Much has changed since 1945 when along with the signing of the United Nations Charter the roles and responsibilities of humanitarian actions and activities in future cross-border wars and conflicts were defined and guided by new International Humanitarian Laws (IHL) and the Geneva Convention (GC). Indeed, the reasons for humanitarian crises and how the world responds to them have changed every decade or so since that time. Today, declared cross-border wars are no longer the norm. The end of the Cold War led to multiple unconventional intrastate conflicts and wars leading to millions of internally displaced and refugee populations. But by the turn of the century nondeclared unconventional wars became the new norm. Social-media-driven nation-state revolts have taken dominance, especially in the Middle East. The rise of multiple nonstate actors with increasingly organized armed violence has shown little knowledge of the GC or respect for the humanitarian principles of neutrality, impartiality, humanity, and independence that have been the foundation of humanitarian assistance by the International Committee of the Red Cross and nongovernmental agencies like Médecins Sans Frontières for decades. Aid worker security is dependent on the perception, by all combatants, that they are independent and impartial. Unfortunately, today more aid workers are killed each year than Peacekeepers, and insecurity or danger to staff has resulted in the rate of aid projects closed or suspended to double each year. ¹

Nowhere has this dilemma proved more complex and dangerous than the plight of citizens in war-torn Yemen. Yet, few in the outside world are aware of the dire circumstances and severe implications this brings, not only to the current state of need for a ravaged society but to how we all perceive the world’s risks, and responsibilities, to both inaction and how global health security itself is being played out every day in Yemen. In point of fact, few peer-reviewed medical journals have reported on the devastating health effects that the GC violations against human rights in the poorest country of the Arab world will have on the feasibility of future humanitarian aid operations both in Yemen and in other conflicts worldwide.Reference Ripoll Gallardo, Ragazzoni and Della Corte ^{2 -} Reference Salisbury ⁴

The current conflict in Yemen comes after several decades of political and social decline characterized by almost uninterrupted violence that began following its unification in 1990. In 2011, the unrests following the Arab Spring ended the 3 decades of President Saleh’s supremacy and led to a series of international efforts to mediate a successful post-conflict transitional process based on a widely inclusive system of elite political players and local groups. However, the process was perceived as lacking transparency and accountability and the transitional government and its newly appointed leader Abdrabbuh M. Hadi were deemed incapable of addressing local and national grievances and improving Yemeni living conditions.Reference Salisbury ⁴ In 2014, the Iran-backed Shiite Houthi rebels, supported by ex-president Saleh and his political network, seized the capital and deposed the short-lived government. In a state now on the verge of collapse, a Sunni coalition led by Saudi Arabia set off a military intervention of massive airstrikes in March 2015, on a claim of national security and the restoration of the United Nations-recognized Haidi government.Reference Black ⁵ This political and social instability has been exploited since the very beginning by nonstate and terrorist actors to sow chaos and expand their presence across the country.

The figures reported by the UN Office for the Coordination of Humanitarian Affairs reveal a country where more than half of the 24.97 million Yemeni population lived below the poverty threshold before the escalation of the violence and where the estimated number of the population needing immediate humanitarian assistance was raised to 21.2 million. ⁶ Since the beginning of the airstrikes, a total of 30,000 casualties have been reported and at least 6000 (90% civilians) have lost their lives. ^{7 , 8} Moreover, 2.76 million people are internally displaced (IDP) and 177,620 have already fled the country and sought asylum elsewhere, mostly in Oman, ⁹ the only member of the Gulf Cooperation Council that decided not adhere to the Saudi Arabia-led coalition. As expected, this fighting has prompted the quick deterioration of the already precarious living conditions, with 2.7 million people requiring shelter, 14.4 million being food insecure, and 19.3 million having no access to clean water. This situation turned even more critical after the severe flash floods that hit the country in November 2015 and April 2016.

