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Health dynamics in war-torn Yemen: insights from 32 years of epidemiological data (1990–2021)

Population Health Metrics volume 23, Article number: 4 (2025) Cite this article

Abstract

Background

Yemen is the poorest and war-torn country in the North Africa and Middle East region and lacks a comprehensive assessment of temporal trends in the overall disease burden, injuries, and disabilities at the country level; these insights are required to guide healthcare interventions and improve overall population health. We estimated the burden and temporal trends of diseases and their risk factors in Yemen between 1990 and 2021 using data from the Global Burden of Diseases (GBD), Injuries, and Risk Factors Study 2021.

Methods

In this systematic analysis, we presented all-causes and cause-specific mortality rates, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), as well as the life expectancy at birth and health-adjusted life expectancy (HALE) using the standardized GBD methodology. Moreover, we compared the disease burden of Yemen with the top five war-torn countries based on the Global Peace Index (GPI) 2021, including Afghanistan, Syria, South Sudan, and Iraq.

Results

In Yemen, the life expectancy at birth increased from 59.0 years (95% UI 56.4–61.8) in 1990 to 65.3 years (95% UI 62.2–67.9) in 2021. Between 1990 and 2021, the all-causes age-standardized mortality rate in Yemen decreased from 1471.7 deaths (95% UI 1268.4-1696.3) to 1347.2 deaths (95% UI 1097.5-1659.5). However, the age-standardized mortality rate caused by conflict and terrorism substantially increased from 1.9 deaths (95% UI 1.7–2.1) to 50.0 deaths (95% UI 45.5–55.0) between 2010 and 2021. In 2021, ischemic heart disease, COVID-19, stroke, hypertensive heart disease, conflict and terrorism, and neonatal disorders were leading causes of age-standardized mortality and YLLs rate. Dietary iron deficiency, low back pain, depressive disorders, headache disorders, anxiety disorders, and gynecological diseases were the leading causes of age-standardized YLDs rate in 2021. High blood pressure, high levels of low-density lipoprotein, smoking, low birth weight, and short gestations were the leading risk factors for age-standardized mortality in 2021. Yemen ranked 3rd in terms of high age-standardized all-causes deaths, YLLs, and lowest HALE at birth and lowest life expectancy at birth among the top five war-torn countries in 2021.

Conclusion

Yemen must proportionately address the burden caused by non-communicable diseases, communicable, maternal, neonatal, and nutritional diseases, and conflict and terrorism. Prioritizing these areas will improve the overall population health and prevent premature mortality and disabilities.

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Introduction

Yemen, one of the poorest countries in the Middle East, ranked 166th out of 167 countries according to the Legatum Prosperity Index 2023. The country has been devastated by a destructive phase that began in 2014 and escalated from 2015 onwards. The conflict has resulted in an estimated 100,000 deaths from combat and 130,000 deaths due to lack of food, healthcare, and infrastructure. Tragically, this includes around 3,000 children. Additionally, 3.6 million people have been internally displaced, and nearly 80% of Yemen’s population of almost 30 million people requires humanitarian assistance [1, 2]. Access to food and healthcare is a significant challenge, with 45% of children who are dying suffering from severe malnutrition. Women and children make up 50% of the conflict’s victims. The economy has crumbled, with gross domestic product (GDP) declining by 50%, and an alarming 58% of Yemenis now live in extreme poverty, compared to 19% before the conflict [3]. The healthcare system has been severely impacted, with less than half of public health facilities functioning properly. Health workers have gone unpaid for extended periods, and there is a shortage or absence of essential medications and equipment. Health facilities have been damaged or destroyed, and healthcare workers have been targeted, resulting in a significant reduction in infrastructure and human resources for healthcare provision [4].

A significant number of humanitarian assistance entities are actively involved in responding to the crisis in Yemen. According to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), the total humanitarian funding provided in 2018 amounted to 5.17 billion USD. At the end of 2018, there were 133 organizations operating in Yemen, including 10 United Nations organizations, 31 international nongovernmental organizations (NGOs), and 92 national NGOs. However, despite the presence of these entities, delivering aid and materials to people in need has been extremely challenging [5, 6]. The difficult operating environment, including the ongoing conflict and insecurity, has hindered the effective distribution of humanitarian assistance. This has made it difficult to reach all affected populations and provide them with the necessary support [7].

