Ethiopia Tigray crisis

People left with few healthcare options in Tigray as facilities looted, destroyed

The looted and damaged wards of Selekleka hospital. As a result, the hospital is now closed and unable to function, leaving a huge gap in the needs of the local people. Tigray region, Ethiopia, February 2021. © MSF

Press Release

15 March 2021

• Violence in Ethiopia’s Tigray region has extended to attacks on health facilities, with barely one in 10 functioning.
• Of the 106 health facilities MSF teams visited, one in five had been or was occupied by armed soldiers; one facility is being used as an army base.
• The damaged, looted facilities and resulting lack of medical staff means people in the region have very little access to healthcare.
• MSF urges all armed groups in the area to respect medical facilities and for services to be restored as soon as possible.

Addis Ababa – Health facilities across Ethiopia’s Tigray region have been looted, vandalised and destroyed in a deliberate and widespread attack on healthcare, according to teams from Médecins Sans Frontières (MSF). Of 106 health facilities visited by MSF teams between mid-December 2020 and early March 2021, nearly 70% had been looted, and more than 30% had been damaged; just 13% were functioning normally.

In some health facilities across Tigray, the looting of health facilities continues, according to MSF teams. While some looting may have been opportunistic, health facilities in most areas appear to have been deliberately vandalised to make them non-functional.  In many health centres, such as in Debre Abay and May Kuhli in North-West Tigray, teams found destroyed equipment, smashed doors and windows, and medicine and patient files scattered across floors.

In Adwa hospital in central Tigray, medical equipment, including ultrasound machines and monitors, had been deliberately smashed. In the same region, the health facility in Semema was reportedly looted twice by soldiers before being set on fire, while the health centre in Sebeya was hit by rockets, destroying the delivery room.

MSF teams recently visited 106 medical facilities across Tigray region, Ethiopia. Of the facilities visited:

3% – had been damaged

73% – had been looted

87% – were no longer functioning or fully functioning

Hospitals occupied by soldiers

Every fifth health facility visited by MSF teams was occupied by soldiers. In some instances, this was temporary; in others the armed occupation continues. In Mugulat in east Tigray, Eritrean soldiers are still using the health facility as their base. The hospital in Abiy Addi in central Tigray, which serves a population of half a million, was occupied by Ethiopian forces until early March.

“The army used Abiy Addi hospital as a military base and to stabilise their injured soldiers,” says Kate Nolan, MSF emergency coordinator. “During that time, it was not accessible to the general population.”

“They had to go to the town’s health centre, which was not equipped to provide secondary medical care – they can’t do blood transfusions, for example, or treat gunshot wounds,” says Nolan. Health facilities and health staff need to be protected during a conflict, in accordance with international humanitarian law. This is clearly not happening in Tigray.Oliver Behn, MSF general director

Ambulances seized

Few health facilities in Tigray now have ambulances, as most have been seized by armed groups. In and around the city of Adigrat in east Tigray, for example, some 20 ambulances were taken from the hospital and nearby health centres.

Later, MSF teams saw some of these vehicles being used by soldiers near the Eritrean border, to transport goods. As a result, the referral system in Tigray for transporting sick patients is almost non-existent. Patients travel long distances, sometimes walking for days, to reach essential health services.

Many health facilities have few – or no – remaining staff. Some have fled in fear; others no longer come to work because they have not been paid in months.

Devastating impact on people

“The attacks on Tigray’s health facilities are having a devastating impact on people,” says Oliver Behn, MSF general director. “Health facilities and health staff need to be protected during a conflict, in accordance with international humanitarian law. This is clearly not happening in Tigray.”

