Let's Talk webinar series

Selam Gebrekidan:    

Hello, everyone. Welcome, and thank you for joining us for this episode of the webinar in our spring series called Let's Talk Vaccines. I'm Selam Gebrekidan, and I'm an investigative reporter within New York Times, and I'm based in London. Some of you may know Doctors Without Borders, by French-named Médecins Sans Frontière, or MSF, and throughout this webinar we'll be using MSF. And to get to the main topic of our webinar today, we're going to be talking about the current and future to COVID-19 vaccines. What do we mean by equitable access? Some of us may have personal stories about this, for example, I'm based in London. In the UK where 38 or so percent of the population already has had at least a first shot of the COVID-19 vaccine. Our audience members today are probably in the United States, where again, many people have been vaccinated. But my family is still in Ethiopia and they don't have really prospects of getting vaccinated before 2023 or 2024.

So right now, a lot of the world's richest countries have accumulated many of the vaccines. They have secured the vast majority of the supply, whereas we're seeing health systems near collapse, so much death and human suffering in places like Brazil and in India. And across much of the world, frontline health workers who do need to be vaccinated are not getting vaccines. So today we'll be talking about that. Before we continue, I have a few housekeeping items to take care of. This discussion will last for about 45 minutes, so we'll be keeping our discussion brief and quick moving. Wherever you're joining us from today, you can submit your questions for our panelists. If you're watching on Livestream, YouTube Live, Facebook Live, or Twitch, you can send questions in the comments or chat section and our team members will send them to me, and we'll be selecting questions more relevant to the topic of discussion today. There will also be live captions for this event. You can view them on a separate URL, or you can watch on YouTube where you can click on the CC button on the player to turn them on.

All right, so just to introduce the panelists who are joining today, Kate Elder is the senior vaccines policy advisor for MSF Access Campaign. Mona Imad is joining us from Lebanon. She's the project coordinator for MSF COVID response in the country. Zain Rizvi is a law and policy researcher at Public Citizen, with a focus on pharmaceutical innovation and access to medicines. All right, so Kate, I will start with you. I mean, over the last year, we've seen some incredible advances that have given us COVID-19 vaccines, and many of us did not believe that that would have been possible in such a short period of time. And yet access seems to be still a big problem for much of the world. Can you kind of walk us through what has happened over the last year, since this pandemic really became the focus of most of our lives across the world?

Kate Elder:     

Yeah. Thanks, Selam. And thanks for inviting me today. Nice to have everybody tuning in. I think it is, what you just said, it's definitely incredible to just reflect on where we were a year ago around when the pandemic was starting and where we are now in April 2021. Obviously, a year ago, people were very hopeful that we would have vaccines, and we have had them in extraordinarily record times. In terms of the scientific achievement and accomplishment, I think it's completely unprecedented. So acknowledging that and thanking all of the scientists who work diligently to create these vaccines, which are really everybody's hopeful tool for coming out of this pandemic and getting back to the things that we miss so much.

But what we've seen since I guess about five months ago now, when the first vaccines were approved, is we've just seen this incredibly drastic divide of inequity, just mounting by the day. You started speaking about it at the top of our call, Selam, that here in the United States, where many of our viewers probably are and where I'm sitting, we have almost achieved 30% of the adult population, of the eligible population, having received both doses of their vaccines. So almost 30%, a third of our population, is fully vaccinated, whereby in many developing countries, low income countries, they haven't even been able to vaccinate ... I mean, less than 1% of their population. I think it's around ... the WHO tells us about 0.3% of the population now.

So we have 235 million doses that have been administered in the United States, and we only have about 50 million doses that have been shipped worldwide by this mechanism called COVAX, the COVAX facility being the globally agreed upon mechanism that countries are buying into to try and deliver this equity. So the challenge is right now, we just see this inequity growing exponentially by the day, which I think is very visible because people can see what's happening around the world in real time.

Why did this happen? I think we're all responsible for it and our governments are responsible for it. Why did it happen? Well, we had a run on vaccines before they were even available, right? So we had declarations of global solidarity last year in April, when WHO launched an initiative to try and bring this commitment to global solidarity, that we were all in this and committing to future medical tools, whether they be vaccines or diagnostics or medicines as being "global public good." We heard a lot of talk from global leaders around a people's vaccine. And then at the same time, the government that had the money, the government that had the resources, went on and just did a buying spree for vaccines that weren't even available yet. So there is finite quantities of vaccine and that's the challenge, right? These are mutually exclusive. National hoarding is mutually exclusive to equitable distribution of vaccines, but it's in our common good to share these tools. So we're in a pretty serious situation right now.

Selam Gebrekidan:

Thanks for that. We're going to come back to some of the points that you raised there, because I think they're extremely important. But we're moving on with this now, Mona, you are based in Lebanon and you're doing ... you're not just helping the government in terms of vaccinations, you're helping the testing and diagnostics. Can you tell us more about MSF's work in Lebanon and what your role has been in that?

Mona Imad:   

Yeah. So in terms of ... well, we have been supporting the Lebanese Ministry of Public Health since the last year actually, since the onset of the pandemic. And through our medical response team and mobile medical team, I would say, we have been supporting them and diagnosing ... contact tracing and diagnostic tests across the country who are deploying teams around wherever it's needed.

So this has been going on since last year, and since I would say more than a month ago, we have been solicited by the Lebanese Ministry of Public Health to support them actually in implementing the vaccination scheme. And this has been going on for more than five weeks. And up to now, we have been able to vaccinate more, I would say, around 4,000 people. And our support is on people who have difficulty in accessing the vaccines. Namely, we are focusing on elderly people in nursing homes and healthcare workers that work for them within the facilities.

And of course this request came from the authorities, and it reflects the credibility and reliability of MSF as a main partner in implementing such schemes and helping them scale up the response and vaccination process, especially to these people, vulnerable people who are at high risk of contracting the disease.

Selam Gebrekidan:

Thanks for that. I appreciate it. And Zain, you work at Public Citizen and we've had multiple conversations before about equitable access. I know how strongly you feel about this. What of the recent developments have made you think that equitable access is ... do you think that equitable access is even more important now with what we're seeing in places like India and Brazil?

Zain Rizvi:      

Yeah. Thanks, Selam, and thanks, MSF for inviting me today. So just a brief background, Public Citizen's consumer advocacy organization, based in Washington, DC, we work on many different consumer areas. And I work in the global access medicines team. And so right from the beginning of the pandemic, we've been kind of tracking government's response to the pandemic and in particular looking at vaccine development. And it's been astonishing to see, I would say, the hypocrisy really between rich countries talking about equitable access in the grandest of terms, and then taking minimal steps, if any, to actually live up to those commitments.

And so when Kate talks about this astonishing speed with which we were able to develop these vaccines, there were huge, huge sums of public money involved. In fact, we created a tracker looking at just how much one US government agency called BARDA, which is Biomedical Advanced Research Development Authority. They put in like $16 billion, right? So these manufacturers got a huge infusion of public money.

And yet we see now that access is anything but equitable, and it is just heartbreaking. We see India burning, and yet the world has fully yet to realize just what the magnitude of the need is. And I think that's what's really concerning, because there are well-intentioned initiatives like COVAX, for example, that want to vaccinate the world that are desperate for doses and dollars in domestic production capabilities. And yet even COVAX aim to vaccinate between 20 and 30% of the world by the end of 2021.

And so one way to look at COVAX is that the US has already vaccinated more people than developing countries can expect to vaccinate by the end of this year. And so what does that mean? Think about India right now. Think about Brazil. And it's not just India. It's spreading in South Asia, and so my family is originally from Pakistan, and Pakistan recorded the most pandemic deaths yesterday. And there is a special injustice now that we know people are still dying from this pandemic, even though we know that there are existing vaccines that are available that could have protected them had they had the opportunity to get vaccinated in the first place.

Selam Gebrekidan:

Well, I think that as journalists we encounter is when people think about equitable access. Some people would suggest donations, charity-tied donations, from rich countries to lower-income countries, whenever rich countries have protected their population, right? And some people talk about, "No, we should be sharing technology with manufacturers that are capable of producing this vaccine for themselves." And that's more relevant in places like India, where there's a lot of manufacturing capacity. What, what does equitable access mean to you, Kate, in this respect? That is it a lot of options that are available to the world? Is it largely going to be based on the goodwill and donations of people?

Kate Elder:     

I think, just picking up on what Zain said with the very laudable objectives of the COVAX facility. I mean, we, as a global community wanted to do better. I think that's the bit that's so jarring about this.

We knew what we needed to do in order to do better. And yet we stuck with the status quo. And I hope that everybody shares the outrage that I know many of us on this call feel right now with knowing that the status quo wasn't going to deliver equity, if we didn't do something significantly different and change the way we make medical innovation available to people. Everybody saw this coming from a mile away that we would be in this sort of situation. It's the age old adage of the haves versus the have-nots, if you will.           

And when there are tight controls on who gets to produce these medical innovations, whether it's vaccines or diagnostics, and there's tight controls on that, and we don't do it differently, and we leave it up to corporate interests that have a very, very clear objective, right? I mean, their objective is to deliver for their shareholders, right? That's just the cold hard truth is that corporations make medicines to make money and to reimburse their shareholders, not to be too dramatic. But I think everybody's quite aware of that. So if we weren't going to significantly change the way we were producing these vaccines, and we were of course, going to be in this situation where there was limited control and a small group of businesses that were able to decide who they sell to first at what price and in which quantities they produce these vaccines.           

What we needed to do is we needed a multi-pronged approach to making the pie bigger, not to beat this euphemism of just making the pie bigger, right? So we have capable manufacturers in many places of the world. We know that technology transfer partnerships, mentoring companies, sharing the technology, sharing the know-how can equip other companies to make vaccines.    

We know there's intellectual property barriers that prevent other capable manufacturers from making them. But what we needed to do is we needed to get together a plan to force the companies that have the technology. Again, as Zain said, technology that was developed with our taxpayer dollars. We need to force them to share it with other capable manufacturers, whether it's in South America, South Africa, Southern Africa, India, where we see a lot of vaccines being made. And we need to lift all of those barriers as expeditiously as possible, take away the barriers so that the people who can make these vaccines can make them. But we haven't seen that happen, right? So we need governments that paid for these vaccines to push those companies, Pfizer, Moderna, Johnson & Johnson, AstraZeneca to use all that capable manufacturing capacity around the world, making the pie bigger.

Selam Gebrekidan:    

And Mona, maybe you can tell us a little bit more about how this has played out in your region, particularly. We've seen some coverage of Israel's very successful vaccination campaign and has that left other people, for example, people in the Gaza Strip behind. And MSF does some work on that so, can you give us an update on what's going on over there?

Mona Imad:   

I'll gladly give you an idea about the Lebanese context. I mean the Lebanese context as a developing country, we're on the other side of the table, we're on the receiving end of the table. And I agree with Kate. I mean, we're doing fine so far. It has been set out as the priority for the Lebanese government to expand the vaccination scheme. Mostly to curb the collapse of the health structure that has been taken by surprise as it has been globally, I would say.

So, yes, we are on the other side of the table. And I can say that we are at the mercy of suppliers. It has been good so far, but we could definitely expect surprises, and this would definitely influence the national campaign and the objective set out by the government and all the health actors basically fight to this pandemic.

Selam Gebrekidan:    

Right before we move on. I want to take a look at the results from social media quiz that Doctors Without Borders or MSF, ran on Instagram earlier this week. I suspect that Kate has given a way to answer already earlier, but I'm going to read the question now. And for those of you watching, feel free to type your answer in the chat as well.           

Now, what percentage of COVID-19 vaccines administered worldwide have gone to low-income countries 5%, 1%, or 0.3%? So I'm sorry. All right. So the results from the poll about 17% guessed A, which is 5% of low-income countries, 38% guessed B, and 46%, and in fact the majority, guessed the correct answer, which is C, 0.3%.           

And we're getting a few questions from our audience, which I will try to bring in, now. We have Nina on Instagram who asked, "Why can't more countries start producing their own vaccines?" I think Zain would be happy to take that.

Zain Rizvi:      

Yeah, sure. So that's the question, right? What prevents countries from making vaccines? And I think one thing to take a step back and understand is that the way medicines are produced the kind of global system we have involves something called TRIPS, which is an agreement at the World Trade Organization that basically governs how intellectual property is dealt with. It sets minimum standards. And under TRIPS there, it created a system, what it was called intellectual property. And the reason I kind of do bunny ears for that is because this whole idea of IP is a pretty novel concept. It's actually very different from actual property. But the idea here is that you get monopolies over medical inventions. And as a result, companies are able to control decisions about these medical technology. So they get to a determined supply, they get to determine price, they get to determine additional suppliers.

And so you've seen this play out as largely companies are deciding who they partner with companies are deciding how much they scale up rather than any government-led initiative to share technology, to share the vaccine recipe, to help ramp up global production. One of the kind of most egregious aspects of the global response has been that we know there are existing manufacturers out there who want to be able to produce COVID-19 vaccines. Who've asked the manufacturers, "Can you share your technology so we can help start helping ramp up production?" And those manufacturers, despite receiving billions of dollars of public funding have either ignored those requests or denied those requests. And so it just underscores the need for really governments to step up and particularly the Biden Administration, because the US government is the largest funder of coronavirus research and development in the world.

And so the US government has enormous leverage here to try and push the companies to share the technology, to work with manufacturers around the world, and to launch really a global manufacturing program that would help set up regional hubs. So you could get manufacturing done all around the world quickly to meet the global need.

Public Citizen estimates that such a program could cost $25 billion and it could help produce eight billion doses of the NIH Moderna vaccine within about a year's time. And so think about what '22 could look like in the absence of this program and think about what 2022 could look like if there was serious engagement from the highest levels of governments around the world to really end this pandemic once and for all.

Selam Gebrekidan:    

And Kate, can you tell us what you're seeing in terms of what Zain proposed as one of the solutions would be governments taking concrete action. Do you believe that the European Union, the Biden Administration, the US, and other countries that have, through public funds financed a lot of the new technologies that have given us COVID-19 vaccines. Are they moving in the right direction in terms of ensuring equitable access? And if not, are they going to be threatened by the new variants that are popping up in new places?

Kate Elder:     

I think everybody... I'm no scientist, but yet I still know that it's in our interests, those of us sitting here in the United States, around the world to make sure that these vaccines are delivered equitably, right? Everybody's reading daily about the rise of variants and the prevalence in certain countries and the effect of these vaccines, the efficacy of these vaccines on the variants, it should terrify everybody, it's terrified me.           

So you don't need to be a scientist to realize the scientific imperative of sharing vaccines equitably. If we're not going to do it for the right reasons, right? The moral and ethical reasons, at least we would do it, for a self-serving objective, right? But seemingly it hasn't pushed governments enough yet to take steps as expeditiously as possible as Zain has clearly outlined we need to take, which is making the pie bigger.           

So I think we can look at a couple of different examples of initiatives that are happening around the world and how governments are behaving. I mean, one is the process that's happening at the World Trade Organization related to intellectual property rights, as Zain just talked about this, TRIPS. And it is not a surprise to see which governments have been stonewalling that process from moving forward. I don't think anybody thinks that a successful process would equal a windfall of vaccines, but it's still a very important enabling factor to move us forward.          

Secondly, Zain just mentioned other initiatives like the World Health Organization has launched this technology transfer hub specifically focused on the mRNA vaccines, vaccines that Moderna, Pfizer, BioEnTech are making. And they're asking for these companies, "Please come join in good faith, bring your technology, engage in a process with other capable  manufacturers”. Have we seen Pfizer or Moderna quickly step up since that initiative was launched a couple of weeks ago to say, "Yes, we're in. We're going to share our technology"? No, we haven't. And we call on them. We call on Pfizer, we call on Moderna, we call on BioEnTech to bring your A game. Bring your A game to the world so we can all get out of this pandemic. So that's sort of another indicator of this.         

The area where, I think, we're starting to see some progress is sort of this charity model, right? We've heard the US government, just a couple of days ago, announced that we will shift doses of AstraZeneca to the rest of the world, and that's a good step in the right direction. That is one of the most basic steps that we could take, using vaccine that's just sitting in warehouses here in the United States and sharing it with the world. We've heard similar announcements from the French government. We've heard New Zealand in terms of donating doses. And those doses are absolutely needed, so we call on these governments that give those doses urgently now.           

But that is certainly a charity model. That is not changing the way we are equipping governments to be able to support themselves and their populations, too. So I'm hopeful. You have to be hopeful and stay optimistic. I wish that this progress was starting sooner. It's never too late, but we do need to see a lot of pressure from governments on industry. Again, reminding them we paid for these technologies, and now we're calling it in for the rest of the world.

Selam Gebrekidan:    

And Mona, you can really help us with this. I'm speaking to you from London. Zain and Kate are in the US. But our reality is quite different from, I imagine, places like Lebanon or where my family is right now, in Addis Ababa. Here, basically, we're just in the UK. We're just counting down the days until our particular age group is going to be eligible for vaccines. In the US, many of my friends are already vaccinated. How do you view this from where you are? What does it feel like to see people posting pictures of their vaccination cards on social media and talking about what they will do or what they've done because they're vaccinated and protected? And maybe you have already been vaccinated and maybe not in where you are. I just want to know what it feels like, this divide.

Mona Imad:   

Yeah. No, it definitely gives a feeling of security in places like Lebanon and the rest of the world when it's not necessarily the case and seeing the government attempting to prioritize it as for the population and making it a point to do that, so it's definitely a relief for the people.           

For now, we're focusing. I don't know if you've asked me this question. For now, we're focusing on the elderly population. We are focusing on people, as I said before, with difficulty in accessing the vaccines, and of course, in line with the priority population set out by the WHO, and mostly, in a way, to help the... Let's say to prevent any collapsed of the health structure in place.           

And from that, we have been advocating and pushing the Ministry of Public Health for us, as NSF, to expand our support of other population group, also under the idea or the umbrella of equal access for all, and we would be expanding our support to refugees inside the refugee camps, and the migrant workers, and also, to a certain extent, people with disabilities. So hopefully, we're going in that direction.

Selam Gebrekidan:  

So it's optimistic?

Mona Imad:   

Yeah, yeah.

Selam Gebrekidan:  

All right. And I'm going to post the question that's been submitted by a number of our viewers right now and from the livestream. Kim and Olivia are wondering, what can private citizens do to push governments to reduce patent barriers on COVID-19 vaccines? Zain, do you want to take that?

Zain Rizvi:      

Sure. So there's a lot right now. There's a lot. I think individual folks often underestimate the power that they have, but there's a lot that they could do. I think there are... There's a glaring gap, right? I think it's obvious to everyone. At least in the US, from where I'm sitting, there is no plan right now, right? There's no plan to get global access for vaccines. And so that should be remedied, and that should be remedied immediately. And so, I would encourage everyone to get in touch with the representatives to urge the need for global access, to support an ambitious global manufacturing program that helps the world set up regional hubs to mass produce these vaccines, that gets the US to share the vaccine recipes that it has helped fund, and of course, to support the TRIPS waiver instead of locking it.           

So those are kind of the immediate concrete steps. If you want to get more immediate, if you live in Washington, D.C., we're actually holding a socially distance rally next week on May 5th, which is a Wednesday, at the mall, and we are demanding, frankly, that the US government start to act globally now because we are seeing just horrific images of people around the world of the continued spread of the pandemic. And so you can check out freethevaccine.org for more details. May 5th, in front of the mall, please come out

Selam Gebrekidan:    

Because this is an important question, Kate, I'm going to pose this to you as well. What can private citizens do to remove these barriers to access the COVID-19 vaccines?

Kate Elder:     

I think it's been extraordinary to see how civil society and how people have rallied around this inequity. Everybody knows that we're hearing stories from Mona in Lebanon. We're hearing of your family in Addis Ababa, Selam. We hear Zain's family in Pakistan. We all have somebody that's just a text away, right? And we are hearing, firsthand, their experience. I think people are really motivated to help, and civil society has been beating a drum collectively, which is incredibly impressive.           

So in addition to think global, act local, as Zain already said, contacting your representatives. There are partnerships. There is The People's Vaccine. I want to give a thumbs up and an endorsement of People's Vaccine. People can go onto peoplesvaccine.org. to see all of these activities that are happening. There are petitions happening everywhere. There are rallies, as Zain has already said. And they're using your voice or your virtual voice via your social media. So go into peoplesvaccine.org. Many of our organizations, public citizens sign up for what they're doing. They're doing great actions. MSF as well. Please sign up so we can keep you updated on what we're doing from the MSF Access Campaign in terms of these actions as well. But there's many ways to get involved.

Selam Gebrekidan:    

Right. There's some more very great questions, maybe, at the moment. There's one from Nick on livestream. In addition to the actual vaccine, are there still other components of the supply chain that are in critically short supply, for example, what's happening with needles, syringes, cold storage?

Zain Rizvi:      

I can take that.

Selam Gebrekidan:           

Zain, I'm coming back to you, yeah.

Zain Rizvi:      

Yeah, sure. So yes, there are shortages. We have seen manufacturer's report that there are shortages, in fact, of some raw materials now needed to make vaccines and some equipment. Part of what's going on is that some countries have enacted de facto export bans or export bans on some of these key materials. And so we've started to see some release of these materials, but much more needs to be done.       

And I think it really speaks to the need for really concerted government action, because right now, what's going on, in fact, is a lot of the pharmaceutical companies, in fact, they're seeing that there's these supply shortages on the horizon, and so what they're doing is they're placing these massive orders, and then they end up hoarding more materials than they need because they're worried that they won't be able to get the materials in time for the vaccine production itself. And so, it's creating huge distortions and inefficiencies.           

And really, it speaks to the need for governments to step up, to coordinate, to make the investments required to ramp up raw material production, to allocate it effectively and equitably, and to really make sure that we defeat this virus. One thing that's remarkable to remember here is that it was only about a year ago when everyone told us we were in this together. And then what happened, right? What happened? That clearly did not end up occurring. And so I think, really, we need a global solution that requires governments to really step up to vaccinate the world.

Selam Gebrekidan:    

Kate, I have a question for you from Elizabeth on the livestream. You've spoken earlier about how many of the other countries have basically cornered the market for the vaccines. And Elizabeth asks, is there a reason why governments weren't given a minute on how many vaccines they could secure in order to make sure that it was distributed equally?

Kate Elder:     

That's such a great question because, I think, this also goes to the heart of what Zain is saying in terms of, how do you institutionalize global solidarity? How do you take it from lofty declarations and codify it into something that the world has to adhere to? And we do have global treaties that sort of lay precedent for some of the ways that the world needs to work together when we face these catastrophic events that affect all of us. We also have treaties on how we share flu vaccines, pandemic flu vaccines that do try to codify that, what governments will share, what portion of supply they will share with the WHO.           

We didn't take those steps in COVID, and we probably should have. I think there's always this balance of time, right? Time to address the catastrophe and time to think multilaterally and actually sit at the table together, and put the pen to paper, and get the consensus so that everybody has it as good as possible, or at least, not so many people have it so devastatingly bad as we have right here. So we didn't take those steps at the beginning of COVID. We took very important political steps of declarations. WHO tried to convene governments together under what's called the ACT Accelerator, the Access to COVID-19 Tools Accelerator. But yes, that did not translate into this. So there was really no rules of the game, rules of engagement, at how governments were scrambling for these vaccines right now. And now we're paying the price. I think the question is, okay, what do we do next? We're in this situation right now, we got to make this catastrophe as better as possible, improve it right now for this acute period. But are we going to learn? Are we going to learn for the next time that we have such a world altering pandemic? And there's lots of discussions right now about a pandemic preparedness treaty that's happening at the global level. I think the question is, what will governments of the G7, the G20 do? Are we going to basically do the same thing next time? I hope they all realize that we need a real 180 to prevent this from happening again. But right now, yes, we don't have those sorts of rules for how many doses each country buy, and those that had the deepest pockets got the most vaccine.

Selam Gebrekidan:    

That's interesting. And as you say, we could have seen this coming from a mile away. And in some ways in our coverage of the issue of equitable access to COVID-19 vaccines, what became apparent is that there are a lot of parallels to be drawn between what's happening now during the COVID pandemic and what happened before with antiretroviral drugs for HIV/AIDS. And it's the sort of feeling the whole world's repeating the same mistakes again and again. And we're either all protected or we're not protected. I think that's the main takeaway. But part of that is also what people themselves feel about the vaccine, because there's a lot of vaccine hesitancy, and it comes in various forms from people who do not trust the vaccines at all, to people who think that maybe these discoveries have happened too fast. And I encounter quite a number of people in fact who say that they're not anti-vaxxers, but they don't trust the vaccine for a disease whose symptoms have not been established clearly. Mona, are you seeing similar vaccine hesitancy in Lebanon?

Mona Imad:   

Yeah. I would say that acceptance is much higher than the hesitancy, but still there is a, let's say hesitancy rate, particularly towards certain actual vaccines actually and what goes around on social media, in terms of repercussions of the vaccine intake, et cetera. So I guess there is a need to build up some kind of, I would say literacy and awareness around the subject. Yeah. This has been the case, yes. So I would give you an example. So people would trust Pfizer and would reject AstraZeneca for whatever has been circulating as side effects for a certain age group of population. Yeah.

Selam Gebrekidan:    

So even the hesitancy is specific to certain types of vaccines. And I wonder what part of that is because of the way that certain news items are reported and whether that increases hesitancy as well, especially with Johnson and Johnson and AstraZeneca, we get a lot of criticism for being alarmist as journalists. And maybe that's something that we do need to take into account in our coverage as well. And what about the US, Kate or Zain? Are there any specific measures that you're seeing taken against the vaccine hesitancy to ensure that everyone gets to compliance? And there's also a story in the New York Times recently about how certain people in the US are not going back for their second shots, or have run into some sort of hurdles and then have just sort of dropped off with that. Is that going to be a big problem, or is that a very small proportion of the population from what you've seen?

Kate Elder:     

Yeah. I'll just start and Zain, jump in if you want. I think vaccine hesitancy is such a complex topic that we really can't... The topography of vaccine hesitancy is so diverse, and thankfully there's really impressive institutions like at the London School of Hygiene and technical... Sorry, I have my dog behind me making noises. London School of Hygiene and Tropical Medicine has the Center for Vaccine Confidence, which it's full-time job is studying hesitancy and why people are hesitant. So I would never want to try and be conclusive about why somebody is hesitant. My personal anecdote of course, is that I sit in Brooklyn and I have a small toddler. And before COVID many parents of small toddlers also didn't want to get other vaccines for their kids because they just have misconceptions that, well, my kid is not really exposed to that disease. So why would I give them this vaccine?           

I think right now we do see hesitancy, and WHO was anticipating this in a major way. So credit to WHO for already preparing as much as possible to lay the groundwork, work with local leaders, work with governments to stem hesitancy in countries. But we certainly have heard stories of where people think, well, COVID, isn't such a big deal in my country. Why do I need these vaccines? And then the next thing they do is they open up the newspaper and they read about AstraZeneca and possible blood clots, and the thing that just reinforces the decision. So I certainly wouldn't at all blame the media flaw. I'm not going to say that all your job is to report what you're seeing, but of course people have access to information and then they interpret it the way they interpret it.           

I think what just need to always do is of course anticipate, and couple with literacy, as Mona said. We have to get to thought leaders that hold sway and influence in their communities, and we have to do a better job of communicating to them. Sometimes as well the healthcare sector is maybe not the best place to communicate to populations around the importance of vaccination. Maybe it's a different influencer in the community too. So we have to basically just do our homework. I think WHO right now is trying to do a lot of work to stem vaccine hesitancy as well. I'm not sure what's happening Mona, in Lebanon. I'd love to hear about that too, but-

Mona Imad:   

Indeed, yeah. Indeed huge work on risk communication and community engagement actually around the subject. Yeah. We're happy to see that happening, given the fact that as you said, access to, I would say between brackets random information, that would not necessarily help people have like the best informed decision about whether to go get the vaccine or not. And especially again, when you are targeting a specific population group, like people at risk, I would say it's very important to apply these preventative measures in order to decrease the access or the demand on ICU and the health services, and in that case help prevent any collapse of structures. And again, I repeat collapse because the system in Lebanon has been really exhausted by what's happening, especially with the peak in figures and the death rates and the saturation inside the COVID wards. So again, it's a preventative measure that I would say is a right, not as a privilege, and yeah.

Selam Gebrekidan:    

We're approaching the end of time that we have, but Mona, I'd love to hear your thoughts, for example, on do you think that countries would be better prepared? Do you think that we have learned our lessons from this pandemic? Do you think that next time, which inevitably there will be a next time, we'll be able to weather it better?

Mona Imad:   

Who is this question too?

Selam Gebrekidan:    

You. Let's say Mona.

Mona Imad:   

That's indeed a difficult question. You took me by surprise. This is definitely one of a kind pandemic after many years of not having gone through such a thing. And many actors are involved in this, and most of all the pharmaceutical companies, which hold the key. So I think it's a matter of private sector and how to go about it in terms of global access to health and private sector and government. So, I would never know. Let's wait for the next pandemic maybe, and maybe then we can judge. But as you say, given the catastrophic impact on the globe, so I hope we could make the most of the lessons out of it.

Selam Gebrekidan:    

Right. Zain, do you think we've learned our lessons?

Zain Rizvi:      

I have an optimistic answer, which is that the folks watching this are going to get mobilized and act with us and we're going to win. And because we're going to win, we're going to be better prepared for this pandemic and also for the next pandemic. So I am optimistic.

Selam Gebrekidan:

Great. Kate?

Kate Elder:     

I'm with Zain. We have to have our optimism and we have to translate that optimism into concrete action. So I think we'll get there. I think there's a lot of people who are outraged and never want to repeat this again.

Selam Gebrekidan:    

Well, on that happy note, thank you everyone for joining us. And thank you Zain, Kate and Mona for your time today. It was a pleasure talking to you guys. Bye.

Mona Imad:   

Thank you.

Kate Elder:     

Bye.

Avril Benoît:

Thanks so much for joining us. I'm Avril Benoît, I'm the Executive Director of Doctors Without Borders here in the United States. Doctors Without Borders is known internationally as Médecins Sans Frontières, so the acronym we get from that is MSF and over the course of this webinar we are going to be using that every once in a while. Just so you know that it means the same thing.

So this is another episode in a series that we're calling Let's Talk Vaccines. So as the pandemic has rolled along, we thought we'd spend a little more time with each of these episodes to really drill down and find out what's going on with vaccination efforts around the world. Today, we're going to be focusing on vaccines and getting vaccines to the people who need them most here in the United States. So health workers and activists are calling for fair and equitable access to the distribution of vaccines around the world, of course, and we're very much part of that call. Here in the United States it's much the same because we know that no one will be safe until this disease is over for all of us, until we're all safe.

So, just before we get into this, here's how the webinar's going to work. We will have this discussion for around 45 minutes and wherever you're joining today, you can submit questions for our panelists. If you're watching on live stream, YouTube Live, Facebook Live or Twitch you can send your questions in the comments or chat section and our team will pull them out and send them on to me and then I will be able to present those to our panel.

We're going to prioritize questions directly related to this discussion. So, it's not for medical advice specifically for you, but on this question of getting vaccines to everyone who really needs them. We also have live captions for this event, so you can view them on a separate URL, or you can watch on YouTube where you can click on that, that says CC, to catch the live captioning going on and thank you to those working on that. We'll add the links to both of those in the chat so that you have those available.

Joining us today is Dr. Torian Easterling, First Deputy Commissioner and Chief Equity Officer at the New York City Department of Health and Mental Hygiene. Welcome to you Torian. Good to have you with us.

Dr. Torian Easterling:

Thank you for having me.

Avril Benoît:

Also joining us today, Carla Sofía González. She is a nurse and co-founder of Puerto Rico Salud, MSF's partner organization in Puerto Rico responding to inequities in vaccine access. Good to see you, Carla.

Carla Sofía González:

Good morning. Nice to see you and be with you today.

Avril Benoît:

And Dr. Kerry Dierberg, project coordinator for MSF's COVID-19 Operations in Brooklyn, in New York City. And in this role, she's leading a team responding to inequitable access to COVID-19 vaccines in coordination with MSF's local partner, the BMS Family Health and Wellness Center. Kerry, how are you doing today?

Dr. Kerry Dierberg:

Hi, everyone. Good to be here.

Avril Benoît:

And I was with Kerry just yesterday, helping to get the site set up for this completely new offering, just to be able to scale up access to vaccines. And we're going to hear a little bit more about that in a moment. But I thought I could start with you, Dr. Easterling. New York was one of the early epicenters for COVID-19 in the US and we all understand at this point that we need to get shots in the arms as quickly as possible to avoid another year like 2020. And we still have pretty high rates of transmission in New York, high rates of hospitalizations. We want to also really focus on this equity issue. How are you and your team working on this vaccination distribution plan for such a large city?

Dr. Torian Easterling:

Well, thank you so much for the question, Avril. And thank you to MSF for hosting this really important discussion and for having me and this esteemed panel. We're approaching, as we have done with our COVID transmission response, to make sure that we're keeping equity front and center. The conditions that we know have existed BC, Before COVID, continue to exist and will exist even after this pandemic. And so, one, we have to acknowledge the historical and the contemporary injustices, particularly around healthcare access, but we know that it's much larger. There are the social and economic disability that have existed and leading to a lot of the inequities that we see. So we have to continue to acknowledge it, keeping it front and center in our discussions and embedding it into our planning.

We've developed an equity action plan for our overall COVID response, and we're still moving forward with our COVID response because we do have variants of concerns and variants of interests that are circulating in the community. More than 70% of the cases that we're seeing in New York City are variants. So not the classic COVID virus, SARS CoV-2. So we have to keep our foot on the pedal with our prevention strategies and our testing, keeping our testing equitable, and we do have a citywide strategy of bringing testing resources into neighborhoods.

But as you mentioned, you need an equity plan around our vaccine rollout. So that's thinking about how we're allocating supply, where those supply are being matched up in neighborhoods, how we're thinking about eligibility? Even as the governor is expanding eligibility, we need to keep our eye on the priority groups. Those who continue to be most at risk of severe illness for COVID-19. So certainly are elderly, thinking of underlying chronic conditions.

But because of structural racism, we know that there needs to be race-explicit strategies that are really making sure that we're thinking about communities of color and how they've been disproportionately impacted. So really, all in all, we have to just keep our eye on all the different ways that we can get vaccines into communities and support informed decisions.

Avril Benoît:

One of the ways that we in the public can see who's been vaccinated and not is by zip code. And according to different neighborhoods across New York City, we see that there are certain neighborhoods where there seems to be very high levels of vaccination and other neighborhoods much less so. Can you describe that for those who are outside of New York and maybe not following this kind of issue on a daily basis in the local media? What do you see when you look at that zip code map, or the distribution, and what is that telling you, what are those numbers telling you about inequity?

Dr. Torian Easterling:

Well, it's telling us what we've always known. I think listeners are really hearing your question clearly and the response that we've known that these inequities exist. And, folks who've been doing this work, activists and advocates, have been calling up for government to really respond in closing the gap in birth inequities and chronic disease and in housing and stability and food sovereignty. So, these are the same neighborhoods that when you look at health outcomes, economic outcomes, educational outcomes and any other outcomes, these are the neighborhoods that are not invested, have been disinvested for a very long time.

One of the things that we've done is look at... Very similar to the CDC Social Vulnerability Index, make it very clear that we know that there are factors that have led to higher rates of COVID-19. So, your health status, you also have to think about things around poverty, thinking about housing status as well, occupation status. And when we match up those metrics, the neighborhoods that we've known and we've seen to have poor health outcomes are also the same neighborhoods that have been disproportionately impacted by COVID-19 in New York City. South Bronx, North and Central Brooklyn, Northern Manhattan, Lower East Side, because you do have a cluster of Asian-American population that you really have to engage, southeast Queens and certainly parts of Northern Staten Island. So we know where we have to go, it's what we have to do to respond to close the gap.

Avril Benoît:

Well, let's swing over to one neighborhood. Kerry Dierberg, describe to us why MSF or Doctors Without Borders is working in that part of Brooklyn right now.                                                                     

Dr. Kerry Dierberg:

Sure. So BMS or the Brownsville Family Health Center essentially provides primary and preventative health care to the Brownsville and East New York community. This is a federally qualified health center that provides this care regardless of an individual's ability to pay for that care. The neighborhoods in Brownsville and East New York have high poverty rates, some of the highest in the New York City metropolitan area. They have very high rates of chronic disease, such as cardiovascular disease, diabetes, obesity. That also contributed to them to having very high rates of COVID and high rates of mortality from COVID-19 over the past year. Even now they continued to have test positivity rates that are substantially higher than we're seeing on average across New York City. So this community has been historically underserved. BMS is here for that reason and has been here for many decades to try to provide and bridge some of that gap.

So in that context, MSF supported BMS last year with getting COVID testing up and running, particularly when we were at the height of our first wave here in New York City last spring and early summer. So as BMS has been trying to do vaccination over the last couple of months, they've been very limited by staffing and space and other resources they need to really provide the access they want to this community where there has been very limited vaccination availability to the population. So MSF is supporting with helping them with the logistics of both the vaccination at their current clinic sites and then to be able to expand with some additional resources in vaccine that they've gotten here in New York City.

Avril Benoît:

One of the things that seems so surprising is that, we've had vaccination sites in other parts of New York City for a couple of months now. What is the reason that it hasn't scaled up in neighborhoods like East New York and Brownsville until now?

Dr. Kerry Dierberg:

I think part of it was really ramping up some of the funding and the ability to ensure some of the vaccine supply, which I think we've experienced all over the city. I think there has been a much more limited capacity to be able to deliver vaccine. Also, there has been inadequacy in terms of space and staffing even to be able to administer at really high rates within the current FQHCs, such as BMS, in terms of what they have. So they have been providing vaccine since early January, but have been really limited in terms of their capacity to scale that up.

Avril Benoit:

Well, I'm glad we're able to help. Obviously, there's plenty of work to be done all over the city, but in this short little assistance that we're providing I'm really appreciative for all the collaboration that we've got there and that you can be there to help out as well. Let's shift over to Puerto Rico, now. Carla, you have been working there for quite a long time, but you only just started your organization, Puerto Rico Salud, recently. Can you tell us about your organization and what you're focused on right now?

Carla Sofía González:

Well, Puerto Rico Salud started after departure of Medicos Sin Frontera, MSF. MSF came to Puerto Rico to help our communities to help after Maria after the earthquake. And then we came in the COVID, and we came here to monitor everything of the COVID and I started working with MSF. And after that they approached to us, they will help us to keep our mission. Our mission really important, in Puerto Rico Salud it can go to communities that no one else can impact. It's really hard for our communities in Puerto Rico. We are an island, we’re really small but there are some places, that is really hard for us to get there. So that's our mission for Puerto Rico Salud we are going to communities and we're taking the vaccination to the community as well as when MSF came to Puerto Rico, they helped with the COVID monitoring and they came here to help with everything during the COVID pandemic time. So now they came here and they are supporting us to help us with those communities and get the vaccine to the people.

Here in Puerto Rico it's really hard to get vaccination, it depends on where you live, or what town do you live and there, there are not a lot of places doing vaccinations. The health departments are doing vaccinations. Yesterday we have more than one day we did more than 10,000 people, the health department here in Puerto Rico. So the vaccination is coming along really good here. We already have vaccinated more than 1 million of people in Puerto Rico. So that's a lot for us. But the only thing that we're struggling right now is the phases. A lot of people think that, they have to open all ages, there is a lot of talk. Because there's older people, there's a lot of people that doesn't want to get vaccinated, but then, there is a lot of young people or professional people that they want to get vaccinated. So that's the deal that we're, struggling right now, we just have to face it, we have to do it by phases. Because the government is the ones that looking for us. So that's one of the struggles that we're having right now, but Puerto Rico Salud their mission is, MSF is to go to communities, that is really hard for those people to get help, medical help, or any help that we can go in and give to them. That's where Puerto Rico Salud is right now.

Avril Benoît:

Here. I was talking on mute. I should be the last person to make that mistake, so we've got questions already coming in from our live audience right now. And also some that came in, through the registration that people had done ahead of time. And while I've got you here Carla, just talking about this. One of the questions that came in ahead of time from Julie was how does Doctors Without Borders, and in this case also, your organization Puerto Rico Salud, get the vaccines to people far away from big city vaccination sites, cause your also trying to reach those that are further out aren't you?

Carla Sofía González:

Yes. The mission from MSF came, this time again to help us. We get the vaccination, it's a collaboration with other identities like the Nursing School of Puerto Rico and the health department. They are the ones that are giving us the vaccinations then we have to team up with Puerto Rico Salud. And we got to do in the morning, we have other towns we're going to impact. We have our leader of the communities, community leader and we have, we made our own center. That in during the morning they leave, they go to that town, vaccinate there people, they vaccinate their care giver, they vaccinate everyone in that town so we can start protecting small towns by small towns, and then the spreads going to be lowering. This week Puerto Rico has been increasing the COVID, COVID statistics have been really high, so that's one of the things we, why we start doing next Monday. We're going to start vaccinating more than 300 to 500 persons daily in the different communities, so we can start small towns but making an impact and decreasing the COVID.

Avril Benoît:

Well, I really wish you well, that's an ambitious plan. It's a lot to try to get done. All right. So let's go to some of the questions that have come in from our audience, watching the webcast live. A question from Ruby on live stream. Does the US's population population-based allocation further inequity. So why didn't places with more deaths just get more vaccine and why shouldn't places with more transmission rates, right now be allocated more vaccine just like that. Torian Easterling. Why is that happening?

Dr. Torian Easterling:

Well, we knew very early on, based on a CDC guidance, the populations are going to be prioritized in the US, and I think the larger point based on the first question is how are we sort of thinking about other countries and making sure that they're getting backstage and they get the resources. And I think that is an appropriate questions. A I think we're going to have to address this question really, because this is a global pandemic and we want to end this pandemic. It's really about how we're vaccinating, getting to herd immunity across the world and really slowing down the spread. Because we do not want variants to continue to mutate, and so I think it's really an appropriate question. And really does think about, what, what additional steps need to happen to really resource other territories and other countries as well?

Certainly in, in New York City, as we've been thinking about allocation, prioritizing communities with, who've been disproportionately impacted by COVID-19 has been part of our strategy. I talked about CDC, so vulnerability index using that as a guide, we developed a methodology and we looked at those neighborhoods that have been disproportionately impacted and really directing our resources, the limited supply that we've had since December into those neighborhoods. And so even when you look at the map and we've grown our sites over time incrementally, you'll see that majority of those sites are in neighborhoods that have been disproportionately impacted and had high COVID cases and deaths.

Avril Benoît:

Is that something that's happening across the U S that you've got that, that kind of laser focus?

Dr. Torian Easterling:

Yeah, we've certainly seen this in other States as well. We know that Vermont has been leading with this approach as well, looking, using the CDC social vulnerability index. We've seen this in DC. We've seen this in Boston seeing this in San Francisco as well. And I think, matching up the intentions, right? Who needs to get vaccinated with the supply because certainly across each state supply has looked differently. And in governors and, and local municipalities have had to advocate for more supply so that we can match up sort of the population that we know are in those areas that have been disproportionately impacted. So, that rollout has been different in how those States have expanded their eligibility has also played into a count as well. So it's been supply, but there's also been eligibility, as we've been thinking about how, how you can really get to the root of, these structural inequities as well.

Avril Benoît:

Yeah. It's a question that's also coming up from Carly on live stream from a public health perspective, we just don't have the infrastructure resources to prioritize populations that need vaccines the most. How can we plan for better resource distribution in the future? Carla, would you like to tackle this one?

Carla Sofía González:

I think that, that's one of our things that we’re doing, we’re taking the vaccination where it’s needed. It's not an easy plan, it means a lot of logistics. We start next week, we have to have our community leaders and other communities know where the people live, then know when there's going to be at home. It's really logistics thing, maybe I don't know in the States its more difficult here Puerto Rico, we can do small groups, we have six nurses, we divide to teams of three, and then we leave every morning, but I don't anyone doing it on this scale, it's going to be helpful doing it in small. But that's why, when you're a foundation, a lot of people doing the same project a lot of organizations doing the same thing, then we can impact a lot of people so, for me it's a lot of logistics.

The community has to do their part also, their leader of community, we started to tell everyone that we were going to start our project, so community leaders started to get to me, so it's two part, of people who need to be on the part to get the community vaccinated, so for us. It can be done, it can happen, we're going to be doing on the communities also so. It can be done but it's a lot of logistic and effort. A lot of organizations that are together, that's why we thank a lot MSF for giving us the opportunity to make this, project here in Puerto Rico because there is not a lot of people making them and we really need it.

There are a lot of accessible places to go here in Puerto Rico, we have Walgreens we have CVS, we have a lot of places around the city. So a lot of people that want to get vaccinated they have access. But there are a lot of people that want to get vaccinated and then they'll have access.                                      

So it's really important to the government to take action but after the government, our organization and different communities, Puerto Rico Salud started from COVID-19, we professionals working on hospitals, we were professionals working on other places and we decide that this is the moment. Sorry. We decided this is the moment that we have to make a change, that this is more than 100 million of people having COVID in the whole world, so it’s something that we have to take action. So, my answer on that question is that, it can be done but it needs a lot of effort from organizations from the same from health care givers. Because here in Puerto Rico a lot of the vaccinations, have to be, you have to be a volunteer. You don't get paid or nothing so the health care giver also wants to help, sometimes we have clinics with 500 and we only have a couple of health care givers, so I think it’s a compromise that has to be done by a lot of people, so we can get this done more quickly and more efficiently.                                                                                                                                

Avril Benoît:

Yeah. Relying on volunteers is a complicated model. We actually have a question here, Kerry, from Kayla, who's watching on live stream and it tends to college in upstate New York. How can university and grad students play their role in helping with the vaccine rollout as well as with Doctors Without Borders, now what are the kinds of things we need and how can, how can somebody help?

Dr. Kerry Dierberg:

I think that's a great question. And one of the things that places like BMS that we're working with or many other health centers have really struggled with is that getting vaccine is only one component of actually getting vaccine to people. And in order to do that and facilitate organization's ability to do that, you need people to help actually get vaccine to people and do all of the administrative and other logistical components of getting a vaccine site set up and making it run smoothly. And so that you can increase the number of people also that you can vaccinate per day. And for example, here in Brownsville and East New York, we have had some volunteers from MSF and, and other volunteers that actually help with some of those administrative roles in the patient flow through clinics, helping people fill out their forms and understand their consent forms, help with translation, if that's needed, particularly for people who are speaking Spanish or many other languages spoken in these communities to really help with the overall functioning of a site and getting a more vaccine to people. And I think that that's a really key place that anyone with any background can support in.

Dr. Torian Easterling:

And I would just add just to Kayla, right now, very soon Kayla is going to be eligible, depending on Kayla's age, but a college student, most likely very soon. And I would ask Kayla to first think about our elderly and see how Kayla can help our elderly get vaccinated. And so if that's someone in your family, someone that is a distant relative, making sure that they get vaccinated. Because quite often, Kayla has, to Kerry's point, has the means to be able to navigate the websites, the call centers, and may have time to really help our senior citizens to do that. And so if our college students can just make that message very clear to their grandparents and to the elders in their family, I think it will go a long way to really make sure that we're prioritizing our seniors.

Avril Benoît:

Yeah. In my neighborhood in the Lower East Side, actually, there are volunteers, just the digital volunteers, helping folks to sign up and refresh, refresh, refresh the browsers so that they can get those appointments. We've received a few questions, not just today, now live, but also the ones that were sent in in advance about something reasons that people choose themselves not to get vaccinated.

So we'll start with this angle, and then we're going to switch over and talk about this notion of the vaccine hesitancy, both for health workers and also for people who are just in the community. But the question here is from Facebook. May is asking, "A lot of people are reporting side effects from the vaccine. Even though people recover within a short period of time, I'm afraid that this news will be keeping people from getting the vaccine. How can we build vaccine confidence to ensure everyone is safe?" And by the way, can I just say, May, I got my second dose today. So far, I don't feel anything, but who knows how the next 24 hours are going to go. Dr. Easterling, what do you tell people when they say, "I'm not so sure about those side effects."

Dr. Torian Easterling:

Yeah. I think we have to more normalize that these questions are okay to ask. And there are going to be so many questions about vaccines, and there are a lot of people who are coming to this conversation for the very first time. They are taking a vaccine for the first time in their adulthood. We know and have heard this, having volunteered at a number of our vaccine sites, interacting with our elders, with New Yorkers across who are coming to the country and been here for 15 years, they're coming get their vaccine for the first time. And quite often what they're saying is, because someone in my family or someone in my neighborhood inspired me, or I've seen them get their vaccine, take both doses that nothing was wrong with them, that was the linchpin that helped them make the decision. And I think that's going to be important.

We have to make sure that someone who you're close to or someone you know relatively well, it's communicated that the vaccines are safe. And yes, you can have some symptoms, and we know these to be true. This is not just limited to COVID-19 vaccines. We know that all vaccines, there is some level of side effects or symptoms that can show up, fever or low-grade fever or a soreness in the injection site, or even feeling body aches and chills, but they go away in one to three days. The good thing is that you're going to feel as though you're protected and you have that immunity against the virus, and that's really important.

Avril Benoît:

Okay. This one's for you, Kerry, from Brynn, wrote in, "What's being done to address culturally specific vaccine hesitancy?"

Dr. Kerry Dierberg:

Well, I think there's a wide array of things that are being done in different communities and different cities. I think there's a huge effort here in New York City to address this, given that we have people from all over the world with multiple backgrounds speaking multiple different languages. I think that one, it's important to ensure that we are getting education and awareness, other sensitization activities out there in the channels that people are looking for information in. Not everybody's going to the CDC website to get news or to the New York Times. So to get information about vaccine and why it's important and how you can access it in some of the local media channels or on social media and utilizing the networks of community-based organizations, faith-based organizations that have also built trust within the community and that may get at some of the more culturally specific questions and concerns around vaccination.

And then I think there's the language component as well. We are making sure that not all of the information we put out isn't just in English or just even in English and Spanish, given the wide array of places that people are from and languages spoken in this area. And so BMS is a great example of really trying to use its networks within the Brownsville and East New York communities through other community-based organizations locally, through their network, within their patient population, as well as a lot of the faith-based organizations around these communities that they're very closely linked with and have been for many decades.

Avril Benoît:

Your answer, I think, also speaks to Molly's question on the live stream about organizations engaging local community members and community leaders in the vaccination efforts. But can we go back to all this talk about vaccine hesitancy among racialized groups, communities that are Black and Brown identified? And this has received a fair amount of attention. And on the other side, I hear you speaking of the lack of services and just some basic fundamentals that have been slow to get into those communities. Kerry, I mean, is there something to it in terms of this vaccine hesitancy and like, oh, well they're just wary?

Dr. Kerry Dierberg:

I think we have vaccine hesitancy amongst every group of people, however you want to group them, in the United States and elsewhere. I have fellow healthcare workers that I work with in other settings that have not been vaccinated and have concerns about vaccine. I have friends who are vaccine hesitant or have just questions about vaccine and aren't quite sure that they're ready to get the vaccine.

I do think that it's been in the media a lot that there is a higher rates of vaccine hesitancy amongst the Black and Brown communities. I do think that there's a component of that that's contributing towards the lower vaccination rates that we're seeing in some of these communities. But I don't think that that's the only answer. And I think to your question, which is that it's also about ensuring that people are getting the education in the ways or the information they need to make an informed decision through the channels that are they most trust and that they most access and ensuring that they have someone that they trust in to ask questions and build that confidence that they can see more and more of their community members getting vaccinated and help building that confidence. And I think that that is definitely a component here in the East New York and Brownsville communities, for example.

And then I think there's that other aspect of, it's not just that I don't want to get a vaccine or that I don't know about the vaccine, it's that the practicalities of getting to that vaccine are just something that are a huge challenge for me, whether it's that the vaccine site is not close enough to my home, or it's only open during the hours that I have to be at work and I can't afford to take a day off of work or a lot of the appointment scheduling that's happening here is all online, for example. And so if I don't have access to the internet or I don't have a smartphone to be able to easily access all of that information and registering on sites and being online all day waiting for the next appointment, that really impedes your ability to access even the appointments that are available. And so I think we have to overcome a lot of those challenges as well for some of these communities in order to be able to make vaccine available.

Avril Benoît:

And Torian, I think we've also seen that opinions have shifted since the very beginning, haven't they? The latest nationwide poll that I read had, in fact, other groups, it was white conservative males and evangelicals were more likely to be vaccine hesitant right now at this point in the vaccination efforts. And so things are definitely shifting. What are you seeing on this issue? And how do you address those who say, "It's all a question of vaccine hesitance."

Dr. Torian Easterling:

Yeah, no, I mean, I so appreciate the Kerry's comments because I do think what I understand and how I've been reading the situation is that people, they have hope and they want to get out of this pandemic. And having hope is trying to fully understand what's the best path to get out of this pandemic, but also keep myself safe. And so we always knew that there were these three categories. There were people who were just ready, they were primed, and as soon as vaccine were available, that they were going to step in line. Then you have a very large contingency of individuals who are just watchful waiting. And particularly, this is where you find particularly black and brown communities, because information has been not always direct and not always factual. And we also know that anti-vax organizations have targeted communities of color for intentions of really trying to confuse people.

And yes, I think that there's this third category of individuals who truly are saying, "I'm not going to get the vaccine." And for political reasons, very politicize how things would just unfolded with this vaccine rollout, we are seeing that they're particularly more Republican and they're leaning more toward white males. And so we need to really unpack why folks are watchful and why they're waiting for a vaccine. And it's not only just thinking about historical issues, but contemporary issues. A year ago, we saw how allocation was happening and ventilators in the healthcare system and decisions being made in the emergency room. And so the questions that nurses are asking is, "Why do you care about me now in March 2021? What happened in March 2020 when I was looking for PPE?" And so we have to be able to respond that there were mistakes that were made.

There were decisions that were made. There were allocation decisions that necessarily did not fall in your favor. And then also be able to hold the truth that right now, we still want to make sure that you're vaccinated and you're safe and your families are safe. And so we have to have a really honest and transparent conversations that yes, there is truth about the past and what happened last year. But here's another conversation that we can also move forward with. And so it was not actually denying, but also just trying to find a path forward as well.

Avril Benoît:

Carla, one of the questions that we received ahead of time was from Robert asking how best to overcome vaccine hesitancy on the part of health workers. Can you speak to this? Is that something that you've seen in Puerto Rico and how have you managed to overcome it? I'm not hearing you, there seems to be a sound problem. Okay. So while you get yourself set up, Carla, don't worry it. Work on your mic issue. And maybe Torian Easterling, you can speak to this as well because you have the bigger picture of how this has affected health workers. Because that is baffling, especially honestly, those who work in the long-term care facilities, that they should be hesitant themselves just guts the families whose loved ones are in those facilities.

Dr. Torian Easterling:

Yeah, certainly, but because of our work around vaccines at the New City Health Department, this isn't all surprising because every year we're doing our flu vaccine campaign and certainly we've seen the work that we need to do to build vaccine confidence just around the flu vaccine. We've had the most successful flu vaccine campaign in 2020, largely because we were in the middle of the pandemic. And so still, certainly in our healthcare workers, there were questions or concerns that were raised. And so we anticipated, even though our healthcare workers were going to be prioritized first in phase 1A, we anticipated that there was still going to be a lot of work that needed to be done around building vaccine confidence. And so there's still this question around, why are you prioritizing me? Why am I the first in line?

And being able to answer those questions, are the vaccines safe? Are they effective? Are they going to keep our family safe? And so I think those are a lot of the questions that we've had to address. When you unpack and really look at the roles, so physicians and you have to think about nurses, and then you have to think about the physician assistants and your techs, and then also custodian staff, you certainly see differences in who is accepting of the vaccine. And it really speaks to the work that needs to be done to really support conversations and build that confidence. And certainly, we see it, it's different by race and ethnicity, and then also it's different by staff, who's accepting of the vaccine and when.

Avril Benoît:

We're just trying to get Carla back up. She's trying different techniques so that we can hear her again. Another one for you then, Kerry, is from Debbie on live stream. Let's talk a little bit about people who are homeless, who are living in shelters perhaps, living in precarious housing and what have you, what's being done to ensure that they receive the vaccine?

Dr. Kerry Dierberg:

Sure. I can try. I think Dr. Easterling will probably have something to add here, but there people who are in the prison system, who are living within shelters, in other congregate settings, puts people at higher risk for COVID-19 because of the nature of the way people are living and in close proximity to one another. So this has been a group of people that have been prioritized for vaccination and a lot of effort happening to try to bring vaccine closer to those settings so that people can access and not needing to kind of get out to a separate site to get a vaccine. And I know that that's happening, say, at Rikers here in the New York City area, as well as several homeless shelters around the metropolitan area also.

Dr. Torian Easterling:

Yeah, yeah. We're trying to use the Johnson & Johnson doses in an intentional way, so not only our home bound individuals, but also thinking about individuals who are unhoused and really doing outreach and engagement. And there still needs to be a conversation. We're not just saying, oh, because you're an unhoused and you have to take this vaccine. There has to be a decision that's made and certainly that that power of authority is really on the individual to say whether or not they want that vaccine. And then working with our colleagues at the Department of Homeless Services, really engaging in all of our congregate settings. So as Kerry has mentioned, we do have dedicated sites now that we've been working at to really engage individuals who are unsafely housed and making sure that they have access to appointments. And we've been working closely with our colleagues at New York City Health and Hospitals. We have both worked with Department of Corrections and making sure that individuals who are currently incarcerated are being supported with conversations and then getting vaccinated. First starting with individuals with underlying chronic conditions and then being able to engage others.

Avril Benoît:

Well, I can bring my last couple of questions to you, Carla González in Puerto Rico.                                                                                  

Carla Sofía González:

Hi.

Avril Benoît:

On this question about-

Carla Sofía González:

Sorry.

Avril Benoît:

Yeah. No, quite okay. We're actually almost at time, but tell us about the challenges you have, Puerto Rico Salud to reach the homeless. And also if you could speak to the hope of the Johnson & Johnson single dose kind of facts here.

Carla Sofía González:

Okay. I'm going to talk a little bit about the hesitation here with the health worker. It's been a really good impact. They've been really pro-vaccination. So we have not been having a lot of problem with that community. There's a lot of people that want to get vaccinated in Puerto Rico, but there's also some people that do not want to get vaccinated, but we can divide them on different communities because on one community, you can find both things that they want to get vaccinated or not. I can even more younger the person, maybe there are a lot of hesitation, but we say that it's a lot of bad information that they're receiving, it's not good education. So that's one of our things that we're doing a lot of our social media, it's a lot of education. Yes, there are some side effects, but it's normal. It's your body working with the vaccination.

So for us, that's why we tell every person that we are doing the vaccination, we tell them if you feel the symptoms, that is normal, I've had my two doses and I did have some symptoms. So I tell them it's normal because it's your body responding to something. So for me, and I know for a lot of people, it's a lot better than having the disease, right? So the hesitation here in Puerto Rico for, for us, it's more of education. Those people that don't get the right education, but a lot of people get fake news, a lot of fake information is happening here in Puerto Rico, but once they start getting information, I know a lot of people change their minds. So that's one of the things that I want to talk about it. The Johnson & Johnson dose is really important for us as it is our organization because we don't have to program two times on the site.

It's been really difficult. The last week, we have been doing some of the specific communities, but with Moderna, and it's really hard for us making a second approach to the community. So for us, it's really, really important to the health department gets partnered with us and help us to get the Johnson & Johnson does because if we just go and make the vaccination, one dose, and we call the patient, we're calling them two weeks after to see how are they and how everything has gone. So we're doing that on follow-up. Homeless people, here in Puerto Rico, there are a lot of organizations that work with homeless people.

So we have been able to talk to those organizations and we already have made alliances. So we're going to be on April, we're going to be impacting more than 1,000 homeless people in Puerto Rico with the vaccination. So we're really on a good track with that kind of community. Once again, Puerto Rico Salud, our statement or what I every day say, we're going to go where no one else will go. So there's a lot of sites that people can go. I don't want that community. I want the communities that they want to get vaccinated while they are not able to get it. So that's where Puerto Rico Salud comes and thanks to MSF, we're going to do that impact.                                                         

Avril Benoît:

Well, we're really happy that you're there to do this work and support you 100%. And Kerry Dierberg, also happy that you're able to work in Brooklyn and East New York to support the BMS health center to be able to also scale up and accelerate the vaccination efforts. And Torian Easterling, really good luck to you. You've got a massive job and we're counting on you and other officials in the public health sector to be able to facilitate pulling us through this. Thank you all for joining us today. I really appreciate your time.

Dr. Torian Easterling:

Thank you for having us.

Carla Sofía González:

Thank you for having us.

Avril Benoît:

Torian Easterling, New York City Department of Health and Mental Hygiene, Carla Sofía González from Puerto Rico Salud, and Dr. Kerry Dierberg from Doctors Without Borders, our project coordinator in New York for a fascinating conversation. Thanks so much again. And our next webinar in this series is going to be live on Thursday, April 29th, when we'll tackle the global equitable access to COVID-19 vaccines. Another major topic for us here at Doctors Without Borders. So thanks again, apologies if we didn't get a chance to get to your questions, but there were a lot of terrific ones coming in and you can email us for any further follow-up. Love to hear from you. Our email address is [email protected]. You can also visit our website. In the US, it's doctorswithoutborders.org and our international website is msf.org. Look out for us on Facebook, Twitter, Instagram, and beyond. I'm Avril Benoît signing off from New York City. Bye for now.

Kate Elder: 
Hi welcome everybody. Thanks so much for joining us this afternoon for our first episode of the spring webinar series Let's Talk Vaccines. My name is Kate Elder, I am the Senior Vaccines Policy Adviser for the Médecins Sans Frontières, MSF as we will refer to it today, Access Campaign. I’m based here in New York City. 

Today we’re going to be talking about vaccinating during emergencies. While everybody is pretty wrapped up right now with COVID-19 and access to COVID-19 vaccines, understandably as it saturates the news cycle, there are many other essential vaccines that MSF is working day in and day out to deliver to our patients and people around the world. For nearly 50 years MSF has been delivering vaccinations in some of the world's toughest conditions. We’re supporting emergency vaccination campaigns in response to various epidemics and ensuring that routine immunization services continue to operate despite very difficult situations like war or civil unrest. Whether we’re vaccinating against more common or older diseases, like measles or pneumonia, or trying to fight newer threats like Ebola or COVID-19, we know that vaccination is a key component of the medical package and truly one of the most effective public health interventions. So that’s what we’re going to be discussing today. 

Just to start off, a little bit of housekeeping. We will be speaking for about 45 minutes. Wherever you are joining from today, please feel free to pop some questions in the chat. We will be taking those later in the discussion. If you are watching via livestream, YouTube live, Facebook live, or Twitch you can just pop your questions over there and my colleagues working behind the scenes are going to digest those questions and send them over to me. We’ll prioritize the questions that relate directly to what we’re discussing today. There are also live captions if you would like to opt for that. You can view them on a separate URL, or you can watch on YouTube where you click on the CC button to activate that closed captioning. So, without further ado, let's get to your experts and panel who are here with us today. 

