Thousands of South Sudanese in the town of Bor have been denied access to secondary health care services because of their ethnicity. They are living inside an UN-protected camp for ‘internally displaced persons’ (IDPs), which they cannot leave because of killings carried out near the base.
There are approximately 5,000 people living inside the camp, according to UN data. Almost all of them are ethnically Nuer, part of a substantial Nuer minority living in the town of Bor before the events of last December.
One primary health care clinic is operating in the Bor camp, run by the International Rescue Committee. The organization treats cases of malaria, diarrhea, and skin infections, and other illnesses.
For secondary care, Jonglei residents would normally go to the Bor referral hospital, or one of the referral hospitals in the national capital, such as Juba Teaching Hospital.
But under current circumstances, the residents of Nuer ethnicity are unable to leave the base for treatment. Camp residents say they will be killed if they leave UN protection.
This means that some patients’ lives are in danger because of lack of secondary treatments such as ARVs, emergency obstetrics, and surgical services, and some have died.
Pregnant women at the UN base in Bor cannot necessarily receive the treatment they need when giving birth, nor can they seek treatment elsewhere.
The Health Cluster, a coordinating body of different aid organizations, says that there are “inadequate reproductive health services and referral for emergency obstetric care in Bor.”
In update on 27 March, the Health Cluster called the lack of referral services for emergency obstetric care a “critical gap.”
UNMISS, the UN Mission in South Sudan, has been protecting the 5,000 civilians at the Bor bases since mid-December. The peacekeepers call the Bor camp a ‘protection of civilians site’, or ‘PoC’.
Secondary care for civilians protected at UNMISS bases has been limited not only at the Bor PoC but also the Tongping PoC in Juba, where Cambodian peacekeepers run a military hospital that functioned since the start of the crisis as the referral hospital for tens of thousands of Nuer civilians at the Tongping site.
Some types of secondary treatment could not be provided by the hospital, however, nor could it cope with the caseload. In January, an MSF official at a primary care clinic in the Tongping site told Radio Tamazuj that the UN hospital was turning away referrals.
The same health official pointed out that emergency medical responders such as MSF do not normally provide drugs for terminal illnesses such as tuberculosis and HIV/AIDs. He noted that the government normally provides drugs but after the crisis did not do so for the people living in camps such as Tongping and Bor PoC.
Radio Tamazuj has not verified whether this remains the case at the Juba PoCs, but at the Bor base it is so: “In Bor, one of the eight known [HIV/AIDS] patients died due to lack of access to ARVs (drugs for HIV/AIDs) while the surviving seven are facing the same problem,” the Health Cluster disclosed in a regular update in March.
UN dilemma
With 5,000 people unable to leave the UN-protected camp site in Bor, and similar situations in Malakal and Bentiu, humanitarian agencies are faced with one of two options: either bring secondary care into the camps, or provide secure medical evacuations for referral cases.
There are problems with either approach. In an update published today, the UN Office for the Coordination of Humanitarian Affairs (OCHA) acknowledged its main challenge in this respect is lack of funding.
“The lack of secondary healthcare in Bentiu, Bor and Malakal continued due to lack of funds,” OCHA stated.
Meanwhile, medical evacuations on regularly scheduled UN humanitarian or peacekeeping flights face security threats and bureaucratic obstacles.
According to the health cluster, many patients are denied the care they need because of “weak referral and medical evacuation services,” explaining, “Many of those who require evacuation do not meet the health cluster criteria which focuses mainly on evacuation of war related casualty.”
In terms of security, Nuer patients seeking to leave the Bor base via the Bor airport are in danger, even when in the company of UN personnel.
SPLA, the South Sudanese army, has been conducting searches of UN personnel and cargoes coming in and out of Bor airport, as well as checking the identities of people.
According to an update released by UNMISS on Wednesday, peacekeeping ‘assets’ assisted recently in a four-person evacuation operation to Juba, including two patients from the protection site and two from the Bor hospital.
UNMISS did not mention that the armed escort was necessary because on 23 March the army threatened to stop a medical evacuation flight, as well as on previous occasions.
Ethnic killings
IDPs have been killed “just outside the compound” of UNMISS in Bor, the United Nations stated in its interim human rights report published 21 February.
The report says it appeared these attacks “were carried out by SPLA, reportedly of Dinka origin, and armed civilians.”
Incidents of killings and disappearances have been reported independently to Radio Tamazuj by the community in the camp. Rev. William Tut, a community leader on the Bor site, said ‘many died’ since the government recaptured the town.
“For example, one guy was working at the Bor Hospital and wanted to go out, there were forces that killed him, and there were teachers who were staying inside here and one went out, and he was killed,” he said.
The Nuer community leader added, “Nobody wants to go out, because if you go out you can be killed.”
Primary care
Besides the inadequate referral services, health care providers inside the UN base in Bor are coping with some critical gaps at the primary level as well. For instance, there are no laboratory services at the clinic.
In January and February health workers struggled to cope with an outbreak of measles, which started during a period of conflict in Bor.
UNICEF warned in late January of a ‘dire crisis emerging,’ noting that “grave insecurity means only a limited number of aid workers are able to operate within the centre.”
Improving security meant that health agencies were soon able to scale up their response, but by then it was too late; data published earlier this month by the World Health Organization showed that the under five mortality rate at the Bor camp peaked in February at more than eight times the emergency threshold.
According to the UN agency, the sanitation conditions at the “cramped and overcrowded camp” exacerbated the rapid spread of the disease.
These crowded conditions have not changed substantially since January, but a contingent of Korean military engineers attached to UNMISS are now working to extend the current protection site. UNMISS says civilians will be able to settle in the new site within the coming week.
Photo: A pregnant woman at a UN ‘Protection of Civilians’ site in South Sudan (UNFPA)