Essay
How public health officials keep hope alive in Sudan’s civil war
On April 14, 2023, my colleagues in Sudan’s Ministry of Health and I met for the relatively routine business of endorsing a plan to deal with looming epidemics of cholera, dengue fever, and measles. The next morning, my family and I awoke to gunfire in the streets of the capital, Khartoum; we lived near the headquarters of the Army General Command, where the fighting began, and heard the sound of jet fighters bombing the airport and other targets. Civil war had erupted between the Rapid Support Forces (RSF), a paramilitary group, and the Sudanese army. We saw smoke billowing over the city and dead bodies in the street. Hundreds of people died that day.
The fighting plunged the ministry—and me—into dark uncertainty. For the first 72 hours, I felt paralyzed and overwhelmed by the chaos. Khartoum Teaching Hospital, the last hospital still open in the central medical area in the capital, came under fire from the RSF on the third day of fighting. I was in the building, and we made the decision to evacuate all of the patients, some of whom were on ventilators, to other hospitals in safer parts of Sudan.
I kept in touch with the ministry’s staff via WhatsApp and text about their security and safety. Four days after the war began, I managed to run a virtual meeting with my team and we began to figure out how the ministry could respond to this dire threat to the country’s public health. Our health system was fragile before the conflict, and I feared the war would bring its total collapse.
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I stayed in Khartoum for almost five weeks, working to redeploy health resources. By the time I left, most of Khartoum’s hospitals and clinics were damaged by the fighting or occupied by the RSF. The RSF had also seized the National Public Health Laboratory and the Central Blood Bank and looted the main warehouses managed by the National Medical Supply Fund, cutting off the country from medicines, medical equipment, and other supplies. Everything we had intended to use to prevent upcoming epidemics, as well as for existing disease outbreaks, had disappeared.
Most physicians, nurses, midwives, and other health professionals had also fled to safer states inside Sudan or to nearby countries. A small group of health care workers and ministry officials have stayed in Khartoum despite violence and threats, working in the face of shortages of everything. They are part of the reason the country’s health system has not been broken, even with open conflict in more than half of Sudan’s 18 states.
In the year since the civil war began, an estimated 15,000 people have died; tens of thousands more have been injured; and nearly eight million people have been displaced, making this the world’s largest displacement crisis. Displacement, confusion, atrocities, and hardship have tested every aspect of the Ministry of Health and severely curtailed the work we had done to keep cholera, dengue fever, and measles in check.
The only constant has been the dedication and commitment of works at the ministry and on the front lines of health care.
Still, we have continued efforts to ensure early detection of these and other diseases. In the past few months, thanks to help provided by more than 500 surveillance officers trained by the World Health Organization, we have seen a decline in the number of cases of cholera, dengue, and malaria across the country. As reflected in a weekly progress report collected from the states, many of the sentinel sites were not regularly providing regular epidemic reports; along with surveillance, this reporting has also been improved.
In such a fluid situation, the only constant has been the dedication and commitment of works at the ministry and on the front lines of health care. In the early days of the war, we set four key priorities:
Organizing governance and leadership. As people fled Khartoum, the ministry team shrank considerably, to about 10 percent of its pre-war size. We initially assembled a team of 20 health directors, who met virtually, and have since expanded to more than 100 technical staff. We can’t do everything we did before the war for Sudan’s 46 million people, but it is a start. We also established new national and regional partnerships, such as those with King Salman Humanitarian Aid & Relief Centre, the Kuwaiti Patients Helping Fund Society, several Qatari organizations, and a variety of community-based organizations. These partners have helped fill the gaps by supporting services in hard-to-reach states and donating medicines and supplies.
Finding health care financing. Sudan’s national health insurance program has been paralyzed by the war and the ensuing financial crisis. The ministry received no financial support during the first three months of the war; health workers provided services without salaries or payments. The federal government eventually was able to fund 10 percent of the country’s health care facilities, but most hospitals now operate through patients paying out-of-pocket for medical services.
The ministry is now able to cover almost 40 percent of residents’ urgent needs, such as essential medicines and support for emergency services. The ministry also covers free care for approximately 8,000 people needing dialysis and 18,000 undergoing treatment for cancer. Funding comes from the government, United Nations agencies, nongovernmental organizations, and community service organizations, though there have been hiccups. GAVI, the global vaccine alliance, has supported vaccinations and health system strengthening, and the Global Fund helps support the ongoing fight against malaria, HIV, and tuberculosis. Finding ways to continue working with these organizations has been essential for progress.
