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Armed conflict alone does not explain the devastation of Yemen’s health system
  1. Tayseer AlKarim1,
  2. Aula Abbara2,
  3. Bothaina Attal3,4
  1. 1Center on International Cooperation, New York University, New York, New York, USA
  2. 2Department of Infection, Imperial College London, London, UK
  3. 3Cambridge Judge Business School, Cambridge, UK
  4. 4Sana'a Medical School, San'a, Yemen
  1. Correspondence to Dr Aula Abbara; a.abbara15{at}ic.ac.uk

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Summary box

  • Armed conflict alone in Yemen cannot explain the devastating humanitarian situation with other, non-conflict factors also culpable.

  • The traditional role of the central government has been incapacitated and replaced by an archipelago of proto-states.

  • Fragmentation, poor coordination, poor transparency and weak governance have adversely affected the humanitarian response.

  • The mandate of the United Nations (UN) to operate through the governmental framework is invalid in the modern armed conflict and it needs to be developed.

  • The ongoing conflict has created war-business dynamics that further systemised the corruption and patronage networks in the country, which in turn has deprived Yemenis from equal and dignified access to humanitarian aid.

  • Giving a voice to affected communities is a critical concept for provision of ideal healthcare in the armed conflict zones.

Driven by the prolonged internal conflict, external aggression, economic decline and scarcity of resources, Yemen faces the world’s worst humanitarian crisis.1 The ongoing violence has played a fundamental role in shaping this humanitarian crisis. However, violence alone cannot account for the extent of suffering across the country and the collapse of the health system; other factors need to be considered with the aim of drawing strategies to respond to the present and future health and humanitarian needs.

Background to the conflict

Half a decade of relentless hostilities between state and non-state actors, backed by regional and international powers, have devastated the lives of millions of Yemenis and put the country on the brink of total collapse. The civil war ignited in March 2015, when a coalition of states led by Saudi Arabia and the United Arab Emirates (UAE), with support from the USA, intervened to restore the interim president Abdrabbuh Mansur Hadi to power. Today, a complex web of ‘proxy relationships’ fuel this war—from the UAE’s support of separatists in the south, to Saudi Arabia’s support for the internationally recognised government, and Iran’s covert assistance to the Houthis in the Northwest. These intertwined political interests have prolonged and increased the complexity of the conflict in Yemen.2

Despite concerns from human right groups about the humanitarian crisis in the country, overlapping local, regional and western interests continue to fuel the war and its economy. The long-term impacts of the protracted armed conflict in Yemen are vast and place it among the most destructive conflicts since the end of the Cold War.3 Over the last 5 years, almost a quarter of million deaths have occurred as a direct and indirect result of the conflict4; this includes over 12 600 civilians killed in targeted attacks.5 Of the dead, 60% are children under the age of five.3 According to the United Nations (UN), if the war continues to 2022, mortality could exceed 480 000 deaths with an estimated 330 000 deaths of children under 5 years old.3 The conditions Yemen faced shortly after the onset of the armed conflict share similarities to the situation in other Middle East and North Africa (MENA) region countries after several years of armed conflict as in Syria or Libya. Although the contexts of these armed conflicts differed at baseline, the dynamics of violence, involvement of regional and international players, and the acute fragmentation in public institutions bear similarities.

Our aim was to highlight the different political, governance and humanitarian factors that influence the humanitarian space in Yemen and have contributed to the fragility of the health system.

Politics and broken trust

During the course of the armed conflict in Yemen, the political interests of the warring parties have fractured the country into subnational conflicting entities. Consequently, the traditional role of the central government has been incapacitated and replaced by an archipelago of proto-states, resulting in fragmentation of public institutions including the health system. The Yemeni territories are currently controlled by three major conflicting parties, the Internationally Recognised Government, the Houthi Movement and the secessionist Southern Transitional Council (STC). The emerging entities in Yemen have been mostly formed based on political or tribal loyalties, making the future of many Yemenis unequally dependent on which area they inhabit or which loyalty they can offer. In addition to these three major powers, many Yemeni areas are still controlled by local groups or tribes. Although the Houthi Movement and STC have not been officially recognised by the international community, they have taken over wide territories in both the south and north Yemen (see figure 1). With their military gains, they represent difficult figures in Yemen’s present and future, further complicating the political, humanitarian and development crisis.

Figure 1

This map shows the political and territorial divisions in Yemen as of June 2020. (Credit: Crisis Group.)

