The brain drain of medical professionals from African countries to rich countries in Europe, North America, and the Middle East has been particularly pronounced since the 1980s. As Bibilola Oladeji and Oye Gureje have noted, as of 2011, there were more than 17,000 African physicians practicing in the US alone, over two-thirds of whom had been trained in African medical schools. Of this group, two-thirds were trained either in Nigeria or South Africa, the two countries with the most extensive medical training systems on the continent. Psychiatrists have also made up a significant piece of the larger medical migration, drawn by higher salaries, better facilities, opportunities for professional development, and prospects for long-term stability to seek jobs outside of the continent.
The brain drain has become a commonplace terminology to describe the emigration of highly skilled labor from developing countries to highly industrialized states in the post-colonial world. The concept has been particularly valuable for understanding persistent underdevelopment in sub-Saharan African countries as related not so much to deficiencies in African expertise as its redirection primarily for the benefit of wealthy countries. Similar to the “brawn drain” of the Atlantic slave trade or the natural resource depletion that characterized European colonialism in much of the continent, brain drain has had long-lasting impacts on African countries’ internal development and position in the global economy.
The impact of the brain drain on mental health care in Africa can be seen through the example of Nigeria, one of the few sub-Saharan African countries with university hospitals providing accredited medical training in psychiatry. Nigeria’s first trained psychiatrist of indigenous background was Thomas Adeoye Lambo, who studied at Birmingham and the Maudsley Hospital in the UK before returning to Nigeria to practice at the newly founded Aro Mental Hospital in 1954. Lambo and his acolyte, Tolani Asuni, developed much of the infrastructure of Nigerian psychiatry in the 1960s and 1970s, and several Nigerian universities began producing psychiatrists by the 1980s. The purpose of developing such programs was to produce a qualified mental health workforce for the country. Students from other countries in West Africa also trained in psychiatry at Nigerian institutions. Nigeria’s mental health care workforce grew slowly but surely from only three psychiatrists in 1955, to 25 by 1975, and 100 by 2001. But the brain drain has had a major impact on Nigerian psychiatry. Today, there are roughly 250 psychiatrists in Nigeria to serve a population of approximately 190 million. At the same time, a study from 2010 found that there were 384 Nigerian psychiatrists practicing in the US, UK, Australia, and New Zealand, a number 50% higher than the estimated total practicing in Nigeria.
The effects of this psychiatric brain drain have been significant. Beyond the worsening of the psychiatrist-to-population ratio, this phenomenon has the potential of severely weakening ongoing reproduction of this limited resource as more freshly qualified psychiatrists and senior residents are being enticed/encouraged to relocate on the guise of training opportunities abroad, from which they never return. In addition to psychiatrists, mental health nurses are also leaving the continent in droves, with packages designed to make emigration easy and more likely to be permanent. The rate of migration far outstrips the rate of production, leaving a huge deficit in human resources, one of the major pillars of a health system, according to the World Health Organization.
Several reasons have been proffered for the exodus of medical doctors from Africa to the economically developed world. Oberoi and Lin classified these reasons into endogenous and exogenous factors. Endogenous factors include poor working conditions, poor remuneration, and lack of job satisfaction and job security with little or no opportunities for career development. Exogenous factors include social pressures from relatives, preponderances of civil unrest, and armed conflicts with attendant high levels of insecurity. Ironically, the factors that push mental health care workers to relocate abroad are the same ones that likely contribute to rates of psychological distress in their communities of origin that, in turn, require more and better mental health care.
Since the late 2000s, the “global mental health” movement has sought to ameliorate this “treatment gap” in mental health services in developing countries, including Nigeria and others in sub-Saharan Africa. In most cases, reducing the treatment gap relies heavily on training lower-qualified workers to perform the duties of highly-skilled practitioners, a set of practices known as “task shifting.” Task shifting in international public health has existed for a long time, and has been employed extensively in the field of HIV/AIDS diagnosis and treatment in many environments. But it’s use in psychiatric care is somewhat more controversial. Most notably, global mental health has been critiqued as potentially socially and culturally insensitive, importing knowledge and practices from western industrialized countries that might not adequately reflect local cultural beliefs or social determinants of health, while simultaneously marginalizing indigenous health systems.
