A Call to End the Bombing of Yemen and the Blockade on Its Ports

Abstract

The civil war in Yemen, ongoing since 2014, has engulfed neighboring and distant nation-states in an expanding conflict with significant global implications. Yemen was already the poorest country in the Middle East; the United Nations (UN) has now declared Yemen’s plight as the biggest humanitarian disaster in the world. A UN-mandated investigation concluded that all of the major parties to the conflict, especially a Saudi Arabian–led coalition and the Yemeni government it backs, have shown a disregard for civilian life, possibly amounting to war crimes. More than 91,600 people have been killed since 2015, more than 2 million are displaced, and more than 22 million are in need of assistance to survive. This policy statement describes the ways in which this conflict has become particularly deadly and proposes three areas of intervention: (1) the U.S. Congress should continue its efforts to employ the 1973 War Powers Act to end our financing of and military collaboration with warring parties, (2) all parties attempting to enforce a blockade of Yemen’s ports should immediately lift barriers to the entry of humanitarian supplies, and (3) robust UN-led efforts should be undertaken to provide immediate relief and reconstruction, especially of the health, education, transportation, and communications infrastructure that contributes most to health.

Relationship to Existing APHA Policy Statements

APHA has a history of taking a stance against U.S. involvement in war and advocating for the health of populations affected by it. Previous statements adopted by the association related to this issue are as follows:

• APHA Policy Statement 201810: International Food Security and Public Health: Supporting Initiatives and Actions
• APHA Policy Statement 20158: Preventing Occupational Transmission of Globally Emerging Infectious Disease Threats
• APHA Policy Statement Statement 20095: The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War
• APHA Policy Statement 20089: Strengthening Health Systems in Developing Countries
• APHA Policy Statement 200718: Opposition to US Attack on Iran
• APHA Policy Statement 200617: Opposition to the Continuation of the War in Iraq
• APHA Policy Statement 200211: Opposing War in Central Asia and the Persian Gulf

The following statements are to be archived, but they represent historical APHA positions in this area:

• APHA Policy Statement 200030: Preventing Genocide
• APHA Policy Statement 9923: Opposing War in the Middle East
• APHA Policy Statement 9817: Arms Trade Code of Conduct
• APHA Policy Statement 9715: Impact of Economic Embargoes on Populations Health and Wellbeing
• APHA Policy Statement 8926: Foreign Assistance Act
• APHA Policy Statement 8531(PP): The Health Effects of Militarism
• APHA Policy Statement 7913: World Peace and the Military Budget
• APHA Policy Statement 7632(PP): Policy Statement on International Health
• APHA Policy Statement 6716(PP): International Health

Problem Statement

Yemen’s civil war began in 2014 when the nation’s Houthi insurgents took control of Yemen’s capital and largest city, Sana’a, demanding lower fuel prices and a new government. These insurgents were characterized as Shiite rebels with links to Iran, which had a history of opposition to the Sunni government. After failed negotiations, the rebels seized the presidential palace in January 2015, whereupon President Abd Rabbu Mansour Hadi and his government resigned. Beginning in March 2015, a coalition of Gulf states led by Saudi Arabia launched a campaign of economic isolation and air strikes against the Houthi insurgents, with U.S. logistical and intelligence support. President Hadi rescinded his resignation in 2015 and has lived in exile in Saudi Arabia since the end of 2017.[1]

The United States and its allies, Saudi Arabia and the United Arab Emirates, have conducted multiple air strikes on Yemeni markets, hospitals, and other civilian sites during the conflict. Blockades on ports of entry impede the import of food and medicine for this country that is highly dependent on such shipments.[2] Yemen was already the poorest country in the Middle East; it is now the biggest humanitarian disaster in the world, with several rivals for that standing. An investigation mandated by the United Nations (UN) concluded that all of the major parties to the conflict, especially the Saudi Arabian–led coalition and the Yemeni government it backs, have shown a disregard for civilian life, possibly amounting to war crimes.[3]

