The doctors and nurses at Hodeidah city’s al-Salakhanah Hospital know what a cholera outbreak looks like: they’ve seen the influx of patients complaining of diarrhoea before, the crying children afraid of needles and intravenous drips, the nervous family members at bedsides.
Last year, with Yemen’s health system decimated by war, a disease that should be easy to treat spread quickly, and by May 2017 it was taking one life an hour. The disease killed 2,510 people and infected a suspected 1.2 million others since late April 2017, when official records start. It faded early this year.
But cholera is now making a comeback, and something about this spike is different, says Elham Twaiti, a nurse who is busy admitting a line of new patients.
“When we noticed many displaced people don’t have clean water and their baths are outdoors, that’s when we felt cholera was going to come back.”
There are systemic problems that help cholera thrive: poor sanitation and hygiene, shortages of clean water – all aggravated by the war. “But this is not new in Hodeidah,” she says.
Yemen’s currency is now in freefall, making food unaffordable for many. “The new development here is that the economic crisis has left many people in hunger, and cholera hits malnourished children easily,” she says, adding that pregnant women are also vulnerable to the disease.
For months, aid organisations have been warning that cholera was poised to return. Some 1.1 million Yemenis, including 660,000 children under the age of one, have received oral cholera vaccinations since the last surge, but UNICEF, the UN’s agency for children, says that’s out of 9.7 million who need the vaccination to prevent further outbreaks.
It hasn’t been enough to prevent the latest wave. More than 15,000 suspected cases were recorded across Yemen in the last week for which statistics are available, and Hodeidah province, where a coalition led by Saudi Arabia and the UAE are fighting an offensive against Houthi rebels, is reporting some of the highest levels in the country.
Now even veteran health workers like Twaiti are concerned about being able to handle the disease as it overlaps and intersects with hunger, violence, and economic collapse.
Displacement and economic collapse
Ridha Mohammed, a doctor who is trying to insert an IV line into the arm of a thin child, says population displacement was the first reason he and other staffers at al-Salakhanah began to worry that cholera was on its way again.
Starting around June, patients - who arrived seeking treatments for various ailments - said they were coming from makeshift camps, with improvised sanitation facilities and limited access to clean water, he noted. More than 425,000 people have fled their homes in Hodeidah province since the offensive began in June. Bismarck Swangin, spokesman for UNICEF in Yemen, confirms that the “displaced population are at a higher risk of many diseases including diarrhoeal diseases,” like cholera.
“When we noticed many displaced people don’t have clean water and their baths are outdoors, that’s when we felt cholera was going to come back,” Mohammed said. The hospital began to see an uptick of cases in September, and now several rooms are dedicated to treating the disease.
Seven-year-old Saeed Mohanad is one of the children whose cries add to the din of the hospital. His mother, Umm Saeed, told IRIN that the family is originally from a part of Hodeidah city that has been overtaken by fighting. They left their home in June.
Their family of 11 now lives in a makeshift shelter and depends on aid and generous locals to survive. Umm Saeed had to borrow 2,000 rials (around $3) for petrol to make the half-hour drive to the hospital, a debt she was only able to take on because treatment is free.
Yemen’s economy has been collapsing over more than three and a half years of war, and since September the currency has been in a nose dive, leading to rising prices of just about everything, including food and fuel.
This makes seeking treatment even harder for families like Um Saeed’s.
People who can’t afford food are less able to fight off diseases like cholera, and with Yemen constantly teetering on the edge of famine, that means a lot of people are at risk, Twaiti explains.
The UN says 18.5 million Yemenis don’t know where they will get their next meal. And it expects that number to rise by 3.5 million and even more if Hodeidah’s port – a key source of commercial and aid imports – is cut off by fighting.
Long time in the making
None of this is a surprise. Humanitarians have been warning that cholera was likely to make a comeback for months, given that in places like Hodeidah, water and sanitation systems were in bad shape before the war and have further deteriorated.
“Continued fighting is not only damaging the [water, sanitation, and hygiene] system but also causing hurdles in accessing health services by communities in conflict areas.”
“Continued fighting is not only damaging the [water, sanitation, and hygiene] system but also causing hurdles in accessing health services by communities in conflict areas,” says UNICEF’s Swangin.
“It is definitely frustrating, not only for humanitarians but also for families not able to access services and unable to meet the need of their children and families.”
In al-Salakhanah Hospital, staff say they have the medication and resources they need, and they are in an area not yet impacted by violence. But as fighting closes in on some parts of the city, putting civilians in danger and sending more into flight, Mohammed and Twaiti are increasingly concerned about those patients they haven’t been able to treat.
“There are many people that don’t make it to [this part of] the city [or to the hospital],” says Mohammed. “We don’t [even] know about them.”