We have Dorothy Esonwune. She is MSF’s project coordinator in Old Fangak in South Sudan. Welcome Dorothy. 

Dorothy Esonwune:
Hi everyone.

Kate Elder:
We have Mirjam Molenaar, MSF’s medical team leader on Samos island in Greece. 

Mirjam Molenaar:
Good evening.

Kate Elder:
And we have John Johnson, MSF’s vaccination and epidemic response referent based in Paris, France. Hey John.

John Johnson:
Hello.

Kate Elder:
We’re going to start with you, John. Since you’re working at one of our global headquarters there in Paris and you really have an overview of MSF’s vaccination projects across the world, can you tell us John from your perspective, why is it so important to make sure we vaccinate people who otherwise have very limited access to medical care.

John Johnson:
I think I would start by saying it is not just people that have limited access to health care that need to be vaccinated. Obviously, vaccination is a good idea for people who have good access to health care as well. Sort of the basic things, vaccines are used to prevent disease. So, clearly if you can prevent someone from getting sick it’s a very cost effective and rather quick and easy method of avoiding someone from being hospitalized or having a bad outcome like long-term morbidity or death. So, a simple vaccine like measles vaccines or rotavirus vaccine or pneumococcal vaccine can keep a child from coming down with an illness, being hospitalized. In the case of measles, you have not just the disease of measles but also the sequela the follow-up diseases that come with measles, such as post measles malnutrition and other things like that. There is the obviously the prevention of getting sick, which is fairly obvious. It makes sense to avoid sending someone to the hospital when they can just get a vaccine to prevent that. There is also the prevention of outbreaks. So, when we vaccinate people in refugee camps or IDP camps, internally displaced persons camps, you can avoid having a massive outbreak of contagious diseases like meningitis or measles. 

There is the other factor of helping to bring about the end of an epidemic. COVID is a great example. Everybody is looking at how we can stop this epidemic by using vaccines among the other epidemic control measures. So, often MSF will use vaccines like meningitis, yellow fever, measles, cholera to respond to bring about the end of an epidemic more quickly than just classic control measures would be able to do.

Kate Elder:
Thanks John. You’ve given a really good overview of the importance of vaccination. Not only for people who have limited access to health care but just in general as a global public tool. Dorothy you are joining us from one of MSF’s projects in South Sudan, Old Fangak. Can you describe to us a bit your settings, where you are sitting right now and what the context is like and what MSF vaccination activities are like in Old Fangak please?

Dorothy Esonwune:
Old Fangak is in Jonglei states in the new states of South Sudan, and it is the biggest freshwater wetland in the whole world. It has a very beautiful swamp. In Old Fangak, MSF has been there since 2014 during the war there was influx of patients and Old Fangak requested MSF to be there. MSF came, and since that time MSF has been in Old Fangak. It is like a limited place, just like you said. We are there we do routine immunizations that cover children from 0 to 11 months, and we also take children from 12 months and above when they catch them. During the flooding and in Old Fangak they are very limited. There is no vehicle, you only have boats. And in some of the places people can trek up to 72 hours before they get access to the hospital. During the flooding it was very drastic, and people couldn’t walk onto the swamp because the level of the flood is getting to their chests. So, they couldn’t walk. We, to catch people because we had a lot of dropouts in our daily immunizations in the hospital. So, we had a fixed stations like health stations, where we go every month to catch up children that are supposed to be vaccinated. We took extra measures during the flooding. We had health promotion. So, all the places we had displaced people. So, we did our team go and give them health promotion messages, explain to them the purpose of immunization and direct them, the ones that are close to the hospital, direct them to access Old Fangak hospital for their daily routine immunization. But for the ones that couldn’t access, we go to them. What we do is, we have one week planned for the outpatient. Before one week we write letters to inform the community leaders that they will be coming on a particular day. We start from Monday to Friday. So, if your turn is on Friday, we tell you we are coming on Friday. And we use also that opportunity to do health promotion. Then, on the very day of the vaccination, we have a team of the vaccinators and we also have the health promotor that continues throughout the vaccination to give health promotion messages.

It is very interesting. We are so happy for the testimony we got. That is what is motivating us. I can remember once we went for outreach because during this flooding MSF was going every day to assess the flooding and the people are so happy that we are coming to visit them. During one of my visits one of the mothers said, “do you know my husband is not around and the water is getting at my neck level. I have a child that is under 11 months. I couldn't move because I don't have canoe to paddle. But when I saw you come in, I feel so happy.” So, when MSF team came for vaccination, the child was able to be vaccinated. So, she felt very happy, and the testimony was giving us joy. It was also one day when we went for assessment, she was really very sick. She said “oh, I already planned that I'm dying. But I have five children. My husband is not around. So, I was like, who will I leave these children for.” Luckily for her, we just came in for assessment to see how they are faring. We got the information that she is sick. We took her to our boats and referred her to the hospital. So, the testimony is giving us joy. We also have some of them because the health messages we give, and we protect their health card with zip lock. So, one of the women told us that she puts the health card in the zip lock in the roof of her tukul. When the flooding came displaced her house, it was only that that was saved. So, she didn't want to lose it because she had understood the importance of immunization. 

Kate Elder:
Wow. Thank you, Dorothy. That's such an incredibly powerful story and I imagine probably that many other people who work for MSF also see the value of that health care card that parents and caretakers place truly treasuring and making sure that they keep protected the document that shows how their children have been vaccinated. Thanks for sharing with us Dorothy of what your experience has been in Old Fangak and how difficult it is sometimes, despite all circumstances, to get vaccines out to people, taking them to people despite the flooding. Or making sure people understand they need to come for their next appointment to keep on schedule, as you say. Mirjam, tell us, speaking of what Dorothy said. Sometimes they have to use boats in Old Fangak to take health services to people themselves. Many of the people where you are working, Mirjam, have arrived on the island of Samos after some pretty treacherous journeys. Taking boats, as well, and arriving there in this camp setting where you are working. Can you tell us what you hearing from people that are in the camp on Samos island and what sort of vaccination activities MSF is offering there? 

Mirjam Molenaar:
Thank you for having this event. Here on Samos, first of all, we have people coming from many, many different countries, which is very different from any other setting that I have been. We have a lot of people coming from different countries in Africa, but we also have people from Syria, Iraq, Kurdistan. So, there are many different people all together in this camp on the hill. And they all have different experiences with vaccinations. Some people have never in their life been vaccinated. For instance, many people coming from the Congo, and other people coming from Syria that have fled the war might have been vaccinated in the past but have not had any vaccinations for at least ten years since the war started. They have had children, they brought young children with them or they have had children while they were on the way or have had children while they have been living in the camp. As we are here on Samos to fill the gap in absence of health care from the ministry of health. We actually focused initially on mental health here for people as well as sexual and reproductive health care. On our project, we started with vaccinations for pregnant women for tetanus and Hepatitis B. Then we realized that many children in the camp were not vaccinated by the authorities because also COVID had arrived on the island in the beginning of this year and there was the threat of it worsening, so all of these activities were stopped. Our team decided we could not leave the children unvaccinated and so we started a vaccination campaign initially for children under five to catch them up on their immunizations. That was done once a week on a soccer field in front of this camp with all the measures in place for COVID. So, distance, wearing masks, people were screened before they could enter the line and so on. Hand sanitizing and hand washing. Information at the end of the vaccinations, all of these things were put in place. Then since our, the camp here for the migrants is - the conditions are pretty abhorrent. We also received many people after rat bites. 

We as MSF on Samos do not provide primary care to people because there was another organization that does this well. So, we work together with them and whenever somebody was bitten by a rat previously, they got sent to MSF for their tetanus vaccination as well as immunoglobin which is given as an injection when you have sustained a bad wound. Then we realized to protect people against tetanus, we needed to do a campaign for the entire camp. We started this when we actually were full on in the COVID period because we are afraid with the new policies for migrants in Europe, people might be going to a closed camp, where we may not have this kind of access. We decided to put some action into it and in December we did the first round and were able to vaccinate many, many people. I believe we vaccinated some 90 percent of the people in the camp, with the help of our health promotors, with community volunteers with the agreement from the authorities from the official camp here in Greece and also the police. They knew we would have everything in place for COVID measures. So, we did that. 

By now we have given the second dose of tetanus to people which is one month after the initial dose. At the same time new children are being born in this camp and are not being vaccinated in hospitals. So, we also continue to vaccinate these children with the same yellow booklets as Dorothy. They all get a zip lock bags. Although we are in Greece, it is wintertime. So, lots of rain and storms. And so, like you said Dorothy, people guard that yellow booklet and bring it back to us when they come for follow-up. We continue to vaccinate the newborns. Also, some children that might have missed a round of vaccinations. In the meantime, here many people are transferred off the island to the mainland, which is something we actually are really working towards. Because that way people are closer to the necessary facilities for their health care, which are lacking here. And so, we try our best to vaccinate the children completely before they leave the island. So, it's always wonderful, I think vaccination is one of the most gratifying things that we do in MSF. We know what it prevents, and I've been in many different situations where we did emergency vaccination as John explained for measles where you are running to save children from death. It's with one vaccine, it saves many.  

Kate Elder:
Thanks, Mirjam. It is so interesting to hear about the variety of contexts that people have come from when they arrive in Samos at that camp. And just how variable their immunization history is and how MSF is trying to respond to all of those specific needs. You have given us such a clear illustration of the challenges, but also the opportunities as you say. Because vaccination goes so far. John, we had this question from Michelle W when she registered for this event. Mirjam has already listed off a number of different types of vaccines. Could you please just quickly talk us through what vaccines MSF administers in our projects, and then also, if there is an emergency, John, for example an outbreak of measles like in the Democratic Republic of Congo we see right now, what is the thinking with you as the vaccination referent when you work with our medical operations to really assess the community’s needs. What are those steps and how do you work set that action plan? The real mechanics of getting started and kicking off a vaccination activity. 

John Johnson: 
To answer the first question, we do a lot different vaccination activities. All sorts of different activities depending on the project. Some of vaccines we use, I may not name all of them, but measles, meningitis, DTP, polio, tetanus, hepatitis B, pneumococcal rotavirus, BCG at birth, yellow fever, did I cholera, did I say Ebola. Depending on the context and the project, we do all those things. We do projects that are surgical where we do tetanus vaccination, and we do sexual violence projects where we do post exposure prophylaxis with tetanus and hepatitis B vaccinations. So, we do most of them. 

And then to answer your question about how we set up a project. So, classic example would be Congo and the measles epidemic. Typically, what we do is, MSF has sustained presence in the Congo for the last 25 years in all five sections. We all work in different areas of the country; we would send a team to do what we call an explo. They go and visit the area where the outbreak is happening. They meet with the local health officials and typically they will visit the hospital and some of the outpatient clinics and look at some of the data to see how many cases we have been seeing. Then determine if it's an area where they would be interested in our support. We will typically make a proposal for a few months of sort of boosted support where we can come in and help them with case management for severe cases. Typically, we also work on transfers. Some of the biggest issues were patients in these areas where there is limited access to health care is transferring them from where they live, where they may have access to a clinic. Getting them from the clinic to the hospital if it’s a severe case and they need hospitalization. And we’ll set up a reference system usually with motorcycle taxis, things like that, to be able to move patients. We work with small clinics to make sure they have treatment. We give them a kit with certain medicines. And then discuss with them how we would do references. So, they can start treating for simple cases. If there is a severe case, they refer them to the hospital. We will typically set up an isolation unit because measles is obviously a contagious disease. You have to separate these children from the rest of the children in the hospital. And so, we’ll identify an area in the hospital that can be isolated for treating these patients apart from the other children. Or, in some cases, we’ll set up a tent outside and treat the children there. We will bring in extra human resources and obviously medicines and materials to be able to help them ramp up their response. And then if warranted we will look at vaccination activities. It's typically a pretty good activity to get involved in and it usually makes a lot of sense unless you arrive really late in the epidemic. Typically, we’ll discuss how we can help them carry out a vaccination activity. 

Most of these countries where we work, they know quite well how to carry out vaccination activities. They just don’t have the means to do it. MSF will come in and usually work with them on a planning process of, okay, how many sites would you like to have? How many teams would we like to have? And how many children can we reach with this number? And then, how many children are there? So, are we getting the right number of children vaccinated for the area? We’ll usually help them mostly with logistics and human resource support. So, management of the vaccination teams, making sure they’re paid for their work. The logistic side is making sure the vaccines get to the vaccination sites. That is usually one of the trickiest parts in some of these resource poor settings because there is a lot of difficulty in moving things around because in a lot of places there’s not good road access. We have to think of how we can get it from the central warehouse out to these vaccination sites. Vaccinations need to be kept cold and that's one of the biggest challenges, from the time they leave the warehouse until the time they get to the site where they are injected into the patients, the vaccines stay at a certain temperature. To do that you have to use all sorts of different refrigerators but when they leave the central warehouse you need to have what’s called a passive cold chain. That is basically just a cooler where the vaccines are kept cold. You need to make sure that they can stay cold for enough time to get to these sites, and you need to have a good transportation plan, to make sure they are not wasted. That is typically how we go about it. I don't know if that is too long of an answer but that is more or less A to Z for a vaccination response. 

Kate Elder: 
Thanks, John. That’s great to hear the nuts and bolts and to have an appreciation for how many steps there are before we actually get to vaccinating children and other people. A couple of things you said DTP, diphtheria, tetanus, and pertussis vaccine. That is a laundry list of vaccines we offer. I thought it was interesting to highlight to that for every child the World Health Organization has a standard list of vaccines that every kid around the world should get, but you also mentioned other vaccines for particular populations. For example, MSF programs for people who have experienced sexual violence as well. The vaccination protocols for people that have been in certain circumstances too. And of course, in terms of those logistics, not to be under mentioned, the extreme logistics around the cold chains. If there are no roads transportation is hard, and if there aren’t roads electricity might be scarce as well. So, making sure those vaccines stay cold so they can remain efficacious. We know that prevention is better than the cure. We are vaccinating people to try and avoid that disease, so we don’t have to treat that disease. If we focus on routine vaccinations, the effects on a community can be far less severe than if there are deadly outbreaks. We have seen around this around the world where MSF works. We will watch a video about MSF’s recent measles vaccine campaign in Mali. Please join us. 

Thanks for joining us for that video and seeing what some MSF activities are like in the places where we work. I’m going to go to Mirjam. I think you had some reactions to what John just said, we’ve also had a question from our colleagues online. We have a question from Leslie on the livestream directed at Mirjam, has MSF seen any disruption of routine immunization services because of the COVID-19 pandemic? 

Mirjam Molenaar:
Okay, let me first react to John. When he explains what MSF does, I am sitting here very happy. I was in the Congo for one of those reactive measles campaigns where, initially, there was an outbreak of measles. Actually, we had malnutrition before measles broke out because very often it is malnutrition and then people, particularly children, are more likely to get measles. And also, the other way around. We lost many children in that area. The year after that I was in Sudan, not in South Sudan where Dorothy is right now, but in East Darfur and we did preventive measles campaign in a complete different setting with healthy children coming from all over. On carts through the desert, ten kids on a cart drawn by mule, or running through the sandstorm. We vaccinated almost 20,000 children in one week going around in this area with five teams. It was great. In one day with the team that I was with, we would do 1,200 to 1,400 children, all in a line. It was loud, it was happy, I mean parents were happy and even children would go away waving. In that setting we didn't lose any children to measles in my time there, so it was spectacular. 

Here, no, the good thing is when we realized the gap, to answer the question regarding COVID, this is exactly why we picked up doing these vaccinations. Yes, there is a gap for the ministry of health. The hospital on Samos, I am not really sure. But these things are not happening. We realize that so we are filling that gap. And in keeping all these measures that we need to keep to prevent the spread of COVID with a proper set up with logistics and medicals working very closely together. And the proper cold chain we call it the happy temperatures between two and 8 degrees Celsius here. Then you can prevent the lack of vaccinations. Now it is difficult here because these transfers are not always happening with us being aware of them. So, this is very difficult. That's why our HPs run through the camp every day to check on people, to see who is ready to leave the island or who is still there, so that we catch as many as we can. And so, we try as much as possible to prevent these gaps. I strongly believe, as we have shown with tetanus campaign, that we can continue proper vaccinations in times of COVID. It just needs to be set up properly with everybody working together.

Kate Elder:
Thanks, Mirjam. If you are just tuning in now, I want to welcome you to our discussion on vaccination in emergencies, the first session of our spring Webinar series, and invite you to pop any questions you may have into the chat. We will get to some of those questions soon. I want to take a look at some of the results of the social media quiz we did later this week. I will read some of the questions we posted to the audience. Feel free to type your answer in the chat. We will go over what the group responded. How many lives are saved each year thanks to vaccinations? Is it a) up to one hundred thousand lives, b) up to five hundred thousand lives, or c) up to three million lives saved? You can see 83 percent of you got it right. Bravo. Three million lives are saved each year. When you think of prioritizations, making sure it is well resourced. Can you imagine how many more lives we can save if we make sure every person has access to vaccination. Next question. Routine immunizations should be halted when a new disease outbreak strikes. This is false, 82% got that right. You have just heard about the importance of continuing vaccinations services despite what we are hit with. If we can do it safely it is critically important to continue offering people immunization services that target these diseases to make sure people’s immunity remains high. Finally, what is the most critical element of an outbreak response. Is it a) infection prevention and control measures, b) widespread vaccination, c) community engagement, or d) all are important components. The correct answer is D, and 84% of you got that right. Thanks very much for your responses. 

Let's talk about these for a minute actually. That second question perhaps seemed a bit obvious. Of course, we don't want to shift resources away from our existing vaccination work when there is a new outbreak. Especially in some of the contexts where MSF is working and where it seems like there can be many repetitive crises, something like Ebola or, if you will, COVID-19. But it’s not always that simple. John I will throw a question to you. How do we make sure we don't neglect our standard prevention practices for some of the older diseases we have while tackling the new threats? Maybe you can talk about your experience responding to the Ebola outbreak. 

John Johnson:
That is a huge risk whenever you have a big emerging disease like COVID or Ebola. Everything else getting pushed aside. If you look at global vaccination numbers in 2020, they went way down because of COVID. It is not an easy question to say you have to do X and it will solve everything. I think at least for MSF we need to make sure we keep our focus on things that are sometimes boring or tiring to talk about like measles. If you look back in 2019 and 2020 there was the world's largest measles outbreak in the DRC and in Chad and in the Central African Republic, but it got very little attention because of COVID. I think we need to prioritize our activities and make sure we are focusing on things that will save the most lives and that are the most important activities to be involved in. But at the same time, if you look at COVID and Ebola, these diseases are helping us learn how better to work in vaccination and how to adapt our vaccination activities in an outbreak. If you look at COVID and all of the scientific research that’s happened in developing new vaccines, some of these things will help us get better vaccines for other more classic vaccine preventable diseases. We can use technology like mRNA. And that’s super.

Another thing we need to think about how we can combine some of these activities. Just because we are vaccinating for COVID doesn't mean we can't use this opportunity to check vaccination status for measles or other vaccine preventable diseases and train our teams to come back and do the same activities later, how to use some of the same resources later. We will have extra cold chain material available after COVID-19 vaccine rolls through that we can use for activities in the future. It is not an easy question to answer. We need to keep our focus and think of how we can use some of these distractions to our advantage. 

Kate Elder:
Thanks John. And although some may be boring as you say day in and day out, some of the fundamentals, it is not any less important getting it right. Many of us haven't seen measles but it is still a severe problem in many parts of the world. Dorothy I will come to you next. I am sitting here in Brooklyn, New York and there are some people here that don't want to vaccinate their kids. It boggles my mind. My child is vaccinated and will stay on schedule. But the rise of vaccine hesitancy in some places is really alarming. I’m curious, in Old Fangak, in your project how do people respond to the vaccines? Are they eager to get vaccines where you’re working?

Dorothy Esonwune:
In Old Fangak we have some people that -- some people that awareness is the most challenging aspects of it. Some people, that got the awareness, they respond positively to vaccination. But we have other challenges that hinder people from getting vaccinations. One of them is accessibility. Just like we said, some people trek like three days to access the health center. And during this flooding, it was really very disturbing to them. They couldn't trek. So, it's made us to have dropouts of immunization. Not that people are not willing to be vaccinated, but the challenge of accessing the health facilities. Most of them only access when they are sick, and they come for treatment of their child or themselves. They use that opportunity to take the vaccine. In Old Fangak the experience we are having with the flooding. We have experience with movement of people, especially now in Old Fangak where we have food insecurity. Some people are moving in search of food. Crops are destroyed by flooding. Most of the animals are dying due to flooding. Most of the population is displaced. They have been flooding since last July and it is still going on today. Many people have been displaced. There is different shift in the movement that people are looking for mainly food to survive. So, the families are moving and kept moving to higher land. And honestly some of people are leaving the country just to search for food. 

Another challenge we have is lack of awareness. People are not really informed about the importance of vaccines because of where they are. That is why we try to see if we can solve most of the challenges by having this outpatient. By having community sensitization. We also discuss with the county health departments to reach the people that where to reach them is not easily accessible. Some of them live very far from the river and you have to walk days or hours in the swamp, which is very difficult. So, we are working with the country health department to see how we can have volunteer health workers in each community. If they can have that that will be fine. So, the aim to have this is, is to allow these people to educate the community. So, inform them about the importance of immunizations which will prevent childhood diseases which are very infectious. But this is still under discussion. The county will have a new person in the position. So, we will now start again with a new discussion. 

Another thing we plan to do is see, we use our team, we use our staff in the community to tell the community the importance of immunizations. So that they will assess any of the clinics or outpatients or any of the organizations that are doing any of the routine immunizations. And just to add to what John and Mirjam said about immunization. We know it is very important like John said at the beginning, because it helps people with resistance from infectious disease. I remember in 2010 when we did the mass vaccinations in Malawi which was very awesome. We vaccinated millions of children. Our aim, as MSF, is to prevent the outbreak by ensuring people get vaccinated. Ensuring mothers get immunized. We have another component where we try to educate the women, because we also have tetanus vaccinations for mothers from 15 years to 49 years. As we give them health messages, we also explain to them start from the pregnancy period to explain to them about the importance of vaccination when they deliver. I think that is also going a long way to help. Honestly, the dropouts are still there. There are still dropouts. 

Another solution where we are like trying to bring in is the food insecurity. It is very challenging in Old Fangak because people are continuously looking for food and they are moving. If they could have this food, I think it would also make people to stay. They already have, routinely we do screening in our vaccination. We are already doing that. But, to catch the flooded area, we plan from these months to incorporate screening for malnutrition, so that we will be able to identify when malnutrition is going high in this area. 

Kate Elder:
Thanks Dorothy and thank you for sharing with us this really multipronged approach of any time you reach community members of what you are trying to do to educate, support and offer other health services like screening for malnutrition. It is interesting to hear that there is high demand where you are in Old Fangak but, sometimes, people have other priorities because they are facing so many other difficult situations like loss of livestock, their food source, their income stream. You are putting a wonderful illustration to the really tough circumstances in which you are working. Thank you for sharing that from Old Fangak. 

We have a lot of nurses and medical professionals on the chat. Some of them are now wondering what can they do and raise awareness about the value of vaccinations. John do you have any suggestions? I can just offer from my limited experience on vaccine hesitancy, I understand it is incredibly complex. There are good resources out there including the Center for Vaccine Confidence at the London School of Hygiene & Tropical Medicine, that uniquely studies the rise of vaccine hesitancy and the topography of why people might be vaccine hesitant. There is much that needs to be done to dispel misinformation and to counter the disinformation pandemic that many people are talking about. There are some very good resources on WHO's website. Please check back on our website too. But I think any activities in your day-to-day interactions to discuss with people the value of vaccination and to use scientific tools to counter that would be very useful. John do you want to add anything to that?

John Johnson:
Yeah, I would just say that a lot of vaccine hesitancy comes from people that haven't seen these diseases that vaccines prevent. You don't see this same kind of hesitancy in places where people know what measles is and what it can do. If you look at the last few months of COVID vaccination, there was hesitancy at first and then people see it doesn’t actually have that many side effects and it actually prevents this terrible disease. They come around pretty quick to saying it’s a pretty good deal and prevents you from getting sick. That's the obvious thing is people understanding the value of vaccines in that way. If you work in an area where people are less accustomed there are great resources, like you said. WHO is one, and one I really like is a website called Immunization Academy and they have lots of really practical videos for health professionals and that is one I tend to use. 

Mirjam Molenaar:
I totally agree with the importance of the education piece. I think no vaccination campaign can be successful without proper education first. That goes for us in anywhere in the western world or developed countries where people have heard a lot already about COVID. I was in Kabul last year when COVID came around at the beginning of the year. We worked with the ministry of health and we had two tasks there. We had one task to convince them to continue the under-five vaccinations for children, to keep doing this, putting in place COVID measures. And then we already started then to prepare them that maybe in the future there would be a vaccination and to think about that and to start educating the people. I think that is a crucial part about acceptance of vaccination and as John mentioned, the fact these diseases are real and there can be a comeback if people stop accepting vaccines. We will see a rise again in diseases that we had conquered. And they will come back. So, we need to remain vigilant and continue always with our education of people and help them realize the importance of vaccinations.

Kate Elder:
That's a perfect note, Mirjam, to end on. The importance of vaccination. That is all the time we have today. I really want to thank you, Dorothy, Mirjam, and John. These are the colleagues at MSF working day in and out and they will go back to their job’s tomorrow vaccinating people. Thank you for joining us for the discussion. It’s really been a pleasure to join you as host. We will be back in a month. Please join us Thursday, March 25th. We will be talking about the vaccine that every news source is publishing today, COVID-19 vaccines, and how people are getting access to those. If we didn't get in your question you can email us at [email protected] for more information. Also please feel free to visit our web site at doctorswithoutborders.org, and our international website msf.org. Thanks, Mirjam, thanks Dorothy, thanks John. Take care everybody and stay well. 

Avril Benoît:

Welcome. I have unmuted myself this time. Thanks for joining us for this final episode of our Let's Talk webinars series for the fall. We will surely have more of these in the future, but we are going to wrap up this particular part of the series this week. I'm Avril Benoît, I'm the executive director of Doctors Without Borders in the US. You might know of us from our international name Médecins Sans Frontières, which is French, and that's why we often refer to MSF as the acronym that we use all over the world, but Doctors Without Borders is here to talk with you today for about 45 minutes. We're going to be giving you, as always, an opportunity to submit questions.

So if you're watching on Zoom, just use the Q and A function. You know how to do it, I hope by now. On Facebook Live or on YouTube or Twitch, likewise, send your questions into the comments or chat section that you have there, and they will be fed into me and I'll ask them of our panelists today. So today we're talking about a very hot topic. It's not the first time we've reviewed some of this, but it's changing so fast that our theme today is particularly timely. And we're talking about the COVID-19 vaccine. So I'm sure many of you have been following the news with a lot of anticipation. Various announcements have been made recently.

There's a lot of hope that the vaccine will be some kind of panacea and all this misery of the pandemic will end once we all get a shot in the arm, but it's a lot more complicated than that. And we're here to delve into some of the quality issues, the research issues, the development issues, the rollout questions and with the pharmaceutical companies, we have been often pressuring them to be much more transparent and accountable for that. So we're going to explain a little bit why we take some of the positions we do when it comes to the research and development around the COVID-19 vaccine.

So today I'm joined by a couple of experts that are really perfect for this topic today, and they're here to answer your questions. So I'll introduce them now. First, Dana Gill is back. She serves as the US policy advisor on access to medicines for MSF or Doctors Without Borders USA and the Access Campaign. Hello, Dana, tell us where you are and how are you fairing these days?

Dana Gill:

Greeting for all, thanks so much. I am joining you today from Michigan, and as I look out the window, I have to apologize to everyone in advance, the universal law of all of your neighbors mowing their lawn when you're about to get on a webinar has just occurred. So hopefully you won't hear too much of that in the background, but I'm so glad to be with you and excited to speak with everyone today.

Avril Benoît:

If they have the leaf blowers going as well, it'll be the end of us, but we'll live with it. We've dealt with other issues when it comes to sound. But good to have you back with us, Dana. And Dr. Manuel Martin is with us today. He's a medical doctor working as the medical innovation and access policy advisor for the MSF Access Campaign. Hello, Manuel, how are you doing today?

Dr. Manuel Martin:

Hi, everyone, I'm doing well. Thank you. Hi everyone. I'm joining you today from Lisbon, and my apartment is right next to a traditional Portuguese restaurant that does folk music called Fado, very melancholic. So if you hear some music coming from my side, that would be why.

Avril Benoît:

Well, Fado, those Portuguese blues are very much appropriate probably these days in terms of how the numbers of people with COVID-19, people hospitalized, people dying continues to rise. It's on an uptick in many parts of the world. And that's a misery, a sorrow, a loneliness and grief that we all feel after so many months. So the vaccine is this beacon of hope, how we hope to get out of it. And maybe I can start with you, Manuel. As we look at all the avalanche of news, the announcements, how should we make sense of it? What is it that we should be looking for in those announcements from big pharma?

Dr. Manuel Martin:

That's a great question. And I think just to say that even for us following this issue so closely, it's sometimes difficult to just keep up with the news. It feels like we spend 80% of our time just staying up to date. I think that in terms of wondering about access, there's really three different areas that one can analyze when hearing about these new vaccines. First of all is the affordability of the vaccine, so what prices are they likely going to be sold at? The second one is the availability, and that speaks a little bit to the scale of manufacturing for each different vaccine candidate and who will be able to manufacture it at what stage. And then certainly, and this is very important also, the suitability of this candidate. Not all candidates are equally suitable, are equally effective, some of them need to be stored at extraordinary low temperatures, which create some logistical challenges even in high-income countries. And really that is the framework that I tend to analyze things when I get a new piece of news about a new vaccine coming up.

Avril Benoît:

Dana, you are very focused on the policy side of things. What specifically is interesting you with all this news around a vaccine and the different trials that are going on and maybe coming to a conclusion?

Dana Gill:

Yeah. Avril, one of the things that I'm thinking about a lot, and we as the Access Campaign are thinking about a lot is what this means in the larger systems, not only with the vaccine, but also with treatments and diagnostic tools and how the issues that we're seeing about exactly what Manuel just shared, will a product exist, when will it exist, who is going to have access and how much will it cost are issues that we have been watching for decades and that the Access Campaign has been working on for decades. So I find myself saying a lot, COVID is new, but these issues are not new. So we want to look at this moment of time and see if there are ways that we can make reforms so that when the next pandemic comes along, or when we are looking at the research and development system for all of the diseases that are yet to be treated, that we can have some reforms in the system to solve the problems that we're seeing today.

Avril Benoît:

Well, for all those who are rolling up their sleeves to take part in the trials right now, this is a time where there's so much appreciation for people who have participated in this. Obviously the scientists are doing the work, but also regular people have done so. We have a question already from Bruce who's watching us on Zoom and who was a participant in the Johnson & Johnson trials for their COVID vaccine. What are the various types of vaccines in development right now, Manuel? And are you looking at any of them with a little more enthusiasm than others?

Dr. Manuel Martin:

It's difficult to say, it's still early days. First of all, Bruce, thank you for participating. I think your contribution is really important to the research and development process and should be valued the same way that we value other contributions to research and development. But I will say that there's definitely some platforms that is, platforms are the basis on which vaccines are developed. These can be viruses or these can be particular technologies. Some of them are brand new. So you might've heard of the messenger RNA vaccines. These are as of yet unproven, there is no vaccine on the market currently using that technologies and other vaccines that are in development are using more old school, let's say, technologies that have been around for quite a long time period. And they all have their benefits, but also risks. A lot of it is still hypothetical, we just don't know yet. A lot of it is just speculation at this stage.

Avril Benoît:

It's speculation because we don't know enough about the number of people who are part of the trial or the composition of the people who have taken part or what are some of the aspects that can lead to the variability of one's confidence in this vaccine over another vaccine?

Dr. Manuel Martin:

So just because some of the vaccine platforms we are familiar with, there were some theoretical risks, especially at the beginning, people were very concerned about that potentially a vaccine might actually potentiate the effects of the virus. So far that has not turned out to be true, but that was something that people were worried about from the very beginning. Now a concern, just to highlight the Johnson & Johnson vaccine is based on something called the adenovirus. There's this concern that a pre-existing immunity against the virus that is used to deliver the vaccine may actually reduce the efficacy of the vaccine.

And if you're using a vaccine that requires several doses, that may be one dose might induce the immunity, which will reduce the efficacy of the second dose. So these are just some of the concerns that are out there, but it's worth keeping in mind that this is still we're moving very, very fast, and a lot of the data's still to come out and that really speaks to the need for transparency once the data is available, that companies are really expedient and publishing this data openly and transparently. What we've been seeing so far is a lot of science by press release, and unfortunately that makes it very difficult for experts to analyze and truly independently assess the promise and the efficacy of vaccines.

Avril Benoît:

This is one of the tricky issues in many parts of the world where you have skepticism around the efficacy of vaccines and whether they cause harm and we have anti-vax movements and so forth, that can be quite noisy and active at this time. Dana, can I just hear from you a little bit about that phenomenon, because obviously science by press release is not ideal. What is it that you would hope to see in order to give us confidence that whatever vaccine is being proposed for us in whatever country or jurisdiction we live in will be one of the good ones.

Dana Gill:

Yeah. And I hope you'll allow me to expand on that a little bit, Avril, because Manuel said a key word for us that we're speaking about a lot, not only as MSF, but the access to medicines movement in general, and that word is transparency. We need to be able to have independent analysis of the clinical data designs and results that are coming out in real time so that there can be independent experts looking at whether or not everyone feels comfortable with the products that are being rolled out. And we saw an announcement from New York's governor, Cuomo, that he wanted to do just that, before a state rollout of the vaccine, having an independent group of experts and scientists. So there's that research and development data transparency that will be an important piece for vaccine hesitancy and also plays into a larger transparency ask that the MSF Access Campaign has been engaged in along with other groups.

And we have originally called these the four pillars of transparency, and now it's turned into like five and maybe six pillars at this point, as we realize more and more as everything's moving so quickly, how little data we have, how big the information asymmetry is between what governments and pharmaceutical companies know and what we as public know. So some of those other areas are around prices. What at the end of the day is going to be the prices charged for these products, not just vaccines, but treatments and tests. Some of it's available, but not always. We're also talking about really digging in on the costs of research and development. If we step and look at the United States right now, tens of billions of dollars of public taxpayer money are going to the research and development and purchase of products.

And this is important work. This is important for the US and other governments to be doing, but we don't have a breakdown. We don't have a systematic breakdown of how all of those dollars are being used. And so this goes to that bigger picture, systemic question that I brought up earlier, we often hear pharmaceutical companies say that they must charge a high price for their product because they spend so much on research and development. This is a key argument that we hear so often, and we can't say, well, we know what you've spent. So right now in this time of COVID when the pharmaceutical companies are not necessarily paying for their own research and development, public dollars are paying for that. There should be the accountability and transparency of what those research and development costs are so we can start a real conversation about what fair pricing means.

So that's another pillar. We also need to know what sort of patents, what sort of IP protections, what sort of trade secrets do any of these products have, because that ends up having an impact on how quickly we can scale up manufacturing and production of products, which means more people having access if we can have a bigger set of manufacturing and production facilities, and finally understanding what those manufacturing and production costs are. Again, back to that argument of what's a fair price for these products at the end of the day? I think civil society often gets a reputation that we're anti pharmaceuticals or anti profit, and that's not the case, but we do want to have a real conversation about what a fair price is. And when we don't know how much it costs to research, develop and manufacture a product, we can't have that conversation. So this is a moment to really have those areas of transparency, to help with vaccine hesitancy, to help with fair pricing of these products down the line, and really have some systemic changes in the R&D system.

Avril Benoît:

These are the issues that are related to profiteering which is having a profit above and beyond what is reasonable. And in a pandemic, as you say, when there's public funding, tax dollars that have gone into the development and rollout of all of this, it should actually come back to countries and all those that have contributed as lower prices, more access, hopefully free to those who need it. But for those who have more questions about those issues of pricing, Dana Gill just again, is our US policy advisor for Access to Medicines at Doctors Without Borders, USA and the Access Campaign. And also with us is Dr. Manuel Martin, who is a medical doctor currently working as the medical and innovation and access policy advisor for the Access Campaign. Manuel, I have a couple of questions for you about something that's very much been reported on, and this is the whole question of the cold chain.

So Martina on Zoom is asking regarding the need to keep these vaccines at a low temperature, what potential logistics plan could be implemented to reach those remote communities with the vaccine, maintaining its quality, maintaining it in a good state? And likewise, Ben is asking, does MSF have the experience in putting together robust, cold chain plans of this nature where I think we were talking about minus 70 degrees Celsius or something like this. I mean, it's just extraordinary. And what does MSF, or what have we learned from past experiences of managing this kind of vaccine?

Dr. Manuel Martin:

That's a great question. I think when speaking about the culture and I should really flag that I'm no logistics expert, but there's two different types of cold chain. There's the regular cold chain that usually vaccines need to be transported in a refrigerated state somewhere between two and eight degrees. But then there's also the so-called ultra cold chain. And these really are some of the vaccines that are based on this novel technology, MRNA, that need to be stored anywhere between minus 20 to minus 70 degrees Celsius. So that is really much, much lower and requires entirely different infrastructure to deliver these. As MSF, obviously we have quite a lot of experience, we regularly run vaccination campaigns with normal refrigeration of vaccines, a little bit more tricky, but I should say not impossible is the ultra cold chain.

An example of a vaccine that had to be transported at very low temperatures as well was the Ebola vaccine and which we were able to deliver in the most recent outbreak in the DRC. It did require significantly more resources. It was more complicated and wasn't easy, but we did do it. And I think the important takeaway here is that regardless of how cold the vaccine, potential future COVID vaccine needs to be transported, that shouldn't preclude access in low and middle income countries. We shouldn't be saying, oh, just because this vaccine needs to be transported at minus 70 degrees, that means that it won't be any use in all of these poor countries anyway, that is simply not true. It is possible. It just requires additional effort, additional resourcing, finances and logistics.

Avril Benoît:

And it's called a chain because you can't break the temperature. If the temperature suddenly goes up as in a hot environment, a country like India, for example, or in many of the hotter countries at this time of year, it's getting colder in the North, but sometimes warming up elsewhere in the planet, you have a problem where the vaccine can no longer be effective. It just doesn't work anymore. So you use it all you want, but it won't actually protect people.

Dr. Manuel Martin:

That's correct. Yeah.

Avril Benoît:

Another question that I know has been hotly discussed in the news in terms of looking and comparing the different products that are out there or likely to come out has to do with whether you need one dose or two. Can you explain why you sometimes need two doses or boosters and things like that, and why what you're really aiming for is just one dose?

Dr. Manuel Martin:

So that is the case for a lot of vaccines, they don't provide indefinite immunity. Sometimes you can amp up your body's immune response by using a second dose, some vaccines even space the doses apart, several years. The issue of one versus two dose, I think it is pretty clear that the one dose will always be preferable. It's much easier to manage, and you can vaccinate more people with the same amount, physical amount of vaccine. With respect to the timing, for us obviously it is preferable to have those two doses as close together as possible, and not all vaccines that are currently in development have that required two doses have them spaced apart in the same way.

So you'll have some that are 28 days, roughly apart from first to second dose and others that are almost two months apart. And especially when dealing with migrant communities in terms of displaced people, having people in one place for two months is not always guaranteed, and that makes vaccination and then giving the two doses much more tricky. So even if you have a two dose vaccine, the question is how close together are these two doses, and can they be given within just a month, 20 days, or does it require much longer than that?

Avril Benoît:

Another quick question for you is on Zoom. Can you tell us about COVAX? What happens if multiple vaccines in the COVAX portfolio move forward for a disbursement? And maybe you can explain also this COVAX, because we do hear about it, but many of us don't quite understand what it implies.

Dr. Manuel Martin:

Absolutely. I think it is worth explaining because during this pandemic we've had so many new acronyms to learn that I understand why people have a hard time keeping track. So the COVAX facility was set up very much based on the Gavi Alliance for vaccines and immunizations previous advanced market commitments. And that is essentially simply put what it is. It is a bunch of countries coming together, putting money on the table and in a certain kind of way, pre-purchasing vaccines. And thereby also doing some at risk investment, into manufacturing scale-up and research and development for these vaccine candidates, with the understanding that should one of these vaccine candidates be effective, these vaccines will then be distributed amongst the participating countries.

There's a donor element where there's a certain number of countries that are benefiting from foreign development funds, for instance, to obtain these vaccines at a lower price and they don't have to pay as much for them. But high-income countries can also participate and choose whether or not they want anywhere between 10% or 50% of their population to be vaccinated. And the idea behind it is, is to prevent what we saw around the H1N1 pandemic in 2009, which was that all high-income countries hoarded all of the vaccine supplies and less than 10% ended up going to low and middle-income countries. That is fundamentally the idea of it. But if I may expand on that just a little bit, what COVAX really just deals with is from the existing vaccines that are being produced, how are they being distributed.

Using the analogy of a pie, how large of a slice do you equitably distribute across the world or across these countries. But what COVAX doesn't deal with, and that is really unfortunate that they don't, is this idea of expanding, making the pie bigger or indeed producing more pies. And what do you need to do to produce more pies in this analogy? You need to share the recipe. And in the vaccine space, the recipe consists of two things. One is the legal rights to be able to produce the vaccines, and these are the patents and intellectual property that cover them, and also the recipe, instructions that is the technical term for that is the know-how to produce these vaccines. And this typically is transferred. You can transfer this, so a developer that has been working on a vaccine and it shows to be effective, can transfer the know-how and the rights in a process called technology transfer to another company.

And ideally, if you have an effective vaccine, you will have a company share the knowledge and also the rights to produce this vaccine as widely as possibly, and as openly as possibly. Unfortunately, that is not what we're seeing at the moment. We're seeing certain vaccine companies not sharing anything. We're seeing some companies, very selectively signing technology transfer agreements and transferring this technology to certain manufacturers under very strict conditions that they, for instance, don't export out of a pre-agreed territory or that they sell it at a particular price. And that is really not ideally how you'd want to do things. In an ideal world, you'd have them share that openly, especially as, and Dana already pointed this out, we've seen an enormous amount of the research and development costs, as well as the manufacturing costs really being financed through the public funds.

This is all of our taxpayers money that is paying for this and as it should, but it also should mean that we should be using all of the capacity that exists in the world to produce this vaccine. And really that would also go quite a length to combat what we've seen and we're calling a vaccine nationalism because if you have many manufacturers across the world producing the vaccine at the same time, there's very little incentive for any one country to try and restrict the supply just within its borders and issue things like export bans on the vaccine.

Avril Benoît:

It's just so fraught, isn't it? With these dilemmas for those who would hope for fairness and ethics to drive the response to the vaccine in support of the science, which should be also driving the end of the pandemic as opposed to politics or economics. But sometimes it's just so depressing to hear these kinds of things. Dana, I have one for you from Chidinma on Facebook who's asking how possible is the data transparency for low income or developing countries that have issues with data collection? Because you were speaking to the US but how do you see it for countries that have fewer means than the US?

Dana Gill:

Yeah, I think this is a problem that we see everywhere and it's where, if we can't see these types of things happening in a country like the US, where we have websites like clinicaltrials.gov and we have well-researched, well-funded research happening all the time and kind of a well-oiled machine here, of course there are going to be issues elsewhere. And it's an important moment for the US set up a system that could lead by example and share information. We work with a colleague, Manuel and I have a colleague in South Africa that is working on exactly this issue, clinical trial data transparency. And so there are movements with civil society around the world. This isn't just MSF talking about this, this is an urgent need everywhere. And so do know that we are working with colleagues in other countries and other contexts and civil society really has taken this up in a more aggressive way, particularly during this pandemic.

Dr. Manuel Martin:

And if I may just add-

Avril Benoît:

Yeah, please go ahead. Yeah.

Dr. Manuel Martin:

Thanks. Just adding to what Dana said, I think it's important not to think that the only place you can conduct clinical trials is in high-income countries. There's plenty of middle income countries that have very extensive research networks and clinical trial sites with a lot of expertise of running clinical trials. South Africa is a great example of that. And actually there are a number of vaccine candidates currently running clinical trials in South Africa. What will be important to us is that the very communities in which these vaccines are being tested are also guaranteed access to these vaccines. Because one thing that is unacceptable is to test these vaccines in a particular population and then leave them without timely access or affordable access to those same vaccines.

Avril Benoît:

Let's stay with this policy side of things. We have a question from Daphne on Zoom who's asking, even if we had transparency, as you've talked about on the research and development and production costs, could the government actually force these big pharmaceutical companies to charge a fair price for such a valuable product? I mean, wouldn't it go against the grain of how many countries like to manage their economies? Daphne's mentioning a concept like rent control, but for a medical product like these COVID vaccines, what do you think? I don't know, Dana, do you think it will fly?

Dana Gill:

I have a little smile on my face, right? I mean, everything is a choice. Everything is a choice about lives over profit, setting up a system that is more concerned with public health and public interest than commercial interests. So in our market, a lot of the failure of the R&D system is that it is so pointed towards more lucrative products and we've set up a system that kind of feeds into itself. And so governments can take steps for price controls. We do see that happen in other places in the world, but these are choices. And I want to go back to something Manuel said a little bit earlier. Just as I was thinking about preparing for this conversation, a word he said kept coming back to me, which is sharing right? This idea of simply sharing.

If we could share our know-how and our patents, if countries would be willing to share doses, if high-income countries would be willing to share more resources to fund COVAX in a way that made sure everyone had equitable access, some of these pricing issues wouldn't be so much of an issue. So it does go against the grain of some countries' market driven processes, but these are choices and we can make different choices. And we advocate for different choices to be made. We're talking with pharmaceutical companies and the US government agencies that are working on all of this, we're really bringing up all of these pieces. How are you thinking about set asides for humanitarian settings in low and middle income countries? How are you going to share all of the data and know how that we've had? We're asking these questions to try to help officials make different choices, to make things better in the places that we work and the people we care for.

Avril Benoît:

Well let's-

Dr. Manuel Martin:

Sorry.

Avril Benoît:

Oh yeah. I just want to pivot a little bit if you don't mind, Manuel, because there's... and this is also coming back to you, it seemed to be the sharing was off to a good start when the genetic sequence was initially shared. Am I right? I mean, it seemed like, hey everybody, here's what it is. Go off in your own corners around the planet and do the work to find a solution to this, whether it's treatment or vaccine. Am I wrong to have attributed so much hope to that particular moment in time, Manuel?

Dr. Manuel Martin:

Well, I think one could have imagined a very different timeline where after a very open sharing of the initial vaccine, not vaccine, sorry, but the viral genome of COVID-19, a way of openly sharing what you find could have continued. The vaccine developers could have figured out different protein structures that address particular parts of the virus as they have gone and done, but then share that amongst one another and discuss which one is the most promising, which ones should be pursued, which ones are less likely to succeed, and continuously sharing their results. Very likely, especially if that is the case for developers working on the same platform technology. A lot of the same mistakes have been made in many different places, And really one only had to make that mistake once, and then everyone could have learned from it. It would have been a far more efficient way of doing things. unfortunately, that is not yet the world we live in.

But I think it's important to keep in mind this blue sky idea of how we could do research and development in a very time pressured way in order to address a pandemic for the next time it comes around in order to maybe set up the kinds of systems that we do need to ensure that a more open approach is taken. And a big part of that, one question that keeps coming up is like, well, if companies share everything that they do, they can't make a lot of money and it then becomes very difficult for them to have the money to continue to invest in research and development. But what we've really seen now is most of the research and development has been funded by the public, or is heavily supported by the public.

And certainly then at the end, there's a guarantee that countries will be buying these vaccines. We've been seeing a lot of bilateral deals between countries and companies. So the risks that typically are associated with drug development are not so much present here. There's much more willingness and certainly much more money on the public side that has been put into this research and development, and that could mean a much more open approach.

Avril Benoît:

So while we might be displaying some old bad habits in our approach to this, still, it's gone really quickly. I mean, this is much quicker than what was expected by reasonable people who had just looked at the history of vaccine development and how long it takes to really go toward a proper approval. I mean, it is pretty amazing. And now already people are starting to worry about mutations. So we have a question here about that from Amira on Zoom. This question of the concerns of mutations may make the vaccines that are currently under development already, not work. Can you comment on this question of mutations, Manuel?

Dr. Manuel Martin:

I can give it a go. Again, I'll flag that I'm not a virologist, I'm not a microbiologist or a vaccinologist, so this is not my area of expertise. Certainly this is a concern that I've seen coming up again and again, I have not seen any consensus amongst the experts on this. However, whenever this concern has come up very quickly, then there was a kind of counter argument that this actually wasn't such a big concern because the mutations were only changing parts of the virus that the vaccines aren't particularly targeting. One big area where this has come up is now with this new mink strain to Denmark. But again, I think that is up to debate and I'll leave it to the experts to rule on that, but I have not seen so far really serious concerns about.

Avril Benoît:

Here's one from Heena on Zoom who's joining us from Canada. We're already seeing anti-mask rallies in Canada, but also around the world. Certainly it was a huge factor in the presidential campaign as it was coming up in the US, and this is a concern that some people might not want to accept the vaccine, which I alluded to earlier. What recommendations do you have for healthcare providers or whoever it is, officials who are going to be the ones responsible for rolling out the mass vaccinations? How can they increase public acceptance of a COVID vaccine once one is approved for wherever they are? Any ideas on this?

Dr. Manuel Martin:

I think that is a good one and is very dependent on the local population communities and the specific concerns that people have. I think it also depends on the vaccine candidates. I think for some, there may be slightly more legitimate concerns than for others. Overall though, we have seen that there have not been any significant shortcuts made to the research and development process as it normally exists. So we still have had phase one studies, phase two studies, phase three studies conducted, which are meant to catch the really serious side effects. And at least some of the less serious and common ones, it may still be that we have some vaccine entering the market that has a very, very rare side effect that pops up once every 200,000 people who get it. But again, just because we'll be vaccinating so many people hopefully, that will be picked up and certainly regulators across the world continue to monitor the vaccines as they come up.

Dana Gill:

Yeah. And Avril, I'll add to that in terms of making sure that there's a disclosure of the clinical trial designs and data. We have seen a couple of the companies step back and say we need to make sure we are looking at representative communities better and making sure we have participation from representative communities in a more equitable way. And so those are good, important steps in making sure that it is an equitable allocation process that is really taking into account the communities that are most effected. So those are good steps that we have seen and we hope continue to make progress. And Avril, if you don't mind, I'd like to go back to, I think, a couple questions back when we were talking about open science too. If you're on our mailing lists or if you've followed the Access Campaign for any length of time, you've heard us talk about no patents in a pandemic.

And that's one of the things that we're talking about a lot in terms of making sure there is more rapid availability of the information. And we're also engaging in activism around some world trade organization processes that are happening right now, where India and South Africa are pushing to make sure that there aren't patents that are keeping this information held by just companies that would stop the scale up of manufacturing and production. So we're really working on that open science and open information question a lot, and you'll hear more from the Access Campaign on these campaigns.

Avril Benoît:

Let's finish up with a couple of questions because we're almost out of time, but we've had some questions about the cost of it, because in some countries, obviously the public health system, ministry of health, whatever is going to support it in a Medicare for all or socialized medicine system that you have in many countries. But in other places it's unlikely to cover everyone, particularly those who don't have private insurance. Well, Mobashir on Zoom is asking even if the vaccine is available in the market, will it be affordable? And he's talking at the individual level. And Richard on Zoom is asking, what can be done to produce more affordable versions of a vaccine from generic companies, for example? Dana, maybe you could start with that.

Dana Gill:

Yeah. Yeah. And generic vaccines is a little bit more of a technical aspect where it's not quite the same apples to oranges as generics for other medicines and treatments. But what we've been talking about in terms of sharing the recipe as it were, that's the way we're going to be able to scale up this manufacturing and make sure that there are more doses available at an affordable price more quickly all over the world. What we're seeing at the outset is that there are many commitments from government saying that this will be available free and, or very low cost. So we are seeing that commitment in a lot of places. And that's a good first step, right? That's the critical first step. What we're worried about in this bigger system, when we kind of look again at the systemic issues that need to be addressed is what happens after this is a pandemic?

When this is maybe just endemic or in many years in the future if this is more of a disease that's in our daily lives, like the seasonal flu down the line? If companies own and control these recipes that allow them to charge whatever the market will bear, that's when we're really going to have to worry about the price. It seems like there's a lot of commitment right now, but what are we going to be able to do to reform the system in this moment so that in the future we won't be faced with these types of questions that keep so many people from affording the lifesaving medicines they need?

Avril Benoît:

All right. You've talked about a lot of issues. Both of you have touched on policy issues where you're both activists. I mean, you work for our Access Campaign efforts at Doctors Without Borders at MSF. For those who are watching then, what can they do to support these objectives that you've outlined? Maybe I can start with you, Manuel.

Dr. Manuel Martin:

Sure. I think one of the things that you can do is to really engage politically on this question. It is also your tax money that is being funneled into the research and development. You will also in some way, be affected by this. This really affects everyone. And solidarity really is the only way out of this pandemic. And I think on one hand, calling on your own governments to do the right thing and share vaccines in an equitable fair way across the world is incredibly important.

But then secondly, also for governments to be transparent about the kinds of deals that they've been signing, both in terms of the doses that they've been procuring, but also the kinds of deals that they've been signing when it comes to the funding of the research and development, we have yet to see these deals really being published in a truly transparent way. And this is something that would go, I think, quite a great length to reduce the prices and also increase the affordability of the vaccines because it creates a level playing field and reduces that information asymmetry that currently exists. You get to Dana.

Dana Gill:

Yeah. And just adding on to that piece of connecting with your representatives and sharing, you'll hear from the access campaign about things we care about and see as issues that need to be addressed, barriers that need to be removed to ensure affordable and equitable access. So I mentioned one of them earlier, which is the no patents in a pandemic campaign. And then to add on to something I talked about early on, public funding of research and development. There needs to be strings attached. There needs to be conditions, we believe, that comes along with this investment. And if you choose to accept it, it's like a social contract, right? You should be required to be transparent about all of the transparency items we've talked about, to have a fair price. All of these different conditions that we call for are things that could be brought up and watched and monitored by you, and to share your voice about in the public interest and for all of the people we care for.

Avril Benoît:

Keep fighting the good fight, you two. And thank you very much for joining us today. It's been great to have such expertise on the panel. Thanks a lot to Dana Gill, US policy advisor on Access to Medicines for MSF or Doctors Without Borders, USA and the Access Campaign and Dr. Manuel Martin, a medical innovation and access policy advisor for the MSF Access Campaign. Thanks a lot and stay healthy. And we really wish you well in your work and lots of success, and we'll be supporting you all the way, and I know those who are watching will too. So thanks. That's it for our webcast today. Thanks for asking all those great questions. I'm sorry if we didn't get to all of them, but we'll try to follow up by email. We will be continuously trying to find ways to share our perspectives with you.

So while we're wrapping up this series just for the fall, don't worry, we'll be back with lots of other topics. And I just want to remind you that you can always reach the team that puts these together. If you have any follow-up questions or you have suggestions of topics that are of interest to you, we're all ears. So we have an email address you can write to, which is [email protected]. And for more information about all the issues that you heard about today, just go to our website doctorswithoutborders.org. And we also have our international website, msf.org. You can find us on Twitter, on Instagram, on Facebook, of course. And remember, wear your mask, wash your hands, keep a physical distance, and let's just hope that we can get through this together. I'm Avril Benoît, signing out for now. Have a good day. Bye.

Avril Benoît:

Here we go. Now I'm unmuted, that'll work. You'd think by now I would know how to do this properly. Welcome. Thanks for joining us. I'm Avril Benoît, the Executive Director of Doctors Without Borders in the United States, that's Médecins Sans Frontières, or as we're known internationally, especially on the ground in humanitarian crisis zones, MSF. So when you hear MSF, that means Doctors Without Borders, and of course, Médecins Sans Frontières.

So this is a series we've been doing since the beginning of the pandemic, bringing you into our work in different parts of the world to give you a sense of how the pandemic is affecting what we do. And today, it's a little bit different, because we're going to pay attention to a part of the world that is experiencing a really devastating humanitarian crisis. And while we're all focused on the pandemic, and of course, even there as well, we sometimes forget that there are ongoing and exacerbating crises in the world, and this is certainly one of them.

As usual, this is a discussion that will go approximately 45 minutes and you have an opportunity to ask your questions. If you're watching on Zoom, you can send your questions in to the Q&A option. On Facebook Live or Twitch, send the questions in to the comments or the chat section. They will be fed to me, and then I will ask our guests to see what they have to say based on your questions.

Now today, we're talking, as I mentioned, about an under-reported emergency, Burkina Faso. Over the last couple of years, up to one million people and possibly more have been forced to flee their homes due to a rise of conflict of violence in different parts of the country, especially in the north. The Sahel region of Sub-Saharan Africa, is always close to my heart, since I spent nine months, better part of 2015, working in a region that was receiving refugees from the Timbuktu region of Mali. And over on the other side of Mali, we have Burkina Faso, which at that time was much more stable and now is the place where there is so much displacement.

So today, I'm joined by two of our colleagues who are joining us from Ouagadougou, and we're very glad that we got the lines going today. It was a little bit iffy just before we went live. We have both of them to give us different perspectives on what is happening on the ground, what the medical teams are seeing. Dr. Marc Couldiaty, is our Medical Coordinator for MSF in Burkina Faso, and Tommaso Santo, is the Head of Mission for MSF in the country as well. Welcome too both of you, really glad to have you. You're both on mute. I see we're getting off mute all together. Thanks so much for being with us. There we go. Dr. Marc, tell me about your work. What is it that you do in Burkina Faso, which is your home country?

Dr. Marc Ounténi Couldiaty:

Absolutely. My work is to evaluate the needs on humanitarian. Certainly, as you explained that we do have a lot of peoples, more than one million, they leave their house... Now we do have also a health system, which is overwhelmed. So our main focus is to identify the gaps, what are the needs, and how to support and implement the activities to meet the requirements of the displaced population. That's what we are doing in overall countries and what will happen.

Avril Benoît:

All right. And Tommaso, tell us about your work.

Tommaso Santo:

Hi, I'm Tommaso as you said, I'm an Italian, Head of Mission here in Burkina Faso. And actually, I would like to say a word about the complexity and the nature of this conflict because it's quite new in the country, just a few years. And there are many actors involved in the conflicts, there are obviously, the army, the armed group, voluntary militia, international forces with also the participation of the Western country, and also there is an inter-ethnic conflict ongoing. So just to give you an idea of the different levels of the conflict and the complexity.

Avril Benoît:

It's a situation that obviously people in the region have seen grow and build and become more complex over the last couple of years. Maybe Tommaso you can describe why people are fleeing, what is causing so much displacement?

Tommaso Santo:

First of all, insecurity, because those actors that I mentioned before are quite active, especially in some part of the country, in the north, in the border with Niger and the boarder with Mali. So people are seeking for security and safety, and they're fleeing from the conflict. So some of the schools are closing down, most of the health structure are closed, WHO reported more than 300 health structure closed. So obviously, the population is seeking for security, and is going to the big city, where they find more security.

Avril Benoît:

And what kind of conflict are we talking about? Is it all at once, is it low grade constant? Is it small little flares in different regions? Maybe you can just help us to understand or visualize what it's like.

Tommaso Santo:

It's extremely difficult to understand also for me, that I dedicated my day to try to understand it. And between, obviously there is the state, they're fighting against the armed group, then there's the local militia civilians, with weapons, they are fighting against armed groups. Then among the armed groups, they're fighting each other because inside the government groups, there are two main function. One, it's somehow the Al-Qaida branch affiliated, and the other is the Islamic State affiliated group, so they're fighting each other. And then, there is this inter-ethnic conflict, mostly from one part of the population that traditionally was a cow breeders and nomads, and the other part of the population that was traditionally farmers and land owners. And so, as you can imagine, the population is trapped in the middle, and they're the real victim and target of all these actors fighting each other.

Avril Benoît:

Dr. Marc, you have worked in many other conflict zones yourself, with MSF, with Doctors Without Borders, and you're from Burkina Faso.

Dr. Marc Ounténi Couldiaty:

Right.

Avril Benoît:

Which is one of the 10 poorest countries in the world. Can you compare what this conflict zone? And what this conflict is? How it compares to the other places where you've worked?

Dr. Marc Ounténi Couldiaty:

Yeah. I can definitely say that here, it's more complicated, the needs are really huge compared to where I used to work, because from these places, the health systems before the conflict, were already strong, but unfortunately, in our context here in Burkina, even before the conflict, the health system was weak. So now, due to the conflict, we do have more complex crises in terms of... I mean, there are some problems. I mean, I can say, they really need support as MSF is doing to respond to the needs. Otherwise, things will be more worse than what we do. We do have now with the support of the MSF and then yesterday, MSF was with the Ministry of Health.

She really appreciated the help and the support done by our organization. And she asked also to continue and to increase our support in terms of primary health care and to reinforce also the competencies of the health workers, which is also weak in this kind of context. So definitely, compared to where I used to work, I can say that, we really addressed the need and the support is also appreciated by the government and the health authorities.

Avril Benoît:

We have a question for you, Marc from Monica, who is asking it on Facebook. Are you seeing much COVID-19 in Burkina Faso? And if so, what is MSF doing?

Dr. Marc Ounténi Couldiaty:

Yeah. At the beginning of the pandemic, there was an increase, as it was a new disease, no one was not really comfortable on how the spread can be. So MSF really gave a huge support, to take care of the patients. So I mean, in the big centers of the country, which are the referral centers, MSF really support also the Ministry of Health, in terms of medical equipment, in terms of reinforcement of the capacity of the health workers. And then, in terms of supply, in droughts also to respond. But with time, we saw that the trend was not going really up. So we strive to readapt our support, which is still there, but it's a bit light, in terms of monitoring the cases around the country, and how to respond and to support our partners.

Avril Benoît:

This is one of the things that really is striking about this pandemic, is where it has been very serious and where we have not seen such an influx of patients into the hospital with it. Why do you think Burkina Faso has not had a worse crisis of the pandemic of COVID-19?

Dr. Marc Ounténi Couldiaty:

Yeah, me I could say mainly, first of all, I think the people are young also compared to the western countries, that can be an explanation. I can say also that we do not have a lot of chronic diseases, so this also can explain. So some conditions we can be more worse if you get COVID-19, so in our population, we don't have really how proportions of population, which has this kind of disease. So I can say the main two things can explain a bit why we don't have... So I can say to many patients in hospitals, but in the other end, we don't also have a good numbers, because the testing centers are not also enough in overall country. So that's what I can say for COVID-19.

Avril Benoît:

Right. And Tommaso, as the Country Director, I suppose that this is mixed in adding to the complication of trying to respond to the displacement in Burkina Faso. Can you explain how it is that we managed to balance the two both, the fact that we were trying to be there for the medical needs of people who are displaced? And maybe you can describe the kinds of things that they need, and they've gone through? And then, how the pandemic has complicated things?

