A Yemeni health worker fumigates people's hands at a market during a disinfection campaign on April 30, 2020 in Sana'a, Yemen. (Photo by Mohammed Hamoud/Getty Images)

COVID-19 in Yemen: A detonated bomb 

Five years of conflict have destroyed the already fragile public system in Yemen, while mass casualties and multiple outbreaks have dried up scarce health resources. Consequently, nearly 20 million people lack access to adequate healthcare. Only proactive and swift action can protect Yemenis during the COVID-19 pandemic, as one small step in bringing relief to the afflicted country.

Since December 2019, the SARS CoV-2 virus has spread to more than 213 countries and territories, resulting in more than 8.9 million confirmed cases and 468,000 deaths. Crisis-ridden communities are at a disproportionate distress under this pandemic. For war-torn Yemen, the COVID-19 outbreak is an evolving chapter in its tragic history.

Yemen is currently experiencing the world’s worst humanitarian crisis. Even prior to the eruption of the civil war, Yemen was ranked 153 on the Human Development Index (HDI), 138 in extreme poverty, and 147 in life expectancy. A confluence of conflict, famine, outbreaks, and floods, accompanied by widespread poverty, systematic corruption, severe economic decline, and poor governance has crippled the nation of 30 million. The far-reaching damage of the prolonged conflict has exacerbated pre-existing vulnerabilities and accelerated the collapse of public services.

Yemen was the poorest country in the Middle East and North Africa (MENA) region before the conflict even escalated, according to the World Bank. Poverty affects three-quarters of Yemenis. Per the UN, approximately 24.3 million people are in need of humanitarian assistance and protection, including 20 million who are food-insecure. An estimated 2 million children are acutely malnourished. The war has also displaced more than 3.65 million from their homes.

In addition to the 100,000 civilian fatalities that have been recorded, thousands more have died from malnutrition, disease, and poor health. Despite the dire living conditions in Yemen, UNHCR reported that around 275,000 refugees and asylum seekers have sought refuge in the country, fleeing violence and persecution mostly from Somalia and Ethiopia.

An exhausted health system

The Yemeni health system, which was already near collapse, has been subjected to airstrikes and artillery attacks targeting health care infrastructure, according to UNOCHA; with only half of the country’s medical facilities still in service, almost 20 million people lack access to adequate healthcare. Doctors are not available in nearly 20 percent of districts across the country; those working are often not paid for more than a year at a time. Furthermore, almost 18 million Yemenis do not have clean water or access to adequate sanitation. Consequently, the country is in the midst of the largest cholera outbreak ever recorded, resulting in more than 2.2 million suspected cases, with nearly 4000 deaths, half of whom were children.

According to UNOCHA, health facilities across the country were equipped with only 194 ventilators in total as of May 2 of this year. This represents a desperately short supply, usually occupied by other patients —especially in areas close to the fighting front lines—and cannot be dedicated to COVID-19 patients. For example, for the 3 million people, including more than 800,000 internally displaced people (IDPs) in the Marib governorate, local health authorities say that there are only 18 ventilators, which are always in service to those wounded in nearby conflict. Even before COVID-19 outbreak, the supply of ventilators was inadequate for the number of injured in this region, and patients requiring ventilators were sent to other governorates when possible. With the recent increase in supply of ventilators to 295 as of June 18, this quantity is still not capable of coping with the rise in COVID-19 cases and deaths and may still be used to serve casualties of war.

Reporting cases: the current numbers are only the tip of the iceberg

The first confirmed case of COVID-19 in Yemen was announced in Hadramaut on April 10, 2020, and another five new cases were reported on April 29. As of June 21 the national number of confirmed cases has risen to 941, with 256 deaths.  On May 31, 2020, Medicines Sans Frontieres (MSF) reported 279 patients admitted to its center in Aden, at least 143 of whom have died. At 31 percent, and 51 percent respectively, these reports would indicate the worst case fatality rates worldwide. However, conflicting data reports from the various governmental and non-governmental sources prevent a clear understanding of true numbers.

The case fatality rate could be falsely high in part, due to inadequate testing and underreporting; the number of actual cases is likely considerably higher. Unfortunately, the fatality data is also misrepresented, as it neglects those dying without ever reaching a hospital, potentially severely under-representing death toll due of COVID-19 in the country.

