Summary
Somalia has a high incidence of tuberculosis (TB) disease, ranking among the top 30 countries in the world for TB disease and multi-drug resistant cases. Individuals may be hesitant to undergo screening due to lack of familiarity interacting with health care systems. Decades of civil war have led to weakening of the Somali public health system and interruption of TB programs. The lack of routine LTBI screening and treatment in Somalia has led to confusion in the community regarding the diagnosis of latent TB infection (LTBI) and its distinction with TB disease. There is also less awareness of blood testing (e.g. interferon-gamma release assay, Quantiferon) compared to skin testing (e.g. TST, Mantoux). Although most children receive the BCG vaccine in Somalia today, there is confusion regarding the amount of protection it confers to individuals. Many immigrants from Somalia have received LTBI treatment after arriving to the U.S. but have an incomplete understanding of the underlying TB infection.
Recomendations:
- Recommend TB screening for all individuals from Somalia with blood testing.
- Elicit concerns from patient regarding TB screening and treatment.
- Recommend clear education on latent TB infection and the importance of preventive treatment.
- Recommend close follow-up in clinic with treatment to alleviate concerns about treatment side effects and assure treatment completion.
Methods
This profile is based on transcripts from interviews with five Somali community members. A supplemental literature review was also performed.
Burden of Disease
2023 WHO statistics for Somalia1
– Total TB incidence (rate per 100,000 per year): 243
– HIV-positive TB incidence (rate per 100,000 per year): 1.4
– Total Population (2023): 18,140,000
Languages Spoken
Somali (Northern Standard Somali) and Arabic are the official languages of Somalia. Somali is the main language spoken by approximately 95% of the population2. Arabic is mostly reserved for use in religious contexts such as for Quranic education. Latin script was adopted in 1972 as the official national alphabet. This replaced several other writing scripts which were in use at the time. Somali was declared the primary language of administration and education in the Somali Democratic Republic in 1973. Italian had previously been common in Somalia during the Italian colonial period, particularly in administrative circles3. However, the use of Italian is now largely restricted to older generations. Currently, local schools and universities often teach English and offer English language instruction. Significant parts of the population continue to use minority languages, including several Swahili dialects mostly spoken in the southern coastal areas of the country. It is estimated that one third of the population uses a language at home other than Northern Standard Somali or Arabic. Adult literacy levels across the country remain low and are estimated at around 40%, though there is a marked literacy gap between the genders.
In Somali, tuberculosis disease can be referred to as urug and TB. The term urug is more commonly used among older generations, while younger people are more familiar with the term TB. There may be a generational difference associated with the use of terms. Respondents did not note a distinction in terms used for TB disease and latent TB in the Somali language.
Bacillus Calmette-Guerin (BCG) Vaccination
Rates and Understanding
The BCG vaccine is administered at birth in Somalia. The COVID-19 pandemic and ongoing conflict in the country have impacted health campaigns for all childhood vaccinations. As of 2022, 88% of infants in Somalia received the BCG vaccine, up from 59% in 2017. Many of the respondents understood that one can still develop TB disease even after receiving the BCG vaccine. Respondents likened this phenomenon to how one can contract COVID even after receiving COVID vaccinations.4
Diagnosis and Clinical Features Recognized by the community
Most people know that TB disease is associated with symptoms including weight loss, productive cough, and sweat. Some respondents expressed familiarity with sputum testing. Multiple respondents mentioned that TB disease was thought to be more prevalent in rural populations, and that residents of these communities often come to towns and cities for medical care.
TB is generally recognized as being very dangerous but also treatable. Some respondents shared the belief that it can be spread by sharing cups, utensils, and plates. They were also aware that sitting close to someone with TB and breathing the same air could lead to transmission. One respondent described burning cups, plates, and other shared items used by a person with TB disease.
Testing of TB disease and latent TB infection
Respondents described familiarity with TB centers that “taught people” about TB disease, also describing specific hospitals that would exclusively treat those with TB disease. Several respondents shared that they did not remember specific campaigns or messaging around TB testing or prevention aside from BCG vaccination campaigns for children.
There was general understanding that testing for TB disease involves imaging and laboratory testing, with several respondents mentioning sputum testing as a key step in diagnosis of TB disease. One respondent was also familiar with extrapulmonary TB since they had a relative who had TB involvement of organs in addition to the lungs. Another respondent mentioned that TB could also be found in the “bone, brain, and stomach.” Respondents expressed understanding that once treated, people who had been diagnosed with TB disease no longer “spread the disease” and that it is very important for people to take “all of their TB medication,” and “never skip a day.”
