health refugees immigrants
The following is general
information about Sudanese meant primarily to help medical personnel in the
U.S. in treating these refugees. Complex societal practices and the enormous
diversity of the Sudanese people have been reduced to generalities for purposes
of easy understanding.
The people of Sudan have
endured great persecution and strife for generations. Political and religious
oppression, famine, floods, locusts, and warfare are endemic to Africa's largest
country, covering over one million square miles. Sudan is among the poorest
countries and its citizens the least literate in the world. In Sudan, "the
expected number of years to be lived in what might be termed the equivalent
of "full health'" is 42.6 years for men and 43.5 years for women.
Sudan is thus 154th among 181 nations ranked by the World Health Organization
(WHO) (WHO, 2000). Among all Americans, this "disability adjusted life
expectancy" or DALE is 67.5 years for men and 72.6 years for women.
Civil war has raged in
Sudan nearly continuously since independence from Britain in 1956. The religious
war between the Islamic fundamentalists in the north, and the diverse African
ethnic groups, many of whom are Christian, in the south, has devastated the
country and its people.
The Islamic government
in the north has a long history of persecution of the Sudanese citizenry,
especially the southerners. In the late 1980's, military leaders withheld
internationally-donated food and relief supplies in the regions of the south
already devastate by drought and warfare; the government in Khartoum frequently
uses starvation as a warfare or political tactic. In 1988 alone, more than
250,000 Sudanese died of starvation. By 1989, inflation had risen by 80%,
and the debt had risen to $13 billion, and yet there was no plan by the government
in the capital of Khartoum to rebuild the country. The corruption of the country's
leaders prevented aid from such organizations as the United Nations, USAID,
and UNICEF from reaching the rebel-held areas. The cities swelled with refugees
fleeing the devastated countryside, and millions of Sudanese fled to the neighboring
countries of Ethiopia, Uganda, Kenya, and Egypt. In 1993, it was estimated
that 4,750,000 Sudanese found refuge in other countries, excluding the greater
than 1,300,000 who died in the flight. From these camps, refugees from Sudan
have been accepted for resettlement in the United States since 1990.
There are several different
types of refugees from Sudan. The largest number in the United States are
refugees from the south of Sudan, composed of various minority ethnic groups
fleeing religious and political persecution, warfare, and starvation. Additionally,
there are political dissenters from the north who escaped from the oppressive
Muslim fundamentalist regime in Khartoum. Many of these fled to neighboring
countries, especially Ethiopia, to escape forced conscription, or in fewer
cases, religious persecution, in particular against Bahaiís. The United
Nationís High Commissioner for Refugees (UNHCR) assisted these refugees
Refugees from the south
of Sudan come from the three different geographical regions, the Bahr-el Ghazal,
the Upper Nile, and Equatoria, the latter containing Juba, the capital of
the south. There is tremendous cultural diversity not only between the Sunni
Moslem north and the animist (traditional) and Christian south, but within
the southern region itself. Tribal affinity among the "Nilotic" groups (a
reference to the thin physique and common ancestral language of those groups
living along the Nile) is the norm, with infrequent intermarriage. Many ethnic
languages are not mutually intelligible, although English, and to a lesser
extent, Arabic, are the most widespread languages.
There are at least ten
different ethnic groups from the south that are represented as resettled refugees
in the U.S. (this is by no means an exhaustive list). The largest in number
are the Nuer. Formerly a pastoralist group, the Nuer have suffered great destruction
and strife as they are located most closely to the Arab-occupied areas along
the Upper Nile. As the ethnic group is quite widespread and is divided into
about ten subgroups or clans, there are several dialects of the Nuer language;
many speak Arabic as well. Two other ethnic groups of lesser number also came
from the Upper Nile region and are resettled in the U.S., the Anuak, and the
Next to the Nuer, the
second largest Sudanese population in the U.S. are the Dinka, who represent
the majority group in southern Sudan. They originated primarily from the Bahr-el
Ghazal region of southwestern Sudan, where they were pastoralists and agriculturalists.
They speak Dinka, and secondarily Arabic and English. Like the Nuer, there
is much diversity within the Dinka, with at least two dozen recognized subgroups,
as well as great contrast between the missionized and pagan groups. Some other
groups coming from this region include the Balanda and the Ndogo.
