Of a population of 20.440 people potentially infected, were diagnosed 11.364 new cases and died 3.510 people in 2017

The lack of resources will prevent to achieve the goal of eradicating tb by the year 2035

First comes a dry cough, with mucus and blood. Then, the bacteria infect the lungs, eating away at the tissues. Come the night sweats, and the fever increases. At the end of the day, the tiredness is extreme and is accompanied by lack of appetite and subsequent weight loss. If not treated, pulmonary tb, seriously weakens the people, that end up emaciated. Finally, the lungs fill with fluid, causing chronic respiratory failure. At that stage, the treatment is already useless. The patient will die.

In the refugee camps of South Sudan, these symptoms are recognizable to most people; they know that they should go to a doctor as soon as they appear and feel sick.

In the isolation ward of the hospital of Doctors Without Borders (MSF) in the field of Protection of Civilians (PoC) in Malakal, there is a young man sitting next to his bed: lean and with a suit that is dirty and poorly-adjusted. To his side, his elderly mother is concerned about their appearance, and like all visitors from the room, wearing a mask in the mouth to prevent the spread of tb.

despite the insistence of the woman, who tells her that he is recovering, the young lady looks fragile and barely speaks. It is so thin that it is tied a piece of string around the waist to hold the pants. In the soil, has a bowl which he uses as a spittoon. The disease has progressed, but there is still a chance to recover, though only be achieved with medication and proper treatment.

MSF provides tb treatment both for the displaced people in the PoC as to the inhabitants of the neighboring city. Of a population of 20.440 people potentially infected, it is diagnosed 11.364 new cases and died 3.510 people in 2017, according to official figures. This represents a figure in South Sudan approximately 13 times higher than the European Union average.

however, it is almost impossible to find accurate figures on cases of tuberculosis due to the constant movement of people fleeing the violence and lack of medical facilities in unstable areas. So the number of cases could be even higher.

A man sick of a tuberculosis waiting with his mother in the isolation ward of the MSF. P. C.

The tragedy of the youngest nation of Africa is that tb can be treated, even in its advanced stages, “but in a refugee camp, where people live in huts, living on top of each other, the disease is easily transmitted. Tuberculosis is primarily a disease of the vulnerable,” says Harry Aichner, doctor of MSF in Malakal.

“Many people live with latent tb; but they have a strong immune system, and can live a long time without being detected or sick,” she added from the MSF hospital.

There are many forms of tuberculosis, but in South Sudan the lung is the type most commonly diagnosed and represents 80% of the cases.

it Could be said that the tuberculosis patients in Malakal are lucky, because they have access to health services. However, the living conditions in the settlement are terrible. The field has always been densely populated. Currently, the area of settlement of each person is 17 square metres on average, when the standard humanitarian minimum is 30 square metres. Two years ago, the population was double what it is now, and lived in half the space. Are perfect conditions for the spread of pulmonary tuberculosis.

“I Was having a fever, this would come and go. I think I got from a friend. I have been told that I will be under care for three weeks”, pointing to a man of about 30 years.

Many of these people have lost their homes and have been witnesses of how the conflict has claimed lives of friends and family. The men in age to fight at the front are afraid to leave the camp, which is protected by the UN, for fear of being recruited into a militia or even directly killed.

drug Resistance and treatment toxic

The civil war in South Sudan has forced many people to flee their homes, away from the health centres available. In addition, as the funds for the health system evaporate, the hospitals and clinics that existed before the fighting, trying to barely stay open.

it Is estimated that one of every three people are displaced in this country or living as refugees outside of this. In both circumstances, getting a diagnosis and treatment for tuberculosis is incredibly difficult.

The majority of patients in Malakal have had to move several times due to the conflict. Each time that the front line is about a population, families take what they can and flee toward the forested area. For patients with tb, this can mean losing the possibility of having vital drugs and medical assistance.

Without treatment, the tb bacteria can adapt, grow, and become stronger and develop an immunity to the most common drugs. When this occurs, the MSF teams need to find alternative drugs, which can sometimes be toxic, with what is required these cases to monitor closely. With these added complications, the patients take longer to recover.

The stress that causes to live in a war zone leads to many people to the consumption of alcohol and other substances. For some of the inhabitants of the PoC in Malakal, that is the only way to release the pressures of day-to-day of a conflict. “The abuse of alcohol exacerbates the effects of tuberculosis, as it weakens the immune system, decreased by malnutrition,” says Aichner. In addition, the excessive consumption of alcohol can also affect the medication and cause liver damage”.

Many of the patients are in the isolation ward of the MSF hospital admit that they drink a lot and they spend up to six dollars a week on alcohol. This is the sum of colossal in a place where there are few jobs and almost all survive thanks to the assistance of humanitarian organizations. “Many drinkers end up by selling their food rations to buy marisa, the local alcohol,” adds the doctor.

For example, the story of a young man of 27 who lives displaced in the PoC in Malakal: “I Drank about half a litror marisa all day. I started feeling bad and coughing. I lost my appetite and I lost weight. In total, I’ve spent three weeks in the hospital.”

Flee toward Sudan

The tuberculosis has spread to the north and crossed the border into the refugee camps in the state of the White Nile (in Sudan) by means of refugees fleeing the violence. Only in 2017, 53,000 people sought refuge in these settlements. Some of them took three weeks to make the trip across the border to the mega field of Khor al Wharal, who arrived weak and malnourished.

MSF provides care on both sides of the border along the main route of migration. The teams work hard to meet the medical needs of the population, very changeable due to the large flow of refugees. The tuberculosis program is developed on the side of the sudan border in the refugee camps of Khor al Wharal and Al – Kashafa.

The majority of the refugees live with a diet based almost exclusively on sorghum. Poor nutrition can lead to a recovered patient of tuberculosis relapse, since your immune system remains weakened. This vicious circle can be repeated time and time again.

“treatment can be difficult, especially for refugees who do not have access to good food”, explains Yumo Arop, clinical assistant of MSF in Khor al Wharal. “When someone starts to take their medicines, his appetite suddenly increases. But if you do not have what to eat, the hunger could cause terrible pain, so many patients stop taking their medications completely.”

In 2016, MSF developed a specialized program of treatment and training in tuberculosis for the Ministry of Health. The gains were immediate in 2017: of the 190 patients in treatment of tuberculosis in the refugee camp, Khor al Wharal, 66% are recovered fully.

although the rate of TB infection is definitely higher in the refugee population, the local community of the host also is benefiting from the advanced treatment offered by MSF. Hameia Hamed Kameh, an elderly woman, in sudan, has seen how it has changed your life after you have left the bed where he was lying prostrate tuberculosis which affects his spine. “With the help of my friends and family, I went to the MSF hospital. Other doctors charge a lot of money for the attention, and in addition I was diagnosed wrong. The MSF treatment is free,” he says.

The war in South Sudan has had an enormous cost for its people and has become a treatable disease such as tuberculosis in a disaster-threatening for the public health. The international community must do more to support health systems in South Sudan, especially in places like the upper Nile state. The investment in health care (health personnel, facilities and supplies) can bring a real change to the lives of these people, even in the darkest moments.

(*) Philippe Carr is a member of the Communications team at Doctors Without Borders.

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