From a lack of basic public services, to violations of internal humanitarian law by warring parties, Yemen’s humanitarian crisis is daunting. But infectious disease outbreaks, like the cholera currently sweeping Yemen, should not be considered inevitable. By pressuring donors to urgently deliver on pledged resources, and by supporting humanitarian advocacy efforts to protect and promote access to health and other essential commodities and services, cholera can be stopped.
In terms of health security risks, cholera in Yemen is a ‘known known’. We know that infectious diseases such as cholera spread in conflict zones, where there is lack of water, poor sanitation and a weak or absent health system. We know this from the experience of Goma in the Democratic Republic of Congo (then Zaire), where in 1994, after the Rwanda genocide, 12,000 refugees died from the disease. We also know this from Haiti where, over the last six years, 800,000 people have been affected by cholera amidst a weak international response.
The current cholera epidemic in Yemen, which began only six weeks ago, has now reached more than 124,000 suspected cases; nearly half of them are children. Oxfam estimates that the epidemic is killing one person almost every hour. To date, 19 out of 23 governorates in Yemen have been affected and there have been 932 associated deaths registered so far.
According to the UN, Yemen is experiencing ‘the largest humanitarian crisis in the world’. Seventeen million people are food insecure and 14 million lack access to clean water; there are now 22 million people living in areas considered at high risk of cholera transmission. These statistics are not unconnected: cholera spreads through contaminated water and the disease is more likely to flourish in places where malnutrition and conflict exist.
In addition, the conflict has led to disruption of Yemen’s public services; workers have not had regular salaries paid since last September. Garbage remains uncollected in congested urban centres, where overcrowded settlements with precarious sanitation are at high risk of infectious disease. In rural areas, fuel shortages (even if fuel is available, it’s almost unaffordable for many) mean water cannot be pumped from wells and people are drinking surface water, in places where open defecation is common.
There are a number of key response efforts ongoing. To prevent further contamination, hundreds of wells, as well as private tanks and sources in the public water network, have been chlorinated. Thousands of kits containing water purification tablets for people to treat water in their homes have been distributed. Cholera awareness campaigns are being broadcast daily across Yemen, with key hygiene messages around prevention. As well as supporting vital public services by improving access to water and sanitation, and collecting garbage, emergency responders are also providing access to healthcare. A network of temporary cholera treatments centres has been set up in affected areas.
However, scaling up such a decentralized and extensive response enough to keep up with the pace of this epidemic’s ‘unprecedented’ spread is challenging. Only 10 per cent of the smaller ‘oral rehydration’ corners have been set up, along with only 20 per cent of planned cholera centres. Waste management (vital for prevention) does not have enough resources.
Most of the treatment facilities are set up around Sana’a, meaning that while the outbreak is slowly being controlled in the capital, in other cities and in rural areas not enough help is present. Meanwhile, people continue to seek care at hospitals where they may be unnecessarily treated with intravenous fluid and antibiotics. For severe cases this is necessary, but given the country’s resource shortages, the preservation of precious medical supplies is critically important.
Until last year, when a previous epidemic hit, cholera was not a known disease in Yemen. This means local health workers and volunteers, in addition to being overworked, are not necessarily equipped with the knowledge and experience needed to treat it. This is where the global health community can step in, making sure the transfer of knowledge and experience, as well as accompanying resources, is accelerated and amplified.
Time for more support
Beyond cholera, the lack of a functioning health system and collapsing public services means Yemen is at risk of other diseases that may pose more of a global health security risk. When ‘we are only as safe as the most fragile states’, Yemen – arguably that most fragile place right now – needs more support.
From the global health community, such support means providing organizations on the ground with adequate technical, financial and material resources. Operating in Yemen is expensive and risky. Donors need to recognize this and provide resources accordingly, by supporting emergency appeals and pressuring to ensure money pledged is received in-country.
However, money and resources are only part of the solution; in addition, support to end this epidemic also means confronting the politics that have facilitated the rapid spread of the disease. This means, for example, working to lift the import restrictions that limit the availability of essential commodities such as fuel, compelling authorities to pay public sector salaries, and advocating for humanitarian interventions to be protected when warring parties are attacking or obstructing the provision of healthcare.
The global health community and its donors cannot end conflict and famine in Yemen, but they can help end this epidemic.
Rachel Thompson Research Associate, Centre on Global Health Security.