Health

Renewed conflict in South Sudan has displaced 2.3 million people outside the country, of whom 789,098 (35%) have taken refuge in neighbouring Uganda. Eighty-two percent of South Sudanese refugees are women and children. With increasing barriers to operating within the country due to ongoing instability, some organisations supporting primary health care in South Sudan have also turned to exploring how South Sudanese refugees in neighbouring countries can be assisted.

The sustained movement of people, goods and ideas across the African Red Sea Region has been and continues to be so intense that it binds together communities throughout the region in a unified multifaceted socio-economic system that transcends ethnic, linguistic and political divides.

Where people went, viruses, bacteria and parasites followed. As a result, this region—comprised of present-day Sudan, Eritrea, Ethiopia, South Sudan, Djibouti and Somaliland—should be treated as a single disease environment.

This report examines the history of epidemic disease in this region in order to shed light on the current COVID-19 pandemic and its likely course. Rather than attempt to be comprehensive, this study focuses on three diseases that have caused at least one serious regional epidemic over the past two hundred years: Cholera, smallpox and syphilis.

The courses of these epidemics have been shaped by political violence and structural poverty. These two forces combined have led to an intensification of human migration across the region and to the growth of cities, creating new patterns of disease transmission and potential nodes of infection.

Over the last two centuries, the regional disease burden has shifted. Previously, risk was shared across various segments of society. At present, however, there are new social classes that are uniquely exposed to contagious infectious diseases, including refugees and internally displaced people living in camps and settlements, and the urban poor.

This uneven disease exposure will likely structure the course of the current COVID-19 pandemic. High-risk groups also tend to suffer from malnutrition or undernutrition and other previously under-control diseases rendering them even more vulnerable as COVID-19 spreads through the region.

Background
Community health worker (CHW)-delivered acute malnutrition treatment programs have been tested previously, but not with low-literate/-numerate cadres who operate in areas with the highest malnutrition burden and under-five mortality rates. The International Rescue Committee developed low-literacy-adapted tools and treatment protocol to enable low-literate/-numerate community-based distributors (CBD, the CHW cadre in South Sudan) to treat children for severe acute malnutrition (SAM) in their communities.

Methods
The authors conducted a prospective cohort study in March-September 2017, with 44 CBDs enrolling a total of 308 SAM children into treatment in their communities. Child treatment outcomes and length of treatment were documented. Uncomplicated SAM cases, defined for our study as children with mid-upper arm circumference (MUAC) of 90 to <115 mm or bilateral pitting oedema, without any medical complications, were treated for up to 16 weeks, and were considered fully recovered when they reached MUAC≥125 mm for two consecutive weeks.

Results
The recovery rate from the severe to the moderate acute malnutrition (MAM) cut-off of MUAC 115 mm was 91% (95% confidence interval (CI) = 88%-95%). The median length of treatment was five weeks. The recovery rate of children from SAM to full recovery was 75% (95% CI = 69%-81%). The median time to full recovery was eight weeks. The recovery rates reported here exclude children referred for care from the denominator, per standard reporting of acute malnutrition treatment recovery rates. When the data were compared against routine monitoring and evaluation data from nearby static clinics, children treated by CBDs appeared to have improved continuity of care and shorter time to recovery.

Conclusions
The recovery rate for SAM children enrolled in acute malnutrition treatment by low-literate CBDs shows promise that deploying CHWs to treat SAM in areas with high prevalence and low treatment access may lead to higher recovery, better continuity of care in the transition between SAM and MAM, and shorter treatment time. Proper adaptations of tools and protocols can empower CHW cadres with low literacy and numeracy to successfully complete treatment steps. Key questions of scalability and cost-effectiveness remain.

