Malnutrition and suspected cases of cholera are escalating amongst people sheltering in the bush near Pieri, South Sudan, putting the health of thousands of people at risk, according to international medical organisation Doctors Without Borders (MSF).

More than 27,000 people have fled their homes in Yuai and Waat since mid-February after clashes between the Sudan People’s Liberation Army (SPLA) and opposition groups. Those who escaped to Pieri have told MSF teams that civilians were shot at, raped and killed and their houses burned to the ground. Now desperately short of food, water and shelter, many of the displaced people are living under trees and eating leaves to survive. 

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In April, MSF clinical staff in Pieri reported 28% of general acute malnutrition & 9% of severe malnutrition among the children under five years old.
Photo: Amandine Colin/MSF

In response, MSF teams are providing basic health care and treatment for cholera and malnutrition. But unless people’s living conditions improve and they are provided with more and regular humanitarian assistance, the situation is likely to deteriorate further, warns MSF. 


"They killed the women, the girls, everybody in the town, and they also raped women" 

William Nyuon Kuolang, 41, is a father of five.

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William Nyuon Kuolang, 41, is a father of 5. He used to live in Yuai, a place he fled on the 15th of February 2017 following some fighting between the SPLA and opposition groups. Photo: Amandine Colin/MSF

Until February this year, he lived in Yuai, when fighting between the Sudan People’s Liberation Army (SPLA) and opposition groups forced him to flee. Since then, he and his family have been sheltering in a village near Pieri.

“I left Yuai on 15 February because of the fighting. Armed men attacked us at 14h00 in the afternoon. I had to run with my wives and children. I left running – there was no time to take anything. I was just carrying the baby and running away.

They [the armed men] were firing their guns in the town. They killed the women, the girls, everybody in the town, and they also raped women. They killed my sister and both her children, and also my father and my uncle. When they kill a lady, they put a stick in her vagina. If it is a child, they put a bullet in the anus.

They burnt some of the tukuls [mud huts], they took the cattle and they even destroyed the boreholes in the community. In Yuai I had a big garden and some cattle. I lost my cows and the goats.

Life in Yuai used to be good. There was a lot of medicine, but when they attacked the city, they took the medicine and they also took the clothes. The children now have no medicines, no clothes; they sleep under the trees.

I come every day to Pieri. It is four hours’ walking. I come to find food for the children. Also, I come to know what’s going on today with the war. I don’t stay in Pieri with my family because I am afraid they could come and attack the town. Last week they came and stayed three hours. There was some shooting but nobody died.

When we were in Yuai, I had enough food for the family. The only food I get now is from [aid] distributions and the leaves from the trees. After eating the trees’ leaves, we feel pain in the stomach. I think that it is what brings diarrhoea. One of my kids died from cholera a week ago. His name was Nyadel, he was five years old. I knew there were not enough drugs in Pieri, and I thought he would get better and it was better to wait. The next day, he was dead.

We get water from the boreholes, but there is not enough water for the whole community. That’s also why I come to Pieri – it is easier to get water here than in my village. When the rainy season comes, I’ll have water closer to my home. But when the rain comes, we will need plastic for shelter. I now live under a tree, there is nothing.”


"It is not the first time I’ve been displaced from my home"

- Elisabeth Nyamoun, 44, has eight children and six grandchildren.

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Elisabeth Nyamoun, 44, is a mother of 8 and a grandmother of 6. She lives in Pieri, under a tree with her family since she had to flee Pieri 3 months ago. Photo: Amandine Colin/MSF

Since fleeing Yuai three months ago, she and her family have lived in Piero, sheltering under a tree.  

“I have been in Pieri for three months. I stay in town, under a tree in someone else’s compound. My whole family is in Pieri after we fled because of the fighting. Armed men come and kill people – that’s the only way to win. They fired guns in the community. It is not the first time I’ve been displaced from my home. The last time was in 2013. I was in Malakal when fighting happened there – that’s why I came to Yuai. Now I have had to leave again.

When we had to flee, some children got lost because it was impossible to run with them. Fifteen people I know got killed and ten others got shot. There were children, women, men.

On 16 February, people went back to the town to find food. I know that more than 30 women were raped that day and two young girls were killed. They were 15 years old. They wanted to bring food, clothes, everything they needed to settle outside Yuai. Some women went to Lankien to get medical attention after it happened, but a lot of them just don’t tell anyone, not even their husbands.

Three things are difficult for us here: there is no shelter, there is no food and the cholera is coming. We are eating only the leaves on the trees and the food from the food distribution. It is difficult to get food. We got one bag of sorghum, which is what we need for 12 days, more or less. There is still a little bit left, but people who cannot get a card to get food come and beg. They come from the villages around and I give them food.

There are some people in the town who are disoriented because of the lack of food and water. People also think about what they have left behind.  We try to make tea, but it is expensive in the market and we don’t have money. Nobody has a salary so nobody would buy firewood, and if I cannot sell anything, then I don’t have money to buy anything in the market.

The water comes from the borehole and we don’t have enough for everyone. I cannot go back to Yuai until there are no soldiers in town anymore. Our tukul [mud hut] is burnt, but I would like to go back.”


"They killed people who were not running, the elderly and disabled"

- Nhiaan Chaar,* 29, worked as a pharmacist for MSF in Yuai.

