Critical care in Gaza amidst military pressure: the struggle of healthcare workers in Gaza’s Warzone

Summary box.

• Gaza’s healthcare system was already fragile before 7 October 2023, due to blockade, repeated conflicts and chronic shortages of supplies.

• The current war has led to the collapse of critical care services, forced extreme triage decisions and driven staff to psychological burnout.

• Findings underscore the urgent need for international protection of healthcare in war zones, development of wartime critical care protocols and long-term investment in critical care under war conditions.

Introduction: context before and after the 2023 aggression

The Gaza Strip, home to more than 2 million people within 365 km², has long faced structural vulnerability in healthcare. Before October 2023, the Ministry of Health (MoH) operated 35 hospitals, many of which struggled with electricity outages, equipment shortages and limited staff.¹

The blockade in place since 2007 had restricted the import of medical supplies and blocked international medical missions.

Since 7 October 2023, the situation has deteriorated. Over 55 000 Palestinians have been killed, with more than 128 000 injuries reported. Healthcare facilities have experienced over 700 attacks, leaving approximately 47% of hospitals only partially functional.²

Challenges and impacts of constrained and aborted critical care

Al-Shifa Hospital’s critical care unit had 17 beds prewar. Within 24 hours of the escalation, all beds were occupied. In response, the hospital expanded its critical care capacity to 37 beds, reallocated resources and brought in additional medical staff. However, this expansion still did not meet the overwhelming demand.

A triage system was implemented to prioritise patients based on the urgency of their needs and potential benefit from intensive care using the prioritisation model. This model is particularly useful during mass casualty events or in low-resource settings where intensive care unit (ICU) capacity is severely limited.³

Patients were categorised into three levels of priority. Only those with the highest potential for survival and urgent need for advanced support were admitted. Those with either very low or extremely high likelihoods of survival were excluded, and where possible, directed towards either ward-level monitoring or palliative care. A summary of the triage model is presented in table 1.

Table 1. ICU prioritisation model in resource-limited wartime settings.

Priority level	Description	ICU admission	Examples
Level 1	Critically ill with potential for recovery; require interventions only available in ICU	Yes	GCS 6–12, intra-abdominal haemorrhage, ventilated chest trauma, post-operative patients
Level 2	Low-risk patients who require close monitoring but can be managed outside ICU	No	Diabetic ketoacidosis (pH>7.1), COPD managed with a Venturi mask.
Level 3	Patients with poor prognosis; ICU unlikely to alter outcome	No	GCS<6, unwitnessed cardiac arrest, irreversible shock, multi-organ failure, burns>40% TBSA

COPD, chronic obstructive pulmonary disease; GCS, glasgow coma scale ; ICU, intensive care unit; TBSA, total body surface area.

When data are available, ICU scoring systems like Modified Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation II scores are utilised to quantify the patient’s severity and estimate mortality risk.^{4 5}

Additionally, considerations regarding the availability of critical care resources and ICU bed capacity play a crucial role in decision-making processes.

Surgical and anaesthesia care challenges

Al-Shifa Hospital, the primary referral centre in the Gaza Strip, had over 20 surgical theatres and 506 beds. Before the escalation, Al-Shifa typically performed 28 000 major surgeries annually, and 10–15 emergency surgeries per day.¹ During the war, demands increased exponentially, overwhelming the system and resulting in all operating rooms being utilised continuously.

Between 7 October and 15 November 2023, there were over 27 000 reported injuries, while more than 69% of hospitals in the Gaza Strip became non-functional.⁶

In response to the unprecedented increase in demand for the operating theatres at Al-Shifa Hospital, surgical teams had to convert recovery rooms and hospital corridors into makeshift operating suites, where sterile conditions could not be guaranteed. Many patients died while awaiting emergency surgery due to overcrowding. Additionally, critical anaesthesia agents like propofol were nearly depleted, forcing surgeons to perform certain procedures such as amputations and debridement under local anaesthesia or without sedation.⁷

Between 2024 and early 2025, the surgical infrastructure in Gaza collapsed, with Al-Shifa Hospital becoming non-functional by mid-2024, leaving Al-Ahli Hospital as the sole operating facility, with three functioning theatres for over 1 million residents.^{8 9}

By 17 June 2025, the WHO reported that Gaza City had a total of eight operating rooms, highlighting a significant inadequacy in medical infrastructure for wartime trauma care.²

Staffing shortages and psychological impact

In addition to the physical challenges, the psychological impact on healthcare workers was immense. The evacuation orders issued on 13 October 2023,¹⁰ which forced families to flee northern Gaza, led to separation of healthcare workers from their families. This separation exacerbated stress levels. Additionally, many intensivists have faced burnout from extended shifts lasting over 30 consecutive days in high-risk environments with minimal respite. Notably, the division of the Gaza Strip into two regions made it difficult for medical staff living in the south to reach their workplaces, further exacerbating staffing shortages.

