“OUR HEARTS HAVE
GONE DARK”
THE MENTAL HEALTH IMPACT OF SOUTH SUDAN’S CONFLICT
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First published in 2016
by Amnesty International Ltd
Peter Benenson House, 1 Easton Street
London WC1X 0DW, UK
amnesty.org
Index: AFR 65/3203/2016
Original language: English
Printed by Amnesty International,
International Secretariat, UK
Cover photo: Military tank in Upper Nile state, South Sudan, 2009. ©Tim McCulka
CONTENTS
ACRONYMS
4
GLOSSARY
5
1.
EXECUTIVE SUMMARY
7
2.
METHODOLOGY
11
3.
WAR, TRAUMA AND MENTAL HEALTH
13
South Sudan’s Long Legacy of War
13
Renewed Conflict in 2013
14
The Mental Health Impact of Armed Conflict
16
South Sudan: A Traumatized Nation
17
4.
19
SURVIVORS SPEAK OF TRAUMA
“Sometimes i dream that I died with those who were killed”: Targeted killings in Juba
20
“I am still scared because of what happened”: Attacks on civilians in Malakal
22
“People are traumatized”: Attack on the Bor UNMISS PoC Site
25
“I am never happy”: Detention and torture in Juba
26
“I am nothing”: Sexual Violence Outside Bentiu PoC Site
29
“We are all alone”: Death, Abduction, and Disappearance of relatives
32
5.
LACK OF ACCESS TO MENTAL HEALTH CARE SERVICES
36
Government Mental Health Services: Practically Non-Existent
36
Government Mental Health Policies
39
International Assistance and Cooperation
40
6.
44
SOUTH SUDAN’S LEGAL OBLIGATIONS
The Right to Mental Health Care Services as part of the Right to Health
44
Violence as A Violation of the Right to Mental Health
48
The Right to Mental Health Care Services as part of Victims’ Right to Reparations
49
7.
51
THE WAY FORWARD
End Violations and Abuses of Human Rights and Humanitarian Law
51
Improve the availability, accessibility and quality of mental health services across the country
52
Ensure integration of Mental Health and Psychosocial Support into Emergency Response Programming
55
Provide Reparations For Psychological Harm
55
8.
CONCLUSION: THE IMPORTANCE AND URGENCY OF MENTAL HEALTH SERVICES
57
9.
RECOMMENDATIONS
59
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ACRONYMS
ARCSS AgreementontheResolutionofConflictinSouthSudan
AU
AfricanUnion
AUCISS AfricanUnionCommissionofInquiryonSouthSudan
CPA
ComprehensivePeaceAgreement
IASC
Inter-AgencySteeringCommittee
IDP
Internallydisplacedperson
IGAD
IntergovernmentalAuthorityonDevelopment
IMC
InternationalMedicalCorps
IOM
InternationalOrganizationforMigration
IRC
InternationalRescueCommittee
MI
MilitaryIntelligence
MSF
MédecinsSansFrontières(DoctorsWithoutBorders)
NGO
Non-governmentalorganizations
NSS
NationalSecurityService
POC
ProtectionofCivilians
PTSD
Post-traumaticstressdisorder
SDG
SustainableDevelopmentGoal
SPLM/A SudanPeople’sLiberationMovement/Army
SPLM/A-IO
SudanPeople’sLiberationMovement/Army-InOpposition
TGoNU TransitionalGovernmentofNationalUnity
UN
UnitedNations
UNMISS
UnitedNationsMissioninSouthSudan
UNOCHA
UnitedNationsOfficefortheCoordinationofHumanitarianAffairs
UNPOL UnitedNationsPolice
WHO
WorldHealthOrganization
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GLOSSARY
DEPRESSION
Amooddisordercharacterizedbysadness,social
isolation,inactivity,difficultywiththinkingand
concentration,asignificantincreaseordecrease
inappetiteandtimespentsleeping,feelings
ofdejectionandhopelessness,increased
irritability,and/orsuicidalthoughtsorattempts
tocommitsuicide.
MENTAL HEALTH
TheWorldHealthOrganization(WHO)defines
mentalhealthas“astateofwell-beinginwhich
anindividualrealizeshisorherownabilities,
cancopewiththenormalstressesoflife,
canworkproductivelyandisabletomakea
contributiontohisorhercommunity.”
MENTAL HEALTH DISORDER OR CONDITION
Amedicallydefinedconditionassociatedwith
painordistressthatnegativelyimpactsa
person’sthinking,feeling,ormoodandaffects
hisorherabilitytorelatetoothersandfunction
onadailybasis.
MENTAL HEALTH SERVICES
Themeansbywhichinterventionsformental
healthcarearedelivered.Thisincludes
outpatientfacilities,mentalhealthdaytreatment
facilities,psychiatricwardsinageneral
hospital,communitymentalhealthteams,
supportedhousinginthecommunity,and
mentalhospitals.Itincludesnon-biological(also
referredtoaspsychosocialsupport,treatment
orrehabilitation)orclinicalinterventionsto
supportpsychosocialwell-being,alsoreferred
toaspsychosocialsupportservices.Itmayalso
includetraditionalorreligioushealingpractices.
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MENTAL OR PSYCHOLOGICAL DISTRESS
Atermusedtodescribearangeofpsychiatric
symptoms,suchassadness,anxiety,rage
anddepression,thataretroubling,confusing
ordisruptactivitiesofdailyliving.Mentalor
psychologicaldistressisbroaderinscopethan
mentalhealthdisordersorconditions,inthata
personmayexhibitsymptomsofpsychological
distresswithoutreachingthethresholdof
sufferingfromanymedicallydefineddisorderor
condition.
POST-TRAUMATIC STRESS DISORDER (PTSD)
Aclinicalmentaldisorderthatarisesafter
experiencingorwitnessingaverystressful,
frightening,ordistressingevent.Anindividual
sufferingfromPTSDexhibits:1)intrusive
symptomssuchasnightmaresandflashbacks,
2)avoidanceofreminders—suchasthoughts,
feelings,people,andplaces—associatedwith
thetrauma,3)negativechangestothoughts—
suchasnegativebeliefsaboutoneselforothers,
self-blame,anger,shameguiltorfear,and4)
changesinphysiologyandreactivity—suchas
irritability,aggression,recklessbehaviour,poor
concentrationandsleepissues.Symptoms
mustbepresentformorethanonemonthand
createsignificantdistress/impairmenttodaily
functioning.
PROTECTION OF CIVILIANS (POC) SITE
Camp-likesettlementforinternallydisplaced
peopleestablishedwithinexistingUnited
NationsMissioninSouthSudan(UNMISS)
compoundsandguardedbyUNpeacekeepers.
PSYCHOSOCIAL SUPPORT SERVICES
Subsetofmentalhealthinterventionswhich
aregenerallynon-biologicalornon-clinicalin
natureandincludehelpwithsocial,emotional,
psychologicalandpracticalneeds.
PSYCHOLOGICAL TRAUMA
Adistressingemotionalresponseresultingfrom
experiencingorwitnessingaverystressful,
frighteningordistressingevent,inwhicha
person’scapacitytocopeand/orintegratehis
emotionalexperienceisoverwhelmed.
PSYCHOSIS
Aseriousmentaldisordercharacterizedby
defectiveorlostcontactwithreality,often
involvinghallucinationsordelusions.
TRAUMATISED
Atermusedinthisreporttodescribeindividuals
experiencinglonger-termpsychologicaldistress
asaresultofexperiencingaverystressful,
frighteningordistressingeventandwhose
capacitytocopeisoverwhelmedandabilityto
managedailylifeactivitiesiscompromised.
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1. EXECUTIVE SUMMARY
PartiestoSouthSudan’sinternalarmedconflictthateruptedinDecember2013haveviolated
internationalhumanrightsandhumanitarianlaw,withadevastatingimpactoncivilianpopulations.
BoththeGovernmentofSouthSudanandtheSudanPeople’sLiberationMovement/Army-InOpposition
(SPLM/A-IO),togetherwiththeirrespectivealliedforces,deliberatelyattackedandkilledcivilians,
abductedandrapedwomen,committedactsoftorture,destroyedandlootedcivilianproperty,and
attackedhumanitarianpersonnelandassets.Suchactshaveledtoanunknownnumberofdeaths,
physicalinjuries,thedisplacementofovertwomillionpeople,lossoflivelihoods,andhighlevelsof
foodinsecurity.Theyhavealsohadlessvisible,butnolesssignificant,repercussionsonpeople’s
mentalhealth—thestateofemotionalandpsychologicalwellbeinginwhichindividualscanrealize
theirpotential,copewiththenormalstressesoflife,workproductively,andbeactivemembersoftheir
community.
ThisreportdescribestheseriousandsignificantmentalhealthimpactofSouthSudan’sconflictto
highlighttheurgencyformoreattentionandresourcestoimprovetheavailability,accessibility,and
qualityofmentalhealthservicesinthecountry.Itisbasedoninterviewswith161internallydisplaced
peoplelivinginUnitedNationsMissioninSouthSudan(UNMISS)ProtectionofCivilians(PoC)
sitesinJuba,MalakalandBentiuandinaninformalsettlementatMahadSchoolinJuba.Amnesty
InternationalresearchersalsointerviewedgovernmentandUNofficials,donors,representatives
ofnon-governmentalorganizations(NGOs),andinternationalandSouthSudanesementalhealth
professionals—includingpsychiatrists,psychologistsandpsychosocialworkers.
InternallydisplacedSouthSudaneseimpactedbytheconflictdescribedexperiencingarangeof
symptomscommonlyassociatedwithmentalhealthdisorderssuchaspost-traumaticstressdisorder
(PTSD)anddepression—havingnightmares,gettingangryeasily,feelingunabletoconcentrate,and
consideringsuicide.Manyspokeofheadaches,stomachpains,backaches,andheartpalpitations—
commonphysicalmanifestationsofpsychologicalstress.Theyalsotoldoffeelingunabletowork,
study,carryoutbasicdailytasks,careforchildren,ormaintainrelationshipswithfriendsandfamily.
Theyattributedthesemental,physical,emotional,relational,andspiritualimpactstotheirexperiences
asvictimsof,orwitnessesto,torture,arbitrarydetention,sexualviolence,killing,andforced
displacement.
ThedirementalhealthsituationinSouthSudanisnotsurprising.Studiesinconflict-affectedregions
acrosstheworldhaveconsistentlydemonstratedthatarmedconflicthasaseriousnegativeimpacton
mentalhealth.Duetoarmedconflict,peoplearemorelikelytosufferarangeofmentalhealthissues:a
minoritywilldevelopnewanddebilitatingmentaldisorders,manyotherswillexperiencepsychological
distress,andthosewithpre-existingmentaldisordersoftenwillneedmorehelpthanbefore.TheWorld
HealthOrganization(WHO)estimatesthatinsituationsofarmedconflictandotheremergencies,the
proportionofthepopulationsufferingfrommildormoderatementaldisordersrisesfromapproximately
10%to15-20%.
InSouthSudan,decadesofconflicthaveleftalegacyofpsychologicaldistress.Therenewedviolence
sinceDecember2013hasfurtherexacerbatedthesituation.Whiletherearenoofficialnational
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statisticsonmentalhealth,theDirectoroftheMinistryofHealth’sDepartmentofMentalHealth
acknowledgedthattherehasbeenanincreaseinthenumberofpatientswithmentalhealthconditions
sincethestartoftheconflict.Thisconclusionisreinforcedbyindependentresearch.A2015study
bytheSouthSudanLawSociety(SSLS)andtheUnitedNationsDevelopmentProgramme(UNDP)
foundthat41%of1,525respondentsacrosssixstatesandAbyeiexhibitedsymptomsconsistentwith
adiagnosisofPTSD.A2015surveybySSLSinMalakalPoCsitefoundthat53%ofrespondents
exhibitedsymptomsconsistentwithadiagnosisofPTSD.TheAfricanUnionCommissionofInquiryon
SouthSudan(AUCISS)notedinitsfinalreportthat“traumaappearstobeakeyconsequenceofthe
conflict.”ThesefindingsareborneoutbyAmnestyInternational’sownresearch.
Theoverwhelmingmajorityofpeopleinterviewedwhowereexperiencingpsychologicaldistressfelt
theywouldbenefitfrommentalhealthorpsychosocialsupportservicesandprogrammes,butfewhad.
Intervieweesspokeofhowneighbours,friends,relativesandchurchmembersadvise,counsel,and
comfortthem,providingsomerelief.Conflictanddisplacementhave,however,severelyweakenedand
stretchedthesetraditionalsupportnetworksandtheirabilitytohelppeoplecope.Oftenthepeopleto
whomindividualsfacingdistresswouldturnforsupportareeitherabsentorarethemselvessuffering
fromheavypsychologicalburdens.Peoplewithmentalhealthproblemsarealsosubjectedtosocial
stigma,andfamilymembersgenerallyhavelimitedinformationaboutmentalhealthandtraumaor
whatconstitutesappropriatecareandtreatment.
Despitesignificantandwidespreadneeds,theavailabilityandaccessibilityofmentalhealthand
psychosocialsupportservicesinSouthSudanisextremelylimited.JubaTeachingHospital—theonly
publicmedicalfacilitythatprovidespsychiatriccare—hasonly12bedsinitspsychiatricward.The
availabilityofpsychotropicdrugsisinconsistentandlimited.Thereareonlytwopractisingpsychiatrists
inthecountry,bothofwhomareinJubaandneitherofwhomseespatientsonafull-timebasis.As
aresultofthelackofappropriateservicesandfacilities,peoplewithmentalhealthconditionsare
routinelyhousedinprisons,eveniftheyhavecommittednocrime.
ThoughSouthSudan’shealthsectorpoliciesandplanssince2006haverecognizedtheneedfor
improvedmentalhealthservices,statedgoalshavenotbeenreached.Objectivesforincreasingthe
numberoftrainedmentalhealthstaff,forexample,havenotbeenachieved.Mentalhealthservices
havenotbeenintegratedintotheprimaryhealthcaresystem,andthereisnodedicatedmental
healthpolicy,strategy,orlegislation.Partoftheproblemisexplainedbythegovernment’schronic
underinvestmentinhealthcaregenerally,anditsfailuretomakethefinancialcommitmentsnecessary
toimprovetheavailabilityandaccessibilityofmentalhealthservices.Thisismirroredbythefactthat
internationalassistanceandcooperationtothehealthsector,thoughsubstantial,hasoverlookedmental
health.
Inthiscontext,servicesprovidedbyinternationalNGOsareinsufficienttofillthegapandmeetthe
tremendousneedsofthepopulation.InJuba,Malakal,andBentiuPoCsites,someNGOsoffermental
healthandpsychosocialsupportservices,buttheirinterventionsareinsufficientgiventhesizeofthe
populationstheyareintendedtoserve.Thereisaparticulargapintheavailabilityofspecializedmental
healthservices,suchaspsychotherapy,grouptherapy,orpharmacologicintervention,forpeoplewith
severementaldisorders.Thereareonlyafewinternationalorganizationswithprogrammessupporting
theimprovementofmentalhealthserviceswithinthepublichealthsector.Somechurchesandsmaller
NGOscarryoutcommunity-basedinterventionsthatseektoaddresstrauma,butthesearelimitedand
uncoordinated.TheWHOofficeinJubahasnotprovidedsubstantialtechnicalorfinancialsupportto
expandingmentalhealthservicesinSouthSudan.
SouthSudanhascommitteditselftorespect,protectandfulfilarangeofhumanrightsincludingthe
righttohealthandhasassumedarangeofrelevantobligationsunderinternationallaw.Thisrequires
SouthSudantoensureaccesstomentalhealthservices;refrainfromactssuchastorturethatcause
psychologicalharm;andpreventsuchactsbythirdparties.SouthSudanmustalsoensurethat
victimsofserioushumanrightsorhumanitarianlawviolationsorabusesreceivecompensationfor
mentalharmandrehabilitation,includingpsychologicalcare,infulfilmentoftheirrighttoreparations.
AmnestyInternational’sfindingsleadtotheconclusionthatSouthSudanisfailingtoliveuptothese
commitmentsandobligations.
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Thegovernmentshouldurgentlyprioritiseguaranteeingaccesstoessentialmentalhealthcareand
treatment,includinginformationandservices.SouthSudanshouldworktoprovidementalhealth
treatmentthroughprimaryhealthcare;providecareatthecommunitylevel;makepsychotropicdrugs
available;educatethepublic;establishnationalpolicies,programmesandlegislation;supportresearch
andmonitoring;develophumanresources;increasefundingtomentalhealthservices;andmainstream
mentalhealthinterventionsacrossothersectors.Thegovernmentshouldalsomakefinancialand
programmaticcontributionstomentalhealthservicesinemergencysettingsandshouldfacilitate
andencourageinternationalcooperationandsupportforimplementationoftheInter-AgencySteering
CommitteeGuidelines(IASC)onMentalHealthandPsychosocialSupportinEmergencySettings.
SouthSudanisfacingasevereeconomiccrisisduetohighinflationandasharpdeclineinnational
oilrevenuesasaresultofreducedproductionandadropininternationaloilprices.Eveninthis
challengingcontext,therearestepsthegovernmentcouldtaketoimprovementalhealthservices
thatrequirepoliticalcommitmentmorethanfunds.Thedevelopmentofamentalhealthpolicyand
legislation,forexample,couldgoalongwaytowardsgalvanizinggreaterattentiontomentalhealth
inSouthSudan.TheMinistryofHealthcouldalsomoreeffectivelyseekinternationalcooperation
andassistancetosupportmentalhealthcareservicesbymakingspecificrequeststodonorsforsuch
supportandbyworkingwithdonorstoensurethatgeneralsupporttothehealthsectordoesnot
neglectmentalhealthneeds.TheMinistryofHealthcouldalsocallonothergovernmentministries,
internationaldonors,andNGOstomainstreammentalhealthandpsychosocialsupportinitiativesinto
alldevelopmentandhumanitarianinterventions.
TheAgreementontheResolutionoftheCrisisinSouthSudan(ARCSS),signedbypartiestothe
conflictinAugust2015,shouldsignaltheturningofanewpage.ThenewTransitionalGovernment
ofNationalUnity(TGoNU)musttakestepstoendtheseriousviolationsandabusesofinternational
humanrightsandhumanitarianlawthatcontinuetotraumatizethepeopleofSouthSudan,aswell
asthelongstandingimpunityforsuchviolationsandabuses.Thegovernmentmustprovideallforces
withclearordersdetailingconductthatisprohibitedunderinternationallaw;establishmechanisms
toadequatelymonitorconductofforces;andinitiateprompt,effectiveandimpartialinvestigationsto
bringthosecrediblysuspectedofcriminalresponsibilitytojustice.
TheARCSSoffersanimportantopportunityforfulfillingtherightofvictimstoreparations,including
compensationandrehabilitationformentalharm.TheTGoNUshouldworkwiththeAUtoensure
thespeedyestablishmentoftheHybridCourtforSouthSudan(HCSS),theCommissiononTruth,
ReconciliationandHealing(CTRH),andtheCompensationandReparationsAuthority(CRA)provided
forinthepeaceagreement.TheTGoNUshouldensurethesebodiesgiveappropriateconsideration
tothementalhealthconsequencesoftheconflictandtheresultingneedformentalhealthand
psychosocialsupportasanelementofindividualorcollectivereparationsprogrammesandinitiatives.
Internationalbodiesmustalsodotheirutmosttopreventanddeterfutureviolationsofhumanitarian
lawandviolationsandabusesofinternationalhumanrightslaw.TheAUCommissionshouldquickly
establishtheHCSStoinvestigateandprosecutegenocide,warcrimes,crimesagainsthumanity,and
othercrimesunderinternationallawcommittedduringtheconflict,asrequiredintheAugust2015
peaceagreement.TheUNSecurityCouncilshouldimposeacomprehensivearmsembargoonSouth
Sudanandtargetedsanctions,includingtravelbansandassetfreezes,againstcivilianandmilitary
officialswhohaveengagedinviolationsofinternationalhumanitarianlawandviolationsandabusesof
internationalhumanrightslaw.
Doingmoretoaddressmentalhealthneedsisnotonlyessentialforindividualwell-being,itisalso
criticalforSouthSudanesetoeffectivelyrebuildtheircommunitiesandcountry.Poormentalhealth
negativelyimpactspeople’sabilitytocarryoutday-to-dayactivitiesandpursuelivelihoodsoreducation.
Poormentalhealthamongparentsalsohasaninter-generationalimpactonchildhealth,development,
andgrowth.Restoringmentalhealthcanplayavitalroleincontributingtosustainableeconomic
growthandpovertyreduction.Thisisreflectedinthefactthat,inSeptember2015,theUNincluded
mentalhealthasanelementofthenewglobalSustainableDevelopmentGoal(SDG)onhealth.
ManySouthSudaneseandinternationalobserversidentifypoormentalhealthasadestabilizingforce
thathascontributedtoviolentbehaviouratfamily,community,andnationallevels—anobservation
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supportedbystudiesshowingthelinksbetweenpoormentalhealth,angeranddesireforrevenge.
SouthSudan,togetherwiththeAU,theUNandotherinternationalpartners,mustthereforeprioritize
effortstohealthethousandsofSouthSudaneseaffectedbyconflictinordertoensurethatpoormental
healthdoesnotcontinuetounderminepeacebuildingeffortsinSouthSudan.Restoringmentalhealth
isaprerequisiteforachievingandmaintainingpeace,stability,andreconciliation.
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2. METHODOLOGY
ThisreportisbasedprimarilyonresearchconductedbyAmnestyInternationalinAprilandMay
2015,andinMay2016,inthecitiesofJuba,Malakal,andBentiu,whichhaveallbeenaffectedby
theinternalarmedconflict.Italsodrawsonresearchcarriedoutsincetheoutbreakoftheconflictin
December2013.
Theconflicthasresultedintheinternaldisplacementofapproximately1.7millionSouthSudanese.
Ofthese,200,000arelivinginsixProtectionofCivilians(PoC)sitesacrossthecountry.PoCsitesare
thecamp-likesettlementsforinternallydisplacedpeopleestablishedwithinexistingUnitedNations
MissioninSouthSudan(UNMISS)basesandguardedbyUNpeacekeepers.Otherinternallydisplaced
peoplehavesettledinhostcommunities,liveininformalsettlements,orhavefledtoremote,hardto-reachareasofthecountry.AmnestyInternationalresearchersinterviewed161internallydisplaced
peoplelivinginPoCsitesinJuba,MalakalandBentiu.Researchersalsoconductedinterviewsinan
internallydisplacedpeople’ssettlementattheMahadSchoolinJuba.Researchersselectedthese
locationsbecausetheywereaccessibleandhostlargeconcentrationsofindividualsaffectedbythe
internalarmedconflict.
Researchersselectedforinterviewsinternallydisplacedpeoplewhowerevictimsoforwitnessesto
violationsorabusesofinternationalhumanrightsandhumanitarianlaw,individualswhoshowedsigns
ofpsychologicaldistress,andtheirfamilymembers.Thoseinterviewedweregenerallyreferredbynongovernmentalorganisations(NGOs)orcommunitymembers.Researchersalsointerviewedcommunity
leaders,womenleaders,churchleaders,elders,andtraditionalleadersaboutcommunityperceptionsof
andresponsestopsychologicaldistress.
Interviewswithinternallydisplacedpeoplefocusedontheviolationsandabusesintervieweeshad
experiencedorwitnessed,othersourcesofstressandtraumawithintheirlives,behavioursand
symptomsassociatedwithpsychologicaltrauma,andtheimpactofthesebehavioursandsymptoms
ontheirday-to-daylives.Mostinterviewslastedapproximatelyonehour.Interviewswereconductedin
privateorsemi-privatesettings,suchashomes,NGOoffices,ormeetingspaces.
Researcherstookcaretoensurethatintervieweesrepresentedacrosssectionofthepopulationwith
respecttogender,age,andethnicity.Giventhattheconflicthas,inmanyinstances,pittedethnic
communitiesagainsteachother,witharmedactorsdeliberatelytargetingciviliansbasedontheir
ethnicityandperceivedpoliticalallegiance,itwasimportantfortheresearchtoreflectexperiences
ofpeoplefromdifferentethnicgroups.However,becausethevastmajorityofindividualswhohave
takenrefugeinJubaandBentiuPoCsitesarefromtheNuerethnicgroup,allinternallydisplaced
peopleinterviewedintheselocationswereNuer.ThepopulationoftheMalakalPoCsiteismixed,so
researcherswereabletointerviewindividualsfromtheNuer,Shilluk,andDinkaethnicgroups.Atthe
MahadSchool,intervieweeswerefromtheDinka,Murle,andAnyuakethnicgroups.
