Eastern Mediterranean Health Journal | All issues | Volume 31 2025 | Volume 31, issue 4 | Meeting the rehabilitation needs of children with debilitating injuries and disability in Gaza

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Meeting the rehabilitation needs of children with debilitating injuries and disability in Gaza

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Policy and practice

Ala Shatali1,2, Fatima Rashid1, Ilham Lubbad1,3, Joanne Potterton4, Bart Geilen1, Sanah Ali1 and Abu Sidhanee1,5

1Children Not Numbers. 2Department of Physiotherapy, Shifa Hospital, Gaza, State of Palestine. 3Al-Azhar University of Gaza, Gaza, State of Palestine. 4Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. 5Division of Physiotherapy, Institute of Health and Social Care, London South Bank University, London, United Kingdom (Correspondence to Abu Sidhanee: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Abstract

Background: Children have been severely affected by the October 2023 war in Gaza. Over 12 000 of them have been injured and many live in unprecedented circumstances with debilitating injuries and disability.

Aim: To document the rehabilitation needs of children with debilitating injuries and disability in Gaza.

Methods: We reviewed the clinic data of children in need of rehabilitation from the Children Not Numbers database to highlight their disability types and the treatment and care required and received.

Results: Until the time of this documentation, 242 children from Gaza had been referred to Children Not Numbers for management, of which 63 (26%) required rehabilitation due to debilitating injuries and disability. The majority (60%) of those requiring rehabilitation presented with traumatic conditions and 32% presented with neurologic conditions. Average age of these children was 6.9 years (range 4 months to 17 years).

Conclusions: Rehabilitation and continuous care and support is essential for injured and disabled children who survive the war in Gaza, to give them a better chance of achieving optimal functional outcomes and wellbeing. And this can only be achieved through intersectoral, international collaborations and partnerships to address their needs beyond the cessation of hostilities.

Keywords: rehabilitation, injury, disability, children, developmental assessment, monitoring, Gaza

Citation: Shatali A, Rashid F, Lubbad I, Potterton J, Geilen B, Ali S, Sidhanee A. Meeting the rehabilitation needs of children with debilitating injuries and disability in Gaza. East Mediterr Health J. 2025;31(4):219–225. https://doi.org/10.26719/2025.31.4.219.

Received: 28/10/2024; Accepted: 16/04/2025

Copyright © Authors 2025; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Background

Conservative estimates indicate that more than 11 000 children have been killed in the Gaza war in the past year, higher than any other conflict in the past 20 years (1), and possibly underestimated because of the unidentified and unrecovered bodies or deaths due to indirect effects of the war (2). With nearly half of the population below 18 years (3), children have disproportionately suffered the impact of this devastation. Calculating the total number of injured children in this conflict is challenging, however, the latest data from the Palestinian Ministry of Health reports that over 12 000 children have been injured in Gaza since the conflict started, making an average of 70 children injured each day (4). Rehabilitation services are essential for children with injuries and disability to prevent complications and ensure optimal recovery, and should be integrated in emergency response (5,6).

Injury and disability among children in Gaza

The types of weapons used during this war have caused significant damage, maximising the number of casualties (7). Since October 2023, thousands of children have been afflicted with new disabilities in addition to the 98 000 who were already living with disabilities before the conflict (8). The use of explosive weapons has resulted in severe injuries, including limb loss, spinal cord injuries, traumatic brain injuries, burns, and significant psychological trauma (9,10).

During the first 2 months of the war, more than 1000 children in Gaza lost one or both legs (11). Where limb salvage surgeries are no longer possible due to disruption of health services, amputation is often the only viable option (5,10), and this has long-term psychological and physical implications for an unprecedented number of children (12).

Rehabilitation helps individuals of all ages achieve maximum independence during daily activities and facilitates their participation in education, recreation and meaningful life roles (13). It aims to enhance functioning, social participation and quality-of-life of children (14). However, Palestinians, have limited access to rehabilitation services, as in many other low- and middle-income countries where skilled rehabilitation professionals are scarce (14,15). This makes effective response to rehabilitation needs during conflicts and humanitarian crisis extremely challenging (16).

Traumatic injury resulting from violent conflict can lead to devastating physical and psychological disability, and timely management and long-term rehabilitation are vital to improve quality-of-life and regain independence (16–18). Before the October 2023 war, many children in Gaza were already suffering from injuries or disabilities due to previous conflicts, harsh living conditions and lack of medical services (9), just like tens of thousands Palestinians in Gaza with pre-existing conditions who now lack access to essential rehabilitation services and assistive products needed to maintain their health and independence (5). As war-inflicted injuries increase the demand for assistive devices such as wheelchairs, crutches and orthoses also increase (19).

