Homecoming: Caring for South Sudan’s Returnees

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altThere is something truly unique about the frenzied energy of a refugee/displaced person/ returnee camp, especially in its first few days of life. In some ways it reminds me of the emergency department I work in back home: the eager, well-meaning, often exhausted professionals scurrying about, each trying to accomplish their individual tasks as rapidly as possible

There is something truly unique about the frenzied energy of a refugee/displaced person/ returnee camp, especially in its first few days of life. In some ways it reminds me of the emergency department I work in back home: the eager, well-meaning, often exhausted professionals scurrying about, each trying to accomplish their individual tasks as rapidly as possible, doing their best to coordinate with each other while also competing for scarce resources in a logistically challenging and constantly shifting environment, all the while struggling to keep the interests and dignity of their patients (or beneficiaries) at the top of their agenda. Like the ED, when a refugee camp works well, it feels like organized chaos and nobody will ever hear about it. Unlike the ED, when it doesn’t work well, it has the potential to become an international humanitarian catastrophe.


Last Spring I was called by International Medical Corps (IMC) to be part of a project to rapidly scale up capacity for trauma care within the District of Jonglei in the new country of South Sudan. Since independence from Sudan last year, the government has been struggling to build up its healthcare infrastructure, but large swaths of the sparsely populated country remain without functioning primary care or hospital systems. IMC had been helping run one hospital and several primary health centers in Jonglei, but over the past year had seen large numbers of trauma patients presenting at their facilities due to sporadic fighting between two local tribes, the Luo Nuer and Murle.

About a day before departing for South Sudan, I received word that I would temporarily be needed in another capacity. Somewhere between 10,000 and 15,000 South Sudanese were going to be repatriated from Khartoum (Sudan) to Juba (South Sudan) over the following two weeks, and a camp was going to be set up outside of Juba to house them, at least for a few months. IMC had agreed to cover health and nutrition programs for the returnees, and I was needed to help rapidly set up a clinic to manage healthcare within the camp.




Prior to South Sudan becoming an independent state last July, there had been hundreds of thousands of South Sudanese living in the north. After independence, many repatriated on their own to South Sudan, but many others elected to remain. In the months that followed, as tensions began to flare again between Sudan and South Sudan over the still contested border and oil deposits, Sudan began a process of forcibly deporting South Sudanese. In this particular case, several thousand South Sudanese living in Khartoum had been forced into a camp near the town of Kosti in Sudan several months prior, and now the Sudanese government planned to deport the entire camp en masse to South Sudan.

During my nearly 48 hour trek from Boston to Juba (with long layovers in Frankfurt and Addis Ababa), IMC worked with the International Organization for Migration (which was helping coordinate the safe transfer of the returnees) and the South Sudanese government to find an acceptable spot to house the incoming returnees until they could be reintegrated back into Juba. Though the returnees had originally come from Juba, most had been living in Khartoum for the more than a decade, in some cases several decades. Their children, for the most part, had been born there, and few families had homes or even relatives still in Juba to which they could go, let alone jobs to help support their families. As a result, there was a great likelihood they would be stuck for at least several months, perhaps longer, at this new location before being integrated back into South Sudanese society. Technically, they were not refugees, as they were officially citizens now of South Sudan, to which they were headed, not Sudan, from whence they were coming. But they also weren’t Internally Displaced Persons, such as those displaced by the earthquake in Haiti, as they were crossing an international border (albeit a new one) and hadn’t been living recently in the country. Officially the international community was referring to them as returnees, a rarely used term in humanitarian parlance and outside the official mandate of organizations like the UN High Commissioner for Refugees, and therefore off the radar for many humanitarian organizations.




The first group of 1800 returnees arrived by barge at Juba port, on the Nile River on a Wednesday, about 12 hours after my own arrival in country. Our team met the barge as it arrived late Wednesday morning, and started doing rapid triage to identify any seriously ill patients and transport them quickly to Juba Teaching Hospital, the primary referral hospital in South Sudan. The 1800 returnees had spent the previous 25 days on board the barge, and though as a population they had been relatively healthy (for South Sudan) prior to their trip, we saw many patients, and especially children, who had developed malnutrition, diarrhea, and dehydration as a result of their journey. To compound matters, their had apparently been an outbreak of chicken pox on board the barge, which can be particularly dangerous in children already suffering from malnutrition.

Once seriously ill patients at the port had been transferred to Juba Teaching Hospital (with the rest remaining on the barge until shelter could be set up for them at new locations), our team went to survey the site that had been identified the day before to temporarily house the returnees. It was the National Teacher Training Institute, a lovely collection of buildings on an expansive campus about 30 minutes outside of Juba by a wide, if sometimes rough, dirt road. The Institute had been built recently by the Japanese government as a gift to South Sudan, but had yet to open its doors due to lack of funding to run it. While the South Sudanese government provided the space, they made it clear that only the grounds (and none of the dozen or so buildings that included lecture halls, dining halls, and bathrooms) could be used by the returnees. To make the grounds habitable for nearly 10,000 people would require a massive scale up in terms of shelter, water supply, sanitation facilities, food distribution, cooking facilities, and healthcare provision. And it all had to be done rapidly, as nearly 700 returnees would be arriving each day from Khartoum to Juba by plane, in addition to the 1800 that had already arrived by barge, until the Kosti camp was completed emptied. And the first planes were set to arrive the following morning.

