Introduction¹

On 15 December 2013, only two and a half years after the Republic of South Sudan had become an independent state, the long-simmering tensions between President Salva Kiir and his former vice-president, Riek Machar, erupted into armed clashes in the capital, Juba. War soon broke out. This article seeks to document and analyse violence affecting the provision of healthcare by Médecins Sans Frontières (MSF) and its intended beneficiaries in the early stage of the current civil war in South Sudan.² It focuses on the first few months of the war and on two areas of Unity state: Bentiu, the state capital, and the town of Leer.³ Between December 2013 and May 2014, these two locations successively came under attack and repeatedly changed hands between pro-government and rebel forces. Following a pattern replicated in many cities across Unity, Upper Nile and Jonglei states, offensives often triggered an early retreat by the military force in place, leaving, as Human Rights Watch put it, ‘civilians behind to face the brunt of attacks from forces bent on pillage and revenge’ (Human Rights Watch, 2014: 21). In Bentiu and Leer, violence associated with the dynamics of offensives extended to the hospitals run or supported by the Dutch section of MSF (MSF-Holland, hereafter MSF-H). What motivated these specific acts of violence? And what were the effects of these attacks on the provision of healthcare in the area?

Concerns expressed over the last decade by medical aid organisations and public health institutions regarding attacks on health facilities and personnel have generated a growing demand for multi-country or global quantitative studies on the issue. In contrast, efforts to produce substantiated accounts of incidents in specific contexts are still rare. Often methodologically wanting and more normative than analytical in their approach, as Fabrice Weissman has shown (Weissman, 2016), these quantitative studies offer little interpretation of violent incidents other than to say that they demonstrate a lack of respect for international humanitarian norms that require belligerents to protect and facilitate the provision of healthcare to the sick and wounded. They tend to reinforce the assumption, widely held among the aid community, that violence on health facilities and personnel is primarily, if not exclusively, motivated by belligerents’ intent to deprive their enemy and its associated population of access to healthcare (Rubenstein and Bittle, 2010; International Committee of the Red Cross, 2011). This article attempts to present a more complex picture and broaden understanding of the issue by providing a detailed narrative of episodes of violence affecting MSF-supported health structures, one that contextualises these violent incidents with regard for the dynamics of conflict in South Sudan as well as MSF’s operational decisions, not least the withdrawal of international teams from the areas under attack. The absence of expatriate witnesses from the most violent events in the situations reviewed here highlights the need to combine and contrast institutional and academic sources with direct testimonies from local MSF personnel and residents – voices that are rarely heard in security analyses. This attention to local experiences and interpretations of events offers greater insight not only into the circumstances and logics of violence but also into the concrete ways in which healthcare practices adapt in the face of attacks and how these may reveal and put to the test the reciprocal expectations binding international and local health practitioners in crisis situations.

Context

The Republic of South Sudan was proclaimed as a new, independent nation on 9 July 2011, following decades of civil war in Sudan and six years after the Sudanese government in Khartoum and the main rebel movement of South Sudan, the Sudan People’s Liberation Army/Movement (SPLA/M), signed the Comprehensive Peace Agreement (CPA). MSF had been involved in the Sudanese conflict since 1983. Most MSF sections had remained throughout the CPA process, and health activities were ongoing at the time of independence. In November 2012, MSF-H released a report entitled South Sudan’s Hidden Crisis, which recorded eighteen months of what it termed ‘intercommunal violence’ in the state of Jonglei (Médecins Sans Frontières, 2012). According to the report, the disarmament campaign carried out by the Sudanese government, though ‘aimed at bringing security and stability to Jonglei’, had led instead to widespread insecurity, localised displacement and abuses (ibid.: 1). The six health facilities run by MSF-H and MSF-Belgium in Jonglei had treated many wounded patients, most of them civilians, including women and children. Not only were civilians the prime targets of violence, the authors of the report asserted, but ‘healthcare itself’ had been ‘under attack’: in August 2011, only a few weeks after the independence ceremony, an MSF-run health facility in Pieri had been looted and burnt down; over the year that followed, armed groups had again ransacked, damaged or destroyed three more health structures supported by MSF (ibid.: 17). Although the report’s authors labelled these attacks a ‘disturbing new trend’, events in Jonglei were not interpreted as foreshadowing an extension of violence in South Sudan, and for MSF, as for most observers at the time, the civil war that broke out a year later largely came as a surprise. Significantly, while MSF-H’s health programmes in Jonglei were conceived as responding to the effects of localised violence on the population, its plans for projects in Unity state rested on the assumption of a stable environment in the years to come. In Bentiu, the capital of Unity state, MSF-H had ceased its nutritional activities in 2012–13 and invested instead in the treatment of tuberculosis and HIV patients in Bentiu State Hospital, both pathologies requiring long-term and sustained care. In Leer, where it had been independently running the town’s hospital since 2005, the organisation was planning a phased withdrawal and a possible handover of the facility in the next three to five years.⁴

