How to Fight Disease in a War Zone: Yemen’s Cholera Epidemic

 By Christian Duborg

In 1916, during the First World War, German physician Friedrich Prinzing named the six diseases that throughout history had “usually followed at the heels of belligerent armies” and termed them war pestilences. These war pestilences are dysentery, plague, smallpox, typhus, typhoid, and cholera. Today, Prinzing’s words are proving to be prophetic, as the ongoing civil war in Yemen is now accompanied by a massive cholera outbreak.

UN investigations into the conflict and the outbreak have led to the conclusion that this outbreak is a “man-made humanitarian catastrophe” and the direct result of the fighting in the country. The war between the UN recognized government of President Abdarabbuh Mansur Hadi and the Houthi rebels has not only killed over 10,000 and displaced as many 2.6 million, but caused a health crisis that has already infected as many as 200,000 and killed 1,310 already, with projections to get much worse.

In the midst of this crisis, it is worth taking a look at how Yemen has reached this point and where it can go from here to alleviate the situation.

Yemen’s current situation finds its roots in 2004, when the Yemeni government under Ali Abdullah Saleh attempted to arrest Hussein Badreddin al-Houthi, a leading Zaydi religious leader. al-Houthi had led a movement to secure more autonomy for the Zaydi stronghold, Saada governate in the country’s north, and stand against perceived corruption and support for the US and Wahhabism by the Yemeni government. He was accused of trying to become an Imam(a religious title given to the rulers of Yemen for centuries), establishing an illegal Zaydi religious network, and leading a rebellion against the government. Al-Houthi was killed in clashes with security forces a few months later, but the movement he founded was just getting started.

The group, whose members became known as Houthis, continued their insurgency from 2004 onwards. At the core of the movement was its Zaydi identity. The Zaydis are a sect of Islam that has been present in Yemen since around 740 AD, when their founder, Zayd ash-Shaheed, led a failed rebellion against the Umayyad Caliphate. The Zaydis are a branch of Shia Islam, and make up a as much as 40% of the population of Yemen, while the remaining 60% are almost exclusively Sunni.

The Zaydis hold that their founder gives them a tradition of standing up to corrupt rulers, and that is exactly what the Houthis say they are doing.

The Houthis claimed that they were leading a movement to expel a corrupt government and establish a true republic. Their revolt, conducted by their armed wing known as Ansar Allah, was also widely seen as a bid to secure more autonomy for the largely Zaydi Saada Governate, leading to accusations that it was being supported by Iran as a bid to expand Shia influence. The Yemeni government, for its part, was largely believed to have support and even intervention on its behalf by Saudi Arabia, the region’s leading Sunni power, and the United States.

Location of Saada Governate within Yemen

The insurgency made limited progress until protests began in Yemen’s capital, Sanaa, against the Yemeni government and longtime president Ali Abdullah Saleh. The revolution lasted a little over a year, culminating in the resignation of Saleh and the overthrow of his government. During this time, the Houthis declared support for the opposition, but also capitalized on the chaos by taking control of Saada and al-Jawf Governates and advancing into Hajjah Governate. This placed the Houthis on the doorstep of Sanaa and gave them significant influence by the time Saleh resigned and Hadi, up to then Saleh’s Vice President, was elected. Hadi was sworn in as Saleh’s interim replacement while a new constitution was drafted up for presidential and legislative elections in 2014.

Originally, the Houthis joined the National Dialogue Conference, which was convened after Hadi’s election to reform the constitution and create a new system for Yemen. Among other reforms, it did guarantee freedom of religion and guarantee the government as nonsectarian in response to Houthi concerns. The Houthis, however, rejected the deal, and instead invaded Sanaa under the pretext of protests against fuel subsidy cuts.

After forcing the Prime Minister to resign and agreeing a new power sharing deal, it looked like the situation would stabilize and a new constitution would be reached. However, in January of 2015, the Houthis staged a coup to gain control of the process of constitutional reform. It is widely believed that this takeover happened due to an alliance between the Houthis and their longtime enemy, Ali Abdullah Saleh.

Hadi and his entire government resigned rather than obey the Houthis demands. They responded by dissolving the government and legislature and established their own Revolutionary Committee. However, Hadi fled to Aden and led his army and allies against the Houthis. Hadi secured intervention from Saudi Arabia and gradually began fighting back, launching a full scale civil war.

Current Military Situation in Yemen: Red controlled by Hadi Government, Green by Houthis, and White by Al-Qaeda in the Arabian Peninsula

And it is this war which is the source of the current crisis epidemic. Cholera is a water borne disease spread by bacteria, often tied to human waste seeping into the water supplies. Extensive sanitation is often sufficient to prevent this from occurring, but outbreak of the war has made that nearly impossible. The ongoing fighting between the Houthis and the Government, not to mention the Islamic State and Al-Qaeda in the Arabian Peninsula (AQAP), has led to widespread destruction.

Map of Yemen’s Cholera Crisis: Areas in Purple and Red are currently infected

The current conflict is in a stalemate, in which areas are subjected to near constant fighting. This has led to the complete destruction of much of the country’s basic infrastructure. Every side is also seeing its finances drained by the conflict, and cannot repair the damages to water, electricity, transportation, communication, and food infrastructure. Furthermore, there is no money for basic health services to fight the disease, with many health workers not being paid.

The fighting on the ground has been further compounded by airstrikes, blockades, and alleged weapons smuggling by foreign nations. This has only exacerbated the severe damage on the infrastructure and made it even harder for essential supplies to move around to keep people healthy and sanitation up. One key example is in Sanaa itself, where air raids have caused severe damage, further compounded by the failure of the Houthi government to maintain basic sanitation, such as trash collection.

Perhaps one of the most important thing is that all these factors have not only displaced millions and led to a massive disease outbreak, but have further led to a massive food shortage that has further plagued the country. Over 17 million Yemenis (of an estimated 25 million people) now do not have enough food, and this widespread famine and malnutrition is estimated by UNICEF to make people 9 times more likely to die from cholera (

No side is trying to make people sick or starve them to death, but the fact is that the health and food crises have been a direct side effect of this war. Now we must turn toward what can be done to improve the situation.

The Water Sanitation Hygiene (WASH) group for Yemen released a report which laid out a plan to contain the outbreak, prevent the spread of the disease and lower the mortality rate as much as possible. In order to do this, the group calls for funding to establish or support labs and testing forces at the local and national level in order to swiftly detect contaminated sources and alert the public. Furthermore, the group wants to set up centers specifically meant to treat the symptoms of the disease and distribute kits to individuals. This is important because so long as it is effectively treated, cholera isn’t usually fatal. Finally, the plan calls for the provision of chlorine, salt, and other supplies necessary to disinfect water supplies and promote sterilization and sanitation.

These steps appear to be on their way, as the report states that in order to implement these measures, an additional $66.7 million in donations would be needed. About one month after the report, Saudi Arabia provided a donation in that exact amount to UNICEF and the WHO to combat the outbreak. This donation will be critical, and these organizations’ measures will likely save many lives in the coming weeks and months. However, while these measures will likely contain and reduce the outbreak, it will likely not completely eradicate the disease in Yemen.

There is a reason cholera is referred to as a war pestilence. It is often, as it is in this case, brought on by war, and to combat it is an operation involving nearly military level organization. One key lesson of military history is that it is hard to fight on multiple fronts simultaneously. Right now every side is fighting the disease, famine, and their enemies all at once. So long as the bloodshed persists,as infrastructure is being bombed, money is being poured into bullets, and clinics are being caught in the crossfire, it seems likely that doing more than slowing the disease will be a tall task.

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