The challenges facing children with pulmonary tuberculosis—a catastrophe of civil war: Letter from Sudan

Abstract

Pulmonary tuberculosis (PTB) is one of the communicable respiratory diseases that has a major impact on vulnerable populations worldwide. It has been estimated that every year around 10 million people are infected with TB. It is a preventable and curable respiratory disease, but still 1.5 million people die from TB every year, making it the world's top infectious disease.1 Even though there has been progress internationally, with average annual reductions in TB incidence rates of 2%, the disease is becoming concentrated in low socioeconomic status populations. Sudan is one of the developing countries where PTB is a major public health challenge. Despite national and international efforts, PTB among children remains a significant global public health concern and the situation in Sudan is much worse.1 The armed conflict in Sudan erupted in the capital city of Khartoum on 15 April 2023 after a long period of political instability. It is risking the health and wellbeing of 24 million Sudanese children.2 The ongoing armed conflict in Sudan led to severe compromise of the functioning healthcare facilities, leading to less than one third of hospitals in the warzone being operational and providing only basic services.2 We have seen many of the challenges facing the healthcare workers of Khartoum during this armed conflict. Most affected are vulnerable people, particularly women and children suffering from chronic diseases such as diabetes, chronic renal disease, cancer patients and infectious diseases such as PTB. Image: Public health tour with medical students to North Kordofan, Sudan, to raise the awareness of rural women and children about the importance of hand hygiene. We will discuss here the impact of the Sudan war on the wellbeing of children with PTB and the challenges facing healthcare providers since the start of the war. Before the eruption of this war, the PTB cure rate was reported to be 76.5% with treatment success rates reaching 88.2% and a death rate of 6.1% among children, many of whom were HIV positive.3 Low socioeconomic status, overcrowding, malnutrition and HIV are among the main risk factors that contributed to the increase incidence of PTB. Therefore, Sudan is one of the countries with highest prevalence of PTB in children.3 Besides the underfunded, fragile healthcare system in Sudan, the war loaded extra burden and exacerbated the difficult situation of the healthcare system. The war erupted first in Khartoum State then spread to Darfur States and from there to other states including Kordofan and Jazeera. Currently there is fierce fighting in the Blue Nile and the White Nile States. The healthcare system is collapsing due to attacks on health institutions, with some hospitals demolished while others are vandalized or looted. The healthcare workers in these health institutes have been personally targeted, where some were killed and others were abducted.4 Unfortunately, the medical records of patients in many of these hospitals were lost or burned inside, which complicates the follow-up of patients who are displaced to other safe states. Unfortunately, there is no accurate statistical data to reflect the mortality and morbidity of Sudanese children during this war, but for sure in the states where two thirds of the government hospitals are out of service, it will be difficult to diagnose new cases. It is another challenge to identify drug-resistant strains, particularly in children who are not taking their medications regularly. Mortality will subsequently increase among those who could not get their medications. Accessing treatment in a timely manner is a real challenge. The Federal Ministry of Health, the WHO and other local and international stakeholders have been working under extremely difficult conditions to provide and maintain the TB national program in the states that are not directly affected by the war. Food shortages, displacement, interrupted water and electricity supply are among the main challenges and risk factors that led to increased TB mortality among children.4 The hideous scenes that families and their children went through had huge psychological impact on their mental health and wellbeing. In addition, the stigma of having PTB led to anxiety and fear of social isolation of affected children and their families.4 Moreover, the poor healthcare services and low detection rates of new cases, along with overcrowding in the displaced settlements outside the warzones, led to spread of PTB. Another challenge is the disruption of the National Vaccination Program in the war-affected states, despite all the efforts from the Federal Ministry of Health and the WHO. If the situation continues, this may lead to a catastrophic situation not only in Sudan but extending to neighbouring countries. However, local organizations and international aid agencies are working tirelessly to ensure PTB services continue despite the challenging circumstances. Unfortunately, many of the efforts to secure safe channels for delivery of medical and humanitarian aid failed. Deploying mobile clinics to reach displaced populations is proving difficult in such situations. Another important challenge is the timely distribution of PTB medication and diagnostic tools, which are essential to prevent treatment interruptions and reduce prevalence of the drug-resistant strains.3 Despite these efforts, providing PTB services during conflict remains a formidable challenge. The effectiveness of interventions can be limited by factors such as insecurity, logistical barriers and funding constraints. To address these challenges and to avoid further impact on children's wellbeing, there should be an urgent local, regional and international coordinated, comprehensive approach to have a long-term ceasefire, opening safe and secure channels to deliver humanitarian aid to the people facing famine and addressing the pending malnutrition in children. There is an urgent need to re-establish the PTB control program in Sudan and improve access to healthcare services, taking preventative measures, and providing psychosocial support for affected children and their families. Additionally, efforts to promote a long-term peace and stability in the region are essential to create an environment where children can easily access healthcare services, food, and clean water to overcome PTB and thrive well. The authors declare no conflicts of interest.