The Right to Mental Health in Yemen: A Distressed and Ignored Foundation for Peace

Volume 23/1, June 2021, pp. 43-53

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Waleed Alhariri, Amanda McNally, and Sarah Knuckey

Abstract

Mental health issues are all too common consequences of conflict and atrocity crimes, often causing upwards of one-quarter of the postconflict, post-atrocity population to suffer from physical and mental sequelae that linger long after weapons have been silenced. After more than six years of ongoing conflict, Yemen’s already weak health care system is on the brink of collapse, and population resilience has been severely stressed by indiscriminate attacks, airstrikes, torture, food insecurity, unemployment, cholera, and now the COVID-19 pandemic. This paper examines Yemen’s responsibilities regarding the right to mental health and details the few actions the government has taken to date toward fulfilling this right. It also presents the current status of mental health care in Yemen, discussing some of the barriers to accessing the available care, as well as alternative models of mental health support being used by the population. In light of the pandemic presently facing the world, the paper also discusses COVID-19’s impact on Yemen, detailing its further degrading effects on the country’s health care system and people’s mental health. Finally, the paper highlights the importance of addressing mental health in furtherance of the peace process.

Introduction

Yemen’s fragile postrevolution transition was derailed by the Houthi movement’s September 2014 takeover of the capital Sana’a and the subsequent military intervention by a Saudi- and Emirati-led coalition in March 2015. The ensuing war and its nearly 50 active frontlines has effectively fragmented the country; 80% of the population of 30.8 million lives in Houthi-controlled northern governorates, while government forces, the secessionist Southern Transitional Council, and militias split fluctuating control of the south.^[1] Parties to the conflict have engaged in indiscriminate shelling, disproportionate airstrikes, obstruction of humanitarian relief, laying of landmines, recruitment of child soldiers, torture, arbitrary detention, and attacks on health care facilities.^[2] This violence has directly killed or injured over 20,000 civilians, and combined with the resultant humanitarian catastrophe—regularly cited as the world’s worst humanitarian crisis of our time—the war has killed an estimated 233,000 Yemenis.^[3] Four million Yemenis have been displaced, over 2.5 million have had cholera in the world’s worst epidemic on record, at least 85,000 children have died of starvation, and 2.5 million children under the age of five are projected to suffer from acute malnutrition in 2021.^[4] The COVID-19 pandemic has only further exacerbated this dire situation.

For over six years, Yemenis have been continuously exposed to these stressors and harms, in addition to widespread economic insecurity, fractured social ties, poverty, the absence of basic services, and government neglect.^[5] The World Health Organization estimates that, 22% of the world’s conflict-affected populations will suffer from a mental disorder, such as depression, anxiety, bipolar disorder, posttraumatic stress disorder, and schizophrenia.^[6] In Yemen, where the average 25-year-old has already lived through 14 armed conflicts, an estimated 19.5% of the population suffers from mental disorders, most prevalently anxiety, depression, trauma, and schizophrenia.^[7] Children have been particularly affected; studies have found that 55% of children are sad or depressed, 19% of children are always fearful, and 79% of school-aged children in Sana’a report symptoms of posttraumatic stress disorder.^[8]

The country’s already weak health care system has been further deteriorated by the conflict and is unable to meet the demands of this potential mental health crisis. Only 51% of all health facilities are fully functional, health care workers’ salaries have gone largely unpaid, and essential medications are in short supply.^[9] Mental health care is further burdened by a pervasive stigma that discourages specialized training by medical students and complicates people’s willingness to access the few mental health resources that do exist.^[10] Many Yemenis turn to traditional healers, local sheikhs, and other community leaders for mental health support.

Before the most recent war, the Yemeni government largely ignored its legal responsibilities to respect, protect, and fulfill the right to mental health. The corruption, poverty, and disinterest that prevailed then have only been exacerbated and compounded by six years of war. Continued failure to realize the right to mental health for Yemenis, however, may have damaging effects for the ongoing peace process and future stability.

Mental health obligations of the government of Yemen and the international community under international law

The right to mental health has increasingly been recognized as an integral part of the right to health, which is enshrined in human rights instruments such as the International Covenant on Economic, Social and Cultural Rights (art. 12), the Convention on the Rights of the Child (art. 24), and the Convention on the Rights of Persons with Disabilities (art. 25)—all of which have been ratified by Yemen.^[11] The International Covenant on Economic, Social and Cultural Rights contains the most explicit validation of the right to mental health in international human rights law by recognizing the “right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”^[12]

As a party to these treaties, the Yemeni government is obligated to respect, protect, and fulfil the right to mental health, including by refraining from interfering with the right and by ensuring that third parties (such as hospitals and residential treatment centers) do not violate this right. Through ratification, the government of Yemen has also committed to “adopt[ing] appropriate legislative, administrative, budgetary, judicial, promotional and other measures towards the full realization of the right to health.”^[13] Additionally, the International Covenant on Economic, Social and Cultural Rights outlines that mental health facilities, goods (including essential medicines), and services must be available, accessible, acceptable, of good quality, and provided without discrimination.^[14]

