The COVID-19 pandemic has sown the seeds of a mental health crisis around the world; in Palestine it highlights preexisting challenges in mental health provision. Although Palestinians have survived previous episodes of collective anxiety, restriction of liberties, uncertainty, and loss, the pandemic uncovers a historically neglected mental health system which is currently facing a double struggle of COVID-19 and the ongoing Israeli occupation. Yet, this crisis can be used as an opportunity to correct the wrongs and advocate for strengthening the mental health system in Palestine.
It has been claimed that among countries in the Eastern Mediterranean region, the country with the greatest burden of morbidity due to mental illness is Palestine.*1 Mental illness is one of the most significant public health challenges in Palestine due to the context of chronic occupation and the exposure to violence (WHO, 2019).*2 The anxieties and fears of facing a pandemic are now added to preexisting vulnerabilities. The need for mental health services is expected to rise as stress factors, such as social isolation, health-related fears, and loss of jobs and income put additional pressure on people, sometimes aggravating domestic violence. People with chronic illness, especially psychiatric patients, encounter additional challenges. Among the first affected patients were drug addicts seeking rehabilitation at the Palestinian National Rehabilitation Center in Bethlehem. They were discharged in order to convert the center into a coronavirus center. We already know that a few have relapsed, some have attempted suicide, and others went to prison during the pandemic.
Outpatient governmental services are offered in each district in the West Bank through fourteen community mental health centers. Statistics from 2019 indicate that around 3,000 new patients and 92,000 activities were observed last year, yet, less than 2 percent of the employees and 2 percent of the budget are invested in mental health in the governmental sector. Nongovernmental organizations, ubiquitous within the mental health domain, offer psychosocial and counseling services. The YMCA completed an extensive survey in 2014 and found that there are 148 organizations that provide mental health services, 109 of which are nongovernmental organizations, 27 private-sector organizations, and 7 international organizations, as well as the Palestinian Red Crescent Society and the United Nations Relief and Works Agency. This variety of organizations can be an asset as well as a complication in providing a cohesive mental health response in times of crisis.
The mental health response to COVID-19 in Palestine involved a multi-step plan to prevent the collapse of the mental health system, in addition to providing psychological first aid to COVID-19 cases and their family members, providing counseling services via helplines, distributing various types of services among the organizations engaged in the field, and ensuring the availability of medication.
As the head of the Mental Health Unit (MHU) of the Palestinian Ministry of Health (MoH), I have been involved since the beginning in providing a mental health response to the pandemic, drafting recommendations and pushing against bureaucratic resistance for their implementation. The MHU developed a five-step plan that was issued to the MoH with regard to critical mental health issues. The priority is to prevent the collapse of the mental health system and to ensure that support be provided to the general public, health workers, and patients and their families, which involves strengthening services as well as documentation and research. The specific steps of the plan include providing psychological first aid to people who tested positive for COVID-19 and their family members, with special attention to children. It was recommended that the health workers administering the testing for COVID-19 should be responsible for informing the patients about the possibility of receiving psychological first aid which would then be provided by trained professionals. During the testing process, patients who needed further attention or who were showing signs of distress would be referred to psychologists for additional treatment.
Second, it was proposed that the MoH administer a national helpline, a process which was unfortunately complicated due to the numerous layers of bureaucracy. By the time the necessary approval was provided, there were already many other helplines being implemented by local and international NGOs. It was concerning to see that the majority of these helplines, possibly due to the quick implementation, lacked standard operating guidelines on confidentiality and clarity regarding the training and supervision of those who provide the services. In addition, there was no protocol for guiding the work of the counselors and ensuring the quality of services. Another issue was the lack of referral system from first-responder services to second and third levels of more specialized services. Some hotlines employed highly specialized staff who were, however, confronted with logistic concerns, such as the provision of food parcels, which illustrates that the capacities and expertise of staff were not well used.
Mental health is an asset, especially in a nation such as Palestine, where it is being targeted.
So at the MHU, we gave up the helpline so as not to replicate existing services and thus create more confusion for people in need of support. Instead, a number of changes to the existing system of helplines were proposed, and it was suggested that the ministry would endorse one hotline, which is closest to the quality criteria for providing services, and develop a referral system that could utilize other highly specialized professionals. After taking steps to further improve its services, it would be considered the national hotline for remote services. This was done in order to avoid any overlap among the many already existing services.
As a third component, the MHU recommended that tasks be shared among different organizations and activities distributed to the various local and international NGOs in order to respond adequately to patient needs. It is essential, for instance, to not only provide care to patients but to take into account the needs of their caregivers and other people who work on the front lines during this emergency. The fourth point highlighted the need to prevent the collapse of the health system, whereas the fifth point stressed the importance of ensuring the availability of psychiatric medication when needed.
Mental illness affects one in five Palestinians, causing immense suffering with a great cost to the nation’s society and economy.
Furthermore, the MHU developed recommendations for all fourteen governmental community and mental health centers to implement high-quality remote services. In order to encourage patients to stay at home, those with severe mental health disorders were particularly targeted since the necessary information and guidelines might not have reached them. Telephone follow-up on mental health patients was advised in order to refer patients to the nearest clinic that offers mental health services. Communication with family members was proposed to ensure that medication for chronic illnesses was not overlooked and to give recommendations on communication styles at home, since it is known that high emotional expression contributes to relapses in psychological disorders such as schizophrenia. Family members were advised on how they can help to contain emotions and support patients in coping with this difficult situation.
