Narrative Descriptive Reports on Public Health Impact of Conflict among War-Affected Zones at Amhara Region, 2022

Introduction

Conflict is actual or perceived need value belief and interest between two or more states. And in political science conflict mean war or revolution which may use force which is called armed conflict. Armed conflicts within States are political conflicts involving citizens fighting for internal change. Most armed conflicts are fought not only by regular armies but also by militias and armed civilians with a little discipline and ill-defined chains of command [1]. Armed conflicts present a multitude of risk factors that enhance disease emergence and transmission, especially in poor countries Conflicts and wars, a commonplace in today’s world have left populations in dire poverty, displaced people from their homes, and deprived them of having access to essential services and made people vulnerable to various diseases. Detection and control of diseases in conflict- affected regions is an arduous task because of multiple risk factors that promote disease transmission and hinder control in many poor-resource settings [1, 2]. Detection and control of diseases in conflict-affected regions is an arduous task because of multiple risk factors that promote disease transmission and hinder control in many poor-resource settings. Conflict is the ultimate social determinant of health, and conflict-affected countries are lagging. More and more people are being forcibly displaced inside their own countries, while still others attempt to cross into neighboring countries and beyond [1, 3].

The public health impact of a crisis ranges from both direct (injury or death from the crisis itself) to indirect (changes in living conditions, forced displacement, lack of legal protection or decreased access to health care). Based on the situation reports from the health sector, these humanitarian crises resulted in a significant impact on the health and well-being of affected populations. The social support and interactions have also been interpreted in these areas which can create panic and anxiety in the affected community [4]. Conflicts arising due to violent differences between two opposing groups or individuals present a multitude of risk factors that enhance disease emergence and transmission, especially in poor countries. Conflicts and wars are commonplace in today’s world have left populations in direct poverty, displaced people from their homes and deprived them of having access to essential services, and made people vulnerable to various diseases. It is one of the most common disasters and a global health issue. Long-lasting and protracted conflicts in particular have consequences not only for the war-wounded but also for the health of entire communities [1, 5]. In recent years Ethiopia has also one of the victims of conflict with TPLF and other armed forces. So, conflict is one of the most common disasters in Ethiopia including in the Amhara region and its respective zones. Even if the government of Ethiopia has taken different interventions the disaster of conflict is now away from a serious problem in the Amhara region from different directions. And it results in acritical public health impacts. Despite this, the regional disaster risk management early warning and preparedness and mitigation intervention are very weak and too limited Notification and supporting letters were written to the department of Amhara public health institute. Give clear information about the participants. Participants have the right to give their opinion, the right to withdraw, and refuse the interview at any time. In addition, written informed consent was also requested for their readiness to participate during the data collection period.

Result

The TPLF invasion of the Amhara region starts on July 10/2013 and scaleup up to many zones and districts of the Amhara region within a short period Following this conflict different public health emergency responses at different times at different phases have been cascaded. Regional disaster risk management situation: there is a leading sector of disaster risk management at the regional level in the form of a disaster risk management office. with a role in disaster prediction, data analysis, interpretation, and result dissemination, in addition, to organizing the responsible stakeholders before and after the occurrence of an emergency and emergency preparedness and readiness plan within the participation of members of the leading sectors such as health, agriculture, water and security. Early warning and preparedness: Though there were some clues about the Tigray invasion since October 24/ 2013 EFY; there is no documented and organized risk prediction, analysis, evidenced preparedness plan, or emergency preparedness plan concerning conflict and other disasters except drought and flood. Even if no risk mapping and prediction when the conflict starts; some evacuation, readiness to relief response, and collective site selection had been done some weeks before the risked area was invaded. In addition to human evacuation, there were some medical supplies, medical equipment, and other materials have been evacuated. The Ethiopian pharmaceutical supply agency (EPSA) evacuated a supply and medical equipment which cost 227million birr from eastern Amhara EPSA, and the Regional health bureau has been evacuated ambulances which cost 3 billion ETB. As evidenced by the regional health bureau report, especially from the north wall, south wollo, and North Shewa.

Emergency public health response: Even if it was weak and non-resilient there have been established technical working groups (TWG), Taskforce, and rapid response teams (RRT) as a region that can provide different relief tasks during an emergency of conflict. As a result, 37 collective sites were selected and responsible TWG and task force were assigned at all levels for providing different services such as food distribution (984,000ton) shelter establishment (234,0000), finical empowerment (168,234,345ETB), and sanitary equipment such as soap, detergent, blench (2,134.654psc), modes (454,000pcks), different cooking materials which cost (1256712ETB), lancets (689,000), and maters and (534238 pcs) have been distributed. As a region, a total of 132,865,123(ETB) have been allocated for purchasing drugs, medical equipment, and other supplies. About 452 additional health professionals have been employed for the mobile clinic to do different tasks such as nutritional screening, vaccination, health education, gender-based violence (GBV) screening and linking to treatment, and follow-up for chronic follow-up (Table 1).

