At the age of 27, in order to get a change of scenery and to leave the hospitals of the metropolis for a while, Arthur (1) had chosen a medical internship in Guyana for the summer of 2020. It was just before the pandemic:
“I chose my period well, you will tell me: after the first deluge of patients in metropolitan France, the Guyanese wave. Without being a journalist myself, I will try to follow this quote from Albert Londres: “Our job is not to please, nor to do harm, it is to carry the feather in the wound.” This testimony will therefore necessarily be unique to me, with my vision as a caregiver, my bias as a metropolitan and the inherent bias in preserving anonymity while trying to remain faithful to what is happening away from cameras and institutional social networks. I will mainly talk about hospital and territorial management but will not address the issue of city medicine due to ignorance of the subject.
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“Before talking about Covid, I would like to paint a quick picture of the health situation here: Guyana is currently suffering from a dengue epidemic, and for a long time that of HIV. And that’s without counting the problems that are much more frequent than cardiovascular disease or cancer. Take Saint-Laurent-du-Maroni for example, for a population pool of several tens of thousands of people, the number of hospital beds in acute medicine outside the Covid-19 period is … 30. It is not to sink into the miserable but it is certain that 30, that calms down … In total, there are three hospitals on the coast distributed in the big cities (Cayenne, Kourou and Saint-Laurent-du-Maroni) and centers of health dispersed in land and along waterways. We all know that the investment and skills of caregivers are very heterogeneous in the hospital… but here we can say that it is pushed to its climax. Before detailing the dysfunctions in the management of this crisis, I would like to greet some incredible caregivers: those who have been pillars of care in this department for several years, those who have set up services, those who allow the hospital to stand up. But alongside these staff, we find jumbled mercenaries who don’t care, those who don’t have the skills but don’t realize it, and those who feed their ego. In such a difficult environment, the contrast is striking.
Staggering lack of communication
“You have to adapt in Guyana all the time. We have to adapt to patients: to a sometimes exacerbated precariousness, to the different language barriers, to their paperwork problems, to their life outside the big cities of the coast. We have to adapt to the means: digestive endoscopies are Cayenne, urology is Kourou, ophthalmology is Saint-Laurent-du-Maroni. Certain biological examinations… it is the metropolis. So I can understand that we cannot work as I am used to in metropolitan France, that we have to juggle and make compromises. But some situations are just indecent. Not in France, not in 2020: we do not refuse to take a patient in his thirties in intensive care under the pretext that he is HIV and Brazilian. We do not die after having an epidural for childbirth. We are not saying that we do not care if we made a mistake because the patient speaks poor French and will not file a complaint. You cannot be unreachable when you are on call… I think that in metropolitan France, no one would accept some of the things that I have seen here. And that can be brushed aside with the back of the hand since “It’s that or nothing, there is no one else”. It is not acceptable, it is indecent. And still I’m lucky in my medical practice, I’m a guy, people listen to me. It sucks, but that’s how it is. This is clearly not specific to Guyanese hospitals: more than once when I was a student I was spoken to instead of my boss. But here it is exacerbated, I am ashamed to have to repeat what my female colleagues say so that less competent men listen to them. It is blatant, it is shameful.
