© Brendan Bannon
13 Jul 21 16 Jul 21

South Sudan: An MSF record of the consequences of violence since independence

On 9 July 2021, the Republic of South Sudan marked its tenth birthday. This significant milestone is also marred by the bloody legacy of its first decade, including a five-year civil war.

A new Médecins Sans Frontières (MSF) report, South Sudan at 10: an MSF record of the consequences of violence, offers a consolidated account of MSF’s experience in South Sudan since 9 July 2011. It seeks to serve as a record and reminder of the human toll of violence since independence, as seen by MSF – through its staff and patients.

Independence to civil war

At independence, South Sudan was grappling with at least 30 humanitarian emergencies.

Parts of the country were engulfed in increasingly fierce intercommunal clashes, and there was renewed conflict in border areas with Sudan.

Sudanese refugees began streaming across the border into South Sudan in June 2011 when conflict erupted between the Khartoum government and the rebels of the Sudan People’s Liberation Movement-North (SPLM-N) in Sudan’s South Kordofan State.

Despite the challenges, the first years in the post-independence period were a time of anticipation and optimism and, for most of the country, it was a period of relative peace.

However, by December 2013 – less than two years after independence – the country had rapidly imploded into civil war, quickly exposing the fragility of the emerging young state.

Dozens of burned dwellings are viewed from the air in the town of Leer, South Sudan, February 23, 2014.  The MSF hospital in the town was also thoroughly looted, burned, ransacked, and effectively destroyed, along with most of Leer.

"After these 22 years of civil war came, then there came independence in 2011. The whole population was joyous. We were happy because a new country was born... but all this hope and dreams became all of a sudden no more." – MSF staff member, Yambio, August 2019. 

Extreme violence

The five-year conflict is estimated to have led to nearly 400,000 deaths, many the result of ethnically motivated targeting of civilians, including children and the elderly.

Women wait in the waiting room of the MSF clinic in Gumuruk, Jonglei state, South Sudan. The MSF clinic saw almost entirely women and children arriving for treatment, while men appear to be hiding in the bush.

Sexual and gender-based violence (SGBV) has been used as a weapon of conflict, with systematic ethnically and politically motivated attacks.

Some of the most extreme violence was conducted in places of refuge and sanctuary, including state hospitals, where patients and people seeking shelter were killed in a series of brutal attacks.

The burned and destroyed office at the MSF hospital in Leer, South Sudan, February 23, 2014.  The hospital was thoroughly looted, burned, ransacked, and effectively destroyed, along with most of Leer.

Millions of people have been displaced, often multiple times, inside and outside South Sudan.

"Since independence, 24 of MSF’s South Sudanese staff have been killed by violence, five while on duty"

This includes hundreds of thousands of people who sought shelter in Protection of Civilian (PoC) sites, inside the bases of the United Nations Mission in South Sudan (UNMISS).

Since independence, 24 of MSF’s South Sudanese staff have been killed by violence, five while on duty.

All of MSF’s patients, staff and their communities have been impacted directly and indirectly by conflict and violence.

Deaths from preventable diseases

Across the country, people have been subject to destruction, displacement, disease, and death.

Violence disrupts access to healthcare, including routine vaccination, while increasing the risk of disease transmission and food insecurity.

South Sudan. The Greater Pibor Administrative Area. Pibor Town. September 9, 2020. An MSF’s nurse inserting an IV needle to an arm of a patient with severe malaria and measles in Pibor town.

There have been repeated failures to ensure dignified living conditions for people in refugee camps and PoC/Internally Displaced Persons (IDP) sites.

"MSF has recorded three to five children a day dying from preventable diseases – such as malaria – in different refugee camps and PoC sites"

Instead, people fleeing conflict and violence have, over and again, been forced to live in deplorable conditions – with basic requirements for living space, water and sanitation unmet, far below the minimum emergency thresholds for survival.

Tens of thousands of people from all over the nearby region prepare to receive their first distribution in many months in Thonyor, South Sudan. Many residents from Leer fled to Thonyor feeling saver there.

At its worst, MSF has recorded three to five children a day dying from preventable diseases – such as malaria – in different refugee camps and PoC sites.

