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Where the light enters: Reflections on the fight against COVID-19 in war-torn Yemen

Introduction by Croakey: The United Nations World Food Programme warned last month that the world is no longer moving towards Zero Hunger.

“Progress has stalled, reversed, and today, up to 270.5 million people are estimated to be acutely food insecure or at high risk in 2021, driven by conflict, economic shocks, natural disasters, and the socio-economic fallout from COVID-19,” it said, highlighting famine-like conditions in Ethiopia, Madagascar, South Sudan and Yemen in 2021.

According also to UNICEF, six years into an armed conflict that has killed over 18,400 civilians, Yemen remains the largest humanitarian crisis in the world, with around 21 million people in need of humanitarian assistance, including more than 11 million children.

Dr Khairil Musa, is a Sydney based emergency doctor who, in 2020, was sent as a field worker with Médecins Sans Frontières(MSF)/Doctors Without Borders to Yemen and later Iraq. He writes below about his time working in a COVID-19 treatment centre, run by MSF in Yemen, which has just emerged from another COVID-19 outbreak.


Khairil Musa writes:

Photo by Felicity Ogilvie

Intensivists are trained pragmatists. Our work is highly cerebral yet very clinical. I wasn’t a novice to suffering or death, encountering this daily in the time I’ve worked in the intensive care unit (ICU) in Sydney.

What was hard to swallow was the volume I was exposed to in Yemen at the height of the first wave of COVID-19 in the country, a relentless stream of misery and loss, without reprieve.

With each death it felt like a piece of me died too. Over time my heart felt, not unlike when you fall asleep on your arm, a heavy, detached limb, which you try to massage back to life.

In Yemen, the daily ward round in our hospital felt punishing to a degree I’ve never experienced before.

Row upon row of patients suffocating, gasping for breath and groaning with distress. A cacophony of voices from our Yemeni doctors and nurses yelling “Oxygen! Oxygen!” and our team of porters rushing to the bedsides of patients, to change over empty oxygen cylinders. A macabre dance repeated multiple times throughout the day. It was a special kind of hell on earth.

How does one describe a place like Yemen? Even with its struggles, it was truly a remarkable place.

Filled by the light of the spirited Yemenis, doctors, nurses, porters and countless others I was fortunate enough to meet along the way. Stubbornly refusing to accept the status quo, fighting to make things better each day and full of hope and love for their people and their land.

War is horrendous. Add COVID-19 to the mix and the result is devastation. I was but a temporary guest, bearing witness to the awful situation they were facing.

In the first months of 2020, I remember watching with mounting concern as China, Italy and many parts of the world grieved for the lives claimed by a virus that literally takes your breath away.

Eye of the storm

In the midst of this global upheaval, I received a phone call from Médecins Sans Frontières/Doctors Without Borders (MSF) one afternoon: A COVID-19 project in the Middle East needed an ICU doctor to join the team, was I interested? Immediately accepting, I was flown into Yemen the following week and my life changed in a way I could never have imagined.

MSF had always occupied a special place in my heart. As one of the biggest medical humanitarian organisations in the world, their work providing care to the most vulnerable was aspirational. When I finally joined their ranks in early 2020, it felt like a dream come true.

In Aden, Yemen, we were in the eye of the storm, the COVID-19 treatment centre bursting at the seams. Fear of the virus had permeated through Aden city and other hospitals refused to treat any patients with respiratory symptoms. With nowhere else to turn, many travelled hours to get to our facility, an hour’s drive from the heart of the city. We had 32 beds in our inpatient unit and a seven bed ICU, which filled within days of opening.

Limited access to essential drugs and equipment, created immense difficulties. Our team desperately tried to source supplies: nearly impossible with the grounding of flights and the closure of many international borders. Our MSF medical supplies remained overseas, stuck behind red tape. Sourcing oxygen –  the basic necessity for the treatment of respiratory failure was a struggle. With no access to liquid oxygen, we had to use bulky oxygen cylinders, more than 250 per day, to treat the patients.

