Since October 2023, Gaza has witnessed surging rates of infectious diseases. By June 30, 2024, WHO reports showed nearly a million cases of acute respiratory infections, more than half a million cases of diarrhea, and approximately 104,000 cases of acute jaundice syndrome[1]. In addition to a high number of skin disease cases: over 103,000 cases of scabies and pediculosis, nearly 66,000 cases of skin rashes, and 11,214 cases of chicken pox[2]. A UNICEF survey in February revealed that over 90 percent of children under five years old were found to have one or more infections within the two-week period before the survey[3]. The incidence of disease spread continues to soar due to disruptions that affect health facilities, water, and sanitation systems, in addition to overcrowding and malnutrition.
The spread of infectious disease represents a further facet of Israel's war on the Gaza Strip which began in October 2023 and continues with evidence of ongoing genocide[4]. Since the war started, over 145,000 Palestinians have been killed, injured[5], or reported missing[6], and 70 percent of these are children and women[7]. Such mass casualties within this period represent the highest since the occupation of Palestine in 1948 (aka the Nakba). In addition to these figures, thousands of excess deaths are occurring from infectious disease outbreaks, malnutrition, and exacerbation of chronic illness, according to a projections study conducted by researchers at the London School of Hygiene and Tropical Medicine and Johns Hopkins University[8].
Poliovirus Outbreak
Another disturbing barometer of the infectious disease crisis in Gaza is the recent poliovirus outbreak. Poliovirus type 2 was detected in environmental samples collected in June 2024 from Gaza[9]. In August, a 10-month-old unvaccinated child was paralyzed due to polio, which is the first case detected in 25 years[10]. This devastating event is a further example of how unconditional support to Israel in its military attacks on Gaza has rapidly eroded two decades of progress in the Palestinian health system. The Palestinian Ministry of Health, with the support of the World Health Organization (WHO), UNRWA, UNICEF, and other international and national health stakeholders, has started two phases of polio vaccination to halt the transmission[11]. However, WHO has indicated that efforts to acquire vaccines are not enough to ensure that vaccines cross the border as the Israeli authorities impose restrictions,[12] and the vaccination campaign is limited to seven days[13].
Gaza's pre-war immunization coverage rate of polio was 98.8 percent in 2022, according to the Ministry of Health report in the Gaza Strip. Since October, the immunization program and disease surveillance system have been disrupted by the systematic assault on the health system and the constant displacement of the population. WHO stressed that the high risk of vaccine-preventable infectious diseases among children under five years old is due to the fact that the majority of them have not been vaccinated during the last nine months because of the Israeli military attack[14]. The population has had to move amid warfare in order to vaccinate their children. UNICEF has estimated that nearly 17,000 children have missed their pre-war routine vaccination in the first three months of the Israeli war on Gaza[15]. That puts the children at risk of deadly infectious diseases like measles and poliovirus despite the fact that these are vaccine-preventable diseases. The current polio outbreak represents an early manifestation of the disruption and the consequent poor vaccination coverage, and the probability that hundreds are vectors spreading the disease. There is an imminent risk of other vaccine-preventable infectious disease outbreaks, including measles, mumps, rubella, and pertussis. Researchers have projected the mortality of thousands of cases in outbreaks of these vaccine-preventable infections in Gaza given the current health crisis.[16] Even if a ceasefire is agreed upon now, the risk of outbreak and mortality exists because it takes time to restore healthcare services, improve the water, sanitation, and hygiene (WASH) status, and reduce malnutrition[17].
How Does the Ongoing Israeli War on Gaza Pose Risks of Infectious-Disease Outbreaks?
The humanitarian and public health catastrophe in the Gaza Strip is consequently associated with an increased risk of infectious diseases[18]. This increase is attributed to several interacting factors categorized under WASH, overcrowded shelters, malnutrition, and disruption of healthcare services.
Breakdown of WASH Status
Oxfam has noted that every three days since the start of the war, five water and sanitation sites have been damaged or destroyed by the Israeli army, in addition to the destruction of the primary water quality monitoring laboratories in Gaza[19]. All sewage treatment systems and 70 percent of wastewater pumps have been destroyed[20]. This has consequently affected the breakdown of water, sanitation, and hygiene measures.
- Breakdown of water measures with less than 1 liter of water per person per day (l/p/d) for drinking, washing, and bathing[21]. The Sphere humanitarian standard is 7.5 l/p/d for survival and a minimum of 15 l/p/d.[22] As a result, residents of the Strip have been forced to resort to non-drinking water sources[23]. In addition, access to clean potable water is a concern, with an estimated 0–0.6 liter per person per day.
