Introduction

One common explanation for the apparent failure of many refugees to look beyond their immediate survival needs and plans to reconstruct their future is that they do not intend to remain permanently in exile. But in all poor societies, people are likely to have a more immediate sense of how fleeting is the temporal than are those who may take for granted an infrastructure which promotes good health and a stable food supply. The constant reminder of the immediacy of death may in part account for the greater emphasis which is placed upon interpersonal relations in most poor societies as well as for the elaboration of beliefs and practices concerning the spiritual.

It is widely recognized that without the provision of clean water, a stable food supply, basic sanitation and the elimination of such environmental risks as the mosquito or the tsetse fly, very little 'development', societal transformation or improvement in health care is likely to occur. The practice of curative medicine will not solve these problems. It could be argued that it is the lack of the basic requirements for environmental health which most sets the societies of the 'have nots' of this world apart from those of the 'haves'. Enthusiasm for the 'barefoot' doctor approach to the health problems of poor countries is a response to these realities. As one advocate put it:

The spectrum of diseases which we encounter in general in refugee camps ... is typical of the kinds of diseases we encounter in stable communities as well . . . Where there has been a change in the last ten or fifteen years in the provision of health care [it] has been away from the idea that we can ever sort out these problems by putting white coats on people and give them a stethoscope and a syringe. (Dick 1984.)

There are several fundamental problems with the present emphasis upon primary or preventative health care as the solution for the health problems of poor countries when at the same time massive advances in health science and technology continue elsewhere. Early attempts to improve the health conditions in the southern Sudan illustrate this point. As part of the rehabilitation programme for the southern region after the cease-fire in 1972, international agency personnel drew up a health programme. The plan, the Primary Health Care Programme for Southern Sudan 1977/8 - 1983/4, was published in 1976.

Even if this 'green book', as the plan is called, had been fully implemented during the eight years it was prescribed, it is unlikely that it would have brought about great improvement in the health of the people. Some of its weaknesses will be discussed shortly, but many simply reflect the fact that it was devised by outsiders and based upon inadequate knowledge of local environmental and social conditions. More to the point, however, it was based upon an assumption that someone else was going to ensure the other basic requirements of environmental health, an expectation that was not realized.

There is another fundamental problem with primary health programmes for the poor. Even if a health programme is drawn up in consultation with indigenous medical experts, it is unlikely that either the outsiders or the indigenous professionals (or anyone else with the resources) will ever be forced to subject themselves to the health care system they impose on others. During my fieldwork in southern Sudan two expatriate doctors were evacuated to Europe for treatment - one for a burn and the other for malaria. Funds are found in the Sudan for a surprising number of highly placed individuals to travel and to pay for curative treatment outside the country. This is a general pattern in the so-called third world.

There seems to be an assumption that preventative and environmental health can be taught in a vacuum, outside the context of efforts to improve the totality of the lives of the poor and without the security of curative medicine, but this is not the case. A surprising number of the major health problems of the refugee settlements are the direct result of poverty and a significant number of illnesses are worsened by the failures of the aid programme. Everyone prefers to drink clean water and even if the specifics of the health hazards are not understood, most people regard human waste as polluting. I dare say that no one prefers walking barefoot in their fields, but even shoes cost money. If relatively small amounts of money were available to raise the general standard of living in the settlements and the surrounding region, much illness would simply not occur. The need is not so much for doctors but for a habitable environment, and a standard of living above the level of subsistence and debilitation.

'Everybody has to die once'

The great disparities of wealth and health services between the 'first' and

'third' worlds are so great that some doctors who work in poor countries have apparently reinterpreted the Hippocratic oath. In Africa it has become fashionable to speak of 'nature's way', although we all know that the real problem is lack of resources and that 'nature' is rarely permitted to take her own uninterrupted way where personal circumstances allow access to the fruits of modern scientific advance. As one nurse working for SCC put it, 'For 25 years I have been working to save lives in Tanzania. This is against the rules in southern Sudan.' Although most who believe that the first priority is to establish primary health care programmes would argue for a balance between curative and preventative approaches, balance was conspicuously lacking in the 'green book' programme for southern Sudan. Here the pendulum has made the full swing: curative medical facilities were sorely, if not completely, neglected.

The psychological response of agency personnel to a human disaster has received little attention. Viewers of a BBC film broadcast in early 1985 must have been shocked to hear expatriate medical personnel explaining the necessity to deny treatment (food or medicine) to those refugees from Tigrey who were unable to walk to the clinic, but humanitarians in the field are constantly faced with such decisions. As de Waal (1985) provocatively puts it.

Most people who start working for relief agencies in Africa have not had previous experience of knowingly contributing to the suffering and death of large numbers of people. Relief agencies do not tend to attract people who have had this sort of experience, and they do not include it in their job descriptions when they are recruiting Yet the disturbing activity of voluntarily being unpleasant to strangers is one of the most frequent experiences confronted by agency personnel in a relief situation .

Ken Wilson (Wilson et al. 1985), interviewed an elderly blind man who had walked 110 miles from Katigiri settlement to Kaya to trade tobacco, guided by his six-year-old son. 'The journey was so strenuous that it took him three months to recover, but enabled him to get some income to supplement and possibly justify the charity he received from a neighbour.' In a footnote, Wilson reports his own reactions to such suffering.

When I asked this man if he had anything to say to me, he said he was only crying with hunger and that's how I should know him. But I should know that he was not only crying for himself but for all the other vulnerables [i.e. handicapped] who, when times were hard, could not at least work for food or find new opportunities. He did not know how he could survive and that one could only trust in God. As his case unravelled, I started to cry quietly and there was silence. Then he told me not to worry, that I should just stop thinking. This is certainly the only comforting thing to do as a powerful westerner surrounded by the misery of disaster.

The situation for doctors working under such conditions is indeed difficult. It should not be surprising to discover that most individuals find it is necessary to manufacture mechanisms for coping with their fundamental powerlessness to alter the status quo.

Denial is perhaps the most easy response to situations one is unable to change. As Chambers (1983) has observed, most experts, especially the foreign ones, never see the poor and can thus easily dismiss any report which challenges their opinions. For example, although a UNICEF study had identified sleeping sickness as the most dangerous disease prevalent in Eastern Equatoria and had singled out Yei and Torit as areas of high concentration (Kurup 1983), when the alarming number of reports of this disease began reaching the UNHCR office, especially from Kala settlement, the response from GMT was as follows:

... sleeping sickness is present in YRD, particularly on the Juba road in the Loka area and on the Kajo-Kaji road in the Limuro area. The cases are sporadic and have caused very few problems in terms of medical care. There is always the possibility that many cases are not being diagnosed because they do not come to the health units ... but again, I stress that it is not a major health concern. The disease can be diagnosed at any dispensary with a microscope, and [the] patient sent to Yei hospital for treatment. (12 June 1983.)

Not every medical doctor would agree that sleeping sickness is so easily diagnosed, since the symptoms patients first present are non-specific. A successful cure is dependent on early treatment. Moreover, only five out of the 25 settlements had a microscope and one of these was later stolen.

Another and all too common mechanism for dealing with scenes of death and misery is the convenient belief that 'Africans do not suffer as "we" do.' I cannot count how many times such reassurances were repeated by colleagues in the field. According to them, Africans do not suffer either physical or psychological pain in the same way as do 'white' people, 'They are used to death and suffering' and therefore no longer feel these things. There is perhaps no more dramatic way of expressing psychological distance or for denying a common humanity.

