Malnutritioned, underdeveloped children flank her every side. The sound of shelling reverberates in the distance. Amidst the chaos of grieving mothers and over-subscribed nurses, Dr. Mekkia Mahdi, one of a dwindling number of healthcare professionals in Yemen, laments, “we Yemenis don’t need malnutrition treatments or cholera and COVID vaccines.” She pauses, adding, “we need a vaccine that will end this war."
Having dragged on since 2014, the Yemeni civil war has wreaked havoc on the nation's healthcare system, with a disproportionate impact on Yemen’s 13 million children. Yet many often perceive Yemen’s malnutrition crisis, the worst on record in history, only through its medical dimension, rather than through a broad, comprehensive biosocial approach that examines the role of war in perpetuating the food crisis epidemic while taking into account the many historical, environmental, cultural, and social factors at play too. Doing so has only inflamed (and will continue to inflame) a synergy of epidemics threatening an entire generation of Yemenis.
The Origins of Yemen's Poverty
Ultimately, violence alone cannot account for the extent of suffering from malnutrition across Yemen and the complete collapse of the healthcare system in responding to this epidemic. An analysis of Yemen’s modern day poverty, where the World Food Program reports 17.4 million people are chronically food insecure, extends back to November of 1990. During this time, barely six months after the People's Democratic Republic of Yemen was united with the Yemen Arab Republic, marking the country’s unification, Yemen was asked to vote on US-sponsored Resolution 678 at the United Nations Security Council regarding Iraq, just four months into Iraq’s occupation of Kuwait. At the time, President Saleh’s positive relationship with Saddam Hussein prompted Yemen to cast the only negative vote against this resolution. As a response, author Helen Lackner in her book “Yemen in Crisis” notes that “the US Ambassador to the UN, Thomas R. Pickering, brazenly threatened the Yemeni representative on the UNSC, telling him that “this will be the most expensive vote you ever cast.” Indeed, the US immediately cut off US$70 million in aid to Yemen, influencing international neoliberalist institutions that it both funded and ideologically guided to stay away from Yemen. As a result, few projects were financed by the World Bank and no agreement was reached with the IMF until 1995 (the end of Yemen’s first Civil War), long after the rest of the Middle East had implemented the West’s neoliberalism.
Yemen’s isolation, both economically and politically, led to rapidly deteriorating economic conditions for most of the Yemeni population, contributing to the political instability that led to Yemen’s first civil war between May and July of 1994. The wave of neoliberalist policies forced upon the Saleh regime in the decade and a half preceding the Arab Spring, in lieu of the Washington Consensus, compounded with the discovery of Yemeni oil, shifted economic power from individuals to a centralized state. The impacts of this shift were two-fold. First, as Dr. Salmaan Keshavjee put it in his ethnography on neoliberalism and its infiltration into global health interventions, the outcome “was to relieve governments of the responsibility of looking after their poorest citizens and to put the burden on individuals themselves regardless of their capacity to pay for services,” thus inducing “a moral transformation in the doctor-patient relationship—from healer and patient to service provider and paying client.” Second, and even more ironic, the West’s obsession with neoliberalism as a means of bringing about democracy in authoritarian states backfired. Neoliberalist market requirements enabled authoritarian regimes like Saleh’s, failing to stimulate the economy and simply reaffirming corruption, cronyism, and inequality in the region. This resulted in extreme poverty and food insecurity in Yemen today, while the international community largely evaded responsibility for it.
Culturalist Explanations of the Yemeni Conflict
Equally devastating and incriminating, culturalist explanations of the Yemeni conflict that were perpetuated by Western leaders and media outlets attributed human rights abuses to ‘tribalism’ and bad governance. Thus, they shrouded the malnutrition epidemic in excuses and diluted the accountability of all actors involved, contributing to a broad clinical nihilism that has caused dismal inaction. While Yemeni political analyst Abdul Ghani al-Iryani estimates that no more than 20 percent of Yemenis even belong to tribes, Western analyses of the Yemeni crisis more often than not attribute the conflict and its cruelty to tribalism, over-exaggerating the importance of tribes in the political sphere and identifying tribes as the only actors in the war, and thus the only perpetrators of violence. This oversimplification of the conflict in Yemen shifts blame from international actors involved in the war, such as Saudi Arabia and Iran, who have turned the conflict into a proxy-war by supplying opposing sides with weapons and funding, to the Yemeni people. As such, this oversimplification unjustly blames Yemenis for the escalation of a war they had little power to resist, a textbook example of what Dr. Paul Farmer calls immodest claims of causality, claims that mistake structural violence for “culture”, blaming individuals for the predicaments in which they find themselves.