Replenishing the health workforce. In an effort to counter the initial depletion of the health care workforce, the Ministry of Health and the Sudan Medical Council (the national authority regulating the medical profession) continue to issue certificates, license physicians, and enroll new physicians in residency programs. In the Darfur region, Gezira, and Khartoum, the Academy of Health Sciences had to stop training nurses, midwives, and other allied health professionals. However, its branches in safer states enrolled more students—almost 7,500 for the 2024 academic year.
Assuring the supply chain. We initially used multiple approaches to maintain a supply chain, redistributing medicines and supplies based on where people were moving and the demand from health facilities. We shifted donations to the actual need and asked partners like GAVI and the Global Fund to replace medicines and vaccines that had been looted or lost. We also allocated some of the government budget to buy essential medicines and supplies not covered by others.
We now have a decentralized supply system with storage capacity in all states, making it possible for the Ministry of Health to ensure access to medicines and supplies, though the ongoing war can affect their timely delivery.
At the start of the war, all 26 of the country’s pharmaceutical factories were located in Khartoum state; they closed when the war erupted. Some were looted and destroyed. We are working on strategies to restart private sector importing and manufacturing medicines.
We have made enough progress on these initial priorities to add two more:
Realigning services. The search for safety has redistributed Sudan’s population, changing the needs of the health system in each state. Health care facilities in states deluged with displaced people are overburdened, resulting in shortages of hospital beds, overtaxed medical devices and equipment, and increased needs for supplies. These population movements may change the patterns of disease in the country. The need for dialysis, for example, has significantly changed in some states. Khartoum had low levels of malaria, but many residents fled to Gezira, where the incidence of malaria is high. Gender and age demographics have shifted, which will eventually require remapping health services.
Reestablishing the flow of public health information. War seeds pestilence. It also makes it difficult, if not sometimes impossible, to collect and share the data needed to detect and manage disease outbreaks. We know we need timely reporting of surveillance data to prevent and manage diseases like hemorrhagic fever, malaria, cholera, polio, and others. Yet in states where the war is active, the flow of information has been cut off to a trickle, if that.
What’s needed to improve public health
What the country really needs is a ceasefire and, ideally, a peaceful end to the conflict. Absent that, the ministry has several major goals in 2024:
Seventy-five percent of Sudan’s hospitals in each region should function at least partially by the end of 2024. In safer states, we aim to restore access to specialized surgery as well as services for cardiac, renal, and gastrointestinal needs. These ambitious goals require significant external support.
The ministry staff and the public health corps who remain at work have committed to the goal of saving lives, and that has kept the system functioning when many, including me, thought it would collapse.
Malnutrition, a burden in Sudan even before the war, is now estimated to have stunted the growth of almost one-third of Sudanese children. We project 3.5 million children will experience acute malnutrition this year, including more than 700,000 who are expected to suffer from its deadliest form. After the revolution in 2019, a global support campaign pledged $1.5 billion in bilateral aid for Sudan’s humanitarian crisis. Unfortunately, only about 10 percent of that has been released. We are urgently working to gain the rest and reinstate countrywide programs at the primary health care level.
To improve the flow of public health information, and with the support of the World Health Organization, we are working to strengthen the software surveillance system in all states, aiming to ensure that at least 90 percent of the sentinel sites from across the country have the ability to report public health data in a timely manner.
Looking ahead
Managing Sudan’s federal Ministry of Health in the midst of a civil war has been a harrowing experience, personally and professionally.
When the war started, what I saw happening around me was horrific. I felt sad and angry. I was eventually able to move with my family to a safer state, but being internally displaced has been hard for us, as it has been for the millions of people in Sudan who had to move to escape violence. Working to protect the health of the Sudanese people helped me through my depression. Members of the ministry staff and the public health corps who remain at work have committed to the goal of saving lives, and that has kept the system functioning when many, including me, thought it would collapse. I am proud to say that never happened and, with internal solidarity and the support of many people within Sudan and outside of it, the health system has managed to continue providing services to the people of the country.
