In the fall of 2021, one year into the genocidal war in Tigray, I received a voice message from my nephew via a stranger’s number on WhatsApp. This marked the first time I had heard from my family since the start of the telecommunications blackout in the region, imposed by the Ethiopian federal government. The message began with simple greetings and reassurances that my family in Tigray was still alive. My nephew then informed me that my older brother, his father, was seriously ill and needed medical treatment. The urgent care he needed included having one of his legs amputated due to an infection caused by undiagnosed diabetes. He asked if I could do two things: send money to help pay for medical expenses, and smuggle medicine that his father desperately needed into Tigray.
By this time, a relentless campaign of decimating infrastructure and preventing access to medicine had culminated in the total collapse of the healthcare system in Tigray. Access to the most basic medical supplies was severely restricted or nonexistent. For tens of thousands of people with immediate healthcare needs, like my brother, the possibility of death was imminent. In this death-dealing context, people were forced to find other means of acquiring life-saving medicine. As I scrambled for a solution, I realized that there was not a single person outside the region that I knew who could help as almost every friend and relative was either detained or in hiding to escape the ongoing mass roundups and arrests of ethnic Tigrayans across the country.
This crisis illuminates how access to medicine and healthcare was weaponized in the genocide of Tigrayans, one of the deadliest wars of the twenty-first century. It is estimated that 800,000 to 1 million people were killed—up to 14 percent of the region’s total population of 7 million—and over 2.2 million have been displaced. While the various forms of violence—massacres, door-to-door executions, enforced disappearances, mass displacements, and indiscriminate bombings—waged against the Tigrayan population during war have been recognized, to an extent, as constituting the crime of genocide, an often-overlooked feature of the overall genocidal campaign is the weaponization of medicine and healthcare systems. The deprivation of medicine became a technology of genocide, actualizing more death and ensuring the future death of a people deemed undesirable.
Medicine as a Genocidal Technology
Historically, medicine has played a controversial role in the context of genocides. During the nineteenth and twentieth centuries, entire Indigenous populations were subjected to medical experiments to support pseudoscientific claims about racial hierarchies. This includes atrocities committed by Germany during their colonial occupation of Namibia (1884–1915). During their regime, one invested in and inspired by American eugenics, German officials led a genocidal campaign to crush Indigenous resistance against their occupation. They massacred Nama and Herero people, established concentration camps, and conducted medical experiments. These violent experiments contributed to Germany’s eugenicist theories of race and racial superiority, which laid the groundwork for Nazism and its future terrors.
In addition to medical experimentation, medicine has also been associated with deliberate sterilization and population-control strategies targeting groups deemed undesirable. In apartheid-era South Africa, family planning initiatives were widely perceived to have arisen from concerns among white communities about the growth of the Black population. Similarly, Black and Indigenous populations conquered by the United States and other settler colonial countries have also been subjected to systematic sterilization campaigns.
Another way marginalized populations have been decimated is through the denial of access to medicine, which is often used as a strategy of war and genocide. Postcolonial theorist Achille Mbembe, in his work Necropolitics, argues that a feature of contemporary warfare is the deliberate destruction of everything that supports life. According to Mbembe, different forms of weapons are deployed in the interest of maximum destruction of persons and the creation of death-worlds, new and unique forms of social existence in which vast populations are subjugated to conditions of life conferring upon them the status of living-dead.
The aim of such warfare, he argues, is not just to assert power but to achieve the total “shutting down [of] the enemy’s life-support system,” particularly by inflicting harm to the civilian population.
In living with and interrogating genocidal violence, attention is often paid to immediate deaths resulting from direct attacks like organized massacres and indiscriminate bombings. However, equally significant, yet overlooked in the landscape of genocide, is genocide by attrition: the deliberate denial of human rights and essential services producing prolonged suffering and death during and after genocidal violence. These deaths occur gradually as the conditions to sustain life deteriorate—supporting the maximization of death even after active warfare has ended.
