Abstract
Importance
The Gaza Strip has been enduring a severe humanitarian crisis due to prolonged conflict, blockade, and systemic instability, resulting in the collapse of its healthcare system.
Objective
To explore the impact of healthcare collapse on the spread of infectious diseases in Gaza, focusing on the challenges faced by healthcare workers, the barriers to disease management, and the coping mechanisms employed by the community.
Design, settings, and participants
In this qualitative research, semi-structured interviews and focus group discussions with healthcare professionals, humanitarian workers, and community members in the Gaza Strip were utilized. In total, 30 interviews were conducted with healthcare professionals and humanitarian workers, and 6 focus group discussions (FGDs) with community members were held in three different locations across the Gaza Strip. Each interview lasted approximately 45–60 min, and FGDs ranged from 60 to 90 min. All interviews and discussions were audio-recorded with participants’ consent. The semi-structured interview guide used in this study was specifically developed by the research team to address the study’s objectives. The guide was informed by a review of relevant literature and expert input to ensure comprehensiveness. An English-language version of the interview guide has been provided as a Supplementary File 1.
Main outcomes and measures
Descriptive themes of participant experiences to identify key challenges and patterns related to the collapse of the healthcare system and its impact on infectious disease spread.
Results
The study found that the collapse of healthcare infrastructure in Gaza could have exacerbated the spread of infectious diseases, as it created conditions that may have increased the risk of transmission. Key challenges included severe shortages of medical supplies and equipment, overcrowded healthcare facilities, and inadequate sanitation and hygiene conditions. These issues were compounded by the psychological stress and burnout experienced by healthcare workers. The lack of effective disease surveillance and delayed international aid further impeded the response to infectious disease outbreaks. Participants reported a reliance on traditional remedies and community networks due to a loss of confidence in the formal healthcare system.
Conculsions and relevance
The findings underscore the urgent need for comprehensive international support to rebuild Gaza’s healthcare infrastructure and improve disease management. Addressing the shortages of medical supplies, enhancing disease surveillance, and providing psychological support for healthcare workers are critical steps in mitigating the spread of infectious diseases. The study highlights the broader implications of healthcare system collapse in conflict zones and calls for coordinated global efforts to address the underlying issues contributing to public health crises in such settings.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12889-025-21817-1.
Keywords: Gaza Strip, Healthcare collapse, Infectious diseases, Humanitarian crisis, Healthcare infrastructure, Disease management, Qualitative study
Introduction
Gaza has long been subject to cycles of conflict and political instability, with hostilities intensifying in recent years. While historical hostilities have deeply shaped the region’s healthcare system, the escalation of violence following the recent events that began on October 7, 2023, has further exacerbated the healthcare challenges faced by the population [1, 2]. This ongoing conflict has had devastating effects on the infrastructure and capacity of healthcare facilities, contributing to the breakdown of essential medical services and increasing the vulnerability of the population to infectious diseases [3, 4]. Gaza’s healthcare system is a complex network of public and private healthcare facilities, including hospitals, clinics, and primary healthcare centers. Prior to the recent escalation, Gaza had approximately 32 public hospitals and 70 primary healthcare centers, providing healthcare services to over 2 million residents. However, the healthcare infrastructure has been severely affected by years of blockade, recurrent conflicts, and resource shortages. Many hospitals and clinics have been damaged or destroyed, and critical medical supplies remain limited [5]. The shortage of staff, medical equipment, and essential medicines has left healthcare providers struggling to meet the needs of the population [6–9].
Infectious diseases, particularly those that thrive in settings of overcrowding and poor sanitation, such as diarrheal diseases, respiratory infections, and skin infections, have become increasingly prevalent in Gaza [7–9]. The collapse of water, sanitation, and hygiene (WASH) systems, compounded by the lack of healthcare infrastructure, has created conditions that facilitate the transmission of these diseases [10]. As access to clean water is limited and sewage systems are frequently damaged, waterborne diseases such as cholera and typhoid fever pose significant threats to public health [11]. Additionally, overcrowding in hospitals and shelters for internally displaced persons (IDPs) has accelerated the transmission of airborne infections like tuberculosis (TB) and respiratory viruses [12].
