Memo to the World Health Organization: Your Silence on the Presence of Cholera in Sudan Prevents the Deployment of Oral Cholera Vaccines to Areas at Continuing Risk

Cholera was first reported in Sudan in August 2016, during an outbreak in Blue Nile State. The deadly disease spread to nearly all Sudan’s eighteen states and continues to be reported in Darfur, where the number of cases has risen and fallen for months. As recently as March 15, 2018 Radio Dabanga reported:

After a few days of showing a downward trend, 12 new cases of “acute watery diarrhoea,” suspected to be cholera, have been reported in Central Darfur. (“12 new cases of suspected cholera reach Central Darfur centres,” Radio Dabanga, March 15, 2018 | NIERTETI )

 

[See also Appendix A: “An Open Letter to Dr. Tedros Adhanom Ghebreyesus, Director General of the UN’s World Health Organization, from American physicians”]

 

The cholera bacterium (Vibrio cholerae) almost certainly remains in significant reservoirs in Sudan, and the upcoming rainy season poses extraordinary dangers of an explosive resurgence.

That the disease is cholera is beyond dispute, as Radio Dabanga has repeated reported (most recently March 21, 2018):

 

In spite of numerous independent confirmations (conducted according to World Health Organisation (WHO) standards) that the disease which broke out in Blue Nile State in August 2016 was cholera, the Sudanese authorities and several international organisations still call it “acute watery diarrhoea.”

 

 

 

That the UN’s World Health Organization is one such “international organization,” that the WHO refuses to name the disease for what it is—out of deference to the sensibilities of the brutal Khartoum regime—is disgraceful. Such silence not only sets a terrible precedent in yielding to a country’s desire to avoid the “stigma” associated with cholera, but prevents the deployment of medical resources that could be used to control the ongoing cholera outbreak in Sudan.

 

The failure of WHO to name the disease has clear and deadly consequences; this is made clear in the conclusion of a recent article from the distinguished New England Journal of Medicine (February 8, 2018):

“Single-Dose Cholera Vaccine in Response to an Outbreak in Zambia,” New England Journal of Medicine, February 8, 2018 [378:6 | www.nejm.org/]

 

Our results show the short-term effectiveness of a single dose of Oral Cholera Vaccine (OCV) during an outbreak. Previous studies measuring the protection provided by a single dose of OCV were conducted in areas with recent exposure to cholera, which raises the possibility that single-dose regimens might act to boost natural immunity [footnotes 2, 3, 5]. Our results indicate that single-dose regimens provide protection in populations with less exposure to cholera, such as those in in Lusaka [Zambia] and much of sub-Saharan Africa, where multiyear lull periods are punctuated by explosive outbreaks

 

Authors:

 

Eva Ferrera, M.Pharm., M.Sc. (Epicentre | Paris, France)

Elizabeth Chizema-Kawesha, M.D., Ph.D. (Ministry of Health | Lusaka, Zambia)

Marc Poncin, Ph.D. (Médecins sans Frontières | Geneva, Switzerland)

Francisco J. Luquero, M.D., Ph.D. (Epicentre | Paris, France)

and Others

 

This is clear evidence that the populations at risk in Darfur and elsewhere in Sudan could be protected from what all evidence indicates is cholera. Yet continued silence by WHO—and thus continued refusal to begin an OCV campaign in areas where there have been many very recent reports of cholera—simply adds to a disgraceful performance to date.

 

Moreover, a WHO mission to Central Darfur in mid-February was confirmed to me by several high-level officials in the UN and U.S. government; and yet even now WHO refuses either to confirm or disconfirm the presence of Vibrio cholera in Sudan (see the Washington Post, “As the death toll climbs in Sudan, officials shy away from the ‘cholera’ label,” September 14, 2018).

 

The Khartoum regime is destroying—by way of uncontrolled inflation—the ability of ordinary Sudanese to purchase inordinately expensive (because imported) medicines. It is especially disgraceful that Khartoum’s fear of being stigmatized by the presence of cholera in Sudan is paralyzing a feckless leadership at the UN’s World Health Organization and preventing the deployment of critically necessary medical resources, including Oral Cholera Vaccines.

 

This UN treatment of the people of Darfur and Sudan is an outrage.

 

APPENDIX A: An Open Letter to Dr. Tedros Adhanom Ghebreyesus, Director General of the UN’s World Health Organization, from American physicians
 

September 11, 2017

 

Concerning Cholera in Sudan: An Open Letter to Dr. Tedros Adhanom Ghebreyesus, Director General of the UN’s World Health Organization, from American physicians

 

Dr. Tedros Adhanom Ghebreyesus, United Nations Office at Geneva | Palais des Nations, 1211 | Genève, Switzerland

 

The mandate of the UN’s World Health Organization (WHO) could hardly be clearer; in the words of the Organization:

 

Our primary role is to direct and coordinate international health within the United Nations’ system.

Our goal is to build a better, healthier future for people all over the world. Working through offices in more than 150 countries, WHO staff work side by side with governments and other partners to ensure the highest attainable level of health for all people.

