South Sudan © Shannon Jensen

As South Sudan marks the first anniversary of its independence on July 9, Médecins Sans Frontières (MSF) teams are struggling to save lives in one of the most complicated and challenging refugee crises in its history. Having arrived with stories of violence, some 100,000 Sudanese refugees, many of them ill, have sought sanctuary in camps in Upper Nile State with inadequate resources and harsh living conditions. Here, we take a look at the year that led up to this emergency. #

South Sudan © Redux

With South Sudan’s public health system on the brink of collapse, a series of emergencies erupted over the past year, culminating in an overwhelming number of refugees with medical needs along the border with Sudan. #

South Sudan © Robin Meldrum/MSF

MSF teams have been responding where the needs are greatest in South Sudan: running more than 15 hospitals and field clinics in eight states and the disputed Abyei border region, and sending mobile clinics and outreach teams to reach some of the country’s most remote communities.  #

South Sudan © Redux

Every day medical teams see the evidence of unmet needs for services such as reproductive care, primary and secondary health care, treating victims of violence and people who been displaced; they offer care for diseases including malaria and kala azar, and treat malnutrition and other maladies. #

South Sudan © Corentin Fohlen

In the lead–up to the vote for independence in July 2011, heavy clashes and bombings took place in and around Abyei, a contested oil–rich area on the north–south border. While maintaining its regular programs, MSF has been almost constantly engaged in responding to acute emergencies in South Sudan over the past year. #

South Sudan © Corentin Fohlen

MSF was forced to suspend primary medical activities in Abyei in May 2011 and instead set up mobile teams along the roads to provide displaced people with medical assistance, food, and relief items like plastic sheeting and mosquito nets. Some 25 miles (40 km) south, in Agok, where MSF runs the only secondary care center in the area, teams focused on lifesaving surgeries, as well as vaccinations and reproductive healthcare.  #

South Sudan © Cédric Gerbehaye /Magnum Foundation Emergency Fund /VU’

Extreme violence and fighting has not been limited to the border area. Intercommunal attacks of appalling brutality took place in Jonglei State. MSF treated more than 100 people at its clinic in the town of Pieri following a large–scale and deadly raid there and in 12 surrounding villages in August 2011. Many of the injured were women and children suffering from gunshot wounds. #

South Sudan © MSF

A member of MSF’s South Sudanese national staff was killed during the raid; and MSF facilities were looted and burned in Pieri. #

South Sudan © Liang Zi

Between Christmas and New Year’s Day, further attacks around the town of Pibor in the south of Jonglei State forced thousands of terrified families to flee deep into the bush, where they had no access to medical care and were beyond the reach of humanitarian assistance for weeks. #

South Sudan © Robin Meldrum/MSF

Too afraid or traumatized to return to their villages, many people set up makeshift shelters along the banks of dry riverbeds.#

South Sudan © Robin Meldrum/MSF

MSF returned on January 7th and set about rehabilitating the ransacked hospital in Pibor and clinic in the village of Lekwongole. In the following weeks the medical team treated more than 100 patients with gunshot and stab wounds, many of them women and children. #

South Sudan © Robin Meldrum/MSF

A mass movement of refugees from Sudan began in November. Some 13,000 people escaped violence in their villages and towns by fleeing across the border to the remote town of Doro in Upper Nile State, Maban County. MSF immediately started an emergency medical intervention. #

South Sudan © Robin Meldrum/MSF

More refugees arrived through December and MSF scaled up to full emergency response mode. Water quickly became a major concern and MSF became increasingly involved in the struggle to provide the bare minimum of drinking water for ever-growing numbers of people. #

South Sudan © Robin Meldrum/MSF

Displaced people continued to come in large numbers and resources were stretched beyond capacity. A second refugee camp had to be set up in the town of Jamam. Exemplifying the scale of the crisis, one elder said he believed his entire community of 5,000, mainly subsistence farming families, had fled. “We came, all of us,” he said. “No one remains behind.” #

South Sudan © James Keogh/Wostok Press

While the refugee camps in Upper Nile State occupy much of MSF’s emergency resources, every day more families flee across the border from South Kordofan's Nuba Mountains into a refugee settlement in Yida, a large border village in South Sudan’s Unity State, due to ongoing aerial bombardments and food insecurity in their homelands., Fighting erupted in the Nuba Mountains in June 2011 and continues to produce hundreds, if not thousands, of new arrivals daily. As the rainy season begins, the health conditions at the Yida camp worsen and MSF increases its activities to keep pace with an escalating health crisis. #

South Sudan © James Keogh/Wostok Press

MSF had already set up a 15–bed hospital unit in Yida in late 2011, focused mainly on pediatric care. They also took over an existing clinic that had been operating sporadically in Yida; as of March 2012, approximately 700 patients sought care each week, with 30 percent of the patients under five years old. #

