Inside story'Diseases don't have borders. We need to take this seriously'

As soldier with fungal infection dies, fears grow of Gaza diseases spreading into Israel

Cause of soldier’s death not yet confirmed; civilian medical experts warn of cases of potentially deadly fungal infections, other serious afflictions among soldiers

Renee Ghert-Zand is the health reporter and a feature writer for The Times of Israel.

  • Internally displaced Palestinian children living in a school run by the UN agency for Palestinian refugees (UNRWA), walk across a wet courtyard following overnight rainstorms in Rafah in the southern Gaza Strip on November 15, 2023, during the Israel-Hamas war. (SAID KHATIB / AFP)
    Internally displaced Palestinian children living in a school run by the UN agency for Palestinian refugees (UNRWA), walk across a wet courtyard following overnight rainstorms in Rafah in the southern Gaza Strip on November 15, 2023, during the Israel-Hamas war. (SAID KHATIB / AFP)
  • Men use their hands to drink rainwater dripping from the roof of a tent amid water shortages at a United Nations Relief and Works Agency for Palestine Refugees (UNRWA) school in Rafah, southern Gaza Strip, converted to a shelter for internally displaced Palestinian during the Israel-Hamas war.  November 14, 2023. (SAID KHATIB / AFP)
    Men use their hands to drink rainwater dripping from the roof of a tent amid water shortages at a United Nations Relief and Works Agency for Palestine Refugees (UNRWA) school in Rafah, southern Gaza Strip, converted to a shelter for internally displaced Palestinian during the Israel-Hamas war. November 14, 2023. (SAID KHATIB / AFP)
  • A boy looks at piles of garbage littering the Bureij refugee camp in the central Gaza Strip on November 4, 2023, during the Israel-Hamas war. (MOHAMMED ABED / AFP)
    A boy looks at piles of garbage littering the Bureij refugee camp in the central Gaza Strip on November 4, 2023, during the Israel-Hamas war. (MOHAMMED ABED / AFP)
  • Young Palestinians sit outside on mattresses covered with plastic at a camp for displaced people in Rafah, in the southern Gaza Strip on December 13, 2023, during the Israel-Hamas war. (Mahmud HAMS / AFP)
    Young Palestinians sit outside on mattresses covered with plastic at a camp for displaced people in Rafah, in the southern Gaza Strip on December 13, 2023, during the Israel-Hamas war. (Mahmud HAMS / AFP)
  • A carries an infant in the playground of a United Nations Relief and Works Agency for Palestine Refugees (UNRWA) school in Khan Younis, southern Gaza Strip, converted into a shelter for internally displaced Palestinians during the Israel-Hamas War, October 25, 2023. (Mahmud Hams/AFP)
    A carries an infant in the playground of a United Nations Relief and Works Agency for Palestine Refugees (UNRWA) school in Khan Younis, southern Gaza Strip, converted into a shelter for internally displaced Palestinians during the Israel-Hamas War, October 25, 2023. (Mahmud Hams/AFP)
  • Palestinians walk in the rain at a camp for displaced people in Rafah, in the southern Gaza Strip on December 13, 2023 during the Israel-Hamas war. (MAHMUD HAMS / AFP)
    Palestinians walk in the rain at a camp for displaced people in Rafah, in the southern Gaza Strip on December 13, 2023 during the Israel-Hamas war. (MAHMUD HAMS / AFP)

The death of a badly wounded IDF soldier in an Israeli hospital who was infected with a dangerous strain of fungus while fighting in the Gaza Strip has raised concerns about disease in Gaza affecting troops and possibly spreading to Israeli civilians.

According to a Kan public broadcaster report, the soldier was brought to Assuta Ashdod Medical Center two weeks ago with severe limb injuries. Despite round-the-clock care, the fungus proved to be treatment-resistant and the soldier succumbed to his wounds.

Military medical officials have not yet determined his cause of death, but confirm that there are isolated cases of similar fungal infections among wounded soldiers returning from Gaza.

Civilian experts who spoke with The Times of Israel warned that cases of potentially deadly fungal infections — and other serious afflictions among soldiers — are less isolated than has been reported.

All Israeli hospitals have reported that a significant percentage of wounded soldiers have come back with serious antimicrobial-resistant infections that they’ve picked up through contact with contaminated soil, among other factors, said Prof. Nadav Davidovitch, an epidemiologist who heads Ben-Gurion University of the Negev’s School of Public Health.