In March 2019, the U.S. Congress actively objected to U.S support of the war in Yemen with the passage of resolutions for reclamation of the War Powers Act by both the House and the Senate, which would require withdrawal of such support without the approval of Congress. That effort was, however, vetoed by the president in April 2019. On May 24, Secretary of State Mike Pompeo informed Congress that the president was invoking his “emergency authority” to sidestep Congress and complete arms deals with Saudi Arabia. These policies have emboldened the Saudi-led coalition to continue its war and the blockade on Yemen, irrespective of international laws governing war. Millions of Yemeni civilians are affected each day, especially by the blockade of food, medicine, fuel, and essential goods, most of which Yemen must import. The result is a man-made famine, scarcity of medicine for chronic and infectious diseases, inadequate medical services, and the largest cholera outbreak in recent history.

The heavy toll of the conflict in Yemen includes more than 91,600 people killed since 2015 (Armed Conflict Location & Event Data Project [ACLED]), more than 2 million displaced (Office of the United Nations High Commissioner for Human Rights [OHCHR]), and more than 22 million in need of assistance (United Nations Office for the Coordination of Humanitarian Affairs).[4]

The war on Yemen and especially the imposed blockade have profound public health consequences and represent an entirely preventable source of the world’s worst humanitarian crisis.

This APHA policy statement was submitted as a late-breaker in the autumn of 2019. U.S. bipartisan congressional action in April 2019 employed the 1973 War Powers Resolution to suspend U.S. attacks on Yemen. This action, however, was vetoed by President Donald Trump the following month. Immediate support from U.S. public health advocates is needed to encourage Congress to take further steps to suspend involvement in Yemen.

Civilians: According to OHCHR, as of November 2018, around 6,800 civilians had been killed and 10,768 wounded, the majority by Saudi Arabia–led coalition air strikes. These numbers reflect direct causes of war and thus do not include secondary (i.e., indirect) causes.[5]

Children: Geert Cappelaere, regional director of the United Nations Children’s Fund (UNICEF), has described Yemen as a “living hell” for children given the limited access to clean water and food, leaving nearly 400,000 young lives at risk of severe acute malnutrition.[6] An international aid group estimated that 130 children or more die every day in Yemen from extreme hunger and disease. According to different reports, continuing blockades by the Saudi-led coalition caused the death of more than 50,000 children in 2017.[7]

At least one child dies every 10 minutes in Yemen because of preventable diseases such as diarrhea, malnutrition, and respiratory tract infections. Children are especially affected by growing rates of malnutrition. An estimated 2 million children are acutely malnourished, including nearly 360,000 suffering from severe acute malnutrition. The risk of acute malnutrition among children under age 5 remains high, especially in active-conflict or access-restricted communities such as Al-Hudaydah, Hajjah, and Taizz. An estimated 7.4 million children need humanitarian assistance, representing a 12% increase since 2017.[3]

Children also experience severe psychological effects from war, including anxiety, depression, posttraumatic stress disorder (PTSD), anger, and hopelessness.[8,9] Exposure to community violence, including witnessing atrocities, can result in aggression and antisocial behavior among children at the time as well as years after the exposure.[10] In April 2018, an interagency needs assessment showed that 96% of respondents noted significant changes in the behavior, attitudes, and psychosocial well-being of children and child-care providers.[3]

Protracted conflict and economic hardship are increasing risks of family separation, child recruitment, child marriage, exploitive forms of labor, and child trafficking. More than 1,200 unaccompanied and separated children are in international displaced persons settlements in Yemen. In addition, child marriage rates are rising, increasing threefold among girls younger than 18 years between 2017 and 2018.

