CSU 115/2011: INFECTIOUS DISEASES BURDEN IN SOUTH SUDAN

Saturday, 2nd of April 2011

The Lancet Infectious Diseases, Volume 11, Issue 4<http://www.thelancet.com/journals/laninf/issue/vol11no4/PIIS1473-3099(11)X7029-9>,
Pages 266 - 267, April 2011

Full text at
http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(11)70083-4/fulltext

Infectious diseases burden in South Sudan

Original Text

Talha Burki<http://www.thelancet.com/search/results?fieldName=Authors&searchTerm=Talha+Burki>

On July 9, 2011, South Sudan will become the world's newest country, in accordance with the wishes of almost 99% of those who participated in January's referendum. Salva Kiir is likely to take on the presidency. He faces an uphill struggle: South Sudan is in a dire state.

90% of the population lives on less than US$1 a day. More than 80% have no toilet facilities whatsoever. Even in the capital Juba—which lacks a working sewerage system—it is difficult to get hold of clean water. In other parts of this vast and fertile country, nonetheless plagued by malnutrition, a mere 1% of children finish primary school. The maternal mortality rate—an estimated 2054 maternal deaths<http://ssccse.org/storage/Key%20Indicators%20Final%2014%2012%2010.pdf>per 100 000 live births—is the worst in the world (small wonder given that 95% of births are not attended by medical staff). In West Equatoria state, almost 20% of children do not live to see their fifth birthday. In the
nation as a whole, more than one in ten children die before they reach the age of 1 year.

There is a huge disease burden. The biggest childhood killer is malaria; some regions of South Sudan are hyperendemic for the disease; others are holoendemic. Less than 10% of children stricken with malaria receive treatment within the first 24 h of the fever presenting itself. The tuberculosis burden is unknown, but control efforts cover less than 50% of the country, which has an estimated population of 7·5—9·7 million. The UN Population Fund (UNFPA <http://sudan.unfpa.org/souther_Sudan/index.htm>) has described South Sudan as an “HIV/AIDS time-bomb”. Here too prevalence is unknown; estimates suggest 1—8% of the general population and 3·1% of those aged 15—49.

The reason behind all this is war. First there was a lengthy conflict with the north. This initially began in 1955 and lasted until 1972. 500 000 people died, mostly civilians. A ceasefire, of sorts, prevailed until 1983,
when hostilities broke out again; this phase of the war—which lasted until a Comprehensive Peace Agreement was signed in 2005—saw almost 2 million people die, either from the fighting itself, or during the drought and famine that the fighting brought.

Unrest has continued in South Sudan since the peace accord. Equatorial states have been subject to raids from the Lord's Resistance Army, sundry bands of armed militias have terrorised local populations, and the northern states have seen the eruption of tribal conflicts. It has led to the displacement of some 500 000 people over the past 2 years. In 2009, for example, the village of Lekwongole was caught up in fighting between tribes, forcing 5000 people to flee to Pibor County, which soon afterwards saw an
outbreak of cholera.

Every now and again, the ongoing violence forces aid organisations to close down—a huge problem in a country where non-governmental organisations (NGOs) provide 86% of health services. In 2009, Médecins Sans Frontières (MSF) had to suspend its work in a health centre in Jonglei state—which served around
30 000 people, treating malnutrition and providing antenatal care and vaccinations—after harassment from militias. In February of this year, a hospital in the same region was forced into a full-scale evacuation after
the surrounding area became too dangerous, Jorge Alvar (WHO, Geneva, Switzerland) told TLID. The clinical officer, a newly appointed local man, tendered his resignation.

“It's a major challenge to build a new state in a country which has been ravaged by war for so long”, notes Koert Ritmeijer (MSF Holland, Amsterdam, Netherlands). “Especially in health care, but also in infrastructure, there is nothing in South Sudan. It really has to be built up from scratch.” Take the roads; work recently began on paving the country's first highway, but otherwise there are only dirt tracks. And during the lengthy rainy season—which starts in April or May—these become impassable. “South Sudan becomes one huge swamp”, said Ritmeijer “supplies can only be delivered by plane.” Some parts of the country are inaccessible for 8 months of the year.

