Trans-Frontier Socio-Cultural Interactions and Learning for Epidemic Preparedness and Control

Abstract

West Africa’s extensive migratory activities and unregulated cross-border community interactions between countries pose challenges to epidemic preparedness and control. Understanding of the nature of these activities and interactions is therefore necessary for epidemic preparedness planning and response. We used a qualitative cross-sectional study to conduct focused group discussions and key informant interviews in contiguous border communities in Ghana and Burkina Faso to assess if and how cross border interactions compromise or facilitate management of public health emergencies. Knowledge and perception of the severity of epidemics in Ghana and Burkina Faso is high, and existing local networks and institutions have the capacity to effectively respond to public health emergencies when properly mobilized. Managing cross-border community interactions and interrelationships and respectful cross-cultural dialog among the multiplicity of stakeholders within and between the two countries is sine qua non for constructing a robust and responsive architecture for effective epidemic preparedness and control.

1. Introduction

West Africa is a beehive of activity. The sub region’s colonial past and haphazard partitioning into different political and linguistic boundaries has done little to curtail cross border movement of people, products and services [1, 2, 3, 4]. Besides, the rather liberal Economic Community of West African States (ECOWAS) Protocol (A/P.1/5/79) on free movement of persons, residence and establishment bolsters free trans-border movements [3].

Over time, the people have self-identified as one people, from one ancestry with a common destiny. Different tribes that have found themselves dispersed across the borders of countries have not resisted the lure of reconnecting. This is particularly so of the Kasena in Ghana and Burkina Faso who are sparsely distributed across contiguous communities between the two countries. Whereas these cross border movements – most of them unofficial - have fostered strong community bonds that may augur well for regional peace and security [5], they could also compromise the ability of health authorities to effectively respond to emergency situations. This leaves a wide room for speculation. What is the nature of these interactions and how do they strengthen cross border collaboration or weaken concerted action in cases of emergency such as the Ebola outbreak in West Africa and the global Coronavirus pandemic (COVID 19) that dismantled borders and devastated populations across the globe?

By August 2020, COVID-19 had spread across more than 200 countries infecting over 30 million people with close to 1 million deaths [6]. At about the same time, Ghana recorded 108,226 active COVID-19 cases with 874 deaths [7] whereas Burkina Faso’s active cases were 13,625 with 169 deaths at the same time [8]. The pandemic wreaked considerable economic and social costs, bringing down Ghana’s GDP by 27.9%, pushing 3.8 million Ghanaians into temporal poverty [9], and plunging the Burkinabe national economy into recession, compromising its ability to service its external debt [6]. Similarly, the 2013–2016 Ebola virus disease (EVD) outbreak in West Africa was the biggest in history. Having peaked at 28,646 infections and 11,323 deaths, it surpassed all previous outbreaks put together. Guinea, Liberia, and Sierra Leone bore the brunt of the 2015 Ebola outbreak that ravaged countries across West Africa [10, 11]. But Ebola did not enter Ghana. The setting up of a West African Ebola Response Center in Ghana to coordinate regional effort, and other national emergency response actions to combat the disease, are well documented. Yet what cross border communities, such as those between Ghana and Burkina Faso, did or did not do that stopped Ebola from crossing the border into Ghana, is relatively unexplored. Not all public health emergencies can be prevented, which means it is better to be prepared to handle them when they arise [10]. Though the importance of small cross-border trade and cross-cultural learning as a means of economic survival cannot be emphasized enough, challenges remain [5]. Sustained action by national and international partners to support wide-ranging epidemic control measures is critical, but solving basic operational problems to contain an epidemic largely requires a local approach and initiative [12]. To date, cross border trade, cultural and agricultural interactions and interrelationships among Kasena communities in Ghana and Burkina Faso are more of the norm than the exception [13]. This provides a unique opportunity to examine the nature and scope of these networks and cross border interactions and how they influence effective prevention and control of public health emergencies.