 

And yet this impressive mandate is daily made a mockery of by WHO’s refusal to refer to the cholera epidemic raging in Sudan by name. Neither your organization nor the UN’s Office for the Coordination of Humanitarian Affairs will refer explicitly to the fact that what you continue to call “Acute Watery Diarrhea” is in fact cholera, Vibrio cholera—a fact established by laboratory tests in Sudan.

What is most troubling in the present crisis is WHO’s failure to confirm or disconfirm the findings of Sudanese labs tests in Geneva, using stool samples appropriately transferred from Sudan. As you well know, this is entirely practicable; cholera is easily diagnosed unequivocally in stool samples by bacterial culture.  Laboratories across the world can readily do this using a samples shipped to them.  If this requires special conditions for shipping (e.g., specimen has to be collected and stored in a special fluid called transport media to keep the bacteria alive), the effort seems nonetheless unsurpassably urgent, given the spread of what all evidence indicates is cholera, now rampant in most of Sudan.

 

By failing to conduct such laboratory tests, you are conspicuously failing in fulfilling your mandate as Director General of WHO. Of more immediate consequence, you are failing the people of Sudan, who have suffered so much at the hands of the current regime.

 

We are forced to ask: why has such an “unequivocal diagnosis” not been rendered by WHO, given the massive spread of cholera in Sudan since August 2016? To be sure, the Khartoum regime has made clear that it will punish Sudanese journalists and health officials who dare to use the word “cholera,” and no doubt threats have been issued to WHO, demanding that you be complicit in silence about this terrible disease. The regime’s motive is transparently a desire that the “reputation” of Sudan not be compromised by associations the regime perceives would inhere in any accurate designation of a disease that is clearly out of control. But the effect of WHO’s silence is to ensure that Sudan has not received international medical resources necessary to combat cholera—preeminently massive supplies of re-hydration equipment; medical epidemiologists as well as specialists in treating cholera epidemics; and water/sanitation equipment and engineers.

 

By yielding to the Khartoum’s regime’s threat, you are complicit in the failure to respond to a disease that currently threatens many hundreds of thousands of Sudanese civilians—and is currently active in at least twelve Sudanese states.

 

As you are no doubt aware, the current National Islamic Front/National Congress Party regime—which came to power my means of a military coup in June 1989—is guilty of continuous assaults on its own people for almost three decades. Among the most barbaric means used in serial genocidal counter-insurgencies has been the thoroughly documented denial of humanitarian assistance to desperately need civilians—in Darfur, in the Nuba Mountains of South Kordofan, in Blue Nile, and in South Sudan during the long civil war. Eastern Sudan has also been systematically denied critically needed humanitarian resources.

 

Equally well-documented are the Khartoum’s military assaults on humanitarians—most recently and notoriously, bombing of hospitals in South Kordofan (Doctors Without Borders/Médecins Sans Frontières (MSF)—twice—in Frandala, as well as the repeated bombings of Mother of Mercy Hospital near Kauda in the center of the Nuba Mountains). Bombings and assaults on humanitarian sites were commonplace during the North/South civil war (see http://wp.me/p45rOG-Pv/).

 

Your silence about what is clearly a massive cholera epidemic in Sudan daily becomes more reprehensible. 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. The inevitable history that will be written of this epidemic will surely cast you in an unforgiving light.

 

Signatories,

 

Richard B. Brown, M.D., Senior Clinician, Infectious Disease Division, Baystate Medical Center, Springfield, Massachusetts | Professor of Medicine, Tufts University School of Medicine

Joanne Levin, MD, specialist in infectious diseases, Northampton, Massachusetts

William Swiggard, MD, specialist in infectious diseases, Northampton, Massachusetts

Karen Abrashkin, MD, Westbury, New York

Julia De Almeida, MD, Easthampton, Massachusetts

Peter A. Elsea, MD, Northampton, Massachusetts

Elizabeth Feuer, M.D. Colts Neck, New Jersey

Aisling Gaughan, MD, Lunenburg, Massachusetts

Samuel Gladstone, MD, Amherst, Massachusetts

Jay Holtzman, MD, Belchertown, Massachusetts

Mordechai Kamel, JD, MD, Easthampton, Massachusetts

Ellen Kaufman, MD, Northampton, Massachusetts

James Kirchhoffer, MD Easthampton, Massachusetts

Jeffrey Korff, MD, Northampton, Massachusetts

Joel Rosen, MD Northampton, Massachusetts

Henry Rosenberg, MD, Northampton, Massachusetts

Carl Saviano, MD, Northampton, Massachusetts

Ellen Senghas, MD Southampton, Massachusetts

http://sudanreeves.org/2018/04/01/memo-to-the-world-health-organization-your-silence-on-the-presence-of-cholera-in-sudan-prevents-the-deployment-of-oral-cholera-vaccines-to-areas-at-continuing-risk/

 

(c) 2018 SUDAN Research, Analysis, and Advocacy

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