Finally, there are Sudanese
refugees in the U.S. who originally lived in the Equatoria region in southernmost
Sudan, the Azande, the Moru, and the Madi. All three groups were primarily
agriculturalists, and are now predominantly Christian.
is quite diverse, especially in the southern regions, where each tribe has
its own language and sometimes several dialects. However, rudimentary Arabic
language is spoken by almost all Sudanese, as it is the common language of
commerce and discourse between tribes. In southern Sudan, English is only
spoken by the educated minority. English was the official language until independence
in 1956, when it was replaced by Arabic by the Khartoum government; English
is still more common in the south.
Literacy is very low,
especially since schooling has been disrupted by chronic warfare and strife.
Dinka and Nuer are written languages, "romanized" by missionaries in this
century, but can only be read by those with some schooling. Literacy in Arabic
is less than the tribal languages, and English lower still. Hence, except
with the educated, it is not beneficial to use written health or other materials.
In terms of social etiquette,
there are some generalized distinctions between the Islamic north and the
African south. For example, for Muslims, when greeting, men shake hands with
men, but it is not culturally-appropriate for men to shake hands with women,
except within the family. Respect should always be afforded to the man as
the household head, but typically mothers will be more knowledgeable about
children's health and can be addressed directly, especially with southern
families, where the rules of interaction are less rigid. Separation of the
sexes is common to the Muslim north, and even homes are divided into male
and female areas.
Muslim women from northern
Sudan may be quite reluctant to be examined by a male physician, although
most southern Sudanese women will view this as a medical necessity. In general,
great diplomacy must be used in exchanges on gynecological matters. Sudanese
women will frequently use euphemisms when referring to genitalia, or when
English is poor, to avoid the topic completely.
Especially among the
southern groups, relative age is of great importance in interpersonal relationships,
determining not only the terms of address but also the manner of acting with
others. For example, men of the same "age set" will call each other "brother"
and will act informally with one another. Alternatively, someone older than
you is afforded utmost respect, and is referred to as "uncle" or "aunty,"
or even "father" or "mother" if related by blood.
About 70% of the population
of Sudan are Sunni Muslims, the vast majority in the north. About one-quarter
of the peoples practice only "indigenous beliefs," and the remainder Christian;
both these groups are found mainly in the south (Gray-Fisher 1994). While
the Christians are a small minority, they tend to be the most educated. This
Christian community is disproportionately represented in the resettled population,
as their claims to asylum were the most well-founded. They tend to be rather
fervent in their Christian beliefs here (Gray-Fisher 1994).
There is widespread belief
in Sudanese culture, especially among southerners, in the spiritual realm
and its manifestations on health and illness, although the beliefs vary greatly
from one tribe to the next. The Nuer, for example, believe in a pantheon of
Gods and spirits, both supernatural beings and spirits of animals, especially
birds. During periods of epidemics or even individual health crises, oracles
are sought out to identify the offended spirits and determine the proper recourse.
Frequently an offering is presented or an animal is sacrificed in order to
appease or drive away the evil spirit. A typical Dinka ceremony involves a
spiritual elder praying over and then sacrificing a special white chicken
in the presence of the afflicted. There is also a widespread belief in the
concept of the "evil eye," where a malevolent person possessing supernatural
powers can cast a spell on someone just by gazing upon them.
These spiritual beliefs
and practices are observed mostly by non-Christians in the south and are sometimes
sources of contention with the Christian community. In most cases, other available
medical resources are resorted to when spiritual healing does not bring about
the desired outcome.
There are multiple herbal
and "traditional" remedies used by Sudanese (although lack of availability
limits their use here in the U.S.). For example, a widely-used cure for migraine
headaches is a certain chalky compound (clay, mixed with certain leaves and
water) which is rubbed over the head. To relieve the symptoms of malaria,
there is a certain root chewed like a stick. One common form is called "visi
ri," a bitter shrub that bends its shoot to follow the sun. I have heard
the testimonial of a highly educated southern Sudanese who swears this cure
is more effective than chloroquine and other western drugs.
There are also certain
leaves that are boiled and consumed to relieve malarial sweats; the same mixture
can also be used to treat stomach disorders. For wounds, there are special
leaves found in the bush which are tied over the wound like a plaster. These
leaves may sometimes be burned and the ashes spread over the wound site.
