Extremely high acute malnutrition levels underscore the risk of Famine in Upper Nile State

New field assessment data collected in June and July affirm prior warnings of the risk of Famine (IPC Phase 5) in Luakpiny/Nasir (Nasir) and Ulang counties in Upper Nile State, South Sudan, as issued by the IPC and FEWS NET in June. Emergency (IPC Phase 4) and Catastrophe (IPC Phase 5) outcomes are already ongoing in Nasir and Ulang, and extremely high levels of hunger, malnutrition, and mortality will likely persist until at least the end of the lean season in October, when the rainy season ends and the harvest begins. Global acute malnutrition rates (GAM) among children under five have reached 25.4 and 23.4 percent, respectively, based on mid-upper arm circumference (MUAC) measurements collected in areas accessible to humanitarians. 23 and 11 percent of households, respectively, are experiencing extreme hunger indicative of a ≥50 percent food consumption deficit based on Household Hunger Score (HHS). Conflict between national army and local militia forces, a severe cholera outbreak, and starvation have also resulted in household reports of atypically high mortality, though trauma deaths remain the highest driver. These data suggest the food consumption and acute malnutrition thresholds for Famine (IPC Phase 5)¹ may have been passed in Nasir (Figure 1); however, non-trauma mortality remains relatively low. Conditions in inaccessible areas are largely unknown,² but it is likely that the severity of acute food insecurity is similar to or worse than that observed in accessible areas.

If a scenario materializes in which seasonal floods and a resurgence of violence converge to further isolate the population from sources of food amid high disease prevalence, then Famine (IPC Phase 5) would be the credible alternative outcome in Nasir and Ulang. While evidence of extreme outcomes is more limited in neighboring areas of Upper Nile and northern Jonglei states, similarly severe food security conditions also warrant close monitoring of the risk of Famine (IPC Phase 5) across this region. Even if this alternative scenario does not materialize, food assistance needs are expected to deepen and hunger-related deaths are expected to increase until at least the end of the lean season in October. Government and humanitarian actors must act immediately to restore safe access to the region and rapidly scale up multisectoral food, health, nutrition, and water, sanitation, and hygiene (WASH) assistance to prevent further starvation and death.

Since February, conditions have rapidly deteriorated in Nasir and Ulang, where over 133,350 local and displaced people reside. Violent conflict escalated sharply between February and May, leading to the displacement of around 80,000 people (over 50 percent of the population) and severely disrupting agricultural and fishing activities, market functionality, sanitation and health services, and food assistance delivery. The displacement of local populations and arrival of thousands of refugees and returnees from Sudan into areas with extremely poor WASH facilities have fueled a worsening cholera outbreak in both counties: the cumulative cholera case fatality rate reached 7.8 percent in Nasir and 2.6 percent in Ulang in July, far exceeding the 1 percent threshold that is considered a marker of effective control of cholera outbreaks. Meanwhile, the June/July survey and FEWS NET’s key informant interviews indicate widespread, sustained reductions in access to food, increasing the interaction of hunger and disease. Insecurity prevented the World Food Programme (WFP) from delivering food assistance to the area from March to June after a planned, typical three-month pause (December-February), and continues to impede deliveries by river via Akobo County. In May, a government-funded effort to air-drop food assistance into the region likely had limited impact due to insufficient quantities and reports of communal distrust, possible diversion, and other inefficiencies. In July, WFP also resorted to airdrops, targeting roughly 40,000 people with rations of 7.5 kilograms of sorghum and 0.75 liters of oil per beneficiary, according to key informants. At best, this would provide roughly 30 percent of the population with 50 percent of their daily kilocalorie needs; however, actual coverage is likely lower given the difficulties of effective targeting when deploying airdrops.  

Conditions in Nasir and Ulang are expected to remain dire as the lean season deepens and seasonal flood extent reaches its peak between August and October. Rainfall is forecasted to be above average this year, and analysis by FEWS NET’s partners at USGS and NASA indicates seasonal flooding will likely be similar to or worse than in 2024. Communicable disease prevalence typically surges during the rainy season, especially along the Sobat River corridor where these counties are located. Violent attacks and looting have decimated health and WASH services, forcing Médecins Sans Frontières (MSF) to permanently close its hospital and 13 community-based facilities in Ulang in June. As of July 30, the Greater Upper Nile Region accounts for 21,892 cholera cases and 474 deaths out of a national total of 84,606 cases and 1,477 deaths since the start of the outbreak last September. Cases and deaths are likely higher than reported in conflict-affected areas, where high displacement and limited physical access are undermining disease surveillance and response efforts. The effects of violence, displacement, weather shocks, and disease are also expected to result in a significantly below-average harvest between October and December, underscoring the urgency of immediate intervention to save lives and support households in rebuilding their livelihoods.  

Emergency (IPC Phase 4) outcomes with pockets of households in Catastrophe (IPC Phase 5) are also expected in neighboring counties of Upper Nile and northern Jonglei states, including Baliet, Canal/Pigi, Fangak, Fashoda, Malakal, and Panyikang. Collection of new quantitative evidence on hunger and acute malnutrition is underway, with similar concern that worse outcomes would materialize if conflict, flooding, and displacement further isolate households from sources of food and fuel the cholera outbreak. Across these areas, insecurity and displacement are already restricting physical access to food and cash income. Since May, attacks and sustained aerial bombardments have displaced nearly 38,000 people within Fangak, according to local authorities, and over 3,800 individuals from New Fangak town to Ayod town. An assessment conducted by REACH in May and confirmed by FEWS NET’s key informants in July found that most households in Fangak are currently relying on gathering wild foods and fishing to obtain food, yet access to these options is frequently impeded by insecurity. According to WFP’s distribution reports, insecurity and funding shortfalls are also limiting food assistance deliveries, especially in Upper Nile State (where significant assistance has only reached Malakal and Maiwut) and Canal/Pigi County in Jonglei State. Even in areas where assistance has been delivered, key informant reports suggest it is inadequate to substantially mitigate hunger.

In June, the IPC update estimated over 83,000 people — primarily comprising local and returnee households across northern South Sudan and Greater Pibor Administrative Area and including over 22,000 people in Nasir and Ulang — faced Catastrophe (IPC Phase 5) even after accounting for planned food assistance deliveries. FEWS NET expects the total number of people who need food assistance to prevent Catastrophe (IPC Phase 5) from occurring is likely even higher. The region has experienced consecutive years of severe conflict, flooding, and economic shocks that have eroded the population’s coping capacity. If armed violence resurges to a level similar to or higher than in March-April 2025, and/or if severe flooding in August-October restricts households’ mobility even further, then there is a credible scenario in which levels of hunger, acute malnutrition, and excess deaths would cross the Famine (IPC Phase 5) thresholds. Immediate, large-scale intervention must occur now to prevent this risk. Government authorities and humanitarian actors must urgently restore safe access corridors, dramatically scale up multisectoral assistance delivery, and bolster disease surveillance and treatment capacity.