That attacks on healthcare denounced by MSF in Jonglei could be interpreted as one such ‘bad thing’ meant, in de Waal’s words, to ‘signal seriousness in bargaining’ to the opposite side (Ibid.: 362).

Political rivalry at the top of the system between President Salva Kiir and Riek Machar entailed a similar show of force, which, after initial clashes in Juba, was demonstrated in Unity, Upper Nile and Jonglei states from December 2013 onward. Having fewer resources available, de Waal noted, Riek Machar, a member of the Nuer ethnic group, was more inclined than Salva Kiir to appeal to ethnic loyalty, and he mobilised a militia of Nuer youth, known as the ‘White Army’, alongside defecting forces making up the SPLA In Opposition (SPLA-IO). However, both sides soon proved ready to let loose grass-roots logics of predation and revenge to keep the conflict running while political bargaining continued, amid regional efforts to push for a peace settlement (ibid.: 365–7). Analysing the events in Juba in the immediate aftermath of the showdown between Kiir and Machar on 15 December 2013, Human Rights Watch pointed to the Presidential Guard’s – recruited among the President’s Dinka community – mass targeting of Nuer civilians, including public figures, for arrest and execution in the capital city as playing a crucial role in the rapid mobilisation of Nuer on the opposition’s side in Unity and Upper Nile states and in setting the tone for the cycle of violence in both states (Human Rights Watch, 2014: 23). Insecurity in Juba also forced MSF-H early on to adapt its logistics set up and the movement of its international teams. From December to January, the capital-based coordination team retreated to Lokichogio, in Kenya, through which supply lines and expatriate movements to and from South Sudan were organised for most of 2014.

Experiencing, Interpreting and Coping with Violence in Unity State

Located near strategic oil fields, Bentiu had seen an extension of the conflict only days after fighting broke out in Juba. On 21 December, after three days of fighting at the Unity and That Jat oil fields and inside the headquarters of the local SPLA Division, its Commander Major General, James Koang Chol, announced he had defected and deposed the Governor of Unity state, thus taking control of Bentiu and other cities in the area (Human Security Baseline Assessment for Sudan and South Sudan, 2014: 6). After partially evacuating its team on 20 December, MSF-H adapted its operations to the new context: the organisation deployed a new team to Bentiu State Hospital to support surgical activities managed by the hospital’s regular staff and the International Committee of the Red Cross (ICRC). It also set up a primary healthcare clinic inside the local Protection of Civilians (PoC) site, run and secured by the United Nations Mission in South Sudan (UNMISS), where about 8,000 people had sought shelter amid tensions and fear between the different communities present.

