COVID-19 Chapter 8: Disparities

This frustrates me a lot. First, not everyone who is locked up has been convicted of something. Many of my clients are locked up because they could not make bail. Also, minor crimes should not carry a death sentence. When courts went to restricted schedules in mid March, my office started filing motions for bond for clients whose cases had been continued. One of my colleagues contacted the local jail to find out information on male inmates' abilities to social distance and

maintain hygiene. Female inmates are housed elsewhere and we did not receive information on their situation. We found out one showers and toilets are shared with one shower for sixteen to seventeen inmates. Two clothing is washed twice per week, linens are washed once per week, and blankets are washed monthly. Three two or three inmates sleep on the floor of a pod designed for fourteen. Four There is no access to hand sanitizer. Five there are limited supplies of soap,

toilet paper, and tissues. And six there is not enough physical space to allow inmates to maintain three foot separation, as was the recommendation at the time the judge hearing our motions was and at the time of writing this still is of the opinion that inmates are safer in jail than out on the streets. Of the approximately twenty bond hearings we did the first day, two or three

were granted. For our next round of motions, my colleague went to court with an article from a national newspaper and a PowerPoint presentation, both written by an epidemiologist who studies disease in jails and prisons, as evidence that one case in a jail or prison would spread like wildfire throughout the inmates and correction staff. But since there wasn't a peer reviewed study and the epidemiologist was not physically in court to present her research. The judge would not

let my colleague admit the article or PowerPoint. The lack of scientific consensus is a roadblock. We keep running into news reports say studies show various underlying conditions cause greater risk, but we have no way to present that evidence as evidence, so the judge does not consider it when making determinations. We have tried to proffer what we have read in news reports, but the prosecutor objects and the court does

not accept our attempts. In all, the jail population has been reduced about fifteen percent, which is not bad, but it does not fix the hygiene issues or the fact that inmates cannot physically maintain the now recommended six foot distance. I do not know how many inmates are immunocompromised, nor how many have other health issues which would put them at greater risk if they were infected. I do know there are inmates in those situations. I represent some of them.

I do not know what measures the jail is taking to screen inmates who may be showing symptoms. The local hospital is small and already has coronavirus patients. I get multiple calls a day from incarcerated clients asking if they can have a bond hearing or a furlough motion. Some I can file, most are not eligible. Many of my clients have read in the paper about inmates and other jails getting out, which is true. But my clients are

not in those other jails. They are where they are with judges who still believe they are safer locked up. A few jails in my state have now had outbreaks. So far we have I've not had a positive case in our jail, but I believe it is only a matter of time.

Just before the start of the pandemic, I had accepted the admission offer into the PhD program began making plans to move and in the process of starting a research position at the institution in May. Unfortunately, all of those plans have been put on hold due to COVID nineteen. I am passionate about public health and had been volunteering at my county's public health department, so I heard about the novel coronavirus shortly after the first incident was reported

to the WHO. I began to worry about my parents when I saw that patients who seemed to be impacted most severely and also dying were older people with underlying conditions. My mom is a breast cancer survivor and also has an underlying heart condition, and my dad just recently fell sick from pesticide exposure. I am constantly telling my parents to be careful, wash their hands, etc. But it's difficult when you can't be there and they're struggling both financially

and health wise. Add on their undocumented status and it really amplifies the fear when you're undocumented. Moving through society undetected feels like the key to survival, and a lot of times, seeking professional medical attention feels like a risk too big to take. At the start of the pandemic, I felt hopeful because I trust our leaders in scientific research spaces as well as our medical and health care staff.

But I quickly came to realize how much impact the administrative and political side of things has on science ability to save lives. Aside from my worry stemming from the lack of leadership coming from people in positions of power, I was also just really stressing out about the fact that most people I knew or was connected to via social media had no idea how to get reliable information.

