When civil war first broke out in Sudan, medical care for children with diabetes was upended. Sudanese families scattered across the country, and many of the clinics where their children received insulin and other elements of diabetes treatment were abandoned or damaged amid the violence.

Untold numbers of these children died, said Dr. Salwa Elhassan, a pediatric endocrinologist and the clinic coordinator for the Sudanese Childhood Diabetes Association, or SCDA.

But nearly three years later, even as the conflict continues to rage, the situation is “much more stable than it was a few months ago,” Dr. Elhassan said.

The SCDA, Sudan’s Federal Ministry of Health, the country’s National Drug Supply Fund, and Direct Relief have worked together to build a stronger supply chain for insulin and other diabetes treatment items.

“Children and families can now access insulin closer to where they live,” Dr. Elhassan said. “For healthcare providers, this has made clinical work more efficient and safer. With reliable access to insulin and supplies, providers can make better treatment decisions and manage diabetes emergencies more accurately.”

When conflict breaks out, humanitarian groups often focus most on emergent needs: physical injury, triage, and restoring basic primary services. While all of these are essential and lifesaving, it often means people with more complex conditions, like cancer, diabetes, kidney disease, or hemophilia, go without the treatment they need to stay alive.

“Even though chronic conditions require constant attention and resources, they are often forgotten in conflict settings, except by the people who need or provide that care every day,” explained Kelsey Grodzovsky, Direct Relief’s director of global programs.

Against a background of war, and with decades of experience supporting Sudanese providers, Direct Relief works with on-the-ground partners across Sudan to rebuild access to treatment for diabetes, cancer, kidney disease, and other chronic diseases that form some of the most severe, widespread risks to health in a conflict.

Direct Relief’s support to Sudan has totaled more than $31 million since April of 2023, and included insulin and other diabetes treatments for both children and adults; cold chain support for temperature-sensitive medications, including two 40-foot containers for centralized cold chain storage and 35 solar-powered refrigerators; treatments and funding for kidney disease, dialysis, and transplant; cancer medications; acute stroke medicines; treatments for autoimmune and inflammatory diseases, lifesaving anticoagulants; and Factor VIII for hemophilia.

In addition, Direct Relief supports health providers in South Sudan and Chad who provide healthcare to refugees from the war as well as local populations.

These partners include the International Organization for Migration in South Sudan, which provides comprehensive healthcare to displaced and local populations, and Chad’s Ministry of Public Health and Prevention.

“Direct Relief has played a crucial role,” Dr. Elhassan said.

“This is How”

During Sudan’s civil war, the supply chain for cancer medicines “came to a stop, basically,” said Dr. Iman Ahmed, a Sudanese-Canadian global health expert who works with Direct Relief and other nonprofit organizations to place oncology medicines in the country.

“Since the onset of the conflict, [violence] has systematically destroyed the health system,” Dr. Ahmed said. Hospitals were attacked and militia-controlled supply routes decimated the country’s pharmaceutical supply system.

“This was especially challenging for cancer medicines,” many of which must be stored and transported at precise – and precisely monitored – temperatures, Dr. Ahmed explained. (Insulin also requires precisely monitored cold-chain conditions to be safe and effective.)

She was especially concerned about cancer patients because she knew they’d be a lower priority.

“The humanitarian system…doesn’t prioritize cancer,” she said. Specialized oncology medications, which often require special importation measures and are more expensive, became all but unavailable.

Grodzovsky explained that diseases like cancer and diabetes can strain public health systems even without conflict, because they require more complex treatment and steady access to medicine.

“Even in stable settings, chronic disease medications can take up a significant share of public healthcare budgets,” she said. “During conflict, those costs become harder to absorb as resources are strained and priorities shift to the most emergent needs.”

To fill the gaps in oncological care and other medical specialties, experts like Dr. Ahmed have worked hand in hand with Direct Relief and other NGOs to create new supply chains for lifesaving medicines.

