Reducing the Stigma Surrounding Mental Health in the Somali Community

This paper focuses on mental health in the Somali community. Mental health has been considered a taboo topic within the Somali community for many years. In this paper we will discuss the importance of understanding mental health and the different health issues that are common amongst the community. With the stigma surrounding mental health individuals in the community to choose to ignore their mental health issues affecting their relationships with their families. In this paper we will also discuss the importance of bringing awareness into the community and the different resources that are available to the community in order for them to receive proper health care.  This paper also discusses the different programs that exist that have tried to help the community.
Mental health does not exist on its own. It is an integral and essential part of overall health, which can be defined in at least three ways as the absence of disease, as a state of the organism that allows the full performance of all its functions or as a state of balance within oneself and between oneself and one’s physical and social environment (Bhugra, Till & Sartorius, 3). People in the community need to understand that even though they might think that they are healthy physically they also need to focus on their mental health as well. Mental health impacts other parts of their overall health as well. When mental health illnesses are ignored people tend to have a difficult time connecting with others forcing them to be isolated from their environment. Because of the traumatic experience that many Somalis’ in the community have experienced, they choose to ignore their illnesses since it isn’t visible to them.
Bringing the awareness of mental health issues into the Somali community allows people to discuss their mental health issues ending the stigma surrounding the issue, allowing people to receive proper health care services.
What is mental health
According to World Health Organization, Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make contribution to his or her community (World Health Organization, 2014). Mental health can affect a person’s daily life, relationships, and even their physical health. Mental health is away of describing how a person feels and how he or she manages to cope with their own emotions. Any severe illness of a family member creates stress for the rest of the family. The mental ill are unable to carry out a normal life pattern. Mental illness usually expresses its itself in a deviant behavior and in interpersonal difficulties causing family routines to be disrupted. Not only does mental illness remove a family member from the family it also causes change in family structure and function as a whole (John, C., Marian Y., 1955).
With many people in the community who have experienced the civil war they are prone to mental health issues. The civil war has had a huge impact on the community mentally and for some even physically.
There are two prevalent mental illnesses among the Somali refugees are Post Traumatic Stress Disorder and Depression (McCrone, P.,Stansfeld, S., Craig, T., Warfa, N., Curtis, S., Bhui, K., Mohamud, S., Thornicroft, G., 2006). A common illness that people who experience war go through is Post-traumatic stress disorder PTSD. . PTSD “is an anxiety disorder with exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following, directly experience the traumatic event, witnesses the traumatic event in person, learns that the traumatic event occurred to a close family member or close friend, or experiences first hand repeated or extreme exposure to aversive details about the traumatic event” (American Psychiatric Association, 2013). People with PTSD can experience flashbacks and exaggerated startled responses to normal stimuli (Warfa et al., 2006).
The second most prevalent mental illness in the Somali community is Depression. Depression is defined as having at least five of these nine symptoms: “irritable, decreased interest or pleasure, significant weight change, or change in appetite. Change in sleep, activity fatigue or loss of energy, guilt or worthlessness, lack of concentration, suicidality” (American Psychiatric Association, 2013).
The History of Somalia
The people of Somalia have traditionally been nomads, traveling between two main rivers as well as fishing around the coast (Warfa, et al., 2006). Around the mid-1800s, the country of Somalia has been colonized and divided by several foreign entities (Bhui et al., 2003). This included France, Great Britain, Italy, and Ethiopia. For generations, the people of Somalia have witnessed firsthand violence and wars. The violence lasted until 1991 then the civil war broke out. This civil war led to an estimated 400,000 deaths, as well as 45% of the population being displaced from their homes (Condon, 2006).

