“OUR HEARTS HAVE GONE DARK”€¦ · OUR HEARTS HAVE GONE DARK THE MENTAL HEALTH IMPACT OF SOUTH...

THE MENTAL HEALTH IMPACT OF SOUTH SUDAN’S CONFLICT

“OUR HEARTS HAVE GONE DARK”

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First published in 2016 by Amnesty International Ltd Peter Benenson House, 1 Easton Street London WC1X 0DW, UK

Index: AFR 65/3203/2016 Original language: English Printed by Amnesty International, International Secretariat, UK

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Cover photo: Military tank in Upper Nile state, South Sudan, 2009. ©Tim McCulka

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AMNESTY INTERNATIONAL

OUR HEARTS HAVE GONE DARK THE MENTAL HEALTH IMPACT OF SOUTH SUDAN’S CONFLICT

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. SURVIVORS SPEAK OF TRAUMA 19

“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. SOUTH SUDAN’S LEGAL OBLIGATIONS 44

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. THE WAY FORWARD 51

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,socialisolation,inactivity,difficultywiththinkingandconcentration,asignificantincreaseordecreaseinappetiteandtimespentsleeping,feelingsofdejectionandhopelessness,increasedirritability,and/orsuicidalthoughtsorattemptstocommitsuicide.

MENTAL HEALTH TheWorldHealthOrganization(WHO)definesmentalhealthas“astateofwell-beinginwhichanindividualrealizeshisorherownabilities,cancopewiththenormalstressesoflife,canworkproductivelyandisabletomakeacontributiontohisorhercommunity.”

MENTAL HEALTH DISORDER OR CONDITION Amedicallydefinedconditionassociatedwithpainordistressthatnegativelyimpactsaperson’sthinking,feeling,ormoodandaffectshisorherabilitytorelatetoothersandfunctiononadailybasis.

MENTAL HEALTH SERVICES Themeansbywhichinterventionsformentalhealthcarearedelivered.Thisincludesoutpatientfacilities,mentalhealthdaytreatmentfacilities,psychiatricwardsinageneralhospital,communitymentalhealthteams,supportedhousinginthecommunity,andmentalhospitals.Itincludesnon-biological(alsoreferredtoaspsychosocialsupport,treatmentorrehabilitation)orclinicalinterventionstosupportpsychosocialwell-being,alsoreferredtoaspsychosocialsupportservices.Itmayalsoincludetraditionalorreligioushealingpractices.

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MENTAL OR PSYCHOLOGICAL DISTRESS Atermusedtodescribearangeofpsychiatricsymptoms,suchassadness,anxiety,rageanddepression,thataretroubling,confusingordisruptactivitiesofdailyliving.Mentalorpsychologicaldistressisbroaderinscopethanmentalhealthdisordersorconditions,inthatapersonmayexhibitsymptomsofpsychologicaldistresswithoutreachingthethresholdofsufferingfromanymedicallydefineddisorderorcondition.

POST-TRAUMATIC STRESS DISORDER (PTSD) Aclinicalmentaldisorderthatarisesafterexperiencingorwitnessingaverystressful,frightening,ordistressingevent.AnindividualsufferingfromPTSDexhibits:1)intrusivesymptomssuchasnightmaresandflashbacks,2)avoidanceofreminders—suchasthoughts,feelings,people,andplaces—associatedwiththetrauma,3)negativechangestothoughts—suchasnegativebeliefsaboutoneselforothers,self-blame,anger,shameguiltorfear,and4)changesinphysiologyandreactivity—suchasirritability,aggression,recklessbehaviour,poorconcentrationandsleepissues.Symptomsmustbepresentformorethanonemonthandcreatesignificantdistress/impairmenttodailyfunctioning.

PROTECTION OF CIVILIANS (POC) SITE Camp-likesettlementforinternallydisplacedpeopleestablishedwithinexistingUnitedNationsMissioninSouthSudan(UNMISS)compoundsandguardedbyUNpeacekeepers.

PSYCHOSOCIAL SUPPORT SERVICES Subsetofmentalhealthinterventionswhicharegenerallynon-biologicalornon-clinicalinnatureandincludehelpwithsocial,emotional,psychologicalandpracticalneeds.

PSYCHOLOGICAL TRAUMA Adistressingemotionalresponseresultingfromexperiencingorwitnessingaverystressful,frighteningordistressingevent,inwhichaperson’scapacitytocopeand/orintegratehisemotionalexperienceisoverwhelmed.

PSYCHOSIS Aseriousmentaldisordercharacterizedbydefectiveorlostcontactwithreality,ofteninvolvinghallucinationsordelusions.

TRAUMATISED Atermusedinthisreporttodescribeindividualsexperiencinglonger-termpsychologicaldistressasaresultofexperiencingaverystressful,frighteningordistressingeventandwhosecapacitytocopeisoverwhelmedandabilitytomanagedailylifeactivitiesiscompromised.

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1. EXECUTIVE SUMMARY

PartiestoSouthSudan’sinternalarmedconflictthateruptedinDecember2013haveviolatedinternationalhumanrightsandhumanitarianlaw,withadevastatingimpactoncivilianpopulations.BoththeGovernmentofSouthSudanandtheSudanPeople’sLiberationMovement/Army-InOpposition(SPLM/A-IO),togetherwiththeirrespectivealliedforces,deliberatelyattackedandkilledcivilians,abductedandrapedwomen,committedactsoftorture,destroyedandlootedcivilianproperty,andattackedhumanitarianpersonnelandassets.Suchactshaveledtoanunknownnumberofdeaths,physicalinjuries,thedisplacementofovertwomillionpeople,lossoflivelihoods,andhighlevelsoffoodinsecurity.Theyhavealsohadlessvisible,butnolesssignificant,repercussionsonpeople’smentalhealth—thestateofemotionalandpsychologicalwellbeinginwhichindividualscanrealizetheirpotential,copewiththenormalstressesoflife,workproductively,andbeactivemembersoftheircommunity.

ThisreportdescribestheseriousandsignificantmentalhealthimpactofSouthSudan’sconflicttohighlighttheurgencyformoreattentionandresourcestoimprovetheavailability,accessibility,andqualityofmentalhealthservicesinthecountry.Itisbasedoninterviewswith161internallydisplacedpeoplelivinginUnitedNationsMissioninSouthSudan(UNMISS)ProtectionofCivilians(PoC)sitesinJuba,MalakalandBentiuandinaninformalsettlementatMahadSchoolinJuba.AmnestyInternationalresearchersalsointerviewedgovernmentandUNofficials,donors,representativesofnon-governmentalorganizations(NGOs),andinternationalandSouthSudanesementalhealthprofessionals—includingpsychiatrists,psychologistsandpsychosocialworkers.

InternallydisplacedSouthSudaneseimpactedbytheconflictdescribedexperiencingarangeofsymptomscommonlyassociatedwithmentalhealthdisorderssuchaspost-traumaticstressdisorder(PTSD)anddepression—havingnightmares,gettingangryeasily,feelingunabletoconcentrate,andconsideringsuicide.Manyspokeofheadaches,stomachpains,backaches,andheartpalpitations—commonphysicalmanifestationsofpsychologicalstress.Theyalsotoldoffeelingunabletowork,study,carryoutbasicdailytasks,careforchildren,ormaintainrelationshipswithfriendsandfamily.Theyattributedthesemental,physical,emotional,relational,andspiritualimpactstotheirexperiencesasvictimsof,orwitnessesto,torture,arbitrarydetention,sexualviolence,killing,andforceddisplacement.

ThedirementalhealthsituationinSouthSudanisnotsurprising.Studiesinconflict-affectedregionsacrosstheworldhaveconsistentlydemonstratedthatarmedconflicthasaseriousnegativeimpactonmentalhealth.Duetoarmedconflict,peoplearemorelikelytosufferarangeofmentalhealthissues:aminoritywilldevelopnewanddebilitatingmentaldisorders,manyotherswillexperiencepsychologicaldistress,andthosewithpre-existingmentaldisordersoftenwillneedmorehelpthanbefore.TheWorldHealthOrganization(WHO)estimatesthatinsituationsofarmedconflictandotheremergencies,theproportionofthepopulationsufferingfrommildormoderatementaldisordersrisesfromapproximately10%to15-20%.

InSouthSudan,decadesofconflicthaveleftalegacyofpsychologicaldistress.TherenewedviolencesinceDecember2013hasfurtherexacerbatedthesituation.Whiletherearenoofficialnational

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statisticsonmentalhealth,theDirectoroftheMinistryofHealth’sDepartmentofMentalHealthacknowledgedthattherehasbeenanincreaseinthenumberofpatientswithmentalhealthconditionssincethestartoftheconflict.Thisconclusionisreinforcedbyindependentresearch.A2015studybytheSouthSudanLawSociety(SSLS)andtheUnitedNationsDevelopmentProgramme(UNDP)foundthat41%of1,525respondentsacrosssixstatesandAbyeiexhibitedsymptomsconsistentwithadiagnosisofPTSD.A2015surveybySSLSinMalakalPoCsitefoundthat53%ofrespondentsexhibitedsymptomsconsistentwithadiagnosisofPTSD.TheAfricanUnionCommissionofInquiryonSouthSudan(AUCISS)notedinitsfinalreportthat“traumaappearstobeakeyconsequenceoftheconflict.”ThesefindingsareborneoutbyAmnestyInternational’sownresearch.

Theoverwhelmingmajorityofpeopleinterviewedwhowereexperiencingpsychologicaldistressfelttheywouldbenefitfrommentalhealthorpsychosocialsupportservicesandprogrammes,butfewhad.Intervieweesspokeofhowneighbours,friends,relativesandchurchmembersadvise,counsel,andcomfortthem,providingsomerelief.Conflictanddisplacementhave,however,severelyweakenedandstretchedthesetraditionalsupportnetworksandtheirabilitytohelppeoplecope.Oftenthepeopletowhomindividualsfacingdistresswouldturnforsupportareeitherabsentorarethemselvessufferingfromheavypsychologicalburdens.Peoplewithmentalhealthproblemsarealsosubjectedtosocialstigma,andfamilymembersgenerallyhavelimitedinformationaboutmentalhealthandtraumaorwhatconstitutesappropriatecareandtreatment.

Despitesignificantandwidespreadneeds,theavailabilityandaccessibilityofmentalhealthandpsychosocialsupportservicesinSouthSudanisextremelylimited.JubaTeachingHospital—theonlypublicmedicalfacilitythatprovidespsychiatriccare—hasonly12bedsinitspsychiatricward.Theavailabilityofpsychotropicdrugsisinconsistentandlimited.Thereareonlytwopractisingpsychiatristsinthecountry,bothofwhomareinJubaandneitherofwhomseespatientsonafull-timebasis.Asaresultofthelackofappropriateservicesandfacilities,peoplewithmentalhealthconditionsareroutinelyhousedinprisons,eveniftheyhavecommittednocrime.

ThoughSouthSudan’shealthsectorpoliciesandplanssince2006haverecognizedtheneedforimprovedmentalhealthservices,statedgoalshavenotbeenreached.Objectivesforincreasingthenumberoftrainedmentalhealthstaff,forexample,havenotbeenachieved.Mentalhealthserviceshavenotbeenintegratedintotheprimaryhealthcaresystem,andthereisnodedicatedmentalhealthpolicy,strategy,orlegislation.Partoftheproblemisexplainedbythegovernment’schronicunderinvestmentinhealthcaregenerally,anditsfailuretomakethefinancialcommitmentsnecessarytoimprovetheavailabilityandaccessibilityofmentalhealthservices.Thisismirroredbythefactthatinternationalassistanceandcooperationtothehealthsector,thoughsubstantial,hasoverlookedmentalhealth.

Inthiscontext,servicesprovidedbyinternationalNGOsareinsufficienttofillthegapandmeetthetremendousneedsofthepopulation.InJuba,Malakal,andBentiuPoCsites,someNGOsoffermentalhealthandpsychosocialsupportservices,buttheirinterventionsareinsufficientgiventhesizeofthepopulationstheyareintendedtoserve.Thereisaparticulargapintheavailabilityofspecializedmentalhealthservices,suchaspsychotherapy,grouptherapy,orpharmacologicintervention,forpeoplewithseverementaldisorders.Thereareonlyafewinternationalorganizationswithprogrammessupportingtheimprovementofmentalhealthserviceswithinthepublichealthsector.SomechurchesandsmallerNGOscarryoutcommunity-basedinterventionsthatseektoaddresstrauma,butthesearelimitedanduncoordinated.TheWHOofficeinJubahasnotprovidedsubstantialtechnicalorfinancialsupporttoexpandingmentalhealthservicesinSouthSudan.

SouthSudanhascommitteditselftorespect,protectandfulfilarangeofhumanrightsincludingtherighttohealthandhasassumedarangeofrelevantobligationsunderinternationallaw.ThisrequiresSouthSudantoensureaccesstomentalhealthservices;refrainfromactssuchastorturethatcausepsychologicalharm;andpreventsuchactsbythirdparties.SouthSudanmustalsoensurethatvictimsofserioushumanrightsorhumanitarianlawviolationsorabusesreceivecompensationformentalharmandrehabilitation,includingpsychologicalcare,infulfilmentoftheirrighttoreparations.AmnestyInternational’sfindingsleadtotheconclusionthatSouthSudanisfailingtoliveuptothesecommitmentsandobligations.

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Thegovernmentshouldurgentlyprioritiseguaranteeingaccesstoessentialmentalhealthcareandtreatment,includinginformationandservices.SouthSudanshouldworktoprovidementalhealthtreatmentthroughprimaryhealthcare;providecareatthecommunitylevel;makepsychotropicdrugsavailable;educatethepublic;establishnationalpolicies,programmesandlegislation;supportresearchandmonitoring;develophumanresources;increasefundingtomentalhealthservices;andmainstreammentalhealthinterventionsacrossothersectors.ThegovernmentshouldalsomakefinancialandprogrammaticcontributionstomentalhealthservicesinemergencysettingsandshouldfacilitateandencourageinternationalcooperationandsupportforimplementationoftheInter-AgencySteeringCommitteeGuidelines(IASC)onMentalHealthandPsychosocialSupportinEmergencySettings.

SouthSudanisfacingasevereeconomiccrisisduetohighinflationandasharpdeclineinnationaloilrevenuesasaresultofreducedproductionandadropininternationaloilprices.Eveninthischallengingcontext,therearestepsthegovernmentcouldtaketoimprovementalhealthservicesthatrequirepoliticalcommitmentmorethanfunds.Thedevelopmentofamentalhealthpolicyandlegislation,forexample,couldgoalongwaytowardsgalvanizinggreaterattentiontomentalhealthinSouthSudan.TheMinistryofHealthcouldalsomoreeffectivelyseekinternationalcooperationandassistancetosupportmentalhealthcareservicesbymakingspecificrequeststodonorsforsuchsupportandbyworkingwithdonorstoensurethatgeneralsupporttothehealthsectordoesnotneglectmentalhealthneeds.TheMinistryofHealthcouldalsocallonothergovernmentministries,internationaldonors,andNGOstomainstreammentalhealthandpsychosocialsupportinitiativesintoalldevelopmentandhumanitarianinterventions.

TheAgreementontheResolutionoftheCrisisinSouthSudan(ARCSS),signedbypartiestotheconflictinAugust2015,shouldsignaltheturningofanewpage.ThenewTransitionalGovernmentofNationalUnity(TGoNU)musttakestepstoendtheseriousviolationsandabusesofinternationalhumanrightsandhumanitarianlawthatcontinuetotraumatizethepeopleofSouthSudan,aswellasthelongstandingimpunityforsuchviolationsandabuses.Thegovernmentmustprovideallforceswithclearordersdetailingconductthatisprohibitedunderinternationallaw;establishmechanismstoadequatelymonitorconductofforces;andinitiateprompt,effectiveandimpartialinvestigationstobringthosecrediblysuspectedofcriminalresponsibilitytojustice.

TheARCSSoffersanimportantopportunityforfulfillingtherightofvictimstoreparations,includingcompensationandrehabilitationformentalharm.TheTGoNUshouldworkwiththeAUtoensurethespeedyestablishmentoftheHybridCourtforSouthSudan(HCSS),theCommissiononTruth,ReconciliationandHealing(CTRH),andtheCompensationandReparationsAuthority(CRA)providedforinthepeaceagreement.TheTGoNUshouldensurethesebodiesgiveappropriateconsiderationtothementalhealthconsequencesoftheconflictandtheresultingneedformentalhealthandpsychosocialsupportasanelementofindividualorcollectivereparationsprogrammesandinitiatives.

Internationalbodiesmustalsodotheirutmosttopreventanddeterfutureviolationsofhumanitarianlawandviolationsandabusesofinternationalhumanrightslaw.TheAUCommissionshouldquicklyestablishtheHCSStoinvestigateandprosecutegenocide,warcrimes,crimesagainsthumanity,andothercrimesunderinternationallawcommittedduringtheconflict,asrequiredintheAugust2015peaceagreement.TheUNSecurityCouncilshouldimposeacomprehensivearmsembargoonSouthSudanandtargetedsanctions,includingtravelbansandassetfreezes,againstcivilianandmilitaryofficialswhohaveengagedinviolationsofinternationalhumanitarianlawandviolationsandabusesofinternationalhumanrightslaw.

Doingmoretoaddressmentalhealthneedsisnotonlyessentialforindividualwell-being,itisalsocriticalforSouthSudanesetoeffectivelyrebuildtheircommunitiesandcountry.Poormentalhealthnegativelyimpactspeople’sabilitytocarryoutday-to-dayactivitiesandpursuelivelihoodsoreducation.Poormentalhealthamongparentsalsohasaninter-generationalimpactonchildhealth,development,andgrowth.Restoringmentalhealthcanplayavitalroleincontributingtosustainableeconomicgrowthandpovertyreduction.Thisisreflectedinthefactthat,inSeptember2015,theUNincludedmentalhealthasanelementofthenewglobalSustainableDevelopmentGoal(SDG)onhealth.

ManySouthSudaneseandinternationalobserversidentifypoormentalhealthasadestabilizingforcethathascontributedtoviolentbehaviouratfamily,community,andnationallevels—anobservation

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supportedbystudiesshowingthelinksbetweenpoormentalhealth,angeranddesireforrevenge.SouthSudan,togetherwiththeAU,theUNandotherinternationalpartners,mustthereforeprioritizeeffortstohealthethousandsofSouthSudaneseaffectedbyconflictinordertoensurethatpoormentalhealthdoesnotcontinuetounderminepeacebuildingeffortsinSouthSudan.Restoringmentalhealthisaprerequisiteforachievingandmaintainingpeace,stability,andreconciliation.

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2. METHODOLOGY

ThisreportisbasedprimarilyonresearchconductedbyAmnestyInternationalinAprilandMay2015,andinMay2016,inthecitiesofJuba,Malakal,andBentiu,whichhaveallbeenaffectedbytheinternalarmedconflict.ItalsodrawsonresearchcarriedoutsincetheoutbreakoftheconflictinDecember2013.

Theconflicthasresultedintheinternaldisplacementofapproximately1.7millionSouthSudanese.Ofthese,200,000arelivinginsixProtectionofCivilians(PoC)sitesacrossthecountry.PoCsitesarethecamp-likesettlementsforinternallydisplacedpeopleestablishedwithinexistingUnitedNationsMissioninSouthSudan(UNMISS)basesandguardedbyUNpeacekeepers.Otherinternallydisplacedpeoplehavesettledinhostcommunities,liveininformalsettlements,orhavefledtoremote,hard-to-reachareasofthecountry.AmnestyInternationalresearchersinterviewed161internallydisplacedpeoplelivinginPoCsitesinJuba,MalakalandBentiu.Researchersalsoconductedinterviewsinaninternallydisplacedpeople’ssettlementattheMahadSchoolinJuba.Researchersselectedtheselocationsbecausetheywereaccessibleandhostlargeconcentrationsofindividualsaffectedbytheinternalarmedconflict.

Researchersselectedforinterviewsinternallydisplacedpeoplewhowerevictimsoforwitnessestoviolationsorabusesofinternationalhumanrightsandhumanitarianlaw,individualswhoshowedsignsofpsychologicaldistress,andtheirfamilymembers.Thoseinterviewedweregenerallyreferredbynon-governmentalorganisations(NGOs)orcommunitymembers.Researchersalsointerviewedcommunityleaders,womenleaders,churchleaders,elders,andtraditionalleadersaboutcommunityperceptionsofandresponsestopsychologicaldistress.

Interviewswithinternallydisplacedpeoplefocusedontheviolationsandabusesintervieweeshadexperiencedorwitnessed,othersourcesofstressandtraumawithintheirlives,behavioursandsymptomsassociatedwithpsychologicaltrauma,andtheimpactofthesebehavioursandsymptomsontheirday-to-daylives.Mostinterviewslastedapproximatelyonehour.Interviewswereconductedinprivateorsemi-privatesettings,suchashomes,NGOoffices,ormeetingspaces.

