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.
Despite having ample time to prepare, Sudan was far from ready for the novel coronavirus when its first case was confirmed in March 2020. The announcement was met with panic, disbelief, disgust and defiance. Now, almost two years later, little has changed.
Official case numbers suggest that Sudan appears to have fared better than many other countries with only 38,824 cases and 2,967 deaths officially reported. But this number is suspected to be a huge underestimation, with estimations that only 2–5% of deaths due to Covid-19 are actually being reported, particularly with a vicious fourth wave likely ushered in by the highly infectious Omicron variant.
Governments all over the world have struggled to control the spread of Covid-19 with preventive measures ranging from simple advice on hand hygiene to strict lockdowns and fines. Bar vaccination, public health and social measures have proven to be the most effective means of control compared to pharmaceutical interventions. But these measures require immense cooperation from and constant communication with the community, and most importantly: economic and political stability. None of these factors exist in Sudan.
“They’re postponing the beginning of the school year again because of this ‘Corona outbreak’,” complains Fatima, the latter part of her statement reflecting a tone of ridicule spoken in disbelief. “There’s no outbreak, it’s just an excuse the government is using to scare people, so they won’t keep protesting.”
Fatima’s suspicion of ulterior motives is shared by many across the country as government messaging around Covid-19 waxes and wanes, evolving in an ever-confusing manner and fuelling the sense of mistrust that our research shows is widespread and a major obstacle in the face of public adherence to preventive measures. The prevailing sense of mistrust comes at a high price. It is not unique to Sudan, but with the country mired in post-revolution dynamics and in the aftermath of three decades of systemic destruction, the timing could not have been worse.
By many measures, this is considered the most challenging period in Sudan’s modern history.
The short-lived transitional government that was smothered in its cradle by a military coup in October 2021 generally followed a reactive firefighting approach as it grappled with the various political, economic and health crises it was facing. These conditions worsened dramatically after the coup with massive protests and unrest taking over the country, chaos in the corridors of the different ministries and withdrawal of anticipated international aid for health programmes which in turn brought all forms of funding to a screeching halt.
Throughout this, efforts to control the spread of Covid-19 or even remind people of its deadly presence have been furtive and limited. A key weapon in the armoury of protection – vaccination – has fallen short of its target by miles with the poor community response flamed by rumours and misinformation. The pitiful condition of health institutions has been compounded by inability of health workers and patients to reach health care with the erratic closures of roads and bridges, and regular disruption of telecommunication lines. And to add fuel to the fire, authorities threatened to go into a new lockdown with the rise in Covid-19 cases – a pretext to quell protests and force citizens into submission.
This is not to imply that the public’s adherence to preventive measures was sterling prior to the current political mayhem. Particularly measures to enforce a reduction in social mixing were met with defiance and refusal. Our interviews with participants from six different communities across the country showed that avoiding handshaking, reducing gatherings in weddings and funerals and practising social distancing in group prayers were far from acceptable. Even those who wished to protect themselves or others found it difficult to comply due to bullying and fear of losing social capital that usually came from being immersed in these communal practices.
Epidemic preparedness then and now
The Sudanese health care system arrived at its current point of breakdown through a long series of rises and falls: from the 1960s and 1970s focus on primary health care under the socialist regimes, to a user-fee based system following the free market policies of the al-Bashir regime as the government gradually reduced its own responsibility to provide public health, entrusting it instead to the market to dictate what provision is available to whom at what cost. As all matters of policy in Sudan, the health system is fragmented, poorly informed and suffering from recurrent institutional memory loss with the ongoing brain-drain.
Epidemics were previously managed through collaborative approach managed by federal and state directorates of primary health care with early warning non-governmental agencies system back-up, where – upon disease surveillance mechanisms detecting an outbreak – committees would be promptly formed with representatives from the designated directorates, and teams would be dispatched to the affected states to work alongside state authorities within the respective local public health system. The federal-level committee with the involvement of donors and programme representatives also allowed for rapid re-routing of existing funds to support the response on the ground in a timely manner.
