Abstract
Introduction: Family medicine responses to armed conflict are rarely documented, especially those led by
refugees. This brief report describes the creation, scope, and early outcomes of the Family Doctor Initiative
(FDI), a refugee-led primary care response during the Gaza war. The FDI was launched in January 2024 by a
displaced family physician to deliver comprehensive care in tent-based clinics located within refugee camps in
the middle of the Gaza strip. Services include acute care, chronic disease management, mental health support,
breastfeeding and nutrition counselling, and health education.
Methods: Service and staffing data from May 2024 through April 2025 are reported.
Results: Over 12 months, the FDI conducted 38,326 patient encounters across three sites. Most visits addressed
acute concerns (79%), while 14% focused on chronic conditions such as diabetes and hypertension. Additional
services included 495breastfeeding and nutrition counselling visits and 8,225 mental health consultations. The
FDI is staffed by locally trained health professionals and integrates family medicine’s biopsychosocial model
within the surrounding community of tents.
Conclusions: The FDI exemplifies a community-embedded, continuity-focused, family medicine approach to crisis care. It demonstrates how family physicians, even as refugees, can lead localized, sustainable, and
responsive care models in conflict settings where traditional systems have collapsed or are focused on acute
care. It also underlines the value local expertise can add to the relief efforts of international NGOs.
Introduction
Little is published on primary health care delivery,
especially Family Medicine, during armed conflict.
Depending on the degree of destruction to the health care
infrastructure, primary care physicians, as has occured in
parts of the Ukraine, remain in place but expand their
scope to include more acute trauma
management.1However, when health care structures are targeted and destroyed, as in the Gaza War, hospitals and
clinics are vacated or continue to function under severe
strain, often with the support of international aid agencies
(NGOs).2Health professionals are sometimes killed, and
many are forced to flee. Some continue to practice in the
damaged facility, often risking their lives. As staff are lost and patient loads increase, health profession students
nearing the end of their training are often pulled into
service.4
In Gaza, the ongoing war has created continuing
casualties, but health needs extend beyond acute injury
that are often ignored because trauma takes precedence.
Chronic health issues, such as diabetes, need
management.5Health prevention education and
activities,and mental health services also require
attention.6The continued Israeli military presence and
supply blockades, and the cost of transportation prevent
many from seeking care for non-urgent issues. Even
when they do, they are often dissatisfied.
In late 2023, Dr. Khashan, a displaced family physician,
founded the Family Doctor Initiative (FDI) in the Al
Bassa area of Deir Al-Balah area of the camp where she
was living with her extended family. She was inspired to
do so when she encountered a depressed and anxious
mother trying to secure care for her child’s
pneumonia.7The objectives were: 1) To give
comprehensive, whole person and whole family care,
with a biopsychosocial family approach that targeted the
needs of all family members and 2) To provide services
where people lived they are not subjected to danger when
trying to access health care. The report describes the
initiative and summarizes one year of care data.
Setting and Services
The Mawasi Al-Qarara camp is the temporary home to
nearly a million Gazans, with approximately 34,000 per
square kilometer.8TheFDI opened its first tent in January
2024 with a family physician, a general practitioner (GP)
a nurse, and a logistician. By March, the initiative had
grown to three tents offering acute care, chronic diseases
management, mental health support, breast feeding and
nutrition counselling and health education. Locations are
within ten minutes of the sea, distributed seven to ten
kilometers apart, within ninety minutes to two hours
walking distance, running north to south (Al-Zawayda
Deir AlBalah, Al-Qarara). Services are available for all
ages six days a week.
Breast feeding and nutrition support as well as mental
health services were expanded at the Al-Qarara, Khan
Yunis site in June 2024 and August 2024, respectively
based on community assessment. Health education
includes learning about topics such as poliomyelitis to
encourage immunizations and diabetes education groups
Referral hospitals are located 8 to 30 km, or one to three
hours walking, from the tents.
Team and operations
Unemployed Gazans were hired as staff. Dr. Khashan
assembled a trusted team that included a nurse, physician
and an administrator to determine roles and salaries. To
ensure sustainability, wages were set below government
and NGO levels. Transportation support was later added
due to safety and cost concerns in order to support the
team in reaching the tents. The positions include family
physician, GP (who completed medical school and an
additional year of training in predominantly hospital
rotations) nurse, health educator, pharmacist, logistician,
driver, psychologist, and community liaison. The
administrative team is composed of the director, social
media overseer, in-the-field supervisor, treasurer,
photographer, two logistic assistants, and driver. They
communicate routinely through WhatsApp. In April
2024, Dr. Khashan relocated to Oman for her infant’s
safety but continues to direct the FDI remotely.
Given the toll of the ongoing war and repeated
displacements, Dr. Khashan sought ways to support the
team’s morale. Monthly gatherings, which included
sharing food and fun, were held when funds allowed.
Though these ended due to financial constraints, a
proposal to renew support remains unfunded.
