The state's health infrastructure has not been made a priority after five years of civil war ended in 2018 and the majority of care provided comes from the non-profit sector.
It began with a dry cough, weakness and back pain. For Reagan Taban Augustino, part of South Sudan’s small corps of health workers trained in treating Covid-19 patients, there was little doubt what he had.
Days later, hardly able to breathe, the 33-year-old doctor discovered just how poorly equipped his country is for the coronavirus pandemic: None of the public facilities he tried in the capital Juba had oxygen supplies available until he reached South Sudan's only permanent infectious disease unit, which has fewer than 100 beds for a country of 12 million people.
It took more than an hour to admit him. “I was almost dying at the gate,” he said from the unit last week.
The pandemic is now accelerating in Africa, the World Health Organization says. While the continent had more time than Europe and the United States to prepare before its first case was confirmed on February 14, experts feared many of its health systems would eventually become overwhelmed.
A nation with more military generals than doctors
South Sudan, a nation with more military generals than doctors, never had a fighting chance. Five years of civil war and corruption stripped away much of its health system, and today nongovernmental organisations provide the majority of care. Nearly half of the population was hungry before the pandemic. Deadly insecurity continues, and a locust outbreak arrived just weeks before the virus.
When world leaders talk about the pandemic not being over until it's over everywhere, they are talking about places like South Sudan.
The United Nations says the country's outbreak is growing rapidly, with nearly 1,900 cases, including more than 50 health workers infected, more than 30 deaths and no way to know the true number of infections. At one point several members of the Covid-19 task force tested positive, including Vice President Riek Machar.
“It can be out of control at any time,” said David Gai Zakayo, a doctor with the aid group Action Against Hunger.
“The groups we are treating are malnourished,” Zakayo said. “My big worry is if the virus begins spreading to those groups we are treating, it will be a disaster.”
Team of 16 works up to 16-hour days
At South Sudan’s only laboratory that tests for the virus, supervisor Simon Deng Nyichar said the team of 16 works up to 16-hour days slogging through a backlog of more than 5,000 tests. Around 9,000 samples have been tested since early April, when the country became one of the last in Africa to confirm a coronavirus case.
With materials in short supply, testing is largely limited to people with symptoms of Covid-19. It can take weeks to receive results, “creating mistrust in communities and resentment toward contact tracers,” the Health Ministry said last week.
Three lab workers have been infected and recovered, Nyichar told the AP. “This is the nature of our work. We are not scared of the disease.”
With the long hours, they work in pairs to stay sharp. “It’s a must for everybody to have a buddy as a helper to monitor all the steps on the dos and don’ts, otherwise we would have infected all of us,” he said.
Lack of public trust
While they’re aware of the dangers, South Sudan’s population at large still takes convincing.
The government’s loosening of lockdown measures last month was “perceived as an indication that the disease is not in South Sudan,” the Health Ministry said. Bars, restaurants and shops are open after people said they feared hunger more than the disease.
Some people have died waiting for rapid-response teams to arrive, the ministry said. And this month it stopped issuing “Covid-19 negativity certificates,” citing the peddling of fake ones — especially around Juba International Airport.
Covid-19 spreads to more rural areas
The virus has spread into more rural areas, including one of the United Nations-run camps upcountry where more than 150,000 civilians still shelter after South Sudan’s civil war ended in 2018.
There’s been an increase in deaths related to respiratory tract infections at that camp in Bentiu, WHO official Wamala Joseph told reporters last week, though it's not clear whether they were from the virus. Testing is difficult as all samples must be flown to the capital. “This is a very vulnerable population,” he said.
Three of the six camps have no virus screening at the gate, according to a UN migration agency document dated this month. One camp has no facility to isolate the sick, and another will only have one when a generator is installed. Listed under preventative measures for the two camps in Juba, home to 30,000 people: “Face masks to be distributed in coming weeks.”
Meanwhile “our hospitals are full,” Wolde-Gabriel Saugeron, who leads the International Committee of the Red Cross’ team in Bor, wrote last week. “Covid-19 means that we need to create more space between our hospital beds, which has reduced the number of people we can accommodate in our wards by 30 percent.”
Famine and the urban poor
The pandemic is also worsening what was already a major problem in South Sudan: hunger.
Most border crossings are closed, and food prices in the markets have shot up. Now the rainy season has started, making transport and storage more difficult.
More than 1.5 million people in South Sudan are newly vulnerable, including the urban poor who had not been receiving aid before, the UN humanitarian agency said last week.
“I cannot be saying famine, but I can say Covid-19 will worsen the situation,” said Kawa Tong, health and nutrition manager for the aid group CARE.
She knows the country already faced a long and winding path to emerge from multiple crises, starting with progress on the peace agreement that ended the civil war. Security would need to improve, people would find the confidence to return to their homes and begin cultivating their crops, and hunger would fall.
But now, of course, there’s the pandemic, and Tong has no idea when or how it will end.
“People are overwhelmed,” she said. “People are scared.”