Yemen conflict takes its toll on civilians

Abstract

International agencies say that the health situation facing thousands of people displaced by repeated bouts of fighting in Yemen is becoming increasingly desperate. May Meleigy reports.Yemen is facing a growing humanitarian crisis due to the ongoing civil war between the government and Shia-Al Houthi rebels, in the northern governorate of Sa'ada.Despite several attempts at peace, there have been six episodes of fighting since the beginning of the war in 2004, and the latest episode in August, 2009, has led to an additional displacement of several thousands of people. Irshad Shaikh, regional adviser for emergency preparedness and humanitarian action in WHO's Regional Office for the Eastern Mediterranean Region (EMRO), said that these internally displaced people (IDP) have undergone repeated displacements, which “has led to exhaustion of their coping capacities due to loss of their livelihoods and assets”. Furthermore, as food, water, sanitation, shelter, and health-care needs have become extensive, he added, “the population is on the brink of disaster if the conflict is not stopped and a solution found”.The UN High Commission for Refugees, currently estimates the number of IDPs to be 200 000, which mainly includes women and children. Aanchal Khurana, communications and advocacy officer, emergency preparedness and humanitarian action, WHO EMRO, said “catering for the increasing number of IDPs and their increasing health needs is becoming more challenging, whereby prolonged displacement with no end in sight is making them more vulnerable to poor health outcomes and outbreaks of communicable diseases”. Although no outbreaks have been reported per se, the risk remains high and the disease surveillance system for IDP needs to be strengthened.The health problems encountered in the IDP are representative of diseases endemic in Yemen such as diarrhoeal diseases, malaria, respiratory tract infections, measles, meningitis, urinary infections, and skin infections (mainly scabies and rashes). Shaikh said that there has been an incremental increase in consultations for respiratory tract infections, malaria, and diarrhoeal diseases as more people are attending the mobile medical clinics that have been set up by WHO and the ministry of health in the IDP hosting governorate's of Al Jawaf, Hajjah, and Amran, along with a fixed clinic in Al Mazrak camp in Hajjah. Ben Abdallah Kamal from UNICEF said that because of ongoing fighting, the Sa'ada governorate is inaccessible to humanitarian agencies.The recent cold weather has further increased the incidence of respiratory chest infections and skin infections in internally displaced children in Sa'ada and Amran, where children make up more than 75% of the IDP population.WHO, in collaboration with the ministry of health, is supporting the routine vaccination of displaced children, against measles, whooping cough, meningitis, tetanus, and diphtheria. Shaikh said that “the paradox of conflict is that when an otherwise inaccessible population in remote areas are forced out of their homes in its wake, they usually gather at service delivery points in search of food, water, and shelter. This presents an opportunity to vaccinate them, which would have otherwise not been feasible due to difficult or no access.” The measles campaign also distributed vitamin A supplements to IDP both within and outside the camps.In response to the renewed conflict in August, 2009, the UN and the ministry of health established a health cluster approach to address the multidimensional nature of the crisis, with international and local non-governemental organisations and UN agencies being an integral part of the relief response. Most of the aid provided so far has been in secure and accessible areas and has included emergency education, food, health, shelter, water, sanitation, and hygiene. The health ministry is providing relief efforts or basic services to populations in Sa'ada.Kamal said that “UNICEF is the lead cluster in water, sanitation, and hygiene promotion field interventions (WASH) in Al Mazrak camp and is providing life-saving assistance to conflict affected populations and surrounding governorates of Amran and Hajjah and the host communities”.Yemen is one of the world's most water-stressed countries, with only 50% of an estimated 6·6 million urban population having access to public water systems, and 40% of an estimated 17 million rural population receiving a piped water supply. The access to potable water is even lower for the conflict-affected areas.The WASH programme included provision of chlorinated, reliable, and adequate potable water; improved storage facilities, distribution of hygiene kits and separate basins for jerry cans. It led to a substantial improvement in diarrhoeal diseases from 192 cases the first week to 105 in the fourth week. Each displaced person receives 20–30 litres per day, which is thought to be 100% coverage. Sanitation coverage also improved to almost 95% for 1200 families because UNICEF and OXFAM constructed 1150 latrines, installed 919 water filters, distributed chlorine tablets, installed 15 showers, and improved hand-washing facilities. 