Mental Health and the Psychological Impact of War on Individuals, Families, and Communities in Yemen: A project to advance research, services, and advocacy

Executive Summary:

The ongoing war in Yemen has spurred the world’s largest food security emergency and the largest cholera epidemic ever recorded. Millions have been sent into abject poverty, the nation’s economy has been destroyed, and basic public services have evaporated. At least 50,000 civilians have been killed or wounded during the conflict, with the belligerent parties committing a litany of war crimes and violations of humanitarian law against the civilian population, including arbitrary detention, torture, indiscriminate attacks and murder.

The war thus has immediate and long-term implications for the mental health and psychosocial well-being of Yemenis, with much of the population exposed to serious and repeated stressors, harm, and trauma. The challenges to addressing the psychological needs of Yemenis are daunting: the ongoing conflict is continually increasing the breadth and depth of exposure to trauma; the minimal level of pre-existing public health resources has been further reduced by the country’s current full-scale institutional collapse; there is a profound lack of funding and interest from national and international stakeholders for mental health issues as well as an entrenched social stigma regarding such; and, crucially, the extreme paucity of research and analysis regarding mental health and psychosocial well-being in Yemen – including risks, services, opportunities, and needs amongst the population – inhibits understanding of the issue and the building of evidence-based recommendations and action.

In an effort to bridge this research and advocacy gap, in 2017 the Sana’a Center for Strategic Studies (SCSS), the Columbia Law School Human Rights Clinic (HRC), and the Columbia University Mailman School of Public Health (MSPH) initiated Mental Health and the Psychological Impact of War on Individuals, Families, and Communities in Yemen: A Project to Advance Research, Services, and Advocacy. This project aims to improve the understanding of and responses to mental health concerns in Yemen, and produce research that shapes advocacy and policy at the local, national, and international levels. The project aims to help bring mental health issues to the table during the peace and reconciliation processes and push for psychosocial interventions during conflict and in post-conflict recovery efforts. In doing so, the SCSS, HRC and MSPH seek to improve conditions for those psychologically affected by the Yemeni conflict, and help protect and advance the right to mental health in Yemen and globally.

This paper provides background on mental health and armed conflict in Yemen, explaining the need for dedicated research and advocacy on this neglected issue. It details the limited development of and access to mental health and psychosocial services in Yemen pre-conflict as well as the devastating impact of the current conflict upon service provision, and it identifies the basis for serious and far-reaching concerns about the physical, social, and psychological well-being of millions of Yemenis, while also illuminating the crucial gaps in current knowledge and analysis.

Introduction

The current conflict in Yemen has lasted more than two years and has effectively fragmented the country. In the north, the Houthi fighters and forces allied to former President Ali Abdullah Saleh hold the capital, Sana’a, and most of the country’s largest population centers. In the south, the internationally recognized government of President Abdo Rabbu Mansour Hadi and allied forces have established a de facto capital in the city of Aden from which — with the backing of a Saudi-led military coalition — they have been attempting to retake the north.

Though the frontlines have moved little over the course of the last two years, the country has been devastated. The UN declared Yemen the world’s largest food security emergency in early 2017. The cholera outbreak that began in the spring of 2017 has become the largest ever recorded. Millions of people are suffering destitution as the economy has crumbled. Basic public services are in collapse with more than a million public servants without a salary for almost a year. And the conflict has claimed more than 50,000 casualties, with all belligerent parties being frequently accused of committing war crimes and humanitarian law and human rights law violations.

The war has exposed the civilian population of Yemen to extreme and continuous stressors, harms of many forms, and direct and vicarious trauma. Although largely unstudied, the war has likely had a devastating impact on the mental health of a significant proportion of the Yemeni population.

