The need for rigour and balance in reporting the health impacts of conflict in Tigray, Ethiopia

Background

The untoward effects of war on healthcare infrastructure, health professionals and the general welfare of populations in conflict zones are well established.1 2 A rigorous assessment of the impact of each conflict is critically important to help policy-makers formulate and implement remedial measures during and after the conflict.3 However, due to security, political, ethical and other obstacles associated with wars and related armed conflicts, gathering reliable health data and information in the course of an active war is exceedingly challenging.4 The reliability of information is often compromised by the inherently partisan nature of the primary sources and the constantly changing power balance on the ground. These dilemmas are complicated by the ubiquitous social media, where there is the tendency to disseminate disinformation and misleadingly alarming messages without accountability. The problem is further aggravated when the information is intended for use as an instrument of propaganda by the warring parties.

We carefully reviewed the article by Gesesew et al5 which attempts to document the impact of war on the health system of the Tigray region in Ethiopia. While the authors acknowledge the limitations of their work, the paper is regrettably fraught with inaccuracies, factual errors, gross misrepresentations and inflammatory statements.

To fully characterise the health impacts of the conflict in Ethiopia and appreciate the flaws of the paper,5 it is important to contextualise the complex backdrop of the crises which involves long festering internal ethnic grievances, regional rivalries and global power struggles.

In this commentary, we highlight the glaring shortcomings of the paper5 including methodological flaws, inflammatory statements and reporting of misleading statistics, and make suggestions for the need to conduct comprehensive research on the health system impacts of the crises not only in Tigray but also in other parts of Ethiopia that are affected by the conflict.

Methodological shortfalls

The authors compare the healthcare systems during two periods, viz., pre-war and the first few months of the ongoing war. Data for the pre-war period are principally based on an unpublished 2019 report of the Tigray Regional Health Bureau and the latest Ethiopian Demographic Health Survey report. Data during the ongoing war are mainly based on reports from the Tigray Regional Health Bureau, with no verifiable citation, and on other anecdotal sources, including opinion pieces, press releases and situational updates. The entire analysis of the paper rests on the erroneous premise that these two data sources are comparable, disregarding the fact that these two sources of information are fundamentally incongruent with respect to quality and methodological rigour. This is a major flaw despite the authors’ cursory effort to give their article a scientific veneer.

There is also much to be desired with regard to the description of the methods used to generate the data or to ascertain the authenticity of the data sources. As such, many of the assertions and claims are not supported by evidence or rigorous statistical analysis. For example, they report: ‘as a result of the war, it is estimated that more than 52 000 civilians have been killed, 2.3 million people displaced, while 70 000 people have crossed to the neighboring Sudan in the first 3 months of the war’. However, there is no credible description of the data source, or the method of estimation used to arrive at the indicated figures. In other cases, the authors make vague or casual references to sources of data. A case in point is their assertion: ‘…a total of 2000 healthcare workers were reportedly registered in internationally displaced people camps.’ Yet, there is no mention of who reported it.

Further, the analytical methods used to derive many of the statistics that are the basis for their assertions are not clearly stated. For example, in the abstract, they report, ‘… a conservative estimate places the number of girls and women raped in the first 5 months of the war to be 10, 000.’ However, there is no description of how the numbers were obtained anywhere in the paper.

Unverifiable assertions and inflammatory statements

A recent report, which is the most comprehensive of its kind to date, was jointly issued by the United Nations High Commissioner for Human Rights and the Ethiopian Human Rights Commission.6 The report, while acknowledging the occurrence of serious abuses and violations of human rights, assigns culpability to all parties to the conflict, including the Tigray People’s Liberation Front (TPLF) fighters.6 However, the paper5 is peppered with numerous unverifiable and one-sided assertions and sensational statements about the crimes that are unworthy of reporting in a peer-reviewed journal. For example, in their conclusions, the authors make a reference to ‘…the widespread use of rape and sexual harassment as a systemic weapon of war, and the occurrence of the independently confirmed ethnic cleansing and atrocities…’. According to the above report,6 there was no evidence to support their assertion of ‘use of rape and sexual harassment as a weapon of war’ or ‘ethnic cleansing’ committed in the context of the conflict.

There are several other glaring omissions throughout the paper. One of the most significant omissions is the disregard of the health impacts of the aggression by the TPLF7 in the Amhara and Afar regions of the country.8 Notable examples include, as reported by Amnesty International,9 the egregious atrocities committed in such places as Mai-Kadra, where ethnic Amharas were massacred.9 Further, the authors limited the temporal and spatial scope of their article to exclude the well-documented destruction, by the TPLF, of health facilities and other infrastructure following the June 2021 declaration of a unilateral ceasefire by the government of Ethiopia. Instead of taking this opportunity to pursue a peaceful resolution to the conflict, the TPLF expanded the war into the neighbouring Amhara and Afar regions, employing child soldiers,10 committing massacres,11 perpetrating sexual violence,8 looting health centres, and displacing thousands of Ethiopians.12

Another glaring omission of the paper is the effort by the central government to rehabilitate and support the people of Tigray during the period covered in the paper. For example, according to published reports, the government covered 70% of the humanitarian assistance in the region during that time period.13 In particular, the Ministry of Health (MOH) of Ethiopia, in collaboration with key stakeholders, did put in place several emergency measures, including installation of mobile clinics, nutrition stations, and other temporary health facilities. Notably, during the same period, the MOH and the interim government of Tigray restored essential health services in 52% of the health facilities, 63% of the hospitals and 52% of the health centres in areas that were considered safe from TPLF attacks.14 In addition, the MOH implemented several intervention measures in support of victims of gender-based violence, in such places as Axum, Adigrat, Shire, Adwa and Wukuro.14 The paper would have been more balanced if such data had been included in the assessment.

Conclusion

As in all other similar situations, the conflict in Northern Ethiopia has inflicted devastating damage on the health infrastructure and well-being of the citizens of the conflict zones. The academic community and peer-reviewed journals have a moral and professional imperative to document these calamities with the highest possible scientific rigour and transparency to help policy-makers formulate and implement viable measures and solutions. Biased and unsubstantiated reports can be misleading and pose obstacles to any efforts to prevent and mitigate human suffering. It is unfortunate that the paper misses the opportunity to focus on the ravages of the ongoing war in an objective and impartial manner. Given the gravity of the situation in Northern Ethiopia, it is recommended that a thorough study on the subject be conducted by independent scholars.