This blog was written and submitted by Dr Nahla Gafer, a clinical oncologist at the Khartoum Oncology Hospital, Sudan. 

Watchful Waiting.
It all started by hearing some fireworks on Saturday morning, 15th of April. Thank God the boys were at home, in addition to their friend and a lady who helps with the house-chores once a week. When the shooting did not seem to end, we opened the news (Alhadath TV channel), and there it was: a conflict between 2 armed forces in Sudan. We are hearing mixed information about who started the fight, but what was sure is that the fight is extensive at several cities, all parts of Khartoum and using all types of arms.

Through WhatsApp and Facebook we received the information to stay at home, that it was dangerous to leave house, as well as information showing which party is on the right and which party is winning (which is strangely each side!) and that everything will end in a day or two.

From that moment our lives changed 180 degrees. All daily plans were cancelled, even near-future plans became so absurd. A war was held on top of our heads and we have no say in it and not even the right to ask, or check how we are going to survive. WhatsApp messages were active throughout the day. We were checking about our close relatives and neighbors. Comforting ourselves that if they are okay, we shall be okay; that if they are staying, it is safe for us to stay. Advising them to store up water and food supplies, and they in turn advising us to stay on a ground floor: We live on the first floor. It is not possible for us suddenly to change residence. 

But our situation is relatively good. People were stranded in the middle of Khartoum in their work or study institutes. With no food, no bed, and no silence at night. There was no transport, no cars. You cannot even pop your head outside the door. And a lot of them ran out of charger or mobile credit. An artist was caught up in the national museum, under the direct fires of a snipper above him. For three days he ate nothing but his paints; luckily, they were organic. 

On the second day, there was a 3 hour “truce.” My son’s friend had his father come to a nearby place to pick him up. The house help said it is better for her to try to return home, because living in the peripheries of the city, there is less shooting. [She reached safely through a large lorry that collected a group of people and took them to the other side of Khartoum, across the bridge. Two days later she called. They are without electricity and without water]. We passed the 2nd night only myself and my sons. We took turns in sleeping, in case the sound of the shooting increased, or we were hit, and were forced to move! Although we had no idea where to move to.

Luckily, up to the third day, we had no electricity cut outs. I started filling all containers with water and told the boys to help with that. Then the water supply was cut. I was angry to find a jug under the table missed by my son. Water economizing started when the tap water stopped running: we were eating in the same pan we cooked in, reducing the items to wash; we were collecting used water to drain down the toilet. Just in case, we prepared each a bag with our main documents and essential personal items. I looked back to all my possession in the apartment, reflecting on where, when, and why I got them, how I sweated in order to have them, and realizing that I might have to leave them and never come back.

Meanwhile, I started receiving some text messages from my patients. Some had an appointment for pain follow-up and drug prescription; some were just starting their journey of chemotherapy.  To all I had to reply, sorry we are not working tomorrow, and we do not know when we shall return.

I contacted a family whom we were supposed to visit their mother on Monday. The trip is cancelled. Unfortunately, we had not even done the preliminary assessment. We shall wait for the sound of bombings to lower before conducting a meeting through WhatsApp video.

In the afternoon, my phone rang. It was a very nice lady, she told me, “Doctor, I have an appointment tomorrow, are you working?” I asked her where she was calling from as I thought she was staying in one of the few cities unaffected by war, and she answered, “I am in Khartoum, in Sahafa district.” My second question was, “Can you go outside the front door?” and the answer was no. I told her, “We are in war, you cannot go out; neither can I.” 

Your life is the most valuable thing
A friend of a friend from another Arab country was trapped in the center of Khartoum. I was informed to contact him on Tuesday. I told him that his location is a death trap, urging him to get out. That triggered the thinking that our location would be a death trap in a few days. I watched some YouTube videos about how cities forge under war as well as how a country changed in 10 years due to war. 

The decision came to escape. I had a colleague living at the outskirts in Khartoum. It was a Wednesday, it was a “truce” period. Truce because both fighting parties agreed to cease fire, but the parenthesis is because within a few hours within its start, we hear the bombings and the shootings. We prepared our bags, left a lifetime of possessions and pastimes, and walked into the deserted streets. Sometimes being alone in a street with not a single sound, not even a bird chipping, can be one of the most frightful experiences – it’s like moving in the dark; you do not know what might come next.

