Treating Patients During a Civil War | Stats + Stories Episode 337 / by Stats Stories

James J. Cochran is associate dean for research with the University of Alabama’s Culverhouse College. He is also a professor of statistics and the Rogers-Spivey Research Fellow.



Mulugeta Gebregziabher is professor of biostatistics and vice chair for academic programmes at the Medical University of South Carolina. He is a health scientist investigator and methods core leader with the Health Equity and Rural Outreach Innovation Center of Veterans Affairs Health Services Research & Development, and director of the Region IV Public Health Training Center for South Carolina.

Check out their articles in Significance Magazine and the BMJ Global Health Journal

Episode Description

The civil war in the Tigray region of Ethiopia, which lasted from November 2020 to November 2022, left as many as 600 thousand people dead. The war fought by the Tigray People’s Liberation Front on one side and Ethiopian and Eritrean forces on the other also had a devastating impact on the health system in Tigray. That’s the focus of this episode of Stats and Stories, with guests James J. Cochran and Mulugeta Gebregziabher.

“We acknowledge the brave efforts of the Tigray health workers and our global health research collaborators.”

+Full Transcript

Rosemary Pennington
The Civil War and the Tigray, the war fought by the Ethiopian and Eritrean forces on the other also had a devastating impact on the health system integrity. That's the focus of this episode of Stats and Stories, where we explore the statistics behind the stories and stories behind the statistics. Stats and Stories is a production of Miami University's Department of Statistics and media journalism film, as well as the American Statistical Association. Joining me is regular panelist, John Bailer, emeritus professor of statistics at Miami University. We have two guests joining us on the show today. James J. Cochran is a professor of statistics at the Mike and Kathy Murrow research chair and the University of Alabama's powerhouse College of Business. He's also the editor of the INFORMS analytics body of knowledge, full of data together, Mulugeta Gebregziabher is Professor and Vice Chair of academic programs at the Medical University of South Carolina and research health scientist at the Charleston VA Medical Center. He's also a fellow of the American Statistical Association. They're co-authors of a Significance article about the impact of the Tigray civil war on the health system there. Thank you both so much for joining us today.

James Cochran
Thank you for having us.

Mulugeta Gebregziabher
Thank you for having us.

Rosemary Pennington
The hot part of the conflict ended in November of 2022. Can you remind us sort of what caused the conflict to break out in the first place?

Mulugeta Gebregziabher
Yeah, so this the war between really the Tigray Defense Forces, we call them the TDF. And the other side, you have Eritrea, Ethiopia and south of the regional forces, they take the region in Ethiopia, started lightly said November, straight oratory is really the basis for the war, you can really characterize it by what political issues, you know, which were not settled through the associations. And the second one, you can say here is race involvement is kind of revenge, because there was a war that happened in 1998 it was right around 2000 between Ethiopia. So it was kind of a revenge agreement that they made with the government. And maybe a third reason is you have all these other forces, especially the Emperor rigid, who have had certain claims that they were able to settle through the ETA constitutional framework. So this force found a way to join HUDs really to attack a region within Ethiopia. So you have one rigid, which has about six to 7 million people. So those of us in that region are Eritrea, which is a country that became independent in 1993. And then south of the Tigray region you have all proper Ethiopia, including on the western side, the Amhara region. So all these verses come together for their own reasons, Eritrea for like I said, for revenge on a government entity or federal government, for its own political issues that could settle with the Tigray region. And the same is with the power of horses, if you have to define really the key characteristics of this armed conflicts, which is now actually classified as genocidal war, by the do lines institute a think tank in the United States, where there was a total blockade of Cuba trade aid, which is what analyzation of humanitarian aid, that there was worth the destruction of comes facilities, more than 80% of this facility is destroyed. And that there were a lot of casualties. There's a displacement of billions of people. And of course, very, very tragic, systematic, conflict related sexual violence, rape of more than 120,000 people. So really, the basis of the war, I could say, could be sorted out by this.

John Bailer
Wow. That's a great burden on a country and a community. So you dove into this question related particularly to the healthcare impact. What is it that led you to think about this and what were some of your initial ways of framing this problem that you were going to explore?

