Salam Khashan & Danya Qato
Middle East Report Online / April 2, 2020
Danya Qato, an epidemiologist at the University of Maryland, Baltimore, interviewed Salam Khashan, a physician at Nasser Hospital in Khan Yunis, Gaza, Palestine on March 28, 2020, about the decimated Palestinian health care system and what this means for Gaza as COVID-19 looms.
Since the economic blockade against Gaza was imposed by Israel 13 years ago, there has been a sharp decline in the health of Palestinians living there. Health infrastructures, including hospitals, have also been deliberately targeted in Israeli military strikes. Blockade and attacks have led to a health system that is increasingly unable to provide care to the population. The interview was conducted in Arabic and English. The transcript was edited for clarity.
Q: Can you describe the barriers to public health and health care provision you experienced in Gaza before the emergence of COVID-19?
A: Before COVID-19, because of the economic blockade of Gaza by Israel, there were problems in all aspects of our life, including medical life. We don’t have enough hospitals, or primary care centers, we don’t have essential medications—about 50 percent of essential medications and supplies are not available—and even basic medical equipment like gloves, glucose test strips, pulsometers, and more, are not available in sufficient quantity.
We don’t have enough hospitals, or primary care centers, we don’t have essential medications—about 50 percent of essential medications and supplies are not available—and even basic medical equipment is not available in sufficient quantity.
The problem with the capacity of the medical system predates COVID-19 and was very stressful. We’ve always had a problem with the high number of patients. For example, recently I worked in a United Nations Relief and Works Agency (UNRWA) primary care clinic in Khan Yunis, and each day I had to see at least 100 patients in that shift (typically from 7:30 am to 1pm). That means I only have two minutes for each patient. That’s simply not enough time to do a comprehensive medical history and full physical exam.
In the Nasser Hospital Internal Medicine Department, one of the problems we’ve had to deal with is the lack of availability of medications. We may ask the pharmacy, for example, for ceftriaxone (an antibiotic) for patients with urinary tract infections and they tell us it’s not available and we have to choose an alternate medication. For patients with diabetes, we ask for glucose test strips to monitor their plasma sugar levels, and we’re told they aren’t available.
I also work in the government-run primary care centers, and some patients visit me more than four times, not because they have a new complaint but because they are checking to see if their medication is now available. Patients with chronic conditions like bronchial asthma, hypertension and diabetes mellitus have to have their medications on a daily basis and they don’t have the money to buy their own medications. The government can’t supply them because 50 percent of medications are not available, so I have to tell them to try again in another week or a few days.
Q: What happens to these patients if they can’t get their medications?
A: Some patients manage to buy the medications on the private market, or they have a chance to follow up with UNRWA, or they go without. For example, if I’m a patient I may go to UNRWA and if they don’t have the medication, I go to the government centers. So some patients find a way to use two systems to supply their medicines. If one doesn’t have it, they resort to the other. Patients who can’t afford to buy medicines or aren’t covered by UNRWA remain without medication and their health outcomes are not controlled in terms of their blood glucose, blood pressure and asthma exacerbations.
Q: When you say 50 percent of essential medicines are not available, do you mean at the clinic or in all of Gaza?
A: At the Ministry of Health government clinics. Even at UNRWA we have shortages. In my experience, sometimes we don’t have azithromycin (an antibiotic), for example, for patients with respiratory problems and sometimes we run out of medications for bronchial asthma. In many cases, we don’t have the medication in all of Gaza, and even though we know the diagnosis and management plan, we have to refer the patient out of Gaza just to get their medications, especially medications like immunoglobulins or chemotherapy. These are among the medicines that are prohibited entry into Gaza by the Israeli government because of their supposed potential for “dual-use.”
Q: What other barriers to care did you see prior to COVID-19?
A: There are two million people in the Gaza Strip and there are only 22 UNRWA clinics. We have a shortage of primary health care centers and the number of hospital beds in relation to the number of people, that’s a problem. We also have a problem with electricity cuts. Many patients rely on equipment that is dependent on electricity, for example ventilators or dialysis machines, especially in the intensive care units (ICU). Our electricity is not reliable, it goes on and off in 8 hour cycles. In the hospital, while there is a generator, if one doesn’t work, it disrupts care and forces us to delay care that puts patients at risk.
Q: Is there a difference in the situation now with COVID-19?
A: As of today, we only have a total of nine cases in Gaza. We don’t have the problem yet of running out of ICU beds, or ventilators, or medications that are needed to care for COVID-19 patients. But we anticipate that this will change, and this is causing us stress as health care providers.
We know that if all health care personnel, including all the nurses and staff, used personal protective equipment appropriately they would be gone in less than a week and we haven’t yet begun to deal with the full crisis.
