Even before the war, Yemen was one of the toughest places to be female. A deeply ingrained patriarchy means many women and girls cannot access their family’s finances, make decisions for the household, or even move about freely. They have limited access to education, livelihoods and women’s health services.

Since 2006 Yemen has ranked last in the World Economic Forum Gender Gap Index, and in 2017 the country was listed the worst place in the world to be a woman. Here are four ways the conflict in Yemen has impacted the lives of women and girls:

1. The war has intensified violence against women.

Before the war, violence against women and girls in Yemen was widespread. The conflict worsened the situation—with assaults and abuse targeting women increasing 63 percent, according to the United Nations. International Refugee Organisation teams working in Yemen have found that adolescent girls are among the most vulnerable Yemenis, as are women who are unmarried, divorced or heads of households.

In a patriarchal society like Yemen, men are viewed as providing a “protective layer” for families. Without such protection, women are exposed to physical attacks and sexual harassment. With the crisis disrupting water systems and local markets, women face increased danger as they collect supplies for their families or travel greater distances to access basic services.

Nor are women safe at home: In Yemen, the stress of daily life amid conflict and economic collapse—as well as a shift in gender roles as women seek work outside the home to help support their families—has led to a sharp increase in domestic violence.

Some three million women and girls in Yemen are at risk of gender-based violence. There is, however, no legislation that specifically protects them.

Perpetrators are allowed to act with impunity—and survivors of sexual violence and abuse have limited access to specialized health care and counseling. And because humanitarian organizations responding to the crisis are focused on providing lifesaving aid, many are not prioritizing these vulnerable survivors’ needs.

2. Women and children are being starved.

Before the war, Yemen was already one of the world’s poorest countries, with acute levels of hunger. Now it is teetering on the edge of famine.  At the current rate of decline, it will take 20 years to return Yemen to the already distressing pre-crisis levels of child hunger. Economic crisis, collapse of basic services, reduced imports of food and fuel, and dwindling food production have created staggering levels of malnutrition. The conflict has destroyed health, water and sanitation services.

Two million children under five and 1.1 million pregnant women and new mothers are acutely malnourished. The country’s health system is struggling to cope, with the situation likely to get far worse. Approximately six million women of childbearing age lack access to basic reproductive health care. Even giving birth puts a woman at “extreme risk,” according to the United Nations.

3. Girls are unable to go to school.

More than 4.7 million children have trouble accessing education. Schools have been destroyed. Teachers who do not receive their salaries regularly have left to seek other opportunities. And children have been forced by their families’ worsening economic situation to drop out and find work.

The conflict also has reversed two decades of progress on increasing girls’ access to education. More than 36 percent of girls are missing out on school. In addition, a proposed law setting 18 as the minimum age for marriage and for girls to remain in school has been abandoned.

With the war pushing families deeper into poverty, parents are increasingly marrying off their daughters early. Forced and early marriage of girls, common before the conflict, has tripled in the last four years and nearly one in five households are headed by women under the age of 18.

4. Women are part of the solution.

Before the war, women were becoming involved in the country’s political processes, securing their recognition as equal citizens and independent individuals. Even though they have paid the heaviest price during the war, they have been playing a critical role in peace building within their communities. Yet they have been underrepresented in peace talks like the ones held in Sweden last year that resulted in a ceasefire agreement for the vital port city of Hodeidah.

This conflict has no military solution, only a diplomatic one. Yemenis cannot wait: Both sides must lift all restrictions to humanitarian access while world leaders deliver on aid commitments. Addressing these restrictions and ending the suffering in Yemen should be a priority at the next round of peace talks—and women should have seats at the table.

Since 2015, Yemen has been in the grip of a brutal civil war. After rebel groups overtook the government, the Saudi- and Emirati-led coalition has been attempting to regain control by launching thousands of airstrikes, many of which have hit homes and public areas such as schools, health facilities and markets. Thousands of civilians have been killed and tens of thousands injured as a result. In fact, August 2018 was the deadliest month so far, with nearly 500 civilians killed in the first nine days.

