1. Context

The ongoing war in Gaza, which intensified dramatically after October 7, 2023, has led to one of the most severe humanitarian crises in modern history. The Palestinian people, already living under a 17-year blockade imposed by Israel, have been pushed to the brink. This war, marked by massacres, mass destruction, and relentless bombardment, has inflicted untold suffering on Gaza's two million civilians. As of September 24, 2024, Gaza's Ministry of Health reported over 41,495 Palestinians killed and nearly 96,006 injured, the majority of whom are women and children.[1] This staggering death toll has not only overwhelmed families and communities but also crippled the already fragile health and infrastructure systems that sustain life in Gaza.

Long before the 7th of October 2023, Gaza's water, sanitation, and hygiene (WASH) systems were on the edge of collapse. Over decades, Israel's military occupation, imposed blockade, and resource control have systematically undermined Gaza's infrastructure. Palestinians in Gaza have long struggled with inadequate access to safe water, proper sanitation, and healthcare services. The blockade, which restricts the movement of people, goods, and resources, has affected the repair and upgrading of essential facilities, leaving the population dependent on international aid to meet even their most basic needs.

Since the escalation in hostilities after October 7, the situation has worsened exponentially. The destruction of key WASH infrastructure—including water wells, sewage systems, desalination plants, and rainwater drainage networks—has left most of the population without access to safe drinking water or adequate sanitation. The war has created perfect conditions for public health disasters, especially as overcrowded shelters, overwhelmed hospitals, and widespread infrastructure damage exacerbate the risk of disease outbreaks.[2]

The scale of the current destruction is unprecedented. Israeli airstrikes have targeted civilian infrastructure, including hospitals, schools, water facilities, and residential areas, forcing over 90 percent of Gaza's population to flee their homes. Entire neighborhoods have been reduced to rubble. As the rainy season approaches, the threat of flooding and sewage overflows looms large, adding to the already unbearable living conditions for displaced families.

However, this crisis is not merely the result of recent events. It is deeply rooted in the long-standing political denial of Palestinians' rights to self-determination.[3] Since the 1948 Nakba, Palestinians have faced ongoing displacement, dispossession, and denial of their basic rights. The Gaza Strip has been subjected to repeated wars, military incursions, and collective punishment measures, leaving its population trapped in a cycle of destruction and rebuilding. The international community's failure to address the root causes of the crisis, including the ongoing occupation and siege, compounded by the paralysis of diplomatic efforts, has left Palestinians with limited hope for a sustainable political solution.

2. Key Actors

2.1 Israeli Military Forces

According to the principles of international humanitarian law, Israel, as the occupying power, is responsible for ensuring the welfare of the civilian population in occupied territories. However, it has repeatedly violated these obligations by targeting civilians, using water as a tool of collective punishment, and restricting the entry of humanitarian aid, fuel, and spare parts essential for repairing Gaza's WASH infrastructure. As the occupying power, Israel exercises significant control over Gaza's air, sea, and land borders. The ongoing war and blockade have deepened the humanitarian crisis, making it nearly impossible for Palestinians to access basic necessities such as safe water and medical supplies. Israel's military operations and restrictions have systematically targeted civilians and WASH infrastructure, effectively weaponizing water and committing genocide. By restricting humanitarian aid and imposing collective punishment, Israel continues to exacerbate the crisis and impede Gaza's WASH professionals from leading recovery efforts independently.

2.2 Palestinian Authorities

The ongoing hostilities in Gaza have created an environment in which Palestinian authorities and international agencies are struggling to maintain basic WASH and health services. The Palestinian Water Authority (PWA) and the Ministry of Health (MoH) are on the front lines but face severe limitations. The war has claimed the lives of many WASH and healthcare workers, significantly reducing the capacity of the PWA and MoH to manage the crisis effectively amid widespread fatalities, the destruction of critical infrastructure, and severe shortages of vital supplies. They are striving to collaborate with international partners, but the persistent hostilities severely constrain their efforts to restore services and manage disease outbreaks. A focus on enhancing their agency and capacity to operate independently is crucial to sustainable solutions.

2.3 Local Service Providers

The Coastal Municipalities Water Utility (CMWU) and local municipalities, particularly in Gaza City, Khan Younis, and Deir al-Balah, are struggling to keep essential services running. However, their capacity to function has been devastated by the war, which has destroyed the majority of Gaza's WASH infrastructure. Service providers' proven track record in operating complex projects under dire conditions highlights the need to empower local actors, yet they are hampered by inadequate fuel and technical support. Local service providers require resources and international backing to restore basic services effectively and sustainably.

