Facing COVID-19 and Refugee Camps on the U.S. Border.

Over the last week, COVID-19 has progressively made its way deeper into our communities, and we have reached a tipping point. Medical personnel and epidemiologists tracking the disease all agree: we aren't prepared. We desperately need an objective, evidence-based response, yet our local hospitals and health departments are operating on vastly different plans, leading to increased confusion.

Now imagine trying to develop a plan for 2000 people living in tents crammed together on the border of the United States and Mexico. With an average of 4 people per tent, communal cooking, meal distribution, and porta potties, any quarantine—self- or enforced—is nearly impossible.

Global Response Management, a U.S.-based, veteran-led medical nongovernmental organization, runs the only clinic servicing asylum seekers in Matamoros, Mexico, seeing an average of 40–50 patients per day. Many of these patients are chronically malnourished, and respiratory and gastrointestinal illnesses are common. If facing coronavirus in the U.S. health care system is perilous, fighting an outbreak in an outdoor, close-quartered community of asylum seekers is akin to Sisyphus being forced to roll a boulder uphill, only to have it roll down again. After weeks of preparation, we have now begun to put measures in place for prevention, fortification, and treatment.

How do we implement prevention in a camp where >2000 people are crammed into an area the size of 2 football fields? In a place where resources are limited, we follow a best, better, minimum strategy. We know that isolation is best, and social distancing is better, but we logistically cannot keep people the recommended 6 feet apart. We ask people to wear a mask if they are coughing. We recognize that while people are coughing during sleep, they cannot cover their mouths, so we provide them with a plastic barrier to hang in their tent at night and ask that they sleep head to foot. We ask people to call our hotline if they are sick so they can stay in their tent and we can come to them to check on them.

How will COVID-19 affect a malnourished population worn down from stress and the elements? We don't know, but we are fortifying everyone with multivitamins containing vitamin D and zinc where there are some data to show a decrease in respiratory tract infections (1,2). We are identifying individuals that are at higher risk and attempting to maximize their current health. How do we test? We can't. Instead, we use handheld ultrasound to monitor lung pleura, rapid flu tests to rule out influenzas A and B, and clinical presentation to do the rest (3).

How do we follow the treatment recommendations of intubation and ventilatory management when we have no ventilators? We can't. We will be putting them on higher dose of zinc and adding chloroquine, both of which have shown some promise in early clinical trials (4, 5, 6). We have a tent where we can place them on oxygen using concentrators. We are hoping to buy a few portable ventilators and use T tubes to extend them to 4 patients, but these are expensive, and we are short of funds (7). We will do what we can. We will attempt to transfer them to local hospitals, but they will likely be overrun themselves.

As an organization, we exist to bring the best possible medical care to people displaced by conflict, war, or disaster in high-risk, low-resource areas. We have served as an organization in Iraq, Yemen, Bangladesh, Northeastern Syria, The Bahamas, and Mexico.

Despite our history of going where others won't, to do what others can't, this might be the greatest challenge we face. Our M.A.S.H.-style infirmary tent for the sickest patients looks nothing like an American intensive care unit. It certainly won't have the amenities of one. With no running water and limited electricity in the middle of a muddy field, that won't be possible. What it will have is a team of dedicated professionals relentlessly pushing themselves to deliver innovative, evidence-based solutions and compassionate care to 2000 people fleeing violence and trauma. We are willing to cut the Gordian Knot for people who deserve dignity even in their largely invisible state.