Author: Sarah Schroter
On July 9th, 2011, the Republic of South Sudan was declared an independent state from Sudan. The Republic of South Sudan consists of approximately 11 million people of varying ethnic groups, with the largest groups being the Dinka, Nuer, Zande, and Bari. It is important to note that during the transition to independence, there were clashes between varying ethnic groups in South Sudan. This republic only had two years of independence prior to its civil war, which lasted until from the summer of 2013 to fall of 2018.
Conflict Origins
In the summer of 2013, South Sudanese President, Salva Kiir Mayardit, dismissed his Vice President, Riek Machar Teny, and his cabinet ministers. President Kiir accused Vice President Machar of plotting a coup to overthrow him; Machar denied this accusation. Machar is a member of the second largest ethnic group in South Sudan, the Nuer group. Kiir, on the other hand, is a member of the Dinka ethnic group. Both President and Vice President were previously leaders in the Sudanese People’s Liberation Movement (SPLM), the party that brokered the Republic of South Sudan’s freedom.
The origins of the plotted coup accusation remain murky to this day, but it is understood that the accusation was a result of a power struggle within the SPLM, which both Kiir and Machar held leadership roles in. The dismissal of Machar led to a split in the SPLM, with Machar’s supporters creating the Sudan People’s Liberation Movement in Opposition (SPLM-IO), also known as the anti-governmental forces (AGF). The AGF is considered to be the “rebel” of the South Sudanese Civil War, with the SPLM group led by Kiir being the “governmental” forces.
Tipping Point
In December of 2013, violence erupted between the SPLM and the AGF, with Dinka soldiers backing Kiir, while Nuer members supported the ousted Machar. This coincided with Kiir’s coup accusation becoming public. The violence between the Dinka and Nuer groups quickly spread from the capital city, Juba, to the states of Jonglei, the Upper Nile, and Unity. In response, Marchar fled the country. The UN Security Council authorized a “rapid deployment” of 6,000 security forces to supplement the 7,600 peacekeepers already in the country.
This violence progressed along ethnic lines, with the smaller South Sudanese ethnic factions aligning with either the Dinka or Nuer. This ethnic-based violence included human rights atrocities such as sexual violence, burning people alive, property theft and destruction, and child-recruitment into the militia ranks. From civilians not directly involved in this conflict, there was a great amount of resentment for the two factions for attacking civilians and not the opposing forces directly.
Impact
At this point in the conflict (early 2014), thousands of South Sudanese were dead and hundreds of thousands displaced, with 494,000 being displaced internally, and others fleeing to nearby countries including Uganda and Sudan. On the 21st of April, 2014, hundreds of non-Nuer South Sudanese and foreign nationals were “sought out and killed” in what is now known as the Bentiu massacre. The Nuer rebels (supporters of Machar and the AGT) targeted a mosque, a church, and a hospital in the city of Bentiu, which is the capital of Unity State, based on rumors that smaller ethnic groups in the city allegedly backed President Kiir.
Due to the extreme human rights violations on both sides, South Sudan was threatened with international sanctions, and the Intergovernmental Authority on Development (IGAD) supported rounds of negotiations between the SPLM and AGT. On January 23, 2014, the IGAD Monitoring and Verification Mechanism (MVM) for South Sudan was set up after the signing of the Cessation of Hostilities Agreement (COHA) between the South Sudanese government, led by President Kiir, and the AGT.
However, this IGAD MVM, led by Special Envoy Ambassador Seyoum Mesfin, only served to formally observe, document, and verify violations of the COHA and later agreements. No tangible action was taken by IGAD to prevent further human rights violations. The 2014 COHA was an attempt to pursue a peaceful solution to the violence. Further involved with this COHA and the IGAD MVM was the United Nations Mission in South Sudan (UNMISS). Special Representative of the Secretary-General, Hilde Johnson, briefed the UN Security Council on the COHA signing directly from Juba. UNMISS personnel forces were dispatched to help pursue the COHA and consisted of 67 countries providing troops and police forces. At this point in time, the UN Security Council noted that 73,000 South Sudanese civilians were attempting to seek refuge on UNMISS bases.