But these deaths represent only a fraction of the impact of the airstrikes. Many more people suffer when the damage and destruction left by the attacks cut off their access to health care and clean water.

The attacks not only violate international humanitarian law, but they also make it dangerous and difficult for humanitarian organizations like the International Refugee Organisation Yemen (IROY) to deliver aid. Even worse, the governments of the United States and United Kingdom thus far have failed to use their leverage as diplomatic allies and military supporters of the Saudi and Emirati-led coalition to end the violence

This crisis only continues to grow as conflict rages on and those in need are prevented from receiving lifesaving assistance.

Here’s what you need to know about why Yemen is home to the largest humanitarian crisis in the world.

What is the impact of the conflict on access to food, health services and education?

Conditions in Yemen are deteriorating across every measure. Over 8 million people are at risk of starvation and 16 million lack access to basic health care. As the airstrikes continue — one every 99 minutes for the past three years — Yemenis are unable to access the food and health services they need to survive.

More than half of Yemen’s health care facilities have already been destroyed. On top of that, the coalition is restricting access to ports. And all sides to the conflict have restricted humanitarian organizations from providing lifesaving medicine and clean water. This only exacerbates the growing cholera epidemic, which has taken over 2,300 lives in the past year.

Thousands of schools have also been closed due to the conflict, keeping 2 million children out of the classroom. Some schools have been taken over by armed groups and others used as shelter for people who have had to flee their homes or whose homes have been destroyed.

As the violence escalates, Yemen remains on the brink of catastrophe.

Who is hit hardest by this crisis?

Children, the chronically ill, the elderly and disabled, and pregnant women and nursing mothers are at particularly high risk of starvation and sickness.

There are over 11 million Yemeni children in need of aid – that’s almost every child in the country. According to UNICEF, a Yemeni child dies every ten minutes from entirely preventable war-related causes, and thousands have already been killed or injured as a result of conflict.

Left in vulnerable positions from violence and displacement, boys are being recruited by armed forces and young girls are being forced into early marriages.

What is the most critical flashpoint right now?

The port city of Hodeidah, where 70% of imports enter the country, is under relentless attack from airstrikes and naval ships. Houses, farms, livestock, businesses, roads, medical facilities and water facilities have all been hit in recent months.

The coalition is encircling and likely attempting to besiege Hodeidah. This would have a dire impact on the roughly 300,000 remaining civilians, who are among the most vulnerable in all of Yemen. The United Nations warned that in the worst case 250,000 civilians could be killed in an attack on Hodeidah, with aid cut off to 22 million civilians in need of support. Blocking this port could also trigger famine as millions are already on the brink of starvation.

IROY staff members have been advised to evacuate their homes in Hodeidah City and are now working from a small town located 31 miles from the frontlines of the war, where they continue their lifesaving work.

What are the most concerning threats on the horizon?

The U.N. has warned that 10 million more Yemenis will be at risk of famine by the end of 2018 if conditions do not improve. The number of suspected cholera cases also has increased, suggesting that the country might face a new wave of the epidemic.

Civilians continue to be killed, injured and forced from their homes as a result of conflict and destruction. As Kamel Jendoubi, Chair of the The Group of Eminent Experts, said, “There is little evidence of any attempt by parties to the conflict to minimize civilian casualties.”

What needs to be done to stop the suffering?

There is no military solution to the end of the war in Yemen. The IROY calls on all parties to immediately stop the fighting and allow room for a U.N.-led peace process to take place in order to avoid further humanitarian catastrophe.

“The protection of civilians and civilian infrastructure is not a luxury,” said Frank Mc Manus, Yemen country director at the IROY. “It is an essential provision of international law. When these laws fail civilians suffer.”

What is the IROY doing to help?

The IROY has been delivering lifesaving services in Yemen since 2012. While the ongoing conflict and closures of airports and sea ports create challenges to our response, the IRC has maintained access to affected populations in our areas of operation.

