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

doi:10.1111/disa.12027 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, Vietnam1 The impact of conflict, particularly conflict arising during civil wars, on the provision of healthcare 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 healthcare 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 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 Government 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 580  Rob Kevlihan   This second civil war was marked by a number of important milestones of particular relevance to Malakal and the surrounding areas (this account draws mainly from Johnson, 2003; see also Metelits, 2007, 2010) The main anti-government protagonist in this second war was the SPLM/A, which coalesced under the leadership of Dr John Garang, a former military officer and member of Sudan’s largest ethnic group, the Dinka The Sudan People’s Liberation Army (SPLA) received considerable 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 backing 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 democratically 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) in power   The 1990s also saw a number of significant changes, including the fall of the proSPLA 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 garrison 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 homelands of all three groups.6 Malakal straddles the borderlands between the Chollo/ Providing health services during a civil war: the experience of a garrison town in South Sudan 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 administration and a logistics base for Christian missionaries These missionaries provided one 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 denominations 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 organisation 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 stoppingoff 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 component 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 significant 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 situation in the immediate vicinity of Malakal during the mid-1990s, despite an initial 581 582  Rob Kevlihan intensification of military pressure on government forces in Upper Nile This pressure 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 on northern government support (Young, 2007) appears to have led to strengthened government control in Malakal town itself; these factions later formalised their relationship with the Khartoum government through the signature of a separate peace agreement in 1997 Lam Akol’s mainly Chollo/Shilluk forces, now known as SPLAUnited, 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, conditions in its rural hinterland remained unstable owing to continued factional fighting and the unpredictable loyalties of local Nuer militias, including those known collectively 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-andmortar 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 expatriate 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 programme 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 Providing health services during a civil war: the experience of a garrison town in South Sudan Table Details of participants in adult literacy programmes Location Date Approximate number Ethnicity of participants Language used by participants Town 13 October 2005 20 Shilluk/Chollo Dhok Chollo12 Town 13 October 2005 20 Murle, Anuak, and Nuer Arabic, English (one participant) Town 14 October 2005 Shilluk/Chollo Dhok Chollo and Arabic Rural 16 October 2005 15 Dinka, Nuer, and Shilluk/Chollo Dhok Chollo Rural 17 October 2005 16 Shilluk/Chollo Dhok Chollo Rural 17 October 2005 20 Nuer Nuer Rural 17 October 2005 Nuer Nuer Town 18 October 2005 20 Shilluk/Chollo and Nuer Arabic, English (two participants) Town 19 October 2005 Shilluk/Chollo Arabic and Dhok Chollo 10 Town 19 October 2005 Shilluk/Chollo Arabic and Dhok Chollo Total 141 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 northern 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 comparison to my previous visit, the general security and surveillance situation in the town had eased considerably The people interviewed were much freer in their conversations 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, particularly those in predominantly Nuer displaced camps located outside of Malakal where focus-group discussions seemed much more constrained in terms of participant 583 584  Rob Kevlihan 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 hoarding 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 surrounding 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 situations in the future   ‘Opportunity hoarding’ (Tilly, 2005, p 74) happens when ‘members of a categorically bounded network acquire access to a resource that is valuable, renewable, subject 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 exclusion strengthens those who enjoy access to the resource relative to those who not, through processes of exploitation Tilly (2005, p 74) defines exploitation as occurring 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 Providing health services during a civil war: the experience of a garrison town in South Sudan outside of the network defined by opportunity hoarding processes, and actively preventing 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 dynamics 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 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 hostilities, 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 overland journeys, and even then with great difficulty, leaving garrison towns heavily 585 586  Rob Kevlihan 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 foreign 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 thereafter 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 permits, 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 contraction occurred in service sites established by other denominations.24 Providing health services during a civil war: the experience of a garrison town in South Sudan   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 involved 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 