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.

While we're still unable to provide direct patient care in nearly every place where we work, we're beginning to resume direct activity in places where health authorities have deemed it safe to do so. In late May, we were able to resume providing surgeries in Vietnam and Italy.

This “COVID-19 Conversation” featured a live question-and-answer session on the topic of going the extra smile to support patients and families affected by COVID-19 lockdowns in India and Madagascar with Abhishek Sengupta, Operation Smile India's executive director and regional director for India, Russia and Italy; and Dr. Howard Niarison, Operation Smile Madagascar's COVID-19 program coordinator and education and training coordinator. 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.

Click here to watch a previous COVID-19 Conversation.

Event Transcript

Laura Gonzalez: All right, we're going to jump right in. Again, welcome everyone, thank you so much for joining this COVID-19 Conversation on going the extra mile in India and in Madagascar. My name is Laura Gonzalez, and I am the digital content manager for Operation Smile. I work a lot in helping to tell our story to our online audiences. I'll kick it over to my colleague John Streit for his introduction.

John Streit: Hi, everybody. I'm John Streit, our managing editor and writer. Today, I'll be moderating the chat and questions area of our conversation today. If you have any questions or any comments or want to discuss anything on the side while our panelists are talking, feel free to enter that into those two fields, and then at the end of our discussion with them today, we will have an audience Q&A portion, which I'll be leading as well. Thank you all for joining.

Laura: Thank you, John. Now I am so excited to introduce you to our esteemed panelists today.

Leading this conversation, we have Operation Smile India's executive director and regional Director, Abhishek Sengupta. Abhishek became involved with Operation Smile, first as a college student when he was recruited to translate Bengali to English for a medical mission near his school. Since then, he has grown with the organization and has held many roles, including program coordinator, program manager and regional program manager, which led him to his current position as the executive director of Operation Smile India, and the regional director in India, Russia and Italy. His organizational knowledge and expertise in international development are essential to our operations in India, a country with a tremendous need for cleft care.

We also are happy to welcome Operation Smile Madagascar's education and training coordinator, Dr. Howard Niarison (I'm going to say that wrong. I have no French background, so thanks for your patience, Howard!) Howard is a doctor and graduate of the Medical School of Antananarivo in Madagascar. He has served with Operation Smile since October of 2019 as the education and training coordinator for our Global Essential Surgery project and, since April of 2020, as the COVID-19 program coordinator.

Howard, Abhishek, thank you so much for participating today.

Let's jump right in. Howard, what is the current state of COVID-19 in Madagascar, and how has the virus impacted day-to-day life and the way that we're working with our patients?

Howard Niarison: Thank you for your question, Laura. First, hi, everyone, and we're so happy to talk with you today. We're going to talk about COVID-19 and this current state and the impact of this terrible virus. Unfortunately, unlike some western countries, Madagascar is now around the pandemic take. It's shown by the incredible increase of numbers for two months now. Just to show you, on July 15th, we registered around 5,600 confirmed cases and 43 deaths. You may say for 26 million of people, it's not that much, but it could be explained in part by a low testing capacity in the country. We have also two epicenters of COVID-19 now. First big one is Tana, the capital of Madagascar, the city where I am, and Tamatave; it's on the east coast. Both regions are under total lockdown. In other regions, lockdown is reduced, but the sanitary emergency situation still remains.

All the facilities are now overwhelmed, then the government started last week to open three new COVID-19 treatment centers. It should receive around 1,000 patients, especially with symptoms.

Let's talk a little bit about impact of COVID-19 virus. As we are part of a low- and middle-income country, the virus hit hard the country and still impact us more than others economically, socially. But because many shops had to be closed and many employers had to pull (out their) workers, unemployment, as like in many other countries in the world, an indirect impact of that is more shortage in security, because in daily normal lives, it already existed much in the country.

Concerning medical care delivery, we just need to keep in mind that in Madagascar, prior to the coronavirus, there is a lot of lethal disease like malaria, dengue, plague. And then medical care must go on into our bases of centers, which are pillar of our health system, vaccination, care for pregnant woman, care for babies continue. But at the higher levels, like regional hospital or university hospital, there's more impact because when a hospital department is not overwhelmed, it's quarantined. Then, only emergency surgeries and care are delivered now in the country.

Last point I would mention is that people are scared to go to the hospital now in the country. That's why the government spreads the message of preventive measures and for those who get a chronic disease like diabetes, to continue the treatment and control. Thank you.

