Mukesh Kapila  – 31 August 2021

As Ethiopia’s civil war  approaches its first deadly anniversary in November, there is, as yet, little prospect for peace.  The underlying causes of the immediate conflict are bitterly contested and the essential conditions for solutions remain elusive.  Geopolitical factors mean that the African Union and United Nations are paralysed, even if there was a mood for external intervention after the Afghanistan debacle.

Ethiopia was starting to do well…

Ethiopia has a long and bloody history with repeated internal conflicts distinguished by extreme brutalities. But recent periods of peace and stability were bearing fruit. By 2019, the country had crawled up to 173^rd out of 189 countries on the Human Development Index.

The aggregate statistic does no justice to the impressive strides made since the Millennium.  By 2019, Ethiopia’s GNI  had trebled to $2207 per capita (in 2017 PPP$)  and life expectancy had jumped by nearly a third to 66.6 years. Health indicators mirrored or exceeded general  progress with a stead fall in under-5 child mortality (51.8/1000 live births), and effective universal health coverage reaching 46.5% by 2019.   Within Ethiopia, Tigray’s 6-7 million population were, on average, fairing slightly better than the country, as a whole.

It seemed that there was nothing to stop Ethiopia’s estimated 118 million people becoming Africa’s development motor. 

Then started a brutal civil war…

In November 2020, the motor stuttered when an armed conflict broke out between the forces of the Tigray regional authority and the Federal government.  At the heart of the dispute are competing notions of unitary state formation in a diverse nation of over 80 ethnic groups (Tigrayans constitute 7%) with contradictory ideas around democracy, decentralisation, internal boundaries, and governance.

Ethiopian leaders have deployed dehumanising hate language to fire-up their constituency, and pressed all government to levers to advance ‘total war’. The identity-centred nature of the violence is highlighted by a cultural genocide dimension that seeks to denigrate and destroy Tigray’s ancient heritage.  

The brutal nature of physical fighting has been well-evidenced through the mass atrocities attributed to the forces of Ethiopia and Eritrea. They include large-scale war crimes and crimes against humanity that, prima facie, satisfy the criteria for genocidal acts. Summary executions have also been recorded, evidenced by numerous bodies floating down rivers.

A few weeks ago, Tigray’s defenders turned the table and rolled back the Ethiopian military. The federal government retaliated by purging its Tigrayan-identity citizens, including civil servants and private business people. Thousands have been rounded up in Addis Ababa and elsewhere and disappeared to locations, often unknown. Reports of arbitrary harassment, degrading treatment, and worse have emerged.

Direct combat deaths among fighters may range between 10,000 and 30,000 (my estimate), although no definitive figures are available with differing assertions by opposing sides. Short-term casualties among civilians may be three-fold this number, with the longer-term toll from indirect consequences – due to disease and hunger – projected to run into millions, depending on the overall length and severity of the conflict. 

Epidemiological studies of violence indicate that it often behaves like a contagious disease.  So, it is unsurprising that the warfare has extended to Tigray’s neighbouring regions of Afar and Amhara. Other simmering ethnic disputes have also re-emerged, for example, involving the Oromo and Somali groups. As disaffected groups – each with their own complaints –  form tactical alliances – there is a real risk of nation-wide destabilisation.

Will the conflict be controlled within Ethiopia? The country inhabits a long-troubled region with many quarrelsome neighbours. It has restive borders and simmering disputes with  Sudan, Egypt, Somalia, Djibouti, and a mixed relationship with Eritrea.   Widening of the current conflict is a real risk.

This may be triggered by increasing population displacement. Already more than 2.2 million Tigrayans (a third of the population) are displaced and at least 63,000 have sought refuge in Sudan where they live in difficult and disorganised physical circumstances.  More recently, over 270,000 have been additionally displaced in Amhara and  Afar regions, as fighting extends outwards.  

Health is a strategic frontline target…

Civil wars are generally low-cost ventures that strike at the softest, most vulnerable targets so as to achieve the most  devastating physical and  morale-sapping impact. The Tigray conflict is a classic case study. 

War-making tactics include the deliberate destruction of Tigrayan livelihoods. As this is mostly agriculture-based, killing, intimidating, and prohibiting farmers from planting has had cataclysmic consequences. Famine is already prevalent with one million people affected, and increasing starvation deaths. That is just the tip of the catastrophe.  Screening shows that 47% -70% of pregnant and breastfeeding women are severely or moderately malnourished. Among young children,  2.3%  per cent are severely and 15.6%  moderately  malnourished, exceeding the emergency threshold of 15%.

Sexual violence is the conflict’s hallmark: tens of thousands of women – from children to grandmothers –  have been raped, including in multiple rapes accompanied by extreme physical cruelty. Disgracefully, the UN’s own in-country staff minimised the initial reports and failed to respond. With the wanton destruction of health facilities as well as the associated stigma felt by affected women, only a small proportion of survivors have received any therapeutic or prophylactic treatment.

At least 70% of Tigray’s hospitals and health centres were destroyed or looted in the early phase of the war. Ambulances were targetted and their incumbents slaughtered, as they tried to navigate hostile check points.  Many health facilities were taken over by fighters as billets or command posts. There are numerous testimonies of – largely Eritrean but also Ethiopian – soldiers running amok to gun down patients – including pregnant women – and health workers.  Some of them were raped within the sanctuary of health facilities. Many health workers who survived have fled. Those who made it across the border into Sudan are the backbone of refugee health services there.

Understandably, civilians are reluctant to return to health facilities which were sites of such horrors.  In any case, there is little point in doing so as there were few supplies  and little electricity for the most basic of functions such as the cold chain. Needless to say, essential public health functions such as vaccinations have folded. Water and sanitation services were also devastated.

