Hospital El Salvador: broader questions remain
Authors: Arevalo Amaral, Clare Wenham
Journal: The Lancet Global Health (2021)

During COVID-19, El Salvador's Government introduced some of the most stringent approaches to infection management.1Amaral A Wenham C Covid-19 in El Salvador: safeguarding public health or restricting human rights?.https://blogs.lse.ac.uk/latamcaribbean/2020/04/13/covid-19-in-el-salvador-safeguarding-public-health-or-restricting-human-rights/Date: 2020Date accessed: January 4, 2021Google Scholar 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.2Aragon GL De nada sirve la cuarentena si nos mezclan.https://elfaro.net/es/202003/el_salvador/24127/%E2%80%9CDe-nada-sirve-la-cuarentena-si-nos-mezclan%E2%80%9D.htmDate: 2020Date accessed: January 4, 2021Google Scholar Given this, Manuel Bello and colleagues' Comment (March, 2021)3Bello 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 is one of the first global explanations of what steps Bukele's Government has taken to manage the pandemic, with a focus on intensive care unit (ICU) capacity building through a video monitoring hub in the newly created Hospital El Salvador. As academics researching health emergencies in El Salvador, we read this with interest, but it raises several questions. Given the hostile division between the Government and the scientific community, we are interested in the decision-making processes that established this hospital as the priority area. We do not know of any other country that has taken this approach, and thus what might have spurred this activity, beyond a small pilot in San Rafael. The Comment states that the hospital was designed by medical experts, but was this strategy designed by intensivists, or did it also have input from public health, epidemiology, and social scientists? It appears the motivating factor was the desire to reduce specialists' infection risk. Why was the decision made to invest in treatment of the very sick, rather than efforts to reduce the disease's spread? The most effective interventions against COVID-19 are at population level.4Han E Tan MMJ Turk E et al.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 (449) Google Scholar The financial investment in Hospital El Salvador, although not public, must be substantial. This fact must be understood in a context where millions of Salvadoreans live in extreme poverty without access to water for handwashing and where a large informal sector relies on a daily income and is unable to isolate.5Mariana B 2020. FUSADES: El Salvador entra a recesion profunda por COVID-19.https://www.laprensagrafica.com/economia/FUSADES-El-Salvador-entra-a-recesion-profunda-por-covid-19-20200603-0113.htmlDate: 2020Date accessed: January 4, 2021Google Scholar The gendered effects of this ICU-based approach are also notable: male intensivists sit behind screens and female front-line nurses provide direct care under their command, increasing their risk of infection. Health systems reproduce wider inequalities in society, and these must be addressed in system design. Making any objective international comparisons is hard given restrictions on public data sharing, including the mechanisms for taking, processing, and disseminating test results, which are under embargo until June, 2022. We fear that Hospital El Salvador will be lauded a success as part of broader propaganda without independent analysis of whether it has been a better investment than reduction of COVID-19 in the wider population. We declare no competing interests. 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 remain – Authors' replyWe thank Amaral Arevalo and Clare Wenham for their interest in our Comment.1 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,2,3 we understand the importance of public health measures such as disease surveillance, prevention, containment, and mitigation in slowing outbreaks. Full-Text PDF Open Access