Bones

My third day working independently here. Saturday is nominally a regular work day, although I’m told it’s usually very “light” in the operating room (or, “operating theatre” – OT, not OR – hey, after all this time, I’m back in the theatre!). Today, just a circumcision of 3-year-old with “paraphimosis” – his foreskin had gotten stuck behind the head of his penis and swollen up to the point that it was choking off the blood flow to the head. It can lead to gangrene and the loss of the penis head, but I think it was caught in time. And a 6-year-old with a broken thigh, whom we had to figure out a way to put into “traction,” the old-fashioned way of dealing with these things.

This encounter can stand in for what, for me, has been the biggest revelation so far: the miracle of modern orthopedic care. I’ve already had a lot of respect for it since, as some of you know, I had both my hips replaced last year (still not perfect, but much, much better than they were before the operation!). Also, I had a colleague in Egypt during my public health days whose husband was a pediatric orthopedic surgeon, and I’d gotten a little glimpse of how his work could save kids from neonatal conditions that would otherwise have left them crippled for life. We were sitting outside having some juice when a young man recognized him and came up with a face full of gratitude, thanking him for “setting him straight” (ortho-pedic = “straight child”) when he was young.

Something I hadn’t thought of before, though, was what it used to mean to have a broken bone. The kid we treated today had, I think, fallen out of a tree; he had the requisite x-ray (gotten at the one private clinic in town; the hospital has almost no film), which showed the two pieces of his thigh-bone overlapping by several inches (when you break a limb, your muscles shorten since they are no longer being held at full length by the bone and the bone pieces slide by one another). For it to heal properly, it has to be re-stretched, so the broken ends of the bone are somewhere near each other. These days, you just go into surgery, put a piece of metal in there, and that holds it in place till it heals. You can go home, move around on your legs the next day, live a normal life.

Here, however (and, thus, 80 years ago in the States, too), what you have to do is STRETCH the leg with weights until the ends of the bone are near each other, and then – wait. (You know the cartoons or old comedy routines where people are lying in a hospital bed with huge casts on their leg and a system of pullies and rigging over them? – like that.) Wait for 4 – 6 weeks, if you are an adult, a little less if you are a kid. Four to six weeks largely immobile in bed with a weight hanging off your leg. Does this or does this not sound like torture? Add to that that here, the bed you are waiting will be in a crowded, insufferably hot and humid hospital tent, redolent of all the effluvia of the human body, and you get an idea of what this poor kid now needs to do.

Happily, kids are amazingly self-repairing. If he were middle-aged, and we didn’t do it right, he would probably have a short, game leg for the rest of his life. With this guy, we probably don’t have to be perfect, because, in a way that reveals “the miracle of life” to be more than a cliché, his thigh will keep “trying” to return to its original length and position; it will “remodel” itself until, hopefully, it is as good as new.

Which is good, because we were far from perfect. After I sedated him (he was an excellent patient, he kept breathing!), my colleague adjusted the makeshift pulley device he had constructed by adding and removing – I’m not kidding – rocks from just outside the tent. In the end, we got the bone-ends not too far from each other (a half-inch of overlap, maybe? A little more?), and somewhat straighter than they had been with the previous traction setup. I still don’t see how he is possibly going to remain there for as long as he has to, having all his bodily functions tended to by his mother or another family member, and without going insane with boredom. But – well – we did what we could. (There is no pediatric orthopedist here, by the way – all of this was done by a general doctor, working out of an illustrated book on how to address surgical problems if you are in a place with no supplies and you aren’t a surgeon.)

I mean, no one likes to break a bone. But in the States – do we think of it as a PROBLEM? Isn’t it more kind of a right of passage of childhood; you get to stay home from school for a day or two, get lots of attention, everyone signs your cast – cool! The misery that it entailed at one time really hadn’t crossed my mind before this moment. Misery and disability: Despite kids’ amazing plasticity, they aren’t perfect. I noticed that a student who comes into my OT on certain days was limping and asked her if she’d hurt her leg; she said “no, my knee – problem since childhood.”

