Ethiopia’s Tigray dialysis service cut due to dwindling supplies amid war

Lived experience of healthcare providers amidst war and siege: a phenomenological study of Ayder Comprehensive Specialized Hospital of Tigray, Northern Ethiopia

BACKGROUND

Most wars are fought in poor countries and result in significant proportions of disabilities and mortalities. The consequences of wars and political instability on health workers and access to healthcare remain under-studied. This study aimed to explore the lived experience of healthcare providers amidst war and siege, in a teaching hospital in northern Ethiopia.

METHODS

The study was conducted between February 2022 to March 2022. A qualitative phenomenological study was conducted between February to March 2022 with 20 healthcare providers working in Ayder Comprehensive and Specialized Hospital (ACSH), Tigray, Ethiopia, during the Tigray War. The study employed in-depth interviews.

RESULTS

The main themes identified included the consequences of the siege on health service delivery at ACSH, personal survival threats posed by the siege, immediate health consequences of the siege among care providers, and consequences of the siege on the motivation and energy of health professionals.

CONCLUSIONS

Health workers are exposed to a range of direct and indirect impacts of war, emphasizing the need to amend the conditions in which they live and work.

Providing Hemodialysis in Unstable Areas: An Assessment and Framework for Effective Care

Introduction

Providing hemodialysis to patients with kidney failure (KF) in conflict-affected areas poses a significant challenge. Achieving and sustaining reasonable quality hemodialysis operations in such regions necessitates a comprehensive approach.

Methods

In the conflict area of Northwest (NW) Syria, a 3-phase project was initiated to address the quality of hemodialysis operations. The assessment phase involved the examination of infection prevention and control (IPC) protocols, staff training, medical protocols, individualized hemodialysis prescriptions, and laboratory testing capabilities. The second phase involved activities toward capacity building and implementing an action plan based on feasibility and sustainability.

Results

The assessment phase revealed that only 7 of 14 centers had IPC protocols, and 8 centers provided IPC training for their staff. Furthermore, only 7 centers had medical protocols, and 5 used individualized hemodialysis prescriptions. Difficulties in testing for potassium was reported in 7 centers and the inability to perform hepatitis B and C serologies was reported in 3 centers. Only 2 centers adhered to machine and water treatment system maintenance guidelines, and 4 conducted daily water quality checks. Recommendations were formulated, and an action plan was developed for implementation in the second phase. The plan encompassed enhancements in IPC practices, medical protocols, record-keeping, laboratory testing, and equipment maintenance.

Conclusion

This project underscores that hemodialysis services in conflict-affected areas do not meet the standards for quality care. It emphasizes the necessity of implementing a comprehensive framework that engages relevant stakeholders in defining and upholding quality care, a model that should be extended to other protracted conflict-affected regions.

Impact of a double catastrophe, war and COVID-19, on health service utilization of a tertiary care hospital in Tigray: an interrupted time-series study

BACKGROUND

In developing nations with fragile healthcare systems, the effect of war is likely to be much worse than it would be in more developed countries. The presence of COVID-19 will also likely exacerbate the war's impact. This study set out to determine the effect of armed conflict and the COVID-19 pandemic on health service utilization at Ayder Comprehensive Specialized Hospital, in the Tigray region of Ethiopia.

METHODS

An interrupted time-series study design was used to analyze patient visits over forty-eight consecutive months (from July 2017 to June 2021) at inpatient, outpatient, and emergency departments. Data were analyzed using segmented regression analysis with a defined outcome of level and trend changes in the number of patient visits. In addition, negative binomial regression analysis was also used to estimate the impact of both COVID-19 and the war on patient flow.

RESULTS

There were 59,935 admissions, 876,533 outpatient visits, and 127,872 emergency room visits. The effect of COVID-19 was seen as soon as the Tigray regional government imposed comprehensive restrictions. Immediately after COVID-19 appeared, all the service areas exhibited a significant monthly drop in visits; [-35.6% (95% CI: -48.2%, -23.1%)] for inpatient, [-60.6% (95% CI: -71.6%, -49.5%)] for outpatient, and [-44.1% (95% CI: -59.5%, -28.7%)] for emergency department visits. The impact of the war became apparent after a lag time of one month. Controlling the effects of time and COVID-19, the war led to a significant fall in inpatient visits [-44.3% (95% CI: -67.2%, -21.5%)], outpatients [-52.1% (95% CI: -82.7%, -21.5%)], and emergency-room attendances [-45.0% (95% CI: -74.8%, -15.2%)]. An upward trend in outpatient flow was observed after the war [1,219.4 (95% CI: 326.1, 2,112.8)].

CONCLUSIONS

The present study has clearly indicated that the war and COVID-19 have led to a large reduction in admissions, outpatient attendance, and emergency department visits. The evidence from this study suggests that due to this double catastrophe, thousands of patients could not gain access to healthcare, with probable negative consequences. Governments and organizations should implement measures to buttress the healthcare system to maintain pre-war status of service.

