The consequences of Sudan’s armed conflict on public health: a closer look at the devastating impact

Introduction Sudan, a country in Northeast Africa, is currently experiencing armed conflict, with clashes that erupted on April 15, 2023, between the Sudanese military and paramilitary forces1. This latest conflict adds to Sudan’s history of war, including the notable Darfur war in 20031. The power struggle between the 2 main factions of Sudan’s military regime, with the armed forces loyal to Gen Abdel Fattah al-Burhan and the paramilitaries of the Rapid Support Forces loyal to Gen Mohamed Hamdan Dagalo (Hemedti), has intensified in recent years, particularly after the 2019 uprising that ousted former dictator Omar al-Bashir. These power dynamics have geopolitical implications, with Russia, the United States, Saudi Arabia, the United Arab Emirates, and other actors seeking to influence Sudan. The impact of this conflict on public health in Sudan is grave, given the already fragile state of the country’s health system. Over 8 million children under 5 are at risk of not accessing essential health services, and significant disparities exist between urban and rural areas and between the rich and poor2. The ongoing armed conflict is likely to exacerbate these challenges. Maternal mortality rates are high, with most deaths resulting from home deliveries without skilled birth attendants and the lack of emergency obstetric care in medical facilities2. Malnutrition and neonatal mortality rates are also major concerns. It is crucial to examine the devastating impact of this conflict on public health in Sudan and develop strategies to address these challenges. Impact of the conflict on public health The ongoing armed conflict in Sudan is having a devastating impact on public health in the country. With the already fragile health system, the conflict has only exacerbated the challenges. The conflict has resulted in the death and stretching of available health facilities, making it difficult for individuals to access essential health services. The World Health Organization (WHO) has documented 11 attacks on health facilities and has called for a cessation of such violence3. Reports from UNICEF indicate that 9 children have been killed, and >50 have been injured, putting the lives of vulnerable Sudanese children suffering from malnutrition at further risk4. The ongoing conflict has led to critical disruptions in care for an estimated 50,000 severely acutely malnourished children, which poses a significant threat to their survival5. As a result, WHO has urged for a humanitarian corridor for health workers, patients, and ambulances to ensure access to critical care for those in need. A recent report from Médecins Sans Frontières (MSF) describes intense fighting between the Sudanese Armed Forces and the Rapid Support Forces in Khartoum and other regions of Sudan, leading to numerous civilian casualties6. The MSF-supported South Hospital in El Fasher, North Darfur, has received 279 wounded patients since the conflict began, with 44 fatalities. Most of the wounded were civilians, including children hit by stray bullets. The hospital is currently facing shortages of medical supplies, and the staff has been unable to work due to the ongoing fighting. Other hospitals in the area have also had to close due to the intensity of the conflict or their proximity to the fighting. As airports across the country remain closed, MSF cannot transport supplies to North Darfur. The situation is dire, and MSF has warned that if humanitarian access is not granted, there will be an even more significant loss of life. Currently, medical supplies at the hospital are only sufficient for 3 weeks, and the medical staff is working tirelessly, overwhelmed by the high number of patients. MSF is actively exploring ways to bring supplies and experienced trauma surgeons into the country when the situation permits. It is essential to grant MSF access to all health facilities nationwide and for warring parties to spare civilian lives. The humanitarian crisis in Sudan demands immediate action to save lives and prevent further suffering. Furthermore, the armed conflict has violated United Nations–established humanitarian corridors, compromising the safety and well-being of civilians and aid workers. The corridors were created to provide safe routes for civilians to access essential aid, but heavy clashes have rendered them unsafe. This leaves civilians at risk of being trapped in conflict zones or struggling to escape to safety, while aid workers may face challenges delivering aid, leading to shortages of critical resources and increased suffering among those in need. The violation of humanitarian corridors undermines the efforts of humanitarian organizations and the principles of international humanitarian law, as they are based on neutrality, impartiality, and independence. Parties to the conflict are obligated to respect them. When such corridors are violated, it erodes the confidence of aid workers and organizations, leading to increased fear and anxiety and reducing their ability to assist. This undermines the legitimacy of humanitarian efforts, putting the safety and well-being of those in need at risk. To ensure that critical aid reaches those who need it most, parties to the conflict must prioritize the safety of civilians and aid workers and uphold the principles of international humanitarian law. Respect for humanitarian corridors is essential to protect vulnerable populations and uphold the legitimacy of humanitarian efforts. Moreover, the ongoing conflict in Sudan can potentially exacerbate the spread