By the time the current conflict in Sudan broke out in mid-April, people living in the country's Darfur region had already been facing war and ethnic violence for over two decades. Today’s fighting—which first erupted in Khartoum between the Sudanese Armed Forces (SAF) and the paramilitary Rapid Support Forces (RSF)—has rekindled fault lines in communities throughout Darfur, particularly the city of El Geneina.
Intense fighting, intercommunal violence, and large-scale attacks against civilians have driven hundreds of thousands of people to flee across the border to Adré, eastern Chad. Like other towns along the Chad-Sudan border, Adré has been struggling to accommodate the rapid, massive influx of refugees as access to food, medical care, and other necessities was already limited.
Doctors Without Borders/Médecins Sans Frontières (MSF) teams have been providing care in Adré since 2021. We scaled up operations significantly over the past three months to expand capacity in local health care facilities and improve the quality of care as large numbers of people continue to arrive from Sudan. Many of these refugees arrive with gunshot wounds and other injuries sustained along the way from El Geneina. In testimonies gathered by MSF in recent weeks, many patients said they were victims of Arab militias in El Geneina and during their escape to Chad. They report being targeted because of their Masalit identity.
“We didn’t expect so many wounded”
Violence intensified in West Darfur state in late May and early June. Yet only a few wounded people managed to escape across the border to an emergency surgical unit in Adré hospital set up by MSF teams in partnership with the Chadian Ministry of Health.
The sound of explosions and the sight of plumes of smoke were daily reminders of the fighting taking place just across the border in Sudan. On June 2, a total of 72 wounded patients were treated at Adré hospital. Most of these people had gunshot wounds and came from the town of Masterei and its surroundings, south of El Geneina. Upon reaching the Chadian town of Goungour, they received care from Ministry of Health and MSF medical staff and were referred to Adré hospital. At the time, there were reports of hundreds—if not thousands—of injured people unable to access vital medical care in Darfur, with many medical facilities looted, damaged, and lacking staff and supplies. The main road linking Adré to El Geneina, the capital of West Darfur, was closed at the time.
Sara* was admitted to Abéché hospital with a bullet lodged in her neck after fleeing Sudan. Chad 2023 © Mohammad Ghannam/MSF
Everything changed on June 15, when people managed to escape to Adré after being stranded for two months in El Geneina. Adré hospital received 261 war-wounded patients on that day alone.
Dr. Papi Maloba, the only MSF surgeon present in Adré at that time, had started the day as usual: after making his round of the patients and selecting those who were to go into the surgical room, he and his team began operating on a young boy. He shares his account of the day below:
“Suddenly the calls started: ‘Come on, come on, there are patients arriving from everywhere!’
“I explained to my colleagues that we couldn't leave this patient with an open abdomen. In the operating room, everything was calm, but outside there was a great deal of commotion. There were vehicles from the joint Chad-Sudan military force bringing in patients; MSF teams bringing in patients; others arriving on donkey carts or carried by relatives. We didn't know where to start. The injuries were serious: to the abdomen, chest, lower limbs, buttocks, and back. Our job was to triage the most serious injuries, examine them, and prioritize them for surgery.
“And in the blink of an eye, the hospital was transformed into a veritable camp in less than two hours. We didn't know where to put the patients who were still pouring in. We knew that if the road to El Geneina opened up—if there were successful negotiations to open up a corridor that would let patients from El Geneina through—more people would be arriving at Adré hospital. We were prepared, but we weren't expecting so many wounded patients all at once. We thought that the next day would be a bit calmer, that it would allow us to plan things properly. It turned out to be worse: The next day we received close to 400 new casualties."
People in Adré responded to this massive influx of casualties with many efforts to host and provide medical treatment to the new arrivals. Space had to be made, tents set up, and additional support found. The town's residents brought food to the patients and other refugees. The hospital's head doctor and pediatric resident lent a hand in the emergency surgical unit, along with several Ministry of Health staff, while the organization Première Urgence Internationale took care of the so-called "green cases," in which the patient's life was not immediately in danger.
The majority of patients suffer multiple gunshot wounds, particularly to the abdomen, back, and legs. Chad 2023 © Johnny Vianney Bissakonou/MSF
“We had two operating rooms," explained Dr. Maloba. "A large, well-equipped room and a smaller one that didn’t have all the equipment we needed. So we had to alternate between rooms and patients. As soon as I finished operating on one patient—for example, a laparotomy—I switched to the small room where I could easily do chest drainage, debridement, or other less demanding procedures while the first room was being cleaned, and so on. We worked like that from 8 a.m. until sometimes 11 p.m. It was really exhausting. The Chadian government then sent a surgical team to reinforce us, which was a great relief.”
