Photo: Ayder Referral Hospital, Mekele, Tigray
L. Lewis Wall, MD, DPhil
Female Pelvic Medicine & Reconstructive Surgery: May 2022 – Volume 28 – Issue 5 – p e137-e141
In November 2020, the federal government of Ethiopia invaded its northern region of Tigray, in collusion with the Government of Eritrea and ethnic Amhara militias. The invading forces pillaged the schools, destroyed the transportation infrastructure, burned crops and killed livestock, and looted the health care system. Thousands of civilians were killed, often in extrajudicial executions. Thousands of Tigrayan women were raped. Tens of thousands of Tigrayans fled to Sudan as refugees. Hundreds of thousands face famine and millions more have been internally displaced. The region is under a total communications blackout. The banking system has collapsed. The federal government has harassed external aid workers and imposed a de facto blockade on all medicines and famine relief. A man-made humanitarian catastrophe unlike any in recent memory is unfolding. The world medical community must speak up. The madness must stop. The use of rape, starvation, and the destruction of healthcare infrastructure by the Ethiopian government violates the laws of war and the Geneva Conventions.
What do you do when your friends are starving and you can’t feed them?
What do you do when your medical colleagues are totally overwhelmed by illness, injury, and disease but they have no resources with which to treat patients?
What do you do when your hospital lacks both oxygen and electric power?
What do you do when your trauma surgery waiting list has more than 1,500 names on it and you have no surgical supplies?
What do you do when your hospital and your community have no telephones, internet, or e-mail and the world hardly knows you exist?
What do you do when children are dying of malnutrition on your pediatrics ward but all you have is tap water with which to try to rehydrate them?
What do you do when nurses and medical students are raped by soldiers on your hospital grounds?
What do you do when your ambulances have all been stolen, looted, or destroyed by the army?
What does it matter, since there is no fuel to run them anyway?
This is not a scene from some futuristic, dystopian novel. This is the day-to-day reality at Ayder Comprehensive Specialist Hospital in Mekelle, Ethiopia, the primary teaching and referral hospital for the College of Health Sciences at Mekelle University in Tigray, the northernmost region of Ethiopia.1
I know it well. I hold an appointment there as Adjunct Professor of Obstetrics and Gynecology. Ayder Hospital is my hospital, too.
I made my first trip to Ethiopia in 1994, to visit Dr Catherine Hamlin at The Addis Ababa Fistula Hospital for Poor Women with Childbirth Injuries. It was an inspirational visit, and I have been back to Ethiopia many times since.
I love the country and its people.
In 2010, I made my first trip to Ayder Hospital and I soon became a regular visitor, traveling as often as 3 times each year. My wife and I lived in Mekelle for 8 months in 2014, when I had a Fulbright Scholarship to the Department of Obstetrics and Gynecology at Ayder Hospital. I gave lectures, saw patients, carried out research, performed operations, and participated in strategic planning discussions with senior clinicians.2–8 We dreamed about the future, and together, we created the first subspecialist urogynecology fellowship training program in Ethiopia. The fellowship has been a resounding success, a model of international multi-institutional medical collaboration.6 I toured rural Tigray, visited health centers, talked to midwives, and eventually took a “road trip” the length of the country with an Ethiopian family that my wife and I regard as part of our own.
They are now refugees of war living in the United States.
In November 2020, the federal government of Ethiopia invaded Tigray in collusion with the government of Eritrea and ethnic Amhara militia groups.9 The specific details of what actually precipitated the conflict are largely irrelevant to the story that has followed. The roots of the conflict are complex.10–13 They are deeply embedded in recent history, personality clashes, ethnic hatreds, political rivalries, and the quest for power. The match that was struck that caused the conflict to burst into flame was a contested election in Tigray and accusations that the Tigrayan political party—the Tigray People’s Liberation Front (TPLF)—had raided a federal military installation. The details of those events now matter very little to the suffering people of Tigray.
Initially, the invasion was portrayed as only a “police action” to put down the rebellious TPLF. Mekelle, the capital city of Tigray, fell to the federal forces in less than a month as the TPLF leadership fled into the mountains to regroup. Ethiopian Prime Minister Abiy Ahmed declared, “Our focus will now be on rebuilding the region and providing humanitarian assistance while federal police apprehend the TPLF clique.”14 In saying this, he recognized his obligations—carefully delineated in the Geneva Conventions—to restore civil order, to protect civilians and their property, to provide medical assistance to the sick and injured, and to facilitate the delivery of humanitarian relief to a troubled area under his control.15 He had no intention to do this. It was all a smokescreen.
