COVID-19 Conversation: Continuing Our Commitment to Patients in Nicaragua
Our promise of improving health and dignity during the COVID-19 pandemic endures. We're helping front-line health workers stay safe, nourished and empowered to better serve their patients by providing life-saving supplies and equipment, as well as remote training to bolster their response. We’re also providing nutritional assistance, hygiene kits and virtual health services to support people and their health needs so they can thrive. If you can, when you can, help us keep our promise to care for children and create hope for tomorrow.
Now, more than ever it’s our charge to safeguard the health and well-being of individuals around the world. We’re building upon our expertise in delivering cleft surgery and care in resource-limited settings as well as our history of improving the health and dignity of those we serve.
That’s why we’re finding the most meaningful ways that we can support people and their health needs in the communities where we work, even when medical missions are postponed, care centers are closed, and the future feels uncertain. It’s in this uncertainty that our swift action is required, and we’re doing everything that we can to help patients, families, and countries as this affects them.
This “COVID-19 Conversation” featured a live question-and-answer session with Indiana Siu, Operation Smile's regional director for Nicaragua, Dominican Republic and Guatemala; Tatiana Morales, Operation Smile Nicaragua's executive director; and Scarlette Gomez, Operation Smile Nicaragua's staff speech therapist. The session was hosted by John Streit, our managing editor and writer; and Laura Gonzalez, our Digital Content Manager, moderated the audience’s chat and questions.
John: Hello, good afternoon, everybody. Thank you so much for joining us today for our COVID-19 Conversation. I'm John Streit, Managing Editor and Writer for Operation Smile, and alongside Laura Gonzalez, our Digital Content Manager, we spend a lot of our time working really closely with all of our stories dealing with the COVID-19 response of our organization, and we really just want to give a heartfelt thanks to you guys for joining us this afternoon so that we can connect with some wonderful colleagues of ours from Nicaragua who are doing amazing things to stay in touch and reach our patients.
If you're joining us and you happen to be a front-line health care worker, we extend our extra heartfelt thanks to you for taking time out from saving lives every day to join us. We really appreciate it. I'll kick it over to Laura who will be moderating the questions and chat portion of this webinar today.
Laura: Hi everyone. Thank you so much for joining. I'm excited to have you all here to hear about the amazing work our colleagues in Nicaragua are carrying out. I just want to let you know, if you have questions throughout, you can input them into the chat and we will reserve a few minutes at the end of this conversation to answer any questions that come through. However, do not fear, if we run out of time, we will send you personalized answer to any questions that you ask, and I'll be answering some of the simpler ones if we have them already. I'll kick it back to you John.
John: Awesome. Thanks a lot Laura. And yeah, I'm just really excited to introduce three of our colleagues from Nicaragua and a regional director as well. So, with that I’ll introduce Indiana Siu. She's our regional director and she manages the country portfolios of Dominican Republic Guatemala and Nicaragua. Indiana has served for eight years as the executive director of Operation Smile Nicaragua before becoming the regional director of those countries in 2018. As a regional director, Indiana provides leadership and support to our organization’s work in her countries with a focus on business operations, strategic planning, program development, stakeholder engagement, strategic initiatives and special projects. Welcome, Indiana.
Next, we have Tatiana Morales, Operation Smile Nicaragua’s executive director. She got her start with Operation Smile Nicaragua as a volunteer nurse, and then joined the staff as a patient care coordinator in 2015 before becoming the center coordinator in 2016, program coordinator in 2017, and executive director in 2019. So she's seen a whole spectrum of roles with Operation Smile Nicaragua and this unique experience strikes a balance of patient and volunteer advocacy with organizational strategy to help move the foundation forward. Welcome, Tatiana.
And we have Scarlette Gomez, our speech therapist with Operation Smile Nicaragua. Scarlette is a speech language pathologist who's worked as a speech therapy provider for Operation Smile Nicaragua for the past three years. Since there's no degree for speech language pathology in Nicaragua, she received her degree from Iona College in New York and has trained with Operation Smile volunteers at medical missions and at our care center in Managua over the past three years. Welcome all, and thank you for joining our conversation today.
