Yemen is a country racked with violence. Religious sectarianism, rebellion in the north, a secessionist movement in the south and the resurgence of Al-Qaeda are all playing out against a background of economic collapse, insufficient state capacity, corruption and tribalism. A large number of security incidents have affected Médecins Sans Frontières (MSF) projects in Aden and Amran governorate north of the capital Sana’a (some 40 documented between April 2010 and July 2013 by MSF’s French section alone), including security forces and armed men entering medical facilities to seek out patients, family and tribal revenge attacks against patients or doctors within hospital confines, the use of threatening behaviour to force doctors to treat family members and the retention of vehicles. Few of these incidents resulted in physical harm to patients or doctors, though one patient was killed in the emergency room of the MSF-supported hospital in Khamer in July 2011.
In March 2013 MSF began a research study to investigate the various forms of insecurity affecting MSF projects in Yemen and the ways the organisation and other health professionals had adapted their work practices to meet them. The research took place in Amran, where an MSF project was opened in February 2010 to treat internally displaced people (IDPs) fleeing fighting in Saada governorate. After the return of most IDPs in 2011, the project evolved to cover medical and surgical emergencies, with outreach activities in remote villages. MSF supports the Ministry of Health hospital in Khamer, as well as the health centre in the town of Huth. In Khamer, MSF is in charge of all hospital wards except the outpatient department, running mostly emergency activities but also providing maternity and paediatric in-patient services, as well as care for patients with leishmaniasis and rickets. After emergency treatment, patients are referred when necessary to secondary healthcare centres in Amran and Sanaa.
Khamer is a peaceful town where international personnel live without fear. They walk around the town freely, except at night (when stray dogs are a nuisance). The MSF team only spends a couple of nights a week in the rather less peaceful Huth.
The challenge of documenting insecurity
In a setting where violence and verbal threats are so prevalent, documenting insecurity is a real challenge. Should the team only record events that have a direct impact on operations (shootings in the hospital, car-jackings etc.), or should they document everything (including minor threats)? The decision on whether to report an incident or not depends on how the person responsible for drawing up the report wants to portray the reality to alert or, on the contrary, reassure headquarters and the coordination team in Sana’a. Assessing the degree of severity of a threat or incident is equally challenging, particularly for international employees. For instance, in Yemen a qita a tribal roadblock, during which tribesmen hold a car or people hostage in exchange for a variety of demands is often seen as non-violent and commonplace. Being threatened at gunpoint is viewed as less serious than a slap in the face.
Threats occur against the backdrop of a structural problem in the relationship between doctors and patients/carers. A review of the press and interviews with doctors and non-doctors in Sana’a, Amran and Aden reveal the extent of the difficulties, whatever the level of political tension in the country. An article published in National Yemen in July 2012, entitled ‘Yemeni Doctors Cause More Harm Than Good’, noted that:
Many patients have died or been left disabled due to gross negligence and medical errors that frequently pass unpunished in Yemen. Thousands of Yemenis fall victim to medical errors at the hands of doctors, whose unearned and undeserved titles and certificates are the only things which connect them with the practice of medicine.+‘Yemeni Doctors Can Cause More Harm Than Good, National Yemen, 18 July 2012.
Yemeni health workers are extremely worried about their security. One Ministry of Health-employed doctor in Khamer explains: ‘there are 20% chances [he] get[s] killed in the hospital, 80% chances [he] stay[s] safe’. It is not so much the actual incidents or their number that are the cause of stress, but more the doctors’ perceptions of insecurity.
The underlying causes of insecurity
In three of the four incidents described in the Annex, the underlying source of conflict was the poor quality of relations between patients and medical staff. Doctors tend to blame this on the lack of education and an ‘archaic tribal system living off the lack of strict regulation of government allowing any member of a tribe to do whatever he wants’.+Interview, hospital director, Sanaa. People from villages outside Khamer – the primary target population of the project are perceived to be the main trouble-makers. Other factors which negatively affect relations between doctors, patients and their families include problems with the location of the triage area, admission and referral criteria, the practice of orthopaedic surgery by Yemeni general surgeons and the lack of rigour in patient follow-up. An additional risk factor is the gap between the reality of care in Yemen and the high expectations patients have of doctors.
