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Direct Relief News
36 minutes | Jul 26, 2021
Connect Podcast – Episode 2: “Cooking Easy Things The Hard Way” For Good
Graham a.k.a. Tabetai Cooking, a Food & Drink content creator, and Rose Levy, Program Manager for Global Programs at Direct Relief, discuss the joys of creative home cooking and how it can be utilized to raise funds that help community health centers. Cooking livestreams, innovation awards for health centers, and “cooking easy things the hard way” are all discussed at length in today’s episode. TabetaiCooking’s Twitch channel: https://twitch.tv/tabetaicooking Direct Relief Cooking Sessions, August 2-7: https://www.directrelief.org/sessions
15 minutes | Jul 23, 2021
Mental Health Support Goes to First Responders of Surfside Condo Collapse
When a condominium in Surfside, Florida, collapsed last month, killing almost one hundred people, the mental health of survivors and their families was a clear priority. Many experienced unthinkable loss, while others are still missing loved ones who remain unaccounted for. For those responding to the tragedy, the experience has had traumatic impacts, as well. In the days following the collapse, Oxnard Fire Chief Alexander Hamilton was deployed to the scene to provide mental health support to first responders working to find victims. With funding from Direct Relief that the Miami Heat raised, Hamilton and a team of clinicians, first responders, and peer support officials organized group and one-on-one support sessions for search and rescue workers. In this episode of the podcast, we speak with Hamilton about the search and rescue effort and its effect on those involved. Transcript AMARICA RAFANELLI: Can you describe what it was like when you first touched down and arrived on the scene there in Florida? ALEXANDER HAMILTON: We arrived on a Monday. If you recall, they had that section of the building that was still standing, so they had just demolished that section of the building Sunday night. Because of the instability of that part of the building, there were a bunch of bedrooms that they couldn’t search, so as soon as they had collapsed that other section, they immediately were able to search in an area they had previously not had access to. There was actually a ton of activity going on when we first arrived. Crews worked for an hour on and an hour off, so the first crew I interacted with had just come off the pile after recovering a family of four, so some pretty tough situations for the search and rescue teams. RAFANELLI: Can you describe the services that you were providing? Were they group sessions, were these one-on-one counseling sessions? HAMILTON: The situation was really unique for me in my experience because the vast majority of the time, when I’m providing mental health support to first responders, it’s after an incident has terminated. It’s after the fact that we go in there, and we help folks start processing their experiences. In this case, though, they were still very much in the middle of the incident. Certainly, there was a lot of work that could be done to bring closure to the families. It was a bit of an unusual response for us because they really can’t start processing their experiences because they’ve got to go back and keep working. It was as much as anything, ensuring they knew that there was support. There were times where were people that would come off that were feeling overwhelmed and so we would go and have a little one-on-one session, but more often than not, it was groups of five or six and, and sort of relatively brief conversations, some of which you’d get into some of their experience, but a lot of times it was a chance for them to check out. They wanted to know how we load hose on our fire engine to California, for example, versus the way they do it. So we had these small talk conversations. Some of it, too, was understanding some of their needs. Florida is incredibly hot. It’s incredibly humid. So having good quality wool socks was something that they needed. So it was sort of these little compact things that we were able to pick up on and do something about. Neck gators, wound tactical socks. It was day 12 or 13, I think, after the collapse when we got there, so these crews hadn’t been near their families in that time. So one of their requests was better wireless coverage so they can FaceTime with family members and just sort of have that check-in. So there were little things that we were able to provide while also being there to give them support if they needed that support. RAFANELLI: I can only imagine how physically and emotionally demanding this response was, trying to find victims of the collapse. Did any of the responders share their thoughts on that experience or how it affected them? HAMILTON: Yeah, there were little pieces of stories that would come out. Obviously, decomposition is happening quite rapidly in those conditions, so the state of the bodies, if they hadn’t been impacted by the collapse itself, were relatively intact. I think that was one of the hardest things. You could smell it when you were out there. It was really strong. So that was pretty impactful for a lot of them. You know, doing their very best to obviously bring closure to these families and also respecting these victims as they’re recovering. One guy said it best to me, one of the crew members that recovered that family of four said, ‘I prefer to save people,’ you know, not do this. He’s like, I know we need to do this, but I don’t like it. That was sort of the sentiment. They knew it needed to be done but that it was really difficult circumstances. RAFANELLI: So you’ve said that in the initial phases of this response, most of their needs were wanting to speak with their family, some practical needs, like wool socks. Do you anticipate that the recovery for these first responders is going to be more long-term? HAMILTON: Without a doubt. When we first got there was a lot of behavioral health support at the site, particularly during the day: clinicians, chaplains, people with therapy, dogs, and that kind of thing. Not a lot of them had cultural competency in dealing with search and rescue teams or dealing with, with firefighters. So, within a day or two of us being, at the site and on the ground–we were all wearing these yellow lanyards to identify ourselves very clearly–people started gravitating towards those yellow lanyards. We quickly developed that trust to some level. So yeah, I absolutely anticipate that there’s going to be some long-term issues for all of those respondents to work through. That was one of the things that we were starting to work on is a plan for when everyone’s going home and how they were going to manage that behavioral health component. RAFANELLI: So, as a fire chief, you’ve been involved in addressing the mental health needs of first responders for a while now. What got you into the work, and why did you identify mental health as a need among your colleagues? That question comes up a lot. With my colleagues, everyone has a different story, whether it was an issue that they face personally or some adversity that people were able to work through. Ultimately for me, it was a call–that’ll actually be 10 years ago this Thanksgiving–that I went on, and it was a little boy that had catastrophic injuries after being hit by a car, similar age to my own child at the time. It was really difficult seeing and we were there for a long time. Ultimately my response initially to that was, was pretty myopic. I just sort of took care of myself. I was an engineer, so I was a driver on the engine, but about eight months after that, the firefighter that was with me on that call, he came to me, and he says, ‘I’m just not coping with life.’ That was kind of my moment. I dealt with my issues, and I’d gotten some help. I could still tell you everything about that call to this day. But at the same time, when he came to me and said, he’s not coping with life, we didn’t have anything in place. We had a big distrust of our employee assistance program, which is common, unfortunately. All we had was to call the number on the back of the health care card for mental health support. And if you’ve ever tried to do that, it’s not a good way to get mental health support because the insurance company will give you a list of like 12,000 providers in your area, the vast majority of whom are not taking new clients and then there’s people that just don’t call you back. It’s a really clunky way to get behavioral health support. So, that was the point where I realized that we needed to do things a lot differently and a lot better. That sort of took me down this road into peer support. And then, obviously, suicide was just starting to become an issue in the fire service. Unfortunately, it’s grown exponentially since we got involved. So, we started doing suicide intervention classes, suicide awareness classes. Now, we’re just starting on teaching a resiliency class to try and sort of build those coping skills early so that hopefully we don’t end up in a bad place. RAFANELLI: In your opinion, has climate change and the increasing frequency and severity of natural disasters, like wildfires, increased the need for mental health support among first responders? HAMILTON: Yeah, climate change is one part of it, but our profession has changed pretty dramatically as well in the last 10 or 15 years. We’re doing a better job with behavioral health services, but the job has become infinitely more demanding. Our members are exposed to a lot more violent incidents. They are exposed to longer hours and these more grueling campaign fires that go on for weeks at a time. So it is absolutely having an impact. Through COVID–last season was a particularly bad fire season–I think agencies all across California and likely across the rest of the country were short-staffed because we either had to pair back on training new firefighters or for a host of different reasons. So, there have been people working incredibly long hours. Last September, when the fires were at their worst, some of my firefighters did 25 days at the fire station in a month, and that’s a 24-hour shift. Because of COVID, they couldn’t have their families coming to visit stations. We had to be really careful about that, keeping our workforce healthy. So, really demanding and our firefighters, they will do it. They’ll occasionally complain, but for the most part, they understand this is the job, and this is the mission. But also, it needs to be acknowledged that it’s an incredibly heavy burden that they have to take on and that we need to be able to try and support them. This transcript has been edited for clarity and length.
27 minutes | Jul 12, 2021
Connect Podcast – Episode 1: How Far Will Gamers Go to Support Charity? Jitsu May Have Found the Limit
Introducing Direct Relief Connect, a new podcast by Direct Relief. The show brings together highly skilled philanthropists and members of Direct Relief’s staff to provide an in-depth look at the organization’s work, as well as give a glimpse into guests’ personal journeys and how they came to support causes they are passionate about. For the first episode, Jitsu, a gaming content creator who focuses on Monster Hunter and horror games, and Annie Vu, Direct Relief’s Manager of Program Operations speak with Amarica Rafanelli about live streaming antics, digital fundraising, unusual donation incentives (such as getting a tattoo for charity), and Annie’s donation-funded work, which includes responding to emergencies and managing requests for medical aid.
11 minutes | Apr 29, 2021
In Homeless Communities, Gaining Trust is Key for Vaccination Efforts
While those experiencing homelessness are some of the most vulnerable to Covid-19, the population faces substantial barriers to accessing vaccines. Many lack transportation to get to and from a vaccination site. Others live nomadically, making it difficult to commit to a second vaccine appointment. But according to homelessness activist Tasia Thompson, misinformation is the primary issue: “Our main barrier is the fact that we have lots of social media, lots of internet sites, giving information, which may not be correct.” Thompson works for Groundswell, a UK-based grassroots organization that connects those experiencing homelessness with health care services. Like many of their employees, she was homeless for years before getting involved. “That’s the hardest thing is trying to get across to people that yes, we may be coming from the health side and worked with the doctors, but we understand their fears and we’ve all been there,” said Thompson. On this episode of the podcast, we speak with Thompson and others about their own experiences with homelessness and the obstacles preventing those who are homeless from accessing the Covid-19 vaccine. Direct Relief has supported Groundswell with a $125,000 grant to support their vaccination efforts in homeless communities across the UK. The group helps individuals register to receive the vaccine, accompanies them to their appointments, and delivers information. In addition, the organization is training an outreach team to administer the Covid-19 vaccine to individuals living in homeless shelters and encampments. All staff members involved in Groundswell outreach efforts have had previous experience with homelessness. Tasia Thompson, left, is a project worker at Groundswell where she is helping individuals who are homeless get vaccinated against Covid-19. (Photo courtesy of Groundswell) Transcript: People who are homeless urgently need the Covid-19 vaccine, but getting it to them is hard. THOMPSON: So at the moment, we are doing loads of COVID vaccinations outreach, which has been a very prime thing right now where the government wants to make sure that everyone is getting at least their first vaccination. Tasia Thompson is a project worker at Groundswell—a UK based organization that connects those experiencing homelessness with health care services. THOMPSON: So we’re going to lots of hostels, temporary accommodation, also going to people on the streets to ask them if they want to be vaccinated. So we’re very, very busy at the moment. Lots going on. Thompson got involved with the organization after years of homelessness. THOMPSON: About five, six years ago, I had myself a nice mental breakdown due to stresses of work, stresses of life. Never, ever thought that I would ever be in that situation. I was one of them people who was always like that will never be me, that won’t happen. I have enough support. It can’t happen. You could have the greatest support and still have a moment where things don’t connect correctly for you. So, I became homeless. RAFANELLI: What would you say is the biggest barrier to vaccination? THOMPSON: The biggest barrier is, I believe, is the fear from social media. We have lots of different sites that are telling people all different news. I’m sorry, you want me to stop? Cause that lovely police car. You can tell we’re in London. OK, I’ll start again. Essentially, misinformation. Thompson says its rampant. THOMPSON: So our main barrier is the fact that we have lots of social media, lots of internet sites, giving information, which may not be correct. So people have read all different horror stories. People have been told that they’re going to have a chip put in them or that they’re doing this because it’s a big scheme to do something. And that’s the hardest thing is trying to get across to people that yes, we may be coming from the health side and worked with the doctors, but we understand their fears and we’ve all been there and we’ve done our research and here is what we’ve got to show you to be able to say don’t panic so much. Cause that’s the hardest thing. Social media has caused a massive stir with this jab. Dena Pursell is also no fan of vaccines, but even she has made an exception for Covid-19. PURSELL: I mean, I’m an anti-vaccinator. And I had the vaccine. Pursell is a homeless healthcare navigator at Groundswell. Like Thompson, she was homeless for years before getting involved at the organization. PURSELL: I thought how can I go and encourage people if I haven’t had it myself? Because I was very anxious. It’s a new vaccine. We don’t know much about it. But then I talked to a local doctor who we call GP service over here and listening to him it actually made me want to have the vaccination, because he explained to me what the vaccination does. He explained to me what the virus does, you know, and the implications if you don’t have it are quite severe. So that encouraged me and now I’ve took it. It’s making me much more confident in trying to encourage others. In addition to misinformation, she says general fear and anxiety are an obstacle to vaccine uptake. PURSELL: I mean, a lot of them have got good intentions. They do want to have the vaccine, but a lot of them are unable to get to that point. Being homeless in itself is such a big obstacle. Not only have they got homeless and to be quite honest, a lot of people who are homeless, their health is their last concern. Their health doesn’t come first to be quite honest. And it’s their health that suffers a lot when they are homeless, mental health, physical health. So a lot of people who’ve got fear and anxiety, so they’ve got addictions, a lot of people self-medicate, you know, I don’t want to think about that, you know, and. Obviously now, you know, people have to think a bit, they’ve not only got themselves to think about, and we’re trying to encourage people, you know, we’ll all be all the people, your friends and your peers and your families, and, you know, you need to keep everybody safe, you know, not just yourself. Throughout the pandemic this line of reasoning has been used to encourage adherence with public health measures. Wear a mask to protect not only yourself, but those around you. Get vaccinated to slow the spread in your community. Public health officials have called upon individuals to put the interests of society before their own. But for those experiencing homelessness–many of whom feel alienated by society–this may not be the most effective approach. TASIA: I feel a lot with people that are homeless, they feel a little bit like no one probably really cared before so why would you now need me to come along and do something? It feels like there’s a bit of a hidden agenda behind it. Especially for some people they don’t have a doctor because they don’t want to be attached to the system. And so it feels a little bit like, to some people, that they’re being made to be part of this system and that there’s very much a big scam behind all of it, so they feel like they’re being asked by the system, which they feel hasn’t given them anything or hasn’t helped them.They’re being asked by the system to re return some favor. That’s never been. You know, given to them? THOMPSON: Yeah, It’s like, ‘Oh, here you go. We haven’t done anything for you, but now we’re going to just give you this vaccine and we want all your details please.’ And it’s like, ‘You didn’t help me last week when I needed to go and see someone because I had an abcess on my arm or my mental health, you left me then.’ But because now this is global, we have to look as if we’re doing the correct thing. And it is, people do feel very much like that. They’re just like, ‘No, not having it. I’m not, I’m not going to do that.’ To better understand the roots of this skepticism, I spoke with homelessness expert Dr. Elizabeth Bowen BOWEN: I am Elizabeth Bowen and I’m an associate professor at the University of Buffalo School of Social Work. She says many individuals’ past experiences give them reason to distrust authority. BOWEN: So it’s really a given that trauma goes along with homelessness, many people that are homeless have experienced various types of trauma prior to becoming homeless, as well as trauma while being homeless. And that can be in the form of violence that occurs to people physically mentally, emotionally and psychologically, sexually while being homeless and while living on the street or in other unstable housing situations. And sometimes that trauma is from other people. Sometimes that trauma may come specifically from authority figures, from police and from other people that are in various positions of authority. So, because this is such a new issue of vaccinations and COVID vaccinations it is not that well researched at this point, but I would think that these issues of trauma and specifically with people in authority are going to come up often as a barrier, that people that are homeless may not trust people who are saying they get a vaccine and they have good reasons not to trust people in authority. That was the case for Pursell. She became homeless when she was 16 and from there was either living on the streets or in prison. She began using drugs to cope. PURSELL: I felt alienated by everybody, but then that was partly, probably be my fault, you know? They did try and support me, but it’s very difficult to explain when you’re homeless, you’ve lost all hope, you’re at the end of the road, you probably self-medicate because you don’t want to think about all the crap that’s going on, all the rubbish that’s going on around you. The only thing you’re thinking about is to get away from that horrible place, that horrible space. So if you’re self-medicating, you know, you don’t want anyone to come and try and help you, you really don’t. So that was probably one of my downfalls not accepting all the support that I probably could have had, and lack of trust as well. It’s hard to trust people, especially when you’re homeless and maybe you’ve been let down by one person in your life or in services, it’s very hard to build that trusting relationship again. It’s really difficult. Now, Pursell has been drug-free for 19 years. She’s been volunteering at homeless charities for over 20. This transcript has been edited for clarity.
13 minutes | Apr 12, 2021
Chronic Disease and Mental Health are Linked. But How?
Chronic disease and poor mental health are both prevalent conditions that share a complicated relationship. While the two have been shown to be highly correlated, scientists are still exploring exactly how. The link is believed to be bi-directional, meaning both contribute to one another. Research by the CDC shows nearly one-third of patients diagnosed with diabetes also experience depression, while those with depression are at higher risk of developing a chronic condition, according to the National Institute of Mental Health. The relationship is often attributed to behavioral factors, such as diet and exercise. But scientists say physiological changes due to depression and chronic disease could also play a role. "For a long time... it was thought that whatever happens in the body stays in the body," said Dr. Alan Kim Johnson, a professor of health psychology at the University of Iowa. But now, researchers have shown "profound communication between the brain and the body," said Johnson. As theories on what causes these comorbid conditions develop, so has treatment. "In our culture, we really split people apart," said Dr. Tim Derstine, a consulting psychiatrist at Centre Volunteers in Medicine. Dersteine is involved in the clinic's effort to integrate mental health services and chronic disease care. "We try to look at it from 360-degrees," said Derstine. On this episode of the podcast, we explore the relationship between mental health and chronic disease and speak with providers who are integrating therapies to more effectively treat their patients.
12 minutes | Feb 23, 2021
Treating an Opioid Use Disorder Is Difficult. A Pandemic Doesn’t Help.
Getting treatment for an opioid use disorder can be complicated, often requiring daily visits to receive addiction medication under the supervision of a provider. While guidelines have been relaxed to reduce barriers for those seeking care, it’s not clear how effective the changes have been. “Their barriers are huge here,” said Kim Brown, the founder of Quad Cities Harm Reduction (QCHR), “and they’ve been exacerbated by the pandemic.” QCHR distributes supplies, including naloxone, the medication used to reverse opioid overdoses, to drug users across Illinois and Iowa. On this episode of the podcast we speak with Brown about how the pandemic is affecting access to opioid treatment as providers navigate a new regulatory landscape. Since January 2020, Direct Relief – through a donation by Pfizer – shipped 863,680 doses of naloxone to harm reduction groups, clinics and health centers across the United States, including Quad Cities Harm Reduction, which received 650 doses of naloxone, as well as personal protective equipment for their volunteer staff. https://feeds.soundcloud.com/stream/990765676-directrelief-treating-an-opioid-use-disorder-is-difficult-a-pandemic-doesnt-help.mp3 Listen and subscribe to Direct Relief’s podcast from your mobile device: Apple Podcasts | Google Podcasts | Spotify Transcript: Getting treatment for an opioid use disorder can be difficult. During a pandemic it’s even harder. People are navigating a changing landscape with shuttered programs and ambiguous new treatment guidelines. And they’re doing it even as overdoses are on the rise. BRENDAN SALONER: I think what’s really changed is that with the pandemic many programs, frankly, just shut their doors. Brendan Saloner is a professor of health policy and management at Johns Hopkins University. He studies access to treatment for those with opioid use disorders. SALONER: I think, you know, there was a moment of panic back in March when places realized this was spreading very fast and nobody really knew how to contain it. So, in that immediate aftermath of the emergency, there was this move to completely shut off these points of connection with care. And for many patients that was very devastating. People lost one of their main sources of continuity, not only with medication and with treatment, but also with the community of people that was there for them and part of their support network. For many opioid treatment involves taking one of two drugs: methadone or buprenorphine. These are both opioids that act by binding to the same receptors in the brain as heroin or oxycodone, but they don’t have a euphoric effect. They help by reducing cravings and preventing withdrawal symptoms. During the pandemic, the federal government has lifted certain regulations around the prescription of these drugs. The intention is to reduce barriers as social distancing and shutdowns make getting to a doctor’s office more difficult, but it’s not clear how effective these measures have been. RAFANELLI: What regulatory changes have been made around prescribing addiction medication? SALONER: So it’s still the case that patients can only get methadone through opioid treatment programs. What happened under the regulatory changes is that patients can now get more days of what’s known as take-home methadone, meaning methadone that they’re allowed to take out of the clinic and give to themselves at home, so that was a big deal. And that was done very deliberately to try to reduce crowding in the clinical setting. For buprenorphine, right now it’s still is the case that not every doctor or clinician can prescribe buprenorphine. It’s also regulated under a separate set of federal regulations called the X waiver. So to get buprenorphine a doctor has to have this additional credential or license from the federal government. So the X waiver still exists, even though there was some attempt recently to get rid of it. But what has changed is that doctors that prescribed buprenorphine right now are not needing to meet the same kinds of face-to-face requirements around initiating patients and then continuing patients in their treatment. So there again the intention has been to try to limit the number of times the patients actually have to come into their doctor’s office to get their medication. But the new laws are somewhat ambiguous leaving it up to providers to interpret. SALONER: The real tricky thing is that, although there has been some greater allowances of this take-home methadone–you know, allowing patients to not have to take the medicine every day in the clinic under observation–not a lot of guidance is out there about who should be eligible for take-home methadone. The federal regulation is pretty ambiguous about what a “stable” patient is who would be eligible to get up to 28 days of take-home methadone. And that ambiguity has, I think, given rise to very, different kinds of treatment protocols in different clinics. Some clinics are having those patients coming in very often to get their dispensed medication. That’s been the experience of Kim Brown who runs Quad Cities Harm Reduction in Iowa and Illinois. The group distributes supplies to people who use drugs, including Naloxone or Narcan–the medication used to reverse opioid overdoses. KIM BROWN: I founded QC Harm Reduction officially in 2015, but we were out on the streets slinging Narcan from 2012 onward. I’d get my hands on Narcan one way or another and it went to the drug users in our community. She says during the pandemic, many of those enrolled in opioid treatment programs haven’t benefited from the new rules. RAFANELLI: Can you talk about the regulatory changes and how they’re affecting the drug users that you know? BROWN: Folks with an opioid use disorder, who are a protected class under the ADA, were supposed to get take-homes for a month, at the least take homes for two weeks, to keep them safe. They didn’t follow those mandates. If somebody had drugs in their urine, they refused to give them take homes and demanded that they get on the city bus or try to find a ride to get to the clinic every day between 6:00 AM and 12:30 to get their dose during a pandemic. Those are the barriers that have been placed in front of our participants. According to the law providers are allowed to administer urine tests to patients undergoing opioid treatment. When and how frequently is up to their discretion. And because guidelines around what is considered stable and unstable are vague, some providers may use a urine test to decide. As Brown has found, those deemed unstable may not be eligible for multiple weeks’ worth of take-home medication, meaning they need to go to a clinic every day to take their prescription. While the pandemic has made accessing daily treatment more difficult, providers are experiencing challenges of their own. RAFANELLI: Tell me a little bit about how the pandemic is affecting your operations at QC Harm Reduction and the people that you reach. BROWN: In January and February we were really getting up and running over in Rock Island, getting all our services set up and we were paying attention to the pandemic, but I don’t think anybody realized the significance of it, right, until it got significant. So, I think part of the struggles for our drug users is many of them are unhoused. The shelters decided to house all of our unhoused folks–well, as many as they could–in the motels on the outskirts of town. They could be in Davenport, they could have been over here out by the airport, they could be in Bettendorf, but they housed them in motels to help people stay physically distanced from other folks and to try to keep folks safe. Once that happened, it was kind of like everybody scattered. Does that make sense? Once they were in the motels, then they had rules to follow. It was almost like everybody quit moving around in the Quad Cities. And when we went out on outreach to find the folks that were moving around, they were very seldom where they always were before the pandemic started. They were indoors door shut away, following rules and not out engaging with us on a weekly basis. Across the nation, drug overdoses have increased substantially during the pandemic, according to data released by the CDC. Drug related deaths were up 20% in the 12 months leading into spring 2020. While the numbers show death rates rising before the pandemic, the biggest spike occurred between March and May of last year. The CDC attributes these increases primarily to the polluted drug supply. RAFANELLI: I know there’s been disruptions in the drug supply chain. How have these disruptions affected drug users in your community? BROWN: In this area, they’re encountering a lot of adulterated methamphetamines, a little bit of heroin. We don’t have that much heroin here in our area right now. It’s almost all fentanyl. And they were reduced to buying the methamphetamines, a little bit of heroin here and there, but by and large, most of the drug supply that came in through here was adulterated with fentanyl. And if people weren’t testing their dope, they were overdosing and dying because they weren’t familiar with the amount of fentanyl that was present in that particular batch of dope. I know in Illinois overdose death rates went up approximately 19%–those numbers could have changed. And I believe Iowa’s went up to like 35 or 36%. And it was because people were using, they were self-isolating, right? So they were using alone. You never use alone, but they were using alone because they were isolated in motel rooms. They were isolated in housing apartments. They weren’t with people. They were using extremely adulterated dope, not testing it if they didn’t have the strips. But if you’re alone and you’re isolated and you can’t get somewhere, you’re going to do what you do. And what they were doing is using alone with no one there to look after them in the event of an overdose isolation. RAFANELLI: So you think isolation is the main driver behind the national increase in overdoses? BROWN: I think it had a lot to do with it. Don’t you? This transcript has been edited for clarity.
