MSF in South Sudan

Last updated: August 2012

South Sudan was officially recognized as an independent country by the United Nations on July 9, 2011. This followed a January 2011 referendum that where nearly 99 percent of the electorate voted for independence.

The South has borne the brunt of years of chronic warfare from the time of Sudan's independence from the United Kingdom in 1956 to the present day. In 2005, the Comprehensive Peace Agreement between the Sudan People's Liberation Movement (SPLM) and the Sudanese government set a timetable for a vote on South Sudan's independence and was meant to bring an end to decades of civil war. Despite the agreement, violence, along with disease and poverty, have continued to ravage the region.

South Sudan's public health system and other services remain devastated from the legacy of violence and instability. Few people have access to adequate healthcare; more than 80 percent of healthcare available in South Sudan is provided by international NGOs. South Sudan has some of the highest maternal and infant mortality rates in the world; many women in labor have to walk for hours or even days to reach a health facility. 

Because there is so little capacity to deal with them, preventable diseases and conditions, such as malaria, acute diarrhea, and measles, are common causes of death. People are often infected with neglected diseases such as sleeping sickness (human African trypanosomiasis) and kala azar due to population movements caused by violence and instability.

There are around 210,000 people displaced by conflict in South Sudan, according the the Internal Displacement Monitoring Center (IDMC).

The resources that exist are extremely overstretched. As the date for the referendum neared, southerners who had fled to the north to escape the conflict years ago began to return south in droves. Around 300,000 returnees came back, not only to a lack of food and shelter, but also to little or no public services for healthcare, water and sanitation, education or transportation. They tend to have poor immunity to diseases such as kala azar and are at increased risk of sexual violence. They are also in a difficult socioeconomic position, as they face problems accessing and cultivating land. 

MSF has worked in the South Sudan area since 1978.

Current Activities

Violence continues to ravage the population of South Sudan, including fighting between northern and southern Sudanese forces in the transitional border area of Abyei, inter-tribal or inter-communal conflicts, and violence by new Southern militias. As of July 2011, there have been at least 18 incidents related to the Lord's Resistance Army rebel group in Western Equatoria State that have resulted in abduction, death, or displacement. Events such as these create fear and anxiety in communities already struggling to survive. Insecurity increases vulnerability to disease and further restricts people's access to healthcare. It also hampers the delivery of drugs and medical supplies.

MSF runs 13 regular projects across eight of the 10 states in South Sudan, providing care to victims of violence, disease, displacement, malnutrition, and a lack of access to essential services. The needs are tremendous. As of July 2011, MSF had already treated 10,000 people for malaria. And, in addition to offering basic and specialized healthcare, with a focus on maternal and child health, this year MSF has also sent emergency teams to assist people wounded or displaced by violence in several states.

Here is a breakdown by state of MSF's current activities:  

Warrap State

On June 18, MSF launched a second emergency team upon discovery of nearly 5,000 people who had also been displaced by the violence in Abyei and who had sought refuge in the villages of Mayen Pajok and Juong Pajok, near Akon. The number of displaced people had grown to 6,300 by early July.

It took many of this group up to 12 days to reach Akon, arriving without access to food, clean water, shelter or healthcare. Exposed to the harsh sun, they tried to build basic shelters with twigs and clothing to shield themselves. MSF distributed non-food-item kits containing essential items like cooking utensils, blankets, soap, and jerry cans to 222 families. MSF also conducted a mass vaccination campaign against measles for 3,052 children under 15 years of age, in addition to providing BP-5 emergency nutrition biscuits for more than 1,500 households and a peanut-based therapeutic food for 38 malnourished children. MSF also started mobile clinics to provide regular healthcare to these two pockets of displaced people.

In mid-May, heavy clashes and bombing in and around Abyei between the northern Sudanese Armed Forces (SAF) and southern Sudan People's Liberation Army (SPLA) caused a massive exodus of an estimated 60,000 people south. Many gathered on the road to Agok, Bahr-El-Ghazal State, or near Mayen-Abun or Turalei in Warrap State. The MSF team in Gogrial carried out a first assessment May 27 and provided assistance to displaced people in Alek, in the form of a mass measles vaccination to 165 children and BP-5 emergency biscuit distributions to 315 people.

