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Against a Background of War, Sudan Works to Restore Clinics, Distribute Medicine, and Locate Patients
Patients with non-communicable diseases, like diabetes and cancer, have died as Sudan’s war made medicines or care unavailable. Across Sudan, responding organizations are working to rebuild supply chains, locate displaced patients, and restore care.
A young child with Type 1 diabetes receives a medical examination in Darfur. Many providers in areas where the fighting is worst have elected to stay with their patients. “I cannot leave those children. We will die together or live together," one physician said. (Photo courtesy of the Sudanese Childhood Diabetes Association)
When Dr. Salwa Elhassan talks about the children who have been killed by Sudan’s war, she isn’t only referring to the casualties of violence. She’s also talking about children who have died from lack of medicine or medical care – including those with Type 1 diabetes who died because insulin or other essential elements of diabetes care weren’t available.
“I hear the daily stories of children who lost their lives because of lack of insulin or diabetes complications,” said Dr. Elhassan, a pediatric endocrinologist and clinic coordinator for the Sudanese Childhood Diabetes Association.
Before Sudan’s conflict between government factions broke into open war on April 15, 2023, the SCDA cared for about 11,000 children with diabetes, in 26 clinics across Sudan. The organization ran the most advanced pediatric diabetes center on the African continent in Khartoum, Sudan’s capital city. Staff had been trained to store and transport insulin under fastidious cold-chain protocols; to educate young patients and families about managing the disease; and to keep precise clinical records that ensured precious insulin was available when and where their young patients needed them.
“We had a very meticulous system,” Dr. Elhassan recalled. “The situation was completely stable.”
War upended that system essentially overnight. Militias occupied the Sudan Childhood Diabetes Centre in Khartoum in 2023. The center had cared for 3,000 young patients – and served as a storage facility for insulin used in all 26 other clinics. Because electricity has been interrupted, Dr. Elhassan knows those medicines are unusable, their safety and potency compromised.
Insulin must be kept within certain temperature ranges to be safely used. For people living with Type 1 diabetes, improperly stored insulin isn’t just ineffective. It can be life-threatening.
Displaced families are scattered across Sudan, and many have left the country. Although SCDA has worked to connect many displaced children with Type 1 diabetes to a new clinic, Dr. Elhassan said keeping track of all their patients has been impossible. “Many, we don’t know what happened to them. They are not reported in clinics, many were lost in hospitals.”
Before war broke out in Sudan in April 2023, the Sudanese Childhood Diabetes Association cared for 11,000 children with Type 1 diabetes at clinics across the country. Now, providers are working to obtain insulin and other components of diabetes management, treat displaced patients, and restore care to areas affected by the fighting. (Courtesy photo)
The fighting is currently concentrated in Darfur, as well as many areas in the west of Sudan. In these places, insulin and other Type 1 diabetes treatments are difficult to come by. Dr. Elhassan said many of SCDA’s patients in the area have died, often because treatment was unavailable and their families were unwilling to take the risk of fleeing.
“Many families prefer to lose one child from diabetes, rather than the whole family having to be displaced,” she said.
The fighting has also brought severe, often fatal, interruptions to medical care for non-communicable diseases.
This group of diseases, which includes diabetes, hypertension, cardiovascular and kidney diseases, and cancers, has been a growing threat to health for decades, and is the most common reason people seek healthcare in most parts of the world. Before the war, NCDs accounted for more than half the reasons Sudanese patients sought healthcare, said Dr. Dalya Eltayeb, the director-general of primary health care in Sudan’s Federal Ministry of Health. In Sudan, care for these diseases is provided by the federal government and is free of charge in many cases.
But the outbreak of war has altered the country’s medical landscape. In 2023, Rapid Support Forces seized control of the country’s medical supply warehouses in Khartoum, essentially erasing much of the country’s inventory of medicines and supplies. Tahani Gawish, the national drug supply chain coordinator for Sudan’s Federal Ministry of Health, estimates that $500 million of medical supplies were destroyed. Warehouses, cold storage rooms, and other essential infrastructure were damaged or looted.
Conflict and militia control of supply routes make it difficult to get medications like insulin or oncology medications to many areas of the country.
Dr. Eltayeb described losing access to three national centers for cardiac care because of the war, as well as more than 150 kidney dialysis units, a national radiotherapy center, the country’s main centers for cancer therapy, and a number of diagnostic laboratories. Many of these resources were clustered in Khartoum, a major urban center where the fighting has been particularly intense. (The Sudanese government announced about a month ago that the Rapid Support Forces had been pushed out of the area.)
In Sudan, mobile clinics are reaching patients whose access to care has been limited by the ongoing war. (Photo courtesy of Sudan’s Federal Ministry of Health)
“It happened suddenly,” she said of the losses.
Many healthcare providers have fled their homes for safety – making them among the 13 million displaced by the conflict, according to UNHCR. Displaced patients often can’t get near enough to a clinic to receive medical care.