The conflict has also taken a severe toll on children’s access to education. Some 2 million children are out of school, depriving them of an education and exposing them to greater risks of recruitment to armed groups and child marriage.[3]

Women and girls: Women and girls suffered disproportionately from gender-based violence, poverty, and violations of basic rights before the conflict. The World Bank estimates that, relative to the population as a whole, women are shouldering an inequitable share of the burden in terms of worsening poverty rates and deprivations.[11]

Deteriorating security and economic conditions are affecting women’s and girls’ mobility as well as their access to services and resources. Their ability to reach health, nutrition, and other services remains a challenge due to distance and a lack of financial means to afford transport. The death of male relatives, given that men are usually the primary breadwinners in Yemeni families, increases economic pressure, especially for female-headed households.[3]

Cause-specific health burdens: In addition to direct air strike attacks, civilians face further risk from infectious disease and malnutrition because of the destruction of the infrastructure and blockades of humanitarian aid entry through the Al-Hudaydah port. An outbreak of cholera began in Yemen in October 2016 and was ongoing as of July 2019. More than 1.3 million suspected cholera cases and nearly 2,800 associated deaths have been reported in 306 districts across Yemen—the worst single outbreak on record. In February and March 2017, the outbreak seemed to decline during a wave of cold weather, but the number of cholera cases resurged in April 2017.[12] In 2018 alone (January to November), more than 311,000 suspected cases were reported. This was due to the ongoing prevalence of risk factors, including collapsing health, water, and sanitation facilities.[3]

Diphtheria, a vaccine-preventable disease, has been widely reported in Yemen since the beginning of the war. A total of 1,294 probable cases of diphtheria were reported from 177 districts, with an overall case fatality rate of 5.6%. Approximately 65% of the patients were children younger than 15 years, and 46% of patients had never been vaccinated against diphtheria.[13] Access to vaccines is restricted, increasing the risk of several serious childhood diseases, as pointed out in a National Public Radio report on November 5, 2018.[6]

Most food imports enter the country through the Al-Hudaydah and Saleef ports. Before the escalation of the crisis, Yemen imported about 90% of its staple food and required an estimated 544,000 metric tons of imported fuel per month.[14] One of the primary barriers to food security is the restricted ability to import food, as ports are blockaded.[3]

The risk of famine in Yemen is intensifying. An estimated 7.4 million people in the 230 highest-risk districts do not know how they will obtain their next meal. Most households’ livelihoods in these districts have totally or nearly collapsed. This has triggered spiraling coping behaviors such as the sale of houses, land, productive assets, and livestock, exacerbating household food insecurity. Families are increasingly going into debt to access food. In addition, 3 million people need nutrition assistance, including 2 million acutely malnourished children under age 5.[3]

Malnutrition in Yemen has three main underlying causes: (1) inadequate access to food, (2) inadequate child-care practices, and (3) poor water, sanitation, and health services.[3] The past 4 years of conflict in Yemen have further exacerbated the impact and severity of these factors.

The latest ACLED data show that between January 2016 and March 2019, more than 3,000 direct attacks targeting civilians were recorded, resulting in approximately 7,000 fatalities — over 2,300 of which occurred in 2018 alone.[15]

Responsibility for the highest number of reported civilian fatalities in Yemen is linked to the Saudi-led coalition, with approximately 4,700 reported civilian fatalities since 2016 — including 67 in 2019 — stemming from coalition activity.[15] The Houthis and their allies are responsible for approximately 1,300 reported civilian fatalities, including 149 in 2019.[15]

To date, 2019 was the only year in which the Houthis were responsible for the direct reported killing of more civilians than the Saudi-led coalition. The UN reports that at least 7,025 civilians have been killed and 11,140 injured in the fighting since March 2015, with 65% of the deaths attributed to Saudi-led coalition air strikes.[15]

Psychological harm suffered by civilians as well as combatants includes PTSD, depression, alcohol misuse, and anxiety disorders, all of which can persist for years after the end of combat.[16–18] Victims and survivors of explosive-related incidents need access to proper assistance, including medical, rehabilitation, psychosocial, and socioeconomic inclusion, particularly when survivors are women. Conflict is undermining children’s psychosocial well-being. At least 35% of child protection incidents reported to social workers in 2018 were related to mental health and psychosocial issues.[3]

