Battling COVID-19 in a war zone: a field doctor’s point of view from Yemen

 

Yemen has been embroiled in a brutal civil war since 2015. In June 2021, President Joe Biden announced his administration would donate 500 million doses of COVID vaccines to low-income countries. Prime Minister Boris Johnson followed shortly afterwards with an announcement of the British donating 100 million excess vaccines. These measures were celebrated around the world.  At the time, I was working in Yemen as a field doctor for a humanitarian medical organisation. Whilst vaccine supplies seem to be the biggest hurdle that the media is focussing on, much more complex problems such as infrastructure, poverty, illiteracy and healthcare-seeking behaviours in various cultural contexts lie beyond the supply issue.

COVID was as real in Yemen as it was in the UK but the task of containing its spread appeared much bigger. The official line dictated by the Houthi authorities controlling north Yemen was that COVID was not a threat. Masks are rarely worn in the community, though women move around with niqabs covering their faces. We had no access to staff or patient testing, so we had to rely solely on symptoms to make a diagnosis of COVID. It was impractical to ask exposed or symptomatic staff to self-isolate based on symptoms alone. Contact tracing was also impossible without confirmatory testing.

We had received donations of COVID Personal Protective Equipment (PPE), but it was difficult to get staff to use the PPE properly and there was a constant fear of running out. I was involved in transferring a woman to intensive care who developed respiratory distress and pyrexia. She was intubated in the Emergency Department, but nobody told me when I took the call, so when I arrived I was horrified because not only was I not donned up with an FFP3 mask, visor and gown, but the door to the room was wide open and staff were moving in and out without any awareness of the aerosol generation through the intubation.

Under the stress of the civil war, the public health care system has nearly completely collapsed.  Government healthcare workers have not received a regular salary for years and many have left the system to work in the private sector, which most Yemenis cannot afford. In such circumstances, even if these promised vaccinations arrive in Yemen, who will get them into people’s arms?

With this desecration in primary health care services, most Yemenis are not in the mind frame to think about preventative treatments such as vaccines. We struggle to convince pregnant women to attend antenatal clinics for routine visits, so it will not be easy mobilising the population to come forward for one or two doses of a vaccine; for an illness that the authorities deny the existence of. Many Yemenis have an innate distrust of hospitals (“where people die”), so even when they develop medical problems, they often wait to seek care due to the time and expense of travel, preferring to seek out local traditional healers first. One of my patients arrived in status epilepticus for the preceding six hours.  Another was bleeding from a ruptured uterus and arrived two hours after her baby’s head was born (shoulders were still not delivered). One woman had a headache from evolving pre-eclampsia for over a week and only came to hospital when she lost her sight.

Finally, there is vaccine skepticism. There is so much fear of the vaccine even amongst healthcare staff because they get a lot of their news from social media, and there is no national messaging from trusted sources. Plus, the risk of COVID just does not seem that large compared to the risks of all the other challenges people face on a daily basis.

There is no silver bullet for how to tackle such complex challenges. Here are two ideas from a field doctor to policy-makers:

  1. Do not cut the aid budget. The general state of the humanitarian crisis in Yemen and the COVID crisis are both intrinsically linked. General healthcare infrastructure and vaccine delivery programmes need funding. Just supplying vaccines is not enough.
  2. Double down on diplomatic efforts to end the war in Yemen. As long as war rages in Yemen, the country will remain vulnerable to COVID and a multitude of other threats.

Lack of vaccine supply is the tip of the iceberg in this global pandemic. We need to also seriously consider how we end poverty and violence, and provide clean water, housing, roads, primary healthcare and education for the people in Yemen and indeed all our global citizens. In this way, our response to COVID is an opportunity to create a healthier world than the one that existed before it.

 

About the author: Dr Sabrina Das is a Consultant Obstetrician & Gynaecologist in Imperial College Healthcare NHS Trust, with a special interest in high risk pregnancy, global health and quality improvement. She worked in Yemen for Medecins Sans Frontieres in March – July 2021. Views are personal and not reflective of her employer. She tweets at @drsabrinadas.

Acknowledgements: Sincerest thanks to Shahan Mufti for his editorial input.

Funding: Dr Sabrina Das received the Bernhard Baron Travelling Scholarship from the Royal College of Obstetricians and Gynaecologists to carry out her sabbatical as a field doctor in Yemen.

Competing Interests: None

Handling Editor: Neha Faruqui

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