Of course, the fulfillment of economic and social rights, including the right to mental health, can take time and resources to achieve. The covenant, therefore, calls for the progressive realization of these rights.^[15] Progressive realization, however, does not release Yemen of its obligations to respect, protect, and fulfill the right to mental health equally and without discrimination. Rather, “progressive realization means that States parties have a specific and continuing obligation to move as expeditiously and effectively as possible towards full realization.”^[16] Additionally, Yemen must meet non-negotiable minimum core obligations, including the obligations to ensure the right of access to health facilities, goods, and services on a nondiscriminatory basis; to ensure access to the underlying determinants of mental health (including minimum essential food, basic shelter, housing, and sanitation, and an adequate supply of safe, potable water); to adopt and implement a national mental health strategy; and to monitor the progress made toward realizing the right to mental health.^[17]

There is also an obligation of international cooperation for the realization of the right to mental health recognized in articles 55 and 56 of the Charter of the United Nations, in international law principles, and within the International Covenant on Economic, Social and Cultural Rights.^[18] The Committee on Economic, Social and Cultural Rights has emphasized that it is “incumbent upon those States which are in a position to assist others” in the realization of the rights do so.^[19] This is reinforced by the commitment to global partnership in working toward the Sustainable Development Goals.^[20] Goal 3 is to “ensure healthy lives and promote well-being for all at all ages,” and includes target 3.4, which requests that countries “reduce by one third premature mortality from noncommunicable diseases through prevention and treatment and promote mental health and well-being” by 2030.^[21] Therefore, the international community should also take steps to assist in fulfilling the Yemeni people’s right to mental health.

Evolution of mental health care in Yemen

Yemen’s record in taking steps toward the progressive realization of the right to mental health in the country is brief. The first psychiatric sanatorium was established in Aden in 1966, when southern Yemen was still a British colony. The sanatorium’s rooms resembled jail cells, and the facility received its patients from nearby prisons. Prior to 1966, psychiatric patients were kept in prison among other prisoners without formal mental health services.^[22] In the 1970s, a clinic opened in Al Jumhurriyya Hospital in Sana’a, and later, a modern 208-bed psychiatric hospital was built in Aden, funded by the Kuwaiti government.^[23]

In an effort to create a national foundation for psychiatric practice, in the 1980s the World Health Organization helped establish psychiatric clinics in three hospitals (in the cities of Sana’a, Taiz, and Hudaydah), trained local doctors, and provided basic equipment, including electric shock therapy machines.^[24] In the late 1980s and early 1990s, a national mental health program was established by ministerial resolution and administered within the primary care division of the Ministry of Public Health and Population that was established following the unification of the north and south of Yemen. This program sought to improve treatment in mental health hospitals and ensure that patients were cared for by qualified psychiatrists.^[25]

In the early 2000s, the International Committee of the Red Cross sponsored two national workshops on mental health, which resulted in the government’s drafting of a national mental health strategy in 2004.^[26] The draft strategy sought to promote mental health awareness among the Yemeni population and improve access to mental health care.^[27] Following this draft, legislators proposed before Parliament a Mental Health Act based on the draft strategy.^[28] According to the 2011–2015 National Mental Health Strategy, the proposed law addressed definitions and mechanisms to address mental health care.^[29] However, the bill failed in part because it was vague in terms of its definitions and concepts.^[30] But a larger factor was that officials did not see mental health as a political priority.

In 2007, the Ministry of Public Health and Population amended the 2004 proposed mental health legislation.^[31] The amended law was more comprehensive; it better defined mental health, included requirements for treatment, widened the range of patients’ rights available, and set punishments for negligent treatment.^[32] The amended legislation, however, was not referred to Parliament.^[33] As explained by Muteei Jubayr, an official in charge of drafting laws at the Ministry of Legal Affairs, there has been no further action “because it is neither a political nor a popular issue.”^[34] Jamed Juneid, deputy health minister, has further explained that “unfortunately, psychiatric disorders are not a priority … [a]nd relevant health services including therapy sessions and medicines are limited.”^[35] Many officials from the Ministry of Public Health and Population and the Parliament’s Committee on Health and Population have not even seen the draft legislation, and there has been no follow up from the Ministry of Public Health and Population.

In 2010, the Ministry of Public Health and Population and the Social Development Fund, a nongovernmental organization supporting development opportunities and building capacities at the national level, adopted the National Mental Health Strategy for 2011–2015.^[36] The strategy included steps to promote mental health, improve the treatment of disorders, and address stigma and discrimination through community mobilization. The strategy sought to develop destigmatizing media campaigns using well-known public figures, identify nongovernmental organizations that could assist in providing mental health services, and begin dialogues with religious and traditional healers on the reduction of harmful treatment practices.^[37] In the period in which it was to be implemented, however, Yemen witnessed a popular uprising, and the subsequent unrest led to the abandonment of the strategy.

