The burden of war-injury in the Palestinian health care sector in Gaza Strip

Adolescent health research and initiatives in the occupied Palestinian territory: a scoping review

OBJECTIVE

Adolescence is a period characterised by profound changes that warrant special attention, particularly for adolescents living in conflict-stricken regions. The dearth of available information regarding observational health research and interventions in the occupied Palestinian territory emphasises the need for a comprehensive examination of all accessible data. The aim of this review is to conduct a thorough analysis of the existing literature and initiatives focusing on adolescent health in the occupied Palestinian territory.

DESIGN

Scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) framework.

DATA SOURCES

PubMed, Embase, Web of Science, Scopus, CINAHL and PsycINFO, along with grey literature, were searched for the period between 2012 and 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Research studies, programmes or interventions targeting adolescents aged 10-19 years, conducted in the occupied Palestinian territory, and published between 2012 and 2023 were considered. Both peer-reviewed articles and grey literature were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers conducted abstract and full-text screening of the selected articles. Discrepancies were resolved through discussion, with a third reviewer consulted when necessary. Data extraction was performed using Excel software by two independent reviewers. Extracted data were categorised as either intervention or observational research. For analysis, the extracted data underwent an explanatory frequency analysis using SPSS software.

RESULTS

Our search yielded 114 research projects and 19 interventions from peer-reviewed and grey literature searches. The most frequently addressed topic was non-communicable diseases, with health awareness being the most common method employed in interventions. The studies targeted both male and female participants, with a particular focus on adolescents aged 10-19 years. The majority of the included studies received funding from international sources and were conducted by foreign and local researchers.

CONCLUSION

This review sheds light on the current framework of adolescent health interventions, identifies areas where research is lacking and advocates for evidence-based practices to enhance the well-being of Palestinian adolescents. Future interventions should encompass the younger age group, and research should strive to provide precise information for each age group independently.

Feasibility of telemedicine in civil protection: a prospective observational study during a music festival

BACKGROUND

As disasters intensify and professional deficits persist, civil protection is reliant on medical volunteers. With limited physician availability, telemedicine is promising. No system currently empowers lower-qualified paramedics for physician-delegated telemedicine. Existing telemedicine technology unfits for civil protection. This study aimed to evaluate a modified system at a music festival to simulate disaster situations.

METHODS

A tablet-based telemedicine system, integrating vital sign monitoring, was deployed at the "Summerjam" music festival characterized by various medical emergencies. A physician could be contacted via telemedicine or requested onsite. Medical feasibility was rated by patient condition changes, with National Advisory Committee of Aeronautics (NACA) score and Primary Ranking for Initial Orientation in the Rescue service (PRIOR) algorithm for triaging. Technical feasibility was assessed by connection stability, communication, and vital sign transmission.

RESULTS

Of 404 treatments, 34 (8.4%) were performed using telemedicine, 49 (12.1%) were carried out with a physician onsite. Telemedicine treatments accounted for 40.9% of all treatment in which a physician was involved. Patient conditions varied up to NACA III (moderate disturbance). A variety of internal medical (76.5%) and surgical (23.5%) conditions were addressed, some of which required invasive measures or application of medication. No patients experienced a deterioration in their condition. Despite technical difficulties, treatment was not significantly impacted, confirming technical feasibility.

CONCLUSION

The study shows that lower-qualified paramedics can effectively use telemedicine for physician-delegated treatment, suggesting potential applicability to civil protection. Nonetheless, further system robustness improvements and research are needed.

Impact of war on oral health: a systematic review

AIM

To systematically review the evidence from published literature about the impact of war on oral health among children and adults.

METHODOLOGY

The electronic search was carried out in the following databases Pubmed, Cochrane, Scopus, Embase, Google Scholar. In vitro studies, cross-sectional, case control studies, and randomized controlled trials conducted during the war time were included. Cross-sectional and case control studies were assessed based on the Newcastle-Ottawa Scale, whereas randomized controlled trials were assessed based on the ROBINS-I tool. In-vitro studies included in this review were assessed using the United States national toxicology program tool.

