Perspectives of public health professionals on border control practices for COVID-19 management in Europe

Objectives During the COVID-19 pandemic, internal European borders were temporarily re-established to mitigate the outbreak. Much research on pandemic border control measures has focused on quantifying their effectiveness for infectious disease control as well as on their social consequences for cross-border life in the European Union. However, little attention has been paid to the impacts for the practice and organisation of cross-border public health. To address this gap, the present study analysed the experiences and perspectives of public health professionals working in European border regions regarding border control measures in the pandemic. Study design Qualitative interview-based study. Methods In total, 27 semistructured interviews with public health professionals were conducted in the border regions between Germany, the Netherlands and Belgium. Participants were asked about their perspectives on border control and the spread of COVID-19 in the region. Interviews were performed between December 2020 and April 2021 and carried out in German, English, Dutch and French. Results Before the COVID-19 pandemic, borders had become largely invisible with extensive cross-border social life and mobility. Participants were sceptical about the role of cross-border mobility as a pandemic driver and consequently the effectiveness of enforcing border control for reducing the spread of COVID-19 in their border regions. At the same time, participants raised concerns about the negative consequences for the social fabric and provision of cross-border public health. Conclusions Public health professionals highlighted the uncertain role of border control measures for regional infectious disease control in border regions. Rather than border control, sustainable cross-border communication and collaboration is crucial to ensure effective pandemic management in border regions.


Introduction
During the COVID-19 pandemic, despite the World Health Organisation recommendations against travel restrictions, 1 border control measures were imposed at an unprecedented global scale to regulate and reduce the spread of the novel virus. Although border control measures varied in their rigidity, they posed significant challenges to the ideals of a 'borderless' European Union (EU), where borders have been systematically dismantled over recent decades. 2 These challenges were particularly evident in European border regions because an estimated 37.5% of EU citizens live in these border areas 3 and, in 2020, almost 2 million EU residents worked across the border in a neighbouring country. 4 The widespread pandemic resecuritisation of borders across the EU was rather controversial. Advocates justified it as necessary to contain the spread of COVID-19 and protect citizens' health and security. 5 Critics, on the other hand, pointed to international and European laws, disruptions for cross-border life, socio-economic costs and the inappropriateness of nationalistic, rather than collaborative, responses to a global crisis. 6e8 Numerous studies have focused on assessing the effectiveness of border controls for COVID-19 management. These studies, largely based on quantitative modelling, have yielded inconclusive and sometimes conflicting findings, 9,10 with some showing that travel-related measures reduced the spread of disease 11,12 and others describing limited or no effects. 13 In addition, the insights provided by modelling approaches have been criticised for lacking 'real-life' evidence and contextual understanding of public health experiences related to border control and cross-border movements. 10,14 From the beginning of the pandemic, social sciences and public health scholars have reflected upon the meanings and consequences of border control on cross-border realities in the EU. For instance, Novotný and B€ ohm analysed the experiences of German-Czech cross-border commuters, highlighting the complexities of navigating different national COVID-19 regulations and the lack of crossborder management systems supporting commuters during the pandemic. 15 A similar study by Opiola and B€ ohm focused on the challenges created by border control measures for cross-border governance in Polish borderlands. 16 Another research by Medeiros et al. argued that 'covidfencing' strategies adopted by many EU countries highlighted the urgent need for improving cross-border cooperation in economic, social, as well as public health spheres. 2 Although different studies investigated the experiences of EU cross-border commuters and the role of national border policies for the governance of border regions, the present article focuses on the practices, experiences and organisation of cross-border public health. Specifically, the experiences of public health professionals involved in COVID-19 management in the border region between North Rhine-Westphalia (NRW) in Germany, the Netherlands and Belgium were analysed. This study aimed to understand how local public health professionals perceived and experienced border control measures in their border region. By exploring their perspectives, this study provides in-depth, empirical insights on the role and consequences of pandemic border control in a specific European border region.

Study design and participants
NRW, the Netherlands and Belgium have a shared border of about 500 km and constitute one of the EU's oldest and most integrated internal border areas. For instance, in 2019, 7490 Dutch and 5160 Belgian people worked in NRW. 17 Before the COVID-19 pandemic, public health professionals working in the region had initiated and developed various forms of cross-border collaborations for infectious disease control (IDC), such as notification forms for various infectious diseases and antimicrobial resistance. 18 During the pandemic, the three countries applied different border control policies, making this border region a particularly rich research setting (Panel 1). To explore the perspectives of public health professionals, an empirical research based on the collection of semistructured interviews with German, Dutch and Belgian public health professionals involved in the local management of the COVID-19 pandemic was conducted. Based on purposive and snowball sampling, participants in relevant border regions from all three countries were recruited via e-mail or phone through the authors' professional networks and participants' contacts. Relevant regions included the NRW districts of Borken, Kleve, Viersen, Heinsberg, Aachen, Euskirchen and Düren, the Dutch provinces of Dutch-Limburg, Gelderland and Twente, and the Belgian provinces of Belgian-Limburg and Li ege.

