Today, close to 100,000 people are huddled on United Nations military bases around the country, just a fraction of the almost 1.5 million who have been put to flight and are waiting out the war as internal exiles or as refugees in the bordering nations of Uganda, Ethiopia, Kenya, and Sudan. Such massive levels of displacement guarantee another nightmare to come. Since so many subsistence farmers weren't around to plant their crops, despite fertile ground and sufficient rain, seeds never met soil and food never had a chance to grow.
"At this point in time, because it's the rainy season, there's nothing we can do in terms of agriculture," says Caroline Saint-Mleux, the regional emergency coordinator for East and Central Africa at CARE International. Above us, the sky is darkening as we sit in plastic chairs in the muddy "humanitarian hub," a grimy ghetto of white tents, nondescript trailers, and makeshift headquarters of aid agencies like the International Committee of the Red Cross and MSF, on the outer edge of the U.N. base at Malakal. Her organization did distribute a limited number of seeds to farmers still on their land earlier in the year, but can do no more. The planting season is long past. "It would be a waste of energy at this point," she says, resignation in her voice.
Famine "is a very realistic possibility," Deborah Schein tells me. She's the coordinator for the United Nations in Upper Nile State, where Malakal is located. Right now, experts are crunching the numbers and debating whether to formally declare a famine. Whether it's this fall or early next year, aid workers say, it's definitely coming and the sooner it comes, the more lives can be saved. Recently, U.N. Security Council President Eugà �ne-Richard Gasana called attention to "the catastrophic food insecurity situation." Already, 3.9 million people -- about one in three South Sudanese -- face dangerous levels of food insecurity. However, unlike in Ethiopia in the 1980s, where drought led to crop failures that killed one million people, Vanessa Parra, Oxfam America's press liaison in South Sudan, says this country is facing an "entirely man-made famine."
Nyajuma's Story
If it were dry, it would take only five minutes to walk from Deborah Schein's office at the U.N. base in Malakal to the Medecins Sans Frontià �res field hospital in the adjoining IDP camp where 17,000 South Sudanese are now taking refuge. But the rains have turned this ground into fetid mud and an easy walk into a slip-sliding slog.
At the end of a gray, mucky expanse that nearly sucks the boots off your feet, an MSF flag flies outside a barn-sized white tent. Before you enter, you need to visit a foot-washing station, then have your feet or boots disinfected. Even then, it's impossible to keep the grime out. "As you can imagine, this is not the best environment for a hospital," says Teresa Sancristoval, the energetic chief of MSF's emergency operations in Malakal.
Step inside that tent and you're immediately in a ward that's electric with activity. It's hard to believe that this 24-hour-a-day, 7-day-a-week hospital is manned by only three expat doctors and three expat nurses, plus a medical team leader. Still, add in various support personnel, local staff, and the many patients and suddenly this giant tent begins to shrink, putting space at a premium.
"The great majority of the hospital is pediatrics," says Sancristoval, a compact dynamo from Madrid with the bearing of a field general and intense eyes that go wide when making a point. Not that she even needs to point that out. In this first ward, the 15 metal-frame beds -- blue paint peeling, thin mattresses, four makeshift bamboo posts topped with mosquito nets -- are packed tight, all but two filled with mother and child or children. Some days, there's not a bed to spare, leaving patients ill with infection and wracked by disease to sleep on whatever space can be found on the floor.
On a bed adjacent to the main thoroughfare sits a tiny girl in a yellow top and pink skirt, her head bandaged and covered in a clingy mesh net. Nyajuma has been in this hospital for two weeks. She was lying here inside this tent, wasted and withered, the night we were having our Christmas feast at the embassy about 400 miles south in Juba.
Nyajuma weighed only 11 pounds on arrival. According to the American Academy of Pediatrics, the average one-year-old girl in the U.S. weighs more than double that. She was quickly started on the first of two powdered therapeutic foods to combat her severe malnutrition, followed by a regimen of Plumpy'nut, a high-protein, high-calorie peanut paste, four times a day along with two servings of milk.
It would have been bad enough if her only problem were severe malnutrition, but that condition also exacerbated the skin infection beneath the bandages on her head. In addition, she suffers from kala azar, a deadly disease caused by a parasite spread by sandflies that results in prolonged fever and weakness. On top of that, she is being treated for two other potentially lethal maladies, cholera and tuberculosis. Her mother, resting beside her, looks exhausted, world-beaten. Pregnant on arrival, she gave birth five days later. She lies next to Nyajuma, listless, but carefully covers her face with her arm as if to shield herself from the harsh world beyond this bed.
During her first week at the hospital, nurse Monica Alvarez tells me, Nyajuma didn't crack a smile. "But now, voil," she says lifting the child, sparking a broad grin that reflects the sea change in her condition. Nyajuma is enduring the rigors of kala azar and tuberculosis treatments with great aplomb. "She's eating well and she's smiling all the time," says Alvarez, who's quick with a smile herself. But Nyajuma is still in the early stages of treatment. Once stable, severely malnourished children can be transferred to ambulatory care. But it takes roughly six weeks for them to make a full recovery and be discharged. And in today's South Sudan, they are the lucky ones.
Of those who make it to the hospital in such a condition, 10% don't survive, Javier Roldan, MSF's medical team leader, tells me. "We have people who come in in later stages or have a co-infection because malnutrition has compromised their immune system, which makes treatment much more complicated." He talks of the difficulty of losing patients for want of better facilities, more staff, and greater resources. "The outcome of a baby weighing one and a half kilos [3.3 pounds] in Europe or America would be no problem at all, but here there's quite a high mortality rate," says Roldan. "It's very frustrating for the medical staff when you have patients die because you don't have the means to treat them."
And Malakal is no anomaly. At the MSF feeding station in Leer, a town in adjoining Unity State, they've treated roughly 1,800 malnourished children since mid-May, compared to 2,300 in all of last year. North of Leer, in Bentiu, the site of repeated spasms of violence, the situation is especially grim. "Over five percent of the children are suffering from severe acute malnutrition," says CARE's Country Director for South Sudan Aimee Ansari. "On the day I left Bentiu, CARE helped parents transport the bodies of children who had died from malnutrition to a burial site." In all, according to the United Nations Children's Fund (UNICEF) and the U.N. World Food Program (WFP), almost one million South Sudanese children under five years of age will require treatment for acute malnutrition in 2014. UNICEF projects that 50,000 of them could die.
The Camps and the Countryside
At the U.N.'s Tongping camp in Juba -- where nearly 11,500 of the area's tens of thousands of internally displaced persons are taking refuge -- the food situation is "not very good at all." So John, a 17-year-old resident, emphatically assures me beneath the relentless midday sun. "Outside, when I was living at home, we could have fruit or whatever we wanted." Here, he eats no fresh food and no vegetables. Its sorghum and "the yellow food" mixed with sugar, oil, and water. "This food doesn't even compare," he says more than once.
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