858 war-wounded patients in just three days
This influx of casualties at Adré hospital was one of the largest that our teams have ever seen, with 858 war-wounded people received from June 15 to 17—including 387 on June 16 alone. Over the following days, the emergency room received an average of 46 wounded patients each day. From June 25 through the end of July, the average decreased to 10 or fewer patients each day.
The vast majority of patients were suffering multiple gunshot wounds, particularly to the abdomen, back, and legs. They were mainly men, with a smaller proportion of women and children. The youngest patient hospitalized was two months old; the oldest was over 70. Seven patients were found dead on arrival.
Chad 2023 © Mohammad Ghannam/MSF
Around 47 percent of patients were assessed as green cases and were able to walk. About 49.5 percent were classified as "yellow cases," or those who needed treatment but whose general condition allowed them to wait without critically worsening their prognosis. 3.4 percent were absolute emergencies requiring very quick treatment, classified as “red cases.” Patients with open fractures requiring orthopedic surgery, which was not available at Adré hospital, were referred to hospitals in Abéché.
The high proportion of "green" and "yellow" cases suggests that it was mainly those stable enough to undertake the journey to Chad who were able to reach our medical services. Many others in more critical condition were left behind in Darfur.
Treating pregnant women after violent attacks
Between June 15-18, 62 pregnant women received care for gunshot wounds or injuries from beatings and other assaults.
“The first patient I was called in to see was a woman who had been shot in the stomach and chest while she was six months pregnant," said Clémence Chbat, a midwife with MSF. "We were very afraid for her because a piece of bullet was lodged in her uterus. Unfortunately, the baby died, but she was able to survive. It was striking to see so many pregnant women with injuries to their limbs and abdomens. They came from El Geneina and reported terrible scenes such as having to run under bullets at the risk of losing their children on the way, and being attacked and raped.”
Testimonies describe targeted ethnic violence
With a few exceptions, the wounded patients at Adré hospital belong to the Masalit ethnic group, a non-Arab Darfuri community that lives in both Chad and Sudan. Before the conflict, there was already a large Masalit community in Adré, which partly explains why those fleeing violence sought refuge there. Many say they were attacked by Arab militias in El Geneina and during their escape to Chad. They report being targeted because of their Masalit ethnicity.
The stories they share reflect the experience of the Masalit people of El Geneina—an experience that doesn’t represent the whole population of West Darfur or El Geneina.
"At first, I had no plan to leave El Geneina. Me and my two daughters along with my mother and four of my sisters moved to a collective shelter in the Al Madares neighborhood […] Then, Arab militias attacked us in the shelter. They told us that this wasn’t our country and gave us two options: immediately leave for Chad or be killed. They took some men and I saw them shooting them in the streets, with no one to bury the corpses. So we fled in a big group.” — H
Several testimonies echo similar threats and report recurring attacks in neighborhoods such as Al Madares, Al Jabal, Area 13, and Al Jamarik, as well as the presence of snipers targeting civilians venturing out to fetch water or supplies. Other patients recall continued ethnic-based violence on the road to Chad and its dozens of checkpoints.
Chad 2023 © Mohammad Ghannam/MSF
“I am from the Al Fur tribe and there at the checkpoint you can’t lie to them because they know the Masalit people from how they look. I saw them telling Masalit people to leave the cars and I don’t know what happened to them because we drove off.” — M
“On June 18, I paid an Arab armed driver 300,000 Sudanese pounds [about $500 USD] to get my wife and children to Adré. I couldn’t leave with them because the driver said it wasn’t safe for my family if I’m around, they will know we’re from Masalit tribe. On June 25, I went out to the hills in northern El Geneina to try get some mobile signal. I saw at least 20 bodies when I looked down the valley, and I prayed to God to save me and enable me to join my family. I left on June 28 and at all the checkpoints, the driver said “he’s one of us,” and we were fine. Of course, I paid him a lot of money to say that, and many people didn’t make it to Chad and were killed just because they were Masalit.” — K
"A collective decision to leave"
A variety of factors prompted a large part of the Masalit population of El Geneina to try to flee to Chad in mid-June, after several weeks of clashes and violence: the murder of the governor of West Darfur, Khamis Abakar; escalating threats; and reports of a massacre during an attempt to reach a Sudanese army camp in Ardamatta, an area in the eastern part of the town.
