Care under attack: a qualitative study of healthcare system disruption and health worker resilience during airstrikes on Lebanon

Abstract

Introduction

War severely disrupts healthcare systems by damaging infrastructure, limiting access to care and placing healthcare workers (HCWs) at physical and psychological risk. During the 2024 Israeli war on Lebanon, repeated airstrikes created major challenges for healthcare delivery. This study explored HCWs’ experiences and examined the impact of conflict on healthcare system functioning and service continuity.

Methods

A qualitative study was conducted using semi-structured interviews with 19 HCWs involved in emergency response and patient care, including nurses, paramedics and ambulance staff affected during the conflict. Data were analysed using reflexive thematic analysis informed by a critical health systems framework.

Results

Two overarching themes emerged: (1) operational disruption and failures in preparedness and accountability and (2) workforce resilience and professional commitment during crisis. Participants described attacks on healthcare facilities, ambulances and infrastructure that disrupted services, caused shortages of staff and medical supplies and reduced access to care. HCWs described a substantial psychological toll, including fear, anxiety, burnout and emotional exhaustion, alongside moral distress arising from having to weigh patient care against their own safety and from being unable to provide the standard of care they were committed to. Despite these conditions, participants demonstrated resilience through teamwork, rapid adaptation and strong professional dedication, helping sustain essential healthcare services during the conflict.

Conclusions

The findings highlight the vulnerability and resilience of healthcare systems in conflict settings, as well as the considerable psychological and moral burden borne by HCWs. Strengthening emergency preparedness, protecting HCWs and facilities and improving accountability for attacks on healthcare are essential to maintaining healthcare delivery and safeguarding workforce well-being during armed conflict.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Armed conflict disrupts healthcare systems by damaging infrastructure, interrupting service delivery and placing healthcare workers (HCWs) at significant risk. Previous research, much of it conducted in low- and middle-income and conflict-affected countries, has documented attacks on healthcare facilities and the psychological burden experienced by frontline workers. However, evidence capturing HCWs’ own real-time experiences during active conflict remains limited, particularly in Lebanon.

WHAT THIS STUDY ADDS

• This study provides qualitative evidence on HCWs’ experiences during the 2024 Israeli war on Lebanon. It highlights the operational challenges faced by healthcare systems, including workforce shortages, disrupted access to care and safety concerns, while also demonstrating the resilience, adaptability and commitment of HCWs during crisis conditions.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The findings support the need for stronger emergency preparedness, workforce protection strategies and accountability mechanisms for attacks on healthcare. They may inform future research on healthcare resilience in conflict settings and guide policies aimed at safeguarding HCWs and maintaining continuity of care during armed conflict.

Introduction

Armed conflict poses a threat to health systems, limiting the availability, accessibility and quality of urgent medical services needed. Despite the protections set by the International Humanitarian Law (IHL), violence has been directly and indirectly affecting health facilities and healthcare workers (HCWs) in conflict-affected areas.^1–4 In 2023, the WHO reported 1520 attacks on healthcare globally, causing at least 750 deaths and 1250 injuries among HCWs and patients.⁵ Independent monitoring indicates a substantially higher burden. For the same year, the Safeguarding Health in Conflict Coalition (SHCC), using data compiled by Insecurity Insight, documented 2562 incidents of violence against or obstruction of healthcare across 30 countries and territories, including more than 480 health workers killed.⁶ These differences reflect in part the broader case definition and the open-source and partner reporting used by the SHCC, and both sources note that such counts are likely to underestimate the true toll. Attacks on healthcare not only cause immediate casualties and damage to the infrastructure but also result in long-term disruption of the health system and services provided.^7–9 Low- and middle-income countries (LMICs) are particularly affected due to the fragility of healthcare infrastructure (eg, weaker supply chains, inadequate staffing and dependence on external funding) and persistent and compounding conflict in these areas.¹⁰

