Correspondence
health care, including disease diagnosis, including strengthening disease Al-Buluk Children’s
treatment, and surveillance, therefore surveillance and reporting and
increasing the risk of zoonotic disease conducting awareness campaigns.
Hospital in Khartoum
transmission to humans. Historically, Furthermore, promoting collaboration Sudan’s war broke out in April, 2023,
the country has had conflict-driven with the Food and Agriculture and has had a deadly impact on
outbreaks of yellow fever and Crimean– Organization of the UN, World children’s health services. Before the
Congo haemorrhagic fever with high Organisation for Animal Health, and start of the war, the capital Khartoum
case fatality rates reaching up to 57%.3,4 WHO is important for getting essential had a dozen paediatric hospitals.
These outbreaks could serve as a harsh resources, expertise, and training to Only one remains: Al-Buluk Children’s
reminder of the health consequences strengthen the veterinary sectors in all Hospital, a government hospital near
related to zoonotic disease outbreaks conflict-affected areas. shifting front lines.
during war. Overall, the ongoing armed conflict Al-Buluk is small: 26 emergency beds
Moreover, the destruction of in Sudan has severely impacted vet and 80 inpatient beds. It has wards
key laboratories and equipment at erinary services and zoonotic disease for malnutrition, neonates, general
Sudan’s Central Veterinary Research management, posing clinically paediatrics, and a high-dependency
Laboratory (CVRL) could be a crucial significant risks for animals and unit serving patients with renal,
factor contributing to the spread of humans. To effectively address respiratory, cardiac, and neurological
zoonotic diseases, as the CVRL has the challenges that might arise, a problems. It also has malnutrition,
played a fundamental role in controlling collaborative One Health approach, diabetes, and vaccination clinics. Each
these diseases. Due to the conflict, targeted interventions, and emergency week, about 12 inpatients die.
cold storage equipment containing response strategies are crucial. The One patient journey illustrates the
pathogenic isolates (eg, Rift Valley global community can support Sudan scale of the crisis. Khadija (not her
fever virus) was destroyed or emptied by assisting in rebuilding veterinary real name) is a 17-year-old girl with
and looted. This theft and destruction services and facilities. Without this type 1 diabetes from Dar al-Salam, a
poses a substantial risk, as individuals collaboration, the health systems will displacement settlement 20 km west
who had contact with this equipment be further strained in the event of an of Al-Buluk. Her area was besieged
were exposed to deadly pathogens, outbreak. by one of the two armies fighting
escalating the likelihood of infections I declare no competing interests. inconclusively for control of Khartoum,
and outbreaks. Editorial note: The Lancet Group takes a neutral and bombarded by the other. Fighting
The displacement and mixing of position with respect to territorial claims in shut the hospital where she received
animals and humans are major drivers published text and institutional affiliations. dialysis. Last year, Khadija’s 8-year-old
for disease transmission.1 The conflict Yassir Adam Shuaib brother was diagnosed with diabetes.
displaced millions of livestock and [email protected] The family’s insulin supplies dwindled,
forced them to alter their traditional Department of Preventive Veterinary Medicine and and Khadija rationed and then stopped
migration routes in search of new Public Health, College of Veterinary Medicine, Sudan taking insulin, so her brother could live.
grazing areas, increasing contact University of Science and Technology, Khartoum Her condition deteriorated and she
North 13321, Sudan
between livestock from different areas. undertook the perilous journey across
1 Cornwell MS, Dodd CC. The role of veterinary
Moreover, according to the UN’s Office services in areas of conflict. Rev Sci Tech 2020; front lines to Al-Buluk. She arrived
for the Coordination of Humanitarian 39: 451–60. emaciated and unconscious, and died a
Affairs, since April 15, 2023, more 2 Wilson RT. Livestock in the Republic of the week later.