Another big stressor is money, but I think there are a lot of people stressing out about that right now, Like a lot of people, I don't have an income now, but I still have rent and bills to pay. I also regularly help my parents financially, but I can't do that now either. I think the message that I want

to drive home the hardest is number one. There are populations in the country who have been victims of exploitation, who have dedicated their lives to becoming true Americans, who have selflessly given their labor and their bodies to prove that they can be and are productive members of this national community, who will, unfortunately not be granted access to aid during this pandemic, and these are decisions that have been purposely made by the people who have been elected

to lead. Not only is this a humanitarian crisis in our country, but it also costs a lot more money to disenfranchise communities and limit their access to health care than to grant them the tools and services they need to stay healthy. Number two, there are a lot of health care providers and staff who are putting their lives on the line for our communities, and they are also probably experiencing some level of oppression. They really need the

support of their community. They need to feel that their community is behind them, backing them up when they are expressing concerns regarding their safety and working conditions. It is pretty obvious now that the fight against this pandemic will have to be led by the people on the ground who hold no administrative power but care enough about preserving

human life to take on the fight. But those of us who will be stepping up to make homemade masks, organized donation drives, and offer free meals and services must remember to make an intentional effort to consider and include the most marginalized folks in our communities.

on upcoming episodes. We're asking for you to go to this podcast will Kill You dot com and click on COVID nineteen firsthand to fill out the form there and we can get back to you.

that other listeners have recommended. And then I also want to just give a little friendly reminder that even though public libraries are closed, if you have a library card and an appropriate device, you can still check out ebooks. You can still check out audiobooks, you can still check out magazines, and there are also a ton of other amazing resources on libraries online, so you should check out your local library website.

The first is about herd immunity. So in one of our COVID nineteen episodes, we said something like herd immunity as a strategy is a terrible strategy, which in retrospect may have been a bit confusing because we usually talk about the importance of maintaining herd immunity in preventing outbreaks. So why would herd immunity be a bad strategy? Well, first, let's just go over the definition of hurd immunity. Herd immunity is simply that if there's a large proportion of

people who are immune to a particular pathogen. Outbreaks of that pathogen are less likely to happen because the chain of transmission can't be maintained. It's the way that we achieve herd immunity that makes it a good or bad strategy. So you can achieve her immunity by either vaccinating people or through actual infection with a pathogen. Right now, we don't have a vaccine for the virus that causes COVID nineteen, So the only way to achieve herd immunity for that

would be through having everyone get infected. But if we were to do that, an unbelievable number of people would become severely ill or die. Our hospitals would be overburdened even more than they currently are. And so that is why herd immunity for COVID nineteen at this point is a bad strategy. It's sort of just the way you get hurt immunity.

smallpox is between three and a half and six. So when we talk about bringing it down, bringing the are not down, how can we even do that?

has immunity to that pathogen. The number of people infected from that one person in that community would be the are not value that would be the basic are not. The effective are not depends on how many people in that community are immune, or on how much people change their behavior to actually decrease their exposure, So both of

these numbers are context dependent. The basic are not of measles is twelve to eighteen, but the effective are not in a community that has high rates of protection against measles, for example, high rates of vaccination is much much lower because there aren't enough susceptible people in that community to

actually sustain that chain of transmission. So in the absence of an effective vaccine such as we're living right now with COVID nineteen, we can still drive down the ar not by breaking the chain of transmission through changes in our behavior, which brings us to a very important discussion in this interview today.

really good way to prevent that from happening. But what if you don't have clean water or soap, What if you're not able to shelter in place because you're fleeing from a war, or what if you can't practice social or physical distancing because you live in a slum or refugee camp.

We brought him onto the podcast to talk about how this pandemic is likely to impact populations that are already vulnerable or whose health and safety is constantly under threat, and to discuss what we can learn from working in past public health crises with limited resources.

At the moment, I'm talking to you from Beirut in the Middle East, and what I'm working on at the moment is one hundred and ninety percent COVID nineteen.