Ample research has explored the effects of violence on healthcare systems in conflict-affected countries including Syria, Gaza, Yemen, Sudan and Ukraine.^{5 11–15} Studies have shown that insecurity and attacks lead to limited functionality of healthcare facilities and shortages in medical supplies, which in turn cause disruptions in the continuity of emergency care and management of chronic diseases.^16–20 Emergency medical teams (EMT), such as ambulance response staff, also face direct targeted attacks and indirect disruptions due to road closures, increasing the risk of morbidity and mortality.²¹ Conflict further creates a stressful environment that constrains operational healthcare facilities capacity to function as normal. Research has highlighted that HCWs are disproportionately affected in these contexts.^{22 23} The increased rates of injury, burnout and mental distress that frontline HCWs suffer from during conflict, as well as factors such as increased staff shortage due to displacement, injury or fear, further limit the health capacity available.^{22 24 25}

However, existing research has largely focused on documenting the immediate and measurable impacts of attacks on healthcare, such as infrastructure damage, casualties and service interruptions. Limited attention has been given to understanding the underlying mechanisms of health system disruption, including the specific operational challenges that arise during attacks, the strategies HCWs use to adapt and sustain care and the forms of mutual support that emerge in crisis settings. Existing evidence is derived from remote assessments or secondary reporting, which makes it difficult to capture disruptions in healthcare functioning, provider experiences and real-time adaptations.⁴ These limitations are particularly evident in Lebanon, where there is limited empirical research capturing HCW perspectives during active conflict. As a result, critical dimensions of how health systems function under airstrikes remain underexplored.

Lebanon’s healthcare system has been severely affected by economic collapse, political instability, the COVID-19 pandemic and the Beirut port explosion.²⁶ Since the escalation of violence in October 2023, which culminated in the 2024 Israeli war on Lebanon, hospitals, primary healthcare centres (PHC) and EMT have faced direct attacks, largely by airstrike.²⁶ Reports documented assaults on 68 hospitals, 63 PHCs and 237 EMT units, leading to the closure of eight hospitals and 58 PHCs, and at least 47% fatality rate among HCWs and patients, surpassing that reported in Gaza and Ukraine.¹² Independent monitoring reported a comparably severe toll. Between October 2023 and December 2024, Insecurity Insight documented 507 incidents of violence against or obstruction of healthcare in Lebanon, including at least 415 health workers killed, 426 injured and health facilities damaged on at least 208 occasions, all attributed to Israeli forces.²⁷ Existing studies on conflict and health in Lebanon have mainly focused on refugee health, system financing or disaster response, rather than understanding the lived experiences and impact of war from the perspective of HCWs during war.^28–30 This lack of data hinders efforts to understand the war’s impact on the provision of healthcare services and to hold perpetrators accountable for the violations.

To address this gap in knowledge, we conducted a qualitative study examining the impacts of Israeli airstrikes on healthcare delivery in Lebanon from the perspectives of HCWs. Specifically, this study aimed to explore the operational disruptions experienced by healthcare facilities and EMTs, the challenges faced by HCWs in sustaining care under conflict conditions and the adaptive strategies employed to maintain service continuity during the 2024 war on Lebanon.

Methods

Study design and approach

A qualitative research design was implemented to evaluate the impact of Israeli airstrikes on medical service provision in Lebanon. To guide our approach, a critical health systems theoretical lens was adopted. This framework emphasises how disruptions to healthcare systems stem from broader socio-political violence, policy shifts, militarisation, attempted and actualised occupation of lands and the neglect of institutional structures.^{31 32} Accordingly, this lens was used to understand the impact of health system disruption on health within a broader political economy, where war, limited governmental capacity, infrastructure instability and increased emergency care demands collectively reduce workforce availability and strain healthcare delivery.³³ This framework further informed our interpretation of findings by examining how broader structural and political factors shaped disruptions, workforce experiences and adaptive responses. We considered how these disruptions resulted from compounded and disruptive events affecting Lebanon over the past 3 years, including economic collapse, the Beirut port explosion and ongoing regional hostilities. Data were analysed using reflexive thematic analysis (RTA) to explore patterns of disruption and HCW experiences.

Interview guide development

A semi-structured interview guide was newly developed in consultation with public health professionals and emergency medical response experts engaged through the research team’s professional networks. The guide draws on key domains identified in the literature on health system resilience, emergency preparedness and conflict-related disruptions to healthcare delivery. Its domains were informed by existing work on health systems resilience in fragile and conflict-affected settings,¹⁰ on how health workers cope with shocks³⁴ and on hospital emergency preparedness in Lebanon, adapted to the Lebanese context and the study objectives.

