Southern Sudan: Dying in Peace

July 21, 2008

This article is part of the Summer 2008 issue of the MSF Alert newsletter.

OPERATIONAL OUTLOOK

For 21 years, the south of Sudan was the country’s hotbed of conflict. A civil war with the North resulted in an estimated two million people dead and four million driven from their homes. In 2005 the Comprehensive Peace Agreement (CPA) was signed, formally ending the war. But today, southern Sudan, where Doctors Without Borders/Médecins Sans Frontières (MSF) is present in more than a dozen villages and towns with about 130 international and 1,300 national staff, is facing an increasingly dire situation.

While the conflict has subsided enough for an estimated 1.2 million internally displaced people (IDPs) and refugees to return to the region, violence has flared up again, its roots in territorial disputes that were never resolved by the CPA. With elections slated for 2009, and a referendum for independence from the North scheduled for 2011, the future is increasingly uncertain.

And while vast numbers of people are coming home to an environment that is decidedly less violent than the one they fled, these returnees and those who did not leave are facing severely strained health care resources. Public services such as health care, education, roads, and water and sanitation were barely developed in southern Sudan before the civil war began in 1986, and the region has not made great progress since then.

“I have been to other war zones, but at least after the war there was something to go back to,” says Martin Braaksma, MSF head of mission in southern Sudan. “And I think that’s a very big difference in southern Sudan. Because it’s not just rebuilding a country: it’s building a country. There is nothing in place.”

Malnutrition is especially worrying; maternal mortality rates are among the highest in the world; tuberculosis and kala-azar are ongoing problems; and large-scale outbreaks of meningitis, measles, cholera, and malaria are common.

Another major concern is food insecurity: the World Food Program (WFP) has made cutbacks in food aid and delivery trucks often cannot enter unstable areas; the price of food is rising; and major floods in 2007 destroyed much of the crops in some areas.

In the midst of all of this, humanitarian aid is conspicuously lacking. Some major donors have redirected their funds to development after the signing of the CPA because, supposedly, the emergency in southern Sudan is over.

Sporadic Violence and Displacement

An issue the CPA did not resolve is whether certain oil-rich areas are part of northern or southern Sudan. The region to which these areas rightfully belong will reap the economic benefits.

At the end of 2007, fighting broke out between the armed forces for southern Sudan and northern-backed militia in an oil-rich area near the town of Abyei, where MSF supports a hospital and a therapeutic feeding center for malnourished children.

In February 2008, after an extremely violent attack in this area, thousands of new IDPs gathered in three sites: Mathiang Dot Akot, Leith, and Rumerol in Northern Bahr-el-Ghazal State, and an estimated 10,000, possibly more, dispersed into the bush.

On May 14, fighting broke out in Abyei between the North’s armed forces and the southern rebel group Sudan People’s Liberation Army (SPLA), virtually destroying the town and driving nearly the entire population north and south to seek safety.

An estimated 60,000 people are now displaced. By late May, only some of the 700 malnourished children MSF had been treating in Abyei have been relocated; in early June, an MSF team, including a surgeon, were treating wounded in accessible towns near Abyei and providing water and shelter for these refugees who had to flee their homes with absolutely nothing.

Health Needs: Rising Malnutrition and Maternal Mortality

When MSF was able to arrive at one of the IDP camps, people had been there for a month without receiving aid, and 20 percent of the children were malnourished.

“When I met these families …. I was struck by their despair, which bordered on aggression,” says Gabriel Trujillo, an MSF program manager in Sudan. “In the Mathiang Dot Akot site, we were surrounded by men, women, and children who were slapping their stomachs and holding their fingers up to their mouths to express their hunger in a universal language. They showed me their only resources: leaves and small nuts gleaned from the bush.”

MSF opened therapeutic feeding centers in the state capital, Aweil. By the end of April, MSF teams were treating nearly 1,500 children, almost half of whom were displaced or recently returned.

While there is a fledgling health system developing in southern Sudan with oil revenues and donor funding, it has a long way to go before it can serve the region’s eight million people.

For many decades, there was only a minimal educational system in the region, and there are few medical professionals there now. Since the peace agreement and establishment of a government, many doctors and nurses who are in the region have been in training or in new official positions rather than working in the hospitals and clinics. So, while funding and attention are decidedly on development instead of meeting the current health needs, populations will remain dependent upon aid organizations, including MSF.

Meanwhile, the health needs are many. Pregnant women die at a rate of 2,053 for every 100,000 live births, about 200 times the number of maternal deaths in the US. “A girl is more likely to die in childbirth than she is to finish primary school in southern Sudan today,” says Vanessa Von Schoor, MSF operational manager for Sudan.

Women tend to deliver at home and, if the birth becomes complicated, there is often no medical facility nearby; too frequently, by the time a woman does arrive at a facility, it’s too late. There is also the problem of medical staff not having the training to perform a C-section, which can mean the difference between life and death during complicated deliveries.

In 2007 MSF saw 6,800 women for antenatal care, compared to 2,500 in 2006. In Aweil, MSF has set up a referral system throughout the state that could avert 250 maternal deaths this year.

Responding to Epidemics

With its harsh environment, southern Sudan is subject to frequent epidemics. In 2007 MSF treated 2,113 people and vaccinated more than 630,000 for meningitis, while also responding to several outbreaks of cholera. MSF also ran measles-vaccination campaigns and treated populations for outbreaks of malaria, pneumonia, and diarrhea. One of the region’s biggest killers is TB, and MSF has set up “TB villages” where infected women can receive treatment for the required six to nine months while their children are put on prophylactics so they do not become infected. However, there is not nearly enough coverage for TB treatment.

TB patients usually appear at MSF clinics during the last, worst stages of the disease, which means there are untold numbers of people with TB not receiving treatment, likely infecting others. Similarly, MSF estimates that only half of the people suffering from kala-azar, a potentially deadly parasitic disease, receive treatment for it. Though the toll from HIV is not known, MSF offers testing and treatment at several projects, and there is concern that populations returning from other areas could bring it back with them.

Hopes and Fears

The instability of southern Sudan’s future, however, has not affected the stream of returnees. They continue to come back after many years, perhaps hoping for a better future.

“I think there’s hope since the civil war has stopped for three years, and the country is starting to establish itself, they’re going home, and they have a skill set that they can come with to help and rebuild,” says Von Schoor. “There is hope that they can live safely back home again.”

However, she says, “Sudan is where we’ve seen some of the worst famines in the past. Our experience has been that when you are looking at famines, it’s never just one cause, usually. It’s this combination of factors with high prices, insecure distribution routes, and we’re seeing a couple of these key elements starting to come up and it’s a concern.”

As day to day life continues precariously and needs continue to multiply, MSF finds itself increasingly alone in providing emergency medical aid. In 2007 the number of MSF patients increased by 40 percent, and many projects are operating at maximum capacity in the face of more and more need. At the same time, insecurity further compromises the ability of aid groups to stay in the region.

“Our concern,” says Von Schoor, “is that we’ve been working hard treating all these people, and now we’re looking at the numbers, going, ‘No wonder we’re exhausted and overwhelmed.’ We can’t do it on our own.”

 

Related:

• MSF Frontline Reports
• Abyei, Sudan: “They only have the clothes they were wearing when the fighting started”

Tags: Sudan, Armed Conflict, Refugees and IDPs, Tuberculosis, Kala Azar, Maternal Health, Paediatric Care, Malnutrition, Women's Health