Relationship between Armed Conflict and Sudden Death: An Analysis of Causes and Consequences, Sudan 2025

Introduction

Armed conflict significantly impacts public health, leading to increased morbidity and mortality. The Sudanese conflict, which began in April 2023, has caused large-scale displacement and severe damage to healthcare infrastructure, leaving millions without access to essential medical services. Reports indicate that 60 attacks on healthcare facilities resulted in 34 deaths and 38 injuries, while 222 attacks between January and October 2023 led to the destruction of at least 49 health centers [1]. The direct targeting of healthcare facilities exacerbates the suffering of vulnerable populations.

This study aims to fill a critical gap in understanding the impact of war on sudden mortality in Sudan by analyzing socio-demographic factors, primary causes of sudden death, and healthcare accessibility challenges. Unlike previous research, this study focuses on how occupation and psychological trauma contribute to mortality risk, providing a foundation for policy interventions.

War is defined as combat between nations or within a nation and may also involve armed groups not recognized by the international community fighting against an occupying government or regime [2]. War directly and indirectly affects public health, leading to increased morbidity and mortality [3]. The consequences of war include physical, psychological, social, and economic distress, with many individuals exposed to conflict developing post-traumatic stress disorder (PTSD) [4].

Sudan's humanitarian crisis escalated following the rebellion of the Rapid Support Forces (RSF) against the Sudanese Armed Forces (SAF) [5]. Initially concentrated in Khartoum, the fighting soon spread to western and central Sudan [6]. Since April 2023, over 8.4 million people have been displaced, including 1.7 million who fled abroad [7]. According to the World Health Organization (WHO), between April 15 and December 15, 2023, 60 attacks were recorded on healthcare facilities, resulting in 34 deaths and 38 injuries [8,9]. Around 70% of hospitals in conflict zones became non-functional [9]. Unfortunately, the systematic targeting of medical facilities, which should serve as sanctuaries during crises, exacerbates the suffering of already vulnerable populations [10].The impact of conflict is not limited to increasing the demand for healthcare, but also severely restricts access due to the destruction of infrastructure and the loss of healthcare workers. In post-conflict phases, health systems often emerge fragmented and unsustainable, largely due to weak local capacities and limited investment in building resilient health structures[11].

The direct and traumatic nature of death in war is among its most distressing aspects [12]. War deprives individuals of the ability to prepare for death, often leaving no time for acceptance or farewells [13]. The immediacy of death, particularly with modern weaponry, results in mass casualties within seconds [14]. The unpredictability and scale of such deaths create widespread despair, stripping individuals of their final moments of consciousness and reinforcing the fragility of human existence [15].

In conflicts involving weapons of mass destruction, victims often die instantaneously, never having the opportunity to comprehend or respond to their fate [16]. The widespread devastation caused by war transforms the concept of death from an expected transition to an abrupt and disorganized tragedy [17]. War victims are denied their fundamental right to life, leaving survivors to bear the disproportionate burden of loss [18].

Materials and Methods:

Study Design: A cross-sectional survey was conducted to collect quantitative data on the impact of war on sudden death in Sudan. The cross-sectional design was applied in this study as it is currently the most effective for establishing the relationship between conflict and sudden death. The cross-sectional design allows for direct and accurate data collection, providing a clear picture of the direct impact of conflict. Through this design, information related to the incidents can be analyzed in a timely manner without the need for long-term follow-up, as may be the case in the current Sudan crisis. This design also, enables the production of results that can be rapidly applied towards the formulation of intervention strategies to mitigate the impact of conflict on public health.

Study Population and Sampling: Total of 412 participants were included in the study. Inclusion criteria required participants to be adults (18 years and older) who had personally known or lived with the deceased and were willing to share information about the circumstances surrounding the death. Individuals who lacked direct knowledge of the deceased's experience or were unwilling to participate were excluded. While purposive sampling enables rich data collection,

Data Collection Method: A structured questionnaire was administered both online and in-person, ensuring voluntary informed consent was obtained from all participants. The survey included sections on general demographic information, circumstances of death, psychological effects, and healthcare access. The questionnaire was developed by the research team based on a review of relevant literature and study objectives. To ensure clarity and content validity, it was assessed and validated by an external reviewer with expertise in the field.

Data Analysis: Descriptive and inferential statistics were used to analyze the data, employing SPSS for statistical computations. Chi-square tests were conducted to examine associations between key variables. The data were anonymized to maintain participant confidentiality and minimize potential biases.

