Eleni Konstantinou, a 2001 Sylff fellow, is a psychologist and group and family therapist who now works for the municipality of Pallini, Greece. She discusses how the measures in response to COVID-19 have impacted social support services in the municipality, with personal observations about how people, including herself, have adjusted largely positively to the lack of direct contact.

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The aim of this article is to present how COVID-19 and the imposed measures have altered, changed, and affected the delivery of supporting services such as psychological support, consulting, and lifelong learning programs in the Municipality of Pallini.

I am a psychologist, family and group therapist, and a member of the Sylff community. I received the Sylff grant in 2001 during my postgraduate studies in school psychology. In 2018 I was very honored to be chosen to attend the Sylff Leaders Workshop in Japan—a great experience that helped me deepen my knowledge in international cooperation for a common goal. I had the chance to meet and communicate with exceptional people from all over the world who are expert in their field of work and studies. I also had the privilege of experiencing and tasting Japan’s culture. I am more than thankful to the Sylff Association secretariat for organizing this memorable and unique event with great success.

I have been working in the Municipality of Pallini (Region of Eastern Attica, Greece) for a decade. Since 2016, I have been in charge of the Education, Continuing Education, and Culture Section of the Department of Social Policy.

The mayor of Pallini, Mr. Athanasios Zoutsos, expresses the basic principle of the municipality during the pandemic as follows: “Νo one should be left alone, without access to public services in these harsh times.” But how could this happen? Is it possible for people to access public services when there are strict measures on circulation to lower the number of active COVID-19 cases? After the outbreak of the pandemic, people have had to send a text message to 13033 to get a circulation permit within their prefecture. Οne can only move around for health reasons (e.g., to see a doctor or to go to the hospital or pharmacy), to shop at the supermarket, to go to the bank, or to help someone in need. It is also permissible for divorced parents to visit their children. If a ceremony such as a wedding, christening, or funeral takes place, only a few relatives are able to attend. Finally, in order to leave the house, everyone must carry an ID and send the aforementioned required message to 13033, even if it is to walk his or her dog or just exercise individually. Wearing face masks is compulsory everywhere. Due to the above, when the mayor of Pallini speaks of supporting the citizens, he is referring to the ability to access public services mainly digitally via Internet. Moreover, because of the reduction in circulation, there are certain cases where municipal staff must visit vulnerable people in need and offer goods for free from the local grocery store.

If I could briefly explain my current position, I would mostly refer to consulting, consultation programs, and consulting groups for parents and teachers. Furthermore, part of my job is to organize continuing education activities and programs and supervise school cleaning staff.

Consulting

Before the outbreak of the pandemic crisis, people used to visit me in my office at the Town Hall, asking for information and apply for consulting. A therapeutic procedure was designed according to their needs, including personal consulting sessions, couples’ therapy, and even group therapy. That was the formal procedure. Now consulting is mostly done on the phone. People can receive our services only with prior arrangement by phone. We are all obliged to wear masks and keep a 1.5-m distance.

Personal contact is essential during consulting. Now that we miss smiles and facial expressions in general, we have to cultivate and promote other skills to communicate effectively with one another. In the beginning, counseling on the phone was a bit awkward for both therapist and client, since our service is not a phone line. But we had to adjust to the current situation and overcome this obstacle by focusing on the voice tone, the pauses, or even the breathing. Unfortunately, group therapy meetings had to stop for safety reasons.

Meeting with teachers at school.

Moreover, we created a series of videos with relaxing music in the background, pleasant images, and tips on surviving curfew (https://www.youtube.com/watch?v=4p711Di-3Nc, https://www.youtube.com/watch?v=NwmL4v_1hok, https://www.youtube.com/watch?v=xY6PZCDLsPg). Making these videos was incredible, as I worked together with people whom I had never met. We cooperated harmoniously and effectively without knowing one another. Respecting one another and knowing that we were working for a common goal were enough for us. Our meetings were held only by telephone. I was very honored that my script was narrated by a famous Greek actor and member of the City Council, Mrs. Aspasia Tzitzikaki, while Mr. Michalis Christodoulides composed the original soundtrack. Finally, Mrs. Karolina Kosmetatou was responsible for the image editing. Because of the current circumstances, we have not managed to meet till now! What we have learned from this experience is that such skills as flexibility, adjustment, and resilience are essential not only for survival but also for creativity.