- There is a collapse of sanitation with reports of over 883 persons having access to only one toilet[24], whereas the humanitarian standard stipulates a maximum of 50 persons per toilet[25]. Sometimes toilets are not functional and open defecation has been reported[26]. In addition to the unavailability of safe water, the very limited access to hygiene products in the market is further breaking down WASH status[27]. Hygiene items have been reported to be unaffordable, given the significant increase in the cost of basic hygiene items, when available. For instance, the cost of soap in July 2024 increased by 1,117 percent, and the price of shampoo increased by 490 percent across the governorates of the Gaza Strip compared to July 2023[28]. In addition, over half a million menstruating girls and women continue to struggle to access hygiene products.(4) Waste management systems in Gaza have collapsed due to Israeli attacks on infrastructure and civil service properties, with trash mounds growing and sewage being discharged onto the streets[29].
Food Insecurity Predisposes People to Infectious Diseases
Human Rights Watch documented that Israel has used the starvation of civilians as a method of warfare in their military war on Gaza[30]. Israel has targeted and destroyed the food system and its infrastructure, in addition to blocking external food supplies[31]. All Palestinians in the Gaza Strip face crisis levels of food insecurity (Integrated Food Security Phase level 3 or higher)[32] [33], with 15–35 percent of households facing catastrophic levels of food insecurity and imminent risk of famine[34]. Furthermore, UNICEF has highlighted the high level of malnutrition and wasting among children under five years of age and pregnant and breastfeeding women[35] [36]. Thirty-one deaths, among them 28 children, were recorded, and the cause of death was malnutrition and dehydration[37]. Acute food insecurity and malnutrition put individuals at high risk of catching infectious diseases[38], and increase the risk of dying from these diseases due to the absence of adequate medical care[39] [40].
Overcrowded Shelters and Camps
The intensive aerial bombing and the ground offensive have resulted in over 70 percent of the Gaza Strip's residential buildings and infrastructure being damaged or destroyed[41], alongside the extensive large-scale (multiple) forced displacement of more than 2 million people out of the pre-crisis population of 2.3 million, the majority of whom have been displaced several times[42]. Most displaced people are living in tents and overcrowded shelters that are concentrated in an ever-shrinking geographic area with minimal access to water and sanitation[43]. Many shelters are UNRWA schools that house an average of 18,000 people, which exceeds the pre-crisis plan of 200 people per shelter[44]. The overcrowding in shelters and camps increases the risk of infectious disease transmission among the displaced population and predisposes the people to outbreaks, especially if associated with disruption of healthcare services, immunization, and disease control programs[45]. Thousands of displaced people living in tents and camps are facing dire living conditions, with insufficient food and medical assistance[46] [47]. A UN assessment of one of the camps reported a severe lack of clean water because the military attacks had damaged the camp's water supply, solid waste had accumulated and sewage overflowed near the sleeping sites, and there was no access to cleaning or hygiene supplies[48].
Disrupted Access to Quality Healthcare Services
Israel has carried out 505 attacks against healthcare to date, affecting 110 health facilities, including 32 inpatient hospitals, 115 ambulances, including 63 that sustained damage, with abundant fatalities and injuries among health workers and patients[49] [50]. The attacks against the healthcare system have not left even one fully functioning healthcare facility[51]. In addition to security, access to medical care has been disrupted due to impassable roads and damaged infrastructure. Israel has clearly violated international humanitarian law which mandates protecting health facilities, medical personnel, and patients, as well as ensuring access to and receiving medical care during war[52] [53] [54].
The structured attacks against health infrastructure components, including the health frontline, health facilities, numerous evacuation orders, and near-complete blockade of medical, humanitarian, and fuel supply chains, have resulted in severe disruption of healthcare services with the virtual collapse of the health system and its components, including the surveillance and immunization program. The collapse of the health system is further manifested by the re-emergence of preventable infectious diseases[55].
Attributing Responsibility
International humanitarian law obligates the occupying power to ensure provision of food and medical supplies, maintenance of medical services, public health, and hygiene[56] [57]. Specifically, article 56 highlights the significance of halting the spread of infectious diseases and epidemics[58]. The sharp rates of infectious diseases in Gaza, particularly the polio outbreak, showcase the public health crisis that Israel has created. Water, food, medicine, and fuel are being used as weapons of war[59] [60]. Such actions have historical precedent as when colonizers induced waves of contagious diseases among the Indigenous population—for example, epidemics among the native population in North America when colonizers distributed blankets contaminated with smallpox with the aim of ethnically cleansing the native population[61]. In occupied Palestine, the brutal military assault has created a perfect environment for the occurrence and spread of infectious diseases, as well as for implementing elements of biological warfare. There is therefore a direct parallel between the actions of European colonizers in North America and European colonizers in Palestine. The infectious disease burden in Gaza, in addition to its urgent public health significance, has serious implications when considered alongside Israel's obligations as an occupying power to comply with international humanitarian law and other statutes.