Our investigation singled out the dispute over jobs among the area’s families and tribes and friction between different categories of staff (staff employed under Ministry of Health contract, staff under contract but with MSF incentives and Yemeni staff under MSF contract in particular) as other key elements in creating tensions potentially leading to incidents. Hospital staff have more than doubled since MSF’s arrival in 2010 and MSF’s incentive payments have resulted in a significant increase in the average wage. In a region with few employment opportunities, disputes over access to jobs at hospitals contribute substantially to tensions. Security incidents such as hijacking may also be seen as a way of applying pressure on local authorities to secure jobs and salaries or resolve family feuds. According to the driver, there were over 30 ambulance hijackings between 2006 and 2013, most of them involving demands for money from sheikhs or the government.
Responding and adapting to insecurity
Given these risks, doctors working in Yemen have attempted to adapt their work practices. Across the country, accounts of doctors trying to avoid treating highly complex medical cases and referring patients for security reasons abound. While there are situations calling for exceptional measures, for example openly hostile or armed patients or their families, conflict within the hospital and revenge killings, other patients who are merely perceived as a security risk are also increasingly being referred elsewhere. As one MSF-employed doctor put it, ‘if there is a security risk, it is better to refer’.+Yemeni doctor, MSF, Khamer. While this practice is a reaction to insecurity, it can also cause insecurity.
In 2012 and 2013, three MSF-employed Yemeni doctors left the Amran project, each after having been either threatened or involved in an incident. All three gave the same reason for leaving: a general lack of motivation to continue working stemming from insecurity. MSF itself, and the way it has adapted its activities or reacted to incidents, is also seen as a direct source of insecurity. Contested practices include the partial reimbursement of medical expenses incurred by patients in Sanaa or abroad in response to pressure on MSF, or the fast-tracking of referrals to the MSF surgical programme in Amman. Employees fear that resorting to such measures can only increase the pressure they face from patients. In a region where everybody is armed, many viewed MSF’s decision to remove its armed guards from the hospital gate as bordering on foolhardiness.
But it is debates around whether or not to suspend activities after an incident that are the most animated. Apart from when a hospital is damaged or destroyed, MSF rarely suspends activities after one incident. Some incidents lead to a suspension, while others do not. In most cases, the decision is preceded by discussions between field, coordination, ‘Desk Team’ and, at times, hospital management. Justifying or extending a suspension of activities involves a range of factors, including the gravity or perceived gravity of an incident, the type and relevance of the services provided (interviewees, for and against suspension, frequently viewed the suspension of hospital activities as a ‘collective punishment’), and the reaction of the community/population/local leaders. Do they support MSF’s decision? Are they pushing for a resolution? The lack of a straightforward policy on suspension is problematic, albeit establishing one is widely acknowledged to be an impossible task.
While its employees do not expect MSF to provide full protection, they do believe that it is the responsibility of the organisation to recognise their situation and demonstrate a real determination to improve working conditions. Some Yemeni employees perceive MSF to be over-reliant on traditional tribal reconciliation mechanisms when dealing with the aftermath of an incident. While this approach has resulted in a low prevalence of life-threatening incidents, it has not led to a significant reduction in exposure to risk. Identifying with a culture and achieving acceptance also means having to adopt its visible codes in this case tolerating violence and focusing on crisis resolution rather than prevention. Yemeni staff acknowledge the limits of the sheikhs’ ability to resolve disputes. Sheikhs have only limited control over their ‘people’, in part because they are principally based in Sanaa.
