Before fighting broke out in Juba, the capital of South Sudan, on December 15, 2013, MSF had been working in approximately 12 projects in eight of the 10 states of South Sudan, providing a range of health care services including inpatient and outpatient care, nutritional support, reproductive health care, kala azar treatment, surgery, and pediatric and obstetric care. Since then, MSF has increased its capacity to rapidly respond to emergency medical needs in the country. MSF teams are now working in 20 projects in nine of the 10 states in South Sudan, providing basic health care, surgery, vaccinations, as well as clean water to people who fled their homes. MSF has also established emergency programs in Kenya, Ethiopia, and Uganda to assist South Sudanese refugees. More than 322 MSF international staff are on the ground working together with 3,364 South Sudanese colleagues.
The following is a transcript of a press teleconference conducted by Jerome Oberreit, MSF Secretary General, and Chris Lockyear, MSF Operations Manager for South Sudan and for MSF's response to South Sudanese refugees who have fled to Ethiopia. This transcript has been lightly edited. The original audio recording is also available.
Good morning, everyone. As mentioned, I am Jerome Oberreit, MSF Secretary General. I recently returned from visiting programs in South Sudan with a small delegation and meeting with government officials, opposition, and diplomatic officials. What I want to do today is share with you some of the most pressing and acute issues of this worsening crisis more than three months after it began in mid-December. There is a strikingly slow and inadequate response from the humanitarian aid system to the crisis, with large proportions of displaced people receiving little to no assistance. The UN today estimates the displacement to be at around over 900,000 people, of which some 700,000 are within South Sudan and over 200,000 having fled across the borders in neighboring countries.
Today we reach some 150,000 to 170,000 affected internally displaced inside South Sudan and another similar number which have fled to neighboring countries and are assisted in refugee camps. It is hard really to verify what the real scale of displacement is due to. First, the likelihood that there are small pockets of IDPs in South Sudan, in what would be very hard to reach areas, but also the different definitions of what really constitutes an affected population by the recent fighting due to not only the power situation in South Sudan but also some of the semi-pastoralist habits of the population.
But regardless of the true numbers, the scale of the crisis cannot be underestimated. We basically have today hundreds of thousands of displaced and a destitute population with little to no access to food, and which are totally dependent on humanitarian assistance. Unfortunately, the vast majority of these people have been forced to flee their homes and are surviving with little to no humanitarian assistance today.
We have received assurances from all the meetings we’ve had that access would be granted across all front lines, to both government and opposition areas, from both top-level officials in the government and in the opposition. So really, access by NGOs to be able to go and reach, today, the most affected regions, should not be an issue.
But one of the main concerns that we’ll also be discussing today is actually the lack of respect we’ve seen over the past month towards the medical mission – towards not only patients but also caregivers and the medical infrastructure. This message was well heard by top-level officials in the government and the opposition, but our worry, and one of the main questions that we’ll just have to see in the coming months, is how far this respect has been able to trickle down to the field because clearly that has not been the case over the past months.
Right now, the populations in South Sudan should be planting their fields, but instead they’ve really been driven from their homes, and the national government itself has actually run out of a lot of the resources. And the UN system is also currently nowhere near the capacity it had during the second war. So the past 20 years before the peace agreement was signed, where there was Operation Lifeline Sudan in place between the 90s and the early 2000s, which gave a lot of capacity not only to NGOs but to the UN system itself, to actually provide in a full-blown crises.
Unfortunately, today, when we look at the UN capacity, it has nowhere near the same capacity. There’s not the big base that there was that came out of Kenya and obviously there was a big shift towards a much more reconstruction agenda. And since December we haven’t seen the kind of return or reinvestment that we would expect to see with the conflict and the high displacement that has occurred.
So there’s been very little additional capacity and little additional funding that has gone to humanitarian relief, while, on the other hand, there’s also been the freezing of some of the development aid, some of it for basic health programs for instance, which is is still very much necessary. So most of the non-governmental organizations today in South Sudan are completely dependent on the UN system to reach these areas, and yet that system is not expanding — or hasn't expanded — in line with the crisis.
Perhaps one of the most striking examples of the slow and inadequate response to this crisis, even if it’s one of the most accessible areas of the country, is the Tomping internally displaced persons’ camp in Juba. This camp is actually inside the compound of the UN Mission in South Sudan — UNMISS — which opened its door to some of the IDPs following the fighting in December to protect them within the camp. Here, you will find some 25,000 people living in what I saw to be completely horrific conditions.