RESULTS

The search strategy yielded a total of 5126 articles and finally 21 articles were included in the review. The influence of war on oral health was categorized among both the children and adult population. A total of 14 studies were carried out in children whereas the remaining seven studies were carried out in adults. A decrease in dental caries was observed in more war-prone areas due to the limited availability of carbohydrates and sugar. Severe periodontal disease in the adult population, mainly due to less availability of food and diminished oral hygiene habits, was also reported.

CONCLUSIONS

This review underscores the multifaceted impact of war on oral health, revealing a notable prevalence of periodontal problems, craniofacial injuries and varying rates of dental caries across affected populations.

Characteristics of injuries during the 2006 Lebanon conflict: a three-center retrospective study of survivors, 16 years after the conflict

Background

Armed conflict injury is a growing public health concern, particularly in regions like the Middle East and North Africa (MENA). The protracted conflicts and political unrest in this region have led to a substantial number of injuries. Despite this, there is still limited understanding of the specific injury patterns stemming from conflicts, such as the 2006 Lebanon conflict. This study aimed to assess the characteristics and burdens of injuries resulting from this conflict, which occurred 16 years prior to this research.

Methods

This retrospective study analyzed data of individuals affected by the 2006 Lebanon conflict, across three tertiary care centers. Demographics, injuries, complications, injury management, and hospitalization expenses were extracted from medical records and analyzed using SPSS version 29.0. Categorical variables were presented as counts and proportions, and continuous variables as mean ± standard deviation (SD). Hospital comparisons utilized chi-square or Fisher's exact tests for categorical variables, and one-way ANOVAs for continuous variables. Analysis was conducted from September to November 2023.

Results

Across three hospitals, 341 patients were studied, comprising 73.6% males and 26.4% females. Among them, a notable proportion (57.3% males and 34.1% females) fell within the 18-39 age range. Children and adolescents under 18 years accounted for 15.9% of males and 25.9% of females. Blast-related injuries predominated, with 24.5% resulting from direct damage caused by explosive parts and 33.3% from blast wave forces. Extremity trauma occurred in 49.0% of patients, and head/neck trauma in 24.9%. Common injuries, including penetrating, musculoskeletal, and traumatic brain injuries affected 34.9%, 31.1, and 10.0% of patients, respectively. Wound repair, fracture treatment, and debridement were the most performed procedures on 15.5, 13.5 and 9.7% of the patients, respectively. The total cost of care was USD 692,711, largely covered by the Ministry of Public Health (95.9%).

Conclusion

Conflict-related injuries significantly contribute to the global burden of disease. Therefore, there is a pressing need to improve national guidelines to prioritize life-threatening cases and potential long-term disabilities. Furthermore, enhancing electronic registry systems to collect clinical data on injured patients is essential for conducting research and better understanding the needs of conflict casualties.

The integration of ortho-plastic limb salvage teams in the humanitarian response to violence-related open tibial fractures: evaluating outcomes in the Gaza Strip

BACKGROUND

Limb salvage by ortho-plastic teams is the standard protocol for treating open tibial fractures in high-income countries, but there's limited research on this in conflict settings like the Gaza Strip. This study assessed the clinical impact of gunshot-related open tibial fractures, compared patient management by orthopedic and ortho-plastic teams, and identified the risk factors for bone non-union in this context.

METHODS

A retrospective review of medical records was conducted on Gaza Strip patients with gunshot-induced-open tibial fractures from March 2018 to October 2020. Data included patient demographics, treatments, and outcomes, with at least one year of follow-up. Primary outcomes were union, non-union, infection, and amputation.

RESULTS

The study included 244 injured individuals, predominantly young adult males (99.2%) with nearly half (48.9%) having Gustilo-Anderson type IIIB fractures and more than half (66.8%) with over 1 cm of bone loss. Most patients required surgery, including rotational flaps and bone grafts with a median of 3 admissions and 9 surgeries. Ortho-plastic teams managed more severe muscle and skin injuries, cases with bone loss > 1 cm, and performed less debridement compared to other groups, though these differences were not statistically significant. Non-union occurred in 53% of the cases, with the ortho-plastic team having the highest rate at 63.6%. Infection rates were high (92.5%), but no significant differences in bone or infection outcomes were observed among the different groups. Logistic regression analysis identified bone loss > 1 cm, vascular injury, and the use of a definitive fixator at the first application as predictors of non-union.

