MacEachron S and Watt P. An epidemic within a pandemic: the impact of COVID-19 on substance use in the United States. HPHR. 2021;48.
After only a few months of the first outbreak in Wuhan where scientists identified (SARS-CoV-2) the novel respiratory syndrome coronavirus-2, the world health organization (WHO) declared Coronavirus (COVID-19) an international public health emergency case and a worldwide pandemic on March 11, 2020. This pandemic eventually reached Yemen, with the first laboratory-confirmed case announced on 10 April 2020, in Hadhramaut, the southern province of Yemen in a 60-years old patient.1 The World Health Organization (WHO) recorded 6981 active cases, and 1368 deaths by 19 July 2021.
Before the international crises resulting from COVID-19, Yemen was subjected to a number of various internal and external issues. A decade of economic and political crisis and over five years of war has extremely devastated the country. Furthermore, a hotspot Integrated Food Security Phase Classification analysis issued in July 2019 showed 1.2 million people in the 29 analyzed districts were in severe acute food shortages.2 According to the United Nations (UN) an estimated number of about 24 million people, almost 80% of the population needs all kinds of aid in Yemen. Humanitarian aid from countries has become the basis of survival for hundreds of thousands of Yemenis after the threat of famine. COVID-19 has contributed to an increased risk of the existing famine threat and with the ongoing war; little can be done to prevent contraction of the virus. Although the official COVID-19 cases in Yemen are, considered low compared to other Middle East countries, this is due to many non-operational airports and transportations networks in Yemen because of the civil war.3
Another possible reason could be the lack of medical kits like PCR, which does not allow the confirmation of cases.4 The United Nations estimates that around 3 million people suffer from starvation because of the coronavirus pandemic.5 An analysis from WHO suggests that the economic impact of COVID-19 in poor countries will be more devastating than the disease itself, which is evident in Yemen due to the global restrictions of COVID-19, food imports are scarce and other needs for cars and factories like petrol and diesel are unavailable.6
Many factors have increased the crisis in Yemen and its dependence on external humanitarian aid including the violent civil wars since 2015 and their continuous effects until now. The current situation in Yemen is severely ravaged because of the civil war, and the country is divided between conflicting parties. Some regions are in control of the legitimate government, some are in the control of Houthi rebels, and some under the control of other parties that leads to difficulties in conducting effective research about the current situation.7 Alongside this, the civil and medical infrastructures are very poor, the economic blockade and transportation networks are not operating efficiently. The lack of electricity has led to dependence on generators and fuel that require exorbitant costs; therefore, food distribution, water supply, access to health services and basic facilities have been officially suspended.4
A neglect of global factors in terms of health, nutrition and spread of malaria and cholera increased Yemenis’ vulnerability to famine and infectious diseases during the pandemic. The devastation of the pandemic to developed countries leaves no doubt about the detrimental effect it would leave in a war-torn country like Yemen. A surge in unemployment and late salary payments leaves families with no income to feed their families especially in the Houthi control regions. The lack of children’s education also prevents financial security for future generations.
