Targeted attacks on healthcare in Gaza and their impact on health workers

The Gaza Strip has endured repeated attacks in recent years resulting in tens of thousands of deaths and injuries, repeated mass population displacement [7], and the widespread destruction of health services and public health infrastructure [8]. Repeated attacks on health workers in Palestine have been documented across many years of Israeli military attacks on Palestine [9–11]. Since October 7^th 2023, there has been an unprecedented increase in the number and severity of Israeli attacks on the health system in Gaza, resulting in the death and injury of hundreds of health workers, patients and caretakers as well as damage to essential health infrastructure [12]. The health system has all but collapsed, with the World Health Organization (WHO) reporting that as of February 28^th, 2025, 886 people have been killed in attacks on healthcare since October 2023, while only 18 hospitals in Gaza are partially functional, leaving the remaining 20 hospitals completely out of service. The Palestinian Ministry of Health reported that 986 health workers were killed as of September 2024 [13]. Within just the first six weeks of the assault, 25% of hospitals in Gaza had craters left by 2000-lb bombs within lethal range and 83.3% had these craters within infrastructure damage and injury range [14], and spatial analysis confirms that the destruction of civilian infrastructure including health systems is not random or accidental [15]. This is further supported by documentation of the hundreds of health workers abducted and often tortured or killed in Israeli prisons [16–18]. Weeks after the withdrawal of Israeli occupying forces from Al-Shifa Hospital following a horrific ground invasion, Palestinian health workers uncovered a mass grave near the hospital containing the remains of patients, some with wound dressings and catheters still in place [19]. Shortly thereafter, an even larger mass grave was discovered near Nasser Hospital, with some bodies found with bound hands or feet [20]. While not the first instance of attacks on health workers in Palestine, it is unprecedented in its brutality. In November 2023, a Médecins Sans Frontières (MSF) nurse texted his colleagues from the basement of Al-Shifa Hospital, where he and his family were taking shelter during intense Israeli bombardment: “We are being killed here, please do something.”[21].

Mental health in Palestine

Many prior studies have measured the psychological burdens carried by healthcare workers in Palestine related to the baseline state of working while subject to Israeli settler-colonialism. Abu-el-Noor et al found that approximately 90% of doctors and nurses surveyed likely had probable posttraumatic stress disorder (PTSD) following Israeli attacks in Gaza in 2014 [22]. A follow up study two years later showed minimal changes in reported symptoms, which they attributed to minimal interventions [23]. Veronese et al measured posttraumatic growth and sense of coherence, two related constructs which focus on psychological resources for making meaning out of suffering and mobilizing individual-level coping strategies [24]. Recognizing the many threats to validity of PTSD symptom checklists and other self-reporting instruments as well as debate over the validity of PTSD in the Palestinian context [25], Afana et al described culture-specific expressions for both coping resources and psychological distress, many of which frame Palestinian suffering as it relates to their national cause [26]. Particular attention has been given to the notion of “sumud”, translated as steadfastness, which is profoundly important in Palestinian society [27]. Wick characterizes sumud as a coping mechanism used by Palestinian health workers to navigate the daily challenges associated with their jobs [28]. While sumud is indeed an intergenerational mental health resource, it is also fundamentally a cultural and psychological tool to resist colonial oppression [29]. As Meari describes, sumud is a practice that allows Palestinian political prisoners to be both victims of colonial oppression and agents who resist that oppression at all costs. The concept of sumud, rooted in the forced displacement of Palestinians since the Nakba of 1947–9, takes on new meaning in the context of the ongoing, accelerated genocide [30–33].

