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The mental costs of being a refugee in America



TONIC — When Ahmed Hassan decided to major in psychology at Southwest Minnesota State University, his Somali-born community assumed he was training to be a psychic. Not an unexpected reaction, given the popularity of psychic hotlines in the early 2000s—and the lack of anything equivalent to psychotherapy in Somalia.

Hassan, of course, had no interest in the likes of Miss “Call Me Now!” Cleo. He’d gotten an A in his intro to Psychology course, and wanted to learn more.

But there’s no word for mental illness in Somali. “You are either sane or insane,” says Muna Mohamed, a Somali-born case manager at a mental health support clinic in Minneapolis. “There is nothing in between.”

Despite a lack of descriptive language, refugees suffer from depression and post-traumatic stress disorder at a much higher rate than the general population. It’s estimated that between 14 and 37 percent experience PTSD and major depression, compared to between 6 and 8 percent of the general population. It’s not known how many immigrants living with mental health issues go undiagnosed and untreated. When refugees arrive in the US, an initial medical exam screens for everything from malaria to intestinal parasites. But screening for mental health disorders is tricky—there’s no equivalent to a tuberculosis skin test for diagnosing depression—and has only been recommended by the CDC since 2011.

Minnesota is currently piloting mental health screening for refugees, and this is part of an upward trend: About half of states now offer some sort of mental health screening for refugees or new immigrants, up from about four in 2010. This includes California, where most of the 12,000 Syrian refugees in the US have landed. “One reason for doing the screening is that about a third of refugees will have a diagnosable condition such as PTSD or depression, and 50 percent will have experienced torture—themselves or an immediate family member,” says Patricia Shannon, associate professor in the School of Social Work at the University of Minnesota. “But not all will have a diagnosable condition. Many of those who don’t are still vulnerable to mental health issues, however: Many were exposed to trauma in the course of being a refugee, fleeing through jungles or other unsafe conditions. We need to get them help sooner rather than later so they can get to a healthy resettlement.”

The importance of long-term mental healthcare on a population level has become increasingly evident. As recent research illustrates, unmet mental health needs contribute to crowded jails and prisons, higher suicide rates and student populations with more challenging behavior, absenteeism, dropout rates, and underachievement.

But successful treatment is complex, requiring a multi-pronged approach to effect change. Immigrant hubs across the country face a steep learning curve of setting best practices for newly-arrived refugees who do not share the Western concept of mental health. That means everything from systemic reorganization (starting with the screenings in that first medical exam), to overcoming language barriers and confidentiality issues with unregulated interpreters, to basic Western psychoeducation. None of those things can happen without people who can bridge cultural gaps, who understand that “mental illness” translates to “crazy” in another language. Hassan is one of a small but growing number of Somali-born psychotherapists who connect the two cultures.

During a time when Somalis were fleeing the country’s civil war, fighting between clans, and a famine, Hassan won a lottery for a Diversity Immigrant Visa that granted him entry to the US. Even now, Hassan’s deep brown eyes sparkle when talking about it: “I don’t get excited easily, but that’s one moment I was just so excited I didn’t even feel my body,” he says. “I was so excited, I was jumping, screaming, doing crazy things. Even when I graduated from college, I didn’t feel that way.”

When his plane landed in Virginia in 2002, he had a backpack and $20 in his pocket. He and the Somali family he stayed with would go to a mall and a bowling alley and watch the crowds, unaccustomed to seeing people who looked different from them: Asians, whites, African-Americans. Within a few months, Hassan, eager to pursue a college degree, decided to move to Marshall, Minn., population 13,680, to attend Southwest Minnesota State University. Marshall was home to a community of Somalis ever since the town’s turkey plant started hiring Somali workers in 1992. Of the approximately 84,000 Somali refugees in the US, about 40 percent live in Minnesota because of the state’s active voluntary agencies that work with the State Department to resettle refugees.