Tommaso Santo:

Well, I will start with your second question. Also, the added value for us for being here, is to stay close to the health system, because obviously, they have already a limited capacity. And if they dedicate the few resources that they have, for respond to the pandemic, other disease, really deadly disease, such as malaria, malnutrition, they'll be somehow neglected, and this is our fear. So this is why we stay close to the health structure, to the community, to the Ministry of Health, to support them to not just forget about malaria, and malnutrition and dengue, now, we are also at the peak of dengue. So obviously, they're deadly disease, even much worse than COVID.

So this is why we stay here to support them also for not just dropping down things. And regarding... and I also would like to add another thing, we have to understand that, as I said before, the conflict is quite new, so people, they didn't have time to develop what we call coping mechanisms. So the population is not that resilient as it happened in other country that unfortunately, are living in a conflict, like Central African Republic or Democratic Republic of Congo, South Sudan, where there is a conflict that somehow it's part of the day life. Here the conflict is quite new, it's just two years conflict. People, they're not used to, they develop mental health problems, post-traumatic stress syndrome for stress disorder, because they don't use, they were living in peace until a few years ago. And now, when you see the numbers of the internal displaced people, you can see that there's a sharp increase from 8000 people in January 2018, we reached now October 2020, 1.3 million, that it's more or less the 7% of the total population, just to give you some preview.

Avril Benoît:

You actually touched on something that Rick is asking, through Zoom, to speak a little bit more about the mental health needs of the displaced people in Burkina Faso. Dr. Marc, can you describe for us what sort of things that they are telling us they have been through, what they have experienced?

Dr. Marc Ounténi Couldiaty:

Yeah, for the mental health, is one of the weakness of the Minister of Health as we're seeing, I can say it's something which is not integrated in the system. So it's something which is innovative for MSF to bring it into the health system and to strengthen the system also. I mean, what we are providing, is the whole package of the mental health disease since the community side to improve the awareness of the mental health issues, because there is a lot of all sorts of stigma around, this kind of topic. So our team in the village, in the communities is trying to improve the awareness of this such kind of disease, to have also support from the community leaders. So in the health system, we are also doing trainings to the health workers for them to be able to provide counseling to such kind of patients and also to give drugs if there is a need.

So we are also planning to have a curriculum of training for the whole package of the mental health gaps, to be able to provide quality of care. If there is a need, we will provide also a specialized care like a secret care to these kind of patients. So we're really providing the whole package to this kind of patients. The need is really huge, in terms of drugs, in terms of trainings. And so, we are working on that right now.

Avril Benoît:

The people who are coming with mental health problems, who have been through so much, what have they told us about what they witnessed or experienced themselves?

Dr. Marc Ounténi Couldiaty:

So we have a lot of rapes, for example, which is traumatizing. Two weeks ago, for example, we had one which unfortunately, is now pregnant, due to the rape. So we have these kind of situations, and then we have also some patients when they get birth, it's not really working well, so they will be depressed. So this is kind of the most complicating cases due to the rape, or when they lost the baby in our facility. So all of those needs are addressed by MSF. And as I was saying, It's new for the country, even, in the curricula of the training of the health workers, this kind of specialties of topics are not really known, because there is more priority for the... I mean, the health authorities, as Tommaso was saying, like malaria. So these kind of things are not really known by the health system.

Avril Benoît:

A question for you Tommaso, from Kathy, who's asking it through Zoom. She's asking about a drought in Burkina Faso this year. And a related question, about climate change and how that may be exacerbating or making more complex, the insecurity in the country. Can you speak to that?

Tommaso Santo:

Yeah, this for sure is a worsening factor, because it's adding another level of complexity. So the drought and the flooding this year, we witness a phenomenon, that probably it's linked to bigger climate change phenomenon like El Niño, or others. So suddenly, all the region of Sahel was flooded, that happened from South Sudan to Burkina Faso. And a lot of people lost the few things they already had like the smaller shelters, the small houses made in plastic sheeting. So we had to provide an initial help to those people that were losing everything for security and for the flood. And then suddenly, now it's not raining already since a month. And I think it would be like this forth until next June. So definitely, climate change is worsening the climate crisis.

Avril Benoît:

Right. And the cascade, I suppose with the conflict, with the displacement. How is all of this affected food security?

Tommaso Santo:

Yeah, as I said, people doesn't have access to health care, but also doesn't have access to food. They're really dependent from the humanitarian aid. And these numbers of people dependent from humanitarian aid, including food, it's rapidly increasing every month. So that's obviously, we are really worried about. And on top of it, I insist, sorry, on the violence aspect, because I saw also another question after the one from Sandra, saying that the government say that now the situation is more secure and especially, in the north and central north region, and probably, they also want to pass this message because there is election now. The 22nd of November, the people from Burkina Faso will be voting and definitely the message from the government is a message that was, despite drought, despite the lack of food, despite the security, but what we are seeing in the field, it's really different. We don't see situation getting better. As Marc said, we see people raped, people killed, people abducted, looting.            

And just for telling a story, just yesterday, I was speaking with a good colleague of mine, a nurse, and I said, "Where are you from in Burkina Faso? Can you show me your village in the map?" And he pointed out a small village in the border with Mali, and I said, "Wow, and explain to me how you can go there to see your family because I would like to have the same access and to send my team there to check the humanitarian situation there." And he said to me, "Well, it's incredibly complicated, because I have to call my father first. He has to greenlight my visits. I will go there for lunch, and then I cannot sleep there in the house of my father and my mother, because as I'm a nurse, I'm under threat to be kidnapped, because I would be an asset in this conflict." And I was really sad knowing that imagine that this guy working with us, cannot even sleep at his father and mother home and has to come back because it would not be safe for him.

Avril Benoît:

That's something that we see in other conflict zones, isn't it? The targeting of especially, medical workers, people who can be useful in conflict situations, and it makes it that much more difficult. So there is this question from Borchueh Wu on Zoom about the election, and how it's affecting things. So you mentioned that the government is trying to send a message of reassurance. But you're seeing and hearing other things from the people. Dr. Marc, how are the elections likely to change things in the crises? I mean, not to comment, we're obviously not taking sides, we're neutral in this. But what do we expect of the movement of people and maybe flare ups of more violence during this election period?

Dr. Marc Ounténi Couldiaty:

Yeah, I can say also, during this election period, we do have an increase of violence. We already have where we are working, the more thefts are also due to the violence. So with the elections, we are waiting and plan to respond to more wounded and then some mass casualty also can happen in our health facilities. So we know that the context is not so really helpful, so we are planning in case, we will be able to react and respond at the good moment.

Avril Benoît:

Sam on Zoom is asking about the opening and closing of health facilities amidst all of this instability and crisis. How stable is the presence of health facilities of small clinics in villages and in towns, right now? Are they able to remain open?

Dr. Marc Ounténi Couldiaty:

No, for me, all of this is a bit due to the elections. So the authorities, they're trying to reopen, but health facility is not only to be open, so we have to think on the health workers, we have to think on the drugs to apply, we have to think on... I mean, there is a lot of things. So politically speaking, so they are saying, we are reopening, but they are not really functional. It's still weak, and then even some health workers, it's not safe for them to be in such areas. Definitely, I can say the situation is really going a bit worse, because we are in the field, we are in the village, we are really with the peoples, we are seeing that... I mean, there is no change, positive change, I can say for that question.

Avril Benoît:

Tommaso, you in your role as the Country Director, have a lot of interaction with other providers from the humanitarian community. Natalie on Zoom is asking about the presence of other organizations such as UNHCR. Who are the others that are working in also in response to the crises in Burkina Faso that we have some interaction with as MSF?

Tommaso Santo:

Well, definitely, we have interaction with all the actors. Definitely, we speak with them. When it's possible, we try to coordinate with them. So we don't try to duplicate services. But in general, there is still a need of scale for humanitarian assistance. The actor there now is not enough. The act of respond, that is ongoing, and one important things, in my opinion, is that these humanitarian assistance has to be impartial and independent, and not to link with the security and stability agendas. Because then, when we start to link the stability and security agenda with the humanitarian response, we lose neutrality, and somehow we're part, we're becoming another actor of the complexity of the conflict.

Avril Benoît:

Caroline is asking about where the conflict really is spreading, where it's located. I know, Tommaso you have a map ready to put up on your screen, if you maybe could explain to us and describe the zones that are hot, that are cooling down, that are heating up and what concerns us. If you can go ahead.

Tommaso Santo:

I can open Google Maps. Wait a sec, can you see Google Maps?

Avril Benoît:

Yes.

Tommaso Santo:

So we have... as you see Burkina Faso, there's a lot country doesn't have access to see. Now we're speaking from here, from Niger, the Ouagadougou is the capital. And MSF is mostly working in the border with Mali, so in the north west of the country, in the north. So we are working in the north of the country as well, in the triple frontier, what we call the triple border between Niger, Mali, and Burkina Faso, is a really complex area, because the armed group are really active there. And also, we are working in the east region, so all the border with Niger and the boarder with Benin. So our response consent, it's focused on north, north west and north east.

Avril Benoît:

And so, those are places where we are able to work and where we have a presence, where is the center of the conflict?

Tommaso Santo:

Well, there is not a center of this conflict. There is not, because the technique of this conflict are typical, what we call a hit and run for the armed group on the main roads. They're the international coalition and the states are doing strike with airplanes. So there is not a line of conflict, how it was Aleppo for the Syrian conflict a few months ago. There is not a specific geographic area of the conflict, it's all spread in this area that is called the triple frontier, the triple border.

Avril Benoît:

Carol on Zoom is asking that given that this current conflict really, which has been building up for the last couple of years, but has become even more of a crisis in the past 12 months, since it's a relatively recent development. Is there any hope of returning to peace soon?

Tommaso Santo:

Well, this is our hope. And I guess it's the hope of the people here from Burkina Faso. But unfortunately, as Marc said, not in the short term, we will see what happen with the election period, we will see what happen after the election. But the signal we see in the field, they're going through a worsening of situation.

Avril Benoît:

I have a comment to pass along for you, Dr. Marc, from a former colleague of yours who is tuning in on YouTube, Ghada is writing, "I worked in Burkina Faso in 2011, 2012 with Dr. Marc in Titao and it's so hard to imagine this country becoming a conflict zone."

Dr. Marc Ounténi Couldiaty:

Yeah.

Avril Benoît:

Now tell us about the other places you have worked and your decision to come back home.

Dr. Marc Ounténi Couldiaty:

Yeah. Now, I am just coming back from the Philippines. So in the Philippines, so we do have also a project there in Marawi City, due to the conflict also in 2017. So the situation is a bit different because Philippines has, for example, a strong health system. So you can find good nurses, good doctors, you can find also good hospitals around, good supply in terms of droughts, in terms of medical equipment. But here, we did not have this kind of, I mean, level. So due to this conflict, I can say that, the needs are really different and more needs here than in the Philippines, from my point of view. I also know that there is still need there, but as I can do also useful with my experience to my country. So that's why it was a pleasure for me to come back because I was graduated in 2009, and I joined MSF three days after in that I started in Titao. So I really worked and I like this work with MSF. Because as Heather was saying, if you see the situation, which was in 2019, in Titao, and today it's really sad and painful for us to see this kind of situation. So this is a bit what I can say on my prospects to work in my own country.

Avril Benoît:

We have a few questions from people such as Natalie on Zoom asking, "What can we do to help meet the needs of MSF and MSF patients, our patients and all the patients that we work with of course, the government health facilities?" How can people who are watching support efforts to raise awareness of this crisis? So it's not forgotten and that more help comes.

Dr. Marc Ounténi Couldiaty:

Yes. So I think that this kind of webinar is really helpful, so to raise the awareness of the current situation. So from my side, I think our communication team are also really working to raise the awareness. Because we cannot really have the real situation happening in the field, if it's not the humanitarian actors as MSF, which are close to the peoples, who live with the peoples every day, we knows their real needs. So it's really our organization, who have to raise the real information around this crisis, which is not known around the world.

Avril Benoît:

Tommaso, when you interact, as you often do in your role with the local authorities, national authorities, also with international aid organizations, such as ours, is there is there optimism? What are you hearing about the future in terms of that analysis?

Tommaso Santo:

Well, the hope is the last to die. We have for sure optimist, it's a sort of mantra and energy that make us work better, and we're try to do our best every day. And we will never lose the hope and the optimist every day. But it's a really difficult situation and for us, as I said also, or as I think also other question asked, one of the most important things is to ensure access to health care, and to ensure this kind of neutrality and impartiality of the health structure that we support because it's the only way that we can provide safety also. And not only health care, we can also provide a safe space to these people they're fleeing from violence and from the war, actually. The hope is still there, but we are also realistic, and we have this moment to multiply our efforts in order to be able to respond to these incredible increasing needs.

Avril Benoît:

I'd like to give you the last word, Dr. Marc. What is it that gives you hope to keep going and working for your people in Burkina Faso?

Dr. Marc Ounténi Couldiaty:

Yeah, for me, is the capacity of MSF to respond when there is really a need. This is really useful for the displaced population. We know that, as I was saying, the health system is really weak. The needs is really dynamic, it's increasing but fortunately, we are able to really respond when there is a need in a short period and with a good result. So this is really exciting because we can have this kind of feedback also, from the community, from the patients. And then also yesterday, our meeting with the Minister of Health, was a really nice because she recognized that we are friends. It's really difficult for them. They are overwhelmed but MSF is a friend. MSF is here, because there is need. They really know what we are doing. And they are also asking us to continue. They know that the need is really huge, but they also ask MSF to really help and continue to help. And then, this is also happiness also for us as we are helpful. This is what I can say about what is really relevant to work in my country.

Avril Benoît:

And for those who are watching, we just want to thank you for joining us to learn about this. And also for your ongoing support of our work. We really could not do it without you. We are financially supported by millions and millions of donors around the world, people who make it possible for us to do everything we can in places like Burkina Faso, that are not always in the news, especially in a pandemic. So thank you both for joining me today. That's all the time we have, a good place to end. Dr. Marc Couldiaty, Medical Coordinator for us and Tommaso Santo, Head of Mission or Country Director both joining us from Ouagadougou. Thanks so much and may you have courage, strength and be safe also in your working.

Tommaso Santo:

Thank you for your support.

Dr. Marc Ounténi Couldiaty:

Okay. Thank you.

Avril Benoît:

Thank you so much. And again, thanks for joining us, If you're watching. Apologies if we didn't get to your question, but really stay in touch. You can stay connected with us at Doctors Without Borders, at MSF by emailing us. The team that puts on these webinars can be reached at [email protected]. For more information, of course, just go to our website, we have doctorswithoutborders.org also msf.org. You can find us on Twitter, on Instagram, on Facebook, you name it. And we'll be back in another couple of weeks with another edition of this, Let's Talk webinar discussion, that'll be on November 12th, so we hope to see you there. I'm Avril Benoît. Have yourself a great day. Bye, bye.

Tommaso Santo:

Bye, bye.

Dr. Marc Ounténi Couldiaty:

Bye.

Avril Benoît:

Hi, everyone. Welcome to this special Let's Talk COVID-19 series that we've been doing since the beginning of the pandemic to give you some insights about our work and how it all relates to what we're all experiencing, which is this unprecedented time. So today we're going to be talking about mental health. Mental health care, particularly for our patients, also for the caregivers and for the health care workers, because that's very much the world that we inhabit. So I'm Avril Benoît. I'm the executive director of Doctors Without Borders in the United States. We're known internationally as Médecins Sans Frontières. And that's why you might hear the acronym MSF pop up throughout the conversation. The discussion today will last around 45 minutes. As usual, lots of opportunities for you to ask questions. You can pop in your questions on Zoom in the Q&A box. If you're joining Facebook Live or YouTube live or even Twitch, you can send your questions in the comments or the chat section. We will find them and they will be fed to me.

I'm really excited to be talking about this is not the first time we've actually touched on this subject, because it is so central to the well-being as we get through this awful phase. World Mental Health Day was October 10th, and with the number of COVID cases rising around the world and also the onset of flu season, which is potentially going to make things more complicated, winter right around the corner. And so, an expectation if we haven't already had our second waves arriving, that we will be in it soon. Very stressful time for everyone. As an increasing number of jurisdictions are imposing the kind of quarantines and lockdowns really severing our freedom and our ability to be with the people we love and that the people who can hug us to help us get through it. 26 million cases now have been diagnosed, 863,000 deaths. So, we have some terrific people to help us work through this. It's not a therapy session, but it is going to give us a lot of insights, I think, in terms of how we can look after one another.

We have Athena Viscusi, who's also been with us before on this series. She's a clinical social worker and a psychosocial care specialist working with Doctors Without Borders USA. Welcome, Athena. And maybe you can just pop in as an icebreaker and tell us where you're joining us from and what strange noises we are likely to hear in the background.

Athena Viscusi:

Hi. It's great to be here. I'm calling from my apartment in Brooklyn and you might hear the neighbors.

Avril Benoît:

Some creaky neighbor floors upstairs with me as well. Also joining us, Ebony Lucas, a therapist and wellness support officer who worked with us in a program that we were doing with long term care facilities in Detroit, Michigan. Welcome, Ebony. How are you doing today? And what strange noises are we likely to hear on this call?

Ebony Lucas:

Hello, everyone. I'm very excited to be here. I'm here in Detroit, in my home. And I think the strange noise that you might hear in my home is maybe doors or floors creaking. That's about it.

Avril Benoît:

Same thing. Okay, all right, good. No dogs barking or babies screaming in the background today. Sanne Kaelen is a clinical psychologist with MSF working with us in Belgium. And not only with lots of experience in mental health programs, but she's also researching the impact of these programs in the COVID19 pandemic. Hello, Sanne. How are you doing where you are?

Sanne Kaelen:

Hi, everyone. I'm good. I'm calling in from Brussels, the headquarters here of MSF in Belgium. And normally no animals or baby sounds here, just some colleagues who might be walking around.

Avril Benoît:

Okay, it should be good. It's so good to have all three of you here with us today. And, Ebony, if I can start with you. Tell us about the work that you've been doing in Detroit. What were you specifically working on in the long-term care facilities?

Ebony Lucas:

Thank you. So specifically what we were working on, we came into the nursing homes to provide wellness support. My title was the Wellness Support Officer. So what we did is we came in and we met them where they were as we provided a variety of mental health services so we referred them and linked them to local as well as national resources. We did in services as well as on site therapeutic sessions. We were very open and just kind of multitasking because again we met them where they were at. And so whatever the need was, because each facility had a different need, we try to be flexible in our services to meet that specific need.

Avril Benoît:

And the mental health challenges that the people you were trying to help were facing. Can you give us an overview of what some of those issues were?

Ebony Lucas:

Of course, across the board there was a lot of stress, of course. So I saw lot of compassion fatigue and also a lot of secondary trauma. So a lot of the in services focused on secondary trauma and then aspects of compassion fatigue. But one thing that I found very interesting is that so during this time, we should have seen a focus of seeking the services, going toward the services. But what I saw was people kind of drawn back from mental health services and kind of put the focus more on the physical, which I understand. And it had gotten to a point, from my observation, that the mental health was being ignored. And so we had cases of people chronically stressed out. It was a lot of burnout because these things were essentially being ignored and the staff essentially didn't know what to do. Everyone was confused and here we were increasing their demands, but not providing any services. So that's what we came in to do. We came in to provide them with hands-on services.

We also taught them how to make resource boards where they were able to make this with us, with MSF staff and put on their local resources, resources that they could easily access. And there was also a focus on the DON, so the director of nursing, making sure that they have services, because the issue with them was they were expected to provide the support for the staff. But here they didn't get any support. And so they didn't know what to do. So we had a big job ahead of us, we really did.

Avril Benoît:

We have seen similar kinds of stressors in our projects all around the world. Sanne, maybe you can describe what you've seen in your research as far as that goes.

Sanne Kaelen:

Yes, indeed. We did the same intervention in Belgium, in the nursing home since March. Until now recently, we finished that. And then in May, we started a research specifically on the mental health impact on the residents. Because I know interventions, we were mainly focused on the staff which was very much needed, of course. But then looking deeper into the impact on the residents, we discovered that actually their basic psychological needs were challenged, they were not met. And those basic psychological needs, that's autonomy, having control over your situation, competence, feeling useful in the society and relatedness, connectedness. So this was these IPC measures that were implemented in nursing homes were in fact-

Avril Benoît:

And IPC we should explain is...

Sanne Kaelen:

Sorry. Yeah, it's infection prevention control measures. And these were in fact having harmful consequences on the mental well-being of the residents. And we noticed also that the staff was really suffering with this because they have been all this time, they could not take care of their residents as they were used to take care of them. And that created also some ethical dilemmas for the staff and some moral distress, like we see the harmful effects of these measures. But we are blocked, we can't give them the physical affection that they sometimes want or they had to replace families. Even their families could not enter the nursing home anymore.

Avril Benoît:

We've heard a couple of concepts come up. You talked about moral distress and Ebony, you were talking about secondary trauma. Would you mind, Athena, maybe explaining what those are and how they have come into your work?

Athena Viscusi:

I'm sure my colleagues could, too. But thanks for asking. And what I do in my current work, I work in the field with MSF, in our project running mental health programs. What I do in my current work is counsel our staff. And so secondary or vicarious trauma is when we take on the traumatic reaction of something that hasn't happened to us but has happened to our patient or to a colleague or to... It's something that mental health practitioners in our training, we have to learn how to deal with that or we're toast, right? But it's not in the hands of medical professionals or at least enough. And especially not with the para professional staff that so much works in the nursing home for instance. We know we have to be on alert for that all the time because our job is to listen to distress, right? And help not to take that on and not ourselves wake up with nightmares of something that's happened to somebody else. So that's secondary or vicarious trauma. And what was the other one that you asked me?

Avril Benoît:

Moral distress.

Athena Viscusi:

Oh, moral injury, right.

Avril Benoît:

Moral injury.

Athena Viscusi:

So that's the thing. We learn a lot actually from work that's been done with veterans. We don't like to as caregivers. We don't like to compare ourselves with soldiers. We want to pretend we're very different. But actually, something that came out of veterans were the first people who'd been in combat to talk about the moral distress of when you do something that's against your ethical values. Maybe that's what you had to do in the moment. Maybe it was sanctioned by the organization, maybe you were told to do it. But it still, it goes against your values and then you're left with that inner conflict. In COVID what it was, was not being able to provide the care that people thought was needed and especially the emotional care. I mean, you mentioned Ebony, the staff wanting to hug the patients because they know that normally their family comes in. But you can't because of the infection control and so those dilemmas. Even if intellectually it's the right thing to do, emotionally and ethically it doesn't feel right. Maybe other people want to add something.

Avril Benoît:

Yes. Maybe you first, Sanne, and then we'll come around to you, Ebony.

Sanne Kaelen:

Yes, it is indeed there's dilemma between quantity of life and quality of life that in the beginning of the epidemic, which is also very normal, everyone wanted to shield the elderly off COVID-19, of the infection, after the spread. But in these protective approach, we kind of missed the mental health point. It's something that Ebony also said that mental health went a little bit to the background. And then we saw the detrimental effects of that. So it's now urgent time indeed to put mental health back to the front again and to focus on both infection prevention and mental well-being indeed.

Avril Benoît:

Ebony, can you give us, yes, maybe a concrete example of some situations that you saw for these things?

Ebony Lucas:

Yes. I work with a lot of nursing homes staff that talked about at the beginning of the pandemic when things were... it was still the big unknown. And a lot of people, a lot of the homes didn't have the PPE gear, the safety gear, infection control gear. But they were still expected to perform those services. It's a thing called a level of care. So it's a standard that you as a health profession, you are to provide that standard. But what do you do if you were supposed to provide a standard, but it provided a nonstandard? You're not only putting yourself at risk, but you're putting your family at risk as well, because you can bring those things home.

And so I saw a lot of staff that talked about how they actually had initially quit their jobs, which caused for them a strong moral dilemma because they enjoy what they do. And they understood that now, more than ever before, the residents at the long care facilities really need us. But I feel like I'm putting my life in danger. So how do I reconcile that within myself? How do I go in and provide a service that I know I could not only be putting myself at risk, but my family? And then we have several staff that described for me the fact that they did contract COVID as well as some of their family members. What I found to be very inspirational is those same staffs had came back to work once they had recovered and they came back with a new zest, a new zeal to provide the services. But that's what they talk about. They talk about not having what was needed to provide the services.

Then they also talked about wanting to touch the residents who no longer could have their family members touch because founding members were no longer allowed to go into the facilities anymore. So we had workers who were saying basically the residence being almost ignored from a simple touch. They wanted to but they knew the risk was great. So that was another moral dilemma that I saw come up a lot. And a lot of the workers developed strong relationships with the residents. And they described them as family. So for them, it was a chronic thing that kept happening over and over again.

Avril Benoît:

I can imagine that for a caregiver who's usually, the reason they were pulled into that particular career path, that kind of work, is because they really want to give so they give, give, give. And this is the profile often, isn't it? Of people who go into this line of work. Sanne dig into the research a little bit for us to describe what it is that you were trying to unpack, because we've now outlined some of the issues. We're going to talk about more and we welcome your questions through the chat or Q&A function here, they'll be passed on to me. But give us a sense of some of the things that you're trying to unpack here.

Sanne Kaelen:

Yes. So for this research we went to those nursing homes, again, to have interviews with the residents themselves. We wanted to hear their voice of how they experienced these periods of confinement, of lockdown. And we saw impacts in different aspects of their life. A very big one was the loss of freedom that they could no longer go where they wanted to go. They were not allowed anymore to leave the nursing home for summer. I work here now in Brussels for examples, not all those nursing homes have a garden that meant they had to stay inside for months, some even in room isolation. That's a really small room. I can't say it in English terms, in American terms, but very small, yeah, place to stay in. And they said we were becoming crazy. Those are people who experienced the World War. And they said that is not as bad as experiencing this lockdown periods. This is worse to be locked up, to have no more freedom, to not be able to touch anyone indeed. They said it was the most horrible period of their life.

And then very strikingly finding that we found in this research is that all of them said they were not afraid of COVID-19. They were afraid for the second wave that they would be quarantined again in isolation. That was their main fear, to be locked up again. As they said, most of them they are... you have reached an age and you're like, you know you're going to die of something. And they really were like, this is not how I want to live my last days like this in a nursing home. Where no activities took place, before you have some activity, some distraction, stimulation. That was not happening anymore. You could not see the people you wanted to see and even your meals you had to take in your room. They had to take in their room, not together anymore. Most of them could not even see each other anymore. Your neighbor across the hall because they had to stay in their rooms. So these different losses, their loss of freedom, loss of social life, loss of distraction, loss of autonomy had a major impact that made us question okay, what can we do also as MSF to change our intervention also in these nursing homes?

So we worked the past month in nursing homes to help them find the balance again, help them to restart activities in a safe way, help them to open up again the nursing home for visitors and to really improve this mental and social well-being of the people living there. Because in the end, if these care homes are residents homes, it's the place where they live. It's their home. And life needs to continue. We cannot stop life for them. It needs to continue in some way.

Avril Benoît:

I think many of us can relate to that. But in Belgium specifically, I've heard that the rates have gone up so much that you are very clearly now in a phase of a renewed lockdown. Is that right?

Sanne Kaelen:

Yeah. The second wave is hitting us quite hard now. And we are very afraid that all those nursing homes are going back in full lockdown again because it was the biggest fear of those residents. So we are now trying to support them, help them. If you have good infection prevention control measures put in place in your nursing home, you don't need to go back in full lockdown. And you can allow visits and do activities in a safe way just to prevent all these mental health impacts indeed, yeah. But we see if I can just add some one more thing. We feel also now that the staff working in those nursing homes, they are exhausted, they didn't recover yet from what happened in the March, April, May. They had no time to rest, to recover. And it's starting again. And you can feel their despair even. This is not going to end and winter still has to begin. They're very afraid of that.

Avril Benoît:

Yeah, it's a long, long slog ahead. We're getting some great questions here. And I want to encourage you to put them in however you're watching. We have three fantastic guests with us, Athena Viscusi, a clinical social worker, Ebony Lucas, a therapist and wellness support officer and Sanne Kaelen, a clinical psychologist, all working with Doctors Without Borders, with Médecins Sans Frontières. Athena, here's a great question for you. And it's about people being reluctant to ask for help. Stigma when it comes to people asking for psychological psychotherapy, all these kinds of supports with the various techniques is often quite present. Marshall is asking on Zoom are health care workers generally open to reaching out for help with things like secondary trauma? And if so, who treats them?

Athena Viscusi:

Right. Well, yeah. Great question. In MSF, we have a system in place where we proactively reach out to our providers and our projects all over the world. Because, no, it's not in health care providers' DNA to say that they need help. Their helpers. And even in this society, we give very mixed messages. We say thanks for being a hero. Well a hero doesn't need help. I mean, basically, when you're saying you're a hero, you're saying you have some supernatural ability to handle at large. And we don't need to take care of you. Thanks for being a hero.

So we do it proactively and myself. But I think what we need to do is... and I think COVID the vocabulary is changing, but you have to preventatively just say an epidemic causes stress, the disruption of school and work causes stress, working long hours causes stress. Working at home with your children going to school at home, causing stress. Stress untreated causes reactions, physical and emotional reactions. And so we all need, the more stress you are receiving, the more mitigating measures you need to be taking so as not to suffer the effects. Untreated stress leads to affect in everybody, in heroes and in not heroes, in patients and in caregiver. In the general public. In our leadership. That we all are facing stress and we all need, I guess, I'm using these mitigating measures. We all need to take some treatment for the stress.

And so we wear a mask not to get the virus. But what is our emotional PPE? What do we do to protect ourselves from the emotional? And so, in fact, because MSF has so much experience with epidemics and with supporting our staff, our patients, our patients’ families, our staff and our staff's families, through these epidemics. Local health care providers we're reaching out to us for advice on how to handle this during the peak like in New York. And that's why we designed these interventions that Ebony and Sanne bit in the long-term care facilities because we know that.                              

Avril Benoît:

Yeah, well, emotional PPE is a great way to sell it to convince someone that this is a good idea. It's a protection for yourself, for your well-being. Ebony, so who is doing the treatment for these health care workers? How do you offer it?

Ebony Lucas:

We offer direct service when we're there. And then we also link them or refer them to outside resources. And I say link and refer them because these are services that we know they can benefit from and they can access. So part of that will be vetting the resources out and making sure that it's available and that is easy for them to access. And then we provide the information on how they can access that.

But I really want to tag on to what Athena was saying. I totally agree with that. Heroes or helpers, they see themselves as having some type of supernatural quality where they are not susceptible to the same things that I guess you could say the rest of us are susceptible to. And so what I found when I went into these long term care facilities in my attempts to provide them with the services, they were very resistant initially. I did often hear, well, we're fine. We don't need anything. But I had to be very resilient in my quest provide them with services and I had to be flexible. Again, I had to meet them when they were. So I went in knowing that I would be met with some resistance and so knowing that I knew how to approach it. And a resistance kind of manifested itself not only in them saying that they don't need the help, but even with staff and coworkers joking about the services. And saying, oh, you're in there getting us... you're having a mental health session.

It was really interesting. And even people coming in and not attending sometimes the in services. And so I was creative and I think that's one thing that MSF prepared us for. So I literally would walk around and talk to them, say, hey. I'm having this in service, just come in and sit down for a minute, and I'm sure you will find it very interesting. We always try to make it very interactive so that the word will spread around, hey, this is a fun thing. This is something that we can all benefit from. Just take a little time out your day and no one's saying that, is there anything wrong with you. Because part of the problem, I think, is the whole stigma that comes with mental health. And so we have to kind of work to normalize it and break down that stigma, not only among staff. But, again, also among the supervisory staff. Because we need them to support the staff and seek in this service, we needed them to urge and support the staff in receiving the services. So I think that was a very important thing.

Avril Benoît:

Yeah, it strikes me that this stress that everyone is under in the zones that have been deeply affected by this. And certainly anyone working within a long term care facility would feel it, but also all the cities that have had peaks or even rural areas now we're hearing increasingly across the United States are really under duress. It seems like the norm would be to feel stressed, that it's a signal that you're processing the seriousness of the pandemic to feel stress. And to deny the stress. I mean, look at all the people who watch a sentimental video and they burst into tears now. And they're hugging trees because it's a living being. If you're feeling so isolated, people are resorting to all kinds of ways to self-medicate themselves through this. So it just seems so normal that we should just acknowledge, you know what? We're all cracking under the pressure now and then. And the best thing you can do is protect yourself. I can see Athena you want to comment.

Athena Viscusi:

But what you raised Avril, is that if people don't have positive ways of addressing the stress, they will turn to negative ways. We've had a documented increase in drug abuse during the pandemic because that's a great way not to feel. I mean, this is an adaptive reaction to overwhelming feelings is to try not to feel. And if we don't provide people with techniques to tolerate their feeling, right, or to connect with other people who, at a minimum can commiserate and ideally can actually help them feel better, people will turn to negative. We see a rise in domestic violence during the pandemic, during the isolation when people are cut out. One of the techniques of domestic abusers is to isolate the victim. Well, the pandemic's done a great job of doing that.

And even we're seeing now an increase in gun violence in this country because this is what happens under stress. If we don't give people positive ways to address it, they will default to negative ways, denial. Denial is a negative way of coping with the stress, the overwhelming stress of a pandemic. And we see this is being marketed to people. Deny it and you will feel better, very dangerous. So more and more important that we have this dialogue of you will be affected by this. And here are some positive ways to get through it because if we don't do that, people will default to these negative ways.

Ebony Lucas:

And just to add onto that. Yes, it is a lot of denial that's going on across the board. I experienced a lot of staff that told me I'm not stressed. I don't feel stressed. I'm fine. So sometimes people don't know how to recognize it. And I do think that part of that is a little bit of denial. But just educate people on the symptoms or what you're seeing or you're experiencing these things is a sign that you're pretty stressed out. So for me, just helping people also to recognize what the symptoms will look like and then offering them tips and techniques to deal with it, to cope with it in a positive way. And not in a negative.

Avril Benoît:

Let's jump into some of the techniques, because we're getting a number of good questions around this and some of these techniques I don't know anything about. So I'm very curious to hear. And I don't even know for this specific question from Donald on Zoom, who will know or have a response to this one. But Donald is asking has MSF considered using eye movement desensitization and reprocessing EMDR as a treatment model. Who wants to have a go at that one? Sanne go ahead.

Sanne Kaelen:

Yeah, I am familiar with EMDR indeed, but we haven't, well, at least here in Belgium, we haven't used that in the type of intervention here because we work mostly in groups. We did a group approach because infectious diseases can isolate people very easily. Everyone has their own fear, stress, other sorts of feelings. But by opening this up in group, you can notice that you're not the only one having these emotions. And by sharing them with others, you create again connectedness, relatedness which are all coping ways that can help alleviate the stress. And I think this group approach was used more indeed because in these times we have sometimes a feeling that it's hard to feel connected with other people. So it was a very important one for us.

And the same one is also for the other I mentioned them already, the other basic psychological needs. So this is one of them and the other one is competence, how to make people feel useful again. Okay, creating a buddy system, as Ebony said, learning to recognize stress signals with your colleagues or your friends or your family by talking to each other. Okay, how do you experience stress? How can I see that you're stressed? So that you can warn each other like, I think you're reaching a high stress level now. Maybe it's time to take a break or do whatever works for you, because this is another important message I think.

When you talk about how can we deal with stress, this is really a personal recipe you need to make for yourself. Some people can benefit from meditation or relaxation exercises, while others need to be very active, need to go through running or do some sports. Others want to ventilate, need to ventilate and maybe some other people benefit from a Netflix marathon. So everyone really has their own ways of coping. And you need to find the best recipe for yourself. What helps for you.

Avril Benoît:

A question from Helen on Facebook and a few others just asking about then the techniques. You mentioned Sanne group support. So what is the technical approach to a group counseling session? And I don't know, Athena or Ebony, if you talk about the kind of techniques that you use as therapists, as specialists.

Ebony Lucas:

So during the time of COVID-19 having a type of group support is important because it does, it creates a connectedness. It helps with the isolation. And then it helps for just the overall group dynamics and lends its way for a healthy recovery. Just talking about the different experiences and the different tips of techniques that you apply. One of the things that we always emphasize in our work in the nursing homes when it comes to specific techniques is using a peer support system or using a buddy system with your coworker, learning how to recognize or acknowledge distress. And the either one of you could be experiencing.

But then also being able to admit, talking to a supervisor and say, hey, my buddy or my coworker is feeling stressed today. Is there a way that they can get a longer break, or can they go home early? But then it comes to the supervisor being willing to support that peer connection. Being willing to say, okay, yes, they can go home early. Also, maybe the support person, if they've noticed that the person is feeling stressed or not having a good day, perhaps they can take up some of the slack for that person's work through that day. We really sought to offer practical tips and techniques that they can employ in their day to day life.

And it's important, like she mentioned, to have your own stress recipe. I think that's pressing because each person is an individual. So you have to find what fits for you. For some people, it could be group or some people it could be peer support. Some people could be individual things, walking, meditation, writing. But knowing that you have to put the focus on your mental health, on the stress at this point, I think is the important. Just putting that focus on it and then normalize it throughout the entire facility.

Avril Benoît:

Mohammed is asking on Zoom for some more of those efficient practical tips. You've mentioned a few here, how do you get somebody to see that there is an option, that they do have options to look after themselves? Athena, you have lots of practice working with people who've just returned or are still in very high stress humanitarian crisis zones right in the middle of a stressful situation. So what would you tell Mohammed in terms of how to help somebody figure out what that stress reducing technique would be?

Athena Viscusi:

Well, I mean, we prefer to prevent. So before people go out on assignment, when we do their preparation or pre-departure preparation, we have people... so everybody's been through stress before, right? It's a function of life. Good stress, bad stress, stress. You've taken exams. You've gotten married. You've gotten divorced. You've got people die. If you've gotten this far as to become a professional caregiver, you've been through stress. You know how to... And so you've either adopted some... you probably have lots of positive coping skills in your pocket and probably some negative ones, too, right? And so reflecting on when you've been through stress before, what did it look like? What are your signs? Both Ebony and Sanne have stress, this is individualized. There's not a formula. So what does it look like? Some of us overeat when we're stressed. Some of us stop sleeping. Some of us yell at people, what is the sign that the people around you see when you're stressed?

And telling your buddy, if you have a buddy system, this is what happens to me. Can you tell me if I'm starting to do those things? Because when I'm down that rabbit hole, it's too late. I don't see it anymore. So can you tell me? This is what happens to me, okay. So how have I dealt with it in the past? When I was in that terrible part in my life, when I was going through that terrible thing in my life, how did I get on the other side? What helped me? Who helped me? Who's my best friend who always helps me? Even if I'm in South Sudan on an assignment, can I get in touch with her? Because she's my lifeline. Don't cut myself off of her. Or what's helped me? What's that book that really inspired me? Was it prayer? Was it meditation? Was it running? What was it?

And if I don't have something then I need to find something. I only started doing yoga and I messed up. I hated it before. It turns out it's something you can do when you're confined to a very small room in a war zone where they... And it's awesome. So I didn't have that in my toolbox, I needed to find it. But I had some other things in my toolbox that I kept. But we can't say this is great and then not practice it, we need to practice it. And again, that's where everybody's help us. And that's where, then, supervisors were trained to identify these things saying, you said it's really good for you to run. You haven't been on a run in two weeks. What's that about? So what we do is help people develop a plan before they go out. What are the signs of stress? What are the things that have helped you in the past? And what can you do proactively in this situation, right?

And we even interviewed some of our experienced fieldworkers who had lived under confinement before. What are their top tips for living in a confined space and isolated? And advice that they could give to the general public from what they have learned there. So those are the things and there's a lot of research from like I said, from combat veterans, from Holocaust survivors, from survivors of all kinds of horrible things about what... because you will have 100 people go through the same event. And they will have different reactions, right? So EMDR is something that helps people, that was mentioned before that helps people to integrate traumatic memories and no longer have painful reactions to those traumatic memories. But what makes that some people never even have painful reactions to their traumatic memories?

And we found one is social connection. The people who have strong social connection, are less likely to have post-traumatic stress. They will have stress reactions in the moment but to have them long term post-traumatic. And then Sanne has mentioned so much the sense of competency of mastery. When we have felt completely hopeless. When we were in the situation, when we saw no outcome, we're more likely to have long term effects from that. But people who've been able to see the light at the end of the tunnel, maintain that hope, to remember that they've been through things before. So that sense of connectedness and mastery, some kind of confidence, some kind of not feeling completely overwhelmed and helpless, hopeless and helpless. People who feel hopeless, helpless are more likely to have long term effects. So how can we remind each other that there is a light at the end of the tunnel? And to see the good, to practice... we've talked about gratitude not as a feeling but as a practice. What are the three things that are going well right now? There's a pandemic going on. I'm talking to all these amazing people that are concerned about mental health in a pandemic. How cool is that?

Avril Benoît:

Yeah, I know.

Athena Viscusi:

But do we note those things every day, right?

Avril Benoît:

Yeah. But, Jill on Zoom is asking this question and I'm going to send this over to you Sanne because I see you're trying to jump in here. I'm zoomed out, I miss the social connection, I miss people. And she's asking, how does group support work function? When you're trying to social distance, how can it be as effective if you're the kind of person that actually craves people to sit with and eat with in our nursing home, you just crave that those moments of connection with your family? How does this work when we're socially distancing?

Sanne Kaelen:

That's a very fair question indeed in these social distance times. I prefer also the term physical distance. Hence, so it's not always social distance but physical distance that is needed. And we looked for creative solutions here. For example, meeting each other outside, keeping the one meter and a half distance and interacting in a safe manner like that. That is possible. Sometimes we're very much blocked by all the rules, but it asks a lot of creativity of us. Or for example, I myself I had a hard time reaching out to my support system via telephone only. So we went for a walk, having the mask on and everything, being safe outside just to feel indeed like there was someone physical next to me. But we were interacting in a safe manner.

And I indeed want to intervene on what Athena has said, because it's super interesting to hear her tell about this toolbox, because this is exactly how I was prepared as a psychologist to go to the fields, to go to a Central African Republic, which is in the conflict zone, and which was very an overwhelming experience. But by having this toolbox and I really made that that exercise with the psychologist here in Brussels on paper, you feel prepared, you feel like, okay, I can reach out to something. I have written this before, what is my self care plan? What can help me in this stressful time? Because even though I am a psychologist, I don't always recognize myself when I am stressed. Or I don't always know what helps me. So just if you have this toolbox and try to do this exercise in a moment that you feel calm and then when you have the emotional capacity to sit down and write all these stuff down, it will help you prepare for more difficult times. So this is a tool I really want to sell to everyone, try to do this exercise for yourself indeed.

Avril Benoît:

Yeah. The list of what are the behaviors or things that I do when I'm stressed. And what are the things that make me feel better when I'm stressed, that have worked in the past. Just make the two lists and then be able to refer to it. We're almost out of time here. I suspect that we could go on forever. But Ebony I'd like to finish with you with a question from Bruce on Zoom. He's asking specifically related to this issue of stigma, seeking mental health treatment. Now, people are not so... not sure that they should go there. What can ordinary people, people who are not caregivers, what can we all do to help reduce the stigma? So that caregivers and also the people living in these long-term care facilities and just those who are struggling and suffering is central workers, et cetera, how can we help reduce that stigma so that they do seek the help they need?

Ebony Lucas:

That's an excellent question. And I will have to say so at the individual level, we need to start where we are. So at the individual there are some specific things that I can do to lessen the stigma that is at war with mental health. I can be supportive of someone as a caretaker, someone seeking mental health services. I could work towards prevention. I myself could seek out mental health services while also having resources readily available. For instance, and I think it's always important to have every day technique things that everybody can do. So just starting at the individual level, it would be great to have maybe a magnet on your refrigerator that says if you're feeling down today or having the number to the National Suicide Hotline. And basically, just being open for a conversation around mental health.

And knowing that is something that each of us on different levels have experienced as well. And I think that at the individual level, there are lots of things that we can do. For instance, if you notice someone being a little, what you may call, they seem down or they seem... I'm sorry, let me fix my... They seem stressed, you can advocate for them to seek services. So I think at the individual level, there are lots of things that we can do to lessen that stigma because again it starts from where we are. So I think that it would be a good thing for everyone to have a yearly mental health screening.

I think that if we were to see things like that, that would help to normalize it against the all. And just being supportive and letting people know or understand this something that we all experience. But also it's important to understand that the stigma that relates to mental health, for seeking mental health services is something that is multilevel. So it's cultural, it's societal. So it has a lot of levels to it. But I think if we start at the individual level and doing basic things that we can do every day to support one another, we can go from there.

Avril Benoît:

Sounds like a great place to end. Thank you so much, all of you, for being with us today. That was Ebony Lucas, a therapist and wellness support officer who worked with MSF, with Doctors Without Borders in our long term care facilities program in Detroit, Michigan. Also with us, Athena Viscusi, a clinical social worker and psychosocial care specialist working with MSF, USA in New York City. And Sanne Kaelen, a clinical psychologist with MSF, and she has joined us today from Brussels. Thanks, all of you. And I hope you're doing well. Hang in there. You're doing great work. And thanks for sharing your wisdom with us today.

Apologies if you tuned in and we didn't get to your question, but please stay in touch with us. You can always write to us and we'll try our best to get back to you. Our email address for this series is [email protected]. And for more information about our mental health work, you can see lots of stories and insights on our website Doctors Without Borders.org and on our international website, MSF.org. You'll also find us on Twitter, on Facebook, on Instagram, the works. And we'll be back in another couple of weeks with another Let's Talk webinar series, this series that we've been running since the beginning of the pandemic. So that's coming up in two weeks time, October 29th. So thanks again for watching. I'm Avril Benoît signing off, take care.

Avril Benoît:

Welcome and thanks for joining us for the final episode in this summer webinar series, Let's Talk COVID-19. Today we're going to talk about how far we have come in the last six months or so and discuss the challenges and opportunities that lie ahead as we work toward ending the pandemic once and for all. I'm Avril Benoît. I'm the Executive Director of Doctors Without Borders in the US. You might know us from our international name which is Médecins Sans Frontières. And that's why you might hear the acronym MSF come up, that means Doctors Without Borders. I'm really delighted to be with you today.

We'll talk for about 45 minutes or so. And you can ask your questions. We really encourage this as a chance for us to connect with one another. If you're watching on Zoom, the questions can be placed in the Q&A option that you see there. If you're joining on Facebook Live, YouTube Live, or Twitch, you can send your questions through the comments or the chat section that you have. So here we are six months later. Six months since the World Health Organization declared COVID-19 as a global pandemic. And as of today, the latest numbers that we have are that 26 million people have the confirmed positive COVID-19. Over 863,000 deaths worldwide due to the Coronavirus, this novel Coronavirus, and many more losses as health care systems have struggled to cope with the demands and have had to shut down different services and people have had difficulty to get health care. So a lot of impact of this all over the place. You've been following it in the news. We'll take you a little more deeply into the heart of the humanitarian work that we do as a medical organization.

And if you've been tuning in over the course of this whole series, you know that we've touched down on ... we try to go a little deeper each time with specific topics. So we talked about how we're intervening in Latin America, what we're seeing in Yemen, impacts on reproductive health, all these kinds of subtopics can all come together today if you want. If these are the questions that you asked we will answer them. Obviously, we're looking to support all the essential health workers that are facing a staggering challenge. And we're looking also to strengthen the health systems, public health promotion in all kinds of ways that we have to work to combat the pandemic. As you heard even last time we have to combat the misinformation around this particular virus. 

So you've heard from MSF teams who have been working with local health authorities trying to support them, trying to support community groups in the US and around the world to help slow the spread of this disease. And so now, we're ready to talk to you about how we're taking action to ensure that any tests, or treatments, or vaccines for COVID-19 specifically are safe, affordable, and available for all the people who need them. So that's our webinar for today. It's about all of it. So today, we welcome back to familiar faces that you've perhaps seen before in this series. Kate White is a specialist in emergency response and public health for MSF's Emergency Support Department based in Amsterdam. And she's currently the medical technical lead for MSF's COVID-19 pandemic response. So welcome. Nice to see you again, Kate. 

Also joining us, we have Matt Coldiron. A physician, and a medical epidemiologist at Epicentre, which is an epidemiology and research satellite of MSF, of Doctors Without Borders. Nice to see you as well, Matt. So Kate and Matt, maybe you could start. Kate, what's your level of energy after six months of working nonstop on this?

Kate White:

To be really honest, I'm quite tired. It's been a very boring six months. And I think I need a very long holiday, but that won't be happening for a little while yet.

Avril Benoît:

Sorry to hear that. How about you, Matt? How you holding up? 

Matt Coldiron:

I think it's the same. And I think that we've heard these anecdotes all around. Everyone is physically tired, everyone is emotionally and mentally tired. I remember being in lockdown in New York and going and volunteering in the public hospital system and doing my day job with COVID and then things still go on. Just recently in Niger yesterday, we were enrolling a patient in a brand new trial of malaria. Let's not forget that there are still millions of children every year that are getting sick with malaria and it's not stopping because of COVID.

Avril Benoît:

Well, we look forward to throwing some good questions to you. There might be things that have come up before, but again, if you're watching, please put your question in the Q&A function on Zoom. And we have our staff here also responding in the chat if there's something specific that we're not going to address necessarily just because of the volume of questions. So the first question is from Jean posing it on Zoom. I'm wondering if MSF has plans to acquire a COVID-19 vaccine once it's approved. Matt, what do you know about this?

Matt Coldiron:

Well, I think I'll take maybe the first ... the second part of the question which is maybe the first, which is, "When is the vaccine going to be approved or when will different vaccines will be approved?" There are dozens of candidate vaccines right now. And several of them are allowed. Maybe two handfuls are actually in advanced phase trials or the phase three trials, which is usually the sort of the end of the road of the clinical evaluation of the vaccine. Some of the results may be ready soon and maybe before the end of the year even. And then the question is, with which speed the regulatory authorities, like the FDA here in the United States or the European Medicines Agency, will sort of examine all of the evidence and say, "This vaccine is safe and effective." And then sort of put the stamp on it and say, "Yes, people can use it." So that's the first part of it. And I think it's possible that there could be one or maybe two vaccines approved around the end of the year, maybe early next year. And the second part maybe Kate can talk about MSF.

Kate White:

Yeah. Would MSF like to secure some vaccines? Yes. What is the likelihood of that happening within the timeframe that Matt refers to? Probably not very likely. There will be multiple buyers on the market that will want to get their hands on an effective vaccine for their own populations. I think the US, European governments. I know I'm from Australia, and you've already seen many, many countries put in what they see as an intention to order and it's very difficult sometimes for us to compete with that. And also for many of the countries where we work to compete in that market to be able to get the vaccine. I think either way, MSF wants to be involved with how the vaccine gets to the populations that we work with. Whether that's with our own stocks or really working with the health authorities on the ground to make sure that vaccine then gets to the populations that need it.

Avril Benoît:

And if you were both to speculate then, assuming that it starts with not enough vaccine for the whole world, the manufacturing capacity would have to build up and the stocks would have to build up. You've mentioned the richer countries would likely have the means to be able to acquire, hold, hoard even some of the vaccine for their own populations. How much time or what would be the sequence of things for a vaccine that's approved to become available to some of the more difficult countries and countries in crisis who don't have a financial means themselves to place that kind of order with the manufacturers? How will it work? Matt.

Matt Coldiron:

The first rule I've learned with COVID is to never speculate, but since first-

Avril Benoît:

Sorry.

Matt Coldiron:

No, no. Just a joke. But I think optimistically, and this is just my personal feeling based on my reading of the politics of the situation, maybe 2022, maybe. But I think the biggest problem we're having right now is there's so little funding available committed towards stockpiling vaccines for low and middle income countries. I think there's a lot of statements, sort of general statements saying, "Yes, this will be a global public health good, global good. And yes, we will work towards access to all populations," but there hasn't a lot of concrete steps towards actually buying or committing towards buying. So I'm not particularly optimistic that developing countries will be faring as well as some of the richer countries.

Avril Benoît:

Well, we have a hope that with the vaccine, we have the end of the pandemic. And having heard all the complexity of that, and I'm sure there are more questions that will come over the course of the webinar around this, but in the meantime, Francis is asking a question on Facebook. Is it possible to beat COVID-19 or will it always be with us in some form or another like the flu, or SARS, or even Ebola? There was a bit of news around polio which is mostly conquered in most parts of the world where the vaccine programs have worked. And when you have a breakdown, you'll have to catch up again, but is it possible for us to really close the book on COVID-19 specifically, Matt?

Matt Coldiron:
I don't think so. The caveat is we don't know. This is a new disease, we've got eight months of experience, we don't know. I think that the best guess is that it probably will be something that stays with us. And that in some way it will maybe end up looking like the seasonal flu. I think one of the challenges right now is it’s brand new. No one in the world has ever sort of seen it. So people are very, very susceptible. If it circulates for five or 10 years and there's a vaccine, we will sort of as a population be better protected against it. So I don't think that 10 years from now it will cause the dramatic effects that we saw say in New York City in April and that would be my hope. Little by little, it sort of normalizes and stabilizes and becomes a little bit more manageable like we manage with the seasonal flu, which is still obviously a large problem, but we know about it, we know how to deal with it and we have a lot of tools in our toolbox to fight.

Avril Benoît:

Right. And more and more tools will be found presumably. Kate, here's one for you from Luther asking the question on Zoom. What are your greatest equipment, resource, or medical supply needs right now? All health responders in this have communicated initially about the shortage of PPE, but where are we now in terms of that? And have the supply chain issues been resolved or are still impacted by the pandemic?

Kate White:

They're definitely much better than they were at the start of this. And the global supply chain really has opened up in terms of PPE, but what we see now is that there is still a great need in the places that we work. And that need will continue because as sort of Matt has alluded to, it's now how do we treat malaria, how do we treat malnutrition in the context of COVID? Because it's kind of a new normal, so to speak. So all of our forecasts in terms of how much of this equipment we would need have all gone up and now it's about supplying that for the future. And in the past, we would have sort of six months buffer stock on the field, now we've got three months. And so whilst we have stock and it's much better than it was before, there is still a lot of pressure on the global supply chain to push the PPE. And that will continue for the coming year at least.

Avril Benoît:

You've both mentioned malaria and the complexity of that, Kate, can you elaborate a bit more? There's a question from Casey on the Zoom about malaria. How has COVID-19 really impacted MSF's ability to continue with other programs like that?

Kate White:

It's impacted it in terms of HR and supplies, but in a number of ways, it's also had a good impact. I think in terms of malaria, there are many places where we've been able to do sort of prevention strategies that we wouldn't have always, in normal situations, been able to do. So we've done mass drug administrations in a number of locations to help decrease that malaria burden that we knew would come, whilst we were also having to deal with COVID. So that's a great thing, but it has definitely impacted how people access healthcare. People are reluctant to come sometimes to health centers because they see them as places where they get COVID-19. So that is really where we've had to tackle the stigma associated with many of the other things that we deal with on a day-to-day basis.

Avril Benoît:

That's something that you talked about also last time that you joined us on the webinar. This concern that we had that while it was okay to pivot programs and start focusing a little more on COVID-19, we were quite worried about what programs that we were having to slow down or cut. How are things now, Kate, in terms of that? And this is a follow-up question from the last one. Have you had to cut back on some programs to focus on the pandemic response? We know that was the case initially, but is it still the case now?
Kate White:

Luckily in the majority of places that we work, we've been able to if not get completely back to normal, at least program or do activities for those particular components, whether it be maternal and child health or malnutrition in a way that we can still treat patients and still have our patients still have access to health care, but it may not look exactly the same way as it did before. But luckily, it's changed.

Avril Benoît:

Now, Matt. One of the things that you've really been tracking is all the research around this. I mean this is the main focus of your work. How are we doing with treatment options? Speaking to the resource shortage, initially it was, "We need ventilators everywhere to do this intubation." And then it started to be questioned and so forth. How do you see things now?

Matt Coldiron:

I think that there are a few things to say. One is that there has been an incredible amount of research. The sheer volume of research that's being done is incredible. And we went from knowing nothing this time eight months ago to knowing a whole lot. There's still a lot of open questions, but I think objectively you have to take a step back and say, "We have learned a lot amazingly fast." I think there are a few problems. In some places, there are studies that are being planned and resources being plowed into them that are not asking the right question, or not looking at it in the right population, or not sort of ... not with enough collaboration, or maybe in a place where there's not enough disease. I think one of the things that we've learned in the vaccine research is that it's important to run the studies in places where there are lots of cases. The big trial that got a lot of news that had the sort of the biggest result so far happened in the UK. And they were able to do this trial of Dexamethasone and several other treatment options. There were tens of thousands of cases in the UK.

It's really important to do the research there because you have the numbers of cases to be able to get the answers that you want. It doesn't do anyone any good to design a trial that needs 5000 patients if you're only going to expect 200 or 300 to show up in your clinic or your hospital over the next few months. So I think there's a lot that've been done. There have been some great examples of collaborative work and I think that we're seeing more and more that there has also been a lot of waste or at least waste of resource or waste of energy into the studies that are not going to really come to fruition or be as valuable as they could have been. We're doing okay, but we could do better.

Avril Benoît:

Can you give us an example of a kind of research line that was a waste?

Matt Coldiron:

I think that the best things sample is with hydroxychloroquine. And that was for a long time seen as potentially very useful in the treatment of COVID for a lot of reasons. It was easily available, it has sort of a long track record, we know more or less how it works, and there was a supply of it. So it made sense to look into, but it became fairly clear fairly early on that it was not going to be great. And there were still a lot of effort going into some of these trials. And there were hundreds of trials, of small trials of, "We're going to enroll 300 patients in our single hospital and see if hydroxychloroquine works." And the fact is you're never going to answer that question with 300 patients in your single hospital. Sort of the proliferation of studies around that single molecule I think was a waste of resources. I'm not saying it wasn't valuable. People were certainly trying and had their heart in the right place for wanting to do it, but it wasn't as impactful as it could have been had there been a little bit better coordination.

Avril Benoît:

Do you see that kind of coordination for convalescent plasma?

Matt Coldiron:

Not so much. I think there's been a lot of coordination towards getting people convalescent plasma. There's two examples I'll give. One is in the United Kingdom. Again, this trial where they showed that Dexamethasone was an effective treatment for some patients that need oxygen. They've now also been randomizing patients to receive plasma or not. And that's sort of important because then you can really compare people who got plasma and who didn't get plasma and see what their results are. It is an open question whether it works. There was a very large study in the United States and it led to an emergency use authorization by the US FDA. 35,000 people who got plasma. Unfortunately, it was an observational study.  So instead of comparing people who got plasma and who didn't get plasma, they compared it to people who got plasma early versus late. The results suggested they compared to people who got plasma late to people who got plasma early. It did better, which is good but sort of in the absolute, we're not sure compared to people who wouldn't have gotten plasma at all is it okay?

We don't want to withhold treatment for anyone if there could be a benefit, but it takes time and energy to harvest the plasma. So if we're spending all this time, all these resources in doing it and we don't actually 100% know that it works maybe it's the time and the resources that could be better spent elsewhere. Which is not to say one shouldn't take it or one shouldn't get it, but it's ... there's still a lot of questions.

Avril Benoît:

Yeah. Kate, here's one for you from Jamil on Zoom asking about the vaccine. There are people who don't want to get a COVID-19 vaccine once it's released. They won't have confidence for a variety of reasons and maybe good ones because maybe things will be rushed or there's a sense that things are getting hyped and they're not so sure. What would you say to people who have reservations about the development of a vaccine and how much confidence they should have? How should they know that the one they might have access to is okay? 

Kate White:

Great question. Vaccines have to go through a number of different phases of trials. And there's a whole process to seeing how effective they are. So by the time it actually gets to the point where you would have mass distribution and administration, their efficacy is proven, so to speak. However, having said that, there will always be a group of people who don't want to be vaccinated. And you see that with pretty much every vaccine preventable disease. Which is one of the reasons, kind of going back to the first question, I think we will always see COVID-19 around in some way, shape or form even if it's small pockets or it's seasonal because even with the development of an effective vaccine, and even if we were able to mass produce it at a level that we could get coverage of the global population, there will always be people who refuse to have it. I can give all the scientific reasons why it will work and why I should be confident in it, but sometimes that is just not enough for many.

Avril Benoît:

Matt, this is the time of year also where many of us will get the flu vaccine and yet there are large numbers of people who won't. What is the connection then between getting the flu vaccine and the current pandemic?

Matt Coldiron:

The current pandemic has all that more reason to make sure you get your flu shot like you should every year because the flu is seasonal. We know that in the Northern Hemisphere, we'll start seeing it in October, November, December and through the winter months, the opposite in the southern hemisphere, but we don't know yet whether there is that same mark of seasonality with this novel coronavirus. Some people think that there will be. I think it's prudent to plan that there also will. It might not happen. This is sort of going back to what I said we don't know everything yet. We know a lot, but we don't know everything. But at the very least it's prudent to anticipate that things might get worse this winter in the Northern Hemisphere. So all the much more reason to get your flu shot like you do every ... like you should every year.

Avril Benoît:

All right. We're also hearing from Matt on Zoom. Does MSF or Epicentre play a role in sentinel surveillance or EID? Are there other collaborating partners? Who do we work with do have a look at all of this?

Matt Coldiron:

So I can answer briefly and then Kate probably answer too. I think MSF in the field around is collaborating both in our projects where we're supporting issues of health or sort of acting in the community to provide great data. Both feeding into the national system and also looking at our own patients that we're taking care of in a very collaborative way to have a global understanding of as an organization, as an international medical humanitarian organization, can MSF look at sort of how we're doing in taking care of patients in Yemen comparing those to patients in Brazil, comparing those to patients in Mali, for example. And so we've put a lot of effort into that because it's important to understand. It's important for us to look at how we're doing. And I think the biggest benefit of collecting data like that as a physician or as a clinician is to understand, are we doing a good job?

Avril Benoît:

Yeah. And so these EID, Early Infectious Diseases, are there any others that are colliding our way that are likely to make it more complicated to deal with COVID-19, Matt? I see you nodding.

Matt Coldiron:

Yeah. So emerging infectious diseases, there are more and more. Actually, there was a really thoughtful piece by a medical historian and Dr. Fauci that came out last week talking about how pandemics are the new normal. A lot of the diseases that we see that are sort of scary and new like Ebola, or like this novel Coronavirus, or other things like the Nipah virus. One of the things that they have in common is that they have some element of animal ... Animals are in their lifecycle somehow. Whether it's animals are sort of hosts occasionally or whether animals directly transmits to humans. 

And as we see this confluence of deforestation, changing environments, urbanization, humans are being brought more and more into contact with a lot of these animals, and then also in more and more contact with each other. And the confluence of that plus climate change I think is really going to be driving the emergence, putting pressure on the emergence of new diseases. Maybe things that have just been sort of simmering around in the background that have never left one village and one place that we've never seen, but as our behavior changes, then we will be in more and more contact with them. You get on an airplane and you're halfway across the world in 12 hours. So I think it is the new normal. Do I know when the next one? No. Do I know where it's going to come? No. A lot of smart people have a lot of lists and there are some that they're looking at very closely, but we might be up for a new surprise.

Avril Benoît:

I think this one is enough for me right now. One at a time, please. Kate, as somebody who's working very closely with our emergency planning, one of the things you've had to do is pivot, adapt to all these unknowns and especially as we're learning more and more about this disease. Can you tell us a bit more about how far things have come in terms of the innovations and the ways that Médecins Sans Frontière or MSF has been able to adapt especially in the recent months?

