Article: Cross-Border Socio-Economic Dynamics, community vulnerabilities and the Threat of Cholera Resurgence in Uganda: Insights from Kasese, Hoima, and Kikuube districts

BackgroundCholera remains a global public health threat, causing an estimated 1.3-4 million cases and up to 143,000 deaths annually, mostly in low- and middle-income countries with poor water, sanitation, and hygiene (WASH) systems. In sub-Saharan Africa, outbreaks are driven by poverty, displacement, climate change, and weak health systems. In Uganda, border districts such as Kasese, Kikuube, and Hoima remain vulnerable despite no reported cases since 2018 following vaccination campaigns. Socio-economic activities like fishing, cross-border trade, and seasonal farming continue to heighten exposure. These districts exemplify how livelihoods, mobility, and inadequate infrastructure converge to sustain cholera risks and threaten resurgence even after periods of apparent control. MethodsA qualitative study was conducted in the three districts of Hoima, Kikuube and Kasese in the Albertine region to explore the socio-economic and structural drivers of vulnerability to cholera resurgence. Data were collected through Focus Group Discussions (FGDs), Key Informant Interviews (KIIs), In-Depth Interviews (IDIs), and direct observation. Participants aged 18-77 years included community members, caregivers, health workers, and district officials. Nine FGDs, eleven KIIs, and ten IDIs were conducted. Analysis followed manifest and latent content approaches using open, axial, and selective coding, complemented by ChatGPT 4.5 for verification of meaning units. ResultsInadequate sanitation (open defecation and lack of toilets), unsafe drinking water, seasonal farming settlements without latrines, cross-border movements from the Democratic Republic of Congo (DRC), crowded or makeshift housing, and weak surveillance were identified as underlying vulnerabilities that erode the benefits of vaccination hence drugging these districts to a possible cholera resurgence. ConclusionThe drivers of cholera vulnerability are deeply interconnected: Cholera vulnerability in these districts is rooted in systemic inequities in sanitation, water access, and health infrastructure. Strengthening WASH systems, promoting hygiene behavior change, and improving cross-border surveillance are essential to achieving sustainable cholera elimination and resilience. SynopsisCholera, a preventable yet deadly diarrheal disease, continues to threaten millions globally, especially in regions where access to clean water and sanitation is limited. This study, conducted in Ugandas border districts of Kasese, Hoima, and Kikuube, explored how daily livelihoods such as fishing, farming, and cross-border trade intersect with environmental and social conditions to increase vulnerability to cholera resurgence. Through community discussions and interviews with health workers, local leaders, and residents, the research revealed how open defecation, unsafe water, migration, and poor housing sustain the risk of future outbreaks even after vaccination efforts. The findings provide crucial insights into how human behavior, ecology, and health systems interact, highlighting that preventing cholera is not only a medical issue but a social and environmental challenge. By understanding these links, the study contributes to global health and life sciences knowledge on infectious disease resilience, emphasizing the need for integrated interventions that combine water safety, community education, and stronger health infrastructure.