In Sudan, the first case of COVID-19 was reported in Khartoum on 20 March 2020.  As of October 7, 2020, more than 13,600 cases and 836 deaths had been reported. Most of these were in Khartoum, the country’s largest city where testing is most easily accessed[1].  According to Worldometer, the  fatality rate of 6.1% is high compared to many countries. However, few cases or deaths have been reported in the western Sudanese state of Central Darfur.

Although very few cases of COVID-19 were reported in Central Darfur, the population spent months under strict pandemic containment measures while the Ministry of Health promoted the now well-known, somewhat standard, WHO/CDC personal hygiene and social distancing measures.  As part of a nation-wide lockdown, public transport within and between states was limited to prevent the spread from one area to another; central markets, shops, businesses, and government offices were closed,  curfews were put in place, and people were instructed to stay home – all to prevent groups from gathering.

When the pandemic began, I was working alongside Tufts University to conduct research on resilient livelihoods in Darfur. As I observed that people were not following most of the health guidelines, I shifted gears to document what was happening in my state. I interviewed (by phone) members of the Ministry of Health, organizations involved in health programming, NGOs, and community leaders about why people were not following the guidelines promoted by the Ministry of Health and private organizations in the state. Through the interviews I specifically explored challenges that organizations faced in convincing people to abide by the containment measures, and the challenges that people faced in abiding by the measures, even when they were convinced that they should. Additionally, I interviewed humanitarian organizations in the area to understand how they were supporting the population in this midst of this crisis.  Although semi-arid, remote, rural western Sudan is a somewhat unique region with unique challenges, many of the challenges highlighted by this study echo those reported around the world.

Struggles to get convincing messages out

Ministry of Health representatives and non-governmental organizations (NGOs) explained that it was difficult to get messages out to the public and also difficult for the public to follow the guidelines, much less to ensure people received the care they needed for the following reasons.

• Banditry and ethnic and political clashes limited the movement of some organizations who were trying to promote health guidelines.
• Chronically weak health service providers closed when people were not able or were afraid to travel to the clinics for routine treatment.
• State health institutions, including treatment centers, are not fully staffed.
• Budgets for pandemic-related activities are limited or non-existent.
• Some international organizations intervened in ways that did not support the Ministry of Health’s plans and priorities.
• Many people were not willing or able to change lifestyle habits to respect the lockdown.
• People had to meet their daily needs in places with limited infrastructure, for example fetching water from shared water-collection points sometimes led to crowd around those points.
• People did not want to give up their social norms, for example shaking hands, sharing meals during Ramadan.
• Many households are crowded with extended family living in one home with few rooms.
• Many people are not literate and have limited education to read or understand health messages

Some NGOs supported the Ministry of Health by promoting the social distancing messages.  However, most international humanitarian and development agencies, when asked how they were addressing the pandemic, focused on livelihood activities similar to those they normally  implemented in their on-going development programs, for example:

• Distribution of dairy goats for families with malnourished children
• Distribution of seeds (vegetables, millet and fruits)
• Distribution of cultivation equipment
• Small grants to village group savings and loan associations and cooperatives
• Vaccination and supplementary feeding programs for livestock

While communities did stress a link between livelihoods and barriers to complying with containment measures, many of the livelihood activities that NGOs named would not immediately improve livelihood situations and would actually have required that people violate containment measures in order to make use of them.  For example, the early days of the pandemic fell during the planting season, a critical time for farmers.  The distribution of seeds and cultivation equipment would have been very welcome but would require travelling outside of the village and working in groups to make use of these, violating the local containment measures.  Small grants are most often intended to support small businesses, again an activity that was discouraged by the containment measures.

Perhaps a greater, underlying challenge to convincing people to comply with the containment guidelines was that many community members, especially in rural areas, didn’t believe the disease existed or that it was present in the state in high enough numbers to warrant changing their normal activities.

Struggles to Comply with the Messages

Community representatives gave another view of the barriers to comply with containment measures.  Like the Ministry of Health, they too mentioned social norms as a barrier, but stressed more practical limitations.

Water in this arid climate is limited and soap is a relatively costly expense. Although people traditionally use water when using the latrine, or before prayers, it is unusual for people to wash their hands frequently with soap. Additionally, rural lives almost always? require contact with more people than just one family because multiple families live in close contact to provide mutual support. Most villages have central water points for clean household water, often attracting groups of people in the mornings and evenings.

The pandemic lockdown started just before the start of the main rain-fed agricultural season and continued through the entire rainy season.  Most households in rural Darfur depend on a combination of cultivating farms and herding livestock.  The work people do during the rainy season is critical to provide food and income for the rest of the year.  If people had remained at home in accordance with the containment measures, they risked food insecurity or even destitution.  The poorest depend on daily wage-labor, requiring them to leave their homes each day in search of work. Most families also depend on weekly visits to the marketplace to sell and purchase important items. Despite restrictions, many weekly village markets continued so that people could earn and income and buy what they needed.

