Nairobi — Limited Access to Water, Electricity, Medical Care Fuels Humanitarian Crisis
The two warring armed forces in Sudan have repeatedly used explosive weapons in urban areas that have caused loss of civilian life and property, damaged critical infrastructure, and left millions without access to basic necessities, Human Rights Watch said today. The United Nations Security Council should urgently adopt measures to deter abuses and act to hold those responsible to account.
On April 15, 2023, fighting broke out in the capital, Khartoum, between the country’s military, the Sudan Armed Forces (SAF), and the Rapid Support Forces (RSF), an autonomous force. Sudan’s military and the RSF have used explosive weapons with wide-area effects in populated areas–including tanks, artillery, rockets, and air-delivered munitions in the case of the SAF–that frequently result in indiscriminate attacks in violation of the laws of war. Many civilians in Khartoum and elsewhere have been forced to remain in their homes, enduring water and power shortages in sweltering heat, and lacking access to medical care. Many hospitals and other medical facilities have had to close.
“Sudan’s warring armies are showing reckless disregard for civilian lives by using inaccurate weapons in populated urban areas,” said Mohamed Osman, Sudan researcher at Human Rights Watch. “Rockets, bombs and other types of explosive weapons are killing and wounding civilians and damaging infrastructure critical for access to water and medical care.”
The outbreak of hostilities followed weeks of mounting tensions between the army chief, Gen. Abdelfattah al-Burhan, and the RSF leader, Gen. Mohamed Hamdan Dagalo (“Hemedti”), who together led a coup against Sudan’s transitional government in October 2021. The fighting quickly spread to Khartoum’s adjoining cities of Omdurman and Bahri–a metropolitan area of 6.5 million inhabitants–as well as provincial towns including El Fasher, Nyala and then El Geneina in Darfur and El Obeid in North Kordofan.
Black smoke rises above Khartoum on April 19, 2023 during fighting between Sudan’s military and Rapid Support Forces. © 2023 Footage by AFPTV via Getty Images
Between April 15 and April 30, Human Rights Watch interviewed by phone 23 people, including residents, medical professionals, and aid workers from Khartoum, Nyala, and El Obeid. Human Rights Watch also verified 10 videos showing the Sudan military and RSF using explosive weapons in populated areas in the greater Khartoum area. Human Rights Watch further analyzed satellite imagery and four videos and eight images showing apparent attacks on healthcare facilities and a water treatment plant.
The fighting in Sudan has resulted in hundreds of civilian casualties. The UN reported on May 2 that at least 528 people had been killed and 4,599 injured. Doctors told Human Rights Watch that hospitals only record those who die in hospitals or whose bodies are brought in, resulting in death tolls that are no doubt well below the actual number. Neither party to the conflict appears to have taken possible measures to minimize harm to civilians, whether conducting attacks or deploying their forces as required by international humanitarian law.
The fighting appears to have damaged many homes and other civilian objects. Attacks on Khartoum’s water systems have cut swathes of the city off the grid. Parts of Bahri were cut off from water when a massive fire shut down the water treatment plant on the first day of fighting. Water authorities reported that forces had repeatedly prevented them from accessing the plant due to insecurity, hampering repairs.
A residential building on Sittin Street in Khartoum sustained heavy damage during fighting in Sudan, April 21, 2023. © 2023 Footage by Mahmoud Haggag Mahmoud Ali/Anadolu Agency via Getty Images
The fighting has damaged at least 16 hospitals, while dozens of others have had to shut down due to lack of supplies, water, electricity, and staff. On April 18, two aerial bombs hit one of Khartoum’s largest public hospitals, El Shaab, forcing the hospital staff to evacuate the patients. Only the Sudan military is known to possess and operate SAF aircraft in Khartoum.
A doctor in Khartoum said on April 28 that major hospitals continued to function with only their remaining medical stocks.
In Nyala in Darfur, heavy fighting has resulted in hundreds of civilian casualties, primarily with gunshot wounds. Over several days, unidentified armed groups attacked, looted, and then burned the town’s main medical storage facility. A doctor said the fighting had overwhelmed the town’s three already-depleted hospitals: “We have an acute shortage of medication as the medical supplies were all looted and burned. The streets are unsafe, so doctors and patients cannot move freely.”