Task shifting has also been proposed as a strategy for alleviating the effects of the brain drain on the health care sector. In a review of policies to address brain drain in sub-Saharan African countries, Edward Zimbudzi has identified some areas of possible intervention. These include ethical recruitment, brain drain tax or compensation for source countries, increasing investment in training more professionals, improving remuneration of health workers and working conditions in general, importing more staff, ensuring political stability, and encouraging remittances. However, the review concluded “that there is considerable consensus on task shifting as the most appropriate and sustainable policy option for reducing the impact of health professional brain drain from Africa.” While some studies have concluded that task shifting has effectively filled the treatment gap, others have indicated that it is by no means a comparable substitute for professional mental health care due to lack of proper supervision and training of lower level workers, among other factors.
But we would like to offer a different critique of the task-shifting discourse: it’s tendency to normalize the brain drain of health care professionals. Global mental health has always emphasized practicality over ideology: anything that can be done to fill the “treatment gap” is presumably better than not doing it. The origins of the medical brain drain are not really global mental health’s concern, but its consequences are a large part of the foundation of the movement’s argument for “scaling up” the health care workforce to address the “treatment gap,” which is effectively the primary justification for the movement’s existence. However, in making the case for immediate action, the discourse on task-shifting in global mental health replicates the long history of ignoring the long-term exploitation of African resources in order to focus on short-term, externally funded, non-state interventions to provide what Africa supposedly “lacks.”
Promoting task shifting to lower cadre health care workers as the best way to scale up mental health services in low- and middle-income countries indirectly suggests that these countries cannot hope for better, even as billions of dollars are lost by African countries from investment in training highly qualified health workers who go on to treat patients in wealthy countries. Meanwhile wealthy countries acquiesce to helping train up less-qualified caregivers to fill the “treatment gap” created in part by this brain drain. It also implies that African countries can get by on less than wealthy countries. Indeed, severe mental illness continues to be neglected under the “task shifting” model that does little to increase specialist capacity to handle such cases. While this rather popular principle in global mental health appears practical, it inadvertently panders to the notion that some lives are more important than others, and calls to question the relative value placed on the health and lives of citizens of the developing countries of Africa compared to the developed world. It reinforces and normalizes global inequalities.
Mitigating the psychiatric brain drain must ultimately be about much more than filling “treatment gaps.” It must also be about addressing the geopolitical and macroeconomic conditions that have produced the gap in the first place. Developing equitable and sustainable mental health services for all Africans is a political, economic, moral, and ethical issue of contemporary urgency and historical significance.
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Kisumu County’s Fragile Food Security
Reliance on imports from as far away as Tanzania, Uganda and even China, leaves Kisumu County’s accessibility to food on a fragile footing.
A ceasefire had to be called at the height of the 2007/8 post-election violence and a corridor created for the safe passage of foodstuffs from the Rift Valley to the lakeside city of Kisumu to avert a food crisis. The post-election violence had erupted barely 10 days earlier.
For a region that enjoys adequate rainfall and has good agricultural soils, the lack of access food supplies within days of a crisis breaking out is indicative of the problems generated by how food systems are structured in Kisumu County.
Kisumu County has a considerable shoreline along Lake Victoria that extends from Seme to the south to Nyakach Sub-County to the north. Apart from Kisumu city, the county also has a number of smaller towns such as Muhoroni, Ahero, Katito, Maseno and Kombewa.
Eighty per cent of the food consumed by the county’s 300,000 households—including maize, potatoes, onions, vegetables, milk, rice, eggs and bananas—is imported from as far as Uganda and Tanzania along with imports of fish from China.
