Community approaches to epidemic management in South Sudan. Lessons from local healthcare systems in tackling COVID-19

ABSTRACT

Across South Sudan, long before the global COVID-19 pandemic emerged, communities have created systems and structures to control the spread of epidemics and infectious diseases. South Sudanese people have extensive knowledge of infectious diseases and experience of organizing responses to epidemics during wars and other crises. Most people have experience of multiple epidemics within their households and neighbourhoods. Many informal healthcare providers have been involved directly in organized medical responses to past epidemic outbreaks in several areas of the country people have been involved in contact tracing and infection management since the 1970s. This research report details community infectious disease management strategies developed within the realities of South Sudan's local healthcare systems. Because the South Sudan clinical healthcare sector is overstretched and only semi-functional, the majority of South Sudanese people mostly rely on non-clinical medical advice and support from a wide field of healthcare workers and caregivers, including small private clinics and unlicenced pharmaceutical sellers, traditional herbal and surgical experts, midwives and spiritual healers. South Sudanese community-led infectious disease management relies on symptomatic identification, the containment of potential infections through applying knowledge of infection vectors and pathologies, and creative treatment using a high level of botanical knowledge. There are multiple, locally-specific methods used by communities for interrupting infection transmission and managing epidemics. For airborne diseases or infections spread through contact, people often organize houses for self-isolation, mark out separate food and water access points for households, make homemade rehydration salts, carefully manage dirty linen, bed spaces and drinking water provision to avoid cross-contamination, and use urine, hot water and ashes for disinfecting. Different communities across the country use crossed posts, rope barriers, or ash markings across paths to warn people away from sick households in quarantine. Particular care is taken to avoid transmission to high-risk residents, especially pregnant and post-partum women and young children. Across research sites, people are already working on developing local safety measures and strategies to prevent the further spread of COVID-19 in South Sudan. This research documents these community infectious disease management strategies, based on sustained investigative research in the Yei, Juba, Wau, Malakal, Aweil West and Rubkona areas, both in-person and remotely via telephone, from August to November 2020.1 The health and wellbeing of the team and our interviewees was the prioritythroughout the project. Interviewees include midwives and traditional birth attendants, male and female nurses, herbal experts, traditional healers, pharmacists, chiefs and community elders, elderly women, and local public health workers, among many others. Recommendations for action include 1. Collaborate with wider non-clinical health workers and caregivers, who are often first responders, including women, midwives, herbal experts and local pharmaceutical sellers. Include these workers in public health planning and clinical training. 2. Support communities with the broad epidemiological and logistical skills to prepare for COVID-19 and other epidemic outbreaks. Build sustained and detailed public health information systems to help local non-clinical and clinical workers plan locally appropriate infectious disease management strategies. More detailed and sustained information drives, in partnership with local first responders, will also build trust and counter misinformation and fatigue. 3. Localise epidemic response planning. Central planning is heavy handed and ineffective, overlooking critical local knowledge and community leadership that will make responses effective. Public health strategies should aim to build on measures people already take to try to protect themselves and their communities from multiple infectious diseases.