A cholera epidemic in Yemen, one of the worst ever recorded, is likely to surge again around March, giving global health experts a few months to get vaccines in to the war-torn country to try to limit the next wave of cases.
Some three million doses of oral cholera vaccine are currently available in a global stockpile designed for such emergencies, according to the World Health Organization.
They could be shipped to Yemen in time to be used in a preventative immunisation campaign ahead of the rainy season, when the risk increases that cholera will spread further through water contaminated with faeces. A million people have been infected so far in the epidemic, according to the WHO.
But a previous plan to get vaccines to Yemen's suffering population was aborted earlier this year, because of the country's ongoing civil war, with both the WHO and Yemen officials citing logistical and technical obstacles.
As a result, WHO officials are not sure this next hoped-for vaccination plan will come off.
"The plans have been discussed in principle, but much depends on the situation on the ground," said Gregory Hartl, a spokesman at the WHO's headquarters in Geneva.
Abdulhakeem Alkohlani, a spokesperson for Yemen's health ministry in Sanaa, said the ministry had "decided to postpone the vaccination until next year," but gave no further details.
Yemen's cholera epidemic is one of the biggest and worst on record. More than 2,200 lives have been lost since April to a disease that thrives in times of conflict and disaster, using poor sanitation to hitch a ride from victim to victim.
The suspected case count has now reached one million, the International Committee of the Red Cross said on December 21. The country also has seven million people on the brink of famine and now an acute outbreak of diphtheria too.
Dominique Legros, a WHO cholera expert, told Reuters the aim would be to vaccinate in a step-wise plan, district by district, starting early in 2018.
"We should be using (cholera) vaccines in Yemen - today, and at large scale," he said. "If we could reach a million people before the next rains, that would be significant. But of course in Yemen, as elsewhere, it is ultimately the decision of the government whether to go for it or not."
Supply would not be an issue, Legros said. As well as the three million doses in the global stockpile, another couple of million doses a month can now be churned out of factories in India and South Korea.
Since conflict and cholera often come together, however, global health specialists say politics will ultimately determine whether the programme will get underway. Earlier this year, a cholera vaccination campaign almost got off the ground, but then never happened.
In June, the WHO's office in Yemen requested 3.4 million doses of cholera vaccine from the Geneva-based International Coordinating Group (IGC) on Vaccine Provision - the gatekeeper of the vaccine stockpile system designed to deliver vaccines to countries hit by disease epidemics.
With about two million doses immediately available at that time, the IGC decided to allocate half of that to Yemen.
Yet three weeks later, the Yemen vaccination plan came to an abrupt halt. With the first half million doses sitting at the airport in Djibouti, the WHO made the unexpected announcement, on July 10, that the decision to vaccinate had been reversed.
Legros said the decision was not the WHO's. "It was the (Yemen) ministry of health's decision finally...not to use the vaccines. That's how it was. So we had to re-ship the vaccines to another country."
The Sanaa health ministry's Alkohlani said the vaccine plans had been made too late, and that the decision not to go ahead with it in July was "purely technical."
IN A HOSPITAL WARD IN YEMEN, THE COLLAPSE OF A NATION
Nahla Arishi, chief paediatrician at the al-Sadaqa hospital in this Yemeni port city, had not seen diphtheria in her 20-year career. Then, late last month, a three-year-old girl with high fever was rushed to Arishi's ward. Her neck was swollen, and she gasped for air through a lump of tissue in her throat. Eight days later, she died.
Soon after, a 10-month-old boy with similar symptoms died less than 24 hours after arriving at the hospital.
Two five-year-old cousins were admitted; only one survived.
A 45-day-old boy, his neck swollen and bruised, lasted a few hours. His last breath was through an oxygen mask.
One morning in early December, 16-month-old Sameh arrived at the hospital carried by his aunt and delirious with fever. Arishi immediately recognised a new case of diphtheria. "Put on your mask," she ordered the aunt.
Sameh's father, a fighter in Yemen's three-year war, rushed in, grabbed his son, yanked off the baby's shoes and threw them on the floor. "Sameh is the light of the house," he wailed, feeling the boy's feverish brow and body.
This is the emergency ward to a nation. After three years of warfare, cholera and hunger, Yemen faces a new battle: In the past four months, doctors across the country have recorded at least 380 cases of diphtheria, a bacterial disease that last appeared here in 1992.
Arishi, like her country around her, is struggling to cope. Every month, she and her team drip-feed dozens of Yemen's half a million severely malnourished children. Her ward has also treated hundreds of the one million people infected by cholera.
This spring, Arishi and her colleagues reopened an abandoned wing of al-Sadaqa hospital, fenced it with chicken wire and created a makeshift cholera treatment centre. Now, they are converting part of that centre into a diphtheria ward, cordoning off isolation units by barring hallway doors.
