"NGOs, they cannot kill people": Cholera Vaccination in the Context of Humanitarian Crises in South Sudan

Cholera is endemic and remains a significant public health problem in places like South Sudan where decades of war have devastated basic infrastructures and left people vulnerable to diseases mostly forgotten in other places. In 2010, the World Health Organization (WHO) recommended that oral cholera vaccination (OCV) be used in conjunction with other cholera prevention and control measures and an OCV stockpile was created to improve access to the vaccines in situations of outbreaks, humanitarian emergencies and other high risk settings. Four years later, following the eruption of a violent political crisis that has left more than 50,000 people dead and another 2.5million displaced, OCV campaigns were conducted in PoCs (Protection of Civilian areas) across South Sudan with vaccines provided from the stockpile. This was the first use of the OCV stockpile in a humanitarian crisis. The potential social and health systems effects of the vaccine have so far been unexplored. This thesis uses qualitative methods to examine the socio-cultural and political dimensions of cholera and OCV campaigns among internally displaced Nuer people living in PoC areas in Juba, South Sudan, and their relation to perceptions of health, cholera risk and vaccination decisions. Interviews were conducted with humanitarian health professionals involved in the cholera response as well as with Nuer residents in the two PoCs where the OCV campaigns were conducted. Their narratives were interpreted with attention to the political and humanitarian crises in South Sudan as well as the humanitarian response by domestic and international actors. This thesis argues that the violent conflict, which led to the displacement of Nuers in Juba into UN-protected areas also led to changes in their conceptualization of risk and health. Both became intertwined in a socio-political narrative, framing the Dinka dominated SPLM government as a source of disease and UN/NGOs as a source of health. Cholera risk and vaccination decisions were described in non-political and political terms. Vaccination decisions were one of few means Nuers had of exercising political autonomy and control. Similarly, for humanitarian health professionals, the provision of OCVs was an essential aspect of building credibility and trust among Nuers in the PoCs. In this context, trust in institutions emerged as the most significant influence in vaccine decision making. The significance of trust, which is not encompassed in a typical “exposure-outcome” framework of epidemiology, also explains why vaccine recipients neither perceived their risk of cholera as diminishing nor perceived a reduced need for preventative practices, such as hand-washing, five months after vaccination. The thesis concludes that vaccination in a humanitarian crisis context warrants re-conceptualization not simply in an equation weighing epidemiological risk and disease perception on the part of the target population, nor a simple decision of doing what is best from the perspective of humanitarian actors, but as part of a complex process also considering the political and social dynamics surrounding health interventions and their influence on public willingness to accept them.