Yemen is on the edge of a cliff. Will COVID-19 push it over?
Mazrak camp in the tough mountainous scrublands of Yemen's north-west border with Saudi Arabia is now home to more than 10,000 people displaced by the escalating war between the government and rebels from the Huthi clan.
By Giancarlo Atassi, MPH; Nina Zhou, BA; and Alexandra Isaia, BS
COVID-19 continues to take a significant toll on the global community. In the United States, healthcare workers are struggling to handle 8.2 million confirmed cases and over 240,000 deaths as of November 10. Amid a public health crisis, the American system has also found itself reckoning with longstanding issues of systemic racism. With these parallel issues pulling the attention of the global community elsewhere and each nation preoccupied by its own outbreaks, many developing nations have endured devastating damage from COVID-19 with little international recognition, and COVID-19 relief for developing nations has slipped below the radar. Yemen – the epicenter of one of the world’s worst active humanitarian crises – has been particularly deprived of support. As of August 31, UNICEF had requested $535 million for its 2020 Yemen Humanitarian Action for Children (HAC) Initiative, of which only $193 million had been funded, and had requested $103 million for a targeted COVID-19 response, of which only $42 million had been funded.1 Greater than 80% of its population (approximately 24 million people) require humanitarian assistance and protection to some degree. Families in flood-affected areas are left without homes, help, or clean water as a cholera outbreak continues to plague the nation. Vaccination programs are down, and a new polio outbreak was recently declared. Millions of children are out of school and decades of work in educational achievement are poised to be lost, and nearly 14 million of the 24 million lives in Yemen have urgent healthcare needs, to name just a few elements of the humanitarian crisis.1 COVID-19 now threatens to further cripple a medical system on the verge of collapse.
Yemen’s current crisis traces back to 2011, the year the Arab Spring resulted in a transition of power from President Ali Abdullah Saleh to Abdrabbuh Mansur Hadi. After the new government’s installation, Ansar Allah, a radical Shi’ite political faction also known as the Houthis, opposed the new President’s reforms and secretly allied itself with former President Saleh and elements of the Yemeni military. Allegedly aided by the Lebanon-based Hezbollah and the Iranian government, the movement overthrew Hadi’s internationally recognized government in 2015. This coup has since sparked a civil war, with a Saudi-led, US-supported coalition seeking to eliminate the Iranian-backed Houthi movement and restore Hadi to power.
The war’s impact on the Yemeni people has been immense. Data from the publicly available Armed Conflict Location & Event Data Project (ACLED) has recorded over 122,000 fatalities directly due to conflict from June 2015 to October 29, 2020, not counting deaths attributable to lack of food, health services, and infrastructure. Over four million people have been uprooted due to the war, with many currently living in unsanitary, densely-populated refugee camps.2 Incredible damage has been inflicted on healthcare infrastructure, resulting in only 51% of health facilities being fully or partially functional. Reported resource shortages include staff, medicine, equipment, fuel, and water. Yemen’s healthcare system is effectively in ruins,3 and facilities are reportedly being targeted by combatants on both sides of the conflict. Additionally, Yemen has been experiencing the world’s largest active outbreak of cholera since October 2016, with over one million suspected cases and two thousand related deaths reported.4
As a result of the extended upheaval, Yemen is poised to face one of the worst famines in a century if fighting continues. Throughout the conflict, the economy has contracted and left its people suffering devastating levels of poverty – there has been a 19% depreciation in the national currency since December 2019 alone – and hard-won gains in food security are at risk of reversal. The World Food Programme reports 20 million people facing food insecurity, with 10 million of those acutely food insecure and greater than three million women and children requiring treatment for acute malnutrition. One analysis notes that the number of malnourished children alone could reach 2.4 million by end of 2020, among which 360,000 are at risk of dying without treatment.5 A separate analysis of Yemen’s southern areas found nearly 100,000 children with severe acute malnutrition requiring urgent intervention and at high risk of passing away from diarrheal diseases or acute respiratory infections.6
Amidst this, Yemen is wholly unprepared to tackle COVID-19. Data is scarce, but as of August 15, roughly 22,000 testing kits had reportedly been distributed.7 As of October 25, Yemen had reported approximately 600 deaths attributable to COVID-19 – a satellite imagery analysis of burial activity in Yemen, however, points towards an estimated 2,100 “excess deaths” between April and September, hinting at a higher death toll than official government figures.8 In the first half of May 2020 alone, the city of Aden recorded 950 deaths, roughly four times as many deaths as in the entire month of March, further pointing at the creeping death toll of COVID-19.9 The case fatality rate for COVID-19 in Yemen is high (nearly 25% per reports) and though the UN is mounting a COVID-19 response, its overall portfolio of Yemen programs is underfunded at baseline. Of $4.2 billion in aid requests in 2019, only $3.6 billion was received. As one technical advisor on the ground succinctly put it: “COVID-19 could be the straw that breaks the camel’s back.”10 The question then becomes – how should we respond?