The most progressive move toward recognizing mental health as a serious health issue was witnessed during the 2013–2014 National Dialogue Conference (NDC)—a transitional dialogue process facilitated by the United Nations (UN) and sponsored by the 2011 Gulf Cooperation Council Initiative for Yemen—and the 2015 constitution draft that resulted. The NDC outcomes proposed

working to strengthen personal health and its importance to general health by creating the appropriate infrastructure for mental health services to be provided in hospitals in the major cities, the capitals of the governorates, and throughout the country. The necessary funding should be provided for mental health services, and the cadres working in this field should be trained.^[38]

NDC outcomes further called for the prioritization of “mental health programs for children and youth, and a personal health program in schools.”^[39] The draft constitution took into account these recommendations and, in a major breakthrough, dedicated a constitutional article to Yemenis’ right to physical, mental, and psychological integrity.^[40] The draft constitution also emphasized the prevention of potential mental health impacts on children by prohibiting children’s employment “in jobs that expose their physical, mental or psychological integrity to danger.”^[41]

Before the adoption of the NDC outcomes and the draft constitution, conflict broke out and the Houthi rebels took control over state institutions in a coup against the internationally recognized and regionally backed President Abdo Rabbu Mansour Hadi. The Houthi rebels took advantage of weak and corrupt leadership, as well as a transitional process based on a Gulf Cooperation Council agreement mired with flaws and the misguided interference of local power brokers and the international community.[42] The agreement included an unconditional immunity for former President Ali Saleh, his family, and his inner circle, which Saleh later used to maintain a political role as head of the General People’s Congress ruling party. The majority of the party’s officials and supporters, who were present in all state institutions, remained loyal to Saleh and helped him orchestrate an alliance of convenience with the Houthi rebels to overturn the transitional process in the hope that Saleh and his family would rule again.

Later in the conflict, the Houthi rebels clashed with Saleh, ultimately killing him and consolidating their power. At the time of this writing, the conflict continues unabated, and, as a result, governmental concern for mental health has fallen to the wayside.

By and large, mental health policy in Yemen is still being developed and requires “support in both human and material resources as well as the development of a database of resources, statistics and epidemiological information.”^[43] Notably, current laws in Yemen do not reference mental health.

Current mental health care services in Yemen

The lack of a mental health care policy at the national level has translated into few and poor-quality mental health services throughout the country. These services have become scarcer and poorer in quality during the conflict and accompanying humanitarian crisis, which have included systematic and widespread atrocity crimes perpetrated against the civilian population.^[44] Mental health is not integrated into the primary health care system, and many Yemenis are unable to access mental health treatment when they first make contact with the health care system. A recent assessment, for example, found that only 10% of primary health facilities in Yemen had staff trained in the identification or treatment of mental health disorders.^[45] Considering that 30.6% of the population lives more than 30 minutes from the nearest functioning primary health facility, it is likely that only a concerningly low number of Yemenis receive mental health treatment from primary care facilities.^[46]

Shockingly few specialized resources exist for the population of 30.8 million. There are only four psychiatric hospitals in Yemen—one located in each of the four most populous governorates of Sana’a, Aden, Hudaydah, and Taiz.^[47] Yemen’s Ministry of Public Health and Population recently reported that there are also 7 outpatient psychiatric clinics in public hospitals, 5 private psychiatric hospitals, 34 private mental health clinics, and 3 residential psychiatric treatment centers.^[48] There are also mental health clinics in the central prisons of Sana’a and Taiz. The Family Counseling and Development Foundation has only recently established Yemen’s first and only specialized mental health clinic for children.^[49] These few available hospitals and clinics, moreover, are suffering from a shortage of qualified staff; there are only an estimated 130 trained therapists, and the number of psychiatrists in the entire country does not exceed 59.^[50] These numbers indicate there has been little progress in building the cadre of mental health professionals in Yemen, as in 2010, there were an estimated 44 psychiatrists.^[51] Though the number of psychiatrists is on par with many conflict-affected countries in the region—in 2007, Iraq, Libya, Somalia, Sudan, and Syria also had fewer than 0.5 psychiatrists available per 100,000 persons—Yemeni mental health professionals have indicated that they believe the number to be inadequate for the needs of the Yemeni population.^[52]

The quality of care provided by the country’s mental health services is at times suspect and deeply impacted by a shortage of staff and a lack of funding. A pervasive practice within the community, the shackling of persons with mental health disorders, even takes place in some mental health facilities.^[53] In early 2021, a reporter visiting the Taiz mental health hospital found that many of the facility’s patients were heavily sedated and shackled to “stop them from escaping.”^[54] Only two nurses were responsible for caring for the hospital’s 143 inpatients, some of whom sat in urine-soaked clothing. The hospital receives enough funding to buy only a quarter of the medications needed to manage its patients; this reflects a common problem, as 75% of Yemen’s health facilities report never having essential psychotropic medications available.^[55]

