The scale of the data collection alone makes the study remarkable. The research team, led by Brhane Ayele of the Tigray Health Research Institute together with colleagues from Mekelle University, the Tigray Regional Health Bureau, and the University of South Carolina, analyzed records for 30,935 live births. The first eighteen months of life is widely recognized as a critical period for long-term survival, yet robust evidence on mortality during this window in conflict-affected settings has been persistently scarce. Health systems in Tigray collapsed under the strain of fighting that began in November 2020, leaving clinics nonfunctional, supply chains severed, and families displaced into camps or hiding. Against that backdrop, the study provides something rare: a statistically rigorous, population-wide measurement of what happened to children born into catastrophe.

The headline number is stark. Of the 30,935 live births tracked, 1,430 children died before turning one and a half years old, a mortality proportion of 4.6 percent with a 95 percent confidence interval of 4.4 to 4.9 percent. Even more striking is the timing of those deaths: three-quarters occurred during the neonatal period, the first four weeks of life. This concentration in the earliest days points directly to the machinery of safe childbirth as the broken link. When hospitals and health centers close, when skilled birth attendants disappear, and when roads become impassable, the moment of delivery itself becomes the deadliest passage a child faces. The mean survival time among the cohort was 524.69 days, with a confidence interval of 523.41 to 525.97 days, a figure that conceals the sharp clustering of deaths in the opening weeks.

To understand which children were most at risk, the researchers deployed the standard analytical toolkit of survival analysis. Kaplan-Meier curves were used to estimate survival probabilities over time, while log-rank tests compared differences between groups defined by maternal, household, and geographic characteristics. The team then fitted a Cox proportional hazards model, the workhorse of epidemiological time-to-event analysis, to estimate adjusted hazard ratios for each potential predictor while controlling for the others. A hazard ratio above one indicates elevated risk of death at any given moment; the study declared statistical significance at a p-value below 0.05, and all analyses were performed in SPSS. This layered approach separates genuine risk factors from mere correlations, and the results are sobering in their clarity.

The single most dramatic predictor was where and how a child was born. Babies delivered at internally displaced persons camps or on the way to a health facility faced a 4.27-fold higher hazard of death compared with those born in safer conditions, with a confidence interval of 3.08 to 5.92. Children born in the bush, away from any medical infrastructure, carried a 1.74-fold higher hazard, ranging from 1.36 to 2.23. These numbers translate an abstract statistic into a concrete picture: a mother in labor fleeing her home, delivering in a tent or a field, without sterile equipment, emergency obstetric care, or neonatal resuscitation, faces odds that her child will not survive that are several times worse than a facility birth would have offered. The finding underscores that the collapse of institutional delivery services was not a peripheral casualty of the war but a central driver of infant death.

Reproductive and household characteristics also carried enormous weight. Multiple pregnancies, meaning twins or higher-order births, were associated with a 4.91-fold increase in the hazard of death, with a confidence interval of 4.02 to 6.00, reflecting the intrinsic biological vulnerability of multiple births compounded by the absence of specialized neonatal care. Short birth intervals, the spacing of pregnancies too closely together, emerged as the strongest single predictor in the entire model, raising the hazard of death by 6.96 times, with a confidence interval of 5.89 to 8.24. This finding aligns with decades of demographic research showing that depleted maternal recovery time between pregnancies compromises both fetal development and newborn resilience. In a war zone where contraception and family planning services evaporated, the biological consequences of uncontrolled fertility were amplified into a lethal risk multiplier.

Geography and social structure left their own fingerprints on the survival curves. Children living in rural areas faced a 1.37-fold higher hazard of death than their urban counterparts, with a confidence interval of 1.16 to 1.62, a gap that reflects both the greater destruction of rural health infrastructure and the longer distances to any functioning care. Districts classified as having an extremely very high level of maternal mortality transition showed a 1.33-fold elevated hazard, from 1.04 to 1.70, indicating that the places where mothers were dying in greatest numbers were also the places where their babies were most likely to die. Residence outside Mekelle, the regional capital, was independently associated with higher mortality, as was male infant sex and membership in smaller families, the latter possibly reflecting reduced household support networks and caregiving capacity during displacement and scarcity.

