The world is facing the largest humanitarian crisis since 1945, the UN humanitarian chief has said. More than 20 million people in Yemen, Nigeria, Somalia and South Sudan are at risk of starvation. In parts of South Sudan, the United Nations declared the world’s first famine since 2011. At least 100,000 people in the country are facing starvation and another 1 million people are on the brink of famine, according to the UN. The total number of food insecure people is expected to rise to 5.5 million people, around half of South Sudan’s population, by July 2017. How did the situation in South Sudan became so concerning, and what impact do war and famine have on the health situation in the country?
The country of South Sudan has a history of civil wars and conflicts. The first Sudanese civil war started in 1955 and took place between the Sudanese government and southern rebels who demanded representation and more regional autonomy for southern Sudan. The conflict ended in 1972 with the Addis Ababa Agreement, which promised a degree of self-government for southern Sudan. However, tensions did not disappear with this agreement and fighting broke out again in 1983 between north and south Sudan after the Sudanese government cancelled the autonomy arrangements. This second Sudanese civil war has been the longest-running civil war in history and has one of the highest civilian death tolls since World War II.
In 22 years around 2 million people died as a consequence of famine and disease caused by the conflict. A comprehensive peace agreement was signed in 2005 that lasted until July 2011. South Sudan emerged as an independent state in July 2011, after 98.83% of the population had voted for an independent South Sudan at a referendum. Independence was declared on the 9th of July 2011, but unfortunately the celebration was short-lived.
Starting in December 2013, a big conflict erupted that reopened deeply rooted political and ethnic tensions that had not yet been reconciled. President Salva Kiir Mayardit, of the Dinka ethnic group, accused former vice president Riek Machar, of the Nuer ethnic group, of attempting a coup d’état. Riek Machar denied the allegation, but the event triggered the start of the South Sudanese Civil War. Fighting broke out on the streets of Juba, the capital city of South Sudan, and quickly spread to other parts of the country. Armed groups, both government forces and opposition fighters, have committed violence against civilians because of their ethnicity or perceived political alliances. Around 300,000 people have been killed since the start of that war in 2013. More than 3.5 million people have been forced to flee their homes. An estimated 2.1 million people have been internally displaced and another 1.5 million people have fled to neighbouring countries, especially Ethiopia, Kenya, Uganda and Sudan. Despite a peace agreement between president Salva Kiir Mayardit and the former vice president Riek Machar signed in August 2015, fighting is still ongoing.
Famine as a result of war
On the background of the conflict another large problem has been growing for the South Sudanese population. As a result of the violence, farmers have been displaced and therefore disrupted from planting and harvesting crops for the past three years, which causes food shortages in the country. Food shortages have been exacerbated by poor agricultural conditions, such as floods during the rainy season and drought. From the start of the conflict, it was becoming clear that the food supply would not be sufficient and various NGOs expressed their concerns about the situation in the young republic. In July 2014, the situation deteriorated quickly and the UN Security Council declared the imminent shortage of food in South Sudan the worst food crisis in the world. The UN called for urgent action and mobilized additional resources and capacity for an emergency response, which helped to prevent widespread starvation in 2014. However, the continued violence constrained people from getting the food they needed to survive and the situation deteriorated again. On the 20th of February 2017, the United Nations declared a famine in parts of South Sudan and they warned that urgent action is needed to prevent more people from dying of hunger. A famine is declared when at least 20% of the population in a region faces extreme food shortages; when acute malnutrition rates exceed 30%; and when the mortality rates are at least two deaths per 10,000 people per day. The famine in South Sudan is different from the one declared in Somalia in 2011, which was caused by a severe drought. The situation in South Sudan is man-made: war has disrupted agriculture, which lead to a collapsing economy. Supply routes have been cut off, and access for aid agencies has been hindered.