We work in seventeen countries around the world. We respond to epidemics, so this is not something new for us in the sense that it's we do work on epidemic response, but we also respond to neglect, people that are excluded from access to healthcare, and the impact of conflicts, disasters, et cetera. So with COVID we've been we've been responding since the beginning when it started in China, and the epicenter, as you know, has now shifted to to to Europe

and North America. And what's what's interesting is that for the first time in MSF's history, we are conducting a major medical emergency response in Europe. So the crisis, the emergency has overwhelmed the health system in Europe and there was a need for MSF to to respond to this emergency. So we're now working in Italy, Spain, Belgium, France, a

few other countries in Europe. And this kind of epidemic it requires work on multiple different levels, from community levels right up to hospital care and very sophisticated hospital care. But what we've seen in Europe is that it's the health system as a very individually based model, so focuses very much on the individual and it's very hospital focused. So for example, if you have cancer, you would want to be in Europe to receive treatment if you're facing

a pandemic. It's something that Europe hasn't dealt with for one hundred years. But at the same time, Europe is not going to stay and North America is not going to stay the center of this epidemic for long, and we're extremely worried about about what's going to come next, where we start to see the virus entering into lower resourced countries where the kind of next wave of this pandemic will will hit and then we will face different dilemmas and difficulties more linked to the already week week

and overstretched health system. So, yeah, grappling with all of these issues from our emergency response as it stands today to preparing for when the next wave hits are what we're really focused on at the moment.

lower the number of critically ill. So in this sense, the community component is quite similar to what we see in other epidemics. We can't wait for patients to reach the hospital to tackle the pandemic. We need to work at a community level. It's a critical part of the overall response, and that's very similar to the kind of

work that we do and for example in Ibola. The problem with COVID nineteen is that the measures that people need to take to protect themselves are hard or even impossible in some places, distance from taking distance, social distance, isolating the elderly, the medically vulnerable, hand wash and the disease is also transmitting when people are mildly sick or even not symptomatic at all, which makes the management of tracing contacts or if one person that is sick has

contact with another person, we call it contact tracing and we try to follow the potential spread of the disease.

This is very difficult in COVID in COVID nineteen, So usually in an epidemic situation for doctors without borders, if it was happening in one specific location, we would deploy the full scale of our emergency response and supplies and we would set up large scale response in a specific location that identifies people that are sick, traces who they've been in contact with, educates the community about the virus or the disease, make sure that they refer to the

right place, that they have the right kind of sanitation equipment, et cetera, to be able to wash their hands or whatever the case might be to prevent transmission, and we would do that alongside the Ministry of Health would make sure that we were able to respond in the hospital when patients do become sick, and we would potentially be

able to handle it and bring it under control. In cases where vaccines are available, with then be able to do a large scale vaccination campaign to prevent to prevent further transmission. All of this is needed in the COVID nineteen response, but it's happening everywhere at once around the world, so it's not in a specific, confined location, and we're facing a lot of supply shortages of protective equipment of masks. Testing capacity is limited, so we're struggling to be able

to test everyone that needs to be tested. Logistical challenges are occurring in terms of flights, so we're really we have to get creative and pragmatic to respond, and this is how it's different to some of the other epidemics that we would usually respond to. M Yeah.

So do you think that there are some lessons that these other hospitals in some of these regions that are currently being impacted right now, that they can learn from physicians or logistical coordinators that have worked in these crisis situations previously.

So what a high income country system is not used to necessarily as organizing patient flow from triage to treatment and to discharge while keeping infection infected and non infected areas entirely separate with high volume of patients, and this is something that we're very used to doing with a large quantity of patients and having to manage that infection control at the hospital level, and this is what we've really been helping hospitals with in Italy and Belgium, for example,

in Spain as well, is how to adapt the flow of patients through the hospital and how to think differently about infection control when you're dealing with this volume and scale of an epidemic. And then, as I think, there's a more unfortunate lesson that we're able to share, and that's making tough decisions, ethical decisions about who to treat and who not to treat when you're facing resource limitations.

