Sudan: Voices from the cholera outbreak

Strength you didn't know you had

Angela Giacomazzi—a human resources coordinator working in Tanedba, Gedaref state—describes the evening of 1 September.

One night I was working around 9PM with a couple of colleagues. As always in MSF, we have very long nights and very early mornings. We received an alert that a car carrying five suspected cholera cases, was coming to our hospital. Unfortunately on the way to the hospital one of the people had passed away in the car. The other four cases were serious, but the car wasn't coming here anymore, it had gone back to the village with the dead body. 

While an ambulance went to pick up the patients, the team and I went to prepare everything we would need for when the patients arrived. The cholera treatment centre was already completely full so we needed to find new beds from wherever we could. Everyone was on their feet, ready to respond to this new emergency. 

When the four patients arrived, we realised that two of them were very critical. One was a kid who was also malnourished. Malnourished kids always look so fragile and cholera can really push their lives to the extreme. 

When you see them in those conditions you find a strength in yourself that you didn't know you had. You become fast, you become efficient and you become the best person that you can ever imagine to be.

Everything was happening automatically: everyone was in the right place at the exact moment, doing the exact thing that was needed to get these people into hospital and to take care of them. All of us complementing each others actions in a frantic race against the clock, because this little one was bad, but at least she was stable. 

One adult male was in shock, he was unconscious. This is how you die of cholera, dehydration causes the body to go into shock. When the body reaches that point after a few minutes it’s already too late. You are never coming back. We only had a few minutes. While the doctors were resuscitating him, literally squeezing litres of fluids in his veins, everyone else was there, ready to provide what help they could.

We run out of giving sets and we were running out of staff.  It was pretty crazy; in those five minutes a lot happened. Everything was very quick, I brought a box of fluids, the last box, into the ward and as I arrived I saw the patient who had been unconscious was now conscious, he was okay.

Those five minutes between his arrival and his resuscitation. Through the, I don't know, ten liters of IV infusion, we’d saved him and suddenly, covered as I was in sweat and mud, I realised that we had made it and that nobody had died out of the group who made it to hospital. All of four of them were stable.

I realised that the patient who had been unconscious didn’t know he was going to live. Even though he was awake he still didn’t know. His face and his breathing were really showing so much panic. And fear. He met my eyes with a very questioning look and I smiled at him. And I nodded, because I wanted to let him know that everything was going to be all right. He looked at me and he nodded back at me, nodding in response.

And in that moment, all those early mornings and late nights, they made so much sense.

Ongoing war, floods and now cholera

In August, Sudanese authorities declared a cholera outbreak, which is currently heavily affecting the states of Kassala, Gedaref and River Nile, followed by Al Jazirah and Khartoum. According to the Ministry of Health, over 5,000 cases of cholera and 191 deaths have been reported. In the second half of August the weekly cases of the disease multiplied by four.

Cholera cases are not uncommon in Sudan, but this is the second year since the start of the war in April 2023 that the country is faced with outbreaks of the disease. For the past two years, our teams have been actively engaged in emergency responses to mitigate their impact.

“The menacing mix of heavy flooding and torrential downpours with woeful living conditions and inadequate access to drinking water that millions have today, particularly in crowded camps for displaced people, have created the perfect storm for the spread of this often deadly disease,” says Esperanza Santos, MSF emergency coordinator for Sudan.

In Kassala, for instance, heavy rains and river floods have destroyed water and sanitation infrastructure and put both internally displaced communities and Eritrean and Ethiopian refugees in even more appalling living conditions.

Cholera adds yet another challenge to the crisis in Sudan and to the decimated health system, already struggling with increasing child malnutrition, high numbers of war wounded and regular cases of preventable diseases. Regularly obstructed by both warring parties, the humanitarian response remains far below what is needed.

Case management and water and sanitation

MSF teams in Khartoum, River Nile, Kassala and Gedaref have mobilized to support the Ministry of Health to respond to the situation, by setting up and running cholera treatment centers and units (CTCs and CTUs) or providing support to existing overwhelmed treatment facilities in some of the most affected areas and in hard-to-reach places where cases are upsurging. Between the end of August and 9 September, we treated 2,165 patients in our supported facilities.

Caused by a water-borne intestinal infection, cholera is transmitted through contaminated food or water, or through contact with fecal matter or vomit from infected people. Cholera can cause severe diarrhoea and vomiting, and rapidly prove fatal, within hours, if not treated. But cholera is very simple to treat—rehydration is key.

MSF teams are setting up oral rehydration points, trucking drinking water, constructing handwashing points and latrines, distributing hygiene kits and doing health promotion in the affected communities.

In Darfur, where no cases have yet been registered, MSF teams are helping to improve preparedness.

Unrestricted rapid access for staff and supplies

“People are dying from cholera right now; hence we plead on the UN and international organizations to fund and scale up activities, particularly water and sanitation (watsan) services, which are crucial to stop the lethal spread,” says Frank Ross Katambula, MSF medical coordinator.

After nearly 17 months of challenges and obstructions around the provision of humanitarian assistance in Sudan, MSF also calls on warring parties to allow unhindered access of medical staff and supplies to all the areas in need across Sudan to enable a quick and coordinated response and prevent avoidable deaths.

“There is a risk of running out of essential supplies such as cholera kits in a moment when scaling up the response is urgently needed. We call on the authorities to fast-track and facilitate the delivery of supplies and drugs, as bureaucratic obstacles remain a major challenge,” says Katambula.