BACKGROUND

While the relationship between conflict-associated injuries and antimicrobial resistance is increasingly being elucidated, data concerning civilian casualties is sparse. This systematic review assesses literature focused on Global Antimicrobial Resistance Surveillance System (GLASS) Priority Pathogens causing infections in civilian wounds and burns in conflict-affected countries within the World Health Organisation's Eastern Mediterranean Region Office (EMRO)

METHODS

 A systematic literature review was conducted following Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Five databases and grey literature were searched, identifying studies published from January 2010 to June 2024. Search terms included "wounds", "burns," "antimicrobial resistance", and the twelve countries of interest. Included studies reported resistance of GLASS pathogens. Two reviewers used Covidence to assess papers for inclusion. Data were extracted into a spreadsheet for analysis. Where quantitative data were available, medians, interquartile ranges and percentages were calculated by pathogen and country.

RESULTS

621 records were identified; 19 studies met inclusion criteria. Nine of the papers were from Iraq, three from Libya, three from Lebanon, one each from Yemen and Gaza; two reported on conflict affected refugees in Jordan. A total of 1,942 distinct microbiological isolates were reported, representing all four critical and high priority GLASS pathogen categories. Among the isolates, Staphylococcus aureus was the most prevalent (36.3%). Median resistances identified: Methicillin resistant Staphylococcus aureus (n = 680): 55.6% (IQR:49.65-90.3%); carbapenem resistant Pseudomonas aeruginosa (n = 372): 22.14% (7.43-52.22%); carbapenem resistant Acinetobacter baumannii (n = 366): 60.3% (32.1-85%); carbapenem resistant Klebsiella pneumoniae (n = 75): 12.65% (9.73-34.25%); ceftriaxone resistant Escherichia coli (n = 63): 76% (69-84.65%); ceftriaxone resistant Klebsiella pneumoniae (n = 40): 81.45% (76.73-86.18%). Only three studies had a low risk of bias.

DISCUSSION

Findings imply high rates of GLASS priority pathogens among wounded civilians in conflict-affected EMRO countries. However, evidence was heterogeneous, low quality and sparse in certain countries, highlighting the necessity of effective surveillance including standardised data collection. Improving primary data will facilitate the production of large, high-quality studies throughout the EMRO, including under-represented countries.

Conclusion: Laboratory diagnostic capacity building and improved surveillance in conflict-affected settings in the Eastern Mediterranean Region are required to assess the burden of GLASS priority pathogens in vulnerable non-combatant populations.

AIM

Assess the microbiology and treatment outcomes of post-traumatic osteomyelitis (PTO) patients in Medecins Sans Frontieres (MSF) supported reconstructive surgical facilities in Gaza, pre-October 7, 2023, and identify recurrence risk factors.

BACKGROUND

PTO is common among war-wounded in conflict-affected settings in the Middle East. The ongoing war in Gaza since October 2023, has severely disrupted healthcare, increasing suspected and sub-optimally treated PTO, and related literature is scarce.

METHODS

Two-centre retrospective cohort study including PTO patients diagnosed by microbiological confirmation via bone biopsy and treated between December 6, 2018 and September 8, 2021, with follow-up until January 31, 2022. Differences between multi-drug resistant (MDR) and non-MDR, polymicrobial and monomicrobial PTO were assessed. Predictors of recurrence were identified using cox proportional hazards multivariate regression.

RESULTS

202 patients with 275 PTO episodes and 441 isolates were included. MDR was present in 53% of episodes; 43% episodes were polymicrobial; recurrence occurred in 26%. Twenty patients (10%) underwent amputation. Staphylococcus aureus was the most prevalent (35%) isolate (62% methicillin-resistant), followed by 13% Enterobacterales (59% extended-spectrum beta-lactamase producers), 10% Pseudomonas aeruginosa and 3% Acinetobacter species. The 6-month survival (recurrence-free) probability was 79% (95% CI: 73-86) decreasing to 56% (95% CI: 47 - 68) by 24 months. Significant risk factors of recurrence included up to 3 procedures, fibula fractures, PTO with Enterobacter cloacae or Staphylococcus aureus.

CONCLUSIONS

Managing PTO in Gaza is complex. Rebuilding the healthcare system, strengthening local capacities, ensuring access to necessary resources are essential for the long-term management of PTO in Gaza.

