Albert Gonzalez Farran © MSF

MSF internal review of the February 2016attack on the Malakal Protection of Civilians
Site and the post-event situation
Public document
emergencygap.msf.es
June 2016

Executive
summary

Violence erupted between internally displaced persons (IDPs)
of different ethnic groups in a Protection of Civilians (PoC) sitein Malakal, South Sudan, on 17 February 2016 and continued
until the next afternoon. There are strong indications thatexternal military forces were also involved in the fighting.
The violence and ensuing fire caused the destruction of large
swathes of the camp (35 per cent of shelters were destroyed)
and left between 25 and 65 people dead (including 2 MSF
staff), 108 injured and over 29,000 IDPs displaced once again.
This report constitutes the findings of an internal review
conducted by Médecins Sans Frontières (MSF) into those
events. The review aimed to provide lessons learned from
MSF’s medical emergency response, as well as to help better
understand the circumstances around the events and the roleof the different actors.
Findings of the review:• The findings exposed a glaring failure on behalf of the UN
Mission in South Sudan (UNMISS) to protect the civilians
residing in the PoC site. By not ensuring that adequate
preventive measures were taken, failing to act to stop theviolence in a timely manner and actively blocking the IDPs
from reaching safety during a large part of the emergency,
UNMISS effectively failed to protect the civilians it ismandated by the UN Security Council to protect.
• The rigid structure of the UN integrated mission within the
PoC site prevented an efficient emergency response, as thestrong reliance that humanitarian organisations had on the
UN security apparatus and its recommendations for security
meant that they could not be mobilised and thus assist in thehumanitarian and medical emergency response. This resulted
in a short yet acute emergency gap during the peak of theincident, where the emergency response capacity of thosepresent in the PoC site could not be counted upon.
• MSF’s medical response to the crisis was timely, relevant
and effective. MSF took the lead in the emergency response
and was able to act when many others couldn’t. It treatedmany patients and provided refuge for the IDPs in its hospital.
The team, and most notably the national staff, showed a
dedicated commitment to the emergency response. The
need for better emergency preparedness and more efficientand dignified management of dead bodies are among thelessons learned by MSF from the incident. The circumstances
surrounding the death of the two MSF staff need to befurther investigated.

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MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Due to the volatile context in South Sudan and frequentattacks on civilians, people will most likely continue to seek
refuge in the PoC sites for the coming months and years,
especially in the Greater Upper Nile region. It is therefore
worrying that the living conditions of those residing thecamp are still appalling four months on from the February
attack. The findings of a recent MSF survey in the PoC
camp show that security remains the key to whether peoplechoose to stay or go. Staying inside the PoC, however, has notguaranteed freedom from violence and the survey showedthat confidence in UNMISS peacekeepers amongst the
population is low. The IOM, UN agencies and internationalNGOs have been working to expand the camp in a movetowards achieving basic humanitarian standards. UNMISS,
however, is reluctant to extend protection for the new sector.
Worryingly, there are no signs, four months after the events,that the UN is taking steps to improve the situation in the
PoCs or admit its mistakes in the February events. The UN
Under-Secretary for Peacekeeping Operations has recently
announced that the findings of the two UN investigations
conducted will shortly be made public, and we urge the
UN to delay no longer. This report is intended to open up a
constructive debate within the international community toensure that the failures of the February events are discussed
and concrete measures put in place to improve the protection
and living conditions for IDPs in Malakal and other PoC sites
in South Sudan.
PoCs continue to be the only partially efficient, albeit
uncomfortable, solution for the dire protection needs of the
population. As long as there is no better or safer alternative,
they cannot be dismantled and identified gaps in protection
and assistance must be addressed.

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MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Tableof contents

5

Acronyms

66
78

Introduction
About this report
Methodology and limitations
Structure

9
9
10
11
15

01 The context
The PoCs in South Sudan
The town of Malakal
MSF in Malakal PoC and town
Summary of key points from section one

16

23

02 The incident of 17-18 February 2016
and the MSF response
Warning signs and rising tensions
Brief overview of the events
Direct effects of the incident
MSF response
The dedication of MSF national staff during the eventsof 17-18 February
Summary of key points from section two

24
24
24
25
26
28
31

03 The response of UNMISS and humanitarian agencies
UNMISS response
UNMISS preventive measures
Role of UNMISS in managing the crisis
Response of other humanitarian agencies
Post-incident response
Summary of key points from section three

32

33

04 The situation four months on: findings of a surveyof Malakal PoC residents on living conditions,protection and returning
Summary of key points from section four

34

Concluding remarks

16
17
17
19
21

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MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Acronyms

CHW
DPKO
DRC
FC
GRSS
HRD
ICRC
IDP
IMC
IOM
MCP
NGO
PMR
MSF
OCHA

Community Health Worker (MSF)
UN Department of Peacekeeping Operations
Danish Refugee Council
Field Coordinator (MSF)
Government of South Sudan
Human Rights Division (UNMISS)International Committee of the Red Cross
Internally Displaced Person
International Medical Corps
International Organisation for Migration
Mass Casualty Plan
Non-Governmental Organisation
Project Medical Referent (MSF)
Médecins Sans Frontières
United Nations Office for the Coordinationof Humanitarian Affairs
PoC
Protection of Civilians site
SPLA
Sudan People’s Liberation Army
TB
Tuberculosis
UNDSS United Nations Department of Safety and Security
UNMISS United Nations Mission in South Sudan
WASH
Water, Sanitation and Hygiene
WHO
World Health Organisation

5

MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Introduction

About this report
On the night of 17 February 2016, fighting broke out in
the Protection of Civilians site (PoC) in Malakal, South Sudan.
The fighting went on for some hours and started again thenext morning. MSF immediately activated its mass casualty
plan and, over a space of 24 hours – with specialised support
from International Medical Corps (IMC) doctors – treated atleast 108 casualties in its hospital. A number of bodies werebrought in dead on arrival, and many others were treated on
the spot. The fighting caused substantial damage, with over
35 per cent of shelters destroyed1 and the displacement ofan estimated 29,000 people living in the PoC at the time.
While this happened, the rest of the humanitarian community
remained immobile for a large part of the emergency.
As a result, MSF, as well as IMC who provided medical
support during most of the emergency, were the only actors
able to effectively respond from a humanitarian andmedical perspective.
Although several reports have been produced in relation
to the events,2 none of them focus sufficiently on thehumanitarian emergency response to the violence in the PoC
and the failure of the United Nations Mission in South Sudan(UNMISS) to protect the civilian population.3 Moreover, MSF
believes that four months down the line, there is insufficientevidence that improvements are being made or of intentions
to recognise and address shortcomings. Reports of the two
UN investigations carried out by UN bodies into the February
events should shortly be made public.4
Due to the circumstances surrounding the events that
unfolded over those two days and in the weeks following it,
MSF believes that the situation warrants a deeper and moreobjective review of the response of MSF, UNMISS and otheraid agencies. This allows MSF to review internal decisionmaking regarding response and security management, as
well as to identify lessons learned for other similar situations

1 IOM (2016) Displaced Again: Stories from Malakal (Juba, IOM).
2 There has been a report by the Center for Civilians in Conflict (2016) A Refuge in
Flames: the February 17-18 Violence in Malakal PoC (Washington, D.C., Centre for
Civilians in Conflict), investigating the events and a report by IOM (2016) If We Leave
We Are Killed (Juba, IOM) offering a wider review of the PoC site system.
3 The Protection Cluster, however, did write a short report on the incident that gives an
overview of the events from the humanitarian protection perspective. See Protection
Cluster South Sudan (2016) ‘Violence in the Malakal PoC Site, 17-18 February
2016’, Protection Cluster South Sudan Briefing Note.
4 An internal, Special Investigation by UNMISS in Juba and a Board of Inquiry from
DPKO Headquarters in New York.

