Tigray, Ethiopia: The War May be Ending but the Challenges Facing Humanitarian Responders Are Immense

By Charlotte Roy, MD, MPH, Rebecca Leff, MD, Tsion Firew, MD, MPH, on behalf of the SAEM Global Emergency Medicine Academy

While the ongoing conflict in Ukraine inspired increased attention to global humanitarian efforts, it also exposed imbalances in aid delivery. Armed conflict in Tigray, a northern region of Ethiopia, began in November 2020 and has resulted in one of the world’s greatest humanitarian crises. Yet, according to UN OCHA, Ethiopia received less than half of the humanitarian funding required in 2022. In November 2022, the Government of Ethiopia and the Tigray People’s Liberation Front signed a peace treaty agreeing to a “permanent cessation of hostilities.” This development will greatly increase access in Tigray, which has been cut off from the rest of the country and the world since the war began. Nonetheless, the humanitarian needs of Tigrayans and the challenges that lay ahead for humanitarian responders are immense.

War between regional Tigrayan forces and the federal government of Ethiopia began in November 2020 and has resulted in the forced displacement of more than 2.3 million people. Many more have been subjected to arbitrary detention, torture, abduction, and enforced disappearances. Particularly troubling are reports of attacks against civilians, including ethnic-based killings, who have taken no direct part in hostilities. All sides, including military forces from Eritrea, have been accused of engaging in human rights violations, including acts of sexual and genderbased violence. Conflict in Tigray has also spread to neighboring regions of Amhara and Afar, resulting in an expanding area in severe need of humanitarian assistance. continued on Page 34

Among the devastating effects of the war in Tigray is the near complete destruction of the region’s health care system. Prior to the conflict, Tigrayans benefitted from a strong system of community-based primary health care known as the Health Extension Program.

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After the war began, this network collapsed due to a combination of the destruction of facilities, disruptions to the supply chain, and loss of health care workers who fled or quit their posts to find an alternate means of income (health care workers have been paid seldom or not at all during the war). An assessment of more than 250 hospitals and health centers by Gesesew et al. in June 2021 showed that only 27.5% of hospitals and 17.5% of health centers were fully functional, and more than 50% of health workers were no longer reporting to their place of work.

The consequences of this collapse have been disastrous. Vaccination coverage rates plummeted, contributing to disease outbreaks, including cholera and measles, throughout the country. In Tigray, doctors report not having the most basic supplies, such as gauze and saline, and shortages of essential medications including antibiotics and insulin have led to countless preventable deaths. The fuel shortage has made it difficult to keep generators running in hospitals, and those still functioning grapple with intermittent power outages that affect infant warmers, ventilators, and basic lighting. Oxygen is also in short supply: according to data from the regional health bureau, from June 2021 to May 2022 only 13% of the oxygen needed to meet demand was available. Even more devastating is the dramatic and widespread rise in malnutrition, particularly among children under five. A rapid nutritional assessment conducted in July 2021 showed that 28% of children under five had moderate or severe acute malnutrition, nearly triple as many as in 2019. The World Food Program estimates that 5.2 million people in Tigray (91% of the population) and 12.2 million people across Northern Ethiopia are in need of emergency food assistance.

The peace treaty signed on November 2, 2022, officially brought an end to the conflict in Tigray, but rebuilding their previously robust health care system poses an enormous challenge. Over the past two and a half years, Tigray has been almost completely cut off from the rest of the world, both in terms of communication and physical access. Roadblocks, fighting along aid delivery routes, and damage to infrastructure has made it nearly impossible for humanitarian agencies to get supplies such as food, medicines, and gasoline into the region. In fact, roads into Tigray and surrounding regions only became accessible to humanitarian responders in early December 2022. Many of the humanitarian aid groups who were previously forced to leave the region are in the early stages of re-establishing operations. Other groups are working to scale up the distribution of aid as access to remote areas remains challenging. However, rebuilding the health system in Tigray will not be the responsibility of international non-governmental organizations (NGOs) alone. It is critically important that humanitarian aid groups work hand in hand with local NGO and government partners with the goal of making Tigray self-sufficient again.

With this in mind, the first priority of humanitarian responders should be to re-establish preventative and acute care systems by repairing health centers and hospitals and staffing them with local health care workers. Humanitarian aid groups must engage existing, highly skilled health care workers at every level, from community health workers, to nurses, to doctors. This may involve salary support provided by international NGOs until compensation for government employees has been restored. The safety and security of both international aid workers and local health care workers will be of utmost importance. As security throughout the region improves, health care workers may be deployed to support health systems rebuilding in more remote areas. Another priority for humanitarian responders will be to re-establish the supply chain for medications and vaccines. This will facilitate the reopening of regional programs for the management