Abstract
What is the Gaza Medical Reserve Corps?
Gaza is overpopulated, with 2.1 million people living within its 141-square mile landmass. It lacks an adequately staffed, sustainable, coordinated healthcare system to tend to its population's needs. Ongoing conflict, lack of electricity and running water, and poor sanitation compound the issue. High rates of poverty and the ongoing land, air, and sea blockades also exacerbate the situation. This commentary is a policy recommendation to create the Gaza Medical Reserve Corps, an organization of public health and preventive medicine (PHPM) specialists (reservists) who would be trained in emergency and crisis care to provide aid during turmoil, war, and epidemics/pandemics, such as the current coronavirus disease 2019 (COVID-19) pandemic. During peaceful times of noncrisis, reservists would provide primary care services that are currently unavailable in Gaza. They would target those who are most in need in underserved neighborhoods and refugee camps.
The authors conceptualized the Reserve Corps and serve as its leadership. They are currently organizing a Gaza Public Health Advisory Network composed of key community stakeholders, such as medical and dental schools, affiliated hospitals, the Palestinian Ministry of Health, humanitarian aid organizations (such as the United Nations Relief and Advisory Network), invested private entities, and neighborhood elders. Building the Advisory Network will help the Reserve Corps best coordinate care as a partner to Gaza's core healthcare system and assure that reservists fill a gap in the healthcare sector. 1
The ultimate goal is to transition Gaza away from the need for short-term aid and assistance by creating a self-sustaining, financially sound, long-term health system that has the capacity to coordinate care effectively and efficiently. The Advisory Network is crucial for garnering community support and assisting with recruiting reservists. The network serves as a means of “public health system strengthening,” which is found to be critical for effective primary care service delivery in low- and middle-income countries. 2
PHPM physicians in the United States often work on population health while also practicing as clinicians for a portion of their time. 3 Canadian PHPM residents gain training in health advocacy, research, communication, and collaboration. In the United Kingdom and Japan, however, nurses, community semigeneralists/semispecialists, and public health practitioners may become certified PHPM specialists in addition to licensed physicians.4,5 This is the model proposed for Gaza. As PHPM specialists, reservists would rotate their time among 4 distinct divisions. Reservists would work in their clinical practice (eg, dentistry, nutrition, nursing) during their Division 1 primary healthcare time, then rotate through Division 2 education and outreach, Division 3 research and development, and Division 4 public health policy and advocacy.
Division 1: Primary Healthcare
Division 1 would provide primary healthcare services during peaceful periods of noncrisis. Currently, the United Nations Relief and Advisory Network's 22 healthcare facilities serve 96.9% of Gazans. 6 The facilities provide primary care, dental, laboratory, and X-ray services. Gazans have a high use (greater than 3 times per 6 months) of primary healthcare services, 7 and the average number of daily medical consultations per doctor is 113. 6 Reservists would help alleviate the burden of these overworked clinicians. Reservists would also assist in prioritizing residents in refugee camps, since chronic diseases have been found to be about 40% higher among those living in the camps. 8
Using Telehealth Services
For cost-effectiveness and greater efficiency, the Reserve Corps would provide telehealth services. The US Centers for Disease Control and Prevention advocates telehealth for non-US countries, particularly low-income countries. 9 Much of the customized hardware and software and telecommunication technologies are open source, and thereby affordable to implement. The specific advantages of telehealth to Gaza during the COVID-19 pandemic include the ability to employ various professionals of different specialties in a short amount of time, treat patients when hospitals are unavailable, and reduce patient waiting time in medical offices. 10 A Gazan telehealth system would include a regional electronic medical records system to streamline and automate the current paper system of discharge summary notes, progress notes, referrals, and prescriptions. 11
Current issues that prevent the use of telehealth services include inadequate education on telehealth for both physicians and patients, the unavailability of needed infrastructure, and lack of funding. 12 In Syria, remote training sessions were provided over online platforms such as Skype, Zoom, GoToMeeting, and Google Meet. 13 The Advisory Network can assist by helping to build the necessary infrastructure. Medical schools would also provide telehealth training to reservists.
