NAIROBI — In mid-June, Yurub and her family fell ill with what they believe was COVID-19. They were coughing, had fevers, sore throats, and body pains.
When people in their community in the city of Erigavo, in northeast Somaliland, found out, she said they labeled them as sinners, saying that COVID-19 had befallen the family as divine punishment. Community members wanted nothing to do with them. Relatives stopped communicating with them. The family felt so targeted that they didn’t go to the health facility to seek care over fears of how the community would react to them there.
Almost two months have passed and Yurub, who wishes to go by a false name, hasn’t been able to earn a living. Nobody will buy bananas from her at the market — for fear that she is spreading COVID-19 and that they might contract the virus from the fruits she sells. Her savings have dried up.
The pandemic response across the globe
“This sickness destroyed my income. I’m worried about how I will support my children,” she said. “COVID is a problem here, it exists everywhere in Somaliland and Somalia, but people don’t want to admit that it’s here. Because of that stigma, people don’t want to say that they have COVID, they are instead saying that they have the flu, or something else.”
Stigma and misinformation around COVID-19 is complicating the response to COVID-19 in Somaliland and Somalia. As well as preventing people from getting tested and from taking the proper measures to prevent its spread, it is threatening the incomes of many, according to humanitarian organizations working to stop the spread of the virus.
The shame surrounding COVID-19
Officially, there are 3,227 cases in Somalia, and 93 deaths.
“The numbers that have been reported officially are very few,” said Abdikadir Ore Ahmed, health specialist at CARE International in Somalia and Somaliland. “But the informal information that we get, of the number of deaths, is really high. And it's spread to all the rural areas.”
This is partly because the governments don’t have the capacity to conduct wide-scale testing and also, for many Somalis, there is no point in getting a COVID-19 test. If you test positive, it could accompany long-term social and economic repercussions that outlast the actual risk of you transmitting the virus to others, according to humanitarian groups.
Some people are leaving home, moving to other villages where nobody knows them, if they have or are suspected of having the disease, Abdi Nur Elmi, the emergency director for Somalia and Somaliland at CARE International told Devex.
“They want to hide and go to other villages where they're not known. It continues the spread of the disease because people are not aware that they are sick,” Elmi said.
People also shame others for wearing masks, yelling out “COVID” to you as you walk by, suggesting you have the virus if you wear one, said Sadia Allin, head of mission in Somalia for Plan International.
At least 28 of Save the Children’s staff members in Somalia were infected with COVID-19, but some didn’t report their cases to the organization, said Binyam Gebru, head of health and nutrition in Somalia for the organization. A staff survey found that stigma was a key driver behind this lack of reporting.
Such stigma is compounded for people living in internal displacement camps who are often already ostracized from the host communities where they live and typically not provided access to services, including health care, Ore Ahmed said.
“It's like we are going back against the gains we have made.”— Abdikadir Ore Ahmed, health specialist, CARE International
Many women that live in displacement camps work in host communities, earning money through tasks such as washing dishes and clothes, he said. Some have lost these jobs because of fear over the spread of COVID-19.
Organizations such as CARE have worked over the years to improve the relationships between displaced populations and host communities, encouraging them to come together to share facilities.
“It's like we are going back against the gains we have made,” Ore Ahmed said
Weak health systems and impractical advice
Across Somalia and Somaliland, health systems are weak and some areas are inaccessible due to conflict. Because of this, widespread contact tracing is not happening and health facilities often don’t have emergency specialists or the right equipment to handle severe COVID-19 cases.
Across Somalia and Somaliland, there are eight polymerase chain reaction, or PCR, testing labs, six testing centers using GeneXpert machines and only 24 intensive care unit beds for critical cases of COVID-19, according to an email from the World Health Organization.
Given this, some see little benefit in knowing whether they have the disease — the chances that they would get access to quality health care if their case becomes severe are slim.
Many prevention measures are also difficult for people living in poverty or in crowded displacement camps with limited access to water. Telling people to stay home from work is also often impractical.
“It's a very hard decision to make: Do you stay at home and follow the guidance or do you go out and take a risk and see what you can do so you can feed your family at the end of the day?” asked Andrea Solomon, program director of Somalia and Somaliland for Concern Worldwide.
It is also impractical for many Somalis, who are pastoralists, to stop moving across the country and borders with their herds, said Amran Ahmed Shire, humanitarian program manager in Somaliland for CARE International, adding that this movement can also spread the virus.
A crisis among crises
COVID-19 added to a “perfect storm” of preexisting crises in Somalia and Somaliland, according to humanitarians.
This includes the worst locust outbreak Somalis have experienced in 25 years that threatens food security, floods that displaced over 650,000 people this year, and ongoing conflict. It also follows years of drought, which has contributed to the displacement of an estimated 2.6 million people. Currently, an estimated 3.5 million people can’t meet their minimum food needs. The pandemic has also weakened the flow of remittances, which many Somali families depend on.
Because of all of this, some people choose to neglect public health messages around COVID-19, feeling already overwhelmed by the multitude of existing challenges, Allin said.
“People are really tired and they don't know what to predict,” she said.
“Sometimes, when people talk about COVID, they say that they don't care about the infection. That shows despair, which is very worrying. They will tell you: Anyway, I'm dying because I don't have food.”
A key priority for humanitarian organizations in the COVID-19 response is prevention messaging.
CARE, for example, is working on awareness campaigns through television and radio stations, at health facilities, and through hygiene promoters in communities. The organization is telling people that COVID-19 can affect everybody, irrespective of economic status and regardless of religion, Ore Ahmed said.
For Save the Children, this includes holding forums through media outlets to create a two-way dialogue around the obstacles to preventing the spread of the virus.
“There are real barriers in terms of telling a community to wash hands if they don't even have water to drink, so we have to find out what those barriers are,” Gebru said.
To get access to people without radios, televisions, or internet access, humanitarian groups like Plan International are placing amplifiers on the top of cars that broadcast public health messaging, Allin said.
“They have been moving in and out and around the [internal displacement camps], telling them about hygiene promotion,” she said.
Religious gatherings should respect social distancing guidelines, take place outside when possible, and include sanitization measures, according to guidance from UNICEF and Religions for Peace.
There is also a need to get religious leaders to play a more active role in combating misconceptions around COVID-19, Gebru said. Despite warnings against mass gatherings, mosques are still open and packed with people. Some religious leaders in Somalia have also told their followers that COVID-19 does not impact Muslims, Allin said.
For those who have lost income, a significant part of the response to assist families are cash transfers, which organizations have used in Somalia in recent years to ensure that targeted families have consistent income through rough spots, such as recurring droughts.
Organizations have changed how they target and register participants, no longer using biometric registration systems because of the risk of COVID-19. For example, while CARE used to implement programs where some people worked for cash, it is now providing the cash without conditions, where people receive the money directly to their mobile phones to reduce the risk of virus transmission. It's currently serving 84,000 people, according to Elmi.
The Somali Cash Consortium recently received $5.8 million from the European Commission’s European Civil Protection and Humanitarian Aid Operations to respond to the locust crisis with cash transfers, Alessandro Bini, director of the consortium, wrote in an email.
Areas hit heavily by COVID-19 were part of the considerations when communities were targeted for the transfers, including those that have lost income. While the targeting of participants used to include home-to-home verifications, the process is now almost completely remote.