The city of Ta’iz has been besieged since early April 2015 when an alliance of local forces led by the Muslim Brotherhood fought off the Houthis’ attempt to control the city. The Houthi rebels responded by cutting off roads and blocking the delivery of food and medical aid. Pro-government forces partially broke the siege in heavy fighting in March. However, since then, neither side has been able to extend control over the entire city. Recent reports suggest that the city is still under siege.

The United Nations (UN) defines a besieged area as “an area surrounded by armed actors with the sustained effect that humanitarian assistance cannot regularly enter, and civilian, the sick, and the wounded cannot regularly exit the area.” Access in and out of Ta’iz is restricted and dangerous for both civilians and humanitarian agents. All roads into and out of the city are controlled by the Houthi armed group and its allies. The only access into the city is the al-Duhi crossing in the West, however this is only opened on an intermittent basis and is heavily controlled; as such, residents are mostly trapped inside. Around 200,000 people are living under siege in Ta’iz with almost no access to humanitarian aid. Hospitals in Ta’iz continue to receive a high influx of wounded patients as a result of the intense fighting in the area. A large part of the population is displaced within the city. Fighting is so severe that aid workers have reported being unable to arrive to medical facilities.

Blockages of Aid Deliveries

In May 2016, John Ging, Director of Operations in the Office for the Coordination of Humanitarian Affairs (OCHA), said that Yemenis were dying of preventable illnesses because of the limited availability of even the most basic medical supplies. Checkpoints and intense fighting have stopped humanitarian aid from being delivered to Ta’iz. Between August 2015 and January 2016, there were no deliveries of medical aid. Such severe shortages led to the cessation of wound treatment, surgery, and other types of care on multiple occasions. Malnutrition and vaccine-preventable diseases are prevalent. Medical personnel struggle to treat chronic conditions like heart disease and strokes. There are no provisions or resources for mental health care.

On 16 January 2016, Doctors Without Borders (MSF) delivered two trucks with essential medical supplies. The delivery followed five months of negotiations with officials, which saw governmental and non-governmental organizations trying to gain access to the city. Karline Kleijer, MSF’s emergency manager for Yemen, said, “These essential medical supplies – including chest tubes, anesthetic drugs, fluid, sutures and antibiotics – will support lifesaving surgeries in the hospitals.”

On 31 January 2016, the World Health Organization (WHO) was finally able to deliver over 20 tons of medicine and medical supplies. The delivery followed eight weeks of the agency being unable to enter Ta’iz. The supplies were distributed to the city’s Al-Thawra, Al-Jumhouri, Al-Rawdha, and Al-Ta’aown hospitals and included trauma kits, interagency emergency health kits, diarrheal disease kits, and oxygen cylinders. All together, these supplies could reportedly provide for around 35,000 people. Al-Thawra hospital was also equipped with dialysis solutions, which would allow for 30,000 dialysis sessions in the following year. WHO representative Dr. Ahmed Shadoul said, “Hospital staff in Ta’iz City are desperate for medicines and medical supplies so that they can continue to offer the most basic medical care.”

In early February 2016, the International Committee of the Red Cross (ICRC) said that it had made two deliveries of medical supplies to Ta’iz. The organization provided three tons of medical supplies including surgical items, intravenous fluids, and anesthetic supplies, which would provide for the treatment of hundreds of injured people. In addition, medicines and supplies for pregnant women were provided. This was the first time that the ICRC had been able to enter the city since August 2015.

Shortages of Oxygen Cylinders

The Ta’iz Medical Committee, which is tasked with distributing medical supplies and addressing the medical situation, reported that before the conflict began, hospitals in the city required 200 – 250 cylinders of oxygen per day. In February 2016, these hospitals were sharing between twenty to thirty oxygen cylinders per day. The cylinders are smuggled in across the mountain. They now cost an average of $70 each, where before they were $20. There are approximately 300 donkeys and twenty camels being used to bring food, medicine, propane, and oxygen into the city. A smuggler named Noaman Zaid reported making YR5000 ($23) for carrying an oxygen canister; with his camel, he is able to transport two canisters at a time and can make two trips per day. Doctors themselves are tasked with going to meet the animals and their owners in order to be sure that the oxygen goes straight to the hospitals, where it is needed. Some local non-governmental organizations (NGOs) support these smugglers. “Hand in Hand,” is a campaign run by Esam Albdulhamid A-Batra, which raises money from individuals and charities in order to buy oxygen cylinders in Aden, and then send them to Ta’iz. A-Batra described the complicated process of smuggling oxygen cylinders into the city, “We buy an oxygen cylinder for YR3000 ($14), and pay YR5000 ($23) for a car to bring it to [the smugglers’ village]. Then we pay YR5000 ($23) to the camels’ owners, then YR2000 ($9) for cars to transport the cylinders to the hospitals. So the one cylinder costs around YR15000 ($70).”

