Conflict and Contagion: Analysis of Infectious Disease Dynamics in War Zones

Introduction

Globally, armed conflicts have long-term negative impacts on the population’s public health and exacerbate the burden of communicable and non-communicable diseases. Besides the immediate devastation caused by violence, the systematic breakdown of a country’s healthcare infrastructure, including the decimation of services needed to prevent and manage infectious diseases, is a characteristic of the continuing effects of armed conflict on public health (Mulugeta Wodaje Arage et al., 2023). It’s become common in conflict zones for hospitals, clinics, and other medical facilities to be seen as legitimate targets, with acts such as these significantly reducing the capacity to provide care under the circumstances. As of 2024, a quarter of all hospitals and one-third of all primary healthcare centers in Syria remain non-functional and unable to respond to the growing health needs of populations living in conflict-stricken regions (WHO, 2024). The loss of healthcare personnel, many of whom have either fled, been injured themselves, or killed, compounds this chaos and destruction (Webster, 2011). The additional disruption to medical supply chains also works to impede the healthcare system's ability to respond effectively to ongoing and emergency healthcare needs (Bastani et al., 2023)

As of December 2022, the total global number of people internally displaced by conflict and violence across 65 countries and territories reached an estimated 62.5 million, the highest level on record since the IDMC began monitoring global displacement in 1998. the persistence of existing conflicts and the emergence of new ones have caused the number of internally displaced persons to double since 2012 (IOM, 2022). The displacement of civilian populations due to armed conflict further complicates the public health landscape. Civilians fleeing conflict zones all too often end up in overcrowded refugee camps or temporary shelters where there is little to no availability of resources like clean water and sanitation services. Conditions such as these are ideal for the spread of infectious diseases (Cuadrado et al., 2023). Cholera outbreaks have frequently been reported in such settings, with Yemen experiencing over 2.5 million suspected cases and approximately 4,000 deaths from cholera since 2016 (Ng et al., 2020). The stress and nutritional deficiencies that can accompany displacement can weaken immune responses and make an already vulnerable population even more susceptible to infectious disease outbreaks (Gorji and Ghadiri, 2020).  Addressing health challenges in conflict-affected regions is of the utmost priority, particularly in light of the ongoing conflicts that we are seeing across the globe that are devastating populations and destroying public health infrastructures. Conflict zones exhibit high mortality and morbidity rates that are not only associated with direct violence but also with the indirect effects of ongoing conflicts, such as the spread of infectious diseases. Vulnerable groups such as children, pregnant women, the elderly, and the disabled are all disproportionately affected when healthcare infrastructure is damaged and services disrupted, leading to preventable deaths and unnecessary suffering. For instance, in Yemen, 5.5 million women and girls of childbearing age in Yemen have little to no access to reproductive health services, with one woman dying during pregnancy and childbirth every two hours (UN, 2023a).  Addressing these needs is a moral obligation and a critical intervention crucially needed to alleviate human suffering in war-torn regions.

Controlling infectious diseases in conflict zones is crucial for maintaining good levels of health among the affected populations while maintaining regional and global health security. It’s pretty evident that Infectious diseases do not respect national borders, so the complications brought about by the displacement of populations, the compromised health surveillance, and the inadequate preventive measures available to officials can potentially lead to widespread outbreaks of communicable diseases leading to epidemic or pandemic level events (Valia Marou et al., 2024). Effective health interventions in these settings are essential to contain diseases within borders and prevent them from becoming global crises, such as the resurgence of polio in Syria, which not only affected the local population but also posed a threat to neighbouring countries and the international community in which Syria's displaced populations hoped to resettle, necessitating extensive regional vaccination efforts (Al-Moujahed et al., 2017). Conflict can erase decades of progress made in establishing effective health systems. The destruction of healthcare infrastructure often means rebuilding processes can become lengthy and costly. Early targeted interventions are essential in protecting healthcare facilities while maintaining healthcare delivery and supporting healthcare workers. Interventions like these can preserve critical infrastructure and ensure a faster and more effective post-conflict recovery. Robust health interventions such as those mentioned can play a significant role in stabilisation and peacebuilding efforts (Martineau et al., 2017). Providing access to primary healthcare reduces disease burden, alleviates suffering, and builds community trust. Health initiatives often foster cooperation across conflict lines and lay a foundation for broader peace and reconciliation processes.

Turning to the duties of the international community, many countries and international organisations are bound by legal and ethical responsibilities to provide humanitarian aid and to lobby for the opening of humanitarian corridors for the free movement of civilians and desperately needed food or medical products (Humanitarian Practice Network, 2023). International humanitarian law, such as the Geneva Conventions and their Additional Protocols, mandates that parties in conflict must facilitate the rapid and unimpeded delivery of humanitarian relief for civilians in need (American Red Cross, 2011). Resolutions such as the United Nations Security Council Resolution 2286 specifically address the protection of healthcare in conflict, condemning attacks against medical facilities and personnel in conflict zones (United Nations Security Council, 2016). Failing to meet these legal standards can result in legal consequences on the international stage, all the while undermining what are considered global norms regarding the conduct of war and the treatment of civilians. Already, these conditions render areas affected by conflict especially vulnerable to disease and public health crises. All the more reason, then, for the international community and its various leaders – including the WHO, the UN, and NGOs– to actively pursue health agendas in conflict-affected areas (UN, 2023b).

