From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

Ecuador’s Response to the Coronavirus Pandemic: The August Update (2020)

Irene Torres, PhD, Fundación Octaedro, Quito, Ecuador*
Fernando Sacoto, MD, MPH, Ecuadorian Society of Public Health, Quito, Ecuador
Daniel López-Cevallos, PhD, MPH, Oregon State University, Corvallis, Oregon, USA
* Email: irene@octaedro.org

According to official WHO estimates, Ecuador is no longer the worst affected country by COVID-19 in Latin America. However, the country continues to withstand the onslaught of the pandemic and suffers from systemic deficiencies of the public health sector, including limited testing capacity. For instance, Ecuador has conducted only 227,000 PCR tests to August 3, or 12,898 per million people (compared to Chile, with 88,733 tests per million people).

In other words, Ecuador has been detecting only the tip of the iceberg from the beginning of the pandemic. Unfortunately, these figures have been used for decision making and for international comparisons. Containment, mitigation and clinical care have been conducted, basically, in the blind, as the undercount would make it seem as if the country is doing better than it is.

The same happens with COVID-19 deaths, of which Ecuador has 326 confirmed deaths per million people, which already places the country 18^th in the world in that category. However, the 25,500 excess deaths, i.e. 1,448 per million people, during the pandemic make Ecuador one of the worst performers, since the direct and indirect impact of COVID-19 clearly overburdened the health network.

Despite repeated calls for a more robust public health response, a community-based epidemiological surveillance system has not been put in place, largely due to the continuing and now exacerbated fragility of public primary health care, which has about 1 facility per 10,000 people (n=1,939, excluding the 721 rural community health centers administered by the Peasants’ Social Security Administration).

Avoidance of such an approach may be interpreted as an undeclared strategy of seeking herd immunity, especially given the declarations by the Minister of Public Health insisting that between 33% and 45% of people in Ecuador have been infected with SARS-CoV-2. Meanwhile, international evidence shows that these rates have not been reached even in locations with high COVID-19 burden and that herd immunity cannot be achieved in a short time.

Due to pressure to resume commercial activities, the Ecuadorian government has actively supported re-opening of businesses and exit from confinement. At the same time, social protection measures are scarce so the growing informal economy (which was already large) is met with hefty fines (first offenders, $100; second offenders, $400, which is equivalent to the minimum wage in Ecuador) for people who gather or do not wear a face mask. Much of the national government’s efforts have centered around labeling the public (and even regional/local authorities) as undisciplined, and therefore subject to blaming, and heavy monitoring by the national police and army.

Concurrently, once the reopening strategy began in late May, only a handful of municipalities have returned to strict confinement measures, once the number of cases and deaths increased beyond the benchmarks stipulated  by the National Emergency Operations Committee. For the rest of the country, there has only been a one way forward (i.e., continue to reduce restrictive measures), which runs contrary to what is being practiced in more successful countries (i.e., where there is selective lockdown depending on need).

So, in the absence of a robust evidence-based, public health oriented response, the curative hospital level has borne the brunt of a mishandled emergency. Even though journalistic reports revealed the struggle to access health care, the Minister of Public Health argued the public health care system is not overburdened because there are no waiting lists, only “regular bed rotation.” In the capital city of Quito alone, there were 63 people on waiting lists for ICU, and 93 for hospitalization in public facilities, on July 30, 2020.

Evidence from other middle-income countries in Latin America that are doing better (e.g., Costa Rica, Uruguay) indicates that such an approach has major limitations. No amount of clinical resources will help us to flatten the curve and get a grip on the COVID-19 pandemic. And coming into this crisis, Ecuador was already in the midst of an economic downturn.

Given the limitations in data collection and quality of information mentioned above, we have little clarity regarding the evolution of the pandemic in Ecuador. In the absence of reliable national estimates, we are left with worrisome mathematical projections (e.g., Imperial College) of a significant rise in cases and deaths from October, assuming current measures are relaxed. August 5 will mark such a moment, as beaches will become open to the public.

We are running out of time to put forward a primary care-based response to the COVID-19 pandemic and its aftermath, articulated from the local level (municipalities) up instead of the top-down approach that has been the norm so far. In order to increase transparency and community participation, a crucial tenet of health promotion, we also need an independent assessment of the response, with broad access to all data and decision-making processes by the National and Provincial Emergency Operations Committees.

