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In Minnesota, a measles outbreak exposes the gaps in public health

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The Riverside Plaza high-rise apartments, the iconic symbol of the Somali community in Minneapolis, are a short walk from the People’s Center Health Services, where most of the patients are of Somali descent. A parent with sick children, or an elder who needs diabetes care, does not have to travel far to see a doctor.

Generally speaking, Somalis in the Twin Cities of Minneapolis and St. Paul are not facing a lack of access to health care providers. At least, not in terms of distance.

At a community meeting on Wednesday night in the neighborhood, the actual issues of access to health care were on display.

Minnesota State Rep. Ilhan Omar and public health officials spent an hour and a half talking about measles and vaccinations with about 30 people at the Brian Coyle Community Center.

After a presentation on why children should be vaccinated, the floor was given to audience members for questions and comments.

The presentation comes amidst a rare measles outbreak that started in the suburbs of Minneapolis and has so far affected 63 children and three adults, the majority of whom are Somali, according to the Minnesota Department of Health.

The immediate cause of the outbreak has been linked to a precipitous drop in MMR vaccinations in Minneapolis. More than 90 percent of Somali children were vaccinated before 2008; that rate has dropped to about 40 percent according to state health officials.

The change is fueled by fears of autism. A report released by the University of Minnesota in 2013 confirmed that autism shows up in higher rates among Somali children (one in 32) than other minority groups in Minneapolis, though roughly on par with whites (one in 36). Some parents, concerned for their children, have come to believe the discredited theory that MMR vaccines are the culprit.

Kamal Hassan said he contracted measles as a child and knew firsthand the importance of vaccinations, which he made sure his own children received. In his native Somalia, people did not question the safety of vaccines, he said. The doubts only began when Somalis moved to the US.

“The system failed our community,” he said, by not being more proactive to “compete with bad information” from anti-vaccination groups, as well as provide public health outreach in general.

Anti-vaccination advocates were there Wednesday night too, continuing to challenge health officials’ message. Jan Frederick of the Vaccine Safety Council of Minnesota handed out printouts that claimed: “some children suffer permanent brain damage from the vaccine, and some die from it.” As the event closed, a young woman in the audience accused Omar, the first Somali American legislator in the US, of “supporting white supremacy” because she would not field any more questions or comments.

But long before this outbreak thrust Somali public health into the spotlight, community activists like Abdirizak Bihi have said that there are reasons that health issues — like measles — disproportionately affect his community. He worked for Hennepin County’s Office of Multicultural Services for three years from 1999 to 2002. The problem, he says, is a lack of education about how to engage the health care system on the patient side, and a lack of cultural awareness on the provider side. It’s a gap in understanding, Bihi says, that public health officials used to fill fairly well on a local level — but no longer do.

Abdirizak Bihi translates for Ilhan Omar at her event in Brian Coyle Community Center in Minneapolis on May 17, 2017. Credit: Arthur Nazaryan/PRI

Just a few years ago, Bihi estimates, it was common to see county health workers at community events and in the lobbies of high rises. “The county was visible,” he says, even at Friday prayers in the local mosques. But this hasn’t been happening in recent years, and their absence has helped anti-vaccination advocates to spread their false message.

Jillian M. Kyles, program manager at Hennepin County’s Office of Multicultural Services, does not share Bihi’s assessment. “I have not seen that diminish,” she says.

Kyles, who was once Bihi’s supervisor, says her staff are present at the community center several nights a week.

“We spend from April to probably November almost every weekend and many weeknights at community resource fairs, with resource tables. … Our office is a walk-in office that’s very well-known in the community,” she says.

But grants for specific projects sometimes do dry up and those projects disappear. As the Somali population grows, she says, these projects are not sustainable solutions.

Alison Pence, the director of community engagement for nonprofit health care provider Allina Health in Hennepin County, says relying on grants is a problem. If grant money isn’t laid aside specifically for Somali neighborhood outreach, it typically doesn’t happen. Once a public health worker herself, Pence knows that frustration very well.

“What we have found is that the Somali community tends to pop up in just about every category in terms of having a level of disparity … meaning that they’re not being served as well as others,” she says.

The problem is not just in the Somali community. Laura Hanen of the National Association of County and City Health Officials told NBC News that staffing is a problem. “We have seen our public health workforce decline since the 2008 recession,” she says.

And while measles and autism are in the news, they are not the only public health issues that deserve attention. Bihi says that diabetes is another major concern among Somali Minnesotans, who number about 30,000 and often left conflicts and refugee camps to live in the state.

Health care providers have tried to fill the gap with programs for doctors. Allina conducted a series of presentations that focused on cultural awareness for Somali patients. At Fairview Health Services, Dr. Aner Vlodaver, a pediatrician who regularly sees Somali patients, helped develop an intensive cultural competency training for staff at two clinics. There were six sessions at each clinic over six months starting in February 2015, including basic Somali language instruction.

