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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.”

Crime

Somalia’s first forensic lab targets rape impunity

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AFP — Garowe – The new freezers at Somalia’s only forensic laboratory can store thousands of DNA samples, although for now there are just five.

The big hope is that they could be the start of a revolution in how the troubled Horn of Africa country tackles its widespread sexual violence – provided some daunting hurdles are overcome.

The first sample arrived at the start of the year taken on a cotton swab from the underwear of a woman, a rape victim from the village of Galdogob.

It was wrapped in paper and driven 250km to the Puntland Forensic Centre in Garowe, capital of semi-autonomous Puntland, slipped into a protective glass tube and placed in one of the three ultra-low temperature fridges.

If DNA ID can be teased from the sample, this would be a crucial step in convicting the woman’s rapist.

No longer would it be a case of he-said-she-said, in which the survivor is less often believed than the accused. Two decades of conflict and turmoil have made Somalia a place where lawlessness and sexual violence are rampant.

“Now, people who have been raped hide because they don’t have evidence,” said Abdifatah Abdikadir Ahmed, who heads the Garowe police investigations department.

But with the lab, he said, “it’s a scientific investigation. There are biological acts you can zero in on.”

Challenges

Not yet, however.

Abdirashid Mohamed Shire, who runs the lab, has a team of four technicians ready but is awaiting the arrival of the final pieces of equipment.

Their work to provide the evidence that might convict or exonerate is yet to begin.

And the pressure is on. The freezers mean the DNA samples can be safely stored for years but Somali law allows a rape suspect to be held for a maximum of 60 days. Shire needs the analysis and identification machines urgently so that, as he put it, “justice will be timely served”.

The laboratory, partly funded by Sweden, was launched last year after the Puntland state government enacted a Sexual Offences Act in 2016, which criminalised sexual offences and imposed tough penalties.

But technology alone will not solve Somalia’s many judicial weaknesses.

The DNA sample from Galdogob, for example, was stored in unclear and unrefrigerated conditions for five days before being sent to the lab, meaning a defence counsel could potentially argue the DNA evidence had been tampered with.

Human rights lawyers worry the new lab might backfire for this reason.

“A lot of thought needs to be given to how the chain of custody can be preserved in these kinds of cases,” said Antonia Mulvey of Legal Action Worldwide, a Kenya-based non-profit organisation.

More fundamental still is the failure of Somalia’s police to take sexual assault cases – and their jobs – seriously.

Corruption is rife, with a legal advisor to Puntland’s justice ministry saying officers “meddle” in cases, undermining them for personal gain.

“My concern is that the corrupted system could not make a sure success of the lab,” the advisor said, requesting anonymity to speak candidly. “Investing in the lab is good, but we need to think about the preconditions.”

The UN Population Fund (UNFPA) which helped pay for the lab is trying to address this by running training programmes for dozens of the Garowe police on sample collection, gender violence investigations and documentation.

But, the legal advisor cautioned that donors can only do so much.

“The issue is more complicated than training police. It relates to the political commitment of the government. UNFPA can train police but who will pay those you train? Are they given power to do the work?”

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Minnesota vaccination activists now are seeking political allies

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A severe measles outbreak sickened dozens of Minnesotans last year and threw a harsh light on activists with vaccination concerns, but now they are back, believing they have gained the political clout to push through legislation that would alert parents to the rare but documented risks of vaccines.

At a forum for state legislators on Wednesday, leaders of the Vaccine Safety Council of Minnesota hope to persuade lawmakers to support an “informed consent” bill, which would require doctors to discuss risks with parents before vaccinating babies.

“There’s been a shift in this country,” said Jennifer Larson, a leader of the nonprofit council and an organization called Healthchoice that organized the forum. “I think it’s tough for anyone to say more information is not better.”

Larson said her group is not anti-vaccine; they believe consumers just need more upfront information about risks. But state health officials worry that opponents want to promote unproven claims that could unnecessarily scare people away from vaccinations.

