It was a typical busy Monday morning. I was about to enter the exam room when my assistant informed me the patient did not speak English; therefore, she was unsure what the patient needed. I opened the door to a young Somali mother named Hawa and her five children. When I asked her what brought her in today, she handed me a paper from the school that stated that her 5-year-old needed shots. She was a new patient and I was uncertain of what dialect she spoke.
I accessed interpreter services and within minutes we found an interpreter who spoke her dialect. Because the interpreter was male, however, Hawa refused to speak with him. A few more minutes passed before a female interpreter was available. We were then ready to start our visit.
Hawa explained that although they had been in the United States for a year, they had never sought medical care. Although the purpose for this particular visit was to have her child vaccinated, Hawa herself appeared exhausted as she tended to her children. Upon further questioning, she relayed through the interpreter that she had had diarrhea for the past month and had lost weight. Her last menstrual period was 4 months ago. It was evident that she needed immediate medical attention.
After several ova and parasite (O&P) stool samples were submitted to the lab, Hawa was diagnosed with giardiasis, a common illness among refugees. Hawa also had a positive pregnancy test; thus, she was referred to infectious disease for treatment because metronidazole is contraindicated in the first trimester. After successful treatment and recovery, Hawa gained weight and was able experience a healthy pregnancy.
Refugees in the United States
According to the United Nations High Commissioner for Refugees, there were an estimated 803,500 refugees in the Americas (United States, Canada, Venezuela, and Ecuador) by the end of 2008; and from 2004 on, approximately 12,000 of them were of the Somali Bantu population.1,2
Most refugees in the United States access the healthcare system at some time, whether to give birth, receive immunizations, or for medical emergencies. However, many healthcare providers are not equipped to handle the infectious tropical diseases and/or cultural healthcare practices associated with these patients. In addition to addressing health issues and cultural practices, providers must be able to communicate with the patients, many of which do not read, speak, or understand English. This is a growing concern as millions of people in the United States live in households where English is not spoken, according to the Modern Language Association.3,4
The author had the opportunity to work with the Somali Bantu population for more than 4 years and she also lived in Somalia for 2 years. These experiences gave the author the chance to become familiar with many of these issues and practices. While some of the healthcare practices among the Somali Bantu people are harmless, many are very dangerous. There are many cultural practices of the Somali Bantu, as well as common tropical and parasitic health issues and diseases that providers may encounter while caring for these patients.
The Somali Bantu
The Somali Bantu and Somali cultures are similar, although their histories differ. According to VanLehman and Eno, "The Somali Bantu can be subdivided into distinct groups. There are those who are indigenous to Somalia; those who were brought to Somalia as slaves from Bantu-speaking tribes but integrated into Somali society; and those who were brought to Somalia as slaves but maintained, to varying degrees, their ancestral culture, Bantu languages, and sense of southeast African identity."5
Most of the Somali Bantus were farmers whose land was taken over during the civil war, which has not yet ended. The Bantu are often excluded from educational, political, and economic advancement in Somalia, and have to settle for lower-status occupations. Their physical features differ from those of the Somali nomads, which subjects them to additional discrimination.5
The average Bantu family consists of four to eight children with an extended family that includes grandparents, aunts, uncles, and other relatives. Many Bantu men practice polygamy in Africa and continue that practice in the United States. Because polygamy is unlawful in this country, the second, third, and fourth wives are classified as "single mothers" and many of the marriages are conducted in mosques.6 These marriages are recognized in their society and among their family members. Divorce is not uncommon among the Bantu. Typically the young children remain with the mother, but the older children may go with the father.5
According to VanLehman and Eno, "Due to their exclusion from formal education and positions in Somalia that require literacy, the Bantu have remained largely illiterate."5 It is estimated that only 5% of all Bantu refugees have received formal education. This low literacy rate presents problems in healthcare when it is necessary to provide these patients with culturally relevant written teaching material.
