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COVID-19: The virus arrives in war-torn Yemen where health care is challenged and hand-washing is hard to achieve

Kwan Kew Lai, MD, DMD, FIDSA
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The following is a guest post by Kwan Kew Lai, MD, DMD.

Yemen, one of the Arab world's poorest countries has been devastated by civil war. It has the world’s largest humanitarian crisis, with 24.1 million people in need, and about 10 million of them are on the brink of starvation, especially in the Houthis controlled northern heartland of Saada province and the neighboring areas.

Nearly five years of war exacerbated the widespread poverty, conflict, poor governance, and severe economic decline. Since the escalation of the conflict in 2015, humanitarian needs have increased sharply across all sectors and accelerated the collapse of public institutions, including the health sector. Less than half of its already fragile health facilities are functioning and there is a severe shortage of medicines, equipment and medical staff. Access to healthcare is severely limited.

After the airport in Sana’a was closed to commercial flights in August 2016, the United Nations estimated that up to 20,000 people were denied access to potentially life-saving healthcare. At the end of 2019, the Saudi-led coalition announced it would allow some flights out of Houthi-held Sana’a for civilians requiring life-saving medical treatment.

In February 2020, the first medical evacuation flew seven critically ill patients and their families to Amman to receive life-saving medical treatment. According to the UN, around 32,000 patients with serious illnesses signed up for medical evacuations.

This was a small triumph as analysts are not optimistic about the recent signing of an agreement between the internationally-backed government of Yemen and a UAE-supported southern separatist group designing to bring an end to this complicated five-year war.

Now Yemen reports its first case of COVID-19 infection in Hydramaut, in the eastern region--- A long-awaited and dreaded piece of news.

I recently joined a non-governmental organization, MedGlobal, along with a group of volunteers offering medical surgical education program and care at two government hospitals in Yemen; Sayoun General Hospital, a 75-bed hospital in Sayoun in Hydramaut governorate, and traveled for five hours through the desert to Kara General Hospital, a 100-bed hospital in Marib in Marib governorate, stopping at numerous checkpoints, escorted by the military. Marib is only 75 miles west of Sana’a, controlled by the Houthis. We worked closely with a local partner Estijabah Foundation.

Most of the healthcare workers fled Sana’a to come to Marib or Sayoun to work when the Houthi took control of the capital. They have adapted to resource-limitations, but the basic infrastructure of the hospitals needs an urgent overhaul.

The starkest observation of our visit was the distinct lack of sinks for handwashing. Most of the available sinks were non-functional with missing faucets and drain pipes. There were no soaps or scrubbers by the sinks in the operating rooms. The 6-bed intensive care unit in Sayoun General Hospital had only a sink in a bathroom situated in a far corner of the unit. It was a disincentive for the healthcare workers to wash their hands in between patients. In the maternity ward of pre- and post-delivery rooms of about 14 beds, there was a sink in the reception area far away from either ward. There was another sink in the same area but that had been non-functional for a period and the staff did not know when it would be fixed.

Similarly, a single sink situated 50 feet away from the furthest patient room served a surgical ward of thirty patients. The doctor only washed his hands after he finished seeing all the patients, thus providing excellent opportunities for cross-contamination. To walk the length of 50 to a 100 feet in between patients to perform handwashing would add more time to the ward rounds. If the hospital had access to waterless alcohol hand sanitizers, it would have solved the problem. An alcohol-based hand sanitizer by each bedside or on the rolling desk of the rounding doctor would provide a ready source for hand-washing, however, such commodities are difficult to come by during wartime.

On the other hand, at Kara General Hospital, alcohol-based hand sanitizers were placed on the walls of the emergency rooms but these disappeared and left the healthcare workers with nothing with which to sanitize their hands.

The lack of hand-washing facilities and soaps and water are so common that the healthcare workers have all but forgotten that hand-washing is their armor against infections.

Almost all the wards from medical, surgical, pediatric, and maternity, were crowded. Beds were barely three feet apart from one another. Visitors swarmed them, camping by the bedsides and the hallways. It seemed an entire family, ranging from the very young to the very old, would come and visit, and very often shared a meal, sitting on the floor, and eating with their hands as is their customs. Family units and support are paramount in this society. The infection control service in Kara General Hospital had a difficult time controlling the number of visitors into the wards.

Every day, no matter what part of the day, in front of the hospitals and at the entrances to all the outpatient services were crawling with waiting patients. Evening prayer was conducted on the ground right in front of the hospital. Addressing and enforcing social distancing to prevent the spread of the coronavirus would be practically impossible except if fear of the virus itself should keep the people away from seeking care.

Personal protective equipment was also in short supplies. Most healthcare personnel made do with a pair of gloves or masks, with no gowns or eye shields for protection from blood or fluid splashes when taking care of trauma patients.

Make-shift refugee camps cropped up in the cities with tarps, plastic sheets, reeds, and branches; with nongovernmental organizations offering aids at sporadic intervals. In the morning, droves of scruffy children with a sack hanging over their shoulders, scavenging for scraps of food or whatever that could be salvaged from the garbage dumps, competing fiercely with the stray dogs which, like the children, were the victims of this long-drawn-out and forgotten war.

It is very bad news indeed that the coronavirus has arrived in Yemen. Its already hobbling healthcare system, crippled further by the five-year war, will not be ready. Save the Children reports that Yemen has 700 intensive care unit beds and 500 ventilators for a population of 30 million. Not only is there a lack of intensive care unit beds and personal protective equipment, but the simple sinks with running water and soap are also not widely available.

In these days of coronavirus pandemic where hand-washing and social distancing are keys for killing and slowing down the spread of the coronavirus, it would be extremely difficult and challenging for Yemen. When the number of COVID-19 infections begins to escalate, its collapsed health infrastructure will not be ready to care for them. Additionally, the crowded conditions of the camps, like almost all the refugee camps in the world would have their hands full to control its spread. 


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