By Dr Shaima Hassan, Collaboration for Leadership in Applied Health Research and Care (North West Coast) at the Department of Health Services Research, University of Liverpool and a member of the Health Systems in Fragile and Conflict Affected States Thematic Working Group
The numbers in Yemen’s cholera outbreak are stark. Since the outbreak was confirmed by health authorities in October 2016, the spread has been rapid. Against the background of ongoing conflict, a crumbling health system and widespread malnutrition, the ‘worst cholera outbreak in the world’ has now affected over half a million people, with an estimated 5000 new cases each day. Over 2000 people have died. But this is not the only story.
Looking beyond these figures, the local level picture is complicated, with great variation in areas and people affected (pdf). Within a community, it is the most vulnerable people who are most affected by cholera and who die of cholera – those who do not have connections, who may not understand what the disease is or where they could go or may not have the resources to pay for medical care.
In this current outbreak, it is the elderly, women and particularly children who have been disproportionately affected. However, cholera and conflict are not the only battles raging in Yemen. With acute malnutrition rates rising, children’s immunity is seriously compromised, leaving them much more susceptible to infection.
Access to healthcare?
Even prior to conflict, the poor transport infrastructure left communities isolated and unable to access healthcare in certain parts of the country. Now, with the bombing of roads and air strikes on main urban centres, people have been forced out to rural areas, creating a more challenging and desperate situation to contend with.
Most of the cholera treatment facilities are set up around the capital, Sana’a. While the outbreak is now slowly being controlled in the capital, in other cities and in rural areas not enough help is present. Access to functional health facilities is critical; overall, 99.5 per cent of people with suspected cholera who reach health services are surviving, and surveillance confirms a decline nationally in suspected cases during July. However, in some of the most affected areas like Amanat al-Asimah, Amran, Hajjah, and Al Hudaydah, there is no decline in cases or even an increase.
Destroying a weak health system
Yemen’s health system showed significant weaknesses and structural vulnerabilities before the current conflict. A fragmented health system heavily reliant on private, out-of-pocket spending created significant access barriers, such as rising treatment fees combined with high transport costs for patients.
Service delivery was characterized by significant inequalities in availability and access between urban and rural areas. Curative care services were generally of poor quality, particularly with respect to patient perceptions of care, and were neither readily available nor accessible across the country, especially in rural areas. Pre-conflict, the country showed inequitable urban-rural distribution of healthcare workers (HCWs), shortage of female HCWs, and low public sector HCW pay.
The conflict has crippled this already weak health system, with many health facilities no longer functional, either because of further deterioration of prior poor functioning or because they were destroyed military action. The severe shortage of medical supplies and equipment, and significant shortage and overburdening of HCWs (with more than 30,000 not having received their salaries in more than 10 months) makes the situation even worse. This health system disruption has made the situation of the cholera outbreak more severe and difficult to control.
The disease should not be so ferocious. Yemen has experienced periodic cholera outbreaks in the past, for example in the 1994 Aden war. However, what is different in this current outbreak is the scale of the epidemic and the geographical spread of cases – similar to the Dengue outbreak in 2015-2016 which was worse than previous outbreaks.
What can the global community learn?
Devastating as the cholera outbreak is, it is important to focus on the overall situation that war-torn Yemen is in. The lack of a functioning health system and collapsing public services means Yemen’s people face multiple health risks, including other diseases that may pose even more of a global health security risk. But can we learn, even in the face of this? Where have small successes occurred, and why? Do some of the local differences reflect how communities and the health system have responded during the conflict and/or during the outbreak? The global health community must look at this outbreak and learn – for Yemen and other settings of conflict and crisis; for now and for the future.
Musāhamatna is a UK-based civil society initiative bringing together diaspora Yemenis and others to consider how to support health system rehabilitation and reconstruction in Yemen.