South Sudan has been grappling with an outbreak of cholera since October 2024, which has been fueled by dire water and sanitation conditions and gaps in health care and other essential services.
After overseeing MSF’s response in recent months, Dr. Mohammed Musoke, MSF medical adviser for South Sudan and Chad, calls for urgent action to strengthen and properly fund South Sudan’s fragile health care system so that further outbreaks can be avoided.
Dr. Mohammed Musoke
There is something very unusual about the cholera outbreak in South Sudan, and that is the speed at which the disease has spread across the country. Back in October, when the outbreak was first declared, everything was localized in Renk, in the north near the border with Sudan. In a normal outbreak, it would be contained there—maybe spreading to one or two other areas before being brought under control. Over the following three months, however, it spread to seven of the 10 states in South Sudan, as well as to Ruweng Administrative Area, at an alarming rate.
The initial confirmed cases were among Sudanese refugees. After a concerted effort, we are finally beginning to see a reduction in the number of cases in Sudan, but in South Sudan we are still on high alert. To date there have been 24,418 cases and 475 deaths. We have been supporting the Ministry of Health with the cholera response, setting up a total of 388 beds in cholera treatment centers across five of the affected states and vaccinating over 200,000 at-risk people.
Funding cuts have deeply weakened South Sudan’s health care system
The outbreak has laid bare the fragility of South Sudan’s health care system, and although there are many factors that have contributed to the gravity of the situation, one of the most significant is the impact of the funding cuts that began to hit the country in 2022.
Access to basic health care was already limited before the cuts, but the situation further deteriorated when hundreds of health clinics and even the state hospitals began to lose funding. Although a new funding mechanism was implemented in 2024, staff across the country went unpaid for months, supplies ran out and stocks were not replenished. Additionally, none of the health facilities that closed in 2022 have been reopened.
With this weak health system as the foundation, it has been very challenging to respond to cholera. In Renk, far too little was being done to support people even before the first cases were detected. Although a humanitarian response was mobilized to support refugees and returnees in 2023, it was nowhere near strong enough, and the cholera outbreak has further weakened it—and highlighted the glaring gaps.
Abysmal hygiene conditions in Renk aid the spread of cholera
In Renk, people are living in horrific conditions where contaminated water sources, open defecation, and overcrowding have made it easy for the disease to spread within the community. On top of that, the constant flow of people arriving into this squalid environment, and then swiftly moving to other parts of South Sudan, is the driving factor behind its rapid spread across the country.
We saw cholera spread from Renk, to Malakal, to Bentiu, to Juba in just a matter of days, and although it is being brought under control in these areas now, we are very worried that it will soon emerge in a new location.
Displacement camps and informal settlements at heightened risk
We are particularly concerned about the displacement camps and informal settlements around Juba, where living conditions mirror those in Renk where we also saw an explosion of cases. When we visited the camps in Juba, there were already over 20 reported deaths in the community, which has suffered years of systemic neglect.
We were shocked by the conditions. Uncollected waste was piled up in the streets, latrines were broken, people were defecating out in the open, and raw sewage was running between people’s tents. There was hardly any access to clean drinking water, so when we set up our cholera treatment center, patients were arriving in critical condition.
Prevention, not reaction, is key to effective outbreak control
To curtail the outbreak, preventive action is needed. In terms of the overall response so far, it has been very reactionary. Effort has been put into treating those already suffering from the disease, and vaccinations have begun, but we need to identify where the next hotspots will be so that we can vaccinate people before the disease reaches them. Of course, it helps to vaccinate people where the disease is already present, but the response needs to try and get ahead of the spread.
We suspect that the informal settlements around Juba could be where it hits next, and this is why we have vaccinated people in Rejaf and Don Bosco—two informal settlements surrounding the capital. We’ll also distribute water purification tablets so that people can make the dirty water safe to drink.
People need proper services in these areas for the long term—clean water sources, proper waste management and adequate health care. Work in this regard has begun in the worst-hit areas, and we’re seeing a stabilization of cholera cases at the moment, but we are not yet out of the woods. We remain worried about the mobility of the disease—it could easily pop up anywhere, which is why preventive action is vital.
Overall, although the outbreak is now getting under control, even when it is over, it will only be a matter of time before another disease outbreak occurs—and when it does, unless action is taken to strengthen and properly fund the fragile health care system, we will see this scramble to respond being repeated time and time again.