I often find myself thinking that medicine doesn’t really matter that much, is not that important; that it’s your soul that counts and is really “you,” all medicine does is give you a little more or less time to live with that soul, and, if we were all ascended masters, a little more or less time wouldn’t matter that much. Blah, blah. But working in places like this really calls me on that. I realize that it can unburden us.

My body here, my heart back home

Haven’t felt much like blogging over the last couple of days. The events in Louisiana and Minnesota, and now in Dallas, have left me feeling sour and dispirited and incredibly ANGRY. The shootings in Dallas were of course horrible and demonic and destructive; I would use the word “counterproductive,” except that would give them the dignity of being an actual, thought-out plan to achieve something. It sounds to me like they were more along the lines of Sandy Hook and Orlando, a troubled guy with too easy a chance to buy guns (though I am sure the Republicans will waste no time in blaming Black Lives Matter).

The Louisiana and Minnesota killings stick in my heart more, though. I would like to say it is because of my burning sense of and thirst for justice. But, to be honest, I think it is just that I hate bullies so much. Bullies, and people who arrogate to themselves the right to substitute what they want and their well-being to what others have a right to. To do something that makes them feel better even if it makes someone else feel much, much, much worse (or feel nothing at all), and who then have the fucking temerity not to own up to their own shortcomings but, instead, to brave it out and say they had a right to do it. There is something from my childhood – I haven’t figured out what, exactly, though I have some ideas – that makes that intolerable to me.

It makes me angry at policemen who seem to think that their personal fear or rage is a justification for ending someone else’s life. It makes me angry at them for not having asked themselves, after two years of these stories making the 6:00 news, why, exactly, they get scared so easily when they see a young black man, and whether maybe they have an obligation to question and adjust that fear. It makes me angry at departments that have not yet said, wow, if other departments have this racism problem, we probably do, too – we better take steps now to avoid doing these stupid and tragic things ourselves. It make me furious at the chummy, clubby, clannish camaraderie I see among policemen on the streets and in the stations of New York, “us-against-the-world,” as if it is some sporting event we are talking about and not people’s lives. The “blue wall of silence” that puts loyalty and self-protection above justice and truth. It makes me furious that so many cops appear to feel that the public is some sort of brutish enemy, and that their primary job is intimidation rather than conflict de-escalation. It makes me furious at legal standards that for some inexplicable reason make the officer’s fear, not reality, the measure of whether his actions are justified or not – that make it not “was he, realistically, in danger from this unarmed man, when he himself had a gun?” but “did he FEEL he was in danger from this unarmed man?” (if I “feel” I have a right to your car, can I take it?). It makes me angry at the lack of honor in a profession that doesn’t say, “When in doubt, I’ll take the risk,” but instead, “shoot first, ask questions later.” Maybe we don’t pay cops enough to make them willing to adopt this more selfless standard – in which case, let’s pay them more, enough that we can demand it of them. The response to doubts about whether a man is reaching for his wallet or for a weapon (this was the “issue” with Amadou Diallo, too, remember?) should be more time taken to find out which it is, not sudden, lethal gunfire.

So that’s what I’ve been thinking about for much of the past two days. I’ll get back to what’s going on here soon.

Article about my project!

Wouldn't you know it. MSF just put out a story in their on-line magazine that describes, in detail and rather effectively, it seems to me, the exact project I'm working on. About half the people featured in the article are still here, and are my colleagues for the next several weeks. Have a look!

https://medium.com/msf-alert/one-day-in-aweil-an-msf-team-portrait-bb0fa1f95755#.eh8oqjnbt

Impressions from the first two days in South Sudan

- First 16 hours here – not much to say. It is very beautiful and green from the air (rainy season has started), though flat. “The whole country is a flood plain,” I am told. Juba airport tiny (although there is evidence of a “real” terminal being built beside it). In one of those bad-dream-like concatenations, where every line you switch to suddenly becomes the slowest-moving one, I somehow manage to be the absolute LAST person from the plane to make it through passport control. But the Customs guy laughs and tells me I look like “Ivanovich from Chelsea” (I check later, and, yes – I can see the resemblance!), and all is mended. Then it is meetings; a short trip through the dusty, hardscrabble, but big-tree-filled capital; a tasty dinner at the residence; an interrupted, jet-lagged sleep where, famished in the middle of the night, I come out and eat a whole second big meal; then sleep again, shower, office, and off to the airport once more.