Another method of coping with the extraordinary differences in the standard of health care available in poor countries compared with those elsewhere is to deny the acceptability of better medical services to the poor. This belief has helped make more tolerable the vast differences in provision of health care even between refugee communities. For example, on one hand, OXFAM has severely criticised the health programme for Palestinians because medical staff make no house-to-house calls. (Coleridge 1982.) On the other hand, an OXFAM doctor described the programme in southern Sudan

which omitted far more than first house-calls, as 'adequate'. After pointing out this contradiction, I asked how he defined 'adequate' in this context. He was at first reluctant to answer, saying that if he did, I might think he was a racist. He eventually replied, 'We must just accept that Africans have culturally determined lower expectations for health.' It is not sufficient to categorize such views simply as 'racist' of course, but it is important to note the ways in which unexamined beliefs about non-western societies are important in shaping the actions of individuals in the field.

This doctor took his evidence from the fact that people resort to traditional healers or magical practices, sometimes in preference to available western medicine. This is a complicated topic, but the size of the queues at any clinic anywhere in Africa contradicts the notion that Africans are unconcerned about their health or resist 'western' therapy. That they may try every possible remedy does not set them apart from people in any society. In the case of many refugees it was the absence of other sources of medicines that led many to resort to herbs and leaves.

Evaluating an aid programme

Although no effective system of monitoring food production was being implemented in the southern Sudan, the objective of any assistance programme is to make refugees 'independent', 'independence' being minimally defined as independent of relief food. A more immediately available and a more empirical basis for assessing the effectiveness of an aid programme is to measure the health of the aid recipients. Refugees are expected to become independent through their own physical labour. The UNHCR Handbook elaborates in considerable detail the standards of medical assistance to refugees which should be applied. And it includes such requirements as keeping records of the births, deaths, and morbidity. Yet, as Kibreab (1983 :1) has noted, 'There are no data that show what percentage of refugees who arrived alive in the country of asylum die in the circumstances that give rise to a refugee situation, or during actual flight and during asylum phases.'

The lack of these data should be a matter for serious concern. It is obviously in the interests of donors that the health and nutritional needs of refugees be well-attended, especially during the relief stage of the exercise. Yet in Yei River District both these basic needs were neglected. Refugees are expected to depend on their physical labour to remove themselves from relief rolls, yet are forced to divert other inputs; they are forced to sell their blankets and hoes to obtain food and medicines, for example, and they often had to eat the seed intended for planting. The evidence collected by the survey shows two things. First, that throughout 1982-4 some refugees continued to suffer from malnutrition; and second, in many cases, the health of refugees actually deteriorated under the aid umbrella. These facts are not officially acknowledged.

The failure to supply the needs of the people who were the objects of the assistance programmes reflects all the standard problems which obtain in such an environment - the poverty and lack of infrastructure; bureaucratic bungling at the international level; inter- agency conflict and competition at the field level; a persistent shortage of qualified staff- especially to monitor the programme; the lack of authority to control the quality of the work of the voluntary agencies; the lack of consultation with qualified medical personnel among refugees; and insufficient supplies.

But most importantly, there is no sound information on which to base aid policy. A general argument of this book is that assistance should be directed to the community as a whole on the basis of need and should not single out one group for special treatment. Ironically, the main problem with the programme in the Yei River District was that the German Medical Team (GMT), the agency given the

responsibility for health, persisted in implementing an integrated programme despite indications that in this area, it would not work. The problems which developed with the health programme show how important it is that assistance programmes are both flexible and responsive to the immediate conditions in which they are implemented.

The Ugandan refugees arrived with high expectations for health services and they practised higher standards of sanitation than the Sudanese. They also demonstrated considerable knowledge about health and nutrition. As it

was, Ugandans had a positive effect upon local practices. In Juba, for example, Ugandans are praised for having set the example of digging latrines which is now being followed by many Sudanese as well. Every self-settled refugee compound I visited in the Kaya area had at least one latrine. Many had attempted to protect a water source or to dig a shallow well. It would, for example, have been possible to have followed the model provided by Somalia. There, the standards of health care established in refugee camps were gradually extended to the local health programme and thus had the potential of promoting a long-term improvement in overall community health. And, unlike the situation among the refugees from the Ogaden, there were many qualified medical personnel among the Ugandans. They could have been used more effectively to upgrade the local programme.

Across the border, in Zaire, one case was reported in which Ugandans had established a separate health facility which was also open to the locals who previously had none. A Ugandan doctor had been put in charge of a settlement. He started a hospital with surgical facilities. Having escaped with his own vehicle, he was assigned the responsibility of supervising clinics in neighbouring settlements. As a result, local people found that the presence of refugees was an advantage to them, and Ugandans - rather than being totally dependent upon others - were taking responsibility for their own health.

Refugees outside the aid system in Yei River District attempted similar self- help schemes. With the permission of local chiefs, some opened clinics: later when this came to the attention of health authorities, the clinics were raided by police and their equipment was confiscated. Other refugees erected buildings in remote areas after GMT had assured them that if buildings were put up, staff and medicines would be supplied. In the years that followed, in only one case (a dressing station at Yundu) was this promise fulfilled.

Ugandans who got employment in the Sudanese primary health programme faced another type of problem. Better trained and more accustomed to discipline, their performance reflected on that of their Sudanese colleagues and this created tensions. Even coming to work on time was against the norm. Those who did not lose their jobs soon learnt the wisdom of simply acquiescing to entrenched practices. Clearly, another approach was needed in Yei River District. Had GMT been more flexible and responsive to local conditions, a satisfactory health scheme might have been devised. A health system run in the field by the Ugandans could have had a very positive effect upon the district.

The health programme in Uganda

Although I have little information on the actual functioning of the health programme in Uganda, its structure and objectives were described by Ugandan medical staff and other refugees. I describe it because it demonstrates the enormous gulf (at least at the ideological level) between the situation in the Sudan and the modest medical services which many in Uganda had come to consider normative. These services drastically declined in Uganda after 1979 and much equipment and many medicines were looted. Some appeared on the market in the Sudan.

Uganda had a primary health care system which emphasized prevention. There were four levels of health care, beginning with sub-dispensaries staffed by a dresser and a sweeper. Dispensaries, each employing a nurse, dresser, and a sweeper, served a maximum population of 5,000, and were supervised by the district nursing officer on a monthly basis. Health centres served a population of 10,000 and each was staffed by a medical assistant, two nurses, two midwives, a dresser, and a laboratory assistant. Both dispensaries and health centres provided curative care, and the availability of transport meant that emergency help was no more than two hours away from any unit. In the area north of Arua - an area of 4-5,000 square miles, where the bulk of the present refugee population came from - there were four hospitals, including a major hospital at Arua. These hospitals were reasonably well-equipped with good theatre services which were said to function round the clock; all bedding and meals were provided for in- patients. Medical services were free except at mission centres, where a subsidised fee was payable. Referral beyond the district level hospitals was possible when the need arose, and the referring hospitals provided transport.

