Where the Light Enters: Reflections on the fight against COVID-19 in war-torn Yemen

Intensivists are trained pragmatists. Our work is highly cerebral yet very clinical. I wasn’t a novice to suffering or death, encountering this daily in the time I’ve worked in the intensive care unit (ICU) in Sydney. What was hard to swallow was the volume I was exposed to in Yemen at the height of the first wave of COVID-19 in the country, a relentless stream of misery and loss, without reprieve. With each death it felt like a piece of me died too. Over time my heart felt, not unlike when you fall asleep on your arm, a heavy, detached limb, which you try to massage back to life. 

The eye of the storm

I was part of the team working in a COVID-19 treatment centre run by Médecins Sans Frontières / Doctors Without Borders (MSF). The daily ward round in our hospital felt punishing to a degree I’ve never experienced before. Row upon row of patients suffocating, gasping for breath and groaning with distress. A cacophony of voices from our Yemeni doctors and nurses yelling “Oxygen! Oxygen!” and our team of porters rushing to the bedsides of patients to change over empty oxygen cylinders.

In Aden, Yemen, we were in the eye of the storm, the COVID-19 treatment centre bursting at the seams. Fear of the virus had permeated through Aden city and other hospitals refused to treat any patients with respiratory symptoms.

With nowhere else to turn, many travelled hours to get to our facility, an hour’s drive from the heart of the city. We had 32 beds in our inpatient unit and a seven-bed ICU, which filled within days of opening.

Limited supplies

Limited access to essential drugs and equipment created immense difficulties. Our team desperately tried to source supplies: nearly impossible with the grounding of flights and the closure of many international borders. With no access to liquid oxygen, we had to use bulky oxygen cylinders, more than 250 per day, to treat the patients.

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

Critical decisions

The distress our patients experienced was palpable, words expressed in short bursts of Arabic: “Doctor I can’t breathe; When will I get better? Please help me.”

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

“What do you think of bed 21?” asks my colleague, a Canadian intensivist, who I worked with in the treatment centre. The patient was a young guy in his thirties, only a few years older than I am, who had a history of hypertension and obesity.

“Oxygen saturation 70 per cent on the Special.” The Canadian had coined this term, the Special. It was a combination of nasal prongs and a reservoir oxygen mask, which we used concurrently to deliver 30 litres of oxygen to patients. It was a crude attempt to increase the oxygen flow for patients in extremis, when they did not have access to the higher level of care an ICU offered. 

“What about the patient in bed six?” I asked in return, “Male, forties, with no co-morbidities, Sats 65 per cent on the Special. No improvement with proning.”

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

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

In the end, both men died. The older one in ICU, where he developed a secondary infection, a common complication. The infection caused his kidneys and heart to fail; we had no access to dialysis and only rudimentary drugs to manage his heart failure.

The man in his thirties died on the ward, within days of his admission. All the ventilators were in use and he died of hypoxia.

For reasons still unknown, the hypoxia associated with COVID is tolerated for far longer than in any other illness, so a slow death occurs over days, rather than within minutes. Men and women drowning on dry land, desperate for air. With my years of knowledge and training, I felt useless without resources. I could only offer my hand to hold theirs and a prayer to recite under my breath. It didn’t feel enough.

Solace

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

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

Still some patients made their mark.

A woman in her late seventies, breathless as many of the others, deteriorating even with the maximum treatment we could offer her. When I went to reposition her oxygen mask I noticed how lucid she was despite her condition. As I moved to walk away, forlorn, she laid a trembling hand on my shoulder. She looked at me with clear eyes and smiled so brightly. As if she knew her time had come, and to tell me it was okay. It was a gesture so full of meaning it broke me. In that moment I felt so humbled, that I was being comforted, when I had no comfort to spare her.

The one dying gave solace to the one living.

Mourning

I found myself in a strange place emotionally after that encounter. Like my colleagues, I was exhausted from the long hours, but even sleep couldn’t replenish my depleted tank. A deep weariness set in.

I’d spend time sitting alone in my room, tears streaming. It felt like the darkness I had been witnessing had found its place in my heart. In those moments I mourned; for the lives lost, for the ones pleading to live and the ones still to come.

My mind was filled with bleak thoughts: What are we doing here? Why do we carry on when things feel so futile? Am I just here to watch all these people die?

Moments of triumph

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

It was hard to escape from the virus taking over every aspect of our lives in the field, but we tried our best. A stray kitten rescued outside our compound became our mascot. Somewhat ironically, I called her Covid the Cat and the name stuck. We showered her with love and in return she gave us joy and helped us face each day, one unsteady step forward at a time.

As the weeks progressed things began to take a turn for the better. Further reinforcements from our headquarters brought more expertise on the ground, our teams gained more experience at fighting this virus, we standardised our care, and our access to supplies improved. Slowly it felt like the breath we had been holding in could finally be exhaled.

I was redeployed to MSF’s Trauma Hospital in Aden. Treating the injured and the war-wounded carried its own challenges, but the change of pace was welcome.

Looking back

War is horrendous. Add COVID-19 to the mix and the result is devastation. I was a temporary guest in Yemen, bearing witness to the awful situation they were facing. I was privileged to work alongside many Yemeni doctors, nurses, porters and many others, who are still in Aden, continuing to provide vital healthcare in difficult circumstances. I was struck many times by their stubborn refusal to accept the status quo, their fight to make things better each day, and the hope and love many of them expressed for their people and their land.

I learnt many lessons during my time in Yemen. I understand now that the value of the work isn’t just in knowing how to use a ventilator. The value is also showing up and being present, bearing witness. I learnt that time spent caring for others is never wasted, and that the smallest grain of hope is enough to carry you through the darkest of days.

Ultimately, I left Yemen deeply inspired by my colleagues and patients, to try to serve others, to be kind and brave, and to remain hopeful, even when the world seems to be without hope.