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 Soon after, a 10-month-old boy with similar symptoms died less than
24 hours after arriving at the hospital.
Two five-year-old cousins were admitted; only one survived.
A 45-day-old boy, his neck swollen and bruised, lasted a few hours.
His last breath was through an oxygen mask.
One morning in early December, 16-month-old Sameh arrived at the
hospital carried by his aunt and delirious with fever. Arishi
immediately recognized a new case of diphtheria. "Put on your mask,"
she ordered the aunt.
Sameh's father, a fighter in Yemen's three-year war, rushed in,
grabbed his son, yanked off the baby's shoes and threw them on the
floor. "Sameh is the light of the house," he wailed, feeling the
boy's feverish brow and body.
This is the emergency ward to a nation. After three years of
warfare, cholera and hunger, Yemen faces a new battle: In the past
four months, doctors across the country have recorded at least 380
cases of diphtheria, a bacterial disease that last appeared here in
1992.
Arishi, like her country around her, is struggling to cope. Every
month, she and her team drip-feed dozens of Yemen's half a million
severely malnourished children. Her ward has also treated hundreds
of the one million people infected by cholera.
This spring, Arishi and her colleagues reopened an abandoned wing of
al-Sadaqa hospital, fenced it with chicken wire and created a
makeshift cholera treatment center. Now, they are converting part of
that center into a diphtheria ward, cordoning off isolation units by
barring hallway doors.
But with rusty oxygen tanks and only two functional ventilators in a
different part of the hospital – and with the expectation that the
cholera epidemic will worsen in coming months — her triage upon
triage is no longer working.
"We're getting more patients but we can't deal with them. We don't
have supplies. We don't have money," said Arishi, "This war has got
to end."
For the past three years, Yemen has been the combat zone of a
struggle for regional supremacy between Saudi Arabia and Iran.
Riyadh and some of its Arab allies jumped into Yemen's civil war in
2015 to help quell an uprising by the Houthis, an Islamic
political-religious movement backed by Iran. In addition to
airstrikes, Riyadh – with U.S. and U.N. backing – has positioned
ships in Yemeni waters as a way to stop arms reaching Houthi
militia.
But the blockade has ended up isolating a country that was already
the poorest in the Middle East. Vital provisions – food, medicine,
fuel, medical equipment, batteries, solar panels and more – are not
getting through. Humanitarian shipments of food and medicine have
mostly been allowed into the country. Yet Saudi-led forces have
severely delayed aid shipments or closed ports outright, especially
in northern Yemen where fighting and the humanitarian crisis are
most acute.
The war and blockade have also thwarted Yemen's vaccination
programs.
Seven years ago, 80 percent of children were fully immunized with
three doses of diphtheria, whooping cough and tetanus vaccine, or
DTP as the combined shot is called, according to Zaher Sahloul, a
critical-care specialist who cofounded a nonprofit called MedGlobal.
Now, he says, that has dropped to 60 percent.
Poor record keeping means there are discrepancies in data related to
vaccine coverage. Yemen's Ministry of Health says 85 percent of
Yemeni children have been immunized against diphtheria, whooping
cough, tetanus, Hepatitis B and bacterial influenza since the
beginning of the conflict, a mere two percentage point drop from
pre-war years.
In late November, the U.N.'s World Health Organization (WHO) sent a
shipment of diphtheria antitoxins - designed to treat those already
infected - and vaccines to the capital Sanaa. The vaccines were
delayed by the Saudi blockade for a week, the WHO said.
In July, the Geneva-based International Coordinating Group on
Vaccine Provision earmarked a million cholera vaccines for Yemen. An
initial shipment of 500,000 doses was sent to the African Horn
country of Djibouti, and was ready to send on to Sanaa. But the WHO
and local authorities in Sanaa decided together to scrap the
vaccination plan, citing logistical and technical issues.
"Yemen needs a Marshall Plan," said Sahloul, who was visiting al-Sadaqa's
treatment center in December. "It is difficult to foresee an
optimistic scenario if the current conditions persist," he said.
DISEASE AFTER DISEASE
Arishi began her medical career in the mid-1990s after Yemen unified
following years of conflict between communist and pro-western
forces. She joined the al-Sadaqa hospital, which was built in the
1980s with funds from the Soviet Union.
In her two decades at the hospital's pediatric ward, Arishi has seen
Yemen slowly come apart again. Even in the mid 2000s, the country
faced widespread hunger because of rising food prices. The feeding
center of al-Sadaqa's hospital, she said, was crowded even before
the new civil war began.
In the spring of 2015, Houthi forces, aided by the now-deceased
former president Ali Abdullah Saleh, advanced south from their
stronghold in the Yemeni capital Sanaa and took over Aden's airport.
It was then that the coalition of Arab states led by Saudi Arabia
joined the war and began launching airstrikes against Houthi-held
enclaves. Fighting raged until troops backing the
officially-recognized government wrenched Aden from Houthi control
in July of that year.
During the first months of fighting, al-Sadaqa filled with hundreds
of wounded children and adults.
By the middle of 2016, another group of patients began pouring into
the hospital. A cholera outbreak that started in Sanaa had spread to
Aden. Dehydrated children, their condition made worse by
malnutrition, flooded into her pediatric ward. Many did not survive,
Arishi said.
Cholera can kill because patients quickly lose their fluids through
vomiting and watery diarrhea. When caught early, it can be treated
by replacing fluids.