Internally displaced persons and host communities: Shifting frontlines, food insecurity, disputes over land use and ownership, and natural disasters all contribute to primary and secondary displacement. As of late 2018, an estimated 3.3 million people remained displaced in Yemen. In 2019, displacement was anticipated to continue in proportion to the intensity of the conflict. Between 500,000 and 1.2 million people will be newly displaced depending on conflict dynamics. According to the findings of a nationwide multicluster location assessment, internally displaced persons, host communities, and returnees most frequently identified food, livelihoods, and drinking water as their top priorities. In 2018, 60% of respondents to an interagency child protection assessment confirmed cases of family separation in their neighborhood due to internal displacement.[3]

Health care services and infrastructure: According to a 2018 Lancet report, more than half of the health facilities in the country had been destroyed by constant air strikes and regional conflicts, and many Yemeni medical personnel had been working without pay for nearly 2 years.[19] Sameh Al-Awalqi, a health specialist from Yemen, confirmed that health workers in many areas have yet to receive their salaries, some for the third consecutive year. Also, access to services is restricted by the active conflict in hot zones.[19] In addition, the fractured health system due to the war has left two ministries of health, resulting in delays in paperwork necessary for aid organizations to provide health responses along with confusion from international health organizations when designing and managing programs for the country.[19]

Human rights: Violations of human rights, including torture, erosion of free speech, and detention, are common during the war and ultimately compromise health and well-being.

Conflict and economic pressure increase risks of gender-based violence, which disproportionately affects women and girls. In 2018, Yemeni women and girls received nearly 85% of all services for gender-based violence survivors, including psychological, legal, health, and shelter support.[3]

From October 2017 to September 2018, the Country-level Task Force on the Monitoring and Reporting Mechanism verified and documented 2,367 victims of grave child rights violations (1,852 boys, 512 girls, 3 children of unknown sex), an increase of 23% from the previous year. These violations included killing and maiming of children, abduction of children, attacks against schools or hospitals, recruitment or use of children as soldiers, denial of humanitarian access for children, and sexual violence against children; overall, there were 1,843 cases of killing and maiming (1,346 boys, 494 girls, 3 children of unknown sex), an increase of 51% since 2017. The actual extent of grave violations of children’s rights is almost certainly far higher than the number of reported and verified cases.[3]

Evidence-Based Strategies to Address the Problem

Involvement of the United States in the war in Yemen: U.S. involvement in the war in Yemen is explicitly prohibited by the War Powers Act of 1973. This resolution states that involvement of U.S. armed forces in war is allowed by order of the president “only pursuant to (1) a declaration of war, (2) specific statutory authorization, or (3) a national emergency created by an attack upon the United States, its territories or possessions, or its armed forces.”[20] Because support for Saudi-led forces has come from the president despite there having been no declaration of war, statutory authorization, or attack upon the United States from this war, involvement in it is unlawful. The United States Congress proposed a bill invoking this resolution in 2018 regarding U.S. support for Saudi-led military involvement in Yemen, and the bill passed both the House of Representatives and the Senate in early 2019 before being vetoed by the president in April 2019. An essential strategy to avert U.S. involvement in this and other unauthorized wars is continued advocacy with both Congress and the administration as to the importance of U.S. adherence to the War Powers Act.