14 minutes | Jan 19, 2021
Growing Up in a Pandemic: How Covid is Affecting Children’s Development
While Covid-19 is typically benign in children, the pandemic could have long-lasting impacts on society’s youngest members. With childcare programs closed and social distancing measures in place, many children are missing out on opportunities for development. “Children are not getting the cognitive and social stimulation that they would normally get outside their home,” said Dr. Michelle Aguilar, the head of pediatrics at Venice Family Clinic in Los Angeles, California. Providers have noted delays in speech and language as well as trouble sharing and being in groups. But for children, a delay in social skills may not be the only consequence of the pandemic. With many parents undergoing financial stress, children face higher rates of housing and food insecurity. And others are subject to rising rates of neglect and household dysfunction – all of which can affect a child’s trajectory into adulthood. “Numerous studies have shown that early life experience and adverse life events have had a negative impact on the health and development of children,” said Aguilar. In this episode of the podcast, we explore the full scope of consequences for children growing up in the Covid-19 pandemic, from the short term effects to long-term implications. We speak with experts in the field and health providers, including Venice Family Clinic’s Dr. Michelle Aguilar and early head start director, Stacey Scarborough. Since 2008, Direct Relief has supported Venice Family Clinic with financial assistance and medical aid, including prescription medications for chronic disease care, disaster response supplies, and most recently, PPE, such as N-95 masks, protective gowns, and face shields. https://feeds.soundcloud.com/stream/964557079-directrelief-growing-up-in-the-midst-of-a-pandemic.mp3 Listen and subscribe to Direct Relief’s podcast from your mobile device: Apple Podcasts | Google Podcasts | Spotify Transcript: COVID-19 is typically benign in children, usually presenting as a mild flu or nothing at all. But for society’s youngest members, the effects of the pandemic go beyond the disease itself. From the moment a child is born socializing plays an important role in their development, from learning to share to honing their language skills. But with social distancing measures in place, many kids are missing out on opportunities to play. So how is that affecting their development? I spoke with Stacey Scarborough, the head of Venice Family Clinic’s early head start program in Los Angeles, California. RAFANELLI: “Tell me a little bit about the clinic’s head start program.” SCARBOROUGH: “Sure. So we are an early head start program, so we provide services to families with young children, birth to age three and pregnant women. And we do home visits with families and we offer them play groups. And we have a center-based program where children come to the center each day for their educational component and nutritional component.” Teachers lead children through group lesson plan designed to promote basic developmental growth from speech to fine motor skills. A typical day might include counting cheerios, scribbling with crayons and crawling through obstacle courses. While Scarborough says most children are hitting their developmental milestones, they have exhibited abnormal behavior. SCARBOROUGH: “We do see such a heightened awareness of everything. Like they’re constantly telling on their peers: ‘They touched this and didn’t wash their hands,’ ‘My mom didn’t brush my teeth.’ So they are telling everything because they have such a heightened awareness and they’re really into wrong and right at this age. So our providers have been very cautious, like, ‘What’s happening with this generation?’ They’re constantly telling on each other. So there’s a lot of mental health to help kids relax and play and not be so concerned about everything, which they are.” RAFANELLI: “Do you think the lack of social interaction has affected kids in any way?” SCARBOROUGH: “Yeah. I don’t know if I can come up with a very specific story, but they’re very aware that they need to stand apart, they’re very aware that they shouldn’t touch another item that somebody has. And that’s hard for sharing. This is an age where you learn how to share and we’re kind of encouraging no sharing. And that’s a big skill that you need as an adult to bring into the workplace. This is the age where you work on developing those skills and we’re kind of saying, ‘You can’t do that.’ So, this is the window of opportunity. You know, they’ll learn it later, but it’s a harder thing to learn when you’ve learned not to share under trauma and then we’re going to say later in life, “You have to share. You’re not a good human being if you don’t know how to share.’ So those soft skills are tough right now to be learning when they’re supposed to be learning them.” But interpersonal skills like sharing or learning how to work in a group are not the only areas of concern. Stacey and other providers at the clinic have noted delays in speech and language AGUILAR: “They’re lacking from those social interactions that they would have normally gotten from people outside their homes. They’re lacking that play time with other children.” Dr. Michelle Aguilar is the head of pediatrics at Venice Family Clinic. She sees patients from birth up to 18 years of age. She says during the pandemic, many kids are receiving less attention. AGUILAR: “Many of our caregivers are now under a lot of stress and having to divide their attention to other children who are older and would have normally been at school. So the parent used to have time and attention to give to the younger child.” For many parents, money has become a major source of stress. With millions of Americans out of work, the pandemic’s financial fallout has been significant. And for those struggling to pay rent or put food on the table, providing for their children’s basic needs can be difficult. During the pandemic, housing and food insecurity have skyrocketed, at the same time as rates of domestic abuse and neglect have increased. These kinds of stressful events, referred to as adverse childhood experiences, can have long-term consequences. AGUILAR: “So studies have demonstrated that adverse childhood experiences have detrimental effects on brain development and overall health. So we see long-term effects: learning disabilities, depression, obesity, heart conditions. So, it does have a huge impact.” RAFANELLI: “Have you had any patients that have experienced what you would consider an adverse childhood experience because of the pandemic?” AGUILAR: “I would say yes. Families have had to separate when a caregiver or a family member becomes ill. They’ve had to separate for some time to stay with other family members, so they do not get exposed. Housing insecurity: having to move into multi-generational homes that are now crowded. So, yes there have been ongoing adverse childhood experience due to the pandemic leading to toxic stress.” The pandemic’s effects on children are not only catching the attention of parents and pediatricians. A handful of researchers are looking closely at the issue, including Dr. Rashmita Mistry. MISTRY: “My name is Rashmita Mistry. I am a professor in the department of education at the University of California at Los Angeles.” Dr. Mistry is interested in how major historical events affect the children who live through them. She’s the author of a recent study on how the pandemic is likely to affect children’s health and wellbeing. RAFANELLI: “So what are the long-term implications of experiencing a pandemic at a young age?” MISTRY: “So let’s take the example of children’s cognitive development and academic achievement. So there’s really strong, compelling evidence that, especially for children from lower income households and backgrounds, that access to high quality early childcare programming really helps lessen some of the achievement gaps that have been documented for children from wealthier families and households as compared to lower income households. So if the pandemic hits, and a parent loses their job and their child care provider is shut down because of concerns around the spread of the virus or their provider shut down because they can no longer afford to stay open or because the parent can’t afford to send their child to that program because they can’t afford it, then the child has lost access to critical resources that are likely to help support not only their cognitive development, but also their mastery of basic foundational academic skills, as well as key social emotional learning that we know happens in early childcare programs and spaces. And that’s not to say that parents can’t and don’t do a lot of that support at home, but for lower income children, we know access to high quality early childcare programs are also really, really important and instrumental.” These kinds of disruptions, don’t just cause temporary setbacks. Dr. Mistry says they can have consequences that continue throughout the long-term. MISTRY: “So we’re now moving beyond the pandemic, the child is a four or five-year-old enrolled in school and they’re going to maybe start a little bit further behind in terms of that key foundational academic knowledge or those kind of social, emotional skills. So they’re going to have more catch up to do. But the child, let’s say for example, is attending a neighborhood school in a lower-income community that maybe doesn’t have the same level of resources or the same level of teacher qualifications or is just under-resourced in ways that better funded public schools might not be. So that child’s educational experience is further compromised in that circumstance. Had that child been able to attend a higher quality school maybe that catch-up would have happened and would have been sufficient, but if that child then continues to attend an under-resourced school that is struggling in its own ways due to a lack of public funding and support, then that child’s cognitive and academic and social, emotional development is going to continue to be compromised in ways that are important. And we know that the third grade is this critical transition point. It’s not super fatalistic. But we know that if you haven’t really mastered those foundational skills by then, then those disparities just continue to widen, so kids continue to fall back or move forward based on these early educational opportunities and skills. So it’s really this like cascading effect. And again, if there aren’t points in the system to catch it and correct it, then what’s likely to happen is that there’s just going to be this accumulation of shocks and disruptions and disadvantages that are going to continue to play out.” RAFANELLI: “So it seems like you’re saying that economic resources–child’s socioeconomic status–plays a major role in their healthy development. But can you talk more about how the pandemic, specifically, plays into this?” MISTRY: “The pandemic in some ways is making a lot of this a lot more visible. It’s been there for a while, at least speaking within a U.S. context. Issues around childhood poverty have existed. We have almost one in four children pre-pandemic that were living in families that were officially designated as poor. And so poverty is not new in the pandemic. It’s been elevated. There are more families that are struggling and more children that are being placed at greater risk for experiencing poverty and then experiencing all of the net negative repercussions of that. And again, like I said, we already know that young children are particularly vulnerable to the long-term adverse consequences of experiencing poverty compared to older children, so it’s not that any of this is new to us. In fact, it raises the alarm for being even more concerned about how the pandemic is likely to affect children’s short-term and long-term developmental outcomes, especially for kids who were already vulnerable prior to the pandemic.” This transcript has been edited for clarity and length.
6 minutes | Dec 2, 2020
Sometimes, Getting to the Doctor is the Hardest Part
Chronic conditions require routine care and strict medication regimens, but for millions, transportation stands in the way of accessing timely health care. From rural communities to urban cities, patients struggle to make routine appointments. Some can’t afford a vehicle, others live hours, if not days, from the nearest point of care. The distance–and lack of transportation–leads to delays in medical care, which for some, can be deadly. On this episode of the podcast, we explore how transportation poses a barrier to care for patients around the world, from rural Nepal to the United States, and what the consequences are for those in need of chronic care. Direct Relief provides many local health organizations, including Casa de la Amistad in Mexico and Mountain Heart Nepal, with funding to purchase vehicles and provide transportation services to patients and health care providers. The organization has also provided funding for mobile health units that can be deployed to communities without regular access to health care or after a disaster, including rural communities in the United States. https://feeds.soundcloud.com/stream/936119242-directrelief-sometimes-getting-to-the-doctor-is-the-hardest-part.mp3 Listen and subscribe to Direct Relief’s podcast from your mobile device: Apple Podcasts | Google Podcasts | Spotify Transcript: Chronic conditions like diabetes, heart disease and cancer require routine care and strict medication regimens. But sometimes, getting to the doctor is the hardest part. Five months ago, Rosa Hernandez moved to Mexico City with her son, Andry, who has been undergoing chemotherapy since being diagnosed with leukemia last year. “La verdad ahora sí, necesitamos estar cerca del hospital,” she said. Before the move, Rosa’s in-laws helped drive Andry to and from his appointments, but the constant travel became expensive and time consuming. Now, they’re living at Casa de la Amistad. “My name is Leonardo Arana and I’m the general director of Casa de la Amistad Niños for cancer in Mexico.” Casa de la Amistad is a full-fledged support center for pediatric cancer patients and their families. “They will come to Casa de la Amistad here in Mexico city and we will take care of everything. We will take her of the medicines, housing, and transportation, which is very important,” explained Arana. According to a study by the American Association for Cancer Research, 38% of cancer patients in Mexico report transportation as a barrier to timely care. Most cancer treatment centers are located hours if not days from rural communities. For those undergoing consistent treatment—like chemotherapy–the distance is a problem. “Cancer needs to be treated in years, over years. That that’s the way it has to be. So if you bring somebody once and then you don’t give them the possibility to go back they will die.” Across the globe, in Nepal, a rural population experiences similar challenges. “In Nepal, healthcare facilities are mostly concentrated in urban areas,” explained Dr. Aban Goutam, the founder of a non-profit health care organization, Mountain Heart Nepal, that The group transports doctors and nurses into rural communities to provide healthcare services. “Mostly the rural villages are located on hilly or mountainous reasons,” he said, “and they consist of smaller health care clinics or community hospitals with limited treatment options.” On average, it takes Nepal’s rural population more than 2 hours to get to a clinic for basic care. And 92% don’t have a vehicle they can use to traverse the distance. Most walk, bicycle or rely on the public bus. “In many villages, when the mode of transportation is by foot, this often results in delay of treatment.” While delays can be fatal for those with emergent medical needs, chronic conditions are just as deadly when neglected. In Nepal, getting diagnosed with diabetes or heart disease before it becomes an emergency is rare. Without consistent treatment at the onset, chronic conditions escalate. For example, unmanaged diabetes can lead to poor circulation and nerve damage, putting patients at risk for developing ulcers and wounds in their limbs. “These patients with diabetes, the wounds, they do not heal and it takes a long time to heal. So for those people in rural areas, they are mostly farmers, so they have to work and they’re not, they do not consider it as important. If patients delay care, these wounds can become severe enough to require amputation. Goutam says it’s not uncommon for those with diabetes to lose legs and feet. And, survival rates after amputation are low. “There are some studies which have highlighted that people with diabetes and have their feet amputated did not live more than five years. So that is more deadly than, uh, cancer.” In the United States, transportation also poses a barrier to care. In 2017, nearly 6 million people delayed medical visits because they didn’t have a way to get to their doctor. And according to a study published in JAMA Network—a peer reviewed medical journal–a lack of transportation is associated with a higher number of emergency department visits among Americans. But in some places, primary care is right around the corner – thanks to the community health center. “We have clinics in neighborhoods, hence the name and so many, many of our patients walk to our clinics.” Dr. Charles Fenzi is the CEO and Chief Medical Officer of the Santa Barbara Neighborhood Clinics – a network of federally qualified health centers in Santa Barbara County, California. “We’re in the neighborhood and we provide transportation. In fact, that’s written into our contract with the, with the Feds.” Under the Public Health Service Act, federally qualified health centers are legally obligated to provide enabling services. These are services that break down barriers to help patients access care. Transportation is one of them. If a patient needs to use a driving service to get to their appointment, the health center pays the fee. For the most part, Fenzi says transportation isn’t a major problem for patients because they ensure it’s not. That’s the model of community health centers, he says. This transcript has been edited for clarity and length.
