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This brief summarises key considerations concerning cross-border dynamics between South Sudan and the Democratic Republic of Congo (DRC) in the context of the outbreak of Ebola in North Kivu and surrounding provinces.
In light of the DRC outbreak, South Sudan began preparedness activities in August 2018 with the development of the first South Sudan National Ebola Preparedness Plan (August 2018 – March 2019) and the formation of the National Ebola Task Force (NTF) and Technical Working Groups (TWGs). Health care workers, frontline workers, community volunteers and military personnel in high risk states were trained on EVD surveillance (detection, alert and investigation), management of suspected and confirmed cases, laboratory safety procedures, safe and dignified burials, risk communication and social mobilisation, and infection prevention and control (IPC). An Emergency Operations Center (EOC) was established in Juba and a free hotline to report EVD alerts set up (with the call-in number 6666). Rapid Response Teams (RRTs) were put in place across the country and local capacity for GeneXpert testing was established. Screening points and four isolation units were set up and vaccination of frontline health workers started. i The focus of the Second EVD Preparedness Plan (April – September 2019) shifted from initial preparedness needs to active response should a single case be confirmed. Priority activities included establishing effective mechanisms for the notification of an event, public messaging on prevention and further spread, the rapid deployment of multidisciplinary RRTs, the implementation of targeted containment measures and a coherent package of activities for the operation of isolation facilities including basic maintenance, the ability to scale up the number of staff and supplies, and streamlined local control and management in the event of patient care being launched. ii In November 2018, WHO conducted an assessment of South Sudan’s overall Ebola readiness level and rated it 17% prepared. iii A more recent assessment in March 2019 found the country was 61% prepared and the WHO reported in June 2019 that 2,793 frontline health workers had received prophylactic vaccination with the Merck vaccine (rVSV-ZEBOV).
iv This brief provides details about cross-border relations, population movements, political and economic dynamics, conflict and insecurity, burial practices and trusted local actors in the borderlands of South Sudan. It was developed by Naomi Pendle (London School of Economics) and Ferenc David Marko (Small Arms Survey) with support from Ingrid Gercama, Theresa Jones and Juliet Bedford (Anthrologica). It builds on a rapid review of existing published and grey literature, long-term ethnographic research in the region, and findings from rapid fieldwork conducted at intervals between January and October 2019 that tracked key developments related to the threat of Ebola and preparedness efforts. Fieldwork was conducted by Beatrice Diko, James Eggo, Onyango Galdine, Ingrid Gercama, John Kenyi, Apayima Malitano, Ferenc David Marko and Naomi Pendle. Prior to finalisation the brief was reviewed by expert advisory colleagues from UNICEF, CDC, King’s College London, Durham University, London School of Hygiene and Tropical Medicine and London School of Economics. Responsibility for the brief lies with the Social Science in Humanitarian Action Platform (SSHAP).
Key considerations
• Borderlands: The operational context of the borderlands between South Sudan, DRC and Uganda is extremely complex and areas of the borderlands have been highly contested over time.v Since December 2013, there has been armed conflict between the South Sudan government and the armed opposition that spread into areas that border DRC and Uganda in late 2015. The recent conflict displaced over 4 million people and has been characterised by UNHCR as the fastest growing and largest refugee situation on the African continent.vi Recent fighting in the Equatorias resulted in people continuing to flee to safe areas in South Sudan, DRC and Uganda, despite the Agreement on the Resolution of Conflict In the Republic of South Sudan (R-ARCSS) that was formalised in September 2018. There has also been a broader shift in South Sudan to encourage returns and incentives have been introduced by the government and the Sudan People’s Liberation Army – In Opposition (SPLA-IO), potentially to enhance constituencies before the election that may be held in 2021. Yet, formal resettlement programmes and policies to guarantee returnees their basic needs have not been established. Building on the dynamics of humanitarian programming in these areas, Ebola preparedness efforts have the potential to become rapidly politicised and must be carefully negotiated in terms of local dynamics of power and authority.