The outbreak of yet another war with almost uninterrupted air attacks targeting mainly civilians have harshly stricken the communities and the capacity of the health care system to respond. The increasingly scarce numbers of health care professionals are unable to provide even basic assistance to the continuous waves of casualties among whom at least 8 children are mutilated or killed every day. Many local health staff have relocated or fled the country to protect their families, leaving only a few still on duty without salary for months under conditions of shortage or absence of essential medicines, supplies, and equipment. ⁶ Basic health care today is dependent on the interventions of international humanitarian organizations with health workers struggling to provide first-line emergency health care, leaving follow-up treatment of chronic health disorders impossible.Reference Ripoll Gallardo, Ragazzoni and Della Corte ² With the indiscriminate bombing of markets, universities, and essential public health infrastructure, all in clear contravention of IHL and the GC, the humanitarian aid organizations have only limited access to the population in need despite the rising numbers of injured and dead. ^{10 , 11} Neither the IDP camps nor warehouses hosting humanitarian supplies have been spared, with dozens of civilians killed by air raids while seeking protection outside the cities or during desperate attempts to reach emergency health facilities only to be stopped or delayed due to the lack of petrol, countless and poorly improvised checkpoints, and unusable roads.

While health care needs continue to increase, the security status for local and international humanitarian actors has become extremely dangerous. In March 2015, several humanitarian organizations were forced to leave the country because of security constraints,Reference Samar ¹² with hospitals suffering unmitigated damage. At least 3 appropriately and clearly designated medical centers run by Médecins Sans Frontières have been bombed, ¹³ and dozens of other health facilities have also been destroyed or rendered unusable by airstrikes. Nongovernmental organizations face a severe shortage of a well-prepared and experienced workforce, which is increasingly exposed to injury or death while trying to provide relief to civilians caught up in this massacre. Bureaucratic hurdles posed by current local leaders pose a hug additional impediment for essential technical need assessments and the mobilization of teams and supplies of emergency assistance to the most conflict-stricken areas.

In contrast with other ongoing humanitarian crises such as Syria or Iraq, this conflict has been relegated to a lower order of priority on the international media landscape despite representing one of the world’s worst humanitarian crises ever recorded. Usually, mass media campaigns are often triggered by external ad hoc political interests and huge movements of refugees across borders or via sea routes. Noteworthy in this tragedy is that the movements of civilians appear irrelevant to the outside world in great part because of geographic and geopolitical hurdles that leave the fleeing Yemeni population with very few viable options. Expansive and dangerous desert terrain and extremely insecure sea routes that only lead to severely disrupted and hostile countries such as Somalia leave fleeing populations exposed to a merciless cross fire from competing nonstate actors.

Regrettably, these atrocities are being committed daily in front of an indifferent and silent international audience. At the time of this writing, the third round of UN-mediated peace talks are being held in Kuwait. Yet, this senseless massacre is still being fueled by economic interests and strategic advantages of countries like the United Kingdom, United States, France, and Canada, to name but a few. ^{14 ,} Reference Wearing ¹⁵ These geopolitical factors contribute to the depiction of a war that is no longer, or has never truly been, a conflict between 2 big coalitions but rather a scenario where a clear victory by any of the multiple local and external players involved is quite unlikely. Moreover, it is paramount that the outside world gain a deeper understanding of other minority, but equally important, local actors that should be taken into consideration when drafting any roadmap leading to a long-lasting cease fire. This is critically necessary to avoid a resumption of violent clashes immediately after the end of the ongoing conflict. This pattern of behavior and outcome, now occurring in Yemen, also occurred in collapsed countries like Libya, Iraq, and Syria and represent very clearly the consequences of inaction by the international community at the initial stages of the conflicts. While there is still hope for resolution through political mediation leading to a peace treaty, opportunities for an outside peaceful intervention are lessening with the risk of Yemen turning into a hopeless failed state rising day by day.

Sadly, we have become a global society numbed by one senseless war after another. Denial is protective to one’s collective psyche only in the short term. History tells us as a global community that inaction will only cease if we recognize that which initially drove the international community to derive the unprecedented IHL and GC challenges after WWII. These same legal principles must be reborn in today’s disruptive global society. To do so we must regain the humanitarian principles relevant to criteria under today’s unique international and noninternational armed conflicts. Sir William Osler reminded graduates of a medical school in 1906 that medicine is the “only world-wide profession, following everywhere the same methods, actuated by the same ambitions, and pursuing the same ends...a homogeneity not shared by the law” and certainly not by religions.Reference Osler ¹⁶ In similar spirit, today’s global health community must in solidarity take collective responsibility and immediately call for all belligerent parties to cease the massacre and commit to international humanitarian law as there is “no moral, legal, or strategic justification” for this war to continue.Reference Thrall and Glaser ¹⁷ Vulnerable people must be spared, medical assistance guaranteed, provision of humanitarian aid permitted, and free flow of information supported.