South Sudanese refugees in Uganda face overwhelming odds against COVID-19
Life in Northern Uganda’s Kiryandongo refugee settlement is difficult at the best of times. Nearly 60,000 refugees, who are predominantly South Sudanese, contend with overcrowding and limited access to healthcare services, especially mental health and psychosocial support. It is into this environment that the COVID-19 pandemic will soon be introduced.
COVID-19 prevention messages (Source: Unicef South Sudan)
“Case numbers are increasing exponentially in the African region,” said Dr Matshidiso Moeti, the World Health Organization (WHO) regional director for Africa. It took twenty-six days to reach one-thousand cases of COVID-19 in Africa. Five days later, the number of cases had tripled across the continent. When this highly infectious respiratory disease arrives in Kiryandongo, the results may be devastating.
Professor Pauline Byakika, a specialist in infectious diseases at Uganda’s Makerere University, says that fighting the virus in a refugee camp will come down to prevention and control. The United Nations High Commissioner for Refugees (UNHCR) agrees. At Uganda’s border, the UN has established handwashing and temperature screening facilities. They are educating refugees already in Uganda about hygiene and sanitation while training health workers and increasing distribution of hygiene products. Such measures may keep the daily number of cases at a low level. However, flattening the curve in a refugee settlement may not be enough. A review of the Kiryandongo refugee settlement’s healthcare system reveals that any number of cases above zero should be considered unmanageable.
The Kiryandongo refugee settlement has three primary healthcare facilities. The health centres that are available are understaffed and under-resourced. Making matters more challenging, Professor Thumbi Ndung’u of the African Institute for Health Research says that, “[Africa doesn’t] have the hospitals, the ICUs or the ventilators to deal with massive amounts of [infected] people.” The COVID-19 pandemic has imposed unprecedented challenges on healthcare systems in developed nations, resulting in problems with staffing and resources. A system that is understaffed and under-resourced to begin with, such as in refugee settlements, is not well-positioned to meet the challenge of a highly infectious disease.
Jane Ruth Aceng, Uganda’s minister of health, says the country is prepared to handle an outbreak in their refugee settlements. “We have tents that we have procured, and [which are] ready to be set up to manage people who may get infected wherever. For those who are severely ill, they will be referred and managed in the regional referral hospitals whose capacities are being built to handle COVID-19.” Uganda’s minister of health suggests that refugees with the virus will be properly quarantined.
One would expect Uganda to be at the forefront of protecting refugees against COVID-19, as they have long protected refugees from other crises, such as the conflict in South Sudan. Uganda is known for its progressive refugee policies and allocating land plots to individual refugee families. Their generous policies have so far attracted 1.4 million refugees, mainly from neighbouring South Sudan and the Democratic Republic of Congo.
Of the more than 800,000 South Sudanese refugees in Uganda, a reported 13,500 of them arrived between January 1 and March 24 2020. However, on March 25, the government made the decision to close its borders to new refugees. In fairness, Uganda may only have been following the lead of the European Union. Several weeks earlier, the EU’s foreign policy chief, Josep Borrell, told migrants in Turkey: “Don’t go to the border. The border is not open.” But as Filippo Grandi, the UN High Commissioner for Refugees, has pointed out, “everyday life has come to a standstill… [but] wars and persecution have not stopped…”  Less than a week after the Commissioner’s statement, Uganda closed its borders, putting South Sudanese refugees, and their own nationals, at risk.
However, it is not easy to close a large open border like Uganda’s overnight. Titus Jogo, the Refugee Desk Officer in Adjumani, a small town in the Northern Region of Uganda that hosts many refugees, says that despite the closure they receive between 30-34 South Sudanese people per day. The refugees enter through informal border crossings, collect food and money from humanitarian agencies and then cross back into South Sudan. While in Adjumani, the South Sudanese come in direct contact with townspeople, against what are now common practices of social distancing. With the border officially closed, the South Sudanese individuals still entering Uganda are likely to forgo the UNHCR’s disease monitoring efforts in fear of reprisals. Closing borders to non-essential travellers is perhaps a positive measure in most circumstances around the world. In this case however, closing the border to refugees discourages monitoring and increases back-and-forth travel, exposing both countries to higher risk of transmission of the virus.
Beyond measures of prevention and control, however successful, further measures will be required to manage the hidden and potentially fatal effects of the virus. Stress, anxiety and depression caused by the pandemic will compound the already challenging mental health statistics among South Sudanese refugees living in settlements in Uganda. In these settlements, suicides more than doubled in 2019 compared to the previous year, the UNHCR reported. The UN Refugee Agency attributes the higher rate of suicide to key factors such as, “sexual and gender-based violence, traumatic events both before fleeing the home country and after arriving at a refugee settlement, extreme poverty, and lack of meaningful access to education and jobs.” The pandemic will only increase the need for mental health support on a system that is already beyond strained. Of all the South Sudanese refugees who sought mental health and psychosocial support in 2019, only 29 percent received them.
