Debating Ideas is a new section that aims to reflect the values and editorial ethos of the African Arguments book series, publishing engaged, often radical, scholarship, original and activist writing from within the African continent and beyond. It will offer debates and engagements, contexts and controversies, and reviews and responses flowing from the African Arguments books.

Discussing RVI Community Approaches to Epidemics Management in South Sudan report with a group of traditional leaders, traditional birth attendants, herbalists and local health workers at Majok village

South Sudan had just emerged from its second wave of Covid-19. The official statistics of Covid infection in the country now stand at 10,891 cases with 117 deaths – but the actual numbers of infections and deaths from Covid might be higher, given the authorities’ limited capacity to conduct tests across the country. The first case in South Sudan was confirmed on 5 April 2020 at a time when the country was already crippled with both economic and health crises (Kindersley and Majok 2019; Thomas 2019; Kindersley et al. 2020). The South Sudan government’s response – following other regional African countries’ governments issuing a decree on national TV – was to initially impose a partial lockdown; suspending both international and inter-state flights, banning gatherings and closing international borders (Craze and Pendle 2020).

On 28 April 2020, as confirmed Covid-19 cases increased, Dr Riek Machar, who just returned from rebellion and was leading the national taskforce on Covid-19, imposed authoritative restrictions on free movement within the cities or between towns and the rural areas; an order that was enforced by state security apparatus. These further restrictions closed down markets, schools, public institutions, and local bars, tea and shisha stalls, to fight and stop the spread of the virus (Craze and Pendle 2020; Kindersley et al. 2020; Bank 2021). This top-down approach, which adopts South-East Asia’s complete lockdown model seen in China and in neighbouring countries like Kenya which entered lockdown before South Sudan, requires effective economic and health structures to then respond to any infections and disruption of livelihoods at the grassroots (Kindersley et al. 2020).

The South Sudan government was fully aware of the country’s fragmented health system and its inability to fight such a deadly global pandemic and therefore opted for a complete lockdown strategy, halting movements and contacts between Juba and the states as the only means at hand to curb the virus from spreading to rural areas – where economic and health conditions are far worse compared to Juba. As a result of the government’s preferred pandemic response policy strategy, the poor majority, especially in the rural areas – whom the government ought to protect – were suddenly faced with food shortages because their livelihoods are dependent on daily markets and long-distance trading, and were already suffering from other endemic diseases. As a country with its health system in crisis, many people in South Sudan found the lockdown conditions more devastating than the virus itself (Craze and Pendle 2020). Without government support for the affected poor in the form of public health and economic support campaigns, international health NGOs and faith-based groups stepped in and attempted to conduct individual case-by-case Covid messaging, provide food assistance to poor households and medical support to the few operational health facilities in the rural areas. These measures continued to fall short of supporting the economic and social security needs of the impoverished vast majority of the population facing market and trade lockdown. The lockdown further compounded the state of South Sudan’s fragmented healthcare systems (Kindersley et al. 2020).

South Sudan’s fragmented health systems

South Sudan’s clinical healthcare system is fragmented and fragile. The country’s formal clinical healthcare largely relies on community health workers with some basic training, primary healthcare units scattered in rural areas operated at county headquarter level, and a few hospitals situated in towns. According to Gilmartin, Collins and Driwale (2020), there were a total of 1,893 health facilities across the country in 2019, of which 419 were classed as ‘non-functional’ while the function of the remaining 955 was undermined due to a shortage of trained health personnel, drug supply and underpaid or delayed salaries (ibid.). A survey by the Global Health Workforce Alliance (2019) concludes that an estimated one trained doctor exists for 65,000 people while one trained mid-wife covers 39,000 maternal cases. Almost half of the country’s population do not have access to clinical healthcare services, and 70% of those with access to clinical health services are more than an hour’s walk away from a health facility – more so in the rural areas where the majority of the population resides. Over 70% of the medical, financial and logistical support to those semi- or fully-operational health facilities across the country is provided by aid agencies and church charities, with a few privately owned pharmaceutical stores (WHO Annual Report 2019).

The health sector crisis in South Sudan is exacerbated by political violence and civil war that started in 2013, which saw government funding shifted to the security sector. The continuing inflation that hit the country from 2015 rose to over 600% by 2016 (Thomas 2019), aggravating poverty and a worsening health condition as public health facilities do not receive adequate drugs, and clinical drugs and food commodities tripled in prices, largely making them unaffordable to many rural poor households (Kindersley et al. 2020).

Community approaches to alternative healthcare

This snapshot of South Sudan’s 2020 Covid-19 lockdown strategy and the state of its clinical healthcare system do not take into account the informal/traditional healthcare system. In reality, South Sudan’s healthcare systems incorporate both the formal (clinical) healthcare and informal (traditional) healthcare systems. People are able to access both traditional and clinical healthcare services in different health and economic situations across the country. Before the Covid-19 lockdown was imposed, many South Sudanese people in the rural areas had shifted to rely on both clinical drugs, with botanical herbs and spiritual blessings. Families who do not have access to health facilities, those residing in areas with drug shortages or in the nearby public health facilities, or people dissatisfied with private pharmacies, which commonly blanket all diagnosed symptoms as typhoid and malaria to make high profits from their expensive drug sales, would often seek treatment from herbalists and traditional spiritual healers as an alternative source of treatment (Kindersley et al. 2020).

There is little research on this alternative system of traditional medicine. In a recent multi-sited study on ‘Community Approaches to Epidemic Management in South Sudan’ by the Rift Valley Institute (Kindersley et al. 2020), it was found that traditional medicine and healthcare providers are generally the first responders in health crises across the country, more so in rural areas. Traditional caregivers were found to be at the forefront of the fight against Covid across South Sudan – even if excluded from the national policy.