“When your shipments are coming, we are in a state of alert all along the chain of communication,” she told Direct Relief. “This is how we are trying to create a safety net: mobilize and dispatch.”

For Dr. Jeffrey Samuel, a clinical pharmacist and Direct Relief’s Africa regional director, working with local providers and networks has been one of the great strengths of rebuilding medical access in the war-torn country.

Participating in specialized task forces, such as the International Society of Nephrology Sudan Task Force, and other collaborative efforts has made it possible for Direct Relief to receive real-time lists of the highest priority medicines and to move specialty medications quickly to providers in Sudan, as well as specialists in neighboring countries caring for Sudanese patients.

“In Sudan, the specialists are there, but the medicines often are not,” he explained. “We are able to align our humanitarian supply chain with clinical expertise to help keep patients alive and in care during an incredibly fragile time.”

“They’re not going to buy any medication”

Dr. Hatim Hassan, a nephrologist at the Mayo Clinic, was born in Sudan and has dedicated the past few years to building dialysis centers and increasing access to transplant and treatment for Sudanese patients with kidney disease, through the Habib Al Rahman Charity Organization.

Today, the organization provides dialysis treatment, transplants, and other renal care at specialized centers in Omdurman and Port Sudan.

At least 6,000 patients in Sudan have end-stage renal disease and urgently require dialysis to survive, although Dr. Hassan said the actual number is likely to be much higher.

“The need is tremendous there right now,” he said.

Kidney disease in Sudan has skyrocketed, Dr. Hassan explained. Part of the problem is that chronic diseases like hypertension and diabetes have gone widely untreated since the war began. Both of these conditions can quickly cause kidney disease when they’re not properly managed, damaging the organ’s blood vessels and reducing its ability to filter waste.

“People right now, they don’t have money even just to buy water,” he said. “If they have high blood pressure or diabetes, they’re not going to buy any medication.”

Before war broke out, he said, many people with chronic diseases were able to procure medication, and Sudan was able to provide dialysis care primarily through public facilities.

Direct Relief has provided extensive support to nephrology care in Sudan, shipping transplant medication and dialysis fluid to the Federal Ministry of Health, and awarding Habib Al Rahman Charity Organization with more than $240,000 in grant funding to support a solar power installation at the Habib Alrahman Charity Kidney Center in Omdurman, the transfer of hemodialysis supplies, and the purchase of additional transplant medications.

“Up Close and Personal”

Because conflict has made roads more dangerous and power more unreliable, being able to provide localized care is essential to saving Sudanese lives, multiple providers told Direct Relief.

The Sudanese Childhood Diabetes Association now has 26 clinics currently operational. Direct Relief provided 35 solar-powered medical refrigerators to store insulin across these facilities.

Dr. Elhassan called having reliable cold chain storage “a major achievement, allowing safe storage of insulin and ensuring continuity of care even during prolonged power outages.”

This increase in stability doesn’t translate to the areas where fighting is worst. Dr. Elhassan described having to transport insulin, blood glucose meters, and test strips via military aircraft to the city of Ad-Damazin, which was under siege, because there was no other way to get them to patients.

And getting insulin to the western areas of Sudan, currently under Rapid Support Forces control, is still extremely difficult. Dr. Elhassan said the organization’s two clinics in that area are unable to operate, and displacement and violence have made it impossible to keep track of how many pediatric patients in the Darfur area have survived.

Rebuilding specialty medicine, with its focus on more complex diseases and treatment, is precarious during an ongoing war, Dr. Ahmed said.

“Many facilities undergo multiple, repeated attacks, and as we speak, there is no guarantee,” she explained. “Many doctors have fled the country…Drugs and supplies still remain a challenge because we haven’t rebuilt the supply chains that existed before the war.”

Like many members of the Sudanese diaspora, Dr. Ahmed has dedicated much of her time to building new pathways to aid in her country of origin. She has worked in conflict zones in Yemen and Syria, but Sudan’s war is different.

“My connection with Sudan is unwavering,” she said. “When this war happened, it was up close and personal.”