Sudan: policies, production, problems and
than 8·1 million people have been possibilities. Animal Husbandry, Dairy and Khartoum’s hunger crisis aggravates
displaced—6.3 million people within Veterinary Science 2018; 2: 1–12. the child health crisis. Most nutrition
3 Ahmed A, Dietrich I, LaBeaud AD, Lindsay SW,
Sudan and 1.8 million people have Musa A, Weaver SC. Risks and challenges of
centres are shut, and each week,
fled abroad.5 Most people who were arboviral diseases in Sudan: the urgent need Al-Buluk admits about 25 children for
internally displaced took refuge with for actions. Viruses 2020; 12: 81. severe acute malnutrition. Each week,
4 Gayer M, Legros D, Formenty P, Connolly MA.
their relatives, increasing human contact Conflict and emerging infectious diseases. two or three of them die. The hunger
and the associated risk of disease Emerg Infect Dis 2007; 13: 1625–31. crisis is linked to a wider economic
transmission. Given that zoonotic 5 United Nations Office for the Coordination of collapse devastating the health system.
Humanitarian Affairs. Sudan situation report.
disease outbreaks are more likely to 2024. https://reports.unocha.org/en/country/ Private hospitals—the majority—no
occur in densely populated areas, Sudan sudan (accessed March 6, 2024). longer have paying patients. Al-Buluk
6 Stephens PR, Gottdenker N, Schatz AM,
might face such outbreaks.6 Schmidt JP, Drake JM. Characteristics of the
is a government hospital. Government
To mitigate the impact of the conflict 100 largest modern zoonotic disease facilities charge for services and
on zoonotic disease management, outbreaks. Philos Trans R Soc Lond B Biol Sci prescriptions. Fee exemptions for
2021; 376: 20200535.
targeted strategies are required, children younger than 5 years reduce
1020 www.thelancet.com Vol 403 March 16, 2024
Correspondence
cost burdens on many Al-Buluk colleagues’ conclusions about the three University of Helsinki and Helsinki University
patients. Free medicine supplies often trials analysed;1 however, we would like Hospital, Helsinki 00029, Finland (TES, HG);
University of Oulu, Center for Life Course Health
run out: even before the war they were to highlight the following points. Research, Oulu, Finland (TES); Wihuri Research
in short supply and since the war began, First, the participants in the trials Institute, Helsinki, Finland (PTK)
pharmacies and warehouses have been were in their late midlife, and more 1 Ridker PM, Bhatt DL, Pradhan AD, et al.
looted, and pharmaceutical imports than half of them were in the secondary Inflammation and cholesterol as predictors of
cardiovascular events among patients
have fallen sharply. prevention groups. Consequently, receiving statin therapy: a collaborative
Al-Buluk still receives some supplies: advanced atherosclerotic lesions had analysis of three randomised trials. Lancet
2023; 401: 1293–301.
oxygen and some medicines from the already developed in the susceptible 2 Tokgözoğlu L, Libby P. The dawn of a new era
health ministry, fuel and laboratory re arterial walls. Second, during statin of targeted lipid-lowering therapies. Eur Heart J
agents from Médecins Sans Frontières, treatment, low-density lipoprotein 2022; 43: 3198–208.
3 Visseren FLJ, Mach F, Smulders YM, et al. 2021
and donations from local charities to cholesterol concentrations at baseline ESC Guidelines on cardiovascular disease
cover treatment for children without were on average 2·0 mmol/L in each prevention in clinical practice. Eur Heart J 2021;
42: 3227–337.
resources. But salaries are no longer trial, that is, above the concentration
4 Strandberg TE, Libby P, Kovanen PT. A tale of
paid, and many staff cannot afford to at which atherosclerosis begins and, two therapies lipid-lowering vs. anti-
work for free: staff shortages have closed particularly, above the current target of inflammatory therapy: a false dichotomy?