Since the beginning of the armed conflict, hundreds of thousands of Sudanese have fled to other parts of Sudan or to neighboring Egypt, Chad, South Sudan, and Central African Republic. A 34-year-old woman said she finally decided to leave her home in Khartoum following days of continuous attacks in her neighborhood: “You either stay at home with little or no electricity or water and risk having your house bombed, or take your chances driving to a safer place, still risking being caught in crossfire.”
Hundreds of foreign diplomatic staff and UN and other aid officials have evacuated Sudan by land and air. The limited international presence will affect the delivery of humanitarian aid and the monitoring of the warring parties’ abuses, Human Rights Watch said.
The SAF and the RSF have long records of serious violations of international humanitarian and human rights law. Both sides should abide by the laws of war, including the prohibition on indiscriminate attacks, take all feasible measures to reduce civilian harm and allow the safe movement of civilians, treat everyone in custody humanely, and facilitate humanitarian access to people in need, Human Rights Watch said.
Sudan’s regional and international partners, the African Union Peace and Security Council, and the UN Security Council should adopt concrete measures to reduce harm to civilians, including an arms embargo and targeted sanctions. The UN Human Rights Council, which has been silent on the conflict, should hold a special session and create a mechanism to gather and preserve evidence of crimes under international law for possible future prosecutions.
The parties to the non-international armed conflict in Sudan are bound by international humanitarian law, known as the laws of war, which can be found in the Geneva Conventions of 1949 and customary international law. A fundamental principle of the laws of war is that parties must distinguish between combatants and civilians at all times. Parties may not make civilians and civilian objects the deliberate object of attacks or conduct attacks that fail to discriminate between combatants or civilians or would disproportionately harm civilians. Warring parties are required to take all feasible precautions to minimize harm to civilians and civilian objects. International human rights law also remains applicable.
Individuals who commit serious violations of the laws of war with criminal intent, that is deliberately or recklessly, can be held liable for war crimes. Commanders who knew or should have known about abuses by their forces and failed to stop them or punish those responsible can be prosecuted as a matter of command responsibility.
“UN and African bodies urgently need to put pressure on the warring forces to abide by international law and ensure everyone has access to aid and medical care,” Mohamed Osman said. “To keep a bad situation from getting worse, it’s critical for the Security Council to block all arms transfers to Sudan, ensure reporting on abuses, and create a mechanism to help bring those responsible for serious crimes to justice.”
Deployment of Forces in Populated Areas
To the extent feasible, forces must avoid deploying near densely populated areas, and endeavor to remove civilians from the vicinity of military objectives.
A Khartoum resident said that RSF fighters deployed in front of her house, which is a 5 to 10-minute drive from the international airport. She described the fighting during the first few days as “unrelenting.” “Just outside my building was an [anti-aircraft cannon],” she said. “Each time there was a plane, they would fire.” She said she saw at least 10 RSF fighters sleeping in her building. Human Rights Watch verified a video shared by the resident showing an RSF soldier firing an anti-aircraft cannon in a densely populated area in Khartoum, west of the airport.
A resident of Mohandseen, near the SAF’s engineer post in Omdurman, said his house was hit on three occasions by “heavy bombs and small arms fire”:
The RSF have been gathering immediately behind my house, many forces are just behind there. There is a small road, and they are hiding there…. There’s shelling between army and RSF as the military post is not far. Both are shooting. The heavy bombs are from the army. They’re the only ones who have those. The RSF are using smaller weapons.
A 33-year-old resident of Jabra, south Khartoum, described seeing several RSF vehicles, some with anti-aircraft cannon, lining up in a nearby narrow alley lined with houses from his rooftop on April 16:
They [RSF] were shooting in the alley into the air from time to time, maybe aiming to shoot military planes. It was very loud. They would move around the area, but the moment a military jet or helicopter would appear in the sky, they would come back to hide in that alley.
Use of Explosive Weapons in Populated Areas
The parties to the conflict should refrain from using explosive weapons with wide-area effects in populated areas. Explosive weapons encompass a range of surface-fired and air-dropped weapons and other munitions, including aerial bombs, artillery and mortar projectiles, and rockets and missiles. These weapons frequently are too inaccurate, or their blast radius is too large for them to be used in populated areas without causing unlawfully indiscriminate harm.