The collapse of healthcare services in Gaza is not only a consequence of the ongoing conflict but also of broader systemic issues [13]. The long-standing blockade has severely restricted the import of medical supplies and equipment, preventing healthcare workers from adequately responding to public health emergencies [14]. Moreover, the political and economic challenges faced by the Palestinian health authorities have hindered their ability to provide a coordinated and effective response to infectious disease outbreaks [15, 16]. These compounding factors have left the healthcare system in Gaza unable to meet the needs of the population, especially during periods of intensified conflict or crises.
Previous studies have highlighted the significant impact of conflict on public health systems and disease outbreaks in other regions of the world, such as Syria, Yemen, and South Sudan [17, 18]. In these settings, healthcare collapse has been closely linked to increased morbidity and mortality from infectious diseases. However, there is limited research specifically examining the unique challenges of infectious disease management in Gaza’s protracted crisis. This gap in the literature underscores the need for a focused examination of how healthcare collapse in Gaza contributes to the spread of infectious diseases, as well as the coping strategies employed by healthcare professionals and the broader community.
While the healthcare system’s collapse in Gaza has led to a wide range of health hazards, this study specifically focuses on the spread of infectious diseases due to their potential for rapid transmission and the significant burden they place on an already overwhelmed healthcare system. The aim was to understand how specific mechanisms, such as lack of sanitation, overcrowding, and insufficient medical supplies, might facilitate the spread of infectious diseases in conflict settings, with the goal of informing targeted interventions.
Methods
Study design
This study employed a qualitative, phenomenological approach to explore the lived experiences of healthcare workers, patients, and community members in Gaza amidst the ongoing healthcare collapse. Phenomenology is a research methodology that focuses on understanding individuals’ subjective experiences in specific contexts, aiming to uncover the essence of these experiences by identifying key themes and patterns in participants’ perceptions, thoughts, and feelings [19]. This approach was deemed appropriate given the need to capture the firsthand accounts of individuals navigating the healthcare crisis in Gaza.
Participants and sampling
A purposive sampling strategy was employed to recruit individuals directly affected by or involved in the healthcare system in Gaza, including healthcare professionals, patients, and community members. Diversity in the sample was ensured by including participants from different professional backgrounds and geographic locations within Gaza.
A total of 30 participants were included:
15 healthcare workers (doctors, nurses, and other medical staff).
15 community members affected by the healthcare crisis.
Data collection
Data were collected through semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs) conducted between April 20 and August 12, 2024. Two distinct interview guides were developed to align with the study objectives.
Individual Interviews (IDIs): Focused on personal experiences, professional challenges, and coping strategies.
Focus Group Discussions (FGDs): Encouraged group reflections on shared challenges, healthcare gaps, and community perspectives.
Both guides covered key topics, including:
The state of healthcare infrastructure and service delivery.
Challenges in managing infectious diseases.
Personal and professional struggles in providing care.
Coping mechanisms and potential solutions.
Interview Setting and Virtual Interviews.
In-person interviews were conducted in healthcare facilities or neutral locations, ensuring privacy and participant comfort.
Due to security constraints and accessibility challenges, some interviews were conducted remotely via Zoom and WhatsApp. Efforts were made to maintain data quality in virtual interviews by ensuring stable internet connections, clear audio, and participant confidentiality.
No significant differences in data quality were observed between in-person and virtual interviews.
Interview Duration and Participant Reactions.
The average duration of individual interviews was 45–60 min, while FGDs lasted 90 min.
Some participants exhibited visible distress and frustration, particularly when discussing the overwhelming burden on the healthcare system and their inability to provide adequate care. In such cases, interviewers allowed brief pauses or reassured participants to ensure their well-being.
All interviews and discussions were conducted in Arabic, audio-recorded with participant consent, and transcribed verbatim.
Data analysis
Data analysis was conducted using NVivo 12 (QSR International, 2018) software. A thematic analysis approach was employed, ensuring systematic identification of recurring patterns. The analytical process followed these steps:
Familiarization: The research team read and re-read transcripts for an in-depth understanding.
Open Coding: Line-by-line coding identified meaningful segments corresponding to key concepts.
Categorization: Initial codes were grouped into categories based on their relevance to the study objectives.
Theme Development: Categories were refined into broader themes, capturing core aspects of participants’ experiences. Thematic development was both inductive and data-driven to ensure transparency.
