Lancet Global Health
Jan 2019 Volume 7 Number 1e1-e159
Yemen needs a concrete plan—now
The Lancet Global Health
More than 3 years into the current conflict, the situation in Yemen has reached catastrophic proportions. These have been exacerbated by the collapse of the national economy and by intense fighting around Hodeidah, the country’s principal port on the Red Sea where most commodities, including food and medicines, enter the largely import-based Yemeni market. The planned peace negotiations are dependent on the goodwill of two warring parties whose disregard for international law has already led to large civilian casualties and the destruction of essential infrastructure such as health facilities, water systems, roads, and markets. As the world barely watches, at the convergence of all these events, an estimated 14 million Yemeni people—half of the country’s population—have now been brought to pre-famine conditions.
The global apathy in the face of Yemen’s continuing struggle has been disrupted in recent weeks. Increased media attention to the plight of hundreds of thousands of severely malnourished children has led to renewed concerns about the fate of the Yemeni people. On Nov 26, the CEOs of five international non-governmental organisations openly called out the role of US geopolitics and trade in the killing of innocent civilians, spurring discussions on the global responsibility for the war. And probably because one number sometimes speaks louder than words, earlier on Nov 21, Save The Children presented in a press release their straightforward estimation for the number of deaths due to untreated severe acute malnutrition between April 2015 and October 2018: close to 85 000 children under 5 may have died a preventable death in that period.
In truth, most health-related numbers coming from Yemen cannot be more than estimations—how could a collapsed health system generate robust data? But we know that the Yemeni people are suffering. Of all the scourges affecting Yemen, the prospect of a famine seems to have taken centre-stage in the media again, but there are many other enduring ones. We know that civilians are dying in the conflict, though unofficial data are vague and largely underestimated. We know there are outbreaks of diphtheria, measles, and probably other vaccine-preventable diseases. We also know that the cholera epidemic that started in April 2016 is still going on: the latest report available from the WHO Eastern Mediterranean Regional Office indicates that there were over 240 000 cases in the first 42 weeks of 2018. This cholera epidemic, the largest documented in history, illustrates how a weakened population, and a crippled health system, can be swiftly and durably overpowered in the midst of conflict. However, it is also an opportunity to learn, in the hope that this situation can be reversed in Yemen, and prevented elsewhere.
Thankfully, such learnings are happening. In May 2018, The Lancet Global Health published a modelling study by Anton Camacho and colleagues in which surveillance data were used to identify the drivers of the cholera epidemic, linking rainfall to the second wave of the epidemic, generating potentially important information for timing and enhancing control efforts. In a subsequent exchange of letters with Fekri Dureab and colleagues, the authors evoke the difficulties in identifying the mechanisms of transmission, in spite of robust modelling, in part because the war’s disruption of water and sewerage systems confounds the analysis.
Also importantly, in a report released on December 4, the Johns Hopkins Center for Humanitarian Health presents a detailed evaluation, based on an in-depth review and data gathered through 71 key informants, of the epidemic preparedness and response up until the second wave in July 2018. It brings forth unsurprising but sobering facts, among them the likely association between the conflict and increased cholera transmission; the lack of preparedness in terms of surveillance and response capacity; or coordination issues between international and national actors of the response. The 20 global and Yemen-specific recommendations cover the fundamental need of addressing insecurity, of urgently clarifying and harmonising coordination and preparedness, and of making the response more agile by improving surveillance. They include specifics of a targeted WASH and vaccination response and rely on strong integration of planning across sectors, all sensible responses to the issues identified in the analysis.
These concrete, action-related reports should be precious input in tackling this and future outbreaks, particularly in war-torn areas. But Yemen needs even more—and the time is now.