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MSF in South Sudan, 2011
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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 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 years of violence and instability. Few people have access to adequate healthcare. Insecurity, violence, and mobility of the population help facilitate the spread of diseases including malaria, sleeping sickness (human African trypanosomiasis), and kala azar.
Because there is little capacity to deal with them, preventable diseases and conditions, such as malaria, acute diarrhea, and measles, are common causes of death.
The resources that exist in South Sudan 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. They 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.
MSF has worked in the South Sudan area since 1978.
Sudanese refugees living in appalling conditions in camps in South Sudan have been falling ill and dying at rates above accepted international emergency thresholds, MSF reported in August 2012. Epidemiological data gathered by MSF reveal an average of five children dying per day in Yida camp in Unity State, where some 55,000 refugees are seeking sanctuary. Additionally, one in three children was found to be malnourished in Batil camp in Upper Nile State. And a month earlier, preliminary epidemiological data showed both crude and child mortality rates well above the emergency threshold in the Jamam camp, Upper Nile State, as well.
MSF began its emergency intervention among these refugee populations late in 2011, when some 13,000 people fled violence in their villages and towns in Sudan and crossed the border before settling in the remote South Sudanese town of Doro in Upper Nile State’s Maban County. 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.
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.”
Through July, more than 100,000 Sudanese refugees arrived in Doro, Jamam, and a third location, the Batil camp, which was opened well after it became clear the first two were overcrowded and, in the case of Jaman, prone to severe flooding during heavy rains. People were turning up with wrenching tales of violence and deprivation, frequently having had left relatives behind. But what they were finding was no less challenging. Children in Jamam were seen sleeping in wet clothes and wet blankets, for instance, on muddy, waterlogged ground. Malnutrition, respiratory infections, and diarrhea were the main medical issues.
While the camps in Upper Nile State received most of the early attention and resources, more and more families have been streaming across the border from Sudan’s South Kordofan State into a refugee settlement in Yida, a large border village in South Sudan’s Unity State. Fighting that erupted in South Kordofan’s Nuba Mountains in July has persisted, and some people have reported aerial bombardments of their villages. As in Doro, Jamam, and Batil, the onset of the rainy season this summer caused health conditions in Yida to deteriorate and made transport to and in the area exceedingly difficult.
Meanwhile, MSF was still operating numerous other programs in the country, including nutrition and supplementary feeding programs for displaced people seeking sanctuary in and around the town of Agok, in the southern part of the contested Abyei border area. In essence, be it in Maban or in a place like Gogrial, a great many people in South Sudan live everyday with profound—and often unmet—medical needs.
This is all happening against the backdrop of South Sudan’s ongoing rivalry with Sudan. In April, open conflict erupted briefly between the national forces of the two countries Sudan along their shared (and contested) border. MSF performed multiple surgeries for four patients wounded during aerial bombardments of the town of Abiemnom, about 22 miles (36 km) west of Agok in Unity State.
MSF also treated more than 30 victims of the same conflict in the towns of Bentiu, Unity State, and Malakal, Upper Nile State. Many of the patients were women and children; three were evacuated for surgical care at MSF’s hospital in Leer.
Generally speaking, MSF teams have been responding where the needs are greatest in South Sudan. They run more than 15 hospitals and field clinics in eight states and the disputed Abyei border region, and send mobile clinics and outreach teams to some of the country’s most remote communities. Every day medical teams see the need for services such as reproductive care, primary and secondary health care, care for victims of violence and the displaced, and treatment for potentially fatal diseases such as malaria and kala azar, along with malnutrition and other maladies.
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.
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
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.
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.
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.
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.
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.
Following a January 2011 referendum in which 98.83 percent of the electorate voted for independence, South Sudan became 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.
We have seen thousands of people—mainly women and children—carrying bags on their heads, or sitting on mats on the side of the road, exhausted by hours of walking.
—Raphael Gorgeu, MSF head of mission
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.
Violence is not the only issue. 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 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.
Overview of MSF's 2011 Activities:
In Jonglei State, site of increasingly deadly intercommunal fighting, MSF carried out around 12,500 consultations in Pibor and more than 11,800 in the villages of Lekwongole, and treated approximately 2,500 patients for malaria, 1,000 children with severe malnutrition, and 500 people with violence-related injuries. In December, however, an MSF watchman and his wife were killed when attackers ransacked MSF’s hospital and set MSF’s clinic in Lekwongole on fire. MSF treated 108 wounded people.
To the north, MSF’s clinic in Lankien and outreach sites in Pieri and Yuai treated nearly 75,000 patients for anything ranging from respiratory tract infections to malaria to spear wounds. After an August raid on Pieri and surrounding villages, MSF treated over 100 people for injuries—the majority women and children. One MSF staff member and her entire household were killed.
MSF’s hospital in Agok, treated some 2,300 patients after fighting in the contested Abyei area. MSF also distributed medical supplies and relief items to displaced people and, in December, supplementary food to 10,200 children.
In Aweil, in Northern Bahr El Ghazal, MSF enrolled 1,200 children in nutrition programs, assisted in 3,400 births, and admitted almost 3,800 children to the hospital’s pediatric ward. In Western Bahr El Ghazal, performed 12,000-plus pediatric consultations and admitted 1,600 children to Raja civil hospital. And in Western Equatoria, MSF provided maternal, pediatric, nutrition, and malaria care to some 24,000 patients.