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The impact of conflict on medical education: Institutional and student insights from Iraq

Journal: BMJ Open

Manuscript ID bmjopen-2015-010460

Article Type: Research

Date Submitted by the Author: 04-Nov-2015

Complete List of Authors: Barnett-Vanes, Ashton; Imperial College London; St George's, University of London, Faculty of Medicine Hassounah, Sondus; Imperial College London, Primary Care and Public Health Shawki, Marwan; University of Baghdad, Department of Medicine Ismail, Omar; University of Baghdad, Department of Medicine Fung, Chi; Imperial College London, Faculty of Medicine Kedia, Tara; Dartmouth Medical School, School of Medicine

Rawaf, Salman; Imperial College London Majeed, Azeem; Imperial College, Primary Care

<b>Primary Subject Heading</b>:

Medical education and training

Secondary Subject Heading: Global health

Keywords: Conflict, War, Medical education, healthcare, Training

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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The impact of conflict on medical education: Institutional

and student insights from Iraq

Ashton Barnett-Vanes1,2*

Sondus Hassounah1,3 Marwan Shawki4

Omar Abdulkadir Ismail4

Chi Fung1

Tara Kedia5

Salman Rawaf1,3 Azeem Majeed1,3

1. Faculty of Medicine, Imperial College London, London, UK

2. Faculty of Medicine, St George’s University of London, London, UK

3. WHO Collaborating Centre for Public Health Education and Training, Imperial College London, London, UK

4. University of Baghdad, Baghdad, Iraq 5. Dartmouth Medical School, Hanover, NH, USA

*Corresponding Author: [email protected] Ashton Barnett-Vanes, Desk 60, Sir Alexander Fleming Building. Imperial College London, South Kensington. SW7 2AZ

Key words: Conflict, medical education, war, healthcare, training

Word Count: 3450

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ABSTRACT

Objective

This study surveyed all Iraqi medical schools and a cross-section of Iraqi medical

students regarding their institutional and student experiences of medical education amidst ongoing conflict. The objective was to better understand the current

resources and challenges facing medical schools, and the impacts of conflict on the training landscape and student experience, to provide evidence for further research

and policy development.

Setting

Deans of all Iraqi medical schools registered in the World Directory of Medical Schools were invited to participate in a survey electronically. Medical students from

three Iraqi medical schools were invited to participate in a survey electronically.

Outcomes

Primary: Student enrolment and graduation statistics; human resources of medical

schools; dean perspectives on impact of conflict. Secondary: Medical student perspectives on quality of teaching, welfare and future

career intentions.

Findings

Of 24 medical schools listed in the World Directory of Medical Schools, 15 replied to an initial email sent to confirm their contact details, and 8 medical schools responded

to our survey, giving a response rate from contactable medical schools of 53% and overall of 33%. Five (63%) medical schools reported medical student educational

attainment being impaired or significantly impaired; 4 (50%) felt the quality of training

medical schools could offer had been impaired or significantly impaired due to

conflict. A total of 197 medical students responded, 62% of whom felt their safety

had been threatened due to violent insecurity. The majority (56%) of medical students intended to leave Iraq after graduating.

Conclusions

Medical schools are facing challenges in staff recruitment and adequate resource provision; the majority believe quality of training has suffered as a result. Medical

students are experiencing added psychological stress and lower quality of teaching; the majority intend to leave Iraq after graduation.

ARTICLE SUMMARY

Strengths and limitations of this study

• This study is the first to provide insight into the medical school and student

experience in Iraq amidst ongoing conflict.

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• The method employed is a simple survey providing detailed data to a range of

questions.

• This survey does not permit a detailed subjective discussion concerning finer

considerations of educational policy and has a low response rate.

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INTRODUCTION

Conflict or violent insecurity remains a persistent international problem.

Approximately 300 million people live amongst violent insecurity worldwide 1, with one fifth of the world’s population in countries affected by fragility and conflict, a

figure predicted to rise to one-third by the end of 2015 2. The presence of conflict or instability within or between states affects access to ordinary civil activities such as

employment, healthcare and education 3-5.

The health burden during conflict or violent insecurity is influenced by several interacting ‘direct’ and ‘indirect’ factors. Direct factors include injuries sustained

through violence and psychological illness such as post-traumatic stress disorder

(PTSD). Indirect factors include other causes of ill-health such as disease and malnutrition resulting from diminished access to or availability of basic health care,

food, water and sanitation 6. These may be exacerbated by population displacements, damage to healthcare facilities or violence towards personnel, and

infrastructural degradation which disrupt logistics and supply chains 7. The collapse

of national public health programmes such as maternal care or childhood vaccination

further compounds the health burden 7-10.

A breakdown in civic activity during violent insecurity can lead to the delay, reduction

or cessation of education and training programmes in medicine 5, affecting those still studying, soon to graduate or already in practice 11-13. Given the often significant

health needs of conflict-affected populations, a failure to continue training and graduation of medical students in-country represents a double hit: a stagnation or

reduction in national medical workforce capacity due to the reduced availability of qualified doctors, who are fluent in regional languages and sensitive to cultural

norms; and an economic loss due to the sums of (often public) money invested in

their training which have not resulted in medically qualified doctors ready to practise.

Given the unmet and frequently escalating health burdens in affected countries, a

lack of national medical capacity is on occasion met by overseas assistance, which whilst well-intentioned may not be sufficient, timely, sustained or culturally sensitive 14-17.

Isolated reports exist on the impact of conflict and violent insecurity upon medical education. These conflicts are of varying scale and nature, including inter-state and

asymmetrical wars. For example, in the United States, the Second World War saw a substantial increase in the volume of medical graduates, with emphasis added on

curricula components such as first aid and emergency medicine 18. During the 15 year Lebanese civil-war, educational activities at the American University of Beirut

Medical College were at times suspended 19. Whilst in the 2006 Lebanon-Israel war,

despite the curtailing of formal education, some medical students were exposed to additional wartime medical challenges and training 20. In the Balkan Wars of the

1990s, buildings of the satellite colleges and hospitals of Zagreb Medical School were significantly damaged; eventually the Osijek branch was closed and students

transferred to Zagreb city 11. Medical students were active in both preparation of medical supplies and serving on the frontline 12. At the only recognised medical

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school in Liberia, the civil war stretching over 20 years caused significant delays in

medical training due to destruction of college infrastructure and loss of teaching staff 13. Such reports offer testament to the complex challenges faced by medical institutions, their faculty and students in times of conflict or violent insecurity. In Iraq,

a series of interventions and crises in recent years have placed Iraqi civil society and educational institutions under significant strain: from the prolonged intellectual

embargo 21, 2003 invasion 22 and now protracted conflict involving ‘Daesh’ or ‘ISIL’ militants, these events have exerted profound negative effects on societal function 23.

The aim of this study was to examine the feasibility of surveying medical schools and

medical students in Iraq; identify impacts of the ongoing conflict on medical

education; and inform wider multilateral studies seeking to identify pragmatic programme and policy solutions to the issues arising.

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METHODS

Medical Schools

Medical schools in Iraq were identified using the World Directory of Medical Schools database. Emails of medical school deans were collected and deans were invited to

complete an online questionnaire survey (GoogleForms) in English (Appendix 1). Reminders were sent twice by email over the 3-month data collection period (March-

May 2015). The questionnaire asked deans to complete questions relating to: their total number of students, teaching and administrative staff; annual student

graduation and enrolment; levels of student dropout and the average cost of training each medical student; whether conflict had affected medical student training or

attainment; the impact of conflict on staff recruitment and retention; the effect of

conflict on local infrastructure and deans’ perspectives on areas for assistance. The questionnaire was validated in partnership with an Iraqi medical school Professor.

Medical school geographical location images were generated using GoogleMaps© and are accurate as of August 2015.

Medical Students

Due to the absence of institutional student emails, medical students from 3 large Iraqi medical schools were invited to participate in English in an online survey

(GoogleForms) through medical school online forums and social media (Iraqi

Medical Schools, International Federation of Medical Student’s Associations, Facebook IFMSA). The questionnaire asked medical students to complete questions

relating to: their basic demographics; whether they were a guest or ordinary student; the impact of conflict on their training; whether they were considering dropping out;

their academic and welfare concerns; whether their or their peers’ safety was threatened; future career intentions and students’ perspectives on areas for

assistance. The questionnaire was validated in partnership with Iraqi medical

students (IFMSA Iraq). Full questionnaire details can be found in Appendix 2.

Data Analysis

Anonymised data was collated using GoogleForms, organised in Excel and figures

were generated using Adobe Illustrator v6. Statistical analyses were applied using GraphPad v5.

Ethical Review

Exemption from review was granted by the Ethics Review Board of Dartmouth College, Hanover, New Hampshire, United States (Appendix 3).

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RESULTS

Medical schools

As shown in Table1, Iraq currently has 24 medical schools listed in the World Directory of Medical Schools. Of these, 15 medical schools replied to an initial email

sent to confirm their contact details, we were unable to elicit a response from the remaining 9. Of the 15 who replied, 8 medical schools responded to our survey,

giving a response rate from contactable medical schools of 53% and overall of 33%. Of the 8 responding medical schools, Figure 1 illustrates their geographical location

and Table 2 details the number of medical students across year groups. As a newly established institution, one of the respondents, Jabir Ibn Hayyan Medical University

has only begun enrolling students recently.