Effective rehabilitation requires community-based and integrated interventions, including support from families, schools and local institutions. This holistic approach, which facilitates social reintegration, is very difficult to achieve among communities displaced by war (20). Palestinians face restricted access to medical care within and between Gaza and the West Bank, causing delays or failures in seeking care and treatment, and thus hampering effective rehabilitation (21). To reach rehabilitation facilities, Palestinians must navigate active war zones and Israeli checkpoints, making it difficult to access care.

The numerous evacuation orders from the Israeli military, including for hospitals, force Palestinians to delay or abandon seeking care (22). The closed Rafah crossing, travel rejections and lack of a clear patient evacuation process have severely limited medical evacuations since May 2024 (23). Consequently, children cannot access long-term rehabilitation within or outside Gaza.

Children who are not directly impacted by violence or disease are profoundly affected by displacement, economic challenges, destruction of community infrastructure, as well as the loss of parents and/or caregivers, family and friends (24). Young Palestinians in Gaza already suffer from high rates of psychological and anxiety-related challenges secondary to war-related trauma (25). Many Gaza child amputees suffer depression, anxiety, sleep disorders, and other mental health challenges (12,26), which often hinder their ability to seek rehabilitation services. Therefore, to be effective, address the child’s holistic needs and increase resilience, rehabilitation should address the physical and mental health needs of such children (27–29).

Challenges with rehabilitation infrastructure in Gaza

Before the October 2023 conflict began, Gaza had a functional rehabilitation infrastructure, which was managed by the Ministry of Health and provided services in 11 hospitals and 5 primary health centres. Nongovernment organizations and aid agencies also provided several outpatient and community-based rehabilitation services and these services were structured to meet the diverse needs of children with physical and mental health issues. The war has severely disrupted all hospital services, including rehabilitation. Gaza's 3 inpatient rehabilitation facilities and other critical infrastructure have been damaged, resulting in an overwhelming demand for services (5,10).

The high injury rates and the severe shortage of hospital beds mean that most patients requiring rehabilitation services cannot receive them. Even when therapists are available, essential equipment like crutches and wheelchairs are often unavailable or in poor condition, and many of the rehabilitation workers lack specific training and experience in treating paediatric trauma, which is often complex and requires specialised care (10,30). Power outages and fuel shortages further limit care for newly injured and hospitalised patients (10). Many children are being treated in tents or overcrowded shelters which are not conducive for providing services.

The conflict has had a devastating impact on healthcare workers, with more than 885, including 47 physiotherapists, killed since the beginning of the war (31). The death of health professionals, the inability of the surviving ones to reach hospitals to provide services, displacement, and heavy workload under challenging situations have severely compromised the capacity to provide rehabilitation services to injured patients in Gaza (5,10).

Response by Children Not Numbers

Children Not Numbers (CNN) is a nongovernment organization providing support and long-term rehabilitation for children affected by conflicts (32). CNN has established innovative rehabilitation initiatives to support children and families in Gaza. It has over 100 personnel from more than 15 countries, including a global collective of rehabilitation professionals who collaborate with a Gaza-based team to provide rehabilitation assessments and interventions for children in Gaza (32).

To address the inability of children to consistently and safely access rehabilitation services, CNN provides services free to affected children and families through an organised network of clinicians and caseworkers directly on-ground and/or virtually. Rehabilitation professionals in Gaza coordinate face-to-face assessments and interventions in local health care settings and visit families where possible, including in refugee camps.

Analysis of children referred to CNN for rehabilitation

As of the time of this documentation, 242 Gaza children had been referred to CNN, and 63 (26%) of them were identified with distinct rehabilitation needs. The average age of those referred to CNN for rehabilitation was 6.9 years (range 4 months to 17 years). Over one-third (35%) of them were under-5 and 6% were younger than one year. The children were referred for 3 primary reasons (Figure 1), in addition to the need for developmental assessment and monitoring.

The largest cohort of children requiring rehabilitation (60%, n = 38) were referred for traumatic injuries, including skeletal and neurologic injuries and burns, followed by children with primary neurologic conditions (Figures 1 and 2) (32%, n = 20), while 8% (n = 5) had pre-existing musculoskeletal conditions such as Perthes disease, juvenile arthritis and hip dysplasia.

Skeletal trauma, including crush injuries, fractures and amputations, was the most common type of trauma. Skeletal and neurologic traumatic injuries are a direct result of the war, predominantly caused by explosions, bullets, shrapnel, and falling rubble from building destruction. The average age of children referred for rehabilitation who experienced traumatic injuries was 8.1 years (range 4 months to 17 years).

