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The impact of attacks on urban services II: Reverberating effects of damage to water and wastewater systems on infectious disease

Published online by Cambridge University Press:  03 November 2021

Michael Talhami  and
Mark Zeitoun
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Abstract

This article investigates the effects that attacks during armed conflict which damage water and wastewater services have on the outbreak and transmission of infectious disease. It employs a lens of uncertainty to assess the level of knowledge about the reverberations along this consequential chain and to discuss the relevance to military planning and targeting processes, and to the laws of armed conflict. It draws on data in policy reports and research from a wide variety of contexts, and evidence from protracted armed conflicts in Iraq, Yemen and Gaza. The review finds a strong base of evidence of the impact of attacks on water and wastewater services, and a high level of confidence in information about the transmission of infectious disease. One clear risk identified is when people are exposed to water supplies which are contaminated by untreated wastewater. Obtaining a similar level of confidence about the cause and effect along the full consequential chain is challenged by numerous compounding variables, though there are a number of patterns related to the duration of the armed conflict within which the attacks occur. As the conflict protracts, both the risk of the spread of infectious disease and the evidence base for gauging the reverberating effects becomes stronger, for example. The article concludes that the reverberating effects of damage from an attack can be foreseen in some contexts and can be expected to become more foreseeable over time. The analysis suggests that the most pragmatic path for military institutions and those involved in targeting operations to take this knowledge into account is through a “precautionary approach” which assumes the existence of the reverberating effects, and works them in to the standard information-gathering and planning processes.

Keywords

urban serviceswater and warinfectious diseasepublic healthprotracted armed conflictcritical infrastructure
Type
Selected articles
Information
International Review of the Red Cross , Volume 102 , Issue 915: Non-State armed groups , December 2020 , pp. 1293 - 1325
Copyright
Copyright © The Author(s), 2021. Published by Cambridge University Press on behalf of the ICRC

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Footnotes

*

The authors would like to thank two anonymous reviewers and colleagues who contributed their specialist's perspective, notably Abby Zeith Stephen Kilpatrick, Mirko Winkler, Louis Maresca, Erini Giorgou, Mohammad al Sa'idi and Aula Abbara.

References

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2 Frontlines Lab, “Beyond Casualty Counts: Building Dynamic Models to Capture and Foresee Civilian Harm”, Draft for Comment, 2020; InterAction, Building the Evidence Base: Addressing the Reverberating Effects of Military Operations on Civilian Life, 2 November 2020, available at: https://www.interaction.org/blog/building-the-evidence-base/ (all internet references were accessed in October 2021); Christina Wille and Alfredo Malaret Baldo, Reference Framework: Menu of Indicators to Measure the Reverberating Effects on Civilians from the Use of Explosive Weapons in Populated Areas, United Nations Institute for Disarmament Research (UNIDIR), 2020, available at: https://unidir.org/publication/menu-indicators-measure-reverberating-effects-civilians-use-explosive-weapons-populated; U.S. Department of Defense, Annual Report on Civilian Casualties in Connection with United States Military Operations in 2020, Washington, DC, 2020.

3 Ucko, David H. and Marks, Thomas A., Crafting Strategy for Irregular Warfare, National Defense University Press, Washington, DC, 2020Google Scholar; John Spencer, “The Eight Rules of Urban Warfare and Why We Must Work to Change Them”, Modern War Institute at West Point, 12 January 2021, available at: https://mwi.usma.edu/the-eight-rules-of-urban-warfare-and-why-we-must-work-to-change-them/.

4 Charles Pede and Peter Hayden, “The Eighteenth Gap – Preserving the Commander's Legal Maneuver Space on ‘Battlefield Next’”, Military Review, Vol. 101, Issue 2, 2021; U.S. Army, “U.S. Opening Statement”, in Protecting Cvilians in Urban Warfare: Towards a Political Declaration to Address the Humanitarian Harm Arising From the Use of Explosive Weapons in Populated Areas, 3–5 March 2021, Dublin, 2021, available at: https://www.dfa.ie/media/dfa/ourrolepolicies/peaceandsecurity/submissions3-5march/Opening-Statement---EWIPA-Mar-3-5-CLEAN.pdf.

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7 As noted later in the article, the “precautionary approach” referred to in this article stems from research and policy on mitigating environmental harm of infrastructure projects, and is distinct from those specific IHL obligations that require parties to conflict to take a range of precautions in attack and against the effects of attacks to protect civilians and civilian objects. See, for example, Protocol Additional (I) to the Geneva Conventions of 12 August 1949, and Relating to the Protection of Victims of International Armed Conflicts, 1125 UNTS 3, 8 June 1977 (entered into force 7 December 1978) (AP I), Arts 57 and 58; and Jean-Marie Henckaerts and Louise Doswald-Beck (eds), Customary International Humanitarian Law, Vol. 1: Rules, Cambridge University Press, Cambridge, 2005 (ICRC Customary Law Study), Rules 15–24, available at: https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1.

