Deficiencies in desalinated water could lead to increase in heart attack deaths

Desalinated water has always been touted as Israel’s magic bullet: a solution to the challenging trifecta of desert climate, hostile neighbors and global warming. For the past decade, the whirring osmosis machines located along the shore of the Mediterranean allowed Israelis to ensure water flowed through their shower heads and filled their hotel swimming pools, even as the worst drought in 100 years forced the Sea of Galilee to record lows.

But health officials are warning that there is a dark underside to the wonders of desalinated water. Desalinated seawater has none of the minerals naturally found in ground water, minerals that humans require for a healthy growth and development, especially magnesium.

A lack of magnesium in water could contribute to hundreds of cardiac deaths per year, according to a 2018 study from Bar-Ilan University, Clalit Medical Services, and Tel Hashomer Hospital. The study examined 178,000 patients who are members of Clalit, Israel’s largest HMO. The study divided the patients into two groups: one group living in areas where desalination accounts for a greater percentage of drinking water, such as on the coast, and one group living in areas like the Upper Galilee or Golan Heights, which currently do not have access to desalinated drinking water and get their water from other sources.

The study found that people from the area with desalinated water were 6% more likely to have heart issues, including death from heart attack.

The Health Ministry estimated in 2012 that approximately 250 deaths each year could be attributed to low magnesium levels.

In response to a similar report from Bar-Ilan and Tel Hashomer in 2016, Prime Minister Benjamin Netanyahu instructed the Health Ministry to run a pilot to examine the logistics and cost of adding magnesium to desalinated water. But two years later, the pilot has yet to begin, and the amount of desalinated water Israelis use each year has doubled.

Good to the last drop

“Desalination is on level with God,” said Peretz Darr, a water consultant and the former head of the Urban Water department at the TAHAL water engineering group. “It’s one of the gems of the Israeli legend and people are not so happy to delve into it and analyze it.”

Water quality is often overlooked, but it can be a deadly issue, even in first-world countries, Darr said, pointing to Flint, Michigan, where lead in the city’s water has been blamed for serious health problems.

“We agree that Flint is one of the biggest water quality issues in the world, and in Flint, [only] five people have died,” Darr said.

Darr, who has helped design water efficiency guidelines during droughts for the Water Commissioner, believes the Health Ministry’s estimate that 250 people die from cardiac attacks due to magnesium deficiency is too conservative. He also worries about the impact of lack of magnesium on children’s development, referring to studies that tenuously link mineral deficiencies to higher levels of ADHD.

“We’re talking about children whose mental capacity is being impacted by this water and nothing is being done,” he said. “It is a situation that is so bizarre, it is almost unbelievable.”

There are already some minerals being added to desalinated water. The desalination plants add calcium before the water is distributed to the national water carriers, because desalinated water is slightly acidic and corrosive to water pipes over time. Calcium helps combat the acidity, and is relatively inexpensive to add. Calcium, as a mineral, is also beneficial to humans and plants.

Darr, the Health Ministry, and a number of other public health officials want magnesium to be added to all desalinated water, in order to ensure that the population gets the needed magnesium.

But the Water Authority says that could cost as much as NIS 600 million (approximately $160 million), and the government needs to find a way to fund that without raising the cost of water for consumers.

Additionally, less than 5% of water used in households actually goes toward cooking and eating, according to the Water Authority, says spokesman Uri Schor. “We are talking about hundreds of millions of shekels when a small percentage of water actually gets to your mouth,” said Schor.

The FYI on Mg

Magnesium is an essential mineral for human growth and development, which is involved in more than 300 biological reactions in the body. Primarily, magnesium affects muscles, especially cardiac muscles, improving people’s ability to survive a heart attack. Magnesium also affects nerve function, energy production, protein production, and the synthesis of DNA and RNA.

People who are lacking in magnesium rarely feel side effects and will suffer heart attacks at the same rate as people with normal levels of the mineral. But studies show that their survival rate from heart attacks is lower.

Magnesium shortages can also lead to osteoporosis and bone mass issues, and higher blood pressure, as well as a decrease in cognitive ability, fatigue, and increased aggression. Scientists have studied the connection between magnesium, zinc and cooper deficiencies and ADHD in children, but the studies are not large enough to be conclusive.

People who eat a balanced diet, with plenty of green leafy vegetables and nuts, can generally get most of their magnesium from food.

The Health Ministry recommends 320 to 360 mg/day of magnesium for women and 410 to 420 mg/day for men. Popping a daily single multivitamin, which usually has around 50 mg of magnesium, can easily cover any deficit in your diet to obtain the recommended level of magnesium per day.

