COVID-19 in Yemen: A disaster rarely comes alone

Yemen was one of the very last countries to be hit by the COVID-19 pandemic. On April 10, the first case was detected in the eastern governorate of Hadramawt, and on April 29, a further five cases, two of them deaths, were announced in Aden. The South Yemeni port city would go on to become the epicenter of COVID-19 in the country, with 71 cases officially diagnosed by mid-May.

By July 9, 1,318 people in Yemen had been infected with the coronavirus, 351 of whom had died, according to figures from Johns Hopkins University. At first glance, these numbers do not seem to give reason to be too concerned, especially when compared with those in Europe or the U.S. However, the situation on the ground in Yemen is far more complex than the official numbers suggest.

The conditions in the COVID-19 treatment center in Aden, operated by the NGO Médecins Sans Frontières (MSF), give a better indication of the difficulties. The center received 279 patients from April 30 to May 31, 143 of whom died. Most of those who died were between 40 and 60 years old, which is a lower average than in Europe or the U.S. Many of the patients arrived at the center in acute respiratory distress, too late to be saved. It is believed that many more people have died at home without having sought treatment, as more sudden deaths than usual have been reported in South Yemen since early May. Normally, around 10 deaths are reported per day in Aden; however, in the first three weeks of May, 950 people died in the city. Due to a lack of testing kits, official reports lag far behind infections, although recent media reports suggest that the daily death toll in Aden has begun to fall of late, declining over the course of June.

Interlinked disasters

A disaster rarely arrives alone in Yemen, and Aden and the South Yemeni coast were hit by flash floods from a storm on April 21. These affected at least 150,000 people, claimed dozens of lives, and destroyed numerous homes and infrastructure. In early June, heavy rains again struck the southern governorates. In addition, the floods intensified the outbreak of already widespread diseases such as dengue fever, malaria, chikungunya, and cholera. The latter has been a particular issue in recent years. Since April 2017, at least 2,226 people have died and more than one million people have fallen sick from cholera in Yemen.

Since the outbreak of the war in 2015, the humanitarian situation in Yemen has been regularly labelled by the UN and the media as the worst man-made humanitarian crisis in the world this century. Today 80 percent of the Yemeni population — or around 24 million people — are dependent on humanitarian aid, and 10 million people are at risk of starvation.

Before the war, Yemen’s infrastructure (electricity, sanitation, garbage disposal, sewage, etc.) was already weak. However, since 2015, it has completely collapsed in large parts of the country. Likewise, the health system has suffered enormously from the war. Health facilities and hospitals were destroyed in attacks, and the facilities that are still running lack basic equipment and medical personnel, especially in rural areas. As a result, the Yemeni population is highly susceptible to diseases today due to a weaker average immunity brought about by the effects of war. In the past, however, even widespread diseases like dengue fever, malaria, and cholera did not result in as high a number of deaths in such a short time as is currently being observed in South Yemen.

Old and new structural challenges

On May 14, the UN’s acting assistant secretary-general for humanitarian affairs and deputy emergency relief coordinator, Ramesh Rajasingham, briefed the UN Security Council on the humanitarian situation in Yemen. He emphasized that, due to cumbersome government processes that, at times, interfere with the independence of aid, “Dozens of NGO projects have gone months waiting for approvals in the south, effectively blocking $100 million in donor funding.”[1] This was one of the many explanations cited by the Southern Transitional Council (STC) in its declaration of self-administration in the South Yemeni governorates on April 25. According to the declaration, however, the floods in South Yemen and the subsequent lack of aid and support from the government of President Abed Rabbo Mansour Hadi were the decisive factors.

The STC has set up various accounts at the National Bank of Yemen, to which customs revenues and other sources of income have been redirected by local institutions and authorities. According to the STC, this measure is designed to safeguard the income from government corruption and to apply it directly to the provision of basic services and salaries that have not been paid for several months.

Although the Hadi government has described Aden as an “infested city,” the government nevertheless tried to push its troops from Shoqra in eastern Abyan toward Aden in May and June, hoping to capture it from the STC. STC-aligned troops have prevented them from advancing, however. These moves have been made despite the Saudi-led coalition’s announcement on April 9 of a one-sided, nationwide cease-fire in response to the call by UN Secretary-General António Guterres for a global cease-fire during the pandemic. With the Hadi government’s actions, and the Houthis’ outright rejection of the cease-fire, ongoing military escalation continues to hinder a unified effort to control the pandemic across the country. Since the end of June and due to renewed talks in Riyadh, a cease-fire has been achieved between government troops and STC-aligned forces in Abyan.

