Dr. Najla al-Sonboli is no longer paid to go to work as head of the Al-Sabeen Hospital for Children and Women in Yemen’s capital Sana’a. Amid a devastating conflict and with an economy in freefall, the government ran out of resources for payroll last year. But each morning, she and other health workers dip into their savings to find enough money for transport. If they don’t come to the hospital, no one will be there to treat the hundreds of patients arriving with cholera in the worst outbreak of the disease in the world today.
“The situation is so bad it and is getting worse from day to day,” she told Devex in a phone call. “People are so poor and the general health situation is deteriorating. There is no clear water, there is a lot of garbage of the street and this has helped to spread a lot of diseases. There is a lot of cholera.”
Today, many Yemenis live in near-famine conditions with almost no economic resources and in the midst of ongoing warfare. Their suffering has been exacerbated by the limited aid response mounted in harrowing conditions. Conflict, lack of supplies, costly logistics and inadequate funding have all deterred or prevented humanitarians from scaling up.
Yet even more critically, Yemen itself has few coping mechanisms left after more than two years of conflict. By the time cholera struck, public services in Yemen had collapsed, including the systems for health and water. Aid groups say that means there is a limit to what any response can accomplish. Even with more robust relief, the cholera outbreak is likely to continue for months. After it passes, Yemen will be equally vulnerable to another threat. Until the conflict ends, few expect that grim reality to change.
Across the country’s clinics and hospitals, the government has stopped paying salaries. Facilities lack up to 70 percent of the supplies they need, and many buildings have been damaged from bombing or shelling. Urban hygiene has deteriorated since municipal workers are also no longer paid and water treatment plants don’t have enough fuel to pump sewage. More than half of the drinking water in Yemen must be purchased from private boreholes, which few households can afford.
“Cholera appeared in systems that were collapsing totally,” said Dr. Caroline Seguin, deputy program manager at Médecins Sans Frontières. “There are no salaries, there is no supply [of medicines], some health centers have been destroyed by bombing, and we are in a time of very big economic problems.”
The deterioration has accelerated in recent months. Cholera first emerged in October 2016, but it withered after about 25,000 cases, according to Rajat Madhok, spokesperson from the UNICEF Yemen in Sana’a. By April 2017, however, cholera found a foothold and since then it has exploded into a full-blown health crisis.
UNICEF and the World Health Organization now estimate Yemen sees about 5,000 new cases of cholera a day, bringing the total to an estimated 260,000 cases and 1,614 deaths since the spring, according to the latest U.N. figures. About 50 percent of the cholera patients are children.
Al-Sabeen Hospital alone receives 400 to 500 patients a day, far more than its 110 bed capacity can accommodate, said Al-Sonboli.
“Some of them are so bad,” she said. “We have patients on the beds, on the ground, sometimes on the carts, on the balconies. We put them everywhere. We try to help them.”
In a myriad of ways, three years of fighting have devastated Yemen’s functionality, leaving a gaping humanitarian wound. Families that once had running water and electricity now queue at local mosques to collect water in jerry cans, taking it home to dark, unlit homes. Public sector workers whose wages formed the backbone of the economy haven’t been paid for almost a year; few report to work anymore.
The institutional collapse left Yemen vulnerable to health crises, and cholera has swept the country with alarming velocity. “One of the biggest driving factors — maybe the biggest driving factor — is the erosion of public services,” said Sara Tesorieri, a policy advisor for the Norwegian Refugee Council working in Yemen.
Aerial bombing has caused the most obvious destruction. A Saudi Arabia-led coalition of countries have primarily relied on an air campaign to try and oust an alliance between Houthi rebels and the country’s former president, Ali Abdullah Saleh. Some 45 percent of health facilities are now nonfunctioning because of infrastructure damage, Tesorieri said. In areas close to the frontlines, such as the contested province of Taiz, she estimates the rate of nonfunctioning may be as high as 90 percent.
Imports have also fallen steeply as a result of damaged port infrastructure, a lack of paid employees and on-and-off blockades by the Saudi-led coalition, which has cited concerns that weapons could be brought to the country. As a result, the flow of medicine into the country has dropped by 70 percent, according to the World Health Organization. To get supplies into the country, organizations such as MSF rely on charter flights, costing 260,000 euros a piece, said Seguin.
Food and fuel imports are also well below what’s needed in a country that relies almost entirely on imported commodities. The latter has knock-on effects to a host of other services.
Tesorieri recalled a recent visit to Hudeidah, a city that hosts Yemen’s only operational port and sits below sea-level. “If they don’t pump their sewage, and they don't have the fuel they need to do so now, it piles up in street,” she said. “That’s exactly what I saw: huge puddles along a street where about 20 displaced families were camped out.”