Researcherstookcaretoensurethatintervieweesrepresentedacrosssectionofthepopulationwithrespecttogender,age,andethnicity.Giventhattheconflicthas,inmanyinstances,pittedethniccommunitiesagainsteachother,witharmedactorsdeliberatelytargetingciviliansbasedontheirethnicityandperceivedpoliticalallegiance,itwasimportantfortheresearchtoreflectexperiencesofpeoplefromdifferentethnicgroups.However,becausethevastmajorityofindividualswhohavetakenrefugeinJubaandBentiuPoCsitesarefromtheNuerethnicgroup,allinternallydisplacedpeopleinterviewedintheselocationswereNuer.ThepopulationoftheMalakalPoCsiteismixed,soresearcherswereabletointerviewindividualsfromtheNuer,Shilluk,andDinkaethnicgroups.AttheMahadSchool,intervieweeswerefromtheDinka,Murle,andAnyuakethnicgroups.

AmnestyInternationalresearchersalsointerviewedgovernmentandUNofficials,donors,representativesofNGOs,andinternationalandSouthSudanesementalhealthprofessionals—includingpsychiatrists,psychologistsandpsychosocialworkers—tofurtherunderstandtheimpactoftheconflictonmentalhealth.Inparticular,interviewsfocusedonmentalhealthissuesarisinginthecontextof

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widespreadviolationsofhumanrightsandhumanitarianlaw,andtheavailabilityofservicesforthosesufferingfrompsychologicaldistress.

Researchersinformedintervieweesofthepurposeoftheinterview,thekindsofissuesthatwouldbecovered,itsvoluntarynatureandthefactthattheycoulddiscontinuetheinterviewatanytime.Allintervieweesverballyconsentedtobeinginterviewedandfortheirtestimonytobeincludedinthisreport.InterviewswereconductedinEnglish,Arabic,Anyuak,Dinka,Murle,Nuer,andShilluklanguageswithassistancefrominterpreters.Torespectconfidentialityandprotectvictimsandwitnessesfromreprisal,allinternallydisplacedpeopleinterviewedhavebeenassignedpseudonyms.MostrepresentativesofinternationalNGOsalsorequestedthattheirnamesbewithheld,duetofearofreprisalbygovernmentofficialsforspeakingoutabouthumanrightsissues.

AmnestyInternationalconsultedmentalhealthexpertsindesigningtheresearchmethodologyandthroughouttheresearchprocess.AmedicaldoctorwithsignificantexperienceworkingwithinternallydisplacedpeopleandsurvivorsofhumanrightsviolationsaccompaniedAmnestyInternationalresearcherstoJubaandBentiu.Inaddition,SouthSudanesementalhealthorpsychosocialsupportworkersofferedcounsellingasneededduringandfollowinginterviews,tohelpavoidre-traumatization.AmnestyInternationalresearchersreferredintervieweestorelevantorganizationsprovidingmentalhealthservicesasappropriateandwiththeconsentofindividualsinterviewed.ApsychologistandapsychiatristwithexperienceinSouthSudanreviewedthisreport,andtheirfeedbackwasincorporated.

ThisreportseekstoportraythementalhealthimpactofSouthSudan’sconflict,basedontheunderstandingthatmentalhealthis“astateofwell-beinginwhichanindividualrealizeshisorherownabilities,cancopewiththenormalstressesoflife,canworkproductivelyandisabletomakeacontributiontohisorhercommunity.”1AmnestyInternational,therefore,understandsmentalhealthimpactstoencompassbothspecificmentalhealthconditionsaswellasmoregeneralpsychologicaldistressandtrauma.Researcherssoughttoidentifyanddescribecommonlyrecognizedpsychiatricsymptomsexperiencedbyinterviewees,butdidnotattempttodeterminethespecificmentalhealthconditionsthatmayaffectthem.

Thetermmentalhealthcareorservicesisusedtorefertoabroadrangeofinterventionsdesignedtosupportmentalhealth.Itshouldthereforebeunderstoodtoincludenon-biologicalinterventions,alsoreferredtoaspsychosocialsupport,treatmentorrehabilitation.

AmnestyInternationalwouldliketothankallthesurvivorsofhumanrightsviolationsandabuseswhocourageouslydescribedtheirintimatethoughtsandemotions,aswellastheofficials,healthprofessionals,andaidworkerswhosharedtheirviewsandexperiences.

1WorldHealthOrganization(WHO),MentalHealthActionPlan2013-2020,2013,p.38, availableat:http://www.who.int/mental_health/publications/action_plan/en/

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3. WAR, TRAUMA AND MENTAL HEALTH

SOUTH SUDAN’S LONG LEGACY OF WARThearmedconflictthateruptedinDecember2013isonlythemostrecentepisodeofviolenceinSouthSudan’shistory.From1956to1972andagainfrom1983to2005,theGovernmentofSudanandpro-governmentmilitiasfoughtagainstarmedgroupswhosoughtgreaterequalityandautonomyforthesouthernregionsofSudan.Bothperiodsofcivilwarwerecharacterisedbyextremeviolenceagainstcivilians,grosshumanrightsabuses,andmassiveforceddisplacement.Duringthesecondcivilwarfrom1983to2005,anestimated1.9millionpeople—oneoutofeveryfivesouthernSudanese—werekilledordiedfromdiseaseandfamine,andsomefourmillionpeoplewereinternallydisplaced.2

2UnitedStates(US)CommitteeforRefugees,“Sudan:Nearly2milliondeadasaresultoftheworld’slongestrunningcivilwar,”2001,availableat:http://web.archive.org/web/20041210024759/http://www.refugees.org/news/crisis/sudan.htm

Awomancriesfollowingadeadlyattackbycattleraiders.Chukudum,EasternEquatoriastate,2007©TimMcCulka

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In2005,theSudanesegovernmentandtherebelSudanPeople’sLiberationMovement/Army(SPLM/A)signedaComprehensivePeaceAgreement(CPA)whichgrantedregionalautonomytoSouthSudan.ButtheCPAdidnotbringanendtointernalviolence,nordidSouthSudan’ssecessionfromSudanin2011followingareferendumonself-determination.From2005to2013,fightingbetweengovernmentforcesandarmedinsurgentmilitias,intercommunalviolenceoftenlinkedtolandandcattle,andthewidespreadavailabilityofarmsafteryearsofwarcontinuedtoresultinrepeatedpopulationdisplacements,destructionofcivilianproperty,andahighnumberofciviliandeaths.3

RENEWED CONFLICT IN 2013InDecember2013,growingpoliticaltensionbetweenPresidentSalvaKiirandDrRiekMacharmushroomedintoabrutalinternalarmedconflict.4FightingstartedinJuba,thecapital,wheregovernmentforcesengagedintargetedkillings,primarilyofNuermen.Securityforcesacrossthecountrysplit—withsomemaintainingallegiancetothegovernmentandothersdefectingtosupportthearmedoppositionunderMachar,whichcametobeknownastheSudanPeople’sLiberationMovement/Army-InOpposition(SPLM/A-IO).Bytheendof2013,theconflicthadengulfedpartsofJonglei,Unity,andUpperNilestates.5

Theconflictresultedinthedestructionofhomes,hospitals,andotherbuildings.Bentiu,SouthSudan,March2014.©AmnestyInternational

3Seeforexample,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,ThePendulumSwings:TheRiseandFallofInsurgentMilitiasinSouthSudan,2013,availableat:http://www.smallarmssurveysudan.org/fileadmin/docs/issue-briefs/HSBA-IB22-Pendulum-Swings.pdf

4RiekMacharservedasVice-Presidentfrom2005toJuly2013,whenPresidentKiirremovedhimfromtheposition.InFebruary2016,KiirissuedapresidentialdecreereappointingMacharasVice-President,inaccordancewiththeAugust2015AgreementontheResolutionoftheCrisisinSouthSudan(ARCSS).

5Forbackgroundonthefirstmonthsoftheconflict,seeUNMissioninSouthSudan(UNMISS),ConflictinSouthSudan:AHumanRightsReport,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,May2014(Index:AFR65/003/2014),availableat:https://www.amnesty.org/en/documents/AFR65/003/2014/en/

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Bothgovernmentandoppositionforceshavecommittedseriousviolationsofinternationalhumanitarianlawandserioushumanrightsviolationsandabuses.Theyhavedeliberatelykilledciviliansincludingchildren,womenandelderlypeople,oftentargetingthembasedonethnicityorperceivedpoliticalallegiance.Theyhaveabductedandrapedwomenandgirls;ravagedhospitalsandschools;destroyedandlootedcivilianproperty,includingmeansoflivelihood;attackedhumanitarianpersonnelandassets;recruitedchildsoldiers;andkilledcapturedsoldiersandotherfightersplacedhorsdecombat.Warringpartieshavealsoobstructedhumanitarianassistance,includingmedicalandfoodsupplies,preventingthemfromreachingcivilianpopulationsdisplacedbytheconflict.6Theseactsamounttowarcrimesandsomemayconstitutecrimesagainsthumanity.

Theconflicthashadadevastatingimpactoncivilians.Thousandsofpeoplehavebeenkilledandentiretownsandvillageshavebeenleftinruins.Over2.3millionSouthSudanesehavefledtheirhomessincetheoutbreakoffighting,withsome1.7millioninternallydisplacedandanother600,000livinginneighbouringcountriesasrefugees.Anestimated2.8millionpeople—closetoonequarterofthepopulation—arefacingacutefoodandnutritioninsecurity.7

InAugust2015,followingalmosttwoyearsofon-and-offpeacenegotiationsmediatedbytheIntergovernmentalAuthorityonDevelopment(IGAD),partiestotheconflictandotherstakeholderssignedtheAgreementontheResolutionoftheConflictinSouthSudan(ARCSS).8TheagreementprovidesfortheformationofaTransitionalGovernmentofNationalUnity(TGoNU)andfornationalelectionsaftertwoandahalfyears.Italsoenvisagesbroadsecuritysectorreform,theestablishmentofaHybridCourtforSouthSudan(HCSS)bytheAfricanUnion(AU)Commissiontoprovideaccountabilityforcrimesunderinternationallaw,aCommissiononTruth,ReconciliationandHealing(CTRH),aCompensationandReparationsAuthority(CRA),andforapermanentconstitutionaldevelopmentprocess.9

On26April2016,DrRiekMachar,leaderoftheSPLM/A-IO,returnedtoJubaandwassworninasFirstVicePresident,markinganimportantmilestoneinimplementationoftheARCSS.MinistersoftheTGoNUtookoathsofofficeafewdayslater.AsofMay2016,however,numerousaspectsoftheARCSShavenotbeenimplemented,insomecasesduetooutstandingdisagreementsbetweentheparties.10

Thecountryalsocontinuestobeaffectedbysignificantviolence,despitethepermanentceasefireordersissuedbyPresidentKiirandMacharfollowingsigningoftheARCSS.11 Fighting in southern UnitystatecontinuedthroughDecember2015,andon25April2016,arocket-propelledgrenadelandedinsidetheperimeteroftheUnitedNationsMissioninSouthSudan(UNMISS)compoundinBentiu.12On17and18February2016,violenceintheMalakalProtectionofCivilians(PoC)site

6Ibid.Foradditionaldocumentationofhumanrightsandhumanitarianlawabuses,seeAmnestyInternational,“SouthSudan:Escalationofviolencepointstofailedregionalandinternationalaction,”21May2015,availableat:www.amnesty.org/en/press-releases/2015/05/south-sudan-escalation-of-violence-points-to-failed-regional-and-international-action/;UNMISS,TheStateofHumanRightsintheProtractedConflictinSouthSudan,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,July2015,availableat:https://www.hrw.org/report/2015/07/22/they-burned-it-all/destruction-villages-killings-and-sexual-violence-unity-state;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

7UnitedNationsOfficefortheCoordinationofHumanitarianAffairs(OCHA),HumanitarianBulletin:SouthSudan,10February2016,availableat:http://reliefweb.int/sites/reliefweb.int/files/resources/160210_OCHA_SouthSudan_humanitarian_bulletin.pdf

8SignatoriestotheARCSSinclude: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).

9ARCSS,availableat:southsudan.igad.int/index.php/91-demo-contents/news/299-agreement-on-the-resolution-of-the-conflict-in-the-republic-of-south-sudan.RiekMachar,leaderoftheSPLMA/IO,signedtheagreementon17August2015whilePresidentSalvaKiirsignedtheagreementon26August2015.

10ForanaccountoffailurestoimplementthepeaceagreementbetweenAugust2015andJanuary2016,see:ReportoftheChairpersonoftheJointMonitoringandEvaluationCommission(JMEC)fortheAgreementontheResolutionoftheConflictintheRepublicofSouthSudantotheAfricanUnionPeaceandSecurityCouncil(PSC),29January2016,availableat:http://jmecsouthsudan.org/uploads/AUPSCreport.pdf

11Foraccountsoffightingfollowingthesigningofthepeaceagreement,seeUNMISS,The State of Human Rights in the Protracted Conflict in South Sudan,December2015;FinalreportofthePanelofExpertsonSouthSudanestablishedpursuanttoSecurityCouncilresolution2206(2015),January2016,UNDocument:S/2016/70,availableat:http://www.un.org/ga/search/view_doc.asp?symbol=S/2016/70

12UNOCHA,SouthSudanHumanitarianBulletin,9May2016,availableat:https://gallery.mailchimp.com/f2c222dd83de60ecbebe45951/files/160509_OCHA_SouthSudan_humanitarian_bulletin.pdf

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leftapproximatelyone-thirdofthecampburnttotheground.13TherewereincidentsofinsecurityandfightinginWesternEquatoriabetweenMay2015andMarch2016,duringwhichgovernmentsoldiersattackedciviliansandburnedcivilianhomes.14InFebruary2016,fightinginPiborcountyofJongleistatebetweengovernmentsoldiersandforcesloyaltoformerPiboradministratorDavidYauYaudisplaced30,000people.15InWesternBahrelGhazalstate,governmentsoldierskilled,torturedandrapedciviliansandlootedandburneddowncivilianhomesbetweenDecemberandFebruary2016.AccordingtotheUnitedNationsOfficefortheCoordinationofHumanitarianAffairs(UNOCHA),betweenJanuaryandMarch201616approximately100,000SouthSudanesefledthecountryasrefugees.17Despitethepeaceagreement,therefore,realrespitefromtwoyearsofdisplacement,death,anddestructionisstillfaroffformanySouthSudanese.

THE MENTAL HEALTH IMPACT OF ARMED CONFLICTStudiesinconflict-affectedregionsacrosstheworldhaveconsistentlydemonstratedthatarmedconflicthasanegativeimpactonmentalhealth—thestateofemotionalandpsychologicalwellbeinginwhichindividualscancopewiththenormalstressesoflife,workproductively,andbeactivemembersoftheircommunity.18Duetoarmedconflict,peoplearemorelikelytosufferarangeofmentalhealthissues:aminoritywilldevelopnewanddebilitatingmentaldisorders,manyotherswillexperiencepsychologicaldistress,andthosewithpre-existingmentaldisordersoftenwillneedmorehelpthanbefore.19TheWorldHealthOrganization(WHO)estimatesthatinsituationsofarmedconflictandotheremergencies,theproportionofthepopulationsufferingfrommildormoderatementaldisordersrisesfromapproximately10%to15-20%.20

Studiesalsoindicatethatpeoplewhoexperiencemoreepisodesoftraumaduringconflictaremoresusceptibletomentalhealthproblems.21Traumaticeventsshowntobepositivelycorrelatedwithmentalhealthproblemsincludewitnessingorexperiencingrape,torture,abduction,forceddisplacement,andlossofproperty—allhumanrightsandhumanitarianlawviolationsthathavebeenendemicinSouthSudan’sinternalarmedconflict.Othertraumaticexperiences,suchaslackofadequatefood,shelterormedicalcare,thoughtosomeextentanassumedconsequenceofwar,have,inSouthSudan,beenexacerbatedbytheintentionaldestructionofcivilians’meansoflivelihood22andobstructionofhumanitarianaidbywarringparties.23

13CenterforCiviliansinConflict,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

14HumanRightsWatch,“SouthSudan:ArmyAbusesSpreadWest,6March2016,”availableat:https://www.hrw.org/news/2016/03/06/south-sudan-army-abuses-spread-west

15UNOCHA,SouthSudanHumanitarianBulletin,28March2016,https://gallery.mailchimp.com/f2c222dd83de60ecbebe45951/files/20160328_OCHA_SouthSudan_humanitarian_bulletin.pdf.ThefightingeruptedfollowingPresidentKiir’sappointmentofBabaMedanKonyiasGovernoroftherecentlycreatedBomastate,replacingDavidYauYauasadministratorofthearea.SudanTribune,“SouthSudanPresidentSummonsBomaGovernoroverClashes,”28February2016,availableat:http://www.sudantribune.com/spip.php?article58158

16HumanRightsWatch,“SouthSudan:CiviliansKilled,TorturedinWesternRegion:ProvideJusticeforArmyAbusesinWesternRegions,”24May2016,availableat:https://www.hrw.org/news/2016/05/24/south-sudan-civilians-killed-tortured-western-region

17UNOCHA,SouthSudanHumanitarianBulletin,9May2016,availableat:https://gallery.mailchimp.com/f2c222dd83de60ecbebe45951/files/160509_OCHA_SouthSudan_humanitarian_bulletin.pdf

18WHO,MentalHealthActionPlan2013-2020,p.38.

19WHO,BuildingBackBetter:SustainableHealthCareafterEmergencies,2013,p.4,availableat:http://apps.who.int/iris/bitstream/10665/85377/1/9789241564571_eng.pdf

20WHO,BuildingBackBetter,p.17.

21R.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,thenumberofhumanrightsviolationssufferedbyindividualsduringtheBalkanconflictwaspositivelycorrelatedwithriskofpost-traumaticstressdisorder(PTSD),majordepressionandothersymptomsofmentalhealthdisorders.StefanPriebeetal,“ExperienceofHumanRightsViolationsandSubsequentMentalDisorders:AStudyFollowingtheWarintheBalkans,”SocialScienceandMedicine,2010,p.5,availableat:http://www.ncbi.nlm.nih.gov/pubmed/21041008

22Forexample,betweenAprilandDecember2015,governmentforceslootedandburnedfoodandstolecattleandotherlivestockfromciviliansinsouthernandcentralUnitystate.UNMISS,TheStateofHumanRightsintheProtractedConflictinSouthSudan,December2015,para.43.

