Tuberculosis is a major public health problem in the world and the problem is particularly widespread in sub-Saharan Africa . More than 80% of the people suffering from TB live in sub-Saharan Africa or in Asia , where spending on health care is low and access to drugs is limited. Although good TB programs in parts of Africa had an appreciable impact in the reduction of TB cases, military conflicts and civil strife in some countries play a major role in stalling TB control programs . Many people die each year of TB in those parts of the world because various forms of war and low spending on health care deprive them of access to treatment . Against this backdrop of neglect, it is little wonder that TB has been allowed to spread. Nonetheless, there is a lack of information on the impact of longstanding armed conflict in the SRS on TB epidemics in Ethiopia.
More than 191 million people lost their lives in the 20th century due to armed conflicts . Tuberculosis is known to be a major cause of morbidity and mortality in conflict settings [6–9]. When one combatant dies in the conflict, an additional 14 to 15 civilians die, mostly from preventable infectious diseases such as TB . Conditions of war were associated with the rapid increase of morbidity and mortality from TB . A review of the literature reported an increase in the incidence of TB during war years and excessive morbidity and mortality many years after the war . For example, the TB mortality rate in Holland rose from 154 per 100,000 in 1915, to 180 per 100,000 in 1916, while the TB mortality rate increased by 50% in Berlin from 1916 to 1917 . A prior study conducted in Nepal reported poor utilization of TB treatment and diagnostic services among war affected populations. This was mainly due to massive military campaigns, frequent curfews, and closures of services in conflict areas, and subsequently, to an increase in the prevalence of TB in the population .
Ethiopia ranks 7th of the 22 countries with highest TB burden in the world . The Somali Regional State of Ethiopia is an area suffering from a long running conflict. The conflict has severely undermined the ability of the public sector to deliver basic social services to most of its population. As a result, people in the region are not only exceedingly poor , but also bear a disproportionately high incidence of TB. In the year 2000, the incidence of pulmonary positive TB in the Somali Regional State of Ethiopia was noted at 175-250/100,000, which is much higher than the national level of 165/100,000 .
The population in the region overwhelmingly consists of Somali pastoral nomads; a migratory people whose livelihood is primarily based upon rearing livestock. These people migrate seasonally or episodically in search of grazing lands and water. Despite significant TB-related morbidity and mortality amongst the nomads of this region, the disease has been largely neglected . We conducted a broad-based study that addressed socio-cultural attributes in the management and control of TB among Somali nomads in the SRS of Ethiopia from July to September 2007. As a part of this study, we documented the length of delay in receiving a diagnosis of TB that patients reported  and the barriers to TB care that they perceived (under publication). In this paper, we intend to examine the role of conflict in a regional TB epidemic by comparing patients from conflict zones in the region to patients from non-conflict zones with regard to the delay they experienced in the diagnosis of TB and the extent to which these patients utilized self treatments before the diagnosis of TB was made.
The SRS is the second largest among the nine regions of Ethiopia, with a land area of 375,000 km2 and an estimated population of 4 million people. Three different systems of livelihood exist in the SRS: these are; pastoralism, agro-pastoralism and urban . An estimated 85% of regional populations earn their livelihoods from pastoralism or agro-pastoralism.
The Regional TB control program adopted the DOTS strategy, which is implemented through DOT clinics that are located in major towns. The private sector is very rare in the Somali Regional State of Ethiopia. Neither the private sector nor traditional healers are involved in the regional TB control program.
The region is characterized by longstanding conflict between government forces and local armed rebel forces, i.e., the Ogaden National Liberation Front (ONLF). Although the conflict had been simmering for years, new momentum occurred in early 2007 . The SRS consists of 9 zones. However, most of the battles and war activities are concentrated in 5 zones, i.e., Dhagaxbur, Fiiq, Korahe, Gode and Wardheer. All of these 5 zones are overwhelmingly populated by pastoral nomads [15, 16]. As a result, the nomadic populations are faced with restrictions of movement that prevent them from fully utilizing their traditional survival mechanisms and their access to health care . Medecins Sans Frontieres (MSF) provides health services, including TB care to the people who live in the five conflict zones. However, the Ethiopian government denied MSF access to these zones from April 2007 . This study was conducted from June - September 2007, in the Jigjiga and Shinile zones of the SRS of Ethiopia.