YUSUF BATIL CAMP, South Sudan, March 11 (UNHCR) – A month after she began treatment for hepatitis E, the yellow, jaundiced eyes of Hawa Hamid Ramadan are evidence of her battle with the debilitating disease, though she insists she is feeling better.
Her improvement, she says, is not the result of the medications she was provided by health workers in the Yusuf Batil refugee camp in South Sudan's Upper Nile state, but rather the curative properties of a traditional herbal remedy.
Hepatitis E is a liver disease that is transmitted mainly through drinking water that has become contaminated as a result of poor sanitation. In the South Sudan emergency, the disease was first detected in the Yusuf Batil camp in July 2012 and had reached its peak by November.
A second outbreak was discovered a month later. Nearly 64 per cent of more than 6,500 reported cases of the disease in Upper Nile have occurred at the refugee camp, including 94 deaths. The camp currently holds more than 37,500 refugees.
Ramadan's teenage son was the first member of the family to contract the virus. After he passed it on to his father, it was only a matter of time before Ramadan woke up one morning feeling listless and nauseous, her body aching from head to toe.
Like her son and husband before her, 40-year-old Ramadan sought medical attention at the camp's health centre. There is currently no effective treatment for hepatitis E and the illness is normally self-limiting. Prevention, through improved hygiene standards, is the most effective approach to addressing an outbreak.
When her nausea and body aches did not improve with the help of prescription drugs, Ramadan, like many other infected refugees, turned to traditional medicines. Her Ngassana tribe from Sudan's Blue Nile state have traditionally used so – a combination of herbs and extracts from the bitter tasting leaves of the neem tree – to treat "yellow eyes," which are caused by jaundice.
Ramadan's husband, Burula Fata Takona arrives at the family's home carrying the herbs he has spent hours searching for in the camp's periphery, digging up tubers and collecting leaves to brew the medicine for his wife. The tubers are pounded into paste and soaked in water while the leaves are steeped in boiling water for maximum effect.
The som, taken before breakfast, encourages vomiting which is believed to remove impurities from the body. The juice from the neem leaves is poured over cooked okra and eaten with sorghum, a staple food in South Sudan. During treatment, the recipients steer clear of oil, salt and meat.
"It works!" Burula exclaims. "Look at me now." Like his wife, he had been bedridden, but after taking the traditional medicines he claims that he is stronger and that his appetite has returned and the yellow tinge in his eyes has diminished.
"While we cannot stop people from using traditional medicines which they have relied on all their lives," says Martin Muita, a UNHCR public health officer. "We can and are providing continuous education, options and examples that demonstrate how, through frequent hand washing after toilet use and before food preparation, one can avoid infection and infecting others."
UNHCR has put in place an enhanced hepatitis E public education strategy, which includes awareness campaigns in all camps on the disease's transmission and the need for proper hand washing.
Latrine cleaning kits have been distributed while soap has been handed out to households, and hand washing facilities outside the latrines are supplied with soap every week. Camp cleaning days, when residents are responsible for cleaning their yards and disposing of refuse, have also been organized.
Community outreach workers and hygiene promoters call on traditional healers, birth attendants, sheiks and other leaders in the refugee camps to explain the need to go to the camps' clinics for proper medical care.
"Over time, we have gained the trust of traditional healers and have explained to them that what we are dealing with here is not malaria, which presents similar symptoms, but hepatitis," says Doctor Muita. "Through their leaders we strongly encourage refugees to take advantage of the free health services in the camp clinics as opposed to relying on alternative medicines to treat hepatitis E."
The construction and decommissioning of latrines is continuing in the camp, water is systematically monitored and tested, and new boreholes for the provision of safe water are being drilled.
By Pumla Rulashe in Maban County, South Sudan
Oumi and her husband were farmers in Sudan. Things were quiet for them – until suddenly soldiers were shooting. Artillery shells landed in the village. Planes dropped bombs from above.
Oumi didn’t stop to pack bags or prepare; she did what you or I or anyone would have done: She and her husband gathered their children and ran.
With no safe place to go, they walked for 3 months. Oumi gave birth to her fourth child on the way. Worn by stress, her husband died under a tree. Oumi still regrets not being able to bury him, but she had to continue on to ensure her children would not suffer the same fate.
“If we had not come here, we would have died," Oumi says.
Oumi and her family found safety at the Yusuf Batil refugee camp in South Sudan. People like you helped ensure UNHCR could provide care for families who have fled war and violence.
