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November 1st, 2020

Emerging Local Innovation and challenges in Response to Infectious Disease Outbreaks in Yemen

Historical perspective on Infectious Diseases in Yemen: importance of community-based responses

<p class="font_8">A hundred years ago, as the Spanish Flu outbreak reached northern Yemen, small communities struggled to deal with the devastation. Qadhi Mohammed al-Akwa (a prominent Yemeni thinker and historian?) documented the outbreak in his seminal work ‘A Page from the Social History of Yemen and the Story of my Life’ (<em>safaha min tarikh al-Yemen al-Ijtimayy wa qasah</em> <em>hayaty, 1993</em>), where he referred to the era as <em>Sanah al-Fina’</em> (the Year of Extinction). Indirectly, al-Akwa highlighted the resilience of small communities responding to the health crisis, and the importance of cooperation in absence of state institutions and national strategies to contain such outbreaks. Yemen has experienced similar challenges during the most recent cholera outbreak, and now the Covid-19 period. The response to the Novel Covid-19 virus outbreak since April of 2020 has particularly highlighted the constant importance of small-scale, locally driven initiatives and the role played by Yemenis living abroad.</p>

<p class="font_8" style="text-align: justify">A heightened awareness of history among Yemenis contributed to the initial alarm over the Covid-19 outbreak in 2020, especially as experts around the world compared the spread and mortality of this novel virus to the Spanish Flu outbreak that claimed nearly 50 million lives worldwide. One shouald note similarities between al-Akwa’s account of the fear over the potential devastation in Dhammar, for example, and fears over the Covid-19 virus (coronavirus) among the general population in 2020.</p>
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<p class="font_8" style="text-align: justify">Just prior to the Covid-19 outbreak, Yemen faced a compound crisis amid floods, Cholera and Diphtheria outbreaks nationwide. International organizations, who provide the bulk of funding for emergency responses, relied heavily on small-scale initiatives driven by local civil society organizations (CSOs) to implement ‘rapid response’ strategies addressing hygiene education and clean water needs. In areas of Ibb province, for example, UN agencies relied on community-based local rapid response teams, not government agencies, to distribute basic information and chlorine tablets for clean water. After decades of investment and development, but similar to conditions a century ago, Yemen’s health sector proved insufficient at the onset of this outbreak. Government institutions lacked the capacity to organize and implement a coherent response to the Cholera or Diphtheria outbreaks in recent years. Unlike governments in East Asia, who learned from the SARS (2003) and MERS (2015) outbreaks, war-torn Yemen has been unable to coordinate a government-led response to Covid-19 similar to Singapore, South Korea and Taiwan did in 2020.</p>
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<p class="font_8" style="text-align: justify">Lack of coordination between <em>de facto</em> authorities across the country has also exacerbated the crisis during the Covid-19 outbreak, regarding the response to those infected and implementation of a strategy to contain the outbreak. As the gap in services grows, some highlight initiatives launched by Yemenis living abroad working to fill this gap by disseminating information to the general public, online as well as on the ground. Others organized health care experts providing expertise and equipment to local medical staff. Consequently, these small-scale initiatives have also highlighted disparities across regions, as a disproportionate number of the small-scale initiatives focus on services provided across southern provinces. In the reporting that follows, we note difficulties in accessing information from organizations operating in northern provinces, in particular.</p>

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Covid-19 outbreak in Yemen: innovation in the health sector

Over the past two decades, Yemen’s health care sector experienced progress in various areas, but has proven insufficient as cholera and now Covid-19 outbreaks spread nationwide. Access to health care expanded nationwide in the years prior to the current armed conflict. Yet, as the economic crisis worsens, health care facilities face new challenges as infrastructure crumbles, limited equipment and medical supplies, as well as limited access to potable water and sustainable energy sources. While it is evident that the absence of national bodies coordinating funding, distribution of personnel, and the procurement of medical supplies, exacerbates the crisis in the health care sector, innovation driven by cooperative efforts between Yemenis living abroad and local actors have strengthened resilience across the health sector. A number of small-scale initiatives have proven vital lifelines for Yemenis during devastating times.