The efficiency of these services was encouraged by a training programme which emphasized staff motivation and professional interest, and staff development was ensured by regular supervision and 'up- grading' courses. Negligence, it is said, was severely punished. Centres were stocked with the necessary equipment, a relatively constant supply of drugs, and regular payment of salaries and allowances for field staff. Moreover, Uganda enjoyed good public transport.

Perhaps one of the most fundamental differences between the programmes in the Sudan and Uganda, which the refugees remembered, was the requirement of a sound basic education for recruits to the medical profession. Nursing aides and dressers could only begin their two- year training after seven years of primary school: their training took place in hospitals under the supervision of nurses and doctors. An enrolled nurse had to have completed three years of secondary education before entering a two-year course leading to a certificate. All registered nurses and medical assistants had to complete their 'O' levels (but many had also finished their 'A' levels) before enrolling in the three-year training course. 'A' levels are a prerequisite for the laboratory technicians' four-year course.

Nor was preventative health care neglected in Uganda. Health centres were the focus for the educational work. Midwives organised mother-child health services. A team included health inspectors, assistants, health visitors, and their assistants. It conducted home visits and was responsible for the inspection of such public places as markets, abattoirs, and eating houses, as

well as for the regular medical examination of the employees. There was an area- wide immunisation programme. Special campaigns to control diseases like sleeping sickness, leprosy, and tuberculosis were run by the district medical officer with a team of well-trained auxiliaries. An annual national competition encouraged environmental health. The media (television, newspapers, and especially radio), were used to disseminate information. Schools were regularly visited and there were special radio broadcasts for school children. The Ministry of Health developed visual aids and other community teaching materials. Bore- holes were sunk in every sub-county, and maintained to ensure a reasonably clean water supply. Almost every home had a pit latrine.

The health programme in Yei River District

Following the 'green book', the primary health care programme in southern Sudan recognizes three levels of care, although there are a few dressing stations which are manned by persons with lower qualifications than those who staff the primary health care units (PHCUs). PHCUs are intended, according to the plan, to serve a radius of not more than ten miles. This is the distance presumed reasonable for transporting patients by foot. These PHCUs should serve a population of not more than 4000 people and are staffed by a community health worker who has been selected for training from among his own community. The long-term aim of the plan was to establish self-sustaining, self-financing units at every level. It was assumed that if the community health worker was nominated by his community, the people would accept his leadership and eventually pay both for his services and for the medicines they required. Predictably, this scheme failed.

Both local factionalism and national politics influence the choice of candidates. For example, the Kogwo PHCU, named for the local river, is in the village of Logo. The community health worker comes from a neighbouring village, Pisa, and the chief of Logo and his people assert that he was chosen against their wishes: a medical assistant from Yei selected him because he was a relative. Despite this, the Logo people might have accepted him if he had performed his duties properly. Many letters of complaint were addressed to GMT asking for his removal. At one point, when the Ugandan medical officer was present, the two communities nearly fought.

Every community also had a representative of the Sudan Socialists' Union (SSU), the political party in power, and this representative often had as much or more influence within the community than did the local chief or other groups, such as religious organisations.

The plan requires nominees to be primary school leavers. In practice, some of those selected have not attained even this standard of education. More importantly, most workers never aspired to a career in community health, but lacked the money or the requisite grades to continue their education in another field, and had little choice. This undoubtedly affects motivation.

After nine (in some cases, only three) months' training, and despite their limited basic education, community health workers are assumed to be capable of dressing wounds, diagnosing and treating the most common basic diseases, and recognizing conditions that require referral - such as leprosy, tuberculosis, sleeping sickness, or meningitis. Responsible for drawing up his own work schedule, the PHCU worker is expected to spend three-quarters of it in 'field work', that is, teaching sanitation and nutrition, control of communicable diseases, and protection of the water supply. With the support of local leaders, he is ultimately expected to mobilize his people to build a store and to pay for his services. Given the basis for selection and the lack of training, it is not surprising that this level of mobilisation has not been achieved and workers continue to depend on the government for salaries.

A cluster of PHCUs are linked to a dispensary - the second level of health care - and these clusters are referred to as a 'complex'. Medical supplies for a complex are supposed to be sent from Juba at three-monthly intervals, but deliveries are highly irregular. For example, from January to June 1984, nothing was supplied to the district and the entire programme had to rely on medicines supplied by UNICEF for the refugee settlements. PHCUs were not supplied with stationery.

Most of the PHCUs look impressive: the buildings are prefabricated imports from Italy which, I was informed, cost $22,000 each. Yet they are rarely open. I usually found the community health worker sitting in his home compound, not on duty.

A number of factors discourage these employees. Salaries are paid irregularly, and many have to go personally to Yei to collect their monthly pay. This may require a week's absence. The low salary (at present set at £S42)[12] encourages some to sell drugs. The moment the drug supply runs out, there is no longer any point in seeing patients. The demands of 'fieldwork' and the shortage of drugs are the most frequent excuses for being absent from the PHCU. But it is also discouraging to be expected to enlist local people to

carry out communal work when there are no funds for supplies (such as cement which is needed to protect water sources). Even if a community health worker is able to recognize illnesses requiring referral, there is no transport, and the experience in Yei River District suggests that most are not adequately trained to identify serious cases. For example, during 1983 and up to June 1984, not one PHCU worker had referred a case of leprosy or tuberculosis, although these are the main communicable diseases of public health concern.

Responsibility for supervising the work of the PHCU programme lies with the medical assistant, who is also in charge of a dispensary. Dispensaries (the second level of health care) are staffed by one medical assistant, two nurses, and a sweeper. In theory, this dispensary is the referral centre for five PHCUs serving a total of 24,000 people. A medical assistant should have completed secondary school before two years of training. Nurses receive their training on the job: after two years they receive a certificate. Dispensaries are supposed to be equipped with a microscope and to employ a laboratory assistant. In Yei River District, which according to the 1983 census has a population of around 350,000, there are only eight such complexes. Very few of the dispensaries have microscopes.

The medical assistant is responsible for seeing all cases referred to him from the PHCUs, referring to hospital those requiring surgery or treatment, supervising the work of each of the PHCUs within the complex, and ensuring the proper use of all drugs. He treats the patients who come to the dispensary and organizes and supervises the mother-child health clinics; he is also in charge of the immunisation programme which in Yei River District only began during September 1982. Even if all PHCUs had been located 'not more than ten miles' from dispensaries, the distances would still have been too great for the medical assistant to supervise them adequately. In 1982, bicycles were sold to medical assistants at half price. Within a few months, most of them were 'off the road' because of lack of appropriate spare parts. Moreover, as a medical assistant has more training and usually a wider array of drugs than is available at PHCUs, the case load of the dispensary is too great for him to leave his post.

In addition to the dispensaries in the district, there are two health centres. One is at Tore and the other at Loka. In early 1983, Loka was closed when it was found to lack pit latrines. The Tore centre (a Sudan Council of Churches project), has a small in-patient ward, a midwife, two medical assistants, nurses, and a laboratory technician.

According to the Green book', regular supervision of the complexes should be carried out by a medical doctor. Supervision is restricted to observation and, after the clinic closes, consultation with the health workers. To supervise one unit adequately, a doctor must leave Yei very early in order to arrive in time to observe the work. Distances are too great. Even before the refugees came, the one resident medical doctor and one nurse could not visit each unit even once a month. Supervision is thus limited to a hasty visit to deliver drugs and sometimes to transport a seriously ill person to Yei.

