One hot June day, Zahra Hussain woke up to find her twins had fallen sick, their bodies limp as rag dolls. Zahra had no money for milk – let alone a ride to the nearest hospital, an hour’s drive away. “I’m putting my trust in the hands of Allah,” she decided. Stepping outside into the blistering sun, her daughters in her arms, her husband by her side, she waited for fate to intervene.

Zahra and her family had so far managed to cheat death, surviving both the fighting, and the food shortages that had crested over Yemen during the past two years. Now, cholera was closing in on their village and stalking the country, claiming more than 1,600 lives and sickening more than 269,000 people.

In its most severe form, cholera causes profuse watery diarrhoea and vomiting. These symptoms in turn lead to dehydration, seizures and shock. In severe cases, death comes within a few hours of onset. With proper treatment and rehydration, the death rate is less than one per cent. Without treatment, fifty percent of those with severe symptoms die. It was all a matter of time.

For Zahra, fate eventually did intervene, in the form of a stranger who stopped his car and offered to take her to Abs, where MSF runs a cholera treatment centre (CTC) in a school adjacent to the hospital. For Zahra, the centre signified the best hope she had of saving her daughters, Kholah and Saher. Leaving her four other children at home with her father, who was also ill, Zahra, her husband and the twins got into the car. There was no other choice.

Ahmed Qassem, the Emergency Room Supervisor, was in the hospital when the family arrived. At the CTC, the medic on duty took the babies and made a quick assessment. The 7-month old sisters had contracted cholera three days earlier, were severely dehydrated and had gone into shock, he concluded. The babies were among the youngest patients the clinic had ever received.

“We used to receive ten or fifteen patients a day. Now we see more than one hundred,” Ahmed said. Ten days later his staff would receive a record 479 patients in a single day. The government declared a state of emergency in May. The United Nations has described the situation as the world’s largest humanitarian crisis.

Screenshot 2017-07-13 at 9.32.09 PM
Location of Abs in Yemen.

In many ways, Abs, a small town in Hajjah governorate, has become a crucible of the multiple forces shaping Yemen’s current crisis. It has the highest concentration of displaced people in the region. Many fled violence in their village only to find poverty and insecurity in Abs. The town is about 50 kilometres from the frontlines. From inside the hospital, you can sometimes hear the low hum of war planes circling overhead.

Since the current outbreak erupted, the CTC has treated more than 12,200 people. Treatment is provided free of charge to patients, who hail from as many as ten different districts, and who travel for up to five hours to reach Abs. “People have nowhere else to go,” Ahmed said. Most of his own family had fled the country, to Djibouti, and elsewhere. “We have enough savings to navigate this. I cannot say the same for poor families, and for those whose cities have been destroyed.”

Ahmad Muqbal Aqeeli arrived at the hospital two days earlier from Al Hudaydah governorate, which has the second highest prevalence of cholera in the country. “Lots of patients get even worse trying to reach this clinic. It is a long and tedious journey. Some cannot handle it and pass away on the road,” he said. He arrived with his uncle and grandmother, who was suffering from vomiting and diarrhoea. “We have airstrikes from above and cholera from below,” he said.

Zahra’s town, in Hayran district, is also close to the frontline: “I feel scared. It’s not like before, when you could go anywhere and still feel safe,” she said. Still, she says: “I´d never leave my country. I want my country to go back to the way it used to be.”

Most of Ahmed’s patients are like Zahra: poor, and unemployed. Many are shocked to learn that cholera can be warded off with simple precautions. Most don’t own soap, and, without any access to treated water, they drink whatever they can find. MSF teams have started outreach activities in a bid to contain the epidemic, travelling to remote villages to teach people about proper hygiene and how to chlorinate well water. But the rapid spread of the disease has eclipsed these efforts.

Besides MSF, there are few humanitarian organisations on the ground. The war has disrupted the delivery of aid. Imports, which used to account for 90 per cent of the country’s food, have slowed to a trickle. Most families survive on food rations: flour, oil, sugar and beans.

“It’s hard just to get my children the milk they need. I spend many days looking for milk, worried and anxious. My children have been raised in the war,” Zahra said.
Inside the CTC, the heat was oppressive, exceeding 45 degrees. Medics scrambled to treat the twins for dehydration; then, using a special tape measure, calculated the circumference of their mid-upper arms. The measurement is used to determine whether a person is suffering from malnutrition. For a seven-month old baby, anything under a measurement of 115 millimetres is considered severe. The twins’ arms measured 100 millimetres, well into the red zone.