BACKGROUND

Conflict-related sexual violence (CRSV) is a significant health and human rights issue in humanitarian contexts, but there is a need of further research on differences between sexes in terms of severity of symptoms and improvement. Consequently, we explored the differences in severity and outcomes among male and female survivors of CRSV who received mental health and psychosocial support (MHPSS) in an armed conflict setting.

METHODS

We retrospectively analysed medical records from 3442 CRSV survivors in a MHPSS programme in Borno State, Nigeria, between 2018 and 2019. Patient characteristics, severity (measured with Clinical Global Impression of Severity Scale [CGI-S scale]), and improvement (measured with Clinical Global Impression of improvement [CGI-I] scale) were assessed by an attending counsellor. We assessed predictors for severity and improvement using a multivariable logistic regression analysis and time to improvement by sex using Kaplan Meier (K-M) curves and Cox regression.

RESULTS

We included 3442 patients who had at least one CRSV event in this study (2955 [85.9%] female, 486 [14.1%] male, one unknown). The most prevalent categories of symptoms were depression (49.9%; n = 1716), post-traumatic (25.6%; n = 879), and anxiety (20.3%; n = 697) symptoms. Most patients had mild (59.0%; n = 1869/3170) or moderate (36.4%; n = 1153/3170) symptoms at baseline, with 4.7% having severe symptoms (n = 148/3170). The logistic regression analysis (n = 1106), showed male patients had a 59% higher odds of severe symptoms at baseline than female patients (aOR 1.59; 95% CI 1.04-2.45). Among males, those older than 55 years had three times higher odds of presenting severe symptoms than younger patients (aOR 3.65; 95% CI 1.43-9.34). Women aged 36-55 years were more likely to present improvement than younger female patients (aOR 1.32; 95% CI 1.11-1.58). For both sexes, prompt attention after a CRSV event (≤ 3 days) positively predicted improvement (aOR 13.9; 95% CI 1.48-130 males, aOR 2.11; 95% CI 1.22-3.64 females) compared to late attention. Time to improvement did not differ between sexes, with an average of at least three consultations needed to achieve improvement.

CONCLUSIONS

Our study suggests that psychological attention of survivors within the first 72 h should be a priority. MHPSS programmes addressing CRSV should be inclusive to all patients, and gender-neutral approaches to ensure access, safety, confidentiality, and non-discrimination for all survivors should be developed.

BACKGROUND

The history of conflicts in the Middle East has resulted in a high burden of complications from conflict-related wounds like posttraumatic osteomyelitis (PTO). This is particularly challenging to manage in settings like Mosul, Iraq and Gaza, Palestine, where healthcare systems are weakened. In nonconflict settings, PTO caused by Pseudomonas aeruginosa (PAPTO) can lead to >20% of treatment failures. We aim to describe the clinical characteristics, outcomes, and management, in PAPTO patients admitted to Médecins Sans Frontières (MSF) facilities in Mosul and Gaza between 1 April 2018 and 31 January 2022.

METHODS

We conducted a retrospective cohort study on patients with PAPTO diagnosed with culture of intraoperative bone biopsy, using routinely collected data.

RESULTS

Among 66 PAPTO episodes from 61 enrolled patients, 37.9% had a multidrug-resistant Pseudomonas aeruginosa, with higher antibiotic resistance in Gaza. Polymicrobial infections were prevalent (74.2%), mainly involving Staphylococcus aureus (74.1%), being predominantly methicillin-resistant (95.0%). Overall, 81.7% received appropriate antibiotic treatment, with monotherapy used in 60.6% of episodes and a median treatment duration of 45.5 days. Recurrence was observed in 24.6% of episodes within a median of 195 days (interquartile range, 64-440 days). No significant differences were found in recurrence rates based on the type of antibiotic treatment (mono- or dual therapy) or episode (mono- or polymicrobial).

CONCLUSIONS

Management of PAPTO in the conflict-affected, low-resource settings of Mosul and Gaza achieved a recurrence rate aligned with global reports through appropriate and targeted antibiotic use, primarily in monotherapy, provided over a mean treatment duration of 45.5 days.

