South Sudan:

The smell of sweet ginger coffee being prepared in a little tin hut manages to waft above the putrid smell of green sludge - it’s the smell of life going on. It lingers in the air, and somehow, just like the people here, manages to rise above the suffocating conditions of a Protection of Civilians site.

Since 2013, four million people have been displaced by conflict in South Sudan. Two million sought safety across borders, while another two million remain internally displaced.  During some of the most extreme periods of violence, thousands of people fled in unprecedented numbers to existing United Nations (UN) bases for protection, and as the conflict extended, these bases transitioned into Protection of Civilians (PoC) sites and are guarded by forces from the UN Mission in South Sudan (UNMISS).

‘This one was killed, this one is here, or this one is looking for you.’

Since the signing of an agreement between warring parties last September, discussions on the return of displaced people and the future of the PoC sites are emerging. Currently, around 180,000 people are seeking safety in six of these camps in South Sudan. Médecins Sans Frontières/Doctors Without Borders (MSF) is present in two - Bentiu and Malakal.  Despite the challenging conditions within, for many, the alternative of being outside is worse.

“When my village was attacked, many people were separated and children even ran with different families wherever they were. Everyone was scattered or killed. When we got here, we were only hearing things like ‘this one was killed, this one is here, or this one is looking for you’”, says Teresa from Mayendit, a mother of three at Bentiu PoC.

“Sometimes we hear from the radio about peace, but we don't have full information.”

Fleeing war is difficult, fleeing with one leg even more so. James is a father of four who has lived in Bentiu PoC since 2013. Before the crisis, while working with a company, a chemical caused a severe infection in James’ leg. It needed to be amputated. He underwent surgery at what was then an MSF hospital in Leer in 2012.  When the fighting reached his village in 2013, he was separated from his family and forced to flee.

I come from Leer county. Before the crisis, people were living in harmony with one another; loved each other and things were quiet.

People had cattle and were cultivating. That is how we lived before 2013. The southern areas here were mostly affected by the war, like Leer, Mayendit and Koch. When the crisis started, people were moving to the riverside or inside the water and living there. When we heard there was a break from fighting, people moved to the PoC when there was the chance.

It was really very difficult for me to get to the PoC because I am disabled. It’s not fair the way I had to come. We could not come together as a family or community. Everyone made their way by themselves because the fighting isolated us and we had to flee from wherever we were. People were just running and being killed along the road.

Before this happened (the crisis), I was working with a company and a chemical went into my leg. It became badly infected and needed to be amputated. I had the surgery by MSF in Leer in 2012 before the crisis. Now that I am here in PoC, it's difficult because I can't move around to look for a job like other people who have two legs. I am just sitting here because I don't have anywhere to go. I don't get information about jobs advertised. There is no chance for me. It is very challenging.

My family is here with me. I have four children, two girls and two boys. The boys have been taken by my brother to Uganda, but the girls are still here with me in the PoC. Sometimes we hear from the radio about peace, but we don't have full information. Sometimes those politicians can say something, but things change to something different, and we're not quite sure if there will be peace or not. Some people say there may be peace, some people think there is no peace. We are thinking different things about the situation.

Maybe in my lifetime something might happen, but let's see. I haven't left here in five years and I am thinking that if there is peace, we can go outside, but no peace, then nothing. I continue to receive treatment for my leg at the MSF hospital in the PoC.

What I want to share with the community is that we don't have proper shelter, plastic sheets or space here. People are very many. It's too small. They have been promising that there will be more space, but it's not happening.

Distraction and disease

Across from Teresa, two plastic chairs have been occupied and music is blaring from a speaker tied up to chicken wire. The speaker breathes rhythm into the camp, falling on teenage ears that are maybe listening for hope, love, or most likely - distraction. In Bentiu PoC, for more than 100,000 people living here, the challenges are many; safety, food, water, health and shelter.

“Gatherings of big populations in one place is not good in terms of health. People are not housed properly. The way they construct the houses is by putting five shelters together without being separated. If a person in shelter 1 is infected by TB and does not know his symptoms, we fear this guy will infect all five shelters. Without shelters being separated, there is a greater risk of being contaminated,” says Peter, a father of five now living in the PoC for five years, despite coming from neighbouring Rubkona.

