South Sudan: The Team Behind the ICRC`s Largest Surgical Response

ICRC Washington's Trevor Keck recently returned from nearly a month in South Sudan, where the ICRC has more surgical teams in the field than in any other country. Each four-person team is responsible for treating people wounded by weapons as well as building local health care capacity. While he was there, Trevor spoke with the Deputy Health Coordinator, Yves Giebens, who helps oversee the delegation`s five mobile surgical teams.

Kodok hospital, South Sudan. An ICRC doctor treats a small child. CC BY-NC-ND/ICRC/Pawel Krzysiek

Kodok hospital, South Sudan. An ICRC doctor treats a small child. CC BY-NC-ND/ICRC/Pawel Krzysiek

TREVOR: Thanks for taking the time out of your busy schedule. I would like to start by asking you to describe the ICRC’s mobile surgical teams (MSTs) in South Sudan. What is the current operational footprint and the needs the ICRC seeks to respond to?

YVES: The mobile surgical teams (MSTs) are focused on treating the most serious cases of people wounded by weapons in South Sudan. Most of the patients have been injured as a result of the armed conflict between government and opposition fighters, but the ICRC is also treating many civilians wounded by cattle raids or intercommunal violence not directly resulting from the war.

The ICRC has five MSTs in South Sudan at any given time. Each team has four staff, with the surgeon being the team leader. We also have another 10 medical support staff that ensure the MSTs have all the supplies and medicines they need to do their work. In total, this means that the ICRC has approximately 35 medical staff working to treat weapon wounded in South Sudan. It`s currently the ICRC`s largest surgical response in the world.

Three of the MSTs are working in a fixed location. We have had to move these locations as the frontlines in the conflict have shifted. Right now, we have one team working in a hospital in Kodok, which is in the north of the country in Upper Nile State. This location has been held by government and opposition forces at various points in the war. Currently, Kodok is under control of the opposition. Juba`s military hospital is another fixed location on the government side. We have been working in that hospital since the crisis began in December 2013. On the opposition side, we have one fixed field hospital – in Maiwut – which is on the border with Ethiopia. At times, we also offer rapid medivac support to weapon wounded personnel, which has saved countless lives.

Finally, we have two other MSTs that are flexible, which can quickly deploy near the frontlines of the conflict to treat the weapon wounded. Our MSTs have worked in fifteen different locations around the country since the conflict broke out in December 2013. In total, these teams have carried out more than 5,500 surgical operations since December 2013. In spite of these interventions, not all of the war wounded could be reached. The levels of violence in this country are high, which in turn generates enormous medical needs.

TREVOR: Can you speak about the kinds of conditions that the MSTs are working in and the challenges they face in the field hospitals?

YVES: The MSTs are working and living in extremely basic working conditions. They must learn to improvise and set up a surgical theater in far less sanitary conditions than you would find in operating rooms in Europe, for instance. We must provide all of our own water, electricity and medical materials. Like other field delegates, the MSTs also live in tented camps for weeks at a time. The areas they work in are hot, humid and susceptible to all kinds of primary health care problems. For instance, cholera broke out last year in Kodok, where we are working in a permanent hospital structure. Because we were there, we were able to quickly lead the health response to the cholera outbreak and take preventive measures. But this just gives one an idea of the kinds of challenges that our MSTs deal with other than their daily work of performing war surgeries. Lastly, in addition to all these stress factors, the MSTs live and work under an umbrella of insecurity, which can be particularly concerning given that armed actors do not always respect protections for health structures in South Sudan, as is required by international humanitarian law. So, the MSTs are doing amazing work in very tough working and living conditions.

TREVOR:  The ICRC is able to deliver needs-based medical care to people wounded by weapons on both sides of the armed conflict in South Sudan. How has the ICRC built up this response? Do you think there are lessons that can be applied to other more challenging contexts where the delivery of impartial medical care is less accepted?

An ICRC delegate engages with an armed group to explain the importance of protecting health care personnel and hopspitals.. © ICRC

An ICRC delegate engages with an armed group to explain the importance of protecting health care personnel and hopspitals.. © ICRC

YVES: There are some definite lessons that can be applied to other conflict zones. Gaining support and acceptance for an impartial medical response is difficult work. It requires clear and proactive communication with all armed actors from the beginning. The ICRC has sought to be as transparent as possible, explaining to all that we are here to treat the most serious cases of weapon wounded on both sides of the conflict, fighters and civilians alike. We work hard to position ourselves to treat the most serious cases on both sides of the conflict so as to maintain our neutrality and impartiality.

Adding clear value is also very important. For instance, both sides in the conflict see the ICRC treating their fighters, which are of course entitled to medical care under international humanitarian law. Consequently, local military authorities and communities have a strong interest in ensuring our field hospitals and staff working in them remain safe. As a result, we have achieved a good level of trust and confidence with the warring parties, which helps us make progress on more challenging issues.

TREVOR:   Finally, I understand that the protection of hospitals, health structures and wounded persons have not been respected at various points during this conflict, as is required by international humanitarian law. As we have seen in South Sudan and other conflicts, the destruction of health facilities poses immediate and long-term consequences for the civilian population. What are the humanitarian consequences of this trend in the conflict? Additionally, what is the ICRC doing to promote respect for health facilities and the right of all wounded and sick persons to receive medical care?

YVES: Yes, unfortunately, hospitals, health structures and wounded persons have not been respected at times during the conflict in South Sudan. The ICRC raises such alleged violations of international humanitarian law directly and confidentially with parties to the conflict and the health authorities. Our delegates also communicate the legal obligations concerning respect for medical care when disseminating the rules of warfare to armed actors. But clearly this is a major problem in South Sudan, and we need to see increased respect for medical structures and personnel by those fighting the war.

As you note, destroying hospitals will have long-term negative consequences in any conflict zone. In South Sudan, civilians acutely feel the negative impact for two reasons. First, the logistical challenges in this country make it difficult to quickly restore essential health services. Transport of medical material must be carried out by plane as South Sudan does not have many usable roads outside the capital. This is difficult during the rainy season, as dirt runways may be flooded for days or weeks. Secondly, South Sudan already lacks quality health services, which is why we have deployed our largest medical response in the world here. The destruction of hospitals and health facilities only adds additional strain on what is already a very weak health care system.

Editor's Note: We encourage you to check out ICRC's Healthcare in Danger project (HCiD), which aims to improve respect for medical missions globally.  More information can be found on http://www.healthcareindanger.org.

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Trevor Keck

Trevor Keck serves as Public and Congressional Affairs Officer with the Washington Delegation of the International Committee of the Red Cross (ICRC). In this capacity, he is responsible for representing the ICRC to a range of audiences in the U.S. and Canada, including Congress and leading civil society organizations. Prior to joining the ICRC, he was an Afghanistan researcher for Center for Civilians in Conflict, an organization that seeks to make warring parties more responsible to civilians. Based in Kabul, he conducted research on civilian protection issues, conducted interviews with victims of conflict across Afghanistan, and authored two reports as well as op-eds based on his original research. Before that, Trevor worked with various NGOs conducting research and advocacy on a range of security, humanitarian, and human rights issues. Trevor holds a Masters in Law and Diplomacy from the Fletcher School of Law and Diplomacy at Tufts University. His master’s thesis on the concept of direct participation in hostilities was published in the Spring 2012 edition of the Military Law Review, the official publication of the U.S. Judge Advocate General Corps. He also holds a Bachelor in Peace and Conflict Studies from Chapman University graduating magna cum laude.