Research report provides interim overview of effects of war on water and health in Gaza

On the 24th of April, the Geneva Water Hub published a report on the effects of war induced damage to water and sewage services on public health in Gaza since the 7th of October 2023. Piecing together available data on the changing status of these services and the concomitant effects on public health, the report also reviews the evidence from the point of view of international humanitarian law, which requires military decision-makers to consider the reasonably foreseeable impacts of their attacks.

These foreseeable effects include, on the one hand, the direct and visible impacts of war on water and sewage infrastructure – such as the destruction of a water tower - and on the other hand the indirect and medium-term impacts – such as the release of microbiological and inorganic contaminants into water supplies and the wider environment, which can in turn inhibit health care efforts and expose the public to environmental hazards.  These impacts can ‘reverberate’, leading to detrimental impacts on public health long after the direct impact has been felt. Furthermore, although water and sewage systems may have a basic level of resilience to attacks in that the services can be repaired and restored, services that have been repeatedly subjected to damage and neglect are considerably more vulnerable. Not only does it become more difficult to restore services under these conditions, but a vicious cycle of multiple rounds of damage can also act to amplify the reverberating effects, undermining public health and individual resistance. For some people, these effects can be more dangerous than the conflict itself: UNICEF has shown that children under 5 years of age living in conflict are 20 times more likely to die from diarrhoea linked to unsafe water and sanitation conditions than to direct violence in conflict.

Foreseeing these effects is important in the context of International Humanitarian Law, which describes the rules that should guide the conduct of hostilities, including the reduction of the impact of hostilities on civilians. Article 54(2) of the 1977 Additional Protocol to the Geneva Conventions of 1949 explicitly states that “it is prohibited to attack, destroy, remove or render useless objects indispensable to the survival of the civilian population” and includes drinking water installations and supplies and irrigation works among these objects. Beyond humanitarian law, there is a growing body of norms which serve to protect water and sanitation as part of the set of international norms designed to protect civilian infrastructure. In addition, there are diplomatic initiatives such as the recently launched initiative to spare water from armed conflicts .

In its second section, the report delves into the concrete effects of the war on water and health in Gaza. A total of 33,000 people have been killed in Gaza over the past seven months, and an additional 7,000 are still missing. Before the recent eruption of conflict, urban services have been damaged by several rounds of conflict in 2002, 2008, 2012, 2014 and 2021, with increasingly detrimental effects in water and sewage services. The quality of drinking water was low, and services were hampered by restrictions imposed on the development of the sector. However shortly after the eruption of the recent conflict, the emergency response plans quickly deteriorated into firefighting exercises, maintaining the functionality of priority water points, providing water to shelters, and negotiating a temporary  pipeline from Egypt.

In terms of direct impact, it is estimated that 57% of water infrastructure and assets had been destroyed or damaged by the end of January 2024, including 162 wells and the headquarters of the Coastal Municipal Water Authority.  9 sewage pumping stations have been damaged along with 30 km of sewage pipelines. At the time for reporting a mere 17% of groundwater wells and one bulk water pipeline from Israel were operational. No sewage treatment plants are operational because of Israeli denial of entry of fuel. The average per capita access to water has been reduced to just one or two litres a day (as compared to the Sphere standards , which set a minimum of 15 litres per day). Hygiene is at risk, as in the shelters and camps there is less than one toilet available per 340 people, and one shower per 500 people. As a result,at least 23 children had reportedly died from malnutrition and dehydration by mid-March. Efforts to restore safe water supplies and hygiene are hampered by the limitations imposed on the transport of humanitarian aid.  

In terms of the reverberating impacts, there has been a collapse of the health care system, with damages to all hospitals and the destruction of 25.  200 aid workers and 480 health workers have been killed, along with several water and sewage personnel. As a result, the World Health Organisation and many other health organisations have sounded the alarm over the spread of infectious diseases.  By the end of March, more than 315,000 cases of acute watery diarrhoea had been reported, along with 81,000 cases of scabies, 46,000 cases of skin rashes and 19,000 cases of jaundice. Another 58,000 people are projected to die from injuries and disease by August 2024 if the violence continues at this level. Furthermore, 95% of the population face acute food insecurity, the highest rates ever recorded globally.

Among the longer-term impacts, there have been concerns that the flooding of tunnels with salt water would permanently pollute the main aquifer supplying water to Gaza. There are risks of increased incidences of kidney disease, dangers of the emergence of antimicrobial resistance, and the continued spread of infections.

In order to break this vicious cycle of impacts of the war on water and sewage systems, the report notes that some of the main amplifying factors that cause reverberating effects include the breakdown of the health system, the denial of electricity and fuel, poor sanitary conditions and the lack of water. severe malnutrition, and the denial of humanitarian assistance. This can all be countered through adherence to International Humanitarian Law: all those involved in military decision-making should make provisions for and facilitate the repair and restoration of the services which can prevent the transmission of disease. This means either restoring the damages directly or providing safe access and security for people who run and repair the services. The most immediately beneficial actions Israel could take are to allow the delivery of chlorine, restore the bulk water supplies, repair the water reservoirs, deliver fuel to sewage treatment plants, and provide the means necessary to operate a full scale disease control programme.

 In the report, the magnitude of the reverberating effects of war on water and health services in relation to infectious disease are judged to have foreseeable before 7 October 2023 and were foreseen publicly by several actors shortly thereafter, and future effects have now been quantified and qualified. The title of the report is therefore “Fully Foreseeable: the reverberating effects of war on water and health in Gaza”.