The consequences of over a year of full-blown conflict on the health and wellbeing of people in Sudan are disastrous. The population has faced horrendous levels of violence, succumbing to widespread fighting and surviving repeated attacks, abuse, and exploitation by the Sudanese Armed Forces (SAF) and the Rapid Support Forces (RSF). Drawing on medical and operational data collected from April 15, 2023, to May 15, 2024, this report highlights the patterns of violence observed by our teams, the features of abuse characterising this conflict, and the ensuing health consequences for affected populations.

In active conflict areas in Khartoum and across Darfur states, MSF supports the few remaining hospitals and emergency wards functioning in Sudan. Our teams treat thousands of war-wounded patients in locations affected by crossfire, large-scale bombing, and shelling where homes, health facilities and essential infrastructure were hit, destroyed, and made inoperable. From August 15, 2023, to April 30, 2024, the Al Nao hospital in Omdurman – one of the eight facilities MSF supports in Khartoum state – admitted a total of 6,776 war wounded patients, on average 26 war wounded patients per day, for gunshot (53%), shrapnel (42%), and stabbing wounds (5%). At least 399 of them died from their injuries. Women and children have not been spared, comprising almost 30% of the 624 war-wounded treated – in March 2c024 alone. From May 2023 to April 2024, MSF teams in Bashair Teaching Hospital in Khartoum treated 4,393 patients presenting with trauma related injuries, corresponding to 42% of all Emergency department consultations across the period of analysis.

Across Sudan, people’s access to lifesaving care has been drastically affected due to critical shortages, widespread obstruction and looting of medical supplies, insecurity and attacks against patients and medical staff, breaches of medical protocols in hospitals, and structural damages to healthcare infrastructure. Al-Nao Hospital was hit by shells on three separate occasions in August, October, and June 2024, leading to a reduction in the availability of lifesaving services. In July 2023, a healthcare worker of the MSF-supported Al-Saudi Maternity Hospital was shot dead inside the maternity ward, leading to the closure of the facility. Nowhere is safe for populations trapped in Sudan’s conflict hotspots, forcing millions to flee.

In the camps and gathering sites where refugees and displaced populations seek safety, MSF patients recount horrific stories of inhuman treatment and violence perpetrated by armed groups on the civilian population. People’s accounts describe systematic cases of forced eviction, looting and arson, degrading interrogation, arbitrary arrest, abduction and torture – all against the backdrop of heightened suspicion around those attempting to flee and reach safer areas.

Sexual and gender-based violence is pervasive but critically underreported due to stigma, silence for fear of retaliation, and the void in protection services and confidential spaces conducive to disclosure. Data from MSF facilities supporting Sudanese refugees in Chad hint at the widespread use of sexual violence as a form of warfare, particularly targeting women and girls. Between July and December 2023, 135 survivors turned to our teams in Adre (Chad), disclosing cases of rape, abduction, and exploitation perpetrated in Sudan during the conflict. In 90% of cases, perpetrators were armed men.

In Western Darfur, violence has taken an ethnic dimension, targeted against the Masalit tribe, and has included forced displacement, unlawful killing, and other forms of inhuman treatment reportedly by the RSF and affiliated groups. In June 2023, MSF teams in Chad treated over 800 war-wounded patients in three days, most of them Masalit having fled El Geneina city and its surroundings. A retrospective mortality survey conducted by MSF between August and September 2023 in three Sudanese refugee camps in Chad showed excess mortality across the camps; Ourang camp observed a 20-fold increase in mortality rates from April 2023 onwards with a peak in June, compared to pre-crisis rates. Additionally, an MSF survey conducted in South Darfur in February-March 2024 indicated excess crude mortality rates and found that in north Nyala, the conflict is leading to a doubling of the crude mortality rate (CMR), especially during heavy fighting in October 2023.

More than a year of full-blown conflict has had disastrous consequences on the health and wellbeing of people in Sudan. The physical and mental wounds of violence have been exacerbated by the collapse of the health system and the paucity of the international humanitarian response. MSF teams continue to treat people dying from preventable complications because they were unable to reach any facilities earlier or afford medicine, if available. MSF mental health teams are seeing the tremendous toll of conflict and violence on people’s mental health and psychological wellbeing, with widespread trauma-related symptoms sometimes leading patients to self-harm.

