Tag Archives: cholera

Yemen’s cholera outbreak now the worst in history as millionth case looms

The cholera epidemic in Yemen has become the largest and fastest-spreading outbreak of the disease in modern history, with a million cases expected by the end of the year and at least 600,000 children likely to be affected.

The World Health Organization has reported more than 815,000 suspected cases of the disease in Yemen and 2,156 deaths. About 4,000 suspected cases are being reported daily, more than half of which are among children under five, who account for a quarter of all cases.

The spread of the outbreak, which has quickly surpassed Haiti as the biggest since modern records began in 1949, has been exacerbated by hunger and malnutrition. While there were 815,000 cases of cholera in Haiti between 2010 and 2017, Yemen has exceeded that number in just six months.

Save the Children has warned that, at the current rate of infection, the number of cases will reach seven figures before the turn of the year, 60% of which will be among children. In July, the International Committee of the Red Cross predicted there would be 600,000 suspected cholera cases in the country by the end of the year.

Tamer Kirolos, Save the Children’s country director for Yemen, said an outbreak of this scale and speed is “what you get when a country is brought to its knees by conflict, when a healthcare system is on the brink of collapse, when its children are starving, and when its people are blocked from getting the medical treatment they need”.

Kirolos said: “There’s no doubt this is a man-made crisis. Cholera only rears its head when there’s a complete and total breakdown in sanitation. All parties to the conflict must take responsibility for the health emergency we find ourselves in.”

More than two years of fighting between the Saudi-led coalition and Houthi rebels has crippled the country, causing widespread internal displacement, the collapse of the public health system, and leaving millions on the brink of famine.


When I see a mother lose her baby because of cholera, it makes me so angry

Dr Mariam Aldogani, Save the Children

The crisis was exacerbated when sanitation workers whose salaries had gone unpaid went on strike. This meant garbage was left on the streets, which was then washed into the water supply. It is estimated that 19.3 million Yemenis – more than two-thirds of the population – do not have access to clean water and sanitation.

The government stopped funding the public health department in 2016, meaning many doctors and hospital staff have not received salaries for more than a year. Healthcare has since been provided mainly by international organisations, the efforts of whom have been hampered by the conflict.

The spread of the disease has nonetheless slowed. At the beginning of the most recent outbreak, in May this year, between 5,000 and 6,000 new cases were detected daily. That rate has since dropped to just under 4,000 a day. The mortality rate has also declined, from 1% at the beginning of the outbreak to 0.26% now.

“Whatever decline we’re seeing now is due to the heroic efforts of workers at the scene,” said Sherin Varkey, the officiating representative of Unicef Yemen.

Varkey said the situation would not be solved until there was peace in the country.

“There are no signals that give us any reason for optimism. We know that both parties to the conflict are continuing with their blatant disregard of the rights of children,” he said. “We’re at a cliff and we’re staring down and it is bottomless. There seems to be no hope.”

A worker is pictured in a government hospital’s drug store in Sana’a, Yemen


A worker is seen at a government hospital’s drug store in Sana’a, Yemen. Photograph: Khaled Abdullah/Reuters

Cholera should be easily treatable with oral rehydration salts and access to clean water. But Mariam Aldogani, Save the Children’s health adviser for the city of Hodeidah, said conditions in the country had made this very difficult.

Aldogani said: “All the NGOs are trying to increase the knowledge of how to prevent the disease, because it’s preventable, you have to boil the water. But if you don’t have money to buy gas, and you have to walk a long way to get the wood, how can you boil the water?”

Aldogani, who has been a doctor since 2010, said witnessing the suffering of her patients was deeply painful. “I saw one young man, he had cholera and severe dehydration. He was in a coma and he died in front of his mother. We tried our best, but he came too late and she was crying, and I cried. It makes me angry. When I see a mother lose her baby, especially a stillbirth, she waits for this baby for a long time and then she loses it because of cholera, it makes me so angry.

“The war is a big problem for us, it’s a wound. But with the cholera, you have the wound and you put salt in the wound. It hurts. I hope this war can be stopped. We need peace for the children of Yemen. Our situation before the war was not good, but it was not like this.”

Blame the Saudis for Yemen’s cholera outbreak – they are targeting the people | Jonathan Kennedy

Over the past four months, Yemen has been ravaged by a cholera outbreak that the UN has branded the worst in the world. About 7,000 new cases are reported daily – 436,625 have been recorded since the end of April – and already there have been more than 1,915 deaths.

The epidemic is one aspect of a broader humanitarian emergency in Yemen. Two-thirds of the population – 18.8 million people – require some form of emergency aid. Food production has collapsed and 4.5 million children and pregnant and lactating women are acutely malnourished. Only 45% of health facilities are functioning, and 14.8 million people lack access to basic healthcare. About the same number require assistance to access safe drinking water and sanitation.

