Cultural and Medical Traditions
Minnesota's children’s hospital, Minneapolis, MN
Who are the Somali? The Somali people are an ethnic group in the U.S. who emigrated from the African country of Somalia. Large numbers of Somali refugees began arriving in the United States in 1993. An estimated 50,000 or more Somali now live in Minnesota.2 Many Somali live in the Cedar-Riverside and Philips areas of Minneapolis, as well as smaller groups in St. Paul and greater Minnesota.
Where did they come from? Somalia is a long, narrow country on the east coast of Africa. Most of Somalia is hot and arid, and experiences drought when rainfall is less than normal. About 60 percent of Somalia’s people were nomadic or semi-nomadic herders. The rest were farmers or lived in cities. Mogadishu is the capital and largest city.
How did the Somali get here? Once a colony of Great Britain and Italy, Somalia achieved independence in 1960. From 1960 to 1969 Somalia was a democracy. In the 1980s, however, an increasingly oppressive dictator controlled the nation. Under increasing opposition from the Somali people, the Siyaad Barre regime collapsed in 1991. The country fell into anarchy, with increased fighting between rival clans, as well as armed bandits and warlords. In addition to the civil war, the Somali people suffered drought, food shortages, and famine. Over one million people fled the country to refugee camps in neighboring countries. Relief agencies in 1993 estimated that one half of all Somali children under the age of five had died.3
Language: Somali is spoken universally by the Somali people, with some regional variations. Written Somali uses the Roman alphabet. Arabic is a common second language (It is the language of Islam). Many Somali are fluent in several languages. Older Somali may speak the language of the former European colonists--English or Italian. Literacy is low (its literacy rate in 1990 was 24 percent4), in part because the language was not written until 1971. Because of the civil war and political upheaval, education has decreased considerably.
The Somali language has traditionally been an oral one. Storytelling is a highly honored traditional art. Traditions and political discussions were composed in a poem, which was then repeatedly delivered in numerous communities.5
Social structure: The social structure in Somalia is based on family and clan group. Membership in the clan is determined by the paternal (father’s) lineage. Somali families traditionally live in multi-generation households. Under Islamic law a man may have as many as four wives, but only if he can support them equally. Under the law, a father is duty bound to support his children. In the event of divorce, the children belong to both the father and the mother, but may continue living with the mother.
Divorce was common in Somalia, and continues to be so in the United States. Children become adults at age 15. Young adults and unmarried children live with their family.
Names: Somali names have three parts. The first name is the given name; oftentimes it is the name of a grandparent (but it is the parent’s choice). The second name is the name of the child’s father, and the third name is the name of the child’s paternal grandfather. Thus siblings, both male and female, will share the same second and third name. Other immediate family members will have different second and third names. In addition, women do not traditionally change their name with marriage.6 Traditionally, the Somali use the first and second names when identifying someone, without the use of the last name. This causes confusion with the U.S. system of using the first and last name.
Role of father: Traditionally, the father has been the decision-maker and wage earner for the family. He interacts with society outside of the home. If the father is absent, the decision-making role for the family is passed on to an older male relative, or to an adult son. After the age of ten or so, the father and other male family members assume the role of training the male children.
Role of mother: Traditionally, the roles of men and women have been separated in most areas of life. Today, Somali women carry out many of the duties previously accomplished by men. This change is in part due to the 1991-1994 civil war, when women conducted most of the nation’s business.
Women wield considerable influence within the household.7 The mother cares for the children and prepares the food. Children are highly valued in Somali culture, and a woman’s status is enhanced by the number of children she has. It is common for Somali to have large families. Birth control practices are not widely used. In the past, arranged marriages were more common than now. After marriage, women leave their families to live with their husbands. According to Islamic tradition, women are expected to cover their bodies, including their hair. Most Somali women do not wear a full-face veil.
Role of elders: Elders are respected, and continue to have an active role in the family for as long as they are able. Elders are addressed as “aunt” or “uncle,” even if they are strangers.8
Etiquette: In Islamic tradition the right hand is considered the correct and polite hand to use for daily tasks such as eating, writing, and greeting people. The left hand is considered incorrect. If a child begins to show a left-handed preference, the parents will train the child to use the right hand. Traditionally, men and women do not touch members of the opposite gender outside of the family--handshaking with the opposite gender is not done. Some Somali in the U.S. have adapted to American culture, however, and will shake hands with an American of opposite gender. Many social norms are derived from Islam, and thus are similar to other Islamic cultures.
Religion: The majority of Somalis are Sunnis Muslims. Islamic religion is an important part of Somali life. Islamic religious teachings provide meaning for living, dying, family life, child rearing, and the maintenance of health. In recent years, Islamic fundamentalism has increased as some Somalis have sought comfort from the horrific events of the past few years.9
In Islam, prayer is performed five times a day; at dawn, noon, mid-afternoon, sunset and in the evening. Prayer can be performed at home, in the workplace, in school, outdoors, or in a mosque. Before prayer, the hands, face and feet are washed.10 Islam forbids eating of pork, drinking alcohol or touching (or being near) dogs.
