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The impact of war on the health system of the Tigray region in Ethiopia: a response to complaints

  • Torrense University Australia
GesesewH, etal. BMJ Global Health 2022;7:e008839. doi:10.1136/bmjgh-2022-008839
The impact of war on the health system
of the Tigray region in Ethiopia: a
response to complaints
Hailay Gesesew ,1,2 Kiros Berhane,3 Elias S Siraj,4 Dawd Siraj,5
Mulugeta Gebregziabher,6,7 Azeb Gebresilassie Tesema ,8,9 Amir Siraj ,10
Maru Aregawi,11 Selome Gezahegn,12 Fisaha Haile Tesfay 13,14
To cite: GesesewH,
BerhaneK, SirajES, etal. The
impact of war on the health
system of the Tigray region
in Ethiopia: a response to
complaints. BMJ Global Health
2022;7:e008839. doi:10.1136/
Received 16 February 2022
Accepted 16 February 2022
For numbered afliations see
end of article.
Correspondence to
Dr Hailay Gesesew;
hailushepi@ gmail. com
http:// dx. doi. org/ 10. 1136/
bmjgh- 2021- 008263
© Author(s) (or their
employer(s)) 2022. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
We welcome the opportunity to respond to
Masebo et al’s complaints on our recently
published article.1 Before responding to
the main issues raised (on ‘methodological
shortfalls’ and on ‘unverifiable assertions and
inflammatory statements’), we would like to
emphasise the following general points:
1. Our paper was clear about its scope—limit-
ed in the period under investigation (from
November 2020 to June 2021) and the
region under study (the Tigray region).
Its merits should be judged based on its
explicit geographically and temporally
defined scope. We see our paper as only
one of many that we expect will be pub-
lished—both about the Tigray region (as
the conflict and the complete blockade is
still ongoing) and other regions such as
Amhara and Afar into which the conflict
has unfortunately expanded.
2. We do not condone atrocities on health
facilities by any group in any region. We
condemn any deliberate destruction of
health facilities—regardless of where or
by whom it happens. We look forward to
more objective independent assessments
of what happened in all affected regions,
including Tigray.
3. Our paper was very clear about its data
sources, which included the interim gov-
ernment that was put in place by the Ethi-
opian Federal Government and reputa-
ble international organisations that were
operating in the region during the study
period. Unless Masebo et al believe that
war- time data should never be published,
these data sources are comparable to other
war time publications and are as good as
it gets given the limited access the world
had to Tigray during the study period.2 3
We used multiple data sources including
unpublished reports and reports from
humanitarian organisations, which we ex-
plicitly described. In the absence of direct
and unfettered access to collect primary
data (as is the case in the Tigray region),
we believe the use of such diverse sources
helps to cross validate the findings. We also
highlighted limitations in the data which
resulted due to the limited access to the
Tigray region.
4. Our analysis was based on available re-
ports, that is, published and unpublished
reports. There was no need for any formal
ethical clearance. In this regard, an im-
portant issue to consider is that in times of
war and crises, humankind, and the world
at large benefits from access to important
data and analysis as events unfold, rather
than wait for a time when the data can be
made perfect. Given the level of human
suffering, the world might lose an oppor-
tunity to intervene if one had to wait until
such time that the data can be verified to a
degree that we are used to during peaceful
As also acknowledged by Masebo et al,
acquiring data in conflict zones is always
difficult. In our case, we used several reliable
and independent sources including Amnesty
International and the United Nations Office
for Coordination of Humanitarian Assistance.
Of note, Masebo et al themselves used these
data sources to support their arguments. We
believe that the world needs properly contex-
tualised and carefully interpreted war time
data and reports on a timely manner, with any
limitations properly stated.
