No Place to Heal

South Sudan's hospitals have become targets for both sides in the brutal, ongoing civil war. How can you save lives when doctors and patients are living under the gun?

MALAKAL, South Sudan — Outside the pediatric wing of Malakal's teaching hospital, a human skull lies in the yellowing blades of knee-high grass. "We are finding these all the time," said a groundskeeper, who asked not to be named. "We found two yesterday," he said, shoveling the remains into a cream-colored body bag. 

Malakal is a ghost town. Once South Sudan's second-biggest city with a population of 150,000, it is now home to more soldiers than civilians. Residential areas have suffered an extraordinary amount of damage since civil war broke out in December 2013, and the teaching hospital, which occupies a once-idyllic compound near a stone mosque built by Egypt in the 1940s, has been laid waste on multiple occasions. The trail of corpses now being discovered on the premises points to a disturbing trend in the country's eight-month-old rebellion: the systematic targeting of hospitals and medical personnel. 

"Hospitals and clinics have been targeted to a staggering degree," said Daniel Bekele, the executive director of the Africa division of Human Rights Watch, adding that South Sudan's "entire health system" has been destroyed "because of unlawful tactics used by both sides across the conflict areas." Cosmas Chanda, the representative for the Office of the U.N. High Commissioner for Refugees in South Sudan, called the level of violence directed at hospitals and aid workers "unprecedented" in an interview in Juba, South Sudan's capital.

South Sudan's latest paroxysm of violence has exacted a devastating toll on civilians. Looting, rape, and ethnically motivated mass killings have been unleashed in a relentless pattern of attack and counterattack. The subsequent displacement of 1.5 million people, along with the inability of aid agencies to reach many of them, threatens to push the country over the brink into famine.

Since the first shots were fired in December 2013, at least 58 people have been killed on hospital grounds, while hospitals themselves have been attacked or looted on six occasions, according to the medical charity Doctors Without Borders (Médecins Sans Frontières, or MSF). Countless clinics and pharmacies have also been plundered or damaged, and medical supplies have been stolen or destroyed.

The logic of targeting hospitals is sickeningly simple: Not only do attackers kill civilians, but they ensure that survivors cannot seek medical care. In the current conflict -- which began as a power struggle between President Salva Kiir and former Vice President Riek Machar but quickly morphed into an ethnic conflict, primarily between the country's two largest ethnic groups, the Dinka and the Nuer -- this logic has become intertwined with that of ethnic slaughter. In hospitals across the country's northeast, victims have reportedly been singled out for execution based on their tribal identity. In Bentiu, the capital of oil-producing Unity state, a local radio station went as far as calling for acts of "vengeful sexual violence" against women of other communities when rebel forces overran the city in April, according to the U.N. Mission in South Sudan. A total of 28 people were killed in the hospital there.

At the teaching hospital in Malakal, at least 14 people, including 11 patients, were murdered in their beds when rebel forces overran the city in February of this year. Other patients, mostly ethnic Nuers, were killed on the premises by government soldiers in January. Nobody knows for sure how many people have died here; nobody knows whose remains are being shoveled into the cream-colored bag.

Today, much of the hospital is still in ruins. The neonatal ward is burned and gutted. In the main surgical theater, one of the operating tables is missing, and the contents of ransacked supply shelves spill haphazardly onto the floor -- syringes, antiseptic solution, now-useless vaccines. In one of the patient wards, a single woman's shoe, its rhinestones still in place, rests on a filthy bedside table. 

"They took some things, and they destroyed what remained here," said Yumo Arop Ying, the acting director general of Upper Nile state's health ministry, referring to the three separate instances in which rebel forces seized control of Malakal.

Damage also occurred during periods of government control, according to rights groups like Amnesty International and Human Rights Watch.

While the raids themselves have been brutal, it is their effect on the broader system of health care that is even more troubling. "Attacks against hospitals and medical facilities in South Sudan have led to a collapse of the health system across much of the conflict zone," said Stephen Cornish, MSF's executive director for Canada, who is currently visiting South Sudan. "This in turn creates a number of silent victims to the conflict who perish from diseases which would otherwise have been possible to treat, such as malaria," he said.

On multiple occasions, MSF has been forced to evacuate its medical teams and temporarily suspend the operation of its clinics. According to a report published by the medical charity in July, hundreds of thousands of people have been cut off from medical care because of the violence. Where MSF cannot obtain guarantees of security, or at least of non-interference, "we may simply be unable or unwilling to risk responding," said Cornish.