The recent and early rains that have occurred in South Sudan — so still not the main rains and not as heavy as they will be in the coming weeks or months — have basically been overflowing the few functioning latrines, leaving pools of foul water and human waste so deep that our teams have had to temporarily suspend and close one of our medical facilities in the camp.
So what was supposed to be a place of safety for the population, which is fearful to leave the camp following the fighting that took place in December, risks becoming an epicenter of outbreaks and diseases. The MSF team was already treating large numbers of patients suffering from diarrhea, from malaria, from respiratory infections, and the camp had already failed to meet the most basic public health standards before these early rains destroyed all the functioning latrines.
So, the situation has basically gone from an overcrowded place, a difficult place to be able to actually start meeting the basic needs, to a situation which has drastically gotten worse due to these early rains. But what is important to point out is that Tomping, although being quite emblematic because it’s in Juba—it’s very accessible, and it’s actually happening under the nose of what is a big humanitarian capacity or what should be a big humanitarian capacity in South Sudan—is not the only location where we see problems in terms of the quality of the assistance provided to a largely accessible population.
MSF sees a similar situation in Malakal, but also in safer zones such as Minkaman, which are open camps and not within a UN compound, where some 80,000 people are receiving … the people have moved following the fighting in Bor city and the surroundings, and the site that they’ve located on and where the facilities have started being put up, is actually in the flood plain of the Nile, and it has two main problems: one, it will be flooded, and two, this area should be planted by the local residents and this should be where the crops will come from when the rains begin.
So after being reluctant for three months to to create a camp there or to create new camps, finally four sublocations have been identified. But unfortunately very little has been done and nothing has been put into place in those sublocations. So you have the very absurd situation where nothing has been done in the camp because it was thought to be unsuitable, then finally the UN finds four sub-locations where the IDPs can be moved to, but at this stage they’re not at all ready to receive IDPs. There’s no infrastructure, no latrines, no water point and so on. And yet we know that we’re in a race against time due to the rains – the heavy rains in the coming months.
So, like Tomping, like Minkaman, we also have in places like southern Unity and Jonglei some more dispersed populations which are in smaller regroupments, harder to reach areas -- which actually are no better if not in a worse situation than the populations found in either the UNMISS camp or the bigger regroupment sites along the Nile.
So this is again just to stress that this is not limited to a few sites, but broadly the conditions of what the IDPs — the internally displaced – are facing in South Sudan are appalling. Water/sanitation is a big problem and will only get worse as the areas get flooded and we are simply not ready for the rainy season. This is a particularly vulnerable population that has fled violence and devastating attacks but what’s really important to really stress again is that the worst is still to come.
We are anticipating the huge change of the rainy season, and the complete lack of adequate logistics capacity of the aid agencies, plus [the lack of preparation], is extremely worrying. We should be in a full mode of deploying, preparing and so on, and we still seem to be, for much of the refugee response and IDP response, at the planning stage.
So, the upcoming rainy season will cut off many parts of the country. For those that know Sputh Sudan, even areas with landing strips will be non-landable, so it is really now that there’s still a little, small window of opportunity to get prepared, to deploy, to actually scale up. And the priority right now is actually for all, in particular donors, to recognize the need — the scale of the problem – and to ensure that aid agencies can step up their activities to meet the challenges that we have ahead.
We really can’t afford to continue running behind when so many people have been displaced due to conflict and we know the huge impact that the rains are going to have in terms of making a lot of South Sudan difficult to operate in and inaccessible.
Another key point, which is a broader one, is the need to ensure that in this next period and throughout the rains, there is a lot of flexibility in the response by NGOs. The overall response that I saw while I was there seems to be heavy and bureaucratic. It’s very difficult to release funds and to get NGOs to be able to be operational on the ground.
So there needs to be a broader and more ambitious trigger to the needs of the response in the little time that there is left. Now I’m going to hand over to Chris, who really has an additional perspective.
Thanks very much, Jerome. Again, my name is Chris Lockyear. I oversee MSF’s operations in South Sudan as well as our response to the refugee influx over the border in Ethiopia. I’d like to start by talking about what we’ve seen over the last few months. There’s a really striking thematic when it comes to the lack of protection of civilians as well as medical personnel and facilities, as Jerome was mentioning.
