Diagnostic SUDAN TOWARD A ONE HEALTH APPROACH IN SUDAN: UNDERSTANDING THE NEXUS OF CLIMATE CHANGE, LAND USE, ZOONOTIC DISEASES, AND HUMAN HEALTH ACKNOWLEDGEMENTS This diagnostic (Toward a One Health Approach in Sudan: © 2023 International Bank for Reconstruction and Understanding the Nexus of Climate Change, Land Use, Development / The World Bank Zoonotic Diseases, and Human Health) is one of the products 1818 H Street NW of the World Bank-AGREED trust-funded analytical work Washington DC 20433 carried out to inform strategic business planning and to improve Telephone: 202-473-1000 delivery of ongoing World Bank Environment, Natural Resources Internet: www.worldbank.org and the Blue Economy Global Practice interventions. This work is a product of the staff of The World Bank with The diagnostic was prepared and published, thanks to the external contributions. The findings, interpretations, and efforts of many dedicated World Bank professionals. The conclusions expressed in this work do not necessarily reflect study was led and guided by Dora N. Cudjoe (Senior Operations the views of The World Bank, its Board of Executive Directors Officer). Nada Amin (Consultant) authored the report. Special or the governments they represent. input was provided by Bethany Joy Linton (Consultant). This diagnostic work would not have been possible without the The World Bank does not guarantee the accuracy of the data support by Milena Stefanova (Country Manager for Sudan) included in this work. The boundaries, colors, denominations, and technical guidance and feedback from Lucia Patricia Avila and other information shown on any map in this work do not Bedregal (ET Consultant), Franck Berthe (Senior Livestock imply any judgment on the part of the World Bank concerning Specialist), and Clarisse Ingabire (Livestock Specialist), part the legal status of any territory or the endorsement or acceptance of the World Bank One Health team, as peer reviewers. We of such boundaries. also appreciate the feedback from the following World Bank colleagues: Razan Nimir (Consultant), Daniel Mira-Salama (Lead Environmental Specialist), Mariela Huelden Varas RIGHTS AND PERMISSIONS (Livestock Specialist), and Salah Osman (Health Specialist). The team is also grateful for the management guidance and The material in this work is subject to copyright. peer review from Noreen Beg (Lead Environmental Specialist) Because the World Bank encourages dissemination of its and Stephen Ling (Lead Environmental Specialist). knowledge, this work may be reproduced, in whole or in part, We extend our appreciation to the following professionals for noncommercial purposes as long as full attribution to this for their insights in one-on-one qualitative interviews and for work is given. sharing their technical expertise as subject-matter experts Any queries on rights and licenses, including subsidiary rights, in relation to Sudan’s specific context: Prof. Adil Salman should be addressed to (Professor of Epidemiology and Infectious Diseases, College of Veterinary Medicine and Chairman of the One Health Center, World Bank Publications, University of Bahri), Dr. Betigel Habtewold (Public Health The World Bank Group Specialist, World Health Organization, Sudan Country Office), 1818 H Street NW, Washington, DC 20433, USA Mr. Elmardi Ibrahim (Senior Livestock Coordinator, Food and fax: 202-522-2625 Agriculture Organization of the United Nations, Sudan Country e-mail: pubrights@worldbank.org Office), Prof. Faisal Elhaj (Director of the Dry Land Research Center, Agricultural Research Corporation), Dr. Hassan Elbushra (former Regional Advisor, World Health Organization), Mr. Ibrahim Doka, (Project Coordinator, World Bank Sudan Sustainable Natural Resources Management Project), Dr. Manal Hamid Ahmed (Environmental and Social Safeguard Specialist, World Bank Sudan COVID-19 Emergency Response Project, Ministry of Health), Prof. Muntasir Ibrahim (Director, Institute of Endemic Diseases, University of Khartoum), Dr. Sara Saeed (Assistant Professor and Director, Sudan Natural History Museum, Faculty of Science, University of Khartoum), and Prof. Suad Sulaiman (Professor of Parasitology). Table of Contents I. Scope and Objectives of the Study.....................................................5 II. The One Health Approach......................................................................6 III. Sudan: A Snapshot..................................................................................9 Case Study IV. One Health in Sudan............................................................................. 12 SUDAN Enabling Environment for Implementing a One Health Approach..............12 Existing Efforts................................................................................................................12 V. Identifying Vulnerabilities and Main Drivers of Zoonotic Diseases.. 15 A. Two Core Vulnerabilities..........................................................................................15 1. Climate Change.................................................................................................................. 9 2. Institutional Fragility..................................................................................................... 16 B. Hotspots of Zoonotic Risk....................................................................................21 C. Main Drivers of Zoonotic Risk............................................................................23 Drivers that Increase Interaction between Livestock and Wildlife.................. 24 Drivers that Increase Interaction between Humans and Wildlife..................... 24 Drivers that Increase Interaction Between Humans and Livestock..................25 Factors that Exacerbate Outbreaks............................................................................... 29 VI. One Health Actions: Conclusions and Recommendations.......... 32 Humans............................................................................................................................. 34 Animals...............................................................................................................................36 Ecosystems..................................................................................................................... 38 Appendix A. Methodology and Limitations of the Study.................... 42 Appendix B. Areas for Further Research.................................................44 Appendix C. One-on-One Interviews in Depth...................................... 45 References..................................................................................................... 62 Page 1 Executive Summary The significance of this diagnostic work stems from the This situational analysis examines the nexus among such fact that it is the first of its kind to be carried out under drivers as unsustainable land and land-use practices, the One Health perspective in Sudan. The study aligns agricultural expansion, intensification of livestock with the World Bank’s growing focus on One Health approach production, heightened meat demand, encroachment to preparing for and addressing zoonotic and emerging into wildlife habitats, wildlife trade, population growth, infectious diseases. It systematically draws attention to urbanization, implications of changing climate, and armed the links among the integrity of forests and rangelands, conflict and fragility. land and water management practices, and the ramifications for public health. Studies show that over 30 percent of These drivers aggravate the destruction of natural new diseases that have been reported since 1960 can be habitats and the loss of biodiversity and expose more attributed to land-use change, including deforestation. people to the risk of contracting diseases through Zoonotic diseases, responsible for over 70 percent of disease vectors. Once they are established in humans, emerging infections, pose global risks, as they transfer from these diseases instantly transmit through a number animals to humans, impacting health, environment, livelihoods, of pathways, including contaminated waterborne sources economies, and sustainable development. Despite this, and vulnerable food systems. Understanding these efforts to control them have been predominantly reactive. drivers is essential for making evidence-informed policy to prevent future outbreaks. The study aims to assess Sudan’s susceptibility to zoonotic diseases and related public health threats influenced by Our findings also identify specific risk factors, such as multiple drivers and propose ways to better respond to land degradation, poor disaster-risk management, lack them in more concerted efforts through the lenses of of understanding of disease patterns, and violence, fragility, sustainable land and water management practices. It also armed conflict, and displacement that exacerbate the aims to fulfil the imperative of the World Bank’s technical occurrence and outbreak of diseases. For instance, putting assistance and programmatic nonlending, activity support policies in place to reduce disease frequency is hampered to projects. In order to achieve this, the study makes by poor understanding, mapping, and forecasting of the recommendations on how to improve implementation potential risk of zoonotic diseases. In other words, knowing capability and maximize outcomes on the ground for other which areas of Sudan have the highest risks to livestock relevant project and program experiences in Sudan and health from rangeland practices, climate variability, and other subregional nations. lack of veterinary care services helps identify the areas where interventions will have the biggest effects. These Our analysis offers valuable insights into the significant findings enable the implementation of more focused transmission pathways in areas where various drivers prevention measures and surveillance strategies in a contribute to the emergence, reemergence, and proactive manner. transmission of zoonotic diseases in Sudan. Key findings suggest that the risk of disease emergence is elevated The report proposes a set of recommendations. All are in specific hotspots of rainfed and irrigated agricultural centered on the One Health concept, which is grounded lands and during rainy seasons and heavy floods. These in the fundamental idea that the health of humanity phenomena significantly affect human health and the depends on the health and livability of the planet and country’s large livestock sector, which is reliant the health of other species. The obtained results can predominantly on climatically vulnerable rangelands. be utilized to enhance the precision of surveillance Page 2 efforts and improve the efficacy of controlling newly emerged zoonotic diseases in areas with varying underlying drivers and risk factors that contribute to disease outbreaks. The study emphasizes the urgent need to bolster Sudan’s One Health practices through enhanced coordination mechanisms. Short-term strategies should be focused on supporting a One Health Platform (under formation) to facilitate cross-sectoral coordination, extending beyond human and animal health sectors, to include land and water management agencies so that they can share information, contribute to evidence-based prevention, and conduct joint outbreak investigations and responses. The report also recommends embracing medium- and long-term strategies, including adopting coordinated policies and research methods, implementing reforms, strengthening institutional capacity, and fostering synergies. To significantly improve One Health outcomes, a well-coordinated system for prevention, surveillance, preparedness, and risk management is imperative. Sudan should also invest in developing its One Health workforce; upgrading surveillance and usage of early warning systems, remote sensing, geographic information system, and laboratory capabilities; and continuously educating the public about zoonotic disease drivers, risk factors, and preventive measures. Crucially, the government of Sudan should allocate dedicated funding to aid the operationalization of One Health, fostering multisectoral, multistakeholder, and multilevel intragovernmental coordination. This could be achieved by involving forests, agroforests, land, water, animal health, and other environmental resources management agencies, as well as public health, alongside development partners, the private sector, and rural communities, all under the expert guidance of a designated coordinating agency. Future research should encompass epidemiological studies, laboratory investigations, and economic assessments to evaluate disease impacts on trade, livelihoods, and financial well-being. Page 3 ACRONYMS CCHF Crimean Congo hemorrhagic fever EVD Ebola Virus Disease EIDs Emerging Infectious Diseases FAO Food and Agriculture Organization of the United Nations FCV Fragile, Conflict, and Violence FMOH Federal Ministry of Health GDP Gross Domestic Product GIS Geographic Information System GoS Government of Sudan GPS Global Positioning System H1NI Swine Flu HAACP Hazard Analysis Critical Control Point IUCN The International Union for Conservation of Nature  NRM Natural Resource Management OH One Health OHC One Health Center RVF RVF SARS Severe Acute Respiratory Syndrome SSNRMP Sudan Sustainable Natural Resources Management Project UN United Nations UNEP United Nations Environment Programme VL Visceral Leishmaniasis WHO World Health Organization ZIKA Zika Virus Disease Note: All dollar figures in this report are in US dollars. Page 4 I. Scope and Objectives of the Study This study presents an analysis of Sudan’s zoonotic This study is the first to comprehensively analyze the disease risk profile in relation to climate change and relationship among humans, animals, climate, and land-use practices through a One Health lens. The land use practices in Sudan in relation to zoonotic study aims to illustrate and emphasize the importance diseases under a One Health perspective. It offers of a One Health approach in Sudan for addressing insights that can support Sudan’s One Health Platform zoonotic risk and public health threats. It seeks to foster (under formation) in scoping its priorities and achieving shared understanding and awareness of the intended objectives by coordinating policies and research interconnectedness of health issues affecting humans, methods, implementing reforms, and increasing animals, and the environment. Through evidence-based institutional capacity and synergies. data, the study aims to inform policy decisions in Sudan regarding the impact of climate change and land-use practices on the emergence, reemergence, and spread of zoonotic diseases. Additionally, this study aims to support the government of Sudan and the efforts of its development partners by assessing risks, vulnerabilities, and disease patterns, leading to actionable policy recommendations. The study has been carried out as part of the technical assistance to the (Sudan Sustainable Natural Resources Management Project (SSNRMP). The SSNRMP, implemented from 2014 to 2023, has aimed to adopt sustainable land and water management practices in targeted landscapes while increasing communities’ resilience and capacity to cope with climate impacts. The project is executed by the Sudan Ministry of Agriculture and Forestry with technical and implementation support from the World Bank with $19 million in grant financing from the Global Environment Facility. At the operational level, it is expected that the findings of the study will inform design and implementation of the World Bank and other development partner interventions, guide new sustainable development opportunities in the field, and contribute to a broader World Bank report on the One Health approach. Page 5 II. The One Health Approach The term One Health refers to an integrated, unifying An estimated 60 percent of known infectious diseases approach that aims to sustainably balance and optimize and up to 75 percent of emerging infectious diseases the health of people, animals and ecosystems (figure 1). (EIDs)1 have their origin in animals. Each year, zoonoses It recognizes the connections and interdependency are responsible for 2.5 billion cases of human illness among the health of humans, domestic and wild animals, and 2.7 million human deaths worldwide 2 (Jones et and the wider environment, including ecosystems. al. 2008). This approach aims to mobilize multiple sectors, EIDs are becoming more frequent, and their social disciplines, and communities at different levels of and economic impacts are growing worse, exposing society. They will work together to foster well-being the world to repeated large epidemics and pandemic and tackle threats to health and ecosystems while threats. The yearly probability of an occurrence of addressing the collective need for clean water, energy, extreme epidemics may increase up to threefold in the and air; safe and nutritious food; climate change coming decades (Marani et al. 2021). In 2020, the global resilience; and sustainable development (Joint Tripartite economy contracted by 4.3 percent because of COVID-19, and UNEP 2021). which amounts to about $3.6 trillion worth of lost goods, services, and other output (figure 2). FIGURE 1: One Health Concept 1 EIDs are defined as infectious diseases that are newly recognized in a population or have existed but are rapidly increasing in incidence or geographic range. Many emerging diseases have their origin in animals. EIDs may be foodborne, vector-borne, or airborne. Once an EID becomes established, the infectious agent must be introduced into a vulnerable population, and the agent must have the ability to spread from human to human and cause disease. 