Due to the prolonged conflict in Yemen, there has been a lack of reporting on important health indicators such as prevalence, risk factors, life expectancy, fertility, and mortality since 2014/2015 [8]. Understanding of these health indicators is crucial for effective healthcare planning and resource allocation [9]. The Global Burden of Disease Study (GBD) is a comprehensive effort that quantifies the contribution of specific diseases, injuries, and risk factors to the overall burden of disease in 204 countries and territories, providing regular updates [10]. In contrast, some studies have examined the burden of specific diseases in Yemen [11,12,13,14,15]. These studies are limited to a particular domain and failed to present national-level data over time regarding the overall burden of diseases and risk factors in the country.

Furthermore, there has been no comprehensive assessment conducted to analyze the prevalence and trends of all diseases, injuries, and disabilities in Yemen using the most up-to-date GBD estimates [11,12,13,14,15]. Such an analysis would provide valuable insights into the overall health situation in the country and help guide healthcare interventions and policies. Therefore, this study aimed to systematically analyze the burden of diseases and risk factors in Yemen from 1990 to 2021 using the comprehensive methodology of the GBD study 2021.

Methods

Data sources

A country-specific data for disease burden was extracted for Yemen from the freely available online database sources of the global burden of diseases (GBD) study 2021 (GBD 2021, http://ghdx.healthdata.org/ gbd-results-tool) between 1990 and 2021 [16]. The data sources included registries, surveys, surveillance, and censuses. In collaboration with the World Health Organization (WHO), Global Health Observatory, and the World Bank Open Data, GBD 2021 comprehensively estimates 286 causes of death, 369 diseases and injuries, and 87 behavioral, metabolic, environmental, and occupational risk factors at the country, regional, and global levels. The University of Washington’s Institute for Health Metrics and Evaluation (IHME) is in charge of gathering and managing the GBD data. Consequently, a waiver of informed consent was reviewed and approved by the Institutional Review Board of Washington University [17, 18].

Estimates

We estimated all-causes, cause-specific, all-ages, and age-standardized mortality, disability-adjusted life-years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs) rates across Yemen using GBD 2021 data from 1990 to 2021. GBD consists of four different levels of causes of death and diseases ranging from major level causes (i.e., levels 1–2) to the finest level causes (i.e., levels 3–4). Moreover, deaths and disease are attributed to 87 risk factors comprising four levels. Level 1 comprises three main risk factors, including behavioral risks, environmental and occupational risks, and metabolic risks, and level 2, level 3, and level 4 consist of twenty, fifty-two, and sixty-nine risk factors, respectively. We presented a ranking of level 3 causes of death, YLLs, YLDs, and level 4 risk factors unless otherwise specified [10, 19].

The cause-specific mortality and all-cause mortality were estimated by using the Cause of Death Ensemble model and an algorithm called CoDCorrect, respectively, for both sexes combined, males and females, age groups, location, and year [17]. Age-standardized rates of all-cause and cause-specific mortality were calculated using a variety of data sources, such as vital registration systems, surveys, and censuses. A Bayesian meta-regression method called Disease Modelling Meta-Regression (DisMod-MR 2.1) was used to generate the prevalence estimates for both sexes combined, males and females, age groups, location, and year, and its details are described elsewhere [17]. YLDs is a non-fatal burden and is computed as the product of prevalence estimates, and a corresponding disability weight based on disease severity and comorbidity, and its detailed calculation is previously reported elsewhere [16]. YLLs indicate a measure of premature death. YLLs rate is calculated by multiplying each cause-specific death within each age group by the standard reference life expectancy for each respective age group in which deaths occurred [16]. DALYs were calculated as the sum of YLLs and YLDs for both sexes combined, males and females, age groups, location, and year, and one DALY indicates 1 lost year of a healthy life. Health-adjusted life expectancy (HALE) is the average number of years that a person is expected to live in full health. It is a summary metric of average population health reflecting age-specific mortality and morbidity and was calculated by using YLDS and life Table [20]. Life expectancy (LE) is a metric of the average time that a person is expected to live based on year of birth, age, sex, and other demographic factors. LE at birth and for specific age was computed on the basis of expected mortality rates by using the world population age standard, and its detailed methodological approach has been reported elsewhere [16].