8 ICRC, Urban Services During Protracted Armed Conflict: A Call for a Better Approach to Assisting Affected People, Geneva, 2015.

9 ICRC, ibid.; Emma Lauren Roach and Mohammad Al-Saidi, “Rethinking Infrastructure Rehabilitation: Conflict Resilience of Urban Water and Energy Supply in the Middle East and South Sudan”, Energy Research & Social Science, Vol. 76, 2021.

10 The authors acknowledge that the cumulative impact of armed conflict is in many ways more significant than both the direct and indirect impact of armed conflict (ICRC, above note 8), and likely to be more significant than the reverberating effects of attacks. As the effects of attacks often conflate with the cumulative impact of armed conflict, their impact is more readily understood from within the protracted conflict context the attack occurs – particularly in the protracted urban armed conflicts that this article focuses on.

11 M. Zeitoun and M. Talhami, above note 5.

12 See AP I, Arts 51(5)(b) and 57(2)(a)(iii), and ICRC Customary Law Study, Rule 14. For particular application of IHL to water infrastructure, see Tignino, Mara, Water During and After Armed Conflicts: What Protection in International Law?, Brill, Leiden, 2016CrossRefGoogle Scholar; and Tignino, Mara and Irmakkesen, Öykü, “The Geneva List of Principles on the Protection of Water Infrastructure: An Assessment and the Way Forward”, International Water Law, Vol. 5, No. 2, 2020Google Scholar.

13 See AP I, Art. 57, and ICRC Customary Law Study, Rules 15–21.

14 The reverberating effects of an attack are also commonly referred to as “knock-on” effects: see Schmitt, Michael N., “Wired Warfare: Computer Network Attack and Jus in Bello”, International Review of the Red Cross, Vol. 84, No. 846, 2002, p. 392Google Scholar; Robinson, Isabel and Nohle, Ellen, “Proportionality and Precautions in Attack: The Reverberating Effects of Using Explosive Weapons in Populated Areas”, International Review of the Red Cross, Vol. 98, No. 1, 2017Google Scholar; or “long-term” effects: Humanity & Inclusion, Death Sentence to Civilians: The Long-Term Impact of Explosive Weapons in Populated Areas in Yemen, May 2020, available at: https://blog.hi.org/wp-content/uploads/2020/06/Study2020_Rapport-YEMEN-EWIPA_EN_Web.pdf; ICRC, International Humanitarian Law and the Challenges of Contemporary Armed Conflicts: Recommitting to Protection in Armed Conflict on the 70th Anniversary of the Geneva Conventions, Geneva, 2019.

15 ICRC, ibid., p. 18 (emphasis added).

16 C. Wille and A. Malaret Baldo, above note 2.

17 Attacks on upstream components are the furthest reaching. M. Zeitoun and M. Talhami, above note 5.

18 World Bank, ICRC and United Nations Children's Fund (UNICEF), Joining Forces to Combat Protracted Crises: Humanitarian and Development Support for Water Supply and Sanitation Providers in the Middle East and North Africa, Washington, DC, 2021.

19 James, Rachel, Washington, Richard, Schleussner, Carl-Friedrich, Rogelj, Joeri and Conway, Declan, “Characterizing Half-a-Degree Difference: A Review of Methods for Identifying Regional Climate Responses to Global Warming Targets”, WIREs Climate Change, Vol. 8, No. 2, 2017CrossRefGoogle Scholar.

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21 See Jim W. Hall, Alexander Otto, Adrian J. Hickford, Robert J. Nicholls and Martino Tran, “A Framework for Analysing the Long-Term Performance of Interdpendent Infrastructure Systems”, in Jim W. Hall, Martino Tran, Adrian J. Hickford and Robert J. Nicholls (eds), The Future of National Infrastructure: A System-of-Systems Approach, Cambridge University Press, Cambridge, 2016.

22 See, e.g., Bernard Haemmerli and Andrea Renda, “Protecting Critical Infrastructure in the EU”, Centre for European Policy Studies (CEPS), Brussels, 16 December 2010, available at: https://www.ceps.eu/ceps-publications/protecting-critical-infrastructure-eu/; Public Safety Canada, Risk Management Guide for Critical Infrastructure Sectors, Ottawa, 2010, available at: https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/rsk-mngmnt-gd/rsk-mngmnt-gd-eng.pdf; U.S. Department of Defense, DoD Policy and Responsibilities for Critical Infrastructure, Washington, DC, 2012; Schmitt, Michael N. and Schauss, Michael, “Uncertainty in the Law of Targeting: Towards a Cognitive Framework”, Harvard National Security Journal, Vol. 10, 2019Google Scholar.

