War and chronic illness: a health center-based study of Palestinians with non-communicable diseases in Gaza

Abstract

Background

The war in the Gaza Strip has put immense strain on the infrastructure and health services. As a consequence, the population faces increased risks of morbidity and mortality, not only from violence but also from lack of access to healthcare. This study examines how the war affected Palestinians with non-communicable diseases (NCDs) in the Strip.

Methods

This cross-sectional survey employed a structured questionnaire to recruit 968 patients with six common NCDs from seven leading PHC clinics located in northern and southern Gaza between October and November 2024. The survey collected sociodemographic data, assessed direct war impacts on participants, evaluated accessibility to PHC and medications, and examined health impacts on participants during the war. Following descriptive statistics, inferential analysis investigated the relationships between participants’ perceptions of PHC and their areas of residence or displacement.

Results

Hypertension (64.9%), type II diabetes mellitus (44.4%), and cardiovascular disease (17.1%) were the most frequently reported NCDs. 98.0% of participants were displaced during the war, and 68.1% were still displaced. 29.9% had lost a first-degree relative, and the majority suffered inaccessibility to adequate food and drinking water, lost property and income, and suffered adverse impacts on their sleep and physical exercise habits. 92.8% rated their pre-war quality of life (QoL) as excellent or good, while 81.3% rated their QoL during the war as poor. Adherence to regular follow-ups decreased from 96.7% before the war to 40.7% during the war (p < 0.001). Satisfaction with PHC dropped from 92.9% to 57.33% (p = 0.002). In terms of access to PHC, more than 93% changed their PHC doctor or clinic, and most stated that reaching the clinic was dangerous and necessitated long journeys. Medication unavailability or high cost were the most frequently reported reasons for non-compliance during the war, reported by 42.7% and 18.1%, respectively. Nearly one in five participants spent two or more consecutive months without medication. Participants from the southern enclave were significantly less satisfied with PHC and medications (p = 0.001), and their subjective QoL was significantly worse (p = 0.007).

Conclusions

The study offers important insights into the impacts of high-intensity armed conflicts on people with NCDs. The war in the Gaza Strip has profoundly impacted patients with NCDs and hampered their access to healthcare, leaving the population at risk for higher morbidity and excess mortality rates now and well into the future.

Introduction

Non-communicable diseases (NCDs), such as cardiovascular disease (CVD), diabetes, chronic respiratory disorders, and cancer, among others, represent a major global health challenge. The prevalence of NCDs continues to grow worldwide and in lower-income countries in particular, driven by physiological, behavioral, environmental, and genetic influences [1]. Furthermore, NCDs are a significant contributor to both morbidity and mortality globally, accounting for an estimated 41 million deaths each year, roughly 74% of total global deaths [1]. More than three-quarters of those deaths occur in low- and middle-income countries. Like other developing countries, Palestine is experiencing an increasing NCD burden [2, 3]. In the Gaza Strip, which is a small and densely populated Palestinian enclave with an estimated population of around 2.3 million residents, the incidence of NCDs exceeds 40% [4]. CVDs accounted for an estimated 33.9% of deaths in Gaza in 2022, driven by risk factors such as hypertension, diabetes, and low physical activity, while cancer accounted for 15.1% [5].

Conflicts represent a major obstacle to providing a safe, accessible, and efficient primary healthcare (PHC) service, the lack of which leads to increased complications, morbidity, and excess mortality related to NCD underdiagnosis and undertreatment [6]. For instance, the first four years of the Syrian conflict saw an estimated two additional civilian deaths due to infections and NCDs for each civilian death caused directly by violence [7]. Also, several studies outlined the impacts of conflicts on civilians’ accessibility to healthcare and NCD treatment in Iraq and Ukraine [8–10]. Meanwhile, a study from Lebanon revealed that the population continued to suffer from excess CVD and mortality related to the impacts of the civil war years after it ended [11]. The causes of such findings in conflict-stricken areas are severalfold. Healthcare providers and donor agencies prioritize trauma care and related emergency needs, which often leads to limited attention to NCDs [12]. Additionally, forced displacement disrupts access to essential care, while damaged health facilities, shortages of medical staff, and limited supplies exacerbate these challenges further. Moreover, crises amplify exposure to NCD risk factors, such as unhealthy lifestyles and social determinants like poverty [13]. At the same time, mental distress from extreme living conditions negatively impacts health outcomes for affected individuals [13].

