In Sudan, where military operations have now entered their fifth month, Médecins Sans Frontières (MSF) has been supporting the Turkish Hospital in Khartoum since mid-May. Although there was a risk that MSF would twice have to end it support to this hospital, it has been possible for our teams to maintain and even expand our support -- in spite of immense challenges, which include ongoing visa shortages.

Today, around 100 people come to the hospital for treatment each day, with an average of 40 coming to the emergency room. Our outgoing head of mission, Dr Mego Terzian, provides an update on the situation on the ground.

100 patients a day -- mainly women and children

Over the past few weeks, the majority of our patients have been children and pregnant women, and although our main focus when the fighting intensifies is to treat the war wounded, the Turkish Hospital is actually the only hospital in the area that is available to provide specialised healthcare for pregnant women and sick children.

We are based in Al Kalakla neighbourhood, but we have a lot of patients coming from other areas, and many cross the frontlines to reach us. Two weeks ago, some of the most severe fighting since the start of the conflict began, with airstrikes and heavy artillery shelling taking place around the Armoured Corps army base, which is about five kilometres to the southeast of where we are located.

In the past four months, at least 17 major offensives have been organised to try and take control of this base and we have faced mass casualty arrivals many times. The situation is very dangerous for those who live nearby: life is very hard, including in the hospital, but everyone in the team is conscious that our presence is crucial for the healthcare of people here.

Access to healthcare remains the biggest challenge

The biggest challenge in terms of providing healthcare in Khartoum remains access. There is extreme insecurity, almost zero transportation, and it is very difficult for patients to get to the hospital. There are no ambulances. Any vehicles that go out are commandeered by the armed personnel who control the streets. Even vehicles owned by MSF have been stolen.

We have faced several security problems over the past few months. Currently, at the Turkish Hospital, MSF has only one rental vehicle with one courageous driver who is able to bring in medicines as well as food and water for our patients and staff. However, this is no easy task. There are multiple checkpoints on the roads, and at each one we need to explain our presence, the type of assistance that we are delivering and why it is crucial that we are able to continue the supply chain to the hospital.

As there are no ambulances, patients have to find their own way to get to the facility, and there are very few options available to them. The only vehicles that are able to move freely are the ones used by the combatants.

In addition, there is a city-wide fuel shortage. We see dozens and dozens of vehicles that have been abandoned at the side of the road because they have run out of fuel and become useless after having been stolen. So, people have begun using wooden donkey carts again -- or they simply come by foot. Some patients told me that they had walked up to 15 kilometres and crossed the frontlines to reach us.

"The health system has almost completely collapsed in Khartoum and there are no basic healthcare activities." DR MEGO TERZIAN, MSF HEAD OF MISSION

Maternal health and the collapse of Khartoum’s health system

On average, there are eight deliveries per day in our maternity department, and an average of three C-sections are performed. Most of the women who come are still in good health, but some have anaemia and one challenge when it comes to performing C-sections is the lack of blood. Blood needs to be stored at a very specific temperature, and it is a major challenge to maintain this due to the ongoing fuel and electricity shortages in the city.

Bringing in new medical supplies has become increasingly challenging because travel permits are no longer being issued regularly, and this is preventing our teams from being able to enter Khartoum to restock the hospital.

The health system has almost completely collapsed in Khartoum and there are no basic healthcare activities, with the exception of one health centre that has re-opened in our neighbourhood and a group of Sudanese volunteers who are trying to provide healthcare services in a nearby mosque.

We hope that in the health centre, ante-natal and post-natal care, as well as vaccination activities, will be organised. But for now, these types of activities are almost non-existent and at the moment, we are only able to provide the most urgent forms of healthcare – safe deliveries, emergency C-sections and intensive care for children who are very sick.

"The majority of people I have spoken to think that the war will continue for many more months – even years." DR MEGO TERZIAN, MSF HEAD OF MISSION

Deadly diseases on the horizon

Due to the lack of vaccinations, we are concerned that there will be an outbreak of measles or meningitis in the coming weeks. Cholera is also a very real risk because of the lack of drinkable water and poor sanitation.

Fortunately, in some ways, there are not huge concentrations of people in Khartoum like there were before the war, which may reduce the risk a bit, but the reality is that there are no vaccination activities, there is no clean, drinkable water available and there is a lack of sanitation and hygiene.

We have noticed that the number of children coming with diarrhoea and dehydration has increased, which was not a common problem before the war, but it is due to the poor water quality. Additionally, despite the hot weather, there are a significant number of children with pneumonia and the causes are most-likely the lack of vaccinations, as well as the poor sanitation conditions. With the arrival of the rainy season, we can also expect an outbreak of malaria in the coming weeks.

We have a worrying number of children being admitted with severe malnutrition. Some children are malnourished because of lack of food. Other children are malnourished because they get other diseases and then become malnourished as a result.

When children have malnutrition in combination with other diseases like malaria, diarrhoea with dehydration and acute respiratory infections such as pneumonia, their condition can become critical. We already have a few cases of severe malaria, and among newborns we have a significant number with septicaemia.

Although we have enough beds to treat the number of patients at the moment, when the malaria season starts -- and if the number of children needing treatment for severe malnutrition increases -- we won't have capacity.

Chronic diseases and what is next

We are one of the few health structures providing care for patients with chronic diseases such as diabetes, asthma, and cardiovascular diseases. We have many older patients arriving, especially with complications. For example, sometimes we see older patients with diabetes who arrive in a coma due to having been unable to get insulin because of the war. Because they have no access to treatment in the city, they get very sick, and they reach us in a very bad condition.

One positive thing is that in Khartoum, the mortality rate in the hospital is under two per cent, which is a big success for the medical and logistics team considering the conditions they are working under.

Despite the problems they face every day -- the lack of electricity, water, and oxygen, and sometimes the lack of specific medications for anaesthesia and for blood transfusions -- we have been able to maintain the team there and of continue to deliver emergency healthcare for the people.

Nevertheless, people in Khartoum are very pessimistic. The majority of people I have spoken to think that the war will continue for many more months -- even years.