Tigray Archives - Page 5 of 5 - Professor Tony Magaña

Ethiopia has committed genocide and turned Tigray into a concentration camp

The government of Ethiopia while claiming a law enforcement operation has committed genocide to the people of Tigray and turned Tigray into a concentration camp.

What is the definition of a concentration camp?
According to the highly respected encyclopedia Britannica a concentration camp is “defined as an internment centre for political prisoners and members of national or minority groups who are confined for reasons of state security, exploitation, or punishment, usually by executive decree or military order”. What the Ethiopian government has done to the Tegaru, Irob, Agaw, Kunami, Afar, Orthodox, Catholic, Christian, and Muslims who live in Tigray meets every requirement stated in this definition of a concentration camp and in every way just a deadly as those recalled from previous examples when evil predominated a society.

Actions of Ethiopia against Tigray are more than law enforcement
When the Ethiopian National Defense Forces and Eritrean Army units invaded the Regional National State of Tigray in November 2020 the leadership of Ethiopia specifically stated that was being undertaken was a law enforcement action to capture the leaders of a “terrorist group”, Tigray People’s Liberation Front (TPLF), and that there was no intent to take action against the civilians of Tigray. In fact they explicitly stated they were proceeding with this invasion to not only capture the leadership but also to protect the security and life of their “brother” Ethiopians.

At the time of invasion I was Chief of Neurosurgery and on the faculty of Mekelle University, a federal university not under the Tigray state, which had medical students and specialty trainees from almost every regional state in Ethiopia as well as surrounding countries. Additionally it administered Ayder Comprehensive Specialized Hospital which served a population of about 10 million including not only Tigray but also Afar, northern Amhara, and recently even Eritrea intermittently when the border was open. Additionally we occasionally cared for patients from Addis Ababa and the SNNP (Southern Ethiopia).

Following the complete take over of Tigray we were initially told by the Interim government and military commands that the government, medical, and educational services would be quickly restored. But instead they quickly deteriorated well before the reorganization and re-emergence of the Tigray Defense Forces. Except for a very short time of a few weeks early on the following have been cut-off and never restarted including banking services, electricity, telephone and cell, internet, water, civil infrastructure management, hospital supply, schooling, etc.

Although the Federal government claimed it was giving 70% of the trickle of very basic aid that was coming in reviews by well established international authorities revealed it was less than 3% of the total which was in itself dramatically less than required.

Soldiers of the Ethiopian Army even took videos celebrating the killing of civilians

As the weeks progressed the undeniable evidence was increasingly seen that sexual abuse of women now estimated to be in the thousands, extra judicial killing of whole villages, routine execution of males even those below or above that generally considered to be militarily capable were reported even by the Ethiopian Human Rights Commission. Although there may be a possibility of some actions by Tigray militia which also require investigation the exponentially greater magnitude affecting hundreds of thousands of violation of human rights and killing by soldiers under the direct command of the Ethiopian government cannot be denied. If not stopped the number being threatened will rapidly accelerate to millions.

More than 350,00 people are at critical levels of starvation now and will increase rapidly

Instead of taking corrective action to improve the humanitarian situation which would possibly yield the benefit of making the civilian population of Tigray more peaceful instead new arguments surfaced from mouthpieces of the Prime Minister’s advisors that due to previous claims of unfair treatment by the TPLF that justified the violations of human rights currently underway. Videos emerged stating that every Tigray should be killed at birth. Eritrean and ENDF soldiers have stated to neutral third parties that they were instructed to rape women to destroy the chance for Tigray to have children.

The Nejashi Mosque was bombarded and then ransacked

Religious institutions, artifacts, and worshipers were targeted for destruction which had nothing to do with a “law enforcement” action. One of the most important Mosques in the world in Negash where the followers of Mohammed took refuge from prosecution from pagan Saudi rulers at the invitation of a Christian king was intentionally bombed and ransacked. What does that have to do with “law enforcement”? Monasteries in Western Tigray with religious texts hundreds of years old were attacked with their treasures destroyed and clergy assassinated. The ancient Ethiopian Orthodox Church which traces its roots to the early Jewish religion of Menelik I and then the Christian kingdom of Ezana in Axum was desecrated with the murder of at least 80 unarmed worshipping civilians. What does that have to do with “law enforcement”?.

