This article is adapted from Stronger Than Death: How Annalena Tonelli Defied Terror and Tuberculosis in the Horn of Africa and originally appeared in the Autumn 2019 issue of Plough Quarterly: Vocation.

Ibrahim, a three-year-old Somali boy, suffered from both malnutrition and spinal tuberculosis. Policemen had found him in the desert in northeastern Kenya, dying of hunger. He clung to anyone willing to hold him and pressed his head against that person’s chest. Annalena Tonelli, an Italian working as a teacher in Wajir, Kenya, took him home from the hospital; she wanted to keep him close through the nights too, so he wouldn’t die alone.

When Annalena first stretched Ibrahim out on a bed, he pulled her down to lie beside him and rested his head over her heart. “Who knows how much he has suffered. Now he just wants comfort, peace, and the security of a mother’s heartbeat,” she remarked to another caregiver.

Life was harsh in the 1970s in Wajir, a remote region populated primarily by Somalis. A UNICEF survey declared the water unfit for human consumption. Lions attacked isolated nomads and snakebites were common. Temperatures soared to 105 degrees Fahrenheit and there was no electricity. Rain, on the rare occasions when it did fall, could lead to catastrophic flooding. The hospital lacked sufficient staff, equipment, and supplies. Tuberculosis, malaria, typhoid, cholera, and dengue fever raged.

Annalena moved to Wajir in 1970 to teach, but during a cholera epidemic her work shifted to caring for sick children like Ibrahim. Eventually, she turned all her attention to treating tuberculosis, an infectious disease that carried a powerful stigma among Somalis (and still does). People wouldn’t use the word tuberculosis and insisted they only had a cough. If a community found out a member had TB, the sick person was often ostracized or even abandoned. Many would rather die than be labeled with the diagnosis.

In the developed world, many still assume that TB no longer exists. Dr. Paul Farmer, who battled TB in Haiti, put it bluntly: “The ‘forgotten plague’ was forgotten because it ceased to bother the wealthy.” That only began to change in 2016 when cases increased in the United States for the first time in decades, and in the following year, when drug-resistant TB started killing people in Minnesota. Around the same time, South Korea announced new laws requiring that every citizen be tested twice in his or her lifetime. Media reports contained elements of shock that this Victorian-era disease was still among us.

Dr. Onkar Sahota, chair of London’s Health Committee, said in 2015, “We think TB is a disease of developing countries or of days gone by, but TB is a disease of today. It certainly was a disease of yesterday and we need to make sure it isn’t a disease of tomorrow.”

Annalena hadn’t known much about tuberculosis when she moved to Kenya, but since her youth she had been drawn to the sick, the poor, and the outcast. In her hometown of Forlí, Italy, she had founded an organization called the Committee to Fight World Hunger. But to her, that hadn’t been enough. She discovered a slum known as Casermone, and started spending more and more time there. She took children from Casermone to medical appointments, paid school fees, and even clipped their toenails. The phone at her house would ring, someone would demand wood or coal, and off Annalena would rush.

She urged her friends and siblings to join her and they would, drawn in by her persuasive charisma. One friend, Maria Teresa, became Annalena’s lifelong partner in her vision to serve. When later asked what inspired Annalena, who was raised Catholic and had a deep love for Jesus, Maria Teresa said, “Gandhi, Gandhi, Gandhi.” She added, “She learned from Gandhi that to love one must willingly and deliberately strip away self and restrict one’s own needs.” Annalena referred to the Indian independence leader as her “second gospel.”

During the early 1960s, while Annalena was reading Gandhi, there were also radical shifts in Italian Catholicism. The Second Vatican Council encouraged dialogue with other religions and challenged lay people to live out missionary vocations both locally and globally. Believers wouldn’t have to become nuns or priests, or even work under the auspices of the church, to serve the poor or play a meaningful role in the spiritual life of their communities. This suited Annalena’s independent streak, as did the renewed emphasis on social action as a valid form of the vocation to mission. Her experiences in Casermone led her to search for a place where she could live and serve among the poor for the rest of her life. Inspired by a friend, Pina Ziani, who worked among lepers in east Africa, Annalena settled on Kenya. Pina helped her secure a teaching contract and Annalena left Italy in 1969.

The ways of service are infinite and left to the imagination. Let us not wait to be instructed in how to serve.

“The poor are waiting for us,” Annalena said in one of her few public statements. “The ways of service are infinite and left to the imagination. Let us not wait to be instructed in how to serve. We invent and we live the new heavens and the new earth each day of our lives. If we don’t love, God remains without an epiphany. We are the visible sign of his presence and we make him alive in this infernal world where it seems that he is not. We make him alive each time we stop next to a wounded person.”

Once in Kenya, Annalena became independent from the limitations and structures of the Catholic Church. Yet she knew she needed a supportive community around her. Soon Maria Teresa and five other women had joined her. They prayed and read scripture together in the mornings and spent their days caring for the sick. They built a physiotherapy facility and called it the Farah Center, or Center of Joy.