We reached the main road, ready to run in case we see any military vehicle, except the ones near our house, with whom there was a tacit pact: first day they arrived, they told my son and his friend, when they ventured out, “stop don’t approach”; the second day, my son gave the soldiers cigarettes and the third day, when one of the boys pops his head out of the door he takes permission “going to the shop nearby and coming back”, and they nod .. it’s okay. We became prisoners in our own home.

Back to the day we left home, there was no one in the street, until we reached the main road, we took 4 types of transport, walking for interrupted periods, public transport and two lifts. We arrived at our destination in over three hours; a trip that usually takes about 40 min.

The place where we went to is almost in the outskirts of the city, in a neighbourhood much quieter than home. As a consequence of this war, there was no electricity and no water for the last three days; they needed to buy water from a donkey owner, and it was stale. We developed gastroentritis. In the evening we discussed amongst ourselves the importance of leaving the place; already the food supplies of the generous family hosting us were thinning , there was no internet connection and even at night we heard shootings. In the morning, we saw the reason for the discontinuous shooting, at the bridge, there was a battalion on alert. 

The trip to the second house was another adventure, along the way, there were army vehicles overturned and burnt. Along the way, we saw the young fighters roaming around in different points of irtikas and road intersections. We heard stories about these “militia” stopping cars, asking in a joking way, do you have X or X (their opponents), the answer would be no. Then they say, “You can go. Happy Eid”. It was not a happy Eid for us, and it was not a happy Eid for the 48 million Sudanese people who had their lives overturned in a few days.

Watching the TV, the army is having a strong hold, that they are winning, that they are chasing the “militia”, and some friends working in the army told me, “You shall hear good news in a day or two;” a week passed, and all news was about complete destruction. Renowned hospitals, a couple of banks, the airport, the ministry of higher education, several blocks of houses, which later became hundreds of houses, were all blown up. Along the torturous trip we saw only the RSF, standing by, not disturbing the people.

The good news is that the two armies were not targeting civilians – mainly; the bad news is that they are using all forces to annihilate each other, with little concern about people’s property, comfort, or life.

Kind people under “unkind” rulers

The Sudanese people, in general, happen to be one of the kindest in the world. If you are a guest or a visitor, you are not expected to pay for anything. We witnessed that several times along the way, to the degree that a stranger paid the Rikso driver and gave us cash in order to cover transport expenses back. He understood that we were economizing on the money we had, and that however long it takes, we shall be walking. That city was far off, away from any shootings, but it was a very hot afternoon.
It was people contacting us by phone, offering their houses, and checking that we were safe. People from Sudan, as well as friends from all over the world, asking about us; checking that we are okay, and ready to help by all means.

A kind family took us into their village. So simple, among the fields [third station]. We witnessed village life: tens of visitors in the day, in addition to the already extended family living together. A lady with her husband and children taking in the families of two of her sisters, and her brother; all that in addition to us four, myself, my sons and our friend from Lebanon.

The “last” bus to safety

On the second station in our trip, for a couple of days, it was paradise; we enjoyed a four story building, with huge stocks of water and food. The internet was good; and together with nurse Mahasin, we started contacting the patients whom we were supposed to visit at home. We chatted with 4 patients and their families; we used the video call for examining the patient, asking the co-patient (carer) to open the mouth, and turn over the patient in order to see the bed sores. 

Unfortunately, on the third day, in the evening, the noises from the shooting re-appeared and they were so near to us, we went inside into the innermost part of the house to escape injury. One of the patients we are following remotely mentioned travelling outside Khartoum. I immediately asked her, how are you going to do that. She mentioned, we are renting a bus. I asked her if we can travel with them, that we are four. She came back to me, with a yes. I forwarded the money through bankak (that is, the main bank internet application in the country, which latter malfunctioned, or you can’t connect to it). We were lucky in that the bus they are renting will stop a 20 min walking distance from where we were; otherwise, going across the city to catch the bus, would have been very dangerous. Later I learnt that this company stopped further travels because of lack of buses and fuel.