The interview guide comprised eight sections: (1) Facility and Respondent Information, (2) Effects of Israeli Attacks/Airstrikes, (3) Emergency Preparedness and Response, (4) Financial and Resource Support, (5) Leadership, Governance and Information Systems, (6) Staff Injuries and Deaths and Workforce Challenges, (7) Psychosocial Impact on HCWs and (8) Recommendations and Lessons Learnt. Together, these domains constituted an a priori conceptual framework that directly structured the interview guide. Each of the eight sections corresponds to one or more framework domains, operationalising the constructs of health system resilience, emergency preparedness and conflict-related service disruption into open-ended questions. The guide included approximately 40 open-ended questions, provided in online supplemental appendix A. Supplementary materials are available online.

Sampling, recruitment and eligibility

A list of healthcare facilities was compiled from the official registry at the Ministry of Public Health (MoPH) Lebanon. Facilities were included if they met at least one of the following criteria: (1) hospitals listed in the MoPH registry that were targeted by airstrikes, (2) essential healthcare centres affected by airstrikes and (3) ambulance dispatch centres affected by airstrikes.

A purposive sampling strategy was used to recruit HCWs from affected facilities. Healthcare professionals (eg, physicians, nurses, paramedics, pharmacists, physiotherapists and emergency medical personnel) were eligible to participate if they were present at the facility during the attacks or within 24 hours thereafter. Eligible participants were identified through facility networks and professional contacts and were approached directly by the research team. Participation was voluntary and no recruitment occurred through supervisory structures to minimise potential coercion.

Consented HCWs from multiple hospitals and healthcare facilities were included in the study. Recruitment continued until thematic saturation was reached, defined as the point at which no new themes or substantive insights emerged from additional interviews.

Participants and setting

A total of 22 HCWs participated in the study, including 18 males and three females (gender was not reported for one participant). Participants represented a range of professional roles, including paramedics, physicians, physiotherapists, pharmacists, EMT workers and other emergency medical response personnel engaged in healthcare delivery. Participants were drawn from public and private hospitals, PHCs and ambulance services located in regions affected by airstrikes, including the Bekaa region, South Lebanon and the suburbs of Beirut. Recruitment continued until thematic saturation was reached, defined as the stage at which no substantially new codes or themes emerged from successive interviews. Saturation was assessed continuously throughout data collection and analysis, as later interviews primarily reinforced existing themes rather than generating new insights. To protect confidentiality, all facility names and identifying information were de-identified.

Patient and public involvement

Patients and members of the public were not involved in the design, conduct, reporting or dissemination plans of this research. Given the conflict setting and security concerns during data collection, only HCWs directly involved in emergency response and patient care during the 2024 Israeli war on Lebanon participated in interviews.

Data collection

Semi-structured interviews were conducted between March 2025 and February 2026 with HCWs from public and private hospitals and essential health facilities affected by Israeli bombardment, including those located in the Bekaa region, South Lebanon and the suburbs of Beirut. The interviews aimed to gain a comprehensive understanding of service interruptions, structural damage and workforce challenges across diverse geographical and infrastructural contexts. All interviews were conducted in Arabic by trained research assistants (RAs) fluent in the language. RAs received interview training through both online workshops and in-person sessions led by qualitative methodologists and injury prevention researchers with experience working in Lebanese communities.

Due to security constraints, interviews were conducted primarily via telephone calls, with a small number conducted in person. Verbal informed consent was obtained from each participant prior to the start of the interview. Interviews lasted approximately 20–40 min and were audio recorded. All recorded interviews were transcribed verbatim in Arabic and subsequently translated into English for analysis. To protect confidentiality and participant safety, all identifying information was removed during transcription and participants were assigned unique study codes. Audio files, transcripts, consent forms and related study documents were securely stored on encrypted, password-protected devices accessible only to authorised members of the research team. The study was approved by the Institutional Review Board (IRB) at the American University of Beirut (IRB # SBS-2025-0068).

