The cholera crisis worsens in South Sudan as new fighting erupts and humanitarian aid dwindles.

In January, in Renk, a remote border town in South Sudan's Upper Nile State, Monica Nyandeng lay curled up on the floor of her hut. She suffered severe stomach cramps and constant vomiting. Every movement was painful, and her strength was waning with each passing hour. She felt as if her body was shutting down.

This 32-year-old is one of the more than 47,000 people affected by the country's worst cholera outbreak in more than two decades. "The disease came on me quickly. I felt like my life was slipping away," she recalls by phone three months later, now recovered. Cholera is an acute diarrheal disease that is cured with antibiotics and hydration, but can be fatal in a matter of hours if left untreated. It spreads through contaminated water or food in places with poor hygiene.

The crisis began in October, when seasonal floods devastated their village and contaminated the river, the only source of water for thousands of people. Without clean water or information on what to do, families drank whatever they could find. “We just drank water, clean or dirty,” explains Nyandeng, a mother of three. “No one had given us chlorine tablets or explained the importance of boiling it, especially after the floods.”

The floods not only contaminated the water, but also washed away the dirt roads that connected her village to the nearest clinics, turning them into a mass of thick mud. “It was impossible to go and get help,” she recalls.

South Sudan, the world’s youngest nation , has suffered repeated health and humanitarian crises since gaining independence in 2011, but this latest wave is taking place amid even more dire conditions: flooding, population displacement, renewed fighting, significant aid cuts, and a health system stretched to the limits of its capacity. Since the outbreak in Renk, cholera has struck nine of South Sudan’s 10 states, including the capital, Juba, and spread to neighboring Ethiopia . More than 870 people have died , far surpassing the toll from the country’s last major outbreak in 2016 and 2017, which infected more than 20,000 and killed more than 400.

In the arms of a neighbor who carried her through the mud, Nyandeng finally arrived at a crowded emergency tent for medical care. Inside this makeshift clinic, one of the few functioning treatment centers in the city, medical workers moved quickly amid the large number of patients and the shortage of equipment. “They were clearly overwhelmed and running out of essential supplies, like IVs,” she recalls. “All I could think about was who would take care of my children if I didn’t make it.”

Since the outbreak in Renk, cholera has swept through nine of South Sudan's 10 states, including the capital, Juba, and has spread to neighboring Ethiopia.

Nyandeng spent days battling severe dehydration and exhaustion, clinging to life as medical workers struggled around her. She ultimately survived, but the fear lingers. Three months after her recovery, obtaining clean water remains a daily struggle. “I’m grateful to be alive, but the conditions that made me sick are still there.”

A system at its limit

At the cholera isolation center at Juba University Hospital, Dr. Achai Bulabek is under tremendous pressure. Every day, they receive up to 20 cholera patients, many of them severely dehydrated, who are referred from distant cities or transferred from under-resourced clinics. “It’s often difficult to rescue them because cholera is a potentially fatal disease,” Bulabek explains.

According to UNICEF , 59% of South Sudan's population lacks access to safe drinking water, and only 10% has improved sanitation, making them extremely vulnerable to epidemic outbreaks.

“This is when the real cholera outbreak is emerging, because we are in the middle of the rainy season,” Bulabek adds. “Lack of health education and poor sanitation, along with the shortage of supplies, are the biggest challenges we face.”

The cholera isolation ward at Juba University Hospital, originally designed for 50 patients, now houses more than 90. The patients lie on sagging mattresses, many of them severely dehydrated, with IVs attached to makeshift stands.

Medical staff rush from bed to bed, checking intravenous fluids and watching for any signs of deterioration. Supplies are limited: IV bags, antibiotics, and oral rehydration salts are scrupulously rationed. Outside the ward, families wait anxiously as more critically ill patients continue to arrive.

Bulabek has only been on the job for four months, but she already knows what it means to work in a system on the brink of collapse. On her ward, they too often run out of essential supplies, such as intravenous fluids or antibiotics. And the situation is the same across the country.

Health system at its limit

Years of conflict and lack of investment have left South Sudan's health system in tatters. Less than half of the population lives within five kilometers of a functioning health facility, and more than a quarter of health centers simply don't function. Clinics lack trained staff, essential medicines, and basic supplies. Humanitarian aid funding, once a lifeline, has been drastically reduced to just 16% of actual needs.