Final Review– Identified themes were reviewed in collaboration with the research team to ensure accuracy, consistency, and alignment with the data.
Two independent researchers conducted the coding process to enhance reliability. Any discrepancies in coding were resolved through discussion until consensus was reached.
Ethical considerations
Ethical approval for the study was obtained from the University College of Science and Technology review board. Informed consent was obtained from all participants, and all data were anonymized to protect participant confidentiality. Participants were informed of their right to withdraw from the study at any time without consequence.
Results
Overview of participants
A total of 30 healthcare professionals and humanitarian workers participated in semi-structured interviews, while 6 focus group discussions (FGDs) were held with 40 community members from various regions of the Gaza Strip. The participants included 12 doctors, 8 nurses, 5 infection control specialists, and 5 staff members from international and local NGOs. Community members included patients, caregivers, and internally displaced persons (IDPs) living in temporary shelters. The demographics of participants were diverse in terms of age, gender, and professional experience, reflecting a comprehensive range of perspectives on the healthcare collapse and infectious disease challenges in Gaza (Table 1).
Table 1.
Participants characteristics
| Characteristic | Frequency (%) |
|---|---|
| Total Participants | 30 (100) |
| Gender | |
| Male | 18 (60%) |
| Female | 12 (40%) |
| Age Group | |
| 18–29 years | 5 (16.7%) |
| 30–39 years | 9 (30%) |
| 40–49 years | 10 (33.3%) |
| 50 + years | 6 (20%) |
| Occupation | |
| Healthcare Workers | 15 (50%) |
| Community Members | 15 (50%) |
| Healthcare Role | |
| Doctor | 7 (23.3%) |
| Nurse | 5 (16.7%) |
| Other Medical Staff | 3 (10%) |
| Patient | 15 (50%) |
| Educational Level | |
| Secondary Education | 6 (20%) |
| Bachelor’s Degree | 12 (40%) |
| Graduate Degree | 12 (40%) |
| Geographical Location | |
| Northern Gaza Strip | 9 (30%) |
| Central Gaza Strip | 12 (40%) |
| Southern Gaza Strip | 9 (30%) |
The analysis of interview data revealed three interrelated themes that encapsulate the healthcare system challenges, healthcare workers’ struggles, and the unmet needs of patients in the context of infectious diseases in Gaza.
Healthcare system challenges
Participants consistently highlighted the deterioration of Gaza’s healthcare infrastructure, which has severely impacted its ability to manage infectious diseases. Respondents described the destruction of hospitals and clinics, compounded by a lack of maintenance, electricity, and clean water, as critical barriers to effective healthcare delivery. One healthcare worker explained, “The infrastructure is falling apart; there are no sterile spaces left to treat patients, and basic equipment is either broken or unavailable.” These infrastructural issues have disrupted services such as isolation wards, sterilization, and waste management, creating fertile ground for infectious disease outbreaks.
Another significant challenge was the overwhelming overcrowding in hospitals and shelters. Participants noted that displaced individuals are forced into confined spaces, which lack proper ventilation, sanitation, and access to clean water, further exacerbating the spread of diseases. A community member shared, “We live in one room with ten people. If one gets sick, everyone else does too.”
Healthcare workers’ struggles
Healthcare workers reported immense difficulties in managing infectious diseases with the limited resources available. Many described working under extreme pressure, lacking essential medical supplies, antibiotics, and vaccines. As one doctor stated, “We are trying to treat patients, but without medicine, without proper diagnostic tools, what can we do?”
Staff shortages have also worsened the situation, with many healthcare professionals either leaving Gaza or succumbing to burnout. The remaining staff frequently face moral distress as they must prioritize limited resources among patients. A nurse explained, “We have to make impossible decisions every day—who gets the last dose of medication, who gets admitted to the overcrowded wards.”
Despite these challenges, healthcare workers demonstrated resilience and ingenuity, using makeshift solutions to address gaps in care. For example, one participant recounted sterilizing surgical instruments manually due to a lack of functioning autoclaves.
Unmet needs of patients in the context of infectious diseases
Patients in Gaza face significant unmet needs, particularly in accessing timely and adequate care for infectious diseases. Participants described prolonged waiting times, the absence of preventive care, and the inability to secure treatment due to the high costs of privately sourced medications. One patient remarked, “I had to wait for hours in the hospital only to be told they had no antibiotics for my child.”