23 See, e.g., Joint Chiefs of Staff, Joint Targeting, Department of the Navy, U.S. Department of the Army, Department of the Navy – Marine Corps, Department of the Air Force, U.S. Coastguard, 2013.

24 See Joint Chiefs of Staff, Joint Targeting School Student Guide, Joint Targeting School, Dam Neck, VA, 2017.

25 Other militaries also follow a similar procedure, with different terminology (e.g. NATO employs decide, detect, track, deliver and assess); see Giulio Di Marzio, “The Targeting Process… This Unknown Process (Part I)”, NRDC-ITA Magazine, 2009, available at: https://www.nato.int/nrdc-it/magazine/2009/0911/0911d.pdf. See Joint Chiefs of Staff, above note 23.

26 Ellen Nohle and Isabel Robinson, “War in Cities: The ‘Reverberating Effects’ of Explosive Weapons”, in Humanitarian Law & Policy, ICRC, 2 March 2017, available at: https://blogs.icrc.org/law-and-policy/2017/03/02/war-in-cities-the-reverberating-effects-of-explosive-weapons/.

27 Johnson, Steven, The Ghost Map: The Story of London's Most Terrifying Epidemic – and How it Changed Science, Cities, and the Modern World, Penguin Books, London, 2006Google Scholar.

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29 See also Hunter, Paul R., MacDonald, Alan M. and Carter, Richard C., “Water Supply and Health”, PLOS ONE, Vol. 7, No. 11, 2010Google ScholarPubMed; Hunter, Paul R., Zmirou-Navier, Denis and Hartemann, Philippe, “Estimating the Impact on Health of Poor Reliability of Drinking Water Interventions in Developing Countries”, Science of the Total Environment, Vol. 407, No. 8, 2009CrossRefGoogle ScholarPubMed.

30 The figure is more than the sum of deaths from the “big three” of malaria, tuberculosis and HIV/AIDS combined: Bartram, Jamie and Cairncross, Sandy, “Hygiene, Sanitation, and Water: Forgotten Foundations of Health”, PLoS Medicine, Vol. 7, No. 1, 2010CrossRefGoogle ScholarPubMed. See also Prüss-Ustün, Annette, Bartram, Jamie, Clasen, Thomas, et al. , “Burden of Disease from Inadequate Water, Sanitation and Hygiene in Low- and Middle-Income Settings: A Retrospective Analysis of Data from 145 Countries”, Tropical Medicine & International Health, Vol. 19, No. 8, 2014CrossRefGoogle Scholar.

31 World Bank, ICRC and UNICEF, above note 18.

32 At least for the forty-six of 2120 publications which met the stringent requirements of the systematic review.

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34 Adapted by the authors from WHO, Guidelines on Sanitation and Health, Geneva, 2018.

35 See, e.g., Volodymyr Kalinin, “Key Pipelines Damaged by Shelling”, WASH Incident Report No. 283, 8 May 2021, available at: https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/wash_incident_report_no283_-_080521.pdf.

36 Comprehensive documentation on the effects of armed conflict on water infrastructure is to be found, for example, in P. Giorgio Nembrini's Thirsty Cities in War collection – see Table A in the Annex.

37 M. Zeitoun and M. Talhami, above note 5.

38 Ramesh, Anita, Blanchet, Karl, Ensink, Jeroen H. J. and Roberts, Bayard, “Evidence on the Effectiveness of Water, Sanitation, and Hygiene (WASH) Interventions on Health Outcomes in Humanitarian Crises: A Systematic Review”, PLOS ONE, Vol. 10, No. 9, 2015CrossRefGoogle ScholarPubMed.

39 The review discusses the factors required to robustly evidence causation (especially during the conduct of hostilities): a good “control” case to compare against, agreed health indicator definitions, age-specific, water quality records, seasonal changes in water or wastewater quality, and the confounding variables that make up the “cascade of uncertainty”. See Blum, D. and Feachmen, R. G., “Measuring the Impact of Water Supply and Sanitation Investments on Diarrhoeal Diseases: Problems of Methodology”, International Journal of Epidemiology, Vol. 12, No. 3, 1983CrossRefGoogle ScholarPubMed; Kerridge, B. T., Khan, M. R., Rehm, J. and Sapkota, A., “Conflict and Diarrheal and Related Diseases: A Global Analysis”, Journal of Epidemiology and Global Health, Vol. 3, No. 4, 2013CrossRefGoogle ScholarPubMed; Connolly, M. A., Communicable Disease Control in Emergencies: A Field Manual, WHO, Geneva, 2005Google Scholar; Connolly, Máire A., Gayer, Michelle, Ryan, Michael J., Salama, Peter, Spiegel, Paul and Heymann, David L., “Communicable Diseases in Complex Emergencies: Impact and Challenges”, Lancet, Vol. 364, No. 9449, 2004CrossRefGoogle ScholarPubMed; A. Ramesh et al., above note 38, Discussion, p. 14.