Maria Teresa and the other women provided therapy for those with disabilities caused by polio and other childhood diseases. Annalena was consistently drawn to the poorest and most outcast. At that time, due to the lack of medical care, superstitions, and stigma, this meant her focus turned to Somali nomads with tuberculosis.

One young woman, her name lost to sand and history, was typical of those she served. The woman had suffered polio and now hovered near death from tuberculosis. Annalena sat by her side in the final hours of her life. Though they couldn’t communicate in any shared spoken language, Annalena said she and this woman understood one another.

The woman’s legs were limp, thin as sticks, her body so emaciated it was frightening – a rice sack filled with bones. But her face was filled with expression, an awareness. According to the dictates of her clan, she wore the black veil of a married woman, dignified in its modesty. Even though she was now divorced, she still bore the pride of a woman who had been married, once chosen.

She asked Annalena, with hand gestures and her eyes, to spend the coming night in the room with her. The woman coughed incessantly. Annalena sat beside her. Here was one of “God’s sparrows” – one of Annalena’s favorite terms for describing the sick – falling to the ground, known by her Creator and neglected by her people.

Annalena grew drowsy, the heat pushing her head down toward her chest, urging her to sleep. She prayed to keep herself awake. The heat and fever weakened the sick woman. Annalena wrote that she “loved her with an infinite tenderness.” Even that love couldn’t keep Annalena’s eyes open for the nightlong vigil.

When her head drooped and her body collapsed in sleep, the woman took the dirty pillow from behind her own head and offered it to Annalena. Annalena didn’t refuse, though the pillow was full of infection.

Around five o’clock in the morning, Annalena woke, took the woman’s hand, and smiled at her. “Maybe at the end of my life I can say that all I did was pass through this world, holding the hand of the dying, smiling tenderly,” she said later. The light of the kerosene lamp illuminated the woman’s face. She fought to speak. “God is ... in the name of God, gracious, merciful ... go!” And she died.

“These people must have an extraordinary reward in heaven,” Annalena wrote, “because they have suffered so darkly on earth.”

Despite the infected pillow and ongoing close contact with the sick, Annalena rarely got sick. Occasionally she battled malaria or exhaustion, but she never tested positive for tuberculosis. At Wajir’s hospital, Annalena started to oversee TB medication. Friends in Italy sent her books and articles about TB control and combination therapy. She traveled to Spain, then London, to take medical courses. She learned about a recent experimental exploration of short-course therapy, which could theoretically cut the time of care from eighteen months to six. Given its 33 percent success rate, she felt, it shouldn’t be difficult to do even a little better. Treatment was simple and straightforward but had to be followed with precision: patients had to take the right pills at the right time.

That, Annalena believed, was something she could make sure would happen.

Image courtesy of the author

The trouble was getting nomads to stay in one place long enough for the cure to take hold. Eighteen months? Impossible. But six months? Maybe, just maybe, for a good reason, a nomad could be convinced to stay. But not in a hospital, beneath a roof, or inside the prison of four cement walls. Not without their animals or families. Not without some sense of autonomy, dignity, and productivity.

If the right context of care could be created, the right combination of medicine and relationship established, a nomad might stay. Annalena had been in Wajir long enough to know what Somalis valued most highly: Islam, community, and independence.

Her idea was to invite nomads to the property around the Farah Center, where they could build their huts on her land. They could bring some of their animals and a family member or two. She would have them sign an agreement that they would not leave until their six months of treatment were completed and their sputum test came back negative. She would oversee every single pill dosage and provide meals. She planned to build a mosque and a school. She would create jobs for patients. Above all, she would know them: their names, their families, their stories. She would listen to their voices and hold their hands and kiss their cheeks, even while they exhaled tuberculosis bacteria. She would tend their wounds and their hearts.

Before Kenya could actively promote the new short-course treatment, the country needed to run a trial, to make sure patients were actually cured and that the treatment wouldn’t contribute to drug resistance. In April 1976, Annalena proposed to the Kenyan Ministry of Health that she manage a tuberculosis control test project in Wajir. She received permission to launch her project, with funding from the World Health Organization and the United Nations High Commissioner for Refugees.

In naming her new project, Annalena was careful not to use the word tuberculosis – she never would in her centers. Instead she named it the Bismillah Manyatta, the Village in the Name of God.

The sick came with their camels and the canvasses, ropes, and bent sticks for building their huts. Soon dozens were scattered across the sand near the Farah Center. There was no real wall, so beyond a small row of trees and a welcome sign, huts expanded outward as more and more people were drawn to the village.

Patients signed an agreement to stay at the center; in fact, they had to designate a relative who could chase them down if they left early.