- One thing I do hear chatting with other staff on the porch: At an MSF project in the north – which I am told is “in a swamp,” with impossible conditions for both residents and MSF folks, now made immeasurably worse by the rains – they recently had a young child whose head was bitten by “a tiger.” Of course, there are no tigers in Africa (? – or are there? The strangeness almost makes you wonder). A leopard? Except that, they being my favorite animal notwithstanding, leopards don't fuck around – everyone feels like, if a leopard had grabbed the kid’s head, it would still have it. A cheetah? But they are quite small, and also need running room, which a swamp doesn’t give them. Whatever it was, the kid (who is doing fine now) had big, cat-teeth impressions all around his head. Amazing story….

- Arriving at the airport for my United Nations World Food Program flight to Aweil, I find a scene of apparent chaos – people packed into the one open door, enough to make it burst. How will I ever find where to go; how will I ever fight my way through the lines? Except that, as soon as I approach the door, everything resolves itself. The WFP check-in desk is clearly marked; the security line is orderly (although – perhaps in a stunning display of good sense? – no one stops me from bringing my half-full cup of coffee through). A reminder of how easily I can perceive the unfamiliar as fearsome or even hostile….

- As the plane taxis out, my eye is caught by a person walking next to the runway. Except it isn’t a person – it is a marabou stork. About as tall as a teenager, it picks it’s way over the ground, looking down as if contemplating something. Who could not feel some sort of kinship with this creature, if we didn’t immediately think of it as “just an animal”?

- Waiting in the overfilled gate area, I pass the time by watching the film “Trumbo,” cleverly downloaded to my IPhone for just such occasions. Beside me, a young soldier notices me laughing and looks over to see, too. I show him the screen – and immediately become aware, and abashed both because of the fact itself and because I hadn’t previously noticed it, that the movie is all white people in expensive suits and expensive locales, and the only black people are in prison.

- Most of the people on the flight are going to Wau (Wow!), a town that has recently seen a flare-up of inter-ethnic violence. I wonder what is true about the situation here, or what the range of truths is. What I hear from the expats is that the civil war could re-explode at any moment, and that violence can be unexpected and surprisingly extreme (as it certainly seems to have been when the civil war started, or started on a large scale, in late 2013). I haven’t yet gotten to know anyone from the country well enough to get their impression (and, realistically, might not do that in my entire time here). Also, expats say that, whatever the colonial and post-colonial governments did to stoke interethnic conflict, it has existed here for a long, long time. Which accords with what I’ve picked up from my reading – basically, whether or not ethnic differences have been used to divide-and-rule by various powers, if people themselves describe the tension as ethnic, and if soldiers and gangs choose whom to kill on the basis of ethnicity, then it is an ethnic conflict – isn’t it? Maybe having an awareness of how the conflict was “constructed” by outsiders is useful and important in some ways, but, for a person like me who is here for a short time and just wondering what is likely to happen – if it walks like a duck, etc., can we just call it a duck? Is there a kind of obfuscating PC operating here (oh, no – shades of Donald Trump!)? I am hesitant to say so – I know so little about it, after all - but all I can say is that everyone in my universe here talks like this, ethnicity, is the first-order fault line; the place that things happen when pressure is applied.

- Wau is maybe 50 miles from Aweil, and there is another flare-up to our west. Already, people are moving from Wau towards Aweil, although, as I understand it, those moving here are part of the same ethnic group as the vast majority of Aweil residents, which I hope makes conflict less likely. If one or both of the conflict zones do move toward Aweil, however, the situation here – and at the hospital – could become very different.