The closure of health facilities due to the conflict has meant that hunger wards specifically treating children with acute malnutrition have become harder to come by, forcing families to endure shelling to simply get their children the care they need. Indeed, to Yemenis especially, the severity of Yemen’s malnutrition crisis compounded with the international community’s apathetic view towards it has additionally led to a profound sense of clinical nihilism. For Yemenis, the greatest obstacles to health justice are not to be found in biological labs or hospital wards. Instead, there are to be found in the international community, or, more specifically, in “the pathogenic forces of apathy, cynicism, marginalization, and historical amnesia that drive the acceptance of the suffering of the poor as inevitable misfortunes to be endured, as opposed to injustices to be cured.”
What media attention Yemen has gotten has been centered around questions of biosecurity, ie. how to prevent the introduction and/or spread of disease and bacteria, with Op-Ed’s asking questions like NYT writer Sam Loewenberg’s, “Will the Next Superbug Come From Yemen?” dominating global headlines. Narratives like these primarily concern themselves with the West’s future biosecurity, as opposed to the well-being and health of Yemenis suffering in the present. They are indicative of a racist, imperialist view of global health borne out of the colonialist enterprise, centering white lives and thus dealing with health issues threatening the lives of black and brown bodies insofar as they impact the long-term security and longevity of the white race. Not dissimilarly, the international community’s socialization for scarcity has led to the conception that famine is an economic inevitability. Starvation in Yemen continues to be seen as occurring in spite of the market’s rational distribution of resources, not because of it, rationalizing wealthy Yemenis even as poor Yemenis face famine.
A Socialization for Scarcity
Amidst these war crimes of starvation and induced famine, however, the international community has stuck to its socialization for scarcity, arguing that to provide Yemen with enough food is impossible, and even cutting Yemeni aid in recent years. David Beasley, head of the UN’s World Food Programme has repeatedly warned of and implemented cuts to food rations for millions, citing the economic consequences of the pandemic on the UN’s operating budget. But Beasley simultaneously acknowledges that 16 million people in Yemen are “marching towards starvation." Some 30,000 healthcare workers reliant on UN salaries have not been paid in over a year, forcing a mass exodus of healthcare professionals who are crucial to treating malnutrition in children in the nation.
Unfortunately, the insidiousness of malnutrition could not be clearer. Malnourished children are more vulnerable to other diseases, statistically at 12-times higher risk of death due to infectious diseases, compared to non-malnourished children. Indeed, malnourished children in Yemen faced with the largest cholera outbreak in the world, made worse by the war’s siege on water pumps and pipes, were particularly susceptible to cholera. This tragedy can explain why, by October of 2018, more than 2,500 people—58 percent of them children—had died from the disease. The story of COVID-19 is almost identical. While data in most countries indicated that children could be less affected by COVID-19, over 90 percent of Yemen’s under five population suffers from at least some degree of malnutrition, with 2 million of them classified as severely malnourished, rendering them immunocompromised and thus more susceptible to severe symptoms of COVID-19. Broadly speaking, Yemen’s malnourished children are also at higher risk of contracting and dying from a slew of diarrheal diseases long eradicated in the rest of the world, in addition to malaria and pneumonia, for which stunting increases the risk of treatment failure as well.
