The Corona-Pandemic and South Sudan

A statement by Fabian Nolde, Programme Coordinator South Sudan & Mali

By now I have travelled to South Sudan about 25 times since February 2012 and spent mostly between 2 weeks and a month in the country at a time. I have travelled extensively inside the country by road, boat, helicopter and fixed air wing. Due to the nature of the work that I have been doing, namely the coordination of humanitarian aid to people in need and most of this aid being water, sanitation and hygiene (or what we, in the aid world, call the WASH-sector) focused, I also gained a relatively good understanding of the governmental structures and local authorities capacities in the fields of public health and WASH.

The following scenario and predictions are purely based on my own knowledge (which may be limited in some areas) that I have gained during my travels and in no way constitute a scientific study of any kind.

Limited Testing Capacities

As of right now South Sudan remains one of the few countries that are still declared “corona-free”, although the neighbouring countries have all developed fast spreading clusters. Even a country such as Uganda, which took early and relevant action and based its reaction to the Corona pandemic on its well developed Ebola preparedness, still did not manage to keep the virus out of the country.

As the testing capacities in South Sudan for COVID-19 are quite limited (as far as my knowledge goes only Juba Teaching Hospital has a small amount of tests), I doubt that the official statement is reflecting reality. Yes, the borders are closed by now and yes, Juba international airport has been shut down (I myself flew out during its last days of operation), but until then the who-is-who of the international aid sector and an army of oil and gas employees went in and out of South Sudan without any hindrance.

Fabian Nolde, Programme Coordinator South Sudan & Mali — Fabian Nolde coordinates our programmes in South Sudan and Mali. In addition, he is our focal point for WASH-projects.

Actual Number of Cases Remains Unclear

I am writing this while sitting at home in Cologne where numbers of infected (as in Germany overall) have been growing exponentially and still the numbers that we are seeing most likely do not reflect reality. There is discussion between the experts how high the number of unregistered cases really is (Robert-Koch-Institute is estimating every second case to be unreported as far as I understand, but other experts say that as many as 7-10 cases could be unreported per reported case).

Protection masks — The World Health Organization (WHO) declared the corona outbreak a pandemic.

The fact is, that Germany started testing early on and continues to test on a large scale which seems to be one of the explanations for the exceptionally low mortality rates here as opposed to rates in Italy for example. Apparently Germany also has one of the highest capacities for intensive-care in the world (about 29,2 beds/100.000 inhabitants) and talking to my friends in the medical profession, I know that these capacities are being dramatically increased currently.

When a patient suffers from a severe case of Corona, he or she may need to be in intensive care and connected to a lung machine for 2 ½ weeks, according to my good friend Dr. Lorenz who is working at the University Hospital Essen. That is a long time and binds a lot of capacity.

The Health Situation in South Sudan

There is no current data on the capacity of South Sudan in regards to intensive care units/beds and lung machines, but if I am being overly optimistic, I would think that there might be 10-20 beds at Juba Teaching Hospital while the population of South Sudan ranges somewhere between 10 and 12 Mio. people. So really, statistically those capacities go towards nil. What does that mean for severe cases in South Sudan that are in need of intensive care and lung machines? It is impossible to say that all would die, but the mortality rate would be trending towards that number (100%).

An additional problem is that the number of people in South Sudan who carry a co-infection (bacterial, viral, parasitic, etc.) is high at any given time and is only bound to increase with the on-set of rainy season which is starting now as it also brings a spike in malaria cases. When I asked Dr. Lorenz how many of the patients in intensive care in Essen were likely to survive if they also had malaria as a co-infection is answer was “most likely none”.

Coronovirus: A hospital in South Sudan — The access to health care in South Sudan is very limited.©Brian Lehmann

Half of the Population is Malnourished

Further compacting the problematic situation is that right now close to 6 Mio. people (half of the country’s population) is undernourished and considered in IPC-phase 3 (crisis) or worse (phase 4: emergency and phase 5: catastrophe). At least 40.000 people are in phase 5 right now and that is what one calls a famine if it correlates with a couple of other factors related to morbidity for example.

Hygiene promotion in South Sudan — Help conducts hygiene trainings in South Sudan.

All the above suggests that the number of severe cases will be higher as people’s immune systems are much more compromised than those of people living in western countries. I have read studies about villages in South Sudan where 60% of schoolchildren were infected with at least one neglected tropical disease (most commonly hookworms).

The age pyramid might be very different in South Sudan, but the general health situation and the absence of a functioning health care system not only negate that advantage, but completely obliterate it. Many villages have no running water, no soap and will be inaccessible for humanitarian aid workers over much of the rainy season.

Unfortunately the combination of these factors suggest that the worst mortality rates that we have seen in Europe will be far surpassed by a country such as South Sudan – but no one will really notice because deaths will most likely be attributed to known illnesses such as typhoid, malaria, pneumonia… because who will be there to test the dead?