Sudan & South Sudan: Cholera crosses the Sudanese border and bursts into South Sudan refugee camps

THANKS to Lola Hierro (Hola Lola!) for informative reports and photos from Renk, South Sudan. At the Renk Transit Center, which has a capacity of 3,000 people, there are more than 16,000 current residents, and the roads that connect this out-of-the-way corner to the rest of the country are waterlogged by floods caused by end-of-summer rains. Renk’s risk lies in the fact that this [Vibrio cholerae] bacillus is transmitted through contact with contaminated foods and liquids, in conditions of overcrowding and lack of safe access to water and sanitation. Read more in this report.

From EL PLAIS

By LOLA HIERRO (Renk / Madrid)
Dated Tuesday, 12 December 2023 - 23:40 WET - full copy:

Cholera crosses the Sudanese border and bursts into South Sudan refugee camps

The Ministry of Health confirms a positive case in the Renk Transit Center, located in the north of the country, where thousands of displaced people are living shoulder to shoulder

Waiting room of the clinic located at the Renk Transit Center in northern South Sudan. ALA KHEIR (UNHCR)

South Sudan’s Ministry of Health has confirmed the first case of cholera in Renk, a city in the far north of the country that is suffering a humanitarian crisis amidst the thousands of people from Sudan who have been displaced since war broke out last April. Sudan has been struggling against an outbreak of the diarrheal disease since September 26 and to date has documented 4,000 cases and 130 deaths.

“The public is advised not to panic, as measures have been put in place to respond to this threat,” the ministry has announced. Nonetheless, in Renk, general sentiment is very different, as described via WhatsApp by Atsuhiko Ochiai, coordinator of a Doctors Without Borders (DWB) clinic located in the Zero settlement of Renk, which has more than 3,500 residents. “[The situation] is getting worse. More people come from Sudan all the time and the water, latrines, food, plastic sheets, hygiene kits, etcetera, are just not enough. Open-air defecation is common,” he warns.

Doctor Ochiai’s fears are due to a minimal health infrastructure. More than 400,000 people have crossed the border in the last eight months. They arrive in impoverished conditions, without money, without a home in which to stay, with no hope of feeding or cleaning themselves or accessing any service beyond what meager humanitarian aid they can obtain. That’s because all the most important United Nations agencies and nonprofits are present in Renk, but the funds available to help the population are not sufficient: only 32% of the more than 225 million euros required by the UN refugee agency (UNHCR) have been covered. At the Renk Transit Center, which has a capacity of 3,000 people, there are more than 16,000 current residents, and the roads that connect this out-of-the-way corner to the rest of the country are waterlogged by floods caused by end-of-summer rains.

A woman cares for her son, who has been admitted to the hospital in Renk, northern South Sudan. ALA KHEIR (UNHCR)

Cholera presents a public health problem in 47 of the world’s poorest countries, where between 1.3 and four million cases are registered annually. The illness is caused by the Vibrio cholerae bacteria, which provokesd intense diarrhea, up to 20 liters a day, which can kill a person within four hours. With adequate treatment — rehydration and antibiotics in the most severe of cases— the death rate does not rise above 1%, but without it, it can soar to 50%.

Renk’s risk lies in the fact that this bacillus is transmitted through contact with contaminated foods and liquids, in conditions of overcrowding and lack of safe access to water and sanitation. This is precisely the scenario in the far north of South Sudan. If the region was already living in poverty and had been punished by nearly a decade of violence caused by internal conflicts, with 74% of the population in need of humanitarian aid, the waves of Sudanese and South Sudanese returnees from the new war have only worsened the situation.

The cholera patient identified at the transit center, a 38-year-old man who had recently crossed the border between the two states, has recovered. For the time being, no other positive cases have been reported. But the fear of new cases is very present. “When community-wide transmission of cholera happens in Renk, it will be catastrophic,” Ochiai predicts.

Doctor Francisco Luquero is the head of the team responsible for high-risk epidemic programs at the Global Alliance for Vaccines and Immunization (GAVI) and was in South Sudan during the 2014-2017 outbreak that affected more than 28,000 people. The doctor explains that since 2019 there have been hardly any cases, and those that have appeared have been very mild thanks to the country’s efforts to control the previous outbreak and the prevention campaigns that have been orchestrated “We know that in these scenarios there is a high risk of transmission and that in these areas it is difficult to provide adequate treatment, so there is concern,” he says over the phone.

