The Man-Made Health Crisis in Yemen Cannot Wait for the End of the War: What Can Humanitarian Actors Do?

In 2017, only a few years into a brutal civil war, Yemen reported a cholera outbreak of one million cases, more than half of which were children, making it the worst outbreak in history. At the time, Yemen was already in the midst of what was considered a dire humanitarian crisis, with more than 20 million citizens affected. A year later, the situation has become even more critical, with the United Nations warning of “the worst famine in 100 years” within the next few months if the war continues. Many more Yemenis have died from lack of access to basic needs, such as clean water, food, medical care, and sanitation, than fighting.

Yemen was already considered one of the poorest countries in the world before the war, with low rankings on all indicators of human development. However, the war has completely devastated the nation and the health of its citizens. Multiple outbreaks of infectious disease such as cholera and malaria, high rates of food insecurity and malnutrition, tens of thousands of trauma-related injuries, and widespread mental distress have exhausted the healthcare system. Almost 80% of Yemeni children reported symptoms of post-traumatic stress disorder, an exceedingly high rate even when compared to other conflict-affected nations. Healthcare workers, many of whom have been unpaid for months or years, have been kidnapped, harassed, and killed, while hospitals have been directly attacked and bombed. Medical facilities are left with barely functional equipment, empty supply shelves, and sometimes no medical staff at all. One article detailed how the grandmothers of an infant born four months premature brought him to a hospital where they found no physicians, who had all walked out in protest the previous day after one of them was beaten up by one of the hospital guards. The grandmothers attempted to place the infant into an incubator themselves, but both machines were broken.

In April 2018, as long-term wars in Syria, Iraq, Afghanistan, and South Sudan rage on, as a probable Rohingya genocide in Myanmar goes into its second year, and as natural disasters strike with increasing frequency and strength around the world, United Nations Secretary-General António Guterres called Yemen the world’s worst humanitarian crisis. The International Rescue Committee reports that 16 million people (almost three quarters of the country’s population) cannot access basic medical care, with more than half of the country’s already limited health facilities destroyed. What is left of the health system is Yemen is almost entirely sustained by contributions of medicines, supplies, and money by international donors. An estimated 9.5 million people were provided some form of medical intervention by the WHO and their partners in 2017 alone. However, the politics of the conflict have rendered even this emergency care inconsistent and unreliable. Médecins Sans Frontières (MSF) has occasionally had to cease providing services in some parts of the country due to sustained attacks on their facilities and staff by both Houthi fighters and Saudi warplanes. An intermittent Saudi blockade on Yemen’s ports has prevented humanitarian agencies from bringing in food, medicines, and fuel, and even when supplies can enter the country, distribution networks are insecure due to airstrikes and combatants. Like many of the world’s worst humanitarian crises, the devastating circumstances are almost entirely man-made. It is not lack of money or resources that has brought Yemen to this point- the entirety of the budget that the Yemen Ministry of Health proposed for 2018 amounts to just three days of what Saudi Arabia alone spends on the war campaign.

Yemen would not be the first country to see the health and well-being of its citizens used as a bargaining chip in an intractable conflict. Alex de Waal, a professor at Tufts University and the Executive Director of the World Peace Foundation, called these types of man-made famines and humanitarian emergencies “economic war,” which is much more difficult to classify under international humanitarian law than a violent bombing campaign or overt starvation tactics. “The coalition air strikes are not killing civilians in large numbers but they might be destroying the market and that kills many, many more people,” he told The New Yorker. Couple destroyed markets with ruined medical facilities and it is clear that the quality of life of human civilians will be devastated for the long term. This is by no means a new wartime strategy. Perpetrators try to bring their enemy -combatants and civilians who are in any way affiliated with them- to the brink of humanitarian desperation to force concessions.

What is needed is immediate and meaningful action on the part of the actors involved in the war as well as the international community that is both providing the weapons and aid that sustain the conflict. Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, outlined three requests to ease the humanitarian burden in the country. First, he called for guaranteed safe access throughout all of Yemen so that aid agencies can provide goods and services. Second, he demanded an end to all attacks on health workers and facilities. Lastly, he insisted that civilian health workers who remain in Yemen must be paid for their vital services. Similarly, a report by the International Peace Institute recommends that the international community, especially the UN Security Council, enforce compliance to international humanitarian laws and norms. Humanitarian actors must also work to coordinate their responses by sharing data, involving local stakeholders, and collectively pushing against blockade efforts. While meeting immediate needs is the clear priority, prevention and long-term health capacity building must also be pursued to both avert widespread catastrophe and prepare for the Yemen that will remain after the war ends. None of these actions must wait for a political end to the war, which is the only way to truly protect civilian life and ensure basic access to the human rights of food, water, sanitation, and health. However, these actions can push back against efforts by all sides of the conflict to use the health and well-being of Yemen’s citizens as pawns in the achievement of their aims.

