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In this May 12, 2020 photo, Yemeni medical workers wearing masks and protective gear talk to patients at hospital in Aden, Yemen. People have been dying by the dozens each day in southern Yemen's main city, Aden, many of them with breathing difficulties, say city officials. Blinded with little capacity to test, health workers fear the coronavirus is running out of control, feeding off a civil war that has completely broken down the country.

The Associated Press

Hundreds of people in Aden, southern Yemen’s main city, have died in the past week with symptoms of what appears to be the coronavirus, local health officials said in interviews with The Associated Press.

The officials fear the situation is only going to get worse: Yemen has little capacity to test those suspected of having the virus and a five-year-long civil war has left the health system in shambles.

One gravedigger in Aden told AP he’d never seen such a constant flow of dead – even in a city that has seen multiple bouts of bloody street battles during the civil war.

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Officially, the number of coronavirus cases in Yemen is low – 106 infections in the southern region, with 15 deaths. Authorities in the Houthi rebel-controlled north announced their first case on May 5, and say there has been only two infections, one of whom died, a Somali migrant.

But doctors say the Houthis are covering up an increasing number of cases to protect their economy and troops. And the surge in deaths in Aden – more than 500 in just the past week, according to the city registrar – has raised the nightmare scenario that the virus is spreading swiftly in a country with almost no capacity to resist it.

The upswing in suspected COVID-19 cases in Yemen is sounding alarms throughout the global health community, which fears the virus will spread like wildfire throughout the world’s most vulnerable populations such as refugees or those impacted by war.

“If you have a full-blown community transmission in Yemen, because of the fragility, because of the vulnerability, because of the susceptibility, it will be disastrous,” said Altaf Musani, the World Health Organization chief in Yemen.

WHO says its models suggest that, under some scenarios, half of Yemen’s population of 30 million could be infected and more than 40,000 could die.

Half of Yemen’s health facilities are dysfunctional, and 18 per cent of the country’s 333 districts have no doctors. Water and sanitation systems have collapsed. Many families can barely afford one meal a day.

Yemen has no more than 500 ventilators and 700 ICU beds nationwide. There is one oxygen cylinder per month for every 2.5 million people. WHO provided some 6,700 test kits to Yemen, split between north and south, and says another 32,000 are coming. The health agency says it is trying to procure more protective equipment and supplies to fight the virus. But WHO said efforts have been hampered because of travel restrictions and competition with other countries.

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The ongoing civil war pits the Houthis, who occupy the north, against a U.S. and Saudi-backed coalition that formed an internationally recognized government in the south. Now that coalition in the South has fragmented: separatists backed by the United Arab Emirates rose up and expelled the government from southern capital Aden last summer and declared self-rule last month. The two factions are fighting in Abyan, a province adjacent to Aden.

The war has already killed more than 100,000 and displaced millions.

The two warring sides in Yemen’s civil war have taken vastly different approaches to dealing with the pandemic, each in its own way fuelling the possible spread of the virus.

The south is a picture of utter collapse: Rival factions within the U.S. backed coalition are battling for control. No one appears to be in charge as an already wrecked health system seems to have completely shut down.

Health personnel, with little protective equipment, are terrified of treating anyone suspected of having the coronavirus.

Many medical facilities in Aden have closed as staffers flee or simply turn patients away. No one is answering a hotline set up by UN-trained Rapid Response Teams to test suspected cases at home.

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“If you are suspected of having corona and you are in Aden, most probably you will wait at home for your death,” said Mohammed Roubaid, deputy head of the Aden’s health office.

From May 7 until Thursday, the city’s civil registrar recorded 527 deaths, the head of the office Sanad Gamel told AP.

The causes of death weren’t listed, but the rate was many times higher than the usual average death rate of around 10 people a day, a city health official said. Multiple doctors said they were convinced the deaths are COVID-19 related. In a statement on Thursday, Save the Children put the toll of people with COVID-19 symptoms in Aden the past week at 385.

In the north, meanwhile, the Houthi rebels in power there are waging a campaign to aggressively suppress any information about the scale of the outbreak, even as doctors told the AP of increasing infections and deaths.

The Houthis have refused to release positive test results and intimidated medical staff, journalists and families who try to speak out about cases, doctors and other officials say. Doctors and local health officials said they believed many people are dying of COVID-19 in their homes, undocumented.

Doctors in three northern provinces, including the capital Sanaa, told the AP they have seen increasing numbers of suspected coronavirus cases and deaths. All spoke on condition of anonymity, fearing reprisals from the rebels.

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Houthi militiamen have shut down several markets in Sanaa and locked down streets in 10 neighbourhoods, barring families from leaving their homes, after suspected cases arose.

