Aug. 2, 2022

Somalis—When was the last time you thought about Ramadan when counseling? (Ahmed Ali, S1, Ep 4)

Somalis—When was the last time you thought about Ramadan when counseling? (Ahmed Ali, S1, Ep 4)

Ahmed Ali is a pharmacist by profession, one of the founders and the current executive director of the Somali Health Board (SHB), a nonprofit organization that works to address health disparities within the Somali/East African community. He is an active member within the Somali community, with emphasis on immigrant/refugee health issues both locally and abroad.

Today, in Part 1 of this conversation, we talk about

  •  the history of Somalia including the Somali Bantu population
  •  the importance of understanding important holidays in Islam like Ramadan and how to counsel patients during this time
  • the idea Ayuuto/Hagbad, sometimes translated as mutual aid, and how it has helped the Somali community thrive in Washington. 

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  • Self- Identification:  Remember that Somali people conisder Ogaden, Issas (Djibouti), North Somalia (British Somaliland), East Somalia (Italian Somalia), and the Somalis of North Kenya as one people as shown in their flag
  • Somali Bantu: Recognize that this is a historically marginalized population but well-integrated in community 


  • Displacement: Consider how a generation of displacement has affected your patient's mental health
    • Due to conflict, over 1 million people have fled to neighboring countries

Social History:

  • Religion: Remember that majority of Somalis are Sunni Muslims

  • Health Boards: Somali Health Board works to connect communities to institutions and public health. Incorporate in your plan to connect with health boards as a trusted resource for your patient.
    • For example, in the past, poor efforts made by public health have included translating swine flu to pork flu. Somali Health Board has been in the forefront to create a bridge between the community and institutions
  • Holidays & Fasting: Consider counseling about taking medications for Diabetes, GERD, Hypothyroidism during this time and how to do it
    • Ramadan (9th month of the Islamic calendar), patients will not eat for up to 30 days from sunrise to sunset. This is all able-bodied adults. Fasting can also happen as rituals or more regular outside of holidays.
  • Ayutu & Hagbad: Incorporate community support into your plan. 
    • It is an interest-free rotating savings scheme based on mutual trust.

  • Timespan: 34:32 Min
  • Transcription Type: Cleaned Verbatim
  • Speakers: 2 (Ahmad Ali & Kumara Sundar)
  • Proofreading & Formatting: Done


Ahmad Ali: It is a requirement and a commandment from God; therefore, you will see many of your patients fasting during Ramadan. As a clinician, I think it's really important to understand what that means for your patient. Is this a diabetic patient? Do you have a patient who is on thyroid medication?


Raj: Hey, everyone; welcome to the healthcare for humans podcast. The show is dedicated to exploring the history and culture of Washington's diverse communities. So, clinicians have the right knowledge to care for all patients.

This episode is about Somalis in Washington. Washington state has one of the largest Somali immigrant populations outside Minnesota in Ohio. An estimated 850,000 Somali immigrants live in the US. Washington has nearly 20% of the Somali immigrants at around 30,000 or so. This, of course, is subject to undercounting because nobody knows the exact amount due to many factors. But let's talk about Somalia as a country. Somalia is an important commercial center because of its location. It's in the Horn of Africa, with the Gulf of Aden to the north and the Indian Ocean to the east. Historically, this is the perfect location for trade routes. For example, in the 12th century, the kingdom of Mogadishu built a vast trading network and Empire. Some even considered the wealthiest and most powerful empire during that time. Unfortunately, the saint qualities made it an attractive location for many colonizers, Italy, Britain, and France.

