Hodeida, Yemen - There are never enough hospital beds for all the malnourished children across this poor and parched province. But this summer, even more families than usual had to be turned away from the bursting wards.

In Hodeida’s city hospital one afternoon, infants were crowded two or three to a bed. Their mothers and siblings sat slumped in the gaps in between. Wails filled the ward. Another two dozen children were waiting for space, a doctor said.

Twelve miles away, a rural clinic with 13 beds was uncomfortably still, the children silent, a telltale sign their bodies were wasting away. Malnutrition is widespread in Yemen. But a suffocating mix of high temperatures and humidity “had dramatically increased the number of cases,” said Mona Makki, a nurse there.

Reduced to “skin and bone” and cradled by their mothers on the clinic’s few beds, the children suffered from weak immune systems, she said. “When exposed to heat, that makes the cases even worse,” she added.

Hodeida shows how climate change and hunger are converging in devastating ways. Doctors here say extreme heat is threatening underfed babies and children with ravaged bodies and weakened immune systems. Their experience aligns with emerging research on the direct link between hotter temperatures and worsening malnutrition in some of the world’s poorest countries. The findings are alarming for this part of Yemen, already wracked by war, widespread poverty and suffocating summers.

By 2030, the city will have 152 days per year, nearly five full months, when conditions are so dangerous that spending a short amount of time outside - even in the shade - could threaten a person’s health, according to projections by The Washington Post and CarbonPlan, a nonprofit climate research group.

Hodeida will be the worst affected by extreme heat of any global city with a population of 500,000 or more, the analysis shows.

The projections are based on “wet-bulb globe temperature,” a metric that combines temperature, humidity, sunlight and wind, which experts consider the best way of evaluating how heat harms the human body.

Across Yemen more than 6.5 million people could be exposed to at least a month of dangerous heat by decade’s end, three times the number of people exposed in 2000.

Yemen’s citizens already lack protection in every imaginable way: from capricious violence, from feckless leaders, from hunger and want. In a place where so many are fixated on short-term survival, scant official attention is paid to the impact of climate change, even as droughts, flash floods and other extreme weather events occur with greater frequency.

But in Hodeida, one of Yemen’s hottest and poorest provinces, the threat from rising temperatures over the last few summers has become impossible to ignore.

It compounds the endless, daily trials. Struggling fisherman, toiling in temperatures that felt like 135 degrees or higher, work shorter hours on the Red Sea to avoid dehydration and sunburn, making do with lighter hauls.

Shopkeepers and trinket vendors scraping by on $6 a day are among the few on the streets from 9 a.m. to 3 p.m., when scorching heat makes Hodeida feel like a ghost town.

Temperatures are soaring across the region, but the worst-hit parts of Yemen will fare far worse than those of its Persian Gulf neighbors, like the United Arab Emirates and Qatar. These wealthy nations have built glittering cities with windfalls from oil and gas exports, designed to ensure that their most privileged residents hardly notice the heat: air conditioning cools offices and malls, even stadiums and subway platforms.

“It’s not just about heat indexes, or temperatures, but also, what is the underlying resiliency of these states?” said Ana Leticia Nery, who served for several years as a medical coordinator for Doctors Without Borders in Yemen, in clinics treating the war wounded as well as mothers and their malnourished children. “In the case of Yemen, it’s very, very limited.”

Across Yemen, she said, “the state is eviscerated.”

Doctors in Hodeida, a province that has one of the country’s highest rates of malnutrition, said heat had become a key factor in a complex chain of suffering that begins with desperation.

“People are poor,” said Abdulrahman al-Qadasy, the head of the pediatric department at the Hodeida city hospital. “Beyond your imagination.”

Scars of war

Yemen was already struggling, even before the outbreak of a nearly decade-long civil war. In 2014, a northern rebel movement known as the Houthis stormed Sanaa, the capital, and deposed the government. The conflict widened in early 2015, when a Saudi-led coalition of Arab states intervened, launching airstrikes and imposing a sea, air and land blockade of Yemen. The military campaign, which received support from the United States, was aimed at weakening the Iranian-allied Houthis. But the intervention and escalating violence across Yemen compounded people’s suffering.

Hundreds of thousands of people were killed, many from indirect effects of war like hunger, the United Nations said. Millions were displaced. Aid agencies scrambled to stave off famine amid shortages of food and fuel. Diseases like cholera that had been all but eliminated made a resurgence.

Over the last year, fighting has eased in many parts of the country, and imports of critical supplies have resumed. But Yemen’s fractured state - divided between rival, feuding governments in the north and the south - has left the country in limbo, desperate to end the last phase of the conflict and fearing the outbreak of the next.

Cities are waiting to be rebuilt, the health system is in ruins, and public sector wages aren’t being paid.

