A day in the life of a neurosurgeon in Tigray, Ethiopia battling a deadly brain tumor

The author assisted by a Mekelle University neurosurgery resident performing microscopic brain tumor resection at Ayder Hospital in 2018

The neurosurgical team of Mekelle University’s Ayder Hospital struggles to save the life of a poor farmer from a deadly brain tumor. A critically ill patient who faced death unless he underwent emergent brain surgery.  An intense multi-hour confrontation with a brain tumor.  This became an almost everyday occurrence for our team. 

I had come to Ayder Comprehensive Specialized Hospital in Mekelle, Ethiopia in 2015 to start a neurosurgery program. This was a federal teaching teaching hospital  and part of a university medical center serving about 15 million people. We wanted to create a sustainable medical service that also train neurosurgeons. 

As the family said goodbye to him he left the ICU for the operating room. He had been intubated and resuscitated in the emergency room where he presented with coma. A young uneducated farmer from a remote primitive area who had been deteriorating for a year and half. Tumors in this part of the world are large and angry because they present so late.

A large 4th ventricle tumor next to vital structure would be difficult to remove

The MRI of the brain showed a 10 centimeter ependymoma in the fourth ventricle which was highly vascularized. This is the type of case neurosurgeons dream of, a mix of danger and hope.

The residents and fellows do the initial opening until the back of the brain is exposed which takes the first hour of surgery. I can see the tumor erupting to surface with very swollen blood vessels around it. Instead of the ependymoma (an easier tumor to remove) this was going to be hard. I begin working a millimeter at a time. Gently dissecting tumor from brain, isolating and separating scar bands and blood vessels. Using directed light and magnification for the next 8 hours I cannot take even a 5 minute break. Removing the tumor means there is constant blood loss. The brain receives more blood than any other organ. Tumors cause extra blood vessels to grow into them. As you control one bleeder another 2 start.

By the fourth hour into surgery he has lost 5 liters of blood and his blood pressure is fragile. By the sixth hours there is still about 20% of the tumor left which is covering the cerebral aqueduct. This must be removed to allow flow of cerebrospinal fluid. We are millimeters away from vital areas that cannot be damaged.

Another 2 hours goes by and there are times when the blood loss starts again and pressure gets low even with another 2 units. After 8 hours from the beginning of my part of the surgery the tumor is completely removed. The patients blood pressure is holding thanks to high dose epinephrine (a drug to raise blood pressure in critical patient). Now comes the hardest time. Will the patient wake up? He goes to the intensive care unit and we wait. After a few hours he begins to move in a way that suggest he will emerge from coma.

This is the life of neurosurgeon. Fighting to stay on the brink of life for hours at a time.

Neurosurgical consult for snake bit in Ethiopia

Artist rendition of Ethiopian puff adder about to bite the leg of a passer by. His CT of the brain upon presentation to Ayder Hospital, Mekelle University showed multiple sites of intracranial hemorrhage. 
A case from 2019 in Mekelle, Ethiopia at Ayder Hospital. A neurosurgical consult for snake bit (not too common) causing brain hemorrhage.
This 21 year old man was bitten in the foot by an unknown viper, we latter determined it was most likely an Ethiopian puff adder, three days before being referred to our university hospital for sudden onset of coma after two days in a local hospital without antivenom. On arrival he was bleeding from all orifices and the intravenous site. Platelet count showed no countable platelets and bleeding time was not measurable. On seeing him he had no brain function but agonal respiration. We could not save him.
There a few case reports in Africa of similar nature usually occurring on the third day or so after the bite. I had not seen this in Ethiopia before but many people often do not seek treatment and assume they are going to die. It is imperative that victims of viper snake bit seek treatment at a university hospital with antivenom and advanced capabilities. He came too late for us to save.

An experience with a Palestinian doctor I will not forget

A Palestinian doctor feels lost in the modern world which ignores him

I had an experience with a displaced Palestinian which has never left me. A  doctor who felt his life and that of his community was seen as irrelevant by the whole world.

