The worst humanitarian crisis in the world: war, disease outbreaks and famine in Yemen

By: Silvia Preite, Ph.D.

Source: Wikimedia

War and natural emergencies in low and middle-income countries often result in the weakening of health systems and relaxation of disease surveillance and prevention, leading to increased risk of infectious disease outbreaks. The over four-year civil war in Yemen continues today and, according to the United Nations (UN), has resulted in the worst on-going humanitarian crisis in the world. Hunger and the spread of communicable diseases affects the vast majority of the Yemeni population.

Overview of the ongoing war in Yemen

Before the start of the conflict in 2015, Yemen was already the poorest country in the Middle East, with debilitated health care systems and poor infrastructures. In March 2015, the Houthi movement took over the government in Sana’a (the capital). In response, a Saudi Arabia and United Arab Emirates-led coalition (supported by several other nations including the United States, the United Kingdom and France) started a military intervention in Yemen, with the intention of restoring the Yemeni government. Overall, this conflict resulted in devastation of agriculture, services, and industry in Yemen. Moreover, in more than four years of air strikes, over 50% of Yemeni hospitals, clinics, water treatment plants and sewage have been continuously bombed. The situation is further worsened by restrictions on food and medicines and limited access to fuel, leaving many essential facilities non-functional, including water sanitation centers. These conditions have led to extreme famine and spreading of diseases, including massive cholera outbreaks among the population. 

Cholera outbreaks

Cholera is a bacterial disease leading to severe diarrhea and dehydration, usually caused by the consumption of contaminated water or food. World-wide, an estimated 2.9 million cases and 95,000 deaths occur each year. It has been estimated that cholera has affected more than 1 million people in Yemen, with more than 2000 deaths, becoming the worst cholera outbreak in the world. According to Médecins sans Frontières (MSF) (known in English as Doctors Without Border) and Physicians for Human Rights, hospitals, mobile clinics, ambulances, and cholera treatment centers continue to be bombed, despite the fact that they have been marked as medical centers and the GPS coordinates have been communicated to the Saudi coalition. In addition to cholera, as a consequence of dropping immunization rates, more than 3000 cases of measles have been reported. Cholera and measles can be prevented by vaccinations and proper health infrastructure. Global eradication efforts have been adopted over the years to eliminate these infections, making the spreading of these diseases in Yemen a significant setback. 

Humanitarian violations

The Fourth Geneva Convention concerns the protection of civilians during conflicts, and has been ratified by 196 states, including parties involved and supporting the war in Yemen. The air strikes on medical centers violate the principles of medical neutrality established by the convention that protects hospitals and health care workers from being attacked. Within the standards of this international law, there is also the right of free mobility of medical personnel within a conflict zone. In contrast, during the civil war in Yemen restrictions have been applied by all involved parties on the activity of medical staff, delivery of health care equipment, essential medicines and vaccines. 

Latest UN report on the Yemen crisis

According to the UN, an estimated 24.1 million people (80% of the total population) need assistance and protection in Yemen, and of those, 14.3 million are in acute need (need help to survive). More than 3 million people are currently internally displaced (IDP), living in desperate conditions in Yemen or elsewhere in the region. It is estimated that 20.1 million people need food assistance, 19.7 million people need basic health care services, and 17.8 million people lack potable water, sanitation and hygiene (WASH). 

Children

An estimated 7.4 million children are in need of humanitarian assistance. Severe children’s rights violations are taking place in Yemen, affecting more than 4000 children and including the risk of being armed and recruited in the war for the boys and child marriage for girls. An estimate of 2 million children are deprived of an education, with around 2,000 schools made unusable by air strikes or occupied by IDPs or armed groups. Upwards of 85.000 children under the age of 5 may have died from severe hunger or other diseases. Overall, according to the UN, at least one child dies every ten minutes in Yemen because of diseases that could be normally prevented, hunger and respiratory infections. 

Urgent need for plans and resolutions

Both famine and disease outbreaks are threatening the Yemeni population and their survival currently relies only on international aid. In February 2019, the United Nations and the Governments of Sweden and Switzerland converged in Geneva to face and discuss the “High-Level Pledging Event for the Humanitarian Crisis in Yemen”. The aim of this meeting was to request international support to alleviate the suffering of the Yemeni people, and they requested $4 billion to provide life-saving assistance. Up to now, 6.3% of the requested budget has been funded; it is encouraging to note that last year UN was able to raise almost 100% of what was initially requested through multiple world-wide donations. 

Along with new funding, the OCHA (UN Office for the Coordination of Humanitarian Affairs), argues that urgent action is needed to prevent any exacerbation of the crisis. The most urgent action to resolve this unprecedented, man-made, medical and humanitarian emergency should come from all the parties involved to end the war and allow the re-establishment of food imports and adequate health services.

As the world barely watches, with only intermittent attention given by the international media, the conflicts and emergency remain. Non-profit and humanitarian organizations (UNICEF, MSF, WFP, Save the Children) have greatly aided the Yemeni population, despite challenging operational environments and the import and circulation restrictions. Moreover, when millions of people, including children, die from hunger and preventable diseases every day, the ethical responsibility of this disaster becomes global and concerns all of us. 

