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.

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.

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.

 

 

The ongoing effects on women’s health by the continued Tigray siege

Irreparable harm continues to affect Tigray as the world fails to engage reality

My prospective as a long time researcher, teacher, and physician at Mekelle University on the effect of the Tigray war and subsequent siege on women’s health 

Just prior to the invasion of Tigray by Ethiopian and Eritrean forces we know that Tigray had one of the highest rates of medically assisted childbirth in Ethiopia likely to be close to 20%. This low number reflected that it also included a high number of women who were recognized in screening by local health authorities as at risk for a problem pregnancy which lead them to seek closer follow up and care.

Now the health care extension worker network and local clinic systems staffed by public health officers, nurse, and general practitioners have been eliminated. There is no communication system or reliable transportation system even if there was functioning health facilities to visit.

Tigray already had high levels of birth defects including neural tube defects which require close pre-natal care and surgery immediately after birth to improve the health of mothers and children not only for their survival but to promote prevention. The medical and prevention services for these defects in which Tigray was a leader in Africa recognized for the leading research work done by Mekelle University by the World Health Organization and Ministry of Health which has abandoned Tigray now have essentially ceased.

Vaginal bladder and rectal fistulas which are preventable by pre-natal and appropriate birth care management have already skyrocketed. Additional many horrendous mutilations by invading armed forces further added to this burden. Women with these preventable and treatable conditions require sophisticated counseling and specialized surgical care units to avoid a life of social rejection and isolation. These services minimally exist now.

Female reproductive system, breast, thyroid and other malignancies affecting not just the elderly but often women as young as the second decade were in the pre-war era being addressed by preventive screening and the development of comprehensive cancer treatment at Ayder Hospital in Mekelle. A three hundred bed cancer center which included surgical suites and a radiation therapy installation remains unfinished and somewhat vandalized by the occupation of Mekelle.

Before the war about 25% of Tigrayans required food aid. Most of the rural population of women have to carry out the duties of contributing to farming and raising animals, caring for elderly relatives, collecting daily water, and child care. Poor health compromises their abilities to function in society causing higher levels of birth defects, maternal and child perinatal mortality, and retards the goals of elevating women’s status in society.

Growing opposition against Abiy Ahmed predicts likely country collapse

Over the past few months over 4,000 Amhara including members of militia group FANO, Ethiopian Defense Forces, and others have been arrested reports Reuters. Just a few months ago many Amhara cities like Dessie pictured above supported Abiy Ahmed but now that loyalty seems to have evaporated.

The coalition Abiy Ahmed hastily constructed to consolidate power in Ethiopia seems to be collapsing at a rapid rate. In a not unexpected paradox diaspora supporters of Abiy Ahmed’s military actions and civil rights violations against Tigray and Oromo peoples actions against are now complaining that such actions are illegal when applied to the Amhara. The Ethiopian American Development Council in an Open Letter to Abiy Ahmed complained

We are compelled to write this letter in light of the recent developments in Ethiopia where, based on published reports, over 4,000 citizens, journalists, and patriots in the Amhara region alone, are being kidnapped and detained by the Ethiopian security forces…..
Even more perplexing is the government’s use of unconstitutional and illegal tactics of kidnapping and dramatic abductions of citizens, with no regard to the rule of law or the need to maintain public trust. Maintaining public trust and securing peace is the hallmark of a responsible government. The current actions of the Ethiopian government are counterproductive and are effectively making a bad situation even worse.

After his rise to power in 2018 Ethiopian Prime Minister Abiy Ahmed built an alliance of Eritrean supporters of Isaias Afwerki, Amhara expansionists, former Derg supporter diaspora especially in the USA, and former diaspora monarchists by creating a unified front against a strawman represented by ethnic Tigrayans. This targeting was simplified by the strong unity of the Tegaru for their ruling Tigray Peoples Liberation Front which won an election handily just before the Ethiopian Tigray conflict began in November 2020 in defiance of declaration of the TPLF as terrorists and the Tigrayan election as illegal.

