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WEEKLY NEWSLETTER
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Sudan
Index
Hospital at Li Yubu, near the border with Central African
Republic, cares for lepers and victims of sleeping sickness.
Courtesy Robert O. Collins
Leprosy patients outside the bush dispensary
Courtesy Robert O. Collins
Doctors at a bush dispensary inspecting a pneumonia
patient outside his hut
Courtesy Robert O. Collins
The high incidence of debilitating and sometimes fatal
diseases that persisted in the 1980s and had increased
dramatically by 1991 reflected difficult ecological conditions
and inadequate diets. The diseases resulting from these
conditions were hard to control without substantial capital
inputs, a much more adequate health care system, and the
education of the population in preventive medicine.
By 1991 health care in Sudan had all but disintegrated. The
civil war in southern Sudan destroyed virtually all southern
medical facilities except those that the SPLA had rebuilt to
treat their own wounded and the hospitals in the three major
towns controlled by government forces--Malakal, Waw, and Juba.
These facilities were virtually inoperable because of the dearth
of the most basic medical supplies. A similar situation existed
in northern Sudan, where health care facilities, although not
destroyed by war, had been rendered almost impotent by the
economic situation. Sudan lacked the hard currency to buy the
most elementary drugs, such as antimalarials and antibiotics, and
the most basic equipment, such as syringes. Private medical care
in the principal towns continued to function but was also
hampered by the dearth of pharmaceuticals. In addition, harassed
the Bashir government, the private sector particularly the Sudan
Medical Association, which was dissolved and many of its members
were jailed. Compounding the rapid decline in health care have
been the years of famine during most of the 1980s, culminating in
the great famine of 1991, which was caused by drought and
widespread crop failures in Bahr al Ghazal State and in Darfur
and Kurdufan. The famine was so widespread that, according to
various estimates, 1.5 million to 7 million Sudanese would
perish.
Widespread malnutrition also made the people more vulnerable
to the many debilitating and fatal diseases present in Sudan. The
most common illnesses were malaria, prevalent throughout the
country; various forms of dysentery or other intestinal diseases,
also widely prevalent; and tuberculosis, more common in the north
but also found in the south. More restricted geographically but
affecting substantial portions of the population in the areas of
occurrence were schistosomiasis (snail fever), found in the White
Nile and Blue Nile areas and in irrigated zones between the two
Niles, and trypanosomiasis (sleeping sickness), originally
limited to the southern borderlands but spreading rapidly in the
1980s in the forested regions of southern Sudan. It was estimated
that by 1991 nearly 250,000 persons had been affected by sleeping
sickness. Not uncommon were such diseases as cerebrospinal
meningitis, measles, whooping cough, infectious hepatitis,
syphilis, and gonorrhea.
Even in years of normal rainfall, many Sudanese in the rural
areas suffered from temporary undernourishment on a seasonal
basis, a situation that worsened when drought, locusts, or other
disasters struck crops or animals. More dangerous was
malnutrition among children, defined as present when a child's
body weight was less than 80 percent of the expected body weight
for the age. The weight criterion in effect stood for a complex
of nutritional deficiencies that might lead directly to death or
make the child susceptible to diseases from which he or she could
not recover. A Sudanese government agency estimated that half the
population under fifteen--roughly one-fourth of the total
population--suffered from malnutrition in the early 1980s. This
figure increased substantially during the famine of 1991.
Acquired immune deficiency syndrome (AIDS) was present in
Sudan, primarily in the southern states bordering Uganda and
Zaire, where the disease had reached epidemic proportions. There
had been a steady increase in AIDS in Khartoum, because of the
hundreds of thousands of people emigrating to the capital to
escape the civil war and famine. The use of unsterile syringes
and untested blood by health care providers clearly contributed
to its spread. In spite of the increase in the spread of AIDS,
the Sudanese government in 1991 lacked a coherent national AIDS
control policy.
In the late 1970s and early 1980s, the government undertook
programs to deal with specific diseases in limited areas, with
help from the World Health Organization and other sources. It
also initiated more general approaches to the problems of health
maintenance in rural areas, particularly in the south. These
efforts began against a background of inadequate and unequal
distribution of medical personnel and facilities, and events of
the late 1980s and early 1990s caused an almost complete
breakdown in health care. In 1982 there were nearly 2,200
physicians in Sudan, or roughly one for each 8,870 persons. Most
physicians were concentrated in urban areas in the north, as were
the major hospitals, including those specializing in the
treatment of tuberculosis, eye disorders, and mental illness. In
1981 there were 60 physicians in the south for a population of
roughly 5 million or 1 for approximately 83,000 persons. In 1976
there were 2,500 medical assistants, the crucial participants in
a system that could not assume the availability of an adequate
number of physicians in the foreseeable future. After three years
of training and three to four years of supervised hospital
experience, medical assistants were expected to be able to
diagnose common endemic diseases and to provide simple treatments
and vaccinations. There were roughly 12,800 nurses in 1982 and
about 7,000 midwives, trained and working chiefly in the north.
In principle, medical consultation and therapeutic drugs were
free. There were, however, private clinics and pharmacies, and
they were said to be growing in number in the capital area in the
late 1970s and early 1980s. The ever worsening shortage of
medical personnel and of pharmacenticals had, however, limited
the effectiveness of free treatment. In urban areas, physicians
and medical assistants could be seen only after a long wait at
the hospitals or clinics at which they served. In rural areas,
extended travel as well as long waits were common. In urban and
rural areas, the drugs prescribed were often not obtainable from
hospital pharmacies. In the Khartoum area, they could be obtained
at considerable cost from private pharmacies. In addition to the
problems of cost, however, were those posed by difficulties of
transportation and inadequate storage facilities. In the south,
especially during the rainy season, the roads were often
impassable. There and elsewhere, the refrigeration necessary for
many pharmaceuticals was not available. All of these difficulties
were compounded by inadequacies of stock rotation and inspection.
