: Somalia’s forgotten minorities

My name is John  and I am the Minority Rights Groups’ Executive Director. By way of an introduction to this report, I feel a bit of context for why we undertook the research project would help proceedings. In short, Somalia’s minorities have been comprehensively forgotten both domestically and on a wider international stage. Indeed, all Somalis have been forgotten.

 NGOs have failed Somalia, and the international community retains the cynical perception that the country is little more than a ‘security issue’. These same international organisations have failed in addressing the wider and pressing issues facing this complex issue. Somalia itself is dominated by four ‘majority’ clans that are often referred to as ‘nobles’. These are the Hawiye, Darod, Dir and Rahanweyn. These family clans tend to control Somalia’s politics and economics since independence. The majorities’ over-arching powers cast a long shadow over the rights of the minorities.

 Somalia has always had a very diverse population of minorities. The three largest groups of minorities are the Bantu, Benadiri and Occupational Groups. The Bantu are farmers and were traditionally subjugated by the Arab slave-trade – they are often the victims of land grabs. The Benadiri live on the coast and are mercantile people. They were migrants from all over the Gulf and used to have a sizeable population in Somalia (at one time, they comprised of half the population of Mogadishu). Finally, the Occupational Groups (or caste groups as they’re sometimes known) represent the lowest rung in the socio-economic strata. They especially suffer from a lack of official protection. 

If you’d like to understand the extent to which Somali minorities are marginalised on an international level, you need look no further than the latest International Crisis Group’s latest Somali report, in which the plight of minorities has been wholly omitted. This should come as little surprise to many in the field. After all, the false myth of demographic homogeneity within Somali society is prevalent. It is the purpose of this report to challenge this misconception about the people that make up Somalia. It is not a pastoralist society, but a plural and heterogeneous one. It might be dominated by pastoralist clans, but this is neither here nor there. 

The minority groups within Somalia are an invisible, forgotten people and lack basic access to redress and justice. There is a traditional Somali saying that indicates the historical practice of prejudice within this troubled country: ‘No one will weep for me’. Despite this backdrop of discrimination, there remains a few opportunities for real positive change. As already addressed, our methodology throughout the project was adopting a qualitative approach towards collecting data. Our male and female research team collected some vivid testimonies. We wanted to ensure that our project was not purely based on figures. Ideally, this project would represent a turning point in the normative sense: it was supposed to encourage minority groups to research their own heritage and, as such, compelling them to undertake a greater level of activism. 

The marginalised minorities come from varied backgrounds and have retained their social differences. It is estimated that up to 3 million Somalis fall in to the minorities demographic. Despite their retention of their traditional cultures, there is a large body of evidence to suggest that integration with local clans has been fairly prevalent. Fraternisation with the ‘nobility’ is still frowned upon though and, in some cases, it’s illegal. To develop on the different minority groups as outlined before, a greater indepth analysis of these groups is required:

  Bantu were traditionally from slave communities have maintained many of their socio-cultural institutions and languages despite attempts to repress its peoples. After opportunities afforded unto them with the economic upturn after the 1969 coup, Bantu were granted greater access to state schooling and employment, and they keenly pursued jobs in agricultural development and trade. Despite these developments, the Bantu still suffer at the hands of warlords’ armed militias and agrarian subsistence. 

 The Benadiri built Mogadishu and were instrumental in spreading Islam across Somalia. They traded abroad as well as inland with the pastoralists. They are chiefly based on the Benadir coastlines of Somalia. Benadiri are proud of their cultural heritage and regularly practice Sufi studies and speak in their Swahili dialect. In the early 1990s, warlords’ forces pillaged Benadiri lands and used rape prolifically as a weapon of war – the results of which was a massacre. Food aid from international organisations was diverted and large proportions of their population have fled to neighbouring countries. 

 Occupational Groups could be compared with the untouchables of India – although the use of the term ‘caste’ is only partly useful in describing their heterogeneous nature. They are primarily craftspeople and artists and can be split in to three main groups: the Midgan (aka Gaboye), the Tumal and the Yibro. The Midgan were traditionally hunters and leatherworkers but have also undertaken crafts: use of the term Gaboye in Somaliland is generally considered offensive. The Tumal are chiefly ironworkers and blacksmiths by trade and the Yibro make their living mainly through soothsaying and astrology. 