As MSF continues to respond to urgent medical needs and the consequences of ongoing violence, further exacerbated by lack of humanitarian access and the warring parties’ blatant disregard for human life and international humanitarian law (IHL), MSF calls for:

• Warring parties to cease attacks on residential neighborhoods, allow safe passage and routes for people seeking protection, and protect vital infrastructure from further destruction and looting;
• Warring parties to stop all targeted forms of violence and abuse against populations and ensure that ethnic violence and sexual and gender-based violence are not used as weapons of war;
• Warring parties to immediately facilitate aid; allow unhindered humanitarian access and ensure supplies and staff reach those in need; assistance must be able to reach people in need across borders and front lines.
• Vested partner states and regional bodies to increase pressure on the warring parties in Sudan to abide by their obligations regarding civilian protection and hold those violating civilian protections to account;
• The United Nations to repeat and amplify messages regarding the promotion and respect of international humanitarian and human rights laws, increase field presence of UN senior staff, and ensure that protection responses are scaled up and adequately coordinated;
• Humanitarian organisations to scale up programming and adapt the response across all sectors to the complexity of the operational context in Sudan.

كارثية هي العواقب المترتبة على أكثر من عام من النزاع الشامل على صحة الناس في السودان. حيث واجه السكان مستويات مروعة من العنف، وعانوا من قتال واسع النطاق ونجوا من الهجمات المتكررة والانتهاكات والاستغلال من قبل القوات المسلحة السودانية وقوات الدعم السريع. وبالاعتماد على البيانات الطبية والتشغيلية التي جُمِعت في الفترة الواقعة ما بين 15 أبريل/نيسان 2023 حتى 15 مايو/أيار 2024، يسلّط هذا التقرير الضوء على أنماط العنف التي لاحظتها فرقنا، وسمات الانتهاكات التي تشكل هذا النزاع، والعواقب الصحية المترتبة على السكان المتضررين.

وفي مناطق النزاع النشطة في الخرطوم وفي جميع أنحاء ولايات دارفور، تدعم أطباء بلا حدود المستشفيات وأجنحة الطوارئ القليلة المتبقية العاملة في السودان. وتعالج فرقنا الآلاف من جرحى الحرب في المواقع المتضررة من تبادل إطلاق النار والقصف واسع النطاق حيث تعرضت المنازل والمرافق الصحية والبنية التحتية الأساسية للقصف والتدمير وأصبحت غير صالحة للعمل. وفي الفترة ما بين 15 أغسطس/آب 2023 وحتى 30 أبريل/نيسان 2024، استقبل مستشفى النوّ في أم درمان - وهو أحد المرافق الثمانية التي تدعمها أطباء بلا حدود في ولاية الخرطوم - ما مجموعه 6,776 جريح حرب، أيّ بمتوسط 26 جريح حرب يوميًا، بسبب الطلقات النارية (53 في المئة)، والشظايا (42 في المئة)، وعمليات الطعن (5 في المئة). وتوفي ما لا يقل عن 399 منهم متأثرين بجراحهم. ولم يسلم النساء والأطفال، الذين يشكلون ما يقرب من 30 في المئة من جرحى الحرب البالغ عددهم 624 جريحًا في شهر مارس/آذار 2024 وحده. وفي الفترة ما بين مايو/أيار 2023 وحتى أبريل/نيسان 2024، عالجت فرق أطباء بلا حدود في مستشفى بشائر التعليمي في الخرطوم 4,393 مريضًا يعانون من الإصابات البالغة، أيّ ما يعادل 42 في المئة من جميع استشارات قسم الطوارئ خلال فترة تحليل البيانات.

تأثرت إمكانية حصول الناس على الرعاية المنقذة للحياة بشكل كبيرفي جميع أنحاء السودان بسبب النقص الحاد في التزويدات الطبية، وعرقلة إيصال الإمدادات الطبية على نطاق واسع بالإضافة إلى نهبها، وانعدام الأمن والهجمات ضد المرضى والطاقم الطبي، وانتهاكات البروتوكولات الطبية في المستشفيات، والأضرار الهيكلية التي لحقت بالبنية التحتية للرعاية الصحية. وقد تعرّض مستشفى النّو للقصف في ثلاث حوادث منفصلة في أغسطس/آب وأكتوبر/تشرين الأوّل 2023 ويونيو/حزيران 2024، ممّا أدى إلى نقص في إمكانية توفير الخدمات المنقذة للحياة. وفي يوليو/تموز 2023، قُتل أحد العاملين في الرعاية الصحية في المستشفى السعودي للتوليد الذي تدعمه أطباء بلا حدود بالرصاص داخل جناح الولادة، ممّا أدى إلى إغلاق المرفق. وهكذا فلا يوجد أيّ مكان آمن للسكان المحاصرين في مناطق النزاع الساخنة في السودان، ممّا أجبر الملايين على الفرار.

