Tigray Crisis: “We are suffering from a lack of medical care”

Fighting in Ethiopia’s Tigray region has uprooted hundreds of thousands of people

09 Mar 21

A dire situation in Shire | Risk of a nutritional crisis | Curfew- a major obstacle | Patients with chronic diseases | Sexual violence | Health system in rural areas

Inside Tigray, Ethiopia, most of the displaced people stay with the host community, while tens of thousands live in informal sites or are still hiding in the bush or the mountains. Médecins Sans Frontières (MSF) is deeply concerned about the humanitarian situation of hundreds of thousands of people who have been deprived of medical care for months and have received little humanitarian assistance.

A dire situation for displaced people in Shire 

Thirty-year old Aster* sits in the waiting area of MSF’s primary health clinic at a site for displaced people in Shire. She is eight months pregnant and has come for an antenatal check-up.

30-year old Aster* is 8 months pregnant and has come for a consultation at MSF’s clinic at Primary School IDP camp. Two months ago, she fled Adi Heseray with her husband and two children. She says her house was burned down.

She fled with her husband and two young children from a village in Western Tigray when fighting broke out in November, and now lives with a local family. She says she feels stressed.

“I have not received any food aid. We are getting some food from the people we are staying with, but it is not enough, “says Aster.

“Sometimes, I go out to beg. If they don’t give me anything, we sometimes sleep without having eaten. It is difficult to be dependent. It makes me empty inside. Before, the children had regular meals”.

Waiting area of MSF’s clinic at Primary School IDP site, Shire. 12th of February 2021.

Tens of thousands of people have arrived in Shire, a large town in North West Tigray, since fighting broke out in November. Most are from Western Tigray.

The majority stay with the host community, but almost 20,000 people live in informal sites. They sleep in cramped and often unhygienic conditions in the classrooms of several schools, as well as on the campus of Shire University.

Risk of a nutritional crisis

There have been several food distributions - and with more aid organizations recently arriving, the numbers are increasing - but people say it’s not enough and that the distributions are often unfair, leaving some people with less than others or even nothing at all.

People’s number one concern is a lack of food

Hundreds of people in Shire’s University IDP site live in an unfinished building, where they sleep, cook and eat. Many don’t have mattresses or blankets.

Nobody is formally in charge of the sites, and displaced people appoint community representatives from their home areas to organize distributions and other matters.

Some people sell food donations to buy blankets or other things they need.

All of the food that has been donated so far are bags of wheat and some cooking oil. That means that what most people in the sites eat every day is only bread – which is not nutritious enough, especially for children, pregnant mothers and sick people.

Hundreds of people in Shire’s University IDP site live in an unfinished building, where they sleep, cook and eat. Many don’t have mattresses or blankets.

60-year old Demsas* has type 2 diabetes for which he recently received tablets from Shire hospital.

“The doctor advised me to eat a variety of food – goat meat, milk, injera - but I can’t afford it. Before, I was a farmer and a butcher and ate well, but when I came here, we just received some wheat.”

60-year old Demsas*, displaced from Western Tigray, is living in Shire’s University IDP site with one of his eight children. Through MSF’s referral, he has been able to get medicine for his type 2 diabetes from Shire hospital.

Most shops are now open in Shire and there is food available in the market, but most people have no money to buy it.

The city’s civil servants only recently received their first salary since the fighting started, and even those who have money in the bank cannot access it because most banks are still closed.

The price of food and other items has gone up, and many of the displaced people did not bring any money.

Women are cooking on makeshift stoves outside. As the only donation most people have received is wheat, they eat bread every day.

MSF carried out a nutritional survey with children under five in the sites and found that while the situation is concerning, it is not at emergency level yet.

“What we saw was that the overall global malnutrition rate in the sites was about 11 percent. There was 9% moderate and 2 % severe malnutrition, which is under the emergency threshold. There is food instability and there is definitely a risk for it to become a nutritional crisis. We have to keep a close eye on it,” says MSF medical team leader Juniper Gordon.

