In this episode of A Moment in Health, Dr. Ashish Jha spotlights a sobering data point: 40,000 estimated hepatitis A cases in Gaza since the start of the war in October 2023. He reviews a JAMA Network Open study on chronic disease care in war-torn Tigray, Ethiopia, which found a dramatic decrease in the number of patients with conditions like diabetes who had access to treatment. Dr. Michael VanRooyen, Chair of Emergency Medicine at Brigham and Women’s Hospital and founding director of the Harvard Humanitarian Initiative, joins to outline what it takes to rebuild Gaza’s health system—beginning with stability and governance, clearing unsafe areas, sustaining emergency care, and gradually restoring long-term health infrastructure and workforce capacity.

Dr. Jha discusses:

• War and Health Care Services Utilization for Chronic Diseases in Rural and Semiurban Areas of Tigray, Ethiopia — JAMA Network Open

About the Guest

Dr. Michael VanRooyen is the founding director of the Harvard Humanitarian Initiative (HHI), an interfaculty initiative at Harvard University dedicated to advancing evidence and professional development in humanitarian assistance. He has led complex humanitarian operations with numerous relief organizations in more than thirty countries affected by conflict and disaster, including Somalia, Bosnia and Herzegovina, Rwanda, Iraq, North Korea, Sudan–Darfur, Chad, Democratic Republic of the Congo, Palestine, and Ukraine. Dr. VanRooyen is the Chair of Emergency Medicine at the Massachusetts General Hospital and at Brigham and Women’s Hospital, as well as the Enterprise Chief of Emergency Medicine for the Mass General Brigham health system.

About the Host

Dr. Ashish K. Jha is the dean of the Brown University School of Public Health.

Music by Katherine Beggs, additional music by Lulu West and Maya Polsky

Hey, folks, Ashish Jha here from a cool, increasingly Fallout day in Providence, Rhode Island, and you're listening to another episode of a moment in health, a podcast where we talk about a data point, discuss a study and answer a question. So let's jump right in data point 40,000 that's the number of estimated Hepatitis A cases that have occurred in Gaza since the beginning of the Gaza war two years ago, of October 7. Why is that number Interesting? Well, first of all, it's a dramatic increase from what we've had in the past. And the reason I want to take a minute to talk about it is when we think about conflicts, war, like the war that has happened over two years in Gaza, I think we can all be super thankful it has come to an end. We think about the people who die directly, the people shot, people who get hurt by bombs or killed by bombs, or all of that. And that's, of course, the most visible tragedy, and it is awful, what happens in wars. But there is an underlying important issue, which is that health systems really get destroyed during wars. The ability to take care of people, the basic public health also gets severely compromised. We saw polio vaccinations resumed in the middle of the war. This latest data, 40,000 is really about both the public health infrastructure, the water quality in Gaza, and how the suffering of the people of Gaza because of this war goes so much deeper than the numbers you see in the headlines. So 40,000 you all right, let's talk about a study of the week, and it's going to stay on the same theme. This is from JAMA Network open from a couple of years ago. It's called War and healthcare service utilization for chronic diseases in rural and semi urban areas of Tigray Ethiopia. So for those of you who don't know, Tigray Ethiopia has been having a conflict, and it's been going on for a long time. And what these investigators did was they looked at data from the affected areas and said, what happens to people with

chronic disease during conflict. And they looked at 135 primary care health the primary health care facilities, and looked at almost 5000 patients with chronic diseases, things like diabetes, high blood pressure, tuberculosis, HIV, psychiatric disorders. And said, what happened to their care during the conflict? And you will not be surprised. The answer is, they find about 80% of people are it appears about 80% of people, again, the record keeping here is tough. Are no longer getting any kind of care at all that seems to span all of these different conditions. Essentially, about 20% of people are able to stay in the healthcare system a little bit, maybe get to the doctor's office, maybe continue to get some treatments. But even for those 20% there is a dramatic decline in testing and other things that are so important to managing chronic disease. And basically their conclusion is that health care disruption during a war is very, very high, and most patients are lost to follow up with chronic disease. Maybe some of them were actually directly injured by the war, but if not, the healthcare disruption is going to have very large negative consequences for their health. So war on healthcare service utilization for chronic disease in JAMA Network open.

All right now for the question of the week and for the question of the week, we have a very special guest, my friend, Dr Michael Van Royan. Mike is an emergency physician, Chair of Emergency Medicine at Brigham and Women's Hospital professor at Harvard Medical School. And for this, really the founding director of the Harvard humanitarian initiative, which has been working for years on bringing evidence and systematic approaches to dealing with humanitarian crises. Mike, thanks so much for

being here. Ashish, my pleasure. Thank you.

So my question for you is this, the peers that the war in Gaza is thankfully over, you have studied war torn places, places with humanitarian crises. What is the evidence, data, experience, tell us about how we begin to rebuild the public health system, the healthcare system of Gaza for the people of Gaza.