Global implications and future perspectives 

The on-going conflict in Yemen, illustrates how the support of research into innovative global-health solutions is highly needed. When the traditional healthcare system has collapsed and human rights are suspended, we need technologies which further support the victims of war-torn countries to achieve basic sanitary and health standards, beside disease monitoring and vaccination strategies.

We live in an increasingly interconnected world where outbreaks of neglected or re-emerging infectious diseases know no boundaries. Therefore, the consequences of conflicts and disasters in low-middle income countries pose a significant global threat and may affect even stable healthcare systems. Proper evaluation of the causes and consequences of infection outbreaks during the Yemeni conflict is therefore critical for two reasons: devise new strategies to more effectively control and prevent the spread in war-torn areas, and proactively encourage and support countries in regions of conflict to take the necessary measures to minimize the risk of similar humanitarian disasters in the future.

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Science Policy Around the Web – August 23, 2016

By: Agila Somasundaram, PhD

Aedes aegypti, by James Gathany (PHIL, CDC) [Public domain], via Wikimedia Commons

Zika

How big, really, is the Zika outbreak in Florida?

On Friday, officials announced that the Zika virus had spread to a second area in Florida, the Miami Beach, a popular tourist destination. The Centers for Disease Control and Prevention (CDC) has advised pregnant women to avoid those areas, and in fact, advised pregnant couples concerned about exposure to Zika to “consider postponing nonessential travel to all parts of Miami-Dade county”. Officials note that it will be difficult to limit the spread of the virus in this area because aerial spraying may not work very well around high-rise buildings, and convincing beach-goers to wear long sleeves and pants might be hard. With schools starting today, school officials have distributed mosquito repellant cans to parents, and long-sleeved shirts and pants to students. 37 cases of Zika infection have been reported in the two areas in Miami.

Many scientists are concerned that the outbreak may be larger and more widespread than these numbers. Alessandro Vespignani, a computer scientist at Northeastern University in Boston, who is modeling the spread of Zika, says, “Zika is one of those diseases that is always like an iceberg — you just see the tip.” 4 in 5 people who get the virus don’t have any symptoms, and people who get sick exhibit mild symptoms that could easily be confused with the flu. So only 5 percent of cases get detected, says Vespignani. Models predict that 395 people will be infected with the virus by September 15, in Florida. Only about 80 of them will show symptoms, and about 8 pregnant women are likely to get infected during their first trimester, putting their fetuses at risk for microcephaly, says Ira Longini, a biostatistician at the University of Florid and a collaborator of Vespignani. Zika will likely continue to spread until October or November when the weather becomes cooler. The computer models also predict that Texas might be next. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, says, “I would not be surprised if we see cases in Texas and Louisiana”, given the recent flooding in Louisiana. Zika virus-carrying mosquitoes breed in stagnant puddles, and there will be a lot of problem getting rid of standing water in flooded areas, says Fauci. (Michaeleen Doucleff, NPR)

Global Health

Debate continues over U.N. role in bringing cholera to Haiti

The 2010 Haiti earthquake claimed over 200,000 lives and injured many more. The cholera outbreak that followed months later resulted in at least 7,000 deaths. Cholera is caused by the bacteria Vibrio cholerae, and is transmitted when faeces from an infected person contaminates drinking water. Many investigations have connected the cholera epidemic in Haiti to sewage leaked from a U.N. base that housed Nepalese peacekeepers. Toilets have been reported to overflow from the base into the nearby stream. In fact, the strain of bacteria in the Haiti epidemic was similar to a strain in Nepal. Even though, for year, the Haitians have been accusing the U.N. for the outbreak, the U.N. has never accepted responsibility. This has led to serious distrust among the Haitians about the U.N. troops. In 2013, a class action suit was brought against the U.N. on behalf of Haitians who were affected by the outbreak. But the U.N. is immune to such legal actions under international law.

Recently, Farhan Haq, spokesperson for U.N. General Secretary Ban Ki-moon, said the U.N. “needs to do much more regarding its own involvement in the initial outbreak.” “What we are doing is trying to see how this can be resolved. How to resolve this? How to do the right thing?” Dr. Louise Ivers, senior health and policy adviser with Partners in Heath (that has treated thousands of cholera patients), said that the U.N. should have acknowledged its role a long time ago. Brian Concannon, the lawyer who brought the class action suit against the U.N., welcomes U.N.’s new statements but is not completely happy. He says the U.N. “clearly did not definitively take responsibility for introducing cholera.” (Jason Beaubien, NPR)

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Science Policy Around the Web – March 10, 2015

By: Ashley Parker, Ph.D

photo credit: Staphylococcus aureus Bacteria via photopin (license)

Antibiotic-Resistant Infections

Second Los Angeles hospital identifies “superbug” infections and Hartford Hospital says patients might have been exposed to E. coli

