In early September, Qurraisha Mukhtar’s two youngest children, Salman (1) and Hassan (2), succumbed to a terrifying illness. They suffered from fever, a persistent cough, and gasping breaths. Their throats turned white and their necks swelled dramatically. Despite seeking help from a local healer, Salman’s breathing worsened, and he died one night. The following day, Hassan began choking and also passed away.
Living in a makeshift shack on the outskirts of Mogadishu, Somalia’s capital, Ms. Mukhtar had little time to grieve. Two more of her children soon displayed similar symptoms. She and her husband desperately pooled resources from friends and family to rush them to Demartino Hospital in a three-wheeled taxi.
Upon arrival, they were directed to a building originally constructed during the initial year of the Covid-19 pandemic. Today, it serves a different, alarming purpose: combating diphtheria. This horrific yet preventable disease is now infecting thousands of children, and some adults, across the region.
Diphtheria is caused by bacteria that release a potent toxin, primarily attacking cells in the throat and tonsils. This leads to the formation of a thick, gray membrane of dead tissue that can grow large enough to obstruct the airway, leading to suffocation. It poses an especially grave threat to young children due to their smaller airways. While early detection allows for effective antibiotic treatment, delays can quickly prove fatal.
This disease, once largely eradicated thanks to vaccines, has seen a resurgence in recent years. Factors contributing to its return include mass displacement caused by climate change and ongoing conflicts, disruptions in routine immunization programs during the Covid-19 pandemic, and a concerning rise in vaccine hesitancy globally.
Dr. Mohamud Omar, a pediatrician, examines a child’s tonsils in the diphtheria ward of Demartino Public Hospital in Mogadishu, Somalia, last month.
Significant diphtheria outbreaks are currently plaguing Somalia, Sudan, Yemen, and Chad. These nations, ravaged by civil wars or hosting large refugee populations, suffer from low vaccination coverage, weak surveillance systems, and fragile health infrastructures that often leave infected children undiagnosed or treated too late.
In industrialized nations like the United States, diphtheria was a leading cause of childhood mortality. However, the introduction of a vaccine in the 1940s dramatically reduced cases, making the disease rare by the 1970s. In the two decades following 1996, the U.S. reported only one case per year, with just a handful since.
Even in developing countries, diphtheria was gradually disappearing at the turn of the 21st century. Yet, roughly 15 years ago, cases began to climb again. Venezuela experienced a major outbreak as its once-robust public health system crumbled amidst political instability. Bangladesh saw an outbreak starting in 2017, predominantly affecting Rohingya refugees in overcrowded camps. Over the past two years, Nigeria has reported nearly 30,000 cases, primarily in its northern regions where vaccination rates are particularly low.
Europe has also witnessed recent cases, typically among young immigrants from Syria or Afghanistan who had not been immunized.
In the United States, the few reported cases have been linked to international travelers. However, American vaccination rates have shown a slow but steady decline over the last five years. In the 2024-25 school year, only 92 percent of kindergarten students nationwide had full diphtheria vaccination coverage, a drop from 95 percent in 2020. Achieving widespread immunity requires at least 85 percent coverage.
Children typically receive a five-in-one combination vaccine against diphtheria at 6, 10, and 14 weeks of age. Incomplete vaccination leaves children vulnerable, a common issue for displaced and struggling families like Ms. Mukhtar’s.
Katy Clark, a diphtheria expert at Gavi, an international organization assisting low-income countries with vaccine procurement, stated that in regions with limited diagnostic and treatment resources, up to one in four children infected with diphtheria might die. In contrast, health systems with better resources see a fatality rate closer to one in 20.
Qureisha Mukhtar sits with one of her surviving children in the diphtheria ward.
Somalia is the first country to seek new funding from Gavi for diphtheria booster shots. These boosters would be administered to children in their second year of life, then again between ages 4 and 7, and finally between 9 and 15, targeting areas most affected by the outbreak.
“We didn’t even have a diphtheria support modality, because we didn’t need one,” Ms. Clark remarked. “And now we have to build out a whole new process to help countries respond.”
Somalia’s diphtheria outbreak, which began in 2023, has steadily intensified. Over 2,000 cases have been reported nationwide this year, though Ms. Clark believes this is a significant undercount due to weak surveillance and reporting.
Demartino Hospital in Mogadishu has admitted nearly 1,000 diphtheria patients this year, a stark increase from just 49 in 2024. Eighty percent of these patients are children.
Somalia’s health system, already weakened by decades of civil war, has been further strained by reduced aid from the U.S. government, a consequence of cuts made by the Trump administration. Diphtheria and other infectious diseases are surging as more children suffer from severe malnutrition amidst a sharp decline in food assistance.
Ms. Mukhtar and her family were forced to leave Baidoa, southern Somalia, due to years of brutal drought. A relative in Mogadishu allowed them to build their temporary home on his land.
She mentioned that her 12 children had received at least some of their vaccinations, as she took them to health centers when they were infants. However, with so many children and her inability to read, meticulously tracking their immunizations was a challenge.
The two children Ms. Mukhtar brought to the hospital—a 3-year-old daughter and a severely malnourished 10-year-old son—both recovered from their diphtheria infections. Yet, Ms. Mukhtar incurred approximately $200 in costs for their tests and medications. The hospital operates on a “cost-recovery” basis, with Somalia’s health ministry providing only a fraction of its operational funding.
Dr. Omar examines a child’s tonsils in the diphtheria ward. Diphtheria can cause cells to die in the throat and tonsils, forming a membrane thick enough to lead to suffocation.
In Demartino’s bustling diphtheria ward, all 34 beds were occupied, some even holding multiple children. Pediatrician Dr. Mohamud Omar tirelessly made rounds, closely monitoring airways to ensure that the lumpy obstructions in their throats did not impede breathing. He prescribed supplemental oxygen for several children. Exhausted parents slumped at the foot of beds, many shuttling between four or five infected children.
Three of Amina Hassan’s children were admitted to the ward in mid-September. While her oldest and youngest improved within days, her 4-year-old daughter still required oxygen and had developed an allergic reaction to the standard diphtheria antibiotics. Dr. Abdirahim Omar Amin, the hospital’s director, noted that while the hospital occasionally receives antitoxin—an emergency treatment used in high-income countries—supplies often run short.
Ms. Hassan explained that her children were unvaccinated. She had wanted them immunized, but after her oldest child developed an infection at the injection site following a tuberculosis vaccine at birth, her husband refused any further shots for their children.
Sitting on a hospital bed, with her 4-year-old in her lap and her 1-year-old (whose neck remained severely swollen) slumped against her back, she stated, “After this, I am going to try to convince him to get them vaccinations, and I think he will agree.”
Across the aisle, Hawa Mahmoud sat between two beds holding three of her children. She awaited her husband’s arrival with three more, who had developed symptoms at home. Ms. Mahmoud noted that the illness had affected many students at her older children’s school recently. Now, six of her seven children were infected; so far, her oldest showed no signs, but she remained pessimistic. “They’re coming, one after the other,” she lamented.