But for many people who do not eat balanced diets, especially in lower socioeconomic classes, water has historically provided an important source of magnesium. In Israeli groundwater, magnesium levels are about 25-30 mg/L, which gives Israel the classification of having “hard” or mineral-rich groundwater. Previously, groundwater was mixed with surface water from the Sea of Galilee. Surface water does not have magnesium, but the combination of hard groundwater with surface water created water that was richer in magnesium than the current water available today in most of Israel.

In Israel, all of the water is mixed together in the spider web of pipes that make up the national water carrier system. When you open the faucet, the mix of water that fills your glass might vary from one day to the next, including regarding the percentage of desalinated water or where the groundwater originated. No one is drinking only desalinated water; and no one is drinking only groundwater, except in areas of the Upper Galilee and Golan that do not have access to desalinated water yet.

In areas with “hard” water — water with a high mineral content — people usually obtain about 20% of their daily magnesium intake from water, according to the Health Ministry. (You can “see” the minerals in the water in the hard white matter at the bottom of a well-used electric teakettle. As the water boils, some of the calcium carbonate solidifies and settles on the bottom, building up over time. The calcium is basic, which is why you can use lemons or citric acid to clean electric teakettles.)

Professor Ram Reifen of Hebrew University’s School of Nutritional Sciences said that even if you rely on water for 5% of your magnesium, that is still significant, and missing out on it is a real deficit.

“Five percent is a huge number,” said Reifen. “You could be eating a balanced, healthy diet, and eating enough green vegetables and meat and you get 90-something percent of your magnesium. But if you don’t drink water with magnesium, you are short of magnesium all the time and it adds up,” he said.

Magnesium deficiencies affect more than just drinking water. Animals who drink desalinated water will absorb less magnesium, as will crops watered with desalinated water. Both plants and animals also need magnesium for healthy growth. With time, as magnesium is depleted in the soil, vegetables and meat will in turn have less magnesium. This means that people, even those who eat a healthy, balanced diet, might not be able to get all of their magnesium from food.

Don’t forget to take your vitamins

Some people, including the Water Authority, argue that magnesium shouldn’t be added to the national water carrier, because people can find alternative ways of obtaining these minerals.

Similar arguments concern fluoride, which is added to the country’s water to combat cavities.

There is a movement that opposes adding fluoride to the entire country’s water, believing that individuals should be responsible for brushing their own teeth, flossing, and using mouthwash to avoid cavities.

But lower socioeconomic classes often do not follow these precautions, and without fluoride in the water, they are the ones who suffer from cavities the most. This is why many medical groups, including the Israel Pediatrics Union and other physician’s groups, opposed the decision of then-health minister Yael German (Yesh Atid) to stop fluoridation of national water in 2014. German said that national fluoridation was an infringement on personal rights. Deputy Health Minister Yaakov Litzman (United Torah Judaism) reinstated the fluoridation in late 2017.

Magnesium, in some ways, is a similar issue. People who can afford multivitamins can find alternative ways of obtaining magnesium.

“It’s one of the things people say who don’t agree to it: ‘Oh you can just take pills,’” said Darr. “But people don’t take pills. It won’t happen on a countrywide basis.”

But nobody else adds it

Surface water — water that comes from lakes and streams, like Israel’s drinking water that used to come from the Sea of Galilee — also has little to no magnesium. Groundwater has magnesium because the water absorbs magnesium, and other minerals, from the ground.

In the United States, 68% of people drink surface water. No one is talking about adding magnesium into drinking water on a large scale in America, according to Schor.

“I don’t know of one country in the entire world that adds magnesium to water,” said Schor.

In Israel, desalinated water is becoming a larger and larger percentage of the water used for everything, from agriculture to drinking. Currently, Israel desalinates 600,000,000 cubic meters of water per year, the equivalent to about 70% of domestic consumption. With new desalination plants in the planning stages, desalinated water will account for more and more of the water coming out of the faucets, and the magnesium deficiencies will begin to add up, health officials warn.

The water Israelis drink today continues to make ripples tomorrow. The country excels at recycling water, with more than 80% of the water flushed down the drain eventually treated and recycled into irrigation water.

As desalinated water accounts for a larger percentage of the water draining away and eventually making its way to the country’s fields, scientists and farmers must also focus on long-term effects of using desalinated water.

They first learned this the hard way with boron, explained Professor Jack Gilron, the head of the Department of Desalination and Water Treatment at Ben Gurion University’s Zuckerberg Institute for Water Research.

Seawater has naturally occurring boron, a chemical element. At first, desalination plants removed enough boron to reach a safe drinking level for human consumption. But crops are much more sensitive to boron than people. As recycled water reached the fields, crops suffered from high levels of boron. Now, desalination plants filter out even more boron to ensure that all water is safe for agriculture, no matter where it ends up being used, said Gilron. Ultimately, the standards required for agriculture determine the level of boron removed from desalinated seawater, said Gilron. A similar process of research and action needs to play out where magnesium is concerned, he says.

“We’ve been learning as we go. When we take desalinated seawater, we have to think about what’s missing.”

