ADEN, Yemen -- In the summer of 2017, a plane chartered by the United Nations idled on the tarmac at an airport in the Horn of Africa as officials waited for final clearance to deliver half a million doses of cholera vaccine to Yemen. Amid the country's ruinous war, the disease was spiraling out of control, with thousands of new cases reported each day.
The green light for the plane to head to northern Yemen never came. The U.N. wasn't able to distribute cholera vaccines to Yemen until May 2018 and the outbreak ultimately produced more than 1 million suspected cholera cases — the worst cholera epidemic recorded in modern times and a calamity that medical researchers say may have been avoided if vaccines had been deployed sooner.
U.N. officials blamed the canceled flight on the difficulties in distributing vaccines during an armed conflict. But officials with knowledge of the episode told The Associated Press that the real reason was that the Houthi rebels who control northern Yemen refused to allow the vaccines to be delivered, after spending months demanding that the U.N. send ambulances and other medical equipment for their military forces as a condition for accepting the shipment.
The cancellation of the shipment was just one of the setbacks that aid agencies faced in battling the cholera epidemic, which has killed nearly 3,000 Yemenis.
Relief workers and government officials said they have seen repeated indications that insiders in both the Houthi government in the north and the U.S.-backed government in the south have skimmed off money and supplies for cholera vaccination and treatment and sold them on the black market. In some cases, treatment centers for people who had contracted cholera existed only on paper even though the U.N. had disbursed money to bankroll their operations, according to two aid officials familiar with the centers.
The AP's examination of the efforts to fight the disease in Yemen drew on confidential documents and interviews with 29 people, including aid officials previously based in the country and officials from health ministries run by both the Houthi rebels and the internationally recognized government in the south. Almost all of these individuals — including six relief and health officials who say the Houthis were responsible for cancellation of the 2017 vaccine shipment — spoke on condition of anonymity because of fear of retaliation.
"Both the Houthis and the government of Yemen were trying to politicize cholera," an aid official told the AP.
"The Houthis are taking advantage of U.N. weakness," the official said. "Corruption or aid diversion and all of this are because of the U.N.'s weak position." Relief workers know that if the U.N. speaks out, the official said, "their visas will be denied and they would not be allowed back in the country."
Cholera spread across Yemen in late 2016 and throughout much of 2017 and 2018. It ebbed late last year, but has again picked up in 2019. A new surge in the disease has produced roughly 150,000 reported cholera cases and nearly 300 deaths since the start of this year. The first cholera vaccine drives in Yemen didn't start until May 2018 in the south and August 2018 in the north, aid and health officials told the AP.
Ali al-Walidi, the deputy health minister in southern Yemen, and Youssef al-Hadri, the spokesman of the Houthi-run Health Ministry in the north, both deny there were delays in getting cholera vaccines into Yemen at the start of the outbreak.
Al-Hadri said claims that the Houthis blocked the shipment of vaccines into Yemen are false.
"This is all baseless, and I challenge the agencies to say this officially," he said.
Geert Cappelaere, the Middle East director for UNICEF, the U.N. children's relief agency, declined to blame any particular group for halting the 2017 shipment.
"What is important is that the vaccines that needed to get in have ultimately gone in and have reached the people who needed to be vaccinated," he said. "Has this been simple and easy? Absolutely not. Each shipment has been problematic to get in because of the long approval time" and because of "skepticism among the authorities on both sides" about the value of cholera vaccines.
A RAVAGED LAND
More than half of Yemen's hospitals and other health facilities have been damaged or destroyed since the war began in 2015, after Houthi forces overran much of the country and Saudi Arabia and other Arab nations, with backing from the United States, launched airstrikes and imposed blockades on rebel-held territory.
The conflict has killed more than 60,000 people and much of Yemen has been on the edge of famine. An AP investigation published in December revealed that factions on all sides of Yemen's war have blocked food aid from going to groups suspected of disloyalty, diverted it to front-line combat units or sold it for profit on the black market.
More than 19 million of Yemen's 29 million people don't have access to adequate health care, and more than 17 million don't have clean water, according to the U.N. Those are prime conditions for the spread of cholera, a disease caused by feces-tainted water and food. Cholera can kill swiftly if untreated, its victims drained by diarrhea, vomiting and fever.
The first significant cholera outbreak came in late 2016, leading to more than 25,000 suspected cases and killing at least 129. Soon after, in April 2017, the disease erupted again, this time spreading at an even more furious pace. Within two months, more than 185,000 suspected cases and 1,200 deaths were reported. One local aid worker in northern Yemen recalls house after house with dying children, their small bodies racked by severe diarrhea.