So we'll get right into it, Indiana, as Regional Director for the Dominican Republic, Guatemala and Nicaragua, can you speak about the ways that countries in which you work have been adapting to serve their communities needs during the pandemic?
Indiana: Well, first of all, thank you for the opportunity to showcase what local foundations do around the world. All countries have done an outstanding job supporting COVID during this pandemic, I currently work supporting Guatemala, Dominican Republic and Nicaragua.
Guatemala has provided medical supplies to our mission hospital which attends pediatric patients, and they team up with Rotary and United Way to support 125 families during this outbreak with food and hygiene kits.
Dominican Republic supported with medical supplies in hospitals where we actually perform missions. Nicaragua we are supporting with medical supplies in one of the referral hospitals where we actually host our missions, and now we are teaming up with American Nicaragua Foundation and United Way representatives to support patients with food kits and hygiene kits.
John: That's amazing. Well tell us more about some of the first steps that were taken after the pandemic was declared, and what were your key consideration for your teams?
Indiana: So first was basically assessing the pandemic in the countries we work, knowing what the context was and then work to benefit hospitals but also our patients in our countries. I think malnutrition around (Latin America and the Caribbean) is a fact and to be able to have a chance to fight a virus, they need to be healthy. We wanted to be able to help hospitals and front-line workers as well as some of our volunteers who are there, but also we wanted to try to help patients avoid getting there, so food kids were also our priority. So basically, the main steps were towards trying to support our patients with food and hygiene kits and then with a bit of PPE (personal protective equipment) for hospitals but also for our volunteers on the front lines.
John: Awesome. Thank you. Yeah, it's really staggering to think about the food shortages and how that's affecting people all over the world. So, we really appreciate you reaching out like that. This one's for Tatiana and Indiana: When COVID-19 was declared a pandemic, your team was delivering surgical care to patients at a medical program in Managua. Can you speak to the safety precautions that were put in place in order to ensure that everybody, from patients to volunteers to staff, stayed healthy during that mission?
Indiana: I think when COVID was gaining force, affecting all of our countries, our team and (Operation Smile global) headquarters were really prompt in communicating with our local foundations to explore all scenarios to either cancel or support missions. The pandemic wasn't affecting our country yet. And I just think that volunteers, board and staff decided that we should just carry on the mission and continue until the first case was announced. I also think that effectively we did stop on the same day, but I'll let Tatiana speak more to the decisions and how as a whole COVID affected Nicaragua.
Tatiana: Hello, everyone, and thank you for this opportunity and joining us. Well, first, I think we have amazing volunteers and staff and board members. But as Indiana said, at that time in our country, we did not have any case of COVID-19. As a foundation, we already had an action protocol, our main measure with the volunteers and the staff was education on hand hygiene. We made general information on symptoms and prevention of COVID to inform during our evaluations. We double-checked our patients, and from the time they arrived at the screening, if the patient had a fever they were not admitted with the other patients because our first thing in this mission and all the moments is the safety.
John: Absolutely, and I know safety had to be what led your team to the tough decision to postpone the remaining surgeries and end that program early. Can you tell us more about that tough decisions that you guys had to make on the ground?
Tatiana: During the surgical week, when the first case was officially announced, it was a bit of a sad feeling not only because of what our patients would go through but also what our country would be facing. Even though our volunteers wanted to continue, we knew that the first thing was the safety of our patients, volunteers and staff, for this reason we decided to finish the mission earlier than planned. It was a little was a sad, but the first thing was safety.
John: Yeah, absolutely. I know it just had to be heartbreaking to have to tell families who had travelled, who had sacrificed so much on their end to be a part of that, to tell them that they couldn't receive surgery because of this had to be tremendously difficult. What was it like having to break the news to families during the mission and how else are we staying in contact with patients’ families who still are needing surgery?
