The conflict that started in Tigray, Ethiopia in 2020 continues to cause devastating harm to civilians and the health sector and has led to a large-scale humanitarian and human rights crisis that continues in Tigray and has spread to other regions of Ethiopia. PHR has worked with our medical, public health, and human rights partners in Ethiopia to document conflict-related sexual violence (CRSV) in Ethiopia. In the following Q&A, PHR’s Lindsey Green, MA, senior program officer, shared insights on CRSV in Ethiopia, the toll of the conflict on health care workers, and PHR’s partnerships with intrepid health care heroes throughout this struggle.
What is the current state of the conflict in Ethiopia right now?
Ethiopia continues to be in a deep state of crisis. Since November 2020 Ethiopia has faced escalating conflict, starting with the government of Ethiopia and its allied forces, including the government of Eritrea, against the Tigray People’s Liberation Front (TPLF) – a group located in the Tigray region of northern Ethiopia. The violence caused widespread human rights violations against civilians, including extremely high levels of conflict related sexual violence. The International Commission of Human Rights Experts on Ethiopia (ICHREE) in their September 2023 report estimated that there were at least 10,000 survivors of sexual violence. This number is staggering and likely an underestimate. In addition to this brutal violence there were significant communications, transportation and humanitarian aid blockade imposed as part of the conflict in Tigray. A cessation of hostilities agreement was signed between the government of Ethiopia and TPLF in Pretoria, South Africa in November 2022. At that point, the conflict was meant to stop. But as PHR’s research has shown, CRSV and other severe human rights violations continued.
Today, the situation in Tigray remains tenuous; the region faces famine, a lack of access to health care and humanitarian aid, and a near-collapse of the health system resulting from the conflict. Parts of Tigray are reportedly still occupied by Eritrea and other militia causing greater instability. Nearly 2 million Tigrayans are displaced internally and there have been reports of new displacements from Western Tigray, which is under the control of Amhara regional forces.
“The situation in Tigray remains tenuous; the region faces famine, a lack of access to health care and humanitarian aid, and a near-collapse of the health system resulting from the conflict.”
Governmental forces, ethnic militias, and insurgent factions have escalated conflict in other regions of Ethiopia as well, including recently reported mass killings in the Amhara region, and sexual violence in the Oromia region. Ongoing violence between federal forces and Fano militias, an increased risk of civil conflict, and now an extreme hunger crisis, has prompted the government to extend a state of emergency in the Amhara region. The UN Special Adviser on the Prevention of Genocide has continually raised concerns about increasing risk for genocide and related atrocities in the country.
International support for resolution of the conflict remains limited, with minimal engagement from the U.S. Embassy and the African Union. There is a pervasive silence and inattention to the crisis in Ethiopia at the international level, with much more attention turning to crises elsewhere. This serves to offer implicit support for the government and complicates efforts to resolve the crisis and prioritize the needs for justice for survivors.
How has the medical community been impacted by the conflict? What is it like for health workers right now in Ethiopia?
The conflict has completely changed the health care landscape in ways that are detrimental for patients and health care workers alike. Ethiopia was once championed as a robust system of community health, a leader among countries in sub-Saharan Africa. The conflict, especially in Tigray, has caused stark changes in health care on every level.
Buildings were damaged and destroyed during the conflict, severely limiting access to care. An evaluation of 106 health facilities in 2021 revealed that only 13 percent were functioning normally; updates from 2023 indicate few changes have been made. Medical supplies and access to services became sparse during the height of the conflict and remain so. One health care worker told me that their fridge at home was filled with chemotherapy drugs for a child with cancer, but the drugs could not be delivered to Tigray because of the blockade. Workers were not getting paid for months at the height of the conflict in 2021 and 2022 and could not access their bank accounts. Overall, health workers have had to navigate enormous hurdles to provide care in the midst of this conflict.
How did PHR come to work on Ethiopia?