 

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International Infection Prevention Week: Snapshot from the Field

 

 

During the last two weeks of September, I had the opportunity to participate in a week-long surveillance training and a week-long Ebola/Cholera Preparedness Training, respectively. Here at the CDC Zambia office I work with the Field Epidemiology Training Program. Our goal is to provide technical assistance and expertise in order to build local epidemiology capacity in Zambia. The surveillance training we conducted was geared towards surveillance officers that work in various districts throughout Zambia. These officers are accepted into a Frontline program as residents and trained on the public health surveillance cycle over the course of 3 months. The training is both classroom learning and hands-on application as residents are given projects that take them through the surveillance cycle and provide them with an opportunity to explore the data in their jurisdictions. My role during this first training was to lead excel trainings and assist with daily pre and post tests. I enjoyed the surveillance workshop so much that I feel a similar curriculum should be provided to all entry-level epidemiologists working in governmental public health in the states.

The Ebola/Cholera Preparedness Training was very intense. It was a collaboration between CDC Zambia, WHO, Zambia National Public Health Institute, local universities, and the Ministry of Health. Lectures and hands-on training were incorporated into this workshop as well. The participants consisted of surveillance officers, environmental health technicians, laboratory specialists, and health directors from various districts. These individuals make up a newly developed rapid response team that is being built in Zambia. During the Ebola preparedness portion of the training, participants were trained on triage, wearing proper PPE, lab specimen packing/shipping, setting up a treatment center, and transporting ill patients. The cholera preparedness portion consisted of a discussion about what went well and what didn’t go so well during last year’s cholera outbreak that lasted ~8 months. Participants walked through the process of investigating an outbreak and creating products such as epi curves and line lists. I could see the light bulbs going off for many people as they realized how efficient this was for ensuring data quality and tracking cases. Lightbulbs also went off during discussions about how to appropriately use the Incident Command System. My duties consisted of helping in the triage station, acting out scenarios, and helping with pre and post tests. Participants are now tasked with going back to their jurisdictions to train others.

Some interesting things to note is that we have built in “tea times” where you can take a coffee or tea break and grab a snack, someone is also asked to pray at the beginning and end of the day, and there are usually lengthy delays when it comes to gathering large groups together for training/workshops (but things come together at the end).

 

 

 

Global News Round Up

Politics & Policies

Republicans and Democrats on Capitol Hill hope to combat the opioid epidemic in part by expanding access to addiction treatment, a key part of a major legislative package.

Melania Trump began her week-long sojourn to Africa in Accra, Ghana.  The First Lady was greeted on the tarmac by Ghanaian first lady Rebecca Akufo-Addo and a bouquet of flowers wrapped in kente cloth followed by a performance of dancing and drumming.

Dr. Anthony Fauci says he’s “cautiously optimistic” about the future of global health, which he says has the potential to be enhanced by the development of universal vaccines and improved preventative measures.

In the lead-up to the first U.N. high-level meeting on tuberculosis, global health experts said the momentum was different, that a turning point was near in the fight against the disease, the world’s top infectious killer.

The House and Senate have reached agreement on a big package of measures to address the opioid epidemic.  The legislation, backed by leaders of both parties, is a rare bipartisan achievement that lawmakers are eager to have in hand when they go home to campaign for the midterm elections.

Programs, Grants & Awards

Global Health Corps (GHC), a leadership development organization working to build the next generation of global health leaders, was named for the prestigious of 2018 Skoll Award for Social Entrepreneurship.

October 1 marks World Vegetarian Day 2018, which takes place to raise awareness of the benefits of a vegetarian diet.  With many lpeople now considering at least reducing their meat intake, here we round up what research from the past year says about how a vegetarian diet may be able to boost health.

National Institute of Mental Health and the National Institute of Allergy and Infectious Diseases, is investing in a young generation of HIV prevention researchers by providing African-American and Latino medical students with opportunities to conduct independent research while receiving mentoring, project and salary funding, training, and professional development opportunities.

Research

Fuel cells have long been viewed as a promising power source. But most fuel cells are too expensive, inefficient, or both.  In a new approach, inspired by biology, a team has designed a fuel cell using cheaper materials and an organic compound that shuttles electrons and protons.

Preterm birth remains a global epidemic linked to a lifetime of potential health complications. It also is difficult to study in living creatures–especially the uniquely precise biology of preterm birth in humans.

Although substantial progress has been made in reducing diarrhoeal deaths among children in low-income and middle-income countries, from approximately 1.6 million in 1990 to 450, 000 in 2016, sustaining these improvements will require additional strategies and approaches.

The University of Birmingham has been awarded £1.9 million through the National Institute for Health Research (NIHR) Global Health Research (GHR) Programme to fund world class research into a common heart condition in disadvantaged populations in China, Brazil and Sri Lanka.

