The Palestinian territories: barriers to healthcare and medical education and the strategic role of distance-learning partnerships in education systems strengthening

Introduction

The Israel–Palestine conflict remains one of the most intractable and polarizing conflicts in the world. Originating with the formation of Israel in 1948 from the British Mandate of Palestine, the dispute has resulted in numerous wars, military operations and tens of thousands of civilian casualties (UNISPAL 2013). The Second Palestinian Intifada (‘Uprising’), a period of intensified violence beginning in late 2000, led to a series of widespread measures by the Israeli authorities that have radically affected day-to-day life for Palestinians living in the West Bank, including the continued construction of the Israel–West Bank barrier wall, restriction on movements of Palestinians in the West Bank and to specialist health centres and religious sites in East Jerusalem, and expansion of the Israeli settlement apparatus, (UNISPAL 2013).

Though the political and military elements of the dispute are well documented, the health status of those in the occupied territories remains poorly described in the extant literature, even though the two are inexorably linked and cannot be separated (Horton 2009). The need to redress this insufficiency is paramount: in an increasingly unstable and complex regional arena, the geopolitical status of the Palestinian territories continues to generate unique and unorthodox barriers to healthcare development, solutions to which may have broader implications for other unstable environments. Before discussing our personal experience of the role of global education programmes in Palestine and how these might be utilized and evaluated to bring about sustainable improvements in healthcare delivery, it is important to briefly summarize some of the unique geopolitical challenges confronting healthcare and medical education in the territories.

Defining the problem

The separation wall

Perhaps the biggest hindrance to normality in the Palestinian territories is the Israel–West Bank Barrier. At the time of writing, over 70% of the separation wall has been constructed or is under construction with the remainder planned but yet to begin (B’Tselem 2012). Israel has argued that the wall is required for protecting its citizens from acts of violence and terrorism (Israeli Ministry of Defence 2004), although opponents criticize it as a bid to annex further Palestinian land as around 12% of the West Bank is included on the Israeli side of the barrier (B’Tselem 2005). The International Court of Justice ruled that the wall contravened international law, noting the substantial restrictions imposed on the freedom of movement of Palestinians which hinders access to health and educational services (International Court of Justice 2004). This, in addition to the presence of hundreds of checkpoints, has had a significant impact on the delivery of healthcare and medical education in the territories, with ambulances and paramedic staff delayed from reaching emergency situations, and students and specialty trainees facing interruptions in accessing clinical learning environments (OCHA 2012). The UN Office for the Coordination of Humanitarian Affairs reports that West Bank patients can only access the specialized Palestinian hospitals in East Jerusalem if they have Israeli permits, including in cases of emergency (OCHA 2012). In June 2013, the WHO reported that 15.5% of patients received no response following permit applications and missed their hospital appointments (WHO 2013). In many instances, Israel issues travel permits for a short time only so that patients requiring repeat or long-term appointments have to reapply through cumbersome administrative processes.

Political instability

Following the 2006 Palestinian legislative elections and the ensuing political and military civil war, the Palestinian people came to be represented by two concurrent, disparate authorities separated by ideology and geography: the Islamist organization Hamas in the Gaza Strip, and the more secular Fatah-lead government in the West Bank. This has led to two de facto Palestinian entities, with Israel and much of the world recognizing only the government in the West Bank as the sole representative of the Palestinian people. The result for Gazan residents has been a devastating, sustained blockade by Israel and Egypt with the 1.5 million population facing a 75% reduction of imported supplies and 750,000 people reliant on food aid provided by the United Nations Relief and Works Agency (UNRWA 2012). While Hamas’ authority extends over the entire Gaza strip, the Palestinian National Authority (PNA) controls only certain areas of the West Bank, with approximately 60% of the West Bank classified as ‘Area C’ under full Israeli control (B’Tselem 2012). Israel also controls tax revenue collection in the occupied territories which it is contractually obliged to transfer to the PNA under the 1993 Oslo Accords. However, it frequently withholds tax revenues for punitive purposes making it difficult for the PNA to pay for public sector salaries and services (Guardian 2011; Reuters 2012). In Gaza, the state healthcare system is even more depleted with 80% of the population relying on foreign assistance (UNRWA 2012).

