Building medical education and research capacity in areas of conflict and instability: experiences of the OxPal Medlink in the occupied Palestinian territories

Abstract

Medical education and research capacity are often neglected in areas of conflict and instability. Physical and geographical barriers to accessing clinical learning environments, lack of dedicated teaching hospitals and frequent economic sanctions may all stunt the growth of a robust teaching culture in such regions. Here, we focus on the unique geopolitical situation of the occupied Palestinian territories and present our experiences with the OxPal MedLink, a web-based distance-learning collaboration which aims to address the educational needs of Palestinian medical students.

Keywords:

• distance learning
• education
• internet
• Palestine
• research capacity

Introduction

In regions of instability and recent or ongoing conflict, healthcare and education may be early victims, marginalized by national and international political agendas and the fight for basic human rights. In the short-term, it is often convenient to focus on providing humanitarian aid, defined by relatively narrow parameters. Whilst important in emergency and relief situations, this overlooks the critical need to re-build healthcare and educational infrastructure in ways that are enduring, empowering and self-sustaining. Strategic health capacity building should be considered an essential cornerstone of recovery in a post-conflict country (Collier 2008); indeed, Giacaman et al. posit that ‘advocacy for human rights and restoration of political, historical and moral justice’ go hand-in-hand with development of sustainable public health services (Giacaman et al. 2010).

To maximize impact, any healthcare intervention needs to be targeted towards areas of greatest need. This requires a background of thorough research, with analysis of strengths and weaknesses of previous and current strategies and a firm understanding of the interaction between political agendas and population health and epidemiology. Such assessment must be determined on an ongoing basis, allowing initiatives to evolve to become increasingly impactful and relevant to local deficits. Expanding long-term capacity for healthcare research and clinical education in regions of instability is a global priority but is challenging, requiring resource investment, commitment and above all innovation. Conventional interventions focus primarily on local delivery of educational resources and personnel to affected regions. Whilst such programmes may be effective (at least in the short-term), they are financially and resource-intensive. Recent technological advances have evolved to facilitate web-based distance learning, capable of crossing geographical and political barriers in real-time and at low-cost. Accumulating evidence demonstrates the very real potential of the online platform, which can be used to foster collaboration between areas of relative educational ‘surplus’ and ‘deficit’.

We present here an analysis of some of the major barriers facing development of a robust academic culture in the world’s most fragile states. Drawing on personal experience of the unique geopolitical context of the occupied Palestinian territories, we discuss the role of local and global education programmes and how these might be utilized and evaluated to bring about sustainable improvements in healthcare delivery.

Defining the problem

No consensus has been reached on the definition of a fragile or post-conflict state. However, they are generally ‘characterised by weak policies, institutions, and governance’ (Carvalho 2006) and can be considered ‘unable to perform basic functions [such as] maintaining security, enabling economic development, and ensuring the essential needs of the population are met’ (OECD DAC 2007). Regions of ongoing conflict are perhaps easier to identify; however, cessation of conflict may be difficult to define and is often followed by a period of continuing unrest.

It cannot be assumed that conflict and instability always go hand-in-hand with poverty and poor population health; however, they frequently co-exist. Fragile states are some of the most off-target in relation to the Millennium Development Goals and fare poorly in other global health statistics (DFID 2005). Studies suggest that fragile states or regions within states experiencing conflict or instability, have decreased life expectancy, maternal survival, vaccination status and survival outcomes compared to their regional and income-ranked counterparts (Guha-Sapir and D’Aoust 2010; WHO 2011). These statistics are not generally directly attributable to mortality in conflict, but reflect low baseline health service capacity and a high incidence of non-combat-related death (Garfield 2008). Unstable regions often have higher rates of infectious disease as a result of the destruction of basic infrastructure, reduced public health measures and shortages of medication and supplies for treatment. The security of healthcare infrastructure and personnel may also be at risk from attack or interference during armed conflict.

A distinction has conventionally been drawn between emergency interventions and humanitarian relief on the one hand and longer-term health development on the other, with the two often managed by separate funding streams. Frequently, resource allocation favours humanitarian aid; longer-term investment may be seen as politically or financially risky, with a lower potential pay-off. As aid diminishes during conflict resolution, the resulting funding gap may jeopardize newly established infrastructure and services. Exceptions to this are often countries of strategic and/or political interest to the donor – for example, UK provision to Iraq or Afghanistan (OECD DAC INCAF 2010). There may be cloudy motivations behind such initiatives, with healthcare development entwined with other political goals relating to stabilization and counter-terrorism. Furthermore, donor investment in fragile and conflict states has not grown in parallel with recent rapid increases in global health budgets and allocation of resources is becoming increasingly concentrated – a summary report produced by the Organisation for Economic Cooperation and Development (OECD) Development Assistance Committee (DAC) International Network on Conflict and Fragility (INCAF) in February 2010 highlighted that whilst Afghanistan and Iraq account for 34% of all increases in official developmental assistance (ODA) from the UK since 2000, 10 fragile states have actually seen a fall in ODA in real terms over the same period (OECD DAC INCAF 2010).

