Nyacahne Tut Nien gives water to her 9-month-old son Thak, who is being treated for severe acute malnutrition in an MSF-run hospital in Leer, South Sudan.
Credit: Tristan McConnell

Editor's note: This story was published in June 2014. Here's the latest news on South Sudan.

LEER, South Sudan — Eight months old and weighing less than half what he should, Ruot Diang died in his mother’s arms on a Tuesday night earlier this month.

Doctors at the hospital where he was being treated in rural South Sudan thought it was tuberculosis that finally killed him, after malnutrition severely weakened his body. But they can't say for sure because the hospital’s lab — like its operating theater, emergency room and pharmacy — had been looted and burned when the country's latest civil war reached the town of Leer in January.

Medecins Sans Frontieres (MSF, or Doctors Without Borders) reopened the hospital in May, and since then five children have died there. They are among the first victims of South Sudan's entirely man-made humanitarian crisis, but they won't be the last.

Malnutrition is already severe in much of South Sudan and is predicted to become famine in parts, including southern Unity State where Leer is located. The United Nations says 50,000 children could die in the months ahead as South Sudan’s political leaders wrangle abroad and the fighting rages at home.

Famine is usually largely manufactured, but there’s usually some climatic input, some bad weather, drought or failed harvest involved. Not in South Sudan. Last year’s harvest was above average and the weather has been just fine.

“It’s hard to find any natural, non-social factors for this crisis,” said Sue Lautze, head of the UN's Food and Agriculture Organization (FAO) in South Sudan.

And yet the US-funded Famine Early Warning Systems Network (FEWSNET) says that more than one million already face emergency food insecurity and expects famine in some parts of the country unless humanitarian assistance is delivered urgently.

“This is a man-made humanitarian disaster,” said Susan Page, US ambassador to South Sudan. “It has set South Sudan back years.”

“Even if famine is staved off, 4 million people are still at risk of hunger,” said Page.

Those most at risk are children

Famine or not, children like Ruot are dying now, and will die in greater numbers in the weeks and months ahead, because 1.5 million people have been uprooted by conflict since December.

The dispossessed languish in camps in South Sudan (101,000 of them within 10 UN bases around the country) or have become refugees in neighboring Ethiopia, Kenya, Sudan and Uganda.

In Leer families are trickling back into town to find charred outlines where their homes used to be and their larders and grain stores completely looted. Even if they have seed to plant it is too late because the rains have started, inundating dirt roads, isolating communities and cutting off what little trade survived the fighting.

There will be no harvest for people in Leer this year. “It’s too late now. This is a lost season,” said Lautze.

Men walk on the outskirts of Leer. Since the civil war reached the town in January, many have taken to carrying spears for protection. (Tristan McConnell/GlobalPost)

Those most at risk are children, like one-year-old twin boys Bichok and Both. Before the fighting they were healthy kids, their mother said. They had plump limbs and chubby cheeks. They would crawl around and laugh. Now they are scrawny and listless. The older twin, Both, has a rasping cough that makes him cry out.

The family lived in the village of Kuok, a day’s walk from Leer, until government soldiers swept through in mid-January. “The whole place was burned,” said Nyaway Kuony Thiec, the twins’ 35-year-old mother.

Thiec ran to the swamp to hide and waded in holding her baby boys above the water. For weeks the villagers hid together in the swamp by day, creeping back to higher and drier land by night. They got diarrhea from the river water they drank and cramps from the lily roots they ate to fend off perpetual hunger.

“It feels like nothing in your stomach,” she said. Her boys soon lost weight and fell sick.

When word reached her that the hospital had reopened, Thiec and her mother, Nyakuak, brought the twins here. They were found to be suffering from “severe acute malnutrition.”

On a Wednesday in early June there were 11 patients in the intensive feeding ward at Leer hospital. Ruot, who died the night before, had been the 12th.

Three weeks after the hospital reopened, 1,700 children enrolled in an outpatient feeding program which provided them with sachets of nutrient-rich peanut paste that can ward off the worst stage of malnutrition. During all of 2013 only 2,200 children joined the feeding program.

An initial screening of 600 children conducted in May found 7 percent suffering from severe acute malnutrition, determined by using a color-coded measuring tape around the upper arm. Unity State always grows less food than it consumes — this time of the year is commonly known as “the hungry season” or “hunger gap.” Usually trade and stores make up the shortfall, but this year fighting has disrupted both.

“Malnutrition is a huge, huge problem. It’s way beyond anything we’ve seen here before,” said Sarah Maynard, MSF’s project coordinator in Leer.

South Sudan has fallen far and fast

To reach Leer you either fly to the northern town of Bentiu then drive south for 75 miles, crossing the frontlines between government and rebel forces, or you can fly into the town’s dirt airstrip on a plane chartered from the capital.

Juba International Airport, the gateway to the new nation of South Sudan, hums with forlorn activity. The new terminal, intended to welcome dignitaries to independence celebrations in July 2011, is three years late and incomplete. Hulking Ilyushin-76 and C130 cargo planes chartered by the World Food Program (WFP) are parked on the apron to be loaded up for food drops. Scores of UN and aid agency light aircraft and helicopters line the runway, which is guarded by tanks and an anti-aircraft gun.

South Sudan currently exceeds even the more dire predictions of a “pre-failed state.”

Huge boisterous crowds greeted independence from Sudan. The nation was born with immense international goodwill, generous foreign support and a wealth of natural resources, including oil. But it was also hampered by unresolved disputes with Khartoum and internal strife ignored in the race toward independence.

Those internal tensions exploded on Dec. 15 when President Salva Kiir, a member of the majority Dinka tribe, accused his former deputy Riek Machar, a Nuer, of attempting a coup. Both men rallied their ethnic constituencies and the political rivalry quickly devolved into armed, tribal conflict that spread across half the country.

