On 15 April 2023, intense, unexpected fighting broke out between the Sudanese Armed Forces and the paramilitary Rapid Support Forces (RSF) in Sudan’s capital, Khartoum. It plunged the entire country into chaos as the violence spread nationwide, leading to tens of thousands of casualties and uprooting millions of people from their homes.

Since 2019, following the ousting of former president Omar Al-Bashir, our teams have been expanding medical activities across Sudan amid a volatile transition, working in 11 states. The country already had large pockets of displaced people and refugees from neighbouring countries. When the war began, we refocused our response to meet the needs of those affected.

The MSF-supported South hospital in El Fasher, North Darfur, received 136 wounded patients in the first 48 hours of the fighting. Due to the lack of space, patients had to be treated on the floors and in the corridors of what was originally just a small maternity facility with no surgical capacity. Over the following weeks, we transformed it into a hospital with an operating theatre and emergency room, which can respond to mass-casualty events.  

In Khartoum, where the war began, fierce street fighting, shelling and airstrikes took place. Those who were able to flee the city did so, but many were trapped in their homes because of the intensity of the fighting. Most hospitals in the town quickly ceased to function, and the facilities that could remain open were rapidly overwhelmed.

MSF teams who lived in the city took advantage of any lulls in the fighting to donate medical supplies to hospitals and assess those we could potentially support. By early May, we had brought a full surgical team to Bashair Teaching Hospital. By June, we were fully operational in the Turkish Hospital, initially a small maternity and paediatric facility with no surgical capacity, which we converted into a facility capable of responding to mass-casualty events.

That same month, we began supporting Al-Nao Hospital in Omdurman, treating patients with injuries caused by gunshots, stabbings and shrapnel from explosions, as well as non-trauma-related conditions. In July and August, our teams started working in the paediatric and maternity wards at Umdawwanban Hospital in Khartoum state and Alban Al-Jadeed Hospital – the sole public hospital still functioning in the east of Khartoum state.
 

In June, we also started activities in White Nile state. Our teams working in some of the overcrowded camps for refugees and displaced people were overwhelmed with daily cases of suspected measles and malnutrition among children.

The vast region of Darfur was again, as it had been in the early and mid-2000s, an epicentre of violence. Although relative calm was established in North Darfur after several weeks of intense fighting, in Nyala, South Darfur, an MSF compound and warehouse were attacked and looted early in the conflict. This led to suspending all our activities in the city and surrounding areas.

In West Darfur, the MSF-supported El-Geneina teaching hospital was also looted and extensively damaged during the violence. The city became so dangerous that for many months, no access was possible. Two major massacres took place in West Darfur during the course of the year; it is estimated that between 10,000 and 15,000 people were killed during ethnically targeted violence in El-Geneina alone.

As the fighting continued to escalate around the country, the looting of health facilities and attacks on health premises and health personnel became a hallmark of the conflict, with the World Health Organization documenting a total of 63 incidents during the year. Many took place in MSF facilities and premises.

Although we worked hard to scale up our response in Sudan, we faced innumerable obstructions. Visas for our experienced emergency teams were delayed on multiple occasions. In September, the Sudanese authorities implemented a ban on the transportation of medical and surgical supplies into Khartoum to prevent wounded RSF soldiers from receiving lifesaving treatment. They also implemented a ban preventing humanitarian staff from travelling into RSF-controlled areas. These limitations led to the withdrawal of our surgical team from Bashair Teaching Hospital.

Notwithstanding these challenges, we continued to offer medical assistance in Rokero, in the mountainous area of Jebel Marra, and Kreinik. We also maintained our medical activities throughout the year in several states in the east of Sudan, including Blue Nile, where we treated malnutrition and supported mobile clinics in and around Ad-Damazin.

By December, the RSF had taken control of all major cities in Darfur except El Fasher, where South Hospital had become the main referral facility for all Darfur states. By then, we had also re-established our support for the El-Geneina Teaching Hospital.

At the beginning of the war, hundreds of thousands of people had fled south to Wad Madani, in Al-Jazirah state, seeking refuge from the fighting in Khartoum. Between May and November, our teams provided medical consultations in existing health facilities and via mobile clinics; at least 40 per cent of them were children. However, in December, the RSF took control of the state, and an estimated 500,000 people became displaced once more as they fled from the violence. In an effort to meet their needs, we expanded our existing interventions in Al-Gedaref and Kassala states.

By the end of 2023, almost six million people had become displaced within Sudan, while 1.4 million had become refugees in neighbouring countries, and the health system was on the edge of collapse. A sustained ceasefire has not been achieved, and the fighting continues.