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Everyone and Everything Is a Target THE IMPACT ON CHILDREN OF ATTACKS ON HEALTH CARE AND DENIAL OF HUMANITARIAN ACCESS IN SOUTH SUDAN “Everyone and Everything Is a Target” About Watchlist Watchlist on Children and Armed Conflict (“Watchlist”) strives to end violations against children in armed conflicts and to guarantee their rights. As a global network, Watchlist builds partnerships among local, national, and international nongovernmental organizations (NGOs), enhancing mutual capacities and strengths. Working together, we collect and disseminate information on violations against children in conflicts in order to influence key decision-makers and implement programs and policies that effectively protect children. For further information about Watchlist, please contact: [email protected] or visit: www.watchlist.org This report was researched and written by Christine Monaghan, PhD, with support from Bonnie Berry, Adrianne Lapar, and Cara Antonaccio. Vesna Jaksic Lowe copyedited the report. Watchlist would also like to thank the many domestic and international NGOs, UN agencies, and individuals who participated in the research, generously shared their stories and experiences, and provided feedback on the report. “Everyone and Everything Is a Target” THE IMPACT ON CHILDREN OF ATTACKS ON HEALTH CARE AND DENIAL OF HUMANITARIAN ACCESS IN SOUTH SUDAN Table of Contents Map of South Sudan 2 Acronyms 3 Executive Summary and Recommendations 4 Methodology 10 Conflict Context 11 Pre-2016 Health Context 13 Health Context during the Reporting Period 14 Compounding Health Challenges due to Attacks and Denial of Humanitarian Access 16 Focus Regions 20 a. Greater Upper Nile 20 b. Bahr el Ghazal 25 c. Equatoria 27 Conclusion 32 Endnotes 33 D 24° 26° 28° 30° 32 34 in 36° ° ° de En Nahud r 12° Abu Zabad SOUTH 12° SOUTH SUDAN Ed Damazin SUDAN SUDAN Al Fula Renk Ed Da'ein Tullus Nuba Mts. Famaka Kadugli Umm Buram Muglad Barbit Kologi T Talodi Kaka Paloich B e a l y h i ba r A 10° N Junguls 10° e Radom l Riangnom e 'A it ra Kodok h Boing b W Abyei Fagwir UPPER Malakal Kafia Kingi WESTERN Mayom Bai War-awar Bentiu NILE Daga BAHR Wun Rog Fangak Abwong Post EL GHAZAL NORTHERN The boundaries and names shown BAHR Wang Kai Kan and the designations used on this map do not imply official endorsement or Malek Jur l Nasser Kigille Gossinga EL GHAZAL UNITY Gumbiel a acceptance by the United Nations. n Gogrial Raga f a Akop a Aweil C r i a Kuacjok Leer e Z l g z n Waat 8 Adok e Fathai 8 WARRAP o ° ° r J S Bisellia S h oba Deim Zubeir Madeir a t l B o u Duk Fadiat Akobo CENTRAL L Wau ETHIOPIA Bir Di Atum d P i AFRICAN Wakela JONGLEI b o Tonj d r o LAKES Kongor g Akelo REPUBLIC n Bo River Post W Peper o Rafili h P Rumbek ite Jonglei N Pibor o Akot i Ukwaa m Yirol le O Lol National capital Bor Kenamuke 6° Khogali Boli Pap Swamp Towot 6° State (wilayah) capital Malek Town Mvolo Lowelli Major airport Tambura Jerbar Kobowen Administrative WESTERN Swamp boundary International boundary Amadi Li Yubu Terakeka Undetermined boundary* EQUATORIA Ezo Madreggi Lanya Bunduqiya EASTERN EQUATORIA State (wilayah) boundary Lafon Abyei region** Maridi Juba Kapoeta Main road Yambio CENTRAL Torit Railroad Roue Nagishot Lotagipi DEM. REP. EQUATORIA Swamp 4° 4° * Final boundary between the Republic of Sudan OF THE CONGO Yei and the Republic of South Sudan has not yet Opari Lofusa L. Turkana Kajo Keji (L. Rudolf) been determined. 0 100 200 km ** Final status of the Abyei area is not yet e determined. il 0 100 mi N t KENYA r e b l 22° 26° 28° 30° A UGANDA 34° 36° Map No. 4450 Rev.1 UNITED NATIONS Department of Field Support October 2011 Cartographic Section 2 “Everyone and Everything Is a Target” Acronyms ICRC International Committee of the Red Cross IDP Internally Displaced Persons IMC International Medical Corps INGO International Nongovernmental Organization MRM Monitoring and Reporting Mechanism MSF Médecins Sans Frontières NGO Nongovernmental Organization OCHA Office for the Coordination of Humanitarian Affairs OHCHR Office of the High Commissioner for Human Rights PoC Protection of Civilians SPLA Sudan People’s Liberation Army SPLA-IO Sudan People’s Liberation Army-in Opposition UNICEF United Nations Children’s Fund UNMISS United Nations Mission in South Sudan WBeG Western Bahr el Ghazal The Impact on Children of Attacks on Health Care and Denial of Humanitarian Access in South Sudan 3 Executive Summary and Recommendations The civil war in South Sudan that broke out in December 2013 has led to the near collapse of the nascent health care system. T he United Nations Office for the Coordination of Humanitarian Affairs (OCHA) reported that as of December 2017, at least 20 percent of the country’s 1,900 medical facilities1 had closed and about 50 percent were functioning at extremely limited capacity (e.g., with severe shortages of medicines, equipment, and staff).2 Only about 400 health facilities were fully operational.3 More than 7 million of South Sudan’s 12 million people were in need of humanitarian aid,4 and about 70 percent of South Sudanese lacked access