nongovernmental 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 presence 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 military 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 relocation to Malakal, with energy, at least with respect to the Catholic Church, seemingly focused more intensely on protecting their presence in the educational sphere.26 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 materials 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 providing 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) 587 588  Rob Kevlihan 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 internally 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 western 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 government 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 in June 1988 They found conditions in Malakal to be better than those in Ler—the hospital was still functioning and they could access healthcare there.32 However, pressure 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 supplies 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 exercised 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 aircraft 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 Providing health services during a civil war: the experience of a garrison town in South Sudan 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 difficult 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 throughout 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 concerned with the potential for treachery from within the town itself, especially by anyone perceived to be in a leadership position This paranoia had important implications 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 in Malakal Hospital until 1988, interviews with health staff in the town 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 revealed that South Sudanese doctors working there had been forced to leave one-byone 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 subject 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 589 590  Rob Kevlihan 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 confirmed that government surveillance included close scrutiny of southerners working 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 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 government 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 provision of healthcare services, supported by international NGOs, in Malakal town Providing health services during a civil war: the experience of a garrison town in South Sudan throughout this period Its surveillance and control of these services and of personnel working in these sectors represented its form of opportunity hoarding in action, preventing health and other services from being offered to individuals or populations that might be associated with the SPLA However, the SPLA was not without its own ability to strike back In an echo of previous raiding patterns that shut down service provision in rural areas in the initial stages of the war, in early 1990 the SPLA kidnapped two employees of Médecins Sans Frontières (MSF)-Belgium from their residence in central Malakal during the night While they were eventually released unharmed, MSF-Belgium closed its country programme in Sudan as a consequence (Minear, 1991).43   Interviews conducted in Malakal in July 2006 indicated that local personnel at the hospital where the MSF-Belgium staff worked were surprised that the SPLA could penetrate so far into the centre of the town Given the situation in the town at that time, though, they did not ask any questions—according to one staff member who worked there, in those days you had no information Health workers interviewed also pointed out that, in the wake of MSF-Belgium’s pull out, there was no significant health intervention by an international NGO in the health sector in Malakal until early 1999 when GOAL Ireland established operations there   This event is of note for a number of reasons: it highlights the limits of the government’s capacity to exercise complete coercive control over the town, illustrated by the ability of an armed SPLA contingent to enter and exit the town, hostages in hand, and demonstrates a significant breakdown in government security force capacity (presumably with some inside assistance) From the SPLA’s perspective the action also was effective in undermining government exploitation of health services by denying the civilian population of the garrison access to the health services provided by an international NGO   The denial of health services to insurgents and to populations believed to be associated with them was not confined to everyday healthcare It also extended to the provision of medical services to injured enemy combatants In October 1992, Malakal town was attacked by ill-equipped forces loyal to Wutnyang Gatakek Gatakek, a local prophet from the Nuer ethnic group, assured his followers that government bullets would not pierce their spiritual armour The surprise attack succeeded in overrunning the town’s military barracks (Hutchinson, 2005) Interviewees in Malakal said that the invading forces entered the town proper, where they were halted by government troops The local civilian and military hospitals were not affected by the fighting and, in theory, should have been able to provide assistance to anyone wounded, including enemy combatants However, health workers at both facilities interviewed individually or as part of focus-group discussions (in October 2006) stated that they did not see many southern casualties; 44 the Sudanese army did not take any prisoners—summary execution of captured insurgents being the norm Even town residents of southern origin (particularly Nuer) caught in the wrong place were at risk Only those who were ‘known’ to the authorities would risk seeking treatment at the civilian hospital at this time.45 591 592  Rob Kevlihan Government hearts-and-minds efforts Changes in the alignment of SPLA factions in the 1990s had an important bearing on the configuration of social services in the Malakal area In the immediate aftermath of the SPLA’s split in 1991, SPLA-Nasir established its own relief arm, the Relief Association of Southern Sudan (RASS), as