Addressing mental health needs of the most neglected population:

Somali Refugees Djibril Ibrahim Moussa Handuleh

1Amoud Medical School, Borama, Somaliland2University Hospital, Heidelberg University, Germany

Presentation Outline Somalia as a country and its administrations Refugee crisis in Somalia in the context of global

refugee crisis: Chronic, Acute on Chronic and Acute . Refugees vs IDP

Refugees in and out of Somalia based on UNCHR 2014 statistics

Mental Health and refugees among Somalis in and out of country

Mental health project for refugees in Borama, Somaliland, a de facto state in Northern Somalia

Somalia• Leading fragile state

split into three administrative zones Somaliland(North-West), separate area

Puntland(North-East) and the South-Central Zone

• New administrations within the South-Central zone

• Central government does not control this volatile state

Somaliland• De facto state in

Northern Somalia• Relatively peaceful• Hosts many of Somalia’s

internally displaced people

• Health services are operational but weak!

• Mental health services are in their infancy

• Case study will be from Somaliland

Who is refugeeAccording to the 1951 refugee convention, refugees are

defined by three basic characteristics(UNHCR):• they are outside their country of origin or outside the

country of their former habitual residence;• they are unable or unwilling to avail themselves of the

protection of that country owing to a well-founded fear of being persecuted; and

• the persecution feared is based on at least one of five grounds: race, religion, nationality, membership of a particular social group, or political opinion.

Refugees in 2012

Refugees in 2014

Source of global refugee burden

New Wave of Somali refugees- Current EU refugee crisis

Refugee crisis in Somalia: The overall picture

• Somalia waged war on Ethiopia in 1977-78• Created first wave of refugees from Somali Zone of

Ethiopia to Somalia and Djibouti• Second wave started 1988-1991 when Siad Barre, the

former Somali dictator fought clan war against his own people in Northern Somalia( now Somaliland) into Ethiopia

• Third wave 1991- now , full-blown refugee crisis first into Ethiopia, Djibouti, Kenya and Yemen

• Fourth Wave Middle East then global to Europe, Australia, North America and within Africa and Asia

Copyright: © Daily Mail/Rex / Alamy Stock Photo

Refugees and IDPs in Borama, Somalia1982

Who is internally displaced person?

• According ICRC, Internally displaced persons (IDPs) have fled their homes but have not crossed an international frontier.

• Somalia has one of the highest numbers of IDPs globally.

Somalis internally displaced within Somalia

• First wave , the 1974 famine in Somaliland • Second wave ,The Somali-Ethiopian conflict• Third wave, The 1991 collapse of Somalia • The fourth The 2006 Islamist and subsequent

Ethiopian invasion mostly into Somaliland• The fifth wave, the new war in Yemen 2015

brings new wave of Somali refugees into Somalia again to become IDP in their country

Milestones: The big refugee camps

• Dadaab, the famous largest refugee camp in the world, Kenya

• Dolow, Awbarre and sheedheer are famous ones in Ethiopia

• Ali-Adde in Djibouti• Kharaz camp in Yemen

Transit countries for Somali refugees in Africa and Asia outside

neighbors• Egypt• Malaysia• China/other SE Asian

countries• South Africa• Libya ( another failed

state)• Tunisia • Arab Gulf States

Major Hosting countries for resettlement and naturalization

• UK• USA• CANADA• Australia• New Zealand• Scandinavian countries • Germany• France• Rest other EU states

Refugees into Somalia

A NEW TREND• Yemen Crisis is driving a

wave of refugees to Somalia.

• They are mostly A. Somalis B. Yemenis• Concentrated in A. Somaliland zoneB. Puntland zone

Yemeni family in Qardho, SomaliaSource : IRIN

Mental health among Somalis in the western countries: post- refugee

period• Somalis in UK reported experiencing stress

and movements from place to place for housing and jobs.

Warfa, et al., 2006. Post-migration geographical mobility, mental health and health service utilization among Somali refugees in the UK: a qualitative study. Health & place, 12(4), pp.503-515

Example from the USA

• Mistrust among the community, fear of being labeled crazy and warring clan mentality was reported among Somali refugees in the USA.

Scuglik, D.L., Alarcón, R.D., Lapeyre, A.C., Williams, M.D. and Logan, K.M., 2007. When the poetry no longer rhymes: mental health issues among Somali immigrants in the USA. Transcultural Psychiatry, 44(4), pp.581-595.

Mental Health among Somalis• The image of chained girl in Somalia

showing the dire needs for mental health in countries like Somalia . Collins, P.Y., Patel, V., Joestl, S.S., March, D., Insel, T.R., Daar, A.S., Bordin, I.A., Costello, E.J., Durkin, M., Fairburn, C. and Glass, R.I., 2011. Grand challenges in global mental health. Nature, 475(7354), pp.27-30.

• Weak nature of mental health services in Somalia. Sheriff, R.J.S., Reggi, M., Mohamed, A., Haibe, F., Whitwell, S. and Jenkins, R., 2011. Mental health in Somalia. International Psychiatry, 8(4), pp.89-91.

Mental Health service for the IDPs in Borama ,Somaliland Zone of Somalia

• Mental Health services started in Borama in January 2011.

• The mental health services in based in both hospital and primary care settings.

• Two phasesA.Community oriented mental health care B.Integration of mental health ward into Borama

Teaching Hospital and the development of mental health curriculum.

Mental Health structure

• Inpatient ward and outpatient service in Borama Teaching Hospital

• Community health worker program• Community based mental health service in primary

health care and in hospital ward• Home based mental health care and follow up• Outreach services in prisons, schools, antenatal

settings • Mental health in med/nursing student curriculum.

IDP health service within community outreach

• Partnership with local civil society organizations like women , religious and youth organizations.

• Prominent partner for IDP mental health care is Towfiiq Relief Organization

http://towfiiqrelief.com/Grass root women association offering relief

including shelter, food and financial hand out along with health care services including Mental Health.

How is the service works• The service was in place

since Jan.2012• Home visits twice a week

for 6 hours each• Mental health care by

physician, two community health workers, 2 nurses and 2 social workers

• Financial support for medicines and food with women association

References

Handuleh, J.I., Gurgurte, A.M., Elmi, A., Aye, I.M., Abubakr, F., Kayd, M.A., Walhad, S.A. and Abdi, Y.A., 2014. Mental health services provision in Somaliland. The Lancet Psychiatry, 1(2), pp.106-108.

Handuleh, J., 2012. Experiences of a junior doctor establishing mental health services in Somaliland. Intervention, 10(3), pp.274-278.

Thanks for listeningDiscussion

Email: djibril.ibrahim32@gmail.com