Access to Surgical Care Amidst the Sudan Civil War

By: Shailesh Gullipalli and Wynne Byard

On October 26, 2025, the Rapid Support Forces (RSF) seized the city of El-Fasher, Sudan after an 18-month siege, forcibly displacing an estimated 82,000 people and consolidating the RSF’s control in Darfur. [1] Since April 2023, the RSF and Sudanese Armed Forces (SAF) have competed for control of Sudan following the power vacuum created by the deposition of dictator Omar Al-Bashir. [2] In addition to outbreaks of disease and famine, both sides have committed significant human rights violations against civilians. [2,3,4] The most recent estimates from the UN indicate that 14.5 million people have been displaced, and 8.5 million are facing famine. [4] Death tolls are far more difficult to estimate, with the Sudanese government restricting data collection by outside organizations. [5] As Sudan enters its fourth year of violent conflict with no end in sight, urgent questions need to be addressed about the country’s future.

Understanding Sudan’s Pre-War Healthcare System

A critical lens through which to assess this crisis is the collapse of Sudan’s healthcare system, particularly its surgical capacity. Prior to the ongoing war, Sudan's health infrastructure did not have sufficient capacity to provide proper care for its population, due to a long history of colonialism, ethnic violence, and government corruption. [6,7] Following 2018, Sudan experienced a revolving door of health administrations with limited continuity or plans for expansion. [7] Vaccination coverage was especially poor; DTP3 vaccine rates sat around 60%, and resultant cases of diphtheria, tetanus, and pertussis were exacerbated by regular flooding and limited or no access to clean water for over a quarter of the population. [8,9] These limitations were illuminated by the COVID-19 pandemic, which exposed the health system’s limited ability to respond to large-scale health crises. [7,8,9]

The pre-war health system was critically understaffed, with only 3.7 physicians, 14 midwives, and 9.1 other health professionals for every 10,000 patients. [6] In order to achieve the median Sustainable Development Goal health targets, WHO guidelines recommend a minimum threshold density of 44.5 skilled health workers per 10,000 people. [8,10] Brain drain, largely caused by political instability and a lack of training opportunities, was a significant driver of this low threshold density. [8] In 2020, Sudan had one of the highest maternal mortality rates in the world, at around 295 deaths per 10,000 live births.11 Financial barriers further compounded these issues. In 2019, it was reported that 95.94% of patients paid out of pocket for treatments. [6] Altogether, understanding the barriers that the healthcare system already faced is critical for understanding its rapid collapse.

A Current Snapshot of Surgical Care

Only a month after the conflict started, a majority of the hospitals in war-torn areas shut down, with staff fleeing and supply routes being cut off. Notably, around 70% were shut down in the state of Khartoum. [6,7,12,13] Due to Sudan’s centralized healthcare organization, this was a significant blow. Khartoum is home to around 19% of Sudan’s population, but, prior to the war, provided around 70% of Sudan’s health services and one-third of health provisions. [7,12] Remaining hospitals have faced severe constraints due to workforce shortages and disrupted supply chains. The focus of the remainder of this article will be on surgical care through the first year of war.

During armed conflict, demand for surgical services—essential to preventing death and long-term disability—is considerably heightened. In addition, conditions routinely requiring surgical intervention, including cancer, cesarean sections, infections, and a multitude of others, are often exacerbated during war due to a lack of access to food, water, and regular checkups, as well as limited surgical capacity. Reduced access to surgical care has not only had disastrous impacts throughout the war but also has troubling implications for Sudan’s post-war healthcare capacity.

In an October 2024 survey of 90 surgical practitioners across Sudan, half of respondents stopped practicing within the first year of war, mainly due to displacement or hospital shutdowns, and two-thirds of respondents were displaced, either within or outside of the country. [14] For emergency theater sessions, the number of surgeons performing fewer than three lists per month nearly doubled from 22 pre-war to 42 post-war, while those performing more than 12 lists fell from 18 to 6. Similar decreases were reported in elective surgery (those performing <3 lists increased from 10 to 38, while >12 lists fell from 30 to 8), outpatient clinics (<3 sessions rose from 8 to 36), and teaching activity (<3 sessions increased from 26 to 44). [14] This data demonstrates a widespread decrease in operative capacity and training in only the first year. Qualitative themes reported included junior and student surgeons picking up more of the burden, increased fear of assault on medical centers, and lack of supplies, including electricity, making the task of providing proper healthcare exponentially harder. [14]

