DSpace at VNU: Providing health services during a civil war: the experience of a garrison town in South Sudan

This paper describes the dynamics associated with the provision of health services in Malakal, an important garrison town in South Sudan, during the second Sudanese civil war 1983–2005..

Providing health services during a civil war: the experience of a garrison town

in South Sudan

Rob Kevlihan, PhD Executive Director (Designate), Kimmage Development

Studies Centre, Dublin, Ireland, and Visiting Lecturer, Faculty of International Studies, Hanoi National University, Vietnam 1

The impact of conflict, particularly conflict arising during civil wars, on the provision of care is a subject that has not been widely considered in conflict-related research Combatants often target health services to weaken or to defeat the enemy, while attempts to maintain or improve health systems also can comprise part of counter-insurgency ‘hearts-and-minds’ strategies This paper describes the dynamics associated with the provision of health services in Malakal, an important garrison town in South Sudan, during the second Sudanese civil war (1983–2005) Drawing on the concepts of opportunity hoarding and exploitation, it explores the social and political dynamics of service provision in and around the town during the war These concepts provide a useful lens with which to understand better how health services are affected by conflict, while the empirical case study presented in the paper illustrates dynamics that may be repeated

in other contexts The concepts and case study set out in this paper should prove useful to care providers working in conflict zones, including humanitarian aid agencies and their employees, increasing their understanding of the social and political dynamics that they are likely to face during future conflict-related complex emergencies.

health-Keywords: civil war, complex emergencies, health and conflict, health services,

humanitarian assistance, social services, social theory, South Sudan, Sudan, Upper Nile

Background

The Republic of South Sudan declared independence in July 2011, pursuant to the terms of the Comprehensive Peace Agreement (CPA) signed between the Govern-ment of Sudan and the Sudan People’s Liberation Movement/Army (SPLM/A) in 2005 and as a consequence of a referendum on secession held in January 2011.2 Independence came at a price: South Sudan has endured violent conflict for most of the years since Sudan declared independence from Great Britain in 1956 The first Sudanese civil war, often referred to as the Anya-Nya war, after the name given to the rebels, began immediately before independence in 1955 and lasted until the signature of the Addis Ababa Peace Agreement in 1972 This agreement granted South Sudan autonomy within a unitary state The second Sudanese civil war began in 1983 with the mutiny

of the Bor garrison in South Sudan and lasted until the signature of the CPA

Disasters, 2013, 37(4): 579−603 © 2013 The Author(s) Disasters © Overseas Development Institute, 2013

Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

This second civil war was marked by a number of important milestones of ticular relevance to Malakal and the surrounding areas (this account draws mainly from Johnson, 2003; see also Metelits, 2007, 2010) The main anti-government pro-tagonist in this second war was the SPLM/A, which coalesced under the leadership

par-of Dr John Garang, a former military par-officer and member par-of Sudan’s largest ethnic group, the Dinka The Sudan People’s Liberation Army (SPLA) received consider-able support from the Government of Ethiopia during its early years Disagreements among insurgents also led to the formation of the Anya-Nya II militia, composed mainly of troops drawn from the Nuer, South Sudan’s second largest ethnic group Despite its stated goal of independence for South Sudan, Anya-Nya II received back-ing from the Government of Sudan as a counterforce to the SPLA, particularly in the Upper Nile region In Khartoum, the overthrow of Gaafar Nimeiri’s government led to a series of short-lived military and civilian governments between 1985 and 1989

In 1989, the United Nations (UN) was successful in securing the support of the cratically elected government of Prime Minister Saddiq al-Mahdi and the SPLA for expanded humanitarian access in South Sudan, implemented under the umbrella of Operation Lifeline Sudan (OLS) Subsequently, al-Mahdi’s government in Khartoum was overthrown in a military-led coup that placed the National Islamic Front (NIF)

demo-in power

The 1990s also saw a number of significant changes, including the fall of the SPLA Dergue regime in Ethiopia in 1991, and the subsequent exodus of the SPLA from that country This move precipitated a new split in the SPLM/A between the SPLA-Mainstream led by Dr John Garang and opposing factions led by leaders Dr Riek Machar, Gordon Kong (both from the Nuer ethnic group), and Dr Lam Akol (from the Chollo/Shilluk group3).4 These factions, which themselves remained fragmented and largely driven by individual commanders, initially were known as SPLA-Nasir The majority were later integrated into the pro-government South Sudan Defence Forces (SSDF) The northern government increasingly employed them as a proxy for engagement with the SPLA and for the protection of oilfields and government gar-rison towns, including Malakal.5

