The complexities of conflict-induced severe malnutrition in Sudan

SUMMARY BOX.

• The Food and Agriculture Organization of the United Nations attributes food and nutrition crisis to ongoing conflict and economic deterioration, with forecasts indicating over 20.3 million Sudanese, exceeding 42% of the population, grappling with heightened acute food insecurity by September 2023.

• The conflict crisis has commanded to reduced service quality, escalating health risks and a surge in infectious diseases. Conflict has also disrupted nutritional services, exacerbating malnutrition cases.

• Children suffer the brunt of the malnutrition catastrophe, facing lifelong consequences. Urgent international interference is imperative to address conflict-induced displacement, control of food resources and the weaponisation of hunger practised from the conflict parties.

• Innovative, agile, collaborative efforts from international organisations, non-governmental organisations, and the global community with existing local governments and communities are critical in providing immediate humanitarian aid, rebuilding health and food security infrastructure, and implementing sustainable healthcare and food systems strategies through the humanitarian, development and peace nexus approach.

Background

Sudan, a nation gripped by persistent conflict since April 2023, is facing a humanitarian crisis that extends beyond the visible scars of war. The Food and Agriculture Organization of the United Nations issues a grave alert on Sudan’s deepening food crisis, attributing it to ongoing conflict and economic deterioration.¹ Latest Integrated Food Security Phase Clasification (IPC) projections reveal a dire scenario, with over 20.3 million Sudanese, exceeding 42% of the population, facing heightened acute food insecurity (IPC phase III or above) between July and September 2023.² This marks a nearly twofold increase since May 2022. Of grave concern, 14 million people are in Crisis (IPC phase III), and nearly 6.3 million in Emergency (IPC phase IV), with Khartoum, South and West Kordofan, and Central, East, South, and West Darfur particularly afflicted by active conflicts, where over half the population experiences acute hunger.² Forecasts for October 2023 to February 2024 indicate alarming food insecurity. Approximately 15 million may reach IPC phase III+, peaking during harvest season. Notably, Greater Darfur, Greater Kordofan and Khartoum anticipate the highest Crisis (IPC 3) and Emergency (IPC 4) cases.¹ Conflict-induced malnutrition is pervasive, affecting 3.4 million children under 5 years, with 690 000 severely malnourished. An additional 2.7 million children face moderate malnutrition, along with over a million pregnant and lactating women. The conflict jeopardises food security and healthcare access, and displaces families, exacerbating the crisis.³ Immediate, extensive interference is imperative to avert a humanitarian catastrophe. The consequences of the ongoing conflict are far-reaching, with severe malnutrition evolving as a silent epidemic, silently claiming lives, and compromising the well-being of the most vulnerable populations. This research commentary aims to shed light on the intricate linkages between severe malnutrition and the disrupted health system, and food system disruption in Sudan, emphasising the urgent need for comprehensive intervention strategies.

Sudan’s historical, political and economic situation

Sudan encompasses a Sahelian belt featuring a desert in the northernmost regions, alongside fertile terrain in the Nile valleys and the Gezira region. The nation’s expansive agricultural and food security capacity is distributed across its diverse landscape, extending from Darfur to Kassala, encompassing the states of Blue Nile and Kordofan. This unique geographical composition, comprising arable land and suitable conditions for farming and livestock, positions Sudan as a region with substantial potential for agricultural productivity and food security initiatives.⁴ For most of its independent history, Sudan has faced substantial internal conflict that has weakened its ability to play a leadership role in the region.⁴ Research conducted by the United Nations Environment Programme indicates that a minimum of 40% of internal conflicts within the last six decades can be attributed to the exploitation of natural resources. These resources range from high-value commodities like timber, diamonds, gold and oil to scarce resources such as fertile land and water.⁴ Persistently rising food prices and accumulated grievances spanning over three decades of governance sparked widespread protests, commencing in December 2018. The culmination of these demonstrations was the ousting of the then president, Omar Hassan El-Bashir, from office in April 2019. Subsequently, a transitional government emerged in September 2019, committed to implementing ambitious economic and social reforms. Furthermore, the government actively participated in peace negotiations with armed groups, aiming to tackle conflicts and address long-standing grievances throughout the nation.^{4 5} All those efforts have been dramatically vanished by the October 2021 military step-up, followed by the armed conflicts that erupted in April 2023 which pose intricate challenges for nations affected by them, presenting complexities that are often challenging to quantify or comprehend readily. These complexities encompass immediate consequences such as elevated mortality rates, widespread injuries, the plight of millions of refugees and internally displaced people, complete disruption of food systems, and substantial damage to healthcare infrastructure.⁶