When U.N. officials tried to rush in oral vaccines to halt the spread, some Houthi officials claimed vaccines were ineffective. A few circulated messages on social media asserting that vaccines could be harmful to children. Four aid officials and a former Houthi health official said that some rebel leaders suggested that the vaccination plan was a plot by the U.S. and Israel to use Yemenis as guinea pigs.
A former senior official in the Houthi Health Ministry said the concerns over the vaccines' safety were a pretext. Rebel leaders had a list of demands and tried to bargain with U.N. officials for money and equipment, he said.
During weeks of negotiations over the vaccine program, the rebels demanded that U.N. officials send X-ray machines and other items they could use to treat their wounded fighters on the front lines, according to the former health ministry official and three aid officials.
Al-Hadri, the spokesman for the Houthi-run Health Ministry, denied that Houthi authorities demanded medicine and medical equipment to be used in treating front-line soldiers. Cappelaere, UNICEF's Middle East chief, said he had no knowledge of aid officials bargaining with authorities in Yemen in the effort to import cholera vaccines.
Finally, in July 2017, U.N. officials believed they had the go-ahead to bring in cholera vaccines. Half a million doses were loaded onto a plane in the tiny African republic of Djibouti.
At the last minute, hard-liners in the Houthi-controlled Health Ministry told the U.N. they would not allow the plane to land.
Publicly, the U.N. blamed the change of plans on security and logistical challenges involved in delivering immunizations across Yemen's conflict-torn landscape. A spokesman for the U.N.'s World Health Organization said at the time that delivering vaccines "has to make sense" in terms of the conditions on the ground, adding that the vaccine doses intended for Yemen would likely be re-routed to places that "might need them more urgently."
U.N. officials sent the shipment to South Sudan in central Africa, where the disease had recently erupted. The cholera outbreak in South Sudan left 436 dead but was declared over by early 2018, largely due to the introduction of vaccines during the outbreak's early stages.
The outbreak in Yemen went on unabated.
Hager Taher, a 27-year old mother of two, was one of hundreds who died from cholera in the months after the vaccine delivery into the country had been called off. Taher was in the last days of pregnancy, living in the village of al-Ghareb, an impoverished area in the Houthi-controlled northern province of Hajjah, when she began vomiting and showing cholera-like symptoms.
The only health center in the village of nearly 1,200 people was a building with two rooms and few beds. As the number of suspected cholera cases grew, local authorities used a school to receive patients, who had to lie on the floor in the empty classrooms.
Taher was sent to a hospital run by Doctors Without Borders in the city of Abs. She soon developed complications and was moved to another hospital nearby. It was there, in September 2017, that she died. Her child was born alive but died four days later.
"It's God's will," her husband, Mohammed Hassan, told the AP. "There's nothing to do."
Taher was one of 16 people reported to have died from cholera in her district in Hajjah. Hundreds more were infected.
"The district was gulped up by cholera," said Ibrahim al-Masrahi, a health worker in charge of gathering epidemic surveillance reports.
By the end of 2017, the number of reported cholera cases in Yemen had surged past 1 million, with more than 2,200 deaths. The spread of the disease waned for a time, but rebounded again in the spring and summer of 2018, adding another 370,000 reported cases and 500 more deaths.
U.N. officials continued struggling to find a way to get cholera vaccines into the country.
Houthi officials held a succession of meetings throughout much of 2017 and into 2018 to consider the science and policy questions relating to vaccines. In the spring of 2018, after science panels approved bringing cholera vaccines into rebel territory, Health Minister Mohammed Salem bin Hafez gave U.N. officials the go-ahead to bring in nearly 900,000 doses of cholera vaccine, according to documents obtained by the AP.
Then two of his deputies, both of them well-connected within the Houthi leadership, said the shipment couldn't proceed, asserting that there were still more bureaucratic hurdles before the vaccines' "safety and security" could be assured, according to the documents.
As a non-Houthi, bin Hafez didn't have the power to overrule the decisions of the two deputies who supposedly were working under him. He wrote a letter to the prime minister of the Houthi-controlled government, Abdel-Aziz bin Habtour, detailing how the delivery of vaccines had been once again been put off.
"I am washing my hands of the consequences of these irresponsible actions," bin Hafez's letter said. He told the prime minister that he was "putting the matter between your hands" in the hope the government would "take the necessary measures to use aid in a proper way and create proper work conditions for international and local aid agencies."