With 79 confirmed cases, last year’s measles outbreak was Minnesota’s largest in 27 years, and falling vaccination rates in the state’s Somali community played a role, said Kris Ehresmann, who directs vaccination programs for the state Health Department.

“Seventy-one of 79 were unvaccinated,” she said. “It was very much an outbreak driven by lack of vaccination.”

State records show that more than 90 percent of Minnesota children enter kindergarten vaccinated for infectious diseases such as tetanus, measles, hepatitis B, and chickenpox.

But survey data from the U.S. Centers for Disease Control and Prevention show a small decline in certain immunizations. And President Donald Trump proposed a safety commission to address vaccine concerns, though plans for that panel have stalled and the president didn’t mention vaccines in his State of the Union address last week.

Public health officials also found themselves on the defensive after a report out of Australia late last year, while not related directly to pediatric immunizations, that found that the seasonal flu vaccine is only 10 percent protective. CDC estimates for the effectiveness of the flu vaccine between 2004 and 2017 ranged from a low of 10 percent to as high as 60 percent in any one flu season. The vaccine effectiveness fluctuates because the predominant flu strain is not the same each year.

Anxiety about the safety of vaccines has created an active coalition that includes some Minnesota refugee families, proponents of “natural” medicine, and parents who believe disabilities in their children can be traced back to shots they received.

Larson is the owner of an IT business and an autism treatment center, and recently was named finance chair of the Republican Party of Minnesota, though she stressed in an interview that the new role is separate from her advocacy on vaccines.

Larson said she took on the issues of vaccine administration and informed consent after her son, now 17, developed autism following his infant vaccinations.

“My son had a very clear reaction,” she said.

The autism theory has bedeviled public health advocates, because no broadly accepted studies have proved a link between vaccines and the developmental disorder. Some who have claimed this link have been discredited. But the mere thought of a link has scared some parents into refusing or delaying vaccinations for their children, because autism is more alarming to them than diseases such as polio that largely have been eradicated by vaccination campaigns.

Larson said she believes health officials have exaggerated the safety of vaccines. She noted that the federal government’s National Vaccine Injury Compensation Program has paid $3.8 billion since 1988 to people who claimed vaccine-related illnesses or reactions. “Parents want to be told everything before they inject something into their child,” she said.

Speakers at the legislators’ forum this week will include Del Bigtree, who directed “Vaxxed,” a movie about a federal whistleblower who alleged that the government suppressed information about an autism link, and a Minneapolis woman who received federal compensation after she claimed that her son suffered a disabling reaction from the pertussis vaccine.

Larson supports legislation authored by state Rep. Cindy Pugh, R-Chanhassen, that would require doctors to disclose that neither they nor vaccine manufacturers are liable if they give shots that cause complications, and that scheduled combinations of vaccinations at single office visits haven’t been studied for safety.

Pugh did not comment for this article.

Ehresmann said federal law already requires doctors to give “vaccine information statements” to parents, and the state checks to make sure pediatricians are doing so. The statements refer to vaccine risks and the compensation fund, but also the benefits of vaccine and the threats caused by the infections they target.

“These [vaccines] protect children against some serious diseases,” said Ehresmann, recalling the case of a severe Hib (Haemophilus influenzae B) infection that occurred after parents delayed their child’s shots.

The Minnesota Medical Association, which represents the state’s doctors, opposes Pugh’s bill, according to a spokesman, because it only requires vaccine-risk information that would discourage parents, and does not require information about the risks of children being unvaccinated.

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Somalis Train to Improve First Aid Response Skills

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VOA — Somalia’s capital, Mogadishu, has been rocked by explosions for years set off by Al-Shabab militants battling to overthrow the weak U.N.-backed government. The frequent bombings have killed or injured thousands of civilians. Now, first responders are offering first aid classes to help Somalis learn how to help their neighbors before the ambulance arrives. Faith Lapidus reports.

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