Authors:
Grace Akello, Leben Moro, Godefroid Muzalia
Corporate Author:
Social Science in Humanitarian Action Platform
Published:
2024

Epidemics have long affected the borderlands in Central and East Africa due to a combination of ecological, social, economic and political conditions. For example, porous borders and cross-border social and economic networks make it easy for people – and pathogens – to move from country to country. While preparedness and response activities to disease epidemics have evolved over time, risks remain, and many lives continue to be lost due to preventable disease outbreaks. Policy and practice can build on what has been learned from past and ongoing outbreaks, and from research on borderland preparedness and response. These changes in policy and practice can improve resilience against infectious disease outbreaks and their multi-dimensional impacts.

This short report offers recommendations and reflects on discussions on epidemic preparedness and response in the Central and East African borderlands from a workshop attended by social scientists, policymakers and humanitarian and public health practitioners from Uganda, the Democratic Republic of the Congo (DRC) and South Sudan. The SSHAP Central and East Africa Hub facilitated and hosted the workshop in August 2023 in Kampala, Uganda.

The report begins with a list of recommendations that emerged from the discussion. This is followed by additional context and reflections on the social, economic and political contexts that shape disease risk and which must be considered to improve the effectiveness of future preparedness and response in the region.

Workshop recommendations

Improving regional and cross-border strategies

  • Design locally adapted epidemic response strategies that account for borderland social dynamics. Recognise that people in these areas maintain close social, cultural and economic cross-border ties and often view borders as artificial. Develop approaches that respect these social realities while still effectively controlling disease spread.
  • Improve surveillance beyond formal points of entry. Develop strategies to monitor and engage with the regions’ many informal crossing points, which outnumber formal points of entry. Work with local social networks to enhance surveillance and resources to ensure access to care for all.
  • Improve cross-border cooperation in health systems. Pool financial, technical and diagnostic resources among East African community members for more effective epidemic response and to address inequalities in the capacities between countries.
  • Account for cross-border livelihoods that can be associated with vulnerability to Ensure that risk communication and control strategies do not increase discrimination of frequently mobile groups of people, such as commercial sex workers and truck drivers.
  • Engage newly established National Institutes of Public Health and establish a regional institute to improve cross-country collaboration. Areas for collaboration include sharing relevant public health and social scientific data and knowledge, co-production of ethical research standards to protect vulnerable populations and collaborative preparedness and response plans.

Strengthening health systems

  • Strengthen health systems comprehensively within countries. Equip all public health centres, not just those at border points, to prevent and respond effectively to disease epidemics. Implement the ‘4S’ model (staff, stuff, systems and structures) for nationwide health system strengthening. Engage with private health providers to help them prepare for epidemics.
  • Invest in rural and remote healthcare infrastructure. Ensure that epidemic preparedness extends beyond urban centres and formal points of entry to reach all vulnerable populations.
  • Consider carefully when to frame outbreaks as an ‘emerging’ disease in instances where longer term causes encourage re-emergence or endemic presence. Recognise that many infectious diseases in the region have been known for decades and are perpetuated by unaddressed social, political and institutional problems.

Engaging communities for context-adapted activities

  • Develop community-engaged approaches to preparedness and response. Address both health and security concerns in conflict-affected areas. Prioritise understanding local people’s perceptions and priorities when designing interventions.
  • Integrate cultural and livelihood practices and priorities into epidemic response strategies. Work with local communities to develop culturally appropriate interventions that respect social norms whilst effectively controlling disease spread.
  • Reduce militarisation of epidemic responses. Recognise that securitisation of disease response can lead to public distrust. Explore alternative approaches that maintain public health measures without coercion or force, including community-engaged approaches.

