Architecture of systems affecting disease trajectories in a conflict zone: A community-centered systems inquiry in North Gaza

Humanitarian crises, particularly in conflict zones, create cascading disruptions that impact every aspect of daily life, including health and disease outcomes. While international humanitarian frameworks categorize these crises into discrete operational clusters, affected populations experience them as interwoven, systemic failures. This study examines how conflict-induced disruptions transform a preventable and typically self-limiting disease— Hepatitis A—into a fatal outcome in North Gaza. Using a systems approach, we seek to characterize the architecture of interconnected disruptions leading to preventable deaths.

This study employed the FAIR (Fairness, Agency, Inclusion, and Representation) Framework, a participatory methodology centering community epistemes, to analyze four pediatric cases of Hepatitis A that progressed to fulminant liver failure. Data were obtained through interviews with healthcare providers, caregivers, and community members, supplemented by medical chart reviews. A network-based Architecture of Systems (AoS) map was constructed to visualize the interconnections between war-induced systemic disruptions and health outcomes. Network analysis was performed to identify key nodes, bottlenecks, and pathways within this system.

The findings of this study reveal a complex system of war-driven factors—displacement, destruction of healthcare infrastructure, water scarcity, food deprivation, and fuel blockades— that collectively reshaped disease trajectories. Network analysis of the AoS map identified 138 nodes and 231 edges, generating 41,444 pathways linking conflict-related disruptions to health outcomes. Women’s health emerged as a central mediator, with 95% of pathways intersecting with 13 key nodes related to women’s roles in caregiving, resource acquisition, and psychological stability. The lack of access to food and clean water, combined with the destruction of healthcare facilities and restrictions on medical evacuation, created conditions where a preventable disease became fatal.

This study highlights how conflict restructures health determinants, shaping survival strategies that paradoxically increase morbidity and mortality. By documenting the lived experiences of affected communities, our findings underscore the necessity of a systems-based humanitarian response that accounts for the interconnected nature of crises. Recognizing the pivotal role of women in mediating health outcomes is crucial to designing effective interventions in conflict settings.