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Maar, South Sudan - The Cause We Support

Bouncing and sliding along a muddy road in the heart of South Sudan, our site survey team sat cramped in the back of an old white Land Cruiser along two bench rows that faced each other. Dr. Linda Morgan, a retired Shands Hospital OBGYN Oncologist, shifted in her seat and held on to the bench to avoid falling over as our driver expertly navigated the deep ditches formed by trucks that had previously gotten stuck making this trip. We passed many such trucks stopped on the side of the road attempting to dig their way out of the mud that had been created from just 30 minutes of rain that passed through earlier in the afternoon. Dr. Jacob Atem spoke with our driver in Dinka as I glanced occasionally into the trees for any signs of movement, aware that this road was no stranger to armed assaults from youths passing through in search of cattle and human capital. In fact, a kid had been shot in the arm while walking alone just 2 days prior not far from where we were. After a rain like this such an encounter was less likely, but with dusk approaching we were among the many locals who did not wish to be on that road.  As we drove on, we saw a motorcycle (bodaboda, as it is popularly known) loaded down with three passengers, one of which quite visibly pregnant. The driver attempted to avoid a deep trench which led to all of them tumbling into the ditch on the opposite side of the road. Luckily they were uninjured, but we gathered the two women from the back of the boda and loaded them into our van to share our safer ride up to Panyigoor. They smiled as they stepped into the vehicle and sheepishly awaited their opportunity to depart upon arrival just south of our destination. When we arrived, our reservation at one Non-Government Orgnization’s (NGO) compound had been cancelled for no reason at all by the manager. Thankfully, we were able to secure a room at the CARE compound to rest up for our flight back into Juba as we prepared to head home from our survey. 


We were in rural South Sudan, and this was just one hour’s experience within the brief couple of weeks we spent in the country. For those who call South Sudan home, however, it is their everyday life. For the people that the Southern Sudan Healthcare Organization (SSHCO) serve, this experience was the status quo, and by all accounts, a very uneventful sliver of time. 

 

Since the 1950’s, South Sudan has been in a near-constant state of unrest. With two prolonged civil wars against Sudan, each lasting more than a decade, the nation gained Independence in 2011. However, internal conflict erupted again in 2013, consequently this occurred in the middle of a previous Maar site survey that saw SSHCO’s CEO Dr. Jacob Atem trapped and greatly endangered. This renewed conflict has died down a bit since then, but it has continued to plague the nation as tribal divisions and dark histories continue to haunt the progression of development in the region. 

Located inland in Eastern Africa, South Sudan has been in a near-constant state of instability since the 1950’s. Declared independent from Sudan in July of 2011, South Sudan is the world’s newest nation. During our visit, a long-awaited comprehensive government formation was initiated, delivering hope to many, while some remain skeptical of true progress. The capitol, Juba, is located southwest of Ethiopia’s capitol city, Addis Ababa, which is where our team connected through with Ethiopian Airlines. 


From March 6th to March 17th, our team traveled to conduct a site survey of SSHCO's clinic in Maar, Twic East County, Jonglei State, South Sudan. Our aim was threefold:  to deliver critical medical supplies, shoes and hospital beds; to assess the condition of the clinic; and to identify new opportunities for sustainable development while solidifying key local partnerships. Though the trip had to be cut in half to ensure the team’s safe return back to the USA in light of the COVID-19 pandemic in March, the mission was an overwhelming success.

Pictured: SSHCO’s Site Survey 2020 team. From left to right, COO Chase Bleke, Dr. Linda Morgan, CEO Dr. Jacob Atem, and our driver Atem Garang. This photo was taken upon our arrival in Panyigoor after our successful visit to Maar, the night before we flew back to Juba, South Sudan. 