A woman said that a munition struck her relative’s house in Khartoum’s Burri neighborhood on April 17 and killed her 2-year-old niece. The munition “went through the building and penetrated the walls,” she said. “The walls and roof just collapsed on everyone.” She showed researchers photos of the aftermath of the strike. “My niece was taken to the hospital, where she died.”
A 44-year-old man said that his house in the El-Riyadh neighborhood of Khartoum was hit on the afternoon of April 17 while his wife and two children, ages 2 and 9, were inside:
I heard something like whistling and then a boom. I rushed to check on my kids [since they were] in the room near the explosion. Luckily, I had placed a mattress near the windows, so it reduced the shrapnel and shattered glass. No one was injured, only one of my two dogs. If you see the pictures, it was a huge thing that hit the building. It went through the concrete.
The strike caused significant damage to the house’s water tank and backup generator for electricity. “My kids are panicking,” the man said. “I am also going through so many emotions.”
Human Rights Watch verified 10 videos uploaded to social media showing the Sudan military and RSF using explosive weapons in populated areas in greater Khartoum since April 15. Two videos uploaded on April 15 show an SAF MiG-29 fighter plane launching a missile near the international airport. A second video shows an SAF MiG-29 dropping two bombs north of Omdurman. A video uploaded on April 17 captures the moment an airstrike hits a building on the campus of the Jabra Scientific College for Islamic Studies in Khartoum.
A Sudan military MiG-29 fighter plane launches a missile near the international airport in Khartoum, Sudan, April 15, 2023. © 2023 Mohamed Elha
A video uploaded on April 21, shows an attack helicopter firing several unguided rockets into the façade of a four-story building in Omdurman. In another video, SAF fighters are firing from rockets launchers on a central street in Khartoum. Other videos verified by Human Rights Watch show tanks directly firing projectiles in densely populated areas of Khartoum.
Damage to Infrastructure
Infrastructure that is considered “dual use,” benefiting the military forces and civilians, such as power plants, communications centers, and bridges, may be legitimate military targets. However, such attacks on infrastructure are still subject to laws-of-war prohibitions on indiscriminate and disproportionate attacks. In particular, the destruction of a power plant can have foreseeable long-term and serious harm for the population that far exceeds any military advantage of the attack. The use of explosive weapons with wide-area effects often results in such “reverberating” effects on critical infrastructure, causing loss of access to electricity, water, health care, and education, and forcing displacement of civilians.
Human Rights Watch found that since the start of the Sudan conflict, warring parties have damaged key infrastructure and reportedly impeded vital repairs.
On April 15, the Bahri Water Treatment Plant, north of Khartoum, was damaged, leaving residents in the area without water. A video shared with Human Rights Watch shows a section of the plant on fire. Satellite imagery of the plant shows an impact on the rooftop of a large building that burned on April 16. Part of its rooftop had collapsed, and the fire reached nearby vegetation. Other burn marks are visible around the perimeter of the plant.
A resident of Bahri said that a water engineer had told her that staff had repeatedly tried to enter the plant, but that RSF fighters deployed there prevented them. On April 17, unidentified military forces, including an armored vehicle, are visible on satellite imagery near the plant.
The Khartoum State Water Authority reported on April 19 that the repair teams could not access the site due to security concerns. On April 22, the water authority reported that security was restored in the Bahri station and that repairs were underway.
Water plants in other parts of the city were also affected. On April 17, the water authority reported that the Beit Al Maal Water Plant in Omdurman was exposed to heavy fire and workers were asked to evacuate. Satellite imagery of the same day confirms the presence of military pickup trucks around the plant.
The combined lack of water and electricity in some areas has had a devastating impact on civilians forced to shelter in their homes. “This has been the hardest part … [no] electricity and it is Ramadan … our family is fasting,” said a man in western Khartoum. “It has been really hot, temperatures in the 40s [Celsius] without electricity and cool water for people to break our fast.”
A 62-year-old woman living in south Khartoum said on April 24:
Whenever [we get] water or electricity, we have to make quick decisions about what to do with that … you never know when it is going to be cut again. You can hear kids crying, [but don’t know if it is] because of the sound of gunfire or explosions, or because they are hungry and thirsty.