It can be seen that long-term strategies for improving healthcare in regions of instability constitute a global priority; the challenge comes in making these effective and self-sustaining.

Research as a means of needs assessment

Academic medicine may be loosely defined as the capacity of the health sector to think, study, research, discover, evaluate, innovate, teach, learn and improve (Awasthi et al. 2005). It is easy to envisage how these might be overlooked in resource-limited settings, with systems struggling to meet the most basic healthcare needs of the population. However, it is the authors’ belief that the health consequences of instability can only be identified through valid data collection, such as the extent of morbidity and mortality and influencing factors. Research facilitates effective structuring of healthcare programmes, allocation of resources to areas of greatest need and provides points of reference by which the effects of future interventions can be evaluated.

We draw examples from our own experience of the occupied Palestinian territories. The Israel–Palestine conflict remains one of the most intractable and polarizing in the world; whilst political and military elements of the dispute receive widespread media coverage, the health status of the population is less well reported, even though the two are inexorably linked (Horton 2009). The presence of 100 of Israeli-controlled checkpoints has had a dramatic impact on healthcare delivery, with ambulances and paramedic staff frequently delayed from reaching emergency situations. The UN Office for the Coordination of Humanitarian Affairs reports that West Bank patients can only access specialized Palestinian hospitals in East Jerusalem if they possess Israeli permits, even in an emergency (OCHA 2012). In June 2013, the WHO reported that 15.5% of patients received no response following permit applications and consequently missed hospital appointments (WHO 2013). These same barriers inhibit students and specialty trainees from accessing clinical learning environments; for example, Al Quds University, the foremost of four medical schools in Palestine, has campuses split between East Jerusalem and the West Bank. Furthermore, Israel frequently withholds tax revenues for punitive purposes, making it difficult for the Palestinian National Authority to pay for public sector services and salaries (Guardian 2011; Reuters 2012). This has contributed to growth of private hospitals and pharmacies at the expense of an already depleted public sector. All of the above, coupled with a lack of cross-border collaboration and restricted access to online contemporary medical literature and novel clinical practices, continues to stunt the growth of a robust research and teaching culture in the region.

As stated by Horton, ‘hope for improving the health and quality of life of Palestinians will exist only once people recognise that the structural and political conditions that they endure in the occupied Palestinian territory are the key determinants of population health’ (Horton 2010). The Lancet-Palestine Alliance, established in 2009, endeavours to promote analysis of Palestinian healthcare by local and international researchers (Giacaman et al. 2009; Horton 2010). Since its inception, there has been a rapid increase in literature relating to Palestinian healthcare, with abstracts and publications reporting findings about the health status of a people dispersed across refugee camps, occupied territory and land under siege (Fujiya and Usuki 2012). Such work is vital in identifying and exposing the unique challenges confronting the region. However, one must be careful in claiming that all research has a positive impact. Agendas may be determined by the priorities of research sponsors and academics, resulting in studies aimed at addressing questions of little interest to potential non-academic users of the research (Chalmers et al. 2012). Whilst it is imperative that local and international research continues in areas of conflict and instability, it should be appropriately targeted towards identifying ways of improving healthcare infrastructure to meet the long-term needs of the population.

The role of teaching as a self-sustaining intervention

A prerequisite of sustainable improvement in healthcare provision is sufficient numbers of adequately trained health workers. Educating nurses, physicians and technologists is a long-term and expensive necessity, dependent on access to clinical learning environments and a robust teaching culture. Many government and NGO initiatives in the UK and elsewhere aim to promote such values in regions of identified need. One example is the International Medical Education Trust (IMET), a UK-registered charity which strives to promote lifelong learning and continuous professional development for all working in the health sector. IMET’s work in Palestine includes building local capacity for management of severe burns in children, psychiatry training to improve child mental health in an occupation context, a Centre for Health Sciences Education offering e-learning, telemedicine and specialist training and schemes to upgrade the standard of anaesthesia and intensive care (www.imet2000.org). Another organization, the Al-Quds Foundation for Medical Schools in Palestine, provides assistance to teaching staff, financing of visits to Palestine by international examiners and visiting professors, post-graduate training and short-term elective study placements for Palestinian medical students abroad (www.fqms.org). Such initiatives directly engage clinicians, students and specialty trainees in academic aspects of medicine and promote awareness of the global scene in a region where restrictions on travel and access to online medical journals limit interaction with the international professional community.