Each patient was started on the new short-course therapy. Somalis presented so sick and at such late stages of TB that their dosages had to be adjusted almost weekly as they gained weight from the therapy and the nutritious diet provided. Once the huts were built, people had slightly more motivation to stay put, but still Annalena had to enforce compliance. Patients signed an agreement to stay at the center; in fact, they had to designate a relative who could chase them down if they left early.

Beyond this one promise, Annalena put pressure for compliance on herself, rather than on the patient. Part of her task involved directly overseeing the administration of the medications, down to the actual ingestion and swallowing of them. Annalena kept meticulous records and direct observation became central to her treatment.

People lined up at a table where she set out their pills and small cups of water or the orange drink she despised as too sweet, and her stack of medical charts. One by one, they swallowed the medicine. If someone was too sick to come to the table, she visited their hut. Sometimes she placed the pill on their tongues. She managed these pills around the clock, on a four-hour rotation.

A somali hut called a qal, in the desert, Togdheer region, Burao, Somaliland
Photograph by Eric Lafforgue on Flickr

TB pills were large and hard to swallow. If someone refused, Annalena sat with them until they swallowed the medicine. If someone vomited, she brought a glass of water, sometimes a slice of cake to settle the stomach.

“I was with them every day,” she said. “I served them on my knees. I was beside them when they were getting worse and did not have anybody to take care of them, to look them in the eyes, to give them strength.” Over her thirty-four years in the Horn of Africa, Annalena would achieve a remarkable 93 percent cure rate.

She found the work was both invigorating and exhausting. A Muslim elder in Wajir donated land so Annalena could build a hermitage, a place of retreat where she could be spiritually rested and renewed. She dreamed of spending a year in the hermitage, but a backlog of work heaped up on her desk. She had so many guests at the Manyatta that she read her Bible and prayed at five o’clock in the morning to avoid interruption. New patients, old patients, hungry children, everyone wanted to see her or ask her for something. Maria Teresa called it a “lacerating dichotomy between silence and the sick. The poor called her back from the hermitage, back to their hell, but she knew it was God who took her to the poor and the poor who took her to God.”

People who sensed death’s nearness turned their beds to face Mecca, then called for Annalena.

She tried to only go to the hermitage when she was sure no one was about to die. People who could sense death’s nearness turned their beds to face Mecca, then called for Annalena. “They wanted one hand held by the sheikh and one hand held by Annalena,” Maria Teresa told me. “The sheikh prayed the Koran and Annalena prayed silently, and together they accompanied the person to the door of eternity. So interesting, that a pure Muslim would want an infidel.”

Annalena remained in Wajir until 1985, when her role in exposing a massacre jeopardized her safety and ability to continue. The Kenyan government kicked her out and refused to renew her visa. She moved to Somalia, where she established more tuberculosis treatment centers. Again, she found herself caught up in violence, this time the civil war. She moved to the relatively stable and peaceful region of Somaliland, northern Somalia, and continued her work with the sick.

Most people loved her, but some grew resentful of her presence: a foreigner, a Christian, and a humanitarian whose work drew attention to the weaknesses of the medical care system and local prejudices. In 2003, Annalena won the prestigious Nansen Refugee Award, which increased her profile in Somalia and internationally.

On October 5, 2003, after three decades of serving Somalis with TB and AIDS, Annalena was gunned down by Islamic extremists as she made the evening rounds of her patients in the TB hospital she had founded in Borama, Somaliland.

I was living a few blocks away when Annalena was murdered, having moved to Somaliland in early 2003 with my husband and two children. My husband had taken a job at Amoud University in Borama. Though I never met Annalena, learning about her changed how I wanted to live my life.

Photograph © UNHCR/E. Parsons

The hermitage still stands in Wajir. It is a plain, simple structure; a patch of dirt surrounded by a wall, two small rooms, and a two-story tower with a terrace. Weeds have grown and scraps of garbage pile up in the corners. The Kenyan nuns who work in the Farah Center sometimes come here to pray, but not often. The iron rungs leading to the tower remain firmly implanted in the wall. Retracing Annalena’s footsteps, I scramble up them and perch on the ledge, gazing out over Wajir.

When Annalena stood here, she saw an expanse of open desert and the occasional acacia tree. The town has grown since then and my view is hampered by houses and buildings. Minarets puncture the sky. Camels lumber over dirt trails through town, led by young herders with sticks slung over their shoulders. The wells once on the outskirts of Wajir are now in the center. Where marabou storks once stepped between camels and nomads at the watering holes, truckers use generators to pump water and wash their vehicles.

Behind me, across the dirt road, is the Bismillah Manyatta, still used to house and treat nomads with tuberculosis. Inside the hermitage, down below, is a well with an inscription, “My soul is thirsty for God, the God of my life.” Here, in this place provided by a Muslim for use by Christians, surrounded by stark desert beauty and the vibrant life of a growing town, I feel the possibility of peace, of a world not torn asunder by hatred, fear, and isolationism. I understand why Annalena lingered here.

Annalena Tonelli
Photograph courtesy of the author