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South Sudan at 10 South Sudan at 10 An MSF record of the consequences of violence South Sudan at 10 | 1 Acronyms AWSD Aid Worker Security Database CPA Comprehensive Peace Agreement CMR Crude Mortality Rate EU European Union GPAA Greater Pibor Administrative Area GDP Gross Domestic Product HRW Human Rights Watch IDP Internally Displaced Person ICRC International Committee of the Red Cross IHL International Humanitarian Law IRC International Rescue Committee IPV Intimate Partner Violence MSF Médecins Sans Frontières MoH Ministry of Health NGO Non-Governmental Organisation OCHA United Nations Office for the Coordination of Humanitarian Affairs OHCHR Office of the United Nations High Commissioner for Human Rights PTSD Post-Traumatic Stress Disorder PoC Protection of Civilians site ROSS Republic of South Sudan RPG Rocket Propelled Grenade SMC Seasonal Malaria Chemoprevention SAM Severe Acute Malnutrition SGBV Sexual and Gender-Based Violence SSLS South Sudan Law Society SSPDF South Sudan People’s Defence Forces (formerly the SPLA) SPLA Sudan People’s Liberation Army (now the SSPDF) SPLA-IO Sudan People’s Liberation Army-In Opposition SPLA-N Sudan People’s Liberation Army-North SAF Sudanese Armed Forces TB Tuberculosis UN United Nations UNICEF United Nations Children’s Emergency Fund UNMISS United Nations Mission in South Sudan UNHCR United Nations High Commissioner for Refugees WFP World Food Programme WHO World Health Organization Acknowledgements Special thanks to Cover image Art direction, design + infographics MSF wishes to acknowledge all of its The more than 100 MSF South ©Anna Surinyach. Displaced people Sue Cowell | www.atomodesign.nl staff and patients in South Sudan. Sudanese staff who contributed to within the UNMISS compound in this report;* and to Duncan McLean; Malakal Protection of Civilians site, Boundaries and place names on Authors Pete Buth; Lauren King; Marc South Sudan. 2015 maps in this report do not reflect Mike White and Joanna Kuper Gastellu Etchegorry and Epicentre; any position by Médecins Sans MSF Canada; Christian Captier; Aya Frontières (MSF) on their legal Hammoud; Anna “Juba Log”; and status. Wouter Kok. *Unnamed to protect anonymity 2 | South Sudan at 10 Table of contents 03 Contents 47 Conflict spreads to the Equatoria region: 2015-2016 47 The second Juba crisis: 8-11 July 2016 07 Executive Summary 47 Insecurity throughout Greater Equatoria: 2016-2017 48 Indirect impacts of conflict – malaria and 15 Introduction malnutrition in Aweil 15 An MSF record of violence 48 Access denied 51 Food insecurity and malnutrition 21 The post-independence period: July 2011 to December 2013 53 Continued violence in southcentral Unity: 2016-2017 21 Subnational conflict, Jonglei state: 2011-2012 53 Wracked by violence: 2016-2017 22 Sudan/South Sudan border areas 53 More devastation: 2018 55 Attacks on MSF facilities and activities 25 Civil war breaks out December: 2013 25 Capitals in crisis 57 Upper Nile state, the west bank of the White Nile: 25 Conflict and disease January-May 2017 26 Protection of Civilians sites 57 Repeated displacement 28 Mass killings in hospitals 57 Protection of healthcare in South Sudan 59 An 18-month nationwide cholera outbreak 33 Violence in Unity state: 2014-2015 59 September 2018: renewed peace agreement 33 Southcentral Unity (Leer, Mayendit and Koch 60 Mental health counties): January-April 2014 33 A major outbreak of visceral leishmaniasis 63 Continued humanitarian crises: 2019-2021 (kala azar) 63 Subnational conflicts in Jonglei state and the GPAA: 34 Southcentral Unity state: April-December 2015 January-August 2020 35 Deplorable conditions in refugee camps and 63 Measles PoC sites 64 Renewed fighting in the Equatoria region: 2020 38 Mayom, northern Unity state: June 2014-June 2015 64 Continued violence in 2021 39 Malaria 65 Other medical consequences 41 Fighting in Upper Nile state: 2015-2016 67 Conclusion 41 Violence in Melut: 2015 41 Peace deal: August 2015 70 Endnotes 41 A dangerous place for aid workers 44 Attacks on healthcare 44 Malakal PoC under attack: February 2016 44 Sexual and gender-based violence (SGBV) South Sudan at 10 | 3 MSF team coats, MSF hospital in Aweil, South Sudan. 2017 4 | South Sudan at 10 BAUZA PETER © In Memoriam This report is dedicated to the memory of the 24 MSF staff killed by violence since 9 July 2011, in South Sudan Emmanuel Maichel Aban James Keuth Kulang Luony Zachariah Bantor Puot Biel Tonyan Luwarang Nelson Buleen Boutros Gatbany Machar Koang Tot Tharpi Buoth Yai Chuol Machar Dhuol Myien Char Joseph Amorok Nario Thomas Par Chuol Brown Angelo Mathew Ngbagida Chop Paul Dikson Gawar Top Puoy Simon Gain Nyariek Bangot Reath James Gatluak Gatpieny Allan Rumchar Kueth Gatpieny Joseph Sebit Pech Jock Nhial Abraham Chol Tor Peter Gai Magok Kueth Gatluak Riak Kuong South Sudan at 10 | 5 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. 