South Sudan is the world’s youngest country, having gained independence from Sudan in 2011. If you were to do a Google News search on South Sudan today, you will find headlines dominated by a portrait of a nation held in a violent suspended animation. You will read reports of a civil war possibly reigniting just as the country attempts to hold its first national elections this December. This is accompanied by urgent warnings from the UN about full-scale famine and collapse amidst intensifying fighting between the South Sudan People’s Defence Forces and the Sudan People’s Liberation Movement/Army in Opposition. The headlines describe a battle over aid where the state and opposition groups have transformed humanitarian lifelines into tactical tools, using predatory taxes and bureaucratic roadblocks to gatekeep the very resources meant for its people.
In today’s Substack, conflict/war is not the central hook of inquiry. It’s rather obvious, and I wanted to go digging at other non-obvious stories. That said, of course, it permeates in the background, and is the gravity that pulls at every story. But the true weight of this gravity has to be measured in the survival of the next generation (impact of the conflict), not just the conflict itself. The demographic data shows an under-5 mortality rate (U5MR) that remains among the highest in the world. So, in this week and next, we will explore the demographic indicator of U5MR and what it means.
On the topic of war
War (what is it good for, absolutely nothing) - wreaks havoc for civilians in particular. It devastates life by destroying critical infrastructure, creating acute food shortages, and crippling healthcare systems, leading to long-term health crises and mass displacement. Direct violence combined with the collapse of water, electricity, and sanitation systems causes widespread malnutrition, disease outbreaks, and prevents medical care. And that’s just some of it.
Still, I was curious to see how much war impacts critical indicators like U5MR. Research has shown that children living in fragile and conflict-affected settings face substantially higher mortality rates. To look at the magnitude of that, I looked at the Council on Foreign Relations’ Global Conflict Tracker and filtered for an apples-to-apples comparison by type of conflict. To compare with South Sudan, it made sense to filter for other countries undergoing “political instability” since that is what it was tagged under. Armed with that list, I then compared their U5MR. What I found was quite surprising.
Source: United Nations, Department of Economic and Social Affairs, Population Division (2024). World Population Prospects: The 2024 Revision, custom data acquired via website.
South Sudan is an absolute outlier in the group with respect to the U5MR, despite others being in a similar position with respect to conflict. The difference in what is driving the U5MR then likely is not the presence or absence of conflict, but whether a health system (and other enabling infrastructure) existed before the conflict. Syria had hospitals, immunization programs, and trained midwives to destroy. With repeated civil unrest and a civil war already in South Sudan right after independence, perhaps it never got around to really building that infrastructure. Its children were dying at catastrophic rates before and after this current conflict, and will continue after it, unless structural factors change.
Looking at the U5MR over time, you see a full picture of the cost of war. After independence, progress was fractured by a massive spike in mortality during the civil war years (2013–2018), and though rates have stabilized, they remain tragically high as the country faces new unrest. I should also note that the stabilization/improvement post-war was largely due to the tireless work of humanitarian aid/agencies like USAID, CARE and Doctors Without Borders to name a few.
A note on data
South Sudan has not conducted a census since its independence, which means that much of what we know about the country’s population is built on modeled estimates rather than direct measurements. We are finally seeing some light with the 2025 UNICEF MICS household survey (the factsheet was released literally 2 days prior to my writing this) and I will be citing those direct findings throughout this piece. One number from the MICS jumped out at me in particular: Only 36% of children under five are officially registered or notified through birth notification certificate. While this may seem like a nerdy aside, it’s actually really really critical. If two-thirds of the children in South Sudan are basically non-existent in official records, how can you manage a crisis, mitigate a mortality rate, and properly plan for your population’s futures?
Additionally, there is a certain cognitive dissonance in the current policy discourse: a recent and sudden enthusiasm for AI. Officials have begun pitching AI investment as the key to digital transformation in healthcare and agriculture. But you cannot have a meaningful AI revolution when the country ranks at the very bottom of global AI readiness indices, hampered by prohibitive internet costs and a lack of basic data centers. More fundamentally, AI is only as good as the systems it learns from. In a landscape where the data is either fractured, outdated, or entirely nonexistent, how reliable can an AI-solution be?
So, what’s actually going on?
Globally, most under-five deaths are caused by neonatal conditions and infectious diseases. In 2024, the most prevalent causes of under-five deaths were prematurity (18%), lower respiratory infections (pneumonia, 13%) and birth asphyxia/trauma (10%), which together accounted for more than 40% of under-five deaths.
