Navigating the Human Toll Beyond Bullets: War and the Public Health Crisis in Sudan
Damaged Hospital Bed (Image generated using AI)
This post is co-authored by Lamees Gubara and Jonta Kamara.
Note: This post details traumatic experiences from the current war in Sudan.
Introduction
Following the war in April 2023, there is an unfolding public health humanitarian crisis in Sudan. This has brought devastating consequences across various fronts, including noncommunicable diseases (NCDs), food insecurity, hospital closures, disease spread, and women's health issues. Sudan's pre-existing burden of NCDs, marked by risk factors like obesity and diabetes, has been exacerbated by heightened negative social determinants of health. Food insecurity is a critical concern, resulting from disrupted farming and supply chains while hospital closures and shortages of medical supplies have strained the healthcare system.
Disease spread, such as measles, cholera, malaria, and dengue, is rampant due to overcrowded living conditions and decreased immunization services. Women's health, including pregnancy and menstruation, have been significantly affected, with concerns about gender-based violence, limited maternal care, and shortages of maternal health medications. The mental health impact is profound, manifesting as widespread trauma, depression, and PTSD, particularly among children and women in the population and diaspora.
The war has displaced over 6 million people, including 1.2 million who have been forced to flee across international borders. The UN Reports that “Sudan is now the largest child displacement crisis in the world, with 3 million children fleeing widespread violence.” Urgent intervention is imperative to address the economic, healthcare, and mental health challenges facing the Sudanese population.
In this post, we only highlight a few of the negative consequences of the war on health. Additionally, we incorporate firsthand accounts from Sudanese individuals who have directly witnessed the repercussions of the war, as well as perspectives from those within the diaspora community.
Current Conflict
Omar al-Bashir, the former president of Sudan, was overthrown in April 2019 following months of protests and a military coup. The protests initially began in December 2018 due to the economic collapse brought on by years of sanctions and loss of oil revenue, which led to emergency austerity measures and a sharp currency devaluation. The demonstrations evolved from rising costs to demanding the removal of then-President Bashir, who had been in power for nearly 30 years. The war in Sudan in April 2023 was caused by a power struggle between the Sudanese Armed Forces (SAF) and the Rapid Support Forces (RSF), the two main factions of the ruling military regime. The conflict was sparked by a disagreement over the integration of the RSF into the military as part of the transition toward civilian rule. The image below provides a summary of the key events in the current conflict.
Timeline of Key Events Leading to the 2023 War in Sudan
Image source: Impact of the 2023 armed conflict on Sudan's healthcare system by Alhadi Khogali & Anmar Homeida (2023)
Public Health Concerns
FAO’s recently released geospatial assessment estimates the extent of cultivated cropland throughout the #Sudan for August 2023, compared to last 5-year average.
— FAOSudan (@FAOSudan) November 28, 2023
Read more: https://t.co/IStFfmOpoA
Full report: https://t.co/eOzHcAM7RB pic.twitter.com/xLDNfyqtRW
Food Insecurity
“...there’s a shortage of food so now they have to rely on less nutritious food because it’s either expensive or not even available,” says a Sudanese in the diaspora regarding their family’s situation.
Sudan has become one of the top 4 countries in the world with the highest concerns of food insecurity. Before the war, 60% to 80% of the population relied on agriculture as their main source of income, and sorghum and millet were the main food staples. The war has made it increasingly difficult for farmers to produce their key staple crops especially as fuel prices have become very expensive and supply chains and trade routes have been disrupted. It is estimated that there are more than 3.4 million children who are acutely malnourished. Farmers in the bread basket region say they may not be able to plant crops over the winter, which will lead to more people dealing with food insecurity.
Food security enables the healthy growth of children and also reduces the risk of chronic diseases. This puts children at risk of malnutrition, which will impact their growth and development in the future and their susceptibility to diseases. According to a joint UNICEF and WHO statement, 700,000 children are suffering from severe acute malnutrition, 10,000 children require treatment due to medical complications, and the number of hungry families has nearly doubled. The World Food Programme (WFP) estimates that 20.3 million people (46% of the population) face acute food insecurity.
