In memory of Annalena Tonelli: a health activist who fought TB in Africa, defied hardships and terrorism

Medical practice has always had a small but special place for amateurs.

During China’s Cultural Revolution (1966-1976), 1 million “barefoot doctors” provided primary care and public health advice in rural areas. Most had a junior high education and less than a year of medical training, and they were paid peasant’s wages. Their results were decidedly mixed, and by the 1980s they were gone.

Annalena Tonelli speaks to a patient in a hospital in Somalia. The late health-care activist was trained as a lawyer but spent virtually all her adult life treating tuberculosis, first in Kenya and later in Somalia. (Edward Parsons/UNHCR/AP)

More recently, “community health workers” with better training and narrower responsibilities have become essential to medical care in many parts of the world.

In 2016, Liberia launched a program that has deployed 3,000 health workers who have made 1.6 million home visits and now diagnose about one-third of the country’s cases of childhood malaria.

Sometimes, circumstances force amateurs into the breech. In 1942, three appendectomies were performed by pharmacist’s mates on Navy submarines patrolling in the Pacific. An account of one operation, aboard the USS Seadragon off Indonesia, won a Pulitzer Prize in 1943. (The Navy soon after forbade the practice.)

And then there are amateurs who defy categorization. Such was Annalena Tonelli.

Tonelli grew up in Forli, near Bologna in Northern Italy. She was trained as a lawyer but spent virtually all her adult life treating tuberculosis, first in Kenya and later in Somalia. She cured tens of thousands of people who otherwise would have died of the infection. She was assassinated at her TB hospital in Borama in the self-declared nation of Somaliland in 2003. It had 377 patients and a monthly budget of $20,000. She was 60.

Tonelli was a person of immense skill, patience, courage, idealism and self-effacement. Although just before her death she was recognized with the Nansen Refugee Award, given annually by the United Nations High Commissioner for Refugees (UNHCR), she is hardly known today.

She is the subject of a book published this month, “Stronger Than Death: How Annalena Tonelli Defied Terror and Tuberculosis in the Horn of Africa” by Rachel Pieh Jones. The author and her husband run a school in Djibouti, but at the time of Tonelli’s death lived in Borama, within walking distance of the hospital.

Pieh Jones never met Annalena Tonelli. I am lucky to say I did.

In January 1993, I spent two weeks in Somalia covering the famine that accompanied the country’s civil war. I visited “Koch Hospital,” Tonelli’s TB treatment center in Merca, on the Indian Ocean south of Mogadishu, for three days. (The hospital was named for Robert Koch, the German bacteriologist who identified the “tubercle bacillus” in 1882.) Seven-hundred patients were under treatment and 1,500 waiting to start. They occupied 104 houses Tonelli had rented in town.

I wrote about Annalena Tonelli in The Washington Post when relief agencies considered treating TB in Somalia a lost cause. What struck me was not only her competence but her optimism. “You treat them and they flourish,” she said as we walked through the children’s ward. “They are like flowers. They become so beautiful in a very short time.”

Tonelli went to Kenya in 1969 to be a teacher. She got into medicine after volunteering at a hospital in Wajir, in Kenya’s Northern Frontier District, during a cholera outbreak. The area was populated almost entirely by ethnic Somalis, many of them nomadic herdsmen. Only one-third of TB patients were cured, mostly because they stopped therapy once they felt better. Tonelli had read about a new, six-month treatment strategy and thought she could do better.

In 1976, she got permission from the Kenyan government to manage a “tuberculosis control project” in Wajir, to be paid for by the World Health Organization and UNHCR.

As it happens, TB is the perfect disease for an amateur. You can cure more than 80 percent of people if you just get them to take the drugs and not wander off. That takes time and patience — which Tonelli had plenty of.

She created Bismillah Manyatta, which translates roughly to “In the Name of Allah Village.” It was an area of grass huts and grazing land where a family could stay for six months or, more often, drop off an ill relative to stay at while the family moved on.

Tonelli watched every pill be swallowed. She provided a special diet built around the desert staples of camel milk and corn. Almost every patient who didn’t die in the first two weeks went on to be cured. When treatment was finished, Tonelli put out the word and the patient’s family would magically appear in about a week.