AmnestyInternationalresearchersalsointerviewedgovernmentandUNofficials,donors,
representativesofNGOs,andinternationalandSouthSudanesementalhealthprofessionals—including
psychiatrists,psychologistsandpsychosocialworkers—tofurtherunderstandtheimpactoftheconflict
onmentalhealth.Inparticular,interviewsfocusedonmentalhealthissuesarisinginthecontextof
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widespreadviolationsofhumanrightsandhumanitarianlaw,andtheavailabilityofservicesforthose
sufferingfrompsychologicaldistress.
Researchersinformedintervieweesofthepurposeoftheinterview,thekindsofissuesthatwould
becovered,itsvoluntarynatureandthefactthattheycoulddiscontinuetheinterviewatanytime.
Allintervieweesverballyconsentedtobeinginterviewedandfortheirtestimonytobeincludedin
thisreport.InterviewswereconductedinEnglish,Arabic,Anyuak,Dinka,Murle,Nuer,andShilluk
languageswithassistancefrominterpreters.Torespectconfidentialityandprotectvictimsand
witnessesfromreprisal,allinternallydisplacedpeopleinterviewedhavebeenassignedpseudonyms.
MostrepresentativesofinternationalNGOsalsorequestedthattheirnamesbewithheld,duetofearof
reprisalbygovernmentofficialsforspeakingoutabouthumanrightsissues.
AmnestyInternationalconsultedmentalhealthexpertsindesigningtheresearchmethodologyand
throughouttheresearchprocess.Amedicaldoctorwithsignificantexperienceworkingwithinternally
displacedpeopleandsurvivorsofhumanrightsviolationsaccompaniedAmnestyInternational
researcherstoJubaandBentiu.Inaddition,SouthSudanesementalhealthorpsychosocialsupport
workersofferedcounsellingasneededduringandfollowinginterviews,tohelpavoidre-traumatization.
AmnestyInternationalresearchersreferredintervieweestorelevantorganizationsprovidingmental
healthservicesasappropriateandwiththeconsentofindividualsinterviewed.Apsychologistanda
psychiatristwithexperienceinSouthSudanreviewedthisreport,andtheirfeedbackwasincorporated.
ThisreportseekstoportraythementalhealthimpactofSouthSudan’sconflict,basedonthe
understandingthatmentalhealthis“astateofwell-beinginwhichanindividualrealizeshisorher
ownabilities,cancopewiththenormalstressesoflife,canworkproductivelyandisabletomakea
contributiontohisorhercommunity.”1AmnestyInternational,therefore,understandsmentalhealth
impactstoencompassbothspecificmentalhealthconditionsaswellasmoregeneralpsychological
distressandtrauma.Researcherssoughttoidentifyanddescribecommonlyrecognizedpsychiatric
symptomsexperiencedbyinterviewees,butdidnotattempttodeterminethespecificmentalhealth
conditionsthatmayaffectthem.
Thetermmentalhealthcareorservicesisusedtorefertoabroadrangeofinterventionsdesignedto
supportmentalhealth.Itshouldthereforebeunderstoodtoincludenon-biologicalinterventions,also
referredtoaspsychosocialsupport,treatmentorrehabilitation.
AmnestyInternationalwouldliketothankallthesurvivorsofhumanrightsviolationsandabuses
whocourageouslydescribedtheirintimatethoughtsandemotions,aswellastheofficials,health
professionals,andaidworkerswhosharedtheirviewsandexperiences.
WorldHealthOrganization(WHO),MentalHealthActionPlan2013-2020,2013,p.38,
availableat:http://www.who.int/mental_health/publications/action_plan/en/
1
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3. WAR, TRAUMA AND
MENTAL HEALTH
SOUTH SUDAN’S LONG LEGACY OF WAR
ThearmedconflictthateruptedinDecember2013isonlythemostrecentepisodeofviolenceinSouth
Sudan’shistory.From1956to1972andagainfrom1983to2005,theGovernmentofSudanand
pro-governmentmilitiasfoughtagainstarmedgroupswhosoughtgreaterequalityandautonomyforthe
southernregionsofSudan.Bothperiodsofcivilwarwerecharacterisedbyextremeviolenceagainst
civilians,grosshumanrightsabuses,andmassiveforceddisplacement.Duringthesecondcivilwar
from1983to2005,anestimated1.9millionpeople—oneoutofeveryfivesouthernSudanese—were
killedordiedfromdiseaseandfamine,andsomefourmillionpeoplewereinternallydisplaced.2
Awomancriesfollowingadeadlyattackbycattleraiders.Chukudum,EasternEquatoriastate,2007©TimMcCulka
UnitedStates(US)CommitteeforRefugees,“Sudan:Nearly2milliondeadasaresultoftheworld’slongestrunningcivilwar,”
2001,availableat:http://web.archive.org/web/20041210024759/http://www.refugees.org/news/crisis/sudan.htm
2
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In2005,theSudanesegovernmentandtherebelSudanPeople’sLiberationMovement/Army(SPLM/A)
signedaComprehensivePeaceAgreement(CPA)whichgrantedregionalautonomytoSouthSudan.
ButtheCPAdidnotbringanendtointernalviolence,nordidSouthSudan’ssecessionfromSudanin
2011followingareferendumonself-determination.From2005to2013,fightingbetweengovernment
forcesandarmedinsurgentmilitias,intercommunalviolenceoftenlinkedtolandandcattle,and
thewidespreadavailabilityofarmsafteryearsofwarcontinuedtoresultinrepeatedpopulation
displacements,destructionofcivilianproperty,andahighnumberofciviliandeaths.3
RENEWED CONFLICT IN 2013
InDecember2013,growingpoliticaltensionbetweenPresidentSalvaKiirandDrRiekMachar
mushroomedintoabrutalinternalarmedconflict.4FightingstartedinJuba,thecapital,where
governmentforcesengagedintargetedkillings,primarilyofNuermen.Securityforcesacrossthe
countrysplit—withsomemaintainingallegiancetothegovernmentandothersdefectingtosupportthe
armedoppositionunderMachar,whichcametobeknownastheSudanPeople’sLiberationMovement/
Army-InOpposition(SPLM/A-IO).Bytheendof2013,theconflicthadengulfedpartsofJonglei,Unity,
andUpperNilestates.5
Theconflictresultedinthedestructionofhomes,hospitals,andotherbuildings.Bentiu,SouthSudan,March2014.©Amnesty
International
Seeforexample,AmnestyInternational,OvershadowedConflict:ArmsSuppliesFuelViolationsinMayomCounty,UnityState,
2012(Index:AFR65/002/2012)availableat:https://www.amnesty.org/en/documents/afr65/002/2012/en/;AmnestyInternational,
DestructionandDesolationinAbyei,2011(Index:AFR54/041/2011)availableat:https://www.amnesty.org/en/documents/
afr54/041/2011/en/;SmallArmsSurvey,MyNeighbor,MyEnemy:IntertribalViolenceinJonglei,2012,availableat:http://www.
smallarmssurveysudan.org/fileadmin/docs/issue-briefs/HSBA-IB21-Inter-tribal_violence_in_Jonglei.pdf;andSmallArmsSurvey,The
PendulumSwings:TheRiseandFallofInsurgentMilitiasinSouthSudan,2013,availableat:http://www.smallarmssurveysudan.org/
fileadmin/docs/issue-briefs/HSBA-IB22-Pendulum-Swings.pdf
3
RiekMacharservedasVice-Presidentfrom2005toJuly2013,whenPresidentKiirremovedhimfromtheposition.InFebruary
2016,KiirissuedapresidentialdecreereappointingMacharasVice-President,inaccordancewiththeAugust2015Agreementon
theResolutionoftheCrisisinSouthSudan(ARCSS).
4
Forbackgroundonthefirstmonthsoftheconflict,seeUNMissioninSouthSudan(UNMISS),ConflictinSouthSudan:AHuman
RightsReport,May2014,availableat:
http://unmiss.unmissions.org/Portals/unmiss/Human%20Rights%20Reports/UNMISS%20Conflict%20in%20South%20Sudan%20
-%20A%20Human%20Rights%20Report.pdf;AmnestyInternational,NowhereSafe:CiviliansunderAttackinSouthSudan,May
2014(Index:AFR65/003/2014),availableat:https://www.amnesty.org/en/documents/AFR65/003/2014/en/
5
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Bothgovernmentandoppositionforceshavecommittedseriousviolationsofinternationalhumanitarian
lawandserioushumanrightsviolationsandabuses.Theyhavedeliberatelykilledciviliansincluding
children,womenandelderlypeople,oftentargetingthembasedonethnicityorperceivedpolitical
allegiance.Theyhaveabductedandrapedwomenandgirls;ravagedhospitalsandschools;destroyed
andlootedcivilianproperty,includingmeansoflivelihood;attackedhumanitarianpersonneland
assets;recruitedchildsoldiers;andkilledcapturedsoldiersandotherfightersplacedhorsdecombat.
Warringpartieshavealsoobstructedhumanitarianassistance,includingmedicalandfoodsupplies,
preventingthemfromreachingcivilianpopulationsdisplacedbytheconflict.6Theseactsamounttowar
crimesandsomemayconstitutecrimesagainsthumanity.
Theconflicthashadadevastatingimpactoncivilians.Thousandsofpeoplehavebeenkilledandentire
townsandvillageshavebeenleftinruins.Over2.3millionSouthSudanesehavefledtheirhomes
sincetheoutbreakoffighting,withsome1.7millioninternallydisplacedandanother600,000living
inneighbouringcountriesasrefugees.Anestimated2.8millionpeople—closetoonequarterofthe
population—arefacingacutefoodandnutritioninsecurity.7
InAugust2015,followingalmosttwoyearsofon-and-offpeacenegotiationsmediatedbythe
IntergovernmentalAuthorityonDevelopment(IGAD),partiestotheconflictandotherstakeholders
signedtheAgreementontheResolutionoftheConflictinSouthSudan(ARCSS).8Theagreement
providesfortheformationofaTransitionalGovernmentofNationalUnity(TGoNU)andfornational
electionsaftertwoandahalfyears.Italsoenvisagesbroadsecuritysectorreform,theestablishment
ofaHybridCourtforSouthSudan(HCSS)bytheAfricanUnion(AU)Commissiontoprovide
accountabilityforcrimesunderinternationallaw,aCommissiononTruth,ReconciliationandHealing
(CTRH),aCompensationandReparationsAuthority(CRA),andforapermanentconstitutional
developmentprocess.9
On26April2016,DrRiekMachar,leaderoftheSPLM/A-IO,returnedtoJubaandwassworninas
FirstVicePresident,markinganimportantmilestoneinimplementationoftheARCSS.Ministersofthe
TGoNUtookoathsofofficeafewdayslater.AsofMay2016,however,numerousaspectsoftheARCSS
havenotbeenimplemented,insomecasesduetooutstandingdisagreementsbetweentheparties.10
Thecountryalsocontinuestobeaffectedbysignificantviolence,despitethepermanentceasefire
ordersissuedbyPresidentKiirandMacharfollowingsigningoftheARCSS.11 Fighting in southern
UnitystatecontinuedthroughDecember2015,andon25April2016,arocket-propelledgrenade
landedinsidetheperimeteroftheUnitedNationsMissioninSouthSudan(UNMISS)compoundin
Bentiu.12On17and18February2016,violenceintheMalakalProtectionofCivilians(PoC)site
Ibid.Foradditionaldocumentationofhumanrightsandhumanitarianlawabuses,seeAmnestyInternational,“SouthSudan:
Escalationofviolencepointstofailedregionalandinternationalaction,”21May2015,availableat:www.amnesty.org/en/pressreleases/2015/05/south-sudan-escalation-of-violence-points-to-failed-regional-and-international-action/;UNMISS,TheStateof
HumanRightsintheProtractedConflictinSouthSudan,December2015,availableat:http://unmiss.unmissions.org/Portals/
unmiss/Human%20Rights%20Reports/Human%20Rights%20Update%20Report%20of%204%20December%202015%20(final).
pdf;HumanRightsWatch,TheyBurneditall:Destructionofvillages,killingsandsexualviolenceinUnityState,SouthSudan,July
2015,availableat:https://www.hrw.org/report/2015/07/22/they-burned-it-all/destruction-villages-killings-and-sexual-violence-unitystate;AfricanUnionCommissionofInquiryinSouthSudan(AUCISS),FinalReport,October2015,availableat:http://www.peaceau.
org/uploads/auciss.final.report.pdf;http://reliefweb.int/sites/reliefweb.int/files/resources/2016_hrp_SS_Final_WEB.pdf
6
UnitedNationsOfficefortheCoordinationofHumanitarianAffairs(OCHA),HumanitarianBulletin:SouthSudan,10February
2016,availableat:http://reliefweb.int/sites/reliefweb.int/files/resources/160210_OCHA_SouthSudan_humanitarian_bulletin.pdf
7
SignatoriestotheARCSSinclude:1)TheParties(theGovernmentofSouthSudan,theSudanPeople’sLiberationMovement/
Army-InOpposition(SPLM/A-IO),theformerdetainees,andthepoliticalparties),2)Stakeholders(civilsociety,faithbasedleaders,
women’sbloc,andeminentpersonalities),3)Adherents,4)TheGuarantors(IntergovernmentalAuthorityonDevelopment(IGAD),
HeadsofStateandGovernment,theAU,theIGAD-ledMediation,andinternationalpartners).
8
ARCSS,availableat:southsudan.igad.int/index.php/91-demo-contents/news/299-agreement-on-the-resolution-of-the-conflict-in-therepublic-of-south-sudan.RiekMachar,leaderoftheSPLMA/IO,signedtheagreementon17August2015whilePresidentSalvaKiir
signedtheagreementon26August2015.
9
ForanaccountoffailurestoimplementthepeaceagreementbetweenAugust2015andJanuary2016,see:Reportofthe
ChairpersonoftheJointMonitoringandEvaluationCommission(JMEC)fortheAgreementontheResolutionoftheConflictin
theRepublicofSouthSudantotheAfricanUnionPeaceandSecurityCouncil(PSC),29January2016,availableat:http://
jmecsouthsudan.org/uploads/AUPSCreport.pdf
10
Foraccountsoffightingfollowingthesigningofthepeaceagreement,seeUNMISS,The State of Human Rights in the Protracted
Conflict in South Sudan,December2015;FinalreportofthePanelofExpertsonSouthSudanestablishedpursuanttoSecurity
Councilresolution2206(2015),January2016,UNDocument:S/2016/70,availableat:http://www.un.org/ga/search/view_doc.
asp?symbol=S/2016/70
11
UNOCHA,SouthSudanHumanitarianBulletin,9May2016,availableat:https://gallery.mailchimp.com/
f2c222dd83de60ecbebe45951/files/160509_OCHA_SouthSudan_humanitarian_bulletin.pdf
12
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leftapproximatelyone-thirdofthecampburnttotheground.13Therewereincidentsofinsecurity
andfightinginWesternEquatoriabetweenMay2015andMarch2016,duringwhichgovernment
soldiersattackedciviliansandburnedcivilianhomes.14InFebruary2016,fightinginPiborcountyof
JongleistatebetweengovernmentsoldiersandforcesloyaltoformerPiboradministratorDavidYau
Yaudisplaced30,000people.15InWesternBahrelGhazalstate,governmentsoldierskilled,tortured
andrapedciviliansandlootedandburneddowncivilianhomesbetweenDecemberandFebruary
2016.AccordingtotheUnitedNationsOfficefortheCoordinationofHumanitarianAffairs(UNOCHA),
betweenJanuaryandMarch201616approximately100,000SouthSudanesefledthecountryas
refugees.17Despitethepeaceagreement,therefore,realrespitefromtwoyearsofdisplacement,death,
anddestructionisstillfaroffformanySouthSudanese.
THE MENTAL HEALTH IMPACT OF ARMED CONFLICT
Studiesinconflict-affectedregionsacrosstheworldhaveconsistentlydemonstratedthatarmedconflict
hasanegativeimpactonmentalhealth—thestateofemotionalandpsychologicalwellbeinginwhich
individualscancopewiththenormalstressesoflife,workproductively,andbeactivemembersof
theircommunity.18Duetoarmedconflict,peoplearemorelikelytosufferarangeofmentalhealth
issues:aminoritywilldevelopnewanddebilitatingmentaldisorders,manyotherswillexperience
psychologicaldistress,andthosewithpre-existingmentaldisordersoftenwillneedmorehelpthan
before.19TheWorldHealthOrganization(WHO)estimatesthatinsituationsofarmedconflictandother
emergencies,theproportionofthepopulationsufferingfrommildormoderatementaldisordersrises
fromapproximately10%to15-20%.20
Studiesalsoindicatethatpeoplewhoexperiencemoreepisodesoftraumaduringconflictaremore
susceptibletomentalhealthproblems.21Traumaticeventsshowntobepositivelycorrelatedwithmental
healthproblemsincludewitnessingorexperiencingrape,torture,abduction,forceddisplacement,
andlossofproperty—allhumanrightsandhumanitarianlawviolationsthathavebeenendemicin
SouthSudan’sinternalarmedconflict.Othertraumaticexperiences,suchaslackofadequatefood,
shelterormedicalcare,thoughtosomeextentanassumedconsequenceofwar,have,inSouthSudan,
beenexacerbatedbytheintentionaldestructionofcivilians’meansoflivelihood22andobstructionof
humanitarianaidbywarringparties.23
CenterforCiviliansinConflict,A Refuge in Flames: The February 17-18 Violence in Malakal PoC, 2016,availableat:http://
civiliansinconflict.org/uploads/files/publications/CIVIC_-_Malakal_Report_-_April_2016.pdf
13
HumanRightsWatch,“SouthSudan:ArmyAbusesSpreadWest,6March2016,”availableat:https://www.hrw.org/
news/2016/03/06/south-sudan-army-abuses-spread-west
14
UNOCHA,SouthSudanHumanitarianBulletin,28March2016,https://gallery.mailchimp.com/f2c222dd83de60ecbebe45951/
files/20160328_OCHA_SouthSudan_humanitarian_bulletin.pdf.ThefightingeruptedfollowingPresidentKiir’sappointmentofBaba
MedanKonyiasGovernoroftherecentlycreatedBomastate,replacingDavidYauYauasadministratorofthearea.SudanTribune,
“SouthSudanPresidentSummonsBomaGovernoroverClashes,”28February2016,availableat:http://www.sudantribune.com/spip.
php?article58158
15
HumanRightsWatch,“SouthSudan:CiviliansKilled,TorturedinWesternRegion:ProvideJusticeforArmyAbusesinWestern
Regions,”24May2016,availableat:https://www.hrw.org/news/2016/05/24/south-sudan-civilians-killed-tortured-western-region
16
UNOCHA,SouthSudanHumanitarianBulletin,9May2016,availableat:https://gallery.mailchimp.com/
f2c222dd83de60ecbebe45951/files/160509_OCHA_SouthSudan_humanitarian_bulletin.pdf
17
WHO,MentalHealthActionPlan2013-2020,p.38.
18
WHO,BuildingBackBetter:SustainableHealthCareafterEmergencies,2013,p.4,availableat:http://apps.who.int/iris/
bitstream/10665/85377/1/9789241564571_eng.pdf
19
WHO,BuildingBackBetter,p.17.
20
R.F.Mollicaetal.,“Mentalhealthincomplexemergencies,”TheLancet,2004,p.2059,availableat:http://www.thelancet.com/
journals/lancet/article/PIIS0140-6736(04)17519-3/fulltext?refuid=S0840-4704(10)60254-2&refissn=0840-4704Forexample,
thenumberofhumanrightsviolationssufferedbyindividualsduringtheBalkanconflictwaspositivelycorrelatedwithriskofposttraumaticstressdisorder(PTSD),majordepressionandothersymptomsofmentalhealthdisorders.StefanPriebeetal,“Experience
ofHumanRightsViolationsandSubsequentMentalDisorders:AStudyFollowingtheWarintheBalkans,”SocialScienceand
Medicine,2010,p.5,availableat:http://www.ncbi.nlm.nih.gov/pubmed/21041008
21
Forexample,betweenAprilandDecember2015,governmentforceslootedandburnedfoodandstolecattleandotherlivestock
fromciviliansinsouthernandcentralUnitystate.UNMISS,TheStateofHumanRightsintheProtractedConflictinSouthSudan,
December2015,para.43.
22
InMarch2016alone,UNOCHArecorded60incidentsaffectinghumanitarianaccess.Ofthese,43werecasesofviolenceagainst
humanitarianpersonnelorassets.UNOCHA,SouthSudanHumanitarianAccessSituationSnapshot,March2016,availableat:
http://reliefweb.int/sites/reliefweb.int/files/resources/access_snapshot_20160407.pdf
23
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Commonconditionstriggeredbyconflictincludepost-traumaticstressdisorder(PTSD)andother
anxietydisorders,depression,andpsychosomaticproblemssuchasinsomnia,orbackandstomach
aches.24Symptomsassociatedwiththesementalhealthconditionsandpsychologicaldistressmore
broadlyincludefeelingsofshame,self-blame,fragmentedmemories,alackofconcentration,intrusive
memories,theavoidanceofcircumstancesassociatedwiththestressor,sleepdisorders,nightmares,
flashbacks,irritability,anger,anxiety,andmistrustofotherpeople.Peoplesufferingfrompoormental
health,particularlydepression,mayalsoconsider,orcarryout,suicide,andaremorepronetopoor
physicalhealth,risk-taking,andharmfulbehaviourssuchassubstanceabuse.25
SOUTH SUDAN: A TRAUMATIZED NATION
ThereisnodoubtthatdecadesofwarhaveexactedaheavytollonSouthSudanesepeopleand
contributedtowidespreadmentalhealthissues.Whiletherearenonationalstatisticsontheprevalence
ofmentalhealthconditionsinSouthSudan,surveysassessingratesofpost-traumaticstressdisorder
anddepressioninlimitedpopulationshaveconsistentlyillustratedhighlevelsofpsychological
distress.A2004studyfoundthat50%ofsurveyedresidentsofSouthernSudanand44%ofSouthern
SudaneserefugeesinUgandasufferedsymptomsofPTSD.26Astudyconductedin2007foundhigh
levelsofmentaldistressinthepopulationsurveyedinJuba.Inthisstudy,36%ofrespondentsmet
symptomcriteriaforPTSDandhalf(50%)ofrespondentsmetsymptomcriteriafordepression.27 This
study’sresultsshowedadirectrelationshipbetweenexperiencingtraumaticevents—suchasforceful
separationfromfamilyandbeinginjured—andthelikelihoodofPTSDanddepression.28Research
amongSouthSudaneseex-soldiersin2010foundthat15%reportedwishingtheyweredeador
thinkingaboutsuicide.29
Quantitativestudiescarriedoutsincetherenewederuptionofconflictin2013havereportedsimilar
findings.A2015studybytheSouthSudanLawSociety(SSLS)andtheUnitedNationsDevelopment
Programme(UNDP)foundthat41%ofthe1,525respondentsacrosssixstatesandAbyeiexhibited
symptomsconsistentwithadiagnosisofPTSD.Thedataalsoindicatedhighlevelsofexposureto
traumainthesamplepopulation,with63%ofrespondentsreportingthataclosefamilymemberwas
killedatsomepointintheirlivesand41%reportingthattheyhadwitnessedafriendorfamilymember
beingkilled.30A2015surveybySSLSinMalakalPoCsitefoundthat53%ofrespondentsexhibited
symptomsconsistentwithadiagnosisofPTSD.31
InMarch2016alone,UNOCHArecorded60incidentsaffectinghumanitarianaccess.Ofthese,43werecasesofviolenceagainst
humanitarianpersonnelorassets.UNOCHA,SouthSudanHumanitarianAccessSituationSnapshot,March2016,availableat:
http://reliefweb.int/sites/reliefweb.int/files/resources/access_snapshot_20160407.pdf
23
R.SrinivasaMurthyandRashmiLakshminarayana,“MentalHealthConsequencesofWar:ABriefReviewofResearchFindings,”
WorldPsychiatry,2006;WHO,WorldReportonViolenceandHealth,2002,p.224,availableat:http://apps.who.int/iris/
bitstream/10665/42495/1/9241545615_eng.pdf
24
Forfulldescriptionsofmentaldisorders,seeInternationalStatisticalClassificationofDiseasesandRelatedHealthProblems,10th
Revision(ICD-10),availableat:http://apps.who.int/classifications/icd10/browse/2016/en
25
UnniKrishnanKarunakaraetal.,“Traumaticeventsandsymptomsofpost-traumaticstressdisorderamongstSudanesenationals,
refugeesandUgandansintheWestNile,”AfricanHealthSciences,2004,p.88,availableat:http://kops.uni-konstanz.de/bitstream/
handle/123456789/11366/Karunakara_etal2004.PDF;jsessionid=9B57C94F7346EF5000577E9024A0F3E2?sequence=1
26
BayardRobertsetal.,“Post-conflictmentalhealthneeds:across-sectionalsurveyoftrauma,depressionandassociatedfactors
inJuba,SouthernSudan,”BMCPsychiatry,2009,p.5,availableat:http://www.biomedcentral.com/content/pdf/1471-244X-9-7.
pdfAsurveyofpopulationsinAbyeifoundthat37.8%ofrespondentsmetsyptomcriteriaforPTSD.SeealsoBelkysLópezand
HazelSpears,StabilizingAbyei:TraumaandtheEconomicChallengestoPeace,Kush,2013,availableat:http://server2.docfoc.com/
uploads/Z2015/12/20/zXgw5Bj4vM/7032e8dd1043bb97e5251705dce7182c.pdf
27
Itfoundthatrespondentswhohadexperiencedeightormoreofthe16traumaeventsincludedinthequestionnaireweremore
likelytoexhibitsymptomsofPTSDanddepression.BayardRobertsetal.,“Post-conflictmentalhealthneeds:across-sectional
surveyoftrauma,depressionandassociatedfactorsinJuba,SouthernSudan,”BMCPsychiatry,2009,p.6.