Data analysis

Data were analysed using RTA to identify patterns, similarities and differences across participants’ perspectives and experiences. The analysis followed the six-step approach proposed by Braun and Clarke: (1) familiarisation with the data through repeated reading of transcripts, (2) generation of initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes and (6) producing the final report and manuscript.^35–38 Analysis followed a hybrid deductive-inductive approach. The a priori conceptual framework that informed the interview guide provided the initial deductive coding structure, with the framework domains and their corresponding guide sections serving as the starting codebook. This structure was then expanded and refined inductively through codes identified during transcript review, so that the final coding scheme was both anchored in the framework and grounded in participants’ accounts.

An initial codebook was collaboratively developed by the research team following repeated reviews of the transcripts. Coding and thematic development were iterative processes, supported through regular team discussions to compare interpretations, refine codes and consolidate broader conceptual categories such as ‘physical risks’, ‘psychological risks’, ‘morality and ethical considerations’ and ‘personal adaptation’. Analytic memos were maintained throughout to document emerging interpretations, reflexive observations, coding decisions and evolving conceptual relationships within the data.

To enhance analytical rigour and reflexivity, transcripts were independently reviewed by multiple members of the research team, and disagreements in coding or interpretation were resolved through consensus during regular team meetings. Researchers remained attentive to how their disciplinary backgrounds, experiences and perspectives could shape interpretation throughout the analytic process.

Reporting guidelines

This study is reported in accordance with the Standards for Reporting Qualitative Research guidelines; a completed checklist is provided as supplementary material.

Results

The analysis generated two central themes: (1) operational disruptions and failures in system readiness and accountability and (2) workforce resilience and role identity during crisis. Together, these findings illustrate how systemic fragility limited the ability of healthcare systems to respond effectively to crisis conditions, revealing cascading disruptions across infrastructure, workforce capacity and service delivery. They further highlight how HCWs navigated these constraints through adaptation, teamwork and sustained commitment, enabling partial continuity of care despite ongoing challenges.

Operational disruptions and failures in system readiness

Participants reported widespread disruptions to healthcare delivery driven by cascading destruction across infrastructure, workforce capacity and supply chains. These interconnected disruptions led to partial or complete operational collapse. Facilities in heavily affected areas in the south and Bekaa region were forced to close or reduce services. As a nurse noted, ‘Our hospital was completely shut down except the emergency department’.

System strain due to patient demand

Even in less affected areas, systems experienced strain due to increased patient demand, workforce shortages and uncertainty. Service delivery shifted toward emergency and trauma care, with participants noting that ‘medical services were restricted to urgent and conflict-related cases’ and that ‘the focus of services transitioned from routine medical care to immediate emergency response’. This shift disproportionately affected patients requiring chronic and specialised care. Participants described how the war worsened pre-existing inequities for patients receiving complex care or requiring treatment for life-threatening conditions such as cancer, with one radiation oncologist reporting that ‘all cancer treatments were interrupted’. These inequities were more pronounced in remote and rural regions where access was already constrained, as a humanitarian worker in southern Lebanon explained: ‘Psychiatrists were not available, and patients were always referred to Beirut, which is far from us’.

Infrastructural damage and logistical constraints

Operational disruptions were further intensified by infrastructure damage and logistical constraints. Participants described the partial or complete destruction of health facilities. A pharmacist from south Lebanon described how ‘all of these (pharmacy and house) were completely destroyed’, a clinical staff member explained that ‘the chemotherapy department was severely affected by an attack 20 m away, causing a fire’ and a physical therapist reported that their centre ‘was fully destroyed during the airstrikes… (and) the service remains interrupted due to a lack of financial resources’. Damage extended to essential utilities and transport routes. As one nurse explained, ‘no power was provided because of a shortage of diesel’, while a Civil Defence staff member noted that ‘travel between Nabatieh (south governorate) and nearby villages was dangerous and obstructed by craters, and even cleared vehicles were sometimes targeted’. These disruptions illustrate how attacks on infrastructure extended beyond healthcare facilities to include broader systems essential for service delivery.

Supply chain disruptions played a critical role in compounding these challenges. Participants reported shortages of essential medications, medical supplies and equipment, which directly affected treatment availability. One emergency physician stated, ‘There was no supply to the hospital and no personnel to handle the supplies’, while another noted that ‘supplies like medicine and bandages were hard to obtain due to roadblocks’. These constraints limited service provision, negatively impacted the availability of patient treatments. A humanitarian worker explained, ‘Supplies were not easy to get. One patient had not been able to take her medication for 2 weeks’, highlighting the downstream health risks associated with interrupted care. Cancer patients were reallocated from a southern hospital to a centre in Beirut to complete their treatment, with one physician noting that the interruption risked ‘recurrence of their cancer due to the interruption of services’.

