From the Developing EM Archives: Dr. Nat Thurtle, Palestine, September 2020

In September of last year, Dr. Natalie Thurtle spoke about her experiences dealing with the COVID-19 Pandemic in Palestine in her role with Médecins Sans Frontières (MSF).

Now, in the midst of a once in a century pandemic, Nat and MSF have pivoted their efforts to deal with the current explosion of violence in Palestine.

As the current situation in Palestine unfolds, we look back on the following interview, presented in collaboration with DevelopingEM: A Conference with a Conscience. The interview was recorded last year, and published on September 5, 2020. The original publication can be seen on the DevelopingEM blog here. For an unedited transcription of the dialogue, please scroll below the video.

In the interview, Dr. Nat Thurtle discusses her experiences of the COVID-19 pandemic in Palestinian and refugee populations. This piece was recorded in September 2020; it does not reflect the present situation in Gaza, but provides some background to the situation faced by communities in Palestine at the time.

If you are interested in supporting Nat, MSF and their teams on the ground in Palestine please feel free to donate here.

Mark Newcombe: Okay. Hi, Developing EMer's. Today we're catching up with the wonderful Nat Thurtle. Nat's an emergency physician who splits her time between emergency medicine and toxicology practice in Australia and deployments with MSF [Médecins Sans Frontières].  She's been with us in Developing EM since 2012. And for the last few years has managed our international emergency medicine track. during our recent conference, she presented on her work mobilizing support for the medical care of refugees in the Australian offshore detention camps. And you can find links to that presentation in the notes, accompanying this video. Nat it's great to see you. How are you doing ?

Nat Thurtle: Hi, Mark. Great to see you as well. And yeah, I'm good. Thanks. How are you?

Mark Newcombe: I'm not bad. I'm not bad adjusting to a new normal as we all are, I guess. So maybe for our viewers and listeners, can you remind us where you were and what you were working on before the pandemic hit in March? And then we'll talk about what's going on for you now.

Nat Thurtle: Sure. So I'm the medical coordinator for MSF, France and Palestine. So I'm currently based in Jerusalem and I started that position in January of 2020. So I was there for a couple of months before joining you guys in Cartagena.

Mark Newcombe: And I understand that your trip home or to some sort of home was a little bit different to the rest of us. You got a bit trapped after the conference, what happened?

Nat Thurtle: Yeah, so I think a few people had some, some challenges making it home, but we because with foreign nationals and the Israelis went into lockdown whilst we were in Cartagena. So we had to wait a bit to have permission to return to our positions here. So and we decided that cause we didn't really have a base in Colombia or a big network though. We didn't want to remain in Colombia because it was so putting in fairly stringent containment measures as well, just very quickly in the week after Developing EM. So we actually went to stay with Darryl's parents in Canada and for a few reasons we ended up staying quite a long time and we've just got back to Jerusalem a couple of weeks ago. So we're in quarantine, this is our last day in quarantine. So we've been working remotely from Canada for the last three months which has had its challenges for sure. But I think actually we've been compared to lots of people's experience, extremely lucky cause we, we were in a safe place and we had some outside space and, and, and it's actually, you know. Okay. So yeah.

Mark Newcombe: Good. And look, what does the work entail both in the time that you haven't been in Israel and now that you're getting back to your position after a couple of days anyway, what sort of work are you doing?

Nat Thurtle: So I work as the medical coordinator, which means that I'm sort of medically responsible for the two projects that MSF France has in Palestine. So we have a large project and guys are working on lower limb trauma patients. So we run an osteomyelitis program looking after patients who have got infected wounds and fractures and we also run a large burns program. So we cover outpatient care for burns in Gaza. And we have transversal components of that, so we have physiotherapy, occupational therapy and mental health and social support. So we have quite a big program in Gaza. And then in Nablus in the West bank, we run a mental health program and I'm doing it sequelae from trauma. So my job is to sort of coordinate all of that from a medical perspective. So it's quite a variable job, but most of it can be done sitting in front of a computer, which I guess the truth for lots of us today.