Many providers must use interpreters when caring for these patients, which presents its own challenges. The provider must be able to trust that the interpreter is relaying correct information to the patient. The patient must also be comfortable asking questions through the interpreter. If using a Somali interpreter for a Somali Bantu patient, the provider should not assume mutual trust and respect between them, even in the absence of open hostility.5 It is important to identify the patient's exact dialect because there is compelling evidence that ineffective language access systems pose patient safety hazards.7
Parasitic and tropical diseases
Many of the Somali Bantu have parasitic diseases and other healthcare problems of which they are unaware. These issues are often missed at initial refugee screenings upon entry to the United States. These diseases can lead to physical impairment, chronic diseases, or even death (see Common symptoms and diseases affecting the Somali Bantu Population).
The CDC offers up-to-date treatment information for these diseases on their website (see Recommended websites).
Schistosomiasis (Schistosoma haematobium) is a disease caused by parasitic worms. It is not found in the United States; however, more than 200 million people are infected worldwide. The infection occurs when skin comes into contact with certain types of contaminated fresh-water snails that carry schistosomes, which are tiny flatworms.1 This disease is not contagious.
Symptoms may include hematuria, rash or itchy skin, fever or chills, cough, muscle aches, anemia (seen in children), cystitis, ureteritis, and eosinophilia.7,8 Yet, many infections are asymptomatic. Chronic infections may damage the liver, intestines, lungs, and bladder. Symptoms of schistosomiasis are caused by the body's reaction to the eggs produced by worms, not by the worms themselves.9 The worms can lay up to 1,000 eggs on a daily basis.10
This disease is commonly seen in Somali Bantu refugees and the CDC has recommended presumptive treatment of schistosomiasis in all nonpregnant Somali refugees over age 4 before they come to the United States.11
Giardiasis is an intestinal infection caused by the Giardia lamblia parasite. Giardiasis is found worldwide including in the United States. The disease may be asymptomatic or dormant in incoming refugees, or patients may present acute illness. Giardia cysts can survive several months in cold water. Infection occurs by the ingestion of cysts in contaminated water, food, or by the fecal-oral route.9 Symptoms may include malodorous diarrhea, abdominal pain, bloating, nausea, vomiting, and increased flatulence.7
Tapeworms, roundworms, hookworms, pinworms
Nobody likes the thoughts of worms (including the patients); however, refugee patients often carry them, and must be appropriately screened. Many patients go undiagnosed as the symptoms, which include weakness, headaches, anorexia, abdominal pain, and diarrhea, may mimic other intestinal ailments.9
Hookworm infections may manifest with a pruritic papular rash. Eosinophilia is a helpful indicator of hookworm infections.7 Treatments vary, depending on the type of organism identified.
Entamoeba histolytica is a parasite that causes amebiasis. It is also one of the organisms that causes what commonly referred to as "Montezuma's revenge" or "traveler's diarrhea." Many incoming refugees may be asymptomatic, and again this may be missed during the initial health screening. Symptoms may include abdominal pain, low-grade fever, fatigue, diarrhea, bloody diarrhea, liver abscess, and peritonitis.9 More than 1 million people are infected by this parasite every year.
As with schistosomiasis, the CDC recommends presumptive treatment of strongyloidiasis in the Somali Bantu refugees.11 Symptoms include abdominal pain, diarrhea, and rash, although many patients may be asymptomatic.7 Eosinophilia may be present during the acute and chronic stages. If strongyloidiasis infection disseminates in an immunocompromised patient, it may become fatal.9
All refugees are screened for TB upon arrival to the United States, but are automatically considered high risk if they emigrate from a country with high rates of the disease. Some signs and symptoms of TB include weight loss, cough, chills, loss of appetite, fever, and fatigue.7
Many refugees were given the bacillus Calmette-Guerin vaccine (BCG) vaccine as children to protect them against TB. This vaccine causes frequent false-positive results in TB skin tests. Regardless, it is recommended that patients who received the BCG vaccine as children still be screened in the same way as those who have not received it.7
Patients with a positive TB skin test and a negative chest X-ray may have latent TB or extrapulmonary TB. Extrapulmonary TB can be found in the lungs, kidneys, genitourinary system, bones or joints, central nervous system, or lymph nodes.12,13
The QuantiFERON-TB Gold (QFT-G) blood test is recommended for those patients who have a positive TB skin test and a negative chest X-ray.14 A positive result from the QFT-G blood test is evidence that the positive TB skin test was not a result of vaccination from the BCG vaccine. It is then necessary to contact the local health department, TB clinic, or infectious disease (ID) practitioner for treatment options.
