Women’s Experiences of the 1983-85 Ethiopian Great Famine: A Qualitative Study in Kobo Town, North Wollo Zone, Ethiopia

Phenomenology was employed as an approach to document the lived experiences of women about the great Ethiopian famine in Kobo district of North Wollo Zone. In-depth interview lasting for an average of 40 minutes were carried out among 10 key informants (women who survived the great famine). The interview was carried out using semi-structured interview guides with sucient probes and open ended follow up questions to exhaustively capture the narratives. Texts with similar code were pooled together and presented in narratives using verbatims as illustrations. Texts with similar codes were pooled together and organized into narratives.


Conclusion
The study provided a context-speci c understanding of the Ethiopian Great Famine which is one of the most catastrophic events of the 20th century in Ethiopia. The interviews described here call for further research to determine the long-term health and socio-economic impact of the famine.

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Ethiopia has a long and troubled history of famines including prolonged droughts and frequent and severe rain failure (1). Notably, a widespread famine affected Ethiopia from 1983 to 1985. Its epicenter was Tigray and Wollo regions of Ethiopia, and it was Africa's most signi cant famine (2).
Famine is characterized by excess mortality and high malnutrition in all the age groups of the population, complete destitution, social breakdown and distress migration as people abandon their homes in search of food (3). In assessing the nutrition situation of a society, women are preferred candidates to give narratives of the scenario due to their natural vulnerability, which helps in capturing the phenomena in a better way (4,5). Children born from women affected by famine may have metabolic, physical and cognitive consequences in later life (6). Therefore, understanding the famine context from the famine survivors pave the way for further study, particularly the long term impact of health and economic consequences (7). Greater depth of understanding can be gained through qualitative research which express using individual's own words (8).
In this study, women who survived from the 1983-85 Ethiopian Great famine were interviewed to share their experience during the famine. This is helpful from two overlapping, yet separate, angles. Firstly, famine leads to malnutrition, speci cally affects women which is a public health problem in low income countries including Ethiopia (9). Secondly, women are particularly affected by the famine shock and exposed to hunger mostly due to sex discrimination which is implicit in Ethiopian social systems (10,11).
Besides, women who had experienced famine may understand their lived experiences in different ways. As a result, interviewing women, who confronted the disaster helps to fully understand the hideous reality behind famine. Thus, perceived severity of famine and its overall portrayal is linked to long term consequences of repeated bouts of food insecurity in Ethiopia (12).
Having those assumptions by researchers and witness from literature makes this study more meaningful to the study area. There is no information on women's experience of famine/hunger although the occurrence of famine and malnutrition of mothers/children is prevalent in Ethiopia (13,14). This qualitative study is used to explore experience of individuals from the most affected population groups who had directly experienced the phenomenon. Hence, our study sets out to present in-depth exploration and analyses of the women's narratives of their lived nutritional experiences and copping strategies surrounding the great Ethiopian famine in Kobo district, North Ethiopia.

Study Setting
The study was conducted in Kobo Town, Northeast Ethiopia, as it was the epicenter of the 1983-85 Ethiopian Great Famine. Waja, a small village between Kobo Town and Alamata was the area where the famine rst started (1,15). Because of repeated crop failures, and in part, because of the ghting and civil disruption in northern Ethiopia, large numbers of peasants started to migrate to the roadside towns of Kobo at the time of the crisis (2). Raya Kobo District covers an area of 2,001.57 square kilometers and is located between 11° North and 38° East. This district has an estimated total population of 228,798 (147,837 females, 80,961 males). The district has 36 kebeles (the lowest administrative units of the district); 4 of them are urban and 32 are rural.

Study design
A qualitative study using phenomenology approach was employed to explore the lived experiences of women. This approach aims to avoid assumptions about how people interpret their experience.

Access And Recruitment Of Study Participants
The participants were purposely selected by considering their experiences and expertise regarding their exposure or knowledge of the context of the Great Famine. Women were selected based on their experience with the phenomena, interest to participate in the study and the ability to disclose their experience to the investigator. Local leaders and health extension workers were used to reach women who had exposure to Ethiopian great famine. The data were collected through in-depth interview lasting for an average of 40 minutes were carried out among 10 key informants (women who survived the great famine).