Cholera, a bacterial infection, is spread by water containing contaminated faeces. It can be easily prevented and easily treated. Cholera first spread from the Ganges delta in 1817, and the resulting pandemics killed tens of millions of people across the world over the 150 years. Modern improvements in water and sanitation infrastructure, and better access to medicines and healthcare, have brought a marked fall in the number of cases. Today, outbreaks occur chiefly in areas where water, sanitation and health systems are inadequate, or where they have been destroyed by natural or manmade disasters.

UN agencies, respected media outlets – including the BBC and New York Times – and influential medical journals such as the Lancet all argue that two years of conflict have created conditions conducive to a cholera outbreak. This narrative, while true, tells only part of the story. It fails to account for the possibility that one party might be more culpable for the outbreak and the other more affected by it.

The Yemeni civil war began in September 2014 when Houthi rebels, a group of Zaydi Shia from northern Yemen, took control of the capital, Sana’a, and then, with help from forces loyal to Ali Abdullah Saleh, the former president, overthrew the government the following January. The internationally recognised regime led by President Abed Mansour Hadi set up a parallel government in the southern port of Aden.

Since March 2015, Saudi Arabia has led a coalition of Sunni Arab states that has attempted to restore the government using airstrikes, an air and naval blockade, and ground troops. The US and UK provide the coalition with logistical support and military equipment. The Saudis have accused Iran of assisting the rebels, but there is limited evidence for this claim and it is denied by the Houthis and Iran.

At least 10,000 people have been killed and 40,000 injured in the conflict. Both sides stand accused of disregarding the wellbeing of civilians and breaching international law. The rebels have indiscriminately fired artillery into residential areas in government-controlled areas and Saudi Arabia. But as the Saudi-led coalition commands far greater resources, it has been able to cause destruction of a totally different magnitude.

The Saudi air force has carried out indiscriminate attacks that have caused the majority of civilian deaths and injuries during the conflict. Airstrikes have targeted civilian infrastructure, including hospitals, farms, schools, water infrastructure, markets and the main port of Hodeida. They complement a Saudi-led naval and air blockade of rebel-controlled areas that has caused shortages of many essential items, including food, fuel and medical supplies.

It was not until four weeks after the start of the outbreak that the first plane carrying medical aid was allowed to land in Sana’a. The government no longer pays public employees working in rebel-controlled areas. About 30,000 health workers have not received a salary for almost a year. Sanitation workers and water engineers in Sana’a have been on strike for months, leaving uncollected rubbish on the streets and municipal drains clogged.

So it is not surprising that rebel-controlled areas are disproportionately affected by the cholera outbreak. About 80% of cases – and deaths – have occurred in governorates controlled by the Houthis. In rebel-controlled areas the attack rate – the number of cases among every 1,000 people – is 17, compared with 10 in government-controlled governorates. The percentage of people with cholera who die is 0.46% in rebel-controlled areas, compared with 0.3% in government-controlled governorates. Thus, a person living in areas under rebel control is 70% more likely to contract cholera and, if they do, 50% more likely to die.

These numbers indicate that the outbreak is not simply an inevitable consequence of civil war. It is rather a direct outcome of the Saudi-led coalition’s strategy of targeting civilians and infrastructure in rebel-controlled areas. Criticism of the US and UK governments’ support for the Saudi-led intervention, this has not led to a policy change. In December 2016, the Obama administration banned the sale of precision-guided bombs to Saudi Arabia due to concerns about civilian casualties in Yemen, but in May 2017 the Trump administration agreed to sell $ 500m such weapons as part of a $ 110bn deal. The following month a bipartisan effort to stop the sale failed by a few votes in the Senate. Last month in the UK, the high court rejected activists’ claims that ministers were acting illegally by continuing to sell fighter jets and precision-guided bombs to Saudi Arabia when they might be used against civilians in Yemen. In the absence of strong international condemnation of Saudi-led operations, it is hard to foresee a quick end to this public health emergency and the broader humanitarian crisis.

  • Jonathan Kennedy is a lecturer in global health at Queen Mary University of London

Yemen: more than one million children at risk of cholera – charity

More than one million malnourished children aged under five in Yemen are living in areas with high levels of cholera, the charity Save The Children warned on Wednesday as it began sending more health experts to the worst hit areas.

The scaling up in response came after latest figures show that a deadly cholera epidemic that started in April 2015 has infected more than 425,000 people and killed almost 1,900.

Save the Children said children under the age of 15 are now accounting for about 44 percent of new cases and 32 percent of fatalities in Yemen where a devastating civil war and economic collapse has left millions on the brink of starvation.

“The tragedy is both malnutrition and cholera are easily treatable if you have access to basic healthcare,” said Tamer Kirolos, Save the Children’s Country Director for Yemen.

“But hospitals and clinics have been destroyed, government health workers haven’t been paid for almost a year, and the delivery of vital aid is being obstructed.“

Cholera, which is spread by ingestion of food or water contaminated by the Vibrio cholerae bacterium, can kill within hours if untreated.

