Mekelle፡Telaviv, Nairobi, Pretoria, London,March 16፡2025 (Tigray Herald)
Civilian death and injury from airstrikes:
evidence from the war in Tigray, Ethiopiopia
Introduction
Civilians bear a significant toll of conflict-related morbidity and mortality in modern warfare, particularly in conflicts characterized by the use of explosive weapons in densely populated areas [1] where civilians constitute up to 90% of war-related casualties [2]. In 2022, the war in Ethiopia’s Tigray region accounted more deaths than the war in Ukraine [3] with approximately 600,000 deaths [4].
The Tigray war erupted in November 2020 [5], where the Ethiopian National Defence Force (ENDF), the Amhara Special Forces (ASF), and the Eritrean Defence Forces
(EDF) altogether have committed a genocide [6] captured many part of Tigray including its capital city of Mekelle until June 2021.
The Ethiopian government began to use
airstrikes as an offensive tactic which continued until the cessation of hostilities was signed in November 2022
[7]. Profound secondary effects have been documented on maternal and child health as well as sequelae such as infectious disease [8, 9]. However, limited published data
exists on the consequences of conflict-related injury in Tigray.
Parties to the conflict have used explosive weapons and air-delivered munitions including drone strikes in areas
densely inhabited by civilians during the war in Tigray [10]. Civilian spaces including children’s playgrounds, internally displaced people (IDP) camps, and marketplaces have been targets of indiscriminate bombing
[11, 12]. The civilian casualties of these bombings have included women and children [13–17]. These airstrikes, in addition to continuous artillery shelling, have caused
significant physical trauma to the population [18].
The use of bombing with military unmanned aerial vehicles (UAV) in contemporary wars or armed conflicts has been an issue of significant controversy [19]. The moral facets of the use of armed drones in recent armed conflicts such as Palestine, Syria, Somalia, and Yemen have been highlighted due to the severe consequences on civilians
[20–22].
The first use of drones in the war in Tigray was reported in November 2021 after China, Iran and Turkey reportedly supplied Ethiopia with this technology [23, 24]. The
use of airstrikes in the war in Tigray has since resulted in hundreds of civilian causalities documented by the United Nations High Commissioner for Human Rights
[16]. A community-based assessment conducted during the first eight months of the war from November 2020 to
June 2021 found a 6.9% rate of war-related injury among civilians in the sampled region of Tigray [18]. However, despite numerous media and human rights observator reports [16], there is a lack of published evidence and health facility data on the impact of airstrike on civilian populations after Tigray forces overtook the capital city of Mekelle in June 2021.
In November 2022, the Political Declaration on Strengthening the Protection of Civilians from the Humanitarian Consequences Arising from the Use of Explosive Weapons in Populated Areas (EWIPA) was
signed by over 80 member states in Dublin [25] Ethiopia is not a signatory. The impact of EWIPA has received significant attention in conflicts such as Syria and Ukraine
but has been less-studied in Sub-Saharan Africa [26–29]. Despite the lack of published evidence in the literature, EWIPA inflicts a severe toll on civilianpopulations in
conflicts in Africa such as Sudan and Tigray [30]. In addition to the direct impact on civilian death and injury, the reverberating effects of EWIPA on civilian infrastructure
in settings where access to essential services is already highly constrained is a key driver of displacement and barrier to humanitarian access in such settings [31].
This study aimed to assess the prevalence of airstrike injury and outcomes among civilian casualties from June 2021 to October 2022, before the signing of the African
Union-mediated Pretoria agreement or “Agreement for Lasting Peace through a Permanent Cessation of Hostilities” between the Government of the Federal Democratic
Republic of Ethiopia and the Tigray People’s Liberation Front [7]. The findings of this study may provide increased understanding of the impact of explosive violence on civilian populations in Sub-Saharan Africa and
inform targeted interventions to improve trauma and blast injury-focused care as well as human rights protections in the future.
Methods Study setting The study was conducted in the Tigray region of Ethiopia. The population of Tigray is approximately six million based on projections for the 2016 Ethiopian fiscal year [32], close to 80% of which reside in rural areas. Of
the seven zones in Tigray region, six of them were accessible and included in this study. However, data from the seventh zone i.e. Western Tigray was not included in the
study as it has been occupied by non-Tigray forces and is inaccessible. This area was occupied by Ethiopian, Eritrean, and Amhara regional forces. The types of health
facilities encompassed in data analysis ranged from health posts to tertiary hospitals providing preventive,
curative, and rehabilitative services Study design A retrospective review of all injury data reported from
June 2021 to October 2022 from each health facility of the six accessible zones to the Tigray Regional Health
Bureau (TRHB) was conducted.
Data collection Data were collected by TRHB from June 2021 to October
2022. The beginning of the study time point coincided with the time at which Tigray forces overtook the capital
city of Mekelle in June 2021. In response, the Ethiopian government began to use airstrikes as an offensive tactic
which continued until the cessation of hostilities signed in November 2022 [7]. At the beginning of the war, it
was determined that the existing routine emergency outpatient department registration form was not detailed
enough to capture relevant injury characteristics related to the attacks in general. Therefore, during the first eight
months of the conflict, a reporting form for airstrike and other conflict-related injuries was prepared and distributed to all hospitals by the emergency medical services
of TRHB. This new form included variables such as place, outcome (e.g., injured, dead), and was distributed to facilities in-person by couriers due to the communications
blackout (Supplementary Table 1).
