TB Monitor International-Jail, fines boost compliance
For Somalis, it works
On the front lines of the global fight against TB, trying to ensure patient compliance has always been dicey and difficult.
Health care providers in Somalia have evolved an unusual approach that seems to work: A friend or relative agrees to ensure a TB patient finishes treatment. If that friend or relative falls down on the job, he's fined or even arrested. The use of a guarantor, or Dameen, is widespread in Somalia, and — perhaps as a result — national default rates stand at an impressively low 4%.
Asking a friend to risk a fine or jail time strikes Somalis as perfectly reasonable, adds a local TB expert. "Somalis have strong ties and close family bonds. Finding a Dameen in time of need is not a problem," explains Firdosi Mehta, MD, an officer working for the World Health Organization in that country.
One of the foremost practitioners of the Somali method for gaining adherence is Annaleni Tonelli, an Italian who works in the city of Boroma in the northern part of the nation known as Somaliland. A lawyer by training and a teacher who's devoted 25 years of her life to fighting TB in both Kenya and the adjacent Somalia, Tonelli has added her own refinement to the system, says Mehta. Because many patients must travel long distances to reach the hospital, the Dameen also is required to provide housing for the TB patient in the form of a simple hut, which joins a cluster of other huts, known as a manyatta, in the hospital courtyard, explains Mehta.
Although those who are seriously ill are given hospital beds until they improve, TB patients are expected to live in the manyatta for the duration of the six-month treatment. There, they receive therapy under strict observation. Tonelli supplies three hot meals a day, plus added incentives such as literacy classes and Koranic instruction.
Tonelli is a storied figure whose exploits have been widely featured. With only diploma courses in TB, she left a teaching post in Kenya and began doing TB work on the border of Kenya and Somalia at Wajir, where she originated the manyatta concept. She later moved to Merca, a Somalian city close to the capital of Mogadishu, where she ran a big TB hospital. During the civil war, after one of her colleagues at the hospital was shot and killed by militia, Tonelli returned briefly to Italy. In 1996, she came back to Somalia and began the hospital in Boroma, which she runs now.
She operates the facility on about $6,000 a month, raised from friends and supporters in Italy, says Mehta. WHO provides in-kind donations, including drugs and lab reagents, and oversees Tonelli's work. Cure rates at the Boroma project in 1998 were 91% of 929 cases evaluated. The region in which the hospital is located, Awdal, has a population of about 150,000. Patients include a mix of Ethiopians and Somalis.
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