Sahra Ali, right, checks the blood pressure of an elderly Somali woman at a high-rise in South Minneapolis on December 8, 2015. It was part of a health outreach program that ended in early 2017. Credit: Arthur Nazaryan/PRI

Language, he says, has made a big difference. Vlodaver says one patient drove all the way from Rochester, Minnesota, nearly 90 miles away, just to see him because he is now known as “the doctor who can speak Somali.”

Allina has also helped fund some groups to do outreach, such as A Partnership of Diabetics, a “peer-to-peer diabetes education and support program.” Until the partnership was disbanded this year, every week Somali elders would gather in the community rooms of high-rise apartments, sipping tea and coffee while waiting for volunteers to check their weight and blood sugar. Bilingual staff were present to make sure the patients understood the medical advice of the attending doctors and nurses. They also held monthly support group meetings.

But such efforts might not be enough in the face of an outbreak. Minnesota Health Commissioner Ed Ehlinger has asked the state for $5 million in emergency funding to deal with the measles cases and other infectious diseases.

A week ago, the Hennepin County Health Department reached out to Allina to work together. Allina’s Somali-speaking staff will spread the county’s pro-vaccination message on Somali-language radio stations and media outlets.

“That’s exactly the kind of relationship we want to be having with public health,” says Pence. She says there has been a sharp increase in MMR vaccination rates since the outbreak, which in her mind shows that “public messaging is actually quite effective.”

As for Bihi, who was a translator at Wednesday’s session, these efforts are certainly a step in the right direction. But he’s hoping they will extend beyond the immediate needs of this situation.

“It’s not about outbreak, it’s about beyond that,” he says. “I would love to see in the next five years, that this conversation continues.”

Health

Somali woman researches health risks of skin-lightening practices

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Ibrahim Hirsi

For some Somali women, having lighter skin tone is the ultimate beauty goal and they use skin products containing dangerous chemicals to reach that goal, according to a new University of Minnesota study.

“To be a beautiful Somali woman, one has to have lighter skin color,” Amira Adawe, co-author of “Skin-Lightening Practices and Mercury Exposure in the Somali Community,” said in a recent interview describing the attitude of some women.

Several Somali women who were interviewed for the study published in July said they mix products that include lemon herbal whitening cream, lulanjina, diana and dermovate — some of which have mercury, a poison that can damage the nervous system, according to the study.

“These chemicals are proven neurotoxins and have been linked to birth defects if used by women during the prenatal period,” stated the study. “Inorganic mercury exposure is associated with rashes, skin discoloration, scaring, secondary bacterial and fungal infections, and even renal impairment and damage to the nervous system.”

The study added: “It should also be noted that mercury … can be transferred from mother to infant through breast milk.”

The Minnesota Department of Health recently tested 27 bleaching products, 23 creams and four soaps. The department found that 11 products contained mercury levels ranging from 135 to 33,000 parts per million. “This has prompted both state and federal health officials to issue warnings about the use of these products,” according to the study.

Although Minnesota law bans beauty products that contain mercury, the study said that immigrants have been smuggling the cosmetics from Latin America, Asia, the Middle East and Africa. The products are then secretly sold in Twin Cities-area stories.

“This is not practiced by only Somali women,” said Adawe, a health educator at St. Paul-Ramsey County Department of Public Health. “It’s widely used by Hispanics, Asians and African-Americans.”

Skin-lightening practices

There are various reasons some Somali women rub their body twice a day with skin-bleaching substances, the study stated. Some of them use the chemicals to get rid of the facial masks of pregnancy, which are pigments women develop during pregnancy.

These pigments often appear on cheekbones, forehead, nose, forearms and other parts of the body that are exposed to the sun. Women with darker skin are more prone to skin pigmentation than those with fair skin tone, health reports suggest.

The study indicated that women also use skin-lightening products to attract men. “They see having light skin as more socially acceptable and believe it will increase their chances of finding a husband,” according to the study.

Adawe, who was born in Somalia, said she knows many Somali women who use the products. “You can tell who uses it and who doesn’t,” she said. “You can’t mistake it with naturally light-skin people. These creams give people more of yellowish color.”

Adawe said the women who use the products often aren’t open about the practice. “Actually, they’ll deny when you ask them,” she said.

How study began

Growing up in Mogadishu and in Minneapolis, Adawe said she encountered many women who regularly used the skin-lightening products. She said became involved in the study a few years ago after coming across an article about bleaching cosmetics that reportedly contained mercury. Adawe said he began to worry about the health of women she knew who used these products, so she started investigating the issue in 2011.