Procedures
Between December 2020 and April 2021, interviews were conducted through video or phone calls. Reflecting the region's linguistic diversity, interviews were held in German, Dutch, French and English by the authors L.D. and A.K. who are native or fluent in the respective language. The interviews were conducted using a predetermined topic guide (Panel 2) focusing on the respondents' perspectives related to the public health management of COVID-19 in their border region, with particular emphasis on cross-border aspects. The topic guide was informed by the main research question of this study and a literature review on cross-border COVID-19 management published between December 2019 and December 2020, which was conducted iteratively by L.D. and A.K. The topic guide was piloted during the first three interviews and refined accordingly.
The interviews were audio recorded and transcribed verbatim. Postinterview peer debriefings allowed for iterative preliminary analysis and assessment of data saturation. Following deidentification, interview transcripts were entered into NVivo 12 (QSR International). The interviews were analysed using thematic analysis. 19 Coding followed the themes covered in the topic guide, with additional themes emerging inductively during the analysis process (Panel 3). Due to the language requirements, L.D. and A.K. separately coded a subset of transcripts; where in doubt, they compared and discussed codes until reaching consensus. Analysis and validation of the analysis were done through discussions among L.D., A.K. and K.H. As an additional validation step, two online group feedback meetings in Dutch and German with the participants were organised; the results from these discussions resulted in adaptation and refinement of the analysis. All quotes cited in the following sections were translated, where necessary, into English by the authors. Quotes (Panel 4) are anonymised by using a letterenumber combination (e.g., G1, N2, B3), with the letters indicating Germany, the Netherlands and Belgium, respectively.
All participants provided written informed consent. The study was approved by the research ethics committee of the Faculty of Health, Medicine and Life Sciences of Maastricht University (the approval number is FHML-REC/2021/002).

Results
In total, 38 experts across the three countries were approached to participate in the study; however, 11 declined or did not reply, resulting in a final sample size of 26 interviews and one written reply (11 in Germany, 10 in the Netherlands and six in Belgium). Of the 27 participants, 13 were female and 14 were male. Nine experts attended the feedback sessions. Participants joined the online interview from their workplace or from home. Most respondents worked in different positions for the regional public health services. The remaining participants included general practitioners and staff at public administrations, disaster relief organisations, and COVID-19 test and contact tracing centres. Most respondents held senior positions, although there were also a few participants with junior positions. Interviews lasted between 23 and 86 minutes.
People and goods cross borders daily for numerous purposes, as many residents live in one country and work on the other side of the border, whereas their children might go to kindergarten or school in the third country. In addition, many border region residents have relatives in care homes across the border. Several participants emphasised the border proximity as being a positive factor in their quality of life by enabling wider choices and opportunities. Examples included making regular use of schools, childcare and health care in the neighbouring country, visiting markets and restaurants, and buying groceries or gasoline where prices are cheapest. However, although borders were perceived as either irrelevant or beneficial for the social life of border region residents, the study participants highlighted that borders Panel 1 Border control policies in North Rhine-Westphalia (NRW) in Germany, the Netherlands and Belgium.
Throughout the COVID-19 pandemic, Germany, the Netherlands and Belgium pursued different and frequently changing border control policies, creating a complex and often confusing situation for border residents and public health professionals alike. While only a very general overview can be provided here, the timeline of measures and their changes in three countries can be found on the website of Interreg Euregio Meuse-Rhine Pandemic. 20 Border control policies demonstrated a continuum of verifying degrees of limitations for cross-border mobility, with border closure as the most radical measure. The Netherlands opted against border closures but issued negative travel advice, including for Germany and Belgium, and entry bans from select, high-risk areas (e.g. virus mutation areas). While Germany temporarily closed its borders with several of its neighbours, the political will was to keep the Dutch and Belgian borders open. Although Germany, too, issued travel alerts for the Netherlands and Belgium on classifying them as high-risk areas, special emphasis was placed to ensure the seamlessness of essential border crossings and 'small border traffic' (i.e. short trips of <24 hours). Of the three countries in this study, Belgium followed the most restrictive border strategy. In March 2020 and January 2021, the country temporarily and physically (e.g. through barricades) closed its borders for all non-essential inbound and outbound travel for several months. As in Germany, exceptions to ensure travel for essential purposes have been included in the Belgian legislation. The following example illustrates the complexity around border policies between the three countries. As part of their border management, all three counties introduced various requirements for testing and quarantining. For instance, in December 2020, travellers going from Belgium to the Netherlands by car did not require a negative COVID-19 test. At the same time, when travelling vice versa, a negative test was required if travellers stayed for more than 48 hours in Belgium. For commuters from Germany to the Netherlands, there were no test nor quarantine restrictions in late 2020 and early 2021, whereas commuters from the Netherlands to Germany were required to register in Germany before their arrival and to have a negative PCR or a rapid antigen test taken no more than 48h before arrival.

