health refugees immigrants
Like many other African
countries, the area inhabited by ethnic Somalis has experienced great divisiveness
since at least the mid-1800's, when the area was carved into multiple territories.
the north, now known as Djibouti, Britain and Italy colonized areas further
south, and still other regions were under the rule of neighboring Kenya and
Ethiopia. In 1960, the Italian and British areas were united into an independent
Somalia, and in 1977 Djibouti became a separate nation after receiving independence
from France. The regions of Kenya and Ethiopia which contain large numbers
of ethnic Somalis are sources of border disputes presently.
The anti-colonial, pro-Soviet
civilian government formed at independence was toppled in a coup led by General
Mohammed Siad Barre in 1969. While popular at first, Barre's regime became
increasing oppressive and autocratic, leading to the birth of clan-based opposition
militias. In 1988, full scale civil war broke out, leading to Barre's exile
in 1991. However, up to the present, the clans have continued the bloody war
amongst themselves, with no government being established. The continuous warfare,
together with border clashes, has brought the Somali economy to near collapse.
Mass starvation has ensued, and the level of inter-clan violence has become
extreme, with rape and torture commonplace. An estimated 400,000 Somalis died
during this period, and at least 45% of the population has been displaced
by the fighting. Humanitarian relief forces from the U.N. and the U.S. attempted
to intervene, but by Spring of 1994 all foreign troops had been withdrawn
due to the instability.
Beginning in 1991, at
least one million Somalis fled to the neighboring countries of Djibouti, Kenya,
Ethiopia, Burundi and Yemen, adding to the already overwhelming populations
of refugees in the Horn of Africa. While most remain in refugee camps, some
numbers have been repatriated, and several thousand have been resettled to
the U.S. and Europe. In particular, certain clan-based ethnic groups, the
Benadir and the Barawans, have been selectively resettled en masse.
Somali is the common
language of Somalia, and since Islam is so widespread, Arabic is spoken by
many Somalis. Additionally, educated Somalis are frequently conversant in
Italian, English, and/or Russian, depending on their experiences with the
former colonial powers. Some Somalis near Kenya can also speak Swahili.
While Islam and the Somali
language unite all of Somalia, the societal structure is markedly fractionated
by membership in patrilineal clans (descent through male lines). There are
a few main clans, and multiple subclans, sometimes with geographical and even
social class orientation. For example, the Benadir clan group is comprised
mostly of merchants and artisans living in southern coastal areas. Another
recently arrived group, the Barawans, lived in the Kismayu area, where they
were predominantly fisherman and small-scale artisans like shoe cobblers.
Much of the current strife in Somalia is centered around clan disputes, as
allegiance to the clan far outweighs allegiance to a united Somalia.
Somalis almost universally
can be categorized by their strong adherence to Islam, the Sunni sect in particular.
Accordingly, the Islam religion shapes many aspects of Somali culture. For
example, there is strict separation of the sexes, and women, including sometimes
prepubescent girls, are expected to cover their bodies, including hair, when
in public; facial veiling is uncommon in the U.S. However, women in Somali
culture have considerable status, and many resettled refugee women are highly
educated and held professional positions inside Somalia.
Handshakes are appropriate
only between men or between women. The right hand is considered clean, and
is used for eating, handshaking, and the like; children are taught early to
use only their left hand for hygiene during toilet training. Even in the U.S.,
Muslims prefer to wash with poured water after a bowel movement. Ritual cleaning
of the body, especially before prayers, is dictated by Islam.
Devout Muslims pray five
times a day to Allah; in reality, schedules in the U.S. do not always permit
this. The most important holidays include Ramadan, where adherents fast from
sunrise to sunset (pregnant women, the infirm, and children are typically
exempt), and Eid, a social celebration which marks the end of the fast. Many
religious holidays and events are marked by the ritualized sacrifice of a
goat or lamb; sometimes resettled Somalis arrange for this practice through
rural farmers. Islam particularly proscribes the consumption of alcohol and
Birthdays are not particularly
celebrated by Somalis, and it is not uncommon for people to not know the exact
date of their birth. At the time of immigration, birthdays are typically rounded
off to the nearest year, e.g. 1-1-98, 12-31-62, etc. Alternatively, the anniversary
of family members' deaths are observed and celebrated.