23InMarch2016alone,UNOCHArecorded60incidentsaffectinghumanitarianaccess.Ofthese,43werecasesofviolenceagainsthumanitarianpersonnelorassets.UNOCHA,SouthSudanHumanitarianAccessSituationSnapshot,March2016,availableat:http://reliefweb.int/sites/reliefweb.int/files/resources/access_snapshot_20160407.pdf

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Commonconditionstriggeredbyconflictincludepost-traumaticstressdisorder(PTSD)andotheranxietydisorders,depression,andpsychosomaticproblemssuchasinsomnia,orbackandstomachaches.24Symptomsassociatedwiththesementalhealthconditionsandpsychologicaldistressmorebroadlyincludefeelingsofshame,self-blame,fragmentedmemories,alackofconcentration,intrusivememories,theavoidanceofcircumstancesassociatedwiththestressor,sleepdisorders,nightmares,flashbacks,irritability,anger,anxiety,andmistrustofotherpeople.Peoplesufferingfrompoormentalhealth,particularlydepression,mayalsoconsider,orcarryout,suicide,andaremorepronetopoorphysicalhealth,risk-taking,andharmfulbehaviourssuchassubstanceabuse.25

SOUTH SUDAN: A TRAUMATIZED NATIONThereisnodoubtthatdecadesofwarhaveexactedaheavytollonSouthSudanesepeopleandcontributedtowidespreadmentalhealthissues.WhiletherearenonationalstatisticsontheprevalenceofmentalhealthconditionsinSouthSudan,surveysassessingratesofpost-traumaticstressdisorderanddepressioninlimitedpopulationshaveconsistentlyillustratedhighlevelsofpsychologicaldistress.A2004studyfoundthat50%ofsurveyedresidentsofSouthernSudanand44%ofSouthernSudaneserefugeesinUgandasufferedsymptomsofPTSD.26Astudyconductedin2007foundhighlevelsofmentaldistressinthepopulationsurveyedinJuba.Inthisstudy,36%ofrespondentsmetsymptomcriteriaforPTSDandhalf(50%)ofrespondentsmetsymptomcriteriafordepression.27 This study’sresultsshowedadirectrelationshipbetweenexperiencingtraumaticevents—suchasforcefulseparationfromfamilyandbeinginjured—andthelikelihoodofPTSDanddepression.28ResearchamongSouthSudaneseex-soldiersin2010foundthat15%reportedwishingtheyweredeadorthinkingaboutsuicide.29

Quantitativestudiescarriedoutsincetherenewederuptionofconflictin2013havereportedsimilarfindings.A2015studybytheSouthSudanLawSociety(SSLS)andtheUnitedNationsDevelopmentProgramme(UNDP)foundthat41%ofthe1,525respondentsacrosssixstatesandAbyeiexhibitedsymptomsconsistentwithadiagnosisofPTSD.Thedataalsoindicatedhighlevelsofexposuretotraumainthesamplepopulation,with63%ofrespondentsreportingthataclosefamilymemberwaskilledatsomepointintheirlivesand41%reportingthattheyhadwitnessedafriendorfamilymemberbeingkilled.30A2015surveybySSLSinMalakalPoCsitefoundthat53%ofrespondentsexhibitedsymptomsconsistentwithadiagnosisofPTSD.31

23InMarch2016alone,UNOCHArecorded60incidentsaffectinghumanitarianaccess.Ofthese,43werecasesofviolenceagainsthumanitarianpersonnelorassets.UNOCHA,SouthSudanHumanitarianAccessSituationSnapshot,March2016,availableat:http://reliefweb.int/sites/reliefweb.int/files/resources/access_snapshot_20160407.pdf

24R.SrinivasaMurthyandRashmiLakshminarayana,“MentalHealthConsequencesofWar:ABriefReviewofResearchFindings,”WorldPsychiatry,2006;WHO,WorldReportonViolenceandHealth,2002,p.224,availableat:http://apps.who.int/iris/bitstream/10665/42495/1/9241545615_eng.pdf

25Forfulldescriptionsofmentaldisorders,seeInternationalStatisticalClassificationofDiseasesandRelatedHealthProblems,10thRevision(ICD-10),availableat:http://apps.who.int/classifications/icd10/browse/2016/en

26UnniKrishnanKarunakaraetal.,“Traumaticeventsandsymptomsofpost-traumaticstressdisorderamongstSudanesenationals,refugeesandUgandansintheWestNile,”AfricanHealthSciences,2004,p.88,availableat:http://kops.uni-konstanz.de/bitstream/handle/123456789/11366/Karunakara_etal2004.PDF;jsessionid=9B57C94F7346EF5000577E9024A0F3E2?sequence=1

27BayardRobertsetal.,“Post-conflictmentalhealthneeds:across-sectionalsurveyoftrauma,depressionandassociatedfactorsinJuba,SouthernSudan,”BMCPsychiatry,2009,p.5,availableat:http://www.biomedcentral.com/content/pdf/1471-244X-9-7.pdfAsurveyofpopulationsinAbyeifoundthat37.8%ofrespondentsmetsyptomcriteriaforPTSD.SeealsoBelkysLópezandHazelSpears,StabilizingAbyei:TraumaandtheEconomicChallengestoPeace,Kush,2013,availableat:http://server2.docfoc.com/uploads/Z2015/12/20/zXgw5Bj4vM/7032e8dd1043bb97e5251705dce7182c.pdf

28Itfoundthatrespondentswhohadexperiencedeightormoreofthe16traumaeventsincludedinthequestionnaireweremorelikelytoexhibitsymptomsofPTSDanddepression.BayardRobertsetal.,“Post-conflictmentalhealthneeds:across-sectionalsurveyoftrauma,depressionandassociatedfactorsinJuba,SouthernSudan,”BMCPsychiatry,2009,p.6.

29NinaWinkler,“Pyscho-socialinterventionneedsamongex-combatantsinSouthernSudan,”BonnInternationalCentreforConversion,2010,p.14,availableat:http://www.ssddrc.org/uploads/SSDDRC_Psycho_Social_Assessment.pdf

30ThesurveyusedtheHarvardTraumaQuestionnaire(HTQ)toassess16typesoftraumaticeventsandPTSDsymptoms.SouthSudanLawSociety(SSLS)etal,SearchforaNewBeginning:PerceptionsofTruth,Justice,ReconciliationandHealinginSouthSudan,October2015,p.vii,availableat:file://kenb0-vs-dc1ro/users$/elizabeth.deng/Downloads/Perception%20Survey%20Report%20Transitional%20Justice%20Reconciliation%20and%20Healing%20-.pdf

31DavidK.Dengetal,AWarWithin:Truth,Justice,ReconciliationandHealinginMalakalPoC,2015,p.v,availableat:https://radiotamazuj.org/sites/default/files/SSLS_A_War_Within_Dec_2015_.pdf

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Mentalhealthexpertsandserviceprovidersbelievetheconflicthashadasignificantandwidespreadimpactonmentalhealth.AccordingtoDrAtongAyuel,DirectoroftheMinistryofHealth’sDepartmentofMentalHealth,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.”

TheAUCISSrecommendedfurtherinquiryintothescopeoftraumaandtheneedforpsychosocialinterventionsinthecountry.33

32AmnestyInternationalinterviewwithDr.AtongAyuel,Director,MentalHealthDepartment,MinistryofHealth,Juba,SouthSudan,10April2015.

33AUCISS,FinalReport,para.895.

Awomanwhosehusbandwaskilledbyanunknownarmedgroupthepreviousnight.Gumbo,CentralEquatoriastate,2006©TimMcCulka

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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,approximately200,000arelivinginsixPoCsiteslocatedonUNMISSbasesacrossthecountry.Displacedpeopleseekingrefugeandprotectionhaveconvergedonthesesitesoverthecourseoftheconflict.Therearesome28,000livinginJubaPoCsite,47,000inMalakal,andalmost120,000inBentiu.34

TheresidentsofSouthSudan’sPoCsiteshave,withoutexception,beenprofoundlyimpactedbythehumanrightsandhumanitarianlawabusesandviolationsthathavecharacterizedSouthSudan’sconflict.Theirhomeshavebeenlootedordestroyed,theirlivestockstolen,theirbusinessesruined.Manyhavewitnessedfamilymembersorneighboursbeingkilledorarethemselvesvictimsofphysicalorsexualviolence.35ThoughtheprotectionofUNpeacekeepershasundeniablysavedlives,PoCsiteshavethemselvesbeenscenesofmasskilling:anApril2014attackonBorPoCsiteresultedinatleast47civiliandeathswhileaFebruary2016attackonMalakalPoCsiteresultedinatleast25deathsand120injuries.36TherehavealsobeenincidentsofshellingandgunfirepenetratingPoCsitesaswellasnumerouscasesofkillings,rapes,andabductionsofinternallydisplacedpeoplewhoventureoutsideofPoCsites.37

InternallydisplacedpeopleinterviewedbyAmnestyInternationaldescribedhavingnightmares,gettingangryeasily,feelingunabletoconcentrateandconsideringsuicide—commonsymptomsassociatedwithPTSDanddepression.Manyalsospokeofheadaches,stomachpains,backachesandheartpalpitations—commonphysicalmanifestationsofpsychologicalstress.Theyattributedthesemental,physical,emotional,relationalandspiritualimpactstothehumanrightsandhumanitarianlawabusesandviolationstheyhadwitnessedorexperienced.Theyalsodescribedhowtheseimpactsaffected

34UNMISSupdate,22February2016,http://unmiss.unmissions.org/Portals/unmiss/UNMISS%20Update/2016/February%202016/22.02%20-%20Update%20No.%20114.pdf

35Foranoverviewofconflictrelatedrightsviolations,see,forexample,UNMISS,TheStateofHumanRightsintheProtractedConflictinSouthSudan,December2015.

36UNMISS,TheStateofHumanRightsintheProtractedConflictinSouthSudan,December2015,para.43;UNOCHA,SouthSudanHumanitarianBulletin,3March2016,availableat:https://gallery.mailchimp.com/f2c222dd83de60ecbebe45951/files/160303_OCHA_SouthSudan_humanitarian_bulletin.pdf

37UNMISS,TheStateofHumanRightsintheProtractedConflictinSouthSudan,December2015,paras43-53.

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theirabilitytowork,study,carryoutbasicdailytasks,careforchildren,andmaintainrelationshipswithfriendsandfamily.Theirtestimonyisastarkillustrationofthementalhealthrepercussionsoftheconflict.

Inadditiontoconflict-relatedabusesandviolations,thegenerallydifficultlivingconditionswithinthePoCsitespresentanadditionalchallenge.Limitedaccesstoeducationandmedicalcareincludingpsychosocialservices,amonotonousdiet,crampedandsometimesfloodedshelters,andpoorsanitationexacerbatepsychologicalstressandalsoimpederecoveryfromtrauma.

Familyandcommunitymembersplayanimportantroleinsupportingindividualsexperiencingpsychologicaldistress,butconflictanddisplacementhaveseverelyweakenedandstretchedthesetraditionalsupportnetworksandtheirabilitytohelppeoplecope.Intervieweesspokeofhowneighbours,friends,relativesandchurchmembersadvise,counsel,andcomfortthem,providingsomerelief.Butoftenthepeopletowhomindividualsfacingdistresswouldturnforsupportareeitherabsentorarethemselvessufferingfromheavypsychologicalburdens.Peoplewithmentalhealthproblemsarealsosubjectedtosignificantsocialstigma,andfamilyandcommunitymembershavelimitedinformationaboutmentalhealth,trauma,andwhatconstitutesappropriatecareandtreatment.Manyindividualsexperiencingpsychologicaldistressfelttheywouldbenefitfrommentalhealthorpsychosocialsupportservicesandprogrammes,butgiventhelimitedavailabilityandaccessibilityofsuchserviceswithinthePoCsitesorinSouthSudangenerally,veryfewhad.38

“SOMETIMES I DREAM THAT I DIED WITH THOSE WHO WERE KILLED”: TARGETED KILLINGS IN JUBAInDecember2013,followingtheoutbreakoffightinginJuba,membersofthePresidentialGuard,themilitary,andothersecurityforcestargetedNuersoldiersandciviliansonthebasisoftheirethnicityandperceivedpoliticalaffiliationtoRiekMachar.Governmentsecurityforcesconductedhouse-to-housesearchesinJuba,killingpeopleinorneartheirhomesortakingthemtootherlocations.AccordingtotheSouthSudanHumanRightsCommission(SSHRC),morethan600peoplewerekilledand800injuredinJubaanditssuburbsbetween16and18December2013.39

OneoftheworstsingleincidentsofkillinginJubawasthemurderofapproximately300menfromtheNuerethnicgroupinafacilityintheGudeleneighbourhoodusedbyseveralsecurityforcesasajointoperationscentre,duringthenightof16-17December2013.40Governmentsoldiersandothersecurityofficersgatheredthemeninabuildingandopenedfireonthem,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.”

MalithandothersurvivorswhospokewithAmnestyInternationaldescribedexperiencingpsychologicaldistressasaresultofthedeathstheywitnessedandbarelysurvived.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…

38TheavailabilityofmentalhealthandpsychosocialsupportserviceswithintheProtectionofCivilians(PoC)sitesandgenerallyinSouthSudanisdescribedintheChapter“AvailabilityandAccessibilityofMentalHealthServices.”

39SouthSudanHumanRightsCommission,InterimReportonSouthSudanInternalConflict,December15,2013-March15,2014,p.6,availableat:www.gurtong.net/ECM/Editorial/tabid/124/ctl/ArticleView/mid/519/articleId/15078/SSHRC-Interim-Report-on-South-Sudan-Internal-Conflict-December-15-2013--March-15-2014.aspx

40TheAUCISSconfirmedthisincidentandconductedaforensicanalysisofthebuildingwherethemassacretookplace.AUCISS,FinalReport,paras470-494.SeealsoUNMISS,ConflictinSouthSudan-AHumanRightsReport,paras70-78.

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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

41InterviewwithMalith(pseudonym),Juba,SouthSudan,25April2015.

42InterviewwithPeter(pseudonym),Juba,SouthSudan,2May2015.

UNMISSPoCsiteinJuba,SouthSudan.2014©AmnestyInternational

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WhenthesoldiersandsecurityofficerswhocarriedoutthekillingsinGudelefoundPhillip,anothersurvivor,unharmedunderapileofbodies,theyforcedhimtodrinkthebloodandeatthefleshofthosekilled,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,on16December2013inNyakuronneighbourhood,thentookhimtoGudele,wheretheytiedhisarmsandlegsandbeathim.Peterrecountedthat,afterDuolmanagedtomakehiswaytothePoCsiteon23December2013,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.”

PetertoldAmnestyInternationalthattherewasnoappropriatedoctoravailableatthePoCsiteandhewastooafraidtotakeDuoltoseeadoctorwithinJuba.Withassistancefromafamilymember,DuolwasabletoleaveJubaandtravelledtoKhartoumwherehesawapsychiatristandwasgivenmedication.AccordingtoPeter,thedoctorsaidDuolwas“traumatized.”44

“I AM STILL SCARED BECAUSE OF WHAT HAPPENED”: ATTACKS ON CIVILIANS IN MALAKALThecityofMalakal,inUpperNilestate,hasbeenheavilycontestedsinceDecember2013,changinghandsbetweengovernmentandoppositionforcesatleastadozentimes. Duringtheattacksandcounter-attacksonthecityinthefirstfewmonthsoffighting,bothsideskilledciviliansandlootedanddestroyedcivilianhomes,offices,andotherbuildings.45AmnestyInternationalspokewithwomenwhowitnessedkillingsandsexualviolenceinMalakal,beforetheytookrefugeattheUNMISSPoCsitebetweenDecember2013andFebruary2014.

43InterviewwithPhillip(pseudonym),Juba,SouthSudan,27April2015.

44Peterdidnotknowwhat,ifany,specificdiagnosiswasmade.InterviewwithPeter(pseudonym),Juba,SouthSudan,2May2015.

45UNMISS,ConflictinSouthSudan:AHumanRightsReport,May2014,para.151-160.

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AjakfledtotheMalakalUNMISSbaseon25 December2013,duringthefirstattackonMalakalbyoppositionforces.

“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,affectingherrelationshipswithothers.

“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

NyachoattookshelterinaCatholicchurchintheMedinaneighbourhoodofMalakalon24December2013,alongwithmanyothercivilians.Shesaidgovernmentsoldierswouldcometothechurchtoabduct,killandrapepeoplewhohadtakenshelterthere.Nyachoatwitnessedasoldierkillonewomanwhoresistedrape.ShecametotheMalakalPoCsiteon18January2014.ShedescribedtoAmnestyInternationalpersistentsignsofdistress,includingnightmares.

46InterviewwithAjak(pseudonym),Malakal,SouthSudan,6May2015.

47Interviewwiththedaughter(namewithheld)ofAjak(pseudonym),Malakal,SouthSudan,6May2015.

AviewofthedesertedstreetsinMalakal,UpperNilestateinJanuary2014afterresidentsfledviolencebetweengovernmentandoppositionforces.©UNPhoto/IsaacBilly

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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,untilaneighbourtookhertothePoCmedicalcentrerunbyInternationalMedicalCorps(IMC),whereshemetwithamentalhealthofficerwhoprovidedcounsellingandgavehermedicine,whichshesaidhelpedhersleepandgavetemporaryreprievefromnightmares.49

Nyadeng,amotheroffivechildrenaged14andunder,fledtotheMalakalUNMISSPoCsiteinFebruary2014,afteroppositionforcestookcontrolofthecityforathirdtime.ShehadbeeninMalakalTeachingHospital,whereAmnestyInternationalvisitedinMarch2014anddocumentedkillingsbyoppositionforces.50Nyadeng’ssisterdescribedthechangesshehasseeninherbehaviour,includingmemoryloss:

“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

48InterviewwithNyachoat(pseudonym),Malakal,SouthSudan,2May2015.

49Shedidnotknowthenameofthemedicationshereceived.

50AmnestyInternational,SouthSudan:NowhereSafe:CiviliansunderAttackinSouthSudan,p.24-27.

51Interviewwithsister(namewithheld)ofNyadeng(pseudonym),Malakal,SouthSudan,6May2015.

AwardinMalakalTeachingHospital,wherepatientsanddisplacedpeoplewhohadtakenrefugewerekilledbyoppositionforcesinlateFebruary2014.Malakal,UpperNilestate,March2014.©AmnestyInternational

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52AmnestyInternational,SouthSudan:NowhereSafe:CiviliansunderAttackinSouthSudan;UNMISS,AttacksonCiviliansinBentiuandBor,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.

53UNMISS,AttacksonCiviliansinBentiuandBor,April2014,para.18.



56SouthSudanLawSociety(SSLS)etal,SearchforaNewBeginning:PerceptionsofTruth,Justice,ReconciliationandHealinginSouthSudan,p.25.

“PEOPLE ARE TRAUMATIZED”: ATTACK ON THE BOR UNMISS POC SITEControloverthecityofBor,inJongleistate,changedhandsthreetimesinthefirstmonthoftheconflict,untilgovernmentforces,supportedbytheUgandaPeople’sDefenceForces(UPDF),regainedcontrolon18January2014.Duringtheearlydaysoffighting,thousandstookshelterintheBorUNMISSPoCsite.ThoughthepopulationoftheBorPoCsitewasinitiallyethnicallymixed,DinkawhohadtakenshelterthereprogressivelyleftafterthegovernmentgainedcontroloverBor.ByFebruary2014,thepopulationresidinginsidethePoCsitewasalmostentirelyNuer,surroundedbyapredominantlyDinkapopulationresidinginBor.TensionsbetweenthosewithinandoutsidethePoCsitewerehigh.InMarch2014,AmnestyInternationaldocumentedcasesofkillingsandsexualviolenceagainstindividualswhoventuredoutsidethePoCsite.Asaresultofsuchincidents,manychosenevertoleavethecamp.52

On17April2014,agroupofarmedDinkayouthattackedthePoCsite,atthetimehometo4,800displacedcivilians.53SomefiredintothePoCsitefromoutsidewhileothersbreacheditsperimeterandopenedgunfirefromwithin.Atleast47internallydisplacedpeoplewerekilledasaresult.54Theattackwasaflagrantviolationofinternationalhumanitarianlaw,whichprohibitsattacksonUNpeacekeepingmissionsaswellasonzonesofrefuge.EstherwasintheBorPoCsiteon17Aprilandwitnessedtheattack.

“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,peopleinthecampexpressedfearoffutureattacksandsaidthattheirchildrenwerestilltraumatizedbywhattheyhadexperienced.55 The South SudanLawSociety’sFebruary2015surveyofdisplacedpeoplelivingintheBorPoCsitefoundthatalmostalloftheapproximately100respondentsinterviewedhadsymptomsconsistentwithadiagnosisofPTSD.56

Estherdescribedexperiencinganumberofsignsofpsychologicaldistresssincetheattack,includingpoormemoryandfeelingsofanger.

“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…

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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,saidthatpeopleattheBorPoCsitewerenotthesameafterwards.Sheherselfhasdifficultysleepingandcomplainedofphysicalpainsshesaysshedidn’thavebeforetheconflict.

“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-dayactivitieslikefetchingwater.

“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 JUBASincethestartoftheconflict,governmentsecurityforces,particularlytheMilitaryIntelligence(MI)andNationalSecurityService(NSS),havefrequentlyarbitrarilydetainedperceivedgovernmentopponents.59DozensofformerdetaineesinterviewedbyAmnestyInternationaloverthepasttwoyearshavesaidsecurityofficersaccusedthemofsupportingoppositionforces,butdidnotformerlychargethemwithanyoffenceorpresentthembeforeacourtasrequiredbySouthSudan’sconstitutionandinternationalhumanrightslaw.Formerdetaineesdescribedsecurityofficersbeatingthemwithsticks,

57InterviewwithEsther(pseudonym),Juba,SouthSudan,24April2015.

58InterviewwithElizabeth(pseudonym),Juba,SouthSudan,28April2015.

59FormoreonarbitrarydetentionandtheuseoftortureinSouthSudan,see:AmnestyInternational,DeniedProtectionoftheLaw:NationalSecurityServiceDetentioninJuba,SouthSudan,April2016(Index:AFR65/3844/2016);AmnestyInternational,“DozensofDetaineesatRiskofDeathinShippingContainers,”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.Someremainedindetentionformanymonths,ofteninhorrificconditions.Threeformerdetaineesinterviewedforthisreporttoldoftroublesleepingandothermanifestationsofpsychologicalstress,whichtheysaidresultedfromtheirtimeindetention.

John,ashopowner,saidsoldierscapturedhiminMunukineighbourhoodofJubaon16December2013,whenhewasonhiswaytotheUNMISSPoCsite.TheytookhimtotheGiyadabarracksandputhimintoanundergrounddetentioncellwherehecounted69otherdetainees,mostofthemNuer.Herecountedthatsoldierssubjectedhimtoroutinebeatings,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.”

JohnescapedfromtheGiyadadetentionfacilityon5March2014duringalapseinsecuritythatoccurredwhenfightingeruptedamongsoldiers,reportedlyovertheirsalaries.60LivingintheJubaPoCsiteoverayearafterhisescape,Johnhadlingeringfearsofbeingre-capturedandwastormentedbythememoryofbeingdetained.

