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MALAKAL, South Sudan — Outside the pediatric wing of Malakal's teaching hospital, a human skull lies in the yellowing blades of knee-high grass. "We are finding these all the time," said a groundskeeper, who asked not to be named. "We found two yesterday," he said, shoveling the remains into a cream-colored body bag.
Malakal is a ghost town. Once South Sudan's second-biggest city with a population of 150,000, it is now home to more soldiers than civilians. Residential areas have suffered an extraordinary amount of damage since civil war broke out in December 2013, and the teaching hospital, which occupies a once-idyllic compound near a stone mosque built by Egypt in the 1940s, has been laid waste on multiple occasions. The trail of corpses now being discovered on the premises points to a disturbing trend in the country's eight-month-old rebellion: the systematic targeting of hospitals and medical personnel.
"Hospitals and clinics have been targeted to a staggering degree," said Daniel Bekele, the executive director of the Africa division of Human Rights Watch, adding that South Sudan's "entire health system" has been destroyed "because of unlawful tactics used by both sides across the conflict areas." Cosmas Chanda, the representative for the Office of the U.N. High Commissioner for Refugees in South Sudan, called the level of violence directed at hospitals and aid workers "unprecedented" in an interview in Juba, South Sudan's capital.
South Sudan's latest paroxysm of violence has exacted a devastating toll on civilians. Looting, rape, and ethnically motivated mass killings have been unleashed in a relentless pattern of attack and counterattack. The subsequent displacement of 1.5 million people, along with the inability of aid agencies to reach many of them, threatens to push the country over the brink into famine.
Since the first shots were fired in December 2013, at least 58 people have been killed on hospital grounds, while hospitals themselves have been attacked or looted on six occasions, according to the medical charity Doctors Without Borders (Médecins Sans Frontières, or MSF). Countless clinics and pharmacies have also been plundered or damaged, and medical supplies have been stolen or destroyed.
The logic of targeting hospitals is sickeningly simple: Not only do attackers kill civilians, but they ensure that survivors cannot seek medical care. In the current conflict -- which began as a power struggle between President Salva Kiir and former Vice President Riek Machar but quickly morphed into an ethnic conflict, primarily between the country's two largest ethnic groups, the Dinka and the Nuer -- this logic has become intertwined with that of ethnic slaughter. In hospitals across the country's northeast, victims have reportedly been singled out for execution based on their tribal identity. In Bentiu, the capital of oil-producing Unity state, a local radio station went as far as calling for acts of "vengeful sexual violence" against women of other communities when rebel forces overran the city in April, according to the U.N. Mission in South Sudan. A total of 28 people were killed in the hospital there.
At the teaching hospital in Malakal, at least 14 people, including 11 patients, were murdered in their beds when rebel forces overran the city in February of this year. Other patients, mostly ethnic Nuers, were killed on the premises by government soldiers in January. Nobody knows for sure how many people have died here; nobody knows whose remains are being shoveled into the cream-colored bag.
Today, much of the hospital is still in ruins. The neonatal ward is burned and gutted. In the main surgical theater, one of the operating tables is missing, and the contents of ransacked supply shelves spill haphazardly onto the floor -- syringes, antiseptic solution, now-useless vaccines. In one of the patient wards, a single woman's shoe, its rhinestones still in place, rests on a filthy bedside table.
"They took some things, and they destroyed what remained here," said Yumo Arop Ying, the acting director general of Upper Nile state's health ministry, referring to the three separate instances in which rebel forces seized control of Malakal.
Damage also occurred during periods of government control, according to rights groups like Amnesty International and Human Rights Watch.
While the raids themselves have been brutal, it is their effect on the broader system of health care that is even more troubling. "Attacks against hospitals and medical facilities in South Sudan have led to a collapse of the health system across much of the conflict zone," said Stephen Cornish, MSF's executive director for Canada, who is currently visiting South Sudan. "This in turn creates a number of silent victims to the conflict who perish from diseases which would otherwise have been possible to treat, such as malaria," he said.
