Four months ago, the situation in Yemen was dire: there had been 124,000 suspected cases of cholera, and experts were predicting that it could rise to 300,000. Urgent action was called for – from health and humanitarian actors as well as from warring parties – to allow the population better access to health care and to allow supplies to reach those in need.
These pleas have had little effect. As of 2 November, with an estimated 900,000 suspected cases, Yemen’s cholera outbreak has now surpassed that of Haiti (which has seen 815,000 cases since 2010) to become the largest recorded in recent history. It is estimated the total number of cases is likely to break one million by December according to Save the Children, which predicts that 600,000 of these cases will be children.
Meanwhile, Yemen remains in the grip of the world’s largest humanitarian crisis, with more than 20 million people in need of assistance and 17 million people facing chronic food insecurity. Although recent data suggest the number of new weekly cholera cases is stabilizing, this is bringing new issues, as resources drain away when cases fall and the response scales down.
In the last few months, the crisis has been exacerbated by many of the usual issues that plague both outbreak and humanitarian responses. From a public health perspective, cholera should not be a difficult disease to prevent or control; potentially, more could have been done to avoid the outbreak escalating. However, less than half the country’s health facilities are functioning; health and sanitation workers have gone unpaid for many months; the availability of clean water is minimal; and warring parties are restricting access for aid workers. It is not hard to understand how the situation has unfolded in this way.
War forces further tough choices. Providing support to health systems in conflict zones such as Yemen may mean the transfer of resources to warring parties; for example, fuel is needed to pump water for communities, but the same fuel may also be used in military activities. For those working in Yemen, there are thus big questions around accountability, and dilemmas as to how to deliver aid without contributing to the war economy.
In Somalia, where endemic violence similarly restricts health access, cholera has been contained by a vaccination campaign. This has not been possible in Yemen. A campaign planned to begin in June was curtailed before it began when the government suspended its request for the vaccine; with 21 of Yemen’s 23 governorates affected, it had already become too widespread. Furthermore, there were not enough doses in the global stockpile for all those at risk. On top of the access and logistical challenges (cholera vaccine requires cold-chain storage), it would have been a politically impossible task to decide who would get vaccinated and who not.
From a humanitarian perspective, whether a child with acute watery diarrhea has cholera or not matters little, as the treatment (rehydration and antibiotics) is the same. From an outbreak-control perspective, however, it is crucial to know. Diagnosing cholera is easy but confirming suspected cases is hard, because the main symptoms (watery diarrhea) are common to many illnesses – confirming suspected cases requires laboratory capacity that Yemen does not currently have. Rapid diagnostic tests are available globally but the quality of those in Yemen is poor, and supply chain issues have significantly hampered their distribution.
Data quality in Yemen is an issue across all parts of the humanitarian crisis. For cholera, in addition to misdiagnosis, there is now an incentive for health workers (who have not been paid by authorities) to over-report cases, as the outbreak response attracts money for salaries and other operational costs. Hospital wards treating cholera patients have electricity and supplies. ‘Oral rehydration corners’ – small kiosks where people can get treatment for cholera symptoms – have been over-run with other patients seeking care for a variety of non-cholera related conditions. This is the paradox facing health workers in Yemen: as cholera cases wane, desperately needed resources may be snatched away.
The cholera emergency appeal has been relatively well funded and, arguably, money has not been the main stumbling block in combating this outbreak. Instead, the situation in Yemen highlights how even a fully funded, fully functional response can never be a replacement for the systems and public services required to ensure cholera and other diseases are prevented. Like other countries in conflict, without a political solution – without peace – Yemen remains at risk of future outbreaks; and the next one may be more deadly than cholera.
Rachel Thompson, Research Associate, Centre on Global Health Security.