The attempt to cope with the medical needs of the emergency refugee influx in 1982 will be described below. Before then, the only increase in health services (outside the four refugee settlements) was a dressing station started in early 1982 at Yundu, a market near the border where thousands of unassisted refugees had settled. Despite the great rise in population, additional medicines were not available at the PHCUs or dispensaries. As noted, this put the refugees and the locals in direct competition for scarce resources, and encouraged the illegal selling of drugs.

There are no adequate referral centres in Yei River District. Two hospitals (in name only) are located at Yei and Kajo-Kaji. The expatriate doctor stationed at the Mandari Hospital, Kajo-Kaji, left early in 1983, and was not replaced. Neither hospital had a clean water supply and Mandari Hospital never pretended to have facilites for surgery. The conditions at Yei hospital are best described by the Sudanese Inspector of Health for the district in a memorandum presented to the Provincial Commissioner, dated 25 August 1982.

This noted that funds for the hospital had not been released for nearly two years, and the irregularly-paid staff had become 'disillusioned and dissatisfied'. At one point they went on strike. The hospital had no stationery, which meant there was no paper for keeping patients' records or even for admitting them. There was no fuel for sterilisation of instruments and no towels for the operating theatre. At times there were no post-operative bandages, so scheduled surgery could not proceed normally.

The inadequate staff quarters were desperately in need of repair. The doctor himself lived in a house with huge holes in the ceiling - which allowed rats into the room as well as into the roof. The nurses' quarters, earlier destroyed by fire, had not been rebuilt. As a result, the medical assistant, theatre attendants, anaesthetic assistant, and nursing sisters, 'who, by the nature of their duties need to be accommodated near the hospital' had to live elsewhere. There was no X-ray machine, and no drugs for the treatment of tuberculosis - a disease prevalent amongst the local population as well as amongst refugees. Some latrines had been dug, but there were no funds for completing them. There was no source of uncontaminated water and staff and patients alike had to depend on the nearby river for bathing, washing, and drinking water. There was no money for feeding patients although the hospital had a kitchen. There was no place protected from rainfall for relatives to cook for patients, nor any place for them to sleep while staying there to care for them. At night the floors and verandah of the hospital were filled with sleeping relatives.

The hospital had 115 beds, but only 50 mattresses, and no sheets or blankets. The hospital vehicles (including the ambulance) had broken down and there was no money for spare parts to put them on the road again.

Supplies of all drugs were inadequate. There was no fuel for the emergency generator. Without fuel for his vehicle, the doctor was unable to meet his commitments of supervision or investigation of epidemics and in his memorandum he referred to a report from Kajo-Kaji of an epidemic of 'fatal dysentry' in that area to which he was unable to attend.

The response to the influx

The period from 1979 to 1982, when there were only five assisted settlements in Yei River District, would have been the ideal time to have established a co-ordinated health programme, to have strengthened the referral centres, and to increase the services available in remote areas where the population had risen so sharply. SCC had been meeting most of the exceptional health needs in four of these settlements and had built a medical centre at Tore which could have been developed into a hospital. There was ample time to have organized the emergency response well in advance of the waves of new arrivals.

During the early period, a large number of refugees with medical qualifications had arrived, and although most Ugandan doctors escaped to Kenya, a few fled to Zaire and the Sudan. Some even came from Kenya to the Sudan to offer their services, but on arrival were informed that the area had no need for additional doctors. Yet, in 1982, when the serious deficiencies of the programme attracted international attention, and the need for more doctors could no longer be denied, it was expatriate staff that were recruited. As one refugee rightly observed:

....there is something here which is absurd.... not [to] permit refugees to exercise their professions, including the medical profession. So you find highly- qualified medical people, specialists, going to other countries....If they had stayed in the country of asylum, they could have been in a position to work amongst their own people. It seems to me a bit absurd that because of such policies, refugees go seeking jobs elsewhere, and then you recruit expatriates to come and work where these people should have worked. (Alternative Viewpoints 1984.)

Indeed, one of the doctors who tried to work in the Sudan is now employed by the World Health Organization (WHO) elsewhere in Africa. In 1982-3, other Ugandan doctors working in the prestigious Nairobi hospital expressed their willingness to come to the Sudan if employment could be guaranteed. Yet it was only in 1983, after two of the expatriate medical teams which responded to the emergency in 1982 had left the district, that GMT finally agreed to employ the one Ugandan doctor who had remained in the area.

Given their availability, UNHCR could have involved qualified Ugandan doctors in planning, organizing, and implementing the health programme for the settlements from the first. This would have avoided many of the subsequent problems and would have allowed refugees to take responsibility for themselves in a critical area. This opportunity was missed and resulted in wasted resources.

The 1982 emergency began in April. By May the health programme was in chaos. Lines of responsibility had not been drawn. Some drugs came from the UNHCR store in Juba, others from SCC. As GMT was already responsible for the local health programme in the area, it seemed obvious that this agency should include refugees in its programme. Negotiations were going on between GMT and UNHCR, but the contract had not been signed. There were no emergency medical services at the reception centres on the border where thousands of critically ill refugees were congregated. Both adults and children were severely malnourished, yet there was no feeding programme at these centres. The two Sudanese doctors stationed in Yei had no transport to move out of town. GMT's expatriate field staff for the whole district comprised two doctors, a nurse, and an unqualified assistant. The establishment of each new settlement caused even further chaos.

Ugandans were hastily recruited to man the clinics which should have been ready to meet the first arrivals (usually the most ill) at each new settlement. Recruitment was done mainly by the unqualified expatriate assistant. Penniless, all refugees are desperate for employment. With no Ugandan doctor to vet applications or positively identify those who turned up with certificates, the assistant had to rely on gossip and rumour, with the result that Ugandans without proper qualifications were often employed in responsible positions, while the highly-qualified were turned away. Thirty people interviewed in the survey were employed by GMT in the settlement health programme. Some of these may have been paid watchmen or sweepers, but it is worth noting that out of the 22 who answered the question regarding former employment, only five admitted to having worked in the medical field in Uganda. Of those who said they were dressers in Uganda, all had the requisite educational level required there, of between seven to fifteen years in school.

Among the 17 others, six said that in Uganda they had been 'only cultivators' (one of these had sixteen years of education); two had been students; two others had been primary teachers; one said he was a driver (but he had been to school for ten years); two were businessmen; one a labourer; one a catechist; and two were 'salaried non-professionals'. (Again these two individuals

each had fourteen years of schooling.) Among the group were six who had never been to school. Some of those who had several years of post- primary education may have been soldiers with medical training who felt compelled to disguise their former occupation.

By the time I arrived in Yei in 1982, the town was flooded with refugees. Much of the time more than half the hospital beds were occupied by Ugandans. Few drugs were available in the hospital or the agency stores, so most prescriptions had to be purchased from the local chemist. Even when the drug supplies were placed completely under the supervision of GMT, there were still problems. Refugees could only get prescriptions between 7:00 and 8:00 a.m. After that time, the medical doctor left for field supervision and refused to allow any drugs to be released by the Ugandan attendant. Emergencies cannot wait, and so there was always the problem of finding funds for patients who required medicines outside this one opening hour. UNHCR had no budget for this extra expense so accounts had to be juggled or expatriates paid out of their own pocket.