وفي المخيمات ومواقع التجمّع التي يبحث فيها اللاجئون والنازحون عن الأمان، يروي مرضى أطباء بلا حدود قصصًا مروعة عن المعاملة اللاإنسانية والعنف الذي ترتكبه الجماعات المسلحة ضد السكان المدنيين. وتصف روايات الناس حالات ممنهجة من الإخلاء القسري، والنهب والحرق العمد، والاستجواب المهين، والاعتقال التعسفي، والاختطاف والتعذيب - كل ذلك على خلفية الشكوك المتزايدة حول أولئك الذين يحاولون الفرار والوصول إلى مناطق أكثر أمانًا.

ينتشر العنف الجنسي والعنف القائم على النوع الاجتماعي،ولكن لا يُبلَّغ عنهما بشكل كبير بسبب الوصمة والصمت خوفًا من الانتقام وغياب خدمات الحماية والمساحات السرية التي تساعد على الإفصاح. وتشير البيانات الواردة من مرافق أطباء بلا حدود التي تدعم اللاجئين السودانيين في تشاد إلى انتشار استخدام العنف الجنسي كشكل من أشكال الحرب، ولا سيما ضد النساء والفتيات. وفي الفترة ما بين يوليو/تموز وديسمبر/كانون الأول 2023، لجأ 135 ناجية وناجيًا إلى فرقنا في أدري (تشاد)، وكشفوا عن حالات اغتصاب واختطاف واستغلال ارتكبت في السودان أثناء النزاع. وفي 90 في المئة من الحالات، كان الجناة رجالاً مسلحين.

وحسبما أفادت التقارير، اتخذ العنف بعدًا عرقيًا في غرب دارفور، واستهدف قبيلة المساليت، وشمل التهجير القسري، والقتل غير القانوني، وأشكالًا أخرى من المعاملة اللاإنسانية على يد قوات الدعم السريع والجماعات التابعة لها. وفي يونيو/حزيران 2023، عالجت فرق منظمة أطباء بلا حدود في تشاد أكثر من 800 جريح حرب في ثلاثة أيام، معظمهم من المساليت الذين فروا من مدينة الجنينة والمناطق المحيطة بها. وأظهرت دراسة مسحية للوفيات بأثر رجعي أجرتها أطباء بلا حدود بين أغسطس/آب وسبتمبر/أيلول 2023 في ثلاثة مخيمات للاجئين السودانيين في تشاد زيادة في الوفيات في جميع أنحاء المخيمات؛ وشهد مخيم أورانغ زيادة بمقدار 20 ضعفًا في معدلات الوفيات منذ أبريل/نيسان 2023 فصاعدًا وبلوغ ذروتها في يونيو/حزيران، مقارنة بمعدلات ما قبل الأزمة. بالإضافة إلى ذلك، أشارت دراسة مسحية أجرتها أطباء بلا حدود في جنوب دارفور في فبراير/شباط ومارس/آذار 2024 إلى زيادة معدلات الوفيات ، وتوصلت أيضًا إلى أنّ النزاع في شمال نيالا أدى إلى مضاعفة معدل الوفيات الخام، خاصة أثناء القتال العنيف في أكتوبر/تشرين الأول 2023.

وأسفر النزاع الشامل الذي بدأ منذ أكثر من عام عن عواقب وخيمة على صحة الناس في السودان وسلامتهم. وقد تفاقمت الجروح الجسدية والنفسية الناجمة عن العنف بسبب انهيار النظام الصحي وندرة الاستجابة الإنسانية الدولية. وفي هذا السياق، تواصل فرق أطباء بلا حدود علاج الأشخاص ممن يفقدون حياتهم بسبب مضاعفات يمكن الوقاية منها لأنهم لم يتمكنوا من الوصول إلى المرافق في وقت مبكر أو شراء الأدوية، إذا كانت متوفرة. وتشهد فرق الصحة النفسية التابعة لأطباء بلا حدود الخسائر الهائلة الناجمة عن النزاع والعنف على الصحة النفسية للأشخاص وسلامتهم النفسية، حيث تؤدي الأعراض المرتبطة بالصدمة المنتشرة على نطاق واسع أحيانًا إلى إيذاء المرضى لأنفسهم.