28
NinaWinkler,“Pyscho-socialinterventionneedsamongex-combatantsinSouthernSudan,”BonnInternationalCentrefor
Conversion,2010,p.14,availableat:http://www.ssddrc.org/uploads/SSDDRC_Psycho_Social_Assessment.pdf
29
ThesurveyusedtheHarvardTraumaQuestionnaire(HTQ)toassess16typesoftraumaticeventsandPTSDsymptoms.South
SudanLawSociety(SSLS)etal,SearchforaNewBeginning:PerceptionsofTruth,Justice,ReconciliationandHealinginSouth
Sudan,October2015,p.vii,availableat:file://kenb0-vs-dc1ro/users$/elizabeth.deng/Downloads/Perception%20Survey%20
Report%20Transitional%20Justice%20Reconciliation%20and%20Healing%20-.pdf
30
DavidK.Dengetal,AWarWithin:Truth,Justice,ReconciliationandHealinginMalakalPoC,2015,p.v,availableat:https://
radiotamazuj.org/sites/default/files/SSLS_A_War_Within_Dec_2015_.pdf
31
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Awomanwhosehusbandwaskilledbyanunknownarmedgroupthepreviousnight.Gumbo,CentralEquatoriastate,2006©Tim
McCulka
Mentalhealthexpertsandserviceprovidersbelievetheconflicthashadasignificantandwidespread
impactonmentalhealth.AccordingtoDrAtongAyuel,DirectoroftheMinistryofHealth’sDepartment
ofMentalHealth,therehasbeenanincreaseinthenumberofpatientswithpsychosis,depression,
substanceabuseproblems,anddementia.32
TheAfricanUnionCommissionofInquiryonSouthSudan(AUCISS)notedinitsfinalreportthat
“traumaappearstobeakeyconsequenceoftheconflict.”
“The Commission heard multiple stories of loss of close family
members, children, husbands, wives that left survivors traumatized.
The brutality of atrocities witnessed or survived haunts many victims.
For mothers, separation from or abduction of children has left emotional
and psychological scars and that manifest in various [ways] including
sleeplessness and stress-induced illness.”
TheAUCISSrecommendedfurtherinquiryintothescopeoftraumaandtheneedforpsychosocial
interventionsinthecountry.33
AmnestyInternationalinterviewwithDr.AtongAyuel,Director,MentalHealthDepartment,MinistryofHealth,Juba,SouthSudan,
10April2015.
32
AUCISS,FinalReport,para.895.
33
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4. SURVIVORS SPEAK OF
TRAUMA
“I hear a lot of noise at night. I dream that I am still in
jail…I wake up and I can’t go back to sleep.”
Lual
Ofthe1.7millionSouthSudaneseinternallydisplacedbythecurrentconflict,approximately200,000
arelivinginsixPoCsiteslocatedonUNMISSbasesacrossthecountry.Displacedpeopleseeking
refugeandprotectionhaveconvergedonthesesitesoverthecourseoftheconflict.Therearesome
28,000livinginJubaPoCsite,47,000inMalakal,andalmost120,000inBentiu.34
TheresidentsofSouthSudan’sPoCsiteshave,withoutexception,beenprofoundlyimpactedbythe
humanrightsandhumanitarianlawabusesandviolationsthathavecharacterizedSouthSudan’s
conflict.Theirhomeshavebeenlootedordestroyed,theirlivestockstolen,theirbusinessesruined.
Manyhavewitnessedfamilymembersorneighboursbeingkilledorarethemselvesvictimsofphysical
orsexualviolence.35ThoughtheprotectionofUNpeacekeepershasundeniablysavedlives,PoCsites
havethemselvesbeenscenesofmasskilling:anApril2014attackonBorPoCsiteresultedinatleast
47civiliandeathswhileaFebruary2016attackonMalakalPoCsiteresultedinatleast25deathsand
120injuries.36TherehavealsobeenincidentsofshellingandgunfirepenetratingPoCsitesaswellas
numerouscasesofkillings,rapes,andabductionsofinternallydisplacedpeoplewhoventureoutsideof
PoCsites.37
InternallydisplacedpeopleinterviewedbyAmnestyInternationaldescribedhavingnightmares,getting
angryeasily,feelingunabletoconcentrateandconsideringsuicide—commonsymptomsassociated
withPTSDanddepression.Manyalsospokeofheadaches,stomachpains,backachesandheart
palpitations—commonphysicalmanifestationsofpsychologicalstress.Theyattributedthesemental,
physical,emotional,relationalandspiritualimpactstothehumanrightsandhumanitarianlawabuses
andviolationstheyhadwitnessedorexperienced.Theyalsodescribedhowtheseimpactsaffected
UNMISSupdate,22February2016,http://unmiss.unmissions.org/Portals/unmiss/UNMISS%20Update/2016/February%20
2016/22.02%20-%20Update%20No.%20114.pdf
34
Foranoverviewofconflictrelatedrightsviolations,see,forexample,UNMISS,TheStateofHumanRightsintheProtracted
ConflictinSouthSudan,December2015.
35
UNMISS,TheStateofHumanRightsintheProtractedConflictinSouthSudan,December2015,para.43;UNOCHA,South
SudanHumanitarianBulletin,3March2016,availableat:https://gallery.mailchimp.com/f2c222dd83de60ecbebe45951/
files/160303_OCHA_SouthSudan_humanitarian_bulletin.pdf
36
UNMISS,TheStateofHumanRightsintheProtractedConflictinSouthSudan,December2015,paras43-53.
37
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theirabilitytowork,study,carryoutbasicdailytasks,careforchildren,andmaintainrelationships
withfriendsandfamily.Theirtestimonyisastarkillustrationofthementalhealthrepercussionsofthe
conflict.
Inadditiontoconflict-relatedabusesandviolations,thegenerallydifficultlivingconditionswithinthe
PoCsitespresentanadditionalchallenge.Limitedaccesstoeducationandmedicalcareincluding
psychosocialservices,amonotonousdiet,crampedandsometimesfloodedshelters,andpoorsanitation
exacerbatepsychologicalstressandalsoimpederecoveryfromtrauma.
Familyandcommunitymembersplayanimportantroleinsupportingindividualsexperiencing
psychologicaldistress,butconflictanddisplacementhaveseverelyweakenedandstretchedthese
traditionalsupportnetworksandtheirabilitytohelppeoplecope.Intervieweesspokeofhow
neighbours,friends,relativesandchurchmembersadvise,counsel,andcomfortthem,providing
somerelief.Butoftenthepeopletowhomindividualsfacingdistresswouldturnforsupportareeither
absentorarethemselvessufferingfromheavypsychologicalburdens.Peoplewithmentalhealth
problemsarealsosubjectedtosignificantsocialstigma,andfamilyandcommunitymembershave
limitedinformationaboutmentalhealth,trauma,andwhatconstitutesappropriatecareandtreatment.
Manyindividualsexperiencingpsychologicaldistressfelttheywouldbenefitfrommentalhealthor
psychosocialsupportservicesandprogrammes,butgiventhelimitedavailabilityandaccessibilityof
suchserviceswithinthePoCsitesorinSouthSudangenerally,veryfewhad.38
“SOMETIMES I DREAM THAT I DIED WITH THOSE WHO
WERE KILLED”: TARGETED KILLINGS IN JUBA
InDecember2013,followingtheoutbreakoffightinginJuba,membersofthePresidentialGuard,the
military,andothersecurityforcestargetedNuersoldiersandciviliansonthebasisoftheirethnicityand
perceivedpoliticalaffiliationtoRiekMachar.Governmentsecurityforcesconductedhouse-to-house
searchesinJuba,killingpeopleinorneartheirhomesortakingthemtootherlocations.According
totheSouthSudanHumanRightsCommission(SSHRC),morethan600peoplewerekilledand800
injuredinJubaanditssuburbsbetween16and18December2013.39
OneoftheworstsingleincidentsofkillinginJubawasthemurderofapproximately300menfromthe
NuerethnicgroupinafacilityintheGudeleneighbourhoodusedbyseveralsecurityforcesasajoint
operationscentre,duringthenightof16-17December2013.40Governmentsoldiersandothersecurity
officersgatheredthemeninabuildingandopenedfireonthem,killingmost.Malith,onesurvivor,
spokeofwhathappened.
“We were put in a house with four windows and people shot at us. They
shot from the windows. They also opened the door and shot inside… I
had fallen against the wall and was covered by the weight of others who
had died.”
MalithandothersurvivorswhospokewithAmnestyInternationaldescribedexperiencingpsychological
distressasaresultofthedeathstheywitnessedandbarelysurvived.Thememoryofwhathappened,
Malithsaid,disturbshissleep.Healsohasdifficultyconcentrating.
“Sometimes I dream that I died with those who were killed. I wake up
sweating and trembling. Sometimes I think those people who died are
here with me, alive. The situation is hard. I think about how I survived.
Why did these others die? It makes me feel bad…
TheavailabilityofmentalhealthandpsychosocialsupportserviceswithintheProtectionofCivilians(PoC)sitesandgenerallyin
SouthSudanisdescribedintheChapter“AvailabilityandAccessibilityofMentalHealthServices.”
38
SouthSudanHumanRightsCommission,InterimReportonSouthSudanInternalConflict,December15,2013-March15,
2014,p.6,availableat:www.gurtong.net/ECM/Editorial/tabid/124/ctl/ArticleView/mid/519/articleId/15078/SSHRC-Interim-Reporton-South-Sudan-Internal-Conflict-December-15-2013--March-15-2014.aspx
39
TheAUCISSconfirmedthisincidentandconductedaforensicanalysisofthebuildingwherethemassacretookplace.AUCISS,
FinalReport,paras470-494.SeealsoUNMISS,ConflictinSouthSudan-AHumanRightsReport,paras70-78.
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UNMISSPoCsiteinJuba,SouthSudan.2014©AmnestyInternational
I tried to go to school here but found that I could not concentrate even on
the easy things. They just opened a school here, but my thoughts distract
me. When I sit still, my mind just goes to other things like my children.”
Malith said that NGOs, journalists, and researchers had interviewed him about what happened. But, he
said, “Nobody has come to give me any counselling or support.”41
James, who also survived the massacre in Gudele, said he has difficulty remembering things related to his
daily life. He suffers from headaches and dizziness when he recalls the heat of the house where he was
confined with others before the massacre. He also feels increased aggression and avoids other people.
“Sometimes I get confused. I lost a lot of things. The other day I had 2000
SSP [South Sudanese pounds]. I don’t remember what happened to
that money. After 28 days a man here in the PoC came and gave me the
money saying ‘Did you forget about this money? You said I should keep it
for you.’
I prefer to sit by myself quietly. When people make noise or talk around
me, I feel hot and dizzy and hear voices. I remember in that building it
was so hot. We were dizzy and others died because it was too hot… I
don’t talk too much. I easily get angry. My temper has become so bad.
When I feel my body getting hot and I start getting headaches, I just go
and sit by myself.
You don’t know when you will die. The same people who killed us are still
out there. People are confused, stressed, and traumatized.”
James stated he had not received any psychological care: “I never got any kind of support or counselling,”
he said.42
InterviewwithMalith(pseudonym),Juba,SouthSudan,25April2015.
41
InterviewwithPeter(pseudonym),Juba,SouthSudan,2May2015.
42
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WhenthesoldiersandsecurityofficerswhocarriedoutthekillingsinGudelefoundPhillip,another
survivor,unharmedunderapileofbodies,theyforcedhimtodrinkthebloodandeatthefleshofthose
killed,inexchangeforhislife.Hefeelsadifferentpersonthanbefore.
“They found me, tied my arms behind my back and forced me at
gunpoint to drink blood and eat flesh. I was told that if I didn’t do this I
would be killed. At night when I sleep, those who were killed come back in
my nightmares.
You may think I’m normal, but my mind is not good…I use a wheelbarrow
to carry goods to give myself less time for thinking, to try to delete what
happened from my memory, but that can never happen. I spend little
time sleeping, mostly I stay awake. I can’t eat, I don’t want anything I’m
offered. I don’t think the way I am feeling will ever change.” 43
PetertoldAmnestyInternationalthatgovernmentsoldierscapturedhis18-year-oldson,Duol,on16
December2013inNyakuronneighbourhood,thentookhimtoGudele,wheretheytiedhisarmsand
legsandbeathim.Peterrecountedthat,afterDuolmanagedtomakehiswaytothePoCsiteon23
December2013,hesufferedfromhallucinationsandshowedothersignsofpsychologicalstress,
includingdifficultysleepingandeating.
“They [soldiers] beat him until they thought he was dead. His legs were
tied with chains or ropes—when he came back, he had marks on his
hands and ankles…He was mad completely. He used to walk around,
boxing in the air…He punched in the air because he was trying to defend
himself. He had a perception that someone was trying to fight him, and
that he needed to protect himself.
He’d walk around all day and all night. He didn’t sleep. He’d go and lie
down in the drainage pits. Sometimes if you gave him a bed to sleep on,
he’d prefer to sleep on the ground… He would not eat. If you forced him
to eat, he’d only have a little... We had to force him to take a bath. Four
of us would come and force him to bathe… He would talk to himself in
English and Arabic, mostly about his friend who got killed.”
PetertoldAmnestyInternationalthattherewasnoappropriatedoctoravailableatthePoCsiteand
hewastooafraidtotakeDuoltoseeadoctorwithinJuba.Withassistancefromafamilymember,
DuolwasabletoleaveJubaandtravelledtoKhartoumwherehesawapsychiatristandwasgiven
medication.AccordingtoPeter,thedoctorsaidDuolwas“traumatized.”44
“I AM STILL SCARED BECAUSE OF WHAT HAPPENED”:
ATTACKS ON CIVILIANS IN MALAKAL
ThecityofMalakal,inUpperNilestate,hasbeenheavilycontestedsinceDecember2013,changing
handsbetweengovernmentandoppositionforcesatleastadozentimes. Duringtheattacksand
counter-attacksonthecityinthefirstfewmonthsoffighting,bothsideskilledciviliansandlooted
anddestroyedcivilianhomes,offices,andotherbuildings.45AmnestyInternationalspokewithwomen
whowitnessedkillingsandsexualviolenceinMalakal,beforetheytookrefugeattheUNMISSPoCsite
betweenDecember2013andFebruary2014.
InterviewwithPhillip(pseudonym),Juba,SouthSudan,27April2015.
43
Peterdidnotknowwhat,ifany,specificdiagnosiswasmade.InterviewwithPeter(pseudonym),Juba,SouthSudan,2May2015.
44
UNMISS,ConflictinSouthSudan:AHumanRightsReport,May2014,para.151-160.
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AviewofthedesertedstreetsinMalakal,UpperNilestateinJanuary2014afterresidentsfledviolencebetweengovernmentand
oppositionforces.©UNPhoto/IsaacBilly
AjakfledtotheMalakalUNMISSbaseon25 December2013,duringthefirstattackonMalakalby
oppositionforces.
“As I was running, I saw Nuer soldiers and one tried to shoot me. I saw
people dead on the roads—men, women and children…The Nuer soldiers
stopped us on the road to UNMISS and said, ‘Give money or mobiles, or
we’ll shoot you.”
Thepsychologicalburdenofwhatshewitnessedwasstillwithher,over18monthslater.
“I started suffering as soon as I arrived at UNMISS—I could not sleep or
eat. If I found people quarrelling, I would leave immediately, I could not
accept it. I like to be with people, but if they are talking, I sometimes don’t
follow as I can’t concentrate. I can’t sleep, and when food is brought, I
can’t eat. I only remember the war and what happened to me.”46
Ajak’sdaughterexplainedthathermothershowedincreasedaggression,affectingherrelationshipswith
others.
“Before, she was good. But then she saw many people die and she
became abnormal. She is always angry if someone she does not like talks
nearby. She quarrels with me and with other people, not like before. She
cries to God that she is dying. Her problem is her increasing suffering.”47
NyachoattookshelterinaCatholicchurchintheMedinaneighbourhoodofMalakalon24December
2013,alongwithmanyothercivilians.Shesaidgovernmentsoldierswouldcometothechurchto
abduct,killandrapepeoplewhohadtakenshelterthere.Nyachoatwitnessedasoldierkillonewoman
whoresistedrape.ShecametotheMalakalPoCsiteon18January2014.ShedescribedtoAmnesty
Internationalpersistentsignsofdistress,includingnightmares.
InterviewwithAjak(pseudonym),Malakal,SouthSudan,6May2015.
46
Interviewwiththedaughter(namewithheld)ofAjak(pseudonym),Malakal,SouthSudan,6May2015.
47
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“My head is bad, I just think about the bad things I saw…The things that
happened in the church, I still remember and see them in my mind…At
night I don’t sleep well. I get nightmares and remember the dead bodies
that were around us. I was scared. I am still scared because of what
happened…When I talk to people, and they talk about the conflict, I feel
bad and just cry.”48
Nyachoatalsosaidsheusedtogofordayswithoutspeakingtoanyone,untilaneighbourtookherto
thePoCmedicalcentrerunbyInternationalMedicalCorps(IMC),whereshemetwithamentalhealth
officerwhoprovidedcounsellingandgavehermedicine,whichshesaidhelpedhersleepandgave
temporaryreprievefromnightmares.49
Nyadeng,amotheroffivechildrenaged14andunder,fledtotheMalakalUNMISSPoCsitein
February2014,afteroppositionforcestookcontrolofthecityforathirdtime.ShehadbeeninMalakal
TeachingHospital,whereAmnestyInternationalvisitedinMarch2014anddocumentedkillingsby
oppositionforces.50Nyadeng’ssisterdescribedthechangesshehasseeninherbehaviour,including
memoryloss:
“She can’t manage—she’s not normal. She can talk but it’s senseless.
She quarrels with the children. She cooks, but like a child, she burns
things. She knows the children’s names, but she does not know their
ages. It is the children who tell her to do the things she should do. She
can’t identify what is happening…Sometimes I pray to God to help her.”51
AwardinMalakalTeachingHospital,wherepatientsanddisplacedpeoplewhohadtakenrefugewerekilledbyoppositionforcesin
lateFebruary2014.Malakal,UpperNilestate,March2014.©AmnestyInternational
InterviewwithNyachoat(pseudonym),Malakal,SouthSudan,2May2015.
48
Shedidnotknowthenameofthemedicationshereceived.
49
AmnestyInternational,SouthSudan:NowhereSafe:CiviliansunderAttackinSouthSudan,p.24-27.
50
Interviewwithsister(namewithheld)ofNyadeng(pseudonym),Malakal,SouthSudan,6May2015.
51
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“PEOPLE ARE TRAUMATIZED”: ATTACK ON THE BOR
UNMISS POC SITE
ControloverthecityofBor,inJongleistate,changedhandsthreetimesinthefirstmonthofthe
conflict,untilgovernmentforces,supportedbytheUgandaPeople’sDefenceForces(UPDF),regained
controlon18January2014.Duringtheearlydaysoffighting,thousandstookshelterintheBor
UNMISSPoCsite.ThoughthepopulationoftheBorPoCsitewasinitiallyethnicallymixed,Dinka
whohadtakenshelterthereprogressivelyleftafterthegovernmentgainedcontroloverBor.By
February2014,thepopulationresidinginsidethePoCsitewasalmostentirelyNuer,surroundedbya
predominantlyDinkapopulationresidinginBor.TensionsbetweenthosewithinandoutsidethePoC
sitewerehigh.InMarch2014,AmnestyInternationaldocumentedcasesofkillingsandsexualviolence
againstindividualswhoventuredoutsidethePoCsite.Asaresultofsuchincidents,manychosenever
toleavethecamp.52
On17April2014,agroupofarmedDinkayouthattackedthePoCsite,atthetimehometo4,800
displacedcivilians.53SomefiredintothePoCsitefromoutsidewhileothersbreacheditsperimeterand
openedgunfirefromwithin.Atleast47internallydisplacedpeoplewerekilledasaresult.54Theattack
wasaflagrantviolationofinternationalhumanitarianlaw,whichprohibitsattacksonUNpeacekeeping
missionsaswellasonzonesofrefuge.EstherwasintheBorPoCsiteon17Aprilandwitnessedthe
attack.
“It started with a small demonstration by local youth. They had guns and
other weapons. They wanted to try to break in, but the UN didn’t let them.
Then they went around to the other side, started shooting and broke in.
The UN officers were overwhelmed and couldn’t stop them. They ran for
their lives. After 30 minutes, many UN forces came and the attackers ran
away.
The attackers killed over 100 people [UN figure is 47] including women
and children. They even killed small infants and pregnant women and
they set fire to tukuls [thatched roof homes] with people inside of them.
UNMISS collected all of the dead bodies in two bulldozers.”
Esther’ssisterandhertwochildren,ages13and9,wereamongthosekilled.
AccordingtoUNMISS,formonthsfollowingtheattack,peopleinthecampexpressedfearoffuture
attacksandsaidthattheirchildrenwerestilltraumatizedbywhattheyhadexperienced.55 The South
SudanLawSociety’sFebruary2015surveyofdisplacedpeoplelivingintheBorPoCsitefoundthat
almostalloftheapproximately100respondentsinterviewedhadsymptomsconsistentwithadiagnosis
ofPTSD.56
Estherdescribedexperiencinganumberofsignsofpsychologicaldistresssincetheattack,including
poormemoryandfeelingsofanger.
“My memory is not as good as it was before. I’ve become forgetful. I might
know you, but I forget your name. I’ve become absent-minded. I cannot
remember things. I’ve even gotten lost in Juba…Now I’m fearful and don’t
want to go out…
AmnestyInternational,SouthSudan:NowhereSafe:CiviliansunderAttackinSouthSudan;UNMISS,AttacksonCiviliansin
BentiuandBor,April2014,para.77-78,availableat:unmiss.unmissions.org/Portals/unmiss/Human%20Rights%20Reports/
UNMISS%20HRD%20-%20Attack%20on%20Civilians%20in%20Bentiu%20and%20Bor%20-%20January%202015.pdf.
52
UNMISS,AttacksonCiviliansinBentiuandBor,April2014,para.18.
53
UNMISS,AttacksonCiviliansinBentiuandBor,April2014,para.105.
54
UNMISS,AttacksonCiviliansinBentiuandBor,April2014,para.112.
55
SouthSudanLawSociety(SSLS)etal,SearchforaNewBeginning:PerceptionsofTruth,Justice,ReconciliationandHealingin
SouthSudan,p.25.
56
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I am very bitter. I get angry because of small things. I’m not as tolerant as
I was before. Little things make me angry. I feel very violent. I want to fight
someone so that person might kill me.”
“Little things make me angry. I feel very violent. I want to
fight someone so that person might kill me.”
Esther
Before the conflict, Esther ran a restaurant in Bor town and used her profits to support her grandchildren.
But the mental impact of her experiences has affected her ability to work and pursue livelihood activities.
She feels unable to start any business or even carry out usual household tasks. “I can’t do that anymore
because I can’t focus…My way of thinking is distorted,” she said.57
Elizabeth,whoalsosurvivedtheattack,saidthatpeopleattheBorPoCsitewerenotthesame
afterwards.Sheherselfhasdifficultysleepingandcomplainedofphysicalpainsshesaysshedidn’t
havebeforetheconflict.
“People are traumatized…They have become fearful. If I hear a loud
bang, even if it isn’t a gun, I want to run away…I don’t sleep at night. I
stay awake thinking about the hopelessness of our situation…The future
always looks bleak…I have nightmares. The image of people being killed,
including infants, is stuck in my mind…
My heart beats quickly, and I have headaches and joint pains. I have
kidney problems and stomach bloating. Sometimes I get malaria. I also
have swollen feet—they call it ratuba [arthritis]. I have pains in the back.