A Genealogy of the Genocide in Tigray
The underpinnings of the genocide in Tigray can be traced back to the formation of the country—or, rather, the forging of an empire. While Ethiopia’s imperial monarchy dates to the thirteenth century, Ethiopian state formation began in the nineteenth century, concurrent with European colonial expansion in East Africa. Following the example of European colonialists, Emperor Menelik II (an ethnic Amhara ruler) violently conquered several previously independent ethnic groups and much of the present-day territory south of Addis Ababa. In the north, Tigray was part of an old empire that maintained relative administrative autonomy, with few periods of disruptions, until 1889, when it came under the control of Menelik II. This history of imperialist consolidation and centralization of power foregrounds cycles of contestation by people forcibly absorbed and marginalized by the nation-state.
Ethnic groups opposing assimilation into a singular “Ethiopian identity” (dominated by Amhara and urban elites) faced extreme violence. The second half of the twentieth century was marked by numerous conflicts, political repression, and movements for liberation. This led to the founding of the Ethiopian People’s Revolutionary Democratic Front (EPRDF)—a coalition of ethnically based armed groups formed by the Tigray People’s Liberation Front (TPLF)—in 1988. Under the governance of the EPRDF, Ethiopia adopted a new constitution in 1995 that decentralized political power. This constitution transformed the country into a multinational federation which in theory recognized regional autonomy and governance. It framed Ethiopia as a pluralist country that was multiethnic, multilingual, and multicultural.
While the EPRDF professed a commitment to marginalized ethnic groups, its leadership became subsumed by Ethiopia’s deeply entrenched tendency toward serving the interest of the center, which included the Addis Ababa elite and the political leadership of the party. Internal and external dissent accumulated as the EPRDF suppressed any opposition for nearly three decades. Discontent reached a peak with popular protests initiated in 2014 by youth in Oromia—the largest region in Ethiopia. This resistance movement, ignited by injustices linked to land rights, expanded into a movement against the authoritarian rule of the EPRDF. As protests spread into urban areas and the Amhara region, ethnic strife intensified with targeted violence against Tigrayans, who were widely perceived as the power base of the ruling party. Tigrayans everywhere, particularly in the Amhara region, were subjected to ethnic-based attack and displacements. Following the outbreak of violent protests in Gondar in the summer of 2016, thousands of Tigrayans were forced to flee to Tigray, mainly via Sudan. As a result, when the Tigray war started in 2020, there were already 100,000 internally displaced people living across the region.
"What followed was an implementation of a range of strategies to eliminate Tigrayans, whose regional government was seen as an obstacle to Ethiopian unity and prosperity."
The aftermath of mass protests paved the way for the ascendency of Abiy Ahmed Ali, selected by the EPRDF as prime minister following the resignation of his predecessor, in turn fueling a resurgence of imperial language in political speeches, state-run and private media outlets, and among large portions of the public that denigrated ethnic and religious groups while venerating the country’s colonial history. Ali and his supporters blame Tigrayans and their political movement for Ethiopia’s waning from its glorious imperial past; simultaneously, Amhara supremacists and urban elites saw in Ali an Ethiopianism that could finally dismantle the federalist constitution, which they perceive as a “divisive” political order established by Tigrayans and their political leadership. They believe that Tigrayans are not only responsible for the federalist constitution that reified regional and ethnic autonomy but also for the invention of ethnicity itself, which they consider destabilizing to the national ethos of a singular Ethiopia.
In 2019, following Ali’s removal of TPLF officials from key positions, he dissolved the EPRDF and formed the Prosperity Party. Less than a year after becoming prime minister, Ali toppled regional governors and replaced them with people loyal to him, bypassing the regional councils’ mandates. In the lead-up to the war in November 2020, Tigray continued to resist this new political formation.