In particular, there’s been some very acute examples which we have seen in the projects and the areas that we are working in, as these areas have themselves become victims of devastating attacks. In this, we can say that medical care itself has come under fire, especially when we see patients being shot in their beds and hospitals being ransacked and destroyed.
This clear lack of respect for medical care has deprived hundreds of thousands of people of lifesaving care at a time, as Jerome was describing, when they need it the most. Among the acute examples that we have seen is our hospital facility in Leer, which was the only secondary facility in all of southern Unity state. It served a catchment population of around a quarter of a million people.
This hospital was ransacked and totally destroyed in the final days of January and early February. What was most distressing for us was the fact that our 240 locally hired staff had to flee the hospital. Some of them made an extremely brave decision to return to the hospital to take some of the critical patients, which were on longer term treatment, such as for tuberculosis, and took them into the bush with them for their safety and to continue their treatment.
It took several weeks before we could identify the key groups of our staff in the bush, essentially because this is an incredibly remote area, and they were hiding for their own safety. They, along with the population in southern Unity, live in terrible conditions — at risk of disease, malnutrition, dehydration and violent attack. We’ve just over the last few weeks been able to establish contact with a significant proportion of our staff, I’m very pleased to say, and with them we are trying to respond in the areas of Mayendit and Nyal in southern Unity.
Another example would be on February 22nd, when in the Malakal Teaching Hospital MSF teams discovered at least 14 dead bodies showing clear indications they had been shot while lying in their beds. Many of the hospital wards had been burned and looted and the hospital had been looted throughout.
In mid-January, the MSF compound in Bentiu, which is the capital of Unity state – so north of Leer where I was mentioning before – was looted amidst fighting in the town, which forced MSF staff to evacuate Bentiu state and leave the hospital and drugs and supplies with their patients and their caretakers, hopefully facilitating them to run away again, particularly with the patients which were on longer term treatments.
Thousands of people, as a consequence of this, had no access to health care in Bentiu for several weeks. I’m pleased to say that we are now back in Bentiu, where we have a situation where we’re trying to resume patients’ treatment for tuberculosis, but also scale up in terms of malnutrition response. Day-by-day the number of patients that we have admitted into our feeding program is increasing in Bentiu.
Further, patients were reportedly killed in their beds in the hospital in Bor, which is the capital of Jonglei state — this as a result of fighting or the consequence of fighting in December 2013. It took us a while to ensure the guarantees which Jerome was referencing in his statement, to ensure our safety to be able to visit Bor hospital.
But on arrival in February, MSF staff visiting the hospital discovered decomposed corpses of a mother and child dumped in the facility’s water tank. While the hospital is today functional and well supplied, there are few patients in the wards since most of the town is empty.
This really refers back to what Jerome was saying in terms of the trickle down of the need to respect the medical mission — that being patients, caretakers, and caregivers and the facilities themselves. We, MSF are calling on all parties to respect the integrity of the medical facilities and to allow aid organizations to access affected communities and to allow patients to receive medical treatment, irrespective of their origin or ethnicity.
That’s a bit for what we’re seeing in South Sudan itself, and then I would like to take the opportunity to highlight a bit the regional impact of this crisis.
We currently have refugees pouring into Ethiopia, Kenya and Uganda, and in Ethiopia we’re already seeing emergency levels of malnutrition in the camps in the Gambella region.
The impact of the crisis in spilling across borders with these arrivals of people in the surrounding countries. We’re extremely concerned about these 74,000 refugees who arrived over the past two months in Ethiopia’s Gambella region. There are still more than 1,000 refugees arriving, crossing the border from South Sudan, into the region on a daily basis, some of whom are telling us that they’ve walked for up to three weeks.
The living conditions in these camps are grim and we're deeply concerned for the wellbeing of the refugees not just in the camps, but also in transit and their journey from their homes to these camps. There is extremely limited or next-to-no access to water and sanitation. This concerns us, particularly when looking at pathologies such as diarrhea and respiratory tract infections, and we're currently seeing a situation where malaria is accounting for more than 60 percent of the medical cases that we see. And this is before the real onset of the rainy season. Further, a measles outbreak has been declared by the authorities, and MSF as a result of this, has admitted dozens of children in its hospitals. Here, also, the response of aid actors needs to be scaled up to provide adequate access to food, water and shelter. Basic nonfood items need to be distributed and sanitation needs to be provided to these refugees.