Laura: Thank you for painting that comprehensive picture for us. Abhishek, I know India has been pretty hard hit by the virus. Could you speak a little bit to the effects on both day-to-day life, but also the delivery of medical care?

Abhishek Sengupta: Sure, Laura. Firstly, a big thank you to everyone for joining us, and welcome. I hope the conversations today are insightful.

Laura, coming back to your question, I think India has been very significantly hit. What we realize now is that the virus actually came to India a bit later than when it came to other parts of the world. India did a very good job initially. It closed down its border, so international flights were canceled, and the country went into a lockdown, and that the lockdown continued for pretty much two months, some parts even more than that.

The lockdown was implemented pretty strictly and very seriously. There was no movement within the country, there was no movement even within cities. People did follow it, and to some extent also forced to follow it because there was a huge amount of fines imposed. There were district officials and police officials who were making sure that lockdown was being followed.

I think throughout the lockdown, we didn't see a huge spike in the number of cases, but since things started opening up, and the government was forced to open things up because of keeping economic intentions in mind because people were losing jobs, business were getting shut down. It had a very adverse effect on the economy.

Since the lockdown has opened up, there has been a huge spike in the number of cases. Currently, we have close to 30,000 cases a day, new cases. India is, in the next few days, going to hit about a million cases. We have 936,000 cases currently total.

A good thing is that India being a big country, of course a very highly populated country, but also a big country, we can't look at India as a whole. You have to look at the regional disparities within the country. If you break down the numbers, what we realize is that out of all the cases, close to 83% of the active cases today, are actually concentrated only in nine states, which again is a good thing because you can – state governments are now putting very regionalized lockdowns at different states and cities to control the spread of the virus, as well as movement of people.

In terms of its impact on health system, of course being a late-development country, and given that India did not have a very robust health system even when it comes to primary health care, the impact has been significant. Like Howard was saying, it's actually not just access to COVID patients for treatment, but also this has affected other patients, patients with other ailments including older population, as well as maternal and child health service delivery because people are scared to go to hospitals.

Two, actually, even doctors are scared in many hospitals. You read about it in newspapers, as well as we are hearing it from our medical volunteers, that a lot of times doctors are scared to even admit patients who have even the slightest of symptoms. They might not have COVID, actually.

That has created a bit of a havoc. The government currently is trying its best to handle the overwhelming need within the health care system. There are stadiums which have been converted into COVID wards and quarantine facilities. The government has taken up a lot of the private hospitals, as well as a lot of hotels have been taken up and converted into hospitals.

Indian railways have been supportive, and railway coaches have been converted into quarantine centers. There's a lot of innovative thinking, and the government has done a really good job. Again, you have to look at it regionally because in India, health is a state subject. Different governments and different states are able to formulate their policy. Of course, there's a directive from the central government.

I think overall, the situation with regards to the numbers, still is an upward trend if you look at the whole country. Of course, in the next few weeks, there is no chances of it plateauing or even coming down, but there is some hope if you bring down the numbers and look at it regionally.

I think currently, the government is prepared with the current caseload of COVID, but also slowly preparing for the worst, which is if the numbers exponentially start going up. I think it's a new reality that we all are learning to live with. Like Howard was saying, one of the biggest challenges have been people with other ailments, who are not able to access health systems just because either they are scared, or even hospitals are not welcoming to these patients.

We hope that, socially, as we accept this as a new reality, I think people's health-seeking behaviors are also influenced. Those are some challenges that, as a country, we can overcome.

Laura: I think that's a great point. Howard, you spoke about the fear that people are having from going into medical centers. Could you talk a little bit more about what led to Operation Smile Madagascar's decision to pause the delivery of surgical care?

Howard: Thanks for the question, Laura. First of all, the main factor is COVID-19 and its impact. Safety I think is the key word. We should maintain as much for patients as our volunteers. In one hand, we expected that there were partner hospitals where we usually do international missions will receive COVID-19 patients in the beginning, which is the case now in the country. In the other hand, there is a lot of people interacting during international missions. For example, just to show you, during our last mission here in Madagascar on March, we had around 450 patients, then you can easily imagine that it's not feasible according to the actual situation in the country.

Secondly, a borders problem -- it's a big problem because, since the beginning of the pandemic, our government had to close all borders like all the countries. Most of our international volunteers are from various places in the world, and due to COVID-19, our borders closed as I said. Also, we don't have enough credential local volunteers here to conduct a local mission in Madagascar, then it's a big problem and the third factor in our decision to pause surgery too.

