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As the world’s attention and resources continue to focus on the war in Ukraine, other devastating conflicts persist in many countries with less public scrutiny and far fewer demands for accountability or justice for survivors.
Consider the conflict in Tigray, where the Ethiopian Government and the Tigray People’s Liberation Front (TPLF), alongside the Eritrean army and regional military groups, have engaged in intense fighting since 2020.
This has resulted in the killing of thousands of civilians, life altering injuries, and the collapse of the region’s healthcare system; Ethiopia’s war was described as the world’s “bloodiest conflict” in 2022.1,2
Reports of “widespread and egregious” incidents of conflict-related sexual violence (CRSV) in Tigray emerged from the UN and other human rights organisations, including rape, gang rape, sexual slavery, sexual mutilation, and torture.3,4
Hopes were raised for an end to this violence in November, 2022, with the signing of a cessation of hostilities agreement between the Ethiopian Government and the TPLF.5 Since then, the parties have been attempting to implement measures focused on peace and recovery.6
However, a recent investigation by Physicians for Human Rights (PHR), an international non-governmental organisation, along with Ethiopian partners, found CRSV continues in Tigray.
For this investigation PHR’s research team reviewed 304 medical records (from a total sample of 305 medical records) of CRSV from multiple health facilities in Tigray known to provide clinical services to survivors of sexual violence from visits that occurred between November, 2020 (at the start of the hostilities) through June, 2023.
The findings are reported in a new analysis by PHR, Broken Promises: Conflict-Related Sexual Violence Before and After the “Cessation of Hostilities Agreement” in Tigray, Ethiopia7 that was released on Aug 24, 2023, and to which we contributed. These medical records showed CRSV primarily against women and girls, with survivors aged from 8 years to 69 years.
The incidents recorded were brutal: 233 (76%) of the acts involved rapes by multiple perpetrators, often three or more.7 In 216 (66%) instances survivors of CRSV described perpetrators as speaking Tigrigna, a language of Eritrea and Tigray.
Corroborating this finding, in 143 instances of CRSV survivors said at least one perpetrator was from Eritrea. In almost all the medical records (294 [96%] incidents), survivors identified perpetrators as appearing to be members of a military group and not previously known to the survivors. The highest number of cases reviewed (88 [29%] incidents) were from the western Tigray zone.
The findings of this PHR investigation suggest that these acts were neither isolated nor random but a systematic use of rape as a strategy of war.7 These medical records reveal there were considerable delays in care-seeking; there was a median of 4 months (IQR 18) between when the incident was reported to have occurred and when the survivor presented at a health facility.
For survivors who accessed medical these PHR data show that CRSV had devastating impacts, including severe short-term and long-term physical and psychological consequences.
Additionally, the medical records show that CRSV may have resulted in unintended pregnancy (34 [27%] of 128 patients tested) or contraction of HIV (nine [11%] of 81 patients tested) for some survivors. The concerns highlighted in the PHR analysis provide only a small glimpse into the serious health effects of CRSV in Tigray, since not all individuals who experienced CRSV were able to access care.
Although 169 incidents of CRSV occurred before the signing of the 2022 cessation of hostilities agreement, in seven records the date of incident was not recorded and 128 incidents occurred after it was signed, suggesting ongoing serious violations of one of the key terms of this agreement.
These data point to three key conclusions
First, the scale, pattern, and geographical spread of cases of CRSV, as well as survivors’ description of the perpetrators, indicate widespread and systematic CRSV.7 What is documented in PHR’s analysis points to the use of sexual violence by the military as a tactic to terrorise civilian populations.3,4,7,8
Second, the findings in the PHR analysis suggest military forces, probably associated with the Ethiopian or Eritrean Governments, are likely to have committed severe human rights violations7 that could amount to war crimes and crimes against humanity under international law.9,10
Third, the findings of the PHR analysis show that CRSV continues in Tigray with no notable change in pattern, despite the cessation of hostilities agreement.7
The findings of the PHR analysis accord with other reports of CRSV in this region and underscore the urgent need for the international community to support an impartial independent mechanism to allow for sustained, credible documentation of human rights violations and preservation of evidence during this conflict, including CRSV.3,4,11 In September, 2023, the UN Human Rights Council is expected to receive a report from the International Commission of Human Rights Experts on Ethiopia (ICHREE), which it mandated to investigate human rights violations and atrocity crimes in Ethiopia since November, 2020.12
Despite research confirming violations continue, ICHREE’s report might mark the end of international impartial and independent documentation of the human rights situation in Ethiopia due to a campaign by the Ethiopian Government to shift monitoring to national authorities.13
Evidence of continued violations, including by the Ethiopian military, suggests that ending ICHREE’s mandate and relying on potentially biased national mechanisms is ill-conceived and premature.7,14,15 Numerous cases of CRSV have probably gone undocumented. Survivors of CRSV in Tigray are still coming forward to report past and current cases of sexual violence.7
The medical community has a crucial role in the documentation and preservation of evidence of human rights abuses through their use of standardised clinical tools to obtain valuable information for medico-legal processes and scientific research to expose types and patterns of violence.16
This documentation can present a safety risk for local clinicians and health facilities, who themselves are often the target of attacks during conflict.17 It is incumbent on the international health community to support justice and accountability. Together, we must call for state and regional actors—including those who have led bold calls for justice in Ukraine and elsewhere, such as the USA and the EU—to promote and support independent and impartial monitoring and documentation efforts.
Civilians must be protected and survivors able to access meaningful justice.18 With irrefutable data affirming the persistence of CRSV in Tigray, the international community has an ethical responsibility to prioritise accountability in Ethiopia.
