Sudan Sanctions Deprive ‘Whole Nation’ of Health Care

KHARTOUM, Sudan — Last October, Salaheldin Abusin, president of the Kansas-based Sudanese American Medical Association, got a call from a surgeon in Khartoum who needed sutures to sew up nomads, herders, and subsistence farmers infected by a flesh-eating fungus that had to be carved out of their limbs. The patients could rarely afford the appointment, never mind the stitches. So Abusin reached out to Johnson & Johnson’s multinational medical supply company, Ethicon, which agreed it was a worthy cause and directed him to MAP International, a U.S.-based Christian health organization that delivers Ethicon’s donated goods around the world. But a few weeks later, Abusin received an email from MAP: The charity would have to decline his request because of U.S. sanctions against Sudan.

It was only the latest disappointment for Abusin, whose medical association has been exempted from the sanctions by the U.S. Treasury’s Office of Foreign Assets Control (OFAC) and should be allowed to send equipment like sutures to doctors in Sudan. But MAP demanded a second exemption from the Department of Commerce’s Bureau of Industry and Security. It’s not clear that the second exemption was necessary by law — lawyers say that would depend on how the transaction was structured, among other complicated variables — but therein lies a central problem with the sanctions regime: Uncertainty in interpretation poses a risk that many companies, skittish about costly accidental violations, prefer to avoid altogether.

Ever since the United States designated Sudan a “state sponsor of terrorism” in 1993 and imposed comprehensive sanctions on the country, doctors and scientists in Khartoum say they have struggled to import supplies and conduct research that could eventually save lives. These sanctions have become increasingly complex and difficult to navigate over the years, making it tough to import equipment, even such basic items as sutures. For members of the regime’s privileged elite, who are the intended target of the sanctions, that may not matter, since they can travel to Saudi Arabia, China, and other countries for treatment. But for ordinary Sudanese — 39 percent of whom live on less than the internationally defined poverty rate of $3.10 a day — the blockages can be catastrophic, the difference between life and death.

“A whole nation is deprived of access to high-quality medical technology and pharmaceuticals through no fault of their own,” Abusin says.

Sanctions were initially imposed on Sudan in the early 1990s after it became clear that President Omar al-Bashir’s government was providing safe haven to terrorists, including Osama bin Laden. Over the next two decades, the U.S. government gradually tightened the screws, adding more and more prohibitions on financial transactions until Sudan was effectively frozen out of the global economy. Behind the push for ever more sanctions were evangelical and human rights groups outraged over abuses committed by the Sudanese government in southern Sudan and Darfur, where the U.S. State Department declared a genocide was taking place in 2004.

Today, the sanctions regime remains in place, despite the fact that South Sudan is now independent and the violence has subsided somewhat in Darfur. U.S. officials have said they no longer believe Sudan is spreading terrorism abroad and even promised to remove the country from the “state sponsors of terrorism” list. But nonetheless, Sudan remains on the list, in part because the government continues to commit atrocities against its own people in new conflicts in the southern regions of Blue Nile and South Kordofan. And while there is scant evidence that sanctions have deterred the accused war criminal Bashir, it’s clear that they have set back Sudan’s development tremendously: According to doctors and scientists in Khartoum, the sanctions have isolated the country’s biomedical sector and negatively impacted health-care provision in general.

Food, medicine, and humanitarian assistance are all theoretically exempted, but obtaining sanctions waivers can be onerous. Even when they are granted, many organizations, like MAP International, decline the transactions regardless. If they make a mistake in interpreting the complex web of laws stemming from the sanctions, they can face severe punishments.

“Violations can cost hundreds of millions of dollars,” says Burt Braverman, a lawyer at Davis Wright Tremaine, a firm headquartered in Seattle, Washington, that handles trade, sanction, and export compliance. “People have gone to jail.”

After the 9/11 terrorist attacks, banks have increasingly severed ties with customers that could — however remote the risk — land them in the category of organizations that help finance terrorism or launder money, according to a November 2015 report from the Washington, D.C.-based Center for Global Development. Last year, an example was made of the French bank BNP Paribas, which paid an $8.9 billion penalty for doing business with Sudan, Iran, and Cuba.

