MALÉ, Maldives – The largest Covid-19 treatment facility in the Maldives has almost 300 beds and a constant supply of oxygen. But when the country reported some of the highest per capita cases in the world last month, Covid stations ran out of another vital resource: staff.
"In the worst case, we had a nurse who looked after 20 patients in the general wards," said Mariya Saeed, the director of the Hulhumalé medical facility in Malé, the capital. "We needed staff to adequately care for the many bedridden elderly people, but the nurses were exhausted."
The pandemic has created a shortage of health workers around the world, forcing governments to make an effort. Spain, for example, launched an emergency plan last year to recruit medical students and retired doctors for the Covid service. And in India, Prime Minister Narendra Modi last month asked local officials to start recruiting medical students last year.
But the Maldives, an archipelago with around 1,200 islands in the Indian Ocean, are facing unique challenges. It can't just be crowds of Students because there is only one university with one medical school. And it cannot only rely on its citizens, as its health system is heavily dependent on foreign workers. Many of these doctors and nurses are from India, a country facing its own gigantic outbreak.
One result is that the Maldives, which have otherwise approached the pandemic with great attention to detail, aren't sure how to man their hospitals for the next crisis.
"We spoke to countries like Bangladesh and India about recruiting their doctors and nurses," President Ibrahim Mohamed Solih told reporters last month. "But they cannot provide any help because of their own Covid situation."
The Maldives, a predominantly Muslim country with around 540,000 inhabitants, has described itself as a model of the pandemic response for small countries. With aggressive contact tracing and reliance on the island's scattered geography to slow down outbreaks, the government kept its Covid case numbers low enough to lift restrictions on domestic movement and lure international tourists back to their luxury resorts, a mainstay of the economy. In April, Ramadan festivals and nationwide council elections were held as usual.
"You never know what will happen tomorrow," Thoyyib Mohamed, executive director of the country's official public relations agency, told the New York Times in February. "But first I have to say: This is a really good case study for the whole world, especially for tropical destinations."
Many people in Malé now have a deceased in their extended family, said Marjan Montazemi, the Unicef representative in the Maldives. "Because the numbers are not the same as in other countries, it doesn't get as much attention," she said. "But it was pretty difficult for the country."
Officials in the Maldives have not confirmed how variants could have affected the recent outbreak, but local doctors say the Delta variant, which was first discovered in neighboring India, likely played a role.
As cases rose to more than 1,500 a day last month, hundreds of Covid-19 patients came to the Hulhumalé medical facility. Although the facility with 16 doctors and 89 nurses was built last year to treat Covid patients, it wasn't finished.
"We were always prepared for a possible surge, but such a sudden and massive wave just came unexpectedly," said Nazla Musthafa, government health advisor.
To make up for the shortage of doctors and nurses, the Maldives National University's medical school, opened in 2019, with a total of 115 students, sent dozens of medical and nursing students to Malé's Covid wards. The government also called in retired nurses and hired volunteers with no medical experience.
Ms. Saeed, the director of the Hulhumalé medical facility, said the volunteers mainly helped patients go to the bathroom, turn over in bed, maneuver wheelchairs and oxygen bottles, and perform other basic functions. She said volunteers wore protective clothing but there was no time to screen them for Covid-19.
One volunteer, Rizna Zareer, 35, said she mainly provided moral support to patients who were not allowed to receive visitors.
"We were her family and I saw her that way," she said.
The shortage of medical staff is so great that lab technicians involved in contact tracing have to work around the clock, a team of World Bank experts said in a statement.
The bottleneck underscores a reliance on foreign health workers that the government knew was a problem even before the pandemic broke out.
In 2018, all but a fifth of the approximately 900 doctors and more than half of the Maldives' nearly 3,000 nurses were expatriates, resulting in high turnover that affected the quality of health care, a government report said.
Other countries, including Ireland, Israel, and New Zealand, also rely heavily on expatriates to work in healthcare. But unlike them, the Maldives are not rich. That means it can't compete as aggressively to lure foreign doctors and nurses, especially during a pandemic that has left virtually all health workers outnumbered.
S. Irudaya Rajan, chairman of the International Institute for Migration and Development, a South India-based research organization, said he expected countries that send large numbers of health workers overseas, including India and the Philippines, to adjust their policies to more to keep workers at home.
The Maldives needs a better strategy to ensure more stable supplies of foreign doctors and nurses, Rajan said. One way would be to sponsor Indian medical students in India and require them to work in the Maldives for a few years after they graduate, he said.
"A lesson every country should learn from Covid-19 is: Don't exploit poor countries like India and the Philippines," said Rajan. "Invest in them and their people and they can benefit you."
A spokesman for President Solih of the Maldives did not respond to requests for comment.
The daily average of new cases in the Maldives is now about 260 or less than a quarter of last month's high. However, as of Friday, the country still had around 21,000 active cases, and a 12-hour curfew introduced in Malé last month remained in place. The call to prayer still sounds five times a day from the city's mosques, but only a small number of believers are allowed in.
The government recently announced a plan to build a new 270 bed facility in Malé to cope with future outbreaks and increase the country's total bed capacity for Covid patients from 460 to 730 it.
Mr Solih told reporters last month that his Minister of Health, Ahmed Naseem, hoped to recruit 40 doctors and 100 nurses from India and Bangladesh by the end of June. But at the same press conference, Mr. Naseem tried to lower expectations.
"It is currently difficult to employ people from India, Bangladesh and Sri Lanka," he said. “Sri Lanka in particular is almost impossible. I've tried for many days. "
Maahil Mohamed reported from Malé, the Maldives, and Mike Ives from Hong Kong.