1.1 Cross border movements in ECOWAS

Migration is movement from a person’s usual residence across borders, either within States or between them [14]. But at the mention of the word migration, at least three other terms come to mind – Mobility, Translocality and Itinerant worker. Whereas Mobility is a relationship in which the world is lived and understood [15] translocality describes movements, among others, of people, goods and services across space and time with differing magnitudes [16]. An Itinerant worker moves from their usual place of residence to engage in short-term business transactions in another State or in a different part of the same State. Itinerant cross-border traders have built loose networks in the process of frequent trade mobility [5].

The Social Network theory can be used to explain cross border interactions. According to Killick, the importance of networks rank among the most important explanatory factors for migration [17]. Thus, the central role played by networks in cross-border mobility cannot be emphasized enough. Migrant networks go beyond borders as “sets of interpersonal ties that bring together migrants, non-migrants and former migrants in networks of kinship, friendship and common ancestry [17].

Cross-border trade in West Africa is therefore big business, and the flow of trade is determined by a complex web of relationships [5]. These movements happen within the legal regime of the ECOWAS Protocol (A/P.1/5/79) on Free Movement of Persons, Residence and Establishment. The protocol makes specific provisions for intra-regional movement with right “to enter, reside and establish in the territory of Member-states”. Females dominate informal cross-border trade and they have diverse socio-economic and cultural variables. They also differ in the volume and value of businesses, types of buying and selling activities, travel destinations and types of markets they operate in [18]. These cross-border trade movements are cyclical [16], and the kind of trade they engage in has strengthened social and economic bonds and has remained largely unchanged over a long period of time in spite of the boundaries created [19]. Itinerant traders, especially women, involved in Informal Cross-Border Trade are invisible within the framework of the ECOWAS protocol on Free Movement of Goods and Services across borders [20]. Attempts to remedy the situation through the ECOWAS Common Approach on Migration (2008), ECOWAS Gender and Migration Framework and Plan of Action (2015-2020) yielded limited results. The traders continue to be confronted with formal and informal rules and regulations that are not supportive of their local knowledge and practices [5]. They argue that this disrupts building new alliances and the creation of visions that are liberatory [21]. The ECOWAS protocol has failed to consider the socio-cultural composition of the itinerant traders’ worldviews on trade and free movement. According to Ref. [15], what migrants experience and think has been a lower research priority, to the extent that many of the realities of social life have been largely neglected. Bangu’s [5] research on border posts and informal entry points between Ghana, Togo and Burkina Faso, to determine the lived experiences of itinerant female traders, confirmed [22] report that informal cross-border business transactions potentially improve lives and livelihoods, especially of people living close to border communities. He however concluded that there is limited documented research on itinerant cross-border traders’ lived experiences and social realities in the context of the ECOWAS Protocol. The situation is much more uncertain about how these cross border interactions influence the management of public health emergencies, especially the two most recent epidemics, Ebola in West Africa and the global coronavirus pandemic (COVID-19). This paper focuses on what we can learn from these cross-border interactions and interrelationships for epidemic preparedness and control in the future. Specifically,

1. what is the nature of evidence of cross border interactions between Ghana and Burkina Faso?

2. what basic knowledge about Ebola and COVID-19 do people have?

3. what networks and institutions exist for preventing or effectively responding to public health emergencies?

4. what capacities exist for preventing or managing public health emergencies?

5. what are the pathways for effectively responding to or controlling public health emergencies?