 Ashraf and Shekhal are two religious Islamic minority groups that often provide warring parties with forums in which to discuss matters peacefully. They are seen as major regional players in conflict resolution. They also suffer at the hands of the pastoralists due to their lack of an armed militia to support them.

It should be emphasised that the three regions within Somalia (Somaliland, Puntland and South Central Somalia) treat their minorities in different ways. Somaliland has provided the most rapidly progressive region in advancing minorities’ rights but educational discrimination and objections to intermarriage are still major barriers facing these causes. Minorities in Puntland are regularly internally displaced by pastoralist communities, lack effective avenues for justice and minority women in particular are subjected to genderbased violence. The situation for minorities in South Central Somalia is the most fraught, with the ongoing conflict causing wide-ranging human rights abuses across the region

What is pain?

Pain is an unpleasant sensory and emotional experience. No two people feel pain the same way, even if the reasons for their pain are alike. Pain is a highly personal experience and a person’s report of their own pain is the best measure. Pain can feel mild or severe. Pain can include pricking, tingling, stinging, burning, shooting, aching, or electric sensations.

Pain is among the most important signals our body gives to help us survive. Pain can alert us to harmful changes in the body, like cancer, or help us learn to avoid something harmful, like touching a hot stove. In this way, some forms of pain keep us safe.

In other cases, pain exists or continues without any known cause or benefit. Pain that continues for longer than three months is called chronic pain. Chronic pain can happen without a known cause and persist after an injury or known cause is resolved. It can affect a person’s mood, relationships, movement, and all aspects of daily life. Pain can make it harder to do necessary tasks, work, and enjoy activities.

Patterns and types of pain

There are three primary patterns of pain, which are named based on how long the pain lasts and its frequency.

1. Acute pain starts suddenly and ends when its cause is treated or healed. The feeling of acute pain is usually sharp because it tends to act as a warning signal about a threat to the body 

2. Episodic pain happens from time to time 

3. Chronic pain lasts for longer than three months or the expected healing time. 

1. Nociceptive pain describes pain that is caused by tissue damage and/or inflammation. The sensation can be sharp, pricking, dull, or aching, depending on what caused the damage or inflammation.

2. Neuropathic pain describes pain that is caused by nerve damage due to an injury or disease. 

3. Nociplastic pain describes pain that is caused by changes in how the nervous system processes pain. 

What causes pain?

There is still much to learn about how and why people feel pain in different ways. Acute pain with an obvious cause (an infection or broken bone, for example) is much better understood than chronic pain. Research shows that factors and changes in the body (biological), the mind (psychological), and a person’s experiences with others along with the conditions in their environment (social) are all contributors to an individual’s experience of pain. For this reason, pain is known as a biopsychosocial experience.

Biological factors associated with pain include things like brain function and genetics. Psychological factors are things like mood and stress. Social factors include things like having (or not having) a support system or experiencing biased care. Each set of factors affects and impacts one another. Therefore, treatment for pain is both complex and individual. 

Biological factors of pain

Many different biological factors are involved in the experience of pain, including the type of injury to the body, genetics and epigenetics, the nervous system, the immune system, and the endocrine system.   

Genetics and epigenetics of pain

Each of us is born with a set of genes that we inherit from our parents. However, daily life stressors, lifestyle habits, and medical conditions influence which genes turn on or off over a person’s lifetime. This is the difference between genetics, or the study of genes and heredity, and epigenetics, or the study of how the environment and behaviors change how genes work.

Many genes play roles in how a person feels pain, their risk for developing chronic pain, and how well they respond to pain treatments. This risk comes from genes that control the function of body systems involved in pain and relief. It can also come from genes linked with medical conditions that cause pain. For example, some causes of back pain, such as ankylosing spondylitis (a form of arthritis that affects the spine), have a genetic component. Although genetics might put someone at risk, epigenetics can influence whether that risk becomes a reality.

