01 Pan American Journal Opinion and analysis of Public Health 02 03 04 05 06 Critical care medicine in the French Territories in 07 08 the Americas: Current situation and prospects 09 10 11 1 2 1 1 1 Hatem Kallel , Dabor Resiere , Stéphanie Houcke , Didier Hommel , Jean Marc Pujo , 12 Frederic Martino3, Michel Carles3, and Hossein Mehdaoui2; Antilles-Guyane Association of 13 14 Critical Care Medicine 15 16 17 18 Suggested citation Kallel H, Resiere D, Houcke S, Hommel D, Pujo JM, Martino F, et al. Critical care medicine in the French Territories in the 19 Americas: current situation and prospects. Rev Panam Salud Publica. 2021;45:e46. https://doi.org/10.26633/RPSP.2021.46 20 21 22 23 ABSTRACT Hospitals in the French Territories in the Americas (FTA) work according to international and French stan- 24 dards. This paper aims to describe different aspects of critical care in the FTA. For this, we reviewed official 25 information about population size and intensive care unit (ICU) bed capacity in the FTA and literature on FTA ICU specificities. Persons living in or visiting the FTA are exposed to specific risks, mainly severe road traffic 26 injuries, envenoming, stab or ballistic wounds, and emergent tropical infectious diseases. These diseases may 27 require specific knowledge and critical care management. However, there are not enough ICU beds in the FTA. 28 Indeed, there are 7.2 ICU beds/100 000 population in Guadeloupe, 7.2 in Martinique, and 4.5 in French Gui- 29 ana. In addition, seriously ill patients in remote areas regularly have to be transferred, most often by helicopter, 30 resulting in a delay in admission to intensive care. The COVID-19 crisis has shown that the health care system 31 in the FTA is unready to face such an epidemic and that intensive care bed capacity must be increased. In 32 conclusion, the critical care sector in the FTA requires upgrading of infrastructure, human resources, and 33 equipment as well as enhancement of multidisciplinary care. Also needed are promotion of training, research, 34 and regional and international medical and scientific cooperation. 35 36 37 Keywords Critical care; tropical medicine; French Guiana; Guadeloupe; Martinique. 38 39 40 41 The French Territories in the Americas (FTA)—French Guiana, ICUs in France are defined as units where patients can receive 42 Guadeloupe, and Martinique—are all located in the intertropi- mechanical ventilation. 43 cal zone between latitudes 4° and 16° north. They comprise two Hospitals in the FTA work according to international, Euro- 44 island regions, Martinique and Guadeloupe (and their depen- pean, and French standards. They are an illustration of a 45 dencies Saint Martin, Saint Barthélemy, and the Guadeloupe paradox whereby hospitals in a high-income country are serv- 46 archipelago), and a continental region of the Amazon rainforest ing a significant part of the population with low income and 47 area of South America, French Guiana (Figure 1). in a situation of precariousness. Regarding ICUs, there are not 48 In France, intensive care units (ICUs) are designed to take enough available data covering activity indicators. The inter- 49 care of patients presenting or likely to present with organ failure val between the onset of first symptoms and admission to the 50 and requiring artificial organ support, such as mechanical ven- ICU can be long and therefore may constitute in itself a risk 51 tilation, catecholamines, and dialysis (circulaire DHOS/SDO n° for patients. Many factors can be involved, but the main rea- 52 2003-413 du 27 août 2003 article R. 712-90). Since there is no sons are the delay of medical transportation from areas often 53 common definition of an ICU between countries, schematically, accessible only by air (plane or helicopter) or by boat, the 54 55 56 1 Cayenne General Hospital, Cayenne, French Guiana * Hatem Kallel, kallelhat 3 Guadeloupe University Hospital, Pointe-à-Pitre, Guadeloupe @yahoo.fr 57 2 Martinique University Hospital, Fort-de-France, Martinique 58 59 This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 IGO License, which permits use, distribution, and reproduction in any medium, provided the 60 original work is properly cited. No modifications or commercial use of this article are permitted. In any reproduction of this article there should not be any suggestion that PAHO or this article endorse any specific organization or products. The use of the PAHO logo is not permitted. This notice should be preserved along with the article’s original URL. Open access logo and text by PLoS, under the Creative Commons Attribution-Share Alike 3.0 N61 Unported license. Rev Panam Salud Publica 45, 2021 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2021.46 1 Opinion and analysis Kallel et al. • Critical care medicine in French Territories in