Comparison with the top most war-torn countries

We compared Yemen with the top five war-torn countries based on the Global Peace Index (GPI) 2021 in terms of age-standardized rate of all-cause mortality, YLLs, YLDs, as well as life expectancy at birth and HALE from 1990 to 2021. The GPI estimates the relative peacefulness of countries and regions across three domains, including societal safety and security, ongoing domestic and international conflict, and militarization, which is produced and ranked by the Institute for Economics and Peace (IEP). Among 163 countries, the top five worst peaceful countries were Afghanistan, followed by Yemen, Syria, South Sudan, and Iraq, according to GPI 2021 [21].

Results

Life expectancy and HALE at birth

In Yemen, life expectancy at birth consistently increased from 59.0 years (95% UI 56.4–61.8) in 1990 to 65.3 years (95% UI 62.2–67.9) in 2021. Compared to males, females showed a higher expectancy at birth from 1990 (61.0 years, 95%UI 58.5–63.5 vs. 57.2 years, 95%UI 54.5–60.2) to 2021 (68.5 years, 95%UI 65.5–70.9 vs. 62.4 years, 95%UI 59.4–65.2). Yemen also observed an improvement in HALE at birth between 1990 and 2021 in both sexes (50.4 years, 95%UI 47.1–53.6 to 56.1 years, 95%UI 52.8–59.1), males (50.5 years, 95%UI 47.2–53.5 to 55.2 years, 95%UI 52.2–58.1), and females (50.4 years, 95%UI 46.8–53.8 to 57.1 years, 95%UI 53.3–60.6) (Table S1–S3).

Burden and trends of all-cause, non-communicable diseases, communicable, maternal, neonatal, and nutritional diseases, and injuries related deaths, DALYs, YLDs, and YLLs

The age-standardized all-causes death rate per 100,000 population in Yemen decreased by -8.4% (-13.4 to -2.1) from 1990 to 2021. The age-standardized all-causes YLLs rate declined by -29.8% (-33.0 to -25.1) from 55086.4 (95% UI 47976.4-62655.6) in 1990 to 38617.2 (95% UI 32130.2-46922.6) in 2021. However, the age-standardized all-causes YLDs rate increased from 11929.4 (95% UI 8832.9-15461.7) to 12856.4 (95% UI 9610.4-16909.5) with a rise of 7.7% (7.1 to 9.3) during the study period. The age-standardized all-causes DALYs rate declined by -23.1% (-25.2 to -20.7), but the relative proportion of YLLs to DALYs is significantly higher compared to the proportion of YLDs over the last three decades (Table 1).

The all-ages non-communicable diseases (NCDs) related deaths substantially increased by 101.6% (100.5 to 102.9) between 1990 and 2021. However, the age-standardized NCDs deaths rate decreased from 946.3 (95% UI 799.6-1118.9) in 1990 to 780.2 (95% UI 629.1-970.8) in 2021, with a decline of -17.5% (-21.3 to -13.2). The proportion of communicable, maternal, neonatal, and nutritional diseases (CMNN) to total deaths decreased from 37.6% (36.9 to 38.4) in 1990 to 32.0% (30.1 to 32.6) in 2021. In 2021, 49.5% (49.5 to 50.2) of total deaths were attributable to NCDs, followed by CMNN (32.0%, 30.1 to 32.6) and injuries (18.5%, 17.5 to 19.5). All-ages deaths (-22.5%, -32.9 to -14.2) and ag-standardized deaths rate (-17.4%, -37.6 to -10.2) for CMNN remarkably decreased from 1990 to 2021. Between 1990 and 2021, the all-ages injuries-related deaths and DALYs increased by 174.5% (137.5 to 238.9) and 165.5% (126.2 to 231.8), respectively (Table 2; Fig. 1).