Diseases & Disasters

More than 80,000 Americans died of flu in the winter of 2017-2018, the highest number in over a decade, federal health officials said last week.

Global health officials are preparing for African swine fever, which has been spreading in pigs across borders since 2014, reaching Western Europe last week.

Everyone feels isolated sometimes, but with one in five Americans chronically lonely, has loneliness reached epidemic proportions?  In 1988, the journal Science published a landmark study suggesting isolation was as strong a risk factor for morbidity and mortality as sedentary lifestyle, high blood pressure and smoking or obesity

Governments should raise the price of alcohol and restrict its availability in a bid to reduce harmful drinking, the World Health Organization has said.

Researchers have found a link between sudden cardiac death (when the heart suddenly stops beating) and a common heart condition known as mitral valve prolapse that affects around 12 in every 1000 people worldwide.

The risk of Ebola escaping from the Democratic Republic of Congo is now “very high,” and the outbreak already is nearing Uganda, the World Health Organization said on Thursday.

Technology

Mobile is a key enabler of sustainable economic growth and a major contributor to the delivery of the UN’s 17 Sustainable Development Goals (SDGs), a set of audacious targets to end poverty, halt climate change, and fight injustice and inequality – all to be achieved by 2030.

Environmental Health

Health officials say smoking not only kills about 7 million people every year, but has a devastating impact on the environment contributing to deforestation, water and soil depletion and acidification.

Following the extreme, earthquake-triggered tsunamis unleashed in the Indian Ocean in 2004 and Japan in 2011, a spate of disaster films like The Impossible have depicted doomsday tidal wave scenarios.

A landmark treaty signed in Greenland will help to protect vulnerable fisheries in the Arctic.

October 1 marks the 41st annual World Vegetarian Day and the start of Vegetarian Awareness month. The annual occasion was founded in 1977 by the North American Vegetarian Society and was endorsed by the International Vegetarian Union in 1978 to entice omnivores “to give meatless fare a try (even for a day)” and to commend those with “healthy, compassionate food choices.”

Equity & Disparities

Sweat poured down Fenol’s body as he writhed in pain on a stretcher in a southern Haiti emergency room. Two days earlier, a motorcycle crash caused massive trauma to his abdomen.  His internal injuries had precipitated multi-organ failure and shock, and he had lost precious time searching desperately for a hospital with surgical capacity. His pain, fear, and mortal predicament was borne from a violation of what we believe is a fundamental human right: he had no access to essential, life-saving surgery.

Women, Maternal, Neonatal & Children’s Health

There’s very little research on whether medications are safe and effective in pregnant and lactating women, but an expert panel has ideas for how to close that information gap — and it’s calling on the federal government to take action in a new report that could stir change.

 

Three Observations from UN High Level Health Meetings

During the United Nations (UN) General Assembly, two historical High-Level meetings in the realm of health were held addressing ailments that afflict individuals from every corner of this fragile planet. The first UN High-Level meeting on Tuberculosis (TB), focusing on preventing and treating this elusive disease, was held on Wednesday, September 26th which finally put TB in a global spotlight. Additionally, the third UN High-Level Meeting on Non-Communicable Diseases (NCDs), under the theme “Scaling up multi‑stakeholder and multisectoral responses for the prevention and control of non‑communicable diseases in the context of the 2030 Agenda for Sustainable Development,” took place on Thursday, September 27th. World leaders and their ministers, non-government organizations (NGOs), and other stakeholders partook in these crucial meetings to curtail the suffering these various diseases cause. For each of these meetings, governments approved drafts of political declarations that commit countries to follow through with health policy, funding, and a multisector approach to these disorders. The following summarizes key points and commitments from each of the high-level meetings:

UN High-Level Meeting on Tuberculosis

  • A commitment to mobilize $13 billion for universal access to quality prevention, diagnosis and treatment
  • $2 billion for research and development of new drugs, diagnostics, vaccines, and other tools.
  • Commit to provide diagnosis and treatment with the aim of successfully treating 40 million people with tuberculosis from 2018 to 2022 (including 3.5 million children, and 1.5 million people with drug-resistant tuberculosis including 115,000 children with drug-resistant tuberculosis)
  • Pledge of 30 million people (including 4 million children under five years of age, 20 million other household contacts of people affected by tuberculosis, and 6 million people living with HIV and AIDS) to receive preventive TB treatment by 2022
  • Promise to overcome the global public health crisis of multidrug-resistant tuberculosis through actions for prevention, diagnosis, treatment and care, including compliance with stewardship programs to address the development of drug resistance
  • Oblige to consider how digital technologies could be integrated into existing health systems infrastructures and regulation for effective tuberculosis prevention, treatment and care
  • Commit to provide special attention to the poor, those who are vulnerable, including infants, young children and adolescents, as well as the elderly and communities especially at risk of and affected by tuberculosis.