The Saudi-led coalition’s blockade over ports of entry into Yemen: This policy statement calls for consideration of both the current and lasting health implications of this blockade, as outline above. Blockades as a method of warfare have been condemned by the United Nations, and the starvation caused to civilian populations as a direct result of the Saudi-led blockade is in violation of International Humanitarian Law Rule 53: Starvation as a Method of Warfare, which states that in any blockade in which “the civilian population is inadequately provided for, the blockading party must provide for free passage of humanitarian relief supplies.”[21] Furthermore, according to the protocol additions to the Geneva Convention of 1949, “it is prohibited to attack, destroy, remove or render useless objects indispensable to the survival of the civilian population, such as foodstuffs, agricultural areas for the production of foodstuffs, crops, livestock, drinking water installations and supplies and irrigation works, for the specific purpose of denying them for their sustenance value to the civilian population or to the adverse Party, whatever the motive, whether in order to starve out civilians, to cause them to move away, or for any other motive.”[22]

The Security Council of the United Nations has called for a complete opening of all ports into Yemen as well as increased access to the airport in Sana’a.[23] Despite this call and the Stockholm Agreement reached in December 2018 by all warring parties stating that Hodeidah and the ports of Hodeidah, Salif, and Ras Issa will be secured only by local security forces in accordance with Yemeni law,[24] outside access to the ports remains under the control of the Saudi coalition. The United States, a strong Saudi partner, is actively supplying military aid to Saudi Arabia and therefore has the influence and means to place pressure on the coalition to allow access to the ports. Active opposition by the U.S. public and advocacy with Congress regarding this and other unlawful blockades of humanitarian supplies are essential strategies to counter their use.

Reconstruction in Yemen: Under The Responsibility to Protect, established by world leaders during the 2005 United Nations World Summit, nations are called to protect populations that are “suffering serious harm, as a result of internal war, insurgency, repression or state failure, and the state in question is unwilling or unable to halt or avert it”.[25] This agreement advocates for nations “to respond to situations of compelling human need with appropriate measures,” which the United States as well as all involved warring countries are able to do. Also according to the agreement, nations that have been involved in wars with devastating effects on civilian life should provide “full assistance with recovery, reconstruction and reconciliation, addressing the causes of the harm the intervention was designed to halt or avert.” Advocating for U.S. responsibility to actively address the physical devastation resulting from support of the Saudi-led war in Yemen is an essential component of the public health response.

Opposing Arguments/Evidence

U.S. involvement in the war: An argument for continued involvement by the United States, which includes efforts to prevent the United States from placing pressure on Saudi Arabia to lift the blockade, is based on the relationship between the two countries. Saudi Arabia is considered a U.S. ally in the region, is the main supplier of oil to U.S. markets, and is a major buyer of American arms. Others argue that we need to stand with the Saudis because they are our ally in confronting the Iranian influence in the region. Numerous experts, including those within the U.S. intelligence community, claim that purported Iranian control of and influence over Houthis is exaggerated.[26]

In any case, U.S. involvement in a war without officially declaring war, as noted in the previous section, is unlawful under the War Powers Act of 1973. In addition, this cycle of buying oil and arms between the United States and Saudi Arabia aids the continued use of fossil fuels for U.S. energy and militarism in and by Saudi Arabia, both of which have lasting public health effects, as acknowledged and discouraged by previous APHA policy statements.[27,28] U.S.-Saudi relations, as well as foreign relations between Saudi Arabia and many of its foreign investors, have also become weakened since the murder of U.S. journalist Jamal Khashoggi in the Saudi consulate.[29]

Necessity of the blockades: The main argument in support of the blockade suggests that it is necessary to keep arms out of Yemen. However, the UN already has sanctions in place for this purpose. The Security Council of the United Nations supports the UN Verification and Inspection Mechanism (UNVIM), “which facilitates commercial shipping to Yemen, including by carrying out inspections of commercial vessels over 100 metric tonnes.”[22] In addition, as per the Stockholm Agreement reached by all warring parties in late 2018, an agreement to a cease fire has already been reached in the ports of Hodeidah, Salif, and Ras Issa allowing the UNVIM to be conducted there.[23]

Providing reconstruction to Yemen: An argument against the UN providing robust reconstruction to Yemen immediately and continuing after the war is the idea that Yemen’s civil war should be reconstructed from within the country. However, in alignment with The Responsibility to Protect, because both the UN and several other nations have become involved with the war, it is now the responsibility of all acting parties to provide reconstruction to any areas of the country where damage has occurred as a result of their actions.