The site survey consisted of 4 distinct phases, which are listed below:

Phase I: Logistics & Setup

Phase II: Maar

Phase III: Panyigoor

Phase IV: Juba


Phase I: Logistics & Setup

In order to complete this phase, the team had to coordinate the delivery of 300lbs of medicine and health supplies for the clinic that accompanied all three American-based team members in 6 separate 50lb bags. These supplies came courtesy of SSHCO supporter Dan Warner and team member Dr. Linda Morgan. Additionally, a 3-weeks supply of food and water was purchased in Juba the night prior to departure for the clinic in Maar. Lastly, all of the hospital beds purchased as part of our January fundraising campaign were loaded into two separate trucks along with the food and water to make the trip to Maar from Juba overland. The team flew along with the medicines in a discounted Mission Aviation Fellowship (MAF) chartered flight due to security concerns.

Taken from my window seat on final approach at the Panyigoor airstrip, this photo depicts the road looking South toward Maar. This is the road we traveled, and the road through which many youths traveled northbound with cattle while we were there. Maar is about 1 hours drive during the dry season to Panyigoor, which has the nearest airfield to the clinic currently. The southern drive to Bor is roughly 4 hours during the dry season. To Juba, it takes an entire day. Speeds on the roads max out around 25mph at best due to the hard dirt and deep crevasses created by trucks attempting to make passage after a rain. Passing by these roads in the rainy season is impossible due to the mud. Even during the dry season they are tough, as evidenced by the fact that our country director, Peter, took a nasty crash in transit back to Bor Town on a motorcycle after driving over one of the deep divots. Thankfully he only sustained minor injuries. 

Upon arrival in Panyigoor, sporadic hails of gunfire from passing youths who were herding cattle northward turned a few heads. The gunfire was used to herd the cattle, but sometimes was used for celebration after the sale or purchase of a cattle. Both uses of ammunition were irritants for locals who feared armed incursions and kidnappings from external parties and often struggled to interpret the cause of the gunfire. The team was greeted at the airstrip by our car and our security, and after a short bumpy drive to Maar, we were warmly welcomed by local chiefs and community leaders and got settled in. While in Maar, the trend of skyward AK-47 shots continued, but at a much lessened pace.

The “Triangle of Death” is the name for the region depicted on this map. It is so named for the activities that occur between the Nuer, Dinka, and Murlei tribes with regards to cattle rustling (among other things). This subject is highly contentious and is not one that SSHCO has any official position on. It is included here only as a background information with respect to the impact it has on the delivery of health services in the region. 

Phase II: Maar

Aerial view shot of Maar on our flight in with MAF, who has been flying in South Sudan since 1950. We landed about an hours drive up the road from the clinic at the dirt airstrip in Panyigoor where we hired a car to drive us south to Maar. To the west, you can see a clear line dividing Maar from the swamps (tochlands), this is the dike that is used to protect the village from floods during the rainy season. Each family is responsible for a portion of the dike, and if it breaks they are expected to repair it, no matter what time of day or night this occurs. If they require assistance from other families, they are expected to slaughter a cow for a meal for all parties involved in the repairs after the affair is finished.

In Maar, we worked tirelessly with late-evening debriefs due to a constricted timeline. With temperatures hovering around 100 degrees Fahrenheit, we slept at night outside on mattresses draped with mosquito nets and ate family-style meals consisting of grains and meat (gazelle, chicken, and beef). During the days, we met with community leaders, toured the surrounding area, delivered supplies, held focus groups and training sessions, and implemented new techniques and procedures at the clinic. 

Upon arrival in Maar, the team settles under the shade of a tree to get acquainted with local leadership.

Dr. Linda Morgan’s qualification as an OBGYN was immensely helpful as she instructed local traditional birth attendants (TBA’s) and midwives on procedures that they with hitherto unfamiliar with pertaining to preventing postpartum hemorrhaging - procedures that will directly save the lives of many women in the area. She identified equipment and procedural shortcomings with simple cost-effective solutions while implementing new examination procedures with the clinical officer, Alaak, whom she spent most of her time with. Alaak expressed a constant thirst for knowledge, and both he and Linda wished for much more time together to continue their work. Dr. Morgan’s most poignant qualification, however, turned out to be one over which she has no control, but that is so rare for a person in her position in Maar. Her connection, as a female, to the women of the village was incredible. She held a focus group that yielded deep insight into the inner workings of life in the community and the issues that women face in relation to maternal and child health that, due to cultural factors, no male could have hoped to discuss with them. She even uncovered a list of 30 local women who got their names registered to receive strategic planning guidance and partnerships for entrepreneurial enterprises that they had plans for. With her combination of over 40 years of practiced OBGYN experience, ability to relate to her core feminine audience, and general good will and charisma, Dr. Morgan was able to connect in a very short time on an immense scale with the community, opening up doors of friendship and development for years to come while directly increasing the survivability of expectant mothers in the region. 