Patients also highlighted the psychological toll of these unmet needs, as fear and frustration over the lack of available treatment exacerbate feelings of hopelessness. Many respondents emphasized the critical need for international support to address these deficiencies. One community member appealed, “We are abandoned; the world needs to help us get access to basic healthcare.”
Discussion
The findings of this study reveal the significant impact of the healthcare system’s collapse on the ability of the system to function, including the prevention and control of infectious diseases in Gaza. Several critical factors exacerbate the public health crisis, including the destruction of healthcare infrastructure, overcrowding in shelters, limited access to clean water and sanitation, and disrupted vaccination campaigns. These results align with prior research conducted in other conflict-affected regions, such as Yemen and Syria, where similar patterns of healthcare collapse, overcrowding, and inadequate access to basic resources have led to widespread outbreaks of infectious diseases [20]. By comparing the findings from Gaza to existing literature, this discussion aims to contextualize the specific challenges faced by Gaza’s healthcare system, offer insight into potential solutions, and underscore the urgent need for international intervention.
However, this study provides novel insights into the role of healthcare facilities as significant sources of infection in Gaza, a phenomenon not as extensively documented in other contexts. The prolonged conflict and resource constraints have forced hospitals to operate under suboptimal conditions, including overcrowding, shortages of infection prevention supplies, and compromised sanitation. These conditions increase the risk of nosocomial infections and highlight the dual role of hospitals as both lifesaving institutions and potential amplifiers of infectious diseases during crises.
This finding underscores the urgent need for targeted interventions to mitigate the risk of infection in healthcare settings, such as bolstering infection prevention and control measures, providing adequate supplies, and ensuring the functionality of critical infrastructure like water and sanitation systems within hospitals. Future research should further explore this dual role of healthcare facilities in conflict settings, comparing the Gaza context with other regions to identify universal and context-specific strategies for intervention.
The collapse of Gaza’s healthcare infrastructure, as reported by healthcare workers and humanitarian organizations, has resulted in a dramatic increase in the spread of infectious diseases. The deterioration of sanitation and hygiene within healthcare facilities due to frequent power outages and shortages of medical supplies was one of the most pressing concerns reported by participants. This mirrors the findings of a study conducted in Yemen, where healthcare infrastructure collapse during the conflict was found to have directly contributed to the outbreak of cholera, affecting millions [21].
Overcrowding in healthcare facilities and IDP shelters was another key issue identified in this study, with healthcare workers describing unsanitary and cramped conditions that facilitated the rapid transmission of infectious diseases such as tuberculosis and respiratory infections. This is consistent with research from conflict zones in Syria, where overcrowding in refugee camps and hospitals led to a resurgence of diseases such as leishmaniasis and TB [22]. The spread of respiratory diseases in Gaza’s overcrowded shelters was particularly concerning, given the ongoing COVID-19 pandemic, which poses additional threats to public health in conflict-affected settings [23]. Both Gaza and other regions experiencing healthcare collapse face similar challenges in mitigating the spread of infectious diseases under such conditions.
The chronic shortage of essential medications and protective equipment in Gaza’s healthcare facilities has created significant barriers to effective infectious disease management. Participants reported that the lack of antibiotics, vaccines, and personal protective equipment (PPE) contributed to higher rates of infection among both patients and healthcare workers. This finding is consistent with studies conducted in South Sudan, where shortages of medical supplies during the civil conflict led to high infection rates and preventable deaths from diseases such as malaria and meningitis [24].
In addition, the lack of PPE in Gaza, as reported by participants, reflects similar challenges faced in other humanitarian settings, particularly during the COVID-19 pandemic. A study conducted in refugee camps in Lebanon highlighted that limited access to PPE for healthcare workers was a major factor in the increased spread of COVID-19 and other respiratory infections among both patients and staff [25]. The situation in Gaza underscores the urgent need for a sustained and reliable supply of medical resources to manage infectious disease outbreaks effectively in conflict zones.
The psychological toll on healthcare workers in Gaza, driven by long working hours, resource shortages, the overwhelming number of patients, and the stress associated with having to work in war zone, emerged as a prominent theme in this study. Healthcare workers expressed feelings of helplessness and burnout, particularly when they were forced to prioritize which patients would receive limited treatments. This emotional strain on healthcare professionals has been documented in other conflict-affected regions as well. For instance, a study in Iraq reported that healthcare workers dealing with prolonged conflict and resource scarcity faced high levels of stress, which compromised their ability to deliver quality care [26].