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MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

faced in the contexts in which it works. It also provides anopportunity to analyse the dynamics behind the incident
and flag the issues of concern when providing humanitarianassistance and protection in South Sudan.
Taking the February PoC events as a starting point, this reportaims to further the discussion on these different questions.
MSF was pleased that the IOM initiated a series of sessionsin May 2016 aiming to encourage dialogue around improving
the PoC system over the coming years, and hopes that thisMSF report can feed into those discussions. At a higher level,
though, with this report on the events of 17-18 February 2016
MSF seeks to open up a debate on the failures by UNMISS,
the gaps in the humanitarian emergency response and thepost-incident situation. Greater transparency and willingness
by UNMISS, UN headquarters, the Security Council, member
states and humanitarian agencies to learning the lessons ofwhat happened in Malakal PoC are vital. But beyond this, it
is also essential that specific commitments are made to makesure this doesn’t happen again.

Methodology and limitations
This report was developed by MSF humanitarian affairs
staff. The author visited Malakal from 23-29 March 2016 andconducted 39 interviews (all of them either semi-structured orinformal discussions) involving 53 interviewees.5 It should be
noted that the field visit was a short one, and therefore someinterlocutors could not be met because of time constraints.
Following this visit, the information was triangulated andanalysed in order to provide clear points for discussion andrecommendations. After the visit and during the analysis,
there were many follow-up interactions with MSF field and
HQ staff for further clarification.
Following the March 2016 visit, a survey of 108 residentsof the PoC from all sectors, as well as ten semi-structured
interviews, was conducted from 19-23 May 2016.
Many questions remain unanswered after this internal
investigation. This report cannot establish responsibilities
regarding this attack but, given its critical nature, it is

5 Interviews were conducted with MSF expatriate and national staff present at thetime of the incident, OCHA, UNMISS, UN agencies, INGOs as well as IDPs,
community members and patients.

7

MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

important that the UN formally does so and an independent
investigation would be warranted. MSF will continue to seek
to clarify the circumstances around the death of our two
staff members.
Despite the limitations described above, this report presents
the unfolding of events to the best of our knowledge.

Structure
The report is composed of four sections. It begins with an
overview of the area and the PoC system in South Sudan,followed by a review of the February incident itself and thepeacekeeping and humanitarian response. It then reviews
the current situation facing the residents of the PoC site,
reviewing the main findings of a survey of 108 individuals togarner their perspectives on the living conditions, protection
and returning to their villages. The report ends with a seriesof concluding remarks.

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MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

01
The context

The PoCs in South Sudan
The conflict in South Sudan has given rise to a new type of
IDP settlement, the Protection of Civilians sites (PoCs) within
UNMISS bases. Such camps can be considered as similar
to the "safe havens" seen in the former Yugoslavia, Iraq and
Rwanda in the 1990s, but different in that they are by default
rather than design, and set up more spontaneously.6 Since
protection of civilians was defined as a critical part of the
UNMISS mandate,7 each UNMISS base was tasked withdrawing up contingency plans for a potential influx of civilians.
However, they did not predict the scale of the displacementthat would occur when the conflict broke out in the countryin December 2013.
Albert © MSF

A water collection point in Malakal PoC

By opening its gates during intense periods of fighting earlyin the conflict the UN undoubtedly saved many lives. Since
then, however, deep-seated concerns within UNMISS
over creating a pull factor by providing services within thecamps, have led to intransigence and confusion. Progressin expanding the sites in order to decongest severely
overcrowded areas, or to meet the water, sanitation andshelter needs of new arrivals, has been slow and contested.
Even today, living conditions in places like Bentiu and Malakal
PoC sites fail to meet minimum standards, a problem which
is widely known to produce a detrimental impact on the healthof the camp residents.8
The conflict in South Sudan has so far caused thedisplacement of over 200,000 civilians into six PoCs acrossSouth Sudan.9 MSF is currently present in both Bentiu andMalakal PoCs. Due to the fact that the ethnic lines have beendrawn inside the PoCs just as they have been outside, the
PoCs have themselves now become a pawn in the conflict.

6 See Lilly, D. (2014) ‘Protection of Civilians sites: a new type of displacement
settlement?’, Humanitarian Exchange, 62, pp. 31-33.
7 See Security Council Resolution 2155 of 27 May 2014. The UNMISS mandate isavailable at: http://www.un.org/en/peacekeeping/missions/unmiss/mandate.shtml(accessed 9 June 2016).
8 The arguments in this paragraph are taken from and are further developed in MSF(forthcoming) ‘Protection of Civilians sites in South Sudan are IDP camps which
require minimum standards like any other.’ See also MSF (2015) ‘South Sudan:
Dramatic increase in patients in Malakal’s UN site as living conditions jeopardise
health of thousands’, 18 November 2015, available at http://www.msf.org/article/
south-sudan-dramatic-increase-patients-malakal%E2%80%99s-un-site-livingconditions-jeopardise-health (accessed 9 June 2016).
9 For the latest figures and locations see IOM (2016) ‘South Sudan Humanitarian
Update 62 (31 May 2016)’.

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MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

The town of Malakal
Malakal was an important trading post during British colonial
times and was among the best-maintained towns in the
country. It lies next to the White Nile, and the west bank of
the river is generally considered to be the land of the ancient
Chollo/Shilluk kingdom. For a long time, the east bankhas been disputed, with both Shilluks and Dinka Padang(hereafter, Dinka) each believing that Malakal town and thelands around it belong to them.
The clashes that broke out in South Sudan in December 2013
quickly reached Malakal.10 During 2014 and the first halfof 2015, the town of Malakal went back and forth between
government and opposition, until finally in June 2015 thegovernment wrestled control from the opposition forces and has
maintained the town ever since. But all the fighting has reduced
Malakal to a shell of its former glory. Its civilian population
fled the area to the PoC, the west bank or other areas anduntil February 2016, Malakal town was a military garrison only
inhabited by SPLA soldiers. Its buildings are destroyed andthere is little electricity and functioning infrastructure.
The President of the Republic of South Sudan, in October
2015, issued a decree announcing a new division of thecountry into 28 states rather than 10. The decree divides
the former Upper Nile State into Eastern Nile State(predominantly Dinka, with Malakal as its capital), Western
Nile (predominantly Shilluk) and Latjoor (predominantly Nuer).
With the 28 states decree, the civil authorities havere-established themselves again in Malakal. Since the attackon the Malakal PoC in February 2016, a small number ofcivilians are living in the town again. Around 4,500 settled in
the town after fleeing the PoC following the events of 17-18
February 2016, and a group of others – estimated to be around
1,000 but it could be much less – have arrived from Juba.

10 This paragraph offers a simplified contextual framework for the PoC in Malakal.
For more detailed information on the Upper Nile State context see Human Security
Baseline Assessment for Sudan and South Sudan (2016) The Conflict in Upper Nile
State (Geneva, Small Arms Survey).

10 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Figure 1
South
Sudan:
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Shilluk Area map
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22 January 2016

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NATURAL, WETLAND
Water on the maps in this presentation do
The names and boundaries
not imply ofﬁcial endorsement or acceptance by the Governmentof South Sudan or CCCM. These maps are for planning purposes
only. CCCM cannot guarantee that these maps are error free andtherefore we accept no liability for consequential and indirect
damages arising from the use of these map products.

Creation date: 22 January 2016

Source: Camp Coordination and Camp Management Cluster (2016).

MSF in Malakal PoC and town
MSF was working in two locations in Upper Nile State whenthe events of December 2013 began to unfold. Malakal saw
fierce fighting from the beginning of the conflict. However,the first three months were particularly brutal, when the townchanged hands from government to opposition several times.
MSF teams, together with the International Committee of the
Red Cross (ICRC), provided immediate support to the victimsof the conflict. However, after the first bouts of fighting, many
civilians had fled to the PoC or to Wau Shilluk across theriver, and MSF put in place a complex intervention providing
medical humanitarian assistance on both sides of the river, as
well as support to the Malakal teaching hospital emergency
room, hospitalisation services and post-operative care, with
the ICRC handling the surgical component.