This rapid review synthesises the literature from academic, policy and NGO sources on the drivers of malnutrition in South Sudan. The conflict and lack of a resolution is the key driver and much of the other issues are closely connected to the conflict. UNICEF argue that the main contributing factors to high malnutrition rates in South Sudan are the unprecedented high levels of food insecurity, widespread conflict and insecurity, population displacement, poor access to services, high morbidity, extremely poor diet (in terms of both quality and quantity), low coverage of sanitation facilities and poor hygiene practices (UNICEF, 2017c). Key findings are as follows: first, the population of South Sudan mainly relies on farming, fishing or herding for their livelihoods, but displacement due to conflict has forced people to abandon their source of income and food. Second, displacement also puts a strain on the resources available in areas hosting those displaced. Third, the forced migration of cattle herders leads to the spread of bovine diseases, the loss of cattle and less production of milk. Fourth, the return of people to their areas of origin puts a strain on food resources as food production does not march the population numbers. Fifth, the conflict and resulting insecurity makes it difficult to deliver aid to much of the country and restricts access to safe water and basic sanitation facilities leading to malnutrition and the lack of treatment for the same. Sixth, whilst structural constraints connected to historic poor governance, corruption, the lack of investment in infrastructure, and striking inequality across the country also drive food insecurity. Furthermore, fighting has restricted the planting of seeds, meaning that even though there was decent rainfall in 2018 not enough crops were planted to take advantage and therefore, the conflict food prices have increased dramatically. As a result, many in South Sudan only eat one, nutrient-poor, meal a day. Next, South Sudan’s health system is in dire condition as a result of the conflict, which means people are not being treated at the early stages of malnutrition or for diseases that exacerbate malnutrition, such as cholera. Finally, the Fall Armyworm was first reported in South Sudan in 2017 and has spread across the country, it has led to significant crop loss in the major staple crops in South Sudan maize and sorghum.

While South Sudan is endowed with 3.5 billion barrels of proven oil reserves, the exploitation of this natural wealth is turning into a catastrophe for some local communities, particularly in Melut County. Through focus group discussions, individual interviews, and field observations, we found the following:

Many households in Paloch, Melut County, are in close proximity to oil wells and facilities, and within a short distance of a large lake of toxic produced water, exposing them to highly toxic chemicals.
Livestock graze around the oilfields, passing on highly toxic pollutants to residents through the food chain.
Community drinking water, held in containers that are placed on dusty roadsides by Dar Petroleum Operating Company (DPOC), and chemical containers used by community members to hold water, are likely sources of human exposure to toxic pollutants.
Communities have repeatedly complained about a high prevalence of petroleum pollution that causes diseases and reproductive health issues, including birth defects, infertility, stillbirth, and miscarriages, among others. We discovered 13 cases of birth defects, including spinal bifida, facial and head deformities, sexual organ deformities, limb deformities, and growth retardations.
All of the participants expressed anger and frustration, a sign of a more serious potential crisis that could cripple petroleum industry operations in the area, if not prioritized and addressed.


We recommend the following to the Revitalized Transitional Government of National Unity (RTGONU) and DPOC:

Urgently identify areas sufficiently distanced from the oil fields, build basic services infrastructure in those areas, and relocate residents away from the oil fields and facilities;
Fence off the oilfields to prevent access by humans, livestock, and wildlife;
Conduct a comprehensive environmental and social assessment similar to the one that was conducted in Ogoniland in Nigeria by the United Nations Environment Programme (UNEP) to assess the extent of pollution damage, determine compensation and remediation costs, and make recommendations that are enforceable through an act of parliament or a presidential order; and
Expedite the tabling, review, and passage of the draft Environmental Protection and Management Bill to strengthen environmental protection rules and enforcement capacity to better protect the health and welfare of those South Sudanese suffering from oil industry operations.

While South Sudan awaits the arrival of the vaccines, whenever that will be, the focus should be on the prevention strategies, implemented in tandem with restrictions that should minimally affect daily lives. A mask mandate throughout the country will go a long way in preventing new cases of the virus

This paper reviews the existing literature to determine the adequacy of evidence and extent
of the environmental impacts in the oil producing areas in South Sudan. The following is
revealed:
o Evidence from previous studies shows that there is a serious environmental and
social disaster in the three oil producing areas, even though such evidence does not
generate enough consensus for the decision makers.
o Environmental impacts assessments (EIA) conducted before the oil operations
reveal that (1) the air in these locations was of good quality and (2) the water was
safe for both human and animal consumption, except for the pockets with high
concentration of salt in groundwater in the Um Ruwaba geological region.
o Still, many parameters of environmental quality usually recognized by World
Health Organization (WHO) have not been tested in both the EIAs and related
environmental studies.
o In summary, existing evidence links high concentrations of salt and heavy metals to
oil exploration, development and production, which are the cause of the widely
reported birth defects, miscarriages, infertility, and cancers in the affected areas.
We recommend a comprehensive, independent environmental and social assessment to
determine the extent of environmental and social impacts. Resulting insights could be used
to develop remediation measures to restore the environment and address related health
and social problems. The assessment should be carried out by a reputable firm or an
organization, which would need to be selected by the Ministry of Environment and
Forestry through a competitive bidding process. In the long term, results from this
assessment could help lay the foundation for sustainable development, provide oil
companies with new social license to operate, avert potential conflict and ecological
disasters, and aid in building a lasting peace in the country