of infectious diseases due to the disruption of social structures, the destruction of health care infrastructure, and the displacement of populations. The resulting overcrowding and limited access to clean water, sanitation, and health care facilities create conditions that facilitate the transmission of infectious diseases, including cholera and typhoid fever, with children and women particularly vulnerable. The breakdown of public health systems and the destruction of medical facilities also contribute to the lack of medical supplies, inadequate treatment of patients, and a shortage of health care workers. This situation can lead to preventable diseases such as measles and polio spreading due to a lack of immunization services. In addition, health care facilities may become breeding grounds for infections such as health care–associated infections (HAIs) due to poor hygiene and a lack of infection control practices. Although not a significant risk in this conflict, biological warfare can exacerbate the spread of infectious diseases. Biological agents, such as anthrax, can cause disease outbreaks in both civilian and military populations, while chemical weapons, such as chlorine gas, can cause respiratory damage, making individuals more susceptible to respiratory infections. Furthermore, armed conflicts can lead to food insecurity, malnutrition, and starvation, which weaken the immune system and increase the risk of infections. Using violence and torture can also cause physical injuries that infect and lead to systemic infections. Efforts must be made to prioritize public health in conflict settings to mitigate the risks of infectious diseases. These efforts should include the provision of clean water, sanitation facilities, and immunization services, as well as the implementation of infection control measures in health care facilities. The international community must also work together to uphold international humanitarian law and protect civilians and health care workers in conflict settings. Specific health issues and concerns The ongoing armed conflict in Sudan poses a grave threat to children’s nutrition, particularly those suffering from malnutrition. Conflict disrupts food systems, triggers displacement, and leads to economic instability, which can exacerbate malnutrition rates. In Sudan, where an estimated 3 million children under 5 suffer from malnutrition annually, armed conflict is likely to aggravate the situation2. The disruption of food systems and the displacement of families can impede access to food, making it challenging for parents to provide adequate nutrition for their children. Furthermore, the economic instability brought about by the conflict can make it harder for families to afford nutritious food. Children with severe acute malnutrition are especially vulnerable to the consequences of conflict, as they require urgent treatment and specialized care. In Sudan, over 610,000 children suffer from severe acute malnutrition, and the conflict may impede their access to the required medical attention2. The supply of essential medicines and medical supplies can also be disrupted, making it harder to treat children with malnutrition. Malnutrition can also escalate the conflict by contributing to social unrest and conflict over scarce resources. In addition, the impacts of war on social and economic systems can exacerbate malnutrition. Addressing the underlying causes of malnutrition is vital for promoting peace and stability, and measures to ensure access to food and health care are crucial for mitigating the impact of conflict on nutrition. The impact of armed conflicts on mental health and the prevalence of conflict-related sexual violence (CRSV) are significant global concerns. These issues are particularly relevant in the context of the ongoing armed conflict in Sudan, where both direct and indirect effects of conflict can have severe and long-lasting impacts on mental health and sexual violence. The direct impacts of armed conflict on mental health are extensive and can include post-traumatic stress disorder (PTSD), depression, and anxiety. Furthermore, the trauma of witnessing or experiencing violence, injury, or death can have long-term effects on individuals. Indirect impacts such as displacement, loss of homes and livelihoods, and breakdown of social networks can also contribute to feelings of isolation, depression, and anxiety7. These impacts can persist for years after the conflict has ended, underscoring the need for mental health services and community-based support. The armed conflict in Sudan also poses a risk of CRSV, including sexual assault, rape, forced marriage, and prostitution connected to armed warfare. Women and girls are particularly vulnerable to sexual violence in conflict, and the widespread sexual violence in Sudan can have severe medical, psychological, and social repercussions7. Survivors of sexual violence may suffer from physical injuries, sexually transmitted infections, unwanted pregnancies, and long-lasting psychological disorders such as depression, anxiety, and PTSD. Social consequences may include stigma, ostracism, and the breakdown of social relationships. These impacts of sexual violence extend beyond the individual survivor, affecting their families, communities, and even future generations. Addressing the mental health impacts of armed conflicts and reducing the prevalence of CRSV requires access to mental health services, community-based support, and programs that address the root causes of conflict and promote peacebuilding. In the case of Sudan, it is important to prioritize the provision of