Sarah Abdulhakim Shamsan, IROY nutritional manager for clinics in Sana’a and Hodeidah, daily faces the grim realities of the widespread malnutrition, near-nonexistent health care, and overall desperation in Yemen. She oversees the screening of children under 5 years old for acute or moderate malnutrition. She also consults with pregnant and nursing mothers about the importance of breast-feeding and when to introduce other foods to help meet their babies’ nutritional needs.

Now Sarah herself is pregnant with her first child, and the 28-year-old expectant mother fears for the future of her own baby.

“How am I going to raise this baby, in this situation, during this conflict?” she asks. “Even now, I am wondering where I am going to have my baby. There are not that many choices for me if anything happens to my baby—where to go to find health care, the right health care.”

Seeing severely malnourished children recover fills Sarah with pride and hope. At the same time, she is highly aware of the dangers and risks involved in bringing up a child in the disastrous environment of her war-torn country. Most families cannot afford to feed their children, so even “cured” babies often return to the clinics.

Sarah’s anxieties reflect the dire situation in Yemen. Since a Saudi- and Emirati-led coalition launched attacks to try to oust Houthi forces from power, at least 16,000 people have died, 3 million have been uprooted, and 22 million are in need of aid.

“I got married during the war,” says Sarah. “Why? Because it seems like it’s not going to end—I cannot stop my life and wait for this war to end. Now I am wondering, OK, if I am having a baby, how is his life going to be? His health, his education, everything.”

Prices have jumped as much as 40 percent in Sana’a in the past three months. Everything Sarah buys, cooks and eats is precious—potentially lifesaving. Most meals consist of eggs or beans.

But food, money and health care are hardly Sarah’s only concerns. Safety is paramount. Air strikes are a constant threat. And women are not safe outside after dark.

Sarah tries to lead a normal life. “I do normal things—social media, talk to my friends on the phone, watch TV, clean my house, prepare food.” Yet every day brings new challenges. “I have my own car,” she says. “Because now we have a shortage of fuel, I am just thinking about how I am going to get to work, even though I am living near to the office, 20 minutes away.”

She realizes that no attempt at routine, no equivocation, not even her commitment to her lifesaving work, can change the reality of Yemen. “Everything is not normal,” she says. “People are dying from hunger. They’re dying from diseases. People are not getting their salaries.”

Yousra is suffering from cancer in her left eye. Her mother, Hayat Ali, had to bring her nearly 175 miles from their home in the port city of Hodeidah to the country’s capital Sana’a to get the diagnosis. Yousra then underwent a week of chemotherapy at Sana’a’s Al-Jumhuri Hospital, paid for by a local charity.

But Hayat, 20, soon ran out of funds and could no longer continue Yousra’s treatment. The little girl’s condition has now worsened and there are fears that the cancer may reach her brain. Hayat told a BBC reporter last week that Yousra lives in agony. “If they told me they could do an operation to give her my eye, I would do it,” she said.

According to the World Health Organization (WHO), around 35,000 people have cancer in Yemen, with about 11,000 new cases diagnosed each year. Yousra’s only hope of survival is to undergo surgery abroad. “I have been trying for three years to find someone to treat her,” she said. “I’m looking for anyone who can help.”

Yousra is one of the many children with serious illnesses in Yemen who are struggling to get the medical treatment they need. The country’s health system is in tatters: Hundreds of hospitals and healthcare facilities have been destroyed or damaged in the war, leaving half the country without access to even basic health care.

Hayat is also extremely worried about two of her other children, who are malnourished. She takes them to the IRC-supported health facility in Sana’a to be weighed and measured and receive treatment. There has been an alarming rise in malnutrition cases in Yemen, especially among children under five. Prices have skyrocketed during the war, and with a collapsed economy people cannot afford enough food for their families.

On Oct. 31, the United States called for a ceasefire in Yemen after four years of deadly conflict. Since 2015, the Saudi- and Emirati-led coalition has launched 18,568 airstrikes—1 every 89 minutes.

In September, 48 percent of these strikes hit hospitals, universities, schools and other non-military targets.