Table 1: Iraqi Medical Schools and study participants

Iraq Medical Schools n=24 Replied n=15

Responded n=8

Al Nahrain University N Al-Anbar University N Al-Iraqia University (Ibn Seinna College of Medicine, Iraqi University) Y Al-Qadisiya University College of Medicine N Babylon University N Hawler Medical University Y Y Jabir Ibn Hayyan Medical University Y Y Kufa University Y Y Ninevah College of Medicine N Sulaimani College of Medicine Y Y University of Al-Mustansiriyah Y University of Al-Muthana College of Medicine Y Y University of Baghdad Y University of Baghdad. Al-Kindy College of Medicine N University of Basrah Y University of Diyala College of Medicine Y Y University of Duhok Faculty of Medical Sciences N University of Kerbala College of Medicine N University of Kirkuk College of Medicine Y University of Misan Y University of Mosul College of Medicine N University of Thi Qar College of Medicine Y University of Tikrit College of Medicine Y Y University of Wasit Y Y

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Table 2: Participating medical school’s student population

Medical School Number of Medical Students

Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Al-Muthana College of Medicine

67 32 41 57 35 29

Diyala College of Medicine 60 53 48 64 46 51 Hawler Medical University 157 177 188 165 149 151 Jabir Ibn Hayyan Medical University

100 85 0 0 0 0

Kufa University 160 138 110 115 150 134 Sulaimani College of Medicine

147 177 167 139 136 103

Tikrit College of Medicine 118 106 127 157 113 100 Wasit 77 54 65 85 76 51

We collected a range of details from medical schools to better understand their

institutional experience. As detailed in Table 3 these included: current student enrolment and graduations, levels of dropouts, the number of teaching and

administrative staff employed and the estimated cost of training. In total, 4560

medical students were currently enrolled at the 8 medical schools. We saw a year-on-year increase in student enrolment, which was largely reflected in small increases

in student graduations where data was available; only Hawler and Sulaimani medical schools had small decreases in graduations between 2012 and 2014. Across the 8

medical schools, a total of 59 students had dropped out of their course in 2014, with a total 1105 teaching staff and 728 administrative staff employed in 2015. The

estimated cost of training each medical student to graduation ranged from US$6,450 to US$110,000.

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Table 3: Medical school student and human resource statistics Medical

School Al-

Muthana

Diyala

Hawler

Jabir Ibn

Hayyan

Kufa

Sulaimani

Tikrit

Wasit

Total

No Medical Students

261 322 987 185 807 869 721 408 4560

Enrollment

'14-'15 67 60 - 100 160 147 118 77 729

'13-'14 32 53 154 85 13 146 106 62 651

'12-'13 50 48 151 - 132 154 129 - 664

∆ in 14/15

since 08

17 10 - - 85 45 67 17 -

Graduations

'13-'14 20 43 129 0 120 104 49 48 513

'12-'13 - 32 138 - 105 122 45 35 477

∆ in '13-'14 since

'08

- - 11 - 22 (15) (3) 48 -

Dropouts '14 14 0 0 37 0 5 1 2 59

No Teaching Staff

'15 39 53 263 40 221 203 216 70 1105

Part- vs Full-time

(%)

50 / 50 75 / 25

1 / 99 0 / 100

0 / 100

0 / 100 28 / 72

10 / 90

-

'14 61 47 262 26 221 - 212 60 889

∆ in 14/15

since '08

21 20 - 40 24 - 15 43 -

Admin Staff

'15 46 91 137 - 197 157 60 40 728

'14 50 94 136 16 197 146 52 35 726

∆ in 14/15

since '08

36 51 17 - (23) 157 19 20

Average

Cost to train doctor ($)

10000 165000

- 110000

6450

- - - 72862

Students / teaching staff ratio (2014/15)

6.69 6.08 3.75 4.63 3.65

4.28 3.34 5.83 4.78

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From this data, the staff-to-student ratio of each medical school was determined

which averaged 4.78 students per teaching staff member (Table 3); although schools

have widely different student and staff numbers, their ratios appeared to be consistent (r2 = 0.9586) (Appendix 4). Deans were asked what impact conflict was

exerting on medical student attainment and training quality as shown in Figure 2. Five (63%) medical schools reported student academic attainment

(success/performance) being impaired or significantly impaired, 2 (25%) felt there was no change and 1 (12%) felt it had improved. On quality of training: 4 (50%) felt

training had been impaired or significantly impaired, 2 (25%) felt there was no change and 2 (25%) felt it had improved. Subjective reasons cited by deans as to

why training had been impaired included missed days of classes, and graduation of

students with gaps in their knowledge. Deans also subjectively reported changes in student decision making regarding enrolment, with the safety of the surrounding

region increasingly influential in student decision making on where to enrol.

Medical school deans reported facing challenges in staff recruitment and retention,

and although numbers have increased since 2008, some staff are still unable or

afraid to come to work. At the University of Al-Muthana, 50% are working part-time whilst at Diyala Medical School, as many as 75% of the staff are working part-time

(Table 3). Four (50%) medical schools reported experiencing financial challenges;

deans commented that unreliable administrative resources including email and internet services were also hampering educational activities at medical schools.

Medical students

Respondents totalled 197 students from 3 medical schools spread across Iraq, as detailed in Table 4 and Figure 3. These students were from year 2 to 6 of their

studies; 89% were ordinary students and 11% were guest students from other parts

of Iraq. When asked on the impact of conflict on their quality of training: 63% of

respondents from Baghdad, 57% from Basrah and 60% from Wasit University said

their training had been impaired or significantly impaired by conflict (Figure 4A). Common concerns of students across these medical schools included: their level of

clinical competence, mental exhaustion and personal safety (Figure 4B). Asked on the psychological impacts of conflict, students commonly cited anxiety and

depression (Figure 4B). Other impacts on their student experience included gaps in medical knowledge often due to missed teaching (Figure 4B).

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Table 4: Medical student participant demographics Demographics

Male 77

Female 117 Not given 3 Total 197 Medical School

University of Baghdad 100

University of Basrah 69

University of Wasit 28 Stage of Training

Year 1 0 Year 2 47

Year 3 53 Year 4 37

Year 5 41 Year 6 19 Type of Student

Ordinary Student 175 Guest (transferred) Student 22

Medical students were asked whether they experienced personal attacks or threats

to their safety as a result of conflict: 50% of respondents from Baghdad, 65% from Basrah and 75% from Wasit University reported they had (Table 5); an overall

average of 62% of students. Asked on student consideration of ‘dropping out’ (discontinuation of their studies) as a result of conflict, the majority of respondents

had not considered it (Table 5). Of the 22 guest students included in this survey: 11 (50%) expressed that their needs were being met by their host institution, 9 (40%)

said they weren’t and 2 (10%) did not answer (Table 5). Subjective responses from

guest students included a desire for their hosts to introduce feedback mechanisms to inform understanding of guest student needs and current welfare, these included

enhanced provision of psychological and social support.

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Table 5: Student safety, study plans and future career intentions

Personal attacks / threats

Yes % No % Don't know

% (n)

Baghdad 55 56 19 19 25 25 99

Basrah 45 65 13 19 11 16 69

Wasit 21 75 1 4 6 21 28

Total 121 61 33 17 42 21

Dropping out

Considering % Not considering

% Don’t know

% (n)

Baghdad 27 27 46 46 26 26 99

Basrah 20 29 34 49 15 22 69

Wasit 4 14 17 61 7 25 28

Total 51 26 97 49 48 25

Guest student needs

Being met % Inadequate % N/A %

11 50 9 41 2 9 22

Future career intentions

Leave Iraq % Stay in Iraq % N/A %

109 55 84 43 4 2 197

We then surveyed student career intentions after graduation. As detailed in Table 5, the majority (109, 56%) of students’ intentions after graduation are to leave Iraq.

Amongst these students, the majority wished to pursue a clinical career or undertake further study (data not shown). Of the 84 (42%) students who intended to stay in Iraq,

the majority wished to pursue a clinical career or undertake further study (data not shown). Finally, we invited students to provide (without restriction) subjective

comments on how the educational impacts of conflict could be mitigated. Ninety-two

(47%) study participants replied with comments, these were grouped into personal,

educational and other external themes which were then sub-divided further as

detailed in Figure 5. These included improving student safety and support; changes to clinical training; greater international opportunities; and an end to conflict.

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DISCUSSION

Health systems depend on local educational structures to facilitate training of an

adequate supply of health professionals. Inadequate levels of physicians are associated with increased population disease burden and a reduction in health

system performance 24-26. The impact of conflict on education is well described 5, 27. Reports of the specific impact upon medical education have arisen from several

recent conflicts including Croatia 11, 12, Liberia13 and Lebanon19. These (predominantly retrospective) reports offer insight into the challenges experienced by medical

students in times of conflict or insecurity, who can often find themselves subject to or even participating in the medical response to war 12, 20, 27. However, few studies have

examined the perspectives of both medical school deans and medical students

during conflict.

This study was conducted in Iraq, a country that has experienced decades of conflict, violence and insecurity. During and after the 1990-1991 Gulf War, medical education

in Iraq was impaired by a decade long intellectual embargo. This reduced access to

educational medical books and academic exchange, and drove down academic and

clinical standards, forcing many to leave Iraq 21. The 2003 invasion, war and subsequent violent insecurity has compounded this crisis, leading to an exodus of

Iraqi academics and medical professionals 28. More recently, violence has intensified

further still with the insurgence of non-state actor ‘Daesh’ (ISIL) leading to substantive internal displacement 23: the public health situation in Iraq is now critical 29, 30.

Medical schools

We identified 24 Iraqi medical schools from online searches, 8 more than identified in

a regional review from 2013 31. Participants in this study were spread across Iraq

(Figure 1), but none were in Anbar province in Western Iraq which has experienced

some of the most intense violence 32. We found student enrolment and graduations

at medical schools were relatively stable over the last two years, with the majority of medical schools reporting increases in student and staff appointments since 2008

(Table 3). Interestingly, all participating medical schools had similar student to teaching staff ratios (Appendix 4) suggesting that despite the conflict, medical

education infrastructure and human resources remained balanced across the participating medical schools. The estimated cost of training each medical student

ranged from US$6,450 to US$110,000 compared to a global average of $113,000 24. The size of the variance in these figures – which only 4 (50%) of medical schools

were able to provide – warrants further attention. If true, it suggests a great variation in medical school expenditure which could be further assessed and optimised. The

majority of deans felt both medical student attainment and quality of training had

been adversely affected by recent conflict (Figure 2). Interestingly, Kufa Medical School reported an improvement in student attainment following the conflict, as since

cessation of the international embargo significant efforts have been devoted to developing the institution including partnering with Leicester University’s School of

Medicine in the United Kingdom to advance its academic curriculum since 2012.

