Warning: Hospitals May be Unsafe for the Poor

Most public health initiatives in developing countries focus on controlling infectious diseases in the community. The morbidity and mortality caused by diseases such as malaria, tuberculosis, schistosomiasis, and pediatric pneumonia and diarrhea certainly justify such priorities. But another aspect of the public health system in nations with limited healthcare resources – hospital�acquired infection – has been largely ignored by the public, press, and funding agencies.

Developing nations lavish their limited resources on hospitals, which consume more than 50% of healthcare budgets in many poor countries. Officials in these countries are striving to identify sick patients in the community and to triage them to regional facilities that have the expertise to provide appropriate diagnosis and treatment. Some of these facilities may be modest local clinics with a few beds. Others are regional or national tertiary care centers offering as much high�tech diagnosis and treatment as the country can afford (or persuade industrialized nations or philanthropists to provide).

The craving for expensive, technologically sophisticated care is noteworthy. In part, poor countries make these large investments because they are devoted to improving the quality of diagnosis and treatment. In part, they make them to keep their best physicians. These doctors, trained in advanced countries, return home with a keen desire to use their newly honed skills, only to find themselves hamstrung by outdated radiology equipment, a limited range and unreliable supply of drugs, and primitive life�support technology. High�tech hospitals are also status symbols, and some countries seek prestige by building the most modern facilities. The industrialized countries that build and help fund these projects may be motivated, at least in part, by pressure from the companies that make high�tech equipment and supplies.

Nations that make large investments in hospitals and physicians who are devoted to improving quality of care clearly expect to see improved patient outcomes. But their expectations often are disappointed. Indeed, these huge investments are frequently counterproductive. Many patients enter hospitals only to fall victim to largely preventable, potentially fatal, antimicrobial�resistant infections. These infections also prolong hospitalization and require additional diagnosis and treatment, generally with expensive, difficult�to�obtain antibiotics.

The more advanced (and expensive) the care, the higher the risk. Danger is greatest in intensive care units (ICUs). Concentrating large numbers of critically ill patients on a single ward facilitates transmission of disease�causing microorganisms via the hands of care�givers. Patients admitted to ICUs become colonized rapidly with hospital bacterial pathogens, which often are resistant to antibiotics.

ICU patients are infection�prone because they are exposed to invasive devices (such as intravenous or arterial catheters and mechanical ventilation), complex surgical procedures, and drugs that weaken the immune system. ICUs in developing countries not only have high rates of infection day�in and day�out, but also are subject to devastating outbreaks of lethal bloodstream infection and pneumonia due to contamination of equipment, medications, and other supplies.

The widespread lack of appreciation of the importance of hospital�acquired infections among care�givers and policymakers in developing countries is disheartening. The thirst for technology is not accompanied by an appetite for infection control.

On one occasion, my colleagues and I were invited to a public hospital in a developing country to investigate why the death rate in a pediatric ICU caring for patients with dengue hemorrhagic fever was so high. The prevailing theory held a virulent strain of the dengue virus responsible. Instead, we discovered that most of the children were dying from hospital�acquired bloodstream infection caused by the very devices that were supposed to save their lives – intravenous catheters, mechanical ventilators, and bladder drainage catheters.

Though the equipment was adequate, infection control and staff training were not. A damp towel teaming with hospital bacterial pathogens was used to dry hands. Intravenous and bladder catheters were neither inserted nor maintained properly. Tubing for ventilators (hung to dry over a hole in the floor used to dispose of urine and wastes) was not disinfected correctly. We found innumerable other violations of basic infection control technique. Nonetheless, a bone marrow transplant unit, financed largely by Japan, had just opened in the same hospital – placing the most vulnerable patients at the mercy of deadly infections.

Sound infection control costs only a mere fraction of even basic medical technologies. Granted, countries with limited resources cannot supply their hospitals with the full repertoire of infection controls available in wealthier nations. Yet, much can be done. Infection control principles, such as effective hand hygiene and good aseptic technique, are simple and easily taught. Even where safe water is unavailable, effective decontamination of hands can be accomplished in seconds by using a water�less, alcohol�based hand gel that costs a few US pennies if manufactured locally.

Gloves, locally manufactured, can be reserved for high risk activities to prevent cross�infection among patients and protect care�givers from blood�borne infections. Proper disinfection of equipment is generally affordable (especially in comparison to the cost of equipment itself), and contamination of medications and solutions can be avoided through training and vigilance. Deadly outbreaks of Lassa fever and Ebola have occurred among patients and care�givers in rural facilities simply because gloves and other personal protection necessary to prevent the spread of these blood�borne viruses were unavailable or, if available, not used properly.

Experience shows that invasive devices, such as intra�vascular catheters, ventilators, and bladder catheters, tend to be overused in hospitals that have access to them, and tend to be left in place for longer than is medically necessary. This is the worst�case scenario – expensive material is wasted and the risk of infection increased. Overuse of antibiotics can also be curtailed by standardized protocols, thus reducing costs and retarding the emergence of resistance.

Healthcare policy leaders and funding agencies should remember that even the most fearsome contagious diseases can yield to basic infection control training and equipment. But hospital�acquired infections must be given proper priority. If not, many investments in costly hospital facilities in the developing world may do more harm than good.