Kisumu County continues to import food despite having regions that could potentially support expansive food production in areas such as Muhoroni, Nyamware and Nam Thowi, and the fertile crescents in Seme to the south. Over time, the rich alluvial soils that have been deposited in these areas by floods and rivers flowing downstream from Nandi Hills have created fertile grounds that support farming.
How did we get here?
The persistent issues that have impeded food production in Kisumu County are numerous. Traditionally, communities living in the county practiced fishing and livestock keeping, and subsistence agriculture as their economic mainstay. Commercial farming has only been embraced in recent years, due to interactions with neighbouring farming communities such as the Kisii, Luhya, Abasuba, and Kuria. The majority, however, continue to practice smallholder subsistence agriculture.
The uptake of commercial farming was also hindered by the economic policies of the 1990s that saw the collapse or the weakening of many of the structures that had been established to support food production in the country as a whole and provided extension services, grants, and subsidies to farmers. They include the Agricultural Finance Corporation (AFC), the Agricultural Development Corporation (ADC), Agricultural Training Centres (ATCs), Agricultural Research Institutions (ARIs), and farmers’ co-operatives.
The system of land ownership in Kisumu County is also a hindrance to commercial food production. Most land in Kisumu County is not registered and titled and much of it is inherited property that has been passed down through the generations without legal title.
Recent surveys show that the cost of the farming inputs required to initiate meaningful agricultural production is out of reach for the majority of Kisumu County residents. This challenge is further compounded by the dearth of farming SACCOs (Savings and Credit Cooperatives); with the prohibitive interest rates charged by local banks, obtaining capital to start an agricultural enterprise has proved to be a challenge. These challenges are further exacerbated by the risks associated with farming such as crop losses and post-harvest losses.
The system of land ownership in Kisumu County is also a hindrance to commercial food production.
There is little agro-innovation among Kisumu farmers who still rely on traditional farming methods. There is little irrigation going on in the county. Lastly, there is a serious lack of the human resource required to support food production such as agricultural engineers, extension officers, veterinary doctors, agronomists, sociologists, planners, economists, among others.
Food shortage affects the mwananchi
At Jubilee Market, a major cog in the food supply chain in Kisumu City, traders lament daily about inadequate local food supplies and about middlemen from outside the county who take advantage of food shortages to import supplies and make big profits. The high demand for food and the low supply have an impact on food prices, reducing profit margins for the traders, even as consumers are faced with high food prices.
There is a serious lack of the human resource required to support food production.
The missing link in Kisumu’s economic growth is a buoyant agricultural sector. From observations made when the writer toured Victoria Eco-Farm, a leading food supplier situated at Dunga Beach in Kisumu City, the revival of agriculture in Kisumu is possible. Victoria Eco-Farm deals in poultry, dairy, bee keeping, and the rearing of exotic dogs. The farm has also diversified into agri-tourism, receiving visitors and training both students on attachment and local farmers on best farming practices. Nicholas Omondi, the Director, has become a role model for emerging food producers in the agriculture sector.
Modelling food sufficiency
Based on Walt Rostow’s model of economic growth, Kisumu County will not make a sudden and quick leap out of food insecurity. In Stages of Economic Growth, Rostow outlines the five stages that all countries must pass through to become developed: the traditional society; pre-conditions for take-off; take-off; drive to maturity; age of mass consumption. Regrettably, Kisumu County is still at the stage of a traditional society that is characterized by subsistence agriculture, limited funding and technological innovation, and low economic mobility.
The pre-conditions for take-off will only be fulfilled when the county government, acting in collaboration with the national government, provides adequate incentives for agricultural development. More food crops need to be introduced to farmers in Kisumu County. There is also an urgent need to revitalize existing sectors such as the sugar and fishing industries. The county’s potential to become a prime producer of rice also needs to be actualized.
