The response to the COVID-19 pandemic in complex humanitarian crises, such as Somalia, is a global health challenge, with poor governance, public distrust, and political violence undermining interventions in these settings.
On 9th of May 2020, Somalia registered 997 cases and 48 deaths, with a case fatality rate of 5%. However, according to the country’s COVID-19 task force, there is huge under-reporting of both the mortality and disease prevalence. According to The Guardian, funeral agencies in Mogadishu are now reporting 18 burials in a day compared to 2 in usual daily reported figures (1). Somalia has theoretically adopted a lock-down strategy, which does not seem promising as people in general ignored government’s instructions. Every country is required to conduct regular operational reviews to assess implementation success and epidemiological situation, and adjust operational plans accordingly (2). However, Somalia does not have research competencies necessary to assess the implementation success as well as what has worked and what has not.
The country has five federal member states (FMS), the capital (Mogadishu),and self-declared Somaliland with each having its own Ministry of Health that operates independently. Only Puntland, Somaliland, and Mogadishu (the capital) have slightly better healthcare systems, with the capacity to provide limited health services to its population. The ministries of health of the other four states are barely functional. As a result, the healthcare services in the country is overwhelmingly provided by private system and Non-governmental organizations such as WHO, UNICEF, UNFPA and others (3). The response to the pandemic is haphazardly fragmented. The Puntland, Somaliland and Mogadishu have implemented activities involving testing self-reported cases with suspected COVID-19 symptoms, providing care to the severely sick, and updating the public about the COVID-19 cases and fatalities. Further, the federal government (FG) and FMS alike have introduced measures such as; stay home, self-quarantine and social distancing, but people are not complying with instructions. Consequently, prayers in mosques, meeting in public spaces and all other prohibited social gatherings remain unchanged. Even though there is a curfew in place in Mogadishu from 8pm to 6am, people are congregating in Mosques for Ramadan night-prayers until midnight with authorities having no capacity to enforce the guidelines. For the same reasons, contact tracing of affected persons and subsequently quarantining them for 14 days became an impossible task, making the spread of the disease irrepressible and difficult to trace. It is worth noting that people over 60 years constitute only 3% of Somalia’s population (4), which provides an opportunity for an alternative strategy that is potentially more feasible than lockdown.
The unique vulnerability of Somali people to Covid-19 pandemic
Somali-speaking people inhabit the Horn of African countries -- namely, Somalia, the northeastern region of Kenya, the Eastern region of Ethiopia, and the Republic of Djibouti. Consequently, Somali people, whether they are in the Horn of Africa or in the Western world, are comparatively found to be more prone to COVID-19. Somalia and Djibouti have seen a rapid spike in coronavirus incidences, with the two nations having the highest reported cases of COVID-19 in East Africa. Similarly, Eastliegh state of Nairobi, where Somali people prevail, has been reported to be the hotspot of COVID-19 transmission in Nairobi.
In Scandinavian countries with substantial Somali immigrants, Somalia-born individuals overrepresented both the people infected and those being hospitalized for COVID-19. Out of 15 persons who died of COVID-19 in Stockholm, six were of Somali origin (5). In Finland, nearly 200 Covid-19 cases of Somali-born immigrants have been identified in Helsinki, which translates to an incidence of 1.8%, while the average incidence is 0.2% for all the residents in Helsinki (6). Further, of 829 covid-19 cases with immigrant background in Norway, 201 (24.3%) were Somalia-born individuals (7), though Somalis constitute only 3.4% of immigrants in Norway. Moreover, Somalis are overrepresented in people who have been hospitalized for COVID-19 in Norway. While the average age of hospitalization was 64 years in the country, was 51 years of age among Somalia–born individuals (7). Understanding the factors contributing to Somali community’s vulnerability to the pandemic is important not only for the immigrants-hosting countries but also for the Horn of Africa.
The literature documents two major reasons (8, 9).
First, Somali people barely understand the importance of disease prevention: they seek health care only when they experience symptoms that prompt them to seek care such as persistent cough and fever, severe headache, vomiting, etc. This attitude stems from the fact that Somalia has never had a functioning preventive health service; hence, people have no reference to the notion of disease prevention and hardly comply with preventive-instructions given by health authorities.