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Nhiaan Chaar, 29, used to work as a pharmacist for MSF in Yuai. Since he had to flee Yuai with his 3 children and his wife in February 2017, he now lives and works in Pieri, where MSF set up three mobile clinics for basic primary healthcare. Photo: Amandine Colin/MSF

After fleeing Yuai in February with his wife and three children, he came to Pieri, where he joined up with other MSF staff members to run mobile clinics to provide people with basic healthcare.

“I was born and raised in Yuai. Then, in the early 90s, my parents decided to leave for Khartoum, because of the conflict and because there was no more food. I came back from Khartoum at the moment of the peace agreement in 2004-2005. I got married in Yuai in 2009. My wife is originally from Pieri. At that time, I had a lot of cattle. Now I have only six cows. We had a really good life in Yuai. There were no combatants, it was nice and quiet.

I started working for MSF in 2011 as an outreach worker, and then in 2014, I became the pharmacist. The work was good, we had a lot of patients. We were 30 staff, including 17 medical workers.

The attackers came at 14h00 and they started firing their guns. When we had arrived at the hospital that morning, the supervisor had told us to go back home to be with our families in case the situation got worse. At that time, we heard the guns and we asked the patients also to go back home to be with their relatives.

They [the attackers] took everything in the clinic – everything. They killed people who were not running, the elderly and disabled. Afterward, rapes happened. I only took my bag with my computer and my MSF T-shirt and came here. I left my money behind. When I arrived here with my family, my father-in-law gave us a tukul [mud hut] and helped me to have a bit of money by selling goods in the market.

As soon as we arrived [in Pieri], we – the MSF staff – started working from here, giving the drugs to the patients who needed them. We are three teams, each of them of six medical staff and four guards, running three mobile clinics. When it is possible, MSF brings the drugs here, or we go and meet the MSF teams elsewhere if the plane cannot land.

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MSF nurse gives explanations to Chuol Gatweck Leo & John Malith Reath, two freshly recruited MSF staff. Photo: Amandine Colin/MSF

It is making a big difference, although we don’t have injections and we don’t treat diseases such as kala-azar. Sometimes it is difficult that we cannot help someone because we don’t have the drugs. Also, a lot of children are sick because there is no good hygiene. It’s important to help our community to get their medicine and assistance.

Around 32,000 people used to live in Yuai, but everybody left. Some went to the camps in Uganda, Kenya or Ethiopia. Because there is nothing to eat, people are still going to Ethiopia, but you need money to go there and a lot of people can’t afford it. I could go, but I don’t want to leave Pieri as I’m helpful here.

The food situation in Pieri is very difficult. There is nothing in the market, so people who have nothing cannot buy anything. Most of the NGOs are closed so there is no money. I care for three families – my wife and my kids, my sister and her husband and her four kids, and also my father in law’s family. They don’t have any money. How could I leave for Ethiopia?

People are scared of cholera. They come to the clinic because every problem that they have, they think it is cholera. Twenty-three people died in the community last week and another four this week. I believe they died from cholera. Now we explain to patients how to protect themselves from cholera, but people still don’t know what to do. Even in my house, it is a problem, even though I work for MSF and keep explaining to my family.

I like Yuai, and I don’t want to live here in Pieri. I know that a part of my house was destroyed and that they stole everything and all my money, but I still want to go back.”

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Inside the cholera treatment centre in Pieri where around 20 suspected cases have already been treated on the 24th of May 2017. Photo: Amandine Colin/MSF

“I left running – there was no time to take anything,” says William, 41, a father of five who fled Yuai on 15 February. “They were firing their guns in the town. They killed the women, the girls, everybody in the town, and they also raped women. They burnt some of the tukuls [mud huts], they took the cattle and they even destroyed the boreholes.”

William and his family fled the town of Yuai but, fearful that Pieri too might come under attack, they are living under a tree in a village two hours’ walk from Pieri, surviving on leaves and on the little food distributed by aid organisations. Last week, his five-year-old son died – most likely - of cholera.

The first suspected cases of cholera were reported on 9 May after a general increase in patients with watery diarrhoea. MSF has opened a treatment unit in Pieri, where teams have treated more than 30 patients so far and set up seven rehydration points and a number of chlorinated water points.

MSF’s team of South Sudanese staff from Yuai hospital, who fled alongside the population of the town, are now running three primary healthcare clinics around Pieri.

In mid-May, the team reported a rise in malnutrition levels amongst children under five, with 32 percent suffering from general acute malnutrition and 12 percent suffering from severe acute malnutrition, which is life-threatening. MSF has distributed food rations to the malnourished children, but there is an urgent need for more food to be provided, both to local people and to displaced people around Pieri.

“We got some food two weeks ago,” says Elisabeth, 45, from Yuai, “but this is not enough, and we are also sharing with the people who are not registered for the food distribution. When there is no food, we eat the leaves on the trees.”   

The insecurity in the area presents challenges for aid organisations to reach people, but the current lack of assistance makes the need for aid even more urgent.

“This is happening in an area where there is limited assistance available, a very poor network of basic healthcare centres and where the humanitarian situation was already dire,” says Michael Keizer, MSF’s deputy head of mission in South Sudan. “Considering people’s living conditions and their limited access to water, we are very afraid that the situation will get worse. With the rainy season coming, providing humanitarian assistance will get even more complicated, but the needs of the people will only get higher.”

Read more about South Sudan: Ongoing conflict at root of nutrition crisis.

Find out about MSF's activities in South Sudan.