A patient is hospitalized at the Health Centre of Diofior, which serves the entire Fimela district, an area spanning 1,115 km². In this rural, impoverished context, the work of volunteer women is crucial. Their active engagement within their communities helps bridge gaps in healthcare access, raise awareness, and reduce stigma. The World Health Organization (WHO) emphasizes the importance of addressing health inequalities to achieve "Health for All." People with TB are among the most marginalized and vulnerable populations, often facing significant barriers to accessing care and catastrophic costs due to the disease. Tuberculosis, as an infectious disease, often requires patient isolation and a lengthy treatment duration of six months to a year. This prolonged recovery period has profound social and economic consequences, not only for the individual affected but also for their family. The inability to work during treatment leads to a loss of income, financial strain, and disruptions to household stability. These factors underscore the critical need for early detection, comprehensive care, and community support to mitigate the far-reaching impact of this disease. Diofior, 2024 November 18

Dr. Alberto Brambilla (left), a thoracic surgeon, together with Dr. Giorgio Besozzi (right), President of the Stop TB Italy association, delivers a lecture on the role of surgery in TB treatment during the annual TB training course in Senegal, a high-incidence country with limited resources. Tuberculosis (TB) is caused by the bacterium Mycobacterium tuberculosis, first identified in 1882 by Dr. Robert Koch. It is an infectious disease that primarily affects the lungs, although it can spread to almost any organ in the body such as the kidneys, brain, spine and skin. Treating TB requires a much longer period than other bacterial infections, typically six to twelve months. If left untreated, TB can be fatal. TB is spread through the air when individuals with lung TB cough, sneeze, or spit. A person only needs to inhale a small number of bacteria to become infected. TB is a contagious infectious disease that can be transmitted through respiratory droplets containing bacteria. Transmission typically occurs through close and prolonged contact with patients with pulmonary TB in enclosed spaces. For this reason, isolation of sick individuals is necessary until recovery. Djilor, 2024 February 2

Sarr Bineta, the trained village's “godmother”, holds an idiomatic brochure in her hands, listing the symptoms suggestive of TB as defined by the WHO: prolonged cough (sometimes with blood), chest pain, weakness, fatigue, weight loss, fever and night sweats. These brochures, specifically designed to ensure accessibility and understanding, were created by StopTB Italia association in collaboration with the Senegalese Ministry of Health to address the high levels of illiteracy in the region. Gathering the women of Ndangane village in the courtyard of her home, Mrs. Sarr is leading a health education session to raise awareness about recognizing TB symptoms. Women like Sarr, respected and trusted by the local population, play a critical role in monthly house-to-house symptom screenings using a dedicated tool. Their active engagement in the community provides invaluable support, helping to promote healthier lives for themselves, their families, and the broader community in the fight against tuberculosis. Ndangane, 2024 November 18

At the TB outpatient Health Centre of Diofior, Dr. Seynabou (left), the nurse (below) and the female volunteer (right) assist a patient undergoing treatment by noting the drugs in the TB register. Documentation and record-keeping are essential for tracking services provided and treatment progress. Although TB is a curable disease, it requires a long and expensive standard 6 month treatment course of 4 antibiotics. In some cases, however, the TB bacteria does not respond to the standard drugs and the treatment for drug-resistant TB as well as HIV-associated TB becomes longer, more complex and expensive. The course of TB drugs is provided to the patient along with supervision and support by trained female volunteer. Without such support, treatment adherence can be difficult. If the treatment is not properly completed, the disease can spread further. The WHO guidelines for the fight against TB are based on sound ethics principles and the protection of human rights. However, while social protection is a fundamental human right, access to the welfare systems remains uncertain for people in these poor rural areas. Social protection and poverty alleviation are also key components of the End TB Strategy. Diofior, 2024 November 18