After several days of fighting, internet service in Khartoum was affected for undetermined reasons. A 31-year-old resident of Ma’amoura, in eastern Khartoum, said that during the first days of the fighting they relied on the internet for social media updates on safe routes and for access to online banking applications, which was necessary because obtaining cash was nearly impossible with the banks closed and automated teller machines either out of service or dangerous to reach.
Damage to Medical Facilities
International humanitarian law provides hospitals and other medical facilities special protection from attack. Warring parties must take precautions to avoid harming them even when they are being used for military purposes. The forces must also facilitate access and ensure the protection of medical personnel regardless of whether they are treating civilians or injured combatants.
The fighting in Sudan has already had a devastating impact on the health sector in Khartoum, Darfur, and El Obeid in North Kordofan.
The Sudanese Doctors’ Union said that as of May 2, 16 hospitals had been hit in strikes; 57 were not functioning because of lack of medical supplies, power, and medical staff; and 19 had been forced to evacuate all patients and staff. According to the World Health Organization (WHO), “more than two-thirds of hospitals are not functional due to direct attacks, occupation by fighting parties, access, lack of electricity, water supply or fuel, or stock out of medicine.” Specialty wards and hospitals, including paediatric hospitals, intensive care units, and cardiology wards, have been affected.
Khartoum’s El Shaab hospital, one of the biggest hospitals in Sudan, is 1.5 kilometers west of Khartoum international airport, which has been the site of heavy fighting. The hospital was repeatedly damaged in the early days of the fighting. A doctor there said it was first hit on April 15 by small arms fire, then bombed on April 17 and 18, damaging wards and injuring a staff member:
On Monday [April 17], the hospital was attacked by two [munitions] at around 6 a.m. One hit the parking lot and burned some cars, and another one hit Ward 2, for chest diseases such as tuberculosis. [The patients] all rely on oxygen. People panicked and so we decided to evacuate around 300 patients, leaving only serious cases in the hospital.
A video from El Shaab hospital captures the moment a loud explosion is heard, Khartoum, Sudan. © 2023 Private
A nurse said that on that day, two soldiers were posted inside the hospital.
The airstrike on April 18 was captured on live television. Based on the footage and satellite imagery, Human Rights Watch believes that the strike used a pair of air-dropped bombs. A doctor said that: “On Tuesday [April 18], everyone was exhausted. At 10 a.m. the hospital was attacked again, this time the ICU [Intensive Care Unit] and administrative section. It was then [that] we decided to evacuate the hospital and shut it down. It was no longer safe.”
A video shared on April 19 shows the aftermath of an apparent clash between the RSF and the Sudan military on April 19, about 200 meters from the hospital entrance. Satellite imagery shows two more craters on Army Avenue, directly adjacent to the hospital and 270 meters away from where the clashes occurred. Human Rights Watch was unable to identify the intended target of the strikes.
The bodies of four patients who died in the hospital following the strikes, though not directly because of the strikes, had not been removed as of April 27.
On April 18, another hospital in central Khartoum, the Ibn Sina, was also hit. One image shows that a strike pierced the ceiling of the main hospital building. A video uploaded on April 18 shows a small section of the southern part of the hospital on fire.
The warring parties have also damaged hospitals and medical facilities elsewhere in the country.
In Darfur, where the healthcare system was already in a dire state, healthcare facilities saw significant damage as a result of the fighting. Health care workers also said various nonstate armed groups may have been involved in attacks. Residents of El Genaina, the capital of West Darfur, said that fighting between the Sudan military and RSF quickly turned into heavy clashes between militia members from Arab and non-Arab communities, leading to significant damage to gathering sites for displaced people, schools, and also El Genaina Teaching hospital. The humanitarian organization Doctors without Borders (MSF) said that parts of the hospital were also looted.
In Nyala, capital of South Darfur, a health care worker said that on the evening of April 16, an unidentified armed group arrived in Toyota Land Cruisers and attacked the city’s main medical supply hub and looted medicine. On April 19, unidentified assailants set the warehouse on fire. MSF reported on April 17 that its premises in Nyala, including a warehouse, had been looted.
In El Obeid, North Kordofan, at least one health facility was hit during what a doctor and the media described as heavy fighting between the RSF and Sudan military on April 20.
