The journey is interminable, and probably far too long to save the family in the back of the pick-up truck. The man behind the wheel speeds straight from the landmine that blew them up to the nearest hospital in Mocha. It’s been three hours already that the family has been waiting for medical treatment.
We’re in Yemen, and the family has been wounded by one of the many landmines the army has left behind to be triggered by civilians.
“They’ve literally littered the whole place with them, fields as well as roads,” says Agnes Varraine-Leca who’s been to Yemen three times this year for Doctors Without Borders/Médecins sans Frontières (MSF).
“And who plays in fields? Kids, of course. Who works the land? Their parents. So entire families aren’t able get to their crops and fields, or end up getting blown up by landmines. It’s creating whole generations of amputees.”
Catching sight of the MSF flag, the driver automatically accelerates. The truck throws up gravel in its wake as, its brakes screeching, it arrives at the hospital compound. Then, the bell rings.
“Every time there’s an emergency, you hear the bell ring. It gives you a sinking feeling, a feeling of anxiety because you never know what’s going to be coming in.” Women and men in pale green scrubs surge forward to the pick-up truck.
At the back of the vehicle perches an impressive-looking machine gun whose size and power contrast with the build of the man operating it. The scarf wound around his head half-covered in sand, he looks totally stunned.
The cloud of dust raised by the truck’s ear-splitting arrival still lingers in the air as four bodies are unloaded. First are two adults. Body bags, and then straight to the morgue. There’s nothing more to be done.
“The two children, brothers aged between five and ten years, aren’t dead.” One’s alive, but the other’s having worrying convulsive seizures. “He can’t control them. He looks so small in the emergency room that in comparison seems so huge. His whole body’s shaking.
He has a miniscule hole in his skull that doesn’t look that big a deal to me, but shrapnel has penetrated it. It’s left a really small hole, but internally, inside his head, it’s made a huge mess.
The problem is that you might think it’s a splinter, but you don’t really have a clue. The fact is we can’t give him a scan, because we have no scanner in Mocha.”
The child has to be transported to the hospital in Aden, the big port city in southern Yemen. It’s a six-hour drive away, which may well further endanger his life.
“We’re sending him there with no idea of what’ll become of him. It happens a lot. This is our reality.”
In the hospital in Mocha we live with the ring of the bell, little information, whine of the wind in the operating theatre tents and the thud of artillery fire.
Agnès considers the family’s uncertain fate an important story that has to be told, because the war in Yemen is a conflict played out behind closed doors.
Since 2015, the Yemeni government aided by an international coalition led by Saudi Arabia and the United Arab Emirates has been trying to push back the Houthi rebels to the north.
Yet one more war for a country whose young adults will only ever have known brief interludes of peace.
The brutality of the conflict is concealed by severe restrictions on information, access and travel, not just for journalists, but aid organisations too.
Any news of the war making it outside the country is therefore distorted and tainted by the propaganda put out by the different parties to the conflict.
By accepting to treat combatants as well as civilians, hospitals have become a window into the reality of what’s really going on in the country. A country where it is often people with no role in the conflict who end up paying the price.
As its wheels touch down on the tarmac at Sana’a airport, the plane that has just 16 seats shudders violently.
Chartered by MSF, the plane has flown in from Djibouti several hundred kilometres from the Yemeni capital, which is really the only way to access the north of the country.
At Sana’a airport, there are no queues of planes standing by to land or take off, no snaking lines of luggage carts and no crowds of people impatiently waiting to arrive or depart.
“As you come in to land at the airport, you see carcasses of planes—military and civilian—alongside the runaway,” Agnès recalls.
The hectic hive of people and planes seen before the war has given way to a vast and desolate space. “There’s a counter with a man right down at the end and huge, totally empty halls where everything’s starting to fall apart. It’s all rundown.
You can see the ceiling hanging down in places. Nothing’s right. When you arrive you’re aware you’re entering a country where something’s not working.”
Like the rest of Houthi-controlled territory, for almost five years Sana’a airport has been regularly subjected to international coalition airstrikes.
Originating from the far northwest of the country and marginalised by the government, the Houthis took up arms and advanced south beyond their borders.
