Determinants of Mortality and Morbidity of Children in Yemen

Background

Many people regard the enjoyment of peace and access to medical health as a right. Few are the times that people meditate on the consequences of war and political instability. War does not only lead to loss of property and death, but it also has a direct and devastating effect on the soundness of a health system implying that the life of the conflicting parties and the peaceful ones oscillates around life and death. War loosens all measures, either preventive or curative, laid by individuals or governments in the control of diseases. Diseases like cholera usually thrive and kill more in times of chaos due to lack of infrastructural support and coordination from various arms in the health sector. Children are the most vulnerable as their immunity is low and the efficiency to observe hygiene is wanting due to their playful nature. Adults are not safe either as hygiene demands clean water and access to clean food, which is not available during a warring period. 

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Yemen’s Health Situation

According to the OECD (2015), 1.2 billion people live in states with rampant conflicts worldwide. A problem that remains unresolved is how health systems can remain resilient during periods of chronic political instability. The inaccessibility of war zones and disconnection of the transport and communication facilities serves as a threat for local and international humanitarians who may be willing to continue rendering their services to the affected population. Provision of security personnel is at times not sufficient as people including health workers may suffer from nervous breakdown injected by fear and the love for self, hence their inability to work under such stressful and strenuous conditions. Yemen’s young population is vulnerable to diseases and registers a higher mortality rate due to inadequacies in the structural, economic, social, and health sector development. According to the World Bank (2015), 13 million, which is half of Yemen’s population, live below the poverty line. All citizens of Yemen are guaranteed the right to health by their constitution where the local governorates manage health matters in their jurisdiction. Unfortunately, despite the assurance of the right to health by the constitution, corruption has led to the deterioration of health services due to weaknesses in governance as provided by Transparency International (2015). The government expenditure on health in comparison to GDP is 4%, indicating that this is one of the underfunded sectors of the Yemen economy. That makes it be at the mercy of donors from the private sector like WHO and Food and Agriculture Organization. According to Anderson de Cuevas et al. (2014) patients from rural areas face cost barriers when accessing medical care due to a rise in transport and health care cost.

Political Climate in Yemen and its Effects on Health

Yemen’s civil war between the government of Abdrabbuh Mansur Hadi and the Houthi militia started in 2015. The Houthi’s have also been into war with the Yemen government since 2004 a factor that has crippled development making the country to be the poorest among the Arab nations. The cause of disagreement is in the control of the Yemen government leading to bloody clashes between the supporters of the two rival groups. On March 2015, Houthi-led Supreme Revolutionary Committee deliberated on the interest to overthrow Hadi’s government in order to stretch their control beyond Sana’a. In a span of five days, the militia group had seized Aden, the central power point for Hadi’s government leading to this flight. The Saudi Arabia government and the United States collaborated in a campaign to restore the former government. Statistics provided by the UN and NGO Save the Children shows that the number of deaths due to that war was 13,600 as of 2017, while deaths arising from famine and malnutrition were 50,000, and more than 13 million citizens in Yemen are at risk of starvation in 2018.  Data shows that more than 3.3 million children and pregnant or lactating mothers suffer from acute malnutrition.

UNICEF executive director Anthony Lake and WHO director-general Margaret Chan released a statement on the cholera outbreak in Yemen and suspected that cases exceed 540,000 with associated deaths of 2000. The statements show how civil war cripples an economy and the delivery of survival services like medical care. The statement addresses the effects of the intervention of the Saudi Arabia government, where its military activities have destroyed health facilities and made it almost impossible to access or offer health services. The absence of a stable government and the subsequent collapse of health systems have resulted in the widespread of cholera in every governorate, which is the worst outbreak as elaborated by WHO and UNICEF. An analysis of WHO’s latest epidemiological data acknowledges that malnutrition is the leading cause of increased morbidity and mortality rate in children as it weakens their immunity and makes them susceptible to illnesses. The civil war in Yemen has made families flee for safety and the overall agricultural activities have been suppressed thereby turning the starving citizens to unhygienic means of survival. Safe drinking water and proper sanitation is a challenge to more than 15.7 million people, hence making exponential transmission of communicable diseases (Mokdad, 2016). According to reports by WHO approximately 10.4 million citizens cannot seek healthcare, where more than 1900 health facilities are non-functional, or semi-functional.

