The Public Health Impacts of Gaza's Water Crisis

Gaza has long had water and sanitation challenges, but today it is in a state of emergency. The main source of water—its aquifer—is being depleted and its quality diminished by seawater intrusion, wastewater seepage, and agricultural runoff. Gaza's inconsistent energy supply hinders the operation of Gaza's existing water facilities and prevents the construction of new ones. With insufficient potable water, Gaza residents lack water not only for drinking but also for hygiene and sanitation. More than a quarter of all reported disease in Gaza is caused by poor water quality and access. If present trends continue, Gaza and the surrounding region are at risk of a disease outbreak or other public health crises.

While these problems are not new for Gaza, RAND's analysis shows that a recent confluence of events has exacerbated the situation to a point of great urgency. Recurring conflict with Israel has severely damaged Gaza's infrastructure for water, sanitation, and hygiene, but Israel's and Egypt's restrictions on border access and the movement of goods have hampered repairs. Israel has for years restricted the imports of "dual-use" items that could be used for both civilian and military purposes—including 70 percent of the technical equipment (e.g., pumps, water purification chemicals) that is needed to maintain water and sanitation. Furthermore, Gaza's power supply, always in deficit, has since 2017 been subjected to an intra-Palestinian dispute over electricity payments between the Palestinian Authority (PA) and Hamas, Gaza's de facto government. This dispute, combined with wrecked infrastructure, has left Gaza's residents with only some four hours of electricity per day, far from sufficient to support basic living standards.

In addition, international funding to support urgent humanitarian interventions, finalize reconstruction, and revitalize the private sector economy has been limited. This includes medium- to long-term infrastructure projects in the energy; water, sanitation, and hygiene (WASH); and public health sectors. For example, as of late March 2018, a funding gap of $244 million was cited as hindering reconstruction from the 2014 war, including damage to homes, hospitals, and water and energy infrastructure. International donors made $3.5 billion pledges for reconstruction after the war, but half of these funds have not been disbursed. This example highlights one of the most challenging funding aspects related to Gaza—a lack of donor follow-through. Moreover, the 2017 $547 million Humanitarian Response Plan for the Palestinian Territories, most of it geared toward Gaza, was less than 50 percent funded, with the WASH portion particularly underfunded.

The United States recently decided to cut $300 million in funding this year intended for the UN Relief and Works Agency (UNRWA) for Palestine Refugees in the Near East on grounds that the organization needs to reform and that other donors should step in. This decision could further worsen the situation, especially as Gaza's hospitals are becoming increasingly inoperable. UNRWA supports the WASH sector and provides public health services in Gaza, operating 21 primary health clinics, employing more than 1,000 medical staff, serving more than 4 million annual patient visits, and running schools where some WASH educational programs are taught. In addition to slashing UNRWA funding, the U.S. government also cut $200 million in bilateral foreign aid that was designated for humanitarian programs in the West Bank and Gaza.

Major future projects are also hindered by funding gaps. For example, the Gaza Central Desalination Plant, which is expected to provide 139 million cubic meters (mcm) of water per year by 2023, still needed some $120 million to $230 million to begin construction as of March 2018. Completed infrastructure projects also suffer from underfunding. For instance, the Northern Gaza Emergency Sewage Treatment (NGEST) became operational in early 2018, but there is a $16.8 million funding gap for NGEST to cover operation and maintenance costs (donors are willing to fund infrastructure projects but not operation and maintenance), hindering its ability to provide wastewater treatment for more than 400,000 of North Gaza's residents.

To be sure, the funding shortage and lack of funders' follow-through are not the only challenges preventing the rehabilitation of Gaza's energy, water, and health sectors. More than anything, the water-energy-health crisis in Gaza represents a failure of governance. Indeed, the key underlying problems could be fully addressed in the long term through greater investment in water and wastewater treatment infrastructure and new power infrastructure, along with greater water or electricity purchases from outside Gaza. These are all achievable with existing technologies but are hindered for political reasons. Thus, all stakeholders should strive to find politically feasible solutions, including working with the PA and regional and international mediators. At the same time, it is necessary to relax restrictions on access and movement of goods necessary for the water, energy, and health sectors and to address other implementation challenges, as detailed next.

