The Siege of Ayder Hospital: A Cri de Coeur From Tigray, Ethiopia

Abstract

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.

Full text

The Siege of Ayder Hospital:
ACri de Coeur From Tigray, Ethiopia
L. Lewis Wall, MD, DPhil
Abstract: In November 2020, the federal government of Ethiopia in-
vaded 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 andkilled
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 inter-
nally 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.
Key Words: Tigray, Ethiopia, Eritrea, genocide, humanitarian relief,
medical ethics, rape
(Female Pelvic Med Reconstr Surg 2022;28: e137–e141)
What do you dowhen 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 re-
sources 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 dowhen 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 be-
came 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 Gyne-
cology at Ayder Hospital. I gave lectures, saw patients, carried out
research, performed operations, and participated in strategic plan-
ning discussions with senior clinicians.
2–8
We dreamed about the
future, and together, we created the first subspecialist urogynecol-
ogy 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 in-
vaded Tigray in collusion with the government of Eritrea and eth-
nic 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 po-
litical 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 re-
building 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.
From the Departments of Obstetrics & Gynecology and Antropology, Washington
University in St. Louis, St. Louis, MO.
Correspondence: L. Lewis Wall, MD, DPhil. E-mail: WALLL@wustl.edu.
The authors have declared they have no conflicts of interest.
Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.
This is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the work
provided it is properly cited. The work cannot be changed in any way or
used commercially without permission from the journal.
DOI: 10.1097/SPV.0000000000001181
COMMENTARY
Female Pelvic Medicine & Reconstructive Surgery •Volume 28, Number 5, May 2022 www.fpmrs.net e137

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 vil-
lagers from their homes. They killed thousands of noncombat-
ants.
20
Hundreds of helpless civilians were slaughtered in the an-
cient city of Axum outside the holy Church of St Mary of Zion,
where Ethiopian Orthodox Christians believe the Ark of the Cov-
enant 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, kill-
ing 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 Re-
gional Health Bureau have all documented widespread instances
of horrific abuse.
30–33
Rape was used as a weapon of war to terror-
ize 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 Am-
hara 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 fam-
ily members at gunpoint.
37
Thousands of civilians were killed, often in extrajudicial ex-
ecutions. 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 pro-
mulgated by the invaders.
24
Millions more are now internal refu-
gees, 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 in-
vaders 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 re-
ported that Ayder Hospital had no supplies, no fuel, and no run-
ning 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 out-
lying clinics was forbidden, although those clinics desperately
needed administrative support. The referral and transportation net-
work 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 trav-
eling to Tigray even had their own personal medications con-
fiscated by government soldiers. Nothing was allowed to get in.
44
Telecommunications were severed. A total news blackout was im-
posed, 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, phar-
macists, nurses, midwives, and public health workers. It worked
closely with the Tigray Regional Health Bureau, whose infrastruc-
ture 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 peo-
ple had experienced.
47
Abiy Ahmed, panicked by these develop-
ments, 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.
1,24,4 9,50
The siege ofTigray is relentless, despite international pleas to
permit the distribution of critically needed medical and food sup-
plies.
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. Cata-
strophic complications of obstructed labor have become common-
place, because the healthcare infrastructure has collapsed. Only a
few hospitals in Tigray are functional at any capacity, the transpor-
tation 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
Wa l l Female Pelvic Medicine & Reconstructive Surgery •Volume 28, Number 5, May 2022
e138 www.fpmrs.net © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.

from obstructed labor—nearly eliminated in Tigray within the last
few years—are now depressingly prevalent. The women who sur-
vive 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 elec-
tronic 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 fami-
lies.
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 su-
tures, intravenous fluids, and the constantly diminishing institu-
tional capacity.
1
The supply of critical medications is almost gone.
Almost all of the drugs that remain are beyond their “official”expi-
ration dates.
1
Dialysis patients are dying because the complex med-
ical care that they require can no longer be provided. The computed
tomography and magnetic resonance imaging scanners are no lon-
ger operational. The state-of-the-art oxygen generation plant no lon-
ger 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 relent-
lessly and the COVID-19 pandemic rages on.
1
This madness must stop.
Mekelle has a large, modern airport, fully capable of han-
dling 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 in-
sure that needed supplies arrive, are stored, and distributed care-
fully 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 hu-
manitarian 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 suf-
fered 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 sup-
plies, 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 gov-
ernment deliberately fanned the flames of ethnic hatred, calling
Tigrayans “rats”and “hyenas”that had to be destroyed.
53,54
Am-
hara 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. Ethio-
pian national identity cards now declare the holder’s ethnicity, mak-
ing 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 otheratrocities committed in Tigray, but her re-
port 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 mur-
ders, 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 hor-
rors 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 starva-
tion to achieve political ends. We must condemn the deliberate de-
struction 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 medi-
cal supplies it needs. Our ethical obligations as physicians require this
of us. If we turn our backs on Tigray, history will not forgive us.
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51. Walsh D. On day Biden calls Ethiopia’s leader to urge peace, a drone strike
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