“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…”

60AmnestyInternationalhasinterviewedthreeotherNuermenwhoweredetainedinGiyadaandescapedduringtheMarchfighting.Followingthefighting,theSPLAspokesperson,ColonelPhilipAguer,saidthat100securityforcesofficersarrestedonsuspicionofresponsibilityforatrocitiesinDecember2015inJubaalsoescaped.InterviewwithPhilipAguer,formerSPLAspokesperson,Juba,SouthSudan,26March2014.

61InterviewwithJohn(pseudonym),Juba,SouthSudan,27April2015.

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BeforePalwasdetained,hiswifeandchildrenhadleftJubaandmovedtoKakumarefugeecamp,inKenya.Pal’swifediedinFebruary2014whilehewasindetention.Then,inMarch2015,Palgotnewsthathisdaughterwassickandmightnotrecover.

“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.Hedescribedbeingbeatenandotherformsoftorturesustainedbyfellowdetainees.

“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,NSSpersonneltransportedhimtoanofficetomeetwithaseniormilitaryofficial.Atonepoint,hewasleftunguardedandwasabletorun,getonamotorcycletaxi,andescape.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

LualtoldAmnestyInternationalthatNSSofficersarrestedhiminSeptember2014anddetainedhiminafacilityinJubaalongtheNileRiver,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,securityofficerskilledover60detaineesduringhistimeattheriversidedetentionfacility.

62Interviewwiththeuncle(namewithheld)ofPal(pseudonym),Juba,SouthSudan,25April2015.

63InterviewwithSimon(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.HeeventuallyescapedandmadehiswaytotheUNMISSPoCsiteinJuba.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 SITESouthSudan’sinternalarmedconflict,particularlytheviolenceinUnitystate,hasbeencharacterisedbyashockingfrequencyofsexualviolence.Bentiu,thecapitalofUnitystate,hoststhelargestPoCsiteinthecountry,withapproximately120,000internallydisplacedpeoplelivingthere.Whilethesiteisacriticalsourceofprotectionforitsresidents,manyofwhomhavewitnessedkillingsanddestructionintheirhomeareas,reachingthePoCsitehasnotbroughtanendtotheirexperiencewithviolence.DisplacedpeopleinBentiumustoftenleavethesitetocollectwoodforfuel,food,ortogrindgrain.Theyhavefacedcontinuousthreatswhendoingso;womenhavefacedtheparticularriskofsexualviolenceorabduction.UNMISShasdocumentednumerousincidentsofsexualviolenceoccurringwithintheperimeterofUNMISSsites.AccordingtoUNMISS,inJanuaryandFebruary2015alone,atleast35womenwererapedbygovernmentsoldiersneartheBentiuPoCsite.65

64InterviewwithLual(pseudonym),Juba,SouthSudan,25April2015.

65UNMISS,TheStateofHumanRightsintheProtractedConflictinSouthSudan,December2015,paras46,53.

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NyawalsoughtrefugeintheBentiuPoCsiteinearly2015,escapinganattackonhervillageinGuitcounty.ShewasrapedbyanSPLAsoldierafewmonthsafterarrivingatthePoCsitewhensheventuredouttobuymedicine.

“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.”

AerialviewoftheUNMISSPoCsiteinBentiu.June2016.©UNPhoto/IsaacBilly

66Apseudonym.

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NyawalwastreatedforherrapebyMédecinsSansFrontières(MSF)andalsoreceivedsupportfromtheInternationalRescueCommittee(IRC),whichprovidescounsellingforsurvivorsofsexualviolenceintheBentiuPoC.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

WomenreturningwithcollectedfirewoodtotheUNMISSPoCsiteinBentiu,January2015.©UNPhoto/JCMcllwaine

67InterviewwithNyawal(pseudonym),Bentiu,SouthSudan,16May2015.

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“WE ARE ALL ALONE”: DEATH, ABDUCTION, AND DISAPPEARANCE OF RELATIVES Manydisplacedpeoplearetormentedbythelossofwives,husbands,children,andotherfamilymemberswhohavebeenkilledorabducted.Sometimesindividualsmayhavedisappeared,leavingrelativestowonderwhethertheyarealiveordead.Funeralritescanprovidesurvivorsanimportantsenseofclosure,butthesehaveoftennotbeenperformedbecausesurvivorsdon’tknowtheprecisefateoftheirrelatives,becausetheydon’thaveaccesstotheirremains,orbecausethescaleofdeathmakesindividualfuneralceremoniesimpossible.

SarawaslivinginTerekeka,CentralEquatoriastate,inDecember2013.ShetoldAmnestyInternationalthatherhusbandwastiedupbysecurityforceson18December,takenawayandkilledwithseveralothermenfromtheNuerethnicgroup.NowlivingintheJubaPoCsite,shecriedasshedescribedhowhisdeathhasaffectedherlife.

“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,onlyadayaftershegavebirthtotheirthirdchild.Hehadrunawayfromtheirhome,assumingshewouldnotbeharmed.Hecamebacktofindthebabyalive,andhiswifekilled.Hekeepsgoingovertheincidentandblameshimselfforleavingher.LamtoldAmnestyInternationalthathecan’tstandthinkingofthepastandhasnohopeinthefuture.

68InterviewwithSara(pseudonym),Juba,SouthSudan,24April2015.

NewlyarrivedinternallydisplacedpeopleregisteratUNMISSPoCsiteinBentiu,Unitystate,May2015.©AmnestyInternational

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AchildattheUNMISSPoCinJuba.2015©UNPhoto/JCMcllwaine

69InterviewwithLam(pseudonym),Juba,SouthSudan,25April2015.

“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.RebeccawaslivinginthetownofRubkonainUnitystateinDecember2013.Shelostcontactwithherhusband,agovernmentsoldier,aftertheconflictstarted.ShefledfirsttoYidainnorthernUnitystateandthentoJuba.

“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.”

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RebeccareachedouttomembersofherchurchandfriendsinthePoCsiteforsupport,butfoundthattheytooweresuffering.

“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.AccordingtoRachel,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 absent-minded. You could discuss a lot of things with her, but all of a sudden she’d just forget what you were talking about.”

RachelexplainedthatNyayangalsoshowedincreasedaggressionandviolentbehaviour,includingbeatingherchildren.

“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.Rachelstoppedhertwice.

70InterviewwithRebecca(pseudonym),Juba,SouthSudan,25April2015.

71UNMISS,“UNdemandssafereleaseofabductedpersonnelinSouthSudanairport,”17October2014,availableat:www.un.org/apps/news/story.asp?NewsID=49103#.Vhd_gPmqpBc

72InterviewwithEmmanuel,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,AmnestyInternationalinterviewedthreewomenwhoweregrievingfortheirdaughterstheybelievedhadbeenabductedbyoppositionforces.NyamumwasrunningtotheUNMISSbaseinMalakalduringthefightinginDecember2013,whenher15year-olddaughterdisappearedbehindher.Nyamumbelievesshewasabductedbyoppositionforces.Shesaidshehasnoappetitebecauseshethinksonlyofhermissingdaughter.Shealsohastroubleconcentrating,hasheadaches,andherheartandhandstremble.74

AyenstayedinachurchcompoundinMalakaluntil18February2014,whensheandher18year-olddaughterwereabductedbyoppositionforces.Theywerebeatenandforcedtocarrythings.AyentoldAmnestyInternationalthatoppositionforceslaterreleasedher,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.Shewitnessedoppositionfighterscometothehospitalandkillwomenandchildren.Theyalsoabductedheryoungcousin,Joy.Shesaidthatsincetheabduction,shesuffersfromnightmaresandliveswithconstantfearandanxiety.Shespendshertimegrievingandhasbecomeforgetful.

“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

73InterviewwithRachel(pseudonym),Juba,SouthSudan,5May2015.

74InterviewwithNyamum(pseudonym),Malakal,SouthSudan,6May2015.

75InterviewwithAyen(pseudonym),Malakal,SouthSudan,6May2015.

76InterviewwithNyaban(pseudonym),Malakal,SouthSudan,6May2015.

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5. LACK OF ACCESS TO MENTAL HEALTH CARE SERVICES

WhenSouthSudangainedregionalautonomyunderthetermsofthe2005ComprehensivePeaceAgreement(CPA),thegovernmentstartedtobuildahealthcaresystemfromscratch.Overtenyearslater,SouthSudanstilldoesnothaveadequatehealthcarefacilities,services,treatmentorstafftoadequatelysupportthoseinneedofmentalhealthcare.Thecurrentconflicthasdealtasignificantblowtoanalreadystrugglinghealthcaresystem,withthecompleteorpartialdestructionandlootingofseveralhealthfacilities,includingtheMalakalandBentiuhospitals.77Evenwhereavailable,governmentmentalhealthservicesareverylimitedinscopeandoftenofpoorquality.WhilementalhealthhasbeenincludedinSouthSudan’spoliciesandplansforthehealthsectorsince2006,statedgoalshavenotbeenreached.Thegovernmenthasnotcommittedadequateattention,orfunding,toimprovetheavailabilityoraccessibilityofmentalhealthservices,whilesupportfrominternationalorganizationsanddonorsisalsominimal.

Servicesavailableinconflict-affectedsettings,includingintheUNMISSPoCsites,arealmostentirelyprovidedbyinternationalNGOs.InJuba,Makal,andBentiuPoCsites,someNGOsoffermentalhealthandpsychosocialsupportservices,buttheirinterventionsareinsufficientgiventhesizeofthepopulationstheyareintendedtoserve.Onemajorgapisintheprovisionofspecializedmentalhealthservicesforpeoplewithseverementaldisorders.Additionally,duetotheethnicandpoliticaldividescreatedbythecurrentconflictandthepersistentsecurityrisksinsomelocations,manypeoplelivingwithinthePoCsitesareafraidtoleave.InJuba,forexample,manyPoCsiteresidentsarereluctanttoseekoutthelimitedmentalhealthservicesavailableatJubaTeachingHospital.InBentiuandMalakaltowns,therearenomentalhealthservicesevenifthoselivinginthePoCsitesleave.

GOVERNMENT MENTAL HEALTH SERVICES: PRACTICALLY NON-EXISTENTFewcommunitiesinSouthSudanliveinreachoftheevenmostbasichealthcareservices.TheMinistryofHealthitselfhasdescribedtheavailability,accessibilityandmanagementofhealthfacilitiesasgenerallypoor.78Thereisaninsufficientnumberofhealthfacilitiesandadeficitofhealthprofessionals.AccordingtotheMinistry,in2012therewereonly1.5physiciansand2nurses/midwives

77MédecinsSansFrontières(MSF),“MedicalCareinSouthSudanUnderFire,”24February2014,availableat:www.msf.org/article/medical-care-under-fire-south-sudan.AccordingtoUNOCHA,asofSeptember2015,55%ofhealthfacilitiesintheGreaterUpperNileregionwerenotfunctioning.UNOCHA,HumanitarianNeedsOverview,2016,availableat:http://reliefweb.int/sites/reliefweb.int/files/resources/2016_HNO_South%20Sudan.pdf

78Inthe2009BasicPackageofHealthandNutritionServicesforSouthernSudan(BPHS),theMinistryofHealthestimatedthatoverallaccesstohealthcarewasbelow25%.GovernmentofSouthernSudan,MinistryofHealth,BasicPackageofHealthandNutritionServices,2009,p.11.

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forevery100,000citizens,allofthemdisproportionatelybasedinurbanareas.79Geographicaldistances,poorroads,theabsenceofambulanceservices,andsocio-culturalandfinancialbarriersallcontributetotheinaccessibilityofmedicalcare.80Evenwhereaccessible,thelackofqualifiedhealthworkers,insufficientmaterialresources,equipment,andmedicines,aswellasdysfunctionalreferralmechanismscompromisetheoverallqualityofbasichealthservicesinthecountry.81

WhilstthehealthsystemasawholeinSouthSudanisinadeeplyworryingstate,mentalhealthservicesremainpracticallynon-existent.TheJubaTeachingHospitalistheonlypublicmedicalfacilitythatprovidespsychiatriccare.DuringavisittothishospitalinApril2015,AmnestyInternationalfoundjust12bedsinthefacility’sinpatientpsychiatricward.Duetoinadequateresources,thewarditselfisrundownandindireneedofrenovationandnewequipment.Therearenotherapeuticactivities,homevisits,orcommunityoutreach.82Theavailabilityofpsychotropicdrugsisinconsistentandlimited.83 Evenwhenthedrugsareavailable,familiescanrarelyaffordthem,particularlyforlong-termuse.84 WhilesomepatientstravelfromacrossthecountrytoaccesstreatmentinJuba,thecostoftravelandthelowawarenessofservicesavailablemakethisanunrealisticoptionforthevastmajorityofthoseinneedofcare.85

Thereisadireshortageoftrainedmentalhealthprofessionals.Thereareonlytwopractisingpsychiatristsinthecountry,bothofwhomareinJubaandneitherofwhomseepatientsonafull-timebasis.OneistheDeanofJubaUniversity’sCollegeofMedicineandtheotherdivideshertimebetweentheJubaTeachingHospitalandleadingtheMentalHealthDepartmentintheMinistryofHealth.ThepsychiatricwardatJubaTeachingHospitalisstaffedbyoneclinicalpsychologistandanumberofpsychiatricmedicalassistants,counsellorsandnurses.86

OutsideofJuba,theavailabilityandaccessibilityofmentalhealthservicesisevenmoregrim.Thereisnopsychiatricwardineitherofthecountry’sothertwomajorhospitals,inWauandMalakal.TheUpperNilestateMinistryofHealthsaidittriedtoestablishspecialunitsinMalakalandelsewhereinthestate,butwasunabletodosoduetotheconflictandlackoffunds.87TherearenomentalhealthspecialistsinpublicfacilitiesoutsideofJuba.Primaryhealthcareprovidersarenotsufficientlytrainedtodiagnosementalhealthcases.Eveniftheywere,therewouldbenoclearreferralpathwaysorreasonablyaccessibletreatmentoptions.88

TheinadequatenumberofmentalhealthprofessionalsinSouthSudanisdueinparttothelimitedopportunitiesfortraininginmentalhealthinthecountry.Thereisnospecializedtrainingavailableinpsychiatry,psychiatricnursing,orclinicalorcounsellingpsychology.89Medicalstudentsoftengraduatewithoutcompletingpsychiatricrotationsandasaresultaren’ttrainedtoidentifyoraddressmentalhealthissuesinpatients.TheheadoftheMentalHealthDepartmentlamentedthat,“most of our doctors don’t know anything about mental health.”90 Toitscredit,theMinistryofHealthhastakenthesmallstepofsendingfourstafffortrainingoutsideofthecountry.TheheadoftheMental

79GovernmentofSouthSudan,HealthSectorDevelopmentPlan,2012-2016,p.11,availableat:https://extranet.who.int/nutrition/gina/sites/default/files/SSD%202012%20HEALTH%20SECTOR%20DEVELOPMENT%20PLAN%202012-2016.pdf

80RichardDowner,CenterforStrategicandInternationalStudies,ThestateofpublichealthinSouthSudan:CriticalCondition,November2012,availableat:http://csis.org/files/publication/121114_Downie_HealthSudan_Web.pdf

81Accordingtothe2012-2016HeathSectorDevelopmentPlan,33%ofhealthfacilitiesrequiredcompletereplacementand18%requiredmajorrenovation.GovernmentofSouthSudan,HealthSectorDevelopmentPlan,2012-2016,pp.10,15.

82InternationalMedicalCorps(IMC),MentalHealthFacilities:SituationalAnalysisandStrategy,2013,p.9.

83IMC,MentalHealthFacilities:SituationalAnalysisandStrategy,2013,p.11.

84InterviewwithNGOstaffmember,Juba,SouthSudan,10April2015.Interviewwithfamilymemberofmentalhealthpatient,Juba,SouthSudan,4May2015.

85InterviewwithDrAtongAyuel,Director,MentalHealthDepartment,MinistryofHealth,10April2015.

86InterviewwithDrAtongAyuel,Director,MentalHealthDepartment,MinistryofHealth,Juba,SouthSudan,10April2015.IMC,MentalHealthFacilities:SituationalAnalysisandStrategy,2013,p.9.

87InterviewwithUpperNilestateMinisterofHealth,Malakal,SouthSudan,9May2015.

88InterviewwithNGOstaffmember,Juba,SouthSudan,10April2015.

89IMC,MentalHealthFacilities:SituationalAnalysisandStrategy,2013,p.10.


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HealthDepartmentalsotoldAmnestyInternationalthatsheisworkingtointegratementalhealthintheuniversitycurriculumandteachessomemodulesincollegesofmedicineacrossthecountry.91

Theroutineuseofprisonstohouseindividualswithmentalhealthconditionsisastarkmanifestationoftheinadequacyofmentalhealthtreatment,stigmaaboutmentaldisordersandthedeficitoffacilitiesandtrainedstaff.Individualswithmentalhealthconditionsdeemedtoposeadangertothemselvesorothersoftenenduparbitrarilydetainedinprison,eveniftheyhavenotcommittedanycrime.Theymaybetransferredtoprisonfrommedicalfacilitiesortakendirectlytoprisonbyfamilymemberswhofeelunabletocareforthem.InMay2016,therewere66maleand16femaleinmatesinJubaCentralPrisoncategorizedasmentallyill,morethanhalfofwhomhadnocriminalfiles.92AccordingtoaformerhealthworkeratMalakalHospital,priortotheconflict,therewere27peoplewithmentalhealthproblemsintheMalakalprison. “Some were brought to prison by family members because they were violent, aggressive, and suicidal,” heexplained.93


92Thirty-sixofthementallyillprisonershadcriminalfiles,while36didnot.Interviewwithprisonofficials,Juba,SouthSudan,6May2016.

93InterviewwithformerMalakalhospitalhealthworker,Malakal,SouthSudan,2May2015.

94InJuba,psychiatricstafffromtheTeachingHospitaldovisittheinmatesintheprison.Provisionofmedicationdependsoftenonavailabilityandabilityoffamilymemberstopay.InterviewwithJubaTeachingHospitalstaff,10April2015.SeealsoHumanRightsWatch,“PrisonisnotforMe”:ArbitraryDetentioninSouthSudan,June2012,availableat:https://www.hrw.org/sites/default/files/reports/southsudan0612_forinsert4Upload.pdf

95InMary2016,fivewomenwithmentaldisorderswereinsolitaryconfinementinJubaCentralPrison.AmnestyInternationalobservationsduringvisittoJubaCentralPrison,Juba,SouthSudan,6May2016.SeealsoHumanRightsWatch,“PrisonisnotforMe:”ArbitraryDetentioninSouthSudan.

96Interviewwithprisonofficials,Juba,SouthSudan,6May2016.

Peoplewithsuspectedmentalconditionsareroutinelydetainedinprisons.JubaCentralPrison,Juba,SouthSudan,2011.©RobinHammond

Inprison,peoplewithmentalhealthdisordersreceiveinsufficientmedicalcare,ifanyatall.94 AlthoughgenerallivingconditionsinSouthSudan’sprisonsareextremelypoor,inmateswithmentaldisordersareoftennaked,chainedorheldinsolitaryconfinement.95BetweenJanuaryandMay2016,fourinmateswithmentaldisordersdiedinJubaCentralPrisonduetoinsufficientfoodandtreatableillnessessuchasmalariaanddiarrhoea.96Thedetentionofindividualswithsuspectedmentaldisorders

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violatesahostofrights,includingtheprohibitionofarbitrarydetention,therighttonon-discrimination,tohealth,todueprocessaswellastobefreefromcruel,inhumananddegradingtreatmentorpunishment.97

GOVERNMENT MENTAL HEALTH POLICIESInits2006-2011HealthPolicy,thefirstarticulationofthevisionandprinciplesofthehealthsectorfollowingthesigningoftheCPA,theGovernmentofSouthernSudanindicatedthatitsawmentalhealthas“anessentialcomponentofpublichealth.”Thepolicypromisedthedevelopmentofastrategicapproachtoprotectingandpromotingmentalhealthandwell-being,andthedevelopmentofaflexiblerangeofpost-conflict,integratedmentalhealthsupportandcareservicesatalllevelsofthehealthsystem,particularlyatthecommunitylevel.Itspecifiedthatservicesshouldbe“appropriate,accountable,accessibleandequitable,andensurethatthedignityofpeopleisrespected.”Thepolicyfurtherpromisedthedevelopmentofamentalhealthstrategyandappropriatelegislation.98

MentalhealthisalsoincludedinSouthSudan’sBasicPackageofHealthServices(BPHS),whichprovidesservicenormsandstandardstoprimaryhealthcareservicemanagersandprovidersattheVillage,Boma,Payam,CountyandStatelevels.99The2012-2016HealthSectorDevelopmentPlan,intendedasaroadmapforimprovinghealthservices,recognizedthehumanresourcegapsinthementalhealthsectorandrecommendedthatthenumberofpsychiatristsshouldincreasefrom0in2012to11by2016,andthatthenumberofpsychiatrictechniciansshouldincreasefrom0to112.100

Thoughthesepoliciesandplansforeseesomerelevantimprovementstomentalhealthservices,therehasbeenlittleornoimplementation.Humanresourceobjectives—conservativeastheyare—havenotbeenmet.101Norhavementalhealthcareservicesbeenintegratedintotheprimaryhealthcaresystem.TheestablishmentinJune2014ofaDepartmentofMentalHealthinthenationalhealthministrywasapositivestep,butitremainsunder-staffedandunder-resourced.TheDirector’sgoaltooverseethedevelopmentofaspecificmentalhealthpolicyis,asofMay2016,yettoberealized.102 Nor is there anylegislationconcerningmentalhealthissues,includingontheexistingpracticeofincarceratingpeoplewithsuspectedmentalhealthdisorders.