2 Zoonotic diseases are those diseases transmitted from animals to humans through direct contact or through food, water, or the environment. They contribute to 60 percent of infectious organisms affecting humans. Page 6 These trends are the results of our changing interactions with animals and the environment and can impact development outcomes. The human population is increasing, intensive farming practices are expanding, loss of biodiversity and environmental disruptions are growing, deforestation and forest fragmentation are worsening, and the movement of animals and animal products has shifted as a result of global trade markets. The risk of disease emergence and amplification increases with the intensification of human activities surrounding and encroaching into natural habitats, enabling pathogens in wildlife reservoirs to transmit to livestock and humans (UNEP and ILRI 2020). The COVID-19 crisis brought home the high costs of pandemics, triggering a historic setback in the fight against poverty. It also reinforced the interconnections among people, planet, and economy and called attention to the zoonotic nature of pathogens spilling over from animals to people. To decrease their burden, we must focus on prevention. The One Health approach proposes a way forward to reduce the risk of spillover (Berthe, Bali, and Batmanian 2022). Given the impact of pandemics on human and sustainable development, preventing them should be a primary focus for policy makers, public health officials and citizens. Implementing a One Health approach will improve countries’ ability to prevent outbreaks, prepare for pandemics, and accomplish development goals such as improved health and economic security, climate resilience, and food safety. Page 7 FIGURE 2: EIDs impact snapshot SARS (2003): $30–50 billion Almost 75 of EIDs in humans have % H1N1 (2009): $45–55 billion EVD (2014): $10–53 billion their origin in animals Zika (2015): $7–18 billion (domestic or wild) How much will the next pandemic cost ? COVID-19 cost more than 100 Less than outbreaks per year until $3.6 trillion in 2020. With a projected the 1980s, to 2025 loss of 400+ since 2000 $22 trillion SARS: Severe Acute Respiratory Syndrome; H1N1: Swine Flu (primarily caused by the H1N1 strain of the flu virus); EVD: Ebola Virus Disease; Zika: Zika Virus; COVID-19: Coronavirus disease caused by the SARS coronavirus 2 (SARS-CoV-2) Page 8 III. Sudan: A Snapshot For most of its independent history since 1956, Sudan from Russia and Ukraine, which account for over has had ongoing internal conflicts, social unrest, and 80 percent and 7 percent of Sudan’s wheat supplies, political instability, with intermittent, short democratic respectively. Concerns about the disruption of supply transitional periods. This has hindered its path toward lines have already driven up the global price of wheat democratic transformation and economic growth despite by more than 50 percent (Save the Children 2022). This its very rich natural resources of water, oil, fertile land, has raised import costs, worsening the balance of gold, and minerals. A popular revolution in December payments, and has further contributed to food insecurity 2019 ousted the previous regime and brought significant in the country. political reforms, including an agreement for a new civilian-led government supported by the military to In addition, frequent heavy floods, high input costs, administer the country for a transitional 36-month and limited financial support have reduced cereal period. The 2020–2030 Ten-Year Program for Economic production (sorghum, millet, and wheat for the Reform was adopted by the transitional government 2021–22 season) by 35 percent compared to the with the goal of achieving high, inclusive, and long-term previous year, but this was partially offset by increased economic growth. However, on October 25, 2021, a livestock production and gold exports (Ezemenari et military takeover toppled the transitional government, al, 2023). The ongoing conflict that erupted in April leading to a political standoff that had a detrimental 2023 is deepening the humanitarian crisis, endangering impact on the Sudanese economy. This is currently the production of staple crops and worsening the food worsened by the armed conflict between the Sudanese security of people in several urban and rural areas. Armed Forces (SAF) and the Rapid Support Forces (RSF), Conflict, economic decline, and climate impact have which began on April 15, 2023. driven about 20 million people across Sudan (over 42 percent of the country’s population) into acute food Sudan’s path toward development and economic insecurity (ACAPS 2023). Sudan’s population is growth has been hindered by stressed domestic estimated at about 45 million people as of 2022. The resources and political and economic uncertainty that average inflation rate in 2022 dropped to 164.5 percent are exacerbated by the impacts of compounding global versus 318.2 percent in 2021, as a result of stable crises. More than 42 percent of the population now exchange rate that was taken as part of a package of experience food insecurity as a result of armed conflict, economic reforms in 2021 (Ministry of Finance and economic collapse, and climate impact. Over the past Economic Planning 2023). Based on the latest household decade, Sudan has experienced economic deterioration survey (2014) and gross domestic product (GDP) which resulted in its reclassification into low-income growth projections, the poverty rate continued to country status from July 2020 (World Bank 2022). increase from 18.4 percent in 2018 to 29.1 percent in Grants were expected to provide almost one-third of 2022, at a line of $2.15 per day (World Bank 2022). revenues in 2021–22, but international assistance has been on hold since the military takeover (World Bank Climate variability is having a greater impact on 2022). The pause in external grants caused a depreciation Sudan’s natural resources, causing them to deplete of the Sudanese currency, weakening the balance of on an alarming rate. There are competing demands payments. This has been exacerbated by the COVID-19 from the population for pastures, agricultural lands, pandemic and soaring food prices and further worsened fodder for livestock, and drinking water due to Sudan’s by the Russia-Ukraine war and disrupted grain shipments landscape of arid zones, harsh deserts and limited Page 9 water access. Sudan’s GDP is in large part supported Kingdom of Saudi Arabia and the Middle East region by natural resources including the livestock sector, throughout the year, but volumes peak during the two forests, rangelands, land, and water use. Much of the months prior to the annual Hajj festival. Livestock territory of Sudan is arid or semi-arid, depending largely production meets not only the domestic demand for on seasonal rains to supplement farming and livestock meat but 70% percent of national milk requirements. feeding. Sudan has two cropping seasons; the main The livestock sector in Sudan has suffered from summer rainfed season (May–September) and the negligence compared to the strong development- mostly irrigated winter season (November–March/ oriented policies in irrigation and mechanized farming. April). Climate change is expected to increase Public spending on the sector’s development has been temperatures and change precipitation levels. Higher around 1 percent in spite of livestock’s 20 percent temperatures and evaporation rates, reduced soil contribution to GDP (FAO 1997). This has resulted in moisture, and reduced rainfall will exacerbate the risk several production constraints that have slowed the of future water crises in Sudan. growth of Sudan’s livestock sector, including disease outbreaks brought on by lack of access to vaccines Sudan’s livestock sector is inherently integral to the and animal health services, shortage of grazing land, culture. As of 2021, the total number of livestock was changes in seasonal migration due to climate change, estimated to be about 109.9 million heads, comprising and constrained livestock markets. about 31.8 million cattle, 41 million sheep, 32.2 million goats, and 4.9 million camels (FAO 2021). The country Since Sudan’s livestock market was liberalized in April ranks first to third among all African countries in the 2002, the private sector has taken the lead in providing number of ruminants and third in the number of poultry the production and marketing services required to and it is the top country by number of cattle and buffaloes. facilitate cattle exports. Almost all tanneries and Pastoralists comprise one-fifth of the country’s population slaughterhouses have been privatized, while the public and are the main inhabitants of the arid part of the sector oversees policies, regulations, research, planning, country, Sudan’s largest land area (Markakis 1998). and investment promotion, especially in relation to public health and food safety. In addition, new federal policies The livestock sector plays a vital role in the economy that foster the export of livestock are being developed, of Sudan. Having one of the highest population of such as allowing traders to have unrestricted access to pastoralists in the world, Sudan’s livestock sector their foreign exchange earnings, whether to use them contributes for about 20 percent of the country’s GDP for importation of goods or sell them to the banks or and employs nearly 80 percent of the rural population to a third party (Aklilu 2002) (figure 3). (IFAD 2022). Much of the livestock is exported to the Page 10 FIGURE 3: Situational Snapshot of Sudan Climate change causing unpredictable wheather patterns: GDP largerly longer droughts Unique supported by and heavy rains landscape natural of arid lands and resources limited water access ystem heal os Ec th Economic 70-80% deterioration lth One Ani of population armed conflict, ea Health m employed on h al h Human inflation and paused livestock sector assistance ealth Disruption of suply lines Highest populations of pastoralists in the increased import costs world: 1/5 of total and commodity prices population Increased poverty rate: Livestock sector From 18% in 2018 accounts for 20% to 29% in 2022 of GDP Page 11 IV. One Health in Sudan ENABLING ENVIRONMENT FOR Key challenges identified to the efficient practice of IMPLEMENTING A ONE HEALTH One Health are the lack of sufficient funding for the operationalization of the One Health concept and lack APPROACH of engagement of key sectors and multiple relevant There is a high-level political buy-in to implement a domains; irrigation, agriculture, water and sanitation, multisectoral One Health approach in Sudan. The urbanization, forestry, wildlife, drugs, veterinary, impact of climate change, COVID-19 pandemic, frequent metrology, sociology, industry, trade, and so forth disease outbreaks, and heavy floods in 2020 and 2021 (Ibrahim E. 2022). Other challenges include working at increased the risk and rate of waterborne and vector- the state level to advocate and implement the approach, borne diseases, eroded farms and crops, and exposed integrating surveillance systems at the human-animal people to food insecurity. These experiences created interface and building the capacity of the rapid response awareness in the government that the occurrence of teams to respond jointly against public health threats. zoonotic epidemic diseases is conditioned by multiple There is also the need to support research, laboratories, drivers, and that the response to outbreaks is weakened and testing capacities to better understand the triggers and delayed by lack of capacity, preparation, and of outbreaks and the role of climate change and use of institutional coordination (Habtewold 2022). The natural resources in inducing the emergence and government, therefore, understands the value of reemergence of infectious diseases (Ibrahim E. 2022). embracing a One Health approach to building national mechanisms to address health threats at the human- EXISTING EFFORTS animal-ecosystem interfaces. In August 2022, the Federal Ministry of Health held There is a One Health Platform under formation by a One Health Zoonotic Diseases Prioritization the Federal Ministry of Health that will bring together Workshop with participation of the Ministry of Animal resources on the three sectors (human, animal, and Resources and the Higher Council for the Environment environment) from government, academia, private and Natural Resources and in collaboration with the sector, nongovernmental organizations and United World Health Organization (WHO) and the Food and Nations agencies. The Federal Ministry of Health is Agriculture Organization of the UN (FAO) as well best positioned to oversee the creation and administration as other relevant government and development of the platform in terms of mandate and leadership partners (Habtewold 2022). (Habtewold 2022). The ministry needs to be supported Key outcomes of the workshop are the following: in terms of capacity building and tools to perform risk analysis and mathematical modeling to predict risks • Signing of an agreement for the establishment of a of zoonotic diseases and prepare for them. Through One Health Platform in Sudan. coordination among relevant ministries, commitment • Prioritization of eight zoonotic diseases of of domestic resources, and technical and financial greatest concern in Sudan, including Rift Valley support from partner agencies, the One Health Platform fever (RVF), salmonellosis, dengue fever, rabies, can be more efficient to meet its objectives. brucellosis, Crimean Congo hemorrhagic fever (CCHF), zoonotic avian influenza, and hepatitis E. Page 12 • Development of a joint action plan among the three Despite the fact that the One Health Platform has not sectors (humans, animals, and the environment) to yet been legally constituted, prior experiences have address the prioritized zoonotic diseases under the shown the value of this type of ministerial coordination auspices of the One Health approach. in improving responses to diseases. For instance, during • Establishment of a Joint Coordination Committee the 2022 RVF outbreak in the Red Sea state, the Ministry to kickstart and oversee the formation of the One of Animal Resources assigned a veterinary doctor to the Health Platform. Ministry of Health to facilitate collaboration and information sharing process between the two agencies. Here, it is Since then, the Joint Coordination Committee has held noteworthy that the WHO’s level of involvement in declared a few meetings, but the One Health Platform hasn’t outbreaks is appropriate, but it is crucial to emphasize been formally established. This may be partly due to that declaring zoonotic diseases such as RVF can be the country’s political unrest, frequent government shake- sensitive and politically charged given the potential or ups, and dwindling financing flows and technical assistance likely economic impact of bans on livestock exports, for from development partners in the wake of the military instance (Habtewold 2022). coup that toppled the transitional democratic government in October 25, 2021. This was followed later by the armed In parallel to the government’s efforts, there are other conflict that erupted in April 2023 and led to a detrimental initiatives to promote the One Health concept from impact on health care, causing disruptions to the health nongovernment actors. For instance, there is an system and prioritization of actions on the ground in favor established One Health Center at the University of Bahri of more urgent needs of the civilian population. in Khartoum. Despite being in its infancy and lacking essential financial and technical resources, the center Further, The Federal Ministry of Health declared the has been able to carry out community awareness-raising following objectives and action plans to go along with campaigns and short training sessions on the One Health the creation of the One Health Platform: concept for graduate students. These activities have had a limited impact, and the center has not been able • Enhance joint coordination among relevant to influence any policy change, as policy makers are used sectors in addition to building a common base for partnership at the level of policy making and to working in silos rather than in coordination with other institutional coordination.. pertinent governmental agencies. As a result, they lack operational clarity regarding the applicability of the One • Ramp up efforts to combat the expanding Health concept (Salman 2022). This gap of understanding infections, particularly during the rainy season and and the need to generate better evidence of the benefits the severe flooding that Sudan has experienced of the One Health approach, necessitate garnering in- repeatedly over the past few years. The country’s country and external support to promote dialogue and substantial livestock sector, which is mostly knowledge sharing and build synergies between relevant dependent on extensive production system in institutions (Salman 2022). climatically susceptible rangelands, frequently experiences disease outbreaks, and particular Furthermore, the World Bank’s Sudan Sustainable efforts will be made to respond to these outbreaks. Natural Resources Management Project offers an • Activate the needed cross-sectoral coordination additional instance, having introduced and executed beyond the human and animal health sectors in certain One Health practices in its fieldwork (See Box 1 sharing information, contributing to evidence- for more details). based prevention, and conducting joint outbreak investigation and response. Page 13 BOX 1: Other Existing One Health Practices in Sudan Other One Health efforts are evident in the World Bank’s Sudan Sustainable Natural Resources Management Project, which aims to ultimately inform the World Bank and the natural resource management (NRM) agenda in Sudan and in the subregion for better environmental and public health outcomes. The project focuses on increasing the adoption of sustainable land and water management practices in targeted landscapes across Gezira, Kassala, White Nile, Northern State, North Kordofan, River Nile, Gedarif, and Khartoum, with plans to extend to five additional states. The project addresses landscape degradation challenges in Sudan by promoting a landscape approach to NRM and conservation of biodiversity that considers both geographical and socioeconomic dimensions to managing land, water, and forest resources as a basis for meeting goals of food security and inclusive green growth (Doka 2022). One of the project’s main interventions is the provision of water in water-scarce areas. In order to prevent waterborne diseases through vector transmission, the project granted communities, including farmers and pastoralists, access to hafirs (rainwater-harvesting catchment) while adhering to safety precautions and hygiene norms by segregating water sources for human and animal usage. Also, the project successfully improved natural landscapes and in particular rangelands by establishing sand dune fixations within shelter belts, demarcating animal migration routes and grazing boundaries, managing rangeland for nursery rehabilitation, establishing fire lines, establishing enclosures, and broadcasting seedlings for improved fodder. These activities conserve natural resources while contributing to food security, water access, and sustainable livelihoods of rural communities in the targeted areas (Cudjoe 2022). The project has succeeded in adopting sustainable land and water management practices in a total land area of 133,081 hectares. In Kassala, White Nile, and Gezira States, about 3,764 households have received food security interventions. The home gardens and rehabilitation of rangelands are illustrative examples of project interventions aimed at increasing crop and livestock production employing integrated pest management, organic fertilizers, improved seeds, diversification and intensification of rangelands and agricultural systems in healthy ways that protect soil and water (Cudjoe 2022). Seventeen percent of the total beneficiaries (approximately 3,199 persons) of the project received comprehensive extension services that combine indigenous knowledge and newly introduced modern practices to promote adoption of sound technologies for enhancing crop and rangelands diversity while fully adhering to safety measures. This integrated approach has increased access to food during the dry seasons when communities are most vulnerable. Source: ©World Bank. Mohamed Noureldin Page 14 V. Identifying Vulnerabilities and Main Drivers of Zoonotic Diseases Sudan is extremely vulnerable to the effects of climate vulnerabilities (figure 4), hotspots for emerging infectious change. The risk of pandemics in the country is also diseases (EIDs), and the main drivers of risk are explored ingrained in the existing institutional fragility. These in the following sections. FIGURE 4: Core Vulnerabilities Declining rainfall and rapid warmth Massive floods Climate Food insecurity change Water Increased Potential scarcity vulnerability and to circulating escalating pathogens outbreaks Low government spending in healthcare Institutional Inequality fragility Page 15 A. TWO CORE VULNERABILITIES; (invertebrate hosts such mosquitoes, sandflies, snails, or blackflies), wild or domestic mammals, 1) CLIMATE CHANGE and humans. In many instances, climate change 2) INSTITUTIONAL FRAGILITY offers a favorable environment for various vectors as transmitters of multiple diseases. 