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“The patients, at least as far as I have come across, have illnesses made worse by many social problems. Two like that in your room in metropolitan France, it burns you out for the day. Here it is everyday. Illnesses as in the books and patients who do not fit into the administrative framework. I don’t want you to imagine the Wild West by reading this, but there are so many great projects to strengthen or create, I think our fellow citizens deserve to be done better. So inevitably, when a pandemic emerges, we are not serene. We had two major advantages: a young population and a few weeks ahead of the mainland. We quickly forget the weeks in advance, they were squandered by internal quarrels between hospital management, crisis management and the ARS. It was almost as if we were discovering the problems day to day, with a beautiful ball of hypocrites constantly parading in the media and on social networks. I am very happy to see the director of ARS Guyane, Clara de Bort, pose on the tarmac of the airport with her staff and congratulate herself for carrying out Evasan (medical evacuations) in a beautiful cooperation with the hospitals. Unfortunately, it has happened several times that some of these evacuations were announced on television or on the Internet… before warning the doctors who directly took care of the patients concerned. The first time it was a family who came to ask us at what time their loved one would be evacuated when we had not been informed …
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“Finally, I would have had the right to the same speech here as at the start of the wave in metropolitan France:” No, but France is different, it will not be like Italy “,” No, but Guyana, that will be fine, it won’t be like in the metropolis. ” One day you will explain to me which part of “pandemic” you did not understand. I don’t know, honestly, how we could confidently say that everything was ready, that we didn’t need help and that everything was going to be fine. I feel like I heard Macron say that we never ran out of masks. Nobody one day could assume to say “It’s shit, but we will adapt as quickly as possible, everyone is on the front”? Must always put everything under the carpet? Fortunately, we had help, a lot of help, a lot of people who came to give a helping hand whether it was on their leave, on an agreement between hospitals, via the army or the health reserve. However, I would still like to underline the astounding lack of communication between hospitals, ARS and health reserve. You try to round up your friends to fill in the holes, put on the patches to keep it going and you finally discover that a whole team is arriving but no one has seen fit to warn the staff. You may even hear the phrase “There are too many reinforcements” while services are still understaffed. I know that in the end the whole technostructure will congratulate itself on the excellent management and will go with its little comment, but it is the caregivers who make it possible to hold on.
Infernal mixture of care, public opinion and political interests
“The health reserve I still have a few complaints. Throwing in the room retired general practitioners who have not done hospitality since their start of their careers and putting hospital workers in town, doesn’t that sound like a bad idea? I have no desire to be ungrateful to my colleagues, more than courageous, who volunteered to come, but maybe estimating the needs and positioning the reinforcements accordingly would be a good start. So inevitably when by ego we say that all is well in the services, we find ourselves hearing that a pulmonologist or infectious disease specialist is not necessary in Guyana. Anyway, we are no longer close. Ah and I greet you dear resuscitator colleague who did not want to see respiratory distress because you were eating. I do not forget you. Same for the reinforcements who complained about not being able to tour, I do not forget you either.
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The climax of this infernal mixture between care, public opinion and political interests was the trial planned for plasma therapy (with plasma from patients who had developed antibodies). If we summarize the situation, a trial concerning the interest of plasma therapy in Sars-CoV-2 infection had started in metropolitan France and was to continue in Guyana. There are two advantages to this: to provide patients with a potentially useful treatment and to succeed in including enough patients to reach a robust conclusion. In a context of mistrust of health authorities, media hubbub and the habit of this department being left behind, announcing this news from Paris was very clumsy. Let us add to this that this was done not by a PUPH (university professor-hospital practitioner) but by a PUPH, Karine Lacombe, and it was gone. Everyone has gone there from their affiliations to promote themselves, deputy, local collectives, close to Didier Raoult’s IHU. And in this mess, in the end, people were therefore pushed to demonstrate to refuse the help of an infectious disease specialist and her team in a territory that badly needed it. Admittedly, the announcement was awkward, but we saw people chanting loud and clear that they refused therapeutic help. I thus saw a good number of messages passing to say that the Guyanese patients were not guinea pigs. It’s such a no-brainer: no one is ever forcibly included in an essay if they don’t want to. This is the very basis of our ethical principles. But obviously to say it would do a disservice to conspiracy discourse. On the other hand, promoting the use of hydroxychloroquine without any proof of its effectiveness in Covid, that was to use patients as guinea pigs. Associations have been calling for the creation of a university hospital in Guyana for years… and when a university team comes to do research, the door is vehemently slammed in its face.
“All this reflects a profound ignorance of clinical research and its functioning. So I hope that some people’s political agenda was worth it. In all of these ego bickering, whenever politics take precedence over caregivers and scientists for the wrong reasons, it is the patients who drink. While the Guyanese are worth it that we are interested in their territory, that we invest in improving access to healthcare here and that it be worthy of France. ”
(1) The first name has been changed.
Christian Lehmann doctor and writer