Joal-Fadiouth Cemetery in Senegal stands as a powerful symbol of coexistence and mutual respect. Located on an island formed entirely of discarded shells, the cemetery is shared by Christians, Muslims, and Animists, who are buried side by side—a rare example of interfaith harmony. In the fight against TB, this spirit of collaboration and coexistence is crucial. With nearly 9 million new cases each year and 3,800 deaths daily, TB continues to be an enormous global health problem, particularly for vulnerable populations. According to the WHO 2024 report, a substantial number of new TB cases are linked to five major risk factors, all associated with a compromised immune system: undernutrition, HIV infection, alcohol use disorders, smoking, and diabetes. TB remains the leading cause of death among people living with HIV. TB and HIV form a lethal combination, each speeding the other's progress. In 2023 alone, approximately 161,000 people died from HIV-associated TB, the majority of them in African Region, which bears the highest burden of the dual epidemic. The shared approach at Joal-Fadiouth highlights the value of unity and mutual respect in addressing health crises and societal challenges through collective action. Joal-Fadiouth, 2024 February 2

Madior, holding a freshly harvested papaya, stands in front of an irrigation basin at the Fleur de la Vie agricultural cooperative in Diofior. In 2017, the nonprofit organization STOP TB Italia launched an agro-social project aimed at achieving financial self-sustainability for the healthcare initiative supporting the reintegration of former TB patients into the workforce after their recovery. The income generated from the sale of fruits and vegetables produced by the cooperative supports the workers themselves, their families, trained women’s activities, and the TB clinic at the Health Centre in Diofior, fostering a circular economy that contributes to the sustainability of the healthcare project. Additionally, the initiative emphasizes the importance of nutrition as a key factor in combating the TB disease. Diofior, 2024 January 31

Ndgor, a former tuberculosis patient who has recovered, is cultivating a pepper plant at the Fleur de la Vie agricultural cooperative. The circle of soil around the plant is designed to retain water for irrigation, preventing waste. The agricultural cooperative was established thanks to the donation of a 2-hectare abandoned plot by the local administration, where organic farming of local produce has been initiated. Initially, the recovered former TB patients received training at a local agricultural institute to learn cultivation techniques and become farmers. Currently, the cooperative produces vegetables and fruits such as onions, peppers, peanuts, mangoes, and papayas. Through the crop rotation technique, each season is dedicated to a specific production, ensuring profitability throughout the year. Diofior, 2024 November 20

Three farmers, Ndgor, Mamadou, and Mbissane (from the left) former tuberculosis patients who have recovered, are checking the water levels in the well and collecting samples to measure salinity, which is essential for irrigation at the Fleur de la Vie agricultural cooperative. The Senegalese farmers were trained by a volunteer geologist from the association, learning how to perform salinity checks to avoid using water from the aqueduct and minimize costs whenever possible. Since the establishment of the agricultural cooperative, the association has reactivated existing water wells and provided all the equipment necessary for farming, including solar panels, motorized pumps, seeds, and seedlings. The income generated from the sale of the products is allocated to the farmers’ and their families’ livelihood, supporting TB patients, and funding women’s activities in the villages, as well as the TB clinic, following the principles of a circular economy. This ensures that the agricultural project can continue to fund the healthcare initiative sustainably in the future. Diofior, 2024 November 17

Jenne Marie Dieng (left), a trained village “godmother”, is providing psychological support to a widow (center) who recently lost her husband to tuberculosis and is suffering from anxiety and depression. These resourceful trained women also offer assistance and psychological support to people affected by tuberculosis and their families. It is important to highlight the need to address mental health alongside physical health, especially since people affected by tuberculosis often face additional challenges such as social exclusion, addiction, and broken family ties. Maintaining and preserving mental health through counseling and psychological support provided by these figures can significantly influence treatment adherence and the success of recovery. Long-term TB treatment is an additional source of stress that can greatly impact the quality of life. Djilor, 2024 November 21