But with rusty oxygen tanks and only two functional ventilators in a different part of the hospital – and with the expectation that the cholera epidemic will worsen in coming months — her triage upon triage is no longer working.
"We're getting more patients but we can't deal with them. We don't have supplies. We don't have money," said Arishi, "This war has got to end."
For the past three years, Yemen has been the combat zone of a struggle for regional supremacy between Saudi Arabia and Iran. Riyadh and some of its Arab allies jumped into Yemen's civil war in 2015 to help quell an uprising by the Houthis, an Islamic political-religious movement backed by Iran. In addition to airstrikes, Riyadh – with U.S. and U.N. backing – has positioned ships in Yemeni waters as a way to stop arms reaching Houthi militia.
But the blockade has ended up isolating a country that was already the poorest in the Middle East. Vital provisions – food, medicine, fuel, medical equipment, batteries, solar panels and more – are not getting through. Humanitarian shipments of food and medicine have mostly been allowed into the country. Yet Saudi-led forces have severely delayed aid shipments or closed ports outright, especially in northern Yemen where fighting and the humanitarian crisis are most acute.
The war and blockade have also thwarted Yemen's vaccination programmes.
Seven years ago, 80 percent of children were fully immunised with three doses of diphtheria, whooping cough and tetanus vaccine, or DTP as the combined shot is called, according to Zaher Sahloul, a critical-care specialist who cofounded a nonprofit called MedGlobal. Now, he says, that has dropped to 60 percent.
Poor record keeping means there are discrepancies in data related to vaccine coverage. Yemen's Ministry of Health says 85 percent of Yemeni children have been immunised against diphtheria, whooping cough, tetanus, Hepatitis B and bacterial influenza since the beginning of the conflict, a mere two percentage point drop from pre-war years.
In late November, the U.N.'s World Health Organization (WHO) sent a shipment of diphtheria antitoxins - designed to treat those already infected - and vaccines to the capital Sanaa. The vaccines were delayed by the Saudi blockade for a week, the WHO said.
In July, the Geneva-based International Coordinating Group on Vaccine Provision earmarked a million cholera vaccines for Yemen. An initial shipment of 500,000 doses was sent to the African Horn country of Djibouti, and was ready to send on to Sanaa. But the WHO and local authorities in Sanaa decided together to scrap the vaccination plan, citing logistical and technical issues.
"Yemen needs a Marshall Plan," said Sahloul, who was visiting al-Sadaqa's treatment centre in December. "It is difficult to foresee an optimistic scenario if the current conditions persist," he said.
DISEASE AFTER DISEASE
Arishi began her medical career in the mid-1990s after Yemen unified following years of conflict between communist and pro-western forces. She joined the al-Sadaqa hospital, which was built in the 1980s with funds from the Soviet Union.
In her two decades at the hospital's paediatric ward, Arishi has seen Yemen slowly come apart again. Even in the mid 2000s, the country faced widespread hunger because of rising food prices. The feeding centre of al-Sadaqa's hospital, she said, was crowded even before the new civil war began.
In the spring of 2015, Houthi forces, aided by the now-deceased former president Ali Abdullah Saleh, advanced south from their stronghold in the Yemeni capital Sanaa and took over Aden's airport. It was then that the coalition of Arab states led by Saudi Arabia joined the war and began launching airstrikes against Houthi-held enclaves. Fighting raged until troops backing the officially-recognised government wrenched Aden from Houthi control in July of that year.
During the first months of fighting, al-Sadaqa filled with hundreds of wounded children and adults.
By the middle of 2016, another group of patients began pouring into the hospital. A cholera outbreak that started in Sanaa had spread to Aden. Dehydrated children, their condition made worse by malnutrition, flooded into her paediatric ward. Many did not survive, Arishi said.
Cholera can kill because patients quickly lose their fluids through vomiting and watery diarrhoea. When caught early, it can be treated by replacing fluids.
When a second wave of cholera infections swept Yemen in April this year, Arishi and her colleagues decided to set up the new treatment centre. They picked a building away from the main wings of the hospital to avoid contamination and repaired it with funds from the WHO and medical aid group Médecins Sans Frontières (MSF). Converting the building, which had been abandoned for two years after the war, required "heavy cleaning work, electricity, water system repairs as well as installing air conditioners," according to MSF.
Yet, like the country itself, al-Sadaqa was overwhelmed by the cholera epidemic. Nationwide, a million people have been infected, according to the International Committee of the Red Cross. The WHO says cholera has killed more than 2,200 people.