The impact of systematic damage to the health system and its infrastructure in Gaza will haunt Israel sooner or later. It is obvious that the polio outbreak in Gaza has put Israeli civilians at high risk as there is a large unvaccinated ultra-Orthodox population in Israel who decline immunizations and who are thus at high risk of contracting vaccine-preventable infectious diseases, including polio[62]. The recent polio outbreak also highlighted the rooted health inequity in Palestine between the colonizer and the colonized population. Israel started to vaccinate its soldiers shortly after polio was detected in Gaza sewage water without taking any precautions or actions for the occupied population[63]. It was only weeks after the detection of symptomatic cases that Israel started to take action regarding the civilian population in the Gaza Strip. This attitude emphasizes the link between Israel as a colonial state and the historically consistent attitude of colonizers where the health of the colorized population only becomes a concern for the colonizer when it threatens the health and economy of the colonizers[64]. Furthermore, this attitude is deeply intertwined with a focus on global health security rather than international obligation, justice, health equity, or universal health coverage.[65] Israel, with its status as a high-resource setting, aims to protect its citizens against public health threats coming from the Gaza Strip – a low-resource setting that it besieges – to protect its own national security rather than prevent further outbreaks in the Gaza Strip and solve the root causes of the infectious diseases outbreak.
It is essential to note that Israel's agreement regarding “daily nine-hour humanitarian pauses” in the Gaza Strip to allow the two rounds of a vaccination campaign is to protect its own population. Israeli authorities haven't allowed pauses to fix sewage systems, deliver water, or give other essential routine vaccines such as measles. Vaccination is essential, but resolving the root causes is the only reasonable action to take. Israel's recent agreement to limited pauses specifically in order to access to polio vaccines is insufficient. Universal coverage of vaccines in Gaza is required to avoid vaccine-preventable infectious-disease outbreaks. In addition, parents who expressed the willingness to vaccinate their children are kept wondering how to protect them from airstrikes and ground warfare[66]. The occupying power and its allies enable vaccination against polio only to proceed with their killing by other means.
Recommendations
- Immediate permanent ceasefire continues to be the urgent and lifesaving action needed to mitigate the unfolding infectious diseases crisis. The following steps must also be taken:
- Ensure large-scale, unrestricted, and continuous influx of sufficient humanitarian aid, including clean water, adequate food, and quality medicine to be distributed throughout all governorates of the Gaza Strip.
- Reconstruct water and sanitation infrastructure and shelters to reduce overcrowding while the international community works on rebuilding houses, dwellings, and infrastructure.
- Increase vaccination points to cover more geographical areas and move closer to the population with mass vaccination campaigns at the community level, not limited to polio but that also include other vaccine-preventable infectious diseases. This is crucial to protect healthcare workers, patients, and health facilities, and ensure safe access to health care.
- Revive the destroyed system of surveillance and disease protection of the Ministry of Health and put efforts into rebuilding it so that the system can detect any outbreak early enough to allow the allocation of the resources needed for a timely and efficient response.
- Hold Israel, as an occupying power, accountable in line with international humanitarian law for the burden of diseases occurring among Palestinians under their de facto military control, including the reconstruction bills for hospitals and civilian infrastructure.
[1] World Health Organization. oPt Emergency Situation Update 41 (7 Oct 2023 - 20 Aug 2024) - occupied Palestinian territory | ReliefWeb. Accessed 13 Sep 2024.
[2] Ibid.
[3] UNICEF. Children's lives threatened by rising malnutrition in the Gaza Strip. Accessed 13 Sep 2024.
[4] Albanese F. Anatomy of a Genocide - Report of the Special Rapporteur on the situation of human rights in the Palestinian territory occupied since 1967 to Human Rights Council. Accessed 13 Sep 2024.
[5] UNRWA Updated oPt Flash Appeal April – December 2024. Accessed 13 Sep 2024.
[6] United Nations Office for the Coordination of Humanitarian Affairs - occupied Palestinian territory. Hostilities in the Gaza Strip and Israel | Flash Update #160. Accessed 13 Sep 2024.