I didn’t have these physical pains before. All this came as a result of the
fighting, compounded by the fact that I don’t have money to do a proper
check-up. I was healthy before the crisis.”
Shesaidsheisnotasactiveassheusedtobe,andisunabletocarryoutday-to-dayactivitieslike
fetchingwater.
“Everything is about motivation. There is nothing to motivate me. I’m
depressed. I have no motivation to do work like I used to.”58
“I AM NEVER HAPPY”: DETENTION AND TORTURE IN
JUBA
Sincethestartoftheconflict,governmentsecurityforces,particularlytheMilitaryIntelligence(MI)
andNationalSecurityService(NSS),havefrequentlyarbitrarilydetainedperceivedgovernment
opponents.59DozensofformerdetaineesinterviewedbyAmnestyInternationaloverthepasttwoyears
havesaidsecurityofficersaccusedthemofsupportingoppositionforces,butdidnotformerlycharge
themwithanyoffenceorpresentthembeforeacourtasrequiredbySouthSudan’sconstitutionand
internationalhumanrightslaw.Formerdetaineesdescribedsecurityofficersbeatingthemwithsticks,
InterviewwithEsther(pseudonym),Juba,SouthSudan,24April2015.
57
InterviewwithElizabeth(pseudonym),Juba,SouthSudan,28April2015.
58
FormoreonarbitrarydetentionandtheuseoftortureinSouthSudan,see:AmnestyInternational,DeniedProtectionoftheLaw:
NationalSecurityServiceDetentioninJuba,SouthSudan,April2016(Index:AFR65/3844/2016);AmnestyInternational,“Dozens
ofDetaineesatRiskofDeathinShippingContainers,”27May2016;HumanRightsWatch,“SouthSudan:ArbitraryDetention,
Torture;Military,NationalSecurityServiceRoutinelyBeatDetainees,”18May2015,availableat:www.hrw.org/news/2015/05/18/
south-sudan-arbitrary-detention-torture
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whips,andmetalbars,andgivingtheminsufficientfoodandwater.Someremainedindetentionfor
manymonths,ofteninhorrificconditions.Threeformerdetaineesinterviewedforthisreporttoldof
troublesleepingandothermanifestationsofpsychologicalstress,whichtheysaidresultedfromtheir
timeindetention.
John,ashopowner,saidsoldierscapturedhiminMunukineighbourhoodofJubaon16December
2013,whenhewasonhiswaytotheUNMISSPoCsite.TheytookhimtotheGiyadabarracksandput
himintoanundergrounddetentioncellwherehecounted69otherdetainees,mostofthemNuer.He
recountedthatsoldierssubjectedhimtoroutinebeatings,andthathedidnothaveenoughtoeat.
“They beat me every day. They wanted me to say that I am a rebel.
At around 10pm they would bring me out and start beating me. They
punched and kicked me. They kicked me till my tooth came out. They
would hit me with the butt of a gun and a long metal rod…
Every two nights we were given rice and beans at 11am. Water was put in
a small jerry can once a week. If the water finished, we weren’t given more
until the following week. Some people drank their urine.”
JohnescapedfromtheGiyadadetentionfacilityon5March2014duringalapseinsecuritythat
occurredwhenfightingeruptedamongsoldiers,reportedlyovertheirsalaries.60LivingintheJubaPoC
siteoverayearafterhisescape,Johnhadlingeringfearsofbeingre-capturedandwastormentedby
thememoryofbeingdetained.
“I am not ok. Even now I am still afraid that they’ll come looking for me…I
have a quick temper. Little things annoy me. I can’t calm down easily.
When I talk to people, I just find myself shouting for no reason…
I don’t sleep well. I get nightmares. When I first arrived, I could barely
keep my eyes closed. My mind would not relax. Even now I am very alert.
I always look at the people around me carefully, you cannot trust people.
Nowadays, I can sleep, but not all night. I get dreams. Bad dreams about
my capture, about the torture and the way we used to stay in that cell.
We were like animals. Dirty and filthy. Sometimes I wake up at night and
just start walking. I just walk around the PoC without knowing where I am
going.”61
Amnesty International spoke with the uncle of Pal, a father of four who committed suicide in the Juba PoC
site in March 2015. Before the conflict, Pal was a trader living in the New Site neighbourhood of Juba. He
fled to the UNMISS PoC site in December 2013. According to his uncle, soldiers caught Pal when he left
the site to get water in January 2014 and detained him at a facility in New Site. He escaped during the
fighting among soldiers on 5 March 2014. “When he returned,” said Pal’s uncle, “he wasn’t normal.”
“He was emaciated and very desperate. His life was a mess. He was
beaten badly with metal bars and sticks, and they kicked him a lot. One
of his arms was fractured as a result. When he came back, he had many
wounds on his body…
He couldn’t concentrate or focus…At night, he wouldn’t sleep. He used
to have nightmares. He’d dream that those people who caught him had
come back again, and he would jump up and shout… He would walk
around and talk to himself, in an uncoordinated way…He used to tell
me, ‘Uncle, I don’t have a choice except to die as well.’ He said he would
rather die than live a miserable life…”
AmnestyInternationalhasinterviewedthreeotherNuermenwhoweredetainedinGiyadaandescapedduringtheMarchfighting.
Followingthefighting,theSPLAspokesperson,ColonelPhilipAguer,saidthat100securityforcesofficersarrestedonsuspicionof
responsibilityforatrocitiesinDecember2015inJubaalsoescaped.InterviewwithPhilipAguer,formerSPLAspokesperson,Juba,
SouthSudan,26March2014.
60
InterviewwithJohn(pseudonym),Juba,SouthSudan,27April2015.
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BeforePalwasdetained,hiswifeandchildrenhadleftJubaandmovedtoKakumarefugeecamp,in
Kenya.Pal’swifediedinFebruary2014whilehewasindetention.Then,inMarch2015,Palgotnews
thathisdaughterwassickandmightnotrecover.
“The following day, after he was told his daughter was sick, he left us in
the house at around 3pm and took a rope that is used for tying the tukuls,
and he hanged himself.”
Pal’s family members did their best to support him. His uncle explained, “We counselled him all along.
That’s why he survived [as long as he did]. But none of us are in good health mentally.”62 Pal did not
receive any professional mental health services.
Simon, another former detainee, told Amnesty International he was captured by NSS personnel at the end
of February 2014, when he left the UNMISS PoC site in Juba to withdraw money from his bank account.
He was first detained at an NSS office near the Ministry of Justice and then transported to the NSS
headquarters near Jebel market in Juba.
“I found about 70 people [other detainees].... They [NSS officers] didn’t
say anything about why they had arrested me. Most of the people were
Nuer. They were just arrested on the streets but they would say they
captured them in war, that they are rebels.”
SimonremainedinNSSdetentionforovertwomonths,inpoorconditions.Hedescribedbeingbeaten
andotherformsoftorturesustainedbyfellowdetainees.
“The rooms where we were kept were completely dark – no windows.
There was a small hole where the light would come through. That’s just
how you know it is day or night. We were given rice in a plastic sheet only
once a day at 3 o’clock...
They beat me with pipes. They would say, ‘tell us what you have done’…
Others were pierced with needles. They would strip you naked and pierce
your sensitive parts like the penis with needles.”
SimonsaidthatinMay2014,NSSpersonneltransportedhimtoanofficetomeetwithasenior
militaryofficial.Atonepoint,hewasleftunguardedandwasabletorun,getonamotorcycletaxi,and
escape.NowlivingintheJubaPoCsite,hecan’tshakeoffthememoryofhisdetention.
“I am suffering a lot. I am going insane. I have nightmares all the time. At
night I feel as if I am being attacked and captured and tortured again. I
also get annoyed easily. I was not like that before.”63
LualtoldAmnestyInternationalthatNSSofficersarrestedhiminSeptember2014anddetainedhimin
afacilityinJubaalongtheNileRiver,wheretheychainedhishandsandfeet.
“They beat us every day at 6pm. They used a bicycle lock – with plastic in
the middle and metal locks at the end… We defecated within the cell and
then were forced to clean it. They didn’t give us cleaning supplies, we just
used our hands.
They gave us one piece of bread a day and water with a hosepipe. They
would spray it into the room and we’d have to use our hands to drink it.
They would do this for five minutes and we’d have to scramble to drink.
Then they would take it away.”
AccordingtoLual,securityofficerskilledover60detaineesduringhistimeattheriversidedetention
facility.
Interviewwiththeuncle(namewithheld)ofPal(pseudonym),Juba,SouthSudan,25April2015.
62
InterviewwithSimon(pseudonym),Juba,SouthSudan,25April2015.
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“At eight every evening, they would come and take some to be killed, with
electric shocks. They didn’t shoot you or use crude weapons. Then we
prisoners would have to take them to the river.
Whenever they would kill people, we would be taken to dissect the
stomachs of those who were killed, so they could be thrown into the river
and wouldn’t float. Once your stomach is cut, you don’t float, you just rot
under the water. Because if you float, your body will litter the river and it
will be evidence that people were killed.
I myself had to cut the stomachs of four people. I was given a knife… We
cut the stomachs and then removed the internal organs and put them in
a paper bag. They were disposed of separately, to avoid floating. Then the
officer would take you deep into the river, up to your chest, to drop the
body. We were the ones carrying the bodies.”
Lualspentatotaloffivemonthsindetention.HeeventuallyescapedandmadehiswaytotheUNMISS
PoCsiteinJuba.HetoldAmnestyInternationalthatheisstillhauntedbyhisexperienceindetention.
“I hear a lot of noise at night. I dream that I am still in jail. I am haunted
by the cutting of the stomachs of the victims. I wake up and I can’t go
back to sleep.
I feel hopeless. I’m not interested in talking to people. I prefer to stay
alone… I feel depressed, I am never happy. I am only thinking about how
I can leave Juba… And sometimes I start going somewhere and then all
of the sudden, I forget where I’m going and just go home. I think about
committing suicide. My dignity is challenged. I can’t go beyond this fence.
All of this makes me feel bad, and I hate myself.”64
“I AM NOTHING”: SEXUAL VIOLENCE OUTSIDE BENTIU
POC SITE
SouthSudan’sinternalarmedconflict,particularlytheviolenceinUnitystate,hasbeencharacterised
byashockingfrequencyofsexualviolence.Bentiu,thecapitalofUnitystate,hoststhelargestPoCsite
inthecountry,withapproximately120,000internallydisplacedpeoplelivingthere.Whilethesiteis
acriticalsourceofprotectionforitsresidents,manyofwhomhavewitnessedkillingsanddestruction
intheirhomeareas,reachingthePoCsitehasnotbroughtanendtotheirexperiencewithviolence.
DisplacedpeopleinBentiumustoftenleavethesitetocollectwoodforfuel,food,ortogrindgrain.
Theyhavefacedcontinuousthreatswhendoingso;womenhavefacedtheparticularriskofsexual
violenceorabduction.UNMISShasdocumentednumerousincidentsofsexualviolenceoccurring
withintheperimeterofUNMISSsites.AccordingtoUNMISS,inJanuaryandFebruary2015alone,at
least35womenwererapedbygovernmentsoldiersneartheBentiuPoCsite.65
InterviewwithLual(pseudonym),Juba,SouthSudan,25April2015.
64
UNMISS,TheStateofHumanRightsintheProtractedConflictinSouthSudan,December2015,paras46,53.
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AerialviewoftheUNMISSPoCsiteinBentiu.June2016.©UNPhoto/IsaacBilly
NyawalsoughtrefugeintheBentiuPoCsiteinearly2015,escapinganattackonhervillagein
Guitcounty.ShewasrapedbyanSPLAsoldierafewmonthsafterarrivingatthePoCsitewhenshe
venturedouttobuymedicine.
“That day, we were eight people on the road. Four men, and in front of
me two elderly women, and another woman. We were stopped by two
Dinka SPLA soldiers. The men ran and one SPLA soldier shot at them.
The other pointed his gun at me and the other women. They caught one
man and took him to the bush. I heard gunshots. Maybe he died, I don’t
know. They took all our money, and the flour and sorghum one woman
was carrying. For the two older women, they just took their money. For me
and the second girl, Nyatuong,66 they took us to the bushes in Rubkona
and they raped us. This was at 4pm.”
OntheirwaybacktothePoCsite,NyawalandNyatuongwerestoppedbyanotherpairofSPLAsoldiers,
thistimefromtheNuerethnicgroup.Forthesecondtimeinthesameday,theywereraped.
“They called us and asked for money. We said we didn’t have money,
that our property was taken by other Dinka soldiers. We were afraid.
They were speaking Nuer and said ‘we are your people but we fight for
government’. They took us and led us to the bush. Nyatuong was crying. I
did not feel anything, I knew what they would do. They told us to take off
our clothes. They then tied my eyes with a cloth. I think even Nyatuong
was tied. I don’t know why they were tying our eyes. We had already seen
their faces and it was dark. They were only two men and they had guns.
They wore SPLA uniforms. They then raped us. One took me, the other
took Nyatuong; I could hear her crying. Her man also came to me, I think
the other one also went to Nyatuong. They raped us until around 11pm or
midnight. It was very dark when we went back to UNMISS.”
Apseudonym.
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WomenreturningwithcollectedfirewoodtotheUNMISSPoCsiteinBentiu,January2015.©UNPhoto/JCMcllwaine
NyawalwastreatedforherrapebyMédecinsSansFrontières(MSF)andalsoreceivedsupportfromthe
InternationalRescueCommittee(IRC),whichprovidescounsellingforsurvivorsofsexualviolencein
theBentiuPoC.Herexperiencecausedhersignificantmentalanguish.
“Initially I could not sleep, I was feeling terrible, I felt dirty. I cry all the
time when I think about it. It is better now. What I think about most is if
there was no war, nobody could have forced themselves on me. Nobody
would have done this to me.
I am very angry about what happened…It has changed my life. I am
nothing. I have nothing good. My body was good but now it is not. I had
been married only three months. And then this happened. My husband
and I are OK. He understands. He says it is the way of war, it has
happened to all women.
I am ashamed. It is not a good thing to happen to somebody. Some
people think I wanted it to happen, that I went outside to look for soldiers
to get money. They think it is my fault. Life in the PoC is hard. Women
live in fear here. They have to provide for their families. It is so hard. If
you don’t go outside, your family will suffer, if you go outside, something
will happen to you. Some women go outside and they never come back.
When you go to get firewood, you get raped.”67
InterviewwithNyawal(pseudonym),Bentiu,SouthSudan,16May2015.
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NewlyarrivedinternallydisplacedpeopleregisteratUNMISSPoCsiteinBentiu,Unitystate,May2015.©AmnestyInternational
“WE ARE ALL ALONE”: DEATH, ABDUCTION, AND
DISAPPEARANCE OF RELATIVES
Manydisplacedpeoplearetormentedbythelossofwives,husbands,children,andotherfamily
memberswhohavebeenkilledorabducted.Sometimesindividualsmayhavedisappeared,leaving
relativestowonderwhethertheyarealiveordead.Funeralritescanprovidesurvivorsanimportant
senseofclosure,butthesehaveoftennotbeenperformedbecausesurvivorsdon’tknowtheprecise
fateoftheirrelatives,becausetheydon’thaveaccesstotheirremains,orbecausethescaleofdeath
makesindividualfuneralceremoniesimpossible.
SarawaslivinginTerekeka,CentralEquatoriastate,inDecember2013.ShetoldAmnestyInternational
thatherhusbandwastiedupbysecurityforceson18December,takenawayandkilledwithseveral
othermenfromtheNuerethnicgroup.NowlivingintheJubaPoCsite,shecriedasshedescribedhow
hisdeathhasaffectedherlife.
“At night my body aches everywhere, like something is piercing my
body… I usually think about how my husband died, and it hurts a lot. I cry
and I tremble a lot when I think about what happened … I get confused...
Sometimes, I will walk and forget where I was going. The day before
yesterday I went to buy something in the market, and I just walked and
kept walking till I realised I was lost.”68
Lam’swifewaskilledinJubaon16December2013,onlyadayaftershegavebirthtotheirthird
child.Hehadrunawayfromtheirhome,assumingshewouldnotbeharmed.Hecamebacktofindthe
babyalive,andhiswifekilled.Hekeepsgoingovertheincidentandblameshimselfforleavingher.
LamtoldAmnestyInternationalthathecan’tstandthinkingofthepastandhasnohopeinthefuture.
InterviewwithSara(pseudonym),Juba,SouthSudan,24April2015.
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AchildattheUNMISSPoCinJuba.2015©UNPhoto/JCMcllwaine
“I am unable to sleep. My wife appears in my dreams. Sometimes she
blames me for not performing the required funeral rites…I didn’t go to
church; I blamed God. When I would go to church I would just cry. My
wife used to sing in church. I would remember her voice, how she used to
sing.”
His three year old daughter also has nightmares: “She woke up one night screaming that she had seen her
mother in her dream. Another day she also cried saying she heard her mother’s voice.”
Lam has found some relief from his mental distress through working in the community and helping others.
“The community here made me a leader in charge of the welfare of
orphans. It distracts me from my own problems… When the community
started the cultural dances it helped me relax, and reduced tension in
the community. It reminds me of when I used to court my wife. We used
to dance together. I am happy that this dance has made people in the
community get along. It has reminded people who they are.”69
Thepsychologicaltollofnotknowingthefateofacloserelativeisparticularlyacute.Rebeccawas
livinginthetownofRubkonainUnitystateinDecember2013.Shelostcontactwithherhusband,a
governmentsoldier,aftertheconflictstarted.ShefledfirsttoYidainnorthernUnitystateandthento
Juba.
“We here we are all traumatized. Our minds are lost, our hearts have gone
dark. Even now I want to cry. People who are separated from family are
unhappy and depressed… Our lives depend on the UN and other NGOs.
I have no hope… My children are now sleeping in a flooded tent. We are
all alone.”
InterviewwithLam(pseudonym),Juba,SouthSudan,25April2015.
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RebeccareachedouttomembersofherchurchandfriendsinthePoCsiteforsupport,butfoundthat
theytooweresuffering.
“I speak with the Catholic sisters, but confiding in others who have
problems like yours does not help. They have the same problems as I do.
I just pray as only God can help. I have a friend, but she has her problems
too. I don’t want to burden her.”70
On 10 October 2014, government-allied militia abducted three UNMISS contractors who were working
at Malakal airport. While two were later released, the fate of the third individual is unknown.71 Amnesty
International spoke with Emmanuel, a relative of the missing man, who believes he was killed the night of
his abduction. His wife died of tuberculosis in May 2014. According to Emmanuel, their three young sons,
whom he cares for in the Malakal PoC site, “have no hope.”
“They miss their parents. At night they wake up screaming because of
bad dreams. They think and cry a lot. They don’t talk much. When I tell
them something harshly they just cry. One of them is now fighting with
other children. He was not like that before. I think it’s because they don’t
have anybody to talk to about the things that disturb them most.”72
“They miss their parents. At night they wake up screaming
because of bad dreams.”
Emmanuel
RacheliscaringforthefourchildrenofNyayang,herformerneighbourintheJubaPoCsite.According
toRachel,Nyayang’shusband,asoldier,disappearedduringtheDecember2013fightinginJuba.
Rachelsaidthat,asaresultofherhusband’sdisappearanceandtheconditionsinthePoCsite,
Nyayangstartedtoshowpsychologicaldistress.
“She would stay awake at night and take a chair and sit in front of her
house for a long time. People would ask her, ‘why are you sitting like
that for so long’ and she’d respond that she was thinking. She talked to
herself a lot. It was as though she was speaking to someone else over the
phone… She also wasn’t attentive, and she didn’t eat. If she was called
to eat, she would take two spoons and then abandon the food. She lost
a lot of weight. She cried a lot, every day. She was forgetful and absentminded. You could discuss a lot of things with her, but all of a sudden
she’d just forget what you were talking about.”
RachelexplainedthatNyayangalsoshowedincreasedaggressionandviolentbehaviour,including
beatingherchildren.
“She’d use sticks and beat [them] with the rope that was given to us to tie
the rakubas [thatched shelters]. The kids were bruised, and sometimes
she beat them until they bled. She beat all of them, even the one-year-old.
She would even pick them up and throw them violently. She would say
that she didn’t want children and threaten to go away and leave them.”
OnthreeoccasionsinOctober2014,Nyayangattemptedtocommitsuicidebydrinkingpoison.Rachel
stoppedhertwice.
InterviewwithRebecca(pseudonym),Juba,SouthSudan,25April2015.
70
UNMISS,“UNdemandssafereleaseofabductedpersonnelinSouthSudanairport,”17October2014,availableat:www.un.org/
apps/news/story.asp?NewsID=49103#.Vhd_gPmqpBc
71
InterviewwithEmmanuel,Malakal,SouthSudan,2May2015.
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“When I caught her about to drink the poison, I asked her why she
wanted to do this. She said she wanted to die because she’s helpless and
her children have become destitute and she couldn’t support them.”
Nyayang did not receive psychological support or care for her mental distress. In October 2014, she
disappeared, leaving her three children behind in the Juba PoC site.73
IntheMalakalPoCsite,AmnestyInternationalinterviewedthreewomenwhoweregrievingfortheir
daughterstheybelievedhadbeenabductedbyoppositionforces.NyamumwasrunningtotheUNMISS
baseinMalakalduringthefightinginDecember2013,whenher15year-olddaughterdisappeared
behindher.Nyamumbelievesshewasabductedbyoppositionforces.Shesaidshehasnoappetite
becauseshethinksonlyofhermissingdaughter.Shealsohastroubleconcentrating,hasheadaches,
andherheartandhandstremble.74
AyenstayedinachurchcompoundinMalakaluntil18February2014,whensheandher18year-old
daughterwereabductedbyoppositionforces.Theywerebeatenandforcedtocarrythings.Ayentold
AmnestyInternationalthatoppositionforceslaterreleasedher,butnotherdaughter.
“I’m angry thinking of what happened…Even if I’m hungry I cannot eat,
thinking of my daughter. When she was taken she was in P8 [the final
year of primary school]. I miss her. I have no hope that she will return.
The rebels kill people everywhere. They killed people in the church in
Malakal…I don’t go to church because of what happened in church…
Now there is nobody close to comfort me.” 75
NyabantookshelterintheMalakalHospitalinDecember2013.Shewitnessedoppositionfighters
cometothehospitalandkillwomenandchildren.Theyalsoabductedheryoungcousin,Joy.Shesaid
thatsincetheabduction,shesuffersfromnightmaresandliveswithconstantfearandanxiety.She
spendshertimegrievingandhasbecomeforgetful.
“Until now I have not heard whether Joy is alive or not. There is a rumour
that she was taken by the Lou Nuer and is near the Ethiopian border… So
many thoughts are mixed up in my mind. I worry about Joy, about what
happened and where she can get food…When they came and took her it
was at night, and only in the morning we saw the gate was open…There is
no support, but to pray to God to help me.”76
InterviewwithRachel(pseudonym),Juba,SouthSudan,5May2015.
73
InterviewwithNyamum(pseudonym),Malakal,SouthSudan,6May2015.
74
InterviewwithAyen(pseudonym),Malakal,SouthSudan,6May2015.
75
InterviewwithNyaban(pseudonym),Malakal,SouthSudan,6May2015.
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5. LACK OF ACCESS TO
MENTAL HEALTH CARE
SERVICES
WhenSouthSudangainedregionalautonomyunderthetermsofthe2005ComprehensivePeace
Agreement(CPA),thegovernmentstartedtobuildahealthcaresystemfromscratch.Overtenyears
later,SouthSudanstilldoesnothaveadequatehealthcarefacilities,services,treatmentorstaffto
adequatelysupportthoseinneedofmentalhealthcare.Thecurrentconflicthasdealtasignificant
blowtoanalreadystrugglinghealthcaresystem,withthecompleteorpartialdestructionandlooting
ofseveralhealthfacilities,includingtheMalakalandBentiuhospitals.77Evenwhereavailable,
governmentmentalhealthservicesareverylimitedinscopeandoftenofpoorquality.Whilemental
healthhasbeenincludedinSouthSudan’spoliciesandplansforthehealthsectorsince2006,stated
goalshavenotbeenreached.Thegovernmenthasnotcommittedadequateattention,orfunding,to
improvetheavailabilityoraccessibilityofmentalhealthservices,whilesupportfrominternational
organizationsanddonorsisalsominimal.