In December 2015, Mohammad Shihabi’s newborn baby died hours after his birth as a result of severe oxygen shortages in the city’s hospitals. Mohammad Shihabi, a resident of Ta’iz, visited five separate hospitals with his son in search of oxygen, but was unable to find any supplies. “My son was 14 hours old when he died… When he was born the doctors told us he needed intensive care and oxygen because he didn’t have enough fluids. We took him to every hospital we possibly could before he finally died. I wanted to take him outside the city but there was no way out,” he said. The director of al-Rawdha hospital also highlighted shortages of oxygen faced by hospitals in the city. He said that al-Rawdha hospital was now incapable of carrying out surgery or treating patients in intensive care as a result of the deficit. He stated, “We receive 15 to 20 such cases every day. Today we received five, three of them died. They were all civilians seriously injured during indiscriminate shelling.”

Samar Ameen, an activist from the western neighborhood of Khadeer, recalled an incident in January 2016 in which Houthi soldiers confiscated 34 oxygen cylinders which were due to be delivered to al-Thawra hospital. She said, “They held the driver for three days. He told me that they humiliated him and pressured him to confess he planned to deliver the oxygen to opposition groups.” Residents have reported other instances of the Houthi rebels stopping civilians crossing checkpoints from bringing in oxygen cylinders intended for hospitals. In some instances, the rebels confiscated the goods.

In January 2016, Nora Echaibi, an MSF nurse described the lack of oxygen in hospitals in Ta’iz, noting that Al-Thawra hospital had very little oxygen as did Al-Rawdah, Al-Jamhouri Yemeny, Al-Modaffar, and Ta’aown. She described seeing an oxygen-dependent newborn baby in a maternity ward, which was connected to machinery with no oxygen canister attached. She emphasized that MSF warehouses outside of the besieged area were fully stocked with gas cylinders.

James Lynch, Deputy Middle East and North Africa Director of Amnesty International, said, “The Houthi forces appear to be deliberately barring the entry of civilian goods, including vital medical supplies and food, fueling a humanitarian crisis with devastating consequences for residents of Ta’iz.”

Obstacles to Effective Medical Treatment in Ta’iz

In February 2016, a BBC Arabic documentary reported on the difficulties faced by medical staff in Ta’iz on a daily basis. They were forced to operate on patients without anesthesia, to ration blood, and – on some occasions –watch their patients die because they were not able to provide oxygen. In January 2016, Nora Echaibi described finding medical activities at Al-Thawra hospital dramatically reduced. Medical supplies, particularly anesthesia, were very limited and there was little fuel for their generator. She stated, “It was painful to witness large hospitals like Al-Jamhouri, which I am used to seeing bustling with activity, instead so still.”

In October 2015, Dr. Esam Mahyoub Dahan, head of the Kidney Transplant Department in one of Taiz’s hospitals, stated that the department had been shut down since July 2015 as a result of a lack of solutions necessary for renal dialysis. He added that the Houthi forces were hindering the entry of a shipment of blood solutions donated by the Qatari Red Crescent. Dr. Dahan said, “We suffer in the hospital from a shortage of water which is essential for the department to work and diesel is out of reach. These shortages caused the generators to stop functioning and, therefore, the department stopped working.”

Militarization of Heath Care Facilities

Yemen’s largest cancer hospital, the Amal Hospital, has been unable to treat hundreds of its patients. Many of these individuals are critically ill and risk death without treatment. During the summer of 2015, the hospital was used as a battleground. Houthi rebels stormed the facility and positioned snipers on its rooftop along with tanks around the perimeter. Hospital staff and patients were forced to move to the basement to avoid being injured by mortars, bullets, and shrapnel. After some days of fighting, pro-government forces retook the building. The Houthis responded by shelling the building with artillery. The hospital was almost totally destroyed, along with much medical equipment. Medical personnel were forced to move to a new location in a shopping mall with very little equipment. Although the hospital receives up to 50 patients per day, there are only 20 beds. Many patients encounter difficulties in arriving to the hospital as they are unable to safely cross front lines in order to reach the facility. Over 640 of the hospital’s cancer patients died in 2015, triple the number of deaths the year before.

Attacks on Health Facilities

On 2 December 2015, an airstrike by the Saudi Arabia-led coalition hit an MSF run clinic in Ta’iz’s Al Houban district. The attack wounded nine people, including two staff. The clinic came under attacks despite the organisation making the coalition aware of its location.

