As Yemen enters the new decade, its healthcare system appears to be going back in time, with the re-emergence of long-gone diseases due to years of war. Throughout 2019, frightening outbreaks of disease and epidemics were witnessed in governorates across the country. 2019 was also the year that Yemen joined UN member states around the world in signing the UN Political Declaration on universal health coverage. Labelled by the UN Secretary-General as the “most comprehensive agreement ever” on global health, drastic changes will be required for Yemen to get on track to meet its objectives.

Millions of Yemenis are at heightened risk of contracting deadly illnesses due to the deterioration of water and sewage systems and collapse of the health sector. Severe rates of malnutrition also leave people more susceptible to illness, as do the mounds of waste that have become part of the landscape in most population centers as public employees go without pay. International bodies have repeatedly warned of the perils of continued conflict in Yemen, where less than half of all health facilities are functioning, and coping mechanisms are stressed to their limits. 

Amid the complexity of the crisis and the enormity of the suffering resulting from over five years of war, accurate and comprehensive statistics on the victims of epidemics are lacking. To shed light on the severity of Yemen’s health crisis over the past year, Almasdar Online spoke to healthcare professionals around the country. 

No area left unharmed

In 2019, Yemen suffered its third major outbreak of cholera, which causes severe diarrhea that can kill a patient within hours if they do not receive the necessary medical attention. The first outbreak was in 2016, and by 2017 it had become the worst cholera outbreak in the world. By 2018, the epidemic in Yemen was deemed by international health authorities as the worst cholera outbreak in recorded history.

The United Nations said the disease is spreading like wildfire. Among its victims is a Yemeni doctor named Mohammed Abdul Mughni, who worked in a temporary treatment center for diarrhea in the courtyard of a hospital in Sana'a and died from cholera in 2019.

Early last year, a study by researchers published by the British Wellcome Sanger Institute and the French Pasteur Institute found that the cholera strain that had spread in Yemen came from East Africa and was likely to have been carried by migrants.

The most serious concern is the growth of a strain of cholera resistant to six families of antibiotics, according to an official report issued by the National Center for Public Health Laboratories in Sana'a in April.

The report, obtained by Almasdar Online, showed that cholera bacteria in 2019 became completely resistant to certain antibiotics, which doctors considered a serious development on the effectiveness of drugs in the fight against the epidemic.

Doctors told Almasdar Online that continuing to deal with cholera in this way will increase its resistance and it may become resistant to all antibiotics in the future, which means a disaster that could kill tens of thousands. 

The World Health Organization (WHO) has detected 913 cholera deaths in Yemen, and 696,537 suspected cases of the epidemic from the beginning of 2019 to the end of September alone. “Children under the age of five make up 25.5 percent of all suspected cases, and 305 of the 333 districts in Yemen have been reported to have the epidemic,” the WHO said in a report.

According to statistics released by the Houthi-controlled Ministry of Health, the number of people confirmed or suspected of being infected with the disease over the same period (the first nine months of 2019) was 654,747, and the number of deaths was 872. 

It is impossible to arrive at accurate statistics of actual cholera cases as only a small fraction of suspected cases are tested in order to be confirmed, due to the lack of proper laboratory equipment inside Yemen. Furthermore, in a few governorates the reporting even on suspected cases has been incomplete.

One thing is clear, however: no area of Yemen has been spared from the deadly disease.

In March, a medical source told Almasdar Online that hospitals in several areas of Ibb governorate recorded six deaths and dozens of cholera cases in just days. In April, the Public Health Office in Hajjah province said that the number of deaths recorded from cholera since the beginning of the year was 25, and the number of cases recorded for the epidemic was 15,373. 

In April, Dr. Mohammed Salem Hadi, director of the health office in Bayhan district of Shabwa, told Almasdar Online that 17 patients suspected of having contracted cholera had arrived at the local hospital. “We are afraid of the outbreak of the disease with rain, floods, and poor community awareness of the epidemic,” Hadi said.

Medical sources told Almasdar Online that 84 citizens died of cholera in Dhamar governorate, and that they recorded 41,653 suspected cases of the epidemic, including 8,289 confirmed cases, from the beginning of 2019 to early July.

A preventable epidemic

While the factors contributing to the spread of cholera are complex, the initial outbreak in late 2016 appears to have come as a result of waste piling up in the streets, after public employees stopped removing garbage in protest of the Houthi authorities' failure to pay their salaries.

The degradation of water treatment and sewage facilities – including their destruction by coalition airstrikes and Houthi shelling – has further eroded the ability for local health authorities to address the spread of cholera.

On top of these root causes, the Houthis have consistently hindered efforts by medical professionals to properly address the spread of cholera and other diseases and implement more effective preventative measures.

The Houthis have prevented UN health officials and affiliated organizations from combating the epidemic effectively, having denied visas, restricted access in areas under their control, and rejected the implementation of enhanced monitoring systems that were successfully implemented in government-held territories. 

In April, an investigation by the Associated Press uncovered that the Houthis had blocked the distribution of cholera vaccinations in Yemen, exacerbating the epidemic, and the United Nations was only able to distribute it in May 2018.