Studies of Ethiopian immigration to the United States and Europe showed that the vast majority came between the mid 1970s to the 1990s as former monarchists and then Derg supporters who fled following the Derg’s defeat.  These groups dreamed of a return of a strong political leader to overcome the Zemene Mesafint (referring to a period where Ethiopia had no central leader in the 19th century which lead to the Amharic dominance and expansion of Ethiopia) they saw again prior to Abiy Ahmed.

This coalition supported the brutal invasion of Tigray, confiscation of assets and property, imprisonment without due process, and minimized any violation of human rights against the Tigray saying they were justified. Now that the Abiy Ahmed government has developed concerns that these Amharic expansionist elements are plotting against him possibly in cooperation with Eritrea the tide seems to be turning former allies into threats. Academic studies of despotic regimes in Africa and other regions done by the Rand Corporation, a frequent advisor to the United States intelligence services, has shown that such reversals are not uncommon. The direction of chaos in which Ethiopia seems to be following have a high chance that the current government will not sustain itself base upon historical factors seen in successful insurgencies.

WHO Director-General Tedros Adhanom has an undeniable record of accomplishment

In 2019 when the Ebola crisis in central Africa in a region undergoing civil war Tedros Ahanom was instrumental in helping form an effective international response limiting the spread of the deadly virus as well commencing research efforts. Source Nature

World leaders and analysts have complemented the work of  Dr. Tedros Adhanom Gebreyesus who was elected for another term as Director-General of the World Health Organization. These complements are not just limited to his recent work but began almost twenty years ago beginning with his appointment to the Ethiopian Ministry of Health and continuing during his subsequent office of Minister of Foreign Affairs.  Complaints by malcontents at the current Ethiopian government of covert actions have never been proven. At the same time Dr. Tedros Adhanom Gebreyesus has fully cooperated with international NGOs and the UN to send aid to Amhara, Afar, and other regions of Ethiopia while the Ethiopian government blocked similar aid to Tigray.  I was fortunate to share a table with him at an African Union summit on health care development about 8 years ago. He is articulate and driven by a higher sense of duty not just to Tigray, Ethiopia, or Africa but to mankind.

The expansion of Ethiopia’s health care system commenced in 2004,  when over 30 000 Health Extension Workers were trained and deployed in Ethiopia and over 2500 health centers and 15 000 village-level health posts were constructed. Some analysts have attributed Ethiopia’s successful reforms a to strong leadership and “political will”. However an academic study of these reforms by Kevin Croke from the Harvard Department of Global Health and Population at the T.H. Chan School of Public Health determined that the reality was there was more to the story then will. This analysis was published in December 2020 in Health Policy and Planning. The focus on rural development and stressing the primacy of development as well building alliances among different regions as developed by Prime Minister Meles Zenawi and Tedros Adhanom Gebreyesus is what drove the success in reform. The WHO Director-General has been tested with the Ebola crisis, COVID 19, immunizations, global health inequity, and other issues yet he has stayed on course. 

Today the Ministry of Health has been mostly Addis Ababa centric. The level of spending per capita for health care has gone down from $23 to $18. Even though Tigray is claimed to be a part of Ethiopia no expenditure is currently directed there for any government activity including health care. What aid that comes issues from the World Health Organization, International Red Cross, and other international sources.

After becoming Foreign Minister in 2005 where he served until 2012 he expanded his advocacy for health care development in underdeveloped nations not just in Ethiopia. He joined in international efforts to deal with malaria, tuberculosis, HIV-AIDS setting in motion movements to control these maladies with good results. To some extent this  has followed a general trend in public health among academics to place health care front and center in political considerations for funding and priority.

Dr. Tedros as he is known in Tigray where use of first names is matter of custom was unanimously elected again because of his history of accomplishments recognized by health authorities and elected leaders except for Ethiopia who judges him wrongly because he is Tigrayan.

