Yemen’s health system buckles under Saudi led bombardment and blockadeBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h3549 (Published 29 June 2015) Cite this as: BMJ 2015;350:h3549
Yemen has ground to a halt and faces a humanitarian catastrophe under the twin pressures of war and blockade, say the United Nations and the Red Cross and other international aid agencies.
The country’s health system is in a state of collapse, with at least 158 medical facilities completely shut down, Unicef has reported, and many more operating with little or no electricity.
After three months of Saudi bombing, and with street fighting between contending Yemeni forces, at least 2800 people have been killed and 12 500 wounded. But away from the direct violence it is the naval blockade imposed by the Saudi led coalition that is hurting the most.
The mostly Saudi and Egyptian warships enforcing the blockade are charged with denying alleged attempts by Iran to deliver arms to the Houthi militia, an armed group of the Shi’ite Zaidi sect that overthrew the government in February. But the blockade has actually turned away 80% of commercial shipping from a country heavily dependent on imports for daily survival.
UK military support
The United Kingdom’s foreign secretary, Philip Hammond, promised in March to support the Saudi effort in “every practical way short of engaging in combat,” and the UK has provided many of the bombs dropped on Yemen. But the UK government has become concerned about the effects of the blockade and has urged its coalition partners to focus on “intelligence driven” interdictions only of ships suspected of carrying weapons, though so far to no avail.
A spokesman for the US Department of State said that it continued “to urge all sides, including the Saudis, to exercise restraint and avoid unnecessary violence. We also urge all parties to allow the entry and delivery of urgently needed food, medicine, fuel, and other necessary assistance.” Accelerated US arms sales to coalition members continue, and US navy vessels accompany the blockading forces. UK and US military personnel are involved in planning and targeting coalition operations.
Famine and disease
Yemen, an arid nation of 26 million people, relies on imports for 90% of its peacetime food consumption and all of its medicine and fuel. It is the poorest country in the Arab world.
The United Nations’ envoy to Yemen, Ismail Ould Cheikh Ahmed of Mauritania, has said that the country was “one step away from famine,” with 21 million Yemenis in dire need of aid. “A looming humanitarian catastrophe is facing Yemen,” said Stephen O’Brien, the UN undersecretary general for humanitarian affairs. “People across the country are struggling to feed their families. Basic services are collapsing in all regions.”
The World Health Organization has warned that more than 15 million people in Yemen do not have access to basic health services and that over 20 million lack access to safe drinking water. Rubbish is piled high in the streets, and electricity is available for a few hours a week or not at all.
Diagnoses of dengue fever have risen sharply, with more than 3000 cases recorded by WHO between 27 March and 4 June. Malaria is also on the rise. Vaccination campaigns have ground to a complete halt, and the cold chain is not operating. Aid agencies have said that they feared a resurgence of polio or measles.
The dengue epidemic may be accelerating. On 19 June Marwa Marwan, an emergency doctor at al-Breihi hospital in Aden, where many streets are flooded by sewage, told Agence France Presse that her hospital alone received 90-100 new patients with dengue each day, with 10-15 deaths a day.
Almost all treatment for chronic disease has halted, as drugs and electricity run out. Numbers of admissions to hospital have risen by 150% with the people injured in fighting, and travel has become dangerous and difficult. In accounts of family life published by the New York Times many respondents mentioned a relative whose chronic disease had gone untreated. Another recurring theme was nocturia developing among children in response to the constant explosions, and children who cried on hearing doors slam or even vomited at the sound of aircraft.
Lines of cars waiting to buy petrol are over 3 km long. Ahlam al-Maqtari, a doctor at al-Sabeen hospital in Sana’a, the capital, told UNICEF Connect that two women with complications during delivery “died of excessive bleeding because they couldn’t come to the hospital in time as a result of the fighting and lack of transport.”
Marie-Elisabeth Ingres, who heads Yemen operations for the charity Médecins Sans Frontières, cited the case of a 4 year old boy who died from tonsillitis. “We are quite sure people are left to die in their homes because they aren’t able to receive treatment,” she said.