With Sudan’s outbreak in mind, World Health Organization (WHO) mechanisms have been activated to avoid cholera’s arrival. These mainly involve the promotion of personal hygiene, especially hand-washing, raising awareness in communities, and distributing hygiene supplies to 3,000 households, including domestic items for transporting water like disinfectants and purifiers. But such measures are nearly impossible to implement when there are thousands of people sleeping outdoors, on muddy ground where rainwater stagnates and forms putrid puddles, and where there is no sewage system or toilets.

Water stagnates between tents where thousands of refugees survive in Renk. ALA KHEIR

A month before cholera had its opening act, fears were already present. In Zero’s mobile clinic, doctor Ferida Manoah hardly had time for a break: many small patients required her attention. Patients like Nya, María’s daughter. The little girl, at just over a year old, was due for a medical check-up. Her mother brought her to the health center, accessible only by a long row of sandbags that had been placed over the stagnant water.

Since she was apparently healthy, María only received some tips on nutrition and hygiene. Above all, the latter. “We have a large number of diarrhea cases and we’ve suspected the presence of typhus, but we aren’t able to test,” said Mahoah. Before the cholera outbreak, diarrhea was the third leading cause of mortality in Renk, after malaria and pneumonia.

A simple, but elusive remedy

The plan to address cholera begins with giving specific information to all health staff and community workers on how to inform authorities if they detect a suspicious case. Until there is confirmation, an outbreak is not announced, but independent of test results, it’s very important to provide treatment to patients to avoid death by dehydration.

Blocking the entrance of the illness at the border would be ideal, but in practice that turns out to be nearly impossible. The International Organization for Migration (IOM) has health stations open from 6 a.m. to 8 p.m., which means that for 10 hours a day there is no one available to test. Not to mention, with 2,000 to 3,000 people crossing every day, even if the stations were open 24 hours, it would be very difficult to evaluate everyone who passes through.

Drinking water station in the field of Joda, where thousands of people wait weeks to be transported to the Renk Transit Center in South Sudan. 

LOLA HIERRO

Luquero thinks that prevention at the border is not realistic because similar to people affected by Covid-19, a patient can be contagious and also asymptomatic, something that occurs in 80% of cases. Nonetheless, for him it “is super necessary to replenish kits to treat the sick, because rehydration saves lives.”

The GAVI leader trusts in the skills South Sudan showed in the past thanks to its prevention strategy. “South Sudan has taken a lot of initiative in vaccination, reactive as well as preventative,” he says. They have implemented various campaigns and since 2019, received more than three million doses through the Global Task Force on Cholera Control. “It’s true that it’s a very fragile country, but it’s also a case in which they’ve been able to successfully control a national outbreak,” he says.

Immunization campaigns, however, have not yet arrived to Renk. Luquero thinks it would be best to solicit them as soon as possible from the International Coordinating Group (ICG) on Vaccine Provision, which is in charge of emergency requests. “It’s one method that can be used to access the doses more quickly, linked to the humanitarian crisis in the north, without having to make a global vaccination plan,” he says. “What we need to do is to make a good epidemiological assessment as quickly as possible and, based on that, send the vaccine request as quickly as possible. And I emphasize speed.”

View original: https://english.elpais.com/international/2023-12-12/cholera-crosses-the-sudanese-border-and-bursts-into-south-sudan-refugee-camps.html

END

South Sudan: a country on its knees - millions of lives at stake as ‘unity government’ announced

• “People are tired. Corruption is the medicine of the day.”
• The last time Kiir and Machar clashed, an estimated 380,000 people perished and nearly two million were displaced in a wave of terror and famine which subsumed the country from December 2013 to October 2018.
• Both government and opposition forces “intentionally targeted targeted civilians, often on the basis of ethnicity”, reported Amnesty International in a detailed 2018 study of the conflict.
• While many were killed by gunfire, others were “burned alive in their homes, hung from trees and rafters, or run over with armoured vehicles”. Thousands more were subjected to “rape, gang rape, sexual slavery, sexual mutilation, torture, castration and forced nudity”.
• It was the worst humanitarian crisis in Africa since the 1994 genocide in Rwanda. Read more below.