2. Methodological approach

The studies were conducted in selected contiguous Kasem-speaking communities in the Kasena Nankana Municipality in the Upper East region of Ghana; and Kasem-speaking communities in the Commune Urbaine de Pô in the Nahouri Province in the Centre-sud region of Burkina Faso. Navrongo Municipal is one of the 15 districts in the Upper East Region. The Kasena in Ghana and Burkina Faso speak the Kasem language, share common cultural practices with common historical origins and linguistic affinity [23]. Though Ghana and Burkina Faso share common colonial history, Gold Coast, as Ghana was then known, was administered by the British using Indirect Rule whereas the French used Assimilation in now Burkina Faso [24]. A typographical error in respect of the spelling of “Yoo” in Burkina Faso and “Yua” in Ghana is said to be responsible for the current distribution of the Kasena in their current homeland straddling the two countries. The major occupation of the Kasena both in Ghana and Burkina Faso is agriculture, basically on subsistence basis with up to 96% of the population engaged in it. The rest is typically engaged in the informal sector of cross border trading, hunting, and cottage industry. Nearly nine out of 10 persons in the study area are said to be living below the poverty line [25].

2.1 Study area in Ghana

The Kasena Nankana East Municipal Assembly (KNMA), formerly Kasena-Nankana District, came into existence when the former Kasena-Nankana District, created in 1988, was split into two in 2008. Kasena-Nankana East was elevated to a municipal status in 2012 and renamed Kasena Nankana Municipal Assembly. The Municipal Assembly has a total land area of 767km² and a population of 134,018, comprising 48.8% male and 51.2% female as at 2021. Geographically, KNMA in Ghana is located on 10.8955° N, 1.0921° W. The Municipality was created by the Local Government Instrument (L.I) 1855 of 2007. It shares boundaries with Kasena-Nankana West to the west in Ghana, and Commune Urbaine de Pô and Commune de Tiébélé to the north in Burkina Faso.

2.2 Study area in Burkina Faso

Nahouri is one of the 45 Provinces of Burkina Faso and is located in the Centre-Sud administrative region with Pô as the capital. With a current population of 155,463, women constitute 52%. On healthcare, the Province has 19 health and social promotion centres (Centres de santé et de promotion sociale), 3 doctors and 67 nurses as at 2011. Temperatures range from 25 to 40°C. However, cold and dry Harmattan is also characteristic of the Province around December to March each year. In Burkina Faso, the geographical coordinates of Commune Urbaine de Pô are 11.1697° N, 1.1450° W°. The dominant ethnic groupings in the Province include Kasena and Nankana with most people being multi-lingual as a result of long history of coexistence, interactions and inter-marriages. About 95% of households in the Nahouri Province have no access to toilet facilities and about 90% dispose of their rubbish in a heap outside the house. Also, 68% of households fetch their drinking water from either pond, dug outs or dams and only about 16.3% have access to standpipes or boreholes.

In Burkina Faso, data were collected from the communities of Adong, Dakola, Kayaa and Pô, whereas in Ghana, data were collected from Manyoro, Paga, Pindaa, and Wanjagenia.

2.3 Research design

Research design refers to the systematic plan used for answering the research questions of a study, from conception to data collection and analysis [26]. In order to arrive at a better understanding of the research purpose, the two studies adopted embedded mixed methods, that is, using a combination of qualitative and quantitative approaches for data collection.

“Whereas quantitative or deductive researchers go out in search of data to match a theory, qualitative or inductive researchers go out hoping to find a theory that explains their data from observations and intuitive understandings gained in the field” (Merriam, 1997, 1998, as cited in [27].

The first study assessed community interactions during the Ebola outbreak of 2015 while the second assessed community perceptions of COVID-19 after the relaxation of restrictions including the reopening of Ghana’s borders with Burkina Faso in June 2020. The studies were cross-sectional and non-experimental, using a descriptive case study design complemented by non-participant observation. According to [26] case study is an empirical investigation of phenomena in their natural context. Considering the objectives of the studies, there was the need to describe the nature of cross border social networking and how these influence communities’ capacity to prepare and respond to emergency situations.

2.4 Research methods

The primary data collection methods were Key Informant Interviews and Focus Group Discussions, which elicited information from people regarded as repositories of information. Semi-structured interviews were used to guide key informant interviews and focus group discussions because they provide considerable flexibility for the researcher to survey respondents while maintaining the basic structure of the interview. Although this was a guided conversation between researchers and interviewees, there was the need for be considerable flexibility for the researchers.