11 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

However, more and more civilians were fleeing the town.
Although some 20,000 people had fled to the PoC andwere living in dire conditions, the decision to provide
services there was a difficult one for MSF, especially as thephysical presence on the site of a UN peacekeeping mission
compromised the organisation’s independence, both in termsof perception as well as in practical aspects of operational
independence. However, given that the medical humanitarianneeds and health risks in the PoC were high, and the civilian
population were concentrated there, with little or no secureaccess to the town for medical services, MSF decided toalso provide medical support inside the PoC. The MSF teamremained in Malakal town (house, office and hospital support)
many weeks after all other organisations, except for the
ICRC, had moved to the PoC for their own protection. Despite
suffering a number of security incidents, the team remaining
in the town managed to provide support to the victims of
the fighting during the first two months of conflict. However,at the end of February 2014, the town suffered what was
the most brutal attack yet. Patients were executed in their
hospital beds and the hospital was vandalised and partiallydestroyed.11 The MSF team had to leave Malakal town andseek refuge, with the rest of the town’s remaining population,in the PoC site. The MSF base has remained in the PoC sitefrom that time until today.12

11 For further information see MSF (2014) South Sudan Conflict: Violence Against
Healthcare (Juba, MSF).
12 Although MSF also has another project across the river, on the west bank of the Nilein Wau Shilluk.

12 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Figure 2
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FOOTPATH TO MALAKAL

Sources: IOM, UNMISSSatellite imagery copyright DigitalGlobe Inc. Source: US Department of State, Humanitarian Information Unit, Nextview License. Provided by UNITAR-UNOSAT. Satellite image date: 31 July 2015

Source: Camp Coordination and Camp Management Cluster (2015).

100Meters

The boundaries on this map do not imply official endorsement or acceptance by the Government of the Republic of South Sudan or IOM. this map is for planning purposes only. IOM cannot guarnatee this map is error free and therefore accepts no liability for consequential and indirect damages arisingfrom its use.

Map Production Date: 03 September 201513 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

On six different occasions during 2014, IDPs from different
ethnic groups – mainly Shilluk and Nuer – entered and exitedthe PoC depending on the fighting occurring in surrounding
areas. In this way, the PoC progressively expanded its borders,from the original old PoCs in the UNMISS Logistics Base(hereafter, LogBase) to sectors 1, 2, 3 and 4. In August 2015,
the population increased sharply to 47,000, requiring an
upscale of activities by all agencies. Originally, the site only
had a contingency plan to host a maximum of 18,000 people.
Increases in the site population, however, did not lead to a
proportionate expansion of living space or improvements inwater and sanitation services. But the perception that the
PoC at least offered some safety led people to tolerate theseinadequate living conditions.
Today, MSF operates the main civilian hospital in the PoC
with inpatient capacity and an emergency room. The hospitalreceives referrals from MSF’s project in Wau Shilluk on
the west bank. Other healthcare services are offered by
IOM, IMC and the UNMISS Indian battalion. MSF also
treats neglected and chronic diseases, malnutrition andhas a mental health programme as well as the capacity torespond to emergencies, such as the measles outbreak that
occurred in the PoC in May 2016. MSF medical data suggeststhat the harsh living conditions have a clear impact on theepidemiological profile of the displaced population livingin the PoC.
Arjun Claire © MSF

MSF medical staff in Malakal PoC hospital

A number of other humanitarian agencies are present
in the camp, coordinated by the UN Office for the
Coordination of Humanitarian Affairs (OCHA). The primary
implementing agencies are Danish Refugee Council (DRC)(camp management, shelter and protection), IMC (primary
healthcare, obstetrics and gynaecology), IOM (site planningand management, WASH and shelter), Solidarités (WASH)
and World Vision (general food distribution).
Since the incident in February 2016 and the return of a mainly
Dinka civilian population of around 4,500 people to Malakal
town, MSF has started providing services in the town again
for the first time since early 2014.

14 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Summary of key points from section one• The PoCs are a relatively new phenomenon. Although they
have provided necessary protection for thousands of IDPs,
the PoCs create discomfort for the UN. They also cause
discomfort for humanitarian organisations that have to live
under the UN umbrella and in their compounds, relinquishing
all or part of their operational independence. The PoCs act assingle entities that not only reflect the politics outside theirperimeters, but have also become a pawn in the wider ethnic
and political conflict.
• Due to the unstable nature of the past years’ conflict in South
Sudan and the high likelihood that violence will continue
in the Greater Upper Nile region, Malakal PoC and its
surrounding areas will likely continue to play importantroles in the context for the coming years.
• Malakal town experienced bouts of severe violence atthe beginning of this conflict and operational choices havebeen fraught with dilemmas. For MSF, moving to the PoC –where the numbers of civilians and level of needs were highbut MSF would be embedded with the UN – was not an easy
decision. Renewing activities in Malakal town while concerned
about potential instrumentalisation of aid was at first an
equally unsettling decision.

15 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

02
The incidentof 17-18 February
2016 and the MSF
response

Warning signs and rising tensions
Before the incident, a number of events happened thatindicated increasing tensions. Yet tensions and small-scaleviolence are unfortunately quite commonplace in the PoCs
in South Sudan, and so many incidents may not have been
picked up as "red flags" because they were simply not outof the ordinary.
In the previous weeks
The MSF team all noticed increasing tensions over the weeks
before the attack. Weapons were being confiscated at thecamp gates13 and MSF staff noticed that IDP behavioural
patterns were changing. The Dinka staff were feeling more
uncomfortable coming to work at the hospital and Dinka IDP
patients were no longer coming alone to the MSF hospital.
In the previous days
Fighting was reported between youths, but the community
leaders were not able to come to an agreement so tension
escalated. There were allegations of SPLA soldiers entering
the camp dressed like IDPs, which further increased thetension. MSF received casualties at the hospital due tothe fighting.
The day of the incident, 17 February 2016
In the morning, UNMISS attempted to reconcile the two sides.
At 11am a Dinka woman with machete cuts, injured by Shilluk
youths, was brought into the MSF hospital. By the evening,
the tension was extreme. The Dinkas did not want to leave
Sector 2, and had been advised by their community leaders
not to do so. The PoC marketplace was practically deserted
and there was hardly any IDP movement.
There are different views on what caused the fighting
on 17-18 February. It is obvious, as described above, thatgeneral tensions were clearly rising both outside and inside
the PoC. One of several possible smaller actions is likely tohave triggered the whole series of events (for example, astone thrown at a tent, the beating of an IDP or an alleged
theft by a youth). However, the view espoused by many,
including in public reports, is that the events of 17-18
February may have been foreseeable in the light of theconflict dynamics in the area.

13 Fear, violence and weapons smuggling in Malakal PoC has been ongoing for sometime, see, for example, International Refugee Rights Initiative (2015) Protecting someof the people some of the time: civilian perspectives on peacekeeping forces in South
Sudan. In autumn 2015, there was also an incident where SPLA soldiers entered thecamp trying to steal cattle.