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Medical students

A majority (61%) of students in this study felt that their quality of training had been

impaired by the ongoing conflict (Figure 4A). This seems plausible as evidence from the war in Croatia showed that medical students at Osijek University struggled to

concentrate on their studies amidst the ongoing violence, eventually requiring their transfer to Zagreb Medical School11. Student perceptions of violence are key

influencers of educational achievement, with the stress and uncertainty associated with conflict disturbing all stages and actors in the educational process 33. Key

concerns cited by medical students included their level of clinical competence (Figure 4B); mirroring concerns raised by deans over the graduation of students with

gaps in medical knowledge. Other concerns included: mental exhaustion; fear over

their personal safety (Figure 4B); anxiety and depression (Figure 4B). Attacks on medical facilities, academics and clinicians in Iraq are a long-standing problem 34.

The majority (61%) of medical students in this study felt they or their colleagues had been specifically targeted or threatened (Table 5).

Despite these concerns, most students had not considered dropping out of medical

school: 49% planned to continue until graduation, 26% wished to drop out and 25% were uncertain (Table 5). Conflict drives forced displacement, in the first half of 2015

this stood at 3.2million people in Iraq 23. Medical students - who are often in great

danger during conflict 35 - are frequently forced to transfer their studies for safety reasons 11. Amongst the 194 students that participated in this study, 22 (11%) were

transferred or ‘guest’ students (Table 5); 11 (41%) of whom felt their student needs (such as education and accommodation) were being met, in contrast 9 (38%) felt

they were not and 2 (21%) did not answer (Table 5).

Of most concern, the majority (56%) of students expressed a wish to leave Iraq after

graduation (Table 5). This figure is remarkably similar to published cross-sectional

studies of Iraqi doctor emigration, where 50% of Iraqi doctors responding to a

national survey wanted to leave Iraq 36. Indeed, doctor job satisfaction and decisions to stay or leave Iraq are strongly linked to security and working conditions 37. Iraq is

for example, one of the largest contributors to the United Kingdom international medical graduate pool 38. These findings are particularly alarming given the already

significant healthcare personnel shortages found in Iraq 39. Iraq’s current physician density is 0.6 doctors / 1000 population 40; lower than the WHO target of 1/1000, the

Eastern Mediterranean Region average of 1.6/1000 31 and global average of 1.2/1000 41. With a high birth rate and rapidly growing population, physician

graduations in Iraq need to expand significantly in order to both keep apace of population increases and achieve the WHO target - without which, an increase in

disease burden is likely 26. That such a high proportion of current students are

considering leaving Iraq after graduation warrants immediate attention.

Limitations

This study had a low number of medical school respondents, some of whom were

uncontactable, whilst others may have experienced issues in storing and obtaining information thus precluding their participation. Due to challenges in email reliability,

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students were invited to participate via online notices placed on social media outlets.

Thus, we were unable to control respondent demographics or discern a response

rate. Nevertheless, given the extremely challenging circumstances in Iraq and clear impact of medical education on health system capacity and performance 24, 25, we

feel this study offers important insights that inform educational and policy stakeholders minded to maintain and improve the current and future Iraqi health

system.

Study implications and recommendations

This study is the first to document institutional and student insights of medical

education amidst ongoing conflict. There is a need for more data on the impacts on

medical education and other key institutions in civil society in states that are, like Iraq, experiencing violent conflict. Such information could inform strategies adopted by

domestic governments, international organisations, and other stakeholders to support the maintenance of civil society and domestic institutions in times of unrest.

This could range from formal exchange or ‘buddy’ programmes with medical schools

in the region or internationally; to social, physical, and mental health support for medical students and faculty in-country.

We recommend:

1. Country-wide medical school needs assessment

This study has highlighted shortcomings in medical school resources and staff capacity that is impacting on medical education provision. Given the majority of

Iraq’s medical schools are unaccounted for in this study, we recommend a full

national assessment be conducted, ideally by country stakeholders with WHO

oversight, to systematically examine the needs of all medical schools and options for local, regional and international support.

2. Country-wide medical student cross-sectional survey

Medical student participants in this study indicated a high-degree of psychological

stress; concern over clinical competence; the majority held intentions to leave Iraq. A survey of medical students coordinated by medical schools, national stakeholders

such as IFMSA Iraq and Kurdistan, with oversight from WHO, could inform medical schools and educational stakeholders of the burden faced by Iraqi medical students.

The survey would also help inform strategic decision making necessary to improve

student experience and retention after graduation.

CONCLUSION

The findings from this study provides insight into the medical school and student

experience in Iraq amidst ongoing conflict. Medical schools are facing challenges in staff recruitment and adequate resource provision; the majority believe quality of

training has suffered as a result. Medical students are experiencing added psychological stress and lower quality of teaching; the majority intend to leave Iraq

after graduation. We recommend a country-wide nationally-coordinated needs assessment of medical schools, and cross-sectional survey of medical students, to

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identify areas for local, regional or international support necessary to maintain and

improve Iraq’s medical education and future health service.

ACKNOWLEDGMENTS

We thank IFMSA Iraq, IFMSA Kurdistan, Dr Hilal Al-Saffar, Moa M Herrgård and

Christopher Schürmann for their assistance.

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LEGENDS

Tables

Table 1 Legend

The currently listed medical schools in Iraq according to the World Directory of

Medical Schools, those which replied to an initial email and those which participated in the study.

Table 2 Legend

Total student numbers across each year at participant medical schools.

Table 3 Legend

Participating medical school enrolment, graduations and dropouts; teaching and administrative (admin) staff; and cost to train each doctor (USD). ‘-‘ denotes missing data from respondent, brackets ‘()’ denote decreases.

Table 4 Legend

Personal and academic demographics of medical student study participants.

Table 5 legend

Student safety, study plans and future career intentions. Numbers refer to total

respondents for each option. (n) = total respondents for each medical school, %

refers to the proportion selecting the option from each medical school, total % refers to the proportion selecting the option from total student participants across medical

schools.

Figures

Figure 1 Legend

Geographical location of participating medical schools. Image generated using

GoogleMaps©.

Figure 2 Legend

Deans’ perspectives on the impact of conflict on medical student attainment

(academic achievement/success) (A) and quality of training (B). Numbers (n) refer to total respondents for each option; green=no change, red=impaired/significantly

impaired, blue=improved/significantly improved.

Figure 3 Legend

Geographical location of medical student participants’ medical school. Image generated using GoogleMaps©.

Figure 4 Legend

Student perceptions on the impact of conflict on quality of medical training (A); main concerns, psychological and other impacts of conflict on the student experience (B).

Where numbers (n) refer to total respondents for each option; green=no change, red=impaired/significantly impaired, blue=improved/significantly improved; % of

students refers to the proportion of students selecting the option of total student participants across medical schools.

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Figure 5 Legend

Student perspectives on mitigating educational impact

Student subjective comments were thematically analysed, grouped and sub-grouped.

Numbers (n) refer to total respondents for each option. Themes were sub-grouped according to personal, educational, or other external factors.

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Competing interests disclosed

Ashton Barnett-Vanes: No competing interests

Sondus Hassounah: No competing interests Marwan Shawki: Marwan Shawki was a representative of IFMSA-Iraq (International

federation of Medical Students' Associations-Iraq) during the course of this study, he has no other competing interests to declare.

Omar Abdulkadir Ismail: Omar Ismail was a representative of IFMSA-Iraq (International federation of Medical Students' Associations-Iraq) during the course of

this study, he has no other competing interests to declare. Chi Fung: No competing interests

Tara Kedia: No competing interests

Salman Rawaf: No competing interests Azeem Majeed: No competing interests

Contributorship Statement

All authors have participated fully in the conception, writing and critical review of this

manuscript. All have seen and agreed to the submission of the final manuscript.

Ashton Barnett-Vanes: Idea, literature search, data collection, writing, critical review Sondus Hassounah: Literature Search, writing, critical review

Marwan Shawki: Literature Search, data collection, writing, critical review

Omar Abdulkadir Ismail: Literature Search, data collection, writing, critical review Chi Fung: Literature Search, writing, critical review

Tara Kedia: Literature Search, data collection, writing, critical review Salman Rawaf: Literature Search, writing, critical review

Azeem Majeed: Idea, writing, critical review

Funding and ethics statement

No funding was associated with the collection of data, or preparation of, this

manuscript. Exemption from review was granted by the Ethics Review Board of

Dartmouth College, Hanover, New Hampshire, United States (Appendix 3).

Data sharing statement Technical appendices of survey questions and additional data are included in the supplementary.

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30. The Guardian. UN agencies 'broke and failing' in face of ever-growing refugee

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isis-from-anbar-province. Accessed 17th September, 2015.

33. Engel LC, Rutkowski D, Rutkowski L. The harsher side of globalisation: violent

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39. Zarocostas J. Exodus of medical staff strains Iraq's health facilities. BMJ : British

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Geographical location of participating medical schools. Image generated using GoogleMaps©. 273x171mm (300 x 300 DPI)

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Deans’ perspectives on the impact of conflict on medical student attainment (academic achievement/success) (A) and quality of training (B). Numbers (n) refer to total respondents for each option; green=no change, red=impaired/significantly impaired, blue=improved/significantly improved.

294x180mm (300 x 300 DPI)

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Geographical location of medical student participants’ medical school. Image generated using GoogleMaps©. 239x166mm (300 x 300 DPI)

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Student perceptions on the impact of conflict on quality of medical training (A); main concerns, psychological and other impacts of conflict on the student experience (B). Where numbers (n) refer to total

respondents for each option; green=no change, red=impaired/significantly impaired, blue=improved/significantly improved; % of students refers to the proportion of students selecting the

option of total student participants across medical schools. 356x302mm (300 x 300 DPI)

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Student perspectives on mitigating educational impact. Student subjective comments were thematically analysed, grouped and sub-grouped. Numbers (n) refer to total respondents for each option. Themes were

sub-grouped according to personal, educational, or other external factors. 385x307mm (300 x 300 DPI)

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Appendix 1: Dean questionnaire Survey

1. Name of your medical school

Location City and Province

Language of Instruction eg English, Arabic

Total number of current students in all years

Number of medical students in year 1

Year 2?

Year 3?

Year 4?

Year 5?

Year 6?