Dr. Linda Morgan, who volunteered her time and her funds for critical medications and supplies for the clinic, is shown here explaining a technique for the mitigation of postpartum hemorrhaging to the clinic’s resident traditional birth attendant and head nurse as Dr. Jacob Atem looks on. 

As for myself, I spent my time identifying possible entrepreneurial activities and participants, barriers to entry, and local resources. Additionally, I worked closely with SSHCO's Maar Director Yai Atem to develop a reporting program for clinical patient data and pharmacy inventory tracking that will help SSHCO stay ahead of the curve on medical supply shipments and better track health trends in the clinic for more cost-effective and efficient programmatic solutions. Finally, routine communications and reporting processes were solidified with the clinical leadership that will facilitate increased capabilities moving forward.


Dr. Jacob Atem’s time spent in Maar consisted largely of meetings with the community and observation of clinical operations. His work in massaging connections with local leadership was incredibly time-intensive but critical to the continued success of the citizens and Maar and SSHCO’s mission.

 

Thon Makuach, a platoon commander in the local police, served as our personal security guard and accompanied us from Panyigoor and walked with us to and from the clinic every day.

Overall, thanks to the support of Bidaya's customers and SSHCO donors, we were able to deliver the medical supplies, the hospital beds, and the shoes (donated by Shoes To The World) in the midst of all of the community engagements, training and focus group sessions. 

We were able to ship 300lbs of prescription drugs and supplies for the clinic. Pictured here are the supplies we acquired from Map International with the help of supporter Dan Warner and the supplies that Dr. Linda Morgan donated. 

Dr. Jacob Atem looks on as the team unloads the packaged hospital beds for the clinic.



Pictured here, the first group of pre-registered children to receive their shoes, courtesy of our partner STTW.ORG. In total, 500 children who routinely walked many miles per day in 100 degree heat without viable shoes received a pair on this day. 

Phase III: Panyigoor


After the work in Maar was complete, the team headed north back to Panyigoor to catch a flight the next morning into Juba. While in Panyigoor, we made visits to the Tear Fund compound and to Panyigoor hospital. 

After landing, locals in Panyigoor help our pilot manually turn around his aircraft to prepare for loading and takeoff. 

At the Tear Fund compound, we met up with the Tear Fund Twic East county leadership who, among other projects, managed the team that operated out of the clinic in Maar. We met this team in Maar during our walk-through on the first day and were overwhelmingly impressed with their professionalism and their mission. Stacked into a tiny unvented room, this dedicated team educated, assessed, and delivered life-saving nutritional supplements to pregnant and nursing mothers and children from infancy to the age of 5. Their metric for differentiating which nutritional programs to implement for a given child of a given gender and age was set into motion with the aid of a universally recognized rudimentary tool: an armband labeled with a green, yellow, and red zone that would be applied to the child’s arm to ascertain its circumference. Operating in tandem with our clinic’s treatments and curative consultations, this small team continues to provide foundational life-giving assistance to the region. Our meeting with their leadership in Panyigoor served to shore up our partnership and collaboration for the future, and we are excited for what we can accomplish together in the region. 

Panyigoor from the ground level. A man sets outside his meat shop after an afternoon rain in the heart of Panyigoor. To the right you can can see the protypical motocycle that is commonly used for transportation by those who can afford to rent or own. After a light right, the roads were soft and the air cool.

Panyigoor from the air.  Pictured are networks of tukul huts and trees. Constructed of the dirt and sometimes reinforced with wood (much like rebar in concrete), these huts contain thatched rooves of sticks from the local trees splayed out in a circular array. This roof extends beyond the base in order to prevent rain from coming into the open air vents that surround the hut. The green trees pictured serve as communal meeting spots, as they are the best sources of consistent shade from the sun in heat that steadily swells in excess of 100 degrees Fahrenheit. 

