Five Vice-Presidents, four ventilators: South Sudan, Ebola and COVID-19
Ferenc David Marko
Juba / Budapest, 15 de Abril de 2020
Even without the COVID-19 pandemic, the situation in South Sudan is bleak, so to say. From the estimated population of 11 million, approximately 400,000 people had been killed in the 6 years of civil war (Ref1). Two and a quarter million South Sudanese refugees live in the neighboring countries, while another two million are internally displaced, mostly living in overcrowded peri-urban settlements on the edges of major towns without adequate access to water and electricity. Half of the population – in the UN terminology – face acute food insecurity. Due to the devastating civil war, the free fall of oil prices, and the kleptocratic military aristocracies with their burgeoning patronage networks (Ref2), the country is on the verge of bankruptcy. Salaries for civil servants, teachers, doctors, and even the military have not been paid for months or years. The local currency lost 90% of its monetary value since 2013. The warring factions pledged to implement yet another elite-level power sharing peace agreement, however the negotiations are painstakingly slow. Following two years of haggling, the parties agreed to form a new cabinet just a few weeks ago, however they still struggle to agree on the distribution of state governorships, the real custodians of local power.
The first case of COVID-19 was reported on the 5th of April, in Juba. The unnamed UN employee returned from the Netherlands via Ethiopia, and stayed in the country since the end of February, therefore most probably he got infected while already in South Sudan. This scenario suggest an ongoing community spread of the disease. This would not be surprising at all. The country hosts thousands of NGO and UN employees from all corners of the world, and the 16,000 men strong UN peacekeeping mission has soldiers from China, Bangladesh, India, Mongolia, among other places. In this short piece, I seek to contemplate on the Ebola-preparedness activities that I have witnessed in 2019, and would like to offer some optimism towards the end. If we accept Alex de Waal’s working premise, that “the pathogen may be new, the logic of social response is not”, we might look into what will happen with different reactions to previous pandemics in South Sudan (Ref3).
“We banned bushmeat, you cannot buy it any longer!” – explained to me confidently the young and ambitious minister in Yei River State in early 2019. The state stands on the southernmost edge of South Sudan, on the border with the Democratic Republic of Congo and Uganda. I was carrying out research on Ebola; more specifically the general preparedness of institutions and local people’s beliefs of the virus (ref4). As a trained anthropologists I headed to the market of the small town of Yei and asked around to quickly learn that bushmeat is still very much on the menu. One only have to ask for it as “Ebola-meat” and you will be served inside the shops, under the counter. Bushmeat – a common symbol of the spread of the unknown disease in the Western imagination, think of Coronavirus and the bats – simply disappeared from the eye of the negligent observer. The visual disappearance of bushmeat was celebrated in the weekly Ebola-preparedness workshops, attended by state officials, national representatives of the Ministry of Health from the capital, local health care NGO workers and UN employees (and myself, as a white researcher). Later, the same night, I again met the minister, he greeted me as a friend, as we know each other for years, even before he joined the local government. A couple of folks joined, so he ordered beers and something to eat: BBQ antelope. “Ebola-meat”, I said. We all laughed.
Achille Mbembe – building of the works of Jean Baudrillard – calls these empty and meaningless acts by postcolonial states ‘hollow simulacrum regimes’ (ref5). For me, however this is not just an empty performance and a simple story of state failure to contain a deadly disease, but a very typical dive into the everyday logic of the South Sudanese state. As I argued elsewhere, the seemingly “failed state” is carrying out several functions at once in these situations, through the underpaid and fragile bureaucracies (ref6). The well-paid UN employees and recently arrived “emergency experts” – doctors and consultants who know Ebola from West Africa, but never set foot to South Sudan previously – wanted bushmeat to disappear. Of course, bushmeat cannot disappear from one day to the other, without viable alternatives offered to the local people and without careful explanation of why it needs to disappear. Low level state bureaucrats thus ensured that bushmeat disappears from the foreign eye, so the more important and realistic programming to prevent and contain the virus will go ahead unperturbedly. For these poorly paid – if paid at all – bureaucrats, the running of the programs is also vital to access some personal funding in the name of per diems paid by the international organizations. The majority of state health care workers and bureaucrats I talked to had no other means of income. They were interested to stop the disease and help their constituencies and communities but also wanted to feed their own families.