Some 180,000 refugees from Sudan need our help; the crisis is desperate, and I turn to you for a contribution.
Please make a generous year-end donation now to help refugees like Oumi and her family.
Thank you for your compassion.
It’s 8:30 at night and a group of refugees have just arrived in South Sudan’s Jamam camp from the border with Sudan. They are hungry and exhausted.
Thirty-one year-old Grace Aleng gets word of their arrival. Although she is preparing to sleep, she knows the needs of the new arrivals because she has experienced them herself. And, as a UNHCR protection officer, she also knows that food and water may not be available to them until the next day.
Aleng gets dressed, heads to the local market and uses her own money to buy something to eat for the newcomers. By 10, she has fed the group. When she sees them sitting before her, it is as if she is staring into a mirror. Like the majority of UNHCR staff here, Aleng was herself once a refugee.
“I have the capacity to help and I know where they have been,” she says. “So I have no other choice in my heart but to help.”
For Aleng and other former refugees, their memories of flight are the strongest source of motivation. They see their work neither as a humanitarian calling nor a career, but as an obligation that each day affirms their humanity. “There is a level of commitment from our South Sudanese staff who were themselves refugees that can only be described as extraordinary,” says Kaweh Hagi Negad, a relocation coordinator at Jamam. “They always go the extra mile.”
He knows the feeling. Hagi Negad and his family fled Iran in 1987 during the Iran-Iraq war. And while he believes that there is no comparison between his experience growing up in Sweden and that of other staff here who endured their refugee experience in some of the most difficult environments imaginable, he understands the sense of obligation.
“There is a common experience of breaking from roots, leaving family behind and finding yourself in a completely new environment,” Hagi Negad says. “You identify with people who have been forced to leave their homes because you know what it’s like.”
The urge to protect is second nature to Daniel Wuor, who spent 18 years in exile, first in Ethiopia and then in north-west Kenya’s Kakuma refugee camp. During a recent mission near the Sudan border, the associate protection officer found himself on the banks of a river speaking with a 22-year-old man who had just fled his home in Sudan’s Blue Nile state. The man was stuck on the South Sudan side because he could not swim.
“If he remained there, he would have been exposed,” Wuor recalls. “There are hyenas in this area. He could have been tempted to cross the river by himself. I was not going to just stand by. Saving each person is very important.”
Wuor, rushed into the water and swam to the other side. Minutes later, with the help of Nathan White, a UNHCR security officer and trained lifeguard, the man was taken to safety along a makeshift rope bridge that the team constructed.
“When I see someone who needs help, I understand that my experience as a refugee was not the only one,” the UNHCR staff member says. “I understand that we are many and we are not alone.”
It is an empathy that Jamam ambulance driver Ojulu Jodo knows well. During the exodus of 32,000 refugees from Blue Nile state across the South Sudan border, Jodo ferried the sick and injured to a UNHCR transit centre.
“You would see people arrive and they were sick with malaria. They had nothing,” said Jodo who lived in Ethiopia’s Pinyudo refugee camp between 1990 and 2006. “They would say, ‘Look at our children, they are dying.’”
For many of the former refugees working for UNHCR in Jamam, receiving large numbers of people from Sudan’s Blue Nile state brings back powerful memories.
Aleng remembers crossing a border to Uganda as an eight year-old in December 1993. She still has the scars caused by the tall sharp grass that cut her legs as she fled through the fields to escape war.
Christmas arrived a few days later, when they were in Uganda. Aleng remembers seeing a man buy clothing for his daughter. She turned to her father and asked for a dress – something he would do each week when they were in their village in what is now South Sudan’s Eastern Equatoria state.
When he looked at her with a tear in his eye and said he could not afford it, she first realized she had become a refugee.
UN High Commissioner for Refugees António Guterres warned today that the situation for refugees fleeing Sudan's Blue Nile and South Kordofan states had become critical, with more than 200,000 people displaced into neighboring South Sudan and Ethiopia and humanitarian efforts in South Sudan close to breaking point.
"The combination of difficult and dangerous conditions in South Sudan and the huge numbers of refugees arriving there mean our operations are severely stretched," Guterres said. "And people are still arriving every day, many of them malnourished, and including unaccompanied children in groups."
UNHCR field offices in Ethiopia and South Sudan say 211,700 refugees have so far arrived from Sudan's Blue Nile and South Kordofan states. Some 36,700 of these are in the Assosa region of Ethiopia.