In a country already fractured by war, a collapsed healthcare system and widespread poverty, the work felt insurmountable and very quickly the tide overwhelmed us. Without any of the sophisticated technology or therapies I was used to working with, in my well-resourced ICU in Sydney, I had to go back to basics: relying mostly on my clinical judgement and the few pieces of monitoring equipment we had.

MSF team treating a patient with COVID-19 at its emergency facility in Yemen in 2020. Jacob Burns/MSF

Harrowing choices

It was the same daily routine for each patient we reviewed: an oximeter was placed on a patient’s exposed finger, then, after the inevitable low reading, we increased their oxygen flow. We would ask the patients to turn over onto their stomachs, when the oximeter reading remained low (a manoeuvre called proning: to expand their lung base and improve oxygen delivery). Their distress was palpable, words expressed in short bursts of Arabic, always the same: “Doctor I can’t breathe; When will I get better? Please help me.”

Every day, critical decisions had to be made. Who, out of the many, should be transferred to the ICU? Most of the patients had such severe disease, they would benefit from being on a ventilator. But when there’s only a few to spare; the choice became harrowing.

“What do you think of bed 21?” asks my colleague, a Canadian intensivist, who I worked with in the treatment centre. The patient was a young guy in his thirties, only a few years older than I was, who had a history of hypertension and obesity. “Oxygen saturation 70 per cent on the Aden Special.” The Canadian had coined this term, the Aden Special. It was a combination of nasal prongs and a reservoir oxygen mask, which we used concurrently, to deliver 30 litres of oxygen to patients.

It was a crude and desperate attempt to increase the oxygen flow for patients in extremis, when they did not have access to the higher level of care an ICU offered. “What about the patient in bed six?” I asked in return, “Forty-year-old male with no co-morbidities, Sats 65 per cent on the Special. No improvement with proning.

What would follow was a discussion, often over in a matter of minutes; exploring the pros and cons of choosing one patient over the other. A small voice in my mind screamed at the injustice: that we were forced to make this choice.

I knew that in my ICU back home, every patient would have been on ventilators, not desperately clinging to life in a re-purposed community hall. But this response wasn’t helpful, and a decision still had to be made. So we decided to transfer the 40-year-old man. His illness was more severe in relative terms, and his lack of co-morbidities favoured a more positive outcome.

Upon his arrival to ICU, a special face mask was used to provide high levels of oxygen. Despite this, he continued to deteriorate over the next 48 hours. He was placed in an induced coma and a breathing tube inserted into his trachea, his muscles relaxed with paralytic drugs to allow the ventilator to exclusively manage his breathing, the most invasive form of treatment for COVID-19 we could provide in the project.

However, over the coming days he developed a secondary infection, a common complication, one that would cause his kidneys and heart to fail. With no access to dialysis and only rudimentary drugs to manage his heart failure, like many others before him, he’d die, despite our best efforts.

Drowning on dry land

The 30-year-old man who remained on the ward would die as well, within days of his admission. All the ventilators were in use and he died of hypoxia. The human body can only hang on for so long with such low oxygen levels, even if COVID-19 has changed how this usually happens.

For reasons still unknown, the hypoxia associated with this virus is tolerated for far longer than in any other illness, a slow death occurs over days, when previously hypoxia is known to kill within minutes.

To watch him and countless others in our ward die like this, was the worst kind of torture. Men and women drowning on dry land, desperate for air. With my years of knowledge and training, I was useless without resources. I could only offer my hand to hold theirs and a prayer to recite under my breath. It didn’t feel enough but it was all I had to give.

With each day that passed, the death toll increased. Those we couldn’t admit would die in their homes and the city reported an increase in burial counts up to eight times the daily average, from before the pandemic began.

Many patients we treated began blurring into one another, no matter how much I yearned to know them beyond their demographic and oxygen levels, keeping my distance felt like the only way I knew to protect myself.