Servicesavailableinconflict-affectedsettings,includingintheUNMISSPoCsites,arealmostentirely
providedbyinternationalNGOs.InJuba,Makal,andBentiuPoCsites,someNGOsoffermental
healthandpsychosocialsupportservices,buttheirinterventionsareinsufficientgiventhesizeofthe
populationstheyareintendedtoserve.Onemajorgapisintheprovisionofspecializedmentalhealth
servicesforpeoplewithseverementaldisorders.Additionally,duetotheethnicandpoliticaldivides
createdbythecurrentconflictandthepersistentsecurityrisksinsomelocations,manypeopleliving
withinthePoCsitesareafraidtoleave.InJuba,forexample,manyPoCsiteresidentsarereluctantto
seekoutthelimitedmentalhealthservicesavailableatJubaTeachingHospital.InBentiuandMalakal
towns,therearenomentalhealthservicesevenifthoselivinginthePoCsitesleave.
GOVERNMENT MENTAL HEALTH SERVICES:
PRACTICALLY NON-EXISTENT
FewcommunitiesinSouthSudanliveinreachoftheevenmostbasichealthcareservices.The
MinistryofHealthitselfhasdescribedtheavailability,accessibilityandmanagementofhealth
facilitiesasgenerallypoor.78Thereisaninsufficientnumberofhealthfacilitiesandadeficitofhealth
professionals.AccordingtotheMinistry,in2012therewereonly1.5physiciansand2nurses/midwives
MédecinsSansFrontières(MSF),“MedicalCareinSouthSudanUnderFire,”24February2014,availableat:www.msf.org/article/
medical-care-under-fire-south-sudan.AccordingtoUNOCHA,asofSeptember2015,55%ofhealthfacilitiesintheGreaterUpper
Nileregionwerenotfunctioning.UNOCHA,HumanitarianNeedsOverview,2016,availableat:http://reliefweb.int/sites/reliefweb.int/
files/resources/2016_HNO_South%20Sudan.pdf
77
Inthe2009BasicPackageofHealthandNutritionServicesforSouthernSudan(BPHS),theMinistryofHealthestimatedthat
overallaccesstohealthcarewasbelow25%.GovernmentofSouthernSudan,MinistryofHealth,BasicPackageofHealthand
NutritionServices,2009,p.11.
78
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forevery100,000citizens,allofthemdisproportionatelybasedinurbanareas.79Geographical
distances,poorroads,theabsenceofambulanceservices,andsocio-culturalandfinancialbarriersall
contributetotheinaccessibilityofmedicalcare.80Evenwhereaccessible,thelackofqualifiedhealth
workers,insufficientmaterialresources,equipment,andmedicines,aswellasdysfunctionalreferral
mechanismscompromisetheoverallqualityofbasichealthservicesinthecountry.81
WhilstthehealthsystemasawholeinSouthSudanisinadeeplyworryingstate,mentalhealth
servicesremainpracticallynon-existent.TheJubaTeachingHospitalistheonlypublicmedicalfacility
thatprovidespsychiatriccare.DuringavisittothishospitalinApril2015,AmnestyInternationalfound
just12bedsinthefacility’sinpatientpsychiatricward.Duetoinadequateresources,thewarditselfis
rundownandindireneedofrenovationandnewequipment.Therearenotherapeuticactivities,home
visits,orcommunityoutreach.82Theavailabilityofpsychotropicdrugsisinconsistentandlimited.83
Evenwhenthedrugsareavailable,familiescanrarelyaffordthem,particularlyforlong-termuse.84
WhilesomepatientstravelfromacrossthecountrytoaccesstreatmentinJuba,thecostoftraveland
thelowawarenessofservicesavailablemakethisanunrealisticoptionforthevastmajorityofthosein
needofcare.85
Thereisadireshortageoftrainedmentalhealthprofessionals.Thereareonlytwopractising
psychiatristsinthecountry,bothofwhomareinJubaandneitherofwhomseepatientsonafull-time
basis.OneistheDeanofJubaUniversity’sCollegeofMedicineandtheotherdivideshertimebetween
theJubaTeachingHospitalandleadingtheMentalHealthDepartmentintheMinistryofHealth.The
psychiatricwardatJubaTeachingHospitalisstaffedbyoneclinicalpsychologistandanumberof
psychiatricmedicalassistants,counsellorsandnurses.86
OutsideofJuba,theavailabilityandaccessibilityofmentalhealthservicesisevenmoregrim.There
isnopsychiatricwardineitherofthecountry’sothertwomajorhospitals,inWauandMalakal.The
UpperNilestateMinistryofHealthsaidittriedtoestablishspecialunitsinMalakalandelsewherein
thestate,butwasunabletodosoduetotheconflictandlackoffunds.87Therearenomentalhealth
specialistsinpublicfacilitiesoutsideofJuba.Primaryhealthcareprovidersarenotsufficientlytrained
todiagnosementalhealthcases.Eveniftheywere,therewouldbenoclearreferralpathwaysor
reasonablyaccessibletreatmentoptions.88
TheinadequatenumberofmentalhealthprofessionalsinSouthSudanisdueinparttothelimited
opportunitiesfortraininginmentalhealthinthecountry.Thereisnospecializedtrainingavailable
inpsychiatry,psychiatricnursing,orclinicalorcounsellingpsychology.89Medicalstudentsoften
graduatewithoutcompletingpsychiatricrotationsandasaresultaren’ttrainedtoidentifyoraddress
mentalhealthissuesinpatients.TheheadoftheMentalHealthDepartmentlamentedthat,“most
of our doctors don’t know anything about mental health.”90 Toitscredit,theMinistryofHealthhas
takenthesmallstepofsendingfourstafffortrainingoutsideofthecountry.TheheadoftheMental
GovernmentofSouthSudan,HealthSectorDevelopmentPlan,2012-2016,p.11,availableat:https://extranet.who.int/nutrition/
gina/sites/default/files/SSD%202012%20HEALTH%20SECTOR%20DEVELOPMENT%20PLAN%202012-2016.pdf
79
RichardDowner,CenterforStrategicandInternationalStudies,ThestateofpublichealthinSouthSudan:CriticalCondition,
November2012,availableat:http://csis.org/files/publication/121114_Downie_HealthSudan_Web.pdf
80
Accordingtothe2012-2016HeathSectorDevelopmentPlan,33%ofhealthfacilitiesrequiredcompletereplacementand18%
requiredmajorrenovation.GovernmentofSouthSudan,HealthSectorDevelopmentPlan,2012-2016,pp.10,15.
81
InternationalMedicalCorps(IMC),MentalHealthFacilities:SituationalAnalysisandStrategy,2013,p.9.
82
IMC,MentalHealthFacilities:SituationalAnalysisandStrategy,2013,p.11.
83
InterviewwithNGOstaffmember,Juba,SouthSudan,10April2015.Interviewwithfamilymemberofmentalhealthpatient,
Juba,SouthSudan,4May2015.
84
InterviewwithDrAtongAyuel,Director,MentalHealthDepartment,MinistryofHealth,10April2015.
85
InterviewwithDrAtongAyuel,Director,MentalHealthDepartment,MinistryofHealth,Juba,SouthSudan,10April2015.IMC,
MentalHealthFacilities:SituationalAnalysisandStrategy,2013,p.9.
86
InterviewwithUpperNilestateMinisterofHealth,Malakal,SouthSudan,9May2015.
87
InterviewwithNGOstaffmember,Juba,SouthSudan,10April2015.
88
IMC,MentalHealthFacilities:SituationalAnalysisandStrategy,2013,p.10.
89
InterviewwithDrAtongAyuel,Director,MentalHealthDepartment,MinistryofHealth,10April2015.
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HealthDepartmentalsotoldAmnestyInternationalthatsheisworkingtointegratementalhealthinthe
universitycurriculumandteachessomemodulesincollegesofmedicineacrossthecountry.91
Theroutineuseofprisonstohouseindividualswithmentalhealthconditionsisastarkmanifestationof
theinadequacyofmentalhealthtreatment,stigmaaboutmentaldisordersandthedeficitoffacilities
andtrainedstaff.Individualswithmentalhealthconditionsdeemedtoposeadangertothemselves
orothersoftenenduparbitrarilydetainedinprison,eveniftheyhavenotcommittedanycrime.They
maybetransferredtoprisonfrommedicalfacilitiesortakendirectlytoprisonbyfamilymemberswho
feelunabletocareforthem.InMay2016,therewere66maleand16femaleinmatesinJubaCentral
Prisoncategorizedasmentallyill,morethanhalfofwhomhadnocriminalfiles.92Accordingtoa
formerhealthworkeratMalakalHospital,priortotheconflict,therewere27peoplewithmentalhealth
problemsintheMalakalprison. “Some were brought to prison by family members because they were
violent, aggressive, and suicidal,” heexplained.93
Peoplewithsuspectedmentalconditionsareroutinelydetainedinprisons.JubaCentralPrison,Juba,SouthSudan,2011.©Robin
Hammond
Inprison,peoplewithmentalhealthdisordersreceiveinsufficientmedicalcare,ifanyatall.94
AlthoughgenerallivingconditionsinSouthSudan’sprisonsareextremelypoor,inmateswithmental
disordersareoftennaked,chainedorheldinsolitaryconfinement.95BetweenJanuaryandMay2016,
fourinmateswithmentaldisordersdiedinJubaCentralPrisonduetoinsufficientfoodandtreatable
illnessessuchasmalariaanddiarrhoea.96Thedetentionofindividualswithsuspectedmentaldisorders
InterviewwithDrAtongAyuel,Director,MentalHealthDepartment,MinistryofHealth,10April2015.
91
Thirty-sixofthementallyillprisonershadcriminalfiles,while36didnot.Interviewwithprisonofficials,Juba,SouthSudan,6
May2016.
92
InterviewwithformerMalakalhospitalhealthworker,Malakal,SouthSudan,2May2015.
93
InJuba,psychiatricstafffromtheTeachingHospitaldovisittheinmatesintheprison.Provisionofmedicationdependsoftenon
availabilityandabilityoffamilymemberstopay.InterviewwithJubaTeachingHospitalstaff,10April2015.SeealsoHumanRights
Watch,“PrisonisnotforMe”:ArbitraryDetentioninSouthSudan,June2012,availableat:https://www.hrw.org/sites/default/files/
reports/southsudan0612_forinsert4Upload.pdf
94
InMary2016,fivewomenwithmentaldisorderswereinsolitaryconfinementinJubaCentralPrison.AmnestyInternational
observationsduringvisittoJubaCentralPrison,Juba,SouthSudan,6May2016.SeealsoHumanRightsWatch,“Prisonisnotfor
Me:”ArbitraryDetentioninSouthSudan.
95
Interviewwithprisonofficials,Juba,SouthSudan,6May2016.
96
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violatesahostofrights,includingtheprohibitionofarbitrarydetention,therighttonon-discrimination,
tohealth,todueprocessaswellastobefreefromcruel,inhumananddegradingtreatmentor
punishment.97
GOVERNMENT MENTAL HEALTH POLICIES
Inits2006-2011HealthPolicy,thefirstarticulationofthevisionandprinciplesofthehealthsector
followingthesigningoftheCPA,theGovernmentofSouthernSudanindicatedthatitsawmental
healthas“anessentialcomponentofpublichealth.”Thepolicypromisedthedevelopmentofa
strategicapproachtoprotectingandpromotingmentalhealthandwell-being,andthedevelopmentof
aflexiblerangeofpost-conflict,integratedmentalhealthsupportandcareservicesatalllevelsofthe
healthsystem,particularlyatthecommunitylevel.Itspecifiedthatservicesshouldbe“appropriate,
accountable,accessibleandequitable,andensurethatthedignityofpeopleisrespected.”Thepolicy
furtherpromisedthedevelopmentofamentalhealthstrategyandappropriatelegislation.98
MentalhealthisalsoincludedinSouthSudan’sBasicPackageofHealthServices(BPHS),which
providesservicenormsandstandardstoprimaryhealthcareservicemanagersandprovidersatthe
Village,Boma,Payam,CountyandStatelevels.99The2012-2016HealthSectorDevelopmentPlan,
intendedasaroadmapforimprovinghealthservices,recognizedthehumanresourcegapsinthe
mentalhealthsectorandrecommendedthatthenumberofpsychiatristsshouldincreasefrom0in
2012to11by2016,andthatthenumberofpsychiatrictechniciansshouldincreasefrom0to112.100
Thoughthesepoliciesandplansforeseesomerelevantimprovementstomentalhealthservices,there
hasbeenlittleornoimplementation.Humanresourceobjectives—conservativeastheyare—havenot
beenmet.101Norhavementalhealthcareservicesbeenintegratedintotheprimaryhealthcaresystem.
TheestablishmentinJune2014ofaDepartmentofMentalHealthinthenationalhealthministrywas
apositivestep,butitremainsunder-staffedandunder-resourced.TheDirector’sgoaltooverseethe
developmentofaspecificmentalhealthpolicyis,asofMay2016,yettoberealized.102 Nor is there
anylegislationconcerningmentalhealthissues,includingontheexistingpracticeofincarcerating
peoplewithsuspectedmentalhealthdisorders.
Inadditiontofailingtoadequatelyintegratementalhealthintothenationallegalandpolitical
framework,SouthSudanhasalsofailedtomakeadequatefinancialcommitmentstoimprovethe
availabilityandaccessibilityofmentalhealthservices.Thehealthsectorbudgetasaproportionof
thenationalbudgetdeclinedfrom7.9%in2006to4.2%in2011.103Inthe2015-2016budget
plan,thehealthsectorreceivedonly3%ofthetotalbudgetandonly1%wasallocatedtosocial
andhumanitarianaffairs.Meanwhile,thesecuritysectorreceived44%,thehighestamountinthe
budgetaryallocation.104Whilethereisnospecificrequirementunderinternationalhumanrightslaw
forthepercentageofnationalbudgetagovernmentisrequiredtospendonthehealthsector,inthe
1991AbujaDeclaration,Africangovernmentspledgedtoallocateatleast15%oftheirannualbudget
toimprovingthehealthsector.105Itisunclearhowmuchofthegovernment’shealthsectorbudgetis
spentonmentalhealthservices.106
Thereisnolegislationgoverningtheforcedcommitmentofindividualstomentalhealthoranyotherinstitutionwheretheyare
deprivedofliberty.Thusthereisnoclearlegalbasisforthesedetentions.
97
GovernmentofSouthernSudan,MinistryofHealth,HealthPolicyfortheGovernmentofSouthernSudan,2006-2011,pp.38-39.
http://www.africanchildforum.org/clr/policy%20per%20country/south%20sudan/ssudan_health_2006-2011_en.pdf
98
GovernmentofSouthernSudan,MinistryofHealth,BasicPackageofHealthandNutritionServicesforSouthernSudan,2009.
99
GovernmentofSouthSudan,HealthSectorDevelopmentPlan,2012-2016,p.40.
100
Evenifimplementedfully,thiswouldstillmeanthattherewouldonlybeonepsychiatristper700,000inthepopulation.
101
InterviewwithDrAtongAyuel,Director,MentalHealthDepartment,MinistryofHealth,10April2015.
102
GovernmentofSouthSudan,HealthSectorDevelopmentPlan,2012-2016,p.x.
103
MinistryofFinanceandEconomicPlanning,ApprovedBudgetTables:FiscalYear2015/16,October2015,p.14,availableat:
http://www.grss-mof.org/wp-content/uploads/2015/10/RSS-Approved-Budget-Book-2015-16.pdf
104
105
AbujaDeclarationonHIV/AIDS,TuberculosisandotherInfectiousDiseases,OAU/SPS/ABUJA/3,27April2001,availableat:
http://www.un.org/ga/aids/pdf/abuja_declaration.pdf
AmnestyInternationalwrotetotheMinistryofHealthinApril2016requestingthisinformation,butdidnotreceivearesponse.
106
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INTERNATIONAL ASSISTANCE AND COOPERATION
INSUFFICIENT MENTAL HEALTH SERVICES IN POC SITES AND OTHER EMERGENCY SETTINGS
AnumberofNGOshaveestablishedpsychosocialsupportinterventionsinPoCsites.Interventions
includetheestablishmentofchild-friendlyspaces,grouprecreationalactivities,andpsychosocial
firstaidorsupporttosurvivorsofsexualviolence.TheInternationalRescueCommittee(IRC),for
example,runsawomen’sprotectionandempowermentprogrammeinBentiuPoCthatincludesfive
women’scentresofferingpsychosocialsupportandindividualcasemanagement.107TheInternational
OrganisationforMigration(IOM)hasestablishedandtrainedpsychosocialmobileteamsintheBentiu
andBorPoCsiteswhichprovideservicesaimedatstrengtheningfamilyandcommunitysupport,
suchasrecreationalactivities,discussiongroupsandfocused,non-specializedservicesthroughpeer
supportgroups,laycounsellingandhomevisits.108HandicapInternationalhasaprogrammedesigned
toimprovethepsychosocialsituationofinternallydisplacedpeopleinJubathatincludespsychosocial
counsellingandtheestablishmentofsupportgroups.109Whileimportantcontributions,these
programmesarestillinsufficientgiventhelargepopulationstheyareintendedtosupport.
Thereisalsoaspecificgapintheavailabilityofspecializedmentalhealthcareservices,such
aspsychotherapy,grouptherapy,orpharmacologicintervention,forpeoplewhohavesignificant
difficultiesinbasicdailyfunctioningandhavenotbeenhelpedbymorebasiccommunityinterventions.
Few NGOsinSouthSudanprovidesuchservices.AccordingtooneNGOstaffmember, “everyone
is doing psychosocial support, but it doesn’t help to put people with severe problems into a childfriendly space.”110 TheconcernexpressedbymultipleNGOworkersisthatthereisnoabilitytorefer
casesidentifiedthroughpsychosocialsupportprogrammes. “Demand is being created and there is an
awareness, but where can people go to seek treatment?”askedoneNGOstaffmember.111
InternationalMedicalCorps(IMC)istheonlyNGOofferingmorespecializedmentalhealthservices
intheJubaandMalakalPoCsites.IMChasoneexpatriatepsychiatristwhooverseesmentalhealth
officersstationedatIMC-runprimaryhealthclinicsintheJubaandMalakalPoCsites.112 Through
thementalhealthofficers,speciallytrainedcommunityhealthworkers,andthestaffoftheprimary
healthclinics,IMCprovidestreatment,counselling,andcasemanagementforindividualswith
mental,neurologicalandsubstanceusedisorders.Theyalsooffercommunityawareness-raisingand
sensitizationthroughhomevisits,communitysupportgroups,andlocalradioprogramming.113But
theIMC’ssinglementalhealthofficerinJubaservesapopulationofover28,000,whiletheofficer
inMalakalserves47,000people.InBentiu,where120,000internallydisplacedpeopleliveatthe
UNMISSPoCsite,therearenospecializedmentalhealthservicesavailableforpeoplewithsevere
mentaldisorders.
WhiletherearegapsinmentalhealthserviceprovisionwithinthePoCsites,thesituationisfarworsein
otherareasofthecountryaffectedbyconflict,includingwhereinternallydisplacedpeoplehavesettled
informally,outsideofthePoCsites.Theyhavelittleaccesstoanyformofmentalhealthsupport.
SCARCE SUPPORT TO PUBLIC HEALTH SECTOR
Thereareonlyafewinternationalorganizationswithprogrammessupportingtheimprovementof
mentalhealthserviceswithinthepublichealthsector.HandicapInternationalinitiatedamentalhealth
InterviewwithInternationalRescueCommittee(IRC)staff,Bentiu,SouthSudan,14May2015.
107
InterviewwithInternationalOrganizationforMigration(IOM)staff,1May2015.
108
HandicapInternational,UrbanJubaProject,2016(onfilewithAmnestyInternational).
109
InterviewwithNGOstaffmember,Juba,SouthSudan,7April2015.
110
InterviewwithNGOstaffmember,Juba,SouthSudan,10April2015.
111
IMCalsohasmentalhealthofficersinMinkamaninternallydisplacedpersonssite,inAkoboandatGendrasaandKayarefugee
campsinMabanCountyandoneexpatriateclinicalpsychologistbasedinMaban.InterviewwithIMCstaff,Juba,SouthSudan,10
April2015.
112
InterviewwithIMCstaff,Juba,SouthSudan,10April2015.
113
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projectin2014thatincludesworktosupportandbuildthecapacityofstaffinthepsychiatricwardof
JubaTeachingHospitalandthestaffandauthoritiesatJubaCentralPrisoninissuesrelatingtomental
health.Theyarealsohopingtosupportthehealthministryinthedevelopmentofanationalmental
healthpolicy.114HealthNetTPOhasrecentlyworkedonapilotprojecttointegratementalhealthcare
intothreeprimaryhealthcarecentresinJurRivercountyinWesternBahrelGhazalstate.Theproject,
whichendedinDecember2015,facednumerouschallenges,includingtheabsenceofaguiding
mentalhealthpolicy,insufficienthumanresources,insufficientfunding,andhighturnoverofthestaff
intheprimaryhealthcarecentres.115
SaintBakhitaHealthCentreinYei,CentralEquatoriastate,runbytheCatholicDioceseofYei,provides
directservicestoindividualsinneedofmentalhealthcare.In2014,itprovidedinoroutpatient
servicesto206patientswitharangeofmentalhealthconditions.116They,however,lackspecialized
staff,onlyhaveonepsychiatricnurseandnoseparatewardformentalhealthpatients.117
LIMITED AND UNCOORDINATED COMMUNITY-BASED TRAUMA PROGRAMS
SomechurchesandsmallerNGOscarryoutcommunity-basedinterventionsthatseektoaddress
trauma.MorningStar,forexample,isatraumaawarenessprogramfundedbytheUnitedStates
AgencyforInternationalDevelopment(USAID)whosevisionistocreateopportunitiesforpeopleto
learnabouttrauma,begintoheal,andcometogetherasacommunitytosupportfurtherhealingand
reconciliation.118MorningStarhastrainedfacilitatorswhohaveheldcommunityconversationsabout
trauma.Theyarecurrentlyworkingtorevisetrainingmaterialsandtoconductadditionaltrainings,
includingwithprimaryhealthcareworkers.
Solidarity with South Sudan, a Catholic NGO, has provided a number of healing from trauma workshops
to teachers, church members, soldiers, and prisoners, using a method called Capacitar. The trainings are
designed to enhance individuals’ ability to cope.119
TheSouthSudanPsychosocialSupportProgramme(SSPP),acommunity-basedorganizationfounded
bySouthSudanesepsychosocialcounsellorsandpsychiatricnurses,specializesinprovidingmental
healthandpsychosocialsupportforsurvivorsofwarandorganizedviolenceinEasternEquatoriastate.
Theiractivitiesincludecommunityawarenessraisingonmentalhealth,traininggovernmenthealth
workersonmentalhealth,runningmobilementalhealthoutreachclinicsandcarryingoutindividual
andgroupcounselling.
Suchcommunity-basedtraumaprogrammescanhelpreducestigmarelatedtomentalhealth
symptoms,assistpeopletobetterunderstanddifficultexperiences,increasehealthycoping,and
strengthensupportsystems.Theythereforeplayanimportantroleinthespectrumofmentalhealth
services.But,intheabsenceofaclearmentalhealthstrategy,thereisnooverarchingvisionof
howtheseinterventionsshouldbecarriedout,includingbestpracticesorprofessionalandethical
standardstheyshouldadheretoorofhowtheyrelatetoothermentalhealthinterventions.Asaresult,
community-basedtraumainterventionsarelargelyuncoordinatedandunlinkedtothemoreformal
mentalhealthsector.
INADEQUATE SUPPORT FROM WHO
Withitspublicationofthe2001WorldHealthReport,whichfocusesonmentalhealth,theWHO
soughttodispelthehistoricalneglectofmentalhealthandincreaseattentiontomentalhealthbecause
itis“criticaltotheoverallwell-beingofindividuals,societiesandcountries.”120Sincethen,theWHO
Seewww.handicap-international.us/south_sudan
114
InterviewwithHealthNetTPOstaff,10April2015.
115
PresentationbyCoordinator,SaintBahkitaHealthCentre,10March2015.
116
PresentationbyCoordinator,SaintBahkitaHealthCentre,10March2015.
117
InterviewwithMorningStarstaff,Juba,SouthSudan,9April2015.
118
InterviewwithSolidaritywithSouthSudanstaff,Juba,SouthSudan,6May2015.