Thank you. It's a really pertinent and timely question, so I appreciate your asking it. The first thing I say is that the evidence based is thin, because each one of these are actually quite different based on the capacity that they had before and based on sort of the conduct of the war and the damage. So they're like, you know, each case is, in and of itself, a case. And so I think there are some natural things to think about as we think of some degree of rebuild. Limitation. And the first thing I'll say is that stability is everything. So before anything can happen, there needs to be stability, governance, safety, access, right? And so those things have not been the case. It's been actually, you know, a highly conflicted, very dangerous area where organizations could hardly get any access whatsoever. So there would have to be sort of a renewed commitment and a creation of governance and of structures that will allow the rebuilding to happen, assuming that that can happen in a place like Gaza, which is still incredibly politically complicated, still. Then there's kind of the logistics of getting in and getting started so we can address that. The first is creating a safe environment for people to return to their homes or whatever was left to their I guess, land and a lot of that is actually sort of clearing explosive ordnance, having the professionals do this, I think, engagement with UN agencies that really look at issues like this and other sort of mine action and organizations that look at De conflicting space, I think, is really first so creating a safe environment, first again, giving access to organizations that can work in that area. And then start the lifeline process where people come back, and you can do just in time, ability to care for people who need care on the spot. And these are still going to be humanitarian relief, right? These are organizations who are going to provide health care and water and food and

sanitation all the while, then thinking of, what do you do with this intensely damaged and destroyed area? Like really, virtually all the healthcare facilities are are almost completely damaged, if not completely damaged. So the next thing to do is then the issue of debris and movement and creation of sort of structures, and that's going to take years, actually. So in order to reboot essential health care services and reboot public health services, you need to have facilities and and you also need to have people. And those people are, you know, going to be not there, either, you know, dead or gone or whatever. And so the ability to bring people back and healthcare person power back, to be able to start all of those essential services, and you could list them right. There's everything from curative surgical care to medical care to outpatient treatment to Family Services and planning to obstetrics to nutrition and mental health, and the list goes on. So I think the first thing to do is we still need to keep those emergency medical teams in place while there is some degree of creation of excess and also some degree of stability. Then after sort of that gets started and rebuilding can really happen, which, of course, everything needs to be rebuilt, right? Everything from the grid to water and sanitation to everything. Then it's a matter of really planning the healthcare system. And that's a much more of a sort of a 12 month and beyond, maybe two year and beyond, effort. And that'll be really looking at facilities, how facilities can be run again, person power to help establish that, and then really getting the sort of priorities for health care to get started. And those are supply chain, pharmaceuticals, medical supplies, training, all of those issues. So, you know, the it's a it's an enormous task, but there's some things that really have to come first before we can even contemplate the technical aspects of healthcare reconstruction.

Wow. So first of all, thank you. That's a very thoughtful and helpful answer, because it not only lays out some timelines, but also prerequisites for certain types of activities. And I, you know, the fact that, like, you have to kind of deconflict space, and the fact that, yeah, there's all of this, probably unexploded ammunition, all that stuff, stuff that we don't think about money in my brain, I was like, oh, we should work on rebuilding the health system of Gaza. Well, of course we should do that, but you're laying out governance, cleaning up space emergency care, which will probably have to last for a while until the health system can get stood up. Yes, need for people to come back. It's a great map, a daunting map, one that is going to take a long time. I worry that the world's attention will shift quickly, as it often does, but that's why people like you are extraordinary, because you but others stay in this for the long run to build these things for the long run. Mike, thank you for taking time on short notice and your busy schedule to talk to me about this. That roadmap was great, and I just want to say how beautiful I am for you being this out. So thanks

so much my pleasure. Lushish, have a good day. Thank you. Thank you. Bye.

All right. So there you have it, another episode of a moment in health where we talked about one data point, 40,000 estimated number of hepatitis A cases in Gaza over the two years of the Hamas Israel conflict. And a reminder that war leads not just to direct casualties, but the public health system getting destroyed, fragmented, undermined, whatever you want to say, it ends up harming it, and then you start seeing disease outbreaks like Hepatitis A which is both a failure of the public health system, but also a failure of the sanitation system. We talked about one study war on healthcare service utilization for chronic disease in rural and semi urban areas of Tigra Ethiopia. And there they were looking at chronic disease and what happens with for people with chronic disease like HIV, mental health issues, TB, and what you find is huge disruption. So the thing that we're seeing in Gaza is really kind of a feature of all conflicts, and 80% of people lost a follow up. Even the people who were able to get health care during the conflict saw declines in what they were able to get. A reminder that health care systems are wildly disrupted during conflicts. And then we talked to the great Mike van Roy. Dr. Mike van royen is an emergency room physician at the Brigham at Harvard Medical School, really one of the leading global experts on humanitarian health and what you do in moments like this. And I thought Mike did a brilliant job laying out the steps that need to be taken now. Begins with governance, making sure you have a basic functioning of government begins the next step is de conflicting, I think was the word he used, space. There's a lot of unexploded ammunition. There's a lot of other dangerous things that just need to be cleaned up before you can even start getting humanitarian workers in. Then for six months a year, maybe longer, it's going to be about emergency care, just having people there, managing day to day emergencies, medical

emergencies, building basic public health supplies, food, water, and then the longer term planning of hospitals and equipment and supply chain, and people bringing people back, getting doctors and nurses staffed. All of that is going to take many, many years, and it's really important, after a conflict, when the world begins to lose attention, for all of us to remember that the people of Gaza have suffered immensely in the last two years, and they deserve a health system that will take care of them, and we all have an obligation to do our part to helping Get that rebuilt. So anyway, that's our episode. Really important issue this week, thinking about conflict, public health and how we rebuild Now, thankfully that the war in Gaza appears to be over. Thanks so much for joining me, and next week I'll be back with another episode of a moment in health where we're gonna talk about a data point, we'll talk about a study, and we'll answer a question. Be Well, everybody, foreign.