GAZA – Mohammed Nimnim carries the water for his family. On a scorching late morning last summer, the 15-year-old pushed an old wheelchair piled high with empty plastic jugs through Gaza’s Shati (Beach) refugee camp. He rattled past modest groceries, makeshift tire shops, and graffiti praising Gaza’s martyrs, down broken concrete lanes, and toward the local mosque, where sputtering taps provide the family’s only source of drinking water.

No luck. Although it was 94 degrees and oppressively humid, the taps at the mosque were shut off. Mohammed turned around, empty-handed. He walked back under a pounding sun through the Beach Camp, a place whose very name taunts its residents. Barely 100 meters from the Mediterranean, the 87,000 refugees squeezed onto half a square kilometer here face a growing crisis of scarce and contaminated water.

Mohammed’s mom, Abeer Nimnim, paused to greet us as her son returned with the empty jugs. “May God give you health!” she exclaimed to her visitors. Then she got to the point: “It’s hot and suffocating!”

Four generations of Nimnims, 19 people in all, crowd into three small rooms off a narrow Beach Camp alley. Next to Abeer sits her mother-in-law, Fatemah, 73, who was five when her family was driven from the Palestinian village of Hamama, depopulated during the creation of Israel in 1948. They fled to Gaza, where today three-fourths of the nearly two million Gazans are refugees and their descendants. The family sits on thin cushions on the floor of the airless front room. Because Gaza gets only four to five hours a day of electricity, there’s no fan, not to mention hardly any room to move around. “There isn’t enough space to sleep,” says Abeer. “There’s no space at all, can you see that?”

“And water? Forget about it,” said Abeer’s husband, Atef. “There isn’t any.” In fact, water occasionally runs through the tap, but it’s so salty, no one in Gaza will drink it. “Life is very difficult, you cannot imagine,” Atef laments. “No offense, but dogs live better than me.”

As the effects of three wars, Israel’s economic blockade, the March of Return and tensions between Hamas and Israel grab the headlines, another humanitarian disaster has been brewing in the Gaza Strip. International officials warn of a complete breakdown of Gaza’s water system.

Studies point to sharp rises in water-borne ailments, as doctors here forecast an outbreak of epidemic disease due to deteriorating water quality. Already, 97 percent of the water from Gaza’s wells is unfit for human consumption—the result of seawater leaking into the aquifer from severe over-pumping. And because there’s insufficient electricity to run Gaza’s sewage plant, 110 million liters of untreated sewage flows into the Mediterranean every day.

International aid officials say that without major intervention to shore up supplies of water and electricity, Gaza could soon become uninhabitable. “Otherwise you will see a huge collapse of everything,” says Adnan Abu Hasna, Gaza spokesperson for the UNRWA, the U.N. agency for Palestinian refugees, which was recently cut off from all of its U.S. funding by the Trump administration. “Otherwise, by 2020, Gaza will not be a livable place.”

Adds Rebhi Al Sheikh, the former deputy minister of the Palestinian Water Authority: “U nless this deficit is covered by other sources, the quality will continue deteriorating.”

Alternatives to the salty tap water, however, aren’t much better. Two-thirds of Gazans—those at least slightly better off than the Nimnim family—rely on a network of hundreds of water trucks, which fan out through the refugee camps and neighborhoods, pumping desalinated water into rooftop tanks. Yet the pirate desalination operations are unregulated, and the water production chain—at the local desal plant, and the hoses that fill the trucks—is exposed to fecal contamination, which grows worse the longer it remains in the storage tanks.

“When it is stored at the household water tank for more than 10 days,” says Al Sheikh, “this level of contamination can reach up to 70 percent.” That’s seven in ten people drinking shit, or E. coli if you prefer. And in terms of parts per million, the only really safe level is zero.

“Why? Because the longer they [the E . coli] are there, the more you've got all sorts of other little [microscopic] animals that start growing in your water and it just gets worse,” says UNICEF’s Gregor von Medeazza, riding in a bullet-proof SUV on his way to inspect new water projects in southern Gaza.

One effect: severe diarrhea, which, according to controlled medical studies in Gaza, has risen sharply in recent years. Von Medeazza says this can lead to stunting in children. “What it also means is an impediment in terms of brain development. You would actually have a measurable impact on the IQ of those children as they grow.” In December 2017, a peer-reviewed British medical journal found an “alarming magnitude” of stunting among Gaza’s children.

And that’s just one effect. Doctors in Gaza are dealing with many others.

The doctor with the five o’clock shadow and circles under his eyes took us through a children’s ward in Al-Rantisi hospital in Gaza City. At each curtained-off section, pediatrician Mohammed Abu Samia stretched out his hand, touching tiny infants hooked up to respirators, offering kind words to dazed, anxious mothers sitting at their bedsides.