Psychological constructs for health worker distress and well-being

Reflecting health workers’ frequent exposure to trauma [34–36] and its consequences for health system functioning [34], the broader psychological and health services literatures on the distress and well-being of health workers is vast. Many related and sometimes overlapping concepts have been developed to describe it, including vicarious traumatization [36], compassion fatigue, compassion satisfaction, secondary traumatic stress, burnout, perceived support [37], and moral distress [38]. While there is variation in the definition and application of these concepts, vicarious traumatization generally refers to the stress response of professions with an ongoing empathic relationship with a traumatized client, while secondary traumatic stress (STS) typically refers to an acute stress response which can be experienced by many kinds of health workers when exposed to the suffering of others [36,39]. Burnout (BO), like STS, is applied to many kinds of health workers but reflects a more gradually lost sense of accomplishment and achievement and an erosion of idealism [36,39]. Compassion fatigue (CF) and its inverse, compassion satisfaction (CS) reflect a combination of STS and BO [40], and have also been used to describe the experiences of lay caregivers [39]. Moral distress (MD) is the perception that one’s ethics are compromised due to aspects of their work environment which they cannot control [38]. All of these constructs have been found to play some role in the health worker’s ability to cope with work-related stress. The Professional Quality of Life Scale (ProQOL) incorporates several of these concepts, and was recently administered to Palestinian ICU nurses in the West Bank, with 80% or more reporting average levels of compassion satisfaction, burnout, and secondary traumatic stress [41]. The study team consulted nursing and psychometric experts to approve the tool’s cultural and contextual relevance and construct validity, but did not explicitly explore the political context and its potential bearing on the findings.

Studying the psychological effects of genocide

While existing literature acts as a guide to the study of mental health in Palestine generally and of health workers in Palestine, the current situation for health workers in Palestine is uniquely horrific. For those who survive, they continue to live in perpetual proximity to death [42]. The mental health of health workers is important to the functioning of any health system, but the psychological toll of the ongoing genocide must be studied and understood within its violent political context and the targeting of health workers. While the study of nurses in the West Bank in 2024 reflected an average professional quality of life, the brutal treatment of health workers during the genocide in Gaza needs additional attention.

Genocide is qualitatively distinct as a traumatic exposure and our study of it must take this into account [2]. Alongside the destruction of the healthcare system in the determination of genocide there is also evidence of the destruction of cultural heritage sites, mosques, and churches, which form an important part of the Palestinian social fabric. These components are important in relation to the study of trauma as the nature of traumatic exposure and its context is known to shape psychological sequelae [43–45]. In the words of Albanese: “Israeli soldiers have published footage boasting about their killing of families, mothers, children - the bombing of homes, mosques, and schools. Self-incriminating videos show them sadistically mocking and humiliating their Palestinian victims not only by violating their physical integrity and right to life, but also their dignity, their most intimate possessions and spaces that the soldiers have entered and looted, and by desecrating cemeteries and places of worship.”[5]. Among survivors of the genocide in Rwanda, the peritraumatic response was found to mediate the relationship between the intensity of the traumatic exposure and symptoms of traumatic grief [46]. Their study highlights the importance of measuring psychological experiences proximal to the traumatic exposure and the need to study the specific consequences of genocide as a traumatic exposure, whose nature is highlighted in Albanese’s description.

The psychological effects of any form of extreme trauma on oppressed peoples must take into account the social and political context that shape values, beliefs, and life goals [47]. Health workers attacked by the Israeli military during the 2018 Great March of Return, a historic nonviolent uprising in Gaza, pointed to the structural and continuous nature of violence as key features of its impact [48].

In order to assess and contextualize the psychological impact of the ongoing genocide on physicians and nurses working in Gaza after October 7^th, 2023, we conducted a brief online survey to assess experiences of workplace displacement, personal loss, and the impact of traumatic stress.

We use the word “genocide” to refer to this period of accelerated violence and displacement in Gaza, following preliminary ICJ findings and subsequent detailed reporting by UN Special Rapporteur Albanese [4,5]. It is also consistent with more recent reports of the United Nations Special Committee to Investigate Israeli Practices [49], Human Rights Watch [50], and Amnesty International [51] all finding that Israel has indeed committed genocide in Gaza. These finds are echoed increasingly by genocide scholars [52]. The psychological consequences for health staff enduring this can be understood in relation to past work on the mental health of Palestinian health workers, the mental health of other victims of genocide [46], and the broader literature on the well-being of health workers.

Ethics statement

This research was conducted in accordance with the U.S. Federal Policy for the Protection of Human Subjects (the Common Rule). Boston Medical Center and Boston University Medical Campus Institutional Review Board #: H-44523.

