INTRODUCTION
Demographic changes in the Seattle area are having a profound impact on the local health care delivery system. Health care providers need to hear from ethnic communities about their experience in trying to access health care. Offering culturally appropriate care requires being open to the perceptions, realities and expectations of a community that may be different from one's own.
The Cross-Cultural Health Care Program (CCHCP) in Seattle, WA works with health care providers, interpreters and community-based organizations to address these needs. Established in 1992, the CCHCP is funded by a grant from the W.K. Kellogg Foundation. This "Voices of the Communities" profile is one of a series developed by the CCHCP. The profiles and an earlier survey of 22 underserved ethnic communities are part of the CCHCP's effort to provide a forum for underserved communities to interact with the health care community. These profiles were developed by and in consultation with members of the profiled community.
Location and ethnic group
Somalia is a long, narrow country that wraps around the Horn of Africa and borders both the Red Sea and the Indian Ocean. Many Somalis are nomadic or semi-nomadic herders, some are fishermen, some farmers. Unlike many African nations, Somalia is composed of a single, homogeneous ethnic group who share a language, religion and culture.
History
Colonial rule divided the Somalis from the mid-1800s until 1960, when two territories were reunited to form modern Somalia. Somalia's government fell in 1991 after opposition from clan-based militias and three years of civil war. Since then there has been no effective government. Civilians have suffered from rampant violence, famine and death from starvation. Over one million people have fled to refugee camps in neighboring countries. Resettlement programs have enabled families to move to Europe and the United States.
Language
The Somali language is an Afro-Asiatic language closely related to Oromiffa and more distantly to the Semitic languages Arabic, Hebrew and Amharic. Although written for many years, a uniform orthography was not adopted until in 1973. Since the vast majority of the population is Moslem, Arabic is a common second language. Education was conducted in the language of colonial rule until the 1970s, so older Somalis from the north speak English and those from the south speak Italian. Education was free at all levels until 1991.
Religion and social customs
Almost all Somalis are Sunni Moslems. Attitudes, social customs and gender roles in Somalia are based primarily on Islamic tradition. During the month-long religious holiday of Ramadan, people pray, fast and refrain from drinking during the day, and will eat only at night. Pregnant women, people who are very ill and children are exempted from the fast. Many religious holidays involve the ritual killing of a lamb or goat. Moslem tradition forbids eating pork or drinking alcohol.
Many social norms in Somalia are derived from Islamic tradition. For example, a handshake is the common and polite greeting, but men shake hands only with men, and women with women. The right hand is considered the clean and polite hand to use for eating, writing and shaking hands. If a child shows a left-handed preference, the parents will train him or her to use the right hand. The dress of married Somali women covers their bodies; they veil their faces. Elders are treated with respect and addressed as "aunt" or "uncle" even if they are strangers.
Family life
Family and social structure in Somalia is by clan and subclan. Since Somalis are largely nomadic, it is common for several subclans to live intermixed in one area. Membership in a clan is determined by paternal lineage or marriage into the clan. Men who can afford to do so may have up to four wives. In urban areas, men may provide separate homes for each family. In rural areas it is more common for all to live in a single household and care for the farm or livestock together. Young adults and unmarried people live with the extended family.
Childbearing begins shortly after marriage. A woman's status is enhanced the more children she has. It is common for a Somali family to have seven or eight children. Family planning has little cultural relevance.
Residence
Somalis in the United States live predominantly in San Diego and Seattle. In Seattle, Somalis have settled in the Central Area, Rainier Beach and SeaTac. Most families continue traditional dress and cultural practices.
Community organizations
Since the community is new to Seattle, no formal organization has been established and no official community leader identified. However, the community is close-knit and carries out many of the functions of a community organization. A recently-formed Somali Women's Organization has established a Somali Islamic school (located at Rainier and Brandon) staffed by volunteer teachers. They are also trying to address the community's need for better child care services, ESL classes, and transportation for people traveling between SeaTac and Seattle. Some families send their children to religious school in the evenings and weekends or to the Pan-Islamic school (at 25th Avenue and Cherry).