2.4 International Organizations

UN agencies like UNICEF, UNRWA, and WHO, alongside local and international NGOs, are critical in delivering aid. Their efforts to rehabilitate water systems, distribute hygiene kits, and manage disease outbreaks are crucial in preventing a larger humanitarian catastrophe. However, these organizations face severe restrictions imposed by Israel, including limitations on the entry of essential supplies like fuel and spare parts needed for WASH facilities. Humanitarian efforts, while crucial, must empower rather than create dependency among local professionals. Humanitarian workers face significant dangers in delivering aid, with frequent reports of attacks on aid convoys and workers.

3. Impacts on WASH Infrastructure and Public Health

3.1 Infrastructure Damage and Water Scarcity

According to Oxfam's Water War Crimes report (2024),[4] Israel's targeted destruction of water and sanitation systems is systematic, with approximately five critical WASH facilities being damaged or destroyed every three days. As of September 2024, the majority of Gaza's water production facilities are either nonfunctional or severely compromised.

• Water Supply: Gaza's water production has decreased by 84 percent, leaving around two million people without sufficient safe water. The water supply purchased from the Israeli water company, Mekorot, has been reduced by 78 percent, further straining access. The available water supply now stands at only 4.74 liters per person per day, which is considered less than a third of the Sphere Humanitarian Standards, which recommend a minimum of 15 liters per person daily in emergencies.[5] This deficit has left residents struggling to meet even basic hygiene and consumption needs.
• Destruction of Key Facilities: More than 88 percent of water wells, all water quality testing labs, and many desalination plants—key to providing safe drinkable water in Gaza, where most of the water is non-potable—have been destroyed. Additionally, 70 percent of sewage pumps and 100 percent of wastewater treatment plants are nonfunctioning, creating widespread environmental hazards. Five wastewater treatment plants have shut down completely, leading to the direct release of raw sewage into coastal waters and environment.
• Sewage Overflows and Soil Contamination: The collapse of wastewater treatment facilities has caused an overflow of sewage into the streets and residential areas. Gaza's beaches are heavily contaminated with pathogenic bacteria, microplastics, and solid wastes, rendering these waters dangerous for residents and ecosystems. Without functional rainwater drainage, the approaching rainy season is expected to trigger further flooding, spreading untreated sewage even more widely.
• Solid Waste Accumulation: The accumulation of uncollected solid waste due to the closure of disposal sites, many of which are in heavily populated areas, has further worsened the public health crisis. Garbage accumulation in streets creates breeding grounds for disease vectors such as rodents, flies, and mosquitoes, heightening the risk of vector-borne diseases.

3.2 Public Health Emergency and Disease Outbreaks

The collapse of Gaza's WASH infrastructure has led to an unprecedented public health emergency, with communicable diseases on the rise due to the lack of safe water, proper sanitation, and overcrowded living conditions.

• Polio Outbreak After 25 Years: One of the most alarming developments is the resurgence of polio, a disease that had been eradicated in Gaza for 25 years. The reappearance of polio in August 2024 has triggered an urgent vaccination campaign, covering over 559,161 children under 10 years of age.[6] The resurgence of this highly preventable disease is a direct consequence of the breakdown in WASH services, which has compromised water quality and sanitation to such a degree that the polio virus, transmitted through contaminated water, has re-emerged.
• Waterborne Diseases: The shortage of safe water has also led to widespread waterborne illnesses such as hepatitis A and acute watery diarrhea. As of September 2024, nearly a million cases of acute respiratory infections have been reported in Gaza, along with over half a million cases of acute watery diarrhea, many affecting children under five. Additionally, the lack of safe water has contributed to a sharp rise in hepatitis A, with the most vulnerable—children, pregnant women, and the elderly—at greatest risk. This disease, spread through fecal contamination of water and food, thrives in environments where hygiene cannot be maintained. The lack of safe drinking water and poor sanitation practices, particularly in overcrowded shelters, have contributed to this surge in preventable diseases. Gastrointestinal diseases, which have become prevalent, are linked to the consumption of contaminated water and poor hygiene.[7]
• Skin Infections: Overcrowded shelters without access to proper sanitation have also led to an increase in skin infections, including scabies, impetigo, and other hygiene-related illnesses.[8]

3.3 Antimicrobial Resistance (AMR)

Gaza is also grappling with an escalating antimicrobial resistance (AMR) risk, exacerbated by the war. In 2022, before the escalation of hostilities, AMR bacteria had already been detected in several healthcare settings in Gaza.[9] With the WASH and healthcare infrastructure now in complete disrepair, the conditions are ideal for AMR infections to spread. This is compounded by several factors:

• Contaminated Water Supplies: The use of contaminated water in hospitals and other healthcare facilities, alongside overcrowded, unsanitary conditions, can accelerate the spread of infections. In the absence of safe water supply, healthcare facilities are becoming breeding grounds for drug-resistant bacteria.
• Shortage of Medical Supplies: The war has led to a severe shortage of medical supplies, including antibiotics. This has resulted in the misuse of available antibiotics, which can further accelerate the development of resistance. Trauma injuries and immunocompromised patients, unable to receive appropriate treatment, are left vulnerable to infections that cannot be controlled by the limited medications on hand. This combination of factors sets the stage for a broader AMR crisis that could spread beyond Gaza, affecting the region.