Tatiana: Well, first, it was a very emotional moment. We had many feelings, some were sad, but we were proud to see how far the team had come in four days, and they had come together to discover 74 new smiles. We were filled with hope, knowing that in the midst of difficult times, we have great volunteers who are willing to continue for our patients, for our country and for our family of Operation Smile. I think the last patient is feeling sad, but we talked with them in that we will to continue in the better times. Now, we are in constant communication with them in our clinic online, that in this time, the psychology and speech therapy is the main support for them.
John: Yeah, and Scarlette, I know you had a very hands-on experience talking to families when that tough decision was made. Can you tell us more about that?
Scarlette: Yeah. Hi. Hello, everyone. Thank you for having us and thank you for joining us. So, I was the one actually that had to give the news to the patients; we had around 15 patients that were scheduled for Friday. And we did the last surgery day on Thursday.
It was a really bittersweet moment, because I was so nervous to talk to them, because I didn't know how I could tell them that what you've been expecting and dreaming of can’t happen right now. We just made so many promises that, as soon as we could, we were going to call them and reach out to them so they can have a new date for the surgery. Because we had primary lips on babies and we had like one primary lip on an 11-year-old, and most of them were really sad.
I'm going to be honest, some of them were mad, but they understood the situation and actually, … one of the patients said, ‘Okay, so I don't have anything to else to do here at the hospital, do you want me to help in anyway?’ So he helped us a little bit with the charts and all this stuff. We were trying to figure everything out and to be able to leave the hospital as soon as we could, as with soon as we finished with the surgery schedule that day. So, yeah, bittersweet, but it had to be done for the safety of all of us.
John: Yeah, that's so sweet to hear that people were willing to pitch in and help out how they could. I think that kind of solidarity is something we need more of in the world right now. So back to Tatiana and Indiana: Many of our teams around the world are donating much-needed supplies and equipment to support local health systems. How have these efforts helped local health systems in Nicaragua and how they helped our patients?
Indiana: I think right now there was no country that was prepared for this pandemic. We have supported with supplies to help protect our front lines, which a lot of them are volunteers for Operation Smile. It has helped to deal at some degree how we can treat, properly, people who are accessing care without the fear of being exposed. We also have been advocating for safe surgeries and safe spaces since Operation Smile’s creation. Our patients know we have them in our mind and purpose, we are making efforts to continue their treatment online when possible as well as providing food kits to patients. I think there's even like a second kind of wave of funds that we are trying to gain for them. We are also making efforts to continue their treatment online, and then when we can, we're going to make it safe as possible for them to return to the clinic.
I think also that it's really important to support the food kits. I do want to highlight that we have, regional directors, been supporting foundations around the world with this, because our patients, it's crucial for them to also be ready when we are ready to host missions. It's really important for them to be healthy, to just be ready upon, say, ‘Well I could get an operation as soon as it's possible,’ when the organization begins programmatic activities.
And for most of our patients, they are part of an informal task force. They don't get a steady salary. They don't get a steady income. So most of them – even in social distancing – it's really easy for us to say, ‘Social distancing, take care of yourself,’ but there are some people that actually need the money, need the salary for that day, and social distancing is not helping them to provide for their family. So, I think we have found ways of being there for our volunteers but also to be there for our patients, even while they're at home and away from surgery. So, I'll toss it up to Tatiana.
Tatiana: Okay, I think nobody was prepared for a situation like the one we are going through, and Nicaragua is not the exception. (Operation Smile Nicaragua) with the support of (Operation Smile Global Headquarters), we have provided supplies to some hospitals with which we work. It is incredible to know that thanks to this type of support we are not only supporting the adequate protection of our medical teams, many of them volunteers and others who are at the front line in charge of many patients, and even more so our patients who live in a vulnerable situation not only due to their physical condition but also due to their socioeconomic condition. In these moments, Operation Smile’s support is magnified because we can support the situation of health systems and that of many families. And in this moment, they have really helped, and I think this is a great moment we want for all patients.