Health and medical education in Palestine

The above, coupled with lack of resources, funding and cross-border collaboration, has meant that access to contemporary medical literature, novel clinical practices and advances in medical sciences is restricted. As a consequence, there is a disparity in the rate of healthcare and educational development between Palestinian and Israeli institutions. In some cases the geographic difference is only a few kilometres (e.g. the Palestinian Al-Makassed Hospital and the Israeli Hadassah Medical Centre). This discrepancy has caused a substantial negative influence on patient care and health development indicators (WHO 2012a) and, in particular, an emerging disparity between the West Bank and Gaza (WHO 2012b). The occupied territories ranked 114 out of 187 countries in the 2011 UNDP Human Development Index (UNDP 2011). There are four medical schools in Palestine, serving a population of over four million (PCBS 2009). Despite this, a lack of dedicated teaching hospitals and learning spaces in wards and other clinical settings has stunted the growth of a widespread teaching culture in many Palestinian hospitals.

Education systems strengthening

The complexity of movement across borders in Israel and the occupied territories has prevented the development of robust, indigenous educational frameworks. Notwithstanding these difficulties, several health collaborations have developed between Palestinian healthcare stakeholders and international partners. The International Medical Education Trust (IMET) 2000 has been working with the Palestine Ministry of Health, the Palestine Medical Council and Medical Aid for Palestine to establish several projects including building local capacity for management of severe burns in children, psychiatry training to improve child mental health in an occupation context and a Centre for Health Sciences Education offering e-learning, telemedicine and specialist training (IMET 2000 2013). Similarly, the Al-Quds Foundation for Medical Schools in Palestine (FQMS) has been working for nearly two decades to support medical education in Palestine and is involved in a number of initiatives (FQMS 2013). Importantly, the foundation finances visits of international academics and healthcare actors to Palestine, as well as short-term elective placements for Palestinian medical students in the UK and other countries in the West.

The OxPal Medlink: teaching as a self-sustaining intervention

Despite their excellent work, global health partnerships working on the ground to redress education systems imbalance must work within existing travel restrictions and fluctuations in the geopolitical situation. Thus far, the evolution of online, real-time distance-learning technologies capable of facilitating exchange across physical and geographical barriers has not been adequately exploited. We present here our own experience with the OxPal Medlink (oxpal.org). Established in 2012, the partnership connects clinicians from Oxford University Hospitals with medical students and faculty in Palestine. The project draws inspiration from MedicineAfrica (medicineafrica.com), a web-based teaching platform implemented in several countries including Somaliland, Ghana and Sierra Leone (Finlayson et al. 2010).

The model

For the past 18 months, tutors in Oxford have been using WizIQ, an online virtual-classroom technology (www.wiziq.com) to deliver real-time case-based tutorials to Palestinian medical students on a range of subjects in internal medicine, general surgery, paediatrics and psychiatry. The partnership has aimed to improve students’ clinical reasoning and allow transfer of knowledge application using Socratic methodologies. Clinical cases from the students’ own ward-based experiences in Palestine act as the focus. Tutorials involve discussion of these cases in order to develop skills in clinical reasoning and the formulation of diagnostic and management processes. The virtual classrooms incorporate audio and text-based chat and an interactive white-board technology facilitating a multimedia learning environment requiring only low-bandwidth internet connectivity. As a consequence, operating costs are extremely low, requiring only subscription to the WizIQ platform (kindly supplied by MedicineAfrica).

Format and logistics

Between March 2012 and April 2013, OxPal hosted three 8-week terms of tutorials. Students were recruited by email with full support from the FQMS in East Jerusalem faculty. Initially, around 40 fourth- and fifth-year students were enrolled in the programme with around 12 Oxford-based tutorials. Students were divided into groups of five to six. Following a field visit to the West Bank in April 2013, the project has subsequently expanded to include just under 120 students, from fourth- to final-year students from FQMS as well as both medical schools in Gaza (Islamic University and Al Azhar University). Teaching has also expanded from general medicine and surgery to include paediatrics and psychiatry.

Impact and outcomes assessment

For many Palestinian students, the current political context in Palestine means they will be unable to leave the West Bank and Gaza; OxPal provides a link with the international professional community, and the sense of collaboration and participants have regularly praised the sense of collaboration and partnership. Similarly, many of the tutors have regularly commended the opportunity to interact with Palestinian students and teach to a different cultural viewpoint. We have used a variety of methods to assess the impact of the OxPal teaching programme. On a field visit to the West Bank in April 2013, focus groups and semi-structured interviews were performed with faculty and students at FQMS. Standardized forms were used to transcribe comments and several conversations were recorded for subsequent analysis. Moreover, online feedback questionnaires are frequently administered during and at the end of each ‘term’ of tutorials. Overall feedback has been very positive. From the last survey (40% response rate), 96% rated tutorials as ‘Excellent’ or ‘Good’ with a similar number believing tutorials to be ‘Very’ or ‘Fairly’ relevant to medical practice in Palestine. Qualitative feedback has also been consistent with this trend, with students describing the programme as ‘informative’ and ‘useful’. Participants said that tutorials had taught them ‘how to think systematically’ and ‘how to think in the right way to reach the most appropriate diagnosis’. Moving ahead, we are exploring script concordance testing as a more quantifiable way of assessing clinical judgement: this consists of clinical vignettes that students must respond to, giving a final score that is based on how closely respondents’ performances concord with those of specialists in that given area (Hornos et al. 2013; Petrucci et al. 2013).