After several interviews with Somali women in the Twin Cities, Adawe learned that some of the women used products containing mercury. Adawe then took her findings to officials at the St. Paul and Ramsey County health department. Soon after, the FBI raided stores in Minneapolis and found Minnesota-banned skin-lightening products and took action against owners, said Adawe, a public health graduate student at the University of Minnesota.

Adawe’s investigation prompted the study, thanks in part to her professor and mentor, Charles Oberg, who co-authored the research paper.

Public awareness efforts

Adawe’s is working to tell others about the dangers of skin-lightening practices by speaking out at community and educational forums, appearing on radio and television shows, and meeting with leaders and activists of the Somali community.

Adawe also engages in conversations with 244 members of the Somali community on a Facebook page she created named “Skin-lightening practices & chemical exposure among Somali women.”

Members share articles, videos and studies about the risks of skin-lightening practices, and they discuss ways they can help limit such practices.

On June 11, Adawe posted on the page: “To those of you who are scholars or know the Islamic religion well, can you please educate us about what Islam says about skin-lightening practices?”

Awil Egal, a group member, replied: “Islam has forbidden men or women to change the creation of Allah: Skin color, hair color and the likes. ”

Egal added: “Using cosmetics, creams and other things that are made from chemicals or impure substances and which may have dangerous side effects is definitely haram [forbidden]. It is also another form of deceiving that can create mistrust between people.”

Other members wrote simple lines of encouragement. Khadijo Abdi, for instance, posted: “Beautiful people, leave your skin as God intended!”

Adawe is optimistic the Somali community will understand the risks of the chemicals. And with social media, she said, she’s even more hopeful that the people will be informed faster.

“Everybody is on Facebook and Twitter these days,” Adawe said. “Social media is a great tool to use for spreading awareness on issues like this one.”

Adawe said there are significant numbers of Somali women satisfied with their natural skin tone and don’t consider using the skin products.

“It all depends on their confidence and level of education,” Adawe said. “Uneducated people tend to use these products more often.”

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Somalia, UN seek to vaccinate over 700,000 children against polio

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XINHUA — Somalia’s health ministry and two United Nations agencies on Sunday launched a three-day oral polio vaccination campaign, targeting 726,699 children under five years of age in two districts.

A joint statement issued in Mogadishu said the campaign backed by the World Health Organization (WHO) and UNICEF is taking place in Banadir and Lower and Middle Shabelle regions.

Ghulam Popal, WHO Representative for Somalia said the campaign will be conducted in two rounds through house-to-house visits by vaccination teams, noting that no cases of polio have been detected in Somalia since August 2014.

“However, as a preventative measure; it is imperative that all children under five years of age in targeted locations, whether previously immunized or not, receive two drops of oral polio vaccine,” Popal said.

Banadir region reported the highest number of wild poliovirus cases in Somalia (72 out of 199) during the Horn of Africa outbreak in 2013-2014.

“We urge all families to get their children vaccinated to protect them against this dangerous disease,” he added.

The UN health agencies said the first and second round will involve the use of oral polio vaccine for children under five years of age.

Inactivated polio vaccine (IPV) will be used in the third round to boost immunity among children between 2 and 23 months of age.

According to the UN, conflict and insecurity in South and Central Somalia especially has continued to hinder access to children during polio immunization campaigns in 2017, with about 240,000 children under five years of age reported as not accessible for more than a year.

“This campaign has been carefully planned to make sure that all children in the chosen areas, particularly those who have been missed in previous vaccination campaigns, are reached this time,” said UNICEF Somalia Representative Steven Lauwerier.

The UN agencies said over 4,400 vaccinators and monitors, and around 800,000 doses of vaccine have been mobilized to conduct the activity.

The Horn of Africa nation has been polio free since August 2014, when the last case of polio was reported from Hobyo district of Mudug region.

The declaration by WHO two years ago keeps Somalia outside the last group of countries which still record cased of polio in the world.

WHO has however warned Somalia remains at risk of importation of the virus from these countries.

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Can your blood not be moved for Somalia?

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On Oct. 14, I was participating in “Somali Studies in Canada: Resilience and Resistance,” a multidisciplinary colloquium held at Carleton University.

It was the first of its kind in Canada, and more than 50 brilliant, bright and eager academics, artists, frontline workers, and grassroots activists from Ontario and Quebec gathered to discuss the Somali diaspora’s resilience and resistance over the past 30 years in Canada.

But that was abruptly interrupted as attendees began to hear news of a massive explosion in Mogadishu, Somalia. Two hundred casualties were immediately reported; in just a few hours, more than 300 people were believed to be dead. It is being described as the deadliest attack to take place in the region.

Just two weeks later, on Oct. 28, a car bomb detonated in front of a busy hotel and restaurant as gunmen took hostages inside; later that day, a vehicle carrying government troops triggered a roadside bomb planted by the militant group al-Shabaab. In the end, at least 23 people were declared dead in Mogadishu.