Previous research, for example, has shown that epigenetic changes following regular physical activity are linked with positive changes in a person’s pain experience. Other research has shown that intense emotional stress can cause epigenetic changes in pain-related genes that lead to worse pain outcomes. Newer research is helping us understand how experiences of long-term stress due to social factors like neighborhood, access to healthy food and good medical care, and other social determinants of health contribute to consistent group differences (called disparities) in pain, such as by race/ethnicity, sexual and gender identity, and socioeconomic status.  

Pain and the nervous system

The human nervous system is made up of two main parts: the central nervous system and the peripheral nervous system.

The central nervous system includes the nerve cells that make up the brain and spinal cord. Brain systems involved in the experience of pain overlap with systems involved in the experience of emotions like fear, anxiety and anger, reward and motivation, attention and memory, and sensation. There are also brain systems that contribute to relief from pain. Research shows that changes in these brain systems might contribute to chronic pain risk.  

The peripheral nervous system includes nerve cells that start in the spinal cord and extend out to other body parts. These nerve cells carry information between organs/muscles and the spinal cord, which links the information to the central nervous system.

Peripheral sensitization and central sensitization are terms to describe changes in the peripheral and central nervous systems that make a person more sensitive to pain and other sensations. These changes are one way some people develop chronic pain after an injury has resolved.

Symptoms of nervous system sensitization

Hyperalgesia happens when something that is already painful to a person begins to feel even more painful to that person. Allodynia is the term for when something that previously was not painful to a person begins to feel painful. For example, a person might experience allodynia when light touches feel painful on sunburned skin. Global sensory hyperresponsiveness means the person is very sensitive to many or all sensations, including lights, noises, smells, and foods.

Pain and the immune system

The immune system helps protect the body from outside invaders, like bacteria and viruses, to avoid potential infection. One way the immune system provides protection is through inflammation. Inflammation is a reaction that happens when tissues are injured and damaged cells release chemicals that cause swelling and attract immune cells to “eat” the dead or damaged cells. This process helps with healing.    

In some cases, the immune system is overprotective, and inflammation lasts longer than the expected healing time. This overprotection can backfire and contribute to more and longer lasting pain. Another way that the immune system can be overprotective is called autoimmunity, which happens when the body’s immune system attacks healthy cells. Some autoimmune conditions cause chronic inflammation and pain. 

The endocrine system

The endocrine system is responsible for making hormones, which are a type of chemical messenger that carries instructions throughout the body. Stress-related hormones like cortisol and adrenaline can send messages that make the feeling of pain more intense or less intense. This is partly why finding helpful ways of coping with stress can help lower pain intensity. Additionally, research shows that chronic pain may lead to changes in the way the endocrine system functions over time. 

Psychological factors that contribute to pain

Fear and avoidance

Imagine this scenario: Jason injured his back while lifting a box at work. His healthcare provider tells him not to lift heavy things for a few months to heal.  But after Jason’s back feels better and he is cleared to return to regular activities, he is still worried about re-injuring his back. This is an understandable fear. But this avoidance of lifting things has been affecting Jason’s work and home life. He also avoids doing his physical therapy exercises, making his muscles weaker over time. His mood and stress levels are also affected.   

This scenario is an example of the fear-avoidance model of pain. Although fear and avoidance can help protect a person from dangerous situations, they can also hinder recovery from acute pain and play a role in the transition to chronic pain. Avoidance also contributes to disability and often stops a person from doing the things they enjoyed before the pain started, which can affect a person’s mental health.

Emotions, mood, and mental health

It is common for pain, especially chronic pain, to affect a person’s emotions and mood. For example, many people with chronic pain describe times when they feel anger, worry, sadness, guilt, grief, defeat, hopelessness, frustration, depression, or anxiety because of their pain.

While pain can influence a person’s mood, emotions, and mental health, those factors can also influence a person’s experience of pain. This exchange happens partly because the brain systems involved in emotions, mood, some mental health conditions, and pain overlap. Research shows that major depression, generalized anxiety disorder, post-traumatic stress disorder (PTSD), and sleep problems commonly co-occur with chronic pain. Getting necessary support to help manage the emotions, moods, and mental health conditions that co-occur with pain has been shown to improve chronic pain symptoms, such as muscle tension.           