Ethical Considerations: Approval for the study was obtained by the Ethics Committee of Research and publication office, Dental Alumni and Students Affairs Office,, Karary University. All participants provided informed consent, and confidentiality was maintained by anonymizing data and securely storing information. Measures were implemented to protect the mental well-being of participants during data collection, including access to psychological support services where necessary.

Results

Socio-Demographic Characteristics of the Deceased

This study examines the characteristics of individuals who experienced sudden death during the war. The relationships between the deceased and the respondents in the survey include a variety of categories, such as 16.1% immediate family, 21.3% were parents and siblings, 8.8% were from the paternal family (uncles, aunts, and cousins), 6.7% were from the maternal family (uncles, aunts, and cousins), 6.1% were in-laws, 9.4% were grandparents and extended relatives, 5.6% were other relatives or close acquaintances, and 26% were neighbors, friends, work colleagues, and companions.

In terms of age, the majority of the deceased were aged 36 to 55 years (31.8%), followed by those aged 56 years and above (45.6%), with younger age groups being less represented. Regarding gender, 60.9% were male, while 39.1% were female. In terms of occupation, nearly half were employees (49.3%), while 29.9% were displaced individuals or refugees, and smaller proportions were soldiers, doctors, housewives, or worked in other professions. Concerning residence during the war, the majority of the deceased lived in urban areas within Sudan (58.6%), followed by 28.7% in rural areas, and 10.8% had moved outside Sudan. In terms of education, 49.6% had a university degree, 29.5% had secondary education, and the rest had primary or no formal education. The timing of sudden deaths varied, with the highest occurrence within the first year of the war (42.8%), followed by deaths occurring immediately after the war began (29.1%). The remaining 28.1% of cases occurred more than a year into the conflict.

Causes and Circumstances of Sudden Death

The study explored various aspects related to the sudden death of individuals during the war, focusing on the causes, healthcare access, emotional and financial impact on families, and delays in medical care. The primary contributing factor to the death was psychological trauma, reported by 54.4% of respondents. Other factors included pre-existing health conditions (23.8%) and physical injury during the war (12.4%). A large majority, 76.5%, believed that the death was directly related to the trauma of the war or stress resulting from it.

Regarding healthcare, 35% of respondents received general medical care, 19.7% accessed emergency services, and 1.7% sought mental health services. However, 43.7% of respondents stated that healthcare was not applicable to their situation. Access to healthcare during the war was limited for many, with 37.4% having no access, while 35% had limited access and only 15.8% had continuous access.

The emotional impact on families was significant, with 71.6% reporting a severe impact, and 19.9% reporting a moderate impact. Financially, 38.6% experienced minor or no impact, while 16.3% faced severe financial challenges.

Finally, 47.8% of respondents reported a delay in receiving emergency medical care at the time of death, while 35.4% received timely care, and 16.7% were unsure about the timing of care. These findings underline the multifaceted effects of the war on both the physical and psychological well-being of families.

Table 1 presents the most common cause was heart attack or heart problems, accounting for 35.2%. Other significant causes included stroke (5.3%), respiratory failure (5.3%), and hemorrhagic fever (3.9%).

Table 1 Suspected cause of the sudden death
	Frequency	Valid Percent
TumorPanicAcute circulatory collapseHeart attack or heart problemMalariaHypertension complicationsDiabetic complicationsSudden kidney failureRespiratory failureStrokeHemorrhagic feverShot gunExplosion of a shellalling from a heightElectric shockPsychological/Emotional CausesUnknown causeTotal	4	1.0
2	.5
3	.7
145	35.2
4	1.0
1	.2
7	1.7
3	.7
22	5.3
22	5.3
1	.2
16	3.9
5	1.2
1	.2
2	.5
12	2.9
162	39.3
412	100.0

The table2 shows that, the 30.6% of respondents indicated that the deceased experienced Physical stress or injuries, 57.3% reported they did not, and 12.1% were unsure.

Table 2 Experience of Significant Physical Stress or Injuries During the War
	Frequency	Valid Percent
YesNoUnknownTotal	126	30.6
236	57.3
50	12.1
412	100.0

The table 3 shows that, the 78.9% of respondents indicated that the deceased experienced psychological or emotional trauma

Table 3 Psychological or Emotional Trauma Experienced by the Deceased Due to the War
	Frequency	Valid Percent
YesNoUnknownTotal	325	78.9
85	20.6
2	.5
412	100.0

The table 4 shows that, the 30.8% of respondents reported that the deceased had been diagnosed with an illness, while 68.7% stated they had not. Only 0.5% were unsure. The total number of valid responses were 412.