Our analysis was deliberately descriptive
and comparative. We did not apply rigorous
on March 31, 2022 by guest. Protected by copyright. Glob Health: first published as 10.1136/bmjgh-2022-008839 on 31 March 2022. Downloaded from
2GesesewH, etal. BMJ Global Health 2022;7:e008839. doi:10.1136/bmjgh-2022-008839
BMJ Global Health
inferential analysis as the nature of the data would not
have allowed it. Descriptive and qualitative comparison of
prewar and war time data is an acceptable methodology,
even if the nature of the data may not be directly compa-
rable. We also did not mention the use of parallel meth-
odology, that is, application of Ethiopian Demographic
Health Survey (EDHS) methodology, which is based on
a sample of household survey, as that was not the aim of
our paper. Masebo et al’s conclusion that we used erro-
neous methodology is not supported by any evidence or
logical reasoning.
It is important to clarify that the report by the Tigray
Regional Health Bureau (interim) that we had access to,
is unpublished, as are most internal government reports.
Masebo et al erroneously indicate lack of citations for
some of the data reported in our paper. We urge all
readers to read our paper carefully and to crosscheck
our citations. For example, the source for the data we
provided on rape as a weapon of war is provided in ref
We have now made some minor edits to our paper
to ensure that the numbers we reported are better
aligned with the references, and that references are
made to original sources more directly. As is typical in
war time situations, the numbers reported by various
sources may not always be exactly the same. We note,
however, that all our arguments were fully supported
even without these changes—although indirectly.
Masebo et al pointed out the joint investigation by
United Nations High Commissioner for Human Rights
and the Ethiopian Human Rights Commission (EHRC)
as a reliable source which we should have cited. But we
could not have used the report because: (1) it was not
published by the time we submitted our manuscript;
and (2) by EHRC’s own admission the report was not
complete and calls for further work. We point out the
recent establishment of another commission by the
UN Human rights Council A/HRC/S- 33/L.1: Situa-
tions of Human Rights in Ethiopia on 17 December
2021 which demonstrates the incompleteness of the
investigative process.4 Moreover, the Tigray govern-
ment, political parties in Tigray, civil society organisa-
tion in Tigray had unequivocally rejected the findings
of the joint investigation because of serious methodo-
logical flaws, inconsistencies and lack of impartiality.
The UN security council in its latest open meeting
also admitted the incompleteness of the report and
approved the creation of an independent investigative
body that will investigate all atrocities from November
2020 onward.5
The issues related to the Mai- Kadra massacre
mentioned by Masebo et al are hotly debated and beyond
the scope of our paper. For the same reason, we did not
mention other massacre sites in Tigray including the
ones in Axum, Mariam Dengelat, Mahbere Dego and
others which are widely documented by independent
bodies such as Amnesty International, Human Rights
Watch and media outlets such as CNN, BBC, New York
Times, etc. The proper and rigorous documentation of
these massacres would require much additional work,
for example, as has been initiated by Ghent Univer-
sity and reported on their website.6 We have further
combed through our article to remove any language
that may suggest a political motivation for our analysis.
Regarding the activities of the Ethiopian govern-
ment to rehabilitate the damaged health facilities in
Tigray, we did acknowledge that some facilities were
providing some, although minimal, services during
the Tigray Interim government’s control. We have now
added more details in that regard. Overall, the effort
to support destroyed health system during the time
the Ethiopian Federal Government controlled most
of Tigray region was limited in coverage and scope.
The current state of healthcare service in the region
is reflective of the magnitude of devastation and leaves
millions in desperate need which is compounded by
the ongoing active conflict as well as the complete
siege and blockade of Tigray.7
We hope we have established that Masebo et als claim
that our paper contains ‘inaccuracies, factual errors,
gross misrepresentations, and inflammatory state-
ments’ are unsubstantiated. Our paper was written and
published without partisan motivations, but because
of concerns that urgent actions were (and continue to
be) needed to save lives. In doing so, we have sought to
steer away from partisan political discourse which do
not belong in a scientific paper. We conducted delib-
erately descriptive and comparative analyses, reported
according to well established scientific norms. Our
conclusions remain sound and have since been
corroborated by emerging reports from and about the
ongoing situation in Tigray.8–10 Despite inevitable data
limitations, we believe that papers such as ours that
highlight the devastating impact of war on healthcare
and health systems ought to be encouraged, given the
immense consequence on millions of lives.
