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154 Miscellanea in the corneal epithelium would probably be noticed We should like to thank Dr. M. D. Kipling, H.M. by the sufferer before it could be seen by an examin- Medical Inspector of Factories, Birmingham, for ing ophthalmologist. bringing this problem to our attention, and Dr. W. T. It seems advisable for exposure to these amines to Jones for providing samples of the amines used. be minimized. In our opinion, the attention of workers exposed to this hazard should be firmly REFERENCES drawn to the type of haze that heralds the reversible Amor, A. J. (I949). Manufacturing Chemist, 20, 54I-544. stage of the condition. Kipling, M. D. (I965). Personal communication.

The Future of an Occupational Health Unit in Khartoum University, The Sudan MUSTAFA KHOGALI From the Occupational Medicine and Industrial Hygiene Unit, University of Khartoum, The Sudan

A brief geographical and economic review of the Sudan has been attempted. Occupational health problems of the present and future have been outlined. The potential and intended functions of an occupational health unit are defined. The importance of teaching, surveying industry, and research is stressed.

The Sudan is a zone of steppe extending west of Population the River Nile to rise in the extreme west as volcanic hills of Jebel Marra, 5,000 to 6,ooo feet high, and to The Sudan is inhabited by approximately 13 form the Red Sea Hills in the east which are part million people. The birth rate is 48 per I,OOO and http://oem.bmj.com/ of the Rift Valley and link up with the Ethiopean the death rate 20 per I,OOO. Thus the population is Highlands. increasing yearly by 2-8% and is expected to reach The climate differs in each region. In the Red 25 million in I990. The expectation of life is 40 to Sea Hills the winter is wet and the humidity high. 50 years. As the birth rate is high and the expecta- In the northern region desert conditions prevail; tion of life is short, the population pyramid is quite there are two seasons only--hot, dry summers and steep, as expected in a developing country (Table I). cold, dry winters. The southern part is a region of Ethnologically the Sudanese are a product of tropical forests which has a long wet season from Hamites and Negro people-the result of the Arab on October 4, 2021 by guest. Protected copyright. March to November. The central region, which invasion of Nubia from the north in the seventh includes Khartoum, has a sub-tropical, continental century. The Arabs are predominant, Arabic being type of climate with four seasonal changes, and the the language of the I0 million people of the north. temperature varies throughout the year between Only I5% of the population live in towns; the 500 and 105'F. remainder is a rural population whose chief occupa- The climate influences the type of vegetation and tion is agriculture. Illiteracy is high. agricultural crops. Of the 6oo million acres, 120 million are suitable for agriculture and another 8o million for stock-raising; however, only I5 Economics and Manpower million acres are under cultivation. In 1951 the Sudan was divided into nine provinces In the last io-year plan the economic growth was each with its own elected council. The provinces estimated at between 7% and 8%, which is fair for are further divided into districts, each having a a developing country provided it can keep pace with rural district council or a town council. the population growth. The average income is low but varies greatly for persons in different occupa- Received for publication November 3, I965. tions. Br J Ind Med: first published as 10.1136/oem.23.2.154 on 1 April 1966. Downloaded from

Miscellanea I155 TABLE I finished, is mainly incidental. They include services POPULATION PYRAMID IN THE SUDAN BASED ON I956 CENSUS ranging from the humble to the highly specialized, Age Group Approx. Percentage together with commerce, banking, insurance, and Number entertainment. 0-I4 6,ooo,ooo 46 I5-29 3,500,000 27 Medical Services and Health Problems 30-44 2,000,000 I5 45-74 I,000,000 75 + 500,000 4 The Under-Secretary in the Ministry of Health Total 13,000,000 IOO is responsible for all health services throughout the Sudan including the training of local medical and health personnel. The economically active part of the polpulation is As mentioned before, the country is divided into nearly 45% (as estimated by the Ministry Of nine provinces, in which the Province Medical Labour), but, of this, 25% are below tthe age of Officer of Health (P.M.O.H.) is responsible for the I5 years. The percentage between I5 and 25 years health services. Every province is divided into who are economically active is high at 85% in districts; each district has a hospital and satellite males, as is to be expected in any cdeveloping dispensaries. The Medical Inspector in the country. Due to the population pyrami.d and the districts is responsible to the P.M.O.H. for all health fact that women are not employed, thie ratio of problems in his district (see Figure). dependants on those who are economical] .y active is The Sudan still depends on medical auxiliaries nearly 2 to i, resulting in a reduction of iricome and who represent the front line of this medical service. a lowering of the standard of living. Although statistics are not well kept the figures It is difficult to give a detailed description of below are mainly quoted from the Annual Reports occupational groups, but generally manpower in the of the Ministry of Health of Sudan. Sudan can be classified under three mair headings The average doctor: population ratio is I:20,000, (Table II). ranging from i:I,ooo in Khartoum to I:40,000 in the rural areas. The number of hospital beds is

