By Sara Jerving
18 January 2022
In the basement of her home in the capital of Ethiopia’s Tigray region, Mekelle, in November 2020, Dr. Fana Gebrezgabher and her family hid as the city was shelled around them. Her neighborhood was hit, instantly killing four members of one family and two in another.
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Gebrezgabher rushed her injured neighbors to the hospital in a taxi, with the constant drum of artillery engulfing the city around her.
“I remember the kids,” she said. “They are dead now.”
“That day was really the worst day of my life.”
This was at the onset of the war in Ethiopia. And the other days, working as a doctor during the war, were not much better. In a conflict plagued by sexual violence, Gebrezgabher dressed in clothing aimed at disguising herself as elderly. She worked at a hospital about 12 kilometers (7.5 miles) from where she lived and passed through four Ethiopian military checkpoints to get there. Faking her age was her strategy to avoid getting assaulted.
“Every woman was scared to go to work, but we had to risk it because it’s our responsibility to give health services,” she said.
Gebrezgabher fled the country in March. She spoke to Devex recently from her current location.
The health systems in Tigray are in a state of collapse. They have been pummeled with attacks, looting, and a de facto blockade of medicine and fuel. Health workers have said they have not received payment for seven months. Militants have used health facilities as bases. Patients with chronic illnesses have died from lack of medicines and children are experiencing severe malnutrition.
“The health system is not political,” Gebrezgabher said. “The destruction was done deliberately. It’s not just collateral damage.”
People from Tigray describe two chapters of the conflict — the “war” followed by the “siege.” Following an attack by Tigray forces on a federal military base, the federal government launched attacks on Tigray in November 2020, resulting in the occupation of the region by the government’s military, military from Eritrea, Amhara special forces, and allied militias.
At the end of June, the Tigray People’s Liberation Front took control of Mekelle and the other forces retreated to other parts of the region. Then began the government’s de facto blockade of essential goods into Tigray, which has prevented the entry of medical supplies and fuel. United Nations food distributions are expected “to grind to a halt” because of the escalation in fighting.
The fighting continues in Tigray and has swelled into neighboring regions of Amhara and Afar, with the U.N. saying there are “reasonable grounds” to blame all parties for atrocities. The extent of the damage is still largely unknown because of telecommunications shutdowns and access restrictions.
The health system is a key casualty of the war.
Before Tigray forces took control of Mekelle, Médecins Sans Frontières published a statement in March that said “health facilities in most areas appear to have been deliberately vandalised to make them non-functional.” The organization documented looting, deliberate smashing of equipment, health facilities set on fire and hit by rockets, occupation of health facilities as military bases, and seizures of ambulances.
The organization wrote of women dying in childbirth, children going unvaccinated, and patients with chronic illness without life-saving drugs. Three of MSF’s workers were killed in Tigray in an “apparent attack” in June, where their vehicle was found empty and their bodies were found a few meters away. There has not been an investigation into the murders.
In July, the Ethiopian government suspended MSF’s operations for, among other reasons, disseminating “misinformation” — a claim the organization denies. The suspension was lifted in October. The government has severely restricted humanitarian access, largely preventing aid groups from providing health care to populations in need.
An investigation published in November by UN Human Rights and the government’s Ethiopian Human Rights Commission, which covered the period of November 2020 through June 2021, found that of 224 health centers in Tigray, only 40 were functional.
Much of the destruction, looting, and military occupation of health centers in Tigray happened between November 2020 and June 2021, according to Human Rights Watch. A humanitarian worker told the organization, “When [we were] going through facilities … [t]here were literally pillboxes opened and emptied. [There was] really deliberate destruction.”
And Tigray forces have looted and destroyed medical facilities in neighboring regions.
Hayelom Kebede said Ayder Referral Hospital in Mekelle, the largest hospital in the Tigray region, is a shell of what it once was. He was formerly the acting executive director of the hospital before he fled the country, but his colleagues continue to provide him with updates.
About half of the health workforce of the region were either killed or have fled, Kebede told Devex in an interview, adding that two health workers in the town of Hawzen were shot inside their hospital after refusing to hand over medical equipment and medicines to militants.
And now, under the de facto blockade, health facilities can’t provide services without medical equipment and medicines.
During a recent media briefing, Dr. Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization, said the agency was able to ship medical supplies to the neighboring Afar and Amhara regions in December, but the government has not permitted it to deliver medical supplies to Tigray since last mid-July. These restrictions are not normal for conflict settings, he said.
“Even in the toughest periods of conflict in Syria, South Sudan, Yemen and others, WHO and partners have had access to save lives,” he said.