1. Climate change However, linking these impacts solely to climate change can be challenging, as other factors are Climate change is severely affecting Sudan. According also at play, such as changes in land use and to the Notre Dame Global Adaptation Initiative, human movement. which captures a country’s vulnerability to climate change and its readiness to improve resilience, Sudan • Increased risk of visceral leishmaniasis (VL) is among the ten countries most vulnerable to climate Sudan accounts for roughly two-thirds of all change worldwide (ACAPS 2023). In the past 30 years, yearly reported VL cases in East Africa.4 As Sudan has seen a consistent trend of declining rainfall temperatures increase in the country, so does and rapid increase in average air temperatures that the habitat for VL vector-borne transmission by has increased extreme weather events, including a sandfly (Saeed 2022). flooding, drought, and desertification, which have • Increased exposure to malaria A study on the adversely affected livelihoods and socioeconomic Kordofan Region suggests the risk of transmission stability. Considering the dry ecosystem diversity in potential could be increased substantially by the country, 3 most of its land is quite vulnerable to 2060, in which case the overburdened health changes in temperature and precipitation (Nimir and care system will experience extreme stress and Elgizouli 2016) and ecosystem-level changes result malaria will have a heavy toll on local communities in increased heat stress, disease burden, and mortality (Nimir and Elgizouli 2016). in humans and animals. These types of stressors impact • Increased risk of gastrointestinal parasites on fragile food systems, directly placing communities at livestock, especially livestock feeding under poor risk of food insecurity, malnutrition, and infectious quality pasture conditions (Elhaj 2022). diseases. Some effects of climate change are the following: See figure 5 for an overview of hazard occurrences in Sudan, highlighting the occurrence of flooding • Increased tensions among pastoralist and non- and epidemics. pastoralist communities, as desertification and climate stress have pressured livelihoods traditionally dependent on natural resources. • Increased risk of vector-borne diseases, as climate change alters temperatures, weather patterns, and natural habitats Sudan is endemic to several zoonotic diseases caused by different pathogens such as RVF, trypanosomiasis, leishmaniasis, schistosomiasis, onchocerciasis, and yellow fever. Most of those diseases have complex life cycles that include vectors 3 The country is 29 percent desert, 19 percent semidesert, 27 percent low rainfall savanna, 14 percent high rainfall savanna, 10 percent flood regions (swamps and areas affected by floods), and less than 1 percent mountain vegetation (Nimir and Elgizouli 2016). Mean annual air temperature lies between 26ºC and 32ºC, but in some places it reaches 47ºC, causing significant stress and heat related diseases. 4 VL is a fatal form of leishmaniasis, endemic in the Gedaref state, southern Blue Nile state, and White Nile state. Page 16 FIGURE 5: Average Annual Natural Hazard Occurrence in Sudan for 1980–2020 Wildlife Miscelaneous Drought accident Storm Earthquake Epidemic Flood Extreme temperature Source: World Bank Climate Change Knowledge Portal, 2020. Floods have been the most frequent climate hazard in August-September. Climate change increases the in Sudan between 1980 and 2020 (World Bank incidence of heavy floods, which increase the risk of 2020). The rainy season typically occurs between waterborne diseases and food insecurity and have June and September, with the rains and flooding peaking​ become more frequent and intense during recent years.5 5 Flash floods in 2019 impacted 15 of 18 Sudanese states, with the most damage experienced by lowland communities along the Nile and its tributaries. The floods in 2020 have created conditions for deadly insect-transmitted diseases to thrive. Some 875,000 people across the country have been affected by torrential rains and floods, which have created widespread damage to homes, crops and livelihoods. Page 17 Floods limit clean water supply by contaminating water, Increased incidence of heavy floods directly affects mixing with sewage water and waste disposal sites. the communities largely dependent on rainfed agriculture Increased floods also multiply the number of standing (65 percent of the population), putting food security pools, thereby increasing the prevalence of waterborne at risk. Unreliable rainfall threatens the rainfed agricultural and vector-borne diseases, including cholera, dengue productivity system, resulting in shorter growing seasons fever, RVF, chikungunya, and malaria. These are most likely and making crop yield more vulnerable to drought. Study spread through mosquitoes and other vector species findings show that humid agroclimatic zones will shift whose increased prevalence follows seasonal flooding. southwards, rendering areas of north Sudan increasingly The United Nations Office for the Coordination of unsuitable for agriculture. For example, in the Kordofan Humanitarian Affairs warned that more than 4.5 million Region, mapping models predict that millet production people in Sudan are at risk of mosquito-transmitted will decline between 15 percent and 62 percent, and diseases such as RVF, chikungunya and viral hemorrhagic sorghum yield between 29 percent and 71 percent in the fevers, in addition to malaria, which has had a record period 2030 to 2060 (Nimir and Elgizouli 2016). This number of cases at more than 1.1 million (UNOCHA 2020). trend of decreasing annual rainfall in the past 60 years (0.5 percent) and increased rainfall variability is contributing to successive drought conditions, food insecurity, and severe social and economic implications. Climate change increases the risk of waterborne and vector-borne diseases. In Sudan, as an extremely arid climate, availability of water is a critical issue due to an increased risk of decreased precipitation, increased temperature, and evaporation. Furthermore, water scarcity, exacerbated by weak rainwater harvesting, limited renewal of groundwater, and little conservation, coupled with poor sanitation practices, has created conducive conditions to an abundance of diseases (such as typhoid, cholera, dysentery, and diarrheal illnesses) and increased mortality due to contamination of water sources. Rural populations are the most affected, as they rely on untreated and unsafe water sources of open water reservoirs or shallow borewells locally called hafir that have been found to be highly contaminated by Escherichia coli (E. coli) and other fecal bacteria. For instance, results of a study (based on WHO data and Sudanese Standards and Measurement Operations) in North Kordofan state illustrated significant contamination of E. coli bacteria in all hafirs and household containers across seasons (Edam and Abdelgalil 2022). In addition, conflicts become more common as competition over diminished natural resources, including water, increases, consequently leading to land degradation and fragmentation Hafir in Red Sea State, Sudan, 2009 of the surrounding ecosystem. Source: ©World Bank. Mohamed Noureldin Page 18 Climate and health shocks-exacerbated losses, economic which aggravated an already dire situation for Sudanese fragility, and social despair are compounded crises. households (figure 6). Variable climate events led to The World Bank collaborated with Sudan’s Central crop and livestock losses, increased food shortages, and Bureau of Statistics to implement a high frequency phone increased food prices, ultimately affecting household survey of households from June 2020 to August 2022 welfare, especially among poorer and rural ones. Lack to assess the impact of COVID-19 on households and of agricultural inputs constrained food production and businesses in Sudan. The survey included seven rounds. adversely impacted the livelihoods of households, thereby The results indicated that shocks from the pandemic increasing food insecurity and reducing access to basic and political turmoil were further exacerbated by climate services (Ezemenari et al. 2023). shocks, such as droughts, floods, and erratic rainfall, FIGURE 6: Climate Shocks Directly Impacted Household Consumption and Socioeconomic Status Loss of crop production Loss of livestock/livestock production Loss/damage of the other assets or properties 70 Household members displaced Household members killed/injured 58 48 43 % of a ected households 37 38 36 27 29 26 27 25 22 24 23 23 4 19 20 18 15 16 6 6 5 7 4 Sudan Urban Rural Sudan Urban Rural Sudan Urban Rural DROUGHT ERRATIC RAINFALL FLOODING Source: Ezemenari et al. 2023. Page 19 2. Institutional Fragility • Big disparities in the distribution of health care services and personnel between the public and In Sudan, there is low government spending in health private sectors and between urban and rural areas. infrastructure and health care services, characteristic of the limited health financing in the context of fragility, • Minimal institutional coordination resulting in a weakened capacity of the Federal Ministry of Health to conflict, and violence coupled with a limited overall respond to the increased demand for health services. financing ability (figure 7). Twenty-one of 25  FCV countries, including Sudan, had a per capita health • Limited surveillance of diseases, emergency expenditure below $100 in 2015, and 9 of them spent preparedness and response capacity: For less than $40 per capita (Dong 2019). In Sudan, the instance, early warning indicators of the zoonotic share of public expenditure to the health sector fluctuated outbreaks such as abortions and death of animals between 7 to 8 percent during the past decade, and are usually underreported due to inadequate although it was expected to rise as indicated in the awareness, a weak veterinary surveillance system, transitional government’s plan (WHO 2022), this can and inadequate transparency among relevant sectors (Elbushra 2022). be stalled by the current armed conflict. Some direct effects of low health care expenditure and lack of Population in rural areas (64 percent of total population) evidence-based policy decisions are the following: suffer the most from lack of access to suitable health • Poor health infrastructure including hospitals, care provision in terms of cost, proximity, and quality, laboratories, and medical equipment, workforce, coupled with low awareness and preference for self- and insufficient provision of basic services such as medication. Twenty to 40 percent of the population have medicines, clean water, adequate sanitation, no access to health services (WHO 2013). This is also prevention of infections, and well-maintained due to security concerns in conflict-affected states in roads (Ahmed et al. 2019). Darfur, South Kordofan, and Blue Nile, where most health care facilities are not accessible (WHO 2013), a situation currently worsened by the ongoing armed conflict. FIGURE 7: Functional Allocation of Sudan 2022 Budget Education Administrative sector 2% and social sector 1% Health sector 9% Agriculture sector 7% Economic and Petroleum and finance sector 6% minerals sector 9% Culture, media, and Transport and communication 0% infrastructure sector 1% Sovereign sector 11% Commisions sector 1% Sovereign agencies Defense, security sector 12% Source: Sudan Ministry of Finance and police sector 41% and Economic Planning and World Bank staff estimates, 2022. Industry and commerce sector 0% Page 20 Further, migration and the large influx of people to (figure 8), with other surrounding states, is home to urban areas and cities led to unregulated construction, one of the largest irrigation projects in the world. The poor housing, and unsanitary living conditions that Gezira Scheme was established by the British in 1925 leave people vulnerable to adverse health impacts and enlarged to its present capacity of 2.1 million feddans and the spread of diseases. Low levels of spending of irrigable area (882.000 ha) in the early 1960s. The in public health services increase vulnerability, a Scheme produces large amounts of cotton, food crops situation that is particularly true among several urban and livestock for export and domestic consumption, communities in Sudan. generating and saving significant amounts of foreign exchange to the country (Elshaikh et al 2018). B. HOTSPOTS OF ZOONOTIC RISK Diseases such as RVF are associated with irrigated Heat maps of predicted relative risk distribution of agricultural schemes, heavy rainfall, and flooding that zoonotic EID events (figure 8) show the states of usually increases the mosquito population, leading to Khartoum, White Nile, Sennar, Blue Nile, Gedarel, increased risk of RVF transmission (Himeidan et al. Kassala, with a strongest hotspot in the state of Gezira. 2014). (See Box 2 for an example of the devastating Other parts of southern Darfur and Kordofan regions are effects of the 2006–07 RVF outbreak). also shown with relatively low risk (Allen et al. 2017). The map (figure 9) shows concentration of agricultural FIGURE 9: activities and irrigation canals in the Gezira state The Location and Agricultural Irrigation and surrounding areas and can provide an illustrative System of the Gezira Scheme example of the relationship between increased agricultural intensity and the risk of zoonotic disease emergence. For example, Gezira state, that is shown as the strongest hotspot of zoonotic risk in Sudan FIGURE 8: Hotspots of Risk of Zoonotic Emerging Infectious Diseases Source: Allen et al 2017 Source: Elshaikh et al 2018 Page 21 Another example is the outbreaks of leishmaniasis in cotton and wheat are intensively grown. Countrywide, areas where humans have encroached, such as the Acacia malaria is a major health problem, with the entire population forests in the Blue Nile and El-Gedarif, Eastern Sudan is at risk of malaria epidemics. Based on WHO estimation (Ibrahim M. 2022). This is directly connected to degradation in 2016, about 37 million people were at risk of the disease of natural resources driven by local demand from a growing and an estimated of 4,000 deaths occurred (WHO 2017). population and livestock pressures exerted by pastoralists. Plasmodium falciparum—the causative agent of malaria— Additionally, the increase in malaria incidences in the East is responsible for approximately more than 90 percent of Africa region was associated with the expansion of areas cases (Hussien, Eissa, and Awadalla 2017). The main factors where cotton and wheat crops have been developed, known to influence these epidemics are climatic (heavy highlighting the change of the pattern of malaria transmission, rain and floods), drought and famine, resistance of P. falciparum as the irrigation of wheat during winter months led to a to antimalarial drugs, the movement of populations from second seasonal peak in malaria (Ijumba and Lindsay 2001). low to high endemic areas, instability in bordering countries, This example is typically valid in the Gezira agricultural the influx of refugees, and the establishment of large scheme of central Sudan and surrounding areas where agricultural projects (Aal and Elshayeb 2011). BOX 2: The Rift Valley fever (RVF) Outbreak of 2006-07 Rift Valley fever (RVF) is endemic in Sudan, where outbreaks occur periodically, every few years, in seasons when weather conditions favor vectors. RVF is transmitted by different species of mosquitoes (Aedes, Culex, Anopheles, and Mansonia) as well as blood-feeding flies. Its occurrence in the country has been associated with climatic, environmental, and human factors such as heavy rainfall and intensive agricultural practices that lead to an expansion in the breeding sites and transmission pathways, which in turn can create new hotspots that are at risk for outbreaks. Mainly, it affects domesticated and livestock animals, such as cattle, sheep, goats, and camels, and it can induce sickness and fatality in humans. In Sudan, the disease typically affects individuals who have frequent and close contact with animals, such as herders, farmers, slaughterhouse workers, and veterinary surgeons. Vector bites are the primary source of infection in livestock. RVF can be transmitted to humans through vector bites, direct contact with infected animals, or consumption of untreated animal products such as fresh meat or raw milk. The 2007–08 RVF outbreaks were traced back to heavy rains that flooded irrigation canals and irrigated farms, leaving stagnant pools and water reservoirs, providing breeding sites, increasing the mosquito population, and creating, as a result, an ideal scenario for vectors to infect livestock and humans (Hassan, Ahlm, and Evander 2014). The outbreak was most severe in White Nile, El Gezira, and Sennar states near the White Nile and Blue Nile Rivers. It has been estimated that 75,000 humans and animals were infected; a total of 747 human cases were confirmed, including 230 deaths, with a case fatality rate of 30.8 percent. The outbreak resulted not only in human disease but also large economic losses with an impact beyond the immediate influence on the directly affected agricultural producers (Nguku et al. 2010). The impacts of this outbreak were primarily felt at the farm level, while broader acute economic impacts occurred when the outbreak restricted trade and led to bans of imports of livestock and livestock products to Saudi Arabia and other countries in the Middle East. Page 22 C. MAIN DRIVERS OF ZOONOTIC RISK There are differences in transmission pathways among various disease drivers. For instance, zoonotic diseases Sudan has distinct climate change impacts and political caused by changes in land use are primarily transmitted and social conditions that create an environment through the vector-borne pathway followed by direct conducive for vector transmission that usually leads contact with animals. There are also other pathways to the spread of zoonotic diseases. The primary of transmission, including airborne transmission from transmission pathways through which zoonotic diseases high-risk occupations (slaughtering places) or areas are transmitted vary significantly based on the specific where land disruption activities (mining) are taking drivers that contribute to the emergence of diseases, place; waterborne from contaminated sources; and oral such as land-use change, bushmeat consumption, and transmission, the most pertinent route in food vulnerable food systems. These drivers are largely systems transformation. environmental, ecological, political, economic, and social forces, functioning on a range of different scales, which The main drivers of zoonotic risk include (1) drivers facilitate the emergence, expansion, and adaptation of that increase interaction between livestock and wildlife, a pathogen to a new niche. Zoonotic diseases have a (2) drivers that increase interaction between humans higher probability of being transmitted through vectors and wildlife, and (3) drivers that increase interaction such as mosquito bites or indirect contact such as between humans and livestock in addition to factors through contaminated food or an environmental reservoir. that exacerbate outbreaks (figure 10). FIGURE 10: Main Drivers of Zoonotic Diseases Humans Intensification of livestock sector Wild meat consumption Limited veterinary care Wildlife trade in poor conditions Poverty and urbanization Habitat destruction Food systems Ecosystem Poor land lights governance Livestock Wildlife Interspecies Competition interactions over land Page 23 Drivers that Increase Interaction between the park authorities. Pastoralists graze their livestock Livestock and Wildlife in the surroundings of the park, as well as in areas now occupied by mechanized farming. As a result of this Climate variability in Sudan and subsequent human proximity, leishmaniasis cases in some parts of the Dinder activities resulted in a sharp decline in its biodiversity.6 National Park strongly suggest increased interhuman Wildlife species are found in protected areas and in and sandfly transmission (Osman, Kager, and Oskam fragmented habitats adjacent to protected areas in 2001). Furthermore, intensified competition over land desert, semidesert, low rainfall savannah woodland, resulted in conflicts between pastoralists and sedentary high rainfall savannah woodland, and marine ecosystems. farmers and has led livestock keepers to bring their The Um Jar wetland in the White Nile state is a staging animals into park land to graze, resulting in several area for thousands of migratory and resident waterbirds outbreaks of anthrax that decimated native species such (El Jack 2016),7 allowing this area to qualify for national as antelopes and buffalo. This has affected relations protection status as an Important Bird Area for migratory between the national park authorities and local species or Wetlands of International Importance under communities and pastoralists. the Ramsar Convention. Interspecies interactions Drivers that Increase Interaction between Humans and Wildlife There are links between zoonotic disease emergence Habitat destruction and environmental changes from human behavior, which is relevant to Sudan’s context. When wildlife has Habitat destruction disrupts ecosystem functions and increasingly frequent contact with