TABLE II I-2 per i,ooo, ranging from 3-5 per I,000 in urban areas. PERCENT DISTRIBUTION BY ECONOMIC SECTORS OF MANPOWER areas to o-8 per I,000 in certain rural The IN THE SUDAN AND SELECTED OTHER COUN[TRIES* budget is meagre and the annual expenditure per Country Primary Secondary Tertiary head on health does not exceed nine shillings. Most http://oem.bmj.com/ (both sexes) (%) (%) (%) is spent on the curative side, while prevention takes only Io%. Sudan, I956 86 4 IO India, 1951 7I 10 '9 U.A.R., I951 54 5 41 Medical Training As the Sudan depends U.K., I95I 9 44 47 mainly on medical auxiliaries, several schools have been developed for their training. The School for *Percentages corrected to round figure Medical Assistants, which runs the dispensaries, was established in I9I8; a three-year training is on October 4, 2021 by guest. Protected copyright. Primary Sector This includes activiities which given. The School of Hygiene was established in are mainly concerned with the direct expl1oitation of I932 to train Public Health Officers; the diploma of natural resources whether renewable or niot. They the Royal Society of Hygiene is given at the end of include agriculture, animal husbandry, forestry, three years' training. Other schools have been fishing, mining, and quarrying. established for ophthalmic assistants, theatre attendants, laboratory technicians, radiographers, Secondary Sector This includes activities dental mechanics, and dispensers. For women a among which the main purpose is the transforma- Midwifery School was established in Omdurman in tion of primary or partly finished mateerials into I920, followed by a Health Visitors' School. The finished or nearly finished products. Theey include Nursing College was founded only a few years ago the manufacturing industries of arts and crafts and in the late fifties. The School of Medicine started in addition construction, food processingJ, and the in 1924 and is discussed below. refinement of raw materials. Health Problems Health problems in the Tertiary Sector In this group are asctivities in Sudan are great and diverse. The infant mortality which the use of materials, whether raw or partly rate is 93 per i,ooo, ranging from 25 per I,OOO in Br J Ind Med: first published as 10.1136/oem.23.2.154 on 1 April 1966. Downloaded from

Miscellanea MINISTRY OF HEALTH Under-Secretary Ministry of Health HEADQUARTERS

Deputy U-S. I' Deputy U-S. Assistant U-S. Research Assistant U-S. Assistant U-S. Public Health and Public Health Hospitals Development Laboratories and Planning