Despite the recent surge in intensity, violence against health care is not a new problem in South Sudan. It was a regular feature of the north-south civil wars that raged from 1955 to 1972 and from 1983 to 2005, as well as of the conflicts in Darfur, South Kordofan, and Blue Nile that continue to grind along today. In 2000, for example, Sudanese armed forces bombed the Samaritan's Purse hospital in Lui, a town in what is now South Sudan's Western Equatoria state, three times in the span of a few months. Akec Khoc, a medical doctor who later served as South Sudan's ambassador to the United States, was shot in the shoulder while attending to wounded SPLA fighters in a field hospital during the second civil war. 

Not that Khartoum was the only one targeting medical facilities. Southern guerrilla forces, known as the Sudan People's Liberation Army (SPLA), also attacked hospitals and clinics -- those run by the government of Sudan as well as those run by rival SPLA factions. "From the beginning of the SPLA in 1983, it attacked hospitals, health workers, and aid agencies," said Alex de Waal, the executive director of the World Peace Foundation at Tufts University, who disputed the notion that attacks on medical facilities have grown any more frequent. The SPLA was "exceptionally brutal and matched the government of Sudan and pro-[government of Sudan] militias in this regard," he said in an email.

This long history of medical violence, coupled with Khartoum's deliberate policy of neglect for the south, is largely responsible for the abysmal state of South Sudan's health-care system today. In his first address to the U.N. General Assembly, President Kiir spoke of "construction" rather than "reconstruction" of South Sudan's institutions: "Even before the ravages of war could set in, our country never had anything worth rebuilding," he said. Although he was speaking generally, the president might as well have been referring specifically to the health-care sector. In 2012, the country of roughly 9 million had only 120 doctors and even fewer registered nurses. As a result, nongovernmental organizations provided as much as 80 percent of basic health services, even before the outbreak of civil war. Today, that figure is almost certainly higher. 

Still, a few brave doctors and medical professionals are enduring extraordinary hardship as they work to resuscitate the country's network of hospitals -- and to keep alive the pretense that the government is doing something to care for its citizens in areas contested by the rebels. Despite the damage and persistent insecurity, the teaching hospital in Malakal is now back up and running out of a few rooms that have been restored. Without electricity or sufficient staff, however, it is only able to provide outpatient care for those with relatively minor ailments, such as malaria.

That does not mean the skeleton crew manning the hospital doesn't have to deal with more serious emergencies. "We get trauma patients, sometimes soldiers with gunshot wounds," said Olany Alew Akol, the only physician currently working at the hospital. But without electricity or proper surgical equipment -- the generators and the operating theater were looted in February -- he is forced to stabilize them by the light of a flashlight before he can transfer them to the nearby U.N. base for surgery. "So many things aren't working," he said, "but we are just trying to go ahead." 

For now, progress toward rebuilding the teaching hospital can feel as fleeting as security here in Malakal. Many of the staff members fled to the bush when the fighting broke out, and none of the nurses will work the night shift. Often, rumors of an impending attack will sweep the city, prompting staff and patients alike to seek refuge on the U.N. base, where roughly 17,000 civilians are living in camps. "There were rumors yesterday that rebels are coming, so many people left the town last night," said Olany, adding that only a slow trickle of patients had visited the hospital that morning.

Before the civil war turned his workplace into a graveyard, Olany said the hospital was "too busy." Today, things are also hectic, but only because he's the only doctor on staff. "I am working day and night," he said, shaking his head. "Too busy." 

This reporting was made possible in part by the Pulitzer Center on Crisis Reporting. 



The Pretender to Pakistan's Throne

Imran Khan's populist protest movement is on the verge of taking down Pakistan's dull, dysfunctional government. How did such a lightweight get so far?

ISLAMABAD — In 1960, president and field marshal Muhammad Ayub Khan, Pakistan's first military dictator, built the city of Islamabad almost from scratch. Pakistan's original capital, Karachi, was roughly 800 miles away from his headquarters in Rawalpindi, and Ayub Khan -- as the story goes -- wanted to reduce his commute in order to more easily serve the requirements of both his military office and the presidency of Pakistan. In relatively short order, Rawalpindi had a new twin city and Pakistan had a new capital. Instead of flying from one office to the next, Ayub Khan could now walk, jog, or drive.