James Cochran
Well, Mulugeta, and I have been friends for a while and we talked about working on different projects. He reached out to me and wanted to know if I wanted to assist with this effort. So he and I eventually talked about what data to collect and how to collect it. And one of the things we realized fairly quickly is that if we put too much of a burden on our friends and colleagues and Tigray to collect these data, we would be asking too much of them, that as the amount of data we ask them to collect from each health care facility, increased in size and complexity, we increased the amount of time they would be exposed and the danger they'd be exposed to. We also increased the likelihood that somebody might question the veracity of the data. And then finally, we also realized that, as much as we'd like to show off our modeling skills, and our ability to do flashy things with statistics, the people that needed to see these data needed to see summary statistics. So we ultimately decided on collecting data that we could use to calculate simple proportions, and show tables of data and show graphs, or charts and things of that nature, because that would communicate best with the audience that we really needed to reach.

Mulugeta Gebregziabher
Yeah, I think I could add, actually, or expand a little bit on what Jim said, very well. So to be, you know, this has some perfect personnel, ties or personnel. Because my family is in harm's way, I grew up in technology, went to school there till 10th grade, my mom, who is 80 plus years old, lives there. So I was worried about my family by simply this too. And then you also have a professional aspect to this, which is, I have been doing global health since 2008, which is a partnership between Ethiopia and USC, where I lead this effort. Two of the universities that I collaborate with were either too rigid, namely, actual diversity, which is a city or the historical city of as soon as you have, like LA versity, which is the capital city of Tigray. So they're all the global health infrastructure, we build on the global health connection as partnerships, we build a very big job pretty excited, you know, every year, I traveled with my faculty, colleagues at HVAC, and elsewhere, to the top priority to do capacity development, research methods, in translating translational research. The last time we were there was 2019, just before the war broke out, actually, we were in Addis Ababa, about to come back to the US, there was high profile assassinations in the Capitol and a lot of the regions in the Ethiopia, the general was the Chief of Staff, and his best friend were at home, and they were assassinated that day, when we were about to leave the server, either the Adhara region of Ethiopia, the president of the region, which is kind of equivalent to a state in the United States, and his staff were also assassinated right now. So it was really a significant discovery. Like we expected, in November, the war broke out. So for me, really why I was interested in this was because of the personal reasons, but also, more importantly, the professional aspects of this, which led me to believe that it is time to document what is gonna happen, you know, the two years, you know, sad to report that one of our traders in 2018 cohorts in actual diversity was actually one of those who was killed in a massacre in absolute other say, Zion Church, which is an Orthodox Church, which is really very historical. So yeah, I would like to just herbaceous those important issues, too.

Rosemary Pennington
I know John's gonna ask about the methodology and what you actually did, but I am really interested in the sort of environment that you were gathering this data in Ethiopia had this sort of communication, lockdown, obviously, it's a conflict zone. It's very hard to get data out. So how did you when you were working with people in Tigray? How did you gather this and sort of what kind of conversations did you have about how to do this in a way that, you know, minimized harm for your colleagues? Who were who were there helping?

Mulugeta Gebregziabher
Yeah. So really, the partnership that I have built was really very helpful in this regard, because we have already had people that we trade over the years working in the two universities or I mentioned it also. Even though there was a total blockade and blackouts, at least there were sub Agios. Now given the total physicians, you had agencies and things like that that were still operated on the ground, they have satellites, WiFi systems, I think it's like that. So some people were able to go to these offices to kind of actually share data with us and communicate with us with WhatsApp, we sit down with any secure platform that they find to send information. So some data was caveat, totally it pieces. So we have to find a way to put it together. This was where every job helped. And the team that we put together to work on this was very instrumental because Jim had also insights from other conflicts in the region. So the key issues, let's see, key concerns we had was if, for some reason, somebody identifies that they are sharing data with us, they will be really in harm's way. So we have to be very sensitive to that. Secondly, we needed the data to be really a quality, you know, verifiable. So we have to find a way to verify it through other ways with other contacts that I have established over the years, that government or organizations that we mentioned, in our articles. So you're right, it's a very difficult situation, people could actually lose their lives for sharing this type of data. But they were really courageous enough, and also determined that the world needs to know what is going on. Right? Because the government, you know, all the three parties that were attacking things, right, they didn't want any information to go out. Any person who is filed, you know, passing information, sharing information, even with journalists, was hard. So there is actually a very appointed circumstance where doctors without borders and SF, there were, you know, operating on the ground. Three of their staff were killed. And later we found out, this is also the website of the MSF you and actually killed because they were sharing information. And one of the information that they shared, you see that one in our significance article is that full destruction of the hospital in Iraq, the primary Hospital in Iowa. So it was a risky situation, but people were very courageous arithmetic, grateful and thankful to them.