Data Collection Tools and Procedures
The in-depth interview guide was prepared by the principal investigator and further re ned by inputs from experts in qualitative research and pre-tested in order to ensure its relevance and appropriateness. Data collectors were trained in conducting qualitative interviews. The interview was conducted by two individuals-one speaker and one note taker who have signi cant experience in qualitative data collection. The principal investigator was involved in the interviewing process. The interviews were conducted in the home of the participants in the absence of other individuals except the researchers. The in-depth interview was recorded using digital voice recorder.
Interview guides were developed through review of famine and drought-related literatures. Semistructured interviews questions were used to explore the women's experiences of the famine at the time of its occurrence. The tool was organized under six discussion areas and each participant was asked to give a narrative of what happened on each of the topics identi ed beforehand: (1) the perceived severity of the Great Famine; (2) the duration of the famine and its cause; (3) the socioeconomic groups and areas affected by the famine and how they varied from home to home; (4) coping/survival strategies; (5) the availability of a diversi ed diet for pregnant and lactating mothers and children during the famine; and (6) the diseases related to prolonged famine to which people were more prone to. Each of these major themes was accompanied by several follow-up questions and key probes to get deep insight of women's lived experiences with respect to the Great Famine. A narrative approach was used to give the women give the in-depth description of the scenario during the famine uninterrupted with guiding probes in between. Women were probed to give examples to get metaphorical expressions and catchy verbatims.
Field notes were taken and the interviews were audio recorded after getting the consent of the key informants.

Data Analysis
All interviews were transcribed verbatim and then translated into English by language experts and analyzed with the assistance of ATLAS.ti 7.1.4 (Scienti c Software Development GmbH, Berlin, Germany). The transcripts were read and re-read by research teams who came up with an initial coding structure and then assigned codes. Each researcher independently coded each interview. The initial codes were subjected to discussion and coding disagreements were resolved by consensus as new codes emerged from the text. Then, codes were grouped into code families and sub-themes. Then, results with similar codes were pooled together and organized into narratives.

De nition of Terms
Famine A widespread scarcity of food caused by several factors including crop failure, population unbalance, or government policies. This phenomenon is usually accompanied or followed by regional malnutrition, starvation, epidemics, and increased mortality (16).

Disaster
A serious disruption of the functioning of a community or society causing widespread human, material, economic, or environmental losses which exceed the ability of the affected community and society to cope using its own resources (17).

Drought
A period of below-average precipitation in a given region, resulting in prolonged shortages in its waters supply, whether atmospheric, surface, or ground water (18).

Trustworthiness
Various quality control measures were implemented to ensure the trustworthiness of the ndings.
Data collectors and eldwork supervisors were trained, and the appropriateness and relevance of the data collection tool was ensured through expert reviews and pre-testing. The eld team held debrie ng sessions each day throughout the duration of the eld work. Facilitators' and note takers' impressions were documented for each data source.

Results
A total of 10 women between 54-60 years who survived the 1983-85 Ethiopian Great Famine were interviewed. The data were saturated at ten in-depth interview. Three participants reported to have given birth during the famine, and their children are alive at the time of data collection. Two participants reported to have lost their husbands because of the famine, while two others stated that they lost their daughters.
Experiences of women during the famine Experiences in this paper include stories from ten women. Their stories are powerful and included heartbreaking accounts of the painful events during the Ethiopian Great Famine. Participants re ected on a variety of themes, but one overarching theme emerged was: 'A catastrophic famine and severe loss of human life'. This was a participant's description that re ected other accounts of the global experiences of famine from the women's perspective. Furthermore; sub-themes were described as: perceived severity of the Ethiopian Great Famine, the duration of famine and its causes, socio-economic groups of the society and area affected by the famine, coping strategies used, availability of diversi ed diet for pregnant women, lactating mothers and children, and common diseases that prevailed during the famine.