The toll of ongoing conflict on health services

The protracted conflict in Sudan has severely undermined the country’s health infrastructure, rendering it incapable of providing even basic healthcare services. Hospitals and clinics have been damaged or forced to close, health personnel displaced and supply chains disrupted. Conflict has a profound impact on health services, jeopardising individual and community well-being.⁷ In Sudan, the doctors’ syndicate reports that over 70% of conflict-affected region hospitals have ceased operations as of May 2023, with 13 targeted by bombings and 19 forcibly evacuated.⁷ This ongoing conflict poses formidable challenges, disrupting healthcare delivery, destroying infrastructure and displacing healthcare workers, resulting in reduced service quality and accessibility.⁷

Impact on nutritional services

Malnutrition is not solely a consequence of food scarcity; it is exacerbated by the lack of adequate healthcare and nutrition services.⁸ With health facilities either closed or overwhelmed by the conflict, the delivery of essential services such as routine check-ups, nutritional counselling and therapeutic feeding programmes has become severely compromised. As a result, malnutrition cases have surged, with a disproportionate impact on children and pregnant women. According to the nutrition cluster in Sudan, nutrition services are facing a huge gap as 20% of stabilisation centres, 24% of outpatient therapeutic programmes (OTPs) and 66% of targeted supplementary feeding programmes are not operating, and with low OTP Internally displaced persons - IDP camps coverage in only 48%.^{7 9} The impediments to the extention of prevailing nutrition services coverage encompass serious issues such as conflict induced insecurity which limits the availability of health workers and hindering the expansion of the current nutrition services coverage. Adding to that, challenges include difficulties in paying salaries and allowances for nutrition health workers as well as bureaucratic hurdles, access to health facilities obstructions and heightened operational costs of OTP. Moreover, challenges are also notable in nutrition supplies transportation, reporting from those partially or fully operating facilities and limited provision of any supervision interventions.^{7 9}

The WHO is aiding the expansion of stabilisation centres in Sudan, addressing challenges posed by conflict-related constraints. Despite limited access and operational obstacles, WHO has distributed 517 paediatric kits to 91 stabilisation centres in 10 states, containing vital medicines and equipment. This initiative aims to treat and save the lives of 26 000 severely malnourished children, with additional supplies strategically positioned for further deployment.¹⁰ Children tolerate the brunt of the malnutrition crisis in Sudan. The impact on their physical and cognitive development is weighty, with lifelong consequences as studies showed.¹¹ Many researches underscore that conflict-affected children exhibit stunted growth in comparison to their counterparts born in non-conflict regions, as evidenced by studies conducted across various regional contexts.¹¹ Furthermore, an adverse impact on child weight at birth is noted when mothers experience exposure to conflict during pregnancy.^{11 12} Malnourished children are more susceptible to infections, and the lack of proper healthcare only amplifies the risks. The situation demands urgent attention, as the future of Sudan hinges on the well-being and potential of its youngest citizens.