That little slice of Pakistania illustrates the most important rule of the decades-long contest between Pakistan's unruly civilian democrats and its unconstitutional military rulers: When the Army wants something, it gets it.

Since Aug. 14, Islamabad has been in a state of constant uncertainty and insecurity. Politicians opposed to Prime Minister Nawaz Sharif have been leading a sit-in of thousands of protesters demanding nothing less than the resignation of Sharif -- who has been prime minister twice before and deposed in coups both times.

Today in Pakistan, there are two big questions: Is the military attempting to stage-manage Sharif's third exit? And is his political tormentor, the temperamental former cricket star Imran Khan (unrelated to Ayub Khan), the Army's choice as his replacement?

Two separate camps are conducting the Islamabad protests against Sharif: Khan leads one, and Muhammad Tahir-ul-Qadri, an anti-Taliban cleric formerly based in Canada, leads the other. The two leaders are a study in contrasts, but they share one explicit objective -- to oust Sharif. Pakistani fatigue with the saga has been growing, and on the night of Aug. 28, the Army became explicitly involved as a guarantor of talks between the opposition camps and the government. The announcement of the Army's role as the adult in the room is nothing new for Pakistan, and though expectations are that the crisis is petering out, protests could continue as long as Sharif stays in power.

Where did this mess begin? The 2013 elections brought Sharif back to power for a third term and saw Khan's party, the Pakistan Tehreek-e-Insaf (Pakistan Movement for Justice), emerge as a major force in politics. Khan's complaints that Sharif stole the election received little attention until Qadri entered the picture. A colorful cleric with a superb network of philanthropic activities and a politically insignificant but deeply committed corps of disciples, Qadri has a history of agitating against democratically elected governments. When Qadri announced his decision to return in June from his adopted home in Canada to Lahore to launch yet another agitation, alarm bells went off for Sharif.

On June 17, things took a tragic turn. Already exercised by the 100 degree-plus Fahrenheit heat and smarting at the way senior leaders within Sharif's government had spoken of Qadri, supporters of the cleric clashed with police in Lahore's tony Model Town neighborhood. Fourteen people died, including a teenager and at least two women, with much of the blame for the violence placed squarely on police brutality. The Model Town tragedy galvanized Qadri's supporters and stripped Sharif of whatever moral high ground he had. The shifting national mood after the affair buoyed the opposition's spirits, and Khan could smell blood.

In July, Khan announced his decision to march on Islamabad -- with the objective of ousting Sharif -- on Aug. 14, Pakistan's Independence Day. On Aug. 10, Qadri announced that he would march on Islamabad as well. The processions to Islamabad received wall-to-wall coverage from Pakistani media, with some questioning whether the size and diversity of the protesters deserved such lavish 24-hour exposure. As it has dragged on across two weeks, the crisis has developed a momentum of its own. Khan has planted himself and several thousand protesters in front of the Pakistani parliament building, insisting that he will leave only when Sharif resigns.

Few, if any Pakistanis, would argue against the substance of Khan's complaints -- that the electoral process needs major reforms and that corruption throttles the economy. Instead, most debate focuses on just why Khan is so confident that he will succeed in dethroning Sharif -- despite the prime minister's nationwide support and Khan's falling stock.

Khan's bravado is, on the surface, perplexing. His level of popular support has dropped significantly since the May 2013 election, and his performance since then has been pedestrian, at best. His speeches at these protests have been cavalier, even vulgar: He threatened to send his enemies to the Taliban so that the group could "deal with them," according to the New York Times. He denigrates parliament and the prime minister; in one speech, he proudly proclaimed that the fear of protesters has caused Sharif to "wet his pants." This is hardly the kind of leader whom soldiers from any country would want to call boss -- much less the ultraconservative ranks of the Pakistan Army.

For some, this kind of confidence only comes from the knowledge of having the support of Pakistan's military brass. Could it really be betting the house on Khan?

Probably not. Pakistan's military faces a hostile India on its eastern border and a dysfunctional peace process in Afghanistan on its northwestern one. In between, it is trying to stamp out the remarkably resilient and potent Tehrik-i-Taliban Pakistan, also known as the Pakistani Taliban, against which it recently launched a massive operation in the remote Pakistani region of Waziristan. Now is not a good time for the Army to manage a chaotic political transition.