When death is imminent,
a Muslim cleric, a sheik, is summoned to pray for the person's soul and recite
special versus from the Koran. After death, the body is ritually cleansed
and clad in white clothes for burial.
Please see Religions
for further discussion of Islam.
There are traditional
medical practitioners in Somalia, especially herbalists, bone-setters and
religious practitioners. Herbal medicines are widely used in Somalia, especially
for chest and abdominal symptoms; the herbal pharmacopeia is vast, and some
recipes are closely guarded by practitioners. Healers treat psychosomatic
disorders, sexually transmitted diseases, respiratory and digestive diseases,
and snake and other reptile bites.
Another common practice
is termed "fire-burning," where a special stick is burned and then applied
to the skin. Concepts involving spirits, such as "evil-eye," where excessive
praise or attention can attract evil spirits to a infant or child, can be
viewed as causing illness. Ritualized dancing is used mostly for psychosomatic
disorders, and Koranic cures as well. There is understanding about the communicability
of some diseases, such as tuberculosis and leprosy, and isolation is sometimes
and the Postpartum Period
Somali families are typically
large; seven or eight children is considered ideal. Contraception, and similarly,
abortion, are anathema to most Somalis, given the strong Muslim belief that
pregnancy is a blessing from God and should not be interfered with. Even sexing
of the fetus is not encouraged, as it is God's will and cannot be changed.
Prenatal care is sought by refugee Somali women here, although there is a
marked preference for female examiners. Most women fear Caesarean section
delivery, the perceived method of choice for American women, as it is thought
that the surgery may impede subsequent pregnancies and render to postpartum
mother infirm. Alternatively, many women are concerned that episiotomies or
even natural childbirth could damage the infibulation (see below) and must
There is a culturally-sanctioned
40 day abstinence period, "afatanbah," in the postpartum, when the mother
remains in her household and is assisted by female relatives and neighbors.
Amulets made from garlic can be worn by the mother and newborn to ward off
evil spirits during this period, and incense is burned for the same purpose.
There is traditionally a naming ceremony during this period, but hospital
procedures requiring birth certificates have changed this practice.
Breast-feeding is the
norm, in Somalia and in the refugee community here, sometimes for two years
or longer. However, early supplementation with animal milks in Somalia or
formula in the U.S. is not uncommon, and at least some women believe erroneously
that colostrum is not healthy for the newborn. Infant care includes massages
and warm water baths. Traditionally, an herb called malmal mixed into a poultice
is applied to the umbilicus for a week or so; some researches report the availability
of this herb in the U.S.
Women's Health Issues
Similarly, the common
practice of female genital cutting (FGC) is certain to create controversy
here in the U.S. An estimated 98% of Somali girls 8-10 years of age undergo
FGC, usually Type III (or infibulation), which consists of the removal of
the clitoris, the adjacent labia (majora and minora), followed by the pulling
of the scraped sides of the vulva across the vagina. The sides are then secured
with thorns or sewn with catgut or thread. A small opening to allow passage
of urine and menstrual fluid is left. An infibulated woman must be cut open
to allow for intercourse on her wedding night, and the opening may then be
closed again afterwards to secure fidelity to her husband."female circumcision,"
where the clitoris and part of the labia is excised, ostensibly to keep women
pure and chaste. Web sites concerned with the issue include http://www.fgm.org/
and http://rainbo.org. For a more extensive
discussion and current classification of FGC, readers are also referred to
the section on Refugee Women in this site.
Resettled refugees are
warned of the illegality of this practice in the U.S., and Somali caseworkers
here are quite emphatic that it is not being performed here. I have heard,
however, some discussion that some girls would in the future be sent to Somalia
for the procedure.
Somalian refugees from
the Benadir ethnic group have recently been resettled to the U.S. in large
numbers, and a detailed discussion of this particular group follows.
The Benadirs are a Somali
ethnic group from the Benadir region of Somalia: the southern coastal region
including Mogadishu. Unlike most Somalis, who are nomadic, the Benadir have
a long history as urbanized merchants and artisans. The Benadir exhibit strong
clan allegiance, through intramarriage and self-governance. They are devout
Sunni Moslems, and are well known for their peace-loving, non-violent ways.