Now, we are trying our best to protect ourselves by using personal protective equipment (PPE), but there isn’t enough. For example, in the hospital where I work, my colleagues and I have asked for masks and it’s been difficult to secure them. Once we did secure them, we were told we had to use the same mask for the entirety of our shift, which is 24 hours. We don’t have enough to protect ourselves, and we know that if all health care personnel, including all the nurses and staff, used PPEs appropriately they would be gone in less than a week and we haven’t yet begun to deal with the full crisis. Even now, the Ministry of Health has told us that while there are a few cases, up until now they have been contained and are quarantined and are not cases in the community. But because of asymptomatic carriers, I should still be using PPEs during all my shifts and we are now in discussion with each other and with suppliers about how we can manage the supply chain and prioritize PPEs as the situation worsens.
Q: What’s your biggest fear if COVID-19 cases increase in Gaza?
A: It will be a disaster. We’re talking about two million people living under a blockade enclosed in a total geographic area of 365 square kilometers (226 square miles) with high population density. Based on epidemiologic estimates, approximately 80 percent of the population will be infected, with 20 percent of these cases expected to be severe and 5 percent will require ICUs. Currently we have 60 ICU beds and 56 ventilators in all of Gaza for two million people. If the curve spikes so that cases happen all at one time, we aren’t going to be able to absorb them and stem the tide.
Also, the hospital beds that are available in Gaza as a whole, not more than about 2000 in total, won’t be enough for even a quarter of the population that would need care. The biggest fear is that the health system will collapse and won’t be able to accommodate the surge.
The government can’t impose a strict curfew because it can’t afford to compensate people for lost wages and provide necessities like water and food.
In terms of limiting exposure, it’s also very difficult to convince people to stay in their homes. We live in an economic situation that requires people to go out every day to make a living day-by-day. The government can’t impose a strict curfew because it can’t afford to compensate people for lost wages and provide necessities like water and food. Also, our cumulative stress and trauma affects our behaviour. Of course life and death always matter, but we’ve been through so much trauma and war. Imagine someone who has survived constant military assaults, who has seen their home destroyed and their family killed, the threshold for this person to experience fear and make informed decisions is high.
Q: What is the Ministry of Health in Gaza doing now and what plans do they have if the situation gets worse?
A: A lot of decisions and changes have been made to address, contain and prepare for COVID-19. At the first stage, when we didn’t have any cases yet, any person that came from abroad was required to sign an agreement to self-isolate for 14 days. After a few days, the Ministry of Health discovered that these people were not in fact self-isolating. So there was a decision to convert school buildings (which had been closed) to quarantine centers for those coming from abroad. It was then that the two positive cases from those who recently travelled to Pakistan came to light. This forced a further escalation in strategy. The government prohibited gatherings of 100 or more people, including Friday prayers. Wedding halls and public markets were closed. Then seven cases emerged from those who were in contact with the two original positive cases. They were transferred to a special hospital constructed specifically for quarantine near the Rafah border crossing. Then, in anticipation of the increased cases, all patients in the European Gaza Hospital in Khan Yunis, were transferred to the Hilal Hospital. This will allow the European Hospital to serve as a hub of care exclusively for patients who are COVID-19 positive.
Q: What about the government in the West Bank?
A: The two Ministries of Health work separately, even before COVID-19 emerged. For example, the West Bank ministry asked all female physicians who have children to stay at home, while here we didn’t implement that policy. Two different government ministries, each with their own work and policies. The World Health Organization (WHO) has helped with providing some PCR kits to test specimens for COVID-19. We’re also making requests for ventilators for future use and hoping that Egypt may lend support as well. Even if another country does decide to help, it simply will never be enough. Look at these so-called developed countries, they haven’t been able to provide care and enough equipment for its citizens. You can imagine our situation in Gaza will be much more difficult.
Q: How accessible is testing for COVID-19?
A: This is a problem because we have a limited number of tests. We’re only able to test those with symptoms (fever, cough, chest pain, dyspnea), and we’ll use the limited number of kits for these cases. Even the first two cases in Gaza, who had been in isolation, were only tested after it was discovered that they were in contact with a group of travellers returning to the West Bank who had themselves tested positive.
Q: In general, what do you see for the future of health care in Gaza?
A: Of course, I’d like to paint a positive, hopeful picture full of life, but for Gaza—with the blockade and with the general global sentiment that is indifferent to the suffering due to the blockade—I think the situation is going to stay the same and likely get worse with the increase in population and the deterioration of our health care system over time. We don’t have the capacity to rehabilitate and rebuild our infrastructure.
If we want to advance and improve the health care system we need the border crossings to open to allow entry of essential medical equipment and supplies, allow us to build new hospitals and new centers.
The subject of our health is woven into the reality of the blockade. If we want to advance and improve the health care system we need the border crossings to open to allow entry of essential medical equipment and supplies, allow us to build new hospitals and new centers, send our health professionals to receive advanced up-to-date training abroad. These questions of health cannot be separated or disentangled from the blockade. At the same time that the population size is increasing, the health system is fatigued and getting worse. We hope the situation at least stays the same and doesn’t get worse.
Q: What is a message you’d like to convey to your colleagues abroad?
A: COVID-19 is a global challenge and we need to tackle it collectively because in the end, even if this virus is a negative force and an enemy, it gives us an opportunity to work together, fight together and support each other and transcend politics in the process.
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