Kate White:

Yeah. I think we're lucky in many ways that we're living in a time where also technology is so advanced, that we can do everything from engaging with local universities who have 3D printers to locally 3D print personal protective equipment. Everyone has a smartphone now. Even in the most remote villages in DRC or CAR, the communities that we ... Sorry. Central African Republic, the communities that we work with they have smartphones. So we have things like WhatsApp groups with traditional healers, so that we can work with them and make sure that they can protect themselves, they can refer people who are experiencing severe illnesses, whether that be from COVID-19 or others, and work in a way that we haven't always been pushed to work before. And there are many downsides to something like a pandemic, but what history shows is that these are also the moments where we truly innovate and change the way that we work which has a benefit not only to the now, but to how we do things in the future.

Avril Benoît:

Yeah. It's extraordinary. I suppose there are some things probably that we also tried and didn't work. Care to speak to that?

Kate White:

Yeah. I think there's many things that we tried and it didn't quite work or there were elements of it that worked. I think most of those though are around some of the novels of ... the treatments that came out. When hydroxychloroquine was first the big ticket item in the news, we were one of the first to try and secure some stocks and then it came out that that was not going to be the case. And so we were, "Okay. We're not going to go down that path anymore." Then there are other things. We know we have tried to negotiate and get access to communities. And as a part of that process, we've learned some very interesting things around our regular programming. I know we've also attempted to do some AV materials as a part of sort of teaching communities to sort of empower themselves, but it hasn't always worked. We sometimes do not hit the mark, but overall, I think in general, we've come out winners in many things.

Avril Benoît:

Yeah. It's worth trying the things that we know from experience are so important. And one of the issues that I know has been a major concern of yours, Kate, is how to work with communities. To really work with community partners and to gain that trust. In the early months, we were really comparing it to our experience with Ebola. Finding the commonalities and differences with that. How far have we gotten in terms of building that trust at the ground level and really being partners with the community? Can you maybe give us an example of one that you think is that's the way we should continue to work?

Kate White:

For me, the example that sticks out the most is Nigeria, but we've done it in actually many places. And it's been not just our medical teams, but kind of the whole project really coming together and talking with different members of the community. And so originally, we had this big idea that shielding would work for this population. And so the team went out and they talked with various members in this community. And it was a combination of internally displaced people in this camp setting very close to a host population who was also quite marginalized and disenfranchised in terms of what they were able to access. And so we've always worked across both communities really focusing on the health structures that have been in place. And as the team talked to the community and various members, what came out was that actually for this community, they didn't think that shielding would be the best option for them. And so that was both fascinating, but also for the team quite different. And they learned a lot about this community, both the host community and the displaced population. And they changed actually. They pivoted in terms of what they were going to do. And the wonderful thing that has happened is that they've come back over time to explain what we could do and what we couldn't do. 

There were some things that were not particularly health related, but we were also able to work with other local actors to fulfill those needs. And so now we're six months down the track. They've had these moments three times in that six months. And even our regular programming that we were doing there has changed slightly in terms of how the team goes about it based on this community feedback. And it's something that the entire team has been very positive about and they say, "This is actually how we want to continue to work in the future." And it's built a really good relationship between us, the host population, and the displaced population that's living in the camp site.

Avril Benoît:

Yeah. It's great to know. Thank you for describing that for us. Matt, here's one for you from Jim on Zoom. Countries around the world have taken different approaches to combating the spread of this virus. I remember watching very closely Sweden herd immunity, UK versus New Zealand or all these different approaches and then what happened with Spain. Even a state like Hawaii which seemed to be a model of how to handle things and then it seems less so now. So Jim's answer is what have we learned are the most effective measures in terms of things like masks, border closures, frequent testing, stay-at-home orders, all these things?

Matt Coldiron:

So I think that there's two parts of the question. There's some things that we know that work. So I think the two most important things are sort of masks and hand hygiene. Wash your hands, wear a mask, and avoid being in a small room with a lot of people. Those are sort of the things that we know they work. Now how you translate that into sort of a policy or a strategy, I think different countries have had different ways of playing around the edges with how, do you say 10 people versus 20 people? Do you close the bars or do you have half of the capacity of a restaurant. There's lots of different ways to play with that, but the fundamentals of what works is sort of keeping distance from people, wearing masks, and washing your hands. I think that we have learned a lot of different ways. Governments have learned what works and what doesn't work. 

I think it's also important to remember this is a parallel, a direct parallel of what Kate was just talking about. If we're in an internally displaced persons camp in Nigeria, and we say, "The best way to protect yourselves is to shield the elderly and isolate them from the rest of the community." And the community comes back and says, "No, that's not going to work for us." We adapt our programs. And I think it's the same way in different countries. And different countries have experimented with different policies based on what they think may or may not work or be acceptable in their populations. I think the one thing that's clear is that we can go about things as normal. So in New York City crowded subway cars are not going to be good for anyone. That is unfortunately going to be a problem for figuring out how to sort of reopen schools, to reopen businesses, getting people to work every day. And there aren't going to be easy answers, but some fundamentals are pretty clear at this point.

Avril Benoît:

When you look then at the places in the world that are seeing very dramatic peaks, I'm thinking of India right now and some of the latest numbers from countries like that. How long can they expect it to be so bad? Because that's another thing that seems to have emerged. It's how long you can expect the worst to really grip a local region or a city.

Matt Coldiron:

Again, I don't think that we know 100%, but I think we've had experienced enough in a few places in New York. I'm hate to come back to New York, but that's where I've been living and I've seen it. We had an awful and a catastrophic couple of months. I remember at the beginning, you wouldn't ... you'd walk around and 20% of the people on the street would have a mask on. If you walk around in my neighborhood today, 95% of people are wearing masks all the time. 

So I think as soon as the measures go into place, there are some ... there's usually drastic reductions. The question is, if you're living in sort of an informal settlement in Mumbai where you've got an incredible density of population, are those same measures that we've been able to put in place in Brooklyn going to work there? Are they going to be feasible there? Who's going to buy the masks? Who's going to distribute the masks? Where is there going to be running water for people to wash their hands? And so these sorts of basic things. Like I said, the fundamentals are known. We know the fundamentals and the question is how to implement them. And so I think if Mumbai could do what New York City did, then you could have a very catastrophic peak for six weeks and then maybe climb it down, but if those known countermeasures are not possible then things would go on for a long time. I think we saw that in Brazil where there were few countermeasures put in place for a long time and they just had a very long prolonged outbreak.

Avril Benoît:

Kate, Matt's talking about the informal settlements in urbanized areas like Mumbai. Bridget is asking a question. Oh, sorry. It's Ralph on Zoom asking how COVID-19 has affected what happens in refugee camps. So this was something that we were very worried about for the same reason. So the close proximity of people and the difficulty to have decent services. So he's asking how are the services being carried out with refugee populations around the world?

Kate White:

It's different in so many different places. So if we look at Cox's Bazar in Bangladesh we, and other actors in health authorities, we have been able to continue our programming, it took a lot of concerted effort. And we've also done a massive cloth mask distribution to be able to cover the entire population of what is known as the mega cap. So that's almost a million people. But then, you contrast that to other places. For example, in northeastern Syria, what we've seen is at the beginning we were very worried when COVID-19 hit northeastern Syria that it would get into the displaced persons camps. And it didn't get there straight away because they had various public health measures that were put in place to decrease movements and make sure that it decrease transmission as much as possible, but what we saw over time was that because the case numbers didn't rise dramatically, there was almost this feeling of being safe and the, "Oh, this isn't going to affect us." 

So then they decreased the measures and didn't sustain many at all. And then what we've seen in the last month or so is that those case numbers have risen dramatically. And now we have significant community transmission in some of these displaced population camps. And so I think it's really important that what measures we put in place not only work for communities, but we sustain them because until we either get a vaccine or something happens, this will continue. It's not going to go anywhere. So even though it might seem like there's not so much transmission in the area, as soon as you decrease those measures and make life go back to what it was pre COVID-19, that transmission will go up because most populations are just so mobile these days.

Matt Coldiron:

I would jump in to say, Kate, a vaccine, a few good treatments, and a lot of people are doing these things like masks and hand wash. It's not just a vaccine that's going to solve it, it's sort of ensemble of all of them.

Avril Benoît:

Kate, would it be fair to say that MSF or Doctors Without Borders works in roughly 70 countries around the world. Is every single one of our projects though pretty much prepared if not able a to respond quickly? I know that was a huge push at the beginning to beef up our infection prevention and control measures and so forth and make sure that we had enough PPE for the staff and to make sure that we were ready. Would you say that's still the case now that we are ready pretty much everywhere if not already responding to the pandemic having already arrived?

Kate White:

Yeah. Not only are we either ready to do more or it's almost become our new normal in terms of both treating patients with COVID plus all of the other things that we were doing in many of our locations. And now, we're also at that point where we're saying, "Okay. We need to make sure that we plan for this, for next year, and the year after that." What we call our E-Prep scenario. So emergency preparedness scenarios include this. So what would it look like to do a response to a message influx of refugees in the context of COVID? Do we have all of the things that we would need for that? It's becoming our new normal, so to speak.

Avril Benoît:

That to some extent answers a question from Zoom. How does MSF stay agile to provide care quickly and in so many different places, and contexts? And this will be my last question for you, Kate. It must be pretty overwhelming to think of all the adaptations you have to do, the specificity of the response in different location. How does MSF stay so agile?

Kate White:

With a large number of extraordinary people that work for us across the world, it's not something that's done centrally. Every country, every project location thinks about this and plans for this. And we have thousands of staff worldwide who this is what they do. At certain moments of the year they say, "Okay. What is this going to look like for the next three months? What is it going to look like for the next six months? And how can we continue to respond to malnutrition but where there's community transmission of COVID-19? Or how can we continue to increase our care for malaria, or meningitis or measles or so many other things? It's our extraordinary staff who work in those 70 countries.

Avril Benoît:

And now our final question for you Matt. Every time we do these, and this is the final one in the series, we often have people asking they watch it all, they listen, they're absorbing, they follow the news and they wonder how they can help. What do you tell people? And you're at home in Kentucky if I'm not mistaken. What do you tell people around you in your home community when they say, "Matt, what can we do? How can we help you?"

Kate White:

I think that first thing, and this is a real struggle even in my own family sometimes is that this is a community effort. So to do something starts with protecting those around you. So if you're concerned about wearing a mask or if you're tired of wearing a mask, because we've been wearing a mask for six months, you just need to do it for a little while longer. Because I think the most important thing that you can do to stop COVID is to act yourself, directly for yourself to do the things that you know how to do. I think in terms of other things that you can do to help, if you have COVID, God forbid, be part of a trial of one of the novel therapeutic. If you're in a place where they're doing a trial of a vaccine, that is ... it is a great thing to be able to do. It contributes to our scientific knowledge and altruism towards furthering our knowledge for everyone else. 

And I won't say give MSF money, but there are things that people can do both in volunteering in the field. Volunteering with MSF, but volunteering at home, volunteering with your local shelters or local organizations to help marginalized or vulnerable populations like we do in MSF maybe on the other side of the world or frankly in this pandemic, even at home here in the United States. I guess in the end, I would say just do something and don't say, "Oh, that's not important, or that's just too small." If everyone did something a little bit small, by the time everyone did it, it would actually add up to something large. So I would encourage everyone to make an effort to do something.

Avril Benoît:

Yes. And for those who have supported us and donated money, supported our independent medical humanitarian action, speaking for all of us who are working on COVID-19, we thank you from the bottom of our hearts. We couldn't do it without you. Kate and Matt, always good to see you. And I wish you lots of strength and courage for the month ahead as we continue to do our small part in this global pandemic. Thanks again and do stay healthy.

Matt Coldiron:

Thanks, Avril.

Avril Benoît: I want to thank also those who have joined us. I really appreciate all your questions. All summer long we've been doing this series. This is the last one for now, but we'll come back sometime in the future. We always have webinars on different kinds of topics. And we're open to your suggestions also. Things that you're interested in, people that you'd like to hear from at Doctors Without Borders. If you'd like to contact us, the team that puts these webinars together can be reached by email. The email address is [email protected]. And as always, you can just go to our website. Our International website is msf.org. The US one is doctorswithoutborders.org. You can also find us of course on Instagram, on Twitter, and on Facebook. That's where we try to inform you where you are. Where you'll find us is all good. So keep an eye on that and keep an eye out for our future webinars. I'm Avril Benoît, signing off. And thank you so much for being with us today. Bye for now.

Sandrine Tiller:

Hi, everyone, and welcome. Thanks for joining for our series, Let's Talk COVID-19. Today's episode is focusing on fighting misinformation. I'm Sandrine Tiller, your guest host this week. I'm the lead for a Doctors Without Borders project on misinformation and disinformation. I'm actually based in London. Some of you might know us by our French name, Médecins Sans Frontières, so you'll probably hear us saying MSF throughout the conversation, but it just means Doctors Without Borders.

So, today, we're going to be talking about the shifting online environment, and the explosive growth of misinformation and disinformation about public health issues. The COVID-19 pandemic has triggered a surge of public interest in health care, but also massive confusion as people are flooded with unverified news in social media. The World Health Organization has called this epidemic of bad information an infodemic. It's putting people's health and lives at risk.

So, today, we're going to be talking to MSF aid workers and experts about the impacts on local communities from Haiti to the Democratic Republic of Congo to West Africa and beyond. Before we continue, I have a little housekeeping to take care of. This discussion is going to run for 45 minutes. Wherever you're joining from today, you can submit questions for the panelists. If you're watching on Zoom, send questions using the Q&A option at the bottom of your screen. If you're joining on YouTube live, Facebook live or Twitch, send questions in the comments or chat section. We'll prioritize questions directly related to today's discussion.

So, joining me today are Luz Saavedra. She is the head of mission for MSF in Haiti. Hi, Luz. We've also got Thiaba Anais Fame. She is the MSF regional advisor for community engagement based in Dakar in Senegal. Hi, Thiaba. We have Sabrina Rubli. She's the health promotion manager for MSF in North Kivu, Democratic Republic of Congo. She is in a place called Walikale, which is pretty far into North Kivu, and so her connection isn't great. So, that's why you're seeing a photo of her, and she's on the phone, so that she doesn't break out.

Right. So, we're going to be waiting for your questions, but I'm just going to start off by asking Thiaba to kick us off by looking at the language that we're using. What is the difference, Thiaba, between misinformation, disinformation and rumor?

Thiaba Anais Fame:

Thanks, Sandrine. Hi, everyone. So, here in MSF, we take information as it comes, and every kind of information is extremely important but we... just for the sake of better understanding what is being said. In MSF, what we call misinformation is pretty much a collection of untruthful information. So, it's not always scientifically based, and really nobody really knows where it's from. The sources are sometimes a little blurry. We don't know how it was created. But it's just a couple of information that sounds true, but deep down you know that they are. So they're a little itchy, let's say.

Sandrine Tiller:

Nice.

Thiaba Anais Fame:

Disinformation, however, is a collection of inaccurate information. So, disinformation are usually shared with a more malicious purpose. They tend to be... to refer, for example, to abuse or attacks towards patient or health workers. Sometimes, they can be related to economics, or they can be sometimes politically motivated. So bottom line is they are meant to deceive the population and they're meant to hurt.

Rumors are a mix of myth and hearsay and feedback from the community, so they can be true and sometimes they can be inaccurate. So, the thing is that with rumors, we tend to focus and to talk a lot more about rumors and feedback. We'll talk a little more about that later on. But one thing that we need to remember is that we take all this information very seriously. We tend to address them as quickly as possible because they can have some real damaging impact on our staff, our activities, our reputation, and most importantly, on the health of the population. So, yeah.

Sandrine Tiller:

Right. So, earlier when we talked to you, you mentioned to me that it's important not to dismiss rumors or think that rumors are only bad. So, tell me a bit more about that idea.

Thiaba Anais Fame:

Sure. The thing is that rumors are not always necessarily harmful. Yes, it's true that they reinforce misconception, and they need to be tackled with accurate information. But I think what we really need to remember here is that sometimes when you think deeper and when you search deeper, sometimes, you realize that rumors reflect needs, emotional needs that are not necessarily addressed in the awareness sessions or the key messages that we share.

So, in MSF, we try as much as possible to treat rumors as an opportunity, an opportunity to understand the communities where we're working and to try to dig a little and understand better anxieties because they are legit, they're legitimate anxieties. We need to understand them, we need to acknowledge them, and we need to respond to them. There are a couple of things that can be done in order to respond to them. But really, what is really important and what I guess I want people to remember is that in order to understand rumors, we need to understand the inner drivers behind them and what are they hiding. Sometimes, they hide fear, sometimes they hide anxieties. By understanding that, then we can create the appropriate messages, the appropriate narrative to respond to them.

Sandrine Tiller:

Right, and start a dialogue.

Thiaba Anais Fame:

Exactly.

Sandrine Tiller:

Yeah, great. What about the real world consequences? I'm going to move over to Sabrina in the Democratic Republic of Congo. In your experience over there as a health promoter, have you seen some real-life consequences of misinformation and disinformation circulating online?

Sabrina Rubli:

So, we've definitely seen some consequences of all of the COVID misinformation and especially rumors here in the DRC. What's important to know is that COVID arrived in the DRC, specifically in North Kivu, just as the World Health Organization was declaring the last Ebola epidemic officially over. So, the last few patients were being discharged from the Ebola treatment centers just as COVID was coming in. So, the initial reaction of the community was one of great suspicion, where they, very quickly... They were very quick to say that, "Well, COVID is just another way for the government or for foreigners, white people, Chinese, anybody to kill us since Ebola didn't work."

Then, COVID treatment centers were very quickly being repurposed into COVID treatment centers. The checkpoints for hand washing and temperature that had been used during the Ebola epidemic were now being used for monitoring COVID. A lot of the ways that the government, NGOs, the World Health Organization was communicating about the disease to the community was just in the same way that they've communicated about Ebola. Ebola response had been really controversial. There was a lot of political, a lot of violence, sometimes even towards health centers, MSF included, up in the North. So, the suspicions that had lingered towards health care centers during Ebola transitioned into suspicion about COVID.

Then, because COVID did originate outside of Congo, from China, and then it spread across the entire world, and then finally made its way into Africa and into Congo and into even really tiny communities here, the assumption that white people or foreigners are trying to kill us became quite strong. So, we really had to focus our health promotion activities, and health promotion is where we engage with the communities, where we have medical intervention, so where we're supporting hospitals or health centers. Health promotion is how we communicate directly to the community. So, we did a lot of education surrounding all sorts of health issues.

One of our biggest challenges was integrating the COVID awareness, COVID education, and learning from them what their thoughts and ideas and opinions were about COVID into our existing health promotion activities. So, we didn't just want to stop talking about malaria prevention or malnutrition, or the importance of measles vaccinations because now we had a new epidemic, we had to fit it in into our existing programs, which was a challenge.

One of the biggest rumors that persists is the vaccine rumor. There is a lot of talk about how a COVID vaccine will be tested in Congo, or in Africa. They are very adamant that they will never ever, ever accept any COVID vaccination. So, we have to do a lot of work really telling the people, telling the communities where we're present that it's dangerous to accept any medication that's not verified by the government, by the OMS and even by MSF. That if there comes a day when the COVID vaccine is made available, it will not be tested on Congolese people. There's rigorous testing processes. So, that's a rumor that we can see having issues down the road. Already, we're unable to do vaccination campaigns, even right now because people are very suspicious of any sort of mass vaccination campaign. So, yeah, those are some of the real world consequences that we're facing right now.

Sandrine Tiller:

Yeah. That's really worrying. I think, what I'm reading from what you're telling me, or what I'm reading between the lines is really that it's establishing trust with the community. I'm just going to use that to jump over to Luz, who's in Haiti, and ask Luz a little bit to talk to us about the experience in Haiti. I know you guys have been doing a lot of work to build this trustful relationship. I'm just bringing in a question from Christina on Zoom. She was asking how we stop the spread of COVID misinformation. I think, for us, trust, building a trustful relationship is really key. So, tell us a bit about the situation in Haiti, Luz.

Luz Saavedra:

Thank you. I think that it's very interesting to see how there are certain commonalities between the context because we also have rumors and misinformation here that we are very concerned with because, as my colleagues were saying, it's affecting the health seeking behavior of people. When it comes to trust, I think, that it's important to contextualize where rumors come from.

Prior to the COVID epidemic arriving to Haiti, it's a country that was not in a great situation from the humanitarian perspective. We are talking about a country where more than 60% of the population was living with less than $2.4 a day, under the poverty line. If you compare it with the rest of Latin America and the Caribbean, the average life expectancy here is 10 years lower than in the rest of the countries, and so on and so forth. We can talk about food insecurity or the fact that, for example, something as simple as 50% of women are anemic.

So, I think that when we are contextualizing, we need to understand that COVID has act like a magnifying glass of all those existing vulnerabilities. But not only with regards to the vulnerability of people or what was the situation, I think that it's very important to highlight, and this is not something unique of Haiti, either. That is the uncertainty is related to the economic crisis that is affecting us globally. The political and insecurity stability, all these things have been generating a series of worries, anxieties, and people are basically tired to be fighting for survival. This is something that Thiaba was saying and Sabrina as well.

So, all these impacts, the levels of trust that people have in institutions, their own governmental institutions, but also INGOs like ours. So, we are extremely concerned about rumors and how we can create trust. We have been seriously affected by the epidemic on the way that we can work with people because before, for health promotion, we used to be able to gather a large number of people. Now, because of respecting the barrier measures, we need to change and adapt the way that we talk.

There has been a very interesting, and I would say, not necessarily expected side effect of this, which is that we have been forced to use other techniques to reach out to people. So, for example, to do what, here, we call porte à porte. So, we go to the houses of people with the barrier measures, masks and so forth. We can engage into much more one on one. This enables us not only to do the transmission of information, which is essential, but also to be listening and to understand better what are the pre-occupation kind of worries, what my colleague, Thiaba, was mentioning before and engaging to a communication that is much more on two senses.

Sandrine Tiller:

Interesting. Yeah. Actually, I'll bring in one of the questions that's just coming online. In your experience, Luz, have you been looking into certain rumor and then found that actually it's true? It may have seemed outlandish, but it's true.

Luz Saavedra:

As I was saying before, there's the issue around how you can trust. The fact that there has been declarations, internationally, and public declarations talking about what Sabrina was saying, the vaccination tests, do not help us. When it comes to rumors, there's some elements that were already present in the Haiti context with regards to, for example, injections. So it's very difficult to counteract something that people have the inertia of trusting in that sense. But then, when we see the impacts of these rumors, it's also interesting to see that it's not only direct impacts related to the epidemics in itself.

So for example, with the whole rumor around vaccination is not only because of the rumor that the frequentation of health centers for routine vaccination has gone down by more than 50%. It's also related to the fact that people don't know about this disease. This is an unknown disease, so there's fears associated to that and anxiety. People do not know whether if by going to the... There's fears of contamination. There's also impacts associated to the capacity of responding to the health needs of the population in the sense of functioning health instructors.

So, it's very difficult to understand certain things. At the same time, for example, in the Haitian context, there's a lot of people, given that 60% of the population live with $2.4 a day, there's a lot of people that trust on other ways to try to keep their immune system boosted through traditional medicine and so forth. So, it's very difficult to make the difference between these misinformations about you can cure the disease with just taking something and doing something for yourself with your own means. Of course, we try to be respectful and engage into this dialogue with communities.

Sandrine Tiller:

Right. Thiaba, I'm coming back to you with a question from Miriel about how MSF takes into account cultural sensitivity, and how we address rumors without offending communities?

Thiaba Anais Fame:

So, how we do that? Well, I was mentioning earlier that two things that we've been doing so far is a lot of rumor tracking and a lot of social listening. With that, we've realized what... I think COVID has made us collectively reflect on how we better ask community's perception in the sense that how people cope, how people grieve, how people react in adversity is something that we need to understand better so that in the way we adapt our messages and in the way we adapt our activities, we don't offend people.

We did a couple of relative assessment at the beginning of the pandemic. We realized that religion played a tremendous role in how people perceive the pandemic and how people perceive the virus. Our role here is not to tell people that praying is not going to help them protect themselves and protect their families. What we're trying to do though is two things. First of all, tell them that, "Well, praying is the way you've chosen to address the virus or to protect yourself from new virus, that's up to you. However, we would like to encourage you in the presence of this symptom and that symptom…”.

So, it starts by acknowledging culture and acknowledging that people will address, and people will face the adversity and face the virus the way they see fit. But it's also a manner of collaborating with the people that the community trust the most. So in Cameroon, in Congo, in Mali, in Niger, we've been working hand in hand. It has been hard, but we've been working very closely with religious leaders, with gatekeepers, with traditional healers, with people that when they speak, well, people will pay more attention. So, again, I think it's a matter of how we approach the message. Also, most importantly, it's about acknowledging that people or communities will run back to culture, run back to what makes them feel safe. It is not our place to ... How do we say that? Okay. I have the word in French.

Sandrine Tiller:

To insert ourselves.

Thiaba Anais Fame:

Thank you. Sorry. Sorry about that.

Sandrine Tiller:

Yeah. To put ourselves in the way. Yeah.

Thiaba Anais Fame:

Exactly. To put ourselves in the way, sorry. That's what I was going to say. So, yes. So, definitely, our colleagues, Luz and Sabrina has been talking a lot about trust, and trust is something that you built, you built systematically. You built by asking question, by listening, and by reflecting on who make decisions when it comes to health behavior, who people trust the most. How do we make sure that what we're trying to say and what the message that we're trying to convey does not flush away a little bit what people beliefs are, I guess.

Sandrine Tiller:

Great. Okay. Luz, I can see you wanted to make a point as well. I know this is a big topic for you in Haiti. I know you've been working also on engaging with traditional leaders. So, tell us a bit about that.

Luz Saavedra:

Yeah. In fact, one of the very interesting adaptations that we have to do with regards to COVID was to limit the number of people. So, as I was saying before, that enable us to have more one-on-one discussions and to create that element of listening and respecting and trust. One of the activities that was really successful was working precisely with community leaders.

I would say that it was not necessarily, again, not only transmission of information. Of course, that was part of it. But also understanding how they interact with their community and understanding their role as spokesperson, if you want, of the community. So, with the tracking of rumors, as Thiaba was saying, super interesting to see how certain things start to form a trend so you can adopt your messages better. I would say that normally, we would say training of traditional leaders, but in fact, this was quite a two-way street because we were learning as much from them as we were transmitting information.

I think in that sense and given that we have a US audience, I always say to the teams, a quote from Maya Angelou, that is a fantastic Afro-American writer. She says that people forget what you say, and people even forget what you do, but people never forget how you make them feel. We have been learning so much. As it's a new disease, we are all in our high-learning curve about trying to be more in the listening side of things, and how to do that respecting in that sense.

Sandrine Tiller:

Yeah. I think that's a really important point. Actually, I want to bring in Sabina here because I know that what you described in terms of the mood in the Democratic Republic of Congo, while they've just gone through a very serious epidemic with Ebola, which is, of course, incredibly scary and absolutely deadly, and then now, they have COVID. Then on top of that, they have all these other illnesses that are prevalent in those areas, malaria and measles. There's a huge outbreak of measles last year in DRC.

So, I think, tell us a bit, Sabrina, maybe also just from the point of view, the people you've met in our health centers. Where's their head up? How are we making this emotional connection with their feelings because it's much more than just saying, "Here are the facts." It's about understanding where people are.

Sabrina Rubli:

Yeah, absolutely. I think one of the first things that we noticed... Well, actually, one of the first activities that we did in our COVID response was at all of the hospitals and health centers that MSF supports, we set up a little triage stations and so any patient or visitor that comes has to have their temperature taken and wash their hands. Then, if they have a fever, they go to the side, and the temperature is taken again after a few minutes. Then, if they're deemed to be a suspect case or at risk, then they speak to a doctor who asked them a few more questions. So, there's a whole process that goes on.

One of the quickest reactions to us installing those triage was that we noticed the community no longer wanted to go to MSF health structures. So, that would be a very, very, very serious thing because, obviously, the health care system in DRC, specifically, where MSF works, I mean, in Walikale, here, there's no other actors working, there's no other NGOs. The access to health care is MSF.

So, very quickly, we have to manage that fear, and we have to really understand it. So, why were people afraid of going to MSF health centers? Was it because they thought they would catch COVID? No, not necessarily. They thought they would just, automatically, be put into quarantine. So then of course, we had to tell them and do a lot of focus groups and a lot of discussions and a lot of sensitization, going door to door, telling people and explaining the process, and just what does it mean to be a suspect case.

The fact that, no, if you have a fever and you go to seek health care, you will not automatically be put into quarantine or isolation. That was the fear that they would just be taken and held for 14 days and then released, which was not the case. So, we really had to explain to them that, no, that's not the case. If you have a fever, you will be treated for your symptoms, you will receive a malaria test. If you have other underlying issues, you will be treated. You won't just get put into this corner and left for 14 days.

So, I think for us as the health promotion team, it's all about talking to people. I think, as Thiaba mentioned, it's not about looking at the rumors at face value, but it's looking at as to why people believe that and what their underlying concerns are and what their fears are, and going a little bit deeper. So, focus groups for us have been a really great tool to understand more and more what people are thinking and what people are feeling. For example, one of the things that's come out is that a lot of people really believe that there's... We mentioned churches. Of course, churches here are really important part of the community. But because churches have been closed for so long, and schools as well, but the bars have stayed open, there was a very quick link to be made to, "Well, this is the devil's disease because the churches are closed, so we can't pray, but we can drink and we can take alcohol and all these other things that come along with that."

So again, we have to really manage that, as Thiaba said, very carefully and not say like, "No, you're wrong”. Prayer is a way for a lot of people to find comfort and support, and that's great, but COVID is not, to my knowledge, anyway the devil's disease. So, yeah, it's a lot of talking to people, understanding where their fears are coming from, and how that creates rumors. If we understand where they're coming from, then we can understand how we can manage them and not necessarily dismiss them or get rid of them, but just manage them. So, they exist, but they're not destructive, and they're not causing people to stop accessing health care, and they're not causing people to avoid the hospital and avoid the health centers, but just understand what is happening in their community.

Sandrine Tiller:

Right, right. I think it's a good opportunity to say that we have this environment. Also, in all of the countries where we are, in the UK, and I'm sure in the US as well, there's so much uncertainty right now. The science isn't giving us exactly precise answers. Some people are making up their own theories of why this and why that, what's safe and what's not. I've seen it happen even in my own family.

So, I think it's not a us and them situation. I think it's definitely, in every community, you have this phenomenon of feeling a need to explain what's going on.

Sabrina Rubli:

Exactly. Sorry. Just acknowledging the fact that COVID is really scary, not just for people in Congo, but around the world. It's a new pandemic. Nobody really knows what's going on. Everyone is uncomfortable with this. So, just acknowledging that, yeah, this is a really strange and scary and unknown situation, I think, is also really important.

Sandrine Tiller:

Right, right. Have the people that you've met in DRC, have they... This is a question from Mona in Zoom. Are they aware of the high cases in the US? Are you American, Sabrina?

Sabrina Rubli:

I'm Canadian.

Sandrine Tiller:

Oh, sorry. Well, they might be asking you. Are they asking you about what's happening in Canada or in the US?

Sabrina Rubli:

Definitely. People know that it's a pandemic, and there's massive numbers of cases and mortality around the world. I also bring that up. I give the example of what my own family is going through back home in Canada, where they've been in quarantine for months, and friends as well that are quarantined by themselves for months. I think it's almost like camaraderie, like we're in this together, we're all in an unknown situation. Yeah. People here have access. They know what's going on in the world, a lot of people. So, yeah. It's interesting to see their reactions to that as well.

Sandrine Tiller:

Right, right. Well, let me move to a question from Lily on Zoom. She's asking, and I'll hand this one to Thiaba because I think you're the one who's probably got this in mind. She's asking, "When there's so much information out there, and it evolves quickly and from different sources, what's the best way of keeping track of everything at different levels? So, community level, medical staff, health providers, the authority." How do we manage that, Thiaba? How do you help our teams in the field to manage all these different sources of information, and how to understand what's going on?

Thiaba Anais Fame:

So, at regional level, what we did is that we focus a lot, and by a lot, I mean a lot of energy on rumor tracking. I think when we talk about rumor tracking, people don't necessarily have the idea of how extensive this work is, but it's been super helpful, and it's been actually, one of the best way to make sure that we listen, we collect, we verify, we triangulate from different information, and we capture in one specific place, something that we call a log book, a rumor log book. That helped us analyze and respond to them and act upon them as quickly as possible.

We have to remember that we cannot, physically, react to every rumors. It's not possible. There's not enough of us. So, we have to prioritize them. One way to prioritize them is to see... Because some rumors are very well established and some rumors, in terms of impact or likelihood of happening, are kind of small. So, we don't spend as much energy on those rumors. So, we try to focus as much as possible on rumors that we deem dangerous. So, there are rumors, for example, about stigma, about violence against health workers or health staff, or rumors targeting foreigners, vulnerable groups, migrants, women.

In Niger, for example, we did have a lot of rumors targeting migrants. In one of our project in... I think, it was in Bangui, we had rumors targeting woman from a specific ethnicity that they were target, they were victims of violence, they were verbally and sometimes physically abused, et cetera. So, we tackle those as quickly as possible, obviously.

The thing is that rumor tracking has been... It's an extensive amount of work. But at regional level, what has really helped us well is that we have this working group within different agencies. So, you've got the UN, you've got the Red Cross, you've got MSF, you've got a bunch of people. That has been extremely important and extremely helpful in the sense that we shared and we discuss main trends, basically, what other agency sees on a weekly basis. We work together in terms of how do we improve the way we collect and the way we document this feedback. By working together and working quickly together, we've been able to focus on the feedback itself instead of trying to harmonize our approaches. How the UN works, it's their way of working, that's fine. How the Red Cross work, it is what it is.

So, really, I think that has been extremely helpful because what happens is that once we work all together, we try to extract recommendations from all the rumors that we see in Congo, in Niger, in Mali. We do it by region, and then we share these recommendations at different levels. So, these recommendations can help from a operational perspective. It can also help our teams at field level doing health promotion and community engagement. It can help the teams doing treatment, et cetera.

So, we've been able to maximize these resources and learn from each other and try to see red flags, and learn really from each other. I think that's another good example of how we've learned from past pandemics and past... like Ebola, et cetera. So, I think that has been extremely helpful. But rumor tracking is extensive, and it's systematic and it's regular. The reason why it works is because we listen, and we take these rumors seriously, and we act upon them as quickly as we can.

Sandrine Tiller:

Right, right. This is something, actually, in our little... This new project that we've just set up on misinformation and disinformation is we get to trial some rumor tracking software to see if we can have a more agile system. We don't know if it will work, but it's basically, also, to give people almost a kind of real-time view of rumors because, they move fast. I think it's a great initiative, what you're doing in West Africa because, yeah, we need to share that information and see them coming so that we can anticipate where it comes from.

Yeah. So, I wanted to actually go back to Luz on this topic, and just maybe start to zoom out a little bit about, I guess, maybe the complexity of misinformation in today's world. We've had a couple of questions about the role of government in promoting or disseminating misinformation and how we tackle that. There's different information coming from different authorities that maybe we can't openly say, "Yeah, that's wrong." I know Haiti is one of those contexts, where there's a lot of information coming from a lot of places. It's a place where we've been for many years, partly, because there's so much insecurity and so much contestation of the political space. So, I just thought you're the head of mission there, so maybe you can help us zoom out a bit and talk about maybe the more political angle on things.

Luz Saavedra:

Well, interestingly, Haiti, like many other countries, it's a country that depends a lot on remittances from migrant workers, from the country that are elsewhere. Some of the biggest communities are in the US and in Brazil, and in Chile, my own country, where unfortunately, what the authorities were saying was not necessarily matching what the authorities were saying here. This is an island that has two countries, the Dominican Republic and Haiti.

So, sometimes, these contradictions between what the different governments are saying are quite telling, and they explode a lot into discussions, particularly, on social media. So, that's really interesting that you mentioned that because it has been sometimes, as Thiaba was saying, for us to follow up on the rumors and misinformation. It's a very, very work intensive-element. Talking about the context and the evaluation, it's also true that because we have been forced to be more on the listening side, given the unknown elements of this crisis. People talk to you about which are the barriers that they are having to access help. That is when you start going into more a slippery slope of evidently, in this country, like in many other countries, their financial barrier to access health care is a massive one.

There's elements that are related to security. So insecurity in certain areas, and you can see in the background, a map of Port-au-Prince, it's also a massive barrier, and how we communicate and how we interact with the different groups to ensure acceptance by all parties involved. It's really tricky from a political perspective as well. Then there's elements with regards to... it's not only understanding what MSF can do for you, but also how is the status of certain healthy structures. Are they functional or are they not? Until which point, sometimes the official version is there's X, Y, and Z, but then the reality can be different. So it's a really, really tricky one in that sense on how we communicate with people and how we ensure that our political awareness with regards to certain elements that are linked directly to the levels of social contestation in the country and to what I was referring before, in terms of people are tired, tired of fighting for their survival.

There are certain things with regards to the direct and indirect impacts of COVID, that we as MSF, as Doctor Without Borders, we are not going to say. But of course, I'm very happy to see absolutely, unbelievably, amazing civil society of the Haitian variety groups, activists, and so forth. They are the ones that are in the best position to make a political will of certain situations. A lot of what is happening is linked to a disease that we don't know much. But as I said before, COVID is a magnifying glass of all the structural problems that were there before and that we are seeing.

So for us, I insist, again, because it's really a very important point. We are learning so much, just by enlarging our scope of listening, not only to the populations, but to other colleagues of the local and solidarity networks and so forth that are doing an unbelievably brave work against all winds and tides. We are in hurricane season, so it's not just an expression that help us in that sense to bring the political to understand why needs are as they are and why the capacity of response has been massively impacted by these epidemics.

Sandrine Tiller:

Yeah, thanks. This is definitely my topic and my area, so I'm very interested in that and what you're saying. Certainly, these projects that we've just set up with MSF is to look at how maybe the more political dimensions of the effects of misinformation and disinformation, and how it is going to affect our society. I do think that it is going to have some really serious effects on trust in health providers. I think the example that Sabrina gave about the fact that people are really worried about the vaccines, this is not only in DRC, this is a global issue.

All the points you've just made, Luz, about the political dimensions of who manages truth and who's reality, I think these are really big challenges for us in the future. As a global society and as a global health factor, we really want to get ahead of that curve because I think the effects on health are going to be very serious.

So, we're just at the final minutes of our webinar. So, I'm just going to wrap up, if you allow me. I want to say a big thank you to Luz, Thiaba and Sabrina for a fascinating conversation and for taking the time to be with us today. Really appreciate your insights. I also just want to mention that we had a lot of fascinating questions on Zoom. Unfortunately, not all of them fit in the flow of conversation, but they were really, really interesting. Yeah, I'm still looking at some of them right now.

But I just want to close today. It's been a pleasure to be your host today. I had a little internet connection problem a minute ago. So, I hope that didn't affect you too much. MSF USA's Executive Director, Avril Benoît will be back in two weeks for the next and final episode of the summer series, Let's Talk COVID-19. Join us on Thursday, September 3rd, and we'll discuss the future course of the pandemic and the challenges that lie ahead. Thanks to all of you for joining us. If you have any questions, and you'd like to stay in touch with MSF, you can email us at [email protected]. Thank you very much. Goodbye.

Avril Benoît:

Here I was already talking with the mute on I should know by now. I'm Avril Benoît and welcome. Thanks for joining us for this series that we're doing called "Let's Talk COVID-19." We've been doing this every couple of weeks and it's really important for us to stay connected with you over the course of the pandemic, when so many of us are separated. I also just want to acknowledge that today we're going to be talking about one of the places where we're working on the pandemic COVID-19, Yemen. At the same time our thoughts are very much with our colleagues in Beirut and all the people of Beirut. We are doing this live on Thursday, you may be watching it... the recorded version some days later. So certainly things are changing but since we heard of the massive explosion, our hearts really went out to everyone there and I just want to acknowledge how hard it must be for everyone who is a first responder trying to help.

For the teams of Doctors Without Borders, of Médecins Sans Frontières, we have numerous teams in different parts of the country including in Beirut and they've been working very hard to try to support the local capacity there to provide medical support. So we'll hear just a bit about that in a moment. I'm Avril Benoît, I'm the executive director of Doctors Without Borders in the United States. We are also known by our international name Médecins Sans Frontières, MSF is the acronym you'll often hear over the course of this discussion. I just want to really focus today on Yemen, because it's a place that is one of those crises that has a compounding effect much like what's going on in Lebanon right now with the economic collapse and with the pandemic. All the burden on the political life of the country. In Yemen in particular, we have a national health system that's already been pushed past the brink of collapse for years because of a devastating conflict of course.

As COVID-19 has come into it, we've had a spike in deaths in Yemen, our teams in Yemen are dealing with many, many challenges there from having access to COVID tests, personal protective equipment which has been a pressure point for many of our teams around the world, and of course inadequate hospital staffing and misinformation about the virus. All the things that could go wrong seemed to be going wrong but we are working with health colleagues from Yemen to make it so much better, so we're just going to really focus on that today.

Before I continue a couple of quick little notes about this webinar, we will go for around 45 minutes and wherever you're joining from today you can join with your questions you can ask them. If you're watching on Zoom send the questions through the Q&A, it's just there at the bottom of your screen. If you're joining us on YouTube live or Twitch you can send the questions into the comments section. We will prioritize of course questions related to the pandemic in Yemen. So joining me today we have three guests, Dr. Nizar Mohamed. He's an MSF anesthesiologist and an intensive care unit doctor in Yemen. We also have Dr. Diana Galindo Pineda, she's the medical team leader for MSF in Yemen and Ghassan Abou Chaar, deputy emergency desk manager for MSF and I'd like to say hello to all of you.

Are you all there? We'll just make sure that we have established contact. Ghassan maybe you could tell us, you're also keeping an eye on what's going on in Beirut, maybe you can just give us a quick overview of the kinds of things that we're trying to do to support the injured in Beirut today.

Ghassan Abou Chaar:

So first say that our teams in Beirut are doing fine. Directly after the blast or the explosion, a couple of hours after we have been able to take what we have in stock in terms of essential drugs that could be useful in the hospital that were overwhelmed with the wounded. So we distributed some of our stock and since then we have been going around in the different neighborhoods of Beirut doing assessment and looking at support we can do in terms of medical care for the people in the hospital and outside, but also other needs for the people who are displaced and left without homes and are staying in different areas from where they are originally. So we are sending drugs inside of the country and there's also an extra team that will join the teams in Beirut soon.

Avril Benoît:

Okay, it's really good to hear. It must be so difficult for them and we were heartened soon after the blast to hear that the MSF staff was all accounted for because that's one of the first things that you have to do is just say, "Where are your people? And is everyone okay?" And that's certainly something that we know what a close call it was for so many of them. Maybe I could just check in with you Diana, tell me where you are and what's on your mind today?

Dr. Diana Galindo Pineda:

So I am in Sana’a, I'm actually next to the Dr. Nizar and we're in the coordination office. It's raining so I hope that connection doesn't cut or anything. That's it.

Avril Benoît:

Okay, and how about you Nizar, how are you today?

Dr. Nizar Mohamed Jahlan:

I'm fine but as Dr. Diana says we're raining too much, it was so difficult to come to the coordination office. I'm now in the head of the patient office.

Avril Benoît:

Okay, and so what sort of impact is the does the rain then have on movements around the city?

Dr. Nizar Mohamed Jahlan:

It's so difficult. So a lot of streets, a lot of them it's broken and you cannot cross for several hours sometimes.

Dr. Diana Galindo Pineda:

Sorry, it's an issue for our staff to move but also for patients to move around, and pharmacy and everything is really difficult to move things around the city.

Dr. Nizar Mohamed Jahlan:

Mm-hmm.

Avril Benoît:

We are likely to have a little bit of a delay on the call but that's okay we'll just get used to it. Ghassan maybe you can just start by giving us a general overview of how COVID-19 has affected Yemen?

Ghassan Abou Chaar:

Well, COVID-19 arrived... and first of all we were very surprised that COVID-19 arrived to Yemen. Yemen has been since the beginning of the war in 2015 cut out somehow from the rest of the world, half of the country has some sort of an embargo on it where airports are closed, no commercial flights, ports are very heavily controlled and then in the south of the country there is not much going on, not much exchange, one plane per day maximum so we're very surprised that the virus arrived in the state. After four years, five years today of war the economic situation of the population is very difficult to do the day by day to be able to feed their families, to give to the babies good food, good milk what is really essential for the nutrition. On the same time the health system in the country is already we can say collapsed, is sort of surviving on cost recovery. Patients have to pay for emergency services and the rest on NGOs and hospitals like our hospitals that we run that are free of care for the population.

The COVID when it started it was a big shock for everyone. The Yemenis didn't believe it and I understand that, they didn't believe that exists so it went unnoticed. The Ministry of Health didn't have testing capacity so we were surprised directly by patients arriving on their last breath to our hospitals. So nobody was ready for it, at the beginning the first weeks were very, very difficult we had very high mortality. We knew first about the epidemic by counting tombs in the graveyard, we saw a big increase of death specially first in the city of Aden and then in the city of Sana’a. And surely, the hospital of the Ministry of Health couldn't cope with that and it's really a sad situation even before the COVID outbreak and this outbreak just made it much worse.

Avril Benoît:

I can imagine. Diana and Nizar you're both working at the Al-Kuwait hospital in Sana’a, can you describe Diana what it's like there at that hospital?

Dr. Diana Galindo Pineda:

We're working with the Ministry of Health, we have an ER that gets older patients we treat them. Some of them we discharge them home with just some advices about how to self-isolate and others that come in bad shape then we keep them rather in the IPD or the ICU, we have both services.

Avril Benoît:

Nizar is the ICU very busy where you’re working?

Dr. Nizar Mohamed Jahlan:

Actually, there is a big difference and between... since two to three months from the beginning of the pandemic and the crisis and on those days, the numbers decrease a little bit but also the risk factors decrease more than 50%. There was a huge number of mortality case in the ICU as it was all over the world, but now it's decreased a lot in comparison with the before.

Avril Benoît:

It's difficult though when you don't have access to testing, we have already a question that's come in from someone watching on Zoom and asking is there a real sense of the infection rate of COVID-19 in Yemen? Ghassan you mentioned in the beginning the best we could do was count newly dug graves. How are things now in terms of knowing who has it?

Ghassan Abou Chaar:

Just to give an example of what we have as numbers today, official numbers of COVID-19 cases officially declared by the Government of Yemen is around... I don't know the exact number but it's around 1700. In our two hospitals we have so far treated around 1200 and those are severe cases or very, very severe cases. We know that we don't cover the whole country we only cover two cities, we usually see from the numbers that only 5% require intensive care unit so where are the other 95%? They are today not officially declared. So we think we are only scratching the tip of the iceberg from what we see today.

Avril Benoît:

It must be so difficult to go out and run testing sites. Diana can you speak to that challenge?

Dr. Diana Galindo Pineda:

It's difficult because as I was saying even transportation can be a challenge, and there're shortages everywhere for tests. So Yemen is of course not an exception and it's even more difficult to get them properly done here. So we go a lot with clinics, we go a lot with some other tests, X-ray, CT scan that we can do in some cases but we trust a lot in the clinical sense of our physicians.

Avril Benoît:

Diana how much did this arrival of COVID-19 affect the other medical work that MSF was doing before the pandemic?

Dr. Diana Galindo Pineda:

So, as you were saying it's already a difficult situation sanitary speaking, and the fact that everything stops for all chronic diseases makes it even harder. So we are now seeing a lot of patients that have comorbidities that don't go to another internist anymore, that cannot have any proper control of cancer or hypertension or diabetes and this is young and also old people. So the base let's say it's already affected, and then COVID is just coming and making it... everything much more hard.

Avril Benoît:

One of the things that has been very difficult for many teams and many medical staff all over the world really has been some of the misinformation. Even in the United States I can tell you it's been absolutely appalling the level of misinformation that's been going around even from people who should know a lot better. Maybe Nizar you can tell us what it's like there, what sort of lies and falsehoods are spreading about COVID-19?

Dr. Nizar Mohamed Jahlan:

Because this is a crisis it was sudden and all over the world not just only in Yemen, and regarding the Yemeni people and the community they cannot believe this... we have a COVID-19 in Yemen. They denied it from our society, even from our communities they said we don't have COVID-19 and there was a lot of people dying at home and they don't know that they are getting the disease. Actually, we're receiving a lot of bodies because we have only one center for washing the cadavers and then shifting them to a specific place as guiding by Ministry of Health. So it was so difficult to get any numbers or any information from those people, till now we are still suffering from this issue.

Avril Benoît:

Well, there are a number of issues that I'm sure our audience is interested in asking you about. If you're watching on Zoom again you can send your questions into the Q&A and they will be passed along to me. If you're watching on YouTube Live or Twitch, just send the questions into the comments or the chat section and we'll find them there. Let's talk a little bit about supplies, Ghassan you mentioned the blockade, the difficulties of moving supplies in. Is there not a humanitarian sort of exception for medical people to be able to get what they need for this?

Ghassan Abou Chaar:

We do, we have been able to negotiate access in Yemen for humanitarian aid since after the war started in 2015. The system is very difficult, it's very cumbersome. It costs us a lot of money to be able to navigate it, however we are able to get it in. But the problem is that usually in countries where we work in, as Médecins Sans Frontières where there's a situation of war or there's something, we operate as medical staff, we work in hospitals and there are other hospitals nearby working. It's difficult to take charge of a whole population of 27 million as of Yemen. The problem is that other hospitals and pharmacies are not able to bring in medical supplies quickly and as easily as we can and it backfires on us because we are getting more. For example, what happened in Aden at the beginning of the epidemic is that the rest of the hospitals stopped working because they didn't have enough protective equipment.

So we were the only hospital working in the city and it's a trauma hospital, it's a traumatology hospital we were receiving all the cases. So, issues of supplies already were difficult around the world because the shortages of supplies related to this pandemic were very difficult to get in. We prioritized Yemen as an operation because we know that the country will not be able to get in other supplies rather than the humanitarian aid.

Avril Benoît:

You are watching a special webcast from Médecins Sans Frontières or MSF, Doctors Without Borders, and my guests today are Dr. Nizar Mohamed, an anesthesiologist and ICU doctor working in Yemen, Dr. Diana Galindo Pineda who is a medical team leader, and we also have Ghassan Abou Chaar who's the deputy emergency desk manager for MSF and we welcome your questions. I actually have a question, it's clear that you are the ones who are working in Yemen itself. You're working tirelessly around the clock even at the best of times before this pandemic. Well, there are no best of times because of the conflict. Diana how has the fighting which is sporadic affected the work that MSF does in this pandemic?

Dr. Diana Galindo Pineda:

So in Sana’a we have maybe a little bit less affection let's say, in the south it's definitely different. It depends on how far you are from the frontlines. It doesn't stop... the war doesn't stop and doesn't respect the pandemic, so we just have to cope with having both populations still in need of care.

Avril Benoît:

What effect is the staffing shortage having on our ability to deal with it?

Dr. Diana Galindo Pineda:

Sorry, can you repeat the question please?

Avril Benoît:

What effect has the lack of medical staff and the collapse of the health system also, what effect has that had on our ability to support efforts to address the pandemic in Yemen?

Dr. Diana Galindo Pineda:

That the quality of care will not be ideal and we will not be able to reach the same care that we would like to provide. We don't have the main, the ratio, necessary to treat the... for a certain number of patients we need a certain number of doctors and nurses, and so it's really hard to reach a good level of care and we're still struggling with it.

Avril Benoît:

Yeah, and Ghassan we are trying to work also in support of other organizations you have mentioned already the Ministry of Health, what sort of partnerships do we have in Yemen?

Ghassan Abou Chaar:

Well, most of the work we do in Yemen we try to do it with the local authorities which is the Ministry of Health that operates hospitals, referral hospitals or other that needs support so we come and support those centers. Usually, maternities or trauma centers or even just general hospitals are dealing with everything, and so most of the time we work with the Ministry of Health but we do it very closely with the centers themselves, especially smaller health clinics near the front lines that receive a lot of wounded population but also with a population around that is suffering a lot. So we have direct contact with those health centers and we support them directly with sometimes staff, sometimes drugs depending on each of them. So we do it a lot with health professionals, local health professionals are the ones we do it with and sometimes we do it alone depending on the setup and what is the easiest way to do it.

Avril Benoît:

Dr. Nizar I have a question for you about the intensive care units. There has been over the course of this pandemic of course a lot of new learning about intubation, oxygen, all the ways that you can support somebody in the ICU. What works, what works less well than we thought it would, what has been your experience in the ICU?

Dr. Nizar Mohamed Jahlan:

At the beginning actually we have a lot of challenges regarding this subject. When we are talking about the oxygen supply at the beginning we don't have a reservoir in the hospital, and we starting to receive the patient with... using manifold cylinders supplied by MSF, and we have big challenge also regarding the negative pressure vacuum system which is mandatory in the isolation ICU room in COVID ICU, and that's... At the beginning we have big challenges regarding the staff, health staff so they don't have any experience regarding those patients. So I was with them from the beginning and we were suffering a lot at the beginning, and I got an infection because of this difficulties of managing these patients.

Avril Benoît:

You got the infection yourself?

Dr. Nizar Mohamed Jahlan:

Yes.

Avril Benoît:

And how was it for you?

Dr. Nizar Mohamed Jahlan:

It was so difficult for me because I was afraid I transferred the infection for my wife and she's crying a lot and he told us he became a widow within days. Really, really, it was so difficult for me and for my family also but thanks God I come back and I resume my activity again inside the ICU and I'm still working till today.

Avril Benoît:

Yeah, it must have been so difficult. How has the infection rate been among medical staff, healthcare workers and even hospital staff?

Dr. Nizar Mohamed Jahlan:

Yeah, there was... because there was an epic shortage in our PPE, personal protective equipment at the beginning and most of them they don't have experience how to use it. We did some training courses but we cannot cover all the theme, all the health stuffs was covered by MSF at the beginning of... but later on we don't have the time to cover all of those medical health. So a lot of them they got an infection and we lost a lot of our friend, not in our projects but outside. In our project, there was the only about three to four doctors and nurses with the infection, I was one of them. Actually, it was very, very difficult then after I recovered I insist to come back to work because I know what's the patients suffering from it. So thanks God and I hope all rest patients in the ICU to be recovered as soon as possible.

Avril Benoît:

Yeah, and Diana how was it for you to manage that whole situation?

Dr. Diana Galindo Pineda:

So, to complete a little bit what Dr. Nizar was saying, I think in Yemen as in everywhere in the world there's a high peak of mortality at the very beginning and then it starts going down even if we still have a lot of patients. The teams learn how to... we learn from the other countries, so mortality has been decreasing and also we're having a little bit more of access about certain materials or medicines and even more staff that can come back to work with us.

So it hasn't been easy to see such high mortality rates I... it's the first time that I have so many deaths in a project and it's hard to have to deal with the logistics of dead bodies and huge amounts of oxygen and huge amounts of waste, and it's a whole different way of working that we have never seen before and that we're learning day by day. So it's been challenging but it's been very motivating and the team that we have is extremely motivated, it's very open to all of the trainings. Once again we don't know anything about everything because we're also just learning from what's happened, but we are lucky that we can get that motivation like put in a good way of working.

Avril Benoît:

Yeah, it's... what you're describing is the emotional and psychological toll that certainly doctors in other parts of the world where they were really facing full, full hospitals and that high mortality rate, the difficulty that they have to overcome it but then it's also people who are caring for those who have COVID-19 at home and the fear of all of that. We have a number of questions coming in from people who are watching us on Zoom and on YouTube and on Twitch and all of the rest. This is from Frederica, does COVID-19 also have an impact on cholera in the country? Maybe Diana you could take this one.

Dr. Diana Galindo Pineda:

So, cholera has been around in the country for a long time already. Dr. Nizar he also knows because we actually in Al-Kuwait we used to do already interventions for cholera. So it's something that comes back every now and then, we're crossing our fingers so it doesn't come back very soon because really it's not a good moment to have it. With the rains that are happening we will see how it evolves.

Avril Benoît:

A related question in terms of the specific vulnerability of Yemen is also the food insecurity. Ghassan this is something that we've been watching for many years, what kind of concerns do you have about how the food insecurity is affecting our ability to deal with the pandemic?

Ghassan Abou Chaar:

The food insecurity and malnutrition has been present in Yemen since many years, the effect of the war on it is that more people couldn't have enough purchasing power to be able to have enough resources. We see it in another way, we see it for example the effect on children who are malnourished even before they are six months old which is very strange. Usually, malnourishment are over six months and we see it because the mother is obliged to go to work and she cannot give her baby a formula milk so it has very strange impact. It's not just a shortage of food but it's how the people can access this food and what do they prioritize. For the moment people are still prioritizing buying food for their family, however they are taking from their economies, they are selling land, they are... so it's a very difficult situation if it continues like that it's not something that the people can resist, be more resilient, that the word I'm searching for.

Avril Benoît:

A related question from Kathy who asks it via Zoom, are there COVID cases being identified among children in Yemen as we see in the United States for example? Diana are you seeing children?

Dr. Diana Galindo Pineda:

We are lucky that we are not seeing many children and we're really lucky that it's not the case. We've had a couple of them not more than 10 I would say, but we are... it's not easy to watch them so we really hope that we don't get more.

Avril Benoît:

Yeah, it's difficult though as you described earlier with the lack of testing capacity around the country, and if the people are not so sick as to come to the hospital their chances of getting tested seemed quite limited. Just a follow up to that topic from Jake who's asking is there access to diagnostic testing in Yemen? So we covered this a little bit earlier but maybe Nizar you could speak to this. What is available to somebody who thinks they have it?

Dr. Nizar Mohamed Jahlan:

As we said we have shortages, there was a global shortage regarding the tests especially for the PCR for the COVID-19, but day by day we are dealing more on sample facilities that we have even when we don't have a CT scan inside our hospital. We didn't own the assemble chest X-ray and the skills of our doctors in the ER, in the IPD, in the ICU for the symptoms and the signs which day by day is improved, and still we are depending on it except some people who came from outside, from another private hospital they came by confirmed cases by the CT scan results, we depend on it too much and that's it.

Avril Benoît:

Yeah. We have a question here for you Nizar from Shruti Sharma.

Dr. Nizar Mohamed Jahlan:

Mm-hmm.

Avril Benoît:

What is the general mood of the people in Yemen in relation to the overall situation in the country? I mean we had talked about the cascading problems of the war and malnutrition and cholera, and it just seemed one thing after another and now this. So how are people doing?

Dr. Nizar Mohamed Jahlan:

Yes, a lot of crisis they are facing in our society in Yemen but as I told you the people they said and denied and they said we don't have COVID-19 in Yemen. Till today most of them they say we don't have a COVID so that's it... and a lot of suffering also from people regarding this... and that's it.

Avril Benoît:

We have a question here from Anushka. Are there violent threats for example bombings or attacks affecting MSF hospitals and operations in Yemen? Ghassan what do you know about the security environment as it affects our work?

Ghassan Abou Chaar:

Well, it depends on where we are. We had five of our health centers and hospitals have been bombarded during this war. We had even a death in our teams and our patients during those bombardments... aerial bombardments. This especially in the north of the country in areas where there is a lot of airstrikes, and still ongoing until today that's a very dangerous area to work in. In the south of the country navigating through different fighting due to war but also due to fights in families, and in neighborhoods is a different type of threat environment to work on and to navigate in. So it's... Today Yemen is one of the biggest operations for MSF due to all the medical needs, but it's also one of the dangerous that we are working in.

Avril Benoît:

A question here on Zoom from Borchueh Wu, are you seeing different outcomes in Aden or in Sanaa or is MSF operational response similar in both places? Ghassan what do you know of the difference that we're seeing in the both regions?

Ghassan Abou Chaar:

It's the same that we saw, the same result I would say from... in terms of mortality and in terms of what the patients are responding to. So in the two projects we are minimizing the use of invasive intubation and we are moving to use of non-invasive intubation and we see an improvement and the... and how the patients are responding to that, so mortality rates in our intensive care unit is improving. However, the only difference is that the curve in Aden was much shorter, it was much quicker while in Sanaa its staying. It's going down but in a very, very slow tempo and this curve is not the epidemic curve it's the curve of the patients that we receive in our hospital. So it's... this is how we are reading the epidemic for the moment.

Avril Benoît:

Yeah, and I'm sure there will be lots to analyze. I mean this has been a phenomenon with a novel virus like this how much you learn about what are the techniques that work better, but with people having better survival rates in the hospitals I have a question for you Diana from Katherine Brown. Are people afraid to go to hospitals or clinics because they might get sick inside the hospital and have worse outcomes for having gone? And if so what are MSF teams, what is Doctors Without Borders doing to encourage people to come and re-assure them that things will be handled in a safe way?

Dr. Diana Galindo Pineda:

So, we had sort of two phases of patient arrivals. The first one was at the very beginning of the epidemic, people were really afraid to come to the hospital. There were a lot of rumors, a lot of misconception so people didn't want to come in. They were arriving at a very, very late stage and now we're receiving a little bit more people that come maybe before, but then there's also some kind of denial. So it's just the... they think its just a regular respiratory infection. The caretakers they want to come in, they want to visit their families because they say coronavirus is over so it's very... it changes very fast. So we... Yeah, we faced those two those ways and now we're adapting to how to not make the other caretakers and the other people that are coming for other diseases, not to get infected because we don't want to give them nosocomial coronavirus.

Avril Benoît:

Peter is asking are people required to wear masks in Yemen? And if they are, are they wearing them? I guess not if people don't really believe it's a real thing. Diana?

Dr. Diana Galindo Pineda:

I think Dr. Nizar will be able to tell you about the outside world of the hospital. In the hospital its mandatory and we wear it all, but in the streets Dr. Nizar can tell us more.

Dr. Nizar Mohamed Jahlan:

Yes, humans in the community, Avril?

Avril Benoît:

Yes.

Dr. Nizar Mohamed Jahlan:

Yeah, they stopped even the social distance and wearing the mask outside. In our malls and markets it was a mandatory in the previous month to wearing them, you couldn't go inside the malls without a mask. Now it’s free, all of them they said we don't have more coronavirus and we are okay.

Avril Benoît:

You know what? I was watching the footage from Beirut and their first responders dealing with... trying to rescue people to get them out of harm's way, and looking at the pictures I was really struck by how many masks I was seeing in Beirut among those first responders. I mean not everyone, some of them were wearing under the chin and others are not wearing but it's clear that when you have the compounding effect of a catastrophe, or in the case of Yemen the crisis of bombing shelling and all the violence that can go with being in a conflict zone mixed with the pandemic it's just unfathomable. Ghassan maybe you can just... since we started with you in talking a little bit about the work that you're also managing for Beirut and the emergency response there. How you see this mix exacerbating the problems that we're likely to see in Beirut, just as an example of something that's very much on our minds.