Challenges

Thus far, a small, dedicated group of tutors has been delivering regular, weekly tutorials, with a voluntary administrative staff to handle logistics. As the project has expanded, this group of stakeholders has often been stretched, necessitating expansion in the pool of tutors and administrators. While overheads have been minimal to this point, with donations from MedicineAfrica and other educational healthcare charities working in Palestine, expansion of the project in line with our the aimed expansion of this project will necessitate much greater costs (e.g. in terms of website hosting, future field trip visits and elective programmes). Finally, it has been challenging to use quantitative assessment methods to chart the impact of the project, with semi-qualitative tools forming the bulk of our assessment methods.

Future directions

OxPal has expanded considerably since its inception and is now engaging with stakeholders in three out of the four Palestinian medical schools. Our future aim is to expand speciality teaching to include obstetrics and gynaecology, and emergency medicine. In addition, we plan to develop sustainable and productive postgraduate partnerships with Palestinian speciality trainees. Currently, we have submitted several grant applications to fund development of elective exchange programmes between medical students in Oxford and Palestine. Furthermore, we hope that our model can be successfully replicated for any endeavour aiming to remedy a ‘tutor deficient’ area with a ‘tutor surplus’ area.

Conclusion

With an uncertain future for the Israel–Palestine conflict, there is critical need to build self-sustaining health and education capacities in the occupied territories rather than focusing solely on humanitarian aid defined by narrow parameters. There is reason to hope that emerging international initiatives can help to ameliorate Palestine’s health status. Sustainable improvement in healthcare provision is reliant on education of medical professionals, which in turn depends on access to clinical learning environments and the development of a robust teaching culture. Increasing globalization and the emergence of innovative technologies make the concept of long-distance partnership and remote intervention increasingly feasible. The OxPal model can be replicated for any endeavour connecting remote health care communities, and indeed, as leading global employers, western health communities have a critical role to play in supporting such projects, a contribution which may be viewed as ‘compensation’ for foreign staff recruited into their health systems (Crisp 2007). It is hoped that growing partnerships between Palestinian and international global health actors will help to realize a future in which outstanding Palestinian clinicians are engaged in promoting and sustaining the highest local standards of medical education, research and professionalism in the Palestinian healthcare sector.

Notes on contributors

M.A. Ali is a final-year medical student at the University of Oxford and the director of the OxPal Medlink.

R.S. Penfold is a fifth-year medical student at the University of Oxford and a senior coordinator in the OxPal Medlink.

I. Patel is a specialist registrar in Rheumatology and General Internal Medicine in the Oxford Deanery and the chairman of the OxPal Medlink.

T. MacGregor is a surgical registrar in Oxford, and a clinical research fellow in the Department of Oncology, Oxford University.

T.J. Cahill is an academic clinical fellow in cardiology and general internal medicine at Oxford University Hospitals and a Junior Research Fellow at New College, Oxford. He is the OxPal Clinical Subject Lead for Medicine.

A.M. Ali is an academic foundation doctor at Oxford University Hospitals. He coordinates research and feedback in the OxPal programme as well as delivering surgical tutorials.

S. Shankar is an academic clinical fellow in general surgery with a specialist interest in transplantation. She is the OxPal Clinical Subject Lead for Surgery.

M. Nguyen is a DPhil candidate in Biochemistry at Oxford. He is an academic coordinator in the OxPal Medlink.

A.E.T. Finlayson is a medical doctor who works on the strategic development of MedicineAfrica. As Deputy Director of the INDOX research network at Oxford University he also has an interest in building research capacity in low and middle income countries.

I. Mahmud is the founder of the OxPal Medlink and is a Fulbright Scholar at the Harvard School of Public Health after having completing his medical degree at Oxford.

Acknowledgements

Our thanks are extended to Medicine Africa (www.medicineafrica.com), the Al Quds Foundation for Medical Schools in Palestine (www.fqms.org) and the International Medical Education Trust (www.IMET2000.org) for development grants to support our work and the field visit to the West Bank. In addition to the above authors, the OxPal group includes Saleem Lubbad.