Dr. James Maskalyk struggled to avoid eye contact with those in line or on the dirt floor as he passed by, knowing full well that many patients in the remote and dusty hospital would be turned away by the day’s end. He did not want to disappoint them, but he knew that this was the reality of south Sudan.

Maskalyk is not the only medical doctor who has provided care to patients in Sudan. Currently, there are 3,240 field staff from M’eacute;decins Sans Fronti’egrave;res aiding the country in which preventable, communicable diseases are the leading cause of death.

‘Without health, you have nothing,’ said Maskalyk, assistant professor of emergency medicine at the University of Toronto. ‘Without those fundamental blocks of primary healthcare, you can’t even pursue freedom.’

Imagine a nation where 75 percent of citizens do not have access to even the most basic healthcare, and where 10 percent of children die before the age of one. Welcome to southern Sudan, a war-torn East African country enmeshed in political crises and genocide, where Maskalyk spent six months as a physician with MSF.

In early November, M’eacute;decins Sans Fronti’egrave;res declared an outbreak of the deadly Kala-azar, a parasitic tropical ‘disease of the poorest of the poor.’ Worldwide, it kills 50,000 people a year, and has an almost 100 percent fatality rate if left untreated. However, if treated quickly and effectively, the disease has a 95 percent survival rate. Kala-azar is not the only disease rampant in southern Sudan unnecessarily killing adults and children. In fact, other infectious diseases such as meningitis, malaria, diphtheria and yellow fever are also present in the African region of eight million.

There is an eclipsed issue in Sudan slowly reaching the ears of those in more developed countries: Sudan’s healthcare infrastructure has failed. The lack of access to healthcare contributes to a surge in cases and deaths not seen in developed nations with sophisticated healthcare systems. There is a growing debate whether the humanitarian and government aid provided is actually effective, as deaths due to preventable diseases continue to take a toll. Despite many humanitarian groups across the world contributing to the growing healthcare crises, millions continue to die of preventable deaths.

M’eacute;decins Sans Fronti’egrave;res, more commonly known in the United States as Doctors without Borders, has been a consistent humanitarian presence in Sudan since 1979. According to the organization’s most recent international activity report published last year, the organization treated 9,000 children for severe acute malnutrition and 6,700 for cholera, respectively.

‘Now I realize as someone who knows Sudan, how crucially important that place was and is,’ Maskalyk said fervently. ‘You see within them starvation. It’s not just three or five percent of people-everyone is starving.’

The defining moment of Maskalyk’s service in Sudan was his encounter with a severely dehydrated abandoned girl. ‘She was so thirsty, she tried sucking on my stethoscope,’ he said. He treated her almost daily for Tuberculosis, watching her slow physical recovery as she transformed into a functional child. ‘The unit of human understanding is the story,’ said Maskalyk, author of Six Months in Sudan. ‘It’s the way we make sense of the world we live in. To me, that’s the story of what Sudan is about ‘- that little girl.’

While Maskalyk has made it his life’s mission to practice and teach ‘the medicine of poverty,’ he says that a results driven approach to healthcare in south Sudan has been lacking. ‘The large distribution of money in the form of aid from government to government is a policy failure,’ he said. ‘It hasn’t done anything to eradicate poverty. The body of evidence of this type of medicine is so new that it hasn’t been subjected to the same study of rigor.’

While medical doctors like Maskalyk have traveled to south Sudan to treat patients, others have ventured into the depths of Africa to examine healthcare infrastructure.
Epidemiologist Thomas Handzel, Ph.D., returned from his fourth visit to southern Sudan last week. As a part of the International Emergency and Refugee Health Branch at the Centers for Disease Control, he traveled with colleagues to work on an early warning surveillance system with the World Health Organization. The CDC supports public health needs in Sudan and sees it as ‘very high priority.’

Not only is southern Sudan’s health infrastructure behind that of other countries, according to Handzel, but resources are also lacking. He says transportation systems and roads are flawed, making it difficult to travel to remote locations. Also, Sudan does not have a national reference lab. This means that specimens taken from Sudan to detect outbreaks are sent to Kenya, thereby drastically slowing outbreak detection.

However, the outbreaks are there. ‘The hospital in Malakal had a large number of Kala-azar cases, and was having difficulty finding adequate space for all of them,’ Handzel said of his more than 30 healthcare facility visits in three weeks. ‘It’s a pretty heavy burden. More than half the cases at a health center outside Juba were malaria cases.’
According to Handzel, there are limitations impeding both the humanitarian response and the potential for a functional healthcare system. ‘There is still conflict going on in West Equitoria state,’ he said, recalling the three attacks in the state capital of Yambio during his stay.

West Equitoria state is one of the most dangerous sites in south Sudan affected by the Lord’s Resistance Army, a guerilla organization based out of Uganda that is known to commit crimes against humanity. ‘Agencies have had restricted movement because of the risk for potential of violence,’ Handzel said. ‘It also hurts the humanitarian response and prevents healthcare workers from monitoring conditions.’
While Handzel acknowledges the presence of foreign aid, he believes that it simply is not enough. ‘In more remote areas, access to quality care drops significantly,’ the epidemiologist said. ‘In order to make a difference, much more needs to be done on healthcare, water and sanitation.’

One person hoping to make the difference that Handzel and others speak of is south Sudan native Jacob Atem. A ‘Lost Boy of Sudan,’ Atem traveled 2,000 miles to his freedom when he was a young boy. Now in his late 20s and an American citizen, he is pursuing his master’s in public health with hopes to become a medical doctor.
‘It makes my heart hurt because people are dying from simple diseases,’ Atem said. He added, ‘You are not being shot or eaten by alligator, you are dying from polio, chicken pox, or typhoid.’ Atem’s parents were killed when the ‘Arab muslims’ came and attacked his village when he was six or seven years old ‘- all the Lost Boys of Sudan were assigned the same birth date when they came to America.

Atem founded the South Sudan Health Care Organization, SSHCO, in 2008. He hopes to break ground this month in south Sudan on a health clinic in his home village of Maar. Despite this hope, he speaks candidly about the real issues facing his people, upset with the level of aide provided to southern Sudan by more powerful countries. ‘The United States government ought to do a better job pressuring China,’ he said. ‘You cannot have a health center in place when we are under attack-I cannot build a health clinic in Maar when the regime who killed my parents come and attack the village and kill more people.’
Atem said that the United States must maintain peace between north and south Sudan. ‘The U.S. could give millions of dollars and the next day they are destroyed,’ Atem explained. ‘Peace and stability are critical.’

Peace may, in fact, be imminent in south Sudan, in light of the announcement of an independence referendum to be held in 2011. The refer
endum will decide whether north and south Sudan will become independent countries.
During his service in south Sudan, Dr. Maskalyk saw firsthand the tension between the north and south, saying the country is ‘destined’ to be split in two. ‘If people like those in America and Canada pursue help as much as possible to make a chance for a free and fair referendum, there is a chance it will all end peacefully,’ Maskalyk said of the responsibility of two of the world’s superpowers.
Despite his passion for the ‘medicine of poverty,’ Maskalyk hopes to one day become obsolete in countries like Sudan. He hopes that, with time, emergency medicine will be taught in these countries, allowing others to be health advocates. ‘It’s important to improve the ability of people there to help and have the ability to respond to their own needs in the future,’ Maskalyk explained. ‘Medicine is fun, and it is great to do good medicine. These people will have a chance to really change.’

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