Health in Sudan

History of the medical research and providing professional medical health care in Sudan could be traced back to 1903, when The Wellcome Research Laboratory was established in Khartoum as a part of the Gordon Memorial College.[3]

The reorganization of the services dealing with scientific research in the Sudan in April 1935 made the Stack Medical Research Laboratories the official research organ of the Sudan Medical Service, and Dr. E. S. Horgan-Archibald's successor-was appointed Director to the laboratories and Assistant Director (Research) Sudan Medical Service. The Wellcome Tropical Research Laboratories ceased to exist as such, but thereafter continued to operate as the Wellcome Chemical Laboratories; and after being placed under the control of the Agricultural Research Service for the following four years, they were transferred back to the Sudan Medical Service in 1939.[4]

Sudan, with an increasingly ageing population, faces a double burden of disease with rising rates of communicable and noncommunicable diseases.

• The Sudan Household Survey 2010 showed that 26.8% of children aged 5 to 59 months had diarrhea, while 18.7% were sick due to suspected pneumonia in the two weeks before the survey was done.
• Protein energy malnutrition and micronutrient deficiencies continue to be a major problem among children under 5, with 12.6% and 15.7% suffering from severe wasting and stunting, respectively. The most common micronutrient deficiencies are iodine, iron and vitamin A.
• Concerning the MDGs, still 73 [range: 59–88] (Both sexes) out of every 1000 children born do not live to see their fifth birthday.[5] The Maternal mortality ratio per 100 000 live births estimated at 730 [380–1400] deaths per 100 000 live births in 2010.[5]
• The MDG target for malaria has been achieved, although it remains to be a major health problem. In 2010, malaria led to the death of 23 persons in every 100 000 population; while in total over 1.6 million cases were reported.
• The annual incidence of new TB cases for 2010 is 119 per 100 000, half of them smear-positive. TB case-detection rate of 35% is well below the target of 70%, but treatment success rate at 82% is close to the WHO target of 85%. With respect to HIV-AIDS, the epidemic is classified as low among the general population estimated prevalence rate of 0.24% with concentrated epidemic in two states.[1]

Water is a main cause to each of these.

• The vital statistics below include South Sudan.[6]

Source: UN World Population Prospects[7]

The health services provided in Sudan follow the classical three basic arrangements, primary, secondary, tertiary health care. The primary health care is the first encounter for the patients and includes as mentioned in the organizations the dressing stations, dispensaries, primary health care units and health centers, the latter forms the referral point from the lower facilities.[2] The importance of PHC is that it provides the essential care to all and improves the health status of the community as a whole. In 2003 a package of health care services was introduced to the PHC facilities. This package included vaccination of children, nutrition, reproductive health (RH), integrated management of childhood immunization (IMCI), management of common diseases and prescribing the essential medications.This line of care is almost entirely provided by the public sector.

On the other hand, both public and private sectors work together in the provision of the secondary and tertiary lines of care. Though, the private sectors has been functioning mainly in urban areas.Screening, diagnostic, and therapeutic services are being provided in both health centers and hospitals as secondary care, where major surgical, rehabilitative, and subspecialized tertiary care is being provided mainly at larger public hospitals including teaching hospital, private hospitals, and in specialized centers. These hospitals and centers accepts patients without being referred from the lower facilities indicating a poor referral system.[2]

In the last decade, the number of hospitals has been an increasing trend and it continues to be.It is agreed that a core component of primary health care is health promotion which is limited in Sudan while health problems suitable for health awareness campaigns are present including the enormous communicable diseases, malnutrition, and even the non-communicable diseases.[2]Furthermore, in regard to the services provided at the PHC, these services are not achieving optimum utilization rates. For example, only 81.6% of PHC units provide vaccination for children and 67.3% provide family planning services. Although, these numbers are improving in comparison to the past, they are not ideal and further emphasis on coverage, availability, and accessibility is required.Another notifiable weakness regarding PHC, is that unlike the secondary and tertiary services that are increasing in number, PHC units are decreasing either due to cessation of function or in comparison to the population growth.[2]

Malaria is one of the most deadly and epidemic diseases that affects Sudan and the African region in general. This is mainly due to the high temperatures and inadequate infrastructure regarding drainage and sewer systems. Stagnant and still water that builds up and is not drained becomes a reservoir and breeding ground for mosquitoes. This leads to their large numbers in the affected area. Still, the effect and burden of malaria may be somewhat underestimated. In 2007 a study was conducted in Sudan which revealed underreporting of malaria episodes and deaths to the formal health system, with the consequent underestimation of the disease burden.[10]

Children less than five years of age had the highest mortality rate and DALYs, emphasizing the known effect of malaria on this population group. Females lost more DALYs than males in all age groups, which altered the picture displayed by the incidence rates alone. The epidemiological estimates and DALYs calculations in this study form a basis for comparing interventions that affect mortality and morbidity differently, by comparing the amount of burden averted by them. The DALYs would mark the position of malaria among the rest of the diseases, if compared to DALYs due to other diseases. Uncertainty around the estimates should be considered when using them for decision making and further work should quantify this uncertainty to facilitate utilisation of the results.[10] More epidemiological studies are required to fill in the gaps revealed in this study and to more accurately determine the effect and burden of the disease.