Before the conflict began in November 2020, Tigray had one of the best health systems in Ethiopia, with health posts in villages, health centres and hospitals in towns, and a functioning referral system with ambulances transporting sick patients to hospital. This health system has now almost completely collapsed.Attacks on medical facilities in Tigray

01/ 03Images taken by MSF staff from inside Selekleka Hospital in Tigray, Ethiopia. As a result, the Hospital is now closed and unable to function, leaving a huge gap in the needs of the local population.MSF02/ 03A rocket impacted against the delivery room at the Sebeya health centre, in east Tigray, destroying it.MSF03/ 03Vandalised health center in Debre AbbayMSF

MSF staff conducting mobile clinics in rural areas of Tigray hear of women who have died in childbirth, because they were unable to get to a hospital due to the lack of ambulances, rampant insecurity on the roads and a night-time curfew. Meanwhile, many women are giving birth in unhygienic conditions in informal displacement camps.

In the past four months, few pregnant women have received antenatal or postnatal care, and children have gone unvaccinated, raising the risk of future outbreaks of infectious diseases. Patients with chronic diseases such as diabetes, hypertension and HIV, as well as psychiatric patients, are going without lifesaving drugs. Victims of sexual violence are often unable to get medical and psychological care.

“The health system needs to be restored as soon as possible,” says Behn. “Health facilities need to be rehabilitated and receive more supplies and ambulances, and staff need to receive salaries and the opportunity to work in a safe environment. Most importantly, all armed groups in this conflict need to respect and protect health facilities and medical staff.”

MSF teams are rehabilitating a number of health facilities across the region and providing them with drugs and other medical supplies, as well as providing hands-on medical support in emergency rooms, maternity wards and outpatient departments. MSF teams are also running mobile clinics in rural towns and villages where the health system is not functioning, and in informal sites where displaced people are staying. However, there are still rural areas in Tigray that neither MSF, nor any other organisation, has been able to reach; MSF can only assume that people living in these areas are also without access to healthcare. You could also be interested in

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30-year old Aster* is 8 months pregnant and has come for a consultation at MSF’s clinic at the camp for displaced people located in a primary school. Tigray, Ethiopia, February 2021. © Claudia Blume/MSF

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

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.  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,” she continues. “Before, the children had regular meals.”

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

People’s number one concern is a lack of food. There have been several food distributions – and with more aid organisations 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. Nobody is formally in charge of the sites, and displaced people appoint community representatives from their home areas to organise 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.

Sixty-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,” Demsas says. “Before, I was a farmer and a butcher and ate well, but when I came here, we just received some wheat.”

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.

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 per cent,” says Juniper Gordon, MSF medical team leader. “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.”

Multitude of priorities before COVID-19

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

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. With bricks placed around their sleeping areas, families are trying to create a semblance 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.

In the clinics that MSF has been running in the displaced people’s sites since January, respiratory tract infections are the main illness 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.

Diarrhoea is the second-biggest medical problem, due to a lack of clean drinking water and sanitation, and unhygienic living conditions. We have built latrines in a displaced people’s site in a primary school and carry 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 displaced people’s sites, but in the whole of Shire town. MSF staff conduct a nutritional and pediatrics screening at MSF’s primary’s health clinic at the displaced people’s camp site at the local primary school. Tigray, Ethiopia, February 2021. © Claudia Blume/MSF

Curfew is a major obstacle for pregnant women

Living conditions are particularly hard on pregnant women. Twenty-six-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,” says Adiam. “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.”

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. We are giving expectant mothers safe delivery kits in the sites, in case they go into labour after dark.

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

“I delivered the babies inside the dorms, in the women’s beds,” says Adonay. “There were many people around. There was no privacy.  Fortunately, all deliveries went well.”

“At that time, no health centres were open or staffed,” Adonay continues. “We are several healthcare providers living in this site, and we have been able to help people before MSF and other organisations arrived.” Life as a displaced person in Tigray

01/ 04MSF 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. (16.2.2021)Claudia Blume/MSF02/ 04Hundreds 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.Claudia Blume/MSF03/ 04MSF midwives conduct an antenatal consultation in MSF’s primary health clinic in Shire’s Primary School IDP site.Claudia Blume/MSF04/ 04Several hundred IDPs live in Shire’s high school in former classrooms (14.2.2021)Claudia Blume/MSF

Patients with chronic diseases are without medication

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,” Gordon continues. “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.”