Aksum’s Our Lady Mary of Zion Church where Eritrean soldiers killed civilians

It is well documented that Eritreans, ENDF, and Somali mercenaries destroyed factories and businesses including those of foreign investors who generated income for the Ethiopian government and provided employment for civilians. Many pieces of equipment of not only these but also the national Ethio-telecom company were taken by Eritreans as war bounty to Eritrea. How does this destruction of Ethiopian federal property qualify as “law enforcement”?

The invading forces were instructed to destroy seeds and prevent farmers from planting crops. Many livestock were killed to be consumed by no one or taken to Eritrea in trucks. Both aid and commercial food supplies where blocked from entry to Tigray. Gradually both the Federal Government and the government of Amhara began to change their tune to explain this by saying that the population of Tigray was too supportive of the TDF and that NGOs were smuggling weapons with the aid. They accused organizations with much greater long standing reputations of wrong doing with no evidence instead trying to cover their own genocidal intent.

The government of Ethiopia as late as 2019 was a signatory to the Genocide Convention of the United Nations which states verbatim any of the following acts committed with intent to destroy, in whole or in part, a national, ethnical, racial or religious group, as such:
Killing members of the group;
Causing serious bodily or mental harm to members of the group;
Deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part;
Imposing measures intended to prevent births within the group;
Forcibly transferring children of the group to another group.

The treaty recognizes the following two elements of the crime

A mental element: the “intent to destroy, in whole or in part, a national, ethnical, racial or religious group, as such”; and

A physical element, which includes the following five acts, enumerated exhaustively:

Killing members of the group
Causing serious bodily or mental harm to members of the group
Deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part
Imposing measures intended to prevent births within the group
Forcibly transferring children of the group to another group

Abiy Ahmed and Internal Colonialism in Ethiopia

Abiy Ahmed, Prime Minister of Ethiopia and head of the Prosperity Party

Abiy Ahmed, Prime Minister of Ethiopia and head of his self created Prosperity Party, to many rather than bringing a new vision which encourages development of a universally accepted national unity has instead re-aggravated old flames. His inability to escape internal colonialism, a recurring theme in Ethiopian politics, may be the straw that broke the camel’s back in breaking up the Ethiopian empire.

The rise of Abiy Ahmed was propelled first by the strong calls for inclusivity of the Oromia who make up at least 30% of the Ethiopian population in government. However the initial enthusiasm in cooperation was tempered when a division of the goals developed between many Oromia leaders and the Prime Minister was created. The Prime Minister switched allegiances to the Amhara elites who argued for a more traditional Amhara led model of government giving more power to the central government and less to the regional states. Even though currently the Tigray “rebellion” gets the most national attention there now opposition groups many of which are carrying out armed insurrection in most of the regional states of Ethiopia.

Jawar Mohammed seen on the right was instrumental in mobilizing young Oromian men to the cause of Abiy Ahmed. However now he is in jail on charges of terrorism

Internal colonialism is a reoccurring theme in the struggle for control of the Ethiopian federal state. We often hear the term colonialism and see it most commonly applied as an external phenomena referring to the history of European powers attempts to colonize and control African states over the past two centuries but internal colonialism especially in the case of the Ethiopia, a country which claims it has never been colonized by an outside nation, is one of the dominant forces against sustainment of peace in a empire of many nations.

In 1925 Adolph Hitler described the concept that Germany as an integral part of Europe, had the right to acquire adjacent lands that were poorly utilized and under populated as a result of the unfair treaties ending World War I in 1925. He saw his ethnic group as a part of greater Europe who by right of superiority which was inherent in their nationality had not only the right but the obligation to take control of his neighbors. A description of this type of justification for political action would wait until many years later.

Pablo González Casanova the Mexican socialist who defined internal colonialism in his book “Democracy in Mexico

Although first used briefly to describe the situation in South African apartheid in 1957 this concept becomes well defined by the Mexican sociologist, Pablo González Casanova, in his 1965 book, Democracy in Mexico where he defined internal colonialism as a result of the structure of social relations and exploitation between heterogeneous cultural groups. Although the term is named “internal” he notes the effect of outside powers global and regional does have an effect on this interaction. Traditional social struggle theory as one between classes such as in Europe and the United States is not the only relevant or maybe even predominant factor. Patrimony and oligarchy tend to develop in the push to create strong capitalist systems to engender economic viability of the state. Paulo Henrique Martins , French scholar has described that there is a relationship between social, political, and intellectual imagery that develops and helps steer political action by the dominate group over the lesser ones.

