Dr Melissa McRae is an Australian GP currently working as a medical coordinator in Yemen. The conflict in the country, which has waged for two years now, has been dubbed the “forgotten war”. But it is fuelling a major humanitarian crisis, with doctors and health workers also facing an unprecedented cholera epidemic.
Trauma and Maternity
At halfway through 2017, Yemen had already experienced more air strikes than in the whole of 2016. MSF teams certainly treat a lot of trauma cases — adults and children, civilians and combatants. These include many war wounded and victims of road traffic accidents. The care encompasses ED stabilisation to operating room, and inpatient wards, including high dependency and ICU level care. We also treat many common health problems as there are limited other options for free, accessible, high-quality care.
One of our projects is focused on maternity and child health and we are overwhelmed with the high need for neonatal care beds and support for complicated deliveries. The number of preterm deliveries is increasing, with younger mothers and increased malnutrition and stress all contributing factors.
"MSF has also had some involvement in prevention, but the largest effort has been on case management and rehydrating those with diarrhoea — simple treatments save lives"
MSF has been largely focused on cholera case management. This was a pragmatic decision at the beginning of a rapidly increasing outbreak. When we initially looked at response capacity in Yemen, we knew other agencies were able and willing to do community prevention activities, but very few could rapidly set up and manage cholera treatment centres at the scale and speed required. Essentially, MSF and two other organisations took on this role across Yemen. Of course, MSF has also had some involvement in prevention, but the largest effort has been on case management and rehydrating those with diarrhoea — simple treatments save lives. MSF outreach teams have joined Yemeni Ministry of Health community surveillance teams to investigate reports of community deaths, undertake contact tracing, and to provide health education and home water chlorination supplies and advice. There are effective oral cholera vaccines for outbreak control, but timing is crucial to their effectiveness.
Hygienic waste management is problematic across Yemen with the breakdown of government services linked to no payment of civil servants for over one year, but the individual risk is largely determined by location. As Yemen is a middle-income country, the situation varies according to the living conditions. In major cities, the reticulated water system could be treated by mass chlorination, that is, once the outbreak was detected. This is not possible for families living in remote villages who rely on well or open source water. Wells can be chlorinated, but the response time is slower due to remote access. A focus on household hygiene is an effective and simple protection measure.
"While I tell them to stay home, they arrive ‘better late than never’. They keep on going"
The strength of the MSF local staff is awe-inspiring. Their lives have been turned upside down. These are the individuals who tell me that the local library or store was hit in the latest air strike. They have lost numerous family members and left their homes, which are now looted and overrun. They occasionally tell me of the struggles they must endure to get to work, as the road is blocked or unsafe. While I tell them to stay home, they arrive ‘better late than never’. They keep on going. They are the real humanitarians here, and we are lucky to have their skills and dedication to keep our MSF operations running to support the population in need.
Victims of the conflict
There are really hundreds of patient stories to reflect on, none more important than any other. I do remember the eight-year-old girl whose arm was blown off in a bus explosion, where more than 20 civilians were injured, and the rush to get her to the operating theatre to properly control the bleeding. I also remember the device that exploded under another civilian bus, but was allegedly planted to hit an ‘important leader’ of one of the warring parties. The physical injuries are gruelling and visible and yet the impact on mental health is unfathomable.
A global response
The civilians are paying an extremely high price in this conflict. They live under the constant threat and reality of violence, fear and displacement, while trying to afford everyday commodities in the face of increasing prices and job insecurity. We need the international community to step up and address the crisis in Yemen, not only by stepping up humanitarian solutions, but by addressing the factors that create such enormous humanitarian needs.
A version of this article was first published in Australian Doctor