While governments around the world embark on a race to vaccinate their populations, adopting curated policies to ensure the least number of lives lost during the pandemic, a parallel universe exists in the Occupied Territories of Palestine. The fatality rate resulting from policies promoting ethnic cleansing, blockade, and more recently airstrikes by the Israeli defense military seem to far exceed that of COVID-19. Despite being a global health concern, the pandemic is clearly not the biggest threat to the lives of Palestinians.
Only 3.9% of Palestinians in the West Bank and Gaza are fully vaccinated against COVID-19 in comparison to over 60% in Israel (as of May 23), which had one of the fasted vaccination drives in the world. This vaccine coverage should be questioned rather than praised, as the denominator excludes 5 million Palestinians living under its occupation. Despite having millions of unwanted vaccine doses, the occupying state had refused to provide vaccines to Palestinians, with the exception of workers who come into contact with Israeli citizens and a number of donations. In the past weeks alone, Israeli violence has targeted healthcare services violating the principles and provisions of International Humanitarian Law.
These crimes violate the Geneva Convention which holds Israel, the occupying power, responsible for the health of the population. The Fourth Geneva convention obliges Israel to ensure medical supplies of the population including providing preventative measures necessary to control infectious diseases and epidemics. At the very least, they have the responsibility to facilitate the population’s access to health services, which is currently prevented by the blockade.
The case of Palestine is a classic definition of health inequity. The time has come to shift the global health conversation from topical health programs through aid to more sustainable solutions that address the root cause of problems that create fragile health systems. Not only does the occupation deny Palestinians their right to healthcare, but it also completely hampers and undermines the current global efforts of controlling the pandemic.
Discrimination based on religion, gender or race is a public health concern.
Social injustice is a public health concern.
The health disparities arising from the Israeli-Palestinian Apartheid is a global health crisis which would be impossible to resolve in isolation from the broader context of settler colonialism, segregation, and the ongoing violations of human rights. Any solutions failing to address these root causes are simply treating the symptoms rather than the disease.
It's so easy to forget what a world without vaccines would look like. Would our kids be able to go to nursery at such an early age? Would we feel safe traveling the world so carefree? The answer is probably not.
To many people, vaccines are something checked off the list to allow them to send kids off to schools that would only accept them with a record. The impact they have on our lives seems almost invisible. It's easy to see why almost a century after their discovery, the importance of vaccines in our daily lives has been replaced by some doubt. Doubts about their effectiveness, because why can't we just get sick and reach herd immunity like the good old days?
In the light of COVID-19 vaccine being rolled out globally and many feeling hesitant to take them (which is understandable since it's a new vaccine), here's a quick refresher of a few diseases that would've still been around if it hadn't been for vaccines:
At the end of the day, this is what immunization and prevention programs are all about. They help you forget all about diseases so that you can live your life as "normal" as possible. The new normal that we've been living since COVID-19 began, is actually the only normal there was before vaccines were introduced. A life where infectious diseases are a risk that you learn to live with. Decades later, this generation is truly blessed to have lived through a pandemic and have a vaccine to prevent it within the same year.
Over the past years, it has been refreshing to see the openness of how people speak about mental health. There's been a huge positive shift at the social micro-level visible on social media. It has really shifted from a taboo experience to something that is bravely shared to raise awareness. The idea of seeking help from a professional has become much more accepted within Arab societies compared to previous decades. This made me wonder whether we see the same anti-discrimination leap at a macro-level? Sure, most countries have policies that protect the rights of people suffering from mental illness but the existence of a mental health legislation in a country does not necessarily guarantee that the human rights of people with mental illness are protected.
"The Joker" is a movie that does a great job summing up the structural issues within global mental healthcare in the Western world. While it's always interesting to learn more about mental health practices from the West, at the end of the day, it's one of those topics that looks very different from one region to the other.
Mental Health status in the Arab World
A study in 2013 showed that the Eastern Mediterranean Region had a higher mental disorder burden compared to the global level, with the exclusion of Egypt, Palestine ranking highest due to the chronic exposure to trauma and military violence.
Beliefs that still stop people from seeking help:
Most diagnostic and therapeutic interventions used in the Arab region are exported from more developed countries; these need to be adapted in a culturally sensitive fashion. There are many factors that are specific to the values and beliefs of the region that shape how people view mental health. In the Middle East, strong family ties are viewed as something very sacred. While this is a beautiful value to uphold, it often translates into one's individual behavior being a mirror of the families reputation. The stigma that accompanies mental illness is reflected on an entire family rather than just the individual. Another factor is the belief amongst Muslims communities in the region that strong faith could help treat illnesses such as depression and schizophrenia. Rather than turning to psychiatrists, many would prefer seeking spiritual guidance.