Since those bleak early days, we have made steady progress. Even when our second hub for medicine and supplies in Gezira state was lost to the RSF, we started over again, this time in a more decentralized way.
I wouldn’t wish this experience on any minister of health. And yet, with only 10 percent of the pre-war ministry staff, we have achieved seemingly impossible tasks. If war does come to your country, trust yourself and the people you work with. Don’t give up, and don’t lose hope. Believe in the mission of public health.
Top: Sudan’s Federal Minister of Health, Heitham M.I. Awadalla, administers a cholera vaccine as part of a prevention program during the country’s ongoing civil war.
Photo: Courtesy of the Sudan Federal Ministry of Health
Republish this article
<p>Nurturing resilience amid the ravages of conflict</p>
<p>Written by Heitham Mohammed Ibrahim Awadalla</p>
<p>This <a rel="canonical" href="https://harvardpublichealth.org/global-health/as-sudan-civil-war-raged-its-health-ministry-kept-hope-alive/">article</a> originally appeared in<a href="https://harvardpublichealth.org/">Harvard Public Health magazine</a>. Subscribe to their <a href="https://harvardpublichealth.org/subscribe/">newsletter</a>.</p>
<p class="has-drop-cap">On April 14, 2023, my colleagues in Sudan's Ministry of Health and I met for the relatively routine business of endorsing a plan to deal with looming epidemics of cholera, dengue fever, and measles. The next morning, my family and I awoke to gunfire in the streets of the capital, Khartoum; we lived near the headquarters of the Army General Command, where the fighting began, and heard the sound of jet fighters bombing the airport and other targets. Civil war had erupted between the Rapid Support Forces (RSF), a paramilitary group, and the Sudanese army. We saw smoke billowing over the city and dead bodies in the street. Hundreds of people died that day.</p>
<p>The fighting plunged the ministry—and me—into dark uncertainty. For the first 72 hours, I felt paralyzed and overwhelmed by the chaos. Khartoum Teaching Hospital, the last hospital still open in the central medical area in the capital, came under fire from the RSF on the third day of fighting. I was in the building, and we made the decision to evacuate all of the patients, some of whom were on ventilators, to other hospitals in safer parts of Sudan.</p>
<p>I kept in touch with the ministry's staff via WhatsApp and text about their security and safety. Four days after the war began, I managed to run a virtual meeting with my team and we began to figure out how the ministry could respond to this dire threat to the country's public health. Our health system was fragile before the conflict, and I feared the war would bring its total collapse.</p>
<p>I stayed in Khartoum for almost five weeks, working to redeploy health resources. By the time I left, most of Khartoum’s hospitals and clinics were damaged by the fighting or occupied by the RSF. The RSF had also seized the National Public Health Laboratory and the Central Blood Bank and looted the main warehouses managed by the National Medical Supply Fund, cutting off the country from medicines, medical equipment, and other supplies. Everything we had intended to use to prevent upcoming epidemics, as well as for existing disease outbreaks, had disappeared.</p>
<p>Most physicians, nurses, midwives, and other health professionals had also fled to safer states inside Sudan or to nearby countries. A small group of health care workers and ministry officials have stayed in Khartoum despite violence and threats, working in the face of shortages of everything. They are part of the reason the country’s health system has not been broken, even with open conflict in more than half of Sudan's 18 states.</p>
<p>In the year since the civil war began, an estimated 15,000 people have died; tens of thousands more have been injured; and nearly eight million people have been displaced, making this the world's <a href="https://www.unocha.org/publications/report/sudan/sudan-nine-months-conflict-key-facts-and-figures-15-january-2024" target="_blank" rel="noreferrer noopener">largest displacement crisis</a>. Displacement, confusion, <a href="https://harvardpublichealth.org/global-health/we-must-demand-justice-for-atrocities-against-health-care/" target="_blank" rel="noreferrer noopener">atrocities</a>, and hardship have tested every aspect of the Ministry of Health and severely curtailed the work we had done to keep cholera, dengue fever, and measles in check.</p>
<figure class="wp-block-pullquote alignwide"><blockquote><p>The only constant has been the dedication and commitment of works at the ministry and on the front lines of health care.</p></blockquote></figure>
