Researchers from Israel – a country that has targeted hundreds of healthcare centres in Gaza to much global outrage – have published a peer-reviewed paper that offers “practical lessons that could help hospitals worldwide prepare for prolonged armed conflicts and other large-scale emergencies.”

The paper, published by the Cambridge Univerrsity Press, draws lessons from the MCI (mass casualty incident) protocol in the 300-bed Assuta Ashdod Hospital in Israel during the October 7, 2023, Hamas-led attack. Despite the upheaval, the hospital was able to function, thanks to a rigorous protocol set in place.

Much before the attack, the hospital had installed “a strong culture of emergency preparedness,” that included MCI drills conducted every three months, the researchers found. The hospital was specifically designed with “protected infrastructure,” in sensitive areas with reinforced concrete.

Therefore, on the day of the attack, the hospital’s MCI plan was quickly activated and 87 casualties were treated for gunshot wounds, blast injuries, and burns. After imaging, patients were moved to a “holding area” looked after by an emergency physician while scans were reviewed. “On October 7, patient care was provided while the hospital remained under ongoing rocket attacks,” say the authors.

The day of the attack began with a “massive rocket barrage” followed by “a coordinated ground assault involving approximately 3000 armed militants,” says the study adding that unlike “single-site incidents,” this one “was an ongoing, large-scale, multi-front assault”. Approximately 1,200 people were killed and many others wounded.

A “cornerstone” of wartime health systems preparedness is therefeore hospital MCI plans, reiterates the paper. “The Russian full-scale invasion of Ukraine and October 7 were historical inflection points,” said lead author Maximilian Nerlander, in a release. “It is becoming increasingly evident that at some point in the future, other parts of the world will face the same type of high-intensity asymmetric warfare as Israel did on October 7.”

Curiously, the word Palestine, whose healthcare system is all but dismantled by Israeli strikes, does not figure once in the paper. In the two years following October 7, 2023, over 10% of the population of Gaza has been directly killed or injured by Israel attacks, according to a paper published by The Watson School of International and Public Affairs, at the U.S.-based Brown university. This coincided with the destruction of infrastructure, energy, water, sanitation, agriculture, housing, and healthcare. According to the Gaza Ministry of Health, in the two years after the October 7 attacks, Israel has retaliated with a prolonged war against Gaza, where 67,075 people have been killed and 1,69,430 people have been injured, totalling 236,505 casualties.

Dr. Nerlander hoped that “the tragedy of that day can be converted into knowledge that can save lives and avert suffering in the future, wherever it occurs.” For the Israeli study, semi-structured interviews were conducted with 19 emergency department staff members who worked on the day of the attack, who narrated their professional experiences. The study, said the researchers, hoped to “generate actionable insights for hospitals seeking to develop resilient MCI plans that remain functional during wartime.”

The scientists admitted that real time war exposed crucial gaps in communication, staffing, logistics, and casualty distribution too. While hospitals in Europe and the U.S. have activated MCI plans during incidents such as the 2005 London bombings, the 2015 Paris attacks, the 2016 Orlando nightclub shooting, and the 2017 Las Vegas shooting, these events “did not directly threaten the hospitals themselves,” the paper says.

The researchers concluded that during war, MCI plans can remain effective by prioritising staff safety and mitigating burnout. Information should be collected from multiple sources, and frequent, realistic drills must be conducted to help to maintain operational performance under the extreme stress of war, they added.

“Hospital mass casualty incident (MCI) plans must be able to remain operational during wartime, affirms the says the paper.

Published - August 06, 2026 09:05 pm IST