I was able to do most of my work from Canada though for sure a lot of it was done late at night and very early in the morning because the nine hour time difference. So it was pretty disruptive to my sleep patterns. And we'll say just kind of when I missed a lot, the organic connection with the team and colleagues from other organizations and the local structures that it was quite difficult to maintain really effective communication. And obviously a lot of things have slowed down and we've had cause I wasn't the only person who wasn't able to get it back or, or move. So I think that's been really hard on the team and, and hard on on Gaza particularly where there's already restricted movement. So yeah, it's been, it's had its challenges, but we've been able to move forward.

Mark Newcombe: Yeah, it sounds challenging. I guess both of those places have essentially been off the front page for a very long time and now even more so with the pandemic sort of taking over all international news, it sounds like there would be challenges to dealing with COVID in both Gaza and the West Bank. Have they been badly affected in those regions?

Nat Thurtle: So Gaza has benefited for once from the fact that it's a very restricted access population. So the borders to Gaza are not porous, and people, they're not able to move in and out. And so they, and that has actually worked in their favor. So they have the COVID committee in Gaza has managed to contain cases such that there's only been 72 cases to date and those cases have all been imported and gone directly into institutional quarantine. So that's been good. The risk is always there though. So I think what we're seeing in general globally is that this COVID pandemic is not going away anytime soon. And I think we're going to have the threat of an outbreak or serious outbreak in Gaza for the foreseeable future which I think is hard for everybody to contend with. Then from the MSF side, we have invested in an extensive E preps own emergency preparation to support a response to COVID in Gaza should it be required. So we are ready to do that. In the West Bank, we don't have the infrastructure magically, so because we're running mental health there, we don't have the medical aspects of our project per se. And at the moment the response has been managed by the MOH and other partners. However, in the last two to three weeks, I would say both in Israel and in the West Bank, we're seeing a bit-- a significant escalation in cases. So unfortunately as the lockdown restrictions were released there was a bit of a delay, but then we did start to see really significant number of cases again and actually more than, than we saw initially both in Israel and in the West Bank. So I think it remains to be seen obviously the authorities are working to contain that.

Nat Thurtle: But I think it remains to be seen what is going to happen and in the immediate future with COVID both, both in West Bank and and here in Israel yeah, so let's see. And I, I think that problem is this globally, as I said, I think lots of, there's a bit of complacency perhaps, particularly amongst people who aren't used to the epidemiology of pandemics and, and, and having you know, there's a lot of information about some of it's not, not necessarily correct. And I think globally, we're having to balance the risk of the pandemic and morbidity and mortality from the pandemic with the morbidity and mortality from an economic shutdown. And I think that's complicated for the authorities and, and for us as individuals responding. So, yeah. I guess it's also, it's, it's a bit of reorientation for everybody to a new normal and that's, that's hard. Yeah.

Mark Newcombe: Have you got a sense for what is happening in the refugee situation regionally? The, you know, there are obviously large refugee populations within Palestine, but more recent problems would have sort of newer refugee situations that are less organized again, regional countries related to the Syrian conflict. And that does seem to have evaporated from the front pages. Have you got a sense of whether their own war related lockdown is helping them or whether the diseases impacting them as much as everybody else?

Nat Thurtle: So I'm not working on the Syria context. So I probably don't have up-to-date information, but I guess more, I guess in a general sense, refugee and IDP. So internally displaced persons populations in the region are at an increased risk because of the conditions in which they're living. So not just from COVID, but from other pandemics and other communicable diseases which is kind of what we often see in those populations. And that's where you know, MSF is often mounting a response but also other other organizations. So I think, yeah, it's, it's a worry because of population density because of difficulties maintaining water and sanitation conditions because of poorly managed non-communicable diseases and poor health in general. So for sure, there's lots of risks and I think one of the risks in Gaza that we're all acutely aware of is the population density. So you've got almost 2 million people living in 365 square kilometer block because the Gaza district is 41 kilometers along in about, you know, between six and 10 kilometers wide. And all of those people are living there and lots of them are living in, you know, conditions that really incendiary should we have a communicable disease outbreak. And that is true for populations impacted by conflicts across the region. In Yemen, to which MSF is responding. Again, I don't have all the details of it, but I know that it's been really, really challenging to respond in a meaningful way. Which I think is common to zones where there's active conflict. I mean, it's just an added layer of complexity for the authorities to respond, but also for organizations like NSF.