Yemen was the last Arab country, which confirmed its first case of COVID-19 as BBC; British Broadcasting Corporation indicates this case emerged in Yemen after the ceasefire between the Houthis and the Saudi-led coalition. The United Nations indicated the effects of COVID-19 to be a disastrous as Yemen is already suffering from civil war, scarcity of food and deficit water supply.4
The continuation of the civil war between parties in Yemen has led to this catastrophic situation to the extent an individual is most likely to die from starvation or infectious diseases if not from Covid-19 or the war. Furthermore, conflicts have taken a heavy toll on the infrastructure with lack of health services, electricity, fuel, food and water supply, depletion of reservoirs and a collapse of the country’s networks.8
External humanitarian aid for Yemen is terribly scarce; most of the time aid does not reach the homes of the affected families. About 20 million people are suffering from the crisis, due to disrupted supplies and funding, however, only 8.5 million beneficiaries receive WFP; World Food Programme aid every two months.5
Restrictions imposed by both the Saudi-led coalition and the Houthis prevent the distribution of humanitarian supplies and commercial imports, denying the basic human rights of the affected population.17
During the civil war, The Saudi-led coalition attacked a bridge connecting the Hodeida port to the capital of Yemen, Sana’a, which is used to carry 90% of food supplies donated by the UN. Human Rights Watch (HRW) highlighted the destruction of Yemen’s economic infrastructure such as factories, warehouses, power plants, etc by the Saudi-led coalition.17
The Houthi forces also planted sea mines in the Red Sea, which could be a harmful threat to humanitarian organizations whilst delivering supplies through Red Sea ports.17 Political pressure from the international community should force both the Saudi-led coalition and the Houthis to lift their blockades to allow the accessibility of humanitarian assistance.17 As long as the war continues and the lack of food supply continues to exhaust the population, attempts for fundraising and humanitarian assistance for Yemen are still futile.17
The Saudi led coalition and Houthis have disregarded the policy expecting them to lift restrictions and blockade. Therefore, Yemeni people have to rely on themselves, and citizens living abroad including politicians and political leaders by raising awareness among people, the international community, and humanitarian organizations about the deadly situation in Yemen. Most people in Yemen send their relatives to foreign countries to live a better life and get jobs, and rely on the money being sent to them, especially as employees’ salaries are not paid in the Houthi control regions. Another aspect that can be considered as way Yemeni people are helping themselves to overcome adversity is the wonderful social solidarity that distinguishes them, in terms of family, neighbors, and poor people.
People in Yemen are highly susceptible to infections due to the shortage of nutrition and the difficulty to access safe water and food. A low number of healthcare facilities, lack of hygiene and sterilization materials, and the increased spread of disease.3,10
Recent data provided to the UN indicated a rapid increase in the number of COVID-19 cases, with an alarming fatality rate of 20.8%.9 The actual official number of positive covid-19 cases is still considered low in Yemen, but the UN doubts there are up to one million people who have been affected without knowing because of the lack of testing kits.10
The UN published a report stating more than 200,000 people had been killed since 2015 due to conflict, famine, multiple diseases, and lack of basic services. Most Yemenis do not have the very basic needs to survive.11 1.2 million people have been suffering from acute food insecurity, including 2 million children under the age of five. Around 1.1 million pregnant and lactating women suffer from starvation, and more than 3.25 million women in Yemen face increased risks to health and protection.9
In addition, parties of the conflict and armed gangs banned the delivery of food, medical supplies, and other humanitarian aids, besides attacks on targeted hospitals and civilians as well as child recruitment.8
The impact of covid-19 on nutrition has left a harsh impact in Yemen, for example, people do not have jobs to feed their children and they are torn between staying at home to decrease chances of contracting the virus or starving to death.12 Some have already accepted the low-paid jobs just to meet their small basic needs to survive due to fearing the spread of Covid-19, while many others had to leave to villages, where the basic services are inadequate, especially after prices of food and water increased.12 Owing to the inflation of the Yemeni Riyal against the dollar, when Yemen’s economy collapsed.4 COVID-19 is affecting the ability to produce and distribute goods and crops, market supply and food delivery e.g. cereal production. This year it is 365000 metric tons, which is half the amount before the war.13 People in Yemen mostly depend on agriculture to obtain food, so the Integrated Food Security Phase Classification (IPC) urges for helping and supporting Yemenis with food, assistance, and rehabilitation of their lands, besides flood-damaged water infrastructure. In the shadow of the Coronavirus pandemic, aid-donating countries decided to reduce their supplies due to their fear that the aid would not reach the civilians and intended beneficiaries in the Houthi-controlled provinces.13