CONCLUSIONS

This study highlights the severity and complexity of such injuries, emphasizing their significant impact on patients and the healthcare system. Ortho-plastic teams appeared to play a crucial role in managing severe cases. However, further research is still needed to enhance our understanding of how to effectively manage these injuries.

Management of Severe Burn Wounds Colonized With Multi-resistant Pseudomonas aeruginosa and Fusarium Using Marine Omega3 Wound Matrix in a Female Victim of War

War-related burns are common injuries, also among the civilian population. Additional trauma such as fractures or shrapnel wounds may add significant morbidity. Burn injuries in war zones are furthermore frequently undertreated and hence prone to complications. We report a case of a young female victim of war, whose severely infected burn wounds could be successfully healed using a combination of targeted antimicrobial therapy, wound conditioning using decellularized fish skin, and subsequent skin grafting.

Long-term burden of war injuries among civilians in LMICs: case of the July 2006 war in Lebanon

Introduction

Lebanon, a country located on the eastern shore of the Mediterranean Sea, is one of the world's smaller sovereign states. In the past few decades, Lebanon endured a perpetual political turmoil and several armed conflicts. July 12, 2006, marked the start of a one-month war in Lebanon, which resulted in thousands of casualties. Little is known about the long-term consequences of war injuries inflicted on civilians during the July 2006 war.

Methods

The objectives of this paper were to identify and evaluate: 1- civilians' access to healthcare and medicine under conditions of war; 2- the long-term socioeconomic burden on injured civilians; and 3- their quality of life more than a decade post-war. We adopted a mixed-method research design with an emphasis on the qualitative component. We conducted interviews with patients, collected clinical and financial data from hospital medical records, and administered a self-rated health questionnaire, the EQ-5D-5L. Simple descriptive statistics were calculated using Excel. NVivo 12® was used for data management and thematic analysis.

Results

We conducted 25 interviews. Injured civilians were mostly males, average age of 27. The most common mechanism of injury was blast injury. Most patients underwent multiple surgeries as well as revision surgeries. The thematic analysis revealed three themes: 1- recall of the time of the incident, the thousand miles journey, and patients' access to services; 2- post-trauma sequelae and services; and 3- long-term impact. Patients described the long-term burden including chronic pain, poor mobility, anxiety or depression, and limited activities of daily living.

Discussion

Civilians injured during the July 2006 war described the traumatising events they endured during the war and the limited access to medical care during and post-war. Up until this study was conducted, affected civilians were still experiencing physical, psychological, and financial sequelae. Acknowledging the limitations of this study, which include a small sample size and recall bias, the findings underscore the necessity for the expansion of services catering to civilians injured during wartime.

Knowledge, attitude, and practice among medical students in gaza strip towards voluntary blood donation: a cross-sectional study

BACKGROUND

A major component of emergency medical care is blood. The Gaza Strip has faced repeated wars over the last few years, emphasizing the importance of blood donation even more. This study aims to assess medical students' knowledge, attitudes, and practices regarding voluntary blood donation in Gaza (VBD).

METHODS

This cross-sectional study used stratified sampling method to survey medical students at Gaza's two medical schools, Al-Azhar and Islamic Universities, between March and April 2022. A 35-item self-administered questionnaire with four sections: demographics, knowledge, attitude, and practice, was used. The data were statistically analyzed using SPSS version 25.

RESULTS

A total of 329 students were surveyed (response rate of 89.6%). The median age was 20 (IQR = 3). Males made up 44.7% of the sample. Overall, 54.7% were found to have good knowledge about VBD, 68.1% did not know the time-to-wait between each whole blood donation, and in terms of blood donation criteria, only 30.7%, 25.2% were aware of the appropriate age and weight for donating. Moreover, school was the source of most information (66.6%). Meanwhile, 73.3% of participants expressed a positive attitude toward VBD. Only (17,6%) did not show a willingness to donate blood regardless of their relationship with the recipient. The vast majority (83.3%) had never donated blood before, and 12.5% had no plans to do so in the future. The two most common reasons for this were the lack of opportunity and health issues (31.0%, 11.9%, respectively).