Perceived severity of women towards the Ethiopian great famine
In response to this theme, the majority of the participants mentioned: "…The famine was a catastrophic event in Ethiopian history. It was a very dry season. We survivors only survived after many ups and downs".
"…The dead were seen lying in the streets of the cities and on roads leading into towns. The exhausted, sick, and naked starved people move around the towns and villages hopping to nd food".
...I felt very sad! Individuals were seen walking around without clothing. They covered only their private areas. People laid on the ground… It is better not to remember the famine.
"…About 30-40 people died each day. The dead people were piled together to be transported later to the cemetery, where large pits were dug to bury the dead. About 5-6 people were buried in the same pit". [Participant one] "…Kobo Town was highly affected. All people migrated from the neighboring districts towards the Town. The local people call the famine 'Evil Days". [Participant two] "The famine was the biggest disaster that I have seen in my life. I don't want to remember that shock. There was no food at all, and getting food for survival was not easy. …the pain is still in my mind. It is unforgettable-such 'Evil Days'. Mostly rural people died." [Participant one] …I remember one case where a baby breastfed from her dead mother near our fence…. My mother brought the baby in and took care of it.
"…I don't want to remember that evil day, especially the way people died was very sad. In my home I watched my relatives die-my daughter died while breastfeeding". [Participant two] "...I was without food for 3-4 days. I lost my three-year-old daughter. We were too thin/wasted and easily failed even when there is a wind…. And those from rural areas were highly affected. They died here [in Kobo Town] but no one was there to bury them. We experienced famine here after 1984, but not it was not nearly as devastating as the Great Famine. I will never forget the Great Famine." [Participant three] Some of the women perceived that the crisis was exacerbated since people migrated to Kobo Town from neighboring villages: "…We came here from a place called Zobile. Because of that [the famine period], we are still living here in Kobo Town… We knew that people with different religions (Muslim and Christian) were being buried in the same ditch… My uncle vanished at that time, and we still don't know where he is". All women agreed that the famine duration was for two years from 1983-85 and was the worst disaster in living memory. The famine is known as 'Evil Days' by the local people.
Likewise, all women agreed that absence of rain (drought) for two consecutive years disproportionally impacted women. They tried to associate drought with climatic changes or changes in the natural environment.
…The crops failed to grow. Because we are dependent on rainfall for agriculture, when there is no rain, then no crops grow. We always waited for the rain. In between there were also local con icts which exacerbated the situation. Some people considered this drought and famine as an act of God.

Socio economic status and areas affected by the 1983-85 famine
This theme is to ascertain whether all households were equally affected and whether there are areas free from famine. All participants noted that no places around Kobo Town were free from famine.
"…In my compound all houses were affected by the famine; all places were touched by the famine… No homes were free from stress… All rural and urban areas were affected. All socio-economic groups were equally affected. Of course, the time of exposure [to the famine] may be varied... but everyone was affected". [Participant six] Coping strategies The respondents also pointed out the different coping mechanisms to were used to cope with reduced access to food.
"… Before the famine reached the peak stage (1984-85) ... people used different coping strategies like working longer hours and focusing on increasing income and limiting expenditures... Men migrated to the city for temporary work, women became the heads of their households and had more work and therefore less time to care for their children. People also reduced their food intake, searched for temporary employment in towns and sold things like utensils, jewelry, charcoal, and furniture". "…Change in diet (consumption of wild foods, cheaper foods, etc.) was also a coping strategy. We ate 'Argagisa Zaf,' a kind of local [drought-resistant] tree which is called." [Participant ve] "…Finally, people started to sell goods that were essential for their future livelihoods such as tools, seeds, and livestock or slaughter their livestock; they had to mortgage their farmland or house, sell their farmland or house-all in exchange for staple food". [Participant eight] "…I heard that one big ox was sold for eight Ethiopian birr… this was unforgettable. Because the ox owner believed that selling with eight is better than dying. Since there is no grass and straw to feed them, the animals would die. By using eight birr he could buy two injera (a staple food in Ethiopia)". The other problem related to food aid was: "…Individuals were screened based on their weight and the aid was given to the wasted (thin) people. For those wasted people a 'ticket' (an identi cation card for those are eligible for aid) was given to them. It was used to determine whether a person was famine exposed or not. The aid started on July 1983… There were many ups and downs to get a ticket". [Participant seven] "…I would never forget the famine… The ght for life was a daily struggle…. We were forced to eat dogs, cats, rats, roots, skins, bones from the ground just to survive. Infectious diseases were rife. This was completely against our communities' culture. This was too embarrassing and sickening… I saw people eat dead livestock that had died of starvation themselves." [Participant three] "…I remember one of my relatives. She got an ox head skull, boiled it, and ate it". [Participant ten] Diversi ed diet for pregnant, lactating mothers and children Understanding this theme is used as an evidence to recognize whether the women in Kobo Town were really exposed to deprivation of nutrients or not. A diversi ed diet for pregnant and lactating mothers implies that the pregnant mothers and lactating mothers prone to shortage of both micro and macronutrients are in the early life might be related to adulthood disease (19). This could create another opportunity to further quantify the relation between famine exposure in the early life and adulthood diseases (7). All women agreed that getting diversi ed diet at time was unthinkable.
When asked this kind of question, the women replied: "…Are you joking?! Even getting injera for pregnant and lactating mothers or children was di cult. We simply shared any of the food we could get. There was no special (diversi ed) diet-that would be impossible (unthinkable). Food aid was given based on body size. There was no special food aid for pregnant mothers, lactating mothers, or children. In fact, one thing we cannot deny is that many children survived because of the food aid". [Participant eight] Common disease during famine and the age group expose for famine mortality The participants described that the common disease which were associated with famine described by the women included diarrhea, vomiting, meningitis, and typhus. Starvation by itself was also the cause of death as described by the interviewees.
"…Diarrhea was common among the famine affected people. Because people were eating dead animals or things off the ground, and there was no health center ate time… I remember one of my uncle's sons… He went around the town looking for anything to eat and brought back a lot of abandoned parts of dead animals. He strung the meat upon the fence, boiled it, and eat at night. He died shortly afterward of diarrhea". [Participant nine]