Our neighborhood is the world which we are obligated to serve

Jacopo Bassano
The Good Samaritan
about 1562-3
Oil on canvas, 102.1 x 79.7 cm
Bought, 1856
NG277
https://www.nationalgallery.org.uk/paintings/NG277

For the Good Samaritan the world he knew was just in his sight of what he saw on the road he traveled. But today we have world wide almost instant communication to know not just our neighborhood or country but of the whole world. We cannot claim ignorance. Today thanks to modern science and engineering we can see the plight of others throughout the globe.

During the past month I have been reflecting upon how good life is for most Americans compared with many third world countries. It has been a difficult month for me. A few weeks ago a prostate biopsy was done after routine blood test showed my PSA blood level was elevated. I was diagnosed with an intermediate level cancer for which I subsequently underwent a high tech robotic assisted surgery by an experienced surgeon and his team. Imaging and pathology now show that I have better then 90% chance of being cured. All the while even just before I was anesthetized for surgery I prayed for Tigray. Even while in the hospital I could not take my mind off of the Tigray siege and ongoing hostilities in Ethiopia as well as Ukraine. After having lived in Ethiopia and then Tigray since 2012 until January 2021 it still feels very much like my home town as does the USA. 

I have actively studied religion and theology for the past twenty some years. One of the concepts that arose from studying Anglican concepts is personal versus collective salvation. There is no doubt that God created all mankind to be interdependent one on the other. The parable of the Good Samaritan where upon the protagonist helps a stranger in distress is a clear example of loving your neighbor. I am convinced we cannot reach a personal state of piety for Christianity by giving a blind eye to the plights of others.  When Jesus talks about the difficult of the wealthy to go to heaven for me he is clearly stating that we are called to do more with our lives than just to attend to our own needs or even just those of our immediate family and friends. The more freedom and capacity we have to act for others comes with a responsibility to act faithfully to our commitment to Christ.

Now that the modern medical science of America has with God’s grace given me a chance to live and be productive more than ever I hope to someday return to Tigray when the situation arises where we can continue the work of developing the university and health care capacities.

 

My Christmas Thought for Tigray and Ethiopia

A 500 year old iconic artwork showing Mary with the infant Jesus from what was once the Abyssinian empire where we what call Tigray is today

A little more than 2000 years ago a man was born into the Middle East not far from what is Tigray today. He came from an ancient tradition stemming from a covenant made between God and Abraham that would lead to Judaism, Christianity, and Islam. This shared heritage saw human beings as being created in the image of God, with each having a life with dignity and value, and that the affairs of man should be done in accordance with the commandments of God given to the prophet Moses.

The world Jesus was born into was corrupt and morally lost. The ruler of Jerusalem was a half-Jew who had made an unholy alliance with the Roman Empire to seal his complete power over his domain rejecting the Jewish faith.  A seemingly unquenchable bloodthirst compelled him to kill many of his subjects and even his own wife and her family who came from a ancient rabbinical lineage. When this ruler named Herod heard that a Messiah was born his fear of losing power became so enraged he killed every male child born in the kingdom in a cruel mockery of the Passover story.

Today is the second celebration of the birth of Jesus Christ in the West (while in Ethiopia this will occur in a few weeks) since then the people of Tigray have been under siege, depravity, violation, starvation, isolation, and risk of violent death without end.  I appreciate what God’s grace has given me and my family and am grateful yet everyday my heart sorrows for the suffering of the Tigray people.

As a researcher and physician I have cared for and interacted with thousands of families in distress traveling through much of Tigray. Most of them live a very simple hard life working everyday to have minimal water, food, and shelter which most of the world takes for granted.  Yet they unwaveringly hold their faith in God even in the midst of genocide. Their life is not much different then that into which Jesus was born.

Today the power that brought this suffering to these children of God lies with group of clerico-fascists who have twisted ancient words of wisdom to their own selfish ends like the Sanhedrin that questioned Jesus. They uphold a  ruler who played in a park while his people fought locusts destroying their crops. Whilst children and elderly die from agonizing hunger  he denies them any food. Who forbids any communication between families who for more than year have been in darkness. Who brings death from the sky randomly targeting innocent souls.