16 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Brief overview of the eventsFighting broke out in the PoC around 10.30pm on the nightof 17 February 2016, and continued several hours into theearly morning of 18 February. Around 02.30am, grenades
were thrown into the Nuer section and some tents were burnt.
Although the following day many more IDPs flooded into the
UNMISS LogBase, on the first night initially around 600 IDPs
had already managed to come through a small gate (pushing
their way in when the Charlie Gate between the PoC and the
UN LogBase was opened to let injured people through) andsheltered in the MSF hospital overnight.
There were several hours of quiet until it started again
the next day. Both MSF staff and IDPs were reporting thepresence of armed men inside and outside the PoC. Around
11 am fire broke out in the PoC and burned down substantial
areas in the camp. MSF dealt with the mass casualties, which
occurred as a result of the fighting and fire, in its hospital
located on the border between the PoC and the UN LogBase.
UNMISS had closed the gate between the PoC and the
LogBase the previous night, thus preventing the fleeing IDPs
from accessing the UN Base’s inner compound to reachsafety. On several occasions, MSF urged the UNMISS soldier
guarding the gate to open it, although he asserted that he did
not have the green light to do so. The gate closure caused alarge accumulation of IDPs on the PoC side of the fence andcreated panic. When the fighting got closer, this panic grewand hundreds of people jumped over the fence and started
streaming into the MSF compound (see photograph below).
The MSF team channelled them into the UN LogBase, after
which UNMISS finally opened the gate (on the second day,at around 12 midday), letting the remaining thousands flow in.

Direct effects of the incident
MSF staff, with support from IMC medical staff, treated a totalof 108 casualties, predominantly male. This included 46 gunshot
wounds, four burns cases and 58 other people admitted withinjuries (for example, machete cuts, falls or injuries while
fleeing). As witnessed by MSF, there were 18 fatalities mostly
from gunshot wounds, and all but three were dead on arrival.
Twenty-four injured patients were referred to IMC, the UNMISS
Indian Level II Hospital or evacuated by the ICRC, The total
number of people killed in the fighting is unclear. While MSF did
not register all the dead, it witnessed 18 fatalities, including two
MSF national staff members, one of Shilluk ethnicity and one
from the Dinka community. UN sources speak of 25 deaths,
while community leaders report up to 65 dead people. The
number of victims and the type of injuries suggest a significant
presence of firearms during the events.

17 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Other effects of the fighting include 2,326 structures
destroyed by fire (around 35 per cent of existing shelters in
the PoC) and 6,700 households losing their shelters (thisapplied to 30 per cent of MSF NS), the destruction of the
IOM and IMC clinics inside the camp, damage to latrines andwater storage infrastructure, as well as a large movementof IDPs seeking safety. After the attack, over 25,000 Shilluk
and Nuer IDPs had moved into the UNMISS LogBase, withthe remainder staying in the PoC but near the Charlie Gate
where they felt safer. Between 4,000 and 4,500 Dinka IDPs,
together with Darfuris and Arab traders also residing in the
PoC, moved to Malakal town during the night of the fighting
and the next morning. Sector 2 (Nuer blocks U, V, W, Y) were
torched that night, and later Sector 3 (Shilluk-inhabited) andthe following morning part of Sector 1 (also Shilluk-inhabited).
IOM estimates that close to four million US dollars worth ofdonor-funded materials were destroyed.

Figure 3
IDPs in the PoC

Figure 4
IDPs flooding into the UNMISSLogBaseFigure 5
The aftermath in the PoC

Roger Gutierrez © MSF 2016

Roger Gutierrez © MSF 2016

Roger Gutierrez © MSF 2016

MALAKALMALAKAL
POC POC
21/02/2016

21/02/2016
Figure 6
Prior to incident (6 Feb 2016)
After incident (20 Feb 2016)
Malakal
PoC site(6beforeand after the incident of 17-18 February
Prior to incident
Feb 2016)
After2016
incident (20 Feb 2016)

1

2

1
4

2

4

3

3

SECTORS

Prior to incident (6 Feb 2016)
Source: IOM (2016)

After incident (20 Feb 2016)

SECTORSMap boundaries do not imply official endorsement or acceptance by the Government of South Sudan or IOM. This map is for planning purposes only and IOM accepts no liability for consequential and indirect damages arising fromits use. Satellite imagery copyright DigitalGlobe Inc. Source: US Department of State, Humanitarian Information unit, Nextview License provided by UNITAR-UNOSAT. IOM/CCCM.

18 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

MSF response
Emergency preparedness
Sadly, violence against civilians is frequent in South Sudan.
However, an armed incursion into a PoC is not. Despite there
having been other attacks on South Sudanese PoCs in thepast,14 those occurred much earlier in the conflict and it wasconsidered that at this stage – following the signing of apeace agreement in August 2015 – such an attack
was unlikely.
MSF had made certain contingency plans based on the risingtensions in the camp, but all MSF staff members (and all
external actors) interviewed agreed they had not envisaged
the scenario of the PoC being attacked from the outside oran event of this magnitude.
Although MSF had been revising its mass casualty plan
during the days prior to the events, the plan had not been
approved yet nor had its contents been known by the national
staff. Moreover, the plan had not envisaged an armed attackfrom outside the PoC.
It is nevertheless important to underline that while
preparedness is important, it is still possible to mounta relevant response in an unforeseen situation.
Initial response
The MSF team reacted quickly to the emergency, immediately
ensuring that team members were safe and mobilising only
those necessary to assess the initial situation.
Mobilisation of other humanitarian agencies
and on-the-spot negotiations
MSF immediately tried to mobilise the Health Cluster, as
per the inter-agency mass casualty plan. UN agencies andinternational NGOs were not able to move, however, seemingly
because they were bound by the security recommendations
made by the UN Department of Safety and Security(UNDSS).15 As a result, MSF and IMC medical staff were
the only humanitarians able to contribute to the humanitarianand medical response to the crisis as it was happening.16

14 In December 2013, the UNMISS base in Akobo was attacked, and in April 2014
the one in Bor.
15 For more on this, see the later sub-section on the UNMISS response.
16 Besides trying to mobilise the World Health Organisation (WHO) and the Health
Cluster, MSF also needed to negotiate with different actors on various occasions toconvince them to take part in the response, which was successful to some extent.
For example, medical staff successfully negotiated with the Indian Level II Hospital(UNMISS) for the referral of patients there; the FC negotiated with UNMISS soldiers
at Charlie Gate to try and open the gate; the logistics manager negotiated with the
UNMISS Rwandan Battalion to allow one of their buildings to be used as a possible
evacuation route.

19 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Medical response
The medical team, with four staff members from IMC,
dispatched swiftly to the MSF hospital to respond to the influxof casualties that was beginning. They improvised well in theface of various challenges on the spot (such as establishingtriage areas, constructing a make-shift room for surgery andanother for a morgue) and had significant medical impact in
responding to the mass casualties. The MSF team stayed aslong as they could, until the fighting got closer and requireda short temporary evacuation, since the MSF premises (built
largely with plastic sheeting) could not provide enoughpassive security for the patients nor for the staff.17
Dead body management
There were no clear protocols regarding dead bodymanagement. So there was no consistent approach to receiving
bodies, to ensure the names were noted down when they werebrought in, or to ensure that the bodies were dealt with in an
organised and humane fashion.
Engagement and communications
The public communication around this topic18, as well as
bilateral engagement with UNMISS or other actors involved
immediately after the event, was not sufficiently assertive,
especially in light of the severe failures of protection andassistance and the killing of two MSF staff members during
the events.

17 The hospital had no protection on its side between the hospital and PoC, so the riskof stray bullets hitting the hospital and its staff and patients put them in danger.
Some medical materials were lacking – in particular traumatology materials tostabilise limbs – and not all medical staff realised what stock had been available tothem in the pharmacy until after the events. Referral locations were not clear to
medical staff, which caused moments of hesitation before referring patients. Further,
the MSF staff member left at the base who was charged with contacting the otherhumanitarian organisations had uncertainties about where to find them or how tocontact them. These are points that could have been more clearly revised in a masscasualty plan, and clearly communicated to all international and national staff.
18 MSF issued two press releases following the incident, on 18 February and 2 March.
See MSF (2016) ‘South Sudan: Fighting in Malakal site leaves at least 18 dead, twoof them MSF staff’, available at: http://www.msf.org/en/article/south-sudanfighting-malakal-site-leaves-least-18-dead-two-them-msf-staff and MSF (2016)‘South Sudan: MSF condemns outrageous attack in UN protection site in Malakal’,available at: http://www.msf.org/en/article/south-sudan-msf-condemnsoutrageous-attack-un-protection-site-malakal (both accessed 10 June 2016), as wellas an eyewitness account from an international staff member present at the time,
see Claire (2016) ‘Leaving patients behind is the hardest thing’, the Guardian, Global
Development Professionals Network, Field posts, available at http://www.
theguardian.com/global-development-professionals-network/2016/mar/16/
leaving-patients-behind-is-the-hardest-thing-when-fighting-reached-an-msfhospital-in-south-sudan (accessed 10 Juned 2016).

