KHAN YOUNIS, Gaza –For Faten Youssef Ayyash, the gap between promises and action is measured in an earthen pit. She dug the drainage pit around her tent in Al-Mawasi, a crowded coastal area west of Khan Younis in southern Gaza, so that water would not pool around the living quarters for her and her six daughters.
Water that collects in the pit, when the rains start to fall, will probably be used for dishwashing as well.
“I’m afraid this water brings insects, flies and disease,” said Ayyash, 43, who has been displaced from Rafah, a city on Gaza’s southern border with Egypt, three times since the war began.
All six girls caught chickenpox and gastroenteritis, one after another, and she fears winter rain will flood the tent as it did last year, since there is no escape route for rainwater – or the sewage and waste that it sweeps up in its path. Rats thrive in the waste, however, chewing through the family’s clothes and food.
“This has been going on for three years,” she said.
Only a small fraction of the billions pledged has actually reached Gazans
A little more than a year after the Israel-Hamas ceasefire began on October 10, 2025, donors have pledged billions of dollars to rebuild Gaza, but only a small fraction has reached the some 2 million people in need.
At its first meeting in February, the US-led Board of Peace, which lists 28 founding members, announced about $17 billion in pledges for Gaza, including $10 billion promised by the United States and roughly $7 billion from nine other members, among them the United Arab Emirates, Qatar, Saudi Arabia and Kuwait. A joint EU, UN and World Bank assessment puts Gaza’s recovery needs at $71.4 billion.
By late September, only about $280 million of the pledges had been transferred to the board. On September 23, the board proposed a six-month, $2.45 billion plan to start rebuilding.
The fate of other pledges remains equally hard to trace – like the Team Gaza Initiative, a separate €884 million fund including partners from 13 governments, the World Bank and the European Investment Bank, launched by the European Commission in July.
Speaking at the UN General Assembly in September, European Commission President Ursula von der Leyen announced another €103 million in aid to displaced Palestinians across Lebanon and the Israeli-occupied Palestinian Territories (OPT), as part of a larger aid package to Gaza.
Water, waste and sanitation services collapsed
Since the ceasefire, the tent camps where most Gazans now live are no longer bombed as they were, but water, sanitation and waste services have collapsed and infectious diseases once held in check spread routinely, especially among children, pregnant women and newborns.
Before the war, most Gazans had access to a piped water supply supported by nearly 200 small and mid-sized desalination plants and three water lines bringing in piped water from Israel’s own water authority.
Most of the local desalination plants were destroyed in the war, and service from Israel has only been partially restored. What little piped water is available comes from local councils pumping local wells and running desalination plants on generators. Aid agencies, led by UNICEF, bring water in tanker trucks into the camps.
Toilets drain into latrine pits, many of them unsafe or open, and rubbish piles up because dumpsites are full. Aid groups spray for pests but reach only a third of sites.
In early August, 91% of households surveyed by UN partners faced moderate to high water insecurity. More than 1.3 million people in Gaza have access to less than 6 litres of water per person per day for drinking and cooking, said the United Nations Office for the Coordination of Humanitarian Affairs. That is against a WHO recommended standard of 50 litres and a humanitarian emergency minimum of 15 litres for drinking, cooking and washing.
Some families of six to eight people share just one or two containers of water a day, Salha said, and that has to cover drinking, washing and bathing.
Faecal bacteria and pests
COGAT, the Israeli military body that oversees aid to Gaza, said in a July report that water supplies exceed humanitarian standards, though it acknowledged that sanitation problems remain. It blames Hamas for obstructing aid.
But the data tells another story:
WHO testing found faecal bacteria in nearly 18% of water samples checked in August, and almost three-quarters of samples were not properly chlorinated.
Rats and other pests are seen in 80% of temporary shelter sites, and skin diseases are widespread in almost half.
Cases of scabies transmitted by mites, between January and March, according to the UN agency for Palestinian refugees (UNRWA), with hotspots in Al-Mawasi, where the Ayyash family lives.
