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COMMENTARY
Yemen’s Unprecedented Humanitarian Crisis:
Implications for International Humanitarian Law,
the Geneva Convention, and the Future of Global
Health Security
Alba Ripoll Gallardo, MD; Frederick M. Burkle, Jr., MD, MPH, DTM;
Luca Ragazzoni, MD, PhD; Francesco Della Corte, MD
ABSTRACT
The current humanitarian crisis in Yemen is unprecedented in many ways. The Yemeni War tragedy is
symptomatic of gross failures to recognize, by combatants, existing humanitarian law and the Geneva
Convention that have become the new norm in unconventional armed conflicts and are increasingly
replicated in Africa, Afghanistan, and other areas of the Middle East with dire consequences on aid
workers and the noncombatant population. The health and humanitarian professions must take
collective responsibility in calling for all belligerent parties to cease the massacre and commit to
guaranteed medical assistance, humanitarian aid, and the free flow of information and respect for the
humanitarian principles that protect the neutrality and impartiality of the humanitarian workforce.
(Disaster Med Public Health Preparedness. 2016;page 1 of 3)
Key Words: Yemen, humanitarian crisis, international humanitarian law, Geneva Convention, war
Much has changed since 1945 when along
with the signing of the United Nations
Charter the roles and responsibilities of
humanitarian actions and activities in future cross-
border wars and conflicts were defined and guided by
new International Humanitarian Laws (IHL) and the
Geneva Convention (GC). Indeed, the reasons for
humanitarian crises and how the world responds to
them have changed every decade or so since that
time. Today, declared cross-border wars are no longer
the norm. The end of the Cold War led to multiple
unconventional intrastate conflicts and wars leading
to millions of internally displaced and refugee popu-
lations. But by the turn of the century nondeclared
unconventional wars became the new norm.
Social-media-driven nation-state revolts have taken
dominance, especially in the Middle East. The rise of
multiple nonstate actors with increasingly organized
armed violence has shown little knowledge of the
GC or respect for the humanitarian principles of
neutrality, impartiality, humanity, and independence
that have been the foundation of humanitarian
assistance by the International Committee of the Red
Cross and nongovernmental agencies like Médecins
Sans Frontières for decades. Aid worker security is
dependent on the perception, by all combatants, that
they are independent and impartial. Unfortunately,
today more aid workers are killed each year than
Peacekeepers, and insecurity or danger to staff has
resulted in the rate of aid projects closed or suspended
to double each year.
1
Nowhere has this dilemma proved more complex and
dangerous than the plight of citizens in war-torn
Yemen. Yet, few in the outside world are aware of the
dire circumstances and severe implications this brings,
not only to the current state of need for a ravaged
society but to how we all perceive the world’s risks,
and responsibilities, to both inaction and how global
health security itself is being played out every day in
Yemen. In point of fact, few peer-reviewed medical
journals have reported on the devastating health
effects that the GC violations against human rights in
the poorest country of the Arab world will have on
the feasibility of future humanitarian aid operations
both in Yemen and in other conflicts worldwide.
2-4
The current conflict in Yemen comes after several
decades of political and social decline characterized by
almost uninterrupted violence that began following its
unification in 1990. In 2011, the unrests following the
Arab Spring ended the 3 decades of President Saleh’s
supremacy and led to a series of international efforts to
mediate a successful post-conflict transitional process
based on a widely inclusive system of elite political
players and local groups. However, the process was
perceived as lacking transparency and accountability
and the transitional government and its newly
Disaster Medicine and Public Health Preparedness 1
Copyright © 2016 Society for Disaster Medicine and Public Health, Inc. DOI: 10.1017/dmp.2016.50
appointed leader Abdrabbuh M. Hadi were deemed incapable
of addressing local and national grievances and improving
Yemeni living conditions.
4
In 2014, the Iran-backed Shiite
Houthi rebels, supported by ex-president Saleh and his
political network, seized the capital and deposed the short-
lived government. In a state now on the verge of collapse,
a Sunni coalition led by Saudi Arabia set off a military
intervention of massive airstrikes in March 2015, on a claim
of national security and the restoration of the United
Nations-recognized Haidi government.
5
This political and
social instability has been exploited since the very beginning
by nonstate and terrorist actors to sow chaos and expand their
presence across the country.
The figures reported by the UN Office for the Coordination
of Humanitarian Affairs reveal a country where more than
half of the 24.97 million Yemeni population lived below the
poverty threshold before the escalation of the violence and
where the estimated number of the population needing
immediate humanitarian assistance was raised to 21.2
million.
6
Since the beginning of the airstrikes, a total of
30,000 casualties have been reported and at least 6000 (90%
civilians) have lost their lives.
7,8
Moreover, 2.76 million
people are internally displaced (IDP) and 177,620 have
already fled the country and sought asylum elsewhere, mostly
in Oman,
9
the only member of the Gulf Cooperation Council
that decided not adhere to the Saudi Arabia-led coalition.
As expected, this fighting has prompted the quick dete-
rioration of the already precarious living conditions, with
2.7 million people requiring shelter, 14.4 million being food
insecure, and 19.3 million having no access to clean
water. This situation turned even more critical after the
severe flash floods that hit the country in November 2015 and
April 2016.