We all contributed to the PHR analysis, Broken Promises,7 that is discussed in this Comment. The initial development of this research project was supported through an organisational grant to Physicians for Human Rights, the donor for this grant must remain unnamed at the time of publication. We declare no other competing interests.
*Ranit Mishori, Thomas McHale, Lindsey Green, Rose McKeon Olson, Payal K Shah, The Organization for Justice and Accountability in the Horn of Africa† rmishori@phr.org †The members of The Organization for Justice and Accountability in the Horn of Africa who are authors are unnamed due to ongoing security risks. Physicians for Human Rights, New York, NY 10018, USA (RM, TM, LG, RMO, PKS); The Organization for Justice and Accountability in the Horn of Africa, Washington, DC, USA 1 Knight B. Global conflicts: death toll at highest in 21st century. DW. June 28, 2023. https://www.dw.com/en/global-conflicts-death-toll-athighest-in-21st-century/a-66047287 (accessed Aug 7, 2023). 2 Gesesew H, Berhane K, Siraj ES, et al. The impact of war on the health system of the Tigray region in Ethiopia: an assessment. BMJ Glob Health 2021; 6: e007328. 3 OHCHR, International Commission of Human Rights Experts on Ethiopia. Report of the International Commission of Human Rights Experts on Ethiopia. Human Rights Council, Fifty-first session. 2022. https://www.ohchr. org/en/hr-bodies/hrc/ichre-ethiopa/index (accessed Aug 2, 2023). Comment http://www.thelancet.com Published online August 24, 2023 https://doi.org/10.1016/S0140-6736(23)01734-8 3 4 Amnesty International. Ethiopia: “I don’t know if they realized I was a person”: rape and sexual violence in the conflict in Tigray, Ethiopia. 2021. https://www.amnesty.org/en/documents/afr25/4569/2021/en/ (accessed Aug 2, 2023). 5 The African Union. 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 (TPLF). Nov 3, 2022. https://igad.int/wp-content/uploads/2022/11/Download-thesigned-agreement-here.pdf (accessed Aug 2, 2023). 6 US Department of State. Statement marking six-month anniversary of the cessation of hostilities in northern Ethiopia. May 2, 2023. https://www.state. gov/statement-marking-six-month-anniversary-of-the-cessation-ofhostilities-in-northern-ethiopia/ (accessed Aug 10, 2023). 7 Physicians for Human Rights, The Organization for Justice and Accountability in the Horn of Africa. Broken promises: conflict-related sexual violence before and after the “Cessation of Hostilities Agreement” in Tigray, Ethiopia. Aug 24, 2023. https://phr.org/our-work/resources/ medical-records-sexual-violence-tigray-ethiopia/ (accessed Aug 24, 2023). 8 Fisseha G, Gebrehiwot TG, Gebremichael MW, et al. War-related sexual and gender-based violence in Tigray, Northern Ethiopia: a community-based study. BMJ Glob Health 2023; 8: e010270. 9 International Criminal Court. Rome Statute of the International Criminal Court. 1998. https://www.icc-cpi.int/sites/default/files/RS-Eng.pdf (accessed Aug 2, 2023). 10 International Committee of the Red Cross. International Humanitarian Law. Convention (IV) relative to the Protection of Civilian Persons in Time of War. Geneva, Aug 12, 1949. https://ihl-databases.icrc.org/en/ihltreaties/, https://ihl-databases.icrc.org/en/ihl-treaties/gciv-1949 (accessed Aug 4, 2023). 11 Marks S, Walsh D. “They told us not to resist”: sexual violence pervades Ethiopia’s War. The New York Times. April 1, 2021. https://www.nytimes. com/2021/04/01/world/africa/ethiopia-tigray-sexual-assault.html (accessed Aug 2, 2023). 12 UN Human Rights Council. Mandate of the International Commission of Human Rights Experts on Ethiopia. 2023. https://www.ohchr.org/en/hrbodies/hrc/ichre-ethiopa/index (accessed Aug 4, 2023). 13 Amnesty International. Ethiopia: Government’s effort to end mandate of UN human rights commission must be rejected. March 3, 2023. https://www. amnesty.org/en/latest/press-release/2023/03/ethiopia-governments-effortto-end-mandate-of-un-human-rights-commission-must-be-rejected/ (accessed Aug 6, 2023). 14 Byaruhanga C. Ethiopia war in Tigray: Eritrean soldiers accused of rape despite peace deal. BBC News. Feb 15, 2023. https://www.bbc.com/news/ world-africa-64635898 (accessed Aug 2, 2023). 15 Human Rights Watch. Ethiopia: ethnic cleansing persists under Tigray truce. June 1, 2023. https://www.hrw.org/news/2023/06/01/ethiopia-ethniccleansing-persists-under-tigray-truce (accessed Aug 2, 2023). 16 Van der Straten Ponthoz d, Ferro Ribeiro S. International protocol on the documentation and investigation of sexual violence in conflict: best practice on the documentation of sexual violence as a crime or violation of international law (second edition). UK Foreign and Commonwealth Office, UK Government. March, 2017. https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/attachment_data/file/598335/ International_Protocol_2017_2nd_Edition.pdf (accessed Aug 2, 2023). 17 Insecurity Insight, Safeguarding Health in Conflict Coalition. Ethiopia: violence against health care in conflict 2021. 2022. https://reliefweb.int/ report/ethiopia/ethiopia-violence-against-health-care-conflict-2021 (accessed Aug 7, 2023). 18 European Union External Action. US, EU and UK offer practical support to Ukraine in push for war crimes accountability. May 12, 2023. https://www. eeas.europa.eu/delegations/ukraine/us-eu-and-uk-offer-practical-supportukraine-push-war-crimes-accountability%E2%80%AF%E2%80%AF_ en?s=232 (accessed Aug 6, 2023).
Martin Plaut 