20 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Support to staff
It is evident, on reviewing the events, that MSF took allnecessary steps to ensure that national staff members were
protected as much as possible from the attacks. However,
the review also shows that the follow-up was insufficient
regarding support to the staff and the families of the deceased
staff members.

The dedication of MSF national staff during the eventsof 17-18 February
A special mention needs to be given to our South Sudanesecolleagues and the way they dealt operationally with thiscrisis. MSF had close to 150 national staff working in the
Malakal PoC, all of them IDPs living in the camp, consistingof Dinka, Nuer and Shilluk staff members. In general, thestaff, from those working in the radio room to the medical
staff in the hospital, and to the cleaners and guards, showedcourage and resilience in dealing with this situation that was
not only happening where they were working but was also
affecting their families, friends and communities. While manyof their own shelters burned to the ground and their families
were forced to flee, the Shilluk medical staff, cleaners andtranslators remained in the hospital, working all night long.
Of course, MSF told them they were free to leave and be with
their families if they wished to do so, and some chose to do so.
But on the morning of 18 February, all of the national staff who
were scheduled to work, except for those Dinka staff who had
fled for safety to Malakal town, turned up on time, even after
many of them had lost almost everything and were once
again displaced.
Two MSF staff members were killed during the events, andtheir stories are described in the boxes below. Both died ofbullet wounds, one of them in the middle of the crowd crush
by Charlie Gate while trying to reach the hospital. It is highly
important to note that the details of their deaths have been
put together based on testimonies collected and cannot be
independently verified. MSF finds the allegations of lack ofprecision by UNMISS forces very disturbing and urges further
investigation by competent bodies.

21 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Remembering Abraham Chol Tor, MSF community
health worker in Malakal PoC
Abraham was a community health worker, living in the
Dinka Sector 2 of the PoC. Forty-four years old andoriginally a teacher from Atar, Pigi County, he arrived
at the PoC in 2014 following to clashes in Atar. He
began working with MSF in October 2014. He had awife, three daughters and two sons, and was also thecarer for his two sisters. After the fighting broke out
in the PoC on the night of 17 February, Abraham andseveral other staff members (and likely family memberstoo) came to the small MSF clinic in Sector 2 to seek
protection. According to witnesses, he believed thatbeing at the MSF clinic would protect him from theshooting that was going on around him. A patient was
brought to the MSF emergency room with a wound after
being stabbed. Abraham helped the clinical officers on
duty as much as he could to treat the patient. When thefighting increased, he tried to run to his tent in order tocollect some belongings (IDs, certificates, etc.) with theaim of bringing them back to the clinic to protect them.
He was told not to leave by his medical colleagues as
he was heading towards the fence door. Right before
crossing the door, he allegedly received a stray bullet
coming from one of the sides and fell down to theground, still inside the MSF medical outpost fencing,and died immediately. He was allegedly not wearing his
MSF uniform at the time. Several MSF clinical officers
were eyewitnesses to his death and provided theinformation detailed in this account.

Remembering Emmanuel Maichel Aban,MSF guard in Malakal PoC
Emmanuel was a guard living in the Shilluk Sector 1of the PoC. He was 33 years old, married with two wives(one in Khartoum and one in Yei) and had children.
He was originally from Tworo, Panyikang County andarrived at the PoC in February 2014. He began working
with MSF in September 2015. He was killed on the
18 February at around 1.10 pm during the fighting in
Sector 1, Block H. When the fighting erupted in Sector
1 between armed elements and UN forces, Emmanuelwas said to have gone briefly to his shelter from thehospital where he had been working all through thecrisis, to pick up some of his documents. He had sat

22 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

down a moment in front of his shelter when – according
to colleagues – some armed elements ran by his shelterand UNMISS soldiers, from vehicles driving by on theother side of the fence, in the crossfire, Emmanuelwas hit.19 He was shot in the head, and two others
nearby were also shot (although they survived theirinjuries). Emmanuel was brought on a stretcher to the
MSF hospital, although this was delayed by the huge
crowds amassing at Charlie Gate and was unable to getthrough. He was probably still alive on arrival. However,
he was bleeding profusely and the type of injuries hehad sustained meant that it is unlikely he could havebeen saved. He was allegedly not wearing his MSF
uniform at the time.

Summary of key points from section two• MSF teams did an exceptional job in responding medicallyto this crisis. They responded quickly and effectively, provided
shelter to IDPs and facilitated their access to safety andtried on several occasions to mobilise other actors to help
in the response. However, a more thorough mass casualty
plan that had been properly communicated to all staff, and amore organised and dignified form of conducting dead bodymanagement should have been in place, however.
• The MSF national staff deserve special recognition for
their work, dedication, resilience and commitment to MSF
during the incident. They continued to work tirelessly evenwhen their families were fleeing and their shelters were being
burned down. A special mention should be given to the two
staff members who were killed during the attack.
• MSF did not anticipate and therefore adequately prepare
for this scenario. Although there were some signs thattensions were escalating, these were either unfortunately
part of usual PoC activity, or were not thought exceptionalas the PoC dynamics change constantly. It would havebeen difficult, therefore, for the MSF team to know that thesituation was more tense than usual.

19 It is difficult to triangulate this information as the situation was clearly chaotic.
MSF will strive to find more eye witnesses, but it should be noted that we are notable to verify the account provided through ballistic evidence due to MSF's lackof capabilities in this area.

23 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

03
The responseof UNMISSand humanitarianagencies 20

UNMISS response
Even if an armed attack on the PoC may not have appeared
imminent, all peacekeeping missions that that have aprotection of civilians mandate should be prepared for the
eventuality of incidents such as the one described above. In
the fulfilment of its mandate from the Security Council, oneof the primary operational tasks of UNMISS is to protect the
PoC from external threats and ensure security within thecamp. UNMISS also has important responsibilities relating
to protection of civilians outside of the PoCs. According to
its mandate, UNMISS should use "all necessary means, up
to and including the use of deadly force, aimed at preventing
or responding to threats of physical violence against civilians,
within capabilities and areas of operations, and without
prejudice to the responsibility of the host government."21
Its operational approach rests on four tenets that include
prevention and responding to threats of physical violenceagainst civilians, which are the two most pertinent for theincident of February 2016 and will be looked at here.
UNMISS preventive measures
UNMISS takes on local policing responsibilities in the
PoCs and is supposed to deal with any infringements ofcamp security. By definition, although it is not allowed toprosecute and has no judicial authority, UNMISS has criminal
authority when the GRSS is unwilling or unable to act.22
However, during interviews with agencies and IDPs, it seems
that UNMISS continuously failed to deal effectively withweapons being smuggled into the Malakal PoC and withincidents of violence between the IDPs. An interview from one
humanitarian agency asserted that a week before the incident
it had been informed that part of the fence in Sector 2 hadbeen cut, but despite passing the information to UNMISS sothat the fence could be fixed, nothing was subsequently done
about it. Another organisation also claimed to have informed
UNMISS of the weapons-smuggling problem and UNMISS
insisted they would deal with it, but nothing ever came of thiseither. According to a third organisation, when they noticed
tensions rising in the camp, they informed the UNMISS state

20 For more detailed information on the humanitarian structure in the country, see
Fenton, W. and Loughna, S. (2016) The search for common ground: civil–military
coordination and the protection of civilians in South Sudan (London, Overseas
Development Institute.
21 UNMISS described this as its "core definition" in a presentation to the Protection
Cluster in Juba, 8 March 2016.
22 For more about the customary law judicial mechanisms set up between the IDPs
themselves, see Stern, J. (2015) Establishing Safety and Security at Protection of
Civilians Sites: Lessons from the United Nations Peacekeeping Mission in South
Sudan (Washington, D.C., Stimson Center) and IOM (2016) If We Leave We
Are Killed.