Rebel soldiers stand guard outside a hotel being used as the military headquarters in Leer. (Tristan McConnell/GlobalPost)

Both sides are accused of ethnic massacres, brutal rape, forced recruitment of child soldiers, deliberate targeting of civilians and other war crimes. UN peacekeepers have been killed and wounded. Political leaders have been meeting in Addis Ababa since January, paying lip service to peace while their soldiers repeatedly violate cease-fires.

Few believe Kiir and Machar are serious about ending the conflict.

“Negotiating in good faith is too much to expect of them,” said Jok Madut Jok, executive director of the Sudd Institute think tank in Juba.

They want the war to end, but on their terms. For now neither feels weak enough to give in nor is either one strong enough to win outright. Talks during the coming months may only be a prelude to more fighting when the rains stop.

“What does each get out of the settlement? That is the question,” said Jok. “And that is why military action is always looming.”

Meanwhile the people suffer.

“The hunger gap will be stronger and longer, and in places where agencies are not we will see a high mortality. For some it’s already too late,” said Raphael Gorgeu, MSF head of mission in South Sudan.

“This humanitarian crisis is because of the conflict and [the leaders] have to take responsibility for that and stop the fighting,” said Gorgeu.

Kiir has acknowledged the inevitability of famine as a direct result of the conflict but blames Machar for all of it.

The massive movement of a population fleeing war is only part of the problem. In Leer and elsewhere, basic infrastructure has been wrecked: hospitals, schools, government buildings and markets. Being one of the world’s least developed countries, many of the state’s responsibilities were borne by foreign aid and development agencies. Much of the gradual progress made over the nine years since a 2005 peace deal that ended decades of north-south civil war has been reversed in the last six months.

“We’re back to square one,” said Ettie Higgins, deputy head of UNICEF in South Sudan.

The center cannot hold

Physical things can be rebuilt. MSF reopened its hospital in Leer, albeit with few supplies and mattresses on the floor because all the beds were stolen. But the country’s social fabric will take longer to repair.

“It’s not so much about the infrastructure. It’s the cohesion of the nation that has been destroyed,” said Esteban Sacco, deputy head of the UN’s Office for the Coordination of Humanitarian Affairs (OCHA). “How do you rebuild this nation?”

The depth of division is stark in the squalid camp that has grown within the main UN base at Tomping, adjoining Juba airport. It is home to 14,500 Nuer people who live in safety within the camp but are afraid to leave it.

Abdu Manyal Dar is a businessman, tribal chief and Nuer community leader in Tomping. Like the others he fled here in mid-December as Dinka soldiers rampaged through the city. There is no hiding the ritual scarification that covers almost the whole of his face, branding him Nuer.

“I don’t go out,” said Dar. “They would kill me. You would not see me again.”

“If you were a Dinka you could not sit with me here,” he said. “How will this stop? I don’t know.”

A little over six months ago there was no camp here at the UN base. When a Bosnian UN police officer who had survived the Srebrenica massacre as a young man saw thousands of Nuer approaching the barbed-wire fence, he ordered the gates to be opened.

Now, if you were to replace the branded blue and white plastic sheeting with thatch or corrugated iron, the camp at Tomping would look much like any other market town in South Sudan.

The main drag is a 10-minute walk of rickety shacks selling milk powder, charcoal, onions, cooking oil, rice and biscuits. There are cobblers and shoe-shiners, mobile phone chargers, video halls screening action movies and World Cup matches, restaurants and shisha bars. The smell of incense mingles with cooking fires and the stench from long-drop toilets.

It is socially stratified and regionally divided. An area called "VIP" is where politicians and other high-level Nuers have Thuraya satellite phones and dream of a return to power. Another called "Jamaica" is full of stoned young men who run the black market for alcohol and other contraband. There are different locations for people from Juba, from Jonglei, from Upper Nile and Unity states.

The high number of young men is unusual in a refugee settlement and worries the government. It looks at Tomping and sees thousands of aggrieved, fighting-age men occupying a strategic location next to the airport, a short charge from the president’s home and government offices.

Like any town, Tomping is awash with rumors. Dar whispered that he had compiled a list of 750 people who had “disappeared” from the camp since January and spoke of the recent killing of 20 Nuer whose heads and hands were cut off. Human rights groups investigating these claims found no evidence to support them.

And yet there is an underlying truth in the fear and danger from which these rumors sprout, according to residents and aid workers in the camp.

(Tristan McConnell/GlobalPost)

Men who step out of Tomping to use the showers along the western fence have been snatched by government soldiers who watch from a terrace of corrugated shacks across the road. Sometimes the men are returned, bloodied and beaten, after a couple of hours or a couple of days. Sometimes they do not return.

Women from the camp have been intercepted walking to the nearby market and taken by soldiers to a patch of wasteland next to the airport runway, where they are gang-raped in a metal shipping container within view of UN watchtowers.

To make matters worse, the crowded, unsanitary conditions have triggered a cholera outbreak in Juba. Pre-emptive vaccinations and the quick provision of clean drinking water and better toilets has kept cholera cases within the UN camps to a few dozen, but in the surrounding city there have been more than 1,700 reported cases and 37 deaths. Until May cholera had not been seen in South Sudan since 2009.

Disease, war, famine and death: four years on from its independence and South Sudan is likely to feel the ravages of all four of the Biblical horsemen of the apocalypse before the year is out. It is little wonder the people of South Sudan despair.

“People are now so divided and so determined to destroy each other, the brutality of the violence has been so extreme,” said Jok of the Sudd Institute. “South Sudan has reached the lowest point in its entire history.”

Related Stories