domestic animals, disrupts wildlife behaviors leading to both direct and there is risk of disease spillover, with livestock acting indirect human-wildlife contact. Destructive land-use as a bridge between wildlife and humans. As wildlife practices due to growing extractive industries, agriculture, habitats are fragmented, encroached on, and degraded, and animal consumption often lead to land degradation, animals’ immune systems can become weakened by desertification, soil erosion, a decline in soil productivity, stress and malnutrition. In combination with increasingly and subsequently, poor crop yields. This forces human dense habitat occupation, interspecies interactions migration into wildlife habitat and entrenches the cycle can lead to increased risk of outbreaks of of agricultural expansion and land-use change that puts infectious diseases. pressure on wildlife and increasing competition over land. Communities run the risk of human and financial Competition over land losses (for example, property or crop damage, livestock The designation of the Dinder National Park as a protected predation, or animal attacks). A study found that one area in 1953 and as a biosphere reserve in 1979 has of three EIDs outbreaks is linked to land-use change, threatened the survival of wildlife due to encroachment as shrinking and fragmented habitats promote greater into natural habitats (Yousuf, Ahmed, and Mohammed concentrations and interaction among pathogens, vectors, 2012). Land adjacent to the park has been cleared and and hosts, leading to greater opportunities for disease replaced by large-scale mechanized rainfed and irrigated transmission (Mira-Salama 2020). farms for charcoal production. It is suspected that farm managers supplement the meat supplies of their workers through poaching, a practice almost out of control of 6 Sudan has protected 42,698 square kilometers (km2) of protected areas, where most wildlife species are found, and coastal and marine areas of 10,662 km2 that also support wildlife (IUCN 2020). Sudan has three sites that are designated as Wetlands of International Importance (Ramsar Sites): Dinder National Park, Dungonab Bay, and Suakin-Gulf of Agig (Ramsar Sites Information Service database, 2005, https://rsis.ramsar.org 7 A 2003 census indicated the presence of 168,572 birds of 50 species. Page 24 Weak land rights regulation and governance value wildlife products such as ivory and skins or hides. This is facilitated through bribes, informal markets, Poor delineation of forest land rights and tenure among and personal networks, either by Sudanese or foreigners. local and indigenous groups further complicate land-use Uncontrolled and unsustainable levels of hunting have governance and management. Judiciary uncertainty devastated wildlife populations and reduced the number over the legitimacy of wildlife protection prevents fines of larger species, including elephant, rhinoceros, buffalo, and penalties to deter poaching, incentivizing risk when giraffe, Cape Eland, and zebra. The main center of the potential revenue from illegal hunting is higher than the ivory trade is Khartoum, the capital city, where a potential penalty. 2005 assessment reported there were 50 souvenir shops, 150 craftsmen, and up to 2,000 items in individual Wild meat consumption shops (El Wakeel 2011). Due to the illegal nature of Traditionally, wild meat has been part of the Sudanese such wildlife trade, obtaining data on the impact of diet, except for the most ancient communities along these activities is difficult. the Nile. Ongoing challenges such as famine, conflict, and insecurity have led to severe food shortages in Drivers that Increase Interaction Between terms of both crops and livestock. Consequently, some Humans and Livestock Sudanese individuals turn to a wide range of wild Intensification of livestock production, animals for sustenance, from buffalo to field mice consumption, and trade (El Wakeel 2011). Eating wild hunted meat increases the risk of zoonotic disease outbreaks. Gathering The domestication and rearing of livestock in ever- information about the individuals who rely on wild increasing numbers and in close proximity to expanding meat, however, including their demographics, human populations increased the risk of disease in both geographical locations, socioeconomic status, and populations (World Bank 2010). There are three main specific wildlife preferences, proves to be a challenging production systems in the livestock sector of Sudan: task. However, the broader practices and conditions (1) traditional husbandry or pastoralism, largely reliant related to wildlife consumption and trade, both in rural on natural pasture; (2) semi-intensive production, and urban Sudan, persistently expose the region to a dependent on complementary fodder alongside natural high risk of zoonotic diseases spillover. pasture feeding; and (3) intensive production, dependent on external fodder (WOAH 2013). Intensification of Wildlife trade under unhygienic conditions livestock production to meet increasing food demand In urban areas, informal holding, lairage, transportation, often results in higher livestock density leading to and trade of wildlife species alongside livestock is often amplification of disease spillover—including of zoonoses— done under crowded conditions with poor hygiene and among livestock keepers. In peri urban farms, livestock close contact between animals, and between animals can act as amplifying hosts for wildlife-borne zoonoses and humans. This practice creates prime conditions for (WOAH 2013). Zoonotic diseases such as RVF, brucellosis, pathogen transmission. hydatid disease, and rabies can impact human and animal health, though typically they affect only people in close Trade and commercial hunting for wildlife products proximity to livestock, for example, herders, farmers or butchers (FAO 2002). In addition to hunting wildlife for household consumption, some hunt for commercial purposes such as trade, traditional medicines, clothing or decorations, handicrafts, or sport and recreation. There is a growing illicit industry for commercial hunting to possess high Page 25 Source: ©World Bank. Mohamed Noureldin. Limited animal health services and disease a high negative impact on livelihoods, poverty, and surveillance human health. For example, owning livestock plays a role in determining a man’s position and influence in Insufficient access to animal health and veterinary the Sudanese rural community. Manure produced by services (limited by financial and geographic constraints), livestock also contributes to crop and farm productivity, combined with lack of disease surveillance, lack of which is lost when livestock diseases are not prevented laboratory and diagnostic services, poor regulation, nor controlled (FAO 2002). and poor management of disease-control programs, increases vulnerability on livestock and household Growing urbanization and interior migration income and puts the burden of treating diseases on livestock producers. Because livestock ownership is Urbanization is increasing at an unprecedented rate an accessible means for poor farmers to acquire real due to continued rural migration to national and state assets, the combination of few animals and little to capitals driven by ecological factors (such as recurring no financial reserves means that any combination of drought and desertification), anthropogenic factors events makes loss recovery disproportionally devastating (such as conflict, inequalities, and political instability), (Grace et al. 2017). or for lack of basic services such as water, health, and education in the migrants’ areas of origin. Khartoum’s Increasing poverty population jumped from 245,000 in 1956 to over 7  million in 2012 (Omer 2018). Conflict in Sudan, Due to the lack of access to veterinary services, including in Darfur, the Blue Nile, and the Nuba mountains, pastoralist communities in Sudan are often left to has led to displacement of large numbers of livestock manage diseases burden themselves (Grace et al. 2017), and herders, jeopardizing not only social stability and and animal disease outbreaks are costly both peaceful coexistence between farmers and pastoralists, economically and ecologically. Given the economic but also increasing the likelihood of disease spillover reliance on livestock activities, disease outbreaks have from herds and rural areas to peri urban and urban Page 26 areas. The following factors that come with urbanization • Inadequate infrastructure and services must be considered as drivers of zoonotic provision: Rural-urban migration brings disease spillover: additional health challenges mainly to the urban poor, who increasingly face a quadruple burden • Increased food demand: Growing population of infectious and chronic diseases, and mal- and density in urban areas increased demands for food overnutrition (Ahmed et al. 2019). For instance, and changed consumption habits leading to many rural-urban immigrants build their houses amplified consumption of dairy products, on flood-prone land that has been drained but processed food, and food of animal-sourced origin, where prolonged waterlogging occurs after prepared and sold mostly in public spaces with floods and heavy rainfall, which usually heightens poor hygienic standards. Increased urban demand the risk of waterborne diseases (Ahmed et al. for food also creates a high degree of crossover 2019). Additionally, unsafe water and inadequate between formal and informal systems, resulting in sanitation are two main reasons for the high disease risks to all consumers. However, despite prevalence of diarrheal diseases in cities (Ahmed increased urban food supply, the poor have less et al. 2019). Open drainage and proximity to choice in their food sourcing and are at greatest waste dumping sites are often problems for risk of disease (Ahmed et al. 2019). poorer communities, resulting in higher prevalence of rodent-borne and parasitic • Socioeconomic disparities: More than diseases. This increases exposure to sources of 50  percent of residents in Khartoum live in environmental contamination, such as the informal and squatter settlements on the presence of open sewers, particularly in flood- outskirts of the city, or in neighborhoods that risk areas and areas near refuse dumps (Ahmed lack basic infrastructure (Omer 2018). Large et al. 2019). socioeconomic disparities can be seen in poor housing conditions and inadequate access to Vulnerable food systems8 basic infrastructure and services. In particular, lack of safe drinking water and sanitation in The 2015 WHO report on the estimates of the global these slums is associated with increased burden of foodborne diseases presented the first-ever susceptibility to waterborne diseases. In Sudan, estimates of disease burden caused by 31 foodborne only 68  percent of households have access to agents (bacteria, viruses, parasites, toxins, and chemicals) basic improved water, with disparities in access at global and subregional level, highlighting that more between rural and urban populations at 64 and 78 percent, respectively. There are also than 600 million cases of foodborne illnesses and disparities between states, with just around a 420 000 deaths could occur in a year (FERG 2015). third of households having access to clean water The public health burden of food borne diseases in in Red Sea, White Nile, and Gedarif compared to Sudan is considerable. Different pathogens, toxins, and 90 percent access in Khartoum and the Northern chemical residues in crops and animals were identified States. Lack of funding, inadequate management as causes of food borne diseases and new ones continue and inadequate community participation are to emerge (FAO and WHO 2013). The following factors among the main reasons behind the system’s low highlight the interconnection between food systems functionality levels. An estimated 13 million and susceptibility to zoonotic diseases: people are still using improper drinking water sources (UNICEF 2017). 8 Food Systems are broadly defined as the “production, marketing, transformation and purchase of food, and the consumer practices, resources and institutions involved in these processes” (Waage et al. 2022). Page 27 • Weak enforcement of food safety regulations not much assistance from the state or the and legal framework: In Sudan, all aspects of nongovernmental sector is available (Ahmed public health are governed by the Food Control et al. 2019). Act (1973), which gives power to  the Federal Ministry of Health to supervise food safety Additionally, limited investment in food safety in activities  with support and coordination from domestic markets, improper livestock keeping in other government institutions: Ministries of close proximity with humans (coupled with cultural Agriculture and Irrigation, Animal Resources, behavior like consumption of raw milk and meat), Trade, Industry, Fisheries and Ranges, and the improper professional practices at slaughterhouses, Sudanese Standards and Metrology Organization, and poor food hygiene practices by consumers are among others. Local authorities are enforcing often responsible for the increased incidence of food safety laws through activities carried out by zoonotic diseases. veterinarians and public health officers who are • Meat industry challenges and poor occupational responsible for on the ground actions of these health practices: Poor infrastructure, fluctuation laws (Ahmed 2016). and inadequacy of electricity supply, coupled with However, Sudan faces a deficiency in its capacity noncompliance of food safety standards and high when it comes to policies and governance related temperatures, promote growth of disease-causing to food safety regulations. This includes microorganisms that render meat unsafe for human challenges in ensuring institutional policy consumption and promoting transmission of coherence and effective coordination for foodborne pathogens. Quality assurance programs implementing public health policies and such as those designed by Food and Agriculture mobilizing resources for proper control and Organization of the UN, the United Nations oversight. Additionally, there is a lack of adequate Industrial Development Organization, World research, extension services, food testing Health Organization, and World Organisation for laboratories, and essential awareness and Animal Health assist food producing and technical assistance for producers. manufacturing firms to adhere to good hygienic, agricultural, and manufacturing practices, but their In addition, there is shortage of a trained One assistance is not systematically offered to meat Health workforce to carry out systematic operators. Some occupational health and hazard inspection and food safety patrols for both the analysis critical control point (HACCP) training public and private sector, including small to programs are offered at a cost, limiting the medium enterprises and informal food sellers. participation of small and medium scale enterprises There is also a low level of investment in and (Mustafa and Hamad 2016). compliance with international standards, thus weak monitoring and enforcement of these An assessment of meat hygiene in beef and regulations by authorities. mutton abattoirs In Khartoum was carried out in 2009 in four major slaughterhouses (Alkadaro, Many livestock products are sold in informal Ghanawa, Alhuda, and Assabaloga). The markets, diverse in nature, yet self-organized assessment revealed that each slaughterhouse with complex systems of governance and control, had an acceptable diagnostic laboratory; clean, where basic food safety rules are poorly spacious, and well-ventilated slaughter halls; a implemented, with traditional processing and reasonable number and condition of refrigerators; retailing practices dominating official guidelines and adequate number of veterinarians and and standards. Infrastructure services (roads, assisting staff (Elamin 2009). However, the water, sanitation) and storage (refrigeration, microbial and chemical contamination in poultry cold chain integrity) options are lacking, while and red meat in slaughterhouses and factories of Page 28 Khartoum State is higher than the level 40 percent of internal conflicts over the past six decades recommended by international regulatory bodies, in Sudan can be attributed to the exploitation of natural mostly due to lack of implementation of good resources, including competition over scarce resources, hygiene and manufacturing practices (Mustafa such as fertile land and water (UNEP 2022). and Hamad 2016). With regard to chemical hazards, the review indicated a problem of The new armed conflict coupled with existing conflicts excessive antibiotic use in cattle and poultry for is likely to put more pressure on people’s coping mechanisms meat production and lack of awareness of when combined with the present conflict dynamics. keepers regarding the recommended dosage Escalating conflict poses a risk of making climate change (Youssif 2015). adaptation more challenging by limiting mobility and access to resources that are either economic or natural, Factors that Exacerbate Outbreaks especially for already vulnerable groups. Ongoing armed conflict, violence, and fragility Lack of disaster risk management The ongoing war that erupted in April 2023 between Mortality to natural disasters in countries lacking early rival factions of the military government of Sudan led warning system is eight times higher than those countries to increased fragility, violence and displacement; about with functioning multihazard early-warning systems 4.5 million have become internally displaced persons (UNDRR and WMO 2022). and about 1.1 million people became refugees in neighboring countries. The bulk of these displaced In Sudan, natural disasters and disease outbreaks people are at risk for infectious diseases because they management is largely reactive as opposed to proactive: live in overcrowded camps with inadequate water and • There is inadequate surveillance and limited use sanitation systems, insufficient food supply, and a of early warning systems, remote sensing, and higher risk of disease transmission due to limited access geographic information systems. to basic health care, infection prevention, diagnostic capacity, and treatment (See Box 3 on the impact of • Most of the information and available data in the conflict and displacement on the emergence and literature is collected after the outbreaks occur. transmission of Dengue Fever). In other cases, this may For example, the 2006–08 RVF outbreaks in East be coupled with new exposures, a potential reliance Africa were predicted using remote sensing on wild animals as a source of meat, and movement models but had very low accuracy over Sudan due of people with their livestock to escape conflict to lack of data gathering, surveillance, and reporting (UNDRR and WMO 2022). situations, leading to close proximity and increased risk of zoonosis. In addition, there is a lack of livestock • Low implementation of regulations and safety vaccines and drugs due to the destruction of the Central measures is due to limited supervision and Veterinary Research Laboratory in Khartoum and resources. For example, despite existing damage to facilities owned by private drug suppliers regulations to prevent aflatoxin contamination and manufacturing companies. of feed and food products, they are not implemented, leading to significant human and In Sudan, conflict and environmental decline go hand in animal health damages (Sulaiman 2022). hand. Evidence suggests that climate change has also heightened competition for access to water sources, pastures, and traditional grazing lands. This has led to frequent cycles of intercommunal conflict. Approximately Page 29 BOX 3: Outbreak of Dengue Fever, April-November 2023 Sudan has had multiple dengue fever flare-ups throughout its history. Several outbreaks have been documented in 2010, 2013, 2017, and most recently in 2023. Dengue fever is a vector-borne disease that is transmittable through an Aedes aegypti (A. aegypti) mosquito bite. Occurrence of the disease has been associated with alterations in climatic patterns and other human-related factors. Heavy