Resilience

Resilience reflects a person’s ability to bounce back from and adapt to life’s challenges, such as living with chronic pain. Being resilient does not mean a person is free from worries, anxiety, sadness, anger, or grief about their pain. These emotions are normal and understandable responses to the experience of living with pain. Instead, being resilient means using personal strengths to adapt to the challenges of pain. Examples are a person’s social supports and community, ability to solve problems, humor, use of coping strategies (e.g., deep breathing, prayer), and activities that bring more joy to their life.

Resilience is not something a person is born with or without. Resilience is easier on some days than others and can be built and strengthened with support and practice.  

Beliefs and thoughts about pain

Research shows that beliefs and thoughts about pain also affect a person’s experience of pain. There are some common thinking styles that co-occur with chronic pain. They often happen so naturally that they are called “automatic” thoughts.

• Ongoing concerns about pain: There are many of unknowns when living with chronic pain. Will it ever go away? Will it get worse? These kinds of normal concerns can lead to hopelessness, anxiety, and depression when they continue for a long time.

• “Should” statements: Pain can change the way a person lives their life, causing them to reduce or even stop some activities. Sometimes, a person might feel pressure to live life in the same way they did before. One might experience thoughts that could cause feelings of frustration, anger, and disappointment when expectations don’t align with reality (for example, “I should still be able to do this perfectly,” or “My pain should get better right away.”).

• Self-blame: If chronic pain starts after an accident or a medical condition, a person might blame themselves for the pain being triggered (for example, “If only I hadn’t driven to work that morning,”). But, predicting an accident or the onset of a medical condition is often outside of a person’s control.

These beliefs and thinking styles don’t just come out of thin air. They come from a person’s previous experiences and can be a normal reaction to difficult circumstances. However, they can lead to negative emotions and increase pain symptoms. Getting necessary support to figure out which pain beliefs are helpful, and which might not currently apply or might get in the way of recovery, has been shown to improve chronic pain symptoms.                 

Social factors that contribute to pain

The social determinants of health include the quality of the environments where people are born, live, learn, work, play, worship, and grow older that affect health outcomes. They also include the wider set of policies and systems that shape the conditions of daily life. Some examples of social determinants of health include economic stability, access to quality education and healthcare, living in neighborhoods with safe places to walk, and having close relationships.

According to the U.S. Centers for Disease Control and Prevention, the wider set of policies and systems include economic policies, development agendas, social norms, social policies, racism, climate change, and political systems. These can affect racial and ethnic, sexual and gender minority, and lower socioeconomic groups in unjust ways. Unjust differences in health are known as health inequities. For example, Black and Native Americans are more likely to have chronic pain that interferes with major daily activities yet are less likely to be referred for specialty pain services than non-Hispanic White Americans.

Compared to our understanding of the biological and psychological factors involved in the experience of pain, less is known about the role of the social determinants of health. New research in this area is ongoing and will help address inequities in pain and pain care.   

How is pain diagnosed and treated?

Diagnosing pain

Pain is a subjective experience, meaning only the person experiencing pain can describe how much pain they feel and how it impacts their life. Research efforts are ongoing to find biological markers that can help clinicians diagnose why a person is experiencing pain. After learning about a person’s pain history and other medical concerns, a healthcare provider may conduct physical exams, clinical assessments, and order diagnostic tests and imaging to diagnose or rule out conditions causing or associated with pain.  

Healthcare providers can use the following tools to help identify the cause of pain, including but not limited to:

• Physical and neurological examinations are one of the first steps in diagnosing the cause of a person’s pain. In these exams, the doctor tests movement, reflexes, sensation, balance, and coordination. Physical examination can also detect areas of inflammation, joint or other swelling, and poor circulation.

• Laboratory tests (e.g., blood, urine, and cerebrospinal fluid) can help the doctor diagnose infection, cancer, problems with a person’s nutrition or hormones, and other conditions that may cause pain.