On multiple occasions, MSF has been forced to evacuate its medical teams and temporarily suspend the operation of its clinics. According to a report published by the medical charity in July, hundreds of thousands of people have been cut off from medical care because of the violence. Where MSF cannot obtain guarantees of security, or at least of non-interference, "we may simply be unable or unwilling to risk responding," said Cornish.
Despite the recent surge in intensity, violence against health care is not a new problem in South Sudan. It was a regular feature of the north-south civil wars that raged from 1955 to 1972 and from 1983 to 2005, as well as of the conflicts in Darfur, South Kordofan, and Blue Nile that continue to grind along today. In 2000, for example, Sudanese armed forces bombed the Samaritan's Purse hospital in Lui, a town in what is now South Sudan's Western Equatoria state, three times in the span of a few months. Akec Khoc, a medical doctor who later served as South Sudan's ambassador to the United States, was shot in the shoulder while attending to wounded SPLA fighters in a field hospital during the second civil war.
Not that Khartoum was the only one targeting medical facilities. Southern guerrilla forces, known as the Sudan People's Liberation Army (SPLA), also attacked hospitals and clinics -- those run by the government of Sudan as well as those run by rival SPLA factions. "From the beginning of the SPLA in 1983, it attacked hospitals, health workers, and aid agencies," said Alex de Waal, the executive director of the World Peace Foundation at Tufts University, who disputed the notion that attacks on medical facilities have grown any more frequent. The SPLA was "exceptionally brutal and matched the government of Sudan and pro-[government of Sudan] militias in this regard," he said in an email.
This long history of medical violence, coupled with Khartoum's deliberate policy of neglect for the south, is largely responsible for the abysmal state of South Sudan's health-care system today. In his first address to the U.N. General Assembly, President Kiir spoke of "construction" rather than "reconstruction" of South Sudan's institutions: "Even before the ravages of war could set in, our country never had anything worth rebuilding," he said. Although he was speaking generally, the president might as well have been referring specifically to the health-care sector. In 2012, the country of roughly 9 million had only 120 doctors and even fewer registered nurses. As a result, nongovernmental organizations provided as much as 80 percent of basic health services, even before the outbreak of civil war. Today, that figure is almost certainly higher.
Still, a few brave doctors and medical professionals are enduring extraordinary hardship as they work to resuscitate the country's network of hospitals -- and to keep alive the pretense that the government is doing something to care for its citizens in areas contested by the rebels. Despite the damage and persistent insecurity, the teaching hospital in Malakal is now back up and running out of a few rooms that have been restored. Without electricity or sufficient staff, however, it is only able to provide outpatient care for those with relatively minor ailments, such as malaria.
That does not mean the skeleton crew manning the hospital doesn't have to deal with more serious emergencies. "We get trauma patients, sometimes soldiers with gunshot wounds," said Olany Alew Akol, the only physician currently working at the hospital. But without electricity or proper surgical equipment -- the generators and the operating theater were looted in February -- he is forced to stabilize them by the light of a flashlight before he can transfer them to the nearby U.N. base for surgery. "So many things aren't working," he said, "but we are just trying to go ahead."
For now, progress toward rebuilding the teaching hospital can feel as fleeting as security here in Malakal. Many of the staff members fled to the bush when the fighting broke out, and none of the nurses will work the night shift. Often, rumors of an impending attack will sweep the city, prompting staff and patients alike to seek refuge on the U.N. base, where roughly 17,000 civilians are living in camps. "There were rumors yesterday that rebels are coming, so many people left the town last night," said Olany, adding that only a slow trickle of patients had visited the hospital that morning.
Before the civil war turned his workplace into a graveyard, Olany said the hospital was "too busy." Today, things are also hectic, but only because he's the only doctor on staff. "I am working day and night," he said, shaking his head. "Too busy."