Health

Decades of conflict in South Sudan, pre and post-independence in 2011, poverty and poor access to services have increased the rate of disability and rendered people with disabilities more marginalised and excluded as a result of the numerous attitudinal, environmental, and institutional barriers they face, and the lack of concerted efforts to include them. This rapid review identifies the available evidence on the experiences of people with disabilities living in South Sudan. There are still numerous evidence gaps in relation to the experiences of people with disabilities living in South Sudan as very little research has looked at disability in South Sudan and the available evidence base is extremely limited. Much of the available information focuses on Juba rather than the rest of the country. Further research with people with different types of disabilities, and in different areas of South Sudan is needed to more fully understand the experiences of people with disabilities living on South Sudan, the barriers and challenges they face, and how they and their families have responded to them.

This rapid evidence review provides an assessment of negative and positive coping mechanisms of different groups (based on wealth (below the poverty line/elites), gender, age, (dis)abilities, geographies (rural/urban), and ethnicity of people in South Sudan in relation to different types of shock. It draws predominantly on a range of grey literature from multinational and bilateral institutionsas well as non-government organisations (NGOs) and think tanks. The report highlights that coping strategies are varied and multifaceted, they are a product of the vulnerability of particular individuals, households and communities and are the product of responses to shocks and stressors. These shocks(?) may be acute or chronic. It is also important to note that coping strategies in the South Sudanese context have often been developed in response to food insecurity, climatic change and conflict and that new shocks may undermine these existing strategies, necessitate evolution of these or the adoption of new strategies. It is also important to note that these may have both negative and positive impacts that may differ over short, medium and long term time horizons.

This rapid review focuses on identifying evidence on the secondary impacts of COVID-19 on women and girls in Sub-Saharan Africa (SSA). It aims to enable a greater understanding of the unique circumstances of women and girls in the region, which could assist with the provision of effective support throughout the COVID-19 crisis and its aftermath. Guided by available evidence, the review explores the impact of the COVID-19 pandemic on women and girls in SSA across various issues. These include some of the following – girls’ education, social protection, unintended pregnancies, access to health services, poverty, livelihood, land rights, women’s and girls’ informal employment, food security and nutrition, female health workforce, and access to WASH. The review touches upon, but does not thoroughly investigates the following topics as they are considered in other reviews - Violence Against Women and Girls (VAWG), Sexual and Reproductive Health (SRH), girls’ and women’s rights, child marriage, harmful social norms, and women’s political participation, leadership and empowerment. Despite the limited data, the review found that based on emerging evidence and lessons from past health crises, there is strong evidence to suggest that women and girls in SSA will suffer from extreme and multifaceted negative secondary impact as a result of the COVID-19 crisis. Some of which may include higher poverty rates, increase in unplanned pregnancies, a surge in school dropout rates and child labour of adolescent girls, loss of income and reduced financial empowerment, increased household work, reduced access to healthcare and WASH alongside increased maternal deaths, and greater food insecurity and malnutrition.

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.