Author afliations
1Public Health, Flinders University, Adelaide, South Australia, Australia
2Biostatistics, Mekelle University, Mekelle, Ethiopia
3Biostatistics, Columbia University, New York, New York, USA
4Division of Endocrinology, Eastern Virginia Medical School, Norfolk, Virginia, USA
5Infectious Disease, University of Wisconsin Madison, Madison, Wisconsin, USA
6Public Health Sciences, Medical University of Southern Carolina, Charleston, South
Carolina, USA
7Research, Ralph H Johnson VAMC, Charleston, South Carolina, USA
8The George Institute for Global Health, University of New South Wales, New Town,
New South Wales, Australia
9School of Public Health, Mekelle University, Mekelle, Ethiopia
10Biological Sciences, University of Notre Dame, Notre Dame, Indiana, USA
11Global Malaria Program, World Health Organization, Geneve, Switzerland
on March 31, 2022 by guest. Protected by copyright. Glob Health: first published as 10.1136/bmjgh-2022-008839 on 31 March 2022. Downloaded from
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BMJ Global Health
12General Internal Medicine, University of Minnesota Medical school, Minnesota,
Minnesota, USA
13School of Public Health, Mekelle University, Mekelle University College of Health
Sciences, Mekelle, Ethiopia
14School of Health and Social Development, Mekelle University College of Health
Sciences, Mekelle, Tigray, Ethiopia
Twitter Mulugeta Gebregziabher @ProfMulugeta and Azeb Gebresilassie Tesema
Acknowledgements Authors Yemane Gebremariam Gebre, Samuel Aregay
Gebreslassie and Dr Fasika Amdeslassie are based in Tigray and could not
be involved in developing this response due to the complete absence of
communication to the region.
Contributors HG, KB, ESS, DS, MG, AGT, AS, MA, SG and FHT conceived the
idea. HG drafted the manuscript. All authors critically review and approve the
manuscript. All authors are members of the Global Society of Tigray Scholars &
Professionals (GSTS).
Funding The authors have not declared a specic grant for this research from any
funding agency in the public, commercial or not- for- prot sectors.
Competing interests None declared.
Patient consent for publication Not applicable.
Ethics approval This study does not involve human participants.
Provenance and peer review Commissioned; internally peer reviewed.
Data availability statement All data relevant to the study are included in the
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the
use is non- commercial. See:
Azeb GebresilassieTesema
Fisaha HaileTesfay
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Full-text available
The war in Tigray region of Ethiopia that started in November 2020 and is still ongoing has brought enormous damage to the health system. This analysis provides an assessment of the health system before and during the war. Evidence of damage was compiled from November 2020 to June 2021 from various reports by the interim government of Tigray, and also by international non-governmental organisations. Comparison was made with data from the prewar calendar year. Six months into the war, only 30% of hospitals, 17% of health centres, 11.5% of ambulances and none of the 712 health posts were functional. As of June 2021, the population in need of emergency food assistance in Tigray increased from less than one million to over 5.2 million. While the prewar performance of antenatal care, supervised delivery, postnatal care and children vaccination was 64%, 73%, 63% and 73%, respectively, but none of the services were likely to be delivered in the first 90 days of the war. A conservative estimate places the number of girls and women raped in the first 5 months of the war to be 10 000. These data indicate a widespread destruction of livelihoods and a collapse of the healthcare system. The use of hunger and rape as a weapon of war and the targeting of healthcare facilities are key components of the war. To avert worsening conditions, an immediate intervention is needed to deliver food and supplies and rehabilitate the healthcare delivery system and infrastructure.