The final years of the war were characterised by something of a hurting stalemate,

to borrow the term used by William Zartman (2001) This included occasional switches

of allegiance of commanders between both sides, and ultimately conclusion of the CPA after a concerted international effort to bring the two parties to a settlement

Introducing Malakal

Malakal is one of South Sudan’s most significant towns Situated on the White Nile close to its confluence with the Sobat River, it stretches north–south along the Nile’s eastern bank Its importance as an urban centre is underscored by its location relative

to South Sudan’s three largest ethnic groups—the Dinka, the Nuer, and the Chollo/Shilluk—sitting as it does at or close to the intersection of the administrative home-lands of all three groups.6 Malakal straddles the borderlands between the Chollo/

Shillu (located mainly on the banks of the Nile, particularly the west bank, north

of Malakal7) and the Nuer (located on the southern bank of the Sobat River, and along the White Nile River upstream from Malakal), and is in close proximity to Dinka areas (especially those situated inland on the eastern bank of the Nile north and east of Chollo/Shilluk areas) in the vicinity of Maban and Melut

Malakal was an administrative centre for the Upper Nile region during the period

of British-Egyptian condominium, serving as both a hub for the colonial tration and a logistics base for Christian missionaries These missionaries provided one

adminis-of the earliest, rudimentary healthcare systems in South Sudan, typically opening small dispensaries and schools as part of their mission stations The condominium administration allocated different spheres of influence to different Christian denom-inations undertaking missionary activities As a result, the western bank of the Nile north of Malakal town was ceded to the Catholic Church (mainly in Chollo/Shilluk areas), which established mission stations in places such as Detwok and Lul, while Doleib Hill on the eastern bank of the Nile (located to the south of Malakal town) became a key site for the Sudan Inland Mission, a Presbyterian missionary organisa-tion with links to the United States (McLeish, 1927; Dempsey, 1956) These kinds

of small settlements later became sites for social services available outside of the larger towns.8

In the post-independence period, Malakal retained its important position in the

political geography of South Sudan It has been a major entrepôt for trade between the

north and the south, both because its position on the Nile made it a natural off point prior to advancement into the difficult Sudd marshes of the River Nile further south, and because it straddled the dry season roadway connecting Khartoum with Juba (South Sudan’s largest town and new capital) Malakal was a vital com-ponent of the security network that Sudanese government forces tried to maintain along the north/south borderlands throughout both civil wars and was garrisoned by them during the two conflicts Typically, therefore, it contained a relatively higher proportion of northern Sudanese than many other southern garrison towns, a signifi-cant number of which have had tight links to national military and security operations and/or long-distant commercial networks.9 During the second civil war the town was supplied by air and by river barge; road connections were severed early and were not reactivated until after the CPA

The initial phase of the war impacted directly on Malakal, with road access to the town becoming difficult almost immediately This isolation intensified following the shooting down of a Sudan Airways civilian aircraft as it took off from Malakal airport in 1986, leading to a suspension of flight connections for several months As accounts below highlight, 1988 appears to have been a particularly difficult time, perhaps reflecting the strains of a wider famine throughout the south that year Malakal’s continued vulnerability was underscored in 1990 by the kidnapping of aid workers from the centre of the town by the SPLA (see below)

The 1991 split in the SPLA had a relatively positive effect on the security tion in the immediate vicinity of Malakal during the mid-1990s, despite an initial

situa-intensification of military pressure on government forces in Upper Nile This sure reached a dramatic denouement with the failed assault on Malakal town in October 1992 by a poorly armed Nuer militia led by Nuer Prophet Wutnyang Gatakek (Hutchinson, 2005) This aside, the growing dependence of dissident SPLA factions

pres-on northern government support (Young, 2007) appears to have led to strengthened government control in Malakal town itself; these factions later formalised their rela-tionship with the Khartoum government through the signature of a separate peace agreement in 1997 Lam Akol’s mainly Chollo/Shilluk forces, now known as SPLA-United, remained a relatively inactive force thereafter, with this ethnic group largely sitting out the remainder of the war, although Akol himself rejoined the SPLA in

