When Abdulla Bin Ghooth saw the computed tomography scan of the lungs of a colleague’s brother in Aden, Yemen, in April, he knew the outlook was grim. The 55-year-old man had complained of a fever and shortness of breath, and likely had COVID-19. But hospital staff, afraid of the novel coronavirus, sent him home with an oxygen cylinder, says Bin Ghooth, an epidemiologist at Hadhramout University College of Medicine. He pleaded with friends at the ministry of health to intervene, to no avail. The colleague’s brother was never tested for COVID-19 and died at home 3 days later.
Perhaps no country is more vulnerable to COVID-19’s depredations than Yemen. Even before the virus’ arrival, the country was grappling with “the largest humanitarian crisis in the world,” as a result of a civil war now grinding into its sixth year, says Jens Laerke, a spokesperson at the United Nations Office for the Coordination of Humanitarian Affairs. Yemen has 3.6 million internally displaced people, scores of attacks have left half of the nation’s medical facilities in tatters, and a cholera outbreak has sickened some 2.3 million Yemenis, killing nearly 4000. The United Nations classifies nearly one-quarter of the population of 30 million as malnourished.
And now, after staging massive aid operations in Yemen over the past few years, the United Nations is running out of cash as donations from member countries—busy battling COVID-19 on their own turf—dry up. “Tragically, we do not have enough money to continue” the relief work, the heads of the World Health Organization (WHO), UNICEF, and other U.N. agencies write in an urgent call to donors issued today. “COVID-19 could be the straw that breaks the camel’s back,” says Abdulwahed Al-Serouri, technical adviser to the Yemen Field Epidemiology Training Program run by the health ministry in Sana’a.
The United Nations and Saudi Arabia are cohosting a virtual pledging event on 2 June. If that fails to drum up support, Laerke warns, “The world will have to witness what happens in a country without a functioning health system battling COVID-19. I don’t think we’ll want to see that.”
Yemen reported its first COVID-19 case on 10 April in a port town in Hadhramout governorate; authorities closed schools days later, and mosques posted signs asking people to pray 1 meter apart. Official case numbers remain low: As of 27 May, the country had reported 253 cases and 50 deaths. That’s hard to square with reports of mass graves being dug in Aden, the capital. On 21 May, Doctors Without Borders reported at least 68 people had died from the virus at its facility in Aden alone, and that scores more were dying at home.
In Sana’a, the former capital where Houthi rebels, aligned with Iran, have set up their own government, the rebel health ministry has so far reported just four COVID-19 cases. But Al-Serouri says there are unofficial reports of hundreds of laboratory-confirmed cases. The rival health ministries in Aden and Sana’a “each accuse the other of lying about the extent of COVID-19 in the areas they control,” says Hakeem Al-Jawfy, a critical care and respiratory specialist at Al Thawra Modern General Hospital. Altaf Musani, an epidemiologist who heads WHO’s office in Yemen, says one problem is that official tallies only reflect severely ill patients in COVID-19 isolation wards. People with mild or moderate symptoms—not to mention asymptomatic individuals—are simply not getting tested.
The fuse for a calamity has been lit. “We have at least nine clusters showing active transmission in the south,” Musani says. Earlier this week, during a monthlong ceasefire in much of the country, revelers celebrating Eid, the festival marking the end of Ramadan, thronged markets. “Many people are going about their lives unconcerned and unaware of danger,” says Abdul Rahman Al-Azraqi, a physician and former hospital manager in Taiz.
Based on modeling by a group at Imperial College in London, WHO is bracing for the novel coronavirus to infect about half of Yemen’s population and kill an estimated 30,000 to 40,000. But the toll could be much higher if the United Nations can’t replenish its coffers. Last year, the agency spent $4 billion on humanitarian efforts in Yemen. Nearly halfway into 2020, it has received only $700 million. “Of 41 major UN programs in Yemen, more than 30 will close in the next few weeks if we cannot secure additional funds,” today’s letter from U.N. agency heads says. “This means many more people will die.”
Yemen is facing the crisis after a conflict-driven brain drain hollowed out its ranks of doctors and scientists. In 2011, the Arab Spring stoked a revolution that ended the 33-year rule of President Ali Abdullah Saleh. Fighting broke out in March 2015. Yemen “took a hard hit at the start of the war,” says Hilal Lashuel, a neurobiologist at the Swiss Federal Institute of Technology Lausanne who left Yemen in 2005. “Many Yemeni scientists fled. I don’t believe there’s any serious research activity now.”
“Oh, it’s so sad. The political and security situation has eviscerated the country,” says Mustafa al’Absi, a Yemen-born neuroscientist at the University of Minnesota who led a National Institutes of Health–supported project in Yemen on mental health and substance abuse until 2014.
Deprived of government subsidies, hospitals have sought to prop themselves up by charging more, which put medical care out of reach for poorer patients. Before 2011, people had to pay at most 10% of the cost of procedures, Al-Jawfy says. “Now they pay 100%.” Humanitarian groups have provided basic medicines such as adrenalin, and some protective equipment, Al-Jawfy adds. But his hospital’s MRI machine hasn’t worked in 4 years, he says. He contends that Saudi customs officials seized a shipment of spare parts on the grounds they could be used in missiles. “Most of our ventilators are out of order. No spare parts,” he adds. Only 157 of Yemen’s 500-odd ventilators are working, Laerke says.
WHO has worked to bring into Yemen more ventilators, intensive care unit beds, and other critical supplies as part of its effort to expand the number of COVID-19 isolation wards from 38 to 59 nationwide. And WHO has provided 8400 test kits—a down payment on the estimated 9.2 million kits the organization forecasts the country will need. The government in Sana’a now has a COVID-19 advisory committee that includes representatives from the Yemen Field Epidemiology Training Program, which is also staffing a new COVID-19 hotline. However, notes Nasser Zawia, a Yemen-born pharmacologist at the University of Rhode Island, Kingston, “There is no Tony Fauci of Yemen,” referring to the head of the U.S. National Institute of Allergy and Infectious Diseases.
One asset in the battle against COVID-19 is a legacy of Yemen’s attempts to quell its cholera outbreak, the largest ever recorded. To run down leads and rumors of suspected cholera cases, the United Nations trained rapid-response teams in all of Yemen’s 333 districts. These health care workers, Musani says, are “playing a pivotal role” against COVID-19, sleuthing for suspected cases, contact tracing, and getting samples back to labs in Aden, Mukalla, Say’un, and Sana’a for virus testing. “They’re the real heroes,” Musani says, adding that the United Nations now aims to double the number of rapid-response teams.
This small army on the front lines of Yemen’s existential crisis has its work cut out for them. “Tackling COVID in Yemen,” Lashuel says, “is almost mission impossible.”