Another recommendation centered on ensuring the provision of medications for patients in need by making them available in all districts in Palestine, especially in smaller towns and villages. Since it was not advised for people to leave their houses, home deliveries were also arranged. Psychiatric medication was supplied to stable chronic patients for a period of three months instead of one month so that continuous access could be guaranteed.
Emphasis was also put on the importance of documentation of remote services for mental health patients so that a continuity of information could be assured. Finally, an appeal was issued for close collaboration between doctors who provided COVID-19 interventions and mental health professionals. It was also recommended that primary healthcare provide the necessary logistic support to mental health professionals, enabling them to implement the necessary steps.
The Mental Health Unit at the Ministry of Health is currently drafting the National Mental Health Strategy, the National Suicide Prevention Plan, and the Palestinian Mental Health Act.
In addition to providing these recommendations and plans, the MHU was consulted by some national and international NGOs in regard to mental health issues. In an attempt to ensure that quality services be provided to the patients in need and to offer mutual support and peer supervision to mental health professionals, the MHU hosts an ongoing weekly open webinar that began in mid-March to present new relevant material related to a mental health response during COVID-19 and to help coordination efforts among different stakeholders.
The MoH was keenly aware that providing mental health care in such an unprecedented and challenging situation was a work in progress that required reflection and communication between different actors, since there were no ready answers available, and the situation and level of information regarding COVID-19 and the appropriate responses were evolving continuously. The meetings aimed not only to gather feedback about the work of engaged health professionals, who were either on the staff of organizations or volunteers who were enthusiastic about learning more in regard to providing mental health care, but also to support them psychologically and professionally. Similarly, meetings were held in an attempt to respond to the difficulties of streamlining a cohesive service of hotlines and to alleviate concerns about the quality of services. It could thus be assured that the work of the counselors who were operating the hotlines was strengthened.
The MHU has also been disseminating information and sharing it with a wide audience by giving frequent television and radio interviews and publishing articles in local and Arab media that focused on mental health and fighting misconceptions and rumors related to the pandemic. Topics that were covered were relevant to the Palestinian context and centered, for instance, on how to talk to children, the needs of elderly people, or how to sensitize laborers about COVID-19 without stigmatizing them. The MHU is also currently taking part in a research project examining the solidarity, stigmatization, and discrimination faced by patients and families following the diagnosis of a family member with COVID-19. It also aims to identify and help remove barriers to patients’ reintegration into the community.
The MHU organized a thematic group meeting on April 20 that gathered representatives of many organizations that provide mental health and psychosocial support (MHPSS) services. The meeting focused on analyzing the strengths and challenges of the mental health system in order to develop recommendations that are suitable and effective in the current situation. One of the main challenges was a delayed implementation of the emergency action plan and a lack of coordination in the MHPSS response due to the number of different actors involved. The development of an elaborate national action plan for a response that provides MHPSS services to those affected by COVID-19, directly and indirectly, was the good fruit of a somewhat uneasy meeting.
The process of a mental health response was made difficult due to the historically little political support and logistical help that the MHU is receiving due to ignorance or negative attitudes towards mental health in general. This has resulted in long delays in communication with other actors. This weakness in the governmental system has led to a power struggle and overlap between NGOs. Yet, there exist many gaps and omissions of services, as well as the waste of resources. In addition, the weakness in the governmental system impairs quality assurance and the standards of care in mental health in Palestine.
We believe it is important to be aware of these struggles so that a response to a potential second wave or similar outbreaks in the future can be more cohesive and organized. We must highlight strategies that have worked well in regard to supporting mental health workers, such as weekly support groups and supervision. We are all learning how to deal with this crisis and how to provide appropriate responses on a national level.
To succeed in helping Palestine truly get back on its feet, the Mental Health Unit needs political and logistic support as well as increased funding.
Mental illness causes immense suffering among at least 20 percent of Palestinians and has long-term social and economic costs to society. Palestine will not get back on its feet without giving the mental health of its citizens high priority on the public health agenda. We must redress the historic underinvestment in the field of mental health. For this to happen, the MHU needs top political and logistic support as we are drafting our National Mental Health Strategy, the National Suicide Prevention Plan, and the Palestinian Mental Health Act. Local and international stakeholders need to coordinate their efforts in supporting the MHU to ensure the widespread availability of high-quality, cost-effective services that minimize the gaps in mental health and avoid overlap and waste. If we wish to increase the quality of services in Palestine, it is essential that we create practice protocols and guidelines, standard operating procedures, quality assurance, and clinical audits in mental health. This is a collective work and effort, however, that cannot be done by the MHU alone.
Mental well-being is a national asset, especially for a nation like ours that has been robbed of its natural resources and whose mental health is targeted. Thus, it becomes a collective responsibility and a national priority to give more attention to mental health. This pandemic must be considered an opportunity to improve mental health services, change negative attitudes, and encourage the Palestinian government to put its money where its mouth is with regard to mental health. If taken seriously, such measures and care will surely help Palestinians become more proactive and united when confronted with the next crisis.
*1 Raghid Charara et al., “The Burden of Mental Disorders in the Eastern Mediterranean Region, 1990–2013,” Plos One, January 17, 2017, available at https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0169575.
*2 “The closing ceremony of the mental health project in the occupied Palestinian territory,” WHO, June 13, 2019, available at http://www.emro.who.int/palestine-press-releases/2019/the-closing-ceremony-of-the-mental-health-project-in-the-occupied-palestinian-territory.html.