In Gaza, the combination of psychological stress, burnout, and a lack of mental health support services for healthcare workers exacerbates the challenges of managing infectious disease outbreaks. Prior studies emphasize the importance of providing psychological support and resilience training for healthcare workers in conflict zones to mitigate the long-term mental health consequences of working under such extreme conditions [27].
The reliance on traditional remedies and community networks in Gaza, as reported by community members in this study, reflects the growing mistrust in the formal healthcare system. The inability of Gaza’s healthcare system to provide adequate care due to access restrictions, financial barriers, and the destruction of infrastructure has eroded public confidence, leading people to seek alternative treatments even for serious health conditions. This phenomenon has also been observed in other conflict-affected regions, such as Somalia, where a lack of confidence in the healthcare system led many individuals to rely on informal care networks during the height of the civil war [28].
Moreover, the study found that many patients in Gaza were unable to afford necessary medications or access healthcare facilities due to movement restrictions and economic hardship. This finding is supported by previous research in conflict zones, such as Syria, where the cost of healthcare and transportation was a significant barrier for civilians, further complicating their access to lifesaving treatments [29]. In both settings, the healthcare crisis has intensified the vulnerability of marginalized populations, particularly those living in poverty or displaced by conflict.
This study’s findings suggest that international aid in Gaza, though present, is often insufficient and delayed, leaving healthcare workers and humanitarian responders struggling to meet the population’s needs. This is in line with existing literature, which has repeatedly shown that international humanitarian aid in conflict zones often falls short of addressing the complex needs of collapsing healthcare systems. For example, a review of humanitarian interventions in the Central African Republic revealed that inconsistent delivery of medical supplies and inadequate funding contributed to the healthcare system’s inability to respond to infectious disease outbreaks [30].
In Gaza, gaps in disease surveillance and response mechanisms were also reported by participants, reflecting a breakdown in the public health infrastructure that has severely hampered efforts to track and contain infectious disease outbreaks. Similar findings were reported in a study conducted in Yemen, where the lack of disease surveillance systems led to delays in identifying and responding to outbreaks of cholera and dengue fever [31]. In Ukraine, the spread of infectious disease increased amid the recent war as a result of the disruption of healthcare services, the destruction of critical infrastructure, the displacement of millions of civilians and the crowded living conditions in bunkers [32]. Despite these conditions, undamaged hospitals in Ukraine continued to operate, offering health and treatment services to the public [33]. While many hospitals in Ukraine continue to operate, a critical aspect to a functioning healthcare system is the availability of physical infrastructure, medical supplies and supporting staff [34, 35]. A careful understanding of how the entire healthcare system operates as a network [36]and a stronger disease surveillance effort [37] is key to establishing optimal strategies for the system to provide the desired function. Accordingly, there is a need for more coordinated international efforts to rebuild healthcare infrastructure is crucial for preventing future outbreaks in Gaza and other conflict-affected regions.
This study has several limitations that should be acknowledged. First, due to the ongoing conflict and restricted access to certain areas in Gaza, data collection was challenging, and some healthcare facilities and communities may have been underrepresented. As a result, the findings may not fully capture the breadth of experiences across the entire population. Second, the study relied heavily on qualitative interviews with healthcare workers and community members. While this approach provided valuable insights into the personal and professional challenges they face, it may also introduce biases related to personal perceptions, recall accuracy, or willingness to share sensitive information. Additionally, the lack of quantitative data limits the ability to generalize the findings or assess the exact prevalence of infectious diseases across the population. Third, the study was conducted in a highly volatile and rapidly changing environment, where the healthcare situation and disease outbreaks may have evolved during the course of data collection. This could affect the study’s ability to reflect the most current conditions at the time of publication. Lastly, the study focuses specifically on the Gaza Strip, which, while providing important insights into the impact of healthcare system collapse in a conflict-affected region, may not be directly applicable to other settings with different social, political, and healthcare contexts. Further research in other conflict zones would be necessary to broaden the understanding of how healthcare collapse contributes to disease outbreaks globally.
