COVID-19: South Africa Mass testing
A health worker prepares to swab a patient during a mass COVID-19 screening and testing event held in Johannesburg, South Africa.
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Let's talk COVID-19: MSF responds to a pandemic

Continues on Thursday, June 11, 2020 at 1:00 PM EDT

Join Doctors Without Borders/Médecins Sans Frontières (MSF) for our online discussion series Let’s talk COVID-19. You’ll learn how we’re responding to the global pandemic while maintaining essential medical services in more than 70 countries.

Starting May 28 and continuing every other Thursday this summer, MSF-USA executive director Avril Benoît will talk with MSF aid workers and experts in the fields of medicine, research, and logistics who will answer your questions about the humanitarian impacts of COVID-19.

With global demand for personal protective equipment and supplies skyrocketing, how is MSF managing the already difficult task of obtaining the massive quantities necessary to protect our staff and patients? How are we safeguarding our previously existing medical programs, like vaccination campaigns and care for people living with HIV or tuberculosis? And what can be done to ensure that any new treatments or vaccines for COVID-19 be widely accessible and affordable—especially in low-income countries? These are just some of the topics we may explore in this eight-part discussion series.

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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. 

 

Read transcript here

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.

Read transcript here

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 event.rsvp@newyork.msf.org.

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.

Read transcript here

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. 

 

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