Yemen: The added layer of COVID-19

For my first mission, I would not have imagined finding myself trying to look into the eyes of the worst pandemic in recent years, in a country considered to be the world's worst humanitarian crisis.

From day one, and as my mission continues the menacing shadow of Covid-19 creeps ever closer, the hue of the clouds seems darker and darker and we can hear the thunderclaps resounding elsewhere in the world, from the TV that sometimes plays in the background. The storm promises to be particularly violent. In view of what is happening in countries of great means, we can only fear the worst here. In a place where the health-care system has been ravaged by five years of war, where a large majority of the population fights each day to respond to the cries of their stomachs, to resist the numerous epidemics (cholera, dengue fever, etc.) or to flee the violence of the fighting that continues to rage on. I soon realize that setting up shelters to cope with the arrival of Covid in Yemen is like a race against time...

I land here in early March. Like in the rest of the world, the Covid virus has become the main staple on the plates of the news programs and discussions for some time now. So inevitably, when my temperature is taken at the airport, I figure I shouldn't leave the table on a half-empty stomach. At this point, we are only in the early stages of the drastic measures that are being taken in many countries and still far from the first official case in Yemen. However, I am the first MSF expat to complete a 14-day quarantine in Sana'a and, without knowing it yet, the last one to set foot in the country for almost three months.

My first mission in the capital is to work with Bea, my project manager, on an initial draft of the Covid budget for Hajjah. The plan, on paper, is relatively simple. It is to protect the hospital from the virus by setting up tents at the entrance to detect potential cases among patients and staff (by taking temperatures and asking a series of questions). In addition, an isolation centre is to be set up outside the hospital to treat infected patients. Our job is therefore to anticipate human and financial needs, based on this plan—number of staff, personal protective equipment required, construction, logistics, communications, training, etc.

I find out later that implementing it is fraught with pitfalls. As the hospital is not managed by MSF here, one of the major difficulties is strictly identifying what we are able to provide in the form of support to fight, as much as we can, the impending epidemic tsunami. Unfortunately, we cannot do everything. In dealing with the authorities, we often have to resort to negotiations in order to respond to their numerous requests that we modify the plan. For example, while we have defined the required number of Ministry of Health employees that we are compensating, I regularly receive official letters requesting that we add to the list. So I often have to say no, and at the same time I have to ensure that we maintain the working partnership that we have with one another. 

Things accelerate when Yemen’s first official case of Covid is reported in April. Subconsciously, I was entertaining the slim hope that the virus would not spread here, that the population would be spared from the most serious health crisis of recent years, taking solace in the fact that there was very little movement in and out of the country. But my optimism has its limits. Mr. Corona may have been delayed, perhaps because he had to get a visa first, but he is here.

Therefore, not a single weekly staff information meeting goes by where we do not stress the importance of respecting boundaries and the critical role that our team has to play in its community. Everyone is required to act as an example and spokesperson in conveying relevant information, in a region of the country where rumours often carry more weight in the battle against verified information.

We quickly post informational posters on the walls of the hospital, but it is often difficult to put them into practice. We set up chlorinated water points at each entrance to the hospital, departments and offices. But enforcing systematic hand washing is almost as difficult as trying to maintain physical distancing in the city's khat markets, where men’s hands come into frequent contact as the bags of leaves are exchanged. We repeat, over and over, sometimes with the feeling that we are being regarded as a defender of the planet, arguing with the manager of a plastic bag plant.

I am trying to understand and empathize with a population affected by so many hardships. Why should I change my habits because of a new "epidemic" when sometimes my daily job is nothing more than to do everything I can to see what tomorrow will bring?

At the same time, we are faced with very limited supplies of masks, gloves, aprons, and glasses, and at one point we realize that without any more shipments, we will not be able to maintain operations beyond two weeks... So we have to distribute the PPEs as best we can on a limited basis, provoking the anger of many of the hospital’s staff. If at least they were used properly...daily, we are trying to educate people on how to be more efficient.

As a symbol of the challenges authorities face when it comes to planning, we are warned one afternoon in early May that the tents just set up in front of the hospital will have to be operational by the following morning, with the pressure suggesting that this request sounds more like an order. Of course, the logistics had already been in preparation for several days. Two tents were erected. One for the hospital staff, the other for all the patients. Each patient receives a different-coloured coupon based on the level of urgency of their visit to the hospital and potential Covid symptoms. In the case of Covid, these patients are sent to a special area, the triage area, for further medical investigation. Safety nets and ground markings have been installed to enforce social distancing in the waiting lines, which are themselves covered with long plastic sheeting to provide shade. Guards, nurses, doctors and cleaners have all been recruited to ensure that the new system works well for everyone.

Very well. But if we have to open the next morning, everyone will need to have a clear understanding of the system and the significance of their role within it! So, we hurriedly decide to organise a training course.