Meanwhile, people forced to live in the open, in the bush and swamps, have repeatedly been exposed to disease and extreme hunger.

Woman pass each other while wading through the swamps from Kok Island trying to reach Thonyor in time to receive food distribution for the first time since 5 months in the troubled Unity State in South Sudan. December 2013 - 2015.

In some areas, conflict brought a resurgence of kala azar, the world’s second largest parasitic disease.

In addition, there have been measles, hepatitis C and cholera outbreaks, amongst others.

Kala azar sufferer Ruai Puot Malow (56 years) is assisted by his wife Yakuony Jock Deng (right) and a relative at a Médecins Sans Frontières / Doctors Without Borders hospital in Lankien, South Sudan, Tuesday, 13 Jan 2015.

Mental health

Millions of people in South Sudan have been repeatedly exposed to traumatic events.

MSF has witnessed increases in suicide attempts and has worked with patients coping with post-traumatic stress disorder.

South Sudan. The Greater Pibor Administrative Area. Lukurunyang payam. September 7, 2020. An MSF (Médecins Sans Frontières) mobile clinic brings life-saving medical care to Lukurunyarg.

"The most difficult thing to be South Sudanese is the fear. People facing in fear. People sleeping in fear. So, this creates a lot of trauma on people because people are not free like when we first got our independence." – MSF staff, Mundri, August 2019.

"Today, 8.3 million people – more than two-thirds of the population – are estimated to be in dire need of humanitarian assistance and protection"

The impact of protracted conflict and repeated humanitarian crises in South Sudan is worsened by a weak, chronically underfunded, healthcare system, destroyed in many areas and largely neglected in others.

South Sudan. The Greater Pibor Administrative Area. Pibor Town. September 7, 2020. An MSF staff examines a patient in MSF’s inpatient unit in Pibor town.

In 2020, of approximately 2,300 health facilities, more than 1,300 were non-functional.

Less than half (44 per cent) of the total population and just 32 per cent of internally displaced persons live within five kilometres of a functional health facility.

Women sit with their children in the paediatric ward of MSF´s hospital in Ulang, in northeastern South Sudan.

Continuing humanitarian crises

Despite a peace agreement in 2018 which ended five years of civil war, and the formation of a unified government in early 2020, the situation remains volatile in many areas.

Bentiu, South Sudan, 2018. A woman prays in a church in Bentiu PoC (Protection of Civilians) site.

In 2019, South Sudan saw a resurgence of subnational conflicts and factional fighting, which has since escalated in 2020 and 2021.

Today, 8.3 million people – more than two-thirds of the population – are estimated to be in dire need of humanitarian assistance and protection.

Today, in what is the largest refugee crisis in Africa, 2.2 million South Sudanese people are sheltering in neighbouring countries.

More than 1.6 million people remain internally displaced.

Even in a best-case scenario, South Sudan will remain vulnerable to humanitarian crises for the foreseeable future and will need assistance for some time.

Airview of the Bentiu PoC (Protection of Civilians), one of the largest UNMISS protected IDP camp (Internal Displaced People/Refugees) in South Sudan and shelter approx. 115000 people over the last years.

South Sudan’s leaders must make every effort to ensure civilians' safety and security and an environment conducive to the delivery of humanitarian assistance, independent of any political agenda.

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"For nearly 40 years, the area that constitutes South Sudan has been amongst MSF’s highest global priority countries, in terms of operations, employment and financing"

“My hope for the future for the next 10 years is a transformed society, a transformed community where we can live and co-exist among ourselves. Where I see someone is my brother. I see someone is my sister … Where I can just move without any restriction. Where I can express my feelings, to anyone, regardless of their race, regardless of their tribe. And this is the society that I'm longing for in the next 10 years … It’s the young generation that will inspire the generation that is coming after us,” MSF staff member, 22 April 2021.

Nyathor Lul, 40, had to be evacuated to the hospital of the city of Akobo, half an hour away from home. In the hospital yard, the driver, a medical worker and her husband help her out of the car.

For nearly 40 years, the area that constitutes South Sudan has been amongst MSF’s highest global priority countries, in terms of operations, employment and financing.

As the young nation moves into its next decade, MSF remains committed to the people of South Sudan.

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