One June 2025 study surveyed 1,457 patients who underwent a variety of surgical procedures during the first year of the war. This study found significantly higher rates of infection occurring after these surgical procedures. [15] Conflict zones had around double the rate of postoperative complications as zones that were considered safe at the time the survey was conducted. [15]

A more recent July 2025 study focusing on orthopedic surgery emphasized the higher incidence of explosive trauma and crush injuries. [16] Since Sudan already had only 1.5 orthopedic surgeons per 100,000 individuals, forced relocation of these surgeons is creating geographical gaps in care for many orthopedic procedures. [16] Notably, the paper reports a significant lack of equipment and medications. Without essential supplies, anesthesia, and antibiotics, complication rates are increasing, with around 60% of reported extremity injuries resulting in infection at the time the paper was published. [16]

What is being done to address this?

Currently, healthcare workers are increasingly performing remote consultations through mobile video calls and messaging apps to deliver care where in-person services are unsafe or unavailable. In many resource-limited and high-risk settings, telemedicine represents one of the few viable options for postoperative care and specialty consultation. [14,17] A survey of 2,463 Sudanese physicians, including 371 surgeons, reported that over half used telemedicine to provide care for patients in conflict settings. [17] This system was generally reported as cost-effective and useful, with over 73% of those surveyed reporting increased patient trust. [17] However, only about 60% reported telemedicine as comparable to in-person visits. [17] Although telemedicine is a limited tool, it demonstrates the Sudanese physicians’ adaptability and resourcefulness to sustain care amidst infrastructure collapse and resource scarcity.

In addition, junior doctors and volunteers are filling gaps where experienced surgeons have fled. [6,14] Organizations are calling for better protections for healthcare facilities, improved reporting systems, and coordinated rebuilding efforts. This includes Médecins Sans Frontières (MSF), an organization committed to working with local authorities to provide immediate medical relief, clean water, food, and primary care. [18] According to the Sudanese Doctors Network, hospitals and clinics in the state of Khartoum (which is now under SAF control) are going through the stages of repair and reopening. An estimated 57 of the 120 hospitals that initially closed have resumed at least partial operation. [17] Mobile clinics are also beginning to operate in the neighborhoods of Khartoum most affected by conflict. [17] These efforts are early and limited, but they represent initial attempts to maintain care and plan for post-conflict reconstruction.

What will Sudan’s healthcare system look like post-conflict?

As the war is still ongoing, it is difficult to know. Sudan’s healthcare system, which has faced considerable challenges, will undoubtedly need a long time to rebuild post-war. The length of this period will depend upon the immediate mobilization of resources and staff to address what has now become Sudan’s largest humanitarian crisis ever.3,6,7

It is imperative that a much larger international investment in Sudan’s healthcare system is delivered before the end of the war. A team from Sudan’s Federal Ministry of Health, the University of Greenwich, and Case Western Reserve University Hospital identified that the most pressing needs were medical supplies and financial support. It highlighted the need for a collaborative, bottom-up approach with international organizations, local government, and NGOs, to enhance healthcare capabilities in the communities that remain.6 The most pressing needs for each community must be identified at a local or facility level, especially when looking at differences across regions.6 Many surgeons identified long-term goals as strengthening healthcare infrastructure, ensuring surgeon safety, and supporting the return of displaced medical professionals.14

Outside of international investment, an important step to increase patients’ access to healthcare is for digital infrastructure to be expanded across states with the most damaged health systems.17 Surgical training programs also need to be redesigned to include remote triage and digital communication.17 These will be especially important to maintain sufficient preoperative and postoperative care through the end of the war and beyond.

The people of Sudan are facing unimaginable hardships and an uncertain future. It is crucial that they receive not only compassion and action now, but also continued support throughout the end of the war and rebuilding of systems that sustain everyday life.

References

[1] Ali, M. (2025, November 6). Where are tens of thousands of people in Sudan fleeing to? Al Jazeera. https://www.aljazeera.com/news/2025/11/6/where-are-tens-of-thousands-of-people-in-sudan-fleeing-to

[2] United Nations. (n.d.). Sudan conflict. UN News. https://news.un.org/en/focus/sudan-conflict

[3] BBC News. (2025, November 5). Where are tens of thousands of people in Sudan fleeing to? BBC News. https://www.bbc.com/news/articles/cpvdn8pmmd1o

[4] Cooper, Y. (2026, February 6). It feels like humanity has died in Sudan. The Times.