Another factor that I want to mention is that some patients are from very remote places in Madagascar and would not be able to join the mission site. In the country, some regions are under lockdown, as I said, and which means some roads are totally or partially blocked.

Laura: Is there other factors that your team in India considered pretty similar, Abhishek?

Abhishek: Yes, I think firstly, it was a bummer that we had to suddenly pause all our programs because as you know, we had just come out of a big mission in Durgapur, where we have a center. We had just finished up a big international mission where we did over 130 surgeries. And we actually celebrated 1,000 surgeries in Durgapur, which again was a big thing for us because Durgapur, being a pretty small town, being able to mount a center there and doing 1,000 surgeries, we celebrated it. We had invited people from the local government, and there was a bit of sound and fury around that.

Then, right after the mission, COVID started impacting us. The primary reason to take that decision would be – the last surgery we did at the Durgapur center was on the 22nd of March, and the country went into a lockdown on the 24th. The lockdown was announced on 23rd. We actually took a decision to stop surgeries right before the lockdown was announced.

For us, the biggest point of discussion that we had at that point of time was, one, patient safety and, second, volunteer safety. That is what we championed in Operation Smile, and that is something that we would never compromise. Whether it's in our quality of surgery, the kind of services that we are delivering or any other external influence that might impact our ability to deliver services and quality treatment.

We realized that, although at that point of time, there were no cases in West Bengal, there were no cases in Durgapur. Actually, wherever we run programs, there weren't any cases, but we still realized that it's not long that it's going to hit us, even in these small towns and in the cities that we are working in.

We decided to stop programs. Then just after a couple of days, we realized that it's also a government mandate. Of course, we had to follow that. Like I was saying, the country went into a lockdown, elective surgeries were stopped in hospitals. Of course, for us, at that point of time, there was no question about not listening to what the government was saying.

Then truth be told, when we stopped surgeries, in all honesty, none of us could comprehend that this is how it would shape, that this is the shape this would take. We literally thought that it's going to be like 10 days, 20 days, maybe a month and then we are going to start, then we are going to resume programs. That's how we conveyed the message to our patients as well.

At the center, we have a list of patients waiting for surgery. We pushed them and we said, "Don't worry. You are supposed to get surgery on 29th of March, we'll get back to you on 1st of May." Just push them by one month. Then slowly it dawned upon us that that's not the case, and then we actually had to call up our patients and tell them that why we are not able to open the center. There was a lot of logistics around that as well.

Currently, we have a lot of our patients calling us because kids who were 6 months old, they are now 9 months old. Kids who were 2 years old, just developing speech therapy, need for a palate surgery, are now 2 years and three months older. Again, it's a difficult reality. We know that patients are waiting, and we are, of course, committed to try to get back as soon as possible to ensure that we provide them access to surgery. Of course, the primary and the most important thing we will keep in mind is safety of our patients, safety of our volunteers and our staff.

Laura: Thank you, Abhishek. The topic of this conversation, and what we're about to dive into, is really both of your team's commitment to going the extra mile. Although we can't provide surgery, you guys have both come up with really innovative ways that we can help in our communities, and also help the patients that are waiting. Abhishek, could you speak a little bit about what your team has done to provide food and relief items to families and migrant workers in India?

Abhishek: Yes, absolutely. We are very proud of what we have done, firstly, because something that was off the beaten track, if I can say that, because it’s not something that we generally do in our normal course of work. Also, under the circumstances in which we have delivered this in Bombay, it’s pretty much exceptional.

Once we shut down our programs, within a couple of weeks, we realized that, one, this is going to stay, and two, our teams were there and we wanted to help people. One way was to collaborate with hospitals and provide them with PPE, get our volunteers to help supporting as front-line workers in COVID wards and all of that, but then we realized that there were already people doing that. Plus, at that point of time, there was a huge shortage of PPE, so even for us to buy, it was difficult.

Then we realized that because of the lockdown, there was another challenge. India, as you would know, has more than 4.5 million migrant workers. These are people who come from small villages to smaller towns or bigger cities in search of jobs. All of them were working in the informal sector. They would work at restaurants, pubs, bars, factories, small businesses. Most of them are daily wage earners. Depending on the number of hours they worked a day, they would get paid at the end of the day. That's how they sustain.