The cholera outbreak prompted the United Nations last week to revise its humanitarian assessment and it now calculates 20.7 million Yemenis are in need of assistance, up from the previous figure of 18.8 million in a population of 28 million.

Oxfam has projected the number of people infected with cholera could rise to more than 600,000 – “the largest ever recorded in any country in a single year since records began” – exceeding Haiti in 2011.

Save the Children said it currently operates 14 cholera treatment centres and more than 90 rehydration units across Yemen but was scaling up its response and sending more health experts to the worst hit areas.

The charity said new analysis of district level data revealed more than one million malnourished children aged under five – including 200,000 with severe acute malnutrition – were living in cholera hot-spots.

Millions are malnourished in Yemen where famine looms, the United Nations says. A Saudi Arabia-led coalition intervened in Yemen’s civil war in 2015, backing government forces fighting Iran-allied Houthi rebels and fighting limits access for aid workers. 

‘Cholera is everywhere’: Yemen epidemic spiralling out of control

Ali Muhammad’s entire family are sick. In the months since his home district of Abs in northern Yemen was hit by a cholera outbreak, he has lost both parents and all six of his children have fallen ill.

“Cholera is everywhere,” he said, according to a testimony provided by Médecins Sans Frontières, who are caring for his eldest daughter at a cholera treatment centre in Abs. “The water is contaminated and I don’t drink it. We have tanks, but we don’t get water regularly. The situation cannot be worse.”

As the area grapples with both the cholera epidemic, which began to spread in April, and the impact of the country’s civil war, the life of the qat harvester has become harder and harder. “Everybody is sick and in rough shape, and their poor financial condition does not enable them to move from one health centre to another.

“My father got sick and although we hospitalised him, he passed away. My mother died as well. And I am just like many others.”

The Abs district was the scene of a deadly airstrike by the Saudi-led coalition last August that demolished a hospital supported by MSF, killing 19 people, including one of the aid agency’s staff members, and injuring 24.

Less than a year later, as the ongoing conflict hits an stalemate, creating the largest humanitarian crisis in the world, the MSF cholera treatment centre in Abs town alone is receiving more than 460 patients daily, which is more than anywhere else in the country.

A girl drinks water from a well that is allegedly contaminated with cholera.


A girl drinks water from a well that is allegedly contaminated with cholera. Photograph: Hani Mohammed/AP

The International Committee of the Red Cross warned on Monday that the cholera epidemic in Yemen was spiralling out of control, reaching a milestone of over 300,000 suspected cases. More than 1,600 people have died. Children account for nearly half of all suspected cholera cases in the country, according to the UN’s children agency.

Sana’a-based Taha Yaseen, from the Mwatana Organisation for Human Rights, said obstacles that stand in the way of controlling and containing cholera today in Yemen, include but are not limited to the ongoing war.

“During [the war] almost all health facilities and healthcare services reached a point of thorough collapse and thus are unable to respond to the increasing need to address fatal diseases and civilian victims. Many hospitals [have] shut down and many others were hit either by air or ground strikes, occupied by militias or used as military barracks,” he told the Guardian.

“Most [people] cannot afford even the transportation from their countryside areas or displacements communities to the nearest medical centres to treat them for cholera,” he added.

MSF’s Roger Gutiérrez, who has just returned from a seven-month service in Abs, said the wards in the hospital there, the only public hospital in the area, “are bursting at the seams … what’s happening in Abs sums up the current state of Yemen.”

The district hosts more internally displaced people than anywhere else in the country but most health facilities are not functioning; there is a lack of staff and medical supplies are running short.

“When a plane flies overhead, many patients and staff feel that fear, that vulnerability. For seconds everything stops,” he said, according to a testimony provided by MSF. “You see mothers disconnecting their children’s feeding tubes so they can run out of the hospital’s nutrition ward.”

Ayed Ali, a Yemeni caretaker based in al-Sharq district of Hajjah governorate, said most people in the area drink from exposed wells and tanks, “no matter the water is clean or not”. “There are no salaries and no services,” he said, according to MSF. “Even public hospitals are down. There are no drugs. If you have money, you get treatment. Otherwise, you’ll die.”

The conflict in Yemen is between Houthi rebels controlling the capital Sana’a, who are allied with former president Ali Abdullah Saleh, who led the country from 1990 to 2012, and forces loyal to the ousted president, Abd-Rabbu Mansour Hadi. Since March 2015, Saudi Arabia has led a US-backed military intervention in Yemen, aimed at reinstating Hadi, who lives in exile in the Saudi capital, Riyadh, and countering advances of Iran-backed Houthis.

Yemen expert Adam Baron, speaking to the Guardian, said “the key thing to remember is that while combat deaths continue to get more attention, it is the indirect results of the conflict – things like the cholera outbreak, the hunger crisis and the rise of deaths from preventable disease – that remain the largest killers.”