The second reason mentioned in the literature is the prevalent religious fatalism ideology among Somalis, which refers to the belief that disease prevention is beyond human control. Religious fatalism is generally correlated with lower perceived quality of healthcare (10). Since Somalis have had no access to preventive health services, they have developed the perception that if they become infected by Coronavirus, it will happen anyway, ignoring the Islamic religious duties of first applying the preventative measures.
Conclusions
Coordinated strategy between the FG and FMS has paramount importance in the efforts to contain the pandemic, while fragmented activities in different areas may complicate the situation. There is strong mistrust between the FG and the FMS. However, International Organizations such as WHO and other health partners are highly trusted by all parties. As travel of international staff is highly limited, the WHO and other international partners may help mobilize local researchers and provide them with the necessary training required to perform high quality epidemiological assessment of the pandemic, and subsequent adjustment of the response strategy in the country. As >60 age-group constitute only 3% in the country, an alternative strategy could be a community-led approaches to self-isolate older people, while the business community, the FG, FMS and Somali-diaspora may contribute the food, medicine, and other support required by the elderly. Nevertheless, the safety and feasibility of this strategy in Somalia should be tested prior to its application.
Rapid Response:
Covid-19 response in Somalia: A comparative look
Dear Editor
The response to the COVID-19 pandemic in complex humanitarian crises, such as Somalia, is a global health challenge, with poor governance, public distrust, and political violence undermining interventions in these settings.
On 9th of May 2020, Somalia registered 997 cases and 48 deaths, with a case fatality rate of 5%. However, according to the country’s COVID-19 task force, there is huge under-reporting of both the mortality and disease prevalence. According to The Guardian, funeral agencies in Mogadishu are now reporting 18 burials in a day compared to 2 in usual daily reported figures (1). Somalia has theoretically adopted a lock-down strategy, which does not seem promising as people in general ignored government’s instructions. Every country is required to conduct regular operational reviews to assess implementation success and epidemiological situation, and adjust operational plans accordingly (2). However, Somalia does not have research competencies necessary to assess the implementation success as well as what has worked and what has not.
The country has five federal member states (FMS), the capital (Mogadishu),and self-declared Somaliland with each having its own Ministry of Health that operates independently. Only Puntland, Somaliland, and Mogadishu (the capital) have slightly better healthcare systems, with the capacity to provide limited health services to its population. The ministries of health of the other four states are barely functional. As a result, the healthcare services in the country is overwhelmingly provided by private system and Non-governmental organizations such as WHO, UNICEF, UNFPA and others (3). The response to the pandemic is haphazardly fragmented. The Puntland, Somaliland and Mogadishu have implemented activities involving testing self-reported cases with suspected COVID-19 symptoms, providing care to the severely sick, and updating the public about the COVID-19 cases and fatalities. Further, the federal government (FG) and FMS alike have introduced measures such as; stay home, self-quarantine and social distancing, but people are not complying with instructions. Consequently, prayers in mosques, meeting in public spaces and all other prohibited social gatherings remain unchanged. Even though there is a curfew in place in Mogadishu from 8pm to 6am, people are congregating in Mosques for Ramadan night-prayers until midnight with authorities having no capacity to enforce the guidelines. For the same reasons, contact tracing of affected persons and subsequently quarantining them for 14 days became an impossible task, making the spread of the disease irrepressible and difficult to trace. It is worth noting that people over 60 years constitute only 3% of Somalia’s population (4), which provides an opportunity for an alternative strategy that is potentially more feasible than lockdown.
The unique vulnerability of Somali people to Covid-19 pandemic
Somali-speaking people inhabit the Horn of African countries -- namely, Somalia, the northeastern region of Kenya, the Eastern region of Ethiopia, and the Republic of Djibouti. Consequently, Somali people, whether they are in the Horn of Africa or in the Western world, are comparatively found to be more prone to COVID-19. Somalia and Djibouti have seen a rapid spike in coronavirus incidences, with the two nations having the highest reported cases of COVID-19 in East Africa. Similarly, Eastliegh state of Nairobi, where Somali people prevail, has been reported to be the hotspot of COVID-19 transmission in Nairobi.