Also what happens is, these factories, these restaurants, these businesses where they work, that's where they stay. At night, they would sleep at the factory. At night, they would sleep at the restaurant once it's closed down. Because of the lockdown, suddenly all these businesses were shut. Suddenly, none of these people were being paid. They lost their jobs overnight, literally overnight. Most of them also didn't have a place to stay because, like I was saying, they were still living in the factories itself, or in the place where they work, or even if they were paying rent in a big city, once their daily income is gone, they were not able to pay that rent. There were no trains to go back home. There were no buses to go back home. You would have seen that for about a month, you would see migrant workers literally walk for 7 days, 12 days, 14 days on the highways trying to go back home because there were no transport. There was no other way for them to go back home.

The other problem that happened is because these are people who pretty much live on a day-to-day basis, they don't have any savings. Once they lost their jobs, there were a huge number of people who were actually living hungry, literally they didn't have money to have two meals a day, leave aside three meals a day. We saw this as a problem, and we decided that that is a space we want to work in. Of course, we believe that it is our responsibility to stand beside communities even in times of hardship, especially in times of hardship.

We picked up two cities where we run centers. One is a very small town; another is a bigger city. One is Durgapur; the other one is Bombay. Bombay, as everyone knows, has the most number of migrant workers in India coming from different parts of (the country). We started giving out food supplies to them. Overall, in about four weeks, we were able to support about 2,500 families, providing them food supplies. In each packet, there would be rice, potatoes, lentils or cooking oil, enough for about 20 days for each family. Then, of course, we also gave some hygiene kits, which is masks, sanitizers, soaps, buckets and mugs, because we felt that is important in these times.

I think it was taken very well. And the idea was that, again, we knew from the beginning that we will not be able to support them for a long time, but again, the idea was to make sure they have enough support to get through these hard times when there is a lockdown going on. Then, of course, the hope is that once the economy opens up, they will go back to their jobs, start earning a salary and they wouldn't need this support.

Laura: Can you talk a little bit about how we were able to utilize some of our existing partnerships to help us pivot in this direction of something that we've never done before in India?

Abhishek: Absolutely. I think one of our primary partners was the Inga Health Foundation. We partner in a lot of programs with them. Everything that we did in Bombay was basically done in partnership with Inga. When we're running centers in these two places, in Bombay and Durgapur, we actually already have existing partnerships with the local government, that's the district magistrate, that's the police as well as with a lot of NGOs in these areas because we do a lot of community awareness programs through them.

This time when we wanted to do this, we went them with a very different approach because they're not used to hearing Operation Smile does this, but we told them that we wanted to support communities and provide food supplies. I think everyone was very welcoming. I must say that we could not have done it without the help of our partners because we really needed hands and feet on the ground. Of course, we had our teams, like you can see in this photograph, literally packing, as well as distributing supplies. Of course, we needed a lot more people, so we got volunteers from our partner organizers.

The other thing is, we got a huge amount of support from the local government in both these places. Because just imagine this was a time when there was a lockdown. Even our teams in these areas couldn't leave their homes without the permission from the government. The government was kind enough to actually allow our people mobility. They were given passes so they could go purchase supplies, pack them, and then distribute them, and of course, a lot of support was provided from the local administration.

Then we went and distribute them, because just imagine going into a community with food for about 200 people, there is always overcrowding, and again, some things that we had to avoid at this time is overcrowding because we wanted to maintain social distancing. We wanted to make sure that enough precaution actually is being taken, and that's where we got a lot of help from the local administration, as well as our partners.

Laura: Wonderful. Thank you for describing that for us. Now switching gears to Madagascar. Howard, your team has literally gone the extra mile by creating the Extra S'Mile Campaign. Could you talk a little bit more about what motivated that pivot from the foundation where you work?

Howard: Yes, sure, Laura. First, we really thank God we were able to make the Marh mission, but knowing that we won't be able to make a mission for the rest of this year, we were so sad. As Abhishek said, the people here too are in a very bad condition, especially with food conditions. They may have just have one meal a day. They are living under $2 per day, too. Then the idea of going towards the patients instead of them coming to us came. It's spreading miles to bring smiles. That's how the Madagascar team gave birth to Extra S'Mile program.

Laura: One branch of that campaign is called Extra S'Mile Nutrition. Similar too in India, your team is giving relief and food packs to families. Why is it so important that the families that we serve are receiving these essential items during this time?

Howard: Yes. As I said, it was so important for us to help poor families because they are in a very bad condition, as I said. They were so committed to bring them these food supplies because all of them live at the region under lockdown. That was our main criteria, bringing food supplies for those who were under lockdown, for those who can't work, for those who can't go out, for those who were under quarantine. The Smile Nutri-pack, that was the name of the food supplies, was supposed to last 15 days by delivering around 2,500 kilo calories per day.