Inadditiontofailingtoadequatelyintegratementalhealthintothenationallegalandpoliticalframework,SouthSudanhasalsofailedtomakeadequatefinancialcommitmentstoimprovetheavailabilityandaccessibilityofmentalhealthservices.Thehealthsectorbudgetasaproportionofthenationalbudgetdeclinedfrom7.9%in2006to4.2%in2011.103Inthe2015-2016budgetplan,thehealthsectorreceivedonly3%ofthetotalbudgetandonly1%wasallocatedtosocialandhumanitarianaffairs.Meanwhile,thesecuritysectorreceived44%,thehighestamountinthebudgetaryallocation.104Whilethereisnospecificrequirementunderinternationalhumanrightslawforthepercentageofnationalbudgetagovernmentisrequiredtospendonthehealthsector,inthe1991AbujaDeclaration,Africangovernmentspledgedtoallocateatleast15%oftheirannualbudgettoimprovingthehealthsector.105Itisunclearhowmuchofthegovernment’shealthsectorbudgetisspentonmentalhealthservices.106

97Thereisnolegislationgoverningtheforcedcommitmentofindividualstomentalhealthoranyotherinstitutionwheretheyaredeprivedofliberty.Thusthereisnoclearlegalbasisforthesedetentions.

98GovernmentofSouthernSudan,MinistryofHealth,HealthPolicyfortheGovernmentofSouthernSudan,2006-2011,pp.38-39.http://www.africanchildforum.org/clr/policy%20per%20country/south%20sudan/ssudan_health_2006-2011_en.pdf

99GovernmentofSouthernSudan,MinistryofHealth,BasicPackageofHealthandNutritionServicesforSouthernSudan,2009.

100GovernmentofSouthSudan,HealthSectorDevelopmentPlan,2012-2016,p.40.

101Evenifimplementedfully,thiswouldstillmeanthattherewouldonlybeonepsychiatristper700,000inthepopulation.


103GovernmentofSouthSudan,HealthSectorDevelopmentPlan,2012-2016,p.x.

104MinistryofFinanceandEconomicPlanning,ApprovedBudgetTables:FiscalYear2015/16,October2015,p.14,availableat:http://www.grss-mof.org/wp-content/uploads/2015/10/RSS-Approved-Budget-Book-2015-16.pdf

105AbujaDeclarationonHIV/AIDS,TuberculosisandotherInfectiousDiseases,OAU/SPS/ABUJA/3,27April2001,availableat:http://www.un.org/ga/aids/pdf/abuja_declaration.pdf

106AmnestyInternationalwrotetotheMinistryofHealthinApril2016requestingthisinformation,butdidnotreceivearesponse.

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INTERNATIONAL ASSISTANCE AND COOPERATION

INSUFFICIENT MENTAL HEALTH SERVICES IN POC SITES AND OTHER EMERGENCY SETTINGS

AnumberofNGOshaveestablishedpsychosocialsupportinterventionsinPoCsites.Interventionsincludetheestablishmentofchild-friendlyspaces,grouprecreationalactivities,andpsychosocialfirstaidorsupporttosurvivorsofsexualviolence.TheInternationalRescueCommittee(IRC),forexample,runsawomen’sprotectionandempowermentprogrammeinBentiuPoCthatincludesfivewomen’scentresofferingpsychosocialsupportandindividualcasemanagement.107TheInternationalOrganisationforMigration(IOM)hasestablishedandtrainedpsychosocialmobileteamsintheBentiuandBorPoCsiteswhichprovideservicesaimedatstrengtheningfamilyandcommunitysupport,suchasrecreationalactivities,discussiongroupsandfocused,non-specializedservicesthroughpeersupportgroups,laycounsellingandhomevisits.108HandicapInternationalhasaprogrammedesignedtoimprovethepsychosocialsituationofinternallydisplacedpeopleinJubathatincludespsychosocialcounsellingandtheestablishmentofsupportgroups.109Whileimportantcontributions,theseprogrammesarestillinsufficientgiventhelargepopulationstheyareintendedtosupport.

Thereisalsoaspecificgapintheavailabilityofspecializedmentalhealthcareservices,suchaspsychotherapy,grouptherapy,orpharmacologicintervention,forpeoplewhohavesignificantdifficultiesinbasicdailyfunctioningandhavenotbeenhelpedbymorebasiccommunityinterventions.Few NGOsinSouthSudanprovidesuchservices.AccordingtooneNGOstaffmember, “everyone is doing psychosocial support, but it doesn’t help to put people with severe problems into a child-friendly space.”110 TheconcernexpressedbymultipleNGOworkersisthatthereisnoabilitytorefercasesidentifiedthroughpsychosocialsupportprogrammes. “Demand is being created and there is an awareness, but where can people go to seek treatment?”askedoneNGOstaffmember.111

InternationalMedicalCorps(IMC)istheonlyNGOofferingmorespecializedmentalhealthservicesintheJubaandMalakalPoCsites.IMChasoneexpatriatepsychiatristwhooverseesmentalhealthofficersstationedatIMC-runprimaryhealthclinicsintheJubaandMalakalPoCsites.112 Through thementalhealthofficers,speciallytrainedcommunityhealthworkers,andthestaffoftheprimaryhealthclinics,IMCprovidestreatment,counselling,andcasemanagementforindividualswithmental,neurologicalandsubstanceusedisorders.Theyalsooffercommunityawareness-raisingandsensitizationthroughhomevisits,communitysupportgroups,andlocalradioprogramming.113ButtheIMC’ssinglementalhealthofficerinJubaservesapopulationofover28,000,whiletheofficerinMalakalserves47,000people.InBentiu,where120,000internallydisplacedpeopleliveattheUNMISSPoCsite,therearenospecializedmentalhealthservicesavailableforpeoplewithseverementaldisorders.

WhiletherearegapsinmentalhealthserviceprovisionwithinthePoCsites,thesituationisfarworseinotherareasofthecountryaffectedbyconflict,includingwhereinternallydisplacedpeoplehavesettledinformally,outsideofthePoCsites.Theyhavelittleaccesstoanyformofmentalhealthsupport.

SCARCE SUPPORT TO PUBLIC HEALTH SECTOR

Thereareonlyafewinternationalorganizationswithprogrammessupportingtheimprovementofmentalhealthserviceswithinthepublichealthsector.HandicapInternationalinitiatedamentalhealth

107InterviewwithInternationalRescueCommittee(IRC)staff,Bentiu,SouthSudan,14May2015.

108InterviewwithInternationalOrganizationforMigration(IOM)staff,1May2015.

109HandicapInternational,UrbanJubaProject,2016(onfilewithAmnestyInternational).



112IMCalsohasmentalhealthofficersinMinkamaninternallydisplacedpersonssite,inAkoboandatGendrasaandKayarefugeecampsinMabanCountyandoneexpatriateclinicalpsychologistbasedinMaban.InterviewwithIMCstaff,Juba,SouthSudan,10April2015.

113InterviewwithIMCstaff,Juba,SouthSudan,10April2015.

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projectin2014thatincludesworktosupportandbuildthecapacityofstaffinthepsychiatricwardofJubaTeachingHospitalandthestaffandauthoritiesatJubaCentralPrisoninissuesrelatingtomentalhealth.Theyarealsohopingtosupportthehealthministryinthedevelopmentofanationalmentalhealthpolicy.114HealthNetTPOhasrecentlyworkedonapilotprojecttointegratementalhealthcareintothreeprimaryhealthcarecentresinJurRivercountyinWesternBahrelGhazalstate.Theproject,whichendedinDecember2015,facednumerouschallenges,includingtheabsenceofaguidingmentalhealthpolicy,insufficienthumanresources,insufficientfunding,andhighturnoverofthestaffintheprimaryhealthcarecentres.115

SaintBakhitaHealthCentreinYei,CentralEquatoriastate,runbytheCatholicDioceseofYei,providesdirectservicestoindividualsinneedofmentalhealthcare.In2014,itprovidedinoroutpatientservicesto206patientswitharangeofmentalhealthconditions.116They,however,lackspecializedstaff,onlyhaveonepsychiatricnurseandnoseparatewardformentalhealthpatients.117

LIMITED AND UNCOORDINATED COMMUNITY-BASED TRAUMA PROGRAMS

SomechurchesandsmallerNGOscarryoutcommunity-basedinterventionsthatseektoaddresstrauma.MorningStar,forexample,isatraumaawarenessprogramfundedbytheUnitedStatesAgencyforInternationalDevelopment(USAID)whosevisionistocreateopportunitiesforpeopletolearnabouttrauma,begintoheal,andcometogetherasacommunitytosupportfurtherhealingandreconciliation.118MorningStarhastrainedfacilitatorswhohaveheldcommunityconversationsabouttrauma.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-basedorganizationfoundedbySouthSudanesepsychosocialcounsellorsandpsychiatricnurses,specializesinprovidingmentalhealthandpsychosocialsupportforsurvivorsofwarandorganizedviolenceinEasternEquatoriastate.Theiractivitiesincludecommunityawarenessraisingonmentalhealth,traininggovernmenthealthworkersonmentalhealth,runningmobilementalhealthoutreachclinicsandcarryingoutindividualandgroupcounselling.

Suchcommunity-basedtraumaprogrammescanhelpreducestigmarelatedtomentalhealthsymptoms,assistpeopletobetterunderstanddifficultexperiences,increasehealthycoping,andstrengthensupportsystems.Theythereforeplayanimportantroleinthespectrumofmentalhealthservices.But,intheabsenceofaclearmentalhealthstrategy,thereisnooverarchingvisionofhowtheseinterventionsshouldbecarriedout,includingbestpracticesorprofessionalandethicalstandardstheyshouldadheretoorofhowtheyrelatetoothermentalhealthinterventions.Asaresult,community-basedtraumainterventionsarelargelyuncoordinatedandunlinkedtothemoreformalmentalhealthsector.

INADEQUATE SUPPORT FROM WHO

Withitspublicationofthe2001WorldHealthReport,whichfocusesonmentalhealth,theWHOsoughttodispelthehistoricalneglectofmentalhealthandincreaseattentiontomentalhealthbecauseitis“criticaltotheoverallwell-beingofindividuals,societiesandcountries.”120Sincethen,theWHO

114Seewww.handicap-international.us/south_sudan

115InterviewwithHealthNetTPOstaff,10April2015.

116PresentationbyCoordinator,SaintBahkitaHealthCentre,10March2015.

117PresentationbyCoordinator,SaintBahkitaHealthCentre,10March2015.

118InterviewwithMorningStarstaff,Juba,SouthSudan,9April2015.

119InterviewwithSolidaritywithSouthSudanstaff,Juba,SouthSudan,6May2015.

120WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,pxi,availableat:http://www.who.int/whr/2001/en/

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hasdevelopedorcontributedtoanumberofmentalhealthtools,includingtheInter-AgencySteeringCommittee(IASC)GuidelinesonMentalHealthandPsychosocialSupportinEmergencySettingsandthementalhealthGapActionProgramme(mhGAP)whichfocusesonhowtoexpandservicesformentalhealthinlowresourcesettingssuchasSouthSudan.121TheWHOhasalsoemphasizedthatcountriescanmakesubstantialgainsinmentalhealthservicesduringandfollowingemergencies.Infact,accordingtoWHO,despitetheiradverseeffectsonmentalhealth,emergencies—oftenaccompaniedbyanincreaseinhumanitarianaidandfocusedattentiononmentalhealth—presentanimportantopportunitytotransformmentalhealthcareforthelongterm.122

Accordingtoitsconstitution,theWHOisresponsibleforprovidingleadershiponglobalhealthmatters,shapingthehealthresearchagenda,settingnormsandstandards,articulatingevidence-basedpolicyoptions,providingtechnicalsupporttocountries,andmonitoringandassessinghealthtrends.123 In 2013,theWHOpublishedaglobalMentalHealthActionPlanthatrecommendsthefollowingactionsfortheWHO:buildingcapacityinthedevelopmentandimplementationofpolicies,plansandlawsrelevanttomentalhealth;offeringtechnicalsupportforresourceplanning,budgetingandexpendituretrackingformentalhealth;providingtechnicalsupportforexpandingmentalhealthtreatmentandsupport;providingtechnicaladviceandguidanceforpolicyandactivitiesrelatedtomentalhealthinhumanitarianemergencies;supportingcountriesintheformulationofahumanresourcestrategyformentalhealth;andprovidingguidanceandtrainingonthedevelopmentofinformationsystemstocaptureinformationaboutcorementalhealthindicators.124

Unfortunately,theWHOofficeinJubahasnotprovidedsubstantialtechnicalorfinancialsupporttoexpandingmentalhealthservicesinSouthSudan—afactacknowledgedbytheWHOCountryRepresentative.125TheWHOofficeis,however,hopingtoimproveitssupportformentalhealththroughtherecruitmentofastaffpersonresponsiblefornon-communicablediseases,includingmentalhealth.TheWHOisalsoplanningtoconductanassessmentofnon-communicablediseases,includingmentalhealth,inJune2016. Findingswouldbeusedtoshapeinterventionsandstrategiesonmentalhealth.126TheWHOSouthSudanworkplanfor2016-2017foreseessupportforthedevelopmentandimplementationofamentalhealthpolicyinlinewiththeWHOMentalHealthActionPlan2013-2020andsupportforthedevelopmentofintegratedmentalhealthservices,buttheseactivitiesarenotyetfunded.127

LIMITED DONOR FUNDING

DonorsupporttoSouthSudan’shealthsectorsince2005hascomeprimarilythroughbilateralgrantsupportaswellaspooleddonorfundingmechanismsintendedtosupporttheimplementationoftheBasicPackageofHealthServices(BPHS)andtheHealthSectorDevelopmentPlan.128AlthoughmentalhealthisincludedintheBPHSandanincreaseinthenumberofmentalhealthprofessionalswasoneobjectiveoftheHealthSectorDevelopmentPlan,accordingtomentalhealthworkersinSouthSudan,littledonorfundinghasmadeitswaytosupporttheimprovementandexpansionofgovernment-providedmentalhealthservices.

121WHO,MentalHealthGapActionProgramme(mhGAP):ScalingUpCareforMental,Neurological,andSubstanceAbuseDisorders,availableat:http://www.who.int/mental_health/evidence/mhGAP/en/

122WHO,BuildingBackBetter:SustainableMentalHealthCareafterEmergencies,2013,availableat:http://apps.who.int/iris/bitstream/10665/85377/1/9789241564571_eng.pdf

123WHOConstitution,1946,Article2,availableat:http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf?ua=1

124WHO,MentalHealthActionPlan2013-2020,pp.13-19.

125InterviewwithWHOCountryRepresentative,Juba,SouthSudan,3May2016.

126InterviewwithWHOCountryRepresentative,Juba,SouthSudan,3May2016.

127WHOCountryOffice,SouthSudan,ApprovedWHOWorkPlansfor2016-17Biennium(onfilewithAmnestyInternational).InterviewwithWHOstaffmember,Juba,SouthSudan,28April2016.

128TheMulti-DonorTrustFundmanagedbytheWorldBank,ranfrom2005to20013.Since2013,theWorldBankhassupportedtheRapidResultsHealthProject(RRHP)managedbyIMAWorldHealth(IMA).TheBasicServicesFund,supportedbytheUnitedKingdom(UK),Canada,Norway,Sweden,theEuropeanUnion(EU)andtheNetherlands,ranfrom2005to2012.ThefirstHealthPooledFund,supportedbyAustralia,Canada,theEuropeanCommission,SwedenandtheUKranfrom2012-2016.ThesecondHealthPooledFund,supportedbyAustralia,Canada,theEuropeanCommission,Sweden,theUKandtheUSwillstartin2016.

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Therearemultipleexplanationsastowhydonorsupporttothehealthsector,thoughsubstantial,hasnotresultedinanimprovementofmentalhealthservices.129Forone,theabsenceofanationalmentalhealthpolicyorstrategy,orofcleargovernmentcommitmenttomentalhealth—eitherpoliticalorfinancial—meansthereislittletoinspireorguidedonorsupportformentalhealth.Also,thepaucityofmentalhealthprofessionalsinSouthSudanmeansthattherearefewadvocatesforimprovedmentalhealthservices.TheMinistry’sDepartmentofMentalHealth—thewould-bechampionofmentalhealthservices—doesnothavethehumanorfinancialresourcestoeffectivelycoordinatenationalandinternationalplayersortorallydonorsupport.TheDepartmentinfacthasonlyonestaffperson—theDirector.

Anotherissueisthat,thoughdonorfundingpurportedlysupportsimplementationoftheBasicPackageofHealthandNutritionServices,certaininterventionsareprioritized.TheobjectivesoftheHealthPooledFundforexample(whichinfactmirrorthoselaidoutintheGovernment’sHealthSectorDevelopmentPlan2012-2016)includeto“increasetheutilisationandqualityofhealthservices,withanemphasisonmaternalandchildhealth.”130 GiventhatSouthSudanhasthehighestmaternalmortalityrateintheworld,thisemphasisisappropriate.ButtheHealthPooledFund’s101-pageinstructionstoimplementingpartners,whichoutlineessentialprimaryhealthcareactivities,makenomentionatallofmentalhealthandpsychosocialsupport.131Thisisoneillustrationofhowservicespecificprioritizationsmayovershadowothercriticalelementsofhealthcare,suchasmentalhealthcare.

Thefailuretodeliberatelyensurethatmentalhealthandpsychosocialsupportprogrammesareintegratedintohealthinterventions,aswellasintoworkinothersectors,crosscutsthegovernment,thedonorcommunity,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’sConflictAdvisorinJubabegandevelopingastrategytointegratetraumainterventionsintoprogramsineachofUSAID’sdevelopmentsectors(health,education,governance,foodsecurity,livelihoods,andconflictmitigation).133

Initiatingmentalhealthandpsychosocialsupportprogrammingiscomplex,especiallygivenculturaldifferencesandanabsenceofqualitativeorquantitativeresearchtoguideprogrammedesign.Itisalsodifficulttomeasuretheimpactofmentalhealthservices—unlikeotherformsofhumanitarianassistancelikewaterorfooddistribution.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,mayrequirelong-termtreatmentandcareand,asaresult,anexpectationofalong-termcommitmenttofunding.136

NationalandinternationalNGOworkersfeltthatallofthesefactorscontributedtotheperceivedreluctanceamongdonorstofundmentalhealthservices.

129In2014-2015,forexample,internationaldonorsprovidedUS$230millioninsupporttothehealthsector.MinistryofFinanceandEconomicPlanningoftheGovernmentoftheRepublicofSouthSudan,SouthSudanAnnualAidReport2014/15,2016,availableat:http://www.grss-mof.org/wp-content/uploads/2016/06/South-Sudan-2014-15-Annual-Aid-Report.pdf

130See“KeyobjectivesoftheHPF,”availableat:http://www.hpfsouthsudan.org/background/HealthSectorDevelopmentPlan,2012-2016,p.xi.

131MinistryofHealthandHealthPooledFund,CallforProposals,April2013,availableat:http://www.hpfsouthsudan.org/download/hpf_key_documents/management_of_hpf_mechanism/Request%20for%20Proposals%20-%20Eastern%20Eqautoria,%20Western%20Bahr%20el%20Ghazal%20and%20Unity%20States.pdf

132Emailcommunicationwithmentalhealthworker,May2016.

133InterviewwithUnitedStatesAgencyforInternationalDevelopment(USAID)staff,Juba,SouthSudan,5May2016.

134Interviewwithexpatriatepsychologist,Juba,SouthSudan,7April2014.



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6. SOUTH SUDAN’S LEGAL OBLIGATIONS

SouthSudanisboundbyinternationallawtorespect,protectandfulfiltherighttohealth,whichtheWHOdefinesas“astateofcompletephysical,mentalandsocialwell-beingandnotmerelytheabsenceofdiseaseorinfirmity.”137Thisrequiresthegovernmenttoensureaccesstomentalhealthservices;refrainfromactssuchastorturethatcausepsychologicalharm;andpreventsuchactsbythirdparties.SouthSudanmustalsoensurethatvictimsofserioushumanrightsorhumanitarianlawviolationsorabusesreceivecompensationformentalharmandrehabilitation,includingpsychologicalcare.AmnestyInternational’sfindingsleadtotheconclusionthatSouthSudanisfailingtomeettheseobligationsinanumberofrespects.