For those of us in Canada who arrived in the early 1990s and who left family and people behind, stories of death and violence have become achingly familiar.

Families that have made difficult decisions to leave loved ones and a homeland behind are constantly forced to relive them in the immediate moments after horrific events have taken place.
It felt like I had barely been given a moment to breathe before I began to call family members and friends to make sure everyone was accounted for. This in-between place—of frantic calls, racing hearts, guilt for the relief that everyone is just fine, frustration, anger and fatigue—was eerily familiar.

Since the explosion, the question at the top of the general public’s mind is: “will your community mobilize?”

To me, the question isn’t worth asking. Over the summer, thousands in Somalia were displaced and put at risk of starvation due to a rapidly escalating drought. According to the UN Office for the Coordination of Humanitarian Affairs, Somalia is facing a humanitarian crisis and is at risk of a severe famine—all of this coming just six years after the last deadly drought.

They note that between November 2016 and May 2017, an estimated 739,000 people were displaced by the drought; more than 480,000 of the displaced, or 65 per cent, are younger than 18.

Shortly after learning this information, a vast majority of the Somalis I knew in Canada mobilized. Elders added extra remittance payments to their monthly spends; young people coordinated events and fundraised money. Even those who could not give money retweeted, shared statuses and ensured the public was aware of the dangerous situation Somalia was in. Young Somalis became #FamineResistors with many in our city doing the work to garner attention, collect donations and forward to the appropriate hands in Somalia.

The question, then, is not whether we will mobilize. The question is: will you?

On Oct. 8, just six days before the horror in Mogadishu, 16-year-old Zakariye Ali was killed in a Toronto junior high school parking lot; three days before that, 29-year-old Abdulkadir Bihi was shot to death in Etobicoke: Allahu naxariisto. Mustafa Mattan, 28, was fatally shot through the door of his apartment building on Feb. 9, 2015; no killer has been apprehended.

He is just one of at least 100 young Somali men between Toronto and Alberta whose deaths continue to go unsolved by local police despite active work by community members and agencies such as Positive Change that have worked to address the lack of information provided by RCMP and other authorities. Somalis continue to be deported by the Canadian government by Immigration Minister Ahmed Hussen. Despite Hussen’s identification as Somali, it’s important to remember that representation does not always mean we are allowed to stay.

On top of this, Somalis continue to face negative media depictions that work to present the general public with correlations to terrorism, piracy, and gangsters. Media narratives like Vice’s documentary This is Dixon and the now-discontinued CBC drama Shoot the Messenger which looked to fictionalize the Rob Ford crack scandal.

This scandal saw “Project Traveller” come to a head in June 2013 when police stormed an apartment building on Dixon Road in pre-dawn raids that resulted in more than 60 arrests of primarily young Somali men. When the Canadian public and media only know us through the analysis of violence and terror—a characterization all too frequently and easily deployed—there is only attention granted to us in our deaths.
Why do you only want us when we are dead?

In early October 2017, our mothers cried on camera for the kids they raise here. In July 2017, they wept while they watched Abdirahman Abdi be brutally murdered by police. This week, they weep silently for the family they have lost back home. This middle place they’ve come to reminds them they are not wanted—and still, all everyone offers is prayer.
What happens when the prayers are not enough?

After every death, every drought, every instance of violence, I am hard-pressed to feel grateful that Somalis are granted prayers. We did not get here all by ourselves. We get up and face the onslaught: “Your community again? But how are you feeling?” The answer does not change, and the emotions are the same each time: grief, relief guilt, fatigue, rage, frustration.

We will pray for Somalia, politicians tell us; we will not forget you. But you can not forget those you do not remember. The City of Toronto may light the Toronto sign blue and white, but Mayor John Tory rarely makes commitments to address the violence that lies at the doorsteps of Somali communities.

Somali-British poet Warsan Shire reminds us that “in Somali, when we see injustice, we say ‘dhiiga kuma dhaqaaqo?’ which translates into ‘does your blood not move?’ ”

Can your blood not be moved?

For those of you who are willing to pray and willing to gather in vigil, try something different. Call out false narratives of terror and deficit when you see them. Ask the Ontario Ministry of Children and Youth Services what specific long-term and sustainable services they are allocating to Somali youth in Ontario. Pressure the Toronto Police Services, Ontario Provincial Police and the RCMP to appropriately investigate the deaths of young Somali men.

Stand in the streets when we tell you the Minister of Immigration has deported us. Pay attention to the counter violent extremism programs that criminalize Somali youth that are being funded by Public Safety and Emergency Preparedness Canada.
Prayer is an act of empathy; action is an act of solidarity. We need both if any of us are to survive.

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