"If we step on this landmine, we will see entire psych wards infected"

With not enough protective gear, years of neglect, and marginalized populations not always capable of understanding, Israel's psychiatric hospitals warn of disaster

With not enough protective gear, years of neglect, and marginalized populations not always capable of understanding, Israel's psychiatric hospitals warn of disaster

With not enough protective gear, years of neglect, and marginalized populations not always capable of understanding, Israel's psychiatric hospitals warn of disaster

Doron Avigad

Photo: Shutterstock

March 31, 2020

Summary

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hirty־three Holocaust survivors, advanced in age and therefore part of the population most at risk of the coronavirus (Covid–19), are residents of one of the facilities supervised by Professor Yechiel Levkovitch, the head of the Beer Yaakov־Ness Ziona Mental Health Center. He knows them well, these walking miracles who carry traumas from the past that are almost too hard to bear, and it is with a heavy heart that he has decided to put the institute that houses them on a complete lockdown.

"I’m not sleeping at night," he admits. "The danger of infection at the hospitals and mental health facilities is enormous. We also know that from data obtained from mental health facilities in South Korea that faced the coronavirus. Luckily, we have amazing teams who are showing exceptional compassion that doesn’t receive enough media attention. Their praise remains unsung. They and the management face incredibly hard dilemmas each and every day and are forced to make difficult decisions: for example, putting a care center for Holocaust survivors under lockdown."

How does the daily routine look under the threat of infection־how are you keeping safe?

"We are keeping in contact remotely via phone calls and video calls with families," Levkovitch said. "Patients who can be released go back home. In addition, we have set up a telemedicine system for all out patient care. We have a helpline for employees and their families. We are still short on masks and the means to run tests for coronavirus. We are not high on the healthcare system’s priority list, but we hope this will improve. Currently, we are managing the shortage and trying to prevent mass infection within this vulnerable group."

Dr. Zvi Fishel: "There is unbearable crowding, and it’s very difficult for our patients, considering their psychotic conditions, to adhere to the Ministry of Health's regulations such as frequent handwashing, social distancing, and not touching one’s face."

"We have four main objectives now: taking care of our hospitalized patients; providing a home for special needs groups such as at־risk teens and Holocaust survivors; providing assistance to the very anxious general public; and taking care of the medical personnel themselves־the people who must arrive at work every day and are at immediate risk of infection."

Mental health-years of neglect

The information released by the Ministry of Health every few days regarding the number of medical personnel in quarantine is undoubtedly a source of concern. The last update placed their number at no less than 3,647 doctors, nurses, and auxiliary personnel with another 108 medical personnel confirmed to be carrying the virus.

When dividing the medical system according to specializations, the psychiatric hospitals have managed, to date, to remain at the bottom of the list with only 71 personnel in quarantine compared to 2,139 from the general hospitals, 919 from the four health maintenance organizations, 163 from the Magen David Adom (MADA) emergency service, and 77 from geriatric centers. But no one is under the illusion that it will stay that way.

"It will be very hard to prevent the infection of patients and medical personnel in the psychiatric wards," said Dr. Zvi Fishel, chair of the Israel Psychiatric Association and department head at the Geha Mental Health Center. "There is unbearable crowding, and it’s very difficult for our patients, considering their psychotic conditions, to adhere to the Ministry of Health's regulations such as frequent handwashing, social distancing, and not touching one’s face. We fear that once there is one case, it will spread like wildfire."

Professor Yechiel Levkovitch: "I’m not sleeping at night. The danger of infection at the hospitals and mental health facilities is enormous. We also know that from data obtained from mental health facilities in South Korea that faced the coronavirus."

As far as anyone knows, this first case that Dr. Fishel so fears has not yet occurred. "If we step on this landmine," he warns, "we will see entire psych wards, entire hospitals, infected. Entire teams will collapse and be unable to work־and, ultimately, we will see very high percentages of confirmed cases, critical patients, and perhaps even deaths among our populations and our personnel. We are crying out for protective gear to prevent our teams from carrying the virus into the wards. Our wonderful teams are irreplaceable; this is a very problematic situation."

Do you still not have any protective gear?

"Last week, instructions were issued, for the first time, by HMO Clalit־and I assume the health ministry will follow־that any caregiver who cannot observe a 2־meter distance from patients will be provided with a mask. These are simple surgical masks that prevent the staff from spreading the infection, but they do not necessarily prevent them from being infected. We received gowns so that we don’t go home in the same clothes, but there are no surgical gowns, for example, in stock at the moment."

Do you feel the mental healthcare system is being overlooked during the current crisis?

Mental healthcare systems the world over, and all the more so in Israel, have been neglected for decades־from funding to facilities, hospital beds, and medical, paramedical, and nursing personnel. Today too I feel that we are given belated or delayed consideration. Those in charge just don’t understand what it means to translate the relevant regulations for the mental healthcare sector. I therefore warn them again and again: Be careful, there is a landmine here that we mustn’t step on; this is a population that cannot follow your guidelines, and so we need to take things to the next level of performing tests."

"We cannot arrive at the worst־case scenario of entire wards becoming infected. We need to safeguard the weakest of Israel's population," said Dr. Fishel. "The strength of a population is measured by how it takes care of its weakest members. And our weakest members right now are the elderly, the physically sick, and the psychiatric patients. One must remember that psychiatric patients also have associated conditions such as obesity, diabetes, hypertension, and heavy smoking. They are predisposed to complications should they be infected with the coronavirus, and we need to be careful."