Discussion

This study was conducted to describe the public health impact of the TPLF war in the Amhara region. And the study included all affected zones of the region. Because the war in the Amhara region of Ethiopia by Tigrayan has started on Oct. 2021. It has brought enormous damage to the health system. And this assessment aimed to describe the occurrence of public health impact following the Tigray people liberation front (TPLF) conflict in the Amhara region of the nine affected zones. Due to this conflict within a short period; 45% of hospitals among hospitals in the region and 51.7% of health centers among total health centers of the region were damaged. Overall, 51% of government health facilities were damaged and looted. This resulted from morethan16 million people suffering due to a lack of any type of health services for more than three months and this has resulted in the occurrence of too many communicable and non- communicable diseases incidence. In general, the war altered both rates of change and absolute health outcomes for the worse which is supported in the study conducted in Sri Lanka [3]. If there were strong early warnings and alerts by the regional DRM and national DRM there was a probability of reducing the damage to the health system [1]. However, the limited capacity of the DRM created an opportunity for the TPLF to deliberate destruction, vandalization, and looting of the entire health system in the affected zones of the region. This is in line with a study conducted in sub-Saharan Africa [6].

This war had great public health and economic loss. In the affected health facilities, different types of medical equipment were destroyed, looted, and stolen.it results from a loss of medical equipment which has an estimated cost of

1,512,872,814.97 ETB based on the previously purchased estimate. This results from a need for an estimated budget of 19,634,779,165 ETB to recover and rehabilitate. This economic cost lowers the region as well as the country’s GDP not only this it has substantial effects on both the revenue and expenditure sides of a country’s public finances. This is in line with other studies conducted in sub-Saharan Africa on the economic impact of conflict [7]. Following the conflict women and children who lived in affected zones have lost essential health services. Some of the essential health services included; home delivery (74980), women were lost post- natal care (74,981), women lacking family planning services (137698), women faced unsafe abortion (91), unwanted pregnancy (735), pregnant women were lack ANC1st follows up (96789), about 17,764 pregnant or lactating women have been screened for malnutrition and 3,966 (22.3, gender-based violence (234), severe acute malnourished under five years children 27.7% (13,479) and moderate acute malnutrition 59.4% (16,963). This will result from an intergenerational effect on physiological growth and development; especially in children with malnutrition conditions throughout their lifetime. because household food insecurity is an important factor contributing to poor nutritional status among children during conflict and is associated with the risk of stunting and underweight in children and this has direct negative consequences in terms of disease and disability, brain development, educational attainment and income potential for individuals and communities [8, 9]. Antenatal care for pregnant women is the most valuable maternal health service which helps to reduce maternal mortality by 42% [3]. In general neglecting essential maternal health services during the optimal period will increase the maternal mortality and morbidity alarmingly which is in line with a study conducted at Sub-Saharan Africa [6].

Concerning chronic infectious disease treatment and follow-up; in the war-affected zones of the region, a total of TB (1840), MDR TB (91), leprosy (409), and HIV/AIDS (6698) cases have had treatment and monthly follow up interruption respectively. The treatment and follow-up interruption of infectious diseases especially HIV/AIDS implies an increased risk of death, opportunistic infections, virologic failure, resistance development, and poor immunological recovery among patients those who started and interrupted the follow- up and treatment supported by the study conducted [10, 11]. Based on the major NCD of diabetes mellitus hypertension and mental health problem more than 5041, 5292 and 659 cases were interrupted their follow-up and treatment for three to six months respectively. Discontinue the use of anti- hypertensive have three times higher risk of cardiovascular mortality. In addition to this worsening of the current disease condition; increased uncontrolled hypertension, increases morbidity and mortality secondary to NCD in conflict-affected areas. This implication was supported by other studies conducted in Brazil and Ethiopia [12].

Limitations of this Study

This study design uses secondary data so it has its own limitation of completeness and personal bias.

Conclusion

The displacement of healthcare manpower and damaged infrastructure will have a long-lasting consequence in rehabilitating the healthcare system of the region once. More than 50% of the region’s health facilities were damaged and looted. And it needs more than 9 billion of the estimated cost to do recovering the basic health services on behalf of reconstructing and maintaining the demolished health facilities. Furthermore, the widespread use of rape and sexual harassment as a systemic weapon of the war. And too many chronic infectious disease patients interrupted their treatment and follow-up for more than six months. Therefore, it needs reestablishment of building and furnishing of all types of damaged health facilities. And designing comprehensive chronic follow-up patient tracing and relinking mechanisms and especially providing ongoing clinical evaluation. in addition to this providing comprehensive capacity building for the regional disaster risk management in case of risk assessment and early warning which is supported by advanced technology.