Sudan's civil war has faded from headlines, but monitors say it's the largest humanitarian crisis in the world

The number of Sudanese risking their lives to make it out of the besieged city of El Fasher in North Darfur is rising as the paramilitary Rapid Support Forces (RSF) intensify their attacks on the regional capital, according to aid agencies, including Medecins Sans Frontieres (MSF).

"The numbers are still increasing [from] mid August up to now," said Romain Madjissembaye, the MSF project manager in Tawila. Located about 60 kilometres west of El Fasher, it has become a major hub for the displaced.

He said that last week, they saw around 90 people who arrived in critical condition. "A lot of them are malnourished and they are facing executions on the road, some gunshots," Madjissembaye told CBC News via a Zoom interview.

An estimated 260,000 civilians, including 130,000 children remain trapped in El Fasher according to UN agencies. Surrounded by RSF militias on three sides, the city has now endured over 500 days of siege, cut off from food, medicine or a safe exit.

Some media reports suggest people are having to eat animal feed to survive.

MSF pulled out of El Fasher — one of the few remaining places not under RSF control in Darfur — in August 2024, just a few months after the siege began in May.

"The situation became very, very tricky," said Madjissembaye. "We [faced] a lot of security issues, bombing. Our team, our patients, they feel not safe."

Doctors use mosquito nets to dress wounds

He says they now canvass those managing to make it to Tawila from El Fasher for information on conditions inside. 

One man, who arrived last month with gunshot wounds to his shoulder and leg, told MSF that doctors at El Fasher's last standing hospital were using mosquito nets for dressing.

Madjissembaye says another man had also described dire conditions at the hospital.

"He found many patients [with] bullets in their body. Some of them required amputation. But there are few medical doctors [left]. And they also ran out of medicine."

He says there were also many reports from women who'd been raped or abused on the road out of El Fasher. 

Tawila has now become a massive refugee camp with hundreds of thousands of people displaced from El Fasher and from the Zamzam displacement camp on the outskirts of the city.

Last week, while visiting Tawila, UN humanitarian co-ordinator Denise Brown called it "one of the epicentres of a humanitarian catastrophe."

"It took us five days, through three countries, three different airplanes and three days of driving. We had to go around because there are so many frontlines within Sudan," she said, highlighting the challenges in moving aid.

"Stop the violence, stop the war, let us through."

Agencies challenged to bring aid in 

Sudan has been caught in the grip of a devastating war since April 2023, when two generals who had joined forces to stop a transition to civilian rule fell out and turned on each other.

The RSF has been pitted against the Sudan Armed Forces (SAF) ever since, now controlling most of Darfur and neighbouring Khordofan, while the SAF controls the country's north and east. 

When the SAF recaptured Khartoum earlier this year, the RSF turned its attention to El Fasher more fully, the last SAF stronghold in Darfur.

Reports on the ground suggest civilian gathering points like communal kitchens are increasingly being targeted by RSF shelling as fighters move closer into the city centre.

Last month a drone attack on a mosque killed more than 70 people. 

On Saturday, a co-ordinating group of various "resistance committees" in El Fasher made up of local residents, said on Facebook that the city had become an "open morgue."

The group said residents were facing both deliberate and indiscriminate shelling with attacks on markets and hospitals. 

Despite its absence from the world's headlines, Sudan is the largest humanitarian crisis in the world, according to international monitors. 

The United Nations says more than 12 million people have been displaced since spring 2023. 

Aid agencies say they fear an even bigger humanitarian crisis if the RSF overruns the city.

Madjissembaye says MSF's capacity has already been pushed to the limit. 

The town and the surrounding area are controlled by a group called the Sudan Liberation Movement (SLM), which has adopted positions of neutrality in the past. But aid must come all the way from the border with Chad, and those convoys face enormous challenges. 

"It can take weeks before receiving a supply," Madjissembaye said. "And sometimes [militants] stop the convoy on the road. Sometimes they are targeting the convoy."

'The technology of horror has evolved'

International monitors have accused both sides in the conflict of atrocities.

The RSF today, which is headed by General Mohamed Hamdan Dagalo, grew out of the notorious Janjaweed militias accused of genocide against non-Arab tribes in Darfur in the early 2000s.

On Monday, the International Criminal Court in the Hague handed down its first war crimes verdict for Darfur during those years. 

Ali Muhammad Ali Abd-al-Rahman — a Janjaweed militia leader know as Ali-Khoshayb — was found guilty of crimes against humanity including murder, rape and torture. 

Dr. Mukesh Kapila was the UN's representative in Sudan in 2003-2004, a witness to the horrors taking place. More than 20 years later, he says what's happening on the ground now is even more brutal.

"And the reason for that is that the technology of horror has evolved. Twenty years ago when Ali-Khoshayb was running the roost he was using camels and horses and land rovers and Toyotas and things like that," said Kapila, now a professor emeritus of global health and humanitarian affairs at the University of Manchester.

"Today, we have drones. We have missiles. We have more deadly weaponry, better targeted weaponry, but still with mass area effects."