According to the World Health Organization (WHO), during armed conflict generally an estimated 17 percent and 15 percent of the population will suffer from depression and post-traumatic stress disorder (PTSD), respectively.1 Several other major studies in low-income countries post-conflict have reported far higher rates of mental health challenges amongst the population.2 Indeed, a 2010 study covering a region of Liberia revealed that some 45 percent of the population exhibited symptoms of PTSD nearly 20 years after the end of the conflict.3 Importantly, some studies have also linked trauma exposure and views regarding conflict resolution, with one study on northern Uganda finding that PTSD was correlated with support for violence as a means of conflict resolution.4 

Despite the likely massive immediate and long-term mental health implications of the current conflict in Yemen, research on the issue is minimal, with specific causes, dynamics, and effects largely unexplored. There are few assessments on the forms or prevalence of trauma exposure and the adverse mental health impacts of the conflict on the population, or of the types of local coping and resilience strategies being used. The WHO has noted that there is a “paucity of epidemiological data on mental illness in Yemen in internationally accessible literature.”5 The available English-language literature that exists is generally pre-conflict and often focuses on specific issues such as the impact of khat usage,6 or on specific regions in Yemen.7 Therefore, it is extremely difficult at the current time to assess the general state of mental health in Yemen. Furthermore, there is little advocacy seeking to improve conditions and mental health services – at a time when Yemenis are in dire need of support.

Mental Health and the Psychological Impact of War on Individuals, Families, and Communities in Yemen: A Project to Advance Research, Services, and Advocacy has been jointly conceptualized between the SCSS, HRC and MSPH. This partnership brings together international law, human rights, and fact-finding experts from the HRC, public policy, foreign policy, international relations, and public health experts at the SCSS, and mental health and public health experts at the MSPH. Beginning in April 2017, these project partners began a study on mental health and psychosocial well-being in Yemen, in the aim of developing evidence-based policy recommendations to advance the right to mental health and aid in Yemen’s peace and reconciliation process.

The following provides an overview of the history of mental health services in Yemen, the persistent lack of legislative interest or engagement that has left those services underdeveloped, and the social stigma attached to both people suffering mental health conditions and professionals working in the field. While the WHO has documented the conflict’s devastating impact on health care services generally, this paper discusses how such data specific to mental health services is lacking. Similarly, while little research has been done regarding the current state of psychosocial well-being in the country, the following lays out anecdotal evidence suggesting that the impact has been severe and widespread. In reviewing the available literature regarding the many long-term negative implications of war on the mental health of individuals and their communities, this paper set out the risks facing millions of Yemenis in this regard; it is imperative that mental health issues in the country be properly assessed, appropriately mitigated as much as possible while the conflict is ongoing, and that preparations be made for broader psychosocial efforts and advocacy in post-conflict reconstruction and reconciliation.

The history and development of mental health services

In 1966 the British authorities inaugurated the first psychiatric sanatorium in Aden which, until South Yemen’s independence in 1967, employed just one foreign doctor and one nurse.8 The sanatorium, under the jurisdiction of the Ministry of the Interior and built with rooms that resembled jail cells, received its patients from the nearby Mansoura prison. The administration of the facility did not shift to the Ministry of Health until the early 1970s.9 In North Yemen,10 al-Salaam Sanatorium was built in Hudaydah in 1976, where it served as a basic shelter for those deemed mentally ill, and did not carry out treatment.11 The first institutional mental health treatment services were introduced in North Yemen in 1978 when a Bulgarian psychiatrist was brought in to staff a specialized clinic in the Republican Hospital in Sana’a. This happened shortly after the neurology clinic at the military hospital hired another European doctor to treat severe cases of mental illness.12

A move to establish national foundations for psychiatric practice in Yemen came in 1980 when the WHO commissioned a study to assess the status of mental health in the country. At the time, Dr. Taha Baashar, who ran the study, described how “patients suffering from mental health issues could be seen wandering or begging in crowded streets.”13 Following the study, the WHO helped establish psychiatry sections in three hospitals – in the cities of Sana’a, Taiz, and Hudaydah – and trained local doctors and provided basic equipment, such as electric shock therapy machines. In 1981, Dr. Ahmed Makki became the first Yemeni doctor specializing in mental illnesses to oversee the psychiatry section at the Al Thawra Hospital in Sana’a. This coincided with the work of Dr. Abdullah al-Kathiri in Aden who, in turn, brought in the first contributions of Yemenis to the field of mental health in southern Yemen.