MSF was also to learn that between its departure and the capture of the town by government forces, its office and compounds across Bentiu had been looted. It was unclear whether the looting had been perpetrated by members of the retreating opposition forces or the first government troops reaching town, or both. In any case, massive looting of NGO properties was to be as much a feature of the South Sudanese civil war as violence and predation in health facilities.⁵

On the road to Leer, the MSF teams passed thousands of civilians leaving Bentiu on foot, most of them also heading toward Leer and worried that the exhausting journey could be fatal. Hence, for the seven days that followed, MSF cars went back and forth to distribute high-energy food to an estimated 10–15,000 people on the road and carry to Leer those needing medical attention, such as the wounded, disabled, pregnant women and people with snake bites, on their way back. High-energy food or biscuits, typically used for the treatment of child malnutrition, were valued by soldiers as well. A South Sudanese MSF staff member recounted being stopped by soldiers on the road while driving an MSF car without expatriates. ‘Give us some biscuits and what you have,’ he remembered being told. ‘We gave them to save our lives.’ The incident is indicative of the degree of poverty of the heterogeneous armed forces engaged in the civil war, a fact that made even the nutrition component of MSF programmes, let alone more expensive medical and logistics material, a prized resource for self-sustenance as much as an object of predation.

The relocation of the Bentiu team and its support to the team running the Leer hospital, now one of the few functional medical facilities in Unity state, was short-lived. Leer was the home town of opposition leader Riek Machar and, as such, a highly symbolic target for government forces fighting to retake control of Unity state. Bentiu had been taken on 10 January, and MSF-H anticipated that Leer also would have to be evacuated, and options were being discussed, such as the deployment of a reduced team, including expatriates, in the bush to continue to provide care to the population. Yet as government forces approached Leer, security inside the town deteriorated drastically, with armed opposition soldiers getting increasingly out of control. On 21 January, some of them attacked the MSF compound to steal cars, probably preparing their own escape. As they were driving off with one of them, they shot at the MSF emergency coordinator and an ICRC delegate. Neither was harmed, but the incident convinced the organisation not to keep international staff in the area. The same day, all staff that were not Leer residents were evacuated by plane to Lokichogio in Kenya.

Although most of the town residents and displaced were leaving Leer as well, MSF’s 240 local staff stayed and continued to operate the hospital. Looting of the facility reportedly began in the last days when the staff were present and working, involving civilians and combatants alike in the panic and confusion created by the government’s offensive, including shelling the town. As one local witness recalled: ‘Light things like mats, medicines, items which can easily be picked up were taken by people from the community. Heavy machines were taken by the soldiers, both the rebels and the government soldiers and those who had joined the government like the Darfuri [members of the Justice and Equality Movement (JEM), a Sudanese rebel group whose forces allegedly crossed the border and fought on the side of the South Sudanese government].’ On 28 January, with government troops about to enter Leer, the 240 MSF staff fled the town and joined the population in the bush. Using the remaining MSF cars, 30 hospital staff carried the patients who were too ill to flee. In a press release expressing concern for the fate of its local colleagues and patients, MSF-H indicated that by 31 January the hospital in Leer was empty (Médecins Sans Frontières, 2014b).

Several expeditions were organised, with groups taking turns to seek new drugs in Mayendit and further south in the town of Nyal, each time running the risk of attracting renewed attacks.

We don’t walk in daytime. When we go to Nyal and to Mayendit to collect the drugs, we walk at night. When we come back, the soldiers, they probably know we have brought back some drugs for the community and they come every morning around 10 or 11 to attack us and they push us into the bush. Fortunately, they can’t cross the river with their vehicle, so they just shoot randomly in our direction.

Despite the supply of new drugs, the MSF staff witnessed the effects of hunger on the people hidden in the bush.

There were many hungry people and some children died because of the lack of food. People had run away from their villages and the soldiers, they went and collected all the sorghum from the villages and brought it to Leer. There was nothing at all; people survived eating water lilies for three months.