Mark Newcombe: Yeah. It feels like, you know, just thinking subjectively about it that you know, you've got all this ongoing need, but yet a lack of ability to potentially provide staff from overseas and resources and movement. I imagine the UN is very stretched at the moment is MSF and other NGOs finding similar problems or are they picking up the slack in some way?

Nat Thurtle: Yeah. Look, I think that all organizations that have a global reach, this is a fairly unique challenge, at least in recent times because the need is everywhere all at once. And MSF has also started domestic operations in lots of countries. So MSF has got operations in Italy, in France and in the US and, and in other places where normally they haven't felt that there's an indication to response. So I think that and also in terms of the pool of emergency physicians and ICU doctors and nurses, the pool is, is empty because people are needed in their, in their own countries often. So I think that resource allocation has been very challenging for the organization that I'm not involved in that. So I'm specifically working on Palestine, but I know that it's been really difficult to justly allocate resources.

Nat Thurtle: And I don't think, I think that problem is for the medium term going to remain in place both for myself, but also for other organizations with global reach. And I think COVID has been really hard to predict in terms of where is the need going to be. So I think early on the way that, where, where we were prioritizing perhaps was slightly different to where we're prioritizing now, and I'm not sure it's been possible to really predict where it's going to take hold and where the need is not going to be be as high. For example, I mean, we really thought that Gaza would have an outbreak at least initially because of the population density. But it hasn't happened yet. And so we're ready, but actually the more kind of serious outbreaks so far regionally has been in Yemen. So yeah, I think that it's hard to balance being prepared with, with responsiveness and yeah. Trying to predict where the greatest need is going to be and what that's going to look like. I think that's been really hard because obviously the, the global needs cannot be met.

Mark Newcombe: Yeah. Right. So I guess another issue that's sort of fallen away from media and you know, the population has been our own Australia's own detention centers. I have absolutely no idea what's happening there. It hasn't been spoken about at all. I suppose from a COVID point of view, it may not be a big issue because there's no traffic and they're very isolated, but obviously there's still people in these camps. Does anyone know what's happening there at the moment?

Nat Thurtle: So I guess so there's the offshore population and the onshore population in Australia. And if I take my MSF hat off as as you know, as working as an independent the last year with this population so not speaking with any reference to MSF, my understanding is that say the majority of the population has moved now onshore with as a result, partly of the medivac legislation, but also other pathways where people are trying to access medical care. And so there's probably around 500 people still left offshore. I'm not up to date with what's happening offshore, but I know that PNG for a long time, didn't have any cases in there. I think still is reasonably under control. Onshore the risk to people in, in-place detention has been, has been exploded in the media. And there was a court case around COVID risk because people are not, they're kept in quite cramped conditions. And so they're not able to respect social distancing and the conditions in which that kept onshore. And we'll see, you've got people coming in and out. So you've got security guards and people provide, you know, the motel staff for people that are kept in their pods. So there is, there, there is the risk of community transmission in those facilities. And given the current transmission context in Australia, the risk is low because the risk is low as everybody. But I think if that transmission context changes, which is certainly possible over time, then the COVID risk today's individuals living in cramped conditions will go up again. More broadly. I think that, yeah the situation for those people remains unresolved. And as you referenced lots of things like that are dropping out of the news cycle because of COVID. And I think it lays things open to politicization or being swept under the carpet because there's a lack of focus on, on those issues. So I think it is important to try to keep them in the public consciousness. And okay, I guess it sort of referred back to what I mentioned briefly before that we're all aware of it, but, you know, balancing the risk of COVID and the risk of them morbidity mortality from COVID with the risk of morbidity and mortality from other aspects of life that have been neglected because of the whole COVID response. Which I think is, is key kind of all over the world, not least for that particular population in Australia.

Mark Newcombe: Now you've done an incredible amount of work to resolve some of the aspects of that. And we talked a little bit about that at the conference, in relation to the medivac bill and the movement to try and strengthen your healthcare. We were wondering what the next step was. Have you had time in isolation to preach about this? Almost, it feels like it's an insolvable issue sometimes with a government that is very determined to maintain the status quo. What do you think the next step is for the movement that you and a number of other people created?