Yemen’s impasse makes most travel impossible, with roads closed around major cities like Taiz and no interstate flights connecting the divided country, said Nadwa Dawsari, a Yemen expert at the Middle East Institute. Middle-class workers like teachers and health professionals were being driven into poverty.

“Some do not send their children to school because they cannot afford it anymore. Others can’t afford food altogether,” she said. In Sanaa, the Houthi-controlled capital, more and more people were on the streets begging for food - people who previously “were able to afford the basics,” she said.

Suffering was also widespread in the south, in areas controlled by Yemen’s internationally recognized government. There, half of households are unable to meet basic nutrition requirements because of the soaring cost of food, according to a group of Yemeni and international nongovernmental groups.

Overall, 17 million people - more than half the population - are food insecure and require assistance, according to the World Food Program. In August, the agency said that funding shortages meant it would have to make cuts, including to malnutrition programs for nearly 2 million people, “at a time of more people becoming severely malnourished.”

Almost half of the U.N. agency’s operations worldwide had suffered cutbacks, its deputy executive director Carl Skau told reporters in late July, amid shrinking aid from international donors.

“Now is not really the time to take the foot off the gas in Yemen,” said Richard Ragan, the agency’s Yemen representative. Systems to replace the missing aid, which would require a functioning government, “aren’t yet in place.”

Aid workers were performing “triage,” he said. “More people need food that aren’t getting it.”

‘Children are dying’

Only half of Yemen’s medical facilities are fully operational, aid groups say. Many of those that are look like Hodeida’s al-Thawra hospital on a recent afternoon, its wards and hallways overcrowded, the sidewalks outside filled with people trying to get in.

Doctors and nurses at two pediatric wards that Post reporters visited - at Thawra, and a malnutrition clinic at the Kamaran Charitable Hospital, outside the city - said the summer heat had increased their caseload of malnourished children by 10 percent or more.

Bereft and hungry mothers cradled their children, some on the edge of death. One mother in the Kamaran clinic said she was homeless and forced to beg for money in a local market; it was never enough to feed her kids. Others could not afford baby formula and had been giving their children tea or goat’s milk.

Mothers brought their children to the clinic when they developed fevers, had diarrhea or suffered from loss of appetite, said Makki, the nurse. “Many cases go home because there is no room for them.”

Medical workers in Hodeida were trying to understand why more malnourished children had arrived at the hospital during the summer. For the children filling the pediatric wards, many of whom had already lost water due to diarrhea - both a cause and consequence of malnutrition - the heat could be especially dangerous because it made them more dehydrated.

Experts also say children in low-income countries can suffer from indirect impacts of high temperatures, like crop failures that affect their diets, or more direct effects, like heat exhaustion or heat stroke. According to a recent study linking hotter temperatures to worsening malnutrition, extreme heat could also increase the risk of infectious disease “because microbes tend to thrive in warm environments.”

The paper, published last year in the Journal of Environmental Economics and Management, found that extreme heat worsened chronic and severe malnutrition in several West African countries. It showed that for every 100 hours of exposure to a temperature above 95 degrees Fahrenheit, the stunting rate among children increased by 5.9 percent. Fourteen days of temperatures between 86 and 95 degrees over a 90-day period increased by 2.2 percent the rate of “wasting” - the erosion of muscle and fat tissue that is associated with severe acute malnutrition in children.

John Hoddinott, a professor at Cornell University and one of the study’s authors, said in an interview, “The part we’re certain about is that there is a causal relationship between extreme temperature spikes and adverse nutritional outcomes.” Less clear, he added, were the precise mechanisms at play.

Nery, who worked with Doctors Without Borders in Yemen, said that because severely malnourished children’s immune systems are often compromised, “they get infected more often, and they have infections that are more severe.”

High temperatures could play a “detrimental role” for children suffering from electrolyte disturbances: susceptible both to diarrhea, which can cause dehydration, and unable to easily ingest water, which was dangerous for their weakened hearts.

“In summer, they don’t have a lot of safety nets,” Nery said. “These children are very difficult to treat.”

At the Hodeida city hospital, Qadasy and other Yemeni physicians are trying to figure out on the fly how the heat is affecting their patients.

Heat was a “source of infection,” he said. The ward was “full” of children struggling with infections, he said, raising his voice above the chaos around him. But it was hard to be sure which viruses were circulating without advanced testing, using equipment that the hospital did not have.

For some of the children the hospital received, it was “already too late,” he said.

Nearby, a 10-month old infant, Ali Hassan, emaciated under his tiny tracksuit, writhed in silence. His grandfather, Abdullah Awad Mansour al-Hakimi, said that Ali was unable to eat.

Doctors said the infant had cerebral palsy, which made it difficult for him to eat. He was vomiting and had a fever and diarrhea, doctors said.

The boy’s father was out of work, the grandfather said. His mother said she had trouble breastfeeding him and could not afford baby formula. His family feared the heat had made things worse.

