The large numbers of armed conflicts in Africa may impact TB control programs, because armed conflicts interfere with the goals of identifying and curing TB patients [
21]. This study reports over 3 times higher odds of delay in the diagnosis of TB for patients from conflict zones of the Somalia Regional State of Ethiopia, when compared to their counterparts from non-conflict zones. Delay in the diagnosis of TB patients has been associated with increased transmission of the disease [
22]. Furthermore, conflicts and the resultant restricted access to health services, is known to exacerbate the incidence of tuberculosis [
23]. Armed conflicts may not only fuel TB epidemics by escalating poverty and malnutrition, and thereby increase the number of TB susceptible individuals, but such conflicts may also deter infectious TB patients from seeking prompt diagnosis and treatment. This will lengthen the duration of the infectious period and thus increase the pool of infections within communities. Scenarios of this kind were experienced during the war in Iraq, where the number of new TB cases nearly tripled as the war impoverished people, destroyed health infrastructures and interrupted access to anti-TB treatment [
24]. A four-fold increase of TB incidence has also been recorded in Bosnia and Herzegovina since the beginning of the war in 1991 [
25]. Increased rates of active TB has been associated with conditions of war in a number of reports [
26]. In Ethiopia, over a third of the population is exposed to TB and more than 120,000 new cases were reported in the year 2004 alone [
27]. Unless action is taken to improve the access to TB diagnosis and treatment, the World Health Organization (WHO) predicts that the number of active TB cases in parts of sub-Saharan Africa will double within 10 years [
28]. This is very likely in countries such as Ethiopia, where the vast majority of its people have no access to TB care [
29]. As shown in figure
1, there are only 4 diagnostic centers in conflict zones of the Somalia Regional State; an area in which more than 2 million people are inhabitants, obliging TB patients to walk for more than 100 kilometers to access TB care. As health care needs increase in conflict settings, access to health care is often limited by poverty and by the lack of security [
30]. This is reflected by extremely long patient delay (median, 120 days) recorded for patients in conflict zones of the Somalia Regional State of Ethiopia. The median delay of 120 days in the diagnosis of TB greatly contrasts with the delay in diagnosis recorded for TB patients from non-conflict zones in the same region (60 days), as well as the recorded delays for patients in other peaceful regions of the country, such as Addis Ababa (60 days) [
31], the Amhara region (30 days) [
19], the Southern Nations region (30 days) [
32] and the Tigre region (30 days) [
33]. The finding in this study is consistent with other findings that armed conflicts are a source of diagnostic delay, because they prevent patients from seeking prompt TB care [
34].
The 1978 Alma Ata Declaration stated that access to health care for all is a human right, and its violation has been described as being unacceptable, when the causes for that violation are unjust, avoidable and unnecessary [
35]. We believe that the armed conflict in the Somalia Regional State of Ethiopia is an avoidable factor that substantially contributes to TB epidemics in Ethiopia. Since there is an imminent danger that conflict zones in Ethiopia may be a breeding ground for TB in that country, international organizations and national authorities should establish programs that are specifically earmarked for the prompt diagnosis and treatment of TB for those people who inhabit areas where armed conflicts continue to be waged.
Our study shows that patients from conflict zones have significantly higher odds of undertaking self treatment (OR = 3.34, 95% CI: 1.56-7.12) compared to patients from non-conflict zones. A previous study shows that 87% of the pastoral nomads who were TB patients in the SRS of Ethiopia sought traditional (animist) health care for their illness prior to diagnosis [
14]. For people who have little exposure to modern medical care, an appeal to traditional healers may be the only option. A significant association between self-treatment and long delay in the diagnosis of TB was documented in Ethiopia [
19,
36]. Moreover, self-treatment was also associated with increased morbidity and death from TB [
37]. Armed conflicts hamper TB control efforts not only by disrupting the health system but by diverting economic resources to priorities other than health needs [
38]. When national priorities shift and attention is deflected, TB control efforts may suffer [
39]. The most cited reason for the increase in TB epidemics in Ethiopia is a lack of sufficient funds for TB control programs [
40]. Although underfunding makes the provision of effective intervention difficult [
41], sustainable political commitment for the diagnosis and treatment of TB is a fundamental condition for the implementation of successful TB control programs [
41]. Being mindful of this, we advocate initiatives that will generate and sustain the effective political will needed to insure that effective TB control will be implemented in the SRS of Ethiopia.
The present study has several potential limitations. Since this was a cross-sectional study, we are unable to determine cause-and-effect relationships. Our outcome variables were necessarily self-reported, and these reports may suffer from recall bias.