In the wake of renewed violence and insecurity, South Sudan is now also facing a cholera outbreak. But many aid agencies are working with diminished staff and supplies, which could severely hamper efforts to control the epidemic.
Cholera is spread by food or water contaminated with faeces, and can kill within hours if left untreated, according to the World Health Organisation.
WHO communication officer Jemila Ebrahim says the country's cholera outbreak is approaching its second month, with 586 cases having been reported.
But the WHO's country representative in South Sudan, Abdulmumini Usman, warns that the impending rainy season may bring more cholera cases. "The risk of further spread of the disease is a major concern. With the coming rains, it is realistic to expect an increase in malaria and waterborne diseases."
A recent surge of fighting between forces loyal to President Salva Kiir and those aligned to former vicepresident turned opposition leader Riek Machar has displaced more than 30 000 people, the UN Refugee Agency reports. Many aid agencies have had to temporarily withdraw their personnel and only have essential staff in the country.
Tim Irwin, Unicef's spokesperson in South Sudan, says there is a security threat to aid workers and many parts of the country remain insecure. "We are unable to access them, and this is a concern."
According to Zlatko Gegic, South Sudan country director at the aid organisation, Oxfam, providing aid will become logistically impossible if security conditions deteriorate further. "If aid agencies cannot operate fully, the consequences could be catastrophic," he says.
The WHO, the United Nations Children's Fund (Unicef) and Doctors Without Borders (MSF) have set up a cholera treatment centre at Juba Teaching Hospital in the capital, where the bulk of South Sudan's cases have been reported. As an oral vaccination drive strives to inoculate more than 14 000 people against the disease in high-risk areas — such as camps housing thousands of people displaced by violence — the organisations have also set up eight centres to treat dehydration among people with the diarrhoeal disease.
But aid supplies — including vehicles, fuel and nutritional supplements — of agencies such as the World Food Programme have been looted. With only 200km of paved road in South Sudan and restrictions on internal travel, aid agencies have not been able to restock their bases across the country. Some regions are impossible to get to because even helicopter travel has been prohibited.
WHO epidemiologist Joseph Francis Wamala, who is responding to the epidemic, says the conflict is partly to blame for cholera outbreaks that have haunted the country annually since 2014.
"The fact that we had pockets of insecurity all these years means that you don't have the time you need to build very good water systems and very good sanitation systems to handle sewage," Wamala says.
Decades of conflict have destroyed sanitation and healthcare systems in the world's newest nation, which gained independence from Sudan five years ago. Hunger and malnutrition are widespread and 4.8-million people — nearly one in every three— don't have enough to eat, according to the International Rescue Committee.
The local media is airing prevention messages and advertisements for a toll-free phone line to report cholera cases.
MSF emergency co-ordinator Anja Wolz says people should seek treatment urgently if they experience more than three bouts of watery diarrhoea a day.
"Our main challenge is making sure that people know to protect themselves from cholera and what to do if they think they have the disease," she says.
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