A little over 20 years ago I was consulting in Abu Dhabi with a UAE military hospital which in part involved caring for many victims of Isis being transferred from Iraq for medical treatment.  Our medical team consisted of European, American, Pakistani, North African, Indian and other nationalities working together. Included in our group was a Palestinian translator to help coordinate teamwork and patient communication.  He and his family had left Palestine to escape conflicts. He had undergone medical training in a Moscow university but had never been able to be fully licensed in any of many Middle Eastern countries he subsequently lived on. He was obviously very intelligent and gifted in his multilingual skills. Notably, although he was always attentive and dedicated to his work as a translator in helping facilitate communication with our patients this at least in part seemed to be accompanied always by a clear projection of personal melancholy.

To be honest, although we all appreciated his hard work, none of the medical or administrative professionals really treated him as an equal. He was not invited to social events or meetings other than just being available day or night for translation to communicate with patients. His supervisors were frankly sometimes abruptly short with him if he was tardy when called.

At that time he was not the focus of my reason to be in Abu Dhabi so I did not go out of my way to get to know him better which now I wish I had. However out of what little discussion I had with him about his life and family I learned he felt lost and somewhat hopeless. Palestinians were dominated by the Ottoman Empire and then came under colonial rule of the British. They were mostly bystanders to the emergence of the new prominent Arab identity fostered in Saudi Arabia and the other Gulf states. His people and homeland had never been given a voice to their self determination because they were not numerous in population nor possessing of any strategic influence to the major world powers. In other words the world saw them as irrelevant.

If I could go back in time I would have gotten to know him better. What has become of him I do not know. I do not have a solution for the catastrophe befalling Israel and the Palestinians today but believe the answer is to accept first of all that they are people with families, a part of God’s creation, and should be relevant to the world. The damage of making  them irrelevant to the world must stop.

The paradox of Eritrean children of refugees supporting an authoritarian regime

Eritrean diaspora are caught between the conflict of their national origin and the their new home in Western democracy
Many ask why sometimes 1st generation Eritrean diaspora support the authoritarian government that their parents risked their lives to leave? I have known many 1st and 2nd generation over the past 13 years and have reviewed academic studies one of which is linked below. Like most immigrants to western democracies they want to keep a link to their national origin.
The Eritrean government budget depends upon 1/3 of its funding from diaspora remittances. They have extensive networks in the Western democracies which put on “patriotic events” ostensibly to promote Eritrean culture but in reality to collect remittances which will guarantee the security and well being of relatives left behind.  As the son of an immigrant father I can related to that. Also honestly Eritrean and African immigrants may be subject to discrimination in their new country and their culture frowned upon not just the government that drove them away.
Socialists and political scientists point to the fact the new generation life experience has not included the suffering of their parents. Very effective manipulative propaganda of the Eritrean government as they learned from their Chinese teachers takes advantage of this lack of suffering and discrimination.
Then there is incentive to make sure relatives left in the country are not suffering or subjected to punishment for their relatives leaving.
It is important for Westerners to respect Eritrean culture and not confuse it with the authoritarian government. Refugees should be treated as equal to refugees from other parts of the world. The response of the these diaspora is a result of both propaganda promoting cultural worth and thus identity of these diaspora. Meanwhile Western democracies need to reach out and be more inclusive and accepting of their worth and arrival. Not treat them as outsiders.

Ethiopia persecuted intolerable terror not concern for the welfare of Tigray civilians

There was no attempt by the Ethiopian government to try the traditional approach of winning hearts and minds instead the strategy was one of one intolerable terror.

A review of the actions of military forces supporting Ethiopian invasion of Tigray since November 2020 demonstrates a strategy of persecuting intolerable terror to the civilian population to force an unconditional surrender contradicting the latest pronouncement from the Ethiopian government is that they have deep concern for the welfare of the Tigray. All the while  paradoxically calling for them to bare the sacrifice of suffering concurrently the punishing military operations against their elected leaders in the TPLF. They add that the Tigrayan people need to understand that their sacrifice is necessary during this military operation because ultimately it will be to their benefit.