Testing and treatment for latent TB is uncommon in Somalia, as most efforts are focused on treating TB disease. Interviewees noted a general belief that the BCG vaccine impacts TB testing, and many believe that positive TB tests, without the presence of symptoms, is a result of childhood BCG vaccination. Interviewees were generally unfamiliar with the concept of latent TB. When prompted, however, multiple respondents recalled receiving latent TB treatment after testing positive upon arrival in the U.S.
TB Treatment in Somalia
Decades of civil war have led to a compromised health care infrastructure. Somalia is listed as a top 30 country by the World Health Organization (WHO) based on TB incidence1. TB treatment in Somalia is offered at no-cost by the Ministry of Health, the WHO, and multiple non-governmental organizations. Doctors without Borders provides TB treatment at Mudug Tuberculosis Hospital, as well as at several smaller hospitals. WHO sponsors TB treatment centers, including treatment centers specializing in multi-drug resistant TB. There has been a major focus on developing the country’s TB program in recent years5,6. Over the past two decades, TB efforts in Somalia produced a 14% decrease in TB incidence, an 87% treatment success rate, and an increase from 7 to 109 TB centers.
Social factors and care delivery in Somalia
Social factors play a significant role in tuberculosis care in Somalia. Poverty, stigma, geographic barriers, and limited access to transportation are widespread7. Many people who are treated for TB disease come from outside of the towns where TB care and treatment are administered. Lack of access to shelter and food during long treatment courses can disrupt adherence with treatment. Poverty and lack of infrastructure make regular travel between home and treatment centers extremely difficult.
Stigma towards people with TB also presents a challenge for those undergoing treatment for TB disease7. Respondents recall the sadness felt when a community member is diagnosed with TB disease, knowing that that person would need to be isolated from their community. Others described the use of the word TB as a “curse” and said people would often say “may you get TB” to condemn another person. Generational differences in levels of stigma towards TB appear to exist, with older generations harboring more stigmatized views about what it means to have TB in Somali society.
Experience with TB and Barriers to Care in the United States
Respondents had little to share about their experiences with the U.S. healthcare system. Respondents were established with primary care providers. However, there appeared to be a lack of clear communication and health education around TB. Multiple respondents shared that they did not know what latent TB was, even though they had been diagnosed and treated for latent TB shortly after arrival to the U.S. Language barriers including low literacy rates and a lack of familiarity with latent TB in Somalia likely contributed to gaps in understanding of latent TB.
Relevant Historical Factors
Somalia has experienced decades of conflict, including an ongoing civil war which began in 1991. This conflict has devastated the country and contributed to the spread of TB through increased poverty, malnutrition, and damage to the healthcare infrastructure. Healthcare access has been challenging for Somalis, particularly for those undergoing the prolonged regimens required for treatment of TB disease. Incomplete treatment of TB disease has likely contributed to the high rates of Multi-Drug Resistant (MDR) TB in the country. Nearly half of the population is estimated to have been displaced as a result of the civil war.
The Somali diaspora is one of the largest and most widespread in the world and thought to number between 1.5 to 2 million people. Nearly 200,000 Somalis are thought to be living in the U.S. with large populations in Minneapolis, MN, Columbus, OH, Southern California, and Washington state. Somalia entered the consciousness of many Americans through a battle involving U.S. forces in Mogadishu in 1993 between U.S. forces and those of the Somali faction leader Mohamed Farrah Aidid. This was documented in the non-fiction book Black Hawk Down and subsequently appeared as a motion picture. The battle documented was some of the most intense close combat for the U.S. military since the Vietnam War. Less widely known in the U.S. is that the Somali Civil war has continued and become one of the longest-running conflicts in modern history.
Colonial History
Somalia was divided into British Somaliland (north) and Italian Somaliland (south) during the colonial era. These political borders did not respect ethnic and clan divisions which would ultimately lead to political destabilization. The two regions unified in 1960 to form the Somali Republic. General Siad Barre seized power in a coup and led until 1991.