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43 Abbara, Aula, Zakieh, Omar, Rayes, Diana, et al. , “Weaponizing Water as an Instrument of War in Syria: Impact on Diarrhoeal Disease in Idlib and Aleppo Governorates, 2011–2019”, International Journal of Infectious Diseases, Vol. 108, 2021CrossRefGoogle Scholar.

44 The bulk of the negative impact was indirect, and accumulated over time – manifesting itself most importantly in the lack of qualified staff: Zeitoun, Mark, Elaydi, Heather, Dross, Jean-Philippe, Talhami, Michael, Pinho-Oliveira, Evaristo de and Cordoba, Javier, “Urban Warfare Ecology: A Study of Water Supply in Basrah”, International Journal of Urban and Regional Research, Vol. 41, No. 6, 2017CrossRefGoogle Scholar. For example, the staff either did not show for work because of security reasons, eventually left the country (“brain drain”), or – over the decades since 1990 – simply retired. The biggest impact on hardware was felt in the depletion of spare parts, due both to looting of stores or to the prohibition of importing spare parts: P. Giorgio Nembrini, C. Generelli, A. Al-Attar, et al., Basrah Water Supply During the War on Iraq, Geneva Foundation and International Committee of the Red Cross, Geneva, 2003; Int Doc 039, “Report on Sanitation Activities in Basrah”, Internal Technical Document of the International Committee of the Red Cross, Baghdad, 23rd June 1991; Int Doc 099, “ICRC Sanitation Activities in Basrah Area”, Internal Technical Document of the International Committee of the Red Cross, Baghdad 29 January 1992. The quality of water treatment was reduced due in particular to shortages of aluminium sulphate-dosing equipment, unavailability of the preferred type of chlorine, and broken chlorination pumps: Yves Etienne and P. Giorgio Nembrini, “Establishing Water and Sanitation Programmes in Conflict Situations: The Case of Iraq During the Gulf War”, International Journal of Public Health, Vol. 40, No. 1, 1995; ICRC 029, “Water Treatment”, Baghdad, ICRC News Bulletin, ICRC Iraq, No. 7, March 2000; Int Doc 142, “Wathab General Meetin [sic], on 23.03.2004”. Internal Technical Document of the International Committee of the Red Cross, Baghdad, 6 April 2004.

45 Azhar Al-Rubaie, Michael Mason and Zainab Mehdi, Failing Flows: Water Management in Southern Iraq, LSE, London, 2021.

46 United Nations Development Programme, “UN Joint Programme Document: Response to Basra Water Crisis – Iraq”, 2020, available at: https://info.undp.org/docs/pdc/Documents/IRQ/JP%20Document_Proposal_final%20-Basra%20water%20project%204.NOV.2020%20UNICEF%20signed[2].pdf.

47 P. G. Nembrini, C. Generelli, A. Al-Attar, et al., above note 44.

48 World Bank, ICRC and UNICEF, above note 18, Figure 3.2.

49 M. Zeitoun, C. Generelli, A. Al-Attar, et al., above note 44.

50 Khwaif, J. M., Hayyawi, A. H. and Yousif, T. I., “Cholera Outbreak in Baghdad in 2007: An Epidemiological Study”, Eastern Mediterranean Health Journal, Vol. 16, No. 6, 2008Google Scholar. For longer-term national trends, see also Hussain, A. M. and Latfa, R. K., “Trend of Cholera in Iraq in the Time of Unrest”, Mustansiriya Medical Journal, Vol. 18, No. 1, 2019CrossRefGoogle Scholar.

51 Al Janoonb, personal communication, “Remote Interview with Basrah Water Engineer, 23 December 2013”, anonymized, 2013.

52 Mark Zeitoun, “More Bombs and Bread”, Opinion, The Jordan Times, 2003.

53 Al Janoob, personal communication, “Remote Interview with Basrah Water Engineer, 3 November 2015”, anonymized, 2015.

54 WHO, “Cholera-Iraq”, World Health Organization – Disease Outbreak News, 12 October 2015; Al Janoob, personal communication.

55 Human Rights Watch, “Basra Is Thirsty: Iraq's Failure to Manage the Water Crisis”, 22 July 2019, available at: https://ceobs.org/hrw-basra-is-thirsty-iraqs-failure-to-manage-the-water-crisis/.

56 UNICEF, Water Scarcity Crisis in Basra, 2019.

57 For longer-term trends and comparison with other countries, see knoema.com/infographics/xknpzhb/cholera-outbreak-in-yemen.