Objectives:

In this Article, we look to explore how armed conflict has consequences for the spread of infectious diseases. We will describe the evidence that underpins these challenges and make recommendations for improving policy and practice. We also look to describe how displacement and the destruction of health systems facilitate epidemic-level events by considering the indirect effects of conflict on the public health system. We will detail how vaccine-preventable diseases resurface and the increased risk of antibiotic resistance that often follows a disruption in public health services during conflict.

Health Challenges Posed by Displacement and Infrastructure Damage in Yemen:

The conflict in Yemen has led to one of the most severe humanitarian crises of the modern era that has precipitated severe displacement, erosion of healthcare infrastructure, and a profound decline in the quality of healthcare services that are available to the Yemeni population. The conflict in Yemen has increased the general susceptibility of its population, raising the risk of infectious disease transmission In temporary shelters and resettlement camps (IOM, 2024). The IOM reports that around 1.2 million internally displaced persons (IDPs) reside in around 1,600 displacement camps across Yemen. Many camps cannot provide adequate shelter, clean water, or sanitation facilities (UNHCR, 2023). These conditions resulted in outbreaks like that of the October 2016 cholera outbreak, which resulted in over 2.5 million suspected cases and approximately 4,000 deaths. In 2019, there were 860,000 suspected cases and nearly 1,000 deaths, showing that despite efforts from NGOs, challenges persisted in managing outbreaks (Ng et al., 2020). A similar trend was observed regarding other infectious diseases, although cholera remains one of the most significant outbreaks in Yemen. Yemen has also had multiple diphtheria epidemics between 2017 and 2021, which has resulted in more than 4,000 diphtheria cases with 253 related deaths reported. (Al-Dar et al., 2022).

The damage inflicted on Yemen's healthcare infrastructure has been extensive, with UNICEF reporting that by the end of 2021, 50% of Yemen's healthcare facilities were fully functional (UNICEF, 2022), with 20% of districts in Yemen not having a doctor. Shortages of medical supplies, including essential medicines and vaccines, are widespread across multiple districts (Alsabri et al., 2022). Reports from the WHO in the same year further spoke to this destruction, indicating that 46% of Yemen’s healthcare facilities were either wholly or partially damaged. This included hospitals, clinics, and primary healthcare facilities. The damage to healthcare infrastructure in Yemen was severe, with rebuilding efforts continuing (World Health Organisation, 2023). The Health Resources Availability Mapping System (HeRAMS) in Yemen indicated that of 3,507 health facilities assessed using the system, a staggering 1,607 were either fully or partially damaged (WHO, 2020). Press reports suggest that between March 2015 and December 2020, at least 130 attacks on healthcare facilities and personnel had been recorded. These attacks included airstrikes, shelling, and armed incursions, each brutally and significantly impairing the ability of these facilities to function (McKernan and correspondent, 2020). Critical hospitals like Al-Thawra Hospital in Taiz (MSF, 2020) and Al-Jumhuri Hospital in Sa’ada (WHO, 2019) have suffered repeated and devastating attacks that have led to significant operational difficulties and reduced both hospital's available services. Along with the destruction of healthcare infrastructure, the destruction of the shipping and transportation infrastructure in Yemen has led to a severe shortage of medical supplies and equipment. The UK government released figures that indicated around 30% of needed medical supplies were available in the country by the end of 2021(UK GOVERNMENT, 2022). Healthcare facilities across Yemen have consistently complained of a shortage of critical medical stock, such as antibiotics, surgical kits, along with blood and intravenous fluids. Al-Sabaeen Hospital in Sana’a frequently reported that they had fundamental shortages in supplies for newborns, leading to decreased neonatal survival rates (Alsharif et al., 2023). The conflict has also resulted in the displacement of thousands of healthcare workers, with the Yemeni Ministry of Public Health and Population reporting that 40% of healthcare workers have fled their posts due to localised insecurity, leading to significant human resource gaps within the healthcare sector. Remaining healthcare workers often face salary delays while working under extreme conditions, further straining the healthcare system (Raof Al Waziza et al., 2023) (World Health Organisation: WHO, 2016). Healthcare workers in Yemen also face extreme delays in receiving salary payments, with reports showing the average salary payment delay for healthcare workers in Yemen was six months in 2021 (Elnakib et al., 2021). This has created service delivery inequalities, especially from the health aspect, given that several parts of Yemen are already deprived of health services.

