Hospital El Salvador: broader questions remain

During 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.²

Given this, Manuel Bello and colleagues' Comment (March, 2021)³ 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.⁴ 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.⁵

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.