"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 cholera that have killed people, 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?
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 include cholera, which is an acute diarrhea infection caused by ingestion of food or water that is contaminated with Vibrio cholerae bacterium. (Cholera infections are most commonly acquired from drinking water, according to the Centers for Disease Control and Prevention.)
If left untreated, however, cholera can kill within hours. AWD is a symptom of cholera, but cholera 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. "A medical worker from Blue Nile state revealed an increase in incidences of diarrhea that he believes to be cholera," reported Radio Dabanga, an independent news source that operates out of the Netherlands with correspondents in the field. "He attributes the spread to polluted water and said that hospitals in the state have to isolate patients with diarrhea to avoid infecting others."
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 ongoing conflicts in other parts of the country, principally Darfur in the West and the Nuba Mountains and Blue Nile, which border South Sudan.
President Omar al-Bashir, who has ruled the country since 1989, was indicted by the International Criminal Court in 2009 for allegedly pursuing a genocide campaign in Darfur.
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 index, or first, case was retrospectively identified with an onset of illness on April 23, and then four cases were laboratory-confirmed 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 doses of cholera vaccination in an effort to stem the spread, but an additional 2 million doses are required, according to the agency. 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 further now that it had reached the densely populated capital of Khartoum. Almost 2 million people live in the capital.
ACAPS said a factor in the rapid spread may 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, 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 one.
In fact, Khartoum has actively sought to prevent hospitals, doctors and journalists from reporting that there is a cholera outbreak. As far back as January, doctors reported that laboratory tests on acute diarrhea samples proved that it was cholera. "The management problems at the Health Ministry have impeded containment of the disease. Instead of acknowledging the disease and taking measures to prevent the spread of cholera during the past six months, the authorities opted for not announcing the test results," said one doctor.
Al-Fateh Omar al-Sayed, a leader of the Sudanese Doctors Union and the National Epidemiological Corporation, in June told Radio Dabanga 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. The reporter was accused of "defamation for publishing materials related to the watery diarrhea that has swept many localities in the state and led to the death and infection of hundreds."
– In June, the Sudanese health ministry fired a hospital director who dared to publicly say it 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.
"WHO has not received any lab results to date that confirm cholera in Sudan," said Gregory Hartl, a WHO spokesman. "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. WHO is coordinating efforts with all parties to ensure an effective and rapid response. Early detection is key to containing any outbreak, regardless of the cause."
He added that "whether an outbreak is called 'cholera' or 'acute watery diarrhea' does not alter WHO response, and in the case of Sudan, WHO and partners are free to act on the ground to support the government in providing people with the care they need." 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 WHO, a group of U.S. physicians have decried "WHO's failure to confirm or disconfirm the findings of Sudanese labs tests in Geneva, using stool samples appropriately transferred from Sudan." Addressing WHO Director-General 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 it as AWD to avoid harming the country's tourism industry. Tests by the United Nations confirmed it was cholera that 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. WHO understands that the capacity of the Central Public Health Laboratory of Sudan to test and confirm Vibrio cholerae has been demonstrated in the past, and that the Government of Sudan has in fact performed such laboratory tests in response to the recent outbreaks."
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."
The U.S. Embassy in Khartoum did not respond to a query about why it warned of a cholera outbreak. 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.
An admission of a cholera outbreak would be embarrassing for the regime in Khartoum, exposing its deeply troubled health system. It also comes as the Trump administration is facing an October deadline on whether to lift some sanctions on Sudan. One of the issues under review is improving humanitarian access throughout Sudan.
Eric Reeves, a senior fellow at Harvard University's Francois-Xavier Bagnoud Center for Health and Human Rights who closely follows Sudan, said it was "preposterous" to assume that a government that punishes people for uttering the word cholera could be trusted to report accurate lab results.
The embassy announcement indicated the outbreak was "only now getting attention because it is occurring in areas where Americans might travel (not the case with Darfur, Eastern Sudan, Blue Nile, or South Kordofan)," Reeves said. "Up until then, only Sudanese lives were at risk."
"Any time a specific disease appears in certain nations, political sensitivities unfortunately arise about announcing it," said Amesh A. Adalja, senior associate at the Johns Hopkins Center for Health Security. "Cholera is a disease that does carry some stigma around it and that may be behind the 'acute watery diarrhea' label despite the diagnosis of cholera being confirmed. In early stages of an outbreak when precise causation hasn't been established, a clinical descriptor will temporarily suffice but once a definite disease agent has been confirmed it is important to name it exactly and respond accordingly."
The Pinocchio Test
We understand the diplomatic niceties here. A country's health ministry is supposed to declare a health emergency, and WHO may 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 may be higher (800) in Sudan than South Sudan (250), but that's because 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 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.