An insufficient humanitarian response

Any response to COVID-19 will be hamstrung by system failings. In the nation of 30 million, there are only six laboratories with COVID-19 testing capacity and at the time of this publication, only 20,000 testing kits have been distributed across the country. In many regions in Yemen, such as Marib, a lack of PCR machines means potential cases are managed only on symptoms. If CT images are required for radiologic diagnosis, the patient must be transferred to a hospital with a CT scan, impairing timely diagnosis and intervention, while risking transmission of the virus between hospitals. In select cases, collected samples are sent to neighboring governorate Hadhramout for PCR testing, at least a six to ten-hour drive. Routes, with dozens of armed checkpoints and security challenges, make the transfer of samples extremely difficult and only rarely clinically useful; patients are often dead or recovered before results are available.

Management strategy: What has been done to date?

To mitigate the COVID-19 outbreak over the last few weeks, the local authorities in many governorates have imposed partial curfews. Additionally, several governorates have closed their borders to travelers from other areas. However, imposing the recommended preventive measures, including social distancing, hygiene, quarantine, and isolation could be impossible in conflict settings like in Yemen.  The pandemic has not stopped the ongoing clashes ravaging the country while humanitarian needs continue to increase sharply, exacerbating the existing vulnerabilities and accelerating the collapse of public services. Yemenis are left with the choice of remaining hungry in quarantine or risking exposure to seek food.

Unlike countries employing public use of masks, the acute shortage of Personal Protection Equipment (PPE) in Yemen threatens rampant transmission; without PPE, healthcare providers are at higher risk not only to be infected but spread the virus to the community.

Yemen was hit relatively late by the pandemic, which allowed for a head start in planning. However, despite many promises by the international actors to improve humanitarian efforts, those plans remained on paper. Despite billions of dollars provided to Yemen as aid, funding to combat COVID-19 in Yemen has been far from adequate, and continues to erode. The World Health Organization (WHO) has reduced top-up payments to thousands of healthcare workers across Yemen, even as COVID-19 is spreading.

Humanitarian actions are urgently required

A comprehensive multisectoral strategy is required as the spread of COVID-19 seriously threatens populations across the country. This strategy should not only address the fulminant outbreak but also alleviate the mounting social, economic, political, and security crises that have already devastated the lives of millions prior to the pandemic.

Based on lessons learned from the earliest-hit countries, urgent humanitarian response may mitigate the impending health catastrophe. Well-managed countries have proven that travel restrictions reduce spread; this might occur with improved surveillance, which would include screening questions at all border crossings, especially the only remaining international airports, Aden and Sayoun, and functioning ports. Intensifying social campaigns at a national level to raise awareness among the general population on prevention strategies empowers individuals to control their own risks. Other COVID-19-specific efforts facilitated by an urgent increase in funding from international organizations and donors should include: increasing the testing capacity by supplying all governorates with PCR machines, adequate test kits, provision of sufficient PPE (at the very least for health care workers, but should be distributed widely in the community especially for high risk groups), and strengthening the reserve of local medical providers through incentives, along with training on COVID-19 response and management.

Unlike the pandemic responses in other countries, however, the response in Yemen must include more than just fortification of health systems. It is imperative that all conflicting parties adhere to the international calls for a ceasefire to allow humanitarian and healthcare workers to respond to the outbreak. Social services, food, water, and sanitation infrastructure must be rebuilt and maintained. Intensive resources should be directed to particularly vulnerable populations in IDP and refugee communities, as well as prisons and detention facilities. These measures, in Yemen and in other conflict affected countries, are essential in avoiding a potential second wave of the pandemic.

The tragic situation in Yemen makes the impact of COVID-19 outbreak potentially significantly worse than other places, and it could threaten global health security. The pandemic exposes Yemen to not only a health system collapse, but further social, economic, and political deterioration. Every effort should be made to combat this outbreak everywhere, but particularly in conflict-affected areas that come with their own challenges. Recovery will only be possible with heavy international support in improving the lives of Yemenis during the COVID-19 and in the future.