Ayder hospital is now “nearly collapsing because there is no medicine,” Kebede said.
“The most worrying is the lack of medication of vulnerable cases, such as diabetes, HIV or hypertension,” wrote Apollo Barasa, health coordinator in Ethiopia for the International Committee of the Red Cross, in an email to Devex. The organization works in Tigray, Amhara, and Afar regions. “Some patients with specific diseases need a long term, daily intake of medicine and if they don’t have access to them, they can lose their life or develop serious long-term consequences.” Some hospitals in Amhara have closed because of lack of medicines.
Ayder hospital has not received medication for diabetes patients since June, wrote a physician in an email to international partners, which was sent to Devex. Health workers started doling out expired drugs in September — but even those have run out.
There are an estimated 180,000 chronic disease patients in Tigray.
“We are very sure that we will be flooded with acutely sick patients in the coming weeks but we will not be able to help them,” the physician wrote, adding they are using tap water rather than IV fluid for treatment.
“People are dying because of rabies. People are dying because of starvation and malnutrition,” Dr. Godefay Hagos, head of Tigray’s regional health bureau said on Tigrai TV in October. “Mothers are dying at home while giving birth.”
Health workers have reported a lack, or severely limited access, to gloves, gauze, IV fluids, chemotherapy drugs, anesthesia, antibiotics, pain medication, basic laboratory tests, shortages of oxygen, and blood. They are forced to operate on patients based on clinical examinations rather than conducting CT scans or using MRI images. Health care workers can’t refer patients to Addis Ababa or abroad for radiation treatment.
Patients have died because of lack of catheter tubes used for hemodialysis. People living with HIV are vulnerable to opportunistic infections and have died, without access to antiretroviral treatment.
The director of Nek’sege health center said on Tigrai TV in December that looting left the facility without essential drugs since February. A 14-year-old girl with diabetes, an epileptic patient, and two hypertension patients have died due to lack of access to medication.
Electricity blackouts last for days and there are “no means of communication within the hospital,” according to a statement written by health professionals from Ayder hospital at the beginning of January. While access to essential medicines was about 80% at the hospital a couple of years ago, it’s now about 18%.
In the statement, a neurosurgeon documents a child hit by an airstrike in the skull while watching cartoons. The emergency room had no gloves, gauze, or IV fluids. A power cut left the blood bank nonfunctional and the CT scans were not working for lack of spare parts. “The volume of blood on the floor was inconceivable,” the surgeon wrote. The child died.
Another woman couldn’t give birth at a nearby health facility because it was looted by soldiers, according to the statement. When she finally reached one, she needed surgery, but the doctors couldn’t perform it because of lack of blood. She gave birth to a decapitated baby.
The health workers provided photos of women with untreated cancer eating away at their breast flesh.
“It’s beyond comprehension,” Kebede said.
The U.N. said in early January that no trucks with humanitarian supplies have entered Tigray since mid-December. The U.N.’s humanitarian arm said the partners it works with to deliver aid have warned that if fuel is not allowed to enter, “nutrition interventions will be fully ceased.”
Health workers haven’t received salaries in the past seven months because of a shutdown of banking services, nor can they access savings, according to the statement from Ayder.
“For very long surgery procedures, some of [the health workers] have collapsed because they are so hungry,” Kebede said.
“This is an insult to our humanity to allow a situation like this to continue,” said Dr. Michael Ryan, executive director of the health emergencies program at WHO, during a recent press briefing.
Ethiopia’s Ministry of Health did not respond to repeated requests for comments on these allegations. But the government has publicly accused the Tigray People’s Liberation Front of repurposing trucks intended for delivering aid for “war activities;” blamed the group for the fuel shortages; and for the “crime of starving the people in Tigray.”
‘Horrific’ sexual violence
Of atrocities committed, the stories of sexual violence are among the most heinous. Reports include gang rape, imprisonment, rape in front of family members, forced incest, intentional transmission of HIV, and shoving of objects into vaginas.
According to Human Rights Watch, “Sexual violence — often accompanied with degrading and ethnic-based slurs — has been used as a weapon of war, particularly by Ethiopian, Eritrean, and Amhara forces against Tigrayan women and girls.”
“Tigrayan militia forces have also committed serious abuses, including sexual violence, against Eritrean refugees in the region, and in the Amhara region as the fighting has expanded,” the organization said.
Meaza, who is part of a Sexual and Gender-Based Violence Assessment and Rehabilitation Committee, set up through the facilitation of the Tigray Women’s Affairs Bureau, shared some cases the committee has documented. “The situation overall is horrific,” she wrote, asking to use a pseudonym in order to protect her family in Addis Ababa — where people of Tigrayan origin have been arrested en masse.