In September 2014, they took capital city Sana’a and, in March 2015, attempted to seize control of Aden, the country’s largest port.
This was when the Saudi-led international coalition that opposes the Houthis launched its bombing campaign.
“And then during the first evening there you start hearing the planes flying and start hearing the bombs dropping. You think, ‘oh, okay actually something is really going on here, these are big bombs that are dropping’. And then the house is shaking and, you know, it felt very much like the start of something very big that was happening at that point on.”
MSF Emergency Coordinator Natalie Roberts first arrived in Yemen in mid-2015. “When you were in Sana’a and you heard the bombs exploding around you, you finally start thinking well, like, ‘Are they really bombing legitimate military targets?’
Because even there you're thinking, ‘Well, this is a big crowded city, how do they manage to pinpoint military targets?’ Then as you move in the north, it became a lot more clear that the precision targeting wasn't there
or if it was there then they weren't really using it properly because, the further you went, you moved from Sana’a, the more and more civilian impact you saw in the bombing.”
Sitting in the front of an off-road vehicle, Natalie is on her way to Saada, the historical stronghold of the Houthis proclaimed hostile by the coalition when the war broke out.
People who have not fled and still living there are considered legitimate targets. The city’s inhabitants are trapped by the airstrikes.
The road is strewn with rocks and there’s little sign of life. Every now and again, she’s surprised to see groups of Eritrean and Ethiopian refugees walking—perhaps unknowingly—towards some of the most dangerous places in the region.
The further north she goes, the more apparent is the destruction inflicted by the airstrikes.
“You notice there's a succession of bridges and even by the time I arrived it was only a few months after the bombing had started, all the bridges were gone. And the other thing you see on the road is a lot of bombed-out trucks, particularly food trucks.
And there was one in particular that had got bombed. The heavier bomb was carried on sheep. So, there was a lot of dead sheep on the road.
And when I first drove past it, it'd just been bombed 'cause it was still smoking, the sheep were burning, it was pretty grim.”
Weddings, funerals, schools, markets, gas stations … nothing and no one is safe from the bombs. And the inhabitants even end up refusing to drive trucks carrying food because they too are the targets of airstrikes.
Natalie sees the risks ambulances in the region have to contend with. “You can't get off the road. You're on the mountainside, so if they decide to target you, there's no escape essentially,
so I would get phone calls early in the morning. I would be at one location and a team would phone me from another location saying, ‘We have a patient, he's gonna die. We want to transfer him, but the planes are flying, what should we do?’
And I never have any answer. I would say, ‘I don't know.’ You know you have to explain to the patient and his family that if he stays there he'll die, if he gets in an ambulance he might die.”
On arriving in Saada any lingering doubts about the intensity of the bombing raids instantly evaporate. Buildings on both sides of main roads have collapsed in a domino effect.
“It was impressive how quickly it had been destroyed. That must have happened in the space of two months. So houses destroyed and shops destroyed and just kind of crumbling ruins in lots of the streets. Which makes you quite afraid essentially.
We were staying at night in the hospital in Saada City and everyone kept telling me, ‘You'll be fine 'cause hospitals are fine.’ So, we decide to stay the night in the hospital.”
The number of bombs dropped in the city has something symbolic about it—a city just as much symbolic for the rebels. Elsewhere in the country, the damage is less concentrated.
Southernmost port Aden has not suffered as much from airstrikes. The city was rapidly re-captured by the coalition who then pushed the Houthis slightly further north. A frontline was established around Taiz, the country's third largest city.
Once an intellectual and industrial hub, Taiz has been besieged by all sides to the conflict. For many months, many of its inhabitants have been cut off from the outside world.
In 2016, supplies were brought in at night to avoid the snipers—on foot, of course, up the mountain the city is perched on.
Which is how in early 2016 Emergency Coordinator Thierry Durand managed to get there.
“It’d been brought to my attention because surgeons and people who arrived in Aden after trekking through the mountains from Taiz cried when they showed me absolutely horrifying photos of guys ripped open with their guts hanging out.
They’d run out of everything, they had no oxygen, or anything else, so there was nothing they could do. Most of the hospitals are either closed or unable to perform surgery.”
