Responding to challenge
We have examined war-related injuries in the Gaza Strip, which gives a perspective on the realities of Palestinian life. The study was conducted in response to the call for medical and epidemiological assessment of injuries during frequent wars in the region. The Palestinian health care system suffers from fragmentation, insufficient medical supplies, and limited resources, especially during emergency situations [
19].
During the 2014 Gaza war, the Gaza Strip witnessed the highest rate of internal displacement (about 28% of the population) as a consequence of war [
19,
20]. Most importantly, there were more than 11,000 injured victims reported, the concurrent destruction of medical facilities and health system infrastructure, and other barriers to healthcare access, making it difficult for most people in need of health care to access it [
19,
21,
22].
The study found that injuries in the 2014 Gaza Strip war were 3-fold higher among males than females (male: female ratio of 3.1:1). The study findings support the figures of the official Palestinian MOH report on previous wars in Gaza Strip [
22‐
24] and reports on injury during the Al Aqsa Intifada (uprising) in 2000–2006 [
25]. In Palestine, generally the men are the breadwinners. When a male family member is injured or disabled, the whole family, including the children, suffers. Therefore, wars affect not only males but the whole family by depriving them of the means to obtain food.
Children under 20 years old were the second most affected group after young adults (20–39-year-olds) with respect to number of injuries. This group may in the near future become a challenge for the Palestinian health sector in terms of intervention, management, and rehabilitation.
The Gaza governorate reported a higher proportion of injuries than other governorates, supporting findings from previous studies that the region had the largest number of injuries during wartime in Gaza Strip [
23]. However, considering the number of injuries per 1000 population, the highest was reported in North Gaza and the lowest in Rafah governorate (the southern region of Gaza Strip), indicating that North Gaza was hardest hit of the Gaza Strip regions. Other studies and MOH figures illustrate substantial variation in the number of injuries from one war/invasion to another and among regions in the same territory [
9‐
15].
Our results are similar to those reported in the Palestinian territory [
26] but inconsistent with those reported during conflicts in Libya and Kosovo, which showed an overall number of injuries lower than reported in the Gaza Strip but varying among regions [
27,
28]. Our results also disagree with those reported in Iraqi conflicts, where injuries per 1000 population were higher than those reported in the Gaza Strip [
29]. From our point of view, injury resulting from wars, invasions, or conflicts seems to have more negative consequences than the prolonged impact of such wars, especially as the incidence of injury increases over time in the Palestinian territories. The territory could plan to reorient its health care services to those areas with the higher injury incidence. Additionally, creating advanced field hospitals and adequately re-supplying them, especially during times of crisis and conflict, has the potential to save the lives of thousands of people.
The vast majority of injuries were due to blast or explosion, consistent with findings of the effect of conflict on injury patterns in Baghdad from 2003 [
30].
The highest proportion of war-injury types were: war-related body shrapnel’, burns, and wounds, followed by multiple injuries, fractures, internal organ injury and bleeding, abrasions/lacerations and contusions, amputations, vision/hearing problems or both, and respiratory problems due to poisonous gas inhalation during wartime. The majority of injuries were classified as mild, the rest as moderate-to-severe. The figures show more severe injuries and disabilities than the corresponding figures reported during the 2008 and 2012 Gaza wars [
9‐
11,
22,
31,
32], suggesting that the Palestinian health care system should focus on treating injury victims more efficiently along with people with other diseases. The number of injuries during the Gaza war of 2014 was nearly double that reported in the 2008 and 2012 Gaza wars. Therefore, the number of injuries during the 2014 Gaza war may have exceeded the emergency capacity of the Palestinian health care sector [
9,
10].