Consultation

Before the pandemic crisis, I used to visit schools following teachers’ requests to help them deal with students’ behavioral problems. In addition, the principal of the school would organize staff meetings with me to overcome unpleasant situations at schools involving students, teachers, and parents. Now that schools are closed and lessons are held via an Internet platform (Webex), my communication with teachers and school personnel is limited to the phone. Teachers mention the lack of communication, especially with high school students, and all the difficulties that arise during Webex lessons. They are also anxious about their students’ mental health. Now mental resilience is more important than learning!

School for Parents

The Online School for Parents.

The implementation of prevention programs is one of the main goals of our services. In this context, the School for Parents is a counseling and informative program for parents. There are more than 90 applicants, and approximately half of them attend the lectures. In March 2020 we were forced to stop the meetings because of the enforcement of strict measures against the pandemic. To keep in touch with parents and students, we created a blog with relevant articles written by the guest speakers so that parents would not feel alone or isolated during COVID times. In June 2020 we managed to meet again at the closing ceremony, taking all the necessary measures. During this academic year we had to reform and redesign the format of the School for Parents. We thus organized , consisting entirely of online meetings that took t place once a week every Wednesday from 6 to 8 pm (from January to May 2021). Parents could attend them from their homes. For each session we had a distinguished guest speaker addressing such topics as addiction, safer Internet, eating disorders, learning disabilities, resilience, tips for parents to help their children face the new reality during the pandemic, and crisis management. We missed the direct contact, but it proved to be  very helpful for parents not to have to leave their home and children to attend the lectures.. Parents have expressed gratefulness for this program and that they are looking forward to our meetings. So do we!

Continuing Education activities and program

Continuing education is a very lively program in our municipality. Whenever a program starts, there are many applicants who are interested in taking part in the classes. IT classes for adults were usually held twice a week in municipal buildings. The last program was conducted until July 20, 2020. We were obliged to take all the necessary preventive measures against COVID-19. However, after the last strict measures of quarantine, the programs of continuing education were canceled, following the school closure. But in this case the courses have not been continued by distance learning.

Networking

Networking is necessary for me daily. I think that no one can solve all the problems by oneself. We all need one another. For instance, I come in contact with other institutions (e.g., hospitals and social services) and professionals (e.g., social workers and psychiatrists) in order to effectively face a complex psychosocial case. Networking is very useful between different services that face similar problems and difficulties. In addition, it can be helpful in encouraging solidarity among people. In January 2020, we organized a meeting with mental health specialists from other municipalities, hospitals, and mental health services. We closed this event with a wish as well as a promise to meet again. Unfortunately, we have not managed to make it happen until now due to the circumstances, but I am thinking of proposing a Webex meeting instead. We need to stay connected!

Before closing this article, I would like to underline the necessity of solidarity. Close contact is now being avoided, but this does not have to make people feel alone. Even in conditions of limitation, we can get close to our loved ones and connect with respect for one another, with love and caring, so that we can have a good time and remain safe and healthy, without fear!

Based on a webinar series she gave in August 2020, 2012 Sylff fellow Anindita Roy shares her observations on stress related to the COVID-19 pandemic and how it has affected people differently. Turning to the current culture of information sharing and virtual communication, Roy also touches on the importance of consuming information mindfully.

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I conducted a series of workshops on responding to stress and mental well-being for a local charity at Jamshedpur, India, during the COVID-19 related countrywide lockdown. As part of the workshop, multiple online sessions were offered and were open for all. The broader theme to cover was understanding stress and coping with stress related to the COVID-19 pandemic. These sessions were roughly divided into learning about the stress response and developing resilience to enhance mental well-being. I would like to share through this article observations that formed part of these sessions. However, let me add at the start that the article does not present tools and tips. I am wary of making general prescriptions about stress and coping, although surely one can speak of these more generally. My biggest hope in sharing this article is one of solidarity with my extended Sylff family during these difficult times, by sharing with you another perspective of the COVID experience in another part of the globe. In times when each of us has been confined in our worlds and lives, in isolation and isolated, sometimes alone or lonely, I hope this article brings with it the hope that you are not alone and that we are in this together.

The poster for a series of sessions that the author conducted on stress and mental well-being.