Diseases linked to rodents also have been rising, according to another report by OCHA. Skin infections, including parasitic infestations, accounted for about a quarter of reported disease cases in Gaza in late September, according to OCHA’s latest report.
Failure to advance peace process leaves Gazans in an impasse
The gap between aid promises and delivery, as well as the standoff over water and sanitation, are but two reflections of the impasse in the wider peace process, with Hamas agreeing to hand over its weapons in phases over three years, but only if Israel withdraws. Israel, which controls more than half of Gaza, says it will not withdraw until Hamas is fully disarmed.
A technocratic body meant to run services, the National Committee for the Administration of Gaza, began work from Cairo in January. But Israel denied its members access to Gaza, and so the committee has yet to enter the enclave, which remains divided by a “yellow line” denoting Israeli- and Hamas-controlled areas.
The impasse affects literally every aspect of Gazan’s access to goods critical for health, shelter, sanitation and food security.
Pledges of money are not the only barrier
Israel continues to restrict a wide range of what it regards as “dual use” that it says could still be used for military purposes.
Those range from tents and shelter materials to fuel, medicines, engine oil, spare parts and generator filters, Mohammed Salha, director of the Palestinian NGO Network (PNGO) in Gaza, told Health Policy Watch.
Local charities cannot bring them in at all, and only some international groups and UN agencies can, under heavy restrictions. No new generators are allowed in, and the old ones, in use for three years, have been repaired dozens of times, he said.
Gaza’s emergency drinking water system, which relies mostly on tanker trucks, still needs fuel for its trucks, engine oil for pumps and generators, and chemicals and spare parts for its desalination plants to operate, even partially.
In early October, OCHA reported that shortages of engine oil and spare parts had pushed southern Gaza’s remaining operational desalination plants to their lowest output and were causing generator shutdowns at health facilities.
Basic medical items also are in short supply.
In August, Médecins Sans Frontières (MSF) said Israeli restrictions were preventing the entry of supplies ranging from skin-disease ointments to the rubber seals needed for sterilization equipment.
In October, WHO urged Israeli authorities to stop treating essential medicines as “dual use” items, a classification Israel uses to restrict goods it says could also serve military purposes.
“The issue is not the promises or pledges made by international bodies, but the extent to which the Israeli occupation forces allow what is needed into the Gaza Strip,” said Salha.
Displacement as a chronic condition
More than 71,000 Palestinians were killed in two years of war, according to the joint assessment by the European Union, the United Nations and the World Bank. About 1.9 million people, almost the whole population, have been displaced, and almost 60% have lost their homes. About 1.7 million now live in some 1,600 displacement sites, most of them tent camps, according to the International Organization for Migration.
Israel’s “present policy on quality shelter is not acceptable” Nickolay Mladenov, and Director-General of the Board of Peace and High Representative for Gaza, told the UN Security Council in August.
Disease on the rise – but hospitals only partly functioning
According to WHO, as of September, only 19 of Gaza’s 36 hospitals were functioning even partially, and none fully.
Dr Ahmed Mehanna, director of health programs at the Al-Awda Health and Community Association, a local nonprofit, said its emergency department, especially the children’s section, sees 12 to 15 cases of gastroenteritis or diarrhea every day, and its skin clinic sees 50 to 60 patients a shift.
He thinks some cases are linked to dirty water. “But without lab equipment, doctors cannot be sure what is causing them. Clinics are also short of rehydration salts and skin creams,” he said.
Diseases like these have become common fare in Gaza’s shelters since early in the war.
Dina Helles, 30, fled Gaza City’s Shujaiya neighborhood in October 2023 and ended up in a school in Deir al-Balah, in central Gaza, sharing one classroom with three other families. That winter, her son Zein, then two and a half, developed constant diarrhea and severe dehydration and did not get better after treatment at Al-Aqsa Martyrs Hospital. “He caught the infection in the school’s shared toilets,” she said.
