The Last Flight: Health in South Sudan

La medicina no llega.

The medicine doesn't arrive.

I want to ask you something, Octavio.

Spain spent real money and real political capital on development aid in sub-Saharan Africa for a couple of decades.

Did any of that land in South Sudan, in your memory?

Sí, un poco.

Yes, a little.

Pero es difícil.

But it's difficult.

La guerra para todo.

The war stops everything.

Las organizaciones no pueden trabajar bien.

Organizations can't work well.

That's the trap that every aid operation runs into in South Sudan.

You build a clinic, and then fighting breaks out nearby, and the staff evacuate, and the building gets looted.

It's happened dozens of times.

Médecins Sans Frontières has had facilities attacked, staff killed.

They keep going back, which says something about the need, but also about how brutal the operating environment is.

Los médicos son valientes.

Doctors are brave.

Trabajan en lugares muy peligrosos.

They work in very dangerous places.

Genuinely.

I interviewed an MSF surgeon in Juba years ago, a Colombian guy, and he described doing abdominal surgery by headlamp during a generator failure while gunfire was audible outside.

He told the story the way you'd describe a difficult commute.

Just matter-of-fact.

Eso es increíble.

That's incredible.

Yo no puedo imaginar eso.

I can't imagine that.

Let's talk about the specific health picture in South Sudan right now, beyond the plane crash.

What does the population actually face, day to day?

Hay mucha malaria.

There's a lot of malaria.

Los niños tienen mucha malaria.

Children have a lot of malaria.

Es muy peligrosa.

It's very dangerous.

Malaria is the single biggest killer of children in South Sudan.

It accounts for around forty percent of all outpatient visits.

And it's preventable, treatable, but prevention requires nets, spraying, infrastructure, and treatment requires facilities stocked with artemisinin-based drugs.

Both depend on supply chains.

Which brings us back to the plane.

También hay cólera.

There's also cholera.

El agua no es limpia en muchos lugares.

The water isn't clean in many places.

Cholera outbreaks are almost annual in South Sudan.

The 2022 outbreak hit over 30,000 people.

And cholera is, when you think about it, one of the most preventable diseases we know of.

It's clean water and oral rehydration salts.

That's basically it.

But if you can't get either of those things to the right place at the right time, people die from dehydration that could be reversed with a few liters of sugar-salt water.

Es muy triste.

It's very sad.

La gente muere por cosas pequeñas.

People die from small things.

Cosas con solución.

Things with solutions.

That phrase, things with solutions, is going to stay with me.

Because that's the core of the health tragedy in places like South Sudan.

It's not mostly cancer, it's not Alzheimer's, it's not the hard diseases.

It's the ones we solved, or could solve, but can't deliver the solution to.

La vacuna existe.

The vaccine exists.

El antibiótico existe.

The antibiotic exists.

Pero no llega.

But it doesn't arrive.

There's a WHO report from a few years back that estimated South Sudan has roughly four physicians for every 100,000 people.

The global average is around 150.

Spain, for reference, is around 430.

So when we're talking about a small plane carrying medical supplies going down, we're not talking about a disruption to a functioning system.

We're talking about a crack in something that was already barely holding together.

Cuatro médicos para cien mil personas.

Four doctors for a hundred thousand people.

Eso es un número muy pequeño.

That's a very small number.

It's hard to even picture what that means in practice.

And a lot of those four are concentrated in Juba, the capital, which means in rural areas the ratio is effectively zero.

Now, this connects to something I keep coming back to in this region, which is the brain drain question.

South Sudan trains doctors, with enormous difficulty and expense, and many of them leave.

Sí.

Yes.

El médico estudia mucho.

The doctor studies a lot.

Después va a Europa, va a Canadá.

Then they go to Europe, they go to Canada.

Busca una vida mejor.

They look for a better life.

And who can blame them.

The conditions are brutal, the pay is minimal, the security situation is dangerous.

But the consequence is that the country that most needs doctors is the one least able to keep them.

It's one of the cruelest ironies in global health.

Y los hospitales no tienen buenas máquinas.

And the hospitals don't have good machines.

No tienen suficiente dinero.

They don't have enough money.

South Sudan spends about 2.5 percent of its GDP on health.

The government's own target is 15 percent, a commitment made as far back as 2001 under what's called the Abuja Declaration, which all African Union members signed.

No country in the region has consistently hit that target.

But for South Sudan, the gap between commitment and reality is especially stark, because the country's revenues depend almost entirely on oil, and oil has meant conflict, not development.

El petróleo es dinero.

Oil is money.

Pero el dinero no llega a la gente normal.

But the money doesn't reach normal people.

That is a clean summary of about forty years of resource curse theory.