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,” says Dr Tesfamichael. “We sent the patients’ attendants to Adwa and Aksum hospitals. They went on foot, they took the risk to save their relatives’ lives.”

“Unfortunately, there was no insulin available there either,” Dr Tesfamichael continues. “We reported it to the regional health authorities, but the problem was the transport and the security.” Shire hospital serves more than one million people in the area. MSF supports paediatrics, the nutrition support and waste management programmes. Tigray, Ethiopia, February 2021. © Claudia Blume/MSF

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. 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.

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 paediatric ward, the in-patient therapeutics feeding centre, 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. 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 victims of sexual violence are seeking help.

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

“We have emergency contraceptives, prophylaxis – the problem is, we can’t get the patients,” Dr Berhane continues. “We need to increase health education, community mobilisation and home visits.”

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 victims seeking care is increasing, possibly because more people now know about, and trust, our services. Between 15 and 22 February, 10 patients received treatment and psychosocial support for sexual violence.

We offer counselling and psycho-education sessions in the displaced people’s sites. Many people have been deeply traumatised 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.

“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,” Tesfaye continues. “She has not been in school for about a year – first because of COVID-19, then because of the fighting. She is very upset.”

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* has walked over two hours from his village to get medical care. He says that the health centre 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,” says Birhane. “Many people are sick. Three pregnant women have died during childbirth in the past three months.”

“There is no food in the village. Our fields have been looted,” he continues. “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 southeast of Shire with basic health care. We are also supporting some health facilities with medical supplies and just opened a base in the northwestern town of Sheraro, from where we are supporting the town’s rural catchment area.

Most of the health facilities our teams have visited are not functional. Many were vandalised 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 centres in smaller towns and hospitals in bigger towns. There were health extension workers visiting communities and a referral system with ambulances.

“Now, the health system is completely destroyed,” says Berhe. “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,” Berhe continues. “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.

“These are the people who really cannot access any kind of healthcare,” says Gordon. “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 to protect people’s privacy.Up NextEthiopia Tigray crisis

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MSF staff preparing to transport a patient during an MSF mobile clinic in Hawzen, northeast Tigray. © Konstantina Konstantinidou/MSF

Voices from the Field1 February 2021

Albert Viñas has been involved in almost 50 emergency responses with Médecins Sans Frontières (MSF) over 20 years. He has just returned from Ethiopia, where his role was to prepare for medical teams to access areas of eastern and central Tigray and assist people affected by the current crisis. Since violence broke out in this northern Ethiopian region in early November 2020, some 60,000 people have taken refuge in Sudan and hundreds of thousands have been displaced within Tigray. He describes what he found.

After several attempts, we finally entered the capital of Tigray, Mekele, with a first MSF team on 16 December, more than a month after the violence started. The city was quiet. There was electricity, but no basic supplies. The local hospital was running at 30 to 40 per cent, with very little medication. Most significantly, there were almost no patients, which is always a very bad sign. We evaluated the hospital, with the idea of referring patients there as soon as possible from Adigrat, 120 kilometres to the north.

We arrived in Adigrat, the second most populous city in Tigray, on 19 December. The situation was very tense, and its hospital was in a terrible condition. Most of the health staff had left, there were hardly any medicines and there was no food, no water and no money. Some patients who had been admitted with trauma injuries were malnourished.

We supplied the hospital with medicines and bought emergency food in the markets that were still open. Together with the remaining hospital staff, we cleaned the building and organised the collection of waste. Little by little we rehabilitated the hospital so that it could function as another referral centre.Albert Viñas, emergency coordinator, Tigray, Ethiopia “If hospitals don’t function properly and can’t be accessed, then people die at home. And when the health system is broken, vaccinations, disease detection and nutritional programmes don’t function either.”

