The Blue Nile and the Invisible Wound: Sudan's Health Catastrophe

La inversión pública en salud era mínima, heredada de décadas de dictadura y de sanciones internacionales.

Public investment in health was minimal, inherited from decades of dictatorship and international sanctions.

Lo que existía era frágil, pero existía.

What existed was fragile, but it existed.

Ahora, en muchas provincias, no existe casi nada.

Now, in many provinces, almost nothing exists.

I covered the tail end of the al-Bashir era, not from inside Sudan but through sources in the region.

The international sanctions from the U.S.

and others, they were supposed to pressure the government, but one of the things they actually did was restrict the import of medical equipment.

Sudanese hospitals couldn't get dialysis machines, imaging equipment, certain drugs.

The sanctions hit the population, not the regime.

Esto es algo que se repite mucho en la historia de las sanciones internacionales.

This is something that repeats itself often in the history of international sanctions.

Se diseñan para castigar a los gobiernos y terminan castigando a los ciudadanos.

They are designed to punish governments and end up punishing citizens.

Y en el caso de Sudán, esa herencia hace que ahora, cuando el sistema se colapsa, no haya ninguna reserva de capacidad sobre la que apoyarse.

And in Sudan's case, that legacy means that now, when the system collapses, there is no reserve of capacity to fall back on.

What diseases are we actually talking about right now, on the ground?

El cólera es el más urgente.

Cholera is the most urgent.

Ha habido decenas de miles de casos confirmados desde que comenzó la guerra, con una tasa de mortalidad muy superior a lo que sería aceptable en condiciones normales porque no hay suficiente suero oral de rehidratación ni personal para administrarlo.

There have been tens of thousands of confirmed cases since the war began, with a mortality rate far higher than would be acceptable under normal conditions because there is not enough oral rehydration solution or staff to administer it.

Y luego está el sarampión, que regresó con fuerza porque las campañas de vacunación se interrumpieron.

And then there is measles, which returned strongly because vaccination campaigns were interrupted.

Measles.

A vaccine-preventable disease.

In the twenty-first century.

That's the part that lands differently when you say it out loud.

Y no olvidemos el paludismo, que en las regiones del sur como el Estado del Nilo Azul es endémico.

And let's not forget malaria, which in southern regions like Blue Nile State is endemic.

Sin acceso a mosquiteros, sin tratamiento antimalárico disponible, las tasas de mortalidad infantil en estas zonas se han disparado de una manera que los epidemiólogos definen como una emergencia dentro de la emergencia.

Without access to mosquito nets, without available antimalarial treatment, infant mortality rates in these areas have skyrocketed in a way that epidemiologists define as an emergency within the emergency.

An emergency within an emergency.

That phrase is doing a lot of work.

Es que la situación lo requiere.

The situation demands it.

Fíjate: al mismo tiempo que hay un conflicto armado activo, hay una crisis de hambre que la ONU ha calificado en algunos distritos como hambruna real, no solo inseguridad alimentaria.

Think about it: at the same time there is an active armed conflict, there is a hunger crisis that the UN has classified in some districts as actual famine, not just food insecurity.

Y la desnutrición aguda severa en niños menores de cinco años colapsa el sistema inmunológico de tal manera que enfermedades como el sarampión o el cólera matan a niños que, bien nutridos, habrían sobrevivido.

And severe acute malnutrition in children under five collapses the immune system in such a way that diseases like measles or cholera kill children who, if well-nourished, would have survived.

The interaction between malnutrition and disease is something that gets lost in a lot of coverage.

People see famine numbers and disease numbers as separate columns.

They're not.

A starving child has almost no defense against a respiratory infection that a healthy child would shake off in a week.

Hay un concepto médico para esto: la espiral de deterioro sinérgico.

There is a medical concept for this: the synergistic deterioration spiral.

Cada factor, la malnutrición, la falta de agua potable, la ausencia de atención médica, el desplazamiento, amplifica a todos los demás.

