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'We Are All Displaced Now' - South Sudanese Health Workers Tell of Treating Patients in the Bush

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As the international community holds its breath, hoping that the latest peace deal signed between warring parties in South Sudan holds, civilians caught up in the conflict are praying for an end to the killings, for the chance to return home and to plant their crops.

Almost three months ago, the Médecins sans Frontières/Doctors Without Borders (MSF) hospital in the town of Leer, Unity State, South Sudan was destroyed, one of the many brutal assaults on entire communities in the country since December 2013.

More recent attacks on civilians and the health facilities that they have relied upon for years have been inflicted upon Malakal and Bentiu: both sides have attacked civilians, looted hospitals, killed patients, raped women and generally failed to regard the basic rules that apply in a time of war.

Beyond the scenes of scattered corpses on the dirt roads of town or village squares, beyond the smouldering remains of homes, churches, stores, and health clinics, exist the survivors - hiding in swamps, surviving on plant roots and filthy water, and trying to stay alive.

As the frontline moved closer to Leer, the civilian population - including some local staff - was forced to flee for their lives.

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For three days after the evacuation of international staff, a team of local staffers continued to run the hospital as best they could. When it became apparent that the town would fall and the hospital could be attacked, they took all the patients that could not walk, loaded them into MSF vehicles and fled the town.

Two months on, many remain hidden in the surrounding swamps, treating as many people as they can with dwindling stocks of medicine.

"We split into groups to avoid attention, but the soldiers chased us. We drove as far as we could but then we had to leave the cars and the soldiers took them. "

"We took five surgical patients with us. After we lost the vehicles, we carried the patients on blankets. It takes four people to carry one patient like that. When we become tired we rest and then we start again. There is no road, just bush."

The vast swamps from which South Sudan takes its name have proved to be both an effective and inhospitable hiding place. (The word Sudd means "barrier" in Arabic.)

One team member recounts how their best efforts to save a critically ill patient were not enough. "We had one case that required an amputation, and another with serious burns. We treated them as best we could but then radioed our project coordinator to tell her we need to get these patients out. We were just treating them under the trees with the medication we carried with us."

With great difficulty, a small boat was hired to transport the patients to another area, but it was too late for one of them. "The patient with burn wounds died there on the river bank before we could get him onto the boat."

The teams retreated further into the swamps, splitting up into smaller groups to avoid detection and to be sure of reaching more patients. They mostly treat cases of malaria and diarrhoea, both exacerbated by the harsh living conditions and dirty water. They also try to ensure that tuberculosis patients and people taking antiretroviral drugs are able to continue their treatment.

Among the meagre supplies gathered before the evacuation were post-exposure prophylaxis drugs, necessary to prevent HIV infection in women who have been raped. The team also struggles to assist women who go into early labour or who miscarry because of the trauma they have witnessed and endured.

A recent visit to the area where they are still operating provides a compelling insight into the extended effects of the ongoing assaults on civilians in South Sudan.

Food is scarce, and largely unavailable in the mostly looted or destroyed markets, should people even dare venture forth from the bush. The medical teams and their families, and the patients they treat, live on whatever they can forage, "We have no belongings and no food," said an MSF paramedic. "We survive by eating the roots of reeds. We cut water lilies, dry and grind the seeds and use it like sorghum. We also take wild fruits from the trees. They are not nourishing but they fill the stomach when taken with water. We can't boil water so we have to drink it straight from the swamp. Everyone develops diarrhoea. We might get typhoid, but what can we do? You can't die of thirst when you are surrounded by water."

"It has been a hard life for me and my children since Leer was attacked," said one female staff member. "Our home was burned down and now we live in the bush. I just feed my children water lilies and sometimes we find an animal that has died and we eat that. It's not safe because we don't know what that animal died from, but there is no other way."

For most of the staff in hiding, their unshakeable belief in the value of their work is all that keeps them going.

"When someone has done good to you, you should do the same to them," said one long-serving medic of the Leer team. "When the patients see us, they still have hope MSF will come back."

For others, the work is a form of coping mechanism: "If you love your job, you must do your job. So we must take care of our patients. Helping our patients helps us to cope with the situation we are now in. We are also IDPs [Internally Displaced People] now."

All sound a warning about the coming rainy season, and its accompanying hunger. "When the rainy season arrives it will be disastrous, both for us and our patients," said a member of the 'bush team'. "People have no crops now. From July there will be a big problem with food because people can't go into town, either because it is too dangerous or the town has been burned down. There is some food distribution going on but not nearly enough. Even the host community's food supply is depleted because they have been sharing with the IDPs".

The women are the most blunt. "People are already dying of hunger, especially the children," said a midwife. "When the planes can no longer land because of the rain, no one will hear our voice. We will die. It's simple."

At the moment supplies are still being flown in. The World Food Programme (WFP) is doing some food distributions but not enough to meet the scale of the crisis. MSF is bringing in medicine and ready-to-use therapeutic food for malnourished infants, but is struggling to deliver enough to meet the needs.

In a conflict in which there are few safe spaces - both for people to live and humanitarians to work - it is becoming increasingly difficult for MSF to operate. The costs - both human and financial - rise every time MSF is forced to evacuate a hospital or project. The levels of violence and brutality seem to increase constantly, and the risks to both patients and staff are huge. With almost one million people internally displaced and hundreds of thousands seeking refuge in neighbouring countries it becomes harder each day for aid to reach people - people for whom the presence of basic humanitarian assistance can mean the difference between life and death."

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