Ecuador’s Response to the Coronavirus Pandemic: Update (May 2020)
Irene Torres, Fernando Sacoto & Daniel López-Cevallos

Irene Torres, Fundación Octaedro, Quito, Ecuador*
Fernando Sacoto, Ecuadorian Society of Public Health, Quito, Ecuador
Daniel López-Cevallos, Oregon State University, Corvallis, Oregon, USA
* Email: irene@octaedro.org

The COVID-19 pandemic continues to unfold in Ecuador, making it now the most severely hit country in Latin America. Although there is limited evidence of coordination between the national-level Emergency Operations Committee (EOC), Ministry of Health and municipality-level governments, on April 26 the central government gave responsibility to the municipalities for deciding on stricter or more relaxed measures on mobility and economic activity, using the proposed traffic light system (red, yellow, green). Because dissemination of information is scarce and primarily managed by the national EOC, it seems like an inadequate development; local governments lack a scientific, standardized tool to identify and weigh risks objectively. Some measures reflect this challenge even at the national level. As part of the lockdown measures, the ban on public transportation has pushed health workers, other essential workers, patients and their families to scramble for options to reach their destinations, possibly amplifying the web of transmission. Use of private vehicles makes it hard for local governments to institute security measures for mobile people and control the spread of the virus. Although municipalities decided to buy themselves more time to develop reopening plans, by remaining on “red”, media coverage across the country show levels of movement and concentrations of people that are closer to “yellow”, while confirmed cases and deaths continue to rise daily (29,420 confirmed cases and 1,618 deaths as of May 6). Further, 1,969 health care workers and other first responders have tested positive for COVID-19 (7% of all confirmed cases).

Without a high-level trustworthy scientific commission guiding the COVID-19 response in Ecuador and validating official information related to the pandemic, the Minister of Health declared recently that 120 days after the first case, about 60% of the population (10.5 million) will likely become infected and about 1% may die from COVID-19. In other words, the pandemic may cause 100,000 deaths this year (6,000 per million) when only 71,007 deaths were registered in 2018. Such a statement could be construed as a de facto endorsement of a “herd immunity” strategy, in the absence of a national contingency plan. The central government’s focus is on physical distancing, sanitation precautions, and a phased reopening of the economy. Interestingly, the minister has promised 1 million rapid tests by the end of June, although only 81,392 total tests (both rapid and PCR) have been conducted by May 6. Moreover, the mayor of Quito, the capital and most populous city (2.7 million), recently stated, without providing scientific evidence, that the pandemic will reach its peak there on May 26, 70 days after the first confirmed case, and that his administration would carry out 200,000 PCR tests.

At this point, the impact of COVID-19 must be understood beyond the number of confirmed cases and deaths, and probable or excess deaths, which is largely what the government is reporting on. The scars left by the pandemic in the health sector include corruption scandals related to the emergency response acquisitions at inflated prices above market rates, including body bags, masks and other PPE at public hospitals (the National Anti-Corruption Commission has identified 23 contracts). In the context of this type of mismanagement of resources, and the extended duration of COVID-19 in Ecuador (by May 6, it will be 67 days after the first confirmed case), the window for implementing local surveillance for mitigation is progressively closing. The Central University of Ecuador recently announced that about twenty thousand students would be trained and deployed to support epidemiologic surveillance in Quito. No such strategy has so far been announced at the national level or elsewhere in the country.

It may still be possible to execute a more robust response similar to what other middle-income countries with similar challenges have been able to do (e.g., Vietnam). It would entail moving away from focusing solely on epidemiological tracking, towards tackling the societal dimensions of the pandemic. We need to address, for instance, its gendered and ethnic implications, including issues such as the rise in gender-based violence during lockdown, which will continue to have a direct and indirect impact on health outcomes in Ecuador for years to come. Such a scenario requires a revamping of primary care-based approaches to the health care network of services and its proper articulation at the national and local levels. Moving forward, regional and multilateral agencies should consider facilitating access to financial resources and expertise to support the strengthening of the primary care system, together with an independent observatory with full access to data in charge of verifying the monitoring and control of corruption in the health system, and the evaluation of health services. Such an approach could improve the management of the pandemic moving forward, as well as in systematically documenting lessons learned for when the next health emergency strikes.

Ecuador’s Response to the Coronavirus Pandemic – Original post (April 2020)

Irene Torres, Fernando Sacoto & Daniel López-Cevallos

Irene Torres, Fundación Octaedro, Quito, Ecuador
Fernando Sacoto, Ecuadorian Society of Public Health, Quito, Ecuador
Daniel López-Cevallos, Office of Undergraduate Education & Center for Global Health, Oregon State University, Corvallis, Oregon, USA

Ecuador (population: 17.5 million) is undergoing a severe economic crisis, in great part due to massive debt commitments, government corruption, lower oil prices and a stronger-than-desired US dollar (the country’s currency since 2000) that has made exports more expensive. A possible increase in fuel prices (as originally agreed with the International Monetary Fund) triggered massive protests and paralyzed the country for almost two weeks last October, further weakening an already unpopular government. In this critical context, Ecuador was among the first countries in Latin America to be impacted by the COVID-19 pandemic, on February 29. Only considering COVID-19 confirmed cases, Ecuador has the second highest mortality rate in Latin America (22 per million, on April 15). If, in January, only 3,228,032 of the economically active population (8,379.355) were fully employed, the government estimates the COVID-19 emergency will add 508,000 unemployed and 233,000 informally employed Ecuadorians.