Much of the conflict in the last century can be attributed to the legacy of European colonialism and the impact of Cold War politics. You'll hear some more about this history in today's episode. Because all this history it's led to land occupation by warlords’ displacement of its inhabitants and horrific health statistics. For instance, Somalia has the highest maternal mortality rate and the second-highest infant mortality rate in the world. After 1990, refugee assistant groups, such as the International Rescue Committee, helped resettle Somali immigrants in Washington State. Unlike many other African countries, Somalia has a largely homogenous ethnic population. What does that mean? It means most people in Somalia are Somalis, and more than 99% are Sunni Muslims. This has helped Somalis build a very tight-knit community here in Washington State. After resettling, they established businesses, religious organizations, and communication networks. Check out Runeterra News or Somali TV if you get a chance. To talk about the Somali community. We have Ahmed Ali. Ahmed Ali is a pharmacist by profession and one of the founders and the current Executive Director of the Somali Health Board. The Somali Health Board is a nonprofit organization that addresses health disparities within the Somali East African Community. He's an active member of the Somali community, emphasizing refugee health issues locally and abroad. He also serves on many boards, including the King County immigrant refugee Task Force and the Fred Hutchinson, health disparities community advisory board. And today, in part one of this conversation, we talked about the history of Somalia, including the Somali Bantu population. The importance of understanding holidays in Islam, like Ramadan, and how to counsel patients during this time. And finally, the idea of an Ayuuto or Hakbat, sometimes translated as mutual aid, and how it has helped the Somali community thrive in Washington. Here's Ahmad Ali. All right, Ahmed. Ali, welcome to the show.


Ahmad Ali: Thank you, Raj, for inviting me, and I look forward to having a good conversation with you.


Raj: Yeah, we were talking about how you're a legend in Seattle in many ways before this podcast. But I think it will be helpful as you talk about the history of Somalia because your story is deeply connected to what's been happening in Somalia. And I just have a few notes here that I will review. In the 19th century, Somalia was divided into two regions, the British colonized northern Somalia, and Italian governed southern Somalia. Until 1960 that was the case. But in 1960, Somalia gained peaceful independence and united to form the current borders of Somalia and allied with the USSR. And ten years later, around 1969, General Barr led a coop to develop the socialist military government. There was initially a lot of popular support for the government, but then it waned as the regime became more oppressive. Then around the 1970s and 80s. Local clans formed to oppose its overthrow barre, and its civil war erupted from the 1980s onward to the 1990s. And then, from 1990 to 2012, there were many transitional institutions; a permanent central government wasn't formed until 2012. Because of all the conflict, I saw that over 1 million people have fled to neighboring countries. And resettlement programs have enabled families to move to Europe and the US. And Somalis in the US live predominantly in New York, Los Angeles, DC, San Diego, and our very own Seattle. That's the background I have. And I think your story is connected to that. And I just wanted to start with that. Tell me, was there anything else we should know about the history of Somalia?


Ahmad Ali: Absolutely, Raj. You covered it extremely well, and kudos to you for doing your homework. Somalia is located in the Horn of Africa, the most eastern part of Africa. It's in a unique strategic location. And if you go way back, even before colonial times, it has seen multiple trade routes because of where it's located, the next Indian Ocean and the Red Sea. Going back to the scramble for Africa during the colonization, you're absolutely right. The British and the Italians divided Somalia into two sections but the French as well. The country known as Djibouti, now in the northern part of the Horn of Africa, is of Somali ethnic descent. So, they do speak Somali. And if I walk into Djibouti, nobody will differentiate between the person who lives there as a citizen and me. So, Somalia was divided into three different countries, or parts, by the colonialists at that time. And each of them decided to fight for their independence along the way; Southern and Northern Somalia, what's called the greatest Somalia, now formed the Republic of Somalia, which is now the country of which everyone is aware. In that context, I want to touch on the wire. There's so much conflict in that part of the world. There are a lot of interferences and foreign interferences, and it has always been that way because of the strategic location, as I've mentioned. The western part of Ethiopia is predominantly a Somali ethnic community as well. So, the Ogaden region was part of Somalia before the British gave their part to Somalia, that has also seen a conflict between Ethiopia and Somalia in the 1970s. The northeastern part of Kenya is also predominantly ethnic Somali people that live there. So, it's one thing that unites all the Somalis in that context. Suppose you ever look up the Somali flag; it's blue, with a five-sided star in the middle. It technically symbolizes all the different parts of the Horn of Africa, where the Somali ethnic community lives. It is very homogeneous in a certain way.