John: Thank you. And, Scarlette, because of the virus, we've had to postpone surgical treatments for many of our patients around the world, but what else are we doing to care for our patients beyond surgery?
Scarlette: We are trained to provide as many services as we can. We have been doing consultations over the phone or video calls with the pediatricians and nutritionists, so all of those types of consultations that you could do and it could be done via a screen. So, the mom calls them and explains whatever is going on or explains the routine that their baby's having or if it doesn't go well with the baby. And with the nutritionist we're trying to for the kids to, as Indiana said, to keep them gaining weight, to be healthy, to be in their best shape ever.
And there’s the psychologist; she's available for everyone that wants to have any kind of support, for either the patient or any other relatives, because we know this is a completely different situation that we've ever gone through in our lives. So, it's valid if they want to talk to someone about it and if they're like scared or are afraid of whatever this means in the future, whatever kind of situation they’re going through.
And with speech therapy, which is trained to follow up with all of our patients. We're not doing any outpatient (consultations) right now, just continuing with our 1,800 patients of the clinic right now and we are also having more newborn babies with a cleft either cleft lip or cleft lip and palate. So, we're also, via online or a phone call, the hospital lets us know and then we will call them and give them feeding techniques and just explain the treatment and whatever comes with the condition, so they are prepared. And so, we’ll have way more patients for us when we come back as a physical, essential clinic.
John: That's amazing. I want to focus in on the nutritional aspect, and could you speak with a little more detail why nutritional support is so important, especially for malnourished patients, and tell me a little bit more about ready-to-use therapeutic food and what we're doing with that product as well.
Scarlette: We are really proud of our nutritional program right now because we're able to follow up with the babies that we have diagnosed with malnutrition or in a low weight, and we are trying to make a more controlled way for us as a clinic or the ones that are giving the treatment and for the parents to be as involved and as informed as we can. And with the RUTF or the ready-to-use therapeutic food, what that brings us is a way to give the patient another resource you are adding to their meals, the two or three meals they have a day. We have another resource that can help, and the families usually use them not just with our patients, but with the rest of the family. It's a peanut butter paste that so you can mix it with anything. It's sandwiches or milkshakes or whatever you want to put it in, with cookies. So and the kids, if we’re talking about kids, they love it. It's like really greasy so you can put it on anything and it helped them gain weight really fast and so we can have them prepared (for surgery) as soon as possible.
John: That's really amazing. And then we'll pivot into your specialty, speech therapy, as well. And it's such a vital element of the care that we're able to provide for people and really, especially with those with cleft palate, how critical it is to provide this service for them, even though we're apart right now. Could you speak in more detail about how you've been able to deliver your therapies and just what that means to families right now to be able to receive that kind of support from you?
Scarlette: We're doing as much as we can. We're doing the online video calls. We're doing phone calls. We're sending them through WhatsApp or whatever platform we can use to get to give them stuff like videos and interactive games and pictures or exercises if they can practice. So, it's all on hand, and what I've what they've been telling me, for the little ones, they're really enjoying that their parents are home. And because they don't have to go to school right now or just like are doing little assignments for school. The parents and kids are spending way more time together. The parents are seeing a whole another progress with them, because they know like they are the ones that have to do it with them. At the clinic, it's me or any of the volunteers doing it with the kid and they're just watching. But now, they are the ones that have to understand and be able to practice whatever we are doing with the kid, so that makes it a lot more understandable and they get way more fun out of that experience.
John: That's awesome. What would have some of the parents of patients been saying to you just about what there you're able to bring to their kids?
Scarlette: They're really happy, because with the population that we work with, they’ve got to spend a lot of money on travel. Because we are in the capital city and if they're not near here, it takes them up to four or six hours to come. What they're doing now is that they just get to spend on data that could be 100 percent less of what they were spending, and they get the materials and they get the consultation. They can ask whatever they want.