Although the government opted for a national lockdown on March 17 with only 111 confirmed cases, COVID-19 spread rapidly in the main hotspot (Guayas province, Ecuador’s economic hub) and has been confirmed across the country, including the Galapagos Islands. By April 15, there were 7,858 confirmed cases, 388 confirmed deaths, and 582 probable deaths, with a total of 10,479 pending test results from a total of 26,093 PCR tests. A majority of the confirmed cases concentrate in the Guayas province, where the second most populous city in the country, Guayaquil (2.72 million) is located. On April 15, Guayas province had 5,051 confirmed cases (71% of the total) and 185 deaths (48% of the total).

The Minister of Health over the past nine months, without previous national-level experience in public health management, was replaced on March 21, 2020, in the midst of this crisis. The achievements of the new minister are still unclear in his first month of tenure, when the relatively high number of probable deaths, limited amount of personal protective equipment for health personnel, testing capacity and number of low tests available with limited laboratory infrastructure and resources, are still exceedingly uncertain. This scenario further complicates the assessment of the situation, including detection and isolation of cases, and projections of COVID-19 growth.

As an example, according to official figures, between April 1 and 15, there were 6,703 deaths in Guayas province, and 4,236 in March, compared to 1,679 in February and 1,943 in January of this year. It is likely that a significant number of these excess deaths are due to COVID-19, albeit without confirmation with a PCR test. In fact, on April 16, the government announced that there are an estimated 5,700 excess deaths in Guayas province in April 2020 (compared to April 2019), under circumstances in which news of mortuary services overflow or even collapse have inundated the national and international media.

In Ecuador’s fragmented and segmented network of health services, which has not reached in our opinion the status of a functioning health care system, the uninsured are tested and receive medical attention by the Ministry of Health, which is currently bearing the brunt of the pandemic. Although public insurance gives coverage to roughly 7 million people (40%), by April 15, the Ecuadorian Institute of Social Security (IESS) had only 983 confirmed cases, and 1,376 pending PCR test results (i.e., 12% of confirmed cases and 13% of pending results in the country). Surprisingly, 38% of confirmed deaths (a total of 147) belong to IESS. This may imply existing socioeconomic inequalities are correlated to COVID-19.

Similarly, while the Ministry of Health has 355 hospitalized patients, 135 of which are in critical condition; IESS has 150 hospitalized patients, of which 54 are in critical care. Intensive care beds in Ecuador’s private and public hospitals amounted only to 1,183 (68 per million people) in 2017. A number of provinces do not have any intensive care beds and it has been reported that regular occupancy previously reached or exceeded 80%, meaning that even if capacity was expanded as promised, the country is already at its limit in this respect.

Despite being classified as an upper-middle country, the current pandemic has exacerbated long-standing structural socioeconomic and health issues in Ecuador. According to the World Health Organization, the country is at level 3 of preparedness (in a scale from 1 to 5), equivalent to ≤60% of capacity benchmarks. Consequently, and despite the province of Guayas having considerable resources compared to the rest of the country, the city found itself ill-equipped to respond. The growing consensus is that the governmental response (at the national and local levels) was botched and limited, resulting in an almost natural evolution of COVID-19 in the Guayas province. The Emergency Operations Committee (EOC) has suggested the use of a mobile app. However, only roughly 30% of people have smartphones, so it seems impractical to concentrate information flow through an app to report symptoms, monitor cases, and educate or support the public.

Continuous formal insistence to implement local epidemiological surveillance and support to isolate, monitor and eventually follow up cases during and after a gradual exit from lockdown, should be taken more seriously and rapidly. Incipient data on confirmed cases among indigenous communities also highlights flaws in the provision of care for this population, and there is an urgent need to engage with indigenous organizations, to produce relevant materials in the appropriate languages, and to consider particular contexts.

The almost month-long nationwide lockdown effort has been followed by those who were able to, but has imposed a heavier burden on those needing to support themselves and their families on a daily basis, to seek medical attention for themselves or family members, or to arrange funeral services for relatives. Starting in late April, the government will begin to gradually reduce measures through a “traffic light” system. It seems the red, orange and green signals will ease on restrictions in certain segments of the economy and in certain regions of the country that are not as heavily impacted. However, authorities have yet to provide enough details or technical reasoning behind decisions for control being high (red) or low (green). Just this week, when the system was expected to begin, the EOC extended the nationwide lockdown (“red”) for an additional week.

Even with limited testing capabilities, a locally-based system could be set up to map previously confirmed and suspected cases, isolate and monitor their contacts, and more precisely determine confirmed and suspected deaths, to identify existing and potential hotspots, and to estimate the trajectory of COVID-19. This would demand that Ecuador begins to share information openly, and improves coordination with local governments and community-embedded organizations. As has already been recommended, naming a scientific commission could aid in overseeing how different advices are verified and consolidated at the national, regional, and local levels, and therefore render decision making more transparent and credible.

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