a competitor to the SPLA’s equivalent Sudan Relief and Rehabilitation Association (SRRA) (Rolandsen, 2005) While international organisations provided services in areas controlled by Akol and Machar in the initial period that followed this division of the SPLA, OLS operations in Akolcontrolled areas ended after the 1997 peace accord that he signed with the Khartoum government (Bradbury, Leader, and Mackintosh, 2000), while OLS assistance to Machar-held areas appears to have tapered off in the mid-1990s (Lowrey, 1996)   Within the garrison town and its satellite IDP camps, the Khartoum government attempted its own version of a hearts-and-minds campaign around this period Donald Petterson (1999), the US Ambassador to Sudan at the time, describes two visits to Malakal, in 1993 and 1994 During the first, in September 1993, he found only Sudanese NGOs working with IDPs in the vicinity of the town He points out that four of five operational agencies were Islamic in orientation, and on that trip and a subsequent one a year later, found evidence of attempted Islamisation in IDP camps by at least one agency, Da’wa Islamiyya During the second visit just over a year later, he reported that the situation had changed somewhat, with some of these IDPs now receiving support from the International Committee of the Red Cross (ICRC) and UNICEF Access problems for non-Islamic organisations reportedly persisted with respect to two camps: Obel, where Da’wa Islamiyya was working (focusing mainly on schools teaching the national Islamic curriculum); and another unnamed camp located on the opposite bank of the Sobat River near the Jonglei Canal   The use of Islamic NGOs by the Khartoum government was part of a fitfully implemented attempt to sustain hearts-and-minds evangelisation programmes in areas under its control These NGOs reportedly operated as part of the so-called Comprehensive Call (ad-da’wa as-Shamla) Islamisation programme The importance of these services in consolidating government control in these regions was acknowledged by the Governor of Upper Nile, who said that these services provided citizens with the feeling that, for the first time, there was a government (de Waal and Abdel Salam, 2004) International NGO staff were reportedly barred from working anywhere in government-controlled areas of the south and the ‘transition zone’ between northern and southern Sudan during the period of Petterson’s visits (Burr and Collins, 1995; Petterson, 1999) However, it appears that in the Malakal area at least, these Islamic NGOs suffered from capacity constraints Petterson— a potentially partisan source given US relations with Khartoum at the time—for example, reports observing significant needs in camps served by these organisations during his visits His account was partially confirmed by the fieldwork for this study A representative of an Islamic NGO (interviewed in October 2005 in Sudan), familiar with conditions in the Upper Nile region, mentioned problems with the operational capacity of Islamic NGOs owing to heavy reliance on volunteers or those doing national service, resulting in high staff turnover and a lack of operational continuity 46 Providing health services during a civil war: the experience of a garrison town in South Sudan Return to the status quo Ultimately, while such efforts appeared to have been a prominent part of Khartoum’s approach in the mid-1990s, the government seems to have become less committed to this programme in the late 1990s International NGOs were allowed back into Malakal around this time, for example This may reflect in part the marginalisation of some of the more ideological elements of the governing NIF that occurred following the ouster of Islamic ideologue Hassan al-Turabi and his supporters from the NIF government around this time   The manipulation of services for such purposes should also be placed in context: available health services remained rudimentary and under-resourced throughout this period Inside Malakal town, limited health services were available from the civilian hospital and local clinics For much of the 1990s these services were understaffed, under equipped, and essentially defunct The town also had a military hospital, which, at least one interview indicates, was better stocked than the civilian hospital However, because of its military status, access to the hospital was officially restricted to military personnel and their families Nonetheless, interviewees stated that other northern Sudanese residents of the town also were able to access healthcare there in preference to the civilian hospital   Similar patterns of surveillance and control to those discernible in the 1980s also persisted into the late 1990s, with access to the town often far from guaranteed Aid workers and missionaries were kept under watch when they were permitted to work in Malakal at all.47 The intelligence services imposed control over the movement of personnel involved in social-service provision through the employment of travel permits—processes reminiscent of closed district ordinances imposed by the British during the colonial period For expatriates, permits to travel to southern garrison towns frequently were difficult to acquire from the government in Khartoum and had to be presented to security officials on arrival in Malakal Further permits (for both Sudanese and expatriates) had to be procured locally in Malakal for any travel outside of the town itself Interviews with NGO representatives and ministry of health employees in Malakal revealed that all NGOs, including personnel from Islamic NGOs such as Da’wa Islamiyya and the Global Health Foundation, Sudanese Red Crescent, and even ministry of health vaccination teams had to receive permission from the authorities to travel outside of the town This provided the administrative means for the authorities to regulate the movement of NGO and other social-service personnel and determined where particular NGOs could work at any given time   Health activities in rural areas either controlled by the government or by progovernment militias were kept to a minimum until after the 2002 ceasefire that preceded the CPA Even post ceasefire, it was not possible to provide services from Malakal to