Many Somali Bantu refugees lived in areas with high rates of Hepatitis B, so they should be tested for Hepatitis B infection. Symptoms include low-grade fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, and jaundice.7 They may have dark urine and lightly colored stools. Acute illness typically lasts 2 to 4 months.15 These patients could also be asymptomatic chronic carriers of Hepatitis B.
Pterygium is caused by exposure to intense UV light, dust, and wind.16 Symptoms include itching, pain, visual disturbance, or loss of vision. In some cases it may cover the central cornea. Referrals are necessary to treat complicated cases (See Pterygium seen in a Somali Bantu woman).
Other health issues
Additional health issues are common in this population including syphilis, vitamin D deficiencies, malnutrition, long-standing rashes (such as leishmaniasis and tinea versicolor),7 post-traumatic stress disorder, depression, domestic violence, and severe dental caries. Many of these will warrant referrals to specialists such as dentists, dermatologists, psychologists, infectious disease practitioners, or social workers.
The more providers are aware of the cultural practices of refugee patients, the more they can incorporate these patients' traditions and rituals into the management of their conditions, if appropriate. This helps in building a positive and trusting relationship between the provider and the refugee patient.
Not all Somali Bantu men practice polygamy, but many do. Those who do practice polygamy may have up to four wives at a time. The women normally dwell in separate housing from each other. With this knowledge, the provider should be aware of any communicable diseases or sexually transmitted infections that may be transmitted from wife to wife via the husband, such as syphilis, TB, hepatitis, or other communicable disease. Regulations from the Health Insurance Portability and Accountability Act (HIPAA) can present certain challenges; for example, asking one of the wives to consent for a blood test after diagnosing syphilis in another wife, without revealing that finding to the patient.
Female circumcision is practiced by most Somali and Somali Bantu women. It involves the removal of the clitoris and some, if not all, of the labia minora and majora, depending on the type of circumcision. This is performed between the ages of 6 and 13, depending on local customs. This is not a religious practice but a cultural one. Type I and Type II female circumcisions are usually seen in Somali Bantu women, while Type II and Type III are usually seen in Somali women. 17,18
According to the World Health Organization (WHO) "female genital mutilation is classified into four major types:
- Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, rarely, the prepuce (the fold of skin surrounding the clitoris) as well.
- Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are "the lips" that surround the vagina).
- Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, and sometimes outer, labia, with or without removal of the clitoris.
- Other: all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping, and cauterizing the genital area."19
Type III circumcisions make pelvic exams more challenging. Literature has shown conflicting results, from no increased risk of infertility and no increase in maternal or infant mortality,20 to hemorrhaging, scarring, keloids, maternal complications, and perineal tears.7,21
In most states, it is against the law to perform female circumcision on minors, and 17 states have made it illegal.6,22 Women with Type III female circumcisions are more prone to urinary tract infections, as the urethra is covered with tissue after the procedure. In these cases, a stick is placed under the tissue to form a fistula so the urine can be released during voiding, once the healing takes place.
When performing a pelvic exam on a woman with a Type III circumcision, the smallest vaginal speculum should be used as the opening is frequently small. A pregnant woman with a Type III circumcision should be referred to an obstetrician, as the patient will require repair after the delivery, which may include defibulation.7 Defibulation is a procedure to reverse infibulation and the woman may fear her husband's rejection if she is not circumcised.
Traditional healing by burning
Traditional burning is usually done by heating up a small metal object (such as a nail) and applying pressure, with the intention of healing an ailment or relieving pain in a particular area of the body (See Cultural burning seen in a Somali Bantu man).
It is not unusual to see children with burn marks on their chests due to frequent coughs or pneumonia, or on their heads for headaches, or if the child was born with what their parents perceived to be too large of a head.
The Somali Bantu frequently perform uvulectomies for children with frequent throat infections. The first course is to burn the uvula, but if the infections continue, it is removed.
Other clinical issues and challenges
- Time: Somali Bantu patients perceive the concepts of time and urgency differently. The Bantu's method of telling time differs from ours, which frequently causes them to be late for appointments. In these cases, most of them are more than willing to wait for an opening in the provider's schedule in order to be seen.
