The Sudanese Medical Exodus

Someone in Khartoum said to me that Sudan has no middle class. Was he right? Is Sudan a socialist idyll, where contentment, fraternity and rational distribution flourish under a red-hot sun?

Well no, Sudan is in fact real country, not some rosy proletarian fantasy. My friend went on to declare that Sudanese society consists of just two classes; there are the elites, sitting up high on top of their mountain, and then ‘everyone else’ living down beneath their feet. Now I don’t think that either of us believed literally in this two-class hypothesis. But whether there are really two or twenty-two social strata in Sudan is not so important for the purposes of this post. Rather it is the feeling which prompted my friend, a doctor, to make his comment. It is this same feeling, of disaffection and disempowerment, which drives one of Sudan’s continuing tragedies, the exodus of health-workers. This blog explores this topic firstly through some facts and figures, to get an idea of the scale of things, and then secondly through considering what social status means across different societies and what some of the ‘push and pull’ factors there are for doctors in Sudan.

1 – In Facts and Figures: Education & Emigration

It wouldn’t be an exaggeration to say that almost every medical student or doctor to whom I spoke on my elective expressed a wish to leave Sudan and to work or study abroad. Most people knew someone who had already left and gone to the UK, US, Europe or to one of the states on the Arabian Peninsula such as Kuwait, UAE or Saudi Arabia. Indeed the issue is so widely acknowledged that one of the Sudanese newspapers even carried an editorial on the topic whilst I was there (Sudan Vision 26th September 2012).

So what is the real scale of this? (Here follows five short paragraphs involving one or two statistics which aim to clarify the scale of the ‘exodus’.)

In a study published in 2005, Mullan lists an ‘emigration factor’ for Sudan of 11.1, i.e. 11.1% of doctors who qualified at home now work abroad in either the UK, US, Canada or Australia (Mullan, NEJM 2005). This proportion is likely to be much higher in reality. Mullan does not consider migration eastwards across the Red Sea, or indeed to Ireland where there are reportedly 600 Sudanese doctors registered with the Irish Medical Council (Ali et al 2012). However, using this estimate of 11.1% yields a minimum figure of 1250 practicing doctors who have left Sudan (anyone who wants to see my working is welcome!). Add to this figure those doctors working on the Arabian Peninsula, in Ireland and those within Sudan who have left the profession before retirement-age for whatever reason and you’re looking at a high number of doctors lost to the Sudanese medical system.

Statistics from 2008 show that Sudan had a total workforce of 10,000 doctors serving a population of 35 million people, which yields a workforce density of 0.28 physicians per 1000 population (which is fairly low) (WHO Global Atlas of Health Workforce). For comparison, the UK has a total of around 160,000 doctors serving a population of 62 million, yielding a workforce density of 2.6 physicians per 1000 population (OECD 2011; Global Atlas of Health Workforce2010).

To increase Sudan’s ‘physician density’ (taking into account an annual population growth rate of 2%), Sudan would need to have a net increase of at least 200 doctors per year (i.e. a positive balance between the number of newly-graduated doctors entering the system and those emigrating or retiring out of it) (UN Data).

This might sound fairly easy and indeed there are grounds for optimism from a statistical point of view. There are reportedly 2-3000 medical graduates each year from around 30 Sudanese medical schools, following two decades of rapid growth in the medical education sector (Fadlalla et al 2012; Ali 2009).

However, there are no available data on the rate of medical migration i.e. how many doctors leave each year, so it is impossible to predict the speed with which physician density in Sudan may increase.

Furthermore an increased number of medical graduates doesn’t automatically equate to more doctors. The percentage of government resources spent on health has decreased between 1995-2010, whilst total government resources are diminished following the separation of South Sudan (WHO Global Health Expenditure Atlas). Indeed I met graduates who had waited for up to a year for a House Officer position. So whilst more graduates might help to fill Sudan’s hospitals, they can also lead to a greater pool of young professionals looking for work, and considering emigration.

2 – The Faces and Feelings: Status and entitlements

Photo of London by Jason Hawkes

So much for the facts and figures, what about people and their motivations? One of the doctors I worked with was a fairly typical example, bright, competent and independent – a pretty good doctor to have in your health system. And she wanted to leave. Her brothers worked in the UK, cousins in the US, an uncle in Kuwait and several friends were now in Saudi Arabia. We discussed her own options outside Sudan; the US medical licensing exams (STEP 1, 2 & 3) are hard and require an extended period of intense studying (on top of making a living). The visa requirements for entry to the UK have tightened over the last few years, and include rigorous English language-, and a different set of medical-, exams. It’s easier to get a visa and a license to practice in another Arabic country, but career progression is slower, as employment contracts for junior doctors often include a commitment to an extended period of work at a junior level.  So wherever a prospective émigré chooses, they must jump, spin and study their way through a whole series of hoops, hurdles and exams without a guarantee of success (e.g. gaining a visa or a job) at the end. So why go through it?