2003 Nonetheless, the degree of stability provided by these arrangements should not

be overestimated While the town itself was relatively secure in the 1990s, tions in its rural hinterland remained unstable owing to continued factional fighting and the unpredictable loyalties of local Nuer militias, including those known col-lectively as the White Army (Young, 2007)

When I first visited Malakal in 2000 on an assessment mission as a humanitarian aid worker, the town showed signs of its colonial legacy: it had a small bricks-and-mortar commercial and administrative centre dating from colonial times perched close to the riverbank with the main military base located nearby The majority of town residents, however, lived in houses made of locally available materials (mud brick with grass roofs) in plots laid out in a rough grid system; each plot generally was demarcated by walls made of woven grasses and/or sticks Stretched along the river, the town was longer than it was wide Makalal was a tense place at that time; a curfew was imposed in the evenings, signalled by the patrol of a government armoured vehicle through the town, while local security services remained wary of expatri-ate visitors.10

Methodology

While my interest in the question of service provision during civil wars was sparked

by my experiences as a humanitarian aid worker, including the aforementioned visit

to Malakal, detailed research for this paper was conducted in 2005 and 2006 as part of

a doctoral dissertation.11 This study draws on more than 30 semi-structured interviews

or informal conversations with aid workers and government employees, together with 13 focus-group discussions in Malakal and surrounding areas Ten of these focus-group discussions were with women participating in an adult literacy pro-gramme in Malakal town and in then government-controlled villages and displaced camps located outside of Malakal (see Table 1)

While a small number of focus-group respondents were recently returned refugees (who usually spoke some English), the majority had been in Malakal or its environs for some time The three remaining focus-group discussions were held with health workers: one with a small group of six community health promoters drawn from the town; a second with group of around 20 health workers working in a health clinic in

the town; and the third with a smaller group of four to six health workers working

in a health clinic located about one hour north of Malakal by boat.13

This fieldwork was conducted at a delicate time in Sudan’s peace process The first visit was in October 2005, soon after SPLA troops had entered Malakal as required under the CPA The town at that time was home to three armed groups: regular government soldiers, SPLA units, and Nuer militias that had been allied to the north-ern government during the war The administration of the town was also in a state

of flux; SPLA-appointed advisers were in place, but a newly appointed governor had yet to arrive

During both visits it was not possible to access locations that had not been under government control during the war Consequently, this paper focuses mainly on dynamics within areas controlled by the northern government Nonetheless, in com-parison to my previous visit, the general security and surveillance situation in the

town had eased considerably The people interviewed were much freer in their

con-versations than would have been possible earlier in 2000 All of those interviewed during my 2005 and 2006 research trips had been in Malakal for an extended period—sometimes throughout the entire second civil war—and tended to be quite open about their experiences, in some cases facilitated in part by having met me during my earlier war-time visit and/or by appropriate introductions via a snowballing approach

Discussions with women’s groups proved more challenging, however Women in focus groups were reluctant to speak publicly about their war-time experiences, par-ticularly those in predominantly Nuer displaced camps located outside of Malakal where focus-group discussions seemed much more constrained in terms of participant

Table 1 Details of participants in adult literacy programmes

Location Date Approximate

number

Ethnicity of participants

Language used by participants

1 Town 13 October 2005 20 Shilluk/Chollo Dhok Chollo 12

2 Town 13 October 2005 20 Murle, Anuak,

and Nuer

Arabic, English (one participant)

3 Town 14 October 2005 8 Shilluk/Chollo Dhok Chollo and Arabic

4 Rural 16 October 2005 15 Dinka, Nuer, and

Shilluk/Chollo

Dhok Chollo

5 Rural 17 October 2005 16 Shilluk/Chollo Dhok Chollo

8 Town 18 October 2005 20 Shilluk/Chollo

and Nuer

Arabic, English (two participants)

9 Town 19 October 2005 8 Shilluk/Chollo Arabic and Dhok Chollo

10 Town 19 October 2005 6 Shilluk/Chollo Arabic and Dhok Chollo

engagement and response than in other locations Given the difficult and uncertain environment in which these women have had to live for an extended period of time, caution in this respect is understandable, and is something I respected as a researcher, electing not to probe or to ask further questions when a reluctance to speak on these issues was discernible.14

This fieldwork was supplemented by a review of the available literature on the second Sudanese civil war, particularly with respect to both Malakal and Upper Nile more generally