Table 1 Age-standardized rate of all-cause deaths, DALYs, YLDs, and YLLs per 100,000 populations in Yamen from 1990 to 2021
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Table 2 All-ages number and age-standardized rate (per 100000 populations) of all-causes, non-communicable diseases, communicable, maternal, neonatal, and nutritional diseases, and injuries related deaths, DALYs, YLDs, and YLLs and its percentage changes between 1990 and 2021 in Yemen
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Fig. 1
figure 1

Causes of disease burden 2010, 2021 and annual percent change 1990–2010, 2010–2021, 1990–2021 in age standardised death rates (per 100,000) in Yemen. (A) Disease burden of death, box sexes, all ages (B) Disease burden of DALYs, box sexes, all ages; (Note: The size of each box represents the percentage of total deaths, while the colour intensity or darkness signifies the annual percent change between two time spans, as indicated)

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Trend and ranking of the age-standardized mortality, YLLs, and YLDs rate for the leading causes of diseases, disabilities, and injuries from 1990 to 2021

From 1990 to 2021, based on age-standardized mortality rate, ischemic heart disease ranked as the first leading cause of death, and COVID-19 ranked as the second leading cause of death. Stroke was the third leading cause of death in 2021. Conflict and terrorism was ranked as the 50th cause of death in 2010, but the associated mortality increased from 1.9 (95% UI 1.7–2.1) in 1990 to 50.0 (95% UI 45.5–55.0), and conflict and terrorism was ranked the fifth leading cause of deaths in 2021. Between 1990 and 2021, the mortality rate due to diabetes mellitus increased by 20.7% (12.6 to 25.9), and its rank jumped from 20th in 1990 to 16th in 2021. The age-standardized mortality rate due to cancers substantially increased by 9.8% (1.3 to 14.5) for tracheal, bronchus, and lung cancer and 3.0% (-7.4 to 8.8) for colon and rectum cancer from 1990 to 2021. The age-standardized mortality rate due to six causes, including neonatal disorders, lower respiratory infections, congenital birth defects, diarrheal diseases, maternal disorders, and tuberculosis, decreased by more than 50% from 1990 to 2021 (Table 3).

In 2021, the five leading causes of age-standardized YLLs rate were ischemic heart disease, COVID-19, stroke, conflict and terrorism, and neonatal disorders. Ischemic heart disease was ranked as the first leading cause of YLLs, and stroke ranked the third leading cause of YLLs in 1990, 2010, and 2021. The age-standardized YLLs caused by ischemic heart disease declined by -23.8% (-24.8 to -22.4) and − 32.3% (-35.4 to -28.7) for stroke from 1990 to 2021. The ranking of neonatal disorders based on the age-standardized YLLs rate decreased from second in 1990 to fifth in 2021, along with the YLLs rate reduction by -52.7% (-53.9 to -51.0) between 1990 and 2021. Additionally, ranked 39th in 2010, the age-standardized YLLs rate caused by conflict and terrorism increased from 120.5 (95% 108.3–134.0) to 3175.9 (95% UI 2888.2-3492.5) and was ranked fourth in 2021. Ranked fourth in 1990 and 18th in 2021, diarrheal diseases declined by -93.1% (-95.7 to -91.0). Lower respiratory infections decreased by -75.9% (-77.0 to -76.6) in terms of the age-standardized rate of YLLs, and its ranking declined from fifth in 1990 to 10th in 2021. Eight of the top 26 causes, comprising neonatal disorders, congenital birth defects, lower respiratory infections, maternal disorders, diarrheal diseases, asthma, fire, heat, and hot substances, and protein-energy malnutrition, showed more than 50% reduction in the age-standardized YLLs rate between 1990 and 2021. The age-standardized YLLs rate due to three causes comprising conflict and terrorism, diabetes mellitus, and tracheal, bronchus, and lung cancer markedly increased between 1990 and 2021 (Table 4).