SPLA-controlled areas.48 A rare exception were the vaccination campaigns staffed by ministry of health personnel (usually with support from UNICEF) These teams also needed travel permits to leave Malakal and were required to report to government security officers at each village visited In some instances security officers prevented them from vaccinating outside the immediate environs of targeted villages However there was no requirement for these teams to be accompanied by a security official,49 593 594  Rob Kevlihan giving them a little bit more latitude in some instances, although this was not without risk.50 This absence of social services in government-controlled areas was apparently not matched by an increase in services in insurgent areas under OLS, at least in this part of Upper Nile A report issued in 2005, based on field research conducted in 2000–01 confirms this point, noting that, with respect to health services in SPLA areas, primary healthcare coverage was best in areas located well to the south of Malakal town—all in SPLA zones quite distant from the locations discussed above (Muchomba and Sharp, 2005).51   The CPA brought with it a slow unwinding of the patterns of opportunity hoarding and exploitation established during the conflict While NGOs remained prevented from providing services in areas not under government control for some time—including, in 2006, in areas controlled by Nuer militias opposed to the SPLA—peace brought with it the ability of people to move more freely between rural and urban areas, and thus increased their capacity to access available healthcare As security conditions improved, new or reconstructed health facilities were slowly opened up in areas that had been inaccessible during the war, with the Nile River serving as the main artery for the resupply of these new health posts Levels of surveillance also fell dramatically Ultimately, the end of the war led to the termination of the processes of opportunity hoarding and exploitation that had occurred with respect to health services Conclusion How, then, to analyse this local case study? As is clear from the narrative above, opportunity hoarding and exploitation featured prominently This was not merely in the denial of services in rural areas, but also in terms of access to health services— with northern Sudanese and the military obtaining care unavailable to the general population at the military hospital   Exploitation was most obvious in Malakal in relation to the town–non-town border, both with respect to reports of taxing by soldiers of women seeking to re-enter the town with produce, and on a more macro scale, with regard to the situation of IDP camps outside of town, providing potential hostages to fortune in the event of a major attack Efforts by the government to extend its reach outside of the town through the use of loyal NGOs failed because of a lack of available resources, even in the relatively permissive environment created by its alliance with various progovernment factions, while the provision of these services appears to have done little to strengthen the insurgent factions in question SPLA attempts at opportunity hoarding also are in evidence in the pre-OLS period with attacks on outlying settlements, the closure of land access to Malakal, and endeavours to restrict river and air transport, not to mention its successful hostage-taking raid   Understanding the dynamics of social-service provision in garrison towns during civil wars is important because, sadly, there is a high risk that such events will be repeated Many of the issues noted concerning service provision in Malakal during the period described are not unique to this town The account of Rone (1999) of Providing health services during a civil war: the experience of a garrison town in South Sudan conditions in Wau, another garrison town in South Sudan, corresponds to the findings of this study, as does the report of Deng (1984) of conditions in Abyei at the end of the first civil war Looking beyond South Sudan, the description by Halima Bashir (Bashir and Lewis, 2009) of her experiences as a doctor under suspicion in Darfur because of her ethnic background confirms that these patterns continue to recur in other parts of Sudan in more recent times Furthermore, my experiences as a humanitarian aid worker in Angola in 2000–02 echo some of the macro-level processes, particularly regarding the town–non-town boundary discussed in this case study.52   More generally, this case study highlights the manner in which the provision of health services in garrison towns such as Malakal can be manipulated by armed groups in support of broader war aims—in both individual settlements, and throughout an entire war zone Many of the same processes identified in this case study appear to have recurred throughout South Sudan during the second civil war, including: opportunity hoarding that denied resources to populations considered supportive of insurgents; ‘captures’ of populations in or around urban centres or relief sites where they are easier to monitor and control; and attempts to exploit these populations through use as human shields, extraction of resources, expropriation of goods or recruitment, and/or through the initiation of hearts-and-minds campaigns to change their religious and/or political orientations While such efforts are well documented with respect to the manipulation of food assistance, similar patterns apply, as seen, to the provision of health services during civil wars   More encouragingly, perhaps, the paper also demonstrates the possibilities for the provision of healthcare in war-affected contexts Despite the considerable challenges posed by government paranoia, proselytising ideological imperatives, the logistical challenges of operating in an isolated garrison town during an ongoing war, the manipulation of these services for military and political ends, and the attendant risks to local and international personnel, health services were provided in Malakal town for a considerable proportion of the war Undoubtedly, thousands of people survived as a consequence   For most of this period, these services functioned in large part because of international support, both from donors (financial) and