rains, temperature, and humidity were correlated with dengue incidences in Sudan at different times, leading to favorable breeding sites and density of mosquito populations coupled with shortage of mosquito vector control and spraying operations. A. aegypti mosquito species that deposits eggs in stagnant water usually cause pollution of drinking water from unreliable sources, thereby transmitting dengue fever to hundreds of people who lack access to safe drinking water. Other factors may include, but are not limited to, human population density, mobility, socioeconomic status, population’s immune status, availability of municipal services and waste disposal system, and human-mosquito interaction. Recently, Sudan is witnessing one of its worst outbreaks of dengue fever. Medics in Sudan have warned that cases of dengue fever are spreading due to the impact of more than seven months of war on a health system that was already falling short before fighting began back in April 2023. More than 70 percent of health care facilities in states affected by conflict are out of service, resulting in extremely limited or no access to health care for millions of people (UNOCHA 2023). This shut down of health care facilities is mainly due to numerous attacks on medical providers and health facilities, occupation of hospitals by fighters, and looting of medical supplies and stocks. The transmission of the disease was further exacerbated by population movement in the countryside, where displaced people live in densely populated camps with poor living and sanitation conditions. Lack of water supply necessitated its storage in human-made containers, which favored breeding of A. aegypti mosquitoes and increased human-mosquito contact. Disease-carrying vectors that breed in portable water containers can vastly spread the infection. Sudan Doctor’s Syndicate said 3,398 cases of dengue fever were recorded across al- Qadarif (an eastern state that is crucial to Sudan’s rainfed agricultural production and borders Ethiopia), Red Sea, North Kordofan, and Khartoum states between mid-April and mid-September. “These numbers represent the tip of the iceberg and are much lower than suspected cases in homes and from those buried without record,” the statement said (Reuters 2023). Page 30 Land degradation areas in central Sudan, helps target where interventions will have the greatest impact (Elhaj 2022). In context, Land degradation affects an estimated 3.2 billion zoonotic disease patterns vary between western Sudan, people worldwide, with 40 percent of the world’s central states, and south and eastern areas because poorest living on degraded land, many depending on ecological conditions, land use, conflicts and political ecosystem services for their livelihoods (IPBES 2019). unrest, and the types of diseases are different (Elhaj Forest loss also has important ramifications for public 2022). Lack of mapping these diseases and their modes health. Globally, more than 30 percent of new diseases of transmission, whether animal or human, impedes reported since 1960 are attributed to land-use change, necessary surveillance and identification of potential including deforestation (FAO 2022). In Sudan, outbreaks before they occur. deforestation and rangeland degradation causes migration of potentially infected animals, which can lead to human transmission. For example, in Western Sudan, zoonotic diseases patterns are different than in other regions in the country due to effects of conflicts and political unrest and types of diseases (Sulaiman 2022). A study in Gezira state, home to one of the largest agricultural schemes in the Horn of Africa and Middle East, identified environmental factors that affect RVF and other pathogens—done by tracking the soil type and rainfall patterns and mapping the ecological context on RVF occurrence. The study concluded that mud soil and heavy rainfalls were environmental parameters that indicate increased risk of RVF (Bashir and Hassan 2019). Lack of understanding the patterns In Sudan, there is lack of a conceptual understanding of the patterns of disease emergence and transmission. This typically leads to poor forecasting of potential risk variables that increase or decrease disease occurrence and hence hinder putting policies in place to reduce disease frequency and severity. Disease outbreaks are typically caused by a failure to monitor the trends and factors involved in the emergence and reemergence of diseases, including population, geographic location, timing, and the direct and indirect causes that work together and lead to occurrence and outbreak of diseases. For example, understanding that the locations in Sudan of greatest livestock health vulnerabilities in rangeland management and veterinary care are in North and Western Sudan (North Kordofan and Darfur), Kassala State, and some parts of the rainfed Page 31 VI. One Health Actions: Conclusions and Recommendations The complex interplay of climate change, land use, In Sudan, in order to invest in interdisciplinary zoonotic diseases, food systems transformation, approaches to combatting zoonotic diseases, based human health, population growth, urbanization, and on the One Health approach, a comprehensive conflict in Sudan requires a comprehensive institutional approach is needed. This can begin with understanding. To effectively prevent and better manage the government body (One Health Platform) which is zoonotic diseases and emerging infectious diseases under formation and has the official mandate and (EIDs), it is vital to grasp the dynamics and interactions authority to serve as a central point and decision- of the main drivers. See figure 10 for an overview making power for coordinating joint efforts. Most of recommendations. members are government officials, so that decisions are directly linked to policy and action. The platform Collaboration among relevant sectors at all levels of should include representatives from all relevant society is essential to develop a proactive, rather than ministries, relevant government and nongovernment reactive, preparedness, prevention, and response actors, including civil society, and concerned international framework for zoonotic diseases and EIDs. A systemic development partners. These representatives should approach, encompassing natural resource management regularly meet and progressively align responsibilities (NRM), production, processing, and farm-to-fork practices, and legislations to address the issue of overlapping must be adopted to create cohesive strategies for mandates. Participation can include but is not limited ecosystem-level disease management that safeguards to the Ministry of Health, Ministry of Animal Resources, lives and livelihoods. Ministry of Industry and Trade, Ministry of Irrigation and Water Resources, Ministry of Agriculture and Health systems, designed to manage diseases, are Forestry, Higher Council for the Environment and intricately linked with multiple sectors and governance Natural Resources, Ministry of Federal Government, levels. They rely on these connections to monitor and Ministry of Cabinet Affairs, Ministry of Interior, Forest mitigate disease vectors before outbreaks occur. Effective National Cooperation, Agricultural Research Corporation, land-use management, which includes wildlife habitats General Administration of Wildlife Conservation, and rangelands, should prioritize natural barriers to National Drugs and Poisons Board, Sudanese Veterinary disease transmission, as this represents a cost-effective Council, Sudanese Standard and Metrology Organization, containment strategy for zoonotic disease prevention. Institute of Endemic Diseases at the University of Investing in long-term and sustainable NRM practices Khartoum, and other relevant nonstate actors. (figure 11 across these interrelated sectors sets the foundation provides more detailed information on the for healthy habitats, healthy animals, healthy recommended actions). communities, and healthy natural resources that Sudan depend on. Page 32 FIGURE 11: Summary of Key Recommendations HUMANS ANIMALS ECOSYSTEM Short-term interventions Strengthen joint policy, Enhance risk communications and Enhance community institutions and cross-sectoral stakeholder engagement i.e., involvement i.e., raise awareness collaboration - OH platform mapping exercise, risk reduction by disseminating public health and risk comms. messaging Medium-term interventions Strengthen composition of the Ensure monitoring, surveillance Ensure agricultural safety in OH i.e., advisory committee, and enforcement of animal health rainfed and irrigated areas i.e., subgroups i.e., strengthen Livestock enforce food-safety standards, Biosecurity formulation of the right policies Enhance emergency for pastures, land use, conflict preparedness and response plans Enhance food systems i.e., disease resolution mechanisms prevention in food-safety, Enhance data management, decrease demand for wildlife communications and meat, sanitary prectices, information sharing penalties, improve animal feeds production systems Long-term interventions Enhance government technical Apply animal disease prevention, Enhance gov technical capacity capacity i.e., system development, detection, and response measures i.e., forecasting, laboratories, national laboratories, sharing of i.e., detection and rapid response, mapping, modeling, technology technology/protocols, curricula, vector management, transmission mapping/resource pathways, HACCP measures at OH for land use and pastoral mobilization, financing slaughterhouses systems, demarcate livestock/ wildlife corridors, manage water resources, address contradictions of laws/policies Note: HAACP = hazard analysis critical control point; OH = One Health Page 33 HUMANS • Identify subnational One Health Platforms at the state level. These subnational platforms should Short-term interventions work under the auspices of the federal One Health Platform and abide by its governance and working Strengthen joint policy, institutional, and cross-sectoral arrangements. Their goal is to respond locally and collaboration by identifying governance, leadership, quickly to emergencies and disease outbreaks in and working arrangements of the One Health Platform. close synergies and coordination with the central platform. Work at the state level to advocate and This will require clarity on the purpose and scope of implement the approach, integrate surveillance the One Health Platform tasks and identification of systems at human-animal interface, and build the the stakeholders who should be involved in the capacity of the rapid response teams to respond multisectoral coordination. In this regard, the following jointly and quickly against public health threats. key elements should be considered: • Build capacity. Train the workforce, primarily the members of the One Health Platform, on zoonotic • Agree on governance structure. The elements of diseases prevention, communication, joint risk governance should be agreed upon by members of assessment, joint investigation, and so forth. the platform and should be produced and endorsed in an official document, or charter, by members and the highest possible level of government to increase Medium-term Interventions its authority and convening power. The governance 1. Strengthen composition and effectiveness of the structure should include the administrative organization, code of conduct, financing One Health Platform. arrangements, processes for decision-making (for • Strengthen composition of the One Health example, voting or consensus building), and clear Platform. Include representation from various roles and functional responsibilities of each of the public health, animal health, and environment members, as well as regular meetings and sectors. Identify champions who have voice to reporting mechanisms. advocate for mainstreaming the multisectoral • Decide on leadership of the platform. Currently approach in each government institution. the Federal Ministry of Health is in a better position • Establish a One Health National Advisory to lead the process as it has already taken the lead Committee. The committee should have the in initiating the establishment process of the mandate to advise the Federal Ministry of Health platform and has an existing functional One Health on directions to combat zoonotic diseases and Department. However, chairing of meetings could animal health and advocate for funding. It would be be done on a rotational basis. a group that meets at the most twice a year to • Conduct an initial One Health assessment to review the achievements on One Health and guide identify existing multisectoral mechanisms the government on policy formulation, governance, and funding sources. This assessment is and emergency management. This committee important to avoid duplication of efforts, identify could be composed of external partners who gaps, share lessons learned, and draw a road map provide the main funding on heath and One Health, for work ahead. The assessment could recommend the donor community, and the private sector. It other partners or stakeholders that can join the could also help in resource mobilization or mapping One Health Platform and play an active role, such resources so there is no duplication. This as anthropologist, social scientists, wildlife actors, committee could be jointly chaired by the Minister and so forth. of Health, and a World Health Organization (WHO) representative, with participation of government officials from ministries that are not part of the Page 34 governance structure, academia, experts, • Include communications staff to align nongovernmental organizations, development messages across sectors. Preferably, partners, and leaders of local communities affected communications staff should be trained in risk by emergence of zoonotic diseases. communications and work closely with technical staff to produce awareness, educational, and • Establish subgroups. These groups should work advocacy materials. These materials should be under the action plan or guidelines that establish distributed to the media, government sectors, the functioning of the One Health Platform, public health officials, national veterinary services, meaning that in case of specific events, the national and the public for prevention and risk reduction One Health Platform can delegate the mandate of behaviors among affected populations. certain technical tasks or activities to a subgroup: for example, a subgroup on conducting joint risk • Provide the public and affected communities assessments, planning a surveillance system, or at the community level, with accurate and writing a contingency plan or strategy for a specific timely awareness and public health messages. zoonotic disease, and so forth. Incorporate their indigenous knowledge to protect themselves and prevent risks of 2. Enhance emergency preparedness and diseases transmission. response plans. Long-term Interventions • Maintain a state of readiness for a zoonotic disease emergency. Develop a zoonotic diseases 1. Enhance the government’s technical capacity. contingency plan including emergency preparedness and response action plans to prepare and manage • Develop a coordinated prevention, surveillance, risks at the local and central levels. Collaboration preparedness, and risk management system and coordination at the regional level is important for zoonotic events. This would include a for information exchange, funding, and an efficient mechanism to ensure that each relevant sector is collective response to zoonotic diseases likely to engaged in, or at least aware of, what is happening cross borders. in other sectors. 3. Enhance data management, communications and • Enhance the capacity of national laboratories information sharing practices. to meet international standards across all relevant sectors. These would include academic • Create an information sharing hub. To facilitate and private laboratories to participate in the communication and ensure a steady flow of reliable national surveillance system. These labs should information, it is recommended to create a aim to raise the biosecurity levels, capacity for government “communications hub and/or testing, and making sure labs have the required network” that the platform can use to pool materials and equipment are regularly maintained information sharing with a standardized data and calibrated. format. This network should provide secure and real-time information to facilitate early detection • Promote technology exchange and sharing of and rapid response to infectious diseases. This is protocols between animal health and human especially important during disease outbreaks. health laboratories. Collaborate with established mechanisms to ensure appropriate data collection, • Establish communications mechanisms. analysis, management, and sharing across all Identify focal points in each agency in the various relevant sectors and from the local to the central relevant sectors. Build trust, confidence, and level, with each sector responsible for its own data transparency to exchange intra-ministerial while sharing knowledge in lab diagnosis and information among internal government agencies equipment (such as mobile vehicles, if available). and between government and external partners. Page 35 • Invest in technical capacity building and develop ANIMALS curricula for diseases prevention through health and environmental approaches. Conduct training Short-term interventions and capacity-building workshops such as the national bridging workshop to improve One Health 1. Enhance risk communications and stakeholder governance by including environmental stakeholders engagement. and expanding “scientific inquiry” into the environmental dimensions of zoonotic diseases. • Conduct a mapping exercise to identify key stakeholders and determine how best to engage • Map the human capacity and financial them. Stakeholders particularly important in food resources and develop a resource mobilization systems include farmers’ unions, pastoralists’ strategy. Developing international standards level union, and trade unions; people who are involved in of professional knowledge and training programs the food chain (production, transport, slaughter, for preventing and responding to zoonotic disease and retail); people or groups involved in wildlife through a multisectoral, One Health approach will hunting and trade; geographically or socially require structured training needs and capacity isolated groups; local communities; the public and development assessments. Technical assistance the media; and so forth. from donors and development partners, in particular ones with functioning multisectoral One • Develop risk reduction and risk communication Health Platforms (World Health Organization, strategies. Ensure that communications across Food and Agriculture Organization of the UN, the identified stakeholders and sectors are International Fund for Agricultural Development) regular, transparent, and well defined to address will be critical to enhancing research capacity to outbreaks both before and after they occur. Using identify triggers of outbreaks and to strengthening an approach such as farmer field schools to multisectoral One Health coordination increase farmers’ knowledge on emerging and mechanisms to respond to them. endemic zoonotic disease risks and behavior change through improved animal husbandry • Ensure sustainable and equitable financing as practices is a good example. Also, engage critical for decreasing risks from zoonotic community (animal) health workers to convey the diseases. Funding among all relevant sectors for risk messages is critical to ensure the right ensuring continuity of programs and resource messages can reach those in remote areas in a mobilization are required for both emergencies (for timely manner. example, outbreak investigation, laboratory capacity, quarantine) and routine activities (for Medium-term interventions example, functioning of the MCM, core workforce, routine surveillance, routine animal and human 1. Ensure regular monitoring, surveillance, training, immunization programs). This will enhance the and enforcement of animal health practices and laws. entomological