The genocide in Tigray is the culmination of multiple processes. For many Ethiopian nationalists, Tigray and its political leadership’s continuous opposition to the dismantlement of the federalist structure is the barrier to achieving their end goal: a unified Ethiopia. For Ali and his party, attacking Tigray was a way to consolidate power and secure the support of influential elites. From the outset, his government has been transparent regarding its anti-Tigrayan sentiment turned state policy. Ethiopian officials widely depicted Tigrayans as an anomaly that needed to be eradicated for the nation to reclaim a unified “Ethiopian identity.” Both prior to and during the war, terms like “tumors,” “curses,” and “cursed blood” were often used to describe Tigrayans. Leading up to the genocide, Ali described Tigrayans and their leaders as “cancers” and stated that the country must undergo a painful process to rid itself of them. In 2021, Daniel Kibret, the prime minister’s senior advisor, similarly suggested that the wombs of Tigrayan mothers were cursed and needed to be cleansed. In a televised speech to a cheering audience, Kibret stated:
From now on, we must ensure that people like them are not born under any conditions … There should be no land in this country that can sustain this kind of weed. People like them should not be born in this country ever again. They must be erased not just from institutional registers but also from peoples’ consciousness, from peoples’ hearts, from historical records, they must be erased.
Ethiopian officials, comfortable in their nationalist ethos, did not hesitate to express it to anyone who paid attention. When Finland’s minister for foreign affairs, Pekka Haavisto—the European Union’s envoy to Ethiopia at the time—visited Ethiopia in 2021, Ethiopian officials shared their ultimate objective to “wipe out the Tigrayans in 100 years.” Medicalized descriptions of Tigrayans and the desire to “deal with them” intensified following the start of the war and were echoed even among multilateral agencies and members of the international community. In a memo obtained by Foreign Policy, the United Nations Development Program sought to justify the war and referred to Tigrayans as the “cancer in Ethiopia’s body politic.”
What followed was an implementation of a range of strategies to eliminate Tigrayans, whose regional government was seen as an obstacle to Ethiopian unity and prosperity. On November 4, 2020, following a period of political tension between the Ethiopian federal government and Tigray’s regional government, the conflict escalated with Ali’s launch of a military offensive in Tigray, followed by a telecommunications blackout. For the next two years, the state, along with Eritrea’s national army and Fano paramilitary forces from the Amhara region, engaged in a scorched-earth policy to destroy everything in Tigray.
Collapsing Healthcare Infrastructure as Genocidal Strategy
The collapse of the healthcare system in Tigray is not incidental but, rather, a genocidal policy invested in the deliberate dismantlement of a life-sustaining sector. This becomes evident when we consider that the orchestrated decimation was coupled with a siege aimed at depriving the population of essential medical supplies and care. The deprivation of healthcare access is a weapon designed to maximize death and make certain prolonged suffering among the targeted population, constituting genocide by attrition. The intention is to kill as many people as possible and create long-lasting conditions that ensure future death of a population deemed undesirable. In Tigray, this strategy was implemented in a few critical ways: the systematic destruction of healthcare infrastructure, blockades of medical supplies, targeting of healthcare workers, and sexual violence.
In March 2021, just four months into the war, Médecins Sans Frontières (MSF) reported that 87 percent of the medical facilities their teams visited were either no longer functional or not fully functional. They observed destroyed equipment, discarded medicine, patient files scattered on floors, and broken windows and doors as well as medical facilities that were set on fire. MSF remarked that “while some looting may have been opportunistic, health facilities in most areas appear to have been deliberately vandalised to make them non-functional.”
In addition to looting and demolishing health facilities, armed soldiers also occupied them; according to MSF, this resulted in the takeover of one in five clinics and hospitals in the region. An AP journalist who visited Tigray in 2021 reported:
The Eritrean soldiers … have destroyed hospitals and sometimes set up camp in them. At the Hawzen Primary Hospital, walls were smeared with the blood of the chickens the Eritreans had slaughtered in the corridors. Soiled patient files were strewn on the ground, and the intensive care nursery for babies was trashed, with missing incubators and toppled little beds.
According to doctors in Tigray I spoke with, the first targets, regionwide, were the most critical components of hospitals and health facilities: operating rooms, medical equipment, and medicine. By the end of the war, only 1 percent of medical equipment across the region was found intact, while the few remaining hospitals were rendered nonoperational due to power shortages, as the region was disconnected from the national grid for much of the war and the siege prevented access to fuel for generators. This intentional disruption of the power supply, compounded by suspension of banking services, made it difficult to purchase scarce goods, including medicine, which were being sold at exorbitant prices. This forced depravation highlights as a deliberate tactic the destruction of healthcare infrastructure and support.