I’d like to cautiously use the word homogeneous because, besides the Somali language, other dialects are also spoken within southern Somalia. But the Somali language is the primary language spoken in Somalia. All practices, the same religion, have the same culture. And that's where the homogeneity comes in. Again, after the Civil War in the early 80s, late 80s, and 90s, a large number of Somali folks left the country and settled in Kenya. Some settled in Ethiopia and other parts of Western society. You're absolutely right as far as which states the Somalis have settled here in the United States. But the most significant number is in Minnesota. Over 100,000 Somalis do live in Minnesota in the Twin Cities area. Seattle is one of the other cities that has a large Somali population in the United


Raj: That's important for people to know the consequences of colonialism. Because that, I think, was one of the causes of the conflict, right, artificial drawing of the boundaries, as you're saying, even if the neighboring country has Somalis, too. We said, no, that's a different country whenever the British Italians drew up borders for Somalia. And I think it leads to the question of our responsibility as colonizing nations to take care of refugees as they come to our country. Because we were part of the problem back then. One part of the history that I also want to highlight is the Bantu population, just because it's a unique situation where from my understanding, it was about two centuries ago that enslaved people were brought in from Tanzania and Mozambique to Somalia. And in Somalia, I think there's a clan system since the Bantu population didn't fit into the clan system. They were a persecuted minority. But I think a small Bantu population is here in Seattle too. Is that right?


Ahmad Ali: That's correct. Yes, the Somali buntus are an ethnic minority in Somalia. When we think in terms of a minority, it's not the same context we look at here in the United States. It's a sizable population that lives in southern Somalia. And based on your research, many of them moved into Somalia from Tanzania, Malawi, or other parts of South Africa during this time. We can integrate into the community significantly because most of them speak the Somali language. Still, they also hold on to their own dialects and speeches from the countries they came from. There is a sizable population of Somali Bantu. We share many similarities because they live in Somalia. They are part of the community. But the only way to identify people who identify themselves as folks who look the same, have the same culture the same religion is by bloodlines. That is tribal affiliations, clans, sub-clans, and the Somali Bantu also identify themselves in that context because they have their bloodlines as well, which they go through as a form of identification. Things have changed so much since the Civil War because I think, as folks, identify that specific communities need to be protected. And I think we've learned along the way, but we bear a significant burden because many Somali Bantus were disenfranchised within Somalia. And a good number of the community lives here in Seattle. And even though there is that differentiation between Somalia and Somali Bantu, in most cases, when we see each other, we identify as Somalis, but they also speak their dialect. One of our own board of directors of the Somali Health Board is a Somali Bantu as well because we want to make sure that we are integrated and able to reach all of our communities in terms of the work we do within the organization.


Raj: Awesome. So now that we have the context for the history of Somalia and immigration here let's talk about your story. I think your story is part of Somalia's story in history. I know you grew up in refugee camps, finished schooling in Seattle, and decided you wanted to start a pharmacy. Tell me how that came about.


Ahmad Ali: I was born and raised in Somalia in 1982 before the Civil War; much like my fellow Somalis, we were impacted by the Civil War. In 1990 when the war broke out, my family decided to move to Kenya. And that is where we settled in Nairobi. I was fortunate enough to be able to attend some schooling through family connections there. My family did spend some time in the refugee camps. But I was very young at that age. I came here in 1998, and we settled here in Seattle. I did not know or ever see a place called Seattle on the map before we landed here. I think they draw a loader and determined, okay, that's where you're going. And that was waiting for my family to find peace and tranquility and live in stability finally. So, we settled in South-East Seattle in the neighborhood called Holly Park; now, it is the new Holly and South-East Seattle. That was in October 1998 when I finished high school in North Seattle, Ingram High School. That is where I completed my 10th, 11th 12th grade. In the meantime, while I was doing high school, I was really good in science and math. That's a strength that I picked up on that. At the same time, my parents, much like any other immigrant family, put a lot of emphasis on education. My parents wanted us to focus on instruction while they worked for us. My mother, bless her heart, worked extremely hard.