Despite these limitations, this study provides important qualitative evidence on the intersection of healthcare system collapse and infectious disease spread in a conflict-affected region, highlighting critical areas for intervention and further investigation.
Conclusion
This study provides an in-depth analysis of the healthcare collapse and its role in facilitating the spread of infectious diseases in the Gaza Strip. The findings underscore the severe challenges posed by a failing healthcare system, including the shortages of essential medical supplies, overcrowded healthcare facilities, and the psychological toll on healthcare workers. The convergence of these factors has created an environment in which infectious diseases spread rapidly, compounding the humanitarian crisis in Gaza. Comparing the results to other conflict-affected regions highlights the global nature of these issues, where healthcare system failures consistently lead to public health emergencies.
The collapse of healthcare infrastructure in conflict zones, such as Yemen, Syria, and South Sudan, reflects a pattern of systemic neglect, under-resourced facilities, and insufficient international aid responses. These parallels emphasize the need for immediate, coordinated international efforts to rebuild healthcare infrastructure, ensure reliable access to medical supplies, and provide psychological support to healthcare workers. Urgent interventions must focus on strengthening disease surveillance, improving sanitation and hygiene conditions, and securing adequate resources to address the ongoing spread of infectious diseases. In the long term, rebuilding Gaza’s healthcare system will require sustained international collaboration, investment in health infrastructure, and political efforts to end the conditions fueling the conflict. Without significant reforms and support, the public health crisis in Gaza will continue to worsen, further endangering the lives of its residents. This study contributes to the growing body of evidence highlighting the devastating impact of healthcare system collapse in conflict zones, urging immediate global action to mitigate the consequences and safeguard public health.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
We would like to express our sincere gratitude to the healthcare workers and community members in Gaza who shared their valuable time and insights despite the difficult circumstances. We also extend our thanks to the local organizations and humanitarian agencies that facilitated the data collection process. Finally, we acknowledge the ongoing efforts of all those working to improve healthcare and public health in conflict-affected regions worldwide.
Author contributions
Samer Abuzerr had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Abuzerr.Acquisition, analysis, or interpretation of data: AbuzerrDrafting of the manuscript: Abuzerr, Zinszer, and Mahmoud. Critical review of the manuscript for important intellectual content: Abuzerr, Zinszer, and Mahmoud.Statistical analysis: Abuzerr.Obtained funding: None.Administrative, technical, or material support: Abuzerr, Zinszer, and Mahmoud.Supervision: Abuzerr.
Funding
No Funding.
Data availability
The datasets generated and/or analysed during the current study are not publicly available in order to ensure participant confidentiality while supporting data transparency but are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent of participation
This qualitative study received ethical approval and exemption from ongoing review by the Institutional Review Board at the University College of Science and Technology, Khan Younis, Gaza (Approval Number: UCST/7/2024). All procedures performed in this study involving human participants adhered to the ethical standards of the 1964 Declaration of Helsinki and its subsequent amendments. Informed consent was obtained from all participants, ensuring that they were fully aware of the study’s objectives, procedures, potential risks, and their right to withdraw at any time without consequence. Confidentiality and anonymity were maintained throughout the study to protect participants’ privacy.
Consent for publication
Not applicable. This manuscript does not contain any identifying images or other personal or clinical details of participants that compromise anonymity.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Buheji M, Hasan A. Beyond famine and Chaos -Case of Gaza. Int J Manage. 2024;15(2).
- 2.Ahmed B, Mamadiyarov Z, Hussain A, Ullah R, Wahab S. The humanitarian crisis in Gaza: a tragic nexus of health, mortality, and economic struggles. Int J Multicultural Educ. 2024;25(3).
- 3.Kooli C, Kooli Y. The tragic collapse of Gaza’s Health System. Avicenna. 2023(2).
- 4.AlKhaldi M, Abuzerr S, Abu Obaid H, Alnajjar G, Alkhaldi A, Alkaiyat A. Social Determinants of Health in Fragile and Conflict zones before and during the Coronavirus Pandemic. In: Laher I, editor. Handbook of Healthcare in the Arab World. Springer; 2021. pp. 1–28.