A brief survey of efforts to tackle Cholera, Diphtheria and now Covid-19 outbreaks reveals small, community-based initiatives have played a major role in developing effective response strategies. The number of small-scale initiatives led by Yemenis abroad, for example, continues to multiply as infrastructure in Yemen deteriorates. There are hundreds of such initiatives working to provide food, potable water, solar power, and micro-investments in agriculture to many communities across the country. At the onset of the cholera outbreak, for example, communities in the US and Europe rushed to provide vital medical supplies and chlorine tablets to help households.

AS international health officials began to raise concerns over the Covid-19 outbreak, a number of small-scale initiatives sprung up among Yemenis abroad. Dozens of small groups began raising awareness in Yemen out of fears of a major pandemic affecting a highly vulnerable population, as Yemen experienced during the 1918 Spanish Flu outbreak. Among these small groups we noticed work done by a group of five young women that launched ‘Corona Facts In Yemen’ from their homes in the USA, Romania and Saudi Arabia, the Yemeni Public Health Network (YEMPHNet) and the Yemeni Public Health Group (YPHG). The young women of ‘Corona Facts In Yemen’ focus on sharing facts on a daily basis with new topics, points, reminders, and updates, all written in Arabic and sometimes in a Yemeni dialect.

Their work complimented information published by the Yemen Supreme National Emergency Committee for Covid-19 and helps fight misinformation, quickly becoming one of the more reliable sources of information. The idea for their initiative sprung from "[s]eeing family and friends share inaccurate information on dealing with the pandemic is not only wrong but could be ultimately dangerous and detrimental to their health, it made [them] realize that people are worried about COVID, but they don't have access to accurate and trusted information."
There are also the various components of the diaspora-driven Covid-19 Consultative Group and Yemeni Diaspora Initiative that include the Yemeni Public Health Network (YEMPHNet) and Yemeni Public Health Group (YPHG). YEMPHNet and YPHG are two cross-disciplinary groups of experts formed in 2020 with the specific purpose of assisting local experts and authorities responding to the Covid-19 outbreak. YEMPHNet aims at coordinating with government authorities and related healthcare partners to provide strategic and technical support. The Technical team, for example, focused on strategic thinking and active communication with health stakeholders in Yemen, while the risk communication and community engagement team worked on community awareness to promote disease control and preventive measures. These two initiatives advance the idea of cross-discipline cooperation and strategic planning in response to a virus outbreak in Yemen. We can see how collaboration among Yemenis living abroad, government institutions and local communities, can advance homegrown solutions prioritizing local needs and capacity building.

Much work remains to be conducted on the work and effectiveness of initiatives such as those mentioned here. What remains a constant is the need for services and collaboration across the health sector at the national level. Mounting challenges increase demand for creative solutions that address the root causes of deteriorating health services, for example, and a process that prioritizes a local approach to such needs.

International and local response to health crises and innovation

Amid mounting challenges, civil society continues to drive community-based solutions across Yemen

Amid mounting challenges, civil society continues to drive community-based solutions across Yemen. Small-scale initiatives have been at the forefront of emergency response operations during recent Cholera and Diphtheria outbreaks, and now Covid-19. Civil Society Organizations (CSOs), relying on small teams recruited from within affected communities, have led rapid response teams that grant international organizations and UN agencies the capacity to reach beyond urban centers. A number of these community-based groups are also organized and funded by small groups of Yemeni professionals living abroad.

In other regions of the world, recent outbreaks such as SARS and MERs served to develop new procedures and agencies by government institutions. The trend in regions like Asia has been centralization of response strategies under government agencies. This has raised concerns in the time of the Covid-19 outbreak as a number of governments have used their past experiences to expand emergency powers beyond containment of the outbreak to crack down on political rivals.

In Yemen, amid a protracted conflict, the trend has been in the opposite direction expanding innovative decentralization through small-scale initiatives led by local communities and Yemenis living abroad.

