Tuberculosis and the Creative Spirit

Last Wednesday I visited Abu Anga Hospital in Omdurman, which is the only specialist centre for managing ‘Multi Drug-Resistant’ tuberculosis (MDR-TB) in Sudan.

I travelled by bus, which can get rather painfully hot when stuck in the morning traffic. But buses do give you a chance to see many examples of everyday Sudanese ingenuity at work. Today for instance, as I got to my seat, I stepped over a large hole in the floor resourcefully covered with wooden planks and several dozen nails, so that you could barely even see the road below anymore. Another little example – as the conductor started to collect fares, he ran out of pockets and hands and so started to put coins in his ears. Every inch of space on buses is used. An extra row of seats on hinges fold up and down to fill the aisle, so that passengers are packed in like sardines.

You can get on and off the bus at any point. To get the driver to pull over, you just click your fingers and make a “kssss kssss kssss” sound – as if he were a huge cat (maybe if I try to tickle him I can get a journey for free?). Indeed, for some reason that I haven’t yet discovered, many bus drivers seem to wear furry, leopard-print slippers. There are hundreds of these vehicles on Khartoum’s roads, bus-sized tins of sardines driven by huge furry cats.

Further inspired opportunism isn’t hard to find. Driving past one street corner in central Khartoum, you can see what is very clearly a hearse (i.e. a car with a large glass compartment for displaying a coffin on the way to a funeral). It now rests there on the pavement for evermore, and has been plastered bizarrely with blue and yellow advertisements, plus full colour photos, for a male baldness therapy. But my favourite example of this creative spirit, though unrelated to buses or roads, is the pot of strawberry jam in my room. The maverick designers have created a very colourful illustration on the label, which shows not a single strawberry, but does include figs, bananas, mangos, and (my new favourite fruit) carrots.

Whilst this kind of innovative approach to life can be very handy, when it comes to tackling tuberculosis then good intentions and creativity can create problems rather than solutions. 

The bit about Tuberculosis                                                                                             

Tuberculosis is common in Sudan, out of a population of 44 million people there are around 25 000 new cases every year and a total of about 82 000 cases at any one time (WHO 1). In the UK, for comparison, out of a population of 62 million people, there are just over 7 000 new cases a year, with a total of around 9 600 cases at any one time (WHO 2).

Clinics at both Soba Hospital and the Omdurman Hospital for Tropical Diseases have been full of patients with tuberculosis. The bug – mycobacterium tuberculosis (M. TB) – may infect many different parts of the body, and so patients can present to doctors with symptoms involving anything from the head, neck and spine, to the chest, abdomen and skin.

TB care is co-ordinated by the National TB Programme, based in Khartoum. Treatment for patients should be completely or partially subsidised, and there are very clear World Health Organisation (WHO) guidelines for the use of anti-tuberculous drugs.

(Any readers with a slightly shaky interest in TB management close your eyes now for a couple of paragraphs…)

Patients who fall into ‘Category One’ (i.e. patients newly presenting with tuberculosis) receive first-line treatment (two months of HRZE and then four months of HRE – see below for abbreviations).  If all goes well, patients can be completely cured and symptom-free after six months.

However problems arise when patients present with tuberculosis for a second time, after having started a course of treatment at some point in the past. There are generally three reasons for this:

1) Default – The patient did not complete the full course of medication (i.e. they stopped too early) – for example because they start feeling better, or cannot meet the costs of treatment, or supplies of drugs run out.

2) Relapse – the patient completed the treatment course and was cured, but has been re-infected.

3) Failure – the treatment failed to kill the TB bugs

In re-presenting patients with these backgrounds, the M. TB are more likely to have developed resistance to some of the first-line drugs. They then fall into one of two treatment pathways. Patients who (1) default or (2) have relapsed are deemed to be ‘Category 2’ and are prescribed an adapted regimen including streptomycin (see WHO 2010b).  