On Difference

For a major part of the world’s population today, a pandemic of this scale had not formed a part of our lived experiences. Forcing us to negotiate with something we had no experience of in living memory, the COVID-19 pandemic disrupted the status quo, and the world continues to strive for a “new normal” amid this crisis and beyond. At its peak, the pandemic instilled a general unease in connecting with others, forging a different culture of connection. As we continue to practice social distancing, in many cases, company is still viewed as risky and contact potentially fatal. The epidemic, the related lockdown, and its intensity have not been the same for all. The unprecedented chaos has had different effects on our lives, raising varied concerns. Within the context of the workshop too, it was observed that the pandemic influenced my participants and me very differently. It was necessary to acknowledge as well that it is not only about the pandemic but also about the people and their response to it, and that people are different too.

In an activity with the participants, I encouraged everyone to write with their body parts instead of a pen or pencil. They were requested, for example, to write letters and numbers in the air with their elbows, knees, tongue, and left hand. None of my participants in this session were differently abled, and many initially found the exercise “awkward” and “funny” as they were encouraged to keep their cameras on during this part. Although the scope of the session did not allow us to look at the theme of the body, issues of difference, and disability in great depth, the exercise offered the participants another perspective on their own abilities and the way it may be represented to themselves and others. For instance, some shared that they struggled to twist their tongues or bend their knees, while others who had imagined they could not write with their left hands did so with great ease. There was one participant who noted that their shoulder blade hurt immensely while trying to use their right elbow when making figures in the air.

In a way, this exercise offered an awareness to the participants about the others in their group but also presented the opportunity to know a little more about themselves—at least in that moment. Being on the same boat but not (quite!) in the same journey, this helped with an understanding of difference, while simultaneously offering the possibility to learn together, albeit differently from one another.

On Stress

The above exercise offered a useful understanding of stress itself. Stress affects everyone, and everyone feels stressed from time to time. Yet some cope with it more effectively and recover from stressful events faster than others. When the demands placed on us in any given situation are much greater than the resources we may have (or percieve we have), we find ourselves stressed in trying to meet these demands. Stress is the call for a sense of balance in the face of a perceived imbalance. Stress is different for everyone, and no two people respond to stressors in the same way. What maybe stressful for one person may not be stressful for another, and even if it is, the response to stress and the coping mechanisms could be vastly different between individuals.

Not all stress is bad. In life-threatening situations, stress prepares the body to either fight the threat or flee from it. In non-life-threatening situations, stress can be motivating. Long-term stress, however, is straining on our body and mind, contributing to serious complications and compromising physical and mental well-being. Dealing or coping with stress can be learned and, with practice, can be implemented effectively. This does not eradicate stress in and of itself, nor does it guarantee that one will never be stressed again. However, it offers a roadmap to meander stressful situations, equipping the individual with tools to communicate with stress in productive awareness.

On Stressors

Awareness of symptoms helps with diagnosis. Recognizing stressors is a crucial step toward developing tools to deal with stress. My participants shared some of their stressors specific to COVID-19 and the related lockdown. Most were related to such issues as health in the face of the epidemic, achieving a work-life balance in a work-from-home environment, family conflicts from more time spent at home, difficult conversations due to death, illness, or job loss, and public speaking in meetings via Zoom calls. In going through some of these stressors, an overarching theme that came up was how the pandemic had changed the lives of the participants in different ways. Some of my participants had lost their jobs, some expressed concerns about sick family and friends, and yet others were left worried about elderly parents or children living alone at another location. On the one hand, there was the frustration of students lacking sufficient support and the ambiguity of older school goers on the verge of preparing for their career-defining examinations. On the other hand, there were teachers dealing with the additional responsibility of adapting to newer technologies for teaching and evaluation, as well as pay cuts, in some cases. Most of these stressors fed into a sense of uncertainty. Meanwhile, there were a few participants who expressed their efforts in “trying to find a silver lining” as they talked of rediscovering their long-lost hobbies, nurturing skills such as baking, pottery, poetry writing, and gardening, finding time to exercise, eating healthier, reading more, and writing journals, to name a few.

