International Activity Report 2003
Sudan

International staff: 127 National staff: 1853

We, the citizens, are suffering. – Diu, from Rupnyagai, Sudan

MSF has been assisting the people of Sudan for over 25 years, offering them primary health care, nutritional relief in times of famine, war surgery when needed, and specialized care and treatment for diseases such as sleeping sickness, kala azar, tuberculosis and malaria. During all of these years, the country has been at war. MSF has spoken out on many occasions about the plight of Sudanese caught in their country's vicious hostilities, a conflict that has been all but forgotten in much of the rest of the world.

Sudan is a place where providing meaningful care is a way to connect both with patients and with the fundamental mission of MSF – aid to the most vulnerable people in their time of greatest need. It is a place where expatriates on their first mission can begin to understand some of MSF's core humanitarian principles. "People on their first mission are exposed to a place of chronic conflict," says Manu Moncada, MSF Head of Mission, "where 30 years of war have left people vulnerable, poor, destitute, dying from any treatable disease. For experienced expatriates who may have worked in more 'developed' contexts on highly specialized programs, coming to Sudan is like coming back to MSF's origins. Places like Sudan, Congo, Chad, Liberia, Afghanistan...these are places where MSF has its roots. They give an essential knowledge of why MSF was created years ago."

Care where there is none

MSF's work in Sudan revolves around providing care where there is none. In and south of Bentiu (Western Upper Nile), in and around Lankien (Western Upper Nile), Malakal (Upper Nile), Kadugli county in the Nuba Mountains, in Akuem, Gogrial, Wau, and Tonj (Bahr el Ghazal), and Kajo Keji (Western Equatoria), MSF supports primary health structures, often offering the only medical services available for entire regions (for example in Akuem, where the MSF-supported hospital is the only health facility in the region, 47,543 consultations were realized and 2,527 people were hospitalized in 2002). Activities include vaccinations, maternity and pediatric services, nutritional therapy, and treatment for diseases such as tuberculosis, sleeping sickness and malaria. The programs vary from place to place, depending on the evolution of needs. In Bentiu, for example, where MSF works with displaced members of the Nuer population, a sexual violence component has been integrated into existing reproductive health services. In Marial Lou a special focus on health training for medical students and staff is raising the level of medical knowledge in this rural region. In the Nuba Mountains, clinics see thousands of patients each year. These are only a few examples of the kinds of assistance MSF carries out in Sudan. Vaccination campaigns to halt frequent epidemics are extremely important. MSF teams have vaccinated thousands of children against measles in the provinces of Bahr el Ghazal, Upper Nile, Western Upper Nile, Western Equatoria and Eastern Equatoria. In July 2003, MSF worked with the World Health Organization to vaccinate over 30,000 people against yellow fever in Budi County (Eastern Equatoria).

Nutrition

Nutritional support is an essential part of many MSF projects in Sudan, where malnutrition is common and cyclical with the seasons. In April 2003, MSF opened a new therapeutic feeding center and three supplementary feeding centers in Akuem (Bahr el Ghazal), where a therapeutic feeding center was already supporting more than 200 children (more than twice the number of children admitted the previous year).

MSF called on the World Food Program to continue general food distribution to ensure that the situation did not deteriorate further. In the capital Khartoum, a therapeutic feeding center in Mayo camp for the displaced cared for 926 children in 2002. In Marial Lou (Bahr el Ghazal), MSF also had to reopen a therapeutic feeding center in March 2003 due to the deteriorating nutritional situation. In Lankien (Upper Nile), MSF opened therapeutic feeding centers in February 2003, admitting several hundred severely malnourished children in the . rst few months. In Dirror district (Upper Nile), MSF has set up an outpatient therapeutic feeding program integrated into various primary health care units, to better serve the area's nomadic people.

In Mygoma orphanage in Khartoum, until recently, nearly 75% of the mostly newborn babies admitted each year were dying. At the request of the government, MSF became involved in May 2003. After dramatic improvements in medical and nutritional care, as well as basic care and hygiene, the death rate plummeted to 9%.

Forgotten diseases

"Each one of my patients was special in their own way," says Dr. Nitya Udaraj, who until May 2003 worked in MSF's sleeping sickness program in Kiri. "My worst moment was in December last year when a 12-yearold girl who had just completed treatment and was due to go home the next day started to have convulsions. In spite of all our efforts, we lost her. This girl had been treated with melarsoprol [an older arsenic-based treatment] – it was just before we changed our treatment protocol to eflornithine. If we had been able to give her eflornithine at the time, her life would have been saved. This experience has taught me that life is unfair – in a world that has advanced so much, too many people are still being left behind." MSF has advocated for the production and use of eflornithine to treat sleeping sickness, and is working to secure long-term production of this medicine, which is now being produced by Aventis (but only through 2006). In Kiri and Ibba (both in Western Equatoria) MSF runs programs to screen for and treat sleeping sickness. In 2002, MSF treated 2,623 people for the disease.

In several areas of Sudan, MSF . ghts visceral leishmaniasis, a parasitic disease common in rural areas and developing countries. Also known as kala azar, this disease is spread by sand flies and is 95% fatal if left untreated. A dramatic increase in cases occurred in Lankien in November 2002. "We see so many people arrive at the clinic each day, more dead than alive," said Dr. José Antonio Bastos at the time. "The state of these people is frightening. They arrive on stretchers after days traveling to reach our health center, very thin and severely anemic." In Malakal, Upper Nile, MSF addresses kala azar while also supporting pediatrics in Malakal hospital. Other activities in this con. ict area include treatment for malaria and tuberculosis. It is no accident that epidemics are frequent here. "There is a clear correlation between these endemic regions and the conflict zones," says Bastos. "Insecurity, malnutrition and mediocre access to health care make natural resistance fragile and create a favorable environment for explosions of epidemics, such as this one." MSF also treats kala azar at a 500-bed treatment center in Um el Kher (Gedaref ), where 4,500 people were treated in 2002 and an estimated 6,500 patients are expected to receive treatment in 2003. Insecurity in Western Upper Nile, previously endemic for kala azar, has prevented access for most of the year, so only 185 patients there received treatment.

MSF has also carried out studies on malaria resistance in many project areas, including Kajo Keji, Malakal and the Nuba Mountains.

Precious water

In MSF-supported structures throughout Sudan, particularly in the south, teams are creating new sources of water, educating communities in hygiene promotion and constructing latrines in schools, markets and cultural centers. In Wau county in southern Sudan, MSF fights guinea worm and onchocerciasis (river blindness), diseases directly linked to water quality.

Hindered aid

While medical needs in Sudan are enormous, humanitarian action is often hindered by the civil war. Despite existing cease. re agreements, MSF staff were repeatedly evacuated from various projects over the past year due to fighting. In December 2002, one local staff member was killed and three were injured when a grenade exploded near the hospital in Ibba. Rebel and government leaders engaged in a sixth round of peace talks this year, an event hailed by some as an important step toward a real peace accord. For most Sudanese, however, the reality on the ground has not changed much. The humanitarian presence continues to be important, for the specific medical care it can bring, and for other things. As Dr. Nitya Udaraj, who finished her first MSF mission in Sudan in May 2003, puts it: "Along with the medical care, you are also there talking to patients. You're telling them you're there 'to listen to you, to be with you."