Part I: From the MSF Medical Team in Bahr El Gazal, June 1998
"One child who doesn't die is one child who survives." — Karine Coudert, French nutritionist
Ajiep, June 1, 1998
Simone Van Den Berg, Dutch nurse: The situation is terrible. Mothers have no food too. We see them starving and have to give them Unimix. One mother lying here, she can't get up. Someone comes up to us and says, someone has fainted, and we find two people fainted on the ground--starving. We give them supplementary food. Everyday recently two children die in our therapeutic feeding center. It is terrible.
We talk to people in the community, who say on the outside adults and children are starving, dying. Last night 10 orphans were dropped off at the chief's house, starving children. He asked us for food and we gave him Unimix.
There is no food. Today the general targeted distribution starts. Many people are walking to the airstrip to wait for food. People are eating wild fruits and leaves, but this gives them watery diarrhea and this can be the cause of death.
I have been to three other Doctors Without Borders feeding centers, this place is shocking. Seeing malnourished adults is a bad sign, it is worrying me. There are so many adults like this on the outside, under the trees, malnourished men, women and children.
When I came here 10 days ago I said immediately, this is bad. In Panthou I thought it was bad, in Pakor, worse. Then I came to Ajiep. I am holding dying children every day. There is only Doctors Without Borders here. Food is needed. SFC put in a second water pump, this helps.
When we prepare everything to make therapeutic food, children steal our water and firewood. We have to send guards with the mothers walking out of the compound so their biscuits aren't stolen. When a piece of porridge drops on the ground, children fight to grab and eat it.
I think Bararud will be bad like this. If we can start again there, the word will spread that we are doing feeding and people will come. When we left, there were 300 children in supplementary feeding. It is sure to be growing worse.
Every day we come back to the compound and malnourished adults we saw the day before are gone. Maybe they died or left for another place to find food.
Karine Coudert, French nutritionist: Nobody would believe us about Ajiep at first. Week after week the situation gets worse. Even the local staff have started to ask us for food.
Panthou is one example where the people received some general food distribution. We started to see and hear improvement. Children smiling and dancing. We started to have no new admissions in therapeutic feeding. This is good proof. One child who doesn't die is one child who survives.
When I arrived in Ajiep there was nothing--no food for supplementary feeding. We had only two bags of DSM milk. We opened a day care. We gave the milk throughout the day, admitting five children at a time.
We want to open a 24-hour feeding center for therapeutic cases. We now feed the children five times a day and once at night, an uncooked ration. But we need fences, a structure to protect the food.
The problem too has been lack of water. Now there is a second well.
In Ajiep we start to see severely malnourished adults. I was shocked to see older children who are malnourished. Yes, you see children first like that, but not children of fifteen or seventeen.
This is the worst I've seen in all my experiences. When someone dies in front of our fences, which is happening, it is really sad. But we have to do what we can. We are doing something to stop the suffering.
I was thinking to myself, how could I make people understand what is happening here? What would be good would be to take a photo of a two-year-old child here and one of a two-year-old in Europe. Then people could see what is malnutrition.
I do not understand when people say South Sudan is not news.
Henri Verbeke, Belgian logistician: We have organized and structured medical care and food, and those who visit our centers start to realize it.
I have been going to Bahr el Ghazal for two days a week now to all locations. The main problem in the field is that for my part of the program--logistics--the infrastructure was not able to send enough food. Another main problem is with construction. There is not water everywhere and to build turkuls (huts) for our feeding centers you need water for mud. It is also hard to find people in the community who can assist.
I am impressed with the work of Doctors Without Borders in the field. I have great admiration for our staff. I am absolutely convinced what we do here should be done. We can do good for a small part of the population. We reach only part of the population, the population that can move to us.
I must mention this very important point--half of our staff on the ground is Kenyan. They do a very important job and we couldn't work without them.
Just because the situation on the outside is so bad, it does not mean that what we can, in fact, do is not significant.
William Robertson, Australian logistician: I have spent seven weeks in Bahr el Ghazal, seven months in the region. It is very much an incredible part of the world. The people are amazing--they have such fortitude. They are so strong. It is just so underdeveloped here.
I spent most of my time in Panthou, organizing the building of a therapeutic feeding center and hiring staff for it. Therapeutic feeding is an excellent program. You can see a positive gain. There is very little better than to watch a little child put on weight and walk again.
Even in this big 'backwater' you have to give respect to the people who live here. People who live here, live here forever.
People here are extremely honest. Now yes, children might steal. It must be very disheartening for the Sudanese to see their fabric fall apart.