Source: United Nations Inter-Agency Group for Child Mortality Estimation (UN IGME), Report 2025
In South Sudan, frustratingly and not surprisingly, most of these U-5 deaths are preventable. In the first month (neonatal period), the risks are largely biological and clinical (related to birth conditions). They point to a lack of basic emergency obstetric and newborn care. Once a child survives that first month, the risks shift dramatically to environmental and infectious threats. Leading killers are malaria, respiratory infections, and measles; diseases that don’t require high-tech AI solutions, but rather consistent access to basic medicine, mosquito nets, vaccines, and skilled birth attendants.
Source: UN Inter-agency Group for Child Mortality Estimation (South Sudan)
If you are also puzzling about the “other” category that is the largest in the U5MR bar chart, I am too. I suppose it’s part of the data scarcity or likely includes deaths that weren’t clearly diagnosed or fall into smaller clusters of neglected tropical diseases. I came across a bunch of articles about snakebites (!!!) for example, which are exacerbated by flooding and climate shocks which force snakes into closer contact with human habitats.
In South Sudan, snakebite is a severe and often fatal health issue that is considered a neglected medical emergency. This situation is exacerbated by extreme environmental conditions and a fragile healthcare system. Snakebite is frequently among the top ten reasons for hospitalisation across South Sudan, putting lives at risk. In 2025 alone, MSF treated 197 patients for snakebites in just two hospitals in two areas, including Abyei where I work.
Source: Doctors Without Borders (2026)
Antimicrobial Resistance
While the charts categorize deaths by primary drivers like lower respiratory infections and sepsis, a recent IHME report reveals a critical layer of how these children are dying: Antimicrobial Resistance (AMR). AMR is not a cause of death per se, it is a complication that makes the most prevalent killers in South Sudan far more lethal. This video is really great in case you want to hear more about AMR. (special thanks to MP for sharing great resources with me!)
Astoundingly, in 2021, the largest number of AMR-associated deaths in the country occurred among children under five and is a group that has remained the most vulnerable to resistant infections since 1990. In fact, South Sudan now ranks among the top 10 countries globally for age-standardized mortality rates associated with AMR.
This is terrifying for many reasons: The IHME identifies Streptococcus pneumoniae (the primary pathogen behind the lower respiratory infections that account for 16% of the U5MR) as a leading driver of AMR-associated deaths. This means that humanitarian aid is not just struggling to get medicine across bureaucratic roadblocks; they are now fighting a landscape where some medicines themselves are losing their effectiveness. Without intervention, AMR-associated deaths are projected to rise to as many as 16,400 by 2030, further increasing the tax paid by the nation’s youngest citizens. Encouragingly, the country has a plan. They set up the National Action Plan for AMR in 2023:
It recognizes the interplay of sectors like agriculture, highlighting the need for integrated interventions. By addressing the improper use of antimicrobials in animal husbandry and crop protection, the plan aims to enhance productivity and food security. With commitment from leaders and international partners, this plan promises to reduce drug-resistant infections significantly.
Source: Africa CDC (2023)
There’s clearly a lot going on behind all these numbers, and I am going to try to dig into them a little.
The Cow Economy
In South Sudan, cattle are far more than livestock; they are the foundational infrastructure of social and economic life, used as currency, objects of beauty, and a source of tribal fights. They are the primary store of value and the central currency for bride price: a mandatory customary payment that legalizes marriage and cements kin alliances. This cow economy creates a profound demographic ripple effect, particularly concerning the survival and status of the nation’s youngest citizens.
The pursuit of high bride prices—which average between 40 and 70 cows depending on the region and can reach over 100 cows for an educated bride —incentivizes early and child marriage as families seek to acquire assets quickly during times of economic hardship. In some communities, a booking system allows men to reserve future brides by starting payments while the girls are still toddlers or even before birth. This practice effectively transforms young girls into commodities, stripping them of educational opportunities and entrenching a cycle where their primary value is seen as the cattle they can bring to their male relatives.
Child marriage is used as a coping mechanism in response to economic and food insecurity. Families from the poorest households in South Sudan marry off daughters in order to receive dowry (payments in the form of money, gifts or cattle, from future husbands). Due to instability, cattle raiding has become more common in South Sudan and some families are unable to feed their children. Cattle is used as a currency in marriage transactions and many teenage girls are forced into marriage so their families can receive cows and survive. Some girls are “born so that people can eat.”