On the verge of collapse and facing problems

On April 22, the STC called for an urgent international response to address the consequences of the flooding and COVID-19, warning that southerners cannot combat crises on three fronts: the conflict, the pandemic, and the floods. Taking measures to limit the outbreak on April 29, the STC has intensified its ongoing efforts toward a comprehensive COVID-19 response. In preparation for the arrival of the virus, it had already been coordinating with international organizations and the UN to secure medical and testing supplies, and had been working to establish a quarantine isolation center in Aden. It also implemented a public health campaign and has focused its international work on campaigning for more foreign aid to halt the spread of COVID-19.

However, aid has been limited due, in part, to humanitarian organizations’ restricted access to the country, visa delays for international staff, the continuing enormous uncertainties, and military escalation across the country. In addition, the sea, land, and air blockade by the coalition is preventing the quick import of relief supplies, which has now been made more difficult by further border closures in other countries due to pandemic restrictions. The UN and the World Health Organization (WHO), in particular, also lack the funds to continue their operations in Yemen. The humanitarian response for Yemen in 2020 requires more than $3.2 billion in total; however, at the High-Level Pledging Event in Riyadh held on June 2, only $1.35 billion was pledged of the $2.41 billion needed to cover essential humanitarian activities, including COVID-19 response, between June and December, leaving a gap of more than $1 billion.[2]

The humanitarian problems in Aden and the surrounding areas intensified so significantly in May that South Yemeni civil society organizations have called for help from international organizations and the UN. That same month, Dr. Abdulnasir al-Wali, professor of medicine at the University of Aden, member of the Presidential Council of the STC, and head of its emergency committee, expressed deep concern that, after decades of neglect of the health system by the central government and the destruction caused by the war, there has been no support, bare essentials are lacking, and without outside assistance, the situation is unsustainable. To address these serious grievances and help rebuild the health sector, the self-administration formed a health committee, which is in contact with hospitals, cooperates with local representatives of the Ministry of Health and the Health Office in Aden, and tries to expand relations to international organizations to facilitate their access to the country. What the STC can do depends heavily on whether the international community is willing to work with it, and if it will step up to provide support and aid.

After a number of medical personnel died in Aden due to a lack of personal protective equipment, some private hospitals have stopped accepting suspected COVID-19 patients, and it has been reported that some doctors have refused to work, fearing infection. The situation is even more precarious in rural areas. The case fatality rate of coronavirus patients had been alarmingly high in Yemen, at over 25 percent, five times the global average. According to a field report by university professors of medicine and officials with the Health Office in Aden, there was a decrease in patients coming to the city’s two COVID-19 isolation centers by the end of June. Nevertheless, fatality rates remain very high and have even increased. For example, in the al-Amal isolation center in al-Buraiqa, the fatality rate rose from 41 percent in May to 48 percent in June because people came too late with acute respiratory distress.[3] People have been watching scenes of overcrowded European hospitals on TV, which has aroused fear of and speculation about the virus, leading to a social stigma around COVID-19, which is preventing them from seeking treatment.

Further problems include shortages of testing kits and the spread of other diseases with similar symptoms, like dengue fever, which makes detection of COVID-19 exceedingly difficult without testing. Furthermore, the measures taken by the STC and local authorities to slow the spread of the pandemic have sometimes been met with extreme fear or reluctance by the population. Vendors have protested the closure of their shops, fearing the loss of income. Curfews are difficult to enforce, because many households lack clean water and electricity. Furthermore, extended families live close together in narrow spaces, where infection spreads easily. Due to the lack of medical personnel, relatives accompany their sick family members to hospitals and take care of them, which increases the risk of infection for the entire family.

Poor prospects for the disadvantaged

“Catastrophe unfolding in Aden’s only COVID-19 treatment centre” was the title of a press release issued by MSF on May 21. It was essentially a cry for help and ends with the words of Caroline Seguin, operations manager of MSF for Yemen: “We are doing all that we can, but we cannot face this virus alone. It would be unconscionable for the world to just leave Aden and the rest of Yemen to face this crisis by themselves.”

Recent months have shown that countries with much better-equipped health systems than Yemen are having, or have had, enormous problems in slowing and containing the pandemic. As a result, one can imagine the effects the disease will have in Yemen. Even with mitigation measures, the WHO projects that 55 percent of people in the country will be infected, 42,000 will die, and over 292,000 will require hospitalization. Given the lack of funding and the massive deficits in the health system, it may already be too late to effectively contain the virus in Yemen. In Western countries, it is said that the pandemic will primarily affect the sick and the aged; however, globally, it will be the poorest and most disadvantaged countries that will suffer the most from this pandemic.

Anne-Linda Amira Augustin is a political advisor in the European Representative Office of the Southern Transitional Council, a non-resident scholar at the Middle East Institute in Washington, and a founding member of the Academic Forum Muhammad Ali Luqman. The views expressed in this piece are her own.