One thing is we certainly become a lot more adjusted to seeing starving people. Now when I see a child under 75% (weight for height) I start to think, he or she will be okay. We should not think like this. But sometimes we get a wake-up call. There is the story of the twin babies, one that had already died before the mother came to our feeding center. The woman came in with her baby wrapped up. Her husband had died too. Our team took the baby into our compound at night to try to save its life, at first I thought, shouldn't it die with its mother? They could not save its life even with care throughout the night.
Then in Panthou, Thierry and I were putting up a tent and an old man came to our compound. He sat at the entrance of our compound on a piece of wood and put his face in his hands. It was really sad. He sat there for ages. The watchman then came to us and asked us for our crowbar that we were using to erect the tent. We said, no, we are busy using it. He said he had to bury a body. Then we realized that the old man had died in our compound. When we realized the watchman wanted to bury him, we felt awful. Almost all the time people ask for things for a reason. We have to turn off work occasionally and look at the suffering.
Ler - Western Upper Nile, May 27-28, 1998
Renata van Galen, Dutch nurse: I am now doing training for the feeding center. Our medical coordinator, designed a modified supplementary feeding center considering the constraints of time, climate, space and food that comes in. It is difficult to find national staff that is skilled, some have only finished primary education. And these are the most educated people. I am using the same young men who helped out with the nutritional survey. The women I want to train can't speak a word of English so I must use a translator. The local assistants really helped with the nutritional survey we did recently, although some staff is weaker than others. Ideally we'd like medical assistance but training is very low here and anyone with medical training is already working as a community health worker.
Petra, a German nurse, is training three guys on medical protocol for registering children in the feeding center. We expect many children, we measured 10% of the population, if this was an accurate survey, we could have up to 1000 children but expect maybe 300-500 children for supplementary feeding.
Maria Basaran, Spanish doctor, project coordinator: It was strange, when we first arrived some three weeks ago I had the impression that the children were skinny. Maybe some get used to seeing them like this during the hunger gap, but I almost expected that we would have to open a supplementary feeding center. But I expected maybe 10% malnutrition, not 40%. We checked many times to make sure we did not make a mistake as we had no intention to exaggerate the problem.
If people have seeds, they can withstand more. Seeds is the best contribution Doctors Without Borders has made. For food some still have cattle, but yes, there is malnutrition. It is incredible, amazing how people survive. I saw a child who came to the TB center who was malnourished. I was sure she would die immediately. She is getting better with some extra food!
With this amount of food it is my feeling that this is not enough. They have some reserves maybe and if the rains come they will plant seeds. For the seeds they were divided equally among seven village chiefs who also are to distribute to vulnerable people. This is what the chiefs agreed upon.
The priority now is to give supplementary feeding for children and seeds. We are waiting for the rain.
Joseph, Kenyan Logistician: I started to work in Western Upper Nile (WUN) in 1994 with other NGOs including HealthNet. In 1994 it was a very good year, lots of sorghum and good rain. 1995 was a moderate year. When we came in 1996 again it was not very good. In 1997 it was completely bad, and the same in 1998, no good harvest. We will miss the harvest this year again. Normally in January it gets dry, in February there is drought, in March it is very hot. Suddenly the green grass turns completely brown. You don't even want to walk outside. Rains starts in April, and in May people start weeding so that for the end of May people should plant. By June, it is already too late if there is no rain. Fish is plenty here for people near the water, during the rainy season there is also wild fruits, but this is short lived. There are mangos and watermelons, but they are consumed immediately.
The community depends upon cows, it is their main livelihood. Cow camps are not so close to Ler. In the cow camps the young girls and boys have the responsibility to put cow dung in heaps in the sun. The dung is burned at nights to keep the mosquitoes away, people sleep beside it and the cows are also kept near the burning ash. The dung is put in stocks for burning during the rainy season. It also gives warmth.
When you spend time with the people here you develop trust. When you go to a village maybe you are not able to see the inside story. But you learn that if you have something here, it is not for you alone, you share it with everybody. It is very difficult to be stable in one place, maybe you are displaced.
Now, you definitely see children who are a bit well here in Ler town, but you see starvation in the villages. When you go to villages, you find children eating wild palm fruit. Not everybody has cows, maybe they lost them, people move around a lot. In villages, when we get there--they are very isolated. And you find some villages evacuated completely, to Bentiu because maybe they would get food from the market there. When we ask other people, where did they go, they said, to find food. When I meet with chiefs and ask how is the water, the chiefs say, it is a very big problem in some villages.
Mothers who have no food and water are forced to move, for the cows too. They can walk for days and days. With water, life can be a bit possible. The environment is very hostile. People have a lot of problems, many are in a very bad shape.