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Since the civil war began, the United Nations has reported that more than one million Somalis have left their country as refugees or asylees. Many Somalis started arriving in Minnesota in 1992 and as of 2018, Minnesota hosts one of the largest Somali communities in the Somali diaspora. In 2015, the Census data offered an estimate of 57,000. The majority of Somalis in Minnesota live in the Twin Cities metropolitan area, while others have settled in smaller towns throughout the state (MNOPEDIA, 2018). Because of the civil war families had to witness their lives torn be apart, relocated and uprooted to a foreign country forcing people to learn new languages and adapt to new cultures. Whole the culture they were adapting to new very little about their cultural and religious background. 
Even though Somali people experienced the civil war they had to deal with the stressors of relocating as well. For that reason there is a high prevalence of Post-Traumatic Stress Disorder, Depression, and Generalized Anxiety Disorder in the Minnesota Somali population (Kroll, Yusuf, & Fujiwara, 2010). With experiencing such high levels of trauma this shows that Somali families are more likely to experience higher rates of mental health symptoms. Although exposure to traumatic events increases the risk for PTSD and other mental health problems, also multiple social, cultural, and family-related resources can moderate the association ( Mulki M., Saija K. , Marja T. , Marja-Liisa., and Raija-Leena Punam P., 2017). Even though service utilization is low among children, those from refugee backgrounds may be at greater risk for mental health problems and have greater difficulty accessing services (Linda P., Hillary. B., Abdirahman Y., Francine M., & Anita R., 2014). With the difficulty of accessing services its easier for people to ignore their symptoms and minimize their mental health issues that they might experience.
Being in a foreign country stops people from receiving the proper treatment that they actually need in order to treat their mental health. People have this mindset that they are outsiders in society, so they tend to stick with the community only and with the community refusing to acknowledge mental health issues makes it difficult for people to openly discuss their mental issues. The community needs people who are trained in the health care system who also could connect with the community without feeling like an outsider who is forcing themselves into the community. The community needs someone that they could trust and rely on when it comes to their issues. With a middle-man people are more like to report their health issues and receive the proper treatments that they need.
Parenting in a foreign country
In addition, to relocating to foreign countries, parenting has changed a lot for parents after moving to a foreign country. Being that the Somali community is a collectivist society it was considered that all the adults in the community help raise a child. The adults in the community has as much say in the child’s life as much as the immediate family. Whereas in the western culture the parenting style was more focused on the immediate family raising their child. With the Somali parenting style, children are allowed to run freely since any adult of the community is a part of raising the child (Guerin et al., 2004). If an adult outside of the immediate family finds a child behaving poorly, it is not uncommon for that adult to discipline the child (Guerin et al., 2004). While in the United States of America, it would usually be considered taboo for anyone other than the immediate family to provide discipline (Warfa et al., 2006).
In Somali of the key leaders in the community were considered to be the elders. Elders were considered to be the head of the household followed by the fathers. Elders were held in high positions regarding the decision making as well as the culture keepers in the community. Whereas, today, the roles have shifted, and families don’t rely on the elders as much as people did in Somalia. Looking at my own family I could see the change in family structure compared to when my mother was younger. My grandmother would tell me stories on how family structure is different compared to today’s and how families raise their children. Ln my immediate family my father is considered to be the provider and head of the household, but nothing happens without my mother’s approval. She always has the final say but my father believes that he is in control because he was raised and taught with the idea of the man being the household leader.
Parent Child Communication
As a result of parenting in a foreign country, raising a child in the U.S. has been difficult for parents especially since the roles have shifted. Upon coming to Minnesota, the elders have been taken out of their role due to not being able to adapt to the new way of life (Jaranson, et al., 2004). Because of this, there has been a role reversal where the children are now the experts (Jaranson, et al., 2004). With children being the experts, they have used it to their advantage. Often, due to the language barrier between the adults and schools, the children will act as interpreters and withhold information, thereby leaving the parents uniformed (Ali, 2008; Jaranson, et al., 2004). With the lack of accountability and supervision, this has caused further distress in the parents as well as the children, increasing the likelihood of developing mental illness.  
Barriers to health treatment
In the Somali community there isn’t a grey area when it comes to mental health, you are either sane or insane. When people suffer from mental illness they go to elders or religious leaders in the community in order to be cured or cleansed. Even though there is a need for mental health services there is still the issue of the stigma of mental illness in the culture. The cause of mental illness to the Somali community is often believed to be associated with evil spirit (Warfa, et al., 2006; Guerin, 2004). Somalis, are a very closed net community, they do not want anyone seeing them associated with mental illness, fearing that they will be stigmatized (Warfa, et al., 2006; Guerin, 2004). Because of this strong stigma, it is very hard to reach out to this culture (Warfa, et al., 2006; Guerin, 2004). Some of the reasons that make it hard for providers to reach out is that Somali’s view on mental illness being a challenge that god gave them, and therefore being their burden to carry and pray about (Ellis et al., 2010). It is difficult for people to ask for help, asking for help can be felt as being shameful because of it being their burden to work through (Ellis et al., 2010). The last reason that makes it hard to reach out is because of the stigma and potentially being viewed by the community as insane (Guerin et al., 2004).
Support and awareness in the Community
Furthermore, some of the current supports that the Somali community are religion, family, and community-based supports. Ellis, B. H., Lincoln, A. K., Charney, M. E., Ford-Paz, R., Benson, M., & Strunin, L., (2010) report that the Somali population will first look to religion for mental health support. Being that all of the Somali population is Muslim (Warfa, 2006). This proves that the mosques and other places of worship are major supports for the population. In the study by Ellis et al., they stated that families and family-based supports are considered supports, they reported that because of the stigma around mental illness, families have been shown to shun mentally ill members of the family even though they rely on family members for support.
Lastly, support is community- based, Somalis are unlikely to seek help from mental health clinics (Bentley, 2010). Medical clinics are more utilized because in the Somali culture it is not taboo to seek help for a physical symptom since the symptoms are visible (Ellis, et al., 2010). Even though there are not many, there are a few mental health clinics that specialize in work with the Somali population, such as the ‘Somali and East African Behavioral Health Services Program’ and ‘Somali Family and Youth Services Sabathani Center’, both located in Minneapolis, Minnesota (Volunteers of America Minnesota, 2014; Healing Resources for Refugees, 2014). The problem is these programs are being underutilized due to several barriers such as stigma and language difference between care providers and people in the community.