Between 19 March and 15 July, reported deaths and injuries from health facilities in Yemen reached 8,389 and 56,130 respectively. Given that only 45 percent of health facilities are functioning, the actual figures are likely to be higher. According to the United Nation for Population Fund (UNFPA), more than 45% of Yemen’s population is made up of children below 15 years and the population growth rate is 3% per annum. The rise in population is attributed to high fertility among the adolescent age, failure of adoption of contraceptives, early marriages, and low literacy levels. Population growth is a prevalent problem to the poor nation with no employment and basic resources like clean water and risk of malnutrition. Maternal health is not developed with 84% of births taking place at home and contributing to a higher mortality rate. 

The Saudi Factor

The situation in Yemen is grim. According to Karasz (2018), it has been reported that 85,000 children under the age of 5 have died in the conflict. The cause of deaths has been attributed to hunger. The Saudi led coalition has been held responsible for the bombings and an acute cut off of critical infrastructure necessary to support the supply of basics. Karasz goes ahead to explain that besides the airstrikes, Saudi Arabia has been at the forefront of the hunger and death crisis. Saudis have been imposing economic sanctions and blockades to Yemen, which further escalates the humanitarian crisis. Due to the Saudi actions, the prices of food doubles very often, especially since the foods are imported. Deliveries of foods take three weeks instead of the ordinary one week.

The United States has been on the defense of Saudi Arabia and has instead placed the blame on Iran for the conflict. The United States has provided more than $566 million in aid to Yemen as a means to rescue the situation through USAID (Karasz, 2018). The U.S. notes that the main challenge in providing humanitarian assistance is infrastructural damage. The Saudis and the UAE have been generously donating towards Yemen’s situation. The two allies pledged to donate $1 billion in aid to Yemen (Walsh, 2018). On January of this year, Saudi Arabia deposited $2 billion to Yemen’s Central Bank to stabilize the currency in Yemen (Walsh, 2018). However, this has not prevented a constant increase in the prices of products, especially food, which makes products out of reach for many.

The annotated bibliography that follows is well researched to show how this war-dominated country has been plagued with diseases that are killing its young population. War eliminates sobriety and order that is paramount in unified disease management and control. War itself is a killer as children and adults’ loose life from bomb attacks or from malnutrition due to inaccessibility of food, clean water, proper medication, and shelter. Some children die out of psychological problems generated by war. In addition to war and malnutrition Malaria, pneumonia, cholera, rotavirus, diarrhoea, and bilharzia are the major diseases that kill children in Yemen.

Annotated Bibliography

Webair, H. H., & Bin-Gouth, A. S. (2013). Factors affecting health-seeking behavior for common childhood illnesses in Yemen. Patient preference and adherence, 7, 1129.

Webair and Bin-Gouth research isolates and identifies the factors that affect health-seeking behavior when children are ill and how their survival is affected in Yemen. The mortality rate in children under the age of five years is most prevalent in Yemen than any country in the Middle East. Many children under the age of five in Yemen lose life for reasons that are preventable or treatable like malnutrition and pneumonia. They highlight that the success in reducing deaths is dependent on the success of the partnership between trained health workers and families. The researchers aim is to come up with conclusions that are free from any biases and they try to avoid prejudice by assembling a sample that will be representative of the population. They use a cross-sectional study and collect data with the aid of structured questionnaires in the city of Shehair. They use participants who are most informed in the affairs of children. The study population comprises of the primary caregivers or caretakers of children below the age of five. The sample size was 212 participants who were categorized based on education, marital status, age, occupation, and address. The features of health services are divided based on acceptability, costs, and the implication of traditional medicine. They also put effort to eliminate challenges of language barrier by contracting the services of a community health worker who conducts the interview in their native language of Arabic. They manifest effort to ensure the effectiveness of the questionnaire in addressing the study objectives by incorporating the services of previous researchers in designing the study questions and by use of a pilot study among 30 health workers to help in the modification in accordance to suitability. Their research method is so effective that young scholars and researchers can teach it for adoption. 

