- Houthis are obstructing aid work and access to information, exacerbating a deadly cholera outbreak spreading across the country.
- The cholera outbreak will continue to take lives so long as Yemeni authorities obstruct aid and authorities and the international community fail to adequately invest in prevention and mitigation measures.
- Yemeni authorities should remove obstacles to aid delivery, including to public health information. Houthis should halt arbitrary detentions and release UN and civil society staff and aid workers.
(Beirut) – Yemen’s authorities are obstructing aid work and exacerbating a deadly cholera outbreak that is spreading across the country, Human Rights Watch said today. Parties to the conflict, including the Houthis, the Yemeni government, and the Southern Transitional Council (STC), have obstructed aid and access to information and have failed to take adequate preventative measures to mitigate the spread of cholera. Houthi security forces also have detained and threatened civil society staff, including humanitarian aid workers, in their recent arrest campaign.
Data collected by aid agencies indicate that between January 1 and July 19 there have been about 95,000 suspected cholera cases, resulting in at least 258 deaths, according to an individual working with the Yemen Health Cluster, a group of aid organizations, authorities, and donors led by the World Health Organization (WHO). All parties to the conflict should end their violations and abuses of Yemenis’ right to health, and the Houthis should end their arbitrary detentions of civil society and humanitarian aid workers.
“The obstructions to aid work by Yemen’s authorities, in particular the Houthis, are contributing to the spread of cholera,” said Niku Jafarnia, Yemen and Bahrain researcher at Human Rights Watch. “More than 200 people have already died from this preventable disease, and the Houthis’ detention of aid workers poses a serious threat to further limit the presence of lifesaving aid.”
Human Rights Watch spoke to seven doctors working in hospitals across Yemen on the cholera response, as well as several other health care professionals. Human Rights Watch also spoke to 20 aid agency officials, including doctors and epidemiologists, working to respond to the cholera outbreak and to a government health official. On July 24, Human Rights Watch wrote to the Yemeni government, the Houthis, and the STC with requests for further information. The Yemeni government met with Human Rights Watch and explained that many of their constraints in addressing the cholera outbreak were linked with a lack of funding. They also provided information demonstrating the actions they had taken to inform the Yemeni public about the outbreak. The STC responded stating that Human Rights Watch should direct their questions to the Yemeni government, though the STC comprises part of the Yemeni government’s eight-member presidential leadership council that replaced former President Abdo Rabbu Mansour Hadi in 2022. STC members also lead the Yemeni Ministry of Planning and International Cooperation (MoPIC) and the Yemeni Ministry of Social Affairs, both of which deal with humanitarian aid and have been involved in aid obstruction. The Houthis did not respond.
Yemen has been in conflict for nearly a decade. Beginning in March 2015, a Saudi and UAE-led coalition linked with the government conducted numerous indiscriminate and disproportionate airstrikes killing thousands of civilians in Houthi-held areas and hitting civilian structures, including hospitals, in violation of the laws of war. Warring parties have damaged and destroyed at least 120 medical facilities, as well as water and sanitation facilities.
Though the coalition has not conducted airstrikes since April 2022, when warring parties agreed to a ceasefire that has largely held, neither the coalition nor other warring parties have been held accountable or provided adequate reparations for the harm and damage to civilians. These attacks have debilitated an already underinvested health and sanitation infrastructure and contributed to the immense humanitarian crisis facing Yemen today.
Currently, over 18 million of Yemen’s 30 million people need humanitarian assistance, and aid agency funding has been cut each year, at least in part due to the aid restrictions by governing parties. Yemen’s severely damaged healthcare infrastructure, the lack of safe drinking water, high malnutrition rates, and growing levels of vaccine denial and hesitancy from Houthi vaccine falsehoods, according to several sources, have facilitated the spread and impact of cholera in Yemen.
According to a doctor working with a humanitarian aid organization in Houthi-controlled territory, though patients began showing signs of cholera starting in November 2023, Houthi authorities refused to acknowledge the crisis to humanitarian agencies until March 18, 2024, when there were already thousands of cases. In March, the Houthis finally began providing information about cholera cases in Houthi-controlled territory, but they still have not announced the outbreak publicly.
Houthi authorities have also detained at least a dozen United Nations and civil society staff since May 31, with informed sources telling Human Rights Watch that the number of those detained continues to grow. The arrests have left many agencies questioning whether or how to continue safely providing humanitarian aid in Houthi-controlled territories, which has the potential to further exacerbate the current cholera outbreak.
