When the World Health Organization (WHO) declared lengthy humanitarian crises to be a top health threat, perhaps they had Yemen in mind. It wasn’t one individual bomb landing in Yemen that infected hundreds of thousands of people with cholera. Diseases don’t often provide a single snapshot of impact like that. Instead, it was a long series of bombings that wrecked the water treatment plants, the power grids that provided the plants with electricity, and the healthcare facilities that should have been available to control the cholera epidemic. Today, more than two years after the outbreak started, its end is nowhere in sight.
Complex humanitarian disasters often fade into the background. But they don’t end quickly, if at all. The damage they wreak on public health goes unseen, until a singular image drives media coverage and public scrutiny. Saudi Arabia’s bombardment of Yemen didn’t attract attention until a school bus was hit by a 500-pound bomb in August 2018. When Saudi journalist Jamal Khashoggi was murdered, the scandal completely overshadowed how half of Yemen’s population has been displaced by the conflict, with millions living in desperate conditions.
We see this again with the current ebola outbreak in eastern Democratic Republic of Congo (DRC), which has garnered more headlines in medical journals than in international news outlets. The nation has concluded a presidential election with disputed results; more than one million people in the eastern part of the country have been forcibly displaced; and, with dozens of rebel militias, the population hasn’t known peace in decades, even though the two Congo wars formally ended 15 years ago.
When the first cluster of cases in this outbreak was identified in summer 2018, the DRC government and the WHO had just finished containing a different outbreak in a separate, more peaceful part of the country. This previous outbreak ended quickly - in several months - because health officials worked closely with community leaders to trace everyone possibly exposed to those infected with the virus, and used a new experimental vaccine to protect those at greatest risk.
But in conflict zones, this methodical approach to humanitarian health hits too many roadblocks. Outbreaks of polio, cholera, measles and monkeypox compete for attention in eastern DRC. Community resistance to the interventions and tracing efforts has resulted in occasional flares of violence. This current Ebola outbreak has lasted twice as long as the previous one and is still growing in size – it is now the world’s second-largest – because of the insecurity and chaos.
Eastern DRC and Yemen are connected in a distinct way. Because the world has reacted only passively to years of war and suffering, both places have only got worse. Such situations can become powder kegs, exploding into dozens of crises that spread across borders and even continents. The guidelines and interventions in place for responding to specific health emergencies become less effective in the maelstrom of protracted humanitarian disasters.
For example, to control cholera, the WHO highlights the need for clean water and proper sanitation. In Yemen, many of the facilities needed for these services have been bombed into rubble. The worst Ebola outbreak, which ravaged West Africa from 2013 to 2016, took years to contain. Even after the decades-long conflicts in Liberia and Sierra Leone had ended, communities would not trust corrupt governments - or anyone in a position of authority - with even the most basic of health information. That outbreak led to cases in the US and Europe, and ensuing panic.
In an environment of indiscriminate bombing, guerilla raids, or even desperate poverty, disease containment becomes extremely difficult. In DRC, a volatile political situation and a contagious virus threaten other countries. But there is nothing preventing Yemen or any other long-term conflicts, such as those in Kashmir, Palestine, Syria and Afghanistan, from rising to this status.
There have been a number of United Nations Security Council resolutions addressing the humanitarian crises in DRC, Yemen and elsewhere, but rarely do the force of words carry enough resolve to pacify these disasters. The powers seated at the Council who are fuelling both sides of the Yemeni war, for example, prevent these resolutions from naming and deterring all of the states involved.
The UN needs a stronger stance on the protection of health facilities, as well as water and sanitation infrastructure. In this age of satellite data, monitoring attacks against these off-limit targets should be easier to document, even in the world’s more remote places. Similarly, the outlaw militias in eastern DRC may be able to hide from satellites in the deep rainforest, but when they move, they can be tracked - if there is political will to find them and their sponsors.
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Protracted conflicts are public health crises of the worst magnitude. We need to treat them accordingly. These situations need their own containment plans, and we need to invest in long-term solutions that bring peace and governance, so that the health of long-suffering populations can improve.
Singular snapshots grab attention, but they never capture the entire picture. These complex situations are no longer isolated - they are our present and our future. The instability that long-term conflicts breed is a threat to us all, and should be tolerated no longer.
Paul Spiegel is the director of the Center for Humanitarian Health at the Johns Hopkins Bloomberg School of Public Health. Spiegel and colleagues recently issued a report examining the 2017 Cholera outbreak in Yemen.