8 minutes | Nov 9, 2020
Mental Health Providers See “Unprecedented” Surge During Pandemic
As the third wave of the Covid-19 pandemic fills hospitals to capacity, mental health providers are seeing a surge of their own. “People are under so much stress,” said Ryoko Chernomaz, a licensed clinical social worker at the San Francisco Free Clinic. Issues at home – from increasing childcare responsibilities to domestic abuse – are compounding financial anxieties triggered during the early stages of the pandemic, driving an uptick in mental health needs. Sine the pandemic began, Chernomaz has seen a 30% increase in appointments. At CommunityHealth – a free clinic based in Chicago – licensed clinical social worker Ornella Razetto has observed a similar trend. “It began with anxiety, depressive symptoms and financial insecurity,” said Razetto, but now, “reality has sunk in.” As the pandemic drags on, many of her patients’ initial anxieties are manifesting into chronic depression. Razetto has seen a 75% increase in referrals since March. On this episode of the podcast, we speak with both Chernomaz and Razetto about how the pandemic is affecting their patients’ mental health and what they expect the long-term consequences to be. Direct Relief regularly supports safety-net clinics, like CommunityHealth, with mental health medications and funding to expand mental wellness programs. Since January, Direct Relief has sent nearly 600 shipments of critical supplies, including mental health medications, to 71 clinics and health centers across the United States through the organization’s monthly Replenishment Program. https://feeds.soundcloud.com/stream/923505598-directrelief-during-pandemic-mental-health-providers-see-surge-in-patients.mp3 Listen and subscribe to Direct Relief’s podcast from your mobile device: Apple Podcasts | Google Podcasts | Spotify Transcript: When the pandemic hit, Ryoko Chernomaz saw a surge in patients. “I wasn’t that busy before the pandemic, but since March I’ve been so super busy.” Chernomaz is a licensed clinical social worker at the San Francisco Free Clinic. She provides counseling services and support to uninsured individuals in California’s Bay Area. “A lot of them are undocumented immigrants. And people come from all over the area, not just people in live in San Francisco.” In the beginning of the pandemic, financial stress was the major complaint among her patients. Many lost their jobs overnight and–because of their immigration status—were ineligible for unemployment benefits The stress manifested as anxiety and depression and for Chernomaz, a nearly thirty percent increase in appointments. “Before I always felt like I could do something; I could help. But this is just me because of the number of people and just the degree of the incident. It’s felt like, Oh my God, there may not be, I may not be able to help, uh, all these people. At CommunityHealth—a free clinic based in Chicago–Ornella Razetto was experiencing something similar. “A little bit before the end of March is when they began to see a, the beginning. Of what was to be the surge of referrals to the counseling program,” said Razetto who oversees CommunityHealth’s mental wellness program. “I began to see this surge of referrals, exclusive to anxiety, exclusive to stress and chronic stress.” Like Chernomaz’s patients, many had lost their jobs and didn’t qualify for unemployment—and the social isolation was making matters worse. “It’s not just the health effects of COVID, but I what I was seeing more so was the social isolation effects of COVID and how that was triggering so much anxiety and panic attacks. You name it and it was there.” As the pandemic wears on, these initial anxieties have been exacerbated by relational issues. Chernomaz calls it the second wave. “Now it’s been like 6 months, I believe we are going to start seeing a second wave, which I sort of started seeing already: Increase in divorce, abuse, neglect, those kinds of cases.” She says there’s been an influx of women and children, which reflects broader trends. According to a recent study by CARE—a non-profit international aid organization– women across the globe are nearly three times as likely as men to report mental health issues during the pandemic. While the causes are varied, many experts attribute the discrepancy to women’s role as caregivers. According to US Bureau of Labor, 55% of employed women do housework compared to 18% of men. With children home from school and loved ones sick with the virus, these caregiving responsibilities have increased significantly, and the burden has largely fallen on women. Razetto says her patients are feeling the weight. “It’s this piece of how much more can I give of myself if I was already giving so much before? And there’s this expectation where I have to give more, just because we all have to give more because in COVID everyone has to give until we’re empty” On top of taking on more responsibility, women are also likely to be victimized by an increase in domestic abuse. According to the CDC, one in three women experience domestic violence in their lifetime compared to just 1 in 10 men. And, during the pandemic, domestic abuse has increased by up to 60% in some countries, according to the World Health Organization. The United States is one of the few to report a decrease. But, advocates says it’s likely because survivors aren’t reporting it. Many police precincts require complaints to be filed in person. Regardless, Razetto says her patients are struggling. While she hasn’t received an increase in complaints, she says many of her patients were dealing with domestic abuse before the pandemic. Now, it’s harder to escape. “Whereas for example, if someone says, ‘I’m tired of being at home, listening to him talk all the time and insulting me,’ well before they could have just left the home. Right? Walked out, gone to see a friend, maybe just done something outside of the home. Now, where are you going to go?” Not only is it more difficult to find support in friends and family, it’s also harder to get professional help. As counselling sessions go virtual, some patients are reluctant to talk wit their therapist. “Patients did not want phone consult for counseling,” said Razetto. Understandably, they didn’t feel comfortable talking about their partner inside their home. “I had some weeks where I had, if. If I was lucky, maybe six patients scheduled in a week in a week. Now that she’s back to doing face to face visits, her schedule is booked. There’s even a waitlist. While many of these issues are likely to subside once the pandemic is over, some may be more long lasting. Similar to the Great Depression or even the 2008 Recession, the Covid-19 pandemic could permanently alter how people perceive the world. Before, daily routines were reliable. Future plans were guaranteed. Now, that sense of security has been undermined. “If COVID could have come out just from nowhere, what else could come all of a sudden from nowhere and be here to stay as long or possibly longer,” said Razetto. Many of Razetto’s patients are still unemployed. As the pandemic drags on, they have little assurance their financial troubles will be remedied. Experiencing this kind of stress over a long period of time can have lasting impacts, from anxiety and depression to PTSD. Razetto fears it will cause her patients to be in a constant state of panic. “A long-term consequence will just be that of the perpetual needing to create one’s own safety net.” Chernomaz says she expects a third wave of mental health issues to emerge in the aftermath of the pandemic. Those who lost loved ones or experienced a family separation of any kind may be grieving for years. This is such a huge disaster, she says. It could take generations for people’s mental health to recover. This transcript has been edited for clarity and concision.
7 minutes | Oct 5, 2020
For Pregnant Women, Stigma Complicates Opioid Misuse Treatment
New and expectant mothers face unique challenges when seeking treatment for an opioid use disorder. On top of preparing for motherhood, expectant mothers often face barriers to accessing treatment, which typically involves taking safer opioids to reduce dependency over time. The approach is called medication assisted therapy, or MAT, and is a key component in most opioid treatment programs. But with pregnant women, providers can be hesitant to administer opiate-based drugs. According to a study out of Vanderbilt University, pregnant women are 20% more likely to be denied medication assisted therapy than non-pregnant women. “In the beginning, I was so scared as a new provider to write my first prescription for medication assisted therapy to pregnant women,” said Dr. Linda Thomas-Hemak of the Wright Center for Community Health in Scranton, Pennsylvania. The health center serves low-income individuals who are underinsured or lack insurance altogether, many of whom struggle with opioid misuse. “Pennsylvania was hit particularly hard by the opiate epidemic that really has plagued, terrified and challenged America,” said Hemak, who is a board certified addiction medication specialist. On this episode of the podcast, we speak with Dr. Hemak about whether medication assisted therapy is safe for new and expectant mothers and how the Wright Center is helping women overcome opioid dependency during pregnancy. https://feeds.soundcloud.com/stream/905165122-directrelief-for-pregnant-women-stigma-complicates-opioid-treatment.mp3 Listen and subscribe to Direct Relief’s podcast from your mobile device: Apple Podcasts | Google Podcasts | Spotify Direct Relief granted $50,000 to The Wright Center for its extraordinary work to address the opioid crisis. The grant from Direct Relief is part of a larger initiative, funded by the AmerisourceBergen Foundation, to advance innovative approaches that address prevention, education, and treatment of opioid addiction in rural communities across the U.S. In addition to grant funding, Direct Relief is providing naloxone and related supplies. Since 2017, Direct Relief has distributed more than 1 million doses of Pfizer-donated naloxone and BD-donated needles and syringes to health centers, free and charitable clinics, and other treatment organizations. Transcript: When it comes to getting treatment for an opioid use disorder, pregnant women have an uphill battle. Most patients undergoing opioid treatment are prescribed safer opioids that reduce dependency while limiting the risk of overdose and withdrawal. This kind of treatment is called medication assisted therapy, or MAT. But with pregnant women, providers can be hesitant to administer opioids. According to a study out of Vanderbilt University, pregnant women are 20% less likely than non-pregnant women to be accepted for medication assisted therapy. “In the beginning, I was so scared as a new provider to write my first prescription for medication assisted therapy to pregnant women,” said Dr. Linda Thomas-Hemak. Hemak is a board-certified addiction medication specialist and CEO of the Wright Center in Scranton, Pennsylvania. “Pennsylvania was hit particularly hard by the opiate epidemic that really has plagued, terrified and challenged America,” said Hemak who has been practicing in the state for several years. In 2016, the health center launched a comprehensive opioid treatment program to address the growing crisis in their community. They quickly realized a number of patients were pregnant—and had specific needs, from prenatal care to job support. And so, a new program was born. “The Healthy MOMS program is based on assisting mothers who are expecting babies or have recently had a child, up until the age of two,” explained Maria Kolcharno — the Wright Center’s director of addiction services and founder of the Healthy MOMS program. “We have 144 moms, through the end of August, that we have served in the Healthy MOMS program and actively, we have enrolled 72.” The program provides new and expectant moms with behavioral health services, housing assistance, educational support; providers have even been delivering groceries to moms’ homes during the pandemic. But the crux of the program is medication assisted therapy. Moms in the program are prescribed an opioid called buprenorphine—unlike heroin or oxycodone, the drug has a ceiling effect. If someone takes too much, it won’t suppress their breathing and cause an overdose. Nonetheless, it’s chemically similar to heroin, which may raise eyebrows. But while some substances, like alcohol have been shown to harm a developing fetus, buprenorphine isn’t one of them. “Clearly there are medications, like alcohol, that are teratogenic. And there’s medications like benzodiazepines that have strong evidence that they are probably teratogenic. When you look at the opioids that are used and even heroin, there is no teratogenic impacts of opiates on the developing fetus,” Dr. Hemak explained. So, opioids like buprenorphine can be safe for pregnant women. What’s not safe is withdrawal. If someone is abusing heroin, overdose is likely. In order to revive them, a reversal drug called Naloxone is used, which immediately sends the person into withdrawal. But when a woman is pregnant and goes into withdrawal, it can cause distress to her baby, lead to premature birth, and even cause a miscarriage. Which is also why these women can’t just stop taking opioids. “Stopping cold a longstanding use of an opiate because you’re pregnant is a very bad idea and it is much safer for the baby and the moms to be transitioned from active opiate use to buprenorphine when pregnant,” explained Hemak. Because buprenorphine has a ceiling effect and is released over a longer period of time, women are less likely to overdose on the drug. Regardless, there’s still a risk their baby goes through withdrawal once they’re born. For newborns, withdrawal is called neonatal abstinence syndrome or NAS. Babies may experience seizures, tremors, and trouble breastfeeding. Symptoms usually subside within a few weeks after birth. Fortunately, the syndrome has been shown to be less severe in babies born from moms taking buprenorphine versus those using heroin or oxycodone. That’s according to Kolcharno who has been comparing outcomes between her patients and those dependent on opioids, but not using medication assisted therapy. “Babies born in the Healthy MOMS program, we’re finding, that are released from the hospital, have a better Apgar and Finnegan score, which is the measurement tool for NAS and correlates all the withdrawal symptoms to identify where this baby’s at,” said Kolcharno. But NAS is not the only concern women have post-partum. During and after delivery, doctors often prescribe women pain killers. For those with an opioid dependency, these drugs can trigger a relapse. Dr. Thomas-Hemak says preventing this kind of scenario requires communication. The Wright Center works with their local hospital to ensure OBGYNs are aware of patient’s substance use history. “We want the doctor to know that this may be somebody that you’re really sensitive to when you’re offering postpartum pain management,” said Hemak. That way, doctors know to tailor patients’ post-partum medication regimens. Instead of prescribing an opiate-based pain killer they can offer alternatives, like Ibuprofen or Advil. Maintaining an open line of communication between addiction services and hospital providers also helps to reduce stigma. Women with substance use disorders have long been subject to discriminatory practices by both providers and policy makers. From denying them treatment to encouraging sterilization post-delivery, women struggling with opioid dependency can be hard-pressed to find patient-centered health care. But Dr. Thomas-Hemak says, she’s learned to set her opinions aside. “I think one of the magical transformations that happens when you do addiction medicine really well is, it’s never about telling patients what to do.” It’s about allowing them to make informed choices, she says, and understanding it’s not always the choice you think is best. This transcript has been edited for clarity and concision.