Places such as Summit Guidance in Saint Paul, MN provides a variety of services and programs including outpatient clinics, community-based support and rehabilitative programs, hospital liaison services, intensive family services, and long-term supports. Services are available to anyone. There specialty is caring for people with severe and persistent mental illness such as schizophrenia, major depression, post-traumatic stress disorder, and bipolar disorder and other severely disabling disorders requiring resolution long term or even ongoing treatment and support.
Additionally, there are programs such as Community University Health Care Center CUHCC in Minneapolis, who have been designed to help meet the needs of the Somali community. The clinic provides a wide range of outpatient’s services to the community. The different services include psychiatric assessment, medication management, individual and group therapy.
Even though there are programs designed to help people in the Somali community it will be difficult to connect with the community as long as they don’t feel any form of connection with the care provider. Providers need to find ways to establish trust with the community and that would allow providers to get their foot into the closed community. Before health care providers could start treatment they first need to establish connection with the community
A few of the different approaches and recommendations that studies have mention are having youth engagement, training programs, specific therapy, cultural sensitivity. Youth engagement programs allows health services to help the community in the long term. Engaging with the youth from a young age allows health services to train and teach the youth about the importance of mental health. Being taught at a young age changes how young adults view mental health and how it could help them in the future. The training program allows people in the community to be trained in order to help others in the community. Training a Somali person gives providers a better chance with having someone in the community work with them or even help interpret and be the middle person between the community and health services. These training programs would be helpful to the community leader such as Imams of the mosque. The Imams play a huge role in the community and building that connections between the health services and community leaders would be beneficial when it comes to connecting with the community.
Based on the research if health care providers were to connect with the Imams of the mosque then they would have a better chance of reaching out to the community. Being that religion is a big part of the culture I believe that health care providers would have a greater opportunity in spreading the importance and understanding of mental health issues and how to deal them. Other places that health care providers could visit in order to connect with the community is at the Somali malls. The Somali malls are usually packed every day and even more on the weekends. Health care providers could visit the community within their own space to help them feel more comfortable rather than attacked and defense. 
Other places that the community gathers is local coffee shops Cedar Riverside, where many Somali people reside. The elders in the community gather around these coffee shops and I believe that if health care providers and trained Somali individuals they could talk with the elders and change their mindset about mental health as well as break the cycle of minimizing mental health that has been passed on through the generations. Visiting the community in the space that if feels comfortable in would make the journey of connecting with the community much easier.
The most common mistake that health care providers make is that they send one of their own into a community and hope to get their message across. It is very rare for a community to greet that individual and accept them immediately. I believe that it is important to have an individual from the community who has the proper training to reach out to the community. In the Somali community it would be easier to send in a trained Somali person in to the community because the community is more likely to accept that person because of the similar background that they come from. They both share similar culture and traditions and above all they speak the same language.
Mental health illness is common within the Somali community because of the traumatic experiences that they have been through escaping the civil war and witnessing the violence that comes with it.  With mental illness being invisible to people, people in the Somali community choose to ignore their symptoms and hope that they are mentally stable. Building awareness in the community helps people to open about their health issues also allowing health care services to help people in the community. It is important for health care providers to understand the different barriers that the community experiences, without being culturally competent, the practitioner could do more harm than good in trying to reach out to Somalis. The community needs to feel understood and supported from health care practitioners because they already feel like outsiders living in a foreign country. With the help of practitioner and people in the community opening up about their mental health issues it allows to reduce the stigma surrounding mental health in the community. Training the youth and individuals in the community not only does it help the community in the present but it also benefits the community in the long term. Teaching the youth at a young age what mental health is and the importance of understanding mental health issues allows them to be aware of their own and others symptoms that they might encounter. Whereas to training individuals from the community such as the elders or leaders of the mosques gives providers a higher chance of connecting with the community and spreading the awareness.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Bentley, J. (2010). Cross-cultural assessment of psychological symptoms among Somali refugees [dissertation]. Seattle Pacific University, 2011.160 Pp., , 160-160.
Bhugra, D., Till, A., & Sartorius, N. (2013). What is mental health? International Journal of Social Psychiatry,59(1), 3-4. doi:10.1177/0020764012463315
Bhui, K., Abdi, A., Abdi, M., Pereira, S., Dualeh, M., Robertson, D., et al. (2003). Traumatic events, migration characteristics and psychiatric symptoms among Somali refugees. Social Psychiatry Psychiatric Epidemiol, 38, 35-43. Retrieved from Psych Info database.
Clausen, J. A., & Yarrow, M. R. (1955). Introduction: Mental Illness and the Family. Journal of Social Issues,11(4), 3-5. doi:10.1111/j.1540-4560.1955.tb00338.x
Condon, Patrick. (2006, February 17). Minnesota leads nation in Somali immigrants. Minnesota Public Radio. Retrieved March 3rd 2014 from
Ellis, B. H., Lincoln, A. K., Charney, M. E., Ford-Paz, R., Benson, M., & Strunin, L. (2010). Mental health service utilization of Somali adolescents: Religion, community, and school as gateways to healing. Transcultural Psychiatry, 47(5), 789-811. doi:
Guerin, B., Guerin, P., Diiriye, R., & Yates, S. (2004). Somali conceptions and expectations concerning mental health: Some guidelines for mental health professionals. New Zealand Journal of Psychology 33 (2), 59-67.
Kroll, J., Yusuf, A., Fujiwara, K. (2010). Psychosis, PTSD, and depression in Somali refugees in Minnesota. Social Psychiatry and Psychiatric Epidemiology, 16(4), 265-268. doi:10.1007/s00127-010-0216-0
Jaranson, M. J., Butcher, J., Halcon, L., Johnson, R. J., Robertson, C., Savik, K., Spring, M., & Jibril,(2004) A. K.The acculturative experiences of Somali refugees living in the United States of America. Dissertation Abstracts International, B: Sciences and Engineering, , 1945-1945. Retrieved from (59959374; 200949339)
McCrone, P., Stansfeld, S. A., Craig, T., Warfa, N., Curtis, S., Bhui, K., Mohamud, S., & Thornicroft, G. (2006). Mental disorders among Somali refugees. Social Psychiatry and Psychiatric Epidemiology, 41(5), 400-0. doi:10.1007/s00127-006- 0043-5
Mental health: A state of well-being. (2014, August 15). Retrieved from
Mulki Mölsä, Saija Kuittinen, Marja Tiilikainen, Marja-Liisa Honkasalo & RaijaLeena Punamäki (2017) Mental health among older refugees: the role of trauma, discrimination, and religiousness, Aging & Mental Health, 21:8, 829-837, DOI: 10.1080/13607863.2016.1165183
Volunteers of America- Minnesota (2010). Somali and East African Behavioral Health Behavioral Services Program. Retrieved April 5, 2014, from
Warfa, N., Bhui, K., Craig, T., Curtis, S., Mohamud, S., Stansfeld, S. Thornicroft, G. (2006). Post-migration geographical mobility, mental health and health service utilization among Somali refugees in the UK: A qualitative study. Health & Place, 12(4), 503-515. doi:
Wilhide, A. (2018, February). Somali and Somali American Experiences in Minnesota. Retrieved from