The Gaza Strip is divided into five governorates: North, Gaza, Middle, Khan Younis, and Rafah. The Strip has been under Israeli military occupation since 1967 and has faced a strict blockade for nearly two decades. Prior to the outbreak of the current war in October 2023, health services in Gaza were disadvantaged by the blockade and by periodic conflicts that left hospitals and staff exhausted and on the brink of collapse for years. Decades of economic deprivation, political instability, fragmentation of the Palestinian people, physical barriers to movement, and logistical and financial constraints fostered health inequities and impeded healthcare provision [6, 14, 15]. The current war, therefore, represents the latest and most intense episode in a region of chronic conflict, poverty, instability, and inadequate healthcare. Against this backdrop, persons with NCDs have suffered additional obstacles during the war that hindered their ability to access essential healthcare and obtain medications. Factors such as widespread displacement and continuous attacks on health facilities have overwhelmed PHC providers, who have become unable to meet patient demands. As of May 2024, only 17% of governmental PHC clinics and four of 22 UNRWA health clinics were still functioning [16]. The war also resulted in a scarcity of medication and all sorts of medical supplies, forcing patients to turn to ineffective and lower-quality alternatives [16]. Moreover, Israeli restrictions on medical supply imports into Gaza have exacerbated resource shortages, rendering donations the primary, though oftentimes insufficient, way of supplying persons with NCDs with their medications. As a result, it is feared that for every traumatic death, there may be as many as four additional indirect deaths due to the collapse of essential healthcare services [17]. Due to the fighting, the first months of the war have seen the number of visitors to mother and child healthcare centers decrease by 18%, and the number of visitors to dental clinics drop by 50% compared to visitors in 2022 [18].

Until May 2025, over 52,000 Palestinians have been killed and over 110,000 wounded in the fighting [19]. Furthermore, in addition to the military attacks, the war witnessed significant civilian suffering. On the seventh day of the war, an Israeli military order forced the majority of the residents from the North and Gaza Governorates to move to the southern Governorates. Then, during the subsequent weeks, the Israeli forces separated the two northern Governorates from the southern Governorates with a military corridor, effectively dissecting the Gaza Strip into two isolated enclaves [20, 21]. Each enclave received aid and food separately from different entry points, and residents suffered different living conditions during the different phases of the war. Movement between the two enclaves was not permitted, and the population suffered varying but significant degrees of food scarcity [22].

The present study aims to assess how the war in the Gaza Strip affected people with NCDs in terms of accessibility to healthcare and medications and explore war-related factors that potentially impacted the accessibility. It also explores possible variations in perceptions of PHC services during the war between the separated northern and southern enclaves within the Gaza Strip. With the unabated humanitarian situation, original data from a population-based survey can help stakeholders plan effective healthcare delivery to persons with NCDs during the war.

Methods

Study design, settings, and population

Before the war, major providers of PHC services in the Gaza Strip were either PHC clinics of the Ministry of Health (MoH), which is the largest provider of healthcare in the Gaza Strip with 52 clinics, or the United Nations Relief and Works Agency (UNRWA), which ran 22 clinics [18].

This cross-sectional study was conducted between October 11th and November 10th, 2024. Logistical and safety concerns dictated the use of the convenience sampling method. Data was collected from seven PHC centers run by the MoH: Daraj and Al-Salam PHC clinics in the Gaza Governorate, Deir-Albalah, Al-Zwaida, and Al-Buriej clinics in the Middle Governorate, and Al-Helal and Al-Bandar clinics in Khan Younis Governorate. The clinics were located in areas that, at the time of data collection, were densely populated with residents and internally displaced persons (IDPs). The North and Rafah Governorates were not included in the study because, at the time of data collection, the Israeli military was conducting major ground invasions in both governorates, leading to the suspension of PHC services and the displacement of most of the population to the remaining three governorates.

The study recruited patients with NCDs who visited the clinics within the study period, with any of the following NCDs: Hypertension, diabetes mellitus types I and II, cardiovascular diseases, bronchial asthma, and epilepsy. Each patient may report data on up to three NCDs. Patients were excluded if they were under 12 years of age, could not read or write, suffered mental or cognitive impairment, refused to participate, or had significant missing data.

