The low-lying, arid coastal regions of the Southern Mediterranean Basin, extending over 4,600 km, face daunting sea level rise and hydroclimatic changes due to shifting weather patterns. The impact of these factors on coastal urban buildings and infrastructure must be better understood. Alexandria, a historic and densely populated port city in Egypt representative of several coastal towns in the Southern Mediterranean, has experienced over 280 building collapses along its shorelines over the past two decades, and the root causes are still under investigation. We examine the decadal changes in coastal and hydroclimatic drivers along the city's coastline using photogrammetric satellite images from 1974 to 2021. We explore the interconnectivity between shoreline retreat, ground subsidence, and building collapses. Our results suggest that collapses are correlated with severe coastal erosion driven by sediment imbalances resulting from decades of inefficient landscape management and urban expansion along the city's waterfront. This severe erosion, combined with sea level rise, increases seawater intrusion, raising groundwater levels in coastal aquifers. Degrading ground stability and accelerating corrosion in building foundations ultimately culminating in collapses. We identified a coastal area of high vulnerability with over 7,000 buildings at risk, surpassing any other vulnerable zone in the Mediterranean Basin. We propose cost-effective and nature-based techniques for coastal landscape adaptation to alleviate these dangers in Alexandria and other Southern Mediterranean cities facing similar climatic challenges.