48 IDP volunteers were trained as hygiene promoters and as a result, water-related and sanitation-related diseases have greatly decreased in the general IDP community.UNICEF is also cluster leader for nutrition and in early October carried out a rapid assessment in Al Mazrak camp “tent by tent”, said Kamal. This screening found that of a total of 1074 children aged 6 months to 5 years, there were 10·6% with severe acute malnutrition, 19·5%, with moderate acute malnutrition and 30% with global acute malnutrition. By Oct 9, 2009, UNICEF started an outpatient therapeutic care centre to manage the severe and moderate cases of malnutrition.The IDP volunteers were also involved in screening children younger than 5 years for malnutrition, counselling mothers and families about appropriate nutrition and breastfeeding for children and babies, and following up of malnourished children managed by the outpatient centre. In early November, UNICEF launched inpatient care to target malnourished children with complications and in late November, the outpatient centre was handed to Médecins Sans Frontières, Spain, which is addressing malnutrition in Al Mazrak camp 1 and 2.Yemen has one of the worst malnutrition rates in the world with 42% and 15% of children younger than 5 years being moderately to severely underweight and severely underweight, respectively, according to a recent UNICEF report. Child malnutrition is the underlying cause for around 60% of mortality in children younger than 5 years (73 per 1000 livebirths). Malnutrition is also related to the high incidence of low birthweight (32%), low rate of exclusive breastfeeding babies, and high incidence of diarrhoea (seven episodes per child each year).Kamal indicated that there is no data for malnutrition in Sa'ada before the conflict but national data show that in children younger than 5 years, 42% are moderately to severely underweight, 15% severely underweight, and 12% have moderate to severe wasting, with stunting affecting half the population (53%). Around 48% of households are food insecure, and IDP is one of the most food insecure population groups in Yemen with Sa'ada and Hajjah having the highest food insecurity levels in the country. An interagency assessment done in September, 2008, in Sa'ada found 83% of adult IDP did not eat the entire day or were skipping meals daily, and most consumed small quantities of food of poor quality.The plight of IDP is further compounded by the influx of refugees from surrounding countries such as Ethiopia, Iraq and Somalia, which “are overwhelming an already under-resourced system”, said Aanchal. Sheikh said that, as of last week, the World Food Programme stopped giving food to south-central Somalia because of increasing insecurity, which might mean more Somalis seek refuge in Yemen. The country is already host to nearly 200 000 refugees, mainly in the south, most of whom are Somalis.The UN humanitarian response plan for Yemen is aimed to last from January to December, 2010, and is requesting US$177 428 417 to provide life-saving assistance to 1·4 million food insecure people, including 200 000 IDP and 162 362 refugees. In September, 2009, a flash appeal for $11·6 million was launched in response to the renewed conflict and, as of Nov 12, 2009, 50% was funded.“The pre-existing poor health indicators in Yemen coupled with its vulnerability to natural disasters such as floods and drought, poverty, water scarcity, food insecurity, high population growth rate, severe malnutrition, conflict in the north and refugees in the south, and the recent problem of access and security of health-care providers and donor fatigue, presents the humanitarian community with many challenges for relief efforts”, said Aanchal. International agencies say that the health situation facing thousands of people displaced by repeated bouts of fighting in Yemen is becoming increasingly desperate. May Meleigy reports. Yemen is facing a growing humanitarian crisis due to the ongoing civil war between the government and Shia-Al Houthi rebels, in the northern governorate of Sa'ada. Despite several attempts at peace, there have been six episodes of fighting since the beginning of the war in 2004, and the latest episode in August, 2009, has led to an additional displacement of several thousands of people. Irshad Shaikh, regional adviser for emergency preparedness and humanitarian action in WHO's Regional Office for the Eastern Mediterranean Region (EMRO), said that these internally displaced people (IDP) have undergone repeated displacements, which “has led to exhaustion of their coping capacities due to loss of their livelihoods and assets”. Furthermore, as food, water, sanitation, shelter, and health-care needs have become extensive, he added, “the population is on the brink of disaster if the conflict is not stopped and a solution found”. The UN High Commission for Refugees, currently estimates the number of IDPs to be 200 000, which mainly includes women and children. Aanchal Khurana, communications and advocacy officer, emergency preparedness and humanitarian action, WHO EMRO, said “catering for the increasing number of IDPs and their increasing health needs is becoming more challenging, whereby prolonged displacement with no end in sight is making them more vulnerable to poor health outcomes and outbreaks of communicable diseases”. Although no outbreaks have been reported per se, the risk remains high and the disease surveillance system for IDP needs to be strengthened. The health problems encountered in the IDP are representative of diseases endemic in Yemen such as diarrhoeal diseases, malaria, respiratory tract infections, measles, meningitis, urinary infections, and skin infections (mainly scabies and rashes). Shaikh said that there has been an incremental increase in consultations for respiratory tract infections, malaria, and diarrhoeal diseases as more people are attending the mobile medical clinics that have been set up by WHO and the ministry of health in the IDP hosting governorate's of Al Jawaf, Hajjah, and Amran, along with a fixed clinic in Al Mazrak camp in Hajjah. Ben Abdallah Kamal from UNICEF said that because of ongoing fighting, the Sa'ada governorate is inaccessible to humanitarian agencies. The recent cold weather has further increased the incidence of respiratory chest infections and skin infections in internally displaced children in Sa'ada and Amran, where children make up more than 75% of the IDP population. WHO, in collaboration with the ministry of health, is supporting the routine vaccination of displaced children, against measles, whooping cough, meningitis, tetanus, and diphtheria. Shaikh said that “the paradox of