Before majoring in psychology, Hassan’s experience with mental health was typical of any kid growing up in Somalia. When he was 15, he remembers being with a friend at a mosque when a nearby woman fainted. A bystander told them the woman was experiencing jhin, or being possessed, and asked them to read Quranic verses.

“My friend and I read random verses, and after an hour she woke up,” Hassan says. “At the time, we attributed everything to the verses, because we’d read the Quran and she felt better and woke up.”

Studying psych in the US, he enjoyed learning about theories of human behavior. But gaps between cultures persisted: It wasn’t until graduate school that Hassan fully understood talk therapy. “No one did the ABCs of what it was,” he says. He learned while working as an interpreter on an assignment to take a Somali woman who was having trouble sleeping, presumably due to PTSD, to a psychiatrist. When the doctor referred her to a healthcare provider next door, Hassan helped the woman set up an appointment, assuming the provider would take X-rays or blood samples.

“But we went the next day, and the [provider] kept asking question after question,” Hassan remembers. “After 30 minutes the client looked at me and said, ‘Why is she asking so many questions?’ I said, ‘I have no idea.’ Finally she handed her a slip of paper and said, ‘Come back next time.'”

Hassan and the client assumed the paper was a prescription, but the provider explained that she didn’t dispense medication; the paper was to be given to the receptionist to set up another appointment.

“The client looked at me and said, ‘I will never go back to that woman,’ and I said, ‘Well, I don’t blame you. After all that, all she can give you is this piece of paper?'”

The theory of talk therapy struck Hassan as completely bizarre. Months later, he ran into the client. He asked the woman if she’d gone back.

“She said, ‘Yes. I like her now.’ I think she went back because she felt the [therapist] cared about her.”

It’s a concept that requires experience to appreciate, says Hassan, who says talk therapy is what he now enjoys most in his work.

When care providers don’t completely comprehend the chasm between cultures, patients are often misdiagnosed—or go undiagnosed.

Hassan witnessed this while working as an interpreter: A psychologist started asking a patient if she was seeing people who weren’t there. The woman, who believed in Sufism, or Islamic mysticism, told him she saw and talked to dead people all the time, even threw food to them (a common practice to give the spirits something to eat). Alarmed, the psychologist decided the woman needed to be hospitalized for hallucination. “Everyone who knew her knew she was just normal,” Hassan says. After much struggle and explanation, the woman avoided being hospitalized, but the experience frightened Hassan, knowing that many in the Somali community are scared about being institutionalized against their will.

That was an extreme case, he says; more common are situations in which patients describe mental illness in terms of headaches, stomachaches and heaviness in their legs—and as a result get prescribed inappropriate medication. In 2004, Mayo Clinic researchers analyzed hospital records of Somali immigrants to Minnesota, noticing references to “Sick Somali Syndrome.” Often, the researchers concluded, the culprit of the mystery symptoms—vague physical symptoms such as headaches or stomachaches that couldn’t be traced to a root cause —was undiagnosed mental illness. Mental illnesses often manifest as physical headaches and stomachaches when left untreated.

“When mental health and stress are not addressed in refugee populations, there can be long-term adverse health consequences such as diabetes, hypertension, chronic pain, and other chronic health conditions,” says Shannon. “We know now that physical health and mental health are connected.”
After graduation, Hassan founded Summit Guidance in 2011, billing itself as a culturally competent mental health clinic. Almost every time a new client walks in the door of the clinic, located in a nondescript office building in St. Paul, Hassan sits down with them for a free consultation in which he answers their big questions: ‘if you diagnose me will it prevent me from finding a job or ruin my son’s future?’ … or ‘if i tell you this and this, will immigration arrest me?'” He explains exactly what will happen in psychotherapy [i.e., lots of talking, no drugs, no X-rays.] He walks them through HIPAA forms, explaining the concepts of privacy and confidentiality, which don’t exist in the same way in many countries, especially those with rogue governments. He points out the numbers listed on the form they can call if they feel that he violates the agreement.

