The Palestinian Ministry of Health Is Doing Its Best

The World Health Organization has commended Palestine for the measures the government has taken to confront the COVID-19 virus. Some local Palestinians are complaining, however, about the ministry’s lack of preparedness in the face of such a challenge. How would you reply to such criticism?

I think that the Ministry of Health (MoH) is doing its best and acting in accordance with the recommendations of the World Health Organization (WHO) and international standards in terms of patient testing, the imposition of quarantine, contact tracing, and promoting social distancing and other public health interventions. The measures that were taken early on in Palestine were adopted afterwards by some other countries in the region and by some European countries. Palestine had to rely on prevention because of concerns about limited resources for tertiary care. So, there has been top political involvement in Palestine, and the state of emergency was declared quite early, probably because of our awareness of our limitations. Taking preventive measures is less costly and more feasible for us than facing a situation where many critical cases will need admittance to hospitals, ICU services, and ventilators – a situation that we would not be able to handle if we don’t do enough to flatten the curve of affected cases, given the limitations of medical personnel, equipment, and tertiary care in Palestine.

Among the people facing an anxiety-producing situation such as the current pandemic, there will be those who express anger and accusations. I understand these feelings as part of a grief reaction: people are losing their freedom of movement and their source of livelihood. There is a distressing change in everyone’s routine and a necessity to cancel important events such as weddings, travel, and meetings. I don’t think that ordinary people have enough data or expertise on the subject to judge the preparedness of the ministry, but transparency and a participatory approach taken by decision-makers that educates the public about the reasons behind their decisions will help contain people’s reactions, and I think this is what is currently taking place.

There is nothing shameful about having limited resources. We are living in occupied Palestine where we have no control over our borders to decide who can enter and who cannot; importing medical equipment has to go through many Israeli obstacles. We take pride in being aware of our limitations and being able to design effective interventions within the means that are available to us and in accordance with the best international practices.

Do you think that the means of communication (Facebook, radio) used by the MoH to disseminate information is adequate?

The ministry is using all available means to disseminate information and to engage with and simplify instructions for the public. All official and social media are being used. In addition, there is a hotline to answer people’s questions. At the level of primary health care services, medical personnel are educating people about the challenges that face Palestine and the role that any individual can play at this time. Medical personnel are explaining the need for various changes in service provision at primary health clinics, such as making medications available at village clinics rather than at central ones in order to minimize the obligation to travel, and providing chronic-disease medications for three months at a time instead of one month. What is more important than the specific means of communication is the information that is being disseminated. The precise and clearly explained information that is being shared so far is effective in mobilizing people to take the necessary steps towards infection control.

After all, we don’t have all the answers. There is a general feeling of uncertainty in all parts of the world regarding this health pandemic. This uncertainty is not unique to Palestine, and Palestinians are probably better trained to deal with uncertainty than other nations.

Does the Ministry of Health have a standard set of procedures and protocols for health institutions regarding the admission of patients with flu symptoms?

Of course it does. The ministry has estimated the numbers of people who might become infected, how many of them will need hospitalization, and how many will need an ICU. There are already established protocols and criteria, in accordance with WHO guidelines, regarding quarantine, medical isolation, hospitalization, and discharge. There will be a special work program for the medical staff involved in this emergency to minimize both the personnel gap and the possibility that they would infect others when they go back home.

The MoH has accelerated its preparedness to respond to this health crisis; it expanded the hospitalization capacity by preparing 10 corona centers in the West Bank and scaling up laboratories; similar efforts are being done in Gaza. There is a plan to recruit respirators from private hospitals when needed. The ministry has requested 200 more respirators from donors, in addition to other equipment, swabs, masks, and PPE (personal protective equipment) kits.

Does the MoH give mental health support, particularly to people in quarantine? The media seem to report that mental health-related issues have not been given priority. How can the MoH give psychological and even emotional support to those in isolation, particularly if under prolonged isolation?

