The provision of aid in war zones can be fraught with political difficulties and may itself foster inequalities, as it is rare to be allowed access to civilians on both sides of a conflict. Over the past decade, a United Nations (UN) brokered agreement has allowed Operation Lifeline Sudan (OLS), a UN “umbrella” organisation, to provide the diplomatic cover and operational support to allow long term humanitarian and emergency food aid to both the government and the rebel sides in the long-running south Sudanese civil war. Over the years, the destruction of infrastructure in the country has meant that the provision of basic health care has been seriously hampered. Operation Lifeline Sudan has coordinated the work of most of the non-governmental organisations (NGOs), working in this part of Africa. Each NGO has had responsibility for a particular area of the country and has worked closely with the local Sudanese authorities on either side of the conflict, conforming to strict codes of conduct or “ground rules”, based on neutrality. Operation Lifeline Sudan has provided an air-bridge for emergency relief supplies in regions where road access is impossible, either because of landmines, or simply because the roads do not exist. The war continues, however, and the underlying causes of war—economic exploitation, marginalisation of communities, lack of political representation, and systematic violence and abuse remain unsolved. The warring factions have brought some OLS operations in south Sudan to a standstill recently, for certain political reasons that could have compromised the neutrality of the OLS-coordinated humanitarian aid schemes. It would appear that the only resolution to the country's problems are external political pressure to get the respective combatants to negotiate and, less probably, an undertaking by countries of the developed world not to continue to supply arms. Nevertheless, OLS may serve as a model for how medical aid can be delivered in an even-handed way to the populations of countries where there is civil war, irrespective of where they may live.
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It is not difficult to defend the provision of humanitarian aid in circumstances of natural disasters, such as flood, earthquake, or hurricane. Where there is civil war, however, certain ethical issues are raised. If access is not granted to both sides in a conflict, aid agencies can be accused of political bias and perhaps, of providing the means of perpetuating man-made disasters, through supply of food and more importantly, money, which may be misappropriated by the governing authorities or rebel factions. It is unusual for an established government to allow international aid to the inhabitants of rebel-held areas, but the Sudanese government, although much criticised in the Western press, is an exception. Over the past decade or so, the authorities in Khartoum have allowed Operation Lifeline Sudan (OLS), a United Nations (UN) sponsored organisation, to supply logistical and diplomatic support for other UN agencies, such as the World Food Programme and UNICEF, and a number of non-governmental organisations (NGOs), such as Oxfam and Save the Children Fund, to provide coordinated aid to civilians on both sides of the protracted civil war in south Sudan, a particularly underdeveloped part of Africa. Historically, OLS has been run alongside UNICEF, the leading constituent agency.1 The political impartiality of OLS, in its terms of operation, has recently set the organisation and its constituent NGOs at variance with the warring protagonists, but uniquely in a civil war situation, both the government and the rebel sides have generally allowed access to the ordinary people of the country in an even-handed way. Operation Lifeline Sudan operations serve as a model for distribution of humanitarian aid to other wartorn parts of the world and this article aims to highlight this in the context of the political, social, and economic difficulties that face this part of Africa.
The Sudan is Africa's largest country. It is populated in the north mainly by Islamic people, roughly half of whom consider themselves to be Arabs. In the south, the population is made up largely of non-Arab, non-Muslim, African peoples, such as the Dinka and Nuer, who adhere to Christian and/or traditional beliefs. The north is an arid and largely flat desert, while the south contains the Sudd, a vast, swamp-ridden expanse, into which the Nile empties en route to Egypt. Communication is difficult, and provision of health care in the south has been greatly hampered by the civil war that has been fought, on and off, for more than four decades. It began at independence from Britain and Egypt in 1956, stopped in 1972, and restarted in 1983. This conflict has gained intensity in the past few years. It was the root source of the 1998 famine in the south west of the country, which was the subject of a large international relief effort, coordinated by OLS. There are many political difficulties that engender short term humanitarian crises in the country, and many long term health issues remain unresolved. Apart from war-induced famine and injury, chronic ill health from tropical and infectious diseases is equally important, particularly in the context of a malnourished population. Diseases such as trypanosomiasis (sleeping sickness) are spreading (up to 60 million people are at risk in Central Africa), while World Health Sponsored (WHO) sponsored eradication schemes for this disease and for guinea-worm have not been able to operate effectively, because of the fighting.2,3 This is of major importance because detection of people infected with trypanosomiasis and subsequent patient care requires well-trained staff, sophisticated technical resources, drugs, and well-equipped health centres. Furthermore, without systematic screening of exposed populations, and without treatment, all infected people will die. However, OLS-coordinated vaccination programmes against measles, mumps, rubella, and polio have met with some success in refugee camps and surrounding areas.
