The island nation kept Covid cases low, and its resorts open, for much of the pandemic. But a recent surge exposed its over-reliance on expatriate health workers.
The largest Covid-19 treatment facility in the Maldives has nearly 300 beds and a steady supply of oxygen. But as the country reported some of the world's highest caseloads per capita last month, Covid wards ran low on another essential resource: employees.
"At worst, we had one nurse to attend to 20 patients in the general wards," said Mariya Saeed, the head of the Hulhumalé Medical Facility in Malé, the capital. "We needed human resources to provide proper care to the many bedridden elderly, but the nurses were exhausted."
The pandemic has triggered shortages of health workers around the world, forcing governments to scramble. Spain, for instance, launched an emergency plan last year to recruit medical students and retired doctors for Covid duty. And in India last month, Prime Minister Narendra Modi asked local officials to start recruiting final year medical students.
But the Maldives, an archipelago of about 1,200 islands in the Indian Ocean, faces unique challenges. It can't easily call up masses of students because it has only one university with a school of medicine. And it can't rely just on its citizens, because its health care system depends largely on foreign workers. Many of those doctors and nurses come from India, a country that is facing its own gargantuan outbreak.
One result is that the Maldives, which has otherwise tackled the pandemic with meticulous attention to detail, isn't sure how to staff its hospitals for the next crisis.
"We have spoken to countries like Bangladesh and India" about recruiting their doctors and nurses, President Ibrahim Mohamed Solih told reporters last month. "But they are unable to provide any assistance due to their own Covid situations."
The Maldives, a Muslim-majority nation with a population of about 540,000, has styled itself a model of pandemic response for small countries. Using aggressive contact tracing, and relying on dispersed island geography to slow outbreaks, the government kept its Covid caseload low enough to lift curbs on domestic movements and lure international tourists back to its luxury resorts, a mainstay of the economy. In April it allowed Ramadan feasts and nationwide council elections to go ahead as usual.
"You never know what will happen tomorrow," Thoyyib Mohamed, the managing director of the country's official public relations agency, told The New York Times in February. "But for the time being, I must say: This is a really good case study for the entire world, especially tropical destinations."
Though 59 per cent of the population has received at least one dose of a Covid-19 vaccine, the recent surge took a heavy toll. Nearly half of the country's 200 Covid-19 deaths during the entire pandemic were reported in May.
Many people in Malé now have someone in their extended families who has died, said Marjan Montazemi, the UNICEF representative to the Maldives. "Because the numbers are not the same as in other countries, it doesn't attract that much attention," she said. "But for the country it has been quite difficult."
Officials in the Maldives have not confirmed how variants may have influenced the latest outbreak, but local doctors say the Delta variant, first detected in neighboring India, likely played a role.
As cases surged to more than 1,500 a day last month, hundreds of Covid-19 patients descended on the Hulhumalé Medical Facility. Despite being built last year for the purpose of treating Covid patients, the facility — staffed with 16 doctors and 89 nurses — was not ready.
"We were always prepared for a possible surge, but a wave this sudden and massive was just unexpected," said Nazla Musthafa, a health adviser to the government.
To compensate for a shortage of doctors and nurses, Maldives National University's medical school — which opened in 2019 and has a total of 115 students — sent dozens of medical and nursing students to help work in Malé's Covid wards. The government also called nurses out of retirement and drafted volunteers with no medical experience.
Saeed, the head of the Hulhumalé Medical Facility, said that volunteers mostly helped patients go to the toilet, roll over in bed, manoeuvre wheelchairs and oxygen cylinders, and perform other basic functions. She said that volunteers wore protective gear but that 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 their family, and I saw them that way, too," she said.
The shortage of medical workers is so bad that lab technicians involved in contact tracing must work around the clock, a team of World Bank experts said in a statement.
The bottleneck highlights a dependence on foreign health workers that the government knew was a problem even before the pandemic hit.
In 2018, expatriates made up all but a fifth of the Maldives' 900 or so doctors and more than half of its nearly 3,000 nurses, leading to high turnover that affects 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 health care. But unlike them, the Maldives isn't rich. That means it can't compete as aggressively to lure foreign doctors and nurses, especially during a pandemic that has left virtually every nation's health workforce short-handed.
S. Irudaya Rajan, the chairman of the International Institute of Migration and Development, a research organization based in southern India, said that he expected countries that send large numbers of health workers abroad, including India and the Philippines, to tweak policies to keep more workers at home.
The Maldives needs a better strategy for securing a steadier supply of expatriate doctors and nurses, Rajan said. One option would be to sponsor Indian medical students in India and require them to work in the Maldives for a few years after graduating, he said.
"One lesson every country should learn from Covid-19 is: Don't exploit poor countries like India and the Philippines," Rajan said. "Invest in them and their people, and they can benefit you."
A spokesperson for Solih, the Maldives president, did not respond to requests for comment.
The daily average of new cases in the Maldives is now about 260, or less than one-quarter what it was during the peak last month. A 12-hour curfew put in place in Malé in May remains in effect. The call to prayer still rings out five times a day from the city's mosques, but worshippers are allowed inside only in small numbers.
The government recently announced a plan to build a new 270-bed facility in Malé to deal with future outbreaks and raise the country's total bed capacity for Covid patients to 730 from 460. The main challenge for the new facility may be figuring out how to staff it.
Solih told reporters last month that his health minister, Ahmed Naseem, hoped to recruit 40 doctors and 100 nurses from India and Bangladesh by the end of June. But at the same news conference, Naseem tried to lower expectations.
"Currently it is difficult to employ people from India, Bangladesh and Sri Lanka," he said. "Sri Lanka, especially, is near impossible. I have been trying for many days."
This article originally appeared in The New York Times.
Written by: Maahil Mohamed and Mike Ives
© 2021 THE NEW YORK TIMES