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

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. 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 interconnections between war-induced systemic disruptions and health outcomes. Network analysis identified key nodes and pathways within the systems map. The findings of this study reveal a complex system of war-driven factors including 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 34,458 pathways linking conflict-related disruptions to health outcomes. Women's health emerged as a central mediator, with 97% of pathways intersecting with 25 key nodes including 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 preventable, self-limiting diseases become fatal. This study highlights how conflict restructures health determinants, turning survival strategies into pathways of increasing morbidity and mortality. It also underscores the need for a systems-based humanitarian response that considers the intersecting pathways driving outcomes in crisis settings.