119
WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,pxi,availableat:http://www.who.int/
whr/2001/en/
120
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hasdevelopedorcontributedtoanumberofmentalhealthtools,includingtheInter-AgencySteering
Committee(IASC)GuidelinesonMentalHealthandPsychosocialSupportinEmergencySettingsand
thementalhealthGapActionProgramme(mhGAP)whichfocusesonhowtoexpandservicesformental
healthinlowresourcesettingssuchasSouthSudan.121TheWHOhasalsoemphasizedthatcountries
canmakesubstantialgainsinmentalhealthservicesduringandfollowingemergencies.Infact,
accordingtoWHO,despitetheiradverseeffectsonmentalhealth,emergencies—oftenaccompanied
byanincreaseinhumanitarianaidandfocusedattentiononmentalhealth—presentanimportant
opportunitytotransformmentalhealthcareforthelongterm.122
Accordingtoitsconstitution,theWHOisresponsibleforprovidingleadershiponglobalhealthmatters,
shapingthehealthresearchagenda,settingnormsandstandards,articulatingevidence-basedpolicy
options,providingtechnicalsupporttocountries,andmonitoringandassessinghealthtrends.123 In
2013,theWHOpublishedaglobalMentalHealthActionPlanthatrecommendsthefollowingactions
fortheWHO:buildingcapacityinthedevelopmentandimplementationofpolicies,plansandlaws
relevanttomentalhealth;offeringtechnicalsupportforresourceplanning,budgetingandexpenditure
trackingformentalhealth;providingtechnicalsupportforexpandingmentalhealthtreatmentand
support;providingtechnicaladviceandguidanceforpolicyandactivitiesrelatedtomentalhealthin
humanitarianemergencies;supportingcountriesintheformulationofahumanresourcestrategyfor
mentalhealth;andprovidingguidanceandtrainingonthedevelopmentofinformationsystemsto
captureinformationaboutcorementalhealthindicators.124
Unfortunately,theWHOofficeinJubahasnotprovidedsubstantialtechnicalorfinancialsupport
toexpandingmentalhealthservicesinSouthSudan—afactacknowledgedbytheWHOCountry
Representative.125TheWHOofficeis,however,hopingtoimproveitssupportformentalhealththrough
therecruitmentofastaffpersonresponsiblefornon-communicablediseases,includingmental
health.TheWHOisalsoplanningtoconductanassessmentofnon-communicablediseases,including
mentalhealth,inJune2016. Findingswouldbeusedtoshapeinterventionsandstrategiesonmental
health.126TheWHOSouthSudanworkplanfor2016-2017foreseessupportforthedevelopmentand
implementationofamentalhealthpolicyinlinewiththeWHOMentalHealthActionPlan2013-2020
andsupportforthedevelopmentofintegratedmentalhealthservices,buttheseactivitiesarenotyet
funded.127
LIMITED DONOR FUNDING
DonorsupporttoSouthSudan’shealthsectorsince2005hascomeprimarilythroughbilateralgrant
supportaswellaspooleddonorfundingmechanismsintendedtosupporttheimplementationofthe
BasicPackageofHealthServices(BPHS)andtheHealthSectorDevelopmentPlan.128Althoughmental
healthisincludedintheBPHSandanincreaseinthenumberofmentalhealthprofessionalswasone
objectiveoftheHealthSectorDevelopmentPlan,accordingtomentalhealthworkersinSouthSudan,
littledonorfundinghasmadeitswaytosupporttheimprovementandexpansionofgovernmentprovidedmentalhealthservices.
121
WHO,MentalHealthGapActionProgramme(mhGAP):ScalingUpCareforMental,Neurological,andSubstanceAbuseDisorders,
availableat:http://www.who.int/mental_health/evidence/mhGAP/en/
122
WHO,BuildingBackBetter:SustainableMentalHealthCareafterEmergencies,2013,availableat:http://apps.who.int/iris/
bitstream/10665/85377/1/9789241564571_eng.pdf
WHOConstitution,1946,Article2,availableat:http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf?ua=1
123
WHO,MentalHealthActionPlan2013-2020,pp.13-19.
124
InterviewwithWHOCountryRepresentative,Juba,SouthSudan,3May2016.
125
InterviewwithWHOCountryRepresentative,Juba,SouthSudan,3May2016.
126
WHOCountryOffice,SouthSudan,ApprovedWHOWorkPlansfor2016-17Biennium(onfilewithAmnestyInternational).
InterviewwithWHOstaffmember,Juba,SouthSudan,28April2016.
127
128
TheMulti-DonorTrustFundmanagedbytheWorldBank,ranfrom2005to20013.Since2013,theWorldBankhassupported
theRapidResultsHealthProject(RRHP)managedbyIMAWorldHealth(IMA).TheBasicServicesFund,supportedbytheUnited
Kingdom(UK),Canada,Norway,Sweden,theEuropeanUnion(EU)andtheNetherlands,ranfrom2005to2012.ThefirstHealth
PooledFund,supportedbyAustralia,Canada,theEuropeanCommission,SwedenandtheUKranfrom2012-2016.Thesecond
HealthPooledFund,supportedbyAustralia,Canada,theEuropeanCommission,Sweden,theUKandtheUSwillstartin2016.
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Therearemultipleexplanationsastowhydonorsupporttothehealthsector,thoughsubstantial,has
notresultedinanimprovementofmentalhealthservices.129Forone,theabsenceofanationalmental
healthpolicyorstrategy,orofcleargovernmentcommitmenttomentalhealth—eitherpoliticalor
financial—meansthereislittletoinspireorguidedonorsupportformentalhealth.Also,thepaucityof
mentalhealthprofessionalsinSouthSudanmeansthattherearefewadvocatesforimprovedmental
healthservices.TheMinistry’sDepartmentofMentalHealth—thewould-bechampionofmental
healthservices—doesnothavethehumanorfinancialresourcestoeffectivelycoordinatenationaland
internationalplayersortorallydonorsupport.TheDepartmentinfacthasonlyonestaffperson—the
Director.
Anotherissueisthat,thoughdonorfundingpurportedlysupportsimplementationoftheBasicPackage
ofHealthandNutritionServices,certaininterventionsareprioritized.TheobjectivesoftheHealth
PooledFundforexample(whichinfactmirrorthoselaidoutintheGovernment’sHealthSector
DevelopmentPlan2012-2016)includeto“increasetheutilisationandqualityofhealthservices,
withanemphasisonmaternalandchildhealth.”130 GiventhatSouthSudanhasthehighestmaternal
mortalityrateintheworld,thisemphasisisappropriate.ButtheHealthPooledFund’s101-page
instructionstoimplementingpartners,whichoutlineessentialprimaryhealthcareactivities,make
nomentionatallofmentalhealthandpsychosocialsupport.131Thisisoneillustrationofhowservice
specificprioritizationsmayovershadowothercriticalelementsofhealthcare,suchasmentalhealth
care.
Thefailuretodeliberatelyensurethatmentalhealthandpsychosocialsupportprogrammesare
integratedintohealthinterventions,aswellasintoworkinothersectors,crosscutsthegovernment,the
donorcommunity,andnationalandinternationalNGOs.ASouthSudanesementalhealthworkersaid,
“Most donors have little understanding of mental health. They focus on emergencies like food distribution
and physical health, neglecting mental health and psychosocial support which are crucial during moments
of conflict.”132 Onapositivenote,inAugust2015,USAID’sConflictAdvisorinJubabegandeveloping
astrategytointegratetraumainterventionsintoprogramsineachofUSAID’sdevelopmentsectors
(health,education,governance,foodsecurity,livelihoods,andconflictmitigation).133
Initiatingmentalhealthandpsychosocialsupportprogrammingiscomplex,especiallygivencultural
differencesandanabsenceofqualitativeorquantitativeresearchtoguideprogrammedesign.Itis
alsodifficulttomeasuretheimpactofmentalhealthservices—unlikeotherformsofhumanitarian
assistancelikewaterorfooddistribution.134AccordingtooneNGOstaffmember, “Mental health
and psychosocial support programmes impact things that aren’t tangible—quality of life, security,
happiness. Because the change is difficult to measure, it is sometimes pushed out of the hard core
humanitarian work.”135Individualswithmentalhealthconditions,oncediagnosed,mayrequirelongtermtreatmentandcareand,asaresult,anexpectationofalong-termcommitmenttofunding.136
NationalandinternationalNGOworkersfeltthatallofthesefactorscontributedtotheperceived
reluctanceamongdonorstofundmentalhealthservices.
129
In2014-2015,forexample,internationaldonorsprovidedUS$230millioninsupporttothehealthsector.MinistryofFinance
andEconomicPlanningoftheGovernmentoftheRepublicofSouthSudan,SouthSudanAnnualAidReport2014/15,2016,
availableat:http://www.grss-mof.org/wp-content/uploads/2016/06/South-Sudan-2014-15-Annual-Aid-Report.pdf
130
See“KeyobjectivesoftheHPF,”availableat:http://www.hpfsouthsudan.org/background/HealthSectorDevelopmentPlan,20122016,p.xi.
131
MinistryofHealthandHealthPooledFund,CallforProposals,April2013,availableat:http://www.hpfsouthsudan.org/download/
hpf_key_documents/management_of_hpf_mechanism/Request%20for%20Proposals%20-%20Eastern%20Eqautoria,%20
Western%20Bahr%20el%20Ghazal%20and%20Unity%20States.pdf
Emailcommunicationwithmentalhealthworker,May2016.
132
InterviewwithUnitedStatesAgencyforInternationalDevelopment(USAID)staff,Juba,SouthSudan,5May2016.
133
Interviewwithexpatriatepsychologist,Juba,SouthSudan,7April2014.
134
InterviewwithNGOstaffmember,Juba,SouthSudan,8April2015.
135
InterviewwithNGOstaffmember,Juba,SouthSudan,7April2015.
136
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6. SOUTH SUDAN’S LEGAL
OBLIGATIONS
SouthSudanisboundbyinternationallawtorespect,protectandfulfiltherighttohealth,whichthe
WHOdefinesas“astateofcompletephysical,mentalandsocialwell-beingandnotmerelytheabsence
ofdiseaseorinfirmity.”137Thisrequiresthegovernmenttoensureaccesstomentalhealthservices;
refrainfromactssuchastorturethatcausepsychologicalharm;andpreventsuchactsbythirdparties.
SouthSudanmustalsoensurethatvictimsofserioushumanrightsorhumanitarianlawviolationsor
abusesreceivecompensationformentalharmandrehabilitation,includingpsychologicalcare.Amnesty
International’sfindingsleadtotheconclusionthatSouthSudanisfailingtomeettheseobligationsina
numberofrespects.
THE RIGHT TO MENTAL HEALTH CARE SERVICES AS
PART OF THE RIGHT TO HEALTH
Therighttohealthisenshrinedinnumerousinternationalandregionalhumanrightsinstruments
includingtheUniversalDeclarationofHumanRights(UDHR).138 The Convention on the Rights of
theChild(CRC),towhichSouthSudanisaparty,recognizestherightofthechildto“thehighest
attainablestandardofhealth”andrequiresthatchildrenwithmentaldisabilitieshaveaccesstohealth
careservices.139SouthSudanisalsoboundundertheConventionontheEliminationofAllFormsof
DiscriminationagainstWomen(CEDAW)toensureaccesstohealthservicesforallwomen.140Asa
signatorytotheAfricanCharteronHumanandPeoples’Rights(theAfricanCharter),SouthSudan
hasindicatedanintenttobeboundbyitscontent,includingArticle16whichprovidesthat“every
individualshallhavetherighttoenjoythebestattainablestateofphysicalandmentalhealth.”141
TheTransitionalConstitutionoftheRepublicofSouthSudan(TCRSS),inplacesince2011,also
recognizesthegovernment’sobligationtoprovidehealthservices.Itstatesthat:“Alllevelsof
WHOConstitution,1946,Preamble.
137
UniversalDeclarationofHumanRights(UDHR),1948,Article25.
138
UNConventionontheRightsoftheChild(CRC)1989,ratifiedbySouthSudaninMay2015,Articles23and24.
139
UNConventionontheEliminationofAllFormsofDiscriminationagainstWomen(CEDAW),1979,ratifiedbySouthSudaninMay
2015,Article12.
140
141
AfricanCharteronHumanandPeoples’Rights(AfricanCharter),Article16(1).SouthSudansignedtheAfricanCharteron24
January2013.SouthSudan’sNationalLegislativeAssemblyapprovedratificationoftheAfricanCharterinOctober2013.Theonly
remainingsteptocompletetheratificationprocessisforthegovernmenttodeposittheinstrumentofratificationwiththeAU.Since
SouthSudanhassignedthetreaty,itisboundbytheViennaConventionontheLawofTreatiestorefrainfromactsthatwoulddefeat
itsobjectandpurpose.ViennaConventionontheLawofTreaties,1986,Article18.
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governmentshallpromotepublichealth,establish,rehabilitateanddevelopbasicmedicaland
diagnosticinstitutionsandprovidefreeprimaryhealthcareandemergencyservicesforallcitizens.”142
SouthSudanisnotpartytotheConventionontheRightsofPeoplewithDisabilities(CRPD)orto
theInternationalCovenantonEconomic,SocialandCulturalRights(ICESCR)—twokeytreatieswith
respecttomentalhealth.143However,thetreatymonitoringbodyoftheICESCR,theCommitteeon
Economic,SocialandCulturalRights(CESCR),hasprovidedusefulandauthoritativeguidanceon
howstatesshouldimplementtherighttohealth,includingmentalhealth.Evenintheabsenceof
ratificationoftheICESCR,SouthSudanshouldtakecognisanceoftheCESCR’sguidanceinorderto
effectivelycomplywithitsobligationsunderothertreatiesanditsownconstitutiontoimplementthe
righttohealth.
AccordingtotheCESCR,thoughfulfilmentoftherighttohealthistoagreatextentdependentonthe
availabilityofresources,allcountries,notwithstandingtheireconomicsituation,haveaminimumcore
obligationtoensurethesatisfactionof,attheveryleast,minimumessentiallevelsofhealthservices.144
Coreobligationsofstatesincludetheprovisionofessentialprimaryhealthcareandessentialdrugs.145
AccordingtotheWHO,theprovisionofprimaryhealthcareshouldincludethedetectionandtreatment
ofcommonmentalandbehaviouraldisorders.146Statesarealsorequired,asaminimumcore
obligation,toadoptandimplementanationalpublichealthstrategyandplanofaction.147
Inadditiontoprovidingminimumlevelsofservices,implementingtherighttohealthprovidedinCRC,
CEDAW,theAfricanCharter,andSouthSudan’sconstitutionrequiresthegovernmenttoimproveand
expanduponhealthservicesovertime,inaccordancewiththeprincipleofprogressiverealisation.
Progressiverealizationrequiresstatestotakedeliberate,concreteandtargetedsteps,as“expeditiously
andeffectivelyaspossible”andtothemaximumoftheiravailableresourceswithaviewto
progressivelyrealizingtherighttohealthovertime.148Suchstepsmightincludeadoptinglegislationor
administrative,economic,financial,educationalorsocialreforms,orestablishingactionprogrammes,
appropriateoversightbodiesorjudicialprocedures.Availableresourcesrefertothoseexistingwithina
Stateaswellasthoseavailablefromtheinternationalcommunitythroughinternationalcooperationand
assistance.149ThecontextofarmedconflictdoesnotdiluteSouthSudan’simmediateobligationtotake
stepstoensurefullrealizationoftherighttohealth.150
AccordingtotheCESCR,fulfilmentoftherighttohealthmeansthathealthservices,includingmental
healthservices,areavailable,accessible,acceptable,andofgoodquality.Availabilitymeansthatthere
areenoughmentalhealth-relatedfacilitiesandservicesaswellassufficienttrainedmedicalandother
professionals.Accessibilitymeansthatmentalhealthfacilitiesareaffordable,geographicallyaccessible
andavailablewithoutdiscrimination;italsocomprisestherighttoseekandreceiveinformationabout
healthservices.Acceptabilitymeansthatfacilitiesrespectdifferentculturesandmedicalethics.
Servicesofgoodqualitymeetmedicalandscientificstandardsofquality.151
Animportantprincipleregardingmentalhealthservices,providedforinthe1991UNPrinciples
fortheProtectionofPersonswithMentalIllnessandfortheImprovementofMentalHealth,isthat
everyindividualhastherighttobetreatedandcaredfor,asfaraspossible,inthecommunityin
TransitionalConstitutionoftheRepublicofSouthSudan(TCRSS),2011,Article31.
142
SeeCommitteeonEconomic,Social,andCulturalRights(CESCR),GeneralComment3:TheNatureofStatePartiesObligations
(art.2(1)(GeneralComment3),1990,UNDocE/1991/23,para10.
143
CESCR,GeneralComment3,para.10.
144
CESCR,GeneralComment14:TheRighttotheHighestAttainableStandardofHealth(GeneralComment14),2000,UNDoc
E/C.12/2000/4,para.43.
145
WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,p.59.
146
CESCR,GeneralComment14,para.43.
147
CESCR,GeneralComment3,para.2.
148
CESCR,GeneralComment3,para.4.
149
SeeAnandGrover,ReportoftheSpecialRapporteurontheRightofEveryonetotheEnjoymentoftheHighestAttainableStandard
ofPhysicalandMentalHealth,2013,UNDocA/68/297.
150
CESCR,GeneralComment14,para.12.
151
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whichheorshelives.152Patientsalsohavetherighttobetreatedintheleastrestrictiveenvironment
andwiththeleastrestrictiveorintrusivetreatmentappropriatetothepatient’shealthneedsandthe
needtoprotectthephysicalsafetyofothers.153TheWHOcallsforpeoplewithmentaldisorderstobe
movedoutofprisonsandforallinstitutional-basedcareforpeoplewithmentalhealthconditionsto
bephasedout.AccordingtotheWHO,untilallpatientscanbedischargedintothecommunitywith
adequatecommunitysupport,psychiatricinstitutionsshouldbedownsized,thelivingconditionsof
patientsshouldbeimproved,andproceduresshouldbesetuptoprotectpatientsagainstunnecessary
involuntaryadmissionsandtreatments.154
Fulfillingtherighttomentalhealthfurtherrequiresthatmentalhealthservicesbedesignedtofulfila
widerangeofmentalhealthneeds.AccordingtotheUNSpecialRapporteurontherightofeveryone
tothehighestattainablestandardofphysicalandmentalhealth(SpecialRapporteurontheright
tohealth),“[States]shouldtakestepstoensure[theavailabilityof]afullpackageofcommunitybasedmentalhealthcareandsupportservicesconducivetohealth,dignity,andinclusion,including
medication,psychotherapy,ambulatoryservices,hospitalcareforacuteadmissions,residential
facilities,rehabilitationforpersonswithpsychiatricdisabilities,programmestomaximizethe
independenceandskillsofpersonswithintellectualdisabilities,supportedhousingandemployment,
incomesupport,inclusiveandappropriateeducationforchildrenwithintellectualdisabilities,and
respitecareforfamilieslookingafterapersonwithamentaldisability24hoursaday.”155
TheWHOsimilarlyrecommendsthatprovidingcomprehensivementalhealthcarerequiresavarietyof
services.Theseservicesshouldincludeabalanced combination of medication (or pharmacotherapy);
psychotherapy; and psychosocial rehabilitation.156TheWHO’soptimalmixofservicespyramidframework
(figure 1)indicatesthatthemajorityofmentalhealthcarecanbemanagedthroughself-careand
informalcommunitymentalhealthservices.Whereadditionalexpertiseisneeded,moreformalized
servicesarerequired.Inascendingordertheseincludeprimarycareservices,followedbyspecialist
communitymentalhealthandpsychiatricservicesbasedingeneralhospitals,andlastlybyspecialist
andlongstaymentalhealthservices.157
152
UNPrinciplesfortheProtectionofPersonswithMentalIllnessandfortheImprovementofMentalHealth,17December1991,A/
RES/46/119,Principle7.
UNPrinciplesfortheProtectionofPersonswithMentalIllnessandfortheImprovementofMentalHealth,Principle9.
153
WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,pp.87,114.
154
PaulHunt,ReportoftheSpecialRapporteurontherightofeveryonetotheenjoymentofthehighestattainablestandardof
physicalandmentalhealth,2005,UNDoc.E/CN.4/2005/51,para.42.
155
WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,p.59.
156
WHO,“TheOptimalMixofServicesforMentalHealth,”availableat:http://www.who.int/mental_health/policy/services/2_
Optimal%20Mix%20of%20Services_Infosheet.pdf
157
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WHO optimal mix of services pyramid framework.
158
TheInter-AgencySteeringCommittee(IASC)guidelinesontheprovisionofmentalhealthand
psychosocialsupportinemergencysettings,suchastheUNMISSPoCsites,recommendtheavailability
ofasimilar,layeredsystemofcomplementarysupportstomeettheneedsofdifferentgroups.159(See
figure 2)TheIASCpyramidframeworkcallsfirstlyforbasicneeds,suchasfood,shelter,andwaterto
beprovidedinasociallyappropriatemannerthatpromotesmentalhealthandpsychosocialwellbeing.
Thesecondlayerrepresentsresponsesthatseektostrengthencommunityandfamilysupports,through
forexample,discussiongroups,child-friendlyspaces,andculturalandrecreationalactivities.The
thirdlayerrepresentssupportsnecessaryforasmallernumberofpeoplewhorequireadditional,more
focusedindividualorfamilyinterventionsbytrainedandsupervisedworkers.Thislayerincludesbasic
mentalhealthcarebyprimaryhealthcareworkers.Thetoplayerrepresentstheadditionalpsychological
orpsychiatricsupportsneededforpeoplewhosesufferingisintolerableandwhohavedifficultieswith
basicdailyfunctioningthatexceedthecapacityofanyprimaryhealthservicesavailable.Thoughsuch
specialisedservicesareneededonlyforasmallpercentageofthepopulation,accordingtotheIASC,in
mostlargeemergenciesthisamountstothousandsofindividuals.160
158
WHO,“TheOptimalMixofServicesforMentalHealth.”
159
TheInter-AgencySteeringCommittee(IASC)Guidelinesonmentalhealthandpsychosocialsupportduringemergencysettings
weredevelopedin2007withtheparticipationofmentalhealthpractitioners,universitiesandnumeroushumanitarianandhuman
rightsorganizations.Theguidelinesareconsideredthegeneralreferencefororganizationsprovidingmentalhealthorpsychosocial
supportservicesinthecontextofhumanitarianprogramminginSouthSudan.IASC,IASCGuidelinesonMentalHealthand
PsychosocialSupportinEmergencySettings,2007,availableat:http://www.who.int/mental_health/emergencies/guidelines_iasc_
mental_health_psychosocial_june_2007.pdf
IASC,IASCGuidelinesonMentalHealthandPsychosocialSupportinEmergencySettings,pp.11-13.
160
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Figure 2: IASC intervention pyramid for mental health and psychosocial support in emergencies, as adapted by the WHO.161
WhileSouthSudanisnotexpectedtoprovidethesamelevelofmentalhealthservicesasadeveloped
country,ithasfailedtoguaranteeevenminimumessentialmentalhealthservices,suchasthe
detectionandtreatmentofcommonmentalandbehaviouraldisordersandtheavailabilityofessential
psychotropicmedicines.Inaddition,thegovernmenthasfailedtomakeanyidentifiableprogress
towardsimprovingtheavailabilityandaccessibilityofmentalhealthservicesoverthepastyears.
Notably,ithasfailedtoadoptamentalhealthpolicyortopassmentalhealthlegislation—stepsthat
don’trequiresignificantresources.TheWHOdescribestheabsenceofamentalhealthpolicyas
indicativeofa“lackofexpressedcommitmenttoaddressmentalhealthproblems.”162Thelackof
progressinimprovingmentalhealthservicesoverthepastfewyearsindicatesinsufficientpoliticalwill
andfinancialcommitmenttoaddressmentalhealth.Fortheabovereasons,SouthSudanisviolatinga
numberofobligationswithrespecttotherighttohealth.
VIOLENCE AS A VIOLATION OF THE RIGHT TO MENTAL
HEALTH
Itiswidelyacceptedthatactssuchastorture,sexualviolence,andunlawfulkillingwilloftenhave
anegativeimpactonthementalhealthof“victims”—peoplewhohaveindividuallyorcollectively
sufferedhumanrightsviolationsaswellastheirimmediatefamilyordependantswhohavesuffered
harmininterveningtoassistorpreventvictimization.163Inadditiontobeingseriousviolationsofcivil
andpoliticalrightsinandofthemselves,suchactscan,therefore,alsoconstituteviolationsoftheright
tohealth.
161
WHO,UNHCR,MentalHealthGapActionProgrammeHumanitarianInterventionGuide,2015,p.11,availableat:http://apps.
who.int/iris/bitstream/10665/162960/1/9789241548922_eng.pdf
WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,p.77.
162
Theterm“victim”forthepurposeofreparationincludesthosewhohaveindividuallyorcollectivelysufferedharm,including“the
immediatefamilyordependantsofthedirectvictimandpersonswhohavesufferedharmininterveningtoassistvictimsindistress
ortopreventvictimization.”UNBasicPrinciplesandGuidelinesontheRighttoaRemedyandReparationsforVictimsofGross
ViolationsofInternationalHumanRightsLawandSeriousViolationsofInternationalHumanitarianLaw(UNBasicPrinciplesand
Guidelines),2006,UNDocA/RES/60/147,Principle8.