The epidemic's broad societal impact
The effect of Yemen’s malnutrition epidemic in children on broad societal issues cannot be understated either, as it must also inform the way in which healthcare professionals think about global health interventions in Yemen going forward. In a country with one of the world’s greatest gender-based disparities, malnutrition has only exacerbated gender inequality, which in turn will continue to fuel malnourishment, cyclically worsening all outcomes. Women are the first to skip meals or eat smaller portions to maximize the family ration, resulting in many women suffering from malnutrition most after children, and thus being at increased risk of giving birth to malnourished babies whose life expectancy is threatened before they are even born. Further indicating the link between gender inequality and malnutrition, girls as young as eight and ten are commonly married off to reduce the number of family members to feed and bring in a dowry to sustain the rest of the family and pay off food debts. If Yemen’s malnutrition epidemic continues, gender parity indicators will thus be sure to worsen and again fuel future health crises, as countries with lower indicators of gender parity have statistically been linked to worse outcomes of health.
Take mental health as another example of the effect of Yemen’s child malnutrition epidemic on broader societal issues. For parents across Yemen, watching their children pass away from malnutrition, a clearly preventable outcome, is a harrowing experience. Aisha, a mother of five children featured in the VICE documentary Children of Yemen focused on malnutrition in Yemen, is just one example. Surrounded by mothers holding their severely underweight children, Aisha describes the passing of her 15-month-old Ibrahim, who, suffering from acute malnutrition, went into cardiac arrest and died before Aisha could get him to the nearest clinic over six kilometers away. In the documentary, Aisha stands with her four year old, Adam, in a make-shift clinic near Mirab. She’s brought Adam to the clinic because his hands are ‘dry’. In the absence of food, he has bitten his fingers raw. Aisha reports multiple occasions where she’s found his mouth covered in blood, a result of his incessant gnawing. He, like all the other children at the clinic, has developed acute malnutrition, and while the clinic gives Aisha packets of supplements to treat that acute malnutrition, he passes just two days after the footage is filmed. The depth of Aisha’s loss is unimaginable. But she is just one of thousands of Yemeni mothers who have had to deal with the deaths of their malnourished children, women who, if they live through the war, will be forced to cope with this grief for decades to come, a mental health crisis the international community has not even begun to worry about.
What Care for Yemen Must Look Like
Ultimately, a broad biosocial analysis of the current epidemic of malnutrition in Yemen has illustrated the importance of a biosocial approach to global healthcare delivery, underscoring the complex ways in which health in Yemen has been impacted by social, cultural, economic, and historical factors vehemently out of the control of the Yemeni people. As this analysis has revealed, the tale of malnutrition in Yemen is one of international affairs and political economy in the post-colonial era, punctuated more recently by racism, apathy, and general inaction. While this analysis begins to uncover how healthcare delivery in Yemen cannot just be viewed through the prism of health, more is needed to formulate just, context-specific health interventions with regards to malnutrition. Perhaps most pressingly, the international community must put an end to its culturalist explanations for the Yemeni civil war, holding all actors involved accountable for their war crimes, pushing for an end to the war, and ultimately ensuring that malnourished children are receiving the care they deserve — both in the present and the future. This type of care should look like caring for the memory of those children who have passed from malnutrition, a critical component of caregiving outlined by Harvard Professor Dr. Arthur Kleinman and often overlooked in the broader field of global health, as well as providing direct care to the millions of children still suffering from malnourishment today.
Ultimately, this biosocial approach to analyzing malnutrition in Yemen means little without an intentional, humane focus on those most impacted by the crisis. In the words of renowned global health expert Dr. Paul Farmer, “a nation’s most precious resource is its people,” and rebuilding Yemen and its healthcare infrastructure can only be done through a renewed effort to center Yemenis themselves in all efforts to deliver healthcare and reconstruct infrastructure. Children like Amal, who had lost two siblings to malnutrition by the time she reached the age of five but could not cry for them because of her own underdevelopment, and Abdelrahman whose mother passed away from cholera, in part because she suffered from acute malnutrition, should be at the center of every discussion regarding the failure of healthcare delivery in Yemen. Acknowledging how neoliberalism, culturalism, and socialization for scarcity all fueled malnutrition in Yemen is just the beginning. For each of the children mentioned in this paper, the thousands more who’ve unnecessarily lost their lives to malnourishment, and the millions more already on the brink of starvation today, more must be done. Yemen must not receive only ‘a vaccine to end its war,’ but one to end the depth of its suffering, too.