Health Concerns Surrounding Smoking During Pregnancy

Maternal smoking during pregnancy is a key public health concern in the United States. There are few instances in which environment has such a large effect on development as during pregnancy, which is considered a critical period.2 Prenatal factors have a large influence on a baby’s growth and development, and can lead to health consequences that affect them for their whole lives.2

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Many women still smoke during pregnancy, despite it being well known that it puts the baby at risk of many health problems. There is a significant amount of scientific research proving the adverse effects of smoking during pregnancy, and pregnant women are discouraged from smoking while pregnant.2 However, it is reported that as many as 14% of pregnant women in the US continue smoking during pregnancy.1 Smoking during pregnancy remains the most common cause of infant illness and death, even though effective cessation methods exist.3 Public health is working toward trying to decrease the prevalence of smoking during pregnancy, but historical progress has been slow.3
The period of infant development during pregnancy has arguably the most profound influence on a person’s long term health and quality of life.2 Smoking during pregnancy can negatively influence growth and development to such an extent as to determine future health and behavior of the child.2
There is plenty of evidence proving that the effects of smoking during pregnancy increases the risk of pregnancy complications such as fetal death (spontaneous abortion), fetal growth restriction (reduced birth weight), placental complications, and premature delivery.1,2,3 Smoking also increases the risk of sudden infant death syndrome (SIDS) after birth.3 “In 2002, 5%–8% of preterm deliveries, 13%–19% of term infants with growth restriction, 5%–7% of preterm-related deaths, and 23%–34% of deaths from sudden infant death syndrome (SIDS) were attributable to prenatal smoking in the United States.” 3 Children of mothers who smoked during pregnancy also have increased risk for disease, health problems, and behavioral/ psychological issues later in life.2
There is evidence of a dose-response relationship, that increasing amount of cigarette usage is related to increased risk of defects and complications.1,2 It has been shown that nicotine crosses the placenta, and concentrations of nicotine in the baby can be as much as 15% higher than concentrations in the mother.2 There is also evidence that women who smoke during pregnancy have an increased risk of having a baby with two or more defects.1
There are a surprisingly large number of different physical birth defects that have been associated with significantly higher risk in women that smoke during pregnancy. There is a 9% increased risk associated with cardiovascular/heart birth defects.1 There is a 16% increased risk associated with musculoskeletal defects, such a limb reductions/underdevelopment.1 There is a 19% increased risk of facial defects, especially oral/facial clefts, with eye defects alone being greater than 25% increased risk.1 There is also increased risk of gastrointestinal defects and hernias.1 The most significant effects of smoking are seen in the occurrence and increased risk of limb reductions, club foot, oral clefts, eye defects, and hernias.1 There is not sufficient evidence to show an association between maternal smoking and defects of the genitourinary, respiratory, or central nervous systems, though it is possible that smoking may have some effect.1 (See Appendix B for Figure showing associations of specific defects with smoking)
In the US there are approximately 120,000 babies born each year with a birth defect, which is 3% incidence per year.1 Smoking while pregnant has been proven to be associated with significantly increased risk for a variety of defects including cardiovascular, musculoskeletal, gastrointestinal, facial, and more.1 Many of these birth defects are quite serious, result in physical and psychological illness, require several painful and expensive surgical treatments throughout the infant’s lifetime, and may still result in a disability.1 In the US the estimated total expenditures for treating birth defects was approximately $2.1 billion in 2003.1 In 2004 approximately $122 million in healthcare costs for infants were attributed to maternal smoking.3 Thus it is a significant cost on the healthcare system for women to smoke while pregnant.
Other studies have found behavioral and psychological associations between smoking during pregnancy and the child’s abilities later in life.2 One study suggests that maternal smoking negatively affects a child’s speech and language development.2 Another study found an association with decreased intelligence in the child at age 4.2 There are also several studies that suggest an association with increased externalizing disorders, such as conduct disorder and attention deficit/hyperactivity disorders (ADD/ADHD).2 Cognitive function has been shown to be adversely affected in through decreased attention span, response inhibition, memory, impulsivity, receptive language, verbal learning and design memory, problem solving, speech and language, school performance, and auditory processing.2
It is important to also keep in mind that secondhand smoke after birth also increases a baby or child’s risk for respiratory disease and infections, immune system problems like asthma and allergies, ear infections, sudden infant death syndrome (SIDS), and cancer later in life.2,3
Maternal smoking remains a common problem.2 It is reported that as many as 14% of pregnant women in the US continue smoking during pregnancy.1
For most states the prevalence of smoking hasn’t changed much over time; however from 2000 to 2010 smoking prevalence actually decreased in parts of the US.3 In a subgroup of ten states the prevalence of smoking during pregnancy decreased from 13.3% to 12.3%, and smoking after birth decreased from 18.6% to 17.2% over the 11 year period.3 Sites that showed a significant decrease in maternal smoking from 2000 to 2010 include Colorado, Illinois, Minnesota, New Jersey, New Mexico, New York, New York City, Utah, Washington, Wisconsin and Wyoming.3 New York City achieved the highest annual percentage decrease.3 Unfortunately in Louisiana, Maine, Mississippi, and West Virginia the prevalence of smoking during and after pregnancy actually increased over the time period.3 (See Figures on next page showing maternal smoking prevalence in US by time and location)
In 2010 prevalence of smoking before pregnancy ranged from 9.2% in New York City to 46.2% in West Virginia, with an average of 23.2% of women that reported smoking during the 3 months before pregnancy.3 At the time only New York City and Utah had achieved the Healthy People 2020 goal of reducing prevalence of smoking during the 3 months before pregnancy to 14%. 3

Figure 1 from Source 3 Figure 2 from Source 3
In 2010 prevalence of smoking during pregnancy ranged from 2.3% in New York City to 30.5% in West Virginia, with an average of 10.7% of women that reported smoking during the last 3 months of pregnancy.3 At the time none of sites had yet achieved the Healthy People 2020 goal of reducing prenatal smoking prevalence to 1.4%.3
In 2010 the percentage of women that had smoked but quit before the last trimester had increased significantly, especially in Illinois, Massachusetts, Michigan, and New Jersey.3 Unfortunately in Louisiana the number of women quitting smoking while pregnant actually decreased.3 In 2010 the percentage of women that quit smoking while pregnant ranged from 34.3% in West Virginia to 74.6% in New York City, with an average of 54.3% of women that reported quitting smoking during pregnancy.3 All sites with data available had achieved the Healthy People 2020 goal of increasing smoking cessation during pregnancy to 30%.3
In 2010 the prevalence of smoking after birth had decreased significantly, it ranged from 4.1% in New York City to 37.5% in West Virginia, with an average of 15.9% of women that reported smoking 4 months after delivery.3
In Iowa, from 2007 to 2012 the trend overall has been an average of a 15% decrease in women that have smoked before and during pregnancy.4 Unfortunately, despite this downward trend, there still remain 15% of women in Iowa that smoke during their first trimester, and 12% of women that smoke throughout their entire pregnancy.4 Awareness is helping, and there is now 41% of women in Iowa that smoked before pregnancy but quit while pregnant.4
Prevalence of smoking during pregnancy varies widely depending on maternal age, ethnicity, education, and health insurance coverage.1,2,3 Priorities can be highlighted based on this demographic information. In the US on average 20% of women less than 25 years old smoke while pregnant, compared with only 9% of women 35 years or older.1 Also 22% of women with less than 12 years of education smoke while pregnant, compared with only 6.5% of women with greater than 12 years of education.1 Some studies have even suggested that the percentage of women under age 20 that are smoking while pregnant has increased.2
Based on the demographic information presented in the Table in Appendix A, groups that need the most assistance are identified. It is easy to see a trend that women age 20-24, that are American Indian/Alaska Native, had 12 or less years of education, and had Medicaid coverage (low income) were more likely to smoke before, during, and after pregnancy.3 Women that were less than 20 years old, Asian/Pacific Islander, had greater than 12 years of education, and had private insurance coverage were all more likely to quit during pregnancy.3 (See Appendix A for Table showing maternal characteristics in prevalence of prenatal smoking)
Smoking during pregnancy has been a continued problem within the US. Maternal smoking has been proven to increase risk for many birth defects.1 Educational information encouraging women to quit smoking before or during pregnancy needs to be stressed.1 Educational and policy efforts also need to be targeted especially toward women under age 24, with 12 or less years of school, in lower socioeconomic groups, because they are more likely to smoke while pregnant.1,3
Efforts to reduce prevalence have only been mildly successful.3 In 2010 none of the states with data available had achieved the goal of reducing prevalence of prenatal smoking to 1.4%.3 If trends continue at the current slow rate then it could take another 100 years to reach that goal.3 Current tobacco control efforts in most states are probably not adequate to be able to reach national goals in reducing the prevalence of smoking during pregnancy.3
Appendix A
Table 2 from Source 3 –