A well known phenomena commonly seen in developing countries as noted by the World Bank is that their capital cities tend to develop much faster then the rest of the country. I have written about how the Addis Ababa identity differs significantly than that of the rest of the Ethiopia. Peter Calvert has described how this accelerated growth of cities and its effects on the surrounding area becomes the center of power, identity, and social action. It should be noted that Ethiopia is most rural country in world (90%) such that Addis Ababa with a population of 4 million in a country with 110 million represents barely 0.4% of the population. As I have previously written the growth of other cities and universities is beginning in other regional states but they have little political impact.

Ethiopia was ruled by Amharic royal for centuries until attempted coups began in 1960 ultimately leading to a socialist communist takeover in 1974 called the “Derg” or worker’s party which was heavily supported by the Soviet Union. It was quite repressive although ideally not specifically linked to any particular ethnic group. Then a popular uprising revolted against the Derg leading to new leadership lead by the Tigray Liberation Peoples Front in cooperation with other ethnic fighter groups. Following the death of Melez Zenawi in 2012 uprisings in the Oromia and Amhara regions eventually lead to the placement of Abiy Ahmed, a half Oromia, half Amhara as the Prime Minister in 2018.

Although initially promising free speech, welcoming of opposition groups, political prisoner release, free press, and creating a new political party based upon a unifying national identity all was short lived. He went on to imprison Oromia allies who helped bring him to power, made dissent illegal by person or press, outlawed the leaders of the Tigray regional state calling them terrorists and finally invaded Tigray with the help of an old enemy Eritrea.

When you look at Ethiopia it is a tough region in which to thrive. There is very little water for agriculture and very little land which is really productive for food. The term internal colonialism was used by Oromia opposition groups against the TPLF during their dominance as they felt the federal government was interfering too much in land use and distribution decisions. Similarly the area of Western Tigray which is also very fertile has increasingly been claimed by Amhara elites.

As I previously discussed there has never been a strong claim of a national unity except by the Amhara peoples. Many other groups continue to claim national ethnic identity that trumps their Ethiopian identity. Those who are more educated and/or spent significant time living or being in university in Addis Ababa are more likely to see their Ethiopian identity over their regional one.

Meles Zenawi here seen in his youth as a rebel to the Ethiopian regime became the spokesman for the TPLF leading the revolt against the Derg. His democratic developmental state concept created dramatic economic growth in Ethiopia

Meles Zenawi the late leader of the TPLF developed the concept of the democratic developmental state. This was based in large part in how South Korea recovered following World War II and the Korean conflict where at first their was a military oligarchy that had a first priority to create an infrastructure and lead business initially but then over time would allow more economic Ethiopian People’s Revolutionary Democratic Front (EPRDF). freedom of private interests but with significant government input. Although there was a vision of a coalition of nations in forming the government via Ethiopian People’s Revolutionary Democratic Front (EPRDF) Meles realized that there was in fact a danger of internal colonialism taking root. The argument of one nation versus a confederation of nations was continued by opposition groups which magnified upon his death in 2015.

Ethiopia has always been an empire not a nation for the Tigray

Tigray Defense Forces parade their success

Introduction

There is a global misperception often forwarded by Amhara expansionists that Ethiopia has been a nation for centuries. But instead the area we call Ethiopia came into being less than 200 years ago when Amharic kings become dominant over the Tigrayan monarchy and then conquered Cushitic peoples in Oromia, the Southern Nations, the Afar, and were “gifted” part of Somalia by European powers. In reality the Tigray have always thought of themselves as a nation in an empire.

Recently the world was stunned when the very small region of Tigray managed to retake most of its territory back from the federal forces of the Ethiopian national government last summer who had one of the largest armies in Africa. To those who know the past 100 years this is not so surprising. A look at the recent history of the Ethiopian empire, a collection of many ethnic groups struggling for dominance, over the past century lends insight to current events.

How Western Civilization Has Looked at Ethiopia

Many scholars had looked at what had happened to Ethiopia in the 19th and 20th centuries trying to understand its evolution and how it would progress. Donald Levine wrote in his work Greater Ethiopia: The Evolution of a Multiethnic Society that Ethiopia would develop a national identity due to experience of war, famine, religious conflict, trade development etc. The dominance of Amharic emperors during this time period until the late 1960s favored the development of an idealistic concept of Amharic elitism as a central theme as well.