Study design, setting and population

We conducted an anonymous, English language cross-sectional online survey between December 24, 2023 and January 30, 2024. Participants had to be physicians or nurses that worked as employees or volunteers in Gaza before October 7th, 2023 and continued to work there for at least some of the period following. We chose to focus on a more homogenous group of health workers to improve validity since we were expecting a small sample, and we chose to focus on physicians and nurses since they are the majority of frontline health workers in Palestine [53,54]. Both those born in Palestine and their colleagues born abroad but working in Gaza were included. Medical and nursing students were not included. Participants had to be age 18 or older.

Recruitment

A physician study leader born in Gaza and trained in Palestine led the development of outreach plans, consulting with Palestinian physicians and researchers locally and internationally to determine contexts and methods for outreach which were effective and sensitive. We used the respondent-driven sampling method as described by Wejnert and Heckathorn [55], with which we sought “seed” participants affiliated with institutions in all five governorates of the Gaza Strip. We prompted these seed participants by email to take they survey if they met inclusion criteria, and to disseminate it using a recruitment message to their professional networks, including to colleagues linked to hospitals in Gaza, and Ministry of Health (MOH), UNRWA, and other primary healthcare centers. Additionally, we encouraged participants to share the survey link and outreach message across various channels such as email, health worker group chats, and community networks. It was not shared via other social media.

Of the 26 potential “seed” participants initially invited to complete the survey, four (including the recruitment lead) recruited additional participants. They were situated in North Gaza and Khan Younis before October 7th, 2023. Physical exhaustion, displacement, forced hospital evacuations, attacks on hospitals, and prolonged disruption to internet connectivity hindered survey participation. One co-author’s displacement resulted in the loss of their laptop, further impeding study recruitment. Most survey participants were recruited by invitation either in person or via bilateral personal conversations.

Participants provided informed consent on the first page of the online survey. The Boston Medical Center and Boston University Medical Campus Institutional Review Board determined that this study was exempt from full review on the basis of its anonymity and the limited in-person interactions required for participation. Sensitive questions, such as those pertaining to personal loss or psychological distress, could be skipped at the respondents’ discretion to mitigate the potential harm caused by active retrieval of traumatic memories. The consent process emphasized the voluntary nature of the survey and the option to close the browser and end the survey at any time and without need for justification.

Survey development

We developed and distributed the survey using the web-based Qualtrics Research Suite software. In addition to demographic data, the survey included questions about workplace displacement, personal experiences of death and injury among family members and colleagues, and an instrument for measuring the psychological impact of providing medical care in the context of the genocide (S1 Text). We selected the Professional Quality of Life Scale for Health Workers (ProQOL-H) developed by the Center for Victims of Torture [56]. It assesses compassion satisfaction, burnout, compassion fatigue, moral distress, and secondary traumatization among health workers and other professionals working with victims of torture and other extreme trauma exposures. Questions are answered using a five-point Likert scale. Among our colleagues, we asked those who would potentially qualify as participants for feedback on the draft survey prior to seeking IRB review. We initially intended to use the Arabic version of the survey, however questions 13 and 18 in the Arabic version of ProQOL-H translate “well-being” as “rafahia.” We felt this translation gave these questions a more frivolous connotation with potential to offend participants, given the context. Creators of the instrument require permission to modify the survey, which we were unable to obtain, so we proceeded with the English language version, without modification. English is spoken by the majority of physicians and nurses in Palestine. The ProQOL, another version of the instrument, has also been administered in English to ICU nurses in the West Bank [41].

Participant demographics, their experiences of displacement and personal loss, and their ProQOL-H scores are presented in the form of simple descriptive statistics. To further explore the ProQOL-H outcomes and generate hypotheses to drive future work, we stratified ProQOL-H outcomes by gender, by profession, by most recent workplace governorate, and by the type of facility lived in.

Recruitment

57 surveys were returned. One response was removed as it was suspected to be a duplicate due to substantial similarity with another response in completion time, demographics, and the formulation of open-ended responses. Completion rates varied across survey sections, with 50 (89%) of respondents reporting demographic information, 46 (82%) reporting on workplace displacement, 41 (73%) reporting on personal experiences with death and injury, and 35 (63%) completing the ProQOL-Health instrument. All participants who started the ProQOL-Health completed all 30 questions.