Social dynamics: opportunity hoarding and exploitation

This paper offers an analytical framework for understanding the impact of conflict

on social services, drawing on concepts developed by US political sociologist Charles Tilly and his collaborators (McAdam, Tarrow, and Tilly, 2001) This approach focuses

on patterns of social interaction, termed ‘causal mechanisms’, that recur across diverse situations The paper employs two causal mechanisms, namely opportunity hoard-ing and exploitation (Tilly, 1998), as an ideal typical lens with which to examine the effect of the second civil war on the health system of Malakal town and the surround-ing areas It seeks to highlight what occurs in such towns during conflicts Knowledge

of these dynamics can better prepare humanitarian aid workers to face similar ations in the future

‘Opportunity hoarding’ (Tilly, 2005, p 74) happens when ‘members of a ically bounded network acquire access to a resource that is valuable, renewable, subject

categor-to monopoly, supportive of network activities, and enhanced by the networks modus operandi, then excludes others from use of that resource’ In other words, it involves acquiring and maintaining control of a resource and the exclusion of someone or a group from the benefits that can be derived from that resource This process of exclu-sion strengthens those who enjoy access to the resource relative to those who do not, through processes of exploitation Tilly (2005, p 74) defines exploitation as occur-ring when a ‘well connected set of actors controls a valuable resource, harnesses the efforts of others in the extraction of returns from that resource, and excludes those from the full value added from their effort’ For Tilly (1997), exploitation meant a process of extraction of surplus In my view, however, valuable resources need not only be financial or material Exploitation can also increase the prestige, standing,

or social influence of a particular individual or collectivity

Opportunity hoarding draws a border between those with access and those who are excluded; exploitation extracts gains to the benefit of those who control the resource as compared to others who have access, but not control When operating

in tandem, these two mechanisms function to the benefit of those with the capacity

to establish, maintain, and control key brokerage positions For effective opportunity hoarding to take place on an ongoing and stable basis, brokerage occurs in a number

of ways: creating and maintaining exclusive social networks that limit access to some resource, breaking any pre-existing linkages with social sites, groups, or individuals

outside of the network defined by opportunity hoarding processes, and actively venting any new linkages outside of the existing network Exploitation requires that brokers maintain dominant positions within or between clearly defined networks, often at principal ‘choke points’ that enable the extraction of gains or surplus A high degree of coercion is necessarily involved in the creation and maintenance of these networks and of control during civil wars While the focus of this study is on dynam-ics related to the provision of one particular scarce resource—health services—the causal mechanism approach can be useful in understanding dynamics associated with contestation and control of any valuable resource during a civil war.15

pre-War comes to Upper Nile

The commencement of war, brought about by the mutiny of the predominantly southern military garrison at Bor in May 1983, had immediate consequences for the configuration of social services in the Upper Nile region While initial hostilities were internecine in nature—between the newly formed SPLA and rival Anya-Nya II militias—within a year violence had transformed into a more direct confrontation between the SPLA and government forces (Wama, 1997) At the outbreak of hostili-ties, combatants on all sides jockeyed for control and/or sought to deny others access

to key resources It was in this period that patterns of opportunity hoarding of social services observable throughout the war between government-controlled towns and rural areas were established

Periodic raids either by government or insurgent forces targeted rural settlements (including social-service sites such as health clinics and schools) with violence in an effort to institute opportunity hoarding patterns favourable to the war aims of the various combatants Among the first SPLA targets were international companies engaged in prestige projects of national significance By early 1984, a French company involved in the construction of the Jonglei Canal (whose base was located close to Malakal on the Sobat River) and US company Chevron (engaged in successful oil exploration to the west of Malakal) had ceased operations after insurgent attacks (Scott, 1985; Burr and Collins, 1995).16

Instability and violence in rural areas, frequently targeting smaller undefended settlements, was followed by SPLA efforts to place larger garrison towns under siege This in turn led to the progressive isolation of government-held towns in the region Government workers employed in rural areas fled to larger urban settlements, often temporarily while they sought safe passage elsewhere (usually, in the case of Malakal, north to Khartoum), while southern towns also experienced an outflow of populations considered potentially hostile to those in control (such as Dinka living in Malakal).17