Although many languages both Cushitic and Semitic are spoken in Ethiopia, for approximately the past 150 years the Amhara leadership of the country (beginning with the monarchy) as well as the Ethiopian orthodox church essentially mandated that the Amhara language would be the official language of commerce and government. Elite schools and universities taught in Amharic thus its speakers were seen as superior to the non-speakers of Amharic. Those wishing to become “educated” had to learn Amharic. Political ideas and policies thus became mostly associated with this Amharic elitism. Until just the past two decades attendance of the prestigious Addis Ababa University was limited to the Amhara.

What is the Tigray Identity

The Tigray people claim their ancestry to the Axumite empire which was started by the Queen of Sheba, a Biblical figure, who lived thousands of years ago ( an aristocrat of the ancient Saba people who lived about the eastern and western areas bordering the Red Sea and spoke a Semitic language). Legend has it she conceived a son with King Solomon of Israel and converted to Judaism. Centuries later the Axumite empire converted to Christianity under King Ezana. Although early kings of Northern Ethiopia were Tigray they eventually lost power to the Amhara whose background is also related to that of the Tigray. The Tigray have a long tradition of being a warrior clan. In fact going back centuries in both domestic battles and battles against foreign invaders their abilities as fighters and commanders of armies were always sought. At same time these qualities have always fostered suspicion by other ethnic groups especially when the military services of the Tigray were no longer needed. Most recently the term Tigray is most often used to describe the region while the term Tegaru is coming more into use to describe its people and now even being used to differentiate them from Eritreans.

The Rise of the Tigray

The rise of the Tigray who make up only 6% of the population of Ethiopia to lead an alliance that would topple a powerful government without any outside assistance starting from essentially no resources was unexplainable to scholars. Daniel Young a journalist with the Sudan Times began to follow their rise in 1988 and eventually wrote the definitive scholarly work, The Peasant Revolution of Ethiopia.

He did numerous interviews with peasants after gaining their trust. He noted then as did others that although there has always been talk about a greater nation for the most part over the past century there have always been nationalist movements within Ethiopia. Ethiopia has always been a empire and not a nation. Although the goal of the Tigray (Tigray Peoples Liberation Front) was primarily to overthrow the Derg (a quasi communist-socialist multiethnic movement which included many military leaders and was supported by the Russian communist party) the TPLF developed the concept that to be successful they had to gain great support from the countryside peasants. One important component was they incorporated educated Tigray women into leadership roles. The Tigray were remarkable for developing and sticking to their ideals and goals, creating alliances, strong action against dissent for which they have been criticized, and finally for basing their strength from a bottom up approach which is significantly different then the Amhara elite model which is a top down scenario.

Bottom Up versus Elitist Lead Revolution

From a social science perspective there has always been controversy over whether a revolutionary movement can be driven by perceived peasant led initiatives (bottom up) or by elitist lead initiatives. The successful revolt of the Vietnamese against French Colonialism and American interference is often demonstrated as a model of the bottom up approach. Thus what we are seeing now is a repeat of this ongoing struggle in Ethiopia of peasant based vs elite based focus and empire vs nation identity once again. How will it turn out?

This article has been updated from its original form

Physicians duty in war

A woman is taken to Ayder Referral Hospital, in Mekelle, after an airstrike in Togoga, Ethiopia’s Tigray region June 22, 2021. Picture taken June 22, 2021. Tigray Guardians 24 via REUTERS

Being in the middle of the Tigray-Ethiopian conflict for three months and now following it I have pondered about were do health care workers duties fit into this all too common human situation. In the midst of war questions may come up about what are called conflicts of dual loyalty for doctors. However physicians of the Jewish, Christian, and Islamic faith recognize that they have a duty to their patients be they ally or enemy. This ethic goes back to the times of the medical scholars Hippocrates, Maimonides, and Al-Ṭabarī.

The Jewish rabbi physician Maimonides in discussing his interpretation of the Jewish law in the Mishneh Torah said that everyone who found anyone missing a possession should have it returned to him. That included health which meant physicians had to treat all comers including those of different faith and ethnicity. He said “ On the basis of this reasoning, the art of medicine is given a very large role with respect to the virtues, the knowledge of God, and attaining true happiness. To study it diligently is among the greatest acts of worship.”

Religious medical scholars on ethics of the Jewish, Christian, and Islamic faiths have given a very large role with respect to the virtues, the knowledge of God, and attaining true happiness. Al-Ṭabarī , Islamic and medical scholar, expanded upon Hippocrates incorporating Islamic principles found in the Qur’an of dignity of the individual, charity, dutiful study of the healing arts, and faith playing a role in the formation of a good healer.