When a second wave of cholera infections swept Yemen in April this
year, Arishi and her colleagues decided to set up the new treatment
center. They picked a building away from the main wings of the
hospital to avoid contamination and repaired it with funds from the
WHO and medical aid group Médecins Sans Frontières (MSF). Converting
the building, which had been abandoned for two years after the war,
required "heavy cleaning work, electricity, water system repairs as
well as installing air conditioners," according to MSF.
Yet, like the country itself, al-Sadaqa was overwhelmed by the
cholera epidemic. Nationwide, a million people have been infected,
according to the International Committee of the Red Cross. The WHO
says cholera has killed more than 2,200 people.
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Most of the infected were in the populous north of the country. But
al-Sadaqa, which took in patients from across south Yemen, was also
unprepared. Arishi and her colleagues had expected 10 patients at a
time. Instead, by the summer, they were treating more than a
hundred, mostly adults, a day.
Since September, the spread of cholera across the country has
abated. However, doctors agree that a new wave of infections is
likely in March, when the country's rainy season returns. Cholera
spreads more easily in wet weather, because the bacteria live in
rivers and coastal waters which swell with the rain. Rain brings
sewage into sources of drinking water.
In August, a new disease began to emerge. In Ibb governorate, 170 km
south of Sanaa, a 17-year-old boy was diagnosed with diphtheria,
according to the WHO.
Diphtheria is caused by bacteria that mainly infect the throat, nose
and airways and send toxins into the bloodstream. It has largely
receded as a global health threat, because much of the world's
population is protected through routine immunization.
But the disease is highly contagious once it takes root, doctors
say, since it spreads in the droplets from coughing and sneezing.
Small children are particularly vulnerable because toxins from the
bacteria build up a coating of dead tissue that blocks their small
airways.
Since the mid-August case, more than 380 patients have been admitted
to hospitals across Yemen with diphtheria-like symptoms, according
to the WHO. Doctors diagnosed the cases based solely on patients'
symptoms. Close to 40 of the patients have died, by WHO estimates.
The first case of suspected diphtheria reached al-Sadaqa in
November. Of the seven children who arrived within a fortnight,
nearly all were initially misdiagnosed with mumps or flu. Four died.
Arishi faced the problem of isolating children with symptoms of
diphtheria. She asked hospital administrators to block a hallway
door with a cupboard. Behind it, she tried to isolate those who
might infect others.
But she lacked basic resources to treat the new disease. Al-Sadaqa
hospital, like most others in Yemen, does not have the reagents
needed to test for diphtheria. In fact, none of Arishi's diagnoses
has been confirmed by laboratory tests.
Marc Poncin, an MSF emergency coordinator in Ibb governorate, said
the lack of recent experience means it could be harder to treat
diphtheria.
"There has been a loss of knowledge regarding its treatment, because
it's become something of a neglected and forgotten disease," he
said.
After a diagnosis, treatment is far from easy. Doctors can prescribe
antitoxins and antibiotics. But until a few weeks ago, Yemen had no
such antitoxin stocks.
The United Nations Children's Fund and the WHO have imported more
than 5 million doses of vaccines to immunize children in the worst
affected areas. The WHO has already distributed antibiotics to
patients and, as prophylactics, to their families.
Some diphtheria patients need emergency surgery to remove blockages
from their airways or need machines to breathe. But most of Yemen's
hospitals don't have such equipment. As of early December, only two
of al-Sadaqa's three mechanical ventilators were working, and the
hospital didn't have an isolated operating room for diphtheria
patients.
The lack of resources has caused strains with the hospital's
supporters. When Arishi cordoned off a part of the cholera ward for
the incoming diphtheria patients a couple of weeks ago, the WHO was
not happy with the decision, according to Hussein Hassan, head of
the WHO's Aden office.
"We cannot confidently say that cholera is over. It is a seasonal
problem and it may come back. What happens if another wave starts
and the ward is filled with diphtheria patients?" said Hassan.
"I DIDN'T WANT TO LOSE MY KID"
Arishi says there is another sign that Yemen is breaking down:
parents' waning faith.
She sees more examples of families that have not vaccinated their
children because they distrust both their government and
international organizations.
Earlier this month she confronted Saleh Khaled, the father of a
five-year-old boy called Yasir, who arrived with severe diphtheria
symptoms.
"Why did you not vaccinate your son?" Arishi asked.
Yasir's first cousin, who was also five years old and unvaccinated,
had died a few days earlier. When the first symptoms had appeared on
Yasir's neck and chin, the boy's parents had given him honey.
Khaled said he had heard rumors, years earlier, about children who
had died after healthcare workers had allegedly switched vaccine
vials with insulin during a door-to-door vaccination campaign.
"I didn't want to lose my kid because of something like this," he
said. "We don't trust the people who work in the health department."
Others in the al-Sadaqa ward that day echoed similar fears.
"We live only because of God's mercy," said Khaled Nasser, the
father of 16-month-old Sameh. Nasser, a member of a local armed
group that fights alongside Saudi-allied forces, said fellow
fighters had helped him buy medicine when Sameh got sick.
Arishi herself barely ekes out a living. She makes $210 a month at
al-Sadaqa and works at a private clinic three days a week to
supplement her income. The mother of three treats neighbors and
relatives without getting paid. Her husband, also a pediatrician,
works at another clinic in Aden.
For Arishi, war is both burden and inspiration. She says it has made
her commitment to medicine stronger.
"If I leave and my husband leaves and everyone leaves, who will stay
to treat our patients?" she said. "Aden is my city. It is my
responsibility."
(Additional reporting by Kate Kelland in London and Stephanie
Nebehay in Geneva. Edited by Alessandra Galloni and Simon Robinson)
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