Radiation emergency preparedness in the middle east: Public health consequences, water security vulnerabilities, and evidence-based countermeasures.

The ongoing military conflict involving the United States, Israel, and Iran has transformed long-theorized nuclear emergency scenarios into credible near-term threats. Iran's Bushehr Nuclear Power Plant, located on the Persian Gulf coastline just 17 km from the city of Bushehr, lies closer to several Gulf Cooperation Council capitals than to Tehran. At the same time, Qatar, the United Arab Emirates, Kuwait, Bahrain, and Saudi Arabia depend on seawater desalination for 60-90 % of their freshwater supply, with strategic reserves typically lasting between 36 hours and seven days. This convergence of nuclear proximity and water dependency creates a compound public health risk insufficiently addressed in the current literature. This review aimed to characterize plausible nuclear and radiation threat scenarios in the Middle East, map the spectrum of public health consequences from immediate blast and thermal injuries to long-term genetic damage, examine the risk of radiation contamination of the Persian Gulf leading to regional water supply collapse, and propose an evidence-based preparedness framework. A narrative review of peer-reviewed studies, international agency reports, and governmental guidance was conducted using MEDLINE/PubMed, Web of Science, Scopus, and grey literature from major global health and nuclear safety organizations. A single nuclear detonation in a major Gulf city could result in hundreds of thousands of immediate casualties while rendering seawater unusable for desalination over a prolonged period. Freshwater reserves would be rapidly depleted, leading to the simultaneous collapse of healthcare services, food systems, and sanitation infrastructure. Children and fetuses represent the most vulnerable groups, with increased risks of thyroid cancer, neurodevelopmental damage, and heritable mutations following radiation exposure. Key preparedness strategies include potassium iodide prophylaxis, shelter-in-place protocols, expansion of water reserves to at least 90 days, and strengthened regional civil defense coordination. Preparing for low-probability, high-impact events is far less costly than the consequences of inaction. See also the graphical abstract(Fig. 1).