And this is something that's sadly msf in counters in many parts of the world where we work, and there are limitations to the resources that are available and difficult ethical decisions have to have to be made, and this is something that our health workers are unfortunately exposed to, and it's something that many health workers in parts of the world have not had to face to the extent

that they are today. I think the other thing is we are our role is as an organization is always to be advocates for the most vulnerable, to ensure that the most vulnerable are able to receive treatment based on their needs and not based on their ability to pay. And I think many of these vulnerable groups that are often most at risk are overlooked by the health systems that are responding to these needs today. I think maybe one of the lesson would be I've touched on it earlier,

but on the public health kind of response. So I think there's a lot to learn in high income country about the need to fight an epidemic at the community level before it reaches the hospital. And I've mentioned already that we can't only rely on on high level medical

care to save lives in this pandemic. It's it's it helps, of course, and it's incredibly important, and it's needed them and Doctors without Borders is also involved in providing high level care where it's where it's needed, but it's only part of the picture. And and to win against an epidemic like this, you really need to tackle it in the household, in the in the streets, in the towns and the villages, in the in the neighborhoods and communities.

This is something we're very used to doing, but it's something that's that's advanced. Cell systems that are much more focused on individual patient care in a hospital have often lost the ability.

not something that can easily be put into place. So we're rightly telling people, and we're rightly being told to wash our hands regularly, but you know, how do you wash your hands regularly if you have limited access to water, you don't have much soap, and you live in a

refugee camp in Bangladesh, for example. So refugees are a key, key vulnerable group that we're that we're seeing from the islands in Greece to Bangladesh to to many other places where they're living in high density conditions with very limited access to basic essential essentials like soap and water. We're also told, rightly so to keep social distance, to keep a space between between us, to reduce the chance of transmission.

But how are you going to do that if you live in a slum in Rio or Johannesburg or Nairobi, where again high density populations, many people living in in in one building. I'm talking to you from Beirut today and recently I heard of people living in a in a house, in a in a refugee camp and the outskirts of Beirut where they have to take shifts in sleeping because there's not enough space to sleep because of

the density of people living in in one room. So keeping social distance when you're forced to live in those kinds of conditions is something that's not very feasible. The other measure that we've seen is border clothes. This is something that's being implemented all around the world to limit the movements of people. But when you're a Syrian refugee fleeing the conflict in Idlib, it's not something you can

do to stop crossing stop crossing a border. We also know that people with pre existing health conditions like diabetes or other chronic conditions can be particularly vulnerable to severe illness when they get COVID nineteen. But we also know that many of these people around the world already don't have access to the life saving treatment that they need for these chronic conditions. So we can tell them to take extra care from preventing infection with COVID nineteen, but

they can't access their insulin for their diabetes. So I think the thing that we're concerned about is that the people that are going to most suffer from this pandemic are those that are already neglected, those that are already excluded, that are that are overlooked, And it's going to be those that have fled from war, those that don't have access to treatment because healthcare is privatized, because there's literally

no treatment available where they are. It's those who can't stock up on food and isolate themselves because they're literally living from one day to the next. It's people that have lost social support because of austerity measures that are falling through the cracks in society, and the governments are

either neglecting or in some cases even targeting. Yeah, and it's people that are trapped in conflict, under bombing and in siege, and these are the most vulnerable and the communities where controlling the epidemic is going to be the most difficult.

vulnerable communities in the world. And so we need to ensure that they continue to have access to life saving services. But actually we also need to adapt our activities to be able to prevent the epidemic getting out of control in many of these of these locations. So we're having to increase our hygiene promotion work, make sure people have access to the kind of water and sanitation that they

need to prevent the epidemic. Where we're trying to put in place some isolation capacity in different places before we reach the peak of the of the epidemics that we're able to quickly isolate patients when they've when they've been identified, And we're really trying to also educate people about what

is COVID nineteen how to protect themselves. I think it's one thing to tell people what to do, but it's another thing to explain what this is and how to become an active participant in preventing and protecting yourself and your family. But we know that in many of these places the pandemic is inevitable. It's it's going to peak in slum populations and camps in places that are experiencing conflict, so we really have to prepare for when that happens.