Appendix B
Figure 1 from Source 1-
“Summary of the meta-analyses for maternal smoking in pregnancy and birth defects. The pooled ORs are shown for each body system and specific defects (total number of malformed cases in brackets). CI: confidence interval” 1


Hackshaw A, Rodeck C, Boniface S. (2011) Maternal smoking in pregnancy and birth defects: a systematic review based on 173 687 malformed cases and 11.7 million controls. Human Reproduction Update 2011; 17:589–604. doi: 10.1093/humupd/dmr022; URL:
Knopik VS, Maccani MA, Francazio S, McGeary JE. (2012). The epigenetics of maternal cigarette smoking during pregnancy and effects on child development. Development and Psychopathology 2012; 24(4):1377-1390. doi:
Tong VT, Dietz PM, Morrow B, D’Angelo DV, Farr SL, Rockhill KM, England LJ. (2013). Trends in Smoking Before, During, and After Pregnancy – Pregnancy Risk Assessment Monitoring System, United States, 40 Sites, 2000–2010. – Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) Surveillance Summaries 2013; 62(6):1-19. URL:
Muldoon, J. (2013) Percent of newborns exposed to maternal smoking, by county. IA Dept. Public Health: Vital Records and Bureau of Family Health, Div. Tobacco Use Prevention & Control, IDPH; 2013. URL:


Issues Surrounding the Interpretation of the Hominin Remains

Issues surrounding the interpretation of the hominin remains and associated cultural evidence from Liang Bua cave on the island of Flores, Indonesia

In September 2003 an archaeological excavation in the Liang Bua Cave, Flores (Figure 1) unearthed the LB1 skeleton (Brown et al. 2004). Most of the skeleton was discovered in a small area of 500 cm², with some anatomical features still articulated, no fossilization or covering of calcium carbonate was noted (Brown et al. 2004). Recovered elements included an almost complete cranium, mandible, right leg, left innominate, fragments of the vertebral column, sacrum, scapula, clavicle and ribs, femora, tibia, fibulae, patella and incomplete hands and feet, (figure 2) (Brown et al. 2004). Initial observations of the tooth eruption and pelvis indicated the LB1 skeleton to be that of an adult female (Brown et al. 2004). The LB1 holotype skeleton was identified as a new hominin species Homo Floresiensis (Brown et al. 2004).

Figure 1 Liang Bua Cave excavations 2007 (Aiello, 2010).

Figure 2 Skeleton of LB1 (Aiello, 2010).

Homo Floresiensis has been identified as a bipedal homo species, standing at 1.06 meters with an endocranial volume of 380 cm³ and found alongside advanced microblade tools (Jacob et al. 2006). Initial dating of the skeletal remains, together with remains of extinct taxa found within the same stratigraphy, provided dates of habitation from 65 to 89 kya (thousand years before present) and 86.9 to 71.5 kya (Argue et al. 2017). However, since the initial finding and publication of skeleton LB1 there has been considerable debate surrounding the interpretation thereof.

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Initial analysis of the mandible indicated that Homo Floresiensis lacked the masticatory adaptions present in Australopithecus and Paranthropus (Brown et al. 2004). Further evaluation and reconstruction of the cranium revealed that Homo Floresiensis’ cranial vault was much smaller than that of Homo Erectus, Ergaster, Georgicus and Sapien, (Brown et al. 2004). Although there were many aspects in relation to the cranium and stature that link Homo Floresiensis with that of early Australopithecines, the facial features and dental proportions are more closely linked with that of Homo Sapien-like obligate bipedalism, whilst the masticatory process resembled that of modern humans (Brown et al. 2004).  Homo Floresiensis was determined to be more closely related to Homo Erectus and which Brown et al. (2004) argued were the result of endemic dwarfing of an earlier Homo Erectus population.

In 2005 further excavation was conducted at Liang Bua, additional skeletal remains of LB1 and nine individuals were unearthed, alongside Stegodon taxa and stone tools, dated to 95-74 kyr (Morwood et al. 2005). The uppermost excavated deposit of 3.7m revealed remains of Homo Sapiens from the Holocene period, however, all remains uncovered within the Pleistocene stratigraphy were attributed to those of Homo Floresiensis (Morwood et al. 2005). In figure 3, nine unearthed individuals’ skeletal remains can be seen, however, none were as complete as the Holotype LB1. High densities of stone cores, flaking debris, retouched tools, anvils, evidence of fire and faunal remains were discovered indicating that Homo Floresiensis were capable of tool making, complex behaviours and cognition, however no pigment or symbolic items were found (Morwood et al. 2005). The adult mandible of LB6, (Figure 3), closely resembles that of LB1, however, LB6’s remains were dated to 3kyr younger than that of LB1 (Morwood et al. 2005). Morwood et al. (2005) argue these similarities and dates provide evidence that LB1 and LB6 are representatives of a small-bodied homo population upon Flores, whose features had never been recorded within the homo genus before.