During these sessions, the participants were encouraged to reflect on how the pandemic and the related lockdown had impacted their lives in terms of perceived differences between before and after the pandemic. These helped explain to a certain degree the levels of stress brought about by sudden changes such as death, illness, and unemployment and stress related to changes in routine such as the pressures of school, work, family, and other responsibilities. The very nature of the epidemic, the ever-evolving research, government guidelines and containment measures, death tolls, major gaps from unequal access to a variety of resources, ranging from healthcare to education to support services, etc, and related information—these all added to the atmosphere of dealing with an unknown future, the uncertainty of not knowing, or the inability to accurately predict some semblance of a known “normal.” (Dare I mention the minefield of mis/disinformation further adding to the confusion?)

My participants and I wondered if we could structure some sense of certainty in the face of unprecedented changes, and how. The idea of this attempt was not to judge whether the glass is half full or half empty but to give back to the participants the power to refill the glass, even amid the crisis. A sense of the familiar in the face of overwhelming change somehow offers a sense of control or of taking back some control. My participants and I discussed forming a routine that suited them and how having one was helpful to combat uncertainty by establishing some predictability. One way to do this is goal setting, preferably setting small achievable chunks as part of formulating one’s routine. This not only helps to get organized but also brings back a sense of certainty and control by helping the individual to lean into things that one can change within their routine. This is also a good way of attaining motivation. Nonetheless, this also extended to the disclaimer that one must not blindly borrow someone else’s routine, specifically out of the “fear of missing out.”

Within the ambience of “influencers,” information overload, and frequent “forwards,” “likes,” “comments,”and “subscribes,” the consumption and sharing of information is undeniably important to one’s overall well-being. Another stressor, broadly relevant to the contemporary age of newer technologies and the present culture of virtual communication, is FOMO, or the “fear of missing out.” FOMO was a significant stressor for some of my participants during the lockdown. For instance, it was distressing for a participant how a friend had lost weight while they had piled on multiple kilograms during the lockdown. They had found creative expression through online platforms and were unhappy with the number of “likes” they had on their pictures and profile. Their friend had been following a certain diet and achieved a significant “transformation,” along with more subscribers, likes, and views from the pictures shared since the “transformation,” or so thought this participant. The latter was extremely eager to go on the new diet and transform themselves too in the lockdown. They did not initially feel the need to consult a nutritionist and said that all the information about the diet was available for free online. My personal hesitation about the diet is that it leaves out an entire food group, but my participant did not want to lose out on the benefits—benefits they thought their friend had gained from following this certain diet.

I would like to end this article with a brief take on “infobesity,” or information overload, another stressor in the lockdown. Information today is widely available and often easily accessible at the click of a button (at least to many sections across society, if not everywhere). However, when there is too much information, there is also the possibility of mis/disinformation. This was briefly discussed in the context of the pandemic in one of my sessions. At the risk of repeating what my researcher colleagues may already know, here are some ways to challenge information abuse (and also help with information overload):

1. Verify information before you consume it. When verifying the authenticity of a piece of information, check for the information’s
2. time stamp
3. where it was published
4. their author
5. the intended audience
6. whether the information is sponsored in any way, and if so, whether the sponsorship or affiliation is clearly declared to avoid any conflict of interest.
7. Be mindful when sharing information with another. Pause. Think. Forward (or maybe not).

The COVID-19 lockdown saw instances of information abuse in the form of inaccurate information and fake news. Although not typical to the pandemic and its related lockdown, information abuse should be challenged, and one can do so only if one is mindful of their information consumption. Information is useful. Information about COVID-19, local guidelines, helpline numbers, food banks, and now vaccines is significant and potentially life saving. Information is power, and I take this opportunity to remind us of the power we have and of the choices we can continue to make even in crisis, and beyond.

General sessions open for the public can be viewed at:

https://youtu.be/BJEBGn2CLSE

https://youtu.be/CIpDX0SGa1Q

Elvisa Frrokaj  is a psychologist-psychotherapist (MSc, PhD-C.) and a former Sylff fellow at the University of Athens. She discusses the impact of COVID-19 on mental health, describing the detrimental influence of the pandemic on mental health, which, as studies are beginning to show, is in jeopardy.

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The Importance of Solidarity in the Face of a Pandemic

In both my capacities as a person and a psychologist at the community level, I share the same passion with the SYLFF Association for making the world a better place. I utterly believe, as we say in Greece, that all people can contribute positively to a situation, each by adding a “small stone.” This means that by cooperating and thus becoming small parts of a large sum, it becomes much easier to tackle the challenges of life. As we humans are social animals, the value of a strong commitment to giving back to the community is of utmost importance to our physical and mental well-being.