Reform-oriented policies such as titling and surveying are needed in order to transform the existing models of landholding and land ownership. Farming communities in the county also require extensive sensitization and training on emerging technologies and innovations. Most importantly, existing lacklustre attitudes to farming as an economic activity among Kisumu County residents will need to be addressed.
However, the current tax regime is inimical to the drive to boost food security and needs urgent review. In effect, no serious gains can be made in the agriculture sector anywhere in the country as long as the national government continues to insist on enforcing policies that increase production costs and make it cheaper to import food from Tanzania and Uganda than to grow it at home.
The current tax regime is inimical to the drive to boost food security and needs urgent review.
Leaders must realize that whether they are in the opposition or in government, relations with state agencies, especially those in the agriculture sector, are key to developing farming in Kisumu County, that in the interest of economic development, they must always be in constant touch with the government for purposes of support, lobbying and relaying feedback in development processes. Existing attitudes and brands of politics that lead to self-marginalization must be removed at all costs.
It must be recognised, however, that the county government has taken initial steps to start addressing the challenge of food insecurity. In partnership with the Food and Agriculture Organization (FAO), the county government has established a youth-focused Food Liaison Advisory Group (FLAG), leading to the promotion of urban agriculture, the strengthening of rural mechanisms for food production and initiating programmes for the training and deployment of agricultural extension officers.
It is to be hoped that such initiatives will contribute towards alleviating the food insecurity situation that the residents of Kisumu County continue to grapple with.
This article is part of The Elephant Food Edition Series done in collaboration with Route to Food Initiative (RTFI). Views expressed in the article are not necessarily those of the RTFI.
How Twitter’s Negligence is Harming Kenya’s Democracy
Twitter’s trending algorithm has been abandoned to disinformation campaigns and attacks, failing Kenyans as political actors use it to control political narratives by harassing dissenting voices.
On the 24th of June 2021 at around 6 a.m., an insidious hashtag, #KatibaMbichi, appeared on Kenyan Twitter timelines. Its trend seemed to be driven by a number of faceless bots, and retweeted by a series of catfishes that sent it to the number one spot on the Kenyan Twitter trends.
Our investigations have uncovered how such malicious, coordinated, inauthentic attacks that seek to silence members of civil society, muddy their reputations and stifle the reach of their messaging, is a growing problem in Kenya. Twitter, especially, has been central to these operations due to the influence it has on the country’s news cycle.
The proliferation of digital media platforms in Kenya carries the promise of a renewed definition of freedom of speech. Moreover, Twitter has been a vital tool of expression for many Kenyan citizens, many of whom use it to hold their leaders to account and to call out their failures. But civil society members and journalists have increasingly come under attack thanks to disinformation campaigns in the country.
Through a series of interviews with anonymous influencers involved in these campaigns, we accessed their inner workings and gained crucial insights into how they are organized.
An examination of the campaigns has provided our team with a window into the shadowy world of Twitter influencers for political hire in Kenya. Many of the accounts and individuals involved promote brands, causes and political ideologies without disclosing that they are part of paid campaigns.
Twitter features such as the trending algorithm are exploited to achieve the goals of these campaigns by amplifying them. Certain verified accounts on the platform are complicit in leading these attacks. The goal of these campaigns is to exhaust critical thinking and poison the information environment by muddying the truth.
Our investigations examined two months’ data between 1 May 2021 and 30 June 2021, with a particular focus on the Constitutional Amendment Bill—famously known as the Building Bridges Initiative—that was being promoted in Kenya at the time.
With the aid of Twint, Sprinklr and Trendinalia, we trailed the attacks by mapping and analysing specific hashtags that the influencers used on Twitter. This involved mapping certain accounts that posted malicious content targeting Kenya’s activists and judicial officers. The flagged hashtags often displayed synchronized publishing timestamps within the metadata, with a lack of content on most days, followed by one very sharp burst of activity and then fizzling out.
In total, using Sprinklr, which has access to Twitter’s full historical archive, we flagged 23,606 tweets and retweets released by 3,742 accounts under the 11 hashtags. We also obtained 15,350 of these tweets using the Twint package on Github to carry out further analysis of the content.