In addition, we gave them reading material and flyers on healthy diet. We would like to show them how to eat properly, what to eat exactly to reinforce the immune system which will help them to fight disease more easily. Extra S’Mile Nutrition had two phases. We were able to visit six regions in Madagascar during phase one and phase two. We distributed Smile Nutri-packs to 532 patients and their families. Also, we were able to distribute 26 Smile Nutri-packs to 26 malnourished patients. Among them all, we are not forgetting our volunteers. We gave food supplies to 120 of them.

What is in Smile Nutri-packs? It's quite similar with what Abhishek gave in India. We gave them 25 kilogram of rice, three kilograms of legumes, two concentrated milks, two bottles of cooking oil, two kilogram of sugar, one bar of soap, and, of course, five washable masks.

I just want to bring precision on what we've done for malnourished patients. We also gave them adaptive formula, therapeutic food. This to continue our existing nutrition program here in the country because normally, in normal times, we cover all malnourished patients in the nutrition food camp for two days, but since it's impossible due to the situation, we travel to each of their places.

In addition of that, for volunteers, we added N95 masks and sanitizers, as most of them are working in the hospital, on the front lines against the COVID-19 war.

Also, there's another aspect of extra malnutrition. We made the partnership with a local institution, National Office of Nutrition, here in Madagascar. Our main focus area was on the east region named Moramanga, because we heard from them that there's a lot of people who are under quarantine, and they just threatened the government to go out because they needed food; they needed enough to eat. They were just hungry. That's why we made this partnership with National Office of Nutrition by giving them these donations. And with local authorities’ help, we were able to give 30 kilograms of rice, two barrels of cooking oil and 12 kilograms of legumes to 145 households quarantined at home in Moramanga. It has the expected impact because number of cases in this region continue to decrease right now and that is our goal to contain the spread of this terrible COVID-19 virus.

Laura: That's incredible. Your team should be insanely proud of the work you've been able to achieve and the hard work of traveling across Madagascar to deliver this type of relief. I understand that there are other focus areas of the campaign targeting hospitals, public awareness and then education-based webinars. Could you talk about some of the other focus areas?

Howard: Yes, as you said, Laura, we had three components of this Extra S’Miles program: Extra S’Miles Hospitals, Extra S’Miles Awareness, and Extra S’Miles Webinar. For Extra S’Miles Hospitals, we gave PPE for health workers, professionals, and because most of them are testing positive now, and we wanted to make a difference by giving PPE and disinfecting products to help them facing this COVID-19 pandemic.

Also, Extra S’Miles Awareness, who made a partnership with another organization, named MedAir, and they are working on another epicenter … They are spreading direct messages about COVID-19 to the larger public. But not only, they are also acting on other several areas of prevention and control of infection, like agent training, disinfecting public places and those facilities, distribution of wash kits and PPE donation to all facilities.

The last component is Extra S’Miles Webinar. We are sharing to local partners and volunteers, most of them, mostly medical volunteers, relevant webinar concerning COVID-19 from Operation Smile (Global Headquarters).

Laura: Anecdotally, what have you been hearing from either the patients, the families, the volunteers, or the partners who we've been able to help with this campaign? What does it mean to them?

Howard: Yes, that's a good question. It was a great mission because we mostly saw grateful eyes and smiling for those patients who received food supplies. They were so happy. We wish, of course, we could do more for more patients, but what we got from (Operation Smile Global Headquarters) and local donors here in Madagascar, they were a very big part of this project, (and they helped people who are) already very vulnerable. We did our best to provide the necessaries for those who mostly needed it. To resume, we saw happiness everywhere we traveled. Thank you.

Laura: Abhishek, you spoke about a lot of the obstacles that the country is facing in response to the virus, but could you speak about some of the obstacles your team is either currently trying to overcome or has already overcome in providing aid to these families, community members and then anyone else that you're able to help?

Abhishek: Yes, I think initially it was a bit of a challenge for us because, first week, there had to be a big mind shift from where we are supposed to and condition to function because it was over and about what we are used to doing. There is some logistical challenges, especially in Durgapur. Mumbai was a bigger city so things were available, but in Durgapur, once the lockdown was in place, even supply chains were affected. Under those circumstances, trying to buy supplies, rice, potatoes, cooking oil as well as lentil in massive quantities was a challenge, and it took us a bit of time. It took us about a week to actually be able to procure things in a larger quantity, because by then, things were also getting streamlined by the day and the government also realized that that's a challenge and supply chains were being streamlined.

