The assault on health care in Tigray

In 2019, Ethiopian Prime Minister Abiy Ahmed Ali was awarded the 100th Nobel Peace Prize. The Nobel Committee cited both his making peace with Eritrea and ending Ethiopia’s state of emergency at home. These acts will not, however, be his legacy. Rather, Abiy will be known for the war crimes and crimes against humanity that may have been committed by his military forces, along with the Amhara militia seeking Tigrayan territory his new ally, Eritrea, in the Tigray region of Ethiopia.   

The origins of the conflict are complex, but what is incontestable is that Abiy’s forces have massacred civilians, committed sexual violence, destroyed farms, arrested thousands, and displaced millions of Tigrayans. They wantonly destroyed the region’s health care system. The result is a massive humanitarian crisis, including famine, and yet Abiy blocked access to humanitarian aid. 

Although it has gained the least attention, the destruction of Tigray’s health care system may have the most far-reaching effects, which will far outlast the conflict.

The assaults began almost immediately, including artillery attacks on hospitals and civilians inside them. In January, the United Nations reported that only five of 40 hospitals were functioning. A survey conducted in March by Médecins Sans Frontières (MSF) found “deliberate and widespread attacks on health care,” resulting in 73 percent of health facilities being intentionally being destroyed or looted. Only 30 ambulances remain from a total of 280 pre-war. 

That was just a prelude. Nurses have been detained. In March, a medical student was raped at a hospital by Ethiopian soldiers. After that report, 10 other women came forward to say that they had been raped as well. Hundreds of women have spoken up since. In June, Eritrean forces assaulted a vaccination team, and later that month, three MSF health workers were murdered. 

U.N. Secretary-General Antonio Guterres said he was “deeply shocked by the murder of MSF staff,” which he described as “an unacceptable and appalling” violation of international humanitarian law. The vulnerability of health workers led hundreds of them to flee, further depleting resources for health. In the face of this crisis, the Ethiopian government suspended MSF’s medical work based on false allegations of spreading misinformation and other absurd charges. 

Despite their prohibition, attacks on health care in armed conflict are not uncommon as a strategy of war. They may be employed to demonstrate the futility of resistance to power, to force populations to move or to impose suffering on a recalcitrant civilian population for years to come.  

In Syria, the Assad regime has bombed or shelled at least 540 hospitals and killed more than 900 health workers as a military strategy; in Myanmar, where health workers have been leaders in opposing the military coup, the junta perpetrated more than 250 acts of violence against health workers and hospitals.  

Attacks on health care appear to be one of Abiy’s strategies. Tigray’s health system, one of the best in Ethiopia two decades in the making, has all but collapsed. MSF reported in March that pregnant women experienced severely reduced access to pre- or postnatal care, children went unvaccinated, and patients with HIV, diabetes, hypertension and other diseases lost access to lifesaving drugs. Survivors of sexual violence did not receive medical or psychological care.   

Five years ago, the U.N. Security Council took a stand against violence inflicted on health facilities and personnel and called on governments to reform their military practices and discipline soldiers who commit violations. Where domestic accountability fails, the council called on global action to stop the atrocities and prosecute perpetrators through the International Criminal Court (ICC) or other venues. But those commitments have not been carried out. 

The Biden administration has used its voice and power to seek to stop the atrocities in Tigray. It has imposed targeted sanctions, withheld some non-humanitarian aid, demanded an end to the crimes, sought resolution of the conflict, provided humanitarian aid and sought free passage of that aid. And it has called for justice and accountability. 

But Abiy has resisted all entreaties. He did not even meet with USAID Administrator Samantha Power when she visited the region in early August. The administration must ratchet up the pressure and end Abiy’s impunity. Secretary of State Antony Blinken must release his department’s findings on war crimes, crimes against humanity and genocide in Tigray. The administration must not allow Ethiopia and its apologists to obstruct referral to mechanisms of international justice. Above all, urgency is needed to save the people of Tigray.

Leonard Rubenstein is a professor of the practice at the Johns Hopkins Bloomberg School of Public Health and the author of “Perilous Medicine: The Struggle to Protect Health Care from the Violence of War.” Mulugeta Gebregziabher, a native of Ethiopia, is a professor of biostatistics and vice chair of the  Department of Public Health Sciences at the Medical University of South Carolina.