Figure 3 The detailed remains of nine individuals excavated at Liang Bua cave in 2005 (Morwood et al. 2005)).

In the five years following Morwood and Brown’s initial publication of LB1, numerous arguments were published for and against a pathological explanation for LB1’s height, cranial capacity and features. Indrati (2007) noted that scientists with a broad background in modern human variation were prone to favouring the argument for a pathological variation, whereas, those within the field of palaeoanthropology favoured the ‘new species’ hypothesis.

After conducting their own reanalysis Jacob et al. (2006) concluded that LB1 was not a new species but rather an ancestor of the native Rampasasa Pygmies who now inhabit the island, albeit with developmental abnormalities, including microcephaly. With the use of CT scans, analysis of the cranium and facial features, particularly the mandible, Jacob et al. (2006) argued that LB1 had features common within 93.4 % of the current living population of Rampasasa pygmies living nearby Liang Bua Cave. LB1’s right humerus provides possible evidence of abnormal traits, the thickness in comparison to length could infer robustness, however, upon closer analysis, according to Jacob et al (2006) there is evidence of weak muscle attachment together with evidence provided by CT scans which revealed thin cortical bone with large marrow cavities. They continue to highlight evidence of abnormalities in the form of asymmetry evident within the patella and facial features (Jacob et al. 2006). Nevertheless, it should be noted that Jacob et al. (2006) began analysis on the remains of LB1 with the bias that they were that of a pathological human, and others of similar bias were invited to join in conducting this analysis (Aiello, 2010). Further tensions arose when the remains were not only returned late but damaged (Aiello, 2010).

Hershkovitz et al. (2007) provide an alternative argument to LB1’s short stature and appearance, Laron Syndrome. Hershkovitz et al. (2007) argued their hypothesis with the description of LB1’s skeleton provided by Morwood et al. (2005) and Brown et al. (2004), together with their own study of forty-six adults diagnosed with Laron Syndrome (2007:). Figure 4 shows the differences and similarities that Hershkovitz et al. (2007) used in order to construct their hypothesis. Skeletal study, with the use of CT scans, shows similar abnormality combinations within fifteen patients and those described for LB1, for example an extreme oval shaped pelvic inlet or bell-shaped thoracic cage (Hershkovitz et al. 2007). They continue to agree with the argument made by Jacob et al. (2006) that LB1 is not a unique homo but rather a member of the Sapien species, albeit within a pygmy population of heavy inbreeding resulting in abnormalities such as the mutation caused by the GH receptor found within patients with Laron Syndrome. Hershkovitz et al. (2007) end their publication stating that only DNA analysis will confirm and ultimately prove their theory. Falk et al. (2009) published their own findings in order to disprove Hershkovitz et al. (2007).

Falk et al. (2009) argue against the hypothesis of Hershkovitz et al. (2007), that of the ten key defining features assessed in patients with Laron Syndrome, LB1 shares few if any of these features. Furthermore, it is concluded that LB1 shares none of the additional features mentioned by Hershkovitz et al. (2007) such as cranial facial asymmetry, cranial bone thickness, clavicular size and shape along with numerous others (Falk et al. 2009).  Falk et al. (2009) agree that only the short stature and nondiagnostic angles of the femur are similar between the patients and LB1. However, they argue that current pathological arguments against LB1 being a smaller bodied member of the homo species do not provide adequate evidence or explanation and although open to other pathological interpretations lean towards Homo Floresiensis being a newly discovered Hominin species (Flak et al. 2009). Nevertheless, Falk et al. (2009) use endocasts, measurements and findings of others studies of LB1 and patients with Laron Syndrome to build their hypothesis.

Figure 4 Table used by Hershkovitz et al. (2007) for their comparison between LB1 and the fifteen patients with Laron Syndrome.

Stone tools found in the Stoa basin at sites Liang Bua, Mata Menge, Boa Lesla and Kobatuwa, were discovered alongside fossilized remains of Stegodon Floresnsis, Komodo Dragon, rat and other taxa (Brumm et al. 2006). Many of these sites have been dated between 840-700 kyr, of which Mata Menge holds the largest with over 570 stone tool artefacts (Figure 5), these include small-medium size flakes from cobble and flake blanks (Brumm et al. 2006). The tools were found alongside raw materials of volcanic/metovolcanic and fluvial cobbles which were obtained locally and made up 91% of the artefacts (Brumm et al. 2006). Brumm et al. (2006, 2010) highlight similarities between the tools found at both Mata Menge and Liang Bua even though they are separated by 700 kyr, these similarities include the same raw materials and emphasis of freehand reduction of cores, one difference is the discovery of heat fractured artefacts discovered only at Liang Bua. The stone tools found at Mata Menge have as yet not been associated with any skeletal remains, those found at Liang Bua cave were found alongside the nine individuals Morwood et al. (2005) discovered. Brumm et al. (2006) theorise that the similarities between the associated tools indicate a continuous technology created by the same hominin lineage. Brumm Et al. (2010) re-evaluate their argument stating that although there are some similarities between the tools found at Mata Menge and Liang Bua, there are noticeable differences. Evidence is provided in the form of technological variation more closely linked to modern humans, they conclude their analysis stating that further investigation is required to fully understand how, why and when this occurred (Brumm et al. 2010).


Figure 5  Stone artefacts from Mata Menge including Chert bifacial radial cores, Volcanic/metavolcanic bifacial radial cores, Volcanic/metavolcanic retouched flakes, Volcanic/metavolcanic cobble radial core, Chert flake, Chert flake with microwear in the form of edge rounding and edge scarring  and Volcanic/metavolcanic flake with microwear.  Scale bars are in 10-mm increments. (Brumm et al. 2006).

