It has now been over four months since the fighting broke out between the Tigray regional state forces and the Ethiopian government forces (alongside Amhara Special forces, Amhara militia, and Eritrean government Forces). Despite the Ethiopian Government’s denial, active military engagement is still going on in the region and the humanitarian and health situation of the people of Tigray remains deeply alarming.
To document the impact of the War on non-communicable disease (NCD) patients in Tigray, we pull together a range of sources including recent perspective pieces on the impact of the war on the health system in Tigray and the food and health care impact of the war on Tigray, media releases; a report released by the current interim administration of Tigray and other multilateral organisations such as the World Health Organisation (WHO), United Nations International Children’s Emergency Fund (UNICEF), Médecins Sans Frontières (MSF) and Save the Children. Dr Gebremariam also adds firsthand insights and medical field notes from a recent trip to assess the health situation in the region. We both grew up and worked in the public health space (the first as a researcher and the second as a medical doctor) for several years in Tigray and as such understand the health system and health service delivery in the region. Hence, we believe, it is reasonable for us to provide some insights on the impacts of the war on people living with noncommunicable diseases in the region.
The destruction of healthcare in Tigray
There is no denying that every health program in the embattled region is severely affected. For this reason, access to health services including clinical follow up for noncommunicable diseases is barely available in almost all parts of Tigray and many patients are dying at home from these conditions.
Many health system infrastructures such as hospitals, health centres, health posts and ambulances are either destroyed or looted. For instance, out of the 205 health facilities that were assessed by the regional administration, 165 (81%) are out of order because of either looting or destruction. Furthermore, out of the 40 health facilities that are currently functioning, only 28% of them are receiving medicine supplies. On top of the looting and destruction, health providers have either fled the conflict or been killed, ambulances were destroyed or stolen by the Ethiopian or Eritrean defence forces.
No access to lifesaving medications
Prior to the conflict, health service access in Tigray was universal. Hospitals, health centres and other services were within reach for almost all people in Tigray. However, after the fighting commenced, most Tigrayans no longer have access to basic health services, with some exceptions in major cities such as Mekelle, Adigrat, Axum and Shire. Among others, people living with NCDs are suffering the most due to their reliance on health services to collect their life saving medications. Hayelom’s story, (from the diary of Yemnae Gebremariam who recently visited Adigrat hospital in eastern Tigray) is one of the many heart-breaking stories which exemplifies the dire health situation that millions are experiencing in Tigray.
Hayelom Tesfay was a lecturer at Adigrat University with Type I diabetes mellitus (DM) and must regularly collect his insulin supply from the nearest health facility in his neighborhood. On the 4th of November 2020, war broke out in the region where he resides, and he was forced to flee from the city to save his life – just as many others did to escape the indiscriminate bombing and shelling that came with the fighting. Yet for Hayelom, there was another time bomb looming within him and on one unfortunate day, his neighbors recall “he felt the pace of his breath change, got dizzy, and had a pain in his abdomen”.
Hayelom was aware that he had developed the acute complication of DM called diabetic ketoacidosis (DKA) – a life-threatening condition when the blood becomes too acidic. He urged people to get him insulin or take him to Mekelle, the capital. But even while asking, he knew that it was not possible as there was heavy fighting all the way to Mekelle, so neighbors took him to a nearby health centre in a remote village. To the dismay of all, there was no insulin and Hayelom who escaped from bullets succumbed to an insulin-deficit.
Hayelom’s is only one story, with many others who are trapped in the war-torn region suffering the same fate. Several such cases have been on other media outlets and on Social Media, and several others have been included in Tghat’s victim list. Even among those who manage to get insulin, storage is problematic. There was no electricity for more than two consecutive months all over the region (which has not yet fully been restored) and Tigrayans must flee almost daily to safer places and hideouts.
More devastating stories from the field
A paediatrician from Mekelle also recalls her agony due to the escalating adverse DM events all of which are preventable with appropriate medical care: “there were a lot of kids who have established a great bond with me; some of them used to give me a call for greeting but they are not coming to the health facility or giving me a call anymore. Now, I do not know their whereabouts. In recent days, I have to deal a lot with constant exacerbations of DKA, insulin interruptions and all that because many of my patients are deprived of insulin. Even when it becomes available, the regimen varies from time to time and most often it’s mixed insulin which I don’t recommend for kids.”
In our recent systematic review before the war, NCDs such as DM, cardiovascular diseases (hypertension, ischemic heart disease, stroke and rheumatic heart diseases), cancer and chronic obstructive pulmonary diseases were common in Tigray. Before the fighting, there were more than 180, 000 people with NCDs who missed their clinical follow up, of which 24,000 had DM and 20,000 had hypertension. There are mounting reports of people dying from the lack of basic medication for NCDs such as insulin, antihypertensive drugs and lack of regular clinical follow ups. For instance, before the war in Ayder Referral Hospital, one of the biggest hospitals in Tigray, there were 1, 400 children and more than 2, 000 adults with DM on insulin. While there are six confirmed deaths due to the lack of insulin, hundreds are lost to follow up– possibly due to death.
Another doctor’s diary below further demonstrates the depth and extent of the suffering and death shared among thousands because of the lack of basic medical services and medications. In the general hospital, he recalls two cases of status epilepticus (i.e. seizures) who succumbed to death. “They came in a coma and when I checked their history both were on Phenobarbitone (anti-epileptic drug) with good control but came with status epilepticus after supply was suddenly cut off. Oxygen was short, no Phenobarbitone and all colleagues and I tried starting them on the only available medications but it was all inadequate and they died. It’s very challenging to be a physician these days in Tigray. The supply and demand gaps are very wide, we must make forced change in regimens and the result is usually poor. We do not have even long-term controllers for asthma and as a result, we manage exacerbations very frequently. There are a lot of missing patients, but I can’t enumerate them as we are currently doing only simple life saving measures”, he says in anguish.
An official of the regional health bureau within the interim administration also reflects on the deteriorating condition. “Currently, we are only mobilizing the available limited resources to run mobile clinics. We don’t know how many cases of chronic illnesses were nor do we have current assessment. We are in no position to furnish hospitals because there is ongoing looting by the Eritrean forces and resources are scarce.”
The way forward
In conclusion people with NCDs are dying at home due to lack of basic health services and medications such as insulin, antihypertensive, asthma and epilepsy treatment due to the ongoing fighting and insecurity in the region. The following actions must be urgently taken to put an end to this.
- International and regional governments and organisations must enhance their efforts to stop the fighting.
- Aid agencies should be urged to support the supply of insulin, antihypertensive and epilepsy drugs.
- The Ethiopian Ministry of Health should scale up its efforts to address the medicine supply chain challenges.
- It is highly recommended to redesign the delivery of health services to a vertical and targeted program (e.g., NCD, TB, HIV and malaria program) to address the need for treatment of NCDs and other conditions.
About the authors
- Dr Fisaha Haile Tesfay is a postdoctoral research fellow at Deakin University, Institute of Health Transformation. The views expressed in this opinion piece are only the author’s, not necessarily the funders.
- Dr Yemane Geberemariam is a Paediatrician at Adigrat University. The views expressed in this piece are only the author’s, not necessarily the funders.