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.ReliefWeb - Ethiopia - Tigray Region Humanitarian Update Situation Report, 6 January 2021. 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.
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.
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.