Table 4 Pre-War Illness Diagnosis of the Deceased
	Frequency	Valid Percent
YesNoUnknownTotal	127	30.8
283	68.7
2	.5
412	100.0

The table 5 shows that most of the diseases diagnosed in the deceased before the war were hypertension and diabetes (3.2%), hypertension alone (7.8%), and diabetes alone (5.3%). Other conditions included cardiac disorders (3.9%), neurological disorders (2.4%), and cancer (1.0%). A significant portion of respondents (69.4%) indicated that no disease diagnosis was known.

Table 5 Pre-War Disease Diagnosis Among the Deceased
	Frequency	Valid Percent
Hypertension and DiabetesHypertensionDiabetesRheumatismNeurological Disorders (Alzheimer’s, Parkinson’s, Stroke and Epilepsy)Systemic Lupus ErythematosusRenal FailureThyroid disordersCancerCardiac disordersAsthmaProstatic disordersPsychological disordersOtherN\ATotal	13	3.2
32	7.8
22	5.3
1	.2
10	2.4
1	.2
3	.7
1	.2
4	1.0
16	3.9
4	1.0
3	.7
4	1.0
12	2.9
286	69.4
412	100.0

The table 6 shows that, the 79.4% of respondents reported that the deceased had not been diagnosed with a disease after the war began.For psychological conditions, the majority (59.7%) stated that the deceased were not diagnosed with any psychological condition.

Table 6 Post-War Disease Diagnosis Among the Deceased
Physical Disease Diagnosis
	Frequency	Valid Percent
YesNoUnknownTotal	71	17.2
327	79.4
14	3.4
412	100.0
Psychological Conditions Diagnosis
Yes	46	11.2
No	246	59.7
Unknown	120	29.1
Total	412	100.0

The table 7 that, 51.2% of the deceased experienced symptoms of psychological stress such as depression, anxiety, or PTSD.

Table 7 Psychological Stress Symptoms Among the Deceased
	Frequency	Valid Percent
YesNoUnknownTotal	211	51.2
92	22.3
109	26.5
412	100.0

Table 8 reveals statistically significant relationships between demographic and occupational factors and the causes of sudden death. Age is significantly associated with the cause of sudden death, as well as the likelihood of experiencing physical stress or injuries during the war (p < 0.05). Gender also plays a role, with males more frequently reporting physical injuries, while females emphasize healthcare deficiencies. Sudden death has a substantial emotional and financial impact on families. Occupation is strongly linked to experiences of physical stress and psychological trauma during the war, with statistically significant results for both physical (57.663) and psychological trauma (250.912) (p < 0.05). Additionally, occupation influences access to healthcare during and after the war, where employees and retirees had the highest levels of continuous access, while teachers and freelance workers faced the most difficulties. There is also a significant association between occupation and contributing factors to sudden death, with pre-existing health conditions and psychological trauma being the most reported causes. Employees and retirees exhibited high levels of psychological trauma, while soldiers and employees were notably affected by physical injuries sustained during the war.

Table 8 Factors Associated with Sudden Death: Analysis of Age, Gender, Occupation, and Psychological, Health, and Social Impacts"
age and the cause of sudden death.
	Value	df	Asymp. Sig. (2-sided)
Pearson Chi-Square	79.270a	48	.003
age and the cause of sudden death
	Value	df	Asymp. Sig. (2-sided)
Pearson Chi-Square	20.053a	6	.003
Age and Experience of Physical Stress or Injuries During War
	Value	df	Asymp. Sig. (2-sided)
Pearson Chi-Square	20.053a	6	.003
Factors Contributing to Sudden Death Based on Gender
	Value	df	Asymp. Sig. (2-sided)
Pearson Chi-Square	26.594a	8	.001
Emotional Impact of Sudden Death on Families
	Value	df	Asymp. Sig. (2-sided)
Pearson Chi-Square	58.210a	21	.000
Financial Impact of Sudden Death on Families
Pearson Chi-Square	55.646	21	.000
Occupation of the Deceased and Experience of Physical stress During the War
	Value	df	Asymp. Sig. (2-sided)
Pearson Chi-Square	57.663a	26	.000
Occupation of the Deceased and Experience of psychological trauma During the War
Pearson Chi-Square	250.912	26	. 000
12Occupation of the Deceased and Access to Healthcare During and After the War
	Value	df	Asymp. Sig. (2-sided)
Pearson Chi-Square	74.168a	39	.001
Occupation and Contributing Factors to Sudden Death
	Value	df	Asymp. Sig. (2-sided)
Pearson Chi-Square	236.286a	104	.000