While Houthis have taken some significant losses this year, Baron said the conflict has largely seen a continued stalemate on most key fronts. “By and large, the war in Yemen continues to flare,” he said. “Airstrikes and shelling continue as civilians continue to get caught in the crossfire. But even as the conflict proves to be the catalyst for the collapse of Yemen’s already weakened healthcare system, the country continues to get little attention. The worry is that this won’t change until it’s far too late.”

According to the World Health Organization, suspected cholera cases have been reported in 95.6% of Yemen governorates. Apart from Hajjah, the other three affected areas are Amanat al-Asimah, al-Hudaydah and Amran. Only 45% of health facilities in Yemen remain with limited functionality, the UN has said.

Aid workers warn of ‘devastating’ cholera outbreak in South Sudan

Doctors, aid workers and officials in South Sudan are warning of a “devastating” outbreak of cholera that could kill thousands of people in a country where millions are already threatened by famine.

More than 2,500 cases of the disease have been registered since April, a sharp increase over previous months. The total over the last year has now risen to 8,000, with about 250 confirmed deaths. Experts say this is likely to be only a fraction of overall toll.

With no sign that conflict in the world’s youngest country will abate soon, and with the population weakened by years of displacement and malnutrition, there are fears that cholera could spread out of control.

Medical staff fear an outbreak in hospitals. There are few functioning medical institutions in South Sudan and these often care for three or four times the number of patients they were designed to accommodate.

At al-Shabbah children’s hospital in Juba, where a single bed is shared between three patients, three cases of suspected cholera were reported last week. “The fear is that such an infectious disease in this very overcrowded hospital could be devastating. The children are very weak and we don’t have enough drugs. The demand is huge,” said Dr Felix Nyungura, director of the hospital.

More than 200,000 people are living in “protection of civilian camps” set up by the UN to provide a haven for those displaced by the ongoing fighting across much of South Sudan. They too are threatened by the disease, which can kill in hours.

“Last year we had cholera incidents in the camp and now the rainy season is here cholera is the big concern,” said Thomas Makur, an administrator of a camp where more than 30,000 people live adjacent to the principal UN base in Juba, the capital.

People displaced by recent fighting are at most risk. The international NGO Médicins Sans Frontières has opened a cholera treatment centre near Pieri in the remote north-east of South Sudan.

More than 27,000 people have fled their homes in the region since mid-February after clashes between the Sudan People’s Liberation Army (SPLA) and opposition groups.

South Sudan map

Last week the UN said the number of people struggling to find enough food each day in South Sudan had grown to 6 million – up from 4.9 million in February. This was the highest level of food insecurity in the country since it gained independence from Sudan in 2011 after decades of intermittent conflict.

Though South Sudan has suffered drought, the crisis has political rather than climatic causes. Violence surged last year after a peace deal between President Salva Kiir and his rival Riek Machar collapsed. Machar has now fled the country, but groups loyal to him continue to fight government forces. The government’s authority is limited, with widespread and increasingly chaotic conflict between local factions, cattle raiding and armed robbery.

Almost all protagonists in the fighting have been repeatedly accused of systematic and extensive human rights abuses.

There is a strong ethnic dimension to the violence, with civilians frequently targeted because of their tribe. Kiir and Machar come from rival ethnic groups. Civilians who have fled the violence to neighbouring countries say government troops, mostly drawn from Kiir’s Dinka tribe, carry out killings and other crimes against Machar’s Nuer and other smaller tribes suspected of supporting rebels.

A UN report last year described evidence of widespread atrocities against civilians including massacres, gang rape, abduction of children, unlawful detention and torture. The government has rejected its findings.

Senior UN officials say the combination of violence, ethnic strife, lack of development, climatic factors and international neglect in South Sudan is unmatched anywhere in the world.

“There are dead ends all around … I think we can still do something but we desperately need international pressure on the parties to go back to the table and be serious about peace,” Filippo Grandi, the head of the UN high commission for refugees, said last week.

Aid workers were struggling to raise funds, partly because of frustrations over the lack of progress in peace talks and partly because the scale of the problem was hidden, Grandi said during a visit to Juba.

“They [South Sudan’s refugees] don’t arrive on the shores of Europe, or Australia or at the border between Mexico and the US. Those are the places where refugees become visible and their voices are heard,” he said.

In an interview with the Guardian, David Shearer, the top UN official in South Sudan, underlined the logistical problems of operating in the country.

“No one quite realises the logistical hassles of this place. You can’t even move around. Travelling the 600 miles … takes two and a half weeks. In the wet season the roads are just impassable. There are 220 kilometres of tarmac roads in a country the size of France,” Shearer said.

More than 2 million people have fled South Sudan, with more than a million now living in neighbouring Uganda.

Aid workers warn of ‘devastating’ cholera outbreak in South Sudan

Doctors, aid workers and officials in South Sudan are warning of a “devastating” outbreak of cholera that could kill thousands of people in a country where millions are already threatened by famine.

More than 2,500 cases of the disease have been registered since April, a sharp increase over previous months. The total over the last year has now risen to 8,000, with about 250 confirmed deaths. Experts say this is likely to be only a fraction of overall toll.