Over the past two years we have heard and seen time and again from Abiy Ahmed supporters that the military action and removal of human rights of the Tigray people by Ethiopia was necessary. The Ethiopian Prime Minister complained following his “withdrawal” from Tigray in 2021 that he could not persuade the Tigrayans to stop supporting the TPLF. His Social Minister Daniel Kibret said that the Tigrayan people should be totally erased from history. Other leaders in the Amharic community stated that Tigrayans should be killed at birth.

Just to review what has been well documented since the onset of conflict in November 2020. In fact lets start even before that. Whilst about 3 years ago Abiy Ahmed gave a speech to the Ethiopian Parliament that the TPLF was a good example of government that works for its constituency just a year later he called them terrorists. At the time the leaders of the TPLF had pretty much left Addis Ababa and focused on Tigray. They had accepted the change in leadership. Yet Abiy Ahmed and his coalition of Amhara supporters decided that they all of sudden wanted no tigray in the parliament at all so they outlawed the TPLF.

At the same time in the year before the conflict Tigrayans were removed from administrative posts, academic counsels, and budgets for everything in Tigray began to be sharply cut. As the Tigrayans were no longer allowed in Parliament they had no voice. Amhara Prosperity Party members created and voted on a proposal that they were “Terrorists” without any due process. The Ethiopian Constitution which clearly states that the different regional states have a right to maintain defense forces and forbids one region’s defense forces from attacking another.

We know that a military buildup occurred in the regional states adjacent to Tigray well before November 2020. In anticipation of a bloody conflict, the Ethiopian federal government had set medical teams to care for military casualties month before. The “peace agreement” between the leaders of Ethiopia and Eritrea had contained an agreement for military alliance against Tigray. An immediate payment of $ 6 billion was given to Eritrea quickly at the onset of hostilities.

If the Ethiopian government was so concerned for the welfare of the Tigrayans consistently through this conflict the evidence to the contrary stands against this claim. The Ethiopian and Eritrean military forces have killed thousands of civilians, destroyed villages, farms, factories, homes, and places of business estimated to be worth worth one hundred billion birr by the Tigray Interim Administration appointed by Abiy Ahmed before Mekelle was retaken by the TDF.

Thousands of Tigrayans not even in Tigray proper have been detained without due process, allowed no right of free speech, had assets and property confiscated without cause, blocked from receiving medical care, and driven off land their families have worked for generations. Their representation in the Parliament has been effectively abolished.

For more than 2 years Tigray has endured an almost complete blockade of food, medical supplies, and fuel has been performed by the Ethiopian government. Electricity, phone service, and internet have been blocked. Clearly the intent of the Ethiopian government to was to convince the leadership of the TPLF that they would make the Tigrayan people suffer more and more hardship as a way of convincing the TPLF to give up. There was no attempt by the Ethiopian government to try the traditional approach of winning hearts and minds instead the strategy was one of one intolerable terror.

Howard University venue for Ethiopian government healthcare claims claiming Tigray inclusion

Open Letter to Howard University October 13, 2022

Subject: Use of Howard University Venue to promote Ethiopian government healthcare achievement while Tigray under  medical blockade

Dear Sir/Madamn,

Many of us who are concerned with the dire situation in Tigray and are concerned about the use of a Howard University venue for the promotion of a government deeply involved in the deprivation and violations of a minority. Howard University is a historic and important institution in American history which was created to offer those who were denied opportunities a chance to reach their potential which also enriched America as a whole. Today I am writing you about something that denigrates the legacy of your fine institution.

At this moment the 6 million plus population of Tigray is faced with an essentially complete blockade of medical supplies, fuel, and electricity. The 8 major hospitals including the tertiary Federal Mekelle Hospital which is a part of the Federal Mekelle University are not functioning. I was present in Tigray since 2015 including the first three months of the Tigray occupation by the Ethiopian government which began in November 2020.

