Published date: Mar 29 2024

Journal Title: Sudan Journal of Medical Sciences

Issue title: Sudan JMS: Volume 19 (2024), Issue No. 1

Pages: 132–148

DOI: 10.18502/sjms.v19i1.15789

Tahra Al Sadig Al Mahditahrasadigalmahdi@gmail.comHead of the Medical Education Unit, School of Medicine, Ahfad University for Women, Sudan

A. H. FahalDepartment of Surgery, Director of Mycetoma Research Center, Faculty of Medicine, Khartoum University, Sudan

Abdelmuniem S. El MardiChair of Biomedical Sciences Department, Dubai Medical College for Girls, UAE

Background: Sudan’s history is marred by ongoing sociopolitical challenges, with deep cultural divisions fueling numerous wars. A new conflict erupted on April 15, 2023, pushing the country closer to a full-scale civil war. This war has severely crippled Sudan’s already fragile healthcare system, rendering 70% of hospitals in combat zones nonoperational, causing 12,000 deaths, thousands of injuries, and leaving 11 million in dire need of healthcare. More than seven million people are displaced, half of which are children, and are facing severe health challenges, especially vulnerable groups. Heath situation is threatening with unchecked spread of outbreaks of communicable diseases that were previously controlled and marked failure in meeting the health demands of patients with noncommunicable diseases, reproductive and child health issues, and people with serious conditions that require adequate follow-up. Moreover, the projections threaten with more catastrophic consequences including famine, environmental destruction, and further displacement of people. This review article highlights the urgency of the situation and explores potential solutions to enrich global understanding of crisis management.

Methods: To comprehensively assess the impact of the crisis and propose a way forward, we drew data by exploring search engines and databases such as Google, Humanitarian Agencies Websites, Google Scholer, and PubMed along with some relevant reports. The search terms included are “Sudan’s war”, “impact of war on healthcare systems”, and “Sudan’s armed conflicts”.

Results: More than 19 publications on the impact of the war on health in addition to periodic reports from international organizations and governmental authorities were reviewed.

Conclusion: Although all publications point to the gravity of the situation and the need for prompt response, this crisis offers a unique opportunity to rebuild Sudan’s struggling healthcare system with the principles of social accountability. Through domestic and international collaboration, this sector can become a model for similar nations, meeting the needs of its people and promoting sustainable development.

Keywords: armed conflict, crisis management, health impact, health system, social accountability, transitional period

[1] Humanitarian Coalition. (n.d.) What is a humanitarian emergency? Humanitarian Coalition. https://www.humanitariancoalition.ca/what-is-ahumanitarian- emergency

[2] Worldmeter. (n.d.) Population. Worldmeter. https://www.worldometers.info/world-population/ sudan-population/

[3] BBC News. (2023, September 13). Sudan country profile. BBC News. https://www.bbc.com/news/ world-africa-14094995

[4] Boyce, R. (1979). Ancient nubian artifacts yield evidence of earliest monarchy. The New York Times, 1. https://www.nytimes.com/1979/03/01/ archives/ancient-nubian-artifacts-yield-evidenceof- earliest-monarchy-clues.html?smid=url-share

[5] Middleton, N., & O’keefe, P. (2006). Politics, history & problems of humanitarian assistance in Sudan. Review of African Political Economy, 33(109), 543– 559. https://doi.org/10.1080/0305624060101067

[6] Britannica. (n.d.). Sudan. Britannica. https://www. britannica.com/place/Sudan/Cultural-institutions

[7] Hassanain, S. A., Eltahir, A., & Elbadawi, L. I. (2022, June). Freedom, peace, and justice: A new paradigm for the Sudanese health system after Sudan’s 2019 uprising. Economic Research Forum (ERF).

[8] The Sentry - War Crimes Shouldn’t Pay. (November, 2021). Sudan’s coup: New Report Spotlights Corruption of Military and Security Services. https://thesentry.org/2021/11/03/6424/sudanscoup- new-report-spotlights-corruption-militarysecurity- services/

[9] Iacobucci, G. (2023). WHO calls for protection of health workers and patients amid increased violence. BMJ, 381, 892. https://doi.org/10.1136/bmj.p892

[10] Alfadul, E. S., & Alrawa, S. S. (2023). Fighting rages in Sudan—Its people and their healthcare pay the price. BMJ, 381.

