By Nabeeha Karadawi, MBBS, MRCP, Salma Awad Elkareem Ali Mohamed, MD, and Nagham Ali

“I will see the doctor here, but I’m not sure how much help they’ll be able to offer. I just hope I can see my kids reach safety.”

Dr. A* is a doctor and mother of three who was diagnosed with de novo hormone sensitive metastatic breast cancer whilst breastfeeding her 3-year-old child. She was taking palbociclib and letrozole, until the conflict struck in Sudan, and she was left without access to medication and the sudden need to escape the war-torn bloodshed in the capital city, Khartoum. Dr. A and her family travelled to reach Wadi Halfa, in hopes of crossing the border to reach safety in Egypt—a journey that took a fortnight.

At the crowded bus stop where many Sudanese anxiously wait for the next bus to Egypt, Mr. Y* is in the midst of a frantic crowd, struggling to stand. Those around him are unaware that he has recently been told that he had metastases in his back and is losing his ability to walk. He contacted a doctor who advised him to start dexamethasone; however, there is none to be found in Sudan, forcing Mr. Y to resort to paracetamol. He hopes he can see a radiation oncologist soon to relieve his pain, but until then he stands in silence, fighting the pain with uncertain hope.

Dr. A and Mr. Y are just two out of millions of people who have been affected by the conflict in Sudan.

Sudan is one of the largest countries in Africa, with a population of almost 50 million people. Despite the governmental instability since gaining independence, Sudan managed to maintain a reasonable health system, although there is no national cancer registry activated yet. The first radiation and oncology centre was established in Khartoum in the 1960s, in cooperation with the International Atomic Energy Agency. There are two public radiation centres in Sudan, one at Khartoum Oncology Hospital and one in Wad Medani. In the past few years there has been a movement towards decentralising cancer care by opening satellite centres in other areas of Sudan, but Khartoum has remained the centre that patients travel to for advanced diagnostics, imaging, and highly experienced health care staff. Only four or five private centres exist where chemotherapy and targeted therapy were delivered to patients.¹

As such, a significant number of patients from the peripheries of Sudan, as well as citizens from neighbouring nations such as Eritrea and Chad, sought medical advice in Khartoum. There are no radiation centres in Eritrea, Chad, or South Sudan. Radiation treatment was offered at a minimal cost for both Sudanese citizens and international patients. The Khartoum Oncology Centre used to deliver infusion chemotherapy and other anticancer medication to more than 80 patients per day. They cared for almost 200 new patients in outpatient services weekly, including delivering oral anticancer treatment. The total number of outpatient reviews exceeded 1,500 every week.²

On the morning of Saturday, April 15, 2023, fighting broke out between the Rapid Support Forces (a paramilitary group) and the Sudanese militia. For all those going about their normal errands, Khartoum suddenly became the centre of bombing and gunfire, with many wounded bodies in sight. The unanticipated nature of the conflict led to disbelief. No one was prepared.

Health care facilities were attacked.³ Health care workers, patients, and caregivers were forced to leave hospitals. Since the start of the war, all ongoing anticancer treatments in Khartoum and Darfur centres have been placed on hold. All stored chemotherapy agents and other infusion anticancer treatments have expired due to electricity shortages. The National Medical Supply, the main supply for all medicines in Khartoum and other provinces, has been severely damaged, impacting the care of patients with a variety of diagnoses, including cancer.⁴

Many began a new journey full of suffering, uncertainty, and hopelessness. More than 2 million people have been displaced from their homes, either to other provinces or outside of Sudan entirely. Patients on active treatment have lost contact with their primary physicians. Those who have managed to flee have done so with no documents, medical reports, or results, creating more pressure on centres outside and inside Sudan, which have no way of reviewing patients’ histopathology results, imaging, and history. Helpless physicians have fled in search of refuge elsewhere. Medical and clinical oncologists have lost their jobs and have been forced to leave to protect their families.

With the abrupt nature of the war, even healthy people have struggled to deal with the physical, mental, and financial consequences. The sandy roads are filled with potholes and travel is dangerous. Healthy individuals seeking refuge have died due to the length and danger of the journey, and it is even more arduous for patients with cancer whose health is already compromised.⁵

Many Sudanese oncologists living abroad have tried to reach out through social media to direct or sometimes give advice over the phone. Some patients were directed to cancer care centres in peripheries, who have opened their arms to care for and treat patients, despite the inability to get new medication supplies and unbearable pressure caused by the huge extra demand for treatment. Despite our continuous efforts to help, we face many obstacles in supplying chemotherapy and even basic therapies such as tamoxifen and letrozole. Cold chain transportation is extremely difficult and is accompanied with little financial support. It is impossible at a personal level to make a difference. A drastic and immediate international effort is needed to support the devastating situation that patients with cancer in Sudan face, mirroring the aid given to Ukraine, Syria, and other countries recently affected by conflict.

Globally, cancer care is based on a multidisciplinary approach. Due to the heterogeneity of cancer and the diversity of populations in many nations, gathering globally as one community will surely help to develop a better strategy to care for patients with cancer in every country, not only during times of conflict and natural disaster but as a way of providing the care that patients have always deserved.

Despite the many devastating effects that war and tragedies around the world have had on patients and doctors alike, we think we can all agree that these tragedies have also bridged the gap between us, caused us to strive for improvement in patient care and, perhaps most importantly, humanised us all.

We would like to thank ASCO in helping us raise awareness and address the drastic situation in Sudan.

*Names and details changed for patient privacy.

Dr. Karadawi is a consultant medical oncologist originally from Sudan and currently working abroad. She completed her specialist training in Ireland and moved recently to the Middle East. She aims to improve cancer care for countries in crisis through advocacy and initiative. Disclosure.

Dr. Mohamed is a consultant clinical oncologist at Khartoum Oncology Hospital, Sudan. Disclosure.

Ms. Ali is a medical student at Queen’s University Belfast. She strongly believes in advocating for those who do not have a voice, hoping to better their health care outcomes. Disclosure.

References

1. Christ SM, Siddig S, Elbashir F, et al. Radiation Oncology in the Land of the Pyramids: How Sudan Continues to Push the Frontiers of Cancer Care in Eastern Africa. Int J Radiat Oncol Biol Phys. 2021;110:931-9.
2. Abdelhafiez N, Osman S. Cancer Care in Sudan During the COVID-19 Pandemic. The ASCO Post. 2021 Apr 25. Accessed 2023 Sep 8.
3. Sudan fighting in its 10th day: Here is a list of key events. Al Jazeera. 2023 Apr 24. Accessed 2023 Sep 8.
4. Siddiqui U, Mohamed H. Internet Outage Reported Across Sudan as Deadly Fighting Persists. Al Jazeera. 2023 Apr 23. Accessed 2023 Sep 8. 
5. Al-Mandhari A, Moeti M. Three months of violence in Sudan: Health hanging in the balance. World Health Organization. 2023 Jul 24. Accessed 2023 Sep 8.