By Angelo Ngor
July 9, 2012 — After 56 years of marginalisation, oppression, slavery and negligence by the Sudanese Islamic regime in Khartoum, South Sudanese have been severely deprived of developmental programs both in health, education and or infrastructure. At least the second Sudanese civil war led by the Sudan People’s Liberation Army and Sudan People’s Liberation Movement (SPLA/SPLM) for the last twenty two years has finally achieved the dreams of most South Sudanese if not all. After attaining her independence on July 9, 2011 and subsequently being recognized by the world and notably the United Nations and in Washington DC, the youngest nation and 54th African country continues to fight internal and external foes. The situation is largely compounded by rampant corruption which saw $ 4 billion vanished between 2005 and 2011. The phenomenon known as “sorghum saga” and “misappropriation” through bogus companies have prompted the President Salva Kiir Mayardit to write to 75 current and former government officials to account for the $ 4 billion. The fight against corrupt officials recently initiated by the President and endorsed by lawmakers will soon materialize as the President of the new nation is put to test on his zero tolerance policy, a chorus that has been overheard in South Sudan. However, hope of most South Sudanese begin to fade away as the path of retrieving the stolen funds is narrow and the fight against these corrupt officials is a highly sophisticated one and must be handle with due care for a fear of internal rebellion and its aftermath price.
Given these perspectives, one thing the government and the department of health have forgotten is the health planning and preventive medicine. Of recent, there was a tension between the private universities and ministry of higher education when the latter decided to close down private universities upon their failure to comply or meet the necessary requirements of the higher education sector. The minister of higher education was right in that we need to benefit from a quality education and not a quantity one though his decision was slammed by the affected parties. At least higher education sector is finding its way.
As for the department of health, lack of enough funds to address health issues has become an excuse of doing nothing. If we think we are better off with getting monthly salary and sit in offices doing nothing, we are not. And if we think we can embark on foreign advice and expatriate services, we are not. The only solution is to think wisely and to act wisely. Now that the department of health has failed to take appropriate measures regarding population health, we are faced with devastating ends expected in the near future. What our health policy makers did not take into account is preventive medicine which should not be redefined as cleaning up Juba and other big cities coupled with culture of drinking bottled water by minorities who afford to pay, but by carefully defining preventive medicine as constructive strategies undertaken to prevent diseases other than treating them at all levels. The most devastating phenomenon to be faced is certainly underway, the era of antibiotics which is close at bays. Now with the new Republic being born, there comes an era of investment and with it a fast-money-making business, the drug selling stores referred to as pharmacies and “hayada”, the clinics run by quack doctors and unqualified pharmacy dispensers that call themselves “pharmacists”.
By allowing rampant dispensing of medicines by unqualified persons or even qualified pharmacists without proper guidance is an invitation of invisible war by multi-drug-resistant organisms (MDRO). Despite decades of triumph against bacteria, what once appeared to be miracle medicines have been beaten into ineffectiveness by the bacteria they were designed to knock out though once, scientists hailed the end of infectious diseases. Now, that the post-antibiotic apocalypse is within sight, will the poor and youngest nation afford to fund this war? It is probably big no. The current knowledge and the rapid trend of MDRO put our anxiety to the new level so far. I do not intend to discuss the whole range of bacterial resistance but to highlight a few dangerous ones that we might not put to an end should they evolve soon.
It was once believed that most MDRO only exist in hospital environments, but have now been discovered as having found their way into community and become community acquired infections. These include methicillin-resistant staphylaococcus aureus (MRSA) and Vancomycin-Resistant Enterococcus (VRE). For the last two decades or even more, 3rd generation cephalosporins for example, have been used heavily against Gram negative bacteria with major triumph, but surprisingly, two very important types of ?-lactamase mediated resistance have emerged against these antibiotics: Class I ?-lactamase production and Extended spectrum ?-lactamase (ESBL) production . Organisms capable of class 1 ?-lactamase production include ESCAPPM or (Enterobacter, Serratia, Citrobacter freundii, Acinetobacter spp., Proteus vulgaris, Providencia spp., Pseudomonas aeruginosa and Morganella spp.). ESBL on the other hand are active against older penicillins and cephalosporins, 3rd generation cephalosporins and some are active against 4th generation cephalosporins. A more dangerous superbug gene has been recently published by Professor Timothy Walsh in the lancet infectious diseases at http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2812%2970044-0/fulltext?_eventId=login, the New Delhi metallo-beta-lactamase-1 (NDM-1), this Indian superbug gene and enzyme recently discovered is resistant to almost all antibiotics. NDM-1 has already been imported from India to the United States and other nations and now almost widespread.