However if (3) first-line treatment has failed, then there is a strong possibility that the patient is infected with Multi Drug-Resistant Tuberculosis (defined as proven resistance to H+R). This can be investigated with Drug Susceptibility Testing (DST) of the TB bugs, though this is expensive and can be time-consuming. Where DST is not available (like in Sudan, where it is normally used only for research purposes), such patients are assumed to have MDR-TB, and begin treatment with second-line drugs (see note below for more detail on these).

This second line regimen is far more expensive, lasts for longer, and has more potential for causing serious side-effects in the patient. Financial help is available from a WHO subsidiary called the Green Light Committee (GLC), subject to some fairly stringent criteria to do with the use and monitoring of these second-line drugs. Considering the difficulties that many countries face in applying international standards even for first-line drugs, it can be a huge challenge to satisfy conditions for GLC funding. In such countries, the spectre of an MDR-TB epidemic is alarming.

In Sudan, data from 2009 shows that a quarter of previously-treated patients were confirmed as having MDR-TB, much higher than rates in neighbouring Ethiopia (12%) or Uganda (13%) (Eldin et al 2011).  This is where we come back to the beginning and the ‘creative spirit’.

(…and open your eyes again)

TB drugs are not like buses, you cannot get on and off when you want, you must stay on for the full ride (around 8 months for first line drugs). If part of the drug regimen is missing, it cannot just be tacked over and forgotten about. Each drug acts in a slightly different way, and if one of them is missing, then the M.TB may survive and develop resistance to the first line drugs.

Unlike my strawberry jam label, patients need to be very clearly informed about what they are about to consume. TB drugs can have a range of nasty side-effects. Doctors need to educate their patients, to steel them against coming difficulties, and advise them to continue taking their medications and report any side-effects.

But it’s difficult. Poverty and a lack of education are powerful stimulants to ‘creativity’. If you get some side effects, like hepatitis, or losing your colour vision, then without free and easy access to a doctor and some treatment it’s rather tempting to stop taking your TB pills – particularly if your cough has cleared up.

If they have run out of a particular TB drug at your local clinic or district hospital, or it is only available upon payment (as opposed to being free), then both patients and doctors may try to ‘adapt’ drug regimens to make the best of what they have. This has been a problem in Sudan, with patients being hurt by inadequate private sector regulation (Maalaoui 2008).


So what to conclude? I guess many of the things I’ve discussed here affect people all over the world, not just in Sudan – so maybe this should end with some kind of rallying call for global health. Tuberculosis is not like buses or strawberry jam, and health is not just about pills and doctors. It also involves access to healthcare, income levels, education, private sector behaviour, government regulation, international organisations, guidelines and financial programmes – and that’s all before you get down to the individual, creative level. So it’s not all that simple. It involves structures and processes which can appear very difficult to change, and presents some fairly testing challenges. But with a bit of creative thinking in the right places, surely its possible to get it right?



First line drugs: H = Isoniazid; R = Rifampicin; Z = Pyrazinamide; E = Ethambutol; +/- S = Streptomycin

Second line drugs: These include a parenteral drugs such as amikamycin; fluoroquinolones, such as moxifloxacin and levofloxacin; oral bacteriostatic agents such as ethionamide or cycloserine; and ‘group 5’ drugs such as clofazamine and imipenem (see WHO 2011, especially p19, and WHO 2010b p84-7).

DST – Drug Susceptibility Testing

GLC – Green Light Committee

M.TB – Mycobacterium Tuberculosis

MDR-TB – Multi drug-resistant tuberculosis

WHO – World Health Organisation



Eldin et al (2011) Tuberculosis in Sudan: a study of Mycobacterium tuberculosis strain genotype and susceptibility to anti-tuberculosis drugs. BMC Infectious Diseases. 11: 219   –

Maalaoui, N. (2008) Strengthening TB Drug Management in the Sudanese National TB Control Program: In-Depth Review of TB Drug Management –
WHO (2011) Guidelines for the programmatic management of drug-resistant tuberculosis (2011 Update) –
WHO (2010a) The human face of tuberculosis in
WHO (2010b) Treatment of Tuberculosis: guidelines for national programmes. 4th edition
Green Light Committee (WHO subsidiary for tackling MDR-TB and XDR-TB) –
Sudan: Stop TB website – Eastern Mediterrean Regional Office – (Information about the National TB Programme).