“Directly observed therapy” for TB had been tried as early as 1958, but Tonelli was among the first to try the six-month version (called DOTS, for “directly observed therapy, short course”) in Africa. At certain times her cure rate was 96 percent — so high that she was dismissed as an outlier in the medical world. She didn’t publish papers. She’s not mentioned in textbooks. She wouldn’t even let me take a photograph of her.

Who I am does not matter,” she told me. “If you do something for others, nobody should know about it. I believe this absolutely.

Tonelli was expelled from Kenya after she publicized the 1984 Wagalla massacre in which Kenyan army troops killed hundreds — and possibly thousands — of ethnic Somalis in a complicated inter-clan struggle. She returned to Europe and took courses at the Liverpool School of Tropical Medicine. In 1987, she returned to Somalia and recommenced treating TB, first in Beledweyne, then in Mogadishu, and eventually in Merca, trying to stay out of the way of Somalia’s civil war.

Pieh Jones’s account is drawn from the recollections of childhood friends and African colleagues, and from many letters to friends and family in Italy, which were later published. They sketch a picture of someone who was dedicated to both serving poor people and living their lifestyle from an early age.

Pieh Jones writes that, according to Tonelli’s brother, Bruno, “from the time Annalena started reading Gandhi, she stopped doing the twist. She stopped listening to music. She didn’t take an extra glass of water and would rarely sit down to a full meal. ‘She never wanted to take more than the poor would have,’ Bruno said.”

She was a devout Catholic, ready to see the hand of God in unexpected places, including hardship and life-threatening events. She was also an anti-missionary. She did no proselytizing (although she did build a chapel-like “hermitage” in Kenya for her own use). She raised a number of abandoned Somali children (several disabled) and made sure they were instructed in Islam.

Annalena saw the faith of Muslims and embraced it as authentic. She called it the most extraordinary gift she received from the desert nomads, Pieh Jones writes.

Tonelli’s respect for local ways, however, led her to do something she came to regret and would seek to atone for thereafter.

In the early 1970s, she consented to the ritual genital mutilation of five orphan girls she was helping to look after. She later changed her mind about the custom and became a vocal opponent of it. When she worked in Borama in the 1990s, she provided 28 female “circumcisers” with cash grants to start small businesses, and paid their children’s school fees, on the condition they’d give up the practice.

Her courage was legendary, her dedication to her calling hard to fathom.

In Kenya in 1974, she and an Italian colleague, Maria Teresa Battistini, were beaten by two men who considered them infidels. In 1990 in Beledweyne, Somalia, she and members of her staff were kidnapped and one was severely wounded before they were rescued by government soldiers. In Mogadishu in 1991, her house was robbed at gunpoint. In Merca, her house was shot and she was given a handwritten death threat. In the months after my visit she was attacked twice, once with the butt of a gun, suffering a cheekbone fracture.

Pieh Jones quotes Battistini saying: “Annalena told me many times that she never showed fear and she believed that was why she was still alive.”

In late 1993, however, fundamentalist rebels presented her with a list of extortionist demands she refused to accept. After the last of her patients finished treatment she returned to Italy once more. But she returned in 1995, this time to the breakaway nation of Somaliland in the north.

She faced all of the usual problems there — plus a new one. AIDS had finally arrived in Somalia, greatly reducing the chance for cure in the TB patients who were co-infected. Some people even blamed her for the new disease. Pieh Jones quotes a WHO official as saying: “There was so much pressure on her. And when people started coming and not being cured, that became really dangerous.”

Whether that had anything to do with why someone shot her twice in the head on Oct. 5, 2003, is uncertain. Two weeks later, two British teachers nearby were shot and killed in their home. Pieh Jones says that “Annalena was the first foreign victim of the group that would become al-Shabaab.”

Annalena Tonelli’s is a life that makes anyone question the opinion that they’re a pretty good, selfless person. Clearly, it’s done that for Rachel Pieh Jones, who talks about her own faith and service in the book, which she will be discussing in Washington on Wednesday evening at the Potter’s House and on Thursday evening at the American Enterprise Institute. It reminded me of Tracy Kidder’s musings about his inadequacy as he chronicled the American physician Paul Farmer’s work in Haiti in the book “Mountains Beyond Mountains.”

“Stronger Than Death” is a long way from a definitive biography of Annalena Tonelli. But it’s a start. More people should know her story.

I’m sure of one thing. She’s the most remarkable person I’ve ever met.

David Brown is a physician and writer who for many years covered medical and science issues for The Washington Post.

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