And interestingly enough, she never went to school herself. She'd never held a pen. I never had that opportunity, but I understood that for us to be able to do well in this society, we had to go to school and complete that. And that is a testament to many immigrant families, especially parents who understand that is a strength they need to empower their children. After graduating from high school, he went to WSU Washington University, did my undergraduate in biology, and then applied for the pharmacy program, where I obtained my doctorate in pharmacy in 2008. I have always been interested in how I make an impact within the community that I came from. So, practicing in the pharmacy field for some time, I did not want to confine myself to the four walls of the pharmacy where I see one patient talking about the medications, side effects, and so forth. Still, I wanted to have a broader impact on public health. And with that, Kim, this opportunity to work along with Phyllis want to help professionals and figure out how we organize ourselves to impact the community to make sure that the resources and the services that they're supposed to get from public health and the health institutions are supposed to serve them, actually does that? And at the same time, how do we ensure that the health system understands the challenges facing the Somali community so they can respond to them? Then 2012, 2013 is when we formed the Somali Health Board, which is on a mission and vision a liaison between the health systems of the Somali community to address health disparities facing the Somali immigrant refugees that speak the Somali language.


Raj: Yeah, that's impressive. A lot of people want to support the community. But not everybody has the idea. Well, and then the action to make it happen. So, let's dig a little deeper into the Somali Health Board. I think it's an impressive model. And we can also talk about why it needs to exist because it's supposed to be trusted Somali leaders who can reach the Somali community about different health issues, including any emergency preparedness, because public health or healthcare institutions cannot connect with them. Is that right?



Ahmad Ali: That is correct. When we initially founded the Somali Health Board, I believe many other things were happening within the larger context of public health in 2008 and 2009. There was a severe windstorm here in Pacific Northwest that there were power outages, and stuff that extended public health tried its best to make sure that communities heard about carbon monoxide poisoning. But my community was very new here in the United States. Unfortunately, there were not enough language translations that happened at that time. And there, no outreach was done for a tiny community population. And I know a lot of work was done by public health. But I think that is where the Somali Health Board and where comes in. Unfortunately, a family in Kent experienced carbon monoxide poisoning at that time because they used the stoves after the power went out. So, we did have some conversations with myself and others who initially were the brains behind the Somali Health Board just to figure out how we work with public health. How do we ensure that certain materials are translated into the Somali language? And we did that, and we had those conversations with them at that point.

The following year, a swine flu pandemic hit the country. Public health was very much alert at this point. And they did their best and translated swine flu and pork flu into the Somali language. And you can imagine what the question was, is where a lot of Somalis who are predominantly Muslim Yeah, he pork Becerra, you know, we're not going to get this vaccine because I think the context behind it is either people who eat pork or the ingredients that are made out of this vaccine is pork. So, there was a lot of hesitancy about the vaccination itself. And we went back to the drawing board again, and we decided, listen, next time, before you send anything out, please make sure that you communicate with us, you talk to us, let us review, let's make sure that we're sending to the proper channels. And that is what happened.

We started these conversations on ongoing basis quarterly meetings, basically, with King County Public Health, and the major hospitals are Harborview Swedish and some of the local clinics on quarterly basis. Bringing them to the table, and having conversations with the Somali community, what are some of the challenges facing the community? And what are some of the challenges facing the health systems and based on that, we're able to craft this model, right, whereby there is a complete dialogue between the system and the community and all the programs we've managed to establish within Somali Health Board was developed based on discussions that came from those meetings in itself. The measles outbreak was something that did take place in Minnesota. And we ensured that, knowing our community understanding that we are very much linked. A person in Seattle has folks in its WhatsApp group in Minnesota, San Diego, Somalia, and other parts of the world. So, we figured that we must ensure that families are interconnected to get the right messages. We also wanted to avoid any measles outbreak here in Seattle and Washington, DC. Because we understand that our families also move between here and Minnesota, they will travel during the summertime.

