Critical care medicine in the French Territories in the Americas: Current situation and prospects

ABSTRACT Hospitals in the French Territories in the Americas (FTA) work according to international and French standards. This paper aims to describe different aspects of critical care in the FTA. For this, we reviewed official 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 injuries, envenoming, stab or ballistic wounds, and emergent tropical infectious diseases. These diseases may require specific knowledge and critical care management. However, there are not enough ICU beds in the FTA. Indeed, there are 7.2 ICU beds/100 000 population in Guadeloupe, 7.2 in Martinique, and 4.5 in French Guiana. In addition, seriously ill patients in remote areas regularly have to be transferred, most often by helicopter, resulting in a delay in admission to intensive care. The COVID-19 crisis has shown that the health care system in the FTA is unready to face such an epidemic and that intensive care bed capacity must be increased. In conclusion, the critical care sector in the FTA requires upgrading of infrastructure, human resources, and equipment as well as enhancement of multidisciplinary care. Also needed are promotion of training, research, and regional and international medical and scientific cooperation.

The French Territories in the Americas (FTA)-French Guiana, Guadeloupe, and Martinique-are all located in the intertropical zone between latitudes 4° and 16° north. They comprise two island regions, Martinique and Guadeloupe (and their dependencies Saint Martin, Saint Barthélemy, and the Guadeloupe archipelago), and a continental region of the Amazon rainforest area of South America, French Guiana ( Figure 1).
In France, intensive care units (ICUs) are designed to take care of patients presenting or likely to present with organ failure and requiring artificial organ support, such as mechanical ventilation, catecholamines, and dialysis (circulaire DHOS/SDO n° 2003-413 du 27 août 2003 article R. 712-90). Since there is no common definition of an ICU between countries, schematically, ICUs in France are defined as units where patients can receive mechanical ventilation.
Hospitals in the FTA work according to international, European, and French standards. They are an illustration of a paradox whereby hospitals in a high-income country are serving a significant part of the population with low income and in a situation of precariousness. Regarding ICUs, there are not enough available data covering activity indicators. The interval between the onset of first symptoms and admission to the ICU can be long and therefore may constitute in itself a risk for patients. Many factors can be involved, but the main reasons are the delay of medical transportation from areas often accessible only by air (plane or helicopter) or by boat, the 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 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 Unported license. multidisciplinary care time in the emergency sector, which does not necessarily have all the resources immediately accessible, and the lack of ICU beds.
The aim of this paper is to describe different aspects of critical care in the FTA. It focuses on the impact of social and environmental determinants on health and the need for more intensive care beds. It also discusses the prospects for upgrading infrastructure and human resources and on promoting research.

POPULATION CHARACTERISTICS
The estimated population size in 2019 was 400 000 inhabitants in Guadeloupe (including Saint Martin island), 358 749 in Martinique, and 290 691 in French Guiana (www.insee.fr). In terms of population growth, French Guiana is the most dynamic region, with an average yearly growth of 2.3%, whereas the migratory balance sheet is negative in Martinique and Guadeloupe. This is partly because French Guiana has a younger population: around 50% are under 25 years compared with less than 30% in Guadeloupe and Martinique. Further, Martinique and Guadeloupe benefit from a significant influx of tourists, whereas French Guiana faces immigration, sometimes clandestine, from its neighboring countries (Brazil and Suriname), from the Caribbean arc, mainly migrants from Haiti, and more recently from the Middle East (Palestine, Syria, and others). Population flows, whether travelers or migrants, play a significant role in the development of epidemics and/or emerging pathologies (1). Furthermore, French Guiana is the French overseas territory that registers the most asylum requests (40%), the vast majority of which are refused, leading to numerous undocumented foreign residents, most often without solidarity medical insurance such as the State Medical Aid (AME in French) or the Complementary Universal Medical Coverage (CMUC in French). Thus, they contribute significantly to precariousness and the high poverty rate of the population. Indeed, in 2015, the National Institute of Statistics and Economic Studies (www.insee.fr) estimated the poverty rates at 19% in Guadeloupe, 21% in Martinique, and 44% in French Guiana. Obviously, precariousness and poverty are leading causes of renouncement of health care and contribute to longer length of hospital stay and hospital occupancy rate (2). It is also important to emphasize the impact of cultural diversity and public confidence and practices on the spread of illness.

