South Sudan: Afflicted with dual Weapons of War, Starvation & Rape, women bear face of genocide Print E-mail

 Volume 389, No. 10083, p1967–1970, 20 May 2017

Special Report

Famine in South Sudan

By Sharmila Devi

Famine affects over 100 000 individuals in a country struggling through a violent civil war, where aid workers risk their lives to provide support, hindered by denial of access.

Asunta wiped the tears from her face with a blanket as she cradled her 4-year-old son Riak, who lay listless from malnutrition and suspected acute anaemia. The Al Sabah Children's Hospital, the only facility of its kind in the South Sudanese capital Juba, had run out of blood and Asunta could not afford to buy any. Mercy Kolok of UNICEF who had accompanied The Lancet to the hospital immediately got on her mobile to arrange for a blood donation. The life-saving transfusion was on its way but Riak died barely an hour later. This is a familiar scenario for South Sudanese and foreign health workers trying to help millions of people in a country where civil war broke out in late 2013.

The first famine in 6 years was officially declared by the UN in parts of South Sudan in February, affecting more than 100 000 South Sudanese, with a further 1 million on the brink of starvation. Food aid is acting as life support for many, but a shortage of basic drugs condemns others to death. Aid officials accuse both government and multiple opposition forces of using hunger as a weapon of war, since aid is routinely denied access to the thousands displaced. Added to this are ethnic atrocities and massacres, rape, and oppressive security measures.

South Sudan, together with Yemen, Somalia, and Nigeria pose what the UN calls the biggest humanitarian crisis since 1945 as millions flee conflict and drought within their own countries or across borders ( panel).

  • Panel
  • Famine in Yemen, Somalia, Nigeria, and South Sudan
  • Almost 20 million people are at risk of starvation because of war and drought­10 million of whom are children­across Yemen, Somalia, Nigeria, and South Sudan. There is a short timeframe, estimated to last only until July, to prevent a catastrophe, aid officials say.
  • More than US$5·6 billion is needed for the four countries, Stephen O'Brien, a senior UN humanitarian affairs official, told the General Assembly last month. But less than a quarter had been raised, he said.
  • “The numbers are staggering”, he said. “Some 1·4 million children are severely malnourished. Over 21 million people lack sufficient access to health care, at a time when three out of the four countries are experiencing cholera outbreaks. And more than 20 million people lack clean water and sanitation.”
  • The first official famine in 6 years was declared by the UN in parts of South Sudan in February. In the last famine in 2011, 260 000 people died of famine in the Horn of Africa, half of them children.
  • “Peace is of course the key to ending these crises. But even in times of conflict, there is much we can do to fight hunger and avoid famine”, said José Graziano da Silva, director-general of the UN Food and Agriculture Organisation.
  • Aid workers say conflict is the common thread across these four countries and they face differing but extreme challenges in each while political settlements remain elusive.
  • In Yemen, a Saudi Arabian-led and US-backed military intervention has been battling Houthi rebels for the past 2 years. About 19 million people out of around 27 million are now in need of some form of aid but the World Food Programme (WFP) says it can only afford to feed 3 million.
  • “Men with guns and power inside Yemen as well as in regional and international capitals are undermining every effort to avert an entirely preventable famine”, said Jan Egeland, head of the Norwegian Refugee Council, shortly after a visit to the country in early May.

  • Somalia has been caught in civil war since 1991 and faces an Islamist insurgency. A recent increase in piracy off the coast is partially caused by famine, said the top US military commander overseeing troops in Africa. Some 1·4 million children in Somalia are projected to be acutely malnourished this year, an increase of 50% over last year, Unicef said.
  • “The combination of drought, disease, and displacement are deadly for children, and we need to do far more, and faster, to save lives”, said Steven Lauwerier, UNICEF Somalia representative.
  • In Nigeria, an insurgency by the jihadist group Boko Haram in the northeast has killed more than 20 000 people. Some 4·7 million people are facing severe food shortages but the UN said it could run out of money by June or July.
  • “There are 47 000 people living there in famine-like conditions”, said Winnie Byanyima, executive director of Oxfam International. “Another 5 million could experience famine in the next few months.”
  • The overall threat is of historic proportions. “This is the first time that we are literally talking about famine in four different parts of the world at the same time”, Arif Husain, chief economist of the WFP, told Reuters earlier this year.

