The situation of the mentally ill in all Somali spoken territories is very alarming. The same is in the Somali communities in Diaspora.We hear from European countries, USA and Canada that the jails and the psychiatric wards are full of young Somali men.What is going on? My own professional experience is 37 years old :Denmark, Greenland, Norway , 5 years in Burco and the last year in Belet Weyne.In  Mogadishu  I  had the opportunity to meet with professionals working in the psychiatric field and my impression is that the situation of the mentally ill in Somalia is the same as in Somaliland.I have been contacted by professionals in Baidoa, Nairobi(East Leigh) and Jigjiga and the narrative is the same.The mentally ill are contained in the families by chaining them for years, there is no access to psychiatric medication, there are very few in-patient units where the mentally ill can be hospitalized and treated under humane conditions.

There is a boom of so called Elajs, where men (and few women) treat the mentally ill with readings from the Koran. I have visited several of these Elajs in Burco and established cooperation with few of them.The understanding of the mental illness is that the patient is possesed by Jinn,”evil spirits”. The diagnosis is clarified by shouting Koranic verses in the ears of the patient or by subjecting the patient to electric chok. If the patient cries or screams then he/she is possesed, if he/she remains quiet then the problem is minor   and the patient needs no treatment at the Elaj. The cost per month is about 150 – 250 US $ and the families have in most Elajs to provide the patient with food.

A psychotic patient can be violent and the families fear not only for their lives but also for the lives of others. Imagine if the psychotic man hurts  or kills somebody and his family has to pay the Dia/compensation which many families cannot afford.The cost of the Elaj is also high for most families but I know that most of the money comes from the Diaspora.

What I would like to discuss in this article is:

  1. How can the psychiatric services be organized in the Somali spoken territories?

2.What can be done to reduce the frequency of destructive behaviour and psychological problems in the Somali communities in the  Diaspora?

I do not claim that I have the right answers but I would like to share my experience and hope to raise a debate.

1.Organization of psychiatric services .

Mandhaye Mental Health Center in Burco had only 15 beds in the in-patent unit: 5 for women and 10 for men.The out-patient unit had a very large number of patients and the services were based on a community psychiatry model meaning that the mentally ill that are chained at home or to a tree in the bush could get home visit from the center and treated right where they lived. A similar model was implemented by Dr. Yakoub Aw Adan with success in Borama.

The philosophy of this model is that you can reach a larger amount of patients than having large and expensive in-patient wards that demand a lot of staff. And by visiting the patient at home the professionals have the possibility of meeting with the family of the patient and give them information about mental illness and treatment (psycoeducation).

In big cities like Mogadishu where there is a large number of mentally ill homeless people living in the streets it is important to establish shelters where these people can live and have a home. Shelters are cheaper then big psychiatric hospitals and the patients living there can be treated by the staff from the community psychiatry centers that should be established widely.

Local psychiatric capacity building is crucial.The doctors, nurses and assistants need ongoing educational sessions and supervision in order to be able to take care of the job after the Somali professionals from Diaspora or from foreign NGOs have gone back to their countries.Mandhaye Mental Health Center in Burco is a good example. As a result of good training the nurses and the assistants are able to take care of the mentally ill with few hours assistance from a junior doctor.The situation is, of course, not ideal but better than before Mandhaye was established.

One more thing that makes Mandhaye/Burco unique was  the weekly telepsychiatric consultations given at the time by 2 Somali psychiatrists in Sweden and Norway.

I am sure that the Mandhaye/Burco model with few beds, large out-patient services and telepsychiatric consultations by Somali professionals in the diaspora ,is the way ahead for a country with massive mental health issues and few ressources.

At the general hospital of Belet Weyne we started an psychiatric out-patient unit functioning with a doctor and 2 nurses from march this year.The role model is Mandhaye/Burco and the unit is called Mandhaye/Belet Weyne. The idea is to spread the Mandhaye model to so many Somali cities as possible.The name Mandhaye was given to us in Burco by our great poet Hadrawi.

Mandhaye/Belet Weyne is sponsered by money coming from the Somali diaspora and the services are free of charge. Most of the work is via homevisits and patients are met where they are and ,when the ressources will allow,the medication will be given for free to the poor patients.

I am available via Skype both to assess a patient or to discuss a problematic issue with the staff.

My vision is to create at Mandhaye/Belet Weyne a center where all mental health workers from the country can be trained.

2.Mental Health issues, drug abuse and crime in Somali communities in Diaspora.

My work experience is mostly from Denmark but I know that Somalis in all Diaspora have the same problems : young people that are born in Diaspora or came as small children develope psychological difficulties or mental illness , problems with drugs or alcohol abuse and, for some, ending in crime. I met several families with a son or a daughter with psychological problems or mental illness. ‟What did we do wrong?” That is the question the parents are constantly asking themself. My impression is that most parents are good and caring parents that want the best for their children. However they need to understand the dilemmas and questions the growing child or youngster meets. It is not part of our culture to sit with a child and ask: ‟How was your day,what did you experience today?” The child is living in 2 totally different worlds and it takes a very robust psyche to deal with it: a Somali, moslem family at home and a Western,christian/secular society outside. At home the values are, among other things, the respect for the parents and your parents know best.The values at school are, among others, to question authorities and to think yourself. What a clash! And if the parents are very religious and afraid of the influence the outside society will have on their child they will do everything to minimize the contact the child has with the outside world. I heard several times from Somali parents that they were trying to keep their child as a good Somali and moslem because they someday will go back to Somalia.The history , also with other ethnic minorities ,shows that they are not going back but will after decades still live with the dream of going home. They are not there physically in Somalia and they are not here mentally in the Diaspora.

In Denmark there is an organization of Somali Health Workers (SSF-Somali Sundheds Forbund). They are doing a great job for the Somali community. In each of the 4 major cities they organize yearly 2 meetings lasting 2 days, gather the Somalis and give information on all health aspects. They also do clinical work during the 2 days, measure blood pressure, cholesterol and blood sugar. All citizens in Denmark have free access to a family doctor but we know  that many Somalis do not go to their doctor and during these Health days cases of illness are discovered. Afterwards the advice is that the person goes to the family doctor. If needed the person’s doctor gets contact from someone from the organization.

Some years ago I started working with this organization and I make speeches on mental health issues, on how the Danish psychiatric services are organized, how and where you can get help if you have problems. I know that many Somali families do not trust the Danish psychiatric services, they fear that they will be met with racism and prejudices. It happens that the mentally ill will be sent home to Somalia to get treated. I met in Burco 2 young men, one from the UK and one from Denmark, both schizophrenic. The young man from Denmark was in an Elaj, where I met him. He was chained, naked and alone in a dark room. Treatment? This was torture.

I think that organizations like the one in Denmark should be in each country where Somalis live. I know that there are Somali social workers,doctors and nurses everywhere and my advice is that Somali professionals should take the responsibility of helping their fellow Somalis. Health professionals should be bridgebuilders between the Somali community and our new societies.

There should be advice centers where well integrated Somali professionals  can help the dysfunctional families with advice and information. Support both to the parents and the young people that are falling  between 2 chairs.

In Copenhagen I started,together with 5 Somali and 2 Danish professionals, a counselling center Tusmo targeting the Somali families in Copenhagen.We are both health and social workers ,we work on voluntary basis and guide the families to get the needed help in the existing Danish institutions.

It takes time to find out how to navigate in a new society but some people never learn this and their children will pay the price.Somali social and health workers in Diaspora can play a crucial role for these families.

Dr. Fatuma S. Ali Jiumale