As an international medical community, we adhere to certain ethical principles. Though clinicians are largely not legally bound to care for non-patients, helping to alleviate suffering is inherent to the profession of healing. Virtue ethicists such as Pellegrino argue that physicians should strive to cultivate character and habits aligned with “the preservation, promotion, and restoration of health.” As future physicians, we believe it is reasonable to conclude that those same values should be reflected by the medical community at large, and that supporting Yemen through this crisis would align with those values. From a utilitarian perspective, supporting Yemen’s COVID-19 response via raising awareness would potentially benefit millions while costing little in return, a massive net good. The net good multiplies when one considers the scenario of millions of Yemeni citizens who have already fled, millions more to follow, and the practical reality that large refugee populations are fertile ground for new outbreaks of COVID-19 or other diseases which not only strain host country resources but are also at high risk for rapid spread. It is apparent from a multitude of perspectives that a strong and sustained response to Yemen’s humanitarian crisis, particularly as it relates to COVID-19, is the most ethically sound course available to the international community.
With this in mind, we call on the American Medical Association and the medical community to take steps to promote awareness of the ongoing situation in Yemen and rally global humanitarian aid. We do not pretend to have solutions for these crises, but those who are working toward solutions – the UN and its programs – are under-resourced at baseline and in need of assistance. We can aid them by using our voice, leveraging our public health expertise and the respect afforded our profession, to call for further support of Yemeni-targeted international assistance programs and coordinated international responses to support Yemen through COVID-19. This will not solve Yemen’s problems, nor should it detract from or replace focus on other national and international issues – whether of systemic racism in the United States and abroad, international sovereignty claims, or the ongoing pandemic. But it is imperative that Yemen receive support – failing that, we risk watching in real time, through news headlines and social media, as an entire people, a legacy and inheritance spanning millennia, slide further into chaos and destruction, propelled by the accelerant that is COVID-19.
Giancarlo Atassi is a fourth-year medical student at Northwestern’s Feinberg School of Medicine. Prior to medical school, he received his undergraduate degree in Neuroscience & Religious Studies at the University of Miami, and his Master’s in Public Health through George Washington University. He is pursuing a career in anesthesia & intensive care, and hopes to integrate his public health and critical care interests by working on global health security and preparedness for emergent infectious diseases such as COVID-19.
Nina Zhou is a second year medical student at Feinberg School of Medicine at Northwestern University. She obtained a bachelor’s degree in Biological Science and Psychology from Northwestern University in 2019. Her research interests include social determinants of health in pediatric patients in regards to atopic conditions and additionally, global health outcomes.
Alexandra Isaia is a fourth-year medical student in the MD/MA program at Feinberg School of Medicine and is pursuing a Masters’ degree in Bioethics and Medical Humanities. She is applying into Emergency Medicine and is interested in healthcare access, social determinants of health, and healthcare disparities.
References
1 UNICEF. “Yemen Country Office: Humanitarian Situation Report.” August 31, 2020. Accessed October 29, 2020.
2 Council on Foreign Relations. “War in Yemen.” Global Conflict Tracker. Accessed July 10 2020. https://cfr.org/global-conflict-tracker/conflict/war-yemen
3 UNOCHA. “Attacks on hospitals deprive vulnerable Yemenis of health care.” February 11, 2020. Accessed October 29, 2020. https://www.unocha.org/story/attacks-hospitals-deprive-vulnerable-yemenis-health-care
4 Al-Mekhlafi HM. Yemen in a Time of Cholera: Current Situation and Challenges. The American Journal of Tropical Medicine and Hygiene. 2018; 98(6); 1558–1562.
5 UN News. “Waiting to declare famine ‘will be too late for Yemenis on brink of starvation.’” July 10, 2020. Accessed June 30, 2020. https://news.un.org/en/story/2020/07/1068101
6 UN News. “Yemeni children suffer record rates of acute malnutrition, putting ‘entire generation’ at risk.” October 27, 2020. Accessed October 29, 2020. https://news.un.org/en/story/2020/10/1076272
7 UNOCHA. “Yemen: COVID-19 Preparedness & Response Snapshot.” August 15, 2020. Accessed October 29, 2020. https://reliefweb.int/sites/reliefweb.int/files/resources/Yemen_COVID_Weekly_Snapshot_15_August.pdf
8 Kelland, K. “Grave-counting satellite images seek to track Yemen’s COVID death toll.” Reuters. October 27, 2020. Accessed October 29, 2020. https://www.reuters.com/article/us-health-coronavirus-yemen-graves/grave-counting-satellite-images-seek-to-track-yemens-covid-death-toll-idUSKBN27C3BT
9 Sirgany SE & Kiley S. “Coronavirus death rates in Yemen’s Aden could exceed its wartime fatalities. June 12, 2020. CNN. Accessed October 29, 2020. https://www.cnn.com/2020/06/12/middleeast/yemen-coronavirus-deaths-intl/index.html
10 Stone R. “Yemen Was Facing the World’s Worst Humanitarian Crisis. Then the Coronavirus Hit.” Science. AAAS, May 28 2020. https://www.sciencemag.org/news/2020/05/yemen-was-facing-worlds-worst-humanitarian-crisis-then-coronavirus-hit
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