58 REACH, Secondary Desk Review on WASH Assessments in Yemen, May 2020, available at: https://reliefweb.int/sites/reliefweb.int/files/resources/reach_yem_report_wash_secondary_desk_review_may_2020.pdf.

59 Anton Camacho, Malika Bouhenia, Reema Alusufi, et al., “Cholera Epidemic in Yemen, 2016–18: An Analysis of Surveillance Data”, Lancet Global Health, Vol. 6, No. 6, 2018.

60 For example, Dureab, Fekri, Shibib, Khalid, Yé, Yazoumé, Jahn, Albrecht and Müller, Olaf, “Cholera Epidemic in Yemen”, Lancet Global Health, Vol. 6, No. 12, 2018CrossRefGoogle ScholarPubMed.

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62 NWSSIP, National Water Sector Strategy and Investment Programme, 2005–2009, Final Draft 17 December 2008; Leslie Morris-Iveson and Ahmed Alderwish, “Experiences with Local Water Governance and Outcomes for Vulnerable Communities in the Tihama Region of Yemen”, Water Alternatives, Vol. 11, No. 3, 2018.

63 World Bank, Yemen Dynamic Needs Assessment: Phase 3 (2020 Update), Washington, DC, 2020.

64 Yasir Mohieldeen, Responses to Water Scarcity: Social Adaptive Capacity and the Role of Environmental Information. A Case Study from Ta'iz, Yemen, 1999, available at: https://www.soas.ac.uk/water/publications/papers/file38366.pdf.

65 Humanity & Inclusion, above note 14.

66 GIZ, Yemen Water Sector: Damage Assessment Report of Twelve Water Supply and Sanitation Local Corporations (LCs) and their Affiliated Branch Offices and Utilities – Stage III, Part 2: Situation Assessment Report and Development of Technical Assistance and Investment Plans for the Infrastructure Rehabilitation of Water Supply and Sanitation Services, Annex 2: Technical Assessment Report for Aden LC, 2018.

67 WHO, Domestic Water Quantity, Service Level and Health, Geneva, 2013.

68 International Organization for Migration/United Nations High Commissioner for Refugees, Task Force on Population Movement (TFPM), 13th Report, March 2017, available at: https://reliefweb.int/sites/reliefweb.int/files/resources/draft_tfpm_13th_report_feb2017_v4.pdf.

69 KfW, Technical Needs Assessment Report, 2015.

70 World Bank, above note 63, p. 120.

71 OCHA, above note 61, p. 94.

72 Republic of Yemen, National Report for the Third UN Conference on Housing and Sustainable Urban Development – Habitat III, Sana'a, 2016.

73 REACH, above note 58; Al-Gheethi, Adel A. S., Abdul-Monem, M. O., Al-Zubeiry, A. H. S., Efaq, A. N., Shamar, A. M. and Al-Amery, Ramzy M. A., “Effectiveness of Selected Wastewater Treatment Plants in Yemen for Reduction of Faecal Indicators and Pathogenic Bacteria in Secondary Effluents and Sludge”, Water Practice & Technology, Vol. 9, No. 3, 2014CrossRefGoogle Scholar.

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75 Adapted by the authors from Mohammad Al-Saidi, Emma Lauren Roach and Bilal Ahmed Hassen Al-Saeedi, “Conflict Resilience of Water and Energy Supply Infrastructure: Insights from Yemen”, Water, Vol. 12, No. 11, 2020.

76 M. Al-Saidi, E. L. Roach and B. A. H. Al-Saeedi, ibid.; World Bank, above note 63, p. 148.

77 Federspiel, Frederik and Ali, Mohammad, “The Cholera Outbreak in Yemen: Lessons Learned and Way Forward”, BMC Public Health, Vol. 18, No. 1, 2018CrossRefGoogle ScholarPubMed.

78 UNICEF, Water under Fire, Vol. 3: Attacks on Water and Sanitation Services in Armed Conflict and the Impacts on Children, New York, 2021.

79 Indirect impacts of the longer-term aspects of the war were felt on the water providers’ governance systems, bill-collection rates and staff: GIZ, above note 66. The impact on staff was due in part to the lack of salaries paid and also because of brain drain: World Bank, above note 63.

80 REACH, Access to Improved Water Sources in Yemen: Secondary Data Review, July 2017, available at: https://reliefweb.int/sites/reliefweb.int/files/resources/reach_yem_situation_overview_access_to_improved_water_sources_july_2017_final_0.pdf; see also Erika Weinthal and Jeannie Sowers, “Targeting Infrastructure and Livelihoods in the West Bank and Gaza”, International Affairs, Vol. 95, No. 2, 2019.