May 19, 2012: Camp Rising
By Wednesday afternoon, the day before the first returnees arrived at the camp, approximately three large tents, each enough for fifty people, had been erected on what had been the football pitch of the National Teacher Training Institute. A handful of representatives from the International Organization for Migration (IOM), as well as perhaps a dozen local staff, busy working to erect more tents, were the only people there. It seemed difficult to believe that an entire camp could be erected in time for the arrival of the returnees. Racing against time, our team from IMC plunged into work on our piece of the much larger pie: de
signing the clinic that would provide healthcare for the camp.

By the time the first 11 buses carrying nearly 350 returnees arrived at the National Teacher Training Institute from Juba airport, about a dozen large tents had been erected, including the one that would house our clinic. Using tarp and rope, tables and chairs, and a bit of imagination, we subdivided the clinic into registration and triage areas, consultation areas, a pharmacy and “lab” (the only diagnostics we were equipped to run that day were rapid tests for malaria), as well as a supply room and hand-washing station. We had secured an Interagency Emergency Health Kit from the World Health Organization, which included about 26 boxes of supplies intended to be able to run a refugee camp clinic for 10,000 people for 3 months. Still, the medications and supplies available in the kit were pretty meager compared to what we would use on a regular basis back in the US, or even at a standard district hospital in Africa. We had exactly three oral antibiotics, paracetamol and ibuprofen for pain, a couple medications for high blood pressure and heart failure, basic wound care equipment, oral rehydration and intravenous fluids, and a whole bunch of antimalarials. By the time we began seeing our first patients in the clinic, we had no running water, no electricity, and hence nothing that required refrigeration (a separate unit from the state ministry of health brought coolers of vaccines from Juba each day for mass immunization of children). And just about a half-dozen staff members, many of whom had been pulled from administrative jobs in the International Medical Corps office in Juba.



Incredibly, despite the chaos of people arriving in the camp after days of travel and our own mad dash to set up the clinic and make it functional, things ran relatively smoothly that first day. We saw about 60 patients presenting with the full range of primary care and emergency care complaints of the developing world, from pneumonia, diarrhea, and fever in children to chronic untreated hypertension, heart failure and diabetes in adults to random injuries, somatoform disorders, and the occasional snake bite. Sure there was some chest pain, but given our lack of an EKG or even aspirin, I convinced myself it was unlikely to be cardiac in nature. Ditto for abdominal pain – their abdomen’s were soft, and without a CBC or a CT or even an ultrasound, I wasn’t going to pursue acute abdomen much beyond that. There were certainly a handful of far sicker patients – a child with severe malnutrition, another with severe dehydration from diarrhea, a few adolescents and adults with possible typhoid or bacterial meningitis, several young children with pneumonia. While we had a car on hand to transport truly emergent patients to Juba Teaching Hospital in town, the only referral hospital in the area, we hesitated to do so unless absolutely necessary, given that their capacity was relatively limited as well – no ventilators, limited surgical capacity, an x-ray machine and ultrasound and a limited number of overworked doctors and nurses.
 By the second day, as several hundred more returnees arrived in the camp and our daily census at the clinic swelled to over 90 patients, IOM had erected 30 large tents and a number of smaller ones to house the returnees.

The non-government organizations (NGOs) Medair and ZOA had completed their first 8 latrines and had another dozen in the works, Islamic Relief Worldwide (IRW) had begun trucking in clean water to the camp while also getting the generator that pumped water into the large water tower on the premises up and running, the NGO ACROSS and the World Food Program had begun running a large communal kitchen to temporarily feed the returnees until other cooking options could be set up for them, and IOM had begun handing out kits of non-food items, like bedding, soap and mosquito nets to the returnees.



By the third morning since refugees began arriving, we had our own generator at the clinic to power fans during the day to make the oppressive heat a little more bearable, lights to allow us to continue treating patients into the early hours of the evening, and refrigeration for perishable medicines. We had also began recruiting clinic staff from among the returnee population itself, identifying several English speakers to work as translators, a couple guards and cleaners, and even a pharmacist and a nurse’s assistant. IRW had set up several more water taps, ZOA had built a total of 20 latrines (still now less than 1 per hundred or so returnees in the camp), and IOM had erected about a hundred additional small tents (each large enough to house about 10 people, or one extended family). The entire football pitch and most of the level ground around it were now occupied by a seemingly endless sea of white tents, and still more were going up as large additional swaths of the Institute grounds were being cleared of brush and tall grass. Quite importantly, the first garbage bins were set out that afternoon, and garbage collection began soon thereafter, where it was carried to an incinerator located in the far corner of the property.


