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Being Present

treat many patients, sending me the sickest or those suspected of having TB. I would evaluate them for possible admission to the IPD or TFC, begin screening themfor TB, or, when possible, treat themand send them home. Since virtually all communication was through translators, the work went slowly.

I was also responsible for the health of all the expat and Ethiopian staff, about 100 in all. The harsh environment and the religious practice of fasting for Ramadan—which fell during my stay, and during which adherents take no food or liquids from sunrise to sunset—took a toll. I saw as many as 10 of the Ethiopian staff every day. Sometimes reassurance and paracetamol, as acetaminophen is known outside the U.S., were enough. Sometimes antibiotics, and occasionally evacuation for more sophisticated evaluation and treatment, were necessary. "Rest" was a frequent prescription for the most common "diagnosis"—generalized body pains—though compliance and resolution of the symptoms were unlikely.

After the midday break, I returned to the OPD, discussed patients with the health officers, saw any staff who needed attention, and then made rounds again on the sickest patients in the IPD and TFC. During the late afternoon, I'd also meet with Dr. Valeh, discuss possible referrals, and, when I had the time, learn more about the treatment of TB in Galaha—a very unique and challenging project.

Tuberculosis—a worldwide scourge until about 50 years ago but nearly forgotten in the second half of the 20th century—is on the rise again, especially in developing countries. Its spread has been hastened by the HIV epidemic, which leaves its victims more susceptible to TB because of their compromised immune systems. Chronic malnutrition and poor living conditions also play a part in the spread of TB. A third of the world's people are infected with the TB bacillus, with 95% of active

Above, a little boy who represented one of the success stories of the Galaha TFC. Below, another mother whose youngster was doing very well.

cases and 98% of deaths (2 million this year) occurring in the developing world. This growing humanitarian crisis, and economic burden on the world's poorest countries, can no longer be ignored.

The Afar suffered dreadfully from TB and could neither find nor afford reliable treatment before the MSF program in Galaha opened in 2001. A survey of the Afar conducted by MSF identified TB as a leading cause of morbidity and mortality. The prevalence of TB among the Afar was related to a number of factors: the presence of the disease in their herds, the fact that unpasteurized milk is one of their daily staples, the chronic malnutrition they suffered, and (since TB is an airborne bacillus) the poor ventilation in their daboytas.

The greatest challenge we faced was getting a nomadic people to stay in one place for the several months of treatment. Other organizations had tried but given up because of the large number of patients who dropped out of treatment before completing the prescribed course of medications. MSF began the Galaha TB

project in the hope of demonstrating that Afar TB could be treated comprehensively and successfully. Our primary mission in Galaha was to decrease the TB infection rate and death rate through proper treatment of active tuberculosis cases. Galaha was chosen as the site for the

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