Many of the Overcrowded living conditions seen in resettlement camps have now become a common occurrence and, as such, have raised the susceptibility of these micro cities to infectious diseases; the resettlement camps in Al-Hudaydah governorate, where the majority of Yemen’s resettlement camps are situated, are a prime example of what many families are forced to live in. crammed into small living spaces with little to no access to sanitation services across the camp. They are facilitating the spread of respiratory infections as well as diarrheal diseases (Qaserah et al., 2021). Poor sanitation is a significant issue in Yemen's displacement camps. Human Access reports that 30% of the displaced people in resettlement camps can access adequate sanitation facilities (Human Access, 2023). With Access to clean water also being extremely limited, many families admitted to relying on contaminated water sources. In the Taiz district governorate, 55% of the vulnerable people living In resettlement camps in their district are reported as using unprotected water sources, increasing their risk of cholera and other waterborne infections (Jafarnia, 2023). The irreparable and unnecessary destruction of Yemen's healthcare infrastructure has resulted in many displaced persons having limited access to medical care. The shortage of healthcare workers in many of Yemen's governates, combined with issues with obtaining medical supplies and retaining adequate supply levels, has left many without the necessary treatments, causing unnecessary pain and suffering for many innocent individuals. The Al-Sadaqa Hospital in Aden is one of the few functioning hospitals in the country. Still, like many others in the region, Al-Sadaqa frequently reports that running out of essential medicines has been a common occurrence, forcing patients to seek help from other facilities that are already overwhelmed or forced to go on without receiving treatment (International Medical Corps, 2017). One significant example of the combined effects of these challenges is its effect on maternal and child health services, which, according to records coming out of Yemen, indicates that it has been the most severely affected services, with UNICEF estimating that 80% of pregnant women in displacement camps do not have access to proper antenatal care, leading to increased maternal and neonatal mortality rates (UNICEF, 2024).

NGOs have played a vital role in addressing many of the health challenges people in Yemen face. Médecins Sans Frontières has established and successfully operated multiple cholera treatment centers across Yemen, with figures estimating they have reached and treated over 200,000 cholera patients since 2016. They have also been highly successful in distributing hygiene kits and conducting health education across multiple districts to aid in the prevention of disease transmission (Médecins Sans Frontières, 2019). The International Rescue Committee has also implemented critical interventions within the region, helping to provide primary healthcare services to the displaced populations, providing services such as vaccination campaigns and nutritional advice. Reports from the IRC indicate they have successfully treated over 100,000 people in 2020 alone, along with substantial advances in providing clean water and adequate sanitation facilities to reduce the risk of disease outbreaks (IRC, 2020). As expected, the  WHO has been instrumental in leading and coordinating the international health response within Yemen. Successful programs have helped supply over 2 million doses of oral cholera vaccine and supported the re-building of 75 healthcare facilities, providing equipment to ensure staff can handle all emergency health needs (World Health Organisation, 2023). The WHO has also made strides toward training local health workers in disease surveillance and outbreak response, which has improved the early detection and management of infectious diseases within resettlement camps across all of Yemen's districts (World Health Organisation, 2023).

Despite the Yemeni government's limited resources, it has continuously worked to collaborate with many international organisations in efforts to restore and rebuild its healthcare infrastructure. This collaboration has successfully included the reparation of 50 hospitals and clinics, along with deploying mobile health units to reach the most remote and displaced populations (IOM, 2024b) (Raof Al Waziza et al., 2023). The Yemeni government's Ministry of Public Health and Population has launched public health campaigns in conjunction with the WHO and UNICEF to increase awareness of disease prevention and hygiene practices among displaced communities in resettlement camps (UNICEF, 2023). The healthcare challenges posed by displacement and infrastructure damage in Yemen highlight just how critical the need is for comprehensive and coordinated international response efforts. Providing emergency healthcare, rebuilding infrastructure, and enhancing disease prevention and surveillance systems are essential components in any effort to mitigate the infectious disease risks faced by displaced populations in conflict-affected regions of the world. The efforts of NGOs, health agencies, and local governments have been pivotal in bridging the gap left in the healthcare infrastructure of war-torn nations. However, there still remains an ongoing need to support policy changes and the establishment of interventions crucial in addressing the evolving health needs of displaced populations and preventing further deterioration of the wider public health.

