Amir M. Mohareb, M.D., and Louise C. Ivers, M.D., M.P.H., D.T.M.&H
How can the medical community take stock of the humanitarian disaster in Yemen? The 3-year-old war intermittently garners attention from Western media — for example, in August, when an air strike on a school bus killed more than 50 civilians, mostly children — but is woefully [bedrövligt] underreported relative to the magnitude of the ongoing crisis. Such neglect highlights the numbing of our collective sensitivity to atrocity [illdåd]. Although the human toll of any war is dreadful, the infliction of suffering in Yemen has particularly toxic characteristics that we believe demand attention from health care providers worldwide: the destruction of health care facilities and the spread of disease and hunger as apparent means of waging war.
A Mobile Phone Tower Destroyed in Sa’ada, July 2018.
Yemen was beset with widespread poverty and an ailing health care system when this conflict began. Most health indicators ranked in the bottom quartile of the world, with 1 in 25 children not surviving to the age of 5. In March 2015, after the Houthis, a faction based in the north of the country, took over Sana’a (the capital city), a coalition led by Saudi Arabia and the United Arab Emirates and supported by the United States, the United Kingdom, and France, launched air strikes in the country to overturn the Houthis. In more than 3 years of air strikes, Yemeni hospitals and clinics have continued to be destroyed, both indiscriminately and sometimes apparently deliberately [medvetet]. With access to health care almost entirely eliminated owing to bombings and blockades, infections have spread as — at best indirect and at worst direct — weapons of war.
A massive cholera outbreak is the most obvious example of the devastating impact of the war on health. It is suspected that more than 1.1 million people have had cholera, and at least 2000 people have died from it, nearly 20% of them children under 5 years old.1 Geospatial patterns of cases of diarrheal disease reveal alignment of the spread of cholera with patterns of aerial bombardment by the Saudi-led coalition.2 Civilians living in Houthi-held areas had higher cholera attack rates and higher case fatality rates between September 2016 and March 2018 than those in government-held areas.2
The Saudi-led coalition — heavily supported by the United States through munitions sales, military training, and aerial refueling — has bombed both medical facilities and water-treatment centers in these areas. Within the first few months of the war, a major water-treatment plant outside Sana’a was out of operation because its electrical grid had been bombed. Subsequent [senare] restriction of fuel imports by a Saudi-led blockade caused the facility to lose all power and become inoperable, according to UNICEF. Then the deadly grip of diarrheal disease took hold. Shockingly, water-treatment plants and sewage systems continue to be bombed. UNICEF reports that between March and July 2018, water-treatment facilities in the Sa’ada governorate were repeatedly attacked, which left much of the nearby civilian population without safe drinking water and caused thousands of dollars of damages to water-treatment projects.
Direct bombardment of medical facilities has triggered the spread of disease and put health care personnel and relief workers in danger since the start of the war. Médecins sans Frontières (MSF) reported that 39 hospitals were bombed during the first 7 months of the conflict despite the fact that they were clearly marked as medical centers and their GPS coordinates had been shared with Saudi authorities. Both MSF and Physicians for Human Rights have reported that assaults on hospitals, mobile clinics, ambulances, and cholera treatment centers continue to occur.
Targeting of health care facilities by warring parties is strictly prohibited by the fourth Geneva Convention, which also stipulates the need for free mobility of medical personnel within a conflict zone to carry out humanitarian assistance. Yet humanitarian organizations report that medical staff and supplies have been restricted from reaching the populations in greatest need.
Diphtheria is another ancient scourge [gissel] that has emerged in Yemen as a result of the war. The 48 reported cases in 19 governorates (according to the World Health Organization) probably reflect a larger unmeasured epidemic, given that the country currently has limited diagnostic capacity and few functional health centers. More than 3000 cases of measles were reported in 2018,3 probably largely attributable to a documented drop in immunization rates in Yemen since 2013 for all childhood vaccines.4 There is serious concern about a potential outbreak of polio.
Saudi-led blockades of ports of entry to Yemen have severely limited the ability of international agencies to support the local response to outbreaks, prevented fuel importation, and exacerbated [förvärrat]food insecurity to the point of near-famine. Even after a blockade in late 2017 was eased, importation of essential medicines, vaccines, and health care equipment remains limited. The problem has only worsened since attacks on the port city of Hodeida in June 2018 strangulated the entry point for much of the country’s food imports. Currently, half of health facilities are reported to be nonfunctional; 14 million people are at risk of starvation, according to the United Nations Office for the Coordination of Humanitarian Affairs; and the value of the local currency, the Yemeni rial, has depreciated rapidly. This situation makes a dire public health emergency almost impossible to address.
With so many humanitarian crises facing us, why should physicians give special attention to the war in Yemen? The Yemeni medical disasters are man-made, with outbreaks of infectious diseases and starvation following bombing. The war has been characterized by a violation of medical neutrality — the principles and laws protecting health care workers and hospitals from being targets in conflict. As hospitals have been attacked, the country’s remaining physicians and nongovernmental organizations have endured sometimes deadly risks to their own safety.
When health care facilities and the movement of health care workers are consistently the casualties of a war, condemnation from medical and public health communities around the world should follow. How can we accept these violations of our duty to care? We believe that physicians everywhere have a special responsibility to advocate for a complete cessation [upphörande] of attacks on civilian and health care infrastructure, an end to blockades on Yemen’s ports of entry, and full access by humanitarian actors to all parts of the country. The U.S. government has agreed to more than $100 billion in arms sales to the Saudi military, in addition to ongoing logistic and diplomatic support. As evidence mounts that these armaments are used in civilian attacks, including on health facilities,5 we ought to advocate for the United States to suspend military support for the war in Yemen, as was proposed in a bipartisan Senate resolution this year.
Impartial bodies such as the International Humanitarian Fact-Finding Commission — established to respond to incidents related to international humanitarian law — should be allowed to investigate attacks on medical facilities and personnel committed by parties on either side of the conflict. Whether the devastation has resulted from deliberate targeting or gross negligence, the perpetrators of such attacks ought to face legal repercussions [återverkningar].
These responses are, in our view, the only just course of action and are the way to erect necessary safeguards for the future. We rely on humanitarian programs and on the principle of medical neutrality as a salve for the painful consequences of armed conflict. The moral responsibility for this catastrophe is collective. Those of us whose governments support the war’s attack on civilians and civilian infrastructure through their direct actions or through their inaction at the United Nations Security Council can do more than stand by silently wondering what the warring parties hope to inherit at the end of the day. A generation of Yemeni people is being sacrificed.
Disclosure forms provided by the authors are available at NEJM.org.
This article was published on November 21, 2018, at NEJM.org.
