In this blog, Paul Richards reflects on what aid agencies in South Sudan can learn from the Ebola response in West Africa. Perhaps the most critical is that the response to an infectious disease is most effective, and conflict sensitive, when it works with communities and supports their initiatives, and is least effective when local knowledge is ignored or disregarded.

The number of cases of COVID-19 in South Sudan is rising, and there is a short opportunity to both slow the spread and prepare for larger numbers of cases. Until treatments are available everything depends on community action to control the spread of disease and care for the sick. This is particularly important in a context such as South Sudan, where there is insufficient capacity to manage a large number of cases, and so a lot more effort needs to be put into prevention. There are three general principles of effective community action – hygiene, social distancing and shielding (protecting the most vulnerable from infection). Translating these principles into effective action will require widespread community consultation. If well planned, this can open the door to effective, and conflict sensitive community led responses, that can both prevent harmful interactions, and enable necessary interactions to continue.

Hygiene

The first step in prevention is to make sure the risks of carrying the virus from our hands into our mouths, nose or eyes are as small as possible. For this, the number one issue is regular and thorough hand washing with soap. This will be very challenging in areas where water supply is a problem and soap is expensive.

During the Ebola epidemic in 2014-15, public buildings of all kinds, including village court houses or verandas of chiefs, had hand washing stands and people were required to wash hands before they entered. Many householders soon copied the practice, and visitors had to wash their hands before entering domestic compounds. The Veronica Bucket (a plastic bucket with a tap at the bottom) was invented by a public health nurse in Ghana who had seen how difficult it can be to organise handwashing in public places in rural Africa. Other local innovations have included, for example, large recycled plastic bottles filled with water hung on a frame, allowing the user to operate the water flow by knocking with the elbow to further avoid the risk of infection.

While there is limited evidence to show that facemasks protect people from the disease, they can serve to reduce the spread of COVID-19 by people who are asymptomatic and do not know they are infected. Local tailors throughout Africa are rising to the challenge, and these can also be improvised at home using clean cloths. They should, of course, be regularly washed, and never shared.  Masks might help save the lives of older and vulnerable people if they are worn by those who attend to or care for them.

If community consultation enables groups to discuss how they would implement such hygiene measures, and what challenges need to be faced and overcome (including details such as where washing stations should be placed, how supplies will be maintained, how facemasks should be made and used), then these measures can be tailored to and owned by communities, who are more likely to implement them as a consequence.

Social Distancing

‘Social distancing’ combines two separate aspects – maintaining physical distance and limiting the number of social contacts.  Coughing and talking can spread the virus on people’s breath.  It is currently thought that keeping a distance of two meters away from everyone else in a public place should be enough to avoid most or all of the virus hanging in the air.

Physical distance

Markets, mosques, churches and public transport all carry high risks of infection because many people are often crowded together. The first reaction of authorities has therefore often been to ban all crowded events, including religious services, markets and public transport. But this is not sustainable over the longer term and alternatives have to be found, based on the rule of two metres separation.

This requires community consultation and discussion.  Local ideas are urgently needed for “de-crowding” essential public events, including consulting with those in charge of markets and shops about crowd control options.  For example, markets or shops might be “de-crowded” by asking only one member of each household to buy market items, supported by ways of identifying a designated shopper.

Queuing systems could be considered, for example with simple barriers (sticks or tape), provision of shade, hand washing facilities, and supervision by security or police to ensure that people stand waiting at the safe distance.  Again, how this is done depends on the actual setting, and requires involvement of all stakeholders to devise a workable, fair and safe system.

Religious services have been suspended in many countries, but a question arises for how long this is sustainable. People may need the strength of religious association to cope with the challenges of the epidemic. However, the practices that are most deeply held, rooted and socially and psychologically meaningful may also inadvertedly become transmission pathways. (E.g. For the Azande, relatives gather when someone is sick, staying with them until they die. The Moru are expected to pay their respects to one another in times of sickness of death. Failure to do so can lead to community ostracization.) Authorities and aid agencies need to consult with pastors, imams and traditional leaders and with their congregations and communities on how feasible different solutions might be (e.g. holding services outdoors and people sitting or standing at the required distance).

The literature from the Ebola epidemics provides guidance on organising safe and respectful funerals that also respect basic safety rules. But the general rule is clear – only those intimate with the deceased in life can know how local practices and rituals need to be modified to bury them safely and respectfully.