Vaccine-Preventable Diseases and Antimicrobial Resistance in Syria:

In March 2011, Syrian President Bashar al-Assad initiated what would be the beginning of a protracted 13-year-long war that continued until November 2024. The onset of this violence severely disrupted vaccination campaigns within the region while also seeing an increase in reports of new Antibiotic resistance infections. In the first years of Syria's civil war, the healthcare infrastructure had suffered severe damage, reducing the system's ability to provide routine immunisation, proper consultation, and full-course treatments for bacterial infection. As a result of this, vaccine-preventable diseases like polio (Ibrahim Abdullah Beshr et al., 2023) and measles (Batarfi et al., 2024) had a dramatic resurgence. Since the onset of the civil war, there has also been an alarming increase in antibiotic-resistant infections, which is further exacerbated by the lack of proper medical oversight and the widespread misuse of antibiotics in conflict zones (Jakovljevic et al., 2018). The overall healthcare system collapse that has occurred in Syria has had severe implications in undermining public health efforts, with the country seeing increases in morbidity and mortality rates among the population due to the indirect consequences of war.  Prior to 2011, Syria had a robust vaccination strategy with high levels of coverage. The national immunisation coverage for the third dose of diphtheria, tetanus, and pertussis (DTP3) was around 83%, and measles vaccination coverage was at approximately 80%. However, it was established that due to the disruptions that the onset of the civil war created, these vaccinations tremendously reduced, with DTP3 coverage down to 47% as well as measles vaccinations declining to 52% by as late as the end of 2016 (Grundy & Biggs, 2018) (Fahmy et al., 2024).

This significant decline seen in vaccination rates in Syria has led to several outbreaks of vaccine-preventable diseases. Reports coming out of the country indicated that two years after the start of the civil war, enough damage had been inflicted on the country's healthcare infrastructure that the nation recorded its first polio outbreak in 14 years, with 36 confirmed cases (Mbaeyi, 2017).  It impacted Syria but could also pose a risk to other countries, given the possibility of vertical transmission across borders. As a result, countries in the region, including Iraq, Jordan, and Turkey, stepped up their efforts to immunise their citizens against polio with a view to avoiding the spread of the disease in their respective territories (Raslan et al., 2017). These are not merely isolated incidents with recurrent measles outbreaks reported yearly, with 7,000 reported cases in 2018 alone (Mehtar et al., 2021). The rise in antimicrobial resistance in Syria is also something of grave concern among the international community; since Alexander Fleming's discovery of penicillin in 1928, antibiotics have saved countless lives and been used to eradicate diseases like smallpox, but now antibiotic resistance threatens to render what were once-treatable infections deadly. The WHO reports increased levels of AMR in pathogens like Klebsiella pneumoniae and Escherichia coli (Bourgi et al., 2024). With a study conducted in 2019 finding that 60% of K. pneumoniae isolates and 55% of E. coli isolates were resistant to third-generation cephalosporins, a class of antibiotics critical in the treatment of severe infections (Cirit et al., 2019). The misuse of antibiotics in conflict zones has been associated with the unregulated sale and the lack of proper access to medical care and advice, which has been a significant driver of this resistance. This is compounded by the lack of adequate diagnostic facilities to appropriately identify infections in order to prescribe the appropriate antibiotics, further exacerbating the problem. In conflict zones such as Syria, the high prevalence of antibiotic-resistant bacteria makes the challenge of treating common infections all that more difficult, leading to extended hospital stays, higher medical costs, and increased mortality rates (Parums, 2024).

Efforts to maintain vaccination coverage and combat antimicrobial resistance in Syria have faced significant challenges brought about by the ongoing conflict; NGOs and other international health agencies have played an essential role in mitigating these challenges. Collaborative efforts from both UNICEF and WHO have successfully established emergency vaccination campaigns that target children in conflict-affected areas. The efforts of a national immunisation campaign in 2017 aimed at vaccinating 2.7 million children against polio helped significantly reduce the chance of further polio outbreaks (UNICEF, 2017).

At the same time, similar efforts have been adopted to address antimicrobial resistance by the WHO, which is cooperating with local health authorities in this area to strengthen infectious disease surveillance systems and promote the proper use of antibiotics. The establishment of an AMR surveillance network by the WHO in Syria in 2018 is one instance of this kind of work. Networks like this monitor resistance patterns and are used for guidance on treatment protocols within the region. Other NGOs working in the region have undertaken campaigns to train healthcare workers in matters such as antimicrobial stewardship and reinforce their knowledge of infection control standards (Khadse et al., 2023). However, it is difficult for the international community to enforce and/or implement any regulatory strategy as the efforts are often rendered ineffective due to the continuous instability in the region and the considerable damage sustained by the healthcare infrastructure.

Local governments, assisted by international organisations, have been participating in reconstructing and rehabilitating the healthcare infrastructure required for these public health interventions. These include reopening health facilities, filling essential drug gaps, and, in hard-to-reach and conflict-affected regions, mobilising targeted health teams to provide immunisations (Osman et al., 2021). The disruptions to vaccination programs and the rise in antimicrobial resistance in Syria since the beginning of the conflict have presented significant public health challenges, with continued damage to the healthcare infrastructure further exacerbating these issues, which has led to resurgences and outbreaks of vaccine-preventable diseases and the spread of resistant pathogens. While efforts by NGOs, international health agencies, and local governments have made some progress, ongoing support and coordinated global efforts are essential to address these challenges effectively.