In 1986 there were three practicing psychiatrists in North Yemen,14 which at the time had a population of 9 million people. In South Yemen, mental health services were officially added to primary health care services in the early 1980s. Under the supervision of the Ministry of Health, and later in 1984 following the inauguration of the University of Aden Hospital for Nervous and Mental Disorders, the WHO’s mental health program attempted to expand psychological services across the southern governorates by providing training workshops for doctors from Lahij, Hadramawt, Shabwah, and Abyan. Between 1986 and 1990, patient cells were decommissioned at the old Aden sanatorium and patients were transferred to the new hospital clinic.15

After the unification of North and South Yemen in 1990, administrative and supervisory bodies were developed within the organizational structure of the unified Ministry of Health, based in Sana’a. This included the High Council for Mental Health, which was a temporary cooperation between the Ministry of Health, the Ministry of Interior, and the General Prosecutor’s Office. Moreover, the Mental Health Program was established at the Ministry of Health to take over planning and development in the mental health field in Yemen. This included a round table conference and national seminar – held with the support of the International Committee of the Red Cross (ICRC) – to discuss the present reality and the future of mental health, which was then followed by a national strategy for mental health, drafted with the assistance of the WHO in 2004.16

These steps did not, however, translate into a sustained institutional effort to address Yemen’s mental health challenges, with the necessary financial and human resources failing to materialize. Despite the work done on the Mental Health Act in 2004, it was not approved by the Yemeni Parliament. Revisions and amendments aimed at addressing shortcomings were subsequently made, resulting in the draft Mental Health Bill of 2007 to regulate mental health services provision in Yemen; this too was not approved by Parliament.17

This lack of legislative follow-through is symptomatic of the long-standing and entrenched lack of concern regarding mental health issues on the part of Yemen’s political leadership. While local doctors have often lobbied to secure funds for their own clinics, there has been little organized national advocacy on behalf of mental health issues and institutional reform in the sector, with advances in this regard coming largely at the impetus of foreign aid agencies. Much of this may stem from a crucial lack of local mental health expertise. There were no universities in either North or South Yemen until the establishment of the University of Sana’a in 1970 in the north, and then the University of Aden in the south in 1977. In 1983, the Faculty of Arts at Sana’a University started offering a major in psychology and graduated its first class in 1987. The Faculty of Medicine was established in 1981-82, with psychiatry first taught in the 1987-88 school year.18 Enrollment, however, has remained persistently low, with the annual number of program applicants typically in the low single digits.19

Concurrently, general public ignorance of mental health issues has remained.20 The social stigmatization associated with mental illness has left many Yemenis reluctant to seek professional services for conditions they may be suffering.21 Reports suggest that Yemenis suffering from mental health conditions have been “detained in family homes” or left to “wander the streets of cities and towns.”22 It has also been reported that some groups within Yemeni society – women, for example – face particular challenges in accessing treatment.23 Anecdotal evidence suggests discriminatory and negative social attitudes are not confined to patients but extend to psychiatrists as well. This is among the reasons cited by the Arab Board of Medical Specialties in the Faculty of Medicine at Sana’a University for the persistent limited enrollment in upper-disciplinary programs studying mental illness.24

Mental health services before the current conflict

It is difficult to find detailed information on mental health services in Yemen, but what is available suggests relevant institutions in Yemen are few and generally of poor quality. According to the most recent Yemen National Health Strategy from 2010, of the 8,500 specialist doctors in the country, there were only 44 psychiatrists.25 Statistics compiled for the WHO’s 2011 Mental Health Atlas indicated that there were four mental health hospitals in Yemen, and just 0.21 psychiatrists and 0.17 psychologists per 100,000 people.26 This compares to 12.40 psychiatrists and 29.03 psychologists per 100,000 in the United States, and 29.68 psychiatrists and 54.28 psychologists per 100,000 people in Norway.27 The WHO’s most recent Mental Health Atlas from 2014 did not include data on the number of mental health professionals in Yemen and identified just three mental health hospitals and one psychiatric unit in a general hospital.28 Yemen’s National Mental Health Strategy, however, suggested that there were 19 mental health facilities in the country, including hospitals, clinics, and health facilities in prisons.29 This appears to conflict with WHO data, again demonstrating the challenges in collecting reliable information regarding mental health services in Yemen.