Other essential infrastructure that was destroyed includes the internet, telecommunications, and banking. Public and private sector employees have not been paid for many months. Even if people had money, there is little to buy. This is compounded by the Ethiopian government’s blockade of Tigray and  denial of humanitarian access.

Thus, humanitarian aid – including healthcare – has been instrumentalised as a tool of war, in flagrant and ongoing breaches of international humanitarian law. This has meant that barely 5%  of the life-saving aid – some 100 truckloads of food, medicines and other necessities  are needed daily – has been getting through.  Additional bureaucratic restrictions have been imposed from Addis as well as the demonisation of the more outspoken humanitarian agencies, three of which have been suspended. At least a dozen aid workers have been killed, including three health workers.

Humanitarian and health sector are responding

The Tigrayan state authorities and a few humanitarian health agencies are doing their best to revive the health sector, against overwhelming odds.  A recent UN humanitarian update indicates that the interagency health cluster has 23 organisations working for 3.8 million people with health needs of which 2.3 million are being targetted by the UN’s so-called “Northern Ethiopia” Response Plan; only a dismal 87,000 have been reached.  The nutrition cluster  has 12 agencies targetting 1.4 million of the 1.6 million in need but have reached just 66,000. The 18 agencies in the water and sanitation cluster aim to help 3.2 million of the 4.5 million in need, and have reached a creditable 1.2 million.

The UN’s Financial Tracking Service reports US$ 1.4 billion humanitarian funding for Ethiopia in 2021 of which $722 million is for the Tigray complex emergency.  Of the latter, health’s share is $40 million, nutrition $52 million, and water, sanitation & hygiene $49 million.

Only $200 million of the Tigray appeal had been received by appealing organisations by the end of August. It is not clear how much has been spent i.e. converted into goods and services.  It seems that while the world is generous in committing towards Tigray’s succour, practical  assistance that relieves suffering and makes a difference on the ground  is fairly minimal. This is mostly due to the humanitarian blockade.

Such ‘dashboard’ statistics obscure as much as they reveal.  Appeals under-estimate real needs because agencies often assess needs based on their own capacity to deliver which is severely constrained when there is restricted access. What happens to the un-counted and un-reachable who don’t make it into “operational plans” that are the basis of donor funding?  Some agencies have been providing valuable but discreet assistance, especially  the ICRC  that works alongside the Ethiopia Red Cross. This includes much valued services such as prisoner/detainee visiting, and re-establishing family contact and reunification.

Overall, agencies tend to over-estimate their delivery and exaggerate their impact, as part of their fundraising or profile promotion. Ad hoc relief deliveries depending on temporary access have limited benefit. This applies particularly to much of medical provision and health assistance except, perhaps, when one-off interventions are better than nothing eg immunisations (including preventive oral cholera vaccines) or trauma management. 

This overview does not do justice to the desperate but ingenious self-help and mutual-help efforts of Tigray’s stricken community. They include surviving doctors, nurses, and other health workers as well as the contributions of the diaspora that have found creative ways to reach out to friends and family or trickle support to local voluntary groups. The Health Professionals Network for Tigray  has been filling a serious gap with health supplies and technical support inside Tigray and refugee camps in Sudan.  Global reporting systems don’t capture – nor value and appreciate – the magnitude of such efforts. 

Tigray’s war-related woes are compounded by other factors. COVID-19 is an underlying anxiety; vaccination coverage is some 2% in Ethiopia and close to zero in Tigray. Despite restricted telecoms and electricity, the recent initiative of a toll-free call centre seeks to provide Covid-related information as well as counselling for sexual violence… for those who can connect.

Then there are the swarms of locusts to which the region is prone, as well as the health and related impacts of accelerated climate change in  fragile environments as highlighted by the latest IPCC report.  

The mental health impacts of a brutalised and traumatised population are just beginning to be recognised. These will not be restricted to this generation but transmit to the next with profound implications.  If psycho-social healing does not happen at some time, further cycles of violence are inevitable. That is the lesson – if anyone cares to learn – from Ethiopia’s own history as well as from worldwide experiences of war and peace.

Those experiences  teach us that post-conflict healing requires accountability, justice, and restitution for the grave wrongs done during any vicious conflict. These are pre-requisites for, and not the consequences of a sustainable peace.

The global health voice is muted

My stance on Tigray’s tragedy is shaped by  my experiences of confronting genocidal situations in, for example, Rwanda, Darfur, and Srebrenica.  These shook me to my personal and professional core.  Vowing “never again” means acknowledging that a crime against humanity in one place is a crime against all humanity everywhere, and requires everyone to give voice and act in solidarity.

But my greatest disappointment is that this is not happening. The UN’s own political leadership has been non-existent.  The hypocrisy of the global health community – many of them my distinguished colleagues from a lifetime of shared  values and endeavours – is expressed through their near-silence.  They are not backward in advocating  on vital but “safely” abstract health matters such as COVID-19 inequities or universal health coverage. Yet they are strangely cowardly in taking a stand on immediate existential threats: mass atrocities are also bad for your health!  In the evil business of crimes against humanity, such silence kills more efficiently than bombs and bullets.

Meanwhile, humanitarian and health assistance must, of course, be maximised despite the obstacles.  But its purpose is not just to bandage the wounds. Its greater value is in lighting the path to humanity and peace, whenever people wish to tread it.  Such a journey in Ethiopia will be long and tortuous.

First published 31 August 2021 at GENEVA HEALTH FILES