The average age of children who presented with neurologic disability was 4.8 years (range 6 months to 16 years). They were referred for various congenital and acquired neurologic conditions (Figure 3). Most of the children had pre-existing disabilities and rehabilitation needs and almost all of them were experiencing a deterioration in their function and independence because of the war. Children with pre-existing musculoskeletal conditions required coordinated paediatric orthopaedic, orthotic and physiotherapy services.

Description of selected cases

The following cases illustrate some of the categories of injury or disability experienced by the children in Gaza:

Case 1: Trauma

Case 1 was a 12-year-old with gunshot wound to the spine and permanent loss of all motor and sensory function below the waist. This child was shot in the back by a sniper with the bullet exiting through the chest. The child experienced acute respiratory distress secondary to pleural effusion related to the exit wound, which required chest drain. A severe infection at the chest drain site complicated management. The spinal injury at the T10-T11 level rendered the child paraplegic, with complete loss of sensation and movement below the umbilicus, and double incontinence. It was advised that the child would need surgical stabilisation of the thoracic vertebrae, however, this could not be done due to the destruction of existing facilities and lack of specialist neurosurgical input. Secondary complications arose from the lack of rehabilitation, including chronic pain and pressure sores, further hampering the child’s recovery. Typically, a child with this type of injury would be managed at a spinal trauma unit followed by intensive specialist and multi-professional rehabilitation. This standard of care and treatment is currently unavailable in Gaza.

Case 2: Pre-existing disability

Case 2 was a 7-year-old child with developmental dysplasia of the hip and congenital spina bifida resulting in paraplegia with bilateral calcaneo-valgus and double incontinence. Before the war, this child was managed at a paediatric orthopaedic clinic and had access to a wheelchair with assistive technology, an alternating pressure mattress and specialised splints and braces for the hips, feet and ankles. Since the war began, the child had been unable to access physiotherapy and rehabilitation and had to be carried long distances by family members. The child had developed pressure sores due to their immobility. Necessities such as wheelchair or nappies have become nearly impossible to obtain due to the blockade on humanitarian aid to Gaza. Without access to rehabilitation services, this child’s quality-of-life is severely limited. This case underscores the need to prioritise rehabilitation services for children with pre-existing disabilities and congenital abnormalities.

Case 3: Routine management complicated by current circumstances

Case 3 was a 7-year-old child with explosive injury to the left foot, resulting in an open, comminuted ankle fracture. This injury was managed with an external fixator spanning the ankle joint. Due to the lack of services, the fixator was left in-situ for 3 months and the ankle joint could not be reconstructed. In normal circumstances, this child would have been managed in a trauma centre with extensive reconstructive surgery and rehabilitation to preserve function of the foot. However, prolonged use of the external fixator led to recurrent infections around the pin sites. Due to limited access to physiotherapy and poor skin graft healing, the child had developed an equinus contracture of the ankle. These issues were further complicated by malnutrition, which contributed to recurrent breakdown of the skin grafts and a significant deterioration of the child’s mental health. This case highlights the need for coordinated physical and psychological rehabilitation through orthopaedic and plastic surgery.

Strength and limitations of this report

To our knowledge, this is the first report focusing specifically on the rehabilitation needs of children in Gaza rather than the overall health challenges. The primary limitation of the report is the paucity of reliable data regarding the number of deaths and injuries, due to the contemporaneous nature of the conflict. The data reviewed was from one organisation and may not be representative of all children requiring rehabilitation in Gaza.

Conclusion

Children with new traumatic injuries and pre-existing conditions in Gaza have complex rehabilitation needs. However, the dwindling healthcare workforce and collapsing infrastructure make it impossible to meet these needs. Physical rehabilitation can mitigate the burden of disability experienced by children in Gaza and should be regarded as a vital part of the emergency response (10,33). Given the number of disabled and injured children, a substantial expansion of existing rehabilitation services is essential to manage the long-term needs and optimise the functional outcomes and wellbeing of the children (5). Innovative solutions such as CNN's rehabilitation initiative can support specialists in Gaza in managing children with rehabilitation needs. Ensuring critical rehabilitation for children in Gaza is a moral and humanitarian imperative.

Further research is needed to evaluate the most efficient and most effective methods to deliver rehabilitation interventions in this and similar conflict areas. Such methods must be culturally sensitive and contextually relevant to be acceptable and effective (34). Early access to comprehensive rehabilitation and prosthetics must be assured based on the disability-adjusted life years (DALY) and the anticipated lifespan of the children (35).