BNP’s breach was egregious, but it functions as a stern warning of the type of penalties at stake if banks misjudge a transaction. With about 30 agencies involved in regulation, Vijaya Ramachandran, a senior fellow at the Center for Global Development and lead author of the report, says, “banks get mixed and sometimes contradictory signals, and they respond by deciding to not do business.” That is especially likely when the risk is high and there is little profit to be gained — exactly the case that ordinary Sudanese citizens present. “The financial exclusion of such clients creates yet another obstacle for poverty alleviation and economic growth, especially in poor countries,” the report concludes.

Because banks must handle financial exchanges — payments for sutures, for example — doctors in Sudan often make do with old or inadequate technology, rely on black-market imports, or simply go without. Inevitably, it is ordinary citizens who suffer the consequences. Last November, a heart surgeon named Ahmed Elsayed was on duty in Al-Shaab Hospital in Khartoum when a 14-year-old boy arrived from the Darfur region. He had suffered massive internal bleeding from his aorta, the main artery from the heart, and needed an emergency surgery to implant what is known as an aortic graft. But Al-Shaab only orders the grafts on a case-by-case basis because they must be imported to Sudan through a complex informal market involving third-party shippers — thanks again to U.S. sanctions. Also, the hospital often has to cover the cost, around $2,500, because few patients can afford it. Elsayed immediately placed an emergency order, but it was delayed for a few weeks on its circuitous route to Sudan. The boy died a week before it arrived.

“I wish the guys who pass the sanctions in Congress would be subjected to seeing these patients,” Elsayed said. “They do not know the ramifications of their laws.”

Sudan’s specialists have other complaints: Two of the five echocardiography machines used for heart ultrasounds at Al-Shaab Hospital have been out of commission for several years, which means that patients with potentially lethal heart conditions must wait weeks for a diagnosis. The machines were manufactured by General Electric, and cardiologists in Sudan say that the U.S.-based company won’t send spare parts or help with maintenance — even though the hospital is willing to pay for both. GE also refused to service the mammography machine at a major clinic for breast cancer treatment, Khartoum Breast Care Centre, according to medical professionals. GE did not respond to multiple emailed requests for comment.

Doctors in Sudan say that U.S. companies are often vague about why they deny requests for medical supplies, technology, and drugs, but many assume it is because of concerns surrounding U.S. sanctions — that or all the bad press Sudan has gotten because of celebrity visits to Darfur and South Sudan. Similar stories abound in Iran, another country that the United States intensively sanctions. In 2013, anecdotal reports of drug shortages in Iran were corroborated by an analysis from the Washington, D.C.-based Wilson Center showing that medicine imports from American and European manufacturers plummeted by 30 percent the year before, despite exemptions for clinical care.

Embargoes also make it difficult for academics to access vital bodies of scholarship. In a large, immaculate office at the Sudan University of Science and Technology in Khartoum, the dean of the Faculty of Pharmacy, Sami Khalid, complains that the university cannot buy subscriptions to scientific journals or even books online through Amazon. The university is also shut out of scientific databases that laboratories around the world use, he says.

“We cannot even update Adobe PDF to read publications,” Khalid says. “So if I want to read the scientific literature, I need to use a program called Hide My Ass.” Khalid laughs as he says the name of the software, which relatives buy for him abroad because sanctions prevent Sudanese from buying goods online with credit cards. But he grows somber quickly. He says he dislikes resorting to back-alley means to conduct science: “This is professional demoralization. We are equipped knowledge-wise, and we have the skills and motivation, and money, but we are handicapped by these sanctions.”

A few years ago, Khalid flew to Dubai to purchase a high-end chemistry instrument known as a chromatography machine. He needed the instrument to search for new drugs from plants, including those that might be used as treatments for malaria and mycetoma, the flesh-eating fungal infection that burdens Sudan’s poorest. But when he returned to Khartoum with the machine, its American manufacturer refused to help him install it in the lab. It now collects dust. Khalid declined to name the company for fear of jeopardizing the agents who helped him buy the machine.

