Cholera in Yemen: war, hunger, disease…and heroics
The harms done by war are many and complex. Death, injury, and displacement are the most obvious, but infection is also closely intertwined with conflict. Across the Middle East and Africa, outbreaks of infection have occurred as a direct effect of war, compounded by food and water shortages, displacement, and damage to infrastructure and health services. Nowhere is this web of interconnections more clear than in the cholera epidemic in Yemen.
Cholera is an opportunistic disease. It strikes where populations are displaced, where people are left vulnerable by malnutrition and drought, and where sanitation and hygiene are poor. It emerged in Haiti after the disastrous earthquake in 2010, and it is now ravaging east Africa and the Middle East: after more than 2 years of fighting, the epidemic in Yemen has boomed in recent weeks, with WHO and UNICEF estimating more than 200 000 cases in total.
The outbreak, which began in October, 2016, appeared to peak in December, before abating by April 2017, with around 25 000 cases suspected. The establishment of treatment centres and expanded surveillance by WHO and aid agencies seemed to have worked. But in May, a resurgence began. At the time of writing, an estimated 5000 new cases are occurring every day across Yemen.
The fighting between a Saudi-led coalition and Houthi rebels has decimated the country. Of a population of 27 million, an estimated 14·5 million do not have access to clean water and sanitation. Many displaced people—more than 2·2 million—reside in temporary camps, where hygiene and waste management facilities are practically non-existent. The country is at risk of famine, with 17 million people at high risk of food insecurity, and UNICEF estimates that 400 000 children are severely malnourished, giving them little chance to fend off infection. Add to this the difficulty of delivering supplies and aid across the warzone, the conditions—all stemming from the conflict—are ideal for cholera to take hold.
Cholera is easily treated, but access to basic health care is also hampered by war. Targeting health services in war has become more common in recent years, particularly in Syria, but also in Yemen. According to WHO, only 45% of health-care facilities in Yemen are fully functional, with reports of both sides targeting health-care facilities and workers. Health facilities run by Médecins Sans Frontières (MSF) alone have been hit four times, including by aerial bombardment. Access to essential medicines is stymied by difficulties in importation and transport, and with the Yemeni economy in ruins, there is little money to pay for what supplies are available. Health-care workers are working in incredibly challenging conditions, even though many have not been paid for almost a year.
The situation is bleak, but the international community is doing what it can to halt the epidemic. The UN and partners have sent 1 million doses of cholera vaccine, half the global stockpile. Tons of water purification and medical supplies, including rehydration salts, have been airlifted in, and hundreds of rehydration points and 20 diarrhoea treatment centres have been established. MSF has its largest mission—1600 staff—working in Yemen.
The toxic mix of conflict, disease, and famine is not confined to Yemen. Outbreaks of cholera have also been reported recently in Nigeria, Somalia, South Sudan, and Sudan, and it is no coincidence that the disease has emerged in countries dealing with wider humanitarian crises brought about by fighting, drought, and displacement. And war can hinder efforts to eliminate disease as much as it can create the conditions to generate it. The latest report on polio from WHO highlights the challenges of reaching remote communities in northern Nigeria—an area beset by the terrorist organisation Boko Haram and the consequent displacement of people. As a result, it is likely that wild poliovirus is circulating undetected in northern Nigeria. Vaccinators face difficult and dangerous conditions to deliver vaccines in war-torn regions. In Nigeria and in Syria, which has been plagued for years by civil war, cases of circulating vaccine-derived poliovirus type 2 infection have been reported, a sure indicator that vaccination coverage is not currently sufficient in these regions. Despite the danger, plans for supplementary immunisation are underway.
Aug 19 marks the UN’s World Humanitarian Day. Not only is it time to raise awareness of humanitarian crises around the world, but also it’s a chance to applaud the bravery and dedication of health workers and others striving to alleviate suffering in the most dire situations. To those people everywhere, we say—thank you.