8 minutes | Sep 11, 2020
Wildfires and Covid-19. Overlapping Emergencies Strain Resources, Demand Strategic Response
Over 100 wildfires are raging across the western United States, setting the stage for an unprecedented fire season as the Covid-19 pandemic persists. In California, six of the state’s ten largest wildfires are currently burning. At the same time, uncontrolled blazes are ravaging parts of Oregon, Washington, and Arizona, torching millions of acres and killing at least 11 people. Requested medical supplies arrived at the Chino Valley Community Health Center in San Bernardino County, California, on Sept. 11, 2020. The El Dorado Fire is impacting air quality in the region, and supplies delivered to the health center included respiratory medicines, opthalmic supplies and other essentials often requested during fires. (Chris Alleway/Direct Relief) Direct Relief has deployed several kits of emergency medical supplies, including N95 masks, hygiene items, and essential medicines, to health facilities in fire zones. The current wildfires have only compounded the effects of the Covid-19 pandemic, flaring up respiratory illnesses and straining already limited resources. On this episode of the podcast, we speak with Direct Relief’s head of emergency response, Andrew MacCalla, about how the organization is approaching the concurrent emergencies, ensuring an urgent and robust response to both. https://feeds.soundcloud.com/stream/891817678-directrelief-wildfire-response-interview-9-11-final.mp3 Listen and subscribe to Direct Relief’s podcast from your mobile device: Apple Podcasts | Google Podcasts | Spotify
11 minutes | Aug 26, 2020
“Way Beyond Their Medical Needs.” Health Care Providers Prepare for Hurricane Laura
As Hurricane Laura bears down on the border of Louisiana and Texas, a number of the area’s safety net providers are preparing to close. Ubi Caritas Health Ministries isn’t one of them. Located in the hurricane’s predicted path, in Beaumont, Texas, the clinic treats a medically underserved population – about five to 10% of whom executive director Lauren Rahe estimates will choose to ride out the storm at home. “For our patients, what they have, that’s all they have… Leaving that is a big ordeal for them,” she said. “We want to make sure we’re up and running as quick as we can,” even using a mobile unit if the clinic itself is too damaged. Rahe is worried about Ubi Caritas’s patients. The clinic has already seen a surge in uninsured patients, thanks in part to pandemic-related job loss. Now, her patients are threatened both by the pandemic and the incoming storm. Texas Clinic Braces for Hurricane Laura https://feeds.soundcloud.com/stream/882635341-directrelief-way-beyond-their-medical-needs-health-care-providers-prepare-for-hurricane-laura.mp3 Listen and subscribe to Direct Relief’s podcast from your mobile device: Apple Podcasts | Google Podcasts | Spotify In the Storm’s Path Many of the clinic’s patients have diabetes, hypertension, or morbid obesity, “so Covid is a big concern,” she said. For the majority of people who have elected to leave the area, “they’ve gone to these shelters, all these shelters are going to be trying to social distance, but how well can you really do that in a situation like this?” Patients who need medications to manage a chronic disease may not have enough, Rahe said. She’s also anxious about the clinic’s ability to be able to be there for patients in the weeks after the hurricanes. Ubi Caritas, standing through multiple storms, has been lucky thus far. It’s managed to keep the doors open and its services accessible to patients through a number of calamities. But “with this hurricane, I’m very worried that we will actually have enough damage” that that won’t be possible, she said. The clinic plays an extensive role in patients’ lives in the weeks after a disaster. Staff members act like case managers, helping patients enroll in social services and receive post-disaster funding. In some cases, they’ve even worked to remove mold and damaged material from people’s houses. “What we start to do goes way beyond their medical needs,” Rahe said. Then there are mental health concerns. After a hurricane or tropical storm, Ubi Caritas sees “an increase in mental health [needs], 100%,” Rahe said. “They’ve gone through a trauma.” Since mental health plays a significant role in health overall, that oftentimes means setbacks for patients confronting additional medical issues. Further Afield But even for those not directly in the storm’s path, mental health issues are a concern, said Shawn Powers, CEO of Baptist Community Health Services in New Orleans. Powers expects to see strong showers, but not much else. Still, he said, “we have noticed that trauma within our community tends to be elevated when we see a hurricane.” Storm-prone New Orleans knows what it’s doing, Powers said – he praised state and local efforts to prepare communities for incoming storms like Hurricane Laura – but people are still affected by the experience, which can affect health care issues more generally. Baptist Community Health Services’ patient population “is medically underserved, and I would consider some of it medically somewhat fragile,” Powers said. A hurricane or strong storm “tends to exacerbate the cracks in that system.” Like Ubi Caritas, the health center plans to stay open, through telehealth if need be. Even if the city’s power system goes down, they’ve designated hotspots that will allow them to offer telehealth services. But Powers said his emergency management team is also preparing for a spike of patients, as evacuees move into shelters and temporary housing in the urban area. “They’ve already begun to arrive,” he said. “It’s kind of odd that New Orleans is the place to run to,” considering its storm-drenched history. For a number of those patients – particularly those with Medicaid or Medicare insurance – Baptist Community Health Services will become a temporary provider. “We’re trying to maintain some level of continuity” for those who are displaced and away from their primary care provider, Powers said. Even with safety net providers stepping up, the pandemic complicates matters. “One of the biggest wrinkles we have [when preparing for Hurricane Laura] is it’s also the Covid-19 pandemic,” Sinitiere said. “We kind of have this down to a science because we’re so used to this, but we can’t congregate people in shelters the way we normally would.” In addition, Sinitiere said, testing – a vital tool in preventing the spread of Covid-19 – will be interrupted by the storm. “Unfortunately, New Orleans is oftentimes the beneficiary of major storms like we’re seeing this week,” Powers said. But the Covid-19 pandemic “affects clinic operations well beyond these short-lived hurricane events.”
6 minutes | Aug 25, 2020
In Sudan, Those with Diabetes Face Increased Risks Amid Pandemic
Rising food insecurity coupled with strained health care systems has created new challenges for those managing diabetes during the Covid-19 pandemic. When food is scarce and meals are inconsistent, diabetics may experience extreme blood sugar spikes--or dips--that can lead to heart disease, kidney failure, and even death. In Sudan, where the number of people facing acute food insecurity has increased 65% since last year, pediatric endocrinologist Dr. Omer Babiker says malnutrition has become a serious problem among his diabetic patients. "We see, on a weekly basis, patients that have malnutrition" said Babiker, the deputy director of the Sudanese Childhood Diabetes Association. As a result, many patients' blood sugar has become uncontrolled and some are facing acute complications due to a lack of food. Others have been unable to access health care services because of Sudan's nationwide lockdown. For Babiker's patients, the consequences have been severe. On this episode of the podcast, we speak with Dr. Babiker about how the Covid-19 pandemic is impacting his patients and escalating the risks of their condition.