“In the summer days, the hospital has been very, very busy,” said Abu Samia, the director of pediatric medicine. To begin with, the doctor reported sharp rises in gastroenteritis, diarrhea, and dehydration. And because of high nitrate levels, the doctor was seeing other effects.

“We have children, their kidneys are not working now,” Abu Samia said. “Before, we had 15, 20. Now, 40. Every day I have 10 babies on hemodialysis because of renal failure. And that number is increasing.”

Also on the rise due to elevated nitrate levels, he says, are cases of blue baby syndrome—“bluish lips, bluish face, bluish skin, and blood the color of chocolate.” Before, the overwhelmed doctor saw one or two children with blue baby syndrome in 10 years. “But now I see five cases in one year.”

It gets worse. Abu Samia says he’s seeing more cases of pediatric cancer—whether from bad water, the effects of three wars, or something else, he doesn’t know. And he’s seeing the effects of malnutrition, which he blames less on the tainted water supply than on Israel’s economic blockade of Gaza.

“No water, no electricity, poverty is very very high, and nutrition is very bad,” Abu Samia says. “It is affecting babies. Before the siege, we didn’t have any patients with malnutrition. Now we have nutritional diseases,” including a sudden rise in infants with marasmus—severe chronic malnutrition, or, as the doctor sees it, “just bone and skin.”

In some cases, no formal studies exist to corroborate what Abu Samia is seeing. “We don’t have medical research for these,” he says. “We live in Gaza, in an emergency situation,” and need to “relieve the problem, not to research it.” But data from the Palestinian Health Ministry notes “serious increases” in kidney disease, and in food and waterborne diseases.

“The risk factors are related directly to drinking water,” and to a lesser extent, to exposure to sewage-laced seawater, says Dr. Majdi Dhair, director of preventative medicine at the Palestinian Ministry of Health. “We already registered a huge increase in waterborne diseases,” he said. These include a “doubling” of cases of diarrhea, and sharp rises in salmonella and typhoid this summer, compared to the five-year average for these diseases, and to the data for the same period in 2017, Dhair said. “We are near to declare an outbreak in diarrheal disease,” the world’s second leading cause of death for children under five.

Independent medical journals have documented similar results. The British medical journal The Lancet linked water shortages to sharp increases in diarrhea among Gaza’s young children. Other peer-reviewed journals confirm increases in infant mortality, anemia, and a significant increase of intestinal parasites among Gazans.

“All the people in Gaza—so much hard suffering,” says Dr. Abu Samia. “We’re talking about life and death. It’s enough.”

Assigning blame for the water crisis facing Gazans, and the resulting health effects, is not simple. Take the fact that only 3 percent of Gaza’s drinking water wells are actually drinkable. Who’s to blame?

Gaza’s citrus farmers pumped too much for decades, accelerating the sinking of the aquifer and the intrusion of the sea. For that matter, so did Israeli agricultural settlers before they left Gaza in 2005. Another huge factor was the “Nakba,” or Palestinian catastrophe, in 1948, when Gaza’s population quadrupled in just a few weeks, putting immense new pressure on the aquifer. And then there is Israel’s bombing of wells, water towers and pipelines, and sewage plants in Gaza, which caused an estimated $34m of damage.

Finally, there is Gaza’s political and military isolation from the West Bank, which sits on the Mountain Aquifer—a vast source of water that in theory could alleviate Gaza’s suffering, but which remains effectively under Israel’s control.

As for the alarming rise in disease, that’s in part because the power is shut off for 19 hours a day, leading to food contamination and raw sewage pouring into the sea. Some blame Israel and Egypt for withholding fuel delivery to the power plant. Israel is Gaza’s main supplier of electricity, for a scant five hours a day. Others blame the rise in disease on the fight between Palestinian factions, Hamas and the Palestinian Authority, which has slowed the arrival of fuel and certain medicines, according to Dhair.

Yet all of these factors, according to doctors and human rights groups, are minor compared to Israel’s ongoing economic blockade of Gaza, which has restricted the movement of basic goods, including medical supplies. “Occupation and siege are the primary impediments to the successful promotion of public health in the Gaza Strip,” declared a 2018 study in The Lancet, which cited “significant and deleterious effects to health care.”

Israeli officials refute those charges in repeated statements, laying the blame squarely on Hamas. “What's going on in Gaza is a real catastrophe. The situation there is unbearable,” acknowledges Uri Shor, spokesperson for Israel’s Water Authority. “But it's also frustrating because it's a bit difficult to help someone who doesn't want to help themselves. The problem in Gaza is really that Hamas people do not do anything to even try to solve the problem. They burn our fields and they try to go into Israel in order to kidnap and to murder whoever they can.”