On 27 December we entered Adwa and Axum, two towns to the west of Adigrat, in central Tigray. There we found a similar situation: no electricity and no water. All the medicines had been stolen from Adwa general hospital and the hospital furniture and equipment were broken. Fortunately, the Don Bosco institution in Adwa had converted its clinic into an emergency hospital with a small operating theatre. In Axum, the 200-bed university hospital had not been attacked, but it was operating at only 10 per cent capacity.

On roads where the security situation remained uncertain, we trucked in food, medicines and oxygen to these hospitals and began to support the most essential medical departments, such as the operating theatres, maternity units and emergency rooms, and to refer critical cases.

Health centres looted and not functional

Beyond the hospitals, around 80 or 90 per cent of the health centres that we visited between Mekele and Axum were not functional, either due to a lack of staff or because they had suffered robberies. When the basic healthcare service does not exist, people can’t access or be referred to hospitals.

Before the crisis, two appendicitis operations were performed on any single day at Adigrat hospital. In the past two months, they haven’t done a single one. In every place, we saw patients who had struggled to get to hospital. One woman had been in labour for seven days without being able to give birth. Her life was saved because we were able to transport her to Mekele. I saw people arrive at hospital on bicycles carrying a patient from 30 kilometres away. And those were the ones who managed to get to hospital…  

If women with complicated deliveries, seriously ill patients and people with appendicitis and trauma injuries can’t get to hospital, you can imagine the consequences. There are large numbers of people suffering, surely with fatal consequences. Adigrat hospital has a catchment area of more than one million people and the one in Axum has more than three million.

If these hospitals don’t function properly and can’t be accessed, then people die at home. And when the health system is broken, vaccinations, disease detection and nutritional programmes don’t function either. There have been no vaccinations in almost three months, so we fear there will be epidemics soon.

In recent weeks, our mobile medical teams have started visiting areas outside the main cities and we are reopening some health centres. We have seen some health staff returning to work. Only five people attended the first meeting we organised in Adwa hospital, but the second was attended by 15, and more than 40 people came to the third.

Fear, queues and lack of basic services

In this part of Tigray, there are no large settlements of displaced people – instead, most have taken refuge in the houses of relatives and friends, so many houses now have 20 or 25 people living there together. The impact of the violence is visible in the buildings and in the cars with bullet holes.

Especially at the beginning, we saw people locked in their homes and living in great fear. Everyone gave us pieces of paper with phone numbers written on them and asked us to convey messages to their families. People don’t even know if their relatives and loved ones are okay, because in many places there are still no telephones or telecommunications.

When we arrived in Adigrat, we saw queues of 500 people next to a water truck waiting to get 20 litres of water per family at most. The telephone line was restored in Adigrat just a few days ago. The situation is improving little by little, but as we moved westwards to new places, we found the same scenario: fewer services, less transport…

We are very concerned about what may be happening in rural areas. We still haven’t been able to go to many places, because access is still difficult, either because of insecurity or because it is hard to obtain authorisation. But we know, because community elders and traditional authorities have told us, that the situation in these places is very bad.

Large areas of Tigray have a very mountainous terrain, with winding roads that climb from 2,000 metres above sea level to 3,000 metres. Cities like Adwa and Axum are built on the fertile highlands, but large numbers of people live in the mountains and we have heard that there are people who have fled to these more remote areas because of the violence.I am struck by how difficult it has been – and continues to be – to access people in great need in such a densely populated area. Albert Viñas, emergency coordinator, Tigray, Ethiopia Share

Logistical challenges, late response

The effort of our teams has been huge at all levels – medical, financial, logistical and human resources. It’s an incredible challenge without telephone or internet. At first there were no flights to Mekele and we had to move everything by road from the Ethiopian capital, Addis Ababa, about 1,000 kilometres away. You couldn’t make money transfers because the banks were all closed. Yet we managed to start our operations.