The altitude 2,500 metres, Thierry struggles to find his breath. At last, the convoy of donkeys, camels and men reaches a town that’s regularly bombed at night.
“Someone phoned me, ‘it looks like the hospital was bombed last night.’ So, the next morning I went over there. I saw the director and said,
‘I heard you were bombed last night.’ The guy burst out laughing. He said, ‘Yeah, only for the 60th time.’”
The façade of the hospital in Taiz is riddled with holes left by bullets and rocket and mortar fire. “‘But we're used to it. We don't work on any of the upper floors anymore,
only in the basement and on the ground floor.' They’d already reduced the number of beds to about a 100, down from the 600 they had before.”
In Yemen, hospitals are just as much targets as anything else. Since the beginning of the conflict, MSF facilities have come under attack six times—and that’s not counting the damage done to health centres that were already there.
“When they bomb a hospital, they're not necessarily getting that many people depending on how many people were in the hospital, but they're wiping out the potential to save lives afterwards.
Health system is one of the main building blocks in social infrastructure and, if you're trying to destroy the population, you attack their health system.”
The war has at the very least killed 91,000 people, and left countless others wounded. Among them are victims of international coalition airstrikes, but also of landmines the Houthis have laid near frontlines in the southwest of the country.
Coastal city Hodeidah in the west is the country’s strategic port on the Red Sea. During an offensive in 2018, the city also suffered an incursion of ground troops and intense coalition airstrikes.
“From the beginning of 2018 to June, we saw coalition forces advancing along the entire southern frontline that extends from just above Taiz towards Mocha and up to Hodeidah.
They reached Hodeidah,” recalls Agnes, who went to the region a few months later. “It was this offensive launched with ground troops and massive airstrikes that led us to set up operations in Mocha in August and then Hodeidah.”
MSF opens two new projects, one north of the frontline in Hodeidah and one in Mocha, to provide medical care to people trapped by the fighting to the south.
120 kilometres further south, small port town Mocha has the misfortune of being in a strategic location. Mid-way along the only road between Hodeidah and Aden.
The road cuts through a wide desert strip along the Red Sea. Tiny villages, a few burnt-out tanks and beached rusting boats are the only landmarks. That’s it. Nothing else.
“But when we say there’s nothing, it’s not a figure of speech. There really is nothing. A road, and that’s it. So, if you happen to be a haemophiliac and you cut your little finger, you’re not going to make it! It’s literally a medical desert.”
So, within a few weeks a tent hospital is assembled in Mocha and the first patients quickly begin to pour in—women about to give birth and people with war wounds, often the victims of landmines. Many are emergency cases, and arrive when it’s already too late.
“Landmines are the most cruel and senseless of the lot. Anti-personnel mines, the booby-trapped toys the Soviets dumped during the war in Afghanistan for kids to pick up,” comments surgeon Bernard Leménager.
“I don't know if in Yemen landmines are laid intentionally to target the population. I'm not sure, but it’s probably to stop troops advancing.
But these buried mines explode. It’s the kids who are worst affected, because kids run around all over the place.”
Bernard sees many civilians in his operating theatre. “The war affects people of all ages. It’s affecting everyone. And it’s not just 7 to 77 year-olds we treat. We’ve had a 7-month-old and a 107-year-old.
Well, maybe not 107, I think 103, but it was someone who’d reached the century. The 7-month-old kid, he’d taken a bullet in the abdomen that perforated his stomach.
It was quite a serious wound, because a Kalashnikov bullet does a lot of damage to a tiny 7-month-old baby. But, he came through. And the granddad of 100 plus years—I say plus—, he was definitely over the 100.
He was born during the Ottoman Empire. We don’t we see many patients born during the reign of the Sultan of Istanbul.
And so this granddad of 100 plus years had small shrapnel fragments that weren’t that serious, and a few days later he was able to go home.”
Many patients have shrapnel wounds—small fragments of bombs, which cause damage that’s difficult to evaluate. It’s sometimes safer to leave the body to heal itself around the metal fragments.
The consequences for people too close to a landmine when it explodes can be devastating.
“There are lots of amputations. Amputations pose a problem for surgeons who have to decide whether or not to proceed. They need to know the patient’s chances of recovery and if they’ll have a functional limb.
