Majok Wutchok, PhD Scholar (Thesis Submitted) | MPH | GPH | BSc Hons

Background: What does it feel like to hold Australian citizenship and still be called a refugee? For thousands of South Sudanese Australians, that question is not rhetorical, it is a daily reality. Acculturation among communities with refugee backgrounds in Western countries involves layered experiences of identity, discrimination, media portrayal, and psychological health, yet empirical research on these processes within Australia's South Sudanese community has been slow to catch up with the lived realities on the ground. Objectives: Drawing on a 2017 community survey, this study set out to map the psychosocial terrain of acculturation among South Sudanese immigrants in Australia, specifically their encounters with racial discrimination, their relationship to Australian media narratives, their psychological stress loads, and the degree to which they felt a genuine sense of belonging in their adopted country. Methods: A structured self-report questionnaire was administered to 105 South Sudanese community members resident in Australia in November 2017, with Likert-scale items completed by 90 respondents. Data were analysed descriptively. The study is theoretically situated within Berry's (1997) bidimensional model of acculturation and Tajfel and Turner's (1979) account of social identity formation. Results: Experiences of racism and discrimination were widespread: three-quarters of respondents (75.28%) reported encountering bullying, racism, or low social judgement. Media victimisation was near-universal 93.26% felt personally targeted by Australian news coverage of their community, and 92.22% reported being labelled refugees despite holding citizenship. These figures stand in sharp and instructive contrast to findings in the social participation domain, where 75.55% felt accepted within multicultural Australian society and 83.33% reported feeling welcome in community activities. Post-migration stress was heavily prevalent, with 84.45% describing themselves as overwhelmed by competing pressures, prominently including the financial obligations of supporting family members still in South Sudan. Conclusions: South Sudanese immigrants in Australia inhabit a contradictory acculturation space simultaneously welcomed and marginalised, belonging and othered. Media stigmatisation and persistent refugee labelling emerge as the sharpest structural threats to community well-being and identity. Policy responses must address these structural mechanisms directly, rather than defaulting to individual-level settlement support alone.

South Sudan presents one of the most complex and severe disease burden profiles in the world. The country faces a 'triple burden' of communicable diseases, malnutrition-associated mortality, and an emerging burden of non-communicable diseases (NCDs), all operating simultaneously within a health system that has been repeatedly shattered by protracted armed conflict, displacement, and humanitarian crises. Malaria alone accounts for 64% of national morbidity. The convergence of an extreme maternal and neonatal mortality crisis, a worsening HIV epidemic, a high tuberculosis burden, neglected tropical diseases, acute and chronic malnutrition, and nascent NCD pressures constitutes a public health emergency of extraordinary complexity. Despite this, comprehensive cross-disease burden synthesis for South Sudan remains virtually absent from the peer-reviewed literature. This systematic review synthesises evidence on the overall burden of disease in South Sudan across communicable diseases (malaria, tuberculosis, HIV/AIDS, neglected tropical diseases), maternal and neonatal conditions, malnutrition, and non-communicable diseases. It evaluates the relative contribution of each domain to total disability-adjusted life years (DALYs), premature mortality, and health system utilisation; examines the health system, political economy, and social determinants that determine burden distribution; and identifies evidence-based public health interventions with the highest potential impact. A systematic search was conducted in PubMed/MEDLINE, Embase, Global Health (CABI), WHO IRIS, the Global Burden of Disease (GBD) 2023 Study database (IHME), and grey literature from WHO, UNICEF, the World Bank, CDC, and the South Sudan Ministry of Health. Studies published between January 2010 and March 2024 reporting disease burden estimates, mortality data, morbidity indicators, or health system performance data for South Sudan were eligible. The PRISMA 2020 framework guided reporting. A narrative synthesis was employed given study heterogeneity. Forty-three studies and institutional reports were included. Communicable diseases overwhelmingly dominate the South Sudan disease burden, with malaria responsible for 64% of national morbidity and a leading cause of all-cause mortality across age groups. Tuberculosis incidence is estimated at 227 per 100,000 population, compounded by a high HIV-TB co-infection rate. The maternal and neonatal mortality crisis with an MMR of 1,223 per 100,000 live births and a neonatal mortality rate of 40 per 1,000 live births constitutes one of the largest contributors to lost DALYs. Severe acute malnutrition, affecting a significant proportion of children under five, functions as both a cause and amplifier of communicable disease mortality. The NCD burden, while less well-characterised, is emerging as a significant source of premature death and disability in urban areas. Health system underdevelopment, sustained conflict, inadequate financing, and workforce shortages constitute the structural determinants of this multi-layered crisis. South Sudan's burden of disease is the product of a health system in crisis, a political economy defined by conflict and resource misallocation, and a population exposed to multiple simultaneous health threats. Addressing this burden requires integrated, cross-disease programmatic approaches, conflict-sensitive health system strengthening, sustained, and coordinated international engagement.