This is where we come back to my friend’s feelings about social relations. On the one hand, students and doctors wanted me to share in their strong affection for their people, country and it’s potential. On the other, they felt strongly that staying in Sudan themselves meant accepting for some years a life of limited opportunity and social stasis.

Without getting too theoretical, there are many ways to analyse a person’s societal status. In simple terms, you might consider the size of their bank balance, house or car. At the more sophisticated end is Amartya Sen’s Entitlement theory which was developed in the context of famine. Here, an individual’s status is effectively defined by their ‘entitlements’ which include all the means they can access, whether legal, financial, moral or whatever-else, to use in getting what they want (Sen 1981). Simplifying and applying this beyond a famine setting to society in general, a person’s status might be defined by all the means and opportunities they have to improve their professional or domestic situation – their chances of gaining a better quality of life.

Graduating from medical school in Sudan does not mean the same things as it does in the UK. In Britain, I don’t think it would be too controversial to say that medical qualification signifies an individual’s accession to a comfortable middle-class status. UK medicine (whatever doctors might grumble), is a well-rewarded profession. It carries a decent salary, robust degrees of domestic comfort and job security, and opportunities for career advancement. It also generally means admission to one of the medical unions, such as the British Medical Association (BMA) or the Medical Defence Union (MDU) which act to protect doctors’ interests. So for UK doctors, entitlements (as defined above) come in all shapes and sizes; financial resources, career mobility (i.e. you can progress up the career ladder) and legal support.

And isn’t this the way it should be? On the one hand, quite apart from the fact that doctors are all delightful people, they actually provide a very valuable service to their community. Shouldn’t they be afforded the advantages proportionate to this social worth? On the other hand, aren’t doctors merely performing their job like another other honest citizen and so should be paid on the same scale? Does a doctor working nine-to-five in an air-conditioned clinic have a harder job than the man who works day and night washing cars? It would be an abuse of doctors’ position to demand more money, no? In fact this second stance is perhaps not too far away from where things are in Sudan.

A hard-working car-washer can reportedly earn more in a month than a junior doctor (around US$500 or ~SDG£95/day). After their first year as a House Officer, Sudanese doctors must then take a pay cut and work without a contract as a ‘General Practitioner’. Career progression to the post of registrar depends on studying hard, saving-up the entrance fee for a further set of exams (e.g. the UK MRCP or MRCS exams) and doing enough shifts to stay afloat. Whilst Sudan does have its own “Medical Specialisation Board”, openings for postgraduate training are acknowledged to be limited and poorly funded. So it’s quite possible to get stuck at this level for several years (although once at the Consultant level remuneration can increase exponentially as opportunities for private sector work arise).

Since they may be unable to get a foot on the property ladder at this stage, doctors often live in hospital accommodation – which may be subsidised or even free – unless they can live with family. Whilst this might be a cheap, convenient and communal option, it is not (to put it one way) exorbitantly luxurious. Neither are the parking nightmares lived by UK healthcare staff a feature in Sudan, since relatively few doctors have cars.

As for legal rights, medical organisations do not function as trade unions and so do not engage in any political action. In 2010-11 doctors’ strikes were organised independently over unpaid salaries, working conditions and accommodation. These were met bluntly with threats, arrests and imprisonment, with no subsequent action taken by the government to address doctors’ grievances (McDoom 2010; Sudan Radio Service 17 March 2010; Sudan Tribune, 18th March 2010, 3rd June 2010, 17th May 2011). The government response to this was perhaps tempered by remembrance of the 1985 revolution overthrowing Sudanese President Jafaar Al-Nimieri, which involved professional unions of doctors, lawyers, bankers and academics.

So overall, many of the entitlements that define UK doctors’ status are rather different in Sudan – whether this is in terms of a salary, a house, a car, job security, professional training and promotional opportunities or legal protection. So are doctors so different from car-washers in Sudan?