2.4.1 Focus group discussion

Focus Group Discussions (FGDs) enable researchers obtain in-depth information that can be analyzed for perceptions, attitudes, feelings and beliefs about issues pertaining to the objectives of a study [27]. Cross section of Focus Group discussants:

• Clan/Lineage Heads, Elders, Thought Leaders/Opinion Leaders (women and men)

• Trade associations, farmer associations, community networks, youth groups

These were prioritized ahead of others to compose the focus group discussions because, by virtue of their positions and traditional roles, they are endowed with important information about the community, its traditions and belief systems and practices. The focus groups also served as a pool from which key informants were identified and followed up later in the research. The use of Focus Group Discussion as a method allowed for the observation of group dynamics, discussions, and first-hand insights into the behavior, attitudes, and opinions of community stakeholders such as thought leaders, chiefs and indigenous institutional functionaries on issues relating to cross border movements and interactions and how these affect the delivery of public health interventions.

2.4.2 Key informant interviews

This requires careful selection of participants considered to be the most knowledgeable on the subject. Key Informant Interviews (KIIs) allowed the researchers to probe respondents and guide the interviews according to the respondent’s answers [28]. Key Informant Interviews is one of the methods that make up for the limitations of Observation as a method of data collection, whether structured or unstructured. The indirect approach to conducting interviews enables the researcher to obtain answers, which the respondents may not consciously be aware.

2.5 Sampling and inclusion criteria

Community traditional leaders were earmarked for in-depth interviews. Additional key informants were obtained through snowballing or identified from focus group discussants. Participants for the KIIs and FGDs were selected based on a predetermined inclusion criteria. Respondents aged 18 years and above, traditional authorities, opinion leadership, local political actors, civil society organizations, immigration officers and traders met the inclusion criteria.

2.6 Data collection instruments

• Focus group discussion guide

• Semi-structured interview guide

• Digital audio recorder

• Digital camera

2.7 Analytical approach

Audio recordings were transcribed and translated into English and coded before using the conventional content analysis approach to analyze the qualitative data. This was suitable for these studies given that existing research literature on cross border interactions in the study area is limited. Conventional content analysis steps were used in the data analysis during which transcripts were first read through to achieve immersion and obtain a sense of the whole. Codes were derived from the text, by first highlighting the exact words from the text that captured key thoughts or concepts which were then grouped into themes. The qualitative data was then analyzed quantitatively to get both an understanding of people’s perspectives and feelings as well as the general distribution of opinion among study respondents on key variables. This allowed the transcribed data to be organized, analyzed and visualized for presentation.

2.8 Ethical considerations

Ethical issues surrounding the study were considered and addressed first by assuring participants that the research was purely for academic and public health purposes and not to assess their competencies, legality or profitability of their cross-border dealings. Secondly, the consent of all participants was sought before interviews were conducted. An assurance was given to those who declined to participate or discontinued the process after the interview got under way. Participants were also educated to decline answering questions that they were not comfortable with. And as way of deepening confidentiality, participants were assured that their personal details and private information will not be exposed in the report.

3. Results and interpretation

3.1 Evidence of cross border interactions

Contiguous communities between Ghana and Burkina Faso regularly cross the border to reconnect with their kith and kin because they see themselves as one people separated by an artificial border:

“When you come here, we say ‘a member of our household has come’, and when we also come to your home, you’d say a member of your household has come. So now that you are here, when someone asks me, I would say ‘a member of our household has come to trace the family ancestry’. What is more edifying than that?” - key informant, Commune de Tiébélé, Burkina Faso.

The two studies uncovered considerable cross border movements and activities between Ghana and Burkina Faso:

“We have our farms several kilometers across the border into Burkina Faso where our Ancestors lived and farmed long before the colonial period. We still cross over to farm without any difficulties” – Key Informant from Pindaa in the Navrongo Municipality of Ghana.