Ghassan Abou Chaar:

I think the... I was... I'm Lebanese as well but I was surprised to see since the beginning of this pandemic and the cases in Lebanon that the people started wearing masks, I was thinking they will not wear it. There everyone was wearing it because they knew that the health system in Lebanon is weak already and in case the number of severe patients that need hospitalization go up very, very high we will just collapse. So, the people were wearing it out of fear of it, and now with this bomb that happened I agree with you I saw a lot of people still wearing them not the majority, but today it's changing again and the people are going back to taking care of that because the people are afraid of this mix of so many factors, the economy and the blast and the homelessness and yeah the health system will not be able to cope.

Avril Benoît:

Well, let's do a final round. We have many people asking how can they help? It's sometimes so overwhelming what's going on all around the world and when we really focus in on Beirut and on Yemen, it's sometimes also you just think, "My goodness, what can I do?" Ghassan what would be your message to those who would like to help?

Ghassan Abou Chaar:

I've been following Yemen since 2017. I've been there in 2017 and we see the number of donations going to the... not only to Médecins Sans Frontières but to the UN, to the whole humanitarian community is decreasing a lot and this year has decreased a lot, and without this humanitarian aid it would be very difficult for the population to keep going. Today there is no work, there is no income, there is no trade and the country is closed up. So for us it's... for us in Médecins Sans Frontières we are suffering with that, we are seeing other NGOs around us that used to be... we used to be working together filling gaps here and there, it's still not covering the whole country. Now we see them decreasing their projects and their support one by one and this year was really very... like a big decrease even with the COVID and the people are decreasing and we see less activities. We see health center that used to have malnutrition children are not supported anymore. Usually people who are likely given assistance is not receiving it anymore so we need this.

For us Médecins Sans Frontières, we also are suffering from this crisis to be able to find all the drugs and the supplies to send, and to have enough people to send and help as well. For us we need people, we need supplies to be able to continue working because Yemen is... as I said it's one of our biggest operation and it's very big, but there are other countries that are also starting to suffer from this pandemic so we are increasing everywhere. I think most importantly for me is not to forget that there is Yemen and this is happening there, and there is an ongoing war since now five years and it doesn't look like there's an end.

Avril Benoît:

Diana, what do you tell people who say, "I'd like to help, what can I do?"

Dr. Diana Galindo Pineda:

I would say wash your hands, take care of yourself and others, wear a face mask when required and fund us, we're really underfunded. I find myself comparing prices of antibiotics so that I give the cheapest one that is still good quality, and it's hard for me as a general physician to have to make these concessions or to have to think I'm going to use this instead of that because this is way too expensive and it's actually not that expensive.

Avril Benoît:

And finally Nizar, what can people do to help?

Dr. Nizar Mohamed Jahlan:

I advise everyone that we are not... and we are still in waiting for the second wave of COVID-19 we are not in safe sight till now, so everybody they should take care.

Avril Benoît:

Okay, we will and I really wish you lots of courage, and to the entire team working in Yemen thank you so much for all the efforts-

Dr. Nizar Mohamed Jahlan:

Thank you.

Avril Benoît:

Under very difficult circumstances and I really appreciate that all of you were able to take a bit of time off today to talk to us. It's been really a rich conversation and I wish you all the courage in the world to keep going. My guest today have been Dr. Nizar Mohamed, MSF anesthesiologist and an ICU doctor in Yemen. Dr. Diana Galindo Pineda, medical team leader for MSF in Yemen and Ghassan Abou Chaar deputy emergency desk manager for us. Thank you all and thanks to you if you are watching thanks for joining us, I really appreciate all these really good questions. Apologies if we didn't get to your question today, we'll be back with another of these Let's Talk COVID episodes in a few weeks. We're going to focus on disinformation next time, this whole question of the falsehoods and how it makes life so much more difficult for all the health workers who are doing their best to keep people safe, and get us through the worst of this.

So for more information on all of this you can check out updates on our website about our work in Yemen, about our work in Beirut, about our work in all the crisis zones emergency situations around the world where Doctors Without Borders has activities. In the US our website is doctorswithoutborders.org, internationally it's msf.org. We have a number of Facebook sites in English it's msf.english, on Twitter you can find us @MSF_USA and on Instagram we are also all over it. So for more specific questions that you might have please don't hesitate to contact us we would love to hear from you. We have an email address called [email protected]. I'm Avril Benoit signing off and thanks again for tuning in. Bye for now.

Wendy Lai:

Welcome everyone. Good afternoon or good morning or good evening from wherever you're joining us. Thanks for joining us for our series Let's Talk COVID-19. This is the fifth episode in an eight-part series which is presented every two weeks through to September 3rd.

My name is Dr. Wendy Lai. I am your guest host this week since Avril Benoît is away. I'm an emergency physician and I'm the President of Doctors Without Borders here in Canada, joining you from Toronto, Ontario.

You may know our organization by our international name in French, which is Médecins Sans Frontières or MSF. It's an acronym for the French title and you'll be hearing us talk a lot about this today. We use the short form, MSF, for everything.

Today, we'll be talking about the devastating impacts of the COVID-19 pandemic on residents of nursing homes and other long-term care facilities, especially in older adults who are at far greater risk of being infected by and dying from this new coronavirus.

MSF has been assisting the elderly in care homes in several countries in Europe and we're now applying a similar model to our work in the US. Today, we'll talk about what can be done to protect vulnerable people in long-term care facilities and how to support the essential workers who are caring for them.

Before we start, though, a bit of housekeeping. This discussion will last approximately 45 minutes and wherever you're joining from today, you can submit questions to add to our discussion. We really do want to hear from you. If you're watching on Zoom, send questions using the Q&A option at the bottom of your screen and if you're joining on YouTube Live or Twitch, you can send questions in the comments or in the chat section. We will, of course, be prioritizing questions that are directly related to today's discussion.

I'd like to introduce you to my two guests today joining me for this conversation. Firstly, Luis Encinas, a registered nurse and medical advisor for MSF's COVID-19 response in Spain and Portugal, which included support to care homes, and Heather Pagano, the emergency coordinator for MSF program in Michigan, supporting long-term care facilities. So hello to you both.

Heather Pagano:

Hi Wendy.

Wendy Lai:

Hi.

Luis Encinas:

Hello. Thank you.

Wendy Lai:

Hi Luis. Let's start by telling us maybe a little bit about where you're joining from and how things are going today. Luis, do you want to start?

Luis Encinas:

Yes, I do. Welcome and thank you for inviting me. I'm right now in a small village in Vendée in France in Saint-Laurent –sur-Sèvre, so a small village on the West Coast in France.

Wendy Lai:

Wonderful. Jennifer?

Heather Pagano:

Hi. I'm Heather and I'm here in Detroit with my amazing team. They're out actually in three facilities at the moment doing the super hard work while I'm here with you all. So thank you for having me.

Wendy Lai:

My apologies, Heather. Thanks for joining us. I'd like to start with this, which is a lot of people and perhaps including our usual supporters may not expect MSF to have activities in long-term care facilities, especially in places with significant resources like in Europe and in the US. So I think it would be useful for us to hear why MSF decided to respond in the places where you are and maybe we can talk a little bit more specifically about the kinds of activities that we're doing.

Luis Encinas:

Should I start?

Wendy Lai:

Sure. Go ahead. Thanks Luis.

Luis Encinas:

Or maybe ladies first. Well.

Wendy Lai:

Go ahead, Luis.

Luis Encinas:

We receive, in fact when we start the intervention middle of March in Spain, we directly had a contact with our colleagues in Italy. At this stage, they were already in front of the situation very actively with different realities and we realized that should really be a very worst case scenario, but that's coming probably in Spain in the coming days or weeks. So we were really alert on that. And we received a call from a doctor from a member of MSF who was in charge, as well, for different residents and the description was terrific. So we were really identified quickly that was one of the two important realities that we wanted to work with is to really focus on the vulnerable people.

So in the hospitals, directly from the very first stage in the residence, in what we call the elderly care homes. So we were really focused on this and why? Basically because there was nobody, no other people working there. We were really seeing the attention, the over-attention on the hospital realities, but these people were already, I would say abandoned or really not put on the edge of the attention. So that's what the reason that we were starting to work from the very beginning in this reality.

Wendy Lai:

And in the US? Yeah.

Heather Pagano:

I'd fully agree with Luis. We saw this here. For myself, it's pretty surreal. I've worked for MSF for 12 years and I never thought I would be back in the US working in my home country. So it's, of course, very unusual that we're here and working with this very vulnerable population in the elderly homes, but it's also fully aligned with who we are as an organization at the same time because we look for situations of vulnerability and neglect.

And nursing homes house now some of the most vulnerable people in society to COVID-19 as we know. It's been well-documented. And hospitals, as we said, receive the majority of the attention, the resources, the infection control training and nursing homes were more or less left to fend for themselves without protective equipment, without the training. And nursing home facilities across the US and actually in many of the other programs that we've seen in Europe, for instance, have been chronically short of staff, have had chronic problems. So what we saw here was an acute crisis on top of an ongoing chronic crisis and MSF intervenes in moments of acute crisis where we can help.

We saw, as well, that in this environment in the more developed, well-resourced areas and countries let's say, that our epidemic expertise might be of use here because we've been working in our own hospitals protecting them with infectious disease infection control for 50 years. But huge outbreaks of infectious diseases haven't taken place on this scale in the US or in Europe for many years. So putting that epidemic expertise into play, that's how we wanted to try to help. So that's what I've been doing here.

Wendy Lai:

Thank you. And as you point out, Heather, MSF does indeed have a long and, I think, fairly deep experience in terms of responding to epidemics. And I think you've both been part of some significant, perhaps more traditional epidemic response in the past, things such as Ebola or cholera. Luis, I understand you've worked in some Ebola projects in the past. Can you talk a little bit about what do you find similar in terms of responding to COVID-19 and Ebola and what do you find different? Where are the parallels and where are the divergences there?

Luis Encinas:

Yeah. There was an incredible number of parallel points. In fact, at the very beginning, it was a new unknown disease, a pandemic, so the society was not prepared. We need to change our mentality to really go to an emergency. What does emergency mean in 2020 in Spain, where we were more than eight decades really a capacity to deal with different situations? But to really pass from a normal status to an emergency, that was for me something very familiar and really, what I mention, as well, the importance of having the people in the same direction understanding with a very clear, unique coordination. So that is something very important.

And I just realized so many times back to Guinea in 2014 or recently in the last year in DRC, where you see the residents of the population because this kind of reality of the permanent emergency, what we are completely inverse in Spain. So when it was a very ... and I just jump on what others say. It's more than 20 years that I start with MSF and to be as a national staff dealing with this reality and trying to convince the people the importance to anticipate, to have a contingency plan and to really do on the simulation.

Really, okay, you need to be prepared. Don't expect the reality of the hurricane arrive. This is a very strong metaphor, but that was the reality. So we need to react and we need to learn already what happened in Italy or in the recent different regions of Spain before to act. So that was for me the similarities and the differences important that I mentioned.

Wendy Lai:

Heather, what are your thoughts on those similarities and those differences? Luis has also touched on this concept which you've also mentioned, working with MSF and responding to an epidemic in your home country, which many of us thought was challenging.

Heather Pagano:

There were many more similarities than I expected I have to say. And the number one is that it's true in most every single outbreak and it's fear, the fear and the uncertainty that outbreaks inspire in people. And it's normal and it's natural and people react to fear in a variety of different ways. And trying to explain the importance of public health measures and the same challenges that I saw in Ebola that my last project in cholera in Northeast Nigeria, the same sort of reactions and the fears and the questioning you see.

And equally also, the impact on healthcare workers because they're the ones that are on the front lines that are rushing towards the fire, but that doesn't mean that they're not afraid. It doesn't mean that they don't have uncertainties. They're not only afraid for themselves in caring for their patients or their residents in this case, but what they may bring home.

And so I think one of the things we've tried to bring to our project here in Michigan is we've had these processes in place for the mental health of our staff because we know that it's so stressful to work in these environments. It's stressful for everyone, but front-line workers really need extra support. And bringing those elements to these facilities that were really forgotten and in many ways, actually demonized.

Hospital workers, rightly so, received a lot of praise for an amazing work that they've been doing, but nursing homes have been demonized more or less actually for the numbers of fatalities that they've suffered in each facility and it's super hard on the staff. And I think us trying to be there in solidarity with our fellow healthcare colleagues is really important. And just being there with them and saying you're not alone, we're not here to punish you, we're here to be in support with you is actually indirectly providing its own mental health benefits, I think, I hope.

Wendy Lai:

Yes. Absolutely. And I think in many ways with all parts of the world facing coronavirus and the challenges of bringing it together in some ways can really reinforce that solidarity. So I think that's an important concept. Can you tell us a little bit more about some of the activities you're doing in terms of addressing the mental health needs of the healthcare workers and as well, what it is that you think we can do about addressing these questions of fear and stigmatization?

Heather Pagano:

I think the first thing to say, especially for the nursing homes, is if you know anyone working there, be kind. They work unbelievably hard, long hours that I don't think the majority of people I know would be happy to do day in and day out for very little money. So be kind. I think that they actually have created in some facilities an amazing community on their own. They do amazing activities together to boost their own morale.

A facility I went to yesterday, they had what they called nerd day. So they all dressed up like characters. Some of my American colleagues that are on this call will remember Saved By The Bell. So they all dressed up as Screech and whatnot from that TV show from the '90s. It was really cute. It was for the residents, but it was also for them. And then they had a little competition about who won and it's small little things like this, but you have to create community, especially at this point in the pandemic because from a psychological perspective, right now compassion fatigue is setting in and it's normal. We've seen it in many long-standing outbreaks we've worked in other places.

So to see it coming out now and knowing what kind of strategies and tips you can put in place to create community amongst the staff to support each other. Creating resource boards. We have a staff wellness officer. She's incredible, named Ebony, and she's putting together these boards with different types of resources that people can do, but it's also a talking point. So staff gather around and then discuss with each other what works for you? How do you keep sane and safe in these stressful times?

And I think us trying to help facilitate that and let people know that resources do exist. Sometimes they have access to psychological support they didn't know. So that support, I think is really vital.

Wendy Lai:

Luis?

Luis Encinas:

Yeah.

Wendy Lai:

What are your thoughts on this? Yeah. Go ahead.

Luis Encinas:

I just listening at Heather, it’s incredible, we have an ocean between us, but it's the same reality. Definitely the fear, it's like a train. It's really another outbreak. When day of this pandemic arrived, this fear reality is present everywhere, every single house, every single reality because we cannot predict what happens tomorrow, what will be especially in the very first weeks that the situation was really very logarithmically significantly changing in a very bad reality.

So coming on this mental and psychological support, probably the first point was to listen, to listen to them, to let a window open and to really say you are not alone. We understand. And when an NGO like Médecins Sans Frontières just take the time to listen and say this is a very strong and difficult situation and you are doing an incredible work. We acknowledge them. This is a powerful point. A powerful present for them and say we will be together. So we will know that there's a very new situation and we really go to give some practical solutions.

I remember one of the first points was we have no material. We have no PPE. We have completely ... so what can we do? Even with papers or something very easy very practical to give some answer and not just say okay, you will receive a protocol next Monday or okay, we listen, but very be there and call back and not let them alone. I think that is very fundamentally important and do not forget that they are a human being, we are all human beings and we need all to be together.

So that was probably one of the strong reactions and the other fact is to be as MSF, we do believe that we need to be there to support you until you feel comfortable. That was very well-coming and very well-appreciated.

Wendy Lai:

Okay. Luis, I do think that power of listening is incredibly important and it reinforces this sense of solidarity. And also, something I've been thinking about a lot lately in terms of MSF, one of the things that we talk about is about recognizing human dignity. We talk about saving lives and alleviating suffering and sometimes we forget that third part about dignity. And when I think about the long-term care centers, the dignity piece, I think, really figures into that and the first part of that, as you say, is listening.

So in the spirit of listening, there's some questions from our audience and I think I'm just going to read this out. Before I do this, for those of you who are joining us, we do indeed want to hear what your thoughts are, so please ask your questions in the Q&A function for Zoom. That should be at the bottom of your screen and you can also, if you're joining on YouTube Live and Twitch, you can put your questions or comments into the comments section.

So the question we've got from Borchueh Wu says, "How does MSF develop it's provider protocols at each mission site and does this process differ in the most recent responses in Spain and in the US?" I think this speaks a lot to how also we interact with some of the local partners that we're working with. I don't know who wants to go first.

Heather Pagano:

I'm happy to.

Wendy Lai:

Go for it.

Heather Pagano:

It's a really good question actually. We work closely with the health department, both at state level and county health level, but we also follow quite closely the CDC guidelines. So in terms of what infection control advice we give to the facilities, we use a combination of our own practices and expertise, but also, follow, of course, the national guidelines. And I think it's an important part to note that what we're trying to do here is create a model of intervention that we hope can be carried on after we leave with others.

The idea is that we will create a package of materials that maybe schools of nursing could use so that nurses could gain some more practical experience, graduates in some facilities and give extra infection control, experience and support because these facilities are chronically understaffed and they need more in-person support.

The system, the way that it's set up here today in the US, any support is mostly virtual and that's not as helpful as really being inside and tailoring your guidelines to the individual facility for all different shapes, sizes, different types of buildings, different types of things you need to do there. And so we're trying to create some materials that we can actually, hopefully, will expand further beyond our project.

Wendy Lai:

Thanks Heather. Luis?

Luis Encinas:

Yeah. From outside, it was very interesting because at the end, COVID was not something that we have expertise, nobody has, no? But we realize that according the reality we just receive from the residents, we wanted to give a following on this and we create at the very beginning of the intervention what we call a platform where the world's space for regular webinars only created according to needs that we received from the people. So that was a very interactive reality. So the very beginning of the webinar is how to deal with a suspicion of a patient in a residence. So different questions and we really were responding on the real time this webinar and creating, as well, training and materials and protocols.

Another point, as well, was due to the fact that we were on the lockdown situation, we need to be creative. We need to be very important imagination and we create what we call the V-A-R, so the VAR. It's tele-support. We work from a space to really give information with a video and giving some in the real time support and responding to the needs of the different resident's reality. So it was not just a webinar for everybody, it was tailor made. So that was very powerful.

During the training and the webinars, were this question and answer with this interaction with the people, so it was very, very powerful, and it's something new. And I think it's important for MSF that we ... all the time that we have this disequilibrium to realize that we create new things and new ways to work. So that was very important. How was imagination before to do so many things from my home? That was really something important that we never imagined in the past.

Wendy Lai:

Thank you. I have another question from Amelia on YouTube. "Are there worker's unions or other advocacy groups focused specifically on nursing home staff?"

Heather Pagano:

We…

Wendy Lai:

Yep. Go ahead.

Heather Pagano:

I didn't know if they meant in the US. Indeed, there are various union groups, as well, and associations for healthcare workers, especially on the clinical side. What's important about nursing home environment is that there's a whole nonclinical part that's really important, so especially when you're talking about infection control. And these folks hardly get any training or support and this is where extra attention needs to be. For instance, if you're doing good hand hygiene and good training on all of this with all of the nursing staff, but you have a cleaner who has one rag for the whole floor that gets used for the toilet and the doorknobs and the handlebars and everything, then your infection control is probably not where it needs to be, definitely not where it needs to be. So that is an element that really needs some more advocacy and some more attention devoted to it, I think, at least here in this context in the US.

Wendy Lai:

Indeed and I notice that here where I work, as well, that there is all this attention ... So I work in an acute care hospital and there's a lot of attention put on physicians and nurses. Of course, we have to remember that there is a whole team of people who help to make a place function and often, these are people who, they're the unsung heroes and often working lower-wage jobs, cleaners and food workers and security, etc. Luis, I think you had something you wanted to get in.

Luis Encinas:

Yeah. We were working and we did an incredible lobby and advocacy work, as well, in Spain particularly. Just one example come in my mind is this combination from MSF and Amnesty International, what we just co-write a letter, and we just focus on the needs to protect our healthcare staff. So just for you, Spain was one of the most countries in terms of health staff. So that's something about to protect them. So we did and our GD and the GD from Amnesty International were written this letter to the authorities, the local authorities.

Wendy Lai:

Yeah. Luis, I think you're talking about essentially that we have a responsibility to ensure that healthcare workers and that's everybody who works in healthcare facilities have the means with which to protect themselves. And actually, the next question actually follow on quite nicely from this last one. So from Shannon on YouTube, "What can we do to support these workers moving forward?" I'll go with Heather.

Heather Pagano:

There's something else that this reminds me of that's true in every single outbreak you hear. Outbreaks start and stop in the community. So everything that we can do to make sure the outbreak doesn't further by wearing masks, by washing our hands, by keeping our distance and being as careful as we can be will help alleviate pressure on these facilities because you can follow where the big outbreaks are in nursing homes. They're correlated where there are big outbreaks in the community and normally in urban areas often, as well, where the outbreaks are propagating. So the safer we can keep these facilities and their staff is by what we can do outside in the community by keeping ourselves safe, everybody.

Wendy Lai:

Yeah. Luis?

Luis Encinas:

Yeah. General when you mentioned this question there was an example coming into my mind. I don't know if that's happening in the US, but here in Europe and especially in Spain, every day at 8:00 p.m., everybody were going to the balcony and they were starting to applaud and to really give a very good intention to really support. I just wondering how to translate this from an action on the reality and this is, as well, coming to the pressure how important the help, it's basically that we need. So respect of all the healthcare staff was really, as you mentioned Heather, so avoid a second wave and to really be responsible. As a whole society, respect this and to take on your shoulders some responsibility and to listen, to protect yourself and to protect the others. So that's for me one of the important points we can do.

Wendy Lai:

Here in Toronto, there's been a public discussion, also, about recognizing the value of the work that people do and paying people a living wage, as well as this idea of ensuring that people have the stability so they're not needing to work in, for example, multiple facilities at different times because of course, that can carry the infection along, and also, having paid sick days. So some of these policy questions can be very related to support of staff and mental health of staff, but also, in terms of what drives the pandemic forward.

I have a bunch of questions and there's a bunch of questions coming up, as well, from the audience. I wanted to go back a little bit and hear some more in terms of the impact of COVID on people and on the residents of these facilities. I wonder if there's maybe a story or two that stand out for you in terms of what living there is like and what it's been like since the pandemic started. Luis, do you want to start?

Luis Encinas:

That was a story of ... sorry, come again?

Wendy Lai:

Of a resident of a care home and what their experience has been like in these last few months.

Luis Encinas:

Yeah. I just have an example coming in my mind when the official explanation every day, every evening of the news and saying the rules and regulations. And in a certain moment, there was a person from a residence saying I have no clue. That's not my book of learning. That's not my understanding. So if it's so important for people, how elders should be in the focus of the attention, just speak the language they understand and just let them, as well, able to be part of the decision platform, as well.

So considering the person, elder, as a person, as a human being. So probably this is what's for me one of ... I was listening this on the radio and said wow, come on. I just coming from one year ago from Congo, where I was fighting to say we need to talk the local language and the culturally accepted. Why it's so difficult to do it in our first world, you could say?

Wendy Lai:

Heather, what stands out for you in terms of what people have lived through?

Heather Pagano:

The loneliness is really terrible and you see the facilities tell us all the time that they're really worried about the cognitive decline of their residents, especially those in memory care, because the regular interaction with your family members is really important and especially for our elders. It's a beautiful thing that we've been able to do, Zoom and Skype and this sort of thing and some of the staff and subs use their own person phone when the resident wakes up in the middle of the night and wants to talk to a family member. They do their best to care for other people's loved ones as much as they can, but it's no replacement for that and the residents suffer for it.

They have these drive-by parades that are quite sweet, where the residents can be outside and at least wave, but this director of nursing was telling me yesterday that I just cry because this resident I was with said I can wave at my daughter, but I just want to hug her. And I'm going to have a grandchild who's walking before I've ever even held them. And I think that the day-to-day loneliness can't be underestimated.

Heather Pagano:

And another truth about this disease that's really awful that reminds me a lot of people although, Luis, I'm sure you feel the same is people dying alone. No one should die alone and this is a horrible truth. It has happened across the country, across the world and it's really awful.

Luis Encinas:

Yeah. I just feel your pain and I just sharing the full reality in Spain, as well. In terms of for the person, for the residents, for the personal, for the family it was horrible. It was very, very difficult time and I was facing this with Ebola in Congo. When you say to the person I'm sorry, this is a person with Ebola. We have to take care about him. You will never probably see again if it's your daughter or if it's your mother. And just to realize, that happened in my reality, in my country. And just explaining, as well, how difficult it is. So it's a trauma not only directly for the person in first-line, but as well as a society. It's a very, very hard time and we need to really understand that.

And I was really fighting from the very beginning. We need to give at least with probably all the conditions of protection, but we need to have one word in mind, dignity. How will you imagine you when you decide something wherever you are that you will not apply the same thing with your father, with your brother or with your son. So yeah, that's very important. And I have an image, as well.

In Spain, we are very, very touchy people. We need to touch. It's very important. So that as well was a traumatize, and I have an example in my mind where they put a plastic sheet and some gloves and people just have a hug. It was a marvelous point. Using tablets, using a connection just to have a space and put words where this is really heard. So that's very important.

Wendy Lai:

Thank you for that story, Luis. I also think about patients that I've met in the hospital who've died alone and it is deeply impactful I think. Yeah, I agree. We've had a comment from Berin, who says that they're alone in the US and tired of being home alone and asking if there are creative ways that we can create safe spaces for older people to meet with friends and family. So this follows on nicely from this creativity, Luis. Being able to have a hug and to touch in way that's safely. Are there other ideas that you've seen or things that you've tried out in the facilities in terms of trying to include families and have contact and when I say contact, I mean both emotional contact and physical contact, but contact in ways that can be supportive? Go ahead.

Heather Pagano:

It's a really good question. So here in Michigan, the facilities are still closed to the public for the most part. So what we're trying to do, our psychologist has put together some suggestions and ways of doing this for when things do start to open for friends and family because it will be a bit of a jarring experience. They'll have to reconnect and the ways that they can do that safely.

So just come up with a couple of things that stand out for me like you could draw. It needs to be outside. It'll be the safest if you do it outside, the way the virus transmits and being in closed spaces can be quite dangerous. So that if you have six feet apart, but each family could draw a flower on the ground, especially if there's kids, and they have to stay inside the flower to make sure to keep your distance, this kind of thing. It's little things like this that will be deeply important for whenever it's allowed. Again, it's incredibly important for elders living in these facilities that are ... They say to us that they're more worried about loneliness sometimes than COVID.

Wendy Lai:

Luis, have you seen other creative solutions, in addition to your hugging devices?

Luis Encinas:

The two I already mentioned. The third one coming in my mind that was, as well, is to have with the distance, whatever say, and it's important to put in balance, risk to do it and not to do it. And I think just to put words one more time, to listen to family, to listen to the person in the residence alone. Just imagine that in one day, in 24 hours, you are alone in your room. You cannot go anymore in the living room sharing with other people. That creates stress for you, for the others, so we need to prepare, as well, the others, the rest. And I think with the distance and to not be shy to put words and to have a space for that and to listen and to really be humble and realize how putting words is so important already as a first stage.

Heather Pagano:

That reminds me of one thing that's actually… I know it's hard for people to picture what it looks like inside these facilities for residents, but when we're all sick of staying at home in maybe our houses or our apartments or whatever, we can at least move from room to room. The residents have to stay in their physical rooms. They can't go out and even meet their friends inside the facility. They really do need to try to stay as far apart as, inside. But imagine being stuck in the same space for four and a half months. They deserve a lot of our empathy and respect for what they're all going through.

Wendy Lai:

Yes indeed and Heather, maybe you can go into a little bit more depth. Someone has asked about how do you address issues around Alzheimer's and dementia in these facilities? So you were talking particularly about the needs of patients with memory issues. What do you suggest?

Heather Pagano:

It's super hard. It's one of the hardest things that we've had to ... and it's not, like we were saying it's an unusual environment for MSF to work in. So this was a particularly challenging aspect, but also, for the facility, not just with memory care, but for many older adults wearing the masks. Sometimes elderly adults revert to being somewhat like children. If you try to imagine making a 5-year-old wear a mask all the time, for some elderly adults, it's similar or to stay in your room.

So there were a variety of different ways that the facilities ... We've tried to do cohorting as they call it, so try to separate out the distance for the safety of the residents. But it's not easy and it's not perfect and it's one of the things that the facilities often ask us for advice for first and foremost. And sometimes just saying actually you are doing it right and going the correct direction is what they wanted to hear.

Wendy Lai:

Yeah. Luis, Elise Goldberg asks, "What would need to happen in order for visitors to be able to return safely?" I'm going to editorialize a little here and say is there a way that we can think for families to be considered part of that care team? What do those look like?

Heather Pagano:

Yeah. I think it's very important. It's very important that ... Suddenly what's happening in Spain and in different countries, it's from one day to another something changes completely, radically. January and February, the situation was deteriorating slowly, but in one day, suddenly we close the residence. You have not access. We have to overprotect and there was people dying and that's in the middle of a pandemic. That is not just touching your region, your country, but the world. So that's so important, where now the social psychological support, where social has an important weight.

So what's so important when the people and family arrive and it's to inform them, to explain in very simple words what's the situation? What will be accessible, what will not and why, explaining the why and try to deal with it. To let the space because it's all right to the family members to do or not to do. But that's all right. I want to see, but I don't feel comfortable. I have my kids at home and I feel that I will be guilty tomorrow. It's your choice. You need to know what's the limits. So that's considering one more time people as people.

Wendy Lai:

We're running low on time and Heather, there's a particular question I want to ask you about the context in the US and this is really about a number of commentators have talked about how the pandemic is disproportionately impacting communities of color. And I'm wondering if you've seen evidence of that in the facilities where you are working and what that looks like?

Heather Pagano:

Absolutely. So in Michigan, the State Health Department released numbers that African Americans, while they're only 14% of the population, it's one-third of the positive cases and 40% of the deaths. It's astronomic, off the charts in terms of disproportionate effects. It's also one of the reasons we wanted to be here, to be with these communities. So we see that. In Detroit, it's a chronically underfunded, under-resourced city and there are many issues around social determinants of healthcare and the comorbidities, the extra hours, the front-line workers. And we see this here for sure.

There's another aspect to our program that's not connected directly to long-term care facilities. It's a smaller component, but it's around trying to do what we call digital health promotion. So this is using platforms like Facebook to try to get out messaging to target specific communities. One thing that we saw in Michigan is the Hispanic LatinX communities have lower rates of testing than they should. And this is maybe linked to issues of fears around immigration status. Because if you go to a facility, are you going to be followed? Who is going to know your name? All of these sort of things.

So one of the aspects of our project, as well, has been around trying to target these communities with where you can go to be safely tested where you don't have to worry about that to try to increase the numbers of testing there, for instance. Because these are problems. These are barriers to access to healthcare that we see here and whatever we can do to help alleviate that, we will try.

Wendy Lai:

Yes. Thank you. And certainly MSF, when we respond, wherever we're responding is often about understanding what are the particular barriers that some of the most vulnerable are finding. So I'm very glad to hear that we're thinking about that.

I think a lot of our audience will also have questions around what it is they can do to help either where they are locally or with MSF more generally, in particular relationship to elder care. I think you've both touched on this a little bit. A lot of this is about communication and supporting workers, but do you have final thoughts on that before we go? Luis?

Luis Encinas:

Yeah. I am not sure that I catch all of the question because now it's clicking, but can you repeat again?

Wendy Lai:

I think people will want to know what it is they can do locally, either in their region for eldercare or with MSF in addressing eldercare.

Luis Encinas:

First of all, probably it's to consider that it's one of the most vulnerable populations and to really, I just have an example coming in my community about we are now 80 families in the same building and there was a spontaneously a person put in the lift. Okay if you need some support, some this kind of community support and as well, simply as well with a well you have no car, but your mother or your sister is in a healthy place, I can just give you a lift. So that's one point.

The second is, as well, to recognize that the situation very difficult that is not still over. So we still have a situation ongoing. So we need to protect them. We know that the prevalent studies in Spain is around 5%, so we still have far away from a certain considering protection. So we need to have that in mind. And I just have an example about now there is a kind of rebound, especially with the young people, no? If these young people come in more and more affected by COVID and now the residence reopen, how it's in your responsibility. So we need to protect our elders. We need to think and to know that this generation was the generation about building after the world war.

So there was people fighting in '68 for rights. So we are there, thanks to them, too. So it's important by respect and considering this, as well.

Wendy Lai:

Thanks Luis. Heather, what can people do?

Heather Pagano:

I think in every outbreak, it tends to bring out sometimes the best in people and sometimes the worst. And I think what Luis touched on in the beautiful sense of community that you've seen, that spontaneous outpouring of people looking after each other and looking after elderly in their communities and buying them groceries and just seeing how they can help is absolutely gorgeous. But also, then you see people crowding the bars and not wearing masks and thinking that it's over, especially if you have a lull in a state and wanting to go back to normal. Everyone understands that, but it's really important.

We all have an incredibly important individual responsibility. And I know it can feel quite far away from people who don't see it, who aren't next to what COVID looks like or seeing what it looks like being in a long-term care facility and see these really vulnerable, lonely elders that are unable to see their families because the virus continues to rage outside because people need to be more individually responsible. That's the main message. We all have to do whatever we can to make this end so that we can try to get back to some semblance of reality for our most vulnerable especially.

Wendy Lai:

Yeah. Thank you. In many ways, COVID has, I think, helped to hold up a mirror to ourselves and our societies in terms of showing us who those most vulnerable communities are and what we need to do in order to look after them. And I think you've made very good points that there is absolutely that connection. For a long-term care center, it may seem like a closed off place, but it's absolutely connected to the community that it's in and the people who work there and the families who are connected to a place and that the epidemic in terms of it's being driven by various groups outside, those are all part and parcel of what's going to happen next and how we're going to get through this. So thank you for your insights.

So that's pretty much all the time that we have. I really want to thank Luis Encinas, nurse and medical advisor for MSF COVID-19 response in Spain and Portugal and Heather Pagano, emergency coordinator of MSF’s program in Michigan, supporting long-term care facilities. Thank you both very much for taking the time to be with us today. Thanks for a really interesting conversation. I've learned a lot.

Thanks to all of our listeners for joining us today and our apologies if we didn't have time for your questions. It's been very much a pleasure for me to be your host today. Avril Benoît will be back in two weeks for the next episode of Let's Talk COVID-19. For more information please visit our website in the US at doctorswithoutborders.org or globally at msf.org. You can also follow us on Facebook, msf.english, at Twitter, which is @msf_usa, on Instagram doctorswithoutborders. And for more information or questions that we didn't get to, please contact us at [email protected]. Thank you everybody. Have a great afternoon.

Luis Encinas:

Goodbye.

Heather Pagano:

Bye. Thank you.

Avril Benoît:

Hello and welcome, I'm Avril Benoît, I'm the executive director of Doctors Without Borders in the United States. Doctors Without Borders known internationally by our French name, Médecins Sans Frontières, and the acronym MSF will come up over the course of this discussion. So when you hear MSF, you know it's Doctors Without Borders. Today as part of our series, Let's Talk COVID-19, where we're bringing you into our operations, our medical work around the world and giving you a lens through which we are looking at this pandemic. 

Today we're talking with a couple of MSF physicians about how the pandemic is affecting access to critical sexual and reproductive healthcare for women and girls. Since the start of the pandemic, there have been even more barriers to accessing antenatal, postnatal, emergency obstetrics, contraception, safe abortion care, treatment for sexual violence and other sexual and reproductive health care, and we will be explaining all of these terms for you today. The key part for us, and the big worry is that, without access to these essential lifesaving services, we at MSF, Doctors Without Borders, fear an increase in preventable deaths, maternal and child deaths in the coming months.

From our experience in past outbreaks, such as with Ebola, several times we have seen that deaths can be caused by cutting women off, women and girls off, from access to the healthcare that they need in this realm, and can be even more deadly at the end of the line than the coronavirus itself, that's our big fear right now. We're going to have this webcast for around 45 minutes, a chance for you to ask many questions, wherever you're joining from today, you can submit your questions to us. If you're watching on Zoom, send your questions into the Q and A option. If you're joining on YouTube Live or Twitch, you can send your questions in the comments or the chat section, we will prioritize questions that are relevant to COVID-19 and sexual reproductive health and how the pandemic is affecting all these areas.

So, we are here with a couple of doctors. I mentioned Dr. Manisha Kumar is a family medicine physician, and she heads MSF taskforce on safe abortion care. Also, joining us, Dr. Maura Lainez, is a community doctor working with MSF in Cortés, in the Cortés Department of Honduras. So welcome to you both. It's so great to have you with us. If I could just, by way of introductions, yesterday we were a little worried about your internet access Maura, have we got you okay? Maybe you can describe a little bit where you are today.

Dr. Maura Emelina Lainez Vaquiz:

Well, actually I'm at home right now. I have been doing tele-health consults because I'm pregnant and I can't be in the frontline of the COVID epidemic right now, but I hope the internet is going to be stable today.

Avril Benoît:

We're also hoping that, and we also have Dr. Manisha Kumar. Manisha, where are you joining us from today?

Dr. Manisha Kumar:

Hi everybody. Yeah, I'm joining you from my apartment in Amsterdam. It's 7:00 PM here, so evening and a gray rainy Amsterdam evening.

Avril Benoît:

All right. Well, we're all safely indoors away from the rain. Manisha maybe you could just start by explaining some of these concepts because for those who are unfamiliar with SRH, which is the medical jargon that we toss around, but sexual reproductive health, why is it so vital? Explain the full package of what we mean when we talk about this?

Dr. Manisha Kumar:

Sure. So, sexual and reproductive health services are so vital because they are lifesaving. So just to take a step back to say, what are sexual reproductive health services, it's really a full package of care. It ranges from everything such as providing antenatal care, so care during pregnancy, care during delivery and postpartum care as well as contraception and safe abortion care services. It includes treatment of sexually transmitted infections or STIs, and it also includes treatment for survivors of sexual violence. So really that phrase, sexual and reproductive health encompasses this really broad range of healthcare services that are vital for women and girls, and then also their families and communities. So, the healthier that women and girls are, the healthier that their children and their families are as well.

Avril Benoît:

And Maura, can you describe then what did all of this look like before the pandemic and now after in Honduras where you're working?

Dr. Maura Emelina Lainez Vaquiz:

Well, in Honduras actually before the pandemic we're having troubles always with family planning, especially in the sexual health area, because it's like really limited and it's like people don’t want all these young girls have access to it because it's a taboo theme in here. It feels like something that you don't want to go to the doctor and ask for a pill. If you want to go into the pill or as for any other method of family planning, because you're going to be seen bad at that point.

Right now we have more limited access to it because it's not an emergency and all of our health centers, at least the majority are working just for the epidemic right now. So it's like taking the power of the women to decide into her body when to plan to have a family or not having a planned family at all. You're putting this girls behind a wall and a sword in deciding to have a baby or not.

Avril Benoît:

In Honduras, to what extent is the lockdown complete over what are considered these non-essential health services of all kinds?

Dr. Maura Emelina Lainez Vaquiz:

Non-necessary health services are locked down. If you need an emergency service, you can go and there will be assistance in there. But for example, if you need the pill, because you're in the pill and you want to go to your health center to take your medicine, you can't go because it's no longer an emergency, it's no longer considered that you need it. It's like, "Oh, you are in it but you can wait or you can go and buy it." Most people doesn't have the money to go and buy this kind of stuff. So they go to your health center that is from the government because it's the only way to go and get it without spending that much money.

Avril Benoît:

Yeah, and we must be seeing this in many other parts of the world. Manisha you've got a bit of the view of the whole, can you give us an idea of how the pandemic is affecting other parts of the world with these services that are essential but have fallen into the basket for some governments of being cut off?

Dr. Manisha Kumar:

Yeah. So what happened at the start of this pandemic is basically ... all governments, countries, institutions were forced to make decisions about what is essential versus not essential care. For a lot of people, essential more means current emergency, right? Without thinking about what could be the potential indirect effects if people do not have access to this care. So what we saw is that different countries and different agencies responded differently, but what the trend was, was that already to begin with, a lot of SRH services are not necessarily seen as essential or emergency. The way that we would typically imagine like if someone that needs emergent surgery, yeah, because they have an acute physical injury.

So services like contraception and safe abortion care have historically not been seen as essential or lifesaving services, and that's what made them even more vulnerable to becoming deprioritized. So what we saw was during the pandemic, a lot of resources got pulled away from a lot of routine services and care, and those resources got diverted to more direct coronavirus response activities, which in some ways we could think would be a logical response, right? We have a virus, we have a new emergency, we absolutely need to invest resources into addressing that. But what we've seen in history, as you mentioned earlier, such as in the Ebola epidemic, is that some of the indirect consequences are the collateral damage of taking that type of approach is that when we shut down these routine services, we actually saw an increase in maternal and child deaths from preventable causes.

So there are certain things that we know we can do to prevent death and suffering. We know that treating malaria will prevent death and suffering. We know that treating malnutrition, routine vaccination campaigns. So even though a routine vaccine today isn't necessarily seen as an emergency, it's still lifesaving. Similarly, for contraception or family planning like Maura was talking about, today she's not having an emergency, but if she is unable to access her family planning method today, it can start a cascade of events. Yeah? That can ultimately lead to her death. So if she makes the decision to continue the pregnancy, it's more likely to be a high risk pregnancy because it was a mistimed pregnancy.

So maybe she already has and recently gave birth, maybe she has a lot of children already. We know that these pregnancies, if they're continued and to have more complications, or if she decides not to continue the pregnancy and she does not have access to safe abortion. What we know in MSF is that women are then more likely to resort to unsafe abortion methods that put their life and their health at risk. So, this one event, this one blockade, right? Really can set off a domino effect or a cascade of events that really have long-term impacts on women in their communities.

Avril Benoît:

You've mentioned the diversion of resources from all the kinds of SRH care, sexual reproductive health care toward COVID-19 focused efforts. Maura, in Honduras, we have a question here from Zainab, and you are here giving us the example from one country, but we know that it's also something that is being experienced by MSF teams elsewhere. To what extent did MSF divert resources from sexual reproductive health toward the COVID-19 intervention in Honduras?

Dr. Maura Emelina Lainez Vaquiz:

Actually, we don't have any problems like taking this medicines to the other communities, but is the health centers that are not getting it from the government right now, especially, but MSF have been really responsive in this emergency, in the COVID-19 not just as the disease itself, but it's also as the sexual reproductive health that it had been responding. We have the family planning in our clinic, we have a clinic here that we work 50/50 with the health secretary here in Honduras, and we have to bring this access to the women in here. So they don't fall in this cascade as Dr. Manisha was talking about.

This cascade of events that actually will be falling if they get pregnant and they don't want the baby and they try to get ... and not safe abortion or anything other events that we're going to be. For example, here in Honduras, in Tegucigalpa, the MSF community is in charge of one of the branch of the resources for the COVID-19 in a national stadium in here. So we're in front of the lines trying to protect our communities bringing health, bringing attentions, bringing all this support that Honduran people need right now.

Avril Benoît:

You are listening and watching a special webcast series that we're doing here at Doctors Without Borders, Médicos Sin Fronteras, and Médecins Sans Frontières or MSF about COVID-19 and various other aspects of healthcare. Today we're talking about sexual reproductive health with two physicians. So, Dr. Maura Lainez who's a community doctor working in Honduras and Dr. Manisha Kumar, family medicine physician, who is the head of our task force on safe abortion care globally. We have a question here from Ruth, and by the way, I should mention again that you are more than welcome to ask your questions in Zoom in the Q and A option, or on YouTube Live or Twitch in the comments or the chat function. Manisha, this one's for you, and it's from Ruth. How are we working with closed borders during the pandemic?

Dr. Manisha Kumar:

Oh, that's a great question. So the closure of a lot of borders has really been a challenge for our teams. So, the two most obvious ways that come to mind are one, in terms of moving our staff, and the second one is in terms of moving our supplies and being able to get the medical supplies where we need them. So for a lot of our programming, it's been really challenging to be able to send our international staff to a lot of our project locations where we're working because of these travel restrictions and closed borders.

So what that has meant was an increased reliance on our teams who are already the ground and maybe can't leave, who are probably, who are, working really hard. So they're not getting the relief that they need, but at the same time, we work in collaboration of course, with a really amazing national staff or a local staff on the ground who have really been working hard to make sure that the populations we serve still get the care that we need. Then in terms of the supplies, a lot of our projects across the world, we send supplies to them from Europe, which is where most of our headquarters are based. We have a very strict quality assurance for our materials because we take our responsibility to provide high quality medicines and supplies very seriously.

Dr. Manisha Kumar:

So that has been a huge challenge, and specifically for SRH services when it comes to contraceptive methods, a lot of them or a lot of the precursors were made in China. And so being able to get the contraceptive methods into the hands of our patients is really dependent on this whole global system. I think it's really revealed how interconnected our world is because the closed borders have really impacted our projects.

Avril Benoît:

Yeah, and that's been the case for other medicines as well, hasn't it? I've heard of, especially in the early going, there was a gasp when we realized that malaria medications were dependent upon China and all the borders were closed around there in terms of the flow, the outflow and the shipping. Yeah, it's been extremely complicated for many areas of medicine. To bring it back to sexual reproductive health, Maura, how is it looking from the Honduras side in terms of closed borders and the effect that's having on women and girls?

Dr. Maura Emelina Lainez Vaquiz:

Actually it's really affecting a lot, because there is so many supplies that we need and it's not coming in because the borders are closed. Most of our supplies and medicine that come from other countries, far away countries, and especially those that have to do with family planning. So we're not receiving all the supplies, and most of the health centers doesn't have any family planning medicine right now. So they're low in stock, they're going back to use just condom instead and most of the people doesn't want to use barrier method. So they stop using it, and we have a lot of pregnancy right now, actually today, early this morning, I was talking one of the doctors of our community in Choloma, and she was like, "We have to find a way out to make this work because we're having a lot of pregnancy during this quarantine."

When she was like, in a month we had like 10 new girls pregnant, now she has like 30. She is really worried because these are pregnancies that are not planned at all. So this not only affect the family, but will affect the community in this manner. It's not only with this health, is also with all of the medicines that we have. With this ivermectin is getting a little bit low in our country because it's now one of the protocols that we have for COVID in here, it’s not like FDA approved but we have to ... in here locally, we're using it, and it have been tested and we can see some kind of work in it, but it's not like we're going to go into a drug store and get it with a physician prescription, but we have to go into the hospital, see how we get it, and it's a little bit more collapsible, it's like a chronicle of the death, already announced with that.

Avril Benoît:

We have another question actually about the big picture, it's from Maria, who is asking, do we have hard numbers showing a reduction in sexual reproductive health services for women and children globally or for specific countries? Manisha, do you have a view of the global numbers?

Dr. Manisha Kumar:

So, in terms of the global numbers, what we have now at this stage in the pandemic is estimations. So, different organizations or different agencies have conducted studies that looked at what the impact of a 10% reduction in service would be. The impact showed that there would be, in low and middle income countries alone, an additional over 15 million unwanted pregnancies, over 3 million unsafe abortions and over 28,000 maternal deaths. So if you look at the number of maternal deaths from unsafe abortion annually, it's at least 22,800. So that's a doubling of maternal deaths from that one particular cause.

But if we look at what's actually happening on the ground frontline health workers like Marie Stopes International and International Planned Parenthood Federation, they're reporting service reductions as great as 80%. So those numbers I gave you were with a 10% reduction. So, imagine eight times those figures. In terms of MSF and our data and our numbers, because we work in so many different countries and so many different contexts, in some places I would say we've seen an increase, for example, the number of deliveries that we're seeing in the hospitals, if, for example, the other hospitals in the area have shut down their maternity service and the MSF hospital's the one that's open.

In some places we see the opposite. So we see a decrease in the number of deliveries or the number of women coming for other services, either because potentially we've stopped those services or the people that we're working with have stopped supporting, or women are no longer able to access them, because transportation to health facilities has also become an issue. So right now at this phase in the pandemic, we mostly have estimations and predictions moving forward.

Avril Benoît:

I guess related to this is what is the timeline? And Maria is also asking, how long will it take for these numbers to show up? You say there are already indications, and even Maura you were saying there seem to be more pregnancies. When we know that the pandemic will go on for an indefinite period of time, maybe a year, a year and a half, two years, until it is presumably hopefully brought under control, how do we expect those numbers in that burden and in that hardship, are those statistics with always human stories behind every single one of them to show up in the graphs over the course of the pandemic?

Dr. Manisha Kumar:

I mean, I think right now, as you said, our biggest worry is that the numbers and the figures and the graphs are going to go up, right? That we're going to see a big increase in mortality and morbidity. Right? But if we're looking more specifically at maternal deaths, that we are going to see an increase, one of the really challenging things about maternal death and maternal mortality in calculating or counting maternal deaths, for example, when we're talking about unsafe abortion, so one of the leading causes of maternal death worldwide, but obviously a very stigmatized topic.

Lots of times women that resort to unsafe methods, they suffer at home or in the community, and don't even make it to a hospital, or if they make it to a hospital the diagnosis is not in line with what the actual cause of death was. Right? So they might get diagnosed as an abdominal infection. Right? And that would be the cause of death or a trauma to the intestines. Right? So, one of the things that I think is going to be really challenging is to really try to quantify the exact impact of the pandemic, but it's certainly something that we're doing in all of our projects. We already have very systematic data collection systems in place so that we can keep an eye on this.

Avril Benoît:

Yeah. It's devastating to think about it. When you think of Honduras, Maura, what do you expect will be the overall outcome and impact of this on death rates?

Dr. Maura Emelina Lainez Vaquiz:

On death rate? So the death rate will be going up, definitely. Most of the women doesn't want to go to the hospitals because they're afraid to get contaminated with COVID. So they're avoiding to go there and they're going to start going back to the midwives, they are not like professional midwife we have in here. So they are the ones that go in the terrain with them, they're in the community already. So, most of them won't have the access to a proper health service. All the mortality will go up, all the pregnancy will start showing up indefinitely. Actually, we don't have a culture where you can say that the family will say, "Okay, we're going to have just this amount of babies or we're going to plan to have a really spacious time for the babies."

So it's going to increase mortality, is going to increase poverty, is going to affect the whole community in this sense, because we're not going to have pregnancy in a lot of manner, but we're going to see death. We're going to see risk, a lot of risk in these girls, they're going to try to find out a way how not to get pregnant, and they're going to start making some practices that are not going to be really good for their health.

Avril Benoît:

We have a great question here for you Manisha from Michael asking to what extent has the current U.S. administration, the U.S. President Trump impaired MSF operations in any way, particularly regarding all aspects of women's reproductive health. Now, we do not accept funding from the U.S. government, that's to be clear. However, we work alongside organizations that do, and we work in that global health space where some of the statements about sexual reproductive health have been made from the U.S. government. Can you describe what's going on there and how that's had an effect on MSF?

Dr. Manisha Kumar:

Absolutely. So, historically the United States has been in a position to have a lot of influence about the sexual and reproductive health care and the services that are available to women and girls all over the world. So even pre-COVID, things like the global gag rule, for example, which Trump reinstated and reinforced and made stronger, really limited how people could talk about abortion, what providers could say, who could provide abortions, who could not, and that is already on top of other policies in which no U.S. government funding can go to support places that provide abortions or abortion care.

During this pandemic in the United States, some state governors have used this as an opportunity also to really label abortion as a non-essential healthcare service, and try to use the opportunity to restrict abortion within the U.S. even more. Beyond the United States, the U.S. government actually wrote a letter to the United Nations, arguing that sexual and reproductive health services should not be seen as an essential service, and even more specifically, that abortion should not be regarded as an essential healthcare service. This was to the United Nations, that's part of what puts in place a lot of the practices and the WHO guidance in particular that impacts women and girls all over the world, and MSF we don't work in isolation, we work in partnership with lots of other organizations with ministries of health.

So these types of messages from the United States really undermine our ability to really work in this system where we can talk openly about what are the real health needs of women? How can we look holistically at all of the needs and then do our best to provide that before unable to even say the phrase sexual reproductive health? Then that really limits our ability to provide any type of care.

Avril Benoît:

One of the reasons that we've spoken against this from the international president to statements we put on our website, and you can find those on doctorswithoutborders.org. Okay. Let's move along to a question to you, Dr. Maura. Are pregnancies going up during quarantine because of rapes, sexual violence or domestic violence? Or, you seem to be alluding before, it's more ... well, you had mentioned that the lack of being able to access contraception, that people are willing to use?

Dr. Maura Emelina Lainez Vaquiz:

Essentially for the lack contraception, we have a lot of cases of sexual violence in our country, especially in our area that we're in Choloma and here in Department of Cortés where we have our MSF staff. But at this point, what I have in hand is that is because of the lack of family planning.

Avril Benoît:

Okay. Another one for you, this is from Rashid asking, how do you compare the past coronavirus infections, which were SARS and MERS to that of COVID-19 in terms of pregnancy outcomes in the areas where you're working? And actually, I guess it's not just coronavirus, because any kind of pandemic, we've talked about Ebola or we've talked about other things, you had Zika in the region. Dr. Maura, can you speak to that in terms of what you saw during the past ones?

Dr. Maura Emelina Lainez Vaquiz:

Well, actually during the past ones, we didn't have SARS or MERS in here in Honduras, but we have like dengue and Zika, there are more transmitted by mosquitoes bites. We can see that, for example, in pregnancy, we have a lot of issue with the babies in that moment, especially with Zika, because it was like STD. It was a sexual transmitted disease, not just because of the mosquito bites, and we have difficulties with the moms that were having pre-labor terms, we were having abortions, spontaneous abortions. We would have malformations in babies during their period of pregnancy, and when they come here with microcephaly, we have a lot of babies in that period of time when Zika was in here and it was one of the most effected.

So during COVID, we have seen that these ladies, the pregnant women in our country have been reducing their visits to the doctors and putting their self in risk without taking all the measures, when they go out, the bio safe measures, or taking their pills, the prenatal pills or eating well, because they're afraid to go out. We have a low rate of pregnant women in Honduras with COVID, but all the women that have been with COVID and are pregnant, most of them have been recuperating, actually we have a loss in this morning, a girl that was ... she was 29 weeks pregnant. They had to do a C-section and an emergency C-section because it was too unstable to take it to the OR, and so they did it in the ICU unit, and sorry she died today. It was a big case for all that community, the gyno community here, because it was like ... losing a patient is already really hard to us as doctors and losing a patient that is already a new mom is bigger.

So COVID have been pushing out all the prenatal care, even though we're trying to in tele-health consults, we are trying to have this prenatal care to these ladies so they can have all this information they need. And with the past, it wasn't this big of a deal because it wasn't mosquito bites, and if you can use a barrier contraceptive it will be fine if you want to have a sexual relation, but now it's like you don't know anything. Everything is contaminated, and as we said in here, in Honduras everything is COVID unless it's proven contrary.

Avril Benoît:

Yeah. You mentioned there that you were doing more tele-health for the antenatal and prenatal care.

Dr. Maura Emelina Lainez Vaquiz:

Yes.

Avril Benoît:

Describe that for us.

Dr. Maura Emelina Lainez Vaquiz:

Okay, we have a number here in Honduras that you can call or you can text us and I can give you some advices, tell you what to do. If you have any questions related and you need some tests that you have to take, I do the prescription, send a picture and they can take it out in the lab or in a drug store. So, they can have or at least try to have all the counsels they need during their pregnancies.

Avril Benoît:

Sounds like ... yeah, you're boxed in by necessity to do things that way and hope for the best. Let's shift our focus a little bit to a country with a very high burden of COVID-19 cases. Manisha, we have a question from Joanne, have you seen differences in sexual reproductive health services in Sub-Saharan African countries, from other countries in the world when you compare, especially wondering about South Africa, where there are so many COVID cases?

Dr. Manisha Kumar:

Yeah. So, specifically in South Africa, our project teams have really had to adapt and work hard in order to maintain the sexual and reproductive health services that we provide. So, in a lot of places what the health facilities did was to take a lot of measures, to try to increase the infection prevention and control measures, make sure we kept our patients safe and did a lot of triage, by necessity that reduced the number of patients that we could treat. But what we saw was that a lot of clinics went beyond that and shut down services, more so than they really needed to, again, thinking that these are less essential.

So antenatal care services or postnatal care services, contraception, and more of the outpatient ones, where that morning you walk into the clinic you're healthy and you can walk out of the clinic and you're still healthy, but the care you're receiving is still essential. So in a lot of those countries, we really had to work even harder to make sure that we could maintain services. Sometimes we were successful in that, and sometimes were not successful.

Avril Benoît:

Well, let's keep going with you, Manisha with a question from Ashley. What do you think the ideal course of action is in terms of the allocation of resources in the midst of a pandemic? So, how can the magnitude at which sexual reproductive health services and resources are compromised be minimized?

Dr. Manisha Kumar:

Yeah, that is really great question, and something that we've been thinking about obviously, and working a lot here at MSF. So, one of the things that I think we can do is to be more innovative and creative in what we do with our resources, right? To think about new ways of doing things, it was clear in the coronavirus that we can't keep doing things the way that we used to before. The one way, for example, that we could have a more effective use of our resources in some ways is instead of sitting in the health facilities and waiting for patients to come to us, right? Which is the traditional approach, and then you have a face to face consultation, then the patient leaves is to do what I refer to as more self-care or community based care.

So in self-care, the approach is more one of empowering communities, families, women, people to manage their own health. So this can be via community health workers, this can be via peer educators, this can be via women's groups, and I think contraception and safe abortion care lend themselves to these types of interventions really easily because they are so safe, right? So something like emergency contraception, there's almost no contraindications to emergency contraceptions. In many countries, you don't need a prescription from a doctor, right? This is something that you can get over the counter by a pharmacist.

So, one approach to have a more effective distribution of our resources or allocation of our resources is to say, "Okay, we are going to make sure that emergency contraception is now available at the community level”. We don't want to have to wait for people to come to the facility.

Avril Benoît:

And for those who are unclear about emergency contraception, can you explain what that is and why you're so hopeful that that can really help?

Dr. Manisha Kumar:

Absolutely. So, emergency contraception is a contraceptive method that you can use within five days of having unprotected sex, if you do not wish to become pregnant. So in the United States, we also refer to it as the morning-after pill or Plan B, and the pills is one of the more common methods of emergency contraception. So it's one pill that you take within five days of unprotected sex. The earlier you take it, the more effective it is, and it can prevent the unwanted pregnancy and that whole cascade of complications that we were talking about earlier.

So, as I said, there's no contraindications and it's an extremely safe pill and it's quite an effective pill, yet it's really hard to get into the hands of women and girls that need them in the United States, let alone in humanitarian settings, right? Let alone in poor and crisis conflict settings. But that would be one way, right? To try to adapt, to modify at least our services in a way that really meet people where they're as if ... the same way that I could go to buy condoms at a local store or a local pharmacy, or buy ibuprofen or Tylenol for a headache, if I could also access, the women also access to emergency contraception, that could really prevent a lot of deaths and save a lot of lives.

Avril Benoît:

Okay. Next one for you Maura, this is again from Zainab, some women may be hesitant to go to a hospital due to misinformation around how doctors inject patients with a lethal injection, notions of misgivings that people might have, maybe misinformation as Zainab is calling it. How is MSF tackling this issue?

Dr. Maura Emelina Lainez Vaquiz:

Actually misinformation in here is like everyday stuff. We have to tackle it from the community. We have our health promoters that started talking about how you contract the infection, how you prevent it, how you can go into the hospital and nothing's going to happen to you because some doctors are going to go and put you a lethal injection just because you have COVID. We try to educate the population. Actually, that's our goal to go into the community and start talking about what is a health service actually, that is not like you're going to go in and you're going to die, is trying to make those bullet points necessary to them to get fixed in their head that we're here to cure, we're here to protect, we're here to help you around, not to mistreat you, not to make you harm.

We're here to make you well, actually, we're here to try to make you feel better and to try to bring your health back to you, and misinformation in here, for example, with COVID have been extremely, some people are taking Clorox as a method of cleaning their self, making themselves ill, and they have to go to a doctor and they think there is something else, but they're getting intoxicated because my neighbor told me that she did that and I go and do it. So, misinformation, we tackle with true information, we tackle with posters, we tackle with mouth to mouth when we go into the community, we tackle in meetings with the community so they can hear from expertise, or they can hear from us too, that is not we're killing people, hospital doesn't kill people.

Avril Benoît:

Okay. A final question for both of you, and we'll start with you Maura, since you're there.

Dr. Maura Emelina Lainez Vaquiz:

Okay.

Avril Benoît:

What can individuals who are watching do to push authorities to make maternal healthcare and sexual reproductive health a priority during this pandemic?

Dr. Maura Emelina Lainez Vaquiz:

Actually, it's really hard in here in our country, our government is like, they don't really care. So individuals in the communities, they should start asking for their rights because it's a right, especially healthcare is something that you need. It’s not that you can avoid it, especially to pregnant women or, sexual reproductive health is something that is a right. It's a woman right that we have earned through the last years, and it has been taken from us right now. At least I feel it that way, and most of the girls that I have been talking to, feel it that way, that they don't have power in their self anymore because no one cares at all.

They can go internationally as they file petitions and stuff but the government doesn't really care. We're trying from the doctor's side, try to tackle it from the inside so they can go into the outside to the health care communities. But it's like really hard to go in there. There is so many politics involved, at least in here.

Avril Benoît:

Yeah. It's devastating to hear you talk about a sense that no one cares.

Dr. Maura Emelina Lainez Vaquiz:

Yeah. It's really hard. You can feel the politics, we have a lot of bunch of money for this emergency, and none of it is have been really going through the emergency. It hasn't been doing it at all, we have lost a lot of resources, we have lost human resources, doctors, we have lost from health promoters, we have lost nurses, RNs, and no one really cares from the government, they're leaving us in the behind.

Avril Benoît:

Well, the rest of us care. So now let me ask you this question Manisha, which came in through YouTube. What can individuals watching do to push authorities to make this a priority during the pandemic?

Dr. Manisha Kumar:

So, I have two answers. So, one of them is, if you're in a country where you can vote, vote. Your elected officials have a huge impact, especially in the United States, right? Have a huge impact on the type of healthcare that people around the world, including women and girls receive. So, if you can, that's great. I think change also starts on a personal level, on an individual level, think about the women and girls in your life, and what type of care you want for them, and how are we showing up for each other, in what way, shape or form, I think this pandemic has really put us in a position where we're rethinking, and we're re-imagining what we want our society and what we want our world to be.

I think that for me, the future is thinking about how can we be in solidarity with women and it made me think about the title of this panel, even, protecting women and girls, right? I want to be in a place where we can listen to women and girls, where we can support women and girls, where we are in solidarity with women and girls. So for me, I think also thinking on an individual personal level, how do I do that? How do I show up? For the women and girls in my life is another thing that viewers can do.

Avril Benoît:

Great. We shall show up. Thank you so much both of you for sharing your expertise today, very difficult topic, but you absolutely have brought us into the complexity of this world and the things that we can all do. Today's panel is Dr. Manisha Kumar, a family medicine physician, head of MSF’s taskforce on safe abortion care, who joined us from Amsterdam, and Dr. Maura Lainez, community doctor working with MSF in the Cortés Department of Honduras. Thank you so much to both of you for being with us today.

Dr. Maura Emelina Lainez Vaquiz:

Thank you.                  