from NGOs (operational) specialising in healthcare during emergencies The latter supplied the institutional means with which to channel essential direct support to defunct government health systems, effectively reconstituting them operationally at a time when functioning health services were in desperate need The provision of these services may have served the northern government’s interests by supporting patterns of opportunity hoarding and exploitation in its favour (and indeed in supporting SPLA interests where services were offered in areas under its control), but these services did not support government aims to the same extent as would have occurred had resources been channelled through the government itself While health-service provision supported by international NGOs specialising in emergency health provided some de facto material support to whichever party was in control in that particular zone of operation, it did not provide ideological support for the programme of either side Efforts to utilise health services in support of hearts-and-minds campaigns suffered as a result This is 595 596  Rob Kevlihan perhaps the best outcome possible when governments are committed to programmes of ideological conversion and to using social service systems, including healthcare systems, to further their ends   Better understanding and anticipation of these likely dynamics can improve the delivery of healthcare services in these contexts In anticipation of opportunity hoarding processes, for instance, health service providers may consider negotiating crossline access for particular types of activities that may be of less perceived military utility to insurgents—such as Expanded Programmes of Immunization (targeting young children)—in advance of engagement on the ground   Organisations should also carefully assess the risks to national staff to be assigned to any given location, particularly more senior national staffers and/or qualified male personnel who might be targeted by security services because they are educated and from the region Organisations also need to consider potential risks that staff in control of medical inventories (such as pharmacists and storekeepers) may be exposed to because of the perceived utility of these drugs to insurgents Complete and transparent inventory management systems with checks and balances that allow agencies to demonstrate where and when medications have been dispensed and to whom may assist in this regard In addition, clear communication with local government counterparts (including, if necessary, local security services) on any targeting plans may also help in this respect—such as confining interventions to mother and child healthcare instead of comprehensive primary healthcare in the initial stages of an intervention in order to build a degree of trust in the organisation locally   It is difficult for organisations to prevent many of these processes from occurring However, anticipation of potential difficulties and challenges associated with the operation of these processes may reduce their impact while also protecting staff from possible harm Such steps may also increase the odds that essential healthcare services can be maintained, and by extension, more lives can be saved, even in the most challenging of circumstances Acknowledgements This paper draws on research conducted by the author as part of his doctoral dissertation at the American University in Washington, DC—funded in part by a Hurst Scholarship and a doctoral fellowship from the university The author would like to thank Alan Glasgow and his stalwart team, without whom this research would not have been possible In addition, gratitude is extended to the numerous other friends and colleagues—both Sudanese and khawajaat—who offered support during work and research in Sudan All views expressed here reflect those of the author, and not those of any government, institution, or organisation Correspondence Rob Kevlihan, Kimmage Development Studies Centre, Whitehall Road, Dublin 12, Ireland Telephone: +353 406 4386/4380; e-mail: rkevlihan@gmail.com Providing health services during a civil war: the experience of a garrison town in South Sudan Endnotes Rob Kevlihan served as a visiting lecturer at Hanoi National University in Vietnam during the autumn 2013 semester and will be taking up a new role as the Executive Director of the Kimmage Development Studies Centre in Dublin, Ireland, in January 2014 Consistent with standard approaches to describing this group, reference is made to the movement and to the army (SPLM/A) The SPLA, as the name implies, was the armed wing that actually fought the civil war, whereas the SPLM represented the political wing Both were unified under a single leader It is generally accepted that the military wing took precedence during the civil war During fieldwork in Malakal, I was informed that the Shilluk should be referred to as Chollo, reflecting their own name for their ethnic group Current literature on the subject usually refers to Shilluk For the purpose of clarity, therefore, this paper uses the more widely known term Shilluk, in addition to Chollo, when referring to this group The Chollo/Shilluk, unlike the Dinka and Nuer, traditionally has been a more cohesive and hierarchically organised ethnic group under the leadership of a king, known as the Reth This may explain the relative lack of fragmentation within the Chollo/Shilluk during the war as compared to other large ethnic groups, such as the Dinka and Nuer The Chollo/Shilluk was also in a relatively more vulnerable position in comparison to other groups Concentrated in Malakal town and on the western bank of the Nile north of Malakal, it was particularly vulnerable to assaults by northern forces For further discussion of the SSDF see Young (2006) I am grateful to an anonymous reviewer for this point With a smaller cluster of Chollo/Shilluk also located on the eastern bank where the Sobat River joins the Nile, particularly around the site of the Doleib Hill mission station This was despite significant disruption to services owing to the first civil war (1955–72) The Addis Ababa Peace Agreement, which ended this conflict, allowed these social-service sites to be reconstituted, in