Discussion
To our knowledge, this is the rst qualitative study which explored women's lived experience about the Ethiopian Great Famine. The women provided important insights about the worst famine of the 20th century, which gives a deeper understanding of the crisis.
In the study, interviewees described the famine as 'very catastrophic'. Most of the participants described it as the biggest disaster that occurred in their life. The pain is still in their mind and they remember the time as the 'Evil Days'. The participants concurred that the two years (1984-85) was the peak of the crisis, which is consistent with other reports (15) which classify the famine as one of the worst to have ever hit Ethiopia and one of the worst in recent world history. Up to a million people may have died, and many more were left destitute, making it one of the worst famines in recent history (1).
The participants witnessed that there was both internal and external displacement during the 19854-85 Great Ethiopian Famine. This is due to the fact that permanent emigration, rural-to-urban migration, and sometimes the settlement into new agricultural areas is one of the long-term consequences of famine (20), as people are forced to leave their homes during periods of famine. The women stated that many people migrated to other parts of Ethiopia, particularly to southern and western Ethiopia as part of famine mitigation intervention. Historically, during famines in other countries such as France (21), Belgium, Russia (22), Ireland (23), India (24), peasants migrated to different parts of the continent.
In this study, the social impact of the famine on the population was also noted. The respondents explained that people did not seek to help each other through this time and instead began doing terrible things just to survive-for example, a wife stole food from her husband (as described by a 58-year-old study participant). Initially, there is likely to be mutual help among kinship groups or friends and attempts at preferential concern for the vulnerable, especially children and the elderly. However, as famine progresses in severity and duration, normal social behavior-including personal pride and sense of family ties-gradually disappears, leaving only a struggle for personal survival. In society as a whole, this pattern of family breakdown is seen in a magni ed form, with increasing disintegration of social structures, lawlessness, and abandonment of cooperative efforts as famine reaches its later stages (1,25). Our nding is supported by studies conducted in France during the eighteenth century in which social disturbances increased with the worsening of the economic situation of the masses and the deterioration in their diets (26).
The starved people during Great Ethiopian famine described as 'sticks' (skeleton) or 'dry beef' (a body without esh). This is explained by the relationship between starvation and protein de ciency as a result of prolonged famine (27). As the participants describe, the people were without food during the Ethiopian Great Famine for many days.
The study also tried explored the duration and the causes of Great Ethiopian famine. Different documents written on the duration of the famine reported different timing. Knowing the year of crisis is helpful to identify who was and was not exposed to the famine. This, in turn, helps to explore the long-term impact of the crisis including the health and economic consequences (28). The participants agreed that the famine duration was for two years 1983-85 (1976-1977 (29). Similarly, the reports of Gill (1986) (30) and Africa Watch Committee (1991)(2) a rmed that continuing drought meant that many harvests failed towards the end of 1985. The crisis stopped towards the end of 1986 when harvests were at almost normal levels.
As revealed by the respondents, the cause of famine was drought, which is consistent with a study conducted in Zimbabwe (31) and Kenya (32). This implies that such a dependence on rain fed agriculture makes many countries more prone to such kind of crisis, especially now in the era of climate change (33).
In this study, the civil war between the 'Derg' regime and local bandits were described as exacerbating the famine. This is consistent with famines in Ukraine (34), the Netherlands (35), and Nigeria (36).
Concerning the issue of whether the famine equally affected all parts of the areas and households, altogether respondents pointed out that the entire kebeles (smallest administrative units in the district) and districts near Kobo Town were affected. All the households and all socioeconomic groups of the society were equally affected and stressed due to the famine. This nding is consistent with other reports in Ethiopia (2,37).
Regarding the coping strategies, the respondents described a series of survival strategies to minimize the impact of food shortage for all household members. Understanding coping strategies through an in-depth investigation of individual experiences can provide an insight into the various potential coping strategies to manage starvation. The respondents revealed the following coping mechanisms: longer work hours, limiting expenditures, reduction in their food intake, labor migration (search for temporary employment in towns), and sale of nonproductive assets (utensils, jeweler, wood, charcoal, furniture). This nding is consistent with other countries which were struck by famine-Russia (Leningrad) (38), China (39), Nigeria (36) and Kenya (32).
The respondents also explained about the relief in the form of food from the government. However, the aid did not reach the affected individuals due to internal and external factors including political factors.
In this study, women were interviewed about the availability of diversi ed foods for pregnant and lactating mothers and children which has an impact on the future health of a child. All of the women interviewed agreed that a kind of diversi ed diet for pregnant and lactating mother and children such as fruits, vegetables, cereals, meat, and milk were impossible to access. This is an apparent evidence to investigate the permanent effects of undernutrition in early life (39). The Dutch Famine of 1944-1945 is one exceptionally well-studied famine that supports this assumption. In this situation, a previously wellnourished and healthy population suffered an average calorie intake of 670-740 for six months and a de cient diet for the preceding year (35). This implies that all other major famines in this century have involved previously undernourished and underprivileged populations, and famine effects could be more severe because they are superimposed on chronic undernutrition and a high prevalence of infection (41).
In this study, disease such as diarrhea, vomiting, meningitis, and typhus were the common causes of death during famine period. It is known that famine is a catastrophic food crisis that results widespread acute malnutrition (42). Malnutrition weakens the body immune system which increases the body's susceptibility to infection (43).
People also died of starvation-mainly from dysentery and vomiting. This is as a result of deterioration in the health environment-overcrowding, poor personal hygiene, and the movement of populations-which leads to epidemics of infectious disease that cause high mortality rates. This further worsens nutritional status, which is considered an underlying causes of famine mortality (44). For example, in the Warsaw ghetto in 1940, not starvation per se-but typhus, diphtheria, and virulent tuberculosis-were the great killers. Not only adequate provision of food, but also access to curative health care, environmental sanitation, and shelter can avert many deaths due to famine (45).

