Sudan , illustrated brochure, May 1996
The conflict in southern Sudan has caused untold suffering among the civilian population for the past 13 years. The ICRC's programmes to protect and assist conflict victims in the Sudan are twofold: first saving lives, through its surgical work in Lokichokio and in Juba; and second providing a means of survival in the longer term through community health care training, improvements to water supply systems and the provision of farming tools, seed and fishing equipment. Ultimately the ICRC hopes to help those affected regain a degree of self-sufficiency.
ICRC, Geneva, 1996, 16p., 30 cm
Available in French, English, Arabic and Japanese
The ICRC in the Sudan - why and how
Civil war has been eating away at southern Sudan for the past 13 years. Africa's largest nation, over ten times the size of the United Kingdom, is rent apart by violence that no longer makes newspaper headlines, yet the magnitude of the suffering endured b y the Sudanese people is as great as, if not greater than, at the start of the conflict. What began as an armed uprising in the south against the government in Khartoum has developed over the years into a complex conflict, in which factions have splintered and alliances shift regularly. This fighting between the government and the opposition and between the factions themselves has even had a certain destabilizing effect on some neighbouring countries. Within the Sudan whole communities are regularly displaced as they flee the fighting. Their crops are abandoned, their cattle slaughtered, their homes burned.
As this forgotten conflict goes on relentlessly, so too does the destruction of civilian lives. The ICRC endeavours to limit the effects of the war on civilians by ensuring that they have access to emergency surgical care, basic health care, safe water supplies, the means to start anew when they are displaced and the opportunity to stay in touch with their relatives. Yet however much help comes from the outside, it will never be enough, the needs are that great. In this light, our philosophy in the Sudan is to do as much as we can. Save as many lives as possible.
This brochure gives a rundown of the work we do. We have 64 expatriates working on the operation, 24 of them from the National Red Cross Societies of Australia, Austria, Belgium, Canada, Denmark, Finland, Germany, Hungary, Iceland, Japan, the Netherlands, Norway, Sweden, Thailand and the United Kingdom. Most of them are based in Lokichokio, just inside the Kenyan border, where we have our main logistical base. From there they carry out missions to the field, depending on which places are accessible. Others are stationed permanently in Khartoum, Juba and Nairobi. As regards local staff, we have 530 on full-time contracts, and a further 150 daily workers.
War surgery at Lopidin g
Fortunato, after 12 years of hobbling around on his own home-made prosthesis, has just had surgery to straighten his foot.
Thierry Gassmann/ICRC (ref.KE-42/5A)
Lopiding Hospital, just a couple of miles outside Lokichokio, was opened by the ICRC in 1987. Since then it has developed to keep pace with the surgical needs of victims of the conflict in southern Sudan. The hospitals capacity has risen from 40 beds to 560, and it now boasts X-ray, laboratory and sterilization facilities, as well as two operating theatres and a prosthetic-orthotic workshop where amputees are fitted with artificial limbs.
Besides the two expatriate surgical teams and half a dozen expatriate nurses, there are 10 Kenyan registered nurses and 35 assistant nurses working in the hospital. Ten local orthopaedic technicians make artifi cial limbs under the supervision of an expatriate orthopaedist. A further 130 Kenyan auxiliary staff are employed at the hospital.
Jorma, the senior surgeon at Lopiding seconded to the ICRC by the Finnish Red Cross, tells us more about this field hospital in the middle of nowhere:
" The work we do here is to save lives. This is not a referral hospital for the north-west of Kenya, it is a war-surgery hospital for Sudanese war victims. Its sometimes difficult for the people in Lokichokio to understand this, especially since the nearest hospital is a good half-days drive away. Ten years ago Loki was just a small place but now it has grown to a town with 20,000 inhabitants, so we are often faced with the dilemma of having to turn people away. However we do always accept local people requiring emergency treatment. "
Not all of the patients that are flown out of the Sudan to Lopiding are wounded in the fighting. Some are in need of life-saving operations that they simply cannot get in their own country because the conflict has destroyed almost the entire surgical infrastructure. A lot of patients are brought in with obstructed labour or hernias, or with nasty bites from hyenas or snakes. As soon as they are well enough, the patients are flown back home or may choose to be referred to the UNHCR's refugee camp at Kakuma, in north-western Kenya.