Abiy repeatedly lied to the world about what was actually taking place, even denying for months that he had conspired with Eritrean dictator Isaias Afwerki to organize the invasion so that they could both settle old, festering scores with the TPLF, who had ruled Ethiopia for nearly three decades, including the years 1998–2000 when Ethiopia fought a bitter border war with Eritrea.16,17 The true motivation behind the invasion was revealed by Pekka Haavisto, the European Union’s special envoy to Ethiopia. After 2 days of intense diplomatic discussions with Ethiopia’s leaders, Haavisto reported that they had said the purpose of the invasion was “to wipe out the Tigrayans for 100 years.”18 They had embarked on a vicious campaign of ethnic cleansing.
Armed Amhara militias—old ethnic foes of the Tigrayans—invaded western Tigray from the southwest.19 The Eritrean army invaded across the Tigrayan-Eritrean border from the north while Ethiopian federal troops invaded from the south. They drove villagers from their homes. They killed thousands of noncombatants.20 Hundreds of helpless civilians were slaughtered in the ancient city of Axum outside the holy Church of St Mary of Zion, where Ethiopian Orthodox Christians believe the Ark of the Covenant resides.21–23 They burned crops, killed livestock (especially the oxen needed to plow the fields), and destroyed stores of seed grain needed for planting.24 They ransacked and destroyed schools.25 They looted and vandalized hospitals, clinics, health posts, and ambulances and carted their booty back to Eritrea in military convoys.26,27
Eritrean refugees living in Tigray were especially targeted by Eritrean troops. Eritrea is one of the most repressive countries in the world—Africa’s version of North Korea. Nearly 10% of the population of Eritrea has fled the country and there were more than 100,000 Eritrean refugees in Tigray when the war broke out. The Eritrean army raided and looted the refugee camps, killing many, and hauling others back to Eritrea as political prisoners who now faced a very grim future indeed.28,29
The worst excesses of these invasions were visited upon Tigrayan women, who were systematically gang raped. Amnesty International, Human Rights Watch, CNN, and the Tigray Regional Health Bureau have all documented widespread instances of horrific abuse.30–33 Rape was used as a weapon of war to terrorize the Tigrayan population.34,35 One Tigrayan woman was pulled off a minibus, held for 11 days, and repeatedly gang raped by 23 soldiers.33 Another woman watched as soldiers killed her 12-year-old son in front of her, and then took her to a camp where they gang raped her for 10 days.33 After raping the women, the soldiers often mutilated them as well, searing their genitals with hot irons, burning them, or stuffing their vaginas with nails, rocks, pieces of shrapnel, and other foreign objects.33 A group of 4 Amhara militiamen gang raped one women, and when they were done, they shoved a hot metal rod through her vagina into her uterus, telling her “Our problem is with your womb. A Tigrayan womb should never give birth.”36 Daughters were raped in front of their mothers.33 Tigrayan men were ordered to rape female family members at gunpoint.37
Thousands of civilians were killed, often in extrajudicial executions. Tens of thousands of Tigrayans fled across the western border, seeking refuge in Sudan, accompanied by the bodies of their not-so-lucky countrymen, which floated down the Tekeze River near Humera.38 Hundreds of thousands of Tigrayans are threatened by starvation as the result of a deliberate, man-made famine promulgated by the invaders.24 Millions more are now internal refugees, flooding into Mekelle and facing acute food insecurity. The genocidal plan is working.39 The world is largely silent.