Dietary iron deficiency and low back pain were the top two causes of age-standardized YLDs rate in 1990, 2010, and 2021. Between 1990 and 2021, the age-standardized YLDs rate for four of the top 25 causes markedly increased by 19–342%, including osteoarthritis, other musculoskeletal disorders, diabetes mellitus, and conflict and terrorism. Moreover, the age-standardized YLDs rate for four causes, including depressive disorders, anxiety disorders, neonatal disorders, and falls increased from 1.9 to 5.6% during 1990–2021. From 1990 to 2021, the age-standardized YLDs rates increased by more than 100% for two causes, including diabetes mellitus and conflict and terrorism. However, the age-standardized YLDs rates significantly declined for dietary iron deficiency, low back pain, gynecological diseases, age-related and other hearing loss, road injuries, Alzheimer’s disease and other dementias, asthma, and stroke between 1990 and 2021 (Table 5).

Table 3 Age-standardized rate (95% UI) of deaths with percentage changes between 1990 and 2010, 2010 and 2021, and 1990 and 2021 for the leading causes of diseases, disabilities, and injuries in Yemen
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Table 4 Age-standardized rate (95% UI) of YLLs with percentage changes between 1990 and 2010, 2010 and 2021, and 1990 and 2021 for the leading causes of diseases, disabilities, and injuries in Yemen
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Table 5 Age-standardized rate (95% UI) of YLDs with percentage changes between 1990 and 2010, 2010 and 2021, and 1990 and 2021 for the leading causes of diseases, disabilities, and injuries in Yemen
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Ranking of all-causes age-standardized DALYs and risk factors associated with deaths from 2010 to 2021

Ischemic heart disease ranked as the leading cause of age-standardized disability-adjusted life years (DALYs) in Yemen in both 2010 and 2021. By 2021, COVID-19 emerged as the second-highest cause, reflecting its significant health impact during the pandemic. Notably, injuries related to conflict and terrorism in Yemen showed a dramatic increase, rising from the 51st position in 2010 to the 3rd in 2021, highlighting the worsening impact of political instability and violence on public health. Additionally, neonatal preterm birth remained a prominent cause of DALYs, ranking closely behind the leading conditions in 2021 (Fig. 2).

Figure 3 illustrates the prominent risk factors for deaths in both 2010 and 2021. High blood pressure and high LDL consistently maintained their top positions as the leading risk factors associated with non-communicable disease-related deaths in Yemen throughout the period from 2010 to 2021. Notably, there was an increased rank observed for smoking and lead between 2010 and 2021. From 2010 to 2021, low birth weight, short gestation, household air pollution, and child underweight emerged as the predominant risk factors for deaths linked to communicable, maternal, neonatal, and nutritional diseases. Concurrently, occupational injuries claimed the top rank for injury-related deaths during this period, constituting 6.30% of total deaths in 2021 (95% CI: 4.79–8.06). In 2021, smoking featured prominently among the top ten leading risk factors for all causes of death, contributing to 6.05% of total deaths (95% CI: 4.68–7.38). The ranking of risk factors associated with DALYs closely mirrored the patterns observed in mortality.

Comparison with the top most war-torn countries

Estimates for Yemen were compared with the top five war-torn countries based on the Global Peace Index (GPI) 2021 including Afghanistan, Syria, South Sudan, and Iraq. Of these countries, Yemen ranked 3rd in terms of high age-standardized all-causes deaths, YLLs, and lowest HALE at birth and lowest life expectancy at birth after Afghanistan and South Sudan and ranked 2nd in terms of high age-standardized all-causes YLDs after Afghanistan for both sexes in 2021. Moreover, Yemen ranked 1st and 4th for the high age-standardized all-causes YLDs rate for females and males in 2021, respectively (Table S1–S3).