MSF’s projects in Amran have to work within several constraints: health facilities are jointly managed with the Ministry of Health representatives, they host a range of activities which MSF does not fully control and, lastly, the project is one of the major employers in a region with very few employment opportunities. Services are contested, at times for what they deliver and at others for what they do not. The project has to rely on doctors with low social status, whose medical and social skills are mistrusted. The combination of these factors results in a high rate of exposure to tension and risk for health workers. In order to protect themselves or simply improve their working environment, they have developed as elsewhere in Yemen coping mechanisms which can in turn become aggravating factors of the very situation they are meant to contain.
Despite the specificity of the context, the issues experienced by MSF in Amran have much in common with those MSF and health professionals encounter in hospitals all over the world. MSF operates in settings where a high degree of violence is socially acceptable and intimidation an integral part of social regulation. No measure apart from withdrawal from a project can ever fully protect its employees. However, the research shows that humanitarian organisations do not have to see themselves as passive victims or Yemeni patients as inherently dangerous. For MSF, as for other medical actors working in such contexts, adjusting the operational strategy to deal with the needs of local actors, improving medical practices and instituting a stronger political base and more robust security management all contribute towards a better working environment.
Michaël Neuman is Director of Studies at the Centre de réflexion sur l’action et les savoirs humanitaires, MSF.
Annex: Security incidents affecting MSF
For the research, four short stories of incidents were compiled.
Incident number 1
Huth Health Centre, September 2012
One night, two armed men tried to enter the health centre in Huth. One was wounded and his friend appeared to be under the influence of the stimulant khat and drugs. A Yemeni MSF doctor was forced to treat the wounded patient with a Kalashnikov held against his head. Once stabilised, the patient was referred to Khamer. His friend stayed on the premises for a while, threatening to kill all three clinic staff if his friend died, before finally leaving. As a result, MSF and the Ministry of Health suspended their activities. The ministry resumed work a couple of months later, while MSF did so only six months after the incident. The MSF-employed doctor left with a financial package and psychological support.
Incident number 2
Khamer, February 2013
A family transporting a patient suffering from severe burns crashed their car through the main gate of the hospital. Although the patient was treated immediately in the ER, her family did not believe that she was taken care of quickly enough and threatened the doctor and nurses on duty. Once her condition had stabilised, the patient was transferred to the in-patient department. While the doctor on duty was calling a surgeon because the patient’s head wound was severe, the patient’s brother slapped him. The doctor hid for a while in the kitchen, and then left the hospital. The relatives calmed down and agreed to leave.
MSF decided to suspend activities, sending international staff and Yemeni personnel not from the region to Sana’a. Local sheikhs convened and sent apologies. The suspension lasted for two weeks.
Incident number 3
Amran to Khamer road, June 2013
An MSF surgeon operated on a patient’s leg in Khamer hospital in September 2012. Dissatisfied with his post-operative care, his family sent him to Egypt in March 2013. When he did not recover full mobility the family accused MSF of mismanagement. They sent a number of messages to MSF via staff saying that they would take action if nothing was done. The Project Coordinator visited the family, who gave MSF two weeks to come up with a solution.
One week later, two MSF international staff travelling by car were held up at gunpoint between Amran and Khamer and forcibly detained by the relatives of the patient. The family demanded the MSF car in compensation for the cost of treatment in Egypt. After some discussion, the MSF staff members were allowed to return to the car and they drove off unharmed. An investigation revealed that there had indeed been failings in the management of the case, and the patient was fast-tracked to MSF’s surgical project in Amman.
Incident number 4
Khamer, MayJuly 2013
An ER doctor on duty allegedly denied access to care to an old man accompanied by two members of a powerful family in Khamer. This apparently benign incident turned into a family feud, involving the hospital watchmen as well as the director. This incident illustrates the competition for resources and jobs in particular. In the space of three months, a number of security incidents occurred: gunshots in the hospital compound, threats against an MSF Yemeni doctor, armed men preventing people from entering the hospital, the hijacking of the hospital ambulance and then of an MSF car and, lastly, death threats by text message against the MSF international team.