Sample size and study instrument

The estimated population of the Gaza Strip in mid-2023 was approximately 2,226,544, and the Palestine Annual Health Report 2023, released in June 2024 by the Ministry of Health, indicated that PHC centers registered around 341,000 patients with non-communicable diseases, including hypertension, diabetes mellitus, and cardiovascular diseases [18]. The minimum required sample size was 663, determined using the Raosoft Inc. online calculator, with a margin of error of 0.05 and a 99% confidence interval. The authors increased the desired sample size by 45% to enhance the statistical power and representativeness of the study, resulting in a target sample of 962 individuals.

Data was collected using a self-filled structured questionnaire comprised of four sections. The first included sociodemographic information, including age, sex, occupation, educational level, and the original and current governorates of residence. The second surveyed the war’s impacts on the participant, including variables such as injury, military detention, forced displacement, living conditions, accessibility to food and water, and loss of relatives, property, or source of income. Additional questions in this section surveyed participants’ subjective QoL before and after the war using a continuous scale comprised of four possible answers, in addition to prewar and new eating and physical activity habits, which were assessed using a dichotomous (yes/no) scale. The third section concerned pre-war health status related to the participants’ NCDs. Collected variables included the duration since each NCD’s diagnosis, compliance with medications and regular checkups, and satisfaction with medications’ quality and quantity before the war. The fourth section, concerned with NCD-related health during the war, surveyed variables similar to those of the third section, in addition to other questions that assessed the barriers to accessing PHC during the war and compliance with medication. Unless otherwise specified, participants were instructed to answer based on their overall experience during the war until data collection. A pilot study was conducted on 30 participants, following which some questions were rephrased or separated into two questions. The final survey comprised 50 questions in total. The pilot surveys were excluded from the final analysis.

Statistical analysis

Variables were represented as frequency and percentages rounded to two decimal points. Age was presented as quartiles and the mean ± standard deviation (SD). Then, inferential analysis was done using the Chi-square test to explore the relation among study variables and to test if PHC services provided during the war differed significantly between the present northern and southern enclaves. A p-value equal to or below 0.05 was considered statistically significant. Data was analyzed using SPSS version 27. Figures were prepared using R Studio and Prism GraphPad softwares.

Ethical considerations

Ethical approval for this study was granted by the Institutional Review Board (IRB) at the Islamic University of Gaza (IUG). Administrative approvals were obtained from the Palestinian MoH. Participants provided written informed consent. The confidentiality of information was maintained throughout the data collection and analysis phases.

Results

Cohort characteristics

The study cohort included 968 participants, with 605 females (62.5%) and 363 males (37.5%) and a mean age of 54.67 ± 14.38 years. The majority were unemployed (70.6%). Hypertension was the most frequently reported NCD (64.9%), followed by type II diabetes mellitus (44.4%) and cardiovascular disease (17.1%). More information is presented in Table 1 and Fig. 1.

Table 1.

Cohort characteristics

Items	Categories	N	%
Sex	Female	605	62.50
	Male	363	37.50
Age (quartiles)	< 47	261	26.96
	47–55	230	23.76
	56–63	249	25.72
	≥ 64	228	23.55
	Mean age 54.67 ± 14.38 years, Mode 62 years, age range (12–93) years
Governorate before the war	Northern governorate	119	12.29
	Gaza governorate	383	39.57
	Middle governorate	213	22.00
	Khan Younis governorate	165	17.05
	Rafah governorate	88	9.09
Governorate (current)	Gaza governorate	286	29.54
	Middle governorate	385	39.77
	Khan Younis governorate	297	30.67
PHC center	Daraj clinic	127	13.11
	Al-Salam clinic	159	16.42
	Deir-Albalah clinic	126	13.01
	Al-Zwaida clinic	131	13.53
	Al-Buriej clinic	128	13.22
	Al-Helal clinic	152	15.70
	Al-Bandar clinic	145	14.97
Employment	Government employees	129	13.32
	Self-employed	92	9.50
	Private sector employee	64	6.61
	Unemployed	683	70.56
Education	No formal education	46	4.75
	Basic education	365	37.71
	Secondary education	331	34.19
	Diploma or Bachelors	197	20.35
	Master’s or PhD	29	2.99
NCD*	Hypertension	629	64.98
	Diabetes type I	75	7.75
	Diabetes type II	430	44.42
	Cardiovascular disease	165	17.05
	Asthma	78	8.06
	Epilepsy	21	2.17

*Total may exceed 100% as each participant can report up to three NCDs

Fig. 1.