Much of the fighting took place in rural Tigray, which the invaders struggled to control. In Mekelle, however, the federal armed forces took charge, but rather than restoring civil order and facilitating the distribution of humanitarian aid, instead they instituted a de facto aid blockade. In December 2020, only a few weeks after Mekelle fell to the federal troops, the Red Cross reported that Ayder Hospital had no supplies, no fuel, and no running water.40 Instead of restoring services, a dusk-to-dawn curfew was implemented with a “shoot-on-sight” enforcement policy that prevented anyone from reaching the hospital in an emergency. Law and order broke down as criminal gangs roamed the streets, looting businesses and robbing innocent civilians. Rapes and armed robberies—unknown when my wife and I lived in Mekelle—became commonplace. A close friend of ours—a well-known surgeon—was beaten and robbed by a gang of 16 armed men in his home. The acting director of Ayder Hospital was assaulted by soldiers in his office. Communication with outlying clinics was forbidden, although those clinics desperately needed administrative support. The referral and transportation network broke down.24,26,27 Humanitarian aid workers were harassed and prevented from distributing supplies.41,42 Three employees of Doctors Without Borders were murdered to further disrupt the distribution of supplies in outlying areas.43 Journalists were expelled. Food aid was cut off. The importation of medicine and surgical supplies to Tigray was forbidden. Humanitarian workers with nongovernmental organizations who were traveling to Tigray even had their own personal medications confiscated by government soldiers. Nothing was allowed to get in.44 Telecommunications were severed. A total news blackout was imposed, and yet stories of the unfolding horrors continued to leak to the world press.
I still get messages, irregularly, from friends in Mekelle and colleagues at Ayder Hospital. They confirm the truths laid out in the intermittent reports that international news agencies manage to file.
Before the war, Ayder Hospital was one of the “crown jewels” of the Ethiopian health care system. It was the second-largest hospital in Ethiopia, the tertiary referral center for 9 million people in the Amhara, Afar, and Tigray regions. Only 14 years old, it was a stunning educational success, training internists, surgeons, obstetrician-gynecologists, pediatricians, physical therapists, pharmacists, nurses, midwives, and public health workers. It worked closely with the Tigray Regional Health Bureau, whose infrastructure reached into the most remote rural communities. Tigray had the best health care system in Ethiopia.26,27 It was a model for low-income settings. It had been designed and implemented by Dr Tedros Adhanom Gebreyesus, the current Director of the World Health Organization, who started his career as the head of the Tigray Regional Health Bureau, and who has watched in horror as his home community has been despoiled by a genocidal war.45
In a stunning reversal of fortune for the Ethiopian Federal Government, the Tigrayan Defense Forces regrouped and counter attacked in June 2021, killing and capturing thousands of troops.46 The federal forces abandoned Mekelle, declaring a “unilateral cease fire” to cover up their humiliation. The Tigrayans broke out of their region and advanced into Amhara and Afar, pushing toward Addis Ababa, the national capital. Tigrayan reprisals on other civilian populations took place in revenge for what their people had experienced.47 Abiy Ahmed, panicked by these developments, organized a massive influx of unmanned military drones from China, Turkey, and the United Arab Emirates, allowing him to push the Tigrayans away from the capital.48 The Tigrayan Defense Forces withdrew back into Tigray itself, and the federal government tightened its genocidal blockade, a blockade that is now well into its second year.1,24,49,50
The siege of Tigray is relentless, despite international pleas to permit the distribution of critically needed medical and food supplies.1 President Biden called Abiy Ahmed personally in January 2022 to no avail. A drone attack in Tigray killed 17 more civilians on the day of their phone call.51 The people of Tigray are being garroted by their own national government.
Conditions at Ayder Hospital are now appalling.1,50 Maternal mortality has exploded in Tigray, with more than 500 recorded maternal deaths in 2021, and many, many more unreported. Catastrophic complications of obstructed labor have become commonplace, because the healthcare infrastructure has collapsed. Only a few hospitals in Tigray are functional at any capacity, the transportation network has fallen apart, the telecommunications network has been destroyed, and access to safe, timely cesarean delivery has dwindled to almost nothing.24,26,27 Vesicovaginal fistulas from obstructed labor—nearly eliminated in Tigray within the last few years—are now depressingly prevalent. The women who survive with a fistula are, perhaps, the lucky ones, because uterine rupture from obstructed labor is almost universally fatal in the conditions that currently exist. Pregnant or laboring women with complications do not want to risk leaving home for fear of federal government drone strikes on markets and civilian areas.51
The banking system is in ruins. (Federal troops robbed the banks in Mekelle as they left). Nobody has been paid in more than 8 months. Tigray is a cash economy—there is no system of electronic transfers or credit cards—and circulating banknotes are now in critically short supply.1 Doctors have to go out and beg for food after completing their shifts if they are to feed their families.52 Nurses and surgical technicians are fainting during extended operations from lack of nourishment, but the number of operations is rapidly falling because of lack of anesthetic drugs, surgical sutures, intravenous fluids, and the constantly diminishing institutional capacity.1 The supply of critical medications is almost gone. Almost all of the drugs that remain are beyond their “official” expiration dates.1 Dialysis patients are dying because the complex medical care that they require can no longer be provided. The computed tomography and magnetic resonance imaging scanners are no longer operational. The state-of-the-art oxygen generation plant no longer works, because of lack of spare parts and an inability to perform needed maintenance. There is no other source of oxygen in Tigray, yet the flood of sick, injured, and dying patients continues relentlessly and the COVID-19 pandemic rages on.1
This madness must stop.