He noted that currently, there are not large numbers of soldiers sick with the illnesses spreading among Gazans.

The war between Israel and Hamas has led to the destruction of large swaths of Gaza and the internal displacement of the vast majority of its population, resulting in what is being described as a humanitarian crisis for the Palestinians living in ruins and refugee tent camps. These conditions have led to outbreaks of various diseases, which can potentially threaten the well-being of the hundreds of thousands of IDF troops fighting in Gaza. They can also ultimately spell trouble for public health in Israel.

The Israel Defense Forces Spokesperson’s Office told The Times of Israel that there have been no outbreaks of communicable disease among the IDF soldiers.

However, public health experts warn that it may only be a short time before some or all of the diseases in Gaza make their way into Israel via returning troops or otherwise.

“Diseases don’t have borders. We need to take this situation seriously,” said Davidovitch.

Antimicrobial-resistant infections have been a huge problem in Gaza for years, he said, because of the use of unsuitable antibiotics or patients’ failure to complete courses of treatment due to drug shortages.

Prof. Galia Rahav, head of Israel’s Infectious Disease Association, in a recent interview with the Hebrew-language Ynet media outlet, echoed Davidovitch. She added that the existence of highly resistant bacteria in Gaza is well-documented thanks to joint Israeli-Gazan research.

Wounded Israeli soldiers arrive at the Hadassah Ein Kerem Hospital in Jerusalem, October 7, 2023. (Noam Revkin Fenton/ Flash90)

Gazan hospitals are hotbeds for these superbugs. Before the war, Gazan patients brought them to Israeli hospitals when they came for surgeries and treatments, sometimes causing serious outbreaks in wards.

“Just to be clear — the injured IDF soldiers are not being treated in Gaza hospitals. They are picking up these infections because these bacteria, fungi, or parasites are in the dirt or mud in Gaza where they are lying until they are evacuated. They have deep, open wounds that the microbes infect,” Davidovitch explained.

Fertile ground for epidemics

According to the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNWRA), 85 percent of Palestinians in Gaza — 1.9 million people — have been internally displaced by the war between Israel and Hamas that began on October 7, sparked by Hamas’s murderous attack on thousands of people in southern Israel, mainly civilians, and the taking of 240 hostages.

As Israel retaliated with aerial bombardments and a ground offensive against Hamas, Gazans were instructed by the IDF to escape the fighting by moving to the south of the Strip.

A girl carries a bucket of water at a camp for displaced Palestinians in Rafah in the southern Gaza Strip on December 16, 2023, during the Israel-Hamas war. (MOHAMMED ABED / AFP)

The displaced Gazans are reportedly living in squalid, overcrowded winter conditions with little clean water for drinking and washing. According to the Taub Center for Social Policy Studies in Israel, water allocation to each Gaza resident is currently about three liters per day, while the World Health Organization (WHO) recommends between 50 and 100 liters per day.

In Gaza, there is also a high level of food insecurity and few functioning medical facilities. It’s a perfect breeding ground for epidemics, especially among children, the elderly, and the immunocompromised, say public health experts.

Existing problems made much worse

For years, experts have warned of threats posed to Israelis’ health by severe public health deficiencies in Gaza.

These include defective treatment of wastewater and sewage in Gaza that is interfering with Ashkelon’s desalination plant and the Shikma facility for groundwater penetration, and polluting of Zikim beach just north of the border with Gaza.

Air pollution from the burning of garbage in the enclave, and the above-mentioned introduction of antimicrobial-resistant infections by Gazan patients treated in Israeli hospitals, have also been issues.

Conditions are considerably worse now with the near-complete lack of fuel and electricity to operate sewage treatment equipment and hundreds of tons of garbage piling up daily in southern Gaza.

Makeshift toilet at a camp for displaced Palestinians in Rafah, in the southern Gaza Strip on December 13, 2023, during the Israel-Hamas war. (Mahmud HAMS / AFP)

“Without enough latrines, open-air defecation is prevalent, increasing concerns of further spread of disease, particularly during rains and related flooding,” said a December 22 update from the UN Office for the Coordination of Humanitarian Affairs (OCHA).

Davidovitch said that satellite images and water sampling have shown that since the war started, the water in the Mediterranean flowing northward from Gaza toward Ashkelon and beyond is more consistently contaminated with dangerous bacteria, including E. coli, and viruses.