Improvements in the quantity and quality of available mental health services in Yemen will be difficult in the immediate future if the current funding crisis continues. The UN—a main donor of the Ministry of Public Health and Population—has raised less than half of the US$3.85 billion necessary to fully fund the 2021 Humanitarian Response Plan for Yemen.^[56] This, combined with the similarly large shortfall in 2020, has led to the shuttering of existing services. In 2020, the United Nations Population Fund had to withdraw funding from the Taiz mental health hospital and closed 80 of the 180 health care facilities it supports, including some providing psychosocial services.^[57] The funding crisis has further diverted focus away from mental health care and toward emergency lifesaving treatment. ^[58] Yemen’s Deputy Public Health Minister Ishraq al-Subaie has acknowledged that “efforts have been focused on rebuilding hospitals, treating the war-wounded and addressing reproductive healthcare … Mental health has been completely neglected.”^[59]

Pandemic-related stressors

Public health emergencies, including health pandemics, are often more severe in conflict zones. Yemen in particular has been dealing with a number of outbreaks, with alarming numbers of individual cases associated with cholera and, more recently, COVID-19. In late 2016, health authorities announced a cholera outbreak, primarily resulting from old unmaintained sewage systems and heavy rains; the outbreak has led to over 2.5 million suspected cholera cases and nearly 4,000 deaths.^[60] As it still struggled to contain the cholera epidemic, Yemen recorded its first positive COVID-19 test in April 2020.^[61] Reported positive cases subsequently increased exponentially, quickly overwhelming the health care system. As of May 20, 2021, there were 6,587 confirmed cases of COVID-19 and 1,299 deaths in Yemen, with many cases and deaths going unrecorded due to political interference and the lack of testing.^[62]

The response to these public health outbreaks in Yemen has been left largely to international organizations such as the World Health Organization, Médecins Sans Frontières, and UNICEF.^[63] With minimal resources and without the authority to enforce restrictions on gathering in public spaces, international organizations are severely hamstrung in their ability to deal with the pandemic. Local authorities have attempted to absolve themselves of responsibility and have neglected and undermined public health efforts by continuing military clashes which have created additional hardships for civilians and increased pressure on health facilities. At the onset of the COVID-19 pandemic, in the north of Yemen, authorities in Houthi-rebel-held areas suppressed information on COVID-19 cases and did not implement public health measures to prevent or contain the spread.^[64] Meanwhile, the internationally recognized government in the south enacted restrictions without interventions intended to ease the economic hardship created by the pandemic.^[65] Warring parties have continued fighting on a number of frontlines, which goes against the spirit of responsible leadership and the UN Secretary-General’s plea for a global ceasefire in conflict areas. In particular, the Secretary-General has called on warring parties to declare a nationwide ceasefire in order to focus efforts on combating the spread of COVID-19.^[66]

The UN has additionally urged governments worldwide to take measures to protect the most vulnerable—including health care workers, young people, and those with preexisting mental health conditions—from the mental health impacts brought on by COVID-19.^[67] COVID-19 has added new stressors to vulnerable populations worldwide; in Yemen, job loss and decreases in remittances have greatly magnified economic suffering.^[68] Fear of becoming ill, worry about the lack of available health services, and increased social isolation have added to the stress of Yemen individuals, families, and communities.^[69] With a severely weakened health care system now overburdened with COVID-19 and decreased international funding to Yemen, little has been done to address these added stressors.^[70]

Superstition and stigma further complicate mental health care access

In Yemen, mental health disorders have traditionally been associated with “myth, superstition, witchcraft and jinn (spirits),” and the topic of mental health is generally stigmatized and taboo.^[71] Many Yemenis might describe those seeking mental health support as “not normal,” “not stable,” “possessed by some kind of demon or jinn,” “crazy,” or “far from God.”^[72] Persons with mental health concerns are often considered dangerous, with accounts of crimes committed by persons with mental illness circulated on social media.^[73] This stigma has contributed to a belief that mental health hospitals are only for people who are out of control and that persons with mental health needs should be kept apart from the rest of society.^[74] Accordingly, many Yemenis turn to community-based or superstitious remedies (such as witchcraft) before seeking medical treatment.

Coping in the state’s absence

Turning to traditional healers, sheikhs, and other community and religious leaders for support for mental health conditions is one way by which Yemenis have sought to cope with the lack of services and information provided by the state.^[75] Formal psychiatric treatment is often sought only for severe cases of schizophrenia or psychosis.^[76] Instead, wallies, or traditional healers, are often the primary caretakers for people suffering from mental health conditions; these healers combine religion, hypnotism, suggestion, and native herbal medicine in the treatments they offer.^[77]

Social solidarity, or a sense of community interconnectedness, is an extremely important coping mechanism in Yemen. With deteriorating state institutions, private individuals help one another; namely, families, friends, and neighbors provide financial support, shelter, fuel, food, water, and companionship.^[78] However, social networks are being eroded by the conflict.^[79] Due to widespread displacement, many communities and families are now physically separated from one another. Many social gatherings have thus disappeared altogether, with others made extremely difficult by the circumstances. In pre-conflict Yemen, men and women commonly gathered separately to socialize or chew khat—a stimulant plant chewed in groups—in the evening. Now, checkpoints, fighting, and darkness from lack of electricity lead people to stay in their own homes at night.^[80]

Yemen, the international community, and mental health

The government of Yemen cites the ongoing conflict as a major impediment to advancing human rights, including the right to mental health.^[81] Despite the challenges of the conflict, the responsibility to address issues related to the well-being of people in Yemen remains with the government, a fact emphasized by domestic and international civil society organizations and by UN member states at the Universal Periodic Review of Yemen in January 2019.