The second was, like I was mentioning, that the first couple of times when we tried to do this I think there was a bit of overcrowding because we did not have much of an idea about that. But then, later on, we had understood so we'd send in advance teams, give out tokens first, make sure people are properly lined up and make circles and make sure they're standing three meters apart from each other to ensure the social distancing norms.

I think those were the challenges it was just like there wasn't anything extraordinary, but it was more of trying to do something for the first time. I wouldn't call them challenges, but they were actually learnings. I think we were able to adapt fast and, of course, ensure that those issues were taken care of within the first week or first couple of weeks.

Laura: Howard, how about for your team? Did you have obstacles you had to overcome or did you turn them into learnings as well?

Howard: Yes, during this mission, phase one and phase two, of Extra S’Mile mission we had no major obstacles. At the beginning, the authorization to proceed was a bit hard to get from the COVID-19 operational command, but with precious inward support, it went smooth. Also, I'd say that confirming the beneficiary patients from our database by call was a challenge too because we had to call them in advance to tell them the place, the date and the exact hour of distribution to tell them what to do. As Abhishek said, preventive measures like how to lineup, how many patients should come at this time, at this time but we've agreed, and through the incredible work of our patient coordinators, we were able to join and manage those 532 patients as well.

Laura: How has your team been able to stay in touch with the patients during this time?

Howard: Here in Madagascar, we have these patient advocates disseminated in different places. They are mainly parents of patients in the past. They are our main contact point in the country. They are responsible too of local awareness on cleft,  because they used to being in touch with patients. They are from the regions. Patients are not afraid of them. They are also the first responsible for follow-up of malnourished patients. Generally, when some patients have problems here, patient advocates are reporting to our patient coordinators and they are searching for a way to solve or to help those patients as much as we can do.

Also, through our (Ministry of Health) partnership, based in health centers, are a great help for us. For example, on following-up patients' weight, it's an important nutritional indicator, especially for our malnourished patients, because we have to remember that during this Extra S’Miles mission, we had 26 malnourished patients. These centers are also taking part of awareness by gathering newborn babies with cleft lip or cleft palate.

Laura: Abhishek, at the top of the call you talked about how you guys have been staying in touch with patients. Could you just elaborate on that a little bit more for us?

Abhishek: Yes. We have been in touch with patients. That's one of the most critical things and that's one of the most high-priority things for us because of two reasons. One is, it's very important because there are a lot of patients whose treatment have been planned in the sense that they are either going through a long process of orthodontic treatment, or they are going through a process of dental treatment or speech or their surgeries have been lined up. That is the reason. There's a lot of rescheduling happening. We keep pushing them.

In terms of the orthodontic patients, we've actually arranged phone calls with our orthodontist with some of these patients, because a few of them also have some fixtures that needs to be loosened, tightened and adjusted. That cannot be done without clinicians' or orthodontists' intervention. Our patient coordinators have been in touch with our patients, similar to what Howard mentioned. We also have patient coordinators across the countries in the different areas in which we work. One is, of course, planning, continuing to stay in touch to be able to keep their treatment plan in order. That's one.

The second, I feel it is also important because unless we are in touch with patients, once we can get back, it's going to again take us a long time to go and build rapport and find them. I think it's also critical depth. There's a couple of other things that we're doing, which I think is very interesting.

Which is basically trying to make use of this time because our patient coordinators in their normal life are always traveling. They're traveling 20 days, 28 days a month and they are normally working 10, 12 hours a day. We wouldn't have this time, but we have some downtime. We are using this time to conduct the patient assessment program. What we are doing is we are calling 1,200 patients only about … the last couple of years and trying to understand, one, their health-seeking behavior, two, their need and three, what are preventing them or was preventing them to get access to surgery?

Let me give you an example. We are finding some very interesting things there. For example, Vijayawada is one of our sites where we keep going back every year. We have been doing that for the last five to six years. We don't have a center there. We go there every year, we do a mission and we come back. What we're hearing now through our patient assessment which is just midway, is patients in Vijayawada, a lot of them, about 120 patients are saying that they need speech therapy.