In March 2011, MSF also added a new medical element to the project when it began to provide treatment for people with tuberculosis. In the first month, the team provided treatment to 26 people with TB. As well as running the regular primary and secondary healthcare project, MSF teams responded to several emergencies, including measles outbreaks and violence. In the first days of January 2011, an MSF team vaccinated 13,000 children in Kuajok, following a measles outbreak in the transit camp for people returning from North Sudan, and the host community.  

In December 2009, MSF began working in Gogrial West County. Initially, MSF provided basic healthcare on an outpatient basis. There was no hospital in Gogrial West County, so people in need of urgent surgery were forced to travel long distances at great personal expense. In order to meet the medical needs of the approximately 240,000 people living in this area, MSF built a brand new primary healthcare center, with inpatient wards, a pharmacy, and a laboratory. In 2010, MSF set up two inflatable clinics to provide maternity, emergency obstetric, and surgical care. In 2011, MSF began to build more permanent structures for these units.

Unity State

MSF is one of the few organization providing medical care in Leer, an area located close to the contested north/south border area and numerous oil fields. Teams run a hospital that provides all levels of care, including emergency surgery, outpatient healthcare, and response to emergencies and outbreaks. The area has been troubled by tuberculosis, HIV/AIDS, malnutrition, and malaria. In Bentiu, the capital of Unity State, MSF has run a feeding program since July 2010.

Northern Bahr-el-Ghazal State

In Aweil Civil Hospital, MSF works with the Ministry of Health to reduce maternal and pediatric mortality, to treat malnutrition and to respond to emergencies. MSF staff perform minor surgeries and Caesareans in addition to providing gynecological, obstetric, and mother-and-child healthcare, including ante- and post-natal consultations and vaccinations.

Western Bahr-el-Ghazal State

MSF began working in Raja County in August 2010, focusing on emergency preparedness and reducing maternal and pediatric morbidity and mortality.

Western Equatoria State

MSF's mobile teams provide essential primary and secondary healthcare in Yambio, including emergency medical care, mental healthcare, and relief activities for people affected by violence. MSF also supports Ministry of Health facilities in Makpandu refugee camp and runs mobile clinics where needs arise around Yambio. In Yambio Civil Hospital, MSF supports the pediatric, surgical, outpatient, inpatient, and reproductive health departments, as well as its sleeping sickness program.

Jonglei State

Intercommunal violence and cattle raiding near Lekwongole forced MSF teams to evacuate from the healthcare clinic in Pibor June 25, reducing medical activities to life-saving only.

Apart from a small Ministry of Health facility in Pibor town, MSF is the only primary healthcare provider in this part of Jonglei State, home to around 160,000 people, where villages are often far apart and roads are impassable. MSF has been in Pibor since April 2005. Teams run a primary healthcare clinic providing emergency care, inpatient care, outpatient care, and reproductive health services, including antenatal consultations, nutrition, maternity care, and treatment for tuberculosis and sexually transmitted infections.

MSF also runs two outreach primary healthcare units in Lekwongole and Gumuruk, providing basic care, such as general consultations, treatment for malnutrition, deliveries, antenatal care, and vaccinations, as well as referring more complex cases to Pibor. During the rainy season, which lasts from May to September or October, both these sites are only accessible by boat or plane. Emergency surgical cases are referred to Boma and Juba for operations, and are flown directly by an MSF plane.

In the remote northern area of Lankien, MSF runs a clinic which serves around 127,000 people. In conjunction with outreach centers in Pieri and Yuai, MSF teams provide all levels of medical care, ranging from treatment for respiratory tract infections to spear wounds. Clinics also respond to the ongoing kala azar outbreak.

Upper Nile State

The wider Upper Nile region is the epicenter for kala azar in South Sudan. In 2010, the largest outbreak of kala azar in eight years occurred, with MSF teams treating more than eight times as many cases than in the previous year. Parts of Upper Nile and Jonglei States were mainly affected and it is anticipated to spread further in 2011. High levels of malnutrition, population movements due to violence and resulting displacement, and the presence of returnees to South Sudan with little to no natural immunity against kala azar will contribute to increased cases in 2011. MSF assists a clinic in Old Fangak and a Ministry of Health hospital in Malakal with technical and material support. MSF also runs a hospital in Nasir that offers primary and secondary healthcare.