HOSPITAL NETWORK
In the FTA, the public hospital network encompasses several sites across four main locations in Martinique, six in In 2020, the National Professional Council on Intensive Care Medicine (CNP MIR) judged that the rate of intensive care beds in France was very low and must be upgraded to 10 ICU beds/100 000 population, representing at least 3% of hospitalization capacity (5). Critical care capacity in the overseas French departments is not cited in that report.
The ICU beds in the three departments ensure the management of 2 262 patients annually on average. The ICU characteristics are summarized in Table 1.
Seriously ill patients admitted to local hospitals or remote health facilities will, therefore, have to then be transferred to the ICU, which is only possible by air transportation, most often by helicopter. Moreover, some medical specialties (neurologic or cardiologic surgery, pediatric ICU, severe burns) or technologies (circulatory assistance, extracorporeal membrane oxygenation [ECMO]) are only available in one or two referral sites or are missing from the entire region (e.g., interventional radiology). It is usual to medevac, for a second time, patients to the most appropriate health facility, which can either be among the three referral hospitals in the FTA or in mainland France. The use of air transport (regular or special flights; airplane or helicopter) is common. Medevacs are ensured by SAMU 971, 972, and 973. In the last five years, SAMU 971 Guadeloupe, and three in French Guiana, with one referral hospital in each geographic department. Even though Martinique and Guadeloupe hospitals are university health facilities, Cayenne hospital is still a general hospital, despite seven units being led by university professors (intensive care, infectious diseases, dermatology, public health, laboratory, pediatrics, and neurology). All three hospitals receive residents and medical trainees within their medical course and participate, at the same level, in the university education.
First response for acute medical care is through regional call centers for emergencies: SAMU 971 in Guadeloupe, SAMU 972 in Martinique, and SAMU 973 in French Guiana. Although the travel time to the nearest facility with ICU beds can be about 10 to 20 minutes by car in the urban areas, it can be up to 100 minutes by helicopter from isolated areas. These delays are much higher than those reported in mainland France (17 minutes) (3).

CRITICAL CARE BED CAPACITY
There is also an ICU in each geographic department, including in those hospitals. In 2020, we identified a total of 66 beds dedicated to intensive care in all three territories, distributed as follows: 7.2 ICU beds/100 000 population in Guadeloupe, 7.2 in Martinique, and 4.5 in French Guiana. Figure 2 shows the inequality of distribution of intensive care beds by the

SPECIFICITIES IN CRITICAL CARE
Specificities in critical care comprise the range of infectious diseases, toxicology, envenoming, in addition to a significant rate of cardiovascular diseases and stroke events. Indeed, the diversity of fauna, flora, and ecosystems, as well as the tropical climate with cyclonic components (Guadeloupe and Martinique) and very high rainfall (French Guiana), result in exposure to certain tropical infectious diseases (Table 2) (7,8), which may require specific knowledge and critical care management. In addition, the high level of forestry and aquatic activities, whether professional, military, or recreational, can result in traumatic accidents with specific injuries. Severe stab or gunshot wounds are frequent and reflect a high level of delinquency and crime in the FTA. Indeed, during the last five years, 450 gunshot injuries were recorded only in Cayenne, French Guiana. Envenoming, mainly snake bites, is frequent in Martinique and French Guiana (9)(10)(11), and its treatment requires specific knowledge and a critical care environment (11,12). Moreover, the prevalence of obesity, diabetes, and cardiovascular diseases in the FTA is among the highest in France (13)(14)(15). These are responsible for neurological, renal, and cardiac complications and are common reasons for hospitalization in ICU.
In addition to these specific diseases, the FTA have a high frequency of traffic injuries, accounting for more than 30% of admissions in the three ICUs. In addition to patient care, hospitals face logistic issues, the management of which is much more challenging than in mainland France. Indeed, getting medical devices or consumables that conform to European standards from neighboring countries might not be an option, which instead entails ordering them from mainland France with long delivery times as a consequence (on average six to eight weeks).

CRITICAL CARE BED CAPACITY DURING THE COVID-19 CRISIS AND BEYOND
The COVID-19 crisis has shown that the critical care capacity in the FTA is unready to face such an epidemic. In recent years there has been a growing awareness of the increasing incidence of emergent tropical disease outbreaks. It was hoped that lessons learned during the dengue, chikungunya, and Zika epidemics would serve as an impetus for a revised approach in the strategic planning for critical care readiness in the FTA.
Faced with the COVID-19 epidemic, hospitals in the FTA have significantly expanded their capacities and ensured availability in staff and equipment. As a result, French Guiana has added 35 acute care beds (+270%), Martinique 31 (+119%), and Guadeloupe 11 (+41%). This bed capacity expansion has been organized thanks to the local workforces, the French Ministry of Health and local authorities, regional cooperation, and volunteer nurses and doctors.
After the COVID-19 crisis, a gradual increase in intensive care bed capacity is planned in accordance with the recommendations of the French authorities and the French Society of Intensive Care (5). The target capacity is about 10 ICU beds/ 100 000 population and 3% of total hospital beds.  The promotion of regional medical cooperation has consequently seen the coming together of agencies such as the Pan American Health Organization (PAHO), the French Regional Health Agency (ARS), the European Union's INTERREG funding mechanism, the University Hospital of Martinique (CHUM), the Territorial Collectivity of Martinique, the Territorial Collectivity of Saint Martin, and the Department of Guadeloupe to facilitate training and teaching in intensive care.