“The suffering in South Sudan is of almost Biblical proportions but it is man made”, a long-standing foreign observer in Juba, who did not want to be named, told The Lancet. “The UN and NGOs are doing what they can and they should. But there are also big questions that are impossible to answer about whether it's immoral to pay for salaries of health workers, teachers, and so on, when the government and militias are waging war and don't care about the people. It will likely get worse before it gets better.”

The surge of violence has fuelled Africa's biggest cross-border refugee crisis since the 1994 Rwandan genocide, the UN says. In a few months, 5·5 million South Sudanese­nearly half the country­will be struggling to survive extreme hunger, it warns, in a country about the size of France. Opportunistic diseases such as cholera are on the rise.

Some 1·9 million people are internally displaced while 1·6 million have fled to neighbouring countries. A total of 830 000 South Sudanese refugees have fled to neighbouring Uganda and the UN expects this figure to reach more than a million by mid-year.

 People waiting for the national flag to be raised at the official independence day ceremony, July 9, 2011 (Petterik Wiggers / Panos)

A resurgence of conflict to blame
After decades of war, mostly Christian South Sudan gained independence from the Muslim Government of Sudan in 2011, partly with the backing of influential US supporters and Christian groups during the administrations of presidents George W Bush and Barack Obama. There were high hopes for the country as investors and members of the diaspora flooded in. But tensions that existed within the liberation movement, the Sudan People's Liberation Army, returned to the fore. Rivalry between President Salva Kiir Mayardit, who is from the Dinka tribe, and his then Vice President, Riek Machar, who is Nuer, descended into ethnic violence in late 2013.

Machar is now in South Africa, but a plethora of rebel groups, some of which have broken away from his faction, are now in conflict with Kiir's government forces across a country that is home to 64 tribes. Grievances range from disgruntlement against the Juba elite, held responsible for stealing millions of oil dollars, to local land and clan issues. Kiir himself said in 2012 that South Sudanese officials had “stolen” an estimated US$4 billion of public money. Critics meanwhile accused his government of doing little to clamp down on the widespread corruption.

The UN High Commissioner for Human Rights, Zeid Ra'ad Al Hussein, has warned of a rise in hate speech and incitement to violence by some leaders. Last November, during a visit to the country, Adama Dieng, the UN special adviser on the prevention of genocide, reported the potential for genocide if violence escalates along ethnic lines. The UK secretary for international development, Priti Patel, said after a visit to South Sudan in April: “There are massacres taking place, people's throats are being slit…villages are burnt out, there's a scorched-earth policy. It is tribal, it is absolutely tribal so on that basis it is genocide.”

There has been an upsurge in violence, particularly in the last couple of months, documented by the UN and others, as the government tries to take tactical advantage ahead of the summer rainy season when the movement of heavy weaponry becomes impossible. UN officials say many atrocities including mass rape committed by government and rebel forces appear to be locally rather than centrally led.

A formal UN declaration of genocide has to meet stringent legal definitions under international law and would bring responsibility to intervene on the part of the international community. “As far as I can tell, it is genocide but it does need more investigation and evidence”, one UN insider told The Lancet. “I have emailed numerous reports to UN officials but some don't want to get involved because the issue could be career suicide [because of a reluctance to make unauthorised political statements]. We continue to monitor and try to do what we can to help people in an extremely dangerous environment.” A debate is now under way.

Threats to aid workers and civilians on the ground
Arrival at Juba's international airport is an immediate, sensory introduction to the country. The terminal consists of a tent above wooden planks mired in mud. Most of the planes on the tarmac are operated by the UN Humanitarian Air Service, International Committee of the Red Cross, and other agencies. A new terminal is under construction nearby but is months behind schedule, like so many of the other big plans made for the country after independence.

The Lancet observed two soldiers with their AK-47s bubble-wrapped for an internal flight to Renk in the oil-producing north of the country where fighting has displaced thousands. They were escorting a large, blue metal chest, which a local passenger whispered probably contained cash to pay troops. Three-digit inflation means even simple transactions in South Sudanese pounds entail wads of notes held in elastic bands. Photography and filming are strictly forbidden at airports and military installations. Taking out a camera in urban and other areas could also invite the attention of soldiers. Conversations with South Sudanese and international aid workers are often off the record amid real dangers. Smaller aid agencies in particular are afraid to be seen criticising the government for fear of being expelled from the country.

