As a humanitarian worker for over two decades, my commitment to assisting people in crises has remained unwavering. I would actually argue that our work has never been more relevant; from the consequences of intensifying geopolitical tensions to the resurgence of diseases that were once eradicated, to more – and more severe – climate change induced extreme weather events, we face today more needs, more complexity and more uncertainty than we ever had. Humanitarian organisations like MSF have to remain focused on growing their capacity to match those needs whilst adapting to increasingly challenging circumstances. In particular, we have seen this year unprecedented attacks on humanitarian principles and the values that underpin them. Field workers, supporters and the aid community at large, we all bear a responsibility in protecting those values by for example championing them in our communities and lobbying to hold perpetrators of International Humanitarian Law violations into account. For years, our teams around the world have been striving to achieve that, and your continued support has been, and will continue to be, invaluable.

Our MSF teams have responded in the wake of devastating earthquakes in Syria, Türkiye (in February) and Afghanistan (in October) which wrought havoc on already precarious lives and health care systems; we have extended our medical assistance to people facing gang violence in Haiti and to those suffering in Ukraine where violence has been relentless, and since the horrifying events of October, we strive to continue providing medical care in Gaza, which has been made incredibly difficult and dangerous by the siege and indiscriminate attacks on healthcare facilities. While some of these crises have been under the media spotlight, others have tragically been overlooked.

Our response also extends to the bloody internal conflict in Sudan. Despite beginning in April and continuing every day, the conflict has received disproportionately little attention. We have been witnessing how the conflict takes the lives of the civilians and devastates their homes and lands repeatedly. While our teams made the best effort to stay in the country to help the wounded and offer basic medical care, sometimes we have no choices but to temporarily suspend some of our operations due to the blockage of medical supplies.

In this issue of Borderline, we would like to bring to your attention the devastating situation inside Sudan, as well as the desperation Sudanese refugees facing in neighbouring countries where humanitarian assistance is not keeping pace with the massive needs.

Please take a moment to read the testimonies of our patients and MSF colleagues experiencing the consequence of warfare firsthand. The world needs to know what has been happening and take action to save lives and alleviate suffering.

Olivier Franchi

Executive Director, MSF Hong Kong

Since the conflict escalated on 7 October, our teams working in Gaza have seen horrible situations in the hospitals and communities from the north to the south – severe shortages of fuel, medical supplies and clean water, as well as communication blackouts and indiscriminate attacks, including those targeting medical facilities. In Jenin, in the occupied West Bank, civilians and medical workers also faced violence as tensions over the conflict in Gaza increased. MSF has been providing specialised medical care in Occupied Palestinian Territories (West Bank and Gaza Strip) since 1989. Currently we have around 300 Palestinian staff in Gaza, among whom some are still supporting the health system across the Strip. A team of 15 international staff entered Gaza on 14 November from Egypt via the Rafah crossing point to continue the support for humanitarian and medical response, after we evacuated 22 international mobile staff earlier in the month.

While we welcome the ceasefire agreement achieved on 24 November, a couple of days is not nearly enough. MSF maintains our call for a sustained ceasefire to stop indiscriminate and relentless attacks, as well as assaults on hospitals and medical staff – and for an end to the siege and restrictions on aid.

December marks eight months since the conflict in Sudan began in Khartoum and quickly spread throughout the country. Since then, much of the country has been gripped by armed conflict, including devastating attacks on civilians, residential areas and healthcare facilities. This has forced more than 6.3 million people to flee their homes, including more than 5.1 million internally displaced and over 1.2 million seeking refuge in neighbouring countries where the provision of shelters, clean water and healthcare is not keeping pace with the massive needs. Hospitals in Sudan remain stretched to capacity, medical supplies are low, and in many parts of the country, humanitarian aid has come to a halt.

On top of that, the Sudanese authorities are also blocking lifesaving surgical supplies from reaching hospitals serving people in areas of Khartoum that are under the control of the opposition group Rapid Support Forces (RSF). This will likely cause more deaths of the sick and wounded, who already face huge challenges accessing medical facilities due to the violence in their communities.