Leptospirosis
On an as-needed basis, specific training in areas such as Ebola and Zika virus disease management has been undertaken for medical staff across the wider Caribbean, with sessions conducted in both Martinique and Saint Lucia with the participation of 42 nurses and 5 medical doctors. The main objective of the training is to create individual abilities and conditions of autonomy at the island level. The additional benefit is reduced travel and accommodation costs for patients and accompanying relatives. Indeed, between 10% and 15% of admissions to ICUs in Martinique and Guadeloupe are foreign patients, sometimes without health insurance. For this, cooperation with neighboring countries with local capacity-building is essential and could be cost-saving (22,23). It is expected that this cooperation, together with the launch of a road map, will catalyze initiatives at regional, interregional, and national levels, with the support of PAHO/World Health Organization offices, ministries of health, and other stakeholders.
French Guiana. French Guiana is located in the Amazon region, and patients living in the Brazilian and Suriname riverside areas regularly seek treatment in the hospitals of French Guiana and are then transferred to the ICU in Cayenne Hospital when necessary. In the field of critical care, the nearest ICU in Suriname is in Paramaribo (336 km from Cayenne), and in Brazil it is in Macapa (Amapa state, 782 km from Cayenne). However, there is no formalized cooperation established between French Guiana and neighboring countries. Recently, cooperation with health authorities in Brazil has allowed experience exchange and patient management, mainly in the field of animal envenoming (12,24).

PROSPECTS
Looking forward, the promotion of intensive care in the FTA needs enhancement of the ICUs in the three sites with an upgrade of the ICU infrastructure in French Guiana and Guadeloupe. Indeed, the ICU admission capacity in the FTA is lower than in mainland France and Europe (3). This insufficient capacity became more evident during the COVID-19 crisis.
Also, the setting up of a complete technical platform is necessary for full autonomy of management of severe cases, to reduce the number of medevacs to mainland France, which are risky for unstable patients and costly. Recently, telemedicine systems have opened the door to closer working between the three teams and intensive care specialists in mainland France and in the Caribbean region. It has allowed experience exchange and e-learning, which have contributed to the improvement of practices and strengthened the collaboration between the three sites. In addition, the Caribbean doctors' network was set up in 2020, with regular videoconferencing meetings to exchange experiences about COVID-19.

TRAINING
The French West Indies University's Faculté de Médecine Hyacinthe Bastaraud is based in Pointe-à-Pitre, Guadeloupe, with two other remote sites in Martinique and French Guiana. Professors working in the three sites meet regularly, as well as with students through classroom presentations and Internet videoconferencing. Each year, the French West Indies University graduates 150 doctors of medicine, 10 specialist doctors in emergency medicine, and 10 in anesthesiology.
There are three schools in the FTA that train nurses and anesthetist nurses. During their studies, student internships are ensured in the hospitals. Each year, the three schools graduate 306 nurses and 15 anesthetist nurses.

INFECTION CONTROL AND BACTERIAL RESISTANCE
In the FTA, hygiene, bacterial resistance, and antibiotic consumption are monitored, studied, and managed according to national programs and standards. According to the national surveillance network, high levels of antibiotic resistance and antibiotic consumption are recorded in the FTA (https://invs. santepubliquefrance.fr). Indeed, in this region, the incidence rate of extended-spectrum β-lactamase producing Enterobacteriaceae (ESBL-PE) is among the highest in the world, at up to 51% for Klebsiella pneumoniae and up to 18% for Escherichia coli (16,17). Conversely, a low level of methicillin-resistant Staphylococcus aureus is recorded (18). The regional surveillance network in ICUs is planned to take appropriate measures to prevent the spread of drug-resistant bacteria.

RESEARCH
The FTA face infectious diseases, indigenous forms of opportunistic or tropical diseases, some chronic diseases with a genetic predisposition (sickle cell disease), environmental disaster (invasion of Sargassum seaweed), and the health consequences of specific environmental pollution (chlordecone in the West Indies, mercury in French Guiana) (19)(20)(21)(22). Monitoring and research needs are therefore important and are attractive for researchers and students. To promote this, local research structures, regional cooperation, national programs, and international medical and scientific cooperation are already established. Several Caribbean countries are currently working together on different projects. However, to progress significantly on knowledge of tropical epidemiology, an adequate flow of researchers and partnerships should be strengthened with universities of neighboring countries, national institutions such as the National Institute of Health and Medical Research (INSERM), the Institut Pasteur (located in Guadeloupe and French Guiana), the Research and Development Institute (IRD) (located in French Guiana and Martinique), University Hospital Centers in metropolitan France (e.g., Assistance Publique des Hôpitaux de Paris), and the National Institute for Public Health Surveillance.