SOUTH SUDAN: A COUNTRY GRIPPED BY VIOLENCE

South Sudan gained independence from Sudan in July 2011, becoming Africa’s first new country since Eritrea in 1993. Since then, however, hopes for the future of the young state have slowly crumbled and in 2013, as the government collapsed and intercommunal violence reached explosive levels, South Sudan edged towards civil war.

Jonglei state has seen some of the worst violence since independence, a result of conflicts that are rooted in cattle raiding. In March, however, the situation became even more unstable as the army launched an offensive against a rebel group led by David Yau Yau. In April, Médecins Sans Frontières (MSF) was forced to suspend activities in Pibor because of threats against staff and patients and was preparing to return in May, having secured the necessary assurances, when the hospital in Pibor was looted and rendered unusable. This was the sixth time an MSF medical facility had been looted or damaged in Jonglei state in two years. It is difficult and expensive to build hospitals in South Sudan, and what takes a matter of hours to destroy can take months or even years to reconstruct, leaving many thousands of people without adequate healthcare.

As the fighting in Jonglei state intensified, almost the entire population of Pibor county sought refuge in the bush. People were too afraid to leave their hiding places to seek medical attention, and so MSF went to them: a small clinic was set up in Boma town, staff continued to run a health post in Gumuruk, and mobile clinics – some carried out by helicopter – conducted hundreds of consultations in the bush in southern Pibor. Before MSF could deliver assistance to those in hiding though, requests for government permission to travel to opposition-held territory were repeatedly denied.

December violence

In Juba, amid a power struggle inside the ruling Sudan People’s Liberation Movement (SPLM), South Sudan’s president, Salva Kiir, sacked his cabinet in July and so rid himself of his main political rival, vice-president Riek Machar. What started as a political dispute exacerbated ethnic tensions in an already divided country. On 15 December, fighting broke out between battalions of the Sudan People’s Liberation Army (SPLA), spilled onto the streets of the capital and resulted in Kiir accusing Machar of an attempted coup d’état. Conflict subsequently spread throughout the country, between those loyal to the government and those supporting the former vice-president. Civilians sought shelter in UN bases and in the bush, and many others crossed into neighbouring countries such as Uganda, Ethiopia and Kenya.

Following the eruption of vicious fighting in Juba on 15 December, people fled for their lives and sheltered in two UN compounds. MSF set up clinics in both camps, and also provided Juba Teaching Hospital with drugs and medical supplies. As the situation in South Sudan deteriorated, MSF suspended activities for two days at the hospital in Malakal, Upper Nile state, because staff were unable to gain safe access due to outbreaks of violence. In the same month, staff had to be evacuated from Leer hospital owing to safety concerns. Bor, the once bustling capital of Jonglei state, had become a ghost town by the end of the year as government troops and SPLM-in-Opposition (SPLM-IO) battled for control. It was the first major area to fall to the rebels after the December violence. Thousands of civilians fled to the town of Awerial, on the banks of the Nile in Lakes state, and MSF’s emergency team supported two Ministry of Health clinics by providing consultations and obstetric care and donating medicines. Clean drinking water and measles vaccinations for children were a priority. With very little infrastructure in place, and an already weakened population, the risk of disease in makeshift camps such as Awerial and Minkamman loomed large and the situation will only be exacerbated once the rainy season starts and settlements begin to flood.

Sudanese refugees

Amid the mass internal displacement and instability that took hold of the nascent country in 2013, it could be forgotten that South Sudan is also home to hundreds of thousands of Sudanese refugees, the majority of who fled conflict in Sudan’s South Kordofan and Blue Nile states in 2011 and 2012.

In refugee camps in Unity and Upper Nile states, cholera, malaria and measles are all a threat, and hepatitis E outbreaks have had a major impact on mortality in camps near the border with Sudan. MSF ran a number of vaccination campaigns in 2013. In April, more than 105,000 Sudanese refugees and 27,500 residents of Maban county were immunised against cholera; this was the first time MSF had used the two-dose oral vaccine as a preventive measure on such a large scale, in such a remote location. The pneumococcal conjugate vaccine was used for the first time in South Sudan in Yida camp, Unity state, in August.

MSF has been working in what is now South Sudan for 30 years and even before this latest conflict access to healthcare was limited and providing it was a challenge. This is a barren region, with rivers, swamps, and barely any roads. By the end of the year, MSF’s priority became identifying where needs were greatest, and responding accordingly even if it meant staff leaving ongoing, long-running projects focused on acute needs.

With interethnic tensions increasing, people’s needs growing ever-greater and resources scarcer due to the departure of international organisations in December, as 2013 drew to a close the situation in South Sudan was poised to become dramatically worse.

For more details of MSF’s response in South Sudan, see the country report, pp.82 – 83.