Nat Thurtle: Yeah, I think the revelation from a medical perspective for this population is resettlement. And I think everyone including the government of Australia is aware of that, but there's ongoing work for sure. But within the independent doctor network and also within the other organizations in the sector and within the Australian government to try to resolve this situation, because I think it's clear for everyone that is not resolved. We, in terms of what I can say, they were 279, I think transfers in the end under the medivac legislation or after legislation was removed in terms of honoring the intent of the legislation from the government of Australia. So those who have come to Australia in most of them, we haven't, there's been no independent assessment as to what has happened to those individuals. However they, there are pathways for them to access care here and there is monitoring in place of those pathways. So for sure this, their medical situation hasn't resolved because whilst they remain in detention, it's hard to resolve their medical situation. However, they have access to care that there's more robust and consistent than what they were able to access off shore. So I think it's a stage forward for them, even though the conditions in which they are contained are very concerning and it's not over.

Mark Newcombe: Yeah, well maybe we could rephrase that question by asking we're in a very lucky situation here in Australia. I think a lot of us are a lot less busy than we expected to be at this time. And we, we have time to research time to involve ourselves in movements and inform ourselves of what's going on. We have this unsolved refugee situation and detention situation in our own country. Where can people find out now that this has moved off the front pages? Where can people find information about what's going on and what the future might hold?

Nat Thurtle: I think there are people doing if anything, communication about this issue MSF did put an op-ed out in, on the blog last week. There there's other sets of communication ongoing with regards to the conditions. So there is information out there. I think that the the independent doctors who were involved in assessing patients under the medivac legislation organizing themselves again and looking at how they can potentially contribute to what's happening to, to outlining what's happening oshore. But yeah, I think COVID has been a significant disruption to all of that. So yeah, I think if people are interested in that in what's happening onshore they can reach out to me and can put them in touch with, with the individuals who are working in that space, ongoing. If there remain people off shore, nd then also the people that have been transferred onshore via the medivac legislation are where the most unwell people that were offshore and they remain in close attention. So for sure there's ongoing serious medical problems onshore. We just don't have that visibility in a meaningful way at the moment.

Mark Newcombe: Hmm. Okay. Well, it sounds like there's still work to do in terms of both exposure and potentially moving forward with a longer-term solution for those who are interested we will keep you appraised of what's happening and include some information in the liner notes to this video. What do you think your next year looks like over there? And do you think you'll be back in Australia anytime soon?

Nat Thurtle: Yeah, honestly, I have no idea. I, my contract is until January next year, but because of the disruption from COVID, it's been hard to implement some of the long-term longer term strategic goals that we have in this context. And so I it's possible that I will stay a bit longer to try to follow some of that stuff through. But I think it would say it really depends what happens with COVID here and we might end up suddenly being involved in a response. And, and I guess that will change everything. So yeah, I'm just happy to be back and happy to be working back with my colleagues and a bit closer to, to the people that we're trying to support.

Mark Newcombe: And I believe there's a very important birthday coming up very soon.

Nat Thurtle: Yeah. It's, Leah's birthday. My, my daughter is turning two in less than a month, so it's going to be a bit of an odd birthday. Like I'm not, I'm not sure that having a socially distanced toddler party is going to work. So we'll just have to say and roll with it a bit and say that she's already excited. I think she's not quite sure what it is she's excited about. She, she wants to have a pizza-- she's clear on that. So, yeah, we'll do our best to make it a fun day

Mark Newcombe: For those of you who don't know, Nat's been with Developing EM since 2012, and Leah's has been with us for two years having presented in Fiji and, and she's an integral part of the team, so we wish they were very happy birthday. 

Nat Thurtle: Thank you.

Mark Newcombe: Sorry, I cut you off.

Nat Thurtle: Oh, she was around, but I think Darryl's taken her off for a nap, else I'd bring her up for an interview.

Mark Newcombe: Just to let you know, we're, we're working towards having an event in 2022 and we love having your involvement. Do you think that that's might be possible?

Nat Thurtle: Just put me on the spot! Yes. Anything is possible. No. I love where I came into developing. For sure. I'll be excited to work in 2022. So yeah, we can chat about it.

Mark Newcombe: Oh, very good. Excellent. Well, look, thank you very much for your time today. Nat, I'm glad that you're safe and sound and where you wanted to be. And that you'll be back to work properly in a couple of days. So thank you very much. Great to catch up and talk soon.

Nat Thurtle: Absolutely. Thanks!