The ongoing war in Sudan has often been overlooked amid higher-profile conflicts raging across multiple continents. Yet the lack of media and geopolitical attention to this 18-month-long conflict has not made its devastation in terms of human lives any less stark.
Since fighting broke out in April 2023 between the Sudanese Armed Forces and the paramilitary Rapid Support Forces, both of which had been part of a power-sharing military government, the country has seen the displacement of more than 14 million people and the carving up of the country by geography and ideology.
And while we may never know the exact death toll, the conflict in Sudan is certainly among the deadliest in the world today.
As scholars of public health, conflict and human rights and Sudanese-American health workers, we are keenly aware of how fraught it can be to estimate mortality in war for a slew of practical and political reasons. But such estimates are of critical importance: They allow us to understand and compare conflicts, target humanitarian aid for those still at risk, trigger investigations of war crimes, bear witness to conflict and compel states and armed groups to intervene or change.
The difficult work of counting the dead
A profound humanitarian crisis is occurring in Sudan, characterized by ethnic cleansing, mass displacement, food scarcity and the spread of disease, complicated further by flooding in the northern states.
Considering a death toll in such a conflict includes counting not only those who are killed as a direct result of violence – itself a difficult thing to determine in real time – but also those who have died by conflict-exacerbated factors, such as the absence of emergency care, the breakdown of vaccination programs and a lack of essential food and medicine. Estimating this latter death toll, called indirect mortality, presents its own challenge, as the definition itself varies among researchers.
In congressional testimony, U.S. special envoy to Sudan Tom Perriello recognized the estimation challenges when noting there had been anywhere between 15,000 and 150,000 deaths in Sudan – an exceedingly wide range that was attributable, in part, to the complexity of determining indirect mortality.
Armed Conflict Location and Event Data (ACLED), a nonprofit specializing in conflict-related data collection, has recorded an average of more than 1,200 direct conflict deaths per month in Sudan, with nearly 19,000 deaths in the first 15 months of the conflict. This figure is similar to the 20,000 deaths estimated by the Sudan Doctors Union and the 19,000 figure used by the Sudan Protection Cluster, a centralized group of U.N. agencies and NGOs that used World Health Organization data.
ACLED sources its estimates of deaths from traditional media, reports from international NGOs and local observers, supplemented by new media such as verified Telegram and WhatsApp accounts. The Sudan Doctors Union, on the other hand, gives on-the-ground estimates of conflict deaths.
When available, distinct data sources such as surveys, civil registers and official body counts can make an estimation more accurate. However, this data is often available only in retrospect, after the cessation of conflict. It is therefore critical to use both the available data and precedents from previous conflicts to capture a reasonable estimate of the human costs of an ongoing conflict.
A 2010 article in The Lancet estimated that there are 2.3 indirect deaths for every direct conflict death, based on data from 24 small-scale surveys conducted in Darfur from 2003 to 2005. As such, using ACLED's data of 18,916 direct deaths, we estimate that in the current Sudan conflict, there are an additional 43,507 indirect deaths – or more than 62,000 total deaths.
We believe our estimate is very conservative. When estimating mortality in the ongoing conflict in Gaza, a different group of scholars, also writing in The Lancet, used a multiplier of four indirect deaths for every direct death to estimate the overall mortality there.
Meanwhile, a report from the Geneva Declaration Secretariat showed an average of 5.8 indirect deaths for every direct death across 13 armed conflicts from 1974 to 2007.
Using that latter multiplier, the number of indirect deaths in Sudan would jump to nearly 110,000 – meaning the total deaths in the region amount to 130,000 – double our estimate.
This range is wide, but it acknowledges how difficult it can be to estimate indirect deaths and how they can vary significantly with the shape of a conflict.
The Sudanese conflict in context
For all the tremendous loss of life these numbers reflect, they surely underestimate the true human costs of the conflict.
Sudan already had a fragile and underfunded health system before the fighting started. And compared with other ongoing conflicts such as in Gaza and Ukraine, there was already a more precarious baseline, with higher child mortality and lower life expectancy.
Since the war in Sudan began, there have been consistent reports of mass killings, forced disappearances, sexual violence, deliberate blocking of food and medicine, and other forms of violence against civilians.
Much of the violence is ethnically targeted, and the Darfur region – where a full-scale famine has been declared – has suffered disproportionately.
The destruction of civilian infrastructure and interrupted aid mechanisms are preventing medicine, food, clean water and vaccinations from getting to in-need populations.
Health care workers and facilities, not only in at-risk Darfur but also throughout the country, have been the target of attacks. Nearly 80% of medical facilities have been rendered inoperable. And at least 58 physicians have been killed, in addition to the many that were targeted in previous crises.
Given the persistent targeting of health care systems and restricted access to humanitarian corridors, indirect deaths in Sudan are likely to grow as hospitals shut down, even in the capital Khartoum, due to bombardments, ground attacks and a lack of critical supplies.
The costs for Sudanese children are especially alarming. Thirteen children die per day in Zamzam camp in North Darfur, according to Doctors Without Borders, mostly due to undernutrition and food scarcity.
And nearly 800,000 Sudanese children will face severe, acute malnutrition through 2024, a condition that requires intensive care and supplemental nutrition merely to prevent death. Even before the conflict, children were severely threatened by a lack of access to care, including basic preventive care such as early immunization.
Finally, the transmission of communicable diseases thrives in conflicts like the one in Sudan, where there has been widespread population displacement, malnutrition, limited water and sanitation, and lack of appropriate sheltering. In August, a cholera outbreak led to a spiking death rate of more than 31 deaths per 1,000 cholera cases. And instances of such disease effects are likely underestimates in a country lacking health care penetration and monitoring.
The limitations of estimations
The massive internal displacement of more than 14 million people in Sudan complicates the estimation of death tolls, as shifting populations make establishing baselines nearly impossible.
Moreover, there is typically a dearth of official information collected and released during conflicts.
So establishing a concrete estimate of the true impact of armed conflict often comes after the cessation of hostilities, when expert teams are able to conduct field studies.
Even then, estimates will require assumptions about direct deaths, indirect-to-direct death ratio and the quality of existing data.
But as scholars working at the intersection of public health and human rights, we believe such work, however imperfect, is necessary for the documentation of conflict – and its future prevention. And while there are many current global conflicts that require our urgent attention, the conflict in Sudan must not be lost in the mix.
_Editor's note: Israa Hassan, a physical medicine and rehabilitation resident at Texas Rehabilitation Hospital-Fort Worth and advocacy director at the Sudanese American Physicians Association, contributed to this article.
(Authors: Sarah Elizabeth Scales, Post-Doctoral Researcher, Department of Environmental, Occupational, and Agricultural Health, University of Nebraska Medical Center; Blake Erhardt-Ohren, DrPH Candidate, University of California, Berkeley; Debarati Guha Sapir, Professor of Public Health, Université catholique de Louvain (UCLouvain); Khidir Dalouk, Assistant Professor of Medicine, Oregon Health & Science University, and Rohini J Haar, Faculty, Epidemiology Division, School of Public Health, University of California, Berkeley)
(Disclosure Statement: Rohini J Haar receives funding from FCDO. Blake Erhardt-Ohren, Debarati Guha Sapir, Khidir Dalouk, and Sarah Elizabeth Scales do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment)
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