• Population movement: The borderlands are also characterised by important historical, cultural, socio-economic and trading links. Population movement across the borderlands is significant and fluid with people moving to visit family, for economic reasons, to farm land and attend school and seek traditional and biomedical healthcare, as well as movements by internally displaced peoples (IDPs), refugees and returnees (see below). Most ‘official’ movement from South Sudan to the neighbouring countries and vice versa, goes via Uganda, although a large number of travellers also cross the border from DRC, including from Ituri Province (which at the time of writing continued to report active Ebola transmission). The borders between South Sudan, DRC and Uganda are highly porous and many travellers avoid the formal routes and crossing points, choosing instead to use panya roads (informal roads in the bush) and to cross the border at night to avoid checks and taxation. Such informal routes are also used by armed opposition groups, people trading in illicit commodities and those who fear military authorities at border posts because of recent aggressions. vii For many in the borderlands, the official demarcations that separate South Sudan and neighbouring countries are seen as an impediment to informal movement and are often inconsequential to daily life. To fully understand movement, trading patterns and the crossing points being used, it is vital that local knowledge continues to be harnessed as movement patterns are constantly in flux and tend to shift quickly in response to a variety of factors.
• Trade dynamics: Years of instability and weak governance have left South Sudan with poor domestic productive capacity and a dependency on imports of consumable goods and services. The vast majority of official imports come from neighbouring countries Uganda and Kenya, with informal trade also flowing from DRC and Sudan (cross-border trade was recently re-opened with Sudan).viii,ix Large-scale, commercial trade is predominantly through the Nimule border (bordering Uganda) although there is flourishing trade at border crossings including Lasu (bordering DRC) and Kaya (bordering Uganda, with direct road connection to DRC), whilst women traders sell their wares at the numerous smaller-scale border markets. Most informal trade with the DRC is in small goods traded from motorbikes or bicycles. Petty traders usually pay a flat rate tax per month but avoid additional customs duties unless they are stopped at a roadblock, which is why they prefer to cross border undetected. Trade dynamics between South Sudan, DRC and Uganda are a risk factor in terms of the spread of Ebola, but also provide a potential opportunity for preparedness and prevention efforts. Positive steps have been made by Ebola preparedness actors to engage with the private sector, businesses and entrepreneurial traders. This is critical, not only for their safety, but because they can access areas that many preparedness actors find difficult to work in due to insecurity dynamics, have in-depth knowledge about cross-border connectivity, and can cascade information to multiple communities.
• Health systems and care-seeking: Across South Sudan, biomedical health services are largely provided by a patchwork of international and local non-government organisations as conflict and economic decline have continued to erode basic governmentsupported healthcare delivery.x Crossing the border between South Sudan, DRC and Uganda to seek healthcare is common, particularly by those who do not have access to formal biomedical care in the areas they live.xi A proportion of people who cross into South Sudan are known to continue their travel onwards to Uganda as it is perceived, in general, to have a significantly stronger and more developed health system than both South Sudan and DRC (although in reality some border areas of Uganda still have weak health infrastructure). xii Those who cannot afford biomedical care in South Sudan may also cross into DRC to access non-biomedical healthcare. As such, finding the ‘best available’ local solutions to the challenges of Infection Prevention Control (IPC) and access to basic care must be done collaboratively at the community level and with health workers. Communities and local healthcare workers often have pragmatic solutions for overcoming barriers during an emergency situation, and these should continue to be developed and supported. Local sources of care (pharmacists, spiritual and other kinds of healers) should be more purposively included in Ebola preparedness efforts as they are often the first point of contact for many people. Women are usually the primary carers at the household level and specific efforts should be made in providing them with basic training particularly in terms of IPC for homecare and identification of symptoms. Communities should continue to be supported in making rapid alerts to health workers or via the Ebola hotline, and in the promotion of early presentation at health facilities.