- During the tour I’m given of the MSF “base,” I am shown our three, count ‘em, three “safe rooms” (anyone remember the Jodie Foster movie??). They have food, water, even air conditioning (that is, if whoever is attacking doesn’t think to turn off the generator, which, I have to say, doesn’t seem that likely to me!). We’re supposed to go there if we hear shooting, if there is sustained conflict outside the base, etc. Hmmmm…. I’m also shown the system for coping with being held at gunpoint (which, they do inform me, they have “never had to use”!). As I said before, the extreme rarity of actual physical violence, whether on the streets of NY or to expats working on international health projects, usually means that it’s the last thing I worry about. But this does make it all a bit easier to imagine…!

- Ahh – first visit to the hospital! So important. Before, I have visions of some super-emergency operation where I can’t find the spinal kits, don’t know how the ventilator works, etc. Now – in addition to having seen for myself what everyone has told me: how on top of everything my local colleague is – I feel like, in a pinch, I could make it work. (Although the ventilator does seem strangely complicated and bizarre.) It was also mercifully “light” in the OR today. It’s 2 pm and I’m already sitting at the porch table. Resting up for tomorrow. Breathing easy.

Sleepless in Dubai

Hi – It’s 5:30 here in Dubai, where I had to spend a night on my way to South Sudan, and – though I slept more than 8 hours on the flight over, and for a good spell at the beginning of the night here – I’ve been up for several hours now. Spent a good while listening to a tape of “The Silk Roads,” a delightful new book about the place of Central Asia in world history – great listening; if you’re bored of where you are, tune in and you’re off to a market town in 1^st century Afghanistan! But, alas, that failed to put me to sleep, either. In these situations, there comes a time when you just have to get up.

I wanted to write, anyway, to give you a sense of the things I’m thinking about, here on the cusp of actually arriving in the country.

1. I think my biggest worry – apparently it happens to everyone on their first MSF job – is, “what if there is a situation I don’t know how to handle?” This is not a completely unrealistic fear – a friend of mine who is mostly an intensive-care doctor had to resuscitate newborn babies and do nerve blocks without any imaging technology. And the last thing any of us wants, after having sold ourselves as bearers a certain level of expertise, is to end up providing inadequate care instead. But the more I learned about the project, the less worried about it I got. For one thing, I did a fair amount of studying of techniques, medicines, and diseases that I don’t usually encounter in the States but that I might here (and made myself a nice book of “cheat sheets”!). For another, I will be working in what is essentially an MSF obstetric and pediatric hospital-within-a-hospital, completely run by the group and staffed with their employees (expat and national). Which means that I will have a lot of people around me whose expertise, approach to medicine, language skills, etc. will be basically familiar – in other words, it will be a supportive rather than an isolating situation. Perhaps less interesting in some ways, but good for a first placement. For a third, it sounds like the local anesthetist whom MSF has hired and with whom I will share the work is SUPERB. And, finally – I’m now two years out of residency. Which is not the same as being five years out, or twenty years out. But – it’s undeniable – you do get better at it the more you do it. I faced some pretty weird situations at the community hospital in the US I was working at last winter, and seem to have figured out how to pull through all of them. It’s no guarantee – but it does make me feel more at ease.

2. I found the death we all had to deal with in Sierra Leone harder than I thought it would be. Hopefully, there will be nothing like that level of death here. But South Sudan does have what may be the world’s worst maternal mortality ratio, and this is an obstetric hospital. I talked to a colleague who worked here a few months ago, and he said that, in fact, he – as an anesthesiologist; I’m sure it’s different for the OBs and midwives – didn’t see any maternal mortality. And the pediatric mortality will hopefully be negligible – for me, it’s a lot of dressing changes for kids who may be badly injured or burned but who, in theory at least, are getting better. The one thing my colleague did say he saw was C-sections where the baby was stillborn. And in general, there will probably be more bad outcomes here than in a hospital in the US, and every time there is a bad outcome, whatever you did or did not do, you feel bad and you wonder. So I probably do have that to look forward to (though I’m hoping not too much).