6 | South Sudan at 10 Executive summary 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. ~ “After these 22 years of civil war came, then there weapon of conflict, with systematic ethnically and politically came independence in 2011. The whole population motivated attacks. Some of the most extreme violence was was joyous. We were happy because a new country conducted in places of refuge and sanctuary, including the was born... but all this hope and dreams became state hospitals of Bor, Malakal and Bentiu, where patients and people seeking shelter were killed in a series of brutal all of a sudden no more.” attacks. Millions of people have been displaced, often multiple times, inside and outside South Sudan. This includes MSF staff member, Yambio, August 2019 hundreds of thousands of people who sought shelter in Protection of Civilians (PoC) sites, inside the bases of the United Nations Mission in South Sudan (UNMISS). The medical humanitarian organisation Médecins Sans Frontières (MSF) has worked in the area that today Medical consequences constitutes South Sudan since 1983. South Sudan at 10: an Across the country, people have been subject to mutually MSF record of the consequences of violence, offers a consolidated reinforcing cycles of destruction, displacement, disease, account of MSF’s experience in South Sudan since 9 July 2011. and death. Violence disrupts access to healthcare, including In so doing, it seeks to serve as a record and reminder of the routine vaccination, while increasing the risk of disease human toll of violence, since independence, as seen by MSF – transmission and food insecurity. There have been repeated through its staff and patients. failures to ensure dignified living conditions for people in refugee camps and PoC/Internally Displaced Persons (IDP) Since independence, 24 of MSF’s South Sudanese staff have sites. Instead, people fleeing conflict and violence have, been killed by violence, five while on duty. All of MSF’s over and again, been forced to live in deplorable conditions patients, staff and their communities have been impacted – with basic requirements for living space, water and directly and indirectly by conflict and violence. sanitation far below the minimum emergency thresholds for survival. Background Preventable diseases and hunger At its worst, MSF has recorded three to five children a day At independence, South Sudan was grappling with at dying from preventable diseases in different refugee camps least 30 humanitarian emergencies. Parts of the country and PoC sites. Meanwhile, people forced to live in the open, were engulfed in increasingly fierce intercommunal in the bush and swamps, have repeatedly been exposed to clashes, and there was renewed conflict in border areas disease and extreme hunger. with Sudan. Despite the challenges, the first years in the Malaria is a leading cause of death in South Sudan and its post-independence period were a time of anticipation and prevention and treatment makes up the majority of MSF’s optimism and, for most of the country, it was a period of medical activities countrywide. MSF has seen dramatic relative peace. South Sudan’s rapid implosion into civil war, increases in rates of malaria in patients who have been however, quickly exposed the fragility of the nascent state. exposed to the elements. In some areas, conflict brought a resurgence of kala azar, the world’s second largest parasitic Civil war disease. In addition, there have been numerous outbreaks The five-year conflict is estimated to have led to nearly of diseases such as measles and cholera, amongst others. 400,000 deaths, many the result of ethnically motivated targeting of civilians, including children and the elderly. Sexual and gender-based violence (SGBV) has been used as a South Sudan at 10 | 7 Medical numbers: 2011-2020 Malnutrition Malaria Measles Kala azar Mental health 146,000 2,300,000 635,000 23,000 53,000 MSF treated more than MSF treated more MSF conducted more MSF treated nearly MSF carried out 146,000 patients for than 2.3 million than 635,000 measles 23,000 cases of kala nearly 4,000 individual malnutrition – 101,000 cases of malaria. vaccinations and azar, the majority in mental health as outpatients and treated more than the Lankien area. consultations and 45,000 children 14,700 patients for more than 5,200 admitted to inpatient measles. group sessions. feeding programmes. 40-year-old Nyathor Lul is helped out the car by her husband and MSF staff after she was medically evacuated to hospital in Akobo, Jonglei state, 2017. © FRÉDÉRIC NOY, 2017 NOY, FRÉDÉRIC © 8 | South Sudan at 10 Mental health restriction. Where I can express my feelings, to In South Sudan, millions of people have been repeatedly anyone, regardless of their race, regardless of their exposed to traumatic events.
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