Avril Benoît:

And apologies if you're watching and you asked a question we didn't get to, but we're trying to get to them in the chat as well. So thanks for your patience. We are going to be back in another couple of weeks with another, Let's Talk COVID-19, and that time we're going to be talking about the disproportionate effect on older adults, particularly those living in long-term care facilities, nursing homes here in the U.S. and also in other parts of the world, namely in Europe, where we saw quite a burden, it's been a tragic trend that we've seen as part of this pandemic in our programs and we will share what we've seen and what we've learned in two weeks, same place, same time.

So if you want more information, go to our website, it's doctorswithoutborders.org for the U.S. and the international website is msf.org. You can follow us on Facebook on many languages, but look for us in msf.english, on Twitter you can find us @MSF_USA, Instagram @doctorswithoutborders, and if you have any specific information or questions that we didn't quite get to, you can always contact us for the team that put this together, [email protected]. I'm Avril Benoît, the executive director of Doctors Without Borders in U.S. Signing off, see you next time. Thanks for watching.

Avril Benoît:

Hello, welcome, and thanks for joining us for another one in our series called Let's Talk COVID-19. This is something that we're doing every couple of weeks over the summer months, and we're really delighted to have you with us. I'm Avril Benoît, I'm the executive director of Doctors Without Borders in the United States. Doctors Without Borders is also known internationally as, Médecins Sans Frontières. That's why we often use the acronym MSF. So when you hear MSF, you know it's Doctors Without Borders. And so what we're doing with these live opportunities for you to exchange with us, is to really focus on different aspects of our work in this pandemic. The COVID-19 response in the United States has been a very serious one for us. We're in the epicenter of the pandemic, in particular, we want to look today at how we're doing in New York City, in the Southwest of the United States among indigenous native American communities.

And in the programs that we're going to focus on, we're going to hear about the partnerships, local organizations, local community groups, local leaders have played a critical role in determining the scope of our activities and the effectiveness of our work. So today we're looking at those key relationships and how MSF collaborates with local responders to make sure that our operations are addressing those needs. So just a couple of quick points, this discussion is going to last around 45 minutes, wherever you're joining from today, you can submit questions to add to our discussion. If you're watching on Zoom, you can send the questions into the Q&A option.

If you're joining on Facebook live or YouTube live or Twitch, you can send the questions in the comments or the chat section. We will prioritize those that are related to today's discussion. So joining me today, we have Michelle Mays, who is a nurse and MSF project coordinator in New York City, and Ruth Kauffman, a nurse, midwife and MSF project coordinator in the Southwest. I would to welcome both of you. Are you there?

Michelle Mays:

Thanks Avril, great to be here.

Avril Benoît:

Fantastic. Good to have you. And we've got Ruth as well. I think we're having some difficulty getting Ruth up and online. Where are you joining us from right now, Michelle? Maybe you can describe, that you've got a map in the background.

Michelle Mays:

I'm in the MSF office in New York City, which is our normal office. But we have also been running the New York operations out of this office since the end of March.

Avril Benoît:

Okay, fantastic. Have we got Ruth? We had her a minute ago when we were doing our run up, but she doesn't seem to be there. So we'll maybe-

Ruth Kauffman:

I'm here. Can you hear me?

Avril Benoît:

Now we see you. Okay, fantastic. Very good. Ruth, tell us where you are right now.

Ruth Kauffman:

I'm actually in a small town in the middle of New Mexico called Silver City, where I'm doing my clinical training to become a nurse practitioner.

Avril Benoît:

Great. Very good. So let's jump right into one of the questions that I've been getting from the beginning, and having been in the room, I know the answer to it, but I'm going to ask you how you answer this question. Why is it that MSF is doing work in the United States? Why are we suddenly after all these years of working in other parts of the world, actually running projects here? Michelle, maybe you can start.

Michelle Mays:

Sure. Well, I think this is an unprecedented time for the entire world. And as a medical humanitarian organization, we felt it is our responsibility to look and see where the needs are, and where the needs are the greatest during any humanitarian crisis. And so, when the pandemic hit the US, we started taking a look at it, to see, is there an added value for MSF here in the United States? What are the needs? Where could we be useful? And that's how things got going.

Avril Benoît:

And how about you Ruth? When people say, what are you doing here? How do you explain it?

Ruth Kauffman:

The thing that I would add to what Michelle had to say, is that, MSF is made up of many individual health workers, logistic workers, administrative people, and as association members, who live and work in the United States, we also felt very strongly that we as individuals, people in our organization needed to help in this unprecedented time, and to look at where it was that needs were, that MSF could fulfill. And so I think it came from a lot of different sides. One of them being from the community of MSF workers that really wanted us to do something in the United States.

Avril Benoît:

All right, well, look, we are going to get going with some of the questions that we are receiving from our audience. Again, just put them in the Q&A function, and we've got our two project coordinators ready to go to answer your questions. Another thing that's really come up quite a lot is, in such a rich country, with so many resources, this particularly is perhaps one you can address Ruth, why should there be a need for an organization that has limited resources, we're stretched quite thin, actually responding to this pandemic in many parts of the world?

Ruth Kauffman:

That's a great question, Avril. And I think that one of the things that COVID has done is to highlight actually the poor public health system that we have in the United States, or rather the lack of a public health system that we've had in the United States. I'm old enough to remember when we had community health centers all over the country that you could go to, if you were sick, if you were pregnant and get care that was either free or at low cost, those things were dismantled in the 70s and 80s, and the health disparities among different groups of people in the United States are so well documented, that we see the COVID brought up this reality that the US health system was unprepared. US health system did not have resources, even testing basic protective equipment for health workers.

And at the same time, we also saw that we laid off 1.4 million health workers in the month of April, who could have been maybe deployed to different areas where health care was needed. And so we just see that COVID really highlighted the lack of a good health infrastructure that we have in the US, even though we have money and we spend a lot of money on healthcare, that money is not distributed in a way that's fair across the country.

Avril Benoît:

And what would be the situation in such a rich city like New York City, Michelle?

Michelle Mays:

So that was a big question that we discussed and debated quite a lot, especially, back in March, when we saw the epidemic really spreading throughout the country, and where should we focus our attention. New York City, very quickly became the epicenter of the pandemic across the world. And so we said, okay, well, we have to take a look here. And as we started, we very quickly saw quite huge needs among the homeless population in New York City. There are about 80,000 homeless people in New York City. And several thousand of those people sleep on the streets every night. And while the entire country and city were being told to stay at home, that's how you can protect yourself, where are homeless people supposed to go? Many of these people, about 60,000 of them sleep in shelters, and many of these shelters are congregate settings, where you cannot isolate and you can't protect yourself as easily as I am able to in my apartment, by any means.

So many people who were sleeping in shelters before chose to sleep on the streets, because that was how they felt they could best protect themselves as well as their community, because, some of these people were positive themselves or became positive, or weren't sure if they were positive and didn't want to affect people around them. It's been a very difficult time and difficult period for them, because homeless people can't stay home. The challenge to protect yourself in a pandemic are quite enormous for them.

Avril Benoît:

We have also with the activities that we did in New York. Maybe you could describe it a little bit, something that's not so medical, in terms of hands on patients. It bears explaining why we took that approach.

Michelle Mays:

I will say operating medically in the United States is not very easy. New York state is the most heavily regulated state in the US, and even with a lot of the different legal changes and stuff to make it easier for healthcare workers who are licensed in other states, et cetera, to work in New York state and across the country, even with all of that, it's quite difficult. And I think it says a lot about the flexibility of the US healthcare system to respond to its own needs. That it is, it's just hard to do that. There's a lot of strict rules and regulations, which can be there for many good reasons, but then making it quite difficult to respond in an emergency.

So, we really tried to be, as we are in many emergencies, flexible and adaptable to see what needs we could respond to fastest and most effectively. And a lot of that were in some of the wraparound needs. So for example, we got plugged into the supportive housing network of New York, which supports around 32,000 supportive housing units in New York City. And these are, they're a network of organizations who support people, most of them are formerly homeless and are now in these supportive housing residences. And some of them are semi congregate environments where there are shared kitchens or shared bathrooms. These are high risk populations, often people with underlying conditions, elderly population, so at high risk for complications, if they contract COVID, and they were really struggling to figure out how do we keep our residents safe?

So we worked with them on infection prevention and control measures that they could put in place in their various residences. We also started showers for mostly street homeless people. We have two shower sites, because access to hygiene facilities is already a problem in New York City, but because of the pandemic and things closing down, it became an even greater need. We distributed hand washing stations, because of course, washing your hands is one of the most effective ways to prevent transmission. So we really tried to focus on the larger public health concerns, but looking at how we could support local organizations rather than starting our own parallel thing, because there are a lot of services in New York City, and amazing organizations, but none of them had ever worked in an epidemic, let alone a pandemic. So MSF with, a lot of the things that we were able to learn in other epidemics settings, we were able to take a look and see where we could help and give them a bit of a boost through that critical period.

Avril Benoît:

For sure. Well, we have so many questions for you. I'm sure, coming in, about how we make those decisions, how we decided to work with certain groups, how we found those partnerships. And we have one here from Bob. MSF typically faces major political challenges in its work in areas of conflict around the world. And I assume the intervention is not a similar challenge in the United States, or was it in some places? Ruth, you want to take that one, because you worked in conflict zones. In fact, I think the two of you worked in South Sudan together, so maybe you can compare and contrast.

Ruth Kauffman:

Well, it's interesting, let's say bureaucracy of the health system that Michelle spoke to, that actually makes it in some ways harder to work in the United States context, to provide direct medical care. The other thing is resistance, whether it's internal to the organization or publicly as to should MSF be spending MSF donor money in the United States when there is all of this theoretic healthcare resources. So there is definitely bureaucracy to look to. When you look at working, let's say with the Pueblo sovereign nations in New Mexico, there's a whole other level of bureaucracy that they struggle with.

For example, health care is provided by Indian Health Services, that's been a complex relationship for many years. The federal government, for example, I think it was $8 billion was supposed to go to Native American communities around the country. And much of that was held back based on politics. And so after, Native American communities were not even included in the original budget for the cares act. So there is a lot of bureaucracy that happened in the response to COVID-19 all over the United States.

Avril Benoît:

How are people reacting to that locally, Ruth, when they see the inequity, when they see the injustice of that?

Ruth Kauffman:

So communities, right, and this is something that we often forget about the history of the United States, indigenous communities in the United States, have faced a lot of issues, obviously over 600 years and are incredibly resilient, have many, many answers within their own communities. And I think though the frustration is there, what's clear and what is stated by Pueblo leaders for example, is that, the federal government does have treaty obligations to sovereign nations. And those treaty obligations have never been fulfilled properly, which led to what has happened with the health inequities during COVID-19. And that those obligations are in the constitution, they have been Supreme court decisions, legal aspects. So people, yes, are frustrated and frustrated that response in terms of support did not come through.

And at the same time are not waiting around expecting that the US government is going to fulfill their obligations now, after not having done so in so many years. And so it was incredibly interesting to watch how each community really came up with their own solutions, how communities work together to come up with those solutions. For example, in the Pueblo nations, one specific Pueblo, opened an isolation and quarantine facility, so that all other Pueblo communities, and then later, Apache communities could utilize, as opposed to trying to rely on a New Mexico state government or an Arizona state government structure.

Avril Benoît:

So they also were able to rely on MSF to some extent. A question from Catherine here, Catherine Brown asking, are we going to expand our work in the future for more native peoples on these reservations or in the areas where they live?

Ruth Kauffman:

That's an interesting question, that a lot of people have been asking. When you introduced this, you talked about working with local community and community organizations. And what happened in particular in the Pueblo communities, is that, we took leadership from what was asked of us to do. And there were two pueblos in particular that had high rates of infection, that wanted MSF support in really specific areas, helping figure out how to decrease community and household transmission, how to make sure that there was good communication between IHS and the community leadership, how to get health center back and working and doing training. Michelle talked about this IPC issue and it has this idea of what is IPC infection prevention and control. And there's so many aspects of that, that we as MSF have experience working in outbreaks, that looked at, for example, how to get an IHS clinic, to be able to see patients who had COVID, who needed some medical care. And how did it see patients who did not have COVID, that needed basic health care and how to do that in a safe way, how to set up triage systems, how to set up patient flow systems and how to utilize the knowledge that we have at the time to decrease transmission in those settings.

So, because of that, the long roundabout way to answer that question, is to say, our intervention there is very limited and we're actually finishing up our intervention now, because the communities have asked us for what they have needed. We have tried to work in the way that was requested from us and that we've handed over to the community based emergency operational centers that exist, the health centers that exist in the community and community health teams that were developed in each community to take on these issues.

Avril Benoît:

It must be difficult, Michelle, to see disparities though, and the needs, even in such wealthy places as where you're a project coordinator for Doctors Without Borders in New York City. There's a good question here from Salva asking, for your personal perspective really to both of you, but I'll start with you, Michelle, about how do you personally feel about having MSF doing an intervention in your own country?

Michelle Mays:

It's been interesting. I think it's been really humbling as well, because working in my own country and my own city, I've learned a lot of things that I didn't know, about my own country and my own city. I've spent more than 10 years working with MSF. And so, working back in the US for the first time in more than 12 years has been very interesting. Just like in any setting that I go to, you're always learning and you're always, even though I have a lot of experience working in various contexts with MSF, every new village, new project is a new learning experience and you have to spend time really listening to people and learning. And it's been the same in my own country. That's been really interesting, but I think what has also been quite, not to be cheesy, but quite inspiring, is being able to work with other organizations and actors in the US, who have spent years and decades fighting for people who are underserved and are short changed with the way that our public health system and other systems are set up.

For example, one of the other aspects of our project has been to support a testing site in Brownsville, Brooklyn, which is a historically underserved community and population. This is a community that already has very poor health outcomes and already has limited access to healthcare, because, whatever, lacking insurance or not having a good quality of insurance, which is what, one of the things that the research is showing, is affecting the outcomes of COVID-19, is that, it's not just about having insurance or not having insurance, but the quality of health insurance that you have. If you're on Medicaid, you're less likely to have a primary care provider, which means that you're less likely to have regular follow-up on your various health issues, which means that you may be more at risk for complications of COVID-19. It's complicated.

Working together with this clinic in Brooklyn, we've learned a lot about that population and about the overall needs. They talk about food insecurity in Brownsville, Brooklyn, which is something that I'm used to talking about in a place South Sudan. And I think, wow, this is a place 45 minutes away from where I live and from my house, and they're having the same conversations or similar conversations in a different way, because it's a different setting, but that I've seen in other places around the world. It's been very humbling, but also, like I said, it's been very inspiring to see these organizations that have been working for years and years and years on these things and supporting these communities and fighting for them.

Avril Benoît:

And then what would be your lens, now that we've got these operations, we've got this presence on, one of the issues that's come up through Black Lives Matter, which is the racial dimension of health disparity, health outcomes in this pandemic. What would you say, would be your conclusion now that you've really seen it firsthand?

Michelle Mays:

Well, Brownsville for example, it's about 70-75% African American population and other 15ish percent Latinx, and then a small percentage of other groups. If we look at the health outcomes of COVID-19, you see statistics 58% mortality deaths among Black and Latinx populations versus 25% among the White population, that's in New York City. That's already like, how can this be? Clearly, there is a problem, clearly we have enormous disparities, where people are not set up to be able to have a successful health experience, let alone in a pandemic where systems are overstretched. Just to give another example, among the homeless population, 86% of homeless New Yorkers are people of color. 53% of New Yorkers are people of color. So you see already just where those disparities are.

There's a slogan that many of the homelessness organizations that we've been working with use, they say housing is healthcare. And then a pandemic housing is a healthcare, you need to isolate, you need to stay home, you need shelter and you need housing and safe housing in order to do that. So when you see these numbers, it's clear that people of color have been really not set up to succeed by our systems. And this is not okay.

Avril Benoît:

It's the old social and racial determinants of health. It's something that, I guess, I'll take the Salva's question to you Ruth now, on a personal level. How do you feel about MSF doing an intervention in your own country?

Ruth Kauffman:

I wanted to add something to what Michelle said, is that, I think one of the things that's very key is to always remember, right, communities know the answers to communities’ own problems, and communities need support and resources in answering to those needs. And I think that's become very clear in the US context, but it's also the same in South Sudan, in Sierra Leone, in Bangladesh where MSF is working in COVID response too. And sometimes as big international organizations, we don't always remember that the communities need to take leadership of their own responses to their own problems. So the big part about working in the US context, is that was much more straightforward. MSF did not have big numbers of staff, big amounts of money to provide, because we're providing services all over the world.

And so we really had to take the lead of what communities were asking from us and to do interventions on really small scale, let's say more sustainable way that we don't always use that word in MSF lingo, when we're talking about humanitarian action. And so I think working in the US context, for me confirmed that, as Michelle said in the introduction, we need to work where we need to work, and it shouldn't be about, the United States is not a poor country, so therefore MSF doesn't need to be there. Then MSF can have a role, whether it's on migration issues, whether it's on environmental health disparities, and whether it's on obviously the huge issues of racial health disparities that exist in this country.

Avril Benoît:

Well, yeah. And for sure with respect to the Pueblo, for example, we have a question from Linda here about which were hardest hit. The Navajo people were in the news quite a lot, but not so much other indigenous groups. Maybe you can speak to that.

Ruth Kauffman:

And that's a great question, Linda. So one of the things that's interesting is for the Diné people of Navajo nation, they used the media to motivate resources. And that was that choice. In the Pueblo communities, the communities were very private, they did not want public health data printed about themselves. And it specifically asked us not to mention which communities, and which is why we're very vague, and we say Pueblos in general. There were a few Pueblos that were hard hit and had high rates, 17% at the highest of positivity. But one of the interesting things that we see all over the world is the stigma that comes with infectious disease.

We wouldn't think that COVID-19 would bring up stigma in the same way that say that Ebola did in Guinea, but it has for certain communities. Some of the responses we wanted to do, for example, in multigenerational household, is to provide extra toilet facilities in the form of porta-potties. That was one idea that came from the community, but then it was decided by the community that that would place stigma on those households that had COVID-19, within their households. So, I'm not going to answer that question to specific communities. But to say that, everyone has struggled. And I think when we look particularly at Native American communities within the United States context, is to understand the history of what people call germicide and genocide, which is this historical reality of communities losing their elders and losing therefore traditional knowledge, because of infectious disease that was introduced purposefully and, maybe not so purposefully into communities. And that is very real today, too.

Avril Benoît:

It bears mentioning also, I guess, that we are working in a number of other places. So we've got the two of you here representing all of the operational activity that we've done in New York City and also in the Southwest of the United States, but in Puerto Rico, MSF began offering medical consultations in remote locations where access to healthcare was limited and has been limited during the pandemic. So we've got a team there providing home based care and also pop up clinics, MSF, focusing on providing support to healthcare workers and organizations in different places, but they're particularly those that are assisting vulnerable groups. So that includes those who experience homelessness, substance abuse disorders, the elderly communities that were also hard hit by recent earthquakes.

And then in the Detroit area, this is a place that we haven't communicated too much about what we're doing there, but the focus is on long-term care facilities. And there again, so in Michigan you've got healthcare workers and staff working in these facilities that are just overwhelmed with all the guidelines, all the protocols, all the things they're supposed to do, and just don't have the people power to be able to get certain things done. So, our teams are helping with infection control and prevention in the nursing homes, particularly offering recommendation that are really tailored to the space they have, because it's not always so obvious. Every facility being a bit different.

And we're also doing a lot of training for staff at these nursing homes, a part of our work in this particular pandemic, that is, capacity building. So as a humanitarian organization, here we are doing capacity building, which is usually something we don't talk a lot about. And yet we do in most places, don't we? Can you give me a sense, Michelle, of how you have been able to provide some advice, that advice role, not that we're technocrats saying, here's what to do and follow our guidelines, but rather the, how to take the guidelines that exist, the advice that exists and then just apply it in a way that makes sense, based on our experience.

Michelle Mays:

Well, one of the big challenges for the whole world in this pandemic, MSF included, is that the science is evolving and we are learning more and more about COVID-19. So I've worked in cholera outbreaks before, where the research is there and we have very clear protocols and ways of working and that's evidence-based, and we know how to do it. But COVID is new for everybody. So there was a lot of, let's try this, okay, new science, we need to try something different. Let's try that. So, especially in terms of infection, prevention and control, we all remember how the guidance came out. Should you wear a mask? Should you not wear a mask? How should this work? And in terms of, cleaning protocols and what to do, if somebody is a suspect case, do you go to the ER? Do you not go to the ER? Do you call your doctor? What do you do if you don't have a phone or a way to access your doctor? Should you just go show up at an emergency room somewhere?

All of these things have been quite difficult to navigate, but I think that, because we've just had such amazing partners with these other organizations. We've had really great collaboration and just a lot of brainstorming and trying to think creatively and outside the box, about how to keep people safe as much as possible through these difficult times. So, working in some of these supportive housing facilities, for example, a lot of them are in old buildings in New York City that, there's not a lot of flexibility, small corridors, teeny tiny elevators and how to do this and how to put this in place in a safe way.

A lot of the people who live in these facilities, like I mentioned before, they have a lot of underlying conditions and mental illness is a big issue there. So how do you talk to somebody who has a mental illness, where they might not be able to follow instructions or fully understand all of the logic behind various prevention things and how do you work with that? And to try to keep them safe, and also, for them to be able to protect other people living in their community and in their building. A lot of brainstorming, creative thinking, unfortunately, not a lot of magic bullets, except socially distance, wear a mask, wash your hands, wash your hands, wash your hands. Just reinforcing those messages over and over again and trying to be as creative as possible.

Avril Benoît:

That was actually one of the first requests that came in, was from a group representing farm workers in Immokalee, Florida. The thinking was, can you help us with this whole hand washing thing, we're out in the fields and it seems rather complicated. That's a place where, 15 to 20,000 migrant farm workers who are mostly from Mexico or central America or Haiti were working, despite limited access to COVID testing, health care prevention, going to the fields on buses, living in dormitories, all very complicated situations. And we worked a lot with the Coalition of Immokalee Workers and also the Florida Department of Health and the Health Care Network of Southwest Florida to increase the testing capacity for this particular group of people.

And I'm mentioning this, because it links to one of the questions that we're getting from a lot of people, which is, if we will continue working in the US, both for COVID or for other needs that are arising, and migrants, undocumented migrants in particular, who don't have access to healthcare and have a lot of concerns around going to a facility, this is a group that will always be vulnerable in the U.S. Once the pandemic is over that group is going to continue to be vulnerable. What's your answer to those who say, will you stay and will you throw a dart at the US, where you will definitely find needs for additional healthcare support? Ruth.

Ruth Kauffman:

That's a hard question. I actually live and work in El Paso, Texas, and have worked close and personal with the migration issue, the cross border complications, the current stress on communities, based on the stay in Mexico policy for asylum seekers and what it's doing to communities with the border closure. I don't have an answer for that. My answer would be that I think that, MSF as an international organization should have our eye on what's going on in the world and to make choices that are smart, in times that we can make those choices. And if there's a role for us in the migration issue, which we are doing a lot in Mexico, for example, we have a lot of health clinics in Mexico for asylee seekers that are coming through. We have some programs in the Mexico side of the border. And so I think that there could be potential future roles for MSF in the US.

Avril Benoît:

It's a difficult one though, because there are needs for us in Yemen, where we were one of the only independent health providers offering free healthcare in a conflict zone. We have massive needs that we respond to in Democratic Republic of Congo. I mean, you name it, all those 70 countries where we typically work, because they're already in crisis, are really at a point of, for many of them, of crying out for more MSF, not less. And so in a situation unfortunately of limited resources, we'll do the best we can to have the greatest impact.

We have a question here from Karen, how did your donors feel, US donors, about the decision to work in the US during this time? Did you receive pushback from donors who feel our mandate is actually in those low and middle income countries? The places in crisis where we typically work? I don't know if you've had contact with donors, but from the position of the executive director, I can say that we've had an outpouring of support for our work here. And if anything, it's a bit worrisome that there's an expectation that we will keep doing and exponentially expand our operational presence in the United States. Because we know that the way the curves are going in certain areas, how it's moving around the United States, so many States with an increasing number of cases, and hospitals are full and the pressure is on. There's going to be a lot of pressure on us to keep doing more and more and more.

So the best we can possibly do is have these light touch, build up the capacity, try to have a short term intervention that makes it possible for our local partners to have the ongoing work, to do it in a safe way for their staff and for the patients that come in. It's a difficult one, but our supporters across the US has been enormously generous with us, and we're very thankful because that's made it possible for us. As it always is, as an independent organization to be able to pivot and respond quickly and fully when there's an emergency, and we have an added value.

Okay, let's go to some other questions. This one's for you, Michelle, because you were one of the early members of our operational team in the US. Describe the challenges of working in the US. What were the startup challenges?

Michelle Mays:

It was such an uncertain time for everybody. The whole world saw this thing coming, and will it affect us? How will it affect us? And then all of a sudden it was everyone hit from nowhere on this, and everyone completely adjusting their lives, whether it's having your kids home from school or no longer going into the office or just not being able to do anything. The whole country, slowing down and many parts of the country completely shutting down, like New York City did. So that was a challenge. It was a challenge that also opened some doors. So for example, the showers that were running, we were able to use, in the beginning we used the parking lot of a church in Midtown, near Penn station, because they weren't using their parking lot. So we are able to use an area that was not normally available.

So, sometimes these things can also be opportunities. We tried to find those opportunities wherever we could, but a lot of things just took a lot of time, just getting supplies as everybody knows, trying to buy many things became extremely difficult and we are used to in MSF, responding to an emergency in a place or a country, yet, the whole world was completely out of whack. So moving people and goods became really difficult, which is usually a core part of what we do in MSF. So we had to get really, really creative, trying to find supplies and how to get them and how to get them quickly.

That was also a big challenge. There were many challenges, but also, like I said, some opportunities that it also provided, we have to be a bit agile and work around it. That's also something that I think MSF has a lot of skill, in that we have a lot of experience in how to be agile and flexible and very complex in difficult circumstances. So that experience, I think was definitely a benefit.

Avril Benoît:

We had an outpouring of offers of PPE, the personal protective equipment, from different companies that had their channels and pipelines to China and so forth, and said, we can get it for you. So we're very thankful for all that support, because it was really a combination of donations and very low prices for us to be able to procure what we needed for our teams, not only here in the US, but in other parts of the world. So that was actually a really wonderful expression of generosity that we got from the private sector on that. Here's a question for you, Ruth. What about working in prisons, where, it's an enclosed environment, also a racial disparity there, we've heard horrible stories from inside of how it's going there. What can you tell us about that?

Ruth Kauffman:

Yes, the only thing in particular, and I wanted to follow up on Michelle talking about congregate living situations, what that means is there's a lot of people in one place, right? And so that could look like a nursing home. It could be a school, it could be a prison or detention center. So one of the things in Navajo nation that was seen as a priority from the community, that other people weren't able to deal with was, the Navajo nation prison system. We were able to do training of all of the facilities, but one in particular that had 31% of their staff had tested positive. They had had to close and to send the people that are living there and the workers out, until they could clean the place and everyone got off of quarantine or isolation.

And so, yes, it's very difficult place to work. We see that in the detention centers for migrants in the border regions, in prisons, everywhere. And it's one of the areas that as MSF, we were unable to access except for on Navajo nation. That was really an important part of the intervention there, was to support people in those systems, to be able to set up systems and to get the whole idea across, that actually guards and people incarcerated need to be a team to prevent the spread. You can't have the animosity and working against each other, if you want to decrease the risk of outbreak.

Avril Benoît:

Tough with the dynamics that exist. Wow. Really difficult one. One of the things that we have to think about also, when we feel okay, our job is done here, time for us to move on so that we can focus on our efforts somewhere else, is the sustainability of the projects and the activities that we started. And I know Michelle, you have a lot of worries about the access to the showers in New York City. Can you describe what worries you about the continuity of this very essential service that we offer?

Michelle Mays:

There are thousands of people who are street homeless in New York City, and many of them were newly street homeless, because of COVID, because they lost their job, lost their housing, et cetera. Or like I said before, chose not to live in a shelter, because they felt it wasn't safe. So access to showers and hygiene facilities is a long standing issue in New York City. It's something that predates the pandemic, but was particularly critical during the pandemic, just because everything's shut down. So we open these showers and even though the acute parts of the pandemic is, it seems we're over the curve in New York City and hopefully it will stay that way. The need is still there.

So we are really fortunate to have found an organization and be working with a local organization called Shower Power, which has actually been working for many years, trying to open up a shower facility and really taking this opportunity to take over one of the shower sites and continue offering showers to people. But they're a small local community organization and they're volunteer run, they don't have a lot of money and resources. So if anyone out there is interested in donating to a local organization doing really amazing work, go to, showerpowernyc.org, and they have information about taking over the showers, but every little bit helps.

They have, like I said, it's mostly volunteer run. So, the money goes really to offering showers and giving people access to hygiene facilities, which is not just a public health thing. It is a public health thing, but it's also basic human dignity. So I think it's a really important thing to support.

Avril Benoît:

Happy to share the love.

Michelle Mays:

Thank you.

Avril Benoît:

We need the financial support ourselves, but our partners do as well. Hey, that reminds me. There's one really good question here for you, Ruth, just as we wrap up and look to the longer term for these indigenous communities. Is it time to eliminate the Indian Health Service, if they haven't been able to do the job, if they're ineffective?

Ruth Kauffman:

It's time to dismantle white supremacy and colonial construct of all of our systems. I think that's very clear right now. That's a really complicated question. There are alternatives to IHS in communities, they're called 638. And as different communities decide for themselves, whether IHS is no longer serving their needs or not. I think that that is an important discussion moving forward, but a complex one, right? Because it's part of again, treaty agreements from the federal government. So, how for communities to develop a health system that's responsive to their needs and that's controlled and run by the community is a really great thing, moving forward to think about.

The other piece of it that we didn't talk about just to jump on Michelle's comments, is that, many of the homeless people in the New Mexico area for example, are also Native American people. And so part of the response too, needs to be in areas that are not part of the Pueblo community or Navajo nation, but in the urban context or border towns as they're called locally. And so, one of the areas we helped with there too, were shelters and getting the IPC set up in shelters and triage systems and places that were safe for people to smoke cigarettes, for example, when they needed to take a break outside. And so those kinds of long-term follow-ups are also important.

Avril Benoît:

Well, it's been great to hear about your work. Thank you so much. And thanks to everyone who is working with Doctors Without Borders on these various projects all over the US. It's been really good to have your perspective, and that you're game to take some of these tricky questions, these challenging questions, which not only speak to the present, but the future. Michelle Mays, a nurse, an MSF project coordinator in New York City and Ruth Kauffman, a nurse, midwife, MSF project coordinator in the Southwest. Thanks to both of you.

Michelle Mays:

Thanks Avril.

Avril Benoît:

And thanks to you for joining us today. Sorry if we didn't get your questions, hopefully we can respond to those in the chat itself. We'll be back with another episode of this summer long series, Let's Talk COVID-19 in a couple of weeks. And at that time we're going to be talking about the impact on access to essential, sexual and reproductive health care. Things like safe abortion care. So that's coming up, do come back and join us then.

So for more information, you can visit our website. In the US, it's doctorswithoutborders.org. And globally, it's msf.org for Médecins Sans Frontières. You can also follow us on Facebook, different languages available, but we have msf.english. Twitter is @MSF_USA. On Instagram, you'll find us @DoctorsWithoutBorders. And if you have any specific questions, things you want to follow up on, by all means contact us. Our email address is, [email protected]. I'm Avril Benoît. Bye for now.

Avril Benoît:

Hello and welcome to this special, Let's talk COVID-19. A special series that we're doing every couple of weeks here at this particular spot on the internet, this Zoom room, Facebook room. We're going to do this all summer long, every two weeks. I'm Avril Benoît. I'm the executive director of Doctors Without Borders in the U.S., you might know us also by our international name, Médecins Sans Frontières. And from that, we get the acronym that we use all over the place, MSF. Today's focus as we continue our series about the pandemic is the indirect impacts of the pandemic. So we have health systems where we work, which we're already overburdened, perhaps under-resourced, perhaps in places of conflict or instability, you have the added challenges of the pandemic, which created shortages of supplies and travel restrictions affecting the movement of our expert staff to be able to go from one zone or one country to the other.

We've had some of our international aid teams adapting to the existing situation, trying to take the medical services we were already offering and keep them up and running while at the same time, pivoting to look after people who might have COVID-19 or are confirmed with it. Our teams all over the world have not only adapted but I'm really delighted that today we're going to focus on how they have innovated. They've found creative solutions to continue providing care to our patients. And so, today we're going to talk about this unprecedented time, these unprecedented challenges but also highlighting the innovations, the new things that we're trying out, things that we've shown to work.

So just a few quick notes about this session, will go maybe 45 minutes and wherever you're joining from today, you can submit your questions, jump into the discussion. If you're watching on Zoom, you've got the Q&A option. If you're on Facebook Live or Twitch, you can send your questions or your comments in the chat function there. And we will prioritize all the questions that are really related to how the pandemic is affecting humanitarian medical operations. I have a couple of great people here to answer your questions. They both have a medical background having trained as nurses, having trained in emergency management and in tropical medicine, public health, all the things that really make them fantastic speakers today.

Kate White is a specialist in emergency response and public health for our emergency support department based in Amsterdam. And she's now the medical technical lead for MSF's COVID-19 pandemic response. And also joining us, George Mapiye. He’s deputy project coordinator with MSF based in his Eshowe, South Africa, where our teams are maintaining lifesaving HIV and TB services, while also dealing with the new threats presented by the coronavirus. So welcome to you both. It's so good to have you. Thanks for taking the time out. Kate-

Kate White:

Thanks for having me.

Avril Benoît:

Kate. Describe where you're joining us from. What's the setup where you are?

Kate White:

So I'm in my apartment in Amsterdam. It's early evening here. It's been a really, really cold and gray day but lo and behold, the sun has decided to come out, especially for this broadcast. So I'm super happy. We still got to talk about-

Avril Benoît:

Very good.

Kate White:

... another three hours.

Avril Benoît:

And George, where do we find you today?

George Mapiye:

Yes. I'm in South Africa, the Southern part of South Africa in a province called KwaZulu-Natal. In our small, semi-urban and rural community of Eshowe where we are doing HIV and TB response.

Avril Benoît:

Okay. And I see you're in the office.

George Mapiye:

Now with COVID-19.

Avril Benoît:

Yeah. And you're in the office.

George Mapiye:

Yes. I'm in the office.

Avril Benoît:

You don't have that kind of... I was going to say you don't have that kind of décor at home with the posters in the background but look, we've got lots of potential for the questions for the discussion. We're really looking forward to hearing from our audience. We did have some people come in a bit earlier and suggest some questions for you. So if you don't mind, I'll jump right into it. Kate, for you as a COVID medical lead, really focusing on how we can adapt our services. What's your focus right now? And what is on your mind the most? What preoccupies you the most, Kate?

Kate White:

I think it's two things that the first thing really is balance between making sure we don't respond to COVID and neglect many of the other things that are happening in our projects that cause mortality and morbidities in the places that we work. And then innovating and pivoting those responses to make sure that we can continue them. So making them more community-based and really looking at how we can continue to keep services like maternity running. So, yeah, those are the two big things for me.

Avril Benoît:

George, from your side of things, what can you tell us about what's mainly preoccupying you and how you're putting all your energy into specific things in Eshowe?

George Mapiye:

Yeah. We are working with the communities that has been affected much with HIV and TB. And now overburdened with COVID-19. At the same time this is a community which mostly depends on informal sector. So they are not able to access the healthcare services, at the time the healthcare services are overburdened. So we are working with the ministry of health. We're to make sure that all the gains that we had made previously do not fall to zero and pose for us more complications than we had avoided before.

Avril Benoît:

Talk a bit more George, about the gains you had made and how that is potentially jeopardized by the pandemic.

George Mapiye:

Yeah. South Africa is one of the top five countries that is affected by HIV and there's also a high burden of TB. So, we have been working in Eshowe since 2011 and worked towards the WHO, the UN set 90-90-90 goals that were to be met by 2020. So we achieved these goals and surpassed some of them by 2018, which is two years ahead of the time. Which means the first 90 is 90% of people know their HIV status. And the second 90 is 90% of those will know their status are on ARVs and we got to 94. Then of those we're taking ARVs, they've got their HIV suppressed and we got that 95% within the community that we have had.

So we achieved this by 2018 and we kept on pushing to make sure that TB also management is achieved very well. So we wouldn't want that to go down to drain but we want it to continue being sustained. And the activities that we implemented are also reciprocated in other communities. So now the coming in of COVID-19 has impacted negatively, puts a pressure on the resources that are limited. So we are making sure that we balance the two, responding to emergence and still maintain the gains that we had.

Avril Benoît:

I guess that's one of the big preoccupations, isn't it? That if somebody already has HIV or TB, what will they go through if they get COVID-19? I'm sure you're seeing some of that already in South Africa with the burden there. Kate, can you explain to us this impact, this conjunction then of the excess illness and deaths in communities where we work and how the pandemic is playing out?

Kate White:

Yeah. I mean, there's two compounding factors. First, there is both of many of the places that we work, these illnesses or diseases have an impact on the immune system. And we know that in terms of, if someone has COVID-19 and some form of disease that affects their immune system, it puts them at greater risk of having a severe form of the disease and then a higher risk of dying from it. But separate to that, what we know is happening in many places is people aren't getting access for the care that they need on a day to day basis for whatever illness they might have underlying, whether that's because they can't move to the health center or because the health center is overwhelmed with people already and then it just can't deal with anymore cases.

So there's so many reasons why this might be happening and then people don't end up accessing care. They don't get the care that they need for HIV, TB, other forms of heart disease, diabetes. And then they end up suffering the consequences in the community and potentially dying. And that's where we see these sort of, what we call excess mortality, which is not directly related to necessarily getting COVID-19 but is an impact of not being able to access healthcare like you could before.

Avril Benoît:

And Kate, how will we know that there is excess mortality?

Kate White:

That's a really good question. So what's really important in these moments is to, for places that we've had programming in for a period of time, track. We're still seeing the same numbers of people with the same trends in morbidity. And on top of that, look at ways that we can do, what we call community-based surveillance. So looking at how many people are dying in the communities that they live in and what ways can we do that? And I think for me, that's one of the things that we've always been quite successful at, particularly in outbreaks, is providing some form of community-based surveillance, whether that's through phone, through going door-to-door in places that people live in and trying to extrapolate how many people are dying on a community level.

Avril Benoît:

And George, how is that playing out in KwaZulu-Natal? How is that happening that you're able to know what is the excess burden of the pandemic?

George Mapiye:

Yeah. I can tell you that before we did the intervention that we were having HIV and TB before, we had people reporting that every Saturday they are going to the funeral. And when we put the interventions that could help sustain their lives and help them go back to earn some income, we made great strides that we could get applauses from people to say, "Yeah, you have done well." So now with the complications that come through defaulting, we have a number of lockdowns that many countries have entered into. We also started doing a lockdown level five, which is closed down of everything in March, which means even moving. And with the low understanding of people, they didn't know what is it that they have to do and what is it that they are not supposed to be doing.

So we had a lot of lost to follow up of patients and we had to quickly come back to them to look for them through our door-to-door services, through our loud hailing, health promotion, so that they come back to continue with the medication. We know how it is that once you default the first line and it is difficult for you to maintain that again on the first line, then the second line, which is quite expensive, cannot be sustained by overburdened countries. So we have really thought about it and de-centralized the healthcare services so that people can have access within the communities that they are living, instead of for trying to get to where they can get something, but bring it closer to them.

Avril Benoît:

We are starting to get questions in from the audience now. And just a reminder, if you're watching on Zoom, you've got the Q&A option to pop in your questions about the indirect effects of COVID-19 on people's health status in the countries where Doctors Without Borders works. And of course, if you're on Facebook Live or Twitch, you can send your questions into the comment or the chat function. All right. Let's jump right into these questions now that are coming in from our audience, this one's for you Kate. How do we decide where to respond to COVID? Which countries? Where do you start?

Kate White:

That's a really good question. And I don't think it's a particularly easy one. We look at a whole bunch of factors, so where cases are happening and particularly where we see extreme increase in numbers, what we like to call hot spots. And then on top of that, we want to factor in a few other things like how well is the system dealing with that in that place? Is it overburdened? Are there particularly vulnerable groups that have been left out? And I think we've seen in some of our responses in places like Europe and U.S., that there are particular groups, even within our home countries that are really heavily affected by this, nursing homes and those spaces where you have older vulnerable people and the system is so overwhelmed that it hasn't had a chance to look at that.

The good thing about how we operate is that we're super flexible. So our response can look different in a different place. In some countries, we might need to open up a full scale treatment center and have a response that goes from the community through to treating people. In other places, the system might need a little bit of an extra hand in how can we better support our elderly population, support in terms of infection, prevention and control. And so in that way, it can have what we might call a lighter touch, you can do multiple sites but the decision to go somewhere is very dependent upon caseload. How many cases, the vulnerability of the people living there and how well the system is able to cope. And from that we decide.

Avril Benoît:

Just a reminder to those watching, Kate White is the medical technical lead for MSF's COVID-19 pandemic response, joining us from Amsterdam. And then from Eshowe in South Africa, we have George Mapiye, deputy project coordinator, working there to expand what we're doing in so far as an HIV and TB project, to be able to also respond to the needs of coronavirus. George, one of the things that you always have to think about when it's HIV in particular is there's... I guess, TB as well. There's a dimension that's more than just physical, isn't it? It's also economic and it's psychological. We have a question here that maybe you could just describe what's the psychosocial impact of COVID-19 on our patients and on our staff as well.

George Mapiye:

Yeah. Thank you very much. That's a very nice question that shows that for sure people are concerned. Yeah. So the same consent that we have with everyone around that, this is a new disease and we don't know where it will get us to, so people are concerned to say, "Okay, how am I going to survive when I'm being taught?" If they get the needs, which they do not understand very well, they are confused to say, "Okay, what is it that I'm going to do?" So what we have done, our interventions are both prevention and curative. So in prevention, we've implemented health education to make sure that people understand exactly what COVID-19 is, the impact COVID-19 has in their lives and the potential dangers that they can get from COVID-19 and other complications. So we try to allay anxiety through engaging them directly.

We have opened a call center where people can call in when they have questions, when they've issues that they've had and they do not understand very well. And we go around the community with our health promotion team. We engage with not only the health professionals but the community health workers would live in the communities themselves. And we have also engaged with the community leaders, the traditional leaders and also the counselors, as well as the religious leaders together with the traditional health practitioners, so that at every area, people will get the correct information. And they are able to be helped whenever they have challenges.

And we have counselors. We are working with the department of social development that is also a pool of counselors who are able to engage the people in the community, one-on-one, so that their anxieties are laid. We started to hear about COVID-19 when it was far away and as it gets closer, people become so anxious. And we have tried to make sure that they get the correct information. And also de-stigmatize, those who are infected with COVID-19.

Avril Benoît:

How do you explain to someone though that they shouldn't be ashamed that they have it? How do you take the stigma away of something so unknown, so mysterious and so scary.

George Mapiye:

Yes. That's a good question. So what we are informing people is that COVID-19 does not see any boundaries, COVID-19 affects each and every person. So, whoever is infected needs the support, because we don't even know when and who is going to be infected next. So we keep on encouraging to support them. Those who are not eligible for admission in the hospital, they are self-isolated at home when their facility is there. And do we don't just let them go but we go and we engage with the family. We engage with the community that they are accepted, that there will be no stigma against them.

Avril Benoît:

One of the things that, Anya, who's popped a question into Zoom is asking, is in areas where social distancing is nearly impossible, where there's no running water, what is MSF or Doctors Without Borders actually doing to assist those people? Kate, maybe we'll start with you.

Kate White:

That's a really good question, because I think the physical distancing public health measure is something that many of the places that we work in, it's just not a possibility. It's a luxury of other places. But one of the strategies that we've taken in many places like Bangladesh, like Nigeria, is to really look at, okay, what public health measures are actually not only good for COVID-19 but will have an impact on the health status of this group but other things as well. And so, they are exactly what you talk about, making sure that they have a portable water or water supply that they can drink and use in their household to improve their hygiene, that they have the storage mechanisms for that water, so things like jerry cans, and that there are appropriate latrines.

And really looking at many other public health measures, which will have low on effects in the future as well. So they will help to reduce the risk of transmission within that community for COVID-19. But they will also help to prevent diarrheal disease in the future and other things. And then in some places, we are looking at the ability to distribute masks, cloth masks at a community level. So, that at least it will hopefully help to prevent transmission on a community level within the household.

Avril Benoît:    

George. Do you find that people are generally receptive to the idea of wearing masks where you are?

George Mapiye:

It has been a challenge. And as the infections or numbers get closer to their own communities, some have started to do the correct way of wearing masks. It has been a challenge. I tell you, we have been educating people. As I mentioned before we are working in both town, which is urban and rural areas. So you'd find different acceptance at both levels, especially in the rural areas. We got way into the period of COVID-19 when they were not accepting it or that it will get through them. But now, as we start to give cases that some of them are coming from their own communities, people... you can see around people wearing masks but there's still a good number of people who are not wearing masks or they wear them on certain occasions, like if they are getting into the facility, into a building, into a shop where it is mandatory that one should be wearing a mask. So they wear a mask and get in. Once they are out, they take it off again.

And we recently opened schools. So you will find that school children as well, they can wear a mask as they're coming from home. Then along the way they do not have, when they get to school, they wear masks. So there's still a good number of people that are still not following properly but it's encouraging that quite a lot also they are accepting.

Avril Benoît:

Yeah. Look, I'm joining you from New York City, from a place that had a huge burden of COVID-19, a lot of deaths, and all the health officials and even the politicians were saying, "Everybody, please wear a mask outside." And you'd still see people not wearing masks. So it's tough to get people to adhere to that kind of instruction. But George, I'm reminded of the historic issues sometimes in South Africa around stock outs, which back in the days when I was a project coordinator in Musina in Limpopo, this was a major issue of people who needed their HIV or TB medications and the pharmacies were bare and it was just about the management and the ordering and things needed to get shaken up in terms of the structure.

Now, with COVID-19, with the pandemic, there's a lot of preoccupation around the restrictions in terms of importing the medication you might need or bringing drugs in travel bands and things. How has that played out for people with HIV and TB, who need their medication? Have you had more issues because of the pandemic?

George Mapiye:

We've had in the country, in some parts of the country that they are starting to almost run out but within the community that we are in, within the province that we are in, we still, we have... I can say enough quantities but this quantity is not beefed-up by any new supplies. So we are working with our different advocacy levels to make sure that we do not totally run out because we are pushing now with our programs to make sure that even those that had defaulted for a few weeks come back to get their medication. But if we bring them back to take their medication and to run out again, then we are not saving anything. So we are really pushing to make sure that whatever we have should be beefed-up, should be topped up so that we don't get to such kind of a condition anymore.

Avril Benoît:

Kate, we're here talking about the indirect effects of the pandemic in the places where we work. Can you speak to this issue of the shortages of medication, of supplies, things that are there for other kinds of ailments, other morbidities that have been made worse or more complicated because of the pandemic?

Kate White:

Yeah. It's been a domino effect because it's... many of our drugs that we get from antibiotics through to anti-malarials, the raw products come from China. And then they are manufactured elsewhere and then distributed out. And what's happened with the pandemic is everyone has closed down a little bit. So China has limited what products they're exporting for manufacture. The next country is also then, they want to make sure they have drugs for their population. So then they're limiting again, what they export out for others. And so, then you're left with a dramatically smaller pile of drugs than you had before. And so for us, it's really, really trying to do a bit more longer term pushing and planning that we don't get into this situation where we are running out.

We're still currently have drugs and yes, we are trying to move them. And that's very difficult sometimes with airlines, that movement restriction. But we can get creative as long as we have the supply, we can help get people to do hand-carries in. We can get other mechanisms but it's really about in six months’ time, making sure that those that are producing these drugs, they open up to export so that we can get supplied back on track globally. And we don't have a situation where we no longer have anti-malarials to give to children who are coming in with malaria and needed to be able to survive. And I think that's really important is that the impact is not just about today. It will really be felt sometimes six to 12 months down the track if something doesn't change now.

Avril Benoît:

For sure. And from the perspective of the questions, one of the questions arising is, have you had to really innovate? Is there something innovative in just adapting? Maybe George, you can speak to that.

George Mapiye:

What we have done... I'm not sure if the question is related to the drugs or to the activities but I will just speak about the activities that we have put in place in that... Due to the lockdowns, we have created a community-based approach where we have said, okay, people who have chronic diseases, not only HIV and TB but also diabetes, hypertension, that they do not struggle to come to the facilities but we have points that we are distributing medication. We collect from the health care centers where they used to collect from then we bring closer to their communities. We have what we call Luanda sites, 12 of them and where we don't have MSF Luanda sites, we have identified the walls, the schools that were not in use, churches that are not in use now. And altogether we have 35 sites that we are bringing medication closer to the community. And people can just walk to go into collect from that site. And we also added the collection of bloods that needs for the monitoring of their conditions. And whenever they have complications or abnormal readings, that's when they have to go to a healthcare facility. So this is something that was not in place but something that we've put in place to make sure that we access all these people. And we've actually also added the secondary activities, like familiar planning, like immunization that we have brought closer to the communities.

Avril Benoît:

Kate, we have a question here from Borchueh, I believe. How does MSF's headquarter offices like where you are help the many projects around the world adapt to new protocols, new ways of working involving protecting the staff, protecting the patients?

Kate White:

That's a really good question. A number of different ways, I think, a nice link, a little bit to your question before around innovations, we actually have a team, a small team dedicated to that, really looking at ways that we can do things differently or access different resources globally. They've looked into 3-D printing and so we've done some great partnerships with different local universities in countries that we work in places like Addis in Ethiopia and Goma in Congo. And they are helping us do things like 3-D printing face shield, so that we have extra personal protective equipment. A part of the team that I work with here in headquarters is a group of infectious disease clinicians. And I mean, this is a disease that in terms of treatment options, how it looks in different groups of people all over the world changes almost on a daily basis. And trying to keep up to date with the scientific research that is coming out is quite exhausting. So, that's their responsibility. And they really look at making sure our protocols and our clinical guidance are up to date and in line with the best evidence. And on top of that, we've been able to create and innovate ways that that can get to the field faster. So we have an online platform, which is a community of practice and it's for our clinicians and our nurses in the field to be able to ask some of the questions that are really puzzling them and get not only support from their fellow peers in other countries in terms of what they're seeing and how they're dealing with it but also support from your expert specialists back in headquarters. And so those are a number of the different things that the headquarter functions do in order to make sure that our projects can run as smoothly as possible.

Avril Benoît:

And Katie, we have a question from Facebook about, for all of the efforts, what is MSF actually doing to stop the spread of this virus? Are there any innovations or approaches that you want to share with us? Things that have worked?

Kate White:

Well, things... I think that the biggest things that have worked are things that are very local and very contextual because different groups of people behave differently. And you really need to take that on board when you look at trying to reduce risk. I think one of the best things that all of our teams did at the beginning is they really engaged with communities at a local level to see what's going to work for them. Because I think the big take home lesson that I've learned from every single outbreak that I have ever worked in is unless you have your local community on board, wherever that may be, you will not stop transmission. And so that is really the foundation. And so they've really worked with communities to say, "Who are your most vulnerable? How can you protect them? And how can we facilitate that as MSF." Whether that be helping to provide your water, sanitation and hygiene for that community, ensuring they have a referral pathway for healthcare, that we bring healthcare to a community level, they have the means to be able to provide some form of protection for themselves. And all of those public health measures, when communities are on board and accepting and will really take them on and do them, that's how you reduce transmission. Unfortunately, just implementing things and telling people what to do, never works. I know when someone tells me what to do, I generally don't have the best attitude.  

Avril Benoît:

Yeah. I can understand. But... George, we've got a great question here and I keep muting myself because there's somebody suddenly doing construction in my backyard, in the building next door. But George, one of the things that you always have to deal with and this is a question from the audience is how do you help communities to stay up to date with the real factual information and counteract what might be disinformation or those who are just trying to create a lot of mistrust toward the people like you, who are trying to help?

George Mapiye:

Yes. So our intervention here in Eshowe is at three levels, like at the hospital level, secondary healthcare and primary care level, and in the community. So we train the health care workers the capacity building to make sure that they are well-informed. They implement the correct ways of prevention and managing COVID-19. At community level, we have got the... at primary healthcare level, we have health desks at the entrance of each facility that, whatever you have come for, you are able to get information. You are able to get flyers, you are able to be tested. At community level, we have the health promotion team that goes around the communities loud hailing.

We have also a community that has been doing... a team that has been doing community screening. And ahead of the community screening team, we've been loud hailing, we've been giving health education to make sure that people are informed and it just, this week we are starting on... we have a local radio station where we have engaged with them. And soon we'll be having slots every Tuesday to make sure that people are informed and people call in and we give them information. We have, like I mentioned before, we have a call center where people... it's a toll-free number, people can call in and get information.

So we are making sure that at every level, at every opportunity, people get access to that. Like I mentioned before, we have engaged the community leaders, which include the counselors in urban areas, the traditional leaders in the rural areas to make sure that they are well informed and people can get information from them, whatever they do not understand. We have community health workers where they can walk into the facility or to their homes to get more information. So this is how we have made sure that whatever that is spread is taken out.

We are working very well with a local Muslim community who have allowed us to use their Mosque mic that we can share the message through the mic and because it is high up, everyone in the town can hear the message. And they continuously play the message so that people are well informed. And whenever are gathering in town, we have all these last days of the months where people are queuing, we have been engaging with people, putting hand washing points, educating people, whilst they're in the queue to maintain physical distance, to distribute flyers, to explain to them individually and in a group.

Avril Benoît:

I can see how those things where you have a strong team, that the community knows that I've always been there for people, how that would work and be essential. You've got the trusted relationship already. Kate, you are also keeping an eye on places that are in conflict and knowing your previous work with Diphtheria and Ebola and so forth. I mean, right now in Yemen, just to pick one spot, what would be your concerns about the indirect effects of the pandemic and this difficulty of you can't just move around in a conflict zone to do all that kind of community work that George was describing that they're able to do in Eshowe. Tell us what it's like for the teams in Yemen.

Kate White:

Yemen is... Yeah. Yemen is really feeling the impact of this pandemic and of COVID-19. And I think part of what you see at the moment is people not being able to access health care for all of this until they're really, really at the end of their disease process. And so in terms of how do we turn it around? There's a few things, whilst we, and sometimes healthcare workers that are working for us are not able to access different communities, there are still ways that you can get a message across or have interactions with them. And so in many complex zones, there are people within those communities that are trusted for those communities. And you'll generally have some phone contact with them. You can set up surveillance groups or on... WhatsApp is a wonderful thing that I think, since its invention, we've used it in so many different ways.

And you're then able to help both guide the information that is flowing in there and also look at other ways in which you can support that community to respond itself. But Yemen is an extraordinarily difficult one. There's multiple frontlines, getting supplies in is across those front lines is difficult. There's no easy fix but we're really looking at ways that we can tap into different networks in different communities and try and use those to get people in. And then the really important part is screening and screening for COVID-19 for anyone who comes into our health facility because if we can pick them up early, then you have a much better chance of survival.

Avril Benoît:

We are coming up to the end of this session talking about the indirect effects of the pandemic on medical work that we do as Doctors Without Borders, Médecins Sans Frontières, MSF. Kate, you've got the big picture view of things. How has this response trying to really stop the pandemic, help people with it, through it? Has it affected our operational expenses?

Kate White:

It's massively affected our operational expenses. We've seen the cost of basic protective equipment triple in a very short space of time. And we know that, that we'll also see that increasing cost in terms of getting suppliers in, also HR, we have an impact there in the terms that we have many staff that have been affected by this and they are at home on sick leave. And so, we have to reduce sometimes the services that we provide but the expenditure is still the same. It will have a massive impact in the future. And I really hope that with the support of people around the world, like my mum, my mum is a donor, she gives $50 a month, that we can continue at the same rate that we have but us, we are, we will potentially just be as affected as many others in this, in terms of the economic impacts of this pandemic on the world.  

Avril Benoît:

Oh, please thank your mother for us.

Kate White:

I will.

Avril Benoît:

George. Final question to you for those who are watching, what can they do to help?

George Mapiye:

Yeah. One of the things that we have actually done locally is to form a task force of all stakeholders so that they can support. And we encourage everyone around the world that, yes, this has affected the whole world but the interventions that we are doing also save ourselves as well, so whatever service that you can give, whatever donation that you can give in, will you help us, like what we have heard from Kate, that it has affected the healthcare workers, it has affected each and every one at every level, at every... I can say profession that works to make sure we deliver what we need to deliver, needs to be supported. And we are running out of funds. So we would encourage donations towards the activities. And as you go to our websites, you can see how massive our works have been and they are now being affected and we would want to continue to do more.

Avril Benoît:

Yeah. Well, we will do more. We're not running out of funds to the point that we're not... but we do appreciate all the help. No, we're doing a ton. But thank you so much for all the work that you're doing, George. And to you as well Kate. It has been absolutely a pleasure to have you both sharing your wisdom, your insights and your experiences with us. So, thanks again. And just to let you know that Kate White is medical technical lead for MSF's COVID-19 pandemic response. George Mapiye is MSF’s deputy project coordinator in Eshowe in South Africa. So thanks again to both of you. We'll be back in another couple of weeks for another, Let's talk COVID-19, I don't know why I was doing the air quotes, in the two weeks.

But in the meantime join us next Thursday at this time for a special live event in honor of World Refugee Day, registration is on our website under the upcoming events part of it. And you can also search for World Refugee Day on that website. The website is doctorswithoutborders.org. And also the global website is msf.org. You can also find us on Facebook in many languages, including MSF.English, on Twitter it's @MSF_USA, Instagram Doctors Without Borders, pretty easy to find. And for more specific information or questions that we may not have gotten back to you on, don't hesitate to contact us. Our email address for this team is [email protected]. I'm Avril Benoît, executive director of MSF-USA. Thanks very much for watching and we'll see you in a couple of weeks. Bye for now.

George Mapiye:

Okay. Thank you. Bye.

Avril Benoît:

Bye.

Avril Benoit: 

Welcome and thanks for joining us for our series Let's Talk COVID-19 which we're doing here every two weeks. I'm Avril Benoit. I'm the Executive Director of Doctors Without Borders in the United States. We're known internationally as Médecins Sans Frontières and from that we get the acronym MSF which you might hear occasionally just to save time.  

Today's focus is on the global race to develop a vaccine against COVID-19 building on MSF's decades of experience with vaccine, vaccine development, vaccination campaigns and saving lives through vaccines. And we're going to focus on the challenges we continue to face when we're trying to ensure access to safe vaccines for everyone because we know that there is this global race. We've got research teams all over the world competing to be the first, and they're a lot of issues around access. I know already since we're promoting this through Facebook et cetera that there are a lot of skeptics about vaccination and we would like to address that as well because that movement needs to be taken into consideration as we try to save lives with vaccines.  

So the discussion will last around 45 minutes. Wherever you're joining today, you can submit your questions, join in with the discussion. If you're watching on Zoom, you can send your questions into the Q&A option. If you're joining on Facebook or Twitch just send your comments in the comments section and we'll prioritize questions related to vaccines and this specific discussion.  

In other weeks we will tackle other aspects of the response to COVID-19. So joining me today we have some experts. Kate Elder, the senior vaccines policy adviser for MSF's Access Campaign and Matt Coldiron, a medical epidemiologist at Epicenter which is an epidemiology and research satellite created by Doctors Without Borders/MSF. Welcome to both of you. Good to see you.  

Matt Coldiron: 

Nice to be here. 

Kate Elder: 

Hi Avril. 

Avril Benoit: 

How are you both doing? Matt, you first. 

Matt Coldiron: 

I'm great. Living the dream. Working from home in Brooklyn. I've been baking sourdough for a long time well before this so I haven't even had a chance to find a new hobby. 

Avril Benoit: 

Kate, how about you? 

Kate Elder: 

I'm not baking bread. I'm working really hard at home and trying to balance childcare with very long days but doing very well. Thanks, Avril.  

Avril Benoit: 

I'm glad you're taking the time to share your expertise with us. Let's start with you, Kate. What is your main preoccupation when it comes to this whole topic? When you think of this lodestar of it will all be over as soon as we all get the vaccine as if it's easy? What's on your mind when people like me say things like that? 

Kate Elder: 

I've got two big preoccupations right now. One, what COVID-19 is doing in the context for MSF work. In all of the work that we routinely do to try and vaccinate kids. It's one of the core medical services that MSF offers in the places where we work and there has been a significant interruption of the vaccination services and other child health services. I mean rightly so because we need to prepare and prevent the spread of COVID but that's having devastating effects on children and children's lives. That's my first big preoccupation. 

And then of course is preparing for when we have this vaccine which everybody is eagerly awaiting. Who's going to get it? What price is it going to be at? Can we as MSF get it to vaccinate the vulnerable populations that we see? Those are the things that are keeping me up at night right now. 

Avril Benoit: 

And for Matt, you're looking at a lot of the research that's coming through not just for vaccines but for the sake of today's discussion, what is it you're looking for in all the literature and the news that you're following in this area? 

Matt Coldiron: 

Well, I think this is an epidemic a pandemic that's really... We've never seen anything like it before. MSF we deal with lots of epidemics in places around the world and sometimes they don't get as much press but here we have everyone, every single day, everywhere on the news, on Twitter, on Facebook, on everything else so I think the biggest challenge so far has been to control the quality of the evidence that's coming out. There is a lot of stuff out there, and it is just... I can't think of any other circumstance where there's been such a glut of information. Really separating through what's good and reliable from what is unreliable has been a challenge. 

Avril Benoit: 

Yeah, and where do you go for the reliable information. 

Matt Coldiron: 

I think the classic is peer-reviewed publications. Even though we know that peer-reviewed publications are not without their shortcomings sometimes, that's sort of the highest level of evidence. We're not quite there yet but often what happens when you make public policy is that you have independent groups or independent expert groups that will review all against the ensemble of evidence from peer-review publications. We're not quite to that level yet in this epidemic but that's the best place to start.  

Avril Benoit: 

And Kate, you focus on all of the kinds of vaccination programs that we do at MSF. With COVID-19 a lot of it has been quite disruptive. The effect of COVID-19 on our ability to bring people together for campaigns or even to look after other patients. Can you give us a bit of an overview of how COVID-19 is actually affecting other kinds of vaccination programs? 

Kate Elder: 

Absolutely. We're seeing COVID-19 affect our immunization programs, government immunization programs and a multitude of levels. First and foremost is just the disruption of the healthcare workers in the system as countries prepare for COVID-19. So people that are typically in primary healthcare centers with a focus on immunization are being diverted to other necessary preparations. Healthcare facilities, healthcare wards. Being changed from a maternity ward for example into a COVID-19 treatment ward. So that's the first thing is just a shift in focus to this priority pandemic.  

Second is can we even hold vaccination campaigns anymore? I mean in the places where MSF works we do vaccination in three different ways. One is through primary healthcare. The routine day in and day out. Kids getting their routine shots as we do here in the United States when I take my daughter for a vaccine or in Europe they also do in developing countries.  