Diseases because of malnutrition
Malnutrition is a major public health emergency in South Sudan. Children are most seriously affected: more than 1 million children across the country are currently suffering from acute malnutrition. While treatment can prevent a child from dying, it cannot undo the long-term physical and mental health consequences. Malnutrition severely influences the development potential of children and thus their ability to learn new things. Overall, malnutrition is the number one cause of death for children and it is the underlying contributing factor in about 45% of all child deaths. This can be explained by the fact that malnutrition makes children, and people in general, more vulnerable to infectious diseases because of a weakened immune system. Rain and standing water also increase the risk of disease since communicable and waterborne diseases, like malaria and cholera, spread quickly in these conditions. In addition, infections can get caused by contaminated water. To prevent disease outbreaks in South Sudan, there is an urgent need for access to clean water and sanitation facilities. More than 30% of the people in South Sudan do not have access to safe water supplies and only 15% has access to sanitation facilities. Providing these basic facilities will be challenging in the current context of war.
The health system in South Sudan has been weakened by years of unrest. Essential infrastructure, such as health centres, has been destroyed. In addition, there is a severe shortage of trained health workers since many of them have fled the area. Already before the conflict broke out again in 2013, South Sudan was struggling with health and nutrition problems. The country has one of the worst health statistics in the world. Infant mortality and child mortality are extremely high with respectively 75 deaths per 1,000 live births and 105 deaths per 1,000 live births. The maternal mortality ratio is estimated at 2,054 maternal deaths per 100,000 live births, which is the highest maternal death rate in the world. This is caused by a lack of trained midwives (only 19% of births are attended by skilled personnel), inadequate health facilities, and extremely high rates of teenage pregnancies (300 per 1,000 females aged 15-19). Many preventable diseases like malaria, yellow fever, meningitis and cholera are currently taking the lives of South Sudanese people. Another challenge in the country remains access to education, especially for girls. Only 27% of the population over 15 years is literate, with significant gender disparities: the literacy rate for males is 40% compared to 16% for females.
Amref Flying Doctors is trying to tackle the above mentioned challenges and works to improve the health situation in South Sudan by training doctors, nurses, clinical officers, community midwives and community health workers. It is of major importance that health care improves in South Sudan, because more deaths occur in the country due to lack of access to health care than by civil conflict. The facts about South Sudan are worrisome and the future of the world’s youngest nation is uncertain. However, stories like the one from Grace give hope and show that some progress is being made.
The story of Grace
Grace Konga is trained to be a clinical officer at the Maridi National Health Institute in South Sudan. She is proud to be helping other women access good quality health care. “I am aged 27 years and married with one child. I come from Eastern Equatoria State, Torit County in South Sudan. Torit County has an approximate population of 260,000 people with poor infrastructure, social and health delivery services. As a young woman, I feel challenged with maternal mortality rate in Eastern Equatoria and as whole Southern Sudan. On realisation of the huge contribution I could make to change the situation, I decided to enrol for the Diploma in Clinical and Public Health. The skills and knowledge I obtain will help create confidence in the women of South Sudan and motivate them to seek medical assistance in health facilities.
In my culture, it is seen as a taboo for women to be physically examined by a male who is not the husband of the woman being examined. Because of this, women tend to refrain from seeking medical assistance in health facilities, especially the antenatal clinics, and turn to Traditional Birth Attendants to help. This is because most of the health practitioners in the health facilities are men.
The knowledge I acquired in clinical medicine and public health has helped me to develop in many ways, and I have learnt about the prevention diagnosis and treatment of many diseases. Currently, I am working at Nimule Hospital, for my internship practice where I am able to translate the knowledge gained in the class into practice through hands-on experience. My patients have become impressed with my work and have developed more trust in me. This has given me courage and pride to be a clinical officer. I wish more young women could be trained as clinical officers to help treat the women’s health issues like HIV/AIDS, antenatal care, breast and cervical cancer awareness, child health and nutrition in my country.”
*Patricia Vermeulen is CEO of Amref Flying Doctors in the Netherlands.