Conclusion, Recommendations, and Future Directions:

When considering the health impacts of armed conflict, several vital themes become apparent that suggest a pressing need for a more holistic approach to tackling these challenges. Armed conflicts pose a threat to public health both directly and indirectly, and have already boosted the burden of both communicable and non-communicable diseases among the affected population. The deliberate and often systematic destruction of a country's healthcare infrastructure through direct attacks on healthcare facilities and the disruption of medical supply chains affects the ability of health workers to deliver essential health services to an already desperate population, which in turn translates into higher morbidity and mortality rates as an indirect outcome of violent conflict. IDPs & refugees face devastating exposure to a plethora of diseases related to the effects of displacement by conflict, which further increases the complexity of the public health landscape in regions affected by war. through the construction of overcrowded resettlement camps with little to no services like clean water and sanitation facilities. The groundwork has been laid for the conditions in which infectious diseases have the potential to outbreak, such as the case of cholera in Yemen and the re-emergence of vaccine-preventable diseases like polio and measles in Syria. Antimicrobial resistance is an urgent challenge that could render valuable medicines that have been deployed in the treatment of bacterial infections obsolete for more than half a century. Due to the lack of medical oversight, antibiotics are being unintentionally misused, which has led to the rapid emergence of resistant pathogens.

The collective action of NGOs, international health agencies, and local authorities has worked to significantly reduce the impact of the mitigating health damages caused by conflict. Interventions such as emergency vaccination campaigns, rebuilding healthcare infrastructure, and strengthening disease surveillance systems have successfully broken down barriers that lead to poor health associated with infectious diseases in conflict zones. Yet, in active conflict regions, the success of good public health strategies have continued to hinge on achieving stability in the region, with progress being achieved when both parties can find common ground. Humanitarian delivery and health programming in conflict-affected areas are imperative to the international community in both a legal and moral sense. So much human suffering can be prevented through the protection of healthcare facilities, humanitarian corridors, and investment in the resilience of healthcare infrastructure. Solving health problems in conflict zones needs global cooperation and continuity. This includes protecting and rebuilding healthcare infrastructure, addressing the needs of the displaced, building back healthcare to be more robust, and countering the emergence of antimicrobial resistance. Focusing on health and global cooperation can mitigate the catastrophic health consequences of armed conflict and help create conditions that will make populations affected by war more stable and healthier in the future.

Below are several critical policy recommendations developed as a product of this piece of work

(Table 1—Policy Recommendations for Addressing Public Health Challenges in Conflict Zones: This table includes evidence-based policy recommendations on minimising public health impacts during armed conflicts, focusing on reinforcing health care infrastructure, boosting disease prevention and control, supplying vital medical products, safeguarding health care personnel, and accelerating international cooperation.)

Below is a table of key areas of future research required when addressing health challenges in conflict zones. These research domains will help address the long-term health consequences of displacement, innovative approaches to improving health, vaccination strategies, and antimicrobial resistance. Regions, policymakers, and health organisations can identify and prioritise these areas to design focused approaches for system strengthening, health improvements, and minimising public health risks in areas impacted by protracted conflict and damaged infrastructure.

(Table 2: Future Directions for Research on Public Health in Conflict Zones: This table includes future research priorities for Public Health in humanitarian Crises. Examining the long-term health effects, disease surveillance, health care provision in unstable environments, resilient health systems, and the socio-economic determinants of health)

References:

ACCESS, H., (2023) 567 displaced families survive on water and sanitation services. [online] HUMAN ACCESS | A non-profit organization in Yemen. Available at: https://humanaccess.org/m/news/567-displaced-families-survive-on-water-and-sanitation-services.

Al-Dar, A.A., Al-Qassimi, M., Ezzadeen, F.H., Qassime, M., Al murtadha, A.M. and Ghaleb, Y., (2022) Diphtheria resurgence in Sada’a-Yemen, 2017–2020. BMC Infectious Diseases, 221.

Al-Moujahed, A., Fares Alahdab, Heba Abolaban and Beletsky, L., (2017) Polio in Syria: Problem still not solved. Avicenna Journal of Medicine, [online] 72, p.64. Available at: http://www.avicennajmed.com/article.asp?issn=2231-0770;year=2017;volume=7;issue=2;spage=64;epage=66;aulast=Al-Moujahed [Accessed 31 Jul. 2019].

Alsabri, M., Alsakkaf, L., Alhadheri, A., Cole, J. and Burkle Jr., F., (2022) Chronic Health Crises and Emergency Medicine in War-torn Yemen, Exacerbated by the COVID-19 Pandemic. Western Journal of Emergency Medicine, 232, pp.276–284.

Alsharif, A., S Faisal Ahmed, Almatary, A.M. and Badheeb, M., (2023) Maternal Mortality Over a Seven-Year Period of Conflict at Jiblah Referral Hospital in Ibb City, Yemen: A Retrospective Observational Study. Cureus. [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10374169/#:~:text=Yemeni%20women%20face%20a%201.

