It’s not just bullets and bombs. I have never seen health organisations as worried as they are about disease in Gaza

These aren’t anywhere near what we would consider safe public health zones.’ Temporary shelters for displaced people in Rafah, Gaza, on 8 December 2023. Photograph: Xinhua/Shutterstock

The Israel-Gaza war has set several world records. It’s the deadliest conflict for journalists in 30 years. It has caused the largest single loss of life for United Nations staff in the history of the organisation. It is set to have the worst ever total number of attacks on healthcare facilities and their personnel, and has devastated schools, with 51% of education facilities damaged. International rules such as the Geneva conventions have not been respected: hospitals and ambulances have been targeted, medical relief organisations such as Doctors Without Borders (MSF) and Save the Children are under attack, and have lost staff members.

The Israel-Gaza war is also deadly for children, reportedly the deadliest conflict for children in recent times: roughly 160 children were being killed a day last month according to the World Health Organization. Compare this with three a day in the recent conflict in Syria, two a day in Afghanistan, and 0.7 a day in Ukraine. The total number of children killed is already more than 5,300 says Unicef, the United Nations Children’s Fund. They didn’t choose to be born there, and are innocent, but are bearing the brunt of these attacks.

Tragically, the nearly unprecedented death and injury we have seen so far is likely to only be the beginning. From looking at similar conflicts across the world, public health experts know that we are likely to see more children dying from preventable disease than from bullets and bombs. While the Israeli government has spoken about safe zones for families to flee to, these aren’t anywhere near what we would consider safe public health zones. They don’t have clean water, functional sanitation and toilets, enough food, or trained medical staff with medicine and equipment. These are the basic needs that any human, especially babies and children, need to stay healthy and alive.

The WHO spokesperson Dr Margaret Harris has said that diarrhoea rates among children in refugee-like camps (sheltered housing) in Gaza were, in early November, already more than 100 times normal levels, and with no treatments available, children can become dehydrated and die quickly. Diarrhoeal diseases are the second leading cause of death in children under five worldwide, and they are caused by contaminated water sources and lack of access to oral rehydration fluids. Upper respiratory infections, chickenpox, and painful skin conditions have also increased, and there are fears that the recent floods may result in untreated sewage mixing with fresh water used for drinking and cooking, and cause a cholera outbreak.

Disease has played a role in battle for centuries. During the American civil war, two-thirds of the estimated deaths of soldiers were caused by pneumonia, typhoid, dysentery and malaria. In 1994, two diseases, cholera and dysentery, linked to unclean water and conflict zones, killed more than 12,000 Rwandan refugees in only three weeks in June 1994.

An estimated 85% of Gaza’s inhabitant are already displaced according to the UN Relief and Works Agency. Experts analysing previous refugee displacements estimate in the Lancet that crude mortality rates (that is deaths per 1,000 people) were more than 60 times higher than when each conflict began, on average. Extrapolating this to the current situation in Gaza, where the crude death rate before the conflict was 3.82 in 2021 (relatively low because of its young demographic), mortality rates could reach 229.2 in 2024 if the conflict and displacement continue at the current level of intensity, and Gazans continue to lack access to sanitation, medical facilities and permanent housing.

Ultimately, unless something changes, the world faces the prospect of almost a quarter of Gaza’s 2 million population - close to half- a million human beings - dying within a year. These would be largely deaths from preventable health causes and the collapse of the medical system. It’s a crude estimate, but one that is data-driven, using the terrifyingly real numbers of deaths in previous and comparable conflicts.

International organisations are trying to raise the alarm about this situation, with Harris lamenting: “It seems the world has lost its moral compass.” Unicef has warned: “Lack of water, food, medicine and protection is a bigger threat than bombs to the lives of thousands in Gaza.”

I have been working in global public health for 20 years, and I have never heard health and aid organisations as forthright and concerned as they are about the level of suffering and deaths in Gaza. It is an unprecedented conflict, breaking the most tragic records, and while experts might debate whether it’s a genocide or not, the truth is we’re witnessing the mass killing of a population, whether by bomb, bullet, starvation or disease.

By Prof.

Prof Devi Sridhar is chair of global public health at the University of Edinburgh