Ahead of the Universal Periodic Review, a group of representatives from the Sana’a Center for Strategic Studies, the Columbia Law School Human Rights Clinic, and the Brown School at Washington University held advocacy meetings with Human Rights Council member states, urging them to call on the government of Yemen to take measures to strengthen the right to mental health. Various UN member states—including Cyprus, Iceland, Malta, France, Switzerland, Brazil, and Slovenia—raised the issue of the right to mental health in their statements to the government of Yemen.^[82] Many other member states were interested in the group’s suggested recommendations for the government of Yemen, including the recommendations to ensure that mental health is an important factor in all its national planning; promote access to appropriate psychosocial support for persons living in Yemen; take steps to support more training for counselors, psychologists, teachers, and community leaders; immediately make all efforts to reduce the burden of the conflict on Yemenis, including by paying public sector salaries; reopen the Sana’a International Airport; lift unnecessary import restrictions; and reduce impediments to people’s movement.^[83] The group also called on the Yemeni government and all parties to the conflict (including the Houthi rebels and the Saudi-led coalition), along with the UN Special Envoy to Yemen and the international community, to ensure that mental health is taken into account during peace talks.^[84] Three years later, these recommendations to the government of Yemen and various international actors remain regrettably relevant, as the crisis has only deepened and progress toward the realization of the rights to mental health has stagnated.

Emerging from war and atrocity: Addressing mental health in peacebuilding

Mental health is often overlooked during and immediately after conflict and mass atrocity; this neglect may have reverberating effects on future peace and stability. First, poor mental health can have direct effects on ceasefire and peace negotiations. For parties to the conflict and others who participate in peace processes, heightened threat perception, distrust, deteriorated intra-communal relationships, and other manifestations of poor mental health may impact the interest in, effectively engage in conflict resolution and peacebuilding.^[85] Left unaddressed, prolonged exposure to violence and trauma may increase individuals’ threat perception, leading to attempts to protect oneself with defensive violence and negative coping strategies such as an unwillingness to compromise.^[86] Additionally, exposure to trauma may lead to a lack of confidence in reconciliation measures by intensifying feelings of anxiety, fear, and anger.^[87] These constant feelings of anxiety and fear may transform into a general distrust—toward society at large, authorities, and even neighbors—which may undermine reconciliation efforts.^[88] Conflict-induced poor mental health may also affect cognitive skills such as perspective taking and problem solving.^[89] Depression and rumination can create a spiral of negative thinking that interferes with the ability to have perspective and find creative solutions.^[90] Due to these manifestations, conflict- and atrocity-induced poor mental health has been associated with greater support for violence as a way to respond to conflict, and a lower likelihood of envisioning nonviolent solutions, leading to reduced support for peace and reconciliation.^[91] Mental health and psychosocial interventions—including individual psychiatric services, the facilitation of community-based social support, and psycho-education—however, can temper these effects and even contribute to more constructive peacebuilding.^[92]

As part of a successful agreement to end armed conflict, Yemen will likely design and implement programs created to build peace while seeking justice for the human rights abuses that have occurred.^[93] Truth-seeking mechanisms, criminal prosecutions, and reparations programs are three ways of advancing reconciliation and justice.^[94] Considering the extent of mental health harms caused by conflict, it is important for these processes to find ways to meaningfully acknowledge and address these harms, improve the general well-being of the population, and prevent the effects of these harms from impeding participation in reconciliation.

Acknowledgments

This paper results from a long-term research and advocacy collaboration between the Sana’a Center for Strategic Studies and the Columbia Law School Human Rights Clinic. This paper summarizes and builds on a series of research projects and publications by the two centers. A special thanks to Farea Al-Muslimi for sharing his expertise on recent contextual developments and to Susan Sevareid for her initial editorial review and feedback.

Waleed Alhariri is Policy and Partnerships Director at the Sana’a Center for Strategic Studies, Sana’a, Yemen.

Amanda McNally is a Research Fellow at the Sana’a Center for Strategic Studies, Sana’a, Yemen.

Sarah Knuckey is a Clinical Professor of Law and Director of the Human Rights Clinic and Institute at Columbia Law School.

Please address correspondence to Waleed Alhariri. Email: alhariri@sanaacenter.org.

Competing interests: None declared.

Copyright © 2021 Alhariri, McNally, and Knuckey. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction.