At the start of hostilities, river traffic on the Nile and the strategically important dry season truck route from Kosti (located to the north of Malakal) to Juba were among the first targets of insurgent attacks, with river traffic south of Malakal ceasing almost immediately Consequently, only heavily armed military convoys could make over-land journeys, and even then with great difficulty, leaving garrison towns heavily

reliant on air transport (Burr and Collins, 1995) Ultimately, such limited access by land came to an end, with overland access from the north remaining closed for the remainder of the conflict, illustrating the limits of what was possible, even through zones controlled by putatively pro-government militias.18

Establishment of patterns of opportunity hoarding

Before the war, government social services in rural areas largely followed patterns first laid out in the colonial period; small settlements typically were supplied with a school and a small dispensary/health clinic, often accompanied by the presence of Christian churches With the outbreak of war, the services available in these smaller settlements gradually closed or the facilities were evacuated from 1983 onwards However, this process was uneven in the first few years of the conflict Usually it took a violent or threatening event in or near a locality to force final closures during the first few years of the war One missionary interviewed in Sudan in July 2006, who was also present in the region at this time, described the increased insecurity at his mission station at Lul (a small settlement located to the north of Malakal) after the commencement of the conflict Having re-established a foreign missionary presence there after the Addis Ababa Peace Agreement of 1972,19 by 1985 there were two for-eign missionary priests present, together with two nuns, one of whom worked in the government school located in the settlement, while the other worked in a health clinic.20 One Saturday evening in 1985, a group of local cattle raiders, not affiliated

to any political faction, but capable of operating in the area because of the general instability, arrived looking for the priests They claimed that they wanted to take them (forcibly) to a refugee camp in Ethiopia The said priests were not present at the time and so escaped capture They departed the settlement, together with the two remaining nuns, the following morning.21 A few months later the SPLA attacked the settlement Most of the town’s inhabitants left when the assault occurred, fleeing into the bush or to Malakal The area remained under SPLA control for some time there-after and, as a consequence, buildings there were shelled by government barges as they passed on the river.22 An interview with a former Lul resident in October 2005 indicated that, by the early 1990s, the government had regained control of the area While residents of Lul could travel by barge to Malakal with government travel per-mits, they were not allowed to travel overland Foreign missionaries did not return

to Lul until 2001, more than 15 years later, when they celebrated a Centenary Mass They found everything flattened except for the big mission house All of the other buildings had been taken apart and the military had used the bricks to construct

small tukuls.23

Such events were repeated in other mission stations in the Upper Nile region As late as 2000, a Catholic Church website listed nine of 16 parishes in the region as being ‘cared for by catechists’ in the Diocese of Malakal, including Detwoc, Kodok, and Lul, all Catholic parishes on the western bank of the Nile The same contrac-tion occurred in service sites established by other denominations.24

These accounts illustrate the way in which opportunity hoarding patterns were established and maintained outside of Malakal town The SPLA’s capture of Lul provided it with access to physical infrastructure in Lul but not to the services that previously were being provided there Catholic missionaries, who were heavily in-volved in supporting government services in Lul, having evacuated to Malakal, were not permitted to return to the area once it was lost by the government, while non-governmental organisations (NGOs) and others did not work in SPLA-controlled areas in this early part of the war (see below) The SPLA’s occupation of the town was followed by shelling of the settlement by government barges It is possible that the shelling may have been of a defensive nature—the barges being vulnerable to attack from an SPLA-controlled part of the riverbank—yet the effect was nonetheless

to impede the possibility of the SPLA using existing buildings (including a health clinic and a school).25

This forced contraction of social services in rural areas, combined with the ence of government-controlled services in the nearby garrison town of Malakal, had a net effect that was favourable to the government All benefits associated with the provision of social services became concentrated in its administrative and mil-itary centre to the detriment of areas located outside of its control, albeit at levels that could not match demand and under extremely challenging conditions

The involvement of missionaries in the health sector, which was an important part

of their work in rural areas, appears to have been scaled back after their forced cation to Malakal, with energy, at least with respect to the Catholic Church, seem-ingly focused more intensely on protecting their presence in the educational sphere.26

relo-Catholic missionaries displaced from missions such as Detwoc and Lul opened a school in Malakal town, for instance The pressure of the war often was too much, however, even in Malakal The displaced missionaries of Doleib Hill, for example, were forced to close a high school/training school for primary teachers, catering for some 1,000 students, in Malakal town after the outbreak of the war (Swart, 1998).27