Each factor, malnutrition, lack of clean water, absence of medical care, displacement, amplifies all the others.

No se suman, se multiplican.

They don't add up, they multiply.

Eso es exactamente lo que está ocurriendo en el Estado del Nilo Azul y en Darfur y en Jartum.

That is exactly what is happening in Blue Nile State and in Darfur and in Khartoum.

Let's talk about Khartoum for a second, because the capital being a war zone is something that still feels surreal to me.

This is a city of six or seven million people.

I spent two days there in 2004, passing through on my way to cover something in Eritrea.

It was functional, it was bustling.

What's left?

Poca cosa.

Very little.

Los principales hospitales de Jartum fueron escenario de combates directos.

The main hospitals in Khartoum were the scenes of direct combat.

El Hospital de Enseñanza de Jartum, que era el centro médico de referencia del país, fue ocupado por las FSR durante meses y cuando las fuerzas armadas lo recuperaron, el equipamiento había desaparecido o estaba destruido.

Khartoum Teaching Hospital, which was the country's reference medical center, was occupied by the RSF for months and when the armed forces recovered it, the equipment had disappeared or was destroyed.

Hablamos del hospital donde se formaban los médicos especialistas de todo el país.

We're talking about the hospital where specialist doctors from across the country were trained.

And losing that training infrastructure isn't a six-month problem.

That's a generational problem.

You lose a decade of trained physicians.

Totalmente.

Completely.

La fuga de cerebros en el sector sanitario ha sido devastadora.

The brain drain in the health sector has been devastating.

Médicos, enfermeras, técnicos de laboratorio: muchos han cruzado a Egipto, a Etiopía, a países del Golfo.

Doctors, nurses, lab technicians: many have crossed into Egypt, Ethiopia, Gulf countries.

Los que se quedaron lo hicieron por razones personales o porque no pudieron marcharse.

Those who stayed did so for personal reasons or because they couldn't leave.

Y están trabajando sin suministros, sin electricidad estable, en condiciones que en cualquier otro contexto serían impensables.

And they are working without supplies, without stable electricity, in conditions that in any other context would be unthinkable.

The international response.

I want to push on this, because it has been, by almost any measure, inadequate.

The UN has been repeatedly calling for humanitarian access and repeatedly being blocked.

What's the dynamic there?

Las dos partes, tanto el ejército sudanés como las FSR, han usado el acceso humanitario como arma.

Both sides, both the Sudanese army and the RSF, have used humanitarian access as a weapon.

Literalmente como arma.

Literally as a weapon.

Bloquear la llegada de comida y medicamentos a las zonas controladas por el enemigo forma parte de la estrategia militar.

Blocking the arrival of food and medicine to enemy-controlled areas is part of the military strategy.

Esto viola el derecho internacional humanitario de manera flagrante, pero ninguna de las dos partes tiene incentivo para cumplirlo si la otra tampoco lo hace.

This violates international humanitarian law in a flagrant way, but neither side has any incentive to comply if the other doesn't either.

And the geopolitics of who's supporting whom makes collective international pressure nearly impossible.

The UAE has been accused of supporting the RSF, Egypt has been backing the Sudanese Army, Russia has had its own interests tied in there.

It's a proxy map that nobody wants to draw cleanly.

Y mientras se juega esa partida de ajedrez geopolítica, en el Estado del Nilo Azul, en Darfur, en el Nilo Blanco, la gente muere de cólera y de hambre y de heridas de guerra que nadie puede tratar.

And while that geopolitical chess game is being played, in Blue Nile State, in Darfur, in White Nile, people are dying of cholera and hunger and war wounds that no one can treat.

La distancia entre las capitales donde se toman las decisiones y los campos de desplazados donde se viven las consecuencias es, en este caso, absolutamente obscena.

The distance between the capitals where decisions are made and the displacement camps where the consequences are lived is, in this case, absolutely obscene.

I want to zoom out for a second, because there's a bigger pattern here that I think is worth naming.