3. I have some concern about simple psychological distress. Anyone ever read The Sheltering Sky? Or A Passage to India? Remember how the heroines in both cases kind of fell into this situation where, with so much unfamiliar, so much unfamiliar stimulation, so much stress, so much apprehension on their parts, they both decoupled from the world a bit, lost a little track of what was real and what wasn’t…? Don’t worry – I don’t expect my embassy will have to find me in a house down an alley somewhere in the Sahara! But I have always found that being in a foreign place where I don’t know anyone, don’t speak the language (although I have had two Dinka lessons!), where no one knows me, where I can’t be sure of being understood – it can send me into a pretty isolated internal space that is tense and unpleasant. But, again – the situation here seems reasonably well set up to work against that – particularly the fact that I will be living with 20+ other MSF staff in a large compound near the hospital. Hopefully if I start to get too weird and internal, I will remember to go find someone to talk to.

4. Then there is the question of whether all this is futile, anyway. I mean, of course it isn’t, for the individuals we help. But I’m reading a book right now by a former MSF person about how, in some situations, humanitarian interventions might actually make things worse (Fiona Terry, Condemned to Repeat? The Paradox of Humanitarian Action). And however that may be, I certainly have no illusions that what I’m doing will bring better governance to South Sudan, or help reduce the number of weapons circulating, or rebuild interethnic trust. And I think, just on principle, that all of us doing this kind of work should ask ourselves from time to time whether and how much what we are doing might be a sort of disaster tourism, and whether, in fact, we depend on there being disasters out there to give us something to do. I have met a lot of people of whom I do NOT think that is true – people who really inspire me (many of them in Sierra Leone). I will try to be like them.

5. Other worries – political insecurity/violence; disease; transportation disasters – nah, they don’t bother me much. Aweil appears (?) to be an area that has had relatively little violence even at the height of the recent civil war, and seems to be stable now. And although I’m told that some people in South Sudan are ambivalent about MSF because the organization tends to drop in to solve problems and then leave without doing much local capacity building (that’s the way it’s structured), I’m also told that medical people in general are held in high regard, which hopefully translates into security. Re: disease: I’ll take my malaria pills; I have Cipro ready for the stomach problems that I’m told have become very common on this project (!). For transport - it’s the rainy/mud season, so maybe people won’t be driving that fast; and as for plane crashes – what can you do? If it happens, it happens. Seriously – all of these things seem to me both unlikely and the kinds of things you really can’t do much about anyway, so – why worry? For better or worse, I can be very “rational” about stuff like that – it’s the way I’m wired.

So there’s a peek at my mindset as I head into the country. (Of course, there are also lots of things to look FORWARD to – interesting encounters; getting to know people; learning more and more; experiencing another environment and a taste of some other cultures; the simple pleasure of feeling like I’ve helped out. But I tend to focus more on my worries – again, the way I’m wired.) Since I started writing this, I have made my way onto the plane to Juba, whose human cargo strikes me as pretty classic for a country in crisis: Mostly men; some beefy/ruddy military types (humanitarians? mercenaries? who knows…); some folks whose country of origin suggests they are probably working on oil and infrastructure projects; some tweedier looking (and occasionally even female) development (?) people – even a few folks who might be South Sudanese! That the mise en scene is so familiar is mildly depressing – the rote, prepackaged response to a country in crisis? On the other hand, I could see it as encouraging evidence of the world’s ability to place skilled people in a country that needs them. Whichever way it is, on this particular day, I’m a part of it.