<p>Still, we have continued efforts to ensure early detection of these and other diseases. In the past few months, thanks to help provided by more than 500 surveillance officers trained by the World Health Organization, we have seen a <a href="https://who_emro.cmail19.com/t/d-e-efkkik-dyujhjldur-i/#:~:text=decline%20in%20the%20number%20of%20cases%20of%20cholera%2C%20dengue%2C%20and%20malaria" target="_blank" rel="noreferrer noopener">decline in the number of cases</a> of cholera, dengue, and malaria across the country. As reflected in a weekly progress report collected from the states, many of the sentinel sites were not regularly providing regular epidemic reports; along with surveillance, this reporting has also been improved.</p>
<p>In such a fluid situation, the only constant has been the dedication and commitment of works at the ministry and on the front lines of health care. In the early days of the war, we set four key priorities:</p>
<p><strong>Organizing governance and leadership.</strong> As people fled Khartoum, the ministry team shrank considerably, to about 10 percent of its pre-war size. We initially assembled a team of 20 health directors, who met virtually, and have since expanded to more than 100 technical staff. We can’t do everything we did before the war for Sudan’s 46 million people, but it is a start. We also established new national and regional partnerships, such as those with <a href="https://www.unicef.org/gulf/partner/ksrelief" target="_blank" rel="noreferrer noopener">King Salman Humanitarian Aid & Relief Centre</a>, the Kuwaiti <a href="https://www.unhcr.org/kw/en/our-partners/private-sector/patients-helping-funding-society/" target="_blank" rel="noreferrer noopener">Patients Helping Fund Society</a>, several Qatari organizations, and a variety of community-based organizations. These partners have helped fill the gaps by supporting services in hard-to-reach states and donating medicines and supplies.</p>
<p><strong>Finding health care financing.</strong> Sudan's national health insurance program has been paralyzed by the war and the ensuing financial crisis. The ministry received no financial support during the first three months of the war; health workers provided services without salaries or payments. The federal government eventually was able to fund 10 percent of the country's health care facilities, but most hospitals now operate through patients paying out-of-pocket for medical services.</p>
<p>The ministry is now able to cover almost 40 percent of residents' urgent needs, such as essential medicines and support for emergency services. The ministry also covers free care for approximately 8,000 people needing dialysis and 18,000 undergoing treatment for cancer. Funding comes from the government, United Nations agencies, nongovernmental organizations, and community service organizations, though there have been hiccups. GAVI, the global vaccine alliance, has supported vaccinations and health system strengthening, and the Global Fund helps support the ongoing fight against malaria, HIV, and tuberculosis. Finding ways to continue working with these organizations has been essential for progress.</p>
<p><strong>Replenishing the health workforce.</strong> In an effort to counter the initial depletion of the health care workforce, the Ministry of Health and the Sudan Medical Council (the national authority regulating the medical profession) continue to issue certificates, license physicians, and enroll new physicians in residency programs. In the Darfur region, Gezira, and Khartoum, the Academy of Health Sciences had to stop training nurses, midwives, and other allied health professionals. However, its branches in safer states enrolled more students—almost 7,500 for the 2024 academic year.</p>
<p><strong>Assuring the supply chain.</strong> We initially used multiple approaches to maintain a supply chain, redistributing medicines and supplies based on where people were moving and the demand from health facilities. We shifted donations to the actual need and asked partners like GAVI and the Global Fund to replace medicines and vaccines that had been looted or lost. We also allocated some of the government budget to buy essential medicines and supplies not covered by others.</p>
<p>We now have a decentralized supply system with storage capacity in all states, making it possible for the Ministry of Health to ensure access to medicines and supplies, though the ongoing war can affect their timely delivery.</p>
<p>At the start of the war, all 26 of the country’s pharmaceutical factories were located in Khartoum state; they closed when the war erupted. Some were looted and destroyed. We are working on strategies to restart private sector importing and manufacturing medicines.</p>
<p>We have made enough progress on these initial priorities to add two more:</p>
<p><strong>Realigning services.</strong> The search for safety has redistributed Sudan’s population, changing the needs of the health system in each state. Health care facilities in states deluged with displaced people are overburdened, resulting in shortages of hospital beds, overtaxed medical devices and equipment, and increased needs for supplies. These population movements may change the patterns of disease in the country. The need for dialysis, for example, has significantly changed in some states. Khartoum had low levels of malaria, but many residents fled to Gezira, where the incidence of malaria is high. Gender and age demographics have shifted, which will eventually require remapping health services.</p>