Dr Christos Christou, International President of MSF, describes Sudan’s crisis as a “catastrophic failure of humanity” that is marked by the warring parties’ failure to protect civilians or facilitate essential humanitarian access, and by the dire neglect and shortcomings of international organisations in delivering an adequate response.

Aerial view captures the fighting and violence that erupted in Khartoum, Sudan.

© Atsuhiko Ochiai / MSF

Until November 2023, about 1.2 million Sudanese refugees fled to Chad, Central African Republic, South Sudan, Ethiopia and Egypt after the conflict started and the humanitarian situation in Chad has become particularly difficult.

MSF supported Bashair Teaching Hospital in south Khartoum received over 60 wounded patients and 43 deaths after an explosion in a market on 10 September 2023.

© Marie Burton / MSF

Jessica Comi is an experienced operating theatre nurse. She flew to Khartoum in early May, less than one month since the conflict broke out, and joined the MSF team in the Bashair Teaching Hospital to provide emergency healthcare to the wounded men, women and children. Despite having worked in conflict setting many times, she says this assignment in Sudan was her toughest one yet.

“(The team) found a hospital in South Khartoum – Bashair Teaching Hospital – which was virtually empty and being run by volunteers,” Jessica says. “When the conflict started, a lot of the hospital staff had left, so volunteers had stepped in to restart activities. They got in contact with MSF and asked for help.” Jessica and the team were asked if they can reopen the operating theatres in less than a day.

Experiencing supply blockage amidst shortage

Quickly resuming the surgical capacity of an abandoned hospital to cope with the influx of patients with complex war wounds was already not easy, but the difficulties of getting supplies made things even more challenging.

“The biggest problem we had was getting enough fuel for the generator so we could have electricity. The head of MSF in Sudan and the drivers spent a lot of time driving around Khartoum during the fighting trying to source fuel to keep us going,” Jessica says. “It was like Christmas for us when they came back with boxes of supplies. We’d open them up and it would be like: ‘Wow, examination gloves! Disinfectant for instruments!’ ”

In the eight weeks she was there, 525 surgeries had been conducted on 485 patients. From mid May to mid October, MSF’s surgical team has performed more than 3,000 surgical procedures.

However due to the blockade on surgical materials being transported from Wad Madani to south Khartoum for over a month, the team had to suspend life-saving surgical activities at the Bashair Teaching Hospital. Adding to the severity of the situation, travel permits of humanitarian workers – including medical personnel – are also being denied.

MSF head of emergency response for Chad and Sudan, Claire Nicolet, stated that the ban on surgical supplies entering southern Khartoum is a ruthless tactic which must be immediately reversed. “If we continue to be denied permission to bring surgical supplies to our hospital, soon they will have no options at all.”

The outgoing Head of Mission in Sudan Dr Mego Terzian summarises the situation of the Turkish Hospital in Khartoum in September.

© Mohammad Ghannam / MSF

As the conflict broke out and the level of violence escalated, many health workers were forced to leave the city. Now the hospital is only able to provide the most urgent forms of health care, mainly safe deliveries and emergency C-sections for pregnant women, and intensive care for children who are very sick. “The health system has almost completely collapsed in Khartoum and there are no primary healthcare activities,” Dr. Mego Terzian, then MSF head of mission in Sudan, says.

Responding to the looming infectious diseases

The shortage of vaccinations and sanitation facilities puts the children at risk of numerous preventable infectious diseases. Malaria, measles, meningitis, cholera and pneumonia are common illnesses, while medical staff have noted increases in cases of diarrhea and dehydration due to the poor drinking water quality.

Amid the challenging situation, the mortality rate in the hospital was under two per cent as of September, which is a big success for the medical and logistics team considering the abject conditions they have been working under.

“Despite the problems they face every day – the lack of electricity, water, and oxygen, and sometimes the lack of specific medications for anaesthesia and for blood transfusions – we have been capable of maintaining the team there and continuing to deliver emergency health care for the population,” Terzian concludes.