Parasitism is very common
amongst Sudanese, especially tapeworms, amoebas, bilharzia (schistosoma),
and roundworm (Ascaris). To cure infection from Ascaris, leaves and roots
are boiled to produce a bitter liquid, which when swallowed expels the worms.
Thread worm infection, under the skin, is treated by slowly rolling the emerging
worm on a stick until the whole worm comes out.
All these curative measures
are particularly relied upon where there is no access to clinics. Most of
these cures are not commonly used by resettled refugees, as they are not readily
available here, nor are the specialists who are sometimes required to make
Resettled Sudanese in
the U.S. experience numerous difficulties in accessing medical care, although
to different degrees depending on background factors like educational level
and prior exposure to biomedical care in Sudan. Language and cultural obstacles
are obvious barriers, but also factors like name and birthdate discrepancies,
and the general lack of previous medical documentation, greatly confound the
Most Sudanese have not
had well care or medical checkups in Sudan and therefore present with medical
conditions of which they were previously unaware. Common undiagnosed cases
include diabetes, hypertension, food allergies, severe cases of depression,
vision and hearing loss, and parasitism (Wakoson pers. comm.). Also, dental
problems are also significant, especially as food habits change here in the
Sudanese routinely share
over-the-counter medications or borrow prescription medicines from others
for cases of similar symptomatology. This is a result of coping with chronic
shortages of medicines and severely limited care facilities in Sudan, and
of course it circumscribes expensive medical costs here. Similarly, Sudanese
also tend to discontinue Western medicines as soon as symptoms resolve rather
than completing the full course of treatment. Education on self-treatment
and the importance of completed therapy is imperative for this population.
The following information
pertains mostly to the southern Sudanese, and in some cases is specific to
Nuer culture. References to northern Sudanese culture are noted.
Childbearing and infancy
During pregnancy, women
frequently eat a special kind of clay, which is rather salty. When chewed,
this type of clay is believed to increase the appetite and decrease the nausea
associated with pregnancy. There are not really any specific food restrictions
during pregnancy which are not otherwise observed, such as the taboo against
At delivery, village
midwives usually deliver at home, as few have access to hospitals, except
civil servants and the wealthy. First-born boys are afforded special attention,
and are usually raised in the maternal family's village. Virtually all women
breast-feed, for about two years. Soft porridge made from sorghum and soups
of boiled meat are believed to stimulate breastmilk production. At delivery,
a cow or goat is frequently slaughtered to ensure enough meat for the postpartum
period. Weaning typically occurs when the child is walking, or is otherwise
ready as judged by the parents. Apart from cow's milk, a soft porridge made
from fermented sorghum, mixed with a sour fruit, is commonly used as a weaning
food (as well as a food for the infirm or elderly). In the general diet, sorghum
is the most common starch, prepared in many different ways. Vegetables and
greens, both wild and cultivated, make up a large proportion of the traditional
diet, with meats including beef, goat, sheep, freshwater fish, and chicken
(although chickens are generally more valued for egg production).
The system of naming
children is rather complex. In some groups the child is named after the male
lines, but traced either through the mother's or father's ancestry. A similar
system gives the child the last name of the paternal grandfather's first name,
the middle name being the father's first name, and the first or given name
selected by the father. Christian children often have Biblical names and Sudanese
names, used interchangeably. First names, when used, are commonly preceded
by a title, like "Mr."
Birth dates are also
quite confusing, as most southerners do not follow the Georgian calendar and
at best know only the year and season of birth, and few tribal groups kept
official records. In many cases, birth certificates have been lost or destroyed.
In resettlement, commonly, a default date of January 1 is selected (Power
and Shandy 1998). As age is a critical criterion for resettled refugees in
receiving benefits and enrollment in school, incorrect birthdates can be a
significant barrier for Sudanese refugees (Gray-Fisher 1994). Moreover, ambiguity
in birthdates for children can confound immunization schedules and growth
assessment for health care providers.
Childrearing is traditionally
the responsibility of all the women in the village; while the father takes
considerable pleasure in his children, discipline is the responsibility of
In southern Sudan, while
childhood is characteristically carefree, puberty as seen as the passage into
adulthood and its responsibilities and is a marked occasion for both sexes.
