Civilian death and injury from airstrikes: evidence from the war in Tigray, Ethiopia.

Background: Civilians bear a significant burden of morbidity and mortality in modern armed conflicts, particularly when explosive weapons are used in densely populated areas. Many civilian facilities were attacked in the war in Tigray since the beginning of hostilities in November 2020. This study assessed the impact of airstrikes on civilians from June 2021 until the signing of the Agreement for Lasting Peace through a Permanent Cessation of Hostilities between the Ethiopian Government and the Tigray People's Liberation Front in November 2022.

Methods: A retrospective review was conducted of all injury data reported between June 2021-October 2022 from each district health facility in six zones of Tigray, Ethiopia. Descriptive analysis was conducted for variables of interest (e.g., age, sex, location, injury outcomes).

Results: A total of 1,143 casualties from airstrikes were reported from six zones and 24 districts of Tigray, Ethiopia. From the total of 80 instances of drone and aerial bombardments incidents, one third of the airstrikes resulted in death (33.7%, n = 385). The mean age of the victims was 28.9 years (SD = 17.9) with a range of less than 1 year to 87 years. Almost a third of the victims (28.3%, n = 323) were children aged < 18 years. Approximately 5% of casualties were age > 60 years (5.3%, n = 61). Almost half (45.1%, n = 516) of the causalities were female including pregnant and lactating women. The Southern and Northwest zones suffered the most casualties, followed by the Southeast zones and Mekelle. The airstrikes took place predominantly in civilian areas, including marketplaces, internally displaced persons (IDP) camps, residential areas, public transportation, villages, children's playgrounds, churches, mills and hospitals, resulting in numerous casualties that disproportionately affected civilians, especially children, the elderly and women.

Conclusions: Civilians suffered significant death and injury from airstrikes during hostilities in the war in Tigray, including a high proportion of women and children. The most common targets were civilian facilities including IDP camps, which the United Nations has determined to be a crime against humanity. Enhanced collaboration between health and protection stakeholders can improve support to victims from immediate post-injury care as well as rehabilitation so that they can live as healthy, dignified, and productive citizens.