Venn diagram illustrating the frequency (%) and overlapping of the three commonest NCDs reported

Direct impacts of the war on participants

The vast majority of participants (98.0%) had been forcibly displaced during the war, and 68.1% were still displaced. Nearly one of every ten participants had been injured, and among those, over a tenth (12.6%) suffered permanent disabilities due to their injury. Also, 29.9% had lost a first-degree relative in the war. The majority reported inaccessibility to adequate food and drinking water, lost property and income, and reported adverse impacts on their sleep and physical exercise habits. Also, most (92.8%) rated their pre-war quality of QoL as excellent or good, while 81.3% rated their current QoL as poor (Table 2). The decline in the portion of participants who maintained a healthy diet and regular exercise during the war compared to before the war was significant, with p < 0.001 for both variables.

Table 2.

War’s direct impacts on participants

Items	Answers	N	%*
Forced displacement	Yes	949	98.04
	No	19	1.96
Currently displaced	Yes	659	68.08
	No	309	31.92
Military imprisonment	Yes	7	0.72
	No	958	98.97
Personal injury	Yes	95	9.81
	No	871	89.98
Permanent disability due to this injury**	Yes	12	12.63
	No	83	87.37
Entering ICU due to this injury**	Yes	1	1.05
	No	94	98.94
Lost a first degree relative	Yes	290	29.96
	No	678	70.04
Poor food quality	Yes	948	97.93
	No	20	2.07
Inability to afford food	Yes	910	94.01
	No	58	5.99
Shortage of drinking water	Yes	865	89.36
	No	103	10.64
Loss of source of income	Yes	653	67.46
	No	315	32.54
Loss of privacy	Yes	689	71.18
	No	279	28.82
Loss of house or property (e.g., land, cars, business, ….)	Yes	749	77.38
	No	219	22.62
War’s impact on economic status	Became worse	930	96.07
	Improved	4	0.41
	No significant change	24	2.48
War’s impact on participants’ sleep	Changed significantly	666	68.80
	Changed slightly	238	24.59
	No significant change	62	6.40
	Improved	0	0.00
Maintained a healthy diet before the war	Yes	859	88.74
	No	107	11.05
Maintained a healthy diet during the war	Yes	95	9.81
	No	873	90.19
Exercised regularly before the war	Yes	480	49.59
	No	488	50.41
Exercised regularly during the war	Yes	61	6.30
	No	907	93.69
Subjective QoL before the war	Excellent	394	40.70
	Good	504	52.06
	Acceptable	56	5.78
	Poor	14	1.44
Subjective QoL during the war	Excellent	1	0.10
	Good	38	3.93
	Acceptable	142	14.67
	Poor	787	81.30

*Variability in total numbers is due to some missing data   **Of those who were injured (n=95)

Health status and accessibility to PHC before and during the war

Adherence to regular follow-ups declined from 96.7% before the war to 40.7% during the war (p < 0.001). Similarly, 92.9% of participants were satisfied with the overall PHC service before the war, but only 57.3% were satisfied during the war (p = 0.002).

In terms of PHC accessibility, more than 93% had to change their usual PHC doctor or clinic, and most stated that reaching the PHC clinic was dangerous and necessitated long journeys. Only 70.1% received a month’s need of medications per prescription during the past three months, while the remaining participants had to visit the PHC more often for medication refills. Medication unavailability or high cost were the most frequently reported reasons behind non-compliance during the war (reported by 42.7% and 18.1%, respectively)(Table 3).

Table 3.

