Sanitation Crisis in Gaza Spreads Disease

In a sprawling tent encampment in Gaza, the Israeli bombs fall close enough to hear and feel. But daily life is also a struggle against hunger, cold and a growing sanitation crisis.

A lack of sufficient toilets and clean water, as well as open sewage, are problems that displaced Palestinians have struggled with since the early days of Israel’s assault on Gaza.

For two months after Salwa al-Masri, 75, and her family fled to the city of Rafah, at the southernmost tip of Gaza, to escape Israel’s military offensive, she said she would walk 200 yards to reach the nearest bathroom. If she was lucky, younger women in line would let her jump ahead. Other times, she might wait up to an hour to use a dirty toilet shared with thousands of other people.

“It’s horrible,” Ms. al-Masri said via WhatsApp recently from her family’s ramshackle tent, which they made out of wood and plastic sheeting. “I wouldn’t drink water. I would stay thirsty so I wouldn’t have to go to the bathroom. I stopped drinking coffee and tea.”

Many other Gazans, already facing hunger and thirst as a result of Israel’s more than four-month siege of the territory, say they, too, have tried to cut back on eating and drinking even more to avoid an uncomfortable and unsanitary visit to the toilet.

Recently, Ms. al-Masri’s son and other relatives bought a cement toilet basin and dug a hole behind their tent, where the sewage gathers. It is a closer bathroom and one she shares with fewer people.

But the challenges of getting water to wash with and of the accumulating sewage are threatening their health, and the stench of sewage fills their makeshift encampment.

Last month, the World Health Organization reported that cases of hepatitis A had been spreading in Gaza. It also said that there were several thousand people with jaundice, which is caused by hepatitis A, among other conditions. Cases of diarrhea among children have also skyrocketed. All of it is linked to poor sanitation, according to UNICEF.

“The inhumane living conditions — barely any clean water, clean toilets and possibility to keep the surroundings clean — will enable hepatitis A to spread further,” Tedros Adhanom Ghebreyesus, the director general of the W.H.O., wrote on social media at the time, “and highlight how explosively dangerous the environment is for the spread of disease.”

Prominent epidemiologists have estimated that an escalation of the war in Gaza could cause up to 85,000 Palestinian deaths over the next six months from injuries, disease and lack of medical care, in addition to the nearly 30,000 that local authorities have already reported since early October. Their estimate represents “excess deaths” that would not have been expected without the war.

Schools, hospitals, mosques and churches have become overcrowded shelters for Palestinians seeking safety from Israeli airstrikes. The few available bathrooms have to be shared among hundreds or thousands of people who sometimes wait in lines for hours to use them.

Israel’s bombardment of Gaza and the accompanying ground offensive have increasingly pushed Palestinians south into the overcrowded corner of Gaza around Rafah and forced them to erect makeshift tents. As a result, access to bathrooms and sanitation has only worsened.

Some 1.5 million displaced Palestinians are now in Rafah — more than half of Gaza’s total population of about 2.2 million — even as Israel threatens to invade the area.

After the Hamas-led attacks on Israel on Oct. 7, Israel’s near-complete siege on Gaza has prevented most things from coming into the territory, creating a dire shortage of food, water and medicines. Additionally, representatives of both UNICEF and the Palestine Red Crescent Society said their organizations have tried to bring in portable toilets and materials to build sanitation facilities, but the Israeli authorities prevented them.

“It is a public health concern,” said Abrassac Kamara, a UNICEF manager for the Palestine WASH program, which helps deliver safe water and sanitation services. “But the second thing is simply just dignity. It is something we take for granted, but it’s really how we are taking dignity away from people.”

Israel’s civil administration, the bureaucratic arm of its military in the occupied West Bank and Gaza, said the restrictions on certain goods entering Gaza prevented the entry of items that could also be used for military purposes.

Hamas “exploits civilian resources in order to strengthen itself militarily at the expense of caring for the civilian population,” the civil administration said, without explaining how portable bathrooms could serve military needs.

UNICEF officials said they have had to resort to constructing toilets out of wood, concrete and plastic sheeting — materials already available in Gaza — often at a high cost. The agency plans to make 500 such toilets in Rafah to help reduce the congestion.

“At the moment, anything that is considered construction material — mostly metal, but also sandwich panels, nails, reinforcement rods — are all banned,” Mr. Kamara said. “We are making do.”

UNICEF had planned to build another 500 toilets in the southern Gaza city of Khan Younis, but had to abandon those efforts as Israel’s ground offensive moved into the area recently.

“They will literally put any sort of privacy screening — plastic at the back of the tent — and just dig and bury when they need to relieve themselves,” Mr. Kamara said. “We are back to the basic sanitation of digging a hole and covering it.”

In a video posted on Instagram last month, Bisan Owda, a Gazan journalist and documentary filmmaker, chronicled the daily struggle of finding a latrine. As she walked past tents in the street, carrying a large jug of water, she narrated her challenges.

“This is my daily routine,” she said, “walking for almost 20 to 25 minutes to reach a bathroom — struggling to reach a bathroom, actually.”

Other women have lamented a desperate lack of sanitary pads in the territory, and at least one of them told The New York Times that she had started taking birth control pills to stop her period altogether.

Sana Kabariti, 33, a pharmacist from Gaza City, in the north, said she fled home with her family to the town of Nuseirat, in central Gaza, as Israeli bombs rained down on their neighborhood in the first few days of the war. She and some 40 members of her extended family, including 10 children, cloistered in a small room and shared one bathroom, she said. But there was no water and no toilet paper.

So despite the dangers, they returned to their homes.

“With regards to the toilet, there wasn’t any water,” she said. “And this is what led to the families with us to return to Gaza City, and to the danger, because they couldn’t handle the lack of water and lack of toilet paper.”

Eventually, the bombing in Gaza City became so intense that she and her family had to flee again. They headed south, first to the city of Deir al Balah and eventually to Rafah.

They are better off than many in Rafah because they are sheltering in a room in a house shared among many. But the bathroom is small, and they must trek each day to get water to wash themselves and try to keep the bathroom clean. Showering is a luxury they can rarely afford.

They do not use toilet paper. Even if they can find it at markets, the price is exorbitant: Israel’s siege has driven up the cost of what few goods are still available in Gaza.

Instead, the family cuts up pieces of fabric to use, Ms. Kabariti said.

“There are many people who aren’t willing to use the bathroom more than once a day,” she said.

In her neighborhood, she recounted meeting an older woman who refused to use the bathroom in the center where she was sheltering because it was so dirty and unhygienic. Instead, neighbors allowed her to use their bathroom.

But not wanting to impose, she uses it only once a day — right after sunrise when she has said her morning prayers. Afterward, she holds it in until the next morning.

“I don’t know how long a person’s body can continue like this after nearly four months,” Ms. Kabariti said.

Abu Bakr Bashir contributed reporting.

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