Assessment in Cuiebet

This assessment was conducted by our Emergency Response Team (ERT) in July, but I’m just getting around to posting. I guess ‘better late, than never’ applies in this instance.

As the adage goes, admitting there is a problem is the first step in solving it. But for emergency response, we amend the adage slightly to become,‘identifying a problem is the first step in solving it.’ That was our goal as our team set out for Cuiebet County to assess the emergency situation in the area.

We had heard reports that due to inter-communal violence and cattle raiding, a large number of people had been displaced from their villages. Displacement is one of the triggers that makes our ERT jump into action. When a displacement occurs, people are forced to flee their homes and leave everything behind. They seek protection in an unfamiliar community, where they may have nothing – not even a place to sleep. Sometimes the displacements a short, but more often people are displaced, and therefore vulnerable, for long periods of time. We responded to the area to see what the situation was and to determine if there were ways that Medair could help.

We flew into Rumbek and supposedly Cuiebet is just a short drive away down the main road. Cuiebet is located in central South Sudan in the former Lakes State. It didn’t take long to understand the state’s namesake because it seemed that all of the lakes in question were in the road between Rumbek and Cuiebet. This drive would’ve taken about 2 hours in the dry season, but now took nearly 4. We were among the fortunate ones though, because we made it to our destination. Many of the other cars on the road got stuck in the mud and were delayed hours, if not days, until they could be freed. This part of the country floods when the rains begin. The dry, flat ground from January is replaced by massive swamps. The sandy riverbeds quickly fill (and sometimes overflow) with water. Considering these facts, I shouldn’t have been so surprised to hear, in our first meeting on the ground, that many of the areas we wanted to reach were “inaccessible.’’

Fortunately we were staying with the German branch of Veterinaires Sans Frontieres. They had been working on livelihood programs in Cuiebet for quite a few years. They gave us directions, and advised that if we got a few days in a row without rain, then it may be dry enough for us to make it to the farthest locations. They also recommended bringing a shovel… just in case.

There were two locations we knew we wanted to reach, but also knew would be difficult to access; TiapTiap and Pagor. We spent our first few days visiting the nearest health facilities, and doing focus group discussions in the community to assess needs. It was after one of these focus groups that I was offered the opportunity to become the 7^th wife of a village elder. It would have been an elaborate deal involving 1500 cows for my dad and 12 children for me. It didn’t work out.

Another day, I had the opportunity to have a focus group discussion with the traditional birth attendants, TBAs. It was a group of six TBAs and intended to give them an opportunity to discuss the births in the area, maternal and neonatal deaths, emergency procedures, and what challenges they face. Most times, these women have not had any professional training. They've handed down their craft from woman to woman, usually through story telling and apprenticeship. People come to them night and day, and the TBAs will walk hours through mud, and swamps, and bush to help the mothers deliver. They are generally volunteers, but may receive small gifts for their help. They are extremely respected and trusted in the communities. As I sat across from them, I was struck by all the things they have witnessed; all the new lives they’ve brought into the world, and sadly all the loss they’ve encountered. It was quite a privilege to discuss with them. In many developing nations, healthcare is trying to shift away from use of TBAs to having a skilled healthcare worker performing the deliveries. But in most areas of South Sudan, TBAs are the only option for women. When it came time ask them what they need, they had just simple requests- raincoats, gumboots, and flashlights. They simply wanted to be safe while they continued to reach women in need, no matter the weather.

Finally, we had a couple of days with only a little bit of rain, so we took our chance and set out for TiapTiap. The going was slower that expected because there was still a fair bit of water, and the road we needed was usually pedestrian and ungulate (cow) traffic only. The day we were trying to drive it, was also the day one of the area cattle camps was breaking up. The cattle camps are an interesting aspect of South Sudanese culture, usually existing far away from any town or infrastructure. They are often in low lying areas that still have water in the dry season. Cattle are an integral part of life and cultural traditions for many of the tribes of South Sudan. When the seasons shift, and the rivers and swamps dry, people will pack their belongings and their families, and walk with their herd to the cattle camp. They will remain there until the next rainy season, then will return to their homes to plant gardens.

As this was the beginning of the rainy season, many cattle camps across the country were dividing and returning to their own communities. It just so happened that the path to get to TiapTiap was along the same road as one cattle camp. For much of the drive we were moving head-long into thousands of cattle. They were being herded by armed men and boys, while the women followed with the goats, sleeping mats, and calabashes of fermented cows milk. Almost anytime you see cows, you will also see the armed people trying to protect them. Cattle are often associate with violent crime in South Sudan and are considered very valuable. As we drove, the driver was particularly careful to avoid brushing any of the animals, so our movement was very slow.

When we finally reached the facility, we found crowds of people around a small mud building. I learned that there was no health facility here, so the community made it themselves. The health workers had only received on the job training, and had supplies delivered every 3 months- though they usually ran out in 2. We spent a few hours talking to patients, interviewing the health workers, and taking inventory of the supplies. It was humbling. These workers were doing their best, with what they had available. And now, to add to the pressure, their community had now just grown with all the displaced people seeking refuge. Many were sleeping under trees, even in the rain.

All of the facilities we reached we heard the same stories. Too many patients, not enough medication, no mosquito nets, no clean delivery kits for pregnant mothers. The most common request we got from the staff was for more training so they could provide better services. Then there were the other things, no chairs so everyone has to sit on the ground, no room for expectant mothers to have privacy for their consultations or delivery. In one location, the clinic was so busy 24 hours a day, that the staff had taken to sleeping in the same ward as the patients so they would be there if there was an emergency. There were other NGOs working very diligently in the area, but the need is simply greater than the resources.

Despite the very drastic needs we saw in these communities, these conditions are still far too common across South Sudan. So common in fact, that our assessment concluded that the area did not meet the triggers for an ERT health response. Even though the health facilities were small, they were functioning, which is more than can be said about other places. It was a difficult realization for me. Even with huge gaps, our resources were more urgently needed elsewhere. But because so many of the facilities had requested training, we planned a small response all the same to provide training to the health staff and TBAs. I was also relieved to know that other NGOs were working to improve services in the area.