South Sudan © Avril Benoit/MSF

Around the town of Agok, in the southern part of the contested Abyei area, displaced people and residents faced the specter of a food shortage in early 2012. MSF launched a preventive supplementary feeding program for children at risk of becoming malnourished in the months ahead. #

South Sudan © Heather Whelan/MSF

MSF evacuated 13 severely wounded people by air from its clinic in Yuai, Jonglei State, to the MSF hospital in Nasir, Upper Nile State, for urgent surgical care on January 11, 2012. This followed intercommunal attacks in northern Jonglei where most of the victims were, once again, women and children who suffered beatings and gunshot wounds. #

South Sudan © Maimouna Jallow/MSF

Open conflict erupted briefly in April between Sudan and South Sudan, with fighting along the border. MSF provided multiple surgeries for four patients wounded in April during aerial bombardments of the town of Abiemnom, about 22 miles (36 km) west of Agok in Unity State. #

South Sudan © Olga Overbeek

Victims of the same conflict in the towns of Bentiu, Unity State, and Malakal, Upper Nile State, also needed emergency medical care. MSF teams in both locations treated more than 30 people with gunshot wounds, including many women and children, and evacuated three severely injured patients for surgical care at MSF’s hospital in Leer.#

South Sudan © Jenn Warren

Violence is not the only cause of medical emergency response in South Sudan. The Upper Nile State area sees frequent outbreaks of kala azar, or visceral leishmaniasis, a parasitic disease transmitted by the bite of a sand fly. Without treatment, nearly all patients die. In 2010, the largest kala azar outbreak in eight years began and MSF teams treated eight times as many people as it had the previous year; numbers continued to be high in 2011.  #

South Sudan © Spencer Platt/Getty Images Europe

Yambio, Western Equatoria State, which borders the Central African Republic and Democratic Republic of Congo, has a history of conflict due to the presence of Lord’s Resistance Army (LRA). MSF supported a program that helped children once kidnapped by the LRA and used as slaves or fighters reintegrate back into community life.  #

South Sudan © Robin Meldrum/MSF

In many parts of South Sudan quality health care is simply not available and an MSF clinic or hospital is a lifeline for the community. This pregnant woman in Gogrial, Warrap State, told MSF that she had traveled a great distance for a consultation: “I came yesterday, walking from dawn to sunset. There is no health center near my village. I have pain in my stomach and back, so I would prefer to deliver my baby in the health center here.”#

South Sudan © Spencer Platt/Getty Images Europe

The country has some of the world’s highest maternal and infant mortality rates—which MSF tries to address by providing dedicated maternal and child health services in the majority of its programs. At Aweil Civil Hospital, the only referral hospital in Northern Bahr–El–Ghazal State, teams focus on reducing maternal and pediatric mortality and treat malnutrition #

South Sudan © Robin Meldrum/MSF

MSF sees increases in malnutrition during the ‘hunger gap’, the period when the last year’s food stocks are running low and before the next harvest has been collected. But 2011’s unpredictable rain patterns and lower than usual harvest are leading to levels of malnutrition in some locations that are causing MSF teams to dramatically scale up their malnutrition activities. #

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South Sudan © Shannon Jensen

While the general lack of health care in South Sudan leads to substantial MSF activities throughout the country, the worsening refugee crisis is where MSF’s focus lies on the eve of the anniversary of independence. In May and June, just as the rainy season was getting underway, around 35,000 additional refugees crossed the border from Sudan’s Blue Nile State bringing the total of refugees in Upper Nile State to more than 100,000. #

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South Sudan © Shannon Jensen

The response to this refugee emergency is exceptionally challenging. The whole area where the refugees have arrived is uniquely unsuited to accommodate a large number of people. In the rainy season the land becomes a vast swamp with very few small islands of dry ground. #

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South Sudan © Shannon Jensen

As more refugees keep crowding into the camps, the flood levels have been rising and in the Jamam camp children are sleeping in wet clothes and wet blankets, on muddy, waterlogged ground. The rise in diarrhea, respiratory diseases, malaria, and now hypothermia, is pushing MSF’s medical teams to their limits. #

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South Sudan © Shannon Jensen

The year for MSF draws to a close with uncertainty about the future of health care throughout South Sudan, and uncertainty about the future for the refugees from Sudan. “These people have fled terrible violence in Sudan and lost family members during their arduous journeys for safety,” said Tara Newell, MSF emergency coordinator in Jamam refugee camp. “And now they are sitting exposed in refugee camps on a flood plain and dying from preventable diseases due to horrific living conditions. We have to proceed with a great sense of urgency.” #

MSF has been active in the region since 1978.