“There is no electricity. We don’t have batteries. No fans. No solar panels,” the grandfather said.

“I am just waiting for God’s will,” he said. “I am just going to wait for him to die.”

Ferima Coulibaly-Zerbo, the nutrition lead for the World Health Organization in Yemen, said the agency had not yet established a “causal relationship” between climate change and undernourishment, but was not ignoring a possible connection.

In Yemen, U.N. agencies had made “great efforts to save the lives of these children,” she said. “There is a need to consider the threats climate change can have jeopardizing all these efforts.”

“Children are dying,” she said. “And they should not be dying.”

‘Every year is becoming hotter’

The road leading to Hodeida city provides a glimpse of Yemen’s degraded state. Dust storms whip through farmland that is being invaded by waves of desert sand. Dead cows lie on the side of the road, a few miles from a neighborhood destroyed by fighting during the conflict. The area has been emptied of residents but is still littered with unexploded ordnance, city officials warn.

At night, on one of Hodeida’s main avenues, Sanaa Road, bright lights illuminate the restaurants, supermarkets and cellphone shops - signs of a city trying to get back to normal - even as many of the buildings are still dark. Electricity is only available a few hours a day.

At daybreak, the drivers who ferry passengers from Hodeida to Sanaa - a five-hour drive on a mountainous, winding road - are asleep on top of their Toyotas, where the luggage usually sits, the only place to catch a breeze.

By 6 a.m. at Hodeida’s fish market, workers and buyers are already drenched in sweat. Mohammed Ahmed, 60, has been chopping fish for decades.

The work was increasingly exhausting, he said. “This year is hotter than last year. And it’s tiring to stay until 12.”

It wasn’t just the heat. There was less money around, and fewer customers. The fishermen had a harder time paying for expenses, including diesel fuel. The summer winds drove the fish farther from shore. More and more of the fish was exported because few in Hodeida could afford it.

“The work was better in the past,” he said.

Fishermen complained that unemployment in the city was driving more people to eke out a living on the Red Sea. Now there are too many boats and too many nets for a dwindling number of fish. The heat made all the new challenges worse.

“It’s more tiring now, more than normal,” said Eliyas Abdu Saleh, 35, who sat in a boat, having just returned from the sea. “In the past I used to stay out three days. Now I stay two days.”

“Every year is becoming hotter,” said Taleb Muhayyem, a 70-year old fisherman. “We feel like it’s doubling.” His eldest son had been killed a few years earlier when an airstrike hit their boat, he said. Underneath his mustard, button-down shirt, his skin was burned, he said.

“I can’t take breaks,” he said. “I need to work.”

The Houthis have sought to blame Yemen’s many calamities on their adversaries: the Saudi-led military coalition and their partners in the Yemeni government.

The fishermen said some of that blame was well placed, citing years of coalition attacks on their industry.

But as the war has subsided, a groundswell of anger has targeted the Houthi-led authorities, who control all levers of government across northern Yemen.

People have taken to social media over the last two summers to complain about the lack of electricity in Hodeida, blaming corruption and posting pictures of children suffering in rural areas, under hashtags that include “#Hodeida_is_dying.”

“There is a lot of suffering because of the heat,” said Ahmed al-Bishri, Hodeida’s deputy governor, in an interview in his office. “Every year the heat has gone up. It’s affecting the poor people, the simple people,” he said.

The city made efforts this summer to provide some relief - moving school hours earlier in the morning, for instance. The Houthi authorities in September announced the opening of a solar farm that it said would provide electricity to more than 7,000 homes in Hodeida.

Bishri said his office was trying to provide basic services but was at the mercy of powerful outside forces - not just the Houthi’s military adversaries, but also Western, industrialized nations. “The polluters,” he called them.

“And we are the ones who are suffering.”

Outside the city, Khawla Mohammed Yahya, 20, was unprotected in every way, living with her husband and three young children in an unfinished hut of concrete and straw. The kitchen was a patch of dirt outside where they lit fires to cook. It was not really their home, but a place they were allowed to settle after being displaced by the war.

Her husband had been a beekeeper until pesticides killed his bees. He had occasional work now as a motorcycle courier.

One of their children, 3-year-old Shaimaa, was severely malnourished, and required most of the couple’s attention. They had taken her to a nearby clinic a year ago, and again in June. On this day, doctors from the Kamaran Charitable Hospital were making a house call.

Shaimaa sat silently on a green day bed. She had been running fevers and had diarrhea several times a day, Yahya said.

Her other two children had started to develop heat rashes, she said, clutching her 8-month old, Mohammed, whose hair was wet from perspiration, and a can of baby formula the doctors had given her.

“There is no electricity,” she said, and no fans. Nothing stood between her family and the heat.

Veronica Penney and Niko Kommenda contributed to this report.