Responding to cholera generally takes two tracks: clean water and health care. The former is how the epidemic can be stopped — or how it accelerates.
People are getting sick because of “the shortage of clean water,” said al-Sonboli, describing the long queues for water at tanks and wells.
Humanitarians say they feel almost blind in improving the water situation in Yemen. The data on cholera cases is piecemeal and many areas are beyond access. “Normally in cholera, the epidemiologist is the one who will guide where to put in efforts” to decontaminate water supplies and educate residents about how cholera spreads, said Christina Imaz, a WASH expert in MSF’s emergency unit.
In Yemen, however, insecurity and poor access have prevented comprehensive epidemiological tracing. MSF and other health and WASH providers must instead rely on a now unpaid network of community health workers to report cases as they arise.
Once communities are identified to have cholera, aid workers should treat the water sources with chlorine and educate community members about how to avoid future contamination. But both pieces are proving complicated. Many boreholes are privately owned, meaning that there is no record of where they are; humanitarians must rely on communities to point out their water sources.
Nor do aid groups have access to many cholera-stricken communities for a long-term intervention. MSF, UNICEF and others in the WASH sector are relying on distributing family kits that include supplies such as chlorine tablets, jerry cans and soap, as well as easy-to-follow instructions about how to avoid infection.
They aren’t reaching everyone; Imaz estimates that maybe two out of seven affected villages have received supplies. Areas particularly along the frontlines of conflict are out of reach.
“Here, we are a bit blind, so we don’t really know what is happening in those places,” said Seguin. “In Yemen, we see bad things, but I think there are even worse things we don’t see.”
Humanitarians say the cholera epidemic likely hasn’t peaked, and risks accelerating as the rainy season begins in a few months.
“There are still thousands who are becoming sick with the disease every day. The situation remains alarming,” a WHO spokesperson told Devex in an email. “We just revised our budget because we expect we’ll be responding to cholera for at least another six months and probably into next year.”
The lack of prevention and ongoing caseload means treatment is vital — and insufficient, for now.
Patient care relies on a network of hastily opened rehydration centers and diarrhea centers, including those supported by WHO, UNICEF and MSF, as well as government hospitals. The latter facilities are heavily oversubscribed.
UNICEF has established more than 500 rehydration centers, where patients are screened for watery diarrhea, and can be treated either on site or sent to a hospital for specialized care, Madhok said. The U.N. agency has also reached more than 5 million people with chlorination tablets, waste water plants and other water and sanitation services at their homes.
Supplies are also in short order, according to Madhok. Funding and logistics are largely to blame. The humanitarian response in Yemen has only one-third of the funding needed, according to U.N. data. WHO alone is requesting $64 million through the end of the year, $18.2 million of which it has received.
Meanwhile imports are a standing challenge. A severe cholera patient, for example, can require up to 10 liters of intravenous fluid, most of which now has to be brought into Yemen by plane.
By everyone’s admission, the current response is not enough to contain the epidemic. MSF says it has seen many NGOs balk at the risks and costs of operating in Yemen. “We have the feeling that we are the only NGO really working to treat patients on the ground,” said Seguin. “WHO is trying to do what they can, but the response is not enough.”
Imaz said that UNICEF has tried to encourage more NGOs to scale up their response, including through a recent high-level conference call. UNICEF declined to confirm any specific calls, but said there is always a need for more aid. WHO said, “several NGOs will be scaling up operations, particularly related to WASH, to respond to the need.”
The need is “for more operational capacity,” the WHO spokesperson said. “We need health workers to be paid and in their posts, and we need more international partners to join us on the ground in Yemen.”
Seguin also worries that the haste with which treatment centers have been built has left room for grave mismanagement. Her organization’s facilities often receive patients who had sought care elsewhere without success, she said. Worse yet, poorly supervised treatment centers can become hotbeds of disease transmission if patients and water supplies aren’t properly isolated.
Many patients can’t afford the transport to a medical facility or the cost of treatment there; government hospitals, while meant to be free, now charge for medicines because their own supplies have been exhausted. Many families are avoiding treatment until they are in a desperate condition — at which point it is much more difficult to treat them.
Others arrive already malnourished and unable to weather a usually treatable disease. “We have heard of children who were already severely malnourished and contracted this disease and died as a result,” said Madhok of UNICEF.
With limited options for care, the fatality rate for cholera is Yemen is higher than it should be for this sort of outbreak, both MSF and NRC say.
Al-Sonboli describes a scene of immeasurable suffering — one that has no foreseeable end. Each day she prays there will be fewer new patients when she arrives at work; each day, there are more.
Asked what could halt the outbreak, she replied simply.
“I think only this will happen if the war stops.”
Read more international development news online, and subscribe to The Development Newswire to receive the latest from the world’s leading donors and decision-makers — emailed to you free every business day.