James Cochran
And as concerned as we were about the safety of our colleagues who were collecting these data surreptitiously and getting them out to us, we had to walk a fine line, it's very difficult to convince people of the veracity of your data, when you can't give them all the details about how the data were collected. So as more data said, we had to resort to other means to provide verification of the data. But if you know I mean, if, if we can't make people believe the data are honest and true, then all the work that our colleagues did, and all the risks that they take, are for naught.

Rosemary Pennington
You’re listening to Stats and Stories. And today we're talking about stats in the Civil War integrate with Jim Cochran and Mulugeta Gebregziabher.

John Bailer
You know, my head's exploding with questions right now. So I'm gonna try to keep it to maybe 60. So, Jim, you sort of let this idea of kind of limiting the kinds of variables you would collect, you know, that sort of you had kind of a very focused attention on what you wanted for each of these health care facilities. So I guess I'm just curious if you could tell us something about the number and types of healthcare facilities and what data you were asking people to collect. And I'm gonna drive Rosemary crazy, because I'm gonna ask him one more kind of question. As you're thinking about the one thing that would help me understand this is I'm trying to picture what it was like for a data collector to go in the field to kind of go to one of these facilities and record what you are asking them to record?

James Cochran
In a simple nutshell, there were four primary types of healthcare facilities in Tigray. So we ask the individuals to go to every single health care facility in the region, we essentially got a census, not a sample. And that was really impressive. Some of these are very hard to get to. Some of these are out of the way. There are small clinics that service a few dozen people or a few 100 people, some were hospitals, but they had to go to these facilities and they had to assess what the working conditions were. What are the operational conditions for these facilities? Are they fully operational? Still, were they 75% 50% 25%? That sort of thing? Is there something you want to add to that well together?

Mulugeta Gebregziabher
Yes, definitely. So to be exact, pre the war, pre November 2020. There were 1,007 and fully functioning health facilities, right 40 of these are hospitals with more than 3,500 beds and the health coverage was about 30 billion visits per year. 90% of them were women who have access to antenatal care 73% of children receive all basic vaccinations, pre war. So as there were about 20,000 health workers, about 700 MPs and about 7000 nurses, I think there were about 270 ambulances. So had the hospital system of the healthcare system. At this 40 years, you have the tertiary care, which is by specialized referral hospitals, which as I mentioned, two of them actually had have had official partnerships with ADSC, which is the back end a Mercy Hospital, which we call it the either hospital famously, and the absolute University Hospital, which is located in the historical city of axon. And then they have secondary care through General Hospital. These were 14 of the others you have primary care for, this is provided by healthcare centers. And these healthcare centers are classified as a primary Hospital, a health center or a health post. These numbers are 44 for private hospitals, 226 for health centers, and about 741 for health sports. So this, this is what the statistics look like. So they have to go to each of these 1007 health facilities one way or the other. If they can't access them, because of hostile situations in the area, they find a proxy to go and make assessment for them. So they made assessments like GE patients.

Rosemary Pennington
So I categorized this, the impact of the war on the system is sort of devastating. And I think you call it a crisis, a health crisis in the BMJ Global Health article. So what did these people find, I guess, is my first question. I'm gonna pull up John and ask multiple parts. So what did your collaborators integrate when they were doing this census? And I guess your articles were published months before the end of the war? I guess I'm kind of what were things like when the war ended? And I guess what are things like there now? Well, yeah, go ahead.

John Bailer
Would you like to budget first?