War’s impact on participants’ health and accessibility to PHC

Item	Categories	N	%
Number of medications used before the war	One	162	16.74
	Two	229	23.66
	Three	173	17.87
	More than three	404	41.74
Regular follow ups before the war	Yes	936	96.69
	No	32	3.31
Regular follow ups during the war	Yes	394	40.70
	No	574	59.30
Satisfaction with PHC before the war	Satisfied	899	92.87
	Unsatisfied	69	7.13
Satisfaction with PHC during the war	Satisfied	555	57.33
	Unsatisfied	413	42.67
Changed PHC doctor during the war	Yes	909	93.90
Changed PHC clinic during the war	Yes	904	93.39
Had to travel long distances to obtain medications	Always	214	22.11
	Sometimes	483	50.00
	Rarely	172	17.77
	Never	99	10.23
Reaching to the PHC clinic to obtain medications was dangerous	Always	253	26.14
	Sometimes	437	45.14
	Rarely	163	16.84
	Never	115	11.88
Rates of prescription renewals during the past three months*	Weekly	35	3.62
	Biweekly	187	19.32
	Monthly	679	70.14
Primary cause of non-adherence to some or all medications during the war (N = 634)	My medication was unavailable	271	42.74
	Medications became too expensive	115	18.13
	I became unable to afford the medications	99	15.61
	I don’t care if I need medications anymore	37	5.83
	I was unable to reach the PHC clinic due to danger	36	5.67
	The nearest PHC was so far away	27	4.25
	There were no pharmacies near my place of residence	19	2.99
	I don’t believe I need the medication	19	2.99
	My doctor was killed/missing/unreachable	6	0.94
	The PHC clinic was destroyed or rendered nonoperational	5	0.78

*Prescriptions and medications were dispersed monthly before the war

War’s impact on specific NCDs

Table 4 reports the satisfaction rates with medication before and after the war and the longest period spent without medication during the war. Nearly one in four participants with type I diabetes and asthma (24.0% and 24.4%, respectively) suffered two or more continuous months without their usual medications, and the percentage was even higher (57.1%) among participants with epilepsy. Comparing the proportion of patients who spent two or more months off their medications revealed no significant associations (p > 0.05) with residence (northern vs. southern enclaves) during the war for any of the six NCDs.

Table 4.

War’s impact on specific NCDs

NCD	Item	Answers	n	%*
Hypertension N = 629	Time since diagnosis	1–5 years	171	27.19
		> 5 years	457	72.66
	Satisfied with medication quality	Before the war	571	90.78
		During the war	336	53.42
	Satisfied with medication quantity	Before the war	333	52.94
		During the war	180	28.62
	Suffered complications during the war	Yes	166	26.39
	Longest continuous period without medication during the war (due to unavailability)	< 2 weeks	77	12.24
		2–4 weeks	78	12.40
		1–2 months	83	13.20
		> 2 months	114	18.12
		I always had medications available	222	35.29
Diabetes mellitus type I N = 75	Time since diagnosis	1–5 years	30	40.00
		> 5 years	45	60.00
	Satisfied with medication quality	Before the war	67	89.33
		During the war	30	40.00
	Satisfied with medication quantity	Before the war	27	36.00
		During the war	9	12.00
	Suffered complications during the war	Yes	39	52.00
	Longest continuous period without medication during the war (due to unavailability)	< 2 weeks	12	16.00
		2–4 weeks	9	12.00
		1–2 months	16	21.33
		> 2 months	18	24.00
		I always had medications available	19	25.33
Diabetes mellitus type II N = 430	Time since diagnosis	1–5 years	96	22.33
		> 5 years	334	77.67
	Satisfied with medication quality	Before the war	392	90.93
		During the war	256	59.53
	Satisfied with medication quantity	Before the war	276	64.19
		During the war	162	37.67
	Suffered complications during the war	Yes	121	28.14
	Longest continuous period without medication during the war (due to unavailability)	< 2 weeks	59	13.72
		2–4 weeks	48	11.16
		1–2 months	55	12.79
		> 2 months	68	15.81
		I always had medications available	148	34.42
Cardiovascular disease N = 165	Time since diagnosis	1–5 years	34	20.60
		> 5 years	131	79.39
	Satisfied with medication quality	Before the war	151	91.15
		During the war	89	53.94
	Satisfied with medication quantity	Before the war	117	70.91
		During the war	60	36.36
	Suffered complications during the war	Yes	51	30.91
	Longest continuous period without medication during the war (due to unavailability)	< 2 weeks	24	14.55
		2–4 weeks	26	15.76
		1–2 months	22	13.33
		> 2 months	28	16.97
		I always had medications available	49	29.70
Bronchial Asthma N = 78	Time since diagnosis	1–5 years	35	44.87
		> 5 years	44	56.41
	Satisfied with medication quality	Before the war	66	84.62
		During the war	45	57.69
	Satisfied with medication quantity	Before the war	32	41.03
		During the war	21	26.92
	Suffered complications during the war	Yes	32	41.03
	Longest continuous period without medication during the war (due to unavailability)	< 2 weeks	11	14.10
		2–4 weeks	6	7.69
		1–2 months	11	14.10
		> 2 months	19	24.36
		I always had medications available	21	26.92
Epilepsy N = 21	Time since diagnosis	1–5 years	6	28.57
		> 5 years	15	71.14
	Satisfied with medication quality	Before the war	19	90.48
		During the war	6	28.57
	Satisfied with medication quantity	Before the war	2	9.52
		During the war	2	9.52
	Suffered complications during the war	Yes	11	52.38
	Longest continuous period without medication during the war (due to unavailability)	< 2 weeks	2	9.52
		2–4 weeks	2	9.52
		1–2 months	2	9.52
		> 2 months	12	57.14
		I always had medications available	2	9.52