It is also difficult to find detailed publications on the roles of traditional healers, sheikhs, and other community leaders in providing mental healthcare and psychosocial support to Yemenis. Traditional and Quranic healers serve as the primary caregivers for many Yemenis who suffer from mental health conditions, often due to public ignorance and animosity toward professional mental health services as well as affordability – Quranic healers typically ask for little money in payment relative to doctors in both public or private clinics. Traditional healers combine “religion, suggestion, and native herbal medicine” to treat mental health conditions.30 Psychiatric treatment is often only sought when conditions have seriously deteriorated, such as severe cases of schizophrenia and psychosis.31

The Ministry of Health and Population adopted a National Mental Health Strategy for 2011-2015, which included steps to promote mental health, improve treatment of disorders, and address stigma and discrimination through community mobilization.32 However, the economic conditions and the disruption of public services following the 2011 uprising, the subsequent political crisis, and the onset of full-scale war in 2015 led to the strategy being discontinued.33 Since 2011, mental health has been viewed as a non-priority compared to other public health issues that include the spread of infectious diseases and vaccination campaigns, among others.34

In addition to limited facilities and a lack of trained professionals, the quality of available mental health care in Yemen has been a concern. Yemeni mental health professionals have cited a number of factors impacting existing quality of care. There is a lack of specialized care for specific groups such as women, children, teenagers, and the elderly, as well as for those suffering from chronic conditions or addiction.35 Mental health is not integrated into the primary health care system and, therefore, many Yemenis are unable to access treatment when they first make contact with the healthcare system.36 While a group of Yemeni psychiatry professors drew up an official protocol document in 2009 to standardized mental health diagnosis, assessment, and treatment, it is not widely consulted or applied among mental health professionals in the country.37 In addition, the cost of medication is prohibitive for many Yemenis, and the use of electroconvulsive therapy remains common.38

Impacts of the war on mental health services

The ongoing conflict has severely affected access to healthcare in Yemen, through damage to health facilities, shortages of clinical supplies,39 fuel, electricity, and essential goods,40 and risks to the physical well-being of healthcare professionals.41 In December 2015 the WHO stated that the Yemeni health system had collapsed, leaving 14.8 million people – more than half the population – without adequate healthcare.42 The WHO’s Health Resources Availability Mapping System (HeRAMS) surveyed health facilities in 16 out of 22 governorates in Yemen and found that, out of 3,507 surveyed facilities, 1,579 (45 percent) were fully functional and accessible, 1,343 (38 percent) were partially functional and 504 (17 percent) were non-functional.43 The survey also found that 274 facilities had been damaged as a result of the conflict, including 69 facilities totally damaged and 205 facilities partially damaged.44

To date, there has not been a detailed breakdown of the conflict’s impact specifically on mental health care facilities and access to services. The WHO HeRAMS survey found that amongst 3,507 health facilities, “services for noncommunicable diseases and mental health conditions are only fully available in 21 percent of health facilities.”45 There has also been a shortage of psychiatric specialists in Yemen since the start of the conflict; in January 2016 the WHO estimated that there were 40 psychiatric specialists in Yemen, most of whom were based in Sana’a;46 in December 2016, the director of the mental health program at the Ministry of Health suggested there were just 36.47

The WHO stated in early 2016 that it was engaged in training health and community workers outside of Sana’a using the WHO’s Mental Health Gap Action Programme Intervention Guide to help increase access to mental health services.48 Amid the international medical and humanitarian response to the crisis in Yemen, however, the overwhelming focus of aid agencies has been on immediate needs responses, with mental health needs being of low priority and receiving scant attention and funding.49   

The Yemeni war, mental health, and psychosocial well-being

The far-flung implications of the war in Yemen – such as the population’s frequent exposure to violence, widespread insecurity, famine, disease, rampant and accelerating poverty, fractured social ties, and a lack of basic social services – create immense stressors on the population and significantly heighten the threat of widespread deterioration in mental health.

A person who is 25 years of age today in Yemen has already lived through 14 other major armed conflicts in his or her lifetime. Many Yemenis have directly or vicariously experienced serious harm and trauma — threats to their lives from armed groups, the disappearance of relatives, airstrikes, arbitrary detainment or torture, attacks by non-state actors and militias.  