American Red Cross, (2011) Summary of the Geneva Conventions of 1949 and Their Additional Protocols. [online] American Red Cross. Available at: https://www.redcross.org/content/dam/redcross/atg/PDF_s/International_Services/International_Humanitarian_Law/IHL_SummaryGenevaConv.pdf.

Bastani, P., Omid Sadeghkhani, Parisa Bikine, Gholamhossein Mehralian, Mahnaz Samadbeik and Ramin Ravangard, (2023) Medication supply chain resilience during disasters: exploration of causes, strategies, and consequences applying Strauss and Corbin’s approach to the grounded theory. Journal of Pharmaceutical Policy and Practice, 161.

Batarfi, S.A., Sutan, R., Ismail, H. and Bin-Ghouth, A.S., (2024) Immunization of Children under 2 Years Old in the Coastal Hadhramaut Governorate, Yemen, during Public Health Emergencies: A Trend Analysis of 2013–2020. Vaccines, [online] 123, p.311. Available at: https://www.mdpi.com/2076-393X/12/3/311 [Accessed 26 Apr. 2024].

Bourgi, N., Olaby, A.A., Najdi, A. and Hatem, G., (2024) Predictors of antibiogram performance and antibiotic resistance patterns in the northern Syrian region: A cross-sectional investigation. Exploratory Research in Clinical and Social Pharmacy, [online] 13, p.100416. Available at: https://www.sciencedirect.com/science/article/pii/S2667276624000118 [Accessed 14 Feb. 2024].

Cirit, O.S., Fernández-Martínez, M., Yayla, B. and Martínez-Martínez, L., (2019) Aminoglycoside resistance determinants in multiresistant Escherichia coli and Klebsiella pneumoniae clinical isolates from Turkish and Syrian patients. Acta Microbiologica et Immunologica Hungarica, 663, pp.327–335.

Cuadrado, C., Libuy, M. and Moreno-Serra, R., (2023) What is the impact of forced displacement on health? A scoping review. Health Policy and Planning.

Dureab, F., Ahmed, K., Beiersmann, C., Standley, C.J., Alwaleedi, A. and Jahn, A., (2020) Assessment of electronic disease early warning system for improved disease surveillance and outbreak response in Yemen. BMC Public Health, 201.

Elnakib, S., Elaraby, S., Othman, F., BaSaleem, H., Abdulghani AlShawafi, N.A., Saleh Al-Gawfi, I.A., Shafique, F., Al-Kubati, E., Rafique, N. and Tappis, H., (2021) Providing care under extreme adversity: The impact of the Yemen conflict on the personal and professional lives of health workers. Social Science & Medicine, 272, p.113751.

Fahmy, K., Hasan, Q., Md Sharifuzzaman and Yvan Hutin, (2024) Analyzing Subnational Immunization Coverage to Catch up and Reach the Unreached in Seven High-Priority Countries in the Eastern Mediterranean Region, 2019–2021. Vaccines, 123, pp.285–285.

Federspiel, F. and Ali, M., (2018) The cholera outbreak in Yemen: lessons learned and way forward. BMC Public Health, [online] 181. Available at: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-6227-6.

Gorji, A. and Ghadiri, M.K., (2020) The potential roles of micronutrient deficiency and immune system dysfunction in COVID-19 pandemic. Nutrition, p.111047.

Grundy, J. and Biggs, B.-A., (2018) The Impact of Conflict on Immunisation Coverage in 16 Countries. International Journal of Health Policy and Management, 84, pp.211–221.

Humanitarian Practice Network, (2023) Responses to the humanitarian situation in Gaza and Israel. [online] Humanitarian Practice Network. Available at: https://odihpn.org/publication/responses-to-the-humanitarian-situation-in-gaza-and-israel/.

Ibrahem Abduallah Beshr, Mohammed Sadeq Beshr and Hibah Abdulqader Al-Qubati, (2023) Polio outbreak response, Yemen. Bulletin of the World Health Organization, [online] 10112, pp.808–812. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10680107/#:~:text=Between%202019%20and%202021%2C%20Yemen [Accessed 11 Apr. 2024].

International Medical Corps, (2017) Yemen’s Tragedy: A First Responder’s Blog from Inside the Crisis. [online] International Medical Corps. Available at: https://internationalmedicalcorps.org/story/yemen-first-responder/.

IOM, (2022) Internally displaced persons. [online] World Migration Report. Available at: https://worldmigrationreport.iom.int/what-we-do/world-migration-report-2024-chapter-2/internally-displaced-persons#:~:text=Displacements%20in%202022 [Accessed 4 Jun. 2024].

IOM, (2024a) CLIMATE CHANGE IN YEMEN | 2023 1 REPORT ON MIGR ATION, ENVIRONMENT, AND CLIMATE CHANGE IN YEMEN. [online] Available at: https://environmentalmigration.iom.int/sites/g/files/tmzbdl1411/files/documents/2024-03/yemen-desk-review.pdf.