Now, almost three months after the start of the conflict, other organisations are beginning to appear, little by little, in some areas. I am struck by how difficult it has been – and continues to be – to access people in great need in such a densely populated area. Considering the means and capacity for analysis possessed by international organisations and the UN, the fact that this is happening is a failure of the humanitarian world.

We still don’t know the real impact of this crisis, but we have to keep working to find it out as soon as possible.

Other MSF teams are also currently delivering medical care in different areas of central, south and north-west Tigray. As well as its activities in Tigray, MSF teams have provided healthcare to thousands of displaced people and supported health facilities at the border of Amhara region and are responding to the needs of Ethiopian refugees across the border in Sudan.Up NextEthiopia Tigray crisis

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A woman holds her baby, having arrived at the Hamdayet crossing point, following a walk of many miles to escape violence in Tigray, Ethiopia. Hamdayet, Sudan, November 2020. © ©Olivier Jobard/MYOP

Project Update12 January 2021

Hundreds of thousands of people have been forced to leave their homes in the Tigray region of northern Ethiopia after fighting broke out in early November 2020, according to OCHA.<a href=”https://reliefweb.int/report/ethiopia/ethiopia-tigray-region-humanitarian-update-situation-report-6-january-2021″>ReliefWeb – Ethiopia – Tigray Region Humanitarian Update Situation Report, 6 January 2021.</a> Some 50,000 people have crossed in to Sudan as refugees, while many others are displaced within the region, staying in towns, remote areas or trapped between localised outbreaks of fighting. Teams from Médecins Sans Frontières (MSF) have been providing medical care to people in Tigray since mid-December.

People in Tigray short on shelter, food, water, communications

For those areas MSF teams could access, tens of thousands of displaced people are living in abandoned buildings and on construction sites in northwestern and western areas around the towns of Shire, Dansha and Humera, while others have found refuge in host communities in the east and south of the region. These people have very limited access to food, clean water, shelter and healthcare. MSF teams have also heard reports that many people are still hiding in the mountains and in rural areas across the region.

In some of the places visited by MSF, power lines are cut, water supplies are not functional, telecommunications networks are down, banks are closed, and many people are afraid to return to their places of origin because of the ongoing insecurity.

Often, they have no way to contact their relatives or to buy essential items for their households. Some people are also hosting family members displaced from elsewhere in the region, creating an additional burden on them.

The fighting broke out at harvest time in a region where crops were already badly damaged by desert locusts, leaving food in short supply. Before the fighting started, nearly one million of people were already dependent on humanitarian assistance. Although aid agencies and local authorities are distributing food in some areas, they are not reaching everyone. A man carries his child while walking on the outskirts of Um Rakuba refugee camp. Gedaref Region, Sudan, December 2020. © Thomas Dworzak/Magnum Photos

On the other side of the border, in Sudan, Kiera Sargeant, former MSF medical coordinator in Sudan, describes MSF’s response to the refugee crisis on the Ethiopian border.

What is happening at the border between Sudan and Ethiopia?

In early November 2020, new arrivals from the Tigray region of Ethiopia started crossing into Sudan at two points, Hamdayet and Ludgi.  In total over 55,000 refugees have arrived from Tigray since then.

The refugees are staying in Kassala and Gedaref states. In Gedaref, there are two permanent official camps, Um Rakuba and a new camp, Al-Tanideba. The transport of the refugees from the border reception camps to the official camps in Gedaref can take between 10 to 15 hours.

How is MSF responding to the influx of refugees?

MSF has been working in Sudan for many years already. However, when fighting erupted in Ethiopia in early November, we adapted our approach and headed for the Ethiopian border. On 19 November, we set up our first clinic in Gedaref.