team’s capabilities for mosquito control: RVF (RVF), malaria, and so forth. • Strengthen livestock biosecurity. Implement measures that prevent entry of viruses, such as • Enhance technical and financial resources for adopting good animal husbandry practices, good research, investigation, and laboratory testing handling of animal products, good fencing, and capacity during outbreaks. Developing a reduced contacts between animals and wildlife. mobilization strategy for the Sudan One Health Other elements that should be included here are program gleaning experience from other World geared toward strengthening animal health service Bank supported initiatives is therefore pivotal for delivery. These would ensure animal protection meeting the program goals. through mass immunization, disease surveillance, early detection, and outbreak response. Also, Page 36 making resources such as vaccines and vaccination • Strengthen food safety legal frameworks along and extension services available to farmers and the value chain. Enforce these measures across livestock keepers will be beneficial. Prevention products including livestock meat, poultry, and measures such as broad and requisite vaccination dairy, as these are either a common conduit or schemes, proper density stocking, animal multiplier of disease transmission. husbandry, quality nutrients, rangeland management, surveillance, diagnostic laboratory • Improve animal feeds production systems. From capacity, and hygienic conditions will securitize pasture to food production and consumption, livestock investments and prevent disease assessing and monitoring the intersections of occurrence and transmission. livestock markets, farm biosecurity, and veterinary services can aid in the prevention and tracking of 2. Enhance the food system. potential zoonoses and EIDS. • Place food safety at the center of One Health. A • Target food and meat processing firms with central issue in food safety is the lack of cross- extension services and food quality and safety sectoral collaboration among animal health, food standards capacitation. Improve food safety control, and the human health sector along the measures in handling, packaging, and sales of food chain. Examples include programs to educate agricultural crops to reduce risk of contamination food chain actors about food safety without and transmission. undermining the crucial role of informal food • Conduct information and education programs. markets by enforcing strict regulations. It is This can encourage better hygiene practices and crucial to determine the possible agricultural and behavioral changes, especially within mixed health effects of agricultural interventions in production systems of farming and animal keeping. order to lower health risks, particularly in areas like antimicrobial resistance, where health risks Long-term interventions from agriculture are still poorly understood. • Integrate disease prevention in food-safety 1. Apply animal disease prevention, detection, and directives and trade. This can stimulate the response measures. domestic market and maintain livestock export • Ensure early detection and rapid response. If competitiveness. indeed a disease breaks out, isolating the vector and • Decrease demand for wildlife meat. Enable more any exposed is critical to prevent losses and spillover. crops and meat variety to reduce exposure to Frequent testing, monitoring, and farm level species that carry dangerous disease vectors. demarcation can aid this effort (Sulaiman 2022). It is also important to include compensation schemes • Adopt sanitary practices. This should be done in as incentives to the declaration of diseases in order both slaughtering houses and public markets, to facilitate the implementation of control measures where meat from both wild and domestic origins that might include detection and culling. is sold. • Coordinate vector management efforts in high- • Enforce penalties for violation of food-safety risk areas. This aspect goes hand in hand with measures. Penalties could include those for risk assessment in hotspot areas, by better improper meat storage and selling or animal housing. understanding the drivers and behavior that lead to the introduction and spread of zoonotic and EIDs. Once hotspots are identified, then some measures of control for vector-borne diseases can be implemented, by (1) ensuring proper use of chemicals and matching spraying equipment and Page 37 international standards, (2) establishing threshold implementing vector control measures to target indicators for insecticide use, and (3)  creating larval mosquitos, along with the use of bed nets, for risk maps. the vector-borne pathway. Implementing this approach will enable the surveillance of zoonotic • Implement a joint hemorrhagic fever notification diseases to transition to move toward a proactive network in medical centers. This an excellent strategy, utilizing more focused public health activity of joint collaboration and communication interventions to proactively prevent the among public health, animal health, and transmission and emergence of zoonotic diseases. environmental services and helps to activate alert mechanisms and conduct joint outbreak investigation and reinforce disease surveillance in a ECOSYSTEMS coordinated manner. Short-term interventions • Identify the main zoonoses transmission pathways. Our findings indicate that the occurrence 1. Enhance community involvement as the central point of disease in areas affected by changes in land use is of education and knowledge sharing about zoonotic primarily due to transmission through vectors and diseases, risk factors, modes of transmission, signs direct contact with animals. Therefore, in areas and symptoms of the infection, and basic prevention where there is active land-use change, it is important measures that should be followed to avoid transmission. to implement control measures that prioritize vector control (such as managing the environment to • Enhance community resilience and participation control larvae and using mosquito nets), prevent as a prerequisite in prevention and control transmission through direct animal contact (such as activities. Engage youth, women, and traditional using personal protective equipment and practicing leaders at the local level. It is essential to build hand hygiene), and reduce the risk of airborne sustainable management committees and empower transmission (such as wearing masks or light cloth their inclusion in natural resources management by to prevent inhalation of infectious agents in high- harnessing their indigenous knowledge and locally risk occupations or areas where land disruption inherited practices while introducing technological activities are taking place). innovations and applications to improve results. Their involvement is also significant in disease • Implement hazard analysis critical control point reporting and in adhering to disease prevention (HACCP) measures at slaughterhouses. Do this measures. Examples of local platforms around hafir in conjunction with regular training of meat governance have seen some success, but there is inspectors and other awareness campaigns on much work to be done to scale and implement these safe handling practices of animal products that models linking them with central institutions for will reduce exposure to high-risk species and water management. Immediate entry points of the high-risk settings where infection is most likely to One Health approach could be through the World spread between animals and people, including Bank (Sudan Community Resilience) Project infection of RVF. currently under preparation, The wholistic One Health perspective could offer solutions to • Conduct animal and environmental surveillance strengthen local services, local institutions, and to give early warning of zoonotic disease events. livelihoods in conflict-affected communities Public health initiatives can implement control in Sudan. strategies that prioritize modifying behavior in high-risk populations to reduce contact with • Raise awareness and understanding by potential sources of infection and target specific disseminating public health messages. These routes of transmission: such as promoting personal should address zoonotic risks, chains of protective measures for direct animal contact or transmission, and ways of prevention for the Page 38 general public. Especially bring forward messages • Identify hotspots through data mapping and related to climate change and how it increases the modeling. This can help vulnerable areas or sectors risk of occurrence and recurrence of zoonotic adopt precautionary measures both at the farm diseases and associated prevention measures. and market levels. Most importantly, further study Ensure this messaging is communicated with on geographically specific land-use practices and special focus on livestock owners, market suppliers, their potential impact on zoonotic pathogens will sellers, and any livelihoods involved in basic food help inform policies on outbreak management by safety and food handling practices. combining experimental, field, and historic data to model a localized strategic plan for pathogens. Medium-term interventions • Mobilize funding in partnership with the private 1. Emphasize agricultural safety in rainfed and sector and development partners. This will aid the operationalization of One Health. It will support irrigated areas. access to the required technical resources of remote • Enforce food-safety standards in rainfed and sensing, GIS, and GPS and the enhancement of irrigated agricultural activities. This can help laboratory equipment. prevent a number of strains of zoonotic pathogens. 2. Adopt a One Health approach for land-use management • Formulate the right policies. This is essential for and pastoral systems to mitigate the vulnerability to land use, regeneration of pastures, setting up local Zoonotic diseases. conflict resolution mechanisms to address issues between pastoralists and farmers as they occur. • Manage natural resource assets to create healthy ecosystems and wildlife habitats decreasing the Long-term interventions risk of interspecies disease spillover. Management toward this end also provides access to healthier 1.Enhance the government technical capacity. food systems and water access, supporting income streams and access to markets that can sustainably • Develop the government’s forecasting abilities. support livelihoods. Preemptively forecasting climatic conditions can help predict and manage zoonoses. Modeled remote • Keep natural areas intact and ecosystems whole. sensing and geographic information system (GIS) This is one of the cost-effective methods of data can create early warning systems to detect preventing disease emergence. potential outbreaks. • Manage land for climate resilience and healthy • Strengthen the capacity of federal and state level animal habitats. This can be accomplished through laboratories to accomplish early detection and adopting a landscape approach that considers rapid response (Ibrahim E. 2022). This will be social dimensions of land management, integrating important for areas such as the Nile banks and livelihoods and landscapes to benefit the irrigated areas that are densely populated and have environment, agriculture, animal life, and the people potential for high transmission. dependent on land. • Improve technology and apply accessible and • Plan land use to reduce exposures. This can current technological tools. These can include, for include establishing buffer areas to separate example, GIS, global positioning systems (GPS), people and wild animals and designating protected mapping tools, smartphones, and market areas and species. information systems. The use and uptake of these tools are conditional on developing the capacity of stakeholders to use them. Page 39 3. Identify and demarcate livestock and wildlife 4. Manage water resources. corridors. • Improve the hafir infrastructure to prevent the • Manage and limit contact between wildlife and creation of an environment suitable for the livestock habitats and keep wildlife corridors spread of waterborne diseases and intact to prevent fragmentation and atypical transmission of disease vectors. In order to wildlife migration. This strengthens zoonotic ensure that water access is not affected by any disease and EID prevention through the dilution potential negative consequences, it is crucial to of likely vectors and ensuring healthier habitats effectively manage and, in certain cases, restore for healthier wildlife. Keeping livestock away from these sites. The creation of a hafir, for example, wildlife and at appropriate stocking rates and requires careful consideration of its potential as a density will help prevent zoonotic transmission. conduit for diseases between humans and Though costly, establishing livestock boundary animals, and adopting hygienic practices and demarcation efforts by region or state is more safety measures by separating water points for cost-effective through large-scale approaches, humans and animals use. This is important rather than stand-alone projects. Jointly manage despite the limitations in controlling certain corridors together with government, local environmental factors that could be addressed institutions, and native populations. This ensures by incorporating an environmental and social inclusion and representation, which will safeguards plan. This plan should aim to ultimately lead to more efficiency, sustainability, proactively identify challenges and risks prior to and accountability. the construction of the hafir and involve all relevant stakeholders in a collaborative manner. • Manage rangeland for healthy livestock habitat. Invest in several land-use approaches, including • Manage hafirs for the use by pastoralists and integrating urban forestry, agroforestry, and farmers. As with corridor demarcation, include native pasture systems into rangeland and urban institutions, women, and youth in decision-making livestock systems. Cross-border livestock bodies to reach tailored solutions. movement needs to be jointly managed with pastoralists to develop government policy and 5. Address contradictions and overlapping of laws, practice. Engage pastoralists to improve institutions, and policies by adopting a holistic approach transboundary trade, policy, and implementation for policy formulation and law enforcement. of sustainable practices. • Formulate unified laws and policies to respond to • Recognize that pastoralists have necessary the lack of an overarching land-use management resource needs along livestock corridors. These policy in Sudan. This could minimize contradictions include routes, water supplies, resting areas, and and the overlapping of some of the sectors’ laws other services that should be conceived as one and policies in respect to land management. A clear package for viable livestock economy. example of this issue is the expansion of the mining and extractives into the agricultural lands, forests, • Involve the private sector in livestock production and protected areas. and marketing. Adopt improved norms and veterinary standards, investing in water, developing • Fortify the land tenure system and governance in market information systems, and so forth. Assist Sudan. This can help prevent conflicts and changes marginalized pastoralists in adopting alternative in land use, which often result in permanent livelihoods and consider some form of insurance or destruction of natural landscapes (for example, mutual fund to assist herders and traders when urban expansion). Addressing land-use and land disruptions to livestock marketing chains occur management plans could effectively mitigate due to disease outbreaks. spread of zoonotic diseases. Page 40 In order for Sudan to develop in climate and disease resilience, formal and informal institutions from civil society, the private sector, and government will need to inclusively make choices that prioritize risk reduction across health, environment, and food systems. The government of Sudan, with support from international cooperation, must integrate climate and health considerations across ministries and cohesively disseminate plans to stakeholders and community leaders. The common denominator to accomplish this is sustained institutions that are capacitated to take action and address emergent risks. To develop strong partnerships and sustainably manage key resources, political leadership must support information sharing and inclusive decision-making with women, youth, local communities, and native institutions. Page 41 Appendix A: Methodology and Limitations of the Study The methodology of this study consisted of a Armed Forces (SAF) and the Rapid Support Forces. In structured approach of comprehensive literature the future, officials from relevant ministries and review and exclusive one-on-one interviews with government institutions should be consulted. subject matter experts. The literature review included scanning, selecting, analyzing, and interpreting Access to a variety of government reports that are publications, peer-reviewed articles and grey literature available online and in university and public libraries in an integrated way to answer specific research questions and research institutes was used to close this and areas of concern. The study sought answers for information gap. Further, exclusive one-on-one prime questions related to understanding the nexus interviews with subject matter experts from academic of the effect of land use, agricultural intensification, institutions, nongovernmental organizations, think and climate change on zoonosis at the wildlife–livestock– tanks, and international development partners were human interfaces with emphasis on risks, vulnerabilities, conducted to provide insight on Sudan’s specific context. main drivers, and trajectories of disease transmission Their diverse backgrounds in endemic diseases, veterinary in Sudan. medicine, agriculture, public health, epidemiology, climate change, and natural resource management Upon scanning some of the key literature, a further provided well-informed insights and data that enhanced search for particular zoonosis, specific evidence was the study’s content. Their high- level technical knowledge made, both by using keywords and by searching and expertise provided first- hand testimonies, situational manually, including back-tracking and citation tracking analysis, and scientific knowledge in relation to zoonotic of related articles, medical journals, empirical evidence disease transmission by human- livestock–wildlife reports and books. The websites of relevant institutes interaction and the current status of the multisectoral and international agencies were also explored for reports, One Health approach in Sudan. These testimonies set data, policies, and evidence such the World Health the stage for further research, interventions, and Organization (WHO), Food and Agriculture Organization strategic activities to better prepare Sudan for the of the United Nations (FAO), United Nations Environment threats of climate change, land degradation, and Programme (UNEP), The  International Union for zoonotic disease. Conservation of Nature (IUCN), alongside regional and locally produced publications. Additionally, and when the country’s circumstances permit, other research methodologies should be There were some limitations, in particular to access explored such as surveys, questionnaires, and focus to direct official government records and one-on- group discussions on farming, pastoralism practices, one interviews with public officials and relevant and trends and observations on the occurrence and authorities, during drafting this report. These are transmission of zoonotic diseases. Targeted categories mainly related to COVID-19 restrictions, security should be outreached such as farmers’ union, pastoralists’ concerns, and external regulatory precautions, and union, trade unions, private sector, people who are restrictions from the World Bank owing to the OP 7.30 involved in the food chain (production, transport, slaughter, triggered pause of its financial disbursements and selling, end users), people who