Migration route
Study participants mapped out their seasonal migration route. The agro-pastoralists (Group 1), reported that they subsist through a combination of farming and raising livestock. They reported five different seasons each year in their territories, which according to them determine their migration route. These seasons include the following:
Jilaal
A dry and very hot season that lasts from January to March. Pasture and water are scarce leading to long migrations.
Gu'
The first long rainy season that normally lasts from April to June. Pasture and water are abundant and there is no migration at all. People engage in farming.
Xagaa
A dry season that lasts from July to August. It is mildly hot and very windy. Suitable pastures and water are scarce; however mobility is limited and often dependent on the situation.
Karan
Short wet season that lasts from August to September. In this period there is no migration at all.
Deyr
Second major rainy season that last from October to December. Pasture and water are abundant and farming takes place. There is no migration in this period.
Study participants told that, each year, they receive three rainy seasons that satisfy periodic crop production. During these seasons, agro-pastoralists told that they dwell in permanent villages which are located east of Qabribayax District, namely Xananley, Juuq, Danaba One and Barakaraamo where they engage in small scale farming. These villages are within 20 minutes walking distance of Qabribayax District where there are two health facilities that provide TB care. However, when expected rains fail, and farming becomes impossible, agro-pastoralists migrate eastward into forested areas; namely Karingal, Bilcilbur and Moyaha, in search of pasture and water for their livestock (thin arrows in figure 1, indicates migration during dry season). The length of their stay in those forests varies within each season and it is often determined by the length of the draught. When the rainy season begins, agro-pastoralists migrate back to their permanent villages in Qabribayax (bolded arrows in figure 1, indicates migrations during wet seasons).
Discussions facilitated by the PRA technique revealed that agro-pastoralists reside within walking distance of TB clinics during wet seasons. In this period, they reported that they do not experience major barriers in accessing TB services. During dry seasons however, even though they migrate to a remote area that is 60 km away from health facilities in Qabribayax, they still rely on these facilities when illness strikes.
By contrast, the nomadic pastoralist group reported that their community practices an exclusively nomadic lifestyle. They reported having two dry seasons each year namely Jilaal, and Xagaa, and two rainy seasons namely Gu', and Dayr. They do not experience Karan; a brief rainy season that is common in the agro-pastoralists' area of the SRS (semi-highlands).
During wet seasons, nomadic pastoralists told that they spread across valleys of Fiidoole, Daacadhuur and Xasbahal, that are located at the base of Qarinjuqood mountain. During these periods, the respondents told that pasture is plentiful everywhere and seasonal swamps and ponds provide water for the livestock. As pasture and water in the valleys dry out, they said that they undertake a long migration, ascending an extended chain of mountains known as the Qarinjuqood mountains (thin arrows in figure 2, indicates dry season migration). According to the respondents, these mountains are not used for grazing in the wet seasons and are therefore rich in pasture during dry seasons. They reported that they stay on top of these mountains for almost six months each year (jilaal and xagaa seasons). Study participants told that because of difficulties in ascending the mountains, months may pass without anybody coming to the area aside from pastoralists searching for pasture and water:
"The mountains are hard to climb and there are no roads except footpaths. In this period, we don't see anybody except nomads in neighboring hamlets throughout the season" (Nomadic pastoralist, Jigjiga Health Center).
Once the rainy season begins, pastoralists migrate back to the valleys (wet season migration is shown by bolded arrows in figure 2). The nomadic pastoralists who participated in the PRA were asked to identify the nearest TB facility to their location in both seasons. They identified three DOT facilities, all of which require several days walk to access, regardless of the season.
Perceptions and management of TB symptoms
Respondents were asked to describe the cause of TB. A majority perceived TB to be the result of internal injury due to hard work or malnutrition. Persistent cough is also perceived to be a normal phenomenon and therefore not necessarily associated with TB. Pronounced weight loss and cough accompanied with blood were symptoms strongly associated with TB. A male pastoralist explains:
"People cough for years and they still look healthy. If a coughing person becomes rapidly wasted or cough is accompanied with blood, then we suspect the person of having TB" (Agro-pastoralist patient, Qabribayax DOT center).
When people develop symptoms that are associated with TB, they often seek traditional medicine. The majority of informants reported that they first used traditional herbs, locally believed to cure TB. One respondent who was a traditional healer reported that he treated TB with tetracycline capsules which he believed could cure TB:
"We have capsule with red and yellow color called tetracycline. We buy it from towns. It must be available in every pastoralist's house because we use it for treatment of both men and livestock diseases such as TB" (Nomadic pastoralist, Jigjiga DOT center).
If symptoms do not subside after using traditional medicines, patients reported that religious remedies are applied in the form of Koranic verses that are read for the patient. The majority of respondents told that they had tried all available traditional means and they only sought biomedical treatment when they run out of traditional options. One of the participants explains:
"I tried local herbs, I avoided sex, I tried religious remedies in many occasion and I didn't seek treatment until my situation reached to a point that I couldn't milk camels for my children" (Nomadic pastoralist, Jigjiga DOT center).