We want to use this knowledge to redesign our programs. What does that mean? I'm already starting to think about maybe a small speech clinic in Vijayawada. We don't have to mount a full-fledged center because that's expensive. It's difficult to mount, but a small speech clinic is not difficult. We're already thinking of mounting that in partnership with the hospital when we work in Vijayawada and provide this comprehensive and complete care to patients whom we are taking care on missions.

I think it's been very interesting, this patient assessment there are a lot of – it's basically a very bottom-up approach to programs. It's not about the deciding which patient needs surgery, it’s what kind of treatment those patients need and then going with it. It's more of patients telling us what they need.

In a way, I also look at it as patients demanding certain services. I think this whole conversation is going to help us design more targeted programs which will address these patients' needs. Again, basically trying to take advantage of the downtime of our patient coordinators who are always running around to get into understanding our patients a little bit.

Laura: That's so important. I think we're seeing that in a lot of our foundations. Howard, is your team taking similar steps to really improve the way you're able to deliver cleft care once it's safe to do so?

Howard: For sure. I think that Abhishek, India and Operation Smile in Madagascar are trying to take the same pathway now simply because we are also searching a way to develop the comprehensive cleft care in the country. We are working to on speech dental, on psychosocial programs. We are trying to redefine the whole program. We're designing now, but we have nothing structured yet. But we are trying to find a way to deliver the comprehensive cleft care. As I said, we don't have nothing structured but we want to do it with the safest way possible as we can do with the best resource we have like equipment, human resources and infrastructure.

Talking about resuming surgery: resuming surgery is not our top priority. Our motto is, as I said, the safety of our volunteers and our patients as we don't have an Operation Smile center here in Madagascar, all our operational hospital partners are not safe for surgery yet. Many health professionals working too are testing positive.

Unfortunately, most of our volunteers who are credentialed are testing positive or presenting symptoms or are at a higher risk in the hospital because they are in the front line. We are not ready to start surgery anytime soon. I want to mention again what I've said with thousands of cleft cases in the world, we have always focused our time and our energy to organize more and more internal missions, but our main focus this new fiscal year is to try to develop how a comprehensive cleft care should look like in Madagascar.

Laura: Thank you. Before we kick over to audience Q&A portion, Abhishek, did you want to add anything to that, your next steps for resuming care and surgery?

Abhishek: I think the thinking is very similar to Howard what you mentioned because safety is paramount. To me, I think there is two things to consider. One is safety of our patients, of our volunteers, of our staff. The second thing is also the way I'm looking at it is also sustainability, because we don't want to open up a center and then again have to close it down after three months because there is a sudden spike in numbers, or because we don't have the available resources, or maybe there's not a sudden spike in numbers, but there's some restrictions on the government because we are not able to move patients. There are a lot of things that we are considering.

First and foremost, like I mentioned, in the when you look at India, you have to break down the numbers regionally. For us, that is the most important part because you can't look at India as a whole, we have to look at it regionally. Places where the curve has started to flatten or there is a plateau, or things are going down, those are the areas where we're going to start operating first.

A lot of things to consider around that, of course, it's a given that all necessary precautions in terms of PPE, as well as other protection devices, as well as social distance measures, they will need to be followed. Operation Smile has actually developed a fantastic document. It's guidelines for foundations to restart programs, which talks about exactly what's kind of the PPE we need, how much quantity we need. Of course, it goes without saying that we will be following that, and that needs to be followed.

I think a couple of other things that I have in mind is, one, is mobility and movement of patients, which is very critical because when we start a center, we are going to have patients, we need to have patients come on a steady flow. Unless public transportation is open and safe for patients, I believe we wouldn't be able to go back and open up a center or run a program.

Second is even if we are bringing patients, which is what we’ve done many times in the past, we may now put them in vans and cars and bring them in. Is there a government restriction of mobility between one district to another district, one town to another town? Those are some things we have to keep in mind.

The third is testing, because India has increased, ramped up its testing capacity quite a bit. Still again, one of the things that we have to do and we want to do is make sure any kid that's going on the table is COVID negative, so we will be doing a COVID test on them. Currently, the way it works, again, there’s a huge regional disparity on the number of testing and the ability of testing. Kits have been in shortage for a long time in the country. That's why it's highly regulated by the government. Again, we are waiting for testing to become a little easier.

Nowadays, results take about 40 to 48 hours, maybe sometimes even 50, 60 hours, too. Again, trying to wait and see, because in some places, the timeline has already shortened, some places it's already within 24 hours, 12 hours, and you are getting a result. So, trying to figure out all of these different elements before we are able to get back to work. Currently, we are actually looking at starting the center in Bangalore sometime in August. We took a decision on it last week, but then again, in the last seven days, we are seeing there's a bit of a spike in the numbers in Bangalore. Actually, again, it's gone back into consideration.