Khalid says it has also been much harder to collaborate with U.S. scientists since the sanctions were put in place. He recalls his previous relationships with American researchers nostalgically, remembering, for example, how he and a botanist at Old Dominion University in Norfolk, Virginia, collaborated on a study funded by the U.S. Agency for International Development to uncover how parasites on sorghum infect this staple crop in Sudan. That was back in 1986, before the Islamist regime took power and before the U.S. sanctions regime changed everything.

Now something as simple as getting an article published in an academic journal can lead to a dead-end. In 2003, the U.S. Treasury warned the U.S.-based Institute of Electrical and Electronics Engineers (IEEE) that it risked violating sanctions by editing manuscripts submitted by Iranian scientists. Doing so could lead to 10-year jail terms and fines of up to $1 million. Immediately, about 100 scientific journals published by IEEE stopped accepting reports from Iran, Cuba, Libya, and Sudan. The following year, Elsevier and other publishers filed a law suit against the U.S. government, arguing that it was unjust and illegal to isolate scientists from the international world of research. The Treasury Department has since revised the rules, and IEEE has resumed publishing manuscripts from Sudan, but critics including Elsevier say the sanctions remain vague enough to scare some publishing houses away from working with Sudanese scientists.

“It is risky to interpret these guidelines. Informational material can’t be paid for, but if the author has already written the piece, maybe I can publish it with some light editing, but maybe not if I have to do substantial editing,” says Braverman, the lawyer. “It’s quite serious because this is an extension of U.S. foreign policy with respect to the war on terror, to the nonproliferation of nuclear weapons, and organized crime enforcement, so the government will not tolerate any carelessness.”

When asked about its policy on funding research in Sudan, the U.S. National Institutes of Health deferred to the State Department, which said in an emailed statement that the current system of exemptions allows certain technology and medical equipment, as well as vital humanitarian aid, to be exported to Sudan. Meanwhile, USAID told Foreign Policy in an email that it does not fund science in Sudan, but it does provide humanitarian assistance: In 2015, the agency disbursed some $228 million in aid to Sudan, which included payments for medicine. The nonprofit Gates Foundation said that it supports several programs involving global health in the country, but none that are focused on fundamental research that could lead to the discovery of new drugs for diseases like mycetoma that affect many Sudanese. Both American and Sudanese researchers complain that the majority of smaller funding bodies won’t touch Sudan because of the sanctions.

The U.S. Treasury says it tries to minimize damage to medicine and research through exemptions and outreach with banks and companies. Sometimes, these efforts work. For example, the Carter Center in Atlanta, Georgia, funds some biomedical research in Sudan with U.S. Treasury licenses. But neither Treasury nor the State Department has signaled a change in its policies toward Sudan. In an email to FP, a Treasury spokesperson reiterated the rationale behind the strict U.S. laws: “The goal of U.S. sanctions is to pressure the Government of Sudan to change the way it treats its people, as well as to renounce its role in state-sponsored terrorism.”

Yet after nearly 25 years of U.S. sanctions, Bashir remains in power and conflict continues in the Blue Nile and South Kordofan regions (and to a lesser extent in Darfur). Among the Sudanese, some of the president’s most vocal critics are doctors and academics who have been crippled by the American sanctions regime. “The president will be very happy if all of the intellectuals leave,” Khalid says, adding that they are already doing so in droves. Khalid acknowledges that doctors and scientists also leave their posts as salaries decrease and Sudan’s economy plummets, but he says the hardships caused by the sanctions are equally if not more of a problem. For those who cannot afford to travel abroad for treatment, this translates into worse health care.

“We know the sanctions were not made to hurt ordinary people, but this is the end result,” says Abusin. “You don’t get the care you need because you are from a country that is a pariah to America.”

This story was supported by travel funds from Global Health Now.

Photo Credit: STUART PRICE/AFP/Getty Images