Source: Girls Not Brides
This has serious implications for U5MR and bears out in other data: According to the MICS, 28% of women aged 20–24 had their first child before turning 18.
Source: UNICEF (2023)
This system also drives a violent cycle of cattle raiding, which has become increasingly lethal with guns replacing spears/bows and arrows. Young men, unable to afford the inflated bride prices required to marry and earn respect by paying bride price, often resort to raids to build their herds. These raids do not just cause direct casualties; they trigger unending cycles of revenge killings and displace entire communities, destroying the very healthcare and nutrition systems that children rely on for survival. In a country where livestock numbers outnumber the human population, overgrazing and the pollution of scarce water sources create a constant environmental burden, which further affects causes of mortality downstream. Additionally, the close proximity of human and livestock populations facilitates the spread of zoonotic diseases like brucellosis which further impact mortality rates.
All in all, while the economic logic of the system makes sense, the ones who seem to suffer the most are the country’s youngest.
The Sudd and Flooding
The swamps and floodplains of the Sudd are among the most important wetlands in Africa, supporting a rich biota, which includes over 400 bird species, and over 90 mammal species. The ecoregion is located in South Sudan and comprises one of the largest swamps in Africa and is also one of the largest floodplain wetlands in the world, about 600 km long and a similar distance wide. So when it floods, that’s a natural part of how the ecosystem survives. In recent decades, it has been catastrophic.
“Floods have an ongoing impact on access to health care, and lead to delays in the diagnosis and treatment of non-communicable diseases such as diabetes and hypertension,” added Tremblay. In the longer term, heavy rains and flooding can lead to an increase in the mosquito population and a heightened risk of vector-borne diseases such as dengue fever, malaria, and yellow fever. They also increase people’s exposure to chronic health issues such as schistosomiasis, a disease caused by parasitic worms.
“We are seeing the cumulative effect of the floods of recent years,” says Mamman Mustapha, MSF’s head of mission in South Sudan. “People in this area have been displaced several times since 2022 and arable land has [decreased], as have food rations provided by WFP. Communities are constantly having to move to a new location, not knowing if they will be able to harvest what they have been able to sow.”
Source: Doctors Without Borders
Indeed, the Sudd has become the epicenter of a climate catastrophe. Between 2019 and 2024, unprecedented rainfall in East Africa caused the wetland to expand to record-breaking levels, with floodwaters covering thousands of square kilometers. This cycle has transformed the Sudd from a life-sustaining resource into a driver of despair (and possibly death): Due to this 6th year of flooding, 57% of the population face acute levels of hunger, putting 2.3 million children aged under 5 at risk of acute malnutrition. The recent MICS shows that recent malnutrition indicators are already high for the U-5 age group: 19% are stunted (too short for age) and 17% are wasted (too thin for height).
Source: Health Policy Watch (2025)
The extent of this flooding has profound consequences for public health, particularly the U5MR. The stagnant floodwaters create ideal breeding grounds for mosquitoes, leading to significant peaks in malaria (which we saw is a leading cause of death) in the country. Beyond malaria, the flooding facilitates the spread of waterborne illnesses like cholera and acute diarrhea, which are exacerbated by the widespread contamination of scarce clean water sources.
Speaking of cholera, I cannot resist pointing out this excellent ProPublica report from last year that highlights specifically what happened when USAID assistance was cut to South Sudan:
The MICS shows that only 3% of the population has access to basic sanitation services. This medical crisis is compounded by the systematic destruction of infrastructure; hundreds of health facilities have been submerged or destroyed, leaving thousands of families without access to basic medical care or nutrition services.
The human cost of this environmental shift is a cycle of chronic displacement. For many, this is not a one-time event; families are frequently displaced multiple times as floodwaters fail to recede even during the dry season. This permanent state of flux has a devastating impact on nutrition. Submerged farmlands and drowned livestock have wiped out harvests and pastures, pushing millions into catastrophic levels of food insecurity.
The flooding in the Sudd does more than just displace people; it traps children in a lethal synergy of disease and starvation, ensuring that for many, survival past the age of five remains precarious.
