In March 2023, Matt Cowling embarked on his first assignment with MSF in Sudan as a humanitarian affairs manager based in Khartoum, the capital city. However, conflict between the Sudanese Armed Forces (SAF) and Rapid Support Forces (RSF) erupted in mid-April. For nearly a year, Matt moved with MSF, in various roles in our emergency response and following the displacement routes of the Sudanese people across the country. His year-long experience has led him to share his observations of the ongoing hostilities in Sudan.
I began my assignment with MSF in Sudan in the capital city of Khartoum. I was excited to start this new role and be part of MSF operations in the country. The rich Sudanese culture was quite interesting and new to me. MSF has been here for a long time, which intrigued me. Little did I know just how eventful and challenging my time in Sudan would become.
When fighting first broke out in Khartoum mid-April, we had to spend eight days in hibernation in Khartoum, something none of us were prepared for. No one saw the conflict coming, we all thought it would be in Darfur and didn't anticipate that SAF and RSF would start fighting in the streets of Khartoum, and where we were located,- an area in the central part of Khartoum called Amarat. We were relatively safe in our guest house, but other MSF colleagues were quite close to the fighting. In fact, fighter jets were constantly flying overhead, and explosions were a regular occurrence. It was an incredibly tense time.
The evacuation was equally, if not more, terrifying and uncertain. We were trying to understand where the checkpoints were, coming out of the city, but nobody knew. Eventually, MSF organised a convoy out to Gedaref where I stayed for a month. Then, I moved to work with the emergency response team based in Port Sudan. There, I contracted dengue fever and was medically evacuated for treatment. I took some time off to recover before returning to Port Sudan in mid-November, where I worked with the MSF coordination office before heading to Wad Madani and then Tenedba in Gederef.
Displacement in every direction
I'll never forget a woman I met while working in Gedaref. She lived in a makeshift shelter at a gathering site with her children. She spoke good English and shared how little aid they received. I first encountered them in Tenedba, where we provided food assistance and conducted a mobile clinic.
A month later, due to scarce resources and limited options, they moved to Kassala, to a reception center. She recognised me there. They were disappointed by the lack of help and desperately needed to find safety. They were being asked to leave the city, but they did not know where to go. They were in dire need of food.
Seeing the same person in different cities under the same difficult circumstances deeply moved me. I found it striking that I had been in the same place at the same time as her twice. That was a significant moment for me.
On 15 December, new clashes between RSF and SAF erupted in Al Jazirah state, when the conflict spread to Wad Madani, hundreds of thousands of people fled to adjacent states like Gedaref, Kassala, and Red Sea, which comprise eastern Sudan. We were already conducting an assessment in Kassala state, and as a result MSF began providing aid.
The conditions in Wad Madani were already overwhelming, with limited access to healthcare, many people were living in informal settlements or gathering sites, mostly schools, but people were also sleeping on the street. There were approximately 40,000 internally displaced people who fled to Kassala, adding to the over 150,000 people already in the state following the clashes in Khartoum of the previous year. MSF started supporting four primary healthcare centers, providing a full package of primary healthcare, including sexual and reproductive health referrals. This effort lasted for six weeks, after which the project was extended for another four weeks. During this additional period, MSF established mobile clinics targeting key gathering sites.
Medicine or food?
From the mobile clinic, and given the winter season in Sudan, symptoms such as a cough, cold, and flu often lead to respiratory tract infections, the most common morbidity. Living in inadequate or predominantly outdoor, substandard shelters may be a concerning factor in exacerbating these morbidities. Alongside this, we witnessed chronic diseases and significant barriers for people to access chronic disease medication. For instance, insulin prices have dramatically increased; when people are living in gathering sites following the collapse of the National Health Insurance Fund, the looting, and the loss of supplies from the National Medical Supply Fund, the cost of medication, particularly for chronic diseases like diabetes, skyrocketed, and people simply can’t afford it.
People are forced to make decisions like, "Do I buy food, or do I buy my insulin?" They are living through an enormous level of stress, which is also detrimental to their health if they’re managing a chronic disease, particularly when you must manage your diet and care for your family while living in an overcrowded, severely underserved gathering site.
Small and insufficient yet differential attempts of aid
In an attempt to alleviate the water scarcity, we managed to connect some gathering sites to the city water line. We intervened in 47 different gathering sites, improving access to water and carrying out significant rehabilitation to latrines.
In one gathering site, predominantly comprised of families with members who had a disability, either wheelchair users or those on crutches from before the conflict, our team made sure there were ramps and handles in the toilets for easier access. Our ten-week emergency response ran its course. Unfortunately, the dire needs of internally displaced people and host communities remain largely unaddressed, with almost no other humanitarian actors taking over following the closure of our emergency response in Kassala.
The assistance that organisations are providing right now is like a drop in the ocean. The gaps are so significant that it might seem like this aid isn't making a difference. Despite their lack, it still makes a tangible difference in some people’s everyday life.
While some organizations provided food assitance, people rely on their neighbours, the goodwill of communities, charitable people, extended family members, and a hospitable culture. That escalates the needs of the host communities from which the assistance is predominantly coming.
Protracted conflict and dismal reality
A family originally from Darfur, displaced to Khartoum, had to grapple with displacement again, this time to Wad Madani, when the conflict started last April. The mother, nine-months pregnant, gave birth at a gathering site. Fortunately, both the baby and the mother were safe. However, when the conflict reached Wad Madani, they had to flee to Gedaref.
The family had separated for the journey after fleeing Wad Madani, where their seven-year-old son had received specialized operations for his brain injury (caused by a piece of shrapnel). They believed it would be easier for the father to find a place to continue his son's treatment alone. After uncertain and difficult time, the family managed to reunite at the gathering site in Tenedba. Such specialized treatment was only available in Wad Madani. But the question arises: Are these facilities only accessible to people when they cross brutal front lines and risk their lives to reach Wad Madani? MSF provided basic care, wound dressing, and infection control for the child, but we were unable to provide the specialized treatment he still needed.
The prolonged nature of the suffering people are currently enduring is astounding. It's remarkable how little attention Sudan receives, and how the experiences of its people are hidden from the world. The situation in Sudan is largely overlooked by the media. I believe this is primarily because journalists cannot enter the country and organisations are not vocal enough about what's happening there. We are facing coordination issues and a significantly underfunded response. Now, we have a situation where people are being displaced multiple times and the needs are enormous. Another grim aspect of this situation is within the RSF-controlled areas, where access is extremely limited: We are looking at severe acute food insecurity, which is a significant concern for the future as we're nearly one year into the conflict, and we still don't see any substantial progress or movement toward a peaceful resolution or an end to the conflict.