163
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Tortureandothercruel,inhumanordegradingtreatmentareprohibitedunderSouthSudan’s
ConstitutionaswellasundertheUNConventionagainstTortureandOtherCruel,Inhumanor
DegradingTreatmentorPunishment(CAT),towhichSouthSudanisastateparty.Theinflictionof
severepainorsuffering,whetherphysicalormental,isakeyelementofthedefinitionoftorture.It
follows,therefore,thatactsoftorturearealsoviolationsoftherighttohealth.Indeed,theCESCRhas
statedthattherighttohealthincludestherighttobefreefrominterferences,suchastorture.164
TheSpecialRapporteurontheRighttoHealthhasaffirmedthatviolencehasadirectimpacton
theenjoymentoftherighttohealth,sinceitresultsin“significantphysical,psychologicaland
emotionalharmtoindividualvictimsandcontributestosocialproblemsforindividuals,familiesand
communities.”165RespectingtherighttohealthasprovidedintheCRC,CEDAW,andtheAfrican
CharterthereforerequiresSouthSudantorefrainfromactsthatinterferewithindividuals’mental
health.SouthSudanmustalsoprotectindividualsfromactsthatcausementalharmbypreventing
suchactsbythirdparties.AccordingtotheCESCR,violationsoftherighttohealthinclude,“the
failuretoregulatetheactivitiesofindividuals,groupsorcorporationssoastopreventthemfrom
violatingtherighttohealthofothers”and“thefailuretoprotectwomenagainstviolenceorto
prosecuteperpetrators.”166SouthSudanmustthereforeexerciseduediligencetoprevent,investigate,
andprosecuteactsthatcausenegativementalhealthimpacts,whetherperpetratedbyStateactorsor
privatepersons.
InthecontextofSouthSudan’scurrentinternalarmedconflict,governmentforceshavecommitted
torture,rape,enforceddisappearancesandarbitrarykillings—whichhaveterrorizedcivilian
populations.SouthSudanhasalsofailedtoinvestigateandprosecutesuchacts,contributingtoa
cultureofimpunitythatallowsthemtocontinueunabated.Bothbycommittingandnotaddressing
thesedeliberatetargetedacts,SouthSudanhasfailedtorespectandprotecttherightofitspopulation
tothehighestattainablestandardofhealth.
THE RIGHT TO MENTAL HEALTH CARE SERVICES AS
PART OF VICTIMS’ RIGHT TO REPARATIONS
Inadditiontorefrainingfromandpreventingactsthatcausepsychologicalharm,thegovernmenthas
anadditionalspecificobligationunderinternationallawtoprovidenecessarymentalhealthservicesto
victims.Thisobligationstemsfromtherightofvictimstoaneffectiveremedy,whichincludeseffective
andpromptreparationforharmsuffered.167Whilstitisrecognisedthattheprovisionofeffective
remedies,includingreparations,doeshaveresourceimplications,thisobligationisnotsubjectto
progressiverealisationandthereforerequiresimmediateandconcretemeasures.
Reparationencompassestheconcretemeasuresthatshouldbetakentoaddressthesufferingof
thesurvivorsandvictimsandtohelpthemrebuildtheirlives.Theaimofreparationisto“asfaras
possible,wipeoutalltheconsequencesoftheillegalactandre-establishthesituationwhichwould,
inallprobability,haveexistedifthatacthadnotbeencommitted.”168Formsofreparationinclude
restitution,compensation,rehabilitation,satisfaction,andguaranteesofnon-repetition.169Whileall
formsofreparationwouldlikelycontributetoalleviatingpsychologicalharmsufferedbyvictims,mental
healthservicesarespecificallyconsideredasanelementofstates’obligationstoprovidecompensation
CESCR,GeneralComment14,para.8.
164
ReportoftheSpecialRapporteurPaulHunttotheCommissiononHumanRights,TheRightofEveryonetotheEnjoymentof
theHighestAttainableStandardofPhysicalandMentalHealth,2004,UNDocE/CN.4/2004/49,para.84,availableat:https://
documents-dds-ny.un.org/doc/UNDOC/GEN/G04/109/33/PDF/G0410933.pdf?OpenElement
165
CESCR,GeneralComment14,para.51.
166
TherighttoaneffectiveremedyisincludedinArticle8oftheUDHRaswellasintheCAT,CEDAW,CRC,andtheAfricanCharter,
allofwhichbindSouthSudan.
167
PermanentCourtofArbitration:ChorzowFactoryCase(Germanyv.Poland),1928.
168
TheUNBasicPrinciplesandGuidelinesrecognizefiveformsofreparation:restitution,compensation,rehabilitation,satisfaction
andguaranteesofnon-repetition.
169
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foreconomicallyassessabledamage,includingmentalharmandthecostsofmedicalandpsychological
care,andtoensurerehabilitation,includingpsychologicalcareandsocialservices.170
SouthSudanbearstheprimaryresponsibilityforprovidingreparationtovictimsofhumanrights
violationsinthecountry.ThereisanexpresslegalobligationonSouthSudantoprovidereparation
whenviolationsarecommittedbyagentsofthestateorunderthestate’sauthority.Whencrimesare
committedbyagentsofotherstatesornon-stateactors—forexample,theSudanPeople’Liberation
Army-InOpposition(SPLA-IO)—SouthSudanhasanobligationtoensurethatvictimscanclaim
reparationagainstthoseresponsible,includingbymakingclaimsthroughthenationaljusticesystem.171
Whenobtainingredressfromotherstatesornon-stateactorsisnotpossible,suchaswheretheperson
responsiblecannotbeidentifiedorlocated,orwherethereareobstaclesthatwilldelayvitalmeasures
ofassistancerequiredbysurvivorsorvictims,SouthSudanshouldstepinandprovidereparationto
survivorsandvictims,includingthroughadministrativeprogrammes,andthenseektoreclaimanycosts
fromthoseresponsible.
ThescopeofmentalhealthservicesthatSouthSudanmustmakeavailabletohasbeenelaborated
inrelationtovictimsoftorture.AccordingtotheUNCommitteeagainstTorture,compensationand
rehabilitationshouldcaterfortreatmentoftraumaandpsychologicalassistance.172TheUNVoluntary
FundforVictimsofTorture,establishedtocontributetotherehabilitationoftorturevictims,defines
psychologicalassistancetoentail“individualtherapy,whetherbasedonclinical,psychoanalytical,
behaviouralorothertherapy…toassistvictimswiththeirgradualreintegrationintosociety.Psychiatric
therapymaybecombinedwithmedicationtoalleviatephysicalandpsychologicalsymptoms.”173
Psychologicalrehabilitationhasalsobeenrecognizedasparticularlycriticalforvictimsofsexual
violence.AsastatepartytoCEDAW,SouthSudanisrequiredtoestablishorsupportservicesfor
victimsofrape,sexualassaultandotherformsofsexualviolence,including“rehabilitationand
counselling.”174AccordingtotheUNDeclarationontheEliminationofViolenceagainstWomen,South
Sudanshouldalso“ensure,tothemaximumextentfeasibleinthelightoftheiravailableresources
and,whereneeded,withintheframeworkofinternationalcooperation,thatwomensubjectedto
violence…havespecializedassistance,suchasrehabilitation…treatment,counselling,andhealthand
socialservices…andshouldtakeallotherappropriatemeasurestopromotetheirsafetyandphysical
andpsychologicalrehabilitation.”175
Asdescribedabove,mentalhealthservicesarepracticallynon-existentinSouthSudan.Thisisthe
casebothforthegeneralpopulationaswellasforvictimsofhumanrightsviolationswhoexperience
psychologicalharm.Therearenocollectivereparationsprogrammesforvictimsofconflict-related
violations.AmnestyInternationalhasnotidentifiedanycaseinwhichthegovernmenthasprovided
anyindividualvictimofconflict-relatedviolationswithcompensationforpsychologicalharmor
psychologicalrehabilitation.
170
UNBasicPrinciplesandGuidelines.TheCRCrequiresstatepartiestofulfiltherighttorehabilitationandto“promotephysical
andpsychologicalrecovery”ofchildvictimsoftortureandarmedconflict.CRC,Articles24and39.TheCATrequiresthatstates
partiesensure“asfullrehabilitationaspossible.”CAT,Article14.
171
Thestatehasadutyto“providethosewhoclaimtobevictimsofahumanrightsorhumanitarianlawviolationwithequaland
effectiveaccesstojustice...irrespectiveofwhomayultimatelybethebearerofresponsibilityfortheviolation.”UNBasicPrinciples
andGuidelines,Principle3(c).
172
InresponsetoSriLanka’sreport,theCommitteerecommendedto“establishareparationprogramme,includingtreatmentof
traumaandotherformsofrehabilitation,andtoprovideadequateresourcestoensureitseffectivefunding.”UNCommitteeagainst
Torture,ConclusionsandRecommendationsoftheCommitteeagainstTorture:SriLanka,2005,UNDocCAT/C/LKA/CO/2,para.16.
InresponsetoChad’sreport,theCommitteecalledonitto“[o]fferfullreparation,includingfairandadequatecompensationfor
thevictimsofsuchacts,andprovidethemwithmedical,psychologicalandsocialrehabilitation.”UNCommitteeagainstTorture,
ConcludingObservationsoftheCommitteeagainstTorture:Chad,2009,UNDocCAT/C/TCD/CO/1.
173
UNVoluntaryFundforVictimsofTorture,availableat:http://www.ohchr.org/EN/Issues/Torture/UNVFT/Pages/WhattheFunddoes.
aspx
174
CommitteeontheEliminationofDiscriminationAgainstWomen,GeneralRecommendation19:ViolenceagainstWomen,1992,
para.24.
UNGeneralAssembly,DeclarationontheEliminationofViolenceagainstWomen,1994,UNDocA/RES/48/104.
175
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7. THE WAY FORWARD
END VIOLATIONS AND ABUSES OF HUMAN RIGHTS AND
HUMANITARIAN LAW
Theviolationsandabusesofinternationalhumanrightsandhumanitarianlawcommittedbywarring
partieshaveheightenedthepsychologicalburdenoftheconflictoncivilianpopulations.Actssuchas
rapeandotherformsofsexualviolence,tortureorotherill-treatment,targetedkillingofciviliansand
thelootinganddestructionofcivilianhomes—allofwhichcantriggerpsychologicaldistressandother
mentalhealthconditions—arewarcrimes.Thehunger,dispossessionandconstantinsecurityfaced
bysomanyarealsoexacerbatedbyunlawfulactssuchastheobstructionofhumanitarianaccessand
intentionaltargetingofcivilianlivelihoods.Theeffectiveavailabilityandprovisionofmentalhealth
serviceswillhavelittleimpactonanindividualornationallevelaslongastheseruthlessandinhumane
acts,whichcontinuouslypiletraumaonthepeopleofSouthSudan,continue.
Onecorecomponentofaddressingthementalhealthimpactofthisconflictandfutureones,will
thereforelieinchangingthecultureofwarfareandendingtheseeminglyroutineandflagrantviolations
andabusesofhumanrightsandhumanitarianlaw.Tothisend,theTransitionalGovernmentofNational
Unity(TGoNU)shouldworktoendandsupressallviolationsandabusesofinternationalhuman
rightsandhumanitarianlawcommittedbymembersofthearmedforcesorassociatedpersonneland
ensurethatviolationsandabusesarenotcommittedwithimpunity.Specifically,allforcesshould
immediatelyceaseunlawfulkillings;actsofsexualviolenceandanyotherattacksoncivilians;looting
anddestructionofpublicandprivateproperty;violenceagainsthumanitarianpersonnelandassets;
andotherobstructionstohumanitarianassistance.ItisalsocriticalthattheTGoNUprovideall
forceswithsufficienttrainingandclearorderstoensuretheyareawareofwhatconductisprohibited
underinternationallaw.Thegovernmentandtheoppositionshouldalsoputinplacemechanismsto
adequatelymonitortheconductoftheirforces.
ThesigningoftheAugust2015peaceagreementwasquicklyfollowedbytheannouncementofa
permanentceasefirebySalvaKiirandRiekMachar,buthasunfortunatelynotbroughtacompleteend
tofightingortoitsaccompanyingviolationsofinternationalhumanitarianlaw.TheJointMonitoring
andEvaluationCommission(JMEC),whichoverseesimplementationofthepeaceagreement,should
continuouslycondemnviolationsandabusesofhumanrightsandhumanitarianlawbypartiestothe
conflict.TheCeasefireandTransitionalSecurityArrangementsMonitoringMechanism(CTSAMM),
thebodyunderJMECestablishedtomonitorandreportonceasefireviolations,shouldensurethatits
monitoringandreportingaddressestheparties’respectforinternationalhumanitarianlaw.
Adeepandpervasivesenseofimpunityhasemboldenedarmedactorstocommithumanrights
violationsandabuses.Todeterfutureviolations,SouthSudanshouldfulfilitsobligationtoinitiate
prompt,effectiveandimpartialinvestigationsintoallallegationsofcrimesunderinternationallawand
humanrightsviolationsorabusesbyallsidestotheconflictandbringthosecrediblysuspectedof
criminalresponsibilitytojusticeinopen,accessibleciviliancourtsandinfairtrialswithoutrecourse
tothedeathpenalty.TheTGoNUshouldimmediatelysuspendmilitaryandcivilianofficialsforwhom
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thereiscredibleinformationthattheycommittedcrimesunderinternationallaworhumanrights
violations,untilallegationsconcerningthemcanbeindependentlyandimpartiallyinvestigated.
Whileconductinginvestigationsandholdingindividualsresponsibleaccountableistheprimary
responsibilityofSouthSudan,ithassofarfailedtodemonstrateawillingnesstodischargethis
obligation.176ItisthereforecriticalthatUNMISSprovideregularandtimelyreportingonthehuman
rightssituation,asmandatedbytheSecurityCouncil.TheAUCommissionshouldquicklyestablish
theHybridCourtforSouthSudan(HCSS)withamandatetoprosecutegenocide,warcrimes,crimes
againsthumanityandothercrimesunderinternationallawcommittedduringtheconflict,asisprovided
intheAugust2015peaceagreement.
TheUNSecurityCouncilshouldusethetoolsatitsdisposaltopreventanddeterfutureviolationsof
humanitarianlawandviolationsandabusesofinternationalhumanrightslaw.Specifically,itshould
imposeacomprehensivearmsembargoonthedirectorindirectsupply,saleortransfer,including
transitandtrans-shipment,ofweapons,munitions,militaryvehiclesandanyotherformsofmilitary
assistance,includingtechnicalandfinancialassistance,equipmentmaintenanceandtraining,to
SouthSudan.TheSecurityCouncilshouldalsoimposetargetedsanctions,includingtravelbansand
assetfreezes,againstcivilianandmilitaryofficialswhohaveengagedinviolationsofinternational
humanitarianlawandviolationsandabusesofinternationalhumanrightslawinSouthSudan.
IMPROVE THE AVAILABILITY, ACCESSIBILITY AND
QUALITY OF MENTAL HEALTH SERVICES ACROSS THE
COUNTRY
SouthSudan’songoingviolationoftherighttohealththroughfailuretoprovideadequatemental
healthservicesmustberemediedthroughtheimprovementinavailability,accessibility,andqualityof
services.TheWHOrecommendsthatinordertoimprovementalhealthservices,resourceconstrained
countriessuchasSouthSudanshouldprioritizeprovidingtreatmentthroughprimaryhealthcare;
providingcareatthecommunitylevel;makingpsychotropicdrugsavailable;educatingthepublic;
establishingnationalpolicies,programmesandlegislation;supportingresearchandmonitoring;
developinghumanresources;increasingfundingtomentalhealthservicesand;mainstreamingmental
healthinterventionsacrossothersectors.177SouthSudan’smentalhealthplansandpoliciesshouldbe
directedtowardsthesepriorities.
INTEGRATE MENTAL HEALTH TREATMENT INTO PRIMARY HEALTH CARE
Theintegrationofmentalhealthwithinprimaryhealthcare—alreadyamongthestatedgoalsofthe
healthministry’sDepartmentofMentalHealth—iscriticaltomakingmentalhealthcaremoreavailable
andaccessible.178Integrationincreasesthelikelihoodthatmentalhealthproblemswillbedetected;
contributestodestigmatizingmentalhealthcareasmental;andsavescostsbyreducingtheneedfor
specializedmentalhealthprofessionals.179
Themanagementandtreatmentofmentaldisordersinprimarycarewillrequireadequatetrainingof
primaryhealthcarestafftotreat,manageandappropriatelyreferpatientssufferingfrommentalhealth
conditions.Therealsoneedtobesufficientnumbersofstaffwiththeknowledgeandauthorityto
prescribepsychotropicdrugs,andmentalhealthspecialistsshouldbeavailabletosupportandmonitor
generalhealthcarepersonnel.180
176
ThoughSouthSudanclaimstohaveconductedmultipleinvestigationsintoconflict-relatedabuses,theresultsofthese
investigationshavenotbeenpublishedandcriminalproceedingshavenotbeeninitiated.
WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001.
177
InterviewwithDr.AtongAyuel,Director,MentalHealthDepartment,MinistryofHealth,Juba,SouthSudan,10April2015.
178
WHO,“IntegratingMentalHealthServicesintoPrimaryHealthCare,”availableat:http://www.who.int/mental_health/resources/
mentalhealth_PHC_2008.pdf;WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,p.89.
179
WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,p.90.
180
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PROVIDE CARE AT THE COMMUNITY LEVEL
SouthSudanshoulddevelopcommunity-basedmentalhealthservicestoprovidelocally-based
treatmentandcarethatiseasilyaccessibletopatientsandtheirfamilies.Community-basedfacilities
mightincludementalhealthoutpatientfacilities,short-stayinpatientcare,daycarecentres,and
programmestosupportpeoplewithmentaldisorderslivingwiththeirfamilies.Greatercollaboration
with“informal”mentalhealthcareproviders,includingfamilies,aswellasreligiousleaders,faith
healers,traditionalhealers,schoolteachers,policeofficers,andlocalNGOsisalsoneeded.
Asapriority,thegovernmentshoulddevelopaplantoremovepeoplewithmentaldisabilitiesfrom
prisonsandtoprovidethemwithappropriatementalhealthservices,ingeneralhospitalsorcommunity
settings.
MAKE PSYCHOTROPIC MEDICINES AVAILABLE
Thegovernmentshouldimprovethecurrentlylimitedandinconsistentavailabilityofpsychotropic
medicines.AccordingtotheWHO,thesedrugscanamelioratesymptoms,reducedisability,shortenthe
courseofmanydisorders,andpreventrelapse.181Thegovernmentshouldalsoensurethatsufficient
fundsareallocatedtopurchasepsychotropicmedicinesandmakesuretheyareavailableinprimary
caresettings.Internationaldonorsshouldsupporttheavailabilityofthesemedicines.
EDUCATE THE PUBLIC
InSouthSudan,awarenessandunderstandingofmentalhealthissuesisgenerallylow,impacting
thelikelihoodofseekingcareandalsoincreasingstigmaassociatedwithmentalhealthconditions.
Increasingawarenessaboutthenatureofmentalhealthconditions,theirtreatability,therecovery
process,andthecareoptionsavailablecanincreasetheuseofmentalhealthservices,andreduce
stigmaanddiscrimination.182
ESTABLISHING NATIONAL POLICIES, PROGRAMMES AND LEGISLATION
Mentalhealthpolicyandlegislationareimportantprecursorstosignificantandsustainedaction.The
MinistryofHealth,currentlyintheprocessofrevisingtheNationalHealthPolicy,theHealthSector
DevelopmentPlanandtheBasicPackageofHealthServices,shouldensurethatallofthesepolicies
addressmentalhealthneeds.TheMinistryofHealthshouldalsosupporttheDepartmentofMental
Healthtodevelopamentalhealthpolicyandappropriatementalhealthlegislation.Stakeholders,
includingpersonswithmentalandpsychosocialdisabilities,carersandfamilymembers,professionals,
policymakers,andotherinterestedpartiesshouldparticipateinthedevelopmentofapolicyand
legislation.183Thepolicyandanylegislationshouldcomplywithinternationalandregionalhumanrights
standards.TheWHOshouldprovidetechnicalassistance,ideallythroughalong-termmentalhealth
officerbasedwithintheWHOoffice.
Thementalhealthpolicyshouldprovideconcreteandmeasurablestepstowardsensuringthatmental
healthservicesareavailable,accessible,acceptable,andofgoodquality.Itshouldalsospecify
necessaryactionstoincorporatementalhealthinformationandservicesattheprimaryhealthcare
level,includingnecessarytrainingforhealthcarestaffandcommunityworkerstoprovideessential
information,care,supportandreferralservices.Itshouldsetprioritiesandoutlineapproaches,based
onidentifiedneedsandtakingintoaccountavailableresources.Itshouldtakeintoaccountthe
particularneedsofchildren,women,theelderly,anddisplacedpeople.
Mentalhealthlegislationshouldguaranteerespectforthedignityandhumanrightsofpeoplewith
mentaldisorders,particularlynon-discrimination,freedomfromtortureandill-treatment,andphysical
integrity.Legislationshouldprohibittheincarcerationofpeoplesolelyonthebasisofmentaldisability,
WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,p.110.
181
WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,p.111.
182
TheCESCR’sGeneralComment14recognizes”participationofthepopulationinallhealth-relateddecision-making”ascritical
totherighttohealth.CESCR,GeneralComment14,para.11.WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,
NewHope,2001,p.80.
183
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andinsteadarticulateclearregulationsfortheadmission,forcedcommitment,anddischargeofpeople
withmentaldisabilitiestomedicalfacilitiesinlinewithinternationalstandards.Legislationshouldalso
establishrulesonconsenttotreatment,andensuretheexistenceofmechanisms,suchasamonitoring,
reviewboardorcomplaintmechanismtopromoteandprotecttherightsofindividualswithmental
healthconditions.
SouthSudanshoulddemonstrateitscommitmenttorespecting,protectingandfulfillingtherightto
healthbyratifyingoraccedingtotheInternationalCovenantonEconomic,SocialandCulturalRights
(ICESCR),theInternationalCovenantonCivilandPoliticalRights(ICCPR),andtheConventiononthe
RightsofPeoplewithDisabilities.TheGovernmentshouldcompleteratificationoftheAfricanCharter
onHumanandPeoples’Rights(theAfricanCharter)bydepositingtheinstrumentofratificationwith
theAfricanUnion(AU).
SUPPORT RESEARCH AND MONITORING
Theformulationofamentalhealthpolicyandeffortstoimproveservicesshouldbebasedonreliable
information,includingquantitativedataontheprevalenceandimpactofmentalhealthconditions.
Acomprehensiveassessmentandcontinuousmonitoringofexistingmentalhealthresourcesand
structures,andtheextenttowhichtheyfulfilmentalhealthneedsisalsonecessarytoinformthe
designofappropriateinterventions.Thereis,however,anotablelackofsuchresearchandmonitoring
inSouthSudan.TheMinistryofHealthshouldtakestepstoremedythisgap.TheWHOshould
contributetobuildingresearchandmonitoringcapacity.
DEVELOP HUMAN RESOURCES
Thelackofspecialistsandhealthworkerswiththeknowledgeandskillstomanagementalhealth
conditionsisasignificantbarriertotreatmentandcare.TheMinistryofHealthshouldexplorebuilding
partnershipswithexternalinstitutionsandmentalhealthtrainingfacilitiestohelptrainexistingstaff.
TheMinistryofHealthalsoshouldworkwiththeMinistryofHigherEducationtointegratemental
healthandpsychosocialtrainingintouniversitycurricula,particularlyindepartmentsofmedicine,
psychology,andsocialwork,sothatnewgraduatescaneffectivelycontributetotheprovisionofmental
healthservices.
INCREASE ALLOCATION OF FUNDING TO MENTAL HEALTH SERVICES
TheMinistryofHealthshouldworktoensurethatfundsareavailabletoincreaseandimprovemental
healthservices.Specifically,theMinistryshouldensurethatthereisaclearbudgetaryallocationto
theDepartmentofMentalHealthtosupportmentalhealthprogramming.TheMinistryshouldseek
internationalcooperationandassistancetosupportmentalhealthcareservicesbymakingspecific
requeststodonorsforsuchsupportandbyworkingwithdonorstoensurethatgeneralsupporttothe
healthsectordoesnotneglectmentalhealthneeds.Internationaldonorsshouldprovidenecessary
financialandtechnicalsupporttoincreasetheavailabilityandaccessibilityofmentalhealthservices
aspartoftheirdevelopmentandreconstructionassistance.TheWHOshouldadvocatefordonor
supporttomentalhealthandtakegreaterresponsibilityformobilizingnecessaryresourcestoensure
implementationofitsMentalHealthActionPlan.