While visiting Panyigoor hospital - which truth be told was little more than a collection of cinderblock hovels with some beds, staff and a couple trained doctors - we toured the spaces and forged relationships with the local leadership. In doing so, we walked through the ward that housed dozens of patients in a collection of rooms totalling less than 400 sq ft in all. 


The Maternity compartment of Panyigoor’s ward.

One of the patients was a youth who had been shot in the arm 2 days prior by cattle raiders. Tuberculosis was a major concern in these conditions, but we were advised that they lacked the materials to properly diagnose the condition, and relied on symptomatic diagnosis. Furthermore, the nearest treatment capabilities lay in Juba’s hospital, which required a flight that the overwhelming majority of citizens could ill afford. 


Phase IV: Juba


After a bit of a sketchy ride with some Ukranian pilots who didn’t check the weight of any passengers or cargo of our small commercial out of Panyigoor, we diverted to Bor for a couple hours on account of low airfield visibility in Juba before making it into the capitol later that day. Perched along the White Nile, Juba is the capital of South Sudan and the central node from which all NGO’s and government agencies operate. Upon arrival, we were fortunate to score meetings with sustainable development and agricultural expert Dan Jansen as well as the Twic East County Health Director, Abraham Chol Leek. 


Dan is a unique character. He sported a bright orange Chicago bears dri-fit polo with cargo shorts and a quizzical gaze while he went to work on a cheeseburger that our hotel in Juba served up. He spoke of his experiences with training South Sudanese on the proper stewardship of resources and agricultural expertise in varying regions. He addressed the mechanics behind “market garden” systems, which are designed as work-for-service programs to ensure that NGO services rendered are earned through whatever means the local populace has to offer, in this case it was labor in a garden for vegetables to be sold at market in exchange for credits for service in health clinics. He spoke of training dogs to act as de-facto fences, guarded crops, patrolling treelines, and guarding children to and from school. He spoke about receding water planting and how it could facilitate year-round crop cultivation (even in spite of the floods experienced during the prolonged rainy season). Most importantly, he expressed enthusiastic interest in going to work in Maar to implement these strategies, which can serve as a critical next step toward the sustainable development of the community as SSHCO looks to create the model for expansion in Twic East County. 

Twic East County Health Director, Abraham Chol Leek Deng during a meeting at the dining area of a hotel in Juba.

The following day, prior to our evening flight to Ethiopia, we met with Abraham Chol Leek Deng, the Twic East County Health Director to discuss our partnership and the management of the clinic. This meeting was immensely productive, and it positioned SSHCO properly to facilitate a positive impact well beyond Maar in the coming days. The result of this meeting was a resounding feeling of mutual agreement and camaraderie as we look forward to tackling the challenges of healthcare in South Sudan. 


Conclusion


Throughout this survey, it was readily apparent that barriers to a safe and secure life for the citizens of South Sudan abound. Lack of security, clothing, stability, peace, income, food, economy, technology, information, and opportunity would seem to define the situation. Indeed, a sense of dependency of NGO’s and government agencies is prevalent. 

 As I worked between the pharmacy and the main consultation room, a young boy waiting for services followed me around. I never was able to coax a name out of him, but he seemed to have a great time watching me work. Aside from his bright red shirt, he was completely naked from the waist down.
On our final day, children wait for shoe disbursement outside the Maar community hall. 

However, the common theme of the people we encountered was a quiet, resilient resolve that could only be born by people who face these challenges daily and conquer them. The good news is that with continued education, training, support, and the maintenance of peace in Juba, focused sustainable development efforts can help lead directly to their prosperity. SSHCO is the leading organization providing reliable clinical services to the surrounding area of Maar, which has a population that reaches upwards up 40,000. However, SSHCO is the only organization to my knowledge that is focusing directly on the sustainable development of this community. With your continued support of Bidaya, SSHCO can carry out this vital mission and save lives that otherwise might not be saved.



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