South Sudan is bleeding itself dry

Blood donations are scant in South Sudan as the process is frowned upon and treated with suspicion by locals.

When Saba Alfred Jamal was eight years old, a drunken relative accidentally shot him in the leg. 

His parents rushed the bleeding boy to the biggest hospital in Juba, the capital of South Sudan, but there was little chance of saving Saba’s life. There was no blood available at Juba Teaching Hospital. There were no blood stocks in the whole of South Sudan, for that matter. The war-torn region – then still part of Sudan before its independence in 2011 – had no blood bank.

Saba’s blood did not match that of any of his relatives either. None of them could help.

Now a strapping teenager, he has little recollection of the night ten years ago – or of the stranger who saved his life. “Somebody came to donate me blood,” he says. “I didn’t recognize that person because I was unconscious.”

The misunderstood blood of a new nation
Saba’s story is highly unusual.

There are strong traditional taboos against blood donation in South Sudan and decades of conflict destroyed infrastructure and health services. As a result, there was no blood transfusion service when the world’s youngest nation was formed five years ago.

At the time, a single fridge in Juba Teaching Hospital’s laboratory could hold only 50 pints of blood, doctors recall. These were mostly donations from family members for patients who were to undergo surgery. The laboratory was the only room powered by a backup generator, and the rest of the hospital often experienced blackouts.

Even when blood was imported from neighbouring countries, the family-sized fridge was the only facility to store it in, says Abdulmumini Usman, the World Health Organisation (WHO) representative in South Sudan.

Cultural practices mean that people oppose the idea of blood transfusion. “Some South Sudanese ethnic groups will, for example, not donate blood to someone who doesn’t eat the same food as them, nor take blood from them,” Usman explains.

Some tribes believe they can’t give blood to an in-law. Many people think blood should not be mixed, that men should not give blood to a woman or that sharing blood is unnatural.

Many people simply don’t understand the importance of giving blood, says Narik Wal, project manager of South Sudan’s National Blood Transfusion Services.

“Some people will say, ‘I am getting married, I cannot donate my blood’ and some people will say, ‘If I give my blood now, how am I going to survive for the next few days?’,’’ Wal explains. “Some people will say, ‘I cannot give my blood because I have to give it only to my relatives. I cannot give it to random people’.”

High rates of maternal deaths, trauma and conflict fuel the need for blood
The country has one of the highest maternal mortality rates in Africa, Usman points out. According to the latest World Bank data, 789 South Sudanese mothers die per 100 000 live births. This would be the fifth highest maternal mortality rate in Africa — and the world. But the WHO uses the research of a 2006 national survey, which found the maternal mortality rate to be much higher (2 054 deaths per 100 000). This would make South Sudan the  most dangerous place to give birth in Africa.

“The main cause of maternal death in delivery is blood loss,” Usman explains. “Having a blood transfusion service is the most important life-saving intervention. You can’t do surgery without blood.”

To make matters worse, traffic accidents are a regular occurrence on the country’s poor road network. Many children suffer from anaemia caused by malnutrition, which is often exacerbated by malaria.

“The thing is that South Sudan is really, really in need of blood,” says Usman. “There is a lot of conflict — and when conflict breaks out, we can’t wait for donors.”

Five years ago, doctors referred patients to nearby countries for blood transfusion and blood samples were sent to Nairobi, in Kenya, for diagnosis of diseases. For the majority of people in the poverty-stricken country, this option was too expensive.

It was when civil conflict broke out in 2013 that the fledgling government acknowledged there was a need for a blood transfusion service, Usman explains. “A lot of people got injured. They had to import blood from neighbouring countries by air, but by the time it arrived, many had already died.”

In July 2014, the country’s brand-new national public health laboratory, with a blood bank and diagnostic centre, was opened in Juba with great pomp and ceremony by President Salva Kiir. The facilities, built by the United National Development Programme (UNDP) with money from the international financing mechanism the Global Fund to Fight Aids, TB and Malaria, had a capacity of more than 1 000 litres of blood, according to a press release from the United Nations mission in South Sudan. The laboratories could test for HIV infection, malaria, tuberculosis and cholera.

But the refrigerators stayed empty. One hospital in Juba collected a mere 124 voluntary donations in 2014, the WHO reported.

Fresh hope for life-saving services?
Last year, the WHO and the government of Japan stepped in to boost the country’s blood supply. “We worked with the local authorities to put together a public advocacy campaign to convince more people to donate blood,” says Usman.

“We needed a different approach to break down the taboos. We tried to portray it in the media that everybody can donate blood.”

Foreigners from other African countries such as Kenya and Uganda started giving blood voluntarily, as well as aid workers, members of the peacekeeping force, civil servants and the employees of major supermarkets and companies. This was not only to increase the blood stocks, but also to show the South Sudanese that the process was safe.

One regular donor, 39-year-old civil servant Chiok Gajang, was inspired when he saw people volunteering to give blood in the Unites States in 2012. “When I came to Juba I saw a woman needing blood. I said let me take courage. Let me give blood if this woman could be as safe as I saw before [in the US]. The woman and her child were saved.”

Since then Gajang has donated blood six times and has encouraged others to do so.

Last year, the WHO saw a tenfold increase in donations.

“We are gradually breaking down the barriers,” Usman says, emphasising he is very cautiously optimistic.

Blood transfusion vehicles have been imported and, with state-of-the-art equipment, Usman hopes to have a blood transfusion service that can test for all pathogens up and running in Juba before the end of the year.

“Of course we have to make sure our blood is safe. Hepatitis is common, as is HIV. We have to check the quality of the blood otherwise we can’t guarantee its safety.

“We started the blood bank at the Juba teaching hospital as a nucleus. Now we are expanding. We want to create a regional blood transfusion service.”

Africa's newest nation still mired in conflict
But the project has been delayed. Plans to have two regional blood banks — in Wau, about two hours’ flight from Juba, and Malakal in the northeast — fully operational by now, were hampered by renewed outbreaks of violence and the subsequent displacement of thousands.

When violence flared in Juba in July, blood supplies reportedly ran out because many wounded soldiers needed surgery.

“Our main problems are conflict and a lack of funding,” says Usman. “The security sector is allocated a bigger portion of the budget than health.”

With the entire health system in South Sudan near economic collapse, the blood bank depends on donors, but the spiral of violence also caused aid to dry up. Only Japan is left propping it up.

“If we can’t move forward [politically], we’ll continue to plug the holes,” Usman says.

The gains made by breaking down the taboos will be lost and giving blood will, once again, become the exception.

For Saba Alfred Jamal, now an 18-year-old student, a return to the days before a blood bank is unthinkable.

He still donates blood as an acknowledgement that his life was saved.

“Today I am alive and I am healthy. The leg which was hit is ok now and I can play football. All thanks to that person who saved my life.”

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