What Can Be Done to Lower the Risk of a Waterborne Health Crisis in Gaza?

Given the significant challenges at the intersection of water, energy, and public health in Gaza, RAND researchers analyzed how improving each of these critical sectors would help ameliorate the waterborne risks to Gaza residents. This analysis draws on a variety of sources, including reports by governments and international organizations, policy papers by think tanks and research institutes, media and news reports, and off-the-record conversations with current and former Israeli and Palestinian government officials and diverse experts from the United Nations, World Health Organization (WHO), the Office of the Quartet (an organization that includes the United Nations, United States, European Union, and Russia), and nongovernmental organizations.

We identified a number of near- and long-term steps—some of which are already under way but at risk of being undermined due to political tensions—that would address many challenges in the areas of power and water infrastructure and public health. We recognize, however, that implementation issues that stem from the region's complex political context defy easy solutions. Based on our analysis, we make the following recommendations.

Increase the Quantity and Consistency of Gaza's Electricity Supply

Without a consistent supply of fuel and electricity, Gaza's capacity to operate its existing desalination, freshwater, and wastewater treatment plants and build new ones is severely limited. The following recommendations are aimed at increasing the quantity and consistency of power:

• Advance the "161kV Line"—a high-voltage connection between Gaza and the Israel Electric Corporation grid—that would add 100 megawatts (MW) per day within a few years. Israel and the PA have in principle agreed to establishing this connection, yet the agreement has not been finalized, and funding is lacking.
• Increase power supply from Egypt. An additional 25 MW per day could be available by mid-2019, according to the Quartet.
• Upgrade and expand the electricity transmission network to Gaza and its internal distribution network to enable additional and diverse domestic generation capacity and imports. A first step should be rehabilitating the connection with Egypt, which has been unreliable.
• Restore the fuel storage tank at the Gaza Power Plant (GPP) to enable more sustainable operation.
• Connect the GPP to a natural gas supply pipeline, which would allow it to operate at its maximum capacity of 140 MW per day (increased from the 0 to 25 MW produced as of mid-2018 at a substantially lower cost). In the longer term, connect Gaza more broadly to Israel's natural gas infrastructure to support new gas-fired power plants. Gas-based power generation for Gaza could increase to some 600 MW per day.
• Ensure a reliable power supply to the NGEST plant.
• Supply the 1.5 MW required to operate the Khan Yunis Short-Term Low-Volume (STLV) desalination plant for 22 hours per day, which would provide potable water to the 75,000 residents of Khan Yunis and Rafah.
• Invest in new solar energy projects, which could make lifeline infrastructure more resilient.
• Improve fee collection and mediate intra-Palestinian arrangements to ensure that these fees are used to cover the ongoing cost of Gaza electricity.
• Advance development of the Gaza Marine gas field, located 20 miles off the Gaza coast and estimated to hold more than 1 trillion cubic feet of natural gas.

Increase the Potable Water Supply and Improve Wastewater Treatment

Several of the recommendations that follow depend on resolving Gaza's inconsistent supply of fuel and electricity but also concern other issues:

• Augment the potable water supply by increasing water purchases from Israel. Israel and the PA should advance the finalization, and then the implementation, of the previously agreed-upon Red Sea–Dead Sea project between Israel and the PA, which is designed to provide additional quantities of potable water to Gaza (and the West Bank).
• Increase desalination capacity, allowing for additional treatment of raw water at the industrial or household scale.
• Advance plans to begin construction of the Gaza Central Desalination Plant, which will initially provide 55 mcm of potable water yearly. To do so, donors should help close the remaining $230 million funding gap, and Israel and the PA, with the support of the international community, should agree on the terms for entry of construction materials into Gaza.
• Improve the water storage and distribution system in Gaza. Additional storage would allow Gaza to purchase more water, and repairing the transmission and distribution pipes would prevent water loss to leakage and ensure that treated water reaches residents.
• Invest in various wastewater treatment methods to eliminate exposure to raw sewage and the incidence of waterborne hazards.
• Distribute chemicals and spare parts for existing household treatment systems, including materials on Israel's dual-use list, to prevent outbreaks of waterborne disease.
• Construct more wastewater treatment plants, including the three or more projects that are already under way. Ensure that the funding gap for NGEST is closed and that the PA finalizes plans for sustained operations.
• Consider using treated wastewater to recharge the coastal aquifer (indirect potable reuse) or as a primary source for potable water (direct potable reuse). The former could also potentially prevent further seawater intrusion and reduce chloride and nitrogen levels.
• Repair the wastewater collection system to reduce the flow of untreated sewage into surface waters and groundwater and connect the remaining third of Gaza residents who lack access and now use cesspits and open drains.