Facilitating At-Home Healthcare Visits
Wealthier Gazans sometimes request physician home visits, which were especially convenient during COVID-19 lockdowns. Service pricing was dependent on the physician's specialty, availability, location (travel time), and the urgency of the requested home visit. This practice is not standardized in Gaza; private clinicians conduct business and set rates independently. Gazans find physicians who provide such services by word of mouth, so availability is not widely known. Providing various specialty home visits would be an added convenience for wealthier Gazans. To systematize and mass market this premium service is plausible.
Division 2: Health Education and Community Outreach
Media—specifically social media—would be used to educate and reach the public. Successful COVID-19 educational campaigns in Syria used Facebook and WhatsApp for updates, daily communication, and team management. 13 Social media and communication tools were also used to collect health information, communicate health messages, and answer queries from the general public. In Lebanon, health workers flooded traditional media (ie, print, television, radio) and social media outlets with relevant information during the COVID-19 pandemic. 14
For greater educational impact, in-person education is preferred and sometimes necessary. For example, Afghanistan and Ethiopia both employed health workers to inform citizens verbally about COVID-19 due to low literacy rates.15,16 However, due to Gaza's high literacy rates, 17 reservists can create and publish visual graphics, news articles, and white papers in traditional media to educate Gazans.
Mobilizing Volunteers to Support Health Education and Community Outreach
Part of Syria's response to the pandemic included activating thousands of volunteers to nearly all the region's localities. 13 Volunteers were organized in various technical teams and neighborhood committees. This framework of organization is practical for Gaza since citizens also identify by neighborhood residence. While such examples are specific to health messaging during the pandemic, reservists would continuously educate Gazans on the importance of a healthy lifestyle (which discourages smoking and encourages physical activity) due to high rates of preventable chronic disease in the enclave.8,18
Division 3: Research and Development
Public and private research enables scientific discoveries, leads to the creation of new technologies, and generates innovation—primarily in the biological, biomedical, and health sciences—in countries to assure their economic success.19,20 In Gaza, research occurs in academic institutions, nonprofit organizations, humanitarian organizations, government agencies, and independently. Because Palestine's health system was found to be underperforming, 21 adopting open science principles would be ideal.
Maximizing the Impact of Health Research
The pandemic proved that research efforts are most beneficial when they use open science principles, such as ensuring data transparency, sharing procedures and protocols, encouraging collaborations, and assuring fast and efficient global distribution of critical results. 22 COVID-19 research crosses various disciplines, including business, economy, tourism, mental health, and aging.23-25 It is anticipated that such research in all industries will continue past the decline of the pandemic. As open science practitioners, the authors would instruct reservists accordingly. Hence, the Reserve Corps would play a pivotal role in teaching and advocating open science principles to the Advisory Network member organizations and local researchers. Collaborative, honest, and open research would increase research performance and outputs for all of Gaza.
Supporting Financing and Development Efforts
In addition to disseminating data through academic publications and other forms of scholarly works, funding development duties would be accomplished in Division 4. Although initial funds must be awarded by the government and international community to launch the Reserve Corps, Division 4 would ensure that the Reserve Corps is a self-sustaining and financially sound entity. First, telehealth and home visits in Division 1 would be billable services. Second, development duties will include writing grants, seeking donors, and developing diversified funding streams. The Reserve Corps qualifies for various grants, such as treatment programs for populations at risk (using data from Division 1), creative health education and community outreach campaigns (programming from Division 2), education and training for the Reserve Corps and Advisory Network members, the development of telehealth and electronic medical records services, and the execution of critical public health policy and advocacy efforts (work by Division 4).
Division 4: Health Policy and Advocacy
Reservists will be trained to create advocacy campaigns, write critical papers such as this one, lobby for policy change, and empower the public to advocate for data-driven services and health equity. The pandemic has proven the dire need for policymakers to prioritize the health sector in its budget allocations, and “the public health community should not miss this once-in-a-lifetime ‘policy window’ to raise the level of advocacy for appropriate investment in the health sector.” 26 Healthcare systems must be financed and structured so that all those who require care may access it. 27 COVID-19 has shown health inequity to be a major problem that must be addressed—not only to prepare for the next pandemic but also to ensure people are treated and cared for no matter where or who they are.