(WHO1) WHO Tuberculosis statistics for Sudan:

(WHO2) WHO Tuberculosis statistics for Great Britain and Northern Ireland:


Beans, Grains and Madura Foot: Tasty Food, Tasty Medicine

I’m eating quite alot of beans at the moment.

‘Ful’ is the most widely-eaten meal in Sudan. It is made from black beans, cooked until they are soft, and then eaten with cheese, salt, onions and bread. Fasulya is made from white beans, and is cooked in the pot with some meat on the bone for flavour. They, along with some saucy dishes of potatoes, courgettes and peppers form the basis of diet, supplemented by a rather delicious range of fruit juices and the odd half-chicken.

There are many restaurants around Khartoum, serving a range of Sudanese, regional (as in Egyptian, Lebanese etc) and Western food. However due to burgeoning US sanctions, no American companies (like MacDonalds) can set-up shop here.

Being so ‘ful’ of beans (ho ho ho) can be rather useful for long ward rounds. I’ve seen a number of very interesting clinical cases over the past couple of weeks. Briefly, I’ve seen patients with pellagra (vitamin B6 deficiency with the clinical triad of dementia, diarrhoea and dermatitis); with Guillain-Barre Syndrome where polio and mercury- and lead-poisoning from mining were real differentials; with severe, quinine-resistant falciparum malaria and acute renal failure; with a bad drug-reaction to anti-malarial quinine therapy; and with complicated portal hypertension, resulting in different patients from chronic hepatitis, schistosomiasis and alcoholism. At the clinical meetings, I’ve also heard two interesting case presentations, firstly of a patient diagnosed with Churg-Strauss Syndrome (in the textbook this is late onset asthma, eosinophilia, small vessel vasculitis and a range of other potential features), presenting with joint pain, purpuric rash, dyspnoea, peripheral neuropathy, loss of vision and fever. The second case was a patient brought in from Jezira State, south of Khartoum, with DIC (blood clotting inside the blood vessels) resulting from a cobra bite. All these  cases were of  patients on the general medical ward.

I also spent some time at a specialist institute, the Mycetoma Research Centre, at Soba University Hospital. Mycetoma  is also called Madura Foot, named by British physicians in the Indian city of Madurai, Tamil Nadu State. It is found across the world in the ‘Mycetoma Belt’, stretching around Brazil and Mexico, through Africa and Arabia to India and South-East Asia.

It is a progressive, granulomatous inflammatory disease caused by particular species of bacteria (actinomycetes) or fungi (eumycetes). It still most commonly affects patients’ feet and legs since the most common route of inoculation is via a thorn, carrying the bacteria or fungi, piercing the skin.

It presents as a clinical triad of a painless, subcutaneous (under the skin) mass, sinus formation and the discharge of yellow and red (actinomycetoma) or black (eumycetoma) grains. As it is painless, many patients present relatively late (i.e. several months or even years after inoculation). This can lead to devasting consequences, as the mycetoma may spread beneath the skin and destroy deeper structures such as bones. Following evidence-based management guidelines developed at the centre, patients have a set of diagnostic and staging investigations and may then undergo medical (taking medicines) and surgical (cutting bits out or off) therapy. Over months, patients can make a full recovery, although recurrence rates are high.

Both the Mycetoma Centre at Soba, and the Institute of Endemic Diseases at the University of Khartoum conduct  ground-breaking, cutting-edge research in their respective fields – fields which are comparatively neglected in other, richer countries with different burdens of disease. They are staffed by well qualified, highly motivated and internationally published and respected scientists and clinicians.