Patients struggle to obey the guidelines

Israel currently has over 4,000 hospitalized psychiatric patients in specialized mental health hospitals and in psychiatric wards in the general hospitals. "The patients understand the situation, and 99% of them try and cooperate," said Professor Levkovitch, who also heads the Psychiatry School of Continuing Medical Education at Tel Aviv University. "It is perhaps surprising that someone in a psychotic state can still comprehend reality. Patients do, however, sometimes find it difficult to follow the health ministry's instructions."

"Our patients are, overall, exemplary. They understand the situation. They are not anxious. Everyone is asking me about the tremendous anxiety we must be feeling in our wards, and I keep saying that all the tension is experienced by us־the staff. We are apprehensive of what is to come. The patients are not anxious. For people with psychosis, the internal world is threatening and the external world is irrelevant. However, a small number of the patients really do not understand־and that is difficult. They pass cigarettes and phones between them or eat from the same sandwich or snack, and it will therefore be very hard to prevent infection."

How can that be managed?

"We are pressing for the establishment of wards dedicated to psych patients with coronavirus," said Professor Levkovitch. "This way, the psychiatric patients will receive treatment, and we will prevent the virus from infecting entire wards. A first ward of this kind was opened last Wednesday in the Sheba Medical Center at Tel HaShomer. Of course, psychiatric patients infected with coronavirus who are in a more serious condition will be transferred to a general hospital. We will not allow a situation where a patient is prevented from receiving optimal care just because they are a psychiatric patient."

"Alongside the medical personnel," said Dr. Fishel, "those who are even more worried than the patients themselves are their families, who know them better than anyone else and know how unlikely they are to obediently wash their hands or calmly answer a police officer who stops them while they are wandering around the neighborhood."

Every such action, which most of us now execute almost on autopilot, can explode within seconds. "The families understand that you can't really tell these patients what to do, even if you are a police officer. Therefore, and because it seems that the Home Front Command is now taking control of things, I would like them to take the mental health patients into consideration as well. They need to have a list of names of people who cannot take care of themselves."

A pressure cooker in each and every home

Beyond the existing distress within the mental health facilities, it is clear that the current situation, in which people are cloistered within their homes, each with their own "pressure cooker," constitutes a great challenge for the mental health of many among the general population.

"To our surprise, the number of visits to emergency psychiatric care facilities has not changed," said Professor Levkovitch. "But we are treating thousands of people who are approaching the clinics and day care facilities, and we can tell that anxiety is on the rise. I can see it with my personal patients. It is very difficult to be locked up at home, and anxieties about livelihood play a major part in the current crisis. People are worried about their financial future. The situation of being imprisoned within the same space is hard on couples and on people who live alone, and very hard with children as well."

According to Dr. Fishel, "there is an increase in the number of people seeking treatment due to matters related to coronavirus. Until now, that increase was manifested mostly via communication with family practitioners, general ER, and emotional first aid services like ERAN. However, there is a limit to the containment capability of the first response system, and we are therefore seeing a rise, which will continue to grow, in the number of people looking for emergency psychiatric care."

Anxiety levels are not about to go down anytime soon.

"Instead of the government being a factor in containing anxiety and restoring balance, we see anxiety being transmitted from the leadership via the health ministry and the press. It is unclear whether those who are at the helm of the battle against coronavirus are talking from their own private anxiety about how they will look the day after during the public inquiry phase," said Dr. Fishel.

"It is very hard to take what they say at face value, because everyone is asking themselves: is this justified panic or panic for the purpose of later being able to say, we told you and you didn't listen. There is an imbalance between the responsibilities being demanded from private citizens and the commitments of the system and the establishment. Furthermore, there is almost no attempt to alleviate the public's concerns about what happens the day after."

Could the pandemic leave behind traumas similar to the experience of wars, intifadas, or an everyday routine that includes rocket attacks? Professor Levkovitch thinks it is too early to tell. "We are currently undergoing a period of uncertainty, but rockets are easier to endure, because there are good guys and bad guys and a clear enemy. Here the enemy is unseen and can attack each one of us, anywhere. Biological catastrophes are sometimes more difficult than a missile attack."

"The level of anxiety felt as a result of a red alert and a rocket explosion is immense, more than the anxiety caused by coronavirus," said Dr. Fishel. "However, coronavirus is an unprecedented experience: it is a global event, a blow that is poised to hit the entire world."

"A strange situation has been created in which we can actually see what we might experience in the future. We are not necessarily observing the countries that are managing the pandemic successfully, but, primarily, the countries that do not like Italy and Spain, and we tell ourselves that we will be there soon. But that is untrue־it is just one option out of several. We can still choose the amount of damage based on how closely we choose to follow the health ministry's directives."

Can you see any signs of optimism?

"Yes, the good news about this issue is that we are in the 21st century. That means that most people spend a lot of their time at home even without quarantine and coronavirus. The way we communicate and consume entertainment has changed, and there are so many technological options that can make seclusion easier. However, quarantine creates tension between household members; even more than that, it creates a tension within yourself. For example, for workaholics who deal with issues by doing things, the fact that they suddenly have nothing to do can lead to tension, anxiety, difficult thoughts, and depression."