Recognized by the World Health Organization (WHO) as one of the top countries for managing the COVID-19 crisis, Colombia enters a new phase of control through Testing, Tracing and Isolation, known as TTI (in Spanish: Pruebas, Rastreo y Aislamiento Sostenible – PRASS).
Applying TTI will enable the country to open its economy to secure the livelihood of millions already impoverished as a result of confinement, while keeping a grip on infection, and, eventually, controlling it.
The City Paper spoke to Luis Guillermo Plata, director of Colombia’s Emergency Fund (FOME), and manager of the COVID-19 pandemic. As the mastermind behind adapting TTI methodology to the complex and challenging reality of Colombia, he explained the importance of keeping people safe while safeguarding the economy. Luis Guillermo clarified the scope of the country’s PCR testing capabilities and performance indicators. He also spoke about the relevance of quarantine, the challenges of managing the crisis in an open economy, as well as the assessment of Colombia’s healthcare system and overall achievements.
The City Paper, TCP: Up to now, Colombia has had one of the longest quarantines in the world. Why?
Luis Guillermo Plata, LGP: We have had a long quarantine because we acted quickly when things started to become difficult. That said, it has not been a complete quarantine. It started with a lot of restrictions, but we’ve gradually opened. Right now, most economic sectors are working. Obviously, bars, restaurants, gyms, theaters are not, and that is why you see many people going about their business, and traffic is an issue again in Bogotá.
But, quarantine has been very important because Colombia has performed quite well compared to other countries. And, while this is not a competition to see who does better, it is important to understand how we are performing as a nation.
Two indicators are particularly important when assessing Colombia’s performance. By looking at the total cases-per-million population, which is the right way to measure this because results are in proportion to the population of the country, Colombia ranks number 75 in the world by having 827 cases-per-million. Being 75 in this ranking is good because it means we don’t have that many cases compared to our 50 million citizens.
And, when we look at the deaths-per-million ranking, we are number 64 with 27 deaths per million. I know these numbers are cold, it’s rather a heartless way to look at the problem, but it gives us an assessment of how we are doing, and I think the quarantine was fundamental in decelerating the spread of the disease.
TCP: Concerning other countries, how does Colombia rank regarding its medical system to attend the pandemic?
LGP: When we first looked at Colombia’s ICU capacity, it turned out we had a bigger ICU capacity per one hundred thousand inhabitants than Spain or Italy. This was two months ago – when it really got ugly in Italy and Spain – and we were fearing the worst for Colombia.
One of our biggest concerns was that when you see countries such as Italy or Spain on their knees, you think: What is going to happen to us? But, as it turned out, our response capacity was stronger than other countries, and this, has surprised me positively.
TCP: The ratio of ICU units compared to 100,000 inhabitants in Colombia is concentrated in certain areas. What is the Government’s strategy regarding remote and impoverished places with lack of medical infrastructures like Chocó, La Guajira or Leticia in the Amazon?
LGP: ICU capacity obviously is somewhat concentrated in certain areas. When we talk about ICUs, we are not just talking about machinery or the ventilator, it’s the whole set-up. We can send ventilators and monitors to remote parts of our geography, but if we don’t have technicians and doctors to operate them, it’s not going to achieve much.
In those remote areas, we have been increasing capacity. We have been sending testing material and ventilators. We sent most of the first 92 ventilators to Buenaventura, Tumaco and Leticia, as well as other places. But, keep in mind that it’s not just the ventilator, it’s about having the whole infrastructure in place for this to work.
We are doing our best to supply remote areas, which have a big legacy of problems. And, it’s hard to correct structural issues during a crisis. We are doing what is strictly necessary to have some capacity to operate ICUs in such places. But, sometimes it makes more sense to bring people to where the capacity is.
If you have 100 ventilators, it’s probably smarter to set them up in qualified hospitals with technicians and doctors in big cities than to send five ventilators here, and two there, or four to another place where there is no infrastructure.
It’s a combination of both, we have to watch out of for our regions where a lot of the infection has taken place, but that said, we have to be careful of how we use our resources most efficiently so we can save the most number of lives.
TCP: What is Colombia’s current medical inventory to face the pandemic, especially now that we are starting to ease lockdowns and open fully the economy?
LGP: As I mentioned earlier, we are quite well equipped, we have about 12 ICUs per 100,000 inhabitants, and that is a pretty good number. Altogether, we have some 6,000 ICUs and have devoted 2,650 exclusively to COVID-19. The idea is to continue growing that capacity.
We have a lot of intermediate care units, which are essentially ICUs with no ventilator. We are setting up ventilators to up-grade the units. So far, we have bought 2,767 ventilators, we are negotiating 3,200 more, which should be arriving in June and July.
We are almost tripling our capacity of ICUs for COVID-19, and this should keep us afloat in the most difficult moments of the crisis. Of course, if it were possible to get more that would be great, but there are restrictions in the international markets, and competition is fierce. We have 190 countries looking for the same products and are willing to pay exorbitant prices for them, including for faster delivery times, and delivery time is of the essence.