[11] Yuan, S. (2023). Hospitals closed amid Sudan violence. Lancet, 401(10386), 1412. https://doi.org/10. 1016/S0140-6736(23)00849-8

[12] Chutel, L. (2023). Health care system in Sudan is collapsing. The New York Times, A7-L.

[13] Saied, A. R. A. (2023). Sudan’s health-care system is in danger of collapse. Lancet, 401(10388), 1565. https://doi.org/10.1016/S0140-6736(23)00858-9

[14] Thornton, J. (2023). Attacks on health care continue in Sudan. Lancet, 401(10391), 1837. https://doi.org/10.1016/S0140-6736(23)01112-1

[15] Aborode, A. T., Fasawe, A. S., Agwuna, F. O., Badri, R., & Adewunmi, R. O. (2023). The critical state of children’s health during the Sudan crisis. The Lancet. Child & Adolescent Health, 7, 526–528. https://doi. org/10.1016/S2352-4642(23)00140-2

[16] Hammad, N., & Ahmed, R. (2023). Sudan: Current conflict, cancer care, and ripple effects on the region. Lancet, 402(10397), 179. https://doi.org/10. 1016/S0140-6736(23)01303-X

[17] Mohammed, F. E. A., Viva, M. I. F., Awadalla, W. A. G., Elmahi, O. K. O., Wainstock, D., & Patil, P. (2023). Defending the right to health during Sudan’s civil war. The Lancet. Global Health, 11(9), e1327–e1328. https://doi.org/10.1016/S2214-109X(23)00300-5

[18] WHO. ( June-December, 2023). WHO emergency appeal: Sudan and neighboring countries. WHO. https://www.emro.who.int/images/stories/ sudan/WHO-emergency-appeal-Sudan-andneighbouring- countries.pdf?ua=1

[19] Aderinto, N., & Olatunji, D. (2023). The consequences of Sudan’s armed conflict on public health: A closer look at the devastating impact. International Journal of Surgery. Global Health, 6(4), e0179. https: //doi.org/10.1097/GH9.0000000000000179

[20] Siddig, E. E., Eltigani, H. F., & Ahmed, A. (2023). Urgent call to protect children and their health in Sudan. BMJ (Clinical Research Ed.), 382, 1799. https://doi.org/10.1136/bmj.p1799

[21] Hassan, H. A., Hafez, M. H., Luyckx, V. A., Tuğlular, S., & Abu-Alfa, A. K. (2023). Kidney failure in Sudan: Thousands of lives at risk. Lancet, 402(10402), 607. https://doi.org/10.1016/S0140-6736(23)01370-3

[22] Alfadul, E. S. A., Alrawa, S. S., Eltigani, H. F., Ahmed, A., & Siddig, E. E. (2023). The unraveling of Sudan’s health system: Catastrophic consequences of ongoing conflict. Medicine, Conflict, and Survival, 39(4), 364–368. https://doi.org/10.1080/13623699. 2023.2253059

[23] Dafallah, A., Elmahi, O. K. O., Ibrahim, M. E., Elsheikh, R. E., & Blanchet, K. (2023). Destruction, disruption and disaster: Sudan’s health system amidst armed conflict. Conflict and Health, 17(1), 43. https://doi.org/ 10.1186/s13031-023-00542-9

[24] Oduoye, M. O., Zuhair, V., Marbell, A., Abdullahi, Z. Z., Fatima, E., Kaushik, I., Valentina Sih, C. M., & Adam, M. F. (2023). Devastating health issues caused by Sudan crisis in 2023: A call for global action. International Journal of Surgery. Global Health, 6(5), e0243. https://doi.org/10.1097/GH9. 0000000000000243

[25] Alrawa, S. S., Alfadul, E. S., Elhassan, M. M. A., & Hammad, N. (2023). Five months into conflict: Near total collapse of cancer services in Sudan. ecancer, 17, ed128. https://doi.org/10.3332/ecancer.2023.ed128

[26] Khogali, A., & Homeida, A. (2023). Impact of the 2023 armed conflict on Sudan’s healthcare system. Public Health Challenges, 2(4), e134. https://doi.org/ 10.1002/puh2.134