The study reveals that in some geographical regions the services of traditional healers and self- treatment for ailments like diarrhea was sought for more than modern care. Medical care services come as a last resort after all other remedies fail and at a time where in accordance to the assessment of the caretaker, the health of the child has significantly deteriorated or is not improving. Caretaker’s education level affects health-seeking behavior, with the uneducated mothers taking too long to judge the condition of their child on whether it needs the attention of doctors. Their study leaves room for social scientists and ethnographic studies in order to determine the role of cultural beliefs in addressing access to professional medical care. The research results, conclusion, and recommendations are timely to Yemen’s children population, as its application may reduce significantly the prevalence of life-threatening illness due to timely detection and quick professional treatment and medication. 

Al-Badani, A., Al-Areqi, L., Majily, A., AL-Sallami, S., AL-Madhagi, A., & Amood, A. K. (2014). Rotavirus Diarrhea among Children in Taiz, Yemen: prevalence—risk factors and detection of genotypes. International journal of pediatrics, 2014.

The research appreciates that diarrhea among children under the age of five is an imperative area that should attract a great concern in the discipline of public health as it poses both mortality and morbidity threats in developed and developing countries. They have identified Rotavirus as the utmost cause of gastroenteritis infection among infants. The motivation of their studies emanates from data showing a number of infant deaths surpasses 700,000 in low-income countries annually, which is alarming and a threat to the prosperity and wellness of a nation. The study conducted in Taiz, Yemen seeks to determine factors contributing to the prevalence of the Rotavirus among infants under the age of five years. Taiz is a governorate in Yemen with the highest population of more than 540,000 infants under the age of five in accordance with the 2004 national census results released by the Central Statistical Organization.

 The study reveals that the Rotavirus is most common during the winter and summer seasons, an establishment made from the long study period, and is congruent with studies in Jordan. The study cautions against associating Rotavirus diarrhea with symptoms like fever and vomiting, as they are not clinically conclusive. Latrine and personal hygiene have been suggested for people in rural areas, as they are susceptible to contract Rotavirus than residents of urban areas. The study results match the findings of another research in Yemen that reveals poor prescription of drugs by medical personnel to Rotavirus patients. Majority of clinical workers recommend diarrhea patients to use antibiotics due to poor diagnosis or lack of proper lab equipment, which may cause serious side effects to children.

Tate, J. E., Burton, A. H., Boschi-Pinto, C., Parashar, U. D., World Health Organization–Coordinated Global Rotavirus Surveillance Network, Agocs, M., … & Ranjan Wijesinghe, P. (2016). Global, regional, and national estimates of rotavirus mortality in children< 5 years of age, 2000–2013. Clinical Infectious Diseases, 62(suppl_2), S96-S105.

The research seeks to estimate the mortality rate of children under the age of five in a span of 14 years as a result of contracting Rotavirus. Rotavirus is categorized as one of the global causes of severe diarrhea among children under the age of five years. Since the licensing of two rotavirus vaccines in 2006, the World Health Organization (WHO) later (2009) recommended the introduction of the vaccine in all countries susceptible and experiencing high diarrhea mortality rate in its young population below the age of five. The research informs us of the success story of countries that adopted the vaccines and thereby documenting a tremendous decline in severe diarrhea relating to the virus. In areas with high child mortality, the effects of the vaccine are yet to bear tangible results. Decline in mortality rate due to rotavirus is attributed to a rise in hygiene and sanitation standards. 