In terms of complications, 27 (4.3%) of hypertensive participants were hospitalized due to uncontrolled hypertension, while 10 (13.3%) and 40 (9.3%) patients with type I and type II diabetes mellitus, respectively, suffered hypoglycemia attacks. Also, seven (9.3%) participants with type I diabetes suffered diabetic ketoacidosis (DKA), while five (1.4%) with type II diabetes suffered a hyperosmolar coma. Four (2.4%) patients with cardiovascular disease were admitted with a myocardial infarction and five (3.0%) with an arrhythmia. Eighteen (23.1%) of asthmatic participants visited the hospital due to an asthma exacerbation, and 11 (52.4%) of participants with epilepsy suffered uncontrolled epilepsy.

There were no significant differences in the overall satisfaction rates with medication quality or quantity before the war based on residence (p = 0.055 and p = 0.594, respectively) (Table 5). However, during the war, participants in the southern governorates were less satisfied with the quality and quantity of their medications (p = 0.001 and p = 0.001, respectively) (Table 5). On the other hand, subjective QoL was significantly worse for those living in the southern governorates during the war compared to the north (p = 0.007) (Fig. 2). At the same time, no significant difference was found in the subjective QoL before the war (p = 1.0).

Table 5.

Inferential analysis comparing some study variables against the pre-war and current area of residence

Variables	Categories	N (%)	p
Satisfaction by quality of medications before war	Lived in the North or Gaza Governorates	442 (88.05)	0.055
	Lived in the Middle, Khan Younis, or Rafah Governorates	428 (91.85)
Satisfaction by quality of medications during war	Lives or displaced in the northern enclave	200 (69.93)	0.001
	Lives or displaced in the southern enclave	304 (44.64)
Satisfaction by quantity of medications before war	Lived in the North or Gaza Governorates	190 (37.85)	0.594
	Lived in the Middle, Khan Younis, or Rafah Governorates	168 (36.05)
Satisfaction by quantity of medications during the war	Lives or displaced in the northern enclave	87 (30.42)	0.001
	Lives or displaced in the southern enclave	111 (16.28)
Subjective QoL before the war (answer “Poor”)	Lived in the North or Gaza Governorates	7 (1.39)	1.000
	Lived in the Middle, Khan Younis, or Rafah Governorates	7 (1.50)
Subjective QoL during the war (answer “Poor”)	Lives or displaced in the northern enclave	217 (75.87)	0.007
	Lives or displaced in the southern enclave	570 (83.60)

Fig. 2.

Comparison between participants from the northern and southern Governorates in terms of medication satisfaction and rated QoL during the war (Chi square test, ***indicates p value < 0.01)

Discussion

This study evaluated the repercussions of the war in Gaza on a representative cohort of patients with non-communicable diseases (NCDs). Hypertension was the most prevalent condition in the study (64.9%), followed by type II diabetes (44.4%) and cardiovascular disease (17.1%). The war had profound direct effects: 98.0% of participants were displaced, and 68.1% had not returned home. This aligns with reports from the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), indicating that nearly 80% of Gaza remained under evacuation orders as of October 2024 [21]. Most participants reported severe disruptions to diet, sleep, exercise, and overall QoL. Access to PHC also declined sharply. Before the war, over 90% were compliant with regular follow-ups and medications and were satisfied with the level of PHC services and medications. during the war, only 59.3% were compliant with follow-ups, and 42.7% remained generally satisfied with the PHC services, while nearly one in five participants went two or more consecutive months without medication.