[27] Nashwan, A. J., Osman, S. H., Mohamedahmed, L. A., Osman, S., & Mohamed, L. (2023). Violence in Sudan: A looming public health disaster. Cureus, 15(6), e40343. https://doi.org/10.7759/cureus.40343

[28] Hashim, A. (2023). Attacks on healthcare facilities in Sudan: An unprecedented surge amid a military coup. Medicine, Conflict, and Survival, 39(1), 86–92. https://doi.org/10.1080/13623699.2022.2162299

[29] OCHA. (2023 September). Sudan situation report. OCHA. https://reports.unocha.org/en/country/sudan/ [accessed 13 September 2023].

[30] WHO. (2023, December 15). Sudan health emergency – Situation report no. 4. WHO. https://www.emro.who.int/images/stories/ sudan/WHO-Sudan-conflict-situation-report-15- December_2023.pdf?ua=1

[31] UN Security Council. (2023, August 31). Situation in the Sudan and the activities of the United Nations Integrated Transition Assistance Mission in the Sudan - Report of the Secretary-General. UN Security Council. https://unitams.unmissions. org/sites/default/files/eng-n232485185.pdf

[32] Reliefweb. (2023, July 13). Darfur: Aid workers witness hundreds of murdered bodies including children abandoned in the streets. Reliefweb. https://reliefweb.int/report/sudan/darfur-aidworkers- witness-hundreds-murdered-bodiesincluding- children-abandoned-streets

[33] Africanews. (2023, July 13). UN reports newly discovered mass grave in Darfur. Africanews. https://www.africanews.com/2023/07/13/unreports- newly-discovered-mass-grave-in-darfur/

[34] International Organization for Migration (IOM). (2014, January 03–2023, December 28). DTM Sudan weekly displacement snapshot 16. IOM. https://dtm.iom.int/reports/dtm-sudan-weeklydisplacement- snapshot-16

[35] The Eastern Mediterranean Public Health Network. (2024, January 4). Health situation in Sudan. EMPHNET. https://emphnet.net/media/pqwfkqhu/healthsituation- in-sudan-january-4-2024.pdf

[36] International Rescue Committee. (Updated 2024, January 4). Crisis in Sudan: What is happening and how to help. https://www.rescue.org/article/fightingsudan- what-you-need-know-about-crisis#:${\sim}$: text=War%20continues%20to%20rage%20in,to% 20reports%20of%20ethnic%20cleansing

[37] Akbarzada, S., & Mackey, T. K. (2018). The Syrian public health and humanitarian crisis: A ‘displacement’ in global governance? Global Public Health: An International Journal for Research, Policy and Practice, 13(7), 914–930. https://doi.org/10.1080/ 17441692.2017.1285338

[38] Dzhus, M., & Golovach, I. (2022). Impact of Ukrainian–Russian war on health care and humanitarian crisis. Disaster Medicine and Public Health Preparedness, 17, e340. https://doi.org/10.1017/dmp.2022.265

[39] Ebrahim, E. M., Ghebrehiwot, L., Abdalgfar, T., & Juni, M. H. (2017). Health care system in Sudan: Review and analysis of strength, weakness, opportunity, and threats (SWOT analysis). Sudan Journal of Medical Sciences, 12(3), 133–150. https://doi.org/10.18502/sjms.v12i3.924

[40] Istratii, R. (2021). War and domestic violence: A rapid scoping of the literature to understand the relationship and to inform responses in the Tigray humanitarian crisis [Working Paper 2]. Project dldl/: Bridging religious studies, gender & development and public health to address domestic violence in religious communities. https://docs.google.com/viewerng/viewer?url= https://jliflc.com/wp-content/uploads/2021/05/ Working-paper-2_Project-dldl-1.pdf

[41] Greene, M. C., Jordans, M. J. D., Kohrt, B. A., Ventevogel, P., Kirmayer, L. J., Hassan, G., Chiumento, A., van Ommeren, M., & Tol, W. A. (2017). Addressing culture and context in humanitarian response: Preparing desk reviews to inform mental health and psychosocial support. Conflict and Health, 11, 21. https://doi.org/10.1186/s13031-017-0123-z

[42] Karunakara, U. K., Neuner, F., Schauer, M., Singh, K., Hill, K., Elbert, T., & Burnha, G. (2004). Traumatic events and symptoms of post-traumatic stress disorder amongst Sudanese nationals, refugees and Ugandans in the West Nile. African Health Sciences, 4(2), 83–93.

