Tigray: the challenges of providing care in unimaginable conditions

During a pre-covid sabbatical in Ethiopia, one of the world's poorest countries, we had the privilege of seeing many healthcare facilities. Working for almost three months, we visited tertiary, private, and community hospitals, as well as community health centres in the provinces of Amhara, Oromia, and Tigray. One of our striking impressions during this sojourn was the gap between the extremely high level of knowledge and skills of health professionals and their practical ability to deliver effective healthcare.

Everywhere we encountered dedicated medical staff, nurses, medical students, and public health experts, all equipped with wide-ranging knowledge. But we also experienced day-to-day issues unimaginable to physicians working in high or middle-income countries. At every turn we observed how our colleagues coped with limited supplies for dialysis, a shortage of medications, dysfunctional machines with little hope of repair owing to a lack of technicians and parts, and a guessing game in pathology owing to a lack of immunohistochemical stains.

Together with our friends, we encountered patients with diabetes having to bury their three-month supply of insulin in the ground for lack of refrigeration, patients forgoing simple tests such as electrolytes for lack of funds, and of course, patients and families “going against”—the term used to describe patients leaving the hospital despite medical advice—owing to lack of resources to support a relatives’ treatment, or because of more pressing priorities at home such as the impending annual harvest.

One remarkable facility we visited was Ayder Comprehensive Hospital in Mekelle. At this tertiary care centre (>500 beds; >2000 staff) with its renowned medical school, we encountered a dynamic team of leaders, administrators, and clinicians dedicated to solving the unsolvable, obtaining the unobtainable and providing services like dialysis, oncology treatment, cardiac catheterisation, and endoscopies, at a level unimaginable 14 years previously when they took over the hospital on the northern periphery of Ethiopia, while engaging fully with the community.

Today in the midst of war, this facility—and others in Ethiopia—are struggling with child malnutrition at triple the rate seen in the recent past due to the widespread civil war. Malnutrition is occurring even in the middle classes who cannot access their savings. Patients, who one year ago could receive up-to-date care with dialysis or chemotherapy, are dying because of a lack of consumables, drugs, and supplies. Doctors are unpaid and malnourished. They are doing the unimaginable—reusing dialyzers, prescribing outdated drugs in inadequate dosages, performing complex surgery without imaging, and all too frequently, sending patients home to die from easily treatable ailments. All this because of a civil war and a blockade of fuel and food. Few aid trucks have made it into Tigray over the past few months and the UN estimates that more than 90% of the population in the region is in urgent need of humanitarian assistance.12

When we were there in 2019, before covid-19 and the war, we often considered how we, as academically trained clinicians, so proud of our easy familiarity with high tech care, would have coped with managing patients’ needs under the burden of such an extreme lack of resources. Even in peacetime, we had observed with admiration how our colleagues coped, both in Gondar and Mekelle. But now, with the blockade lasting many months, doctors in Tigray have spoken out about the disastrous impact that it is having on the healthcare they are able to provide.3

The months-long blockade threatens the entire region and especially the seven million inhabitants of Tigray for whom Ayder Hospital was a lifeline. The situation was already unfair, even before the war. For example, high income countries have long benefitted from poaching well trained healthcare personnel from low- and middle-income countries, including physicians from Ethiopia. The dire effects of vaccine nationalism on LICs have also been well documented.4

It is time to support and show solidarity with the dedicated healthcare professionals in Ethiopia who are working around the clock, with extremely limited resources, to provide healthcare to the population. What is missing is food, equipment, and medicine. World leaders and politicians must step up, and ensure that these resources reach health facilities like Ayder, so that the people of Tigray receive the care they need and deserve, and that their skilled workforce is able to provide, despite their own hunger.