During the first two hours of the trip we could barely breathe. The bus came by a carro driver, and a bridge, a few hours later we learnt the bridge was attacked and the carro driver was slaughtered by prisoners released from prison and handed white weapons. Three prisons where opened, and the prisoners released, mainly because the prisoners were kept without food for three days; it is unclear which group released the prisoners. Each is accusing the other, in addition to Kataeeb Alzil “literally troops of the dark”, an Islamic terrorist group interested in the propagation of war, and the sabotaging of all democracy efforts.

The family of my “patient”, actually my “saver” lives in a secluded village where social ties are strong, and the people are forward and simple. They had tall walls made of mud, which made need for air coolers minimum; they also had a manual water pump, but there were no telephone or internet connections. Me and my sons stayed there for some time. Our Lebanese friend travelled further north trying to cross to Egypt.

I kept hearing stories from our neighborhood in Menshia, a house near ours was destroyed and three members of the family died on the spot. Shops are not working, banks are not working, western union is not working, the circulating currency is getting smaller, no access to internet banking, no police around, no official guidance or rescue missions. It seems as if the government is targeting its people. The city entered into a difficult phase: no security: you can be stabbed by a knife if you walk down the streets; water and electricity and mobile connections are cut off, no petrol for the cars, and as such no health care, no food supplies entering, making it more dangerous and more expensive to get out. Food supplies are running out, and more crimes appearing with complete absence of the police, even there is organized rubbery: a minivan with 3 or 4 men attacking disserted shops and carrying all valuables. No transport, no work, no schools, no source of income, and no water. All pointing to a volcano of catastrophe soon to erupt.

Dr Mohja Khairallah is a family physician and palliative care specialist at the Khartoum Oncology Hospital in Sudan. She founded the Comboni Palliative Care Volunteers (CPCVs) and recently led palliative care trainings in Mauritania through Cairdeas Sahara. During this last week of April 2023, she shared her observations and reflections on the need of palliative care – and peace – in Sudan.

Note that accompanying photos are taken before 2023 during a time of peace in the Khartoum area.

Since 15th April (the first day of our social unrest) I've been locked in my small town 40 km south of Khartoum, Sudan where I live with my family, and we are all safe physically (thank God). I have cared for three patients with different neurological conditions at their home, with no resources, in this time. Unfortunately, I lost two of them because they couldn't get the hospital care (ICU) that they needed; we thank God the third one is stable and well. The current need for palliative care is the greatest ever.

1. For cancer patients:

Unfortunately, opioids have not been available for the last 4 months, and now even the access to the alternative available pain killers, cancer treatment, and face to face support are no longer possible, especially in the capital city.

2. For patients with medical emergencies, injuries, and chronic diseases:

Most of the hospitals are out of service or closed, due to lack of medicine, that the staff cannot reach the hospitals and insecurity. Death is everywhere, with very sick patients who have left the hospitals, HDUs & ICUs and have died in the community (homes).

3. The death of innocent people and the smelly dead bodies thrown in the streets cause a lot of pain and worries for families and communities. 

4. Lack of basic life needs (water, food, security) makes people terrified. Now, a lot of Sudanese are leaving the country to face a new suffering of becoming refugees.

5. Telemedicine is no longer an option to provide palliative/medical care since the networks and tele. companies have no /or interrupted services.

I've tried to help my people and wrote a letter to our local community and army leaders asking for their support, protection, and contribution in establishing a volunteer clinic for patients with chronic diseases (including cancer). This clinic would aim to provide simple palliative and medical care and follow-up services safely, while reducing the workload for the only functioning hospital in the area.

But as you know, a such process to set up a volunteer clinic can take time, especially in times of war. Yet I am waiting for their positive response.

Lately I have noticed in myself and most of my friends, that watching news on some channels have increased our sadness, tension, and fear.

After a while we discover that the news channels only amplify these feelings, so we have decided to engage the news of reality. That is, the news based on what we see with our eyes (the streets are clear) and what we hear from others. (I call my loved ones in different areas, and they reassure me about their wellbeing, their family, and their neighbourhood.)

Really, the news of reality is different.

