“All that I did over 40 years has turned to ashes before my eyes,” says Prof Ahmed Fahal, of the destruction of his research centre in Sudan’s capital, Khartoum. His once-gleaming laboratory, where a team of white-coated expert clinicians once busied over their work, is now little more than rubble.
“I built everything from scratch. I knew every corner, every brick of the building. I can’t describe the pain,” he says.
As Sudan enters its third year of war, its infrastructure has been decimated and scientific, educational and research institutions have ground to a halt. According to the Sudanese National Academy of Sciences, more than 100 universities and research centres – among the most reputable in Africa – have been damaged or looted.
Since 1991, Fahal has headed the Mycetoma Research Center (MRC): the only such institution in the world dedicated to the neglected tropical disease. The centre has been reduced to rubble, wiping out decades of vital data.
When the Sudanese army regained control of Khartoum in March, Fahal’s team was able to visit the centre for the first time since the outbreak of war and take stock.
“We lost everything: the biobank that contained rare fungus and bacteria; micro-organisms that we collected over 40 years; samples and biopsies that we stored for genetic research.
“We also lost the laboratory equipment, three ultrasound machines and the pharmacy, where we stored all the free medications for the patients,” says Fahal.
The only thing to survive were the patients’ files, which had been saved electronically.
Since the MRC opened, Fahal and his team have treated about 12,000 patients. The first recorded case of mycetoma in the country was in 1904, and, of the 102 countries where the disease has been identified, Sudan has the highest number of documented cases. “Sudan is the homeland of mycetoma,” says Fahal.
Mycetoma is an inflammatory disease caused by fungi or bacteria and leading to tumour-like growths. Most commonly people become infected through contact with thorns of the acacia shrub, which can carry the fungus. The disease primarily affects farmers, herders and the impoverished who work barefoot. In Sudan, children make up approximately 20-25% of patients.
Untreated mycetoma can cause severe deformities and permanent disability. In Sudan, about 70% of cases are caused by eumycetoma, a fungal form of the disease.
Five days before the war between Sudan’s army and the paramilitary Rapid Support Forces (RSF) broke out in April 2023, Fahal returned to Sudan after spending several weeks in Switzerland and Japan presenting the results of a clinical trial on fosravuconazole – a new treatment to improve patients’ quality of life.
Two days later, he left for Egypt, from where he received news of the conflict and realised he could not go home.
“When the fighting intensified in the capital, the volunteer teams we had organised had to move south to Wad Madani, 190km away,” he says. There they resumed their work. However, the fighting followed them.
“They kept moving ,” Fahal says, “but the war was on their heels again and destroyed everything the teams tried to build.”
In December 2022, the MRC and Drugs for Neglected Diseases initiative (DNDi) had presented the results of its clinical trial on fosravuconazole to the National Medicine and Poisons Board, the pharmaceutical regulatory authority in Sudan.
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Dr Borna Nyaoke-Anoke, head of the global mycetoma programme for DNDi, says: “The board found it adequate and provided authorisation for fosravuconazole to be used as a mycetoma treatment in Sudan, but then the conflict broke out. The result: itraconazole – the first-line drug – is not available in the country, and our programme to introduce fosravuconazole in Sudan in 2023 has been stopped.”
The war has meant that more than 12,000 mycetoma patients treated by the clinic have not received medication, says Fahal. Without treatment, bacterial infections bloom easily, leading to sepsis, amputations and, ultimately, death. “Many have died, but we don’t have the figures,” he says.
Researchers have warned that “Sudan’s already fragile health system is about to undergo a complete collapse after the war started.”
The Health Science Reports paper said: “The public health sector is chronically underfunded, and its financial losses are more than $700m [£500m], as its GDP went down by 1.4% [as] the funds have been mobilised for the military and defence.”
The World Health Organization estimates that 70-80% of health facilities in conflict areas, including Al Jazirah, Kordofan, Darfur and Khartoum, are either closed or not fully operational.
For Marmar A El Siddig, a professor of microbiology at the University of Khartoum, the war’s impact is massive: “Most of the scientific and medical research in the country was done through universities or institutions belonging to them, which were concentrated in the centre of Khartoum. Now, 95% of these facilities have been damaged or destroyed,” she says.
Another concerning aspect, according to El Siddig, is the destruction of laboratories containing samples of viruses, bacteria, fungi or tissues: all potentially highly toxic materials. “My microbial culture collection unit, where I stored more than 200 strains of salmonella used for scientific research, was destroyed. This poses a high risk of disease spread into the environment,” she says.
The destruction of the Sudan Natural History Museum and the Institute of Endemic Diseases, where poisonous snakes and scorpions used to develop vaccines were kept, also poses a danger.
Fahal, stuck in Cairo, has been unable to keep practising due to the lack of a work permit: “During all this time, I’ve seen three patients: one in a cafe, one in an apartment and the last one in a public square. I examined them and connected them with my Egyptian colleagues.
“I used to see 200 patients a week – now I can’t even see one.”
But he still hopes to rebuild: “My team has already started to assess the damage and I spend my days writing proposals for international donors to get funding. However, the main problem is that organisations are directing their funds to Gaza or Ukraine because, for them, mycetoma is not a priority.”