Even during this time before the Tigray Regional State retook control in July 2021 the Ethiopian Ministries of Health under Dr. Lia Tadesse and Education essentially stopped all support of the hospital and university When Dr. Tadesse came to visit Mekelle she refused to have a meaningful discussion with Tigray health and university officials and just used the visit as a photo opportunity.

Over a half a million people in Tigray have died from lack of health care, starvation, and civilian casualties from military targeting by Eritrean and Ethiopian forces. Thousands of women were raped and mutilated but their suffering is aggravated by the lack of medical services.

Dr. Tadesse has published glowing reports of medical progress in all the “substates” of Ethiopia while neglecting to declare that her office which she oversees provides NOTHING to Tigray. The only medical supplies come from foreign donors and only a trickle of what is donated is allowed to pass through a government inspection. This restricts the vast majority of aid reaching Tigray. While Filsan Abdullahi Ahmed, the Minister of Women and Children, resigned her position when she confirmed the violence against women, Dr. Tadesse has been silent.

This week the United States State Department in cooperation with 6 other countries called upon the government of Ethiopia which is represented by Dr. Tadesse and others who are being given a venue in your university to stop blocking humanitarian access to Tigray and to address the human rights violations that have occurred.

Finally and not the least important, last night I was on the phone with a Tigrayan student at Howard University who informed me that on campus and in Washington DC in general, there is an underground network of Ethiopia government supporters who frequently and in fact openly intimidate Tigrayans and Eritreans. She is fearful to discuss the issues on campus. Imagine the sentiments felt by students who have seen their families killed, violated, displaced, and deprived when their institution is supporting the agent of their despair without reasonable allowance for fair discussions of opposite views.

Ethiopian evil debtera magic versus Tigray Christian mercy in war

Daniel Kibre, a “deacon” and Social Affairs Ethiopian Minister defames Tigrayans as demons and subhumans worthy of extinction. He and other EOC followers tell their recruits that special blessings are upon to protect them from harm and punish the Tigray. While the Tigray leadership treats POWS with mercy and has EOC priests from Tigray pronounce forgiveness for Ethiopian POWS after their rehabilitation. In the background is a rare photo of a secret book of spells used by debtera.

Religious belief and custom are affecting the Ethiopian Tigray conflict. Ethiopia is relying on ancient beliefs of magic while Tigray counters with traditional mercy. The Ethiopian leadership under Abiy Ahmed is trying to use traditional mysticism and imperial religious stature rendered by Donatistic convictions to motivate and justify its sadistic aggression while the Tigray leadership is countering these using the conventional Christian virtue of mercy. The Ethiopian leadership of Abiy Ahmed and his religious supporters use the traditionally high stature of religious leadership along with the populations belief that they may have supernatural powers which can break established moral norms to achieve ends in war resulting in a perfect recipe for genocide.

Daniel Kibre, a “deacon” and Social Affairs Ethiopian Minister defames Tigrayans as demons and subhumans worthy of extinction. He falsely pronounces that Tigrayan leadership, Tigray Peoples Liberation Front are atheists and thus not eligible for Christian mercy.  The deceased leader of the TPLF, Meles Zenawi, was a practicing Ethiopia Orthodox believer and is buried on holy ground at Holy Trintiy in Addis Ababa.

Kibret’s actions are exhibiting the classic role of a debtera. He and other EOC followers tell their recruits that special blessings are upon to protect them from harm and punish the Tigray. While the Tigray leadership treats POWS with mercy and has EOC priests from Tigray pronounce forgiveness for Ethiopian POWS after their rehabilitation. 

There was not much communication with the Eastern Orthodox Church or Roman Church for hundreds of years due in part to the expansion of Islam which isolated Ethiopia . Many cultural factors including the close relationship of the clergy to the imperial state  and a strongly pious population created a unique form of Christianity which affected their daily lives.

The power of religious leaders was enhanced by two strong cultural developments. While much of Western Christianity rejected Donatism, the idea that for a priest to be holy enough to prepare the Eucharist or give blessings must be in a state of grace with God, for Ethiopia this become the rule. This greatly enhanced their status as advisors to government leadership as well as in communicating to the population giving them a great power of influence over both.

