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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.

INTRODUCTION

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 in Ethiopia.

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 Shilluk.

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.

COMMUNICATION

Linguistically, Sudan 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.

RELIGION

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.

HERBAL MEDICINES

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 them.

WESTERN MEDICINE

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 encounter.

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 U.S.

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.

LIFE CYCLE

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 eating snake.

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 the mother.

Adolescence

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 home-manager.

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

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

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)

  • Malnutrition
  • Intestinal parasites (Enterobius, Trichuris, Strongyloides, and Ascaris)
  • Filariasis
  • Leishmaniasis
  • Hepatitis B
  • Tuberculosis
  • Low immunization rate
  • Dental caries
  • Typhoid fever
  • Malaria
  • Trachoma
  • Syphilis
  • Dengue fever
  • HIV infection
  • Diarrheal illnesses
  • Hansen's disease

Recommended Laboratory and Other Tests for Refugees from East Africa

  • Nutritional assessment
  • Stool for ova and parasites
  • Hepatitis B surface antigen
  • Hemoglobin or hematocrit
  • VDRL
  • HIV
  • PPD
  • Peripheral smear for malaria should be considered

Other problems that practitioners should be especially alert to are cervical cancer, ectoparasites, and post-traumatic stress disorder.  

NOTES

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

Acknowledgements

Mayen Ater

Hamid Abdalla

Author: Lance A. Rasbridge, PhD

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