The use of modern medicine is seen as a valid alternative when the available traditional remedies have failed and patients have reached a critical stage of illness. However, even if they seek and partly trust biomedical treatment they still believe that it must be complimented by other practices. Abstaining from sex when TB patients are under treatment were practices reported amongst several respondents. A male respondent explains:
"My family [wife] was moved to Jigjiga area by relatives [to interrupt sexual contacts] and my wife will never come here until I finish 8 months TB treatment course". (Agro-pastoralist, Qabribayax DOT center).
Some agro-pastoralist patients told that they were planning to stay in the town throughout the 8-month course of treatment, just to abstain from sex. To enforce this practice, nomadic pastoralists apply strict rules. One of the study respondents explained how his nomadic community strictly forbids sexual contact by TB patients;
"When I go back to my community, elders will assign members of close relatives to scrutinize me such that I never meet my wife privately until I fully recover from TB" (Nomadic pastoralist, Jigjiga DOT center).
Because TB is characterized by loss of weight, a majority believed that TB could be cured only when treatment is supplemented with the intake of highly nutritious food, a term locally called baan. Conventional treatment alone, which is not complemented by nutritious food, is believed to result in a resurgence of the disease.
Access to health care
According to the respondents, there is a discrepancy in access to health care between the two pastoral groups. When we asked participants about their access to TB services, respondents from the agro-pastoralist group stated that they are semi-urban people and they live in close proximity to health services during wet seasons. However, during dry seasons they migrate to areas far away from health facilities. The majority of the respondents in this group told that in case of illness during dry season they often postpone seeking medical care until next wet season. One respondent told:
"During dry season, we use traditional medicine. The individuals who are severely sick are sometimes transported by camel to Obole village [a village along the main road] where they can hitch for a car to Qabribayax" (Agro-pastoralist patient, Qabribayax DOT center).
By contrast, nomadic pastoralists reported that they do not have easy access to health care at any time of the year. Despite this, they told that people with symptoms suspected to be TB often seeks medical care during wet seasons. In this period, the increased availability of pasture and water reduces the workload of the herders, providing TB suspects a suitable time to seek treatment. One of the respondents explained:
"We seek health care during wet seasons because there is not much to do in this period. Livestock can get pasture around the hamlets and water is everywhere. During dry seasons however, families can hardly cope with the dry season burden in our absence" (Nomadic pastoralist, Jigjiga DOT Center).
A majority of the study participants said that there are no road connections between their dwellings and the major towns where TB clinics are found. Because they occupy a very remote area with no infrastructure, they told that they trek over a hundred kilometer in search of TB treatment. One of the informants explained that their choice of where to seek TB treatment is often influenced by two factors; the presence of relatives to help them whilst they undergo TB treatment and a good price for their livestock. Based on these factors, nomadic pastoralists often seek health care in Jigjiga town (the capital of SRS).
"The major towns where TB care is found such as Jigjiga, Dhagaxbur, and Godey have similar distance to our area. The difference of Jigjiga is that majority of our people have relatives in Jigjiga and livestock prices are higher" (Nomadic pastoralist, Jigjiga DOT center).
The majority of patients said that they had to sell livestock to cover their health care costs and living expenses whilst undergoing the intensive phase of TB treatment. Several patients told that they drove heads of livestock all the way to Jigjiga, which stretched the duration of the trip. The majority of study participants reported that it took them between 25 to 28 days from their residence to Jigjiga DOT center. One respondent reported that the nature of the journey excluded vulnerable groups such as women, children and elderly people from accessing biomedical diagnosis and treatment of TB:
"I am a man and I had a hard time to reach here. It is difficult to bring children and women along. When they [children and women] get TB, we treat them with traditional medicine. Sometimes they are cured or they may live with the disease for a long period, or in some cases they die. That is all we can do (...)"
(Nomadic pastoralist, Jigjiga DOT center).
Although the distance to treatment delivery points was a burden, the main concern of participants was the economic cost incurred by pastoralist families seeking TB treatment. Patients told that they sold an average of 4 camels or 26 goats to cover their daily costs during the intensive phase of treatment. As the livestock is the sole means of their survival, pastoralist had to weigh expenses on their health care against other family needs. One of study participants explained:
"Some people in our community possess few goats. Such people can hardly seek TB care because they can not pay the cost" (Nomadic pastoralist, Jigjiga DOT Center).
Health planners' views regarding provision of TB care to pastoralists
The health officials who participated in this study agreed that pastoralists in SRS can hardly ever benefit from the existing health services. One of the regional health officers explained the challenge that pastoralists pose to current regional health delivery systems:
"Establishment of a health facility in a particular area is determined by population density of that area. For instance, health post which is the lowest in the hierarchy, as a rule serves 3000-5000 people. As pastoralists are sparsely dispersed into large geographical area, they can hardly meet this condition"
Another health officer attributed the absence of TB services in pastoralist dominated areas of the region to their migratory lifestyle:
"If DOTS facilities are established in pastoralist areas, next day you may not get a single individual, they migrate".
The longstanding conflict in the Somali Region and the subsequent high staff turn-over, particularly in the rural areas, was reported by one health official as the reason of pastoralist's poor access to TB care:
"The health facilities in the rural areas are empty of staff because those areas are hard to reach due to insecurity combined with poor infrastructure. Accordingly, the health workers in the rural parts of the region may not receive salary, sometimes for several months. They often come back to Jigjiga [the capital town] and they never go back again".