A key informant from Adong in the Commune Urbaine de Pô in Burkina Faso confirmed this information:

“The people of Pindaa have their farms deep inside our territory where they have cultivated till date without any dispute with us. In the same way, our people regularly cross the border into Pindaa [in Ghana] to have their children vaccinated during national immunization days. They have not been turned away before because we are one people”.

“During the off-farming season here, our people go to Ghana and farm and on their return they buy agrochemicals [because the agrochemicals are cheaper in Ghana]” – Key informant from Pô of the Commune Urbaine de Pô in Burkina Faso.

Most of the cross-border movements involved the use of unapproved and unmanned routes, thus circumventing the closure of Ghana’s borders with Burkina Faso during the COVID-19 period.

3.2 Basic knowledge about Ebola and COVID-19

The epidemiology of the Ebola disease was well known to most study participants with 83% mentioning correctly at least one country that was affected by Ebola in West Africa. Knowledge of the epidemiology of COVID-19 was varied, with many people not knowing how it started or where it came from. However, all participants said COVID-19 pandemic had affected all countries. Twenty-eight of forty three respondents or almost two-thirds (65.1%) were able to mention at least three ways of preventing the spread of COVID-19. Knowledge about Ebola and COVID-19 was high among community members and this augurs well for effective prevention and control measures in health emergency situations.

3.3 Public health emergency response networks

The two studies also identified a network of individuals and organizations that are involved in emergency/disaster prevention/response work in both countries. Distinct to Burkina Faso were Action sociale and the Armed forces, whereas those peculiar to Ghana were the National Disaster Management Organization (NADMO) and the National Commission on Civic Education (NCCE). For obvious reasons, the health sector, including the ministries of health, doctors, hospitals, health directorates, health workers, health volunteers, veterinary officers and environmental health workers, were deeply involved in the Ebola and COVID-19 response in both countries. With regard to COVID-19, a woman at Kayaa in the Commune Urbaine de Pô in Burkina Faso stated that “the doctors, if you seek early treatment from them, they can prevent you from dying from the disease”. Critical structures common to both countries were research institutions, transport operators especially long-distance truck drivers (whose work was curtailed during COVID-19), the Red Cross and Red Crescent Society, border security, district assemblies, traditional and religious leaders, media and information services. Both Ghana and Burkina Faso have a decentralized system of government that can serve as the basic infrastructure for managing epidemics at the local level. Under Burkina Faso’s le Code Général des Collectivités Territoriales (CGCT), the Conseiller heads the Conseils Villageois de Développement (CVD). This is the equivalent of Ghana’s local government system and the District Assembly with the Assembly member who chairs the Unit Committee. The CVDs or Unit Committees can be the first line personnel at the community level who can be trained to conduct disease surveillance to support the health system. A network of institutions therefore exists in both Ghana and Burkina Faso that can be mobilized in cases of health emergencies.

3.4 Capacity for managing public health emergencies

For Ebola and COVID-19, like any other disaster with devastative impact on victims and the entirety of communities, there is the need for capacity to prevent or respond effectively to possible outbreaks. Respondents identified and emphasized the need for communities and organizations within each country to work collaboratively towards the management of any emergency.

Knowledge was identified as a bedrock to curbing Ebola and COVID-19. A focus group discussant from Dakola in the Commune Urbaine de Pô in Burkina Faso asked a rhetorical question:

“Knowledge differs from individual to individual, from community to community and from country to country. So should we not find a way to learn from each other?”

Thus, cross-cultural learning and unity of purpose are key for effective handling of public health emergencies. Participants’ idea of working together spans sharing of information, skills and experiences, sharing or pooling resources together, taking collective decisions and distribution of tasks, and building of trust among parties. Nearly all respondents (98.6%) agreed that networking among cross-border communities and organizations is critical for the prevention of Ebola. A Key Informant from Wanjagenia in the Navrongo Municipality in Ghana emphasized the rationale for people to work together; “The destructive nature of the disease [Ebola] and the speed at which it spreads makes collaboration a must”. A focus group discussant from Kayaa in the Commune Urbaine de Pô in Burkina Faso was more specific; “We also need to form joint task forces, effective border checks and screening, real time communication, and sharing of new technology in the fight against Ebola”.