THE RIGHT TO MENTAL HEALTH CARE SERVICES AS PART OF THE RIGHT TO HEALTHTherighttohealthisenshrinedinnumerousinternationalandregionalhumanrightsinstrumentsincludingtheUniversalDeclarationofHumanRights(UDHR).138 The Convention on the Rights of theChild(CRC),towhichSouthSudanisaparty,recognizestherightofthechildto“thehighestattainablestandardofhealth”andrequiresthatchildrenwithmentaldisabilitieshaveaccesstohealthcareservices.139SouthSudanisalsoboundundertheConventionontheEliminationofAllFormsofDiscriminationagainstWomen(CEDAW)toensureaccesstohealthservicesforallwomen.140AsasignatorytotheAfricanCharteronHumanandPeoples’Rights(theAfricanCharter),SouthSudanhasindicatedanintenttobeboundbyitscontent,includingArticle16whichprovidesthat“everyindividualshallhavetherighttoenjoythebestattainablestateofphysicalandmentalhealth.”141

TheTransitionalConstitutionoftheRepublicofSouthSudan(TCRSS),inplacesince2011,alsorecognizesthegovernment’sobligationtoprovidehealthservices.Itstatesthat:“Alllevelsof

137WHOConstitution,1946,Preamble.

138UniversalDeclarationofHumanRights(UDHR),1948,Article25.

139UNConventionontheRightsoftheChild(CRC)1989,ratifiedbySouthSudaninMay2015,Articles23and24.

140UNConventionontheEliminationofAllFormsofDiscriminationagainstWomen(CEDAW),1979,ratifiedbySouthSudaninMay2015,Article12.

141AfricanCharteronHumanandPeoples’Rights(AfricanCharter),Article16(1).SouthSudansignedtheAfricanCharteron24January2013.SouthSudan’sNationalLegislativeAssemblyapprovedratificationoftheAfricanCharterinOctober2013.TheonlyremainingsteptocompletetheratificationprocessisforthegovernmenttodeposittheinstrumentofratificationwiththeAU.SinceSouthSudanhassignedthetreaty,itisboundbytheViennaConventionontheLawofTreatiestorefrainfromactsthatwoulddefeatitsobjectandpurpose.ViennaConventionontheLawofTreaties,1986,Article18.

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governmentshallpromotepublichealth,establish,rehabilitateanddevelopbasicmedicalanddiagnosticinstitutionsandprovidefreeprimaryhealthcareandemergencyservicesforallcitizens.”142

SouthSudanisnotpartytotheConventionontheRightsofPeoplewithDisabilities(CRPD)ortotheInternationalCovenantonEconomic,SocialandCulturalRights(ICESCR)—twokeytreatieswithrespecttomentalhealth.143However,thetreatymonitoringbodyoftheICESCR,theCommitteeonEconomic,SocialandCulturalRights(CESCR),hasprovidedusefulandauthoritativeguidanceonhowstatesshouldimplementtherighttohealth,includingmentalhealth.EvenintheabsenceofratificationoftheICESCR,SouthSudanshouldtakecognisanceoftheCESCR’sguidanceinordertoeffectivelycomplywithitsobligationsunderothertreatiesanditsownconstitutiontoimplementtherighttohealth.

AccordingtotheCESCR,thoughfulfilmentoftherighttohealthistoagreatextentdependentontheavailabilityofresources,allcountries,notwithstandingtheireconomicsituation,haveaminimumcoreobligationtoensurethesatisfactionof,attheveryleast,minimumessentiallevelsofhealthservices.144 Coreobligationsofstatesincludetheprovisionofessentialprimaryhealthcareandessentialdrugs.145 AccordingtotheWHO,theprovisionofprimaryhealthcareshouldincludethedetectionandtreatmentofcommonmentalandbehaviouraldisorders.146Statesarealsorequired,asaminimumcoreobligation,toadoptandimplementanationalpublichealthstrategyandplanofaction.147

Inadditiontoprovidingminimumlevelsofservices,implementingtherighttohealthprovidedinCRC,CEDAW,theAfricanCharter,andSouthSudan’sconstitutionrequiresthegovernmenttoimproveandexpanduponhealthservicesovertime,inaccordancewiththeprincipleofprogressiverealisation.Progressiverealizationrequiresstatestotakedeliberate,concreteandtargetedsteps,as“expeditiouslyandeffectivelyaspossible”andtothemaximumoftheiravailableresourceswithaviewtoprogressivelyrealizingtherighttohealthovertime.148Suchstepsmightincludeadoptinglegislationoradministrative,economic,financial,educationalorsocialreforms,orestablishingactionprogrammes,appropriateoversightbodiesorjudicialprocedures.AvailableresourcesrefertothoseexistingwithinaStateaswellasthoseavailablefromtheinternationalcommunitythroughinternationalcooperationandassistance.149ThecontextofarmedconflictdoesnotdiluteSouthSudan’simmediateobligationtotakestepstoensurefullrealizationoftherighttohealth.150

AccordingtotheCESCR,fulfilmentoftherighttohealthmeansthathealthservices,includingmentalhealthservices,areavailable,accessible,acceptable,andofgoodquality.Availabilitymeansthatthereareenoughmentalhealth-relatedfacilitiesandservicesaswellassufficienttrainedmedicalandotherprofessionals.Accessibilitymeansthatmentalhealthfacilitiesareaffordable,geographicallyaccessibleandavailablewithoutdiscrimination;italsocomprisestherighttoseekandreceiveinformationabouthealthservices.Acceptabilitymeansthatfacilitiesrespectdifferentculturesandmedicalethics.Servicesofgoodqualitymeetmedicalandscientificstandardsofquality.151

Animportantprincipleregardingmentalhealthservices,providedforinthe1991UNPrinciplesfortheProtectionofPersonswithMentalIllnessandfortheImprovementofMentalHealth,isthateveryindividualhastherighttobetreatedandcaredfor,asfaraspossible,inthecommunityin

142TransitionalConstitutionoftheRepublicofSouthSudan(TCRSS),2011,Article31.

143SeeCommitteeonEconomic,Social,andCulturalRights(CESCR),GeneralComment3:TheNatureofStatePartiesObligations(art.2(1)(GeneralComment3),1990,UNDocE/1991/23,para10.

144CESCR,GeneralComment3,para.10.

145CESCR,GeneralComment14:TheRighttotheHighestAttainableStandardofHealth(GeneralComment14),2000,UNDocE/C.12/2000/4,para.43.

146WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,p.59.




150SeeAnandGrover,ReportoftheSpecialRapporteurontheRightofEveryonetotheEnjoymentoftheHighestAttainableStandardofPhysicalandMentalHealth,2013,UNDocA/68/297.


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whichheorshelives.152Patientsalsohavetherighttobetreatedintheleastrestrictiveenvironmentandwiththeleastrestrictiveorintrusivetreatmentappropriatetothepatient’shealthneedsandtheneedtoprotectthephysicalsafetyofothers.153TheWHOcallsforpeoplewithmentaldisorderstobemovedoutofprisonsandforallinstitutional-basedcareforpeoplewithmentalhealthconditionstobephasedout.AccordingtotheWHO,untilallpatientscanbedischargedintothecommunitywithadequatecommunitysupport,psychiatricinstitutionsshouldbedownsized,thelivingconditionsofpatientsshouldbeimproved,andproceduresshouldbesetuptoprotectpatientsagainstunnecessaryinvoluntaryadmissionsandtreatments.154

Fulfillingtherighttomentalhealthfurtherrequiresthatmentalhealthservicesbedesignedtofulfilawiderangeofmentalhealthneeds.AccordingtotheUNSpecialRapporteurontherightofeveryonetothehighestattainablestandardofphysicalandmentalhealth(SpecialRapporteurontherighttohealth),“[States]shouldtakestepstoensure[theavailabilityof]afullpackageofcommunity-basedmentalhealthcareandsupportservicesconducivetohealth,dignity,andinclusion,includingmedication,psychotherapy,ambulatoryservices,hospitalcareforacuteadmissions,residentialfacilities,rehabilitationforpersonswithpsychiatricdisabilities,programmestomaximizetheindependenceandskillsofpersonswithintellectualdisabilities,supportedhousingandemployment,incomesupport,inclusiveandappropriateeducationforchildrenwithintellectualdisabilities,andrespitecareforfamilieslookingafterapersonwithamentaldisability24hoursaday.”155

TheWHOsimilarlyrecommendsthatprovidingcomprehensivementalhealthcarerequiresavarietyofservices.Theseservicesshouldincludeabalanced combination of medication (or pharmacotherapy); psychotherapy; and psychosocial rehabilitation.156TheWHO’soptimalmixofservicespyramidframework(figure 1)indicatesthatthemajorityofmentalhealthcarecanbemanagedthroughself-careandinformalcommunitymentalhealthservices.Whereadditionalexpertiseisneeded,moreformalizedservicesarerequired.Inascendingordertheseincludeprimarycareservices,followedbyspecialistcommunitymentalhealthandpsychiatricservicesbasedingeneralhospitals,andlastlybyspecialistandlongstaymentalhealthservices.157

152UNPrinciplesfortheProtectionofPersonswithMentalIllnessandfortheImprovementofMentalHealth,17December1991,A/RES/46/119,Principle7.

153UNPrinciplesfortheProtectionofPersonswithMentalIllnessandfortheImprovementofMentalHealth,Principle9.

154WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,pp.87,114.

155PaulHunt,ReportoftheSpecialRapporteurontherightofeveryonetotheenjoymentofthehighestattainablestandardofphysicalandmentalhealth,2005,UNDoc.E/CN.4/2005/51,para.42.


157WHO,“TheOptimalMixofServicesforMentalHealth,”availableat:http://www.who.int/mental_health/policy/services/2_Optimal%20Mix%20of%20Services_Infosheet.pdf

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WHO optimal mix of services pyramid framework. 158

158WHO,“TheOptimalMixofServicesforMentalHealth.”

159TheInter-AgencySteeringCommittee(IASC)Guidelinesonmentalhealthandpsychosocialsupportduringemergencysettingsweredevelopedin2007withtheparticipationofmentalhealthpractitioners,universitiesandnumeroushumanitarianandhumanrightsorganizations.TheguidelinesareconsideredthegeneralreferencefororganizationsprovidingmentalhealthorpsychosocialsupportservicesinthecontextofhumanitarianprogramminginSouthSudan.IASC,IASCGuidelinesonMentalHealthandPsychosocialSupportinEmergencySettings,2007,availableat:http://www.who.int/mental_health/emergencies/guidelines_iasc_mental_health_psychosocial_june_2007.pdf

160IASC,IASCGuidelinesonMentalHealthandPsychosocialSupportinEmergencySettings,pp.11-13.

TheInter-AgencySteeringCommittee(IASC)guidelinesontheprovisionofmentalhealthandpsychosocialsupportinemergencysettings,suchastheUNMISSPoCsites,recommendtheavailabilityofasimilar,layeredsystemofcomplementarysupportstomeettheneedsofdifferentgroups.159(See figure 2)TheIASCpyramidframeworkcallsfirstlyforbasicneeds,suchasfood,shelter,andwatertobeprovidedinasociallyappropriatemannerthatpromotesmentalhealthandpsychosocialwellbeing.Thesecondlayerrepresentsresponsesthatseektostrengthencommunityandfamilysupports,throughforexample,discussiongroups,child-friendlyspaces,andculturalandrecreationalactivities.Thethirdlayerrepresentssupportsnecessaryforasmallernumberofpeoplewhorequireadditional,morefocusedindividualorfamilyinterventionsbytrainedandsupervisedworkers.Thislayerincludesbasicmentalhealthcarebyprimaryhealthcareworkers.Thetoplayerrepresentstheadditionalpsychologicalorpsychiatricsupportsneededforpeoplewhosesufferingisintolerableandwhohavedifficultieswithbasicdailyfunctioningthatexceedthecapacityofanyprimaryhealthservicesavailable.Thoughsuchspecialisedservicesareneededonlyforasmallpercentageofthepopulation,accordingtotheIASC,inmostlargeemergenciesthisamountstothousandsofindividuals.160

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Figure 2: IASC intervention pyramid for mental health and psychosocial support in emergencies, as adapted by the WHO.161

WhileSouthSudanisnotexpectedtoprovidethesamelevelofmentalhealthservicesasadevelopedcountry,ithasfailedtoguaranteeevenminimumessentialmentalhealthservices,suchasthedetectionandtreatmentofcommonmentalandbehaviouraldisordersandtheavailabilityofessentialpsychotropicmedicines.Inaddition,thegovernmenthasfailedtomakeanyidentifiableprogresstowardsimprovingtheavailabilityandaccessibilityofmentalhealthservicesoverthepastyears.Notably,ithasfailedtoadoptamentalhealthpolicyortopassmentalhealthlegislation—stepsthatdon’trequiresignificantresources.TheWHOdescribestheabsenceofamentalhealthpolicyasindicativeofa“lackofexpressedcommitmenttoaddressmentalhealthproblems.”162Thelackofprogressinimprovingmentalhealthservicesoverthepastfewyearsindicatesinsufficientpoliticalwillandfinancialcommitmenttoaddressmentalhealth.Fortheabovereasons,SouthSudanisviolatinganumberofobligationswithrespecttotherighttohealth.

VIOLENCE AS A VIOLATION OF THE RIGHT TO MENTAL HEALTHItiswidelyacceptedthatactssuchastorture,sexualviolence,andunlawfulkillingwilloftenhaveanegativeimpactonthementalhealthof“victims”—peoplewhohaveindividuallyorcollectivelysufferedhumanrightsviolationsaswellastheirimmediatefamilyordependantswhohavesufferedharmininterveningtoassistorpreventvictimization.163Inadditiontobeingseriousviolationsofcivilandpoliticalrightsinandofthemselves,suchactscan,therefore,alsoconstituteviolationsoftherighttohealth.

161WHO,UNHCR,MentalHealthGapActionProgrammeHumanitarianInterventionGuide,2015,p.11,availableat:http://apps.who.int/iris/bitstream/10665/162960/1/9789241548922_eng.pdf


163Theterm“victim”forthepurposeofreparationincludesthosewhohaveindividuallyorcollectivelysufferedharm,including“theimmediatefamilyordependantsofthedirectvictimandpersonswhohavesufferedharmininterveningtoassistvictimsindistressortopreventvictimization.”UNBasicPrinciplesandGuidelinesontheRighttoaRemedyandReparationsforVictimsofGrossViolationsofInternationalHumanRightsLawandSeriousViolationsofInternationalHumanitarianLaw(UNBasicPrinciplesandGuidelines),2006,UNDocA/RES/60/147,Principle8.

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Tortureandothercruel,inhumanordegradingtreatmentareprohibitedunderSouthSudan’sConstitutionaswellasundertheUNConventionagainstTortureandOtherCruel,InhumanorDegradingTreatmentorPunishment(CAT),towhichSouthSudanisastateparty.Theinflictionofseverepainorsuffering,whetherphysicalormental,isakeyelementofthedefinitionoftorture.Itfollows,therefore,thatactsoftorturearealsoviolationsoftherighttohealth.Indeed,theCESCRhasstatedthattherighttohealthincludestherighttobefreefrominterferences,suchastorture.164

TheSpecialRapporteurontheRighttoHealthhasaffirmedthatviolencehasadirectimpactontheenjoymentoftherighttohealth,sinceitresultsin“significantphysical,psychologicalandemotionalharmtoindividualvictimsandcontributestosocialproblemsforindividuals,familiesandcommunities.”165RespectingtherighttohealthasprovidedintheCRC,CEDAW,andtheAfricanCharterthereforerequiresSouthSudantorefrainfromactsthatinterferewithindividuals’mentalhealth.SouthSudanmustalsoprotectindividualsfromactsthatcausementalharmbypreventingsuchactsbythirdparties.AccordingtotheCESCR,violationsoftherighttohealthinclude,“thefailuretoregulatetheactivitiesofindividuals,groupsorcorporationssoastopreventthemfromviolatingtherighttohealthofothers”and“thefailuretoprotectwomenagainstviolenceortoprosecuteperpetrators.”166SouthSudanmustthereforeexerciseduediligencetoprevent,investigate,andprosecuteactsthatcausenegativementalhealthimpacts,whetherperpetratedbyStateactorsorprivatepersons.

InthecontextofSouthSudan’scurrentinternalarmedconflict,governmentforceshavecommittedtorture,rape,enforceddisappearancesandarbitrarykillings—whichhaveterrorizedcivilianpopulations.SouthSudanhasalsofailedtoinvestigateandprosecutesuchacts,contributingtoacultureofimpunitythatallowsthemtocontinueunabated.Bothbycommittingandnotaddressingthesedeliberatetargetedacts,SouthSudanhasfailedtorespectandprotecttherightofitspopulationtothehighestattainablestandardofhealth.

THE RIGHT TO MENTAL HEALTH CARE SERVICES AS PART OF VICTIMS’ RIGHT TO REPARATIONSInadditiontorefrainingfromandpreventingactsthatcausepsychologicalharm,thegovernmenthasanadditionalspecificobligationunderinternationallawtoprovidenecessarymentalhealthservicestovictims.Thisobligationstemsfromtherightofvictimstoaneffectiveremedy,whichincludeseffectiveandpromptreparationforharmsuffered.167Whilstitisrecognisedthattheprovisionofeffectiveremedies,includingreparations,doeshaveresourceimplications,thisobligationisnotsubjecttoprogressiverealisationandthereforerequiresimmediateandconcretemeasures.

Reparationencompassestheconcretemeasuresthatshouldbetakentoaddressthesufferingofthesurvivorsandvictimsandtohelpthemrebuildtheirlives.Theaimofreparationisto“asfaraspossible,wipeoutalltheconsequencesoftheillegalactandre-establishthesituationwhichwould,inallprobability,haveexistedifthatacthadnotbeencommitted.”168Formsofreparationincluderestitution,compensation,rehabilitation,satisfaction,andguaranteesofnon-repetition.169Whileallformsofreparationwouldlikelycontributetoalleviatingpsychologicalharmsufferedbyvictims,mentalhealthservicesarespecificallyconsideredasanelementofstates’obligationstoprovidecompensation


165ReportoftheSpecialRapporteurPaulHunttotheCommissiononHumanRights,TheRightofEveryonetotheEnjoymentoftheHighestAttainableStandardofPhysicalandMentalHealth,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


167TherighttoaneffectiveremedyisincludedinArticle8oftheUDHRaswellasintheCAT,CEDAW,CRC,andtheAfricanCharter,allofwhichbindSouthSudan.

168PermanentCourtofArbitration:ChorzowFactoryCase(Germanyv.Poland),1928.

169TheUNBasicPrinciplesandGuidelinesrecognizefiveformsofreparation:restitution,compensation,rehabilitation,satisfactionandguaranteesofnon-repetition.

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foreconomicallyassessabledamage,includingmentalharmandthecostsofmedicalandpsychologicalcare,andtoensurerehabilitation,includingpsychologicalcareandsocialservices.170

SouthSudanbearstheprimaryresponsibilityforprovidingreparationtovictimsofhumanrightsviolationsinthecountry.ThereisanexpresslegalobligationonSouthSudantoprovidereparationwhenviolationsarecommittedbyagentsofthestateorunderthestate’sauthority.Whencrimesarecommittedbyagentsofotherstatesornon-stateactors—forexample,theSudanPeople’LiberationArmy-InOpposition(SPLA-IO)—SouthSudanhasanobligationtoensurethatvictimscanclaimreparationagainstthoseresponsible,includingbymakingclaimsthroughthenationaljusticesystem.171 Whenobtainingredressfromotherstatesornon-stateactorsisnotpossible,suchaswherethepersonresponsiblecannotbeidentifiedorlocated,orwherethereareobstaclesthatwilldelayvitalmeasuresofassistancerequiredbysurvivorsorvictims,SouthSudanshouldstepinandprovidereparationtosurvivorsandvictims,includingthroughadministrativeprogrammes,andthenseektoreclaimanycostsfromthoseresponsible.

