The devastation of Sudan’s ‘forgotten war’

20-to-30 per cent of health facilities remain functional

Ms Claire Nicolet, Head of Médecins Sans Frontières/Doctors Without Borders (MSF) Emergency Response in Sudan, spoke to the Medical Independent (MI) on 25 March about the impact of the crisis

MI: Could you describe the nature and scale of the humanitarian impact on the people of Sudan since the eruption of the conflict, and is the humanitarian situation continuing to deteriorate?

Across the country, the situation is continuing to deteriorate. After nearly a year of fighting, there is no end to the conflict in sight. 25 million people are now in need of humanitarian assistance – almost a 40 per cent increase compared to the previous year. More than 6.5 million people have become displaced within Sudan, and over 1.7 million have become refugees in neighbouring countries.  

Airstrikes, drone strikes and heavy weapons, including tanks, have destroyed markets, infrastructure, crucial buildings – including healthcare facilities – and residential neighbourhoods. Street battles have raged through suburbs and villages, while some reports suggest that snipers have shot people leaving their houses to fetch food and water. 

The unrelenting violence in Sudan has led to catastrophic injuries, and our teams regularly treat severely injured patients, including women and children. 

The UN recently estimated that 13,900 people have been killed since the war began, but this is likely an underestimate. In Darfur, it is estimated that at least 10,000 people were deliberately killed in ethnically targeted violence.   

MI: What is the extent of healthcare provision in Sudan and neighbouring countries for those displaced. What is the level of access to healthcare and essential medicines for people with acute injuries, and existing long-term conditions, both in Sudan and neighbouring countries?

There are extreme levels of suffering across Sudan, either as a direct or an indirect consequence of the war. The Sudanese health system was fragile even before the conflict started – now it is under even more pressure. 

It is estimated that only 20-to-30 per cent of health facilities remain functional in Sudan, meaning that it is extremely difficult for people to access healthcare. Essential supplies and equipment are lacking, and many hospitals have closed completely. The availability of healthcare staff has also been severely disrupted by the ongoing conflict due to Ministry of Health staff salaries not being paid for many months.

MSF works in health structures across 12 of Sudan’s states, and patients often reach us in a critical condition either due to the violence, distance to health facilities, or the cost of transportation. The cost and availability of medicine has also [been drastically impacted] meaning that those with chronic diseases are unable to manage their condition – we often receive patients in a diabetic coma who have run out of insulin, for example.

Various parts of Sudan have seen large-scale outbreaks of vaccine-preventable diseases like measles, cholera cases have surged, and children in some parts of the country are experiencing devastating levels of malnutrition. In the city of El Fasher and in Zamzam camp in North Darfur, vaccines ran out in February, and in South Darfur the last remaining doses of pentavalent, polio, and measles vaccines available in the entire state were administered at the start of March. These vaccines are provided to the MoH by the UN, but the Sudanese authorities have prevented the UN from bringing supplies into, or through, RSF-controlled areas for months. One of the results of this is that children are now exposed to serious illnesses and complications that are totally preventable, so there is now a huge risk of disease outbreaks. In El Fasher, there have been four suspected cases of measles this month.

More than half a million people have fled to Chad since the start of the conflict. In June 2023, more than 850 war-wounded Sudanese, mainly with bullet wounds, were received in the MSF-supported hospital in Adré in the space of just three days. Hundreds of thousands of people previously trapped in West Darfur joined them en masse from June onwards. We heard horrific stories of violence, including sexual violence, from survivors.

After the first episode of violence, we also did a retrospective mortality study in refugee camps, asking families who among them died and when (before or after the beginning of the crisis), and of which cause. The refugees who came from West Darfur’s capital El Geneina were particularly affected, with a mortality rate 20 times higher compared to before the conflict began. 83 per cent of those deaths were men, consistent with accounts of systematic targeting of the men. And 82 per cent of the deaths were caused by violence, mostly gun violence. 

In the camps in eastern Chad there is currently an outbreak of hepatitis E, which is being exacerbated by poor sanitation and a desperate shortage of clean water in the camps. In Adré camp, there is just one latrine for 677 people, while in Metché camp there is one latrine for 225 people. Without swift action to improve sanitation infrastructure and enhance people’s access to clean water, there is a risk that we will witness a surge in preventable diseases and unnecessary loss of life. 

MSF is currently providing more than 70 per cent of the drinking water available in Adré, Aboutengue, Metché and Al-Acha camps. Despite this, people are receiving just 11 litres of clean water per day – well below the 20 litres per person per day recommended for emergency settings. Despite our relentless efforts, the humanitarian response in eastern Chad has been hampered by insufficient funding for humanitarian organisations on the ground, leaving critical gaps in the provision of food, water and sanitation.

Over half a million people have also fled to South Sudan, where a humanitarian crisis is escalating in Bulukat and Renk, two of the busiest transit sites in Upper Nile state. Many have no clear destination and spend weeks or even months in and around the transit centres, struggling to survive with a scarcity of humanitarian aid.

Renk has two transit sites, both of which are dangerously overcrowded, with almost 30,000 people living in an area meant to host no more than 12,000 people. The transit site at Bulukat is smaller – it has consistently hosted around 5,000 people at any given time since last July – but people’s living conditions are also harsh. Many families fled their homes with few or no belongings, and are now vulnerable to hunger, malnutrition and disease, exacerbated by inadequate shelter and the lack of clean water and sanitation facilities.