Secondly, the Eastern tradition of great attention to mysticism was greatly stressed in Ethiopia. A few elite clergy and lay practitioners in each generation were taught secret prayers and rituals which could cure the sick, affect natural events, place curses, or even change behaviors of individuals or groups. This prayers and rituals were closely guarded secrets. Both  selected clergy and a special class of religious zealots, debtera,  have special access to secret texts which describe special prayers and rituals which can perform alleviation of suffering such as  healing of the sick but also can be used to do harm. Anthropology researcher, Diego Maria Malara,  noted  

Yet, while drawing on this tradition, the debtera’s ritual repertoire also transgresses some of its central proscriptions. Transgression, in this context, does not abolish the boundaries it violates, but reinstates their legitimacy. This dynamic prompts debtera to engage in imaginative ethical reassessments of the unstable relationship between illicit knowledge and official tenets. Through their transgressive performances,debtera enable their clients to secretly address and actualise sinful desires that otherwise remain unacknowledged or are suppressed by the Ethiopian Orthodox Church.


Tigray famine has higher death rate then 1980s Ethiopian famine

The severe restriction of aid shipments to Tigray may result in higher percentage of deaths of those affected by famine then occurred in the 1980s Ethiopian famine.

Ethiopian blockade of Tigray has caused a famine creating a higher percentage of death of those affected then the Ethiopian 1980s famine. Considering the similarities of the 1983 to 1985 famine of Ethiopia under the Derg Regime to that of the current Tigray siege we can estimate that at least 125,000  may actually have died so far. In the following analysis one striking difference is that the percentage of the population severely affected in Tigray may be higher then in the previous famine. The difference is due to the fact that international aid was eventually allowed by the Derg Regime after the international community became involved beginning in 1984 whereas the Ethiopian government has not relented and imposed even greater obstructions then did the Derg Regime.

Currently there is a lack of means to adequately assess the number of deaths from the Ethiopian blockade driven starvation in Tigray, however, we can make estimate looking at what we know about the death rate that occurred in widespread famine of Ethiopia from 1983 to 1985 when the Derg Regime like the Abiy Ahmed government of today used starvation as a weapon to subjugate the populace, restrict agricultural production, and food aid initially.

The United States government estimates that 80% of the Tigrayan population is food insecure compared with only 15% before the onset of Ethiopian Tigray conflict in November 2020. Whereas international aid agencies determined more than 100 trucks a day were needed since that time the actual number that arrived was miniscule.  Tigray agricultural production was severely restricted as admitted by members of the Tigray Interim Administration with no supply of seed, fertilizer, destruction of farm animals  and equipment, as well as the displacement and murder of many farmers in the countryside.

The affect of the Ethiopian government induced famine on Tigray can be estimated by looking at the widespread famine that affected all of Ethiopia from 1983 to 1985. At that time almost 10% of the population was severely affected leading to the deaths estimated to be between 300,000 to 1.2 million out of 40 million population.  Thus we can estimate that out of 4 million affected about 25% of those eventually died.

We can assume a conservative figure of 6.5 million to 7.0 million population in Tigray at the start of war. We can assume that 80% or 5 million are facing severe food insecurity. If 10% of these 5 million or 500,000 are severely affected we would expect that they would have at least a 25% death rate. This assumption this would bring us to the conclusion that 125,000 Tigrayans have died just from starvation since the onset of the Ethiopian Thus Tigray conflict is averaging  almost 63,000 deaths per year and will continue to do so until the blockade is stopped and food production returns to its pre-war levels.



Medical blockade prevents life saving c-sections for Tigray mothers and infants

A nurse midwife at Mekelle University Ayder Hospital tends to mother and a newborn prior to the invasion of Tigray in November 2020 and subsequent medical blockade. Source WHO

Destruction of health care facilities and blockade of medical supplies to Tigray by Ethiopian government cost the lives of Tigrayan mothers and newborns who need caesarian section.