The aim should be an agreed set of community-endorsed emergency protocols covering burial activity so there is clarity on what is permitted in regard to burial for the duration of the epidemic. This was particularly critical for Ebola as the viral load increased in recently deceased people and the burial practices were a transmission route. At the same time, while mass gatherings at funerals could be a ‘super-spreading event’, safe practices in caring for the sick may be more important given the nature of transmission of COVID-19.

Reducing social contacts

The other part of social distancing is reducing the number of social contacts we have, especially with people whose disease status we do not know.

In many parts of the world, this has been attempted by imposing lockdowns, where people are confined to their homes, with some exemptions for essential activity, such as exercise or shopping for food and medicine. It is not at all clear that this is the best approach in African countries, or even the only way to achieve a reduction of external social contacts, especially in overcrowded areas such as informal settlements. It is possible that attempting to lockdown large inter-generational extended families in poor housing conditions might even act as a way of spreading infection.

Other ways of attaining the same result need to be considered. For example, it might still be allowed to visit friends, and empathise with the sick, but only in small numbers and when correct distancing is observed. Rather than traveling to market, perhaps householders could purchase items via motorcycle taxi riders acting as couriers, with payments handled through mobile money transactions, where possible. Social distancing protocols should be developed with community inputs to cover absolutely essential social activity, such as visits of well-wishers for births and funerals.

The aim should not be to ban these activities, but for authorities and communities, acting together, to re-think them in a way that achieves the aims of social distancing and minimising potential negative consequences of social distancing measures. This is particularly important given the dependence of many on daily income or social connections for survival. A study by Juba University found that the number of people who can only afford one meal per day has increased from 33.4 per cent in February to 64.2 per cent in April. ¹

Shielding the Vulnerable

Special attention should be paid to protecting those who are most vulnerable (including the elderly or those with conditions such as HIV-AIDs and TB). The basic principle is to make the vulnerable visible and to provide a protective space around them, which the vulnerable and their carers are vigilant in maintaining. The demographic profile is very different in Africa – where over-65s account for 2-3% of the population (compared to 26% in Italy). A major concern (on which there is as yet very little information) is how having malaria will affect vulnerability to COVID-19.

How this is to be done will depend on residential and social settings. Again, only communities, including the vulnerable themselves, can figure out the basic ground rules with tailor-made approaches. For example, designated zones in markets where vulnerable elderly people can wait for their families could be considered. When Ebola spread into the West Point ghetto in Monrovia the authorities tried to impose their own lockdown, but it failed, and the only option was to hand over the problem of infection control to community groups – in this case, to motorcycle taxi riders and commercial sex workers, who devised a solution.

A particular group requiring shielding are health workers, because of the extent to which they contact the virus on a daily basis. There is a great need to keep the virus out of health facilities, to protect other medical functions. In Asia, Europe and North America this has resulted in the construction of large, temporary field hospitals to nurse the more serious cases. In Africa, this may mean building or allocating a specific area – simple tented or thatched structures, where each patient can be nursed, largely by a family volunteer, with some basic PPE and palliative medicines, supervised by a health worker operating at a distance.

Conclusion

The value of community action and consultation is clear and aid agencies in South Sudan should be designing their activities based on the following:

• If people clearly understand what they are doing and why, and if their own suggestions are listened to carefully, the resulting community-led public health measures are more likely to be conflict sensitive, more effective and sustainable in the longer-term.
• Enhancing communities’ and individuals’ sense of control and action may also help to mitigate against the panic that can arise as a consequence of misinformation and uncertainty.
• Enable those who are intimate with cultural expectations and daily ways of life to play a greater role in navigating the difficult changes needed to respond to COVID-19. This is a key international best practice which has been well-proven in other epidemic contexts, such as West Africa during the Ebola crisis.

This blog will be complemented by a short analysis piece in which Professor Richards will look in more detail at suggestions for a conflict sensitive community-led response in South Sudan.

Paul Richards has lived and worked in West Africa over several decades and is currently an emeritus professor at Wageningen University, The Netherlands, and adjunct professor at Njala University, Sierra Leone. He is also an honorary professor at the University College London, and previously taught at the School of African and Oriental Studies, University of London and the University of Ibadan, Nigeria. After the Sierra Leonian civil war, he turned to conflict analysis and has written widely on the anthropology of armed conflicts, and more recently, the Ebola crisis. In 2016, he published Ebola: How a People’s Science Helped End an Epidemic.

Picture: © JWale2