Impact on Health Care and Other Essential Services
In addition to the attacks on medical facilities, hospitals are also reeling from rapidly dwindling medical supplies, power outages, and a shortage of medical staff. A resident of Khartoum, who survived a strike on his home, said:
Being injured is worse than death right now…. no medicine, no antibiotics, no doctors or hospitals…. some people we know got in a car to get food and were shot at. They had to wait for hours until they found a safe route to a hospital and even [longer] for a doctor to come and perform surgery.
A doctor at the Omdurman Teaching Hospital said on April 19 that the hospital had been without water for two days, which affected its critical functions, including the ability to perform surgery.
Another doctor at Omdurman hospital said patients were being turned away as the ward had run out of basic supplies. She said the hospital was mainly treating civilians suffering from conflict-related gunshot wounds, but: “I have no oxygen in the hospital. I can’t help as many patients. I can’t help chest care patients.”
MSF reported that, “In Khartoum, even ambulances are being turned back. They are not being permitted to pass in order to retrieve the bodies of the dead from the streets – or to transport those who have been injured to hospital.”
One of the Omdurman doctors said that as of April 20, the hospital was “surrounded by the Rapid Support Forces.” Doctors were unable to leave or enter the hospital because of the presence of forces nearby and the fighting. Those stuck there had been working nonstop since the start of the conflict, while other critical staff, including surgeons, could not get into the hospital.
Even morgues have been affected, adding to the anguish of families, and raising public health concerns. The body of a man killed by an attack in Khartoum was taken to the Al-Jawda hospital morgue but could not be stored there because of electricity outages, a neighborhood resident said. “They couldn’t find the family, so they kept him on the street in front of the hospital [until] they couldn’t wait anymore,” and buried him before he could be identified.
In Darfur, a doctor at the Nyala Teaching Hospital said on April 22 that the main three hospitals in the town might have to shut down within days if no supplies were provided. He described a rapidly deteriorating situation:
Besides the increasing numbers of death and injuries among civilians, we are concerned about a spike in cases of acute malnutrition for children under 5 and water-transmitted diseases, among others…. [T]here is not much food or water for our staff who working tirelessly to tend to every patient…. [T]his is going to lead to a catastrophic situation and we do not have the capacity to respond to that.
According to the Sudan Doctors Union, Nyala Teaching Hospital continues to provide their services as of May 2.
In an April 26 news briefing, Dr. Tedros Adhanom Ghebreyesus, the director-general of the WHO said: “On top of the deaths and injuries caused by the conflict itself, WHO expects there will be many more deaths due to outbreaks, lack of access to food and water, and disruptions to essential health services, including immunization.”
The UN Security Council and AU Peace and Security Council should take meaningful action to address serious violations, including:
- Holding regular public meetings and publicly calling on the warring parties to immediately end unlawful attacks on civilians and civilian infrastructure and allow for safe and unhindered humanitarian access.
- Underscoring that warring parties should ensure that all aid and medical staff, humanitarian and medical facilities and supplies, are protected from attacks and looting and that medical staff and aid agencies are able to carry out their work free of harassment or other interference.
- Urging all countries to respect the UN Security Council’s Darfur arms embargo and to stop transferring weapons, ammunition, and materiel to the warring parties.
- Imposing an arms embargo on the warring parties throughout the country. Both the SAF and RSF have a history of widespread and systematic abuses that justifies an arms embargo.
The UN Human Rights Council should:
- Hold an urgent special session on Sudan.
- Establish a strong mechanism with the mandate to collect and preserve evidence of crimes under international law committed by all parties and provide concrete recommendations on accountability.
The UN Security Council, the AU Peace and Security Council, the European Union, and other concerned governments including the United States and the United Kingdom, should:
- Use existing authority or provide new authority to impose targeted sanctions on leaders of the SAF and RSF and others responsible for serious abuses against civilians.
To international humanitarian agencies and donors:
- Increase support for the humanitarian response to the crisis, especially in harder to reach parts of the country such as Darfur, as well as in neighboring countries.
To Sudan’s neighboring countries, including Egypt, Chad, Ethiopia, and the Central African Republic:
- Allow those fleeing the conflict prompt access to humanitarian assistance and expeditiously and impartially process asylum applications.
- Allow for unhindered humanitarian access across borders into Sudan.