[7] Children's lives threatened by rising malnutrition in the Gaza Strip. Accessed 13 Sep 2024.
[8] Jamaluddine Z, Chen Z, Abukmail, H. Crisis in Gaza: Scenario-Based Health Impact Projections. Accessed 13 Sep 2024.
[9] UNICEF and WHO. Variant type 2 poliovirus in Gaza - Situation Report Issue 1 (16 July - 5 August 2024) - occupied Palestinian territory | ReliefWeb. Accessed 13 Sep 2024.
[10] United Nations. Gaza: First polio case confirmed in war-shattered enclave | UN News. Accessed 13 Sep 2024.
[11] UNICEF and WHO. Variant type 2 poliovirus in Gaza - Situation Report Issue 1 (16 July - 5 August 2024) - occupied Palestinian territory | ReliefWeb. Accessed 13 Sep 2024.
[12] United Nations. Gaza: ‘Frightening increase' in Hepatitis A cases | UN News. Accessed 13 Sep 2024.
[13] World Health Organization. Humanitarian pauses vital for critical polio vaccination campaign in the Gaza Strip. Accessed 13 Sep 2024.
[14] World Health Organization. Children in Gaza are now at risk of polio as well as bombs – we need a ceasefire now. Accessed 13 Sep 2024.
[15] Delivering life-saving vaccines to every child in the Gaza Strip | UNICEF State of Palestine. Accessed 13 Sep 2024.
[16] Jamaluddine Z, Chen Z, Abukmail, H. Crisis in Gaza: Scenario-Based Health Impact Projections.. Accessed 13 Sep 2024.
[17] Ibid.
[18] World Health Organization - Regional Office for the Eastern Mediterranean. Risk of disease spread soars in Gaza as health facilities, water and sanitation systems disrupted. Accessed 13 Sep 2024.
[19] Ibid.
[20] Oxfam International. Israel using water as weapon of war as Gaza supply plummets by 94%, creating deadly health catastrophe. Accessed 13 Sep 2024.
[21] UNRWA Updated oPt Flash Appeal April – December 2024. Accessed 13 Sep 2024.
[22] Sphere Association. The Sphere Handbook | Standards for quality humanitarian response. Accessed 13 Sep 2024.
[23] Action Against Hunger. Health Crisis Looms in Gaza Due to Inadequate Water and Sanitation - occupied Palestinian territory. Accessed 13 Sep 2024.
[24] UNRWA Updated oPt Flash Appeal April – December 2024. Accessed 13 Sep 2024.
[25] Sphere Association. The Sphere Handbook | Standards for quality humanitarian response. Accessed 13 Sep 2024.
[26] United Nations Office for the Coordination of Humanitarian Affairs - occupied Palestinian territory |. Humanitarian Situation Update #214 | Gaza Strip [EN/AR/HE] | OCHA. Accessed 13 Sep 2024.
[27] Human Rights Watch. Israel: Starvation Used as Weapon of War in Gaza [EN/AR] - occupied Palestinian territory | ReliefWeb. Accessed 13 Sep 2024.
[28] Ibid.
[29] United Nations. Gaza: ‘Frightening increase' in Hepatitis A cases | UN News. Accessed 13 Sep 2024.
[30] Human Rights Watch. Israel: Starvation Used as Weapon of War in Gaza [EN/AR] - occupied Palestinian territory | ReliefWeb. Accessed 13 Sep 2024.
[31] Food Production Systems Under Attack in Gaza. Accessed 13 Sep 2024.
[32] UNRWA Updated oPt Flash Appeal April – December 2024. Accessed 13 Sep 2024.
[33] IPC Global Famine Review Committee. Famine Review Committee: Gaza Strip, June 2024 - IPC's third review report. Question of Palestine. Accessed 13 Sep 2024.
[34] Ibid.
[35] Children's lives threatened by rising malnutrition in the Gaza Strip.. Accessed 13 Sep 2024.
[36] Gaza Strip: Almost 3000 malnourished children at risk of dying | unicef.ch. Accessed 13 Sep 2024.
[37] United Nations Office for the Coordination of Humanitarian Affairs - occupied Palestinian territory |. Humanitarian Situation Update #214 | Gaza Strip [EN/AR/HE] | OCHA. Accessed 13 Sep 2024.
[38] Morales F, Montserrat-de la Paz S, Leon MJ, Rivero-Pino F. Effects of Malnutrition on the Immune System and Infection and the Role of Nutritional Strategies Regarding Improvements in Children's Health Status: A Literature Review. Nutrients [Internet]. 2024;16(1).