Any emergency and pandemic response is not merely a technical question, but a political one as well. Irrespective of the wealth of the country, or the ideological background of the given politician, each and every actor will try to exploit possibilities and will seek to minimize the political losses. Public health is always politics. This was the hardest pill to swallow for the international emergency consultants in the case of the Ebola-preparedness activities. In an emergency, it is the imagined “expert knowledge”, based on hard science that should dictate, and everyone must follow suit. The problem is that South Sudan is imagined and framed as a permanent state of emergency since at least 1983, the outbreak of the Second Sudanese civil war, therefore for South Sudanese, this emergency is not different from all the previous others.
“I would rather shoot my ill soldier dead than sending him to the hospital in Yei for treatment” – argued one of the commanders of the National Salvation Front (NAS) through a murky Thuraya satellite line. NAS is fighting a rebellion against the central government in Yei River State. For the international experts, this was deemed to be a “dangerous and selfish” position by a “bad guy”, a “military warlord” that weakens Ebola response, and puts local populations at risk. This was also how the central government wanted the international experts to see the rebels: a bunch of irresponsible militants, who can be blamed if things go out of hand. However, the commander had a very valid point: the Ministry of Health and the NGOs set up the Ebola isolation ward in the hospital of Yei, in a government controlled town, and nobody gave him any guarantees that his soldiers will not be arrested, tortured or killed. The commander feared of the information the government might extract from his soldier. We should not be surprised by political calculations in public health measures and citizens’ compliance with these measures. They might be misinformed or might calculate erroneously, but everyone will have a legitimate excuse to follow some guidelines and ignore others. However there is space for optimism here as well: the Ebola epidemic in West Africa (and more recently in Congo) taught us that people will very quickly adapt to strategies that work on the ground (ref7). This will be no different with COVID-19.
The new government of South Sudan formed a High-Level Task Force (HLTF) to combat COVID-19, chaired by one of the most seasoned and experienced politicians, Dr. Riek Machar, First Vice-President of the country and the leader of the largest opposition alliance. The HLTF banned most of the international and internal flights, imposed quarantine for all incoming travelers, promised to beef up checks and security at overland borders, and trace all contacts of suspect cases. There is also a recommended social distancing in place, a reduced number of office hours for state employees, closure of schools, ban on religious and public events, and a mandatory nighttime curfew.
However, it is almost impossible to stop the spread of COVID-19 in South Sudan, as it is no Ebola. People without symptoms can spread the disease. South Sudanese deal with all kind of severe illnesses without adequate (or in most cases: any) health care. Malaria, TBC, HIV-AIDS, severe flu, just to name a few illnesses that most South Sudanese only cure when they already have serious effects. In late February, Patrick, my driver kept working for three days, while he was battling with diagnosed malaria, and he only informed me once he felt better, as he was afraid of losing his income. No doubt, majority of South Sudanese cannot afford to stay at home, as they have to grow their own food or make the daily income to feed their families. The socioeconomic impacts of a lockdown is even more severe here, as in more developed countries. The question for the HLTF and the international organizations advising the government: is it necessary?
Flattening the curve is exercised everywhere to stretch the length of the epidemic, so to avoid the overstressing of the health care systems. But what if there is nothing to overstress, as there is no health care system to speak of? First Vice-President Riek Machar announced that there are four ventilators in the entire country (ref8). Local friends quickly joked – in a quintessentially typical way – that South Sudan is the only country with four ventilators and five Vice-Presidents. South Sudan tries to contain the disease with contact tracing, and it might work. However, if the virus starts spreading in the communities, the HLTF will face a tough choice on the next measures. General lockdown is almost impossible and most probably would be more harmful than COVID-19 in itself.
