Sana'a - Mohammed Al-Hassani
Walking through her school in Sa’wan, north of the Yemni capital of Sana’a, 11-year-old Zainab can almost hear her father again, almost see him still in this classroom teaching. She cannot believe still that she has lost him to a dig bite.
Saleh Majli Hammoud, 43, died a year ago some 50 days after a dog bit his right hand. During 10 days immediately after the attack, he was transferred six times and eventually to the Rabies Control Unit at the Republican Government Hospital, the only center in Sana’a that treats rabies. But it was closed.
According to a spokesperson for the National Rabies Program, the unit shut down from for about two months from Jan. 27, through March 22, 2018 due to the lack of financial allocations, serums, and vaccines needed for treatments.
During the intermittent periods that the Rabies Control Unit operated over 2017 - 2018, it admitted more than 7,000 patients. According to Mokhtar Abdel Nour, deputy director of the Department of Stray Dogs and head of the Cleaning Project Initiative of the capital’s Municipality, the number of rabies cases is increasing as more than 70,000 dogs run through the streets of Sana'a. The National Rabies Program in the Ministry of Public Health and Population, launched in 1990, the Department of Stray Dogs Control in the Municipality of the capital, and the Veterinary Laboratory of the Ministry of Agriculture and Irrigation all are doing less.
Hamoud went untreated for 51 days. A month after the attack, he began vomiting and showed an intense fear of light and water, aggressive behavior and imsonia. He experienced involuntary contractions of the nerves, all classic symptoms of rabies. His family tried to buy serums and vaccines, but pharmacies, which depend on private companies to import them, had little.
A field survey of 53 pharmacies in Sanaa found just three, all in the center of the city, that had rabies serum. Prices ranged up to 25,000 riyals (circa US $50), which is about half the average monthly salary in the country. The vaccine is available at prices ranging between 8,000 and 13,000 riyals. According to the National Rabies Program, these serums and vaccines are supposed to be administered for free.
Pharmacist Mansur Hassan, the procurement officer at Sam City Pharmacies, explained that during 2017-2018 demand for rabies treatment jump 300 percent.
Tamish Saleh Tamish, an on-call doctor at the Khirbet Medical Center near Sawan, mentioned that the family got Hamoud an anti-tetanus dose, immediately following his attack, to prevent bacterial contamination in the affected area. He also noted that Hamoud was finally transferred on April 1 to the Rabies Control Unit.
On that day, Zainab was not reassured. She was watching her father’s symptoms intensify. “When my dad began fearing water and light, I was prevented from seeing him,” she said sorrowfully..
Tamish said: “Upon arrival, the Rabies Control United refused to formally admit him, given that case was in the advanced stages. He died three hours after.”
According to the Rabies Control Unit, 7,356 people were diagnosed with the disease during 2017-2018, and 27 died. In the last year alone, 4,214 cases were registered, and 15 patients died.
Data show that 82 percent of patients infected with rabies were males and 18 percent females. Children under 15 accounted for 52.5 percent of the cases.
Annual reports of the National Rabies Program of the Ministry of Public Health and Population during the period of the program 1990 -2018 revealed an increase in the number of rabies victims. The figures show an annual increase of 17.3 percent and 18 percent for injuries and deaths over the pre-war period. Looking just at the period of the war from 2015=2018, there’s been a 29.37 percnent hik in injuries and 24.5 percent rise in rabies-related deaths.
Neurosurgeon Jamal Mohammed al-Shami at Sanaa Republican Hospital explains that ravies is a viral infectious disease that causes severe even deadly brain inflammation.
Muhammad Ali Ezz-Alddin, 9, was attacked by a dog Aug. 8, 2017, while riding his bike near his family home in Bani Hashish, north of Sana'a. He was attacked in the foot and chest and his mother was bitten on her hand when she tried to save him.
The two were taken to the Rabies Control Unit, but there was no serum to treat them. The head of the family, Ali Ezz-Alddin, 35, was forced to buy the serum for 22,000 riyals (about USD 44) from a pharmacy outside of the Hospital. Of the seven doses of vaccine prescribed for each patient, the family received only two doses for free and had to buy the rest for 130,000 riyals (circa USD 260).
Mukhtar Abdel Nour, deputy director of the Department of Stray Dogs Control in the Municipality's cleaning project, estimated that there were around 70,000 stray dogs in 2017 and the number is increasing.
"Every year we carried out three to four intensive campaigns to eradicate stray dogs,” he added. The last was in 2014, when more than 25,000 stray dogs were eliminated. "Then the administration stopped working because the budget was suspended and the price of dog toxins rose from 170,000 riyals to 1 million per kilogram."
The Rabies Control Unit is actually a 2-by-5-meter room with a refrigerator at the back to store vaccines and serums, a registration desk, and six seats in a waiting area where patients receive the serums and vaccines before heading home.
Warning: This photo contains violent content.
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Warning: This photo contains violent content.
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Daily, 50 to 70 patients bitten by stray dogs come into the unit, of which nearly 20 a day are new cases. The unit also receives cases from the provinces around the capital, namely, Al-Mahweet, Amran, and Hajja, as well as the capital's municipality and the Sana'a governorate, which includes Sa'wan, where Majali and his daughter Zeinab used to live.
