My critical care crusade: Why low-resource countries need more than primary care

critical care crusade

“I know that my child died because I am poor.”

These are words I will never forget. They were uttered by a dejected mother as she watched us, her daughter’s medical team, desperately try to resuscitate the child.

She was right.

Because she could not afford the antibiotics to treat severe pneumonia,  her daughter died when the infection overwhelmed her little body.

As a Pediatric Critical Care specialist, I am trained to help children survive their most acutely ill states. I fight death, in the literal sense. Over the last few months, while working in Rwanda and Liberia, I have all too often found myself staring helplessly at parents and family members as they watch their young children succumb to disease. Much of the western medical advances that allow us to minimize childhood mortality rates have not yet made it to these countries.

In Sub-Saharan Africa and other low resource areas, preventative strategies and primary healthcare are the focus of governments and ministries of health. The need for basic healthcare services will always be present, but tertiary healthcare systems — including critical care — are becoming more important as childhood mortality rates decline. These supplementary services must be incorporated into the fabric of existing healthcare structures.

Although critical care is often understood to mean intensive care units that deliver expert, specialized care, the truth is that many diseases are pre-critical. For example, strep throat can lead to rheumatic heart disease when left untreated. If issues such as this are not addressed early, they will progress and overcome the body’s defenses.

Preventative care, primary care and specialized care overlap and must be developed alongside one another to minimize morbidity and mortality. Disease prevention decreases the burden of need for critical care intervention, but does not eliminate its necessity.

Disease prevention decreases the burden of need for critical care intervention, but does not eliminate its necessity.

Why is critical care undervalued?

There are many reasons cited for the slow development of critical care in global health, including:

  • lack of qualified human resources (health care workers)
  • deficiencies in fundamental logistics (clean water, reliable electricity, medical equipment, etc)
  • poor health care infrastructure
  • financial limitations

Because of the many competing human needs, engaging in complex and critical care can seem exorbitant and reckless. Efforts to provide critical care are often abandoned because the cost per patient of providing high intensity care is often significantly higher than that of providing other services such as clean water, vaccinations, nutrition and other primary healthcare concerns. The World Health Organization defines a “very cost-effective” intervention as one that costs less than the value of gross domestic product (GDP) per capita per disability-adjusted life year (DALY).

In some countries such as Egypt, South Africa and Kenya, quality pediatric critical care comparable to U.S. standards is available at private and university hospitals. But the provision of care is greatly skewed: it can only be afforded by a minority of families. Health care resource allocation and accessibility remain important issues of global justice.

I believe every life matters. Preventable death should be minimized if not eradicated in all corners of the globe. This is not simply a challenge for primary healthcare systems, but tertiary healthcare systems that address every sickness in every child. To succeed, tertiary healthcare systems must be developed alongside primary healthcare systems for balanced prevention and treatment strategies that will lead to continual decline in childhood mortality.

Unami Mulale 2Una Mulale, MD, is the first Pediatric Critical Care Specialist from Botswana. She is currently a Pediatric Global Health fellow at Boston Children’s, and plans to return to Botswana upon completion of her fellowship. Her goal is to implement tertiary healthcare structures in low-resource countries in Africa and around the world.



Learn more about the Global Pediatrics Program.