We are now scaling up our activities at the border crossing locations and in the two permanent official camps. In these permanent camps, we are providing primary healthcare, reproductive healthcare, mental healthcare, vaccination, malnutrition treatment and treatment for chronic health conditions. We are also preparing an inpatient care department and provision of water and sanitation facilities. Our activities always include engagement with communities on their needs.

On the border in Hamdayet, we are supporting a Ministry of Health clinic to provide free healthcare to both the Hamdayet community and refugees, working with communities and setting up services for reproductive healthcare, mental healthcare, treatment of chronic health conditions and provision of water and sanitation facilities.

Our teams are also at the points where refugees cross the border providing health checks – including screening for malnutrition. As there are no other organisations at the border crossing points, we often also provide information and guidance to the new arrivals about where they can go next and what services they can reach – as the reception camp is on the other side of town.

What is the health condition of the refugees on arrival?

Initially people’s physical health condition was okay, as they had not travelled long distances. But as time has progressed, new arrivals are often exhausted and in a worse health condition due to the journey. We are also concerned about people not having access to required medications for chronic health conditions.

The main medical conditions our teams see are respiratory tract infections, acute watery diarrhoea, as well as people with chronic health conditions, such as diabetes and hypertension. We’ve treated several shrapnel and bullet wounds, and people are expressing mental health-related concerns to us. Anecdotally we’ve heard reports of sexual violence and we’re spreading the message within the community that we can provide victims with medical and psychological care.

What are living conditions like in Hamdayet and the official camps?

The humanitarian situation in the reception area in Hamdayet is poor: there is not enough shelter, food, water or essential relief items for the people there. Many of the refugees are staying in the village, as there are more shelter options there.

In the camps, services are still being scaled up, but the response is too slow. Since 3 November, between 250 to 350 refugees a day have been moved to Um Rakuba. Movement of people to Al-Tanideba camp started in the first week of January, although the site is hardly prepared to receive people.  We are extremely worried refugees are arriving at a camp that lacks essential services, and that their basic needs will not be met.

At the same time, refugees keep arriving in Sudan, which means that services in the transit camps need to be well maintained and improved, as the total number of refugees in these sites continues to be high.

What are the refugees’ main concerns?

Many of the refugees became separated from family members as they fled, so one of their main issues is concern for family and loved ones, due to the limited phone network in the Tigray region.

We have seen several unaccompanied children, most of whom were separated from their families as they ran away from their homes. We refer the children to the UN Refugee Agency’s (UNHCR) child protection services.

What are the main challenges in responding to this refugee crisis?

For MSF, one of our biggest challenges was to get hold of enough medical supplies. We are seeking emergency importation of medical supplies so that we can respond in a timely manner. The pandemic has also created challenges to bringing in experienced medical staff, as there is already a shortage in the country.

The sudden influx of refugees has put a strain on existing infrastructure and the health service in Sudan. This came on top of existing fuel shortages and steep inflation in Sudan, which have caused logistical and financial difficulties for everyone involved.

In general, there is an urgent need to increase assistance rapidly to address the needs of the refugees; particularly in advance of the rainy season, which will make this area of Sudan very difficult to access. It is extremely important that the Government of Sudan, the UN, donors and NGOs do everything in their power to scale up; coordination by UNHCR and the Sudanese authorities (COR) needs to be improved; more money from donors is urgently needed; and permissions to import supplies and start activities must happen in days, rather than weeks.

Read the stories of those on the other side of the border: new refugees in Sudan are exhausted

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MSF providing medical care in hospitals and clinics in Ethiopia

In southern Tigray, MSF teams are running mobile clinics and have restarted some services at health centres in the towns of Hiwane and Adi Keyih, alongside staff from the Ministry of Health. Between 18 December and 3 January, MSF teams in Hiwane and Adi Keyih provided 1,498 medical consultations to people.

In eastern Tigray, MSF is supporting the hospital in Adigrat, the region’s second city. When an MSF team arrived in the city on 19 December, they found the hospital, which served a population of more than one million, had partially stopped functioning. Given the urgency of the situation, MSF sent oxygen cylinders and food for patients and their caretakers from Mekele, 120 kilometres further south, and referred patients to Afder hospital in the region’s capital city.