CONCLUSION

The sampled medical students had a positive attitude toward VBD, but there were deficiencies in their knowledge of blood donation criteria, and most had not donated blood. Adequate awareness campaigns are required to increase awareness about this universally and locally important subject.

Prevalence, causes and outcomes of war-related civilian injuries in Ethiopia's war-torn Tigray region: a community-based descriptive study

OBJECTIVE

War and armed conflicts are the major causes of mortality, morbidity and disability. This study was aimed at assessing the prevalence of injury, cause and its outcome among civilians during the war in Tigray, Northern Ethiopia.

RESULTS

A community based cross sectional study was conducted to collect data from a total of 4,381 sample households. Descriptive analysis was applied and the data are presented using frequencies, percentages, tables and statements. Of the study participants, 6.9% (95% CI: 6.2%, 7.6%) of civilians encountered any kind of war-related physical injury. About Two-third (95% CI: 59%, 73%) of the physical injuries were caused by bullet followed by heavy artillery shelling (proportion = 23%; 95% CI: 17%, 29%). Painfully, about 44% (95% CI: 37%, 50%) faced death following injuries and the other 56.2% (95% CI: 50%, 62.5%) either survived or encountered disability. Post war rehabilitation for the disabled is recommended to enable them live healthy, dignified, independent and productive citizens.

Responding to the Humanitarian Crisis in Gaza: Damned if You do… Damned if You don't!

Palestine, since 1948, has endured frequent military occupations and uprisings, intifadas, in a limited geographic area that has resulted in one of the worst humanitarian crises. The prolonged nature of this military occupation has created a biosphere of war that is uninhabitable, whereby Palestinians suffer from physical, psychological, and social wounds. Israel also imposed restrictive measures in Gaza, making it difficult for Palestinians to obtain permits to work and travel throughout Palestine. Israel continued to intensify the restrictions on Gaza, reaching a blockade on the Gaza Strip, which cut off Palestinians from Jerusalem, where hospitals, banks, and vital services are found. This form of permanent siege resulted in a surge in the unemployment rate, poverty, and poor nutritional and wellbeing status. The siege also resulted in the largest open-air prison, as people became stuck between an incomplete life and the absence of total death. The major challenge is that humanitarian interventions, in the case of Gaza, are ineffective, as they are part of the siege framework. This is because any humanitarian aid meant for Gaza needs to be approved by Israel. Thus, when the emergency becomes chronic and humanitarian interventions become part of the siege framework, how can Gaza rebuild its health capacity in a permanent emergency, and to what extent can the humanitarian sector make a change?

Association between war-related traumatic events and blood pressure trajectory: a population-based study among the mid-aged and older Palestinian adults living in Gaza

Background

Little is known regarding health status in an environment characterized by instability and ongoing war risks. This study investigated hypertension disease burden and associations of war-related traumatic events with blood pressure (BP) trajectory over time amongst mid-aged and older Palestinian adults in Gaza Strip.

Methods

From nine primary healthcare centers, medical records between 2013 and 2019 were collected for 1,000 mid-aged and older Palestinian adults living in Gaza. Multinomial logistic regression analysis examined associations between war-related traumatic events and BP trajectories derived using latent class trajectory analysis (LCTA).

Results

The prevalence of self-reported injury (of participants or their family members), death of a family member, and violence due to house bombing was 51.4%, 54.1%, and 66.5%, respectively. In total, 22.4% and 21.4% of participants had constant-very-high (CVH) systolic BP (SBP) (>160 mmHg) and diastolic BP (DBP) (>95 mmHg), and normal-stable SBP and DBP was found only 54.9% and 52.6%, respectively. Injury (participants or family members), death of a family member, and violence due to house bombing during wars were associated with CVH SBP with odds ratios [95 CI, OR = 1.79 (1.28-2.48), 1.90 (1.36-2.65), and 1.44 (1.01-2.05)], respectively. The corresponding figures were [95 CI, OR = 1.92 (1.36-2.71), 1.90 (1.35-2.68), and 1.62 (1.13-2.38)] for CVH DBP. Living in debt was positively associated with CVH SBP, [95 CI, OR = 2.49 (1.73-3.60)] and CVH DBP, [95 CI, OR = 2.37 (1.63-3.45)].