Then, both the patient and their family have to be persuaded. That’s really challenging because, on top of everything else, we don’t speak the language and they believe that because we’re MSF, with all our resources, we should be able to avoid amputation.”
Amputation is the most conspicuous sign of the price the war exacts from civilians. And, the impact of landmines extends beyond the wounds they inflict,
as they also prevent people from moving around freely and cultivating their fields to feed themselves.
Along the road from Mocha to Taiz the enormity of the problem is fully revealed. The road passes through a lunar landscape
where countless plastic bags are entangled in small shrubs on dunes. The driver of the off-road vehicle transporting Agnès scans both sides of the road.
He’s careful to stay between the small red-painted stones the deminers have placed to delimit either side of the de-mined path.
“In 10, 20, 30 years, it’ll still be a problem and it always will be, because for the moment it’s the army doing the de-mining—soldiers specialised in mine clearance.
But they only clear the places they’re interested in, which means mainly access roads. That’s about it.
There’s very little of what’s called civilian de-mining, so nobody’s clearing the fields.
The local inhabitants continue to get blown up by landmines and can’t cultivate their fields—which they can't anyway. It’s a problem that's not going to go away any time soon.”
A bomb destroys a building and claims its victims. But, its less obvious ramifications are as indirect as they are accumulative.
Destroying a road, a bridge or a hospital causes the social and economic fabric of an entire region to crumble. Resources become scarce or more difficult to get hold of.
“When you leave Sana’a, you see long queues of cars that go on forever,” remembers Agnès.
“You drive up a line of cars, all waiting to get gas. Some wait one or even two or three days to fill up their cars at totally insane prices.”
In the case of disease and war wounds, the calculation becomes economic. “Transport’s really expensive. We see people showing up literally at the last minute
because they’ve said to themselves, ‘Let’s wait and see. The child’s sick, but he looks ok and we don't have the money, so we’ll give it a while.’”
In Yemen, people die because they delay going to the hospital or don’t have enough money to get there. A situation Natalie sees far too often.
“Sometimes they would be already dead by the time they arrived and there's nothing to be done about that. They'd arrived quite quickly and it just depends on the severity of their injuries.
But, with the transport difficulties for people who weren't wounded, they lost time until they had enough money or until they could find someone to give them transport.”
“We saw so many small children dying of things that were very avoidable that you just needed to have antibiotics for.
Newborn babies was a particular problem because if the mother hadn't been able to feed her baby, she would wait and wait and wait and then eventually the baby would arrive, but, by the time it got to the hospital,
often they'd die within the first half hour because there's very little you could do for them when they were there so very late.”
Another symptom of a broken health system, the MSF teams are witnessing a resurgence in diseases that had disappeared from Yemen.
In 2016, an epidemic of cholera breaks out in the country. By the time Deputy Head of Emergencies Ghassan Abou Chaar arrives in 2017, the situation appears to have stabilised.
So much so that cholera is barely mentioned in his teams’ contingency plans for the upcoming months. That is, until…
“A project in Khamer in the north is reporting two possible cases of cholera. The next day it increases from two to six.”
Cholera patients in the hospital in Khamer are put into isolation. By the third day, the isolation unit is full and a large nearby tent is requisitioned. Then an entire school is taken over to treat the sick.
The number of patients cared for by the MSF teams gradually begins to slow down—from over 11,000 a week at the peak of the epidemic to 500 in mid-October.
“We’ve seen WHO’s figures for the country. They’re continuing to increase, even in the places where we work.
We’ve got almost empty treatment centres, and WHO is reporting 200, 300 cases exactly where we are, in the same town.”
As MSF closes down its temporary treatment centres, the WHO’s calculations of over a million patients do not appear to correlate with the reality.
“Everyone’s telling us that the doctors, nurses and health workers don’t want cholera to be over because, if that happens, they won’t get their bonuses or their pay.
So they carry on reporting cases. Every day a guy gets up and says he’s seen 15 cases, but nobody’s checking. There’s no one going to see if these cases are real or not. It’s a good system.”
In this context, it’s a challenge for NGOs to supervise and manage their programmes. With travel subject to the goodwill of the authorities and therefore severely limited, no organisation is able to provide insight into the humanitarian situation at national level.
