Amid epidemic in Sudan, officials won’t say ‘cholera’
“As of July 7, health actors had recorded more than 23,200 cases of acute watery diarrhea (AWD) since August 2016, according to the U.N. World Health Organization (WHO) and the Government of Sudan (GoS) Ministry of Health (MoH).”
— U.S. Agency for International Development, fact sheet, July 27, 2017
“The U.S. Embassy in Khartoum informs U.S. citizens that there are confirmed reports of cholera cases in some areas of Sudan, including the greater Khartoum metropolitan area, that have resulted in fatalities.”
— U.S. Embassy in Khartoum, emergency message, June 1
The State Department and USAID are related agencies, both reporting to the secretary of state, but there is an odd disconnect in how they have described a looming public-health emergency in the African country of Sudan. The embassy declared that there were “confirmed reports” of fatal cholera cases, whereas USAID, citing the World Health Organization and the Sudanese government, said there were cases of “acute watery diarrhea,” known in medical circles as AWD.
What’s going on here? The Facts According to the WHO, there are three types of diarrhea: acute watery diarrhea, which lasts several hours or days; acute bloody diarrhea, also called dysentery; and persistent diarrhea, which lasts 14 days or longer. AWD can manifest in cholera, which is an acute diarrhea infection caused by ingesting food or water contaminated with the Vibrio cholerae bacterium.
If left untreated, cholera illness can kill within hours. AWD is a symptom of cholera, but cholera illness requires more urgent care and immediate rehydration.
The first indication of a problem in Sudan was in August 2016, when 100 deaths, mainly children, were reported in Sudan’s Blue Nile state.
Sudan has known little but civil conflict since its independence more than a half-century ago, especially between the largely Arab, Islamic northern part of the country and the largely animist and Christian African south, which formed the independent country of South Sudan in 2011. There are also conflicts in other parts of the country, principally Darfur in the West and the Nuba Mountains and Blue Nile, which border South Sudan.
South Sudan, the world’s youngest country, descended into civil war shortly after independence, and a cholera outbreak was declared there in May 2014. The first case was retrospectively identified as an onset of illness on April 23, and then four cases were laboratoryconfirmed in Kenya; by May 25, officials had reported 586 cases, including 22 deaths.
The WHO has assiduously tracked the spread in the country and administered more than 1.5 million cholera vaccinations in an effort to stem the spread. Recent reports say another 2,500 cases in South Sudan have been registered since April, for a total of 8,000, including 250 deaths.
The cholera outbreak in South Sudan is probably linked to the growing health emergency in Sudan.
ACAPS, a nonprofit, nongovernmental project that assesses humanitarian needs, on June 16 issued a report stating that a “cholera outbreak” that started in Blue Nile “began to spread rapidly as of April this year. Conservative estimates suggest a minimum of between 15,000-23,000 people infected, with 280-820 deaths.” But the group said that without immediate intervention, infection is likely to spread farther now that it has reached the densely populated capital of Khartoum. More than 5 million people live in the city’s metropolitan area.
ACAPS said a factor in the rapid spread might be the large refugee population from South Sudan that fled the fighting and is crowded in refugee camps in the White Nile state. “ACAPS is curating and triangulating a lot of different sources to produce its own independent analysis,” said spokeswoman Caroline Draveny. “In the case of Sudan, all data we analyzed led us to call it cholera.”
In its reports in South Sudan, the WHO acknowledged that “all the states bordering South Sudan are affected” by a growing number of cases of acute watery diarrhea.
But here’s the problem: The government in Sudan refuses to acknowledge even one.
In fact, Khartoum has actively sought to prevent hospitals, doctors and journalists from reporting a cholera outbreak. As far back as January, doctors reported that laboratory tests on acute diarrhea samples proved a diagnosis of cholera.
Al-Fateh Omar al-Sayed, a leader of the Sudanese Doctors Union and the National Epidemiological Corporation, in June told Radio Dabanga, an independent news source, that the cholera epidemic has turned from a severe temporary situation to a constant epidemic. But the Sudanese government has taken steps to play down the threat:
In April, newspaper reporter Ammar al-Daw was detained for reporting on the outbreak and accused of defamation by the health minister of his home state, Gedaref, of violating the Information Crimes Act.
In June, the Sudanese health ministry fired a hospital director who dared to publicly say the institution was treating cholera cases.
In July, security officers questioned a group of volunteers who had set up an awareness campaign on how to prevent the spread of cholera in the area. “The volunteers were told to stop mentioning cholera,” Radio Dabanga reported.
Gregory Hartl, a WHO spokesman, said: “WHO has not received any lab results to date that confirm cholera in Sudan. However, the Government of Sudan has confirmed an outbreak of AWD. Preventing the spread of the AWD outbreak and saving lives are two of the highest priorities for WHO and Sudan’s Federal Ministry of Health.”
He added that “whether an outbreak is called ‘cholera’ or ‘acute watery diarrhea’ does not alter WHO response.” He did not respond to a query about whether a cholera declaration would allow the use of the cholera vaccine to prevent further spread of the disease.
In an open letter to the WHO, a group of U.S. physicians have decried “WHO’s failure to confirm the findings of Sudanese labs tests in Geneva, using stool samples appropriately transferred from Sudan.” Addressing WHO DirectorGeneral Tedros Adhanom Ghebreyesus, the letter said: “Your failure to transport stool samples from victims in Sudan to Geneva for official confirmation of cholera makes you fully complicit in the terrible suffering and dying that continues to spread, out of control, with daily new reports confirming that this is indeed a cholera epidemic.”
When he was health minister of Ethiopia, Dr. Tedros, as he is known, was accused of covering up cholera outbreaks by labeling cases as AWD to avoid harming the country’s tourism industry. Tests by the United Nations confirmed cases were cholera and had led to 60,000 infections and more than 600 deaths.
WHO’s Hartl insisted: “Sending stool samples overseas is not called for at this point.”
A USAID spokesman noted that “typically, a cholera outbreak is declared by the Ministry of Health in the affected country, in coordination with the World Health Organization. In Sudan, there is no official cholera declaration.” He said USAID was responding to the AWD outbreak and added: “The United States calls on the Government of Sudan to support timely testing and identification of the causes of acute watery diarrhea, in order to enable both government and international donor efforts to address the immediate outbreak, and provide longer-term solutions.”
Representatives of the Sudanese embassy in Washington and Sudanese mission to the United Nations did not reply to queries about the government’s handling of the health emergency. The Pinocchio Test We understand the diplomatic niceties here. A country’s health ministry is supposed to declare a health emergency, and the WHO might be reluctant to intervene for fear that the regime would eject needed medical professionals. But it seems absurd for the State Department to warn Americans of confirmed reports of deaths from cholera while USAID sticks with the more politically convenient designation of acute watery diarrhea, even as the death toll rises.
Amazingly, the death toll might be higher (800) in Sudan than in South Sudan (250), but that’s because the WHO has been able to respond to the crisis in South Sudan with a program of vaccinations and education about the deadly disease. The Pinocchios here are mainly for the Sudanese government, which refuses to admit an apparent cholera outbreak, but the WHO and USAID should not escape blame, either. Words make a difference. The accusations that WHO’s director-general tried to mask a cholera outbreak in Ethiopia by labeling it as AWD when tests showed otherwise make it even more imperative that the international agency should appear above politics.
A cholera patient lies in bed at a hospital in South Sudan. Regional officials have avoided discussing the outbreak in concrete terms.
The Fact Checker