TCP: When will Colombia peak?
LGP: Well, it’s hard to tell as I am not an epidemiologist, so I am always careful with this question. My job is to manage things, how to assemble teams and how to organize and apply a methodology to chaos. Peaks may change depending on many factors: on how strong quarantines have been, and on the behavior of people.
If people behave properly, we might be able to slow down the peak. If they don’t and go out and party, the peak could come sooner and stronger. It’s all relative, I would hate to give a specific date, it’s very hard not to make a mistake.
Right now, we are increasing with an estimated 1,500 cases per day, which means we are starting to climb the curve with 51,000 cases nationwide, and this is the moment when we need to be extra careful managing things, exert as much self-discipline as possible to make sure we can contain the spread of the virus as much as we can.
TCP: You have been working with Invima (equivalent of the U.S FDA) and local initiatives developing reasonably inexpensive ventilators compared to those produced overseas. When will these machines be operational?
LGP: We have 21 initiatives for locally-made ventilators. Some are in more advanced stages than others. Making ventilators is not as simple as one may think. This medical equipment needs to be tested extensively and certified, and Invima is making sure that things available to the public are safe.
These ventilators need to go through a process of validation and certification. It’s not a simple process. It has four different stages because this machine is used for saving lives. And, if the equipment is improperly used or defective, it can actually kill people. So, this is nothing to be taken lightly.
To circumvent the Invima validation process, we rely on Law 23 of 1981, which allows the use of experimental technology in extreme situations, like the one we are living, with the patient’s or the patient’s family consent to use the equipment.
These locally-made ventilators can be used as a last resource, when we know that it’s either this or people dying, and with the consent of the family or the patient.
This opens the door responsibly to locally-made ventilators. But, we can’t just take an unproven product that is making the transit from prototype to commercial production and just use it freely.
InspiraMed, a Medellín based company, is prepared to release the first 100 ventilators as soon as this week.
TCP: You have said ventilators are quite expensive, even more as the result of current demand. How much will these Colombian-made ventilators cost?
LGP: I don’t know, but I don’t think you can compare one thing to the other. They are different products in different stages of development. We are glad to have Colombian ventilators, but we yet have to see how they work. I don’t think we can make an apples-to-apples comparison between domestic ventilators and those on the market for years.
TCP: Minister of Health Fernando Ruíz announced that Colombia will apply PRASS, the methodology from Johns Hopkins University to handle the pandemic in a normalized economy. What is PRASS, when does it start?
LGP: PRASS is a methodology that we have been working on with agencies and ministries in Government. I worked very hard and diligently on adapting the general methodology to Colombia’s social and economic realities, as well as the idiosyncrasy of its people. Once we were ready, we presented it to the Minister of Health. PRASS is something very simple. In English it is Testing, Tracing, Isolation (TTI). In Spanish: Pruebas, Rastreo y Aislamiento Sostenible.
This is something very intuitive, but it needs to be done massively and effectively. Let’s imagine that Luis Plata gets infected, gets tested and turns out positive. We need to immediately trace back who Luis meet within the past few days, and among those, who are of greater risk of being infected.
Let’s say that the obvious choice is Luis’ wife and son because they live in the same place, but maybe Luis had lunch with a friend. Maybe he had a meeting with a colleague, and they both spoke in a room for over 15 minutes. They didn’t keep their distance, and maybe that someone is also a high-risk candidate.
It’s likely Luis met with 40 people (that’s the global average) that he knows of in the days before showing symptoms. Maybe he was in a line at a bank or at a meeting with people he didn’t know.
We need to do a memory jogger, and ask, “Hey Luis, who did you meet with?” And, figure out who, among those 40 people Luis met in the past week or so, are really at risk, who he spent more time with, or if he was unprotected when he met with them. We need to identify them.
Once we identify them, we will isolate all 40. We’ll say to them: you were with Luis, he is infected and you have to go home. But, among those 40, there are 20 that were very close to Luis and we need to test them. We need to find out if they are positive or not. And that is what we call Tracing and Isolation, and that is how you break down the contagion chain.
This is how you identify who is infected and who is at risk of being infected. And that is how, instead of locking down 10 or 20 or 40 million people, you might end up isolating 100,000 or 200,000 that are at most risk.
The advantage of this strategy is that the economy can continue, things can continue to move on, while we rapidly trace who is infected or who is at risk of being infected, and break the chain. This is the most important action we can take, this is how we win the war. This is the stage we are moving in to.
TCP: Is tracing the greatest challenge you have faced up to now?
LGP: The first challenge we faced was acquiring test kits. There was a huge demand for testing materials, it was hard, but we managed to acquire the extraction kits for the testing.