Further issues arise with the revision of stratigraphic dating and chronology of Liang Bua. Sutikna et al. (2016) argue that unlike previous dates, Electron Microprobe of volcanic glass, Direct AMS Radiocarbon dating of charcoal and many other forms of dating were used in order to obtain a more accurate date. Their findings indicated that Homo Floresiensis inhabited the Liang Bua from 100-60 kyr, they further argue that stone tools attributed to the species date from 190-50 kyr (Sutikna et al. 2016). However, Gagan et al. (2015) discovered a possible pit fall trap at the rear of Liang Bua cave, and 220 skeletal remains of giant rat, pigs, primates and other mammilla together with 17 stone tools were discovered within the Liang Bawah cave. These have been dated to 180 kyr and according to Gagan et al. (2015) may contain remains of Homo Floresiensis, however further excavation is required in order to confirm this hypothesis.

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In 2016 an industrial co-led excavation by Gerrit Van den Bergh discovered a molar within a partial jaw and six teeth of an adult and two juvenile Hominin species dated to 700 kyr at Mata Menge (Callaway. 2016). The newly discovered remains are suggested by Van Den Bergh et al. (2016) to be derived from Australopithecus and Homo Habilis thereby supporting the theory that Homo Floresiensis is a dwarfed descendant of early Homo Erectus. The Mata Menge remains are estimated to be smaller than those of Homo Floresiensis and are suggested as being ancestors of Homo Floresiensis (Van de Bergh et al. 2016). Further finds of stone tools found in North Flores at Sulawesi indicating other possible sites were more fossils could be unearthed (Callaway. 2016).

Issues continue to surround the interpretation of the hominin remains and associated cultural evidence found at Liang Bua cave. Post excavation skeletal damage and varnishing have distorted LB1’s and LB6’s features and can inhibit further analysis and findings. Furthermore, the bias of original excavators and those conducting analysis of LB1 can and have impacted the arguments for and against the origins and genus of the hominin remains. A key issue surrounding the remains is, as yet, there has only been one partial holotype skeleton discovered alongside fragmented skeletal remains of other individuals and possible new ancestors at Mata Menge. These fragments, however, do not provide enough evidence that the Holotype LB1 is either a member of a smaller hominin species or an individual with abnormal traits and will continue to cause debate and contention until new skeletal remains are discovered.



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Brumm,A.; Moore, M.W.; Van Den Bergh, G.D; Kurniawan, I.; Morwood, M.J. and Aziz, F. (2010). Stone technology at the Middle Pleistocene site of Mata Menge, Flores, Indonesia. Journal of Archaeological Science, 37(3), 451-473.

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A Critical Analysis of The London Stadium and Surrounding Development

In this essay I will be critically analysing the building and surrounding development of the London Stadium. I will analyse the journey the building has taken, from being the Olympic stadium to now the new home of West Ham Football club, the London Stadium.
The Olympic stadium began construction in May 2008 and ended in March 2011. It was opened on May the 5th 2012 for the London Olympics. The Stadium is located in the Olympic Park in Stratford, London, on a 40 hectare, island that resembles a diamond in the south area of the Olympic park. The site consists of factories, railways, power stations, gas works, houses and flats. The stadium was designed by Populous who are specialist in sports venues.

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The stadium is one of the most environmentally friendly Olympic stadiums ever to be built. Sustainability was an important role in the design, less steel and concrete were used on the construction, having one quarter of the steel required in comparison to Beijing’s Bird Nest Olympic stadium. The steel used in the roof was from old steel tubing in gas pipelines and Police guns. The cost of this project was £498 million which came underbudget and was completed one year early, winning many prizes even before the Olympic games had begun.

Figure 1: Layers
The design of the building was to create a compact, flexible and lightweight design embracing the phrase reduce, reuse and recycle. In terms of the design it had an elegant and light tubular white steel roof that contrasted well with the black steel that supports the upper seating tier. ‘Embracing the temporary’ was a key theory that was embraced in the design to achieve a balance between the short and long term use of the stadium. This is why the structure consisted of two parts: an elliptical sunken concrete bowl built into the ground allowing for lower seating rows. In addition, an independent structure that was comprised of the upper tier and roof, all planned to be temporary construction. One of the key forms throughout the stadium was V- shaped steel supports that act as bracing, while carrying the steel truss structure. A series of cables hold up the lightweight roof membrane and in terms of the small details bolted connections where preferred to welded connections.

Figure 2: Steel Structure

Figure 3: Section, diagram
The roof of the stadium is made up of 112 membrane sections, individual elements made up of PVC-coated polyester fabric. This allowed for a smooth, crease free layer allowing well placed openings for cables, pipes etc. The wind flow in the stadium, lighting, viewing angles, heat movement were all thought about and influenced the design to create a world class venue for athletes to perform at their best, as well as a great viewing experience.
The main features of the Olympic stadium are firstly the bowl – a sunken bowl was built into the ground to contain the field of play and was meant to bring spectators close to the action. The seats were a key part of the stadium as the idea was to have a demountable seating plan. 25,00 seats are permanent and 55,000 are demountable. The roof as shown above and described will cover two thirds of spectators. Around the stadium a fabric curtain will wrap the inside structure. This will add protection and shelter for the spectators.
Olympic legacy

A legacy plan was promised to rejuvenate the area of East London when London won. The bid to host the Olympics. Using past Olympic failures such as Athens the project wanted to redefine the site creating a vibrant new community. The 2012 Olympic games were a sporting success, but the success of the legacy is arguable. All eight permanent venues in the Olympic park are open and functional, some venues were removed. The Olympic Park now renamed to Queen Elizabeth Olympic Park is 2.5 square kilometres of parkland used well by the locals and is used for events throughout the year.
The Olympic stadiums legacy has not been fulfilled to what was imagined. Instead of being used solely for athletics, it has become the home of Premier League football team West Ham, which I will talk about in greater detail further on. The Copper Box arena has been a success and is a leading example of how to design a venue. Many events can be held in the area due to its structural flexibility unlike the Olympic stadium.