Fig. 2
figure 2

Changes in the ranking of age-standardised rate of disability-adjusted life-years between 2010 and 2021 for the all causes (Level-4) of diseases, disabilities, and injuries in Yemen

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Fig. 3
figure 3

Leading level-4 risk factors for deaths (ASR, per 100,000) associated with non-communicable and communicable diseases and injuries in Yemen in 2010 and 2021, both sexes

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Discussion

Our findings provide an important insight into the health situation in Yemen and shed light on the impact of the ongoing conflict and terrorism on the country’s population health status between 1990 and 2021. We observed that the life expectancy at birth and HALE in Yemen significantly improved and females showed consistently higher life expectancy and HALE compared to males during the study period. The age-standardized all-causes deaths, DALYs, and YLLs rates significantly declined, but the age-standardized all-causes YLDs rate significantly increased. The all-ages number of mortality and morbidity due to NCDs markedly increased, but the age-standardized mortality and morbidity rates significantly decreased during 1990–2021. Moreover, the all-ages number and the age-standardized mortality, DALYs, and YLLs rates due to CMNN remarkably declined except for YLDs.

Both the all-ages number and the age-standardized mortality and morbidity rates attributable to injuries significantly increased between 1990 and 2021. In 2021, ischemic heart disease, COVID-19, stroke, hypertensive heart disease, conflict and terrorism, and neonatal disorders were leading causes of age-standardized mortality and YLLs rate. Dietary iron deficiency, low back pain, depressive disorders, headache disorders, anxiety disorders, and gynecological diseases were the predominant causes of age-standardized YLDs rate. In addition, high blood pressure, high levels of low-density lipoprotein, smoking, low birth weight, and short gestations were the prominent risk factors for age-standardized mortality rate.

The findings of improvement in the life expectancy and HALE at birth in Yemen from 1990 to 2021 indicate positive developments in healthcare and overall well-being. The gains in life expectancy at birth and HALE in Yemen could be due to the substantial reduction in the mortality and morbidity rates attributable to CMNN. The all-ages number and the age-standardized mortality and DALYs rates due to CMNN remarkably declined during the study period. The proportion of CMNN to total deaths decreased from 37.6% in 1990 to 32.0% in 2021. Moreover, the age-standardized mortality and YLLs rate due to CMNN, including neonatal disorders, lower respiratory infections, congenital birth defects, diarrheal diseases, and maternal disorders, decreased by more than 50% from 1990 to 2021. However, it is important to note that females consistently showed higher life expectancy compared to males. This gender disparity highlights the need for targeted interventions to address health issues specific to males and bridge the gap in life expectancy. Our finding is consistent with previous studies [9, 22].

Our findings revealed a decline in the age-standardized all-cause death rate, YLLs rate, and DALYs rate in Yemen over the study period. This decline suggests an improvement in overall mortality rates, a decrease in premature mortality, and an overall improvement in population health and well-being in Yemen. However, there has been a slight increase in the age-standardized all-cause YLDs rate. This suggests that while fewer individuals are dying prematurely, there has been an increase in the prevalence of non-fatal health conditions and disabilities. Factors such as population growth, changes in disease patterns, and improvements in healthcare access and diagnosis may contribute to this increase in YLDs.

Conversely, we found that the relative proportion of YLLs to DALYs is significantly higher compared to the proportion of YLDs. It means that a larger proportion of the overall disease burden in Yemen is attributable to premature mortality (YLLs) rather than years lived with disability (YLDs). This finding suggests that while efforts to reduce premature deaths have been successful to some extent, there is a need to focus on addressing the underlying causes of these premature deaths, such as improving healthcare access, disease prevention, and early intervention strategies.

Moreover, our findings also highlighted the mortality and morbidity burden due to NCDs in Yemen. The age-standardized NCDs death rates declined. However, the absolute number of NCDs-related deaths substantially increased, which is consistent with reports from other Organization for Economic Cooperation and Development (OECD) countries [23]. We found that ischemic heart disease and stroke consistently remained among the top three leading causes of the age-standardized mortality rate and premature deaths (YLLs) between 1990 and 2021. The age-standardized death rates due to diabetes mellitus, chronic kidney disease, and tracheal, bronchus, and lung cancer significantly increased during the study period. These findings underscore the need for comprehensive prevention strategies, early detection programs, and improved management of the NCDs in Yemen.

