospital or the Ministry of Health, MB, LC, WH, and XS are government employees. All other authors declare no competing interests. The views and opinions presented are those of the authors. Hospital El Salvador: a novel paradigm of intensive care in response to COVID-19 in central AmericaOn March 18, 2020, the first case of COVID-19 was confirmed in El Salvador.1 Closely monitoring pandemic trends worldwide,2–4 local experts realised that if El Salvador's cases were to mirror global trends, 20% of people infected with severe acute respiratory syndrome coronavirus 2 would require hospitalisation, and between 5% and 8% would require an ICU bed.5 Yet there were only 94 ICU beds in the public health system, distributed between nine hospitals (1·45 ICU beds per 100 000 people). By March 18, the occupancy rate was already 80%, meaning that only 19 ICU beds were available for critically ill patients with COVID-19 across the country. Full-Text PDF Open AccessHospital El Salvador: broader questions remainDuring COVID-19, El Salvador's Government introduced some of the most stringent approaches to infection management.1 In March, 2020, President Nayib Bukele's Government declared a state of exception, introduced absolute quarantine, and established containment centres to house those arriving into the country possibly with COVID-19 infection. These measures resulted in questionable human rights abuses, and cases soon spread within these centres and into communities, which did not have adequate public health measures. Full-Text PDF Open Access