On November 28th, Margaret Harris, a spokesperson for the World Health Organization (WHO), warned that the catastrophe unfolding in Gaza was likely to become even worse. “Everybody everywhere [in Gaza] has dire health needs now because they’re starving, because they lack clean water, and [they’re] crowded together,” she said at a UN briefing in Geneva, before concluding with an ominous pronouncement: “Eventually, we will see more people dying from disease than we are even seeing from the bombardment.”

Israel’s ongoing war on Gaza has already killed nearly 23,000 people, with 7,000 others buried under rubble and 55,000 more injured. But what Harris was pointing to was a second, quieter war front that now stands to escalate dramatically. Since October 7th, Israel has severely reduced the entry of food, water, and fuel into Gaza, successfully creating what global health expert Yara Asi described as “a dire human-made humanitarian catastrophe” characterized by mass hunger, thirst, homelessness, and lack of medical services. As months pass without any meaningful relief, these conditions have produced “the perfect storm for disease,” in the words of United Nations Children’s Fund spokesperson James Elder. On January 2nd, the WHO announced that there are currently 424,639 cases of infectious diseases in Gaza. Since such official counts only represent those who were able to make it to a clinic or hospital, experts assume that the true rates are much higher. A half million infectious disease cases would still have overwhelmed Gaza’s healthcare system before October 7th, though many would have been treatable with food, water, and medical care. But today, amid an ongoing assault that has destroyed 27 of Gaza’s 36 hospitals, as well as the very foundations of the enclave’s public health—in the form of food, water, and shelter—epidemics are likely to mean mass death. “You don’t need overt bloodshed to cause significant violence that ends people’s lives,” Asi told Jewish Currents. “Many people will die unnecessary deaths due to deprivation.”

This concern has a firm historical basis: In most wars, including in Iraq, the Democratic Republic of the Congo, Yemen, and Darfur, far more people die of disease and starvation than through direct military assault. Indeed, according to public health scholar Barry Levy, indirect health-related deaths—which are seldom discussed when reporting the death toll of a war—can outnumber direct deaths by more than 15 to 1. In Gaza, such deaths are likely to keep increasing even if there is a ceasefire. Public health scholar Devi Sridhar recently estimated that, barring a dramatic shift which includes a resuscitation of the health system, half a million people—a quarter of Gaza’s population—could die from preventable health causes in the coming year.

In Israel, these grim warnings have not initiated any change of course. In fact, a vocal minority on the Israeli right has even lauded the spread of disease and starvation as a way of weakening Hamas. In October, Likud lawmaker Tally Gotliv argued in front of the Knesset that “hunger and thirst among the Gazan population” would help Israel’s war efforts, enabling the recruitment of desperate collaborators for intelligence purposes. Retired Israeli general Giora Eiland, who was formerly head of the Israeli National Security Council and is now an official wartime advisor to Defense Minister Yoav Gallant, has likewise asserted that Israel “must not be deterred” by the international community’s warnings about a humanitarian disaster in Gaza because “severe epidemics in the southern Strip will hasten our victory.” This position has not yet found purchase as an official war tactic: Prime Minister Benjamin Netanyahu has expressed opposition to it, and it has faced especially harsh criticism from Israeli public health experts. But analysts say Israel’s current policies are nevertheless consistent with the use of disease as a weapon. “When you cluster people and keep them away from medical care and water . . . it doesn’t take an epidemiology degree to know what’s going to happen,” Asi told Jewish Currents, adding that even though Israel is not intentionally introducing disease into Gaza, “if you wanted to [spread disease], you would do exactly what Israel is doing.”

The current health emergency in Gaza builds on the ruinous effects of years of Israeli restrictions on the Strip’s health system. As Asi told the Foundation for Middle East Peace on November 14th, “we’ve heard increasingly . . . that Gaza’s health system has collapsed. But in reality, Gaza’s health system has been on the verge of collapse essentially for 16 years.” Over that time, Israel has kept Gaza under a tightly controlled blockade, restricting access not only to medical equipment and medications, but also to food and water. Documents show that at one point, Israel even calculated the minimum caloric intake needed for survival; these restrictions have rendered 63% of Gaza’s population food insecure and left 30,000 children under the age of five severely malnourished. Similarly, 96% of Gaza’s water was already unsuitable for drinking before October 7th, causing a quarter of the enclave’s illnesses. As of 2018, waterborne illnesses were the leading cause of death for children in Gaza.

Israel’s newly intensified siege is exacerbating these vulnerabilities. In recent weeks, between 100 and 120 aid trucks have been entering Gaza each day, an 80% decrease from the pre-October 7th number. This chokehold on humanitarian supplies has led to calamitous shortages of basic necessities. For instance, according to the independent Famine Review Committee, 80% of the Palestinians in Gaza have reached the two most extreme levels of its food insecurity classification system—“emergency” and “catastrophe”—with half of the population at risk of starvation. Water shortages are also rampant in Gaza, and with the lack of fuel severely curtailing wastewater treatment and solid waste management, clean drinking water is impossible to find. As a result, people are drinking and cooking with unclean water, some digging wells to access water contaminated by sewage and solid waste build up, and others resorting to drinking seawater, where over 100,000 cubic meters of waste is discharged daily.

This growing sanitation crisis is compounded by constant Israeli bombardment, which has released toxic substances into the air and resulted in high numbers of unburied dead bodies in the streets and under rubble. Bombings and forced evacuations have also caused massive overcrowding. Since October 7th, Israel has displaced 90% of Gazans from their homes, pushing them into smaller and smaller areas and creating breeding grounds for disease. As of January 1st, about 1.4 million of the Strip’s 1.9 million displaced Palestinians were sheltering at United Nations Relief Works Agency (UNRWA) schools, sharing one toilet to every 486 people. (At least one UNRWA school has already reported a Hepatitis A outbreak.) In such close quarters, sick Gazans are unable to follow quarantine orders, leading to what WHO head Tedros Adhanom Ghebreyesus described as “the ideal conditions for disease to spread.”