The World Health Organization was notified by the Federal Ministry of Health of Sudan of an outbreak of yellow fever in 2012 which affected five states in Darfur.[11] The yellow fever outbreak resulted in 847 suspected cases including 171 deaths. To reduce the spread of yellow fever, The World Health Organization worked with The Federal Ministry of Health in Sudan on a vaccination campaign that halted the outbreak.[12]

Nodding disease or nodding syndrome is a new, little-known disease which emerged in Sudan in the 1980s.[13] It is a fatal, mentally and physically disabling disease that only affects young children. It is currently restricted to a small region of southern Sudan.

Sudan is bordered by seven countries in which HIV/AIDS is highly prevalent, therefore Sudan is susceptible to an increase in HIV/AIDS prevalence. In 1986, the first case of HIV and AIDS in Sudan was reported.[14] Sudan's HIV epidemiological situation is currently classified as a low epidemic, as of July 2011.[15]

The main mode of transmission worldwide is through heterosexual contact, which is no different in Sudan.[14] However transmission varies in different countries, in the United States, as of 2009, men who had sex with men was the main mode of transmission, accounting for 64% of all new cases.[16] In Sudan however, heterosexual transmission accounted for 97% of HIV positive cases.

As of January 5, 2011, the Adult(15-49) prevalence in Sudan was found to be 0.4%, an estimated 260,000 were living with HIV and there were 12,000 HIV related annual deaths.[17] A population based study was conducted in 2002 which estimated the sero-prevalence to be 1.6%. According to recent studies, the HIV and AIDS prevalence in Sudan among blood donors has increased from 0.15% in 1993 to 1.4% in 2000.[14] Sudan is considered to be a country with an intermediate HIV and AIDS prevalence[14] by the World Health Organization(WHO).[18]

HIV/AIDS related-services have been introduced in all the states of Sudan. Free services have been provided across the country, which have significantly improved the life of people living with HIV.[15]

• HIV/AIDS estimates as of 2014[19]

Sudan has been polio-free since 2009 but is vulnerable to transmission from refugees from high-risk countries. A polio vaccination campaign was launched in 2018, supported by the World Health Organization. 5 million doses have been provided.[20]

Sickle cell anemia is an inherited blood disorder due to the substitution of valine to glutamic acid in position number 6 in the β-globin chain, this will cause deoxygenated sickle hemoglobin to form polymers that ultimately destroy red blood cells [21]. In Africa, sickle cell disease (SCD) is reported to be associated with a very high rate of childhood mortality, 50%-90%, yet there is a lack of reliable, up-to-date information [22]. In Sudan, sickle cell disease was first reported in 1926 by Archibald [23]. The disease is considered one of the major types of anemia especially in western Sudan where the sickle cell gene is frequent [24] Sickle cell disease is the major haemoglobinopathy seen in the Khartoum, the capital of Sudan. This may be attributed to the migration of tribes from western Sudan as a result of drought and desertification in the 1970s and 1980s, and the conflicts in Darfur in 2005. The rate is higher in Western Sudanese ethnic groups particularly in Messeryia tribes in Darfur and Kordofan regions.[25][26]

The Federal Ministry of Health issues an annual health statistical report that includes data on causes of hospital mortality. Over the past decade, cardiovascular disease has been consistently reported in the top 10 causes of hospital mortality, with malaria and acute respiratory infections as the first two causes.[27]

The SHHS reported a prevalence of 2.5% for heart disease. Hypertensive heart disease (HHD), rheumatic heart disease (RHD), ischaemic heart disease (IHD) and cardiomyopathy constitute more than 80% of CVD in Sudan. Hypertension (HTN) had a prevalence of 20.1 and 20.4% in the SHHS and STEPS survey, respectively. There were poor control rates and a high prevalence of target-organ damage in the local studies. RHD prevalence data were available only for Khartoum state and the incidence has dropped from 3/1 000 people in the 1980s to 0.3% in 2003. There were no data on any other states. The coronary event rates in 1989 were 112/100 000 people, with a total mortality of 36/100 000. Prevalence rates of low physical activity, obesity, HTN, hypercholesterolaemia, diabetes and smoking were 86.8, 53.9, 23.6, 19.8, 19.2 and 12%, respectively, in the STEPS survey. Peripartum cardiomyopathy occurs at a rate of 1.5% of all deliveries. Congenital heart disease is prevalent in 0.2% of children.[27]

In Sudan, the national prevalence of diabetes in adults is 7.7% and is expected to reach 10.8% in 2035.[1]There were  over 2.247.000 cases of diabetes in Sudan in 2017.[28]

The decay-missing-filled index are indicators used to determine the status of dental caries. The table below is from a 1993 report reporting on such data.[30][32]

* A total of 275 pre-school children in kindergartens from Khartoum were studied.

[36]

This malformation showed a prevalence of 0.9 per 1000 in Sudan. More girls are affected than boys, with a male:female ratio of 3:10. (44% cleft lip with cleft palate, 30% only cleft palate, and 16% cleft lip alone).[37]