2. How many students graduated in 2014?

How does this compare to number of graduates in 2013?

2012?

2010?

2008?

2006?

2004?

2002?

2000?

3. How many first year medical students did you enrol this 2014/2015 academic

year?

How does this compare to number of enrolled students in 2013?

2012?

2010?

2008?

2006?

2004?

2002?

2000?

4. How many students dropped out of their studies across all medical school years

in 2014?


2012?

2010?

2008?

2006?

2004?

2002?

2000?

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5. Approximately, how much does it cost in total to train a single medical student to

become a doctor at your medical school? (in USD $)

How does this break down over each year?

Year 1?

Year 2?

Year 3?

Year 4?

Year 5?

Year 6?

6. Have there been delays in medical student training since 2010 due to conflict? If

so, for how long did this delay affect student graduations?

• Never

• Less than one 1 month

• 1 Month

• 1-6 months

• 1 Year

• Greater than 1 Year

• Other:

7. In your opinion, what percentage of currently graduating medical students from

your medical school intend to leave Iraq after graduation?

• None

• Less than 10%

• 10-20%

• 20-40%

• 40-60%

• 60-80%

• 80-100%

8. In your opinion, how has conflict affected the educational attainment of medical

students?

• Significantly impaired

• Impaired

• No change

• Improved

• Significantly improved

9. In your opinion, how has conflict affected the quality of training students receive?


• Impaired

• No change

• Improved


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10. In your opinion, what has been the psychological impact of conflict on medical

students?

11. What have been the other impacts of the ongoing conflict on students at your

university? Choose as many that apply

• Missed days of classes

• No structured national medical board licensing exams

• Students displaced and cannot attend

• Students afraid to come to university

• Gaps in medical knowledge, but students are still graduating

• Students must take on patient care responsibilities before graduation

• Other:

12. Currently in 2015 how many teaching staff do you have?

How does this compare to 2014?

2012?

2010?

2008?

2006?

2004?

2002?

2000?

13. Currently in 2015 how many administrative or support staff do you have?


2012?

2010?

2008?

2006?

2004?

2002?

2000?

14. In your opinion, has the quality of teaching staff improved or declined since the

recent onset of conflict?(Recent - since start of 2014)

• Significantly declined

• Declined

• No change

• Improved


15. Have you experienced difficulties in retaining and/or recruiting teaching staff

recently? Please explain

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16. In your opinion, what level of resources do teaching staff have at their disposal?

• Very limited

• Limited

• Adequate

• Good

• Very good

Has it always been this way or have the available resources increased / declined

since the onset of conflict in 2014?Please explain

17. What have been the other impacts of the ongoing conflict on faculty at your


• Teaching staff must take on patient care responsibilities instead of teaching

• Teaching staff unavailable

• Teaching staff afraid to come to university

• Administrative staff displaced and unable to attend

• Administrative staff afraid to come to university

• Administrative staff lack experience

• Lack of admin resources (stable internet, email, data storage)

• Other:

18. What is the approximate % annual breakdown of funding at the medical

institution in your university?

Government funding (%)

Industry funding (%)

Student fees funding (%)

Charitable / grant funding (%)

Other?(%)

19. How has conflict/insecurity affected transport to your university and hospital

sites?(Please explain)

20. Has student or staff accommodation been affected by conflict?(Please explain)

21. What have been the other impacts of the ongoing conflict on infrastructure at

your university(Please explain)

• Loss of infrastructure (road/buildings)

• Loss of funding to medical school

• Loss of clinical areas / hospitals for teaching

• Other:

22. In your opinion, how is the ongoing conflict affecting the ability of your country's

health care workforce to meet the health needs of the population? (Please explain)

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23. In your opinion, what do you think is needed to assist medical schools to

maintain or increase medical training?(Please explain)

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1 Student Demographics

1. Please state your age 2. Please state your gender

• Male

• Female

3. Please state your year of study

• Year 1

• Year 2

• Year 3

• Year 4

• Year 5

• Year 6

• Other: (please specify)

4. Please select your university *Required If you have attended more than one, please select your current University

• Al Nahrain University

• Al-Anbar University

• Al-Qadisiya University College of Medicine

• Babylon University

• Hawler Medical University

• Al-Iraqia University (Ibn Seinna College of Medicine, Iraqi University)

• Kufa University

• Ninevah College of Medicine

• Sulaimani College of Medicine

• University of Al-Mustansiriyah

• University of Al-Muthana College of Medicine

• University of Baghdad

• University of Baghdad. Al-Kindy College of Medicine

• University of Basrah

• University of Diyala College of Medicine

• University of Duhok Faculty of Medical Sciences

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• University of Kerbala College of Medicine

• University of Kirkuk College of Medicine

• University of Misan

• University of Mosul College of Medicine

• University of Thi Qar College of Medicine

• University of Tikrit College of Medicine

• University of Wasit

• Jabir Ibn Hayyan Medical University

• Other (please specify)

5. Are you an ordinary or guest student?

• Ordinary Student

• Guest (transferred) Student


If you're a transferred student, at which University did you previously study?

2 Student Questions

6. Since you began your course, how has conflict affected the quality of medical training students receive?


• Impaired

• No change

• Improved


Please briefly justify your answer 7. If it has, which part of your training has been affected the most due to the presence of conflict?

• Pre-clinical Years (1-3)

• Clinical Years (4-6)

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8. In your opinion, what percentage of currently graduating medical students from your medical school intend to leave the country after graduation due to the conflict?

• 0-10%

• 10-20%

• 20-40%

• 40-60%

• 60-80%

• 80-100%

9. What are your concerns regarding yourself and your medical training in light of the conflict?

• Personal safety

• Physical exhaustion

• Mental exhaustion

• Not being adequately prepared to care for patients at the end of training due to conflict

• Post-traumatic stress disorder

• Inability to financially support yourself


10. Are you (or have you at some stage) considering dropping out of your medical course due to the ongoing conflict?

• Yes

• No

• Don't know

11. Do you feel that medical schools, students, and/or professionals have been specifically targeted by attacks during the conflict?

• Yes

• No

• Don't know

Please explain your answer

12. In your opinion, what has been the psychological impact of the conflict on you?

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• Depression

• Anxiety

• Distraction from studies

• Reconsidering career options


13. What have been the other impacts of the ongoing conflict on medical students at your university?



• Some students afraid to come to university

• Some students not graduating




14. In your opinion what could be done to help medical students maintain and improve their studies whilst the conflict continues?

15. As a guest student, do you feel your needs have been met to allow you to continue your studies effectively? Please only answer this if you are a transferred student

• Yes

• No

• Don't know

16. What are your career goals once you graduate from medical school?

• Stay in Iraq and pursue clinical career

• Stay in Iraq and pursue non-clinical career (eg research, teaching)

• Stay in Iraq and undertake further study

• Stay in Iraq and change profession

• Leave Iraq and pursue clinical career

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• Leave Iraq and pursue non-clinical career (eg research, teaching)

• Leave Iraq and undertake further study

• Leave Iraq and change profession

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Page 1 of 2

Trustees of Dartmouth College Dartmouth-Hitchcock Medical CenterCOMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS

Howard Hughes, PhD, Chair CPHS ADaniel O'Rourke, MD, Chair CPHS B and D

Jack van Hoff, MD, Chair CPHS C

63 South Main Street HB 6254 Hanover, NH 03755Telephone (603) 646-6482 Fax (603) 646-9141

EXEMPTION GRANTED

August 25, 2014

Tara KediaGeisel School of Medicine

CPHS #: STUDY00028328 Action: Exemption GrantedPrincipal Investigator: Tara Kedia Action Date: 8/25/2014Submission Type: Initial StudyReview Type: ExemptFunding: NoneTitle of Study: Investigation of the health economic impact of conflict or violent insecurity,

and medical education in 11 conflict-affected statesDocuments Reviewed: • Info Sheet invitation to participate in the research

• IRB Exempt Application

Thank you for submitting the information on the above referenced project.

Please regard this message as notification that the project has been designated EXEMPT from further review based on the following regulations:

Category 1: Research conducted in established or commonly accepted educational settings, involving normal educational practices, such as (i) research on regular and special education instructional strategies, or (ii) research on the effectiveness of or the comparison among instructional techniques, curricula, or classroom management methods.

Category 2: Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures or observation of public behavior, unless: (i) Information obtained is recorded in such a manner that human subjects can be identified, directly or through identifiers linked to the subjects; and (ii) any disclosure of the human subjects’ responses outside the research could reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects’ financial standing, employability, or reputation.

You have met the CPHS requirements to proceed with your project.

Be sure to contact the CPHS office if the circumstances of your project change such that the federal criteria for exemption no longer apply.

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Page 2 of 2

Sincerely,

Lorri WettemannCommittee for the Protection of Human Subjects

cc: Tara Kedia

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Appendix 4: Plot of ratio of students to teaching

Plot showing affine relationship between teaching staff and students for each

medical school using linear regression curve, r²=0.95.

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The impact of conflict on medical education: a cross-

sectional survey of students and institutions in Iraq

Journal: BMJ Open

Manuscript ID bmjopen-2015-010460.R1

Article Type: Research

Date Submitted by the Author: 26-Nov-2015

Complete List of Authors: Barnett-Vanes, Ashton; Imperial College London; St George's, University of London, Faculty of Medicine Hassounah, Sondus; Imperial College London, Primary Care and Public Health Shawki, Marwan; University of Baghdad, Department of Medicine Ismail, Omar; University of Baghdad, Department of Medicine Fung, Chi; Imperial College London, Faculty of Medicine Kedia, Tara; Dartmouth Medical School, School of Medicine

Rawaf, Salman; Imperial College London Majeed, Azeem; Imperial College, Primary Care

<b>Primary Subject Heading</b>:

Medical education and training

Secondary Subject Heading: Global health

Keywords: Conflict, War, Medical education, healthcare, Training


BMJ Open on D

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The impact of conflict on medical education: a cross-

sectional survey of students and institutions in Iraq

Ashton Barnett-Vanes1,2,3*

Sondus Hassounah1,4 Marwan Shawki5

Omar Abdulkadir Ismail5 Chi Fung1

Tara Kedia6 Salman Rawaf1,4

Azeem Majeed1,4

1. Faculty of Medicine, Imperial College London, London, UK

2. Faculty of Medicine, St George’s University of London, London, UK 3. Catastrophe and Conflict Forum, Royal Society of Medicine, London, UK

4. WHO Collaborating Centre for Public Health Education and Training, Imperial College London, London, UK

5. University of Baghdad, Baghdad, Iraq 6. Dartmouth Medical School, Hanover, NH, USA

*Corresponding Author: [email protected]

Ashton Barnett-Vanes, Desk 60, Sir Alexander Fleming Building. Imperial College London, South Kensington. SW7 2AZ

Key words: Conflict, medical education, war, healthcare, training

Word Count: 3450

ABSTRACT

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Objective

This study surveyed all Iraqi medical schools and a cross-section of Iraqi medical

students regarding their institutional and student experiences of medical education amidst ongoing conflict. The objective was to better understand the current

resources and challenges facing medical schools, and the impacts of conflict on the training landscape and student experience, to provide evidence for further research

and policy development.