Transitional Area of Abyei

Since the end of May, Agok has become a host town to thousands of the displaced from the violence in Abyei. Many of the displaced from Abyei also fled to Turalei, Warrap State, 45 kilometers (28 miles) south of Agok. At the end of May, MSF teams set up an emergency therapeutic feeding center in the hospital of Comitato Collaborazione Medica (CCM). In addition, MSF emergency teams run mobile clinics in Turalei, Machbong, and Mayom Abum that screen for malnutrition, provide maternal and primary healthcare, distribute food, and refer serious cases to CCM’s Turalei hospital. 

In Agok, 40 kilometers (25 miles) south of Abyei, MSF runs the only secondary healthcare center in the area, with surgical facilities, out- and in-patient care, reproductive healthcare, and treatment for severe malnutrition. MSF responded quickly by focusing on performing life-saving surgeries, treating malnutrition, providing reproductive healthcare, vaccinating children, and providing access to secondary healthcare. MSF teams are also distributing plastic sheeting and non-food items, such as kitchen sets and soap, to the displaced from Abyei, targeting at least 20,000 people. MSF mobile medical activities are caring for the wounded and displaced in areas outside Agok, including Mading Jokthiang, Rayan, Awal and Mathiang, Rumkor, Mayom Ngok, Ajak Kuach, and Abeimnom. MSF received 53 wounded in Agok hospital in the first four days and treated at least 2,300 people in the first two weeks of the fighting.

MSF has worked in the transitional area of Abyei since 2006. MSF provides primary healthcare and treatment of severe malnutrition of children under five years old through an outpatient clinic in Abyei town and has been running mobile clinics in the northern part of the Abyei area. Between January and April 2011, MSF performed 1,359 outpatient consultations in Abyei town. Following increased violence and hostilities in the Abyei region, MSF was forced to evacuate the Abyei clinic on May 21. At least 60,000 people have fled the area to Agok and Turalei in Warrap State and the surrounding areas. 

2011: Birth of a Nation Plagued With Problems

Following a January referendum in which 98.83 percent of the electorate voted for independence, South Sudan is expected to become independent on July 9.

In April, however, Sudan's president Omar al-Bashir said he would not recognize South Sudan if it continued to claim Abyei, a highly contested, oil-rich border region where MSF has worked since 2006.

While the elections in January were conducted in relative peace, sporadic fighting erupted in late February and March in Upper Nile and Jonglei states, as well as in the disputed oil-rich border district of Abyei—clear evidence that considerable tensions remain. In Abyei, for example, an outbreak of violence in late February forced tens of thousands of people from their homes.

MSF’s hospital in Agok, 24 miles south of Abyei, treated 21 wounded people for gunshot wounds. MSF also donated drugs and equipment to the Ministry of Health hospital in Abyei, while mobile teams were dispatched to assess the needs of people displaced by the fighting. Two weeks later, following clashes in western Upper Nile State, an MSF surgical team at Malakal Hospital provided urgent medical care to 24 people and performed 18 surgical procedures for gunshot wounds. Only a month earlier, 33 wounded people had arrived at the same hospital, six of them in urgent need of surgery.

Fighting broke out throughout Abyei again on May 20. The regional capital of Abyei town lay empty by May 21, as tens of thousands of people fled toward the south. MSF suspended all primary activities in Abyei town and focused on assisting the displaced as they fled, placing mobile teams along the roads. An MSF hospital in Agok, 24 miles south of Abyei town, treated 50 victims of the violence over one weekend. Teams set up a rehydration point in Agok Hospital and provided medical assistance, food, and relief items like plastic sheeting, mosquito nets, and shelters along the roads.

Huge Numbers Affected By Kala Azar, Malnutrition

Violence is not the only issue, however. MSF clinics in the area admitted 13,800 patients suffering from severe malnutrition in the first 10 months of 2010, a 20 percent increase from the same period in 2009, and a 50 percent increase compared to all 2008.

South Sudan also recently experienced the largest outbreak of kala azar in the region in eight years. MSF teams opened programs to support the kala azar treatment unit in Malakal Teaching Hospital and established five kala azar satellite clinics in neighboring Rom, Adong, Khorfulus, Atar, and Pagil, treating thousands of patients in the latter half of 2010.