Christians are familiar with the parable of the Good Samaritan where Jesus tells the story of an abandoned injured man presumable a Jew on the road between Jericho and Jerusalem a place of frequent violence who was ignored by a Jewish priest and a Levite. Traditionally there was hatred between Samaritans and Jews but when a Samaritan encounters him he decides to render him aid and pays his expenses to recover in an inn. Jesus demonstrates charity when asked Who is my neighbor? The response is that all men are our neighbors (All men are a part of God’s loved creation?)

The Islamic faith has long seen medical practice has having an intimate relationship with their faith. A good physician is a faithful one who shows mercy and charity to all men. Incorporating their beliefs into a commonly used oath of which a partial quote is “The doctor will protect human life in all stages, in all circumstances and conditions, and will do his utmost to rescue it from death, disease, pain, and anxiety. He will extend his medical care to the near and the far, to the virtuous and the sinner and to friend and enemy.”

There is a shared believe among the descendants of the covenant that Abraham made with God so many centuries ago that physicians have a common ethic to care for all who are in need.

Although health care providers around the world have been consistent in following this universally accepted moral imperative especially since the medical experimentation done by the Nazis the same cannot be said about the destruction of medical facilities and killing of health care workers. Although the United Nations and member countries have signed multiple treaties forbidding these actions. Despite these diplomatic measures ongoing research has shown their progression.

In Ethiopia during the onset of the Tigray-Ethiopia-Eritrea conflict I spoke with physicians and nurses who had to escape military bombardment and ransacking of medical facilities in Humera, Axum, Adigrat and other places often killing both staff and patients. One wonders what if any consequences will come of these illegal war crimes?

Multifaith community alliance saves hospital in Mekelle, Tigray

drone view of Ayder Comprehensive Specialized Hospital — Shows Ayder Hospital and the streets lining it where a brave protest occurred

How a community of different faiths and ethnicities came together to save their hospital, Ayder Comprehensive Specialized Hospital, in the city of Mekelle, Tigray region of Ethiopia in the face of a horrific invasion by Ethiopian National Defense and Eritrean forces. In the previous post I described the culmination of events that deterred the ransacking. Here I will tell the story of how it began.
I have gathered some more information on how the heroic unarmed resistance began to stop pilfering and ransacking of Ayder Comprehensive Specialized Hospital in Mekelle from the occupying Ethiopian National Defense Forces and Eritreans.

The Adishmdhun mosque where the muazzin made a call to action

Among the first to call citizens to action was the muazzin of the Adishmdhun Mosque. Although there was no electricity in the city using the mosque generator and microphone he called people to guard the hospital. The message was ” to all residents of Mekelle be Muslim, Christian, males or females : Ayder is being looted, so go and protect your hospital “. Immediately the people began to make the gatherings. There was was a group of motorcycle men who tended to gather at a pub just a few blocks from the hospital who began calling the same thing using a speaker. Youth groups and community elders answered the call. The demonstration and blocking of the roads was done with people of all faiths and different ethnicities.

The Nejashi mosque in Tigray was bombed and looted

The Muslim community would later hear about the desecration of the Nejashi mosque in Tigray by ENDF and Eritrean forces. This mosque is particularly significant as it was founded by the first followers of the Prophet Mohammed (Peace be upon him) who were given refuge in Ethiopia from the pagan Saudi rulers.

Throughout the occupation young men volunteered to patrol the streets around the hospital in defiance of the night time curfew pronounced by the ENDF and the Eritreans. Unfortunately some were shot and killed on sight. How many we do not know yet. Sometimes the body was just taken away so that relatives do not know what happened to them.

Mekelle Unarmed Civilians Brave Defense of Their Beloved Hospital-Ayder Comprehensive Specialized Hospital

This is the story I witnessed of the brave unarmed civilians peacefully protesting and blocking invading forces from ransacking Ayder Comprehensive Specialized Hospital in Mekelle, Ethiopia in November of 2020. I had been performing neurosurgery, teaching fellows, and medical students at Mekelle University in the Tigray region of Ethiopia since 2015 in a federal university and hospital. As such I was present in Mekelle from the onset of the war between the Tigray Defense Force and the Ethiopian/Eritrean forces from the onset until my evacuation near the end of December 2020 at the behest of international influence and my family which was three days of driving through multiple checkpoints and unstable areas until we finally arrived in Addis Ababa.