Not only were hospitals rendered nonfunctional, but transportation in the region also became inaccessible. Ambulances were seized by soldiers, rendered nonoperational for lack of fuel, and targeted by armed drones that attacked nearly everything that moved—factors that combined to make it nearly impossible for any remaining ambulances to reach the few operational hospitals.
In the rare scenario that provision of healthcare was possible, the regime’s soldiers refused access. Troops militarized routes leading to major cities and actively obstructed the passage of wounded civilians at checkpoints. For example, in June 2021 an Ethiopian Air Force plane bombed a market in the town of Togoga, killing sixty-four people and injuring over 180. First responders and medical staff from Ayder Hospital, the region’s largest and only functioning hospital at the time, hurried to the town to rescue survivors. A doctor who witnessed the aftermath recounted that during the evacuation of survivors, Ethiopian soldiers who were guarding the city’s gates prevented them from bringing the wounded into the hospital. According to the doctor, this forced them to return to the town, and at least one person died who might have survived, had they received medical assistance.
Another major component of healthcare infrastructure in the region that the federal government’s allied forces destroyed is the Addis Pharmaceutical Factory, one of the country’s largest producers of medicine before the war. Located in Adigrat, two hours north of the Tigrayan capital of Mekelle, the factory was one of the first targets for elimination: according to a United Nations report, the factory was looted and then set on fire by Eritrean and Ethiopian soldiers at the end of November 2020, less than one month into the war. The report also indicated that the soldiers killed sixteen civilians who attempted to stop them from destroying the factory. Its demolition effectively prevented the region from accessing medicine and essential medical supplies.
The scale of damage to Tigray’s healthcare system, and the death caused as a result, is the materialization of the Ethiopian officials stated war aim: systematic elimination of the region’s population. The decimation of the healthcare system was not merely a consequence of war but the deliberate strategy of a genocidal campaign. Rather than being a residual effect of genocide, it was part of the genocide itself.
The Blockade of Medicine
The dismantling of the region’s healthcare system unfolded alongside a complete blockade of medical supplies. While only very limited humanitarian assistance was allowed into the region during the two years of the war, medical supplies were particularly prohibited. Deliveries from the World Health Organization (WHO), including vaccines for COVID-19 and other infectious diseases, were suspended. Medicine and supplies needed to treat various conditions including HIV, diabetes, and tuberculosis were prevented from entering Tigray. With the knowledge that Tigrayans were being actively targeted for persecution, people with chronic illnesses and healthcare workers nevertheless engaged in protests in front of offices that housed international aid organizations and pleaded for help; however, their pleas were largely ignored.
"The dismantling of the region’s healthcare system unfolded alongside a complete blockade of medical supplies."
Underscoring the breadth of the ban on any medical support, the state even prevented humanitarian workers from entering the region with vital medicine for chronic illnesses, including for personal use. According to the International Commission of Human Rights Experts on Ethiopia’s 2023 report,
Humanitarian workers and diplomats … described harassment when traveling to Tigray, reportedly to ensure that they were not carrying unauthorized items. This included searching luggage for non-authorized cash and medication.
A humanitarian worker interviewed by the ICHREE team said: “Our diabetic staff could not travel there [to Tigray] because they could not take the insulin [with them].” The UN office in Ethiopia in its September 2021 report also confirmed that “Medicines … were removed [from UN humanitarian flights to Tigray] during government inspection in Addis Ababa.”
It is important to note that the war started during the height of the COVID-19 pandemic. In addition to the onslaught of violence and collapsing healthcare system, people were also denied access to vaccines and personal protective equipment. Federal government forces and their allies deliberately targeted and seized trucks transporting masks and vaccines. The forced displacement and encampment of millions of people throughout the war without protection, during a global pandemic, was another death-dealing strategy. Due to the incapacitation of the healthcare system, the actual toll of COVID-19-related deaths remains obscured. The genocide in Tigray displaced the pandemic as a primary cause of mortality, diverging from global trends.