For all these reasons, the Benadirs consider themselves a different, elite,
class from other Somalis; consequently, they have been the targets of jealousy
and animosity for centuries.
When massive internecine
warfare erupted in 1990, the unarmed and non-aligned Benadir were caught in
the middle. They suffered greatly at the hands of the other Somali clans:
homes and businesses were destroyed, women were raped in front of male relatives,
and countless were slaughtered. Those that could fled Somalia, for Kenya,
Ethiopia and Yemen, and many died on the high seas during flight. Because
of their vulnerability, even among other Somali refugees, the U.N. established
a separate Benadir refugee camp, Swaleh Nguru, in Kenya.
With the camp population
exploding (approximately 22,000 in 1996), health conditions deteriorating,
their homes and livelihoods destroyed, and the likelihood that they could
never repatriate to Somalia without persecution, resettlement overseas became
the only durable solution for the Benadir plight. Since Spring of 1996, about
3,000 Benadir refugees have been resettled in about 20 sites throughout the
U.S. Of these thousands, there are about a dozen major clans and many more
subclans; family name usually corresponds to clan membership. The elder clan
leaders serve as the cornerstone of Benadir society and should be included
in all decisions surrounding Benadir resettlement.
Benadir refugees on the
whole possess cultural characteristics that may complicate their resettlement
experiences. Chiefly, they may be reluctant to be resettled in larger Somali
communities, especially since persecuting clans may be represented. In our
experience in Dallas, we have seen several different organizations coming
forward claiming to be the representatives of the Somalian community. Similarly,
clan allegiance is so entrenched that secondary migration from the resettlement
site frequently occurs. Likewise, many Somali refugees claimed fictitious
family relations, such as disguising second wives as sisters or daughters,
or even convenience marriages, when it was perceived to improve their acceptance
for resettlement. Many of these artificial families immediately scatter to
other areas to rejoin clan members upon arrival. Furthermore, there will inevitably
be frustration over the downward economic mobility Benadirs will initially
face in starting over in the U.S. workforce.
Somali families are particularly
large, sometimes ten or more individuals; housing laws in the U.S. will require
these large extended families to divide into two or more apartments. And finally,
Muslim proscriptions governing the interaction between the sexes will lead
many Somali women to prefer female interpreters and health care providers.
Health Risks in Refugees
from East Africa (Also see the Infectious
Diseases web site for updates and details)
- Intestinal parasites
(Enterobius, Trichuris, Strongyloides, and Ascaris)
- Hepatitis B
- Low immunization rate
- Dental caries
- Typhoid fever
- Dengue fever
- HIV infection
- Diarrheal illnesses
- Hansen's disease
and Other Tests for Refugees from East Africa
- Nutritional assessment
- Stool for ova and
- Hepatitis B surface
- Hemoglobin or hematocrit
- Peripheral smear for
malaria should be considered
Other problems that practitioners
should be especially alert to are cervical cancer, ectoparasites, and post-traumatic
There were reports of
malaria and a measles outbreak in the refugee camps in Kenya, but treatment
was initiated before resettlement. Another concern for the resettlement providers
is the common practice of corporal punishment of children, and less frequently,
wives. Careful counseling in orientation must be provided to explain the legal
ramifications and definitions of abuse in this country.
Lance A. Rasbridge, Ph.D.
Thanks to Mohammed Farah
and other anonymous reviewers from the Somali community.
OR Back to
Ackerman, L. K. (1997).
Health problems of refugees. Journal of the American Board of Family Practice,
Gavagan, T. & Brodyaga,
L. (1998). Medical Care for immigrants and refugees. American Family Physician,
Lewis, T. (1996). Somali
Cultural Profile. Seattle: Ethnomed
Mypist, E. (1995). Notes
on Benadir Refugees. Mombasa: United Nations High Commissioner for Refugees.
Putman, D.B., and Noor,
M.C. (1993). The Somalis: Their History and Culture. Washington: The Refugee
Service Center, Center for Applied Linguistics.
United States Catholic
Conference 1996 Benadir Refugees from Somalia. Washington: Refugee Information
Series, Migration and Refugee Services.