A solitary horse in the rural area of the Sine-Saloum Delta, a UNESCO World Heritage Site since 2011. Tuberculosis is a public health emergency in all low- and middle-income countries, where social determinants such as poverty, inadequate sanitation, malnutrition, limited access to healthcare, scarcity of safe water, insufficient hygiene facilities, and unreliable access to electricity represent one of the most significant obstacles to its control and epidemiological containment. The nonprofit organization StopTB Italia has conducted a study on TB in Senegal, highlighting the importance of self-sustainable social protection measures, combined with widely used tools (e.g., active case finding by trained women), to improve TB treatment outcomes in a rural, resource-limited setting and break the cycle of TB and poverty. Simal, 2024 February 1

Before a fight, a wrestler washes with milk, accompanied by an assistant who tends to his amulets and prepares him for the match. These traditional rituals are believed to grant the wrestler supernatural powers. Mysticism plays a significant role not only in Senegalese wrestling, the country’s national sport, but also in everyday life. Far from being clandestine, magic is officially authorized and regulated. Amulets, masks, lucky charms, and potions prepared by shamans are integral to daily practices. Traditional medicine practiced by shamans is often the first step in seeking cures for diseases in rural areas of Senegal. This is often the context in which trained women, who enjoy the respect and trust of local populations, work within their villages. Fimela, 2024 February 2

A village woman is engaged in burning household waste. Open-air burning with bonfires remains the most widespread waste disposal practice in Senegal. Plastic, along with other debris, is often incinerated, causing significant harm to both human health and the environment. Toxic particles released during combustion not only contaminate the air but also settle on vegetables, which are later consumed. Poverty, inadequate hygiene conditions, and the absence of social protection that leaves people outside the healthcare and welfare system further contribute to the spread of tuberculosis (TB). Djilor, 2024 November 16

Sarr Bineta, the trained village's “godmother”, on the phone in front of the gate of a TB patient’s home, surrounded by his wife, son (bottom right), and his brother (left), a wrestling champion. Trained women play a crucial role in managing non-clinical tuberculosis cases in their villages. They assist patients in successfully completing the full therapeutic TB treatment, ensuring adherence to the prescribed anti-tuberculosis drug regimen as directed by the healthcare center. Additionally, they encourage patients to undergo timely medical examinations to monitor treatment progress, identify any potential side effects of the medication, and adopt measures to mitigate these effects. They also provide essential social and psychological support to the families of those affected by TB. Ndangane, 2024 November 18

The teacher (right) of a primary school class in Djilor introduces the trainees from StopTB Italia during a health education lesson on tuberculosis (TB). Instilling an understanding of risk factors and the impact of unhealthy habits, as well as teaching the skills necessary for a responsible attitude toward health, self-preservation behaviors, and hygiene awareness in primary schools, plays a crucial role in preventing TB and other infectious diseases. By fostering good hygiene practices from an early age, communities can reduce the spread of TB and instill lifelong habits that support overall health. Tuberculosis is particularly challenging to diagnose in children and remains a significant cause of illness and death among children and adolescents. Every year, more than one million young individuals fall ill with TB. Young children face a higher risk of severe disease and mortality, while adolescents are more likely to develop forms of the disease that can be easily transmitted. Significant gaps persist in identifying children and adolescents with TB and in ensuring they receive timely treatment and preventive care. The role of healthcare workers is vital in preventing, diagnosing, and managing TB in these vulnerable groups. Djilor, 2024 November 21

Jenne Marie Dieng (right), a trained village’s “godmother”, walks door-to-door in Djilor village as part of a community initiative to combat TB. These charismatic women, trained by Stop TB Italia, play a key role in identifying suggestive symptoms of TB, which can go unnoticed for months, delaying care and increasing the risk of transmission. Once suspected cases are identified, they are promptly referred to the Diofior Health Center for confirmation and treatment, significantly reducing diagnostic delays and preventing the further spread of TB. Before the involvement of these trained women, self-referred patients often arrived at the Diofior Health Center in severely compromised states. The active case-finding efforts of these community health workers, combined with TB awareness initiatives, have significantly increased diagnosis rates and made a profound impact, achieving a remarkable 98% success rate in treatment outcomes in this rural and resource-limited district. In addiction these women play a crucial role in health education for TB. They help raise awareness of risk factors, counter harmful habits, and foster self-preservation behaviors essential for adherence to TB treatment. By providing evidence-based information, they dispel myths about treatment and recovery.Djilor, 2024 November 21