many cases with support from Christian churches and international non-governmental organisations such as the Lutheran World Federation Government-provided services continued to operate throughout the 1970s, in spite of increasing budgetary problems towards the end of the decade because of economic austerity measures caused by a global recession and a related debt crisis in Sudan, together with a collapse in international aid (Tvedt, 1998) I am grateful to an anonymous reviewer for this point 10 Something I experienced directly on arrival owing to being ‘voluntarily’ detained for two to three hours pending the appearance of a security officer because of my surprising ability (from a Sudanese security perspective) to be able to speak rudimentary Sudanese Arabic After a brief conversation in Arabic with the said officer, which included a polite request that more health services be provided to men in the town, I was allowed to go on my way 11 This research was reviewed and approved by the American University’s Institutional Review Board for the Protection of Human Subjects at the design stage as part of standard university requirements for dissertation-related research The episodes described in this paper from before 2005 are derived from my direct experience of working as a humanitarian worker in Sudan While these experiences did not comprise formal research, they certainly informed my subsequent research programme and facilitated later engagement as I was able to refer back to a common shared wartime experience of Malakal with some of those interviewed On my return to Malakal as a researcher from 2005 I was careful to explain the purpose of my questions and research to those being interviewed or taking part in focus groups as part of my standard approach to beginning such discussions 12 The Chollo language is called Dhok-Chollo—pronounced Dho-Chollo locally It can also be spelled Dhok-Collo or Dhok-Cöllo Dhok refers to the mouth Interview with a Catholic missionary, Malakal, July 2006 597 598  Rob Kevlihan 13 The number engaged in this focus group varied, because staff were called away to attend to clinic business throughout the discussion This focus group ended suddenly because of the arrival of a young woman suffering severe complications during labour We assisted with her evacuation by boat to hospital in Malakal; regrettably her infant son did not survive the birth See Kevlihan (2013), particularly the introduction, for further details 14 Conversations focused instead on the question of preferred language of instruction in adult literacy classes, a topic respondents were much more willing to discuss; for further discussion, see Kevlihan (2007, 2009) 15 See Kevlihan (2013) for an extended discussion of this topic, which goes beyond health services 16 The Jonglei Canal project was designed to open a water channel between the Sobat River and the White Nile further upstream, cutting travel time by barge to Juba and increasing water flow downstream by reducing the amount of water lost to evaporation in the swampy Sudd region (located between Malakal and Juba on the existing flow of the Nile) The project was reputedly close to completion when the SPLA attacked the giant excavation machine used to construct the canal Chevron’s involvement in oil exploration in Upper Nile also ceased around the same time because of SPLA attacks While Chevron later abandoned efforts to return to its exploration concessions, Chinese and Malaysian oil companies later exploited these areas when they successfully opened up oilfields there in the late 1990s 17 I am grateful to an anonymous reviewer for highlighting the outflow of Dinka from Malakal at the outset of the war 18 Even three months after the institution of a ceasefire in October 2002, as part of peace negotiations that led to the CPA, the dirt track north on the west bank of the Nile was not in use (Coghlan, 2005) 19 Missionaries having been expelled by the northern government in 1964 20 Missionary schools were nationalised immediately after independence in 1957 21 The leader of the raiding group reportedly was a Dinka who had been raised in the Shilluk/Chollo area He led a mixed group of raiders who usually targeted cattle, and normally raided on the far side of the River Nile The interviewee heard subsequently that the SPLA had executed him 22 The ruins of the former mission house of Lul were clearly visible from the Nile, even in 2005 23 A Sudanese colloquial Arabic word for hut—usually it refers to a hut built from locally available materials such as grass and mud In slum areas and in displaced camps in Khartoum, it also referred to huts made from cardboard and other salvaged scraps of building materials, often accompanied by a piece of plastic sheeting provided by a humanitarian organisation 24 Swart (1998) provides an account of the departure of the last missionary from Doleib Hill school (in either late 1983 or early 1984) shortly after an attack on the adjacent Jonglei Canal The school was forced to close completely a few months later after the site was the scene of a major battle that, reportedly, involved, inter alia, killings by the Sudanese army of local villagers who sought shelter in the mission church (Scott, 1985) When I visited this location in late 2005 government forces occupied the site of the old mission station and school 25 A pattern that was repeated throughout the conflict owing to sporadic aerial bombing of small SPLA-controlled settlements, including social service centres, by the Sudanese Air Force 26 This may be unique to Malakal; the Catholic Church remained an important provider of health services in Wau, for example, through its Health Training Institute and other health clinics, over the same period (author’s recollection, based on a visit to Wau, 1999) 27 The same account states that the school was subsequently converted into a barracks and later an Islamic school for girls was established on the site 28 Note, however, that the existence of a ‘hospital’ does not indicate that quality services continued to be provided there In addition, a hospital in Southern Sudan is radically different from what patients would expect in the developed world, typically comprising one or two wards, possibly