Facts and figures for Lopiding hospital
In 1995 :
* 2,000 patients admitted
* 5,500 operations performed
* 500 patients fitted with prostheses
Training nurses : short intensive courses in basic nursing techniques are given to Kenyan students, with a view to creating a pool of auxiliary nurses in Lokichokio. Longer, more in-depth courses are given to Sudanese students, usually with some nursing experience, in order to improve local health care within the Sudan.
A flight from certain death
Thierry Gassmann/ICRC (ref.KE-50/14A)
Guay is four years old. He's used to sleeping outside at night, watching over his family's cattle. Eight days ago he was attacked in his sleep by a hyena which ate almost half of his face. Erika, an ICRC field nurse, tells me this happens quite a lot and that hyenas generally go for young children or old people. Without surgical treatment Guay will almost certainly die as his wounds turn septic and poison his body.
It has taken five days for Guay's parents to carry him all the way to Mapel, where he is taken care of by two MSF field nurses. They keep his pain in check with morphine until the ICRC plane gets there.
Within minutes of arriving were airborne again with Guay and his mother on board and I wonder at the resilience of this little boy. I cant imagine a European or American child surviving a similar ordeal, but then there are undoubtedly many more Sudanese children in similar predicaments that we just don't hear about because they don't make it.
Back at Loki, Guay and his mother are whisked off to the ICRC's surgical hospital, where his face will be stitched up once the infection has gone. No time for anything even vaguely cosmetic - in war surgery the aim is to save lives and nothing more. You might protest that it was a hyena and not a gun that has disfigured Guay. This also went through my mind and then I tried to picture war in my own country: long, wearing conflict that had dragged the nations infrastructure down to its knees; hospitals with no medicines, and no doctors left. I realised then that Guay was indeed a victim of the war and that with his disfigurement he would remain one for the rest of his life.
The vastness of southern Sudan and the partitioning of the region into zones controlled by different parties to the conflict makes travel very difficult, and flying is the only viable option. All medical evacuation flights have to be cleared by the Sudanese authorities and the opposition factions, and it is often the case that particular destinations are declared off-limits. This can mean that by the time some patients arrive at Loki, they can end up having limbs amputated when this might not have been necessary if they had got there sooner. Of course it also means that some patients die needlessly.
Water and health
More than a decade of neglect and destruction has left the water-supply systems and sanitary installations in southern Sudan in an evident state of disrepair. Many villages, isolated by the conflict, have seen their wells dry up or become putrid. Pumps installed before the war have broken down or have been damaged, or people simply have no fuel to run them. Entire communities, obliged to flee the fighting, have been displaced to areas where water sources are scant, or they have returned to their villages to find their wells sabotaged.
The ICRC has a team of specialists dedicated to improving water supplies and sanitation, working its way around villages in southern Sudan, rehabilitating wells, replacing defunct water pumps with hand pumps, unblocking boreholes and drilling new ones. The aim of this is not just the obvious one of providing a water supply for the population, but also to reduce the risk of water-borne diseases, a major problem in many areas, particularly in Jonglei, Lakes and Bahr-el-Ghazal. Local teams of workers are formed and trained by our engineers. We also provide education in basic hygiene and distribute soap a «luxury» for most people in southern Sudan, but one that is so essential to basic health.
In the same communities the ICRC is running a primary health-care programme to help build up existing health structures. Many of these facilities were insufficient even before the conflict, and so a lot of work is often required to attain the most rudimentary level of health care. Six field nurses train local health workers in basic nursing skills which they have either never learnt or forgotten over the years. Midwifery, for example, forms part of this training, contributing to the survival of mothers and babies who could otherwise figure among the many indirect victims of the conflict.
Correct dressing procedure and the proper cleansing of wounds can save lives. For example, something as simple as a cut finger, if not taken care of, can lead to no choice other than amputation of the whole finger within a week.
Juba Teaching Hospital
The city of Juba in southern Sudan is controlled by the Sudanese government. Because of the conflict the main hospital, the Juba Teaching Hospital (JTH), was in a state of general disrepair. Medical supplies were lacking, sanitation poor and surgical needs glaring. This prompted the ICRC to undertake a major rehabilitation programme in 1994, with the aim of making it a referral hospital for surgery. Since then full-scale renovation work has been carried out on the operating theatre, surgical ward, sterilization unit, pharmacy, kitchen, blood bank, X-ray room and casualty ward, and the water-supply and waste-water-disposal systems have been overhau led. Extensive work in this domain has transformed much of the hospital compound from a sewage-ridden «swamp» into a functioning hospital whose buildings are no longer threatened. Further improvements are still going on.