But on the surgical care side, the MSF team in the Turkish hospital recently responded to two mass casualty incidents on 12 and 13 November, receiving 128 wounded. After completing these surgical procedures, our remaining supplies would last less than a month. If we are unable to bring in more supplies soon, the operating theatre in the Turkish Hospital will also have to close its doors.

Marta and her construction worker husband had six children all living in Khartoum, Sudan, after migrating there from South Sudan. Her family’s lives completely changed in April. “Our home was full, and children were running and playing all over the place. Everything was okay until we heard the bombs and gunshots; neighbours and people we knew were dying.”

Facing the dilemma of fleeing, and losing the loved ones

To balance the safety of her children and financial burden, Marta and her husband decided that she and her children would leave to return to South Sudan, while he stayed behind. They took a bus, and moved from one displacement camp to another.

“As we arrived in Alagaya camp within Sudan, the children started to fall sick; they had measles. The baby was the first to get a fever; after one week, the three-year- old and later the nine-year-old. They all died,” she mourned. “I had to bury my three children far from home. Far from anyone they knew. Far from where we were going.”

Finally, Marta and her remaining children arrived at Renk, a small town of South Sudan close to the border, but she found that her eight-year-old son and five-year-old daughter suffered from malnutrition.

From July to early October, the MSF medical facility in Renk had admitted 232 patients for malnutrition and treated 282 cases of measles requiring hospital care. With the double impact of measles and malnutrition, our paediatric hospital in Malakal that receives referred child patients faced a very high 5.95% mortality rate for a certain period.

Although Marta’s children will recover after staying in our feeding centre, the future for her family is still uncertain. “We would need a lot of courage and help to survive the coming difficult days to start a new life in South Sudan. My house will still only be half full.”

Cross-border support for refugees fleeing West Darfur

Despite not being able to run our own medical activities in West Darfur, we scaled up our response in Adré, a Chadian small town on the border with Sudan, to provide medical services to the refugees fleeing western Sudan. Over seven months into the conflict, our teams working there still face immediate and major increases in the number of people arriving in the region. “In the first three days of November, we have seen more new arrivals of Sudanese refugees than during the whole previous month; about 7,000 people crossed the border,” explains Stephanie Hoffmann, MSF outreach coordinator, meaning the clashes in West Darfur has reached a new level of intensity.

In response to the influx of vulnerable people seeking safety, we vaccinate children against measles, screen for malnutrition, and refer those in need of urgent specialised healthcare directly to Adré hospital, where they are being treated by MSF and staff from the Chadian Ministry of Health. We also offer mental health support to people in distress at the crossing and has installed a water tank to provide safe drinking water after gruelling journey.

“Despite the collective efforts of their local communities, authorities and humanitarian organisations, the humanitarian response doesn't yet match the magnitude of the crisis in eastern Chad, which is also putting a strain on vulnerable host communities,” explains Claire Nicolet, head of MSF emergency response for Chad and Sudan. “We continue to call for an immediate scale-up of humanitarian aid to help the most vulnerable, both refugees and Chadians, and to ensure access to basic services such as water, healthcare, shelter and food.”

MSF response in Sudan

MSF has worked in Sudan since 1979. We currently work in 10 states: Khartoum, Al-Jazeera, White Nile, Blue Nile, River Nile, Al Gedaref, West Darfur, North Darfur, Central Darfur and South Darfur state. MSF teams are also assisting refugees and returnees across Sudan ́s borders in South Sudan and Chad.

MSF teams in Sudan are providing emergency treatment, carrying out surgery, running mobile clinics for displaced people, treating communicable and non-communicable diseases, providing maternal and paediatric healthcare, including safe deliveries, providing water and sanitation services, and donating medicines and medical supplies to healthcare facilities, and providing incentive pay, training and logistical support to Ministry of Health staff. We are also continuing some of its medical activities that were in place before the start of the conflict.

MSF ́s response in Sudan has a budget of €76 million for 2023. We have 1,145 Sudanese staff and 57 international staff working in Sudan as of October, and are also paying incentives to 1,358 Ministry of Health staff.