MSF has repeatedly called for conditions and services within the sites to be improved beyond current levels, in particular, water and sanitation (WASH). Overflow from latrines oozes down banks into a stagnant thick sludge, patiently awaiting a young child to investigate and play. The little ones do as children do, but in this environment, instead of just playing catch with your friends, you risk catching a disease, and unnecessarily become a part of the alarming statistics of the place.  Almost half of all patients seen in the outpatient department or admitted to MSF’s 160-bed hospital in Bentiu PoC are children under five, many suffer from illnesses like severe acute diarrhea, skin diseases, eye infections and worms, which can be avoided by improved water and sanitation.

The relative safety found within the camp comes at the expense of unnecessary exposure to life-threatening diseases and undignified living conditions, both factors which should not drive a person’s decision to return home.  

“The first challenge is disease, the second is security.”

Teresa is a mother of four from Mayendit, who has lived in Bentiu PoC since 2013. She fled her village because of the conflict, where she witnessed people burned in their homes and sexual violence. She depends on leaving the PoC to collect firewood, where she is exposed to dangerous situations. Despite the many challenges she faces in the camp, she still believes it’s better than outside.

Before the crisis, things were OK and people were having goats, cows, money and shelters. Leer, Adok, Mayendit, Koch and Guit were very effected by the conflict. They could catch you and put you inside the house when it is burning and kill you like that. What brought me here mostly was that there was a lot of raping in my village, so people were just running wherever they will be safe.

Everyone came separately. Even the children may have ran with a different family. Everyone was scattered or killed. When we got here, all we were hearing are things like “this one is killed, this one is here or this one is looking for you.” So what I was feeling when I came here to the PoC was that I was safe, not like outside. They gave me food, water and shelter.

Most of the women here are widows because their husbands have been killed. There are challenges here. The first challenge is disease and the second challenge is security. We get robbed or places are looted. This is also part of what we are experiencing. There is a disease called Hepatitis here and it is killing people, children and the adults. Even raping is happening here too. Sometimes they can just break your door and rape you inside. So it is happening in here, but even though they are doing this here, it's still better than outside.

The food is not enough, water not enough, everything is not enough and when you have children it forces you to go outside. We depend on going outside to collect the firewood and going outside means you are going to get challenges. Even the men when they are going to collect the firewood or burning the charcoal, they can get killed. When women go out, they are getting raped on the way, so people are just suffering everywhere. It's better for us that we survive in here.

We've heard there is an agreement, but we're not quite sure if there is really peace or not. I heard it when people came in to talk to us, but the community here is not sure. Even though they come and tell us that there is peace, we are doubting, but if there is peace, exactly, if we witness it, we can go outside, if not, better to be here.  What I want to add is that all the women from South Sudan, all the people of South Sudan, hope for peace. If there will be peace, that will be nice.

“There is not enough water; the community is too big here.”

Martha* is a 27-year-old woman from east Malakal county. She has lived in the UN Protection of Civilians (PoC) site since 2014. She was brought to the MSF hospital in the PoC site at the end of March as she was feeling unwell and had serious breathing problems . In the emergency room, the medical staff saw that her oxygen level was very low and diagnosed her with pneumonia. Despite the severity of her condition, she improved after a week of treatment.

I was born in Khartoum, Sudan´s capital, and lived there. We came to South Sudan following my mother’s marriage to my step-father and ahead of South Sudan’s declaration of independence in 2011.

We had a flat and I was studying in Khartoum, but we had to exchange our lives there for new ones in Malakal city. At first, I continued studying in Malakal to earn my secondary certificate. I was preparing for my exams, focusing on economics and commerce, when the fighting started at the end of 2013.

When the conflict began we went to our ancestral village (near Malakal town) and stayed there for about a month. Afterwards, we returned to Malakal, but decided to move to the Protection of Civilians (PoC) site because the situation was very dangerous. It was very difficult emotionally for me to flee. There was heavy fighting in the town. I heard bullets for the first time and saw a woman trapped in a neighbouring house that was on fire. I had never seen anything like this. It was terrible.