People need a hope. How do you divide a cow for no standard price in return? They end up losing if they trade the cow. Transportation also is a big problem here, even if there is food, it can only come if the roads are dry.
Now there are food drops, but it is just not enough, like a drop in the ocean. And what is delivered has to be monitored. If the rain doesn't fall, by the end of this month they will plant in the highlands but don't expect harvest. Maybe close to the swamps they have one more week's chance. If they don't plant, the situation will be worse and it will likely be like this for the year and beyond.
I like working here because for me when I was leaving, people said, you are our brother, don't leave us. Apart from that, when you get to know the people, you develop interest in them, you are happy to learn and help. I learn a lot and compare it with my country.
People start to take care of you too, you know they appreciate you. In 1994 when I was running to jump into a bomb shelter I cut my leg. Women and men heard and came to take care of me, they formed a human shield around the compound. When they take care of you, it is good for your morale. You have to have a big heart to work in a place like this.
Impressions of South Sudan by Carol Devine
May 27, 1998
Below the land suddenly drops off into a big valley, the Rift Valley, which is made of swirly green bushes like soft fur. It is like the land was sucked down by an instant determined force, as definite as the edge of an iceberg. Now the soil is turning more burnt red and the flatter and drier. There are lakes too.
Lokichoggio, 5pm. Four C130 (Hercules) sit on the runway, WFP and UN written on their tails. They've had a poor day in terms of food delivery, due to the lack fuel and food. I am surprised that there are some mountains on one side of the runway. The sun is hot. The pilot reminds me that if it wasn't a protracted political and humanitarian crisis in South Sudan, likely none of us would be here.
After our key Kenyan logistical staff arrived and put new labels on the food and medicine deliveries for Western Upper Nile (WUN), we drive to the relief base. We sign in and look at the flight manifest: people, food, bicycle parts.
May 28, 1998 - 8am
I am now in the air leaving Kenya and going into Sudan. We are going to a lower altitude. Below are round grey-brown turkuls, round mud huts covered with palm or straw roofs. Around them are lines drawn in brown, and piles of grey ash. People walk across the burnt land. I am surprised at the amount of green. The more you see of the world, the more you realize how little you know of it.
We land in Ler and children and adults surround the plane. They smile and shake our hands. They ask my name and tell me theirs. Some people have scars, on their faces, lines cut across their foreheads, or dots around their mouths and foreheads. Some wear dresses, t-shirt and pants, some children are naked except for a string of red, yellow and green beads across their distended or flat bellies.
Standing outside for ten minutes is extremely unpleasant. The heat is oppressive, pushing down everywhere. The flies landing in groups on my feet are less annoying than those on my arms or face. The team briefs me on their impressions, their work to set up the supplementary feeding center, hoping it will open for malnourished children on Monday. All feel they are fortunate to work in South Sudan, for the most part.
The team expects many children to come for supplementary feeding, maybe 500 to start, but it is too early to tell what they will find. They also describe the nutritional survey result that they did in the region, which produced alarming results of 35% malnutrition among children. From Ler, malnutrition is almost invisible so far, except for three or four children I saw in the TB compound that are quietly given supplementary feeding before the center opens in the school turkul next to it. South Sudan is immense, there is only 40km of tarmac road in a country a third the size of the United States. Unofficially figures say that South Sudan has the most landing strips of any country in the world, dirt ones at that.
For the nutritional survey, a standardized one to give an indicator of the level of global malnutrition, one Doctors Without Borders team had to go by car, foot, walking through swamps, by canoe, and by crossing streams up to their waists, to get to a village. There the chief welcomed the team and asked for the children to come out and be tested by weight and height to determine their level of nutrition or malnutrition. The malnutrition in villages in Ler region is worrying.
The team shows their solidarity for the people of Bahr-el Ghazal and the Doctors Without Borders teams working there, where they recognize that the situation is worse.
I am back in the plane now, my body and clothes are filthy and my sweaty body cools down as we move up in the sky. Nobody knows if the 'sky might close', as the French-speaking Doctors Without Borders staff say. The sky reopened on April 1st for 50 locations in Bahr-el Ghazal, and for 180 locations countryside. The rains too can close the landing strips. More food is needed urgently.
We need to continue to advocate for South Sudan.
June 1, 1998
The plane landed on the brown gravel airstrip and we arrived at the supplementary and therapeutic feeding centers. The reports coming out of Ajiep in the last few days were bad. At first 57 children were admitted into the supplementary feeding, and 12 to the therapeutic feeding. Now there are 1,209 children in supplementary and 68 in therapeutic. The figures speak starkly, but numbers are sterile. Landing into a place of death walking is overwhelming.