How disinformation is spread
The Twitter campaigns we looked at were those that were pro-BBI and directly attacked citizens and prominent civil society activists that were vocally opposed to the proposed reforms, and also sought to discredit civil society organisations and activists by portraying them as villains who were being funded by Kenya’s Deputy President William Ruto—he opposes the BBI process.
The well-coordinated attacks are launched through WhatsApp groups to avoid detection. The WhatsApp group admins give direction about what to post, the hashtags to use, which tweets to engage with, and whom to target. They also synchronize the posting to enable the tweets to trend on twitter.
There is money to be made in attacking civil society. Our sources confirmed that they get paid between US$10 and US$15 to participate in three campaigns per day. Those higher up the ranks are on a monthly retainer that can go as high as US$500. Those who are on a retainer supervise the hashtags and ensure that they trend on the days they are posted.
Who the disinformation targets
From our analysis, the top three most frequent victims were Kenyan journalists, judges, and known activists. Prominent anti-BBI activists under the Linda Katiba movement who petitioned the courts against the BBI were the targets of some of the most vicious attacks.
The attacks peaked in early May with the specific goal of trying to discredit the anti-BBI campaign. Jerotich Seii, a key member of the Linda Katiba campaign who was targeted, said in interview that she had to spend a lot of time trying to prove that her activism efforts were genuine and that she was not a front for someone else. “The disinformation attacks against me focussed on painting me as someone with ulterior motives who isn’t interested in the welfare of Kenyans. I had to spend a good chunk of my time defending my position as someone who is actually a patriot who does what they do out of love for their country,” said Seii.
From our analysis, the top three most frequent victims were Kenyan journalists, judges, and known activists.
All this is leading to self-censorship by some of the activists on the platform as they feel that it is pointless to use a platform that cannot deliver any meaningful engagement. One activist we spoke to said that she had significantly scaled down her Twitter activity because of all the trolling she had experienced.
The Kenyan High court struck down the BBI on 14 May on the grounds that the initiative was unconstitutional and the Court of Appeal followed suit on August 20th. The ruling not only strained the already bad relationship between Kenya’s Judiciary and the Executive, it also led to wave after wave of disinformation attacks seeking to question the judges’ judicial independence and the accuracy of their decision.
A notable change in these attacks was how the visual aesthetics of the content within the campaigns evolved; newspaper editorial cartoon-style caricatures and memes were employed, a likely indication of a change of leadership or strategy at the top that sought to make the content more palatable and shareable.
What is the impact of the slander?
The data that we gathered from Trendinalia (which collects data on Twitter trends in Kenya) shows that sufficient amplification was achieved for 8 of the 11 hashtags we identified that became trending topics. This amplification was achieved partly through the use of verified accounts. One anonymous influencer we spoke to said that owners of certain verified accounts involved in these campaigns would often rent them out to improve the campaign’s chances of trending. “The owner of the account usually receives a cut of the campaign loot from the person that rented it from them once it’s over,” the influencer said.
The demand for this service by the political class in Kenya is markedly strong. During the months of May and June alone, we counted at least 31 artificial political hashtags, including the ones linked to the BBI process. This translates to at least one manipulated disinformation campaign that Kenyans have to deal with every two days.
Curiously, there is little evidence that these operations actually sway people’s opinions. However, they do have an effect on how Twitter users interact with their information environment. The goal of such operations is to overwhelm, to create an environment where nobody knows what is true or false anymore. The objective is to exhaust critical thinking and muddy the truth.
During the months of May and June alone, we counted at least 31 artificial political hashtags, including the ones linked to the BBI process.
Typically, a post by any of the prominent activists or judicial officers is bombarded with so much aggression, insults, and dismissive comments that the space for a good conversation is lost. The point is always to ensure that sober-minded people are disincentivized from amplifying the topic after encountering so much aggression in the replies and the quote tweets.