The lay of the land - and a very interesting article

Hi. I want to give a kind of summary of the problems facing South Sudan today, but first - two of my contacts who are experts in Sudan sent me this article (almost simultaneously!) yesterday. I think it gives a very good idea of how ethnicity has been used and manipulated by rulers past and present, and how this has left the country polarized and subject to conflict in the present:

http://bostonreview.net/world/mahmood-mamdani-south-sudan-failed-transition

That said - here is a summary of some of the challenges I see facing South Sudan (where I am heading in about 14 hours!) today:

1.     As I noted before, a huge portion of the population (perhaps 20% or more) remains displaced, either internally or as refugees

2.     A half-century or more of violence has left an oversupply of weapons and a lack of social trust. In many parts of the country, skirmishes continue, and peace between neighbors is not guaranteed. The large numbers of young people (51% of South Sudan’s population is under 18) with doubtful economic prospects and easy access to firearms intensifies these tensions. For example, it seems that cattle raiding – which has apparently been a part of pastoralist life for a very long time; see the Edward Thomas book I cite in the previous post – has gotten significantly more dangerous lately, as economic distress makes stealing cattle more attractive, and the use of guns as weapons instead of the traditional sticks makes it more deadly.

3.     Although the country is gifted with natural resources and has abundant water supplies in at least some places, chronic neglect by central governments over decades has left it with virtually no infrastructure (300 miles of paved roads; no national electricity grid; compromised access to >60% of the population during the rainy season). So making use of its resources is not easy. To take one example, South Sudan is oil-rich (not that this has always been a blessing to developing countries, of course - http://fivethirtyeight.com/features/oil-made-venezuela-rich-and-now-its-making-it-poor/). But the pipeline it uses to deliver its oil to markets runs through the territory of its old nemesis, Sudan. This has already led to economy-threatening tensions, even in the brief time since independence.

4.     At the end of 2015, the World Food Program estimated that 2,800,000 South Sudanese – close to a quarter of the population – were “in urgent need of food assistance”; UNICEF says that 3 times that number will face “food insecurity” this year. This increases volatility and tension, while negatively impacting health. And, while an astonishing number of American politicians still don’t believe (or claim not to believe) in global warming, places like South Sudan are already feeling its effects. This threatens to destabilize the country’s food situation even further, in unpredictable ways.

5.     51% of South Sudan’s people live below the national poverty line; only 20 countries have higher poverty rates. Furthermore, the parts of the economy that go beyond subsistence agriculture and husbandry (which occupy 78% of the population) remain unbalanced and undeveloped. Of the 7,000 businesses in ten of South Sudan’s largest towns, 84% are restaurants or shops. Similarly, the government derives fully 98% its revenues from oil, which leaves it highly vulnerable to recent oil price declines.

6.     Literacy is extremely low – 40% for males and only 16% for females

7.     Major illnesses endemic to South Sudan include malaria, dengue fever, HIV, and TB. Other more “mundane” diseases, such as respiratory tract infections, diarrhea, and meningitis, are also prevalent and destructive. Most tropical parasitic diseases (including 90% of the world’s guinea worm infections) are found in South Sudan, and the country’s maternal mortality ratio – over 2,000 maternal deaths per 100,000 live births – may be the worst in the world. These conditions, threatening in their own right, interact with each other and with malnutrition to magnify the danger. For example, anemia is one of the most prominent effects of severe malaria – but in a population that is already anemic from poor nutrition, the effect is even greater. And pregnant women are even more susceptible to malaria than the population at large.

8.     Governance and accountability remain huge issues. Although the August 2015 peace deal has largely held, flash points abound. For example, in December 2015, after the treaty was signed, President Kiir unilaterally decided to re-divide South Sudan into 28 states rather than the original 10. This move appears to be in conflict with the terms of the peace deal, and some consider it a destabilizing power grab. More generally, as in Rwanda, Northern Ireland, and many other conflict zones, people find themselves living in close proximity with neighbors who until recently may have been trying to kill them. How to manage all this – with what mix of acceptance, punishment, accountability, forgiveness, peace, and justice – remains a fraught question.