We have to understand more about the about the disease. Keep in mind that this is a new and new, a new disease for all of us, So we're learning as well about the virus. So we have to understand which models of care, how do we organize ourselves in the best possible way considering all of these different different limitations. And this is really just the beginning. Unfortunately, what we're responding to today in parts of Europe and what we're preparing for in other parts of the world is really

the beginning of what's to come. We're already we're gearing up for the I guess the public health fight of our lives. Yeah.

some challenges in their in their own right. And then of course, in many places the number of cases is slowly rising and hospitals or even though they haven't reached the peak of the of the epidemic, are already facing extreme pressure, being being overwhelmed even before the peak of of this outbreak in many places outside of where it's currently at its worst. So absolutely, it's it's definitely already

having having an impact on the vulnerable. And I think the other thing to keep in mind is that many of these communities, the capacity for testing is so limited that our ability to actually know where it is and where it's it's it's growing is hampered as well by by by those factors.

if cases deteriorate. And this is a particular vulnerable and excluded parts of the population in many places. And we're also working with homeless people and and with migrants. So as I said, these are communities that have often suffered the exclusion from from access to healthcare at the best

of times. So in Belgium, in France, also in Switzerland, we're working with people that are living in overgrounted conditions that are on the streets, sometimes in makeshift camps if they're if they're migrants, or in substandards housing that exists in many places. And yeah, these communities are are particularly

at risk. And so this is how we're prioritizing our role as doctors with our boarders, is to focus on those that are going to fall through the cracks, who are going to be excluded and who have up until now also been targeted by the state in Brussels. Just to mention as well, so working with the with the with particularly vulnerable and my vulnerable communities as one aspect, but also there's a role for us as as doctors with our borders to play and expanding hospital capacity. Many hospitals,

as I mentioned, are reaching their their their limits. They're overstretched, they have influx of of cases they cannot manage. So we're we're expanding that that capacity by working for example in the in the emergency room to provide care for moderate cases, to be to allow the emergency room of

certain hospitals to take in the most severe cases. And that's something that's really important, is to be able to ensure that the hospitals can can focus on the most critical and the most severe and to take the strain

off of those those hospitals. We've we've set up a fifty bed facility for example in Brussels that's probably going to going to increase to around a half one hundred and fifty beds and this is really again to to focus on the on vulnerable communities of of migrants and the homeless, and to to be able to provide adapted and appropriate care for them and as well to to then reduce the burden on hospitals one other aspect. So

that's that's a key priority for us. As I mentioned in the beginning, is the is the infection control and aspects, and it's an added value that that we found that we that we have we were able to support hospitals in in finding the best way to to to manage and prevent and control infection within the hospitals, and that's something that's that's been really well received. But yeah, I mean the volume of our responses is growing by the

by the day. We are we're really scaling up to to respond to where the needs of the of the greatest. Just recently, over the last days we've we've we've put more than two hundred beds to support the hospital in Madrid in Spain. And yeah, as I said, these beds are to take the burden of the hospital so that they can focus on the more critical patients. So there's a constant growing demand for our emergency capacity and we're able to scale up, but we're also facing challenges and limitations.

the needs where they are the greatest. Unfortunately, we already saw kind of failure in this international solidarity with Italy, where where EU member states were slow to to to provide additional support to Italy when it was in the

peak of own of its own epidemic. And it's difficult to criticize governments that want to keep supplies for their own population, but I think it's it's important as well now to emphasize the fact that our faiths are intertwined, that the ability to control this this pandemic relies on our ability to control it everywhere, and it's it's not the time, nor is it appropriate for a kind of petty nationalism that would focus our efforts on one's specific

geographic you know, barded area, when this pandemic is global, and what's needed is a form of international solidarity that that transverses those those borders. And that's where it's key to to be able to to coordinate amongst the different actors that have the capacity, that have supplies, to make sure that these supplies are going to where they're needed

the most. If we're really going to have an impact on this, on this pandemic, and if we if we don't have that kind of international solidarity, we risk entering and entering into an endless cycle of of of of this outbreak. And that's that's yeah, that's not something we want to see.

to adapt our activities to scale up. But we also face significant challenges from governments as well in terms of restrictions on movement, in terms of supply restrictions, and these our challenges that we're constantly having to innovate around and

adapt to and negotiate our way through. So we're spending a lot of time at the moment negotiating exemptions to some of the rules that have been put in place in terms of movements of supplies and people because we need to, obviously to respond to this as an international organization.