But a small footnote to this is the effect of the unilateral US sanctions, renewed annually by the US Senate, despite promises to repeal them after the signing of the peace agreement in 2005. These sanctions do not just prevent MacDonalds from doing business here, but also prevent a spectrum of American industries, including scientific, technological and manufacturing companies from engaging in Sudan. As is so often the case, the sanctions are hurting the wrong people. That’s not cool beans.


Picture Credit: – Akhtar, M., Latief, P. (1999) Actinomycetoma Pedis. Postgraduate Medical Journal (75) 671 

Fahal, A. (2006) Mycetoma: Clinical Monograph. Khartoum University Press. Sudan

Manson, K. (23 July 2012) US Sanctions take toll on Khartoum. Financial Times.

Institute of Endemic Diseases, University of Khartoum –

Mycetoma Research Centre, Soba University Hospital –

Leishmaniasis galore!

My placement at Soba Hospital hasn’t really settled into any kind of rhythm as yet. Its all a little bit haphazard. I’ve spent quite a number of hours just waiting around, wondering if I’m in the right place. In some ways thats reassuringly familiar – its a major educational dimension of just about every placement I’ve had in London too ! But its also rather familiarly frustrating.

So I’ve started taking a little more initiative, and have been creeping (walking) around the hospital, lurking (waiting) in the places where I know my team of doctors might be – the outpatients referral clinic, the male medical wards, procedure rooms and so on – and then jumping out (standing up) and asking if I can join them.

Through this subtle method, I’ve found out the times and specialties of the clinics each morning, and I’ve seen some very interesting patients.

For example I caught the last three patients in the chest clinic today. The first man had pulmonary TB (in the lungs), with bilateral pleural effusions (water in the lungs). The second was a young man with congestive cardiac failure (a bad heart), with a very clear textbook pansystolic murmur (his heartbeat sounded wrong).The final patient was a young lady in her 70s, who had disseminated TB, including pulmonary, lymphadenitis (Scrofula or TB in the lymph nodes of the neck), Pott’s Disease (TB in the spine) and a TB psoas abscess (an abscess in one of the muscles of the leg). All of this can (and would) be treated, although I’m not sure of the prognosis. (Photo of TB Lymphadenitis below taken with permission of patient)

On Mondays and Thursdays I go the Omdurman Hospital for Tropical Diseases, a 20 minute bus journey across the Nile from Khartoum.

Again, each morning starts gently with some stretching and yawning in the consultation room for an hour or so. But when the consultant arrives, its a fantastic learning experience. I think I probably saw more tropical medicine in my first clinic there, than most UK physicians get to see in their whole careers, and after each patient we discuss the case with the doctor.

From a 17 year old boy, with portal hypertension (high blood pressure in the liver’s blood vessels) from chronic schistosomiasis, through patients with TB, malaria, leprosy, suspected HIV, tertiary syphilis, others with schistosomiasis, to three patients with Cutaneous Leishmaniasis. This disease is endemic in parts of Sudan (as is Visceral Leishmaniasis). One of these patients has a typical history. He is a soldier in his 40s, in the Sudanese army, and has been stationed in the south of Sudan (in South Kordofan State). He has three circular, raised, painless lesions on his arm, the largest is around 5×6 cm, with a dry, ulcerated centre. These are caused by the body’s reaction to infection with a species of Leishmania parasite, which is transmitted via the bites of sandflies. If left untreated, they may resolve themselves, but (depending on the species) may also spread further, or cause Mucocutaneous Leishmaniasis (involving the linings of the nose and mouth) (which is worth avoiding). I think there is a multinationally-sponsored programme for Leishmaniasis in Sudan, and so he will be put into this and recieve for free the treatment of Sodium Stibogluconate (Pentostam). Whilst it may be good in the long run, it has to be administered via painful injections (the drug has local toxic effects) – so this man has some tough days ahead.

For me, tomorrow holds a gastroenterology clinc, so lets see what that throws up (sorry for the pun!).