A whole host of diseases

According to the OCHA update, reported cases of diarrhea in Gaza among children under age five are 25 times the monthly average of before the war.

Prof. Ronit Calderon-Margalit, director of the School of Public Health at Hebrew University and Hadassah Medical Center, told The Times of Israel that gastro-intestinal infections transmitted via the fecal-oral route such as shigellosis, dysentery, and cholera must be closely monitored.

There have also been 160,000 cases in Gaza in the last couple of months of acute respiratory infections, including COVID-19, influenza, and respiratory syncytial virus (RSV), as well as increases in other conditions such as scabies, lice, chickenpox, and skin rashes.

Davidovitch said he was also concerned about potential outbreaks of other diseases such as West Nile virus, which is carried by mosquitos that breed in standing water. Polio and measles could also spread as a result of Gazan children not getting their regular vaccines.

Prof. Ronit Calderon-Margalit, director of the School of Public Health at Hebrew University and Hadassah Medical Center. (Tal Margalit)

Israel’s health system must prepare

The presence of hundreds of thousands of Israeli troops fighting Hamas in Gaza raises the possibility that at least some of them could become infected by the diseases circulating in the Strip and bring them home.

At this point, the soldiers are not in much direct contact with the local civilian population in southern Gaza. However, that could change.

“If the war continues, there will be more and more interaction between soldiers and the local community in the coming weeks and months. I don’t see any other way, because a situation of  two million people in a humanitarian disaster will need to be managed,” Davidovitch said.

“That will definitely lead to more opportunities for the infection of IDF troops and their bringing those infections home to Israel. We, as public health officials, are thinking and planning about this, and the IDF needs to, as well,” he said.

Palestinians sit inside a tent as they cook during the rain at camp for displaced people in Rafah, in the southern Gaza Strip, on December 12, 2023 during the Israel-Hamas war. (Mahmud HAMS / AFP)

Calderon-Margalit said that as far as she is aware, the Health Ministry has not shared any information on any outbreaks of diseases from Gaza taking hold in Israel thus far.

“But if we were to see outbreaks, the most worrisome are the respiratory ones because of their quick aerosol, or airborne, transmission,” Calderon-Margalit said.

Getting food into Gaza to mitigate disaster

According to OCHA, it is projected that by February, the entire population of Gaza (approximately 2.2 million people) will experience severe food insecurity. This, in combination with a lack of water, sanitation, and hygiene, could lead to a completely dire health situation, said the World Health Organization.

On December 21, Israeli President Herzog blamed the UN for preventing food from reaching the half-million Palestinians it said are in imminent danger of starvation.

Herzog said that Israel was checking and approving more trucks with humanitarian supplies than were entering the Strip.

Palestinians loot a humanitarian aid truck as it crossed into the Gaza Strip in Rafah, December 17, 2023. (AP Photo/Fatima Shbair)

“Unfortunately, due to the utter failure of the UN in its work with other partners in the region, they have been unable to bring in more than 125 trucks [of aid] a day,” Herzog said.

“Today it is possible to provide three times the amount of humanitarian aid to Gaza if the UN — instead of complaining all day — would do its job,” he said.

A misinformed and dangerous notion

Davidovitch and Calderon-Margalit were among a group of public health physicians who condemned a provocative statement by former head of the Israeli National Security Council Giora Eiland in a November 21 interview with the Hebrew-language financial publication Globes. Eiland suggested that humanitarian aid should be denied to Gaza so that epidemics would spread and lead Hamas to surrender more quickly.

Prof. Nadav Davidovitch (Courtesy of Ben-Gurion University)

“The spread of diseases won’t break the fighting spirit of Hamas leader Yahya Sinwar. He’s a real psychopath. But there are thousands of Hamas fighters who will be influenced,” Eiland said.

The public health physicians criticized Eiland not only for the immorality of his idea but also for his misinformed belief that outbreaks among the Palestinians would not likely affect the health of IDF soldiers or the Israeli public.

“We can’t say with any certainty that we are not going to suffer from the health crisis in Gaza,” Calderon-Margalit said.

In a letter to Eiland (Hebrew) published by the public health professionals, they reminded the retired major general that strong armies led by Napoleon, George Washington, and US Civil War generals were felled by epidemics.

“More battles were lost due to soldiers dying from illness than from their wounds,” Davidovitch said.

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