Setting

Deans of all Iraqi medical schools registered in the World Directory of Medical

Schools were invited to participate in a survey electronically. Medical students from

three Iraqi medical schools were invited to participate in a survey electronically.

Outcomes

Primary: Student enrolment and graduation statistics; human resources of medical

schools; dean perspectives on impact of conflict.

Secondary: Medical student perspectives on quality of teaching, welfare and future

career intentions.

Findings

Of 24 medical schools listed in the World Directory of Medical Schools, 15 replied to an initial email sent to confirm their contact details, and 8 medical schools responded

to our survey, giving a response rate from contactable medical schools of 53% and overall of 33%. Five (63%) medical schools reported medical student educational

attainment being impaired or significantly impaired; 4 (50%) felt the quality of training medical schools could offer had been impaired or significantly impaired due to

conflict. A total of 197 medical students responded, 62% of whom felt their safety

had been threatened due to violent insecurity. The majority (56%) of medical

students intended to leave Iraq after graduating.

Conclusions

Medical schools are facing challenges in staff recruitment and adequate resource provision; the majority believe quality of training has suffered as a result. Medical

students are experiencing added psychological stress and lower quality of teaching; the majority intend to leave Iraq after graduation.

ARTICLE SUMMARY

Strengths and limitations of this study

• This study is the first to provide insight into the medical school and student

experience in Iraq amidst ongoing conflict.

• The method employed is a simple survey providing detailed data to a range of

questions.

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• This survey does not permit a detailed subjective discussion concerning finer

considerations of educational policy and has a low response rate.

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INTRODUCTION

Conflict or violent insecurity remains a persistent international problem.

Approximately 300 million people live amongst violent insecurity worldwide 1, with one fifth of the world’s population in countries affected by fragility and conflict, a

figure predicted to rise to one-third by the end of 2015 2. The presence of conflict or instability within or between states affects access to ordinary civil activities such as

employment, healthcare and education 3-5.

The health burden during conflict or violent insecurity is influenced by several interacting ‘direct’ and ‘indirect’ factors. Direct factors include injuries sustained

through violence and psychological illness such as post-traumatic stress disorder

(PTSD). Indirect factors include other causes of ill-health such as disease and malnutrition resulting from diminished access to or availability of basic health care,

food, water and sanitation 6. These may be exacerbated by population displacements, damage to healthcare facilities or violence towards personnel, and

infrastructural degradation which disrupt logistics and supply chains 7. The collapse

of national public health programmes such as maternal care or childhood vaccination

further compounds the health burden 7-10.

A breakdown in civic activity during violent insecurity can lead to the delay, reduction

or cessation of education and training programmes in medicine 5, affecting those still studying, soon to graduate or already in practice 11-13. Given the often significant

health needs of conflict-affected populations, a failure to continue training and graduation of medical students in-country represents a double hit: a stagnation or

reduction in national medical workforce capacity due to the reduced availability of qualified doctors, who are fluent in regional languages and sensitive to cultural

norms; and an economic loss due to the sums of (often public) money invested in

their training which have not resulted in medically qualified doctors ready to practise.

Given the unmet and frequently escalating health burdens in affected countries, a

lack of national medical capacity is on occasion met by overseas assistance, which whilst well-intentioned may not be sufficient, timely, sustained or as culturally

sensitive 14-17.

Isolated reports exist on the impact of conflict and violent insecurity upon medical education. These conflicts are of varying scale and nature, including inter-state and

asymmetrical wars. For example, in the United States, the Second World War saw a substantial increase in the volume of medical graduates, with emphasis added on

curricula components such as first aid and emergency medicine 18. During the 15 year Lebanese civil-war, educational activities at the American University of Beirut

Medical College were at times suspended 19. Whilst in the 2006 Lebanon-Israel war,

despite the curtailing of formal education, some medical students were exposed to additional wartime medical challenges and training 20. In the Balkan Wars of the

1990s, buildings of the satellite colleges and hospitals of Zagreb Medical School were significantly damaged; eventually the Osijek branch was closed and students

transferred to Zagreb city 11. Medical students were active in both preparation of medical supplies and serving on the frontline 12. At the only recognised medical

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school in Liberia, the civil war stretching over 20 years caused significant delays in

medical training due to destruction of college infrastructure and loss of teaching staff 13. Such reports offer testament to the complex challenges faced by medical institutions, their faculty and students in times of conflict or violent insecurity. In Iraq,

a series of interventions and crises in recent years have placed Iraqi civil society and educational institutions under significant strain: from the prolonged intellectual

embargo 21, 2003 invasion 22 and – at the time of writing - protracted conflict involving ‘Daesh’ or ‘ISIL’ militants, these events have exerted profound negative effects on

societal function 23.

The aim of this study was to examine the feasibility of surveying medical schools and

medical students in Iraq; identify impacts of the ongoing conflict on medical education; and inform wider multilateral studies seeking to identify pragmatic

programme and policy solutions to the issues arising.

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METHODS

Medical Schools

Medical schools in Iraq were identified using the World Directory of Medical Schools database. Emails of medical school deans were collected and deans were invited to

complete an online questionnaire survey (GoogleForms) in English (Appendix 1). Reminders were sent twice by email over the 3-month data collection period (March-

May 2015). The questionnaire asked deans to complete questions relating to: their total number of students, teaching and administrative staff; annual student

graduation and enrolment; levels of student dropout and the average cost of training each medical student; whether conflict had affected medical student training or

attainment; the impact of conflict on staff recruitment and retention; the effect of

conflict on local infrastructure and deans’ perspectives on areas for assistance. The questionnaire was validated in partnership with an Iraqi medical school Professor.

Medical school geographical location images were generated using GoogleMaps© and are accurate as of August 2015.

Medical Students

Due to the absence of institutional student emails, medical students from 3 large Iraqi medical schools were invited to participate in English in an online survey

(GoogleForms) through medical school online forums and social media (Iraqi

Medical Schools, International Federation of Medical Student’s Associations, Facebook IFMSA). The questionnaire asked medical students to complete questions

relating to: their basic demographics; whether they were a guest or ordinary student; the impact of conflict on their training; whether they were considering dropping out;

their academic and welfare concerns; whether their or their peers’ safety was threatened; future career intentions and students’ perspectives on areas for

assistance. The questionnaire was validated in partnership with Iraqi medical

students (IFMSA Iraq). Full questionnaire details can be found in Appendix 2.

Data Analysis

Anonymised data was collated using GoogleForms, organised in Excel and figures

were generated using Adobe Illustrator v6. Statistical analyses were applied using GraphPad v5.

Ethical Review

Exemption from review was granted by the Ethics Review Board of Dartmouth College, Hanover, New Hampshire, United States (Appendix 3).

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RESULTS

Medical schools

As shown in Table1, Iraq currently has 24 medical schools listed in the World Directory of Medical Schools. Of these, 15 medical schools replied to an initial email

sent to confirm their contact details, we were unable to elicit a response from the remaining 9. Of the 15 who replied, 8 medical schools responded to our survey,

giving a response rate from contactable medical schools of 53% and overall of 33%. Of the 8 responding medical schools, Figure 1 illustrates their geographical location

and Table 2 details the number of medical students across year groups. As a newly established institution, one of the respondents, Jabir Ibn Hayyan Medical University

has only begun enrolling students recently.

Table 1: Iraqi Medical Schools and study participants

Iraq Medical Schools n=24 Replied n=15

Responded n=8

Al Nahrain University N Al-Anbar University N Al-Iraqia University (Ibn Seinna College of Medicine, Iraqi University) Y Al-Qadisiya University College of Medicine N Babylon University N Hawler Medical University Y Y Jabir Ibn Hayyan Medical University Y Y Kufa University Y Y Ninevah College of Medicine N Sulaimani College of Medicine Y Y University of Al-Mustansiriyah Y University of Al-Muthana College of Medicine Y Y University of Baghdad Y University of Baghdad. Al-Kindy College of Medicine N University of Basrah Y University of Diyala College of Medicine Y Y University of Duhok Faculty of Medical Sciences N University of Kerbala College of Medicine N University of Kirkuk College of Medicine Y University of Misan Y University of Mosul College of Medicine N University of Thi Qar College of Medicine Y University of Tikrit College of Medicine Y Y University of Wasit Y Y

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Table 2: Participating medical school’s student population

Medical School Number of Medical Students

Year 1

Year 2 Year 3

Year 4

Year 5 Year 6 Total '14/15

∆ in total since ’12

(24

) Al-Muthana College of Medicine

67 32 41 57 35 29 261 161

Diyala College of Medicine

60 53 48 64 46 51 322 60

Hawler Medical University

157 177 188 165 149 151 987 -

Jabir Ibn Hayyan Medical

University

100 85 0 0 0 0 185 -

Kufa University 160 138 110 115 150 134 807 156

Sulaimani College of Medicine

147 177 167 139 136 103 869 139

Tikrit College of Medicine

118 106 127 157 113 100 721 310

Wasit 77 54 65 85 76 51 408 123

We collected a range of details from medical schools to better understand their institutional experience. As detailed in Table 3 these included: current student

enrolment and graduations, levels of dropouts, the number of teaching and

administrative staff employed and the estimated cost of training. In total, 4560 medical students were currently enrolled at the 8 medical schools. We saw a year-

on-year increase in student enrolment, which was largely reflected in small increases in student graduations where data was available; only Hawler and Sulaimani medical

schools had small decreases in graduations between 2012 and 2014. Across the 8

medical schools, a total of 59 students had dropped out of their course in 2014, with

a total 1105 teaching staff and 728 administrative staff employed in 2015. The estimated cost of training each medical student to graduation ranged from US$6,450

to US$110,000.