A community member, a teacher he said from Wau, who fled from there when fighting broke out in January, walked with us quickly to the Doctors Without Borders compound. A hot walk, many people stopping to shake our hands. Already we saw many people waiting at the airstrip and a stream of people walking towards the airstrip--food was to arrive today.
In front of the therapeutic feeding turkul were 50 mothers with emaciated babies waiting for a feeding. It was quiet and still, only a few children crying. Ann, Peter, and Simone took us around the compound, telling us the problems they've been having with the lack of food, the increasing number of children who need supplementary and therapeutic feeding, and the growing number of malnourished adults in the compound.
Simone took us into a dark turkul with the local authority representative. Inside is the only respite from the burning sun. On a mat was a man lying down, some gray in his hair, a long, spindly body. His eyes were all we could see well, hopeless, tired eyes of death. One woman lay on the ground, a mother, Simone said, that she could only give supplementary food, there was nothing else. Simone told us about the fast-deteriorating situation and the need for general food.
Back at the therapeutic feeding center we looked for the last time at the group sitting under the tree, patient for food to save their children's lives. I had to stop looking at the children, it was all the same, big heads, sucked-in cheekbones, branch-like limbs. You know well what to picture about starvation. It is nauseating writing about the same thing over and over. Simone thanked us for the visit and pleaded for me to tell people about what we've seen.
At the airstrip in Ajiep I was numb. Under the shade of a big tree, and in and around a broken down cab of a truck, people sat patiently and waited for their next meals to fall from the sky. And it's not like they are begging. They've waited and waited, walked and walked, picked and eaten wild foods, eaten, sold, or had looted their lifelines--their cows, survived. How much longer, how many can hang on to the thread?
Acumcum, Mapel - June 1, 1998
We landed on the airstrip in Acumcum and immediately the Doctors Without Borders staff came to greet us. The Doctors Without Borders compound was a short walk away on a tree-lined red dirt wet path. The air was damp. One national staff first showed us the bomb shelter with a muddy entrance, and then 'Helene's garden.' Helene Andresen is a Danish nurse who has been based in Acumcum for four months. Tomato and flowers are trying to grow there. This week there are 650 children in the Acumcum supplementary feeding center, a 46% increase over the figure two weeks before. When the center opened, there were 229 children admitted for supplementary feeding.
Veronique, the Belgian doctor, drove up on her bike asking urgently, 'Where is the pilot?' She told us she had a young man who had been shot in the head and she was going to ask for the 'green light' to transfer him to the ICRC hospital in Lokichoggio. Everyone asked if she thought he was going to make it, if the bullet had penetrated deep into his head. It was decided to wait for her prognosis before taking him, for the official 'green light', that we would return after a stop in Ajiep. When we came back, the young man was on a stretcher near the airstrip, many people surrounding him. Veronique said that she had received the green light, the bullet had only grazed his head and his vital signs were good. The nurse was holding the drip, blood on his gloves. The man's mother was holding the unconscious man's hand. War, displacement, disease, and malnutrition intersect here. What happens to rituals other than death ones here, like marriage and celebration?
We also took a young boy of nine or ten with a severely infected hand. When we saw him the first time, he was wearing a crafted gourd on his head, nothing else but a sling holding up his hand. When we came back for him and the gunshot wound patient, the boy was without his gourd hat and he had blood running down from a fresh wound on his head and lip. Someone said he'd fallen.
The naked boy sat at the back of the plane, a seatbelt tight around his small waist. I wondered what must he think when this plane takes off in the air, off a land without technology. I kept turning around to check if he was okay. Little brown boy sitting in a blue seat in the air. He sat dignified. I waved at him and he smiled back. His smile was so wonderful, I think if I was in his situation could I muster such strength. In the west I am so spoiled I don't know about this kind of survival.
I gave the boy my sandwich. The pilot left his seat to go and open the sandwich for him and put back on his seatbelt, also giving him a cup of water. It's easy to feed one person. Otherwise I felt quite helpless and desperate when mothers pointed to their dying children and to their stomachs. Wait? Thankfully food was arriving.
In Mapel the sun is hot, not as excruciating as in Ajiep, some 10 minutes away by plane. The land is much greener than the last week, everyone tells us. Before it was completely brown. We met Laurence Sailly, the French nurse who gave us four more patients to transfer to the Billing hospital before returning to Kenya.
Yet another red sand airstrip, the plane shakes as we land. Now it is two more hours to get to Loki. The little boy sleeps and the man with the gunshot wound moves his hands. This is a good sign. I cannot but respect the Sudanese survivors of this politically, environmentally-induced hunger.