IOM, (2024b) Yemen’s Unsung Heroes: How Mobile Medical Teams Are Saving Lives. [online] IOM Regional Office for Middle East and North Africa. Available at: https://mena.iom.int/stories/yemens-unsung-heroes-how-mobile-medical-teams-are-saving-lives-amidst-conflict [Accessed 8 Jun. 2024].

IRC, (2020) Yemen | International Rescue Committee (IRC). [online] www.rescue.org. Available at: https://www.rescue.org/uk/country/yemen.

Jafarnia, N., (2023) ‘Death is More Merciful Than This Life’. Human Rights Watch. [online] Available at: https://www.hrw.org/report/2023/12/11/death-more-merciful-life/houthi-and-yemeni-government-violations-right-water.

Jakovljevic, M., Al ahdab, S., Jurisevic, M. and Mouselli, S., (2018) Antibiotic Resistance in Syria: A Local Problem Turns Into a Global Threat. Frontiers in Public Health, 6.

Khadse, S.N., Ugemuge, S. and Singh, C., (2023) Impact of Antimicrobial Stewardship on Reducing Antimicrobial Resistance. Cureus, 1512.

Martineau, T., McPake, B., Theobald, S., Raven, J., Ensor, T., Fustukian, S., Ssengooba, F., Chirwa, Y., Vong, S., Wurie, H., Hooton, N. and Witter, S., (2017) Leaving no one behind: lessons on rebuilding health systems in conflict- and crisis-affected states. BMJ Global Health, [online] 22, p.e000327. Available at: https://gh.bmj.com/content/2/2/e000327.

Mbaeyi, C., (2017) Response to a Large Polio Outbreak in a Setting of Conflict — Middle East, 2013–2015. MMWR. Morbidity and Mortality Weekly Report, [online] 66. Available at: https://www.cdc.gov/mmwr/volumes/66/wr/mm6608a6.htm#:~:text=A%20polio%20outbreak%20occurred%20in%20the%20Middle%20East%2C.

McKernan, B. and correspondent, B.M.M.E., (2020) Health workers targeted at least 120 times in Yemen conflict – report. The Guardian. [online] 18 Mar. Available at: https://www.theguardian.com/world/2020/mar/18/health-workers-targeted-at-least-120-times-yemen-conflict.

Médecins Sans Frontières , (2019) Endemic in Yemen, cholera still hits Yemenis hard | MSF. [online] Médecins Sans Frontières (MSF) International. Available at: https://www.msf.org/endemic-yemen-cholera-still-hits-yemenis-hard.

Mehtar, S., AlMhawish, N., Shobak, K., Reingold, A., Guha-Sapir, D. and Haar, R.J., (2021) Measles in conflict-affected northern Syria: results from an ongoing outbreak surveillance program. Conflict and Health, 151.

MSF, (2020) Relentless attacks on medical facilities in Taiz City, Yemen, hinder access to care and violate international humanitarian law. [online] Doctors Without Borders - USA. Available at: https://www.doctorswithoutborders.org/latest/relentless-attacks-medical-facilities-taiz-city-yemen-hinder-access-care-and-violate#:~:text=On%20March%2013%2C%20Al%2DThawra [Accessed 7 Jun. 2024].

Mulugeta Wodaje Arage, Henok Kumsa, Shiferaw, M., Abebe Tarekegn Kassaw, Ephrem Mebratu Dagnew, Abayneh Tunta, Kassahun, W., Amanuel Addisu, Molla Yigzaw, Tilahun, H. and Lebeza Alemu Tenaw, (2023) Exploring the health consequences of armed conflict: the perspective of Northeast Ethiopia, 2022: a qualitative study. BMC Public Health, 231.

Ng, Q.X., De Deyn, M.L.Z.Q., Loke, W. and Yeo, W.S., (2020) Yemen’s Cholera Epidemic is A One Health Issue. Journal of Preventive Medicine and Public Health, 534.

Osman, M., Rafei, R., Ismail, M.B., Omari, S.A., Mallat, H., Dabboussi, F., Cazer, C., Karah, N., Abbara, A. and Hamze, M., (2021) Antimicrobial resistance in the protracted Syrian conflict: halting a war in the war. Future Microbiology, 1611, pp.825–845.

Parums, D.V., (2024) A Review of the Resurgence of Measles, a Vaccine-Preventable Disease, as Current Concerns Contrast with Past Hopes for Measles Elimination. Medical Science Monitor, [online] 30. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10946219/.

Qaserah, A.M., Al Amad, M.A., Al Serouri, A.A. and Khader, Y.S., (2021) Risk Factors of Cholera Transmission in Al Hudeidah, Yemen: Case-control study (Preprint). JMIR Public Health and Surveillance, 77.