Rations were issued only in settlements. With no provision for feeding patients in the hospital, patients relied on their relatives. Where were the refugee families going to live or cook ? What was to become of those who had no family? From where were patients and their families in Yei going to get food? Even when a plan was devised for providing rations to patients referred from a settlement, it left unsolved the problem of providing special diets. People who are recovering from hepatitis or a hernia operation are unlikely to recover on a diet of beans, rice, oil and milk. Clothing was never available for the new-born and there was no budget for special formulae for infants of non-lactating mothers. And, with such a limited capacity to deal with emergencies, what about such luxuries as spectacles, crutches, or calipers for those refugees who had lost theirs in flight? There was no one to deal with the hundreds of such cases who presented their problems at the UNHCR compound in Yei.

Given the very serious health symptoms which refugees presented, adequate referral centres were urgently required. The population increase since 1980 would have justified the establishment of at least one (if not two) properly equipped and staffed hospitals in the district.

A primary health care system without such back-up services has a seriously demoralising effect upon all personnel. It has yet to be demonstrated that preventive health education can be taught outside a context of confidence in curative medicine. Without proper curative facilities and transport to reach them, people are forced to consult traditional healers. These healers are able to give the patients and their families psychological reassurance and are willing to treat patients in their homes. Traditional healers do not 'work to rule' and are available after the 2:30 p.m. standard closing hours in the Sudan.

Ugandan medical workers said they were encouraged to observe strictly Sudanese working hours. This was the frequent excuse for refusing to see emergency cases after 2:30 p.m. Even feeding programmes for the severely malnourished were closed at weekends, and some claimed that this was 'on instruction' from their employer. The expatriate doctor responsible for supervising GMT's programme had no previous experience in Africa: she and the one German nurse, who left in mid-1982, were unable to cope with the amount of work assigned, and could not exercise authority over staff.

The Ugandan staff in the settlements quickly became demoralised: they lacked sufficient supplies to deal with the numbers and types of diseases they encountered, and had to watch people succumb to illnesses which could easily have been cured with adequate drugs. Having no referral centre, discouraged by low pay and inferior working conditions, and very soon aware that dereliction of duty would go unpunished, many resorted to alcohol, apathy, or corruption, or a combination of these. In one settlement, for example, the community alleged that the medical staff failed to open the clinic and were selling drugs, and a group of residents threatened to beat up the medical staff. The Ugandan administrator of the settlement called a meeting to iron out these differences, but the medical staff fled to the bush.

It could be argued that putting a team of Ugandan doctors in charge would not necessarily have prevented the decline in standards, but the improvement in discipline in those clinics supervised by the Ugandan doctor who began working in 1983 suggests otherwise. The example from Zaire lends credence to the argument that had Ugandans been supported in their initial efforts to develop a health programme which also served the locals, their work would also have contributed to good relations between the two communities.

Although the population of each settlement soon increased to over 3,000 people, the services provided differed according to the staff available or the location of the settlement in relation to the district's PHCUs and dispensaries, not in relation to population. Despite the large numbers of severely malnourished, none of the settlements had a therapeutic feeding programme for children or adults, except for a brief period in Goli, where a highly-qualified and committed Ugandan nurse took charge. The other settlements only offered supplementary feeds. In September at a co- ordination meeting, the OXFAM doctor reported that children in settlements were receiving only 70 Kcal in a supplementary meal which, as he pointed out, did not provide sufficient energy to justify the walk to the feeding centre.

Not only medicine but everything else was in short supply. For the

thousands of new arrivals from May through to July, there were no blankets, no tents, no clothing, no cooking utensils, no buckets, no milk, and hardly any cereal. The cold, rainy weather contributed to the heavy toll of human life. As noted earlier, the office in Yei - not by then recognized by Geneva - had been manned by a storeman. The emergency influx, which began in March, was dealt with by two temporary consultants who lived in Yei, and the programme officer, who commuted from Juba. A message from the programme officer underlines the situation: 'the new refugees are in immediate need of clothes. We see cases of women and men wearing leaves. The region is cold now and clothing is hardly a luxury. I emphasize the need for clothing for adults, particularly men, as previous experience has shown that most donated clothing is for children. We need clothing for everyone.' (19 July 1982.)

To paraphrase the UNHCR policy, an assistance programme has the obligation to raise the condition of refugees to those of the local community, but if those standards are unacceptably low, it then has a duty to raise the standards for all.

Those responsible apparently did not accept the inadequacies of the programme and maintained that to treat Ugandans differently from locals would impede their integration. It proceeded on the false assumption that the health of the refugees was no worse than that of the locals. If no provision was already available, for example, for treating locals suffering from intestinal parasites, for immunising them against contagious diseases, or for ensuring that rabies vaccine was available for emergencies, then the refugees should not enjoy these services. There were no drugs for asthma or yaws, and when rabies struck, two people died because no vaccines were available in the south. Similarly, in 1983 a meningitis epidemic among the self-settled refugees was reported by the Morobo medical assistant. The doctor decided to visit en route to Yei after a long, tiring, day of 'supervision' at Kaya. Four people had already died, and four others, exhibiting all the clinical signs of the disease, were shown to the doctor. Informed that there were many more similarly ill further up the road, the doctor simply instructed the medical assistant to administer sulphur as a prophylactic (some would be sent the next day) and to administer penicillin (also out of stock) to the ill. There was no attempt to determine the type of meningitis suffered. Returning to Yei, the doctor reported the incident to the Sudanese medical inspector who complained that he had no transport to follow up on this report. Apparently the epidemic was simply left to burn itself out in this remote area.

That in some cases refugees represented a serious health risk to the local population was not recognised either. In the case of bilharzia (schistosomiasis) for example, the evidence suggests that the Ugandans brought the disease with them. Wright (in Wilson et al. 1985) found infective levels of schistosoma mansoni in Sudanese were significantly lower than among their self-settled refugee neighbours and lower than all settlement refugees studied. The likelihood of significant counter-infection to the locals was small, as self-settled refugees were fairly recent arrivals. This therefore provides a good reference level of schistosomiasis by which to assess the refugees. In addition, refugees sampled on the bases of home country origin showed similar levels of schistosoma mansoni infections to their home populations. The very long lifespan of the parasites in humans and the abundance of the intermediate host snail found in the rivers of the district makes the refugees potentially a serious health threat through their use of the rivers for drinking, bathing and toilet purposes. There were insufficient drugs for the treatment of bilharzia in Yei or Juba, although as was observed in an office note, 'the seriously long term risk of bilharzia is known and every patient will pass the point where the disease is curable. We are out of drugs for many months now.' (13 August 1983.) In one area where the self-settled lived near Kaya, the population shot up from about 6,000 in 1979 to at least 40,000 by 1983. Thus the Sudanese and Ugandans were competing for the services of a single dispensary which could not possibly cope with the critical health conditions presented by refugees.

Criticisms of the health programme arising from any quarter were always countered with the response referred to earlier that 'this is Sudan'. UNHCR did attempt to put pressure on the agency to improve the quality of its services. But the agency succeeded in retaining its contract. Its performance in the field did not significantly improve.