Eur Heart J Cardiovasc Pharmacother 2021;
an entire wing. Thousands of Sudanese less than 1·4 mmol/L for patients at very 7: 238–41.
doctors work overseas, and donations high risk of atherosclerosis.2,3 We have 5 Miettinen TA, Gylling H, Strandberg T, Sarna S.
from Sudanese medical associations in argued that, in secondary prevention, Baseline serum cholestanol as predictor of
recurrent coronary events in subgroup of
countries such as the USA and the UK a more efficient control of low-density Scandinavian simvastatin survival study. Finnish
supported Al-Buluk’s payroll for many lipoprotein cholesterol with PCSK9 4S Investigators. BMJ 1998; 316: 1127–30.
months. But these donations are drying inhibitors would be equal to statin plus
up, and promised support from other anti-inflammatory treatment.4 Third,
organisations has failed to materialise. there is some evidence that inhibition Elevated high-sensitivity C-reactive
Two specialist hospitals—one near of cholesterol synthesis with statin protein (CRP) concentration is
Al-Buluk, the other 35 km away—still treatment might not be sufficient to considered a risk enhancer in non-
provide treatment for children in a few prevent vascular outcomes, because diabetic individuals at intermediate
specialties. Otherwise, Al-Buluk is the a substantial proportion of patients risk of atherosclerotic cardiovascular
only hospital serving the children of this are high absorbers of cholesterol, and, disease, and favours initiating
vast metropolis, criss-crossed with front therefore, a combination therapy with moderate-intensity statin as primary
lines and checkpoints. This year it can absorption inhibition would be needed.5 prevention.1 As stated in the Article
barely afford to feed its malnourished Last, but not least, evidence (eg, from by Paul M Ridker and colleagues, the
patients. primitive cultures and genetic studies) residual inflammatory risk assessed by
We declare no competing interests. indicates that low-density lipoprotein high-sensitivity CRP on atherosclerotic
Editorial note: The Lancet Group takes a neutral is the early root cause and is essential cardiovascular disease events in
position with respect to territorial claims in for the development of atherosclerotic individuals receiving statin therapy had
published text and institutional affiliations. cardiovascular disease.2 not been thoroughly investigated.2
Esra Eltahir, Khalid Abdelhafiz, Mai Ali, Consequently, the need for anti- In their collaborative analysis of
Sara Abdelgalil, *Edward Thomas inflammatory treatment in combination three trials,2 as compared with the
[email protected] with statins might be too little, too late. lowest high-sensitivity CRP quartile
Sudanese Association of Paediatricians, Khartoum, More efficient and timely recognition (<1·1 mg/L), the highest high-
Sudan (EE); British-Sudanese Association of of individuals at risk of atherosclerotic sensitivity CRP quartile (>4·8 mg/L)
Paediatric and Child Health, Peterborough, UK (KA,
cardiovascular disease is needed. was associated with a greater risk
MA); Shabaka, Brighton, UK (SA); Manson Unit,
Doctors Without Borders, London EC4A 1AB, UK (ET) TES has had educational, research, and consultative of atherosclerotic cardiovascular
collaboration with several companies marketing disease (adjusted hazard ratio 1·31,
lipid-lowering treatments, including Amarin,
95% CI 1·20–1·43). As two-thirds of the
Inflammation, infection, Amgen, Novartis, Orion Pharma, Raisio Group, and
Sankyo. PTK has had collaboration with Amgen, participants in the pooled sample had
a prior atherosclerotic cardiovascular
and cardiovascular risk Novartis, Raisio Group, Roche, and Sanofi. HG has
taken part in educational and consultative
disease, those who used statins for
collaboration regarding human cholesterol
We fully agree that low-density metabolism with Raisio Group. secondary prevention might have had a
lipoprotein and inflammation greater residual inflammation risk and
*Timo E Strandberg, Petri T Kovanen,
both contribute to atherosclerotic were at higher risk of recurrence than
Helena Gylling
cardiovascular disease, and generally those without a prior atherosclerotic
[email protected]
agree with Paul M Ridker and cardiovascular disease at baseline.
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