Staffing the Reserve Corps
Palestine, and Gaza especially, has a high rate of people who are educated but unemployed. Salama 28 found that in Palestine, which includes the West Bank, the rate of unemployment increased as the level of education increased, and Alkafri 29 discovered the unemployment gap between men and women increased as the number of years of higher education increased. In 2017, the unemployment rate of Palestinian youths (aged 15 to 29 years) with an associate's diploma or higher was 55.8% (37.8% male, 72% female), and for those with a science degree the rate was 69.6%. 13 During the fiscal year of 2019, Palestine's overall unemployment rate was 25.3% (21.3% male, 41.0% female; 43% Gaza, 14% West Bank). 30
The Reserve Corps will focus on recruiting recent health science graduates. Given the greater need in particular neighborhoods and refugee camps, a concentrated effort will be made to have Advisory Network members from those geographical areas recruit potential reservists. Hiring female health professionals will also be prioritized because they have a higher rate of unemployment and female Muslims prefer female health professionals.30-32 Hiring from one's own neighborhood or refugee camp ensures a more culturally aware, language-appropriate, and socially acceptable experience between providers and patients. 33
Organizing the Reserve Corps
Due to the COVID-19 pandemic, the Philippines passed a bill in November 2020 to establish a medical reserve corps through recruitment, training, and payment for services rendered by temporary medical reservists. 34 Lessons can be drawn from their experience, as it is similar to the medical reserve corps that we propose. In addition, we can learn from the experience in sub-Saharan Africa, where community health workers were employed after the Ebola epidemic to deliver primary healthcare services such as preapproved treatments and medications, offer health education and advice, and coordinate referrals for low-income communities via smartphones. 35 This approach has proven to be cost-effective, low-cost, and rapidly scalable. Services would continue in noncrisis times.
Timing for Creating the Reserve Corps
International organizations and foreign aid can assist Gaza in its fight against COVID-19 and with its development “without having to contend with the (political) stigma of doing so.” 36 In 2016, the World Health Organization stressed Palestinians' right to quality healthcare and called on the international community to support them in developing and reforming their healthcare system. 37 Since the COVID-19 outbreak has weakened Palestine's already underfunded health and social service system, 38 this is the ideal time to develop a sustainable long-term health sector. Although some called for the Middle East to unify against COVID-19, it never did so. However, the region's wealthier states can “provide logistical, technical, and financial assistance to their neighbors.” 39 For example, they can invest in the establishment of the Reserve Corps and/or its telehealth system. It is anticipated that Palestinian policymakers would support the creation of the Reserve Corps and participate in the Advisory Network. 40
Supporting the Creation of the Reserve Corps
As the primary function of the Reserve Corps is to provide medical support, reservists would always mobilize in times of emergency. Emergency situations supersede their normal functions as PHPM specialists. Reservists would be at the frontlines and support the existing medical infrastructure. By creating the Reserve Corps during this pandemic, reservists would help contain the current pandemic, prevent future epidemics, and provide relief in crisis and conflict.
The Reserve Corps would be a medical workforce of Gaza-trained Gazans committed to building a long-overdue healthcare delivery system for Gaza. The successful implementation of the Reserve Corps will have impacts beyond Gaza. It can be used as a transferable model for similar places that may similarly lack effective healthcare systems, such as the West Bank, Syria, and Lebanon, and throughout the Eastern Mediterranean region.
Conclusions
The authors have successfully recruited a team of 9 global researchers and 7 US-based graduate and undergraduate level researchers to assist in the development stages of the Reserve Corps. This commentary serves as the Reserve Corps' flagship piece, and the team is currently working on critical subsequent papers. They are emphasizing the need to revitalize the PHPM specialty because of the pandemic, compiling the best practices of various low- and middle-income countries to create each of the 4 divisions, and justifying the necessity of a formal community health network. Current medical students and recent health science graduates are being surveyed for feasibility.
Currently, the authors are in discussions with student volunteers to develop a health education and awareness campaign and start a grassroots movement. They have also been actively applying for various grants to make the Reserve Corps a reality. It is hoped that this commentary will be a useful summary for key players and will encourage them to assist in the creation of the Gaza Medical Reserve Corps, ideally during the COVID-19 pandemic.
Footnotes
Acknowledgments
We would like to express our gratitude to the anonymous reviewers for their careful review and insightful comments. We would also like to thank Talya Underwood, MPhil; Michelle King-Okoye, PhD; Arika Virapongse, PhD; Saman Essa; Diana Mora Bermejo; and Lavezza Zanders for their reviews and assistance.