81 World Bank, above note 63.

82 M. Al-Saidi, E. L. Roach and B. A. H. Al-Saeedi, above note 75.

83 GIZ, Yemen Water Sector: Damage Assessment Report of Twelve Water Supply and Sanitation Local Corporations (LCs) and their Affiliated Branch Offices and Utilities – Stage III, Part 2: Situation Assessment Report and Development of Technical Assistance and Investment Plans for the Infrastructure Rehabilitation of Water Supply and Sanitation Services, 2018.

84 UN News Service, “Yemen: Attacks on Water Facilities, Civilian Infrastructure, Breach ‘Basic Laws of War’ Says UNICEF”, 1 August 2018, available at: https://news.un.org/en/story/2018/08/1016072.

85 World Bank, above note 63, p. 72.

86 Naif Abu-Lohom, Dambudzo Muzenda and Yogita Upayda Mumssen, “A WASH Response to Yemen's Cholera Outbreak”, The Water Blog of the World Bank, 13 December 2018, available at: https://blogs.worldbank.org/water/wash-response-yemen-s-cholera-outbreak.

87 Charbel El Bcheraoui, Aisha O. Jumaan, Michael L. Collison, Farah Daoud and Ali H. Mokdad, “Health in Yemen: Losing Ground in War Time”, Globalization and Health, Vol. 14, 2018.

88 The documentation and analysis was completed before the May 2021 hostilities in Gaza.

89 Arie, Sophie, “Gaza is Running Out of Medicines as Egypt Limits Movement Through the Rafah Crossing”, British Medical Journal, Vol. 347, 2013CrossRefGoogle ScholarPubMed; Zarocostas, John, “Quality of Medical Services is in Decline in Gaza, Says UN Official”, British Medical Journal, Vol. 340, 2010Google Scholar.

90 Palestinian Water Authority (PWA), Water Safety for Public Health Status Joint Report, Gaza, 2019; PWA, Water Resources Status Report, Gaza, 2018.

91 United Nations Relief and Works Agency (UNRWA), Epidemiological Bulletin for Gaza Strip, Gaza City, 2016. See also PWA, Baseline Study on Water Quality & Public Health in the Gaza Strip: Final Report, Gaza City, 2015.

92 Oxfam, Still Treading Water: Reviewing Six Years of the Gaza Reconstruction Mechanism and the Dire Water Situtation in the Gaza Strip, Oxfam, Oxford, 2021.

93 PWA, Water Resources Status Report, above note 90.

94 Reem Shomar, Anti-Microbial Resistant Bacteria in Health Care Facilities in Gaza: Exploring Links with WASH. Final Report of a Pilot Study Conducted Under the GCRF/UK Academy of Medical Sciences Networking Grant Networking Grant GCRFNGR4\1490, Gaza City, February 2021.

95 A separate line of enquiry finds that roughly one-quarter of the diseases in Gaza are water-related: World Bank, West Bank and Gaza: Assessment of Restrictions on Palestinian Water Sector Development Sector Note April 2009, International Bank for Reconstruction and Development, Washington, DC, 2009, and are compounded by the additional threat of the spread of anti-microbial resistance: R. Shomar, ibid.; Elmanama, Abdelraouf A., Hartemann, Philippe, Elnabris, Kamal J., et al. , “Antimicrobial Resistance of Staphylococcus Aureus, Fecal Streptococci, Enterobacteriaceae and Pseudomonas Aeruginosa Isolated from the Coastal Water of the Gaza Strip-Palestine”, International Arabic Journal of Antimicrobial Agents, Vol. 6, No. 32, 2016Google Scholar.

96 World Bank Group, “Securing Water for Development in West Bank and Gaza”, in Water Global Practice – Sector Note, International Bank for Reconstruction and Development/World Bank, Washington, DC, 2018.

97 Mads Gilbert, Brief Report to UNRWA: The Gaza Health Sector as of June 2014, UNRWA, Tromso, 2014.

98 United Nations Environment Programme, Environmental Assessment of the Gaza Strip Following the Escalation of Hostilities in December 2008–January 2009, Nairobi, Kenya, 2009, available at: https://www.unep.org/resources/report/environmental-assessment-gaza-strip-following-escalation-hostilities-december-2008; see also EWASH, Gaza Emergency Wash Cluster Weekly Situation Report 24 January 2009, 2009, available at: https://reliefweb.int/sites/reliefweb.int/files/resources/33D83908349E91CCC12575610042BF06-full_report.pdf; Oxfam International, Rebuilding Gaza: Putting People before Politics, June 2009, available at: https://oi-files-d8-prod.s3.eu-west-2.amazonaws.com/s3fs-public/file_attachments/bn-rebuilding-gaza-0906_9.pdf; Palestinian Hydrology Group, Rapid Community Based Water and Sanitation Needs Assessment from the Impact of the Israeli Offensive on Gaza between 27th Dec. 2008 and 17th Jan. 2009, Gaza City, East Jerusalem, 2009.