We found that COVID-19 was the second leading cause of age-standardized deaths and YLLs in 2021. Globally, COVID-19 was the fifth leading cause of death in 2022 [24]. However, the age-standardized mortality and YLLs rate due to CMNN, such as neonatal disorders, lower respiratory infections, congenital birth defects, diarrheal diseases, and maternal disorders, decreased by more than 50% between 1990 and 2021. The reduction in CMNN-related deaths and morbidity in Yemen could be attributed to the supply of vital therapeutic food and medical materials by international humanitarian organizations to treat severe acute malnutrition in women and children [15]. To eliminate all forms of malnutrition by 2030, UNICEF and WHO have implemented a number of initiatives to monitor malnutrition rates and improve the nutritional health status of adults and children in low- and middle-income countries worldwide [25].

Moreover, the impact of the conflict and terrorism on health outcomes in Yemen was evident in our analysis. Conflict and terrorism-related deaths and disabilities significantly increased between 2010 and 2021, indicating the devastating consequences of the ongoing conflict on the population’s health status. Our findings are supported by the previous reports [26, 27]. Conflict and terrorism jumped from the 50th leading cause of death in 2010 to the fifth leading cause of death in 2021. Similarly, the ranking of conflict and terrorism for the age-standardized YLLs rate increased from the 39th position in 2010 to the fourth position in 2021. Since 2015, more than 23,000 airstrikes have severely damaged the already fragile and dysfunctional health facilities, and almost 23% of the health facilities in Yemen are no longer functional. The conflict and terrorism have destroyed the supply chains for food and medicines [4, 27]. According to UNICEF, Yemen continues to be one of the world’s worst humanitarian crises, with almost 20.7 million people, including nearly 11.3 million children in need of humanitarian aid. Malnutrition that already existed was made worse by internal displacement and the severe hunger situation. International humanitarian organizations have been supplying vital therapeutic food and medical materials to treat severe acute malnutrition in children [15].

Mental and headache disorders were among the top five leading causes of YLDs in 2021. Furthermore, our results indicate that high blood pressure, high LDL cholesterol, smoking, and lead exposure were prominent risk factors for deaths in Yemen in 2021. These risk factors were consistently associated with non-communicable disease-related deaths. Numerous studies have demonstrated the association between high blood pressure and increased mortality rates [28]. High blood pressure was responsible for 10.4 million deaths worldwide in 2017 [29].

Similarly, high LDL cholesterol was responsible for 2.3 million deaths in 2017 worldwide [29]. A previous study has highlighted the high prevalence of smoking in Yemen and its association with adverse health outcomes [12]. In addition, The WHO has identified lead exposure as a significant public health concern. Although specific studies on lead exposure and mortality in Yemen are scarce, the impact of lead on health is well-documented globally [30]. Additionally, low birth weight, short gestation, child underweight, and household air pollution were identified as significant risk factors for deaths linked to communicable, maternal, neonatal, and nutritional diseases. These findings are consistent with consistent with existing literature [17, 19, 25, 31,32,33]. Consequently, the close alignment between the ranking of risk factors and mortality patterns, as well as their correlation with DALYs, underscores the importance of focusing on these factors to reduce the burden of diseases and improve population health in Yemen.

The comparison of Yemen with the top five war-torn countries, including Afghanistan, Syria, South Sudan, and Iraq, reveals that Yemen faces significant health challenges. Yemen ranked 3rd in terms of high age-standardized all-causes deaths, YLLs, and lowest HALE at birth and lowest life expectancy at birth after Afghanistan and South Sudan and ranked 2nd in terms of high age-standardized all-causes YLDs after Afghanistan for both sexes in 2021. Moreover, Yemen ranked 1st and 4th for the high age-standardized all-causes YLDs rate for females and males in 2021, respectively. These findings underscore the challenging health situation in Yemen and highlight the substantial burden of disease, premature mortality, disability, and poor health outcomes in Yemen compared to the selected top five war-torn countries. The ongoing conflict, economic instability, and limited access to healthcare services have significantly impacted the health outcomes and well-being of the Yemeni population.