By admitting current shortage and lack of qualified health professionals, high incidence of MDRO has been reported by some of South Sudanese researchers in combination with expatriates in Juba, mostly a result of unnecessary use of antibiotics and lack of public health education. Of recent, South Sudan Medical Journals website published some research reports on MDRO including tuberculosis and recommendations regarding expansion of laboratory services and the need for reference laboratory found at http://www.southsudanmedicaljournal.com/research.html, and in particular by authors Saeed et al (nd.) entitled the “carriage rates, circulating serotypes and antibiotics resistance among streptococcal pneumonia in healthy infants in Yei, South Sudan” at http://www.southsudanmedicaljournal.com/archive/august-2011/carriage-rates-circulating-serotypes-and-antibiotic-resistance-among-streptococcus-pneumoniae-in-healthy-infants-in-yei-south-sudan.html. This research report is an indication that our hospitals are the habitats of MDRO and therefore must be prioritise during national health budget. Hospital acquired infections are more serious and are resistant to most antibiotics because frequent or heavy use of antibiotics in the hospital selects out the mutants within hospital. As well, the emergence of the new Republic of South Sudan attracted many nations and the influx of people from global travel has been seen, however, it is not unusual to see more of the superbugs mentioned finding their way into South Sudan in the near future. These problems are more complicated by rampant “on the counter” antibiotics and unnecessary prescription of the most powerful antibiotics by health professionals in practice due to lack of basic laboratory services and a reference laboratory for confirmation of suspected cases of rare and dangerous diseases. Lack of these basic scientific services has led most doctors to use empirical treatment to remedy the conditions of their clients. If we look further into future health of the people of the Republic of South Sudan, then it is time for health policy makers to properly regulate and review unscrupulous pharmacy entrepreneurships and the local clinics that are involved in medical malpractice widespread across many regions of the country. Health department of the Republic of South Sudan must act on health professionals’ opinions regarding improvement of health services and should not assume culture of ‘know’ and ‘do nothing’.
On the South Sudan Medical Journal website, there is a lot to be taken into consideration regarding published research results. Why then doing research and reporting shocking results if there are no plans by department of health? Why our policy makers continue to operate in the darkest world instead of developing progressive plans to take our new nation ahead. One year is already gone and no substantial progress being made and not even basic health services are met, mortality rates especially among infants dramatically remain high. The only response and statement rampant on media as officials concerned are faced with thousands of questions regarding their corruption scandal is “we have started from scratch”, a statement put to cover up for poor performance and incompetence and that denotes failure by the system to deliver basic services. Juba should wake up and address basic needs.
Now that the system has no regulatory authorities especially for businesses involving chemical substances such as drugs, the civil population is left grappling with all kind of diseases some of which have resulted from malpractice such as unnecessary prescription and dispensing of most powerful antibiotics in the name of investment. How will we invest in the expense of others lives? What are common in media outlets are criticisms regarding government corruption and poor performance but not even a single mention of the deteriorating health of South Sudanese. Educating public about use of “on the counter” medication and in particular, the antibiotics is important and should be encouraged; as well, health professionals should be encouraged to minimize use of antibiotics unless under extenuating circumstances deem necessary. Through these strategies we might be able to delay the negative impact that is eminent in a few decades. Media and public should start criticising the health department of not doing much or even least.
The author is a candidate MSc in Infectious Diseases and holds BSc in Human Biology and Biomedical Science. He is a South Sudanese and a former Jesh Amer in SPLA living in Australia and reachable at firstname.lastname@example.org