- 5.Mahmoud H, Abuzerr S. State of the health-care system in Gaza during the Israel–Hamas war. Lancet. 2023;402(10419):2294. 10.1016/s0140-6736(23)02634-x. [DOI] [PubMed] [Google Scholar]
- 6.Taha AM, Mahmoud H, Nada SA, Abuzerr S. Controlling the alarming rise in infectious diseases among children younger than 5 years in Gaza during the war. Lancet Infect Dis. 2024;24(4):e211. 10.1016/s1473-3099(24)00067-7. [DOI] [PubMed] [Google Scholar]
- 7.Abuzerr S, Nasseri S, Yunesian M, et al. Water, sanitation, and hygiene risk factors of acute diarrhea among children under five years in the Gaza Strip. J Water Sanitation Hygiene Dev. 2019;10(1):111–23. 10.2166/washdev.2019.072. [Google Scholar]
- 8.Abuzerr S, Hadi M, Zinszer K, et al. Quantitative microbial risk assessment for Escherichia Coli O157: H7 via drinking water in the Gaza Strip, Palestine. SAGE Open Med. 2024;12:20503121241258070–20503121241258070. 10.1177/20503121241258071. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Abuzerr S, Nasseri S, Yunesian M, et al. Prevalence of diarrheal illness and healthcare-seeking behavior by age-group and sex among the population of Gaza strip: a community-based cross-sectional study. BMC Public Health. 2019;19(1):704. 10.1186/s12889-019-7070-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Abuzerr S, Hadi M, Zinszer K, et al. Comprehensive Risk Assessment of Health-related hazardous events in the drinking Water Supply System from source to tap in Gaza Strip, Palestine. J Environ Public Health. 2020;2020:7194780. 10.1155/2020/7194780. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.OCHA, Gaza. Lack of clean water brings disease and suffering in Gaza. UN Office for the Coordination of Humanitarian Affairs. Published online 2024.
- 12.World Health Organization. WHO operational handbook on tuberculosis. Module 1: Prevention: Tuberculosis Preventive Treatment: web annex B: conflict of Interest Assessment for experts contributing to the Handbook Content. 2nd ed. World Health Organization; 2024. 10.2471/b09117.
- 13.Juzoor for Health and Social Development. A War on Health: Gaza’s Battle for Survival in a Shattered Health System.; 2024.
- 14.World Health Organization. Country Cooperation Strategy for WHO and the Occupied Palestinian Territory: 2017–2020.; 2017.
- 15.Abuzerr S, Abu-Aita S, Al-Najjar I, Abuhabib A, Al-Jourany H, Zinszer K. Preparedness and readiness strategies for addressing the COVID-19 pandemic in Fragile and Conflict settings: experiences of the Gaza Strip. Front Public Health. 2021;9:766103. 10.3389/fpubh.2021.766103. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Abuzerr S, Zinszer K. The International Fund for the Palestinian Health System to Confront the COVID-19 Pandemic: Strategic Re-Thinking for Sustainable Development. Res Sq. Published online 2024.
- 17.Goniewicz K, Burkle FM, Horne S, Borowska-Stefańska M, Wiśniewski S, Khorram-Manesh A. The influence of War and Conflict on Infectious Disease: a Rapid Review of historical lessons we have yet to learn. Sustainability. 2021;13(19):10783. 10.3390/su131910783. [Google Scholar]
- 18.Blackburn CC, Lenze PE, Casey RP. Conflict and Cholera: Yemen’s man-made Public Health Crisis and the Global Implications of Weaponizing Health. Health Secur. 2020;18(2):125–31. 10.1089/hs.2019.0113. [DOI] [PubMed] [Google Scholar]
- 19.Wanqing Z. The use of mixing procedure of mixed methods in health services research. Med Care. 2013;51(8):e51–7. [DOI] [PubMed] [Google Scholar]
- 20.Raad II, Chaftari AM, Dib RW, Graviss EA, Hachem R. Emerging outbreaks associated with conflict and failing healthcare systems in the Middle East. Infect Control Hosp Epidemiol. 2018;39(10):1230–6. 10.1017/ice.2018.177. [DOI] [PubMed] [Google Scholar]
- 21.Al-Mekhlafi HM. Yemen in a time of Cholera: current Situation and challenges. Am J Trop Med Hyg. 2018;98(6):1558–62. 10.4269/ajtmh.17-0811. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Ozaras R, Leblebicioglu H, Sunbul M, et al. The Syrian conflict and infectious diseases. Expert Rev Anti Infect Ther. 2016;14(6):547–55. 10.1080/14787210.2016.1177457. [DOI] [PubMed] [Google Scholar]
- 23.Hussein S, Ahmed SK, Qurbani K, Fareeq A, Essa RA. Infectious diseases threat amidst the war in Gaza. J Med Surg Public Health. 2024;2:100067. 10.1016/j.glmedi.2024.100067. [Google Scholar]
- 24.Biwott SK, Ngugi A, Ajok J, Gerald A, Oceng PO, Luseni P. Attacks on health system in South Sudan. Int J Sci Res Eng Dev. 2019;2(6).