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Table 3: Medical school student and human resource statistics Medical

School Al-

Muthana

Diyala

Hawler

Jabir Ibn

Hayyan

Kufa

Sulaimani

Tikrit

Wasit

Total

No Medical Students

261 322 987 185 807 869 721 408 4560

Enrollment

'14-'15 67 60 - 100 160 147 118 77 729

'13-'14 32 53 154 85 13 146 106 62 651

'12-'13 50 48 151 - 132 154 129 - 664

∆ in ‘14/15

since 08

17 10 - - 85 45 67 17 -

Graduations

'13-'14 20 43 129 0 120 104 49 48 513

'12-'13 - 32 138 - 105 122 45 35 477

∆ in '13-'14 since

'08

- - 11 - 22 (15) (3) 48 -

Dropouts '14 14 0 0 37 0 5 1 2 59

No Teaching Staff

'15 39 53 263 40 221 203 216 70 1105

Part- vs Full-time

(%)

50 / 50 75 / 25

1 / 99 0 / 100

0 / 100

0 / 100 28 / 72

10 / 90

-

'14 61 47 262 26 221 - 212 60 889

∆ in 14/15

since '08

21 20 - 40 24 - 15 43 -

Admin Staff

'15 46 91 137 - 197 157 60 40 728

'14 50 94 136 16 197 146 52 35 726

∆ in 14/15

since '08

36 51 17 - (23) 157 19 20

Average

Cost to train doctor ($)

10000 165000

- 110000

6450

- - - 72862

Students / teaching

6.69 6.08 3.75 4.63 3.65

4.28 3.34 5.83 4.78

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staff ratio (2014/15)

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From this data, the staff-to-student ratio of each medical school was determined

which averaged 4.78 students per teaching staff member (Table 3); although schools

have widely different student and staff numbers, their ratios appeared to be consistent (r2 = 0.9586) (Appendix 4). Deans were asked what impact conflict was

exerting on medical student attainment and training quality as shown in Figure 2. Five of 8 medical schools reported student academic attainment

(success/performance) being impaired or significantly impaired, 2 felt there was no change and 1 felt it had improved. On quality of training: 4 of 8 medical schools felt

training had been impaired or significantly impaired, 2 felt there was no change and 2 felt it had improved. Subjective reasons cited by deans as to why training had been

impaired included missed days of classes, and graduation of students with gaps in

their knowledge. Deans also subjectively reported changes in student decision making regarding enrolment, with the safety of the surrounding region increasingly

influential in student decision making on where to enrol.

Medical school deans reported facing challenges in staff recruitment and retention,

and although numbers have increased since 2008, some staff are still unable or

afraid to come to work. At the University of Al-Muthana, 50% are working part-time whilst at Diyala Medical School, as many as 75% of the staff are working part-time

(Table 3). Four (50%) medical schools reported experiencing financial challenges;

deans commented that unreliable administrative resources including email and internet services were also hampering educational activities at medical schools.

Medical students

Respondents totalled 197 students from 3 medical schools spread across Iraq, as detailed in Table 4 and Figure 3. These students were from year 2 to 6 of their

studies; 89% were ordinary students and 11% were guest students from other parts

of Iraq. When asked on the impact of conflict on their quality of training: 63% of

respondents from Baghdad, 57% from Basrah and 60% from Wasit University said

their training had been impaired or significantly impaired by conflict (Figure 4A). Common concerns of students across these medical schools included: their level of

clinical competence, mental exhaustion and personal safety (Figure 4B). Asked on the psychological impacts of conflict, students commonly cited anxiety and

depression (Figure 4B). Other impacts on their student experience included gaps in medical knowledge often due to missed teaching (Figure 4B).

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Table 4: Medical student participant demographics Demographics

Male 77

Female 117 Not given 3 Total 197 Medical School

University of Baghdad 100

University of Basrah 69

University of Wasit 28 Stage of Training

Year 1 0 Year 2 47

Year 3 53 Year 4 37

Year 5 41 Year 6 19 Type of Student

Ordinary Student 175 Guest (transferred) Student 22

Medical students were asked whether they experienced personal attacks or threats

to their safety as a result of conflict: 50% of respondents from Baghdad, 65% from Basrah and 75% from Wasit University reported they had (Table 5); an overall

average of 62% of students. Asked on student views of ‘dropping out’ (discontinuation of their studies) as a result of conflict, the majority of respondents

had not considered it (Table 5). Of the 22 guest students included in this survey: 11 (50%) expressed that their needs were being met by their host institution, 9 (40%)

said they weren’t and 2 (10%) did not answer (Table 5). Subjective responses from

guest students included a desire for their hosts to introduce feedback mechanisms to inform understanding of guest student needs and current welfare, these included

enhanced provision of psychological and social support.

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Table 5: Student safety, study plans and future career intentions

Personal attacks / threats

Yes % No % Don't know

% (n)

Baghdad 55 56 19 19 25 25 99

Basrah 45 65 13 19 11 16 69

Wasit 21 75 1 4 6 21 28

Total 121 61 33 17 42 21

Dropping out

Considering % Not considering

% Don’t know

% (n)

Baghdad 27 27 46 46 26 26 99

Basrah 20 29 34 49 15 22 69

Wasit 4 14 17 61 7 25 28

Total 51 26 97 49 48 25

Guest student needs

Being met % Inadequate % N/A %

11 50 9 41 2 9 22

Future career intentions

Leave Iraq % Stay in Iraq % N/A %

109 55 84 43 4 2 197

We then surveyed student career intentions after graduation. As detailed in Table 5, the majority (109, 56%) of students’ intentions after graduation are to leave Iraq.

Amongst these students, the majority wished to pursue a clinical career or undertake further study (data not shown). Of the 84 (42%) students who intended to stay in Iraq,

the majority wished to pursue a clinical career or undertake further study (data not shown). Finally, we invited students to provide (without restriction) subjective

comments on how the educational impacts of conflict could be mitigated. Ninety-two

(47%) study participants replied with comments, these were grouped into personal,

educational and other external themes which were then sub-divided further as

detailed in Figure 5. These included improving student safety and support; changes to clinical training; greater international opportunities; and an end to conflict.

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DISCUSSION

Health systems depend on local educational structures to facilitate training of an

adequate supply of health professionals. Inadequate levels of physicians are associated with increased population disease burden and a reduction in health

system performance 25-27. The impact of conflict on education is well described 5, 27. Reports of the specific impact upon medical education have arisen from several

recent conflicts including Croatia 11, 12, Liberia13 and Lebanon19. These (predominantly retrospective) reports offer insight into the challenges experienced by medical

students in times of conflict or insecurity, who can often find themselves subject to or even participating in the medical response to war 12, 20, 28. However, few studies have

examined the perspectives of both medical school deans and medical students

during conflict.

This study was conducted in Iraq, a country that has experienced decades of conflict, violence and insecurity. During and after the 1990-1991 Gulf War, medical education

in Iraq was impaired by a decade long intellectual embargo. This reduced access to

educational medical books and academic exchange, and drove down academic and

clinical standards, forcing many to leave Iraq 21. The 2003 invasion, war and subsequent violent insecurity has compounded this crisis, leading to an exodus of

Iraqi academics and medical professionals 29. More recently, violence has intensified

further still with the insurgence of non-state actor ‘Daesh’ (ISIL) leading to substantive internal displacement 23: the public health situation in Iraq is now critical 30, 31.

Medical schools

We identified 24 Iraqi medical schools from online searches, 8 more than identified in

a regional review from 2013 32. Participants in this study were spread across Iraq

(Figure 1), but none were in Anbar province in Western Iraq which has experienced

some of the most intense violence 33. We found student enrolment and graduations

at medical schools were relatively stable over the last two years, with the majority of medical schools reporting increases in student and staff appointments since 2008

(Table 3). Interestingly, all participating medical schools had similar student to teaching staff ratios (Appendix 4) suggesting that despite the conflict, medical

education infrastructure and human resources remained balanced across the participating medical schools. The estimated cost of training each medical student

ranged from US$6,450 to US$110,000 compared to a global average of $113,000 25. The size of the variance in these figures – which only 4 medical schools were able to

provide – warrants further attention. If true, it suggests a great variation in medical school expenditure which could be further assessed and optimised. The majority of

deans felt both medical student attainment and quality of training had been adversely

affected by recent conflict (Figure 2). Interestingly, Kufa Medical School reported an improvement in student attainment following the conflict, as since cessation of the

international embargo significant efforts have been devoted to developing the institution including partnering with Leicester University’s School of Medicine in the

United Kingdom to advance its academic curriculum since 2012.

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Medical students

A majority (61%) of students in this study felt that their quality of training had been

impaired by the ongoing conflict (Figure 4A). This seems plausible as evidence from the war in Croatia showed that medical students at Osijek University struggled to

concentrate on their studies amidst the ongoing violence, eventually requiring their transfer to Zagreb Medical School11. Student perceptions of violence are key

influencers of educational achievement, with the stress and uncertainty associated with conflict disturbing all stages and actors in the educational process 34. Key

concerns cited by medical students included their level of clinical competence (Figure 4B); mirroring concerns raised by deans over the graduation of students with

gaps in medical knowledge. Other concerns included: mental exhaustion; fear over

their personal safety (Figure 4B); anxiety and depression (Figure 4B). Attacks on medical facilities, academics and clinicians in Iraq are a long-standing problem 35.

The majority (61%) of medical students in this study felt they or their colleagues had been specifically targeted or threatened (Table 5).

