The political determinants of the cholera outbreak in Yemen
Authors: Jonathan Kennedy, Andrew Harmer, David McCoy
Journal: The Lancet Global Health (2017)

At the end of June, 2017, UNICEF and WHO released a statement declaring that Yemen is "facing the worst cholera outbreak in the world".1UNICEFWHOStatement from UNICEF Executive Director Anthony Lake and WHO Director-General Margaret Chan on the cholera outbreak in Yemen as suspected cases exceed 200,000.http://www.who.int/mediacentre/news/statements/2017/Cholera-Yemen/en/Google Scholar The statement points out that the outbreak is caused by the civil war that began in 2015, but it does not suggest that one party is more responsible than another, simply noting that "two years of heavy conflict" have resulted in "collapsing health, water and sanitation systems". Nor does it point to one side being more affected by the outbreak, stating that "cholera has spread to almost every governorate". When one combines WHO's latest epidemiological data for the period April 27 to July 31, 2017,2WHOYemen cholera outbreak: daily epidemiology update 31st July.http://www.emro.who.int/images/stories/Yemen_daily_epi_update_20170731.pdf?ua=1Google Scholar with data from Risk Intelligence that maps areas of government and rebel control,3Risk Intelligence (@riskstaff)#Yemen map: Government forces advancing in the western coast of #Taiz & on the outskirts of the city.https://twitter.com/riskstaff/status/894870965364150272Google Scholar it is clear that the cholera outbreak disproportionately affects areas controlled by Houthi rebels (table). 67·1% of Yemenis live in governorates wholly or mostly controlled by Houthis, whereas 22·7% live in government-controlled governorates. (The remainder live in Taizz governorate, significant parts of which are controlled by both sides.) 77·7% of cholera cases (339 061 of 436 625) and 80·7% of deaths from cholera (1545 of 1915) occurred in Houthi-controlled governorates, compared to 15·4% of cases and 10·4% of deaths in government-controlled governorates. The attack rate was 17·0 per 1000 population in Houthi-controlled areas compared with 10·0 per 1000 population in government-controlled areas, while the case–fatality rate was 0·46% in Houthi-controlled areas compared to 0·30% in government-controlled areas.2WHOYemen cholera outbreak: daily epidemiology update 31st July.http://www.emro.who.int/images/stories/Yemen_daily_epi_update_20170731.pdf?ua=1Google Scholar One tailed t-tests demonstrate that attack rates (t=–1·882, p=0·038) and case–fatality rates (t=–2·435, p=0·013) are statistically higher in Houthi-controlled governorates than in those under government control.TableThe Yemeni cholera outbreak by governorateCasesDeathsAttack rate (per 1000)Case fatality rate (%)Governorates controlled predominately by governmentAbyan14 4743323·70·23Aden13 0225213·60·40Al Dhale'e24 8497633·00·31Al Jawf4203166·50·48Al Mahrah73114·50·14Lahj7124176·80·24Ma'areb248546·90·26Hadramout2800·00·00Shabwah43010·70·23Socotra000·0··All67 34620010·00·30Governorates controlled predominately by rebelsAl Bayda12 8722616·70·20Al Hudaydah53 80323116·10·43Al Mahwit25 80912833·90·50Amanat Al Asimah53 9756016·30·11Amran44 45715029·10·34Dhamar33 64713215·90·39Hajjah45 34635920·40·79Ibb32 60524210·60·74Raymah77589512·21·22Sa'ada117651·30·43Sana'a27 61311722·10·42All339 061154517·00·46Governorates controlled by government and rebelsTaizz30 21817010·00·56TotalAll436 625191514·70·44 Open table in a new tab Both sides have been accused of disregarding the wellbeing of civilians and breaching international humanitarian law. However, the government is supported by a Saudi-led coalition and this alliance commands far greater resources than the rebels. As a result, Houthi-controlled areas have been disproportionately affected by the conflict, which has created conditions conducive to the spread of cholera.4McKernan B Yemen: almost one death per hour as cholera epidemic spreads like wildfire.http://www.independent.co.uk/news/world/middle-east/yemen-war-deaths-cholera-epidemic-dying-every-hour-a7782341.htmlGoogle Scholar Saudi-led airstrikes have destroyed vital infrastructure, including hospitals and public water systems, hit civilian areas, and displaced people into crowded and insanitary conditions. A Saudi-enforced blockade of imports has caused shortages of, among other things, food, medical supplies, fuel, and chlorine, and restricted humanitarian access. As the Saudi-led coalition has played a key role in the collapse of health, water, and sanitation systems in rebel-controlled areas, it is bizarre that UNICEF recently published a press release welcoming Saudi Arabian "generosity" after the Kingdom donated US$67 million to the cholera response in Yemen.5UNICEFUNICEF statement on Saudi contribution to Yemen cholera response.https://www.unicef.org/media/media_96542.htmlGoogle Scholar This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on September 13, 2017 This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on September 13, 2017 We declare no competing interests. Correction to Lancet Glob Health 2016; 5: e970–71Kennedy J, Harmer A, McCoy D. The political determinants of the cholera outbreak in Yemen. Lancet Glob Health 2017; 5: e970–71—In this Correspondence (September, 2017), the row for Abayan appeared in the table twice. Additionally, the second sentence of the third column should have read: "The attack rate was 17·0 per 1000 population in Houthi-controlled areas compared with 10·0 per 1000 population in government-controlled areas…". These corrections were made on Sept 13, 2017. Full-Text PDF Open Access