Full-text available
Ten years of the Syrian war had a devastating effect on Syrian lives, including millions of refugees and displaced people, enormous destruction in the infrastructure, and the worst economic crisis Syria has ever faced. The health sector was hit hard by this war, up to 50% of the health facilities have been destroyed and up to 70% of the healthcare providers fled the country seeking safety, which increased the workload and mental pressure for the remaining medical staff. Five databases were searched and 438 articles were included according to the inclusion criteria, the articles were divided into categories according to the topic of the article. Through this review, the current health status of the Syrian population living inside Syria, whether under governmental or opposition control, was reviewed, and also, the health status of the Syrian refugees was examined according to each host country. Public health indicators were used to summarize and categorize the information. This research reviewed mental health, children and maternal health, oral health, non-communicable diseases, infectious diseases, occupational health, and the effect of the COVID − 19 pandemic on the Syrian healthcare system. The results of the review are irritating, as still after ten years of war and millions of refugees there is an enormous need for healthcare services, and international organization has failed to respond to those needs. The review ended with the current and future challenges facing the healthcare system, and suggestions about rebuilding the healthcare system. Through this review, the major consequences of the Syrian war on the health of the Syrian population have been reviewed and highlighted. Considerable challenges will face the future of health in Syria which require the collaboration of the health authorities to respond to the growing needs of the Syrian population. This article draws an overview about how the Syrian war affected health sector for Syrian population inside and outside Syria after ten years of war which makes it an important reference for future researchers to get the main highlight of the health sector during the Syrian crisis.
It has been a year since a devastating war broke out in the Tigray region, Northern Ethiopia, where hundreds of thousands of Tigrayan civilians are killed, millions internally displaced and tens of thousands have fled to seek refuge in neighboring Sudan. An alarming development linked to this war is the manmade famine in Tigray that now threatens the lives of the millions of civilians who survived the horrific atrocities during the war. This piece is an attempt to explain why millions of Tigrayans from all walks of life face famine and concludes that famine was from the start an end goal of the Ethiopian and Eritrean regimes and they employed different tactics to ensure that it unfolds the way it does now. Among others, the tactics include (1) the systematic looting and destruction of Tigray's basic economic infrastructures, (2) implementation of different financial measures to deprive people in the region of access to cash, and imposition of a complete siege that hindered access to supplies including lifesaving humanitarian assistance.
Destroyed hospitals and severe shortages of doctors and drugs are taking their toll in Syria after more than two years of civil war, which has led to more than 100 000 deaths, millions of displaced people, and the re-emergence of polio, writes Keir Stone-Brown The Syrian civil war has become one of the worst humanitarian disasters of this century. According to Elizabeth Hoff, the World Health Organization’s representative to Syria for the past year, it has claimed 115 000 lives and injured more than 575 000 people. And, worryingly, no end seems in sight. “The health situation has drastically deteriorated over the past few months, with an estimated 6.5 million displaced within Syria. There are critical gaps in essential healthcare delivery,” she said. What began in March 2011 as a revolution driven by the hope of the Arab Spring, has since deteriorated into a stalemate between President Assad’s regime and tentatively allied opposition forces. As of June 2013, two in every five hospitals were out of service. Lack of power has forced many hospitals to operate in almost impossible conditions. In Homs, a city heavily affected by the conflict, only two hospitals remain open, with the major hospital, Al Watani, badly damaged. In the Aleppo region, near the Turkish border, the situation is unsustainable, according to Omar Abdul Gabbar, a consultant orthopaedic and spinal surgeon and medical lead for the humanitarian organisation Hand in Hand for Syria. “This is a city of five million. Assuming two million have left the town and one million are in the government controlled area, you have a population of two million served by 35 surgeons to treat everything including war injuries,” he said. WHO is providing humanitarian assistance in conjunction with 36 non-governmental organisations. But their work is not straightforward. “We have difficulties in delivering …
Tigray: atlas of the humanitarian situation
  • A Sofie
  • B Tim Vanden
  • N Emnet
Sofie A, Tim Vanden B, Emnet N. Tigray: atlas of the humanitarian situation. J Maps 2021.