International Activity Report 2002
Violence, Health and Access to Aid in Unity State/Western Upper Nile, Sudan

In April 2002, drawing on 14 years of experience in Sudan, MSF released "Violence, Health and Access to Aid in Unity State/Western Upper Nile, Sudan," a report detailing the effects of prolonged conflict on the people of this part of southern Sudan. The collection of testimonies and analysis reveals a civilian population subjected to atrocities from all sides and ravaged by a vicious circle of forced displacement, malnutrition and spiraling disease, particularly since the escalation of the conflict in 1997. During this period, the fighting between the Sudanese government (assisted by militias) and opposition groups has swept across the entire region of central Western Upper Nile, with few villages escaping destruction. The following is taken from the report. Click here to read the full report.

People in southern Sudan sleep outside under mosquito nets when they have them. The looting of bednets by soldiers of all parties leaves civilians vulnerable to malarial mosquitoes and the sandflies that transmit kala azar (visceral leishmaniasis) – a disease that has spread rapidly since it was introduced to the area by soldiers or people migrating after the war broke out in 1983. Thonyor, near Ler, Western Upper Nile, April 2002. © Sven Torfinn

Since the resumption of the civil war in Sudan in 1983, life in Western Upper Nile has been a struggle for survival. For civilians, the war has brought little but misery, particularly since the escalation of the conflict in 1997. Repeated food shortages, displacement and epidemics have been commonplace. Military and militia groups on all sides of the conflict have increasingly targeted civilians and their property. The health consequences of the war are enormous.

Displacement, food insecurity and malnutrition

Displacement has been a common feature of the conflict in Western Upper Nile, and increasingly, the displacement is permanent, leaving communities in areas where they may have little access to land or cattle and are unfamiliar with the terrain.

The link between the conflict, food security and malnutrition is clearly demonstrated in the example of Padeah village, near Ler: a June 2000 survey by MSF found that 75% of Padeah's families had been displaced and 93.4% had lost cattle in the 1999 fighting. The global malnutrition rate was 28.6% and the severe malnutrition rate was 8.7%. The high malnutrition rates were related to the fact that people had been unable to cultivate in 1999 due to their displacement, had lost their cattle, had received no relief food and were forced to await the new harvest in 2000.

Fighting forced Nyageai, a woman in her early 30s, to leave her village in July 2000. She and the other women in her compound were beaten by the soldiers and they fled into the bush. They returned to find their tukuls [huts] burned and their cattle stolen. Some of the girls from the village had been taken by the troops and "used as wives." She and her children spent two days and nights walking through the bush to Bentiu. There they received some relief items and stayed for six months but left because there were "too many people in Bentiu" and children of breastfeeding age were dying. [Many months of forced migration later] sitting in a small shelter north of Nimne, Nyageai says: "We have no hope when we are sitting in this place. We have no hope where help will come from. We have no hope."

Kala azar

Changes in lifestyle produced by the conflict – the displacement, increased malnutrition, cattle raiding and violence – have permitted diseases of various kinds to proliferate in Western Upper Nile. Over 100,000 people are known to have died from one war-related disease alone – kala azar (visceral leishmaniasis).

When we arrived in Ler – I cannot describe it. Everyone was naked and hungry. I walked to Duar and everyone was dead. All the villages along the way were empty. Except for a few people, everyone had died. – Wouter Kok, MSF nurse in Ler in 1988, interviewed in March 2002.

By April 2002, MSF had treated over 20,000 cases of kala azar in Western Upper Nile. As long as the war continues and serious preventive measures and sandfly control are not implemented, treatment of those who access health centers is the only means of reducing mortality.

Veronica, a woman in her 40s, lost four siblings to kala azar in the late 1980s. Of her six children, three died of kala azar or other diseases. Of three remaining children, one is infected with the disease. She brought this child to MSF's treatment center in Nimne, where the girl received the painful daily injections of the medicine from MSF staff and recovered.

Targeting of civilians

Mortality and injuries as a result of violence from military and militia factions are perhaps the most obvious effect of the conflict, but data is incomplete, given that many civilian victims of violence do not reach health centers. From MSF's own records, it is clear that each year dozens of people have been medically evacuated due to war injuries such as gunshot wounds. Killings of civilians, even young children, appear to be commonplace.

In January 2002, Nyakuon, a 14-year old girl was walking from Dablual to Padeah to attend a wedding with her 16-year old friend Nyatek. On the way they ran into a Government of Sudan patrol. Nyatek was raped by a soldier. Nyakuon resisted the rape and was shot in the chest by one of the soldiers. She was brought to a nearby MSF clinic where she was given first aid and then evacuated to Lokichoggio for surgery.

In March 2001, Majak, a man in his late 40s, walked to Lake No to do some fishing. Early the next morning he heard the sound of bombing and shooting and started walking back to his village. As he walked he saw fire and smoke rising and realized the villages were burning. He hid from the troops in the forest, walking on to Bol under cover of darkness. In Bol, he found a devastated village. One person had survived the day's massacre: a young mentally handicapped boy had been spared by the soldiers. He found 30 people in a luak [cattle barn], all dead, two of them young women who had been brutally mutilated.

Constraints on access to humanitarian relief

Relief operations in the context of conflict are not uncomplicated. The problems associated with emergency relief in Sudan and other chronic conflicts include diversion of aid to the military, manipulation of aid, lack of accountability and associated human rights violations. Constraints include denied access – when for instance humanitarian agencies are refused permission to enter an area and provide services – and access limited by security constraints such as active fighting.

We walked over an open grave, past burned huts – everything was burned to the ground. Many people had tropical ulcers – huge wounds – because they had no clean water and nothing to put on the wounds. In most places you will have a piece of cloth to put on the wound, but there they didn't even have cloth to put on the wounds. –  MSF doctor, on a first [1991] visit to northern Paranou, a district where high insecurity and flight bans hinder humanitarian access and the combination of violence, displacement and lack of medical services has resulted in one of the worst situations MSF has ever witnessed.

Conclusion

MSF urges the Government of Sudan, the Sudan People's Liberation Movement/Army, and associated militia groups, to provide protection to medical personnel and medical facilities in accordance with international humanitarian law.

MSF calls on all of the warring parties to respect their obligations to protect civilians.

MSF demands full and unhindered humanitarian access to areas where permission has been denied and where civilians are in need of assistance.

The total mortality from violence, disease and hunger in Western Upper Nile will never be known. The conflict has affected the lives of thousands. Each individual has a story. What is clear is that the war in Western Upper Nile is inexorably killing off the people of the area.

When the war started, it was soldiers fighting each other. Then the soldiers turned on the community and started taking the cattle. We, the citizens, are suffering between the two forces. We don't know why the soldiers have turned against the community. – Diu, from Rupnygai When they [Government of Sudan troops] capture people, if they are young women they rape them. If they are old, they take them to Pariang [Government of Sudan-held town]. If very young children, they knife them and throw them inside the tukuls [huts]. – Arup, from Awet, Panarou