The death toll in Sudan’s civil war is likely far higher than reported as violence, hunger and disease devastate Africa’s third-largest nation, a new study shows.

More than 61,000 people have died in Khartoum state, the capital region where fighting began 14 months ago, according to research from the London School of Hygiene & Tropical Medicine. Among the dead, over 26,000 were killed by violence – surpassing the United Nations’ nationwide count of 20,178 violent deaths reported by crisis monitor ACLED.

The death count in Khartoum, just one of Sudan’s 18 states, suggests official figures severely undercount the number of lives lost in what the UN and aid groups call the world’s worst humanitarian crisis.

Researchers found starvation and disease are the leading causes of death across most of the country, while violence claims the most lives in Kordofan and Darfur, where ethnically targeted attacks and intense fighting continue.

“Our findings reveal the severe and largely invisible impact of the war on Sudanese lives, especially preventable disease and starvation,” said Dr Maysoon Dahab, lead author of the report and infectious disease epidemiologist at LSHTM. “The overwhelming level of killings in Kordofan and Darfur indicate wars within a war.”

The war has transformed Sudan from Africa’s largest agricultural producer and regional breadbasket into a nation where 750,000 civilians now face famine conditions, driving 11 million people from their homes in what the UN calls the world’s largest displacement crisis. Half of Sudan’s population – 24.8 million people – now depends on aid to survive.

“Sudan is trapped in a nightmare,” Rosemary DiCarlo, UN Under-Secretary-General for Political Affairs, told the Security Council on Wednesday. “The people of Sudan need an immediate ceasefire.”

Healthcare collapse fuels rising death toll

The war’s deadliest long-term impact may be its destruction of Sudan’s health and sanitation services. Disease and starvation now account for about half of all deaths in Khartoum amid an acute health crisis sweeping the country, the study found.

Eight in ten hospitals in conflict zones have shut down, leading to a sharp rise in deaths from infectious, non-communicable, maternal, neonatal and nutritional diseases that researchers called “significant, unrecorded and largely preventable.”

An unusually heavy rainy season has fueled a severe cholera outbreak, with contaminated water driving more than 28,000 cases across 11 states, and a surge in dengue fever that has resulted in 12 confirmed deaths since July, according to the UN Office for the Coordination of Humanitarian Affairs (OCHA). 

Disease counts, like death tolls, represent only a fraction of the crisis, OCHA said. Millions remain cut off from care as outbreaks spread undetected beyond the reach of Sudan’s devastated health surveillance systems.

Half of Sudan’s population needs humanitarian assistance, yet aid remains out of reach for most. Aid groups “remain unable to reach the vast majority of people in conflict hotspots,” UN emergency coordinator Ramesh Rajasingham told the Security Council on Wednesday.

“Some areas are completely cut off,” Rajasingham said. “We urgently need the parties to ensure the safe, rapid, unimpeded movement of both relief supplies and humanitarian personnel via all available routes.”

‘Invisible’ deaths go uncounted

Sudan’s ability to count its dead has long been fragile, with no national census conducted in over a decade. Even Khartoum, the capital region, captured just 3-6% of COVID-19 deaths during the pandemic, researchers estimate.

The war has shattered this already weak system. Morgues and hospitals that typically record deaths are now inaccessible or offline, while military factions have weaponized telecommunications, implementing blackouts that further obstruct data collection.

More than 90% of deaths documented in the new study went unrecorded in official tallies. Sudan’s Health Ministry claims just 5,565 war-related deaths have occurred to date.

Dahab said while the team could not estimate mortality levels beyond Khartoum or determine total war-linked deaths nationwide, their assessment offers the first systematic mapping of death patterns during the conflict. 

“The number might even be more,” Abdulazim Awadalla, program manager for the Sudanese American Physicians Association, told Reuters. “Simple diseases are killing people.”

Foreign powers ‘enabling the slaughter’

The SAF and the RSF both think they can win the war in #Sudan, escalating operations, recruiting new fighters and intensifying attacks.
Some of their external backers, who provide weapons and other support, are enabling the slaughter. This must stop. https://t.co/4ainxmL5X1

— Rosemary A. DiCarlo (@DicarloRosemary) November 13, 2024

As disease, hunger and violence claim more lives, evidence mounts that foreign powers are intensifying and prolonging Sudan’s humanitarian catastrophe.

French weapons have been identified in the hands of the Rapid Support Forces (RSF), Amnesty International revealed Thursday, adding to a complex web of international involvement in the conflict.

“Our research shows that weaponry designed and manufactured in France is in active use on the battlefield in Sudan,” said Agnès Callamard, Amnesty International’s Secretary General. The weapons reached RSF through France’s defence partnership with the United Arab Emirates, which has emerged as a key backer of the paramilitary group.

“To put it bluntly, certain purported allies of the parties are enabling the slaughter in Sudan,” DiCarlo, the UN Under-Secretary-General for Political Affairs, told the Security Council. “Both warring parties bear responsibility for this violence.” 

A UN fact-finding mission released in September found both the RSF and government forces have committed potential war crimes and crimes against humanity. The RSF and allied militias face additional accusations of genocide and using mass rape as a weapon of war, particularly in Darfur.

Despite a UN arms embargo, weapons continue flowing to both sides through neighbouring countries, several of which, including Libya, Chad and the Central African Republic, are major arms trafficking hubs, UN experts say. 

While Egypt and Saudi Arabia back government forces, the UAE, Libya and Russian-linked Wagner Group support the RSF. The UAE has invested over $6 billion in Sudan since 2018, viewing the resource-rich nation as key to expanding its regional influence.

“All countries must immediately cease direct and indirect supplies of arms and ammunition to the warring parties,” Callamard said. “They must respect and enforce the UN Security Council’s arms embargo regime on Darfur before even more civilian lives are lost.”

Image Credits: @UNHCR, State of Air Quality and Health Impacts in Africa .