Let’s talk COVID-19: Caring for our elders

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 event.rsvp@newyork.msf.org. Thank you everybody. Have a great afternoon.

Luis Encinas:

Goodbye.

Heather Pagano:

Bye. Thank you.