I think they feel like they are more in touch with every single one of us that are giving the different consultations, and they also feel like they're supported. Like, this is like something we've never seen before, but we're just trying to keep constant calls to see if everyone is okay. We're also giving any kind of information that we have about safety measures or that they can take as parents. It's because here, we have some schools running at the moment, so we're just trying to make the parents understand the situation and for everyone to be as safe as they can.
John: That's really amazing. And I know the work that's happening in Nicaragua right now is really pioneering and really doing some great things and inspiring similar activity across Latin America and other places as well. Thank you so much for what you do and offering that service to people; it's really incredible. I wanted to open this back up to each of you if you had anything else that you wanted to add before we entered into our next phase of the call, which is the audience question-and-answer session. Indiana anything else you'd like to add?
Indiana: I wanted to acknowledge all the heroes on the front line. I think we are full of respect and admiration for what you do for humanity – a big thank you, as well as to local foundations, the headquarters teams, and my fellow (regional directors) that have been tremendous supporting our countries. Just please, everybody, keep safe and healthy. We need you all to continue doing great things.
John: Tatiana anything you'd like to add?
Tatiana: Thank you. I thank them for the support of each one of those great people who are always supporting us; board, donors and staff members of (Operation Smile). And the most important thing is that, in this moment, is all volunteers who are on the front line and who are the true heroes. We are so proud of their courage. Thank you. Thank you for your time and your help – many thanks.
John: Scarlett, anything else?
Scarlette: Yeah. I just want to say that I think the situation is making us grow stronger and to remind ourselves not to take anything for granted. This is an opportunity for us to make yourself valuable, to help as many people as we can, to be as empathetic as we can. And I just want to thank everyone that's working towards making this a better space for us and time for us, and to everyone that's working in the hospitals, and the rest of the volunteers and staff, and all of you that may be behind the stage but are making a lot of things happen.
John: Well, thank you much, and thanks to each of you for joining us today. We really appreciate it. I'm really excited because we have a bunch of questions coming in from our audience. We'll go ahead and get started with that portion of this. Our first comes from Helen: Operation Smile patients come from a wide area. How do the food and hygiene kits reach the families?
Indiana: For many of my countries, it has been a hard task, but it has been two ways. First, we did partner with some organizations like United Way, Rotary International, American Nicaragua Foundation, and others. First, we did get some products from them. We teamed up. Second, they do have presence in some areas that our patients are. Thirdly, we have been actually conveying or asking them to come to a specific point where we deliver the hygiene and food kits. It has been really, really a challenge, but I think our teams and our partnerships have endured to just keep benefiting patients.
John: Awesome. Our next question comes from Linda: How is Operation Smile Nicaragua able to help families by providing technology through the phone or an iPad or an iPhone, so that these remote meetings with nutritionists, speech pathologists, etc. can occur? I think the question is, are we able to provide the physical telephones or iPads to patients so that we can reach them? Scarlette, I think that this would be a question for you. I know that you have other ways of delivering therapy if we don't have internet connectivity.
Scarlette: We're not basically giving the patients any kind of technology, but what we're doing is, right now, the patient coordinator is doing a study to know what are the patients that are able to get internet or have any kind of device, so we can know which of our patients are able to get that consultation. For the other ones that are not able, we are just trying to make as much use as we can of the phone call itself. We're trying to explain to them as easy as we can or for them to tell us what they have around them that we can use for therapy.
In my area, you don't need to have a lot of technologies for it to work. What I do is give them clear instructions to do whatever we have to do with the kids or for the teenager or the adult to actually know what they have to look out for or listen to when we're working together. But we have lot of patients, and we have no way of getting to everyone in that way. We're just trying to make as much as we can of the resources we have right now.
John: Absolutely. That leads us right into the next question that we have from Katie. About how many patients are you able to reach via video or Facebook Live or even through the phone too? I think we're all curious to know how many you've been able to reach.
Scarlette: I don't have an exact number. Since we started in late March, we've been able to reach around 400 or 500 patients. We're just trying to follow up with them. We are working towards reaching out to the other ones that we haven't been able to tell them that we have closed the clinic or that we haven't been able to call them and we haven't been able to give the consultations. For that, we're just trying to make as many volunteers involved in the online consultations. Where it's speech therapy, I have four. For psychologists, I think we have two or three, and with a nutritionist, maybe dietician, we're just trying to get a lot more people so we can cover a lot.