In those early days in the PoC site, there were no water pumps and it was difficult to go to the river to fetch water. The compound was very crowded, there was no drainage system, and the shelters were poorly built. It was not easy to cook proper food.

There are 12 people in my family here, including my father, mother, step-mother and several siblings and children. I have a 12-year-old son called Samuel and my smaller child is nine months old. I am separated from my husband.

Compared to what it was like in the beginning, our shelter now is better, but it is still bad. We still face many challenges. One is hunger; you may have sorghum grain, but you don’t know where to grind it or you may not have money to take it to the grinding mill. Even if you have money to grind the sorghum, you may not have water to cook it. There is not enough water; the community is too big here.

The communities living here have disintegrated; some have family members missing. Some have family members here, while others took refuge in Sudan, or are scattered through other places. Some of my brothers and relatives are in refugee camps there. It is very difficult to contact them. Often, we don’t have money or there is no mobile network.

If the peace agreement doesn´t hold, more disintegration may happen, bringing with it further difficulties. I hope it holds. I would like to continue my studies.

*Name has been changed

Not enough of anything

In Malakal, which was the second most populated city before the war and one of the worst affected areas during it, MSF also runs a hospital inside the PoC where around 30,000 people are seeking protection. Malakal passed hands between one group to another several times. The destruction is still visible as if new. Twisted wreckages, burnt out cars and empty neighbourhoods serve as a constant reminder of the recent past.

“We still face many challenges. One is hunger; you may have sorghum grain, but you don’t know where to grind it or you may not have money to take it to the grinding mill. Even if you have money to grind the sorghum, you may not have water to cook it. There is not enough water; the community is too big here,” says Martha*, a 27-year-old woman from east Malakal county.

“These five years have affected people... Some say it would be better to kill themselves."

Achol is a 32-year-old woman from Obai, a village on the west bank of the Nile River, an hour south of Malakal. At the end of March, she delivered her seventh child, a boy called Timothy John, at MSF’s hospital in the Malakal Protection of Civilian (PoC) site.

Before the conflict, we used to go to the farm and grow sorghum. Other people worked as civil servants or in other businesses. Life was much easier.

I have lived in the Malakal PoC site for the last five years. This is the second baby I have delivered here. The life for everyone, but especially for women, is very difficult. These five years have affected people. They are unhappy, they lost many things when they had to flee their homes, and there have been so many deaths in the community. Some people are mentally ill and even say it would be better to kill themselves.

We used to go to the forest, to collect firewood, which we could make into charcoal to sell and earn some money. Even when I was pregnant I did that. Some women are still going out every day and my husband is now in the forest for example. Other women sell tea, but otherwise there is not much to do. The quantity of food aid we are given is low and there is uncertainty about the future.

The most difficult moment I have faced is when I first came to the PoC site. It was also very difficult when the compound was attacked and burnt in 2016. My shelter and everything I had inside it, including my clothes, was destroyed.

Many people from Obai, my home, are still living here. They would like to go back if peace holds and security allows it, but now nothing is clear. I am still afraid and in our areas there are new occupants.

I dream of peace, so that we can sort out our lives and I will be able to return. Maybe my children will be able to go to school. Now I have a newborn child. I hope for him a brighter future in a peaceful country. I don’t want him to suffer like I have.

“No one would be here if it was not because of the war.”

William Akol is a 46-year-old man from Payindwei village, one hour by car from Malakal. He is suffering from pulmonary tuberculosis. At the time of the interview he had already been at MSF’s hospital in the Malakal Protection of Civilian (PoC) site for three weeks. He has undergone treatment twice over the last two years, but this was interrupted both times. He is married and a father of two boys and two girls, aged between 7 and 14.

Before South Sudan’s independence, I was a soldier, but after that I left the army and retired. I had been living in Malakal town most of my life. Malakal was a great place to live. Our house was a hut with a roof of dry grass. Children were going to school, people were paid salaries. There was a boat bringing many commodities and products from Sudan and Juba along the river. People were selling and buying, and the market was bustling.

