Recovering from multidrug-resistant tuberculosis in Somaliland

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After four years of caring for patients with multidrug-resistant tuberculosis in Somaliland, Médecins Sans Frontières/Doctors Without Borders (MSF) is handing over its project to the Ministry of Health Development.

When nine-year-old Mohamed fell ill, sweating heavily at night and coughing, his mother, Sabah, took him to the nearest hospital. He was misdiagnosed and the drugs he was prescribed had no effect. “He was prescribed some injectable drugs, but they didn’t work,” recalls Sabah. “He was not improving.”

Sabah took Mohamed to another hospital where he was prescribed different medications, which again did not help. “I couldn’t afford to pay for transport, so I had to walk everywhere looking for hospitals and prescribed medications,” she remembers. “It was a difficult time.”

It took three months before Mohamed was finally diagnosed correctly with multidrug-resistant tuberculosis (MDR-TB).

Diagnosing patients with MDR-TB and starting them on treatment in a timely manner have been major challenges for the under-resourced healthcare system in Somaliland, and this is particularly the case with children.

“Diagnosing TB in children is particularly challenging,” says Abdinur Hashi, MSF medical referent for Somaliland. “It is difficult to collect sputum from children, while the available diagnostic tools have limited sensitivity. MDR-TB is common in Somaliland, and having the correct diagnostics is key to ensuring that patients receive the right treatment from the start.”

Sabah felt relief when Mohamed was finally diagnosed correctly. But she also knew that the treatment would not be easy, which worried Sabah a lot.

TB, including drug-resistant forms of the disease, is a preventable and curable bacterial disease, but the treatment can be long and arduous. The bacteria spread through droplets in the air, so patients with any form of TB need to isolate themselves from others until the treatment course is completed. This generally takes from six to 20 months – but can take even longer. In addition, the anti-TB medications can sometimes cause severe side-effects.

At first, Mohamed was fearful of starting treatment at Hargeisa hospital. “I had to take too many pills,” he says. But with time and support from a hospital counsellor, Mohamed adapted to the treatment and even made friends with adult patients within the hospital compound.

For Sabah, coping with her son’s prolonged illness on top of all her other caring responsibilities proved to be both practically and psychologically challenging.

“It was a very emotional time for me,” says Sabah. “I have six other children at home and a sick husband. When I was at the hospital with Mohamed, I would think about my children at home. When I was at home, I would think about Mohamed.”

Psychosocial support for TB patients and their caretakers is paramount for helping patients stay on their course of treatment until the end.

Since 2019, MSF has been supporting the Ministry of Health Development in Somaliland to improve case identification and diagnostics and to provide holistic care to 198 patients with MDR-TB in Hargeisa general hospital and in three regional TB centres in Borama, Barbera and Burao.

Over the past four years, significant progress has been made in improving the quality of care for patients with MDR-TB, while fatality rates have dropped and cure rates have improved. Nevertheless, efforts to raise awareness about TB still need to be stepped up, as it remains a largely unknown or misunderstood disease, particularly in rural areas of Somaliland.

“I had symptoms for four years,” says Omar, an MDR-TB patient at Hargeisa hospital. “I didn’t know what I was sick with, but I felt a lot of shame and I didn’t seek medical attention. One day, I was listening to the radio when I heard about TB. This is when I realised that this might be the disease I have.”

After Omar was diagnosed with TB, he spent six months having treatment and went home feeling better. But the symptoms returned. This time, Omar had developed resistance to multiple drugs and had to begin treatment all over again.

“If I knew before what I know now about TB, I would have sought treatment early,” he says.

With significant progress having been made in improving the quality care for patients, and with health needs now at a more manageable level, MSF is handing over its MDR-TB project to the Ministry of Health Development, who will continue to identify cases of TB, raise awareness of the disease, and nurse patients back to health.

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