13 minutes | Aug 21, 2020
In CA, Wildfires Accelerate Convergence of Public Health Crises
California faces a convergence of public health crises as dozens of wildfires unleash hazardous levels of air pollution across the state. Smoke-laden air has exacerbated conditions, like asthma, while the menace of Covid-19 still looms, mounting a respiratory threat on two fronts. For the more than 650,000 Californians sick with the virus, poor air quality is particularly dangerous. A small increase in air pollution has been shown to significantly increase patients’ risk of severe illness and death. Meanwhile, sweeping evacuations have forced emergency officials to abandon pre-Covid protocols, filling up hotels to avoid crowded shelters. Nearly 50,000 people have been evacuated across the state. On this episode of the podcast, we speak with Direct Relief’s head of research and analytics, Andrew Schroeder, about the heightened health risks of California’s wildfires and more on what those affected should know. https://feeds.soundcloud.com/stream/879771034-directrelief-in-ca-wildfires-brings-convergence-of-public-health-crises.mp3 Listen and subscribe to Direct Relief’s podcast from your mobile device: Apple Podcasts | Google Podcasts | Spotify Transcript: RAFANELLI: How does Covid-19 heighten the health risks of these wildfires? SCHROEDER: I think in a couple of key ways. The first is just that the main route of transmission for COVID is respiratory. And when you have a preexisting respiratory condition that might be exacerbated by wildfire smoke, so you might be an asthmatic that actually has your asthma exacerbated during this time period. If you also get COVID the likelihood of more severe consequences from COVID, is higher for you because of your preexisting co-morbidity being more intense as a result of the smoke exacerbating it. And you know, the second part of it that I think is important, that is hard to know how to actually advise people effectively is just that ventilation of indoor space is much harder. Right now the air quality in the Bay area, in particular, is absolutely abysmal. But this is true to some degree throughout much of the state right now. So you can’t really keep your windows open. You know, if you are, in your house or in a place of business or in a restaurant, et cetera, you have to be able to close off the space to protect the space where you are breathing from the smoke. That means people are more likely to spend more time indoors in less well-ventilated spaces. And if we know one thing so far about the likelihood of transmission of COVID it’s that indoors in poorly ventilated spaces is where you’re most at risk. There’s ways to mitigate that risk, but it’s definitely higher under any scenario. So, the wildfires just make it more likely you’re going to spend that time indoors. And I guess the third is just, with people that are forced to leave their homes there have been some evacuations so far. In previous fire seasons, we’ve seen people spend pretty large amounts of time being displaced from their homes, whether that’s in a shelter or whether that’s in hotels or whether that’s with family and friends, it means that it’s just harder for you to manage health conditions of many kinds, and social distance, while you’re in these kinds of displacement conditions. So the more intense the fires are, the more intense the displacement conditions are. I think that has all kinds of ripple effects and implications for how people manage COVID. RAFANELLI: With tens of thousands of people evacuated from their homes right now, how are emergency managers navigating this fire response amid COVID? SCHROEDER: You know, again, a good question. I should start by saying I’m not myself an ermegency manager. I think it’s important to go back through what the managers themselves are putting out, but there have been efforts to reduce the density in shelters and open up additional spaces for shelters. Maintaining low density is really going to depend on the event. You might have an event comparable to say the paradise fire events or the campfire from last year where the nber of evacuees was straining systems at the time. Reducing the density in any given shelters can be really hard to do. Making sure people in shelters have access to PPE is one way to deal with that, you know, free access to masks and hand sanitizer and sanitary conditions. Just doing a better job than normal protecting people through their access to equipment in the spaces is probably more important than it ever has been. You know, the other thing to bear in mind is just most people that evacuate during a crisis actually don’t go to a shelter. They go to friends and family. How people manage that is going to be an important question for their own protection from COVID. How to effectively manage having additional people that might be in your house for a certain period of time, making sure that you’re vigilant about all of the other protections, procedures that you would go through, even while these kinds of crisis events are ongoing, is going to be more important than ever before and that’s something that individuals kind of have to manage. RAFANELLI: In terms of protective equipment, what kinds of masks should people be wearing right now? There’s so many, from N-95s to surgical masks, and they are all intended for different purposes. Which ones are best to protect people from both smoke and Covid-19? SCHROEDER: Yeah. I mean, I think one of the first things that just remember which may get confusing for folks, just given that there’s so many options, as you say, the purpose of wearing a mask from a COVID point of view is actually less about protecting you and more about protecting others. So, surgical masks are designed to block droplets that tend to come out of your mouth when you just talk or breathe or just normal activity and that’s important because it’s those droplets that are actually transmitting the virus. The surgical mask is not really protecting you from the virus itself. The surgical mask has two score screens to prevent the virus itself from coming through it and it doesn’t really help you in a wildfire either. So wearing a surgical mask is not a great protection against wildfire smoke, but it’s still important under any scenario, given that you still have to protect other people from the potential spread of COVID. The one complexity or nuance that’s come up with the N-95s is just that there’s two primary variants that people see. One is a regular N-95 mask designed for stopping 2.5 particulate matter and it doesn’t have any vents on it and for COVID you really need to use an N-95 mask that does not have vents on it because the vents will actually spread droplets. However, in a wildfire scenario, the vents are actually somewhat better. They allow you to breathe better. If you’re blocking what’s coming in and making it possible to breathe more comfortably, then the vented mask is actually somewhat better. So, if you’re in an outdoor space and you’re not around a lot of people, but you’re in a very smoky environment and you need to protect yourself from the smoke then a vented N-95 mask is actually a pretty good idea. If you’re around a large amount of people, if you’re in an indoor space, and you’re trying to prevent the spread of COVID, you really can’t use the vented N-95 masks. And you really can’t expect a surgical mask to protect you much, if any, from wildfire smoke. RAFANELLI: Over the weekend, many in California experienced rolling power outages and there’s potential for more. How do electricity shortages complicate fire response during COVID? SCHROEDER: In so many ways. The blackouts, I think, have been a little bit of a surprise this time, just given that it doesn’t seem as though they were necessarily needed, or were caused by an unexpected surge in power, but nevertheless, especially coming on the heels of last year is public safety power shutoffs we’re becoming accustomed to this idea that wildfires in California are kind of normally associated with power shut offs. That compounds problems for people that are indoors, so again, going back to the earlier point about needing to shut your windows, needing to be inside, hide away from the smoke for a longer period of time, lack of access to electricity just for everybody, makes life far less convenient. It can produce problems for food storage. It can produce problems for just making it tolerable to be inside for long periods of time. The people that have the biggest problems are those with power dependent medical devices. This was a huge problem last time for those that had breathing assistance or insulin pumps or other ways that they were self-managing chronic illness with power dependent devices, rolling blackouts become a real problem. Very few people in California have significant battery backup or the ability to move off grid with power, so when these outages happen, there’s really a very large percentage of population losing power altogether. And that’s compounded if you also have to evacuate. So, developing better plans for how to manage a chronic illness with power dependent devices. It’s still, I think, at early stages. It’s really up to individuals at this point, from the standpoint of the state, to recharge devices, making sure that you have a plan for power backup. These are new features of life for many people and I think as we factor that into vulnerabilities to COVID, these are also people that have chronic illness and are more at risk for hospitalization and other kinds of acute consequences from COVID, so being very mindful of where the power is shut off, the density of population with power dependent devices, the COVID prevalence in the area, bed capacity, hospital capacity in that area–these things are going to converge in new way to increase risks for a lot of people across the state. This transcript has been edited for clarity.
8 minutes | Aug 12, 2020
A New Way for Health Centers to Keep the Lights On
A fire in 2018 shut down two of Mendocino Community Health Clinic’s four locations. In 2019, power shutoffs designed to deter another wildfire shut the Ukiah, California health center down again – this time, at all four locations, for four days. “Being closed, and the impact of patients not getting care, and staff not being able to work, that’s a lot,” said Tiffany Williams, the Mendocino Community Health Clinic’s safety officer. The Health Consequences of Public Safety Power Shutoffs https://feeds.soundcloud.com/stream/874215598-directrelief-keeping-the-lights-on-during-a-public-safety-power-shut-off.mp3 Listen and subscribe to Direct Relief’s podcast from your mobile device: Apple Podcasts | Google Podcasts | Spotify In addition, the health center lost vaccines, which need to be kept in specialized refrigerators, during the power outages. For a health center treating underserved patients on a shoestring margin, a power outage is serious. It means that patients go without visits or access to medication for days on end. It also means that a health center goes without the revenue – Williams estimated that Mendocino Community Health Clinic’s locations see a total of about 600 patients per day – it needs to keep its doors open. But public safety power shutoff (PSPS) events, during which an electrical company cuts the power to discourage wildfires from happening in a particular area during a hot or dry period, are part of California’s future landscape, said Nora Hawkins, a regulatory analyst for the California Public Utilities Commission’s energy division. A New Solution Then, through Direct Relief, Williams heard about a new state-sponsored rebate designed to help low-income residents living in fire-prone areas – and the critical facilities that serve them – during PSPS events. Through an existing state project, the Self-Generation Incentive Program, the California Public Utilities Commission (CPUC) already offers rebates for people and organizations interested in installing energy storage technology at their home or facility. But a new category, called “Equity Resiliency,” is specifically targeted at communities that are “lower-income, medically vulnerable, and at-risk for fire,” as the CPUC’s website explains. Through Equity Resiliency, about $613 million in state funds will be distributed through 2024 to provide batteries for free, or with some remaining installation costs, to people who are lower income, have a medical disadvantage, and either live in an area that’s especially vulnerable to fire or have experienced two PSPS events. The batteries are also available to the organizations that serve vulnerable communities in high fire risk areas – like fire stations and health centers. The Equity Resiliency rebate came out of “a recognition that we’re seeing increasing wildfire risk throughout the state due to climate change and people moving more into the urban-wildland interface,” Hawkins said. “And so there was a recognition that, as wildfire risk increases….it will probably be necessary to continue relying on these public safety power shutoff events, which of course can have pretty significant customer impacts.” Spreading the Word But while a number of health centers serving low-income populations living in high fire risk areas are eligible for the Equity Resiliency program, it’s not widely known among them, said Andrew MacCalla, Direct Relief’s vice president of emergency response. “None of them know that it even exists,” he said. That’s where Direct Relief comes in. The organization recently held a webinar to alert safety net providers to the program – and to offer to pay the 5% application fee due up front for facilities seeking a battery. About 40 of the organization’s partners have projects in the works so far, MacCalla said. Mendocino Community Health Clinic, which is currently undergoing the review process, is one of them. How It Works Whether it’s a person who relies on a medical device or a health center that needs to keep its vaccines cold and its medical records online, an installation project is undertaken with a developer, who will determine how much electricity is needed to maintain total functioning – the “peak load” – and the capacity a battery needs to have. A battery that’s fully funded by Equity Resiliency can maintain that load for between two and four hours. But should a health center pare down to its most essential functions – its “critical load” – the battery may hold out for hours longer, doing everything from powering exam chairs to – literally – keeping the lights on. The Equity Resiliency program is funded by ratepayers who buy their electricity from California companies. These companies, in turn, will evaluate applications for batteries based on criteria determined by the CPUC. It works as a rebate, which means that an organization is responsible for the up-front cost, although a developer may agree to take some of that on. Then 50% of the cost is reimbursed when the project is completed, and the remaining half is reimbursed over the next five years, provided the organization meets certain requirements regarding the charging and use of the battery. Batteries aren’t just intended to be used as backup. They’re supposed to be charged and discharged daily. “We’d hope to see a lot of batteries charging in the middle of the day when energy generation tends to be cheaper, because we have a lot of solar generating in California,” Hawkins said. “And then we’d want to see these batteries discharging during the evening ramp and peak period, where otherwise a lot of fossil fuel facilities that are more expensive and emit more greenhouse gases are coming online.” This isn’t just meant to be good for vulnerable individuals and organizations. It’s meant to benefit the grid as well. “We are very interested in helping customers achieve enhanced resiliency in light of these wildfire risks, but this is a larger program with additional purposes. So the goal for the battery is to be more than just providing backup power to critical loads,” Hawkins said. There’s no shortage of interest. Hawkins said that the Equity Resiliency budget has had more than 4,200 applicants thus far. “The idea of potentially being able to qualify for funding to cover the cost of the batteries is huge. Health centers use a lot of power, so it’s not just a small battery pack. They’re quite significant. And they do cost quite a bit of money,” Williams said. Mendocino Community Health Clinic hopes to use the batteries to keep its door open to patients and its medications cold during future power shutoffs.
5 minutes | Aug 5, 2020
Fewer Medical Visits, More Unplanned Pregnancies. How Covid-19 Impacts Reproductive Health.
While researchers say the coronavirus pandemic is more likely to lead to a baby bust than a baby boom, it’s limiting access to family planning services and contraception. One-third of American women have reportedly delayed or canceled visiting their provider for reproductive health care services or have had trouble getting their birth control, citing concerns over contracting the virus, and an inability to pay. The percentage of those delaying care increases among low-income women and minority populations. “I’m not getting a lot of demand for family planning services, so that’s where I’m worried,” says Dr. Karen Lamp, a physician at Venice Family Clinic in Santa Monica, California. “I’m seeing a lot of women presenting late in pregnancy.” On this episode of the podcast, we speak with Dr. Lamp about how the Covid-19 pandemic has impacted her patients’ access to reproductive health care and what that could mean for women as the pandemic continues. Direct Relief has committed to distribute 45,000 IUD units to safety-net health facilities across the United States, including the Venice Family Clinic. The IUDs have been donated by Bayer to expand women’s access to reproductive health care in underserved communities. https://feeds.soundcloud.com/stream/870296821-directrelief-fewer-appointments-more-unplanned-pregnancies-how-covid-19-is-affecting-reproductive-healthcare.mp3 Listen and subscribe to Direct Relief’s podcast from your mobile device: Apple Podcasts | Google Podcasts | Spotify Transcript: In the United States, the coronavirus pandemic is more likely to lead to a baby bust than a baby boom. That’s according to researchers at the Brookings Institution. They say women are likely to delay pregnancy because of economic uncertainty and concerns about the state of public health. The result could be up to half a million fewer births within the next year. Despite these predictions, Dr. Karen Lamp says she’s seen evidence to the contrary: “I’m not getting a lot of demands for family planning. So that’s, that’s where I think I’m, I’m worried.” Lamp is a physician at Venice Family Clinic in Santa Monica, California. She says there’s been an uptick in unplanned pregnancies among her patients during the pandemic. “I’m seeing a lot of women presenting late in pregnancy.” According to a survey conducted by the Guttmacher Institute, one-third of women have had to cancel or delay visiting a provider for reproductive health care services or have had trouble getting their birth control during the pandemic. For Latinx women—who make up the ethnic majority of Venice Family Clinic’s patients—barriers to care have been even more significant. Nearly 50% have reportedly delayed services because of an inability to pay or a fear of exposing themselves to the virus. While the LA-based health center has continued to provide services throughout the pandemic, Dr. Lamp says, in the beginning, many patients didn’t know they were open. “It wasn’t until we sent out a message on people’s cell phones saying, ‘We’re open and we’re opening for more services,’ and then our phones really started ringing. I think people were just really sheltering in place.” And others were dealing with changes brought about by the pandemic. “I mean, people who are working have a lot of anxiety because they don’t feel safe at work, or if they’re not working, they don’t know how they’re going to pay the rent, or they have so many of our families live in, you know, with an extended family and one person sick and the whole issue of isolation and quarantine. I mean, just so many other things take taking precedent.” The health center quickly shifted appointments to telemedicine which has helped providers like Lamp easily reach patients that can’t get to the clinic. While it’s easy to refill a prescription or prescribe a new birth control over the phone, other needs have been harder to meet. According to Lamp, cancer screenings have taken a backseat. “They’ve all dropped in the last couple months — breast cancer screening, cervical cancer screening, colorectal cancer screening, biopics–about 6 to 7%.” But patients aren’t necessarily the ones opting out of these appointments. “Honestly we have discouraged them from coming in,” she says. According to Lamp, the risk may not be worth the benefit. That means she must assess each patient individually to determine which screenings are crucial and which ones can wait. “We look at something like cervical cancer, which develops over a very, very long period of time. So we thought, well, if this is, if we’re delaying it by six months or nine months, which initially of course we thought, okay, it was four or five months, but now we’re looking further down the road. And we think that that’s okay to do, um, You know, you look at something like breast cancer and you kind of have to individualize the woman’s risk for that.” The health center also provides prenatal care as part of their suite of reproductive health services. Before the pandemic, they held group classes for expectant mothers. Now, those are canceled and about half of all prenatal visits are being done over the phone. During these over-the-phone checkups, providers often rely on the mothers to report on how they and the baby are doing. “We just ask them if the baby’s moving, have they had any bleeding, contractions, anything like that, but then you always have a low threshold. If there’s any concern you bring them in.” The health center has given blood pressure monitors to high-risk moms, who are older or have had complications during previous pregnancies. Despite these precautionary measures, Lamp says there are still risks that come with virtual care. “If you have somebody who maybe doesn’t give you a great history or downplaying something, you can miss cues.” With health care being delivered over the phone, patients have a greater role to play in the quality of care they receive. But sometimes, stepping into that role can be a lot to ask. Women have so many other responsibilities, Lamp says. Reproductive health care isn’t always front and center. This transcript has been edited for clarity and length.