The MoH sees the mental health response as an integral part of the medical response to the coronavirus crisis. Mental and physical health are interactive. If mental health improves, physical health improves, and vice versa. The MoH has created a free hotline to respond to people’s questions, to reassure them, and to provide accurate information that will minimize panic and denial about the situation. People who need psychological counseling will be referred to a special phone number where trained professionals will provide the necessary interventions.

The minister has appointed me to provide psychological support to the people currently in the quarantine. I have personally visited them and spent some time with each of them individually and provided my phone number to the medical staff and to volunteers who are taking care of them in case they need any supervision on psychological support. Since that visit, I’ve been in touch with them on a daily basis via WhatsApp and have provided support when needed. The quarantined individuals have also established a WhatsApp group to support each other, and each one of them has developed his or her own resilience plan. An important component of that plan is that they become active agents in mobilizing the community and promoting public awareness.

But our mental health response is not restricted to people in isolation nor did it start with the corona crisis. Most of our doctors and nurses are trained in the WHO’s Mental Health Gap Action Programme (mhGAP) processes that enable them to provide necessary mental health support to persons suffering from common psychological disorders, and many have been trained in providing psychological first aid as well. There will be capacity-building activities over the coming weeks.

Why has there been only a relatively low number of Palestinians who tested positive for the COVID-19 virus?

I think the small number of people testing positive is due to the methodology used by the MoH, which identifies suspected people and traces contact. In other countries, real cases (mainly asymptomatic) were estimated to be 27 times the number of official cases. In our awareness messages to people, we ask them to assume that every person is an asymptomatic positive carrier of the virus, this means that individuals must act with great responsibility to protect others from themselves and to be careful to protect themselves from others.  

I believe that this emergency situation will help us develop our psychological immunity by acquiring a sense of social responsibility, cooperation, and altruism. We will learn how to be dynamic and flexible in the face of challenges, with changing routines and developing asceticism in matters that individuals are used to.

We assume that a sufficient number of people work in the health sector. Does the ministry have any contingency plan in case the number of sick who need care – God forbid – grows exponentially?

The lockdown was imposed initially to flatten the curve, so that our hospitals and corona centers would not be overwhelmed and collapse. As cases increase, staff will be obliged to stay in the hospital for 15 consecutive days and afterwards to go into quarantine before they return home and are replaced by another team. It is going to be tough, but this is what needs to be done given the available resources. Other measures such as recruiting volunteers might also be necessary if our staff become overwhelmed with work.

It is important as well to take into consideration the psychological well-being of all the staff who will be working under additional pressure as a result of the increased burden on them, as they have to move away from their children, spouses, and families, and take more precautions than others, especially with the potential to be infected with the virus. 

Before the government declared a state of emergency, most reports shared with the public indicated that all was well, with only a few cases in Palestine.The announcement of a state of emergency took people by surprise and caused panic. With the growing number of infections, this panic has not subsided. Your comments, kindly.

I don’t think that the panic is related to the declaration of the state of emergency. The situation is declared by WHO as a pandemic, and it is taking lives, it is normal to be anxious in the face of such a threat. It is important however, to not amplify the anxiety to a dysfunctional level and create mass panic and confusion. Some manifestations of that maladaptive response include the excessive purchasing of food and cleaning materials, the misuse of gloves and masks that should be reserved for medical personnel at a later stage, and spreading rumors and misconceptions about the health crisis. Among the funniest rumors that I’ve heard are: “the coronavirus is part of the Deal of the Century,” and “the virus won’t reach people who practice wudu’ (ritual purification before prayer in Islam) five times per day!”

The anxiety of people can be expressed as a feeling of anger at governments and the medical sector and its workers. Systems that are stronger in tertiary care were more reluctant to declare a state of emergency, but eventually they had to do it. The MoH worries that our tertiary response will not be sufficient if we fail to isolate the first foci and clusters of the infection, so they have to depend on these preventive measures. Rumors and mistrust in official institutions may be the most harmful thing to people’s mental health at crisis time. Lack of medical information contributes to exaggerating fears in relation to the size of the threat. The MoH has created a dashboard and is publishing new data on https://www.corona.ps/

What measures would you suggest to deal with anxiety and panic beyond engaging in movement, for example, by dancing with children, yoga, other forms of exercise; meditation and mindfulness; spending time in nature, if possible without interacting with others, such as in a garden?