At a much smaller scale, innovation in Yemen has also emerged in the area of digital communications. While governments in Asia have led this innovative response to infectious disease outbreaks, and centralized information and dissemination, in Yemen it has been at the hands of young Yemeni professionals. As previously noted above, young Yemenis living abroad, for example, launched a small-scale initiative to tackle the infodemic emerging around the Covid-19 outbreak. Their initiative “Corona Facts in Yemen” has helped fight misinformation, spread not merely via traditional media outlets but also through new media like WhatsApp and other social media platforms. This group of young Yemeni women has been able to communicate expertise and guidelines from the WHO to communities across Yemen. Their project shows dissemination of information has no limits in digital form.

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The dire situation across the country has also witnessed great resilience. Aden has witnessed a rise in number of small street vendors, importers have managed to establish new ground routes, although far more time consuming. Images from the Oman-Mahra crossing often display the long lines of cargo trucks waiting to cross into Yemen, also highlighting the mounting challenges faced by truckers and importers. Recent video from Taiz showed dozens of trucks traversing difficult terrain around mountains in order to bypass roads destroyed by airstrikes or new check points set up by various groups, often taxing truckers at each point along the road into the city of Taiz.

An area with booming business, as direct consequence of the economic crisis, has been smuggling. Yet, while they are highly effective tactics to cope with emerging crises meeting needs of a specific segment of the population, smuggling creates consequences in the open market with increase in prices, as well as contributes to deteriorating security environment along smuggling routes.

The government of Yemen, attempting to replenish their foreign currency reserves, reported it aimed at increasing oil output by 25% in June 2020. Unfortunately, a number of disputes with international partner companies working in various oil fields have contributed to delays, extending the currency crisis. The Yemeni rial (YR) remains at over YR850 per US$1 dollar, well above the YR550 target set by the government at start of 2020. Adding to Yemen’s woes, the international donors conference of 2 June 2020 failed to meet expectations, with a mere US$1.3 billion pledged out of the requested US$2.41 billion. International organizations have reported donors have yet to deliver on their pledges, with less than half of the funds pledged being distributed to aid agencies.

While de facto authorities across the country fail to reach an agreement to alleviate the economic crisis, local and regional chambers of commerce fight for large corporations and small businesses. In Sana’a, a dispute arose after local authorities levied a tax on street vendors, directly affecting their profit margins already affected by inflation. The chamber of commerce expressed concern over this policy and some vendors were excluded. The Sana’a Chamber of Commerce has also demanded implementation of economic reforms to help importers and retailers across northern provinces, local authorities have yet to respond as priority is given to issues concerning Sana’a International Airport and the Hodeida seaport. In Aden, a number of economic actors, including international organizations have directed their demands at local authorities over access to Aden seaport. They also demand relief from tariffs and other taxes on basic imports.

The ongoing Covid-19 outbreak in Yemen further exacerbates a compound economic crisis

The ongoing Covid-19 outbreak in Yemen further exacerbates a compound economic crisis. Floods, cholera, and diphtheria were already disrupting “access to health and sanitation services” across the country, affecting a population of over 20 million Yemenis in need of assistance. The WFP estimates “3 million may now face starvation due to the [Covid-19] virus” outbreak, while an existing 8.5 million WFP beneficiaries may see services cut due to budget shortfalls amid a lack of contributions from the donor community.

The UN has documented over four million displaced persons, with over an “estimated one million [living] in [some 1,7000] makeshift camps”. Between March and July of this year, IOM reported over 100,000 internally displaced persons (IDPs) due to the Covid-19 outbreak, “most typically related to fears of contracting the virus and the impact of the outbreak on services and the worsening economic crisis.” Misinformation and unclear policies at health care facilities created a new crisis, particularly across southern provinces.