• Imaging, especially MRI (magnetic resonance imaging ) and CT (computer assisted tomography) scans or ultrasound can provide a look inside the body's structures and tissues.  Other examinations for particular types of pain may include tests that look into the digestive system or pelvic area like endoscopy, colonoscopy, or laparoscopy.

• Electrodiagnostic procedures like nerve conduction studies and electromyography and electrocardiography can also help identify and diagnose causes of pain and pain-related conditions.

• Psychological assessments can help identify psychological factors that might be contributing to pain and provide coping strategies.

Treating pain

The goal of pain management is to improve quality of life and function—allowing the person to work, attend school, and participate in daily activities. Treatment options will vary depending on the type of pain, its duration, and the person’s access to care.

The biopsychosocial approach explained above is the best way to prevent, assess, and treat chronic pain. This approach uses an interdisciplinary team of healthcare specialists to help meet a person’s health and pain goals. Pain management teams may include pain management specialists, specialists on any other medical conditions the person may have, nurses, mental healthcare providers, physical or occupational therapists, complementary or integrative healthcare providers, and/or social workers.

While not all pain is curable, all pain can be managed. No current treatments have been proven effective in treating all types of pain or in every person. People living with pain should work with their healthcare team to decide which treatments might be best for them. Common forms of pain management include medications, medical procedures and devices, and behavioral approaches along with physical therapy, lifestyle changes, and complementary health approaches. These treatments are often combined to try to optimize care for an individual.

Medications and substances to treat pain

Medications to treat pain include analgesics, such as common pain medications like acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen, and prescription opioids. Antiseizure and antidepressant medications can also help relieve pain for some people and may be most effective for neuropathic pain. Muscle relaxants are prescribed to reduce tension in muscles and can help manage musculoskeletal pain. Some topical pain creams and gels are also available to help with muscle and joint pain. Some people use cannabis to help treat their pain. Studies are ongoing to learn about its safety and effectiveness for pain.

Medical procedures and devices

Electrical stimulation of nerves or soft tissue is effective for treating pain in some people. There are several devices and procedures that provide electrical stimulation to relieve pain, including:

• TENS (transcutaneous electrical nerve stimulation), which delivers low electrical pulses through the skin to the nerve fibers to help relieve pain for a short time.

• Peripheral nerve stimulation, in which electrodes are placed under the skin near peripheral nerves where a person experiences pain. Low intensity electrical pulses are sent to the nerve site.

• Spinal cord stimulation, in which electrodes are placed under the skin to send electrical pulses to the spinal cord.

Doctors may suggest injections to block pain that is in a specific area of the body. This may include steroid injections to reduce inflammation and immune system activity, botulinum toxin (commonly known as Botox®) for chronic migraines, or trigger point injections to help relieve pain caused by knots in muscles and surrounding tissues.

Other procedures that may help relieve pain for some people include nerve blocks, radiofrequency ablation, and surgery.

• Nerve blocks use a local anesthetic to temporarily interrupt the relay of pain messages between specific areas of the body and the brain. An epidural is a common nerve block used to treat pain during childbirth.

• Radiofrequency ablation uses a radio wave to heat up and destroy a small area of nerve tissue to stop pain signals to the brain.

• Surgery may be helpful for cases when pain is caused by something that can be fixed with surgery, such as endometriosis lesions in the pelvis, a tumor, or joint arthritis.

Behavioral medicine and physical therapy

Several behavioral and physical therapies have been found effective for treating pain in some people. These include:

• Biofeedback, which helps people learn how to control body functions involved in stress reactions (heart rate, breathing rate, and muscle tension).

• Cognitive-behavioral therapy, a form of talk therapy, helps individuals build skills to cope with the emotional toll of having pain and any associated mental health conditions. These skills may include scheduling daily activities and building sleep routines, addressing thoughts and emotions that can increase pain, relaxation strategies, and mindfulness techniques.

• Counseling, which can help support people living with pain through difficult times.

• Physical therapy, which can help a person recover after injury or surgery and manage chronic pain. This can include physical activity like low-impact cardio, mobility, flexibility, and strength training.

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