THE CIVIL WAR
The war in south Sudan, which has been fought by the Sudan People's Liberation Army (SPLA) and splinter factions, has flared up recently for a number of reasons. Firstly, the south has oil and mineral reserves, which understandably, the government in Khartoum is reluctant to relinquish. This situation has been brought into focus by a Canadian oil company, Talisman Energy, which has the drilling rights for the “Greater Nile Oil Project”, including the construction of a 1600 km pipeline to Port Sudan on the Red Sea coast. Secondly, the SPLA has been receiving moral, if not technical and military support, from some of the neighbouring countries, which are fearful of an Islamic fundamentalist regime in Khartoum which has been trying to implement the shari'a, or Islamic law, in the country as a whole. However, the shari'a has never been implemented in the government-held areas of the south, but non-Muslim southerners in the north are subject to it. At the present time, the Khartoum government holds the important fortified garrison towns in the south, including Juba, the main town, with the rebel organisations holding the countryside. Currently, the SPLA has been receiving less support from neighbouring countries, owing to the recent war between Ethiopia and Eritrea. The SPLA received military support from both of these countries in the past, as well as from Uganda. Thirdly, the situation has been further complicated by various splits in the liberation movement, and changing allegiances among the protagonists.
OPERATION LIFELINE SUDAN
The UN aid effort to many parts of heavily underdeveloped south Sudan has been coordinated through an OLS airlift. Air access to this area of the country is vital, because the roads that exist are in a very poor state, heavily mined, prone to attack by bandits and by militia in certain areas such as Eastern Equatoria, and, owing to the frequent rains, they are impassable for most of the year.
The OLS programme is unique, in that it embraces the efforts both of UN organisations such as UNICEF and the World Food Programme, and also of NGOs such as Save the Children Fund and Medécins Sans Frontiéres. This involves both longer term aid, including help with agriculture, fisheries, and livestock programmes, and also emergency relief for those areas of the country that have been caught up by war, drought, or flooding. The Sudanese government is unusual, in that it allows OLS to conduct humanitarian work, both in government-held areas and on the rebel side (supplied mainly through airlifts from a UN base in northern Kenya and also through a base in northern Uganda). The permission for aircraft to land may be granted by all warring parties. However, the government in Khartoum usually places severe restrictions on flights to strategic locations, while the SPLA does not approve flights to government-held areas. The OLS/UNICEF structure makes it possible for the various NGOs to interlink their aid programmes in a constructive and cohesive way, both with one another, and with the UN-funded agencies, such as the World Food Programme, which carries out aerial food drops to areas of acute need. Operation Lifeline Sudan provides the necessary air transport and security for NGO operations, and central to OLS operations are strict codes of conduct or “ground rules” in order to maintain high standards and impartiality in the delivery of humanitarian assistance to civilians in areas controlled by the various warring factions. This has taken on greater importance recently, since aid workers in other conflicts, such as those in Angola, Burundi, and Cambodia, have been the target of attacks. The UN presence in OLS renders it legitimate under internationally brokered agreements, but several organisations, including the International Committee for the Red Cross (ICRC), operate outside OLS codes of conduct where allowed to do so by the warring parties.
On the ground, the OLS organisation is composed of multidisciplinary teams from many different countries around the world, including doctors, nurses, nutritionists, educationalists, hydrologists, vets, and agriculture and livestock experts. In some areas of the country, OLS/UNICEF is cooperating with the SPLA humanitarian wing in landmine clearance. Although 5000 landmines have been cleared, there is much work to do, since, with the advent of each rainy season, the existing mines are washed away to new locations, rendering any previous landmine location map useless.
THE 1998 FAMINE
The Bahr el Ghazal region in the south west of the country experienced a severe famine in 1998, which was brought about by a combination of prolonged drought, and the influx of many thousands of displaced persons from the battle for important government-held garrison towns such as Wau and the surrounding rebel-held areas. Operation Lifeline Sudan oversaw a concerted international relief effort to supply major feeding camps through airlifts of food and supplies from the UN base camp in northern Kenya. Later in 1998 and during 1999 other areas of the country experienced flooding and, again, the relief efforts were coordinated by OLS through airlift programmes.
Over the past 12 months, the humanitarian situation in the Sudan has improved. The famine that peaked in 1998 in the south west of the country has abated. Most of the emergency feeding camps which were opened up by OLS, in response to the crisis, have been closed down and many of the “internally displaced” persons have returned to their homes because of a cessation of fighting in this area. There were some good harvests in 1999 and the people of Bahr el Ghazal are beginning to regain a measure of self reliance.