Conclusion

The disease burden related to war-related traumatic events is high and positively related to adverse BP trajectory among the mid-aged and older Palestinians living in Gaza. Intervention programs are needed to manage and prevent chronic diseases in this vulnerable population.

Better be prepared: the spectrum of neuropsychiatric impairment among Libyan war victims transferred to Germany for trauma rehabilitation

Background

The current Libyan civil war has originated many casualties, imposing medical challenges. War injuries are complex, requiring specialized knowledge and interdisciplinary assessment for adequate patient and intercultural management.

Methods

This retrospective study analyzed records of 78 Libyan patients admitted from July 2016 to November 2017 to neurological and trauma surgical departments of Krankenhaus Nordwest, Frankfurt, Germany. Issues of system preparation of the hospital, demographics, injury patterns and therapies were analyzed. The chi-squared test was used to analyze differences in injury patterns in explosion and gunshot injuries.

Results

Seventy-seven of seventy-eight patients were male (mean age 30.6 years). The patients received primary and secondary treatment in Tunisia (n = 39), Libya (n = 36) and Turkey (n = 23). Forty-eight patients had gunshot injuries, 37 explosion injuries, 11 both. Preparation for management of injuries included hygienic and isolation protocols, organization of interpreters and intercultural training. Patients presented with a broad variety of neurological, psychiatric and trauma surgical injuries. Fifty-six patients had sensory, 47 motor deficits. Nine reported headache, 5 vertigo, 13 visual impairment, 28 psychiatric symptoms. Eighteen patients had central nervous damage, 50 peripheral nervous damage. Central nervous damage was significantly more common in gunshot than explosion injuries (p = 0.015). Peripheral nervous damage was more common in explosion than gunshot injuries (p < 0.1). Fifty-one patients had polytrauma and 49 suffered from fractures. Therapy included surgical interventions (n = 56) and physiotherapy. Structured rehabilitation programs were often indicated.

Conclusion

Specialized knowledge about war injuries and their management including hospital preparation and planning regarding infrastructure may be required anytime. Injuries include a broad variety of neurological, psychiatric and trauma surgical injuries. Therefore, an interdisciplinary approach is crucial.

The pandemic under siege: A view from the Gaza Strip

In this article I argue that while the COVID-19 outbreak is at its early stages in the Gaza Strip, the Palestinian coastal enclave is particularly vulnerable to its effects - not least due to the multiplicity of existing development challenges that have resulted from an ongoing Israeli and Egyptian-imposed blockade. With the economy at a standstill, the Palestinian governing authority has limited financial resources to (re)build key sanitation, hygiene, waste treatment and water supply infrastructure. These (infrastructural) inadequacies, while already a public health concern before the onset of the pandemic, now renders Gaza particularly vulnerable to the spread of viruses and diseases. Additionally, the limited movement of goods because of the siege has led to an acute shortage of medical supplies and equipment that are essential for combating a pandemic. Nonetheless, the COVID-19 outbreak is also "unique" in that it presents Gaza with a crisis that has little to do with the hostilities that define the politics of Israel-Palestine. Yet, the potential of a widespread outbreak also lays bare to the development challenges that Gaza faces as a result of the conflict. This, I conclude, provides an opportunity for the donor community to, under pretext of combating the pandemic, remedy some of the consequences of the conflict and siege without having to contend with the (political) stigma of doing so.

Barriers to managing and delivery of care to war-injured survivors or patients with non-communicable disease: a qualitative study of Palestinian patients' and policy-makers' perspectives

BACKGROUND

Improving access to optimal quality of care is a core priority and ambitious health policy goal in spite of impediments, threats and challenges in Palestine. Understanding the factors that may impede quality of care is essential in developing an effective healthcare intervention for patient with non-communicable disease (NCD) or war-injured survivors.

METHODS

Qualitative interviews were performed using a purposive sampling strategy of 18 political-key informants, 10 patients with NCD and 7 war-injured survivors from different health facilities in Gaza Strip. A semi-structured interview guide was developed for data collection. The interviews were audio recorded and transcribed verbatim. Important field notes of the individual interviews were also reported. Thematic-driven analytic approach was used to identify key themes and patterns.