We wanted to ensure they were protecting their families and vaccinating their children. So, we took that upon ourselves. And we are excited to report that there was zero outbreak in Washington state within the Somali community, although we're very much interconnected, and families visit one another. There was an increase in terms of MMR vaccinations. And one of the things we read we often do is we don't ask Family School to vaccinate your children or get vaccinated. We ensure that we are armed with enough information to give them the proper context to understand why they need to protect themselves and their children. There has been some pushback for us to say we never got this vaccine in Somalia. And we know that's not the case. We often point to them like, “Hey, do you remember that vaccination that happened by the government?”  There are marks on the left shoulder of families who got vaccinated with certain vaccines back in the days. When you have that conversation with families, they understand, “wait a second, my parents protected me when I was younger. It's my time to make sure I protect my kids now.” And that is something I don't think any public health individual can come up with other than our own lived experiences.


Raj: Yeah. What a great example. I think this is an excellent segue to culture because you mentioned many things about the Somali Health Board or having the people in the community lead public health messaging. This is because they understand the culture of the Somali community. But one thing that stands out to me about the Somali community, as you mentioned earlier, was most people in the Somali community are Muslims. So that has a strong influence on their beliefs. But it's not just about a belief; It's a culture, a government structure, and a way of life. Most of the Muslim community here are Sunni Muslims. Right? And then there's, like, think, a small group of Sufis. I don't know if people understand that distinction. Is there anything we should know about Sunnis and Shiyas?


Ahmad Ali:. So, the majority of Somalis are Sunni. I will say probably 100% of Sunni. The Muslim sector is divided into Shia and Sunni. Predominantly in Iran and other parts of the Middle East where you'll find the Shia practicing Muslims in the rest of the particular world word Somali is our Sunni. The Sufis are considered Sunni as well, they are also Sunni, but they're more mystical. It's just a practice, and how they reach out to the community, their religion, and their faith is slightly different. And there is a sizable population of Sufi Somalis in Somalia.


Raj: Okay, I think that'll help a lot of folks. But with Islam being such a big part of the culture, I think it's important for us to understand the holidays. Let's start with Ramadan. It happens in the ninth month of the lunar calendar. So, it varies every year. But I think this year, it was from April to May. Is that correct?


Ahmad Ali: That's correct. Yes.


Raj: Tell me what it means for you to go through Ramadan.


Ahmad Ali: Ramadan is one of the five pillars of Islam. To be a Muslim, there are certain practices that you have to fulfill, and one of them is fasting during Ramadan, as you mentioned, the nine months of the Islamic calendar. And that means you are going for 30 days, 29 to 30, depending on the lunar calendar and the sightings of the moon, from sunrise to sunset. You will be going not eat or drink during that period. And this is for all able-bodied adults or those considered to be of mature age, those who are not sick. Seniors are exempt pregnant women exempt. Those who are ill are exempt as well. Travelers are also exempt. But there are some follow-ups to that. You are exempt but have to make it up if you are an adult and healthy. I think a lot of times there are a lot of contexts in terms of particularly in western society about intermittent fasting. It's not like intermittent fasting; it is abstaining from water, abstaining from drinks, any kind of drink and water and food throughout that period. It could range anywhere from 15,16, sometimes 18 hours of the day, depending on whether it's summer or not.


Raj: Summer in Seattle. Yeah.


Ahmad Ali: So, in Seattle, exactly. If the sun rises around, you know, 3 am or 4 am, that is your last meal that you're going to have. And if the sunsets at 9 pm, you will break your fast. One thing to remember is that, as a Muslim, it is a requirement. It's not a choice; it is a requirement. It is a commandment from God. Therefore, you will see a lot of your patients who actually will be fasting during Ramadan, and it's as a clinician, I think it's really important to understand what that means for your patient. Is this a diabetic patient? You have a patient who is on thyroid medication. How do you talk to him about those medications? When do we recommend that they take those medications? Those are some of the things that a practitioner needs to understand what it means during the month of Ramadan. Often, when we have this conversation with our patients at the pharmacy, depending on the type of medicine they're taking, if it's twice a day, instead of saying take two times a day, you can have that context and tell, hey take during when you break the fast and after you start the Fast. The start is when you break the fast before is when you begin Ramadan early in the morning and which is considered breakfast.


Raj: So, it's important to know that medications are not an exception. Meaning you can't take medications during the day. Is that right?