The role of Twitter Inc.
To many Kenyans, Twitter matters. The platform has become a very critical avenue of expression, networking, running ads, and a means of obtaining information. It is also an important avenue for active citizenship as #KOT (Kenyans on Twitter) is one of Africa’s loudest and most lively internet communities.
On the darker side however, some of the features on Twitter are being exploited for nefarious purposes. The platform is failing Kenyans—and Africans more broadly. Political actors are using it to try to control political narratives by poisoning the platform and harassing dissenting voices.
Specifically, Twitter’s trending algorithm, which selects and highlights content without examining its potential for harm, often serves as an on-ramp for users who are trying to find information on the platform. Our sources said that Twitter trends is the primary key performance indicator by which most of their campaigns are judged. They admitted that without it their jobs would not exist. “The main goal is to go trending on Twitter. I’m not sure what our jobs would look like without that target,” said one source.
The evidence available points to the fact that, for the executives at Twitter, this is not a new phenomenon. The trending algorithm in particular, which is a big part of how Twitter works, has been abandoned to disinformation campaigns and attacks.
Twitter’s Moderation Team should pay close attention, keenly monitor and regulate its trending section. Activists, such as Sleeping Giants, have repeatedly called for Twitter to “untrend” itself. This could be done by either removing the feature completely or by disabling it during critical times such as during election periods.
The evidence available points to the fact that, for the executives at Twitter, this is not a new phenomenon.
Arguably, Twitter does not have an incentive to fix this. It sells ads for “promoted trends” and “promoted tweets” within the feeds of hashtags on its trending topics section to business clients. This puts Twitter squarely in the middle of the mess as it profits from this harmful activity.
Ad Dynamo, an agency that sells Twitter Ads in Kenya, currently offers promoted trends for US$3,500 per day within the country. The overall message this sends is that it is ok to sow hate on the platform so long as Ad Dynamo owners can place ads next to the trending content and make a profit from it.
As Kenya heads towards elections in 2022, the demand for these services will increase and many political parties will seek out malicious coordinated trending models and create the risk of a repeat of the 2007 political violence.
WHO Neutrality in a Time of Crisis at Home: The Case of Dr Ghebreyesus
The UN and its highest officials must not choose inaction under the pretext of observing neutrality especially where genocide, crimes against humanity, war crimes, ethnic cleansing, weaponised rape, and starvation are taking place.
Dr Tedros Adhanom Ghebreyesus was re-elected to serve a second five-year term as the Director-General of the World Health Organization at the 75th World Health Assembly on 24 May 2022. Dr Ghebreyesus is from Ethiopia’s Tigray region and he has been condemning the Ethiopian and Eritrean governments, as well as non-state actors in Ethiopia such as the Amhara militia, for the comprehensive humanitarian blockade, total siege, systematic rape, mass killings, total destruction of health facilities, and killings of humanitarian and health workers, and other atrocious acts committed in Tigray and against its people. There are, however, critics, especially from the Ethiopian government, that claim that he is abusing his mandate as the head of a UN organization. This raises the question to what extent high-ranking UN officials should stay neutral when it comes to conflict and crises in their home countries.
Mandate and watchdog
As the Director-General of the WHO, Dr Ghebreyesus’ statements on the catastrophic humanitarian and medical condition of the people of Tigray and his call on the Ethiopian and Eritrean governments to lift the siege and humanitarian blockade are legitimate and within the purview of his mandate. It is important to understand the context of Dr Ghebreyesus’ statements. Dr Ghebreyesus has the responsibility of upholding WHO principles, which include the recognition that the “health of all peoples is fundamental to the attainment of peace and security and is dependent on the fullest cooperation of states and individuals” and that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”
The war on Tigray started at a time of the rapid spread of the COVID-19 pandemic, and disrupted the efforts of the people of Tigray to prevent and contain the spread of the disease and mitigate its significant health and socio-economic-political impacts. Citing the COVID-19 pandemic as the reason for the move, on 31 March 2020, the National Electoral Board of Ethiopia (NEBE) postponed the scheduled 29 August 2020 legislative elections indefinitely. However, other voices, including the Government of Tigray, have condemned the decision as a corona-clouded power grab.