Conclusion
The study highlights key issues such as the severity of famine, duration of famine, coping mechanisms, and the absence of food for all groups of families (infants, pregnant women, or the elderly). This description of the severity of the famine, lived experience, and coping mechanisms has been useful to highlight the scarcity of existing evidence related to the Ethiopian Great Famine. Despite being one of the worst human crises in Ethiopian history, the world still has a lot to study and learn from the famine. The interviews described here call for further research to determine the long-term health and social impact of the famine.

Declarations
Ethics approval and consent to participate Ethical clearance was obtained from the Institutional review board (IRB) of Jimma University. An o cial letter of co-operation was obtained from the IRB (Ref. No. JHRPGD/660/2019) and given to the health o ce of the Raya Kobo district. Verbal consent approved by the IRB was obtained from each participant before the start of the interview. The purpose and importance of the study were explained to the study participants. Due to the high illiteracy, it was considered impractical to obtain written consent from each study participant. The verbal consent was documented and witnessed by the third party. To maintain privacy and con dentiality, interviews were conducted in private rooms. Further, identifying information was not associated with the transcribed interviews used for analysis, and all digital recordings and identifying data were kept in a separate, secure location.

Consent for publication
Not applicable.

Availability of data and materials
The data used and/or analyzed during the current study are available from the corresponding author on request.

Funding
The study was funded by Jimma University Institute of Health. The institutedid not have a role in the study design; collection, analysis, andinterpretation of data; or in writing the manuscript.

Con ict of interest
The authors declare no con icts of interest. COREQChecklist.pdf