Coordination challenges further undermined system response. Participants described weak or absent coordination between healthcare facilities, local authorities and external actors. Emergency preparedness plans were often insufficient or not implemented, and communication between teams and personnel was impacted by fear of surveillance. One paramedic said, ‘There was fear of phone calls being tracked, so we avoided them completely’.

Workforce displacement hindered system readiness, as one Civil Defence team member noted, ‘Many staff fled with their families, and transportation issues prevented others from reporting to work’.

Workforce resilience and role identity during distress and crisis

HCWs across diverse settings described sustained physical and psychological strain during the Israeli war on Lebanon. Direct exposure to airstrikes, explosions and secondary attacks transformed routine clinical environments into high-risk spaces. Participants reported staff injuries and death, damaged ambulances and facilities and unsafe working conditions. An ambulance service volunteer in south Lebanon recalled, ‘One airstrike landed less than 20 meters from us, injuring two paramedics and damaging one ambulance, though we managed to keep it running’. In many cases, infrastructure damage altered care delivery, with staff reporting they ‘had to operate using a flashlight’.

Dedication to occupational roles despite perils

Paramedics and civil defence personnel emphasised that mobility itself became dangerous, as ambulances, roads and response sites were purposely targeted. This created a tension between clinical urgency and safety. As one paramedic explained, ‘We often delayed response by 5 to 10 min to avoid secondary strikes. These delays sometimes cost lives’. This delay reflects not only operational constraint but also the moral burden placed on HCWs, who were required to weigh patient outcomes against their own safety in real time.

These conditions contributed to widespread psychological distress, including fear, burnout, panic attacks and emotional exhaustion. Participants described ‘countless cases of panic attacks among the staff’ and ‘spikes in anxiety levels… having first row seats to the action unfolding’. Many noted that the severity of the conflict exceeded training capacity, stating, ‘Despite the drills and training - there was panic among healthcare workers due to the unprecedented severity’. Fear was further heightened by ongoing exposure to nearby airstrikes, with an emergency physician describing ‘significant fear for our safety and that of our patients, including fear of shattered glass while providing services’. Distress also affected workforce functioning, with participants reporting that ‘the conflict severely impacted healthcare workers’ performance, productivity and morale’. Prolonged shifts and limited rest intensified this burden, as one HCW described ‘long working hours… sometimes shifts for days on end… [where] the lack of rest led to increased burnout’.

Beyond occupational exposure, HCWs described distress linked to personal loss, financial insecurity and displacement, reflecting disruptions to both professional and personal lives. Workforce instability was compounded by insecurity, as ‘the staff had to flee the war zone’ and ‘some staff members were unable to find shelter… which affected staff availability’. The absence of formal support further intensified these challenges, with participants noting that ‘there was no psychological support or counselling provided to staff during this period’, leaving HCWs to cope independently under extreme conditions. This highlights a critical gap in system preparedness, where workforce sustainability depended largely on individual endurance.

Moral obligations and the drive of community

Despite these conditions, a strong sense of professional identity and moral obligation emerged as a central driver of continued care provision. HCWs consistently framed their persistence not only as a professional responsibility but also as a moral commitment to their communities. As a Civil Defence team leader stated, ‘Many staff were injured, and around 40 died. We continued working despite that’. Similarly, participants emphasised collective endurance through statements such as ‘We never stopped working’, and ‘We stood firm for 66 [war] days. Everyone gave their best’. These narratives reflect resilience as an active and socially embedded process, shaped by shared responsibility and collective identity rather than individual coping alone.