Sady, H., Al-Mekhlafi, H. M., Mahdy, M. A., Lim, Y. A., Mahmud, R., & Surin, J. (2013). Prevalence and associated factors of schistosomiasis among children in Yemen: implications for an effective control programme. PLoS neglected tropical diseases, 7(8), e2377.

 Schistosomiasis is a tropical disease that continues to threaten public life especially children in rural areas of Yemen. The study determines how the disease has prevailed and dominated in killing children in Yemen. Schistosomiasis, one of the most prevalent neglected tropical diseases, is a life-threatening public health problem in Yemen, especially in rural communities. This cross-sectional study aims to determine the prevalence and associated risk factors of schistosomiasis among children in rural Yemen. A sample size of four hundred children is selected where their urine and fecal matter is used as a specimen. The tests seek to find the presence of Schistosoma haematobium eggs and S.mansoni. Questionnaires are designed to help in collecting demographic, social, economic, and environmental data. The study revealed that Schistosoma is a prevalent disease in the population as more than 31% tested positive for the bacteria. Household income, drinking water, springs, and pools of water in the environment are the most associated variables likely to cause schistosomiasis in children. Schistosomiasis is caused by three different species of fluke worms that dwell in the blood or in the intestines. The clinical symptoms of their presence include blood stained stool, severe diarrhea, and abdominal pain. The poverty level in Yemen is highest when compared to other countries in the Middle East with half of the population living below the poverty line. Civil wars have depleted its resources, as well as, destabilized the economy. The situation has made the country endemic to eight neglected tropical diseases. The findings of the research are therefore of utmost help to the government and the public health policy makers as it identifies the factors that make the disease deadly in the rural population. 

The study is in agreement with other studies in Yemen that show the prevalence of the disease among children over the age of ten. A factor of high mobility in that age is attributed to the phenomenon. Cross-border, collaboration with a country like Saudi Arabia can help in eradicating the disease in Yemen as it happened in Saudi Arabia.

 Bamaga, O. A., Mahdy, M. A., Mahmud, R., & Lim, Y. A. (2014). Malaria in Hadhramout, a southeast province of Yemen: prevalence, risk factors, knowledge, attitude, and practices (KAPs). Parasites & Vectors, 7(1), 351. 

The study determines the prevalence of malaria in Yemen after reviewing the literature on how it is a major health problem in the world, especially in sub-Saharan Africa and in the tropical. The literature review shows that on a global scale 3.3 billion individuals are at risk, thus, triggering morbidity and mortality. In the Mediterranean zone, children under five years and pregnant women are at risk of acquiring malaria (43%). The most lethal Plasmodium in Yemen is Plasmodium falciparum. The National Control Malaria Program (NCMP) is on the front line armed with measures to combat malaria through the distribution of insecticides and treated mosquito nets. However, Yemen is not well aligned to meet the objective of malaria reduction by three quarters, an objective formulated by the Global Malaria Action Plan (GMAP)’s, by the end of 2015. Yemen is still lagging behind in the control phase as per the 2013 World Malaria Report. To the contrary, Saudi Arabia, a neighboring country of Yemen, has reduced malaria case by more than 75% and they are on the verge of eradicating the disease. The researcher’s effort is geared towards generating factors that bar progress to eradication phase. Hadhramout governorate in southeast Yemen was identified as the most susceptible region to malaria and, therefore, suitable as a study area for the purpose of the research. Previous research and literature that show seasonality and regional transmission of malaria were found useful for the success of the study. The sample size was 735 with consent from participants and the approval by the Faculty of Medicine, Hadhramout University for Science and Technology. The use of experienced malaria surveyors was put in place and the sample representation was done randomly. The research was conducted for one year in order to account for the effects of seasons and region in malaria transmission. The research involved the collection of blood samples and data was collected by the aid of observation and a pretested questionnaire.  

The findings of knowledge, attitude, and practices towards the control, symptoms, transmission, and prevention of malaria among the household assessed was very poor, hence the prevalence of the disease. Political instability in the country has contributed to the prevalence of the disease among children under the age of five, with an infection rate of 10%.  