are involved in wildlife operations in Sudan. This pause was due to the military hunting and trade, geographically or socially isolated takeover on October 25, 2021 and then the war that groups, and affected local communities. erupted in Sudan in April 15, 2023 between Sudan Page 42 The study also recognizes that among these atypical barriers that undermine understanding and effective strategic planning, preparedness, and response to zoonosis in Sudan is the lack of availability of sufficient evidence based - data on the emergence of zoonoses in Sudan and lack of communication and sharing of knowledge, best practices, and lessons learned which hinder practitioners. The study thus forms a comprehensive yet concise first of its kind account and situational analysis of the nexus between climate change and land use and their impact on the emergence and reemergence of zoonotic diseases in Sudan. This is accompanied by an up-to-date institutional assessment of the current status of the multisectoral One Health approach in Sudan combined with careful locally tailored policy recommendations to manage Sudan’s natural resource assets toward EIDs prevention. Page 43 Appendix B: Areas for Further Research During crafting this report, certain aspects of climate on Protected Areas and the current state of wildlife change and land-use practices have been identified habitats in Sudan, with a few exceptional sources of that warrant further research, which are beyond the international organizations. Information on Sudan’s scope of this study. Sectors such as the agricultural wildlife species composition is not well known, because sector and its linkages to disease and land degradation the majority of these habitats were carved into South should be deeply studied and incorporated into actionable Sudan following the secession. Further, updated surveys policy shifts. Also, it would be interesting to perform and interaction with farmers and livestock keepers through further analyses to understand the particular relationship long-term data-gathering can track indicators of applied between agricultural expansion, types of agriculture, and economics to measure the impact of diseases on trade, agricultural practices that can help or hinder healthy livelihoods, personal and national financial losses. farming systems resilient to EIDs. Future research could also benefit from descriptive An additional area that deserves further investigation and observational epidemiological studies as well as relates to biodiversity fragmentation and loss of natural laboratory and evidence-based cases. habitats, as there was a noticed dearth of information Page 44 Appendix C: One-on-One Interviews in Depth LIST OF INTERVIEWEES Name Job Title Agency 1. Prof. Adil Mohamed Professor of Epidemiology Regulating markets (wild animal and livestock trade) Ahmed Salman and Infectious Diseases, College of Veterinary Medicine 2. Dr. Betigel Habtewold Public Health Specialist World Health Organization (WHO) 3. Prof. Faisal M. A. Elhaj Director Dry Land Research Center Agricultural Research Corporation 4. Elmardi Ibrahim Senior Livestock Coordinator Food and Agriculture Organization of the United Nations (FAO) 5. Dr. Hassan Elbushra Former Regional Advisor World Health Organization (WHO) 6. Ibrahim Doka Project Coordinator World Bank Sudan Sustainable Natural Resources Management Project Implementation Unit (PIU) 7. Dr. Manal Hamid Ahmed E&S Safeguard Specialist World Bank Sudan COVID 19 Emergency Response Project Implementation Unit (PIU) 8. Prof. Muntasir Ibrahim Director Institute of Endemic Diseases-University of Khartoum 9. Sara A.K. Saeed Assistant Professor & Sudan Natural History Museum, Faculty of Science, Director University of Khartoum 10. Prof. Suad Sulaiman Professor of Parasitology Freelancer affiliated with several universities and research centers 1. Professor. Adil Salman Q: What is the One Health Center of the University of Bahri is all about? The One Health Center (OHC) of the University of Bahri was established in 2018 following the approval of the senate and the council of the U of B. The OHC was needed to accommodate all the research activities and training programs addressing Human health, Animal health, the health of the interface which they share, and the effect of climate change. The lack of multidisciplinary research, the absence of cooperation between the decision-making bodies in the OH approach partners, and the absence of a single body in the country that can respond to the combating of the communicable and emerging diseases were one of the most important motives for establishing the center. The staff of the OHC encompasses experts from all the disciplines of OH and the board of trustees includes all the federal ministries that are related to the OH approach, hoping that we can create an OH platform later. Page 45 Q: Has the OH Center been able to achieve any results? The OHC delivered the following activities in collaboration with different partners: • Intensive awareness campaigns covering almost all the members of OH categories, Workshops to introduce the concept of OH. • Training programs targeting members of health sectors, with the coordination of the OH partners, financed by the ICRC. • Workshop on climate change and diseases, financed by the Sudanese Standardization and Metrology Organization. • Meetings with higher rank officials to discuss the establishment of the OH platform. • Enrollment of many students in postgraduate programs in OH-multidisciplinary research. • Preparing concept notes in OH approach such as Climate Adaptation and Resilience (CLARE), Funded by the UK and Canadian donors (Call no. 16). A Concept Note in climate change and vector-borne diseases funded by TDR and WHO. (Call no. 18). • Preparing a research proposal in microbial and chemical risk analysis for food of animal origin, funded by the ministry of higher education-Sudan. Q: What are the main challenges faced by the OH Center? Understanding the nexus of climate change, land degradation, and zoonotic and vector-borne diseases is a multidisciplinary study, which was one of the essential objectives of the OHC and its collaborative partners. The reluctance of the concerned ministries related to the OH programs to cooperate, and the lack of clarity of the concept of OH among many, with the desire of each partner to continue working according to the existing vision and the unwillingness of employees to cooperate fully with their counterparts in the various ministries, greatly hindered efforts to establish the platform. Here the need arises for an external body such as the UN. FAO or WB is acceptable to all parties to facilitate dialogue and integrate with all relevant partners to create this platform. The need for this national platform is highly effective in managing diseases outbreak. In response to an outbreak, there is usually an absence of cross-sectoral cooperation, which leads to wasting scarce resources and wasting time, and effort. Although there is a department of zoonotic diseases in the Ministry of Health –led by an expert veterinarian, other OH partners are missing. The lack of full-fledged research laboratories, in addition to the unwillingness of some ministries to share the data they have collected, contributes to a large extent to the lack of research returns in OH. The absence of an early warning unit used in forecasting and monitoring zoonotic and emerging diseases contributed greatly to the great confusion of decision-makers and academia when diseases outbreak occurs. The Department of Epidemiology and disease control in the ministry of animal resources are using the GIS unit for only disease mapping and hot spot. In the OHC research, we are using mathematical modeling to predict the risk of the disease. Page 46 2. Professor. Faisal Elhaj Q: Is there any evidence suggesting that ecosystem components and functions drives some of these potential diseases? Specifically, how do you think ecological degradation mainly deforestation and rangelands degradation increase the overall risk of zoonotic disease outbreaks? • Overall disease prevalence in cattle, sheep and goats followed pasture condition, being high at very good pasture and decreased with declining pasture condition, but differences were not significant (P > 0.05). • Viral and blood parasites diseases were of relatively higher prevalence in cattle under all pasture conditions compared with other disease causes, with higher wages under very good pasture. • Gastrointestinal parasites were more prevalent under poor pasture conditions. Q: Where are Sudan’s greatest livestock/health vulnerabilities? Greatest vulnerabilities in rangeland management/veterinary care? • Greatest livestock/health vulnerabilities in rangeland management/veterinary care in Sudan are in North and Western Sudan (North Kordofan and Darfur), Kassala State and some parts of the rainfed areas in central Sudan. 3. Professor. Suad Sulaiman Q: In Sudan, is there any evidence proving that ecosystem components and functions drive occurrence and spread of zoonotic diseases? Specifically, how do you think ecological degradation mainly deforestation and rangelands degradation increase the overall risk of zoonotic disease outbreaks? • In general, surveillance systems & data to prove the ecosystem components are lacking. Most of the information & data available in the literature are collected after the outbreaks occur. With the effects of climate change, migration & movement of people, ecosystem components in different geographical areas can affect the transmission and prevalence of zoonotic diseases differently. Zoonotic disease patterns in Western Sudan are affected by the ecological conditions in the region, effects of conflicts and political unrest can be very different from those seen in central states or toward the south & eastern areas. Also, the types of diseases outbreaks are different. • Mapping of diseases, animal & human populations in the different states and disease outbreaks should be monitored by a good surveillance to allow for identify predictors of outbreaks before they occur. Page 47 • Ecological degradation, affected by deforestations and rangelands degradation introduce changes to the transmission patterns of the diseases causing unexpected movements of the infected animals and the vectors of the diseases to adapt. Human populations when caught in these new situations will be affected & the diseases will be transmitted to them. • (Please check the list of publications related to the pattern of zoonotic diseases transmission, mainly arboviral infections). Q: Where are Sudan’s greatest livestock/health vulnerabilities? Greatest vulnerabilities in rangeland management/veterinary care? This information should be obtained from the veterinary and animal resources institutions. Q: What are land degradation links to livestock and how to better restore forest and vegetation cover to avoid diseases of animals? This information should be obtained from the veterinary, animal resources and agriculture institutions. Q: Food chains (livestock meat, poultry, and dairy products) are usually a conduit or a multiplier of risks, are there any regulations and safety measures in the country to reduce this risk? Beside food can you identify high risk areas of contact or activities that promote transmission of zoonotic or vector borne diseases? • Regulations & safety measures are available, but implementations of these measures are lacking. Supervision of the processes in the food chains is lacking which cause extensive risk factors to human & animal health to occur. • Example 1: The problem of aflatoxins’ contamination of food products, secreted by Aspergillus fungi species, is extensive which cause a lot of human and animal health damages. Although regulations are stated in many laws of good agricultural practices, storage of products and processing till consumption by humans & animals, yet the laws are not implemented. • Example 2: Transmission of waterborne diseases in many agricultural areas: The lack of safe water supplies for humans, absence of public health services, for example, latrines, treatment clinics & health awareness, result in spread of many waterborne diseases, for example, bilharzia, giardiasis and other viral infections. Q: Do you think Sudan has the capacity to apply the One Health approach in terms of control of vectors and their ecology, transmission dynamics, risk factors, and the ecology of rangelands/ wildlife and the animal/human interface, prevention, and control measures? • Yes, Sudan needs to apply the One Health approach to control many vectors and their ecology. Two programmes are currently available: • A One Health approach programme at the Federal Ministry of Health composed of many related partners & ministries to coordinate actions related to utilizing One Health approach. Page 48 • A One Health Centre is established at the University of Bahri to run related postgraduate courses and research skills development. The OH center was established about 5 years ago, but due to lack of funding and resources, problems related to academic institutions and so forth, very slow progress has been achieved. • I am member of the Board of Directors of the OH Center at the University of Bahri. • I established a collaboration link with the Swiss Tropical Public Health Center &Swiss Academies through an agreement with the Sudanese National Academy of Sciences to assist in the development of the OH center and help in the teaching and programmes applications. Recently, I facilitated for a PhD candidate to get a scholarship for a PhD and he is applying for grants for studies on arboviral infections to be conducted in Sudan, in collaboration with the research team in Basel, Switzerland. 4. Dr. Sara Saeed Q: In Sudan is there strong evidence or cases demonstrating that zoonotic disease emergence are linked to human activities which bring wildlife, domestic animals and humans into increasingly intense contact? • Around 60 percent of all infectious diseases in humans are zoonotic (Taylor et al., 2001). The risk of disease emergence and amplification increases with the intensification of human activities surrounding and encroaching into natural habitats, enabling pathogens in wildlife reservoirs to transmit to livestock and humans (UNEP report, 2020). • Sudan is endemic to several zoonotic diseases that caused by different pathogens such as RVF (RVF), Trypanosomiasis, Leishmaniasis, Schistosomiasis, Onchocerciasis, and Yellow Fever. Most of those diseases have complicated life cycles that may include the following: - Vector which is an invertebrate host such mosquitoes, sandflies, snails, and blackflies. - Wild and/or domestic mammals. - Human. • Climate change is a major factor in disease emergence as the increase in temperatures can increase the vector population size and distribution, along with the season duration when infectious vector species are present in the environment (El-Sayed & Kamel, 2020). Several reports showed the continuous increasing cases of zoonotic endemic diseases in Sudan due to many reasons including climatic change as main factor. Page 49 • Visceral Leishmaniasis (VL) which is fatal form of Leishmaiasis is known to be predominantly endemic in the Gedaref state, southern Blue Nile state, and some foci in White Nile state (Mahmoud et al., 2017). Epidemiological and entomological studies confirmed sandfly species Phlebotomus orientalis as the main vector in several parts of the country which its presence was typically associated with Acacia seyal and Balanites aegyptiaca vegetation (Zijlstra &El- Hassan, 2001). Elnaiem et al. (2001) have provided evidence that the Egyptian mongoose Herpestes ichneumon is a probable sylvatic reservoir host of Leishmania donovani the causative agent of the disease in wood land habitat. Saeed et al (2009) have reported the presence of Leishmania donovani in African wild cat Felis several philipsi and detected the parasite DNA in cows, donkeys and goats’ samples. Annually, Sudan accounts for roughly two thirds of all reported VL cases in East Africa. Since 2015, around 25 percent of the population of Sudan is considered to be at risk of VL with taking into account that there were unreported cases as a function of poor infrastructure and the lack of ability to diagnose cases locally  (WHO, 2015). • Climatic change factors such as changes in temperature, rainfall and humidity may have strong effects on vectors and reservoir hosts by altering their distribution and influencing their survival and population sizes beside small fluctuations in temperature may lead to profound effect on the developmental cycle of  Leishmania  promastigotes in sandflies, allowing transmission of the parasite in areas not previously reported as endemic areas for the disease (WHO, 2022). 5. Dr. Elmardi Ibrahim Q: Do you think Sudan has the capacity to apply the One Health approach in terms of control of vectors and their ecology, transmission dynamics, risk factors, and the ecology of rangelands/wildlife and the animal/human interface, prevention, and control measures? • Yes, on condition that they receive the right international support. There is a One Health Platform led by the federal Ministry of Health. It involves many stakeholders including the Ministry of Health, Ministry of Animal Resources, Ministry of Agriculture and Forests, WHO, FAO, academia and others. The OH Forum performed well during the time when Dr Akram was the Minister of Health. The best coordination took place during the RVF outbreak in Red Sea in 2020, although the Ministry of Animal Resources was not happy about the declaration of RVF by Dr Akram. FAO was not able to provide any kind of support to the Ministry of Animal Resources to control RFV outbreak in animals because The Ministry refused to request official assistance from FAO. Page 50 Q: Has Sudan been able based on past outbreaks to use the environmental and climate data such as GIS and early warning methods in surveillance systems to predict disease outbreaks? • I know that there is some GIS capacity in the Ministry of Animal Resources but not to the level of predicting disease outbreaks such as RVF. I have no idea about the Ministry of Health Q: Where do you perceive the biggest gaps are between health systems, land-use planning, and the country’s animal resources, mainly livestock? • The biggest gap is in the Ministry of Animal Resources. They still have the mentality of hiding information about diseases that are related to livestock export such as RVF. They have Priority diseases that include RVF, CBPP, AI, brucellosis, PPR and sheep pox. Although most of the staff in the Epidemiology Department are trained in emergency preparedness but the ministry has no capacity to plan, fund and implement an Action plan on EP. They always participate on the One Health Forum like one foot inside and one foot outside. Q: Is there any evidence suggesting that ecosystem components and functions drives some of these potential diseases? Specifically, how do you think ecological degradation mainly deforestation and rangelands degradation increase the overall risk of zoonotic disease outbreaks? • Any interruptions in the ecosystems might lead to flaring up of diseases or appearance of emerging disease risks. For example, RVF is associated with flooding and heavy rains, which impact growth and proliferation of the disease vector. Heavy rains in bare lands in arid and semi-arid condition in North Kordofan have led over the last two decades to emergence of botulism in small ruminants. The outbreaks of botulism have increased in occurrences since then. By the way, botulism is not a zoonotic disease but causing heavy mortalities in small ruminants. The heavy rains just flush out the top soils, which are rich in minerals. The depraved appetite (PICA) forces animals to eat objects such as bones of dead animals looking for salts and hence botulism is developed. Q: Where are Sudan’s greatest livestock/health vulnerabilities? Greatest vulnerabilities in rangeland management/veterinary care? • If the nutrition status of animals is poor this will make the animals more susceptible to diseases. Therefore, rangeland degradation leads to poor quality and quality of