99 Coastal Municipalities Water Utility (CMWU), Damages Assessment Report: Water and Wastewater Infrastructure (Gaza Strip; 7 July–14 August 2014), Gaza City, 2014, available at: https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/assessments/Damage_Assessment_Report_War%202014%20%28%20REV%201%29.pdf; see also EWASH, Gaza Water Disaster: Damages to Water Infrastructure, 2014; E. Weinthal and J. Sowers, above note 80.

100 Office of the Quartet, Report to the Ad Hoc Liaison Committee, Jerusalem, June 2020.

101 Karim Nashashibi and Yitzhak Gal, Gaza: The Water–Energy–Governance Nexus – a Plan of Action for Saving What Has Been Achieved, 2019, available at: https://www.kas.de/documents/268421/8457122/Gaza+The+Water-Energy+Governance+Nexus.pdf/43b30628-9635-e74f-a975-a5c3329aac88?version=1.0&t=1583501742254.

102 S. Arie, above note 89.

103 CMWU, Damage Assessment Report for CMWU Main Building & Al Nusirat Pump Station, Gaza City, 2011.

104 Office of the Quartet, above note 100; ICRC, Israel and the Occupied Territories: Concept Note for Helping to Build People's Resilience to the Humanitarian Conseqences of Chronic Difficulties in the Gaza Strip, Geneva, 2019; K. Nashashibi and Y. Gal, above note 101.

105 ICRC, Towards More Effective Humanitarian Operations in Urban Protracted Armed Conflicts: Lessons from the Application of the “Operational Resilience Approach” and “Institutional Learning” in Gaza, Geneva, 2021.

106 Shira Efron, Jordan R. Fischbach, Ilana Blum, Rouslan I. Karimov and Melinda Moore, The Public Health Impacts of Gaza's Water Crisis: Analysis and Policy Options, RAND Corporation, Santa Monica, CA, 2018; Michelle Malka Grossman, “Gaza Sewage Crisis is a Ticking Timebomb for Israel”, The Jerusalem Post, 17 March 2016, available at: https://www.jpost.com/arab-israeli-conflict/gaza-sewage-crisis-is-a-ticking-timebomb-for-israel-448335.

107 To complement Sahr Muhammedally, “Preparedness in Urban Operations: A Commander's Planning Checklist to Protect Civilians”, Humanitarian Law & Policy Blog of the ICRC, 11 May 2021, available at: https://blogs.icrc.org/law-and-policy/2021/05/11/preparedness-in-urban-operations/.

108 Indeed, the assumption that improved and sustained levels of public health relies on good WASH services is the foundation for most humanitarian and development programmes, whether humanitarian, “development” or military.

109 Pier Giorgio Nembrini, “Lebanon: Water Supply Problems during the 1989 and 1990 Wars”, in ICRC, Water and War: Symposium on Water in Armed Conflict, Montreux, 21–23 November 1994, Geneva, 1994.

110 Aloys Widmer, in ICRC, ibid.

111 Riccardo Conti, in ICRC, above note 109.

112 Riccardo Conti, in ICRC, above note 109.

113 Markus Baechler, in ICRC, above note 109.

114 Robert Hodgson and Alain Oppliger, “After the Battle of Grozny”, in ICRC, War and Water, Geneva, 1999.

115 Mark Buttle, Volodymyr Kalinin and Stas Dymkosvskyy, Incident Analysis January–June 2017, 2017, available at: https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/9._wash_cluster_alert_bulletin._issue_9.pdf.

116 P. Giorgio Nembrini and Riccardo Conti, “In a Town Scarred by War”, in ICRC, War and Water, Geneva, 1999.

117 P. Giorgio Nembrini, “Cities in War: Thirsty Cities – Dili (East Timor)”, Geneva, August 2000, available at: https://www.thirstycitiesinwar.net/.

118 P. Giorgio Nembrini, Huambo (Angola): Water Supply in a War Torn Town: Evolution and Impact of the Different Interventions Since 1985, Occasional Paper No. 3, Cities in War: Thirsty Cities, Geneva Foundation, Geneva, 2001.

119 P. Giorgio Nembrini, Novi Sad (Republic of Yugoslavia): How the Water Supply of the Town Was Affected by the Nato Campaign of 1999, Occasional Paper No. 5, Cities in War: Thirsty Cities, Geneva Foundation, Geneva, 2001.

120 P. Giorgio Nembrini, C. Smith, A. Petters, et al., Cities in War: Thirsty Cities – Monrovia (Liberia). Water Supply for Monrovia During and after the Civil War, Occasional Paper No. 4, Cities in War: Thirsty Cities, Geneva Foundation, Geneva, 2001.