Oil and guns >>>health
We are left to reckon with the most mechanically direct causal chain in this crisis: the collapse of the infrastructure that fuels the state. There was damage to critical oil pipelines in 2024 which led to a sharp drop in oil exports, which have since relatively stabilized. In that period, real GDP is estimated to have contracted by 7.7% in FY25. Because South Sudan derives 90% of its revenue from oil, this shock sent food prices skyrocketing, and occurred around the same time that other crises forced the World Food Program to halve its food rations. Additionally, a UN inquiry concluded that billions of dollars in oil and non-oil revenues have been diverted away from public services into illicit contracts and elite networks, leaving millions of citizens without access to food, healthcare or education.
The government reportedly continues to allocate $2 billion for military expenditures and the security apparatus, while the entire health sector survives on a paltry amount on health:
The findings of a two-year investigation by the independent UN Commission on Human Rights in South Sudan published on Tuesday document how systematic corruption has created one of the world’s worst health crises, leaving the youngest nation in the world with just $7.9 million in health spending last year for 12 million people — comparable to what it spent on its 12-player men’s national basketball team.
The abdication of core government functions from health, to food, and infrastructure has led to a near-total dependence on international aid. Foreign donors fund 80% of South Sudan’s health system, with the United States providing health assistance worth 235% of what the government spends on its own people.
South Sudan now faces the spectre of over half its health spending evaporating under the Trump administration’s foreign aid cuts. It is the third most reliant nation on United States funding for its health services, second only to Afghanistan and Somalia.
Source: Health Policy Watch (2025)
Of course I had to go there. Hot off the press: Compiled by the Center for Global Development, USAID’s FY25 (last 3 months of the Biden term and first 9 months of the Trump term) funding report shows: The largest absolute sectoral decline is in humanitarian support, where spending fell from $8.0 billion in 2024 to $5.8 billion in 2025 and obligations fell from $9.2 billion to $3.5 billion. That is reflected in spending collapses in several countries facing humanitarian crises. At the country level, the dramatic decline in humanitarian support is reflected in far lower flows to countries including Yemen, the Democratic Republic of the Congo (DRC), South Sudan, and Somalia, which all saw spending cuts exceeding 40 percent and obligations drop more than 60 percent.
Source: Center for Global Development (2026)
The result is a lethal synergy between a vanishing state and a poisoned environment. In the oil-producing regions, mercury levels are now seven times the EPA limits, and the rate of birth defects and premature deliveries has risen. Ongoing flooding weaponizes this toxic waste, sweeping it into the primary drinking water for millions and leaving South Sudan with the 7th-highest pollution death rate globally.
Honestly, the confluence of all these factors horrifyingly take its toll on everyone, not least its children. And when all is said and done, many of them remain invisible in national records with no birth registration to begin with.
It is easy to look at the intersection of all this and see only a closed loop of despair. Yet, within the data that highlights these crises lies something of a roadmap for their resolution. The recent release of the MICS proves that data blindness is beginning to lift, providing the first non-negotiable step toward accountability. Ever the eternal optimist, I see hope also in the local public health workforce that persists despite the breakdown of national coordination. Since 2019, initiatives like the Community Outreach Volunteer (COV) program have grown from 100 to 1,200 volunteers, bringing life-saving care directly to the doorsteps of those cut off by distance and insecurity. In areas like Eastern Equatoria, these localized networks helped reduce missed appointments to zero in early 2023. Simultaneously, the adoption of virtual medical education through Project ECHO has allowed over 3,500 healthcare workers across the country to receive expert-level training on infectious diseases like tuberculosis and COVID-19 without the prohibitive costs of travel.
The progress already made in maternal health (where mortality rates dropped from 3,845 to 692 deaths per 100,000 live births in two decades) serves as a powerful proof of concept. Perhaps child mortality is next?
Source: World Bank Gender Data Portal
The Food!
I realize the sad irony in talking about the amazing food we ate right after talking about hunger and food insecurity. Give me a virtual kick in the shin if you please.
We ate so well, friends. I made Rijla (a lamb+lentil stew) which we ate with lavash. I knew Ekim and I would need more heat, so I made shatat dakwa to drizzle on. When I tell you to run and make this, I am not joking. I can guarantee you have everything in your kitchen already. We also had fuul (fava beans), salatat aswad mahrousa (eggplant), and a tomato salad on the side. Yes, that was too much food, no we had zero regrets. We jammed to the spotify playlist, “South Sudanese hits,” with a range of very upbeat happy songs. All of which together betrayed the very serious/grave topics I was researching.