Holidays: The most important is the Islamic holiday of Ramadan. During this month- long holiday people refrain from drinking, taking medications, or eating during daylight hours. Pregnant women, the very ill, and young children are exempted from the fast. Two important religious holidays follow Ramadan. IED-A is about one month after Ramadan, and IED-ALADHI about two months. The Somali Independence Day, July 1, is also a holiday. Many religious holidays involve the ritual killing of a lamb or goat.
Nutrition: The traditional staples of the Somali diet are rice, bananas, and the meat of sheep, goats, cattle, and camels. In the parts of Somalia that were under Italian rule, many people eat pasta as a staple food. The local bread of Somalia is somewhat like pita bread. Corn and beans also are grown and eaten.
The Somali diet tends to be low in fresh fruit and vegetables, though the southern part has locally grown vegetables. Coffee and teas are the preferred drinks. All meat must be ritually slaughtered according to Islamic law. Twin Cities stores sell “Halal” or specially prepared meat. It is customary for Somali men and women to eat separately. Food is eaten with the right hand. Due to the war and drought, many thousands of Somali starved to death or are malnourished.
Use of Stimulants: Qat, (also spelled khat, chat, kat) is a mild stimulant some Somali men use. It is derived from fresh leaves of the catha edulis tree. The leaves are chewed to release the stimulant. Qat is felt to make thoughts sharper, and is often used while studying. In the U.S., the federal Drug Enforcement Agency recently changed the designation of Qat from an unrestricted drug to a schedule I drug (most restricted) due to concerns for potential abuse.11
Time: Traditionally, the Somali organized their activities according to the season, the time of day, and the duties of Islam. Somalis in the U.S. follow Islam, but recognize they live in a secular world.
Medical care and conditions: In Somalia, the major illnesses are malnutrition, including iron deficiency anemia, Vitamin A deficiency, and scurvy. The following infectious diseases are common: diarrheal disease, measles, malaria, and acute respiratory illness.12 Recent emigrants to the U.S. may have these conditions. Some 47 percent of the recently arriving Somali population are affected by one or more kinds of intestinal parasites. However, HIV infection rate in 1997 was 0.25, well below that of other African nations.13
Health conditions in Somalia dramatically declined during the war. In 1991, only 37 percent of the population had access to clean drinking water, and 27 percent had access to biomedical (western) health care services.14 The average life expectancy is now 43-47 years.15
Experience with biomedicine: Before the war, there was limited biomedical health care. National health care services were available on a limited bases. There were some private health care providers. However, most health care personnel and facilities were concentrated in Mogadishu and a few other larger towns.16 Patients of biomedical health care providers were almost always given an antibiotic. Therefore, Somali patients in the U.S. may expect to receive medication with every health care visit.17 Appointments were not taken for a health care visit, and those needing care arrived at the clinic or hospital and waited their turn to be seen.
Traditional healing: Most Somalis are familiar with traditional Somali healing practices. Illness in the traditional worldview may be caused by communicable disease, by God, or by spirit possession. The “evil eye” is a concept believed in by many Somali. The evil eye is misfortune or illness caused by a person wishing harm on another. A mother’s behavior during pregnancy or God’s will affect the health of the baby.18
There are several types of traditional healers in Somali culture. Spiritual healers use religious rituals for healing. General practitioners are skilled in cauterization, minor surgery, blood letting, bone setting, and the use of herbal medications.19 The traditional healers are wise men or women in the community who learned their skills from older family members. Healing techniques include applying a heated stick from certain trees to the skin. This is done for tuberculosis, hepatitis or diarrhea to stimulate the immune system. Herbs and prayer also are used for healing.
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.
Health prevention: Health prevention, in the traditional Somali worldview, is primarily through the use of prayer and living a life according to Islam. U.S. Somalis likely do not practice preventative health. Health care, both traditional and western, is for acute illness. A common view among Somalis is that an individual cannot prevent future illness, as the ultimate decision on this is in God’s hands. Taking medications, such as anti-tubercular agents, when one feels healthy is also not within the traditional Somali worldview.
Health care procedures: Most Somali patients accept surgery and blood drawing. Health care decision making usually involves the entire Somali family, with the male family members being the family spokesperson. The father is expected to give consent for medical procedures or surgery. If he is absent, the mother can give consent. If neither is present, maternal uncles can do so.
Mental health: Mental health care also is a concept new to many Somalis. Traditionally, mental illness is believed to be caused by spirit possession or as a punishment from God. Spiritual healing is required for mental illness. Traditional Somalis viewed people as mentally healthy or mentally ill. They did not see a continuum between the two states.