There are two types of testing. One is the PCR testing and the other is serological testing. PCR testing is more precise. It searches for the virus by extracting the genetic material of the person’s sample by using a thermocycler, the machine that gives you the diagnostic test. You need to do both: testing and extraction. People don’t know that you can’t do testing without extraction.
At one point, we could not find extraction kits. We were down to 1,000 tests a day. We managed to bring 500,000 and distribute them to the regions very quickly. We also managed to upgrade 50 regional laboratories, and we went from doing 1,000 tests to 12,000 and 14,000 per day.
We needed to have the testing capacity. You can have a beautiful strategy, but if you don’t have testing capacity because you don’t have extraction kits, you have nothing. That was the first challenge and combined with buying two Hamilton extraction robots from the U.S., with the permission of the White House, we were able to upgrade the capabilities of the National Health Institute. Each one of these extraction robots can conduct about 1,000 tests per day. So all this combined has allowed us to improve our testing capabilities.
Now that we have testing capabilities, we can improve tracing. We have been doing tracing since the beginning of the pandemic, but we needed to do it at a bigger scale.
We have to go to each of the contacts of all the people that are infected, and we need to identify them, and, isolate them. This is what we are doing. If we manage to do enough testing, contact tracing and isolation, we can break the contagion chain, and be in good shape.
TCP: Are you expecting an increase of cases once the economy opens?
LGP: Yes, there will be an increase in numbers and that is one of the weird things of this pandemic. With more testing, more infected. But, it is a matter of testing. If we don’t test, it will appear that we have very few cases, even if we might have millions.
When we do testing, we know what is happening. When you see some of the numbers in some countries in other continents, you wonder, “wow, this country has a huge population, but has 2,000 infected.” And it’s not that they have 2,000 infected, chances are they haven’t done much testing.
We have processed more than 450,000 PCR tests since we began mass testing. This is important. Other countries are doing the other kind of testing, it’s called serological testing, or what we call Rapid Testing (Pruebas Rápidas).
This test doesn’t search for the virus in the person. What this does is it look for antibodies that have been formed in the blood sample of individuals. It allows us to say that Claudia or Luis was infected, but it isn’t a very good predictive test. It only shows results normally after Day 11 of infection. So many countries are doing serological testing, and when they show their results, they are adding serological to PCR testing. But, what we are doing in Colombia is primarily PCR testing, which allows us to know early-on that who has the virus and act accordingly.
TCP: If you do more testing, you will have more positives. But, do you expect that by opening the economy the virus will spread even more?
LGP: If we respect social distancing, wear face masks, not socialize and follow all the right procedures, I think the pandemic can be controlled.
TCP: Is Colombia going to do massive testing?
LGP: No. Massive testing is not efficient. It’s like throwing a hook into a lake and trying to catch a fish without bait. It’s not that effective. We need to test those who are either showing symptoms, who are at risk, or who were exposed to infected people. This is the only way to be effective.
We can conduct a million tests in the wrong places, without having results. Instead, it is more important to identify who the infected person is, trace down those contacts, and test them because we know they could have been exposed, and are most likely to be infected.
It’s about being smart. It’s not about testing 50 million Colombians. We couldn’t do this. It would cost a fortune. And it would take too long to do. It’s about identifying who are at risk-persons. I can tell you that people that are at risk are the people who are exposed or were exposed to those who got Covid-19.
Other high risk populations are those in jail, people that attended an event, a church, let’s say, that disobeyed isolation measures and held a meeting. Those are populations at risk, and we can test those because we know that there is a likelihood that something might have happened.
TCP: Does Colombia have an official treatment for COVID-19?
LGP: There is a lot of discussion in the world on the treatment for COVID-19. One thing that’s interesting about this disease is how little we know about it, and how often positions get reassessed. This is happening worldwide, not just in Colombia. There is no agreement on how we measure infection, there is no agreement as to how we measure coronavirus-related deaths, there is no agreement on treatment either. And there is no agreement on the vaccine. People say one thing, and the next day they say another.
We follow WHO guidelines. We have good doctors in Colombia, but there is still so much discussion on treatment, as to what works well, what doesn’t and what’s best. And that’s pretty incredible.
TCP: When it comes to a vaccine, what is Colombia’s approach?
LGP: Vaccines are coming, we don’t know exactly when, but we know they are coming. One certain way to know that vaccines are coming is to look at increasing demand for syringes in the world.
When you think of any public health crisis, you must look at the whole chain. If you have the vaccine, but you don’t have syringes, you have a problem. It’s a supply-demand challenge.
Right now we have been buying ventilators, medicines, monitors and PPE. Eventually, we will need to buy syringes and vaccines.
The world is also trying to figure out what is a just way to distribute vaccines, how to secure access to everybody, not just for big countries, or what I call, “bully countries.” That is important. What mechanism will take place for countries that are not superpowers, like us, to get fair access, and equal treatment to medicines and vaccines is of utmost importance.