In contrast, the Covid-19 pandemic landed in the middle of a health system in shambles, and no amount of resuscitation or financial support seems to be enough to maintain efforts of a unified and strong response to keep the pandemic’s threat at bay. This is compounded by information gaps and an absence of a robust track and trace campaign to manage and control the spread of the pandemic, without which any kind of response is based on imagined projections.
Covid-19 testing has been left to the market and for businesses capable of funding its exorbitant costs for clients who can afford private testing. Those who can afford it seek it only out of necessity for international travel requirements such as pre-departure clearance, or in some cases patients being admitted to hospitals, the latter operating on a reduced capacity on account of the pandemic and political instability. Both the test centres and authorised hospital admissions operate only in a handful of areas and states and government announcements do not at all reflect the staggering increase in deaths on the ground despite long queues of mourners waiting in-line at grave sites to bury their dead telling another story.
Against the backdrop of political and economic stability, concerns over contagion risks of Covid-19 became a province of the relatively rich: those who can afford to stay home and shield – a concept where those vulnerable to Covid-19 and its complications are shielded at home with limited contact – and seek health care when sick. Meanwhile the bleak reality of daily life for the majority of people across Sudan is endless bread lines, crowded transportation, the nightmare of public service facilities, and now the political turmoil that brought out huge crowds protesting on the streets. Most of these people make up an informal and undocumented workforce that depends on day-to-day, face-to-face labour to earn a meagre living, and simply cannot afford to shield by “staying home”.
Our research shows that, for most, controlling the spread of Covid-19 and mitigating its effects through physical distancing and movement restrictions seem unrealistic at best, and cruel at worst. In any context – and in Sudan in particular, where social capital provides a lifeline and a safety net not provided by the state – one major obstacle is convincing/forcing people to socially distance for prolonged periods of time. Always and forever, coming together in times of celebration and calamity are one of the few things that bring comfort to a community that is struggling to keep its head above the murky waters of famine and economic hardship.
When asking our study participants about what could assist them in adhering to individual protective behaviours such as social distancing, the overwhelming – and frankly, quite logical – answer is that without the government fulfilling its socio-economic obligation of improving the daily economic realities of those in need, there isn’t much they can do. For many, only when these needs are met or prioritised, can they adhere to Covid-19 control measures.
For the time being, lockdowns and restricting movement are not advised as people will not adhere anyway, and because of the detrimental effect on the livelihood of the masses. It is essential that vaccination efforts pick up particularly for those most at risk, and that shielding the vulnerable be advocated and supported.
Public health now and in the future
In resource-limited settings like Sudan, emergency responses need to take into consideration the fact that the health of individuals and communities is largely determined by social factors outside their direct power. Therefore, the focus of Covid-19 mitigation efforts should not be solely on the immediate determinants of health – and by extension the individual behaviour-change mandates – but those factors that feed into personal decisions of whether to stay protected or not, such as the need to work even in crowded places, or the need to choose between spending money on masks and sanitizers or on rent and food. Furthermore, health policies need to address the perception of Covid-19 risk, against competing priorities, and not only the desire to adhere to these measures, but the actual probability of doing so as determined by economic needs.
There is an urgent need to engage communities through influential gatekeepers whose word is law among the people, and through strengthened local governance systems. Communities need to be involved in the priority-setting and decision-making process, both to guide the government on what is needed and is implementable on the ground, and to ensure the community owns these decisions and complies with them the way they know best.
Our research shows that this is not only possible but expected. During the first Covid-19 wave, the general response – while a little late and poorly coordinated – was strong and wide-reaching, with multiple players complementing efforts to provide protective equipment, health education and financial support. However, in many of these areas the government’s response was guided by obscure processes that did not meet the community’s needs, nor was it appropriately marketed to secure community buy-in and ensure adherence. Many areas were missed completely despite the fact that they were reachable by community volunteers on stand-by.
Our research has also identified the dire need to amplify transparency in order to build trust, justify preventive measures and clearly transmit the urgency of the situation to the public. The constant erosion of what little trust in authorities exists means losing the support of those who want to protect themselves or want to help stop the spread and want to work together to pull through to the other side. The consequences are graver for the majority who are beyond the reach of the state and its public health campaigns, who do not believe in the threat, and are either unable or simply have no interest in yielding to government protective regulations.