IOM had also officially appointed a camp manager by this time for the camp, who began holding daily coordinating meetings for all the NGOs operating there to share progress and troubleshoot obstacles. Representatives from the South Sudanese government began attending by the second meeting, as well as 5 community elders from among the returnees to represent their interests. Given that every tent on the premises was currently occupied or otherwise in use, we all sat in a circle beneath a large tree that provided much needed shade from the burning sun and each briefly described our current operations, asking each other brief questions, setting up side meetings to coordinate further, everything delayed by a pause for translation between English and Arabic for the benefit of the community leaders. It was pretty incredible, a couple dozen men and women from at least 10 different countries, ranging in age from under 25 to over 65, all working together for the benefit of this population. Still, as the meeting stretched out past an hour, I began itching to get back to the clinic, worried about the backlog of patients. By the early evening, our daily census had topped 140, stretching our capacity to the limit, and it only looked like it would keep growing as the camp increased in size.



Of all the many sectors (or clusters, in humanitarian-speak) involved in disaster or emergency response, healthcare is probably one of the least important in absolute terms. Water, sanitation, hygiene, food, shelter, and security all come as higher priorities in terms of reducing disease and saving lives. Of all the various sectors though, healthcare is almost certainly the first to be affected by deficits in any of the other sectors. When food is insufficient, the numbers of children with complications from malnutrition begins to rise; when shelter is inadequate and crowding is high, pneumonia and other infectious diseases become more prevalent; and when sanitation and hygiene are poor, diarrhea rates can increase precipitously. As the lead organization for health in the returnee camp, the other organizations providing services depended on IMC for information on the downstream effects of their own individual programs. Our camp clinic was, in effect, the canary in the coal mine.

One of the biggest challenges in the camp, as the numbers of returnees continued to rise,
was providing adequate sanitation. The organization in charge of digging latrines was having difficulty keeping up with the rising population, and the number of people per latrine rose above 100 (more than twice the emergency limit according to international guidelines). In addition, procuring adequate amounts of water for the growing population was proving difficult, as it had to be trucked in daily from a water treatment plant on the Nile River.

Given the water and sanitation situation in the camp, we were particularly concerned on the fourth day of operating the clinic when we saw a sharp spike in the number of patients presenting with both diarrhea and dysentery. The incidence of cases were not high enough compared to the baseline for South Sudan nor the increase sustained long enough to constitute an outbreak, but it certainly was a concerning sign. We immediately notified the organizations in the camp involved in water, sanitation and hygiene, and they convened an emergency meeting to discuss the situation. We provided them with the daily tallies of diarrhea cases from our clinic, and expressed our concern regarding the sanitation and hygiene situation in the camp. The actors involved in the Water, Sanitation, and Hygiene cluster (WASH), discussed a variety of possible solutions to rapidly improve the situation. One of the first options discussed was designating defecation fields just outside of the camp area, as a simple means for segregating feces from the camp and its water supply. This idea was quickly nixed by locals living around the camp, who did not want to see their newly ploughed fields trampled on by the camp residents. After discussion about other possible options, the WASH cluster settled on renting a backhoe, which would be used to rapidly dig several trench latrines that could be used in the short term while more permanent latrines were built. In addition, several more 10,000 liter tanks were purchased to store the water being trucked in from the Nile, while 40 camp residents were hired and trained as hygiene promoters to educate fellow returnees about the importance of adequate hygiene. Water from the taps in the camp would also be sent for testing to ensure it was not contaminated.  IMC also worked with the World Health Organization to send stool samples from patients with dysentery to the nearest lab that could do microbiological testing, more than 1,000 kilometers away in Nairobi, Kenya.



Meanwhile, as the WASH cluster was rapidly scaling up their efforts to prevent an outbreak of diarrheal disease, more than 600 new returnees continued to arrive daily in the camp. The numbers of patients we were seeing at the clinic each day also continued to rise, passing 150 by the fourth day, then 170 by day 5, and topping 200 a day by day 6, when the estimated camp population just passed 5000 returnees. By this time, our clinic tent had become quite crowded with patients, so we expanded into a second tent next door, giving us the space to set up more two more consultation “rooms” (really just small sections of the tent blocked off with leftover tarp), a basic pharmacy, and a 6-bed observation area for patients requiring rehydration or intravenous antibiotics. Even more importantly, we began hiring local staff to replace the ex-pat staff who had been running the clinic for its first few days. This was not easy, as South Sudan has a severe dearth of health professionals, with less than a hundred practicing physicians for the entire country of 10 million people. We were able though to hire a few nurses and clinical officers from Juba, each with about two or three years of medical training, as well as untrained individuals from within the camp to help with registration, cleaning, organizing, and security for the clinic. Since it was nearly impossible to recruit any local physicians, two International Medical Corps physicians would continue to manage the clinic and be available to handle emergency cases that presented to the clinic, while most primary care in the clinic was managed by the local clinical officers and nurses. By this time, cases of watery diarrhea had begun to level off, perhaps due to the improved sanitation measures. However, with the camp still poised to double in size before the flow of returnees from Kosti finally tapered off, the situation could still change for the worse, and all eyes in the camp would continue to focus on our daily clinic tallies for any signs of impending trouble.

Read more of Dr. Levine’s story in Emergency Physicians International: www.epijournal.com

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