Secondly, we hold mass vaccination campaigns to prevent disease outbreaks. In the places where MSF is working measles epidemics are still raging. Immunity of kids is low so you need to hold mass vaccination campaigns to boost immunity quickly and prevent an outbreak and then thirdly we typically do actual outbreak response campaigns. There is a measles campaign. They're quickly trying to mobilize people in a couple days to vaccinate as many kids as possible. Understanding that we don't want lots of people to gather right now, that has taken away a major tool of vaccination programs that we typically do and we're seeing that level of interruption in terms of our ability to just actually vaccinate. 

Thirdly, getting the vaccines to countries. I think everybody's seen the reduction of course in air travel. UNICEF said that they have seen air flights to Africa decrease by 70 to 80% meanwhile the freight charges have gone up 100 to 200% more in terms of the cost. So just getting the vaccines that we typically do to these countries has been incredibly difficult. To just maintain any services that actually can happen.  

And of course, then there's the community level issues with the demand. People are scared. People have been told not to leave the house in places, so they're not coming to seek healthcare if they typically would. So that's just a few of the areas right now where we've seen immunization programs in the places where MSF works be impacted. And of course just to bear in mind the magnitude of that in a country like the Democratic Republic of Congo compared to the U.S. is significantly different. When a child is not protected against measles in DRC and if they do get measles their ability to get treatment, the rates of illnesses are much higher than in a developed country. So these are some of the concerns that our colleagues working in operations are facing right now. 

Avril Benoit: 

Let's focus on the new vaccine. The vaccine against COVID-19. I'm saying the vaccine as if there's just one. We're starting to get questions through the comments and the Q&A here so let's start with the first one. A vaccine against coronavirus, coronavirus is the common cold. They're in the ballpark together, and there's no vaccine against the common cold, Matt. So Dennis is asking, are vaccines even successful against Coronavirus. 

Matt Coldiron: 

To date, vaccines have been partially successful against other types of coronavirus. To be very clear there is not a COVID-19 vaccine yet. There are some candidate vaccines. Many of them are already doing early-stage testing but we don't have any vaccine yet. Dozens of candidates but we don't have something that we can definitely call a vaccine yet.  

But yeah, it's going to be a question of managing expectations. For many vaccines, we know that efficacy is super high. If you get two doses of measles vaccines, it's going to work 98% of the time and we can sort of say for other diseases how they work. For a lot of these respiratory diseases like the flu and for some of the other coronavirus cousins that have been tried the vaccines are not probably not going to work 100% well but the question is if you can get a vaccine that works 60, 70% of the time, maybe that's a really big public health benefit and that has a massive effect. 

We're probably not shooting for a vaccine that's going to be 100% effective. Definitely not the first one that's going to come out but trying to find something and can reliably prevent disease even half of the time would be really valuable.  

Avril Benoit: 

We're getting a lot of questions about how we seem to be rushing into this. Initially, we were told vaccine development takes five years, 10 years. Now we're going to try and do it in a year and a half and even the different models have shown how everything would have to align perfectly for something to be ready in a year and a half. Do you share the concerns that many people have that we're going to be cutting corners on safety perhaps? That it's just not going to be as secure once there is a vaccine that's validated, Matt? 

Matt Coldiron: 

I would say that I understand the concern. I don't say that I necessarily think that it's a... I don't see it as a major concern but I understand why people would be afraid or be scared. The way that vaccines are brought to market. The traditional classic way it would take five, 10 years from the first step all the way to sort of large scale public health use. We don't have 10 years now. This is completely... It's totally different. No one has ever seen this, so there's a massive amount of funding. There's a massive amount of goodwill, and there's a massive amount of desire and need for a vaccine so I think that some of the moving faster is because there is a massive need in front of us.  

The other part of it is that because there is such a massive need there are some creative ways to look at streamlining the process. I wouldn't call it cutting corners or skipping steps but I would say streamlining. And that involves maybe doing fewer studies in animals but starting to do the studies in humans on a small number of people.  

The way that the studies usually work. You talk about phase one, phase two, phase three and sort of phase three after that then a vaccine will become licensed. Generally, phase one you're talking about tens of participants in a trial. Phase two you're talking about hundreds of participants in a trial and phase three you're talking about thousands of participants. In terms of the safety, the very earliest it's in a very small number of participants and that's just because we want to make sure that there are no safety signals and then in none of the ways that they're talking about streamlining are those early-stage clinical trials going to be in any way streamlined or moved around. I think that the building blocks of how we evaluate vaccines is still the same.  

Avril Benoit: 

And Kate, the pipeline for this vaccine development. What can you tell us about how it typically would work? The challenges to actually making sure that there would be fairness in terms of who gets the vaccine and things like that. 

Kate Elder: 

That's an excellent question. I think never before has the world been in the position where the entire globe expects to hopefully get the vaccine at the same time. There is always, I mean we see this at MSF because many of the vaccines that are available in high-income countries are not yet available in low-income countries where we work. So traditionally because of the biopharmaceutical model, commercial model, there's a huge lag time between when a vaccine is available in high-income countries that can pay top dollar and when it's available in the poorer countries of the world that obviously have significantly lower budgets to spend on health and vaccinations.  

We're in an unprecedented time of the entire world hoping that there will be a vaccine available at sufficient quantities which we know will be challenging too if there's more than seven billion people in the world and it's not necessarily going to be the case that the vaccines, the first ones that are available just require one dose. Many vaccines that MSF administer like Matt talked about before for measles, there's two doses or a couple of doses to be fully protected. So the volumes that we're also looking at are extraordinary. 

So that question of the fairness. Who's going to get it is really at the top of everybody's head right now. MSF has been calling for no profits during a pandemic. We believe that this still indeed is a global public good. We're encouraged by the language we've seen by many global health leaders that indeed this is the peoples' vaccine and a common good so everybody should have access to it in a fair way as soon as possible. But then translating those big political statements into concrete mechanisms and allocation systems is the difficult bit. The devil's in the detail.  

So there's some work right now being done let by the World Health Organization to develop an equitable allocation framework if you will. I think everybody agrees that healthcare workers, the people that are most vulnerable certainly deserve this vaccine first but that's going to take a lot of solidarity. That's going to take countries not hoarding the vaccine. That's going to take countries not already putting in advanced purchases for doses that aren't even available yet which is something that we're seeing with some high-income countries. So I think we're hopeful but we're practical and many steps are being taken right now by the global community to try and set those stipulations in advance. It's not going to be easy, though. It's not going to be easy. 

Avril Benoit: 

Is there any one regulatory body though that can make sure that the things you're talking about are upheld? 

Kate Elder: 

The World Health Organization would definitely be the best place for that sort of solidarity and that framework to be brokered. The challenge is A) Do countries buy in to this multilateral approach that the World Health Organization functions under? Do they have the biding mechanisms to enforce it which are challenging worldwide? But that would be the best place to do it would be WHO.  

The World Health Assembly just concluded last week. The annual general assembly of all countries of the world. The first time I believe it's happened online in one day and there was one resolution on COVID-19 brokered but it's a politically dynamic sphere. Many countries are trying to pull out language that expresses solidarity, not wanting to talk about global public goods. So there's a lot of self-interest at play and it's sometimes hard to really find a consensus.  

Avril Benoit: 

Matt Coldiron, you're a physician and an epidemiologist and when you look at this fixation that many have on vaccine and yet what we hear from other public health experts that in fact it should be about testing and contact tracing and there's a whole different approach that we should be prioritizing. How do you balance the need for a vaccine eventually, maybe the need for treatment at some point with all the prevention work that's necessary to be able to slow down this pandemic? 

Matt Coldiron: 

Certainly in the absence of an effective vaccine, the best way of doing prevention is being able to do the contact tracing, isolation of people at risk and wearing your mask and washing your hands and things like that. That need for good contact tracing is not going to go away once we have a vaccine because when there are cases you will still need to do that same sort of epidemiological tracing but there is, at the same time, need for treatment for people for whatever reason are not protected by an eventual vaccine or who slip through the cracks of contact tracing or become sick even despite the contact tracing. So I think they're complementary. I don't think it's a one or another thing. It's all part of the package.  

Avril Benoit: 

And the testing then. There are different kinds of tests, and you've got the antibody test is a whole other issue as opposed to do you have COVID-19 or not. 

Matt Coldiron: 

Exactly.  

Avril Benoit: 

It seems also that some tests were rolled out that weren't very good, that weren't very accurate, that weren't worth it and yet they were developed and invested in and hopes were pinned on them. Is it possible that we could have a similar situation with a vaccine? 

Matt Coldiron: 

The short answer is yes and I think that's not necessarily a bad thing. As I was explaining before we're not expecting the first vaccine to be a perfect vaccine and I think that sometimes when people have... And there's no test that's a perfect test either. It's a fact. I think that an imperfect vaccine could be an extremely useful tool. If you're able to decrease the number of cases of COVID by 50%, no one would say oh, well your vaccine didn't do us any good because it didn't work half the time. You'd say well you have 50% fewer cases. 50% fewer deaths due to COVID.  

If one looked at it from a public health point of view even a perfect or an imperfectly protecting vaccine is still an extremely valuable tool. I think as Kate was talking about there's sort of an urge to move fast. Where I'm a little bit afraid about that is if one country has the vaccine they push to move it out in their populations. To roll it out very fast. I think that's a potential risk and I think it's going to be about that race mentality. The horse race mentality. 

Avril Benoit: 

For those who are part of the anti-vaccination movement, though, they will say actually the biggest risk is that this vaccine or these vaccines that are proposed will do more harm than good. How does the scientific research process avoid that? 

Matt Coldiron: 

Through rigorous application of protocols. Through rigorous oversight. Through independent review and through continued follow-up even after licensure. What I was explaining before about the way that you go from animal studies to small studies in humans to larger studies in humans and then to very large studies in humans. That is done to mitigate any possible risks. If there are any potential risks with any vaccine, drug, device, anything you want to be looking at the smallest group possible first and generally healthy people as well. You don't want to have an 85-year-old person with multiple comorbidities in a phase one safety trial. You want to look at it in a healthy population similar to you're not going to look at pregnant women or children in those trials. You're going to look at a healthy young adult population.  

And then I think one of the things that's difficult with the anti-vaccine movement is that there are sometimes rare side effects from vaccines. There are rare side effects from drugs. That's just a fact. The problem is that even if you did a massive scale clinical trial with a hundred thousand people in it, which is larger than almost any clinical trial you've ever seen. If you have a rare side effect from any drug or vaccine that maybe happens to one in three million people, you're never going to even see that in the clinical trial so after the clinical trial process if over what happens is that there's post-licensure monitoring of any drug or vaccine or therapeutic. And that's just a part of the cycle. It's regulated by researchers. It's regulated by scientific people. It's regulated by ethics committees. It's regulated by drug regulators and it's just a process. 

Kate Elder: 

Can I jump in there Avril? 

Matt Coldiron: 

Please. 

Avril Benoit: 

Yeah, go ahead. 

Kate Elder: 

Just to underscore the importance of some of the points that Matt's saying. Every single vaccine regardless of where it's produced goes under the same level of scrutiny. There is not a huge number of vaccine producers around the world. It's actually a relatively small group of producers and the level of regulation... Because if these vaccines are being given to healthy people, we're injecting a substance in a healthy person. The bar of safety is incredibly high. There's no such thing as generic vaccines actually. Every single vaccine, whether it's produced by a company in France, here in the United States, in Brazil, in India, go through the same robust clinical procedure that Matt is talking about. It has to go through every same step. There's no such thing as bioequivalence as you seen in a medicine field with generics.  

So just to underscore, there's no such thing as a generic vaccine. Every single one of them where they're coming from goes under the same level of extreme regulatory steps and also the World Health Organization has a program called the Prequalification Programme where they look at all of the data from regulatory agencies and give their stamp of approval as well these are indeed safe. All of the vaccines that MSF buys have received WHO prequalification too. So just to underscore what Matt's saying. These are very safe when they finally get to people.  

Avril Benoit: 

Question from Jessica though which links to something that you mentioned in passing Matt that you wouldn't do the clinical trials with pregnant women for example. So how then when the vaccine is rolled out would you know that it's safe to give it to pregnant women? 

Matt Coldiron: 

Let me clarify. I would not do the very first phase one trial and that's the trial where you're doing it in tens of people. So 10, 20, 30 people. I would not want to include pregnant women in that trial. I think it's extremely important, and we've seen this in the Ebola epidemics and in all sorts of other vaccine development to make sure that pregnant women are offered the chance to participate in these trials. Participation in a trial is not something that's forced on anyone. It's something that's proposed to people and they have a back and forth talking about the risks and the benefits and if they decide they want to participate it's their voluntary choice. So I think there's a very important role to include pregnant women in these trials but just not at that very first stage like the 10, 20 person trial.  

Avril Benoit: 

Another question that comes to mind is that if somebody participates in the trial at a certain point you want to know if they're still carrying the antibodies or they're still protected by the vaccine. I recall participating myself in the vaccine trial for the Ebola vaccine when I was working with Doctors Without Borders in Eastern Democratic Republic of Congo. So that was a year, year and a half ago. Am I still somewhat protected? How will we know? What will be the aftermath of having participated in a trail let alone once an approved vaccine is actually given to the wider population? 

Matt Coldiron: 

This is where we're working on multiple fronts at once. One of the things that we talk about in terms of evaluating vaccines is immune correlates of protection, and that's a big fancy-sounding phrase but it basically says we know what to look for in someone's blood that says if they have this antibody or if they have this type of cell then they're definitely going to be protected. You don't know that yet for COVID-19. With the testing we're looking for antibodies we can say that that means that they have been exposed. We can say for sure that they've had it but it doesn't necessarily mean that they're going to be protected in the future. So we don't know this immune correlate protection against COVID-19 yet. So it does make it a little bit more difficult to do some of these early-phase vaccine studies because we can look for some antibodies but we don't know if the presence of the antibodies will actually confer actual immunity.  

Classically in larger-scale trials of vaccines that would be what would be seen. The people who are planning these trials now are forward-thinking. They're saying well, we're doing the small safety studies now. The phase one. The phase two trials now but if the vaccine looks promising then we need to do it in thousands of people. They're already planning those trials now and getting them on the ground and it will be important to do some of these larger trials in places where there is active transmission because that's going to be the easiest way to see if the vaccine works is if you go into a city or a county where there is a widespread transmission and you're vaccinating some people you can compare to see who gets and who doesn't get.  

Avril Benoit: 

You're watching a live stream from Médecins Sans Frontières/Doctors Without Borders, an international medical organization that is responding to COVID-19 and today we're taking a deep dive into vaccinations and the COVID-19 vaccine. The promise of it to get us out of this pandemic. Now, Kate Elder, you're a senior vaccines policy advisor with our Access Campaign and we have a question here that's come in from the audience how does MSF work with other organizations, other actors at different stages of the development or testing of a vaccine?  

Kate Elder: 

That's a great question. MSF is involved in vaccine development almost across the entire spectrum I would say. Way upstream so to speak when the money is being allocated, we're following that right now. Who's giving the money to develop COVID-19 vaccines? How much are they giving and what strings are coming attached to make sure that the end product...? If this company has a successful product are available to as many people as possible. So I would say we really watch it from the very inception of when this happens that we're doing right now. Trying to trace the money so to speak and make sure there are conditions attached to that money.  

MSF sometimes gets involved in clinical trials itself. We have research arm of MSF, Epicenter that Matt works for and so we participate in many of the places where MSF works, we need to know about the potential success of these vaccines and we're ultimately the ones that also use them. So sometimes MSF actually participates in the clinical trials run by pharmaceutical companies. Further down the line, the Access Campaign, a small arm of MSF that works to ensure affordability and accessibility of medical tools to the people that MSF serves as well as beyond. We follow the access element.  

So what prices are being set? What sort of policies are governing how these tools are being allocated? What do the products even look like? We're talking right now about trying to get a vaccine. We're all eagerly waiting for the first vaccine. The second, the third vaccine but then actually getting that vaccine and distributing it and using it in communities is a very different context in which MSF works in high-income countries. We deal with things called cold chains. You've got to keep the vaccine cold. How do you do that in a place that doesn't have electricity? Many of the vaccines as I said before require multiple doses. Some of them are not in multi-dose vials. You just have one dose. There's one vial. That seems easy. That's what we have in the States but that means you need so much more cold chain refrigeration capacity to get it to these places.  

We're also following what the product characteristics if you will are of these vaccines to try and make sure that they're easy to use in developing country contexts. But we're following it I would say from every single step and we're doing it as you said, Avril, in collaboration with other civil society and NGO partners. There is a huge access to medicine community right now that is following the development of these vaccines very closely because they want to make sure that they're accessible to all.  

I would say in more than a dozen years of working in immunization and vaccination policy I have never seen such interest from the civil-society community in the outcomes of one vaccine. If there's a silver lining for me it's that the access to medicine community is so interested in this vaccine whereas before immunization I would say hasn't really had a huge advocacy constituency in the civil-society community. At least it's not as much as I would like but of course, I spend all day working on vaccines. But right now, the access to medicine community is watching this closely which is great because we're going to have to hold governments and pharmaceutical companies to account when the first vaccines are available.  

Avril Benoit: 

Let's jump right back into another topic in the questions and this one's for you Matt. Will mutation of this COVID-19 virus affect vaccine development? 

Matt Coldiron: 

Maybe. That's the short answer. We don't know. There's been documented small mutations of this virus that's circulating in the community now that don't seem to have clinical impacts on patients that get COVID. For now, it doesn't seem to have any impact on the vaccine targets. I don't want to get too deep into how a vaccine is made but often the vaccine targets a specific part of the germ, in this case, the COVID-19 virus and there haven't been any significant mutations in the part of the virus that many of the vaccines are being mounted against.  

That said, you can look at things like the flu where every year there are mutations and there are differences in what happens and it can affect vaccine efficacy. So it's possible that that happens for COVID-19. I wouldn't say that it's probable at this point or highly likely at this point but it's definitely possible and it's something that researchers and the scientific community will have to keep an eye on.  

Avril Benoit: 

And many of us have heard that there are strains. That you can tell where the vaccine came from. So for example the strain of the virus that has afflicted the northeast of the United States, New York State in particular for example, came from Europe. They can say that came from Europe. Is that a mutation or is that a strain? What is the difference between the two? 

Matt Coldiron: 

It is the result of a small number of mutations that are not clinically relevant or not clinically different. You can sort of take the whole genome of this virus and if there's... I don't know how many genes there are in this virus but if there's two million different little strands of DNA or two million different pieces of DNA, there might be three or four, five or six that are slightly different and you can look at those slight differences on a genomic level, on a molecular level and say that this is different. But then in terms of what you actually see, there's not a difference in terms of the clinical picture or in terms of the transmissibility or anything like that. It's something to watch and maybe in the future, there could be some sort of mutation that would make a difference in clinical presentation or transmissibility. That's not the case yet and for now, it's an epidemiological tool that we're able to look and see on a molecular level who's spreading where. 

Avril Benoit: 

All right. Another question for you Matt. Explain how this herd immunity concept which has flocked in a few countries, maybe is still being tried in other countries, is a question mark, is controversial but how long does it take for a community to have the herd immunity that you would look for in order to diminish the risk of these terrible apexes of cases arriving in intensive-care units in hospitals for example? 

Matt Coldiron: 

Again we don't know the answer to that question yet. There are hypotheses that maybe you need about 50 or 60% of the population in any given community. 40, 50, 60%. But we just don't know the answer to that question yet. The concept is that you want to have... If you get enough people in a given community, you are protected against the disease even if the disease is introduced into that community it doesn't really have the chance to spread and to propagate and that is biological. It's also a mathematical concept. You can sort of look at it the numbers way. We have ideas and hypotheses but we don't know for sure yet.  

But that herd immunity right now is being gained hopefully be people who have been infected and who we hope are protected. We don't know yet, but we hope we will be protected against infection at least for a year or two. And eventually, this vaccine would be able to contribute to providing that herd immunity so you could gain either by natural infection or by vaccination. We'll have to see what that magic number is. Whether it's 50%. Whether it's 75%. It's probably not going to be 90% like it is for some diseases that you need but if we can get to an acceptable level then that would have a big effect. 

Avril Benoit: 

Let's jump in to how long it would take... Let's say we had some notion of which were the vaccines that would succeed through the various hoops that they have to go through for the clinical trials and you start the manufacturing process early. You're tooling up your factories to be able to manufacture and let's say that process is starting in a timely way. How long would it take to vaccinate enough people in the world to create that sense of herd immunity? I don't know which one of you would want to speculate on that. 

Matt Coldiron: 

I can start and say that it takes a lot longer to vaccinate a million people in the Democratic Republic of Congo than it takes to vaccinate a million people in New York City and I think that the question of time is very important because it's one to vaccinate a densely populated urban areas but it's another to vaccinate in some of the places where we work every day in MSF.  

Avril Benoit: 

Kate Elder? 

Kate Elder: 

And with globalization like a lot of people have been saying and it certainly rings true, nobody is going to be without borders. This virus is without borders. With the globalization, with how quickly people travel around right now the idea of countries taking a very nationalistic approach which we do see in some places, that's really a fool's errand right. What are you going to do? Shut down travel indefinitely. People are always going to be traveling into your country, out of your country. This virus as we saw in practice will spread very quickly. We're still bracing for what's going to happen in many of the countries where MSF works. Maybe just the surveillance isn't strong enough yet to really give a clear indication of what's actually happening in a lot of developing countries.  

The availability of the vaccine in terms of what it can do scientifically, medically is a very good question. We can only answer that as well if we actually have the doses available. Are the doses available? Are countries getting them? How quickly are countries getting them? Are they just going to stay these golden tools that only a few have? The people that can pay the highest dollar. The people that can get in the line first. Those are the sorts of questions right now that we need to be preparing for.  

On the manufacturing side, I think it's a great question, Avril because the way pharmaceutical companies typically invest in scaling up their production is... They do it based upon spreadsheets. Budget. How much do they need to produce to make this much money for these shareholders essentially? So they make investments when they're very sure about a market case if you will. In many places where we work as MSF, there are medical tools, there are vaccines that have been around for more than a decade so far and we still can't buy them because the pharmaceutical companies don't think that it's worth their while to produce enough doses to sell to us at a lower price. It's really shameful.  

So what are we doing right now differently as a global community to prepare that? To start putting in place the wheels to manufacture at a huge scale in advance so that when we do have the first ones out of the gate we can produce as quickly as possible. It's also important to note that all of these different vaccine candidates right now that are being developed can in human trials right now, they're all working on different platforms. I think, correct me if I'm wrong Matt, I think there's about eight different vaccine development platforms that they're using right now to develop future COVID-19 vaccines. Some of them are vaccine development platforms that we've used for decades. Some of them are completely cutting-edge. They have never once produced a successful human vaccine. I think people are reading about these things. mRNA, DNA vaccines are totally new. 

Each of those platforms has different implications for how long it takes to develop the vaccine. The product development lifespan and at what scale. How many doses you can produce too. So it's very vaccine-specific but regardless of which ones are out of the gate first, the global community needs to come to an agreement of who's going to get them and what level of priority. This is incredibly important right now especially when you refresh your browser every day, and you see a new merger acquisition from a pharmaceutical company buying up the little guys. 

Merck just bought up a small company recently.  

Matt Coldiron: 

Big one today. 

Kate Elder: 

Big one today. So what does that mean? The companies are the ones that ultimately because unfortunately we have not dealt with intellectual property and we're not doing anything different than we typically do. That means that sadly that these are proprietary tools. They're not truly in the public domain. So the companies get to decide what scale they're producing them. How many doses, what they're pricing at and who they're selling to first. 

Avril Benoit: 

We have a question from Dave about transparency. Kate, will information sharing between these big pharmaceutical companies accelerate the development? Will it go faster if they are more transparent with one another? 

Kate Elder: 

Absolutely. It's a great question from Dave. Absolutely. And I do not want to be all doom and gloom. I definitely want to give credit to the unprecedented level of scientific collaboration that we're seeing right now. WHO is doing a very good job of convening the developers and encouraging sharing of information because indeed it does benefit everybody. It does accelerate on innovation. It does produce a faster COVID-19 vaccine. We have enough scientific barriers alone to lengthen the timeframe but if we can share information yes it will certainly accelerate the availability of these tools.  

Not only sharing information. I think it's also an important point about then sharing the ability to produce it too. Not only in the scientific process but once we actually have a vaccine can we think of a new way to produce it at a huge scale that has the public's interest in mind? Can we not just give the pharmaceutical companies the ability to make these decisions unilaterally? I think that's what people are trying to plan for right now and see what sort of tools we have to push companies to act in a different way than they traditionally do. 

Matt Coldiron: 

Just to jump in or to follow on that point, I think that the question of quantity of production is very important because there is a bricks and mortar implication of this. The machinery, the technology that you must have in a physical place. The vats that you have to produce this vaccine, there are limited numbers of those right now and they cost money to make and this question of where you put them, how you make them, what are you not making if you're using this specific vat for this vaccine. So it's a super important question.  

Kate Elder: 

Have you heard there's a global run on glass? I'm sorry Avril. 

Avril Benoit: 

Yeah, there's a run on PPE and the plastic for face shields. Every part of this COVID response seems to a run on supplies of some kind, but we're focused on the development of the vaccine that will prevent the transmission of COVID-19 and Adam is asking, how do we guarantee a true cross-cultural testing process? I guess this is a clinical trial stage to maybe take into consideration that often with clinical trials it's white men of a certain age span and others are excluded and you never quite know. So how do we address those issues of race and class and location of the perspective people? Matt? 

Matt Coldiron: 

This is in my wheelhouse. This is what we do at Epicenter and at MSF. We run these trials in places where trials are not run and it's super important and I think the nest example that I can give is the trial we did of a novel rotavirus vaccine. It's heat stable. We ran it in Niger which is a country where up to a third of childhood deaths are due to diarrhea and this is a vaccine that stays stable at room temperature for up to two weeks at a time. It's a game-changing tool. And we were able to do it in a population that didn't have access to this vaccine, wasn't participating in trials and it actually turned out that this vaccine did so much better than the other previous vaccines in African populations.  

So it's super important that any intervention, whether it's a vaccine or a drug, could be tested in a populations where it's going to be used. And that's what we do regularly and there are plans being made for some of these trials of COVID-19 vaccine candidates to be done in Africa. Already with one of the vaccines that's being developed at Oxford, there's plans to run inclusions in Kenya, in Kilifi along the coast. CEPI, the Coalition for Epidemic Preparedness, they're already planning to do these trials in Africa. So it's super important and I think personally that it's a very important thing for MSF to support and participate in because it is an equity question just as we need access to the vaccines we need to make sure that the right people are being able to participate in the trials and whatever candidate is being evaluated in the right population. 

Avril Benoit: 

We are coming up to time, but there are a couple of really good questions that I want to get to so we'll try to keep the answers relatively concise. This one I guess is for you Matt, you mentioned earlier that probably the vaccines that are developed won't be perfect. They won't provide 100% coverage. They'll be maybe good enough if I can paraphrase. We've received several questions about whether a partially effective vaccine could really help reduce the severity of COVID-19. So even if you are exposed and you get the virus that actually it helps you to weather it a little better. 

Matt Coldiron: 

It's a great theory and it's a great idea and we've seen it happen with other vaccines before. With other vaccines and other diseases, if you've been vaccinated and even if you get the disease afterwards maybe you have a less severe form. Certainly the flu and maybe measles as well. Definitely precedent for that. We don't know if that would be the case yet for any of these vaccines in COVID but it would certainly be great particularly in the most vulnerable populations. 

Avril Benoit: 

Kate, this one's for you. Flu shots are voluntary, and I have always rolled up my sleeve for the annual flu shot because I feel it's my responsibility not to expose others to my flu especially vulnerable elderly people who might not get the vaccine et cetera. So I'm one of those who will volunteer but do you think the COVID vaccine will be mandatory for some people? Will it be voluntary? What do you think? 

I'm not hearing Kate. That means you're going to have to take this one Matt. 

Matt Coldiron: 

I can jump in and answer that. Yes, I think that it will certainly be mandatory for healthcare professionals as is the case for several other diseases right now. Flu shots, Hepatitis B vaccinations are mandatory for healthcare professionals so I think that that would certainly be the case. I remember when I was a resident and one the novel flus came out they literally brought the cart around the hospital. Anyone that was wearing scrubs. Nurse, doctor, respiratory therapist got the jab in their arm as soon as it was ready. So I think that that will certainly be the case for this vaccine that comes out both to protect the healthcare workers who are at very high risk but then also to protect the others that they're taking care of from going on and transmitting. 

Avril Benoit: 

Right, have we got your mic back on there Kate? 

Kate Elder: 

Yeah, sorry about that. 

Avril Benoit: 

No problem. Matt jumped in and now I'm going to leave you with the final question from Laurie. Kate, Laurie wants to help. On a practical level what can be done and how can those who are watching help on the access to affordable medicine vaccine front for this COVID-19 vaccine? 

Kate Elder: 

That's a great question Laurie, and I'm very glad that you asked because recalling what I said before in terms of the need for civil society and everybody individually to take a role to demand that these future vaccines are available we're going to need your voice. We're going to need your voice to push politicians. We're going to need your voice to push pharmaceutical companies that I said are really going to be unfortunately the ones in the driving seat of determining how these vaccines are priced. We didn't even get to talking about the price, but that's a big concern too and who's getting them first. 

So I would ask you, Laurie, to please check back at MFS websites to keep in touch with us because we will be asking for your support in many different ways in the future to push and use your voice to make sure that everybody really benefits from these tools that indeed actually are a global public good. 

Avril Benoit: 

Wonderful and a great ending for us. Thanks everyone for joining us for this COVID talk. We have had the pleasure of listening to Kate Elder, senior vaccines policy advisor for MSF’s Access Campaign, and Dr. Matthew Coldiron, at Epicentre which is an epidemiology and research satellite created by Médecins Sans Frontières/Doctors Without Borders. So thanks to both of you for being here and apologies if I didn't get to your question. We tried to fit in as many as we could but we will be back here, same place, same time in another couple of weeks for a discussion of the challenges that we as MSF are facing as we strive to deliver medical care in many of the places where there are all kinds of restrictions caused by COVID-19.  

This pandemic has had a massive effect on our operations so that'll be June 11th, 01:00 P.M. Eastern Daylight Time. That's correct. I'm getting the time zone correct. This time. Registration is also on our website for this one and for upcoming events so you can just go to our website www.doctorswithoutborders.org and msf.org. You can follow us on Facebook in different languages including msf.english. Twitter is @MSF_USA and of course, you can find us on Instagram at doctorswithoutborders. 

So please do stay in touch with us. We love to hear from you, and we appreciate and thank you for all your financial support. All the donations are making our operations possible so thank you. I'm Avril Benoit and we'll see you in a couple of weeks. Bye for now. 

Kate Elder: 

Thanks Avril. 

Avril Benoît:

Hello, welcome once again. Thanks for joining us for our weekly series called Let's Talk COVID-19. I'm Avril Benoît, I'm the executive director of Doctors Without Borders, Médecins Sans Frontières, in the United States. I'm joining you from my apartment in New York City. And for Doctors Without Borders, you might know us also by our international name, Médecins Sans Frontières, which is why we get the MSF acronym that you might hear over the course of this discussion today. And I'm really excited today because we're going to be focusing on emergency medicine, emergency care during the COVID-19 pandemic, and lessons that our organization, MSF, has learned from past outbreaks, medical emergencies, and conflicts. The kinds of places where we work, we have a lot that we're able to apply in our response to this particular pandemic.

We're going to speak for about 45 minutes. And wherever you're joining us, you can contribute your questions. This is a live broadcast. Submit your questions on Zoom, if you're watching through Zoom, into the Q&A box, the option that's there. And if you're watching us on Facebook Live or Twitch, you can send your questions through the comments sections. Those will be directed to me and then I'll ask them of our panelists. So I'll get right to the introductions.

Now, joining me from London, is Dr. Javid Abdelmoneim. He's an emergency physician. He's also the President of the Board of Directors of MSF in the UK. And these days he's working at his regular job at the National Health Service Hospital in London, responding to COVID-19 outbreak there. Hello, Javid! How are you doing today?

Javid Abdelmoneim:

I'm doing well, Avril. Nice to see you, nice to see you, Craig. Welcome, everybody. I'm in my home at this moment in London, yes, coming to you at two in the afternoon.

Avril Benoît:

And all quiet over there?

Javid Abdelmoneim:

Today, yes. I think my dog ... I can just hear my dog, actually, coming home from his walk, so you may get a scattering in a second, but all good. It's my day off, I'm in my MSF role today. I'm back in the NHS, in hospital, on Sunday.

Avril Benoît:

Great. Well, as you mentioned, we've also got Craig Spencer. Craig is an emergency physician in New York. He's a member of MSF's Board of Directors in the United States, and also Director of the Global Health in Emergency Medicine, and an Assistant Professor of Medicine and Population and Family Health at Columbia University Medical Center. And these days, he's been working in the emergency room at his hospital in New York City. How are you doing, Craig?

Craig Spencer:

I am doing great. I don't have a dog but I do have a 17-month-old, who's going to go down for a nap soon, so she may make an appearance either vocally or in person.

Avril Benoît:

It's fantastic to connect the two of you, across the ocean, as it might be. You know each other, don't you? Tell me, Craig, what you know of Javid that we ought to know for the sake of this discussion.

Craig Spencer:

Well, I first met Javid ... We were both going out to Ebola in September 2014. We did a training in Brussels, they had like a ... For the Ebola trainers, for the people that were going to deploy, they had kind of like a makeshift Ebola treatment center in the middle of Brussels. So we were there for a couple days, doing some training before we both deployed. So we were able to meet them and our paths have crossed a couple times since then. Myself, on the Mediterranean search and rescue boat through Doctors Without Borders, I was there, Javid was there. I think we both made a couple of appearances there.

Avril Benoît:

Javid, what do we need to know about Craig, from your experience of him?

Javid Abdelmoneim:

As Greg detailed, that's how our paths have crossed. I've had some interactions with the Board of Directors of the MSF USA as well. We've conversed through last summer, I believe, if I recall well, on MSF matters. But yes, I've been seeing Craig being very vocal on social media through this COVID-19 pandemic, and I have to say I agree wholeheartedly with all the sentiments and everything that he's said. He seems to have had a different experience in his emergency room than I have here in London, and perhaps we'll explore some of that later.

Avril Benoît:

Let's start with that, actually. Javid, what is it like where you're working? What kinds of things are you encountering in London?

Javid Abdelmoneim:

It's interesting. In the ER, where I work, across the entire National Health Service in England and the whole of the UK, we've moved to a binary system, a triage where everything at the door is filtered for either being possibly COVID or not, and so we have green and red zones. Overall, in the green zone, we're seeing fewer cases of what might be ordinary ER attendances. But what's coming through the red zone is all ... all one disease, that people are coming through, tend to be a lot sicker, and the entire health service behind us, the whole hospital, has been geared towards the reception of that one illness. So in that sense, it's all ... it's odd.

I have to say we've been very well prepared, we've been able to quadruple our intensive care and ventilator bed capacity in my hospital networks in West London. We've had good supplies, good training, and morale is high. We've managed the flow of patients well. And yeah, in that sense, it's been as good as an experience as it can possibly be given the circumstances.

Avril Benoît:

Craig, how does that compare to your own experience in New York City?

Craig Spencer:

I imagine we're seeing the same patients with the same symptoms and doing a lot of the same stuff, the same treatment. But I think the difference is that, whereas for you, you have a national health system that can put out guidelines and you can help direct different ... whether it be PPE or whether it be ventilators or whatever, all throughout the country were needed, what we're seeing here in the US has been more of a fractured response. We have a big hospital systems. I think what we're seeing here in New York City is really a spotlight on the health inequities that have existed for so long, not only in New York but in the US.

We just got disaggregated information about a week ago and how this is impacting New Yorkers. And unsurprisingly for anyone who's been working in the emergency room, the death rate for Latino or Hispanic New Yorkers, as well as black and African American New Yorkers, is double what it is for white New Yorkers. The impact has been huge in the outer boroughs, so the areas where people do not have the same economic capacity to socially distance or stay at home, like what we've been messaging so much here in New York City. So, this has really highlighted so much of the inadequacies and, really, efficiencies in our health system, and I'm hoping that's something we address after.

But a lot of what we're seeing is quite similar to Javid. A lot of really sick patients. I just worked up until two o'clock this morning, yesterday was a little bit better. I'm hoping that's because the cases are going down, and we think that that's true, but we've also expanded capacity in our ICUs. We've opened up field hospitals, there's field hospitals in Central Park, and stadiums, and ships in the harbor. So we've expanded capacity, we've got a lot more professionals here. Everyone is on the front line, doing whatever they can, and morale is still, thankfully, high.

Avril Benoît:

What connects all three of us is that we work with Doctors without Borders, with MSF, Médecins Sans Frontières. And we know that our colleagues around the world are readying themselves, are transforming our medical approaches in light of the arrival of these COVID-19 patients. But for the two of you, you're among the legions who are essentially grounded in our home countries, and who are practicing medicine and offering to support in your local communities. Tell us what you have learned, particularly from the Ebola outbreak in West Africa. That experience, that muscle memory that you have been able to apply to your work in New York. Maybe start with you, Craig.

Craig Spencer:

Sure. So yeah, I worked in West Africa for ... I did two different missions, one in 2014 and one in 2015, after I had survived Ebola myself. And so I have a different and kind of unique perspective on the disease, both as a patient and as a provider. The skills that I learned in West Africa were critical in what I'm doing right now, in my West Harlem ... my Washington Heights hospital. And the way that I try to describe it is that we can drill, we can drill, we can do a bunch of experiential discussions and debriefs, but nothing is like the real thing.

When I was a patient here in New York City, the ICU nurse who took care of me, who had been doing this for over two decades, missed an IV on me two times, and then a third time, hit a nerve. I'm sure she could get blood from an orange, this woman's incredible, but she was so scared because she was so worried. I think that my big concern is that we had so many people respond globally in West Africa to provide critical care, but so few from the United States due to the legal restrictions, other concerns.

The result is that right now in the US, we have so few people that are capable, that have had this experience, that feel comfortable taking care of patients with a potentially deadly disease, and I think it's really shortchanged us. It's really taken away the tools that so many of us could have, both in terms of understanding infection prevention and control, as well as these more critical care things that we need and those experiences that would do us, I think, a big favor in taking care of patients right now.

Avril Benoît:

Javid, how about you? When you think of what you learned from your experience of working with people with Ebola, how have you been able to apply that to your response in the COVID-19 pandemic?

Javid Abdelmoneim:

Yeah, on a very personal level ... I connect with some of the things that Craig has mentioned. But on a personal level, in the ER, where I work, I was able to predict or put on my colleagues' radars some of the difficulties and challenges that they were going to face in not having a cure and potentially having overwhelmed resources and some of the morally distressing or moral injuries that we might face, potentially having to make decisions about who should get what type of care in a frequency that we wouldn't normally have to make. Life ... CPR decisions, so forth. So talking about moral distress, bringing that to my colleagues in a way that ... I've been there, it was like that in Ebola, and it was a very uncomfortable place to be, and it was a tough experience, and I had help with MSF. And I wanted to put that on my colleagues' radar.

Also, in a much more practical sense, when we first opened the red zone, as Craig said, you can drill all you like, but taking off the PPE in the correct way, ensuring the flow is correct, just paying attention to some little, little kinks in the chain. You need every part of the chain of infection prevention and control to be strong. And I was able, just with my only one-time Ebola experience, add a little bit extra to what had been put in place. And, actually, that sort of helped the team feel a lot more confident in what was there. Because PPE guidance evolved, and we were using, what was felt to members of staff, to be a lower level of PPE than they wished. So with a little bit of support and help and input that I'd had previously, I was able to really help in that small way, and I think it was valuable.

Avril Benoît:

It's tricky to make the comparisons and certainly there were many comparisons made in the early days when there was so much skepticism around, "Ah, this is like the flu, isn't it? It's just a new kind of flu, it's no worse. Flu is deadly, this will be deadly." And with Ebola, I hear a lot of our own medical teams making the links with their history with Ebola. We have a question here, actually, from somebody who's asking, from the patient perspective, how does it compare?

Craig Spencer:

Yeah, I'm happy to-

Avril Benoît:

Maybe you, Javid.

Craig Spencer:

Yeah, go ahead, please please please-

Javid Abdelmoneim:

I'll start and then you finish off for us, Craig. From my perspective, again, it was about the feelings that patients would have of fear, being magnified. You're presented with a healthcare worker whose face you can't necessarily see. So communication, they know it's a disease that doesn't have a cure. These types of fears play on a patient, as well as the fact that they're not necessarily going to have the same visiting rights as they might have with their families. So communication externally and support socially once in hospital. And so, again, I was really keen. That was one of my biggest things from Ebola, was that disconnect that patients had from their caregivers, be they professional or informal, their family. And I really wanted that not to be the case, again, here because that hurt me personally.

And I was able to do that. I'd be in recess, if we're about to put someone on a ventilator, they may not be able to finish a sentence, but I wanted them to be on the phone to their loved one, just to say the words they needed to say because it could have been their last. And so in that way, it's a very similar experience.

Craig Spencer:

Yeah. 100 percent, we've been struggling here. That moral injury that you referred to, Javid, is so important. My providers that I work with here, are not used to this. They'll show up for this, but this is not what they signed up for. From a personal perspective, I've written about this on my Twitter page and in the Washington Post a couple days ago, this feeling that as a patient, looking up, trying to understand a provider who's talking to you through a mask that is muffled, or through goggles that are foggy. And that the whole time ... the same time, feeling toxic. That you could potentially infect that person that's trying to do everything they can to take care of you, while also being completely disoriented, both because you're sick, but being in a place, seeing things you've never seen before. I can't even imagine, even as someone that's been a patient, what it's like for so many ... the people that are coming through our doors right now.

And I think the big difference with what we saw in West Africa ... I mean, think of the inhumanity of all this, not having someone at your side to hold your hand when you die. Right now, I have FaceTime, I have WhatsApp, I have video to do that, but that's something that we didn't have in Guinea, Liberia, or Sierra Leone. And that caused, I think, a lot of problems in terms of community trust, but it also was problems for patients themselves and providers who felt this horrible loss every time somebody died and they weren't able to connect with their family.

Avril Benoît:

We're taking questions on Zoom, in the Q&A option, and also on Facebook Live and Twitch, in the questions and comments section ... or the comments section. And we have a few here that have come in. Craig, I'll address this one to you, and it's about the World Health Organization, the WHO. President Trump announced that he was displeased with the WHO and wanted to cut its funding. It remains to be seen whether he has the power to do that. But certainly, this is a political question, it's one that you've been thinking about. Can you give me your take on what is going on with that, and how you would recommend that people process this kind of discussion about blame? Who's to blame for the pandemic being as bad as it is, who's to blame for knowing things and not sharing, etc.

Craig Spencer:

Yeah. That's a really important and good question. I wrote about this also yesterday in USA Today as an opinion piece. I'm just really concerned about this, I'm concerned for what it represents in terms of the World Health Organization. We can talk about their inefficiencies, they absolutely do need improvement, I completely agree. At the same time, the World Health Organization, this is me speaking as a private citizen and a Director of Global Health at an academic institution, what this represents, I think, is just a dangerous diversion from the fact that our preparedness here in the United States has been suspect and has, unfortunately, been lacking.

We didn't ramp up testing the way that we should have. We're scrounging for personal protective equipment. I've got friends in Ohio and Michigan who are asking me to send them N95 masks because their hospital systems are giving them one a week. This is an absolute crisis, and unfortunately I think that we're diverting some of the blame from ourselves on to organizations like the WHO who, yes, are political organization, not by their own desire, but that's the way that they're funded. This is the way this has changed in the past couple decades. They are funded by countries who do strings attached allotments of money. Many of them, Western countries, especially the United States.

I think that if this administration is so serious about improving global response to pandemics, be it coronavirus or the next one that will undoubtedly hit us, they need to extend a hand and not rip up a check.

Avril Benoît:

All right, we have another question. I'm going to direct this one to you, Javid. It's from Donald asking, "How long will this last? And when to open the parts of the economy that have been shut down." Any sense of that, Javid? I mean, I think we all would like to know. I don't know if you have the answers.

Javid Abdelmoneim:

That is golden eye question, isn't it?

Avril Benoît:

I'm hoping you have- Yeah.

Javid Abdelmoneim:

"It's impossible to say," is the short answer. We've just had our distancing measures extended by three weeks here in the UK, France have just said to mid-May. I think New York just said the same. This will last as long as it needs to last, I'm afraid, in terms of if you look at it purely from the health outcome of ... the primary health outcome that COVID-19 represents. There will be ... the issues that the social distancing measures could have created for the economy, for people's health, otherwise. People are not presenting to health systems as much as they ought to for non-COVID related items. So this is impacting many things and that are negatively. And so that will have to come into consideration, but I don't believe I can answer when this will end. It won't be in the next month, put it that way.

Craig Spencer:

Yeah.

Avril Benoît:

We know that it's reached hundreds of countries around the world. The countries were MSF, Médecins Sans Frontières, or Doctors without Borders, has medical teams operating and just hoping that they can continue with the medical work that we do. As it spreads, what do you expect to happen in those places? Based on ... Both of you have worked in South Sudan, both of you have worked in Lebanon, Syria, and things like this. What is on your mind, as you see how the numbers seem to be picking up in the kinds of places that are already in the midst of some form of humanitarian crisis? Craig?

Craig Spencer:

Yeah, I'm happy to start with that. Look, it's no surprise that we've heard about the greatest number of cases in the economies with the greatest GDP. Like this is China, this is places in Western Europe and in the United States. There are cases and there have been cases in West Africa, and other places in Southeast Asia. We haven't been picking them up and we're seeing them a lot more now. I have worked in Burundi, a small, very dense country of 11 million people in East Africa, for over a year, part of that with Doctors Without Borders, part of it independently with a group of Burundian doctors that have started a health system there. I was talking to one of my friends, he mentioned that they have maybe 10 ventilators in the whole country.

I've seen numbers that CAR, Central African Republic, has maybe half a dozen. We know that in many sick patients with COVID, the only thing that can save their lives is a ventilator in addition to high-level intensive care. Maybe there will be some blunting of the worst part of this impact because populations, especially in Sub-Saharan Africa are younger. But they also have much greater incidence of HIV, malnutrition, other things that we know will likely increase the morbidity and mortality from this disease.

I am so, so, so concerned about the impact this is going to have all over the world. We have now stopped exporting a lot of our personal protective equipment from wealthier nations, so it's much harder and much more expensive for people to get them in places where we're working. We've also not talked about it, right? Like if you're here in the United States, somehow this is a global pandemic that is only impacting the US and maybe Italy. Every time I talk to a news reporter and say, "Hey, these are the things that I want to talk about," they all listen beforehand, say, "Okay, we can talk about the international," but no one ever asked me about that in an actual interview. So I think it's so important for us to really continue to highlight, and I think that's where organizations like the WHO, like Médecins Sans Frontières, other organizations that are working in these contexts and are trusted, and operational in this context, that's where our role is. It's to highlight the impact this is going to have and think about what impact we can have in blunting that impact, from Bolivia to Burundi.

Avril Benoît:

Javid, you've been paying attention to the work that MSF is trying to do to actually scale up, ramp up, get the PPE and other equipment where it needs to go. Can you describe some of that effort for us?

Javid Abdelmoneim:

Yes. It's quite extraordinary, actually, when one looks at what the effort is required. For example, Avril, Craig, you'll know we'll get these internal operational updates three times a week from various corners of the movement, and just yesterday it's had 25 countries in it. And often this would be two or three countries that we'd hear about a big item coming out of that place. And it's 25! That's one third of where we're working around the world and it's all COVID related. Bar one, one was about the measles outbreak. But I worry that, firstly, maintaining operations, as they are in these countries, is under threat, simply because of supply, be they people or equipment. And the second question really for us is ... There are too many questions, I don't even know where to go with it.

I'll answer your question first. Within-

Avril Benoît:

It's a question from Wu, asking-

Javid Abdelmoneim:

Yeah, well-

Avril Benoît:

... what are we doing.

Javid Abdelmoneim:

Yeah. Within all of the projects, as far as I can see and read, where we work and in all of the countries, there has been a pivot towards at the very least doing infection prevention and control teaching of all the staff and the communities as well. So community engagement was one of the biggest learning points from Ebola, was until you convince the community, get their support, and have their understanding of what the measures are required to control the outbreak, then you're really not going to be going anywhere far. Everywhere I read, from Bangladesh and Cox's Bazar, to Juba in South Sudan, to Jordan to, as you said, Burundi, even Brazil, community engagement, and infection prevention and control. Already have set up several isolation units in most of the big fixed hospitals that we have around the world, from Haiti to Afghanistan.

So those are the operations that we've done globally, already. And then it's a case ... Setting aside what's been done in Europe, working with the homeless, with the vulnerable, with elderly populations. Always to look for the most vulnerable, where the people are most going to be disadvantaged by these really difficult social distancing measures that are going to be coming in place.

Avril Benoît:

Javid, we have a question from Alice about how can MSF tackle issues of health promotion in low-resource settings in the midst of an environment of possible contagion, that would be my part to add to it. How would we go about that? Health promotion being ... And maybe you can just highlight what would be the key messages around hand washing, social isolation, stuff like that.

Javid Abdelmoneim:

Yeah, that would be an integral part of everything that we're doing now. So when I was just talking about community engagement, perhaps I should have actually said it as that. It's health promotion. It's getting those key messages, in this instance, it will be, "Catch it, kill it ... " What is it? Now what do we say in the UK? "Catch it, kill it, bin it"? When you have to catch a sneeze, wash your hands, that type of thing. So it's avoiding anything that might increase transmission. So try to catch that cough and sneeze, wash your hands as much as possible.

If you are feeling symptoms, do stay at home. But of course, it's a very privileged ... "Stay at home" message is a very privileged message for us. But even in New York, in London, and particularly in the places where we work, there will be a large number of members of society and communities for whom staying at home is a really, really difficult thing to do. You need to go out and work, and to go out and find your work. You might be in a domestic violence situation, you might be in a situation where you can't get your food or overcrowded.

Those messages are going to have to be tailored specifically to each community where we work, and they will be.

Avril Benoît:

That links to a question from Millie, "Do you think that all countries must have the same inflexibility around quarantine, the same measures. Because if we compare Europe with some countries in Latin America, Asia, or Africa, measures are different from place to place." Craig, how do you see this expectation that countries will have to impose quarantines, but it's just not possible to have the same kind everywhere?

Craig Spencer:

I think that's absolutely true. Look, we're seeing that even here ...

Avril Benoît:

I don't know if I'm the only one having difficulty hearing.

Javid Abdelmoneim:

No, I couldn't hear him.

Avril Benoît:

Okay, let's ask you that question, Javid, while we try to sort out Craig's sound. So the idea of quarantine rules applying pretty much everywhere, but having to be a little different from place to place.

Javid Abdelmoneim:

They're going to have to be different. But let's face it, on some level, just about the only weapon, or the only tool we have in our toolbox in controlling the spread of this disease, has been an element of social distancing, that's what we call it in the UK. It's an element of reducing that RO, that number of infection rate to below one. So, there's going to have to be an element of that, but it will not be the same everywhere simply because of the circumstances of the population, as I alluded to earlier. It takes a heavy toll, and we saw that in Ebola, we've seen that in the UK. People who are self-employed, or people who have to go out and earn money that day to pay for that meal that day, how are they going to be supported in the places where we work, if they're being told to stay at home for the next three months? It's going to be very difficult.

Avril Benoît:

Yeah. Craig, Javid picked up where your mic left off, but I think you're back on. We have a question from Facebook, from Maria, asking, "What do you think about refugee camps, like Moria in Greece, and the effect of COVID-19 in overcrowded camps like those? Craig?

Craig Spencer:

This is one of my greatest concerns and one of my greatest passions. My academic research is focused on migrants, it's focused on the human rights, and the health impact of migrants, primarily, in West Africa, in Niger. That's where I spend a lot of my time studying this issue. And even today, I was reflecting on the fact that this year I'm not going to be able to get out there in the next couple of months, I have a project that's funded, I'm not going to be able to understand the reality in the ground. We know through reporting that's coming out right now, that COVID is being used, not only in Niger, but in the United States and in many countries all over the world, as a tool to both continue to limit migration as well as to continue to push policies that have negative impacts, particularly health impacts, on migrants and refugee populations all over the world.

This happened very early on in all of this. I remember this was in February, I believe, when one of Doctors Without Borders' boats in the Mediterranean was basically quarantined off the coast of Italy before there were really any cases and really for no other concern other than as a way, basically, to continue to highlight this migrant crisis that has been a problem for years. We're seeing it with the impact here in the United States. The Trump administration has put in place measures, through the CDC, to basically stop all asylum applications and all ... Basically, shut down the southern border even further than it had. And so this is something that, unfortunately, is magnifying this increasingly nationalistic and anti-migrant sentiment and policies that have been increasing around the world.

And, in addition to these policies being harsher, the impact on refugee camps, places where water and sanitation is already limited, places where access to health care is already limited, it's going to be absolutely huge. And again, very few people are talking about the impact of that.

Avril Benoît:

One question has come in around aspiring doctors. They want to help, they want to help us, they want to help MSF or Doctors Without Borders. What would you recommend for them or somebody who wants to help in their local community? Craig?

Craig Spencer:

What I've been recommending to even my doctor, nurse, and healthcare friends in our local community here in New York City, is thinking about the vulnerable populations here. My downstairs neighbor, who could probably hear me talking right now, has been in this building for over 50 years. We've done everything we can to prevent her from going out. If she needs groceries, if she needs anything ... I think this all starts small. We talk about community and it can be a small community. Even if you are a health care professional, thinking about the people in your network, in your small community, is really the most important and best place to start.

I think the other thing that we can be doing, as healthcare professionals, is highlighting public health messaging. Highlighting health messaging and trying to separate, especially here in the US, this kind of public health truth from a lot of the political partisan messaging that we've been hearing. And so anyone trained in healthcare, I think can, hopefully, see through that. Sharing that information with your friends, with your loved ones, with your enemies, whomever it may be, in a way that is helpful to highlight what people actually need to know and help them cut through a lot of misinformation which has been so deadly here in the United States.

Avril Benoît:

I have one very practical question. For somebody who starts to have symptoms of COVID-19, maybe they start to have a fever and coughing or they lose their sense of taste, that's been one of the things that we talked about, and it's not so serious that they need to go into the hospital and, possibly, they're in a place where the testing is not really available, so this could happen anywhere in the world, what should they be doing in terms of looking after themselves in their own homes? My first thought, when I have a cold, is to drink tea or eat chicken soup, and things like this. But what are the best ways to alleviate the symptoms and to just get through it, in the hopes that it never become so severe that you have to end up in an emergency room and be treated by either of you, very fine doctors? Javid, maybe you want to take that? What tips do you have for your friends and family who find themselves at home with symptoms of this?

Javid Abdelmoneim:

Yes, that's what I've been telling my friends and family, it's simply just to take care and rest! At the end of the day, it's a viral illness, your body will do what it can to fight it off and you need to support it in doing that. So eat well, rest well, take good sleep, and see it through, as simply as that. And if you have symptoms of pain, try a simple painkiller. If you have a symptom of fever, some people have diarrhea, some people have headache, just manage the minor symptoms any which way you prefer and it's your choice.

What I've been telling my friends to look out for in terms of when I might be interested in seeing them in my ER, not that that's how it works, but a patient ... I've been telling everybody, "If you think you're breathless unnecessarily, especially sitting down, that's something that would make me concerned and that's when I would seek medical attention. But up until that point, essentially, if you think you can manage your symptoms, then do so in the simple ways that you normally might." It's what I'm telling my family.

Avril Benoît:

And what about moving around, even if your body doesn't feel like it? As opposed to just lying down and trying to sleep it off for a week.

Javid Abdelmoneim:

Listen, I'm a fan of rest, rest, rest, and rest for fighting off illnesses. Your body can do marvelous things if you give it a chance. Have some patience, eat well, sleep well, stay hydrated, and take it from there. There is of course, with this being an infectious disease, the added advice that you should be trying to self-isolate and minimize your contacts with others, especially those who we in the UK are calling shielders. People who are particularly susceptible to COVID-19, who currently have got instructions to stay indoors for the next three months, at least two meters away from even their loved ones within their own houses. So there are different classes of patients that you should be trying to stay away from ... if you have symptoms.

Avril Benoît:

A question here for you, Javid, from Ali on Facebook, "Are frontline physicians getting adequate mental health support?"

Javid Abdelmoneim:

The short answer is, "Yes, I hope so." In MSF, we have, at least since Ebola days, five years ago in West Africa, but even before then, when I joined in 2010, we've always had access to psychological support, at the very least, on the way in. And then on the way out and for a year after our time in the field. Since Ebola, we ... Because of the particular moral distress and injuries that were evident there, it's become something that's a lot more ingrained within your time there. So you get face-to-face time with a psychologist, you know who to contact back home in headquarters if you need it.

I think we do support our staff well. I feel supported when I'm in the field, in that way. And it's really, really important because you might not even feel that moral distress at the time, it might hit you long after. So I encourage all my colleagues in MSF to engage with the support that they're given, live, in that situation, and don't wait until you might de-compensate mentally years later.

Avril Benoît:

Craig, you have a young child at home. You're doing long overnight shifts and late shifts in an emergency room. You're trying to raise awareness through articles you're writing and your Twitter threads. How are you managing with all the stress of this?

Craig Spencer:

I think for a lot of people maybe like myself ... I'm drawn to Doctors Without Borders, I'm drawn to public health, because in some sense this is where I thrive. This is horrible and this is a global disaster, but this is where I find energy, this ability to help and hopefully provide some assistance, especially, to our frontline staff not only here in New York, but also in places where we work. Think about how we can support them, commit my time. As a board member, to think about what are the best things that we can be doing for our national staff, how do we adapt our operations when maybe we can't be sending people like myself as often. Of course, because of the risk that, me as a frontline provider here in New York City, I could bring this disease somewhere else. What do we need to be doing, as an organization, to not only help our members here and to help our people in our own societies, but how do we do that in the hundreds of projects we have all over the world?

I think this is where I thrive. This is where I really love thinking about how we can help and hopefully that's what we're all committing our time and our passion to. That's how I do it. And less sleep and probably a little bit more whiskey than baseline.

Avril Benoît:

I think it's not just me worried about you, Charlotte asked the question, "How is this affecting you, personally?" But to hear that you're thriving is like ... You're very special and different! But you're probably a lot like a lot of our colleagues. But I have to say, I am so worried when I think of COVID-19 raging into a region that is already in the midst of a crisis, and the kind of mettle that our teams are going to have to have. Julia on Facebook is asking, "How can MSF operate and tackle COVID in countries where there's an ongoing crisis?" And she's giving an example of Democratic Republic of Congo, the DRC, where there's a threat of stigmatizing the foreigners. Thinking that maybe foreigners have brought it in, foreigners are getting rich off of the intervention, the kinds of things that we saw with the Ebola outbreak in eastern DRC over the last year or two. Javid, how can we work in those kind of environments?

Javid Abdelmoneim:

With the specific example of DRC, it's all about engaging the community and ensuring they understand what we're trying to do. But also ensuring that we are meeting their needs as they perceive them, which is even more important. So, in that instance in DRC, I think even we would say ourselves we could have done more. And three, was it? Ebola ... The three attacks on Ebola management centers, in the space of as many months, at the tail end of the year before last. It could have been done better. Overall, the question was really about how, in these difficult contexts, we're going to be providing COVID-19 care. We're there already, providing some care. So there is a pivot, somehow, to additionally adding on COVID-19 care. In the sense that, say in Afghanistan, in one of our projects that's a maternity hospital, we're going to need to maintain that operationality, and keep COVID-19 out of the hospital. Or at least have a way of filtering it to one side and managing those cases separately.

So, it's very much the case of slightly pivoting in what we're doing already, in all of these contexts, to try and catch or at least ensure the safety of our current ops, and then move on to doing COVID-19. In Yemen, I think the first cases have come through. In Idlib, in northeast Syria, I think the first case has come through. It's going to be hard. I don't envy the task of my colleagues in the field at this time.

Avril Benoît:

Amber is asking a question, "As this eases in the wealthier countries, that we've seen it really rage in, and the United States being at the pinnacle of it right now, what does this mean for MSF staffing in high-risk areas?" Craig, we have, for many countries, travel restrictions.

Craig Spencer:

Mm-hmm (affirmative).

Avril Benoît:

The inability ... Well, forget about the airlines canceling flights, but very serious difficulties. Or countries imposing the 14-day quarantine upon arrival. What is going through your mind, as you grapple with all of that complexity?

Craig Spencer:

I think what this is highlighting, not only for MSF, which is thinking about how we operationally adapt in a situation like this. This is a humanitarian crisis, all over the world, that's going to force us to rethink our global health security agenda, how we are prepared. I think MSF has done a better job than a lot of organizations. Over 90 percent of our staff is national, people that live and work in the communities that they're from, which is super helpful in having a response that's adaptable. We don't have to fly as many people in, and I think that our focus has been on increasing that percentage as high as possible so that people like Javid and I don't need to come in. We have the resources, we train the resources, and they're in place.

The problem is that the way that we've been set up, MSF, other organizations, is that we have supplies in places where they can't leave. We have people in places where they can't leave, or they're not accepted into places where they may be going. We know that some places, some countries, you mentioned Israel, I know for Puerto Rico, for a couple of other places, there are restrictions on who is coming in, and for good reason!

It's worth pointing out that the first three cases in eastern Congo, were from international NGO workers, from these international staff that came in. And so, it makes sense for a lot of places that don't have the same infrastructure as the United States, or the UK, or other wealthier countries, to think about how they can protect themselves. Because, quite frankly, many places don't have the same access to resources, due to export restrictions, due to other things in this global economy, and the way that we're set up, to be able to attack it in the same way that Javid and I can in our own home countries.

Avril Benoît:

We have a really good question coming in from Meredith, who says, "What's the top concern for MSF in terms of ancillary illness or even care of underlying illness, resulting from those that become unemployed or potentially homeless in this crisis?" She has a friend in Ghana that's more worried about starvation than COVID-19. Javid?

Javid Abdelmoneim:

Yes-

Avril Benoît:

What can we expect in terms of other things that would be impacted by all of this?

Javid Abdelmoneim:

I think we can expect that all the ordinary or usual morbidities that we see, all the usual illnesses that we see out there ... The death rates or the illness rates will get worse. And it's a horrible thing to say or to expect, but we will see it in the UK, it is not just going to be everywhere else. When you have to have a total diversion of the health system towards fighting one illness ... We wish it otherwise, but especially when resources are constrained, there will be some reduction in the health status of the remaining population. And that's going through the same, world over. I fully expect it in the UK, and I would be very surprised if that is not the case in areas where we work also.

Avril Benoît:

Let's-

Javid Abdelmoneim:

To give some ... diseases there, the treatment of tuberculosis, the treatment of HIV, the treatment of infectious diseases, otherwise. So diarrheal diseases in camps, vaccination programs, measles outbreaks. All of these things that are going to be interrupted, potentially, we'll see worsened outcomes in every ... Maternal death rates in labor. If this is interrupted service or not done ... If we don't have PPE, how will our staff able to do those things? It's potentially a question that many health services where we are working, and MSF itself, will have to ask itself. And so it's quite daunting.

