The high incidence of debilitating and sometimes fatal diseases that persisted in the 1980s and had increased dramatically by 1991 reflected difficult ecological conditions and inadequate diets. The diseases resulting from these conditions were hard to control without substantial capital inputs, a much more adequate health care system, and the education of the population in preventive medicine.

By 1991 health care in Sudan had all but disintegrated. The civil war in southern Sudan destroyed virtually all southern medical facilities except those that the SPLA had rebuilt to treat their own wounded and the hospitals in the three major towns controlled by government forces--Malakal, Waw, and Juba. These facilities were virtually inoperable because of the dearth of the most basic medical supplies. A similar situation existed in northern Sudan, where health care facilities, although not destroyed by war, had been rendered almost impotent by the economic situation. Sudan lacked the hard currency to buy the most elementary drugs, such as antimalarials and antibiotics, and the most basic equipment, such as syringes. Private medical care in the principal towns continued to function but was also hampered by the dearth of pharmaceuticals. In addition, harassed the Bashir government, the private sector particularly the Sudan Medical Association, which was dissolved and many of its members were jailed. Compounding the rapid decline in health care have been the years of famine during most of the 1980s, culminating in the great famine of 1991, which was caused by drought and widespread crop failures in Bahr al Ghazal State and in Darfur and Kurdufan. The famine was so widespread that, according to various estimates, 1.5 million to 7 million Sudanese would perish.

Widespread malnutrition also made the people more vulnerable to the many debilitating and fatal diseases present in Sudan. The most common illnesses were malaria, prevalent throughout the country; various forms of dysentery or other intestinal diseases, also widely prevalent; and tuberculosis, more common in the north but also found in the south. More restricted geographically but affecting substantial portions of the population in the areas of occurrence were schistosomiasis (snail fever), found in the White Nile and Blue Nile areas and in irrigated zones between the two Niles, and trypanosomiasis (sleeping sickness), originally limited to the southern borderlands but spreading rapidly in the 1980s in the forested regions of southern Sudan. It was estimated that by 1991 nearly 250,000 persons had been affected by sleeping sickness. Not uncommon were such diseases as cerebrospinal meningitis, measles, whooping cough, infectious hepatitis, syphilis, and gonorrhea.

Even in years of normal rainfall, many Sudanese in the rural areas suffered from temporary undernourishment on a seasonal basis, a situation that worsened when drought, locusts, or other disasters struck crops or animals. More dangerous was malnutrition among children, defined as present when a child's body weight was less than 80 percent of the expected body weight for the age. The weight criterion in effect stood for a complex of nutritional deficiencies that might lead directly to death or make the child susceptible to diseases from which he or she could not recover. A Sudanese government agency estimated that half the population under fifteen--roughly one-fourth of the total population--suffered from malnutrition in the early 1980s. This figure increased substantially during the famine of 1991.

Acquired immune deficiency syndrome (AIDS) was present in Sudan, primarily in the southern states bordering Uganda and Zaire, where the disease had reached epidemic proportions. There had been a steady increase in AIDS in Khartoum, because of the hundreds of thousands of people emigrating to the capital to escape the civil war and famine. The use of unsterile syringes and untested blood by health care providers clearly contributed to its spread. In spite of the increase in the spread of AIDS, the Sudanese government in 1991 lacked a coherent national AIDS control policy.

In the late 1970s and early 1980s, the government undertook programs to deal with specific diseases in limited areas, with help from the World Health Organization and other sources. It also initiated more general approaches to the problems of health maintenance in rural areas, particularly in the south. These efforts began against a background of inadequate and unequal distribution of medical personnel and facilities, and events of the late 1980s and early 1990s caused an almost complete breakdown in health care. In 1982 there were nearly 2,200 physicians in Sudan, or roughly one for each 8,870 persons. Most physicians were concentrated in urban areas in the north, as were the major hospitals, including those specializing in the treatment of tuberculosis, eye disorders, and mental illness. In 1981 there were 60 physicians in the south for a population of roughly 5 million or 1 for approximately 83,000 persons. In 1976 there were 2,500 medical assistants, the crucial participants in a system that could not assume the availability of an adequate number of physicians in the foreseeable future. After three years of training and three to four years of supervised hospital experience, medical assistants were expected to be able to diagnose common endemic diseases and to provide simple treatments and vaccinations. There were roughly 12,800 nurses in 1982 and about 7,000 midwives, trained and working chiefly in the north.

In principle, medical consultation and therapeutic drugs were free. There were, however, private clinics and pharmacies, and they were said to be growing in number in the capital area in the late 1970s and early 1980s. The ever worsening shortage of medical personnel and of pharmacenticals had, however, limited the effectiveness of free treatment. In urban areas, physicians and medical assistants could be seen only after a long wait at the hospitals or clinics at which they served. In rural areas, extended travel as well as long waits were common. In urban and rural areas, the drugs prescribed were often not obtainable from hospital pharmacies. In the Khartoum area, they could be obtained at considerable cost from private pharmacies. In addition to the problems of cost, however, were those posed by difficulties of transportation and inadequate storage facilities. In the south, especially during the rainy season, the roads were often impassable. There and elsewhere, the refrigeration necessary for many pharmaceuticals was not available. All of these difficulties were compounded by inadequacies of stock rotation and inspection. Members of the country's elite overcame these problems by taking advantage of medical treatment abroad.

In the mid-1970s, the Ministry of Health began a national program to provide primary health care with emphasis on preventive medicine. The south was expected to be the initial beneficiary of the program, given the dearth of health personnel and facilities there, but other areas were not to be ignored. The basic component in the system was the primary health care center staffed by community health workers and expected to serve about 4,000 persons. Community health care workers received six months of formal training followed by three months of practical work at an existing center, after which they were assigned to a new center. Refresher courses were also planned. The workers were to provide health care information and certain medicines and would refer cases they could not deal with to dispensaries and hospitals. In principle, there would be one dispensary for every 24,000 persons. Of the forty primary health care centers and dispensaries to be completed by 1984, about half were in place by 1981. In addition, local (district) hospitals were to be improved. The program in the south was supported by the Federal Republic of Germany (West Germany), which also provided medical advisers. In 1981 the program was most advanced in eastern Al Istiwai Province, but it was too early to assess the effects on the health of the people, and the program had virtually disappeared by 1991.

Two local programs for the control of endemic disease were also undertaken in the late 1970s and early 1980s. One was in the area of the Gezira Scheme, where it was estimated that 50 to 70 percent of the people suffered from schistosomiasis, a health problem aggravated by the presence of malaria and dysentery. The Blue Nile Health Care Project, a ten-year program inaugurated in early 1980, was intended to deal with all of these waterborne diseases simultaneously. Because people bathed in and drank the water in the irrigation canals, which were contaminated by human waste, a major change in their habits was required, as well as the provision of healthful drinking water and sanitary facilities that did not drain into the canals. Diarrheal diseases were to be treated with rehydration salts that should diminish considerably the very high rate of infant deaths. As of the 1991, the persistent civil war and the collapse of the Sudanese economy made the inauguration of these projects doubtful. Other programs to provide relief to disease and famine victims in Sudan were organized by foreign aid agencies' such as the World Food Program, the Save the Children Fund, Oxford Committee for Famine Relief, and the French medical group, Médecins sans Frontières (Doctors Without Borders).

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