Let’s talk COVID-19: Supporting local efforts to curb the US pandemic

Avril Benoît:

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

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

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

Michelle Mays:

Thanks Avril, great to be here.

Avril Benoît:

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

Michelle Mays:

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

Avril Benoît:

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

Ruth Kauffman:

I'm here. Can you hear me?

Avril Benoît:

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

Ruth Kauffman:

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

Avril Benoît:

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

Michelle Mays:

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

Avril Benoît:

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

Ruth Kauffman:

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

Avril Benoît:

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

Ruth Kauffman:

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

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

Avril Benoît:

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

Michelle Mays:

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

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

Avril Benoît:

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

Michelle Mays:

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

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

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

Avril Benoît:

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

Ruth Kauffman:

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

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

Avril Benoît:

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

Ruth Kauffman:

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

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

Avril Benoît:

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

Ruth Kauffman:

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

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

Avril Benoît:

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

Michelle Mays:

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

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

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

Avril Benoît:

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

Michelle Mays:

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

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

Avril Benoît:

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

Ruth Kauffman:

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

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

Avril Benoît:

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

Ruth Kauffman:

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

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

Avril Benoît:

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

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

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

Michelle Mays:

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

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

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

Avril Benoît:

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

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

Ruth Kauffman:

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

Avril Benoît:

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

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

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

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

Michelle Mays:

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

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

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

Avril Benoît:

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

Ruth Kauffman:

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

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

Avril Benoît:

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

Michelle Mays:

There are thousands of people who are street homeless in New York City, and many of them were newly street homeless, because of COVID, because they lost their job, lost their housing, et cetera. Or like I said before, chose not to live in a shelter, because they felt it wasn't safe. So access to showers and hygiene facilities is a long standing issue in New York City. It's something that predates the pandemic, but was particularly critical during the pandemic, just because everything's shut down. So we open these showers and even though the acute parts of the pandemic is, it seems we're over the curve in New York City and hopefully it will stay that way. The need is still there.

So we are really fortunate to have found an organization and be working with a local organization called Shower Power, which has actually been working for many years, trying to open up a shower facility and really taking this opportunity to take over one of the shower sites and continue offering showers to people. But they're a small local community organization and they're volunteer run, they don't have a lot of money and resources. So if anyone out there is interested in donating to a local organization doing really amazing work, go to, showerpowernyc.org, and they have information about taking over the showers, but every little bit helps.

They have, like I said, it's mostly volunteer run. So, the money goes really to offering showers and giving people access to hygiene facilities, which is not just a public health thing. It is a public health thing, but it's also basic human dignity. So I think it's a really important thing to support.

Avril Benoît:

Happy to share the love.

Michelle Mays:

Thank you.

Avril Benoît:

We need the financial support ourselves, but our partners do as well. Hey, that reminds me. There's one really good question here for you, Ruth, just as we wrap up and look to the longer term for these indigenous communities. Is it time to eliminate the Indian Health Service, if they haven't been able to do the job, if they're ineffective?

Ruth Kauffman:

It's time to dismantle white supremacy and colonial construct of all of our systems. I think that's very clear right now. That's a really complicated question. There are alternatives to IHS in communities, they're called 638. And as different communities decide for themselves, whether IHS is no longer serving their needs or not. I think that that is an important discussion moving forward, but a complex one, right? Because it's part of again, treaty agreements from the federal government. So, how for communities to develop a health system that's responsive to their needs and that's controlled and run by the community is a really great thing, moving forward to think about.

The other piece of it that we didn't talk about just to jump on Michelle's comments, is that, many of the homeless people in the New Mexico area for example, are also Native American people. And so part of the response too, needs to be in areas that are not part of the Pueblo community or Navajo nation, but in the urban context or border towns as they're called locally. And so, one of the areas we helped with there too, were shelters and getting the IPC set up in shelters and triage systems and places that were safe for people to smoke cigarettes, for example, when they needed to take a break outside. And so those kinds of long-term follow-ups are also important.

Avril Benoît:

Well, it's been great to hear about your work. Thank you so much. And thanks to everyone who is working with Doctors Without Borders on these various projects all over the US. It's been really good to have your perspective, and that you're game to take some of these tricky questions, these challenging questions, which not only speak to the present, but the future. Michelle Mays, a nurse, an MSF project coordinator in New York City and Ruth Kauffman, a nurse, midwife, MSF project coordinator in the Southwest. Thanks to both of you.

Michelle Mays:

Thanks Avril.

Avril Benoît:

And thanks to you for joining us today. Sorry if we didn't get your questions, hopefully we can respond to those in the chat itself. We'll be back with another episode of this summer long series, Let's Talk COVID-19 in a couple of weeks. And at that time we're going to be talking about the impact on access to essential, sexual and reproductive health care. Things like safe abortion care. So that's coming up, do come back and join us then.

So for more information, you can visit our website. In the US, it's doctorswithoutborders.org. And globally, it's msf.org for Médecins Sans Frontières. You can also follow us on Facebook, different languages available, but we have msf.english. Twitter is @MSF_USA. On Instagram, you'll find us @DoctorsWithoutBorders. And if you have any specific questions, things you want to follow up on, by all means contact us. Our email address is, event.rsvp@newyork.msf.org. I'm Avril Benoît. Bye for now.