Province Medical Officer of Health PROVINCE

Assistant P.M.O.H. | Province Senior Inspector of Health

Medical Inspector DISTRICT All Medical and Health Services in the District FIGURE. Medical Services in the Sudan the Khartoum Province to I85 per I,OOO in other to 6o, and the faculty has expanded in all its areas. The major causes of death are pulmonary departments. tuberculosis and other respiratory diseases, malaria, and enteritis. Among the communicable and en- The Department of Public Health The demic diseases, malaria tops the list, being endemic department was run by an English professor until all over the Sudan while bilharzia is endemic in I959 when he retired and was succeeded by a Gezira. Diseases due to poor sanitation are pre- Sudanese. There are four lecturers in the depart- valent. Gastro-enteritis is the main cause of death ment, one of whom is also responsible for the of children, especially when complicated by measles Student Health Service. The department is or a secondary respiratory infection. expanding continuously. http://oem.bmj.com/ The Sudan has many public health problems The teaching of public health starts in the second which are exacerbated by the large size of the year of the medical course. An average of I50 to country. Moreover, the long frontier with eight 200 hours is devoted to public health, spread over neighbouring countries coupled with the nomadic the three years that it is taught; much practical work habits of a large section of the population, makes the and field work are given. control of these diseases very difficult. However, The students are also taken on public health tours future planning and the help of international all over the Sudan during the vacations to help them organizations, especially the World Health Organiza- understand the real health problems of the country. on October 4, 2021 by guest. Protected copyright. tion (W.H.O.), makes the eradication of these The department has its own laboratory with three diseases feasible. There are certain projects assisted laboratory technicians but still lacks a statistician. by W.H.O. which must be mentioned. These are The relationship of the department to other depart- the B.C.G. campaigns; a T.B. Pilot Project at Wad ments is good, and a close relationship is being Medani which depends on group examination and created with the Ministry of Health. The Occupa- case finding; a malaria eradication project; the tional Health Unit, which has been recently created, Nursing College; and the Orchocerciasis Pilot Pro- will be part of the Public Health Department for a ject. High hopes are entertained of the outcome of long time to come. Undergraduate teaching will be these schemes. one of the major functions of the Unit. Before dis- cussing the structure and functions of the Unit, it is necessary to consider the industries in the Sudan The School of Medicine The School of and those around Khartoum. Medicine started in I924 with an intake of four students and was affiliated to the University of Industry in the Sudan London. In 1958 the Faculty of Medicine in the University of Khartoum offered its own degree of Industrial development in the Sudan has followed M.B., B.S. The annual intake has risen gradually the pattern seen in the other developing countries Br J Ind Med: first published as 10.1136/oem.23.2.154 on 1 April 1966. Downloaded from

Miscellanea I57 which possess little mineral wealth, namely the pro- society with far-reaching effects on all its members. cessing of agricultural products. Cotton ginning and It involves the transformation of a peasant society the manufacture of cotton textiles are well estab- into a community dependent on factories, and lished, the production of vegetable oils from seed demands migration. Whole communities leave the pressing is undertaken, and sugar refining is im- settled country life to live in or near an industrial portant. Transport is being developed, and railways, town, and the man who is a craftsman in his own roads, and ports are being established while right becomes a cog in a machine. These migrant electricity undertakings have grown apace. workers may be subjected to insanitary living and Rapid industrialization has been the aim of factory conditions. They may contract new com- successive governments and a political slogan of all municable diseases-thus the incidence of tubercu- parties. The general policy has been to distribute losis will rise. Accidents will become more frequent the industries equally, but concentration has and the incidence of tetanus may rise. The agri- occurred mainly around Khartoum since it provides cultural population cannot readily handle the the best consumer market. As petroleum has not modern machines efficiently nor do they master the yet been discovered in the Sudan, the only cheap new techniques easily. It is not easy for them to source of power is hydro-electric schemes. During adapt to the new factory discipline with fixed hours dam building many disasters have occurred which and mass production methods, and they miss their indicate the need for efficient medical services. So free and easy rural habits. far these have not been planned with sufficient The same problems are to be expected in the foresight. Sudan as have occurred elsewhere in Africa. Over- The natural resources of the country have not yet crowding of the industrial estates will be a problem; been fully exploited. Copper, manganese, mica, malnutrition and venereal diseases may affect the gold, and iron are mined on a very small scale. The unmarried and separated. Family ties will be mechanization of agriculture and proper care of weakened and many social and psychological prob- livestock are still in their infancy. lems may arise. Moreover, under the slogans of As well as Khartoum, other foci of industry are rapid industrialization, shabby, unhealthy factories the Gezira area, where all cotton ginning takes and workshops may be built. Workers are apt to be place, the Geneid area, where there are tobacco exploited and may be asked to handle dangerous factories, sugar refineries, cardboard factories, and materials without the necessary precautions being glass factories, and Atbara where there are railway taken to protect them. How to cope with all these workshops and the cement industry; in Port Sudan problems and matters is the future task of the oil refining, oil pressing, and the textile industry are occupational health service. In a developing country http://oem.bmj.com/ found in addition to the activities of a busy port. like the Sudan this will be a part of the work of the The industries in Khartoum Province are con- public health expert. centrated mainly on the industrial estates in Khartoum North, Omdurman, and Khartoum. Labour Legislation Labour legislation in the According to the classification of occupation Sudan consists of two chief categories: that dealing adopted above, only 33% in Khartoum are occupied with the conditions of employment, and that govern- in the primary sector, 30% in the secondary sector, ing the formation and registration of trade unions and 37% in the tertiary sector. Although Khartoum and the regulations of industrial relations. In the on October 4, 2021 by guest. Protected copyright. Province has one-twentieth of the Sudanese man- first category are the Employers and Employed Per- power, it contains about one quarter of the men sons Ordinance I948; the Workshops and Factories engaged in the secondary and tertiary sectors. Ordinance 1949; the Wages Tribunal Ordinance A cross-section of industries is concentrated I952; and the Employment Exchange Ordinance around Khartoum; the textile industry, employing I955. These ordinances have been borrowed freely 5,ooo workers; the chemical industry, for example from similar laws in Great Britain. with branches of I.C.I. and Chloride Batteries; The Labour Department was started in I947 and paints; oil and soap industries; beer, alcohol, and consists of the following sections: (i) Labour other distilleries; glass, sweets, and all consumer Inspectorate; (2) Factory Inspectorate; (3) In- needs; hundreds of small workshops, foundries, and dustrial relations; (4) Training-within-industry; light engineering. Most of these are privately owned (5) Wages tribunal; (6) Housing of workers; although most of the big factories belong wholly or (7) Industrial Standards Board; and (8) Employ- in large part to the government. ment bureau. The Factory Inspectorate section is manned by Problems of Industrialization Rapid in- only six inspectors, none of whom is medically dustrialization implies radical alterations in any qualified; a medical inspectorate has not yet been Br J Ind Med: first published as 10.1136/oem.23.2.154 on 1 April 1966. Downloaded from