While Rome burned

As the British Broadcasting Corporation often warns its viewers, what follows may be disturbing. While anyone with field experience is aware of the problems of incompetence and inter-agency conflict and competition, even those agencies which try to avoid these problems believe it necessary to hide any dirt under the carpet, lest the public become disillusioned with all humanitarians. The problem is that this method of dealing with the situation does not solve it.

The problem of the effectiveness of humanitarian aid programmes is a

complex one. Host governments are too dependent on the aid which agencies control to demand measures of competence. Donor governments, perhaps because of the compassionate nature of the aid programme, have not demonstrated concern either for results or for accountability. Perhaps the only way in which programmes will ever become more effective is for the humanitarian agencies to be made publicly accountable for the vast sums of money they at present distribute. But the only way in which public accountability could be approached would be through independent research which would monitor agency programmes: sound research, which would break the monopoly and control of information that the humanitarian agencies presently enjoy. While the logic of compassion suggests that to scrutinize the quality of the gift would be improper, the logic of economy suggests otherwise.

That UNHCR had itself assumed major responsibility for implementing the programme in Yei River District might have had the advantage of reducing the potential for agency conflict and competition. In general, the more agencies involved in a programme, the greater the problem of coordinating the work. The power struggles which occur between agencies in the field reflect a number of factors: the interests of donor governments who view agencies as their public face of humanitarianism; national and local host government interests; the objectives of the voluntary agencies; but perhaps most dangerous of all, the personal ambitions of individuals who believe they are doing good. Since UNHCR does not solicit independent evaluations of its programmes, success in getting or keeping contracts to implement programmes is seldom based on measures of competence or on any objective assessment of the actual work to be carried out. Rather, acquiring a contract depends on the ability to manipulate all the strings correctly at the same time. One Somalian WHO representative summed the problem up in this way: 'The longer they [expatriates] are in a country, the more clever they are at manipulating local politics. I wouldn't let an expatriate stay in my country more than two years.'

In some cases gifts, or even money, are dispensed to encourage approval of their programme or to ensure permission to enter or stay in a country. The ability to manipulate local politics through such means gives an advantage to those with greater funds and increases inter-agency jealousy and bickering in the field.

Foreign government representatives also try to manipulate agency/host government relations. In 1983, a new agency began working in health in eastern Sudan. The embassy of the agency's home government sent someone to call on the Deputy Commissioner for Refugees in Khartoum. He asked COMREF not to allow this agency to remain. The Deputy declined to follow the advice, suggesting that if something was wrong it should have been dealt with earlier, in the home country. Privately he told me that if this particular government did not like one of its own NGOs, it must mean the agency was a good one!

It may be useful to describe the ensuing crisis in some detail, since it illustrates the tensions and even failures that can occur during times of serious crisis. One UNHCR official in the Juba office expressed the view that voluntary agencies were simply a recent manifestation of the 'scramble for Africa'. Understandably, given this perspective, OXFAM's offer of its services early in 1982 when the emergency began was declined. But even before May 1982, any impartial observer would have questioned the capacity of the agencies working in Yei River District to cope, especially with the health of yet another influx of refugees. But more refugees mean more funds. There is a temptation for some agencies to take on more responsibility than they can competently manage rather than to agree to inviting in others to assist. Apparently, the idea of utilizing appropriately skilled refugees or locals almost never crosses anyone's minds. The situation in the district was allowed to deteriorate.

Beginning in May and continuing through the first week of July, a series of radio messages and memos were sent from the field informing both the Juba and Khartoum UNHCR offices of the escalating numbers and of the lack of supplies. After several such messages, one concluded with the warning: 'Inform Khartoum; if we are not careful this will become a public scandal'. An earlier message had included details of the scale of the influx:

'....on the Nyori road where we stopped, 35 people, two families, reported needing transport to come to settlement. When our lorry went, 92 boarded. Further down the road, there were at least 200 waiting and they were all too weak to walk....I had to hire one lorry at Kaya so we have three now moving from that end. This means at least 200 a day will be arriving here [Yei] and we do not know for how many days. Military [Ugandan] activities all along the border from Kajo-Kaji to Kaya. People on the border are leaving their crops. Attacks on the self-settled refugees include robberies, wounding (six are in the K-K hospital) and kidnap of some who have been taken back to Uganda....the concentration of refugees inside the border appears to have doubled....At any moment these people may all begin to move and it is clear that they are now health-wise in very bad condition. We must deal with present emergency and

be prepared for more if it comes. Since I have been sending urgent radio messages almost daily, you can imagine that I find it very difficult to understand lack of substantial response from Juba.'

Emergency supplies ordered before May the previous year, for the March/ April influx had not even arrived. Whatever were the reasons for withholding the information - that the south was facing an unparalleled crisis with which the programme could not cope - it was only when the British Refugee Council, OXFAM, and the international press got hold of the story that Geneva was informed.

When in Khartoum this leak was discovered, the head of one agency denied any emergency in the south. Perhaps, since he rarely left Juba, he was actually innocent of the real situation. But OXFAM immediately sent a field officer to confirm the facts and again offered an emergency medical team. Shortly afterwards, UNHCR flew in a delegation from Geneva to assess the situation. Their report, telexed to Geneva on 9 August 1982, demonstrates the seriousness of the neglected crisis.

Influx has been taking place since early in the year and amounted by June to over 30,000 refugees. Far from showing any signs of abating, there has been building in numbers in late June and July. Last week there has been a further dramatic increase. Influx has now reached over 900 a day. New arrivals are in poor condition....the organisational capacity to cope with this influx does not exist.

....conducted random sample of a hundred recent[ly] arrived refugee children aged between one and five. 20 per cent were suffering from severe marasmus type malnutrition [sic] (less than 70 percent weight for height) and further 10 percent had kwashiorkor (extreme swelling from malnutrition). The lives of this group are at immediate risk unless medical and therapeutic feeding programmes are established. At present these services are virtually non-existent....there are inadequate water supplies, etc. At the one settlement for which we could find good statistics, there was a death rate of 15 percent. For the West Bank, new arrivals as a whole calculated on an annual basis in an area where there is normally adequate food, these statistics of malnutrition are remarkable. Even with the provision of a general ration, nutritional deterioration will now continue unless special programmes are instituted.

Referring to GMT, the message underlined the fact that its capacities were 'over-estimated' and it had been agreed that further assistance was at least temporarily required. Confirming the urgent need for the OXFAM emergency medical team, in a later message it was stressed: 'No need for more OXFAM surveys, they should be ready to fill immediately gaps already identified....Their input needed at once to save lives.' As another message confirmed, the largest influx during 1982 was occurring on the west bank of the Nile, where 'the implementing capacity is weakest'.

But there was continued resistance to accepting the help of other agencies. Two ministers in Juba were lobbied (unsuccessfully as it happened) to refuse to allow OXFAM to come in. The argument given was that more services were not only unnecessary for the refugees, but that this was just further evidence that UNHCR was solely concerned with refugees to the detriment of the Sudanese.

Now, under pressure from Geneva, GMT did organize a hasty trip to Zaire to recruit more Ugandan medical staff, and UNHCR mounted an airlift to bring in food and other supplies. This and later recruitment trips to Zaire resulted in further dissatisfaction with conditions in Yei River District. In Zaire the team found that:

...support for the refugees in this area is much better than in Yei area....They have over 30 lorries, three big stores with plenty of food. The medical staff (doctors) have UNHCR vehicles, the medical programme is paid for by UNHCR (at least salaries).... In Aru hospital, enough food is given to the refugees. They do not always get the same [diet] (they get even meat, eggs, vegetables, etc.). We are very much surprised about the differences in means employed at both sides of the border, while the refugee population appears to be the same (30 October 1982).