Up to 180 babies are born in Gaza every day. The UN reproductive health agency, UNFPA, says nearly 4,000 pregnancy losses were reported in the first half of 2026, three times as many as in the previous six months.
Rawan Abu Ghali, 26, gave birth to her daughter Maha in October 2025 in Al-Zawaida, in central Gaza. Water was so scarce that she struggled to keep herself clean during pregnancy and after the birth, she said.
Maha, now one, has spots on her scalp, and a doctor blamed pollution and life in the tent, Abu Ghali said. Diarrhea and infection in pregnant women can lead to malnutrition and complications, Mehanna said. Malnourished mothers often give birth to underweight or premature babies, according to UNICEF, and low birth weight infants are about 20 times more likely to die.
Salha said many camps have no clean, private toilets for women and girls, or toilets people with disabilities can use.
Sewage and rubbish
Every major sewage treatment plant in Gaza stopped working over a year ago, and 73 of its 84 sewage pumping stations have been destroyed.
Mohammed Musleh, mayor of Al-Maghazi in central Gaza, described the situation to Health Policy Watch as an “environmental and health disaster.”
About 85% of the sewage system has been destroyed, he said, and raw sewage goes into the sea or collects in ponds near homes and camps. Residents have dug about 320,000 makeshift pits, some on the beach at Al-Mawasi camp, where sewage can seep into already polluted groundwater reserves.
About a million tonnes of rubbish has built up in 323 informal dumps, he said, roughly the weight of three Empire State Buildings. He attributed this to the inability of municipalities to reach the main landfills.
“UNICEF or the Red Cross fund short work schemes in each municipality,” Musleh said. “Workers are hired for 45 days at a time and given donkey carts to collect rubbish and take it to the dumps.”
Families set up tents beside dumps and sewage ponds because there is nowhere else to go, he added.
Due to the Israeli military occupation, the majority of Gazans are now living on less than 30% of the enclave’s land, Salha of PNGO noted.
With winter looming only weeks away, Mehanna called for safe drinking water, regular rubbish collection and the draining of sewage ponds before then.
Sewage crosses all borders
In 2024, the UN Environment Programme warned that sewage was already polluting Gaza’s beaches, coastal waters, soil and fresh water. Since then the problems have only increased.
In September, OCHA, reported that all six of Gaza’s wastewater treatment plants were out of action and 70% of its sewage pumping stations were out of service.
Some of that sewage reaches the sea and some Israeli scientists suspect it helped feed a massive algae bloom that shut down five of Israel’s six major coastal desalination plants in late August.
Sewage discharged along the Gaza coast supplied nutrients that helped the microorganisms multiply, with unusually warm Mediterranean waters creating favorable conditions for rapid growth, according to Avner Rgoss head of Ben Gurion University’s Climate Change Laboratory.
Others were less certain that Gaza’s sewage was the main driver, noting that Egyptian desalination facilities in northern Sinai also were hit by the algae bloom.
Either way, the shutdown also led to another temporary interruption in piped water supplies from Israel in early September – supplies had been partially restored after the war-time halt to services, according to OCHA.
In Al-Mawasi, Faten Ayyash is getting ready for the autumn rains, with the dishwater pit poised right beside her tent – and nowhere else to go.
“We are preparing for the worst. Winter is just around the corner, and we’re bracing for new problems with our health and our shelter,” she said.“The worst part is that we don’t know when this nightmare will end.”
This article is published in collaboration with Egab.
Ansam El-Kattaa is a Palestinian journalist from Gaza who works across print, radio and mobile journalism. She specialises in human-interest stories about civilian life during crises, and her work has appeared in Al Jazeera English, El País, TRT, The New Humanitarian and D+C Development and Cooperation.
Image Credits: Ansam El-Kattaa, cc/Al Jazeera , Global Polio Eradication Initiative, WHO/EMRO , UNICEF/UNI838255/El Baba, OCHA, UNRWA .
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