In the south, the Yemeni government, which includes the STC, quickly responded to the news of the outbreak in October 2023 by working with humanitarian agencies to set up clinics and procure necessary medicines. Though they have continued to share information with humanitarian agencies since the start of the outbreak, an informed source told Human Rights Watch that they have instructed aid groups not to use the word “cholera” in public statements, particularly in Arabic. This hinders people’s ability to take measures to prevent further spread of the disease.
Furthermore, aid agency sources said that the Yemeni government initially blamed migrants from the Horn of Africa for the outbreak, placing migrants in an even more precarious situation in Yemen. Most migrants in Yemen do not have legal documentation, with limited job opportunities and severe difficulties in accessing basic public services.
While the source of the outbreak is not clear, cholera is endemic to Yemen. According to the International Organization for Migration (IOM), during the last cholera outbreak in Yemen from 2016 to 2022, Yemen had 2.5 million suspected cases, constituting “the largest ever reported cholera outbreak in recent history,” with over 4,000 deaths.
Despite that immense toll, the authorities failed to take measures to prevent future outbreaks. Cholera spreads in large part via water and produce, such as fruits and vegetables, yet authorities and donors have not taken sufficient measures to invest in adequate water, sanitation, and hygiene infrastructure, which aid agencies call “WASH,” across Yemen, nor spread awareness in communities on effective, preventative hygiene and agricultural practices.
Many individuals working at humanitarian agencies also discussed the lack of funding for Yemen and the impact it has had on the cholera response.
The Houthis and the Yemeni government are obligated to protect everyone’s human rights in territory they control, including the rights to life, to health, and to an adequate standard of living, including food and water. Their aid obstructions violate these obligations. Although limited resources and capacity may mean that economic and social rights can only be fully realized over time, the authorities are still obliged to ensure minimum essential levels of health care, including essential primary health care.
Yemeni authorities should remove obstacles to aid delivery, including public health information. Houthis should also halt arbitrary detention and disappearances of UN and civil society staff and aid workers and release anyone held arbitrarily.
“The cholera outbreak will continue to spread and take lives so long as Yemeni authorities obstruct aid and authorities and the international community fail to adequately invest in prevention and mitigation measures,” Jafarnia said. “This can only happen in a space where civil society and humanitarian aid agencies are able to work without fearing for their safety.”
Restrictions on Publicizing Critical Health Information
Humanitarian agency sources said that authorities, particularly the Houthis, have pressured UN agencies and humanitarian organizations to stop publicly releasing data on cholera cases or deaths. Since April 30, the WHO has not reported any new data on the number of recorded cholera cases. However, sources told Human Rights Watch that case numbers have rapidly increased since April, when the WHO last reported them. The UN Office for the Coordination of Humanitarian Affairs (OCHA) reported on May 12 that there were about 500 to 1,000 new cases each day, and that “health partners anticipate that the total number of cases could range from 133,000 to 255,000 by September 2024.”
One person working in the Yemen Health Cluster said that in a meeting with the government’s health minister, people were given “clear instructions not to say the word ‘cholera’ and to use ‘acute watery diarrhea’ [instead].” Two sources also said that the director of al-Sadaqa hospital in Aden had been fired after going on television and talking about the cholera outbreak. The Yemeni government’s minister of public health told Human Rights Watch that there is ongoing investigation into the incident, but said that the director was fired for reasons unrelated to her public comments on cholera.
“In the south they’re very cautious about [using] the figures very openly … but the reality is that we have a cholera outbreak, and they haven’t announced it as an emergency and it’s spreading very fast,” said a humanitarian worker.
One local aid agency worker said that the government, while communicating openly with humanitarian aid organizations about the outbreak, was not communicating with the public. “They don’t want to publish any of the data because they don’t want to be blamed for it,” he said. He added that local media were not reporting on the outbreak because it was “sensitive” and may cause the journalists “problems” if they spoke out. Representatives of the Yemeni government told Human Rights Watch that they had publicized the cholera outbreak in several instances, which Human Rights Watch confirmed.
Engaging the public is essential to combating disease spread. A doctor working in Houthi-controlled territories said that cholera patients often did not come to hospitals until they had developed life-threatening symptoms, including impaired kidney function, due to their lack of awareness that they might have cholera and not just diarrhea. “The problem is that people don’t go to hospitals immediately once they get sick,” the doctor said. “And that’s because of the economic situation of the people and their lack of awareness of the cholera outbreak.”
The government also initially blamed African migrants for bringing the disease, risking the stigmatization of, and compounding a lack of adequate care to, the migrant population in Yemen. Migrants in Yemen already suffer from limited access to health services and their lack of legal status leaves them vulnerable to arbitrary arrest, detention, exploitation, and abuse. As several disease experts pointed out, cholera is endemic to Yemen and need not be carried over from another country for an outbreak to occur.