But the major pressure of this influx is on South Sudan, with 62,000 people in Unity state and 113,000 in Upper Nile state – most in remote areas lacking even basic infrastructure. Children and teenagers account for 52% of the refugees in Assosa, 44% in Upper Nile State and 65% in Unity State.
In South Sudan, water supply for this population has become acutely problematic, even with a new rainy season having recently begun. Much of the Jammam camp in Upper Nile, for example, is in ankle-deep water, yet the amount of water available for drinking and sanitation is still far below the levels needed. Boreholes have been dug there and in other camps, but many refugees still receive only a third or less of the minimum daily clean water supply. This heightens the health risks.
"The complexity of the Sudan crisis sets it apart," Guterres said. "We are contending with a situation in which many newly arriving refugees are already dangerously malnourished; the threat from water-born disease is high; large refugee populations are in locations that are unambiguously dangerous; and flooded roads block access and the possibility of relocating people elsewhere – even where better sites can be found. More help is urgently needed."
UNHCR has appealed to the public to help by donating additional funds for the Sudan refugee crisis.
Thousands of people have fled Sudan's South Kordofan and Blue Nile states into neighbouring countries in the last month, putting pressure on existing supplies and services.
In western Ethiopia's Assosa region, nearly 2,000 Sudanese refugees have arrived from Blue Nile so far in May. The refugees cite night-time killings, abductions and the burning of their crops as reasons for fleeing. Many are arriving in Ethiopia with heavy luggage and livestock. They tell our staff that more people are on their way to an area already hosting nearly 35,000 mainly Sudanese refugees. UNHCR is making preparations for the possibility of a further influx.
In South Sudan's Unity state, Yida settlement has received more than 3,200 arrivals from the Nuba Mountains so far this month. That's an average of 550 refugees per day – nearly double the rate in April and six times that in March. The border settlement's population now stands at nearly 30,000 refugees.
UNHCR has doubled its presence in Yida and accelerated the registration of new arrivals. We continue to see increasing numbers of refugees arriving in a malnourished state due to food shortages in parts of South Kordofan. All new arrivals are immediately registered and provided with food assistance including high-energy biscuits where needed. Partner agencies such as MSF-France and Samaritan's Purse are treating malnourished children urgently and implementing therapeutic and supplemental feeding programs. The World Food Programme has sufficient full-rations of food for the entire camp population in Yida, including the new arrivals. It is also pre-positioning food stocks for the coming rainy season when road access to Yida will be cut off by flooding.
As the rainy season approaches, our staff have been distributing additional relief supplies such as plastic sheets and mosquito nets in the camp. New arrivals and vulnerable refugees such as unaccompanied children, the elderly and disabled continue to benefit from targeted distributions.
Although recent hostilities between South Sudan and Sudan did not directly affect refugee-hosting areas in Unity state, UNHCR remains deeply concerned for the refugees' security due to the proximity of Yida to the disputed border area of Jaw.. Preserving the civilian character of refugee locations remains a core priority in all refugee-hosting areas. We therefore continue to advocate for the refugees in Yida to move to other settlements at a safer distance from the border.
Meanwhile refugees from Sudan's Blue Nile state continue to cross the border into Upper Nile state, and are being relocated to safer areas further inland. This week UNHCR completed individual registration and verification of refugees in Doro and Jammam settlements. The presence of 70,000 refugees was confirmed.
In Jammam, aid agencies are stepping up efforts to increase the water supply and reduce the risk of water-borne diseases such as cholera. Our partners have been trucking and piping water to refugee locations and treating surface water where available.
To reduce demands on limited water sources, UNHCR this week started relocating the first of 15,000 refugees from Jammam to Doro I and II camps. We will also continue drilling efforts with partners to provide water in Jammam for the remaining refugees as well as local communities.
Efforts are underway to transport a much larger drilling rig than those already in place, to explore deeper water sources. Transporting such heavy duty equipment to this remote part of the country is a major logistical challenge.
In the meantime, medical and other humanitarian actors have drawn up contingency plans to respond to any eventual outbreak of disease. They have pre-positioned medical supplies and established treatment units.
In total, more than 100,000 Sudanese refugees have fled into South Sudan since the middle of last year. UNHCR has so far received 31 per cent of the US$145 million we need to care for the Sudanese refugees in South Sudan and Ethiopia. More contributions are urgently needed as we accelerate preparation for the camps before access is cut off by rains.
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