In Scandinavian countries with substantial Somali immigrants, Somalia-born individuals overrepresented both the people infected and those being hospitalized for COVID-19. Out of 15 persons who died of COVID-19 in Stockholm, six were of Somali origin (5). In Finland, nearly 200 Covid-19 cases of Somali-born immigrants have been identified in Helsinki, which translates to an incidence of 1.8%, while the average incidence is 0.2% for all the residents in Helsinki (6). Further, of 829 covid-19 cases with immigrant background in Norway, 201 (24.3%) were Somalia-born individuals (7), though Somalis constitute only 3.4% of immigrants in Norway. Moreover, Somalis are overrepresented in people who have been hospitalized for COVID-19 in Norway. While the average age of hospitalization was 64 years in the country, was 51 years of age among Somalia–born individuals (7). Understanding the factors contributing to Somali community’s vulnerability to the pandemic is important not only for the immigrants-hosting countries but also for the Horn of Africa.
The literature documents two major reasons (8, 9).
First, Somali people barely understand the importance of disease prevention: they seek health care only when they experience symptoms that prompt them to seek care such as persistent cough and fever, severe headache, vomiting, etc. This attitude stems from the fact that Somalia has never had a functioning preventive health service; hence, people have no reference to the notion of disease prevention and hardly comply with preventive-instructions given by health authorities.
The second reason mentioned in the literature is the prevalent religious fatalism ideology among Somalis, which refers to the belief that disease prevention is beyond human control. Religious fatalism is generally correlated with lower perceived quality of healthcare (10). Since Somalis have had no access to preventive health services, they have developed the perception that if they become infected by Coronavirus, it will happen anyway, ignoring the Islamic religious duties of first applying the preventative measures.
Conclusions
Coordinated strategy between the FG and FMS has paramount importance in the efforts to contain the pandemic, while fragmented activities in different areas may complicate the situation. There is strong mistrust between the FG and the FMS. However, International Organizations such as WHO and other health partners are highly trusted by all parties. As travel of international staff is highly limited, the WHO and other international partners may help mobilize local researchers and provide them with the necessary training required to perform high quality epidemiological assessment of the pandemic, and subsequent adjustment of the response strategy in the country. As >60 age-group constitute only 3% in the country, an alternative strategy could be a community-led approaches to self-isolate older people, while the business community, the FG, FMS and Somali-diaspora may contribute the food, medicine, and other support required by the elderly. Nevertheless, the safety and feasibility of this strategy in Somalia should be tested prior to its application.
References
1. The Guardian. Somali medics report rapid rise in deaths as Covid-19 fears grow. 2nd May, 2020.
2. WHO. COVID-19 Strategic Preparedness and Response Plan. fEB. 2020. https://www.who.int/docs/default-source/coronaviruse/covid-19-sprp-unct-....
3. Gele AA, Ahmed MY, Kour P, Moallim SA, Salad AM, Kumar B. Beneficiaries of conflict: a qualitative study of people's trust in the private health care system in Mogadishu, Somalia. Risk management and healthcare policy. 2017;10:127-35.
4. Federal Government of Somalia/UNFPA Somalia. Somalia Demographic Health Survey. 2020. https://somalia.unfpa.org/en/publications/somali-health-and-demographic-....
5. Susanne Bejerot, Mats Humble. Inhabitants of Swedish-Somali origin are at great risk for covid-19. BMJ 2020;368:m1101. Available; https://www.bmj.com/content/368/bmj.m1101/rr-10.
6. Foriegner. Helsinki warns of increased Covid-19 cases among Somali community. 2020. Available; https://www.foreigner.fi/articulo/coronavirus/increase-in-covid-19-cases....
7. The Norwegian Institute of Public Health. COVID-19 Dagsrapport søndag 5. april 2020. Available here; https://www.fhi.no/contentassets/ca5914bd0aa14e15a17f8a7d48fa306a/vedleg....
8. Gele A. What works where in prevention of Covid-19: The case of Somalia. WHO Eastern Mediterranean Health Journal (EMHJ), Vol. 26 No. 5 – 2020.
9. Gele A, Abdiqani A Farah. Somalia: Response to Covid-19 in complex humanitarian setting. 2020. https://wardheernews.com/somalia-response-to-covid-19-in-complex-humanit....
10. Nageeb S, Vu M, Malik S, Quinn MT, Cursio J, Padela AI. Adapting a religious health fatalism measure for use in Muslim populations. PloS one. 2018;13(11):e0206898.
Competing interests: No competing interests