Hospital Closures and Medical Supply Shortages
The conflict has led to the severe compromise of healthcare facilities, with only one-third of operational hospitals in conflict zones. Artillery attacks, forced militarization, power outages, and shortages of medical supplies and personnel have further crippled the health system. The World Health Organization (WHO) has warned that hospitals in the capital, Khartoum, are running low on medical supplies and personnel, with some facilities being looted or used for military purposes. Reports indicate that more than 70% of hospitals in areas affected by the fighting are not functional. Specifically, in Khartoum, more than 60% of healthcare facilities have closed due to the conflict with some being shut down completely due to damage from the fighting, and in some instances, patients “couldn’t access a clean clinic.” Furthermore, 13 hospitals were bombed, and 21 hospitals were forcibly evacuated by militants, while 17 hospitals suffered aerial or land bombings.
WHO has estimated that medical supplies in Sudan are currently at about 25% of the actual needs, with shortages significantly increasing over the past few months. The power outages and economic standstill have further jeopardized the availability of insulin and other vital medical supplies, making it difficult for individuals with chronic conditions to receive their necessary prescriptions. Furthermore, the economic downturn has severely impacted people's financial stability. Most Sudanese individuals find themselves in distressing situations, as their savings have dwindled, and they lack the necessary funds to afford the imported medications that are crucial for managing their health conditions.
The convergence of these economic challenges and the scarcity of medical supplies paints a bleak picture of those already grappling with chronic illnesses, as they confront not only the physical toll of their conditions but also the financial barriers hindering their access to vital treatments. The need for urgent intervention and support to address both the economic and healthcare crisis in Sudan has never been more critical.
We have also been reminded of how the hospital closure impacts the elderly. One Sudanese tells us that “[t]he elderly who have to follow up in hospitals, because of the war they can’t anymore and also the availability of their long-term medications”
Disease Spread
“Diseases spread more, with people in Sudan not having access to clean food and water and having to shelter and move around constantly in big groups, it has most likely increased the spread of diseases” - response from a Sudanese
As a result of the conflict, many people are displaced and are living in close living environments. There is virtually no water supply in shelters and people have to buy water in unsafe conditions. These conditions make it easy for infectious diseases to spread, putting millions in the country at risk especially those who are displaced and surviving in overcrowded camps, schools, dormitories, and mosques. As of November 9, 2023, there were 2,252 suspected cases of diarrhea and cholera with a case fatality rate of 3%, which has been documented in 6 states. It is estimated that 3.1 million people are at risk of acute watery diarrhea and cholera in 8 states between July and December 2023.
There have also been decreased or in some cases a complete halt of immunization services making disease spread more prone. This is particularly the case for very young children and individuals who rely on herd immunity for protection as they are immunocompromised. With decreasing immuni\zation services, measles cases have been on the rise. From April to September 2023, the total number of measles cases was over 5,000 with 1,000 cases being reported in one month. The United Nations High Commission for Refugees (UNHCR) also reports that 1,200 refugee children have died due to suspected measles and undernutrition in West Nile State.
During the conflict, there has been a dengue fever outbreak with the first case being reported on July 28, 2022, and there have been 7,935 cases reported as of March 2023. The International Federation of Red Cross states that there are 8,124 suspected cases and 48,000 probable cases and the outbreak remains unstable in Khartoum and Gadarief states. State health authorities have also reported that there have been 710,000 clinical malaria cases with 27 deaths. Detecting these diseases has been difficult as due to the fighting, samples cannot be transported to Port Sudan which is the only functioning public health laboratory facility. With constant violence and the limited functioning of the Ministry of Health, disease surveillance is a challenge.
Women’s Health Issues
A Sudanese sadly tells us, “[m]y teacher died because she had a miscarriage and they couldn’t get her to the hospital”
The consequences of the armed conflict on public health, particularly for women, are extensive and alarming. The disruption of health services and the collapse of the healthcare system have created significant barriers to accessing essential reproductive health services, including prenatal care, family planning, and menstrual health support. The United Nations Human Rights Office (OHCR), has concerns about women and girls being abducted, allegedly forcibly married, and held for ransom. There has also been a spike in gender-based violence due to the use of rape as a war weapon, lack of abortion access, family planning, and HIV medications. Women and children live in makeshift shelters or overcrowded displacement sites increasing the risk of sexual and gender-based violence. During this time, it is also increasingly difficult to find menstrual hygiene products and the lack of sanitation is making the experience unbearable for many. A respondent tells us that “[i]rregular periods due to chronic stress. Limited access to menstrual necessities.” Organizations such as Strategic Initiative for Women in the Horn of Africa, are providing dignity kits, which provide menstrual products for those that need them in Sudan.