For girls, passage from childhood to adulthood is marked by the first menstruation,
at which time the mother prepares her for her soon-to-be role as mother and
For males, there is a
complicated set of rituals which an entire village age-set progresses through,
culminating in ritualized cutting of lines or striations across the forehead,
especially among Dinka and Nuer. There is also a common traditional practice
of teeth-pulling among the Dinka. Other groups have other types of rituals,
often involving cutting marks. Circumcision is common among some groups, especially
in the Equatoria region, but typically for hygenic rather than religious or
cultural reasons. However, there is much variation even within groups.
In northern Sudan, circumcision
for both sexes is widely practiced. For males, circumcision occurs shortly
after birth in accordance with Islamic tradition. Female genital cutting (FGC)
is practiced on females, sometimes under crude conditions, ostensibly to keep
the girls chaste. In northern Sudan, the most common form of FGC is Type III,
(or infibulation) which consists of the removal of the clitoris, the adjacent
labia (majora and minora), followed by the pulling of the scraped sides of
the vulva across the vagina. The sides are then secured with thorns or sewn
with catgut or thread. A small opening to allow passage of urine and menstrual
fluid is left. An infibulated woman must be cut open to allow for intercourse
on her wedding night, and the opening may then be closed again afterwards
to secure fidelity to her husband. Less severe forms of FGC are also practiced
in northern Sudan. Web sites concerned with the issue include http://www.fgm.org/
and http://rainbo.org. For a more extensive
discussion and current classification of FGC, readers are also referred to
the section on Refugee Women in this site.
Marriage is typified
as a sort of contract between the families involved, with the final approval
left to the girl's side. The groom's family is required to pay a dowry to
the bride's family, usually in the form of heads of cattle, to compensate
them for the lost labor of their daughter. The exchange in the north is usually
more in the form of money. While in the north there is preferential marriage
to cousins and other relatives, in the south marriages are exogamous, meaning
that the union can only be between peoples of different clans or villages,
and hence formalizes political alliances as well. The wife does not take the
husband's name. There are strict formalities regarding the interaction between
the man and his in-laws. The newlyweds initially reside with the wife's family,
until after the first child is born and weaned, at which time they move to
the husband's village. Great emphasis is placed on the woman's ability to
bear and raise children; birth control is typically antithetical to this cultural
value. Divorce is possible but discouraged because of the exchange of property
involved. Widowed women become the responsibility of the deceased's younger
brother. Polygamy is practiced and is a sign of wealth and prestige but is
uncommon in southern Sudan.
Death is seen as the
will of a spirit or God and is surrounded by the supernatural. Burial involves
ceremonies meant to appease the spirits so that no more deaths occur. A period
of several months mourning follows the death of a loved one. For Moslems,
burial takes place as soon as possible. The body is taken to the mosque to
be ritually cleaned and blessed by an Imam. The body is then carried to the
previously-prepared grave in a funeral procession. Mourning lasts between
three and seven days. Widows wear black clothes indefinitely, but may remarry.
Health Risks in Refugees
from East Africa (Also see the Infectious
Diseases web site for updates and details)
- Intestinal parasites
(Enterobius, Trichuris, Strongyloides, and Ascaris)
- Hepatitis B
- Low immunization rate
- Dental caries
- Typhoid fever
- Dengue fever
- HIV infection
- Diarrheal illnesses
- Hansen's disease
and Other Tests for Refugees from East Africa
- Nutritional assessment
- Stool for ova and
- Hepatitis B surface
- Hemoglobin or hematocrit
- Peripheral smear for
malaria should be considered
Other problems that practitioners
should be especially alert to are cervical cancer, ectoparasites, and post-traumatic
Power, D. V. & Shandy,
D. J. (1998). Sudanese Refugees in a Minnesota Family Practice Clinic. Family
Medicine Vol. 30, No. 3.
Gray-Fisher, D. M. (1994).
Infogram on the Democratic Republic of the Sudan, "The Land of the Black."
Iowa Dept. of Human Services, Bureau of Refugee Services.
Bates, Denise: MA Thesis
World Health Organization
(2000). Healthy life expectancy rankings. Accessed on the World Wide Web on
October 14, 2000 at http://www-nt.who.int/whosis/statistics/dale/dale.cfm?path=statistics,dale&language=english
Author: Lance A. Rasbridge,
OR Back to