Under the leadership of this dark leader, Abiy Ahmed and his associates, Tigray has suffered like the kingdom of Jerusalem did under Herod. I pray that the Holy Spirit will somehow find its way into the dark hearts causing so much misery. Jesus Christ, the son of God, told us that love between the brothers and sisters of God’s creation is the only way to salvation.

Amen

A positive Mexican-American reflection on American Thanksgiving

Turkey tamales are one innovation Mexican-Americans have added to American Thanksgiving meals which represent a time of bringing families together

As a Mexican-American child growing up in the Rio Grande Valley of Texas I remember celebrating the American holiday, Thanksgiving, as a day which seeked to convey a utopian image of the founding of America between native peoples and foreign immigrants. This remembrance has come under controversy with the emergence of a bitter feud between advocates that it should be a day of shame of European conquest and defenders who note it was and is a symbol of the ideal of what America is striving to be. That although not yet perfect America has made considerable progress to that promised by its inception.

Just before Thanksgiving a year ago I was a part of Mekelle University medical faculty teaching medical students, providing healthcare, and promoting research to improve the lives of Tigrayans as well as their fellow Ethiopians. Unfortunately today I find myself displaced by a horrible war that has killed, starved, deprived, and rendered hopeless tens of thousands of people in Ethiopia. Everyday of the war reminds me they have not yet reached the state of progress we have struggled for in America. We versus they thinking has poisoned their society. They need to be exterminated mentality has ruined a country.

I am currently reading Thaddeus William’s Confronting Injustice without Compromising Truth: 12 Questions Christians Should Ask About Social Justice which has helped me to come to terms with how I view Thanksgiving.

First we have to recognize that all men are created by God in his image. All of us are potential sinners and potentially repentant members of the human family. Neither the native American society nor the Europeans were without sin yet they judged each other as “they” not “we”. Today this lack of seeing others like ourselves deteriorates into volatility and then violence. This has been sin of man since history has been recorded.

As a Mexican-American we honor our native and European roots. They are our mother and father. To hate one and love the other only recognizes half of our whole. The American expansion to the southwestern continental region of North American engulfed our traditional lands which beforehand had been taken from our native ancestors by Europeans.

Today we are a part of a great country, the United States of America, to which we have contributed much including building its infrastructure, harvesting its food, blending into and adding to its culture,  as well as defending its liberty from foreign threats. We cannot change history but we can learn from it. Our identity now is we are an essential part of the American dream and it is an integral part of our culture. Today I can celebrate Thanksgiving because although there was a flawed past there is a  future with  promise. I thank God for his creation of us all.

Taking Mille can save lives for the Tigray while holding Mille allows more killing for Ethiopia

The government of Ethiopia has blocked all food and medical aid to Tigray

Why Ethiopia and Eritrea want to hold Mille and why TDF (Tigray Defense Force) and the OLA (Oromo Liberation Army) wants to gain control of it tells the truth about the real motivations for the ongoing conflict. In the absence of any international attempt to save the millions of Tigrayans from starvation, death from lack of health care, imprisonment for ethnicity, and even just the simple right to make a living the TDF and OLA have no choice but to seize control of the roads connecting ultimately to the seaport of Djibouti. This will allow a high flow of food, medicines, medical supplies, and fuel to Tigray and the Oromo regions. Meanwhile the Ethiopian Eritrean forces want to continue to starve, deprive, imprison, and kill Tigrayans as Abiy Ahmed as well as his supporters put it into an oblivion of dust as if they never existed.

Despite the fact that the Bible and Quran outlaw the use of starvation as a weapons the clerico-fascists of Abiy Ahmed persistent and loudening claims that God has specifically given him the right to use any means necessary to exterminate the Tigray people and subjugate the Oromo similarly continue unabated.  Numerous persons and entities supporting Abiy Ahmed claim to be for an all inclusive Ethiopian identity that would not exclude Tigrayans with the only intent to carry out a law enforcement action against the leaders of the Tigray Peoples Liberation Front and the Oromo. Yet they keep persistently silent when asked why deprive the innocents of food, medicine, and personhood. Why destroy hospitals, schools and factories?