In light of these concerns, 26% of respondents wished to drop out and a further 25%

were uncertain (Table 5). This compares to a global average medical student attrition of 11.1% (range: 2.4–26.2%) derived from a meta-analysis of 40 international studies 36 – though the latter were confirmed ‘drop-outs’ rather than an intention to drop-out,

as reported in this study. Conflict drives forced displacement, in the first half of 2015 this stood at 3.2million people in Iraq 23. Medical students - who are often in great

danger during conflict 37 - are frequently forced to transfer their studies for safety reasons 11. Amongst the 194 students that participated in this study, 22 (11%) were

transferred or ‘guest’ students (Table 5); 11 (50%) of whom felt their student needs (such as education and accommodation) were being met, in contrast 9 (41%) felt

they were not and 2 (9%) did not answer (Table 5).

Of most concern, the majority (56%) of students expressed a wish to leave Iraq after

graduation (Table 5). In comparison, a study of over 900 medical students from 6 African countries found 40% intended to continue their training abroad 38; another

study from Ghana of 393 medical students found 49% had intentions to continue post-graduate training abroad 39, whilst in Pakistan this rose to 60.4% in a study of

323 medical students 40. In all of these studies, the most common intended destinations for students was Western Europe and North America. Further, our

finding accords with published cross-sectional studies of Iraqi doctor emigration intentions, where 50% of those responding to a national survey wanted to leave Iraq 41; moreover, another study of 401 Iraqi doctors who had emigrated found less than a third intended to return to Iraq; the average age of this study population was 36

years, representing a cohort with decades of medical service left to offer 42. Indeed,

physician job satisfaction and decisions to stay or leave Iraq are strongly linked to security and working conditions 43; Iraq is for example, one of the largest contributors

to the United Kingdom international medical graduate pool 44.

These findings are particularly alarming given the already significant healthcare personnel shortages found in Iraq 45. Iraq’s current physician density is 0.6 doctors /

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1000 population 46; lower than the WHO target of 1/1000; WHO Eastern

Mediterranean Region (EMRO) average of 1.6/1000 32 and global average of

1.2/1000 47. With a high birth rate 48 that (population weighted) is the 4th largest in EMRO, and 33% higher than the regional average - physician graduations in Iraq

need to expand significantly in order to both keep apace of population increases and achieve the WHO target; without which, an increase in disease burden is likely 27.

That such a high proportion of current students are considering leaving Iraq after graduation warrants immediate attention.

Limitations

This study had a low number of medical school respondents, some of whom were

uncontactable, whilst others may have experienced issues in storing and obtaining information thus precluding their participation. Due to challenges in email reliability,

students were invited to participate via online notices placed on social media outlets. Thus, we were unable to control respondent demographics or discern a response

rate. Nevertheless, given the extremely challenging circumstances in Iraq and clear

impact of medical education on health system capacity and performance 25, 26, we

feel this study offers important insights that inform educational and policy stakeholders minded to maintain and improve the current and future Iraqi health

system.

Study implications and recommendations

This study is the first to document institutional and student insights of medical education amidst ongoing conflict. There is a need for more data on the impacts on

medical education and other key institutions in civil society in states that are, like Iraq, experiencing violent conflict. Such information could inform strategies adopted by

domestic governments, international organisations, and other stakeholders to

support the maintenance of civil society and domestic institutions in times of unrest.

This could range from formal exchange or ‘buddy’ programmes with medical schools

in the region or internationally; to social, physical, and mental health support for medical students and faculty in-country.

We recommend:

1. Country-wide medical school needs assessment

This study has highlighted shortcomings in medical school resources and staff

capacity that is impacting on medical education provision. Given the majority of

Iraq’s medical schools are unaccounted for in this study, we recommend a full national assessment be conducted, ideally by country stakeholders with WHO

oversight, to systematically examine the needs of all medical schools and options for

local, regional and international support.

2. Country-wide medical student cross-sectional survey Medical student participants in this study indicated a high-degree of psychological

stress; concern over clinical competence; the majority held intentions to leave Iraq. A survey of medical students coordinated by medical schools, national stakeholders

such as IFMSA Iraq and Kurdistan - with oversight from WHO, could inform medical

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schools and educational stakeholders of the burden faced by Iraqi medical students.

The survey would also help inform strategic decision making necessary to improve

student experience and retention after graduation.

CONCLUSION

The findings from this study provides insight into the medical school and student

experience in Iraq amidst ongoing conflict. Medical schools are facing challenges in staff recruitment and adequate resource provision; the majority believe quality of

training has suffered as a result. Medical students are experiencing added psychological stress and lower quality of teaching; the majority intend to leave Iraq

after graduation. We recommend a country-wide nationally-coordinated needs

assessment of medical schools, and cross-sectional survey of medical students, to identify areas for local, regional or international support necessary to maintain and

improve Iraq’s medical education and future health service.

ACKNOWLEDGMENTS

We thank IFMSA Iraq, IFMSA Kurdistan, Dr Hilal Al-Saffar, Moa M Herrgård and

Christopher Schürmann for their assistance.

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LEGENDS

Tables

Table 1 Legend

The currently listed medical schools in Iraq according to the World Directory of

Medical Schools, those which replied to an initial email and those which participated in the study.

Table 2 Legend

Total student numbers across each year at participant medical schools, and in comparison with previous reports in 2012 from 24. ‘-‘ denotes data that was

unavailable.

Table 3 Legend

Participating medical school enrolment, graduations and dropouts; teaching and administrative (admin) staff; and cost to train each doctor (USD). ‘-‘ denotes missing data from respondent, brackets ‘()’ denote decreases.

Table 4 Legend

Personal and academic demographics of medical student study participants.

Table 5 legend

Student safety, study plans and future career intentions. Numbers refer to total respondents for each option. (n) = total respondents for each medical school, %

refers to the proportion selecting the option from each medical school, total % refers to the proportion selecting the option from total student participants across medical

schools.

Figures

Figure 1 Legend

Geographical location of participating medical schools. Image generated using GoogleMaps©.

Figure 2 Legend

Deans’ perspectives on the impact of conflict on medical student attainment

(academic achievement/success) (A) and quality of training (B). Numbers (n) refer to total respondents for each option; green=no change, red=impaired/significantly

impaired, blue=improved/significantly improved.

Figure 3 Legend

Geographical location of medical student participants’ medical school. Image generated using GoogleMaps©.

Figure 4 Legend

Student perceptions on the impact of conflict on quality of medical training (A); main concerns, psychological and other impacts of conflict on the student experience (B).

Where numbers (n) refer to total respondents for each option; green=no change, red=impaired/significantly impaired, blue=improved/significantly improved; % of

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students refers to the proportion of students selecting the option of total student

participants across medical schools.

Figure 5 Legend

Student perspectives on mitigating educational impact

Student subjective comments were thematically analysed, grouped and sub-grouped.

Numbers (n) refer to total respondents for each option. Themes were sub-grouped according to personal, educational, or other external factors.

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Competing interests disclosed

Ashton Barnett-Vanes: No competing interests

Sondus Hassounah: No competing interests Marwan Shawki: Marwan Shawki was a representative of IFMSA-Iraq (International

federation of Medical Students' Associations-Iraq) during the course of this study, he has no other competing interests to declare.

Omar Abdulkadir Ismail: Omar Ismail was a representative of IFMSA-Iraq (International federation of Medical Students' Associations-Iraq) during the course of

this study, he has no other competing interests to declare. Chi Fung: No competing interests

Tara Kedia: No competing interests

Salman Rawaf: No competing interests Azeem Majeed: No competing interests

Contributorship Statement

All authors have participated fully in the conception, writing and critical review of this

manuscript. All have seen and agreed to the submission of the final manuscript.

Ashton Barnett-Vanes: Idea, literature search, data collection, writing, critical review Sondus Hassounah: Literature Search, writing, critical review

Marwan Shawki: Literature Search, data collection, writing, critical review

Omar Abdulkadir Ismail: Literature Search, data collection, writing, critical review Chi Fung: Literature Search, writing, critical review

Tara Kedia: Literature Search, data collection, writing, critical review Salman Rawaf: Literature Search, writing, critical review

Azeem Majeed: Idea, writing, critical review

Funding and ethics statement

No funding was associated with the collection of data, or preparation of, this

manuscript. Exemption from review was granted by the Ethics Review Board of

Dartmouth College, Hanover, New Hampshire, United States (Appendix 3).

Data sharing statement No additional data available.

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45. Zarocostas J. Exodus of medical staff strains Iraq's health facilities. BMJ : British Medical

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Geographical location of participating medical schools. Image generated using GoogleMaps©. 273x171mm (300 x 300 DPI)

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Deans’ perspectives on the impact of conflict on medical student attainment (academic achievement/success) (A) and quality of training (B). Numbers (n) refer to total respondents for each option; green=no change, red=impaired/significantly impaired, blue=improved/significantly improved.

294x180mm (300 x 300 DPI)

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Geographical location of medical student participants’ medical school. Image generated using GoogleMaps©. 239x166mm (300 x 300 DPI)

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Student perceptions on the impact of conflict on quality of medical training (A); main concerns, psychological and other impacts of conflict on the student experience (B). Where numbers (n) refer to total

respondents for each option; green=no change, red=impaired/significantly impaired, blue=improved/significantly improved; % of students refers to the proportion of students selecting the

option of total student participants across medical schools. 356x302mm (300 x 300 DPI)

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Student perspectives on mitigating educational impact. Student subjective comments were thematically analysed, grouped and sub-grouped. Numbers (n) refer to total respondents for each option. Themes were

sub-grouped according to personal, educational, or other external factors. 385x307mm (300 x 300 DPI)

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Appendix 1: Dean questionnaire Survey

1. Name of your medical school

Location City and Province

Language of Instruction eg English, Arabic

Total number of current students in all years

Number of medical students in year 1

Year 2?

Year 3?

Year 4?

Year 5?

Year 6?

2. How many students graduated in 2014?


2012?

2010?

2008?

2006?

2004?

2002?

2000?

3. How many first year medical students did you enrol this 2014/2015 academic

year?

How does this compare to number of enrolled students in 2013?

2012?

2010?

2008?

2006?

2004?

2002?