In October 2018, the United Nations issues an alert, stating that Yemen is on the verge of one of the worst famines the world has experienced in modern times.
In an interview given to the BBC, images of emaciated children precede a solemn UN declaration: “We predict that 12 to 13 million innocent civilian lives are in danger due to lack of food.”
But, this is not what people like Thierry are seeing on the ground. “All I can say is that, personally, I’m not seeing the same high levels of malnutrition I’ve witnessed in Africa and places like Somalia,
and definitely no elements to corroborate a famine situation. Really not. I’ve seen two actual famines, in South Sudan and Somalia in 1992.
Both times they were caused by war, where people were trapped. This isn’t the case in Yemen.”
And, although food is heavily taxed by the authorities and sold by war profiteers at extortionate prices, in spite of everything it continues to be unloaded in Yemen’s ports.
“We have a very partial view of Yemen,” admits Agnès. “Right now, we’re the only NGO with such a massive deployment in the country. We have national and international staff in 11 governorates, which is a huge presence.
But even so, we’re incapable of putting together a countrywide analysis or presenting an overall picture of the situation, quite simply because the perception we get from our hospitals is extremely limited.”
For lack of anything better, it’s the medical centres that are gradually revealing glimpses of what’s really happening—some disturbing, others more optimistic.
“We had this whole spate of Malaria cases that I found very bizarre, because it's up in the hills. You shouldn't really have Malaria, because mosquitoes don't fly that high.”
Natalie tries to find out what was going on with these mystifying patients, all teenage boys arriving from the front line further north.
“And it took a while for them to trust me enough, the staff, to tell me the real story which was they were teenage boys that had been recruited or had joined voluntarily to fight with the Houtis.
So these were the boys that they'd sent up to the front lines to fight, and when they'd got there they'd realized that they'd made a mistake or they had no choice anyway, some of them.
And the staff were giving them a diagnosis of malaria. And then, putting them into a bed for the night.”
By sunrise, the child soldiers are gone. At least they might have a chance of escaping the fighting and not returning to the same hospital riddled with bullet holes.
“I felt that was one of the best things that they could do, actually. In terms of life saving. They probably saved hundreds, and hundreds of teenage boys. So that was an interesting one that I hadn't seen before.”
“This is one of those conflicts where outlying regions oppose the central authorities. Peripheral zones abandoned by the central government and left to fend for themselves. These areas are of no use to the central authorities. There’s no oil, and nothing of any value to them.”
It was primarily the unequal treatment meted out to people in the north that triggered the war in Yemen in 2015. After the reunification of the country in 1990, the north was a region to be avoided.
Public services were failing, civil servants transferred there saw it as a punishment, and too many medical and teaching posts remained unfilled.
These injustices resulted in a first rebellion that took place between 2004 and 2010—a period punctuated by frequent clashes between the Houthis and the government.
In the aftermath of the rebellion and the Arab Spring, war erupted in 2015. It has since escalated and progressively destabilised the very fabric of Yemeni society.
“I see the lack of justice as a fundamental issue, and the root of all the other problems.
There is no justice, other than forms of tribal justice, which are extremely complex and never function properly in war situations.
They require countless, long drawn-out discussions involving various tribal groups to resolve conflicts that might be over something like a donkey, a cow or a cancelled wedding.
So, when it comes to the war, it's just too laborious and complex.” The intricacies of the formal traditional system of justice are substituted for the far more simple methods of popular justice.
Weapons are omnipresent and the insecurity makes it impossible to reach some areas. In the port city of Aden, for example, Ghassan sees how commonplace firearms are.
“My memory of Aden is that, if you can get hold of 10,000 dollars, you can have your own private militia with a pick-up truck and four armed men in the back. You hire them for a month and make some cash.
When I got here, they were everywhere. Pick-up trucks with armed men driving through the city. What’s weird is that nobody knows which group belongs to who. You never know.
Regarding the presence of armed men, I think things have improved since I’ve been here. The city’s a bit more organised, but it’s still a total mess. I see it as a city in a state of civil war.”