Across the country, the cholera outbreak has compounded other deprivations. Roughly 17 million people —two thirds of the population— experience food insecurity, according to the United Nations. Approximately two million Yemeni children under the age of 5 are considered to be acutely malnourished.

Kholah and Saher were fed milk, as they hovered between life and death. Zahra’s thoughts drifted towards the four children she left behind, in the care of her father. Her husband wanted everyone to return home, but medical staff resisted, for the sake of the twins.

“It took a lot of effort to convince the father to leave the children and mother in the CTC. It’s a very common issue. They have other children at home and cannot stay taking care of the sick one for days, and we receive a lot of pressure to discharge the patients much earlier than advisable,” a medic noted.

There are other reasons why patients are reluctant to stay too long. Hospitals, once considered a safe haven, protected under international law, have come under attack. Since the war began, at least 274 health facilities have been damaged or destroyed by airstrikes and in many cases, forced to close, choking off medical access to vast swaths of the population according to the World Health Organization.

Abs Hospital was struck on 15 August, last year. An airstrike hit a car parked in the hospital compound. The force of the blast struck the triage zone and emergency room. Ahmed, in a meeting at the time, initially thought an oxygen tank had exploded. When he stepped outside, he couldn´t believe what he saw.

“It’s impossible to imagine that we were bombed,¨ he remembers thinking at the time. ¨When I saw the E.R. on fire I ran towards the maternity ward. I was in shock, my entire team could be dead. I approached the Emergency Room several times, but it was too painful. Soft tissue, amputated bodies… Terrible.”

A subsequent investigation concluded the Saudi-led coalition had launched a projectile against a mobile target – the car parked inside the hospital compound. An official spokesperson from the Coalition´s Joint Incidents Assessment Team, declared it an “unintentional mistake.” In total, the airstrike killed nineteen people and injured 24.

Ahmed recalls how he felt in the aftermath: “I got home that night and I still couldn’t assimilate what happened,” he said. “I kept moving around the house as if I’d lost something.”

The hospital closed for 11 days. MSF withdrew its staff, returning last November. Initially, patients would come to Abs seeking care for everything from malaria, to complications in pregnancy, to traumatic injury.

When cholera flared in April, everything changed. The hospital overflowed with cases, and staff took over the nearby school, empty because its students were on summer holidays. Tents were erected in the playground, cholera beds moved into the classroom, and chlorine stations set up in the hallways.

Inside the CTC, doctors struggled to stabilise the twins. Kholah and Saher had been in the hospital for more than 24 hours, but every time there was a sign of improvement, a new setback sprang up. One was diagnosed with a chest infection; the other ran a high fever. Their weight was virtually unchanged from what it was when they were admitted, just 3.5 kgs.

Meanwhile Zahra’s concerns about her other children grew. She told the medics she wanted to take the girls home: “Our situation is difficult. My children are in rough shape. Life in the village was hard. I am still worried about them,” she said. The doctors knew if the twins left, there was no guarantee they would receive the care they needed. The hospital in Abs was one of the only fully functioning healthcare facilities left.

Across the country, public health workers have not received their salaries from the government since September of last year. Without staff, many health facilities have been forced to close, or limit their activities, leaving Yemen’s medical service in a state of collapse, at a time when the cholera epidemic is peaking.

“People in this area have nowhere else to go besides this hospital,” Ahmed said. “Their situation is really bad, but they cannot go to other places to seek medical attention.”

On 15 June, two days after they were admitted, the twins were transferred to the Abs hospital’s feeding centre, where they began to stabilise. On 20 June, doctors decided Kholah and Saher showed enough improvement to move to “Transition Phase” where patients could continue to recover under close medical supervision. Their doctors were hopeful. Less than half a per cent of patients admitted to the CTC have died to date. The clinic has prevented the death of more than 12,000 people. Odds were now overwhelmingly in the babies’ favour. For Zahra, this was enough. It was time to take her children home.

“Unfortunately retaining the babies in treatment proved difficult… The family decided that it was too long, and they were taken home (discharged against medical advice).” their doctor noted.

Seven days after the twins arrived in Abs, dying from dehydration, they headed back to their village with their family. Cured of cholera, they had a chance of survival. Their doctor noted: “Both Kholah and Saher were 3.6 kg on discharge, still severely malnourished, but stable.

How is the rest of the country as a whole doing? Not good:

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