PHR’s response to the crisis started in response to widespread conflict-related sexual violence being reported in Tigray. At the time, providers in the region were seeing a massive influx of patients who were survivors of CRSV and showed brutal and complex injuries from those violations. Clinicians were asking for expertise and support to care for patients – women, men, as well as children – who had survived such brutal attacks. They also wanted to know how to document what they were seeing to show the world what was happening in Tigray. Our partnership with the Organization for Justice and Accountability in the Horn of Africa (OJAH) allowed us to work closely with health care professionals in the area to address the documentation needs they had identified.
“Ethiopia was once championed as a robust system of community health, a leader among countries in sub-Saharan Africa. The conflict, especially in Tigray, has caused stark changes in health care on every level.”
Training sessions, which we conducted virtually, occurred during the height of the conflict, often despite incredibly dangerous situations for clinicians on the ground. A drone strike on the hospital would interrupt or delay our sessions. Despite these challenges, our team trained health care professionals to document what they were seeing in the conflict and provide necessary care to survivors of CRSV. We focused on building skills in forensic documentation of sexual violence, survivor-centered care, trauma-informed interviewing, and informed consent. We also introduced a forensic medical certificate to use in documentation which PHR has piloted other contexts as a best practice for forensic documentation.
PHR’s engagement in Ethiopia illustrates our theory of change in action: providing evidence-based tools, resources, and capacity development sessions for health workers; fostering strong networks and partnerships; mobilizing these networks to conduct participatory research; and using documentation to speak out against atrocities and advocate for justice. Together with health care workers, we developed important research questions that we are continuing to investigate.
Our partners in Ethiopia are heroic. They maintained care and services during continued siege through immense stressors and with very little support. They improvised with what resources they had. They faced hunger, food shortages, and economic insecurity. They experienced increased workloads from both high turnover as colleagues were forced to flee and the many patients seeking care because of the conflict. They worried about the survival of family, friends, and community members.
Today, the situation has improved slightly, particularly at the hospitals and with the health care centers as things have opened up and aid has moved more freely. But the long-lasting impact on the health system and health outcomes for people in Tigray cannot be overstated.
What are the outcomes that PHR is hoping for?
We want to make sure people don’t forget the ongoing human rights violations in Ethiopia, and we are part of a global coalition that wants to ensure justice and accountability someday can take place.
There is a transitional justice process that was introduced as part of the cessation of hostilities agreement, but it has not been implemented in a way that is responsive to survivors’ needs. The transitional justice process needs to be responsive to the voice of survivors and have tangible and credible benchmarks, including those related to accountability. And if it’s not, it’s the obligation of the international community to pursue justice and accountability through other avenues and to be supportive of the impartial documentation that this requires.
“Our biggest hope is that survivors of conflict-related sexual violence, their families and communities who have been affected by this conflict will have access to comprehensive trauma-informed health care and services.”
We also want to have irrefutable evidence that can be documented for future accountability, should those avenues become available. We intend to build from PHR’s published research and continue calling for ongoing methodologically rigorous documentation to better understand the scope of what is occurring in Ethiopia. And we are advocating for optimal trauma-informed care for survivors of sexual violence. Our biggest hope is that survivors of conflict-related sexual violence, their families and communities who have been affected by this conflict will have access to comprehensive trauma-informed health care and services.
This work is incredibly difficult. What inspires you to come back to it?
Our partners are working in extraordinarily difficult circumstances every day yet they are still dedicated to providing care to their patients and excited to learn about new approaches to improve their work and draw attention to these issues. Even as we are working together across a great distance, I feel a kinship with our partners because they are so dedicated to their work despite the great personal and professional risks. Their commitment is so inspiring.
We have such a unique opportunity at PHR to work with partners who are so dedicated and working in situations that are so challenging. We are collaborating with them to identify new questions and what clinicians want people to know about their experiences and communities as the conflict continues. We work with them to build skills that will help their work and help their patients have access to the care they deserve.
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Lindsey Green, MA is a Senior Program Officer at Physicians for Human Rights. She conducts research on sexual violence and human rights violations; cultivates relationships with health, legal, and law enforcement personnel; and fosters growth through training and capacity development efforts that support prosecutions and accountability.