121 P. G. Nembrini, P. Jansen, J. F. Pinera, R. Luff, O. Bernard, M. Weber and M. J. Elliot, Kabul Water Supply: Evolution Since the 1992–94 Civil War, Occasional Paper No. 7, Cities in War: Thirsty Cities, Geneva Foundation, Geneva, 2002.

122 Mark Zeitoun, “Conflict and Water in Palestine – the Consequences of Armed Conflict on Drinking-Water Systems in Jenin, West Bank”, in Imad Khatib, Karen Assaf, Dominique Claeys and Ayman Al Haj Daoud (eds), Water Values and Rights, Palestine Academy Press, Ramallah, Palestine, 2005.

123 P. G. Nembrini, C. Generelli, A. Al-Attar, et al., above note 44.

124 Mark Zeitoun, Karim Eid-Sabbagh and Jeremy Loveless, “The Analytical Framework of Water and Armed Conflict: A Focus on the 2006 Summer War Between Israel and Lebanon”, Disasters, Vol. 38, No. 1, 2014.

125 Pier Giorgio Nembrini and A. Moreau, The Gaza Strip: The Last “Ghetto”: An Organized Deprivation and a Denied Urban Development, Occasional Paper No. 9, Cities in War: Thirsty Cities, Geneva Foundation, Geneva, 2009.

126 P. Giorgio Nembrini, The Gaza Strip: The State of the Water Supply after the 2008–2009 War, Occasional Paper No. 10, Cities in War: Thirsty Cities, Geneva Foundation, Geneva, 2010.

127 Pinera, Jean-François and Reed, Robert, “A Tale of Two Cities: Restoring Water Services in Kabul and Monrovia”, Disasters, Vol. 33, No. 4, 2009CrossRefGoogle ScholarPubMed; Pinera, Jean-François and Reed, Robert, “Restoring Services, Rebuilding Peace: Urban Water in Post-Conflict Kabul and Monrovia”, Water International, Vol. 36, No. 2, 2011CrossRefGoogle Scholar.

128 Stephan Magnaldi and Jessica Patera, “Kaboul, de la destruction à la reconstruction”, in François Grünewald and Eric Levron (eds), Villes en guerre et guerres en villes, Editions Karthala, Paris, 2004.

129 Pinera, Jean-François, “Urban Armed Conflicts and Water Services”, Waterlines, Vol. 31, Nos. 1 and 2, 2012CrossRefGoogle Scholar.

130 J.-F. Pinera and R. Reed, above note 127.

131 J.-F. Pinera, above note 129.

132 Jean-François Pinera, Cities, Water and War: Looking at How Water Utilities and Aid Agencies Collaborate in Cities Affected by Armed Conflicts, Lambert Academic Publishing, Loughborough, 2011.

133 Ibid.

134 Ibid.

135 Mary Daly and Christoph Langenkamp, in ICRC, above note 109.

136 Jean-Paul de Passos, “Huambo, une capitale provinciale au cœur de la guerre civile”, in F. Grünewald and E. Levron, above note 128.

137 Les Roberts and Katayon Faramusova, in ICRC, above note 109.

138 Pier Giorgio Nembrini and Riccardo Conti, in ICRC, above note 109.

139 United Nations Human Rights Council, Human Rights in Palestine and Other Occupied Arab Territories: Report of the United Nations Fact-Finding Mission on the Gaza Conflict (the “Goldstone Report”), New York, 2009.

140 Eyal Weizman, The Least of All Possible Evils, Verso, London, 2011.

141 Organization for Security and Co-operation in Europe (OSCE), Access to Water in Conflict-Affected Areas of Donetsk and Luhansk Regions, September 2015, available at: https://www.osce.org/files/f/documents/0/6/183151.pdf; OSCE, Hardship for Conflict-Affected Civilians in Eastern Ukraine, February 2017, available at: https://www.osce.org/files/f/documents/4/0/300276.pdf; UNICEF, Risk Assessment of the “Voda Donbasu” Water System, October 2020, available at: https://www.unicef.org/ukraine/en/reports/VD-risk-assessment-2019.

142 Sowers, Jeannie and Weinthal, Erika, “Humanitarian Challenges and the Targeting of Civilian Infrastructure in the Yemen War”, International Affairs, Vol. 97, No. 1, 2021CrossRefGoogle Scholar.

143 E. Weinthal and J. Sowers, above note 80.

144 Schillinger, Juliane, Özerol, Gül, Güven-Griemert, Şermin and Heldeweg, Michiel, “Water in War: Understanding the Impacts of Armed Conflict on Water Resources and Their Management”, Wiley Interdisciplinary Reviews: Water, Vol. 7, No. 6, 2020Google Scholar.