The political instability in Yemen has deepened the mistrust environment, especially between the controlling authorities and both local and international organisations. Humanitarian operations and personnel are submitted to stringent security checks and mobility restrictions which hampered their access and reach.

Widespread food insecurity

Eighty per cent of the population in Yemen, including 12 million children, requires humanitarian assistance and protection; two-thirds of the population do not know if or when they will eat another meal.6 The number of malnourished children could reach 2.4 million by the end of 2020. This would represent half of the children under five in the country.7 Out of the estimated 3.3 million malnourished children in the country, 1 million suffer from moderate acute malnutrition and over 400 000 from severe acute malnutrition,3 90% of them could die unless they continue to get treatment.8 Food prices were already climbing prior to 2015, leaving much of Yemen’s population especially vulnerable. Food insecurity has been further exacerbated by the naval and air blockade imposed by the Saudi-led coalition since 2015, which has severely restricted the flow of food, fuel and medicine to civilians.9

The ongoing conflict has created war-business dynamics that further systemised the corruption and patronage networks in the country, which in turn has deprived Yemenis from equal and dignified access to humanitarian aid. For example, food assistance provided by the UN has been diverted to areas controlled by Houthis; this has been highlighted by the World Food Programme executive director who said that “the stealing of food from the mouths of hungry people, at a time when children are dying because they do not have enough food to eat … is a criminal behavior [which] must stop immediately”.10 However, systematic and organised abuse of humanitarian aid is not limited to one party of this conflict.

Weakened leadership and governance

Although insecurity and violence have hindered many humanitarian operations around the country, other areas such as Hadhramout, which have been relatively unaffected by active warfare, have seen the same deterioration in its humanitarian situation. This is likely as a result of poor leadership and health governance. From an operational perspective, Hadhramout governorate could play a vital role in responding to the needs not only for its population but also for other areas. Hadhramout contains one of the only two functioning international airports in the country. Furthermore, its infrastructure (especially healthcare facilities) were not as damaged by warfare, making it a potential location for medical or humanitarian interventions including for complex cases which are currently being evacuated out of Yemen. With better leadership, political will and guarantee of beneficiaries’ safety, Hadhramout could serve as a strategic theatre for medical interventions, where, for example, international and local medical teams can cooperate to provide advanced healthcare services such as complex surgeries or even building the capacity of local teams through medical training.

Changing the humanitarian space

Similar to other armed conflicts in the MENA region, Yemen provides another example where the UN is not only challenged by underfunding or inaccessibility or non-cooperation, but more importantly by interpreting its problematic mandate to operate through the ‘governmental framework’. The engagement of humanitarian and civil society organisations in prioritising the intervention strategies is still minimal. On the other hand, the potential role of the private health sector is underestimated. Private healthcare facilities were excluded from the support delivered by the international organisations including supplies, equipment and relevant training opportunities. Consequently, an unequal pattern of healthcare provision is still dominant, especially rural areas.

The role of the UN’s humanitarian operations cannot be underestimated in a place where brutality at the scale seen in Yemen, but its mandate—in the current form—is unsuited to deal with modern conflict dynamics, especially with the accelerated fragmentation among central governments, or their direct involvement in armed conflicts within their borders.

Recommendations and conclusions

For too long, the role of local populations has been underestimated or ignored, augmenting health disparities. Giving a voice to affected communities is possibly the most critical concept for provision of ideal healthcare in the armed conflict zones. Local humanitarian and civil society organisations and marginalised groups must all be decision-makers in short-term and long-term strategies. In addition, the role of the private health sector most be promoted, especially during emergencies and disease outbreaks given their contribution to the health system. Revising the mandate of the UN’s humanitarian interventions is critical, particularly in war zones, where some governments are directly involved in the armed conflict.

There is no easy solution for Yemen’s devastating crisis, but as in medicine, an accurate diagnosis is essential for appropriate management. A ceasefire and funding allocated to humanitarian operations are critical to pull Yemen back from the vicious cycle of vulnerability and fragility. However, the humanitarian plight requires a new and comprehensive approach to be considered; this includes not only tackling the direct impact of violence but also the impact of institutional factors. Failing to do this will make whatever solution a symptomatic remedy rather than a true therapy.

References

Footnotes

  • Handling editor Seye Abimbola

  • Twitter @AulaAb

  • Contributors TA conceived the idea and worked with AA to produce the first draft. TA, AA and BA all heavily edited the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data availability statement There are no data in this work.

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