A patient in the waiting room of the dispensary in Ndangane. In the background, a blackboard displays the availability of medications at the healthcare facility. Women in villages also provide social support focused on the overall physical and psychological well-being of TB patients throughout their treatment journey, including the post-TB period. This involves targeted communication to support survivors who have recently completed TB treatment, helping them care for themselves, reintegrate into society and the workforce, re-establish social links, and get back to normal life, thereby reducing the risk of TB relapse. Ndangane, 2024 November 18

An empty bed inside the Loul Sessène Health Center. The highest number of tuberculosis (TB) cases since global monitoring began was recorded in 2023, according to the latest report published by the World Health Organization (WHO). TB is an infectious disease caused by bacteria and is spread through the air via coughing, sneezing, and saliva. The infection is preventable and usually curable with antibiotics. If treated, most patients survive. Despite this, a total of 1.25 million people died from TB in 2023. The WHO report estimates that TB has likely returned to being the world's leading cause of death from a single infectious agent, following three years in which it was surpassed by COVID-19.Tuberculosis has been and remains an enormous problem. Persistent challenges continue, and countries are far off track in meeting targets to reduce the global TB burden. Over 80% of cases and deaths occur in low- and middle-income countries. In this context, the active case-finding efforts in villages carried out by trained women prove to be crucial detecting TB disease early, thereby improving outcomes for individuals and reducing transmission and incidence at the population level.Loul Sessène, 2024 January 30

At the weekly livestock market in Nguéniène, shepherds gather with their rams and sheep for sale, showcasing the rural and agricultural lifestyle of the Fimela district. With an estimated population of 80,599 inhabitants (population density: 72 inhabitants per km²), the district is predominantly made up of farmers and traders living in rural and semi-urban villages. Senegal faces significant socio-economic challenges, as highlighted by critical national indicators: a Human Development Index of 0.512, an illiteracy rate of 65%, an urbanization rate of 45%, a poverty rate of 46.7%, and an economic dependency ratio of 84 inactive people per 100 active individuals. These challenges are further compounded by health emergencies caused by infectious diseases such as tuberculosis (TB), which predominantly affects low-and middle-income countries. Social protection and targeted interventions—such as the work of trained women—are crucial to addressing the factors that drive the progression and worsening of TB, including poverty, inadequate sanitation, malnutrition, limited access to healthcare, scarcity of safe water, insufficient hygiene facilities, and unreliable access to electricity. Patients face catastrophic indirect costs associated with income loss due to the inability to work during the lengthy TB treatment. Nguéniène, 2024 November 20

At the Boyard dispensary courtyard, trained women from nearby villages, alongside clinic staff and doctors, gather to assist suspected TB patients with diagnosis. Tuberculosis (TB) often results in isolation, marginalization, and stigma, which are significant social determinants of health. Misconceptions about TB lead to widespread discrimination. In some cases, TB is linked to witchcraft and perceived as a "curse on a family" because it can affect multiple generations. This myth arises from the fact that TB is an airborne disease, spreading more easily among individuals living in close proximity. Additionally, TB is often associated with conditions that carry stigma, such as HIV, poverty, substance abuse, malnutrition, and homelessness, or with behaviors perceived as disreputable. Some believe TB is a punishment for moral or personal failings, further fueling discrimination. Women are particularly affected, frequently blamed as the source of the disease, deemed unfit for marriage, or even facing divorce. These prejudices discourage individuals from seeking timely medical care or completing treatment, worsening the disease and increasing the risk of fatal outcomes. Trained women from the community play a critical role in combating these misconceptions, raising awareness, and supporting patients, helping to break the cycle of stigma. Loul Sessène, January 31, 2024