There are some aspects of desalinated water that farmers love, especially the lack of salt. Groundwater, especially in the Negev region, naturally has some salinity, which can be damaging to crops. Desalinated water, as the name implies, is free of salt, which is much better for the crops and the land.

Gilron favors adding magnesium to desalinated water, but only at the sources where it’s most necessary, not across the entire water system. “You absolutely can add magnesium where it’s needed,” he said. “You can add it at the irrigation level, especially because irrigating with desalinated water is of most interest, even more than with direct human water consumption.”

Gilron noted that adding magnesium in the fields will result in an increased cost for farmers, something the government must take into consideration.

To Mg or not to Mg?

“It’s important to stress that we’re not saying, ‘this water is dangerous,’” said Amir Itzhaki, the head of the Environmental Health department for the Health Ministry. The water reaching Israelis, he said, is absolutely fine. There are no guidelines from the World Health Organization or other international bodies that recommend a certain level of magnesium to be added to desalinated water, so Israel is not shirking its duty. Instead, the country, already an international leader in desalination, is starting, slowly, to understand the long-term impact of using desalinated water.

“The conflict is not between the experts and the Health Ministry,” said Itzhaki. “The Health Ministry thinks that this is the right thing to do.”

The real conflict, rather, is between the Health Ministry and the Water Authority, and boils down to who will pay for adding magnesium, and where — or indeed if — it should be added to the water system.

The Health Ministry recommends adding about 20 mg to 30 mg of magnesium per liter of water, bringing desalinated water up to the same levels as Israeli groundwater. The Water Authority has no objection, provided the Knesset approves and budgets it.

Itzhaki said the TAHAL company is currently researching how to run a pilot program which would examine ways of introducing magnesium to the water and the most efficient process for doing this. He estimates that adding magnesium could cost NIS 60 million to NIS 180 million per year, in contrast to the much higher estimate from the Water Authority.

Itzhaki said the Health Ministry expects to hear a presentation of the research in the coming months, followed by additional time to test TAHAL’s recommendations. The final decision about adding magnesium into the 600,000,000 cubic meters of desalinated water used by Israelis each year will rest with the Knesset, similar to the decision to add fluoride to the water.

The Knesset must also decide where the magnesium should be added — on a national level or at the farms — and who will pay for the addition.

If the cost is passed on to customers, it will result in the addition of 10 to 30 agorot per cubic meter of water (3 to 9 US cents), Itzhaki said. A family of four that uses 10 cubic meters of water per month, the average amount allocated to families at the lowest price, would see an increase of approximately NIS 6 (approximately $1.50) per two-monthly water billing cycle.

In 2013, a Central Bureau of Statistics survey [PDF] found that 41% of the public is willing to pay more for their water bill to have better drinking water in the tap at home.

The NIS for the Mg

Schor, the spokesperson for the Water Authority, said that fluoride costs NIS 40 million per year, a relatively small sum. “If the Health Ministry wants to add something to the water, that they say a person needs x, y, or z, that’s fine, but they need to pay for it,” said Schor. “They don’t want to pay for it, they want us to pay for it.”

Schor said that if the Health Ministry is worried about magnesium deficiencies in the agricultural sector, it should subsidize magnesium additives for farmers. Farmers currently use fertilizer enriched with magnesium if they are worried about their plants getting sufficient amounts of the mineral.

Unlike humans, plants with magnesium deficiencies are easy to spot, with wilting, spotted leaves, explained Dr. Uri Yermiyahu, the head of the Gilat Research Center at the Ministry of Agriculture and Rural Development’s Volcani Center. In 2007, Yermiyahu published a paper in Science raising the alarm about tomatoes, basil, and flowers grown in the Ashkelon region near the desalination plant, which were watered with desalinated water and lacking in magnesium.

“I would be happy for them to add magnesium,” said Yermiyahu, whose research focuses on agriculture in arid and semi-arid conditions. “In agriculture, what will happen is with time there will be less and less magnesium.”

“It’s much cheaper to add magnesium at the source [the desalination plant] than in fertilizer.”

Darr, who was a water consultant to the State of Israel for 19 years, until 1995, is frustrated that the government is dragging its feet. “If the Health Ministry says something has to be done, it has to be done,” he said. “If a city engineer says the building is unsafe, you leave the building.”

Israel is in a unique position because the country has both a pioneering role in desalination and a strong public health arena. This allows experts to study the effects of drinking this water in a way that it has not been studied anywhere else in the world, Darr explained.

“It’s very relevant, especially in America, on the West Coast, where they are building desalination plants and people really aren’t aware of this problem,” he said.

“Israel is not going in the right direction. It should, but it hasn’t. If Israel took action on this, and did bring the magnesium values to what they should be [in the country’s water system], it would be a pioneering thing. But they haven’t.”