There are similar units in the provinces surrounding the capital; however, given operations there are inconsistent.
Notwithstanding the above, during 2015-2018, the capital’s Rabies Control Unit was closed four times due to the lack of serums and vaccines. The following was due to the suspension of the operational budget since 2015. Therefore, according to Dr. Abdo Saleh Ghorab, the Rabies Control Unit imposed an operational fee, per application, amounting to 250 riyals (about USD 50 cents). That fee was for staff working the unit.
Ghorab said that following the war, the unit's financial support and the provision of serums and vaccines from the National Rabies Program halted. The unit has become increasingly dependent on health organizations working in Yemen to provide the vaccines, he said, and provision of vaccines is discontinued for long periods of up to five months. He said serums were not available at the unit for two years, as the focus is on obtaining the vaccines from the health organizations and serums are purchased from commercial pharmacies.
He added that the work of the unit has been limited to 8 a,m. to 1 p.m. due to the lack of sufficient medical staff with the suspension of salaries. The crew consists of just two staff members compared to five before the war.
Even basic clinical needs such as proper ventilation, laundries, medical equipment, and beds are in short supply or missing.
Budget Cuts and Staff Migration
National Rabies Control Program reports show that the municipality of the capital is the third governorate in the number of casualties in Yemen after the governorate of Dhamar and Ibb. The percentages are 25.6 percent for the municipality of the capital, 25.8 percent for the governorate of Ibb, and 33 percent for Dhamar governorate.
Ahmed Hassan Al-Ward, program director at the Ministry of Public Health and Population explained that the role of the Program is to support the Rabies Control Units by providing emergency and educational services; however, it has been stopped because of the war and the budget cuts.
He said: "The State was providing 95 percent of the budget and the remaining 5 percent was provided by the World Health Organization, and cumulatively amounted to 63 million riyals per year (about USD 120,000 ). The Program requires 30,000 doses of vaccines annually, he added. "We made a plea to the health organizations operating in Yemen, and we received no response except for the World Health Organization, which provided 3,900 doses of vaccines," just 13 percent of the needed percentage.
He attributed the increase in cases in Sana’a to a 100 percent increase in the number of stray dogs between 2014 – 2018. In addition, the capital has been receiving cases from other provinces.
"Unfortunately, we are unable to commit to providing vaccines, serums, and staff salaries," he said. Along with the cuts to the budget and salaries, we need to also consider the increased migration of staff working with the program.
According to Ahmed, 20 percent of the staff moved during the war.
"I and a group of my colleagues have moved to other programs such as cholera, diphtheria, menopause, and other programs receiving material and moral support from the Ministry and health organizations operating in Yemen," said Ahmed Mohammed, 32, a staff member .
Dr. Youssef Al-Hazzari, spokesman for the Ministry of Health in Sana'a, said that the program depended on government support, which was stopped by war and the siege of Yemen. "They should work on other programs as it is a better alternative than having them stop work altogether," he ssaid.
Another Side of the Problem
Resources available for serums and vaccines have also been wasted through misdiagnosis of rabies. There are instances in which ill-equipped laboratories have been too quick to diagnose rabies in cases where the disease is not present and these patients end up getting treating with serums that that don’t actually need
Since mid-2015, the Veterinary Laboratory of the General Administration of Animal Health of the Ministry of Agriculture and Irrigation has lacked Globin pigmentation. Needed to diagnose rabies cases. Aqeel al-Mutawakil, director, said the lab only records samples and provides positive results for all because they cannot properly examine them..
"I do not have the pigment and there is no alternative solution,” he said. Ttherefore, I give the vaccine even if the condition is negative."
The vaccine does not harm patients, even if his/her condition is negative, because its role is to activate the immune system. He added that since 2015, the laboratory has completely stopped its diagnostic role.
Program Director Dr. Ahmed Al-Ward attributed the suspension of pigments and support from the laboratory to the suspension of the Ministry's budget. For his part, Mahmoud Al-Bahari, deputy director General of the associations and organizations in the Social Affairs and Labor Office at the the capital’s municipality, stressed that the organizations stopped supporting the national rabies control program, the anti-dermatological units, and the veterinary laboratory.
Notwithstanding, Dr. Abdel Nasser Al-Rubai, Director of World Health Organization Epidemiological Surveillance Department, said the rabies epidemic is part of the organization's programs and its grants. Moreover, the World Health Organization is taking requests from the Ministry of Health represented by the National Rabies Program seriously. However, he states that the serums and vaccines are not readily available in the local market and importing them takes time. The organization gave its last grant to the program in May of last year.
"The program is completely paralyzed. We were not doing anything but sitting on our chairs," said Ahmed Mohammed, 32, a former employee.
Zeinab sits in her classroom, and every day she draws new hearts pierced by the arrow of love in the margins of her books and on the pages of pamphlets. "Love my father" she writes next to the hearts.
This investigation was completed with the support of Arab Reporters for Investigative Journalism (ARIJ) www.arij.net and under the supervision of Khaled Elharougy