Overall life expectancy in South Sudan is a mere 57.6 years, one of the lowest on Earth. Very few people live to the age to be in the risk group for the new virus. Only 2.5% of the population is estimated to be above 65, and the number of people above 80 can be measured in the thousands. The influential epidemiological model of the Imperial College estimated that an unmitigated spread of the virus would kill 0.21% of the population of Sub Saharan Africa (ref9). A paper under peer-review by Yale researchers argue, that the gains of social distancing in poorer countries are much smaller as the possible losses. As the researchers argue: “Not only are the epidemiological and economic benefits of social distancing much smaller in poorer countries, such policies may also exact a heavy toll on the poorest and most vulnerable. Workers in the informal sector lack the resources and social protections to isolate themselves from others and sacrifice economic opportunities until the virus passes. By limiting their ability to earn a living, social distancing can lead to an increase in hunger, deprivation, and related mortality and morbidity in poor countries” (ref10).
One underreported aspect of the COVID-19 is the effect on humanitarian aid. Not just simply the funding for humanitarian programs in the wake of the biggest economic crisis, where foreign aid might be an early victim of austerity. But also, the way aid is administered and carried out. Apart from oil, aid is the main component of the political economy of South Sudan, and the myriads of NGOs and UN agencies provide services for the population that would be the task of the state: from running schools to providing health care and from maintaining roads to distributing food for the vulnerable. COVID-19 already has a measurable impact on the programs as hundreds of foreign employees – chiefly from Western countries – cannot return to South Sudan or were evacuated by their governments. Maybe unrealistically, but this gives me some hope. All these programs have to continue, and if the organizations cannot hire foreign experts, they might need to employ long-neglected South Sudanese for the positions. Based on my experience, this might be an eye-opening moment for the humanitarian aid sector. The success of these nationals might – might – move the programming framework a step away from the above mentioned “South Sudan is a permanent and repeated crisis”. The end result might be more agency for South Sudanese nationals, who really understand the political economy of the country where they work and that no relief work is detached from politics.
Ref1: Checchi, F. ; Testa, A. ; Warsame. ; A. Quach, L. ; Burns, R. (2018) Estimates of crisis-attributable mortality in South Sudan, December 2013- April 2018: A statistical analysis, London School of Hygiene & Tropical Medicine
Ref2: Pinaud, C. (2014) South Sudan: Civil war, predation and the making of a military aristocracy, African Affairs, Vol. 113, pp. 192-211
Ref3: de Waal, A. (2020) New Pathogen, Old Politics, Boston Review. https://bostonreview.net/science-nature/alex-de-waal-new-pathogen-old-politics
Ref4: Pendle, N.; Marko, F.D.; Gercama, I. and Bedford, J. (2019) Key Considerations: Cross-Border Dynamics Between South Sudan and DRC, UNICEF, IDS & Anthrologica
Ref5: Mbembe , A. (1992) Provisional Notes on the Postcolony, Africa: Journal of the International African Institute, Vol. 62, pp. 3-37
Ref6: Marko, F.D. (2016) “We Are Not a Failed State, We Make the Best Passports”: South Sudan and Biometric Modernity, African Studies Review, Vol. 59, pp. 113-132
Ref7: Richards, P. (2016) Ebola: How People’s Science Helped End an Epidemic, Zed Books, London
Ref8: Al Jazeera (2020) South Sudan reports first case of coronavirus
Ref9: Walker, P.; Whittaker, C. (2020) The Global Impact of COVID-19 and Strategies for Mitigation and Suppression, Imperial College COVID-19 Response Team
Ref10: Barnett-Howell, Z.; Mobarak, A.M. (2020) Should Low-Income Countries Impose the Same Social Distancing Guidelines as Europe and North America to Halt the Spread of COVID-19?, Yale School of Management