In the last twenty years, the world's worst health crises, and I mean worst in terms of scale, in Yemen, in Syria, in the DRC, in now Sudan, they are almost always conflict-driven.

War is the leading cause of preventable death in this century.

Sí, y hay algo perverso en cómo el mundo de la salud pública tiende a tratar estas crisis.

Yes, and there is something perverse in how the world of public health tends to treat these crises.

Se diseñan protocolos, se envían misiones de evaluación, se publican informes.

Protocols are designed, assessment missions are sent, reports are published.

Pero el problema no es de protocolo: es político.

But the problem is not one of protocol: it is political.

Sin un acuerdo político real entre las partes, todo lo demás es gestión de la catástrofe, no solución.

Without a real political agreement between the parties, everything else is disaster management, not a solution.

Fair point.

And yet I'd push back slightly, because I think there's a risk in saying the health response is useless until there's peace.

There have been cases, northern Uganda in the early 2000s, parts of Lebanon even, where health workers created what they called corridors of tranquility.

Temporary, imperfect, but real.

Tienes razón, y no pretendía decir que sea inútil.

You are right, and I didn't mean to say it's useless.

Lo que digo es que tiene un límite estructural muy real.

What I'm saying is that it has a very real structural limit.

Puede salvar vidas individuales, y eso importa enormemente, por supuesto.

It can save individual lives, and that matters enormously, of course.

Pero sin paz no puede reconstruir el sistema.

But without peace it cannot rebuild the system.

Y lo que Sudán necesita no es solo salvar vidas esta semana: necesita un sistema que funcione dentro de diez años.

And what Sudan needs is not just to save lives this week: it needs a system that works ten years from now.

That's actually the right frame.

The acute and the chronic are two different problems running in parallel, and you can't solve the chronic one while the war is happening.

What does a post-conflict reconstruction of Sudan's health system even look like, realistically?

Llevaría décadas y costaría miles de millones.

It would take decades and cost billions.

El precedente de Sudán del Sur no es muy alentador: ese país se independizó en 2011 con grandes promesas internacionales y en 2013 ya tenía otra guerra civil.

The precedent of South Sudan is not very encouraging: that country became independent in 2011 with great international promises and by 2013 it already had another civil war.

Reconstruir infraestructura sanitaria en una sociedad fragmentada étnicamente, políticamente y económicamente como la sudanesa requeriría un esfuerzo de cooperación internacional sostenido que históricamente el mundo ha sido muy poco capaz de mantener.

Rebuilding health infrastructure in a society as fragmented ethnically, politically, and economically as Sudan's would require a sustained international cooperation effort that historically the world has been very poorly capable of maintaining.

South Sudan.

There's a story that deserved a better ending than it got.

I was in Juba the week after independence.

The optimism was real.

And then it wasn't.

Y lo trágico es que gran parte de la población de Sudán del Sur se refugió en Sudán cuando estalló esa guerra en 2013.

And the tragic part is that a large part of South Sudan's population took refuge in Sudan when that war erupted in 2013.

Y ahora, con la guerra en Sudán, algunos de esos mismos refugiados han tenido que volver a huir.

And now, with the war in Sudan, some of those same refugees have had to flee again.

Es una historia de desplazamientos en círculos que no termina nunca.

It is a story of displacement in circles that never ends.

Displacement in circles.

I keep coming back to the numbers.

Twelve million internally displaced, another two million who've crossed into neighboring countries.

That's a human scale that's hard to hold in your head.

Y cada uno de esos catorce millones de personas tiene una historia médica interrumpida.

And each one of those fourteen million people has an interrupted medical history.

Una madre que estaba en tratamiento por tuberculosis y ya no puede acceder a la medicación.

A mother who was being treated for tuberculosis and can no longer access medication.

Un niño con diabetes que no tiene insulina.

A child with diabetes who has no insulin.

Un anciano con hipertensión sin antihipertensivos.

An elderly person with hypertension and no antihypertensives.

No son estadísticas: son procesos de deterioro lento que nadie ve porque nadie está mirando.