Alternative Strategies

The alternative strategy to opposing the war in Yemen, ending U.S. involvement, ending the blockades over ports of entry, and providing reconstruction is to allow the war to continue as is and continue U.S. aid to the Saudi-led coalition. Due to the mortality and morbidity experienced by the Yemeni people (as described above) and the urgent nature of the situation, we do not believe that this is a humane alternative.

Action Steps

Based on the history of U.S. involvement and the extent of the humanitarian crisis in Yemen, it is critical for organizations such as APHA to support policies and initiatives to address key elements of the problem.

APHA therefore urges:

A. The U.S. government to end the financing of and military collaboration with warring parties and hold such parties accountable for attacks on health workers and civilians, as follows:

• The U.S. government should prohibit any further U.S. assistance or support, including intelligence sharing and logistics support activities, to any members of the Saudi-led coalition in the civil war in Yemen.[30]
• The U.S. government should suspend direct commercial sales licenses for maintenance and sustainment of fighter aircraft used in the Saudi coalition’s offensive operations in Yemen.
• The U.S. government should consider congressional action to cut off arms sales to Saudi Arabia; such action could be limited to certain categories of weapons (i.e., potentially excluding weapons systems that are defensive in nature) or sweep more broadly to include all or greater amounts of weapons.
• Congress should pass the Saudi Arabia Accountability and Yemen Act of 2019,[31] which offers a range of tools to hold the kingdom accountable for its human rights abuses — including the underlying problems motivating Saudi dissidents such as the murdered journalist Jamal Khashoggi to criticize the Saudi government in the first place — and for its devastating restrictions on humanitarian access in Yemen’s civil war.

B. All concerned parties to support an immediate end to the blockade of Yemen’s ports and lift barriers to the entry of humanitarian supplies, as follows:

• The U.S. government should apply pressure on Saudi Arabia to lift the blockades on all ports of entry to Yemen, including air, sea, and land, and especially the ports of Hodeidah, Salif, and Ras Issa, and allow unhindered entry of food, medicine, and essential goods such as supplies for aid agencies and commercial imports.
• The U.S. government should apply pressure on Saudi Arabia to open the Sana’a airport for civilian travel, and representatives of the United Nations, in accordance with the Stockholm Agreement, should lift restrictions on air travel to and out of Yemen and within Yemen, including all Yemeni airports.
• UN agencies such as the World Health Organization, UNICEF, the Office of the United Nations High Commissioner for Refugees, and the UN General Assembly, as well as international nongovernmental organizations including the International Committee of the Red Cross, Oxfam, Doctors Without Borders, Save the Children, and CARE, should express strong opposition to the Saudi-led blockade on the Yemeni people.
• Health professional associations in the United States should adopt resolutions opposing the war and the blockade imposed by the Saudi-led coalition on Yemeni ports, supporting the opening of the Sana’a airport, and allowing the unhindered entry of food, medicine, and essential goods into the country.
• Public health practitioners should increase awareness in their own professional organizations of the humanitarian effects of U.S. collaboration with the Saudi-led coalition blockade on Yemen and urge these groups to take a stand in opposition to it.

C. The UN to lead robust efforts to provide immediate relief and reconstruction in Yemen. The U.S. government should support UN efforts to rebuild destroyed or damaged health centers as well as government and civilian infrastructure, including homes, offices, water and sanitation facilities, and food processing plants in Yemen, and assist in reversing the damage that has been done as a result of U.S.-supported military actions, in accordance with The Responsibility to Protect.

References

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3. United Nations Office for the Coordination of Humanitarian Affairs. 2019 Yemen humanitarian needs overview. Available at: https://reliefweb.int. Accessed November 29, 2019.

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