In August 2015, IGAD brokered the first formal peace treaty of the conflict, the Agreement on the Resolution of the Conflict in South Sudan, which reaffirmed the existing commitments of the COHA and recalled earlier ineffective attempts at peace, similar to the May 2014 Agreement to Resolve the Crisis in South Sudan. This treaty was signed by both Kiir and Machar. After spending the past 2 years outside of the country, Machar returned to South Sudan in April 2016 and was re-sworn in as vice president.
However, this peace treaty almost immediately collapsed, with Kiir unilaterally decreeing that South Sudan would further divide from 10 states, as denoted in the peace agreement, into ultimately 32 states. This state division was a massive issue due to the way it divided resources and land between the warring parties. In June 2016, the fighting between the SPLM and the AGT resumed, resulting in Machar fleeing South Sudan on foot and being detained in South Africa. This fighting once again displaced tens of thousands of people and resulted in new small factions and armed groups breaking off from the original SPLM and the AGT, further complicating the political arena.
In 2017 and 2018, a series of varying ceasefire agreements were “negotiated and subsequently violated between the two sides and other factions.” In June of 2018, Sudan and Uganda mediated negotiations between Kiir and Machar. This resulted in Kiir and Machar signing the Khartoum Declaration of Agreement later that month. While sporadic violations did follow, Kiir and Machar signed a final cease-fire and power-sharing agreement in August 2018. This agreement was followed up by a peace agreement, the Revitalized Agreement on the Resolution of the Conflict in South Sudan, signed by the South Sudanese government, Machar’s opposition party, and several other rebel factions. This agreement defined a new power-sharing structure and reinstated Machar as vice president. In October of 2018, Machar returned to South Sudan for a national peace celebration; however, the peace remains fragile.
As of January 2021, the violence between the SPLM and the AGT has largely subsided, with Kiir and Machar formally agreeing to the National Unity Government in February 2020. Ultimately, over the course of the conflict, an estimated 400,000 South Sudanese were killed and 4 million people were displaced, with 1.8 million internally displaced and 2.5 million fleeing to neighboring countries.
Other Factors
While this civil war was progressing, it is important to note that South Sudan was facing other crises including water and food shortages, disease outbreaks, massive debt, and an influx of refugees.
43% of the South Sudanese population lives on less than $1.90 a day, with 50% of the population lacking basic drinking water. Only 10% of the population has access to basic sanitation. This is all due to weak water sector governance and limited funding, due primarily to the country’s civil war. In 2017, as a result of the country’s instability of water and instability from the civil war, famine broke out. More than 40% of South Sudan’s population required “urgent food, agriculture, and nutrition assistance.” The war’s looting and property destruction included animals and agricultural property as well as personal property, further exacerbating the lack of food supply to civilians. Compounding this lack of food supply was an outbreak of fall armyworm, which fed on South Sudanese staple crops like maize and sorghum. While this outbreak did not infect humans, it took a severe toll on the crop production of the country, with the South Sudanese strains developing resistance to common pesticides.
Due to the Sudanese war in Darfur, 210,000 Sudanese refugees fled to South Sudan in 2013 to escape the tribal violence there. This further worsened political tensions in South Sudan, as well as placed additional strain on the already limited resources of the country.
Population crowding, mass movements, and a lack of water, sanitation, and hygiene (WASH) and proper nutrition resulted in a massive outbreak of cholera in the country, lasting from 2014 to 2017, with the later epidemics being the most widespread.
Cholera
Cholera is an infection of the small intestine by one of two strains of the toxigenic bacteria, Vibrio cholerae. This bacterium is comma shaped and Gram negative, with a single polar flagellum. While there are hundreds of serogroups for cholera, only two serotypes are pathogenic, O1 and O139.
Globally, there are approximately 2.9 million cholera cases each year, with 95,000 deaths occurring annually. While the disease can present as mild or severe depending on the host, 10% of all cholera-infected individuals will develop severe symptoms.
Severe symptoms include profuse diarrhea, abdominal pain, borborygmi (stomach rumbling), vomiting, leg cramps, hypovolemic shock, and even death. Treatments for the bacterial infection primarily consist of intravenous fluids to rehydrate patients. In extremely severe cases, antibiotics will be provided, with doxycycline for adults and azithromycin for pediatric patients.