<p><strong>Reestablishing the flow of public health information.</strong> War seeds pestilence. It also makes it difficult, if not sometimes impossible, to collect and share the data needed to detect and manage disease outbreaks. We know we need timely reporting of surveillance data to prevent and manage diseases like hemorrhagic fever, malaria, cholera, polio, and others. Yet in states where the war is active, the flow of information has been cut off to a trickle, if that.</p>
<h2 class="wp-block-heading" id="h-what-s-needed-to-improve-public-health">What's needed to improve public health</h2>
<p>What the country really needs is a ceasefire and, ideally, a peaceful end to the conflict. Absent that, the ministry has several major goals in 2024:</p>
<p>Seventy-five percent of Sudan’s hospitals in each region should function at least partially by the end of 2024. In safer states, we aim to restore access to specialized surgery as well as services for cardiac, renal, and gastrointestinal needs. These ambitious goals require significant external support.</p>
<figure class="wp-block-pullquote alignwide"><blockquote><p>The ministry staff and the public health corps who remain at work have committed to the goal of saving lives, and that has kept the system functioning when many, including me, thought it would collapse.</p></blockquote></figure>
<p>Malnutrition, a burden in Sudan even before the war, is <a href="https://reliefweb.int/report/sudan/record-numbers-children-seek-life-saving-care-sudan-war-drives-worlds-worst-displacement-crisis-enar" target="_blank" rel="noreferrer noopener">now estimated</a> to have stunted the growth of almost one-third of Sudanese children. We project 3.5 million children will experience acute malnutrition this year, including more than 700,000 who are expected to suffer from its deadliest form. After the <a href="https://www.aljazeera.com/news/2019/12/18/12-defining-moments-in-sudans-12-month-uprising" target="_blank" rel="noreferrer noopener">revolution in 2019</a>, a global support campaign pledged <a href="https://www.aa.com.tr/en/africa/donors-pledge-15b-for-humanitarian-response-to-sudan-un-relief-chief/2926216#:~:text=Donors%20on%20Monday%20pledged%20nearly,the%20UN%20relief%20chief%20said" target="_blank" rel="noreferrer noopener">$1.5 billion</a> in bilateral aid for Sudan’s humanitarian crisis. Unfortunately, only about 10 percent of that has been released. We are urgently working to gain the rest and reinstate countrywide programs at the primary health care level.</p>
<p>To improve the flow of public health information, and with the support of the World Health Organization, we are working to strengthen the software surveillance system in all states, aiming to ensure that at least 90 percent of the sentinel sites from across the country have the ability to report public health data in a timely manner.</p>
<h2 class="wp-block-heading" id="h-looking-ahead">Looking ahead</h2>
<p>Managing Sudan's federal Ministry of Health in the midst of a civil war has been a harrowing experience, personally and professionally.</p>
<p>When the war started, what I saw happening around me was horrific. I felt sad and angry. I was eventually able to move with my family to a safer state, but being internally displaced has been hard for us, as it has been for the millions of people in Sudan who had to move to escape violence. Working to protect the health of the Sudanese people helped me through my depression. Members of the ministry staff and the public health corps who remain at work have committed to the goal of saving lives, and that has kept the system functioning when many, including me, thought it would collapse. I am proud to say that never happened and, with internal solidarity and the support of many people within Sudan and outside of it, the health system has managed to continue providing services to the people of the country.</p>
<p>Since those bleak early days, we have made steady progress. Even when our second hub for medicine and supplies in Gezira state was lost to the RSF, we started over again, this time in a more decentralized way.</p>
<p class=" t-has-endmark t-has-endmark">I wouldn’t wish this experience on any minister of health. And yet, with only 10 percent of the pre-war ministry staff, we have achieved seemingly impossible tasks. If war does come to your country, trust yourself and the people you work with. Don’t give up, and don’t lose hope. Believe in the mission of public health.</p>
<p class="is-style-t-caption">Top: Sudan’s Federal Minister of Health, Heitham M.I. Awadalla, administers a cholera vaccine as part of a prevention program during the country’s ongoing civil war.</p>
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