Still some patients made their mark even through my defences. A woman in her late seventies, breathless as many of the others, deteriorating even with the maximum treatment we could offer her. I noticed how lucid she was despite her condition, when I went to reposition her oxygen mask.

I knew she was dying, even as I nodded emphatically at a question she softly asked in Arabic that I couldn’t really understand. As I moved to walk away forlorn, she laid a trembling hand on my shoulder and looked at me with clear eyes and smiled so brightly it was like staring at an eclipse. As if she knew her time had come, and to tell me it was okay.

It was a gesture so full of meaning it broke me. In that moment I felt so humbled, that I was being comforted, when I had no comfort to spare her. As the one dying gave solace to the one living, I learnt the power of our shared humanity. I realised in the end we can only find our way out of the dark together, hand in hand.

I found myself in a strange place emotionally after that encounter. I was exhausted from the long hours but even sleep couldn’t replenish my depleted tank. A deep weariness set in. Some days I’d spend sitting alone in my room, as tears just steadily streamed out of my eyes, uncontrollably. It felt like the darkness I had been witnessing had found its place in my heart. In those moments I mourned; for the lives lost, for the ones pleading to live and the ones still to come. My mind was filled with bleak thoughts: What are we doing here? Why do we carry on when things feel so futile? Am I just here to watch all these people die?

The volume of work meant that each day passed at dizzying speed. Mercifully in between the struggles, we were granted moments of triumph. One of our sickest patients, a slight gentleman in his fifties disproved our estimates and rallied, improving steadily until he was able to be discharged. His gratitude to us was immeasurable and replenishing in more ways than he could have imagined .It was hard to escape from the virus taking over every aspect of our lives in the field, but we tried our best.

My fellow MSF co-workers, who I grew to regard as my family, shared some special moments together: birthday celebrations under the moonlight, time spent floating in the ocean as the majestic Yemeni mountains towered over us. We looked after each other in the only way we knew how, broken hearts coming together to make something resembling a whole.

A stray kitten rescued outside our compound became our mascot. Somewhat ironically, I called her Covid the Cat and the name stuck. We showered her with love and in return she gave us joy and helped us face each day, one unsteady step forward at a time.

As the weeks progressed things began to take a turn for the better. Further reinforcements from our headquarters brought more expertise on the ground, our national teams gained more experience, we standardised our care, and our access to supplies improved.

Slowly it felt like the breath we had been holding in could finally be exhaled. I was redeployed to MSF’s Trauma Hospital in Aden. Treating the injured and the war-wounded carried its own challenges, but the change of pace was welcome.

I learnt many lessons during my time in Yemen. I understand now that the value of the work isn’t just in knowing how to use a ventilator. The value is also showing up and being present, witnessing the realities of life in a low-resource setting and to tell the stories of those without voices, so they are not forgotten.

I learnt that time spent caring for others is never wasted. I learnt that love is the strongest motivator and that the smallest grain of hope is enough to carry you through the darkest of days.

Ultimately, I left the field deeply inspired: to devote my life to the service of others, to be kind and to be brave and to remain hopeful, in a time when the world seems to be without hope. And emblazoned upon my soul, no matter what hardship I may be facing, a timely reminder as old as it is certain: “This too shall pass.”

Footnote from MSF

After six years of war, Yemen’s health care system has been crippled and the Intensive Care Unit (ICU) treatment capacity is limited.

The Al Gamhouria COVID-19 treatment centre in Aden was established by MSF in 2020, during the first wave of the COVID-19 outbreak. It was later handed over to the Ministry of Health however, following the sharp increase of COVID-19 cases in early March 2021, MSF re-launched a COVID-19 emergency intervention.

By June, following a steep decline in COVID-19 infections in Aden, the COVID-19 patients under treatment at Al Gamhouria were transferred to another MSF supported COVID-19 treatment centre at the Al Sadaqah Hospital.


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