In Aden, any form of normality has gradually disappeared. Amid the political chaos, criminals thrive and are quick to take advantage of the failures of the rule of law. Clearly, they didn’t just suddenly appear when the war broke out, but it did create a vacuum.
“There are loads of criminal gangs and unlawful activity. In fact, even before the war, our hospital’s main activity was treating criminals and their victims,
and this hasn’t changed. Other hospitals don’t want them. It’s an incredible can of worms.
Threats are made, because friends or men of the family of the criminal who’s hospitalised want to get him out or protect him and will do what it takes because they think the cops or the army are going to come for him to kill him.
Or, the family of someone he’s killed is seeking revenge and will come to the hospital to kill him. It happens, in fact it has, lots of times.”
Which explains the impressive-looking security guards posted at the entrance to the hospital in Aden. In the vast hall where patients first arrive, everyone leaves their weapons in safes of varying sizes,
depending on whether it’s a pistol, a Kalashnikov, or an even bigger weapon. A basic but necessary precaution for a hospital right in the centre of Aden treating wounded casualties from all sides
—civilians, coalition soldiers, but also Houthi sympathisers and members of Al Qaeda. Settling of scores and situations that get out of control are never very far away.
“There was a guy who wanted to come in to see his brother. The team said he couldn’t because it wasn’t visiting hours.
So, he decided to take a hand grenade out of his pocket, pull the pin and threaten the guards at the door. He was going to blow it up.
Business as usual for one of the guards, who took the grenade out of the guy’s hand, put its pin back in and kept it.
Then we called security to come and get the guy with his grenade.”
In a city rife with crime and attacks, the hospital is often aware of explosions in the vicinity. One day, Bernard was working in the intensive care unit when he heard a thud and then a slight tremor.
“The Yemenis who were with me and are much more used to it, said, ‘Ah, a bomb’s exploded …’ and very soon after there was a massive influx of wounded casualties.
I’m not sure, but over 100 came in, maybe 130. If I remember correctly, around 50 people were killed in that explosion.”
The ring of the bell usually signals a massive influx of injured people. But this time, everyone is alerted and already on the way to their posts.
An emergency protocol that continues to be a ritual in a city still a prisoner of the war.
There seems to be no way out of the war that for the past five years has been tearing Yemen apart. As for its people, they have no escape.
“Even if you're not being bombed directly, you can't necessarily afford to buy food. You can't necessarily afford to rent somewhere to live.
People living there, their marriages are on standby. Their families on stand by. Their lives are on standby, essentially. But now, it's four years later. They can't carry on. They're on standby.”
In the far north of the country, a few kilometres from the border with Saudi Arabia, the village of Haydan nestles in the mountains.
At the epicentre of Houthi-controlled territory, Haydan has suffered innumerable airstrikes. Its terrified inhabitants have spent a long time holed up in caves—which doesn’t make them very much safer.
“One particular incident where a cave in the next village had been bombed and, from what I understood, the bomb had dropped at the mouth of the cave essentially.
So the force of the bomb had kind of reverberated through the cave and killed people - everybody in the cave. I don't know where that was or how many people were inside the cave,
but the neighbours, in the house nearby had brought a small girl down. And they said she was the only survivor essentially of this family.”
The wound to her forehead is not very serious, but what kind of life is she going back to? Her neighbours tell Natalie about the dismal living conditions inside the caves.
“You can't do anything. It just gets dark. You're sleeping when you can and then, you know, you try and get out and get back to your house to eat if you can. It's damp, it's cold, it's not even safe.
So, this family who brought the little girl said, “We should go back to their house because there's no point living lives in caves. We may as well just live in our house and then see what happens.”
The following morning, the little girl goes back without her family, with people she doesn’t know her only companions.
“And I did wonder how many families had been broken up like that and what was going on behind the scenes and you see, when you get to conflict zones, you know it's just immense violence happens, even domestic violence gets tricky because you've got huge stresses on families, huge stresses on society. Probably a lot of the people we ended up seeing in the hospital were women and girls probably being abused. And partly just because of the stresses going on in the society.
You don't know anything about them. You don't have time to even work out really what's happened to them. You just patch up the physical harm that seems to be happening and then you send them away again and that's pretty much all we're doing.”
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