مع استمرار أطباء بلا حدود في الاستجابة للاحتياجات الطبية العاجلة وعواقب العنف المستمر، والتي تفاقمت بسبب عدم وصول المساعدات الإنسانية وتجاهل الأطراف المتحاربة الصارخ للحياة البشرية والقانون الدولي الإنساني، تدعو أطباء بلا حدود إلى:

• وقف الأطراف المتحاربة الهجمات على الأحياء السكنية، والسماح بالمرور الآمن وضمان الطرق الآمنة للأشخاص الذين يبحثون عن الحماية، وحماية البنية التحتية الحيوية من تعرضها لمزيد من التدمير والنهب؛

• وقف الأطراف المتحاربة جميع أشكال العنف والإساءة الموجهة ضد السكان وضمان عدم استخدام العنف العرقي والعنف الجنسي والعنف القائم على النوع الاجتماعي كأسلحة حرب.

• تسهيل الأطراف المتحاربة إتاحة المساعدات على الفور؛ والسماح بوصول المساعدات الإنسانية من دون عوائق وضمان وصول الإمدادات والموظفين إلى المحتاجين؛ ويجب إتاحة وصول المساعدات إلى المحتاجين عبر الحدود وخطوط المواجهة.

• زيادة الدول الشريكة والهيئات الإقليمية الضغط على الأطراف المتحاربة في السودان لاحترام التزاماتها في ما يتعلّق بحماية المدنيين ومحاسبة من ينتهكون حقوق الإنسان ومبادئ حماية المدنيين.

• تكرار الأمم المتحدة الرسائل المتعلقة بتعزيز واحترام القانون الدولي الإنساني وقانون حقوق الإنسان وتضخيمها، وزيادة الحضور الميداني لكبار مسؤولي الأمم المتحدة، وضمان رفع مستوى استجابات الحماية وتنسيقها بشكل مناسب؛

• توسيع المنظمات الإنسانية نطاق البرامج وتكييف الاستجابة في جميع القطاعات مع درجة تعقيد السياق التشغيلي

BACKGROUND

Fighting erupted on 15 April 2023 in Sudan between the army and the paramilitary Rapid Support Forces. By September 2023, more than 420,000 people had fled to Chad. To describe the health status of the displaced populations in camps in eastern Chad, several surveys were realised. We describe retrospective crude and under five mortality rates, reported causes of death and frequency and type of violence events experienced by displaced populations in three camps in eastern Chad.

METHODS

Cross-sectional surveys were carried out in August and September 2023 in Toumtouma, Ourang and Arkoum camps. Each survey included retrospective mortality and frequency and type of violent events experienced. All surveys considered a pre-crisis and crisis phase.

RESULTS

In all sites, the crude mortality rate (CMR) was significantly higher in the crisis phase than in the pre-crisis phase. The CMR was particularly elevated in Ourang camp (CMR: 2.25 deaths/10,000 people/day [95% CI: 1.77 - 2.74] in the crisis phase versus CMR: 0.11 deaths/10,000 people/day [95% CI: 0.02 - 0.20] in the pre-crisis phase). Violence was the leading self-reported cause of death in all sites. Among households in Ourang, more than 90 percent originating from El Geneina, more than 1 in 10 of all men aged 30 and over died of violent causes. In Toumtouma, Ourang and Arkoum camps, the overall frequency of violence among households was 3.3%, 11.7% and 4.4% respectively, with beatings and shooting most frequently cited.

CONCLUSIONS

In the three camps investigated, excess mortality was observed among households during the crisis phase, with excess mortality primarily linked to violence among men. The population in Ourang camp, largely from El Geneina, appears to have been particularly affected by the violence, with CMR 20 times higher than in the pre-crisis period and mortality rates exceeding the standard emergency threshold (1 death/10,000 people/day).

KEY MESSAGE

Several cross-sectional surveys were carried out among displaced populations arriving in Chad. We provide epidemiological evidence of the high rates of mortality and violence since the start of the conflict in Sudan.