Because of the fuel shortage delaying people’s ability to reach hospitals, said Mareb al-Mahweeti, a vascular surgeon at the al-Oradi military hospital in Sana’a, “We’ve increasingly had to amputate arms and legs because people are arriving with bullet and shrapnel wounds that have gone untreated so long.” The hospital was the scene of a deadly terrorist attack in 2013. The subsequent broadcast of security camera footage showing doctors, nurses, and patients being gunned down prompted a rare public apology from al-Qaeda in the Arabian Peninsula (AQAP).
In Sana’a, a Unesco world heritage site, several hospitals have reported treating more injuries from reckless Houthi anti-aircraft fire than from aerial attack. In Taiz and Aden, shelling and ruthless street fighting have driven hundreds of thousands of people from their homes, while hospitals in Taiz have been looted by militias.
Indiscriminate coalition bombing of civilian areas in the Houthi homeland of Saada governate in the country’s far north west was a clear breach of international law, said the UN humanitarian coordinator for Yemen, Johannes Van Der Klaauw. All of Saada governorate had been declared a military target, said leaflets dropped from coalition aircraft, and civilians were ordered to evacuate the towns of Maran, Sa’dah, and Albiqaa.
Refugees from Saada have described returning to their villages to find them flattened. “The level of destruction in Saada is quite overwhelming,” said Teresa Sancristóval of Médecins Sans Frontières, who worked at the Republican Hospital in Sa’dah City. Civilian infrastructure had been deliberately targeted, she said, though not her hospital.
Ali al-Mudhwahi, an adviser to Yemen’s health ministry, told the Washington Post that medical facilities in Saada have been “systematically” targeted by coalition airstrikes. Coalition spokesman Brigadier General Ahmad Asseri of the Saudi army refused to answer these allegations from the Houthi backed government in Sana’a, saying, “We do not comment on rebel and gangster declarations.”
Tameem al-Shami, a health ministry spokesman, said that at least five ambulances had been destroyed from the air in Saada. The charity Human Rights Watch has accused the coalition of attacking Saada with cluster munitions, lethal to civilians and especially children, who pick up the unexploded bomblets.
No end in sight
No clear end is in sight, and the consensus among foreign observers is that the Saudi leadership had expected a swift military victory and was now at a loss how to proceed. The coalition’s initial campaign, named Operation Decisive Storm, officially ended after a month, in late April, with Saudi Arabia and its partners declaring a switch “from military operations to the political process” and the commencement of Operation Restoring Hope.
The Saudi kingdom announced that it would fund the entire $274m (£174m; €245m) sought by a UN emergency relief appeal. That pledge was doubled by King Salman in May, but none of the money has been paid. Instead the bombing continued under Operation Restoring Hope, including the destruction of the runway at Sana’a airport to prevent the landing of an Iranian Red Crescent flight, an attack denounced by aid groups. The airport was the main conduit for medicines and aid workers entering the country and is no longer functional. Residential buildings in Sana’a and Aden have since been targeted by guided bombs.
Talks in Geneva this month, aimed at reaching a settlement or at least a Ramadan truce, collapsed in farce amid fistfights and flying shoes as Houthi delegates were attacked by Yemenis from the south of the country who chanted that they were “spreading death and disease in South Yemen.”
Even the country’s biggest and newest hospitals are now struggling to stay open. “We could stop at any moment,” Ali al-Mustafa, an intensive care doctor at al-Thawra Modern General Hospital in Sana’a, told CBS News. “We have no water, no electricity, no medicines, no dialysis, and no doctors even.”
“There is no electricity at the hospital,” said Ahlam al-Maqtari at the al-Sabeen Hospital in Sana’a. “We have no oxygen cylinders. How are we supposed to operate? We have infant incubators with no oxygen. How can you carry out surgery without electricity to run the equipment? It makes you feel powerless, as if your hands are cut off, while you are expected to treat all these patients.”
Cite this as: BMJ 2015;350:h3549