Perilous medicine in Tigray: a systematic review

BACKGROUND

The war in Tigray, North Ethiopia which started in November 2020, has destroyed decades of the region's healthcare success. There is some emerging published evidence on attacks on health care in the region, and we synthesized the available evidence on 'perilous medicine' in Tigray to understand the data source, subjects and content covered, and what gaps exist.

METHODS

We employed a systematic review and performed a systematic search of MEDLINE, PubMed, CINHAL, Web of Science and Scopus. We included English written documents published from 4 November 2020 to 18-19 October 2022 and updated the search on 23 January 2023. HG and NF independently performed title, abstract and full-text screening. We used Joanna Briggs Institute (JBI) tools to appraise and extract data, and applied content synthesis to analyze. The PROSPERO registration number is CRD42022364964.

RESULTS

Our systematic review search yielded 8,039 documents, and we finally found 41 documents on conflict and health in Tigray. The areas were: (1) attacks on infrastructure, health or aid workers, patients, ambulances or aid trucks identified in 29 documents-the documents reported targeted attacks on health infrastructure and personnel; (2) interruption of health or social services in 31 documents-the documents reported medical and humanitarian siege; (3) outcomes and direct or indirect impacts in 33 documents-the documents reported increased magnitude of illnesses, and catastrophic humanitarian crises including the use of food, medicine and rape as tools of war; and (4) responses, rebuilding strategies, and recommendations in 21 documents-the documents reported improvisation of services, and calling to seize fire, accountability and allow humanitarian.

CONCLUSIONS

Despite promising studies on conflict and health in Tigray, the documents lack quality of designs and data sources, and depth and diversity of subjects and contents covered; calling further primary studies on a prioritized future research agenda.

War and Siege Halt Gynecologic Oncology Services for Women in the Tigray Region of Ethiopia: A Call to Action

This essay urges action in the aftermath of a war that destroyed the health care system, specifically women cervical cancer screening and treatment, in Tigray.

Social, political and legal determinants of kidney health: Perspectives from lower- and middle-income countries with a focus on India

The social determinants of health (SDoH) are the non-medical factors that influence kidney health outcomes directly or indirectly in a substantial manner and include conditions in which people are born, grow, work, live, and age. Many such challenges in lower- and middle- income countries have an unfavourable impact on kidney health. These conditions potentially influence economic policies and systems, development agendas, social norms, social policies, and political systems. In addition, many political and legal factors also determine and modify the ultimate outcome in patients with kidney disease. Legal factors that ensure universal health care, promote gender and racial equality, prevent malpractices and regulate strict laws in the field of kidney transplantation are the paramount determinants for the provision of necessary kidney care. Converging lines of evidence have supported the impact of social variables such as socioeconomic resources, social inclusion, housing conditions, educational attainment, and financial status on kidney health, particularly affect vulnerable and disadvantaged groups and result in challenges in kidney care delivery. Furthermore, the climate is an important SDoH that plays a crucial role in the occurrence, prevalence, and progression of kidney diseases as highlighted by the presence of higher prevalence of chronic kidney disease in hot tropical countries. The rising incidence of water and vector-borne diseases causing acute kidney injury is another consequence of disruptive environmental and climate change which is detrimental to kidney health. Political risk factors such as conflict also have a devastating influence on kidney health. The relationship between SDoH and kidney health outcomes requires more clarity. Gaps in the current knowledge need to be identified to inform the development of appropriate interventions to address upstream socio-economic risk factors for kidney disease.

Ethiopia's Tigray War: the agony of survival in kidney transplant recipients

A war between the Ethiopian federal government and Tigray regional government broke out on November 4, 2020 and is still ongoing. Regardless of the cause of the war, the civilian populations, who have no agency in the fighting, have often been at the receiving end of atrocities. Eight months into the war, a siege was imposed in Tigray, barring the entry of all forms of humanitarian aid, including food and medicines. As a result, civilians who survived hostilities are dying from hunger and diseases due to the blockade which has been put in place. One particular group of patients whose survival is at stake encompasses those with end-stage kidney disease, including kidney transplant recipients. The leading challenges of providing care to this group of patients amidst war and blockade include a barely functioning dialysis service, due to dwindling supplies, lack of access to the country's kidney transplant center in Addis Ababa, and severe shortages of immunosuppressive medications. To put this into perspective, we report on a 45-year-old female recipient of a kidney transplant at St. Paul's Hospital in Addis Ababa who succumbed in the besieged Tigray region as a result of lack of access to her transplant medicines. We urgently call upon the international nephrology societies and kidney transplant associations to advocate access to immunosuppressive medications for kidney transplant recipients in Tigray, Northern Ethiopia, to avert additional catastrophic events like the reported one.