Between October 2023 and June 2025, the Gaza healthcare sector experienced significant casualties, with 1580 healthcare professionals killed and 300 detained.¹¹

The critical care team at Al-Shifa Hospital dropped from 19 physicians before the war to roughly 47% of its original strength by mid-2025, with nine physicians lost due to fatalities, displacement or arrest.

In May 2025, the Israel Defense Forces ordered the evacuation of staff and patients from the hospital without alternatives, followed by an airstrike on the facility. Also, since 7 October 2023, critical care staff have been working without salaries and under significant personal risk.

Impact of infrastructure destruction and equipment losses

Al-Shifa Hospital, which was already struggling with resource shortages, faced additional devastation when the Israeli military targeted healthcare infrastructure.

On 10 November 2023, bombings destroyed vital medical equipment, including respiratory support machines, and led to the deaths of patients who were reliant on life-saving equipment. This attack was one of many in a series of assaults that resulted in destruction of critical care units and impaired the hospital’s ability to provide care.^{12 13}

By mid-November 2023, Israeli Defense Forces forced patients and staff to evacuate the hospital without any consideration for the circumstances of critically ill patients.¹²

On 15 March 2024, Al-Shifa Hospital was raided, leading to the destruction of its critical care unit and the detention of two intensivists.⁸

The unit reopened in April 2025 with a 12-bed ICU lacking essential medical equipment including ultrasound and dialysis. It also does not have vital monitoring capabilities such as intracranial pressure monitoring and arterial line access, nor a CT scanner, limiting diagnostic options. Additionally, a shortage of ambulances leads to prolonged waiting times for transporting critical patients to the operating room. Due to the high prevalence of mass explosive injuries, there is often a shortage of ICU beds, forcing some patients to remain in the emergency or recovery rooms after surgery until a bed becomes available.

Response by local and international health actors

The Palestinian MoH has coordinated healthcare services in Gaza amid ongoing conflict, despite severe facility damage and resource scarcity. The MoH has collaborated with international organisations to procure critical medical equipment, has facilitated the evacuation of patients at risk of bombardment and has documented violations affecting healthcare operations.

The Palestinian Red Crescent Society’s hospital acted as a referral centre for many intensive care cases when Al-Shifa was at full capacity before its destruction in late October 2023. The Red Crescent established a field hospital in February 2025, which included an eight-bed ICU, alleviating critical care overload.

From April to December 2024, WHO contributed to the restoration of 10 hospitals, facilitated the medical evacuation of 5300 critically ill patients abroad, delivered 6.9 million treatments and supplied 8.8 million litres of fuel to support health facilities. Despite these efforts, over 60% of the missions requested by WHO have either been rejected, delayed or obstructed by the Israeli military.¹⁴

Policy and practice recommendations

Article 18 of the Fourth Geneva Conventions protects medical facilities during armed conflicts, yet hospitals in Gaza have been targeted. There is a need for comprehensive international protection for these facilities and documentation of medical violations to ensure accountability.¹⁵

To improve critical care in Gaza, an intensive care training programme should be established to increase medical personnel in this field, supported by international collaboration. Developing mobile ICUs is necessary to reduce pressure on hospitals, along with essential medical supplies and equipment.

A specialised wartime critical care protocol needs to be developed through collaboration with the MoH, WHO and other organisations. This should include mobile triage and treatment units for mass casualty events.

Conclusion

The events at Al-Shifa Hospital during this ongoing conflict highlight the severe challenges of providing critical care in a warzone. The lack of resources, the psychological burden on staff and direct destruction of healthcare infrastructure have created an unprecedented medical crisis. Despite these obstacles, healthcare workers have demonstrated resilience and commitment to saving lives. Immediate international support and enforcement of international law are essential to ensure the survival of Gaza’s health system.

Data availability statement

All data relevant to the study are included in the article.