“There was an element of [the government] stating it was a problem in migrants and [it] won’t spread to the Yemeni population … They said they’ll just kick out the migrants and problem solved. But of course that’s not how it works, and the disease will spread to the rest of the population,” one disease expert said.
A doctor working with an aid agency said: “Cholera is a life-threatening disease if you don’t treat it well from the beginning. And when it spreads, we need to all be working together to deal with it.”
In Houthi-controlled areas, the authorities have been far less transparent than other authorities in Yemen regarding the outbreak. All those interviewed who work for aid agencies in Houthi areas said that Houthi authorities did not provide any data or information about the cholera outbreak to the Health Cluster until March. Several doctors said that the Houthis actively denied the existence of cholera in the territories they controlled, despite doctors sounding the alarm.
When asked about the impact of cholera on migrants in Houthi-controlled territories, the disease expert said: “I can’t even tell you because I don’t even know. The sensitivity and lack of sharing data means that they’ve never given us any information [about this] so I don’t even know exactly what happens [there].”
Starting on March 18, the Houthis began providing information to humanitarian agencies about the outbreak of cholera, including case numbers. But unlike the Yemeni government, which was providing humanitarian agencies with “raw data,” Houthi authorities were only providing the number of cases in each governorate. Another disease expert said that this was hindering humanitarian agencies’ ability to provide a targeted response, as they needed raw data to “analyze and pinpoint to the areas where cholera is coming from.”
Another aid worker said: “Cholera is not something you can just isolate between south and north. You need to have full data from [both sides], or you can’t respond properly because people move back and forth.”
Houthi Authorities Obstructing Aid
The Houthi authorities’ aid obstruction in the form of onerous bureaucratic aid requirements without justification have exacerbated the spread of cholera. Despite calling on humanitarian agencies to provide aid and funding after case numbers exploded in the spring, the authorities continued to impose cumbersome requirements on agencies to carry out activities, and many programs have been halted because they are waiting for authorizations.
Several people working in aid agencies said they had struggled to get permission to begin their cholera programs in Houthi-controlled territories, in some cases waiting for several months. One doctor working with a humanitarian agency said: “You need to get a specific permission for every single activity in the north; [if] you even want to do a field visit, you need to get permission. You want to conduct a training, you need to get permission.”
Another person said that the Houthis “create lots of administrative requirements and random compliance requirements, they cause complications for visa applications, and have delayed exit visa applications.”
Several people described problems in collecting data under Houthi authorities and the negative impact this had on their ability to respond effectively to the outbreak. Organizations “need permissions for [data collection], need permits, need to submit the tools [they plan to use] … and [the Houthis] may reject specific questions or may reject the questionnaire all together,” said one woman working at an aid agency.
The Houthis’ recent spate of arrests and accusations of spying included people who collected data for humanitarian agencies, demonstrating the significant risks staff face doing this work in Houthi-controlled territories. “It’s becoming more and more impossible to work in the north,” said an aid agency doctor. “All of our red flags have already been overpassed. Do we want to keep continuing like this?”
In November 2023, after several years of failed negotiations, the World Food Programme (WFP) decided to “pause” humanitarian aid to Houthi-controlled areas. Many other aid organizations say that they have struggled to maintain their operations in Houthi-controlled territories because of the extensive restrictions and attempts by Houthi authorities to control their programs.
The Houthis’ requirements that women, including those working for humanitarian agencies, who travel in territory under their control must be accompanied by an immediate male relative have also had critical impacts on aid delivery. In a letter to the Houthis regarding the requirement, several UN special rapporteurs said that “[i]nability to travel means critical work tasks cannot be performed, which leads to loss of work experience, and there are many reports of female aid workers leaving employment and therefore losing much needed income for their families.”
Authorities’ Fragmentation Hindering Response
While the Yemeni government, which includes the STC, has taken steps in the last several years to ease onerous bureaucratic requirements on aid agencies, some sources still felt that they continued to hinder some aid responses through “interference and bureaucratic red tape.” However, the larger issue, several people said, was the infighting between various authorities in the south, particularly between different agencies and between the Yemeni government and the STC, which controls Aden and several other governorates.
One aid worker said that various government ministries—particularly the Yemeni Ministry of Social Affairs and MoPIC, both controlled by STC members—fought over which group was responsible for managing nongovernmental organizations, including who should authorize activities. “This is a problem with the government of Yemen, not about us, but it ends up affecting our work,” he said.
