A Somaliland Toolbox
Community Timeline:
Somaliland is an independent nation located on the Horn of Africa, north-west of Somalia, on the southern coast of the Gulf of Aden. Somaliland is considered a success story, the nation independently initiated and sustained peace, established free and fair democratic elections, and acts as a sanctuary for people fleeing conflict from Yemen, Syria, and Somalia. But this “success” was preceded by significant trauma, that still affects the nation’s people and, in many ways, remains a part of daily life. The Community Timeline of Somaliland is as follows: there were two significant civil wars within the country that were fought from 1987–1996, the first of which was initiated by the Somali dictatorship and involved aerial bombings, land mines, and imprisonment, as well as war crimes / atrocities including torture, and rape. In 1991 Somaliland successfully gained independence from Somalia, but the population suffered additional trauma. Seasonal rain unearthed mass graves from the wars, continued conflict led to displacement, and that instability resulted in increased violence, and poverty. Understanding these events and their repercussions is important because it provides context for why this nation is struggling in the ways that it is — particularly with the lack of mental healthcare. Since the civil wars, and gaining independence, Somaliland has essentially been in a cycle of triage, and mental healthcare hasn’t had the same urgency as physical healthcare and maintaining political stability.
Taking Inventory of the Stigma of Mental Health:
In Somaliland mental illness is understood as binary — someone is either “waali” (mad) or they are not. The most common mental disorders (that get defined as “madness”) in Somaliland are schizophrenia, bipolar disorder, post-traumatic stress disorder, depression, mania, and generalized psychosis, with substance misuse often occurring simultaneously. Once someone is labelled as mad, that is their identity, the stigma is impossible to reverse, and impacts the individual as well as the family. However, when mental illness is only seen as a binary, more common mental health concerns (like anxiety, or stress) don’t get addressed for fear of being stigmatized, leaving the individual untreated, and unwell.
The image below is meant to symbolize a binary lens, specifically what gets missed when something is only seen in black and white. The reveal of the full color painting is a nod to seeing things on a spectrum (in this case the full color spectrum). It creates a clearer, multi-dimensional image.
Current Interventions:
In brief, Somaliland established its first mental health department in 1948, the second department was established 25 years later (1971), and 3 more departments have been introduced since 2009. All these departments are within general hospitals, and their in-patient capacity is limited to about 250 beds, for a population of around 3.5 million people. Out-patient programs are available, but because the general hospitals are in principle towns, that aren’t easily accessible for the more rural members of the population, the out-patient programs have high relapse rates and poor treatment compliance.
There are other treatment options outside of the hospitals, but none of them are regulated, and few of them are humane. The most common form of “treatment” is an Ilaaj, a private facility to which families will send their if they are unable to care for them on their own. The Ilaajs are often overcrowded, patients are forcibly chained, and abused — they will also end up staying there for years because they can only be released at their family’s discretion, and because of the stigma associated with mental illness, it can be difficult — even damning to bring the family member home. So, while family is the closest support system in proximity, they are often not the most effective system on which to rely.
In addition to the Ilaajs there are several traditional and faith-based healers that people will turn to, sometimes these healers will run their own Ilaaj, but other times they will work individually. Islam is the dominant religion in Somaliland and serves as a major anchor for people in terms of finding social support — which is especially helpful for adolescents.
The youth we have been working with in Somaliland have overwhelmingly cited peer-to-peer as the best support system, and social media as the most effective way to stay connected — not necessarily in regard to mental health at the moment, but they believe a social media intervention would be the a good way to spread awareness about mental health and well-being.
Outside of the world of mental health interventions, there are several NGOs currently in Somaliland, but their efforts are more focused on physical health and humanitarian challenges.
Interviews with Community Members:
We are fortunate to be able to work with Fatumo Osman and the Youth Advisory Board in Somaliland, as well as Amound University. Through these connections we have gleaned a lot about the community wealth that exists in Somaliland. Community wealth can be understood as the assets people already have and looking to people as possessing tools and resources to start from a place of abundance rather than deficit.
In Somaliland there’s a robust culture of oral history and storytelling, which seems to reinforce / foster the peer-to-peer support that exists amongst youth.
But perhaps the most interesting insight we have gotten from our conversations with the Youth Advisory Board resides in their understanding of the somatic manifestations of mental illness — how stress, anxiety, or depression, etc. shows up, physically, in the body. Below I have included diagrams that they drew which specify where they physically hurt when they’re struggling with something emotionally distressing. It is this connection — the physical to the emotional, that provides a crucial entry point.
Because of the stigma that exists within their culture, it’s incredibly hard to work through the binary of “mad or not mad,” but connecting things that seem intangible (like anxiety, stress or depression) to tangible somatic symptoms might be a way to begin conversations around the importance of mental wellbeing, rather than only mental illness.
Life is more vibrant when you experience it on a spectrum instead of a simple binary, it’s also more complicated, and sometimes more painful, but it creates deeper understanding of ourselves, our communities, and what we might carry into our futures.