The study is insightful as it opens the door for other research work in the field of malaria. The research equips the government and the public with the knowledge about the disease from the transmission, prevention, and treatment. The research demonstrates how the disease threatens the young population and thereby, putting the future of the country at jeopardy. 

Conclusion

War makes futile any positive efforts geared toward disease management and control. Yemen’s infant mortality rate has increased due to attenuation of the health sector resulting in loss of management of respiratory infections, birth complications, diarrhea, and other communicable diseases Mokdad (2016). An effective policy that would stand to address health matters in Yemen must first start by aligning the political sector, which influences other sectors. Collaboration with other countries is also essential, as sharing knowledge is part of safety measures in prevention and eradication stages.

References

Anderson de Cuevas, R., Al-Sonboli, N., Al-Aghbari, N., Yassin, M. A., Cuevas, L., & Theobald, S. (2014). Barriers to Completing TB Diagnosis in Yemen: Services Should Respond to Patients’ Needs. PLoS One9(9), e105194.

Al-Badani, A., Al-Areqi, L., Majily, A., AL-Sallami, S., AL-Madhagi, A., & Amood, A. K. (2014). Rotavirus Diarrhea among Children in Taiz, Yemen: prevalence—risk factors and detection of genotypes. International journal of pediatrics, 2014.

Bamaga, O. A., Mahdy, M. A., Mahmud, R., & Lim, Y. A. (2014). Malaria in Hadhramout, a southeast province of Yemen: prevalence, risk factors, knowledge, attitude, and practices (KAPs). Parasites & Vectors, 7(1), 351.

Mokdad AH. 2016a. The Global Burden of Disease: A critical resource for informed policymaking in the Gulf region. Journal of Health Specification 4:162–72.

Karasz, P. (2018, November 21). 85,000 Children in Yemen May Have Died of Starvation. The New York Times. Retrieved from https://www.nytimes.com/2018/11/21/world/middleeast/yemen-famine-children.html

OECD. (2015). States of Fragility 2015: Meeting Post-2015 Ambitions. Paris: OECD.

Sady, H., Al-Mekhlafi, H. M., Mahdy, M. A., Lim, Y. A., Mahmud, R., & Surin, J. (2013). Prevalence and associated factors of schistosomiasis among children in Yemen: implications for an effective control programme. PLoS neglected tropical diseases, 7(8), e2377.

Transparency International.  (2015).  Corruption Perceptions Index 2015. Retrieved from http://www.transparency.org/cpi2015, accessed 24 February 2016.

Tate, J. E., Burton, A. H., Boschi-Pinto, C., Parashar, U. D., World Health Organization–Coordinated Global Rotavirus Surveillance Network, Agocs, M., … & Ranjan Wijesinghe, P. (2016). Global, regional, and national estimates of rotavirus mortality in children< 5 years of age, 2000–2013. Clinical Infectious Diseases, 62(suppl_2), S96-S105.

Walsh, D. (2018, October 26). The Tragedy of Saudi Arabia’s War. The New York Times Retrieved from  https://www.nytimes.com/interactive/2018/10/26/world/middleeast/saudi-arabia-war-yemen.html?action=click&module=RelatedLinks&pgtype=Article

Webair, H. H., & Bin-Gouth, A. S. (2013). Factors affecting health seeking behavior for common childhood illnesses in Yemen. Patient preference and adherence, 7, 1129.

Wiens, M. O., Pawluk, S., Kissoon, N., Kumbakumba, E., Ansermino, J. M., Singer, J… & Larson, C. (2013). Pediatric post-discharge mortality in resource poor countries: a systematic review. PLoS One, 8(6), e66698.

World Bank. (2015). GDP per capita (USdollars) 2015. Retrieved from http://data.worldbank.org/indicator/NY.GDP.PCAP.CD, accessed 24 February 2016

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