“Hamas would like the world to believe that it launched its rockets at Israeli cities and towns in an attempt to ‘end the siege,’” the Ministry of Foreign Affairs declared near the end of the 2014 Gaza war. “Nothing could be farther from the truth. There is no Israeli ‘siege’ on the Gaza Strip.”

Yet Israel’s severe restrictions on movement of people and materials to and from Gaza—including “dual-use” items it believes could be used for both civilian and military purposes—are a reason why nearly half the population is out of work and more than three-quarters are dependent on humanitarian aid.

The blockade has worsened what the Harvard political economist Sara Roy calls Gaza’s “de-development.” A 2015 U.N. report found that “ three Israeli military operations in the past six years, in addition to eight years of economic blockade, have ravaged the already debilitated infrastructure of Gaza, shattered its productive base, left no time for meaningful reconstruction or economic recovery and impoverished the Palestinian population in Gaza, rendering their economic well-being worse than the level of two decades previous.”

Now, even within Israel’s military and security infrastructure, alarm bells are going off. “Severe limits on access and movement imposed by Israel and Egypt have hindered post-conflict repair and reconstruction,” says a report by Israel’s Institute for National Security Studies. Israel’s list of dual-use items, the report says, “includes 23 essential items” needed for Gaza’s water, sewage and hygiene (WASH) sector, “such as pumps, drilling equipment, and chemicals for water purification.”

And so the situation in Gaza keeps getting worse. In 2017, the respected Israeli human rights group B’tselem tied the blockade to Gaza’s health crisis: “During the siege, the health system has further deteriorated due to the lack of medical equipment, medicines, and rescue vehicles, and because of the frequent, prolonged power blackouts.”

The blackouts are the main reason why Gaza’s sewage plant is useless, and why every day, long pipes dump all that sewage directly into the Mediterranean. This led directly to the death of a five-year-old boy, who, on a swim at a Gaza beach, swallowed sewage-laced seawater, ingesting fecal bacteria that led to a fatal brain disease. His name was Mohammad al-Sayis. His was the first documented death by sewage in Gaza.

It may seem that Gaza’s torments are sealed off from the outside world by layers of fences, locked gates, patrolling Israeli drones and war planes, and international disdain and indifference. But sewage travels across borders.

“They are carried by the currents,” says Gidon Bromberg, director of Ecopeace Middle East, based in Tel Aviv. “It's led to the closure of beaches directly on the Israeli side of Sikkim and to the closure of the Ashkelon desalination plant, which provides 15 percent of Israel’s drinking water.”

Bromberg says Israelis need to wake up to the unfolding humanitarian disaster in Gaza. “It’s a ticking time bomb. We have a situation where two million people no longer have access to potable groundwater. When people are drinking unhealthy water, disease is a direct consequence. Should pandemic disease break out in Gaza people will start moving to the fences. And they won’t be moving with stones or with rockets. They’ll be moving with empty buckets desperately calling out for clean water.”

Hyperbolic or not, Bromberg’s scenario speaks to the worries of international aid agencies, the Ramallah-based Palestinian Authority, and even, it appears, an emergency response committee of the Israel Defense Forces. In a “Gaza Emergency Response” document circulated to unnamed “Friends and Colleagues,” the IDF calls for “an immediate humanitarian response” to “enhance the energy supply” and “increase the access to potable water” in Gaza. A near consensus is now emerging between UNICEF, other international donors, the PA and the IDF to establish a network of large desalination and sewage plants. This solution carries a $500 million price tag and is years away from operation—if it’s ever built.

A pilot desalination plant in southern Gaza does not inspire confidence. When I visited there in the middle of the day, it was quiet. We could hear birds chirping on the idle plant floor: no power. “We don’t have electricity,” plant manager Kamal Abu Moamar told me. “But we hope. Many of our ministers say that they will solve this problem. But we don’t know when. Or how.”

And then there is the question of whether Israel would decide to bomb the desalination plants in the next Gaza war, just as it bombed Gaza’s power plant and other critical infrastructure in previous wars. In the “Emergency Response” document, the IDF endorsed the Gaza desalination plan, but so far has offered no public guarantees that it wouldn’t target these plants in the next war. An Israeli army spokesperson would not return more than a dozen calls from The Daily Beast. So I put the question to Gregor von Medeazza, asking whether, under the circumstances, investing hundreds of millions in donor funds wasn’t too big a risk.

“Any infrastructure is a risk in a context like Gaza,” the UNICEF official replied. “But then the question is, what are the other options? Really—what is the way forward?”