History

Before the Darfur region became a hotbed of conflict, violence, and abuse, the southern part of Sudan was the focal point of decades of violence that devastated the country. The instability created by near-constant warfare between the government and rebel groups displaced hundreds of thousands of people, many of whom ended up with little to no access to basic healthcare.

Famine Strikes in 1998

In April 1998, MSF responded to urgent health needs in the what was then the southern region of Bahr-el-Ghazal. The entire population was suffering from the effects of the previous year's poor harvest, irregular rainfall, and years of war.

MSF teams throughout Bahr-el-Ghazal, at 12 primary health centers, found severe malnutrition rates to be as high as 40 percent in some areas. On October 26, 1998, MSF, along with the NGOs CARE, Oxfam, and Save the Children, urged the UN Member States of the Security Council to take an active role in ending the fighting in Sudan. In a joint statement issued at the UN meeting in New York, the four largest international humanitarian organizations working in Sudan stressed that the ongoing war and resulting crisis "have now reached an unimaginable and extraordinary level of tragedy....Peace is the only hope for progress and to prevent further humanitarian catastrophe."

Read testimonies from MSF staff in the field in the special report Southern Sudan: Testimonies of a Human Tragedy

Early 2000s: Malnutrition, Disease and Insecurity

Into the early 2000s, MSF continued to battle malnutrition, inadequate healthcare access, and outbreaks of meningitis and cholera. Staff also treated cases of endemic kala azar and responded to emergency medical needs due to violence.

MSF worked throughout the region, in the Bahr-el-Ghazal, Equatoria, Lakes, Jonglei, and Unity (also called Western Upper Nile) areas. Staff were forced to evacuate on several occasions after hospitals were attacked, villages raided, and airstrips bombed.

In Unity State, a disputed region in south-central Sudan, MSF began work in the town of Bentiu in August 2000, caring for severely malnourished children, running an in- and out-patient clinic, and treating kala azar and tuberculosis, in addition to the six primary health posts MSF also maintained in the region. MSF provided aid in several locations in the disputed province, offering basic health care, inpatient and outpatient care, nutrition activities, and tuberculosis and kala azar treatment.

In April 2002, MSF brought attention to the miserable conditions of civilians in the region in the report "Violence, Health and Access to Aid in Unity State, Sudan." Based on 14 years of work in Western Upper Nile, the report showed that repeated displacement and continued fighting, coupled with lack of access to health care and humanitarian aid, were slowly killing off the region's people.

In an attack on the village of Nimne in Western Upper Nile in February 2002, an MSF compound was looted. Days later a local MSF health worker was killed when three bombs were dropped on the village. MSF was forced to suspend its program in Nimne. An MSF health clinic in Bieh also suffered disruption following a helicopter gunship attack. In March, another MSF team in the area was evacuated due to shooting. The attack on Nimne came in the same days that government planes bombed Akuem in the southern state of Bahr el Ghazal, where MSF ran a primary healthcare program and a feeding center. In Akuem, where the MSF-supported hospital was the only health facility in the region, 47,543 consultations were realized and 2,527 people were hospitalized in 2002.

2002 also saw the beginning of a peace process between the Sudanese government and the southern rebels of the SPLA. By 2004, the peace efforts had greatly improved MSF's ability to reach new areas and had reduced the displacement of groups of people fleeing violence. In 2003 and 2004, as the conflict in Darfur spiraled into a full-blown humanitarian crisis, MSF continued crucial, basic services like supplying food, water, and sanitation to the southern part of the country, and also assisted people affected by measles, meningitis, malaria and other infectious diseases. MSF treated people with TB in the towns of Akuem and Mapel in Bahr-el-Ghazal State, in Bentiu, Western Upper Nile State, and in Lankien, Eastern Upper Nile State.

MSF focused on the crisis in Darfur for much of 2004 and 2005, in addition to maintaining its efforts against malnutrition and disease in southern Sudan, where an estimated six million people were reliant on food assistance.