These patterns remained in effect into the early 1990s; the retaking of Lul by the government, for instance, did not improve services there As a mainly military base, access to the site continued to be restricted to civilians, while the remaining mate-rials from the school and the health clinic were dismantled and used to build shelters for government troops

This pattern was repeated across the region and South Sudan more generally Shalita (1994) provides some data on the contraction of health services in the Upper Nile region The number of functioning hospitals, which had increased from seven in

1973 to 11 in 1983, was reduced to only two by 1988 (including Malakal Hospital).28

The ratio of doctors per 100,000 population was estimated to be 0.7 in Upper Nile,

as compared to 98 per 100,000 in Khartoum, with only one civilian doctor working

in Malakal Hospital (Duku, 1998) This focus on limitations in functioning facilities and medical personnel belies another important factor: the acute difficulties of pro-viding healthcare even with the limited resources on offer The only vaccines available

in the town, for example, were those flown in on specially chartered United Nations Children’s Fund (UNICEF) aircraft (Dodge and Ibrahim, 1998)

Exploitation within Malakal

This concentration of available services in Malakal established a boundary between those who could access a valuable resource (health services) and those who could not Insecurity caused by the war also had the effect of concentrating civilians into zones controlled by either one side or the other—typically, at this early stage of the war,

in government-controlled garrison towns, or in SPLA-controlled refugee camps in neighbouring countries, particularly Ethiopia

At the outset of the war, large numbers of people began flooding into Malakal from rural areas despite a lack of resources in the town to support them While inter-nally displaced persons (IDPs) appear to have been allowed access to the town itself

in the early years of the conflict, government opportunity hoarding and exploitation practices later came to prominence IDP camps were set up outside the environs (and security cordon) of the town, for example.29 This excluded IDPs from easy access

to what little social services were available in the town (opportunity hoarding) while also enabling their use as potential human shields (exploitation) in the event of an attack on the town This pattern was repeated in Wau,30 a town located in the west-ern part of South Sudan, where government forces shelled IDP camps during the attempted seizure of the town from within in early 1997.31

Even for those who managed to access services in the town, exploitation by ernment soldiers of their labour made life difficult, if not impossible Hutchinson (1996), for instance, notes the movement of 117 people from Ler to Malakal by river

gov-in June 1988 They found conditions gov-in Malakal to be better than those gov-in Ler—the hospital was still functioning and they could access healthcare there.32 However, pres-sure from the security forces, particularly arbitrary seizure of charcoal and other items the people tried to sell to survive, convinced them that ‘the evil ways of the Arabs’ were still present (Hutchinson, 1996, p 16) Hence, subsequently they relocated to Khartoum.33 The situation in Malakal further deteriorated in August 1986 with the shooting down of the aforementioned Sudan Airways aeroplane by the SPLA in the belief that it was transporting military personnel (Simone, 1994) Consequently, all relief flights were suspended for several months, leading to a cut off of essential sup-plies The result was intensified patterns of exploitation of scarce resources in the town, with the solidification of a monopoly on commercially available food in the market run by the military and local merchants and the selling of food produced or appropriated by the pro-government Anya-Nya II militia, which at the time exer-cised a degree of control over areas outside the town (Cheatham, 1993)

While Cheatham (1993) states that mass starvation did not occur in Malakal at this time, reference was made in focus-group discussions in Malakal town in 2006 to particularly difficult periods in the 1980s, including around the time when the air-craft was shot down This is confirmed in part by other accounts One respondent interviewed by Taban (1998) in a settlement area for displaced people in Khartoum, for example, noted that two of her brothers died of starvation in Malakal in 1986.34

Interviews with people in Malakal also indicate that many left the town for the north around this time, taking a chance on barges that were subject to attack from the

riverbank NGOs were poorly positioned to respond, with only one international NGO—the Lutheran World Federation—together with a handful of missionaries, reportedly working on the ground.35

Difficulties experienced by inhabitants of the town were not confined to the matter

of food security Both 1987 and 1988 were famine years throughout South Sudan—see, for example, Keen (1994) for an account of the dynamics associated with this famine in another part of South Sudan 1988 appears to have been a particularly dif-ficult year One interviewee (interviewed in July 2006) described the 1980s as a time

of fear To paraphrase, the interviewee (who spoke in Sudanese Arabic) said that, during this time, if you were found on the street you were caught and killed and your body was dumped in the river While it was unclear from the interview how long this state of fear persisted, clearly it left a deep impression on the respondent This vulnerability of civilians to arbitrary violence by security forces continued through-out the war, although its intensity varied In one focus-group discussion in Malakal town (held in July 2006), health workers indicated that the 1980s were more difficult than the 1990s Residents said that they believed themselves to be under constant surveillance, while their homes were subject to searches by the military or by the security services at any time of the day or the night Young women were particularly vulnerable to being taken as ‘wives’ by military or security officials,36 with families left with little choice but to acquiesce.37