Perhaps the defining status symbol is a travel visa. Ultimately, medical knowledge and skills provide greater weight to a visa application than a bucket and sponge. Whilst migration may be difficult for Sudanese doctors, it remains possible. And the significance of a visa application is that it is the first step in reaching out towards the opportunities that exist in other countries.

Solutions (?) & Conclusions

The Sudanese Minister for Health, Dr Bahar Idris Abu Garda, is understandably keen to retain doctors within the health system. International solutions have been proposed including tightening immigration restrictions in countries such as the UK, ethical recruitment policies (i.e. not advertising NHS or BUPA vacancies in Africa) and paying compensation for training costs and labour value to the government of an immigrant. Such ‘solutions’ are likely to be little more than fripperous baubles, glittering briefly for those who glance at this issue, but lacking any impact on the root problems.

Surely the only real solution (and the hardest to achieve), is to begin lowering the mountain, to create opportunity, increase social and professional mobility and to close the gap between the elites and ‘everyone-else’. In other words, it would be better to try and make people want to stay, rather than just preventing them from leaving.

Maybe this starts with greater and more structured investment in the health system. There have been significant achievements already; undergraduate medical education has grown rapidly over two decades. Now postgraduate training and employment capacity need the same level of attention.

Quite how this is to be achieved is difficult to conceive, given Sudan’s reduced national income (since the secession of South Sudan), its high defence spending and the burden of international debt. But the green shoots of regeneration are present in the new cohorts of medical graduates and doctors coming through, with their desire to improve their country. The best response is not to decrease opportunities to leave, but rather to increase opportunities for those who stay.

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References

Agwu, K. Llewelyn, M. (2009) Compensation for the brain drain from developing countries. The Lancet (373) 1665 – 1666

http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673609609272.pdf

Ali, Z. (2009) The third international conference on medical education in Sudan: lessons about undergraduate medical education. Sudanese Journal of Public Health. 4 (4) 411-413

www.sjph.net.sd/files/vol4i4/SJPH-vol4i4-p411-413.pdf

Ali, Z., El-Higaya, E., Ibrahim, N., Elmusharaf, K., Shadad, A., Elshafei, M. Ahmed, M. (2012) Migration of Sudanese Doctors: Dynamics and Opportunities – Conference Report. Sudanese Medical Association UK and Ireland. 9th June 2012.

www.slideshare.net/SMAUKI/sma-uk-ireland-galway-conference-report-2012

Chen, L.C., Boufford, J.I. (2005) Fatal Flows — Doctors on the Move. New England Journal of Medicine. (353)1850-1852
www.nejm.org/doi/full/10.1056/NEJMe058188

Commission on the Social Determinants of Health (2010) Closing the gap in a generation: Health equity through action on the social determinants of health. WHO. WHO/IER/CSDH/08.1

http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf

Fadlalla, M., Jaffar, R., Abdalgadir, N. (2012) Strategic analysis of the surgical internship in Sudan. Sudan Journal of Medical Sciences. 7 (1) 35-40

www.ajol.info/index.php/sjms/article/view/78155

McDoom, O. (2010) Sudanese security forces beat doctors in protest march. Reuters.

http://uk.reuters.com/article/2010/06/03/idUKMCD332528._CH_.2420

Mohammed, G.K. (2007) Financing health care in Sudan: Is it a time for the abolishing of user charges?  Sudanese Journal of Public Health. 2 (1) 38-47

www.sjph.net.sd/files/vol2i1p38-47.pdf

Mullan, F. (2005) The Metrics of the Physician Brain Drain. New England Journal of Medicine.  (353) 1810-1818
www.nejm.org/doi/full/10.1056/NEJMsa050004#t=article

OECD (2011), Health at a Glance 2011: OECD Indicators, OECD Publishing

www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2011_health_glance-2011-en;jsessionid=9tamks2ta7noa.delta

Sen, A. (1981) Poverty and Famines: An Essay on Entitlement and Deprivation (Oxford, Clarendon

Press)

Sudan Radio Service (17 March 2010) Doctors Strike in Northern Sudan.

www.sudanradio.org/doctors-strike-northern-sudan

Sudan Tribune (18 March 2010) Sudan’s Bashir threatens to fire doctors on strike over pay.

www.sudantribune.com/spip.php?article34458

Sudan Tribune (3 June 2010) Police in Sudan clash with doctors pushing for nationwide strike.

www.sudantribune.com/spip.php?article35276

Sudan Tribune (17th May 2011) Sudanese doctors go on strike.