Traditional healing
Somali "traditional doctors" are usually older men in the community who learned their skills from older family members. They treat infectious diseases, hunch-back, facial droop and broken bones. Techniques include fire-burning (applying to the skin a heated stick from a certain tree), herbs and prayer. Traditional doctors also help cure illnesses causes by spirits. Somalis believe spirits reside within each individual. When the spirits become angry, illnesses such as fever, headache, dizziness and weakness can result. The cure involves a healing ceremony including reading from the Koran, eating special foods and burning incense.
Somali beliefs also include the "evil eye." A person can give someone else the evil eye on purpose or inadvertently by praising that person, which brings harm or illness to the person praised. Somali mothers cringe when doctors tell them their babies are big and healthy, out of fear the evil eye will cause something bad to happen to the child.
Maternal and child health
Childbirth most often takes place at home, attended by a midwife. The new mother and baby stay at home for 40 days after birth, with female relatives and friends helping to care for them. Newborn care includes warm water baths, sesame oil massages and passive stretching of the baby's limbs. Breast-feeding is common up to two years of age, usually supplemented with animal milk (camel, goat or cow). The animal milk is offered with a cup rather than a bottle. Diapering is not common in Somalia. When the baby is awake, the mother holds a small basin in her lap and at regular intervals holds the baby in a sitting position over the basin. At night, a piece of plastic is placed between the mattress and the bedding. The bedding and plastic are cleaned daily. Somali mothers say infants are toilet-trained in a short period of time.
Circumcision
Both males and females in Somalia are circumcised before age five. Circumcision is viewed as a rite of passage and necessary for marriage. Uncircumcised people are seen as unclean. Male circumcision may be performed by a traditional doctor or by a medical doctor or nurse in a hospital. Female circumcision is usually performed by female family members but is also available in some hospitals. The most common procedure in Somalia for female circumcision, known as "infibulation," involves removal and suturing of most genital tissue, leaving a posterior opening.
Death
It is considered uncaring to tell a terminally ill person or the family that the person is dying. It is acceptable to describe the extreme seriousness of an illness, however. When death is impending, a special portion of the Koran is read at the patient's bedside.
Medical care
Most Somalis, especially those from cities, have had at least some experience with Western medicine. The most common illnesses taken to Western hospitals are diarrhea, fever (usually malaria) and vomiting. Patients almost always receive an antibiotic at the hospital. Families also may bring their children to the hospital to treat a cold and will receive oral medication.
Medical care and providers
Because Somalis are accustomed to getting a medication when they go to a Western-style hospital, even for a cold, they expect to receive medicine from any medical visit. In Seattle, families are often very unhappy when they travel a long distance, wait to be seen in a clinic, and are sent home with instructions that the patient will get better by him- or herself.
Traditional healing
Although most Somalis are familiar with Somali traditional medicine, there are no traditional doctors in the Seattle area.
Circumcision
Circumcision is an important and sensitive issue for Somali women seeking health care. Female circumcision has been debated in the Western world as a potentially harmful cultural practice. However, most Somali women view circumcision as normal, expected and desirable. Somali women in the United States are concerned about how their circumcisions will be cared for during childbirth and whether they will be able to have their daughters circumcised. Some Somali women in Seattle know how to perform infibulations but have not performed any here because of fear of legal reprisals.
Religious and social customs
Other barriers to health care access are similar to those for other Moslem cultures. For example, because of prohibitions against interactions between adult men and women, Somali women have a strong preference to work with female interpreters and health care providers. Because of the daytime fast during the month of Ramadan, patients will take medications only at night when food and liquids may be consumed.
Suggestions
Profile prepared by: Toby Lewis, M.D., Basra Ahmed and Khadija Hussein.
This profile was originally developed by the House Calls project of Harborview Hospital in Seattle, under a grant from the Opening Doors Initiative of the Robert Wood Johnson Foundation.
References include:
U.S. Dept. of the Army. Somali Area Handbook. January 1994.
U.S. Dept. of Commerce, Economics and Statistics Division. National Trade Data Bank (NTDB), CD-ROM, SuDoc, c1.88:994/1/v.2.
This is a condensed version of the profile. For the complete profile and survey report, please contact the Cross-Cultural Health Care Program, (206) 860-0329.
This "Voices of the Communities" profile was made possible by a grant from the SAFECO Corporation.
January 1996