Following the retaking of Mekelle by the Tigray Defense on June 28, 2021 there has been a mixture of sadness and joy. For sometime I have wanted to tell the story of what I think was the most heroic thing I have ever seen in my life which was the unarmed defense of Ayder Comprehensive Specialized Hospital in Mekelle. Prior to this time I felt telling it would result in reprisal to the citizens of Mekelle. Now that Mekelle is free it is important to tell it.

For almost 24 hours on November 25, 2020 the city of Mekelle was attacked constantly by artillery, rocket attack, and airstrikes even though the Tigray Defense Forces had left the city to only civilians. In my own immediate neighborhood just a few blocks from the Mekelle University hospital, Ayder Comprehensive Specialized Hospital many homes and buildings were destroyed and many killed. A market and home for elders was directly hit killing and wounding many.

About 200 yards from my house, a home that housed a large extended family suffered a direct hit that sent shrapnel breaking my windows at about 6:30 in the morning. I ran over there to find a young woman in the street with a severe bleeding wound in upper leg but that was just the beginning of the horror. The walls of the house had been destroyed on two sides and the rest looked like a Swiss cheese with many perforations. On the ground was a motionless young woman who had only a red spot on the ground where her chest was supposed to be. Her lifeless arms were extended with each one holding toddlers. The children where crying. When I pulled back their hair I found that hundreds of small munitions fragments had penetrated the scalp of both children although the eyes seemed okay. There was nothing we could do for the mother nor her mother who lay beside her dead as well from penetrating shrapnel. Remaining family members rushed the sister with the injured leg and the children to Ayder Comprehensive Specialized Hospital.

At the hospital emergency room there was wave after wave of ambulances and private vehicles bringing those hit by the attack who were all civilians. Some could be helped but many were beyond hope. We were able to save the children and their aunt from the attack near my house. Although we would sometimes previously do mass casualty from bus accidents in the past this was a much greater magnitude as we saw more then 120 patients in the first few hours.

Before the invasion of the city, we had been receiving civilian causalities, Tigray Defense Force causalities, and also Federal/Eritrean causalities. We treated them all the same. The local people even brought food and blankets for the all the groups. However after the invasion the tenor of the invading force changed. Many patients were just suddenly whisked away to parts unknown and we were not allowed to inquire.

The next day on November 26, 2020 at which time Federal Ethiopian armed forces and Eritrean forces invaded unopposed the city of Mekelle. For the next few days in Mekelle there were Ethiopian and Eritrean forces looting, shooting, robbing, and harassing civilians all around the Ayder area where I lived and the hospital was located. The hospital was occupied by Ethiopian army regulars, then Special Forces from Oromia, and so-called Federal Police. Then suddenly for about half a day they disappeared.

Rumors where flying in the city that Eritreans where ransacking public utilities, schools, etc. The hospital had always been a source of pride and necessity for not only Mekelle but all of Tigray. The local population of civilians began to put tires, logs, and stones to block trucks or other vehicles in the streets surrounding around Ayder Comprehensive Specialized Hospital, the main teaching and tertiary hospital for Tigray, fearing that the hospital which was highly valued by the city would be destroyed or looted. Special Red caped soldiers showed up and began harassing the locals more and more.

The locals did not back off. They gathered by the thousands and began to surround the hospital 24 hours a day. Many times semitrucks and smaller trucks driven by Eritreans which were empty tried to make it to the hospital to loot it but where physically blocked by protestors standing in their way. At one point a group of young men were shouting about ten feet in front me to the soldiers. Suddenly the soldiers fired at them killed one and injuring two others. At that time there were tires burning all around the hospital with thousands of protesters. The soldiers were scared and I feared the worst was going to happen. It was tense until morning. Finally the lined up trucks driven by plain clothed Eritreans were told to leave by the invading forces. The two that survived to be treated were hauled off from the hospital by the invading forces and have not been seen again as far as I know.

Pictures I had of the event were erased by Eritrean patrols that would search me everyday I went to the hospital but I will never forget the bravery of the people in Mekelle who unarmed defended their hospital.

Coronavirus: A Unique Dilemma for Ethiopia

Ethiopia is facing a potential unprecedented crisis from coronavirus and how she responds is complicated by factors in her culture, traditions, geography, economics, and history.

