By Samah Jabr

The COVID-19 pandemic has the seeds for a mental health crisis around the world; in Palestine it highlights pre-existing 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 (Charara et. Al, 2017). 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). 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, loss of jobs and income put additional tension on people, aggravating domestic violence sometimes. Chronic patients, 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 so the center could be converted into a corona center; we already know that a few have relapsed, some have attempted suicide, while others went to prison during the pandemic.

Outpatient governmental services in the West Bank are offered at 14 Community Mental Health Centers (CMHC), which are located in each district. Statistics from 2019 indicate that around 3,000 new patients and 92,000 activities were observed last year, yet, less than two per cent of the employees and two per cent of the budget are invested in mental health at the governmental sector.

Mental health response to COVID-19 in Palestine
As the head of the Mental Health Unit (MHU) of the Palestinian Ministry of Health, I’ve 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 Ministry of Health in regard to critical mental health issues. The priority was making sure that the mental health system would not collapse. The steps included 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. While doing the testing, patients who need further attention or are showing signs of distress would be referred to psychologists for additional treatment.

Second, it was proposed that the MoH administers a national helpline, a process which was unfortunately complicated due to a high amount of bureaucracy. By the time the necessary approval was provided, there were already many other helplines implemented by local and international NGOs. This meant there was a lack of a referral system from first responder services to second and third levels of more specialized services.

As a third component the MHU recommended to share tasks between different organisations and to distribute activities to the various local and international NGOs in order to make sure that the needs of patients are answered. It is, for instance, essential to not only provide care to patients, but to take into account the needs of their carers and other people working on the frontlines during this emergency.

The fourth point highlighted the need to prevent the health system from collapsing while the fifth point stressed the importance of ensuring the availability of psychiatric medication when needed.

The process of a mental health response was made difficult due to the historically little political support and logistical help that the MHU is enjoying 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 leads to a power struggle between NGOs, an overlap in services or the existence of many gaps and omissions and waste of resources. In addition, the weakness in the governmental system impairs the 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 in the future can be more cohesive and organised and to highlight strategies that have worked well in regard to supporting mental health workers, like weekly support groups, supervision. We are all learning how to deal with this crisis and how to provide appropriate responses on a national level.

This pandemic serves as an opportunity to improve mental health services, change negative attitudes and to encourage the Palestinian government to put their money where their mouth is in relation to mental health. This will surely help Palestinians become more proactive and united when confronted with the next crisis.

Samah Jabr MD is a psychiatrist and psychotherapist; the Head of the Mental Health Unit, Palestine Ministry of Health; and Assistant Clinical Professor, George Washington University, Washington DC, USA. She is also the author of Derrière les fronts (Behind the Frontlines). Her article appeared in MEMO.