With no sign that conflict in the world’s youngest country will abate soon, and with the population weakened by years of displacement and malnutrition, there are fears that cholera could spread out of control.

Medical staff fear an outbreak in hospitals. There are few functioning medical institutions in South Sudan and these often care for three or four times the number of patients they were designed to accommodate.

At al-Shabbah children’s hospital in Juba, where a single bed is shared between three patients, three cases of suspected cholera were reported last week. “The fear is that such an infectious disease in this very overcrowded hospital could be devastating. The children are very weak and we don’t have enough drugs. The demand is huge,” said Dr Felix Nyungura, director of the hospital.

More than 200,000 people are living in “protection of civilian camps” set up by the UN to provide a haven for those displaced by the ongoing fighting across much of South Sudan. They too are threatened by the disease, which can kill in hours.

“Last year we had cholera incidents in the camp and now the rainy season is here cholera is the big concern,” said Thomas Makur, an administrator of a camp where more than 30,000 people live adjacent to the principal UN base in Juba, the capital.

People displaced by recent fighting are at most risk. The international NGO Médicins Sans Frontières has opened a cholera treatment centre near Pieri in the remote north-east of South Sudan.

More than 27,000 people have fled their homes in the region since mid-February after clashes between the Sudan People’s Liberation Army (SPLA) and opposition groups.

South Sudan map

Last week the UN said the number of people struggling to find enough food each day in South Sudan had grown to 6 million – up from 4.9 million in February. This was the highest level of food insecurity in the country since it gained independence from Sudan in 2011 after decades of intermittent conflict.

Though South Sudan has suffered drought, the crisis has political rather than climatic causes. Violence surged last year after a peace deal between President Salva Kiir and his rival Riek Machar collapsed. Machar has now fled the country, but groups loyal to him continue to fight government forces. The government’s authority is limited, with widespread and increasingly chaotic conflict between local factions, cattle raiding and armed robbery.

Almost all protagonists in the fighting have been repeatedly accused of systematic and extensive human rights abuses.

There is a strong ethnic dimension to the violence, with civilians frequently targeted because of their tribe. Kiir and Machar come from rival ethnic groups. Civilians who have fled the violence to neighbouring countries say government troops, mostly drawn from Kiir’s Dinka tribe, carry out killings and other crimes against Machar’s Nuer and other smaller tribes suspected of supporting rebels.

A UN report last year described evidence of widespread atrocities against civilians including massacres, gang rape, abduction of children, unlawful detention and torture. The government has rejected its findings.

Senior UN officials say the combination of violence, ethnic strife, lack of development, climatic factors and international neglect in South Sudan is unmatched anywhere in the world.

“There are dead ends all around … I think we can still do something but we desperately need international pressure on the parties to go back to the table and be serious about peace,” Filippo Grandi, the head of the UN high commission for refugees, said last week.

Aid workers were struggling to raise funds, partly because of frustrations over the lack of progress in peace talks and partly because the scale of the problem was hidden, Grandi said during a visit to Juba.

“They [South Sudan’s refugees] don’t arrive on the shores of Europe, or Australia or at the border between Mexico and the US. Those are the places where refugees become visible and their voices are heard,” he said.

In an interview with the Guardian, David Shearer, the top UN official in South Sudan, underlined the logistical problems of operating in the country.

“No one quite realises the logistical hassles of this place. You can’t even move around. Travelling the 600 miles … takes two and a half weeks. In the wet season the roads are just impassable. There are 220 kilometres of tarmac roads in a country the size of France,” Shearer said.

More than 2 million people have fled South Sudan, with more than a million now living in neighbouring Uganda.

Aid workers warn of ‘devastating’ cholera outbreak in South Sudan

Doctors, aid workers and officials in South Sudan are warning of a “devastating” outbreak of cholera that could kill thousands of people in a country where millions are already threatened by famine.

More than 2,500 cases of the disease have been registered since April, a sharp increase over previous months. The total over the last year has now risen to 8,000, with about 250 confirmed deaths. Experts say this is likely to be only a fraction of overall toll.

With no sign that conflict in the world’s youngest country will abate soon, and with the population weakened by years of displacement and malnutrition, there are fears that cholera could spread out of control.

Medical staff fear an outbreak in hospitals. There are few functioning medical institutions in South Sudan and these often care for three or four times the number of patients they were designed to accommodate.

At al-Shabbah children’s hospital in Juba, where a single bed is shared between three patients, three cases of suspected cholera were reported last week. “The fear is that such an infectious disease in this very overcrowded hospital could be devastating. The children are very weak and we don’t have enough drugs. The demand is huge,” said Dr Felix Nyungura, director of the hospital.

More than 200,000 people are living in “protection of civilian camps” set up by the UN to provide a haven for those displaced by the ongoing fighting across much of South Sudan. They too are threatened by the disease, which can kill in hours.