Fighting is still intense in some areas of south central and southeastern Sudan, particularly in the oil-rich Unity State. Therefore, there are continuing population shifts within the country, which have an impact on the already scarce resources in reception areas, such as Kordofan and Darfur on the border between north and south. The movement of people from south to north has been fairly steady for the last 10–15 years. Many people have also migrated as far as the capital Khartoum and are housed in vast shanty towns. The eventual task of relocation of “internally displaced” people back to their places of origin will not be easy, because of the continued fighting, which shifts from area to area, creating new humanitarian crises in its wake.
At the time of writing, the future of some of the largest NGOs that operate in southern Sudan is in question, due to their refusal to sign a memorandum of understanding with the humanitarian wing of the main rebel faction, the Sudan People's Liberation Movement (SPLM) (the SPLA is the military wing of this organisation). These NGOs feel that joint operations with the SPLM would hamper their neutrality. Their withdrawal from OLS operations has raised serious concerns for food security and health among civilian populations in some areas.
THE UN 2000 APPEAL FOR THE SUDAN
In order to get this area back to a state of normality, concerted humanitarian aid and a negotiated end to the conflict will be required. Therefore, the UN, through OLS, has recently issued a programme for the recovery of the Sudan. This includes 24 projects, totalling US$125.6 million, from eight UN agencies, and 29 projects, totalling US$18.5 million, from nine humanitarian NGOs, aimed at building peace and assisting economic recovery. Emergency food aid is targeted to 2.7 million people in areas of fighting and to those displaced by war. Non-food assistance, including vaccination programmes, the provision of clean water sources, agricultural and livestock schemes, and educational and psychosocial rehabilitation programmes, will target around 5.5 million people in the rebel held areas and 6 million people in the government held areas.
Operation Lifeline Sudan (OLS) is a UN “umbrella” organisation, providing the diplomatic cover and operational support to allow long term humanitarian and emergency food aid to both sides in the long-running south Sudanese civil war.
Non-governmental organisations and UN agencies have been cooperating under OLS auspices to provide a cohesive aid programme to the country.
Operation Lifeline Sudan provides an air-bridge for emergency relief supplies in regions where road access is impossible, either because of landmines or simply because the roads do not exist.
The political situation is fluid and at present threatens continued aid efforts to this part of Africa.
UN sponsored efforts to find a peaceful resolution to the ongoing conflict, are paramount and form a vital platform for the economic and social recovery of the country. Initiatives by the surrounding countries of Eritrea, Ethiopia, Kenya, Uganda, and, latterly, Egypt and Libya, have attempted to bring government and rebel sides to the “peace table”. In addition, UN sponsored conferences have taken place in Nairobi, in order to find common ground on peace and a vision for the future for all the Sudanese people. It is not clear, however, that more of the same aid as before will advance the cause of peace. The UN 2000 appeal seems, at best, well intentioned, but optimistic. Only when other countries that profit from arms deals to the Sudan stop their supply of weapons, will the various warring factions be forced to concentrate on seeking a peaceful way of living together. At present, this seems a forlorn hope.
The provision of humanitarian aid is therefore questionable, but while there is continuing conflict in this, the largest country in Africa, the role of OLS as a coordinator of the UN and NGO development and emergency food aid programmes is far from over. The requirement for daily airlifts to remote parts of the country will continue for many years. It is only with the advent of peace that landmine clearance and road building may begin in earnest, thus allowing land access to parts of the country that are otherwise completely isolated.
In any humanitarian disaster caused by war, medical aid workers should be aware that their presence, however well intentioned, can prolong political conflicts, either because the negotiations that allow NGOs to operate can legitimise warring factions, or more nefariously, because aid money can become misappropriated into non-civilian channels. An even-handed approach to aid distribution to all sides in a civil war is warranted, both in terms of emergency response and with respect to longer term aid. It is important before rushing headlong into humanitarian aid distribution, for individual medical aid workers to understand the cultural, political, social, and religious tensions that lead to war in different parts of the world. It is important for doctors to be aware of the right mix of aid required, and to have sensitivities to local cultural expectations. Longer term aid in the form of the provision of agricultural techniques, the supply of clean water, and the teaching of basic hygiene may be more important than direct medical aid in many instances.
It is easy to project personal bias at an individual or organisational level—which can be fed by the Western media—onto the developing world. It is therefore not surprising that medical aid agencies are often accused of partisanship. The model of OLS in the Sudan is a useful one in that both long term and emergency aid is provided to all sides and encompasses both UN and NGO efforts in a cohesive fashion.
The author has travelled to the Sudan as a guest of UNICEF to observe OLS operations in the south Sudan and northern Kenya.
I am grateful to Sally Burnheim at UNICEF headquarters in New York, Laura Boardman at the UK Committee for UNICEF in London and Dr Adrian Lim of Imperial College, London for useful discussions on the writing of this manuscript.
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