Consequences For Care
Dr. Dafalla Abuidris, Director General of Sudan’s National Oncology Center, described seeing patients dying because the oncological drugs they needed were newly unavailable, or cancer care wasn’t available in their state. “Many cancer patients who cannot afford displacement will stay in the state without treatment,” he said. “There is not much radiotherapy outside Khartoum.”
A radiotherapy center in northern Sudan now has to serve most of Sudan’s patients with cancer. “You can imagine the waiting list,” Dr. Abuidris said. But that facility is about 500 miles from the middle of the country, making it inaccessible to many – and it’s privately owned, which means that patients have to pay for care that would be free of charge at a government facility.
“They hear about the treatment sessions, and they decide not to go,” Dr. Abuidris said. “This is the reason the waiting list is six months. Otherwise, it would be two years.”
Even when people are able to obtain needed medicines through illegal markets, Gawish said lack of regulation makes the practice dangerous. “People have started to smuggle medication, but they can’t guarantee the quality of that medication,” she said. “It is a disaster.”
A patient receives care in a mobile clinic setting in Sudan amid the war. (Photo courtesy of Sudan’s Federal Ministry of Health)
The vast spike in physical trauma and emergent mental health needs – the immediate results of the violence – have strained Sudan’s health system, making fewer resources available to patients managing a chronic condition, Dr. Eltayeb said: “The burden of non-communicable diseases is expected to surge.”
In addition, many of the humanitarian medical donations to Sudan, while urgently needed, have focused on the direct impacts of conflict, according to Gawish.
“The first donation is always about injuries” in a conflict setting, she said.
Meeting Medical Needs
Direct Relief, in collaboration with long-term partners in Sudan, including Life for a Child, the Changing Diabetes in Children partnership, the National Medical Supplies Fund, the Sudanese Childhood Diabetes Association, and the Federal Ministry of Health, among others, is working to help meet the country’s need for non-communicable disease care and cold-chain capacity.
Since war broke out in April of 2023, Direct Relief has shipped $25.9 million in medical material aid and distributed more than $60,000 in grant funding. Much of that support has focused on non-communicable disease care: For example, in 2024 alone, Direct Relief provided enough insulin to meet the needs of over 9,600 individuals, nearly 40% of the country’s population under age 20 with Type 1 diabetes. The organization has also shipped a variety of diabetes management supplies, more than $1.7 million in cancer medications and supportive therapies, and dialysis supplies to help people living with renal failure.
To increase centralized cold storage capacity, Direct Relief also purchased two 40-foot refrigerated containers for Sudan’s National Medical Supplies Fund, primarily intended to store the large volumes of insulin provided in support of SCDA’s activities across the country. Direct Relief has also purchased and delivered 35 solar medical-grade refrigerators to the 25 still-functioning diabetes centers receiving, storing, and dispensing insulin from SCDA to children and young adults living with Type 1 diabetes. Some of these centers are in rural or hard-to-reach areas of Sudan, including East Darfur.
A provider speaks to a young patient with Type 1 diabetes in Kassala, a city in eastern Sudan. (Photo courtesy of the Sudanese Childhood Diabetes Association)
The organization is also assessing the need for centralized and decentralized ultra-cold storage needs across Sudan, to ensure the proper storage and handling of medications and vaccines which must remain frozen.
A Path Forward
Dr. Elhassan, the pediatric endocrinologist, said healthcare workers are beginning to resolve the difficulties of tracking patients and sourcing medicines in many areas of Sudan. They’ve relocated their main diabetes center and established or reestablished care in strategically placed facilities. They’ve developed educational materials to teach families how to keep insulin cold, even during a crisis. Tracking clinic reports has made it easier to manage the insulin supply and transport effectively. The clinics have also developed a chain of communication designed to keep tabs on displaced patients. Even in Darfur, she said, physicians and other providers are choosing to stay amid the danger, without salaries, to care for their patients as best they can.
One doctor told her, “I cannot leave those children. We will die together or live together.”
“We have been able to save many children,” Dr. Elhassan said. “I hear a lot of brave stories about the physicians, educators, dietitians working in these clinics. They make sure to do everything” for their patients.
Even as the war continues, the next priority is to restore continuity of care across Sudan, and to improve the medical supply chain, said Dr. Eltayeb, the director-general of primary health care.
“The fighting is concentrated in a few areas,” she explained.
In the four states of Sudan – there are 18 overall – where instability is greatest, 80% of the primary health centers aren’t functional, Dr. Eltayeb noted. Providing healthcare has meant adapting, such as providing care via mobile clinics, so patients can reach providers safely.
“More and more people are coming back to Khartoum. We need to ensure…there are health services for them,” she said.
Kelsey Grodzovsky, Avrie Collier, Jeffrey Samuel, and Aaron Rabinowitz contributed reporting to this story.
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