In 1963, I was an elementary school child living in the Rio Grande Valley of South Texas when I first learned about hurricanes. My father, a neurologist-psychiatrist, told us that a bad storm was coming. We had to take precautions and ride it out. This was perhaps the first time in my life I had to deal with uncertainty. Although my father looked confident I could sense that we could not know exactly what the future could bring. Hurricane Beulah hit with high winds and much rain destroying much of our town. I thought the howling winds would never end.

Now more than 50 years later I am in Ethiopia facing another type of storm. We have seen the storm form in China, attack Europe, and now with a few cases in Ethiopia it is knocking at our door. Ethiopia where I have lived since 2012 has had her share of calamity. She is an ancient civilization extending perhaps more than 10,000 years before the birth of Christ. Over the past century she has seen multiple attempts at foreign invasion, famine, and civil war. Yet her traditions and strong sense of spirituality tied to organized religion have always seen her through adversity.

As an academic physician and member of the medical faculty of Mekelle University I am very concerned and once again feeling that same sense of uncertainty I did so long ago. How will she face this new dilemma?

The Risk of Epidemic in Ethiopia
Moritz Kraemer, epidemiologist from Oxford University, has identified Ethiopia as one of the countries in Africa most at risk based upon an exhaustive analysis of asset the country possesses or not. Now that Ethiopia has several cases documented in Addis Ababa, what are the risk for spread? Adam Kucharski and his group from the London School of Tropical Health and Hygiene predict from a pre-printed study that when a country like Ethiopia has at least 3 confirmed cases there is 50% chance for the infection to become endemic and spread.

The Effect of Culture,Economics, and Geography
Africa accounts for 16% of the world population but only 1% of health care expenditures. With a 100 million population Ethiopia is the most rural country on the globe with 88% living in the countryside. Many families have incomes less than the equivalent of $20 per month. It may take hours to a day or so to seek medical treatment in a poorly equipped countryside clinic. There is little public health education with 75% of the women and 45% of the men being illiterate. There are few hospital beds (0.3/1000) population, few doctors, and limited diagnostic facilities.

Most Ethiopians do not travel outside the country but Addis Ababa, the capital, is one of the busiest airports and hub of Ethiopian Airlines which has daily flights from around the world including China and Europe. There is little doubt that this was the vector which introduced coronavirus to the country.

Ethiopians are a “touchy feely” culture like the Italians who are so troubled now. While there is little in the way of a government social safety net the people typically depend upon long standing bonds with extended family for emotional and financial support through hardship. Community interdependence is the rule. It is not unusual for people hospitalized to have many visitors and always also to have attendants (family or friend) stay the night helping to care for a patient. Trying to impose social isolation or even just social distancing will be difficult if not impossible.

The economic principle of scarcity, meaning that great value may be placed on resources which are scarce, is strong in Ethiopia. When going to the bank, airport, market, and clinic they frequently are a bit pushy because of a fear that what they are there for while run out before they get their chance. This is no doubt a left over from the Imperial and Derg times leading to distrust of authoritative promise.

When one sees the vastness of Ethiopia, about the size of Texas, and difficulty with transportation, an initial impression is that perhaps the virus will stay only in Addis Ababa. Unfortunately, that lesson was answered years ago when the HIV epidemic started with just a few truck drivers delivering goods throughout Ethiopia.

Typically when Ethiopians who are Orthodox are sick, they will often seek spiritual healing through church services, blessings, and consumption of Holy Water. In fact, every month I have patients with curable brain tumors who presented late only after pursuing this spiritual method.

Many regions of the country have no reserve to deal with pandemics. For example the Tigray Regional Health Bureau only has a budget of 500,000 birr ($15,000 USD) to deal with a potential coronavirus epidemic. The cost of a single coronavirus is test is currently $ 500 USD. The government must try to seek payment from the patient as it cannot sustain doing testing without it.

There are not more than 200 functioning ICU beds with ventilators in Ethiopia. The experience in China, Japan, South Korea, and Europe have shown that if 50% of the population becomes ill, out of that about 20% will require hospitalization, and maybe 10% will need ventilator support. Unfortunately there is no way they will be able to treat 5,000 patients on ventilators.

What Will Happen to Hospitals?
Coming out of the Imperial and Derg times when social institutions like hospitals were rare and for the upper castes they are now seen as pillars of society with an implied unobstructed access. The CDC and WHO call for restricted entry to hospitals as well as the segregation of coronavirus patients to alternate facilities could provoke misplaced fears in the population. There will have to be a clear and repeated message explaining the scientific reasoning and how such measure are really best for the population.