Panel 2
Detailed interview guide. continue to manifest in jurisdictional and administrative matters, for instance, regarding social security for cross-border workers. These juridical and administrative obstacles became much more visible during the COVID-19 pandemic, hindering the potential for crossborder public health collaborations.

COVID-19 cross-border mobility and consequences of border control measures
Public health professionals provided varied accounts regarding the role of cross-border mobility in the spread of COVID-19 in their border regions. A commonly experienced challenge in this regard was the lack of pertinent data, as most public health data were based on country-specific infrastructures that varied in how a 'case' was defined and calculated. However, based on their local and regional pandemic experiences, many experts suggested that crossborder mobility did not play a big role in viral transmission in their region. Most participants did not observe notable spill-overs or virus importation from their neighbouring country and reported that although there were cross-border COVID-19 cases, these did not emerge as the main driver of the local infection scenario.
However, some professionals mentioned border-related movements as an important factor in the infection scenario in their region. They explained this in terms of large differences in COVID-19 incidences between the different sides of the border, whereby lower incidence areas tend to follow the infection trend of the higher incidence area as a result of daily cross-border traffic. At the same time, experts questioned whether it is cross-border mobility as such or different IDC measures that were responsible for higher incidence levels in the neighbouring country.
Many experts argued against the emphasis on borders as drivers of contagion. They explained that mobility, in general, and the resulting social contacts are a cause of infection, but that crossborder mobility is not different nor more risky or more infectious than in-country mobility. Participants challenged the specific focus on border-related movements, whereas in-country movements are largely left unrestricted. Likewise, some participants pointed out that, in their region, virus importation from nearby in-country metropolitan areas probably played a bigger role than importation from across the border.
Several experts questioned the effectiveness of border control measures in Europe. They perceived border closures as political decrees that appear compelling and straightforward on paper but oversimplify lived realities in border regions and contribute little to IDC on the ground. One participant highlighted that IDC measures onsite, rather than at borders, are more important for the reduction of infection levels and thus for the prevention of local clusters. Some participants stressed that border closures are only effective in curbing viral spread if implemented early (i.e. before there are any cases within the country) and rigorously. However, border closures in the study region came too late and could not be enforced with the necessary rigidity as numerous exceptions were necessary to allow people with so-called essential travel purposes (e.g. families, healthcare workers) to continue to cross the borders. Other participants added that even when implemented early, border closures can only delay the introduction and spread of the virus but never stop it in the real-life context of Europe.
Experts' scepticism about border control practices also stemmed from concerns about the enormous social, economic and health costs linked to the tightly interwoven fabric of their border region. Disruptions of cross-border health care emerged as a crucial worry in this context. Public health professionals highlighted that borderland citizens work for as well as make use of healthcare services in the neighbouring country. Border control measures severely impacted residents' ability to seek care or to provide informal care to their relatives across the border. Similarly, several participants mentioned that border control measures hindered the cross-border transfer of patients and ambulance work, raising concerns that these measures could strain previous efforts and progress of established cross-border relations.
Beyond disruptions of borderland life, many participants expres sed worries about the wider symbolism of border control. Experts perceived border control practices within Europe as incommensurable with core European values, such as collaboration, freedom and solidarity. Participants also warned that border-related IDC measures could strengthen right-wing, nationalistic and anti-European ideologies by accentuating the nation-state and demarking people and groups based on national identities.

The crucial role of cross-border collaboration
Participants highlighted the importance of cross-border collaboration and communication for effective public health management of the COVID-19 pandemic. The nature of prepandemic collaborations differed substantially between border regions. In some regions, participants had no or only sporadic previous connections  with the public health authorities in their neighbouring countries and lacked understanding of how public health was organised across the border. As a result, they encountered many challenges in the management of cross-border COVID-19 cases. For example, when a Belgian doctor who lives in Germany but works in Belgium became infected and had to be hospitalised, the German public health department did not know which Belgian authority to inform nor how to inform the doctor's patients. Another German participant described that reporting cross-border cases to their Dutch counterpart was initially a lengthy process because they did not have a direct phone contact with the Dutch regional public health office. In other regions, participants could draw on previously established cross-border public health collaborations (e.g. shared notification spreadsheets for certain infectious diseases, previous Euroregional projects, a border-liaison employee and local government contacts). In these regions, participants reported that preexisting networks helped them reduce the time communicating with their cross-border counterparts. However, even when pre-COVID-19 cross-border channels were in place, participants stated that the contacts were ineffective or insufficiently institutionalised to enable systematic and sustainable collaboration in a pandemic context. A key reason mentioned for the breakdown of cross-border cooperation was that it became deprioritised because compliance with national IDC policies was the primary focus, whereas crossborder aspects were a voluntary 'add-on' for which there were no resources.
Irrespective of whether cross-border channels of collaboration had been in place before the COVID-19 pandemic, participants experienced various difficulties in managing cross-border cases. Experts strongly emphasised that lack of such cooperation is both obstructing IDC and harming the social life of borderland communities. Participants highlighted that cooperation does not have to result in the homogenisation of policies and national systems, which would be unnecessary and unfeasible, but rather, it should be rooted in clear, working channels of cross-border communication.