And this is my wish to you: Keep your inner peace and mental safety. We will have a homeland tomorrow; we want to build Sudan. 

This blog was written and submitted by Dr Nahla Gafer, a clinical oncologist at the Khartoum Oncology Hospital, Sudan. Today she shares about her recent visit to Mauritania and explains more about both Sudan and Mauritania. 

Background

Dr Dave Fearon or "Dr Daveed" as he is called by Dr Ekhtelbenina Zein, director of the National Oncology Center (CNO), has been known as the first one to speak of and push for palliative care in Mauritania. This is our second invitation to Mauritania by Cairdeas Sahara. The first was in 2017 working with the volunteers at the community level and training general practitioners from different states (wilayat). Dr Dave Fearon has paved the way for this visit in order to impact the palliative care services at CNO. This time, we were three trainers from Sudan with more than 10 years of experience in palliative care for oncology patients. 

Positive Aspects at the National Oncology Center

The administration and equipment exceed that of Sudan: the palliative care service has got a dedicated building, with dressing room, nurse office, counselling room, training area and offices for pharmacy, social worker, nutrition office and donating NGOs. All that in addition to the 8-bedded day care area. On the first day, we were met with the director of the hospital and the heads of the different departments. The director of the hospital struck us as amply knowledgeable and committed to providing palliative care to the patients in the center. Nouakchott Oncology Center, a 5 min walk from the Bureau of Palliative Services, provides high level radiotherapy treatments (3DRT, VAT and IMRT) as well as surgery (especially endoscopic), interventional radiology and targeted therapy.

Cultural Similarities

Across four countries in between (Sahel countries), and amongst the eleven neighboring countries for both, no two are so similar as Sudan and Mauritania in culture, nature, and landscape.  With dress, for example, the thoub distinctive to married Sudanese ladies is almost the same malhafa, dressed by all Mauritanian ladies, though fixed in a different manner. Mauritania on the Atlantic Ocean is a bridge between North Africa and the Sub-Saharan Africa, as is Sudan facing the Rea Sea on the extreme east of the continent. Similar attire, similar traditions, similar gender roles, and almost similar beauty standards. Yet to reach such a country we had to travel northeast, leave Africa to Asia (Istanbul, Turkey) and then back southwest to reach Mauritania. 

The South-South Interaction

Apart from the 12 interactive sessions given (for some candidates it was the first training they attend in palliative care), these were the highlights of the visit:

-    Fostering a holistic responsibility for the patient by each of the team members

-    Instilling the values of patient comes first, patient autonomy and patients’ rights, especially with the issue of families refusing the patient be told the diagnosis

-    Working as a team and supporting each other

-    Directing the financial aid according to socio-economic status

-    Addressing spiritual issues (with rephrased questions in Arabic), which were previously ignored for two reasons: lack of insight by the patient, questions not adapted to Islam

-    Implementing a summarized and simplified comprehensive four pages for PC clerking in Arabic (understood by the majority of the team members) compared to the French version which was 17 pages and with less than 50% of the team members able to write in French.

Future Plans

Unfortunately, the taboo surrounding cancer in Mauritania is so great that even asking about the symptoms is a problem. We, as a visiting team would like to co-ordinate further training of the treating physicians about breaking bad news, as well as an annual visit to improve the services – as mentioned by Dr Ekhtelbenina Zein, things can change step by step. Speaking more openly about cancer, we would like to help direct efforts for the early detection and screening, thus making use of the full services offered at CNO.  

This two-week training period has opened the eyes of the staff to a lot of improvements that can be made. It is with such keen administration and caring personnel that positive changes are expected. 

For us, as a visiting team, we have a lot to carry back to Sudan: this model of a stand-alone day care service; my colleague nurse who learnt how to prepare sessions and execute them in a conductive manner, and myself learning from the different aspects of care, especially becoming more proficient in convincing the families about patient’s right to know. It was great for them to attend the sessions conducted by Dr Mohja given in classical Arabic, while she made a second attempt to learn the Hassania dialect. 

Many thanks to Cairdeas Sahara for making such a visit possible, with gratitude to Dr Dave Fearon and to the Mauritanian people.