services and support to vulnerable populations, particularly women and girls who are at risk of sexual violence. Humanitarian response and aid The ongoing armed conflict in Sudan has led to a dire humanitarian situation, with millions needing aid and support. International aid and humanitarian organizations have been working to assist those affected by the conflict, but the challenges posed by the conflict have limited the effectiveness of these efforts. The delivery of aid and humanitarian support has been hampered by the conflict, with fighting and insecurity making it difficult for aid organizations to reach those in need. The destruction of infrastructure, including roads and health care facilities, has also made it challenging to provide essential services. In addition, the displacement of populations has led to overcrowding in camps and temporary settlements, which has made it difficult to ensure access to clean water, sanitation, and health care facilities. Despite these challenges, international aid organizations have been working to provide essential services and support to those affected by the conflict. These efforts have included the provision of food and water, the delivery of medical supplies and equipment, and the provision of health care services. Organizations such as UNICEF and the WHO have been working to provide vaccinations, treatment for malnutrition, and other essential health services. The ongoing conflict has limited the effectiveness of these efforts, but there have been some successes. For example, in 2020, the United Nations reported that it had assisted over 4 million people affected by the conflict in Sudan, including food assistance, health care services, and support for education8. However, much more must be done to address the humanitarian crisis in Sudan. To improve the effectiveness of aid and humanitarian efforts, it is essential to address the root causes of the conflict and promote peacebuilding. This includes addressing political instability, economic insecurity, and social inequality. It is also important to ensure that aid organizations have the resources and support to deliver essential services to those in need, including access to funding, logistical support, and security. Future implications and recommendations The ongoing armed conflict in Sudan is expected to have long-term effects on the health and well-being of the population, particularly vulnerable groups such as children, women, and those suffering from chronic diseases. The displacement, destruction of health infrastructure, and disruption of health services can contribute to a deterioration of health status and the emergence of new health problems. In addition, exposure to violence and trauma can have long-lasting psychological effects, impacting individuals and communities for years. It is essential to address these health concerns in conflict zones to prevent further harm and promote recovery. To address the health challenges in Sudan and other conflict zones, several recommendations are proposed. First, there is a need for the international community to invest in the development and implementation of sustainable health systems that can withstand the challenges of conflict. This includes strengthening primary health care, disease surveillance, and emergency response capacity. Second, it is crucial to ensure the provision of essential health services to the affected population, including mental health care, maternal and child health services, and care for those with chronic diseases. This requires coordination among local authorities, humanitarian organizations, and international agencies. Third, there is a need to address the root causes of conflict, such as poverty, inequality, and political instability, to create sustainable peace and stability. This includes promoting human rights, supporting local communities, and addressing the underlying social determinants of health. Conclusions The armed conflict in Sudan has significant implications for the health and well-being of its population, particularly children and women. The conflict has disrupted food systems, led to displacement, and caused economic instability, contributing to increased malnutrition rates and potential future health problems. The impact on mental health is also noteworthy, with direct involvement leading to PTSD, depression, and anxiety, and indirect effects such as displacement and the breakdown of social networks contributing to feelings of isolation, depression, and anxiety. To address these health concerns in conflict zones, it is crucial to prioritize access to health care, mental health services, and community-based support. It is also important to address the root causes of conflict and promote peacebuilding to prevent future conflicts and their associated health impacts. Providing aid and support to those affected by armed conflicts by the international community is essential, but it is crucial to ensure that this aid is effective and sustainable. The implications of the armed conflict in Sudan extend beyond the country itself, highlighting the broader challenges and implications of armed conflicts for global health and conflict resolution efforts. Prioritizing health and well-being in conflict zones is essential for promoting peace and stability, as health and conflict are interlinked. Ethical approval None. Sources of funding None Author contribution Conceptualization: all authors; writing first and final manuscript: all authors. Conflicts of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) N/A. Guarantor Nicholas Aderinto. Consent None. Assistance with the study None.