Codogno Hospital, Lodi Province
An MSF nurse disinfects her hands before entering Codogno hospital in Italy’s Lodi province.
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Let's talk COVID-19: An OB-GYN on the front line

A live online discussion series hosted by MSF-USA Executive Director Avril Benoît

April 02 2020, 1:00pm - 1:45pm ET

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 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. 


Join us for this live online discussion series to find out how Doctors Without Borders/Médecins Sans Frontières (MSF) is responding to the evolving COVID-19 emergency.

During the event, MSF aid workers and medical experts will answer your questions about the humanitarian impacts of COVID-19.

For this first event in our discussion series, MSF-USA Executive Director Avril Benoît will speak to Dr. Rasha Khoury, an OB-GYN and MSF-USA board member who has completed multiple surgical assignments with MSF, including more than a year spent in a specialized maternity hospital in Afghanistan. Dr. Khoury is currently responding to the COVID-19 pandemic in the Bronx, New York as part of a team of people working to ensure safety of patients as pregnancies continue amidst this emergency.

Your registration allows you to attend all events in this series.

After you register, you'll receive an email confirmation with the Zoom link to attend online. You'll also receive email reminders before each event.


Avril Benoît, MSF-USA Executive Director, has worked with the international medical humanitarian organization since 2006 in various operational management and executive leadership roles, most recently as the director of communications and development at MSF’s operational center in Geneva from November 2015 until June 2019. Throughout her career with MSF, Avril has contributed to major movement-wide initiatives, including the global mobilization to end attacks on hospitals and health workers. She has worked as a country director and project coordinator for MSF, leading operations to provide aid to refugees, asylum seekers, and migrants in Mauritania, South Sudan, and South Africa. Avril’s strategic analysis and communications assignments have taken her to countries including Democratic Republic of Congo, Eswatini, Haiti, Iraq, Lebanon, Mexico, Mozambique, Nigeria, Sudan, and Syria. From 2006 to 2012, Avril served as director of communications with MSF Canada.

Dr. Rasha Khoury, OB-GYN and MSF-USA board member, is a Palestinian physician and public health activist born and raised in East Jerusalem. She moved to the US for medical training, graduated from Yale School of Medicine in 2008, and completed her residency training in Obstetrics and Gynecology at the University of California San Francisco. She then pursued a fellowship in Family Planning and Global Women's Health at Brigham and Women's Hospital and received her Master of Public Health from the Harvard School of Public Health in 2013. In 2014, fulfilling a lifelong dream, she joined MSF and has since completed 6 surgical assignments in Sierra Leone, Lebanon, Cote D'Ivoire, Iraq, and for more than a year in Afghanistan. Dr. Khoury currently works clinically in high-risk obstetrics in the Bronx, NY with a research focus on reducing severe maternal morbidity and mortality.


Future events in this discussion series:

Thursday, April 09, 2020 - 1:00 PM EDT (10:00 AM PDT)

Thursday, April 16, 2020 - 1:00 PM EDT (10:00 AM PDT)

*Each event will run approximately 45 minutes.