While keeping contact with local colleagues, the field coordinator succeeded in making a flash visit to Leer on 14 February. She discovered that the hospital had been fully burned and ransacked – that it had not been spared in the town’s destruction. The South Sudanese government had in fact authorised the visit and requested MSF to resume activities in Leer, now under its control. The town was still largely empty of its population, however, and MSF chose instead to try and reach the displaced by setting up two nutrition programmes in Nyal and Mayendit in March. It was through this set-up that the Leer staff hidden in the bush were able to receive medical supplies. Only after government forces left the area in April, did MSF decide to follow the civilian population and its local staff, who were now returning to Leer. The MSF team started an emergency nutrition programme there in May, treating more children in two months than it had over the previous year, and set out to clean up the devastated hospital amid a continuous flow of patients. According to the MSF-H’s head of mission at the time, the organisation’s return to Leer led government officials to openly question MSF’s impartiality in the conflict: from the government’s perspective, MSF-H had resumed activities only when the town was de facto back in the opposition’s hands.⁶

In turn, there seemed to be little doubt in Leer that the destruction of the town and the hospital had been intended by the government as a political message. ‘This is what [President Salva] Kiir means: he means that the people of Dr Riek [Machar] should die of disease, of hunger, of rain, that’s why he burns the houses, he destroys the MSF hospital, he destroys the market,’ a community leader insisted. For his part, an MSF staff member concluded that the government forces ‘thought that MSF is here because Riek Machar is here’. According to another, ‘they thought that if MSF leaves when they take the town, it means MSF is now treating the rebels and the Nuer [Riek Machar’s ethnic group]’. While paying tribute to the courage and endurance of his local colleagues who had followed and supported the population in hiding over that period, the MSF head of mission reflected that ‘they are MSF staff, all right, but they are above all South Sudanese Nuer with an incredible physical stamina to withstand such conditions and they are also strongly committed politically, which for MSF was at times a bit complicated’.⁷ The comment alluded to the tension between MSF's expectaction of neutrality of its local staff and the acknowledgement of their embeddedness in their social and political context.

Another staff member suggested that this expectation was shared by the local population, recalling: ‘When I was in the bush, people from the community even asked me “but you work for MSF, why are you with us?” … I thought MSF was supposed to look after us. But, they left us.’ Others had a more nuanced view, acknowledging that, unlike organisations with only a few local employees, MSF could not be expected to evacuate its 240 staff and their families. Still, the remarks pointed to differing views on the responsibility and capacity of an international NGO to protect its staff and, more widely, the local community, amid fears of new episodes of violence.

For months after MSF returned to Leer, its team operated with a donkey cart as its sole means of transportation, and the hospital was only partly functional, notably lacking surgical capacity. The enduring instability and the risk of a new attack on the town made the organisation hesitant about reinvesting in a fully functional hospital and bringing new cars to the project. These measures of caution generated some frustration and anxiety among the local staff and population. As one community leader put it, ‘MSF does not come back fully … because you think the fighting will be back again too. If MSF is not going to rebuild [the hospital] properly, then it is not a good sign.’

Indeed, surgical care available to wounded combatants had been considered a trump card to obtain guarantees of respect and protection from the opposition’s leadership, whose soldiers, according to MSF-H’s head of mission’s analysis, benefited more than government troops from MSF’s services due to the projects’ locations and the rebels’ lack of alternative. The destruction of Leer had brought home the related risk that MSF facilities could be targeted by government forces for the same reason, with the effect of depriving civilians of access to care. In turn, would the lack of direct benefits to rebel combatants from MSF’s presence weaken the organisation’s capacity to engage with opposition leaders?

This capacity was tested from July to October 2014, when the SPLA-IO carried out a mass forced-recruitment drive across Unity state that proved especially heavy-handed in Leer. Many staff, medical and non-medical alike, were detained as a result. Rebel soldiers seeking recruits were allegedly more concerned with sharing the war effort than with preserving local medical capacity. ‘They feel bad and think “Why us alone? Why are these people staying behind and don’t go to war like us?”,’ a staff member remarked. By making daily requests based on name lists to the opposition’s Commissioner, the MSF field coordinator managed to secure the release of all staff members before they were sent to training camps. In this instance, then, MSF’s expatriate presence did contribute to the protection of the local staff – but of the staff alone.

