War-time mortality in Sudan: a multiple systems estimation analysis

Background: The mortality impact of war in Sudan, which began in April 2023, remains largely unmeasured due to sparse and methodologically weak data that reflect sparse pre-war vital registration systems and actively restricted access to affected communities. Our study aimed to quantify undocumented war-time mortality levels and patterns in Sudan. Methods: We conducted a retrospective observational study collecting lists of people deceased since April 15, 2023, from three sources: a public social media survey, a survey disseminated through private networks, and public social media obituaries. After probabilistically matching decedent records within and across lists, we described age and cause-of-death patterns by region and month. For Khartoum State, where data were sufficiently abundant, we used multiple systems estimation to estimate all-cause and intentional-injury mortality. Findings: In the war's first 14 months, most reported deaths were from preventable causes, while intentional-injury deaths were disproportionately high in Khartoum State and Gezira State, and highest in the Kordofan and Darfur regions. We estimate that 61 202 all-cause deaths (95% CI 22 286–209 151) occurred in Khartoum State between April 2023, and June 2024, corresponding to a conservatively estimated crude death rate of 9·7 per 1000 persons per year. 26 024 deaths (95% CI 12 571–58 704) in Khartoum were due to intentional injuries. Interpretation: Between April 2023, and June 2024, Sudan's war likely caused a substantial, largely undocumented rise in mortality in Khartoum State, with intentional-injury deaths in the capital alone exceeding the ACLED reported fatalities toll for the same period (ie, 20 178). Across the country mortality was driven by preventable disease and hunger, with intentional-injury deaths predominating in the Darfur and Kordofan regions. Urgent diplomatic and humanitarian action is critical to prevent further avoidable deaths, deter human rights violations, and to support post-conflict recovery and reconciliation. Funding: Centers for Disease Control and Prevention of the US Department of Health and Human Services (as part of financial assistance award U01GH002319) and the UK Foreign, Commonwealth & Development Office.