Figure 5: Queen Elizabeth Olympic Park
The Aquatics Centre has been transformed into a public swimming pool, where it has been reduced in size, but still is viewed as the world’s most impressive swimming pools. The Velodrome has been reopened an is a public venue specific to bike racing, BMX and mountain biking.
A key part of the plan was the addition of residential housing. The Athletes’ village has been converted into what’s called the East Village, where 1,439 homes out of 2,818 are affordable. Five more neighbourhoods are planned to be built where 75 per cent are designed for families and a third are going to be affordable. A new school has been built called Chobham Academy that used to be a gym and security hub during the 2012 Olympics. More plans for housing are in place as well as other functions for other spaces. Positives are that around the stadium there are new rail link and roads, Westfield shopping centre and the use of a brownfield site. The public can now travel to work easier; tourism has increased in the area as well as jobs in construction which has created a multiplier effect. The industrial zones have been replaced with landscaped greenery. Derelict rivers and canals are now functioning with many tour boats and swan shaped paddle boats.
From a general view the legacy after the Olympics has been positive but slower than expected. Using ‘Spaces in Between’ lecture there must be attention paid to the spaces around the buildings to create urban areas that are sociable, vibrant and healthy. At this present time this has not been fulfilled; many homes have been built but increasing prices and affordable targets not being met had caused many residents to move out.

Figure 6: A render of Stratford Waterfront, part of the park’s new Cultural and Education District
Looking at the legacy from an outsider’s perspective, Paris who will be hosting the 2024 Olympics have taken inspiration from the London Olympics. They will have only 3 permanent structures built. For example, “London was very inspiring to us, for sure,” and “we really wanted to have the same impact of change in the local area”, Marie Barsacq.
By looking at the Principles from CABE ‘The Councillor’s Guide to Urban design’ we can apply these principles to the Olympic project:

Character – A strong sense of place and history
Continuity & Enclosure – A place where public and private space are clearly distinguished
Quality of the public realm – A place with public spaces and routes that are lively and pleasant to use
Ease of movement – A place that is easy to get to and move through
Legibility – A place that has a clear image and is easy to understand
Adaptability – A place that can change easily
Diversity – A place with variety and mixed uses and communities

The London Stadium
Lars Lerup – ‘Accept that we will get it wrong’

‘Human action is a complicated matrix with unknowable combinations ‘
‘Our understanding of how behaviour may change is imprecise’
‘As designers we have to become comfortable with this’

Instead of becoming a dedicated athletics venue, the Olympic stadium has controversially become the home of Premier League team West Ham United. Renovation had to be done to make the stadium suitable for football, which cost £323M and subsequently reduced its capacity from 80,000 to 54,000. The original roof and light paddles were inverted, a brand new redesigned, permanent roof that covers every seat, not two thirds, in the venue was installed. The new roof also has been designed to improve the acoustics, reflecting the noise from the fans onto the pitch. Keeping the idea of demountable seating an innovative retractable seating system was installed. This allowed for the stadium to be used for athletic events, also being able to host football matches and bringing the fans closer to the pitch. New facilities where added that are needed in a football stadium that encircle the stadium. The stadium has now turnstiles at entry which were originally put away from the stadium. Now there is public access around the stadium allowing the surrounding area to be used by the community throughout the year. The roof is the largest gravity supported cantilever in the world, as well as having Europe’s largest screens.

Approximately 5,000 people worked over 2 million hours to complete the transformation. The stadium has hosted a variety of sporting events since the 2012 Olympic games e.g.: five Rugby World Cup matches, athletics events and rugby league internationals. The capacity of the new stadium is nearly double of that of Boleyn ground, West Hams old stadium.
There are many issues with the stadium that are acknowledged by various perspectives, architects, football fans, engineers etc. Some say that “The sensible decision would have been to level it and start again, but nobody had the courage”. In 2013 West Ham struck a deal to pay £15 million towards the overall renovations plus £2.5 million rent per year. Many critics believe that without West Ham taking over the stadium it would become a white elephant.
The initial cost of installing a new roof and adding in 21,00 retractable seats was £95 million. This increased to £160million then £272million and now £323million. All these expenses meant that the stadium essentially was rebuilt inside out and serious changes had to be made like the foundations.
Some major problems that have had a great effect on the fans is the:

Distances between home and away fans

The club is carrying out ways to create a bigger distance between home and away fans, to reduce friction. But one serious design problem appears unfixable– the views from the stands. ‘Athletics track in a football stadium doesn’t work, as the sight-lines are all wrong.’ It can be said that the costs of conversion could have been reduced if the original plan for legacy use had been identifies at the beginning, whereas others say designing a stadium suitable for both an Olympics and Premiership football was just simply impossible. An expert on stadium design has said that ‘The geometry needed for an Olympic Games is like a colosseum. It will never have the steeper angles that football requires to bring the crowd closer to the action.’
The architects were also adamant to retain an athletics track, despite evidence of the unsuitability of stadia configured in this way from across the world. Those who led the project were focusing on providing and delivering a spectacular Olympics in a short timeframe. All these issues could suggest that maybe West Ham FC will not remain for the full 99 year lease.
The above can be linked to the principles from ‘The Single House’ – Lars Lerup, ‘Building the Unfinished’ (1978), (from the lecture of Process not product):
From synchronic to diachronic:

Synchronic – concerned with how things fit together at one point in time
Diachronic – concerned with how things develop over time
Buildings have to be seen under a range of different timescales

Part of this lecture I found this quote relates well to this project: “A building is not something you finish, a building is something you start” (Stewart Brand) – “we should embrace adaptability, include for user expansion and learn as we go.” This is something that you would say is the complete opposite of the situation of the Olympic stadium. The stadium during matches has become almost like a theatre or a museum. The fans are so far away from the pitch and the structure of fans is not acceptable in a football stadium. The stadium cannot adapt entirely to the needs of a football stadium reiterating the idea said that ‘The sensible decision would have been to level it and start again, but nobody had the courage’. Similar opinion to Andrew Boff who says: “At the end of the day this all boils down to one political objective – and that was to keep the running track at the Olympic Stadium. If we’d said we weren’t going to keep the running track, this could all have been avoided. Instead we have hundreds of millions of pounds of taxpayer’s money being burned in front of Londoners’ eyes”.

To conclude the journey of the Stadium has been a long and rough one with many changes been put into place. This shows how architects need to a certain degree anticipate all the possible future needs of a building. The building must be able to adapt to the function needed.
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