Offline: A different kind of lockdown

Abstract

In April, 2019, Dr Mai Alkaila became the first woman to be appointed Minister of Health in the occupied Palestinian territory. An obstetrician and gynaecologist by training, she later earned a PhD in health policy and systems. But she also had a taste for diplomacy and has served the State of Palestine as Ambassador to Chile and Italy. Perfect credentials, one might imagine, for a role that comes with already delicate political challenges. And then the COVID-19 pandemic struck. How was a divided land and a divided government under occupation going to handle a health emergency that was confounding even the most united of democracies? Last week The Lancet Palestinian Health Alliance held a virtual workshop to review the COVID-19 pandemic from local Palestinian and regional perspectives. The health system across the territory—the West Bank, the Gaza Strip, and East Jerusalem—is fractured. Services are delivered through a patchwork of providers: the Ministry of Health, the UN Relief and Works Agency, non-governmental organisations, and the private sector. Despite this fragmentation, Dr Alkaila described how Palestine enjoys high primary and secondary care coverage—for example, 749 primary care centres, almost two-thirds run by her Ministry of Health. The country's health indicators bear good comparison with other Arab nations in the region. Life expectancy is 74 years in Palestine, whereas the regional average is 71·4 years. When COVID-19 struck in China, Dr Alkaila set three goals. First, to ensure the continuity of essential health services. Second, to provide specific preventive and diagnostic services for COVID-19. And third, to strengthen the health system in preparation for COVID-19. She set up a command and control crisis management apparatus—the National Emergency Committee—that coordinated surveillance, health system responses, emergency protocols, and research. Crisis management teams were set up at district level. And WHO's Office for the occupied Palestinian territory, led by Gerald Rockenschaub, provided additional technical assistance. The first cases of COVID-19 were reported in March. Sporadic spread with small clusters of cases took place from April to June, but community transmission took grip in July. Clear and consistent communication to ensure community awareness has been a high priority, with print, social media, radio, and television campaigns to emphasise the importance of personal hygiene, physical distancing, and self-isolation if contacted. Triage and quarantine centres were set up in each Palestinian governorate. A mobile app was developed—Amankom: Fight Covid-19 in Palestine—for contact tracing. Laboratory testing capacity was expanded. Seven special treatment centres were built to create over 600 COVID-19 beds. Intensive care capacity was increased to over 150 beds and 189 ventilators. National protocols for treatment were developed with the assistance of WHO. Supplies of personal protective equipment were procured. Infection control in hospitals was strengthened. Cases began to rise in the West Bank during June, peaking in September, with most infections being reported among people aged 20–29 years. And by contrast with many other countries, women made up a majority of cases (55%). The R0 value reached almost 2 in June. It now stands at 0·95. As of Nov 3, almost 60 000 infections have been reported in the West Bank and 7000 in the Gaza Strip. These figures are likely underestimates, of course. And numbers of infected health workers are now increasing. Palestinians have faced unique challenges during the pandemic. Control of borders, restriction of movement between districts, barriers to referring patients, limited access to East Jerusalem, the geographical separation between the West Bank and the Gaza Strip, and worsening social determinants of health. Add to these difficulties a financial crisis for the Palestinian state, shortages of health workers, pre-existing stresses to the health system, and community resistance to the reality of the pandemic. But, according to the Johns Hopkins Coronavirus Resource Center, the West Bank and the Gaza Strip have a COVID-19 death rate of 11·2 per 100 000 persons. The UK's death rate is 73·9. In the USA, the figure is 72·6. Something has so far gone right for Palestine. Professor Abdullatif Husseini, Director of the Institute of Community and Public Health at Birzeit University, said “We are lucky.” The situation could change. But he also noted, “We learned again how to work together.”