2005 to the Present: Post-ceasefire, Violence and Disease Continue

In January 2005, the Comprehensive Peace Agreement (CPA) was signed between the northern government, led by President Omar al-Bashir, and the southern rebel groups. Despite the ceasefire, conflict continued in the Bahr-el-Ghazal region, as a failed rainy season in 2004 led to a spike in malnutrition and clashes between the two main ethnic groups in southern Sudan, the Dinka and the Nuer, over livestock and other food sources. The precarious nutritional situation was aggravated by the return of displaced people and refugees following the peace agreements. Tens of thousands of people returned to Aweil East County alone.

The signing of the CPA triggered a mass influx of Sudanese returning from the north or from refugee camps in surrounding countries. Their arrival made existing gaps in healthcare worse. Hundreds of thousands of people returning to their homelands found a country ill-prepared to receive them, with no transportation system, barely any health infrastructure, and occasional outbreaks of violence. Despite the opening of some areas with the end of the war, the absence of a transport system continued to hamper efforts at increasing access. Much of the country was only accessible by air, an option limited during a rainy season that reduces much of the Upper Nile region to swamp.

Lord's Resistance Army Attacks Borders Areas

Towards the end of 2008, attacks by the Ugandan rebel group, the Lord’s Resistance Army (LRA), in southern Sudan near the border with the Democratic Republic of Congo (DRC) caused thousands of Sudanese people to flee their homes. Congolese refugees also crossed the border to seek refuge in Sudan. In response, MSF started supporting two primary healthcare clinics in Gangura and Sakura, in Western Equatoria State, close to the border with DRC. By the end of the year, 7,200 medical consultations had been provided to the residents and refugees in these two areas.

Escalating violence and disease outbreaks led MSF to launch several emergency interventions in southern Sudan in 2009. Medical needs, which were already at emergency levels in many parts of the country, increased dramatically during the course of the year as clashes between different communities left hundreds dead and thousands displaced.

MSF led emergency interventions in Akobo, Torkej, Lekwongole, Panyangor, Duk Padiet and Terekeka. In the areas where MSF responded, staff recorded that three times more people were killed than were wounded, and high numbers of women and children were affected. Surgical teams in Nasir and Leer performed more than 1,000 surgeries in 2009, more than half of which were for injuries caused by violence.

Throughout the year, the LRA launched frequent attacks on villages near the border with and inside DRC, and on the border with Central African Republic (CAR. These caused thousands of Sudanese people to flee their homes and Congolese refugees to cross the border to seek refuge in Western Equatoria State.

Working in the Abyei Area

MSF teams began working in Abyei in 2006. In February 2008, after an extremely violent attack near Abyei town, thousands of people fled to camps in northern Bahr-el-Ghazal State, and an estimated 10,000 people fled into the bush. In May, fighting virtually destroyed Abyei, displacing another 60,000 people.

In order to reach the people who had fled to the bush, mobile clinics were set up in both Abyei and the nearby town of Agok, and mobile and inpatient nutrition programs were put in place. By the end of the year, 8,950 outpatient consultations had been given and more than 1,200 severely malnourished children had been treated. MSF also organized distribution of non-food items in Muglad, north of Abyei, for around 400 families.

In 2011, an outbreak of violence in late February forced tens of thousands of people from their homes. MSF’s hospital in Agok, 24 miles south of Abyei, treated 21 wounded people for gunshot wounds. MSF also donated drugs and equipment to the Ministry of Health hospital in Abyei, while mobile teams were dispatched to assess the needs of people displaced by the fighting. Two weeks later, following clashes in western Upper Nile State, an MSF surgical team at Malakal Hospital provided urgent medical care to 24 people and performed 18 surgical procedures for gunshot wounds. Only a month earlier, 33 wounded people had arrived at the same hospital, six of them in urgent need of surgery.

Kala Azar Cases Spike

The number of cases of kala azar (visceral leishmaniasis), which is endemic in Sudan, reached an eight-year peak in the south of the country in November 2010. Transmitted by the bite of a parasite-carrying sand fly, the disease is deadly if left untreated. Timely treatment can cure most patients.

MSF treated 2,600 people for the disease in Upper Nile, Unity, and Jonglei states. Patients were treated with a new drug called liposomal amphotericin B, which significantly reduces the length of treatment and has fewer side effects than other drugs. In collaboration with the Ministry of Health, MSF also treated 1,100 patients at a newly opened kala azar treatment center in eastern Al Gedaref state.

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