Addressing root causes and vulnerabilities

  • Address political factors contributing to disease emergence. Conflict in the region frequently displaces people within and across borders, exposing moving populations to poor sanitation. Support conflict prevention, resolution and peacebuilding, while improving conditions in displacement camps, refugee settlements and host communities. Prioritise provision of water, sanitation and hygiene facilities in areas with high population movement.
  • Address socio-economic inequalities which drive disease emergence, re-emergence and spread. Recognise and mitigate factors, such as poverty, overcrowding and lack of basic services, which contribute to epidemic vulnerability.
  • Work to mitigate stigma against marginalised groups that may be disproportionately vulnerable to disease. Advocate to fight everyday discrimination against marginalised groups, such as refugees, internally displaced people, sex workers or men who have sex with men. Ensure risk communication and community engagement around outbreaks does not further stigmatise marginalised

Regional social and political dynamics

The Central and East African region, which includes Uganda, the DRC and South Sudan, is characterised by complex social, cultural, economic and political dynamics that can contribute to disease emergence and spread. The borders between these countries are a legacy of the colonial era. Drawn by Europeans with little regard for indigenous social or political organisation and dynamics, many communities found themselves arbitrarily divided. These borders are also very porous, with informal crossing points outnumbering formal points of entry. This has given rise to a situation in which people living in the borderlands routinely cross between countries to maintain close social and economic ties and networks. For instance, people frequently own property, access services, visit family, attend social and cultural events, and conduct trade across borders. While this frequent movement upholds livelihoods and social networks, it can also facilitate intercountry disease transmission and fuel epidemics.1,2 Sex workers and truck drivers are examples of people who frequently move between countries because they rely on cross-border movement to sustain their livelihoods, and yet they are also at risk of acquiring and transmitting infectious diseases, such as in the current context of the mpox outbreak.3

Political instability and conflict have also been persistent challenges in the region. In the DRC, particularly in the eastern regions, numerous armed groups operate, undermining state capacity, the efforts of humanitarian actors and affecting all sectors, including health.4 People are also routinely displaced and their livelihoods disrupted. South Sudan, born in 2011 after decades of conflict, also remains fragile. Ongoing civil unrest and climate-related disasters, particularly flooding, frequently cause large-scale population displacements while the war in Sudan has also triggered a large number of returnees and refugees to enter the country, straining existing resources and services.5 In both countries, displaced people, refugees and host communities face increased disease risk due to overcrowded settlements with poor sanitation and limited access to healthcare.

Uganda, while relatively stable, has adopted authoritarian and militaristic approaches to governance, including in its response to health crises. For example, during the COVID-19 pandemic, people flouted strict public health measures as a means of survival, but they faced harsh punishments by the armed forces.6 Punitive and authoritarian approaches can undermine the trust people have in responses to disease outbreaks, with the effect of exacerbating them.

Health system capacities and challenges

Health systems across the three countries face significant challenges, albeit to varying degrees. The DRC’s health system struggles with poor territorial coverage, overall low quality of care and insufficient health structures. For a population of 102 million, there is a notable deficit in healthcare infrastructure, particularly in conflict-affected areas. South Sudan’s health system is also particularly weak, with some of the world’s worst health indicators, and it is heavily dependent on resources provided by UN agencies and non-governmental organisations. In the wake of COVID-19, Uganda has made substantial investments in health infrastructure at formal points of entry along its borders as an approach to disease surveillance and control. However, given the dispersed nature of outbreaks and the mobility patterns of borderland populations, which often do not utilise formal points of entry, this strategy may not be effective in preventing or addressing cross-border epidemics.

Across all three countries, there is rather a need to strengthen health systems comprehensively, not just at border points.7 This includes improving staff capacity, equipment, systems and structures throughout national health services, as well as engaging private health providers in preparedness efforts. The ‘4S’ model (staff, stuff, systems and structures) offers a framework for nationwide health system strengthening.8

The establishment of national public health institutes in some countries presents an opportunity to take a more comprehensive approach to public health, including incorporating social and economic factors into epidemic preparedness and response strategies.9 Regional coordination between these institutes, as well as the establishment of a regional institute, can support greater collaboration.

Considerations for community engagement

The social and cultural realities of borderland communities often conflict with standardised epidemic control approaches. During outbreaks, people often support each other across borders, including attending funerals, which can facilitate disease spread but also reflect important social, cultural and spiritual values and obligations.10 These practices can clash with containment measures, such as isolation and quarantine, highlighting the need for locally adapted strategies that respect and integrate local practices and values while also effectively controlling disease spread.11 Meaningful engagement with community members, including through cross-border collaboration, is needed to co-produce appropriate strategies.