Recommendations

Through coordinated response, there is a need to rebuild rehabilitation infrastructure in Gaza; establish mobile rehabilitation units and telemedicine

solutions; strengthen international collaboration among professional bodies, networks, educational institutions and civil society; provide essential equipment and assistive technology devices; support community-based rehabilitation; and address the mental health needs of children affected by the conflict.

Acknowledgements

The authors acknowledge the contributions of Armen Abagyan and Dr Sadia Anwar to the writing of this manuscript.

Funding: None.

Conflict of interest: None declared.

Répondre aux besoins de réadaptation des enfants souffrant de traumatismes invalidants et/ou atteints d'un handicap à Gaza

Résumé

Contexte : Les enfants ont été gravement touchés par la guerre qui a ravagé Gaza en octobre 2023. Plus de 12 000 d'entre eux ont été blessés et beaucoup vivent dans des circonstances sans précédent, avec des traumatismes invalidants et/ou une forme de handicap.

Objectif : Documenter les besoins en réadaptation des enfants souffrant de traumatismes invalidants et/ou atteints d'un handicap à Gaza.

Méthodes : Nous avons examiné les données cliniques des enfants nécessitant une réadaptation à partir de la base de données de l'ONG Children Not Numbers afin de mettre en évidence leurs types de handicap ainsi que les traitements et les soins requis et reçus.

Résultats : Jusqu'à la réalisation de la présente étude, 242 enfants de Gaza avaient été orientés vers Children Not Numbers pour leur prise en charge, dont 63 (26 %) nécessitaient une réadaptation en raison de traumatismes invalidants graves et/ou de handicaps. La majorité des cas nécessitant une réadaptation (60 %) souffraient d'affections traumatiques, tandis que 32 % présentaient des troubles neurologiques. L'âge moyen de ces enfants était de 6,9 ans avec des extrêmes allant de 4 mois à 17 ans.

Conclusion : La réadaptation ainsi que les soins et le soutien continus sont essentiels pour les enfants souffrant de traumatismes et/ou atteints d'un handicap, qui survivent à la guerre à Gaza, afin d'accroître leurs chances de parvenir à un bien-être durable et à des résultats fonctionnels optimaux. Or, cela n'est réalisable qu'à travers des collaborations et des partenariats intersectoriels et internationaux permettant de répondre aux besoins de ces enfants au-delà de la cessation des hostilités.

تلبية احتياجات إعادة تأهيل الأطفال المصابين بإصابات وإعاقات منهِكة في غزة

علا شتالي، فاطمة رشيد، إلهام لُبَّاد، جوان بوترتون، بارت خييلن، سناء علي، أبو سيداني

الخلاصة

الخلفية: تضرر الأطفالُ تضررًا بالغًا بسبب حرب أكتوبر/ تشرين الأول 2023 في غزة. فلقد أُصيبَ أكثر من 12000 طفل، ويقاسي كثيرون منهم ظروفًا غير مسبوقة في حين أنهم يعانون إصابات شديدة وإعاقات مُنهِكة.

الأهداف: هدفت هذه الدراسة الى توثيق احتياجات إعادة تأهيل الأطفال المصابين بإصابات وإعاقات مُنهِكة في غزة.

طرق البحث: راجعنا بيانات العيادات للأطفال الذين يحتاجون إلى إعادة التأهيل انطلاقًا من قاعدة بيانات مبادرة «أطفال لا أرقام»، بهدف تسليط الضوء على أنواع الإعاقة لديهم وما يحتاجون إليه من علاج وعناية وما يتلقونه بالفعل.

النتائج: حتى وقت إعداد هذا التوثيق، أُحيلَ 242 طفلًا من غزة إلى مبادرة «أطفال لا أرقام» من أجل العلاج ، وكان 63 طفلًا منهم (26%) بحاجة إلى إعادة تأهيل بسبب إصابات وإعاقات مُنهِكة. وغالبية الحالات (60%) التي تتطلب إعادة التأهيل كانت تعاني حالات وإصابات رَضْحية، و 32% من الحالات كانت تعاني حالات عصبية. وكان متوسط أعمار هؤلاء الأطفال 6.9 سنوات (يتراوح بين 4 أشهر و 17 سنة).

الاستنتاجات: لا غنى عن إعادة التأهيل والرعاية والدعم المستمرين للأطفال المصابين والمعوَّقين الذين نجوا من الحرب في غزة، من أجل إعطائهم فرصة أفضل لتحقيق مخرجات الأداء المُثلى والرفاه. والسبيلُ الوحيدُ إلى تحقيق هذا الهدف هو التعاون والشراكات الدولية المشتركة بين القطاعات لتلبية احتياجاتهم فيما بعد وقف الأعمال العدائية.

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