We have thirty thousand people working for doctors with our boarders around the world, and many of them need to move to different project locations, need to boost our capacity in certain areas, we need to bring some of them home. In other places, we have supplies that need to be distributed into to some of the hot spots that have to follow the epidemic curve and in different in different places, and that requires a level of agility that's that we're

very much used to as MESF. It's something that we've built up over over fifty years. But when we're faced with many of the restrictions that we see that are imposed by by governments, it's limiting our ability to move those supplies and those people around. And that becomes extremely complex for us in terms of our ability to respond because we are having to negotiate constantly with governments for

exemptions to certain to certain rules. And what we're finding is that governments are are often better at implementing the restrictions and less so at putting together the exemptions that are needed for us to be able to do our work. And this is charted territory for not only for US as an organization, but also for every government that's that we're dealing with. So we're all trying to find the best way to to to respond them to be able

to move those supplies and people. But it does come with a significant need for creativity.

out of this pandemic, a greater realization. I think what I what I would also hope is that is that access to quality health care it has to be. It has to stop being based on purchasing power. We need to move away from from healthcare being a commodity, and it needs to be stopped. It needs to stop being

treated as such by by governments. But I also think that that I hope the governments are after this are able to rethink the made vulnerabilities that that they have created in many cases, whether it's through restrictive migration policies that result in people living in overcrowded conditions or without access to health care, whether it's in their approach to poorer communities that are unable to pay again for for

health care. I think these policy made vulnerabilities are again it's been shown to to affect all of our health at the end of the day. So I guess in essence, maybe it's it's it sounds, it sounds almost naive, but I would hope that that we realize that healthcare must be for for all. It's it's not something that can be continued to be restricted as a commodity for some

who can afford it. And I think if we can acknowledge that it's a it's a good starting point for for reflecting on what needs to change further.

is in most European countries. In Europe, most hospitals and the healthcare in general are more set up for individual care, not for dealing with the volume of people that they're seeing now, because this hasn't happened in Europe in recent history. But this is what MSF does best. They work in

under resourced areas with limited supplies all the time. It is literally what they do, and they can use this experience and adaptability to help these other places scale up their infection control efforts and start to fight this pandemic from a community level. And they're doing this while also prioritizing the needs of the most vulnerable populations to protect them from harm as much as possible. Isn't it incredible?

been doing. But this isn't something a lot of people have experienced so far, and so it can be difficult to organize and get sort of the momentum up and running.

There are people who lack the clean water or soap to wash their hands, and who live in extremely crowded conditions in a refugee camp, or who can't shelter in place because they're fleeing war zones, or they simply don't have a shelter to stay in period. To protect these people. Every person needs to do what they can to break the chain of transmission, all of us.

it's their problem. Now we've dealt with it here. We need a border blind global solidarity with open exchange of information and resources if there's any hope at reducing the global impact of this pandemic.

it absolutely should not be tied to your wealth. When access to quality healthcare is tied to your socioeconomic status, like it is in this country, it creates a positive feedback loop where the poorer you are, the less you can afford healthcare, making you sicker, making you need to spend more on healthcare, making you poorer, etc. We have talked about this cycle of poverty and how it relates to disease on this podcast before, most recently in our

episode on schistosimiasis, which if you haven't heard, it's a great episode, check it out, but it bears repeating in the context of this current pandemic, the most vulnerable populations, like the ones mentioned by doctor Whittall, are the ones that are going to bear the brunt of this pandemic, as they have in other epidemics and disease outbreaks, and this will further increase the massive economic and wealth disparities not only among countries but also within them.

And you know, these data are new, but I think that in the weeks and the months and the years to come, we'll get a much clearer picture that not everyone will feel the impact of this pandemic equally.