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The mental costs of being a refugee in America

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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.

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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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Somalia Opens First Forensic Lab Dedicated to Rape Investigation

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Somalia has opened its first forensic laboratory to process rape kits. Sexual assault is widespread in the country, according to human rights groups, but few victims come forward and few perpetrators are punished. The new forensic lab in Somalia’s Puntland region has been hailed as a step in the right direction, but a long road remains to end impunity for gender-based violence. Neha Wadekar reports for VOA from Garowe, Somalia.

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