When cholera infects the gastrointestinal tract, the bacterium binds to the intestinal epithelial cells that line the small intestine. The bacteria then secrete a toxic byproduct, called cholera toxin. This byproduct forces the intestinal epithelial cells to secrete chloride and bicarbonate into the intestinal lumen, creating an electrolyte imbalance within the small intestine itself. This electrolyte imbalance forces water into the small intestine, creating diarrhea and dehydration. In severe cases, an infected individual can become hypotensive (low blood pressure) within an hour of symptom onset and die within 2-3 hours of symptom onset if left untreated.
Cholera is spread through contaminated water and food and is transmitted human-to-human via the fecal oral route. Cholera is endemic to regions with poor WASH (sanitation and hygiene practices). Humans are the only natural host for V. cholerae, but the bacteria can also be found free living in water as well.
South Sudan’s Health Capacities
Prior to the civil war, 50% of South Sudan’s population was living below the poverty line. Approximately 27% of the population is literate. South Sudan’s maternal mortality rate is the highest in the world with 2,053.9 dead mothers for every 100,000 live births. These maternal deaths occur mainly during labor, delivery, or immediately postpartum. The majority of these deaths could be prevented if these mothers gave birth in an area with good medical infrastructure and trained personnel6. Moreover, the infant mortality rate is 135.3 deaths per every 1,000 children. South Sudanese children have a 25% chance of dying prior to their 5th birthday, with major causes of early childhood deaths being pneumonia, diarrhea, malaria, and malnutrition7. Life expectancy for the country is approximately 55 years.
South Sudan also has an incredibly low immunization coverage, with only 26% of the population having received the standard childhood immunizations. Between 2009 and 2010, the country only had 189 doctors, or 1 doctor for every 65,574 people, and 309 midwives, or 1 midwife for every 39,088 people.
Before South Sudan was an independent nation, the region already was suffering from a massive lack of medical providers and healthcare infrastructure. Once the country gained independence in 2011 as the Republic of South Sudan, the country’s National Ministry of Health (MoH) attempted to develop a health system structure consisting of three tiers: Primary Health Care Units (PHCUs), Primary Health Care Centers (PHCCs), and Hospitals. The South Sudanese government created a Basic Package of Health Services (BPHS) to cover preventative, curative, and health promotion and management services at PHCUs and PHCCs. Once this tier system and BPHS was developed, the MoH decentralized healthcare in the country, allowing each state to regulate and develop its own infrastructure. Many of these state-run tiers are funded by NGOs.
The Famine
Due to the civil war, South Sudan fell into an economic free fall. With the ethnic-based violence causing forced population displacement, over 7.1 million people in South Sudan faced famine by 2017. In 2015, the Famine Early Warnings Systems Network warned that South Sudan was likely to face “catastrophic famine” based on spikes in food prices. Further increasing the likelihood of famine was the drought in the region during this time due to a developing El Niño event.
In August 2016, South Sudan was in a food crisis, and on February 20, 2017, the UN formally declared famine in the Unity State of the country. A primary concern of this declaration was that the famine was spreading to other states. The famine was mainly blamed on the drought and population displacement due to civil war. Moreover, prior to displacement, many farmers had their animals stolen and crops burned during the war, as soldiers were rewarded for their service by looting.
By May 2017, the famine was officially declared to have weakened to a “state of severe food insecurity.” This end to the formal famine is associated with the civil war coming to an end.
Cholera in South Sudan
Between 2014 and 2017, South Sudan had three separate outbreaks of cholera, with practically all of them originating in Juba County. Juba County was the first county in South Sudan to report suspected cases of cholera during all three epidemics. Therefore, it is likely that Juba played a role in maintaining the outbreaks due to the massive amounts of people traveling in and out of the city during this time period. From 2014 to 2018, Juba had suspected cholera cases 44% of the time.
These epidemics each started in the rainy season, which begins in April and ends in November, when temperatures average between 90-95℉. However, it is important to note that while the start of the rainy season has been linked with the start of a cholera outbreak, increases in rainfall after the rainy season began are not associated with any increases in cholera transmission or spatial distribution. This suggests that the rain and humidity may play a role in triggering, but not amplifying, cholera outbreaks.
