Author: Shannon Bocquet
Introduction
The ongoing crisis in South Sudan began in 2013 with the onset of the civil war, though underlying issues existed long before fighting broke out. As with many African nations, Sudan was under British rule until gaining independence in 1956, and the foundation for future tensions were lain with colonial-era borders in the new Sudan not aligning with ethnic distributions, leading to a highly polarized country; northern regions consisted predominantly of Muslim and Arab populations and the south of non-Muslim or Christian Blacks. The newly formed Sudanese government largely consisted of a northern majority who passed discriminatory policies for the southern “African” regions of the country resulting in a neglected and underfunded South, ultimately leading to violent conflict between Northerners and Southerners.
The civil war between northern and southern Sudan took place over the course of four decades, resulting in 2.5 million deaths and nearly 4.5 million displaced persons. Peace was finally achieved with the signing of a Comprehensive Peace Agreement in 2005 which established a referendum for South Sudanese independence after a five-year period, which the United States readily supported. South Sudan officially became its own independent nation in July 2011 after a 98% popular vote in favor of secession. While South Sudan is composed of a range of different ethnicities and underlying ethnic tensions, the impetus of conflict in South Sudan has primarily been political struggle amongst government elites.
Political tensions reached a peak in 2013 when President Salva Kiir dismissed the First Vice President Machar along with other key politicians, leading to outrage across different ethnic groups and regions within the country. Violence broke a few months later between Kiir government supporters, predominantly ethnic Dinkas, and those in opposition or support of Machar, an ethnic Nuer. Many Nuers were initially targeted by government forces for allegedly planning a coup, leading to counter attacks against ethnic Dinkas, and eventually all-out civil war. Violence persisted with intermittent and tenuous ceasefires between the government and opposition forces until the latest peace agreement was signed in 2018. During the war, both sides ruthlessly targeted civilians and humanitarian workers, leading to a mass exodus of people fleeing for their safety and disruption to humanitarian assistance programs.
A Persistent Humanitarian Crisis
Peace negotiations were continuously supported by the Intergovernmental Authority on Development (IGAD), which most other organizations and nations have deferred to and view as the principal authority on a peace settlement for South Sudan. Other nearby nations, such as Sudan and Uganda, have also assisted and been largely involved as mediators to the peace negotiations, though Uganda did deploy troops and provide ammunition and arms to President Kiir and his government at the beginning of conflict. The United States has since proposed to the U.N. Security Council an arms embargo to South Sudan, which has effectively prevented future transfer of arms into South Sudan, though it does little to reduce the weapons already in country.
The years of violent conflict in the region only intensified the humanitarian issues facing the country. An estimated 1.6 million people are internally displaced within South Sudan and another 2.3 million refugees have fled. Countries with the largest populations of South Sudanese refugees are Uganda, Sudan, Kenya, Ethiopia, and the Democratic Republic of the Congo (DRC), and funding campaigns are led by UNHCR to ensure the hosting community can adequately provide humanitarian assistance to those in need. The United States has been by far the largest contributor of humanitarian aid throughout the South Sudan conflict, contributing over $4.5 billion, though funding has been waning over the years.
Further complicating the delivery of assistance to one of the worst humanitarian crises in the world, South Sudan is also host to over 300,000 refugees from other nations such as Sudan, the DRC, and Ethiopia. The southern region of Sudan was historically underdeveloped and underprivileged long before independence, and the civil war has only exacerbated existing issues. South Sudan has the worst maternal mortality rate in the world with an estimated 1,170 deaths per 100,000 live births and an infant mortality of 64.77 deaths per 1,000 live births due to lacking health infrastructure and primary care systems. Malnutrition and starvation are rampant as humanitarian organizations are unable to access much of the population to deliver aid, and armed militias are known to plunder what little food resources civilians may have as a method of warfare. In addition, heavy flooding in the region is increasing each year leading to more displaced persons, devastating sorely needed agricultural lands, and contaminating water sources which raises the risk for infectious diseases.
The United Nations established a peacekeeping force in South Sudan in 2011 following independence, the U.N. Mission in South Sudan (UNMISS), to help maintain peace and lay the groundwork for development. The mission’s mandate eventually shifted with the onset of civil war to protect civilians and assist humanitarian organizations in accessing those in need. When conflict originally erupted, many peacekeepers were targeted by South Sudanese militants and could not effectively provide security for civilians. As people sought to flee the violence, nearly 130,000 people turned to UNMISS Protection of Civilian bases for refuge. While these Protection of Civilian sites did offer a measure of safety from the warring sides of the conflict, they were not intended or equipped to provide long-term housing for displaced persons, resulting in dire living conditions at the sites.
Risk of Ebola Virus Reemergence
With an estimated 1.6 million internally displaced persons (IDPs), much of the population has been effectively cut off from health care and forced into crowded living conditions such as UNMISS bases which exacerbate the spread of communicable diseases. Lack of clean water and substandard sanitation and hygiene practices have led to multiple outbreaks of cholera; uncertain and temporary lodging contributed to an increase in malaria; and widespread disruption of medical treatments due to conflict have greatly impacted those with HIV. Beyond these infectious diseases, there is an ever-looming threat of Ebola re-emerging in the region, either by jumping over the border from another location or arising in a location within South Sudan itself.