an operating room or two, a laboratory, medical pharmacy (often with little or no drugs present), Providing health services during a civil war: the experience of a garrison town in South Sudan a store, and possibly some outpatient rooms These buildings tend to be in a poor physical state: cracked and unpainted walls, few windows, and a general air of disrepair Few had consistent access to running water during the war 29 Three such camps visited by the author in October 2005 were Obel I, II, and III, comprising primarily Nuer from further south The camps were located adjacent to each other in the vicinity of the confluence of the Sobat River and the White Nile According to local informants, this land had been considered Chollo/Shilluk land before the war 30 Based on an interview with an aid worker who had assessed recently bombed areas that had formerly served as camps for IDPs adjacent to Wau in April 2007 31 The focus here is on the hoarding of services, rather than on the hoarding of goods, owing to this paper’s emphasis on health service provision as a scarce resource during civil wars Goods are considered to the extent that government forces sought to hoard access to drug supplies, but this point is largely subsidiary to the focus on services, as without the health services themselves, it is unlikely that drug supplies would be available Note, however, that the model employed here could be applied equally to opportunity hoarding related to physical goods (such as food aid and shelter materials) in future studies 32 An interview with a health worker formerly based in Ler (conducted in July 2006) indicates that the hospital in Ler had closed in 1984 after an attack on a boat travelling from Ler to Malakal The health workers dispersed to other locations 33 Family support networks appear to have been important in helping people to survive within the town itself (as opposed to those located in IDP camps outside of the town), as does access by at least one family member to government employment A survey conducted in June 2005, for example, found that 35 per cent of families in the town had salaried positions paid by the government (Fitzpatrick, 2005) This percentage should be treated with caution: the sample size of the survey was relatively small—only 47 families—and, as it was a livelihoods survey, the interview methodology focused on semi-structured interviews Discovering a consistency in respondent replies, the survey was not extended beyond the 47 households Nonetheless, it indicates the relative importance of government employment to people in the town, and, perhaps, the importance of having this government connection in order to gain or maintain residence in the town 34 Aid workers based in Malakal also were stranded in the town for a number of months Conditions were difficult for everyone during this period One long-time aid worker who was present in Malakal then remembered losing a lot of weight while being stuck there for several months because of the relative shortage of food and the generally difficult health and sanitation conditions in the town Needless to say, moreover, in comparison to most local people aid workers typically were among the best-off financially 35 E-mail communication, dated 25 July 2011, with an expatriate NGO worker stranded in Malakal for 4.5 months in 1986 36 In Sudan, both north and south, formal marriage arrangements require the payment of a dowry to the prospective bridal family, frequently including the transfer of cattle This makes the forced removal of daughters to become ‘wives’ all the more contrary to local traditional norms and practices 37 These dynamics are consistent with research that emphasises the importance of control of areas by either government forces or insurgents in determining the treatment of civilians (Kalyvas, 2006) The government appears to have been in a significantly more vulnerable position in the Malakal area in the 1980s and early 1990s than it was in the second half of the 1990s, once agreements had been brokered with Akol and Machar factions 38 Perhaps not without foundation Sometimes local insurgent leader Dr Lam Akol (2003), for example, acknowledged that the main possibility for a takeover of Malakal came from an internal rebellion rather than an external attack In addition, government forces came close to losing Wau, another prominent garrison town in the south in 1998, as a result of the same process (Rone, 1999) 599 600  Rob Kevlihan 39 One southern doctor remained in an administrative position at the Ministry of Health but did not work in the hospital 40 At least with respect to arbitrary arrest, torture, and execution on suspicion of being sympathetic to the SPLA Women were vulnerable in other ways, especially when they had to pass through security checkpoints in order to cultivate, and younger women also risked being taken as ‘wives’ by members of the security forces One should note too that women have enjoyed significantly fewer educational opportunities in Southern Sudan and so there are fewer educated women than men 41 South Sudan is a difficult operating environment for any fighting force SPLA units that I observed in Malakal in 2005 appear to have been aware of at least some health risks and to have introduced preventative measures Perhaps because of accommodation shortages, some soldiers slept outside on the ground underneath mosquito nets held in place by small branches Malaria, which is transmitted by mosquitoes, is one of the most serious endemic diseases in South Sudan 42 Government garrison towns typically had two security agencies operating simultaneously: National Security and Military Intelligence Many National Security personnel were recruited locally and paid salaries equivalent to those of international NGO staff members Recalling trips to Malakal and Wau during 1999–2000, at least some of these local personnel were distinguishable in garrison towns by the distinctive black and chrome motorcycles they drove, together with their apparently ubiquitous dark sunglasses—the latter presumably a sign of their relatively prosperous position in the local economy With the withdrawal of government forces from Southern Sudan under the CPA, many of these agents reportedly