The United Nations Population Fund (UNFPA) estimates that there are 105,000 pregnant women in Sudan and they are struggling to receive maternal care due to hospital closures and shortages of maternal health medications. Those who cannot travel to give birth are at increased risk of complications, such as sepsis, hemorrhage, and obstructed labor. With the reduction of maternal health care, there is also a reduction in the care provided to the increasing number of preterm babies, posing lifelong developmental defects for babies.
Mental Health
The civil war in Sudan has significant psychological trauma among the Sudanese population and those in the diaspora. A Sudanese in the diaspora tells us “...[i]t has been an extremely difficult time filled with many restless nights worrying about if our families made it to their next destination safely.” The impact of the war has contributed to widespread psychological trauma, including depression, mania, and post-traumatic stress disorder (PTSD). The conflict has led to widespread psychological trauma among children, with exposure to violence, hunger, illness, and loss contributing to their mental health challenges.
It is crucial to note that there are almost no mental health resources available for the population during the war. The limited mental health infrastructure further compounds the challenges faced by individuals grappling with psychological trauma, depression, and PTSD, which has been seen “with many people” due to the loud sounds. Despite the extensive efforts to address the health crisis, the mental health aspect remains largely unaddressed.
The impact of the war in Sudan has been particularly devastating for children, with approximately 19 million Sudanese children out of school due to the conflict. This has resulted in a sense of isolation and voicelessness among these children, as they lack interaction with peers and have limited social lives. Furthermore, young children who have migrated to Egypt and neighboring countries with their families are facing discrimination at school, leading to feelings of exclusion and disinterest in their studies.
Among those who were able to leave Sudan, they still face challenges and discrimination in the country they are in. One respondent tells us “[m]y family on both parents’ sides got displaced. Some fled to Egypt where obviously there are no job opportunities; the financial instability has a great toll on their mental health.” Being forcibly displaced has a toll on an individual’s mental health. Another respondent tells us that “[t]he war forced my family to relocate to a different country which destroyed their mental health.” In addition, those who fled villages outside of Khartoum are having difficulties accessing healthcare, school, etc which has negative impacts on their mental health.
Noncommunicable Diseases
Before this conflict, Sudan had a high burden of non-communicable diseases. In 2018, the World Health Organization’s Noncommunicable Disease report indicated that a total of 147,100 individuals died prematurely from NCDs, accounting for 52% of all deaths in Sudan. Studies have revealed the high prevalence of several NCD risk factors such as overweight/obesity, hypertension, and physical inactivity. Various studies in different cities have also estimated diabetes prevalence to be approximately 19% based on studies in River Nile State. Despite the already high prevalence of NCD, the war has negatively impacted people’s health outcomes due to reduced supply chain of chronic medications and increased negative social determinants of health. Sudanese respondents shared that the war “[c]ompromised my health due to unavailability of insulin for my diabetes” and “[m]y family in Sudan lost access to healthcare essentially, many of those with diseases they needed consistently treated and medications were unable to receive the proper treatment needed.”
Screenshot of a Response
Conclusion
Urgent attention and intervention are needed to stop the conflict in Sudan and also provide humanitarian assistance to the Sudanese population. The Sudanese diaspora continues to experience deep concern for their homeland and families left behind, compounded by the inability to provide assistance and the loss of family members due to the recent war. This situation has left many young Sudanese, particularly millennials and Gen Z individuals who have never set foot in Sudan, feeling disheartened about their aspirations to return and make a positive impact in their home country. The hopes and efforts of these individuals to contribute to the betterment of Sudan now appear to be in jeopardy.
Screenshot of a Response
Acknowledgment: We would like to thank all those in the Sudanese diaspora who shared their personal experiences with us and allowed us to incorporate them in this post.
Guest Contributor:
Lamees Gubara is a Sudanese-Canadian professional, born in Qatar, with enduring ties to Sudan. She holds an Honours Bachelor of Science specializing in biotechnology and chemistry, at the University of Toronto, and a certificate in pharmaceutical regulatory affairs. Passionate about societal well-being, Lamees is an advocate for mental health and social justice.
Beyond her professional pursuits, Lamees finds joy in baking and painting. In her leisure time, she actively engages in learning about climate change and sustainability, reflecting her commitment to environmental awareness. Additionally, she dedicates her time to assisting new Arabic-speaking immigrants in Canada by providing interpretation services and fostering inclusivity and support within the community.
You can reach her via LinkedIn