OXFAM's arrival was delayed (because of an attempted coup in Kenyaduring August 1982). To avoid further conflict, work was divided - OXFAM taking responsibility for the reception centres on the border. Led, not by a doctor, but a public health specialist, the OXFAM team was directed not to administer curative medicine unless UNHCR agreed to dig bore wells, as refugees there were dependent on polluted water. (UNHCR could not even supply settlements with enough wells and could not divert equipment to the border.) This decision pleased no one, least of all OXFAM's highly qualified and experienced nurses, who were limited to organising a therapeutic feeding programme.

Now GMT decided to bring in its own expatriate emergency team. Despite advice from OXFAM, one of these (an administrator, not a doctor), was put in charge of co-ordinating the work of the agencies involved in health. Hearing of the crisis in southern Sudan, Médecins sans Frontières sent a mission to Yei River District to survey the situation. The following excerpts are from their published account.

In the heart of Africa....Francis Charhon and I made our exploratory mission in October. We wanted to evaluate the sanitary and nutritional conditions for the 70,000 Ugandans who are 'piling up' in camps along the.... borders.... We had not been able to collect any information from HCR about the situation of the Ugandan refugees in the Sudan....We only knew that these people were continuing to move from one country to another.... they came back [to Zaire] when in need of medical care or food, which could be provided more generously there than in the Sudan...

One afternoon [in Kaya Transit Centre] enlightened us more than the long reports on the situation of the newly-arrived refugees. The frequency of kwashiorkor in the children, and oedema in the adults is an indication of the extent of the interruption

in normal eating habits. A rapid survey will confirm that 60% of children suffer from severe malnutrition. All these people lay there, resigned in their misery, waiting for UN trucks to be repaired to provide transport to other camps....As usual it is the children who need most attention, with their swollen bellies and faces which look old, their eyes too big. The women too, whose crinkled breasts don't produce enough milk to suckle their children. They are so malnourished themselves....

Around Yei we visited other transit camps which show us the same story, the same horrors, almost tedious in their repetitiveness. However, the organizations responsible for taking charge of refugee health, judge that the situation is not really serious. The German Medical Team present in the region for ten years, does not want to invest too big a part of their activities for benefiting refugees. Caritas has also been on location.... with three nurses and a doctor. Also OXFAM, which obstinately refuses to deal with anything except 'feeding programmes', leaving others the responsibility of caring for them.

....But how can one be satisfied with a health programme where dispensaries don't have enough anti-Paludins and no streptomycin for victims of tuberculosis, where the Ugandan nurses are left without supervision, and lepers deprived of Dapsone. Furthermore up to the present moment, no one has thought about prevention.... 'That's correct,' these people will tell us, 'but now there are enough of us to improve all that.' Let us wait and see.... In the meantime, Francis and I are tempted to think that MSF could have done something. Whatever the situation, they know that another 40,000 Ugandans are about to swell the ranks....in the case of an offensive (already announced) by the regular army against the guerrillas. It seems obvious to us that the burden will be too heavy (it's already enormous), for GMT and OXFAM....

Some agencies make greater efforts than others to avoid public disclosure of competition and conflict. At the very time this report was published in France, agency staff were making valiant efforts to paper over the cracks and, whether intended or not, reduced international attention to the Ugandan refugee issue. Items had appeared in the British press reporting a 30 per cent rate of severe malnutrition among children, predicting a new wave of refugees, and implying that health conditions in settlements were in need of improvement. One agency doctor who had been in Yei was said to have written a report in which he questioned that there even was an emergency in the south. A refugee working for this agency managed to read whatever he had written. Angered, he wrote to The Guardian. Excerpts from his (unpublished) letter, which he handed me in Wudabi in 1983, reveal the extreme frustration and bitterness felt by most refugees concerning the conduct of the health programme.

We have seen malnourished children being fed on a basic diet of milk or porridge. One multivite or iron tablet is given as the only additive until the recovery or death of such a child. Whether or not such a child vomits his feed every time, there is no examination of stool or blood for parasites, yet weights are recorded to check 'improvements'. Even a simple microscope is far from patients - about 50 miles away....A patient having a high fever is not even given an aspirin.... Anti-worming medicine is not given to patients who carry obvious physical symptoms. Most health centres run dry [of] drugs in a fortnight and nothing is replaced....we begin to doubt and question what happens to the donations given by UNICEF, WHO and many other organisations.... To....and its co-workers, this....seems to be unimportant. They care very little about the daily deaths of 3-4 persons. The graves are there for anyone to see....It is a deplorable state of affairs to see some white volunteers who come under the pretence of humanitarians playing a double game....While there are many who labour tirelessly....the majority....simply come to enrich themselves and even go to the extremes of the colour bar [sic]. Where blacks get low payment for the same jobs done by white expatriates, the whites get higher salaries. Although Dr ---- wants to hide the sufferings of Ugandan refugees, we know that the daily influx continues....It was not our wish to come into exile, to suffer, neither to live where we are now. Nor do we appreciate the least services to be rendered to what someone might call 'low class human beings'. We have different professionals in settlements, doctors, teachers, students, farmers, schoolboys, state registered nurses, widows, orphans, the disabled and it was not our wish to come into exile. We suffer through no fault of our own.

It should not be assumed that only Ugandans and expatriates were dissatisfied with the quality of the health programme in Yei River District. The arrival of alternative agencies practising a higher standard of service gave many Sudanese the courage to speak openly about their long-standing grievances. Many unconfirmed stories were circulated. Those who took note of some allegations would not have been reassured by the following note:

We have received the following radio message from....in response to query about several boxes of medicine which arrived on two flights last week. 'Re. your R/261 seven boxes of medicines gift from . The one box we opened contained expired injectible multivitamins. We have not checked the other boxes. There are eight boxes in our office...'

When funds did become available for rebuilding the hospital, GMT was chosen to implement them. The contract was awarded to a non- indigenous builder whose prices were so high that even UNHCR Geneva had forbidden the Yei office to use his services again.

At one point, when pressure on GMT had reached a very high pitch, it over-reacted to the chronic need for an ambulance for the Yei hospital. A note between two colleagues describes what happened:

....big battle over ambulances! Dr ---- went past all of us to convince Mr ---- [a Sudanese official] that he needed a fancy Mercedes ambulance. Remember during

Douglas' [US government representative] visit the patients wheelbarrows at Goli dispensary? Mr. ---- asked me when he was in Juba and I told him that any hospital without a system of support, communication, etc. was useless. We agreed that if an ambulance had to be procured, it should be a modest type. [But] Dr ---- told Mr ---- that the Mercedes is available immediately, and it would take months to get a Landrover, etc., ho hum.

The luxurious ambulance was duly delivered to Yei hospital. Lacking fuel and radio contact, it was used throughout 1983 mainly to go to market during the week and to church on Sunday. On one occasion when there was an attempt to use it to transport a critically ill refugee, the doctor in charge demanded an excessive number of jerry-cans of fuel in exchange for its use; instead the patient was brought into Yei by OXFAM's Landrover.