Avril Benoît:

We have a final question. In fact, we've received several questions based on, I think, what's been in the news lately. And I'll leave this one with you to reflect on, Craig, and that's about reinfection. When you are in the ER, and you're discharging a patient and sending them home, what do you tell them about reinfection?

Craig Spencer:

That's a good question, because we're getting some conflicting information every day. Look, we think the overwhelming likelihood is that you're infected with this once and that you have some immunity to it afterwards. And this is going to be true for, again, the overwhelming majority of people. We don't know if it's 96 percent or if it's 99.9 percent, but, again, the overwhelming majority. We know that you make antibodies, that's been documented. And you will likely have immunity for at least a couple months, maybe longer. We don't know yet. There have been cases reported of possible reinfection, but it's important to recognize that the test, despite it being very good, are not often administered very well. Meaning, that a positive patient can have a negative tests based on how the test is done.

So it may be that people were positive, and then negative, and then positive again. It may be something with a false negative or a false positive in the test. These are scattered reports. What we're seeing is most people who get the disease, thankfully, do well, recover, and then are not getting the disease again. Time will only tell. We learned a lot with Ebola, for example. We saw some people were still harboring virus, either in their protected sites, or even in the brain and the fluid around the brain. We know it's a possibility and it may happen for a very small subset of patients, but I think that there is a lot of other things that we need to be focused and worried about, as opposed to this potential risk of reinfection.

Avril Benoît:

All right, well thank you so much, both of you. And I wish you good health, and continued energy, motivation, and a sense of purpose in the work that you're doing at home, but also in your work as board members with Doctors Without Borders. Thanks a lot, Javid! Thanks, Craig!

Craig Spencer:

Thank you.

Javid Abdelmoneim:

Thank you, both. Thank you, everybody, for tuning in.

Avril Benoît:

Javid Abdelmoneim in the UK, Craig Spencer in the United States. We would love to keep you informed about MSF's work, including our response with the COVID-19 pandemic, and we very much welcome your support. Become a monthly donor. And to find us, if you just go into your search engine and you type in Doctors Without Borders, you will find the national website in your country. And you can find out how to support us, how to sign up for our e-newsletters, how to find out more about these online webcast events. You can also find us, of course, look for us on Twitter, on YouTube. We have channels on Facebook, in different languages, and we really welcome every opportunity that we have to engage with you. Even though we're socially distant, we try to stay connected. So thanks a lot! I'm Avril Benoît signing off from New York. Take good care. Bye for now.

Avril Benoît:

Hello. Welcome and thanks for joining us today for our weekly series, Let's talk COVID-19. A couple of minutes delay, apologies for that. I'm Avril Benoît. I'm the executive director of Doctors Without Borders in the United States. You might know Doctors Without Borders also by its international name. In French, it's Médecins Sans Frontières and that's why we get the acronym MSF. When you hear us referring to MSF, that's Doctors Without Borders.

Today, we're focusing on mental health. One of the reasons we wanted to really touch on this is we know that healthcare workers who are right there with the patients, treating those with COVID-19 and this includes, of course, MSF staff, they're facing intense pressures. They're facing exhaustion. Social isolation, many of them are separated from their own families. They're also struggling with the same feelings of anxiety as the rest of us. But their issues are acute because there are sometimes questions of ethics, guilt can come into it, fear of contagion, the grief of knowing that their own loved ones might be suffering, might be ill, and of course loss. We've all lost a lot of freedom. We've lost of control over our lives. There are any number of layers for us to dig into today.

We'd like you to have the opportunity to ask a couple of mental health specialists for advice and for insights on how to get through this in a good way, in as positive a way as a possible. So, they're going to share how they're specifically supporting mental health aspects for the healthcare teams through this crisis, and how each one of us can take some of these techniques and look after our own mental health as much as possible. Just a couple of quick points around how you can exchange with us. We're going to go for around 45 minutes. Whenever you can, just go into the Q&A option on Zoom. You'll see that as one of the places where you could just pop in your question and then they will be sent to me. If you're joining us on Facebook or Twitch, send your questions in the comment section.

Our guests today are Kaz de Jong. He's a clinical and health psychologist who heads the staff health department for MSF, long time based in Amsterdam, and he's also the mental health advisor for MSF. He's right now working to support our teams who are on the ground in different parts of the world. We work in more than 70 countries with operations. Those teams are very much bracing themselves for the arrival of coronavirus if it hasn't already come into their country in places where we're working and we have staff. He's also, of course, helping with the mental health needs of our staff who are responding to other kinds of emergencies. We respond in war. We respond in other sorts of outbreaks, in refugee camps, in many different kinds of settings where the stress is real.

So, Kaz, maybe you could just let us know how you're doing, where you are, and just give us a bit of a sense of what your setup is there in Amsterdam. I think you're on mute. You have to unmute yourself.

Athena Viscusi:

Yeah.

Avril Benoît:

Okay. Well, there we go, Kaz. I think you're off mute now.

Athena Viscusi:

No.

Avril Benoît:

Oh no, we can't hear you. Okay. Hold there, Kaz. Let me introduce Athena. In the meantime, we'll try to sort out your sound. Athena Viscusi, we do hear you quite clearly. Athena is a clinical social worker, a psychosocial care specialist at Doctors Without Borders in the United States. She is currently supporting our U.S. based MSF staff with the difficult decisions and challenges faced by humanitarian aid workers in this pandemic. Athena, how are you doing and tell me about your setup there at home?

Athena Viscusi:

Well, fine. You hear me?

Avril Benoît:

Yes.

Athena Viscusi:

Okay. Great. Well, I'm calling from the not so exotic location of Brooklyn, New York. I'm in my house. Yeah, in my apartment.

Avril Benoît:

We're in week four of having scattered in all directions when we closed the office on March 13th, the headquarters in New York. Kaz, we got your sound working out now.

Kaz de Jong:

I'm certain. I think so. Yes.

Avril Benoît:

Yes.

Kaz de Jong:

Yes?

Avril Benoît:

Yes.

Kaz de Jong:

Okay. First of all, sorry for that. Anyway, thanks again for the introduction. I'm in Amsterdam. For here, for us, it's a very sunny evening. As in the U.S., we have to stay home. We can't go out, and it's pretty challenging for us in this beautiful weather. We're working from home.

Avril Benoît:

Fantastic, as we should be. If our work can accomplish anything from home, that's where we should obviously do it. But of course many workers are out there on the frontline, essential workers from various walks of life. We've already got our first question from Deborah who's asking how someone like her can support in their own community with the stress and anxiety. What can we do for one another? Maybe I'll start with you, Kaz. Any ideas for that?

Kaz de Jong:

Well, it depends a little bit about your background. Like I have a psychological background. I'm working in my community, the community hospitals, to give staff support for the people working in the intensive care units, in the internal diseases and emergency departments. That is more professional, but what I try to do for people in my own living neighborhood is first of all to be kind. I think this is a very challenging time for all of us and we very easily slip into bad moods and being unpleasant to each other. So, I force myself to give each of my neighbors, if I see them, a small compliment. Not a big one, but a small one. That gives me fun and it gives them fun. In that way, I try to support them. Of course, if they need groceries and stuff like that, I do also those kind of things, but that's very specific. Be kind to each other.

Avril Benoît:

Athena, what would be your suggestions, in addition to kindness, for how we can help one another through this stressful time in our community?

Athena Viscusi:

Definitely. Well, I think it always starts with ourselves, are we taking good care of ourselves, because like Kaz said, if I'm leaving my house in a bad mood or I'm not sleeping, I'm not eating well, I'm not ever going out for a walk, then I don't have anything to give other people. But I will say there's all kinds of, in the States in different communities, mutual health networks. There's people who are organized to get groceries by bicycle for their neighbors. Then there's the wonderful custom that started in Europe but that has spread to the States of people, here at 7:00 pm in New York, that people go outside and clap and holler for the essential workers who are at their job. I think that's so uplifting for the essential workers obviously who hear that, but just it's a moment to remember that there's all these positive people living around us and to not fall into that despair of isolation. That we have to remember, we talk about social distancing, but really it's physical distancing and we need social closeness at this moment in any way that we can have it.

Avril Benoît:

I actually set my alarm so that I always get a two-minute warning before I go out to my window, open it up and start clapping for the essential workers. I think it's really helped become a highlight of my day, which goes to show what's probably going on in my life trying to run MSF at the time when we're all separated within our apartments in New York City. We're receiving questions for both of you through the Q&A function on Zoom and chat on Facebook. So, let's get right into it again. We have Melissa in the Q&A asking about mental health for children.

Many people are trying to teach their kids or organize their kids through schooling through telecommuting or tele-distance type of schooling setups, and these children have anxieties. They see their parents stressed. They see what's going on around. Maybe they're overhearing what's going on in the news. For parents, what kind of things can they do to reassure their kids while not hiding the reality from the kids? Athena, maybe you first.

Athena Viscusi:

Yeah. First of all, I'd say I'm very fortunate that my kids have grown and that we're not quarantined together, but I think exactly the point of how you tell the truth without alarming children. To remember that what children don't understand, they usually think is worse than what it is. So, sometimes we want to hide things from them. That doesn't work. It's just their little emotions run wild. So, it's important to find a way to bring to children. Then may say, "I'm so happy to be home. There's no school," but "Well do you understand why there's no school? What do you think about that? Do have any questions you want to ask? Are you afraid of anything? Is there anything we can do to make you less afraid?" Don't bombard them with information but ask them first what they're thinking and what their concerns are.

They often have quite charming ideas of what's going on, the little ones. So, it can also be helpful to ask, but to really explain to them. Then maintain, again, as much social connection. A six-year-old friend who was just telling me how she went to visit her grandmother and the grandmother was at the doorstep and she was in the car, but how reassuring it was for her. So just remember to find some way for children to maintain those social connections. I don't know. Kaz maybe you've had working frontline healthcare workers and they probably have concerns about their children.

Kaz de Jong:

Yeah.

Athena Viscusi:

That might be... Yeah. What have you found?

Kaz de Jong:

Thanks Athena. It's very important what you say especially explaining and be honest to children and explain it in their language. A two year old understands a different language than a 10 year old, but to be honest and fully don't hide. With the frontline workers, they have an extra problem because they take the disease home. At least that's what their environment thinks and they're scared of doing that. So, what I advise them always is to discuss with their family what they need to do, what kind of rituals they need to do before entering the house in order to avoid the transmit. It means for certain households that they have to get the shoes off, use alcohol to wash their hands. In other families, it means that they first have to go and take a shower and leave the clothes in the bathroom and take fresh clothes on.

So, these kinds of rituals that are done every day are extremely important for the healthcare workers themselves to feel reassured, but also for their family because even if you explain how the virus works, then still people will have bouts of fear and anxiety also in your household even if they admire what you're doing. So, be transparent. Try to bring back these kinds of uncertainties into a structure because humans, and MSFers are always everywhere in the world looking for strange environments et cetera, but we're all human beings including MSFers and we all have one characteristic. We love structure.

So, as soon as we are in new situations, we try to bring it back into a structure and that structure for children is extremely important. So, daily a rhythm. A rhythm means it is predictable. A rhythm means that a child can expect in two hours that there's going to happen something fun and that now the class is going on. So, have those rhythms and structure in your day because that gives them the safety, the feelings of safety which is extremely important. Safety and predictability and that's done from structures. For children, this is extremely important.

Avril Benoît:

I imagine for adults as well at a time like this. One of the things that people found difficult, and it's funny what ended up emerging as themes when we all started staying at home, those of us who are not essential workers out having to do something out in the community, is that people weren't changing out of their pajamas during the day. Personal grooming kind of went down the tubes for a while, things like that. Why does that happen? Why was it so difficult for us to get into the routine of things and maintain the kind of habits even in terms of when we work and when we don't work, when we're working from home? Why is that just so difficult to do the transition?

Kaz de Jong:

I think it's difficult because it's new. If it's a new situation, I see the same thing with our international workers abroad, they have to adjust to the situation and they need to read the environment. They need to read what to say and that's exactly the same for us. Yeah. So, that is why it is difficult, but it gives us a lot of peace of mind once we have established that. So, it really works to go back to that structure. You said it also works for adults in the same way and maybe I'm going to insult people, but adults are just big children. They, like the rest, they like tranquility, predictability and hygiene, just like small little kids. So, that's in the essence how we are.

Avril Benoît:

Well, let's get into some of the questions around humanitarian aid workers and also essential workers within health structures. There's so much that they want to do and we have some constraints. Supplies are very difficult to come by. The personal protective equipment, the PPE we hear a lot about. They don't have the masks they need because there hasn't been enough orders. They can't always put people on ventilators. There's too many people arriving and they're concerned about having to make these difficult choices.

Athena, maybe you could answer Christine's question here about how we as MSF, as Doctors Without Borders, are addressing this stress of humanitarian workers who feel unable to do more in this response, who maybe can't travel, who can't go and take that next assignment to go and help or they just can't plug in and be useful. How is MSF helping them?

Athena Viscusi:

Yeah. So, that's one of the losses you mentioned is that loss of identity as a helper, as a useful, engaged person. MSF attracts, of course, an inordinate amount of people who are used to having the solution. It's very difficult for us to sit on our hands and be told, "No, you can't go. You can't do this." I mean, these are the questions that we're always supporting people with, difficult decisions, inadequate supplies, things that they can't control. We work in areas where you can't get supplies if it rains too hard. You can't get through on the phone if it rains too hard. Where there could be, you have the best laid plans and then an armed group comes to a town and there goes your plans for your vaccination campaign or your nutrition program.

Those of us who give psychosocial support to our field staff, these are the issues that we're dealing with all the time. It's just heightened right now. I think what's so strange right now is that when people are far away from home dealing with these issues, now their families back home are also dealing with these things. So, they don't have that kind of rock to support them because they're freaked out too and they're dealing with all kinds of uncertainties. I mean, even taking a plane these days, you don't know if it's going to take off and hope it's going to land. Is this border going to close before I get there? Everything is so complicated. Quarantine rules changing all the time.

So, the way we're supporting is just being more available than we usually are. Providing also some educational materials, not just responding to crisis like when people are not feeling well, but providing, a lot of the offices have generated a bunch of educational materials for our staff to look at what's normal, what's to expect, what are some coping skills. I don't know if that answers the question. I don't know if Kaz wants to add something.

Avril Benoît:

Yeah. So, what is the setup then, just to elaborate, Kaz? How does MSF as a humanitarian organization respond to, address these mental health needs of its own staff to keep them as healthy as possible and able to get through the difficult times? What is the approach?

Kaz de Jong:

Well, we have people like Athena and we have many of them in our organization. We have availability 24/7 for people in distress. What Athena was saying about people that are workers who cannot do what they actually want to do or what they used to do at home and they cannot do in those countries. That is a matter of frustration and we're confronted with that now also here. So, that's a similarity and it's good to look at it. What we do with those kind of workers who are frustrated about this, I think it's good to be realistic and say, in this situation, it is not there and you better accept it. You're your own worst enemy if you continue to battle things you cannot change. That is a huge source of frustration that I think is nowadays not only part of our international staff, but of all of the people in this world dealing with this COVID. So, accept the situation in which you are.

I think a very, very important other issue is tell yourself the whole story because people tend to focus on what they cannot do. I cannot do this. I cannot go outside. I cannot whatever. Now, again you're your own worst enemy if you only tell that story to yourself and to others. The story is more. Currently, we have healthcare workers in the hospital who are, because of their mask, unable to give proper care, human care, human touch. Even when people die, they cannot be close to them. That's horrible for them. One of the questions we ask them is, "And what did you do," because people usually don't tell that part of the story. It is not what it used to be. You cannot be close as a nurse to somebody who is dying in the way you were before this, but you're still able to do something. It can be a look in the eyes. It's very small things. It can be nice. It can trying to give a good message to the family.

So, this is very important that we tell ourselves the full story, which we cannot do. That's there. Accept it. Acknowledge it, but also give yourself a compliment for what you're doing. That is extremely important to keep the balance of things.

Athena Viscusi:

What you just said about the nurses-

Avril Benoît:

We have a question here from Wilber. Oh, sorry. I'll just keep going through the questions and then you can come back with the nurses. Well actually, let's go into the nurses. We have Carla who is asking about how this compares to our experience as MSF, Médecins Sans Frontières/Doctors Without Borders when we responded to Ebola. What is different because what I see is similar is that people are, when they go into that intensive care unit, they're struggling. Their family is not around. They're not with them. There's no presence of the reassuring loving presence of a family member who will be their advocate right there in the hospital room and things like that. Then if they die, they died alone not surrounded by loved ones. These are some of the things that I've seen as parallels with those who are dying of COVID19.

Athena, what would you say is a way to sort of process that distance when people go into a hospital, when you're caring for somebody knowing their family is not around, all these kinds of scenarios? It's so sad.

Athena Viscusi:

Well, when Kaz was talking about giving care with the mask and feeling like it's a misery, remembering in Ebola, we were wearing these astronaut suits. We had goggles and masks and yet I was amazed that the patients would recognize as individuals with this costume on. They would recognize. Just at times we would write our name in the forehead so they could, but they would learn to recognize us just by our eyes. Don't underestimate the power of human connection. The people are so hungry for connection, but they will recognize the care from the goggles and saying, "How are you today?" That is always there. But yes, I mean it was devastating in Ebola, I've been thinking about that a lot, that the patient would go into the hospital and was just sort of a black hole.

Us, MSF, psychosocial intervention during Ebola. We had staff whose whole job was to stay in touch with the families and to give them information and to keep them updated. They had a hotline for them and that's what made our hospital so different from the other hospitals. That we had this, families anytime, they could not go see, but they could drop off some stuff, their loved ones knew. Then later as it progressed, we developed a system, with that we could have the family talking remotely to the patients inside the treatment center.

And then did that during quarantines when people were quarantined in their village. They could not leave their village. We would record them and bring it to relatives in the village next door. Even there, we were using technology in very creative and… But the support, the psychological support to the families was very important. Also, very important also in maintaining trust in the healthcare facilities because if they just saw them as a place where people, a relative goes and disappears and dies, then if they got sick, would they go to that place or would they try to hide their symptoms and stay home and infect more people? So, building that relationship was important for that particular family member, for the patient but also for the entire community. I hope that in the hospitals here we can build similar things.

We also had a counseling staff who was dedicated uniquely to the families of our workers because a lot of the families were afraid. They were even throwing workers out of the home saying, "Don't come back." Now the infection process for Ebola and for coronavirus are completely different. I mean, it's totally different. If something is contagious but it's only by symptomatic people and this disease we're still not 100% sure how long it stays in the air, how long it stays on clothes, all this stuff. Respiratory, it's very different but still the psychological component is the same. So, we also found we needed to support the families of the workers because again they need that love of their own family being a secure place for them.

Avril Benoît:

There's a lot of camaraderie often within a healthcare team and these moments of really finding meaning in the work. One almost gets the impression that clinical people, doctors, nurses who are seeing lots of people suffer and die every day that's their job as medical people. That they somehow have a kind of a distance or a training in how to keep themselves separate, how to protect themselves emotionally from this kind of circumstance where you just have so many sick people coming in. Kaz, what are you finding of the impact though of this pandemic on healthcare workers? Are they able to keep that sort of professional distance or are you starting to see signs that they're suffering from some of the mental health effects of this?

Kaz de Jong:

Yeah. I think a good healthcare worker, a doctor, nurse, a psychologist is also a human being. Despite your training, there is always a case that affects you. So, that is part of our job. I think it's very important to acknowledge that. It's a big risk if you are impacted by your work and you just deny it. That is probably one of the worst risks for getting burnout or for accumulation of misery in there that causes all kinds of stress and whatever, unnecessary. So, I think we need to acknowledge as healthcare workers that we're also human beings and that's what we tell them. This hurts. The example of myself but also what Athena explains, our own examples of the fear, of the moments of panic, of a rush in your body that you feel, "Did I touch myself or did I not touch myself?" It's part of the human experience that also healthcare workers are experiencing. So, acknowledgement is very important.

It is also important that you are able to also overcome it. So, the distance, of course, is important and you need to function. So, sharing this, acknowledging it for yourself and if you want and this what we're doing all the time here in the hospitals, we debrief people at the end. Now, this is not a structure to debriefing. It's just how was your day, what worked, what can be done better? What was the best experience in this shift? So, in that way to keep the balance. But we're all humans and we should not become robots.

For healthcare workers, it's also important that they understand that their technical actions are also supporting people. So, very often, they are not fully acknowledging what added value they have except for the technicals, but also what they're doing. So again telling the whole story to themselves. Healthcare workers have a risk factor because they're used to care for others, to give to others, and they are always neglecting themselves a little bit more than they should. I'm a healthcare workers so I'm allowed to say this. It's my own experience also. This is something that you should not do because you won't run these kinds of marathons if you don't take care of yourself.

Avril Benoît:

What kind of psychological distress or effects are you seeing now among the health workers that you're helping, Kaz?

Kaz de Jong:

Well, at least we hope, we think we are over the peak. So, what we see is basically the adrenaline rush, the anxiety, the extreme fear is sort of going down. People have gotten used to in between big practice, but developed a certain routine and a certain whatever you call structure. So, now we are bracing ourselves for people thinking that they know it now. They can blow the margins. They can wash their hands one time less. That's one thing and that is dangerous. The other thing is that in high peaks, you don't feel you're fatigued, but if it's going down, you certainly start to feel your body also. The adrenaline has a price and you pay back and that's what they feel now. So, they're experiencing that when they're at home, they think, "Oh, I'm at home. I'm going to do this, this, this." That's their heart thinking, but their body says, "No, I don't want it. I can't do it anymore."

Those kind of experiences they have and it makes them also doubt about, "Am I sick? Should I see a psychologist?" We normalize this. It's a normal thing. You need to pay attention to it but it is still a normal experience. Again, you have to acknowledge and take care of yourself. You get over this for sure.

Avril Benoît:

Athena, I'd be interested to hear you talk about stress because it's related to this. If we're at a heightened level of stress all the time working every day, essential worker, the adrenaline rush is constantly at the peak level, what is the way that we can somehow break the stress in a healthy way without completely just denying the reality that in fact part of that stress is going to protect us because we'll take the precautions necessary. What is a way to modulate the stress if your work is essential and every day you're supposed to give 100% and be completely on because you're an essential worker?

Athena Viscusi:

Like Kaz said, it has a physical component that's mobilizing in the short-term and extremely destructive in the long-term, not healthy. Even it probably lowers immune response to this virus, and then there's the thinking component and then there's the emotional component. What is the stress doing? If my heart is beating all the time, then I need to do some kind of relaxation exercise or take a walk. I need to bring that heart rate down. I have to find a way to do that. If it's tension to the point of having aches, some pains, I need to do something to address that. But if it's emotional, I think we way underestimate, for example, the sadness I mean from the accumulated losses. You need to have a good cry. We have to undo the reaction or it's storing itself.

So, we have charges in some way, a healthy way because there's also that it accumulates and it's unbearable so we don't want to feel it anymore. That's where the risk for substance abuse, where the risk for family violence and for carelessness like Kaz is saying too in our work with that, I'm not going to be able to protect myself 100%. So, we really need to look out for each other on a team. I think one great thinking about our jobs is by saying to people, "You really should have a schedule. You really should eat regular hours." I have to do that now. I find yoga in my calendar now so that you can always go back to it if you want, but from 6:00 to 7:00 you're going to do that because it will accumulate in my body and I need to do something to undo it. So, we just need to schedule, just as we schedule work, we need to schedule, I want to call it, the calendar work. The opposite action.

Avril Benoît:

Yeah. We have a couple of questions about information overload. So, Wilber and others are asking about the anxiety that comes from just paying attention to what's going on in the news and Wendy has the extra layer of the fake news. We watch these daily briefings, the live briefings from politicians and sometimes you know what's coming out of their mouth is political. It's not science and there's a lot of conspiracy theories roaming around and floating into our inbox from relatives and so forth. What can people do about the anxiety that all this news and fake news, and fake news being the expression for misinformation, what it's doing to us in terms of increasing our stress and anxiety? Athena, you want to take it first and then Kaz?

Athena Viscusi:

Well, I mean there are things that we control and there's things that we don't control. You turning on your television is something that you control. So, really thinking again scheduling. How much of your day do you need news? How much has the virus mutated between 9:00 AM and 9:00 PM? Probably not. Do you really need to be minute by minute or do you need to be scheduling sometime to take care of yourself and your loved ones? Like you were saying, putting in your schedule to go outside and clap, people who are going to save us from this.

So, really being mindful, again, of how we're spending our time. We still control our time. We don't control it in the sense if I want to go to a movie, I can't do that anymore. If I want to go to the theater, I can't do that right now. But what I put in its place, I as a fully functioning adult, I control. So, we really need to take the power that we have. We have so little power right now. We need to really enjoy the power that we have and we can filter what we're exposing ourselves to. They are not coming to our house to have the press briefings. We are turning on the televisions.

So, really looking at in 24 hours, how much do I want to expose to this? Essential workers can't control that. They have to be in the hospital 10 hours. So, those of us who can't control, there's these pictures that are going around of healthcare workers with a sign saying, "I have to go to work, so could you please stay home?" I'm going to work, so could you please take care of yourself and your emotional wellbeing? I don't know if Kaz you want to add something?

Avril Benoît:

Well, on Wendy's point about the news cannot be trusted. Here is the miracle portion that cures everything. False hope, that you can order online. Or here's the conspiracy theory where we can blame somebody and other somebody. Kaz, what about this prevalence now of false information that's either making us fear even more or giving us false hope?

Kaz de Jong:

Yeah. First of all, you can also switch that off. If I have one line, that would be my advice. Maybe I can explain a bit more because your brain does not make a distinction between real news and fake news. Your brain sees it as potentially frightening and it arouses the whole system that you very often are not totally aware of. So, the more you watch television, and this kind of news, the more you arouse your system. Now, and in that way, you are continuously stressing your body.

Now, there's a very interesting scientific publication on this after the experience you had on 9/11, the tragedy. They looked at how many people developed PTSD, those who were actually witnessing this and those who were watching television continuously or almost continuously, seven, eight hours a day. Now, the ones who watch television, the amount of PTSD among those people were much higher. Now that illustrates that watching television is arousing your system and potentially traumatizing your system in such a way that you really have to switch that off. That's what we tell healthcare workers, switch it off when you come home. You had already nine hours of Corona and it's enough. It's very strong advice. Really switch it off.

Avril Benoît:

All right. We're going to wrap it up with this last question which is coming in different ways from a variety of people, including Nick, asking about survivor guilt. Survivor guilt is when maybe you got a light version of COVID-19 with hardly any symptoms. You didn't have to go to the hospital. You never even went for testing because you were just managing your symptoms at home, or maybe you were aware you were in a similar situation with somebody. They got it. You didn't. Describe then some ways that we can frame for ourselves survivor guilt if we're feeling that right now. Athena.

Athena Viscusi:

No, I would say one thing that always works is the practice of gratitude rather than guilt. I mean, how wonderful that some of us haven't gotten sick. We don't control who gets sicker and who gets less sick. We don't control that. So, let's celebrate. In Ebola, as tragic as it was, I mean there was one wonderful thing that we did. We had a celebration every time a patient was cured and left the hospital. We had a wall where they would leave hand prints so that we documented it. Yes, we lost so many patients. It's horrible, but to have the gratitude, the celebration for the ones that are here. I didn't do anything wrong that I'm healthy. It's just a beautiful thing and that's what makes that I can go get groceries for my neighbor who's you know.

So, really the practice of gratitude I think it's just so important in this. Like Kaz was saying, also for workers, to celebrate all the good that we're doing than all the things that we cannot do. But our brain is wired for the ‘not’ and we have to rewire it for the ‘yes’ and celebrate all that we do still have. Our health is a wonderful thing. Nobody should feel guilty for being healthy.

Avril Benoît:

Today and through the weekend, those of the Judeo-Christian traditions are trying to find ways to have Seder for Passover, Easter egg hunt for Easter, practice their religion. They're missing their congregations and their groups of people that they normally would get a lot of strength from and that sense of community. Kaz, do you have any words of wisdom for people who are feeling the loss of that connection, those rituals that help to ground them?

Kaz de Jong:

Well first of all, I think it's very good to pay extra attention to those who are still ill, families who are having people in the hospital and people who have lost. I think that this tradition is about mutual solidarity also. So, what I would do is we cannot be together in the way we were and you should not try to do it like that. But you can do something special for those families, something small maybe. Maybe just put something on the doorstep. Maybe just send a message and just check in because I think that is the core of the Christian tradition, and of many other traditions by the way, to be there for the one who's next to you. I think that would be a very meaningful way of celebrating this festivity, this Easter festivity. So, rather than looking how we did it and we cannot do it, try to find a very meaningful way, up keeping this tradition and be creative in it.

Athena Viscusi:

I had to explain to my seven-year-old friend that the Easter Bunny was afraid that he had been contaminated. So, he's in quarantine and really, really wants to bring her eggs but he's just trying to keep her safe. So, he's in quarantine and there will be Easter later.

Avril Benoît:

All right. Well look, I thank you both for sharing your expertise with us. Athena Viscusi and Kaz de Jong, both of you have been wonderful to check in with and thanks for being available for all these questions. That's all the time we have for today for this Let's Talk COVID-19. Apologies if we didn't get to your question, but we're trying to respond to those in writing. So, you should be able to hear from us. We hope you'll tune in every week at the same time when we come to you with different perspectives on the medical humanitarian work of Médecins Sans Frontières/Doctors Without Borders at a time of pandemic.

So, next week we are confirmed to have Dr. Javid Abdelmoneim from the UK, an emergency medicine physician with the NHS in London also working with MSF, and Dr. Craig Spencer. He is hopefully going to be joining us. He's an emergency care physician in New York City and like Javid, a member of the board of directors of Doctors Without Borders. Experienced MSF aid workers who also worked in the Ebola outbreak in West Africa a few years ago.

So, please stay informed about this work that we're doing at MSF and our response to COVID-19, our perspective on many of the issues that are arriving. Our website is doctorswithoutborders.org. You can sign up for email updates. You can support our work financially, including by becoming a monthly supporter. You can follow us on Facebook. That's the MSF English page. Twitter, it's @MSF_USA. Instagram, we're @doctorswithoutborders. We have a YouTube channel, you'll find us. For more specific information, you can always contact us and our events team will try to respond to you with [email protected].

So, my well wishes to you. I hope you are healthy and managing to find your little moments of release from all the stresses that we're under. I'm Avril Benoît. Thanks for watching. We'll see you next week. Bye for now.

Athena Viscusi:

Bye.

Avril Benoît: 

Hello and welcome. Thanks for joining us today for a weekly discussion series. Let's talk COVID-19. I'm Avril Benoît, I'm the Executive Director of Doctors Without Borders in the United States. We're known internationally as Médecins Sans Frontières, that's the French, original name for us as an international medical humanitarian organization. And from that we get MSF, which is the acronym we often use in our discussions. You may have seen that last week we had a lot of questions in this weekly series. A lot of questions about all kinds of things with respect to COVID-19 and coronavirus, the pandemic and what it means to you, but more importantly, what it means for the people that we look after in more than 70 countries around the world. 

Today we're going to go for about 45 minutes or so. We have an opportunity for you to ask questions. So if you're watching on Zoom, you can send your questions in the Q&A function there. You've got that option on Zoom. And then if you're joining on Facebook Live or on Twitch, there is a place where you can send in questions in the comments. So either way we accept all questions and we have the perfect person to answer them for you today. Joining me is Dr. Rasha Khoury, she's an OB/GYN in New York City. She has done several surgical assignments with MSF, with Doctors Without Borders, including spending more than a year in Khost, Afghanistan. 

She's a member of the board of directors of MSF-USA and like many of our humanitarian doctors and nurses who are in between assignments at the moment, she's responding to COVID-19 at her own hospital in Bronx, New York where her focus is on high risk pregnancies. The pregnant women have a lot of worries right now and Dr. Khoury is here to support them. Hello, Rasha? How's your day been so far? 

Dr. Rasha Khoury: 

Hi, Avril. It's so far so good. It's been hectic times. 

Avril Benoît: 

Yeah. Tell me a little bit of what the scene is outside the office door there. I see you've taken a little break to join us today. What's it like on the other side? 

Dr. Rasha Khoury: 

We are in the Bronx, New York, which is generally an area of a lot of high risk obstetrics. People are contending in this community with a lot of different barriers to health and barriers of access. I think the pandemic is extremely, extremely highlighting those issues. So I'm taking care of patients with marginal housing, patients with multiple chronic medical conditions who are also going through a pregnancy. And the disruption of the pandemic to life in general, but also healthcare, our ability to deliver efficient and safe healthcare to a large volume of people is definitely challenged. 

So, this particular room that I'm in looks very calm. Outside of this room is a lot of different attempts to make sure we're appropriately triaging people, making sure that they still feel connected to their healthcare providers, even though they might not be physically seeing them face to face. Making sure that they feel cared for, even if we're having to do a lot more telehealth or a lot more community based care. It's a total shift in the paradigm of obstetric care in New York. And so it's a big adjustment for a lot of people. 

Avril Benoît: 

Well, you mentioned a telehealth. What is it that you're doing for pregnant women as far as that goes? 

Dr. Rasha Khoury: 

Pregnancy is actually a time of deep engagement and care. And it's a wonderful opportunity actually to help people through many medical conditions such as diabetes or high blood pressure or asthma or things they may be struggling with on a daily basis. But pregnancy affords them a time to have health insurance coverage, have access to care, have leeway maybe from jobs or from family constraints in order to be able to come for that care. So normally in pregnancy you're seeing your provider pretty often. Every several weeks for my high risk patients, sometimes it's every two weeks, sometimes every one week. That may be a visit in order to check blood pressure or a physical exam or an ultrasound or blood work. 

And so, transitioning to telehealth means really helping the health system and the patients adjust to something like a phone call or consolidation of a visit so that they're not having to move around the city multiple times in a week or in a day sometimes. So we're really trying to consolidate. We're trying to remain engaged and connected with them. Sometimes the challenge is people don't have working telephones or don't have access to the family telephone at all times or don't have access to transportation beyond public transportation, which right now part of the public health messaging, we're trying to reduce people's moving around the city through public transport. 

The women of color, especially women who might not have status in the US are just exacerbated in a way that I can't, I don't even know if I have the words to articulate, under this current pandemic and under all the restrictions that we're putting in place for the sake of the public good. 

Avril Benoît: 

And what is the specific risk to either the mother or the fetus if she were to contract coronavirus? 

Dr. Rasha Khoury: 

It's very much an evolving story. I think coronavirus is something we're hundreds of thousands of people, scientists, medical workers around the world are trying to understand better. We still don't have a great idea about what exactly is the risk in pregnancy. What we're seeing from preliminary reports out of China, out of Italy, much coming out of New York City actually, is that it does not seem to be as damaging as previous coronavirus strains have been to pregnant women such as SARS such as MERS, such as even H1N1 which is an influenza virus, where women were really, in pregnancy, heavily affected to the point that their mortality was dramatically increased above the adult population that was not pregnant. 

While we still see that pregnant women are very much as likely to contract the virus, they don't seem to be going into respiratory distress and failure at greater proportion than other adults. That said, the number of people who are going into respiratory failure pregnant or not is still unclear. Because we are still working out what is the denominator of people who are infected? What are the exactly the risk factors that are putting people into the severe viral or immunologic phase of the disease? 

There's data coming out every day to inform us better. We are asking all pregnant women to maintain the same precautions that we're asking non pregnant people to maintain. Currently that involves sheltering in place as much as possible. Certainly quarantining if there's indication of symptoms or any positive contacts with coronavirus. Certainly the hand hygiene, which cannot be overstated. And really the ability to alert providers if symptoms are present to let people know that there is a safe way to care for people who are either at risk for having already contracted coronavirus or actually have coronavirus. 

I think a lot of my day to day is spent reassuring people that they will be cared for regardless of whether they have coronavirus or don't have coronavirus. And in fact, in New York City right now we're operating like everybody has coronavirus. And really we're taking universal, additional precautions to protect patients, family members and healthcare workers. 

Avril Benoît: 

And also the healthcare workers which is a huge concern that we have at Doctors Without Borders to make sure that we can continue delivering babies in all the different projects around the world. We have an opportunity for you to ask questions. If you're tuning in on Zoom, you can send your questions through the Q&A option. And if you're joining us in Facebook live or on Twitch, you can send your questions through the comments section and we welcome them. 

Rasha, you mentioned that some of the women that you're seeing and that you look after as part of your regular medical practice as an OB/GYN in the Bronx in New York is women who are homeless who maybe don't have stable housing. We also have concerns about the situation for shelters with a lot of homeless people in them in New York. Can you describe what are the specific risks of that kind of environment, not just to the pregnant women, the ones that you're seeing every day in the hospital and that you're talking to it over telemedicine platforms, but what is the risk to anyone in an environment like that? 

Dr. Rasha Khoury: 

I think that the idea of unstable housing, the idea that you might be moving from one shelter to another shelter or even if you are living among family members and extended family members and friends and you're moving from couch to couch, this idea that you don't have a safe, private space to be in where you could potentially decontaminate that space, make sure your personal hygiene is cared for, make sure that you're not around other ill people. That sort of privilege is not afforded to somebody who is either homeless in shelter system or homeless and traveling between various homes. 

For pregnant women, often, especially my patients in the Bronx, it can mean being marginally housed or homeless with other children. So being in a family shelter situation where the woman might be the primary caretaker of children. And that can be an additional risk for exposure being in a very confined space with multiple other adults and other children who may or may not have symptoms and not really having any other option except being on the street as the alternative, which is certainly not safe even in normal times, not in pandemic times. 

So the ability to make sure that people have access to water, to soap, to showers, to cleaning supplies in order to clean their space, to being separated from other people who might have symptoms. It's very akin to our prison system. Where people who are incarcerated don't have the luxury of having separate space, having the ability to maintain personal hygiene and decontaminate, use protective equipment. We're giving out to patients masks and gloves who are either at high risk because they're in contact with somebody who is positive or have symptoms themselves. But these are finite resources. And it's somebody who might be challenged in terms of financial security may not be able to then continue to afford those resources to protect themselves and their family. 

Avril Benoît: 

One of the reasons that this issue is so important to us is that we know at Doctors Without Borders, at MSF, that there are always these vulnerable and neglected, forgotten groups of people in any kind of outbreak. The ones that are just not reached through the traditional ways of public messaging and daily television briefings from the governor or the mayor or the president and are perhaps going to miss out on crucial lifesaving information. Somebody had posted a question here about Doctors Without Borders actually responding in New York City. 

And I just want to let you know that in fact it is in that area of these shelters, for people who are homeless, who are in precarious situations on the street. That's where we are. Actually, we've got a team that is looking to be able to support those that are running those organizations that support the homeless to make sure that they can remain safe and also do the best they can so that the residents of those structures can avoid being exposed to coronavirus or isolated in a safe way if they seem to start showing some mild symptoms. Rasha, we have a question here about the most important information that somebody that's seeing you as an OB/GYN needs to know. What is the number one thing that you tell them when they come in? 

Dr. Rasha Khoury: 

Before I answer that question, Avril, I just want to say that oftentimes our patients who are marginalized are people in the service industry. Recently, in the last week, what's come up for me a lot with my patients is that the same patients who are suffering with marginal housing are the patients that are considered essential workers in the city of New York. And so it's important, I think when we're thinking about these populations we consider them essential because of their work value and force. But then on a social level to not consider them expendable. Which is how I think it may play out. And so, to really focus on the importance and the value of high value care for those population. 

Avril Benoît: 

No, that's a great point. I'm glad you asked. You're absolutely right. And then to the question that came in about the most important thing that you're trying to convey to somebody coming in to see us for care when they're pregnant, for example. 

Dr. Rasha Khoury: 

Yeah. I think a big part of what I'm doing day to day aside from physical care in pregnancy for people who are persons under investigation for coronavirus or at risk or have it, it's a lot of soothing anxiety and comforting patients and their families that to the best of our knowledge and ability and resources, people will be cared for. Regardless of what the medical need is, that medical need will be addressed and that the fact of the current pandemic or the fact that they have the virus itself is not going to diminish that level of care. 

For a lot of my patients with complicated medical or surgical histories in pregnancy, oftentimes the primary worry is what's going to happen to my fetus, to my baby after delivery? What's my delivery going to be like? So it's a lot of reassuring people that evidence based care, high quality care will continue to be afforded them. I think it's also really important that people recognize that they need to follow the public health messaging that's being delivered to everybody else in the city, in the state, in the country around sheltering in place as much as possible. Acknowledging that the ability to shelter in place is related a lot to economics and whether somebody is able to not be at their job. Are their partners able to not be at their job in order to help with childcare? But that sheltering in place, avoiding public transport, washing hands, avoiding unnecessary travel. These are a lot of the things that I'm discussing with people. 

To the best science that we have so far, it does not seem that coronavirus is transmitted from mother to baby during pregnancy. And this is a huge comfort that I can give to patients. It can relieve a lot of stress around their worries about, "By being in a hospital setting or in a clinic setting, am I exposing my fetus and my pregnancy to this virus?" So during pregnancy, during breastfeeding, to the best of our knowledge so far, it doesn't seem to be transmitted. We of course worry about the acute respiratory complications that can evolve in pregnancy. Pregnancy itself is a state where if you were to develop respiratory distress or respiratory symptoms, it can be quite challenging to take care of a woman in that state. 

And sometimes it might mean the need to deliver somebody prematurely in order to help their ventilation. And that can be very scary both for the medical community and for the patients who are pregnant. So I would say the most important thing to remember is that pregnant people are people and that the precautions they need to take and the care that they deserve is equal to everybody else in society. 

Avril Benoît: 

You mentioned that the babies might not get COVID-19 from their moms, but do they get the antibodies if the mother has mild symptoms and seems to be riding it out and getting better. Can that be transferred either in the moment of delivery from the placenta or the breast milk? I'm not exactly sure how, but is that something that actually affords some protection to the infant? 

Dr. Rasha Khoury: 

So this is our sincere hope. And something that we're investigating at the hospital where I work in New York, but is also being investigated in many, many hospitals around the world, including many studies coming out of China, looking at the serum of the mothers of the babies, the cord blood of the placenta and to look for antibodies. Are women who are exposed to coronavirus developing antibodies that they're passing on? Like you said, whether through blood, whether through plasma, whether through breast milk. It's not yet known whether that is occurring and it's also not known how protective is it for how much time? 

We certainly have had reports of newborns and children being infected probably from exposure to their parents. So we don't quite know actually how the disease is evolving in these young age zero to five. Even ages zero to 19, actually we don't have a great sense of what's happening in that population. 

Avril Benoît: 

Now Rasha, when you're not working in the Bronx as an OB/GYN, you're often to be found on assignment somewhere in a humanitarian crisis zone. And you've done a couple of quite long ones in Khost, in Afghanistan. What are your concerns about COVID-19 coming to Afghanistan? 

Dr. Rasha Khoury: 

Actually, Afghanistan is on my mind every day as is a project that I was in Mosul in Iraq. Because the fragility of the health system that I see in a place like New York City, which is a heavily resourced city, one of the most expensive healthcare systems in the world, and yet I see a lot of chaos, a lot of despair, a lot of under staffing, a lot of people out sick and not being paid for that sick leave, not being replaced. A lack of personal protective equipment, difficulty with infection control in the hospital system. And so every day I'm acutely aware of how multiple times a million that scenario is going to be in a lot of our projects. 

Whether our long-term projects or emergency projects, whether we're in a physical building or whether we're in a camp like setting, I think the issues of volume of patients that we're serving. For example, in Khost, we serve around 2,000 women and newborns every month. In my hospital in New York City, we serve around 2,500 a year. And so that's a staggering magnitude of difference. I think even though right now we're not hearing a lot of numbers of infected people coming out of places like Afghanistan and Iraq or other countries in the Middle East, it doesn't mean that those infections aren't occurring and aren't being transmitted and that people aren't suffering. 

And so, I think it's important to remember that the fragility of health systems in the areas where MSF, works the lack of financial resource by local institutions, governments, public health facilities. The importance of supply chain and how much disruption is ongoing right now to supply chain around the world regardless of MSF or not MSF, in terms of getting equipment and medications to the places where they're most needed. I think these are the sort of the macro things that I think about. 

When I think about Khost, specifically, we have 80 to 90 deliveries every 24 hours. That means people coming in and out of labor and the delivery room, crowded labor rooms, crowded delivery rooms. We certainly in MSF pay a lot of attention to infection control prevention because that's something that's key in any health facility regardless of the pandemic or not a pandemic. But it becomes even more important in a pandemic setting. 

I also think that sometimes, and I see this in New York, the fear of the virus and the pandemic, sometimes it allows people to forget about the other complications that might be ongoing. So for example, in Afghanistan we see it a lot of maternal and neonatal complications that can be really life ending. And if we were to be distracted by perhaps a cumbersome triage system or forget somebody in a corner, or really be overwhelmed by whether somebody has the virus or doesn't have the virus and ignore, for example, a catastrophic hemorrhage or high blood pressure, we could really lose people. 

And so, I think when I think about Afghanistan, I think about how important our ability to triage is going to be, our ability to maintain infection control, our ability to try to isolate in creative ways because we don't have a ton of space to have isolation rooms. But we also have indoor, outdoor, facilities and we have a lot of community based care. We have a really strong health promotion and community sensitization program. And these are really valuable experiences and teams that don't exist certainly in New York where I'm working. And actually I think New York could learn a lot from much of the work that we do in places like Afghanistan to maintain this idea of community based care. 

Avril Benoît: 

And you mentioned that when the women are coming in to deliver in that maternity center in Afghanistan where you worked, there are a lot of family members all around. How can we manage this sort of phenomenon, this desire of women to have either perhaps the child's father or their own mother, other elder women of the family there to support them through this birthing experience? How do you think that needs to be managed when you have a risk of coronavirus? 

Dr. Rasha Khoury: 

In our project in Khost, it's a gender segregated project. So women, once they enter the facility for labor and birth are able to be with a female caretaker. Often it's a mother, a mother-in-law, a sister, while the male caretakers wait outside in our waiting areas. Those waiting areas are often large tents or large containers where upwards of 50 men might be sitting together. And so I think it has to be sort of a key public health message that what we are trying to do is not to disrupt the family structure or the support structure that might be around a woman, but really you're trying to protect the family members themselves by likely asking people to not... Something like I imagine closing some of those waiting areas so that people aren't all sitting in inside together, but perhaps being outside the gates of the facility separated by some kind of physical distance. 

I do think it's really important to reassure people that women will not be forsaken or alone while inside a facility. That's the same in Khost, it's the same in New York. That healthcare workers will really be actively in protective gear, but actively working to support them through often a difficult time, a painful time, a first experience with labor and birth. I think one of the strengths of many of our projects are the experience of our national staff, them being part of the community and so able to communicate whether it's language or in terms of social customs with the patients and offer support. 

I think patients can also offer each other a lot of support. Certainly, I saw that in Khost where women really supported each other through the early parts of labor and often through delivery, even when they weren't family members. That can be a little bit different in a place like that New York. But it can work in, in many spaces. And this idea of like sisterhood and community solidarity, doesn't necessarily have to be me holding your hand while you're in labor, but could be me providing a lot of positive affirmation for the process that you're going through and really being present. 

I experienced it, for example, in New York where we've had COVID positive patients in labor where we're supporting them actually from outside of the room through video exchange or through telephonic exchange. So it is possible to be in accompaniment of people even if physically you might not be able to touch them. And I think we learned a lot about that in a lot of our Ebola projects and treatment centers. 

Avril Benoît: 

That's true. Well, look you're answering all kinds of questions that I have. And I'm asking you the questions coming in through the chat. So, if you're watching us now on Zoom by all means ask a question in the Q&A little option there and on Facebook live or on Twitch, you have the comments section and I will ask your question to Dr. Rasha Khoury, who's an OB/GYN in New York City. Rasha, another question that we often are getting is, let's say we need to prioritize masks. Everyone's wondering now, should I wear a mask? What's the advice? 

It's been confusing. At one point it was if you're sick, if you're coughing, you should wear a mask everywhere you go, including at home. And now there seems to be a bit of wavering on that, about perhaps it's a good idea for everyone to wear masks when we go into a store, for example. That all of the customers, when we do our grocery shopping, we wear a mask. What is your advice on that? 

Dr. Rasha Khoury: 

First, I want to acknowledge the utter confusion that the mask recommendations have created. They're also changing almost every day. And these are from entities like the CDC, like the WHO. So these are from really reputable sources. And I think the goal of course is not to confuse society, but really to try to update as we have more and more knowledge. I think what we know today is that the chance that a lot of people and likely the majority for example of people in New York City right now are positive with coronavirus is super high. 

We have a lot of good data to suggest that some of our tests are resulting in false negatives and so shouldn't be a reassurance to people, if I test negative then I don't have it. Because they could either already have it or contract it tomorrow. And so I think the recommendation on masks has shifted as sort of our understanding of the public health numbers has shifted. Certainly, masks are excellent for covering somebody's cough or sneeze because it avoids them using their hands to cover their face. I think the second reason masks are great is they keep people's hands off of their face. 

Avril Benoît: 

Unless you're fidgeting constantly. Unless you're constantly adjusting it. 

Dr. Rasha Khoury: 

Right. Even I have touched my glasses during this webcast multiple times. It's just something I, when I have my mask on, I'm sort of keenly aware to not do. I think that masks in a healthcare setting are vital and lifesaving both to patients and to staff. And the reason for that is in healthcare setting, you're often in much more close quarters with multiple individuals. And the chance that somebody will cough or sneeze is very high. In labor and delivery, for example, the chance of perhaps needing oxygen support or something like a nebulized treatment or a ventilation or intubation or an emergent delivery that might result in an invasive airway procedure. Those are all highly exposing procedures. 

So currently in my institution, and the recommendation coming out of many big organizations around the world, is probably healthcare providers who are working in very high exposure settings like the ICU, like labor and delivery, like the operating room should definitely be wearing the appropriate masks. What the appropriate mask is changes based on the organization that's making the recommendation. My personal recommendation based on experience here has been to wear an N95 mask for healthcare workers who are working with high exposure possibilities. Whether that's a clinical scenario or a patient. 

I think in the community, it's hard to make a recommendation because we know that community transference is happening. We know that it's happening in the supermarket, in the subway, in the street and you want to keep people protected. Earlier there was this conversation around don't tell people to wear masks because then we'll have a shortage. The reality is we have a shortage and we need to be globally producing more masks and I think telling people not to wear them because of the shortage doesn't quite make medical sense. There are certain different grades of masks that people can wear when the exposure risk is lower. 

So if I were riding the subway or in the supermarket, I'm not wearing the same mask that I'm wearing on labor and delivery. It's a long winded answer to say that we don't have very clear data on what is the safest type of mask. For sure, healthcare workers, people who are coronavirus positive, people who are at high risk of exposure because of family members, those are people who should be wearing masks. And like you said, not overly manipulating the mask when it's on their face. 

Avril Benoît: 

One of the other things that we hear all the time is the N95 mask and PPE. Describe what that is. What are the components of it? Because in my head, having worked in all these years with Doctors Without Borders, I know of PPE from the Ebola perspective and that's what looks like the astronaut suit and the ski goggles and it's a full kit. What's the PPE appropriate for treating somebody with COVID-19 if you're a healthcare worker? 

Dr. Rasha Khoury: 

I think that the extent of the PPE that's necessary is still also not known. Currently, what we do on labor and delivery is we have an N95 mask with a second mask that includes a face shields, often a plastic face shield on top of it. And that's to prevent the soiling of the N95 mask. People are asked to wear two head covers to cover hair. For my kind of hair, it's not that important, but for somebody with longer hair, it is. We're often wearing a first layer of gown and then a second layer of gown for protection from fluids, amniotic fluid, blood, et cetera. And the gloves were often double gloving. So a latex glove first followed by often a sterile glove because we're working in labor and delivery. 

Equally important to wearing the PPE is the right way to put it on and the right way to take it off. And I would say that's a learning curve. I feel very comfortable with it because of my time working with Lassa fever and Ebola. But I recognize that many of my colleagues, both in the US, in New York and around the world have not had that kind of experience. So it's super important to walk people through the way to put PPE on and take it off in a very calm moment where they are not interacting with a patient. Because that can be a high anxiety period. And so you want to be able to make sure that all your staff are well trained. And first of all, what is the PPE? How to put it on, how to take it off, how to decontaminate yourself so that you're not carrying anything out to other team members. 

So, currently that involves after removing all the PPE for a delivery that might have resulted in the intubation of the mother or the baby is actually showering. So it's soap water changing certainly scrubs. There's a lot of counseling to healthcare workers around how to not bring the virus home. And that I think is something we learned a lot during Ebola with our staff that were going home to their families. And something that can be transferred to all over the world with healthcare workers working with coronavirus who are then going home to their families. That's been the biggest difference for me working with coronavirus in New York versus being on an Ebola mission, is here I'm with my family and so I have to be very conscious of what's happening also outside the doors of the hospital. 

Avril Benoît: 

Early in all of this, I remember hearing of somebody who would come home from the hospital and their spouse was saying, "You're not stepping foot in this house or this apartment until you take off all your clothes in the back garden or something and you leave them outside and you're not bringing that stuff inside." And it just seems like a preposterous level of kind of anxiety. But would you say that's, that's actually appropriate now that we know a little more about this virus? 

Dr. Rasha Khoury: 

I think we've seen healthcare workers both become ill and die all over the world. Certainly we've had a lot of stories coming out of Italy. Some stories coming out of New York City. I personally don't think that any amount of precaution is too much. I think it's important to soothe your family, your community, people who are supporting you through this work. And so for me, I do take off all my clothes at the door. Put them in a separate bag. It goes in the laundry, the bag goes in the trash, I go into the shower. And really it's a ritual now that's happening every day. And I think many of my colleagues in New York City are sort of practicing a similar ritual. 

That said, that's the privilege and a luxury of having a home, having a shower, having access to running water at all times. And I think when I think about our projects, that might not be what's available to many of our staff who are working in our project. Going back to the community that's in the same area where we're serving a population that's dealing with internal displacement or a war or post-war. I think I don't think any amount of precaution in New York is too much at this time. 

Avril Benoît: 

You mentioned the kinds of places where Doctors Without Borders works. Often, people who are fleeing from war. And you may have seen this also in Iraq where you worked, often other conditions, the kinds of things that make COVID-19 all the more dangerous for them. Can you describe what are some of those co-morbidities as they're called, which actually makes somebody more vulnerable to serious consequences of COVID-19 beyond being elderly? Because we know that older people are among those that seem to be, statistically we see the numbers they’re more likely to die. But also, people with other underlying conditions or chronic diseases. Tell me about that. 

Dr. Rasha Khoury: 

I think certainly from our projects patients coinfected with HIV, with tuberculosis, patients who are heavy tobacco users and might have underlying lung disease like emphysema, CLPD, patients who were exposed to a lot of air pollution, asbestos and that's often in areas where we work because there might be effects from certainly devastating effects from climate change, from war, from military artillery, from chemical weapons. And Mosul was a very big problem that deeply affected people's lungs. 

Dr. Rasha Khoury: 

And so anything that's sort of chronically affected people's lungs or acutely. So in Gaza, a lot of tear gas. All of these things that can really cause a lot of reactivity in the airway and difficulty with breathing, those people are going to be more susceptible to contracting the virus but also probably more likely to develop the more severe viral phase of the illness. I think the second phase of the illness is sort of immunologic overdrive that can, it seems to be happening sort of at the tail end of the illness, but leading to rapid death. 

Anything that underlyingly affects people's hearts. So heart failure because of very bad chronic diseases, which we're seeing a lot in a lot of our projects. Especially when people are displaced or haven't had access to primary care for a long time or medications that they need such as insulin, blood pressure medications, heart medications. Certainly, a lot of the refugee camps where we work, I saw it in Iraq a lot, people who are displaced from their homes, may have not had access to healthcare for two years prior to that displacement and now are even further susceptible. 

I think we still don't know what are all the underlying diseases that put people at further risk, but we certainly know that there are ones that we contend with in a lot of our projects that already at baseline are very difficult for people to manage and then on top of this to be exposed to something that as contagious as coronavirus seems to be, and as devastating, when it develops and evolves in somebody's body, it can be catastrophic. And I think it's very important to not forget about all these populations. 

Avril Benoît: 

We have a few more minutes left with Dr. Rasha Khoury who's an OB/GYN in New York city. And when she's not doing that, she's working as a humanitarian physician on assignment with Doctors Without Borders. Rasha, another thing that that seems to be coming up a lot, and I can say this for people in the United States and in Europe, in Hong Kong and China who have been through, and Iran, no doubt where you've had this society wide implications of this pandemic, is that the mental health burden of it, the stress of it. And so in your work, you've got women who are maybe delivering for the first time amidst all of this crisis. What do you advise them to be able to kind of, get through this without making things worse for themselves and for their infant, with all the anxiety which, which seems quite widespread and inevitable? 

Dr. Rasha Khoury: 

Normally I would say sort of community solidarity is the key to getting through very difficult times. And I think it's incredibly challenging to maintain community solidarity when you're meant to maintain a kind of physical distancing. It's important to know that physical distancing is not social distancing in the sense of, please stay connected to by phone, by video to the people that matter to you and the people that give you strength. I think it's super important to not feel alone, even though we are all asked to be sort of in our own areas of living, sort of not infecting other people or not becoming infected by them. 

I myself actually, I'm having a baby in a month and it's my first. And so this idea of having a child, bring a child into the world without maybe your family around to actually hold them and see them, it's deeply tragic. And sort of recognizing the sadness of that and that you're not crazy for feeling sad or feeling anxious around that possibility, that you were doing this along with hundreds of thousands, if not millions of women around the world at the same time. That certainly gives me a lot of comfort and a lot of appreciation and gratitude for the things that I do have available to me. 

I think it's important to gauge how much you need to be tuned in or tuned out to have the news. So I have a lot of colleagues who are struggle a lot with that. And that's something I learned in Afghanistan and Iraq is I listen to the security update in the morning with my team members and then I don't log into the news for the rest of the day while I'm working in Afghanistan. And it's not because I want to be ignorant to the day to day happenings, but it's my way of managing information in order to maintain my ability to stay focused and provide the care that I'm there to do. 

I think self-care can never be overestimated and that can look like different things to different people. It can look like better sleep, longer sleep, exercise avoiding toxic things that are just going to drain you. Certainly, in Afghanistan and Iraq, no access to alcohol, very limited access to tobacco, and I think that actually made our team's much healthier. So I certainly practice that here. For some people, storytelling is very helpful or reading or currently there's a big project of the US that's trying to spread internationally to collect stories from health workers working on the coronavirus pandemic. 

And I think just the relief that you get from telling, giving a three-minute audio diary of what happened that day that was either very deeply painful for you or that brought you a lot of joy. I think sharing those moments of joy is also very important. Being somebody who grew up in a war zone who then has worked in war zones, I think you recognize that joy is everywhere also in very small things. And it's important to sort of stay tethered to that because that can be very grounding. 

Avril Benoît: 

Well, I have a final question for you, Rasha Khoury. Are there special considerations for pregnant healthcare workers? And this question is coming from Tao who worked with you in Afghanistan and she's also wondering, Tao is also wondering about separating babies from infected mothers right after the childbirth. 

Dr. Rasha Khoury: 

Yeah. Technically, pregnant health workers are considered a protected class of health worker, like elderly health workers or health workers who may have underlying medical conditions that might make them at extra risk for the severity of the disease. I think right now based on what we know, it does seem like pregnant women are not developing worse symptoms than they're non-pregnant counterparts. And so as a pregnant health worker myself, I've taken that to mean that as long as I'm taking all the precautions in terms of PPE and continue to work with care that I will be certainly as equally at risk as somebody my age and my gender who's not pregnant. 

For me and I think it depends, health worker to health worker. What is the thing that's going to keep them more sane and feel more grounded? Is it to continue to work or is it to not to work? And I think that's a personal decision. It does not seem like pregnant health workers are at greater risk. But certainly there can be a lot of anxieties depending on what else the person is dealing with in terms of health risks, but also in terms of community or family demands. And the second question, I'm sorry, Avril, was around babies. 

Avril Benoît: 

Yeah, so separating. Let's say you have the newborn and the mum who has COVID-19. 

Dr. Rasha Khoury: 

Yeah. So currently what we're doing which is following guidelines from the CDC is we are separating babies for around 72 hours, if the mom is symptomatic. So if the mom is symptomatic, has a birth, the baby's being separated for 72 hours and observed. Sometimes the COVID test is sent on the baby, sometimes it's not. Depends on the facility. But we are trying to maintain breastfeeding and so we're helping the women to breastfeed, to pump breast milk in order to give it to the babies. With 72 hours of no symptoms, it does seem safe for the mother and baby to be reunited as long as the mom is using appropriate hand hygiene and wearing a mask when she's holding the baby. 

One thing that's worked well here is we've had non-sick family members be able to give the breast milk to the baby. We've tried to have some video capabilities that the mom could see the baby. It's a very difficult thing to separate mothers and babies and it's something we're trying to usually not do. Because we know there's so many advantages from skin to skin, from bonding, from breastfeeding. And so I think more data will come out about the safety and it might be eventually safe once we have more information. I think right now we don't have a ton of information, which is why this 72 hours of separation is happening. 

Avril Benoît: 

Well, Rasha, it's been really great to have you explain how this is working from your perspective working in a hospital in the Bronx and also your perspective and comparing it with what you know of humanitarian work and the places that you've been in. Rasha Khoury, is among the Doctors Without Borders physicians who are sometimes working on assignment but also sometimes working at home. And just to address one of the questions that came in about the border closures and how that's affecting Médecins Sans Frontières or MSF. It's enormous. 

So we have difficulty flying our specialist staff from place to place in order to be able to boost up the capacity in certain locations that will be hard hit by COVID-19. We're having difficulty being able to bring in the necessary medical supplies. A lot of flights, cargo flights, airspace closed and that's actually making it very difficult for us to be as nimble as we like to be as an emergency humanitarian organization. But Rasha, I wish you well not only with your pregnancy and what's left of it, but also do stay healthy. We know that, I'm among those who are at my balcony because we care in New York City and I thank you so much for all the work that you're doing to keep the rest of us safe. 

Dr. Rasha Khoury: 

Thank you so much, Avril. 

Avril Benoît: 

Thank you as well. If you've been joining us on Zoom or on Facebook live or on Twitch, we would like to invite you to come again next week. We'll be here every Thursday at this time for this discussion series and, knock wood, next week we will have a couple of guests who are also working on the home front, Dr. Craig Spencer and Dr. Javid Abdelmoneim, two MSF doctors and board members who are working in their area hospitals and who will also reflect on their experience of working in the Ebola outbreak in West Africa and now treating patients with COVID-19 in New York City and in London. 

To stay informed about our work with Doctors Without Borders, MSF, you can always go to our website. We have all kinds of updates about what's happening in terms of this COVID-19 pandemic and the many places where we work. Our website is doctorswithoutborders.org and you can sign up there to receive our email updates. You can also follow us on Facebook, the English channel and our Twitter is @MSF_USA. I'm Avril Benoît, the executive director in New York City and I'll see you next week. Thanks very much for tuning in.