MSF staff outside Pieri Clinic
South Sudan

Hidden impact of conflict

How cycles of violence impede access to basic medical care in Jonglei State, South Sudan

Late in the evening on 3 August 2020, MSF’s coordination office in Juba, the capital of South Sudan received an urgent report. 

“45 wounded in less than 24 hours and reports of hundreds more coming.” 

It was the beginning of my third month in Juba. As an emergency coordinator, I was here to focus primarily on COVID-19 response. That also meant supporting the team here to manage the overload of work and the gaps in supplies and staffing that the COVID restrictions were causing.

But now this. 

The call came from a satellite phone. It was the MSF team in Lankien who had received report from the remote team in Pieri – a town in Jonglei State in the north-east of the country where we run a primary healthcare centre.

Conflict disrupts access to care in South Sudan, Jean-Nicolas Dangelser
In August 2020, MSF Emergency Coordinator, Jean-Nicolas Dangelser led an emergency response in the town of Pieri, following the latest escalation of violence in the Jonglei and Greater Pibor administrative areas of South Sudan.

Planning ahead

As a coordination team, we had already been monitoring the situation in Jonglei State and the Greater Pibor Administrative Area for several weeks. Back in May, an attack on Pieri had left hundreds of people wounded or dead, including, tragically, one of our staff members. Now large numbers of armed youth had mobilised to retaliate.

On 1 August we took a short window of opportunity with good weather to send a plane with medical supplies and two additional staff to Pieri to assist the team for a few hours on the ground before taking off again. We knew that without this support the team would have a hard time keeping all the vital health services open for the community facing this difficult period.  

Patient getting medical care for broken arm at Pieri Clinic
Gatwich, 35-years-old from Pading, (Jonglei State) is treated by MSF operating theatre nurse Bateah in the minor operating theatre in Bentiu Hospital in the Protection of Civilians site (PoC).
Caterina Spissu/MSF

More support needed

Two day after the supply drop, dozens of wounded were arriving at the MSF clinic. Our team worked around the clock to treat them. 

In just three days the team in Pieri saw a total of 73 wounded people – and over 100 within the week. Back in Juba, we were getting regular updates from the team. We decided to send a small team from Juba to support our colleagues on the ground as soon as possible. The Pieri team were exhausted, dozens of the patients were critical, and the security situation was putting everyone under immense pressure. 

As the airstrip in Pieri had been flooded since Saturday, we contacted various organisations in the area to arrange for a helicopter for the next morning. When transportation was confirmed, we packed essential food and communication devices and were ready for departure.

The next morning, after a few hours of sleep, I was on a small helicopter to Pieri along with a medical doctor and logistician. My role would be negotiations, security monitoring, and coordinating actions. In just a few hours, another MSF team would be heading to Pibor to assist on the other side of the frontline. 

Patient being carried into Pieri Clinic
MSF staff carry a wounded person to MSF clinic in Pieri, a town in Jonglei State in north-eastern South Sudan where MSF runs a primary healthcare centre.
Shirly Pador/MSF


We landed on Pieri’s muddy airstrip, where a few of our colleagues were already waiting for us. Around them was a crowd of hundreds of women, children, elderly and armed men from the local community who had returned home from the fighting. All had heard we were coming, and that we might be able to evacuate some of the critically injured.

From the airstrip, we headed straight to the MSF clinic in order to assess the wounded. I could feel the urgency of the situation. The team had briefed us by the satellite phone and I knew there were dozens of patients to be seen. 

We could evacuate some of them with the helicopter to the MSF hospital at the United Nations Protection of Civilians Site (PoC) in Bentiu where MSF have a surgical team. But we would need to make decisions fast.

Patients inside Pieri clinic
MSF commenced an emergency response in Pibor on 11 August, nearly two months after activities were suspended due to immense restrictions directly and indirectly related to the COVID-19 outbreak and rife violence. MSF relaunched the emergency outpatient primary health care activities in the centre of Pibor town so that it may be easily accessed by both host and internally displaced populations.Critical medical intervention urgently needed in Jonglei and Pibor following clashes.