Funding and Supplies
The Ministry of Health (MOH) was supportive of the
FDI from the beginning and provided encouragement and
has helped to facilitate access to medications and
supplies but provides no funding. FDI shares data with
MOH. Monies were secured by building a network of
relationships inside and outside of Gaza through personal
and organizational connections and social media. Dr.
Khashan used social media, especially Facebook, to
communicate about FDI activities. The UK NGO
Doctors Worldwide began funding the FDI in September
2024 and is committed through September 2025.
Securing supplies amid border blockades is an ongoing
challenge. Personal and professional networks have been
key. A colleague’s connection facilitated two vans of
medication transported through the Egyptian Red
Crescent. The MOH director of primary health care had
been Dr. Khashan’s professor. That connection facilitated
MOH helping to secure medications for FDI at times
when the borders were closed. FDI hired drivers and
rented trucks to travel to various locations where FDI
supplies could be secured or purchased. FDI family
physicians created a list of essential medications and
supplies, and the field director has negotiated deals on the “black market” when the bordersare closed. Black
market supplies are understood to be either stolen or
smuggled.
Security and Community connections
Bombing threats and military presence pose constant
threats and continued re-displacement. In February 2025
the most northern FDI tent (Al-Zawayda) closed when
the physicians returned to their pre-war locations. The
tents made of UV-stabilized polyethylene on aluminium
poles are weather resistant, but not
secure.10Anyonecandisassemble the tent, sleep inside, or
enter the tent and steal supplies after hours. Early onDr.
Khashan organized a community liaison at each sitewho
built relationships with the community by assessing
needs, promoting the health services, and recruiting local
community members to protect the tent. A strong
partnership with the community has been essential.
Methods
Although the FDI began in January 2024, consistent daily
reports on patient talliesand demographicsbecame
available in May 2024.One year of data on patients and
health personnel are presented using descriptive statistics.
Results
Across the threetents FCI recorded 38,326 primary care
encounters between May 2024to April 2025, averaging
42 patients per tent per day.Patients were evenly split by
gender, 53% were adults, 35% were children and 12%
over age sixty.Most visits (79%) were for acute issues
such as lice, skin rashes, and gastroenteritis.Chronic
health issues (e.g., diabetes, hypertension, thyroid
disorders) accounted for 14%of the time.About 1%
visits were referred for advanced evaluation, including
suspected appendicitis, meningitis, acute coronary
syndrome, respiratory distress in children, and severe
cellulitis, and trauma.
The breastfeeding/nutrition and the mental health centers
managed 1644 and 8225 encounters, respectively.
Breastfeeding offered support for breastfeeding mothers.
As food became increasingly scarce, malnutrition
assessment was added, andfamilies were supplied with
prepared meals, honey, tahini, peanut butter and
Vitamins. Cases dropped off in early 2025 when the
ceasefire allowed Gazans to move back to their cities.
However, when bombardment started again,
displacement increased,and the need resumed;FDI is
training a nurse to restart the service.Mental health services are delivered by trained psychologists and
include individual and group sessions, education and
psychological debriefs. See Table 1.
FDI health care personnel totals and current employment
for the tents are presented in Table 2. All graduated from
Gaza universities. Three family physicians were in the
final years of the4-year residency program. Staff roles
remained stable, though individuals rotated due to war
conditions. No staff deaths occurred during the study
period.
Discussion
The FDI offers a rare model of family medicine-led
refugee care during war. Unlike many international
NGOs or the UN services, it integrates three key
elements: First, a biopsychosocial, whole-family care
model grounded in family medicine
Secondly,accessibility and continuity with care located
where refugees live; Thirdly, deep community
engagement, including needs assessment and engaging
community members in protecting the FDI tents.
Few published examples describe primary care responses
to war from within refugee populations. In Borkan’s
exploration of this topic, he discussed family medicine’s
commitment to the biopsychosocial model andhow the
4Cs of primary care—first contact, comprehensiveness,
coordination, and continuity principles are paramount, all
practiced within the community. The FDI exemplifies
this framework. In addition, this effort is led by a refugee
family physician, grounded in local knowledge, and built
on resilience and community trust.
Ideally, it would be good to have more comprehensive
data like the types of problems seen, the numbers of
patients participating in diabetes sessions, patient
satisfaction assessment or interviews with patients or
staff about their experiences. The rapidly evolving armed
conflict, bombings surrounding the tent sites, t
everchanging displacement affecting patients and staff,
made more detailed data collection impossible.Research
during armed conflict is difficult and research from
family physicians during war is rare, especially
researchers who are refugees themselves.
Unfortunately, war continues to devastate the lives of
patients and health care professionals throughout the
world, especially in the Middle East. The FDI
demonstrates a replicable model for crisis health delivery
that honors family medicine principles under
extraordinary circumstances. Family physicians, even in
displacement, can lead impactful, community-based care.
The FDI exemplifies a community-embedded
continuity-focused, family medicine approach to crisis
care. It demonstrates how family physicians even as
refugees, can lead localized, sustainable, and responsive
care models in conflict settings where traditional systems
have collapsed or are focused on acute care. It also
underlines the value local expertise can add to the relief
efforts of international NGOs.
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