- Missed appointments: If the patients feel better, or if they cannot secure a ride or child care, they will not come to their appointment. Providers must have flexibility when working with this population. Utilizing an interpreter for reminder calls the night before or the morning of the appointment is helpful. Add-ons are frequent, due to other sick family members, although the appointment was made for a single patient. Again, flexibility is key.
- Age discrepancies: Many Somali Bantu patients may be older or younger than the age stated on their passports. This could be because they do not have birth certificates, or because they had to use the age they were when they came to the camp on their new passports. Sometimes there is as much of an 8- to 10-year difference. Many of the children plot low on the growth charts because of age discrepancies. Once a trusting provider-patient relationship is established, the patient will then reveal his or her real age. In some cases, however, the patient simply does not know his or her real age.
- Referrals: Many specialists do not provide interpreters, due to costs. Many also do not have the extra time that is necessary when working with these patients. Locating a specialist who speaks the patient's language will produce better results. Many refugees need referrals for infectious disease, urology, OB/GYN, and ophthalmology. It may take several months to find a provider to agree to see a patient, because of the cost and the time it may take to hire a qualified interpreter. The specialist must be made aware that the patient does not speak English, and what language they do speak at the time of the referral. The provider should make sure the patient knows the appointment time and reinforces that they are expected to show up on time. Many times specialists who practice in the hospital setting have easier access to interpreters. Regardless, the primary care provider often ends up rendering services that should be provided by a specialist, such as treatment of infectious diseases, because of poor access and language barriers.
- Interpreters: The provider must find a trustworthy and reliable company or interpreter. Family members and other relatives of patients do not make good interpreters, as they tend to filter information.23 Interpreter service providers charge anywhere from $35 to $50 per hour for their services, although this can vary by company and by state. These services are not often covered by insurance. Multilingual health information is available from the Refugee Health Information Network. (See Recommended websites.)
- Illiteracy: Since only 5% of the Bantu have formal education, illiteracy is a huge problem.5 Even if patients speak English, they may not be able to read English.7 These issues are especially critical concerning patient signatures of informed consent for surgical procedures. This information should be issued in the patient's native language with the aid of a qualified interpreter. If no interpreter is available, then the provider must access the Language Line or another language service provider. Some healthcare videos are available in other languages.
- Prescriptions: Many patients take a medication only until it is gone. Even if it is PRN, they will take it every day. Once the medication is gone, the patient will not get a refill unless either the provider or the pharmacist reminds them (such as for diabetes or hypertension). Most Somali Bantu are accustomed to episodic or no care in the refugee camps, and the majority of that care is for acute illness or pregnancy. Most of them do not understand chronic disease and the need for continued treatment or follow-up. If the patient has new-onset diabetes or hypertension, the provider will then have to educate them about the necessity of weekly or monthly visits until the condition is fully understood and under control.
- Payment for services: Most of the Somali Bantu have state-funded health insurance. Healthcare expenditures for immigrants is 55% less than for those who were born in the United States.7 Immigrants also tend to access the healthcare system less frequently than their U.S. counterparts.7 Those without health insurance access the healthcare system in the same way as do U.S. citizens without healthcare insurance.
No matter the challenges, taking care of refugees can be very fulfilling. Seeing a refugee patient's fear turn into a grateful smile is reward enough. Taking the time to care for a population of people that were once discriminated against is very satisfying. Seeing their children grow up healthy is a dream many in Africa will never experience. Earning the patient's trust enough to be invited to participate in their culture and inner circle offers a lifelong feeling of joy.
Julie Parve, DNP, FNP-BC, APNP, acknowledges the assistance of Faria Raghe, the Somali interpreter with whom she closely worked, as well as her advisor Dr. Teri Kaul and her mentor Dr. Janice Hill. Dr. Parve also thanks Sandra Olsen for her support and encouragement of her work with the Somali Bantu.
- Language Line (interpreters by phone): http://www.languageline.com
- Refugee Health Information Network: http://www.rhin.org
- Information on parasitic diseases: http://www.cdc.gov
- Information on cultural customs and beliefs: http://www.ethnomed.org
- Health information in 24 languages: http://ethnomed.org/patient-education/
- Health education materials: http://www.mcedservices.com/qothe.html
- Consumer health information in many languages: http://nnlm.gov/outreach/consumer/multi.html#A8