[43] Aderinto, N., & Olatunji, D. (2023). The consequences of Sudan’s armed conflict on public health: A closer look at the devastating impact. International Journal of Surgery. Global Health, 6(4), e0179. https: //doi.org/10.1097/GH9.0000000000000179

[44] UN OCHA. (2024, January 5) Sudan situation report. UN OCHA. https://reports.unocha.org/en/country/sudan

[45] Levy, A., & Vaillancourt, J. G. (2011). War on Earth? Critical Issues in Peace and Conflict Studies, 217.

[46] Akhtar, M. (2018). Role of identity crisis and relative deprivation as catalysts of political violence and terrorism. SSRN, 2(1), 49–66. https://doi.org/10.2139/ ssrn.3152121

[47] Reliefweb by OCHA. (2023, September). Sudan situation: Health and nutrition update. Reliefweb. https://reliefweb.int/report/sudan/sudan-situationhealth- nutrition-update-september-2023/

[48] Zibulewsky, J. (2001). Defining disaster: The emergency department perspective. Proceedings - Baylor University. Medical Center, 14(2), 144–149. https: //doi.org/10.1080/08998280.2001.11927751

[49] Dobiesz, V. A., Schwid, M., Dias, R. D., Aiwonodagbon, B., Tayeb, B., Fricke, A., Pham, P., & Erickson, T. B. (2022). Maintaining health professional education during war: A scoping review. Medical Education, 56(8), 793–804. https://doi.org/10.1111/medu.14808

[50] UNDRR. (n.d.). Disaster management. UNDRR. https: //www.undrr.org/terminology/disaster-management

[51] Rose, D. A., Murthy, S., Brooks, J., & Bryant, J. (2017). The evolution of public health emergency management as a field of practice. American Journal of Public Health, 107(S2), S126–S133. https://doi.org/ 10.2105/AJPH.2017.303947

[52] Ibrahim, M., Abdelmagid, N., AbuKoura, R., Khogali, A., Osama, T., Ahmed, A., Alabdeen, I. Z., Ahmed, S. A. E., & Dahab, M. (2023). Finding the fragments: Community-based epidemic surveillance in Sudan. Global Health Research and Policy, 8(1), 20. https://doi.org/10.1186/s41256-023-00300-7

[53] Albahari, A., & Schultz, C. H. (2017). A qualitative analysis of the spontaneous volunteer response to the 2013 Sudan floods: Changing the paradigm. Prehospital and Disaster Medicine, 32(3), 240–248. https://doi.org/10.1017/S1049023X17000164

[54] Reliefweb. (2021, March). Sudan Rapid Post Disaster Needs and Recovery Assessment (Rapid PDNRA). Reliefweb. https://reliefweb.int/report/ sudan/sudan-rapid-post-disaster-needs-andrecovery- assessment-rapid-pdnra?gad_source= 1&gclid=CjwKCAiA5L2tBhBTEiwAdSxJX0RA8-eKMl5s5TJ2i49LI95sgySi8fvCijajuVqT6c-p-K1vWCU6TxoCkZQQAvD_BwE

[55] Tsagkaris, C., Dorosh, M., Krasnova, T., & Shkodina, A. Diagnose the present, foretell the future: Health sequelae of the armed conflict between Russia and Ukraine. Esthinktank. https://esthinktank.com/2022/ 02/25/diagnose-the-present-foretell-the-future

[56] Sudanese American Physicians Association. (2023, October). 6 month emergency response report. Sudanese American Physicians Association. https://sapa-usa.org/wp-content/uploads/2023/11/ SAPA-report.pdf

[57] Mohiuddin, A. K. (2023). War and conflict escalation in the context of the COVID-19 pandemic, natural disasters, food, and economic crises: A critical public health issue. Global Journal of Health Sciences and Research, 1–20.

[58] Turner, M., Ginifer, J., & Cliffe, L. (2005). The impact of armed violence on poverty and development: Full report of the Armed Violence and Poverty Initiative. GSDRC.