Somalia: MSF Begins TB Treatment Program in Rural Areas of Middle Shabelle Region

Interview with MSF Medical Coordinator in Somalia Luis Neira

"Health indicators in Somalia have been known to be, for many years already, some of the worst in the world and TB is not an exception."

Doctors Without Borders/Médecins Sans Frontières (MSF) is present in eight regions of Somalia, with more than 1,300 Somali staff providing medical care on the ground. Medical coordinator Luis Neira is part of the MSF team based in Nairobi that remotely supports operations in the war-torn country. He serves as the medical reference for projects in Mogadishu and north of the capital in Middle Shabelle region.  

In several districts of Middle Shabelle, MSF has been providing basic medical care through a network of four health centers in urban and rural areas, as well as a maternity unit in Jowhar town. On June 5, MSF teams began providing diagnosis and treatment of tuberculosis (TB) in the rural areas of Mahaday and Gololey. Here, Neira describes the program.

What is the situation in this area with regards to tuberculosis?

The situation with regards to TB in Middle Shabelle is not different from that in the rest of the country. Health indicators in Somalia have been known to be, for many years already, some of the worst in the world and TB is not an exception. Based on the statistics produced by the World Health Organization (WHO), which have not been updated since 2007, this disease kills over 5,500 people every year.

Through our health centers we have been able to identify a number of suspected TB cases, whose final diagnosis and treatment have been very difficult due to the shortage of programs in the area. The situation is more pressing in the rural areas of Mahaday and Gololey, given that the nearest program, which is the one in Jowhar, is located very far away and this makes it difficult, when not impossible, for rural and nomadic populations in these areas to have access to treatment. This situation has prompted us to open a TB program that enables us to assist sick people who did not have access to this type of care.

What do the services offered by MSF consist of?

Suspected cases are identified in the medical consultations we carry out in our primary healthcare centers in Mahaday and Gololey. Then patient samples are tested in a clinical laboratory equipped for the program and the disease is thus diagnosed and treated. Furthermore, the patient is provided with clinical follow-up, counselling, a medical check-up is conducted for people who are close contacts to detect whether they have TB or not, particularly children under five. And nutritional support is provided to patients who are malnourished due to the disease.

To treat TB, WHO recommends the so-called DOTS (Directly Observed Treatment Short-course) strategy, where patients must take medication under supervision from health staff. This is in order optimize adherence and avoid the development of drug resistance. How can this strategy be implemented in a country as unstable as Somalia?

WHO’s DOTS strategy will be used with the patients that are able to go to the health center on a daily basis. A modified DOTS strategy will be implemented for those patients finding it difficult to go daily, either because they live too far away, or for other reasons. This modified strategy enables them to receive their first dose under supervision from health staff and then continue their treatment at home until their next scheduled appointment at the health center.

We ask that each patient has a treatment assistant. This can be a family member or a friend who will make sure that they take the medication as prescribed. This person is also responsible for informing health staff whether the patient is following the treatment or letting them know if they are suffering from any side effects from the medication. In this way, the burden of following the treatment regime is reduced for the patient. We also find that their adherence to the program is enhanced as they do not need to go to the health center daily, something difficult for rural populations, and they have someone to count on who will encourage them to take their medication on a daily basis.

TB in southern and western African countries has recently been related to HIV/AIDS and outbreaks of resistant strains have also been reported. Are these also concerns in Somalia?

Accurate data is very limited as very little work has been done regarding HIV/AIDS and drug-resistant TB in Somalia. However, we assume that resistance may be a major problem in Somalia. In the few places that treatment is available it is very badly managed, and anti-TB drugs are often sold over the counter in private pharmacies, which means uncompleted, shorter treatments and dubious-quality drugs—another reason that the MSF program is so important.

For the last two years MSF’s programs in Somalia have been run by national staff, supported by management teams based in Nairobi, due to the ongoing insecurity. How have you trained the team in TB diagnosis and treatment?

For our TB team we selected health staff already working in our project in Jowhar, people who have experience and medical skills, and they have been joined by a new laboratory technician who has a great deal of experience in MSF’s TB programs. We have also hired a medical officer specialized in respiratory diseases, who has been working in MSF’s TB programs in Kenya. She will provide technical support to the team from her base in Nairobi and will visit the field whenever possible. This team has received four months of training in TB management and in the overall program. The training has included a theoretical, as well as a practical, component in the TB programs that MSF has conducted in Kenya and other regions of Somalia.

TB Diagnosis and Treatment

TB is a contagious disease transmitted through the air. In its pulmonary form, it is characterized by a persistent cough, shortness of breath and chest pain. In addition to the lungs, the infection can also affect almost any part of the body, such as the lymph nodes, the spine, or bones. One-third of the world’s population is currently infected with the TB bacilli. Every year, nine million people develop active TB and close to two million die from it.

The most widely used technique for diagnosing TB in developing countries is examining a suspected patient’s sputum sample under a microscope, a method developed well over a century ago, and it detects less than half the cases of TB. Currently, the best alternative is a culture which consists of incubating a sputum sample to see whether it contains live TB mycobacteria. This technique is more accurate, but must be done in a laboratory with trained personnel and may take up to eight weeks.

Drugs used to treat TB were developed in the 1950s, and a course for uncomplicated TB takes six months. Poor patient management and lack of adherence to treatment has led to new strains of bacilla that are resistant to one or more anti-TB drugs. Multi-drug-resistant TB (MDR-TB) is the most serious form, defined as when the strain is resistant to the two most powerful first-line antibiotics. MDR-TB is not impossible to treat, but the required regimen causes many side effects and takes up to two years. Extensively drug-resistant strains of TB (XDR-TB) have been identified, making the treatment even more complicated.

MSF has been working in southern central Somalia continuously since 1991. Currently, the organization is present in eight regions of southern central Somalia: Banadir, Bay, Hiraan, Galgaduud, Middle Juba, Middle Shabelle, Lower Shabelle and Mudug.

MSF does not accept institutional funds for its projects in southern central Somalia. All funding comes from private donors.