Fieldset
"They all had gunshot wounds": Emergency mode in South Sudan

When violence erupted in Pieri, South Sudan, killing 200 people and wounding 300 more, the MSF team at nearby Lankien hospital braced for a wave of severely injured patients. Medical team leader Istifanus Chindong Damulak shares his personal account of this traumatic time.

“My wife has just given birth this morning and is still in the health facility. All the staff are now on the run to the bush for safety. I can see smoke from the burnt huts just across the airstrip.”

These were the first words I heard from our MSF health facility supervisor. It was 16 May and 6am – an unusual time for our regular daily call.

I knew before I picked up that this was an emergency situation.

An eruption of violence

He told me that violence had erupted in Pieri, a town about 50 km south of where I'm based, at the hospital in Lankien. By 7 am, the news had spread.

We [would] remain in emergency mode, prepared to react at any moment in the day, when the injured would inevitably arrive at our hospital

From the hospital window, where the local authority office is just opposite, I saw military trucks loading several hundred armed youths as they headed for Pieri.

The safety of the team in Pieri was my biggest concern. I had been there recently, and had only returned to Lankien a week earlier. What would happen to our staff who live there? Run to the bush? How? Where? There's no bunker in Pieri.

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Istifanus Chindong Damulak is the medical team leader at MSF's hospital in Lankien, South Sudan
Istifanus Chindong Damulak is the medical team leader at MSF's hospital in Lankien, South Sudan

Having been through this only two months earlier, I knew we had to prepare for the worst. I called an emergency meeting and updated all the MSF team – both medical and non-medical – that our mass casualty plan was being activated.

I told them we should remain in emergency mode, prepared to react at any moment in the day, because the injured would inevitably arrive at our hospital.

Conflict and COVID-19

But, this time it was different to the violence we saw two months ago. Now the COVID-19 pandemic had reached South Sudan.

I noticed straight away six injured patients, all with several gunshot wounds lying on the ER floor. I checked outside and I saw three military trucks fully packed with injured patients. Everyone was shouting for help.

I was thinking immediately how I could ensure physical distancing whilst the team responded to a large number of casualties at once. I knew full well we had confirmed coronavirus patients in Lankien and that there was very likely already community transmission. 

What came to mind immediately was to order enough surgical masks and other protective equipment for the entire staff who would be involved in caring for the injured people.

The ER

At 9 pm that night, I was called to the ER (emergency room). They had received some casualties. I went quickly.

I noticed straight away six injured patients, all with several gunshot wounds, lying on the ER floor. I checked outside and saw three military trucks fully packed with injured patients. Everyone was shouting for help.

Within a few minutes the ER was full with staff – most of whom had already finished for the day. We received 20 patients at once, all men with gunshot wounds, many with severe injuries.

One patient died on arrival and another with a gunshot wound through the chest died 20 minutes later, during a blood transfusion. Of the patients who were admitted, only two were well enough to be discharged that night.

Injured staff

Over the next days – from 16-20 May – people who'd been injured in the violence continuted to arrive at the hospital. Our team treated 63 people in total, including two of our team members. All had gunshot wounds.

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Facilities at the 80-bed hospital in Lankien, before the mass casualty event in Pieri
Facilities at the 80-bed hospital in Lankien, before the mass casualty event in Pieri

Two days into the violence, some of the staff who had fled the situation in Pieri started to return to Lankien. Incredibly they went straight to work. They received and treated an additional 19 people with gunshot wounds.

One of them shared their own experience from Pieri:

“My mother is old and she stayed with small children in Pieri. She cannot run. I went to save her, but I was ambushed. Several people were shot dead in front of me.

"I was trying to help some of the injured with first aid when someone told me I was bleeding. I had sustained two gunshot wounds. I was bleeding too much. I gave up, believing that I was going to die.”

The aftermath

Even after the violence had subsided, we still continued to receive patients days later, many with septic wounds from abdominal gunshot injuries.

I felt very emotional and helpless at some points, because our hospital is not equipped to do the kinds of surgeries these patients needed. Normally we would refer patients to another facility, but all referral options were closed. With COVID-19 community transmission concerns, it was incredibly hard to refer patients. I saw our patients with abdominal wounds deteriorating and I couldn’t do anything to help.    

I knew full well that they all needed to be on a stretchers, but the stretchers would take up more space on the plane 

Over 200 people died in this latest wave of violence. An estimated 300 more were injured.

For our team it was also very personal, with one of our team members killed in the violence. I had been with him just a week earlier and now he was gone. It was – and still is – incredibly traumatic for the team in Pieri.

The Pieri team is like one family, they are a community and very committed. It will take some time for this pain of losing a team member to ease.

Return to Pieri

I went to Pieri five days after the attack. The town was empty, with only a few men and young people around.

It felt like a ghost town. Every woman and child was still in the bush, wary of another outbreak of violence.

Some of our staff approached me. This is some of what they told me:

  • "I am scared, I lost all my friends in the town. I can’t sleep at night. I felt better at work but once I am at home I am scared.”
     
  • Last week I lost my uncle, someone shot and killed him. This week my older brother was killed in this attack. Now I am alone, there is nobody to help me.”
     
  • "My tukul was burned, I lost everything. I only escaped with these clothes. There is no market now to buy anything, all the traders were killed defending their shops.”
     
  • “I grew up in Kenya, I just came back because of this job. I have never seen something like this in my life. I ran for six hours in the bush. I lost my shoes, my legs are swollen and painful now. I want to leave.”

It’s hard to deal with these events.

I won't forget

I cannot forget the moment I fastened the seatbelt around the eighth patient on a tiny plane, all with severe abdominal gunshot wounds.

Although referrals were incredibly difficult, we'd been able to get agreement for this one. The patients were being airlifted to another hospital.

I knew full well that normally these patients would be on stretchers, not in seats. But the stretchers would take up more space on the plane, which would mean we would have to reduce the number of people being evacuated, with no guarantees of any other flight.

I won't forget that moment.

But then there was the moment we welcomed back these same patients to Lankien, all discharged after successful treatment, all having recovered.

I won't forget that either.

Update: The situation in Pieri

Waves of clashes in Jonglei State and the Greater Pibor Administrative area in eastern South Sudan continue to have a devastating impact on people living here.

This month, thousands of people have fled into the bush as intense fighting over several days, which started on 15 June, yet again threatens the lives of entire communities.

The new and brutal rise in violence has led MSF to suspend our medical activities in Pibor after most of our staff sought safety in the remote bush area.

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