The capacity and opportunity for Ghana and Burkina Faso to collaborate to respond to emergencies is huge but challenges, mainly of mistrust and bureaucratic bottlenecks, remain that need to be addressed.

Inadequate training of health staff and volunteers, scarcity of logistics such as hand gloves, veronica buckets, nose masks, overalls, detergents, as well as the language barrier and poor road network were mentioned as key challenges to effective collaboration to combat public health emergencies such as Ebola and COVID-19.

The capacity of persons, communities and organizations to effectively deal with challenges of disease prevention and control - though currently weak – is crucial as it underpins the ability to mobilize, deploy and judiciously use both human and material resources.

3.5 Pathways to effective epidemic response

The studies found several ways through which the capacities of individuals, organizations and communities can be strengthened to prevent or effectively respond to an outbreak of Ebola in Ghana. Of these, training of health workers, volunteers and Red Cross officials in Ebola prevention and treatment was highlighted.

Continuous education and sensitization of the general public also ranked high as 87% and 92% of respondents of the Ebola and COVID-19 studies respectively highlighted them. Sustainable financing was however identified as the pivot to addressing most of the challenges;

“All the logistics needed, once there’s money, they can be acquired in order for work to be effectively done” – A focus group discussant from Adongo in the Commune Urbaine de Pô in Burkina Faso.

The use of social networks and indigenous knowledge was also identified as a key strategy for effectively managing cross border activities.

“We ordinary community members should not be left out. Day in day out we see people pass through our communities in and out of the country. So if any disease is coming it will affect us first. We can also be trained to screen people most of whom are arriving without travel or medical health records” – Focus group discussant, Nahouri, Commune Urbaine de Pô, Burkina Faso.

Within and between Ghana and Burkina Faso, pathways to effective management of public health emergencies are many and varied.

4. Conclusions

People in the West African subregion are known for their extensive cross border activities, mostly using unregulated routes. This study sought to illuminate understanding about how these cross-border interactions and interrelationships between Ghana and Burkina Faso specifically, compromise or facilitate management of public health emergencies, using the Ebola outbreak in West Africa and the global coronavirus pandemic (COVID-19) as case studies. We found that knowledge and perception of the severity of epidemics was high but challenges of human and material resources remain. There also exists a myriad of local networks and institutions that have the capacity to effectively respond to public health emergencies but they are not efficiently mobilized both within and between countries. Collaboration at different levels is key, but managing cross-border community interactions and interrelationships requires respectful dialog among the multiplicity of stakeholders identified. Given the porous nature of the borders between Ghana and Burkina Faso in particular, and West Africa generally, inter-country networking and cross-cultural learning are sine qua non for constructing a robust and responsive architecture for effective epidemic preparedness and control in West Africa.

Acknowledgments

We respectfully acknowledge our diligent research assistants who helped collect quality data from the field, as well as the forbearance of our research participants in Ghana and Burkina Faso without whose cooperation and perspectives this work would not have been done. All the institutional heads and representatives who supported us throughout the fieldwork are equally duly acknowledged. We are grateful to all those who contributed to this research, no matter how infinitesimal, but have not been singled out for special mention. Funding for this study was made available through a small grant by the American Red Cross Society’s Global Disaster Preparedness Center in partnership with Response to Resilience, an NGO registered in the United States of America.

Author contribution

Dennis Chirawurah: Development of the concept and design of the study, team lead for field data collection, revision and approval of Book Chapter final draft.

Stephen Apanga: Design of study instruments, supervision of field data collection and data interpretation, revision and approval of Book Chapter final draft.

Niagia Santuah: Contribution to data collection and interpretation, drafting of the study report and literature search, revision and approval of Book Chapter final draft.