Impact of the Containment Measures

The impact of the containment measures on a household depended in large part on how wealthy the household was and its sources of income.  In Central Darfur, livelihood options are limited and people often combine multiple activities in order to earn enough to meet their needs.  We can roughly group people by their main source of income – casual daily laborers, farmers, pastoralists, traders, and salaried employees.

The poorest depend on irregular labor that is paid daily and rarely received support from any party in the state.  They have little reserve and must violate the containment measures by leaving their homes and sometimes their villages to find work each day.  The containment made it difficult for them to find work to support themselves.

Farmers needed to go to their fields to cultivate during the rains that fell during the height of the pandemic.  Some farmers also depend on fuel for irrigation, plowing, and processing. The fuel shortage due to the economic crisis in the Sudan was compounded by the pandemic, forcing some farmers to move around the state looking for fuel, which cost them more money when they did find it.

Pastoralists depend heavily on markets to sell animals and buy food.  The central markets closed and major traders did not arrive from urban centers.  This forced pastoralists to use village markets where demand was not high and therefore prices were minimal, which meant pastoralists struggled to earn enough to buy what they needed.

Traders in Darfur move raw goods  and animals from rural to urban areas and manufactured goods from urban to rural areas.  When interstate travel was banned, long-distance traders no longer arrived.  Local traders could not access goods to sell and were afraid to go to Khartoum, where COVID-19 cases were highest, to get them.

Offices closed to one third capacity and many salaried employees, mostly men, were required to remain at home all day, against cultural norms, with no alternative locations to go to.  To avoid stigma or “social defect,” many found justifications to leave the house, which meant that they were meeting up with others.

Primary Conclusion

In my discussions, formal agencies focused primarily on funding, capacity, and logistical barriers to their own activities. On the other hand, community leaders emphasized the negative impacts of the policies on people’s livelihoods and cultural norms. (Both recognized weak health institutional capacity.)   The differences in barriers cited by members of the Ministry of Health, NGOs, and community members themselves indicate their different priorities.  Ministry of Health officials were focused on containing the pandemic using internationally promoted containment measures.  NGOs continued to pursue their program objectives, aiming to mitigate impact on those through additional, similar activities.  Communities, unconvinced of the imminent threat the pandemic posed to their personal health, prioritized their livelihoods and social norms.  Financial difficulties are a common barrier for people to be able to implement the health recommendations, but in this case, following some of the recommendations would have risked destitution for many families.  Neither the government nor the NGOs attempted to directly address these particular people’s barriers to implementing the virus containment measures nor the negative impacts on people’s livelihoods.  Therefore, containment measures went largely unheeded in Central Darfur.

Then why so few cases reported?

Despite the lack of adherence to pandemic containment measures, through October 2020 there have been few infections or deaths reported in Central Darfur. This small number of infections cannot be attributed to adherence to the Ministry of Health’s strict public health guidelines . There must be other factors that we do not know that have kept infection and death rates low. Among the possible causes is the long distance of the state from Khartoum which is considered as the main source of the disease for the rest of the country. Other possible causes are environmental factors such as high temperatures and dry air in the state, low population density, and diets based almost completely on natural forms of food, especially vegetables and fruits, which are abundant in the state, and even possibly infections with intestinal worms that change the immune system (Bradbury et al. 2020, Fonte et al. 2020). Finally, it is possible that there are more cases than recorded but were not detected due to limited testing, though there has not been unexplained excessive illness or death seen in the rural areas.

Authors

Musa Ismail is Director of the Institute of Peace, University of Zalingei, Central Darfur, Sudan.

with

Merry Fitzpatrick is a Researcher at the Feinstein International Center, Tufts University.

Acknowledgements

This study was conducted under the Taadoud II program, funded by DFID. Taadoud II, led by Catholic Relief Services, aims to improve natural resource management and governance, reduce chronic malnutrition, and increase the resilience of livelihoods of vulnerable populations within all five Darfur states to achieve more sustainable access to natural resources. The Feinstein International Center at Tufts University leads the operational research and uptake strategy in partnership with the University of Zalingei and the University of Al Fashir, both in Darfur.

(Author photo: Daily laborers continuing to work during the COVID-19 lockdown).

References

Bradbury, R. S., D. Piedrafita, A. Greenhill, and S. Mahanty. 2020. “Will helminth co-infection modulate COVID-19 severity in endemic regions?”  Nat Rev Immunol 20 (6):342. doi: 10.1038/s41577-020-0330-5.

Fonte, L., A. Acosta, M. E. Sarmiento, M. Ginori, G. Garcia, and M. N. Norazmi. 2020. “COVID-19 Lethality in Sub-Saharan Africa and Helminth Immune Modulation.”  Front Immunol 11:574910. doi: 10.3389/fimmu.2020.574910.

[1] https://www.worldometers.info/coronavirus/