And so it is in times of difficulty that you discover the strength of a team and individual commitment. In a bewildering state of organization three hours later, at 7 pm, the new recruits are given key information by our MSF logistics and medical teams over a period of two hours. I cannot help but be impressed by the incredible energy that is applied to meeting the challenges.

The tents open as planned the next day, not without chaos and much confusion in the first few days, the result of a mixture of fear of the unknown and misunderstandings on the part of all those involved (staff, authorities, patients). This is reinforced by the difficulty in achieving consistent messaging on how the epidemic is to be managed, which does not always lead to actions that are perfect. But, since it is the enemy of the good, we would certainly still be expecting it today...

The provision of information is essential in helping to reduce these fears. If knowledge is a weapon, then we intend to play a role in the war. We decide to organize a large-scale training program for healthcare actors in the various districts of Hajjah governorate. After convincing the authorities of its relevance, and then strongly negotiating the amount of compensation to be provided to each participant for travel and accommodation expenses, Dr. Abdulfatah from the medical coordination teams in Sana'a joins us for 10 days. An orchestra conductor with an organizational sense that is as bewildering as it is efficient, he shares with us the benefits of his many years of loyal service to MSF, and all this in an atmosphere that is enlightened by his humour. In record time, with the help of his ability to work long hours, he organizes a three-time, two-day training program for nearly 90 individuals on a wide range of subjects: description of the virus and its consequences, protection methods, case management, etc.

My contribution involves coordinating the practical aspects of the event. Each day, I make sure that meals and refreshments arrive on time. I prepare stacks of 1000 Yemeni Ryal tickets (on average, 1USD = 600YER), which I distribute to each participant at the end of the session in exchange for their signature. With the assistance of Aida and the logistics teams I am able to maintain an air of calm by providing explanations to those for whom the amount is never enough.

We are pretty happy with the results, even though only the future will give us an indication of the impact of this action. In all cases, we will have been able to strengthen our ties with the network of local healthcare players, who are so critical in achieving a greater impact on the general population.

The days go by and not once on our rare outings into the city are we able to avoid being challenged by cries of  "Corona, Corona." These invective-like appeals are the first signs of the stigma attached to the virus, which I will come back to a little later.

The first suspected cases appear at the entrance to the hospital in May. As the isolation centre is still not yet open, most patients are sent back home to self-isolate. The number of official cases in Yemen is climbing, but none have been reported in the northern part of the country, where we are located. Tests are done only very rarely, and when conducted by the health authorities either we are not given the results or they are provided unofficially. In reality, we are living in the unknown, where it is impossible to accurately determine the progress of the epidemic, and where a large part of the population does not even have access to a health care facility.

Among expats, discussions are regular, and often quite lively, sometimes even tense. Everyone has a different strategy for dealing with the fear, the emotions, and the appropriate behaviours to adopt in trying to cope with the situation. Very often, I have the feeling that we are walking a fine line, like tightrope walkers permanently balancing between safeguarding our own health and continuing our mission, which is acting in this type of situation and working to serve the population. We cannot simply close our offices and send our staff home. We have to try to reassure our staff, even though we are not always reassured ourselves. We have to hammer home the importance of respecting barriers when we don't have enough masks to cover our own faces. 

One day, we all share our feelings, properly distanced, with the psychosocial unit in a very beneficial group externalization session. I realize that I am content with my overall approach to the situation and the associated stress. This is what I also share in the individual sessions. I learn to manage a balance between my personality, which leads me to not worry excessively, and my awareness of the importance of the situation in order to act in the best possible way. I see it as a life experience that helps me learn more about myself.

Quite suddenly, four members of our team are sent home as a result of an MSF worldwide decision to protect potential at-risk cases from possibly contracting the virus. Unquestionably this is a responsible decision, but it places one hell of a stone in the shoe of our operations. From an HR point of view, I am under heavy pressure, both to define what we expect from those who are now working from home indefinitely, but also, and primarily, to find temporary replacements for them. Because we see that the storm approaching we need to act fast.  And this is sometimes difficult. One of the candidates we selected through the recruitment process refuses to join us after sharing the news with his family, who do not wish to have one of their own in direct contact with Covid. I try to emphasize that we will take whatever steps are necessary to provide maximum protection for our staff, but nothing will do. It remains a personal decision.

As a preventive measure, we also decide to not allow any outsiders to enter our house. We have to adapt. So I am working with Aida to set up logistics within our team so that Soria, our cook, can work from home and deliver meals to us each day. Adnan, our cleaning officer, will now focus solely on deep cleaning the office according to strict disinfection protocols, while we set up a schedule that will see each expat cleaning the house as thoroughly as possible on a rotating basis.