Discussion
Expert interviews with public health professionals working in the German-Dutch-Belgian border region illustrated the complexi ty of cross-border IDC and highlighted the consequences of border control measures for both the social fabric of borderlands and cross-border public health collaboration. The research setting of this study is characterised by a high level of mobility, and social and cultural integration, which might be not characteristic of other border regions within and beyond the EU. However, lessons learned from this study are important to current discussions regarding the role and consequences of border control measures for cross-border public health work and future outbreak preparedness.
Literature on border control measures to mitigate the COVID-19 pandemic highlighted varied and inconclusive results from modelling and observation studies. 21,22 Research from specific settings, such as Hong Kong, 23 Australia, 24 New Zealand 25 and Taiwan, 26 reported that strict and early border control policies have contributed to significant reductions in the number of COVID-19 cases. Border policies introduced by EU member states raised concerns, 2,8 especially in the very dynamic border regions, such as the one explored in this study. However, rather than looking into the effectiveness of these measures for the containment of COVID-19, the present study focused on the consequences of border control measures for the realities of public health practices and cross-border IDC in a densely populated region.
Echoing research on border closure between two Australian states, 27 the results from the present study pose a crucial question to national and international public health authorities: how to reflect on and integrate the realities of continuous integration and globalisation of the modern world into current national strategies of public health securitisation? In line with various international calls for better international cooperation, 28,29 experts interviewed in this study argued for the building of long-term and sustainable channels for cooperation of public health authorities across borders. Current national practices and policies of IDC often do not consider the cross-border  We cannot exchange data across borders. I have lists of names of people who have been in contact with someone who turned out to be infected, Aachen has lists of names, Heinsberg has lists of names, but we cannot share them. That is not allowed by law. The only official information that can be shared is that an infection has been confirmed. [N5] The system for controlling infectious diseases works quite differently. The Dutch do it quite differently from us in Germany, also on the basis of different legal rules. They work in completely different systems, you cannot say otherwise.
[G2] Existing cross-border collaborations are necessary I think you need to have established collaborations or collaborative networks based on prior working relationships. I think we haven't gone far enough … that would make things so much easier and so much lower threshold than is the case now. I think we are in a privileged position by having these working relationships, but they could be more intense and could be taken a step further even. [N2] In general, I think that on many issues, we should often work more closely together as local authorities with our Dutch colleagues. If there are more ties, then it is indeed easier to make contact with issues that suddenly arise. mobilities that constitute the social life of border region residents.
Better understanding and communication about cross-border mobility, rather than prohibition and securitisation, should be integrated into future IDC planning at national, European and global levels. This study highlighted how border control measures have disproportionately affected the social life of borderland residents who faced difficulties in navigating their cross-border work and family responsibilities. This situation required public health professionals to adopt additional measures and invest extra time towards helping residents navigate the different COVID-19 requireme nts of the three countries. Although it was argued by state authorities that national border controls were put in place to support the pandemic response, in the highly integrated region of NRW, Belgium and the Netherlands, it created additional work for public health professionals and disrupted previously established crossborder collaborations.
The present study had several limitations. First, a limited number of participants were enrolled, and they were not distributed equally between the three countries. However, the interview data did achieve saturation. Second, the research was conducted between December 2020 and April 2021 during the first year of the COVID-19 pandemic. As the pandemic continues to evolve, it is important to collect and compare public health professionals' experiences relating to the consequences of border control measures from different border regions within and outside of the EU.
The current research highlighted the importance of contextualisation of IDC measures. Working in border regions, participants anticipated difficulties related to cross-border communication and collaboration in the context of a large-scale pandemic. The expertise of public health professionals who have experience and understanding of the dynamics of border regions is essential for addressing the current pandemic as well as for preparing for future outbreaks. Rather than border control, sustainable cross-border communication and collaboration is crucial to ensure effective pandemic management in border regions.