The government allows most reporting of the humanitarian crisis but delving into the political causes of it is difficult and dangerous. “We are seeing very tough limitations on freedom of expression that have worsened in the last year”, Jonathan Pedneault of Human Rights Watch told The Lancet. “Local journalists are bearing the brunt of this, but restrictions, such as expulsion or denial of visas, are placed on international journalists as well.”

Delivering humanitarian aid has become increasingly dangerous, with 82 aid workers killed since December, 2013, the UN said. South Sudan is “the most dangerous country in the world today for aid workers”, Nikki Haley, US ambassador to the UN, said in a statement on May 4.

During violence that erupted in Juba for 3 days last July, between 80 and 100 government soldiers killed approximately 300 people across the city. They attacked a hotel compound where aid workers were housed, where they raped at least five international aid workers after UN peacekeepers failed to respond to their telephone calls, according to a subsequent UN inquiry.

“You can't think about the dangers but just carry on with what you have to do”, said one female aid worker in Juba. “We take what precautions we can, like observe the 7 PM curfew, use only trusted drivers, and so on. And we remember that it's much, much worse for those South Sudanese women who are poor and have nothing.” In some parts of the country, NGOs estimate half of the South Sudanese women have been raped, but exact numbers are impossible to obtain given the taboo around the subject amid the political breakdown.

There are about 12 000 soldiers and 2000 police with the UN Mission in the Republic of South Sudan (UNMISS), who will be joined by up to 4000 soldiers from east Africa later this year as part of a UN-authorised regional protection force with a stronger mandate to protect civilians.

UNMISS has come under much criticism for failing to protect people, but most observers say without them, the situation would be much worse. They have protected some 220 000 South Sudanese who have fled to UN bases across the country since 2013. These camps, known as Protection of Civilian sites, offer security but life is hard in the tents and shacks where the people live. There are two camps close to the UN headquarters in Juba where just under 40 000 people live and receive basic food and health services from agencies such as Concern Worldwide, the lead nutrition partner.

The Lancet sat with three members of the women's committee in one camp, each from a different tribe. They say they stay in the camp for fear of reprisal or revenge attacks by government forces. Since last July's violence, UNMISS has stepped up patrols to venture beyond the camp perimeter, particularly to protect women. 70% of women sheltering in UN camps in Juba had been raped since the conflict began, according to a UN humanitarian survey conducted in December.

Mary Syma Samuel, 28, of the Kakwa tribe, is from Lanya in the south and she arrived in the camp last year. She was almost raped when she was just outside the camp collecting firewood. “I was beaten up by the government soldiers but I managed to run away”, she said. “In the bush, soldiers search you and ask you where is your husband. If you say you don't know, they torture you.”

 Mary Syma Samuel, Deborah Chan, and Ngaguong Gai, in the UNMISS Protection of Civilians site, Juba (Sharmila Devi)

Debora Chan, 38, of the Shilluk tribe, fled the city of Malakal in the north 2 years ago and took a tortuous journey partly by boat to Juba with her children. She has not communicated with her husband since and has no family in the capital. “I really want to go home, I want to feel free. We have security in the camp but services are very basic.”

Ngaguong Gai, of the Nuer tribe, fled from Malakal in 2013. Her husband was a militant and she does not know what has happened to him. “It's a big challenge raising kids here and I'm missing a lot of things that I need like cooking utensils, sugar, and milk. We have some security and food but that's it.”

David Shearer, head of UNMISS, told The Lancet that peacekeepers had stepped up the “robustness of their response” across the country. “For example, when they're denied access at checkpoints which are usually controlled by local forces, not central command, they now maintain pressure to get through.”

He referred to a small arms attack on the UN's base in Leer town on May 3, when Ghanaian peacekeepers returned fire and protected the displaced people sheltering next to the base. “This was the first time the base came under a direct attack and I was pleased to see the stepped up response”, said Shearer.

