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Pieri violence: “I knew we had to prepare for the worst”

Istifanus Chindong Damulak, MSF Medical Team Leader in Lankien, South Sudan, gives a personal account of the violence in and around Pieri this May, that killed over 200 people – including an MSF staff member – and left a further 300 wounded.

“My wife has just given birth this morning and is still in the health facility. All the staff are now on the run to the bush for safety. I can see smoke from the burnt tukuls just across the airstrip.”

These were the first words I heard from our MSF Health Facility Supervisor. It was 16 May and 6am - an unusual time for our regular daily call. I knew then, seeing the phone ring, this was an emergency situation.

He told me of the violence that had erupted in Pieri. By 7am the news had broken in Lankien – the town around 50km north of Pieri were I work in the MSF hospital. From the hospital window, where the local authority office is just opposite, I saw military trunks loading several hundred armed youths as they headed for Pieri.

The safety of the team in Pieri was my biggest concern. I was just there and had only returned to Lankien a week earlier. What would happen to our staff who live there? Run to the bush? How? Where? We had no bunker in Pieri.

Having been through this only two months earlier, I knew we had to prepare for the worst. I called an emergency meeting and updated all the MSF team – both medical and non-medical – that our mass casualty plan was being activated. I told them we should remain in emergency mode, prepared to react at any moment in the day, when the injured would inevitably arrive to us.

But it was also different to the violence we saw two months ago. Now the COVID-19 pandemic had reached South Sudan. I was thinking immediately how I could ensure physical distancing during a mass casualty, knowing fully well we had confirmed coronavirus patients in Lankien and there was very likely already community transmission. What came to mind immediately was to order enough surgical masks and other protective equipment for the entire staff involved in the mass casualty.

At 9pm I was called to the ER (emergency room). They had received some casualties. I went quickly. I noticed straight away six injured patients, all with several gunshot wounds lying on the ER floor. I checked outside and I saw three military trucks fully packed with injured patients. Everyone was shouting for help.

Within a few minutes the ER was full with staff - most of whom had already finished for the day. We received 20 patients at once, all men with gunshot wounds, many with severe injuries. One patient died on arrival and another with gunshot wound through the chest died 20 minutes later while on blood transfusion. Of the 16 patients left that were admitted, only two were discharged that night.

Over the next days we continued to receive wounded people. Over four days – from 16-20 May – we received and treated a total of 63 wounded people in Lankien Hospital – including two of our team members. All had gunshot wounds. Two days into the violence, some of the staff who had fled the violence in Pieri had started to return and incredibly they went straight to work at the health facility. They received and treated an additional 19 people with gunshot wounds.

My mother is old and she stayed with small children in Pieri, she cannot run. I went to save her but I was ambushed. Several people were shot dead in front of me. I was trying to help some injured with first aid and someone told me I am bleeding. I sustained two gunshot I was bleeding too much. I gave up, [believing] that I am going to die.

– MSF staff member

Even after the violence had subsided we still continued to receive patients days later, many with septic wounds from abdominal gunshot injuries. I felt very emotional and helpless at some point because all referral options for surgeries were closed. With COVID-19 community transmission concerns it was incredibly hard to refer patients. I saw our patients with abdominal wounds deteriorating and I couldn’t do anything to help.

Over 200 people died in this latest wave of violence. An estimated 300 more were injured.

After the attack most serious cases were referred by plane to the MSF hospital in the Protection of Civilians (PoC) site in Bentiu. MSF medical staff (left to right: Mariel Selter [medical activity manager], Waltraud Gebhard [head nurse], Suzanne Doeland [nursing activity manager]) assess the condition of 10 years old Nyaduoth in the ER of the MSF hospital in Bentiu Protection of Civilians (PoC) site. Nyaduoth suffered several stab wounds and was transferred from Lankien to the MSF hospital in Bentiu PoC to undergo surgery.

For our team it was also very personal, with one of team members killed in the violence. I had been with him just a week earlier and now he was gone. It was – and still is – incredibly traumatic for the team in Pieri. The Pieri team is like one family, they are a community and very committed. It will take some time for this pain of losing a team member to ease.

I went to Pieri five days after the attack and the town was empty, with only a few men and youths around. It felt like a ghost town with every woman and child still in the bush. Some of our staff approached me. This is what they told me:

I am scared, I lost all my friends in the town. I can’t sleep at night. I felt better at work but once I am at home I am scared.

Last week I lost my uncle, someone shot and killed him. This week my senior brother was killed in this attack. Now I am alone, there is nobody to help me.

My tukul was burned, I lost everything. I only escaped with these clothes. There is no market now to buy anything, all the traders were killed defending their shops.

I grew up in Kenya, I just came back because of this job. I have never seen something like this in my life. I ran for six hours in the bush. I lost my shoes, my legs are swollen and painful now. I want to leave.

It’s hard to deal with these events. I cannot forget the moment I was strapping eight patients with the seatbelts on a tiny plane, all with severe abdominal gunshot wounds being airlifted for referral. I knew full well that they all needed to be on a stretchers, but the stretchers would take up more space on the plane, limiting the chances of others to be evacuated, with no guarantees of any other flight. But I cannot also forget the moment we received these discharged patients, all arriving back in Lankien having recovered.

Waves of clashes in Jonglei State and the Greater Pibor Administrative area in eastern South Sudan continue to have a devastating impact on people. This month thousands of people have fled into the bush in the Greater Pibor Administrative area in eastern South Sudan as intense fighting over several days, which started on June 15, yet again threatens the lives of entire communities. The new and brutal rise in violence has led MSF to suspend our medical activities in Pibor after most of our staff sought safety in the remote bush area


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