Critical care

When we arrived in the clinic, our team on the ground had already grouped the most critical patients in the first tukul – a kind of hut. 

Six patients with gunshot wounds were lying on the floor with blood soaking through their bandages.  
During the rapid medical assessment, I noticed that some of the patients were coughing. This immediately raised concern of COVID-19 - an additional challenge to the already complicated referral process, as already in previous cases we have had staff who had to quarantine after a patient was confirmed as positive to COVID-19.  

We were able to do only one round of medical evacuations that day as the helicopter ride from Pieri to Bentiu takes approximately three and half hours.  COVID-19 distancing measures in such a small space as a helicopter is near impossible, especially when we are trying to evacuate as many critical patients as possible – but this was an emergency. We mitigated the risks as much as possible with masks and protective equipment for everyone. The other critical patients who remained in the clinic would have to wait until the following morning. 

In the next 72 hours, our team did five evacuations of a total of 36 patients. This decongested the Pieri clinic, improving access to medical services for the rest of the local community. For the patients who were evacuated, it meant the difference between being cared for at a clinic in tukuls made of mud, and at a hospital with an operating theatre, a surgeon, anaesthetists.

South Sudan: Conflict and COVID-19
Since August 11, MSF has done over 1,500 out-patient consultations and provided 292 pregnant women with antenatal care.

Back to “normal”

What amazed me the most during this emergency response was the work of our South Sudanese colleagues on the ground who, despite their own suffering, were committed to help others. Seeing my colleagues being so dedicated to serving people deprived of essentials services and basic living conditions is what motivates me to continue my work with MSF. 

The first few days were hectic. Hundreds of armed youths from the local community were returning to the area after the fighting, bringing with them thousands of cattle which they had captured during the attack. They announced their arrival with celebratory gunfire day and night. 

Over the week, the situation in Pieri began to get back to normal. People went back to work, the constant sounds of gunfire stopped. Our emergency team was ready to return to Juba, but the changeable weather conditions made it uncertain when we would be able to arrange the flight. We extended our stay to 10 days.  

As the effervescence faded away, we took the opportunity to visit the communities in the villages around Pieri to assess people’s living conditions and their access to healthcare after the earlier attacks in May. 

Patients outside Pieri Clinic
MSF is operating outpatient activities since 11 Aug responding to increased critical needs of freshly displaced communities the GPAA and Jonglei

Dire conditions

It’s rainy season, which meant several days of walking around in the water and the mud, sometimes up to our knees. These journeys brought us to women, children, men, elderly, youths and community leaders living in dire conditions. 

Having fled to escape the recent violence, some people returned to the area to farm the land after just a few days. Others had come back only a day or two before our visit, feeling safer with the return of the local armed youths. 

Everyone we spoke to shared the same concern – fear of the retaliation attacks that might happen in a couple of months with the end of the rainy season, if not earlier. 

Support to pharmacies
Strike action in the North West province disrupts healthcare and Stop Stockouts Project and MSF, respond to improve patients’ access to medicine. MSF provides support to pharmacies and supply chain mechanisms.
Oksana Parafeniuk

The impact of violence

Although we never saw the “hundreds more wounded” announced in the early reports, some of the youth had never made it back to Pieri, dying from injuries or diseases like malaria on the way, while the others rerouted to other locations in the area.

Instances of violence like this – which have been repeated cycles in the Jonglei and Greater Pibor administrative areas of South Sudan throughout 2020 – have had a devastating impact on the community; disrupting access to healthcare, food, shelter, livelihoods and education. Medical treatment for people wounded in these attacks uses precious resources, hampering the response to acute illnesses and chronic diseases. 

Patient inside Pieri clinic
29-year-old Bol from Paniang, Jonglei State is treated in the surgical ward in Bentiu Hospital in the Protection of Civilians site (PoC).
Caterina Spissu/MSF
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