They are not statistics: they are processes of slow deterioration that no one sees because no one is looking.

That framing, interrupted medical histories, that's something that public health professionals talk about but it almost never makes it into news coverage.

The story is always about the acute: the bombing, the outbreak, the famine number.

The slow erosion is invisible.

Y esa invisibilidad tiene consecuencias.

And that invisibility has consequences.

Las donaciones internacionales responden a imágenes y a momentos de crisis visible.

International donations respond to images and moments of visible crisis.

Cuando la crisis es crónica y silenciosa, los fondos no llegan.

When the crisis is chronic and silent, the funds don't arrive.

UNICEF y el ACNUR llevan meses advirtiendo de que las operaciones en Sudán están financiadas a menos del cuarenta por ciento de lo necesario.

UNICEF and the UNHCR have spent months warning that operations in Sudan are funded at less than forty percent of what is needed.

Less than forty percent.

And the Al-Kili news, the news that actually triggered this conversation, will get maybe a paragraph in most international outlets.

A territorial shift that changes nothing for those twelve million people and is reported as if it might.

Eso es exactamente el problema de cómo cubrimos los conflictos.

That is exactly the problem with how we cover conflicts.

Seguimos los movimientos militares porque son verificables, tienen coordenadas, tienen comunicados oficiales.

We follow military movements because they are verifiable, they have coordinates, they have official statements.

La catástrofe sanitaria que ocurre simultáneamente no tiene portavoz, no tiene mapas claros, no tiene victorias ni derrotas que anunciar.

The health catastrophe that is happening simultaneously has no spokesperson, no clear maps, no victories or defeats to announce.

Octavio, before we wrap up, you used a phrase a few minutes ago that I want to circle back to.

You said the people dying were going through "un proceso de deterioro lento." I understood what you meant but I wasn't entirely sure whether "deterioro" was the same as the English word "deterioration" or whether it carries something different in Spanish.

Buena pregunta.

Good question.

El sustantivo "deterioro" y el verbo "deteriorarse" sí son cognados directos del inglés, y funcionan de manera muy similar.

The noun 'deterioro' and the verb 'deteriorarse' are direct cognates of the English, and they work in a very similar way.

Pero en español se usan con mucha más naturalidad en contextos cotidianos que en inglés.

But in Spanish they are used much more naturally in everyday contexts than in English.

Decimos que la situación se deteriora, que la salud de alguien se ha deteriorado, que las relaciones entre dos países se están deteriorando.

We say the situation is deteriorating, that someone's health has deteriorated, that relations between two countries are deteriorating.

Es una palabra muy flexible.

It is a very flexible word.

So "deteriorarse" is the reflexive form.

The situation deteriorates itself, almost.

It's not done to it, it happens to it.

That reflexive construction in Spanish still catches me off guard sometimes.

Exacto, y eso es algo que los anglófonos tienden a subestimar en español.

Exactly, and that is something English speakers tend to underestimate in Spanish.

Los verbos reflexivos no siempre implican que el sujeto se hace algo a sí mismo deliberadamente.

Reflexive verbs don't always imply that the subject does something to itself deliberately.

A veces simplemente expresan un proceso que ocurre, casi sin agente.

Sometimes they simply express a process that happens, almost without an agent.

"La ciudad se destruyó" suena diferente a "alguien destruyó la ciudad", aunque los hechos sean los mismos.

'The city destroyed itself' sounds different from 'someone destroyed the city', even if the facts are the same.

That's actually a really useful distinction for talking about crises, isn't it.

Whether you say something was destroyed or destroyed itself carries a moral weight in the framing.

Journalists should probably think about that more than we do.

Fletcher haciendo periodismo y lingüística al mismo tiempo.

Fletcher doing journalism and linguistics at the same time.

No está mal para alguien que todavía confunde "embarazado" con "avergonzado."

Not bad for someone who still confuses 'embarazado' with 'avergonzado.'

I walked right into that one.

As always.

Thanks for listening, everyone.