24 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

coordinator that it was getting very tense, but were told thiswas an exaggeration. According to IDPs, on the morning of the
17 February before the incident, small clashes started to breakout within the camp and despite UNMISS being informed by
IDPs and others, they did not act on it so the community tried
to deal with it themselves.23
Role of UNMISS in managing the crisis
Aside from the insufficient prevention measures taken,
UNMISS also did not manage to act swiftly enough during
the crisis itself. The night of the incident and the following
morning UNMISS was not part of the response – not inhumanitarian terms and barely in security terms.24 Early
the following morning, when the situation was quiet forsome eight hours or so, it would have been the ideal timefor UNMISS to carry out certain activities such as patrollingthe sectors, fixing the fencing of the perimeter of the camp,
holding talks with the authorities and summoning the IDP
community leaders for discussions. Yet, according to reports
from fellow humanitarian workers and the IDPs, UNMISS
seems to have been simply missing in action.25 A fire raged
through the sectors on the 18 February, but according to someinterviewees, UNMISS did not move in to contain it until 3pm
or 4pm. In fact, several humanitarian agencies stated that
UNMISS took 16 hours to respond to the incident as a whole.
In meetings with UNMISS afterwards, agencies were toldthat due to the darkness on the night of 17 February UNMISS
soldiers could not see much and could not have intervened.
Speaking with other humanitarian agencies in the PoC, it
seems that soldiers did not have decision-making powers on
the ground, thus causing severe delays in response. Soldiersin the camp had expressed a desire to enter, but were redlighted at Juba level, until much later – in the early afternoonof 18 February, when the soldiers were given permission toenter and use their weapons.

23 In general, in PoCs throughout the country – including the PoC in Bentiu where
MSF is also working – the prevention aspect of the mandate is often not sufficiently
upheld, and many camps have allegedly had the problems of weapons-smuggling,insufficient maintenance of the perimeter fencing and poor lighting. For further
information, see Center for Civilians in Conflict (2015) Within and Beyond the Gates:
The Protection of Civilians by the UN Mission in South Sudan (Washington, D.C.,
Center for Civilians in Conflict). IOM (2016) If We Leave We Are Killed also confirms
these failings in ensuring protection of the PoC sites.
24 There were some reports by IDPs that UNMISS soldiers threw tear gas into thecamp. It is not clear exactly when this occurred but it seems likely to have been
during the night. This may be considered as responding in "security terms". The nextmorning, UNMISS also put out the fire that was spreading through the camp,
although the response was late and much of the damage had been done by the timethey managed to act.
25 In fact, in many interviews conducted with IDPs from the two largest ethnic groups
in the PoC, when describing the events they simply used the phrase "the UN justdisappeared".

25 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

The UNMISS protection response was not timely nor did it
swiftly respond to armed attacks against civilians and against
the UN base.
Not only did UNMISS fail to actively intervene to mitigate thefighting, but they also intentionally blocked the Charlie Gate,
the only route IDPs had to reach safety in the UN LogBase.
This blockage by UNMISS caused a mounting panic andescalating tensions among the IDPs, and the ensuing problem
of crowd control caused increased problems not only for IDPs
seeking safety but also for MSF in trying to provide medical
assistance. By 1pm, IDPs were desperately trying to get in,and UNMISS mobilised their tanks. However, interviewssuggest that this was to protect assets and prevent looting
rather than to assist the IDP population in reaching safety.
As described in more detail in the following sub-section,
UNMISS, at least for a time, also prevented the Indian Level
II Hospital from being used for surgery referrals, which wasa resource that had been stipulated in the inter-agency Mass
Casualty Plan (MCP).

Response of other humanitarian agencies
When the fighting broke out, MSF immediately tried tocontact the WHO to activate the inter-agency MCP. The plan
– although not finalised – was useful in that it assigned
specific roles to different agencies, defined meeting
points and communication lines, and guaranteed a sharingof resources, including personnel, medication and othermedical stock, vehicles and medical workspaces. The WHO,as the Health Cluster Lead, would be responsible for initialcommunications and activating the plan. When MSF tried tocontact the WHO, it was discovered that none of these things
would be done, as the situation was deemed too dangerous forany mobilisation.26 Instead, "bunkerisation" was advised to the
UN agencies and the international NGOs. From interviews
with humanitarian organisations it appears that UNDSS
deemed the PoC a "no-go area" during the incident becauseof fires in certain sectors. As explained to MSF, UN agencies
have the obligation to adhere to UNDSS security rules,
whereas other organisations can choose not to follow thoserules if they so wish.

26 A WHO representative did come to the MSF mass casualty area, but only after thesituation had calmed down. However, according to the MSF medical team, they
seemed to care more about the numbers of casualties and statistics for reporting
than about the WHO’s role in emergency response.

26 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

None of the other actors responded to calls for mobilisation,and MSF and IMC were alone in treating the medical cases.
Although the IMC doctors who came with MSF to treat themass casualties evacuated earlier than the MSF expat team,they contributed substantially to the medical response.
According to one humanitarian organisation interviewed,
IOM and IMC could not give emergency medical assistancedue to the fact that their clinics in the camp were burned
down. In reality, however, movement appears to have been
the main debilitating issue. The UNMISS vehicles were able
to be used for ambulances, as per the inter-agency MCP, but
no resources could be shared as was planned in the MCP and
MSF could not rely on UNMISS for its Indian Level II Hospital
surgical referrals nor for dead body management. MSF sent
an initial five patients to the Indian Hospital for referral, as
stated in the MCP, but the hospital began sending the patientsback, stating that treatment of IDP injured cases was "nottheir mandate" and that they had to maintain capacity forpossible UN expatriate injuries. The MSF medical team leader
went there at midnight and again at 3am to beg them toaccept critical surgical cases. MSF acted swiftly and set up an
improvised operating theatre in the hospital for IMC doctors
to work. Afterwards, IMC managed to get an agreement fromthe Indian Hospital and were allowed to use their operating
theatres, where two more patients were subsequently treatedby IMC doctors.
With regard to the dead bodies, they began accumulatingin the hospital; however, DRC, who were tasked with handlingthe dead bodies, could not take them to the cemetery morgue
just outside of the PoC, as they needed a green light fromUNMISS for a larger vehicle to transport them. They also
requested an armed escort to accompany them and thebodies to the morgue, which delayed the process further.
In the end, none of this could be achieved and three days
passed until MSF, after obtaining the consent of thecommunity leaders to bury bodies that had not been officially
identified, transported the bodies to the cemetery morgue
in one of its vehicles.