Protect Public Health and Promote Hygiene and Sanitation Practices

International funding plays a significant role in protecting public health in Gaza and preventing the spread of disease. The following list includes recommendations for Gaza's global support system:

• Prevent and prepare for disease outbreaks, including by providing cholera vaccinations and World Health Organization/United Nations Children's Fund rehydration salt packets to Gaza residents.
• Maintain basic health services in Gaza, including through international funding for clinics and physicians (e.g., UNRWA), sustaining the energy supply to hospitals (including by guaranteeing emergency fuel supplies are available), and ensuring that sanitation and hygiene are maintained in medical facilities.
• Promote more-rigorous hygiene and sanitation education in general, and especially in schools. Students, as the most vulnerable age group for waterborne diseases, also require better access to safe drinking water and sanitation facilities.
• Create a regional pandemic task force to prevent a disease outbreak and implement containment.

Reduce Import Barriers and Work Within Political Differences

The current barriers to policy solutions are largely political. While there is a need to address these political issues and reach practical arrangements that will enable the PA to assume responsibility for managing Gaza's affairs, we also recommend that regional and international stakeholders render the following assistance:

• Capitalize on the commitments of donors who pledged funds for major WASH projects through the creation of a follow-up mechanism or task force for project implementation. Donor willingness to fund operations and maintenance, and not only infrastructure, could help ensure sustained operations of existing and future water and wastewater plants.
• Reconsider immediate funding cuts to humanitarian causes in Gaza to include a phased and more structured withdrawal of support from UNRWA.
• Increase funds for public health risk mitigation initiatives.
• Relax restrictions on access and movement of goods. Israel and Egypt need to weigh their legitimate security concerns against Gaza's humanitarian needs and the real risk of a public health crisis spilling across Gaza's borders and into Israeli and Egyptian territory. While Israel committed to allow the entrance of materials needed for water, wastewater, and WASH projects in Gaza, the process is cumbersome and delays implementation. A strong level of international political engagement could guarantee that Israel's commitment to support WASH projects will be translated into efficient and rapid processing of demands and authorize the entry of required dual-use materials for these projects.
• Identify trusted third parties to mediate intra-Palestinian disputes over issues like ongoing payments for water and electricity.
• Form international coalitions to address issues of regional concern.
• Address development needs alongside humanitarian relief to alleviate Gaza's dependence on international assistance and help it become more self-sufficient.

Conclusion

While the solutions to Gaza's electricity, water, and public health problems are technical in nature, the reality is that Gaza's access to energy, water, and financial resources depends largely on whether Hamas, the PA, Israel, and Egypt can reconcile their political differences and whether the international community can successfully navigate these political complexities. Even though the international community has repeatedly pledged donations for large-scale energy and water projects in Gaza, follow-through on these commitments has been lacking. In addition, given the complex political dynamic between the different stakeholders in the region, international donors are reluctant to continue funding major projects in Gaza. Some of the proposed solutions require funding of operations and maintenance or investment on the Israeli side (e.g., the 161kV line), which donors are not willing to fund. These solutions have been deterred by the intra-Palestinian rivalry, continued limitations of access and movement imposed by Israel and Egypt, and lack of proper governance in the energy and water sectors. Addressing these issues is therefore necessary to bring long-term and systemic changes to Gaza's water and energy sectors, which will in turn help improve public health there. At the same time, efforts to cope (even partially) with the political challenges should be accompanied by short-term stabilization and risk mitigation measures that can be advanced immediately to prevent a large-scale public health crisis.