According to WHO, during the peak of the genocide in 2022, only 3 percent of the region’s health facilities were operational. Children went without immunization vaccines, and mothers lacked access to maternal care services, causing a rise in maternal mortality from 180 per 100,000 lives before the war to 840. Additionally, infant mortality increased fourfold compared to prewar figures. The lack of access to medical supplies produced challenges treating individuals with chronic illnesses such as cancer, HIV/AIDS, and diabetes. Doctors were often left in despair as they watched chronically ill patients await preventable death.
Targeting Healthcare Workers
Throughout the war, Tigray’s healthcare workers experienced prolonged periods without pay or support. Forced to rely on their own resources, they struggled to care for the wounded, sick, and their own families. The genocide created impossible conditions of providing care with scarce supplies and under the duress of constant attack. Along with having limited equipment, space, and supplies, healthcare workers in particular were also targeted for killings and disappearances, underscoring clear intent to destabilize the healthcare sector. Following a June 2021 attack in which Ethiopian forces killed three MSF workers and set their vehicle ablaze, MSF suspended its operations in the region, entailing the departure of international healthcare staff and halting the work of 1,000 local staff. During a time of immense and urgent need, people requiring medical assistance were left without many prospects for receiving care.
The Womb as Target: Sexual Violence in Tigray
The genocide in Tigray involved the weaponized use of rape and sexual violence on an almost unimaginable scale. One of the commissioners of the ICHREE stated: “I have been to many conflicts, Rwanda and many others. This was as bad as it gets … it included cruelty of the worst kind.” Emphasizing the pervasiveness of sexual violence, US Agency for International Development administrator Samantha Power remarked:
The scale of those crimes, and the reports of the soldiers’ conduct and testimony, suggests that the Ethiopian military, together with their allies in the Eritrean military and forces from the Amhara region, have launched a campaign to shatter families and destroy the reproductive and mental health of their victims.
Over 43 percent of Tigrayan women and girls reported to have experienced rape and/or other forms of sexual violence during the war. There is documented evidence of the use of sterilization techniques like inserting hot metal rods and other foreign objects in the bodies of rape victims. These are tactics used to burn the uterus and permanently damage reproductive capacity. According to reporting by Al Jazeera, one woman who was raped by four men reported that after begging them to stop, they stated: “You did nothing bad to us … our problem is with your womb … a Tigrayan womb should never give birth.” This actualizes the state’s publicly disseminated ideology that “people like them should not be born in this country ever again.”
In addition to harming reproduction, sexual violence was used to intentionally spread infectious diseases such as HIV/AIDS. A recent report by Le Monde, citing aid agencies in Tigray, indicated a shocking figure: nearly 15 percent of women in the region contracted HIV during the period of the war. Not only was sexual violence rampant, but victims were also largely unable to access medical and mental care due to the obliterated health system: nearly 90 percent of rape survivors reported not receiving any medical or psychological support to cope with their trauma.
"The decimation of medicine and healthcare was a genocidal technology used to actualize as many deaths as possible—and one whose future deployment can by no means be ruled out."
The Aftermath of War
On November 2, 2022, a ceasefire agreement was signed, ending the war two years after it began. Though the siege has ended, the past two years have not seen significant improvement of daily conditions in Tigray. The region is now contending with the aftermath of war: devastated healthcare infrastructure, displacement, aid mismanagement, and now famine. Healthcare facilities remain largely in disarray, with little reconstruction or reequipping work undertaken to date. People who worked in the region’s healthcare sector have been leaving their positions in search of safety and better opportunities elsewhere in the country or abroad. Tigray’s medical professionals, who served their people throughout the war, are moving where they can find relief from the deprivation that rendered them unable to effectively care for their patients. This undermines the prospects for survivors to receive the care needed to address the many forms of trauma and health complications they have experienced. This ongoing deterioration of the healthcare system, even after the war, in turn serves the regime’s declared goal of wiping out the Tigrayans. The decimation of medicine and healthcare was a genocidal technology used to actualize as many deaths as possible—and one whose future deployment can by no means be ruled out.