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Tao Sheng Kwan-Gett, MD, MPH
Revised October 7, 1998.
Topic Selections
A focus group of eight male heads of households from members of the Seattle Somali community was audiotaped and the discussion analyzed for themes. The results were then fed back to a male key informant and a female key informant for confirmation and elaboration.
Tuberculosis is distinguished from other causes of coughing on the basis of hemoptysis and/or weight loss. A cough, either productive or nonproductive, is considered to be a chest infection or inflammation (helgap) until the hemoptysis or weight loss characteristic of tuberculosis occur. When fever and chills are prominent and hemoptysis is absent, tuberculosis may also be confused with malaria.
Tuberculosis is known to be a contagious disease, but environmental factors such as hot weather and host factors such as overwork can contribute. Some people believe that it can sometimes be hereditary, following a family for as many as six generations.
The Somali word for cough is qufac. Most Somalis use "TB" or tibisho (derived phonetically from Italian) when talking about tuberculosis. Tibisho is used more commonly in southern Somalia. In parts of Somalia north of Mogadishu, the word qaaxo(pronounced "kah-ho") is sometimes used for tuberculosis. Qaaxo and Urug are historical Somali words for the entity of tuberculosis with cough and hemoptysis. Both words bring to mind a powerful dark image of an isolated, ill person who is close to death. Qaaxo may be even be used as a curse.
A common folk remedy for cough that is used by Somali children and adults consists of a mixture of raw eggs, butter (similar to Indian ghee) and honey. Adults may make this for themselves early in the course of an upper respiratory infection. Young children with a cough may sometimes undergo a uvulectomy.
Some rural Somalis will be familiar with herbal treatments such as Tiire or Khabayere. These are tree roots whose sap is cooked with meat. The resulting soup has purgatory properties useful for tuberculosis.
When an illness is identified as tuberculosis, the family may prepare an especially nourishing diet (baan), used to hasten the recovery from any serious illness or from pregnancy. This diet often includes drinking rendered sheep fat and eating liver, milk (rarely consumed by adults otherwise), eggs, and a mixture of dried meat and butter. A person who uses the stimulant khat (also called miraa) will stop chewing it because its respiratory stimulation properties, though beneficial for asthma and malaria, are thought to be harmful for tuberculosis. A traditional healer may also be sought to administer small, round burns with the end of a hot stick.
Because treatment for tuberculosis has only become known in Somalia within the last few decades, and even now is too expensive for many families, the diagnosis of tuberculosis has traditionally meant a lifetime of illness and stigma. Those with tuberculosis fear that they will be shunned by others. Nomadic families might move their huts away from a family that has tuberculosis. Tuberculosis sufferers may be given their own utensils and drinking cup instead of being allowed to eat with their hands from the same plate of food or drink from the same cup as family and friends, as is customary.
The social isolation is so profound that the stigma of tuberculosis in Somali culture can be as severe as that of AIDS in Western culture. Persons with symptoms of tuberculosis may avoid seeking health care, or once the diagnosis is known, deny their illness to themselves or others. Another implication of this stigma for immigrants to the U.S. concerns contact tracing: a family sharing a house or an apartment with other families may be reluctant to share information with public health authorities to avoid disclosure of their tuberculosis infection status to their housemates and the community.
Tuberculosis skin testing can be a confusing and sensitive topic. Many Somali immigrants had their first experience with skin testing in refugee camps. The repetition of skin testing in the U.S., and the sometimes conflicting results (e.g. a negative test in the camp and a positive test in the U.S.) can raise suspicions of discrimination. Some believe the skin test is an immunization, while others understand the injection to be a source of infection.