ThescopeofmentalhealthservicesthatSouthSudanmustmakeavailabletohasbeenelaboratedinrelationtovictimsoftorture.AccordingtotheUNCommitteeagainstTorture,compensationandrehabilitationshouldcaterfortreatmentoftraumaandpsychologicalassistance.172TheUNVoluntaryFundforVictimsofTorture,establishedtocontributetotherehabilitationoftorturevictims,definespsychologicalassistancetoentail“individualtherapy,whetherbasedonclinical,psychoanalytical,behaviouralorothertherapy…toassistvictimswiththeirgradualreintegrationintosociety.Psychiatrictherapymaybecombinedwithmedicationtoalleviatephysicalandpsychologicalsymptoms.”173

Psychologicalrehabilitationhasalsobeenrecognizedasparticularlycriticalforvictimsofsexualviolence.AsastatepartytoCEDAW,SouthSudanisrequiredtoestablishorsupportservicesforvictimsofrape,sexualassaultandotherformsofsexualviolence,including“rehabilitationandcounselling.”174AccordingtotheUNDeclarationontheEliminationofViolenceagainstWomen,SouthSudanshouldalso“ensure,tothemaximumextentfeasibleinthelightoftheiravailableresourcesand,whereneeded,withintheframeworkofinternationalcooperation,thatwomensubjectedtoviolence…havespecializedassistance,suchasrehabilitation…treatment,counselling,andhealthandsocialservices…andshouldtakeallotherappropriatemeasurestopromotetheirsafetyandphysicalandpsychologicalrehabilitation.”175

Asdescribedabove,mentalhealthservicesarepracticallynon-existentinSouthSudan.Thisisthecasebothforthegeneralpopulationaswellasforvictimsofhumanrightsviolationswhoexperiencepsychologicalharm.Therearenocollectivereparationsprogrammesforvictimsofconflict-relatedviolations.AmnestyInternationalhasnotidentifiedanycaseinwhichthegovernmenthasprovidedanyindividualvictimofconflict-relatedviolationswithcompensationforpsychologicalharmorpsychologicalrehabilitation.

170UNBasicPrinciplesandGuidelines.TheCRCrequiresstatepartiestofulfiltherighttorehabilitationandto“promotephysicalandpsychologicalrecovery”ofchildvictimsoftortureandarmedconflict.CRC,Articles24and39.TheCATrequiresthatstatespartiesensure“asfullrehabilitationaspossible.”CAT,Article14.

171Thestatehasadutyto“providethosewhoclaimtobevictimsofahumanrightsorhumanitarianlawviolationwithequalandeffectiveaccesstojustice...irrespectiveofwhomayultimatelybethebearerofresponsibilityfortheviolation.”UNBasicPrinciplesandGuidelines,Principle3(c).

172InresponsetoSriLanka’sreport,theCommitteerecommendedto“establishareparationprogramme,includingtreatmentoftraumaandotherformsofrehabilitation,andtoprovideadequateresourcestoensureitseffectivefunding.”UNCommitteeagainstTorture,ConclusionsandRecommendationsoftheCommitteeagainstTorture:SriLanka,2005,UNDocCAT/C/LKA/CO/2,para.16.InresponsetoChad’sreport,theCommitteecalledonitto“[o]fferfullreparation,includingfairandadequatecompensationforthevictimsofsuchacts,andprovidethemwithmedical,psychologicalandsocialrehabilitation.”UNCommitteeagainstTorture,ConcludingObservationsoftheCommitteeagainstTorture:Chad,2009,UNDocCAT/C/TCD/CO/1.

173UNVoluntaryFundforVictimsofTorture,availableat:http://www.ohchr.org/EN/Issues/Torture/UNVFT/Pages/WhattheFunddoes.aspx

174CommitteeontheEliminationofDiscriminationAgainstWomen,GeneralRecommendation19:ViolenceagainstWomen,1992,para.24.

175UNGeneralAssembly,DeclarationontheEliminationofViolenceagainstWomen,1994,UNDocA/RES/48/104.

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7. THE WAY FORWARD

END VIOLATIONS AND ABUSES OF HUMAN RIGHTS AND HUMANITARIAN LAW Theviolationsandabusesofinternationalhumanrightsandhumanitarianlawcommittedbywarringpartieshaveheightenedthepsychologicalburdenoftheconflictoncivilianpopulations.Actssuchasrapeandotherformsofsexualviolence,tortureorotherill-treatment,targetedkillingofciviliansandthelootinganddestructionofcivilianhomes—allofwhichcantriggerpsychologicaldistressandothermentalhealthconditions—arewarcrimes.Thehunger,dispossessionandconstantinsecurityfacedbysomanyarealsoexacerbatedbyunlawfulactssuchastheobstructionofhumanitarianaccessandintentionaltargetingofcivilianlivelihoods.Theeffectiveavailabilityandprovisionofmentalhealthserviceswillhavelittleimpactonanindividualornationallevelaslongastheseruthlessandinhumaneacts,whichcontinuouslypiletraumaonthepeopleofSouthSudan,continue.

Onecorecomponentofaddressingthementalhealthimpactofthisconflictandfutureones,willthereforelieinchangingthecultureofwarfareandendingtheseeminglyroutineandflagrantviolationsandabusesofhumanrightsandhumanitarianlaw.Tothisend,theTransitionalGovernmentofNationalUnity(TGoNU)shouldworktoendandsupressallviolationsandabusesofinternationalhumanrightsandhumanitarianlawcommittedbymembersofthearmedforcesorassociatedpersonnelandensurethatviolationsandabusesarenotcommittedwithimpunity.Specifically,allforcesshouldimmediatelyceaseunlawfulkillings;actsofsexualviolenceandanyotherattacksoncivilians;lootinganddestructionofpublicandprivateproperty;violenceagainsthumanitarianpersonnelandassets;andotherobstructionstohumanitarianassistance.ItisalsocriticalthattheTGoNUprovideallforceswithsufficienttrainingandclearorderstoensuretheyareawareofwhatconductisprohibitedunderinternationallaw.Thegovernmentandtheoppositionshouldalsoputinplacemechanismstoadequatelymonitortheconductoftheirforces.

ThesigningoftheAugust2015peaceagreementwasquicklyfollowedbytheannouncementofapermanentceasefirebySalvaKiirandRiekMachar,buthasunfortunatelynotbroughtacompleteendtofightingortoitsaccompanyingviolationsofinternationalhumanitarianlaw.TheJointMonitoringandEvaluationCommission(JMEC),whichoverseesimplementationofthepeaceagreement,shouldcontinuouslycondemnviolationsandabusesofhumanrightsandhumanitarianlawbypartiestotheconflict.TheCeasefireandTransitionalSecurityArrangementsMonitoringMechanism(CTSAMM),thebodyunderJMECestablishedtomonitorandreportonceasefireviolations,shouldensurethatitsmonitoringandreportingaddressestheparties’respectforinternationalhumanitarianlaw.

Adeepandpervasivesenseofimpunityhasemboldenedarmedactorstocommithumanrightsviolationsandabuses.Todeterfutureviolations,SouthSudanshouldfulfilitsobligationtoinitiateprompt,effectiveandimpartialinvestigationsintoallallegationsofcrimesunderinternationallawandhumanrightsviolationsorabusesbyallsidestotheconflictandbringthosecrediblysuspectedofcriminalresponsibilitytojusticeinopen,accessibleciviliancourtsandinfairtrialswithoutrecoursetothedeathpenalty.TheTGoNUshouldimmediatelysuspendmilitaryandcivilianofficialsforwhom

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thereiscredibleinformationthattheycommittedcrimesunderinternationallaworhumanrightsviolations,untilallegationsconcerningthemcanbeindependentlyandimpartiallyinvestigated.

WhileconductinginvestigationsandholdingindividualsresponsibleaccountableistheprimaryresponsibilityofSouthSudan,ithassofarfailedtodemonstrateawillingnesstodischargethisobligation.176ItisthereforecriticalthatUNMISSprovideregularandtimelyreportingonthehumanrightssituation,asmandatedbytheSecurityCouncil.TheAUCommissionshouldquicklyestablishtheHybridCourtforSouthSudan(HCSS)withamandatetoprosecutegenocide,warcrimes,crimesagainsthumanityandothercrimesunderinternationallawcommittedduringtheconflict,asisprovidedintheAugust2015peaceagreement.

TheUNSecurityCouncilshouldusethetoolsatitsdisposaltopreventanddeterfutureviolationsofhumanitarianlawandviolationsandabusesofinternationalhumanrightslaw.Specifically,itshouldimposeacomprehensivearmsembargoonthedirectorindirectsupply,saleortransfer,includingtransitandtrans-shipment,ofweapons,munitions,militaryvehiclesandanyotherformsofmilitaryassistance,includingtechnicalandfinancialassistance,equipmentmaintenanceandtraining,toSouthSudan.TheSecurityCouncilshouldalsoimposetargetedsanctions,includingtravelbansandassetfreezes,againstcivilianandmilitaryofficialswhohaveengagedinviolationsofinternationalhumanitarianlawandviolationsandabusesofinternationalhumanrightslawinSouthSudan.

IMPROVE THE AVAILABILITY, ACCESSIBILITY AND QUALITY OF MENTAL HEALTH SERVICES ACROSS THE COUNTRYSouthSudan’songoingviolationoftherighttohealththroughfailuretoprovideadequatementalhealthservicesmustberemediedthroughtheimprovementinavailability,accessibility,andqualityofservices.TheWHOrecommendsthatinordertoimprovementalhealthservices,resourceconstrainedcountriessuchasSouthSudanshouldprioritizeprovidingtreatmentthroughprimaryhealthcare;providingcareatthecommunitylevel;makingpsychotropicdrugsavailable;educatingthepublic;establishingnationalpolicies,programmesandlegislation;supportingresearchandmonitoring;developinghumanresources;increasingfundingtomentalhealthservicesand;mainstreamingmentalhealthinterventionsacrossothersectors.177SouthSudan’smentalhealthplansandpoliciesshouldbedirectedtowardsthesepriorities.

INTEGRATE MENTAL HEALTH TREATMENT INTO PRIMARY HEALTH CARE

Theintegrationofmentalhealthwithinprimaryhealthcare—alreadyamongthestatedgoalsofthehealthministry’sDepartmentofMentalHealth—iscriticaltomakingmentalhealthcaremoreavailableandaccessible.178Integrationincreasesthelikelihoodthatmentalhealthproblemswillbedetected;contributestodestigmatizingmentalhealthcareasmental;andsavescostsbyreducingtheneedforspecializedmentalhealthprofessionals.179

Themanagementandtreatmentofmentaldisordersinprimarycarewillrequireadequatetrainingofprimaryhealthcarestafftotreat,manageandappropriatelyreferpatientssufferingfrommentalhealthconditions.Therealsoneedtobesufficientnumbersofstaffwiththeknowledgeandauthoritytoprescribepsychotropicdrugs,andmentalhealthspecialistsshouldbeavailabletosupportandmonitorgeneralhealthcarepersonnel.180

176ThoughSouthSudanclaimstohaveconductedmultipleinvestigationsintoconflict-relatedabuses,theresultsoftheseinvestigationshavenotbeenpublishedandcriminalproceedingshavenotbeeninitiated.

177WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001.

178InterviewwithDr.AtongAyuel,Director,MentalHealthDepartment,MinistryofHealth,Juba,SouthSudan,10April2015.

179WHO,“IntegratingMentalHealthServicesintoPrimaryHealthCare,”availableat:http://www.who.int/mental_health/resources/mentalhealth_PHC_2008.pdf;WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,p.89.


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PROVIDE CARE AT THE COMMUNITY LEVEL

SouthSudanshoulddevelopcommunity-basedmentalhealthservicestoprovidelocally-basedtreatmentandcarethatiseasilyaccessibletopatientsandtheirfamilies.Community-basedfacilitiesmightincludementalhealthoutpatientfacilities,short-stayinpatientcare,daycarecentres,andprogrammestosupportpeoplewithmentaldisorderslivingwiththeirfamilies.Greatercollaborationwith“informal”mentalhealthcareproviders,includingfamilies,aswellasreligiousleaders,faithhealers,traditionalhealers,schoolteachers,policeofficers,andlocalNGOsisalsoneeded.

Asapriority,thegovernmentshoulddevelopaplantoremovepeoplewithmentaldisabilitiesfromprisonsandtoprovidethemwithappropriatementalhealthservices,ingeneralhospitalsorcommunitysettings.

MAKE PSYCHOTROPIC MEDICINES AVAILABLE

Thegovernmentshouldimprovethecurrentlylimitedandinconsistentavailabilityofpsychotropicmedicines.AccordingtotheWHO,thesedrugscanamelioratesymptoms,reducedisability,shortenthecourseofmanydisorders,andpreventrelapse.181Thegovernmentshouldalsoensurethatsufficientfundsareallocatedtopurchasepsychotropicmedicinesandmakesuretheyareavailableinprimarycaresettings.Internationaldonorsshouldsupporttheavailabilityofthesemedicines.

EDUCATE THE PUBLIC

InSouthSudan,awarenessandunderstandingofmentalhealthissuesisgenerallylow,impactingthelikelihoodofseekingcareandalsoincreasingstigmaassociatedwithmentalhealthconditions.Increasingawarenessaboutthenatureofmentalhealthconditions,theirtreatability,therecoveryprocess,andthecareoptionsavailablecanincreasetheuseofmentalhealthservices,andreducestigmaanddiscrimination.182

ESTABLISHING NATIONAL POLICIES, PROGRAMMES AND LEGISLATION

Mentalhealthpolicyandlegislationareimportantprecursorstosignificantandsustainedaction.TheMinistryofHealth,currentlyintheprocessofrevisingtheNationalHealthPolicy,theHealthSectorDevelopmentPlanandtheBasicPackageofHealthServices,shouldensurethatallofthesepoliciesaddressmentalhealthneeds.TheMinistryofHealthshouldalsosupporttheDepartmentofMentalHealthtodevelopamentalhealthpolicyandappropriatementalhealthlegislation.Stakeholders,includingpersonswithmentalandpsychosocialdisabilities,carersandfamilymembers,professionals,policymakers,andotherinterestedpartiesshouldparticipateinthedevelopmentofapolicyandlegislation.183Thepolicyandanylegislationshouldcomplywithinternationalandregionalhumanrightsstandards.TheWHOshouldprovidetechnicalassistance,ideallythroughalong-termmentalhealthofficerbasedwithintheWHOoffice.

Thementalhealthpolicyshouldprovideconcreteandmeasurablestepstowardsensuringthatmentalhealthservicesareavailable,accessible,acceptable,andofgoodquality.Itshouldalsospecifynecessaryactionstoincorporatementalhealthinformationandservicesattheprimaryhealthcarelevel,includingnecessarytrainingforhealthcarestaffandcommunityworkerstoprovideessentialinformation,care,supportandreferralservices.Itshouldsetprioritiesandoutlineapproaches,basedonidentifiedneedsandtakingintoaccountavailableresources.Itshouldtakeintoaccounttheparticularneedsofchildren,women,theelderly,anddisplacedpeople.

Mentalhealthlegislationshouldguaranteerespectforthedignityandhumanrightsofpeoplewithmentaldisorders,particularlynon-discrimination,freedomfromtortureandill-treatment,andphysicalintegrity.Legislationshouldprohibittheincarcerationofpeoplesolelyonthebasisofmentaldisability,



183TheCESCR’sGeneralComment14recognizes”participationofthepopulationinallhealth-relateddecision-making”ascriticaltotherighttohealth.CESCR,GeneralComment14,para.11.WHO,TheWorldHealthReport,MentalHealth:NewUnderstanding,NewHope,2001,p.80.

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andinsteadarticulateclearregulationsfortheadmission,forcedcommitment,anddischargeofpeoplewithmentaldisabilitiestomedicalfacilitiesinlinewithinternationalstandards.Legislationshouldalsoestablishrulesonconsenttotreatment,andensuretheexistenceofmechanisms,suchasamonitoring,reviewboardorcomplaintmechanismtopromoteandprotecttherightsofindividualswithmentalhealthconditions.

SouthSudanshoulddemonstrateitscommitmenttorespecting,protectingandfulfillingtherighttohealthbyratifyingoraccedingtotheInternationalCovenantonEconomic,SocialandCulturalRights(ICESCR),theInternationalCovenantonCivilandPoliticalRights(ICCPR),andtheConventionontheRightsofPeoplewithDisabilities.TheGovernmentshouldcompleteratificationoftheAfricanCharteronHumanandPeoples’Rights(theAfricanCharter)bydepositingtheinstrumentofratificationwiththeAfricanUnion(AU).

SUPPORT RESEARCH AND MONITORING

Theformulationofamentalhealthpolicyandeffortstoimproveservicesshouldbebasedonreliableinformation,includingquantitativedataontheprevalenceandimpactofmentalhealthconditions.Acomprehensiveassessmentandcontinuousmonitoringofexistingmentalhealthresourcesandstructures,andtheextenttowhichtheyfulfilmentalhealthneedsisalsonecessarytoinformthedesignofappropriateinterventions.Thereis,however,anotablelackofsuchresearchandmonitoringinSouthSudan.TheMinistryofHealthshouldtakestepstoremedythisgap.TheWHOshouldcontributetobuildingresearchandmonitoringcapacity.

DEVELOP HUMAN RESOURCES

Thelackofspecialistsandhealthworkerswiththeknowledgeandskillstomanagementalhealthconditionsisasignificantbarriertotreatmentandcare.TheMinistryofHealthshouldexplorebuildingpartnershipswithexternalinstitutionsandmentalhealthtrainingfacilitiestohelptrainexistingstaff.TheMinistryofHealthalsoshouldworkwiththeMinistryofHigherEducationtointegratementalhealthandpsychosocialtrainingintouniversitycurricula,particularlyindepartmentsofmedicine,psychology,andsocialwork,sothatnewgraduatescaneffectivelycontributetotheprovisionofmentalhealthservices.

INCREASE ALLOCATION OF FUNDING TO MENTAL HEALTH SERVICES

TheMinistryofHealthshouldworktoensurethatfundsareavailabletoincreaseandimprovementalhealthservices.Specifically,theMinistryshouldensurethatthereisaclearbudgetaryallocationtotheDepartmentofMentalHealthtosupportmentalhealthprogramming.TheMinistryshouldseekinternationalcooperationandassistancetosupportmentalhealthcareservicesbymakingspecificrequeststodonorsforsuchsupportandbyworkingwithdonorstoensurethatgeneralsupporttothehealthsectordoesnotneglectmentalhealthneeds.Internationaldonorsshouldprovidenecessaryfinancialandtechnicalsupporttoincreasetheavailabilityandaccessibilityofmentalhealthservicesaspartoftheirdevelopmentandreconstructionassistance.TheWHOshouldadvocatefordonorsupporttomentalhealthandtakegreaterresponsibilityformobilizingnecessaryresourcestoensureimplementationofitsMentalHealthActionPlan.

MAINSTREAM INTERVENTIONS ACROSS ALL SECTORS

Mentalhealth,likeotheraspectsofhealth,canbeaffectedbyarangeofsocioeconomicfactorsincludingpoverty,educationlevel,employmentstatus,materialstandardofliving,andaccesstobasicservices.Responsibilityforpromotingmentalhealthandpreventingmentaldisordersthereforeextendsacrossallsectorsandallgovernmentdepartments.Thegovernment,internationaldonorsandNGOsshouldmainstreammentalhealthinitiativesintoalldevelopmentandhumanitarianinterventions.

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ENSURE INTEGRATION OF MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT INTO EMERGENCY RESPONSE PROGRAMMINGSouthSudan,throughtheMinistryofHumanitarianAffairsandDisasterManagement,shouldmakefinancialandprogrammaticcontributionstoemergencymentalhealthservicesandshouldfacilitateandencourageinternationalcooperationandsupportforimplementationoftheInter-AgencySteeringCommittee(IASC)guidelines.

Internationaldonorsshouldensurethatsupportformentalhealthandpsychosocialservicesisanappropriatecomponentoftheirfinancialcontributionstohumanitariansupport.Withsupportfrominternationaldonors,humanitarianorganizationsprovidingemergencyassistanceinsettlementsofinternallydisplacedpeopleandinconflict-affectedareasofthecountryshouldworktoincreasetheavailabilityofmentalhealthandpsychosocialsupport,inaccordancewiththeIASCguidelines.Whilethereisaneedfortheexpansionofalllevelsofserviceprovision,thereisaparticulardearthofprogrammingintheprovisionofspecializedservices,suchaspsychotherapyorpharmacologicinterventionforpeoplewithseverementaldisorders.

Thegovernment,humanitarianorganizationsanddonorsshouldworktoensurethatemergencyresponseprogrammingcreatesasustainableimpactandismainstreamedintobroadernationalmentalhealthstrategies.Donorswhofundmentalhealthservicesduringemergenciesshouldbepreparedtofacilitatethetransitiontofundingforlonger-termmentalhealthprogramming.

PROVIDE REPARATIONS FOR PSYCHOLOGICAL HARMTheAgreementontheResolutionoftheCrisisinSouthSudan(ARCSS)providesthatthethreetransitionaljusticeinstitutionsitenvisions—theHybridCourtforSouthSudan(HCSS),theCommissiononTruth,ReconciliationandHealing(CTRH),andtheCompensationandReparationsAuthority(CRA)—“shallindependentlypromotethecommonobjectiveoffacilitatingtruth,reconciliationandhealing, compensation and reparation inSouthSudan.”184TheHCSS,inadditiontoprosecutingandpunishingthoseresponsibleforcrimesunderinternationallaw,ismandatedto“awardappropriateremediestovictims,includingbutnotlimitedtoreparationsandcompensation.”185ThefunctionsoftheCTRHincluderecommending“processesandmechanismsforthefullenjoymentbyvictimsoftherighttoremedy,includingbysuggestingmeasuresforreparations and compensation.”186TheCRAwilladministeraCompensationandReparationFund(CRF)to“providematerialandfinancialsupporttocitizenswhosepropertywasdestroyedbytheconflictandhelpthemtorebuildtheirlivelihoods.”