MSF staff conduct a nutritional and pediatrics screening at MSF’s primary’s health clinic at Primary School IDP site.

Curfew is a major obstacle for pregnant women

Living conditions in the sites are rough. Dozens of people sleep in each of the former classrooms of local schools, between desks and chairs.

Hundreds of people in Shire’s University IDP site live in an unfinished building, where they sleep, cook and eat. Many don’t have mattresses or blankets.

Some have received mattresses and blankets from the community while many others just sleep on the floor or on plastic sheeting.

With insecurity still ongoing, people continue to arrive in large numbers. Many of the newcomers have no choice but to sleep outside or in makeshift shelters in the sites.

Most have fled with few possessions, many just with their clothes on their backs. Some still wear the same clothes they left their homes in, more than three months later.

Some women say they had to tear apart some of their clothing to make sanitary pads, which is a source of humiliation

Displaced people live in classrooms of a primary school in the center of Shire. 15th of February 2021.

On Shire’s university campus, hundreds of people are staying in former student dormitory buildings, sleeping in bunk beds. Those who have not found a place in the dormitories stay in an unfinished building on the campus.

Several hundred IDPs live in Shire’s high school in former classrooms. 14th February 2021.

With bricks placed around their sleeping areas, families are trying to create a resemblance of privacy. Only some people have mattresses or beds, most sleep on the concrete floor.

There are no walls to protect them from the cold at night. There is smoke from fireplaces everywhere, and the ever-present sound of people coughing.

Hundreds of people in Shire’s University IDP site live in an unfinished building, where they sleep, cook and eat. Many don’t have mattresses or blankets.

In the clinics that MSF has been running in the IDP sites since January, respiratory tract infections are the main morbidity our teams are seeing.

Is it COVID-19? Nobody knows for sure. There are no tests available, and there is no way for people to keep a safe distance from each other in the overcrowded sites, no way to buy masks or wash their hands frequently.

Compared to the many other issues people are facing, COVID-19 is low on the list of people’s worries.

36-year old Ayana* has come to the MSF clinic with her 5-year old son. She says her son is sick all the time, coughing, and that there are many communicable diseases in the camp. They arrived in Shire from her hometown Dansha three months ago.

Diarrhea is the second-biggest medical problem, due to a lack of clean drinking water and sanitation, and unhygienic living conditions.

MSF has built latrines in an IDP site in a primary school and carries out regular water trucking. Our teams have also rehabilitated a large toilet and shower building on the University campus.

Water supply is not a just an issue in the IDP sites, but the whole of Shire town.

MSF has constructed latrines for people living in Shire’s Primary School IDP site.

Living conditions are particularly hard on pregnant women. 26-year old Adiam* has fled from a village near Humera and now lives in the University site. She is eight months pregnant with her first child.

“Delivering a baby in these circumstances will be difficult, but I am glad I am here with my family. Many other families have been separated. I want to deliver at the hospital but I am worried what will happen if the baby is born at night, after the curfew. I don’t know how to get to the hospital then.”

MSF has distributed jerry cans, buckets and hygiene products such as soap and sanitary pads to families living in three of Shire’s three IDP sites. 16th February 2021.

After 6.30 pm, people cannot leave their homes, and while ambulances are in theory allowed to operate, none are available. Until recently, there was also no staff in the hospital after dark, leaving patients on their own during the night.

MSF is giving expecting mothers safe delivery kits in the IDP sites in case they go into labour after dark

MSF midwives conduct an antenatal consultation in MSF's primary health clinic in Shire's Primary School IDP site.

Adonay*, a healthcare professional from Western Tigray who lives in the University site, says he has helped deliver three babies there.

MSF nurses clean the leg wound of a 12-year old girl at MSF’s clinic at Primary School IDP site, Shire. She and four other children had found an explosive device near their home outside of Shire that suddenly exploded when they played with it.