Many people in the world affected by COVID-19 will have to confront mental health hurdles. However, those not living in refugee settlements are better equipped to handle day-to-day mental health issues. The WHO, in its considerations for improving mental health during the crisis, emphasizes the importance of maintaining a regular schedule: regular meals, regular sleep, regular exercise, regular contact within social networks while encouraging children to participate often in fun and educational activities. In the Kiryandongo refugee settlement, where meals, potable water and access to jobs and education are lacking, maintaining a regular schedule was already a struggle. Therefore, entirely novel approaches are required in order to support mental health and psychosocial wellness in the settlement. Just as Uganda’s government and the UNHCR have implemented measures to monitor and control the virus to flatten the curve of respiratory illness, a similar dedication is required to screen for signs of mental health concerns. Such a programme, however, will likely only exist once basic needs are met within the settlement.
A COVID-19 vaccine will not be available to South Sudanese refugees for at least 18 months. In the meantime, those in the Kiryandongo refugee settlement, and in Uganda, Africa and the rest of the world, need to take positive steps to limit the disease’s spread. These measures include:
- Training Village Health Team community health workers in understanding COVID-19 and recruiting them to educate refugees and promote hand washing. If soaps and hand sanitizer is in limited supply, refugees can be trained in soap making as has been the case in Kiryandongo. Locally produced soap can be purchased by UNHCR or non-governmental organizations for distribution to all households in refugee settlements and local host communities.
- Training Village Health Team workers to educate refugees on the importance of physical distancing including limiting the number of people who meet together at any one time. Refugees over 70 years old or with additional underlying conditions should be especially protected.
- Church leaders, other faith leaders and other community leaders should be recruited to pass educational messages to their congregations and communities.
- If they come to be required by WHO, cotton face masks can be produced by local refugee tailors, procured by UNHCR or non-governmental organizations, and distributed to refugees and member of host communities living outside refugee settlements.
- If possible, testing refugees to identify asymptomatic people who already have the disease with a view to isolating these people to prevent further spread.
Frontline health workers in health facilities also need to be equipped with proper personal protective equipment. In 2019, the UNHCR and its partners secured only 40 percent of the US$927 million needed to assist refugees and host communities in Uganda. The need for funding, particularly in the healthcare sector to purchase needed equipment and supplies, will surely grow during the pandemic. Jack Dorsey, Twitter’s chief executive, has pledged to donate US$1bn to a charitable fund, called Start Small, to “fund global COVID-19 relief”. Organizations like the Real Medicine Foundation which is running health facilities in the Kiryandongo settlement as well as training of nurses in the Juba College of Nursing and midwifery (JCONAM) should be encouraged to apply for some of this emergency funding to help prepare the settlement for the looming pandemic. In these ways the refugees themselves, the Village Health Team community health workers, the UNHCR and non-governmental organizations and others can support South Sudanese refugees like those in the Kiryandongo settlement and provide the resources and knowledge they need to beat the odds against COVID-19.
- Atari, O. and McKague, K. Using Livelihoods to Support Primary Health Care for South Sudanese Refugees in Kiryandongo, Uganda. South Sudan Medical Journal, 2019; 12(2): 38-43.
- 2.United Nations High Commissioner for Refugees, Uganda Refugee Response Monitoring Settlement Fact Sheet: Kiryandongo - January 2018, 31 January 2018.
- United Nations High Commissioner for Refugees, Suicides on the rise among South Sudanese refugees in Uganda, 24 January 2020.
- The Guardian, Coronavirus in Africa: what happens next? | Global development, 8 April 2020.
- The Guardian, Mogadishu's refugees 'waiting for death' as Covid-19 reaches Somalia, 24 March 2020.
- UN News, UN refugee agency ‘rapidly adjusting’ the way it works amid COVID-19 pandemic, 1 April 2020.
- New York Times, Uganda, Usually Welcoming to Refugees, Bars All New Arrivals to Contain Coronavirus, 25 March 2020.
- The Guardian, Refugees told 'Europe is closed' as tensions rise at Greece-Turkey border | Refugees, 6 March 2020.
- United Nations High Commissioner for Refugees, Statement by Filippo Grandi, UN High Commissioner for Refugees, on the COVID-19 crisis, 19 March 2020.
- The Independent, South Sudanese refugees still entering Uganda despite border closure, 30 March 2020.
- World Health Organization, Mental health and psychosocial considerations during the COVID-19 outbreak, 18 March 2020.
- The Guardian, Twitter chief to donate quarter of his fortune to coronavirus fight, 7 April 2020.
Further reading on COVID-19 and vulnerable groups:
World Health Organization Coronavirus disease (COVID-19) technical guidance: Humanitarian operations, camps and other fragile settings
Interagency Standing Committee COVID-19: How to include marginalized and vulnerable people in risk communication and community engagement
About the Author: Dr Kevin McKague is the Canada Research Chair in Social Enterprise and Inclusive Markets at Cape Breton University, a Visiting Researcher at the Centre for Refugee Studies at York University and a Research Fellow at the Centre for Peace, Democracy and Development at the University of Massachusetts, Boston.