Recent cuts to USAID , the largest source of aid for South Sudan, have forced Save the Children, which supported 27 health centers in Jonglei State, to close seven clinics, downsize 20 others, and lay off 200 employees. A U.S.-funded transportation service has also been shut down, forcing sick people to walk for hours to receive medical care.

Some don't make it to their destination alive. Save the Children says at least eight people, including five children, died after walking for more than three hours trying to reach a health center. Dozens of patients arrive late, dehydrated, or already too sick to be treated.

“The funding cuts have had terrible consequences for South Sudan,” Zakaria Mwatia, head of the Médecins Sans Frontières (MSF) mission in South Sudan, told EL PAÍS in a telephone conversation. “At MSF, we are forced to treat only cholera patients, victims of the conflict, and urgent cases that require immediate intervention.”

Aid workers trapped

In Upper Nile State, where the outbreak first occurred in October, renewed violence is turning a health emergency into a full-blown humanitarian crisis. The 2018 peace agreement, under which President Salva Kiir and Vice President Riek Machar formed a unity government, is now in jeopardy as fighting and political unrest have flared. Since late February, clashes between government forces and the White Army, a militia supporting Machar, have led to deadly attacks, the displacement of more than 84,000 people , and the arrests of opposition leaders, including Machar. The UN warns of the danger of the country slipping back into a full-scale civil war.

The consequences for cholera patients have been felt immediately. “Before the conflict broke out, we had about 50 patients in Upper Nile State,” explains Mwatia. “But due to the prevailing fear and insecurity, they fled the clinic, and now the number of cases has skyrocketed.” The disease spread to Junqali State, Greater Pibor, and across borders to the Gambela region of Ethiopia. According to the UN, 10,000 people have crossed the border into Ethiopia since the beginning of March.

In some of the worst-affected areas, health infrastructure has ceased to function. MSF was forced to close its cholera unit in Nasir County, Upper Nile State, and 23 humanitarian staff members have been relocated due to insecurity in the area, according to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Due to inaccessible roads and a lack of public transportation, many patients were transferred to Ulang, where the nearest operational center was located. But that lifeline soon disappeared as well.

Cutting funding now, in the midst of conflict, with the recovery from the COVID-19 pandemic, an influx of refugees, and an ongoing cholera outbreak, is a devastating blow that comes at the worst possible time.

Zakaria Mwatia, head of the Médecins Sans Frontières (MSF) mission in South Sudan

On April 14, a group of armed men raided the MSF hospital in Ulang, the only one of its kind in the region. They looted the facility and threatened staff. The attack forced the humanitarian organization to suspend services at the 60-bed facility, disrupting “essential efforts to treat cholera patients and control the ongoing outbreak.”

“Due to the fighting, it's virtually impossible for humanitarian workers to reach the affected areas, and security risks prevent us from transporting supplies by air,” Mwatia says. “So communities are at the mercy of disease. Unfortunately, people are dying in remote areas, far from any aid.”

Request for support

Even so, efforts to contain the outbreak continue across the country, especially in regions that have not yet been affected. “In places like Abyei, where cholera has not yet taken hold, although the threat is high, we are equipping communities to stay ahead of the disease,” Mwatia explains.

Abyei is a coveted oil-rich region located on the border between Sudan and South Sudan. There, MSF teams are conducting hygiene education campaigns, distributing chlorine tablets, and preparing rapid response teams. “We have set up quarantine rooms with testing kits and vaccines so we can react quickly if cases arise,” says Mwatia.

But preventative measures are scarce, and without global support, Mwatia warns, they will not be enough. “The international community must recognize the unique situation of South Sudan, a young nation still struggling to stabilize,” he notes. “Cutting funding now, in the midst of conflict, with the recovery from the COVID-19 pandemic, the influx of refugees [from neighboring Sudan], and an ongoing cholera outbreak, is a devastating blow that comes at the worst possible time.” “By withdrawing that support,” Mwatia adds, “the world would be abandoning a nation faced with insurmountable challenges.”