“I delivered them inside the dorms, in the women’s beds. There were many people around. There was no privacy. Fortunately, all deliveries went well. At that time, no health centers were open or staffed. We are several health care providers living in this site, and we have been able to help people before MSF and other organizations arrived.”

Patients with chronic diseases are without medication

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Patients with chronic diseases such as diabetes or hypertension face some of the biggest challenges. They have not received any medication for months.

“Diabetic patients have not had insulin for three months, which is very dangerous,” says Juniper Gordon.

“In the camps, some patients who have TB and HIV also have not had medication for months. Now, the central pharmacy board in Shire is up and running and they are trying to get medication to the facilities."

MSF pharmacists hand out medication to patients at MSF’s primary health clinic at Shire’s primary school IDP camp. 16th of February 2021.

"For some medications like insulin that needs a cold chain it is a big challenge – there has not been electricity until the beginning of February in Shire, and it is still not reliable. In the majority of regions outside of Shire there is still no electricity.”

Waiting area of MSF’s clinic at Primary School IDP site, Shire. 12th February 2021.

Dr. Berhane Tesfamichael is the medical director of Shire hospital. He says the lack of insulin had a severe impact on several of his patients in the period after the fighting started.

Five patients died at the hospital because of a lack of insulin

Dr. Berhane Tesfamichael, medical director of Shire hospital

“We sent the patients’ attendants to Adwa and Aksum hospitals. They went on foot, they took the risk to safe their relatives’ lives. Unfortunately, there was no insulin available there either. We reported it to the regional health authorities, but the problem was the transport and the security.”

MSF and other organizations truck in water for IDPs at Shire’s Primary School IDP site. 12th February 2021.

Even though insulin recently arrived in Shire’s central pharmacy stock, it is still not possible to distribute it to health facilities and patients in need in the rural areas.

Shire hospital serves a population of more than one million people in the area.

Shire hospital serves more than one million people in the area. When MSF first arrived, we helped clean and renovate the hospital and donated food to the hospital kitchen. Shire hospital was not as badly looted as other health structures.

After fighting broke out in the city, many staff members did not return to work for a long time, some out of fear for their safety, others out of a lack of motivation because they did not receive any salary.

Both staff and patients had no food at the beginning, and when MSF arrived, we supplied the hospital kitchen with food and cleaned the facility as no cleaners had come for weeks.

Staff at Shire hospital receive a food donation. They have only received one month’s salary since November. 14th of February 2021.

The hospital was not badly looted, but there have been many robberies at night in the past few months because no staff was present.

MSF is supporting the pediatric ward, the in-patient therapeutics feeding center as well as water and waste management activities at the hospital.

Most of the staff has now returned and Shire hospital is almost fully functional. However, many issues remain – such as a lack of supplies, power cuts and security issues for patients, especially at night.

MSF supports pediatrics, the ITFC and waste management. Shire hospital was not as badly looted as other health structures but there are many robberies after the 6.30 pm curfew.

Apart from the emergency unit, the wards are not busy. Unlike before the crisis, few patients from rural areas are coming now.

The referral system has collapsed and without ambulances, insecurity in many areas and many people not being able to afford the transportation costs to the city, many find it impossible to get to the hospital.

Stigma around sexual violence

One of the issues that Dr. Berhane is most worried about is that not many survivors of sexual violence are seeking help.

Many women get raped but they don’t seek help. They are hiding at home. The women want to go to the hospital, but the culture, the stigma, social norms prevent them

DR. BERHANE TESFAMICHAEL, MEDICAL DIRECTOR OF SHIRE HOSPITAL

"We have emergency contraceptives, prophylaxis – the problem is, we can’t get the patients. We need to increase health education, community mobilization and home visits.”

Entrance of MSF’s clinic at University IDP site, Shire, Tigray. 16th of February 2021.