Resilience was further expressed through adaptive and improvisational practices that enabled continued service delivery despite severe constraints. HCWs described reorganising workflows, redistributing roles and modifying care practices in response to workforce shortages and limited resources. For example, a nurse noted, ‘Doctors [were] working as nurses and nurses cooking meals’, while others described ‘using makeshift alternatives - blankets, tissues, anything available’. Collective coping mechanisms were also central to sustaining operations, with participants reporting shared housing, shift coverage and, in some cases, residing within healthcare facilities to ensure continuity of care. As a nurse from Beirut explained, ‘Some staff shared housing and covered each other’s shifts to keep things running’. Together, these adaptations highlight how resilience functioned as a dynamic, team-based response to system disruption, enabling HCWs to maintain care even as formal structures broke down.

Fragility in operational recovery

Despite these challenges, recovery following the cessation of hostilities on healthcare facilities was described as rapid but uneven. Participants emphasised that recovery was fragile and contingent on infrastructure repair, workforce return and available resources, underscoring the limited resilience of the broader system. Some facilities remained non-operational due to sustained damage and limited resources, as one participant quoted ‘It took them almost a week to perform the needed maintenance on false ceilings and windows and doors’ while other facilities resumed services within days as stated by one physician: ‘The war stopped on Wednesday, [the next day], the equipment was maintained and prepared to be operational again. On Monday, we were able to receive patients and start treating them again’. This unevenness mapped onto the extent of physical damage and the resources available to each facility. Facilities that sustained structural damage or lacked the financing to repair, including those in the heavily affected southern and Bekaa areas, remained closed longer, whereas less damaged or better-resourced facilities, and those whose staff were able to remain or return, resumed care within days.

Across stories shared, HCWs highlighted the urgent need for improved system readiness and accountability. Recommendations focused on strengthening emergency preparedness, prepositioning resources, protecting HCWs and improving coordination mechanisms. A humanitarian worker in north Lebanon stated, ‘It’s important to have a clear plan from the start - where to go, what to do, and to have a supply of chronic medications’, while a nurse from Beirut emphasised that ‘leaders must listen to frontline workers, as they directly face challenges and witness the consequences’.

Participants also underscored the importance of accountability, emphasising that without mechanisms to prevent and address attacks on healthcare systems, similar patterns of disruption and harm are likely to recur, with an ED physician stating ‘The important thing is to reveal the facts of what happened during the war and show that what happened could be repeated’.

Discussion

This study examined the impact of the 2024 Israeli war on Lebanon healthcare delivery from the perspectives of HCWs across multiple levels of care. Two central findings emerged. First, the conflict produced cascading operational disruptions across infrastructure, supply chains and workforce capacity, compounded by gaps in emergency preparedness, coordination and communication. Second, despite these conditions, HCWs sustained care through adaptation, teamwork and a strong sense of professional identity, though often at considerable personal and psychological cost.

To our knowledge, this study is among the first to examine the impact of the recent war in Lebanon on healthcare delivery from the perspectives of HCWs across multiple levels of care. Consistent with existing literature, our findings demonstrate the heterogeneous and multi-layered impact of war on HCWs and health systems.^{38 39} Despite IHL protections, participants described both direct and indirect attacks on the health sector during the 2024 Israeli war on Lebanon.¹ Hospitals such as Tebnine Government Hospital and Salah Ghandour Hospital were struck multiple times, highlighting the persistent targeting of health infrastructure.³⁹ Participants reported repeated exposure to airstrikes, threats to personal safety and the injury or loss of colleagues, resulting in significant psychological distress. These impacts were compounded by pre-existing structural vulnerabilities, including economic collapse, workforce attrition and limited institutional support. Prolonged working hours, unsafe conditions and limited rest contributed to burnout, absenteeism and reduced productivity.^40–43 As workforce capacity declined, HCWs assumed expanded roles beyond their training, increasing emotional strain and discomfort.^{38 44} The absence of formal psychological support further exposed critical gaps in preparedness and workforce protection.^{40 44 45}

The psychological toll described by participants is consistent with findings across the wider literature on health workers under attack, where fear, burnout, exhaustion and enduring distress recur despite very different conflict contexts, suggesting these harms are a systematic consequence of the targeting of healthcare rather than a setting-specific effect. Much of this literature frames such effects through the concept of moral injury, or moral distress, understood as the lasting harm that arises when providers cannot deliver the care they are committed to or are forced to act against their moral judgement. Our findings reflect this directly, as when paramedics delayed response to avoid secondary strikes despite knowing that delay could cost lives. Importantly, moral injury and continued professional commitment were not opposing forces. The same workers who described profound moral burdens also described staying at their posts and sustaining care, indicating that moral injury coexists with rather than displaces a sustained sense of duty. Recognising this locates the source of harm in the conditions imposed on health workers rather than in any failure of resilience and underscores the need for psychological support that does not treat continued commitment as evidence that support is unnecessary.