www.sudantribune.com/spip.php?article38935

Sudan Vision (26th September 2012) The Brain Drain.

http://news.sudanvisiondaily.com/details.html?rsnpid=214526

UN Development Programme (2011) International Human Development Indicators. Sudan Country Profile. http://hdrstats.undp.org/en/countries/profiles/SDN.html

WHO (2006) Health System Profile: Sudan. Regional Health Systems Observatory – Eastern Mediterranean Regional Health System Observatory.

http://hinfo.humaninfo.ro/gsdl/healthtechdocs/en/m/abstract/Js17310e/

WHO. (2012) Global Health Expenditure Atlas. W 74

Available at www.who.int/nha/country/sdn/en/www.who.int/nha/atlasfinal.pdf

Websites

BUPA – www.bupa.co.uk/

General Medical Council (UK) – Postgraduate Education – www.gmc-uk.org/education/postgraduate.asp

Home Office – UK Border Agency – www.ukba.homeoffice.gov.uk/visas-immigration/

Sudan Medical Specialisation Board – www.smsb.gov.sd

United Nations Data. Sudan Country Profile – http://data.un.org/CountryProfile.aspx?crName=SUDAN

United States Medical Licensing Examination – www.usmle.org/

WHO. Global Atlas of Health Workforce.

http://apps.who.int/globalatlas/DataQuery/default.asp

WHO. Sudan Country Profile

www.who.int/countries/sdn/en/

World Bank. Data, By Country – Sudan.

http://data.worldbank.org/country/sudan

WHO. Global Health Expenditure – Table of key indicators, sources and methods by country and indicators

http://apps.who.int/nha/database/StandardReport.aspx?ID=REP_WEB_MINI_TEMPLATE_WEB_VERSION&COUNTRYKEY=84559

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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).

Conclusions

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?

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Abbreviations:

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

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Documents:

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   – www.biomedcentral.com/1471-2334/11/219/

Maalaoui, N. (2008) Strengthening TB Drug Management in the Sudanese National TB Control Program: In-Depth Review of TB Drug Management – http://pdf.usaid.gov/pdf_docs/PDACO436.pdf
 
WHO (2011) Guidelines for the programmatic management of drug-resistant tuberculosis (2011 Update) – www.who.int/tb/challenges/mdr/programmatic_guidelines_for_mdrtb/en/index.html
 
WHO (2010a) The human face of tuberculosis in Sudanwww.emro.who.int/dsaf/dsa1077.pdf
 
WHO (2010b) Treatment of Tuberculosis: guidelines for national programmes. 4th edition
 
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Webpages:
 
Green Light Committee (WHO subsidiary for tackling MDR-TB and XDR-TB) – www.who.int/tb/challenges/mdr/greenlightcommittee/en/
 
Sudan: Stop TB website – Eastern Mediterrean Regional Office – (Information about the National TB Programme).

(WHO1) WHO Tuberculosis statistics for Sudan: https://extranet.who.int/sree/Reports?op=Replet&name=%2FWHO_HQ_Reports%2FG2%2FPROD%2FEXT%2FTBCountryProfile&ISO2=SD&outtype=html

(WHO2) WHO Tuberculosis statistics for Great Britain and Northern Ireland:https://extranet.who.int/sree/Reports?op=Replet&name=/WHO_HQ_Reports/G2/PROD/EXT/TBCountryProfile&ISO2=GB&outtype=html

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.

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Picture Credit: http://pmj.bmj.com/content/75/889/671.full – 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 – http://www.iend.org/

Mycetoma Research Centre, Soba University Hospital – http://mycetoma.uofk.edu/

Khartoum in English – Hello from me!

Summer reading

I’m currently a final year medical student at University College London Medical School.

In September I’m off to Khartoum, Sudan, to spend two months based in one of Khartoum’s main teaching hospitals. This is my medical elective (of which more later).

Whilst I’m there, I hope to keep feeding this blog at least once a week with any little snippets and morsels of what I’m doing, seeing and thinking (assuming anything vaguely noteworthy happens!).

I’m new to any form of blogging, but I’m pretty sure anybody can reply to my posts – so it’d be great to hear from anyone and everyone. Tell me about places you’ve been to, similar experiences you’ve had, things I should (or shouldn’t) eat, see or wear, ask me any questions, or chip in with your own thoughts. In short, stay in touch in whatever way you want!

Before I arrive in Sudan, I’m going try and get in a couple of posts – about medical electives in general, and about Khartoum in particular.

Will write again soon!

Pete.