Feature

Fighting for health

Tigray, the northernmost province of Ethiopia, is ravaged by famine and war. Caroline Sargent reports on the task facing health workers

Tigray has been afflicted by repeated cycles of drought throughout its history. The year 1980 saw the onset of severe drought which lasted through the 1984-85 Ethiopian famine. This situation has been worsened by the continuation of the Ethiopian government’s military campaigns in Tigray which have for 14 years been mounted against the Tigrayan People’s Liberation Front (TPLF). In recent years these military campaigns have increased and have centred on attacks on the civilian population. Aerial bombardments and ‘scorched earth’ tactics by ground troops now appear to be the norm.

Reports from the Relief Society of Tigray (REST) UK and a recently returned British medical team say that action against civilians by the Ethiopian government has included looting and burning of homes, torture and summary executions. This has been coupled with bombing of towns and villages, particularly on market days which has a devastating effect on the rural economy.

Members of the UK medical team have been involved in the care and treatment of patients suffering from Napalm burns. The war has badly affected the health of local people and the provision of healthcare. Civilian injuries have, of course, increased the problems — but the war’s major effects are more subtle, in particular the damaging impact on the local economy and the displacement of whole communities through fear and destruction.

Healthcare services have been seriously limited. According to the UK team, ‘hospitals and clinics, both medical and surgical, have had to be relocated and cannot be operational during daylight hours. All towns and villages have to be evacuated during the day and people are frightened to enter the towns so that clinic attendances have dropped radically.’

Many of the clinics have been destroyed or abandoned. Preventive services such as malaria control have also been suspended. Not only does the war decrease the services but it also prevents their expansion by diverting resources to rebuilding damaged facilities or to the war effort.

Nevertheless the TPLF is trying to tackle these problems head-on. The UK team described the commitment and dedication of the Tigrayan health workers and praised their skill and knowledge.

The major causes of ill health in the region are the diseases that flourish in condition of poverty, poor hygiene and nutrition, inadequate water supplies and overcrowding — conditions made worse by years of war and famine. At present the Tigrayan health department is dealing with a huge malaria epidemic in the west of the province. Although constrained by lack of resources, particularly drugs, the health workers’ expertise has meant few fatalities in the area they cover.

The health services are administered by the department of health of the TPLF. Initially, health cover for the population was limited, particularly in rural areas, but over the last 14 years a system has gradually evolved to cover the whole of the province. To date the Relief Society of Tigray and the TPLF have supported the building of 65 public clinics, each serving a population size ranging from 35,000-50,000. Four regional hospitals have also been established.

The promotion of health and a healthier society in Tigray is linked with developing the initiative and innovation of the people. Dr Barnabus, head of the health department, told a member of the UK team that ‘... healthcare should not be paternalistic but developed by the people for themselves. Effectively Tigray never had a health service before the onset of the struggle; now we have the opportunity to develop one which will meet the needs of our people and prevent the diseases so common in our society.’

The people are ultimately responsible for their own health services, which are available to all. The community maintains control over these services through local health committees.

Prior to 1985 the health system was geared towards curative care, which was reflected in the training syllabus of health workers. Since then there has been a recognition of the need to combine prevention with cure, resulting in a reorientation of the health department to a comprehensive primary healthcare programme.

There is also a strong recognition among all groups that people’s health is dependent on much more than health services. Political rights, particularly for women, agricultural development as well as educational services are all seen to play an important role. There is a health education component in the school and literacy curricula and it is hoped that health education radio programmes will be developed when facilities have been expanded.

Health workers in Tigray have a hard task ahead of them, but there is a strong commitment to improving health despite the severe obstacles in their path.