References

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[2]. Mwatana for Human Rights, Civilians in Yemen remain stuck between the warring parties and waiting for justice (March 2021). Available at https://mwatana.org/en/civilians-in-yemen-remain-stuck/.

[3]. “UN humanitarian office puts Yemen war dead at 233,000, mostly from ‘indirect causes’,” UN News (December 1, 2020). Available at https://news.un.org/en/story/2020/12/1078972.

[4]. United Nations Office for the Coordination of Humanitarian Affairs (see note 1); World Health Organization, Cholera situation in Yemen (December 2020). Available at https://reliefweb.int/sites/reliefweb.int/files/resources/Cholera%20situation%20in%20Yemen%2C%20December%202020.pdf; “Yemen crisis: 85,000 children ‘dead from malnutrition’,” BBC News (November 21, 2018). Available at https://www.bbc.com/news/world-middle-east-46261983.

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[6]. F. Charlson, M. van Ommeren, A Flaxman, et al., “New WHO prevalence estimates of mental disorders in conflict settings: A systematic review and meta-analysis,” Lancet 394/10194 (2019), pp. 240–248.

[7]. Family Counseling and Development Foundation, Estimated prevalence of mental disorders among war-affected population in Yemen (2018), pp. 28–31.

[8]. Save the Children, Five years of fear and loss: The devastating impact of war on the mental health of Yemen’s children (London: Save the Children, 2020); F. al-Ammar, Post-traumatic stress disorder among Yemeni children as a consequence of the ongoing war (Bonn: CARPO, 2018).

[9]. United Nations Office for the Coordination of Humanitarian Affairs (see note 1); K. Garber, C. Fox, M. Abdalla, et al., “Estimating access to health care in Yemen, a complex humanitarian emergency setting: A descriptive applied geospatial analysis,” Lancet 8/11 (2020), p. e1440.

[10]. M. Saleh and A. Makki, “Mental health in Yemen: Obstacles and challenges,” International Psychiatry 5/4 (2008), p. 91; International Medical Corps, Mental health and psychosocial support assessment (Los Angeles: International Medical Corps, 2019).

[11]. Human Rights Council, Report of the United Nations High Commissioner for Human Rights, Mental Health and Human Rights, UN Doc. A/HRC/34/32 (2017).

[12]. International Covenant on Economic, Social and Cultural Rights, G.A. Res. 2200A (XXI) (1966), art. 12.

[13]. Committee on Economic, Social and Cultural Rights, General Comment No. 14, The Right to the Highest Attainable Standard of Health, UN Doc. E/C.12/2000/4 (2000), para. 33.

[14]. Ibid., para. 12.

[15]. International Covenant on Economic, Social and Cultural Rights, G.A. Res. 2200A (XXI) (1966), art. 2.

[16]. Committee on Economic, Social and Cultural Rights (2000, see note 13), para. 31.

[17]. Ibid., para. 43.

[18]. Committee on Economic, Social and Cultural Rights, General Comment. No. 3, The Nature of States Parties’ Obligation, UN Doc. E/C.12/1991/23 (1990), para. 14.

[19]. Ibid.

[20]. Human Rights Council, Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health: Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health, UN Doc. A/HRC/41/34 (2019), para. 29.

[21]. World Health Organization, Mental health included in the UN Sustainable Development Goals. Available at https://www.who.int/mental_health/SDGs/en/.

[22]. World Health Organization, Mental health in the eastern Mediterranean region: Reaching the unreached (2006), p. 303. Available at https://applications.emro.who.int/dsaf/dsa702.pdf.

[23]. Ibid.

[24]. Sana’a Center for Strategic Studies, Columbia Law School Human Rights Clinic, and Columbia University Mailman School of Public Health, The impact of war on mental health in Yemen: A neglected crisis (2017), p. 6. Available at https://sanaacenter.org/publications/analysis/5119.

[25]. Saleh and Makki (see note 10), pp. 90–92.

[26]. Sana’a Center for Strategic Studies et al. (see note 24), p. 7.

[27]. Ibid.

[28]. Yemen Ministry of Public Health and Population, National Mental Health Strategy: 2011–2015 (2010), p. 5. Available at https://sfd.sfd-yemen.org/uploads/issues/health%20english-20121015-132757.pdf.

[29]. Ibid., p. 54.

[30]. Ibid., p. 57.

[31]. Ibid.

[32]. Yemen Ministry of Public Health and Population (2010, see note 28), pg. 57.

[33]. “Mentally ill Yemenis face social confinement,” Arab Reporters for Investigative Journalism (July 6, 2015). Available at https://en.arij.net/investigation/mentally-ill-yemenis-face-social-confinement/.

[34]. Ibid.

[35]. Ibid.

[36]. Yemen Ministry of Public Health and Population (2010, see note 28).

[37]. Ibid.

[38]. National dialogue conference outcomes (2014), pp. 35–36. Available at https://www.peaceagreements.org/viewmasterdocument/1400.

[39]. Ibid.

[40]. Yemen’s draft constitution of 2015, art. 77. Available at https://www.constituteproject.org/constitution/Yemen_2015D.pdf?lang=en.