[5] Roberts, L. (2025, February 26). How many have died in Sudan’s civil war? Satellite images and models offer clues. Science. https://www.science.org/content/article/how-many-have-died-sudan-s-civil-war-satellite-images-and-models-offer-clues

[6] Elamin, A., Abdullah, S., ElAbbadi, A., Abdellah, A., Hakim, A., Wagiallah, N., & Ansah, J. P. (2024). Sudan: From a forgotten war to an abandoned healthcare system. BMJ Global Health, 9(10), e016406. https://doi.org/10.1136/bmjgh-2024-016406

[7] Hemmeda, L., Ahmed, A. S., & Omer, M. (2023). Sudan's armed rivalry: A comment on the vulnerable healthcare system catastrophe. Health science reports, 6(8), e1517. https://doi.org/10.1002/hsr2.1517

[8] Wharton, G., Ali, O. E., Khalil, S., Yagoub, H., & Mossialos, E. (2020). Rebuilding Sudan's health system: opportunities and challenges. The Lancet, 395(10219), 171-173.

[9] Fadul, N., Hussein, M. E., & Fadul, A. A. (2021). Re-opening Sudan: the balance between maintaining daily living and avoiding the next peak of COVID-19. Current tropical medicine reports, 8(3), 231-237.

[10] Ahmat, A., Asamani, J. A., Abdou Illou, M. M., Millogo, J. J. S., Okoroafor, S. C., Nabyonga-Orem, J., Karamagi, H. C., & Nyoni, J. (2022). Estimating the threshold of health workforce densities towards universal health coverage in Africa. BMJ global health, 7(Suppl 1), e008310. https://doi.org/10.1136/bmjgh-2021-008310

[11] Abdelmola A. (2023). Antenatal Care Services in Sudan Before and During the 2023 War: A Review Article. Cureus, 15(12), e51005. https://doi.org/10.7759/cureus.51005

[12] Elnoor, S. (2026, January 12). In Sudan, war erodes what remains of a battered health system. Assafir Al-Arabi. https://assafirarabi.com/en/68670/2026/01/12/in-sudan-war-erodes-what-remains-of-a-battered-health-system/

[13] Sudan Tribune. (2025, December 31). Sudan doctors network says 284 health facilities resume operations in Khartoum. Sudan Tribune. https://sudantribune.com/article/308857

[14] Bashary, M., Eltyeb, D., Hassan, S., Eltyeb, M., Mohamedahmed, A. Y., & Eltyeb, H. (2024). Scalpel and strife: Assessing the impact of Sudan’s ongoing civil war on surgical practice and healthcare delivery. The Surgeon, 22(5), 301–306. https://doi.org/10.1016/j.surge.2024.04.015

[15] Ashraf, A., Ibrahim, A., Ibrahim, S., Adam, T., Mohammed, S., Adam, A., Elbager, R., Abdulaziz, L., Gameraldeen, A., Izzeldin, A., Yassir, R., Khalid, S., & Azhari, A. (2025). The impact of war on surgical interventions: A comparative analysis on prevalence and types of postoperative complications across conflict and safe Sudanese states. British Journal of Surgery, 112(Supplement 10), Article znaf128.475. https://doi.org/10.1093/bjs/znaf128.475

[16] Nawari, A., Zahir, J., & Gomez, J. (2025). Orthopaedic trauma in Sudan: Delivering care and improving outcomes in a war-torn system. Orthopedic Reviews, 17, Article 142600. https://doi.org/10.52965/001c.142600

[17] Suliman A. (2025). Mobile phone-based surgical telemedicine in Sudan: a conflict-driven innovation with global relevance. BMJ global health, 10(9), e020184. https://doi.org/10.1136/bmjgh-2025-020184

[18] Médecins Sans Frontières Canada. (2026, February 11). Sudan: MSF launches an emergency response in El Obeid, close to one of the country’s most active frontlines. Doctors Without Borders / Médecins Sans Frontières. https://www.doctorswithoutborders.ca/sudan-msf-launches-an-emergency-response-in-el-obeid-close-to-one-of-the-countrys-most-active-frontlines/