The methodological foundation of the study deserves attention because it determines how much weight the findings can bear. As a retrospective cohort built on a large community-based survey of under-five mortality, the study captured births and deaths reported by household members rather than relying on hospital records that would have missed the vast majority of deliveries occurring outside facilities. Ethical clearance was obtained from the Mekelle University College of Health Sciences Research and Community Service ethical review board, and informed verbal consent was collected from participants, with adult household caregivers responding when mothers were absent. The primary survey received partial funding from UNICEF and UNFPA, though the funders played no role in data collection, analysis, or interpretation. The breadth of coverage, spanning 121 tabiyas across 31 districts, gives the estimates a population-level authority that smaller facility-based studies in conflict zones have lacked.

The authors frame their conclusions as a call to immediate, targeted action rather than a lament. Their recommendations include expanding community-based delivery services so that skilled care reaches women where they are, strengthening referral systems to move obstetric emergencies to functioning facilities, and promoting safe facility-based births through maternity waiting homes and transport support for mothers in remote areas. They further argue that conflict-sensitive health planning should be institutionalized, with equity-driven resource allocation that prioritizes rural and conflict-affected districts rather than defaulting to urban centers. Integrating culturally appropriate family planning services addresses the short birth interval finding directly, while establishing robust mortality surveillance systems would ensure that future crises are measured in real time rather than reconstructed afterward.

Beyond its immediate regional significance, the study contributes to a growing scientific literature on how armed conflict reshapes demographic risk. The concentration of deaths in the neonatal period, the outsized hazards attached to place of birth, and the powerful effect of birth spacing together sketch a coherent causal architecture: war kills newborns primarily by destroying the systems that make childbirth safe. For humanitarian agencies, the message is that neonatal survival in conflict settings is not primarily a nutrition problem or a vaccination problem, at least not in the first weeks of life, but an obstetric access problem. For epidemiologists, the demonstration that a Cox proportional hazards framework can extract actionable risk profiles from community survey data in a war zone offers a template for future studies in Ukraine, Sudan, Gaza, and other theaters where children are being born into violence. The 1,430 children whose deaths anchor this analysis represent a measured, verifiable accounting of loss, and the predictors identified give the region, and the world, a precise map of where to intervene first when the next crisis comes.

Subject of Research: Child survival and predictors of time-to-death among live births during the Tigray war in Ethiopia

Article Title: Survival status and predictors of time-to-death among live-birth children during war time in Tigray: A retrospective cohort study

Article References: Ayele, B., Teka, H., Legesse, A. Y., Tsadik, M., Gebrekurstos, G., Abraha, H. E., Berhe, B., Fisseha, G., Ebrahim, M. M., Hailu, A. G., Gebremeskel, T., Gebremariam, T., Hadush, M. Y., Hagos, T., Muez, K., Tsegay, H., Mulugeta, A., & Godefay, H. (2026). Survival status and predictors of time-to-death among live-birth children during war time in Tigray: A retrospective cohort study. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07797-0

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07797-0

Keywords: child mortality, Tigray war, Ethiopia, neonatal mortality, survival analysis, Cox proportional hazards, retrospective cohort, maternal health, conflict health, birth interval, internally displaced persons, BMC Pediatrics

The scale of the plant’s importance is difficult to overstate. In Ethiopia’s Tigray region alone, cactus pear historically occupied more than 360,000 hectares, supporting roughly 200,000 rural households with virtually no alternative means of securing a livelihood. In some areas, the fruit provides up to 40 percent of the annual food intake for rural families, while during the lean summer months from June to August it serves as a critical bridge when other crops have not yet matured. The plant’s unique Crassulacean Acid Metabolism, a photosynthetic adaptation shared with other succulents, allows it to open its stomata at night and minimize water loss, giving it extraordinary water-use efficiency in landscapes where indigenous woody vegetation has long since declined. Beyond food, the cactus anchors a seasonal economy of harvesting, transport, and urban street vending that once provided employment for more than 183,000 households, offering a low-entry livelihood for youth and women in cities such as Mekelle, Adigrat, and Asmara.