Our findings further demonstrate how workforce strain was embedded within broader healthcare system disruption, consistent with evidence from Syria, Gaza, Yemen, Sri Lanka, Ethiopia and Ukraine.^{39 41 42} Similar to other LMICs, airstrikes disrupted healthcare delivery across Lebanon.^{28 46–48} Facilities in directly targeted areas experienced closure or evacuation, while facilities in relatively safer areas faced indirect disruption from staff shortages, increased patient influx and strained resources. Healthcare delivery shifted toward emergency and trauma response, reducing access to routine and specialised care and disproportionately affecting vulnerable populations.^49–51 The findings also highlight major gaps in preparedness, coordination and communication. Emergency response plans were often absent or poorly implemented, while coordination between healthcare facilities, governmental bodies, NGOs and emergency teams was limited. Communication challenges caused by infrastructural damage and security concerns further disrupted referral pathways and emergency response. Similar breakdowns have been documented following Hurricane Katrina, the 9/11 attacks and the Beirut port explosion.^{42 43} Strengthening context-specific emergency planning and coordination mechanisms, while incorporating frontline worker perspectives, is essential to improving preparedness and response capacity.^52–56

In addition to institutional gaps, participants highlighted the limited role of the Lebanese government in supporting HCWs and healthcare facilities during the war. Governments play a central role in maintaining infrastructure, coordinating emergency response and protecting healthcare personnel during crises.⁵⁷ However, Lebanon’s economic and political instability constrained governmental capacity, increasing the financial, psychological and professional burden on HCWs.^57–59 Participants described uncompensated extended shifts, transportation and accommodation costs and insufficient institutional support, reflecting findings from other conflict-affected settings.^{59 60} While some HCWs mitigated these challenges through shared housing and coordinated shifts, these adaptations reflected resilience in response to systemic inadequacies rather than sustainable solutions. Despite these challenges, HCWs demonstrated considerable resilience by adapting workflows, redistributing responsibilities and maintaining care provision under extreme conditions, reflecting strong professional identity and moral commitment. This aligns with evidence of moral resilience observed in other conflict settings.⁴⁶ However, continued exposure to traumatic events and prolonged crisis conditions also intensified burnout, distress and exhaustion among HCWs.

These findings resonate with a growing body of qualitative research on health workers’ own experiences of being under attack, while also revealing context-specific differences. As in Syria, participants described moral distress and weighed patient care against personal safety in real time, including delaying response to avoid secondary ‘double tap’ strikes.⁶¹ Similar patterns of extended closures, disproportionate harm to chronically ill patients and community-led efforts to sustain care have been documented in the Central African Republic and other fragile settings.⁶² The prominence of professional identity and moral commitment in our second theme also echoes accounts from Myanmar, where health workers framed continued care as solidarity and resistance.⁶³ Differences are equally instructive, as the sources of violence, the role of the state and the pathways of recovery vary across settings. Attending to these commonalities and differences, rather than treating the impacts of conflict on healthcare as uniform, strengthens the interpretation of our findings. Taken together, our findings confirm the workforce and service delivery impacts reported consistently across conflict settings, extend them by documenting real-time moral distress and uneven resource-dependent recovery and diverge in the single-actor, airstrike-driven nature of the attacks reported in Lebanon.

A notable feature of these accounts was the variation in how disruption and recovery were experienced across settings rather than a uniform pattern of collapse. Disruption was most severe and recovery slowest in facilities that sustained direct structural damage that lacked the financial resources to repair or that were located in the heavily affected southern and Bekaa regions, where pre-existing fragility and workforce displacement compounded the impact. Specialised and chronic care, including oncology and mental health services, was disproportionately affected relative to emergency and trauma care which was prioritised. By contrast, facilities with limited damage, available resources and staff able to remain or return resumed services within days. These differences suggest that disruption and recovery were shaped not by the war alone but by the interaction between the severity of the attack, the level of pre-existing resources and the degree of workforce continuity. Attending to this variation matters because studies that report the impacts of conflict on health systems in aggregate risk obscuring where systems are most vulnerable and where targeted investment in preparedness, financing and workforce protection could most effectively preserve care.