Ahmad Ali: you cannot take the medications during the daytime, which is a conversation you really need to have with your patients. I have done this and all Ramadan presentations during the quarterly meetings of the Somali Health Board. And I always encourage clinicians to think about a month before Ramadan, especially if you see a large number of Muslim patients within your clinic. A month before Ramadan, start having a conversation about what happens during the month of Ramadan. You want to make sure your diabetic patients are continuing to take their medication and continue to check their blood glucose levels. Because some of them, even though they're exempt from fasting, are very religious and will continue to fast. And you can imagine what would happen to a diabetic patient who decides not to take insulin or diabetic medications.


Ahmad Ali: Not eat all Day. Exactly right yet. The other example I'd like to give is thyroid medications. A lot of times, some people will skip the medicine. Or maybe they'll forget to take it because the doctor didn't give them enough information about when to take it during Ramadan. And they will take that after breakfast, which means you need to take this an hour or so before eating. Same thing with your reflux medications like Protonix, and all of that an hour and a half an hour before you eat. So having this conversation with some of your Muslim patients is essential and significant. It's also crucial to understand the context behind the facts. It is not for you to be hungry or on a diet. The main reason we do fast in the scriptures, as laid out, is that you need to understand how a poor person who is hungry feels. Many people who are not in that type of situation will never be able to understand what someone poor comes and says, hey, I'm hungry; can you spare some change? So, it is meant to equalize whether you are rich or poor, for folks to understand that you are sharing the food that you have. And it's a time of giving during the month of Ramadan. It's a requirement for people with a particular wealth to provide two and a half percent of their wealth during Ramadan. So, there's a lot of charity that goes on during the month of Ramadan.


Raj: Yeah, two things remind me of, I think, there's pre-Ramadan counseling, but also, sometimes I see TSH or the thyroid lab come back. And the automatic assumption from the clinician to this, or they're probably not taking it. So, I will have my staff call them to take it. But maybe we need to think about, okay, what is this patient's religion? Is it Ramadan? Is it our fault because we didn't counsel them when to take it, so they're not taking it? So that piece stands out to me. And then the second piece about fasting, I think, in America, everything becomes an individualistic endeavor. Fasting is always in the context of helping me live longer. But fasting in the context of Ramadan is to create a better humanity to understand what others go through and sometimes suffer through. Okay, so that's Ramadan, and then that's, Eid-ul-Fitr, right? That's the month after Ramadan for celebration.


Ahmad Ali: So, Eid-ul-Fitr is a celebration. It's a holiday after the end of Ramadan. It's time for families to get together, enjoy meals together, exchange gifts, and visit one another. It is a time of celebration. We also have another Eid. So, there are two Eids throughout the year. There's Eid-ul-Adha or which marks the end of Hajj or the pilgrimage. And this is when more than 3 million people meet and perform the pilgrimage in Mecca. It's also a time of celebration. It's a time of appreciation and thanks for the life that God has given us.

Meeting with families and celebrating lots of food and gifts exchanged as well. In between that, other minor smaller events do happen, not as big as both Eids that I've mentioned. They're also small, fast things for people who practice religion more to the ways it's in the scriptures. So, you would have seniors who would fast Mondays and Thursdays consistently throughout 365 days. So, it's also important that clinicians have that conversation with their patients. Because sometimes, you assume this patient eats every day, but they have been fasting every Monday and Wednesday for the last 10 or 15 years. My mother is one of them. She is healthy; she walks but fasts every Monday and Thursday. They can do that. I often tell her mom! Remind me next Thursday, and I'll fast as well. When it comes Thursday, here I have breakfast.


Raj: Maybe next Thursday.


Ahmad Ali: Yeah, maybe next Thursday. Sometimes she disciplines herself. And I think it's also important to understand that there are people who live their life like that. And in that context, as a healthcare provider, it's essential to have that conversation with the patients to understand where they are.


Raj: Yeah, yeah. Okay. Another part of the culture in the Somali community is the idea of community and family. Some people say the typical American culture is of individualism. We tried to do things by ourselves compared to other communities who wanted to support each other. So, for the Somali community, I think there's a specific thing that came up call to Ayuuto or Hackbart. Am I saying that right? I don't know if it's being followed right now. But I think that's still part of the community and culture. And this idea of mutual aid has been part of the Somali community, I feel, as far back as we can go.