We have different advice and interventions for different categories of people according to the kind of stress that they face; e.g.: how to talk to children, how to support the elderly, people in quarantine, medical staff, etc. All that you suggest above are helpful behavioral coping mechanisms. In addition, there are a few important cognitive interventions, such as making a realistic estimation of danger. To do that, we need to distinguish rumors from accurate information and to rely on trustworthy sources. On top of all that is mentioned above is the meaning that people give to their experience. Here, we understand that people are compromising their own freedom and livelihood to protect themselves and others. This crisis is not the first for Palestinians. We are a very experienced people; we have survived curfews, invasions, and wars. I even think that we are more accustomed to living with uncertainty than most other nations.

It will also be helpful to avoid “bingeing” on news about the virus and instead continue to plan for the future with the hope that we will survive this crisis.

Special support should be provided for the elderly, as they have greater health and psychological fragility than others, so it is important to stay close to and communicate with them, taking great care not to transmit infection to them, and support them morally in a healthy way. We should not forget about their medications for other chronic diseases. We should provide them with appropriate nutrition and encourage them to get some exercise and fresh air; and we should be attentive to any symptom development, making sure that necessary health care is not delayed.

In your opinion, how should people behave in case things get worse? What kinds of food should they have in their pantry, what other personal care items should they purchase, and in what quantities?

There is no need for people to stockpile food or other items. A 14-day supply is sufficient. Bakeries, pharmacies, and supermarkets will remain open. There is no scientific evidence that alimentary changes would be helpful to face this challenge. People have a tendency to eat more when they are stressed, so storing food at home might enable them to eat too much. It is also important to not drink alcohol or smoke in a self-soothing attempt to deal with boredom or stress. All this will aggravate the physical and psychological health of people.

Palestinian volunteers wear protective gear as they sanitize a mosque to help fight coronavirus, Jerusalem, March 16, 2020. REUTERS/Ammar Awad.

How can daily routines help people cope when they are in isolation and children are not going to school?

It’s time to catch up with work left behind, relax, play with our children, learn new things, read, and exercise. Crises are opportunities. People can learn how to enjoy themselves differently. I remember a similar time during the first Intifada when schools were closed. I was in my early adolescence then. I painted the doors with varnish and read legendary fables and learned to make very interesting salads. Internet was not available, but I love how I spent my time then.

In our awareness-raising messages to people, we ask them to assume that every person is an asymptomatic positive carrier of the virus. This means that individuals must act with great responsibility to protect others from themselves and to be careful to protect themselves from others.

Have you considered offering special TV programs to engage children in meaningful activities to help them deal with anxiety and/or boredom? What is being done, and who is getting involved in such efforts?

There are already plenty of useful internet materials and TV shows to help children cope with the situation. For children, it is important that they be made aware of the situation using language that does not frighten them and that is suitable for their developmental level. It is important as well that parents do not panic in front of their children and talk excessively on the subject. This is also an opportunity to educate children about personal hygiene and fill their free time with useful and enjoyable activities, making sure that their education not be interrupted for too long a period of time, and that the children do not remain locked up at home. They can be exposed to fresh air and the sun under supervision and away from crowds or sick people.

Dr. Samah Jabr is a psychiatrist who practices in East Jerusalem and the West Bank. She is currently the Head of the Mental Health Unit within the Palestinian MoH. She has taught in local and international universities. Dr. Jabr often serves as a consultant for international organizations regarding mental health development. She is also a prolific writer and author of the book Beyond the Frontlines, Derrière les fronts: Chroniques d’une psychiatre psychothérapeute palestinienne sous occupation, which appeared in both French and Italian.
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