John: Well, that's really impressive, honestly.
Indiana: Truly, Nicaragua has been a pioneer in trying to host these speech therapy sessions. Right now, our (regional directors) in Latin American and Caribbean, are working towards creating a proposal to roll this out and just try to gain more access to patients. Just stay tuned for other strategies that we are trying to roll out> I think we will be able to reach many more patients.
John: I think it's super impressive that you've been able to reach the amount that you have so far. If you think about the time that it takes for each call to happen and what you've been able to do since the pandemic hit, it's really impressive, Scarlet. Indiana, we do look forward to the future developments on expanding these programs, too. That leads us into our next question: Helen was just sharing her thoughts, thinking about so many of our patients that don't have access to phones and the challenges of being able to provide information and to work with them. Indiana, I think that you were speaking to just that a moment ago. I guess a good way to think about it is, in the age of social distancing and all of these lockdowns and stay-at-home orders, I think it's just going to be a long-term challenge to be able to get back on the grassroots level and reach patients. Could you share more insight into that idea for us, please?
Indiana: I think that right now, what we're trying to figure out, first, is the volume we're trying to benefit. We do need to do a little bit of socioeconomic profiling for patients. You need to understand more what they have, try to get them quickly to whoever has the technology right now for some consultations, then try to develop some other strategies for patients that can gain access. For example, what if we identify a community leader and then they have like three patients in that community? We could actually call into the community leader and they could kind of like be hosting that at their houses or at their offices. It's just like trying to find several ways of engaging where they don't have the resources and try to meet them at that stage. We're trying to tailor it by country and then by the region and how we're going to roll this out, but it has taken a lot of thinking and a lot of support from (program managers) and (regional directors) just working together to roll this out and just try to keep on benefiting patients, because I think that for social reintegration, being able to speak is just crucial.
John: Thank you so much. Then we have one more question. This comes from Sofia. I think for you, Scarlette, can you tell us more about how you prepare to reach out to each one of the patients you've been able to call? What preparation goes into having your calls when you're delivering speech therapy? That's interesting question.
Scarlette: Yes. What I do is, I have all of the speech files for any of the patients that I was seeing at the clinic. I have a list of every patient I'm supposed to see that day. I review it a day earlier. I see whatever that I've been working with that patient. Because I have to do everything through my phone, I have downloaded a lot of materials and have made myself a lot of materials so I can use them during the consultation and then I send it to them if it's available through WhatsApp, so they can practice on that. It depends on whatever I'm working with. For the babies, we have their early stimulation exercises, and I go through with the mom via video call to see if they're doing it okay or if they have any questions. With the infants and toddlers, I'm just using a lot of YouTube, a lot of songs and videos that they can listen to during the day. A lot of the materials that I'm doing have a lot of clear instructions for the parents so that I can explain to them what they have do. Then, they put it in practice during the week and they send me videos of whatever the result they had. I now have a lot of resource from patients that I can learn from and that I can use them for education to other volunteers for speech. For the adults, I'm trying to use whatever they have at home for what we're doing, because I used to have a lot of things that we could use like mirrors and listening tubes and all that stuff. We're just trying to make them D.I.Y. speech materials or appliances. I just review and I had to transform whatever I was working with at the clinic to have it in digital form.
John: I think that makes that number even more impressive. You've been able to reach so many in such a short period of time. Thank you so much for what you do for all of them. Laura, do we have any more questions from the audience?
Laura: We've had a few more come in. This one's from Nubia. It was originally in Spanish, so excuse me if this translation has been butchered. She is asking, how have the families and patients responded to using the technology and what was their emotional response to receiving therapy from you directly even during times like these? What have their reactions been during your consultations?