UN High-Level Meeting on NCDs

  • Commitments to reduce NCD mortality by one third by 2030, and to scale-up funding and multi-stakeholder responses to treat and prevent NCDs
  • Health systems should be strengthened — and reoriented — towards the achievement of universal health coverage and improvement of health outcomes
  • Greater access to affordable, safe, effective and quality medicines and diagnostics
  • A commitment to ambitious multisectoral national responses, integrating action on prevention and control with promotion of mental health and well‑being
  • Increasing energies to reduce tobacco use, harmful alcohol use, unhealthy diets and physical inactivity through cost‑effective, evidence‑based interventions to halt obesity
  • To develop a national investment plan in order to raise awareness about the national public health burden caused by non‑communicable diseases and health inequities

While these are not all-inclusive of the commitments between nation states at these two meetings, they highlight the prominent concerns leaders in both the political and health dominion share. However, special attention should be brought to the dialogue held before and after the duration of the meetings. These discussions reveal the true apprehensions that world leaders fear affects their citizen’s health and well-being. The following are three observations from these two UN high-level meetings that may provide some significance in the future battle with TB and NCDs.

1. Is health trending towards being a right rather than a commodity among world leaders?

Before the UN high-level meeting on TB came to fruition, there was a highly controversial commitment in the declaration that concerned high-income countries like the United States. The commitment was centered around access to affordable medications, in particular, generic medications. The concerned countries had expressed reservations about language supporting UN member states’ rights to interpret and implement intellectual property rights in a way that defends public health and encourages access to medicines. Global health advocates believed this point as being essential to equitable access to medications across the world – treating health as a right rather than a product. In the end, health as a right was included into the declaration, through the leadership of South Africa and Médecins Sans Frontières (MSF), despite upsetting these powerful nation states. In addition, at the high-level meeting on NCDs, language was included that stated a similar commitment – to affirm the rights of UN member states to use intellectual property flexibilities to safeguard public health. Although the fight against these two devastating classes of diseases is certainly at the forefront of leaders’ minds, the seemingly endless interchange of health as a right and health as a commodity seems to be finally leaning towards the betterment for humanity – health as a right.

2. Technology and Policy – Finally Uniting to fight TB & NCDs

Throughout the UN General Assembly last week, several reports, policies and studies were released or highlighted that may prove to shape the future treatment of TB & NCDs. The following list are just a few of the major contributions that various sources released:

Health care professionals throughout the world realize that diseases need to be undertaken in a biosocial manner – utilizing both technology and policy. The outcomes that resulted from last week’s reports reaffirm that political leaders realize that the true way to overcome these burdens is to address them through this manner.

3. Multi-Sectoral Approaches – How should they be conducted?

One of the biggest initiatives in global health is the necessity to bring together all stakeholders in disease management in order to properly address the situation. With a vast array of input and ideas, different perspectives, and an atmosphere of collaboration, global health is trending rapidly in this manner – with a significant portion of the world partaking in multi-sectoral approaches already. However, the manner in which these are conducted can vary within countries and between NGOs and governments. Although these remarks may not apply to every country, the following statements made by world leaders may provide some insight into how a country could carry out these approaches:

  • A representative from the Netherlands state that including all stakeholders into the approach may cause conflict of interests – “The days are gone when the tobacco industry has a seat at the table” while also stating “multi-sectoral approaches are good, but governments should be in the lead” in reference to NCDs.
  • An NCD Alliance representative mentioned “it is for governments to determine their own priorities” and “civil society is ready to support, but governments must lead the way.” while simultaneously reaffirming her support for multi-sectoral approaches.
  • Finally, Gerda Verburg, coordinator of Scaling-Up Nutrition Movement explained that “Bigger companies are part of the problem, but we won’t succeed unless we make them part of the solution,” while also adding that she realizes that this is often difficult for civil society, and that “too often, they stand with their backs to the table where we need a critical dialogue with the private sector.” In addition, she supports the priority to “strengthen national systems.”

In a global society where the healthcare landscape is in constant motion, the ability to gather world leaders to commit to significant leaps of change is promising to all those who inhabit this planet. However, these commitments need to be followed up with action, funding, and the political will to properly solve the world’s number one killer and the deadliest infectious disease. The global health community should inspire and encourage their governments while correspondingly holding them accountable to adorn these commitments and continue to battle these overwhelming diseases.

 

Read the latest issue of the IH newsletter, Section Connection!

The latest issue of Section Connection, the IH Section quarterly e-newsletter, is now available! You can find the latest issue of the newsletter here: http://bit.ly/SectionConnection9 

If you cannot access the newsletter for any reason please email Theresa Majeski, Global Health Connections Chair, at theresa.majeski@gmail.com