As of July 2017, the total number of internally displaced people (IDPs) was approximately 3 million – roughly 11 percent of the total Yemeni population of 27.8 million.50 Of these, some 52 percent were women. The largest number of displaced people (840,000) was located in Hajjah governorate, followed by IDPs located in Taiz (551,124), Saada (442,200), and Sana’a (285,084). An estimated 20.7 million people are currently in need of humanitarian and/or protection assistance.51 Over 14.5 million people lack access to safe drinking water, 14.8 million lack access to basic healthcare, 4.5 million need emergency shelter, and 8 million have lost their livelihoods.52 The conflict has also pushed Yemen to the brink of famine: approximately 17 million people do not have enough food to eat, of which 6.8 million are in a “state of emergency,” entirely dependent on external assistance for their food.53 The cholera epidemic that broke out in the spring of 2017 had, as of the end of September, caused in excess of 750,000 suspected cases of the disease.54

While there is currently a lack of hard data available on the general status of mental health in Yemen, anecdotal evidence suggests that there has been a surge in mental illnesses. For instance, the manager of the Al-Amal Psychiatric Hospital in Sana’a reported a significant increase in the number of patients relative to the pre-war period.55 Sources at the Ministry of Interior and other mental health experts in Sana’a also reported that suicide rates in the capital rose some 40.5 percent from 2014 to 2015.

Given that children under the age of 14 represent some 44 percent of the total population in Yemen, their well-being is of particular concern, especially given the heightened vulnerability of children. Currently 2 million school-aged children are out of school, 462,000 children under the age of five are suffering from severe acute malnutrition,56 and nearly 1,500 children have been forcibly recruited as child soldiers.57 A case study by Yemen Children Relief (YCR) on children in Sana’a, Aden, Taiz, and Abyan revealed a dramatic increase in feelings of fear, insecurity, anxiety, and anger, with 31 percent of the children in their study exhibiting physical symptoms – headaches, chest pain, abdominal pain, and fatigue – the researchers saw as consistent with psychological distress.58 YCR noted a clear differentiation in the severity of psychological symptoms between governorates, roughly corresponding to the intensity of the conflict in the various areas. According to the study: “when assessing the state of their children, parents reported that 5 percent of the kids are suffering from bed-wetting, 2 percent started stuttering again, 47 percent suffer from sleep disorders, 24 percent have a difficulty concentrating, and 17 percent suffer from panic attacks.”

The implications of large-scale war trauma

Individuals can be affected differently by war and armed conflict. There is ample research, however, to show that the severity, frequency, and duration of exposure to war is associated with the emergence of psychological suffering, with implications for both mental and physical well-being. For instance, a study conducted on mothers at the end of the Lebanese Civil War found that the “level of perceived negative impact of war-related events was found to be strongly associated with higher levels of depressive symptomatology” and that “the level of a mother’s depressive symptomatology was found to be the best predictor of her child’s reported morbidity, with higher levels of symptoms associated with higher levels of morbidity.”59 Other studies have shown that exposure to war and violence in early childhood has negative implications for a child’s personality and psychological well-being later in life.60

A study of 1,137 Palestinian children in the Gaza Strip between the ages of 10 and 18 found that, in terms of conflict-related trauma: 99 percent had suffered humiliation, either to themselves or a family member; 97 percent had heard explosions; 84 percent had seen a martyr’s funeral, and 84 percent had seen shelling from tanks, artillery and/or warplanes.61 Some 41 percent exhibited symptoms of PTSD and of these: 20 percent suffered acute PTSD symptoms; 22 percent moderate symptoms, and 58 percent low-level symptoms. The types of symptoms exhibited ranged from cognitive, emotional, and somatic, to social and academic behavioural disorders.

A study of Sudanese refugees in northern Uganda found similar correlations between exposure to conflict, the prevalence PTSD and depressive and behavioral problems. It also noted that the day-to-day hassles of life these children experienced were higher relative to children in the same area who had not experienced conflict.62 PTSD has also been associated with the comorbidity of wide-ranging symptoms, such as attempted suicide, to bronchial asthma, hypertension, peptic ulcer, among others.63  

Given the available research correlating conflict with poor mental health outcomes, and the severity and length of the conflict in Yemen, large portions of the Yemeni population are almost certainly suffering mental health conditions. Left unaddressed, this will have grave implications not just for immediate post-conflict recovery, but for subsequent generations of Yemenis.     

Looking ahead: toward research and advocacy agenda

The extreme difficulties in addressing the current concerns about mental health in Yemen will continue post-conflict given the lack of institutional capacity, the lack of a functioning public health sector, the lack of international attention to and funding for mental health issues, the social stigma around mental health, and, crucially, the lack of research and analysis regarding the general state of mental health and needs amongst the population. Greater research is critically needed to study the mental health and psychosocial well-being of Yemenis, the risks, the opportunities, the government capacities, and the potential for institutional reform to improve access and services. It is imperative that the depth and the scope of mental health issues in Yemen be assessed and appropriately mitigated through evidence-based interventions as much as possible while the conflict is ongoing, while preparing for broader efforts and advocacy in post-conflict reconstruction and reconciliation.