Coronavirus disease 2019 (COVID-19) was a very representative example of the aforementioned need for commitment to community and a very good opportunity to realize that by working together toward a common goal, we greatly increase the odds to achieving impressive results. The prevention of the spread of coronavirus depends on our individual responsibility, intertwined with collective-community responsibility.

Profound, Unprecedented Changes

When the first measures against the COVID-19 pandemic were enforced around the world, I was shocked, as I could foresee the impact the unprecedented restrictions in personal freedoms would have on public mental health. More particularly, in Greece between March and May 2020 we were in full lockdown. In order to leave home, we were required to send a text message stating the reason for moving. The same applies now for many countries in Europe, as a second lockdown is becoming part of our lives.

For the Western world, this state-enforced control over highly valued personal freedoms is unprecedented and takes a heavy toll on the individual’s mental state. The current situation is something that most of us could never have imagined to ever experience. In myself as well as in my clinical experience as a psychologist, I am seeing a broad palette of negative emotions: surprise, fear, anger, sadness, disappointment, and a sense of insecurity and vulnerability regarding our and others’ health. What is becoming more and more apparent is that COVID-19 will not leave us unscathed. The impact to mental health is happening; it is wide. and it is deep.

As a professional I am seeing the same symptoms, emotions, and thoughts. This new condition is affecting individuals at a personal, interpersonal, and communal level. The common feeling to all is that they do not know the duration of the profound changes they are forced to incorporate in their lives. “Until when?” and “After this, what?” are the most prevalent questions. The inability to make any safe predictions regarding the duration of the pandemic increases the stress on people, who feel helpless due to the perceived lack of control of the situation. For all these reasons, mental health and well-being are in jeopardy.

Scientific Studies Confirm the Observations

The crisis caused by the ongoing pandemic is a new, unknown, and unprecedented challenge that seems to have mentally affected a vast number of people. Recent studies have shown that COVID-19 constitutes a new stress factor or a trauma (Gorwood and Fiorillo 2020), causing several problems, such as intense stress of the unknown, frustration, anger, posttraumatic stress disorder, depression, and several other mental disorders (Shuja, Aqeel, Jaffar, and Ahmed 2020). Patients with mental disorders seem to have been affected more. A strong correlation has been documented between higher exposure to the effects—direct or indirect—of the pandemic and loneliness, depression, and anxiety disorders (Hoffart, Ebrahimi, and Johnson 2020).

The mental health effects of the COVID-19 pandemic may be profound, and there are suggestions that suicide rates will rise, although this is not inevitable. Suicide is likely to become a more pressing concern as the pandemic spreads and has longer-term effects on the general population, the economy, and vulnerable groups. Preventing suicide therefore needs urgent consideration (Gunnell et al. 2020). An area of key concern is the potential of the conditions caused by the pandemic to exacerbate existing psychiatric conditions and influence the manifestation of their symptoms. For instance, patients with paranoid psychosis seemed to have increased illusions under particular COVID-19-related conditions (Coogan, Faltraco, and Thome 2020).

As psychologists at the community clinical level, Ms. Iliana Fylla (psychiatrist, scientific director of the Mobile Mental Health Unit of Child and Adolescent Center, KMPSY, on the island of Chios, Greece) and I studied the consequences of COVID-19 on the psychopathology of our patients after the lockdown that was enforced from March to May 2020. Our studies documented the worsening of mental health among a sample of 450 patients of KMPSY. Thirty-nine of the patients claimed to have experienced a worsening of their mental health after the pandemic. Figures 1 and 2 below illustrate these findings. This study was published at the 28th Panhellenic Psychiatric Conference held in Thessaloniki, Greece, from October 29 to November 1, 2020.

Figure 1. Mental Health Disorders (ICD-10)[1]

Figure 2. Symptomatology after Covid-19 (ICD-10)

More specifically, Figure 1 shows the percentage of the symptoms of mental health patients that were claimed to have worsened. Among all our psychiatric patients (total patients: 450), 39 patients presented a worsening of psychopathology. Figure 2 shows in detail the degrees of worsening of mental health symptoms after lockdown. Thirty-nine of 450 psychiatric patients seemed to have more illusions, delusions, suicidal thought, sexual disorders, and so forth.

