Over two decades after the United Nations Security Council pushed for better protection of civilians (in Resolution 1265), Resolution 2573 (which was adopted in 2021), offers a real chance for progress. In a key paragraph, the Resolution urges all parties to an armed conflict to protect civilian infrastructure, because depriving access to essential services can “compound the spread of infectious diseases.”

The thousands of people experiencing debilitating effects of cholera and diarrhoea in Libya, Syria, Somalia, Ukraine and so many other places know this reality all too well.

But Resolution 2573’s impact hinges on how it is implemented, and those efforts will benefit from a better understanding of the links between damaged infrastructure and public health.

Our recent analysis of the reverberating effects of attacks begins that process. Summarizing part of the analysis, here, we detail how and under what conditions damage to water and sanitation services are likely to lead to water-related infectious disease. Our aim is to start a conversation about the extent to which the growing evidence base on the reverberating effects of attacks on the transmission of disease may inform Resolution 2573’s ability to protect civilians.

Examining evidence from Yemen, Gaza, and Iraq, we argue that the spread of water-related disease may be expected when an attack risks the crossing of drinking water and sewage lines, and that our confidence in this association increases as the conflict protracts. The findings thus extend the calls for limiting incidental harm, through greater compliance with the rules of International Humanitarian Law (IHL) and better transparency, accountability or use of technology. We conclude with some thoughts on how to strengthen Resolution 2573’s impact and minimize civilian harm.

The Risk of Infectious Diseases Is Foreseeable

Public health engineers, often working for humanitarian organizations all over the globe, observe a pattern as routine as it is toxic: Explosions impair electricity services, which can knock-out sewage services; raw sewage contaminates drinking water supplies; existing strains of cholera rip through society.

There are of course other reasons why cholera may develop and spread. International Committee of the Red Cross (ICRC) studies of the impact of explosive weapons show that they can cause direct and indirect impact on the people (such as operators and repair crews), hardware (such as infrastructure and spare parts), and consumables (such as water-treatment chemicals) that make up any urban sanitation service. Furthermore, the services are highly interconnected: if an electrical power plant is hit, the pumps of the water treatment plant that it supplies will no longer function (assumingadequate backup sources are not in place), and once the wastewater pumps fail, the sewage backs up into the streets or can seep into leaky drinking water pipelines.

A century of epidemiological research further informs us that drinking water laced with sewage is directly linked to the outbreak and spread of infectious diseases, especially to the killer forms of diarrhoea, cholera and typhoid (see examples of this research here, here, and here). For example, children living in conflict under 5 years of age are 20 times more likely to die from diarrhoea linked to unsafe water and sanitation than to violence in conflict.

In fact, the “faeces-to-faces” route by which the pathogens spread is so well-known that separating drinking water and sewage pipelines is a fundamental part of emergency preparedness plans to protect critical infrastructure (see examples from the United States here, the European Union here, and Canada here). It follows that a higher risk of an outbreak and or spread of infectious disease can be expected if the effects of an attack during armed conflict may lead to cross-contamination of water and sewage lines.

The Impact of Infectious Disease – and Our Knowledge of It – Increases with Time      

This pattern played out prior to the cholera outbreaks – which affected over one hundred thousand people – in Basrah, Iraq, in 2007 and 2015 (see here, here and here), and over two million throughout Yemen in 2017 (see here, here, and here). Similar conditions existed in Gaza in 2014, where the incidence of watery diarrhoea spiked to nearly 60 cases per 100,000 people following repeated air strikes, and dropped soon after the services were restored.

But gauging the real impact of attacks is tricky and requires also considering the quality of the services before the attack, as seen in the descending path of Figure 1. This “baseline resilience” of services is important, because some systems can bounce back from an attack, while others will fail. Just as a jab to a boxer in the twelfth round of a fight is likely to cause more damage than a jab in the first, the effects of an attack on a water supply system that has experienced years of neglect will reverberate much stronger and longer than on one that has been well-maintained.

Caption to Figure 1: The trends between the baseline resilience of water and wastewater services, the risk of cross-contamination of water and wastewater, and the associated consequences in terms of infectious disease – and their foreseeability. Based on evidence from Yemen, Gaza, Basrah.

The take-away trend of Figure 1 is that the duration of the armed conflict matters. Notably, the more protracted the armed conflict, the greater the risk of water and sewage cross contamination. This is because direct physical damage accumulates and “baseline resilience” decreases. Just as significantly, the more that time passes, the more information about the condition of the infrastructure and the status of service delivery becomes available. This is particularly the case when intelligence, surveillance, and reconnaissance (ISR) is being carried out to inform military planning and the decision-making process regarding targeting. Using remote sensing technologies, open source information, and readily-available expertise (for instance engineers and public health experts), parties to the conflict can assess the location and status of critical civilian infrastructure and develop a nuanced understanding of these systems to inform estimates of the impacts of an attack. The more that reverberating effects are foreseeable, the more they are preventable.

Better Implementation of Resolution 2573

The growing base of evidence and knowledge feeds into the increasing efforts to improve the protection of civilians during armed conflict. The ICRC and other organizations have long advocated for States and parties to armed conflict to enhance their understanding of the cumulative impact of armed conflict and use of explosive weapons with a wide impact area on essential services. The Geneva Principles for the Protection of Water Infrastructure assert and ICRC considers it a legal obligation that reasonably foreseeable reverberating effects of attacks be considered when assessing incidental harm for the purposes of proportionality and precautions in attack.

Security Council Resolution 2573 bolsters this case, particularly in light of the very broad political support it received. The Resolution’s unanimous co-sponsoring and adoption by the Council meant it achieved the status of “presidential text,” which behoves the international community to strengthen and implement legal and policy frameworks to ensure continued access to essential services during armed conflict, and mitigate civilian harm, along the way.

But the real value of this political support will be gauged by the willingness of States to implement 2573 (Operative Paragraphs 1- 6) and facilitate a more apt response in situations where essential services are disrupted (Operative Paragraphs 7 – 10). Mechanisms and actions to implement the Resolution start first and foremost with Operative Paragraph 12, which requests the United Nations Secretary-General to include the issue of protection of objects indispensable to the survival of the civilian population as a sub-item in the (annual) reports on the protection of civilians. National data collection systems on attacks against civilian objects, when they exist, can add to the evidence base by collecting and providing timely, objective, accurate, and reliable information. Even given their limitations, these systems can contribute to enhancing protection of civilian objects, and in so doing prevent or mitigate further civilian harm. Improving the reliability of national and other sources of data also requires unfettered and unrestricted humanitarian access, which enables data collection which can inform prevention and response actions, States shouldintegrate Resolution 2573 into military doctrine, planning, training, and conduct of operations.

We expect the conversation about the evidence base of reverberating effects of attacks on the transmission of disease to continue, and to better inform Resolution 2573’s ability to protect civilians. Ultimately, protecting civilians from reverberating effects requires the political will and resources for combatants to roll up their sleeves and undertake the data collection and analysis to identify critical infrastructure, define how those critical infrastructure are interconnected, and estimate the potential impact of an attack. On the other hand, humanitarian and development organizations require the resources to provide a more holistic response at scale, while further supporting the development of a manual of best practices on strengthening the resilience of the interconnected essential services. It may be a tall order, but the civilians caught up in the wake of fighting deserve no less.

IMAGE: The United Nations Security Council holds a meeting at U.N. Headquarters on Feb. 21, 2023 in New York City. (Photo by John Lamparski via Getty Images)