James Cochran
Sure, I'll go first, they found a lot of devastation, they found a system. Every single facility that they visited was at 100% operational capacity, they were able to do everything they needed to do before the armed conflict. What they found is decimation of the system. I don't remember the exact numbers. But I want to say that less than half was really operational. The riot lost over half of its healthcare capacity, in the first several months of this conflict. So to answer your question about what was left afterwards to happen, when you know, you've already lost over half of your healthcare system, you can't lose a whole lot more. Our biggest concern at this point, going forward is it takes a lot of resources to rebuild this healthcare system. But at this point, you've got starvation and famine, you've got people that don't have housing, you've got people that don't have clothes, you've got all kinds of more immediate needs, that are taking resources away from what could have been used to rebuild the healthcare system. And ironically, you need the health care system to provide a lot of the services that we're talking about that are immediately needed.

Mulugeta Gebregziabher
Yes, so really, I think that that takes us to the heart of the VBA paper, in which we actually report the results in the map. We have all the health facilities in that map, ADR status, which is either fully functional, partially functional and not functional at all. We also have places where we could reach because of occupation by foreign forces, specifically, areas where there are forces. So at the end of the day, when we analyze this data, there were only 3.6% of all health facilities that were fully functional. So you can imagine, compared to pre war, only 3.6 were fully functional. Only some 3.5% of all hospitals, in this case, eight health centers that have the 741 health scores were found to be functional. So it was really a devastation of really, you know, unimaginable proportions. in a sad way. They had all this, more than 80% of all health facilities were destroyed. You know, like I said, the fully functional ones were only 3.6 there were some other Started with partly functional So, but all it all, whether it is physical destruction, or, you know there are who criteria for classified by the way into fully partly through functional status. So based on that 80% of the hospitals have been destroyed. That's what we found.

James Cochran
And I think maybe what was most disturbing to me is how often we found that the healthcare facility had been turned into a military command post.

Mulugeta Gebregziabher
And I think I tried but I couldn't. I could witness that, because it takes us to the story of the picture of Admiral hospital, taken by Doctors Without Borders, that we put out in the article, the significant article, which is my hometown hospital, it's not the actual hospital. So I was able to visit that job as an update in March. So my visit in March, which was for three weeks, it COPASS really want to see, you know, if what we documented in the BMJ article and other articles that we read afterwards, what it looks like on the ground in AMIA is, in my own experience, so that was one thing I did. So I was able to sample it, you know, I'd go to different places, and one of them was at the hospital. So the hospital is now partially functional, actually. But there are other hospitals like Garvey, which was fully destroyed by the war, it still is fully destroyed. And there was one health clinic. It's called the bad guy has a clinic in the eastern part of the guy that was fully destroyed. But now I need to keep their lotteries after November 2020, to rebuild it. So I saw some hope. But I also saw what we were waiting for. So what we documented in our article, body, the bat and significance. So that is what the other part is because sometimes facilities couldn't become functional as a function of health workers, either displaced, killed, or moved out of the country. That was, I think, one of the huge areas why, for instance, I don't have any suffering because there isn't a healthy workforce. They don't have equipment, including diagnostic equipment, even basic laboratory equipment have been either stolen or destroyed. So to conclude this, with what I tried to do at the hospital became an account, I tried a military camp for the Eritrean forces during this war. That's why it has been completely destroyed, loaded, and has become really one of the symbols of health facility destruction in that.

John Bailer
So do you imagine that you might, in the future, send people back to each of these facilities now, to see what they're to see if there's been any change if there's, if there's any evidence of recovery.

Mulugeta Gebregziabher
And that is happening. Luckily, John, so part of that is that, so I was able to rebuild, it also review the memorandum of understanding that we have had with either an absolute University, and now additional work is ongoing to do assessments of not only the health facilities, but also broadly additional surveys or to document what is happening to nutritional status of babies in other vulnerable populations.

Rosemary Pennington
Before we end, I know that there is a late breaking special session of JSM that's going to be taking place around this. So could you guys talk us through what that is going to consist of? And then I think also a special issue of significance, correct?