Mental Health Stigma in Healthcare:
How many times have you visited your physician complaining about chronic physical or mental discomfort only to have it belittled and brushed away with some pain killers? How many times was unexplained pain not taken seriously? This is an issue with a lot of primary healthcare delivery institutions. Lack of training and stigma towards mental health still occurs within primary healthcare institutions which is sometimes the patient's first point of seeking help.
Real socio-cultural change will happen when patients with mental illness visit a healthcare setting where their human rights are openly respected and their condition is accepted by a health professional who has no stigmatizing judgments about the patient or their family. To normalize and increase mental health services, social and religious practices that shape how mental illness is viewed in the region need to be acknowledged and incorporated in to best practices to make seeking and following treatments more acceptable.
There are still milestones to be celebrated with more funds being directed into researching mental illness and promising legislations being rolled out in more countries. Psychiatric services in the Arab world are gradually being replaced by psychiatric units in general hospitals, and mental health training for physicians and other health workers at the primary health care level is becoming available in a large number of countries. This will hopefully reflect positively on how people experience mental healthcare in the years to come.
How is public health different from clinical healthcare? This is a question that I often get asked. The simplest way to answer it is that public health deals with health from the perspective of populations rather than individuals. It extends beyond the individual and focuses on the health outcomes of an entire group, community, culture or country. Public health takes into consideration the social determinants of health which includes socioeconomic status, education, income and access to healthcare. These factors, along with behavior, influence health and may contribute to the success or failure of a treatment. It's also about monitoring trends of diseases, and understanding why and whom they affect, hence using this information to influence health policies and practice.
On the other hand, clinical healthcare providers (e.g. physicians, nurses, hospital administrators) help individuals with their personal health issues. Their primary role is diagnosis and treatment of illness in individual patients. Hospital administrators focus on the efficient management of a healthcare facility, ensuring they operate within budget without compromising the quality of care provided to individual patients.
To illustrate this in an example, let's look at the handling of cardio-vascular diseases by both perspectives. A physician's role would be to listen to the patient's complains, perform the necessary tests and prescribe the appropriate medicine's that would improve symptoms and reduce the risks of death from cardiovascular disease (CVD).
A public health perspective identifies that the major risk factors for cardiovascular disease are poor diet, physical inactivity and tobacco use - explaining 75% of new cases of cardiovascular disease and without these risk factors CVD is a rare cause of death. This shifted focus from individual research towards identifying ways to enable populations to lower their risk of CVD. This redirection of resources towards population-wide measures needs to be supported by government leadership.
How can this be translated into prevention priorities?
At the end of the day, public health and clinical practice are not mutually exclusive and both approaches compliment each other. If public health professionals do their job right, this should improve clinical outcomes. There has already been a lot of effort in the past decades to consolidate efforts on both sides and integrate them as preventive medicine. This includes immunization programs, nutrition counseling, smoking cessation clinics and other lifestyle services. Other ways to track and incorporate population health is to expand intake of centralized data to include patient socioeconomic factors which can be allow clinical care to address health problems more effectively. Moving forward, it is necessary that public health and health care recognize their overlaps and possibilities for mutual progress.
Today's news of pausing the Astrazeneca/Oxford vaccine has been alarming to many. Here's the breakdown:
In clinical trials, there are 2 entities that ensure the safety of a new drug. There's the IRB/Ethics committee who provide the approval that it's safe to start the study. Then there's the Data and Safety Monitoring Board (DSMB) which is an independent committee of experts who have no conflicting interest with the success or failure of the drug and regularly monitor the data from the trial. Before a trial starts, the protocol specifies any adverse events that would call for it to be paused or completely stopped.
It's reported that the vaccine was paused by the DSMB to investigate the event of a volunteer falling sick to ensure that it's not related to the vaccine. This is actually the second time that the trial is paused, which is very common during trials.
I'll leave it at these 2 positive thoughts:
1) Those who are making sure the vaccine is safe are doing their job, in spite of so much political pressure to have a vaccine available! Hopefully, it will resume again.
2) There are 8 other vaccines in phase 3 clinical trials (which is the last phase before it's widely available to the market)