Lack of COVID-19 resources risking millions in Somalia settlement camps

A lack of access to screening services and important information about COVID-19—including all of the ways the highly-infectious virus can be transmitted—could be putting millions of internally displaced people in Somali settlement camps at risk, according to new research by the Yale School of Public Health and The Hagarla Institute.

Three million internally displaced people (IDP) live in more than 2,000 settlement camps in Somalia. The large-scale camps are a tinderbox for potential outbreaks of infectious disease. Overcrowded conditions restrict opportunities for physical distancing and the camps often lack reliable access to basic amenities such as running water, soap, and medical treatment. The situation is exacerbated by Somalia's weakened health care infrastructure, which has been fractured by natural disasters and 30 years of civil war.

The humanitarian crisis is already acute. Somalia has some of the lowest health indicators in the world with life expectancies of 54 years for males and 57 years for females. Somalia ranks 194 out of 195 countries in preparedness for a globally catastrophic biological event such as a disease outbreak, according to the Global Health Security Index. In a broader sense, the conditions identified in Somalia's IDP camps may be an indicator of similar situations within other IDP and refugee camps around the world, where more than 60 million people currently reside.

What Can Be Done to Help?

"A massive influx of resources and targeted interventions is needed to protect the millions of people living in these camps from COVID-19, starting with educating those most vulnerable to infection," said Yale School of Public Health Associate Professor Kaveh Khoshnood, Ph.D., the study's senior author. "We hope this study serves as an incentive for international organizations operating within Somalia, as well as the Somalia government, to expand their investments in a sustainable health care infrastructure, not only to address COVID-19, but to improve the long-term health and prosperity of the population."

Somalia has been fortunate in that the country of 15 million people has reported only 3,371 cases and 97 deaths associated with COVID-19 as of Sept. 13. But health officials remain concerned about a virus outbreak in the camps, given conditions there and the lack of access to adequate prevention resources and medical care.

Recognizing the immediate health threat posed by the coronavirus, a Yale School of Public Health research team led by Khoshnood partnered with doctors and clinicians from The Hagarla Institute in Mogadishu, Somalia to conduct a scientific survey of people living in the IDP camps regarding COVID-19. The investigators wanted to gage people's knowledge and perceptions about COVID-19 and whether individuals were experiencing symptoms of COVID-19. The study also sought to identify pre-existing health conditions within the IDP camp populations that might be exacerbated by COVID-19 and to what extent preventive measures and medical treatment are available. The survey was the first of its kind undertaken in the Somali camps and is believed to be only the second such study to document knowledge of COVID-19, symptoms and risk factors among displaced populations globally.

While 77% of respondents took at least one precaution to avoid COVID-19 (such as frequent hand washing), all reported a lack of adequate sanitation in the camps, an inability to physically distance and a nearly universal inability to get tested for COVID-19 due to a lack of available resources. When asked about specific COVID-19 prevention and treatment options, about half the time respondents expressed no knowledge of them. The majority of respondents were not familiar with basic information about the virus, including the fact that SARS-CoV-2, the virus causing COVID-19, can be transmitted by people who are asymptomatic. A high number of respondents also reported at least one potential symptom of COVID-19 such as headache, cough, fever, etc. although no official diagnosis was undertaken or confirmed. Residents said they trust local radio news reports and religious leaders the most when it comes to getting reliable information about COVID-19.

The study would not have been possible without the expertise and staff resources provided by The Hagarla Institute, a non-profit organization dedicated to clinical research and enhancing health care in Somalia. The Institute operates in the Lower Shabelle region of Somalia, which is considered to be the IDP camp capital of the world. The Institute was founded by former Yale World Fellow Dr. Deqo Mohamed, who is a co-author on the paper. Also listed as a co-author is Dr. Mohamed Abdullahi Awale, a consultant surgeon and senior lecturer at SIMAD University in Mogadishu. Drs. Mohamed and Awale and staff at The Hargarla Institute oversaw and conducted in-person surveys of 401 individuals living in 12 IDP camp across the Lower Shabelle region. A team of YSPH graduate and undergraduate students designed the study and analyzed the data remotely from the United States due to existing COVID-19 restrictions. Khoshnood said the students did a tremendous job pulling the report together under difficult circumstances and a tight deadline.

"It is already difficult to navigate instability in Somalia, but amidst lockdown measures, misinformation, and fear spreading through the community, these circumstances have only been exacerbated during the COVID-19 pandemic," said Jude Alawa, the study's lead author. Alawa, currently a Knight-Hennessy Scholar and first-year medical student at Stanford University, was a Yale Fox Fellow at the time the study was done. He graduated from Yale College as a Global Health Scholar in 2019.

"Our team was incredibly fortunate to be able to collaborate with Drs. Mohamed and Awale and their dedicated colleagues, who worked tirelessly traveling to the IDP camps and addressing the unique challenges we encountered conducting the study," said Alawa.

An Added Benefit and Global Perspective: Because the study also gathered basic demographic and health information from camp residents, local health officials now have a better sense of some of the pre-existing health conditions people are dealing with in the IDP camps. Such a comprehensive survey had never been done before.

"Reporting on pre-existing conditions may seem like the last thing on health professionals' minds in the midst of a pandemic, but these are vital statistics that may determine an inflection point in these individuals' health for years to come," said YSPH student Lucas Walz, MPH '21, a co-author of the study. "Even during an infectious pandemic, access to health care and continuing treatment for chronic conditions must be maintained."

Meeting the health care needs of displaced populations also strengthens the health of the community at large, both locally and globally, said Alawa.

"The COVID-19 pandemic can affect anyone and any response to address this pandemic must necessarily include all individuals, including those displaced," said Alawa. "An inadequate response to COVID-19 in Somalia is likely to threaten global health security and exacerbate the spread of the virus among both displaced and host communities."