Ebola virus commonly emerges in sub-Saharan Africa, causing intermittent outbreaks and then disappearing for a time. There are six serotypes of Ebola virus, with two predominant strains causing disease in humans: Zaire and Sudan. Both serotypes were first identified in simultaneous outbreaks in 1976 in northern Zaire (now the DRC) and southern Sudan, respectively. The primary reservoir for the disease is thought to be a range of fruit bat species, with humans and non-human primates considered end hosts.
The initial clinical symptoms of Ebola Virus Disease (EVD) are non-specific and are difficult to differentiate from other illnesses. Symptoms of fever, headache, and malaise are attributable to a range of sicknesses and may not initially cause enough concern for an individual to seek care, or for health care providers to provide a differential diagnosis once seeing a patient. The incubation period for these symptoms range from 2 to 21 days following exposure to the pathogen. After initial symptom onset, the virus begins replicating rapidly in the host, eventually developing into the more characteristic symptoms of EVD within 2-3 days such as severe vomiting and hemorrhaging. Ebola virus may be spread through contact with bodily fluids from an infected individual and has been shown to be transmissible in semen in recovered individuals months following infection. During outbreaks, many cases of EVD are nosocomial, in that they are transmitted between patient and caregiver, primarily in regions lacking adequate health care infrastructure when proper biocontainment procedures are not available. A growing concern for the emergence of EVD is the interface between humans and nature, where populations may come into direct contact with infected reservoir animals due to land use change.
There are currently two vaccines available for use against Ebola virus. The Ervebo vaccine is the only currently licensed vaccine by the FDA and is effective against the Zaire strain of Ebola virus, while the other has been approved by the Democratic Republic of the Congo (DRC) for use in outbreaks, yet it is still under review by the United States’ FDA. Treatment of EVD generally consists of supportive care such as intravenous fluids, though antiviral therapies are available for use and continue to be researched for better outcomes.
Detection of Ebola Virus is Crucial to Limit Disease Spread
As previously mentioned, clinical symptoms of EVD are often hard to discern before the infection becomes severe. Active infection must therefore be confirmed via molecular diagnostics such as PCR. While PCR is readily available in developed countries, the necessity to confirm cases of EVD via laboratory diagnostics does pose a problem in identifying and containing outbreaks in regions of the world without nearby laboratories. In South Sudan in particular, conflict has left health systems fractured and lab capacity lacking in regions outside the capital.
South Sudan is considered high risk for Ebola virus outbreaks due to it being the origin of Sudan ebolavirus, as well as its proximity to the DRC, where the most frequent and recent outbreaks of EVD have occurred. Of particular concern is the potential for cross-border transmission between the northeastern regions of the DRC, such as the Kivu provinces, and the southwestern states in South Sudan. To combat this risk, a national EVD Incident Management System (IMS) was formed in 2018 in South Sudan to bolster the surveillance and response capabilities in the most at-risk states, including the vaccination of frontline workers. Through this system, the National Public Health Laboratory, located in the capital of Juba, has the diagnostic capacity to test samples collected in the field for Ebola virus. Prior to the development of the EVD IMS, samples were sent for diagnostics to a reference lab outside the country, particularly to labs in Kampala, Uganda, significantly delaying the time for a case of EVD to be confirmed and a response to be initiated. Along with better diagnostics, screenings at high-traffic entry points to the country, such as airports and border crossings were also implemented, enabling better detection of potential EVD cases as well as other infectious diseases common to the region.
While South Sudan has not seen an outbreak of Ebola virus since 2004, the threat of EVD reemerging in the country or the occurrence of cross-border transmission from the DRC is rapidly increasing. Given the protracted conflict in the region and the living conditions of many IDPs, the potential for any infectious disease to spread, let alone Ebola virus, is alarming. Many of the people most at risk from infectious disease are in regions currently inaccessible to humanitarian actors or healthcare professionals should they require aid.
To better address this threat, it is necessary to build sustainable health care systems in the region to bolster surveillance of and response to EVD. Investment in these systems also supports the ability for emergence of other infectious diseases to be detected and subsequently treated in the region. As a short-term mechanism, investments should prioritize mobile laboratories capable of processing BSL-3 and -4 samples in the field without the need for existing infrastructure. The German Development Bank provided funding for one such mobile laboratory in South Sudan in 2016 which has been incredibly useful in running diagnostic tests for infectious diseases in a region which is lacking in many health-related resources, though one laboratory is not enough to support the entire population of South Sudan. Until better diagnostic capabilities exist in the country and are accessible to the populations most at risk, infectious diseases will continue to spread, and the threat from Ebola virus reemerging will continue to persist.
This threat from Ebola and other infectious diseases is only intensified while conflict and instability persist. The country faces food insecurity and climate change issues which will only continue to worsen the existing humanitarian crisis. While there is a peace deal from 2018 which has effectively ended the civil war, violence from militia groups against civilians continues throughout the country. South Sudan may be the world’s newest country, but the underlying issues which led to the current humanitarian crisis are not unfamiliar. South Sudanese independence was widely encouraged by the international community though little assistance was provided when it came to nation building. The region of South Sudan had few resources to bolster an already disadvantaged population, and those who gained power were ill equipped to stand up a functioning government capable of addressing problems such as food insecurity, underdevelopment of infrastructure, and growing climate instability. Rather than devote billions of dollars to alleviating human suffering after civil war, financial resources, mentorship, and mediation could have initially been provided to the South Sudanese government to prevent the near failed state it has become. While humanitarian assistance has waned due to increasing security concerns and the pandemic, it is crucial to invest humanitarian aid in infrastructure and public services as long-term solutions for the South Sudanese population.
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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