MSF was initially facing a similar situation in our clinics in the sites. Our staff hear many stories about sexual violence from the community, but not many women were coming for care.

The number of survivors seeking care is increasing, possibly because more people now know about, and trust, MSF’s services.

Between February 15 and 22, ten survivors of sexual violence received treatment and psychosocial support.

MSF offers counselling and psycho-education sessions in the IDP sites. Many people have been deeply traumatized by the violence they have experienced, by their displacement and bad living conditions, as well by being separated from family members, often without knowing their whereabouts.

35-year old Dehab* has come to MSF’s clinic at the Primary School IDP site to seek help for her mental health issues. She is a single mother of four children and says she feels constantly stressed.

“We all have trouble sleeping,” says 43-year-old Tesfaye* who lives at the High School site with his family.

“We are all thinking about our houses, our businesses, our children who are not going to school. My eldest daughter, who is 14, was one of the best students in her class. She has not been in school for about a year – first because of COVID-19, then because of the fighting. She is very upset.”

Displaced people live in classrooms of a primary school in the center of Shire. 15th February 2021.

Many displaced people are also worried about their future, whether they will be able to go home one day. They also concerned about whether they will be able to stay in the sites.

The health system in rural areas has collapsed 

While the situation for displaced people in Shire is difficult, it is far worse for people living in areas outside of Tigray’s main towns.

Birhane* is a 58-year old farmer who is sitting in the waiting area of MSF’s primary health clinic at the University IDP site. With his weathered face, traditional white headscarf and stooped, thin body perched on a walking stick, he looks much older.

Several hundred IDPs live in Shire’s high school in former classrooms. 14th February 2021.

He says he has walked 2 ½ hours from his village to get medical care. Birhane says that the health center that served his farming community of 2,500 people has been closed since November, and that all six staff have left.

“We are suffering from a lack of medical care. We don’t have any medication; the village’s two ambulances were taken. Many people are sick. Three pregnant women have died during childbirth in the past three months,” the farmer says.

Entrance of MSF’s clinic at University IDP site, Shire, Tigray. 16th February 2021.

“There is no food in the village. Our fields have been looted. Some of our women have been raped. We stayed for two months in the forest and we are still scared.”

Since the end of January, MSF is sending mobile medical teams to provide patients in villages and towns north, east and south east of Shire with primary health care.

We are also supporting some health facilities with medical supplies and just opened a base in the north-western town of Sheraro, from where we are supporting the town’s rural catchment area.

MSF has distributed jerry cans, buckets and hygiene products such as soap and sanitary pads to families living in three of Shire’s three IDP sites. 16th February 2021.

Most of the health facilities our teams have visited are not functional. Many were vandalized and looted and in most facilities, the staff has left. 

Most people have not received any medical care since November

Berhe*, a health professional working with MSF, says that the region used to have a well-functioning health system before the fighting started.

Villages had health posts and there were health centers in smaller and hospitals in bigger towns. There were health extension workers visiting communities and a referral system with ambulances.

MSF has distributed jerry cans, buckets and hygiene products such as soap and sanitary pads to families living in three of Shire’s three IDP sites. 16th February 2021.

“Now, the health structure is completely destroyed. When we visit rural areas, mothers say: “My child is three months old. He has not been vaccinated yet." Maternal and child health is very difficult now."

"During one of our mobile clinics, we heard that a delivering mother died because she could not get assistance from health professionals. In the rural areas there are no health structures, no ambulances.”

As access to towns and villages along the main roads in northern Tigray is getting easier, we are now trying to reach people who are living in the bush, says Juniper Gordon.

Thousands of IDPs live on the campus of Shire University.

“These are the people who really cannot access any kind of healthcare. We try to get there and give a bare minimum of healthcare and see their condition. We hear of people who have been in the bush for months and still don’t feel safe enough to go to the clinic.”

*Names have been changed

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