27 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Post-incident response
A crisis management team was set up by UNMISS. IOM
prepared to find the numbers of displaced and confirmed it
to be 30,000-35,000 people, on the afternoon of 19 February.
IOM and IMC set up basic structures to respond to any
casualties, but it is not clear if this had any effect at sucha late stage. They also began water trucking soon after andProtection Cluster partners worked on locating separated
families. The following map compiled by IOM following theevents shows the damage caused in the camp and describes
the assistance response plan.
The post-incident clean-up and rebuilding of structures
was still ongoing at the time of writing this report. After theincident, some Dinka and Darfuri IDPs were escorted by the
UNMISS back to their homes to collect the belongings anddocuments they had left behind. UNMISS soldiers were puton duty to protect and separate a section of the Dinka houses,
which angered many of the other IDPs in the camp as it
contrasted sharply with the lack of security presence during
the events themselves and made UNMISS appear partial.
Of extreme concern is that UNMISS has not adequately
reinforced the outer perimeter of the PoC to ensure that
attacks like this one do not happen again in the future. Instead,they have put resources into reinforcing the fencing between
the PoC and the UN LogBase (filled earth bags topped withrazor wire). In the event of another incident such as the one in
February, the IDPs would not be able to break through the wire
to the MSF hospital as they did on that occasion; instead, theywould simply be trapped inside the PoC.
The UN condemned the February incident and issued ahalf-hearted apology for "failing to protect the civilians" inMalakal.27 In its public positioning, it has emphasised the"inviolability of the UN compounds" and has stated that
attacks against them may constitute a war crime28 (without
explicit mention that the targeting of civilians inside the
PoC may also be a war crime). However, despite this, it isquick to defend itself, saying that in the Malakal incident
UNMISS police "immediately intervened" with tear gas todisperse the crowds. It has not admitted mistakes, directly

27 See NPR (2016) ‘South Sudan: UN condemns violence in Malakal civilian protection
site’ for the half-hearted apology, available at http://www.npr.org/sections/thetwoway/2016/02/23/467838613/u-n-apologizes-for-failing-to-protect-s-sudancivilians-in-attack-that-killed-18 (accessed 9 June 2016).
28 Ibid.

28 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

criticised the GRSS, or armed groups and militias or shown
any willingness to discuss its response with other actors
present during the events. An UNMISS board of inquiry from
DPKO headquarters in New York has since conducted avisit, but full findings are yet to be made public. It should be
mentioned that some positive improvements seem to havebeen made following the events, as will be described in thefollowing sections, but these need to be backed up with asolid framework that results from reflections and discussions
on the dire issues facing the PoCs today and what needs tobe changed. Overall, serious doubts remain as to the capacityof UNMISS to protect the civilian population if another event
such as this one were to happen.

29 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Figure 7
IOM Malakal response plan, 20 February 2016

IOM MALAKAL RESPONSE PLAN
20/02/2016

Following the 17 February attack of the Malakal
Protection of Civilian site, a fire broke out
damaging shelters and humanitarian
infrastructure. Fearing for their lives, the majorityof the IDP population moved to secure areas ofthe site, primarily within the UNMISS Logistics
base. IOM and humanitarian partners are working
to ensure that the lifesaving needs of those
displaced by the incident are met.

On 19 Feb, IOM sent 6.5 metric tons oflifesaving WASH and Health supplies
On the same day, a team of senior IOM
staff and technical experts was deployed
Shelter framing materials are arriving bybarge on 22 Feb

TO AIRPORT

Kilo Gate/MALAKAL

TO

AI

Health

RT
/

M

AL
AK

=
\ Bravo Gate

MSF provides secondary
health Care

Helipad

=

AL

\

=

RP
O

HealthFour tents donated by
UNICEF have been erected
to serve as a temporary
primary health clinic. The IOM
health team is providing
maternity and antenatal care
as well as administering bothroutine and Oral Cholera
Vaccinations.

\ Alpha Gate=

UNMISS Level II
Hospital
Water
Treatment
Plant

KCB Gate=\

Humanitarian Hub

IOM and IMC provide
support to MSF Mass
Casualty Plan

Parking

UNMISS Offices
and Accommodation

HMEC

WASH
=

IOM team increased waterproduction and improved
accessibility with the reopening of 4 water points in
Sector 1 and theestablishment of 3 newwater points for water
trucking in the Logs base.

4

RWANBATT

3=
UNMISSTransport Section

New Humanitarian Hub=

WASH
IOM WASH team distributed
391,500 liters of water on 20
Feb

=

=

2

=

= Delta Gate
\

1

CTC

INDBATT

MSF= \Charlie Gate

Damaged roads anddrainage are being clearedin Sector 1 Casualty Plan=

TRISTAR

Proposed
Humanitarian
Fuel Depot=

RwandaFPU=

Shelter
MedicalHubHG=
IMC clinic waslootedSECTOR 1
K

F

E

L

SECTOR 2
Market

=

=

P

O

N

M

=

=

=

=

J
I

Public
Space

D

C

S

R

=
T

=
RWANDBATTSECTOR 1

BA

1,688 shelters were burnt=

Two water tanks (5,000 liter)
damaged by the ﬁre beyond
repair=Echo Gate

SECTOR 4C

B

A

Most of the latrines aredamaged but repairable

te

Military Zone
Buffer Zone\

Market

SECTOR 3

Areas where IDPs have
moved (Old PoC 1,2,3,4)
Blocks burnt completely

C

B

D

=

=
=

=

18 Killed

over

90 injured

SECTOR 2
775 shelters were burnt=

IOM primary health clinic wasdestroyed=

One water tank (70,000 liter)
damaged but repairable

ETHBATT=

Of two schools ran by
INTERSOS, one was destroyed,
the other one damaged

Buffer Zone

Damaged Health facilities
Damaged schools

Blocks burnt partially
Blocks deserted

DRC will begin construction of
temporary shade in the old
POCs and the UNMISS logsbase. Medair will distribute themost urgent NFI after the GFD
and the CCCM led head count.
IOM will send supplementary
NFI stock by air, and sheltermaterials will arrive on thebarge on 22 February.

Y

=

\ =
Juliet Gate

Hotel Gate

FOOTPATH TO MALAKA
L

=
\
A

D

W

V

U

Foxtrot Ga=\

IOM began cleaning in known
open defecation areas inorder to reduce healthhazards.

SECTOR 3
94 shelters were burnt

Damaged water tanks

households lost their

6,700 shelter to the ﬁre

An estimated 24,000
IDPs are currently inthe logistics baseFor further information, contact the IOM South Sudan Program Support Unit at ssudanpsu@iom.int

Source: IOM (2016)

30 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Summary of key points from section three• There was a severe failure of UNMISS to provide protection
to the civilian population inside the PoC. Although the
UNMISS mandate includes the responsibility to preventand respond to threats of physical violence against civilians,
UNMISS failed on both counts regarding the February 2016
events. The weak control of fencing, poor lighting, weapons
smuggling and lack of prevention of armed elements entering
the camp all contributed to heightened risks for IDPs in
the camp.
• During the crisis itself, UNMISS was extremely slow tointervene. Initially, it did not intervene and, when it did
finally respond physically to repel the attackers, many people
had already been killed. The military response by UNMISS
was not only delayed but there are concerns regarding theshooting of civilians by UNMISS soldiers, that need to
be investigated.
• UNMISS deliberately closed Charlie Gate, which caused
panic among IDPs and created a massive and dangerous
accumulation of people at the gate. IDPs began climbingover the fence to the MSF compound to reach safety, andsome people were injured while others could not reachurgently needed medical care. UNMISS prevented patientsfrom reaching its Indian Level II Hospital, which had beenplanned for surgery referrals in the MCP, and ambulanceservices were not activated.
• UNDSS security recommendations paralysed almost all UN
agencies and international NGOs, and prevented the interagency MCP from being carried out and resources being
shared. There are fundamental problems when humanitarianagencies operate under the security umbrella of a body which
does not sufficiently measure risk in relation to humanitarianneeds and potential impact. This is problematic on many
levels, conceptually and pragmatically, and it is clearly
unsuited for the management of contexts where there is ahigh potential for an escalation of violence.
• Regarding the post-incident response, there were also
severe delays in the construction of new shelters andassistance for dead body management.