Ahmad Ali: Yes, you've pronounced both of them well. Ayuuto and Hackbarth are similar depending on where northern or southern Somalia where you are. But basically, it means collectively, putting money. It's a trusted system whereby families, close members of society, or even friends, collectively collect certain funds together and support one another in different contexts. For instance, you, me, and five other individuals could decide, hey, listen; I need a car; it's $5,000. There are five of us. I need a car tomorrow because my car broke down. We will form our Ayuuto, and each of us will contribute $1,000.

I'll be the first one to get it. And because there's also that agreement, who gets it first, and who gets it last, before we even start this process. And because I am the one who's in most need now. I get the $5,000, and I will buy the vehicle I need to go to work and do what I need to do. Then in the next four or five months, I'll be paying $1,000 to the next person. It's been part of the Somali culture for as long as the Somali people have been around, and money has been exchanged. And that has always been in place. It's also a unique and trusting system that I don't think any other society has done as much as the Somali community. We're talking about people who established multimillion-dollar businesses based on the same thought process whereby people put together 10,000 /20,000 /100,000 and start their own companies. Most of the small businesses, I'll probably say 90% of that I know, started that way. Whereby not a single person has even borrowed a dime from a bank. And the other thing to remember is that because of religious restrictions, as Muslims, we cannot take certain loans with interest. So that forbids us from going to the bank and saying, hey, I'm going to buy this business, I'm going to start this business; therefore, I need to borrow $100,000 with a certain percentage of interest. Unless it says zero interest, 99 Somalis will avoid doing that. That is where the Ayuuto system comes in, people buy homes that way, interestingly, where they pull their funds together, and they purchase homes, and the next person also does the same, and so forth.


I think it brings a sense of culture and a sense of trust among the community. And the larger the funds being collected, the more trust exists within that group of individuals who will do that. And the other unique aspect is that trust doesn't just appear because I think you're a Somali individual. Other factors come into place. Subclans and clans are also a form of insurance that was by Raj, who was part of this Ayuuto flood with $20,000, then your aunt and your uncle are on the hook for this money. So, you can’t get away with it unless you want to bring shame to the family. So that's another sense of security.



Raj: Yeah, I think it's important to note that because sometimes, when we have these conversations, we talk about how we get specific communities to be more American. But it's a beautiful way of supporting each other. I mean, Ayuuto because many Americans are suffering through this national epidemic of loneliness. I know you might have heard of that. And because people are very isolated. And just having this beautiful Support Network is fantastic to witness and be part of. Thanks for joining me, Raj Sundar, in this episode of the healthcare for humans podcast. Hopefully you enjoyed today's episode. Remember to check out part two of this conversation in the next episode. Show notes and links can be found at Feel free to comment or send me a message there. You can also email me at for feedback and guest ideas. And lastly, make sure you hit the subscribe button and tell a friend. See you next time.


This podcast is intended for educational and entertainment purposes only. Views and opinions expressed in this podcast do not represent any of the participant's past, current, or future employers unless explicitly expressed, so always seek the advice of your physician or other qualified healthcare providers concerning your personal questions about medical conditions you may be experiencing. This Healthcare for Humans project is based on Duwamish land and makes a regular commitment to Real Rent Duwamish.

The transcript ends here.


Ahmed AliProfile Photo

Ahmed Ali

Ahmed Ali is a pharmacist by profession, one of the founders, and the current executive director of the Somali Health Board (SHB), a nonprofit organization that works to address health disparities within the Somali/East African community.

He is an active member of the Somali community, with an emphasis on immigrant/refugee health issues both locally and abroad. He also serves on diverse boards, including the King County Immigrant/Refugee Task Force, city of Seattle's Sweetened Beverages Community Advisory Board, as well as the Fred Hutchinson Health Disparities Community Advisory Board. Along with the SHB team, Dr. Ali is also a recipient of the 2016 Molina Healthcare’s Community Champions Award.