“On the evening of Wednesday, June 14, I had had enough, and I felt there was no way to stay. I left home with my family along with around 200 people toward Ardamatta in northeast El Geneina. When we reached the Al Naseem area, they started shooting at us from the roofs of buildings. Everyone was running in all directions. They killed many of us, it was a massacre. We couldn’t help or carry the dead and wounded, everyone was running for [their] life. I ran with my wife, our one-year-old baby, and a small group of other people. We reached the Al Madares neighborhood and continued forward. We headed west and faced more Arab militias who took our money and phones. Eight of my children are in Ardamatta military camp and I don’t know if they are doing well because communication is so difficult. I hope they are safe.” — A
“The situation was getting really bad. It was a collective decision to leave. Many people fled on foot, heading to Ardamatta, to get protection from the Sudanese army. We were stopped and shot at. I can’t tell how many, but I saw many dead and wounded people lying on the ground. The only solution left was to go west to Adré, [so] people started walking to Chad.” — N
It was the only escape route, but the journey to Chad was nonetheless extremely dangerous. Patients said that they had used various means to get there: on foot, in convoys, and in vehicles whose drivers could guarantee passage for large sums of money. In addition to the risk of being robbed, assaulted, raped, or killed at checkpoints, many patients reported that armed men shot at people fleeing. The town of Shukri is mentioned in several accounts as one of the most dangerous points on the route.
“Women and children gathered [in the] Al Jamarik area at 4 a.m. Our plan was to start marching west [to Chad]. Then men joined [us]—some had guns and cars to defend the people along the way. We were attacked while crossing a town called Shukri. Many were killed by the locals. My people were dropping like flies, it was complete mayhem. Those who didn’t die there, it’s because they were further away from the shooters or other people in front of them took the bullets. That’s the only way some of us got to survive.” — L
“At Shukri, a small group stopped us and asked us to sit down. It was like Judgement Day. I was scared, I prayed to God to get me out of there alive. [They said], ‘All slaves must stand up and if you want to live, leave Sudan because Sudan is for Arabs.’ We started running and the armed men were shooting at people at random [...] Everywhere I looked, I saw death. Believe it or not, death has a smell, and I could smell it. I saw many corpses on my way. I thought I might be joining those corpses in a few moments. But fortunately, we reached the border. That's when I saw a white SUV belonging to Médecins Sans Frontières, which picked me up and took us to the hospital in Adré, where I was treated and looked after.” — C
Humanitarian crisis grows in eastern Chad
Today, around 200 injured people remain in the hospital in Adré. Some of them will need medical follow-up for a long time in order to recover, particularly physiotherapy. At the end of June, MSF set up and started working in its inflatable hospital, including a sterilization and X-ray room and two operating rooms, to improve the available capacity and quality of care.
With the wave of wounded, new refugees from El Geneina also arrived in Adré. According to the United Nations High Commissioner for Refugees (UNHCR), around 130,000 refugees, mainly women and children, have arrived in the town in recent weeks. This sudden increase in the population is generating major humanitarian needs in all areas: medical care, shelter, food aid, water and sanitation, in a place where accessing these needs is already difficult for the local population.
“We used to have between 35 and 50 children in the pediatric unit at any one time, but we are now treating between 200 and 250 children," said Dr. Japhet Niyonzima, MSF medical team leader. "80 percent of them suffer from severe acute malnutrition with complications. One of the priorities today must be to expand the pediatric and nutritional services in the health centers and refugee sites to treat children earlier, before their condition worsens.”
The authorities and the UNHCR estimate that there were 260,000 new Sudanese refugees in eastern Chad in mid-July.
Transit sites are multiplying, and new camps are being set up, including in Arkoum, where MSF has started providing medical care. Some 400,000 Sudanese refugees were already in Chad before this current conflict, having fled their country during the last 20 years. A large amount of humanitarian aid will have to be provided over the long run to support the most vulnerable, whether Chadians or refugees, and help absorb the shockwaves of Sudan’s conflict in an area already marked by food insecurity and lack of access to water and health care.
*Name changed to protect privacy