“Last year we had cholera incidents in the camp and now the rainy season is here cholera is the big concern,” said Thomas Makur, an administrator of a camp where more than 30,000 people live adjacent to the principal UN base in Juba, the capital.

People displaced by recent fighting are at most risk. The international NGO Médicins Sans Frontières has opened a cholera treatment centre near Pieri in the remote north-east of South Sudan.

More than 27,000 people have fled their homes in the region since mid-February after clashes between the Sudan People’s Liberation Army (SPLA) and opposition groups.

South Sudan map

Last week the UN said the number of people struggling to find enough food each day in South Sudan had grown to 6 million – up from 4.9 million in February. This was the highest level of food insecurity in the country since it gained independence from Sudan in 2011 after decades of intermittent conflict.

Though South Sudan has suffered drought, the crisis has political rather than climatic causes. Violence surged last year after a peace deal between President Salva Kiir and his rival Riek Machar collapsed. Machar has now fled the country, but groups loyal to him continue to fight government forces. The government’s authority is limited, with widespread and increasingly chaotic conflict between local factions, cattle raiding and armed robbery.

Almost all protagonists in the fighting have been repeatedly accused of systematic and extensive human rights abuses.

There is a strong ethnic dimension to the violence, with civilians frequently targeted because of their tribe. Kiir and Machar come from rival ethnic groups. Civilians who have fled the violence to neighbouring countries say government troops, mostly drawn from Kiir’s Dinka tribe, carry out killings and other crimes against Machar’s Nuer and other smaller tribes suspected of supporting rebels.

A UN report last year described evidence of widespread atrocities against civilians including massacres, gang rape, abduction of children, unlawful detention and torture. The government has rejected its findings.

Senior UN officials say the combination of violence, ethnic strife, lack of development, climatic factors and international neglect in South Sudan is unmatched anywhere in the world.

“There are dead ends all around … I think we can still do something but we desperately need international pressure on the parties to go back to the table and be serious about peace,” Filippo Grandi, the head of the UN high commission for refugees, said last week.

Aid workers were struggling to raise funds, partly because of frustrations over the lack of progress in peace talks and partly because the scale of the problem was hidden, Grandi said during a visit to Juba.

“They [South Sudan’s refugees] don’t arrive on the shores of Europe, or Australia or at the border between Mexico and the US. Those are the places where refugees become visible and their voices are heard,” he said.

In an interview with the Guardian, David Shearer, the top UN official in South Sudan, underlined the logistical problems of operating in the country.

“No one quite realises the logistical hassles of this place. You can’t even move around. Travelling the 600 miles … takes two and a half weeks. In the wet season the roads are just impassable. There are 220 kilometres of tarmac roads in a country the size of France,” Shearer said.

More than 2 million people have fled South Sudan, with more than a million now living in neighbouring Uganda.

Aid workers warn of ‘devastating’ cholera outbreak in South Sudan

Doctors, aid workers and officials in South Sudan are warning of a “devastating” outbreak of cholera that could kill thousands of people in a country where millions are already threatened by famine.

More than 2,500 cases of the disease have been registered since April, a sharp increase over previous months. The total over the last year has now risen to 8,000, with about 250 confirmed deaths. Experts say this is likely to be only a fraction of overall toll.

With no sign that conflict in the world’s youngest country will abate soon, and with the population weakened by years of displacement and malnutrition, there are fears that cholera could spread out of control.

Medical staff fear an outbreak in hospitals. There are few functioning medical institutions in South Sudan and these often care for three or four times the number of patients they were designed to accommodate.

At al-Shabbah children’s hospital in Juba, where a single bed is shared between three patients, three cases of suspected cholera were reported last week. “The fear is that such an infectious disease in this very overcrowded hospital could be devastating. The children are very weak and we don’t have enough drugs. The demand is huge,” said Dr Felix Nyungura, director of the hospital.

More than 200,000 people are living in “protection of civilian camps” set up by the UN to provide a haven for those displaced by the ongoing fighting across much of South Sudan. They too are threatened by the disease, which can kill in hours.

“Last year we had cholera incidents in the camp and now the rainy season is here cholera is the big concern,” said Thomas Makur, an administrator of a camp where more than 30,000 people live adjacent to the principal UN base in Juba, the capital.

People displaced by recent fighting are at most risk. The international NGO Médicins Sans Frontières has opened a cholera treatment centre near Pieri in the remote north-east of South Sudan.

More than 27,000 people have fled their homes in the region since mid-February after clashes between the Sudan People’s Liberation Army (SPLA) and opposition groups.

South Sudan map

Last week the UN said the number of people struggling to find enough food each day in South Sudan had grown to 6 million – up from 4.9 million in February. This was the highest level of food insecurity in the country since it gained independence from Sudan in 2011 after decades of intermittent conflict.

Though South Sudan has suffered drought, the crisis has political rather than climatic causes. Violence surged last year after a peace deal between President Salva Kiir and his rival Riek Machar collapsed. Machar has now fled the country, but groups loyal to him continue to fight government forces. The government’s authority is limited, with widespread and increasingly chaotic conflict between local factions, cattle raiding and armed robbery.