The catastrophe began, ironically, as a business venture. In April 2003, the carmine cochineal insect, Dactylopius coccus, was intentionally introduced from South Africa to southern Tigray with formal authorization from the Federal Ministry of Agriculture and Rural Development, with the goal of launching a commercial carmine dye industry. The insects were officially released in September 2004 across three trial sites, including the Endayesus campus of Mekelle University. Early returns were promising: farmers collected and exported dried cochineal worth up to 984 dollars per hectare, and the venture generated more than 550,000 dollars in foreign exchange during its first ten months. But the project lacked structured containment protocols, and when the investor’s license was revoked in 2010, monitoring ceased entirely. The insects escaped cultivation and transformed from a managed bio-resource into a devastating invasive pest, capable of killing cactus plants within six to ten months of attack through chlorosis, dieback, and total tissue collapse.

By 2019, more than 75,000 hectares in Tigray were infested, and communities had organized remarkable grassroots responses, including community mobilization campaigns and buffer zones that held the spread roughly in check between 2016 and 2020. Then came the Tigray War. The conflict, which raged from 2020 to 2022, caused a total collapse of these community-led mechanical and chemical control systems. Routine physical monitoring, quarantine enforcement, and the pruning and burning regimens that had kept the pest at bay simply stopped. In the vacuum, wind-borne dispersion of the insect’s mobile first-instar crawlers, driven by prevailing seasonal wind patterns, accelerated unchecked across contiguous cactus belts. Regional infestation coverage surged from roughly 80,000 hectares in 2020 past a projected 120,000 hectares by 2026, a trajectory the review’s author, Mulat Kebede of the Tigray Agricultural Research Institute, characterizes as a rapid post-war surge driven directly by the collapse of human governance.

The review, which followed PRISMA guidelines and distilled 170 core studies from an initial pool of 3,159 records across Scopus, Google Scholar, and Web of Science, quantifies the ecological toll in stark terms. In Tigray, four key indicators of ecosystem health, biodiversity, faunal habitat, soil fertility, and drought resilience, are projected to approach near-zero values by 2026, with biodiversity and faunal habitat plummeting from baseline scores of 100 to approximately 10. In the Eritrean Highlands, the decline is slightly less steep but equally sobering, with drought resilience falling from a near-perfect 98 in 2004 to roughly 32 by 2026. The social consequences are captured in a social crisis index that reaches 95 in Tigray, alongside a degraded land index of 92 and an economic loss index of 88, reflecting a regional catastrophe in which the loss of food security, livestock feed, and soil conservation has fueled rising food insecurity and youth migration from rural areas.

One of the most alarming findings concerns carbon. Managed cactus pear plantations in Tigray sequester approximately 12.8 tonnes of carbon per hectare per year, among the highest rates of any evaluated land-use category in the region, while naturalized wild stands in Eritrea sequester 8.9 tonnes and even abandoned farmlands recolonized by the cactus store 4.5 to 5.1 tonnes annually. Under sub-optimal growing conditions typical of degraded landscapes, the Food and Agriculture Organization and ICARDA estimate that cactus pear can generate sequestration rates equivalent to roughly 30 tonnes of carbon dioxide per hectare per year. As these stands die and their woody biomass decomposes, that stored carbon is released back into the atmosphere, threatening to transform a climate-smart carbon sink into an active carbon source. In a region already battered by drought and displacement, the loss of this biological buffer compounds both the humanitarian and the climate crisis simultaneously.