to adequate health care.5 Medical facilities have been indirectly damaged during the conflict, but parties to the conflict have also directly attacked medical facilities and personnel as a tactic of war. They have also routinely prevented humanitarian organizations from accessing civilian populations, further increasing civilians’ needs for health care, while limiting the functionality of the clinics and hospitals that remain open. Several of the attacks documented in this report fall within the definition of attacks on hospitals and protected persons by the UN Guidance Note on Security Council Resolution 1998, which highlights attacks on schools and hospitals, as well as related personnel, in armed conflict, and directs the Security-General to list parties responsible for those violations in his 4 “Everyone and Everything Is a Target” annual report on children and armed conflict.6 Many of the documented incidents also fall within the definition of denials of humanitarian access—a grave violation but not a trigger for listing—as described in the Monitoring and Reporting Mechanism (MRM) Field Manual.7 Prompted by reports of these attacks and denials of access, Watchlist on Children and Armed Conflict (‘Watchlist’) conducted research missions to northern Uganda in September 2017 and South Sudan in December 2017. Watchlist interviewed South Sudanese refugees, humanitarian actors, and medical personnel8 to investigate attacks on hospitals and denials of humanitarian access, and their impact on children’s health and well-being. Watchlist also conducted a systematic desk review of UN and non-UN organizations’ reports of attacks on health care, denial of humanitarian access, and public health. Watchlist focused its inquiry on the three historical regions that comprise South Sudan—Greater Upper Nile, Bahr el Ghazal, and Equatoria. Watchlist found that attacks on medical facilities and personnel and denial of humanitarian access occurred widely during the reporting period, covering January 2016 to December 2017. Parties responsible for attacks on medical facilities and personnel and denials of humanitarian access include the Sudan People’s Liberation Army (SPLA) and the Sudan People’s Liberation Army-in Opposition (SPLA-IO). In 2016, there were at least 28 attacks on medical facilities, two attacks on medical personnel, and 445 incidents of denials of humanitarian access, according to the UN Secretary-General’s 2017 annual report on children and armed conflict.9 Official figures have not been released for 2017, but information gathered from a variety of sources indicates that parties to the conflict carried out at least 26 attacks against medical facilities and personnel between January and December; the number of denials appears consistent with those perpetrated in 2016.10 In total, during the reporting period, there have been at least 50 attacks against medical facilities and personnel and at least 750 denials of humanitarian access. However, these figures are likely significantly smaller than the actual number of attacks, in part due to chronic underreporting by health and humanitarian organizations. A representative of a humanitarian organization said: “Health partners are very concerned that they risk antagonizing the armed forces or groups controlling their area if they report. Also, so many staff don’t even consider things that happen as serious incidents that merit reporting—it’s just the way things are.”11 Watchlist found that parties to the conflict have damaged or destroyed medical facilities through arson and looting; occupied medical facilities; threatened, intimidated, detained, abducted, and killed medical personnel and humanitarian workers; shot at and stolen ambulances; looted humanitarian convoys filled with lifesaving medicines and nutrition supplements; detained, extorted, or denied passage at checkpoints to persons attempting to reach medical facilities to receive lifesaving treatment or deliver essential medicines or humanitarian aid; and suspended airdrops of food aid to areas unreachable by road. Parties to the conflict have also forced the suspension of water, sanitation, and hygiene activities, and prevented access to humanitarian missions seeking to conduct assessments for famine and cholera. They have The Impact on Children of Attacks on Health Care and Denial of Humanitarian Access in South Sudan 5 imposed bureaucratic impediments, including: escalating fees for work permits required for foreign staff, taxes on humanitarian organizations, demands that humanitarian organizations pay for the release of humanitarian aid, and requirements for clearance by multiple government agencies at national and local levels for transportation and delivery of humanitarian aid. Since 2013, humanitarian organizations have worked beyond their traditional mandate of providing emergency health assistance and have provided up to 80 percent of health care services in the country.12 As such, there is a thin line delineating attacks on medical facilities and personnel from denials of humanitarian access.
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