A 60-year-old woman was raped for a week in a cave by seven members of the Eritrean military. The assailants used the tip of a plow, heated in a fire, in order to burn her vagina. She had hepatitis before the assault, which worsened. She came to Mekelle for treatment but couldn’t find it. “She is on the verge of dying,” Meaza wrote.
Another woman was beaten unconscious and gang raped for over 12 hours. Because the health facilities around her were destroyed, she gave herself an abortion, which left her bleeding. She was able to get help to stop the bleeding in Mekelle, but not full treatment.
Barriers and medicine shortages prevent survivors from accessing post-exposure prophylaxis to prevent HIV and emergency contraceptives.
Meaza said treatable issues, such as infections, have evolved into severe complications that require the removal of ovaries or uterus.
Ayder hospital treated 553 survivors of rape between the start of the war and last June, with ages ranging from 6 to 80 years old. Kebede shared some of the reported assaults, which he called only the “tip of the iceberg.”
He said that soldiers raped a 6-year-old girl in front of her mother. A 21-year-old was imprisoned for two weeks and raped by more than 12 soldiers who demanded 5,000 Ethiopian birr ($100) from her husband for her release. A 33-year-old woman survivor has HIV, severe pelvic inflammatory disease, and rectal prolapse — when the largest part of the intestine falls out of place — and suffers from a “full blown psychiatric illness.” Another woman had a nail shoved into her vagina, and another a hot piece of metal.
Militants used health facilities for sexual slavery, holding women and girls hostage for extended periods of time, Kebede said.
And the scale of assaults will likely never be known. Many survivors haven’t reported cases unless pregnant or suffering health consequences, Meaza said. They stay silent because of stigma, lack of access to health facilities, and fear of airstrikes.
For health facilities near military camps, rape survivors haven’t reported cases because of proximity of perpetrators, Gebrezgabher said. Human Rights Watch interviewed service providers who said soldiers came into health facilities searching for survivors and health records. Militants threatened health workers for supporting survivors of sexual violence.
According to the Sexual and Gender-Based Violence Assessment and Rehabilitation Committee, 2,692 sexual and gender-based violence survivors have reported to six one-stop health centers in Tigray since the onset of the war.
A model health system now in collapse
To understand the damage in Tigray, one must understand the health system that existed before the war, health professionals said.
MSF wrote that “Tigray had one of the best health systems in Ethiopia, with health posts in villages, health centres and hospitals in towns, and a functioning referral system with ambulances transporting sick patients to hospital.” Before the war, 94% of women in Tigray had access to antenatal care, for example, but these services have collapsed.
WHO’s Tedros led the Tigray Regional Health Bureau starting in 2001, then led the nation’s health ministry.
“He completely transformed Tigray from a region with a health system in disarray to one that was a model for the rest of Africa,” Lawrence Gostin, a professor of global health law at Georgetown University, wrote to Devex.
Hagos, of Tigray’s health bureau, said on Tigrai TV, that community ownership was at the root of the successes of the system — more than 70% of health facilities and about half of ambulances were funded through community contributions.
On Jan. 12, Tedros said in a news briefing that “nowhere in the world are we witnessing hell like in Tigray.”
The next day, the Ethiopian government accused Tedros, who is of Tigrayan ethnicity, of spreading “harmful misinformation.”
“Of course, I am from that region and from the northern part of Ethiopia. But I am saying this without any bias,” Tedros said in the briefing.
The collapse, Hagos said, was a deliberate, “systematic destruction.”
“It’s heartbreaking because we worked so hard for this … It had taken a lot of work to come from where we were before,” Gebrezgabher said. “To see that all go away to dust, is really, really heartbreaking for me.”
And even if the war ended today, there’s a long road ahead to rebuild what is broken.
“I think it will take many decades to repair the damage. You can make makeshift shelters, but to rebuild a health system, as it was, would take really quite a long time,” Kebede said.
Update, Jan. 18, 2022: This piece has been updated with Dr. Fana Gebrezgabher’s full name.
Sara Jerving is a Global Health Reporter based in Nairobi. Her work has appeared in The Wall Street Journal, The New York Times, the Los Angeles Times, Vice News, and Bloomberg News, among others. Sara holds a master’s degree from Columbia University Graduate School of Journalism where she was a Lorana Sullivan fellow. She was a finalist for the Livingston Award for Young Journalists in 2018, part of a Vice News Tonight on HBO team that received an Emmy nomination in 2018 and received the Philip Greer Memorial Award from Columbia University Graduate School of Journalism in 2014. She has reported from over a dozen countries.