31 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

04
The situation
four months on:
key findings ofa survey of Malakal
PoC residents on
living conditions,protection
and returning

At the time of writing, most IDPs have returned to the PoC,
but others are still staying in the LogBase waiting to be
relocated to new shelters. Many IDPs, however, also statedtheir fear of returning to the PoC, especially as they assertthat UNMISS has done nothing to improve the security of thecamp from the outside. In fact, as mentioned in the previous
section, its priority seems to have been to reinforce security
between the UN LogBase and the PoC, which in fact meansthat if something happens again it will be extremely difficult
for the IDPs to enter. Many of the PoC sectors have beenrebuilt, and the aim was to have all the IDPs back in the PoC
before the end of May. This deadline has not been met.
Four months on from the February attack, the living
conditions of those remaining in the camp are appalling.
The IOM, UN agencies and international NGOs are working
to expand the camp (sector 5) in a move towards achieving
basic humanitarian standards. UNMISS, however, is reluctant
to provide protection for the new sector. The deadly attack on
the Malakal PoC site detailed in this report could provide noclearer case for the need to protect the population residing
inside the camp.
MSF teams conducted a survey between 19-23 May to findout more about protection and assistance concerns fromthe IDPs living in the PoC.29 The survey briefing provides avaluable insight into the concerns, priorities, experiences andperceptions of the PoC population.30 The findings that are
most relevant to the topic of this report are the following:• Safety was a decisive element why people came to theMalakal PoC. Over 98 per cent of respondents said one of
the two most important reasons they came to the PoC was
because they were directly affected by violence. In addition,
81 per cent listed the threat of future attacks as anothermajor concern.
• Food and health were marginal concerns in people's decision
to come to the PoC. Only 13 per cent of respondents
mentioned food as a factor, while five per cent listed healthas a reason. This clearly shows that people viewed PoC sites
as places of safety rather than camps with easy access tobasic services.

29 The survey sample included 108 respondents(65 were women and 43 were men)roughly reflecting the gender composition of the PoC. The survey was designed torepresent the camp when treated as one coherent unit.
30 Voices of the people: "Security is the most important thing", Findings from MSF
survey in the Malakal UN Protection of Civilian site, MSF briefing, June 2016.

32 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Samuel Carpenter © MSF• Protection concerns: The feeling of insecurity is rife. Over
three-quarters of all respondents (83 per cent) said they do
not feel safe inside the PoC. Physical violence was found to bepervasive with over three-quarters of all respondents (81 percent) saying they have been, or know someone directly who
has been, exposed to physical violence at least once.
• The incidence of sexual violence was high with over half of all
respondents saying that they or someone they directly know
has suffered sexual violence.

Sexual violence against women is especially prevalentoutside the camp, Many are forced to leave collectwood in surrounding areas• Moving to sector 5: All respondents said that they would not
move to Sector 5 without the guarantee of protection, while
67 per cent of respondents said they would if protection
was guaranteed.
• When asked to give two main reasons for not leaving
the PoC until now, insecurity was unanimously mentionedby all respondents.

Summary of key points from section four
• Security is key to people's decision to stay or leave the PoC.
Considerations of food and health tend to be secondary.
• But the PoC has not guaranteed freedom from violence.
The February attack is a flagrant manifestation of the threatof violence. Yet, less conspicuous are the insidious forms ofviolence that torment people’s daily lives.
• Confidence in UN peacekeepers is low. The perception of
the camp’s residents is that they are keener to protect UN
assets than human lives.

33 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Concluding
remarks

The new Transitional Government of National Unity iscurrently discussing the implementation of the peaceagreement and associated arrangements in Juba. It will,
however, probably be a long time before the country is freefrom violence and free of the vast medical and humanitarianneeds being seen in areas to which populations have been
displaced throughout the country. As insecurity and concerns
for their safety persist, people will likely keep flowing in andout of PoCs for years to come, especially in Malakal, which isa strategic centre of the conflict and will not easily be let goby either side.
PoCs are not an ideal solution for anyone, least of all theirresidents. UNMISS and the GRSS do not want them, the
IDPs do not want to live in them and humanitarian agencies
do not want to operate within them. They are, however,an uncomfortable reality of South Sudan today and are
inextricably linked with the ethno-political conflict. Indeed,
the PoCs reflect the dynamics outside their fenced perimetersand have also become a strategic part in the conflict,vulnerable to attacks depending on local political whims. In
general, attacks on civilians in South Sudan appear to be
the modus operandi of the post-December 2013 conflict and
UNMISS, the force commissioned to protect those civilians,
has shown itself to be incapable of stepping up to the task.
This report details MSF' s internal review of the February 2016
events that occurred in the Malakal PoC site. The fighting
resulted in between 25 and 65 people dead, including MSF
staff, and over 100 injured, and caused wide-scale damage tothe camp and the displacement of almost all its inhabitants.
The emergency response by MSF to the ensuing crisis was
exceptional: the medical response was professional andeffective, the reactions of the team were quick and humane,and shelter was given to IDPs who were desperately seeking
safety. Most notably, however, MSF – with strong support
from IMC – was the only actor trying to mobilise others andable to respond effectively during the crisis and thus had
an immeasurable importance in saving lives and alleviating
suffering of the panicking IDP population.
Mistakes were also made by MSF during its response,
particularly regarding the management of dead bodies, thelack of a mass casualty plan and insufficiently vocal public
communications and engagement following the incident.

34 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

Beyond the MSF response, the events in February exposedsevere problems relating to the failure of UNMISS to protect
civilians in its very own compound and one it calls a Protectionof Civilians site. This lack of protection can be illustrated
through five core examples:
1. Insufficient measures were taken to ensure that the campperimeter was secure, that it was free of weapons and thattensions between ethnic groups were sufficiently controlled
and monitored.
2. During the crisis itself, UNMISS did not enter the camp ina timely enough manner to stop the fighting and prevent the
influx of armed elements from outside the camp perimeters.
3. UNMISS kept a vital access gate closed for a large partof the emergency, causing an accumulation of people andheightened levels of panic, endangering the lives of IDPs
fleeing the violence and possibly deteriorating the medical
conditions of injured IDPs being brought to the MSF hospital.
4. The security advice provided by UNDSS to all the aid
agencies prevented UN agencies and international NGOs fromcontributing to the emergency response, thus also making it
impossible to activate the inter-agency MCP.
5. When UNMISS soldiers were given the approval to use
firearms to dispel the armed intruders, it is not clear
how precise the targeting was, and there are concerning
allegations that civilians might have been shot by UNMISS,
including one of MSF’s staff members.
Four months on, it is worrying that there is no sign thatlessons are being learned and shared, and that neither of the
two UN investigations conducted have been made public.
Moreover, there is nothing to show that plans are being madeto ensure greater security for IDPs inside or outside of the
PoC, nor that there is a willingness to improve their living
conditions inside the PoC. The findings of MSF’s survey of thecamp’s residents show that security is the main reason behind
their decision to stay in the PoC. The PoC, however, has notprotected its residents from exposure to violence.

35 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation

The February events in Malakal can be considered a collective
failure by the humanitarian community to respond in acoordinated and efficient manner to emergency needs, andthis exercise in lessons learned aims to serve as a starting
point for discussions on how we can aim to do things better.
But Malakal will have been an even greater failure if we donot tackle, in a constructive manner, UNMISS’s clear inability
to provide protection in the places it is most required to doso. This report is intended to open up a debate within theinternational community – from Juba to New York to member
state capitals – to ensure that the failures of the February
events are discussed and concrete measures put in place
to improve the protection and living conditions for IDPs in
Malakal and other PoC sites in South Sudan.
The IDP population should be able to decide whether to leaveor remain in the PoC. As long as there is no better or safer
alternative, PoCs should not be dismantled and identified
protection and assistance gaps must be addressed.

36 MSF internal review of the February 2016 attack on the Malakal Protectionof Civilians Site and the post-event situation