• Localised response: South Sudan has faced repeated social rupture and readjustments, and the population’s ability and willingness to adapt behaviours and customary practices to save lives should not be underestimated. To align with this opportunity, Ebola preparedness strategies must continue to focus on strengthening local trust and access, working collaboratively with South Sudanese organisations including the church and other faith-based groups, women’s groups, youth associations and media, in particular community and church radio which has wide coverage. Preparedness actors should also consider further developing working relationships with opposition forces and armed actors in key opposition-controlled territories where the government does not have access or legitimacy to engage at-risk and affected populations, although it is well acknowledged that this has security implications. Local actors should continue to be adequately supported in terms of technical capacity and resources (including appropriate remuneration) and more vertical interventions that focus on Ebola readiness must be aligned with longer-term humanitarian principles and ongoing health-system strengthening.
• Community-based surveillance: Between August 2018 and March 2019, 900 health care workers, frontline workers, health volunteers and military personnel in high risk states were trained by the government and partners on EVD surveillance including detection, investigation and the management of suspected and confirmed cases.xiii There remains a critical need for refresher training, ongoing capacity building and the need to more fully integrate disease surveillance activities with routine health monitoring if local populations are to continue seeing the relevance of such activities. Given the porous nature of the border areas, the associated challenges of formal screening measures and the fact that oversight of cross-border movement is limited due to the use of panya roads, community-led surveillance should be a critical component of all preparedness activities and linked to existing communication strategies.
• Armed and state actors: Collaborating with armed personnel in preparedness efforts in South Sudan (pro-government state forces, militia and organised forces including police and fire services, prison guards and wildlife personnel) must be considered with caution. Although some armed actors have already had roles in preparedness activities, in the case of a confirmed Ebola event, armed actors should not be used to ‘track down’ suspected Ebola cases or be involved in contact tracing efforts, particularly in territory formerly held by the SPLA-IO, National Salvation Front (NAS), or other militias. The involvement of armed actors and other security personal in critical Ebola response interventions such as contact tracing and burials could undermine trust at the local level and elevate concerns (as in the DRC) that Ebola is a ‘weapon of war’ and used by the government to coerce, control, displace and monitor affected populations.
• Burial practices: Given the differences in customary burial practices between various population and ethnic groups, it is critical that these are locally assessed in great detail through consultations with chiefs and other figures of authority and at the local level.
There are precedents to adapting burial and funeral practices in South Sudan, particularly during times of conflict, and people are likely to be responsive to temporarily changing practices in the context of Ebola if adaptations are carefully and sensitively negotiated by skilled facilitators. Standard operating procedures for safe and dignified burials must be adapted to granular local contexts and community personnel who are usually involved in burials must be fully engaged. Time and resources spent agreeing changes in burial practices during the preparedness phase and prior to an event will be a valuable investment. Involving the army or other security actors during safe and dignified burials should be avoided at all times.
• Communication: Communication materials and engagement efforts related to Ebola preparedness must continue to be tailored to specific stakeholder groups and be gender sensitive. Many people, in particular women in cross-border areas have low literacy rates and may prefer inter-personal communication methods, making use of creative methods including theatre or video. Given the wide range of languages spoken across the cross border areas there is also a need for further assessment and mapping of the most appropriate and relevant languages to use when engaging different target groups and when using various modes of engagement (e.g., interpersonal methods, radio, printed materials). Two-way engagement has been shown to create a sense of trust and shared ownership, and to mitigate misinformation. Ebola messages should continue to evolve as local-level awareness and knowledge on Ebola grows. Populations engaged in cross-border areas are already calling for more detailed and tailored information on treatment, survival rates and the Ebola vaccine (particularly inclusion / exclusion criteria) and this should be interpreted positively. It is also critical that messaging should continue to be orientated away from ‘Ebola is a deadly and dangerous disease’, towards reaffirming constructive messaging that focuses on the high chance of survival if a patient presents quickly for early treatment.