Late in 1982, UNHCR made an attempt to co-ordinate the health programme. Three meetings were held during my fieldwork in 1982. Representatives from all agencies involved in health were invited. When the first meeting was called, only at the last moment was it remembered that the Sudanese Inspector for Health should be included. The tendency to ignore local institutions and officials when planning refugee programmes was, in fact, quite commonplace. At another meeting, certain plans were made which might have resolved the persistent quarrel over whether refugee health was worse or better than that of the Sudanese. OXFAM offered to carry out a health survey among the Sudanese. It also offered to set up therapeutic and supplementary feeding programmes in each of the settlements although by this time the need for this service in the reception centres had diminished. Later, however, agency conflict prevented the implementation of this plan and OXFAM eventually withdrew its team.

If agencies learn from such bitter experiences, then perhaps in some sense, the suffering they cause (or rather fail to prevent) would not be in vain. Unfortunately, however, the drama of unpreparedness was repeated in early 1983. UNLA attacks, which began on Christmas Day 1982, forced another wave of refugees to seek asylum in the Sudan. Again there was a need for more staff. More hurried trips were made to Zaire and, as noted, in 1983 GMT finally agreed to engage a Ugandan doctor. UNHCR also invited Médecins sans Frontières to assist at Yei hospital and to supply staff for certain settlements. But the attempt to maintain an integrated health programme based on the 'green book's' low standards for the whole population, persisted.

During 1983, the situation continued to reflect the absence of central competent co-ordination. Each agency felt free to do as it wished. Sudan Council of Churches which had always attempted to maintain a high standard of service, had a different drug list, and was better supplied, but was ignored in the agency scramble for contracts with UNHCR. After a bitter exchange between SCC and UNHCR, its only consolation was that it was given the contract to implement a programme for the vulnerable groups, that is, the physically handicapped, the elderly, and orphans.

MSF and GMT supervisors gave contradictory instructions to field staff concerning the treatment of different illnesses. For example, one might advise a full three-day anti-malarial course for adults; another would say that a single dose was sufficient. (The latter eventually became the standard treatment.) There were no regular meetings to discuss common problems or to exchange information. Some agency staff were not even on speaking terms and UNHCR files are full of disparaging notes to the programme officer about the work of the others. For example:

Rumours abound concerning the arrival of a second MSF Team. Although you are aware of the conditions under which the initial request was made....Unless the MSF nurses can act independently they should not come here. it is not only pointless, but very embarrassing when expatriate nurses receive [i.e. require] greater supervision than local staff (as is the present situation), and this also creates more work for us.

Given the situation, this note concluded with the surprising advice: 'Also there is no need for another doctor in this area....(2 September 1983).

Monthly returns from various units were either irregular or did not appear at all. This was not surprising since report forms had been frequently changed, and the one in use at the time was too complicated for most field staff to complete. Proper statistics of births and deaths were never kept. There was little equipment and no stationery. Drug supplies were irregular and always inadequate. There was a chronic shortage of certain drugs, especially for treating intestinal parasites. In Limuru settlement (which had a microscope), 1,120 cases of various parasites were identified, but medicines supplied during the same period could only treat 150 patients. Early in 1984 a survey to establish causes of the widespread anaemia in one settlement (Katagiri) found 69.1 per cent of the sample to have hookworm infestation.

Efforts to involve the community in public health projects failed completely, and little wonder, since neither Sudanese nor Ugandans appreciated or responded to the approach imposed by the expatriates. Their method of encouraging co- operation was to threaten to withdraw all health services, if a community failed to dig pit latrines for the clinic. The Sudanese project manager's inspection tour report (24 May 1983) illustrates a situation which was not atypical.

Wudabi

Health Centre - The refugees have complained bitterly against nursing officer ---- -- for refusing to treat them. The health centre was closed from 15th to 16th of May 1983 on instructions of the SMO [senior medical officer] until the refugees responded to the call to dig 2 pit latrines at the Health Centre on a self-help basis. Obituary: Between the 17th and 21st May '83. 16 refugees died. Of these, 8 died in the health centre....and 8 at the settlement Causes of death are malnutrition, jaundice, diarrhoea, and vomiting...

Burial-cloth: No burial cloth was available in our stores for the 16 persons who died....

I am writing to Wudabi, warning refugees to respond to the nursing officer's call to dig 2 pit latrines and to show better behaviour in future.

I conducted a survey of this settlement from 5 June 1983. The clinic was still closed and no health services were available to Wudabi settlers, the nurse having been transferred elsewhere. Accusations that he was negligent in his duties, and an alcoholic, were later confirmed when he was put in charge of another settlement. A medical worker remaining in the settlement was waiting for transport to leave for Yei. She had broken her arm and the nurse had taken the box of medicines with him when he had been transferred. In the course of our interviews, among the seriously ill we found a woman lying helpless in her tent. Several days previously she had fallen from a tree, and had not even received first aid.

Although from early 1982, Ugandans had been reporting that every refugee hut was infested with rats, no action was taken. In the settlements there is a bizarre form of entertainment for children: 'rat expeditions'. Adults dig under the wall of the house to allow rats to escape while someone inside beats on the walls. (Houses are dangerously weakened by this damage to walls.) Outside, the children (who have congregated with sticks) scream 'Rat running, rat running', as they charge about killing the rats which try to escape. On my first expedition, 'we' only got 32 rats: on the next, the total was 102. I was told I was unlucky. Some expeditions net over 200 carcasses of rats of all sizes. Like children everywhere, these had great fun carrying around the wriggling babies, and frightening the women who watched. After I reported back on my adventure, UNHCR decided to order 20,000 rat traps!

Few Sudanese keep cats. It occurred to me that WFP might be advised to airlift cats to the area, since the rats were probably eating as much food as were the refugees! Moreover, people were bitten during the night: toes, fingers, and heels appeared to be particularly vulnerable to attack. It should not have been necessary for Dr Umar to point out in 1983 in his report to UNHCR that rats are 'reservoirs of infection for the following diseases: ratbite fever, leptospirosis, plague, and salonelosis.'

Towards the end of 1983, UNHCR finally did send a medical consultant to Yei River District. His intervention led to certain improvements. GMT maintained responsibility for co-ordination, but regular meetings for supervisors - as well as inter-agency meetings - began. Exchange of information reportedly improved, and a common strategy for conducting the health programme was devised. Supervisors and field staff were given written instructions; a standard drug dosage plan was drawn up; seminars were organised for field staff as part of their in-service training; better records were being maintained; and stationery supplied. Two limited field surveys were carried out in early 1984; one, as noted, on bilharzia and anaemia, and the other on sleeping sickness.

Some months later, the situation had again altered. In 1984 MSF withdrew from the settlements and, with a reduced staff, only worked in Yei hospital. The settlement clinics were once again supervised only by GMT. Their staff position in June 1984 included two doctors, two medical assistants, one nurse, one midwife, one public health adviser, and one nutritional adviser. Although a considerably larger staff than at any earlier time, their numbers were still insufficient to supervise the 54 different health units in the district. The Kajo- Kaji sub-district was totally neglected. It was supposed to be supervised by an expatriate doctor, but he had not been in the country for most of 1983, and in 1984, due to the worsening military situation in the south, all GMT's expatriate medical staff were evacuated