The war on Tigray, referred to by the Ethiopian government as simply “law and order enforcement” against a few leaders in Tigray, turned out to be a well-planned total war against the people of Tigray that involved significant forces from foreign countries, including Eritrea and Somalia. Several reports by humanitarian organisations and investigations by human rights organisations and international media have repeatedly concluded that the gruesome mass atrocities committed against Tigrayans constitute war crimes, crimes against humanity, and ethnic cleansing that may amount to genocide. This is consistent with Ethiopian officials’ openly stated intent to erase Tigrayans. In February 2021, four months after the war started, they even shared their intentions with Pekko Havvisto, Finland’s Foreign Minister and EU Envoy to Ethiopia. “When I met the Ethiopian leadership in February, they really used this kind of language, that they are going to destroy the Tigrayans, they are going to wipe out the Tigrayans for 100 years, and so forth.
Despite the Ethiopian government declaring unilateral humanitarian ceasefires twice, first on 28 June 2021 and then on 24 March 2022, together with their Eritrean allies, Ethiopian forces have maintained the siege sealing off Tigray from the rest of the world and imposing “a de facto humanitarian aid blockade” as stated by the UN in July 2021. The siege involves a complete shutdown of telecommunications, transportation, electricity, and the banking system with the result that workers’ salaries cannot be paid, people with savings cannot access their money, and the Tigray diaspora cannot send remittances to help their families and friends in Tigray. Even aid agencies working in Tigray were denied cash and fuel and many were forced to halt their humanitarian operations.
By March 2022, 16 months since the start of the war, it was reported that an estimated half a million Tigrayans have been killed. Of those, close to 200,000 lost their lives by starvation, which is being deliberately used as a weapon of war, while another 100,000 civilian Tigrayans died from lack of access to basic medical care. The allied Ethiopian and Eritrean forces deliberately destroyed, damaged, and looted food production and supply chains and the entire health system. It is now close to 20 months since the war started and more Tigrayans have died from deliberate starvation, denial of medical care, torture, extrajudicial killings in the liberated part of Tigray, in western and other parts of Tigray still occupied by Ethiopian federal, Amhara, and Eritrean forces and in internment camps in many parts of Ethiopia.
The allied Ethiopian and Eritrean forces deliberately destroyed, damaged, and looted food production and supply chains and the entire health system.
The Ethiopian government and its allies are indeed working against the core UN charter and instruments including universal human rights such as the right to life, freedom of movement, right to food, right to health, and right to humanitarian aid. The people of Tigray are now denied the enjoyment of a standard of health services that they attained after decades of a hard, consistent and holistic effort to attain primary health care. The WHO sent critical medical supplies to all conflict-affected regions of Ethiopia but while the consignments to the Amhara and Afar regions arrived at destination without problems, those destined for Tigray have been deliberately blocked by Ethiopian authorities and their allies from reaching people who are being deliberately starved and denied access to basic medical supplies.
It is within this context that Dr Ghebreyesus is speaking out and calling for the Ethiopian and Eritrean governments to stop weaponizing access to food and medical supplies. Speaking at the inauguration of his second term, Dr Ghebreyesus said:
“I am humbled by the opportunity provided by the Member States to serve a second term as WHO Director-General”. He added, “This honour, though, comes with great responsibility and I am committed to working with all countries, my colleagues around the world, and our valued partners, to ensure WHO delivers on its mission to promote health, and keep the world safe and serve the vulnerable.”