Civil War
The Somali civil war began in January 1991 when militias overthrew the regime of President Siad Barre5. With no central government, rival warlords and clan militias fought for control of territory and resources. The United Nations subsequently arranged a U.S.-led intervention in the effort of state building. U.S. Marines were sent to Somalia in December 1992 in a UN effort to secure transportation8. In 1993, the U.S.-led operation to capture warlord Mohamed Farrah Aidid resulted in the Battle of Mogadishu, leading to the death of 18 U.S. soldiers and hundreds of Somalis. The UN operation ended in 1995 with withdrawal of forces. A struggle for power ensued with a U.S. supported invasion by Ethiopia to overthrow the Islamic Courts Union which had gained control in Mogadishu and much of southern Somalia. Al-Shabaab emerged as a major force which was pushed back by the African Union Mission in Somalia. The Federal Government of Somalia was formed in 2012 though there has been ongoing conflict with Al-Shabaab.
Co-morbidities/other health concerns in the community
Respondents identified cancer, diabetes, and hypertension as health problems of concern in their communities. Other significant health concerns in Somalia include:
Maternal and Child Mortality
Somalia has one of the highest maternal mortality rates in the world with 621 deaths per 100,000 live births9. Barriers to care including poverty, geographic barriers, and lack of transportation contribute to rates of maternal mortality10. Infant mortality in Somalia is one of the highest in the world, at 68 per 1,000 live births. Additionally, an estimated 1 in 8 children die before they turn five. Women and children continue to experience significant trauma in Somalia, which can impact their level of trust when interacting with health care providers in the U.S.
Measles
Measles is endemic in Somalia, largely impacting children under 5, and significantly contributing to the country’s high infant and child mortality rate11. Poverty, malnutrition, and low levels of vaccination contribute to ongoing measles cases and outbreaks in Somalia.
Cholera
Cholera is also endemic in Somalia, usually caused by poor sanitation, lack of clean water, and damaged infrastructure due to flooding or conflict12. Recent outbreaks impacted more than 10,000 children under the age of 5. As of 2024, the case fatality rate was 1.2%.
Additional Reading: Somali Tuberculosis Cultural Profile, by David Citrin, published 2006
References
- World Health Organization. (n.d.). TB profile. https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&tab=%22charts%22&lan=%22EN%22&iso3=%22SOM%22&entity_type=%22country%22
- Translators without Borders. (n.d.). Language data for Somalia. https://translatorswithoutborders.org/language-data-for-somalia
- Somalia. (n.d.). In Encyclopaedia Britannica. https://www.britannica.com/place/Somalia/Revolt-in-British-Somaliland
- World Health Organization. (2023, November). Somalia immunization programme: Catching up after conflict and COVID-19 in a fragile setting [Case study]. https://www.emro.who.int/images/stories/somalia/Case_study_catching_up_immunization_after_conflict_and_COVID-19_in_fragile_setting.pdf?ua=1
- World Health Organization. (2024, March 24). World TB Day 2024: Somalia reaffirms commitment to make TB history. https://www.emro.who.int/somalia/news/world-tb-day-2024-somalia-reaffirms-commitment-to-make-tb-history.html
- Doctors Without Borders. (2024, September 27). The powerful treatment regimen redefining tuberculosis care in Somalia. https://www.doctorswithoutborders.org/latest/powerful-treatment-regimen-redefining-tuberculosis-care-somalia
- Gele, A. A., Sagbakken, M., Abebe, F., & Bjune, G. A. (2010). Barriers to tuberculosis care: A qualitative study among Somali pastoralists in Ethiopia. BMC Research Notes, 3, Article 86. https://doi.org/10.1186/1756-0500-3-86
- Gebreyohannes, E. A., Wolde, H. F., Akalu, T. Y., Clements, A. C. A., & Alene, K. A. (2024). Impacts of armed conflicts on tuberculosis burden and treatment outcomes: A systematic review. BMJ Open, 14(3), e080978. https://doi.org/10.1136/bmjopen-2023-080978
- UNICEF. (n.d.). Health. UNICEF Somalia. https://www.unicef.org/somalia/health
- Morrison, J., & Malik, S. M. M. R. (2024). Health equity in Somalia? An evaluation of the progress made from 2006 to 2019 in reducing inequities in maternal and newborn health. International Journal for Equity in Health, 23, Article 46. https://doi.org/10.1186/s12939-023-02092-1
- World Health Organization. (2022, April 27). Measles – Somalia. Disease Outbreak News. https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON371
- United Nations Office for the Coordination of Humanitarian Affairs. (2024, January 22). Somalia: 2024 AWD/Cholera outbreak flash update no. 1 (22 January 2024). https://www.unocha.org/publications/report/somalia/somalia-2024-awdcholera-outbreak-flash-update-no1-22-january-2024