Roundtable discussion: Surveillance system challenges in conflict settings

SVEA CLOSSER: Hi my name is Svea Closser. And I’m here with Kunle Alonge and Anna Kalbarczyk. And we’re all faculty at the Johns Hopkins Bloomberg School of Public Health. And today I would love it if Anna and Kunle could discuss a little bit about surveillance in conflict settings. As we’ve discussed in this module, the Global Polio Eradication Initiative has surveillance programs in every corner of the world, and this includes areas with ongoing war and other kinds of conflict. So this presents some obvious challenges and maybe some that aren’t quite so obvious. So Anna, it would be great if you could start us off by talking a little bit about the experience in Syria.

ANNA KALBARCZYK: Sure. Well, that’s a great point. And we have a fantastic reading and resource on how conflict and insecurity influenced the polio program in Syria and then more broadly, in the Middle East. And the conflicts that arose in that region really undermined the polio program and threatened the amazing progress that had been achieved in that setting. And there were really concerns, particularly with the border of Turkey, that all of the progress that had been made with polio eradication was going to fall apart. And remarkably, I think, major teams were able to come in and respond and work with government and work with opposition groups in order to regain some of that ground and meet very at-risk populations.

But this was really, I think, the first time where we saw an area where there had been tremendous progress in polio just be completely threatened by conflict. And so I think for me, it also begs to reason that really long-term ongoing conflict in countries like Afghanistan and Nigeria would have wildly important implications for all types of health programs, including polio.

SVEA CLOSSER: Yeah, so what are some of those implications?

OLAKUNLE ALONGE: Yeah. I think the point you raised, Anna, it’s really important to show that indeed there are challenges with implementing surveillance in conflict setting. So the obvious challenge relates to infrastructure. So in conflict settings, there are clearly lack of infrastructures. And this lack of infrastructure add on to the cost of implementing the surveillance because you really have to mitigate some of these hardware [INAUDIBLE] in order to set up the system. And it also [? reveals ?] that insecurity threatens the lives of the personnel that are involved in the surveillance. So both the lives and the equipment are threatened.

So what happens is exactly some of the points that you were making, Anna, in regards to government and stakeholders trying to seek ways to overcome some of these challenges. And the implication is really that you create some incentive regimes that could– on the short term, they could help to alleviate the issues with regards to implementing surveillance in an insecure setting. But in the long term, they can actually threaten their system. So take for instance the Democratic Republic of Congo. You have scenarios where government and stakeholders had to bring in a lot of resources into very deprived communities in order to set up a surveillance system. And people responded to these resources.

They tried to create a whole trade and a whole business around some of these resources. And I created some incentives, in the sense that people felt this was really so– it wasn’t really fit into the reality of the existing system. So it was creating some distortion within the system. And that, again, led to a lot of community distrust and mistrust in terms of, OK, so you’re spending all of this money and these resources to overcome insecurity within this challenge– within that setting. What about other problems that we have? Why are you not talking about all of that?

So again, I think the obvious problem the fact that insecurity affects lives, it affects properties and equipment and that challenge with infrastructure and development. And these add to the cost of the program. But there are also longer-term implications, which is really the distortion to the system and the [INAUDIBLE] incentives regime.

SVEA CLOSSER: So yeah, so some of the things you can do in the short term that help you achieve surveillance can be problematic in the long term because they’re not integrated into the larger system.

OLAKUNLE ALONGE: Exactly.

SVEA CLOSSER: Yeah.

OLAKUNLE ALONGE: Exactly.

SVEA CLOSSER: Do we have any examples of places where this was maybe done better or slightly well, like where surveillance was more integrated? Or is it– has it been sort of a trend that this has been done in a way that had short-term gains but long term was more problematic?

OLAKUNLE ALONGE: Yeah. I wouldn’t say it’s a classical example. But I know there are principles we can follow. And this [INAUDIBLE] kind of allows you to mitigate even some of these long-term challenges at the outset of any intervention or strategies to address insecurity and conflict. So know in Nigeria, there were instances when there was participation between the community, and they stick with us. They were [INAUDIBLE] the surveillance. So there’s a lot of community education that was happening. And people understood why they needed to have the surveillance in place and why they needed to create these other systems in order to achieve the surveillance goals. So I think one key principle is actually participatory planning.

And that really requires you to engage with the community earlier. And I think that worked in Nigeria. And what that also helps to achieve is that there is some sense of ownership. And you’ll find some source of legitimacy to some of the setup that are put in place. So for instance, a lot of the people that were walking, the civilians, really they came from the community. And that was really because that was interaction with the community, engagement with the community. And that created some ownership within the setting. And of course, we could see how that contributed to success in places like Nigeria.

And again, it helps in transitioning or integrating some of these resources into the existing program because the community really feels involved or they’ll stick with us, feels involved. So they were trying to [INAUDIBLE] places on how to further use or extend the surveillance [INAUDIBLE] system challenges.

ANNA KALBARCZYK: And there were some similar tactics that were used in Afghanistan. I remember some findings about engaging local college students or university students to do some of this work, so again, really utilizing people on the ground who are there, who are part of communities and integrate to do some of those surveillance things that you might not be able to do in a conflict setting, like population mapping, trying to help with monitoring, trying to see what’s really going on on the ground, who’s getting the vaccine and who isn’t, so really engaging with people.

SVEA CLOSSER: Great. Well, thank you both so much, really appreciate it.

ANNA KALBARCZYK: Thank you, Svea.

OLAKUNLE ALONGE: Thank you, Svea. It’s really a pleasure.