Limitations

This study has several limitations. Participants were recruited through existing professional networks and required access to communication infrastructure, potentially excluding HCWs in remote or severely affected areas or those unable to participate due to injury, displacement or psychological distress. Consequently, the findings may under-represent the experiences of the most vulnerable HCWs and facilities most heavily impacted by the war. In addition, consistent with the aims of qualitative research, this study prioritised analytical depth over statistical generalisability. The findings reflect the perspectives of a specific group of HCWs in a specific war-affected context, and their transferability to other settings should be assessed in light of contextual differences. We have therefore described the setting, participant characteristics and sampling approach in detail to allow readers to make that assessment.

Despite these limitations, the study offers timely and detailed insight into the experiences of HCWs during an active war, a setting in which primary data are rarely collected. A key strength is its focus on frontline perspectives which are often absent from analyses of attacks on healthcare. By drawing on accounts from a range of professional roles, including physicians, nurses, paramedics, pharmacists and emergency personnel, and from facilities across South Lebanon, the Bekaa region and the suburbs of Beirut, the study captures how operational disruptions unfolded across different levels of care and geographic contexts. It documents not only the failures in system readiness but also the adaptive strategies and mutual support mechanisms through which HCWs sustained care, offering a fuller picture of both vulnerability and resilience in a war-affected health system.

Implications for policy, practice and research

Our findings point to several priorities for future research and practice. Disruptions to chronic disease management and mental healthcare were frequently reported, highlighting how war deepens existing inequities in access for patients whose care depends on continuity, such as those requiring cancer treatment, dialysis or ongoing psychiatric support. These inequities were most acute in rural and under-resourced areas, where services were limited before the war and where displacement and infrastructure damage compounded existing gaps. Future research should therefore prioritise the inclusion of rural and under-resourced populations, whose experiences are often under-represented yet who may face the most severe disruptions to healthcare delivery. ^49–51Alongside this, approaches such as telemedicine warrant closer evaluation, as they may help maintain access to specialist services and support continuity of care in remote areas, though their feasibility during active conflict, when power, connectivity and devices are themselves disrupted, remains an open question that future studies should examine.^{61 64}

Conclusion

Deliberate attacks on HCWs and facilities have increasingly become a strategy in modern conflicts, seen in Sudan, Gaza, Ukraine and Lebanon.⁶⁴ Although IHLs protect HCWs, these provisions are rarely enforced, leaving HCWs and patients vulnerable and without protection. This lack of accountability perpetuates insecurity and disrupts essential services. As such, results from this study urge international organisations to take concrete actions to enforce the law and hold the perpetrators responsible, in addition to help strengthen system readiness and preparedness to account for the lived experiences of HCWs in severely affected regions during war. This concern is reflected in a recent World Health Assembly decision on the health emergency in Lebanon (Geneva, May 2026), which called for the full protection of healthcare, including patients, health personnel, facilities and transport and requested the Director-General to monitor and document disruptions to health service delivery and to strengthen health system resilience, emergency preparedness and response capacities. Findings from the study further highlight the need for immediate response to road closures and obstacles, so HCWs can access care sites and the provision of beds and amenities for HCWs who decide to stay and respond to patient and public care needs. Psychological support during this time is also vital to ensuring the longevity of HCWs to remain in their roles and to remain resilient against inherent emotional distress experienced at times when they are attempting to save the lives of civilians while also trying to protect themselves from physical, psychological and emotional harm. Findings from our study show the existing gaps in healthcare system resources, infrastructural and personnel and their impacts on patient care particularly in times of crises. Staff shortages and proximity to airstrikes place staff in direct risk of severe injuries and death. This proximity causes short-term and long-lasting impacts on the health and well-being of personnel at times when they feel an intensification of need to give back to their communities and protect others from the atrocities they feel they are facing in their country.

The lead author and guarantor of this paper affirms that this manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted and that any discrepancies from the study as conducted have been explained.

Data availability statement

Data are available upon reasonable request.