The ongoing war in the Gaza Strip has been the longest and most devastating in the history of the conflict in Palestine. It has been characterized by repeated targeting of critical infrastructure, including healthcare facilities and personnel. The World Health Organization (WHO) had, by October 2024, documented at least 516 attacks on healthcare in Gaza, resulting in 765 deaths [23]. Additionally, by the end of 2023, 39 of the 52 PHC clinics operated by the MoH were out of service, of which 11 were directly targeted and damaged, and 28 were inaccessible due to the fighting [18]. Geospatial analyses confirmed widespread damage to hospitals and destruction of civilian infrastructure, including water, education, and transportation networks [24–26]. These conditions directly impacted patients’ access to care. Over 70% of participants in this study reported having to travel long distances to reach a functioning PHC clinic, and a similar proportion felt that reaching the PHC clinic was dangerous. Nearly all (93.9% and 93.4%) had to change both their PHC doctor and clinic during the war. These disruptions likely contributed to the substantial decline in follow-up and medication adherence, where, prior to the war, 92.9% of patients were satisfied with PHC services, compared to 42.7% during the war. For comparison, in Sudan, another region experiencing active conflict, 45.7% of IDPs with NCDs in a recent study interrupted their medication, while 38.6% could not access healthcare services [27]. In northern Ethiopia in 2022, 35.4% of participants in a cross-sectional study reported no interruptions of medications, while only between 10 and 15% of participants in our study experiencing medication interruptions lasting less than two weeks [28]. Mass displacement in Gaza also significantly limited PHC accessibility. In comparison, healthcare and medication interruptions in eastern Ukraine ranged from 9 to 14% among non-displaced patients and from 46 to 77% among displaced patients with NCDs [10].

The study highlighted a significant disruption in medication adherence among participants, particularly among patients with epilepsy, type I diabetes mellitus, and asthma. Only 9.5%, 25.3%, and 26.9% of these patients reported nearly continuous availability of treatments. These conditions are particularly susceptible to acute, potentially fatal complications such as status epilepticus (SE), DKA, and uncontrolled asthma exacerbations. In fact, 52.4% of participants with epilepsy experienced uncontrolled seizures, 9.3% of those with type I diabetes suffered DKA, and 23.1% of asthmatic participants were hospitalized due to an asthma exacerbation. A 2022 study surveyed the main hospitals in Gaza and found that they were poorly equipped to manage SE, a situation likely worsened by the ongoing war [29]. From the authors’ experience, it is not unusual for diabetic patients to visit the emergency room several times a day to receive insulin injections because they cannot secure the medication for use at home.

A plethora of obstacles hindered participants’ ability to obtain sufficient medications. A significant contributor has been the import limitations imposed on the flow of medical supplies, including essential medications, into the Gaza Strip, which have been repeatedly reported by international organizations [30, 31]. Mirroring this observation, the most frequent obstacle to medication adherence, reported by 42.7% of participants, was medication unavailability, while prohibitively high prices were the second most common cause, reported by 18.1%. Additionally, many patients (15.6%) reported becoming unable to afford medications even at regular prices due to a decline in their financial situation during the war. Notably, 5.8% stated that they “don’t care if I need medications anymore,"suggesting psychological distress and, possibly, depression, echoing the findings of recent studies that outlined high rates of depressive symptoms among the population in Gaza [20, 32].

The study found that 96.1% experienced a deterioration in their economic status. Food and water insecurity were severe, with 94.0% unable to afford food, 89.4% facing shortages of drinking water, and 97.9% reporting poor food quality. Aid organizations reported that Israeli authorities were systematically obstructing access to food aid for up to 83% of those in Gaza [33]. Additionally, the World Food Program (WFP) indicated a more than 1,000% increase in the price of basic commodities as of November 2024 [34]. In July 2024, around 2.15 million individuals, representing 96% of the Gaza Strip's population, were experiencing acute food insecurity [35]. Under such conditions, patients often prioritized fulfilling basic survival needs over managing their chronic medical conditions, resulting in widespread non-adherence to medications and neglect of healthcare. Echoing these reports, dissatisfaction with QoL among our participants soared from 1.4% before to 81.3% during the war.

On the other hand, while restrictions on the entry of food and medication were stricter in northern Gaza [30, 36, 37], our study found lower satisfaction with PHC and QoL among those displaced to or residing in the southern enclave. This difference likely reflects the worse living conditions in the south, as IDPs lived in tents and makeshift shelters. Furthermore, population density in the south was far higher, while fewer than a quarter of the Strip's pre-war population lived in the northern enclave during the study period [38]. For instance, an estimated half a million people lived in the two northern governorates in mid-2024, down from a pre-war population of 1.2 million, while the southern city of Rafah -originally home to around 250,000 people- hosted nearly one million IDPs. These overcrowded and under-resourced conditions likely intensified the suffering and compromised healthcare access for displaced individuals in the south [38].