South Sudan: a country on its knees

Report from The Telegraph.co.uk

By Paul Nuki, Pictures by Simon Townsley

Dated week ending 22 February 2020

Millions of lives at stake as ‘unity government’ announced

After a devastating civil war, life in South Sudan hangs by a thread. Can the world's newest nation find a path to unity? 

There are few places left on earth where mobile phone use is not ubiquitous, but South Sudan is one of them.

Yet in this scarcely developed nation of tukul huts and herdsman there is hardly a family among its 11 million population who is not anxiously awaiting news from the capital Juba.

This Saturday, February 22, is the deadline for President Salva Kiir and his former deputy turned rebel leader Riek Machar to stand down their rival armies and form a “unity government”.

It’s the long awaited centrepiece of a fragile peace accord which paused the country’s five year civil war 16 months ago. Only if the two self-styled ‘big men’ sign is the peace likely to hold. 

With the US threatening sanctions and fatigued aid agencies saying they may pull out, the stakes could hardly be higher.

Much of South Sudan's population of 11 million is anxiously awaiting the outcome of peace talks in Juba

With just 48 hours to go, there were positive noises. "We had a meeting with the president on the outstanding issues. We have agreed to form the government on 22 February”, Machar said on Thursday.

Only a few dare to dream that a deal this weekend would set South Sudan, the world’s newest but fourth least developed nation, on a path to modernity.

A country the size of France, it has only 186 miles (300 km) of paved road and 90 per cent of its population are without access to electricity or clean water. An estimated 60 per cent rely on food dropped by World Food Programme planes and helicopters to survive.  

The best that can be hoped for, say observers, is that a deal will avert fresh military calamity. 

“If they can shake hands it would help cement the peace deal and allow the UN and aid organisations like us to keep things ticking over,” said Geoff Andrews, country director of Medair, a Swiss NGO which has been in the country since 1992 and runs its biggest emergency aid programme.

“We talk about failed states but this is a non-functioning state”, says another NGO. “The things that define a state, its institutions, are virtually non-existent”

Two-year-old Ibrahim weighed only a third of what he should when he arrived at the clinic

He is just one of the severely malnourished children receiving treatment from Swiss NGO Medair

Franco Duoth Diu, deputy governor of Southern Liech State which saw some of the most intense fighting, says that unless a deal is done change will be forced on the rival leaders.

“These two men will be looking at something very different unless they can agree,” he warns. “The pressure is from the international community but also the community here.”

“People are tired. Corruption is the medicine of the day.”

What everyone fears, and many are braced for, is no deal at all. The last time Kiir and Machar clashed, an estimated 380,000 people perished and nearly two million were displaced in a wave of terror and famine which subsumed the country from December 2013 to October 2018.

Both government and opposition forces “intentionally targeted targeted civilians, often on the basis of ethnicity”, reported Amnesty International in a detailed 2018 study of the conflict.

While many were killed by gunfire, others were “burned alive in their homes, hung from trees and rafters, or run over with armoured vehicles”. Thousands more were subjected to “rape, gang rape, sexual slavery, sexual mutilation, torture, castration and forced nudity”.

It was the worst humanitarian crisis in Africa since the 1994 genocide in Rwanda.

Across the country, 99 under-fives die per 1,000 births

A mother stands at the grave of her two-year-old child, who died from diarrhoea

A herder with malnourished cattle

This month the Telegraph travelled extensively in South Sudan to document the humanitarian relief effort in the run up to Saturday’s deadline. 

It’s undoubtedly a country on its knees, aptly described by one commentator as a “kleptocracy gone insolvent”, but also a place full of youthful ambition, its average age just 18.

In a tarpaulin-clad clinic run by Medair on the outskirts of Renk, a market town in the north of the country, dozens of pregnant young women queue for check ups. 

They have been tempted in by a volunteer network of local women who preach the benefits of antenatal checks and good hygiene in a bid to cut child deaths and deaths in childbirth; a sort of Avon for health which reaches 10 or more walking or “footing” hours into the bush.

The country’s maternal mortality rate at 789 deaths per 100,000 live births, is the fifth highest in the world - 87 times higher than in the UK where the corresponding figure is just nine.

Macca, a 30 year old mother of seven, is six months pregnant and only half jokes she would like 15 children in total. “I’m replacing the ones lost in the war”, she says, “I’m working for my country.”