[41]. Ibid., art. 125.

[42]. M. al-Madhaji, “How Yemen’s post-2011 transitional phase ended in war,” Sana’a Center for Strategic Studies (November 2017). Available at https://sanaacenter.org/publications/main-publications/39.

[43]. Gater et al. (see note 32).

[44]. Group of Eminent International and Regional Experts on Yemen, Situation of Human Rights in Yemen, including Violations and Abuses since September 2014, UN Doc. A/HRC/45/CRP.7 (2019).

[45]. International Medical Corps (see note 10), p. 15.

[46]. Garber et al. (see note 9).

[47]. International Medical Corps (see note 10), p. 11.

[48]. Ministry of Public Health and Population, The Ministry of Public Health and Population’s plan to respond to mental health needs in the Republic of Yemen, 2021–2020 (2020), p. 6. Available at https://moh.gov.ye/archive/sections/1/guids/2020080908202810The%20Ministry%20of%20Public%20Health%20and%20Populations%20plan%20to%20respond%20to%20mental%20health%20needs%20in%20the%20Republic%20of%20Yemen.pdf.

[49]. Family Counseling and Development Foundation, Family counseling magazine, fifth edition. Available at http://fcdf-ye.org/Uploads/637152793238308482.pdf.

[50]. Ministry of Public Health and Population (2020, see note 49); Family Counseling and Development Foundation (see note 50), p. 14.

[51]. Yemen Ministry of Public Health and Population (2010, see note 28), p. 53.

[52]. A. Okasha, E. Karam, and T. Okasha, “Mental health services in the Arab world,” World Psychiatry 11/1 (2012), pp. 52–54; Family Counseling and Development Foundation (see note 50), p. 14.

[53]. Human Rights Watch, Living in chains: Shackling of people with psychosocial disabilities worldwide (New York: Human Rights Watch, 2020), p. 49.

[54]. I. Yeung, “Hidden scars: Mentally ill patients lost in Yemen’s war,” Guardian (May 11, 2021). Available at https://www.theguardian.com/global-development/2021/may/11/hidden-scars-mentally-ill-patients-lost-in-yemens-war.

[55]. Ibid.; International Medical Corps (see note 10), p. 15.

[56]. B. McKernan and P. Wintour, “Yemen condemns international donor funding shortfall as UK cuts aid,” Guardian (March 2021). Available at https://www.theguardian.com/world/2021/mar/01/uk-under-pressure-over-plan-slash-aid-yemen-civil-war-famine.

[57]. Yeung (see note 55).

[58]. International Medical Corps (see note 10), p. 11.

[59]. Yeung (see note 55).

[60]. World Health Organization (2020, see note 4).

[61]. M. Ghobari, “War-ravaged Yemen confirms first coronavirus case, braces for more,” Reuters (April 10, 2020). Available at https://www.reuters.com/article/us-health-coronavirus-yemen-case/war-ravaged-yemen-confirms-first-coronavirus-case-braces-for-more-idUSKCN21S0EI\.

[62]. World Health Organization, WHO health emergency dashboard (May 2021). Available at https://covid19.who.int/region/emro/country/ye; O. Al-Rawhani, “Houthi Coronavirus coverup unleashes death, suffering as Yemen marks Eid,” Sana’a Center for Strategic Studies (May 2020). Available at https://sanaacenter.org/publications/analysis/9994.

[63] M. Zawiah, F. Al-Ashwal, R. Saeed, et al., “Assessment of healthcare system capabilities and preparedness in Yemen to confront the novel Coronavirus 2019 outbreak: Perspectives of healthcare workers,” Frontiers in Public Health 8 (2020), p. 2.

[64]. Al-Rawhani (see note 63).

[65]. Sana’a Center for Strategic Studies, A grave road ahead–the Yemen review (June 2, 2020). Available at https://sanaacenter.org/publications/the-yemen-review/10047.

[66]. “UN Chief Calls for ceasefire as Yemen braces for possible COVID-19 outbreak,” UN News (March 25, 2020). Available at https://news.un.org/en/story/2020/03/1060302.

[67]. “UN leads call to protect most vulnerable from mental health crisis during and after COVID-19,” UN News (May 14, 2020). Available at https://news.un.org/en/story/2020/05/1063882.

[68]. Sana’a Center Economic Unit, “Yemen’s accelerating economic woes during the COVID-19 pandemic,” Sana’a Center for Strategic Studies (October 2020), p. 11. Available at https://sanaacenter.org/files/Rethinking_Yemens_Economy_No7_En.pdf.

[69]. “The intersection of COVID-19 and mental health,” editorial, Lancet Infectious Diseases 20/11 (2020); S. Al-Awlaqi, “Yemen and COVID-19: What needs to be done,” Sana’a Center for Strategic Studies (March 25, 2020). Available at https://sanaacenter.org/publications/analysis/9435.