James Cochran
Yes, that's correct. Sure, the late breaking session, which will be Tuesday, August 6 at 1030. In the morning, Pacific Daylight Time, for those who want to attend, is called dealing with the challenges of data collection in the context of recent conflicts. And we have four different presentations in the session that we're featuring. One is by Abraham Flaxman, who's with the Department of Health Metrics, sciences and global health in the University of Washington School of Medicine. He's going to talk about data sources and methods for mortality estimation, during armed conflict. Mike Bochy of the department of epidemiology and population health at Stanford, is going to talk about preventing sexual assault, measurement error and violence in the informal settlements of Nairobi. Then we've got Zhao, Hui, Tae, from the Department of Statistics at the University of California Davis, who's going to talk about using satellite and mobile phone data to reveal consequences of conflict in Afghanistan. And then finally, we'll get to and I am going to talk about conflict and data, the pivotal role of academia and professional associations. So we're gonna talk a little bit about our work in tea dry, but we're also going to give a little bit of a call to arms and some explanation to people who are interested in how to get involved. It's kind of like a statistics with Our borders type primer for getting involved in this kind of work and what you can do to, to maybe make a little bit of a difference.

Mulugeta Gebregziabher
Yeah, you know if I put it out briefly here. So I really would like to take this opportunity to thank Jim and people like Jim, I really know who has connections, who has also really, you know, beautiful hearts. We sympathize with what has been happening in the Tigray region. And we have really covered a lot of conversations about this, in this opportunity that he traded is a part of that. process. So if this session, left breaking session, we are organizing, we also wanted to kind of reflect on the type of support we have gotten from our institutions, either, you know, myself, my wife, my son, we kind of are actually now at the Medical University of South Carolina, for instance, we are, you know, colleagues outside is a medical student. So, you know, we have been talking about this for a long time, what did the institution do to help us out with this, you know, kind of a question that I have been asking, at this time, and I'm just bringing the university, but broadly, how about the American Statistical Association, the American Public Health Association and other colleagues, in terms of really looking into this? And how would we really evolve ourselves, either documenting, or even getting help to our colleagues, in harm's way to rebuild the infrastructure that they need to do the work, which would be helpful, you know, for the betterment of I take our world. So that would be part of the conversation we would have in our DSM session.

James Cochran
I have two quick things to add to that one. The special issue of Significance will feature one article from each of these talks. And we're looking at trying to get that out early next year at the latest. Second thing I would say is, look, he is a very close friend. And when he told me about the situation in Tigray is what his family was going through what his mother was going through the difficulties he had getting back to see her, you know, I mean, usually when you hear things like this from a friend, all you can do is put your arm around their shoulder and say, What can I do to help. And when I did that, he had this audacious idea about collecting data, essentially a warzone. And I thought, wow, somebody actually had an answer to the question. And all I could do is say, what, where do I sign on? You know, I mean, this is really incredible. The only worry I had was about all of our friends and colleagues and Tigray, who were putting themselves in harm's way to collect these data and get them out to us.

John Bailer
This is incredible work. And we're truly honored and delighted to have you join us and talk about this work. I think that you may find other partners out there, the internet, International Statistical Institute has a strong presence and a commitment to statistical capacity building as well, as well as concerns about this place and trying to try it and be impacted constantly. So I think that's another picture that even the international biometric society as things start touching on health care would be. So I would also just just encourage you to think about expanding this collection of potential partners.

Mulugeta Gebregziabher
Thank you. Thank you. That's very helpful. I constantly see the point. I get, thank you so much for the opportunity. There are some risks to be taken even by people like me, GDF, for writing those articles, because they don't make you popular by the governments that are, you know, doing all this harm. So that was the other important thing. Actually, Jim was better in the advice that we are how to communicate this information in such a way that it doesn't look like it is full of personal biases, because we want it to be also objective, you know, data delivered. So that was a very important component in our conversations with Jim. Thank you.

Rosemary Pennington
Well, that's all the time we have for this episode of Stats and Stories, merely got to end. Jim and Mulugeta, thank you so much for being here today. Thank you both. Stats and Stories is a partnership between Miami University’s Departments of Statistics, and Media, Journalism and Film, and the American Statistical Association. You can follow us on Twitter, Apple podcasts, or other places you can find podcasts. If you’d like to share your thoughts on the program send your email to statsandstories@miamioh.edu or check us out at statsandstories.net, and be sure to listen for future editions of Stats and Stories, where we discuss the statistics behind the stories and the stories behind the statistics.