2000?

4. How many students dropped out of their studies across all medical school years

in 2014?


2012?

2010?

2008?

2006?

2004?

2002?

2000?

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5. Approximately, how much does it cost in total to train a single medical student to

become a doctor at your medical school? (in USD $)

How does this break down over each year?

Year 1?

Year 2?

Year 3?

Year 4?

Year 5?

Year 6?

6. Have there been delays in medical student training since 2010 due to conflict? If

so, for how long did this delay affect student graduations?

• Never

• Less than one 1 month

• 1 Month

• 1-6 months

• 1 Year

• Greater than 1 Year

• Other:

7. In your opinion, what percentage of currently graduating medical students from

your medical school intend to leave Iraq after graduation?

• None

• Less than 10%

• 10-20%

• 20-40%

• 40-60%

• 60-80%

• 80-100%

8. In your opinion, how has conflict affected the educational attainment of medical

students?


• Impaired

• No change

• Improved


9. In your opinion, how has conflict affected the quality of training students receive?


• Impaired

• No change

• Improved


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10. In your opinion, what has been the psychological impact of conflict on medical

students?

11. What have been the other impacts of the ongoing conflict on students at your




• Students displaced and cannot attend

• Students afraid to come to university



• Other:

12. Currently in 2015 how many teaching staff do you have?


2012?

2010?

2008?

2006?

2004?

2002?

2000?

13. Currently in 2015 how many administrative or support staff do you have?


2012?

2010?

2008?

2006?

2004?

2002?

2000?

14. In your opinion, has the quality of teaching staff improved or declined since the

recent onset of conflict?(Recent - since start of 2014)

• Significantly declined

• Declined

• No change

• Improved


15. Have you experienced difficulties in retaining and/or recruiting teaching staff

recently? Please explain

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16. In your opinion, what level of resources do teaching staff have at their disposal?

• Very limited

• Limited

• Adequate

• Good

• Very good

Has it always been this way or have the available resources increased / declined

since the onset of conflict in 2014?Please explain

17. What have been the other impacts of the ongoing conflict on faculty at your


• Teaching staff must take on patient care responsibilities instead of teaching

• Teaching staff unavailable

• Teaching staff afraid to come to university

• Administrative staff displaced and unable to attend

• Administrative staff afraid to come to university

• Administrative staff lack experience

• Lack of admin resources (stable internet, email, data storage)

• Other:

18. What is the approximate % annual breakdown of funding at the medical

institution in your university?

Government funding (%)

Industry funding (%)

Student fees funding (%)

Charitable / grant funding (%)

Other?(%)

19. How has conflict/insecurity affected transport to your university and hospital

sites?(Please explain)

20. Has student or staff accommodation been affected by conflict?(Please explain)

21. What have been the other impacts of the ongoing conflict on infrastructure at

your university(Please explain)

• Loss of infrastructure (road/buildings)

• Loss of funding to medical school

• Loss of clinical areas / hospitals for teaching

• Other:

22. In your opinion, how is the ongoing conflict affecting the ability of your country's

health care workforce to meet the health needs of the population? (Please explain)

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23. In your opinion, what do you think is needed to assist medical schools to

maintain or increase medical training?(Please explain)

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1 Student Demographics

1. Please state your age 2. Please state your gender

• Male

• Female

3. Please state your year of study

• Year 1

• Year 2

• Year 3

• Year 4

• Year 5

• Year 6


4. Please select your university *Required If you have attended more than one, please select your current University

• Al Nahrain University

• Al-Anbar University

• Al-Qadisiya University College of Medicine

• Babylon University

• Hawler Medical University

• Al-Iraqia University (Ibn Seinna College of Medicine, Iraqi University)

• Kufa University

• Ninevah College of Medicine

• Sulaimani College of Medicine

• University of Al-Mustansiriyah

• University of Al-Muthana College of Medicine

• University of Baghdad

• University of Baghdad. Al-Kindy College of Medicine

• University of Basrah

• University of Diyala College of Medicine

• University of Duhok Faculty of Medical Sciences

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• University of Kerbala College of Medicine

• University of Kirkuk College of Medicine

• University of Misan

• University of Mosul College of Medicine

• University of Thi Qar College of Medicine

• University of Tikrit College of Medicine

• University of Wasit

• Jabir Ibn Hayyan Medical University


5. Are you an ordinary or guest student?

• Ordinary Student

• Guest (transferred) Student


If you're a transferred student, at which University did you previously study?

2 Student Questions

6. Since you began your course, how has conflict affected the quality of medical training students receive?


• Impaired

• No change

• Improved


Please briefly justify your answer 7. If it has, which part of your training has been affected the most due to the presence of conflict?

• Pre-clinical Years (1-3)

• Clinical Years (4-6)

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8. In your opinion, what percentage of currently graduating medical students from your medical school intend to leave the country after graduation due to the conflict?

• 0-10%

• 10-20%

• 20-40%

• 40-60%

• 60-80%

• 80-100%

9. What are your concerns regarding yourself and your medical training in light of the conflict?

• Personal safety

• Physical exhaustion

• Mental exhaustion

• Not being adequately prepared to care for patients at the end of training due to conflict

• Post-traumatic stress disorder

• Inability to financially support yourself


10. Are you (or have you at some stage) considering dropping out of your medical course due to the ongoing conflict?

• Yes

• No

• Don't know

11. Do you feel that medical schools, students, and/or professionals have been specifically targeted by attacks during the conflict?

• Yes

• No

• Don't know

Please explain your answer

12. In your opinion, what has been the psychological impact of the conflict on you?

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• Depression

• Anxiety

• Distraction from studies

• Reconsidering career options


13. What have been the other impacts of the ongoing conflict on medical students at your university?



• Some students afraid to come to university

• Some students not graduating




14. In your opinion what could be done to help medical students maintain and improve their studies whilst the conflict continues?

15. As a guest student, do you feel your needs have been met to allow you to continue your studies effectively? Please only answer this if you are a transferred student

• Yes

• No

• Don't know

16. What are your career goals once you graduate from medical school?

• Stay in Iraq and pursue clinical career

• Stay in Iraq and pursue non-clinical career (eg research, teaching)

• Stay in Iraq and undertake further study

• Stay in Iraq and change profession

• Leave Iraq and pursue clinical career

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• Leave Iraq and pursue non-clinical career (eg research, teaching)

• Leave Iraq and undertake further study

• Leave Iraq and change profession

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Page 1 of 2

Trustees of Dartmouth College Dartmouth-Hitchcock Medical CenterCOMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS

Howard Hughes, PhD, Chair CPHS ADaniel O'Rourke, MD, Chair CPHS B and D

Jack van Hoff, MD, Chair CPHS C

63 South Main Street HB 6254 Hanover, NH 03755Telephone (603) 646-6482 Fax (603) 646-9141

EXEMPTION GRANTED

August 25, 2014

Tara KediaGeisel School of Medicine

CPHS #: STUDY00028328 Action: Exemption GrantedPrincipal Investigator: Tara Kedia Action Date: 8/25/2014Submission Type: Initial StudyReview Type: ExemptFunding: NoneTitle of Study: Investigation of the health economic impact of conflict or violent insecurity,

and medical education in 11 conflict-affected statesDocuments Reviewed: • Info Sheet invitation to participate in the research

• IRB Exempt Application

Thank you for submitting the information on the above referenced project.

Please regard this message as notification that the project has been designated EXEMPT from further review based on the following regulations:

Category 1: Research conducted in established or commonly accepted educational settings, involving normal educational practices, such as (i) research on regular and special education instructional strategies, or (ii) research on the effectiveness of or the comparison among instructional techniques, curricula, or classroom management methods.

Category 2: Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures or observation of public behavior, unless: (i) Information obtained is recorded in such a manner that human subjects can be identified, directly or through identifiers linked to the subjects; and (ii) any disclosure of the human subjects’ responses outside the research could reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects’ financial standing, employability, or reputation.

You have met the CPHS requirements to proceed with your project.

Be sure to contact the CPHS office if the circumstances of your project change such that the federal criteria for exemption no longer apply.

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Page 2 of 2

Sincerely,

Lorri WettemannCommittee for the Protection of Human Subjects

cc: Tara Kedia

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Appendix 4: Plot of ratio of students to teaching

Plot showing affine relationship between teaching staff and students for each

medical school using linear regression curve, r²=0.95.

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STROBE 2007 (v4) Statement—Checklist of items that should be included in reports of cross-sectional studies

Section/Topic Item

# Recommendation Reported on page #

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract 1

(b) Provide in the abstract an informative and balanced summary of what was done and what was found 1

Introduction

Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 4

Objectives 3 State specific objectives, including any prespecified hypotheses 5

Methods

Study design 4 Present key elements of study design early in the paper 6

Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data

collection

6

Participants

6

(a) Give the eligibility criteria, and the sources and methods of selection of participants 6

Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if

applicable

6

Data sources/

measurement

8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe

comparability of assessment methods if there is more than one group

6

Bias 9 Describe any efforts to address potential sources of bias 6,15

Study size 10 Explain how the study size was arrived at 6

Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and

why

6

Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding n/a

(b) Describe any methods used to examine subgroups and interactions n/a

(c) Explain how missing data were addressed n/a

(d) If applicable, describe analytical methods taking account of sampling strategy n/a

(e) Describe any sensitivity analyses n/a

Results

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Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility,

confirmed eligible, included in the study, completing follow-up, and analysed

6

(b) Give reasons for non-participation at each stage 7

(c) Consider use of a flow diagram n/a

Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential

confounders

7,11

(b) Indicate number of participants with missing data for each variable of interest 9

Outcome data 15* Report numbers of outcome events or summary measures 7-11

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence

interval). Make clear which confounders were adjusted for and why they were included

7-11

(b) Report category boundaries when continuous variables were categorized n/a

(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period n/a

Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses n/a

Discussion

Key results 18 Summarise key results with reference to study objectives 13-14

Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and

magnitude of any potential bias

15

Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from

similar studies, and other relevant evidence

15

Generalisability 21 Discuss the generalisability (external validity) of the study results 15

Other information

Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on

which the present article is based

n/a (19)

*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE

checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.

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