3.4 Overcrowding and Impact on Vulnerable Populations

• Mass Displacement and Shelter Overcrowding: With approximately 90 percent of Gaza's population displaced, overcrowded shelters and schools now house tens of thousands of people in unsanitary conditions. Some areas are sheltering as many as 30,000 people per square kilometer. These overcrowded shelters lack adequate water, sanitation, and hygiene facilities, greatly heightening the risk of disease transmission. Conditions in these shelters are particularly dire for women, children, people with disabilities, the elderly, and those with preexisting health conditions. The lack of privacy and limited access to toilets and hygiene products has particularly affected women's and girls' health and dignity.
• Psychological effects: In addition to the physical health consequences, the psychological toll on residents living in such extreme conditions is profound. The constant threat of disease outbreaks, coupled with the lack of safe water, has contributed to widespread anxiety and mental health issues. The breakdown of healthcare services further compounds these challenges, with mental health services being overwhelmed or unavailable.[10] People in Gaza, especially children, are facing unprecedented levels of trauma, with many reporting symptoms of severe stress, anxiety, and depression. Schools, playgrounds, and other safe spaces for children have been destroyed or are nonfunctional, leaving children with few outlets for coping. The MoH estimates that nearly 80 percent of Gaza's children are in need of psychosocial support, but the mental health infrastructure is virtually nonexistent due to resource shortages and lack of professional support.

3.5 Winter Season

The impending rainy season poses an additional layer of crisis for Gaza's already strained WASH and public health systems. Rainwater will exacerbate the flooding of areas where sewage systems have collapsed, leading to the contamination of water sources and widespread displacement.

• Flood Risk: Many of Gaza's low-lying areas, already flooded with sewage, are expected to become further overwhelmed once the rainy season begins. The damaged or destroyed drainage systems cannot cope with the increased water, heightening the risk of contaminated water flooding streets, homes, and shelters. This not only increases the potential for waterborne diseases but will likely displace thousands more, further crowding already overwhelmed shelters.
• Sewage Overflows: The breakdown in sewage systems will lead to more frequent and severe overflows, further polluting water supplies and exacerbating public health risks. In particular, shelters, many of which are makeshift to withstand heavy rains, will be at risk of collapse, worsening the crisis for displaced families.

4. Required Actions

To address the urgent WASH and public health crisis, immediate and coordinated action is essential. The following interventions should be prioritized:

4.1 Immediate International Support for Ceasefire and Humanitarian Access

The situation demands an immediate and sustained ceasefire in line with UN Security Council Resolution 2527, passed in March 2024. Immediate international aid and the provision of essential supplies can help restore key services like water production and sewage treatment. Establishing safe humanitarian corridors is essential for delivering lifesaving supplies to Gaza's WASH and health sectors. The international community must press Israel to allow unhindered access for fuel, medical supplies, and spare parts. Without safe corridors, Gaza's recovery and stabilization efforts will remain impossible. Essential, short-term aid does not address the underlying causes of the ongoing conflict; therefore, long-term political solutions need to be considered to end this crisis and to prevent future cycles of recurring crises.

4.2 Immediate Restoration of WASH Infrastructure

Local service providers, with support from international agencies, must urgently restore critical WASH infrastructure to prevent disease outbreaks and reduce environmental hazards. This includes repairing damaged water wells, desalination plants, and sewage treatment facilities. Water Supply Chain Improvement through mobile water tankers to alleviate the immediate scarcity of clean water can be deployed to areas with the greatest need. This temporary solution will help reduce the reliance on contaminated sources until more permanent facilities can be rebuilt.

4.3 Flood-Risk Management and Sanitation Solutions

Efforts to evacuate flood-prone areas and repair damaged drainage systems are critical but must be coupled with international support to introduce safe shelters and improved WASH services. Shelters must be equipped with proper sanitation facilities to mitigate the risk of disease outbreaks.

4.4 Strengthening Public Health and Disease Prevention Programs

Immediate interventions are needed to control the spread of waterborne and vector-borne diseases. These include providing safe WASH services and hygiene kits, as well as conducting public health awareness campaigns. Special attention must be given to replenishing critical medical supplies and medicines, and expanding vaccination campaigns. International support is also essential for establishing mental health services to address the escalating psychosocial needs of the population. Distributing safe water and hygiene kits while maintaining infection control and prevention measures will reduce waterborne disease rates in overcrowded shelters. However, public health initiatives rely on the availability of medical supplies and fuel, both of which are currently scarce. Delivering these services to the most affected areas is challenging due to restricted access, and addressing the rise of AMR will require longer-term improvements in WASH services.