Limitations

Our study has some limitations. First, the accuracy and reliability of the data used in the study could be a potential limitation. In a conflict setting with disrupted healthcare systems and infrastructure, data collection and reporting may be challenging. There may be issues with data completeness, accuracy, and consistency, which can affect the validity of the findings. Second, the ongoing conflict in Yemen may have introduced biases in the data and affected the health outcomes and trends. The conflict has had a significant impact on the population, healthcare system, and access to healthcare services. It is possible that certain diseases, risk factors, or population groups are underrepresented or not adequately captured in the analysis due to the conflict’s influence. Third, the study relies on the methodology of the Global Burden of Disease study, which has inherent limitations and may introduce uncertainties and biases in the results. Fourth, the findings of the study are specific to Yemen and may not be directly generalizable to other countries or regions. The socio-demographic and geopolitical context of Yemen, including the ongoing conflict and humanitarian crisis, may contribute to unique health challenges and patterns that are not representative of other settings.

Conclusion

In conclusion, this study highlights the devastating impact of the ongoing conflict on the country’s population health status. Despite these challenges, there have been some positive trends in health indicators. Life expectancy at birth has consistently increased over the years, indicating improvements in overall population health. Additionally, HALE at birth has also improved, suggesting that people are living longer with fewer years of disability or ill health. Yemen’s population has experienced significant improvement in CMNN-related morbidity and mortality compared with NCDs and injuries. The age-standardized mortality rate attributable to several CMNNs decreased by more than 50% from 1990 to 2021. However, the age-standardized death rates due to NCDs, including diabetes mellitus, chronic kidney disease, and tracheal, bronchus, and lung cancer, significantly increased during the study period. The all-ages number and age-standardized mortality and morbidity caused by injuries markedly increased in Yemen during the study period. Conflict and terrorism have also emerged as a leading cause of deaths, highlighting the impact of the ongoing conflict. These findings underscore the urgent need for targeted healthcare interventions, resource allocation, and policy measures to address the health challenges posed by the NCDs, injuries, and conflict and terrorism in Yemen. Based on such evidence, targeted interventions for the prevention and management of NCDs and rehabilitation from injuries due to conflict and terrorism are essential to control the increase in premature mortality and morbidity in the Yemeni population. Furthermore, continued monitoring and reporting of health indicators are essential for effective healthcare planning and to guide future interventions in Yemen.

Data availability

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

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Acknowledgements

We would like to thank all the participants for sharing their time and support.

Funding

This work is supported by the Xiamen’s Science and Technology Program (Grant No: 3502Z20209007, 3502Z20224032, 3502Z20241002), Natural Science Foundation of China (Grant No: 32201145), and the Natural Science Foundation of Fujian Province (Grant No: 2023J011681).

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Author notes

  1. Nawsherwan and Sumaira Mubarik contributed equally to this work.

Authors and Affiliations

  1. School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Fujian Branch of National Clinical Research Center for Cardiovascular Diseases, Xiamen, China

    Nawsherwan, Wang Yan & Mangmang Sang

  2. PharmacoTherapy, -Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands

    Sumaira Mubarik

  3. Department of Epidemiology and Biostatistics, School of Public Health, Wuhan University, Wuhan, 430071, China

    Sumaira Mubarik & Chuanhua Yu

  4. Department of Preventive Medicine, School of Public Health, Wuhan University, Wuhan, China

    Shafaq Naeem

  5. Department of Economics, Arid Agriculture University, Rawalpindi, Pakistan

    Rabia Mubarak

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Contributions

N and SM conceptualized the paper. N, SM, and MS downloaded the data and created the tables and visualizations. N, SM, and MS wrote the first draft. N, SM, SN, CY, RM, WY and MS provided data, developed models, reviewed results, provided guidance on methodology, or reviewed and contributed to the manuscript. All authors approved the final version of the manuscript. All authors had full access to the data in the study and N had the final responsibility for the decision to submit for publication.

Corresponding authors

Correspondence to Nawsherwan, Sumaira Mubarik or Mangmang Sang.

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Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

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The authors declare no competing interests.

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Nawsherwan, Mubarik, S., Naeem, S. et al. Health dynamics in war-torn Yemen: insights from 32 years of epidemiological data (1990–2021). Popul Health Metrics 23, 4 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12963-025-00363-3

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Keywords

Population Health Metrics

ISSN: 1478-7954