[70]. International Rescue Committee, As Yemen teeters on the brink of famine, IRC urges G20 to fulfil humanitarian commitments at Saudi Arabia Summit (November 20, 2020). Available at https://www.rescue.org/press-release/yemen-teeters-brink-famine-irc-urges-g20-leaders-fulfil-humanitarian-commitments-saudi.

[71]. Saleh and Makki (see note 10), pp. 90–92.

[72]. Phone interview with expert, conducted by Columbia Law School Human Rights Clinic (May 1, 2019).

[73]. Ibid.

[74]. Phone interview with expert, conducted by Columbia Law School Human Rights Clinic (April 10, 2019).

[75]. A. Alzubaidi and A. Ghanem, “Perspectives on psychology in Yemen,” International Journal of Psychology 32/5 (1997), p. 363.

[76]. Sana’a Center for Strategic Studies et al. (see note 24),p. 8.

[77]. Alzubaidi and Ghanem (see note 76), p. 363.

[78]. Phone interviews with experts, conducted by Columbia Law School’s Human Rights Clinic.

[79]. Phone interviews with experts, conducted by Columbia Law School Human Rights Clinic; Save the Children (see note 8).

[80]. Phone interview with expert, conducted by Columbia Law School’s Human Rights Clinic (April 26, 2019).

[81]. UN Web TV, Yemen review—32nd session of Universal Periodic Review (January 23, 2019). Available at

http://webtv.un.org/search/yemen-review-32nd-session-of-universal-periodic-review/5993268860001/?term=2019-01-23&sort=date&page=3.

[82]. Human Rights Council, Universal Periodic Review: Yemen. Available at https://www.ohchr.org/EN/HRBodies/UPR/Pages/YEIndex.aspx.

[83]. Sana’a Center for Strategic Studies, Columbia Law School Human Rights Clinic, and Brown School at Washington University in St. Louis, “Yemen’s obligations to respect, protect, and fulfil the right to mental health,” submission to UN Human Rights Council (January 12, 2019). Available at https://sanaacenter.org/publications/main-publications/6789.

[84]. Columbia Law School Human Rights Clinic and Sana’a Center for Strategic Studies, International community must respond to mental health crisis in Yemen, say human rights experts (December 19, 2018). Available at https://web.law.columbia.edu/human-rights-institute/about/press-releases/International-Community-Must-Respond-to-Mental-Health-Crisis-in-Yemen.

[85]. H. Königstein, “The influence of mental health on reconciliation in post-war Lebanon,” Institute for International Law of Peace and Armed Conflict (IFHV) Working Paper 3/2 (2013). Available at http://www.ifhv.de/documents/workingpapers/wp3_2.pdf.

[86]. S. Hirsch-Hoefler, D. Canetti, C. Rapaport, and S. Hobfoll, “Conflict will harden your heart: Exposure to violence, psychological distress, and peace barriers in Israel and Palestine, British Journal of Political Science 46/4 (2014), p. 845; S. Hobfoll, D. Canetti-Nisim, and R. Johnson, “Exposure to terrorism, stress-related mental health symptoms, and defensive coping among Jews and Arabs in Israel,” Journal of Consulting and Clinical Psychology 74/2 (2006), pp. 207–218; E. Staub, L. Pearlman, A. Gubin, and A. Hagengimana, “Healing, reconciliation, forgiving and the prevention of violence after genocide or mass killing: An intervention and its experimental evaluation in Rwanda,” Journal of Social and Clinical Psychology 24/3 (2005), p. 297.

[87]. Königstein (see note 86), p. 34.

[88]. L. Laplante and M. Holguin, “The Peruvian truth commission’s mental health reparations: Empowering survivors of political violence to impact public health policy,” Health and Human Rights Journal 9/2 (2006), p. 136.

[89]. Königstein (see note 86), p. 1.

[90]. Ibid., p. 34.

[91]. P. Vinck, P. Pham, and E. Stover, “Exposure to war crimes and implications for peace building in northern Uganda,” Journal of the American Medical Association 298/5 (2007), p. 543; M. Biro, D. Ajdukovic, D. Corkalo, et al., “Attitudes toward justice and social reconstruction in Bosnia and Herzegovina and Croatia,” in E. Stover and H. Weinstein (eds), My neighbor, my enemy: Justice and community in the aftermath of mass atrocity (Cambridge: Cambridge University Press, 2004), pp. 183–184.

[92]. B. Hamber, E. Gallagher, and P. Ventevogel, “Narrowing the gap between psychosocial practice, peacebuilding and wider social change: An introduction to the special section in this issue,” Intervention 12/1 (2017), p. 14.

[93]. T. Radwan, “Rethinking transitional justice in Yemen,” Atlantic Council (February 2017). Available at https://www.atlanticcouncil.org/blogs/menasource/rethinking-transitional-justice-in-yemen/.

[94]. United Nations Secretary-General, “United Nations approach to transitional justice,” Guidance Note (2010), p. 3. Available at https://www.un.org/ruleoflaw/files/TJ_Guidance_Note_March_2010FINAL.pdf.