The resumption of activities in Leer had largely been the by-product of events taking place in Bentiu in mid-April, when the SPLA-IO’s renewed offensive had forced government troops controlling Leer to move back to the state capital as reinforcements. Since the evacuation of its team in January, MSF-H had made several short visits to Bentiu to assess the possibilities of resuming its support to the hospital there. Though many of its staff had not returned, the hospital itself had been untouched during the fighting and, unlike MSF’s compounds and storage, had been relatively spared from looting. As a result, many city residents and some medical staff often stayed in the hospital, feeling safer there than at home (Médecins Sans Frontières, 2014c: 17). MSF’s support to the hospital resumed in February, but the new expatriate team sent to Bentiu would be stationed in the UNMISS base rather than in town. This was a security decision the agency’s coordination in Juba had made only reluctantly, as the UN mission was being criticised by both belligerents for its alleged partiality in the conflict. The opposition pointed to an UNMISS political mandate that gave undue legitimacy to Salva Kiir’s government, whereas the government suspected the UNMISS PoC sites of sheltering rebels in areas it controlled. Both sides thus objected to MSF working in PoC sites. It would, however, remain the only feasible option to keep an MSF team in Bentiu in the years that followed. The April attack on the city, the violence that took place inside the hospital, the dramatic rise of the population on UNMISS grounds and the consequence in terms of living conditions for the displaced would in effect provide strong justifications for MSF to focus its medical assistance inside the PoC site.

Another man recalled: ‘I heard that they would kill people in the houses. That is what I heard. So, I went to the hospital.’ Between the evening of 14 April and the early morning of 15 April, when fighting began inside the city, hundreds of people gathered inside the facility, according to MSF local medical staff. Some staff members identified Darfuri’ – some of them traders from the market, but the majority belonging to the JEM, the Sudanese armed group allied with government forces. According to local accounts, as Bentiu was about to be recaptured by the opposition, JEM soldiers, taking off their uniforms and hiding their weapons, sought protection inside the hospital by mixing with civilians. The violence South Sudanese rebels exercised in Bentiu State Hospital seems to have been largely meant to single out military enemies, though unarmed, who were hoping to benefit from the sanctuary the opposition had itself designated for civilians. Did the SPLA-IO forces retaliate against the abuse by military elements of the protection they had granted to the hospital or, rather, was their message to civilians a premeditated attempt to turn the hospital into a trap for their adversaries? Whatever the answer, in invading the hospital grounds, one could argue, opposition soldiers would be implementing a triage of their own.

Yet, two weeks previously, President Salva Kiir had appointed Major General Matthew Puljang, the Nuer leader of an independent armed group in Mayom county, as Commander of SPLA 4th Division in Unity state, to replace Major General James Koang Chol, who had defected to the opposition in December. Analysts saw the move as serving to split the Nuer community of Mayom between government and rebel supporters (Human Security Baseline Assessment for Sudan and South Sudan, 2014: 16–17). Nuer from Mayom county were thus probably targeted by rebels as potential traitors, like Darfuri traders were for being suspected JEM elements. That opposition soldiers entering Bentiu would have had the capacity to selectively target individuals ‘based on their identities and loyalties’, as the MSF-H programme manager for South Sudan would conclude (Médecins Sans Frontières, 2014d), suggests that people seeking shelter in the hospital, possibly including staff members, may have been forced – or, as troubling as it may sound, volunteered – to take part in the identification.