The review also formalizes the conceptual framework of the conflict-pest nexus as a self-reinforcing feedback loop. Armed conflict drives insecurity, displacement, and institutional disruption, which in turn produce governance failures: diminished surveillance, weakened early detection, inadequate pest control, and collapsed agricultural extension services. These deficits unleash biological outbreaks, marked by heightened insect reproduction and rapid geographic dispersal, which then drive ecological degradation and the loss of forage, soil cover, and ecosystem resilience. The resulting socioeconomic hardship, from plunging household incomes to deepening food insecurity, further erodes societal resilience and administrative capacity, feeding directly back into the initial instability. It is a cascade in which ecological collapse and human suffering amplify one another, and it explains why the cochineal crisis in the Horn of Africa has progressed so much faster than comparable invasions elsewhere.

Yet the research also points to genuine hope, grounded in tools that smallholders can deploy even amid instability. Laboratory bioassays and field trials have shown that aqueous extracts of Tree Tobacco, Nicotiana glauca, mixed with liquid soap surfactants, dissolve the insect’s protective waxy coating and achieve mortality rates exceeding 90 percent. Even more striking, methanol extractions of Solanum linnaeanum, which concentrate lethal secondary metabolites such as tannins, saponins, and alkaloids, have secured up to 99.3 percent pest mortality in controlled tests. These botanical biopesticides, alongside evaluated extracts from neem, Tagetes minuta, and Euphorbia tirucalli, offer a low-cost, decentralized alternative to synthetic organophosphates like Dimethoate, whose supply chains and ecological risks make them poorly suited to conflict zones. Complementing these interventions, tissue-culture protocols using Murashige and Skoog media enhanced with benzylaminopurine can regenerate completely pathogen-free, high-vigor planting stock, while the selection of cochineal-resistant genotypes is supported by documented smallholder willingness to pay for resilient clones.

The taxonomic complexity of the invader adds another layer of urgency. While Dactylopius coccus was the species originally introduced for dye production, ongoing regional monitoring indicates morphological and genetic overlap with Dactylopius opuntiae across expanded infestation zones. This distinction carries real operational consequences, because biological control strategies depend on host-specific predatory beetles such as Cryptolaemus montrouzieri and Hyperaspis species, whose effectiveness varies with the target biotype. Management protocols must therefore verify biotype susceptibility before releasing mass-reared predatory agents, a task that requires exactly the kind of sustained surveillance capacity that conflict has destroyed. In the Near East and North Africa region, where similar cochineal invasions threaten cactus systems, research has moved toward resistant cultivars and biological control; in the Horn of Africa, by contrast, the science has become what the review describes as a science of survival.

Halting the terminal decline, the review concludes, demands a coordinated package: immediate regional stability, formal cross-border scientific cooperation between Ethiopia and Eritrea, tissue-culture propagation hubs producing entirely insect-free clean planting stock, and the large-scale deployment of conflict-resilient integrated pest management that combines field sanitation, resistant varieties, and botanical biopesticides. The stakes extend far beyond a single crop. The cactus pear of the Horn of Africa is a soil guardian, a carbon vault, a famine buffer, and an economic lifeline all at once, and its loss would ripple through food systems, livelihoods, and climate commitments across the borderlands. Whether these highlands retain their prickly green ramparts, or watch them dissolve into white, waxy colonies of a runaway insect, will depend on whether peace and science can arrive before the last cladodes succumb.

Subject of Research: The combined impact of armed conflict and cochineal insect invasion on cactus pear ecosystems and ecosystem services in the Horn of Africa

Article Title: The conflict and pest nexus drives the catastrophic decline of cactus pear ecosystem services in the Horn of Africa

Article References: Kebede, M. (2026). The conflict and pest nexus drives the catastrophic decline of cactus pear ecosystem services in the Horn of Africa. Discover Agriculture, 4(1), Article 293. https://doi.org/10.1007/s44279-026-00762-6

Image Credits: AI Generated

DOI: 10.1007/s44279-026-00762-6

Keywords: cactus pear, Opuntia ficus-indica, cochineal, Dactylopius coccus, Tigray War, conflict-pest nexus, invasive species, carbon sequestration, integrated pest management, botanical biopesticides, food security, Horn of Africa