She is not unusual. Women in South Sudan have an average of nearly five children, largely because the ruthless economics of the place demand it. 

“I want to have 10 children so I have enough if some die,” says Amel, a 23-year-old mother of two. “Without children who will look after us?”

A few metres from the antenatal clinic, the toll of infant mortality is all too evident. In a “stabilisation” room Medair staff are busy reviving distressingly listless toddlers, several of whom have been brought in only a hours away from death. 

Across the country, 99 under-fives die per 1,000 births, compared to just four in the UK. In Renk where acute childhood malnutrition is running at 32 per cent, the odds are even worse. 

Since the end of 2013, conflict has cost almost 400,000 lives and left six million people, of a population of 11 million, desperately hungry

“Malaria, diarrhea or pneumonia are what kills most but it’s because they are malnourished that they are so vulnerable,” says Jimmy Freazer who runs the unit.    

Two-year-old Ibrahim is just a third of his proper weight and has all the signs of a child on the brink. His feet and stomach are swollen, his mouth is white with thrush and his eyes are glazed and unresponsive. His baby sister is almost as big as him having won the battle for his mother’s breast.

“The sudden weaning of children can be a problem,” says Freazer, “Too many stop breastfeeding when they become pregnant. They think they need to save it for the next one.”

At the other end of room, Achol, a little girl of just eight months, is considerably worse. She has a drip in her arm and otherwise still, her tiny chest is heaving.  

Her mother, Nayana, is exhausted from trying to stem a tide of vomit and diarrhoea. The fear in her eyes is so intense that you want to duck her gaze. We leave her - wrongly as it turns out - to what we assume is her infant’s last few hours.

Sudanese civilians collect water form the Nile, in Renk district. Dirty water is a primary cause of disease

When South Sudan won independence from the north in 2011, its people made the fatal mistake of assuming that with independence comes freedom. 

The new government, while promising democracy, adopted the oppressive security infrastructure of the north and set about dividing what little wealth the country had between themselves.

There have yet to be elections and the International Monetary Fund calculates that real incomes in South Sudan today are about 70 per cent lower than in 2011.

Despite taking over about 75 per cent of old Sudan’s oil reserves, the vast majority of the population still relies on subsistence agriculture and gathers charcoal for fuel.

Worse, given the country’s reliance on food aid, the only large scale farms are said to be owned by government acolytes and export much of what they produce abroad. 

A boy plays in the Nile's dirty water

An abandoned ambulance at the military hospital in Renk

A boy with his donkey, carrying water to sell

The Nile runs through the centre of the country and, with modest investment, could be used to irrigate millions of hectares of fertile scrubland. 

But the only machines evident are old Blackstone pumps made in Stamford, England, a decaying relic of the time Britain held sway here. Even then much of the produce was exported.  

“This should be the food basket of the region”, an agricultural adviser with the International Red Cross says. “On the up side, what is grown is organic and the land retains its potential.”

As the deadline for the formation of a unity government looms, rebels in t-shirts and sandals marched alongside government troops outside Juba earlier this week in a display meant to reassure international monitors that progress is being made.

Then on Thursday, Machar said he had agreed to form a unity government by Saturday's deadline. Kiir confirmed the agreement, adding that he will appoint Machar as first vice president on Friday.

"We are going to discuss the security arrangement for the protection of all opposition forces and members," Kiir added.

Eight-month-old Achol with her mother. The malnourished infant is being treated for vomiting and diarrhoea

Just five days after she was admitted to the clinic, Achol is looking much better

There remain two key obstacles to a lasting deal, say analysts. The two rival armies need to be merged into a single force and control over the country’s oil revenues need to be split equitably, ensuring a balance of power.

While the big men quarrel and the nation waits, basic medical science and good care were working their magic in Medair’s health clinic.

Only five days after her arrival, little Achol was sitting up, putting on weight and playing with her delighted mother. 

“I would like to see a point in South Sudan where girls are more likely to complete their education than die in childbirth,” said Natalie Page, Medair’s senior health adviser in South Sudan.

Perhaps, just perhaps, Achol will live to see that dream become a reality if a deal is done this weekend.

View Original: https://www.telegraph.co.uk/news/south-sudan-peace-deal/