- 25.Sakr CJ, Abou Hassan FF, Fakih L, et al. Risk factors for SARS-CoV-2 among a cohort of Healthcare Workers in Lebanon. Workplace Health Saf. 2023;72(2):48–59. 10.1177/21650799231214234. [DOI] [PubMed] [Google Scholar]
- 26.Michlig GJ, Lafta R, Al-Nuaimi M, Burnham G. Providing healthcare under ISIS: a qualitative analysis of healthcare worker experiences in Mosul, Iraq between June 2014 and June 2017. Glob Public Health. 2019;14(10):1414–27. 10.1080/17441692.2019.1609061. [DOI] [PubMed] [Google Scholar]
- 27.De Jong K, Martinmäki SE, Te Brake H, Haagen JFG, Kleber RJ. Mental and physical health of international humanitarian aid workers on short-term assignments: findings from a prospective cohort study. Soc Sci Med. 2021;285:114268. 10.1016/j.socscimed.2021.114268. [DOI] [PubMed] [Google Scholar]
- 28.Elmi MA. ICT, the Somali Diaspora and the stabilization of a failed state. University of Cape Town; 2019.
- 29.Akik C, Ghattas H, Mesmar S, Rabkin M, El-Sadr WM, Fouad FM. Host country responses to non-communicable diseases amongst Syrian refugees: a review. Confl Health. 2019;13:8. 10.1186/s13031-019-0192-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Altare C, Kostandova N, Gankpe GF, et al. The first year of the COVID-19 pandemic in humanitarian settings: epidemiology, health service utilization, and health care seeking behavior in Bangui and surrounding areas, Central African Republic. Confl Health. 2023;17(1):24. 10.1186/s13031-023-00523-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Spiegel P, Ratnayake R, Hellman N, et al. Responding to epidemics in large-scale humanitarian crises: a case study of the cholera response in Yemen, 2016–2018. BMJ Glob Health. 2019;4(4):e001709–001709. 10.1136/bmjgh-2019-001709. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Yasir Essar M, Yasir M, Matiashova L, Tsagkaris C. Infectious diseases amidst a humanitarian crisis in Ukraine: a rising concern. Annals Med Surg. 2022;78:103950. 10.3109/09687637.2015.1016397?journalCode=idep20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Haque U, Bukhari MH, Fiedler N, et al. A Comparison of Ukrainian Hospital Services and functions before and during the Russia-Ukraine War. JAMA Health Forum. 2024;5(5):E240901. 10.1001/jamahealthforum.2024.0901. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Mahmoud H, Kirsch T, O’Neil D, Anderson S. The resilience of health care systems following major disruptive events: current practice and a path forward. Reliab Eng Syst Saf. 2023;235. 10.1016/j.ress.2023.109264.
- 35.Hassan EM, Mahmoud H. An integrated socio-technical approach for post-earthquake recovery of interdependent healthcare system. Reliab Eng Syst Saf. 2020;201. 10.1016/j.ress.2020.106953.
- 36.Hassan E, Mahmoud H. Human-centered Approach for Resilience Assessment of Healthcare Networks subjected to sequential earthquakes. Nat Hazards Rev. 2024;25(4). 10.1061/nhrefo.nheng-1887.
- 37.Taha AM, Mahmoud H, Hassan EM, Ghonaim MM. Harmonizing vaccine and infrastructure development to tame cholera outbreaks across Africa. Nat Commun. 2024;15(1). 10.1038/s41467-024-49077-4. [DOI] [PMC free article] [PubMed]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated and/or analysed during the current study are not publicly available in order to ensure participant confidentiality while supporting data transparency but are available from the corresponding author on reasonable request.