feed, particularly, during the dry seasons; • Food chains and lack of regulations or poor enforcement of existing acts and laws. There is a need to revisit the laws and enforce them. • Extreme climatic conditions (floods and drought) • Favorable conditions for multiplication of disease vectors such as mosquitos and ticks  • Poor veterinary services • Lack of emergency preparedness • Cross border livestock movement • Management of water for livestock Page 51 Q: What are land degradation links to livestock and how to better restore forest and vegetation cover to avoid diseases of animals? • If the nutrition status of animals is poor this will make the animals more susceptible to diseases. Therefore, rangeland degradation leads to poor quality and quality of feed, particularly, during the dry seasons such as HS, TBDs and parasitic infections Q: Food chains (livestock meat, poultry, and dairy products) are usually a conduit or a multiplier of risks, are there any regulations and safety measures in the country to reduce this risk? Beside food, can you identify high-risk areas of contact or activities that promote transmission of zoonotic or vector borne diseases? • This is one of the weakest areas; lack of legislation and in some cases lack of enforcement of laws such and the Meat Inspection Act. Q: Do you think better management of natural resources have relevance for reducing disease transfer? And how? • Definitely, it is related to stabilization of the ecosystems. Q: Is there in Sudan any preservation areas or wetlands that are set outside the national parks for preservation of wildlife habitat? • I have no idea. Q: Is there a hub (coordination body) to explore this nexus? In case if there is, do you think its efficient? In case if there is no hub what’s your view/suggestions to hold this dialogue and take concerted actions? What are the gaps and obstacles to having a more integrated approach? Can the WB or UN host this platform to facilitate dialogue and integration with relevant government (Ministry of Animal Resources/Agriculture/Health) and nongovernment institutions (academia, SCOs, research institutes, labs), and so forth? • Yes. The hub is there as explained above. The hub needs to be strengthened. Q: When there is an outbreak, what institution in the region or country manages the outbreak? Is there a platform within the country that allows cross-sectoral exchange? What is the level of coordination within ministries and with international organizations? Does FAO/WHO/ IFAD look at these cross-cutting issues? • For animal diseases and by law only the Minister of Animal Resources has the power to declare disease outbreaks. Animal disease management is facilitated and led by the Directorate General of the Animal Health and Epizootic Disease Control at the Ministry of Animal Resources. FAO and WHO are participating in the One Health Forum, they are also on the National AMR Platform. FAO provides support to the livestock sector in terms of mobilization of resources and technical support. FAO is expected to establish a national coordination platform for the livestock sector involving all the stakeholders. FAO received a request from the MoARs to establish this forum. Page 52 Q: What is your role in managing this nexus? • I am a member of the One Health Platform representing FAO. Q: Where does the GoS need assistance in terms of policy making, research and law enforcement? • Policy-making in One Health, AMR, Land-use Planning, Access to Natural Resources and land tenure, Food chains, Emergency Preparedness, privatization of the veterinary services, Disaster Risk Reduction and Management (DRM/DRR), Early Warning Early Action, Control of TADs, Epidemio-surveillance, cross border livestock movement. • research gaps in all the above areas in addition to: Adaptation to climate change or land-use planning in general. • Law enforcement: Revisiting and updating all the legislations related to the livestock sector. Enacting new laws in case of gaps. The GoS needs support in all these fronts. 6. Dr. Manal Hamid Ahmed Q: In Sudan, is there a hub (coordination body) to explore this nexus? • Yes, there is One Health Platform including different governmental stakeholders such as FMoH, Ministry of Animal Resources, Civil Defense, as well as partners for instance WHO, GIZ and others. Q: In case if there is, do you think its efficient? • It needs to be strengthened. Q: In case if there is no hub what’s your view/suggestions to hold this dialogue and take concerted actions? • NA Q: What are the gaps and obstacles to having a more integrated approach? 1. Engagement of environment and agriculture sectors into OH 2. Operationalization of the OH concept (implement action plan) 3. Direct funding for OH activities 4. Working at state level to advocate and implement the approach Page 53 5. Integration of surveillance systems at human-animal interface 6. Build the capacity of Rapid Response Teams to respond jointly for public health threats 7. Enhance research to identify the triggers of outbreaks in the human animal population and the role of environment. 8. Increase awareness on outbreaks in the human animal population. Q: Can international development organizations such as the WB or UN agencies host this platform to facilitate dialogue and integration with relevant government (Ministry of Animal Resources/ Agriculture/Health) and nongovernment institutions (academia, SCOs, research institutes, labs), and so forth? • Yes. Attached the final report of (OHZDP) One Health Zoonotic Diseases Prioritization workshop including multisectoral plan of action with possible donors for the pillars of the plan. Q: When there is an outbreak, what institution in the region or country manages the outbreak? • The outbreaks are managed by Ministry of Health. Health Emergency and Epidemics control in coordination with relevant departments. Q: Is there a platform within the country that allows cross-sectoral exchange? • YES Q: What is the level of coordination within ministries and with international organizations? within ministries: 1. High decision makers level. Ministers. Undersecretaries. 2. Director General of Emergency, Epidemiology. 3. Technical staff at federal and state levels. 4. Technical committees for Epidemics. Q: Does FAO/WHO/IFAD look at these cross-cutting issues? • WHO Is counterpart for MOH. Health emergencies and epidemics preparedness and response is supported technically and financially. OIE provides technical support and evaluation for Ministry of Animal Resources FAO supports development programs related to animal health and production. Q: What is your role in managing this nexus? • Zoonotic disease unit in HEEC is the official one health focal point at FMoH and coordinates all plans and projects of OH. Page 54 Q: Where does the Government of Sudan need assistance in terms of policy making, research gaps or land-use planning/enforcement? • As indicated in final report (attached) of (OHZDP) One Health Zoonotic Diseases Prioritization workshop including multisectoral plan of action with donors are required to support all the pillars of the action plan: • Strengthening Multisectoral, One Health Coordination Mechanism. • Support Surveillance (Passive and active). • Support Laboratories and Testing Capacities. • Support Outbreak Response. • Support Preparedness and Planning. • Support Work force and Human Resources. • NOTE: Regarding climate change and degradations of environments it is under the responsibility of The Higher Council of Environment and Natural Resources and Ministry of Agriculture. The HCENR is a member in Sudan One Health Platform. 7. Dr. Betigel Habtewold Q: Is there a hub (coordination body) to explore this nexus? In case if there is, do you think its efficient? In case if there is no hub what’s your view/suggestions to hold this dialogue and take concerted actions? What are the gaps and obstacles to having a more integrated approach? Can the WB or UN host this platform to facilitate dialogue and integration with relevant government (Ministry of Animal Resources/Agriculture/Health) and nongovernment institutions (academia, SCOs, research institutes, labs), and so forth? • Yes. There is one health platform under formation bringing the three sectors (human, animal and environment), academia, private and nongovernmental organizations and UN agencies. The FMOH is leading the process. This idea of having a one health platform was discussed, prioritized and agreed by the three sectors during the one health zoonotic diseases prioritization workshop held last year. Therefore, I believe that with the support from relevant Ministries and partners, the platform can be more efficient to meet its objectives. The government sector is in much stronger position (in terms of ownership and mandate) to lead the platform with technical and financial support from partner agencies. There is no need to reinvent the wheel by creating new or parallel coordination mechanisms at this stage in Sudan. Page 55 Q: When there is an outbreak, what institution in the region or country manages the outbreak? Is there a platform within the country that allows cross-sectoral exchange? What is the level of coordination within ministries and with international organizations? Does FAO/WHO/ IFAD look at these cross-cutting issues? • The FMOH and MoAR are in much better position to answer this question. I defer to Dr Hanadi from FMOH to reflect on this. To the best of my knowledge, in Sudan, there is a growing collaboration between the two sectors (human and animal health) in sharing information and conducting joint outbreak investigation and response. This was proven during last years declared RVF outbreak in Red Sea State. The MoAR assigned a veterinary doctor to the one health unit at FMOH to facilitate the information sharing and collaboration. The level of WHO engagement for declared outbreaks is good. But, it is important to highlight that given the economic impact of declaring zoonotic diseases such as RVF, it is always sensitive and political. As a result, engagement of UN agencies and other partners, aside from the government sectors, is limited. Q: What is your role in managing this nexus? • I am serving as focal person for zoonotic diseases/one health from WHO side. Accordingly, I  supported FMOH, One health unit, to organize and conduct One Health Zoonotic Diseases Prioritization (OHZDP) workshop bringing the three sectors together in Sudan last year and have been supporting the FMOH to materializing all the action plans developed during the workshop. Consequently, Sudan prioritized 8 zoonotic diseases of greatest concern for joint collaboration among the three sectors to prevent, prepare for and respond to them at human, animal and environment interface.  The prioritized zoonotic diseases are: RVF, Salmonellosis, Dengue, Rabies, Brucellosis, Crimean Congo Hemorrhagic Fever, Zoonotic Avian Influenza and Hepatitis E. One of the outcomes of the OHZDP workshop was to develop joint action plan among the three sectors to addressing the prioritized zoonotic diseases under the auspices of one health approach. By the same token, the workshop led to the formation of one health platform in Sudan. The full report on the process and outcome of the one health diseases prioritization can be found from FMOH Zoonotic unit. Q: Has Sudan been able based on past outbreaks to use the environmental and climate data such as GIS and early warning methods in surveillance systems to predict disease outbreaks? • Not to my knowledge. I assume they may have used IGAD or FAO’s predictions. We analyzed five years diseases outbreak data (including zoonotic diseases) to predict risks as part of multihazard health emergencies preparedness and response plan for Sudan every year where few zoonotic diseases always were identified and prepared for. Q: Where does the GoS need assistance in terms of policy making, research gaps or land-use planning/enforcement? • The FMOH need to be supported in terms of capacity building and tools to do risk analysis and mathematical modeling to predict risks of zoonotic diseases and prepare for them. Page 56 8. Dr. Hassan Elbushra Q: Where do you perceive the biggest gaps are between health systems, land-use planning, and the country’s animal resources, mainly livestock? • One health Strategy: Does not exist. • Joint surveillance (sharing Surveillance data): Very poor. • Lack of transparency (Relatively very small number of reports has been published. • Joint response mission (RRT). • Poor documentation. • Lack of relevant/ related research. • Inadequate preparedness. • Inadequate awareness of decision-makers. • Conflict of interest, Corruption (Many stories to tell). • Division of Sudan into geographic zones. • OIE policy (Three-year embargo) Where are Sudan’s greatest livestock/health vulnerabilities? Greatest vulnerabilities in rangeland management/veterinary care? • Accurate census of animal wealth. • Geographical distribution (Updated maps and atlases) for distribution of disease, vectors, reservoirs, vaccination coverage, movement [paths] of animals, clinics, surveillance systems, response activities, and so forth by time, place and person). • Disease control strategies and prepared plans: Manpower, laboratories, regular surveys, vaccine stockpiles, and so forth. Q: Where are Sudan’s greatest livestock/health vulnerabilities? • The Sudan ranks as the second country holding livestock in Africa. • The Sudan - Estimates of livestock population, 2019 Livestock Quantity (‘000 heads) Cattle 31 489 Sheep 40 896 Goats 32 032 Camels 4 895 Total 109 312 Page 57 Q: When there is an outbreak, what institution in the region or country manages the outbreak? Is there a platform within the country that allows cross-sectoral exchange? What is the level of coordination within ministries and with international organizations? Does FAO/ WHO/IFAD look at these cross-cutting issues? • Although zoonotic diseases occur first among animals, outbreaks of zoonotic diseases in the Sudan are usually detected and reported by sentinel disease surveillance system run by the Federal Ministry of Health. Early warning indicators of the zoonotic outbreaks, for example, abortions and death of animals are usually under-reported probably because of inadequate awareness of the people, relatively weak veterinary surveillance system or inadequate transparency among other factors. It is most likely that ministries of health and animal resources share disease surveillance data during outbreaks. Yes, there are inadequate concerted response activities to detected outbreaks due to conflict of interests among stakeholders and involvements other influential authorities. The FAO/WHO/IFAD and OIE usually receive no or delayed and incomplete data about outbreaks of zoonotic diseases. The inadequate transparency could be attributed to difficulties in implementing a functional surveillance system, over-confidence in the national response teams or fear from economic losses. Q: Food chains (livestock meat, poultry, and diary products) are usually a conduit or a multiplier of risks, are there any regulations and safety measures in the country to reduce this risk? Beside food can you identify high risk areas of contact or activities that promote transmission of zoonotic or vector borne diseases? • I do not know an answer for this question. Q: Is there any evidence suggesting that ecosystem components and functions drive some of the potential zoonotic diseases? Specifically, how do you think ecological degradation mainly deforestation and rangelands degradation increase the overall risk of zoonotic disease outbreaks? • I believe that there is a lot of literature that supports the above-mention statement. Yet, I believe that little is published in Sudan as compared to neighboring countries, for example, Ethiopia and Kenya. Q: What are on the ground lessons and how can we incorporate them moving forward? • Zoonotic diseases do exist in the Sudan. • Most of the major outbreaks of zoonotic diseases are inevitable and predictable. • The burden of zoonotic diseases, including morbidity and mortality among humans and animals and their associated economic losses can be minimized toa great extent should there be Political will. • Concerted efforts among different partners. • Establishment of One Health program or coordinating body. • Strengthening human and animal disease surveillance and response activities. • Promoting vaccination programs whenever possible. Page 58 • Promoting public health awareness programs among herdsmen and nomads. • Increasing transparency. • Promoting and supporting research activities; and supporting holding seminars, workshops and national conferences on zoonotic diseases. • Dividing the Sudan into three or four geographical zones with well-defined paths and quarantines for animals to be exported. • Revising the OIE international regulation that ban exporting animals for at least three years from affected countries. Q: Where does the GoS need assistance in terms of policy making, research gaps or land-use planning/enforcement? • I cannot answer this question. Q: Greatest vulnerabilities in rangeland management/veterinary care? • In absence of acceptable level of transparency or at least good and reliable data bases it would be very difficult to accurately identify vulnerabilities or risk factors; and or assess or evaluate improvement or deterioration of veterinary care in countries of interest. Ministry of Animal Resources should have high quality data on occurrence of zoonotic diseases, competent and functional veterinary laboratories as well qualified professionals (epidemiologists, clinicians, public health officers, entomologists and laboratorians). 9. Professor. Muntasir Ibrahim Q: Do you think better management of natural resources has relevance for reducing transfer of endemic and zoonotic diseases? And how? • The emergence of zoonosis including the recent incidence of three viral pandemics and epidemics is complex behavioral environmental and socioeconomic aspects. I can’t see a direct connection between management of natural resources and incidence of viral outbreaks or zoonosis in general. • In fact, one might suspect the opposite: exploitation of natural resources often triggers the onset of zoonotic diseases. Leishmaniasis is a glaring example where treading of the humans into wildlife territories (Acacia forests in the Blue Nile) and the mass mechanization in Gedaref caused the known epidemics od VL. Page 59 Q: What are on the ground lessons and how can we incorporate them moving forward? • We cannot combat infectious diseases without adequate knowledge based on solid research. • Rapid diagnostic tests are essential to monitor the disease dynamics. • The medical and clinical community should come abreast with scientific findings and translate them into practice. 10. Ibrahim Doka Q: What is the focus of Sudan Sustainable Natural Resources Management Project (SSNRMP)? • The project focuses on increasing the adoption of sustainable land and water management practices in targeted landscapes across Gezira, Kassala, White Nile, Northern State, North Kordofan, River Nile, Gedarif, and Khartoum and with plans to extend to five additional states. Q: How does the project address communities’ needs while also adhering to the natural resource management aspect? • The project addresses landscape degradation challenges in Sudan by “promoting a landscape approach to natural resources management (NRM) and conservation of biodiversity, that considers both geographical and socioeconomic dimensions to managing the land, water and forest resources as basis for meeting goals of food security and inclusive green growth. Page 60 References Aal, Rasha A., and Ayman A. Elshayeb. 2011. The Effects of https://documents1.worldbank.org/curated/en/84495156​ Climate Changes on the Distribution and Spread of Malaria 3783610138/pdf/Health-Financing-in​-Fragile-Conflict-and​ in Sudan. American Journal of Environmental Engineering -Violence-FCV-Situations-Five-Key​ - Questions-To-Be​ 1 (1): 15–20. -Answered.pdf. http://article.sapub​.org/10.5923.j.ajee.20110101.03.html. Edam, Wesal, and Ehab Abdelgalil. 2022. “Seasonal Quality of ACAPS. 2023. 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