The disaster could have been avoided if vaccines had been distributed early, but the Houthis required the United Nations to provide them with ambulances and medical equipment. They were eventually provided with 45 ambulances, which the group sent to the frontlines for use in combat, the news agency said.

In January, sources in Sana'a revealed to Almasdar Online that two Houthi leaders sold a quantity of chlorine provided as assistance by international cholera control organizations for 60 million Yemeni riyals (over $100,000).

Moreover, the Houthis have sought to propagandize the cholera outbreak by pinning it on the group’s opponents, while doing little to combat its spread. In Houthi-controlled areas, signs describing cholera as “an American gift from Trump” have been spotted, and Houthi officials occasionally come out with press statements describing cholera and other diseases as “part of an act of hostility against the Yemeni people.” 

Daifallah Al-Shami, the Sana’a-based information minister and longtime Houthi ideologue, said at the end of 2019 that “the increase in epidemics and diseases compared to last year is clear evidence that the use of biological and chemical weapons on the governorates play a major role in their spread.” The Houthi-controlled health ministry is accused of putting medical staff through courses infused with sectarian rhetoric, according to sources who spoke on condition of anonymity, for fear of reprisal.

The Houthis have also been accused of withholding even minimal medical attention to prison populations as a means of getting rid of opponents by “natural” causes. Amat Al-Salam Al-Hajj, who is president of the Association of Mothers of Abductees and Disappeared Persons, told Almasdar Online that Tuberculosis is widespread in Houthi-run prisons in Dhamar governorate, where a number of cases have been recorded.

The emergence of other epidemics 

The second deadly epidemic to hit Yemen in 2019 was dengue fever, a viral disease transmitted to humans through mosquitoes that breed in stagnant waters. Doctors in Yemen say the disease is spreading in crowded communities, especially among internally displaced persons (IDPs) who have fled conflict in other areas of the country and who are as a whole more vulnerable to the spread of disease.

In November, the International Committee of the Red Cross (ICRC) expressed concern over reports of thousands of dengue cases in Yemen. “It is believed that 50 people in Hodeidah died of the disease between late October and early November, and more than 2,000 people are infected,” Robert Mardini, head of the ICRC delegation, said.

Dengue fever has hit Taiz governorate the hardest, where it has spread at an unprecedented rate. On top of the massive number of IDPs in Taiz, fighting is ongoing throughout the governorate and a siege by the Houthis on Taiz city has left one of Yemen’s largest population centers without adequate access to basic necessities and medical supplies.

Between early January and November, a total of 7,990 people were infected with dengue fever in Taiz, according to Tayseer Al-Samei, deputy director of the Department of Information and Health Education at the Taiz Health Office.

Health officials in Aden, Marib, Shabwa, and elsewhere have confirmed to Almasdar Online the spread of dengue fever in governorates across the country. At the end of 2019, the local authority of Nate’a district in Al-Baydha governorate declared a state of emergency after 30 cases of dengue fever were recorded in a two-week period, in addition to one death, the district manager, Massad Al-Salahi, told Almasdar Online. 

A state of emergency was similarly declared in areas controlled by the Houthis in mid-November, in order to cope with the outbreak of dengue fever and malaria in Hodeidah, Hajjah, Al-Raima, Al-Mahwit, Taiz, Ibb and Sa'da governorates. Houthi-controlled media reported on official statistics released by the group, stating that the number of suspected dengue fever cases in 2019 reached 65,747, including 245 patients who died as a result of the disease, during the last quarter of 2019.

In October, MSF announced in a statement that the number of suspected cases of dengue fever had increased in the town of Abbs, Hajjah governorate, with 900 cases recorded in six weeks. Local sources told Almasdar Online that Houthi fighters recently closed the MSF hospital in Abbs to patients with dengue fever and evacuated the hospital in order to make space for its wounded combatants. 

Several other deadly diseases killed hundreds of Yemenis in 2019, including some diseases that were previously unheard of in the country.

The H1N1 pandemic, a rapidly spreading virus that affects the respiratory system and is particularly dangerous in the winter, is another disease that took many victims in 2019. Statistics are sorely lacking on this disease, commonly known as swine flu, but reports from local authorities in Houthi-controlled areas indicate over 100 people have died from it and several thousand have contracted it.

The West Nile virus (WNV), which is transmitted through mosquito bites and can cause neurological infection, was previously unheard of in Yemen until 2019. In December, Al-Samei, the deputy director of the Health Information and Education Department in Taiz, confirmed that over 300 suspected cases of the virus had been detected in the governorate, including 24 laboratory-confirmed cases.

Additionally, between January and October 2019, around 1,600 Yemenis were infected with diphtheria, resulting in 95 associated deaths, according to the WHO.

As war continues to ravage the country and a political settlement remains out of sight, Yemen enters 2020 with several epidemics that could spiral further out of control. Short of a full cessation of hostilities, humanitarian workers need unfettered access and public employees – including sanitation workers – need stable paychecks to continue their invaluable work.