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When the first case of cholera showed up – at a checkpoint where people fleeing the war in Sudan crossed into South Sudan for safety – Dr. Mary Alai and her colleagues were waiting.
Since the conflict escalated into open violence in April 2023, a team of health care workers from the International Organization for Migration in South Sudan – the UN Migration agency – had been providing immediate medical assistance for refugees and South Sudanese returnees at five border crossings in South Sudan. Some issues, like skin and eye infections, physical trauma, exhaustion, and hypoglycemia, could be cared for on the spot. Others, like chronic kidney disease, required swift access to dialysis and hospital care.
“They arrived in really dire condition,” Dr. Alai said of the people fleeing into South Sudan. “All of this is related to what people have gone through.”
From the beginning, IOM South Sudan’s medical team was on the lookout for cholera – a bacterial disease that spreads via contaminated water or food and that can kill quickly through dehydration, especially when instability or lack of resources limits access to supportive care. Waves of outbreak in the country between 2014 and 2017 were closely tied to civil war and displacement in the larger region. Those fleeing the conflict were sheltering in close quarters with limited access to safe drinking water. The eye and skin conditions the team was already seeing were indications of inadequate sanitation. And cases of cholera had recently been reported in Sudan, where attacks on water infrastructure were correlated with increased cholera deaths.
“Where there’s massive population displacement, we know the risk of transmission is higher,” Dr. Alai explained. In a situation like this, “it’s just a matter of time” before cholera appears.
IOM staff care for patients at a mobile clinic set up at a border crossing area in South Sudan. (Courtesy photo)
Cholera was found in South Sudan in late September of 2024: A four-year-old child and her mother were the first diagnosed cases, and Renk County, near the border with Sudan, quickly became the most affected of the border crossing areas. The South Sudanese government declared an outbreak in October, and the disease spread quickly, causing more than 33,000 cases by April of this year.
An essential partnership
But IOM South Sudan’s vigilance had prepared them.
Direct Relief, an IOM partner, had been collaborating closely with medical staff, and dispatched a large-scale shipment of cholera treatment supplies, such as oral rehydration solution and IV fluids; 12 emergency medical backpacks; and other essential medical supplies, including additional oral rehydration solution, that IOM staff received in mid-October.
Equipped with the cholera treatment and emergency medical packs, IOM’s Rapid Response Team deployed to help contain the outbreak, setting up four cholera treatment units and numerous oral rehydration points to provide supportive care for people with cholera symptoms.
An IOM South Sudan staff member prepares Direct Relief medical support for distribution to field locations. (Courtesy photo)
Although vaccines do exist for cholera, and antibiotics are sometimes recommended for severe cases, supportive care – particularly rehydration to replace the fluids and electrolytes lost through diarrhea and vomiting – is widely acknowledged to be the most important aspect of treatment. The vast majority of cholera patients will recover with supportive care, but an untreated case can quickly kill someone.
Direct Relief’s caches of cholera response supplies “can manage both the severe and the mild cases, so it really came in handy,” Dr. Alai explained. “We were able to control the cases in the community.”
In addition, she said, the analgesics, antibiotics, and other first-line treatments in the “meticulously packed” emergency medical packs were essential for patients experiencing pain, exhaustion, and infection. “It was really helpful at that point.”
A flexible approach
Dealing with the cholera outbreak demanded outside-the-box thinking. Because IOM South Sudan’s staff were working at border crossing points, their patients were virtually on the move, often by boat, which meant that providing on-the-spot care alone wouldn’t be enough. Medical staff trained local boat workers to monitor sanitation on board and to administer oral rehydration solution – the most important treatment for cases of cholera – to anyone who showed symptoms of illness. When people docked at Melut, on their way to safety in the South Sudan city of Malakal, medical teams came onboard to assess people and transfer patients in need of more comprehensive care to a local hospital.
“It’s a modality we had to adopt to manage the situation,” Dr. Alai explained.
Patients receive care at the Cholera Treatment Center at Mayom Hospital. (Courtesy photo)
She recalled one pregnant mother, traveling with her children, who became ill while traveling by boat. IOM’s medical team transferred her to the hospital with her children, where she received five days of treatment before traveling on to Malakal.
“A flexible approach” was essential throughout, Dr. Alai said. Even when people arrived at a border crossing with cholera symptoms, and could be cared for at an IOM-run health facility, their families needed cash assistance.
A mother with six children, one of them sick with cholera, might decide “to leave one behind and save the other five” without money to feed them, she explained. “We are happy they didn’t have to make that decision.”
A New Response
Although IOM South Sudan’s original focus had been on providing care to the refugees and returnees at the border crossings, staff members soon got word that Mayom County – an area of South Sudan that’s hard to reach due to flooding patterns and that has a high number of nomadic, pastoralist communities – had been badly affected by cholera.
“It happened so fast that, within one week, 70 people had died,” Dr. Alai recalled.
IOM staff deployed another team to Mayom – also equipped with Direct Relief medicines and supplies – and mounted a comprehensive response. They established an additional cholera treatment unit and a hospital-based treatment center, but again, Dr. Alai said, an innovative response was called for. When people from nomadic communities contracted cholera, they traveled long distances – sometimes for days – to access care.
“People were dying on the road on the way to the facilities,” she explained.
Healthcare workers administer oral rehydration solution via a mobile rehydration point in Mayom County. (Courtesy photo)
Patients who were severely ill often needed to be transported over floodwaters in canoes – a harrowing journey that made supportive care more difficult.
IOM staff set up additional oral rehydration points in cholera-affected areas – places where people with cholera could receive supportive therapies for the disease. Community health workers traveled along the roads, treating people with cholera symptoms as they encountered them. Canoes were outfitted with oral rehydration solution, and community health workers traveled with sick patients to administer treatment. IOM teams rehabilitated a community water source and constructed new sanitation facilities to keep the disease from spreading.
A widespread impact
Asked which elements of IOM’s response were most effective, Dr. Alai pointed to the most unusual ones: the mobile oral rehydration work (oral rehydration points are usually stationary in affected communities) and partnering with and training boat union workers. However, she stressed, a “multifactorial approach” is needed in a complex disease outbreak like this one.
IOM staff educate people about cholera risk at a clinic in Malakal, South Sudan. (Courtesy photo)
Since April 2023, more than 1.1 million people have crossed the border from Sudan into South Sudan. In addition, it’s estimated that more than 50,000 people in South Sudan, including refugees and returnees, contracted cholera during this outbreak, and over 1,000 died from the disease.
But IOM’s presence has had a significant, lifesaving impact. More than 498,000 people received medical assistance from IOM South Sudan’s staff. Five cholera treatment units and a hospital-based treatment center, along with 21 stationary oral rehydration points, have treated thousands of patients.
Cholera is not yet fully contained in South Sudan. However, in Mayom County, an average of 50 people were hospitalized with cholera each day when the outbreak was at its worst. That number has dropped to one.
Direct Relief’s Research and Analysis modeling estimated that the organization’s supplies, about $54,000 in total value, averted 9,450 cholera cases and 366 deaths.
A new Direct Relief shipment containing two additional cholera treatment kits and a large-scale emergency health kit arrived in South Sudan on May 13 for IOM’s medical staff. More shipments of cholera treatment supplies are currently en route to the region.
Aaron Rabinowitz and Mila Dorji contributed reporting to this story.
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