In February 2016, it was reported the Al-Thawra Hospital was damaged as a result of nearby shelling. Pressure from the shelling had caused all the windows to be blown out and several direct hits had almost totally destroyed one ward. Sadeq Shujaa, head of the local doctor’s union, stated that “shelling hit the only cancer hospital and the children’s hospital, shutting them down.”

Abduction of Dr. Abdul Kader Al Guneid

On 5 August 2015, Dr. Abdul Kader Al Guneid, a medical doctor from Ta’iz, was kidnapped by the Houthis. Dr. Al Guneid had been a vocal critic of Houthi crimes from early on and worked as a volunteer lecturer at Ta’iz medical school along with providing free medical care to people in rural areas. Dr. Al Guneid was at home when armed men dressed in civilian clothes broke into his house and threatened his wife. They used physical force to abduct him and then looted the house. His son said, “They stole valuable items…They also stole money, one laptop and three mobiles…They even threatened my mother if she doesn’t co-operate with them.” Dr. Al Guneid managed to tweet, “Houthi rebels are at my house,” before being driven away by the rebels. He has not been seen since. Human rights organisations allege that his abduction is related to his strong presence on online media, particularly Twitter, which he used to document and bring attention to crimes committed by the Houthi rebels. Joe Stork, deputy Middle East director or Human Rights Watch, commented, “Since taking over much of Yemen, the Houthis have arbitrarily detained people critical of their movement.”

Jurisdictional Concerns

The conflict in Yemen is perpetrated by many different parties. The Saudi-led coalition, which includes Bahrain, Egypt, Jordan, Kuwait, Morocco, Qatar, Sudan, and the UAE, is working with units of the Yemeni Army loyal to President Hadi, as well as Southern Separatists, tribal factions, and other forces. These actors are fighting against another group consisting of Northern Yemeni fighters and units of the Yemeni Army who are loyal to the former president, Ali Abdullah Saleh. Further, there are a number of extremist or ‘Jihadi’ groups operating in the country, including the Islamic State of Iraq and the Levant (ISIL) and Al Qaeda in the Arab Peninsula (AQAP). The US is providing direct assistance to the Saudi-led coalition.

International humanitarian law (IHL) differentiates between two situations of armed conflict. The first is international armed conflicts (IACs) and the second is non-international armed conflicts (NIACs). An armed conflict is classified as an IAC when it is between at least two State actors, while an NIAC takes place between a State and one or more non-State actors or between two or more non-State actors. Different IHL rules and protections apply depending on whether an armed conflict is an IAC or an NIAC.

The conflict in Yemen is classified as an NIAC. This is because the Houthis and their allies have a sufficient level of organization to be capable of sustaining military operations and of adhering to IHL, and there is a sufficient degree of intensity in hostilities between the Houthis and their allies and the forces loyal to President Hadi and their allies, as measured inter alia by the weapons employed and the duration of the conflict. Additionally, the conflict is classified as an NIAC rather than an IAC because the UN Security Council has reaffirmed its support for the legitimacy of President Hadi’s government, thus the Saudi-led Coalition is said to be acting at the invitation of President Hadi.

International Humanitarian Law Applicable to the Conflict

In an NIAC, IHL imposes obligations and limits on how parties to the conflict are permitted to undertake hostilities. The obligations arise by operation of Article 3 common to all four Geneva Conventions, Additional Protocol II to the 1949 Geneva Conventions, to which Saudi Arabia and Yemen are parties, and customary international law. Common Article 3 to the 1949 Geneva Conventions and Additional Protocol II are widely recognized to be customary IHL. As such, non-State actors such as the Houthi armed group are bound to uphold the standards they set out.

Common Article 3 Violations

The siege of Ta’iz violates Common Article 3(1)(a), which mandates that all civilians and those taking no active part in hostilities be treated humanely, as the denial of deliveries of food supplies has led the city’s population to famine. In addition, medical facilities in the city have run out of life-saving medicines and medical supplies, resulting in civilians being unable to access adequate healthcare. In this way, the armed actors participating in the siege are contributing to the inhumane treatment of civilians. The continued denial of access for humanitarian organizations violates the prohibitions set forth by Common Article 3, which are binding on States, but their violation may also give rise to individual criminal responsibility, when committed with the requisite intent.