Most infectious diseases are spreading because of war, shortage of food and water and lack of hygiene. Cholera is an example of infectious diseases, it spreads where malnutrition and drought exist and sanitation and hygiene are very poor. Yemen is a vulnerable country to cholera, WHO estimated 200,000 of cholera cases in 2017.18
An estimated 14·5 million people do not have access to clean water and sanitation. The conflict has led more than 2.2 million displaced in temporary camps, where hygiene and waste management facilities, food supply are very poor. The country is at risk of famine giving them little defense against infections. Along with the difficulty of delivering supplies.18
In summary, these circumstances are ideal for cholera to take hold as well as what is happening with other outbreaks in Yemen.18
Famine is threatening Yemen and malnutrition is being recorded at high rates. Most of the cases of acute malnutrition are among children under five, specifically in the areas of conflict, one in four children is acutely malnourished. Yemen reached its peak of famine because of the ongoing civil war, economic crisis, environmental shocks, and spreading infections.19 As acute malnutrition gives rise to infectious diseases, the spread of communicable diseases could also be a major driver of soaring malnutrition.19
Heightened famine risk underlines the need for a holistic approach to prevent famine and infectious diseases, to strengthen resilience amid the conflict.19
There were many outbreaks of infections in 2020 including cholera, dengue, diphtheria, malaria, and COVID-19; conditions are not expected to moderate in 2021 due to the severe vulnerability of the population to infections, lack of capacity to contain the spread of diseases and provide treatment and vaccines by the governmental system. The health system is overwhelmed, many health facilities have been damaged or destroyed, and those that are operating are severely understaffed and unable to provide critical health services. Despite overcoming the most significant cholera outbreak epidemic in recorded history, Yemen still suffers from the underlying conditions that caused the outbreak and drive high morbidity and mortality levels.19 Thus, The COVID-19 pandemic poses a new threat to people in Yemen.
Which affected the aspect of nutrition and the economy. The restrictions imposed have posed a serious challenge in many areas. Despite access and security challenges, the World Food Program and its partners have been able to provide assistance to the vast majority of people in the country.15
The objective of the nutrition program has become to ensure the continuity of basic nutrition services through appropriate methods and enhanced communication strategies together with the Ministry of Public Health and Population and the Nutrition Cluster, UNICEF has led the development and dissemination of adapted feeding protocols.12
Data collected from January to November 2020 showed that nearly 3.6 million children under the age of five were screened for malnutrition, and 231062 severe acute malnutrition were treated without complications.12
In addition, 22,566 children under the age of five suffering from severe acute malnutrition with complications were admitted to 113 therapeutic feeding centers run in cooperation with the World Health Organization.12
About 24,648 Community Health Volunteers (CHVs) reached 8,750 hard-to-reach village health facilities (41 percent of the total targeted villages in the country) to provide integrated basic health and nutrition packages.12 Number of people facing high levels of acute food insecurity is expected to rise to 3.2 million in the south of Yemen. Food shortages will rise sharply in parts of war-torn Yemen in the next six months mainly because of the overall economic decline and the coronavirus pandemic that has ripped through the Arab world‘s poorest country, United Nations agencies have warned.16 A report by the World Food Programme (WFP), the UN Children‘s Fund and the Food and Agriculture Organization said the number of people facing high levels of acute food insecurity is expected to increase from two million to 3.2 million in the country‘s south.16 Coronavirus restrictions, economic shocks, conflict, reduced remittances, desert locusts, floods and significant underfunding of this year’s aid response have compounded an already dire hunger situation after five years of war.16
There is no sufficient research and accurate statistics about the health situation in Yemen, Therefore, the issue cannot accurately reach worldwide. Yemen is practically one of the poorest countries in the world. It has structural vulnerabilities that have developed over a protracted period of conflict, poor governance; also more than 50% live in starvation, or have just one meal a day. Thus, healthcare leaders and polices must give urgent aid very quickly.
Nusaibah Tawfik ALsanabani studies at Abdullah Gul University in the department of molecular biology and genetics.
Haya Mohammed Abujledan is an embryologist, researcher, and international trainer.
Ibrahim Ayman Abdullah is with Damascus University.
Mahmoud Bassiony is a Medical Student Researcher at Alexandria University. He is a Former Youth Ambassador at the Young Utopians, and co-founder and Head of the publishing committee at INNORES Int.