The outbreak of yet another war with almost uninterrupted
air attacks targeting mainly civilians have harshly stricken the
communities and the capacity of the health care system to
respond. The increasingly scarce numbers of health care
professionals are unable to provide even basic assistance to
the continuous waves of casualties among whom at least
8 children are mutilated or killed every day. Many local
health staff have relocated or fled the country to protect their
families, leaving only a few still on duty without salary
for months under conditions of shortage or absence of
essential medicines, supplies, and equipment.
6
Basic health
care today is dependent on the interventions of international
humanitarian organizations with health workers struggling to
provide first-line emergency health care, leaving follow-up
treatment of chronic health disorders impossible.
2
With the
indiscriminate bombing of markets, universities, and essential
public health infrastructure, all in clear contravention of IHL
and the GC, the humanitarian aid organizations have only
limited access to the population in need despite the rising
numbers of injured and dead.
10,11
Neither the IDP camps nor
warehouses hosting humanitarian supplies have been spared,
with dozens of civilians killed by air raids while seeking
protection outside the cities or during desperate attempts to
reach emergency health facilities only to be stopped or
delayed due to the lack of petrol, countless and poorly
improvised checkpoints, and unusable roads.
While health care needs continue to increase, the security
status for local and international humanitarian actors has
become extremely dangerous. In March 2015, several
humanitarian organizations were forced to leave the country
because of security constraints,
12
with hospitals suffering
unmitigated damage. At least 3 appropriately and clearly
designated medical centers run by Médecins Sans Frontières
have been bombed,
13
and dozens of other health facilities
have also been destroyed or rendered unusable by airstrikes.
Nongovernmental organizations face a severe shortage of a
well-prepared and experienced workforce, which is increas-
ingly exposed to injury or death while trying to provide relief
to civilians caught up in this massacre. Bureaucratic hurdles
posed by current local leaders pose a hug additional impedi-
ment for essential technical need assessments and the mobi-
lization of teams and supplies of emergency assistance to the
most conflict-stricken areas.
In contrast with other ongoing humanitarian crises such as
Syria or Iraq, this conflict has been relegated to a lower order
of priority on the international media landscape despite
representing one of the world’s worst humanitarian crises ever
recorded. Usually, mass media campaigns are often triggered
by external ad hoc political interests and huge movements of
refugees across borders or via sea routes. Noteworthy in this
tragedy is that the movements of civilians appear irrelevant to
the outside world in great part because of geographic and
geopolitical hurdles that leave the fleeing Yemeni population
with very few viable options. Expansive and dangerous desert
terrain and extremely insecure sea routes that only lead to
severely disrupted and hostile countries such as Somalia leave
fleeing populations exposed to a merciless cross fire from
competing nonstate actors.
Regrettably, these atrocities are being committed daily in
front of an indifferent and silent international audience. At
the time of this writing, the third round of UN-mediated
peace talks are being held in Kuwait. Yet, this senseless
massacre is still being fueled by economic interests and stra-
tegic advantages of countries like the United Kingdom,
United States, France, and Canada, to name but a few.
14,15
These geopolitical factors contribute to the depiction of a war
that is no longer, or has never truly been, a conflict between
2 big coalitions but rather a scenario where a clear victory by
any of the multiple local and external players involved is
quite unlikely. Moreover, it is paramount that the outside
world gain a deeper understanding of other minority, but
equally important, local actors that should be taken into
consideration when drafting any roadmap leading to a long-
lasting cease fire. This is critically necessary to avoid a
Disaster Medicine and Public Health Preparedness2
Yemen’s Humanitarian Crisis
resumption of violent clashes immediately after the end of the
ongoing conflict. This pattern of behavior and outcome, now
occurring in Yemen, also occurred in collapsed countries
like Libya, Iraq, and Syria and represent very clearly the
consequences of inaction by the international community at
the initial stages of the conflicts. While there is still hope for
resolution through political mediation leading to a peace
treaty, opportunities for an outside peaceful intervention are
lessening with the risk of Yemen turning into a hopeless failed
state rising day by day.
Sadly, we have become a global society numbed by one
senseless war after another. Denial is protective to one’s
collective psyche only in the short term. History tells us as a
global community that inaction will only cease if we recog-
nize that which initially drove the international community
to derive the unprecedented IHL and GC challenges after
WWII. These same legal principles must be reborn in today’s
disruptive global society. To do so we must regain the
humanitarian principles relevant to criteria under today’s
unique international and noninternational armed conflicts.
Sir William Osler reminded graduates of a medical school in
1906 that medicine is the “only world-wide profession,
following everywhere the same methods, actuated by the
same ambitions, and pursuing the same ends...a homogeneity
not shared by the law”and certainly not by religions.
16
In similar spirit, today’s global health community must in
solidarity take collective responsibility and immediately call
for all belligerent parties to cease the massacre and commit to
international humanitarian law as there is “no moral, legal, or
strategic justification”for this war to continue.
17
Vulnerable
people must be spared, medical assistance guaranteed,
provision of humanitarian aid permitted, and free flow of
information supported.
About the Authors
CRIMEDIM-Research Center in Emergency and Disaster Medicine, Università
del Piemonte Orientale, Novara, Italy (Drs Ripoll Gallardo, Ragazzoni, Della
Corte), and Harvard Humanitarian Initiative, Harvard School of Public Health,
Cambridge, Massachusetts (Dr Burkle).
Correspondence and reprint requests to Alba Ripoll Gallardo, Via Lanino 1, PC
8100 Novara, Italy (e-mail: alba.ripoll@med.uniupo.it).
Supplementary material
To view supplementary material for this article, please visit
http://dx.doi.org/10.1017/dmp.2016.50
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