The project initiated between the SCSS, HRC and MSPH aims to improve the understanding of and responses to mental health concerns in Yemen through locally-owned research and evidence-based advocacy. The broad objectives of the project are to conduct interdisciplinary research to better understand the mental health situation in Yemen, including how it varies across experience, gender, and age, as well as assess the capacities of and gaps in mental health services in the country. These findings are then intended to form the basis for policy recommendations for local civil society, national and international stakeholders, and aid agencies on issues related to mental health, and promote the rights of those psychologically affected by the conflict in Yemen.

This project aims to help bring mental health issues to the table during the peace and reconciliation processes and to push for psychosocial interventions, wherever possible, during the conflict and in post-conflict recovery efforts. In doing so the SCSS, HRC and MSPH seek to advance the right to mental health and improve conditions for those psychologically affected by the Yemeni conflict, and in so doing help strengthen the right to mental health globally.

This paper was prepared by Fawziah Al-Ammar, Tawfeek Al-Ganad, Waleed Alhariri and Lindsay Stark; edited by Spencer Osberg.

About SCSS: The Sana’a Center for Strategic Studies (SCSS) is an independent policy and research think-tank that provides new approaches to understanding Yemen and the surrounding region, through balanced perspectives, in-depth studies and expert analysis. Founded in 2014, the SCSS conducts research and consultations in the fields of political, economic, civil and social development, in addition to providing technical and analytical advice regarding key issues of local, regional and international concern.

About HRI

 

About MSPH: Since 1922, Columbia University’s Mailman School of Public Health (MSPH) has been at the forefront of public health research, education, and community collaboration. Addressing everything from chronic disease to HIV/AIDS to healthcare policy, the School tackles today’s pressing public health issues, translating research into action. Within MSPH, the Program on Forced Migration and Health is one of the world’s leading centers on humanitarian research and teaching, and has helped to build a knowledge base that is improving humanitarian action and health during global disasters and conflicts.


Notes:

  1. World Health Organization Executive Board Secretariat, Global Burden of Mental Disorders and the Need for a Comprehensive, Coordinated Response from Health and Social Sectors at a Country Level: Report by the Secretariat, ¶ 3, E.B. 130/9 (Dec. 1, 2011), available at http://apps.who.int/gb/ebwha/pdf_files/EB130/B130_9-en.pdf.
  2.  Jason T. DeJong et al., Lifetime events and posttraumatic stress disorder in 4 postconflict settings, JAMA. 2001 Aug 1;286(5):555-62; also see Kessler RC, Angermeyer M, Anthony JC, et al., Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry. 2007;6(3):168–176.
  3.  Sandro Galea et al., Persistent Psychopathology in the Wake of Civil War: Long-Term Posttraumatic Stress Disorder in Nimba County, Liberia, Am J Public Health. 2010 September; 100(9): 1745–1751.
  4. Betancourt, T. S., Speelman, L., Onyango, G., & Bolton, P. (2009), Psychosocial Problems of War-Affected Youth in Northern Uganda: A Qualitative Study. Transcultural Psychiatry, 46(2), 238–256. Available at http://doi.org/10.1177/1363461509105815
  5.  World Health Organization , MENTAL HEALTH ATLAS 2005: YEMEN 1 (2005), available at http://apps.who.int/globalatlas/predefinedReports/MentalHealth/Files/YE_Mental_Health_Profile.pdf
  6.  Khat is a plant grown in the Arabian Peninsula and the Horn of Africa that is a controlled substance in many countries and is widely used in Yemen as a stimulant for its amphetamine-like properties.
  7.  See, e.g., Nageeb A. Hassan et al., The Effect of Chewing Khat Leaves on Human Mood, 23 SAUDI MED J. 850 (2002); Nabil Numan, Exploration of Adverse Psychological Symptoms in Yemeni Khat Users by the Symptoms Checklist-90 (SCL-90), 101 ADDICTION 616 (2004); Abdullah Alyahri & Robert Goodman, The Prevalence of DSM-IV Psychiatric Disorders Among 7–10 Year Old Yemeni Schoolchildren, 43 SOC. PSYCHIATRY & PSYCHIATRIC EPIDEMIOLOGY 224 (2008).
  8.  Ibid.
  9.  Ibid.
  10.  Yemen remained divided between a northern state and southern state until May 1990, when the current Republic of Yemen was formed after the reunification of the country.
  11.  The clinic functioned as a holding station for detainees who were subject to forced disappearance by the security services; many were sent to al-Salaam Sanatorium following mental collapse due to torture.
  12.  Dr. Jabbari et al., ibid.
  13.  Dr. Jabbari et al., ibid.
  14.  There were two mental health clinics associated with the prisons of Taiz and Sana’a where the hospitals regularly sent their dangerous mentally ill patients.
  15.  Dr. Jabbari et al., ibid.
  16.  Dr. Jabbari et al., ibid.
  17.  Fawziah Al-Ammar interview with a member of the social worker’s union, December 2016.
  18.  Dr. Jabbari et al., ibid.
  19.  Fawziah Al-Ammar interview with Dr. Ali Al-Tarq, the head of the Educational and Psychological Counseling Center at Sana’a University in March 2017; Fawziah Al-Ammar interview with Dr. Mohammed al-Khulaidi, Director, National Program of Mental Health on March 8, 2017; Tawfeek Ganad interview with Dr. Mohammad al-Ashul, a consulting psychiatrist and graduate studies supervisor at the Arab Board of Medical Specialties program within the Faculty of Medicine in Sana’a University, in on January 6, 2017.
  20.  Marwa Najmaldeen, Lost in Yemen’s Streets, YEMEN TIMES (Feb. 20, 2012), http://www.yementimes.com/en/1543/report/278/Lost-in-Yemen’s-streets.htm; Maan A.Bari Qasem Saleh, Psychology in Yemen, 19 PSYCHOL. INT’L. 10 (2008).
  21.  Alzubaidi & Ghanem, supra note 22, at 365.
  22.  Maan A.Bari Qasem Saleh & Ahmed Mohamed Makki, Yemen, in INTERNATIONAL PERSPECTIVES ON MENTAL HEALTH, 236, 237 (Hamid Ghodse ed., 2011).
  23. Ibid.
  24. Fawziah Al-Ammar interview with Dr. Al Ashul, ibid.
  25.  YEMEN MINISTRY OF HEALTH AND POPULATION, YEMEN: NATIONAL MENTAL HEALTH STRATEGY 2011- 2015 53 (Mar. 2010) [hereinafter YEMEN NATIONAL MENTAL HEALTH STRATEGY], available at http://www.sfd-yemen.org/uploads/issues/health%20english-20121015-132757.pdf.
  26.  WORLD HEALTH ORG., MENTAL HEALTH ATLAS 2011: YEMEN (2011), available at http://www.who.int/mental_health/evidence/atlas/profiles/yem_mh_profile.pdf
  27.  WORLD HEALTH ORG., GLOBAL HEALTH OBSERVATORY DATA REPOSITORY (2015), available at http://apps.who.int/gho/data/node.main.MHHR?lang=en