Scarlette: A little bit mixed. It depends on the age of the patient, because the moms are really happy with what we're doing. We send them all of the materials so that they can just do it at home. For the older ones, they are the ones that feel that they need to have it in a physical way, but we are making sure that we can continue with the process as much as we can. For me, I'm not able to actually listen as clearly as I would if I had the patient in front of me, but we're making that work.
They're really happy. They're really happy that we can continue because, for them, we have a lot more frequent sessions now. Because of the travel distance they had to take, they could only go to the center like once or twice a month or every two months. Now, we're able to have it once a week or twice a week or every two weeks depending on their schedule. A lot of them are happy.
I'm not going to say that everyone's really comfortable because some of them are really shy with the cameras and to be able to have it via video call, or they feel a little bit insecure or unsure when they're at home because everyone's listening and that part, we had it at the clinic that it was just between them and me, but we're making it work.
We're also working towards that with the psychologist, whatever that I see that it's not working because of another issue. We are just trying to make it work as a team with the both of us and they know that we're working together to help them be as comfortable as they can be, to be assured, for their home to be a safe space too, that they can practice, that they can have the consultations. We're working with the ones that are not as comfortable, but I think we're getting through it.
John: That's really wonderful. Laura?
Laura: I think we only have a couple more minutes. Do you think we still have some time for a question, John?
John: I think we could do one more.
Laura: Okay, sounds good. There have been a few questions along the same line and either one of you ladies can answer. Indiana, maybe you might have a better idea. The first part of the question is, how long has Operation Smile Nicaragua had an office and been providing year-round care? When were you established? Then the second part of that is, what about the future? What can we expect to see?
Are we going to apply these same virtual consultations or some of the innovations that you all had to create in response to COVID-19 to resuming or returning to whatever is going to be the new normal? What will the future look like, and then, when was Operation Smile Nicaragua founded and when was the office opened?
Indiana: I think the office has been open since 25 years ago. We did have like a partnership in the odontology or dental part for patients since its creation. We tried to open up a center in 2012, but it was basically two consultations: one of surgeon, one of dental. It wasn't until 2016 that we actually could ramp up to 10 specialties attending the center. At the moment, they have 18 specialties and almost 24 services trying to support what they're doing towards care.
I think for the future, I'll talk for the region and I'll let Tati talk for Nicaragua, but for the region, … us regional directors are trying to see this in a multi-solution kind of thing. First, just treat COVID like COVID. Nothing's happening much more than that. The three areas we're trying to target is, first, patients that go to the center: How we could get them back to centers? The second one is patients that can go to center but not that frequently, how are we going to provide care for them? The third one is how we're going to provide care for those patients who cannot access the center? And still the best thing is get care at the center, but how can we continue and just take this moment to be resilient and be stronger after it and just take care of all the sectors of patients, because we weren’t taking great care of that sector, that couldn’t go to the center. But now, we have a unique opportunity of just rolling it out for everybody and just making the world more healthy and better. I'll let Tati talk about Nicaragua.
Tatiana: Thank you, Indiana, I hope we can open the center … in a few months. Really, I want to open the center in three or four-months, but we don't know with COVID-19 here in Nicaragua. But we want to continue providing consultations through the clinic online. … For some patients, we need to provide consultation online because some patients can’t come to Managua for our consultations. Clinic online is a new method for continue to provide consultation. We found more patients and we are continuing receiving new patients and some patients can’t come to Managua. The clinic online is the best way for those patients.
Scarlette: I'm absolutely 100% available to creating a program for the ones at the center and the ones that cannot reach us. Definitely, we're doing that.
John: I think the things we've had to do to adapt are new opportunities, and definitely the silver linings that we can make from this unfortunate situation. Again, I want to thank each of you, Scarlette, Tatiana, Indiana for joining us today and for everybody who joined us online. We appreciate your time this afternoon. We'll be sharing a recording of the event in the coming days. Please, always stay tuned to our blog and social media for the latest and greatest that we have with regard toward our COVID response. On behalf of Laura and everyone online, take care, bye-bye.