Yemen: The struggle to reach aid in the world's worst cholera outbreak

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Yemen’s cholera outbreak has killed at least 2,177 people since 27 April. The World Health Organization now estimates the number of suspected cholera cases to be over 862,000, as of 22 October, making Yemen’s outbreak the world’s worst on record. In Haiti, as of 27 September last month, the WHO had recorded 813,026 suspected cases since 2010. Oxfam Public Health Promoter, Eva Niederberger, reports back on how challenging it is to reach cholera-affected people in Yemen.

The cholera outbreak is widespread

It’s more than 45 degrees C outside and I’m listening to Sameera, a pregnant woman living in Abs city. The city is located in Hajjah governorate, North of Yemen and has been severely affected by the current cholera outbreak.

Sameera tells me about her experience when her husband got infected by cholera few weeks ago. Her husband started to vomit and suffer from diarrhea shortly after having taken his cholera-affected relative to a public hospital. He soon took Oral Rehydration Salt, essential to prevent further dehydration, but his condition continued to worsen.

“I was really worried and not sure how I could protect myself of cholera whilst taking care of my sick husband. Luckily some of Oxfam’s volunteers were there to answer my questions and advised me what to do,” she explained.

Both Sameera and her husband didn’t trust the treatment available at the public hospital and decided to go to a private clinic. A few days later, Sameera’s husband recovered but the treatment costs had worsened their already precarious financial situation: before moving to Abs, Sameera was working as a teacher in Taiz and hadn’t been paid for several months. Her husband currently has no income either.

Trust in the given treatment options is critical for families when they have to decide whether to send a sick family member to the hospital or not – and ultimately save lives in a cholera outbreak. Equally important are traditions, habits and access to treatment. For example, a few days later I am with our public health team in Amran governorate which has to date more than 84,000 suspected cholera cases, counting 170 deaths.

We are trying to understand better how to motivate people to provide early rehydration to sick family members and refer them to a treatment centre if the condition doesn’t improve – both very important factors to reduce and prevent further epidemic spread.

We soon figure out that in some areas people would first rely on natural remedies – in few cases this helped patients; in others it delayed effective rehydration and risked to worsen people’s condition. 

The provision of natural treatment is something which people would often do for less severe health issues: fever, stomach pain, diarrhea or headache. Since the cholera outbreak though, an increased number of affected people are now aware of the importance of oral rehydration salt (ORS). Weam, Oxfam’s Public Health Promotion Officer, tells me that there were four cholera cases in this village and that one man has died because of it.

“Therefore people here fear to get infected by cholera and try to do as much as they can to prevent it,” she said. However, in many cases ORS is not available in the local market, or people do not have the money to pay for transportation to travel to the market in the first place.

Difficulty to access treatment

In both governorates, Amran and Hajjah, we also know that more lives could have been saved if treatment could have been brought closer to affected communities. For example in Al-Wadi village, close to Khamer city in Amran, people tell me that they have to sell the few remaining assets they have, such a jewellery or traditional daggers, to take a sick family member to the treatment center. Others are getting into debt.

Already in early June 2017, when **over 400 cases per day** were reported at MSF’s  treatment center in Abs, their staff told me that there was an urgent need to support the set-up of oral rehydration points where people could quickly access rehydration - and if required being then referred for further treatment. But the response has been slow, hampered by getting customs clearance for supplies from abroad, the lack of critical items in the local market, and inconsistent approval processes to move material across the country.

In addition,** access to highly affected communities remains a real challenge**. For example, in Haradh district most of the people have fled due to the ongoing conflict but there are still almost 50,000 people who are in need of urgent assistance. However the risk that aid distributions and other assistance will be targeted by airstrikes is too high to be able to provide direct support. This makes it very difficult to get security clearances or travel permits to the area.

In other areas, access is only granted after long negotiations with different stakeholders - and even then not consistently guaranteed. Our teams try to develop creative solutions and help as best as they can. For example they work closely with the Ministry of Health to identify community health workers who could be engaged in the cholera response. These people are then trained in an accessible location to promote preventive measures back in their communities. They are further provided with chlorine sachets to make water safe for drinking as well as testing equipment to ensure the quality of treated water.

Ensuring clean water

Yemen is a water scarce country and the lack of access to safe water the primary infection source of the ongoing cholera outbreak.

In Bani Hassan, an IDP camp in Hajjah district, I meet with Mohammed, one of Oxfam’s volunteers. He tells me that five years ago he was already volunteering with Oxfam back in Haradh but then had to flee from the conflict. Since the cholera outbreak, one of his main tasks involves the water quality testing. “Every day I follow-up to understand whether the water delivered by the network is safe for drinking. I test the water quality of the communal tanks and also in some households.”

I ask him whether people agree that he comes to their tent for water testing. “People know me here very well and they trust me.”

Oxfam is there

In some of those inaccessible areas people have mobile phones and there is network, and our Public Health team created a WhatsApp group with a wide network of volunteers. These volunteers often send pictures to document their activities and/or inform about new cases. Our teams check in with them on a daily basis to respond to different queries, take up the case notification to epidemiological units within the districts, and provide technical advice in line with health risks fostering the epidemic spread.

This was the third time that I travelled to Yemen to support Oxfam’s humanitarian program: in 2011 our public health program looked at the increasing rates of malnutrition resulting from the economical and political crisis and increasing poverty levels. I returned in 2015, a few months after the escalation of the conflict, working on access to water, hygiene and sanitation in Taiz - an area heavily affected by ongoing fighting, which cut off over 100,000 people from desperately needed aid.

Two years later the situation has worsened again with the world's worst cholera outbreak, on the top of a war torn country.

This entry posted on 23 October 2017, by Eva Niederberger, Oxfam Public Health Promotion Adviser, who spent three weeks in Yemen.

Oxfam is delivering essential aid in both the north and south of Yemen, and since 2015 we have reached 1.2 million people across the frontlines.

Photo at top: Ahmed Ali sits next to his son Qassem*, 5 years old, who was already suffering from malnutrition, epilepsy, and inability to speak, and now cholera. Credit: Abs, Hajjah – Ahmed Al-Fadeel/Oxfam Yemen

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