“Primary health care is very difficult”, explains MSF's Elin Jones. There is an acute shortage of skilled workers—one doctor per 100 000 people—and MSF reckons that 75% of the South Sudanese do not have access to primary health care. Upper Nile and Jonglei states are part of the kala-azar belt. The
disease is entering a new epidemic phase. 2010 saw about 10 000 patients report for treatment—eight times as many as the previous year. Mortality is 5%, much improved on the near 100% rate that attended the devastating outbreak in the mid-1990s. But this reduction in mortality is among those who can get to treatment centres. 2 years ago, MSF developed a model for estimating the number of infected patients who were unable to access treatment—nearly all of whom would die—and came up with a figure of 50%.

“These are the invisible deaths”, points out Ritmeijer. Needless to say, other diseases carry their own toll of invisible deaths in the country, especially given that in 2010, 83% of South Sudanese children were not fully
immunised.

A particularly pressing problem is likely to be that of the 3 million South Sudanese who fled their homes to escape conflict in the past 30 years. They might have escaped to the north, or to neighbouring countries such as Kenya or Ethiopia. Around 200 000 returned for the referendum, and Alvar suggests that a further 800 000 will return this year. “Many returnees are coming from areas that are hardly endemic for malaria, and are not endemic for kala-azar”, outlines Ritmeijer. “They're settling in endemic areas, but they've developed no natural immunity against those diseases.” Issues of nutrition and overcrowding could spur outbreaks of diarrhoeal sicknesses.

The spread of HIV also seems likely. And of course large groups of unvaccinated individuals are susceptible to diseases such as measles, which broke out among returnees in the state of Warrap late last year.

Ritmeijer has especial worries over tuberculosis. In northern Sudan, tuberculosis-treatment services are poor. Patients collect drugs from the marketplace and frequently do not complete their treatment. “We expect that there will be a high prevalence of drug-resistant tuberculosis with returnees bringing drug-resistant strains into communities in the south, which already has a high transmission of tuberculosis”, Ritmeijer explains.

“This will create a huge problem for the future.”

Experts are also concerned over funding. South Sudan is massively reliant on donors. MSF has been critical of what it perceives as a sluggish international response to the country's immediate humanitarian needs since the Comprehensive Peace Agreement. Ritmeijer argues that donors have not stuck to their pledges to fund Sudanese health care.” Very little money has become available. A lot of health NGOs had to leave South Sudan, or reduce their activities.” He adds that the inadequacy of recent donations has been
coupled with a sense that since the country is technically at peace, it no longer requires emergency health care and humanitarian aid. “During the years of the peace agreement fewer NGOs became involved in health care than there were during the war”, he concluded.

Nevertheless, Ritmeijer is cautiously optimistic about the prospects for what will become the world's 193rd country. He points out that during the war health care was actually targeted by fighting factions. This year, South Sudan can expect around $1 billion in oil revenues, some of which could become available for health care. Moreover, if the country is properly managed, it is capable of attending to the nutritional needs of its
population.

It is certainly crucial that South Sudan establishes a functional infrastructure as quickly as it can. This would ease supply problems and entice medical staff to work outside the urban centres. In terms of health
care, Ritmeijer advises focusing on the phalanx of major diseases that affect the population: malaria, diarrhoea, respiratory infections, maternal health, and vaccine preventable diseases. “I don't expect that the Ministry of Health will also be able to invest in providing quality services for kala-azar, HIV, or tuberculosis” he said.

Regardless, the country's health care is likely to remain dependent on NGOs for the foreseeable future. But whether South Sudan can begin to tackle some of its problems is not solely contingent on donations from abroad. “It's not only a question of money”, says Ritmeijer, “we must ensure that money is supported by good governance.” He warns that new states are particularly vulnerable to corruption.

“The situation in South Sudan is still unstable and unpredictable”, adds Alvar. “How the different groups accept democracy is most important—they've been fighting each other”. Elin Jones is worried that food security could deteriorate, which would have a knock-on effect on diseases such as kala-azar. MSF reports an increasing incidence of malnutrition for 2010, up 20% on 2009.

There is, however, one cause for genuine hope. Independence for South Sudan could spell the end for guinea worm disease. It has been targeted by WHO for eradication, and thanks to the work of the Carter Centre, such an outcome looks eminently achievable. Last year, there were 1785 cases, 1690 of which
were in South Sudan (the handful of other cases occurred in Ethiopia, Mali, and Ghana). This is a reduction of almost 99% since the mid-1990s, and it has come about entirely through education (there is no cure for guinea worm disease). Every one of last year's Sudanese cases occurred in a village affected by conflict. If independence brings stability, then campaign staff should be able to monitor patients, and ensure they do not infect others by allowing the worm to enter drinking water and bathing pools. This would be an encouraging start, at least.

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