There is hopefully a universal expectation, however idealistic, that those with serious illness can have access to safe medical facilities. While the desires of medical providers may be noble, the lack of resources is always an issue. In the case of Somalia, a country without any government for 15 years, state resources are not an option. That leaves only for-profit medicine most people cannot afford or not-for-profit Non-Governmental Organisations (NGO’s) - now the backbone of Somali society - to provide services.

SAACID is such an NGO. Among other health services, SAACID has been operating much-needed TB clinics since 1994. There is no doubt that the services provided are in high demand. At SAACID’s Mogadishu dispensary, every morning a minimum of 260 patients gather for their medication, donated by WHO. However, try to measure what is adequately safe for a medical facility, when the responsibility for providing treatment to the vulnerable is carried entirely by under-funded local NGO’s.

Stepping onto the porch of the SAACID TB clinic one fears falling through the floor. Made up of large thin wooden planks covering 3-feet of hollow space, the floor wobbles and sinks. A new TB patient weighing 35 kilos on average could possibly walk across the floor with no problem, but then their frail body often requires an escort. Termites have invaded the building in recent years and eaten away the walls. The ceiling in most of the rooms, including the laboratory is caving in, with random wires and shafts hanging.

Daring to walk the ‘plank’ Daily routine outside the clinic

The fact that SAACID has managed to run this clinic under the current conditions is both a disgrace and a blessing to the patients. Before the war the grounds on which the SAACID facility was built was a TB clinic, but run and owned by the government. SAACID got permission from elders in the district to resume operations in the grounds and a new structure was built; and operations began at the site in 1994. Everything was fine until 2003, when termites attacked the building and have largely decimated it. Since that time, SAACID has been unable to secure donor(s) to rehabilitate the building (the estimated cost is US $13,500).

Back side of TB clinic Clinic toilet eaten out by termites

The building’s deterioration in no way represents the extent to which it is utilized. Of the 6 currently operating TB clinics in Mogadishu, SAACID’s clinic is the only one operating in the north of the city – covering an estimated population of 360,000 people. People come from villages up to 500 kilometres away to be treated, proving that even crumbling facilities such as this one are few and far between.

Ceiling eaten out by termites Laboratory room in disrepair

Hururo Agey first came to the clinic 4-months ago from Adaleyheh village; some 400 kilometres outside of Mogadishu. The first symptom she experienced was a strong burning sensation up the sides of her body. Her husband had her treated with recitations of the Holy Quran. Unsuccessful, he suggested she had the same disease that he had a short time before. He arranged for her weak body to be transported to the SAACID TB clinic in Mogadishu, where he had also received treatment. Hururo had cared for her husband when he was sick, near him while he was coughing blood, and washed his clothing, dirty from mucus and vomit.

Hururo waiting for her daily course of treatment Hassan Omar taking TB medication

Often the disease is spread from one family member to another. Hassan Omar, a relapse patient, was first diagnosed with TB 8 years ago; his son 3 years later. He comes from a village some 500 kilometres from Mogadishu, but has remained in the city since his first treatment. His family assisted him with travel and medication by giving him a camel to sell, and connecting him with distant relatives. Hassan used to herd livestock, but now he becomes easily tired and can’t walk long or work very hard.

Certainly the cases of Hassan and Hururo are not uncommon. According to the World Health Organization (WHO), TB has been declared an emergency in Africa:

· There are 1,500 TB deaths every day in Africa

· TB killed half a million African people last year, mostly young men and women in their most productive years

· Africa is the only continent where TB rates are increasing

· In just 15 years, overall rates have doubled; tripled in high HIV areas; and quadrupled in countries worst-affected by HIV and TB

SAACID TB patients have indicated a strong need for inpatient care, particularly because relative care-givers are highly at risk. When the TB is active the patient experiences high fever, along with coughing and vomiting blood. There is a strong phobia people have of TB and some relatives fear to help. In addition, some patients coming from far do not have relatives to stay with in the city, increasing their costs. Certainly the building’s limitations, and the lack of resources, keep the clinic from providing inpatient services and anything beyond basic TB treatment. Even with other donations of medicine from international agencies for a variety of health needs, local NGO’s do not have funds to run ‘add-on’ programming to fully utilise what could be offered.

Hururo does not wish to return home to Adaleyheh once her treatment is complete. “If I had known Mogadishu was better than the bush, I would have come to the city long ago. Life is too hard in the bush. You walk long distances to fetch water. Here water comes from the tap”. She says she has one camel that she can sell and start a small business. Ironically Hururo, having never been to Mogadishu before, holds that opinion without having experienced the beauty of the city prior to the war.

Hururo’s opinion holds high significance considering Mogadishu’s ongoing malaise and grinding anarchy. Hururo and Hassan’s desires to remain after treatment seem to prove the thriving life of this city, and its pull as a centre, whether for TB treatment, business interests, or otherwise. Hassan wishes for security, good governance and social services, but seems intent on remaining in this city even if the city remains in a state of ongoing lawlessness.

Called by need and responsibility, and despite the risks and limited resources, SAACID is dedicated to serving patients under the current circumstances. As long as the Mogadishu clinic structure allows, Hururo, Hassan, and others unfortunate enough to contract this illness will continue to have a place to come for treatment. As with everything in Mogadishu today, security is a relative term – how much worse must life be in forgotten rural areas? Yet, SAACID only has inadequate funding for one urban (Mogadishu - 1.2 million people) and one rural TB clinic. The need is overwhelming and no real interest from the international community to alleviate the problem.