It is likely that cholera was introduced into the region at the start of the South Sudanese civil war in 2013 or 2014 as a result of movement across South Sudan’s borders. At the time, there was an outbreak of cholera in Uganda and the Democratic Republic of the Congo, where many South Sudanese fled as a result of the civil war. However, many individuals were fleeing back and forth from Uganda to South Sudan as well due to general instability in the region. Movements of displaced people appear consistent with the geospatial patterns of cholera outbreaks; however, this association could not be statistically quantified due to the nature of tracking individuals’ movements in times of crises. Ultimately, repeated cross-border transmission is the most plausible explanation for how cholera entered into South Sudan as there had not been any issue with the bacteria for at least six years prior to the first epidemic.
Support for the Crisis
Due to the civil war, practically all cholera vaccination campaigns were inhibited and further restricted access in already difficult to reach regions. Out of the 1,805,452 doses used reactively, only 4.1% of cholera vaccines were used prior to or during the peak of each cholera epidemic overall. Further exacerbating this issue was the global shortage of vaccine, as vaccine supply campaigns were small and did not have enough supply to vaccinate the majority of the population. Consequently, only the highest risk individuals were targeted for the cholera vaccine.
As a result of the vaccine shortage, most support in the region was in response to the famine and drought. The government of South Sudan raised the price of business visas into the country from $100 to $10,000, aiming to increase government revenue by targeting aid workers through this visa price increase. External aid funding primarily came from the United Nations (UN), European Union (EU), and Canada. Various UN agencies reached 4 million people in South Sudan with 265,000 metric tons of food. The UN also provided $13.8 million in cash assistance to the country and staffed and stocked 620 feeding centers for severely malnourished children. In February 2017, during the last cholera outbreak, the United Kingdom (UK) issued £100 million in aid, with the EU sending €82 million. In March 2017, Canada sent $37 million CAD for funding UN agencies and NGOs in South Sudan to address the famine. In June 2017, Canada sent another $86 million CAD in funding for the famine.
Lessons Learned and Outcomes
In South Sudan, the focus of peacebuilding on power-sharing was clearly inadequate during this conflict. Negotiations from 2015 through early 2018 resulted in agreements being signed, then immediately violated, wasting international time and resources.
An important issue to note in this conflict is the human rights atrocities committed by both sides of the civil war. Despite having many different agreements to ceasefire and halt civilian violence, there was nothing enforcing the two warring groups and the smaller factions from continuing the violence. While IGAD assisted in peace negotiations, the MVM agreement did little to support the COHA. Furthermore, while the UN continually supported peace in the region, their peacekeeping troops did little to deter the violence and ultimately placed individual peacekeepers in danger, especially during incidents like the Bentiu massacre. Ultimately, the international community needs to acknowledge that peace and ceasefire agreements must be backed via external force, not good faith between the signing parties.
While this civil war was occurring, South Sudan was also facing other major crises including drought, famine, refugee influx, massive debt, and infectious disease outbreaks. A direct consequence of this civil war included three separate cholera epidemics within the country.
As a result of the cholera epidemics, South Sudan was left with a low amount of its population vaccinated against cholera. However, many vaccination campaigns in the region consider themselves to be successful thanks to the high number of “targeted” individuals (individuals who were believed to be most at risk) who were vaccinated. To date, cholera has not been reported in South Sudan since November of 2017. At this point, the region has a large amount of natural immunity, and the high-risk population is mostly vaccinated. While cholera has not been present in South Sudan since 2017, a major factor for the halt in the rainy season epidemic cycle is attributed to a reduction in displaced persons due to the civil war’s end.
Ultimately, there are still poor WASH standards in South Sudan, and South Sudan is potentially still at risk of cholera introduced from other countries in the region. Moreover, the famine was declared to be over in 2017, but many UN agencies still warn of food insecurity in the region without sustained humanitarian assistance and access. It is likely that peace is just the first requirement in promoting better health in the region.
This article was prepared by the author in their personal capacity. The opinions expressed in this article are the author's own and do not reflect the view of their place of employment.
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