At the end of May, things start to pick back up again. The authorities, wishing to ensure that there were no cases in our teams, decide to do testing.  Two were found to be carriers of the virus. A few days later, our project manager is invited to get tested... and the test comes back positive, despite the apparent lack of any symptoms. The consequences are immense. Not only is she sent to Sana'a to quarantine in order to ensure maximum supervision of her health; fortunately she will be spared, but also those with whom she is in close contact must be isolated as a precautionary measure. The expats are concerned. I therefore find myself staying at the house for at least fourteen days, along with Bruno, our Peruvian mental health coordinator. I am remotely monitored several times a day by our medical coordinator when I develop certain symptoms (sore throat, cold, fever). Covid or not, it is difficult to know, as MSF is not allowed to do any testing. But I am not really worried. I know that I would be treated if there happen to be any complications. As usual, the most vulnerable are the poorest, and they are all close by. Yet sometimes I feel that they are so far removed from my situation. I am privileged and wonder if the situation will ever improve for all these people.

I manage the on-going administrative activities as well as I can, constantly adapting. Meanwhile, a real catastrophe is occurring amongst our staff. Many of them are being sent home, either because they are beginning to develop symptoms or because they have been in contact with potential cases. The result is very critical: for more than ten days in June, there were just five employees available to maintain operations in the office.  Dr. Bakeel, who came from Sana'a to help coordinate the medical activities, is of considerable help. His umbrella-like calm manages at times to make us forget that there is now a storm raging over our heads. We continue to walk on, but the stone in our shoe is more the size of a small rock... Fortunately and quite miraculously, none of our staff members turn out to be a severe case.

Once everyone is able to gradually return to the office, we focus on just one thing: opening the isolation centre. Located twenty minutes by car from the hospital and surrounded by mountains, we can’t wait to see it finally welcome its first patients. For weeks now, our medical and logistical teams have been mobilized just for this. The building, a former training institute that has sat idle for years, was requisitioned by the authorities. It is divided into three departments: the triage department, which MSF supports, is intended to provide first aid to referred patients. Depending on their condition, they can then be moved to the intensive care department, or stay the required time in the IPD department. Each day, and sometimes at night, our logisticians are hard at work to deliver whatever is necessary for it to function properly. We install partitions between the 28 beds that we supplied, we provide oxygen cylinders, we build a waste treatment centre, and we set up waiting areas for accompanying caregivers outside the building. I provide on-going support for all these activities, especially arranging the many contracts with subcontractors or making the numerous payments for equipment, all while ensuring that we remain within budget. Some contracts are unusual for me, such as the one for the construction of a morgue. Others are extremely unusual, such as the food contract for patients in the isolation facility. That day, with temperatures in the thirties, we sign the contract on a low wall under a tree not far from the supplier's small kitchen, on paper made damp by the moisture from our hands.

On June 16, it's official. The authorities inaugurate the centre, first and foremost among them, the Minister of Health. The local social networks relay the information. I am proud, after all our efforts, to see the quality of the results and do not pass up the opportunity to communicate this to the staff. The hardest part seems to be over. Finally, the patients will be able to receive treatment in a dedicated centre. Unfortunately, reality will be otherwise.

Almost two months after it opened, attendance is still very low. At its peak, the centre had about ten patients, and the mortality rate is high. They often arrive too late, at a point when their respiratory symptoms are at their most severe and it is often too late to save them.

The primary reason for these findings represents the new battle we are trying to wage, that of reducing the "stigma" associated with the virus.  I would define this broadly as discrimination against potential carriers of the virus. This is associated with a general lack of knowledge, reinforced by fear and persistent rumours. Among these, we repeatedly hear that patients sent to the hospital are given lethal injections. And sometimes we seem to be caught in a vicious circle, such as when companions are refused entry to the centre to visit with their loved ones because of the anti-infection protective measures, all of which serves only to heighten this sense of fear.

To reduce these stigmas we work to the best of our abilities through communication with the authorities and the health promoters at the entrance to the hospital and the isolation centre But we are limited in what we can do. There are things that we would like to be able to do, but we are limited by our means or our authorizations. For example, we would like to be able to travel to various communities to raise awareness about the importance of protective measures and report back any symptoms so that they can be treated as quickly as possible. Or set up a system to allow us to refer patients who live further away from the healthcare centres.

For my first mission, I would not have imagined finding myself trying to look into the eyes of the worst pandemic in recent years, in a country considered to be the world's worst humanitarian crisis. But now, after months of suffering through the storms, I am sensing a form of frustration. After so much collective effort, the results are mixed. We have done a lot, but the impact could obviously have been even greater. But, as is often the case, we are not really even able to measure it. In any event, at the time of this writing everything suggests, according to the authorities, that Covid's dark clouds have since been swept away by the wind.