the Americas FIGURE 1. Map of French Territories in the Americas multidisciplinary care time in the emergency sector, which does from the Middle East (Palestine, Syria, and others). Population not necessarily have all the resources immediately accessible, flows, whether travelers or migrants, play a significant role in and the lack of ICU beds. the development of epidemics and/or emerging pathologies The aim of this paper is to describe different aspects of critical (1). Furthermore, French Guiana is the French overseas territory care in the FTA. It focuses on the impact of social and environ- that registers the most asylum requests (40%), the vast majority mental determinants on health and the need for more intensive of which are refused, leading to numerous undocumented for- care beds. It also discusses the prospects for upgrading infra- eign residents, most often without solidarity medical insurance structure and human resources and on promoting research. such as the State Medical Aid (AME in French) or the Comple- mentary Universal Medical Coverage (CMUC in French). Thus, POPULATION CHARACTERISTICS they contribute significantly to precariousness and the high poverty rate of the population. Indeed, in 2015, the National The estimated population size in 2019 was 400 000 inhabitants Institute of Statistics and Economic Studies (www.insee.fr) in Guadeloupe (including Saint Martin island), 358 749 in Marti- estimated the poverty rates at 19% in Guadeloupe, 21% in Mar- nique, and 290 691 in French Guiana (www.insee.fr). In terms of tinique, and 44% in French Guiana. Obviously, precariousness population growth, French Guiana is the most dynamic region, and poverty are leading causes of renouncement of health care with an average yearly growth of 2.3%, whereas the migratory and contribute to longer length of hospital stay and hospital balance sheet is negative in Martinique and Guadeloupe. This occupancy rate (2). It is also important to emphasize the impact is partly because French Guiana has a younger population: of cultural diversity and public confidence and practices on the around 50% are under 25 years compared with less than 30% spread of illness. in Guadeloupe and Martinique. Further, Martinique and Gua- deloupe benefit from a significant influx of tourists, whereas HOSPITAL NETWORK French Guiana faces immigration, sometimes clandestine, from its neighboring countries (Brazil and Suriname), from the In the FTA, the public hospital network encompasses sev- Caribbean arc, mainly migrants from Haiti, and more recently eral sites across four main locations in Martinique, six in 2 Rev Panam Salud Publica 45, 2021 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2021.46 Kallel et al. • Critical care medicine in French Territories in the Americas Opinion and analysis FIGURE 2. Number of intensive care beds per 100 000 population by departments of France 01 02 Europe (average) 11.5 03 Mainland France (average) 7.6 04 05 Paris 9.3 06 Provence-Alpes-Côte d'Azur 9.1 07 Grand Est 8.4 08 09 Occitania 8.0 10 Hauts-de-France 7.6 11 Normandy 7.3 12 13 Martinique 7.2 14 Guadeloupe 7.2 15 Bourgogne-Franche-Comté 7.1 16 Centre-Val de Loire 7.0 17 18 Auvergne-Rhône-Alps 7.0 19 New Aquitaine 6.9 20 Réunion 6.0 21 22 Corsica 5.2 23 Brittany 4.8 24 Pays de la Loire 4.8 25 26 French Guiana 4.5 27 Mayotte 2.1 28 0246810 12 14 29 30 No. ICU beds / 100 000 population 31 Source: Prepared by the authors using data on the number of intensive care beds from the annual health establishments statistics (SAE) database published in 2018 by the French Ministry of Health; population size 32 from the database published in 2020 by the National Institute of Statistics and Economic Studies (INSEE); and data on Europe from Rhodes et al. (4). 33 34 35 Guadeloupe, and three in French Guiana, with one referral departments of France. These differences are too large to be 36 hospital in each geographic department. Even though Marti- explained purely by differences in the characteristics of the 37 nique and Guadeloupe hospitals are university health facilities, populations and can contribute to high case fatality rates (3). 38 Cayenne hospital is still a general hospital, despite seven units In 2020, the National Professional Council on Intensive Care 39 being led by university professors (intensive care, infectious Medicine (CNP MIR) judged that the rate of intensive care 40 diseases, dermatology, public health, laboratory, pediatrics, beds in France was very low and must be upgraded to 10 ICU 41 and neurology). All three hospitals receive residents and med- beds/100 000 population, representing at least 3% of hospital- 42 ical trainees within their medical course and participate, at the ization capacity (5). Critical care capacity in the overseas French 43 same level, in the university education.