Still, he finds that clients ask the same questions he’d initially asked after his introduction to talk therapy: “Well, what good will you do if we just sit here and talk?” So Summit Guidance also offers services to help people find housing and employment. The combination, he says, works better than psychotherapy alone.

“If a client comes in and says, ‘Oh, I am depressed and sad because I don’t have good housing,’ then once they have housing and are still depressed, they may be willing to explore what’s going on,” he says.

Research has been able to identify some best practices (Shannon points to a study that found that 76 percent of patients kept an appointment when a doctor personally introduced them to the therapist, vs. 44 percent of patients who kept appointments when they were not introduced), but in general, “Mental health is not a cookie-cutter system,” says Ellen Frerich, a refugee health nurse consultant for the Minnesota Department of Health. “One person might need a psychoeducation group, whereas another might need in-patient care.”

Every single client requires a unique treatment plan, says Andrea Northwood, director of client services at The Center for Victims of Torture. “There are no shortcuts,” she says. “So we need to work with each individual’s family, tribe, social class. I have some Somali clients who ask me to explain the neuroscience of trauma, whereas for others, simple psychoeducation [educating patients about their mental health conditions] offered by an imam could be enough.”

While some of those challenges will always be inherent in treating immigrants with mental health issues, other challenges are surmountable. Take interpreting. “Interpreters are regular folks with not enough training about ethics and confidentiality,” says Hassan, who knows from personal experience.

Because medical interpreters aren’t regulated in most states, “anyone can put up a shingle,” says Northwood. “Interpreting is a very challenging profession. There are codes of ethics; that’s what we train people in.”

For $50, anyone can add their name to a registered list in Minnesota, ethics training or not. Some organizations and agencies provide training, and individuals can apply for accreditation through two new national organizations, but the need far surpasses the number of properly trained interpreters.

“Talking to an older gentleman, I asked about his experience with a previous therapist,” Hassan says. “The man said, ‘after a while, I thought the interpreter wasn’t telling the therapist what I was saying, so the whole thing didn’t work and that’s why I left him.”

According to medical ethics, interpreters are supposed to translate everything a medical provider says and everything a client says. But untrained interpreters may pick and choose how much of a conversation to translate from either end, making experiences such as the older gentleman’s common.

Conflicts of interest often arise as well: a patient is paired with an interpreter who came from a warring tribe in their home country, or someone who lives in their building. And some interpreters are fluent in one language but not entirely in the other, so can’t make perfect translations.

Minnesota is currently considering a bill for a registry recommended by the Minnesota Department of Health similar to Oregon’s, one of the few states that regulates interpreters.

After the election, many Somali Americans in Minnesota are on edge. Without citing any evidence, Donald Trump suggested at a pre-election rally that Somali immigrants to Minnesota hadn’t been fully vetted, and vowed that his administration would “not admit any refugees without the support of the local communities where they are being placed.” Also in November, nine Minnesota men were sentenced to decades in prison after being found guilty of trying to join ISIS.

Hassan discusses such current events in sessions he holds at mosques to talk to young people directly about mental illness, in addition to questions about substances, anxiety, depression and explaining how therapists can help.

Today’s children of immigrants may face new issues, Hassan says, pointing to an African proverb: A mule that eats grass with a horse thinks of himself as a horse. He’s been exploring African proverbs recently, with the idea that ancient nomads predated Western thinkers and that many of the messages relate to mental health and “get to the core where everyone can get access and use it.”

The mule proverb “talks about the young people who are going to school here with this culture, but that culture doesn’t think they’re quite American and their own family doesn’t think they’re quite Somali,” he explains.

“But if the culture is rejecting them and parents are not letting them assimilate, they end up with an identity crisis. Then often they’re using substances to deal with their confusion.”

Hassan is now well-known as a Somali-speaking psychotherapist in Minnesota, and no longer gets mistaken for a psychic. But what he talks about more enthusiastically is his growing number of Somali colleagues.

“Younger people are kind of looking at us and saying, ‘Oh, I want to do something similar,” he says.


Somalia’s first forensic lab targets rape impunity



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.”


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



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



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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