conflict is that when an otherwise inaccessible population in remote areas are forced out of their homes in its wake, they usually gather at service delivery points in search of food, water, and shelter. This presents an opportunity to vaccinate them, which would have otherwise not been feasible due to difficult or no access.” The measles campaign also distributed vitamin A supplements to IDP both within and outside the camps. In response to the renewed conflict in August, 2009, the UN and the ministry of health established a health cluster approach to address the multidimensional nature of the crisis, with international and local non-governemental organisations and UN agencies being an integral part of the relief response. Most of the aid provided so far has been in secure and accessible areas and has included emergency education, food, health, shelter, water, sanitation, and hygiene. The health ministry is providing relief efforts or basic services to populations in Sa'ada. Kamal said that “UNICEF is the lead cluster in water, sanitation, and hygiene promotion field interventions (WASH) in Al Mazrak camp and is providing life-saving assistance to conflict affected populations and surrounding governorates of Amran and Hajjah and the host communities”. Yemen is one of the world's most water-stressed countries, with only 50% of an estimated 6·6 million urban population having access to public water systems, and 40% of an estimated 17 million rural population receiving a piped water supply. The access to potable water is even lower for the conflict-affected areas. The WASH programme included provision of chlorinated, reliable, and adequate potable water; improved storage facilities, distribution of hygiene kits and separate basins for jerry cans. It led to a substantial improvement in diarrhoeal diseases from 192 cases the first week to 105 in the fourth week. Each displaced person receives 20–30 litres per day, which is thought to be 100% coverage. Sanitation coverage also improved to almost 95% for 1200 families because UNICEF and OXFAM constructed 1150 latrines, installed 919 water filters, distributed chlorine tablets, installed 15 showers, and improved hand-washing facilities. 48 IDP volunteers were trained as hygiene promoters and as a result, water-related and sanitation-related diseases have greatly decreased in the general IDP community. UNICEF is also cluster leader for nutrition and in early October carried out a rapid assessment in Al Mazrak camp “tent by tent”, said Kamal. This screening found that of a total of 1074 children aged 6 months to 5 years, there were 10·6% with severe acute malnutrition, 19·5%, with moderate acute malnutrition and 30% with global acute malnutrition. By Oct 9, 2009, UNICEF started an outpatient therapeutic care centre to manage the severe and moderate cases of malnutrition. The IDP volunteers were also involved in screening children younger than 5 years for malnutrition, counselling mothers and families about appropriate nutrition and breastfeeding for children and babies, and following up of malnourished children managed by the outpatient centre. In early November, UNICEF launched inpatient care to target malnourished children with complications and in late November, the outpatient centre was handed to Médecins Sans Frontières, Spain, which is addressing malnutrition in Al Mazrak camp 1 and 2. Yemen has one of the worst malnutrition rates in the world with 42% and 15% of children younger than 5 years being moderately to severely underweight and severely underweight, respectively, according to a recent UNICEF report. Child malnutrition is the underlying cause for around 60% of mortality in children younger than 5 years (73 per 1000 livebirths). Malnutrition is also related to the high incidence of low birthweight (32%), low rate of exclusive breastfeeding babies, and high incidence of diarrhoea (seven episodes per child each year). Kamal indicated that there is no data for malnutrition in Sa'ada before the conflict but national data show that in children younger than 5 years, 42% are moderately to severely underweight, 15% severely underweight, and 12% have moderate to severe wasting, with stunting affecting half the population (53%). Around 48% of households are food insecure, and IDP is one of the most food insecure population groups in Yemen with Sa'ada and Hajjah having the highest food insecurity levels in the country. An interagency assessment done in September, 2008, in Sa'ada found 83% of adult IDP did not eat the entire day or were skipping meals daily, and most consumed small quantities of food of poor quality. The plight of IDP is further compounded by the influx of refugees from surrounding countries such as Ethiopia, Iraq and Somalia, which “are overwhelming an already under-resourced system”, said Aanchal. Sheikh said that, as of last week, the World Food Programme stopped giving food to south-central Somalia because of increasing insecurity, which might mean more Somalis seek refuge in Yemen. The country is already host to nearly 200 000 refugees, mainly in the south, most of whom are Somalis. The UN humanitarian response plan for Yemen is aimed to last from January to December, 2010, and is requesting US$177 428 417 to provide life-saving assistance to 1·4 million food insecure people, including 200 000 IDP and 162 362 refugees. In September, 2009, a flash appeal for $11·6 million was launched in response to the renewed conflict and, as of Nov 12, 2009, 50% was funded. “The pre-existing poor health indicators in Yemen coupled with its vulnerability to natural disasters such as floods and drought, poverty, water scarcity, food insecurity, high population growth rate, severe malnutrition, conflict in the north and refugees in the south, and the recent problem of access and security of health-care providers and donor fatigue, presents the humanitarian community with many challenges for relief efforts”, said Aanchal.