The ongoing war in Sudan is often overlooked amid high-profile conflicts raging across multiple continents. Yet the lack of media and geopolitical attention on this eighteen-month conflict has not diminished its devastation in terms of human lives.
Since fighting broke out in April 2023 between the Sudanese Armed Forces and the paramilitary Rapid Support Forces, both part of a power-sharing military government, the country has experienced the displacement of more than 14 million people and the splitting of refugees. the country based on geography and ideology.
And while we may never know the exact death toll, the conflict in Sudan today is certainly among the deadliest in the world.
As public health, conflict, and human rights scholars and Sudanese-American health professionals, we are acutely aware of how fraught it can be to estimate mortality during wars for a range of practical and political reasons. But such estimates are crucial: they allow us to understand and compare conflicts, target humanitarian aid to those still at risk, trigger war crimes investigations, witness conflicts and states and armed groups to intervene or change.
The difficult work of counting the dead
Sudan is experiencing a profound humanitarian crisis, characterized by ethnic cleansing, mass displacement, food shortages and the spread of disease, further complicated by flooding in northern states.
Counting the death toll in such a conflict involves counting not only those who died as a direct result of violence – itself difficult to determine in real time – but also those who died due to factors exacerbated by conflict, such as the absence of violence. emergency care, the failure of vaccination programs and a lack of essential food and medicine. Estimating this final death toll, the so-called indirect mortality, presents its own challenge, as the definition itself varies from study to study.
In testimony to Congress, U.S. Special Envoy to Sudan Tom Perriello acknowledged the challenges to estimates when he noted that there had been somewhere between 15,000 and 150,000 deaths in Sudan — an unusually wide range that was partly attributable to the complexity of determining indirect mortality.
Armed Conflict Location and Event Data (ACLED), a nonprofit organization specializing in collecting conflict-related data, has recorded an average of more than 1,200 direct conflict deaths per month in Sudan, with nearly 19,000 deaths in the first fifteen months of the conflict. This figure is comparable to the 20,000 deaths estimated by the Sudan Doctors Union and the 19,000 figure used by the Sudan Protection Cluster, a centralized group of UN agencies and NGOs that used data from the World Health Organization.
ACLED draws its estimates of deaths from traditional media, reports from international NGOs and local observers, supplemented with new media such as verified Telegram and WhatsApp accounts. The Sudan Doctors Union, on the other hand, provides on-the-ground estimates of deaths during conflict.
When available, different data sources, such as surveys, civil records, and official censuses, can make an estimate more accurate. However, these data are often only available afterwards, after the end of the conflict. It is therefore critical to use both available data and precedents from past conflicts to make a reasonable estimate of the human costs of an ongoing conflict.
A 2010 article in The Lancet estimated that there are 2.3 indirect deaths for every direct death from conflict, based on data from 24 small-scale surveys conducted in Darfur between 2003 and 2005. As such, based on ACLED's data on 18,916 direct deaths, we estimate that in the current Sudan conflict there are an additional 43,507 indirect deaths – or a total of more than 62,000 deaths.
We believe that our estimate is very conservative. In estimating mortality in the ongoing conflict in Gaza, another group of scientists, also writing in The Lancet, used a multiplier of four indirect deaths for every direct death to estimate total mortality there.
Meanwhile, a report from the Geneva Declaration Secretariat showed an average of 5.8 indirect deaths for every direct death in thirteen armed conflicts from 1974 to 2007.
Using that last multiplier, the number of indirect deaths in Sudan would rise to almost 110,000 – meaning the total number of deaths in the region is 130,000 – double our estimate.
This range is broad, but it recognizes how difficult it can be to estimate indirect deaths and how these can vary significantly depending on the form of conflict.
The Sudanese conflict in context
Despite the enormous loss of life these figures reflect, they certainly underestimate the true human cost of the conflict.
Before the fighting started, Sudan already had a fragile and underfunded healthcare system. And compared to other ongoing conflicts such as in Gaza and Ukraine, there was already a more precarious base scenario, with higher infant mortality and lower life expectancy.
Since the start of the war in Sudan, there have been continued reports of mass killings, enforced disappearances, sexual violence, the deliberate blocking of food and medicine, and other forms of violence against civilians.
Much of the violence is ethnically targeted, and the Darfur region – where a large-scale famine has been declared – has suffered disproportionately.
The destruction of civilian infrastructure and interrupted aid mechanisms prevent medicine, food, clean water and vaccinations from reaching the population in need.
Health workers and institutions, not only in high-risk Darfur, but across the country, have been the target of attacks. Nearly 80% of medical facilities have become unusable. And at least 58 doctors have died, in addition to many targeted in previous crises.
Given ongoing attacks on healthcare systems and limited access to humanitarian corridors, indirect deaths in Sudan are likely to increase as hospitals close, even in the capital Khartoum, due to bombings, ground attacks and a lack of essential supplies.
The costs for Sudanese children are particularly worrying. According to Doctors Without Borders, thirteen children die every day in the Zamzam camp in North Darfur, mainly due to malnutrition and food shortages.
And nearly 800,000 Sudanese children will face severe, acute malnutrition by 2024, a condition that requires intensive care and supplemental feeding just to prevent death. Even before the conflict, children were seriously threatened by a lack of access to care, including basic preventive care such as early immunization.
Finally, the transmission of communicable diseases thrives in conflicts such as Sudan, where there is widespread population displacement, malnutrition, limited water and sanitation, and a lack of adequate shelter. In August, a cholera outbreak led to a high mortality rate of more than 31 deaths per 1,000 cholera cases. And examples of such disease effects are likely to be underestimated in a country where healthcare penetration and monitoring is lacking.
The limitations of estimates
Sudan's massive internal displacement of more than 14 million people complicates death toll estimates, as shifting population groups make establishing baselines virtually impossible.
Furthermore, there is usually a lack of official information collected and released during conflicts.
Establishing a concrete assessment of the actual impact of armed conflict therefore often comes after the cessation of hostilities, when expert teams are able to conduct field studies.
Even then, estimates will require assumptions about direct deaths, the ratio of indirect to direct deaths, and the quality of existing data.
But as scholars working at the intersection of public health and human rights, we believe that such work, however imperfect, is necessary for documenting conflict—and its future prevention. And while there are many global conflicts currently requiring our urgent attention, the conflict in Sudan should not be lost in the mix.
_Editor's note: Israa Hassan, a resident of Texas Rehabilitation Hospital-Fort Worth and advocacy director at the Sudanese American Physicians Association, contributed to this article.
(Authors: Sarah Elizabeth Scales, Postdoctoral Fellow, Department of Environmental, Occupational and Agricultural Health, University of Nebraska Medical Center; Blake Erhardt-Ohren, DrPH candidate, University of California, Berkeley; Debarati Guha Sapir, professor of public health, Université catholique de Louvain (UCLouvain); Khidir Dalouk, Assistant Professor of Medicine, Oregon Health & Science University, and Rohini J Haar, Faculty, Department of Epidemiology, School of Public Health, University of California, Berkeley)
(Disclosure Statement: Rohini J Haar receives funding from FCDO. Blake Erhardt-Ohren, Debarati Guha Sapir, Khidir Dalouk and Sarah Elizabeth Scales do not work for, consult with, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic training. appointment)
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