Recent “superbug” outbreaks in at least three hospitals have been associated with a sophisticated surgical instrument known as a duodenoscope. Duodenscopes are fiber-optic instruments used to examine the duodenum (small intestine), and are inserted into the mouth, through the stomach and into the top of the small intestine. Two Los Angeles hospitals, UCLA Ronald Reagan Medical Center and Cedars-Sinai Medical Center have reported seven and four carbapenem-resistant Enterobacteriaceae (CRE) infections, respectively, with two of the UCLA incidents resulting in death. 67 more patients at Cedars-Sinai Medical Center, who were treated with the same instrument are currently at risk. In Connecticut, Hartford Hospital reported at least five patients infected with a strain of drug resistant E. coli. These “superbug” infections were also linked to the use of two duodenoscopes in procedures that involved 281 patients. Dr. Rocco Orlando, the Chief Medical Officer at Hartford, stated that the patients found infected were treated successfully. The hospital remains confident that the 281 patients exposed to the instruments are not at greater risk for infection due to laboratory test revealing the strain’s sensitivity to other antibiotics. However, additional safety measures, including contacting these patients and bringing them in for screening, are currently taking place. In the earlier cases in Los Angeles, both hospitals offered free home monitoring kits to potentially exposed patients.

Hospital officials at all three hospitals stated that they followed the manufacturers’ disinfection procedures correctly to clean and disinfect the instruments. Since the reported outbreaks, both Los Angeles hospitals have enhanced their disinfection procedures beyond those recommended by the manufacturers. Proper sanitation of these instruments is currently under investigation. The U.S. Food and Drug Administration (FDA) released its first warning on February 19 regarding problems with the design of the instrument that may prevent effective cleaning. In this report, the FDA discussed reported issues of disinfecting these surgical instruments and the potential risk associated with the transmission of multi-drug resistant bacterial infections. The FDA Safety Communication also provided recommendations for healthcare providers regarding their responsibility to communicate the potential benefits and risks, and included information for patients who undergo such procedures with these duodenoscopes. The situation is still being monitored and the FDA will continue provide updates regarding the related use of these devices. (Steve Gorman, Reuters and Josh Kovner, Hartford Courant)

Healthcare and Infectious Disease

CDC puts C. difficile burden at 453,000 cases, 29,000 deaths

Hospital-acquired infections and the resulting costs of treating them continues to be an issue in the United States. The Center for Disease Control and Prevention (CDC) has recently reported that the bacterium Clostridium difficile is responsible for more than 450,000 cases per year and results in death in approximately 6.5% of cases. C. difficile is one of the major pathogens responsible for antibiotic-associated colitis, an infection resulting in inflammation of the large intestines. Further damage to the colon can cause the bacterial infection to leak into the bloodstream, resulting in septicemia. This is a major concern, primarily for patients who are treated with antibiotics in hospitals and long-term care facilities such as nursing homes.

Surveillance studies have been reported in the New England Journal of Medicine (NEJM) to monitor new cases of C. difficile. Although there were a considerable number of community-acquired cases in these studies, a significant number of infections were attributed to healthcare-associated environments. Strikingly, 10% of the patients with healthcare-associated infections died within a month.

As a result, serious efforts to reduce the incidence of C. difficile infections have been implemented. Hospitals are now required to report infection rates and healthcare workers are encouraged to use proper hand-washing techniques rather than rely on hand sanitizers to prevent the spread of C. difficile spores. In addition, measures to avoid the unnecessary use and prescribing of antibiotics have improved the incidence of antibiotic-associated hospital cases. Moving forward, additional evidence is needed to better understand the spread of infection and improve the disinfection of healthcare environments. (Robert Roos, Center for Infectious Disease Research and Policy)

Global Health and Infectious Disease

Malawi: Cholera Scare Hitting Malawi, Govt Alert

The United Nations Children’s Fund (UNICEF) is on high alert after a cholera outbreak in Malawi, Africa and its borders. Cholera is an infectious disease caused by the bacterium Vibrio cholerae which infects the small intestine. While some infected persons can be initially asymptomatic, progress of the infection can lead to excessive watery diarrhea, vomiting, severe dehydration, and death in 25-50% of untreated infections. The Ministry of Health in Malawi has reported 39 cases of cholera with two confirmed deaths. These reports are in the southern border areas of Malawi which is shared with the neighboring country of Mozambique. UNICEF has also reported more than 3400 cholera cases in Mozambique, including 37 deaths since December, many of which were children.

The continued spread of this disease is a pressing concern. In Malawi, the disease is associated with major flooding that occurred in January and the more than 230,000 people who are still displaced due to continued rainfall. Mahimbo Mdoe, the UNICEF representative in Malawi stated “[that] as humanitarian actors in Malawi, we need to move quickly.” UNICEF along with other organizations such as the European Union and UK’s Department for International Development are contributing to efforts to prevent the spread of cholera such as providing safe water, sanitation and hygiene services. In addition, UNICEF, in partnership with governmental and non-profit organizations, has dispatched essential medications and healthcare equipment to control the outbreak. (Paul Nthala, Malawi24)

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