RESULTS

From the policy maker's perspective, the following important barriers to accessing optimal healthcare for patients with NCD or war-injured survivors' treatment were identified; 1) organizational/structural 2) availability 3) communication 4) personnel/lack of staff 5) financial and political barriers. Patient with NCD or war-injury had similar experiences of barriers as the policy makers. In addition, they also identified socioeconomic, physical and psychological barriers for accessing optimal healthcare and treatment.

CONCLUSIONS

The main perceived barriers explored through this study will be very interesting and useful if they are considered seriously and handled carefully, in order to ensure efficient, productive, cost-effective intervention and delivery of a high-standard quality of care and better disease management.

Does pain, psychological distress and deteriorated family economy follow traumatic amputation among war casualties? A retrospective, cross-sectional study from Gaza

OBJECTIVES

The aim of this study was to explore determinants of psychosocial distress and pain in patients who have survived severe extremity amputation in Gaza.

SETTING

This study was conducted in a secondary care rehabilitation centre in Gaza, Palestine. The clinic is Gaza's sole provider of artificial limbs.

PARTICIPANTS

We included 254 civilian Palestinians who had survived but lost one or more limb(s) during military incursions from 2006 to 2016. We included patients with surgically treated amputation injuries who attended physical rehabilitation at a specialist prosthesis centre in Gaza. Amputees with injuries prior to 2006 or non-military related injuries were excluded.We assessed their pain and psychological stress using the General Health Questionnaire (GHQ-12). We used income, amputation severity scored by proximity to torso, current employment status, loss of family members and loss of home as independent variables.

RESULTS

The amputees median age was 23 years at the time of trauma, while a median of 4.3 years had passed from trauma to study inclusion. Nine of 10 were male, while 43 were children when they were amputated (17%≤18 years). One hundred and ninety-one (75%) were unemployed and 112 (44%) reported unemployment caused by being amputated. Pain was the most frequent problem, and 80 amputees (32%) reported to suffer from daily pain. Family income was significantly correlated with the physical pain (OR=0.54, CI 0.36 to 0.80, p=0.002). Psychological distress was higher among unemployed amputees (OR=1.36, CI 1.07 to 1.72, p=0.011). We found no association between psychological distress (GHQ-scores) and the extent of the initial amputation.

CONCLUSION

Pain and psychological distress following war-related extremity amputation of one or more limbs correlated stronger with deteriorated family economy and being unemployed than with the anatomical and medical severity of extremity amputations.

Trends and patterns of deaths, injuries and intentional disabilities within the Libyan armed conflict: 2012-2017

Background

The consequences of armed conflicts impose considerable burdens on the economy and health care services, particularly in countries that are not equipped to deal with them, such as in the Middle-East, and North African countries. Little is known about the burden of mortality and injury resulting from the Libyan armed conflict. This study aimed to determine the trends and patterns of mortality, injury and disabilities directly associated with the Libyan armed conflict and analyze the geographic variation within the country during 2012–2107.

Methods

Data on conflict-related deaths, injuries, and disabilities were obtained from the national registry offices. The information included date, place, and demographic information. A questionnaire was also used to obtain information from the affected individuals and their families. National and regional trends of mortality, injury and disabilities were calculated. Spatial analysis was performed using geographic data available on all documented cases to analyze clustering of mortality and injury.

Results

A total of 16,126 deaths and 42,633 injuries were recorded with complete information during the Libyan conflict from 2012 till 2017. The overall mortality rate was 2.7/1000 population and injury rate was 7.1/1000. The overall male-to-female ratio of mortality and injury was 4.4:1; 42.3% were single and aged 20–30 years old, and 26.4% were aged 31–40 years. Moreover, injuries resulted in death in 20.1% of cases and disability in 33.5% of the cases. Most of the disabilities were caused by blasts, while gun shots resulted in more deaths. The overall mortality and injury rates were highest during 2015–2017. These rates were highest in the eastern region. Injuries were most concentrated in Benghazi and Derna in the east, followed by Sert and Musrata in the central region.

Conclusions

Conflict-related mortality, injury and disability has inflicted a heavy burden on the Libyan society that may persist for a long time. The rates of these casualties varied in time and place. National, well-planned efforts are needed to address this serious situation and its consequences.