As clean water in Gaza runs out, a long-expected health crisis has surged in recent days: a steep increase in gastrointestinal diseases and other illnesses tied to poor sanitation.
On Wednesday, the World Health Organization reported that more than 44,000 cases of diarrhea had been documented in Gaza since mid-October — a dramatic increase compared to previous years.
Dr. Ahmed Moghrabi, the head of plastic surgery at Nasser Hospital in the city of Khan Younis in southern Gaza, said he has seen increases in gastrointestinal illnesses. He and his children have been personally affected.
It took four or five days, he said, to recover from the bouts of diarrhea.
The illnesses, combined with overcrowded hospitals, a scarcity of food and other daily traumas, is "a nightmare," Moghrabi told NBC News in a WhatsApp voice note. "We are facing many difficulties."
The exact cause of the gastrointestinal illnesses is unknown; it is impossible to do laboratory testing.
But when clean water is unavailable, people are forced to drink and cook with tainted water, which is more likely to harbor bacteria that can lead to intestinal diseases, such as dysentery and cholera.
"People are resorting to coping mechanisms that are dangerous," said Sean Carroll, president and chief executive of Anera, a nongovernmental organization that provides humanitarian aid to the Middle East, including Gaza. "They're drinking water that they shouldn't drink."
The situation was expected to worsen Wednesday, as there is no longer enough fuel to power many of the water and sanitation facilities. "As of 15 November, public water and sanitation services will start shutting down," the United Nations Relief and Works Agency for Palestine Refugees in the Near East, or UNRWA, said in an online statement.
The shutdown will cause "environmental hazards with around 400 tons of solid waste per day accumulated in all [refugee] camps," the U.N. group said. "This will impose serious threats to public health, with a high risk of water contamination and disease outbreak."
According to global health agencies, including the World Health Organization, people need a minimum of 15 liters of clean water (about 4 gallons) a day to meet basic needs, including drinking, cooking and cleaning. (The average person in the United States uses well over 300 liters a day, or nearly 80 gallons.)
People living in Gaza were already using less than 15 liters before Israel cut off water, electricity and fuel to the Gaza Strip in retaliation for Hamas' terrorist attack on Israel on Oct. 7, Carroll said.
"The situation has been dire for a while," he said. "Now it's actually getting to the point where people will not have water at all."
"Many people will be sick and die simply from loss of fluids," said May Chu, a professor with the Colorado School of Public Health and interim director of the Center for Global Health at C.U. Anschutz in Denver.
Anera, the NGO, installed a water filtration system in Gaza run by solar energy, but the clean water it can provide is "literally a drop in the bucket" of what Gazans need, Carroll said. He has 12 workers in Gaza delivering meals and trying to clean shelters.
"But without fuel and some kind of access to clean or at least safer water, there's no way to keep up with it," Carroll said. "If there's no water, you can't really clean. And the cleaning you can do doesn't take away the danger of disease spread."
Carroll said he has heard reports that people are actively avoiding eating food, despite their hunger. "The sanitary conditions are so horrendous," he said, "they don't want to go to the bathroom."
Other illnesses have also begun to ramp up in overcrowded shelters full of people who have had to flee their homes.
On Wednesday, the WHO said there had been approximately 72,000 cases of acute respiratory infections and 808 cases of chickenpox in Gaza within the past month.
What's more, there have been "close to 14,200 skin diseases, scabies and lice," Dr. Rik Peeperkorn, WHO's representative for the West Bank and Gaza, said during a briefing Wednesday.
Scabies, an itchy rash caused by tiny mites, is "one of those things that no one talks about because it doesn't kill, but it's really annoying," said Dr. Paul Spiegel, the director of the Johns Hopkins Center for Humanitarian Health.
"When you have a lack of water and soap, scabies becomes extremely common. You're not able to wash your bedding or your clothes," Spiegel said. "It's incredibly itchy. When your life is already pretty overwhelming, it's really rough."
The lack of clean water and basic hygiene is concerning to Dr. Adam Levine, chief of global emergency medicine at the Brown University Alpert Medical School and School of Public Health, because they're "tied to so many different health conditions," he said, including diarrheal disease, and skin and respiratory infections.
"Water, sanitation and hygiene are one of the primary priorities of any humanitarian response," Levine said, "because it's such a basic need that leads to so many downstream consequences."