Mental illness had a social stigma and usually the family attempted to care for the ill person within the family.
As with many other refugees, depression and anxiety are common to many Somali in the U.S. Many have lost family members or are separated from them. An estimated 30 percent of all refugees have been victims of torture.20 An estimated three of four Somalis were traumatized by the civil war. Many have psychosomatic symptoms as well.
Death and dying: Somalis view dying in a religious context. Dying is salvation and part of the cycle of life. When a Somali person is terminally ill, it is considered uncaring for a health care provider to tell the dying person. The family should be told. They will tell the patient. It is acceptable, however, to tell the patient about the extreme seriousness of their illness.
When death is impending, a special portion of the Koran, called yasin, is read at the bedside. Following a death, a skeik is called to prepare the body. A female shek cares for women, and a male sheik cares for men. The skeik cleans and perfumes the body, places it in white clothing, and says the appropriate prayers. In Somalia, the deceased’s next of kin is responsible for placing the deceased in the grave. In Minnesota, the Islamic Care Center handles all arrangements, if a family requests them to do so. The anniversary of a loved one’s death is commemorated.21
Pregnancy and childbirth: Traditionally, Somali women marry early and childbearing usually commences shortly thereafter. It is not unusual for a Somali family to have seven or eight children. Expectant and newly delivered mothers benefit from a strong network of women within Somali culture. Before a birth, the community women hold a party (somewhat like a baby shower) for the pregnant woman as a sign of support and celebration.22 Traditional birth attendants assist with the majority of deliveries in Somalia, as well as provide post-natal care. Long training with a seasoned traditional midwife was required before one could become a birth attendant. Births most frequently occurred at home. Traditionally, the baby’s father is not present during the birth, though this is changing in the U.S. Before delivery, a Somali mother’s circumcision must be cut open to allow passage of the infant. After delivery, the area is again sown together.
Post-partum practices: After a child is born, the new mother and baby stay indoors at home for 40 days, a time period known as afatanbah. Female relatives and friends visit the family and help take care of them. This includes preparing special foods such as soup, porridge, and special teas. During afatanbah, the mother wears earrings made from string placed through a clove of garlic. The baby wears a bracelet made from string and herbs to ward away the evil eye. Incense is burned twice a day to protect the baby from the ordinary smells of the world, which have the potential to make him or her sick.
At the end of the 40 days there is a celebration at the home of a friend or relative. The baby is given a name at birth. There also is a (second) naming ceremony for the child. In some families this occurs within the first 2-3 weeks of the baby’s life. In other families, the naming ceremony is held at the same time as the celebration at the end of afatanbah.23
Breastfeeding: Breastfeeding is common for up to two years after birth in Somalia. Most mothers give colestrum. Some believe colestrum is not good for the baby. As a result, supplementation with animal milk (camel, goat, and cow) is often given in the neonatal period, especially during the first few days of life. It was common for infants, including newborns, to be given liquids with a cup rather than a bottle. (In rural areas, access to bottles was limited.) A mixture of rice and cow’s milk is introduced at about six months of age, and solid foods after that. Many Somali mothers in the U.S. now bottle-feed their babies.24
Infant care: Diapering is not common in the rural or poorer part of Somalia. When the baby is awake, the mother will hold a small basin in her lap and then hold her baby in a sitting position over the basin at regular time intervals. Somali mothers claim that within a short period of time infants are trained to use the “potty.” At nighttime, a piece of plastic is placed between the mattress and bedding. The bedding and plastic are then cleaned daily.25
Irregular pigmentation, known as “mongolian spots” may be present on the lower back, buttocks, or thighs of Somali infants, and may be interpreted as bruises by some U.S. health care providers. Pigmentation usually evens out, and the spots disappear by the time the child is three or four years of age.26
Circumcision: Circumcision is universally practiced for both Somali males and females. It is viewed as a rite of passage, and is necessary for marriage, as uncircumcised people are seen as “unclean.” Male circumcision is performed between birth and five years of age. It is accompanied by a celebration involving prayers and the ritual slaying of a goat. The circumcision is performed either by a traditional or biomedical health provider. Female circumcision includes several different procedures in which varying amounts of the genitalia are removed. In Somalia the procedure known as infibulation was practiced, in which all the external genitalia are removed and the labia majora are sutured together leaving a small opening for passage of urine and menstrual flow. A traditional female practitioner performs the procedure in Somalia. It is usually performed between birth and adolescence.
Circumcision creates many health problems for women including urinary tract infections, menstrual problems and infections, and increased risks related to pregnancy, as well as chronic pain.27 Douching is a common practice. Because of long tradition, both Somali men and women fear their daughters will not marry if uncircumcised.