UNMISS reported that on 16 April it evacuated 400 people from the hospital, and that within the next few days around 150 bodies were collected from the hospital and Kalibalik area, adding to the 200 bodies estimated to have been removed from the mosque on 15 April. By 22 April, over 22,500 civilians were seeking protection in the PoC site. That number, well beyond the site’s capacity, only grew in the following months. It reached over 40,000 after government forces reclaimed Bentiu in early May. The SPLA’s control of the city was accompanied by constant harassment and abuse of civilians – by then essentially Nuer – who ventured outside the UNMISS base. When an MSF team went to assess the possibility of working again in the hospital, it found it was being looted by soldiers. The government was largely dismissive of MSF’s claim, blaming the looting, against all evidence, on rebel elements. Insecurity in the city, together with the devastating effects of overcrowding on people’s health conditions, made medical and sanitary intervention in the UNMISS base the focus of MSF-H’s intervention through to almost the end of 2014. In June, up to three children a day were dying in the PoC site, which was being turned into squalid swamps with the advent of the rainy season. Only after the summer could sanitary conditions be sufficiently improved. The team also had to contend with violence in the PoC site. Harsh living conditions combined with continued fighting and harassment around the base meant tensions were rife, erupting in episodes of violence led by mobilised armed youth. In one incident in August, amid a new failed offensive by the opposition, MSF staff were attacked and beaten by a group of 50 youths as a wounded SPLA soldier was brought to them for surgical care inside the base. UNMISS soldiers deterred the assailants, but in the months afterward lingering suspicions of MSF ‘helping soldiers’ still occasioned repeated threats that had to be defused with community leaders.

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Discussion

The events in Bentiu and Leer as analysed in this article challenge the commonly held assumption that depriving an enemy and the civilian population associated with it of access to healthcare is the primary, if not the sole, motivation behind attacks on or in health facilities. To be sure, this is how the destruction of the MSF-run hospital in Leer by the government forces of President Salva Kiir was generally interpreted by local staff and residents. This line of interpretation tends, however, to downplay the fact that, following the evacuation of expatriate teams, the health structure’s resources had already been largely appropriated by residents and rebels preparing to flee the town before government troops seized and destroyed the facility, along with the local market and other buildings. Never acknowledging the responsibility of the SPLA in the destruction, the government then authorised MSF to assess the situation in town and requested that the organisation restart its health activities, presumably as a sign of normalisation that could convince residents of the legitimacy of the government’s control over Leer. Obviously, the government troops’ harassment of the local population displaced in the nearby swamps was sending the opposite message. Likewise, when the SPLA-IO regained control of the area, grass-roots rebel recruiters were following a different logic in seizing MSF medical staff from that of the opposition’s Commissioner, who released them on the MSF project coordinator’s request.

The work of Stathis Kalyvas may be a useful reference here. In The Logic of Violence in Civil War, Kalyvas emphasises that ‘violence is never a simple reflection of the optimal strategy of its users’ (Kalyvas, 2006: 388): the joint product of interactions between rival political elites, and between these elites and local groups, down to individuals with their own interests, violence defies the maximisation logics of any given set of actors. Medical aid practitioners must be aware of these dynamics when making sense of – and trying to anticipate – violent incidents in health facilities. Kalyvas’s analytical framework also rests on a distinction between indiscriminate violence, a costly strategy pursued because of lack of control and local information, which risks alienating the civilian population further, and selective violence, made possible when political and military actors can obtain information from ‘individual civilians trying to avoid the worst – but also grabbing what opportunities their predicament affords them’ (ibid.: 388–9). This framework seems particularly relevant for contrasting the instances of violence analysed in this article: the thorough destruction of Leer by pro-government forces – an indiscriminate violence in which the destruction of the hospital was just a part – reflected the lack of prior influence and control these forces could rely on in the home town of the opposition’s leader. By contrast, the SPLA-IO could afford to exercise selective violence in Bentiu. In this process, Bentiu State Hospital was not targeted for its provision of healthcare but for the convenient space it represented for the identification and killing of presumed ‘traitors’. That places of healthcare, like other institutions deemed sanctuaries, such as mosques and churches, have the potential to facilitate selective violence in conflict is a reality that medical humanitarian actors still seem reluctant to acknowledge. Such a phenomenon, observable in very different conflict settings, has led Adia Benton and Sayed Atshan to wonder ‘if privileging health care sites is even a laudable goal, when the space of the clinic can operate as an extension of the violence enacted in a wider frame’ (Benton and Atshan, 2016: 155). Hence the need to better document, as this article has sought to do, the ways in which forms of care may still be delivered when a hospital comes under attack and international medical support must find its way from a distance.