The lack of clear and verifiable economic data from Yemen at present further complicates analysis on the impact on the Covid-19 outbreak in real terms. Data from international organizations reporting on migration and the IDP crisis does not accurately depict the economic situation on the ground. While imports have been directly affected by the lack of access to air and seaports, residents in both Aden and Sana’a boast of fully stocked markets and robust consumer activity. Until recent months, remittances from Yemenis in Gulf countries, Asia, Europe and the US provided a strong safety net for a large segment of the population, 1 in 10 persons rely on such money transfers (Oxfam). Yet, the flow of cash sent from abroad was itself affected by economic slow-down worldwide as the Covid-19 outbreak surged. Oxfam reported nearly 80% drop between January and April 2020 through money transfer provides in Yemen. In 2019, remittances accounted for about 13% of Yemen’s GPD, around US$3.8 billion.

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Adversity and opportunities to lead from below

Yemen’s resilience through mounting adversity at a time of war continues to create opportunities for new generation of professionals

Yemen’s resilience through mounting adversity at a time of war continues to create opportunities for new generation of professionals, inside and outside the country. The current Covid-19 outbreak has stressed the vulnerable health sector across the country, equally affecting urban cities and small rural communities. In the absence of a coherent national strategy by central authorities, or even regional de facto authorities, the country’s response to the enduring health crisis heavily relies on contributions and operations by international organizations. However, the situation served to create opportunities for an emerging new generation of Yemeni professionals leading civil society organizations.

While opinions on the response to the Covid-19 outbreak worldwide has been mixed, models of success include the response by Singapore, South Korea and Taiwan. Yet among all the successful models, an initial survey points to a heavy top-down approach dependent on State-driven coordination and funding. In the case of countries in Asia, research points to lessons learned from previous outbreaks like SARS and MERS as drivers of policies to reinforce health sector infrastructure and national preventive strategies to coordinate responses for containment. In Africa, where countries face the challenges of multiple outbreaks including cholera, measles, Ebola virus and yellow fever, among so many others, recent research highlighted the role played by international organizations in preparing a ‘multisectoral National Action Plan for Health Security (NAPHS)’ to address gaps identified through evaluation processes.

The direct role played by the WHO in the African continent ‘helped to prolong the containment phase of Covid-19” in many countries. Reports point to heightened preparedness across sub-Saharan Africa as result of “stronger national public institutes, rapid scale-up of testing capacity, better coordination…and the capacity of built-in surveillance and contact tracing.” South Africa’s own National Institute of Communicable Diseases (NICD), for example, proved vital in disseminating WHO recommendations and data collection. This level of success, in a continent ravaged by armed conflict and multiple health emergencies, has received high praises internationally, with a number of western institutions underlining the high marks received in international evaluation reports.

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In the case of the Republic of Yemen, the response to the Covid-19 outbreak produced mixed results. As of the week of 8 October 2020, there were 2,049 reported cases, 1,328 recovered and 593 fatalities. Between 22 September and 5 October there were 15 new cases reported. Organizations working in the health sector report 63 doctors have died of Covid-19 as of the first week of October. Unfortunately, this data is regarded as highly inaccurate due to a lack of capacity nationwide in contact tracing, for example. The weak health sector infrastructure may also lead to many unreported cases in isolated areas. Early reports in April and May claimed many of the initial cases were under reported in order to prevent panic among the general population, leading to widespread misinformation on the outbreak and international recommendations for containment. The the Yemen Supreme National Emergency Committee for Covid-19 reported no new cases on 19 October 2020.

With no opportunity present to evaluate the small-scale initiatives that sprung up since April 2020, a look at initial reports does highlight their role in closing the needs gap. On the other hand, early evaluation of international efforts during the Covid-19 outbreak does highlight a national need for coordinated response strategies. With the recent experience in Yemen, amid growing instability and mounting challenges for the health sector, a look into future outbreaks could benefit from a mixed approach, recognizing the gap in government services, the role played by international organizations and the integral role of community-based initiatives led from below.

It remains unclear if these small-scale initiatives could survive the length of the health crisis in Yemen or evolve to meet new challenges. It is also important to observe how their collaborative efforts linking local health professionals, government officials and Yemenis living abroad could lead to new institutions that better prepare the general population to meet the challenges from future infectious disease outbreaks in the country.

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