TheARCSSplacesparticularemphasisontheroleoftheTGoNUinrelationtointernallydisplacedpeopleandrefugees.TheARCSSrecognizestherightofrefugeesandinternallydisplacedpeople“toreturninsafetyanddignityandtobeaffordedphysical,legaland psychological protection.”188

ItrequirestheTGoNUtoinstituteprogramsforthe“relief,protection,repatriation,resettlement,reintegrationandrehabilitationofinternallydisplacedpersons(IDPs)andreturnees.”189TheARCSSalsorequiresthat,intheprovisionofhealthservices,specialconsiderationbegiventoconflict-affectedpersons.190

184ARCSS,ChapterV,Article1.3(emphasisadded).

185ARCSS,ChapterV,Article3.5.3.

186ARCSS,ChapterV,Article2.1.5.

187ARCSS,ChapterV,Article4.2.d.

188ARCSS,ChapterIII,Article1.1.2.



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Theemphasisintheagreementonreparationsandcompensationoffersanimportantopportunitytoaddresstheimpactoftheconflictonmentalhealth.AstheAfricanUnionCommissionofInquiryinSouthSudan(AUCISS)hasrecommended,reparativemeasuresundertakenshouldincluderehabilitationandpsychosocialassistanceandshouldbeimplementedimmediately.191SouthSudanshouldworktoensurethespeedyestablishmentoftheHCSS,theCTRHandtheCRAenvisagedbytheARCSS.SouthSudan,togetherwiththeAUandothersupportinginstitutionsandgovernments,shouldensurethatinfulfillingtheirreparationsmandates,theHCSS,theCTRHandtheCRAgiveconsiderationtothementalhealthconsequencesoftheconflictandtheresultingneedforpsychologicalrehabilitationasoneelementofindividualorcollectivereparationsprogramsandinitiatives.192InternationaldonorsshouldprovidefinancialandtechnicalsupportfortheestablishmentandoperationalisationoftheHCSS,theCTRHandtheCRA.TheyshouldsupportSouthSudan’sobligationtoensureaccesstoreparations,throughtechnicalandfinancialsupport.

SouthSudanshouldalsoensurethatthenationaljusticesystemallowsvictimsofhumanrightsandhumanitarianlawviolationsandabusestoclaimcompensation,includingforpsychologicalharm,fromindividualperpetratorsincivilproceedings.SouthSudanshouldensuretheprovisionoflegalaidtovictimswhocannotaffordlegalassistance.

191AUCISS,FinalReport,para1152.

192ThePeruvianTruthandReconciliationCommission(TRC),forexample,devotedanentirechapterofitsreporttothedevastatingpsychosocialdamagecausedbythewarandrecommendedthatreparationsprogrammesincludeamentalhealthcomponent.LisaJ.LaplanteandMiryamRiveraHolguin,“ThePeruvianTruthCommission’sMentalHealthReparations:EmpoweringSurvivorsofPoliticalViolencetoImpactPublicHealthPolicy,”HealthandHumanRights,2006.

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8. CONCLUSION: THE IMPORTANCE AND URGENCY OF MENTAL HEALTH SERVICES

Withhighinflationandasharpdeclineinnationaloilrevenuesasaresultofreducedoilproductionandadropininternationaloilprices,SouthSudanisfacingasevereeconomiccrisis.193Thereisalsopersistentviolenceinsomeareasofthecountry.Despitethischallengingcontext,foramyriadofreasonstheremustbeincreasedattentiontomentalhealthbothintheimmediateandlonger-term.

Thoughlackofresourcesisoftencitedasakeyreasonforfailurestoimprovementalhealthservices,therearestepsSouthSudancantakethatrequirepoliticalcommitmentmorethanfunds.Thedevelopmentofamentalhealthpolicyandlegislation,forexample,isnotheavilyresource-intensivebutcouldgoalongwaytowardsgalvanizinggreaterattentiontomentalhealthinSouthSudanandattractingadditionalinternationalsupport.Integratingmentalhealthservicesintotheprimaryhealthcaresystemisalsonotheavilyresource-intensive.

Doingmoretoaddressmentalhealthneedsisnotonlyessentialforindividualwell-being,itisalsocriticalforSouthSudanesetoeffectivelyrebuildtheircommunitiesandcountry.Mentalhealthproblemsimpactphysicalhealthandcontributesignificantlytomorbidity.Theyalsoimpactpeople’sabilitytofunctionasproductivemembersofsociety.Asdescribedinthisreport,peoplewithpoormentalhealthmaybeunabletocarryoutday-to-daytasks,participateincommunityactivities,andpursuelivelihoodsoreducation.

Thesocietalimpactsofpoormentalhealtharealsolong-term.Poormentalhealthamongparentshasaninter-generationalimpactonchildhealth,developmentandgrowth.194AccordingtoapsychologistworkinginJuba,“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—canthereforeplayavitalroleincontributingtohumandevelopment,sustainableeconomicgrowthandpovertyreduction.196 This isreflectedinthefactthatinSeptember2015,theUNincludedmentalhealthasanelementofthenewglobalSustainableDevelopmentGoal(SDG)onhealth.

193SudanTribune,“IMFwarnsoffurtherdeterioratingeconomyinSouthSudan,”2June2016availableat:http://www.sudantribune.com/spip.php?article59164

194DelanDevakumaretal.,“Theintergenerationaleffectsofwaronthehealthofchildren,”BMCMedicine,2014,availableat:http://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-12-57

195Interviewwithexpatriatepsychologist,Juba,SouthSudan,7April2014.

196TheWorldBank,MentalHealthandConflict,“ConflictPreventionandReconstruction,”October2003,availableat:http://siteresources.worldbank.org/DISABILITY/Resources/280658-1172610662358/MentalHealthConfBaingana.pdf;WHO,MentalHealthGapActionProgramme,p.6.

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ManySouthSudaneseandinternationalobserversidentifypoormentalhealthasadestabilizingforcethathascontributedtoviolentbehaviouratfamily,community,andnationallevels—anobservationsupportedbystudiesshowingthelinksbetweenpoormentalhealth,anger,anddesireforrevenge.197 “Societies that didn’t have the space to digest trauma are more likely to go back to violence,”saidoneNGOworker.198ASouthSudanesepeaceactivistdescribedtheleveloftraumaasa “liability to the country.”199 TheAfricanUnionCommissionofInquiryinSouthSudan(AUCISS)emphasizedinitsfinalreportthatreconciliationcannottakeplaceunlessthesufferingandtraumaexperiencedbySouthSudaneseisaddressed:

“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,stabilityandreconciliationinSouthSudan.

197Seeforexample,OscarI.GonzalezandRaymondW.Novaco,“AngerIntensificationwithCombat-RelatedPTSDandDepressionComorbidity,”PsychologicalTrauma:Theory,Research,Practice,andPolicy,2016,availableat:https://www.apa.org/pubs/journals/releases/tra-0000042.pdf;UlrichOrthandEliasWieland,“Anger,Hostility,andPosttraumaticStressDisorderinTrauma-ExposedAdults:AMeta-Analysis,”JournalofConsultingandClinicalPsychology,2006,availableat:https://uorth.files.wordpress.com/2011/01/orth_and_wieland_2006_jccp.pdf


199PresentationbySouthSudanesepeaceactivist,Juba,SouthSudan,9April2015.

200AUCISS,FinalReport,para.894.

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9. RECOMMENDATIONS

TO THE TRANSITIONAL GOVERNMENT OF NATIONAL UNITY (TGONU)

• Endandsuppressallviolationsofinternationalhumanrightsandhumanitarianlawcommittedbymembersofthearmedforcesorassociatedpersonnel.Inparticular,allforcesshouldimmediatelyceaseunlawfulkillings;actsofsexualviolenceandanyotherattacksoncivilians;lootinganddestructionofpublicandprivateproperty;violenceagainsthumanitarianpersonnelandassets;andotherobstructionstohumanitarianassistance;

• Providearmedforceswithsufficienttrainingandclearorderstoensuretheyareawareofconductprohibitedunderinternationallawandputinplacemechanismstoadequatelymonitortheconductoftheirforces;

• Initiateprompt,effectiveandimpartialinvestigationsintoallegationsofcrimesunderinternationallawandhumanrightsviolationsorabuses.Bringthosesuspectedofcriminalresponsibilitytojusticeinopen,accessibleciviliancourtsandinfairtrialswithoutrecoursetothedeathpenalty;

• Immediatelysuspendmilitaryandcivilianofficialsforwhomthereiscredibleinformationthattheycommittedcrimesunderinternationallaworhumanrightsviolations,untilallegationsconcerningthemcanbeindependentlyandimpartiallyinvestigated;

• Ratifyoraccede,withoutreservations,tointernationalandregionalhumanrightstreaties,particularlytheInternationalCovenantonEconomic,SocialandCulturalRights(ICESCR)anditsOptionalProtocol,theInternationalCovenantonCivilandPoliticalRights(ICCPR)anditsOptionalProtocols,theConventionontheRightsofPeoplewithDisabilities,andtheAfricanCharteronHumanandPeoples’Rights;

• Takestepstoimprovetheavailability,accessibilityandqualityofmentalhealthservicesavailableinthecountry.Specifically,thegovernmentshould:

• Worktointegratementalhealthtreatmentintoprimaryhealthcareservicesbyprovidingtraining toprimaryhealthcarestafftotreat,manageandappropriatelyreferpatientssufferingfrom mentalhealthconditions;

• Developcommunity-basedmentalhealthservicestoprovidelocally-basedtreatmentandcare thatiseasilyaccessibletopatientsandtheirfamilies;

• Removefromstateprisonspeoplesufferingfrommentalhealthconditionsandprovidethem appropriatementalhealthservicesingeneralhospitalsorcommunitysettings;

• Improvetheavailabilityofpsychotropicmedicines;

• Increasepublicawarenessaboutthenatureofmentalhealthconditions,theirtreatability,the recoveryprocess,andthecarechoices.

• EnsurerevisionstotheNationalHealthPolicy,theHealthSectorDevelopmentPlan;andtheBasicPackageofHealthServicesaddressmentalhealthneeds;

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• Developamentalhealthpolicyinconsultationwithstakeholders,includingpersonswithmentalandpsychosocialdisabilities,carersandfamilymembers.Thepolicyshould:

• Complywithinternationalandregionalhumanrightsstandards;

• Provideconcreteandmeasurablestepstowardsensuringtheavailability,accessibilityandqualityofmentalhealthservices;

• Specifynecessaryactionstoincorporatementalhealthinformationandservicesattheprimaryhealthcarelevel;

• Setprioritiesbasedonidentifiedneedsandtakingintoaccountavailableresources;

• Takeintoaccounttheparticularneedsofchildren,women,theelderly,anddisplacedpeople.

• Passmentalhealthlegislationinconsultationwithstakeholders,includingpersonswithmentalandpsychosocialdisabilities,carersandfamilymembers.Legislationshould:

• Complywithinternationalandregionalhumanrightsstandards.Inparticular,legislationshouldguaranteerespectforthedignityandhumanrightsofpeoplewithmentaldisorders,particularlynon-discrimination,freedomfromtortureandill-treatment,andphysicalintegrity;

• Provideforandregulatetheprovisionofmentalhealthcareservices;

• Prohibittheincarcerationofpeoplesolelyonthebasisofmentaldisability,andinsteadprovideclearregulationsfortheadmission,forcedcommitment,anddischargeofpeoplewithmentaldisabilitiestomedicalfacilitiesinlinewithinternationalstandards;

• Establishrulesonconsenttotreatment;

• Createmechanismstopromoteandprotecttherightsofindividualswithmentalhealthconditions,suchasamonitoringbody,reviewboard,orcomplaintmechanism.

• Conductandsupportresearchandcontinuousmonitoringoftheprevalenceandimpactofmentalhealthconditionsandexistingmentalhealthresourcesandstructures;

• Integratementalhealthandpsychosocialtrainingintouniversitycurricula,particularlyindepartmentsofmedicine,psychologyandsocialwork;

• Ensurethatfundsaremadeavailabletoincreaseandimprovementalhealthservices,includingbymakingaspecificbudgetaryallocationtotheDepartmentofMentalHealthtosupportmentalhealthprogramming;

• Seekinternationalcooperationandassistancetosupportmentalhealthcareservicesbymakingspecificrequeststodonorsforsuchsupportandbyworkingwithdonorstoensurethatgeneralsupporttothehealthsectordoesnotneglectmentalhealthneeds;

• Mainstreammentalhealthinitiativesintoalldevelopmentandhumanitarianinterventions;

• Makefinancialandprogrammaticcontributionstosupportmentalhealthservicesinemergencysettingswhilealsoensuringthatemergencyresponseprogrammingcreatesasustainableimpactandismainstreamedintobroadernationalmentalhealthstrategies;

• Worktoensureaccesstoreparationsforvictimsofhumanrightsandhumanitarianlawviolationsandabuses,includingforpsychologicalharm.Specificallythegovernmentshould:

• SupportthespeedyestablishmentoftheHybridCourtforSouthSudan(HCSS),theCommissiononTruth,ReconciliationandHealing(CTRH)andtheCompensationandReparationsAuthority(CRA)providedforintheAgreementontheResolutionoftheConflictinSouthSudan(ARCSS);

• Ensurethatinfulfillingtheirreparationsmandates,theHCSS,theCTRHandtheCRAgiveconsiderationtothementalhealthconsequencesoftheconflictandtheresultingneedforpsychologicalrehabilitationasanelementofindividualorcollectivereparationsinitiatives;

• Ensurethatthenationaljusticesystemallowsvictimsofhumanrightsandhumanitarianlawviolationsandabusestoclaimcompensation,includingforpsychologicalharm,fromindividualperpetratorsincivilproceedings.Providelegalaidtovictimswhocannotaffordlegalassistance.

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TO THE JOINT MONITORING AND EVALUATION COMMISSION (JMEC)

• Continuouslycondemnviolationsandabusesofhumanrightsandhumanitarianlawbypartiestotheconflict;

• EnsurethattheCeasefireandTransitionalSecurityArrangementsMonitoringMechanism(CTSAMM)effectivelymonitorsandreportsontheparties’respectforhumanitarianlaw;

• SupportthespeedyestablishmentoftheHybridCourtforSouthSudan(HCSS),theCommissiononTruth,ReconciliationandHealing(CTRH)andtheCompensationandReparationsAuthority(CRA)whichareprovidedforintheAgreementontheResolutionoftheConflictinSouthSudan(ARCSS).

TO INTERNATIONAL DONORS

• Continuouslycallonpartiestotheconflicttoceaseviolationsofinternationalhumanitarianlawandviolationsandabusesofinternationalhumanrightslaw;

• Provideincreasedfinancialandtechnicalassistancetosupportimprovementoftheavailabilityandaccessibilityofmentalhealthservices;

• Mainstreammentalhealthinterventionsintoalldevelopmentsupport,particularlyinthehealthsector.Ensurethatsupportformentalhealthandpsychosocialservicesformanappropriatecomponentoffinancialcontributionstohumanitarianemergencysupportefforts;

• Ensuresustainabilityofmentalhealthandpsychosocialservicesestablishedaspartoftheemergencyhumanitarianresponsebycommittingtofundingforlonger-termmentalhealthreform;

• ProvidetechnicalandfinancialassistanceforthespeedyestablishmentoftheHybridCourtforSouthSudan(HCSS),theCommissiononTruth,ReconciliationandHealing(CTRH)andtheCompensationandReparationsAuthority(CRA)providedforintheAgreementontheResolutionoftheConflictinSouthSudan(ARCSS);

• Supportthegovernment’sobligationtoensureaccesstoreparations,includingforpsychologicalharm,throughtechnicalandfinancialassistance;

• ContinuouslycallontheTGoNUtoadequatelyprotectinternallydisplacedpopulations,ensuretheirsecurity,andhelpcreateconditionsthatwouldallowthemtoreturnorsafelyrelocateinaccordancewiththeirwishes.

TO THE UN MISSION IN SOUTH SUDAN (UNMISS)

• ProvideregularandtimelyreportingonthehumanrightssituationinSouthSudan,asmandatedbytheUNSecurityCouncil;

• Incoordinationwithhumanitarianagencies,worktoincreasetheavailabilityandaccessibilityofmentalhealthserviceswithinProtectionofCivilian(PoC)sites.Alsoworktoimprovegenerallivingconditions,includinghousing,food,andsanitation;

• EnsurethoroughinvestigationstakeplaceintoattacksagainstciviliansinandaroundPoCsites,withaviewtoensuringperpetratorsareheldaccountable;

• TakeallpossibleadditionalmeasurestoensureeffectiveprotectionofcivilianswhohavesoughtrefugewithinPoCsites.

TO THE AFRICAN UNION (AU)


• EnsurethespeedyestablishmentbytheAUCommissionoftheHybridCourtforSouthSudan(HCSS)inaformatthatcomplieswithinternationallaw.ProvidefinancialandtechnicalsupportfortheestablishmentandoperationalisationoftheCommissiononTruth,ReconciliationandHealing(CTRH)andtheCompensationandReparationsAuthority(CRA);

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• Worktoensurethatinfulfillingtheirreparationsmandates,theHCSS,theCTRHandtheCRAgiveconsiderationtothementalhealthconsequencesoftheconflictandtheresultingneedforpsychologicalrehabilitationasanelementofindividualorcollectivereparationsinitiatives;

• Supportthegovernment’sobligationtoensureaccesstoreparations,includingforpsychologicalharm,throughtechnicalandfinancialsupport.

TO THE WORLD HEALTH ORGANIZATION (WHO)

• Providefinancialandtechnicalassistancetosupportimprovementintheavailabilityandaccessibilityofessentialmentalhealthservices.Specifically,theWHOshould:

• AdvocateforincreaseddonorsupporttomentalhealthandtakegreaterresponsibilityformobilizingnecessaryresourcestoensureimplementationofitsMentalHealthActionPlan;

• Worktoincreasenationalcapacitytoconductresearchandcontinuousmonitoringoftheprevalenceandimpactofmentalhealthconditionsandexistingmentalhealthresourcesandstructures;

• Providetechnicalassistance,ideallythroughalong-termmentalhealthofficerbasedintheWHOofficeinJuba,forthedevelopmentofamentalhealthpolicyandlegislation.

TO THE UN SECURITY COUNCIL


• Imposeacomprehensivearmsembargoonthedirectorindirectsupply,saleortransfer,includingtransitandtrans-shipment,ofweapons,munitions,militaryvehiclesandanyotherformsofmilitaryassistance,includingtechnicalandfinancialassistance,equipmentmaintenanceandtraining,toSouthSudan;

• Imposetargetedsanctions,includingtravelbansandassetfreezes,againstcivilianandmilitaryofficialswhohaveengagedinviolationsofinternationalhumanitarianlawandviolationsandabusesofinternationalhumanrightslawinSouthSudan.

AMNESTY INTERNATIONAL IS A GLOBAL MOVEMENT FOR HUMAN RIGHTS. WHEN INJUSTICE HAPPENS TO ONE PERSON, IT MATTERS TO US ALL.

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ViolationsandabusesofinternationalhumanrightsandhumanitarianlawcommittedbypartiestoSouthSudan’sinternalarmedconflictthateruptedinDecember2013havehadsignificantrepercussionsonthementalhealthofSouthSudanese.Internallydisplacedpeopleimpactedbytheconflictdescribedhavingnightmares,gettingangryeasily,feelingunabletoconcentrateandconsideringsuicide—commonmanifestationsofpsychologicalstressassociatedwithmentalhealthdisorderssuchaspost-traumaticstressdisorder(PTSD)anddepression.Theyattributedtheseimpactstotheirexperiencesasvictimsof,orwitnessesto,torture,arbitrarydetention,sexualviolence,unlawfulkilling,andforceddisplacement.

ThisreportdescribestheseriousmentalhealthimpactofSouthSudan’sconflictinordertohighlighttheurgencyformoreattention,andresources,toimprovetheavailability,accessibility,andqualityofmentalhealthservicesinthecountry.Itisbasedoninterviewswith161internallydisplacedSouthSudaneseandwithgovernmentandUNofficials,donors,representativesofnon-governmentalorganizations(NGOs),andinternationalandSouthSudanesementalhealthprofessionals.

amnesty.org

Index:AFR01/3063/2016

January2016

Language:English

THE MENTAL HEALTH IMPACT OF SOUTH SUDAN’S CONFLICT

“OUR HEARTS HAVE GONE DARK”

“OUR HEARTS HAVE GONE DARK”€¦ · OUR HEARTS HAVE GONE DARK THE MENTAL HEALTH IMPACT OF SOUTH...

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