This was highlighted recently – in a manner that might have been funny if the issues weren’t so serious – by a dust-up over an editorial in the New York Times. Published on June 8, it claimed to be jointly authored by Salva Kiir and Reik Machar, and called for de-emphasizing criminal prosecutions of post-independence violence in favor of South-Africa-style “Truth Commissions” (http://www.nytimes.com/2016/06/08/opinion/south-sudan-needs-truth-not-trials.html?_r=0). But the need for criminal accountability had been a key point in the August, 2015 peace agreement. Were the main parties to that agreement now backing away from it? Well, as it turned out – no. In fact, it appears that the editorial was not written by either Kiir or Machar, but by someone on Kiir’s staff, who somehow convinced the Times he had authority to speak for both leaders (http://www.theguardian.com/global-development/2016/jun/10/south-sudan-leaders-controversial-new-york-times-article-aides-say-riek-machar). Machar quickly disowned the document; Kiir’s position on it is less clear to me. Luckily, as of now the error seems not to have touched off additional conflict, as it very well might have. But it does highlight how open the question remains of what to do to heal South Sudan’s wounds and begin to move forward.

So that is a brief – admittedly unbalanced and somber! – look at the history and events informing the place I will be working and affecting the people I will be working with. And with it, you know about as much as I do. I’ll give you a sense of how it looks on the ground – and a clearer view of what I will be doing there, how it may or may not be able to help, and my expectations and anxieties – over the next few days.

Why is there a crisis in South Sudan now?

You might well wonder how likely it was that a country which had been wracked by civil war for some 40 years, with the death (millions), the destruction, and the disorder this implies, would suddenly turn into a stable, happy place with the signing of a peace deal. In the event, this troubled past, combined with ethnic conflict, led to continuing difficulties post-independence.

In South Sudan’s initial government, the post of President was held by Salva Kiir, a member of the Dinka, the country’s largest ethnic group (36%), while First Vice President fell to Reik Machar, a member of the second-largest group (16%), the Nuer. Anyone who can remember back to Zimbabwe’s independence, or to the Rwanda crisis (or, hey, even to the US-installed Iraqi government) might have wondered if this arrangement would last. It did not. In mid-2013, Kiir dismissed Machar from the government, and in December of that year, fighting broke out in the SPLA barracks in the capital, Juba. (For one journalist’s very well written account of this conflict and of the civil war that followed, see Nick Turse’s Next Time They’ll Come to Count the Dead: War and Survival in South Sudan, https://smile.amazon.com/Next-Time-They%C2%92ll-Come-Count/dp/1608466485/ref=sr_1_3?ie=UTF8&qid=1466602319&sr=8-3&keywords=south+sudan+books.)

The initial fighting among army factions almost immediately spilled out of the barracks and onto the streets . Over the next days, weeks, and months, ethnic Dinka combatants in Juba and other locations slaughtered ethnic Nuers – soldiers, civilians, men, women, children, the elderly; it seems not to have mattered. Meanwhile, in predominantly Nuer regions, including the city of Bor, ethnic Nuer did the same to ethnic Dinka. Streets were periodically lined with bodies; bands of fighters with shifting allegiances took and lost and re-took towns; atrocities of every kind were committed; and terrorized civilians tried, often unsuccessfully, to stay out of harm’s way, eventually turning various UN compounds in the country into vast refugee encampments of 100,000 or more. Estimates of deaths during the conflict range from 50,000 to 300,000, and upwards of 2,300,000 people – perhaps 20% of the country’s population – are refugees or internally displaced. Although peace talks in Kenya were ongoing almost from the beginning of the conflict, they remained fruitless for a long time. A series of ceasefires were signed and then broken, sometimes only hours later. Finally, however, in August of 2015, an agreement was signed that, up till now at least, has held.

The end result? In the new unity government, Kiir is President, Machar is First Vice President. One might well ask what all that fighting was for….

(I should note that other intra-community tensions, often described in ethnic terms, have been common at many times in South Sudanese history – for example, Nuer/Merle conflict in Jonglei State (see https://smile.amazon.com/South-Sudan-Liberation-Edward-Thomas-ebook/dp/B00RVXT62W/ref=sr_1_2?ie=UTF8&qid=1467318680&sr=8-2&keywords=south+sudan#nav-subnav). These conflicts didn’t all begin in 2013, and not all of them have been ended by the peace agreement.)

What problems has all this left South Sudan with today? I’ll try to summarize some of them in my next post.