Miscellanea developed. Section I5 of the Workshops and measure the prevalence and severity of any occupa- Factories Ordinance I949 gives power to the Medical tional health hazards. It is planned to carry out this Officer of Health to carry out medical inspections survey as soon as possible. It will entail co-operation of a workshop or factory or employed person as may between the Ministry of Health, the Ministry of be necessary. Labour, and the Factory Inspectorate. Students should be of great help in this work. Functions of the Unit Research A university unit cannot continue to A picture has been presented of the current social develop if it is not engaged continuously in research. and economic conditions in the Sudan to try to give The problems requiring investigation are many and an idea of the type of work the Occupational Health the field is wide open. Unit should be doing as part of the Department of Public Health. Its possible functions may be Library Building a good library and purchasing summarized as follows: sound international periodicals is a necessary part of this development. Teaching Undergraduate teaching is important and should be provided for medical students, non- Occupational Hygiene Laboratory Great medical (engineering) students, and Public Health use should be made of the existing laboratory of the Officers in training. Department of Public Health, which can be The type of teaching appropriate to each category developed to include an occupational hygiene unit. varies, and it is planned that for medical students the occupational health teaching should be confined International Relations The co-operation to basic and related subjects but should also include and advice of experienced bodies is greatly needed. visits to factories and demonstrations of clinical The aim should be to create closer relations both cases. with the universities on the African continent and For engineering students, who will be responsible with the International Labour Office and W.H.O. for creating the new environment in which cther through the organizations functioning in the Sudan. men work, the teaching should be aimed at prevent- The continued advice and help of the Department ing occupational hazards by means of planned of Occupational Health and Applied Physiology at design before the factory is built, as well as con- the London School of Hygiene and Tropical trolling existing hazards. Medicine is envisaged.

The Public Health Officers, as agents of the http://oem.bmj.com/ Medical Officer of Health, need to be taught how to BIBLIOGRAPHY inspect a so be able factory that they may to make Annual Reports of the Ministry of Health, Sudan. recommendations on the environment, hygiene U.N. Department of Economic and Social Affairs. Popula- (general and personal), and disposal of waste in tion Studies, No. 37. Population Growth and Man- accordance with the Factories Acts. power in the Sudan. A joint study by the United Nations and the Government of the Sudan. United Nations, New York. (I964.) Survey of Industries The major practical Webster, M. H. (I960). Cent. Afr. J3. Med., 6, Suppl. to step required at present is to survey the industries: No. I0. on October 4, 2021 by guest. Protected copyright. to try to define the size of the various problems, to Symposium on Occupational Health and Hygiene, 9-14 March, I964, Brazzaville, Republique du Congo. investigate the health of groups of workers and the Fawzi, S. (I957). The Labour Movement in the Sudan, I946- conditions under which they work, and to detect and 1955. Oxford University Press, London.