In addition to this lack of clarity, divisions between authorities in different areas posed further problems: “The issue in the south is the fragmentation,” said another person working at an aid agency. “Suddenly MoPIC in [one governorate] and MoPIC in [another governorate] will tell us that no we need to get approval from them when we thought it was just between us and MoPIC Aden.”
Even within individual ministries, there are often no clear lines of authority. “You ask a person to approve a list of imported medicines and each individual within the ministry wants to have that control and/or power over things,” said one of the humanitarian agency staff.
Lack of Prevention and Investment in Long-Term Solutions
Perhaps the most critical factor contributing to Yemen’s cholera outbreaks has been the authorities’ lack of investment in long-term solutions and measures to prevent cholera. People interviewed described a lack of community health promotion, including safe agricultural practices, and a lack of investment in water, sanitation, and hygiene infrastructure, which is a root cause of the spread of cholera in the country.
While the conflict has damaged an already-fragile healthcare system and infrastructure, the lack of awareness campaigns and community engagement are clear areas in which authorities are failing to prevent the further spread of cholera.
A doctor working at an aid agency said that authorities had done “no health promotion” in communities. “It’s all about prevention,” she said. “There’s no health community worker going out and doing the messages. Nothing is implemented, despite whatever [authorities] have on paper.”
A person working at a local aid agency said: “We don’t see any community engagement, we don’t see a strategy for engaging communities … Most interventions focus on the treatment side and ignore the root factors, which is why we keep seeing a resurgence.”
Houthi authorities have also actively campaigned against vaccines, which can be used to prevent cholera and many other diseases, including measles. “Yemen’s vaccine-preventable disease outbreaks are the direct consequence of increasingly low immunity levels in children,” the WHO said.
There are significant logistical challenges in providing and distributing the vaccines across Yemen, including managing the “cold chain” requirements for the storage and transportation of vaccines in a temperature-controlled environment, as well as a global shortage. However, aid obstruction, arrests of aid workers and pharmaceutical company staff, and anti-vaccine campaigns exponentially exacerbate these difficulties.
“The children in the north haven’t had vaccines for the last three years so they’re much more susceptible to dying because of [vaccine-preventable diseases],” said a doctor working at a humanitarian aid agency. “It’s not about availability,” he said. He described a “huge social media campaign,” which the WHO previously described as “calling into question established scientific fact and sowing fear and doubt in parents’ minds.”
Many people interviewed described the impact of poor water and waste management, including the use of sewage water for agricultural purposes, on the spread of disease. The disease expert said that cholera “can be controlled, but realistically, when 70 percent of the country doesn’t have access to clean water or disposal of waste, there’s a major problem with environmental contamination.”
An official at the government health office in Taizz, in government-controlled territory, said that he and others tested vegetables entering Taizz from northern governorates and found cholera in them. “Those vegetables were watered with sewage water,” he said. He said that people in Taizz needed more support from government authorities to purify water tanks in rural areas of the governorate as well as support in water and hygiene more broadly.
Authorities’ failures to invest in long-term solutions are compounded by the lack of international funding for humanitarian aid agencies. “People aren’t putting money anymore in Yemen,” said one doctor working with a humanitarian agency. Only 22.6 percent of the funding needed for humanitarian aid was received for 2024, according to OCHA.
Two aid workers said that at least part of the reason for funding shortfalls is Yemeni governance actors’ aid obstruction. One aid worker, citing Houthi restrictions, said that compared to other contexts in which their organization works, donors often did not want to fund cholera activities in Yemen because of how long the approval processes might take.
“From the bottom up, it’s a broken system,” an aid worker said. “The health system isn’t fully functional, [neither is] the transport system, [nor] the water system. Neither [the Yemeni government nor the Houthis] can afford to do anything because they don’t have the funding. With the declining donor situation, it’s becoming more and more difficult for [Yemeni authorities] to deal with the root cause of the problems.”
Several doctors and individuals working in humanitarian agencies said that aid agencies need to work with the authorities on a long-term plan. “First of all, create a strategic plan and ensure it’s a long-term plan,” an aid worker said. “If you improve cholera, you improve the WASH sector. If you improve the WASH sector, you improve malnutrition.”
He added that if you respond to cholera only in emergency situations, rather than as a long-term plan for prevention, “every two years we’ll have the same exact outbreaks, and they’ll just give treatment but not address the root causes.”
“Cholera is not a new disease,” said a disease expert working for a humanitarian agency. “It’s a disease that shouldn’t exist. We should have gotten rid of it centuries ago … If you have chlorinated water, control over wastewater, and control over how you’re irrigating your crops, you’ll stop it. The reality is it’s a disease and you can definitely do something about [it].”