18 minutes | Jul 24, 2020
Responding to Covid-19 in the Navajo Nation: A Front Line Perspective
In the Navajo Nation — a sovereign territory spanning 27,000 square miles — responding to Covid-19 comes with unique challenges. A third of residents don’t have access to running water. Grocery stores are few and far between. And many must travel hours to reach the nearest hospital. While the nation has the highest case rate of any state in the country, it’s been successful in containing the spread of the virus through stay at home orders and strict weekend curfews. When the pandemic began, the territory quickly ramped up testing and contact tracing investigations. The Navajo Nation now boasts the highest testing rate in the country with roughly 40% of all residents having been tested for the virus. On this episode of the podcast, we speak with Dr. Jonathan Iralu, an infectious disease doctor at Gallup Indian Medical Center in New Mexico. He discusses how he and his staff adapted to treat an influx of patients during the peak of the outbreak and what they’re doing now to ensure continued access to care. Direct Relief is providing ongoing support to tribal health facilities within the Navajo Nation, including shipments of requested supplies, such as personal protective gear, intensive care medications, and oxygen concentrators. https://feeds.soundcloud.com/stream/863431627-directrelief-responding-to-covid-19-in-the-navajo-nation-a-front-line-perspective.mp3 Listen and subscribe to Direct Relief’s podcast from your mobile device: Apple Podcasts | Google Podcasts | Spotify Transcript: DR. JONATHAN IRALU: The virus probably came from people returning from large metropolitan areas in the bordering States. We initially saw spread related to a sporting event where somebody traveled to a sporting event and returned. And then later on, there were all kinds of venues where it spread–just as it’s been spreading throughout the country–at church events and things like funeral proceedings. The virus spread through the community, initially, through those ways. AMARICA RAFANELLI: Are there any circumstances that are unique to the nation that may have exacerbated the severity of the outbreak? IRALU: Hmm. Yeah. So, the thing that concerns us in Indian country is the lack of infrastructure. We have a tribe that has a beautiful culture. They live in very rural sites, but, unfortunately, some of the parts of the Navajo Nation do not have things like running water and electricity. And so, for a person to come in and get seen in a hospital they might have to drive a long distance, sometimes on dirt roads. So, infrastructure is an issue. And so that makes things like self-care and patient care more challenging, but it’s not something that’s totally insurmountable. RAFANELLI: Can you give me an idea of what your typical shift looks like right now? How has your hospital changed? IRALU: So the hospital has changed, as most hospitals in the United States have changed, dramatically. So when we learned that Covid-19 was starting to spread on the West coast and then on the East coast it really concerned us because we knew we lived in a rural area and that could potentially cause difficulties for us here. So we had to make a lot of dramatic shifts in the way we deliver care. So for instance, early on we shut down our clinics and left a sort of skeleton crew back in the clinics to just handle emergencies and do medication refills et cetera. And we transferred a lot of the staff into the inpatient and to the emergency department areas so that we can enhance the care of people coming in with COVID. So for instance, we very quickly instituted drive-up testing where folks can drive up get their swab testing and then go home. And we were doing that very, very early on in the outbreak. We also made modifications to our emergency rooms, so that a lot of the triage is done outside of the main hospital building. So a person could come in and if they had mild complaints, they could actually be seen in sort of like a medical tent, do their screening down there, and can get some of their care there. And if they’re not critically ill, they could be sent home from there and the people who are really sick would have to be taken into the main emergency room. The hospital itself–we had to create inpatient ward space for COVID patients. And what used to be office space, we had to move folks out of their offices and convert those rooms into COVID care units and that included making modifications in the air ducts and installation of new digital pharmacy equipment so that we can give out meds safely. A lot of modifications had to be done to keep people safe. So, the day to day life in the hospital has changed. So clinic visits, like many parts of the country, involve telemedicine where we telephone patients and do our quarterly updates over the telephone. So those are some of the things that have changed: You have to create COVID units in the inpatient service, like out of a vacuum, and then the clinic has moved from fewer face to face and more telephone visits. RAFANELLI: I do want to follow up on that and just ask: Is access to technology a challenge for your patients that you’re trying to reach through telemedicine. IRALU: Not everybody has access to technology. Sometimes the family will have a shared cell phone. if a person lives in a remote part of the Navajo Nation that’s far from the cell phone tower it’s sometimes difficult to get service. We’ve had people had to drive to the top of the mountain in order to make telephone calls. So you can imagine that would be challenging. RAFANELLI: Do those same patients in remote areas face challenges accessing in-person care as well. IRALU: Ah okay. In the pre COVID era, and partly during the COVID era, we have used homecare extensively for infectious diseases. So, the tribe created a beautiful tuberculosis treatment program along with the Indian Health Service back in the 1970s where they utilize a program of what we call community health workers. I’m sure you’ve heard that term before, but these are folks who are adept at speaking the Navajo language, and many of them are, that have some medical training and they will go into the homes and deliver medications for tuberculosis for instance and this worked well for decades. Roughly I think about 12 years ago we started doing the exact same thing with HIV care. And so we have a long-standing history of having Navajo speaking healthcare workers who are community health workers go into the homes and do direct care. During the COVID emergency we had to curtail the HIV program cause the staff were needed elsewhere, especially in the clinics. The tuberculosis care, which is run by the Navajo Nation, was continued. So when people aren’t able to come in here, we’re able to get to them. And I would also like to mention a really nice program that was started by two of my colleagues, Dr. Jennie Wei of UTI and Dr. Mia Lozada. They worked with the state of New Mexico, McKinley County and many many many many other agencies full of volunteers to take care of people in motels who do not have a place to stay during the COVID emergency. So for instance, if somebody develops COVID and there were healthy relatives at home we would ask that person to stay in the motel for their 10 day isolation period to keep them from infecting other people in the community. If someone was exposed to COVID at home and did not have a place to quarantine themselves they’re also sent to these places. And then lastly, there are people who can’t return home because there’s COVID at home and they need a place to stay. So my colleagues working with state of New Mexico and many other volunteer agencies and universities across the country have sent volunteers to assist in this. It’s a beautiful effort. So though they have a whole group of people who do not have a place to stay, they have ended up staying in the local motels. They get fed. They get looked after by doctors and nurses who come and visit them in the motel room. They’ve done a beautiful job with this and I think it’s been a real benefit to the community that prevents the spread of COVID. RAFANELLI: Given the scale of the outbreak in the Navajo Nation, how has your hospital, in particular, been impacted? IRALU: So, in early March like everybody in the country we were desperate for supplies. Nobody you know could have imagined that this pandemic would hit the United States. So we were just like everyone else. We were short on N-95 respirator masks, surgical masks, gowns, gloves, sterilizing wipes–all that kind of stuff. We were short just like the rest of the country. We have all the same suppliers as everyone else. So, the hospital had to create a personal PPE committee to spend a lot of time ordering and tracking and projecting what the needs would be for the hospital. So that obviously impacted us. As I mentioned before, we were short on space. We only had two medical surgical wards plus a small intensive care unit. And we had to create a couple extra wards. So, we transformed office space into these COVID units and that was challenging to get the ball rolling, but we were able to do it over a period of a few weeks. We had to do some HVAC renovations to kind of strengthen the air flow in some of the parts of the hospital, but that really impacted us a lot in in April when we were at the peak of the COVID emergency. Here, as it is now, things are better and we’re kind of catching our breath. RAFANELLI: Obviously you’re treating a number of COVID positive patients. but have you seen an uptick in the number of patients experiencing health issues unrelated to COVID, but due to some of the circumstances that the pandemic has created? IRALU: Sure. So what I think what you’re alluding to is that when you have to convert a hospital into a COVID care unit things like routine primary care might be put on the back burner. So for instance, a diabetic who would ordinarily see either their provider every three months might not get to see one for a while and their sugar goes up. This is a common scenario. And now that things have quieted down, we’re able to do catch ups by telemedicine. So for instance I spent the morning doing that. I’m catching up with a number of patients using telemedicine, so that’s how we’re hoping that we can get back into the swing of regular primary care again here. RAFANELLI: As an infectious disease doctor, what are your thoughts on the current situation? Are you concerned or do you feel that things are under control? IRALU: Today, at this location, I am cautiously optimistic that things are going to be good for the near future. I’m worried about the possibility of importation of cases of the virus from the neighboring states. The Navajo Nation is a part of New Mexico, a big part of Arizona, and part of Utah and then we have patients coming in even from Colorado. So, we’re in the four corners area and a couple of those four corner states are seeing an uptick in cases. We’re worried about the possibility of reintroduction of the virus from one of these bordering States. That’s our concern. RAFANELLI: Do you feel like your hospital’s response has differed from other hospitals across the country because of the region you serve? IRALU: On one level we would be different from the average small rural hospital in the United States in that we’re the public health service. We do direct patient care and we’re responsible for the public health needs of the patients that we serve. So another hospital would do the direct patient care and then make a referral to the stage or local health care jurisdiction like the county department of health or in the state department of health to do the contact investigations and do the other work. While we do work a lot with the states that we are adjacent to we have to do the public health ourselves. So we have a group of public health nurse across Navajo Nation and other epidemiologists from the Indian Health Service et cetera at different service units or that are doing things that ordinarily are done by states. So we kind of we do two kinds of healthcare both public health and direct patient care. And then I think that some things that are unique are that we serve the Navajo Nation and in some parts they do not have the kind of infrastructure you might find in an urban area–people don’t have running water, the things we already talked about–cell phone access, roads et cetera makes things more challenging than they would be in an urban area or perhaps in a more rural area but one with better services than we have here. RAFANELLI: Can you explain the difference between public health and direct health? IRALU: Oh yes. So, for instance, as an infectious disease specialist, I have spent the whole morning doing direct patient care. So, I I did a consultation in the inpatient units and then I did a number of telephone calls, telemedicine visits, face to face visits in the clinic. So that would be direct kind of direct patient care that we would do. Tomorrow my teams are going to be meeting to do public health work. So, we’ll be following up on persons who have tuberculosis and we’ll be following up on persons who have HIV in the community working with Indian Health Service staff and working directly with tribal workers. So, they will be fulfilling more of a public health role to try to stop outbreak in the community of those infections I mentioned. And so, we have a whole section of the Indian Health Service hospital where I work–it’s called Public Health Nursing. So they would not be doing direct patient care, but they would be doing contact investigations, looking after people with COVID. They’re doing a really beautiful job. I’m proud of their work. This transcript has been edited for clarity and concision.
7 minutes | Jul 16, 2020
“They Don’t Have Food, Period. Let Alone Healthy Options.” How Covid-19 Has Impacted Chronic Disease Care.