International guidelines indicate at least 5% of births should be done via caesarian section (c-section) to preserve the life of the mother and/or infant. This is actually the most common operation done globally. Over the past two decades the availability of this life saving care in Africa including Tigray had dramatically reduced maternal and infant mortality. Still in Ethiopia as a whole the rates were in many regions less than 1% although Tigray was a little better at 2%. This indicated that this important service was insufficient to meet the needs.

Prior to November 2020 hundreds of c-sections were performed at Ayder Hospital yearly, the main tertiary teaching hospital in Tigray. This institution was also in the vanguard performing research and training nurses, midwives, physicians, and obstetrician gynecologists with an experienced faculty.

Following the invasion of Tigray by Ethiopian and Eritrean forces in November 2020 a progressive restriction of pre-natal,  birth, and post-natal care was placed upon Tigray by the Ethiopian government. For a year prior to the conflict budgets for health care coming from the Ministry of Health, Ministry of Women and Children, and the Ministry of Education (the tertiary hospital, Ayder in Mekelle, was a federal facility under MOE) began to be cut instead of receiving the usual 13% increase.

Dr Kahsay Gebremedhin at Ayder Hospital in Mekelle reported in June 2021 that although normally the hospital was performing about 500 deliveries for month it had increased to 700. Even with transportation problems patients were coming to Ayder because out of the 8 major hospitals in Tigray only Ayder was not totally ransacked and rendered unusable by invading Ethiopian and Eritrean forces. Additionally it was the only one with a working generator. Fuel embargoes have severely limited surgical services because the power blockade means generators are the only way to get power for surgical equipment like anesthesia machines, lights, and cautery units.

The exact number of births in Tigray now is unknown however it is estimated that about 30 births per 1000 population occur per year. This means that somewhere near 150,000 occur annually in Tigray. Using the 5% standard one could reasonable estimate that upwards of 7,500 c-sections would need to be done to fully protect maternal and newborn lives. This implies that thousands of mother’s and children’s lives will be lost.


Ethiopia National Bank foreign currency control reduces real spending for human needs

The National Bank of Ethiopia decides when and if any government payment or even private entity payment to a foreign supplier. Foreign currency payments can only occur with its approval.

While the Ethiopian government touts big increases in spending for things like agriculture, education, health care the reality is that this is a farce. Real spending is actually much lower due the hidden way approval for expenditures which require foreign currency payments are tightly controlled by the Ethiopian National Bank under the control of Prime Minister Abiy Ahmed. As an advisor to Mekelle University and other institutions on development I became familiar with how this two level process of approval works in reality. Only budget items that match the monthly priority list and when there is a relative surplus of foreign currency will ever be approved.

Whatever budget the Ethiopian Parliament in agreement with Abiy Ahmed agrees for spending the amount that is actually spent that year will be less. The National Bank sets priorities for which budget item foreign currency will be allowed to leave the country. Needless to say no foreign debtor will accept the birr. The greatest contributor of foreign currency inward to Ethiopia is Ethiopian Airlines and therefore they and the military are always first on the list.

With expenditures of $2 billion per annum in military weapons and costs related to fighting in Tigray, Oromia, and other places while loan allotments from international lenders have been reduced to 1/6 of what they were in 2019 this military cost is actually higher then the rest of the Ethiopian budget combined. The debt burden of the Ethiopian government is well above 30% of the gross domestic product such that it always is on the border of default in loan payments. To date this has resulted in dramatic reduction in loan distributions complicated also by Abiy Ahmed’s avoiding recommendations by foreign lenders or even to meet them.

Additionally although the Ethiopian government uses figures of birr , the Ethiopian currency, instead of international currency equivalents, the greater then 50% de-evaluation hides that real spending has not increased.

Even if the Ministry of Health, for example, approves budgets to buy reagents for lab tests or new diagnostic equipment as these things come from foreign producers requiring foreign currency payments their actual approval for payment for that year often never happens.