And removing Sharif would probably complicate the country's fiscal situation. Pakistan is a poor country with an even poorer record of fiscal management. Outside aid is vital to the country -- be it from the IMF and World Bank or from friendly nations like the United States, China, and Saudi Arabia. International lenders hate instability and coups, and they have a long-standing man-crush on Sharif and his team because they are the big-business, Barbarians-at-the-Gate-type capitalists who love to privatize things while disproportionately taxing the poor instead of the rich. Khan, on the other hand, is a wild man when it comes to economic policy. Just this week, he instructed Pakistanis living abroad to stop using legal means of sending home remittances and once again start using the hundi system -- the preferred cash-mobility solution for terrorists everywhere.

Finance Minister Ishaq Dar, who unsurprisingly is a close relative of Sharif, is surprisingly good at what he does: managing exchange rates, borrowing cheaply, and stamping out dissenting views on the economy. While growth is still sluggish, Dar has convinced lenders that Pakistan is becoming a less risky investment. Bureaucrats from the World Bank and IMF love him because he is an old-school chartered accountant. Sharif loves him because he is family. And though the Army may not love him, they probably like Dar a lot more than they like the prospect of dealing with Khan's cuckoo ideas about how to get remittances to Pakistani shores.

Many in the armed forces think Sharif is being needlessly vindictive in pursuing legal cases against Gen. Pervez Musharraf, the former chief of army staff who seized power from Sharif in October 1999, imprisoning Sharif and later exiling him to Saudi Arabia. Now Sharif is pursuing a case against Musharraf, who is stuck in Pakistan, unable to leave because of a court injunction related to a treason case against him -- though Sharif's people insist the motivation is rule of law and not revenge.

Additionally, Sharif's overtures to India, especially to its newly elected Hindu nationalist prime minister, Narendra Modi, may make some of the generals deeply nervous. Sharif accepted Modi's invitation to his inauguration, and in a break from Pakistani tradition, Sharif did not meet with separatist leaders from Kashmir whom Pakistan supports. If Pakistan and India become normal neighbors, the military's influence in Pakistan automatically decreases. The hawks clearly won't go easily.

But the fears of Sharif improving relations with New Delhi too quickly have likely been assuaged by the rank incompetence with which he implements decisions. Even if he wanted to, Sharif cannot move any faster than a bored glacier on a cold day. He is hamstrung by an obsession with surrounding himself with loyal but inept advisors and bureaucrats.

Sharif has severely undermined his own rule. His shambolic treatment of his own party members, to say nothing of the opposition, is legendary -- often ministers can't get meetings for weeks on end. The presence of his family members in government grates all segments of Pakistani society: Dar's son is married to Sharif's daughter, Asma Nawaz. Chief Minister of Punjab Shahbaz Sharif is his younger brother; Water and Power Minister Chaudhry Abid Sher Ali is his nephew, as is prominent parliamentarian Muhammad Hamza Shahbaz Sharif. If only his strategic vision for the country were as consistent as his nepotism.

On the other hand, the best thing Sharif has going for him is the quality of his competition. Pakistan with Khan at the helm would be a disaster of epic proportions -- and that's even with the country's extremely high tolerance for shambolic leadership.

Khan may be the world's oldest teenager, with a captive national audience. He thumbs his nose at political niceties and employs an invective that dumbs down the discourse. Like Justin Bieber, Khan focuses on electrifying the urban youth who genuinely believe him to be a messianic solution to the disenchantment they feel about their country. And Khan's understanding of Pakistan's problems is probably only slightly more sophisticated than Bieber's. Khan does not have the policy chops to fix what ails Pakistan: The crux of his efforts during these few weeks has been that he, not Sharif, should be prime minister.

Sharif is a known entity and one easy to tame. Khan is wild and unpredictable. He proudly calls his supporters junoonis -- or "crazies." The military might enjoy the troubles Khan gives the prime minister, but it is unlikely to tie its institutional fortunes to unstable and irresponsible political actors like Khan. Pakistani democracy under Sharif will continue to muddle along as it has in the past. Pakistan optimists will be disappointed, because this crisis is unquestionably a setback for democrats. But things could be worse. For now, the most Khan is likely to achieve in challenging Sharif is further strengthening the military's already strong hold on key decisions guiding the country's future.

As Americans watch in horror as Syria, Libya, and Iraq come apart, perhaps they will warm to the idea of a Pakistan managed by its highly disciplined and professional armed forces. That would be exactly the wrong conclusion to draw from the political chaos in Pakistan. Now more than ever, Pakistan needs the rest of the world to reiterate its strong support for democracy.

Photo by ASIF HASSAN/AFP/Getty Images