The WHO Package of Essential Noncommunicable Disease (PEN) Interventions for Primary Health Care recommends maintaining a healthy diet and engaging in regular physical activity to reduce complications and improve outcomes related to NCDs [39]. This study demonstrated that adherence to a healthy diet significantly declined from 88.7% before to 9.8% during the war, while regular physical activity decreased from 49.59% before to 6.30% during the war. Additionally, 29.9% of participants lost a first-degree relative during the war. Studies suggest that a lack of social support worsens health outcomes, increases mortality, and leads to more hospital admissions [40, 41]. Furthermore, 68.8% of participants reported a significant deterioration in their sleep patterns, which may be linked to the development of myocardial infarction in patients with CVD [42].

Concerted efforts involving stakeholder collaboration, teamwork, and technological innovation are essential to mitigate the war’s impacts on patients with NCDs and ensure equitable access to healthcare. Telemedicine initiatives have been effectively implemented during the ongoing war in the Gaza Strip [43]. These initiatives can be especially beneficial for those in besieged areas or those who are disabled. An additional advantage is the recruitment of doctors from abroad, which helps to relieve some pressure from local staff and reduce their high rates of burnout [44]. Artificial intelligence (AI) may provide another tool to connect and assist various stakeholders in sharing relevant databases and streamlining relief efforts. Such initiatives can also enhance efficiency and broaden the pool of beneficiaries. Data collection and real-time surveillance are crucial for gathering data on healthcare access and chronic disease prevalence in conflict zones, which can then inform targeted interventions and resource allocation.

Strengths, limitations, and future directions

The study presented several strengths, including its large sample size and covering all the inhabited Governorates in the Gaza Strip at the time of data collection. It surveyed several diseases that represent a significant portion of the NCD burden in Gaza and examined various aspects of participants’ lifestyles and health behaviors as well. However, there are several limitations to consider. Using a self-reported tool and subjective measures, and the long interval between the war’s onset and data collection, may predispose to recall bias. Furthermore, clinical examination and laboratory tests would be essential to reducing subjectivity bias. Selection bias is another significant issue since a significant portion of elderly patients and those with permanent disabilities might have faced greater difficulties accessing PHCs due to mobility restrictions, and since illiterate patients were also excluded. Consequently, the participants in our study may represent a cohort that is less traumatized or less severely impacted by the ongoing conflict when compared to other patients with NCDs. Thus, the study possibly underestimated the war’s impacts on the NCD population in the Gaza Strip. We recommend that future studies explore the effects of the conflict on additional NCDs not covered in our investigation, such as cancer, chronic kidney disease (CKD), and chronic obstructive pulmonary disease (COPD), and highlight the psychological impacts of the war on patients and caregivers alike.

Conclusions

The war in Gaza has had profound and diverse negative impacts on patients with NCDs. Most participants had endured displacement, loss of property and income, loss of first-degree relatives, poor diet, bad sleep quality, and inability to exercise. Four of five participants reported their subjective QoL as “poor”. Additionally, access to PHC was severely impacted. The majority were unable to commit to regular follow-up or obtain medication regularly, and many suffered long durations without treatment, while some suffered serious and potentially life-threatening complications related to their NCDs. Although methodological limitations predisposed the study to selection and recall biases, the findings are alarming and indicate that the continued war in the Gaza Strip will only expose patients with NCD to increased morbidity and excess mortality. Efforts must be taken to stop the conflict and restore the PHC services in the Gaza Strip and prevent unnecessary and preventable human suffering.

Author contributions

BA and YB: Conceptualization, literature review, study design, and tool development. BA: Supervision. FH, DA, MA, DB, MD, LB, AK: Data collection. BA and SE: data analysis and interpretation. BA: Figure preparation. BA, YB, and FH: Writing of the study manuscript. All authors contributed to the manuscript revision and have approved the final version.

Funding

The study was not funded.

Availability of data and materials

Available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Institutional Review Board (IRB) at the Islamic University of Gaza. Participants provided informed written consent. Confidentiality of the data was maintained throughout data collection and analysis.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.