Non-clinical herbal experts and other traditional healthcare providers have had extensive roles in early symptom identification, early detection of infectious diseases and in setting up warning systems against epidemics within local communities. They were also deeply involved in organizing households and extended families to protect themselves against epidemics in the 1940s, 1970s and early 1990s during outbreaks of cholera, smallpox, Kala Azar (leishmaniasis) and Ebola. These events and tactics are still remembered in rural areas today and become local strategies to fight against and prevent the spread of Covid.

After renewed civil war in 2013 and the subsequent collapse of South Sudan’s economy, which resulted in the closing down of many health facilities, the country witnessed a regeneration of herbal medication administered by herbal experts who are the former spiritual leaders and traditional birth attendants. As church has spread widely, and perhaps is providing emotional comfort and counselling, there is a little return to the traditional spiritual blessing (Kindersley et al. 2020).

However, these informal local structures are excluded from national policy frameworks in response to Covid-19 and other endemic diseases – despite their being caregivers working closely with local clinical healthcare providers in their communities.

The failure of  the top-down approach

According to Kindersley et al. (2020), there are some identified reasons for the failure of the top-down national lockdown approach to managing the contagion. First, the central government’s decision-making approach to pandemic response precluded community buy-in and involvement in decision-making processes over how to respond effectively and realistically to Covid. South Sudanese communities have collectively fought past epidemics through traditional methods of collective action rather than through protection-based Western models. Traditional authorities were central in decision-making when infectious disease outbreaks occurred, implementing measures including the reorganization of homes, water-points and markets. Traditional quarantine rules targeted infected households and re-spaced markets rather than implementing a complete lockdown and restriction of movement. Different communities used similar tactics; in Dinka community areas, for instance, people were encouraged to practice ‘atheek’, meaning ‘self-respect’, similar behaviour to social distancing. This traditional practice allows individuals to keep distance and avoid handshakes, as they continue to pursue their livelihood activities. The inclusivity of these structures through a bottom-up approach would prepare the country for a fight not just against Covid but equally against other diseases.

The second failure was the absence  of a holistic approach to the fight against Covid-19. South Sudanese communities are faced with other daily endemic crises of food insecurity and multiple hazardous diseases. The fight against Covid needs to address these other endemic crises which often appear more dangerous. People’s lives are increasingly dependent on markets and long-distance trade in South Sudan; imposing restrictions on movement and market access under conditions of insecurity is tantamount to subjecting them to death through starvation.

Third, the top-down approach that focused on limited messaging around the symptoms and the impact of Covid-19 does not provide enough information for communities to take practical action. Communities are still unsure of why a simple disease with flu-like symptoms is taken that seriously when other life-threatening illnesses that are killing scores of adults and children each day are comparatively ignored. The lack of involvement of local structures and the absence of infection and mortality data in the national public health campaign to update the rural population about Covid-19’s surge globally, in Africa and South Sudan makes it more difficult for the rural population to take the Covid threat seriously.

With this lack of accurate information to convince the poor majority that Covid is deadly, many people believe that Covid is real and risky, but only for those wealthy people who travel abroad and get contaminated in other countries. This belief was reiterated after an announcement that identified patient zero in South Sudan as an international UN staff member arriving from abroad.

Moreover, with South Sudanese people being aware of their government officials’ greed and corruption, many believe that Covid is just a means for them to lobby for international funding for personal enrichment. In a focus group discussion related to the above study in Wau in May 2020, an elderly woman living in Wau town emphasized that ‘when I heard [the first Vice-President] Riek Machar and his wife [current Minister of Defence] announcing themselves [Covid-19] positive, with all the top government officials following in a row, I realized that Covid has become a business. We heard that each government official who tests positive is paid $5,000 a day’. The constant movement of senior government officials across the country and of INGO staff defying lockdown rules they imposed are seen as evidence in the rural areas of how the pandemic is used as a means to scam money and is not a real threat to humanity.

Conclusion

Covid contagion is still surging globally and in South Sudan a third wave sweeping through the country in future is highly probable. To mitigate the possible effects the South Sudan government and the international health NGOs supporting the country’s healthcare systems should adopt a holistic bottom-up based approach to address the intertwined economic and healthcare situation. The top-down approach adopted from more economically stable countries with fully integrated health systems seems unfit for a country that’s crippled with livelihoods tied to kinship and daily market-based trading incomes like in South Sudan. The top-down approach to fight Covid in South Sudan has not just failed, it also proves to be more devastating to the country’s fragmented healthcare and economic systems.

For South Sudan to fight successfully against Covid, including advocacy for the vaccine rollout and intervention in future healthcare crises, an inclusive bottom-up based policy approach that is inclusive of traditional healthcare systems would stand more chance of effectively leading the country out of the current pandemic crisis.

References

Rift Valley Institute Briefing Paper, 2020, Community Approaches to Epidemics Management in South Sudan: Lesson from the COVID-19 Pandemic, Rift Valley Institute, London.

Kindersley, Nicki at al., 2020,  Community Approaches to Epidemics Management in South Sudan: Lesson from Local Healthcare System in Tackling COVID-19, Rift Valley Institute, London.

Gilmartin, Collin, David Collins and Alfred Driwale, 2019, South Sudan Boma Health Initiative Costing and Investment Case Analysis, Arlington, VA: Management Sciences for Health.

World Health Organization, 2019, ‘Health Force Density’, Global Health Workforce Alliance.

Bank, Leslie, 2021, ‘Culture, Covid and Social Cohesion in Rural Southern Africa’, African Arguments, London.

Thomas, Edward, 2019, Moving towards the Market: Cash, Commodification and Conflict in South Sudan, Rift Valley Institute, London.

*This article is based on the Rift Valley Report Community Approaches to Epidemics Management in South Sudan.