MAINSTREAM INTERVENTIONS ACROSS ALL SECTORS
Mentalhealth,likeotheraspectsofhealth,canbeaffectedbyarangeofsocioeconomicfactors
includingpoverty,educationlevel,employmentstatus,materialstandardofliving,andaccesstobasic
services.Responsibilityforpromotingmentalhealthandpreventingmentaldisordersthereforeextends
acrossallsectorsandallgovernmentdepartments.Thegovernment,internationaldonorsandNGOs
shouldmainstreammentalhealthinitiativesintoalldevelopmentandhumanitarianinterventions.
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ENSURE INTEGRATION OF MENTAL HEALTH AND
PSYCHOSOCIAL SUPPORT INTO EMERGENCY
RESPONSE PROGRAMMING
SouthSudan,throughtheMinistryofHumanitarianAffairsandDisasterManagement,shouldmake
financialandprogrammaticcontributionstoemergencymentalhealthservicesandshouldfacilitate
andencourageinternationalcooperationandsupportforimplementationoftheInter-AgencySteering
Committee(IASC)guidelines.
Internationaldonorsshouldensurethatsupportformentalhealthandpsychosocialservicesisan
appropriatecomponentoftheirfinancialcontributionstohumanitariansupport.Withsupportfrom
internationaldonors,humanitarianorganizationsprovidingemergencyassistanceinsettlementsof
internallydisplacedpeopleandinconflict-affectedareasofthecountryshouldworktoincrease
theavailabilityofmentalhealthandpsychosocialsupport,inaccordancewiththeIASCguidelines.
Whilethereisaneedfortheexpansionofalllevelsofserviceprovision,thereisaparticulardearth
ofprogrammingintheprovisionofspecializedservices,suchaspsychotherapyorpharmacologic
interventionforpeoplewithseverementaldisorders.
Thegovernment,humanitarianorganizationsanddonorsshouldworktoensurethatemergency
responseprogrammingcreatesasustainableimpactandismainstreamedintobroadernationalmental
healthstrategies.Donorswhofundmentalhealthservicesduringemergenciesshouldbepreparedto
facilitatethetransitiontofundingforlonger-termmentalhealthprogramming.
PROVIDE REPARATIONS FOR PSYCHOLOGICAL HARM
TheAgreementontheResolutionoftheCrisisinSouthSudan(ARCSS)providesthatthethree
transitionaljusticeinstitutionsitenvisions—theHybridCourtforSouthSudan(HCSS),theCommission
onTruth,ReconciliationandHealing(CTRH),andtheCompensationandReparationsAuthority
(CRA)—“shallindependentlypromotethecommonobjectiveoffacilitatingtruth,reconciliationand
healing, compensation and reparation inSouthSudan.”184TheHCSS,inadditiontoprosecutingand
punishingthoseresponsibleforcrimesunderinternationallaw,ismandatedto“awardappropriate
remediestovictims,includingbutnotlimitedtoreparationsandcompensation.”185Thefunctionsof
theCTRHincluderecommending“processesandmechanismsforthefullenjoymentbyvictimsofthe
righttoremedy,includingbysuggestingmeasuresforreparations and compensation.”186TheCRAwill
administeraCompensationandReparationFund(CRF)to“providematerialandfinancialsupportto
citizenswhosepropertywasdestroyedbytheconflictandhelpthemtorebuildtheirlivelihoods.”
TheARCSSplacesparticularemphasisontheroleoftheTGoNUinrelationtointernallydisplaced
peopleandrefugees.TheARCSSrecognizestherightofrefugeesandinternallydisplacedpeople
“toreturninsafetyanddignityandtobeaffordedphysical,legaland psychological protection.”188
ItrequirestheTGoNUtoinstituteprogramsforthe“relief,protection,repatriation,resettlement,
reintegrationandrehabilitationofinternallydisplacedpersons(IDPs)andreturnees.”189TheARCSS
alsorequiresthat,intheprovisionofhealthservices,specialconsiderationbegiventoconflict-affected
persons.190
ARCSS,ChapterV,Article1.3(emphasisadded).
184
ARCSS,ChapterV,Article3.5.3.
185
ARCSS,ChapterV,Article2.1.5.
186
ARCSS,ChapterV,Article4.2.d.
187
ARCSS,ChapterIII,Article1.1.2.
188
ARCSS,ChapterIII,Article1.2.1.
189
ARCSS,ChapterIII,Article1.2.2.
190
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Theemphasisintheagreementonreparationsandcompensationoffersanimportantopportunity
toaddresstheimpactoftheconflictonmentalhealth.AstheAfricanUnionCommissionofInquiry
inSouthSudan(AUCISS)hasrecommended,reparativemeasuresundertakenshouldinclude
rehabilitationandpsychosocialassistanceandshouldbeimplementedimmediately.191SouthSudan
shouldworktoensurethespeedyestablishmentoftheHCSS,theCTRHandtheCRAenvisagedby
theARCSS.SouthSudan,togetherwiththeAUandothersupportinginstitutionsandgovernments,
shouldensurethatinfulfillingtheirreparationsmandates,theHCSS,theCTRHandtheCRA
giveconsiderationtothementalhealthconsequencesoftheconflictandtheresultingneedfor
psychologicalrehabilitationasoneelementofindividualorcollectivereparationsprogramsand
initiatives.192Internationaldonorsshouldprovidefinancialandtechnicalsupportfortheestablishment
andoperationalisationoftheHCSS,theCTRHandtheCRA.TheyshouldsupportSouthSudan’s
obligationtoensureaccesstoreparations,throughtechnicalandfinancialsupport.
SouthSudanshouldalsoensurethatthenationaljusticesystemallowsvictimsofhumanrightsand
humanitarianlawviolationsandabusestoclaimcompensation,includingforpsychologicalharm,from
individualperpetratorsincivilproceedings.SouthSudanshouldensuretheprovisionoflegalaidto
victimswhocannotaffordlegalassistance.
AUCISS,FinalReport,para1152.
191
ThePeruvianTruthandReconciliationCommission(TRC),forexample,devotedanentirechapterofitsreporttothedevastating
psychosocialdamagecausedbythewarandrecommendedthatreparationsprogrammesincludeamentalhealthcomponent.Lisa
J.LaplanteandMiryamRiveraHolguin,“ThePeruvianTruthCommission’sMentalHealthReparations:EmpoweringSurvivorsof
PoliticalViolencetoImpactPublicHealthPolicy,”HealthandHumanRights,2006.
192
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8. CONCLUSION: THE
IMPORTANCE AND
URGENCY OF MENTAL
HEALTH SERVICES
Withhighinflationandasharpdeclineinnationaloilrevenuesasaresultofreducedoilproduction
andadropininternationaloilprices,SouthSudanisfacingasevereeconomiccrisis.193Thereisalso
persistentviolenceinsomeareasofthecountry.Despitethischallengingcontext,foramyriadof
reasonstheremustbeincreasedattentiontomentalhealthbothintheimmediateandlonger-term.
Thoughlackofresourcesisoftencitedasakeyreasonforfailurestoimprovementalhealthservices,
therearestepsSouthSudancantakethatrequirepoliticalcommitmentmorethanfunds.The
developmentofamentalhealthpolicyandlegislation,forexample,isnotheavilyresource-intensive
butcouldgoalongwaytowardsgalvanizinggreaterattentiontomentalhealthinSouthSudanand
attractingadditionalinternationalsupport.Integratingmentalhealthservicesintotheprimaryhealth
caresystemisalsonotheavilyresource-intensive.
Doingmoretoaddressmentalhealthneedsisnotonlyessentialforindividualwell-being,itisalso
criticalforSouthSudanesetoeffectivelyrebuildtheircommunitiesandcountry.Mentalhealth
problemsimpactphysicalhealthandcontributesignificantlytomorbidity.Theyalsoimpactpeople’s
abilitytofunctionasproductivemembersofsociety.Asdescribedinthisreport,peoplewithpoor
mentalhealthmaybeunabletocarryoutday-to-daytasks,participateincommunityactivities,and
pursuelivelihoodsoreducation.
Thesocietalimpactsofpoormentalhealtharealsolong-term.Poormentalhealthamongparentshas
aninter-generationalimpactonchildhealth,developmentandgrowth.194Accordingtoapsychologist
workinginJuba,“If you don’t deal with mental health care in the current generation this will create
problems long into the future. A traumatized parent won’t care for their child; the child will grow up
with his own problems, and the cycle will continue. The impact isn’t just about now, it’s about 10-15
years down the line.”195
Restoringmentalhealth—andtheabilityofcitizenstofunctionproductively—canthereforeplayavital
roleincontributingtohumandevelopment,sustainableeconomicgrowthandpovertyreduction.196 This
isreflectedinthefactthatinSeptember2015,theUNincludedmentalhealthasanelementofthe
newglobalSustainableDevelopmentGoal(SDG)onhealth.
193
SudanTribune,“IMFwarnsoffurtherdeterioratingeconomyinSouthSudan,”2June2016availableat:http://www.
sudantribune.com/spip.php?article59164
194
DelanDevakumaretal.,“Theintergenerationaleffectsofwaronthehealthofchildren,”BMCMedicine,2014,availableat:
http://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-12-57
Interviewwithexpatriatepsychologist,Juba,SouthSudan,7April2014.
195
TheWorldBank,MentalHealthandConflict,“ConflictPreventionandReconstruction,”October2003,availableat:http://
siteresources.worldbank.org/DISABILITY/Resources/280658-1172610662358/MentalHealthConfBaingana.pdf;WHO,MentalHealth
GapActionProgramme,p.6.
196
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ManySouthSudaneseandinternationalobserversidentifypoormentalhealthasadestabilizingforce
thathascontributedtoviolentbehaviouratfamily,community,andnationallevels—anobservation
supportedbystudiesshowingthelinksbetweenpoormentalhealth,anger,anddesireforrevenge.197
“Societies that didn’t have the space to digest trauma are more likely to go back to violence,”said
oneNGOworker.198ASouthSudanesepeaceactivistdescribedtheleveloftraumaasa “liability to
the country.”199 TheAfricanUnionCommissionofInquiryinSouthSudan(AUCISS)emphasizedinits
finalreportthatreconciliationcannottakeplaceunlessthesufferingandtraumaexperiencedbySouth
Sudaneseisaddressed:
“In our view, one cannot expect materially deprived victims, those with
unhealed mental scars to embrace reconciliation and forgiveness.
Deep, sustainable reconciliation and peace requires more than
acknowledgement of wrongs and apology. Genuine attempts must be
made to address concerns specific to surviving victims, which may
include loss of family and relatives, displacement, loss of property as well
as physical and mental scars from violations suffered, which necessitate
psycho-social support and rehabilitation.”200
Addressingmentalhealthisthereforecriticaltoachievingandmaintainingpeace,stabilityand
reconciliationinSouthSudan.
197
Seeforexample,OscarI.GonzalezandRaymondW.Novaco,“AngerIntensificationwithCombat-RelatedPTSDandDepression
Comorbidity,”PsychologicalTrauma:Theory,Research,Practice,andPolicy,2016,availableat:https://www.apa.org/pubs/
journals/releases/tra-0000042.pdf;UlrichOrthandEliasWieland,“Anger,Hostility,andPosttraumaticStressDisorderinTraumaExposedAdults:AMeta-Analysis,”JournalofConsultingandClinicalPsychology,2006,availableat:https://uorth.files.wordpress.
com/2011/01/orth_and_wieland_2006_jccp.pdf
InterviewwithNGOstaffmember,Juba,SouthSudan,8April2015.
198
PresentationbySouthSudanesepeaceactivist,Juba,SouthSudan,9April2015.
199
AUCISS,FinalReport,para.894.
200
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9. RECOMMENDATIONS
TO THE TRANSITIONAL GOVERNMENT OF NATIONAL UNITY (TGONU)
• Endandsuppressallviolationsofinternationalhumanrightsandhumanitarianlawcommittedby
membersofthearmedforcesorassociatedpersonnel.Inparticular,allforcesshouldimmediately
ceaseunlawfulkillings;actsofsexualviolenceandanyotherattacksoncivilians;lootingand
destructionofpublicandprivateproperty;violenceagainsthumanitarianpersonnelandassets;and
otherobstructionstohumanitarianassistance;
• Providearmedforceswithsufficienttrainingandclearorderstoensuretheyareawareofconduct
prohibitedunderinternationallawandputinplacemechanismstoadequatelymonitortheconduct
oftheirforces;
• Initiateprompt,effectiveandimpartialinvestigationsintoallegationsofcrimesunderinternational
lawandhumanrightsviolationsorabuses.Bringthosesuspectedofcriminalresponsibilityto
justiceinopen,accessibleciviliancourtsandinfairtrialswithoutrecoursetothedeathpenalty;
• Immediatelysuspendmilitaryandcivilianofficialsforwhomthereiscredibleinformationthatthey
committedcrimesunderinternationallaworhumanrightsviolations,untilallegationsconcerning
themcanbeindependentlyandimpartiallyinvestigated;
• Ratifyoraccede,withoutreservations,tointernationalandregionalhumanrightstreaties,
particularlytheInternationalCovenantonEconomic,SocialandCulturalRights(ICESCR)andits
OptionalProtocol,theInternationalCovenantonCivilandPoliticalRights(ICCPR)anditsOptional
Protocols,theConventionontheRightsofPeoplewithDisabilities,andtheAfricanCharteron
HumanandPeoples’Rights;
• Takestepstoimprovetheavailability,accessibilityandqualityofmentalhealthservicesavailable
inthecountry.Specifically,thegovernmentshould:
• Worktointegratementalhealthtreatmentintoprimaryhealthcareservicesbyprovidingtraining
toprimaryhealthcarestafftotreat,manageandappropriatelyreferpatientssufferingfrom mentalhealthconditions;
• Developcommunity-basedmentalhealthservicestoprovidelocally-basedtreatmentandcare
thatiseasilyaccessibletopatientsandtheirfamilies;
• Removefromstateprisonspeoplesufferingfrommentalhealthconditionsandprovidethem appropriatementalhealthservicesingeneralhospitalsorcommunitysettings;
• Improvetheavailabilityofpsychotropicmedicines;
• Increasepublicawarenessaboutthenatureofmentalhealthconditions,theirtreatability,the
recoveryprocess,andthecarechoices.
• EnsurerevisionstotheNationalHealthPolicy,theHealthSectorDevelopmentPlan;andtheBasic
PackageofHealthServicesaddressmentalhealthneeds;
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• Developamentalhealthpolicyinconsultationwithstakeholders,includingpersonswithmentaland
psychosocialdisabilities,carersandfamilymembers.Thepolicyshould:
• Complywithinternationalandregionalhumanrightsstandards;
• Provideconcreteandmeasurablestepstowardsensuringtheavailability,accessibilityand
qualityofmentalhealthservices;
• Specifynecessaryactionstoincorporatementalhealthinformationandservicesattheprimary
healthcarelevel;
• Setprioritiesbasedonidentifiedneedsandtakingintoaccountavailableresources;
• Takeintoaccounttheparticularneedsofchildren,women,theelderly,anddisplacedpeople.
• Passmentalhealthlegislationinconsultationwithstakeholders,includingpersonswithmentaland
psychosocialdisabilities,carersandfamilymembers.Legislationshould:
• Complywithinternationalandregionalhumanrightsstandards.Inparticular,legislationshould
guaranteerespectforthedignityandhumanrightsofpeoplewithmentaldisorders,particularly
non-discrimination,freedomfromtortureandill-treatment,andphysicalintegrity;
• Provideforandregulatetheprovisionofmentalhealthcareservices;
• Prohibittheincarcerationofpeoplesolelyonthebasisofmentaldisability,andinsteadprovide
clearregulationsfortheadmission,forcedcommitment,anddischargeofpeoplewithmental
disabilitiestomedicalfacilitiesinlinewithinternationalstandards;
• Establishrulesonconsenttotreatment;
• Createmechanismstopromoteandprotecttherightsofindividualswithmentalhealth
conditions,suchasamonitoringbody,reviewboard,orcomplaintmechanism.
• Conductandsupportresearchandcontinuousmonitoringoftheprevalenceandimpactofmental
healthconditionsandexistingmentalhealthresourcesandstructures;
• Integratementalhealthandpsychosocialtrainingintouniversitycurricula,particularlyin
departmentsofmedicine,psychologyandsocialwork;
• Ensurethatfundsaremadeavailabletoincreaseandimprovementalhealthservices,includingby
makingaspecificbudgetaryallocationtotheDepartmentofMentalHealthtosupportmentalhealth
programming;
• Seekinternationalcooperationandassistancetosupportmentalhealthcareservicesbymaking
specificrequeststodonorsforsuchsupportandbyworkingwithdonorstoensurethatgeneral
supporttothehealthsectordoesnotneglectmentalhealthneeds;
• Mainstreammentalhealthinitiativesintoalldevelopmentandhumanitarianinterventions;
• Makefinancialandprogrammaticcontributionstosupportmentalhealthservicesinemergency
settingswhilealsoensuringthatemergencyresponseprogrammingcreatesasustainableimpact
andismainstreamedintobroadernationalmentalhealthstrategies;
• Worktoensureaccesstoreparationsforvictimsofhumanrightsandhumanitarianlawviolations
andabuses,includingforpsychologicalharm.Specificallythegovernmentshould:
• SupportthespeedyestablishmentoftheHybridCourtforSouthSudan(HCSS),theCommission
onTruth,ReconciliationandHealing(CTRH)andtheCompensationandReparationsAuthority
(CRA)providedforintheAgreementontheResolutionoftheConflictinSouthSudan(ARCSS);
• Ensurethatinfulfillingtheirreparationsmandates,theHCSS,theCTRHandtheCRAgive
considerationtothementalhealthconsequencesoftheconflictandtheresultingneedfor
psychologicalrehabilitationasanelementofindividualorcollectivereparationsinitiatives;
• Ensurethatthenationaljusticesystemallowsvictimsofhumanrightsandhumanitarianlaw
violationsandabusestoclaimcompensation,includingforpsychologicalharm,fromindividual
perpetratorsincivilproceedings.Providelegalaidtovictimswhocannotaffordlegalassistance.
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TO THE JOINT MONITORING AND EVALUATION COMMISSION (JMEC)
• Continuouslycondemnviolationsandabusesofhumanrightsandhumanitarianlawbypartiesto
theconflict;
• EnsurethattheCeasefireandTransitionalSecurityArrangementsMonitoringMechanism(CTSAMM)
effectivelymonitorsandreportsontheparties’respectforhumanitarianlaw;
• SupportthespeedyestablishmentoftheHybridCourtforSouthSudan(HCSS),theCommissionon
Truth,ReconciliationandHealing(CTRH)andtheCompensationandReparationsAuthority(CRA)
whichareprovidedforintheAgreementontheResolutionoftheConflictinSouthSudan(ARCSS).
TO INTERNATIONAL DONORS
• Continuouslycallonpartiestotheconflicttoceaseviolationsofinternationalhumanitarianlawand
violationsandabusesofinternationalhumanrightslaw;
• Provideincreasedfinancialandtechnicalassistancetosupportimprovementoftheavailabilityand
accessibilityofmentalhealthservices;
• Mainstreammentalhealthinterventionsintoalldevelopmentsupport,particularlyinthehealth
sector.Ensurethatsupportformentalhealthandpsychosocialservicesformanappropriate
componentoffinancialcontributionstohumanitarianemergencysupportefforts;
• Ensuresustainabilityofmentalhealthandpsychosocialservicesestablishedaspartofthe
emergencyhumanitarianresponsebycommittingtofundingforlonger-termmentalhealthreform;
• ProvidetechnicalandfinancialassistanceforthespeedyestablishmentoftheHybridCourtfor
SouthSudan(HCSS),theCommissiononTruth,ReconciliationandHealing(CTRH)andthe
CompensationandReparationsAuthority(CRA)providedforintheAgreementontheResolutionof
theConflictinSouthSudan(ARCSS);
• Supportthegovernment’sobligationtoensureaccesstoreparations,includingforpsychological
harm,throughtechnicalandfinancialassistance;
• ContinuouslycallontheTGoNUtoadequatelyprotectinternallydisplacedpopulations,ensuretheir
security,andhelpcreateconditionsthatwouldallowthemtoreturnorsafelyrelocateinaccordance
withtheirwishes.
TO THE UN MISSION IN SOUTH SUDAN (UNMISS)
• ProvideregularandtimelyreportingonthehumanrightssituationinSouthSudan,asmandatedby
theUNSecurityCouncil;
• Incoordinationwithhumanitarianagencies,worktoincreasetheavailabilityandaccessibilityof
mentalhealthserviceswithinProtectionofCivilian(PoC)sites.Alsoworktoimprovegeneralliving
conditions,includinghousing,food,andsanitation;
• EnsurethoroughinvestigationstakeplaceintoattacksagainstciviliansinandaroundPoCsites,
withaviewtoensuringperpetratorsareheldaccountable;
• Takeallpossibleadditionalmeasurestoensureeffectiveprotectionofcivilianswhohavesought
refugewithinPoCsites.
TO THE AFRICAN UNION (AU)
• Continuouslycallonpartiestotheconflicttoceaseviolationsofinternationalhumanitarianlawand
violationsandabusesofinternationalhumanrightslaw;
• EnsurethespeedyestablishmentbytheAUCommissionoftheHybridCourtforSouthSudan
(HCSS)inaformatthatcomplieswithinternationallaw.Providefinancialandtechnicalsupportfor
theestablishmentandoperationalisationoftheCommissiononTruth,ReconciliationandHealing
(CTRH)andtheCompensationandReparationsAuthority(CRA);
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• Worktoensurethatinfulfillingtheirreparationsmandates,theHCSS,theCTRHandtheCRA
giveconsiderationtothementalhealthconsequencesoftheconflictandtheresultingneedfor
psychologicalrehabilitationasanelementofindividualorcollectivereparationsinitiatives;
• Supportthegovernment’sobligationtoensureaccesstoreparations,includingforpsychological
harm,throughtechnicalandfinancialsupport.
TO THE WORLD HEALTH ORGANIZATION (WHO)
• Providefinancialandtechnicalassistancetosupportimprovementintheavailabilityand
accessibilityofessentialmentalhealthservices.Specifically,theWHOshould:
• Advocateforincreaseddonorsupporttomentalhealthandtakegreaterresponsibilityfor
mobilizingnecessaryresourcestoensureimplementationofitsMentalHealthActionPlan;
• Worktoincreasenationalcapacitytoconductresearchandcontinuousmonitoringofthe
prevalenceandimpactofmentalhealthconditionsandexistingmentalhealthresourcesand
structures;
• Providetechnicalassistance,ideallythroughalong-termmentalhealthofficerbasedintheWHO
officeinJuba,forthedevelopmentofamentalhealthpolicyandlegislation.
TO THE UN SECURITY COUNCIL
• Continuouslycallonpartiestotheconflicttoceaseviolationsofinternationalhumanitarianlawand
violationsandabusesofinternationalhumanrightslaw;
• Imposeacomprehensivearmsembargoonthedirectorindirectsupply,saleortransfer,including
transitandtrans-shipment,ofweapons,munitions,militaryvehiclesandanyotherformsofmilitary
assistance,includingtechnicalandfinancialassistance,equipmentmaintenanceandtraining,to
SouthSudan;
• Imposetargetedsanctions,includingtravelbansandassetfreezes,againstcivilianandmilitary
officialswhohaveengagedinviolationsofinternationalhumanitarianlawandviolationsandabuses
ofinternationalhumanrightslawinSouthSudan.
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“OUR HEARTS HAVE GONE DARK”
THE MENTAL HEALTH IMPACT OF SOUTH SUDAN’S
CONFLICT
Violationsandabusesofinternationalhumanrightsandhumanitarianlawcommittedby
partiestoSouthSudan’sinternalarmedconflictthateruptedinDecember2013havehad
significantrepercussionsonthementalhealthofSouthSudanese.Internallydisplaced
peopleimpactedbytheconflictdescribedhavingnightmares,gettingangryeasily,feeling
unabletoconcentrateandconsideringsuicide—commonmanifestationsofpsychological
stressassociatedwithmentalhealthdisorderssuchaspost-traumaticstressdisorder
(PTSD)anddepression.Theyattributedtheseimpactstotheirexperiencesasvictimsof,
orwitnessesto,torture,arbitrarydetention,sexualviolence,unlawfulkilling,andforced
displacement.
ThisreportdescribestheseriousmentalhealthimpactofSouthSudan’sconflictinorder
tohighlighttheurgencyformoreattention,andresources,toimprovetheavailability,
accessibility,andqualityofmentalhealthservicesinthecountry.Itisbasedoninterviews
with161internallydisplacedSouthSudaneseandwithgovernmentandUNofficials,
donors,representativesofnon-governmentalorganizations(NGOs),andinternationaland
SouthSudanesementalhealthprofessionals.
Index:AFR01/3063/2016
January2016
Language:English
amnesty.org