I used to wake up early in the morning and tell my children to go to school. I would spend a lot of time in my neighbourhood or by the river with my fishing net. I would bring home any fish I was able to catch, and if there was excess I would take them to the market to sell. People enjoyed life, but the war has destroyed everything.

I remember the day in 2013 when the conflict reached us. The fighting started at about 4 am and continued very heavily for the following hour. We waited until the morning and, when the shooting stopped, I fled with my family. We went to near the UN base. People fleeing were put later in a compound and afterwards the PoC site was constructed. From a distance I saw how my hut had been burnt.

We have been living in the PoC site for over five years. Life has been very bad. The site is very congested; tents are very close to each other. Our tent has to accommodate eight people in two shared spaces, as two other relatives live with us as well as my wife and children. It is like a prison. No one would be here if not for the war. People get tense and fight with each other without any reason.

I have no job and depend on casual work; maybe today I can find work, but tomorrow there will be nothing. I move outside of the compound just a little. My children go to school and my wife sells goods at the market to sustain the family.

At the moment I am like a child and my wife provides for all. I am very weak, as if I were not alive. I can only take juice and Plumpy’Nut [a highly calorific peanut-based paste]. Whenever I eat, I feel nauseous and vomit. I have been ill since December 2017. I visited other organisations, but only MSF could treat me. I just think of recovering now.

In order to leave the PoC site, I would need two things to happen. If my health improves, I would give it a chance. But this move also depends on whether the peace holds. I dream of my children completing school and become successful, so that they can remember me in the future, but I don’t know what will happen to them. They are growing older and developing their own minds. I can only pray for them. 

Existing to survive

These camps came into existence so that people could survive situations of violence that they would otherwise be exposed to outside of them. More than five years on, for some people, qualifying their existence by mere survival is a depressing thought. Throughout 2018, 51 people who had attempted suicide were admitted to the MSF hospital in Malakal PoC, marking an average of one person per week. The MSF teams provided more than 2,400 mental health consultations including in both individual and group sessions – with people’s conditions triggered by a combination of experiencing extreme levels of violence throughout the conflict, and feelings of despair that are exacerbated by, or a direct consequence of, their current environment.

“The life for everyone, but especially for women, is very difficult. These five years have affected people. They are unhappy, they lost many things when they had to flee their homes, and there have been so many deaths in the community. Some people are mentally ill and even say it would be better to kill themselves,” says Achol, a 32-year-old woman from Obai, a village south of Malakal.

Shifting context

Based on what we hear from our patients, temporary movement in and out of both camps is happening, but people are hesitant to relocate prematurely or definitely due to uncertainty about their safety in a context that can quickly shift.

“The most difficult moment I have faced is when I first came to the PoC. It was also very difficult when the compound was attacked and burned in 2016. My shelter and everything I had inside it, including my clothes, was destroyed,” says Achol, a woman from Obai, a village on the west bank of the Nile River, an hour south of Malakal.

Security within the sites is not absolute, with robberies, looting and sexual violence common concerns raised by residents. For those with jobs or a source of income, the risk of being attacked is even greater.

One of MSF’s drivers who has never left the camp unless in an MSF vehicle, says “There is no safety from the place where we came from. We are waiting until the situation calms before we go, but even then, there may not be services for people to be able to survive in their places of origin.”

Similarly, David, one of MSF’s health promotion staff also living in one of the PoCs says “Even me, because I have a job, we are the most targeted people in the PoC. Where can I run though? We don’t have the choice to leave, it’s still better than outside.”

Hope for the future

People’s coping mechanisms have been stretched, but despite the many challenges people are faced with within the camps, and despite feelings of uncertainty about what their future might look like outside of them, there is undeniable hope for what could be.

“If we witness it, the peace, then we can go outside. If not, better to be here, but what I want to add is that all the women from South Sudan, all the people of South Sudan, hope for peace. If there will be peace, that will be nice," says Teresa.

Until then, the rhythm of life in the camps continues; chitter-chatter, hands scrubbing, hearts praying, women fetching, children playing, all struggling, but all resilient - surviving in the most dignified way you can, in some of the most undignified conditions imaginable.