It's a lot to summarize, but in conclusion, three months into the outbreak of the war in South Sudan, we've seen an ineffectual response to protect civilians from violence. We see vast numbers of people receiving little or no aid, hundreds of thousands fleeing the country. And the coming rainy season, the lack of access to food, and an already huge emergency, risk getting even further out of control in the time to come.
With that, thank you, and we're happy to answer any of your questions.
I would like to ask about the camps in Unity State and Upper Nile that received refugees from Sudan, both Blue Nile and South Kordofan. What is the access to these camps? What has been the fate of these people? Are they utterly bereft? And the second question: MSF is in a position to identify many of the perpetrators of these atrocity crimes, and that puts you in a very difficult position. Do you identify them publicly when you know who they are, or do you risk, as a result of doing so, retaliation that will make your job much more difficult or impossible?
I'll let Chris answer the question about the refugee situation. In terms of the question about naming perpetrators, obviously as a humanitarian organization, it's crossing a line to start pointing and naming, and I think it's very important that we remain operational and can go where we can go. And we've had these discussions, both with the government and the opposition, that there's a line where we're going to stop. Regardless of whether we would want to or not, the complexity of South Sudan makes it very difficult to identify who is responsible or not responsible for the acts that are ongoing. So, our role is first to actually provide aid and then to witness what's gone on. It's not for us to start finger-pointing or laying the blame on one side or the other. On the other hand, it's very important for us to discuss with authorities, both government and opposition, the protection of the medical facilities, the patients and the staff, and the incidents that have occurred. And I would say that during my visit there, I was able to have very frank and direct discussions. There was a strong listening ear on the need to ensure the respect of facilities, the respect of patients. Hopefully, this could trickle down to the field level, which is going to be a challenge. Chris, I will let you answer about the refugees.
Yes, you're absolutely right. The refugees from Sudan in the Yida camp in northern Unity State and the Maban camps in Upper Nile are still very present. The numbers of people in those camps has roughly remained stable, although there's been influx and outflux from those camps, over the last few months, as people decide essentially where is the safest place for them. The good news is that those areas, particularly in Maban, haven't been directly affected by this current crisis. There is enough security to allow NGOs with less capacity than we have to be able to increase their efforts, because the conditions in these camps are still incredibly basic. There is obviously some advantage to being several months past the peak of that crisis. The medical situation has somewhat stabilized, but we remain very concerned about the situation in those camps with the rainy season coming up.
What are the transport needs once we get into the rainy season? You’ve got a tremendously difficult logistical problem now, and the rains have indeed, in some places, in Juba and elsewhere, begun early, but once the rains hit in a big way, how—with so many people displaced, and so little capacity on the ground, what kind of transport do you foresee needing and what fraction of that needed transport is either in place or on the way?
Very pertinent question. As Jerome was saying, with the rainy season coming up, that’s a concern in and of itself, with the limited infrastructure in South Sudan, and a reduction in terms of logistics capacity. We’ve lost a lot of our facilities and stocks in a number of areas of food prepositioning. It’s happened to other people as well. So this is a moment when we are normally pre-positioning ahead of the rainy season anyway. In this case we are running behind, partly because our stocks in some places have been looted or burned. On top of that we have a situation where we’re particularly concerned for—amongst other things—malnutrition and malaria. So, we need to ensure that those supplies are in place. But we’re trying to balance that with the risk to our facilities, and we’ve seen some very clear examples where those facilities have come under attack.
I would describe it at the moment as a race against time to ensure that there is enough supply in the relevant places. What this means practically is air movements—so planes throughout a lot of South Sudan. There are some capacities for land trucking of supplies, but that’s significantly reduced over the last few months. So, air capacity, and also on a more local level boat capacity, particularly in areas of Upper Nile down the Sobat River. In Southern Unity State, there’s likely to be a system of islands developing there, and it will probably require boats to reach the people on them. So, it is a very challenging situation from a logistics point of view.
Does Lokichogio need to be brought back into play to provide enough transport?
Well, we certainly have maintained our presence in Lokichogio throughout. That’s proving valuable at the moment. I think that one of the key things to point out is that that’s a support place; we remain coordinated from Juba itself. But yes, Lokichogio has proven very useful for us. For others, I think it would be a case of what best fits their areas of operation and their particular areas of expertise.