Since 23 December, MSF medical teams have been running the hospital’s emergency room, as well as the medical, surgical, paediatric and maternity wards. They are also providing outpatient care for children under five. In total, MSF received 760 patients in the emergency room of Adigrat’s hospital from 24 December to 10 January.

Estimates as many as four million with no access to healthcare

In central Tigray, as far west as the towns of Adwa, Axum and Shire, MSF teams are providing some of the displaced people with basic healthcare and supporting health facilities which lack essential supplies such as medications, oxygen and food for patients. MSF teams estimate that between three and four million people in central Tigray have no access to basic healthcare.

In the western towns of Mai Kadra and Humera, MSF has provided support to some health centres and has been supporting up to 2,000 internally displaced people by providing medical services, supplying water, sanitation and hygiene products, and constructing emergency latrines. Most of the internally displaced people are no longer there.

Prior to the conflict, the population in Tigray, Ethiopia, was around 5.5 million people, including more than 100,000 internally displaced people and 96,000 refugees who were already dependent on food assistance, according to the UN .

As well as our activities in Tigray, MSF teams have provided healthcare to thousands of displaced people at the border of Amhara region since November. They have also supported several health facilities with medical supplies and provided nutritional and mass casualty trainings to Ministry of Health staff. MSF is also responding to the needs of Ethiopian refugees across the border in Sudan.Up NextEthiopia Tigray crisis

“They saw soldiers and civilians coming in, wounded or dead”

Project Update 18 December 2020

Ethiopia: Psychological support for MSF staff on Tigray border

Ethiopia Tigray crisis

“They saw soldiers and civilians coming in, wounded or dead”

On 5 November 2020, MSF’s team in the Amhara region, next to Tigray, heard the shelling and bombing of the first military escalation. They quickly started to support a Ministry of Health-run health centre that was receiving an influx of wounded people from the border areas. Ethiopia, November 2020. © Susanne Doettling/MSF Also available inCHOOSE LANGUAGECHOOSE LANGUAGEEnglishالعربي

Project Update18 December 2020

“We heard the launching, the heavy artillery, and it went on all morning,” remembers Sara,* former MSF laboratory technician in Midre Genet, in Ethiopia’s Amhara region, next to Tigray. “The same day, we received the first wounded. They kept arriving in waves. On the first two days, we received soldiers – all very young. Then the first civilians came in by the truckload, packed into the back of vehicles.”

At the onset of the military escalation in Tigray in early November, MSF had projects in Amhara and other parts of Ethiopia. Amhara region is not far from Humera, a strategic city in the western part of Tigray that was heavily affected by the fighting.

On 5 November, our team started supporting the Ministry of Health-run health centre in Midre Genet, a remote town that was receiving an influx of people from border areas wounded in the fighting. In just a few hours, our team had to switch from everyday medical project activities to emergency medical assistance for the wounded. In one week alone, MSF and the Ministry of Health staff treated 265 casualties, many of them with severe injuries.  

The fighting shifted to other parts of Tigray region and our team focused on supporting internally displaced people in the region. Sara left Midre Genet soon after the acute fighting, when the influx of wounded reduced.

“When I left the project, there was still a sense of sadness and despair among the MSF team,” she says.

What the team experienced during these first days of clashes had a huge psychological impact on their mental health.Kaz de Jong, MSF staff health coordinator “They saw soldiers and civilians coming in, wounded or dead. They had to do triage and make very difficult decisions. It was also hard for the nursing staff, who had to care for the people who had the best chances of survival and leave the others.”

“They saw soldiers and civilians coming in, wounded or dead,” says Kaz de Jong, MSF staff health coordinator. “They had to do triage and make very difficult decisions. It was also hard for the nursing staff, who had to care for the people who had the best chances of survival and leave the others. That is so counterintuitive for their profession. And the sight of blood, suffering and wounds can often leave stressful images.”