Impact of conflict on food security

The ongoing conflict in Sudan has led to mass displacements, forcing communities to abandon their homes and livelihoods. Collier’s research reveals a 2.2% annual decline in gross domestic product per capita during civil wars, with the agrarian sector experiencing heightened physical destruction compared with other sectors.¹³ The correlation between food insecurity and violent conflict is intricate, often linked to multilayered crises involving terrorist groups, small arms proliferation, criminal networks and state fragility.¹⁴ Violent conflicts not only lead to food shortages and starvation but also inflict substantial short-term and long-term repercussions on nutritional status.¹⁵ The findings underscore the complexity and contextualisation inherent in understanding the relationships between economic decline, conflict and food insecurity.¹⁵ Displaced populations are particularly vulnerable to malnutrition due to the loss of access to food sources, disrupted livelihoods and inadequate shelter. Moreover, displacement often leads to unsanitary living conditions, increasing the risk of infectious diseases that further exacerbate malnutrition.^{15 16} The ongoing conflict in Sudan has led to loss of lives and disruption of vital resources, impacting agriculture, trade and infrastructure. Khartoum faces economic distress, with internal trade disruption and an impending economic crisis. Climatic forecasts predict reduced rainfall, posing risks to crop and livestock conditions, further threatening food security.^{4 16 17} Although climate change and conflict lack a direct causal link, understanding their intricate relationship involves direct effect on livelihood deterioration, migration and mobility, involvement of military and armed actors, and political and economic exploitation and mismanagement.¹⁷ The ramifications of conflict currently happening in Sudan encompass destructive outcomes, such as conflict-induced displacement, control of food resources by warring factions and the weaponisation of hunger.¹⁸

Recommendations

The food security predicament in Sudan is characterised by a critical state, impacting 20.3 million individuals who confront food insecurity. Predominant contributors to food insecurity in Sudan include conflict, economic downturn and the influence of climate change. Policy recommendations stemming from the food security crisis advocate for heightened investment in agriculture, the establishment of social safety nets, legislative framework enhancements and financial provision.^{19 20} Collaborative efforts with the Sudanese government and the international community with strong internally displaced community stewardship are also imperative to address the underlying causes of the food security crisis. A joint effort must underscore the significance of data-driven methodologies in addressing food security issues.^{21 22} Using data facilitates the monitoring of fluctuations in cropland area and productivity, the surveillance of food commodity prices, tracking of population and goods movements, and prediction of droughts and floods.²³ Furthermore, the integration of artificial intelligence holds the potential to revolutionise Sudanese agriculture by augmenting productivity, diminishing costs, predicting conflicts and political instability consequences, and advancing sustainability.^{23 24} Furthermore, a multifaceted approach involving policies and interventions is deemed requisite to redress the food security crisis in Sudan. Effectively tackling food security in Sudan necessitates comprehensive and sustainable solutions, with emphasis on fostering peace and stability, investing in climate-resilient agriculture, expanding irrigation infrastructure, augmenting agricultural extension services, providing financial support to farmers, improving market accessibility, and intensifying investments in research and development.^{23 24} This must be coupled with addressing severe malnutrition in Sudan through a comprehensive approach. Moreover, it is imperative for international organisations, non-governmental organisations and the global community to collaborate in providing immediate humanitarian aid, encompassing food assistance, medical supplies and personnel. The focus of efforts should extend to rebuilding health infrastructure, ensuring the availability of essential services, and implementing sustainable, long-term healthcare strategies in conflict zones.

Conclusion

The severe malnutrition crisis unfolding in Sudan—like many other conflict-affected countries—is not a stand-alone issue; it is intrinsically linked to the strain situations in the country due to the protracted emergencies and the already existing complexities with the ongoing conflict and the resultant disruption of food availability and health services delivery.²⁵ Urgent international intervention is needed to break this vicious cycle, providing immediate relief, and working towards rebuilding a robust and sustainable healthcare system, which must be linked with improving agricultural productivity, investing in malnutrition reduction, providing emergency food assistance, and supporting families in growing resilient agricultural social enterprises that have the needed agility to deal with political instability and the ongoing conflict consequences on the national economy. The fate of countless lives, particularly the children of Sudan, hangs in balance, calling for concerted efforts to alleviate their suffering and pave the way for a healthier and further resilient nation. As the world looks on, the plight of the Sudanese people serves as a stark reminder of the interconnectedness between conflict, food insecurity, climate change, healthcare and the well-being of nations. The time for action is now, as the consequences of inaction resonate far beyond the borders of Sudan.

Data availability statement

Data are available in a public, open access repository.

Ethics statements

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