Almost all protagonists in the fighting have been repeatedly accused of systematic and extensive human rights abuses.

There is a strong ethnic dimension to the violence, with civilians frequently targeted because of their tribe. Kiir and Machar come from rival ethnic groups. Civilians who have fled the violence to neighbouring countries say government troops, mostly drawn from Kiir’s Dinka tribe, carry out killings and other crimes against Machar’s Nuer and other smaller tribes suspected of supporting rebels.

A UN report last year described evidence of widespread atrocities against civilians including massacres, gang rape, abduction of children, unlawful detention and torture. The government has rejected its findings.

Senior UN officials say the combination of violence, ethnic strife, lack of development, climatic factors and international neglect in South Sudan is unmatched anywhere in the world.

“There are dead ends all around … I think we can still do something but we desperately need international pressure on the parties to go back to the table and be serious about peace,” Filippo Grandi, the head of the UN high commission for refugees, said last week.

Aid workers were struggling to raise funds, partly because of frustrations over the lack of progress in peace talks and partly because the scale of the problem was hidden, Grandi said during a visit to Juba.

“They [South Sudan’s refugees] don’t arrive on the shores of Europe, or Australia or at the border between Mexico and the US. Those are the places where refugees become visible and their voices are heard,” he said.

In an interview with the Guardian, David Shearer, the top UN official in South Sudan, underlined the logistical problems of operating in the country.

“No one quite realises the logistical hassles of this place. You can’t even move around. Travelling the 600 miles … takes two and a half weeks. In the wet season the roads are just impassable. There are 220 kilometres of tarmac roads in a country the size of France,” Shearer said.

More than 2 million people have fled South Sudan, with more than a million now living in neighbouring Uganda.

Aid workers warn of ‘devastating’ cholera outbreak in South Sudan

Doctors, aid workers and officials in South Sudan are warning of a “devastating” outbreak of cholera that could kill thousands of people in a country where millions are already threatened by famine.

More than 2,500 cases of the disease have been registered since April, a sharp increase over previous months. The total over the last year has now risen to 8,000, with about 250 confirmed deaths. Experts say this is likely to be only a fraction of overall toll.

With no sign that conflict in the world’s youngest country will abate soon, and with the population weakened by years of displacement and malnutrition, there are fears that cholera could spread out of control.

Medical staff fear an outbreak in hospitals. There are few functioning medical institutions in South Sudan and these often care for three or four times the number of patients they were designed to accommodate.

At al-Shabbah children’s hospital in Juba, where a single bed is shared between three patients, three cases of suspected cholera were reported last week. “The fear is that such an infectious disease in this very overcrowded hospital could be devastating. The children are very weak and we don’t have enough drugs. The demand is huge,” said Dr Felix Nyungura, director of the hospital.

More than 200,000 people are living in “protection of civilian camps” set up by the UN to provide a haven for those displaced by the ongoing fighting across much of South Sudan. They too are threatened by the disease, which can kill in hours.

“Last year we had cholera incidents in the camp and now the rainy season is here cholera is the big concern,” said Thomas Makur, an administrator of a camp where more than 30,000 people live adjacent to the principal UN base in Juba, the capital.

People displaced by recent fighting are at most risk. The international NGO Médicins Sans Frontières has opened a cholera treatment centre near Pieri in the remote north-east of South Sudan.

More than 27,000 people have fled their homes in the region since mid-February after clashes between the Sudan People’s Liberation Army (SPLA) and opposition groups.

South Sudan map

Last week the UN said the number of people struggling to find enough food each day in South Sudan had grown to 6 million – up from 4.9 million in February. This was the highest level of food insecurity in the country since it gained independence from Sudan in 2011 after decades of intermittent conflict.

Though South Sudan has suffered drought, the crisis has political rather than climatic causes. Violence surged last year after a peace deal between President Salva Kiir and his rival Riek Machar collapsed. Machar has now fled the country, but groups loyal to him continue to fight government forces. The government’s authority is limited, with widespread and increasingly chaotic conflict between local factions, cattle raiding and armed robbery.

Almost all protagonists in the fighting have been repeatedly accused of systematic and extensive human rights abuses.

There is a strong ethnic dimension to the violence, with civilians frequently targeted because of their tribe. Kiir and Machar come from rival ethnic groups. Civilians who have fled the violence to neighbouring countries say government troops, mostly drawn from Kiir’s Dinka tribe, carry out killings and other crimes against Machar’s Nuer and other smaller tribes suspected of supporting rebels.

A UN report last year described evidence of widespread atrocities against civilians including massacres, gang rape, abduction of children, unlawful detention and torture. The government has rejected its findings.

Senior UN officials say the combination of violence, ethnic strife, lack of development, climatic factors and international neglect in South Sudan is unmatched anywhere in the world.