We found that war-related physical injury was the most common cause of disability in the 2014 Gaza war, in line with a report from the WHO, revealing that physical injury is the leading cause of disability in the world [
33]. Our study supports Damage Need Assessment reports that show a greater number of injuries and disabilities among children and women, many of them being left permanently disabled [
34]. Moreover, these figures were also consistent with a study conducted in Kuwait that addressed injuries sustained during the Second Gulf War, which showed that the majority of severe injuries, particularly vascular injuries, were due to blasts or explosions [
35]. The increasing severity of injuries in our study may have contributed significantly to the increasing proportion of disabilities among injured people, constituting a greater burden on the health care sector in Gaza. The severity of injury may considerably affect the patient’s physiological functions as well as quality of life, since the intensity of injuries could delay the recovery process and prolong the period of treatment, especially for those who had moderate-to-severe injury. It is also important to be aware that multiple bodily functions can be impacted by injuries. For example, persons with moderate-to-severe head injury typically experience problems in concentration, balance, and sustaining attention, as well as in cognitive skills and thinking [
36]. They may be partially or permanently disabled. Therefore, national and international attention should be paid, and sufficient resources devoted and reoriented to reduce the potential burden of injuries on the Palestinian healthcare system. The Palestinians can learn and benefit from the experiences of other countries that have incurred high numbers of injuries during wars, such as Lebanon and Bosnia. Evidence from those countries demonstrates that the best approach to achieving better outcomes and a reduction in fatal injuries is to empower and enhance national practices, skills, and knowledge in how to deal with injury, as well as to make important resources available [
37].
Strengths and limitations
The primary limitation of this study is that, since health providers did not code injuries using ICD categories, there could be misclassification. Secondly, the data sources were hand-written/paper reports made during extreme war injury management under pressure and tension, which may produce inaccuracy and incompleteness. We believe that completing medical records on a computer is much easier than entering all details by hand in paper record-books. It should be noted that the MOH has recently collaborated with the Norwegian Institute of Public Health and the WHO to enhance and strengthen the Palestinian health system network in terms of reporting and registration. Unfortunately, the process has not been completed or even initiated due to the 2014 Gaza war, which has directly affected and restricted this significant effort, leading to delays in the implementation of the plan [
38]. Another limitation of our study is that we were not able to derive the rate of injury due to absence of person-years. We instead computed number of injuries per 1000 population. The identification of the severity of injury was based on physicians perceptions as reported in records of injured patients. The diagnosis may differ from physician to physician without use of ICD codes for injuries, especially with the large number of injuries and limited time and resources in a very stressful situation. We have no further information on the persistence and lifetime severity of injury or disability, nor whether the victims have recovered. It is worth mentioning that in a lower and middle income country without an appropriate and computerized healthcare network, during emergencies such as wars, invasion, or conflicts, it is difficult for physicians to report ICD codes of injuries and provide necessary treatment to the war victims with poor medical facilities. Therefore the study has focused on available medical reports and highlighted the patterns of war injuries in the Palestinian healthcare sector in Gaza Strip, mainly to provide an overview of the issue. We recommend follow-up study of the victims to explore their actual disability and injury severity.
Despite the drawbacks, our study has addressed a significant health problem in the Palestinian healthcare sector, which has not been explored sufficiently in previous studies. Furthermore, as this study was implemented in the Gaza Strip governorates, it might be possible to generalize the findings to nearby regions and territories such as the West Bank, which are politically similar and identical in terms of their customs, ethnic backgrounds, and habits, and have been impacted by conflicts and wars, often at the same time period.
Although this study has provided important findings on the Palestinian healthcare sector, it has failed to suggest any health systems-related solutions for better treating war injury victims in the Palestinian health system.
Implications of the study findings
Our findings may be of direct significance to Palestinian health care by providing useful information on the provision of health care and medical services for injured persons. It is possible that, by giving an overall picture of the patterns of injuries, we may help to facilitate injury management and treatment in Palestinian health care facilities. The healthcare plan should include an immediate, appropriate, and effective intervention and should be incorporated in the general practice to reduce the negative impact of large numbers of injuries on the quality of health care in the Palestinian health sector.
Most importantly, this study could serve as the baseline for further research on Palestinian health care, especially in Gaza Strip. There is little information available on war-related injuries. The current study has focused on incidence and patterns of injuries, causes/mechanisms of injury, disability, and management of injuries. The research community has received vital information on war injuries from the current study.
A new effective strategy should be adopted that would include health education and improving awareness of the possible risks of injury and the necessity of providing suitable assistance and care at the moment of injury, so that the fatality rate of injuries can be reduced. An important strategy is awareness concerning, and avoidance of, hazardous materials during and after wars, which could significantly reduce injury. To make a prevention strategy as successful as possible, the media, as well as the community must engage in the process via special programs and campaigns. Finally, as the war injuries and disabilities addressed in this study have been shown to constitute a great burden, they must be placed among the priorities of national and international health policy. It is hoped that the study’s findings will create a deeper understanding of the burden and characteristics of this significant health problem and contribute to health planning and development processes.