Most of the infected were in the populous north of the country. But al-Sadaqa, which took in patients from across south Yemen, was also unprepared. Arishi and her colleagues had expected 10 patients at a time. Instead, by the summer, they were treating more than a hundred, mostly adults, a day.
Since September, the spread of cholera across the country has abated. However, doctors agree that a new wave of infections is likely in March, when the country's rainy season returns. Cholera spreads more easily in wet weather, because the bacteria live in rivers and coastal waters which swell with the rain. Rain brings sewage into sources of drinking water.
In August, a new disease began to emerge. In Ibb governorate, 170 km south of Sanaa, a 17-year-old boy was diagnosed with diphtheria, according to the WHO.
Diphtheria is caused by bacteria that mainly infect the throat, nose and airways and send toxins into the bloodstream. It has largely receded as a global health threat, because much of the world's population is protected through routine immunisation.
But the disease is highly contagious once it takes root, doctors say, since it spreads in the droplets from coughing and sneezing. Small children are particularly vulnerable because toxins from the bacteria build up a coating of dead tissue that blocks their small airways.
Since the mid-August case, more than 380 patients have been admitted to hospitals across Yemen with diphtheria-like symptoms, according to the WHO. Doctors diagnosed the cases based solely on patients' symptoms. Close to 40 of the patients have died, by WHO estimates. The first case of suspected diphtheria reached al-Sadaqa in November. Of the seven children who arrived within a fortnight, nearly all were initially misdiagnosed with mumps or flu. Four died.
Arishi faced the problem of isolating children with symptoms of diphtheria. She asked hospital administrators to block a hallway door with a cupboard. Behind it, she tried to isolate those who might infect others.
But she lacked basic resources to treat the new disease. Al-Sadaqa hospital, like most others in Yemen, does not have the reagents needed to test for diphtheria. In fact, none of Arishi's diagnoses has been confirmed by laboratory tests.
Marc Poncin, an MSF emergency coordinator in Ibb governorate, said the lack of recent experience means it could be harder to treat diphtheria.
"There has been a loss of knowledge regarding its treatment, because it's become something of a neglected and forgotten disease," he said.
After a diagnosis, treatment is far from easy. Doctors can prescribe antitoxins and antibiotics. But until a few weeks ago, Yemen had no such antitoxin stocks.
The United Nations Children's Fund and the WHO have imported more than 5 million doses of vaccines to immunise children in the worst affected areas. The WHO has already distributed antibiotics to patients and, as prophylactics, to their families.
Some diphtheria patients need emergency surgery to remove blockages from their airways or need machines to breathe. But most of Yemen's hospitals don't have such equipment. As of early December, only two of al-Sadaqa's three mechanical ventilators were working, and the hospital didn't have an isolated operating room for diphtheria patients.
The lack of resources has caused strains with the hospital's supporters. When Arishi cordoned off a part of the cholera ward for the incoming diphtheria patients a couple of weeks ago, the WHO was not happy with the decision, according to Hussein Hassan, head of the WHO's Aden office.
"We cannot confidently say that cholera is over. It is a seasonal problem and it may come back. What happens if another wave starts and the ward is filled with diphtheria patients?" said Hassan.
"I DIDN'T WANT TO LOSE MY KID"
Arishi says there is another sign that Yemen is breaking down: parents' waning faith.
She sees more examples of families that have not vaccinated their children because they distrust both their government and international organisations.
Earlier this month she confronted Saleh Khaled, the father of a five-year-old boy called Yasir, who arrived with severe diphtheria symptoms.
"Why did you not vaccinate your son?" Arishi asked.
Yasir's first cousin, who was also five years old and unvaccinated, had died a few days earlier. When the first symptoms had appeared on Yasir's neck and chin, the boy's parents had given him honey.
Khaled said he had heard rumours, years earlier, about children who had died after healthcare workers had allegedly switched vaccine vials with insulin during a door-to-door vaccination campaign.
"I didn't want to lose my kid because of something like this," he said. "We don't trust the people who work in the health department."
Others in the al-Sadaqa ward that day echoed similar fears.
"We live only because of God's mercy," said Khaled Nasser, the father of 16-month-old Sameh. Nasser, a member of a local armed group that fights alongside Saudi-allied forces, said fellow fighters had helped him buy medicine when Sameh got sick.
Arishi herself barely ekes out a living. She makes $210 a month at al-Sadaqa and works at a private clinic three days a week to supplement her income. The mother of three treats neighbours and relatives without getting paid. Her husband, also a paediatrician, works at another clinic in Aden.
For Arishi, war is both burden and inspiration. She says it has made her commitment to medicine stronger.
"If I leave and my husband leaves and everyone leaves, who will stay to treat our patients?" she said. "Aden is my city. It is my responsibility."