“There are dead ends all around … I think we can still do something but we desperately need international pressure on the parties to go back to the table and be serious about peace,” Filippo Grandi, the head of the UN high commission for refugees, said last week.

Aid workers were struggling to raise funds, partly because of frustrations over the lack of progress in peace talks and partly because the scale of the problem was hidden, Grandi said during a visit to Juba.

“They [South Sudan’s refugees] don’t arrive on the shores of Europe, or Australia or at the border between Mexico and the US. Those are the places where refugees become visible and their voices are heard,” he said.

In an interview with the Guardian, David Shearer, the top UN official in South Sudan, underlined the logistical problems of operating in the country.

“No one quite realises the logistical hassles of this place. You can’t even move around. Travelling the 600 miles … takes two and a half weeks. In the wet season the roads are just impassable. There are 220 kilometres of tarmac roads in a country the size of France,” Shearer said.

More than 2 million people have fled South Sudan, with more than a million now living in neighbouring Uganda.

Aid workers warn of ‘devastating’ cholera outbreak in South Sudan

Doctors, aid workers and officials in South Sudan are warning of a “devastating” outbreak of cholera that could kill thousands of people in a country where millions are already threatened by famine.

More than 2,500 cases of the disease have been registered since April, a sharp increase over previous months. The total over the last year has now risen to 8,000, with about 250 confirmed deaths. Experts say this is likely to be only a fraction of overall toll.

With no sign that conflict in the world’s youngest country will abate soon, and with the population weakened by years of displacement and malnutrition, there are fears that cholera could spread out of control.

Medical staff fear an outbreak in hospitals. There are few functioning medical institutions in South Sudan and these often care for three or four times the number of patients they were designed to accommodate.

At al-Shabbah children’s hospital in Juba, where a single bed is shared between three patients, three cases of suspected cholera were reported last week. “The fear is that such an infectious disease in this very overcrowded hospital could be devastating. The children are very weak and we don’t have enough drugs. The demand is huge,” said Dr Felix Nyungura, director of the hospital.

More than 200,000 people are living in “protection of civilian camps” set up by the UN to provide a haven for those displaced by the ongoing fighting across much of South Sudan. They too are threatened by the disease, which can kill in hours.

“Last year we had cholera incidents in the camp and now the rainy season is here cholera is the big concern,” said Thomas Makur, an administrator of a camp where more than 30,000 people live adjacent to the principal UN base in Juba, the capital.

People displaced by recent fighting are at most risk. The international NGO Médicins Sans Frontières has opened a cholera treatment centre near Pieri in the remote north-east of South Sudan.

More than 27,000 people have fled their homes in the region since mid-February after clashes between the Sudan People’s Liberation Army (SPLA) and opposition groups.

South Sudan map

Last week the UN said the number of people struggling to find enough food each day in South Sudan had grown to 6 million – up from 4.9 million in February. This was the highest level of food insecurity in the country since it gained independence from Sudan in 2011 after decades of intermittent conflict.

Though South Sudan has suffered drought, the crisis has political rather than climatic causes. Violence surged last year after a peace deal between President Salva Kiir and his rival Riek Machar collapsed. Machar has now fled the country, but groups loyal to him continue to fight government forces. The government’s authority is limited, with widespread and increasingly chaotic conflict between local factions, cattle raiding and armed robbery.

Almost all protagonists in the fighting have been repeatedly accused of systematic and extensive human rights abuses.

There is a strong ethnic dimension to the violence, with civilians frequently targeted because of their tribe. Kiir and Machar come from rival ethnic groups. Civilians who have fled the violence to neighbouring countries say government troops, mostly drawn from Kiir’s Dinka tribe, carry out killings and other crimes against Machar’s Nuer and other smaller tribes suspected of supporting rebels.

A UN report last year described evidence of widespread atrocities against civilians including massacres, gang rape, abduction of children, unlawful detention and torture. The government has rejected its findings.

Senior UN officials say the combination of violence, ethnic strife, lack of development, climatic factors and international neglect in South Sudan is unmatched anywhere in the world.

“There are dead ends all around … I think we can still do something but we desperately need international pressure on the parties to go back to the table and be serious about peace,” Filippo Grandi, the head of the UN high commission for refugees, said last week.

Aid workers were struggling to raise funds, partly because of frustrations over the lack of progress in peace talks and partly because the scale of the problem was hidden, Grandi said during a visit to Juba.

“They [South Sudan’s refugees] don’t arrive on the shores of Europe, or Australia or at the border between Mexico and the US. Those are the places where refugees become visible and their voices are heard,” he said.

In an interview with the Guardian, David Shearer, the top UN official in South Sudan, underlined the logistical problems of operating in the country.

“No one quite realises the logistical hassles of this place. You can’t even move around. Travelling the 600 miles … takes two and a half weeks. In the wet season the roads are just impassable. There are 220 kilometres of tarmac roads in a country the size of France,” Shearer said.

More than 2 million people have fled South Sudan, with more than a million now living in neighbouring Uganda.