Failing to engage communities and understand what is important to them can also engender mistrust in preparedness or response measures and actors. For example, during recent Ebola outbreaks in Beni, DRC, there was significant local resistance to response efforts. This resistance stemmed from a complex interplay of factors, including distrust in government and international actors’ intentions,12 and perceptions that disease outbreak interventions are prioritised over addressing ongoing violence, insecurity and other everyday challenges faced by local populations.13 The militarisation of epidemic responses in some areas has also further exacerbated public distrust. These experiences underscore the importance of developing community-engaged approaches to preparedness and response that address not only outbreak priorities, but also security, livelihood and other health concerns of local people, and which also respect and integrate local practices into epidemic response strategies.

Underlying causes of recurring epidemics

The persistence of infectious disease outbreaks in the region is closely linked to underlying social, political and economic factors. As noted, conflict and political instability have led to large-scale displacements, with people often moving to areas with poor sanitation and limited access to healthcare. Refugee settlements and displacement camps frequently suffer from overcrowding and inadequate water, sanitation and hygiene (WASH) facilities, creating conditions conducive to disease spread.

Poverty and the lack of basic services in many areas contribute significantly to epidemic vulnerability. Limited access to clean water, proper sanitation and adequate nutrition weakens populations’ resilience to disease. Moreover, economic hardship often forces people to engage in livelihood activities that may increase their exposure to wildlife and zoonotic diseases or bring them into closer contact with potentially infected populations.

The framing of diseases as ’emerging’ or ‘re-emerging’ in the region can be problematic, as it may obscure the long-term presence of these diseases and the chronic nature of the conditions that allow them to persist.14 Many infectious diseases affecting these countries, such as Ebola, have been known for decades.

Addressing these underlying causes requires a holistic approach that goes beyond immediate health interventions.15 This includes supporting conflict prevention and resolution efforts, improving conditions in displacement camps and refugee settlements, prioritising the provision of water, sanitation and hygiene facilities in high-risk areas, tackling stigma against marginalised groups such as sex workers and men who have sex with men, and overall addressing broader socio-economic inequalities.

References

  1. Bedford, J., & Akello, G. (2018). Uganda-DRC cross-border dynamics. SSHAP. https://opendocs.ids.ac.uk/articles/online_resource/Uganda-DRC_Cross-Border_Dynamics_Dynamique_transfrontali_re_Ouganda-RDC/26428396
  2. Moro, L., & Robinson, A. (2022). Key considerations: Cross-border dynamics between Uganda and South Sudan in the context of the outbreak of Ebola, 2022. SSHAP. https://www.socialscienceinaction.org/resources/key-considerations-cross-border-dynamics-between-uganda-and-south-sudan-in-the-context-of-the-outbreak-of-ebola-2022/
  3. Hrynick, T., & Schmidt-Sane, M. (2024). Roundtable report: Discussion on mpox in DRC and social science considerations for operational response. Social Science in Humanitarian Action Platform. https://www.socialscienceinaction.org/resources/roundtable-report-discussion-on-mpox-in-drc-and-social-science-considerations-for-operational-response/
  4. Muzalia, G. (2024, April 9). Navigating insecurity in North Kivu, DRC: Learning from humanitarian actors, civil society and research. Social Science in Humanitarian Action Platform. https://www.socialscienceinaction.org/blogs-and-news/navigating-insecurity-in-north-kivu-drc-learning-from-humanitarian-actors-civil-society-and-research/
  5. Moro, L., Palmer, J., & Hrynick, T. (2024). Key considerations for responding to floods in South Sudan through the Humanitarian-Peace-Development nexus. SSHAP. https://www.socialscienceinaction.org/resources/key-considerations-for-responding-to-floods-in-south-sudan-through-the-humanitarian-peace-development-nexus-2/
  6. Parker, M., MacGregor, H., & Akello, G. (2020). COVID-19, public authority and enforcement. Medical Anthropology, 39(8), 666–670. https://doi.org/10.1080/01459740.2020.1822833
  7. Akello, G., & Green, D. (2020). Preparedness, heightened response and systems strengthening for Ebola in Uganda [Policy brief]. LSE Firoz Lalji Centre for Africa. https://www.lse.ac.uk/africa/Assets/Documents/Policy-documents/Ebola-Uganda-policy-brief-Grace-Akello-latest.pdf
  8. Ajam, S. (2016, April 27). Solving the ebola outbreak: Paul Farmer and the four s’s. University of Notre Dame College of Science. https://science.nd.edu/news-and-media/news/solving-the-ebola-outbreak-paul-farmer-and-the-four-ss/
  9. Taame, H., Ndembi, N., Ngongo, A. N., Raji, T., & Kaseya, J. (2023). Functional National Public Health Institutes are critical for the health security of Africa. Journal of Public Health in Africa, 14(9), 2863. https://doi.org/10.4081/jphia.2023.2863
  10. Hewlett, B. S., & Hewlett, B. L. (2008). Ebola, culture, and politics: The anthropology of an emerging disease. Thomson Wadsworth.
  11. Moran, M. H. (2017). Missing bodies and secret funerals: The production of ‘safe and dignified burials’ in the Liberian Ebola crisis. Anthropological Quarterly, 90(2), 399–421.
  12. Park, S.-J., Brown, H., Wema, K. M., Gobat, N., Borchert, M., Kalubi, J., Komanda, G., & Morisho, N. (2023). ‘Ebola is a business’: An analysis of the atmosphere of mistrust in the tenth Ebola epidemic in the DRC. Critical Public Health, 33(3), 297–307. https://doi.org/10.1080/09581596.2022.2128990
  13. James, M., Kasereka, J. G., & Lees, S. (2021). The politics of the second vaccine: Debates surrounding Ebola vaccine trials in eastern Democratic Republic of the Congo. Journal of Humanitarian Affairs, 3(3), 4–13. https://doi.org/10.7227/JHA.069
  14. Farmer, P. (2001). Infections and inequalities: The modern plagues. University of California Press. https://doi.org/10.1525/9780520927087
  15. Akello, G., & Parker, M. (2022). Confronting epidemics: The art of not knowing and strategic ignorance during Ebola preparedness in Uganda. In Routledge handbook of public policy in Africa (pp. 459–474). Routledge.