Whilst the work done by such organizations is vital, any initiative working on the ground must operate within existing travel restrictions and volatility in the political situation and is dependent upon a continuous supply of financial and human resources. Advances in IT are providing new tools for delivering and accessing information, as well as for learning. Online education is widely utilized in the US and other developed countries, with demonstrated effectiveness (US Department of Education 2009). Notably, such tools and IT infrastructure are becoming increasingly feasible and cost-effective in more remote and resource-limited environments, providing new opportunities for clinical and research capacity building initiatives. There is a growing body of evidence to support distance learning programmes as a means of delivering access to training, strategic information and clinical care support for clinicians and researchers throughout the world.

We present here our own experience with the OxPal Medlink (www.oxpal.org). Established in 2012, the partnership uses real-time, online classroom-based technology to connect doctors based in Oxford University Hospitals with medical students in the West Bank. Tutorials use cases from the students’ own experiences in Palestine to develop skills in clinical reasoning and the approach to diagnosis and patient management. The virtual classroom incorporates audio, text-based discussion and an interactive white-board and creating a multimedia learning environment requiring only low-bandwidth internet connectivity. OxPal falls within the context of other organizations using distance learning tools in resource-limited settings. It draws inspiration from the social networking model used by MedicineAfrica to promote sustainable transfer of clinical knowledge between the UK and Somaliland (Finlayson et al. 2010). Another programme, set up by the John Hopkins Center for Clinical Global Health Education, aims to develop a full distance learning course for HIV providers in Zambia, the value and feasibility of which has been evidenced so far by high demand and successful online delivery (Bollinger et al. 2011). Technology cannot substitute many aspects of face-to-face interaction; however, accumulating evidence supports the use of online platforms, which can be used to build North–South (or even South–South or South–North) partnerships and promote international collaboration in an educational context. The challenge comes in nurturing these infant partnerships to become sustainable and locally self-reinforcing in regions subject to conflicting financial and political agendas.

Thus far, discussion has emphasized the importance of research and teaching as means of promoting long-term development and stability within the healthcare sector in fragile states. However, it is easy to assume positive impact where there is none and interventions can and must be evaluated. Initially, qualitative and quantitative data can be accumulated from feedback questionnaires, focus groups and semi-structured interviews and such methods have been utilized in evaluation of our own OxPal programme thus far. However, as initiatives expand, more objective and quantifiable methods must be approached. The future scale and acceptability of both on-the-ground and distance learning health education projects will depend ultimately upon demonstration of impact and value, with tangible and quantifiable improvements in both clinical practice and population health.

Conclusions

There is a critical need to build self-sustaining health and education capacities in regions of conflict and instability. Resources are frequently allocated away from healthcare development in favour of emergency interventions and humanitarian relief, which yield results that are perhaps more tangible and cost-effective in the short-term (OECD DAC INCAF 2010). Sustainable improvements require insight into the unique geopolitical and financial barriers confronting healthcare provision in fragile states and this is obtained through systematic and focused research. Education of healthcare workers depends on access to clinical learning environments, awareness of the international academic forum and development of a robust teaching culture; many local and global initiatives work on-the-ground, providing resources and personnel to address deficits identified in these areas. Furthermore, increasing globalization and the emergence of innovative technologies make the concept of long-distance collaboration and remote educational intervention increasingly feasible. Accumulating evidence supports use of the online learning platform, which may be used to remedy ‘tutor deficient’ with ‘tutor surplus’ areas. As leading global employers, Western health communities have a critical role to play in supporting these projects, a contribution viewed by some as ‘compensation’ for foreign staff recruited into their health systems (Crisp 2007).

It cannot be assumed that research and teaching are ipso facto positively impactful. It is vital that financial and human resources are allocated meaningfully and cost-effectively and the impact of any intervention is systematically evaluated. Furthermore, we must always take into account conflicting and fluctuating national and international political agendas which threaten to destabilize educational initiatives. Long-term healthcare development requires ‘collective action between countries as well as within them’ (Smith 2003) and it is the authors’ opinion that teaching and research constitute fundamental pillars of sustainable healthcare development in regions of instability. Structured health investment through international collaboration may, in turn, contribute to state-building, legitimacy and both regional and global security in the world’s fragile and post-conflict states.

Notes on contributors

Rose Penfold is currently a fifth year medical student at Oxford University with a long-standing interest in global health. Since 2012, she has acted as a coordinator for the OxPal Medlink, an education project linking students and faculty from three medical schools in the occupied Palestinian Territories with clinicians based at Oxford University Hospitals in the UK. This has highlighted the important role of technology and international collaboration as a means of global medical education and research capacity-building.

Mohammad Ali is a final year medical student at Oxford University having completed his Bachelors in Medical Sciences in 2011. He currently serves as Director of the OxPal Medlink and is responsible for its day-to-day administration, coordinating a pool of approximately 15 clinical tutors and around 200 Palestinian medical students. Mohammad has a very deep interest in cross-border medical education and a strong interest in writing, with several publications in medical and literary fields.