Additional Protocol II Violations

Additional Protocol II Article 18(2) requires that relief actions be organized for the civilian population in need, but does not contain a specific provision on access to humanitarian relief. However, such access is essential for relief efforts. Therefore, the denial of access of humanitarian organizations violates this article. Article 14, which prohibits the starvation of civilians as a method of combat, has also been breached, as this tactic has been used by the Houthis in the city. The militarization of Amal Hospital for use as a battleground and its subsequent shelling violates Article 11(1), which stipulates that medical units and transports shall be respected and protected at all times and shall not be the object of attack. The continual siege of Ta’iz, and the subsequent effect on food and healthcare within the city, violates Article 4 (b), which prohibits collective punishment. The confiscation of medical supplies such as oxygen cylinders breaches Article 14, which prohibits attacks on or the destruction of objects indispensable to the survival of the civilian population. The Saudi-led coalition’s airstrike on an MSF run clinic violated Article 11 which mandates that medical units shall not be the object of attack.

Customary IHL Violations

The abduction of Dr. Abdul Kader Al Guneid violates Rule 25 of customary IHL, which states that medical personnel exclusively assigned to medical duties must be respected and protected in all circumstances. The militarization of and attacks on medical units such as the Amal Hospital breach Rule 28, which states that medical units exclusively assigned to medical purposes must be respected and protected in all circumstances.

Scope of Protections Afforded under IACS vs NIACs

Given that the siege of Ta’iz has taken place in the context of an NIAC, the relevant legal framework is NIAC law. While the protections provided by Common Article 3, Additional Protocol II, and customary IHL are strong, international law provides even stronger, more specific protections and regulations for situations in an IAC. Were the armed conflict in Yemen to be classified as an IAC, Geneva Conventions I and IV as well as Additional Protocol I would also be applicable.

Article 19 of Geneva Convention I and Article 18 of Geneva Convention IV mandate that civilian hospitals, fixed establishments and mobile medical units of the Medical Service may in no circumstances be attacked, and shall at all times be respected and protected. The militarization of and subsequent attacks on Amal Hospital would breach this article. This attack also violates Geneva Convention IV Article 20, which protects medics and hospital staff and Article 12 of Additional Protocol I, which mandates protections for medical units. The confiscation of medical equipment being transported into Ta’iz would violate Article 35 which states that transports of wounded and sick or of medical equipment shall be respected and protected. Houthi forces have violated Article 16 of Geneva Convention IV, which mandates that the wounded and sick shall be the object of particular protection and respect, by denying the wounded and sick of Ta’iz access to adequate medical care. Article 23 of Geneva Convention IV, which obligates parties to the conflict to allow the free passage of all consignments of medical and hospital stores and objects, are breached by the denial of deliveries of medical supplies and the confiscation of such supplies. The Houthis are obligated to allow and facilitate rapid and unimpeded passage of all relief consignments, equipment, and personnel necessary as mandated by Article 70 of Additional Protocol I. Further, the denial of entry of ICRC actors would be prohibited as stated in Article 81 of Additional Protocol I, which mandates that Parties to the conflict grant to the ICRC all facilities within their power so as to enable it to carry out the humanitarian functions assigned to it by the Conventions.

Medical Impartiality

The siege of Ta’iz violates the principle of medical impartiality on numerous occasions. Attacks on medical units such as the Amal hospital violate the principle of noninterference of medical impartiality. Noninterference prohibits attacks on medical services, the obstruction of a patient’s access to medical services, and obstruction of medical personnel’s access to patients. Medical personnel and deliveries of medical supplies have been denied access to the city, obstructing both patients’ access to medical services and medical personnel’s access to patients. The international principle of medical impartiality, which states that no person or group shall interfere with the access to or delivery of medical services in times of conflict and civil unrest has been breached by the actions of the Houthi forces.

Conclusion

Both the Saudi-led coalition and the Houthi armed group and its allies have been responsible for grave breaches of IHL and medical impartiality since the beginning of the siege of Ta’iz, which may amount to war crimes. Those who are suspected to have committed war crimes must be referred to the International Criminal Court by the Security Council. In addition, ICRC training must take place so that all warring factions understand the laws of war and are thus better equipped to uphold its obligations. This becomes all the more relevant in a conflict such as that taking place in Yemen, where there are multiple actors including many non-State parties.

As the classification of Yemen as an NIAC is not fixed, there must be continual efforts to reassess the situation in case it should meet any requirements that would allow for its reclassification as an IAC. This is especially pertinent given the wider legal protections afforded to the healthcare sector in IACs.

Given the changing ways in which conflicts are fought today, with many increasingly falling under the categorization of NIACs, Geneva Conventions I and IV and Additional Protocol I would offer more explicit protections to medical units, personnel, and health care. The international community should take steps to establish universal recognition of the Geneva Conventions’ protection of medical impartiality in both NIACs and IACs.