Members of the country's elite overcame these problems by taking
advantage of medical treatment abroad.
In the mid-1970s, the Ministry of Health began a national
program to provide primary health care with emphasis on
preventive medicine. The south was expected to be the initial
beneficiary of the program, given the dearth of health personnel
and facilities there, but other areas were not to be ignored. The
basic component in the system was the primary health care center
staffed by community health workers and expected to serve about
4,000 persons. Community health care workers received six months
of formal training followed by three months of practical work at
an existing center, after which they were assigned to a new
center. Refresher courses were also planned. The workers were to
provide health care information and certain medicines and would
refer cases they could not deal with to dispensaries and
hospitals. In principle, there would be one dispensary for every
24,000 persons. Of the forty primary health care centers and
dispensaries to be completed by 1984, about half were in place by
1981. In addition, local (district) hospitals were to be
improved. The program in the south was supported by the Federal
Republic of Germany (West Germany), which also provided medical
advisers. In 1981 the program was most advanced in eastern Al
Istiwai Province, but it was too early to assess the effects on
the health of the people, and the program had virtually
disappeared by 1991.
Two local programs for the control of endemic disease were
also undertaken in the late 1970s and early 1980s. One was in the
area of the Gezira Scheme, where it was estimated that 50 to 70
percent of the people suffered from schistosomiasis, a health
problem aggravated by the presence of malaria and dysentery. The
Blue Nile Health Care Project, a ten-year program inaugurated in
early 1980, was intended to deal with all of these waterborne
diseases simultaneously. Because people bathed in and drank the
water in the irrigation canals, which were contaminated by human
waste, a major change in their habits was required, as well as
the provision of healthful drinking water and sanitary facilities
that did not drain into the canals. Diarrheal diseases were to be
treated with rehydration salts that should diminish considerably
the very high rate of infant deaths. As of the 1991, the
persistent civil war and the collapse of the Sudanese economy
made the inauguration of these projects doubtful. Other programs
to provide relief to disease and famine victims in Sudan were
organized by foreign aid agencies' such as the World Food
Program, the Save the Children Fund, Oxford Committee for Famine
Relief, and the French medical group, Médecins sans Frontières
(Doctors Without Borders).
* * *
Extensively detailed and systematic analyses of contemporary
Sudanese society or any large segment of it were not available as
of 1991. Nevertheless, many monographs have been written on
specific Sudanese subjects ranging from anthropology to zoology.
The Bashir government's systematic purge of the civil service,
the professional associations, the academic community, and the
trade unions disrupted and curtailed the flow of statistics and
information from ministries and other government and
nongovernmental organizations. Such research material has also
been impeded by the civil war in southern Sudan and the recurring
famines.
To understand the physical and geographical nature of Sudan,
K.M. Barbour's The Republic of the Sudan: A Regional
Geography remains the standard work, supplemented by J.M.G.
Lebon's Land Use in the Sudan. Because the Nile flows are
crucial to Sudan, they have been extensively studied, producing a
voluminous literature. Information on this subject is synthesized
in two works: John Waterbury, Hydropolitics and the Nile
Valley and Robert O. Collins, The Waters of the Nile:
Hydropolitics and the Jonglei Canal, 1900-1988.
Interpretations of the population situation by several
authors are found in Population of the Sudan: A Joint Project
on Mapping and Analyzing the 1983 Census Data and in articles
in the Sudan Journal of Population Studies.
Most ethnic studies are monographs that describe a particular
ethnic group. Those include Edward E. Evans-Pritchard's The
Nuer and Francis Mading Deng's The Dinka of the Sudan.
For a more recent and sensitive treatment of ethnicity in Sudan,
see articles in The Middle East Journal, autumn 1990; the
perceptive novel by Francis Mading Deng, Cry of the Owl;
or Abel Alier's Southern Sudan: Too Many Agreements
Dishonoured.
Anne Cloudsley's Women of Omdurman: Life, Love, and the
Cult of Virginity, Asma El Dareer's Woman, Why Do You
Weep? Circumcision and Its Consequences, and Hanny Lightfoot
Klein's Prisoners of Ritual: An Odyssey into Female Genital
Circumcision in Africa, are perhaps the three most
informative studies of women's role in Sudan.
Although it is somewhat outdated (he does not discuss the
Muslim Brotherhood, which only appeared in Sudan in the 1950s),
J. Spencer Trimingham's Islam in the Sudan remains the
best reference on orthodox Islam and the Sufi brotherhoods.
Anthropologist Godfrey Lienhardt's Divinity and Experience:
The Religion of the Dinka explores the importance of religion
among the largest ethnic group in Sudan.
The history of education in southern Sudan is covered in
Lilian Passmore Sanderson and Neville Sanderson's Education,
Religion, and Politics in Southern Sudan, 1899-1964. To
assess the contemporary reordering of the education system, one
should examine M. Abdalghaffar Othman's Current Philosophies,
Patterns, and Issues in Higher Education.
The two standard historical studies of the Sudan Medical
Service are Ahmed Bayoumi's The History of Sudan Health
Services and Herbert Chavasse Squire's The Sudan Medical
Service. (For further information and complete citations,
see
Bibliography.)
Data as of June 1991
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