Mekelle has a large, modern airport, fully capable of handling international flights. A humanitarian airlift, similar to what was accomplished by Allied Forces during the postwar blockade of Berlin by the Soviets in 1948–1949, is urgently needed. Such an airlift—supervised by the International Red Cross—could insure that needed supplies arrive, are stored, and distributed carefully and that contraband military goods are not imported.
There is no military solution to the current impasse between the warring parties.53 The only way to achieve a lasting peace is through an immediate cease fire that will allow the delivery of humanitarian relief to Tigray. This must be accompanied by the start of difficult, serious, good-faith negotiations through which a long-term plan for political reorganization, social reconstruction, and ethnic reconciliation can be developed.
Doing this will be extraordinarily difficult. The grievances run deep on both sides. The former TPLF government of Ethiopia produced a booming economy but accomplished this through authoritarian rule that stifled dissent. Many people suffered and many groups remain bitter about their treatment. The Tigrayan people have experienced a genocidal assault that has destroyed their infrastructure, their livelihoods, their food supplies, and their health care institutions.24,26 They were attacked by their own national government in collusion with a hostile foreign power that hated both them and the ethnically related Eritrean refugees whom they had sheltered. The federal government deliberately fanned the flames of ethnic hatred, calling Tigrayans “rats” and “hyenas” that had to be destroyed.53,54 Amhara militias have systematically driven the Tigrayan population out of western Tigray, claiming the land as their own.19 In addition, the onslaught against Tigrayans goes well beyond Tigray itself. Ethiopian national identity cards now declare the holder’s ethnicity, making ethnic persecution easy. Tigrayans are being rounded up and imprisoned throughout Ethiopia,55 and even Tigrayans in other countries are being persecuted by Ethiopian agents.56
The horrors visited upon Tigray and Tigrayans are all well known to the Abiy government. Filson Abdi, Abiy’s Minister for Women’s and Children’s Affairs, conducted an early official investigation into the allegations of mass rapes, recruitment of child soldiers, and other atrocities committed in Tigray, but her report was suppressed. She resigned from the government in September 2021, later telling the Washington Post, “…I was there. I was in cabinet meetings, and I went and met victims. Who can tell me what I did and did not see?”57
The population displacements, forced starvation, mass murders, and systematic rapes have created a fertile seed bed in which hatred is taking root and where it will flourish for generations. The entire country could unravel. The humanitarian need in northern Ethiopia is immense. Ayder Hospital and the people of Tigray should not be held hostage to the political ambitions of any party to this conflict. The medical and nursing staff at Ayder Hospital are dedicated clinicians with deep humanitarian instincts. In my communications with them, they are aghast at what is happening in their country. They long for healing.
The current Ethiopian Minister of Health, Dr Lia Tadesse, is herself an obstetrician-gynecologist, with deep ties to the United States. The world medical community must speak out against the horrors that are occurring in northern Ethiopia. We must all condemn the use of rape as a weapon of war. We must condemn the use of starvation to achieve political ends. We must condemn the deliberate destruction of health care systems and the intentional harm inflicted upon civilians for revenge and partisan political gain. The siege of Ayder Hospital must be lifted. Our Ethiopian medical colleagues must be protected. Tigray must be provided with the food and medical supplies it needs. Our ethical obligations as physicians require this of us. If we turn our backs on Tigray, history will not forgive us.
The authors have declared they have no conflicts of interest.
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Source: Female Pelvic Medicine & Reconstructive Surgery (Official Journal of the American Urogynechologic Society): May 2022 – Volume 28 – Issue 5 – p e137-e141