What disturbs Stanford pediatrician Paul Wise most about the cholera epidemic in Yemen is that it’s hitting the children hardest and is completely preventable.

The four-year civil war in Yemen has killed hundreds of thousands of people and has led the poorest of the Arab nations to the brink of famine. Some 22 million of the country’s 29 million people are in desperate need of humanitarian assistance, according to the United Nations.

Since 2016, two severe cholera outbreaks have impacted more than 1.2 million people. Children account for 30 percent of the infections; more than 2,500 people have died.

“Children in Yemen are not only the most vulnerable to this ongoing cholera epidemic but they are also suffering from a disastrous famine,” said Wise, a core faculty member at the Department of Pediatrics, Stanford Health Policy and the Center on Democracy, Development and the Rule of Law.

“The cholera and starvation that is currently afflicting Yemen’s children are completely man-made and preventable,” he added. “They are the product of a brutal, protracted war and the ongoing complacency of the international community.”

The conflict pits the country’s Shiite rebels known as the Houthis, against Yemen’s internationally recognized government, which is supported by a Saudi-led coalition that includes the United States. The United Nations is currently brokering peace talks in Sweden.

Wise, who leads Stanford’s Children in Crisis project, joined colleagues at the Johns Hopkins Bloomberg School of Public Health to study the preparedness and response to the epidemic, at the request U.S. Agency for International Development (USAID). 

“The report is an attempt to bring together technical and political analysis in a way that calls attention to both the profound suffering of civilian communities caught up in war — and that real opportunities exist to better protect these communities through urgent global action,” Wise said.

If caught early, cholera can be treated with oral hydration salts, though more severe cases require intravenous fluids and antibiotics. But the bacterium found in food and water sources has overwhelmed Yemen because its health-care facilities and infrastructure have been devastated.

“What is critical to remember is that these cases and deaths are all preventable,” said Wise. “And children are always the most vulnerable to the indirect effects of war, the effects resulting from the destruction of the essentials of life, like food, water, shelter, and health care.”

There were three key findings in the report. First, there was likely an overcount of cases due to financial incentives to label patients with gastrointestinal symptoms as cholera cases.

Second, the report identified technical areas of slow provision of services, such as getting out the relatively new oral cholera vaccine, and poor coordination of essential interventions by the government and international humanitarian agencies.

Third, Wise and his colleagues documented at least 75 instances in which Saudi airstrikes appear to have purposely caused damage to water, health and sanitation facilities in rebel-held territory in the northern part of the country. Despite repeated calls by the international community to protect these public health sites — as is required by international law — the bombings continued.

The report found that in retaliation for rockets fired by the rebels at the Saudi Arabian capital city, Riyadh, the Saudi-led coalition in November 2017 closed the majority of airports, seaports and land crossings. Ports in government-controlled areas were quickly re-opened, but they remained closed in the north. This had the immediate effect of halting the flow of goods into Yemen, which relies almost exclusively on imports for food, fuel and medicine.

“The United States and other Western powers have been indirectly complicit in these airstrikes on civilian water and sanitation targets, as these global powers have provided the weaponry, intelligence, and until very recently, the refueling capacity to support Saudi air attacks,” Wise said. “The report is focused on the cholera epidemic; however, the findings clearly point to the relationship between the outbreak and violations of international norms in how the war is being fought.”

Wise noted that the security environment in Yemen has been one of the most dangerous in the world for humanitarian and health workers. Wise and some of this same group of experts who worked on the cholera report were able to travel to Iraq last year to evaluate the World Health Organization’ system to treat civilians injured in the battle for the city of Mosul.

But Yemen is just too dangerous and they were unable to conduct research on the ground. So they did the next best thing, reviewing dozens of documents and conducting 75 interviews with medical practitioners, donors and technical experts involved with the cholera response.

They found that despite the incredible odds, effective mobilization by community volunteers and health workers was paramount. During the second wave of the cholera epidemic in August 2017, for example, some 40,000 community health volunteers working with the WHO and UNICEF carried a door-to-door cholera-awareness campaign across 14 million households.

“The dedication and courage of these humanitarian and health workers have undoubtedly saved thousands of lives,” Wise said. “However, without urgent global action to end the fighting and provide the essentials of life, many more thousands of children will suffer, and most tragically, many will die from completely preventable causes.”