Just like when I was a small boy, I cannot know exactly what will happen. I will stay in Ethiopia, the country and her people I have grown to love, and pray she finds her way through this test.

Interpersonal Violence and Head Injury in Tigray:Public Health Issue

The head injury problem especially that due to interpersonal violence in Tigray is a growing and significant problem which requires a public health approach.

3d CT scan of man suffering depressed fracture of skull from stone injury

Research published by Fasika et al showed that 24.8% of head injury admissions came from interpersonal violence from 2011 to 2014 which was before neurosurgery was permanently established at Ayder Comprehensive Specialized Hospital. Currently we are seeing about 10 patients a day and operating on 2 to 3 every day. Most of the surgeries we do are for depressed fractures caused by stone injury received in interpersonal violence. The age range of these injuries ranges from preschool to the eighth decade of life. We know there is a cultural proclivity to this type of injury but it is not well studied.

The hospital burden of head injury includes about 19% of adult ICU admissions and bedspace and 25% of pediatric ICU admissions and bed space. Our average daily census on the adult ward is 5 for head injury and on the pediatric ward also 5. The length of stay can vary from 24 hours to months with most of the surgical patients requiring a least a 5 days stay in the hospital.This burden acts to limit the care those suffering from other maladies can receive.

At the current time there is no public health or government plan to try to prevent these injuries.The World Health Organization has created a Violence Prevention Alliance which sees interpersonal violence as requiring a public health approach.

This public health approach to violence prevention seeks to improve the health and safety of all individuals by addressing underlying risk factors that increase the likelihood that an individual will become a victim or a perpetrator of violence.

The approach consists of four steps:

1 To define the problem through the systematic collection of information about the magnitude, scope, characteristics and consequences of violence.
2 To establish why violence occurs using research to determine the causes and correlates of violence, the factors that increase or decrease the risk for violence, and the factors that could be modified through interventions.
3 To find out what works to prevent violence by designing, implementing and evaluating interventions.
4 To implement effective and promising interventions in a wide range of settings. The effects of these interventions on risk factors and the target outcome should be monitored, and their impact and cost-effectiveness should be evaluated.

By definition, public health aims to provide the maximum benefit for the largest number of people. Programs for the primary prevention of violence based on the public health approach are designed to expose a broad segment of a population to prevention measures and to reduce and prevent violence at a population-level.

I propose that Mekelle University put together a multidisciplinary team consisting of not only physicians but also social scientists, public health professionals, police and prosecutors ( this was previously discussed with the head of the Tigray police who was interested), and government stakeholders. This type of investigation and policy development is exactly the type of activity which the University with all its resources and knowledge base should be tackling.

Research:Neural Tube Defects in Tigray Ethiopia

Recent research we have done at Mekelle University soon to be published has confirmed that there is a high rate of neural tube defects affecting the brain and spinal cord in Tigray. Experience suggests this is also the case in other parts of Ethiopia as well. At least 131 out of every 10,000 births is affected with some areas having almost twice that number. Defects result in death at birth for about 77% of the pregnancies affected, usually with anencephaly, while the 23% born alive usually have severe paralysis of the lower extremities and often need a operations to close the open spine, closure of myelomeningocoel, and to control pressure in the brain, ventricular peritoneal shunt, for lumbar and thoracic myelomeningocoel associated with an Arnold Chiari II malformation causing hydrocephalus. Lesser numbers of encephalocoel often requiring closure were encountered as well.

Ethiopian mother hold her child with lumbar myelomeningocoel

The most likely significant cause is lack of diversity in the diet and especially failing to consume foods with the vitamin folic acid. This is usually found in green and leafy vegetables as well as fresh fruits. Cooking foods such as chick peas which may contain folic acid will destroy much of it.

Around the world these birth defects have been reduced about 75% by encouraging women to plan their pregnancy and take 4 milligrams of folic acid daily starting before conception. We are working with our research group at Mekelle University to help the Tigray Regional Health Bureau and the Ethiopian Ministry of Health come up with programs to reduce these defects but this will take time.

In the meantime we encourage all women in Ethiopia to plan their pregnancy, starting folic acid supplementation before they conceive, and practice dietary diversity. They should try to wait one year between pregnancies, and understand that breast feeding increases their need for folic acid. Very young and older women are more susceptible to having children with these defects. Other factors may be involved besides folic acid deficiency but the good news is that folic acid supplementation will likely still reduce these defects.