An ICRC expatriate surgical team has been stationed at the JTH since March 1994, working alongside Sudanese surgical staff and imparting specialist knowledge. Surgical and medical material is regularly flown in.
Through the Juba branch of the Sudanese Red Crescent (SRC) the ICRC is feeding the entire population of the hospital. SRC volunteers prepare two meals per day in the kitchen rehabilitated by the ICRC. The SRC branches in Juba, Bentiu, Malakal, Raja and Wau are all provided with logistical and financial support from the ICRC and participate in cooperation programmes such as tracing, first-aid training, joint dissemination courses and relief distributions.
Thierry Gassmann/ICRC (ref.SD-D82/08)
A means of survival
Thierry Gassmann/ICRC (ref.SD-D81/10)
The conflict in southern Sudan has been going on for more than 13 years. Well before then food was scarce and people adopted a lifestyle which involved gathering wild fruits during hard times and even boiling up tree bark to survive on. The ICRC has realized that in most cases displaced families need the means to start anew, not food handouts that do not last. That is why our relief programme is based on providing the population with a means of survival: seed and tools for people in areas where the land can be worked and fishing twine and hooks for people living near the rivers. ICRC agronomists carry out detailed surveys beforehand to determine the most suitable crop varieties and again afterwards to assess the impact of the programmes. In this way the Sudanese people are regaining a level of self-sufficiency, rather than relying on long-term outside help. The ICRC exchanges information regularly with OLS (Operation Lifeline Sudan), in order to avoid th e overlapping of assistance programmes.
The timing of relief distributions is crucial. The relief operation, like the ICRC's other field activities, is dependent on flight clearances given by the Sudanese government and the opposition. Over the years this has often posed serious difficulties, particularly when certain destinations are suddenly declared off-limits. Linked to this is the problem of the rains: many airstrips become unusable during the rainy season. Thus, if an area remains out of bounds until the rains come, then it is often too late for airlifts to be resumed. Security problems can disrupt flight plans still further.
Farming tools – 1995: 84,000 1996 ( Planned): 20,000
Seed – 1995: 400 tonnes 1996 ( Planned): 200 tonnes
Fish hooks – 1995: 550,000 1996 ( Planned): 1,000,000
Fishing twine – 1995: 79,000 spools 1996 ( Planned): 150,000 spools
Mosquito netting – 1995: 322,000 m2 1996 ( Planned): 500,000 m2
Keeping families in touch
Losing touch with friends and family is a side-effect of many conflicts, and in the Sudan restoring family links is made still harder by the vast expanses of territory involved and the frequent designation of certain locations as «off-limits». Through a network of local tracing officers the ICRC manages to help families keep in contact, whether they are displaced within the Sudan or living as refugees in neighbouring countries.
Thierry Gassmann/ICRC (réf.SD-D83/12)
Running a major operation in the Sudan is not easy, if only from a purely logistical point of view. The main problems stem from the fact that travel by air is the only feasible means of transport and that permission from all the parties to fly is not always forthcoming. As programmes are temporarily halted, the rains come and go, making subsequent distributions of seed, for example, either impossible (because airstrips become unusable) or too late (because the planting season has been missed). Medical evacuations can be delayed, with tragic implications for the patients. People anxious to hear from their families can sometimes wait a very long time before they get news - the pain is inside, but it hurts all the same.
Of course the political ramifications of the conflict are also to blame. It is one of the ICRC's ongoing tasks to try to make the belligerents, and the Sudanese government in particular, understand that they must give regular access to the victims of the fighting. In order to improve this awareness we have a delegate in the Sudan devoted entirely to disseminating the basic rules of international humanitarian law, with emphasis on the combatants. These rules include non-discriminatory treatment for the wounded, protection for civilians and their property, decent treatment for captives, and respect for Red Cross workers. After 13 years of operations in the Sudan we hope that acceptance of the ICRC as a neutral and independent humanitarian organization will enable us to extend our activities to other domains which lie close to the institutions mandate, namely protection and assistance for detainees. So far only the Sudanese Peoples Liberation Army, the main opposition movement, permits visits to some of its detainees. So much more could be done with the greater cooperation of all the warring parties.