With more than 51 million Americans filing for unemployment since mid-March, the financial fallout of the Covid-19 pandemic has made managing chronic disease an afterthought for some, and an impossibility for others. Lacking adequate resources, many are struggling to maintain their medical regimens, which often involve produce-rich diets and regular purchases of prescription medication. “We definitely are seeing a number of patients who are really just barely getting by,” says Dr. Mary Herbert, the clinical director of the Birmingham Free Clinic in Pittsburgh, Pennsylvania. Herbert treats patients with chronic diseases, such as hypertension, diabetes, and heart disease. She says many of her patients are forgoing care to attend to more immediate needs, such as paying the rent or feeding their families. Others have been unable to pick up their prescriptions because they can’t afford the cost of transportation. On this episode of the podcast, we speak with Dr. Herbert and other healthcare providers about how the financial consequences of the Covid-19 pandemic are affecting patients’ ability to manage their chronic conditions. Grace Medical Home received a Continuity in Care grant from a joint initiative between Direct Relief, BD, and the National Association for Free and Charitable Clinics. Since 2008, Direct Relief has provided $373.8 million in medical support to 863 free and charitable clinics, and has also provided more than $2 million in emergency grants and funding focused on chronic disease management. https://feeds.soundcloud.com/stream/858769414-directrelief-they-dont-have-food-period-let-alone-healthy-options-how-covid-19-has-impacted-chronic-disease-care.mp3 Listen and subscribe to Direct Relief’s podcast from your mobile device: Apple Podcasts | Google Podcasts | Spotify Transcript: For Dr. Kirsten Carter’s patients, the last thing on their mind is managing their chronic condition. “I’m asking them about healthy food. They don’t have food period, let alone healthy options.” Carter is an internal medicine physician at Grace Medical Home in Orange County Florida. The clinic offers medical services for free to uninsured individuals. “They are the uninsured of orange County, Florida. So what that means is they either don’t qualify for Medicare Medicaid, they don’t have positions that offer insurance for whatever reason, they don’t qualify for the affordable healthcare act or can’t afford it. And that includes undocumented. Carter’s patients are facing some of the worst financial consequences of the COVID-19 pandemic. Many work in Florida’s service industry, which was gutted overnight by the state’s stay at home order. With theme parks closed and businesses shuttered, these employees found themselves without work–and, for some-without unemployment insurance. Many of Carter’s patients are self-employed–housekeepers, landscapers. Or, independent contractors hired out by hotels and amusement parks to repair appliances or provide cleaning services. Since these workers aren’t required to pay into unemployment, they’re on their own should they lose their job. While federal unemployment benefits have been extended to independent workers under the CARES Act, navigating the application process can be prohibitive particularly for those whose first language isn’t English or who aren’t technologically connected. For the undocumented, protections are especially limited. “A lot of patients have been evicted from their homes because the laws in FL that put a moratorium on evictions do not apply to undocumented. And they’re not eligible for unemployment.” Since unemployment rates skyrocketed, Carter has watched her chronic disease patients slip into poor health. Some can’t afford their medications anymore. “I have a patient who I just saw yesterday that has, um, bad anemia and she wasn’t taking her medication because she didn’t have the $2 to take it. Others are forgoing care to attend to more immediate needs. One of her patients is facing eviction after losing her job in the hospitality industry. When she came in for a recent checkup, her blood pressure had become uncontrolled. “She was so anxious about just trying to find housing for their family and what was going to happen to them that the last thing she was doing was remembering to take her medical regimen.” And others can’t make it to the pharmacy every month to pick up their prescription. “Before, when they were working, they could either take the bus, which costs money, Uber, which costs money, or get a friend to drive them. Now their friend has lost their car or can’t afford gas…So those transportation barriers have gone up significantly.” To help, staff at Grace Medical Home have been hand-delivering medications to people’s homes. They’ll often drop off personal hygiene items and groceries, too. Many of Carter’s patients are food insecure, making it difficult to choose healthy options. Since diet is a hallmark of chronic disease management, the clinic regularly delivers fruits and veggies to patients’ doorsteps. Since March, staff have passed out over 160 boxes of food to patients experiencing food insecurity. But Grace Medical Home isn’t the only safety net provider doing these sorts of deliveries during the pandemic. At the Birmingham Free Clinic in Pittsburgh, Pennsylvania, staff are going into neighborhoods to bring patients medications, food, and cash assistance for rent. “We definitely saw or are seeing a number of patients who, you know, are really just barely getting by.” Dr. Mary Herbert is the Clinical Director of the Birmingham Free Clinic. She says many patients have lost their jobs, and–like Carter’s–are struggling to maintain their housing. “You know, in our state, the governor issued a moratorium on evictions, but some of our patients just, they didn’t even know the first thing about how to begin to advocate for themselves. And they were getting pressure from their landlords that, Hey, your rent is due. And, also thinking about, okay, maybe I can pay my rent this month, but even if I don’t pay it for the next two months, because my landlord gives me a break, I’m still unemployed. And now I’m just racking up this huge rent bill.” These kinds of financial stressors are a double whammy for patients with chronic disease. Not only does it make it difficult to pay for their medication or afford the transportation to pick it up, long term stress also leads to conditions that exacerbate, and may even cause, chronic disease. It’s widely accepted that stress can lead to depression, anxiety, and weight gain—all factors that make it harder to control a chronic condition like high blood pressure or diabetes. But recently, scientists have shown that experiencing high levels of stress over an extended period of time may actually cause chronic disease. According to a study published in Nature Medicine, stress causes an overproduction of white blood cells, which stick to the artery walls and build up as plaque causing heart disease and increasing the risk of heart attacks. And, a limited body of research, suggests a link between stress and insulin resistance, a precursor to Type 2 diabetes. But Dr. Herbert says it’s not all bad for her patients with chronic disease. “I think some of them have actually done a better job of managing their disease state at home.” The need to limit in-person visits has encouraged the clinic to shift its approach to chronic disease management. “Since patients weren’t coming into us as regularly, we wanted to make sure everybody was monitoring at home.” The clinic has gifted patients with monitoring devices to check their blood pressure or measure their glucose levels. And, they’re teaching patients how to interpret those values so they can determine for themselves whether their chronic disease is under control. “The irony is, I think some of those patients, this model that we had pretty quickly transitioned to actually works better for them.” As patients’ circumstances change, so have the ways in which Dr. Herbert and her staff provide care. If her patients face a choice between putting food on the table and affording their monthly medication, what can she do to ensure they’re able to do both? “It pushes us to continue to look at each patient’s own individual capacity,” she says, “That’s really what individualized medicine is about.” This transcript has been edited for clarity and concision.
7 minutes | Jul 8, 2020
Responding to the Coronavirus Outbreak on U.S.-Mexico Border
On the California-Mexico border, the coronavirus continues to disproportionately impact communities where large numbers of essential workers and high rates of poverty render preventative measures, such as social distancing, nearly impossible. In San Diego County, the discrepancy between case totals tracks the region’s socio-economic divisions. In the county’s southernmost zip code, case rates are roughly three times higher than San Diego City itself and five times higher than several of the county’s wealthiest neighborhoods, including La Jolla, Rancho Santa Fe, and Del Mar. “The virus and the impact of the virus follows exactly what we already knew about the impact of zip code and health disparities on life expectancy and outcome,” explains Dr. Jeanette Aldous, the clinical director of infectious disease at San Ysidro Health in San Diego, California. On this episode of the podcast, we speak with Aldous and others on the front lines of the outbreak on the southern border about how their patients have been impacted and what they are doing to respond. https://feeds.soundcloud.com/stream/853992211-directrelief-responding-to-the-coronavirus-outbreak-on-california-mexico-border.mp3 Listen and subscribe to Direct Relief’s podcast from your mobile device: Apple Podcasts | Google Podcasts | Spotify Transcript When Covid-19 was first detected in California, Jeannette Aldous braced for the worst. “We knew it was coming for our community.” Aldous is an infectious disease doctor at San Ysidro Health in San Diego, California. “I direct our infectious disease programs and then I’m also our chair for infectious control so at the moment, as you can imagine, my job is 100% COVID.” The health center has 26 clinic sites throughout San Diego serving low-income communities near the California-Mexico border. Aldous says that in the beginning, South County didn’t necessarily have more cases than any other part of San Diego. But once California issued its statewide shelter in place order, that changed. “Then you start to see this separation where the people that have ongoing exposure and ongoing risk and then more difficulty putting into place these protection measures, have more cases.” Now, South San Diego County is a Covid-19 hotspot. The southernmost zip code has a case rate nearly 3 times higher than San Diego City itself and roughly 5 times higher than some of the county’s wealthiest neighborhoods, including La Jolla, Rancho Santa Fe, and Del Mar. Aldous says the discrepancy is not surprising. “The virus and the impact of the virus follows exactly what we already knew about the impact of zip code and health disparities on life expectancy and outcome.” In San Diego, Latinx residents make up two-thirds of the county’s coronavirus cases, though they represent just one-third of the overall population. Across the nation, similar trends hold. According to the CDC, Latinx people in the U.S. are 4 times more likely to be hospitalized due to Covid-19 than white Americans. “Even though there was no reason for, you know, a person there’s no other reason for a person in the Southern part of San Diego or person in the Northern part of San Diego to be more likely to contract a respiratory virus. It’s a social determinant of health that makes it more likely.” In several of the communities San Ysidro serves, the poverty rate far exceeds the county’s average. In National City, just a 15-minute drive from the border, 1 in 5 people are living below the federal poverty level. And in the San Ysidro District, immediately north of the border, one-third of school children are homeless. “I have some patients who have trouble paying for Ibuprofen. Just simple things are a lot harder for our patients.” Dr. Pomai Roberts is a physician at San Ysidro Health. She works at their site in National City. The area has the second highest case rate in the county. “Most of our patients qualify for Medical, have Medicare, or have no insurance at all.” 9 out of 10 are living at 200% or below the federal poverty level and many are essential workers or work in industries that never fully shut down. “A lot of my patients have continued to work. Housekeeping, cleaning hospitals, construction workers, if they do have jobs. So, a lot of patients have continued to work throughout the pandemic.” Staying at home to avoid the virus wasn’t an option. “They don’t have the choice really to sit at home and not work, so they put themselves at risk to continue to get a paycheck.” As soon as cases began to rise, the health center took measures to make their services more accessible, despite the need to limit in-person visits. They added a hot line that patients could call with questions or concerns. They set up drive-through testing sites. And they ramped up their telehealth program. Dr. Roberts says telehealth has helped patients keep their chronic conditions in check during the pandemic. Within minutes, she can prescribe insulin to a patient or address a blood sugar spike, without them ever having to leave their house. “If I can keep my, you know, my diabetic as healthy as possible and keep them out of the ER, out of the hospital, that’s kind of the best thing I can do for them right now.” And for those who do call in with COVID symptoms, Roberts says providing information is key. “A lot of our patients have more mild symptoms, a little bit of a sore throat or cough, not even necessarily have a fever. And those kinds of patients when they do test positive, a lot of them just need education, a lot of education on what they need to do.” While the usual advice is to quarantine, she’s careful to assume her patients can self-isolate. Because of high housing costs, many live in multi-generational homes. If self-isolating isn’t possible, she offers alternative solutions. “We do have the option of calling county 2-1-1, and there is, um, the option. They will provide free housing.” The county has set aside vacant hotels for COVID positive patients that don’t have a place to quarantine. “Basically once you’re there, you cannot leave until you are safe to go until they tell you, you are safe to go, which is usually for at least 10 days .” Roberts says most of her patients prefer to stay with their families. In that case, she works to minimize the fallout of being sick. Most have to miss work, so she helps sign patients up for grocery delivery services or apply for government assistance. “I’ve made a lot of referrals to our social workers who can help to see if we order meals on wheels or some of my patients are getting groceries delivered to their home.” Even for those who aren’t sick with the virus, the pandemic has brought undue hardships. One of Roberts’ patients had to quit her job working at a fulfillment center for a large online retailer. When she was required to wear a mask to work, her asthma flared up. “She needed the money and was trying to work, but just couldn’t keep the mask on without feeling extremely short of breath and having a panic attack, so we had to remove her from her work because she was at the point of almost passing out working in the situation she was in.” Roberts helped her apply for disability so she could afford to stay home. Now, she’s living on a fraction of her regular paycheck. But, Roberts says, it’s something. This transcript has been edited for clarity.
15 minutes | Jun 30, 2020
In U.S., New Trends Fuel Coronavirus Resurgence
As coronavirus cases surge across the United States, officials scramble to roll back reopening measures in a renewed effort to contain the spread of Covid-19. The reverse course comes as record-breaking case totals threaten to overwhelm hospital systems in several states, including Texas, Florida, Arizona, and California. While the United States managed to "flatten the curve" in May through nearly universal stay at home orders, case totals plateaued at a relatively high level. Now, as preventative measures, such as mask wearing, have been met with controversy, leveling the curve may be more difficult. "I think we're in a much more challenging environment now in terms of compliance with these orders," says Direct Relief's head of Research and Analytics, Andrew Schroeder. "So, that's going to make it so that the tools that are in our toolkit are potentially more limited than they were the first time around." On this episode of the podcast, we speak with Schroeder about the trends behind the recent outbreak and what we can expect as the pandemic progresses, from reopening economies to rolling out mass vaccination campaigns.
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