Government security forces in Malakal also appear to have been greatly cerned with the potential for treachery from within the town itself, especially by anyone perceived to be in a leadership position This paranoia had important impli-cations for health-service providers in the town, as educated southern men received considerable attention from security forces.38 The situation of doctors of southern origin is a case in point While there was one remaining civilian (southern) doctor

con-in Malakal Hospital until 1988, con-interviews with health staff con-in the town con-indicate that,

by the end of the 1980s, no doctors remained.39 This left the hospital under the care

of medical assistants for sustained periods of time The loss of doctors throughout the 1980s may have been due in part to the collapse of the health system and the consequent difficult working conditions However, interviews in Malakal also re-vealed that South Sudanese doctors working there had been forced to leave one-by-one owing to official pressure, including arrest and interrogation by the government’s intelligence services According to an interview with a health worker present at the time (conducted in July 2006), the last practising southern doctor present in Malakal, who was from the area, was arrested in Malakal Hospital during working hours; he left the town soon thereafter By the late 1990s, doctors were once again being posted

to Malakal Hospital from the north, normally on short rotations as part of national service But, reportedly, no southern doctors were sent to the hospital during this time Interviews conducted in Malakal also show that other health workers were sub-ject to arrest and physical abuse as well Health workers interviewed reported that National Security officers arrested 11 male health workers at Malakal Hospital in 1987 They were accused of being part of a fifth column in the town, a charge reflecting

fears within the garrison regarding the allegiances of southerners After arrest they were reportedly interrogated separately by northern security officials Interviewees said that the interrogations were accompanied by beatings with fists and sticks They were released after 12 days in detention when the governor (who had been approached by concerned people in the town) appealed to the head of the military garrison The gendered nature of these counter-insurgency tactics also is highlighted

in this case and it came up during interviews—educated men, rather than women, were the main target of the security forces when crackdowns occurred.40

Furthermore, there seems to have been consistent paranoia on the part of the security services with respect to civilian drug supplies and the possibility that drugs might find their way to insurgents One health worker interviewed in July 2006 mentioned the permanent presence of National Security officials at the hospital, for instance, chiefly to monitor who was coming and going—particularly those with drugs Given the generally difficult health conditions associated with living in South Sudan, measures to deny medicines to insurgents may have constituted an effective counter-insurgency tactic from the government’s perspective, especially in the 1980s, prior to the initiation of the OLS.41

Interviews with several former government employees of southern origin firmed that government surveillance included close scrutiny of southerners work-ing within all government agencies in Malakal, as well as those working for NGOs According to one well-educated Sudanese employee of an international NGO, if you were a prominent educated southerner in Malakal you needed to have some kind

con-of relationship with Military Intelligence to protect yourself—in other words, you had to be known to it.42 Interviews held in Malakal in July 2006 also highlighted

that security services maintained a centre known as Chamsa Beyut (literally ‘Five

Houses’) in the town where those under suspicion were taken for interrogation, which often involved being kicked and beaten, and in some cases, reportedly resulted in the death of those detained

These instances point to an important tension between opportunity hoarding processes and patterns of exploitation The security service’s paranoia about educated southerners and control of medical supplies had a direct bearing on the capacity of Malakal Hospital to provide treatment and care, as it lost the services of doctors for extended periods of time, while access to the facility itself was constrained by govern-ment surveillance activities These factors, which appear to have revolved around suspicion that health services or supplies might be provided to insurgents or to those sympathetic to them, related to the government’s imperative to hoard opportunities associated with the delivery of services However, in seeking to impose its control over the hospital, the constraints placed by the government on the delivery of services lessened the potential for any gains with respect to ‘hearts and minds’ through the provision of services in the town, owing to the deterioration in the quality of services being offered

Nonetheless, despite the pressure being placed on health- and other social-service personnel, particularly in the 1980s, the government continued to permit the pro-vision of healthcare services, supported by international NGOs, in Malakal town