  28.  WORLD HEALTH ORG., MENTAL HEALTH ATLAS COUNTRY PROFILE 2014: YEMEN (2014), available at http://www.who.int/mental_health/evidence/atlas/profiles-2014/yem.pdf?ua=1.
  29.  YEMEN NATIONAL MENTAL HEALTH STRATEGY, supra note 17, at 56.
  30.  Abdulgawi Salim Alzubaidi & Azza Ghanem, Perspectives on Psychology in Yemen, 32 INT’L J. PSYCHOL. 363, 365 (1997).
  31.  Fawziah Al-Ammar interview with Dr. Mohammed al-Khulaidi, supra note 23.
  32.  YEMEN NATIONAL MENTAL HEALTH STRATEGY, supra note 17, at 5.
  33.  Fawziah Al-Ammar interview with officials at the National Program of Mental Health (Mar. 2017).
  34.  Fawziah Al-Ammar interview with Dr. Mohammed al-Khulaidi, supra note 23.
  35.  YEMEN NATIONAL MENTAL HEALTH STRATEGY, supra note 17, at 58.
  36.  YEMEN NATIONAL MENTAL HEALTH STRATEGY, supra note 17, at 5.
  37.  The Directory of General Psychiatry and Pediatric Psychiatry for Primary Health Care Physicians was drawn up under the financing and supervision of the Social Fund for Development, in collaboration with the Ministry of Public Health and Population of Yemen (Primary Health Care Sector); Maan A.Bari Qasem Saleh, Mental Health in Yemen Obstacles & Challenges 14 (2013) (slideshow presentation), http://slideplayer.com/slide/679600.
  38.  Maan A.Bari Qasem Saleh & Ahmed Mohamed Makki, Mental Health in Yemen: Obstacles & Challenges, 5 INT’L PSYCHIATRY 90, 91 (2008).
  39.  Ali al-Mujahed & Hugh Naylor, Yemen Conflict: Doctors Warn of Crisis as Medical Supplies Run Low, GUARDIAN (June 2, 2015), https://www.theguardian.com/world/2015/jun/02/yemen-conflict-healthcare-crisis-medicalsupplies-run-low.
  40.  WHO: Urgent Support Needed to Provide Health Services for 15 million People in Yemen, WORLD HEALTH ORG. (Dec. 15, 2015), http://www.emro.who.int/media/news/support-needed-to-provide-health-services-in-yemen.html.
  41.  Anne Gulland, WHO Condemns Attacks on Healthcare Workers in Yemen, BMJ (May 28, 2015), http://www.bmj.com/content/bmj/350/bmj.h2914.full.pdf; also see UNFPA Response in Yemen: Monthly Situation Report #06 – June 2017 (June 30 2017), http://reliefweb.int/report/yemen/unfpa-response-yemen-monthly-situation-report-06-june-2017
  42.  Dale Gavlak, Health System in Yemen Close to Collapse, 93 BULL. WORLD HEALTH ORG. 670, 670 (2015).
  43.  Survey Reveals Extent of Damage to Yemen’s Health System, WORLD HEALTH ORG. (Nov. 6, 2016), http://www.emro.who.int/media/news/survey-reveals-extent-of-damage-to-yemens-health-system.html.
  44.  Ibid.
  45.  Ibid.
  46.  S Al-Wesabi, Insecurity Drives Health Workers Out of Yemen, WHO YEMEN (Jan. 2016), http://www.who.int/features/2016/yemen-health-insecurity/en.
  47.  Fawziah Al-Ammar interview with Dr. Mohammed al-Khulaidi, Director, National Program of Mental Health on December 15, 2016.
  48.  Al-Wesabi, supra note 41.
  49.  N Al-Sakkaf, The Psychological Cost of Yemen’s War, AL JAZEERA, (June 25, 2015), http://www.aljazeera.com/news/2015/06/psychological-cost-yemen-war-150618112244630.html.
  50.  The Ministry of Health in collaboration with the Central Bureau of Statistics in Yemen, the National Demographic Health Survey 2013.
  51.  Yemen Humanitarian Bulletin Issue 25, UN OCHA, (July 16, 2017), http://reliefweb.int/report/yemen/yemen-humanitarian-bulletin-issue-25-16-july-2017
  52. YEMEN RESPONSE PLAN 2017, supra note 3, at 6-7; also see UNICEF, Statement from UNICEF Executive Director Anthony Lake and WHO Director-General Margaret Chan on the cholera outbreak in Yemen as suspected cases exceed 200,000, (June 24, 2017), https://www.unicef.org/media/media_96544.html.
  53.  INTEGRATED FOOD SEC. PHASE CLASSIFICATION (IPC), YEMEN: PROJECTED ACUTE FOOD INSECURITY SITUATION – MARCH-JULY 2017 1 (Mar. 1, 2017), available at http://www.ipcinfo.org/fileadmin/user_upload/ipcinfo/docs/IPC_Yemen_AcuteFI_Situation_MarchJuly2017_ENversion.pdf.
  54.  Yemen cholera outbreak could hit one million by 2018, Al Jazeera, September 29, http://www.aljazeera.com/news/2017/09/yemen-cholera-outbreak-hit-million-2018-170929140409261.html
  55.  Tawfeek Ganad interview with Dr. Mohammad al-Ashul on January 6, 2017.  
  56.  Yemen Humanitarian Snapshot, supra note 3.
  57.  Yemen: U.N. Verifies Nearly 1,500 Boys Recruited for Use in Armed Conflict, U.N. NEWS CENTRE (Feb. 28, 2017), http://www.un.org/apps/news/story.asp?NewsID=56255#.WNdHJBIrJn4.
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