A desperate lack of resources
Meanwhile, a $1·6 billion UN appeal was launched mid-April. The South Sudanese response plan remains only 14% funded, the UN said. Shearer appealed for more. “The big issue is logistics and it's expensive. To get a truck from Juba to Bentiu in the north, a distance of 1000 km, can take two and a half weeks”, he said. “There are more than 80 checkpoints put up by armed groups and each has to be negotiated.” As we went to press, the UN urged donors to give a further $1·4 billion.

As for the prospects of peace, Shearer said unity in the UN Security Council was vital to push all parties towards dialogue. The 15 member council failed last December to get the required nine votes to adopt a US-drafted resolution to impose an arms embargo and further sanctions on Juba.

Shearer supported efforts by church groups, highly respected by the South Sudanese, to promote dialogue. The situation should not be viewed as hopeless or the South Sudanese as passive victims, said Vernon Burger, whose US church organisation, His Voice Global, has sponsored grassroots dialogue. “It's easy to look at the atrocities and see the vulnerable women and children and give up but we need to equip the South Sudanese to step back and talk”, he told The Lancet.

 Abuk Deng, her son Parid, and daughter Amel, in the Al Sabah Hospital, Juba (Sharmila Devi)

Meanwhile, there remains a struggle to deliver aid. In relatively peaceful areas such as Aweil in the northwest, acute malnutrition is not hard to find. Dozens of women with children were seen waiting at the Maduanyi health clinic under the shade of a tree for health and nutrition services. Many had walked for hours through the countryside to get there. Only 40% of people are within reach of health facilities. WHO is starting a project called the Boma Health Initiative to train community health workers.

Anok Ding has four children. Five others have died. Her twin babies aged 8 months should weigh 7–8 kg but only weigh 3·8–4 kg. “My husband has no job and we don't even have a chicken or a goat”, she told The Lancet. She had spent 2 weeks at the Médecins Sans Frontières (MSF) hospital in Aweil town so her twins could receive regular nutrition. But pressure on space meant she had to be discharged to allow other even more acute admissions.

“With the onset of rains, we are expecting increased numbers of patients suffering from malnutrition and malaria”, Robert Pitia, emergency room supervisor at the MSF hospital, told The Lancet. The hospital takes referrals from the regional state hospital next door where Deng Gol, acting director, was in despair. “We can only do diagnosis and patients have to go outside to buy drugs. If they can't afford them, they die”, he told The Lancet. “For example, we have most instruments needed for general surgery but no oxygen.”

Teresina Athou Lueth, regional state health minister in Aweil, told The Lancet that her immediate priorities were combating malaria and pneumonia before the onset of rain. “I need everything. Women are dying. Kids are dying”, she told The Lancet. “With the rains, people will be cut off because the mud will make transport impossible.”

South Sudanese Government does not prioritise health
Government spending on health accounted for only 1% of the 2016–17 national budget, down from 4% the year before, Abdulmumini Usman, WHO representative to South Sudan, told The Lancet. Meanwhile, the security sector was allocated 60% of the budget, according to local press reports.

“After independence, the country had managed to achieve a lot, for example, in maternal and child mortality but conflict has meant a big rolling back. We are hoping the government will restore health spending to 4% in the next budget and then gradually increase it to 15%. Budget talks start next month [June] so we will see”, said Usman.

“We are also working to coordinate the emergency response in view of the famine. There are 57 partners in the health cluster [that includes UN and other agencies] and we need to decide who goes where and does what and monitor it all. The people need us.”

Back at the Al Sabah Hospital in Juba, Lilliane Kej cradled her 10-month-old baby girl. Aged 22 years, she has nine children. Her baby was dehydrated and a nurse had to scold her for not properly feeding her baby.

On another bed, Abuk Deng sat with her son Paride, aged 2 years, and her daughter Amel, aged 5 years. Both of the children are malnourished. Her son was also suffering from convulsions and her daughter from stomach and leg pains and diarrhoea.

Meanwhile, 2-year-old Daniel sat on a bed under a net covered with angry wounds that looked like burns. He was suffering from kwashiorkor, a condition caused by malnutrition and signalled by too much fluid in the body's tissues causing the skin to swell and split. He died less than a week later.

 Two of Anok Ding's children, waiting at the Maduany health clinic, Aweil (Sharmila Devi)