[39] Caulfield LE, Onis M de, Blössner M, Black RE. Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles123. Am J Clin Nutr. 2004;80(1):193–8.
[40] Kolcic I. Double burden of malnutrition: A silent driver of double burden of disease in low– and middle–income countries. J Glob Health. 2012 Dec;2:20303.
[41] UNRWA Updated oPt Flash Appeal April – December 2024. Accessed 13 Sep 2024.
[42] State of Palestine - Internally Displaced Persons - Humanitarian Data Exchange. Accessed 13 Sep 2024.
[43] UNRWA Updated oPt Flash Appeal April – December 2024. Accessed 13 Sep 2024.
[44] UNRWA at the frontlines: managing health care in Gaza during catastrophe. Accessed 13 Sep 2024.
[45] Topluoglu S, Taylan Ozkan A. Impact of wars and natural disasters on emerging and re-emerging infectious diseases. Front Public Health. 2023 Sep;11.
[46] United Nations Office for the Coordination of Humanitarian Affairs - occupied Palestinian territory |. Humanitarian Situation Update #187 | Gaza Strip [EN/AR/HE] | OCHA. Accessed 13 Sep 2024.
[47] United Nations Office for the Coordination of Humanitarian Affairs - occupied Palestinian territory |. Humanitarian Situation Update #200 | Gaza Strip [EN/AR/HE] | OCHA. Accessed 13 Sep 2024.
[48] United Nations Office for the Coordination of Humanitarian Affairs - occupied Palestinian territory |. Humanitarian Situation Update #187 | Gaza Strip [EN/AR/HE] | OCHA. Accessed 13 Sep 2024.
[49] Heath Cluster. occupied Palestinian territory. Accessed 13 Sep 2024.
[50] World Health Organization. oPt Emergency Situation Update 41 (7 Oct 2023 - 20 Aug 2024) - occupied Palestinian territory | ReliefWeb. Accessed 13 Sep 2024.
[51] Ibid.
[52] Human Rights Watch. Gaza: Unlawful Israeli Hospital Strikes Worsen Health Crisis | Human Rights Watch. Accessed 13 Sep 2024.
[53] Article 16: Convention (IV) relative to the Protection of Civilian Persons in Time of War. Geneva, 12 August 1949. Accessed 13 Sep 2024.
[54] Article 18: Convention (IV) relative to the Protection of Civilian Persons in Time of War. Geneva, 12 August 1949. Accessed 13 Sep 2024.
[55] Goniewicz K, Burkle F, Horne S, Borowska-Stefańska M, Wiśniewski S, Khorram-Manesh A. The Influence of War and Conflict on Infectious Disease: A Rapid Review of Historical Lessons We Have Yet to Learn. Sustainability. 2021 Sep;13:10783.
[56] Article 55: Convention (IV) relative to the Protection of Civilian Persons in Time of War. Geneva, 12 August 1949. Accessed 13 Sep 2024.
[57] Article 56: Convention (IV) relative to the Protection of Civilian Persons in Time of War. Geneva, 12 August 1949. Accessed 13 Sep 2024.
[58] Ibid.
[59] Albanese F. Anatomy of a Genocide - Report of the Special Rapporteur on the situation of human rights in the Palestinian territory occupied since 1967 to Human Rights Council. Accessed 13 Sep 2024.
[60] Human Rights Watch. Israel: Starvation Used as Weapon of War in Gaza [EN/AR] - occupied Palestinian territory | ReliefWeb. Accessed 13 Sep 2024.
[61] Lee NR, King A, Vigil D, Mullaney D, Sanderson PR, Ametepee T, et al. Infectious diseases in Indigenous populations in North America: learning from the past to create a more equitable future. Lancet Infect Dis. 2023 Oct 1;23(10)
[62] Sparrow A. Gaza's Polio Outbreak Won't Spare Israelis. Foreign Policy. Accessed 13 Sep 2024.
[63] Ibid.
[64] Davidovitch N, Greenberg Z. Public Health, Culture, and Colonial Medicine: Smallpox and Variolation in Palestine During the British Mandate. Public Health Rep Wash DC 1974. 2007 May;122:398–406.
[65] Flahault A, Wernli D, Zylberman P, Tanner M. From global health security to global health solidarity, security and sustainability. Bull World Health Organ. 2016 Dec 1;94:863–863.
[66] Al Jazeera. Vaccines do not protect children from bombs, says Gaza mother. Accessed 13 Sep 2024.
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