South Sudan has oil in the south of the country.

But the only pipeline runs north through Sudan, and that relationship has been a source of constant tension and periodic shutdown.

So even when there's theoretically money, the mechanics of getting it to the treasury, and then to health services, and then to rural clinics, and then to actual patients, are broken at almost every step.

Es un problema muy complejo.

It's a very complex problem.

No es solo un problema de dinero.

It's not just a problem of money.

Completely agree.

You could double the aid budget tomorrow and it might not reach the right people, because the systems that move medicine from a warehouse in Juba to a clinic in Jonglei State simply don't exist, or don't function.

That's why those Cessna Caravans matter so much.

They are, in a very literal sense, the system.

Y cuando el avión no llega, la gente espera.

And when the plane doesn't arrive, people wait.

A veces espera mucho tiempo.

Sometimes they wait a long time.

Octavio, I've been thinking about this from a different angle.

What does the rest of Africa make of South Sudan?

There's a tendency in the Western press to treat the continent as a single story of need.

But South Sudan's neighbors, Uganda, Kenya, Ethiopia, have their own complicated feelings about this.

Uganda tiene muchos refugiados de Sudán del Sur.

Uganda has many refugees from South Sudan.

Es un problema para Uganda también.

It's a problem for Uganda too.

Uganda hosts over a million South Sudanese refugees, which makes it one of the largest refugee-hosting countries in the world.

And here's something counterintuitive, Uganda's refugee policy is actually quite generous.

Refugees can work, own land, move around.

But the health pressure on communities near the border is enormous, and it's a dynamic that doesn't get reported very much.

La gente huye de la guerra.

People flee the war.

Llegan enfermos, llegan cansados.

They arrive sick, they arrive tired.

Necesitan ayuda urgente.

They need urgent help.

And the thing I find genuinely hopeful, and I don't say that often about this region, is the community health worker model.

In South Sudan, there are programs, run partly by the Carter Center, partly by NGOs, partly now by the government, that train local people, often women with no formal medical degree, to diagnose and treat a short list of common conditions.

Malaria, diarrhea, respiratory infections.

It's not perfect, but it reaches people that nothing else reaches.

Las mujeres son muy importantes en la salud de la comunidad.

Women are very important in community health.

Ellas conocen a la familia.

They know the family.

They do.

And there's solid research showing that when women are the health workers, vaccination rates go up, child nutrition improves, prenatal care increases.

It's not a coincidence.

It's about trust and access in ways that a stranger with a stethoscope can't replicate.

Eso es bueno.

That's good.

Pero necesitan apoyo.

But they need support.

Necesitan medicinas, también.

They need medicines too.

Which brings us back to the Cessna.

You know, when I started pulling the thread on this story, I thought it was a plane crash.

By the time I'd read enough about it, I realized it was really a story about the three-centimeter gap between a vaccine and a child's arm, and all the improbable machinery required to close it.

Me gusta mucho esa idea.

I really like that idea.

El avión, la vacuna, el niño.

The plane, the vaccine, the child.

Todo está conectado.

Everything is connected.

Hold on, Octavio.

You just used a phrase a minute ago that caught my ear.

You said 'llegan enfermos.' That verb, llegar, I keep hearing it used with this sort of arrival-plus-condition meaning.

Is that a standard construction or am I overthinking it?

No, no.

No, no.

Tú tienes razón.

You're right.

Es normal en español.

It's normal in Spanish.

'Llegar' más un adjetivo describe cómo llegas.

'Llegar' plus an adjective describes how you arrive.

'Llego cansado.' 'Llega enfermo.' 'Llegamos contentos.'

'I arrive tired.' 'He arrives sick.' 'We arrive happy.'

So it's almost like the verb and the adjective fuse together to describe the state you're in when you get there.

In English we'd need a whole extra phrase.

'They arrive and they're sick.' Or we'd use a different verb entirely, like 'they show up exhausted.' Spanish just tucks it all into one.

Exacto.

Exactly.

'Llegar' más adjetivo es muy natural.

'Llegar' plus adjective is very natural.

También con otros verbos.

Also with other verbs.

'Sale contento.' 'Vuelve triste.' Es el mismo uso.

'He leaves happy.' 'She comes back sad.' It's the same usage.

Salir, volver, llegar.

So the motion verb carries you to the place, and the adjective tells you what shape you were in when you got there.

I like that.

Actually useful for me, because I keep reaching for 'estar' when apparently the verb already does the work.

My Spanish teacher would be thrilled that I noticed, and horrified by how long it took.

Sí.

You arrive late to understanding this, Fletcher.

Llegas tarde a entender esto, Fletcher.

But you arrive.

Pero llegas.