A month later, bin Hafez left his post and fled Houthi territory.
Abdel-Aziz al-Daylami, one of the Health Ministry deputies that bin Hafez blamed for holding up the delivery of vaccines, denied that he had stopped the shipment.
"No, there was no rejection, but we had reservations," he told the AP. "We thought that the vaccines would be useless" if they were deployed without more efforts to ensure clean water and reliable sanitation systems.
"We worried that if the vaccine campaigns failed, people would turn against the use of vaccines and that would be disastrous," he said.
ONLY ON PAPER
As Houthi authorities debated the use of vaccines in the north, the U.N. was also working to get cholera vaccines into the country via the government in the south.
But this plan was also marred by delays — and by questions about possible corruption.
After the U.N. was able to get a shipment of vaccines into the southern city of Aden in May 2018, the Health Ministry for the U.S.- and Saudi-backed government there put together teams to raise awareness and administer the vaccines.
But some of the vaccination teams existed only on paper and many workers on the teams never received the full stipends budgeted for them under the program, two aid officials told the AP. The two officials said authorities in the south prevented aid workers from visiting the districts where immunization campaigns were taking place, making it impossible for them to monitor what was happening on the ground and verify how aid money was being used.
In the wake the vaccination campaign in the south, the Houthis broke the logjam in the north. They agreed to allow cholera vaccines into some areas under their control. Immunization drives were launched in three rebel-held districts in August and September 2018.
A senior official who worked with the Houthi-run Health Ministry at the time noted the U.N. had agreed to some of the rebels' wish list of additional medical supplies and equipment, including the purchase of 45 ambulances for the ministry. The ambulances were then sent to the front lines for the military's use, the ex-official said.
Beyond vaccine drives, concerns emerged in both the north and south about whether patients who had already contracted the disease were getting medical treatment targeted for them.
Some centers set up to treat cholera victims weren't functional even though UNICEF and the WHO had provided funding to government authorities and nongovermental groups to cover costs of setting them up and running them, according to two aid officials familiar with the centers.
One of those two aid officials said he was told there were nine cholera treatment centers in Aden. He could find only two. "The rest didn't exist," he said.
Another concern in north and south was whether relief organizations were getting accurate counts of the number of people sickened with cholera in various parts of the country. Two aid officials and a former official with the Houthi-controlled Health Ministry said authorities exaggerated the number of cholera cases to increase the amount of international aid money.
A December 2018 study of the Yemen outbreak by researchers at Johns Hopkins University found that some overreporting was likely due to health workers whose livelihoods depended on money paid by the U.N. Many of the workers hadn't received their government salaries in years and believed that the cholera centers where they worked would be closed and aid money stopped if they didn't report enough suspected cases.
Still, even with overreporting, the outbreak of cholera was "massive," Paul B. Spiegel, the lead author of the study and director of the university's Center for Humanitarian Health, told the AP.
Another study, published in December 2018 in the journal BMC Public Health, called the epidemic "the largest cholera outbreak in epidemiologically recorded history."
The report said the scale of Yemen's outbreak "most likely" could have been avoided or managed if enough cholera vaccines had been deployed earlier in the conflict. It added that even if a large shipment had come into the country early enough, getting the vaccine to those who needed it might not have been possible, given the "deeply chaotic situation" across war-torn Yemen.
More than 2.5 million doses of the cholera vaccine have been transported into Yemen by the U.N. since mid-2018. It's unclear how many of them have been administered to people in target populations. Two Houthi officials confirmed to the AP that nearly 1.2 million doses remain stored in warehouses in Sanaa, the rebels' capital. The Health Ministry there plans to distribute those doses soon in two northern districts, one of the officials said.
A senior aid official said the continuing cholera crisis remains a way for the Houthis rebels to cultivate global sympathy for their struggle against the U.S.-backed and Saudi-led coalition, whose bombing campaign has been blamed for helping to create the conditions that caused the outbreak.
"If you resolve cholera, what are the headlines?" he said. "They managed to control the narrative because it's easy to blame the coalition and not them and they always show up as victims."
Al-Hadri, the spokesman for the Houthi-controlled Health Ministry in Sanaa, called that nonsense. It is international aid officials, he said, who are raking in donations and benefiting from disease and suffering inside the Middle East's poorest country.
"They are profiting from the Yemen crisis and begging in the name of Yemen," he said. "They need the Yemeni crisis more than we need them."
The AP's reporting on the war in Yemen is supported by a grant from the Pulitzer Center on Crisis Reporting.