Male health workers and physicians were more represented among participants than female health workers or nurses (Table 1). This gendered and disciplinary skew in recruitment was recognized early and, although physicians in Gaza are disproportionately male [54], recruiters encouraged additional dissemination of the survey among women and nurses. 90% of participants were born Gaza, with the remainder being born outside Palestine.

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Table 1. Survey Participant Demographics, n = 50.

https://doi.org/10.1371/journal.pgph.0005094.t001

Workplace displacement and personal loss

46 respondents reported whether they relocated to new workplaces for various reasons related to the genocide (Table 2, Fig 1). Prior to October 7th 2023 most respondents worked either in Khan Younis (n = 22, n = 14 at European Gaza Hospital) or Gaza City (n = 14, n = 9 at Al-Shifa Hospital). A smaller number of participants were working in Rafah prior to October 7th (n = 6, n = 5 at Kuwaiti Hospital). Many respondents had relocated to work in Rafah (n = 19 of 46 working in Rafah at the time of survey completion, n = 17 at Kuwaiti Hospital).

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Table 2. Survey Participant Workplace Displacement, n = 46.

https://doi.org/10.1371/journal.pgph.0005094.t002

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Fig 1. Workplace displacement reported by doctors and nurses by Gaza Governorate, December 2023 to January 2024 (n = 46).

https://doi.org/10.1371/journal.pgph.0005094.g001

Personal losses were experienced by 41 health workers as a result of Israeli military violence (Table 3). Among them, 17 of 41 (41%) reported that a family member was killed, and 32 of 41 (78%) reported that a close colleague had been killed. 19 of 41 (46%) reported both a personal loss and workplace displacement.

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Table 3. Survey Participants Reporting Personal Loss after October 7^th, 2023, n = 41.

https://doi.org/10.1371/journal.pgph.0005094.t003

The psychological effects of the genocide on health workers

The quality of responses to the ProQOL-Health scale appeared satisfactory, insofar as there were no instances of “straightlining” (selecting the same response for every item in the grid). Response counts for individual survey items are reported in S1 Table. There was a higher prevalence of “high” compassion satisfaction (scores of 24–30, with 30 being the highest possible score) compared to other subscores, with 49% (n = 17) of respondents reporting high scores (Table 4). 37% (n = 13) of respondents reported high levels of burnout, and 37% (n = 13) reported high secondary traumatic stress. 86% (n = 30) of respondents reported a level of perceived support in the “average” range (scores of 13–23), and 91% (n = 32) of respondents reported moral distress in the average range.

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Table 4. ProQOL-Health sub-scores with median scores (IQR) and number of scores by category as defined by the Center for Victims of Torture (n = 35).

https://doi.org/10.1371/journal.pgph.0005094.t004

There was significant concordance among most respondents for four questions (S1 Table). Specifically, 27 of 35 respondents reported feeling supported by their families in their healthcare work, of which 18 selected “very often.” Similarly, 28 of 35 respondents expressed feeling pride in their ability to help patients, of which 19 selected “very often.” There was strong consensus among workers that their workload seems endless (25 of 35 marked “often” or “very often”) and that work has significantly impacted their work-life balance (29 of 35 marked “often or “very often”).

Stratified analyses did not suggest major differences in ProQOL-H scores based on gender or profession. (S2 Table) Respondents living with family or friends (n = 8) appeared to have lower compassion satisfaction and perceived support than those still at home, staying in the hospital, or living in a refugee camp or school. The single individual working most recently in North Gaza at the time of the survey reported far lower compassion satisfaction and perceived support than the median values reported from those working in Gaza City, Khan Younis, Middle Gaza, and Rafah.

Some participants used the open response spaces to describe the challenges and atrocities they encountered and how they have adapted, or to share other aspects of their experiences. These responses were too few to allow for qualitative analysis, but have been compiled in S2 Text. We include one such response from a young physician:

“I did not expect to live this stage or to see the amount of victims and injured like what I saw. I was choosing between patients who needed a quick operation, who could endure another time, and for whom we could do nothing. I refused to leave the hospital [where] I was staying. We continued with the treatment, but we reached the point where we were forced to leave our workplace by force of arms and fire. They arrested my colleagues and killed others. I saw death and I thought that doctors were protected.”