In sum, the results of our study confirmed the findings of other studies and showed that 11.5% of mental health patients at KMPSY presented recrudescence in their psychopathology (79.0% women, 20.5% men).

Reviews have shown that this pandemic has been compared to natural disasters such as earthquakes and tsunamis, wars, and international mass conflicts, but in these situations the threat is recognized easily, whereas in pandemic the threat is invisible, could be anywhere, and could be transmitted from any person nearby (Gorwood and Fiorillo 2020). The pandemic has created many problems. In this study patients with “affective disorders” presented more intense symptoms. Some of them also had suicidal ideation, increase of compulsions, illusions, and delusion. The best way to confront these consequences is to reinforce and enhance the care support network.

Actions for Public Mental Health

In April 2020 the Psychology Association of Chios took a series of actions to raise awareness in the local community about COVID-19 and foster and reinforce the mental health of people with useful tips and advice. As part of these actions, we gave an interview on local television (https://bit.ly/3519HHl), in which we talked about the psychological impact of the pandemic on young and older people. Understandably, people experience negative feelings such as anger, despair, and depressive symptoms that are caused by the lockdown (April–May 2020). Lockdown affects not only mental health patients but also people who have not had mental health issues before. We tried to propose constructive ways of better managing the situation.

After that, we created a small video (https://bit.ly/3evzCtH ) as an advertisement with a social message—“Keep the coronavirus away and be safe”—in which each psychologist expressed feelings and emotions about COVID-19. Finally, we published articles with tips on how to confront the situation. This multifaceted approach helped people in the local community to stay positive, reduce stress, and avoid panic. I believe that such organized action from professional and scientific organizations can effectively help people confront the situation and the impact of COVID-19.

Useful Tips

• Read reliable sources that are based on scientific data to avoid misinformation, which implies more stress.
• This situation is unprecedented on a global level. The feeling of “helplessness” is expected but renders us more vulnerable mentally. Try to find ways to manage this feeling by being creative or dealing with things that make you happy and positive.
• Find alternative ways of communicating with friends by socializing and having fun using tools that modern technology offers (e.g., Skype, Zoom, Google Meet). It is an opportunity to communicate with our friends and other people or to spend your time by watching interesting videos on YouTube.
• Listen to music, read a book, or exercise to improve mental health and well-being.
• Provide support and dedicate time to elderly people who may feel lonely or to your children and family. Try to show empathy if they are afraid or help them psychologically by listening carefully to their concerns and trying to rationalize them.
• Be positive and focus on what you can control.

To Sum Up

This undoubtedly is a difficult and challenging period, but we can find ways to adapt and be happier living through it, even though there are radical changes in our daily life. It is crucial to focus on the present, in the “here and now,” and to the things that we can control. It is a period that shall pass and may present a good chance for all of us to treasure those little things in our lives, the most precious, which sometimes we take for granted or ignore altogether.

Let’s hope we will get through it soon.
Be strong and take care!

References

Coogan, A.N., F. Faltraco, M. Fischer, and J. Thome. 2020. “COVID-19 Paranoia in a Patient Suffering from Schizophrenic Psychosis: A Case Report.” Psychiatry Research 288 (11).

Fiorilo, A. and P. Gorwood. 2020. “The Consequences of the COVID-19 Pandemic on Mental Health and Implications for Clinical Practice.” European Psychiatry 63 (1), e32: 1–2.

Gunnell, D., E. Arensman, K. Hawton, and L. Appleby. 2020. “Suicide Risk and Prevention during the COVID-19 {andemic.” The Lancet Psychiatry 7 (6).

Hoffart, A., S. U. Johnson, and O. V. Ebrahimi. 2020. “Loneliness and Social Distancing during the COVID-19 Pandemic: Risk Factors and Associations with Psychopathology.” Retrieved from psyarxiv.com/j9e4q. DOI: 10.31234/osf.io/j9e4q

Shuja, K.H., M. Aqeel, A. Jaffar, and A. Ahmed. 2020. “COVID-19 Pandemic and Impending Global Mental Health Implications.” Psychiatria Danubina 32 (1): 32–35.

[1] ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO).