1 Tuberculosis in Somalia

Although the project was initiated by FATA, the Somalis also had an obvious interest in collaborating. According to an estimate, one per cent of the general population and ten per cent of the refugees in Somalia were bacteriologically positive and thus infectious. Addressing TB was one of the main targets of the MOH’s five-year healthcare plan for the years 1981–5.Footnote ³¹ It coincided with the waning of international interest in anti-TB work,Footnote ³² having once been one of the main targets of the WHO and the United Nations International Children’s Emergency Fund (UNICEF) in the 1950s and 1960s.Footnote ³³ The first vertical anti-TB campaign had been implemented in Somalia in 1953 by the Italian administration of the UN trust territory of Somaliland.Footnote ³⁴ The WHO and UNICEF supported the establishment of treatment centres for TB in Hargeisa in the late 1950s, and in Mogadishu just after independence in the early 1960s. They also funded the establishment of the Somali NTCP in 1971 and its implementation in the years following.Footnote ³⁵ Such national programmes had become the WHO flagships for TB control in Africa.Footnote ³⁶ In Somalia, the aim was to expand TB services nationwide by establishing national tuberculosis centres and walk-in or ‘ambulatory’ treatment centres in each district.Footnote ³⁷ By 1980, however, TB had become a neglected disease due to the WHO running into financial difficulties, the disappearance of TB from developed countries, which decreased the general interest in the disease, disappointment with the results of TB control efforts and the Alma-Ata Declaration in 1978, which prioritised the development of primary healthcare (PHC) over specialised vertical programmes concentrating on one disease.Footnote ³⁸ The governmental agreement between Finland and Somalia notes that although there were many donors for public healthcare, there were none for tuberculosis services. The WHO and UNICEF were planning to discontinue their aid to the NTCP after 1980/1.Footnote ³⁹ Thus, a new donor was needed.

As a bilateral aid initiative, the Project was officially based on mutual negotiations between Finnish and Somali parties.Footnote ⁴⁰ The key Somali experts were the director general of MOH, Dr Mohammed Muse Gure, and the director of the NTCP, Professor Yusuf Hersi. They made it clear that Somalia wanted assistance with expanding NTCP among the Somali population. They requested the construction and renovation of TB centres (one in every region), training for anti-TB medical teams and material support in terms of medicine, equipment and transportation.Footnote ⁴¹ FATA, however, had planned to start the Project in the Qoryoley refugee camps. The camps had been established after the Ogaden War between Somalia and Ethiopia in 1978–9. The refugee situation had already received a lot of international attention, as the Somali government had recently requested international emergency aid for the camps.Footnote ⁴² There were officially 70 000 refugees in Qoryoley,Footnote ⁴³ but in 1981 Sellergren estimated the number to be only around 4500.Footnote ⁴⁴ Hellström and Brander drafted the first Project plan for refugee aid immediately after their visit and handed it to the Finnish Ministry of Foreign Affairs on 11 June 1980.Footnote ⁴⁵ This was revised by FATA in July.Footnote ⁴⁶ The governmental agreement between the Finns, Hersi and Muse Gure, plus the plan of operation, were drafted in August 1980.Footnote ⁴⁷ The long-term objective was to support the NTCP – demonstrating that both the Finns and the Somalis wanted to continue aid after 1981Footnote ⁴⁸ – but in practice, FATA’s earlier plans from June and July were carried out. This prioritised the detection and treatment of tuberculosis in the Qoryoley refugee camps by the Finnish team (nurse, laboratory technician and X-ray technician led by a doctor), and to give practical training to their Somali counterparts.Footnote ⁴⁹

In the 1980s, the two most influential players in global TB policy were the WHO and the IUAT. The WHO Expert Committee’s periodic reports were seen as ‘guides to the global TB problem’.Footnote ⁵⁰ IUAT, an international NGO for tuberculosis control and umbrella organisation for national tuberculosis associations around the world, was one of the few organisations that still focused on TB in the 1980s, when most donors had lost interest in the disease.Footnote ⁵¹ Like the majority of African countries,Footnote ⁵² the national tuberculosis programme in Somalia followed the WHO standard treatment: patients were diagnosed using sputum microscopy and given a long-term combination course treatment of inexpensive drugs such as streptomycin, isoniazid and thioacetazone for twelve months.Footnote ⁵³ IUAT’s Tanzania programme also followed these principles in 1977–81.Footnote ⁵⁴ Based on the studies undertaken in Madras (1956–9) and Bangalore, India, the WHO standard treatment was intended as a cost-effective means for combating TB.Footnote ⁵⁵ The challenge with TB is that it is a disease closely tied to social and environmental conditions. Inadequate living and working conditions, overcrowding, malnutrition and poverty – typically related to developing countries – all increase the risk of infection and the chances of a latent disease becoming active. Matters are often made worse by the lack of healthcare infrastructure and material resources to treat the large number of patients falling ill under such conditions.Footnote ⁵⁶ The WHO TB control policy had prioritised the Bacille Calmette-Guérin (BCG) vaccination campaigns rather than treatment.Footnote ⁵⁷ Still, the results of the Madras study especially were regarded as ground-breaking because they indicated that patients living in poor socioeconomic conditions could be cured with cheaper ambulatory treatment and multi-drug chemotherapy instead of expensive hospitalisation, which was the norm in the West.Footnote ⁵⁸

However, it was not possible to reproduce the encouraging results of the closely supervised Madras trials in various real-life conditions elsewhere in the developing world.Footnote ⁵⁹ According to Sunil Amrith, the studies conducted in Bangalore already suggested that, although poor socioeconomic conditions did not affect clinical effectiveness per se, they did have a significant impact on the patients’ chances of completing their treatment.Footnote ⁶⁰ Brander’s travel report demonstrates that both Somali and Finnish tuberculosis specialists were aware that Somalia was a prime example of the typical problems that could befall WHO ambulatory treatment. It was demanding for both the patient and the provider, since it required regular visits to a clinic for twelve months. Patients often ‘defaulted’; in other words, they stopped the treatment too soon. The prevalence of nomadic culture in Somalia also made the treatment difficult to follow through, as did the lack of ambulatory treatment centres, drugs, transportation and staff.Footnote ⁶¹ Defaulting was a problem for two reasons: first, patients stayed infected and infectious; and, second, it encouraged drug-resistant strains of tuberculosis, thus rendering the standard drug regimen ineffective.Footnote ⁶² The fact that these TB drugs were also freely sold in pharmacies only exacerbated the problem further.Footnote ⁶³

Clinically-oriented TB specialists were already concerned about this in the early 1960s.Footnote ⁶⁴ The long duration of the treatment was seen as one of the main obstacles, and so the British Medical Research Council (MRC) carried out trials for short-course therapies in East Africa (Studies X and R), Singapore and Hong Kong during the 1970s.Footnote ⁶⁵ By the 1980s, nobody doubted that they were clinically more effective. In 1982, the report of a study group of the WHO and IUAT (1981) declared that all countries should have access to short-course therapies. Six- to nine-month regimens of rifampicin made patients non-infectious within three months, and this cut down the chain of infection quickly, and also proved effective against TB strains previously resistant to the twelve-month treatment. However, the organisations also stated that the WHO standard treatment should remain a basic regimen in many developing countries.Footnote ⁶⁶ One reason for this was the cost. The short-course regimens violated the PHC policy of the WHO for being too expensive for developing countries to be carried out independently.Footnote ⁶⁷ This was also the case in Somalia, as Hersi had pointed out to Brander and Hellström that the NTCP could not afford rifampicin. It was therefore prescribed only to those patients who could pay for it themselves.Footnote ⁶⁸ The WHO stipulated that the price of the regimens should come down significantly before they could be used.Footnote ⁶⁹ Another serious concern was that difficult clinical conditions might also lead to a rise in rifampicin-resistant strains, as new regimens had not yet been clinically tested in African countries.Footnote ⁷⁰ Both the WHO and IUAT also rejected using mass X-ray scanning for active case-finding as it was regarded too expensive, complicated and imprecise compared to sputum microscopy, thus leading to wrong diagnoses and significant over-reporting of the cases.Footnote ⁷¹ Instead, they recommended examining the sputum of symptomatic patients that independently came to the TB centres; and only bacteriologically positive infectious patients would then be treated.Footnote ⁷²

Despite the above, the WHO and IUAT clearly had different views on testing short-course chemotherapy in clinical practice. Due to the poor treatment results with the WHO standard treatment, IUAT started to use the eight-month regimen in clinical practice in Tanzania in 1982. The regimen was based on the research of the MRC from the 1970s. As Gradmann has pointed out, IUAT’s decision ran counter to the WHO recommendations caused a serious stir between the two organisations.Footnote ⁷³

2 Exporting the ‘Finnish model’

Whereas IUAT’s Tanzania programme was first based on the WHO standard treatment, Finns ignored the global strategy right from the beginning. According to Brander, there were two reasons for this: direct funding from the Finnish government, and the resistance situation.Footnote ⁷⁴ Brander and Hellström had initially planned to rely on the WHO recommendations,Footnote ⁷⁵ but during their visit they collected thirty-six sputum samples for sensitivity tests back in Finland. These took place in June 1980 and results indicated a high level of primary resistance to streptomycin and isoniazid.Footnote ⁷⁶ These were the primary drugs used in the WHO standard regimen, suggesting that, even if patients stayed in treatment for the full twelve months, many would not be cured. The duration of the treatment was also considered too long; and the second plan (made in July) noted that treatment could be reduced to eight or nine months and use more effective and expensive drugs.Footnote ⁷⁷ To avoid resistance, the drug combination had to include at least two drugs to which patients were found to be susceptible. By the autumn, FATA had decided to use a nine-month regimen starting with four drugs taken daily (rifampicin, streptomycin, isoniazid, pyrazinamide),Footnote ⁷⁸ with a follow-up phase where the drugs were taken only three times a week.Footnote ⁷⁹

The second plan was to base case-finding on mass screening with a-miniature X-ray rather than just sputum samples: only those cases revealing pulmonary shadows in their X-rays would then be verified bacteriologically by sputum microscopy. Both bacteriologically negative and positive cases would be treated. The plan was to keep tabs on the resistance situation by sending sputum samples to the Public Health Laboratory in Helsinki for sensitivity tests.Footnote ⁸⁰ Jones connects similar mass-screening preferences in Sri Lanka to a clinical approach where physicians were committed to detect and cure all TB cases.Footnote ⁸¹ Similarly, FATA stated that, instead of ‘constructing extensive systems, where gaining success takes time and is uncertain’,Footnote ⁸² it was aiming for fast and visible results by using methods that were the quickest and the most effective way to tackle TB.Footnote ⁸³ The above stance on ‘extensive systems’ can also be read as an opposition to the PHC policy of the WHO that prioritised the integration of TB programmes to the public health care services. Like IUAT’s Tanzania programme, the Project paid some lip service to the PHC.Footnote ⁸⁴ In practice, both were carried out as vertical, specialised projects.Footnote ⁸⁵ As a bilateral aid, the Project was not obligated to follow any international guidelines. Finns clearly had little trust in the capability of PHC in its ‘mostly non-existent’ state in Somalia.Footnote ⁸⁶ Thus, vertical TB work was seen as a better guarantee for good cure rates than PHC integration.

It is important to notice that the short-term treatment became possible only thanks to the DIDC’s financial support. Brander stated that the second reason for FATA to use rifampicin-based regimens was that the DIDC had turned out to be more generous with government funding than they had first expected.Footnote ⁸⁷ FATA could afford to put medical effectiveness above cost considerations. As Sellergren put it in January 1981:

Defining this ‘right way’ was based on prevalent development ideology that presupposed that donor countries such as Finland had superior knowledge and technology that could be transferred to low-income countries such as Somalia, which would in turn trigger development.Footnote ⁸⁹ FATA’s leading role in the strategy formation was strengthened by the fact that the DIDC did not take an active role in the Project prior 1984. FATA members and DIDC officials justified the Project with the conviction that Finnish medical experts were well-equipped and better trained to tackle the problem in a developing country, especially with their recent experience of successful TB control in Finland.Footnote ⁹⁰ During the most active stage of the Finnish anti-tuberculosis campaign, FATA had become both wealthy and influential,Footnote ⁹¹ but its board members had little to no practical experience of development aid. Only Hellström had direct personal experience, working as the doctor in Tanzania in 1969–70.Footnote ⁹² Of the other board members, the most active in the Project were Brander, the head of a department in the Public Health Laboratory in Finland; Professor Eero Tala, head of the clinic of respiratory diseases at Turku University Hospital;Footnote ⁹³ Sakari Härö, a doctor and senior civil servant at the National Board of Health;Footnote ⁹⁴ and Professor Jorma Pätiälä, FATA director, having recently retired as head of the clinic for respiratory diseases at Helsinki University Hospital.Footnote ⁹⁵

It is not surprising with these backgrounds, that X-ray scanning and the nine-month regimen were adopted, as these were based on clinical practice in Finland. FATA was clearly aware of recent international research on the shorter chemotherapy treatments and their pertinence for developing countries,Footnote ⁹⁶ and this further encouraged the Finns to rely on shorter regimens. But although the four-drug combination and intermittence tallied with international research,Footnote ⁹⁷ the duration of the treatment tallied more with Finnish tuberculosis work, where the nine-month regimen had been tested and used since the 1970s.Footnote ⁹⁸ And using X-ray scanning in TB control was not altogether unheard of in Africa; according to the WHO, it was ‘still used in some countries’ there in the early 1980s.Footnote ⁹⁹ Brimnes and Jones note that X-ray scanning was also preferred by many local clinicians in Sri Lanka and India.Footnote ¹⁰⁰ Yet in Finland the method had a long tradition; between 1952 and 1982 all citizens over the age of fifteen were invited for a screening once every three years.Footnote ¹⁰¹ Representatives of FATA compared Somalia’s TB situation to Finland’s in the 1930s, and justified the use of X-ray and directly observed treatment by referring to the recent experiences and improved TB situation in Finland.Footnote ¹⁰² The fact that the mass screening was also coming to an end in Finland also probably encouraged FATA to continue the practice elsewhere.Footnote ¹⁰³ According to Brander, with its soon-to-be superfluous X-ray equipment and technicians, Finland was suited to export this expertise to developing countries.Footnote ¹⁰⁴

The existence of reciprocity donor and recipient motives was not uncommon in global tuberculosis work, nor in medical development aid in general.Footnote ¹⁰⁵ Indeed, the transfer of Finnish methods is understandable also in the light of FATA’s recent international re-orientation. FATA had been an IUAT member since 1927 and collaborated closely with it since tuberculosis had receded in Finland. It had first participated in global tuberculosis aid by contributing funds to the IUAT Mutual Assistance Programme.Footnote ¹⁰⁶ In addition to giving fast and effective treatment to Somali patients, the methods also offered an opportunity for FATA to participate in testing and improving new treatment measures for developing countries. Soon after the work in the camps had started in 1981, Brander wrote to Sellergren that the results of X-ray scanning should be presented at an international conference to ‘show how the case finding should be conducted in developing countries, for example in refugee camps’ since ‘the WHO experts understand nothing of it’.Footnote ¹⁰⁷ Scientific publications by the Somalia project would be scant.Footnote ¹⁰⁸ According to Maija Kajava, the former office secretary of FATA, scientific interests were not the main motive for the Project.Footnote ¹⁰⁹ Since the Project was more about practical work than scientific data collecting, its results were mostly presented in IUAT conferences and international meetings rather than more strictly scientific arenas.Footnote ¹¹⁰

Both Hersi and the American medical experts that advised the refugee camp authority, however, were critical of FATA’s plans.Footnote ¹¹¹ The Finnish medical team arrived in Somalia in December 1980.Footnote ¹¹² On 3 February 1981, Sellergren wrote to Brander that he had been told that:

1. (a) X-ray machines should not be used at all in the case finding;

2. (b) Refugees should not be treated with anything other than WHO guideline drugs (streptomycin, isoniazid, TB1);

3. (c) One camp should not receive better treatment than the other camps;

4. (d) Refugee camps should not receive better treatment [than the rest of the Somali population].Footnote ¹¹³

Since source material on Somali motives regarding the treatment is scarce, it is difficult to say for sure, why Hersi nevertheless quickly agreed to follow FATA’s methods.Footnote ¹¹⁴ Sellergen’s reasoning and promises might have had an effect. He wrote an open letter to Hersi where he justified the use of X-ray.Footnote ¹¹⁵ As a part of the settlement, they also agreed that part of the rifampicin would be used for chronic cases in the Mogadishu TB Centre, where Hersi was stationed.Footnote ¹¹⁶ Most importantly, however, Hersi was probably aware that the likelihood of him being able to change the Finnish methods into those recommended by the WHO were slim. Maria Eriksson Baaz and others have noted that, despite the rhetoric of partnership, the interests of the donor party often dominate in development co-operation. As a sponsor, the donor can set up ‘the rules of the game’.Footnote ¹¹⁷ In our case, this much was demonstrated already at the planning stage, since the immediate objectives followed FATA’s plans. The fact that it was also a short four-month contract might have created extra pressure.Footnote ¹¹⁸ It was evident that DIDC was interested in continuing the Project after 1981,Footnote ¹¹⁹ but since FATA had no practical experience in implementing aid and since the Project received significant funding from the Finnish government, DIDC wanted to first test the Project.Footnote ¹²⁰ Hersi thought that the continuation of funding would depend on the results from Qoryoley.Footnote ¹²¹ As Finland was the only major donor and the continuation of aid was uncertain, it is plausible that Hersi did not want to compromise the Project by arguing too much over treatment. The refugee aid period thus functioned as a way of forging a new aid relationship that would eventually fulfil more general needs of NTCP.

3 Towards international models

After six weeks of preparations, negotiations and familiarisation with the local conditions in Somalia, the Finnish team and their Somali counterparts started to X-ray refugees on 21 January 1981.Footnote ¹²² The first patients were admitted for treatment on 7 February.Footnote ¹²³ The day-to-day activities in the camps were administered by Tor-Leif Sellergren, a specialist in lung diseases who, among holding other shorter medical posts, had worked since 1965 as a doctor in a TB ward in Raseborg, Finland.Footnote ¹²⁴ Finns and the NTCP staff did clinical work closely together. During the first months, X-ray technicians Raimo Leisilä and Mohammed Cabdi carried out X-ray scanning. Laboratory technician Aniisa Saalax prepared and examined sputum. Samples were also delivered in Mogadishu, where laboratory technician Heli Oramies examined them with the local staff. Sellergren diagnosed patients with Somali doctors Abdullah Shek Mohamed and Moxamed Giuni. Nurses Tuija-Liisa Peltola and Asha Jama Gashan administered the drug distribution.Footnote ¹²⁵ Finns instructed Somali counterparts in TB work, but also received valuable advice on how practical matters should be arranged in the camps.Footnote ¹²⁶ However, the practical decision-making on case-finding and treatment was mainly in the hands of Sellergren. Despite their early differences, he and Hersi shared a mutual respect and seem to have had a good working relationship.Footnote ¹²⁷ However, Hersi was stationed in Mogadishu and, as the director of the NTCP and a professor at the University of Mogadishu, he had also other responsibilities on his plate.Footnote ¹²⁸ FATA’s board and the working committee held meetings only once a monthFootnote ¹²⁹ – insufficient to deal with all that could crop up on a daily basis in that time. Brander explained to Sellergren: ‘It is difficult to get the Board members together’, and ‘besides, they cannot really give any absolute rules on how to treat patients’.Footnote ¹³⁰

FATA’s short-course chemotherapy guidelines were similar to the treatment principles that would later become the DOTS strategy. The case-finding was different, but otherwise principles such as fully supervising drug intake and following each case up with a patient register were alike.Footnote ¹³¹ However, in 1981–3, the Project was not able to follow these principles through in the field. Perhaps the most pressing reason for FATA launching the Project in Qoryoley had been that it expected the camps to be a more stable, ‘realistic’ place to administer and monitor the treatment than the rest of Somalia, where nomadism was common.Footnote ¹³² In practice, however, refugees moved in, out and around the camps.Footnote ¹³³ When people heard how effective the Finnish treatment was, they started coming to the camps from Mogadishu and nearby villages.Footnote ¹³⁴ By the autumn of 1981, the Project’s treatment stations were overcrowded, and the team had to establish additional dispensaries for non-refugees in Qoryoley town and the village of Shalambood.Footnote ¹³⁵ Sellergren suspected that many patients discontinued their treatment as soon as they started to feel better,Footnote ¹³⁶ so, in an effort to prevent mobile patients from defaulting, they were sometimes given drugs for a week or so.Footnote ¹³⁷ Medication was thus not always fully supervised. There were also cases of rifampicin being stolen.Footnote ¹³⁸

FATA’s advice to verify cases bacteriologically was also often disregarded and treatments were sometimes started without a proper sputum sample. Clearly, the Finns felt pressure to start the treatments fast, as not only was the initial contract period short, but case-finding and getting diagnosed patients into treatment lagged during the first months.Footnote ¹³⁹ After three months in the field, Sellergren explained the situation by stating that ‘in the beginning, we might have been focused too one-sidedly on launching the treatments. We wanted to make a good impression and it was also probably the humane thing to do’.Footnote ¹⁴⁰ The team probably wanted concrete results before the next negotiations to be able to vindicate their methods. Also, the tuberculosis was more severe than anything they had seen in Finland.Footnote ¹⁴¹ In Somalia, TB was taboo and unsupervised self-medication was common, so people only came to the clinics when the disease was already further on and more difficult to treat.Footnote ¹⁴² In Finland, forty per cent of the patients who entered treatment were bacteriologically negative and had been diagnosed on the basis of X-ray or clinical symptoms.Footnote ¹⁴³ The Finns, who were used to starting treatment without bacteriological verification, probably regarded it as unnecessary and unethical to wait for such verification when faced with the grim reality in the camps. Sellergren also noted that these hectic conditions explained why both Finnish and Somali team members often failed to collect or annotate the sputum sample properly.Footnote ¹⁴⁴ Although the WHO advocated the sputum microscopy as a simple technology, Jones has demonstrated that similar practical problems in collecting and examining samples were also common in Sri Lanka.Footnote ¹⁴⁵

In order to stop patients defaulting, Sellergren modified FATA’s standard four-drug regimen. According to him, the combination of rifampicin, streptomycin, isoniazid and pyrazinamide was too toxic for the weaker, malnourished refugees, who would suffer from side effects and give up the treatment.Footnote ¹⁴⁶ To avoid this, he instigated an initial clinical examination, where the patient’s overall condition and previous treatment history were all considered. By September 1981, Sellergren had fifteen different regimens in place. The most common were a three-drug combination of rifampicin, streptomycin and isoniazid (250) used in new cases, and a combination of rifampicin, isoniazid and pyrazinamide (151) for those patients who had been treated for tuberculosis before and might be resistant to isoniazid and/or streptomycin.Footnote ¹⁴⁷ During the follow-up phase, the patient was also given the drugs daily rather than intermittently. Sellergren was again worried that intermittence would disrupt treatments as, according to him, the refugees, who were used to daily treatment, did not ‘understand anything about it [intermittence]’.Footnote ¹⁴⁸ The duration of the treatment also depended on the patient’s condition, monitored via X-ray and sputum samples. Usually it would last for nine months, but six- to eight-month treatments were also accepted.Footnote ¹⁴⁹ These solutions were based on clinical experience gathered in Finland and practical experience from working in the camps. According to Dr Liisa Parkkali, the three-drug combinations above were all common in Finland.Footnote ¹⁵⁰ By prioritising treatment over bacteriological diagnosis, and by optimising it for every patient, Sellergren clearly approached the Project from a clinical perspective where curing every TB case was the priority. His stance was not extraordinary, as similar conflict between clinical perspective and policy formation had taken place in the Madras trials.Footnote ¹⁵¹ Sellergren’s approach can be explained by his experience as a clinician in Finland and the treatment-oriented goals of the Project, the success of which were measured by the number of cases detected, treated and cured.

In 1981, 11 337 people were examined by mass miniature X-ray and 1075 patients were admitted for treatment.Footnote ¹⁵² After the first year, the Project seemed quite successful. According to FATA, prevalence of active tuberculosis dropped from 8.5 to 3.1 per cent among those examined within six months. Control X-rays and bacteriological tests also indicated that many difficult streptomycin- and isoniazid-resistant cases had improved with the treatment.Footnote ¹⁵³ In 1982, the Project was extended to Mogadishu, as the Somalis had planned.Footnote ¹⁵⁴ The governmental contract for the years 1982–4, based on a proposal drafted jointly by Hersi and Sellergren, claimed the Project’s results proved the effectiveness of the Finnish method of controlling TB in the refugee camps, especially the usefulness of mass scanning with miniature X-ray.Footnote ¹⁵⁵ The results were presented at both the IUAT African region meeting in 1981 and the IUAT Conference in Buenos Aires in 1982.Footnote ¹⁵⁶

Experiences from the camps, however, also indicated that there were at least some grounds for the earlier criticisms. It had become clear that only a small proportion of patients could be treated with rifampicin – even within the specific Project area – as it was so expensive. In other words, the project had little to no impact on the overall epidemiological situation in Somalia.Footnote ¹⁵⁷ This was a problem when it was evaluated from a public health perspective, i.e. whether the Finnish approach benefited the whole population rather than a small number of individual patients.Footnote ¹⁵⁸ In March 1982, Dr Ron Waldman, one of the refugee health advisors, again bluntly criticised FATA for using methods that Somalia could not afford to continue, let alone expand, once the Finns left. According to him, the Refugee Health Unit (RHU) would never have accepted the Project’s treatment strategy.Footnote ¹⁵⁹ Dr Eeva Rusanen, who started her work as the team leader in 1982, was told by Brander to not be too ‘bothered about’ the above comments.Footnote ¹⁶⁰ Both FATA and Sellergren replied there was no point using the WHO standard regimen in Somalia as it was ineffective against resistant strains and the patients defaulted because the treatment was too long.Footnote ¹⁶¹ The experience from the camps had nevertheless shown that the Finns would need to modify their methods.

In 1982, the Finnish medical team started to work in Mogadishu, where the number of patients was expected to be even greater.Footnote ¹⁶² In early 1982, Hersi suggested that rifampicin be used only for chronic (resistant) cases, so that more patients could be treated.Footnote ¹⁶³ But, whereas public-health oriented experts considered it to be a problem that only small numbers were being treated, clinically-oriented FATA wanted rifampicin-based regimens as a standard treatment for every patient. It set new restrictions on the admission for treatment instead. From as early as March 1981, active case-finding was disregarded, and the treatment of bacteriologically positive cases prioritised – in line with the standard WHO treatment and the IUAT Project in Tanzania.Footnote ¹⁶⁴ In September 1982, Dr Rusanen wrote that the Finnish-Somali team at the UNICEF TB Centre in Mogadishu was limiting X-ray scans to fifty patients per day, and a Somali doctor would then choose two ‘suitable, preferably young and fresh cases’ for the Project.Footnote ¹⁶⁵ The rest were sent to NTCP for the WHO standard treatment.Footnote ¹⁶⁶ This method of case-finding thus moved towards more international models, as the importance of sputum microscopy had increased even if X-ray remained the scanning tool for sample collection. According to Liisa Parkkali, who became team leader in 1983, ‘clear cases’ were still admitted on the basis of X-ray diagnosis.Footnote ¹⁶⁷ Such restrictions were sometimes ethically difficult for the medical team to put into practice,Footnote ¹⁶⁸ but they made sense from the Project’s perspective: it had limited resources, but would be considered successful if the predetermined amount of patients were cured per year.

FATA was more concerned about defaulting patients than the number of treatments, as it directly affected treatment results, was a waste of expensive drugs and might eventually create rifampicin-resistant strains. According to Sellergren’s report from 1982, the defaulting rate had been at fifteen per cent in the Qoryoley camps in 1981.Footnote ¹⁶⁹ If this figure is accurate, the Project was extremely successful in reducing the rate of defaulting. In comparison, Dr Paul Shears calculated that fifty per cent of the 600 patients given the WHO standard treatment between July 1980 and August 1981 in the Somali Sab’ad refugee camps had defaulted, and of 244 patients still being treated, seventy participated only irregularly.Footnote ¹⁷⁰ It is unclear what data the Qoryoley figures are based on though; so far, I have not found clear statistical information on defaulters for the period 1981–3. Another report stated that, by September 1981, 120 of the total of 900 treatments started by that date had ended with defaulting and 170 had been successfully completed.Footnote ¹⁷¹ If we analyse only the treatments that had come to an end (170 cured + 120 defaulted  = 290), it seems that forty-four per cent of the patients had defaulted and sixty-six per cent completed the regimen successfully by autumn 1981.Footnote ¹⁷² According to Liisa Parkkali, the Finns (herself included) did not realise just how many patients were defaulting until they started using IUAT patient records in 1983–4.Footnote ¹⁷³

In August 1981, FATA decided to send the nurse Päivi Kokkonen to investigate the defaulting problem in the camps.Footnote ¹⁷⁴ Taking a public-health oriented stance, she recommended that, instead of trying to export ‘Finnish tuberculosis polyclinics’ to Somalia, the Project should improve treatment compliance by intensifying health education and community involvement at all levels, co-operating with primary healthcare services and using more Somali staff.Footnote ¹⁷⁵ FATA’s solution would remain mainly biomedical: from 1982, the Finns started using an even shorter, six-month course of chemotherapy in Mogadishu, the Qoryoley refugee camps and (from 1983) Kismayo.Footnote ¹⁷⁶ The new drug combination was based on international research (justified by Brander with the publication of Wallace Fox (1981)Footnote ¹⁷⁷ ). Drug-sensitive patients (new cases) received rifampicin, streptomycin, isoniazid and pyrazinamide daily for two months followed by isoniazid and rifampicin daily for four months. For drug-resistant patients (old cases) streptomycin was replaced with ethambutol.Footnote ¹⁷⁸ Concern about rifampicin resistance might have influenced the decision to return to a four-drug combination: streptomycin, rifampicin and isoniazid were a feasible combination in Finland, where resistant TB strains were uncommon,Footnote ¹⁷⁹ but in Somalia the same regimen could cause rifampicin resistance in those patients who were already resistant to streptomycin and isoniazid. In 1982, Brander further instructed that patients’ sensitivity to drugs should be ascertained before treatment was started and constantly monitored throughout.Footnote ¹⁸⁰

In 1981–3, the Finns focused on preventing the defaulting with flexible drug distribution. Despite the shorter treatment time, default rates were calculated to be standing at around thirty per cent in 1982 and 1983. Both Rusanen and Parkkali believed the long difficult journey to the clinics were the main cause, so it was common to give patients enough drugs for one to two weeks at a time.Footnote ¹⁸¹ An alternative solution would have been to restrict treatment only to people who lived near the ambulatories and could visit daily,Footnote ¹⁸² but this was rejected for both practical and ethical reasons. First, it was impracticable in a country that lacked medical services and, with no IDs, patient registers or even system of addresses, it would have been impossible to verify where the patient lived. Second, the idea of denying care based solely on where the patient lived did not tally with the Finns’ humanitarian conception of the Project.Footnote ¹⁸³ Local realities also caused other challenges. Treatments were disturbed when problems were encountered in regulating, ordering and transporting the drugs.Footnote ¹⁸⁴ Finally, the waiting time required for the sensitivity tests was so long that the clinic risked losing contact with patients, so treatments were started before results had come back and only changed later if there was drug resistance.Footnote ¹⁸⁵

The Project seems to be among the first to use the short, six-month course in clinical practice within a national tuberculosis control programme in Africa. While the new regimen was launched in Mogadishu in 1982, IUAT started its ground-breaking short-course chemotherapy pilot programme in Tanzania. The principles of the DOTS strategy were developed in that pilot programme under the leadership of the IUAT scientific director, Karel Styblo.Footnote ¹⁸⁶ The programme was extended district by district to the whole country in 1982–6. Collaborative IUAT projects were also started in Mali, Benin, Kenya, Malawi, Mozambique, Nicaragua, Senegal and Yemen.Footnote ¹⁸⁷ Although the FATA papers do not mention them, the Finnish TB specialists were probably aware of these developments. The IUAT leadership was certainly interested, and aware of the treatment carried out in the Somali-Finnish project. Styblo and Annik Rouillon, executive director of the IUAT, offered advice to FATA in late 1982, and FATA members enthusiastically took part in IUAT conferences and meetings.Footnote ¹⁸⁸ Procuring cheaper drugs through IUAT networks allowed FATA to increase the number of patients in the Project from 1000 in 1982 to 3000 in 1983.Footnote ¹⁸⁹

Although FATA was willing to collaborate with IUAT on its own terms, it wanted to stay in charge of the Project. This became evident when the DIDC asked Karel Styblo to evaluate the Project at the end of 1983. The small number of patients, the cost and the rifampicin resistance became pressing issues again. Both the Somalia-Finland Project and IUAT’s Tanzania programme were carried out as a specialised, vertical programmes based on high medical standards. However, their main difference was that the Tanzania programme had a country-wide approach on TB control. Thus, IUAT – like the WHO – prioritised the treatment of the masses. The Tanzania programme used the cheapest possible short-course treatment that lasted eight months and contained rifampicin only in the two-month long initial phase.Footnote ¹⁹⁰ The Somalia-Finland Project focused on curing a specific number of patients in the project area, and used the shorter and more expensive six-month regimen that contained rifampicin in both the initial and the follow-up phases.Footnote ¹⁹¹ Another significant difference was that the Tanzania programme prioritised the strict supervision of drug intake. Therefore, patients were hospitalised during the initial phase of IUAT treatment to ensure that taking the rifampicin was fully supervised. The hospitalisation was against the WHO guidelines that recommended ambulatory treatment for the developing world.Footnote ¹⁹² In the evaluation report, Styblo pointed out that the supervision had not been possible with FATA’s ambulatory treatment. He recommended that the Finns try out the cheaper IUAT regimen in routine conditions as a ‘pilot study’, but otherwise prioritise supporting the NTCP in improving their use of the WHO standard treatment, so that more patients could be treated. He reasoned that ‘it would take several years to know whether short-course chemotherapy is feasible in Somalia’.Footnote ¹⁹³ It is good to note that even the Tanzania programme could not carry out all its principles in clinical practice.Footnote ¹⁹⁴ Thus, the Somalia-Finland Project was not extraordinary in its incapability to fully follow high medical standards.

Styblo’s recommendations might seem odd in the light of his work in Tanzania, which challenged the WHO standard treatment. However, his stance might be more understandable in the light of his concern about the rifampicin resistance and costs. It is important to note that the short-course chemotherapy had been tested in Tanzania only approximately a little over a year when Styblo evaluated the Somali-Finland Project.Footnote ¹⁹⁵ Gradmann has stated that the Tanzania programme became particularly valuable because it had used both the WHO standard treatment and the short-course chemotherapy, and could therefore convincingly argue for the latter.Footnote ¹⁹⁶ Styblo clearly wanted this testing to happen in Somalia also before changing the regimen. He pointed out that there were no reliable, systematically gathered data on the results of the WHO regimen. He worried about the development of rifampicin resistance and was not fully convinced that Finnish-Somali teams could provide strictly supervised treatment in Somalia. He also evaluated the Project from the viewpoint of building a nationwide TB strategy. Since the Finns could afford to treat only a small proportion of patients with short-course chemotherapy, it made sense from the public health perspective to put more emphasis on the majority of the cases under standard treatment.Footnote ¹⁹⁷

FATA did not accept Styblo’s recommendation to focus on the WHO standard treatment. However, the Project started to hospitalise those patients who were at risk of default (i.e. lived far away from the TB services), supervised rifampicin intake more strictly and included eight-month treatment to the programme. These adjustments towards the IUAT model were highly influenced by the fact that they were promoted by DIDC, which took a more active role in supervision after the evaluation. Hospitalisation and supervision also made sense for the Finnish TB specialists, who saw defaulting as a problem. However, hospitalisation only became possible after 1983, when the DIDC decided to fund the construction and renovation of TB centres. The six-month course was still preferred by FATA and frequently used in daily supervision. Although most of the patients were sputum positive, sputum negative cases were also treated.Footnote ¹⁹⁸

It is important to notice that, after early 1982, there are no sources indicating that Hersi (or MOH) opposed the use of short-course chemotherapy. In the summer of 1982, Hersi actually defended the use of rifampicin-based regimens in the refugee camps, in a letter to the Finnish refugee council. In 1983, Dr Parkkali stated that there were no disagreements between herself and Hersi over medical issues.Footnote ¹⁹⁹ Since the Somalis involved in the Project did not shy away from expressing their differing views on other occasions, it is likely that they would have voiced their objections if they had disagreed about the treatments after the evaluation. It seems that the Somali leadership had developed a more positive understanding of the rifampicin-based regimens over time. On the other hand, the support may also have been first partly tactical, as a way of securing further funding for TB control. As the disease was not a priority in global health during the 1980s, it might have been difficult to find another donor.