Dr Ghebreyesus is therefore acting in line with his mandate to be a voice for the voiceless victims. Dr Ghebreyesus is impartial in that, under his leadership, the WHO has also been dispatching critical medical supplies to the Afar and Amhara regions; the UN system has a watchdog that oversees the impartiality of UN officials. Moreover, the UN also has an Office of Internal Oversight Services, which investigates misconduct and violations by UN officials and submits reports and recommendations to the UN Secretary-General.
The Ethiopian government did lodge a complaint to the WHO Office of Compliance, Risk Management and Ethics (CRE) and to the WHO’s Executive Board, alleging misconduct and calling for the removal of Dr Ghebreyesus from office claiming that he was using the office of the Director-General to further his personal political interests. This is part of the campaign that the Ethiopian government has been waging against all Tigrayans—attacks and witch-hunts against Tigrayans that lack any credibility. UN peacekeeping troops of Tigrayan origin deployed in Somalia, South Sudan and Sudan faced similar attacks which led the UN to treat them as prima facie refugees in need of protection.
In his 2021 book titled Perilous Medicine, Professor Leonard Rubenstein describes the debate within the humanitarian and donor community about the role of neutrality in aid work, which can be extrapolated to the UN’s high-ranking officials.
Neutrality, one of the four principles of UN humanitarian practice (humanity, impartiality, and independence), is about not taking a position on one side or another in a conflict. When undertaking humanitarian and other UN operations in zones of armed conflict, UN officials are expected to remain neutral, avoiding taking sides or showing favouritism. In contrast, impartiality is maintaining non-discriminatory positions towards individuals and groups of people in a conflict needing humanitarian assistance. However, neutrality should not mean that UN officials have to remain tight-lipped and passive when any of the warring parties are massacring and deliberately starving a civilian population and denying them access to life-saving assistance because of their ethnic origin, gender, nationality, political opinions, race or religion. As long as aid workers (or in this case UN officials) maintain impartiality, Professor Rubenstein questions if maintaining neutrality vis-à-vis a waring party or parties is even morally ethical, especially when they attack or deny civilians humanitarian assistance because of their identity, as is the case with ethnic Tigrayans.
The WHO, led by Dr Ghebreyesus, has been impartial in its medical aid delivery to all ethnic groups affected by the civil war in northern Ethiopia. While neutrality has been interpreted as not taking sides, it does not require Dr Ghebreyesus to be indifferent to the suffering of millions civilian Tigrayans when the Ethiopian government and its allies blatantly discriminate against them and deny them access to vital international medical assistance because of their ethnicity.
In her article Neutrality vs impartiality: What is the difference?, Carol Devine of Doctors Without Borders says, “Neutrality is not the same as staying silent. It’s nuanced and even controversial. MSF reserves the possibility to speak in public about massive human rights violations and crimes of humanity, including genocide.” A misguided interpretation of neutrality can lead, as it did in Rwanda, to catastrophic and regrettable tragedies. When civilians are facing crimes against humanity, war crimes, ethnic cleansing and genocide as is still happening in Tigray, taking no action using neutrality as excuse is against the fundamental values and mandates of the UN human rights and international humanitarian law.
A misguided interpretation of neutrality can lead, as it did in Rwanda, to catastrophic and regrettable tragedies.
It is important to be aware of the unfortunate conflation of neutrality with the duty of impartiality. Indeed, former UN Deputy Secretary-General Louis Frechette is cited saying, “The UN cannot be impartial between those who respect international, humanitarian, and human rights laws and those who grossly violate them.” In 1999, former UN Secretary-General, Kofi Annan said, “In the face of genocide, there can be no standing aside, no looking away, no neutrality – there are perpetrators and there are victims, there is evil and there is evil’s harvest.”
The UN and its highest officials must not choose inaction under the pretext of observing neutrality especially where genocide, crimes against humanity, war crimes, ethnic cleansing, weaponised rape, and starvation are taking place. The heads of UN organizations including Secretary-General Antonio Guterres need to join Dr Ghebreyesus in speaking up and acting against the continuing ethnic cleansing, siege and humanitarian blockade of millions of civilian Tigrayans.
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