The situation is particularly difficult for our Ethiopian colleagues, who have many other concerns. The ongoing fighting make them worry about their own future and that of their country. Some have relatives and loved ones who remained in Tigray and they have had no news from them for weeks due to the complete communication blackout. Many have not heard from some of their colleagues either.

“Some of them were companions for years, and from one day to the next, they just disappeared, fled to other towns or neighbouring countries without any notice,” says Kaz.

“Every day, our Ethiopian colleagues see all these people who have been displaced because of the fighting and who are now living in small settlements around them, huddled together in very bad conditions. And, of course, before the fighting started, COVID-19 had already complicated their lives, preventing most children from going to school and increasing the number of unemployed people that they and their families have to support financially.”

“I cannot be happy, but I can be a bit happier”

MSF provides psychosocial support to all the health workers to help them cope with their traumatic situation. This support ranges from phone calls to physical and psychological activities in the field. In Ethiopia, as in any context of fighting and violence, our teams have benefited from group and individual sessions to help them to better manage their daily stress.

The group workshops on stress management usually take place in five steps.

First, participants are asked to make an inventory of all the things that give them stress. They can be small things, such as family issues, or bigger ones, like the fighting. Then the group chooses the most important stress factor they want to discuss. It can be overwhelming to think about multiple problems at the same time, so we ask them to focus on one to explore in detail so that they can have the structure needed to look into improvements. The third step is to think about what is still functioning well.

“Our intention is not to push the problems aside, but rather to tell the whole story,” says Kaz. “Of course, this does not undo all the dramatic incidents, but looking at the whole story, including all the things that are still functioning well, allows them to be more inclined to look at their problems from a solution-oriented perspective. It takes time, effort and courage but people usually manage to switch, as they do not want to be stuck in unhappiness. At the end of the day, they end up thinking ‘I cannot be happy, but I can be a bit happier’”.The way the team rapidly switched from their previous activities – kala azar, TB treatment, snakebites and clinical trials – to go into a very efficient emergency mode was remarkable. Kaz de Jong, MSF staff health coordinator Share

The last two steps involve thinking about how to improve the situation and making an action plan for themselves.  These steps are essential to diminishing the impact of the main issue, which, in this case, is the fighting. Reaching out to friends and colleagues, not only to talk about problems but also to share very simple things in their everyday lives, greatly reduces their stress.

In Amhara region, our team is made up of Ethiopians from different backgrounds. They never mentioned this during the sessions. Instead, they focused on the fact that they had saved lives together, as a team. The guards who helped with the traffic, the physicians who treated the wounds, the nurses who provided the first aid, the lab technicians who carried out the blood tests.

“Everyone had his or her role and they worked together like a smooth machine,” says Kaz. “I must say that I have been in many situations, and the way the team rapidly switched from their previous activities – kala azar, TB treatment, snakebites and clinical trials – to go into a very efficient emergency mode was remarkable. Caring for and treating large numbers of people would not have been possible if they had not been able to do this. The staff are proud of this achievement and they have every right to be proud of it.”

*MSF staff member’s name was changed as she requested to remain anonymous.

MSF has been working in Ethiopia since 1984. For more than 30 years, our teams have responded to emergencies countrywide, including malnutrition, malaria, acute watery diarrhoea, the health needs of refugees and basic access to healthcare. In Addis Ababa, Amhara, Gambella and Somali regions, we run regular projects in collaboration with government health institutions to provide host, refugee and displaced populations general and specialist healthcare, treatments for neglected tropical diseases, as well as medical and mental health support to Ethiopian migrants, most of them deported or repatriated from Saudi Arabia, Kuwait and Lebanon. Our teams have also developed contingency plans to ensure the continuity of our current activities in the country during the COVID-19 pandemic.