In both locations, MSF has launched mobile clinics to provide primary healthcare to returnees, refugees and host communities. Treating around 150 patients every day, the mobile clinic in Bulukat alone has provided over 28,000 outpatient consultations.

MI: What are the key challenges for organisations such as MSF in providing healthcare and humanitarian support for people in Sudan and those displaced in neighbouring countries; to what extent are the ‘actors’ in this conflict preventing the timely provision of these supports?

One of the biggest current challenges is the blockade that has been imposed by the Sudanese authorities on bringing supplies from Port Sudan – where the cargo ships arrive – to RSF-controlled areas. This impacts on many of our facilities – including our hospitals in Khartoum – and therefore our ability to provide healthcare. It also impacts on the UN and other humanitarian organisations, as is the case with the lack of vaccines – especially in Darfur. We don’t foresee that the government will change its policy anytime soon and we are therefore in the process of trying to build a supply corridor from Chad.

There are also high levels of insecurity across Sudan. For many months we were unable to access areas where we had previously had a presence for many years. The looting of health facilities and attacks on health premises and health personnel have, unfortunately, became a hallmark of the conflict. Multiple incidents have taken place in all types of facilities – including those where MSF works. The WHO has documented 62 attacks on healthcare in Sudan since the conflict began in April 2023. So on a regular basis, our ability to deliver healthcare is hindered by violent incidents like this.

MI: MSF has drawn specific attention to the alarmingly high levels of malnutrition to Zamzam camp in North Darfur. What is the situation currently? 

Due to the massive malnutrition and mortality crisis that we found when we carried out our rapid nutrition and mortality assessment in January, we are scaling-up our response in Zamzam camp. We are about to begin a mass screening of 100,000 people – children under-five as well as pregnant and breastfeeding women – to try and reach those in most urgent need of support. We will also soon be opening a 50-bed field hospital, where the most-critical cases will be admitted, while those who can be treated on an outpatient basis will receive therapeutic food. 

We will also open a second outpatient clinic to try and meet some of the huge health needs in the camp, but it will not be enough to address the scale of the disaster. In North Darfur, there is a critical shortage of everything. There are an estimated 2.8 million people living in the state, and there are nowhere near enough health providers operating there to meet the needs of the population. Our small clinic in Zamzam remains the sole provider of healthcare in the camp, which is home to around 300,000 people – and one of the few for the entire 2.8 million people who live in the state. 

Our clinic sees over 200 patients a day – many of whom arrive on foot or by donkey from up to 50km away. Our team is overwhelmed by the vast and growing needs. Over the past few months, thousands of people have been arriving in Zamzam from other parts of Darfur in search of safety. They are sheltering in schools with no food and no access to clean water. In such overcrowded and unsanitary conditions, disease outbreaks are inevitable – and, since there are few vaccines in North Darfur, we expect the already drastic mortality rates that we found to increase even further. 

In terms of malnutrition, all the clinics where children could previously be taken to receive treatment in the state capital, El Fasher, have been closed for months. This means that we receive very critical cases at the paediatric hospital we support in the city – many of the children need to be admitted to the ICU because their condition is so serious. 

Over the past few months, although we have been able to bring in supplies for our facilities in North Darfur from Chad, we remain almost completely alone there. The UN have a very limited presence in El Fasher, as most of their teams were evacuated after the war began. The same goes for other international NGOs, who have not yet returned. The needs of the population are vast and we cannot meet them alone. It is vital and urgent that more organisations come to North Darfur to scale-up the response alongside us. 

We anticipate that the situation will deteriorate even further without an immediate scale-up in the humanitarian response. There have been no food distributions from WFP that we are aware of since May last year. People in the camp were almost entirely reliant on these for their survival. January, when we conducted our assessment, is a time when malnutrition should have been at its lowest, because December is when the harvest usually takes place meaning that stocks of food should be at their highest. But over the past year people have been unable to tend to their crops due to the insecurity, and on top of this, what little agricultural production that has been possible has been below average because of low rainfall. With the usual malnutrition peak just around the corner – between April and September – we are expecting the already enormous number of cases we are seeing now to drastically increase over the coming months.

To provide food rations for 500,000 people in both Zamzam and the state capital, El Fasher, we have calculated that 370 trucks each delivering 20 tons of food will be needed every month. As well as this, there is an urgent need for hospitals, water, sanitation – and access. 

MI: What can countries such as Ireland do to support people in Sudan and help bring an end to this conflict. What are the key actions MSF is seeking from the international community to support people in Sudan and to help end the conflict?

What is needed are guarantees from all parties to the conflict to ensure unhindered access for humanitarian organisations so that the humanitarian response across the country can be scaled-up. Alongside this, it is also vital that they ensure the protection of both humanitarian personnel and the civilian population. The blockade on supplies also needs to be lifted as a matter of urgency.

At present, we bring supplies in from Chad, but this is a long journey that used to be possible by air. There was a recent announcement from the UN that three airports would be opened – including one in North Darfur. This would make a massive difference to the humanitarian response. It would enable a huge and rapid scale-up in North Darfur. The UN have also announced that they have trucks destined for West, Central and South Darfur, where the needs are also huge – but there is no guarantee that they will reach their destinations. UN convoys destined for various locations have been stuck in eastern Sudan for months, unable to move due to the lack of travel permits and insecurity on the roads. The Jeddah talks and other peace negotiations have failed and people are suffering as a result. The international community needs to turn its attention towards securing sustained access for humanitarian organisations and protection for civilians and humanitarian workers. Increased funding for the humanitarian response across Sudan and in neighbouring countries is also vital.