Raof Al Waziza, Sheikh, R., Ahmed, I., Ghassan Al-Masbhi and Fekri Dureab, (2023) Analyzing Yemen’s health system at the governorate level amid the ongoing conflict: a case of Al Hodeida governorate. Discov Health Systems, [online] 21. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10169293/.

Raslan, R., El Sayegh, S., Chams, S., Chams, N., Leone, A. and Hajj Hussein, I., (2017) Re-Emerging Vaccine-Preventable Diseases in War-Affected Peoples of the Eastern Mediterranean Region—An Update. Frontiers in Public Health, 5.

UK GOVERMENT, (2022) Country policy and information note: security and humanitarian situation, Yemen, December 2021 (accessible version). Department of Health. [online] 6 Jan. Available at: https://www.gov.uk/government/publications/yemen-country-policy-and-information-notes/country-policy-and-information-note-security-and-humanitarian-situation-yemen-december-2021-accessible-version.

UN, (2023a) After eight years of conflict and despite a fragile truce, childbirth still a matter of life and death in Yemen | United Nations in Yemen. [online] yemen.un.org. Available at: https://yemen.un.org/en/226024-after-eight-years-conflict-and-despite-fragile-truce-childbirth-still-matter-life-and-death.

UN, (2023b) International Laws Protecting Civilians in Armed Conflict Not Being Upheld, Secretary-General Warns Security Council, Urging Deadly Cycle Be Broken | UN Press. [online] press.un.org. Available at: https://press.un.org/en/2023/sc15292.doc.htm.

UNHCR, (2023) UNHCR Yemen 2021 Country Operational Plan. [online] UNHCR Operational Data Portal (ODP). Available at: https://data.unhcr.org/en/documents/details/85850 [Accessed 7 Jun. 2024].

UNICEF, (2017) More than 355,000 children under five years-old vaccinated against polio in hard to reach areas of Syria. [online] www.unicef.org. Available at: https://www.unicef.org/press-releases/more-355000-children-under-five-years-old-vaccinated-against-polio-hard-reach-areas [Accessed 8 Jun. 2024].

UNICEF, (2019) UNICEF and partners provide vaccination against polio and measles for nearly 232,000 children in Syria and Iraq, many affected by latest violence northeast of Syria. [online] UNICEF UK. Available at: https://www.unicef.org.uk/press-releases/unicef-and-partners-provide-vaccination-against-polio-and-measles-for-nearly-232000-children-in-syria-and-iraq-many-affected-by-latest-violence-northeast-of-syria/ [Accessed 8 Jun. 2024].

UNICEF, (2022) More than 11,000 children killed or injured in Yemen – UNICEF. [online] UNICEF UK. Available at: https://www.unicef.org.uk/press-releases/more-than-11000-children-killed-or-injured-in-yemen-unicef/#:~:text=For%20years%2C%20the%20country [Accessed 7 Jun. 2024].

UNICEF, (2023) Yemen Consolidated Emergency Report 2023. [online] Available at: https://open.unicef.org/sites/transparency/files/2024-05/Yemen%20CER%202023.pdf.

UNICEF, (2024) Yemen: Parenting in a war zone. [online] www.unicef.org. Available at: https://www.unicef.org/stories/yemen-parenting-war-zone.

United Nations Security Council, (2016) Security Council Adopts Resolution 2286 (2016), Strongly Condemning Attacks against Medical Facilities, Personnel in Conflict Situations | UN Press. [online] press.un.org. Available at: https://press.un.org/en/2016/sc12347.doc.htm.

Valia Marou, Vardavas, C.I., Katerina Aslanoglou, Katerina Nikitara, Zinovia Plyta, Leonardi-Bee, J., Atkins, K., Condell, O., Lamb, F. and Suk, J.E., (2024) The impact of conflict on infectious disease: a systematic literature review. Conflict and health, [online] 181. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11000310/ [Accessed 24 Apr. 2024].

Webster, P.C., (2011) The deadly effects of violence against medical workers in war zones. Canadian Medical Association Journal, 18313, pp.E981–E982.

WHO, (2019) Yemen hospital airstrike under investigation amid resurgence of deadly cholera. [online] UN News. Available at: https://news.un.org/en/story/2019/03/1035561.

WHO, (2020) HeRAMS report, 2020 Health resources and services availability monitoring system. [online] Available at: https://applications.emro.who.int/docs/WHOEMYEM031E-eng.pdf.

WHO, (2024) Syria crisis. [online] www.who.int. Available at: https://www.who.int/emergencies/situations/syria-crisis.

World Health Organisation, (2023) Yemen crisis. [online] www.who.int. Available at: https://www.who.int/emergencies/situations/yemen-crisis.

World Health Organization, (2023) Surveillance in emergencies. [online] World Health Organization. Available at: https://www.who.int/emergencies/surveillance.

World Health Organization: WHO, (2016) Insecurity drives health workers out of Yemen. [online] Who.int. Available at: https://www.who.int/news-room/feature-stories/detail/insecurity-drives-health-workers-out-of-yemen.