Authors: This report was written by Grace Akello (Gulu University), Leben Moro (University of Juba) and Godefroid Muzalia (Groupe d’Etudes sur les Conflits et la Sécurité Humaine).

Acknowledgements: This report was reviewed by Tabitha Hrynick (IDS), Melissa Parker (LSHTM), Hayley MacGregor (IDS) and Juliet Bedford (Anthrologica). Editorial support provided by Harriet MacLehose. This brief is the responsibility of SSHAP.

Suggested citation: Akello, G., Moro, L., and Muzalia, G. (2024). Workshop report: What can be done to improve epidemic preparedness and response in the Central and East African Borderlands. Social Science in Humanitarian Action (SSHAP). www.doi.org/10.19088/SSHAP.2024.035

Published by the Institute of Development Studies: July 2024.

Copyright: © Institute of Development Studies 2024. This is an Open Access paper distributed under the terms of the Creative Commons Attribution 4.0 International licence (CC BY 4.0). Except where otherwise stated, this permits unrestricted use, distribution, and reproduction in any medium, provided the original authors and source are credited and any modifications or adaptations are indicated.

Contact: If you have a direct request concerning the brief, tools, additional technical expertise or remote analysis, or should you like to be considered for the network of advisers, please contact the Social Science in Humanitarian Action Platform by emailing Annie Lowden ([email protected]) or Juliet Bedford ([email protected]).

About SSHAP: The Social Science in Humanitarian Action (SSHAP) is a partnership between the Institute of Development Studies, Anthrologica , CRCF Senegal, Gulu University, Le Groupe d’Etudes sur les Conflits et la Sécurité Humaine (GEC-SH), the London School of Hygiene and Tropical Medicine, the Sierra Leone Urban Research Centre, University of Ibadan, and the University of Juba. This work was supported by the UK Foreign, Commonwealth & Development Office (FCDO) and Wellcome 225449/Z/22/Z. The views expressed are those of the authors and do not necessarily reflect those of the funders, or the views or policies of the project partners.

Keep in touch

X: @SSHAP_Action

Email: [email protected]

Website: www.socialscienceinaction.org

Newsletter: SSHAP newsletter