The way I see is I think that West Bengal, Bangalore, these are going to be some of the places where we'll start first. But Bangalore is a small center where we do about 20, 25 (surgeries) a month. There's not a lot of overcrowding. Durgapur is a bigger center. But of course, once we get back, it's not going to be doing huge numbers for the first couple of months. It's going to be starting slow, getting used to the new reality is the way I'm thinking, because right from our patients to our volunteers, everyone has to get used to it. It's just a new way of living, I think.

Get there and then slowly increase the numbers at centers. In terms of missions, like Howard mentioned, of course, we are not looking at any international missions this year.

Even next year, maybe toward the financial year, May, June, if possible, we'll look at the international missions. We are looking at running some international missions in the second quarter of next year. Again, a lot of ifs and buts, it will depend on how things step up.

Laura: Great. Thank you so much. Now we're going to kick it over to John for our last few minutes here to answer some of the questions from the audience.

Audience Q&A

John: Yes, thanks. We have a question coming from Salma. Howard, I'll direct this to you. She's wondering as a high school student, she's interested in how she can contribute and help amidst the COVID outbreak. What advice would you have for her as a high school student?

Howard: Excuse me, can you repeat the question, please?

John: Sure. The question is, as a high school student, I'm very interested in how you think we can help and contribute amidst the COVID outbreak.

Howard: Okay. As a high school student, I think that what she can do now – she's from where, please, John?

John: I'm not sure. I'm sorry.

Howard: Okay. As a high school student, first, all she can do is making sure –

John: UAE.

Howard: Where?

John: United Arab Emirates.

Howard: Oh, okay. As a high school student, I recommend her for this COVID-19 outbreak to respect all preventive measures first, because it's the most important now. Because like that, she can contain the spread of the virus in her country and in her house. Also, getting all information she can (get) and spread it around her, of course, the right message to the right person because this virus is going to change our mentality. There's a lot of things that we have to change. Of course, there's a lot of things that we need to consider for the future, and all I can say now is, as a high school student, to respect all preventive measures.

John: Absolutely and Salma also feel free to reach out to Operation Smile UAE and you can inquire on their student programs and see if there's any initiatives that they have running as well. It could be a great way to get involved.

Okay, our next question is for Abhishek, and it comes from Linda. She also says this is Linda Bucher, Abhishek, someone that I know you know well, so she wishes you all the best and hopes your family is healthy and safe. You alluded to it a little bit. Is there any type of telehealth activities going on in India or Madagascar? With respect to speech therapy, nutritional teaching, etc.

Abhishek: Okay. Firstly, hello, Linda, hope you are well, and you're staying safe. Coming to the question, so see there's not a lot of telehealth activities going on, but it's more of patient assessment piece as well as trying to staying in touch with patients and provide them the right kind of guidance through those and help them get through this till we get back. In India, there isn't. Of course, there's some consultation going on need-to basis in the sense like I was mentioning in terms of the orthodontic treatment.

There are people who already have certain fixtures, and they need to twist this by one inch or one rotation every two weeks, every three weeks. Those are things that we are following up on and we are doing. Other than that, we are in touch with patients through the patient assessment piece, as well as talking to them about this schedule for treatment.

But, no, there's nothing in terms of speech therapy or nutritional teaching over the phone. I know other foundations in Operation Smile are doing it. I know Nicaragua is doing it. Absolutely. Actually, one of the countries that I oversee is doing it, and I know some parts of Russia. Russia is also doing it. They're doing speech therapy as well as some nutritional counseling over video calls as well as telephones.

In India, unfortunately, we're not doing it. We did think about it, but somehow, given the available resources, the restrictions of lockdown, we weren't able to implement it.

I think it's a great point, and we already have been thinking about it, but I think you just reiterate that maybe as we start to live with these new realities, that is something that we should consider and start developing programs and all that. Thank you, but currently, we don't have anything but we will start thinking more seriously about it and maybe have a program soon.

John: Excellent. Well, again, I just want to thank everybody for inputting your questions. I want to thank our panelists, Howard and Abhishek, for their time today. Thank you guys so much for joining us and sharing your insight with our audience and with the world. It means a lot to us. Yes, on behalf of Laura and I, we're signing off for this COVID-19 Conversation, and we'll see everybody next time.