Female circumcision is not a requirement of Islam. In the U.S., it is against the law to circumcise a female child. Female circumcision in the U.S. has become a complex and emotionally charged subject. Most Somalis in the U.S. believe the practice is obsolete.
Suggestions for treating Somali patients:
- Provide information to begin to familiarize Somali refugees with U.S. health care practices.
- Establish a relationship with the Somali family before care begins. Building respect is essential. Providers need to be receptive to the family’s suggestions.
- Try to establish a health care plan with both the father and the mother. But if one is not available, it is acceptable to talk to either parent. Female health care providers may be more effective in talking privately with the child’s mother, without the presence of male family members, as the mother is the child’s primary care provider.
- If at all possible use a trained medical interpreter. Children should never be used. Presence of the family is desirable, but not to interpret the conversation.
- Inquire about dietary restrictions, the use of herbal medications, and provide privacy for prayer. Consider establishing a “walk-in” type clinic rather than set appointment times.
- Keep in mind that many of the Somali refugees have experienced horrific events and may be experiencing posttraumatic stress. Somalis have no word in their language for stress. Many also may be stressed by financial constraints or overcrowded housing.
- If medications are not prescribed during a health visit, providers need to explain why not.
- Keep in mind that the role of the children, particularly adolescents, is changing with immigration. Somali children are quick to learn the values and behaviors of American culture, which may be different from those of their parents. This produces additional stress on a family. Health education materials may need to be given verbally--either in person or in a video--as many Somali have limited English proficiency. Recognize that female circumcision is a sensitive issue for Somali women, and strive to keep the lines of communication open.
- Use the right hand to give food or medications to a Somali client, as the left hand is considered “impolite.”
- Consider changing medication schedules for older children during Ramadan, because they may not be taking any food or fluids during the day.
- Provide opportunities and a location for prayer (at dawn, noon, mid-afternoon, sunset and in the evening). Do not interrupt prayer, as it is a time during which the divine is present.
- Allow patients to wear amulets, if possible. They help keep evil spirits away and have medicinal value.
- Somalis believe spanking is an acceptable practice. This may complicate diagnosis and make Somalis apprehensive about bringing their child in for care.
- Don’t use finger gestures to get attention, as it is viewed as disrespectful.
- Ask for permission before touching the patient to offer comfort.
- During long procedures, repeat necessary information and frequently offer reassurance.
- Ask what their symptoms are. Many Somalis will describe pain by saying they hurt all over.
- Remember that there is always great variability among people in any group. Health care providers are encouraged to view individuals as unique persons within their cultural framework.
1 General characteristics of the Somali as a cultural group are summarized here. Factors such as how long the Somali have lived in the U.S., the strength of their personal identity with their Somali roots, and their Islamic faith will result in individual variation. Children’s Hospitals and Clinics, Minneapolis-St. Paul, Minnesota prepared this description. Representatives of the Somali community of the Twin Cities of Minnesota reviewed and critiqued the information. Somali representatives were: Samira Dini, Asli Egal, Faduma Hassan, Roda Jama, Mohamed Mohamed, Farhiya Mohamed Moor, Nadifa Osman, and Salah Warsame.
2 Somali Benabiri Community of Minnesota estimate.
3 Putnam, D.B. & Noor, M.C. (1993) The Somalis: Their History and Culture (Available from The Refugee Services Center, The Center for Applied Linguistics, 1118-22nd St., NW, Washington DC, 20037).
4 Metz, H. C. (1993) Somalia: A Country Study. Washington, D C: Federal Research Division.
5 Hassig, S. (1997). Somalia. New York: Caverdish.
6 Lewis, T. (1996). Somali Cultural Profile.www.healthlinks.washington.edu/clinical/ethnomed.
7 Hanson-Ericson, V. (1996) Health Care Beliefs and Practices of Somali Immigrants: A Thesis. The College of St. Catherine, St. Paul, MN.
8 Lewis, T.
9 Hassig, S.
10 Davidhizar, R. & Gigier, J. (1998). Canadian Transcultural Nursing. St. Louis: Mosby.
11 Lewis, T.
12 Lucken, S., staff physician, Dept. of Pediatrics, Hennepin County Medical Center, Minneapolis, MN. Improving Health Care for Somali Children by Better Understanding Somali History, Culture and Medicine, Aug. 31, 1999.
13 World Health Organization. Somali Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Diseases, June, 1998.
14 Lucken, S.
15 World Health Organization. The World Health Report 2000 Health Systems: Improving Performance, July, 2000.
16 Metz, H. C.
17 Lewis, T.
18 Hanson-Ericson, V.
19 Hanson-Ericson, V.
20 Hanson-Ericson, V.
21 Lewis, T.
22 Lewis, T.
23 Lewis, T.
24 Lewis, T.
25 Lewis, T.
26 Davidhizar, R. & Giger, J.
27 Hanson-Ericson, V.
Date Last Modified: 08/25/2003