found themselves without gainful employment opportunities 43 The previous December an MSF-France light aircraft had been shot down over Awiel in Northern Bahr el Ghazal, resulting in the deaths of several humanitarian personnel This led to the closure of the MSF-France programme in Sudan and contributed to MSF-Belgium’s decision to withdraw (Minear, 1991) 44 When asked how injured government military personnel of southern origin could be distinguished from rebels, one respondent, who had worked in the military hospital, said that there were a number of ways: for instance, sometimes government troops wore distinctive markings, such as pieces of string of a particular colour, to differentiate themselves The quality of footwear (that is military boots) also was an indicator; or, indeed, whether the injured combatant wore any footwear at all— rebels often being barefoot, or wearing cheap flip-flops 45 Another long-time resident of the town (who was not present during the incursion) said that, when the assault occurred, the town’s defenders started to target Nuer residents These reprisals reportedly ended after some respected people within the town appealed to the governor for them to be stopped 46 A visit to the government garrison of Nagdyar on the Sobat River provided some indication of the conditions under which such facilities operated The isolated settlement (situated about three hours by small boat from Malakal) had been the location of a military school before the war, and during my October 2005 visit had an estimated population of 3,000 The most permanent building in the settlement was a mosque, built, I was told, by Da’wa Islamiyya It had been raining lightly before I arrived and the entire settlement was quickly becoming a quagmire Facilities at the settlement included an (Islamic) school consisting of a small number of classrooms made of crumbling mud brick and wattle with a roof made of locally available materials, and a muddy floor, hardly suitable for the inclement weather The only other public amenities were a deserted ministry of health mud hut and a second recently constructed mud hut used for health outreach activities two to three days a week by an international NGO During a focus-group discussion in the settlement with approximately 20 women, they noted that no effective health services had been provided there throughout the war 47 However, the consequences of security-service suspicion usually were a lot less severe than for locals—typically, foreigners perceived as troublesome were made persona non grata by local authorities and often had to leave the country as a result Providing health services during a civil war: the experience of a garrison town in South Sudan 48 One health worker interviewed in Malakal in October 2005 described an outreach health programme provided by MSF-Holland on the Sobat River Like other NGOs, its teams required daily travel permits in order to access these locations, located in a government-held village approximately 70 kilometres away on the Sobat River The SPLA controlled the opposite riverbank While the team was allowed to cross the river with the permission of local Military Intelligence to purchase fish and other food from a village on the other side, it was not permitted to provide health services there 49 With respect to the Malakal area, one Expanded Program of Immunisation (EPI) team was arrested by SPLA troops in Fanjak, a settlement to the south of the town The team was composed of local Nuer and Chollo/Shilluk The (Nuer) SPLA troops alleged that the Nuer members of the vaccination team were sympathetic to rival militias and roughed them up, leaving the Chollo/Shilluk members of the team unharmed All were subsequently released after eight days as a result of intervention by southern sector officials (interview with a health worker familiar with this case, Malakal, July 2006) A more serious incident occurred in the Kodok area in 2004, when a plain-clothes security official attached himself to a vaccination team without permission He was recognised in a village by the SPLA and summarily executed The other team members were beaten and sent back to Kodok The military moved the inhabitants of the village involved into Kodok but did not take any steps against the vaccination team (focus group discussion with health workers, October 2005, and interview with a health worker familiar with this case, July 2006) 50 The volatile situation in Upper Nile State meant that any activity outside the larger towns carried with it some risk I can recall a conversation with a Sudanese aid worker around 2000 in which he described another close shave in the region He was a member of a team dispatched as part of a UN annual needs assessment The team stayed overnight in a village that was raided by the SPLA Members of the team fled to the riverbank to hide (successfully) while the SPLA escorted captured villagers away at gunpoint 51 In addition, 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NGOs and Foreign Aid Africa World Press Inc., Trenton, NJ Wama, B.L (1997) Prolonged Wars: The War in Sudan Air Command and Staff College, Montomery, AL.Young, J (2006) ‘Armed groups in Sudan: the South Sudan Defence Forces in the aftermath of the Juba Declaration’ Sudan Issue Brief (October) Small Arms Survey, Geneva Young, J (2007) The White Army: An Introduction and Overview A Working Paper of the Sudan Human Security Baseline Assessment Project of the Small Arms Survey ( June) Small Arms Survey, Geneva Zartman, W.I (2001) ‘The timing of peace initiatives: hurting stalemates and ripe moments’ Ethno­ politics 1(1) pp 8–18 603 ... (1999) of Providing health services during a civil war: the experience of a garrison town in South Sudan conditions in Wau, another garrison town in South Sudan, corresponds to the findings of this... permit the provision of healthcare services, supported by international NGOs, in Malakal town Providing health services during a civil war: the experience of a garrison town in South Sudan throughout... Providing health services during a civil war: the experience of a garrison town in South Sudan   These accounts illustrate the way in which opportunity hoarding patterns were established and maintained