Sudan is still recovering after a 30-year dictatorship and does not have the infrastructure to tackle the Covid crisis at the local level, says Dr Nada Fadul, one of the co-founders of Sudan’s Community Medical Response Team (CMRT).
“We leveraged youth organisations that led to Sudan succeeding in overthrowing this dictator, finding that energy, directing it into a new channel to help get the country over this crisis,” says Fadul, an infectious disease physician at the University of Nebraska in the US.
Medical students, many of whom were sitting at home because of Covid-19 school closures, already had the trust of community members in their neighbourhood, along with the energy, knowledge and training.
“They already engage in some management of minor things – it’s very normal when you’re a medical student that your neighbour will ask you to come and check her blood pressure, or give an injection, so why don’t we leverage that trust in the neighbourhood to help these students direct people to do the right thing?” says Fadul.
The programme, set up with co-founder Dr Reem Ahmed of Emory University, also in the US, brought on more enthusiastic medical students as well as Sudanese doctors in the UK, Ireland, and the Gulf. Both Fadul and Ahmed are part of a coalition of Sudanese organisations against Covid-19, and utilised their contacts to help get the programme off the ground.
The ECHO model was created by Project ECHO, a medical telementoring programme developed by the University of New Mexico (UNM). The idea is to use video conferencing to create global health continuing education and problem-solving initiatives, according to Dr Bruce Struminger, professor of infectious diseases and associate director of Project ECHO at UNM.
“We’re the technical assistance partner and have trained Nada and her team of clinical leaders – doctors who will be the subject matter experts – working with medical students who connect to them using their laptops or cellphones,” says Struminger.
The group has trained more than 150 medical and health-care students in over 50 Sudanese neighbourhoods to manage patients with Covid-19 in their homes.
Although the majority of recorded Covid-19 cases have been in Khartoum, the capital, and Omdurman, in Khartoum state, Fadul wanted to bring this system to other parts of Sudan that are more remote and less likely to conduct testing.
The teams started in Khartoum, in Bahri and Omdurman and then a team was added for east-central Al Jazira state, she says, adding that the focus is not just on the regional capital of Medani, but the villages around it.
They have also started a team in remote Northern State, collaborating with the University of Dongola and are now looking to find medical students and doctors in Darfur, with already some interest in Geneina, the capital of West Darfur.
Organising teams in different parts of the country was something new for Leila Ismail, the coordinator for the CMRT programme, because working virtually is a novel concept in Sudan.
“Most of the challenges we faced involved getting them connected and having them organise their team and having them work at a distance,” says the Omdurman-based coordinator.
She made sure that the four teams stayed on track as well as dealing with recruitment of medical students.
Team members in Northern State have been unable to travel to Dongola every week to attend ECHO sessions. So seminars are recorded and sent to the medical student on internet.
The students register for the session, then fill out an assessment to confirm their attendance and understanding of what was discussed.
“They get reimbursed on a monthly basis for data usage for all the sessions they have attended,” Fadul explains.
“It was a non-traditional way of doing this, using ECHO dollars, but that was the way that we could get students engaged and get the programme to be sustained for 10 months,” she adds.
Sudan’s special situation
Although the team uses the Project ECHO model, its implementation is unique, due to the current situation in Sudan.
The medical students normally would be using video technology to spread the latest information, or to give out their phone numbers to possible Covid-19 patients and follow them to ensure they have medical care.
The work has produced a lot of ideas on how to successfully implement the programme in different areas.
“In some neighbourhoods, the mosque Imam has a lot of respect, power and influence – in that case, we tell the student, go connect with the mosque Imam and explain to them the project and the benefits and have them be the advocate of the project in the community,” says Fadul.
Those who approached the Imams were allowed to give a brief introduction to the project after prayers, as well as hand out their contact numbers.
“Some students went to the local schools because they felt some students at school are more likely to absorb this information and become advocates in their households,” she says.
And still other more affluent neighbourhoods were able to create a WhatsApp group that included a Google form for people to fill out and send if they have symptoms.
“This has actually worked pretty well in some neighbourhoods in Omdurman – we’ve had eight cases referred that way,” she adds.
Using local students
The programme has yet another benefit – by speaking to people in their own neighbourhood, the medical students are trusted to dispel any sort of misinformation.
Fadul and her colleague Ahmed have mentored the students during the process, especially on how to deal with the challenges of stigma and resistance.
Some of that stems from people’s disappointment with the transitional government after 30 years of dictatorship. The new administration has been in power for two years, and progress is felt to be slow.
“People who caused a lot of suffering and grief have not been held accountable yet, so there’s a lot of disappointment in the community, there’s a lot of distrust,” says Fadul.
“The prior regime is spreading all kinds of rumours and misinformation, suggesting that Covid is something that the government is using to distract people from the important issues. It’s been terrible,” she adds.
Saida Abdallah, a medical student in Khartoum who is part of the programme, says that it was initially frustrating to try and explain about coronavirus in a way everyone understood and accepted.
“We had first to build the bridge of trust to get to their level. The majority listened to us and the data we provided and all the instructions, but there was a tiny group that was stubborn,” says Abdallah.
“We kept trying. We’ve built the trust with the others and they are familiar with our faces and they are expecting to get updates and instructions needed and they are ready to follow,” she adds.
Dealing with difficult cases
The intricacies of Sudanese government also created obstacles in trying to set up the programmes due to the decentralised system, says Fadul.
“The ministry of health is a policy and guidelines agency, but implementation happens at the state minister of health and each minister has a completely different system,” she says.
For critical cases, needing admission to hospital, each town dealt with Covid patients in a different way. In order to get around this obstacle, an ‘escalation team’ was created that includes registrars and medical officers who work in hospitals in the region.
“They are familiar with where the centres are and operate – we connected them to the teams, so in case I have a patient today and tomorrow I call and they are complaining of chest pain – then we can call an escalation team member,” she explains.
Either the escalation team member directs the student on what to tell the patient, or they call the patient directly. Medical students are under strict guidelines and do not prescribe medicines or interpret test results; these go immediately to the escalation team member.
The 10-month programme began at the end of May and will function through to March, where the model is slated to spin off to help with prenatal care, heart disease or other medical treatment.
Both the medical students and the neighbourhoods they operate in benefit from this special system, says team coordinator Abdallah.
“The value of this communication work is really huge – at a personal level, community level and as a group,” she says.
Fadul says the model of an academic NGO and government partnership to get a programme off the ground has been very successful.
“But what has really made this a success is the energy and enthusiasm and thirst for knowledge and connection that these students bring with them,” she says.