Medical staffers said they are under surveillance and can’t speak about what they see inside health centres.

Both local health ministry and international aid officials have been warned not to discuss cases or of possible local transmission of the virus, since the rebels insist the north’s few cases came from abroad, according to two officials with knowledge of the discussions.

In the first week of May, a surge of patients entered the Kuwait Hospital, the sole fully operating COVID-19 treatment centre in the capital, said four officials. One official said 50 of them were likely infected with the coronavirus and 15 later died. Staffers say they believe the patients were infected because Houthi authorities never revealed the results of their tests.

“When it’s negative, they give the results to us,” the official said.

An internal document with test results at the hospital on May 4 showed three positive cases. On one page was scribbled the name of a woman who died. The AP obtained a copy of the document, which also circulated on social media. Two officials confirmed its authenticity.

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Families of those who died of suspected coronavirus infection say they are left in the dark.

Relatives of a man who died in Sanaa recently said Houthi authorities refused to release their father’s body from the morgue, saying they were awaiting test results. They believe Houthi officials wanted to bury the body without a mass funeral that could spread the virus.

After three days, under heavy pressure from the family, Houthi officials released the body, but not the test results. Two other families told AP about similar experiences.

In Houthi-controlled Ibb province, a local official said at least 17 people had died. “The situation is very dangerous and out of control,” he said. A doctor in Ibb said tests are sent to Sanaa but results are never revealed, adding, “There are cases, but I’m not allowed to speak.”

In Dhamar, a local medical official said at least 10 suspected coronavirus cases had been hospitalized and at least two people had died. One had come from Sanaa, meaning it was a local transmission.

“We buy plastic sheets and stitch them together to make protective gowns and masks. There is no other way,” one health offical said.

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UN officials said the Houthis’ control of information about the spread of suspected COVID-19 cases has hampered their response to the outbreak. As long as the Houthis do not officially acknowledge cases, the UN cannot rally global donors to send supplies to tackle the outbreak, officials said.

In the south, authorities announced the first confirmed coronavirus case on April 10, a man in his 70s working at a port in Hadramawt province.

Many families fearing the outbreak fled from Hadramawt to Aden.

Twenty days later, authorities announced a cluster of cases in Aden’s densely populated district of Mansoura.

By early May, city officials reported dozens of deaths per day.

Basic services in Aden were already in shambles because of the civil war. The situation worsened after a separatist group took over.

Health authorities were split between two camps – those loyal to the internationally-recognized government and those who answer to a group that split off last year – so employees have no clue who to report to, and no one is sure who is making decisions.

In the midst of the confusion, many health facilities are shutting their doors. At least five doctors suspected of being infected with the coronavirus have died, according to a health ministry official.

As a result, no one is testing – and authorities are not eager to see higher numbers anyway, said one official, adding, “The whole chain is dysfunctional”

International aid agencies believe the coronavirus has been circulating in Yemen since March. But doctors may have missed it in part because of flooding that struck Aden in April, leaving entire sections submerged in sewage and water for weeks.

That flooding helped cause an outbreak of other diseases, including Dengue fever and Chikungunya, three health officials said. But health officials said past outbreaks of these diseases have had nowhere near the same death toll

Zakariya al-Qaiti, the outgoing head of Aden’s sole isolation centre at Al-Amal Hospital, said he had no doubt about the cause. “I can affirm that coronavirus is breaking out in Aden.”

The isolation ward has so far received 60 cases, 20 of whom died, officials said.

The facility is often engulfed in darkness because it runs out of fuel for its power generators. For weeks, it had no equipped laboratory and no special ambulance to bring coronavirus patients.

It also didn’t have any money – Mr. al-Qaiti said the government withheld its budget after the separatist takeover. So its 100 staffers have not been paid, and 15 of them have quit.

The international humanitarian group Doctors Without Borders is now running Al-Amal.

Aden resident Assem Sabri said his friend Nabil Abdel-Bari, a young businessman who was suffering from shortness of breath and fever, was refused entry at four hospitals.

“The doctors took one look at him and shouted, `You have coronavirus,“’ Mr. Sabri said. “Doctors in Aden have lost all their humanity and mercy. We are heading in a very dangerous direction.”

Mr. Abdel-Bari returned home and died days later, Mr. Sabri said.

At al-Qateea, one of the smallest of Aden’s six cemeteries, Abdullah Salem, a gravedigger, said he receives 10 to 15 bodies a day, about 10 times more than normal.

He said he doesn’t know how to deal with the bodies, because burial permits do not list a cause of death.

“Is it corona, dengue, or TB? We have no clue,” he said.

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