4.5 Empowering Local Institutions and Workforce

Empowering Gaza's local institutions, such as the Palestinian Water Authority (PWA), and the service providers, including Coastal Municipalities Water Utility (CMWU), to independently manage and operate WASH services recovery efforts is essential for sustainable rebuilding. International organizations should support training, resource allocation, and technical assistance to strengthen local capacity. Additionally, Palestinian professionals should be supported through financial and technical resources, allowing them to spearhead WASH and health interventions in coordination with international agencies.

4.6 Long-Term Development and Resilience Building

The cycle of destruction and reconstruction in Gaza will only end with a sustainable solution to its political challenges. Long-term WASH and health resilience strategies are necessary to empower Gaza's population and avoid future humanitarian crises. The international community must advocate for a political solution that addresses the root causes of Palestinians' suffering, including lifting the blockade and ensuring Palestinians' rights to self-determination.

5. Conclusion

Gaza's WASH infrastructure is in a state of collapse, with dire consequences for public health. The destruction of water wells, sewage treatment plants, and drainage systems, combined with the displacement of around two million people and the accumulation of solid wastes, has created a humanitarian crisis. The huge number of fatalities and injuries, the emergence of polio, the increased risk of antimicrobial-resistant infections, and the severe overcrowding in shelters are all urgent red flags.

The coming rainy season will exacerbate the crisis, with flooding and sewage overflows likely to contaminate water supplies and displace even more people. Immediate, coordinated action is required to prevent further loss of life, control disease spread, and alleviate suffering. The following recommendations outline essential steps for immediate response and long-term resilience building.

6. Recommendations

• Ceasefire and Humanitarian Access: Implement a sustainable ceasefire in line with international humanitarian law, allowing for the safe and unrestricted movement of humanitarian aid. A stable ceasefire will enable critical repairs to WASH and healthcare infrastructure and provide safe conditions for humanitarian workers and affected communities.
• WASH Infrastructure Restoration: Mobilize international support for both immediate and long-term restoration of Gaza's WASH systems. This includes emergency repairs of water wells, desalination plants, and sewage systems, as well as the deployment to mitigate public health risks.
• Strengthening Healthcare for Vulnerable Populations: Improve healthcare access and vaccination campaigns, preventive care, and trauma support, particularly for children, the elderly, and those with chronic conditions. Field hospitals, mobile clinics, and psychosocial support services are essential to address immediate needs and to alleviate pressure on Gaza's overstretched healthcare facilities.
• AMR Mitigation: Address the hidden but escalating threat of antimicrobial resistance by improving hygiene and sanitation measures, expanding access to safe water, reducing overcrowding in shelters, maintaining infection control protocols, and ensuring the appropriate use of antibiotics. These actions are vital to containing AMR and preventing the spread of resistant infections.

Through a coordinated response that balances immediate humanitarian action with long-term resilience building, Gaza's WASH and health sectors can begin the path to recovery. Only by addressing the root causes and ensuring consistent, equitable support can the international community help Gaza's population secure their right to health, safety, and dignity.

[1] UNRWA, “UNRWA Situation Report #140 on the Situation in the Gaza Strip and the West Bank, including East Jerusalem,” 2024, accessed on September 27, 2024.

[2] OCHA, “Humanitarian Situation Update; Gaza Strip,” 2024, accessed on September 27, 2024.

[3] M. Zeitoun, N. Carmi, L. Turley, and M. Tignino, “Weaponising Water in Gaza,” Geneva Policy Outlook, 2024.

[4] L. A. Samad, M. Butcher, and B. Khalidi, “Water War Crimes: How Israel Has Weaponised Water in Its Military Campaign in Gaza,” Oxfam Policy & Pratice, 2024.

[5] Sphere Association, The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response, fourth edition, Geneva, Switzerland, 2018.

[6] WHO, “oPt Emergency Situation Update-Issue 45,” accessed on September 19, 2024.

[7] OCHA, “Humanitarian Situation Update; Gaza Strip,” 2024, accessed on September 27, 2024.

[8] A. Abbara, R. Abu Shomar, M. Daoudy, et al., “Water, Health, and Peace: A Call for Interdisciplinary Research,” Lancet, 2024, (published online, March 2024).

[9] R. Abushomar, M. Zeitoun, G. A. Sittah, A. A. Fayad, A. Abbara, N. El Achi, and A. Elmanama, “Antimicrobial Resistant Bacteria in Health Care Facilities: Exploring Links With Water, Sanitation, and Hygiene in Gaza, Palestine,” Iproceedings, 8(1), e37246 (2022).

[10] Health Cluster, “Health Cluster Bulletin - Aug 2024,” accessed on September 25, 2024.