Discussion

This study expands on the socio-demographic profile, etiology, and risk factors for war-related sudden death, emphasizing the psychological and health consequences. The findings indicate that 60.9% of the deceased were male, and 77.4% were aged 36 years and above, aligning with previous studies that link war-related stress to higher cardiovascular disease risks in older populations [12]. Evidence suggests that older individuals are particularly vulnerable due to increased physical and psychological burdens associated with war exposure.

The study found that 35.2% of sudden deaths were attributed to cardiovascular diseases, 5.3% to strokes, and 5.3% to respiratory failure, confirming previous research on war-induced stress elevating cardiovascular events, displacement, and unaffordable medical care [13]. Psychological trauma, reported in 54.4% of cases, plays a significant role in health deterioration, exacerbating chronic illnesses and increasing the risk of sudden death [14].

A major issue highlighted by the study is the lack of access to proper healthcare, with 37.4% of respondents reporting no available medical services during the war, consistent with data from other conflict zones, such as Syria, where infrastructure destruction led to preventable deaths [15]. Furthermore, 47.8% of respondents experienced delays in emergency care, mirroring global patterns in conflict-affected regions where logistical and security challenges prevent timely medical intervention [16].

The study found that 78.9% of the deceased experienced psychological trauma, while 30.6% endured physical stress. Research by Heszlein-Lossius supports these findings, indicating that war survivors frequently develop stress-related disorders that contribute to long-term health deterioration [17]. Additionally, 30.8% of the deceased had pre-existing illnesses, suggesting that war-related stress and inadequate medical care may have worsened pre-existing conditions [18].

A significant correlation was found between age, gender, occupation, and cause of sudden death (p < 0.05). Occupational factors played a major role, with employees and retirees showing higher levels of psychological trauma, whereas soldiers and manual workers exhibited greater physical stress. Findings from post-war Bosnia and Herzegovina support this, showing that individuals in economically unstable environments experience heightened psychological distress [19]. Furthermore, freelancers and teachers faced the greatest healthcare access challenges, reflecting structural inequities in conflict-zone healthcare systems [20].

Overall, this study strengthens the growing body of evidence linking war to increased mortality through psychological trauma, healthcare system failures, and exacerbation of chronic conditions. Additional research is needed to develop targeted mental health interventions and improve healthcare access for the most vulnerable populations in conflict settings [21].

Conclusion

This study revealed the significant impact of armed conflict on sudden death in Sudan, with psychological trauma, limited healthcare access, and worsening chronic conditions being major contributing factors. Males, the elderly, and urban residents were the most affected, with cardiovascular diseases and strokes as leading causes. Occupational risks were also evident, especially among employees, retirees, and soldiers.

The study recommends urgent interventions to expand emergency services, provide mental health support, and enhance mobile and telemedicine units. Special attention should be given to vulnerable occupational groups. Future research should explore long-term health effects and strategies for rebuilding healthcare systems in conflict-affected areas.

Limitations

This study acknowledges several limitations that may impact its findings. The use of purposive sampling, while effective for gathering in-depth information, may introduce sampling bias and limit the representativeness of the study population. Additionally, the inability to independently verify causes of death presents a challenge in ensuring data accuracy. Security risks and population displacement also posed significant constraints on data collection, restricting access to certain affected groups. Furthermore, recall bias may have influenced participants' responses, particularly regarding psychological distress and healthcare access. Lastly, the findings may not be fully generalizable to other conflicts or regions, as war-related health outcomes vary based on contextual factors.

Acknowledgment

Our heartfelt appreciation goes out to the Sudanese people who continue to endure the hardships of war, especially those who have lost loved ones or suffered greatly. Our commitment to tackling impactful problems is fueled by their resilience. It is with deep gratitude that we acknowledge the outstanding leadership and invaluable contribution of Dr. Henry V. Doctor, who is the Coordinator for Information Systems for Health at the World Health Organization, Regional Office for the Eastern Mediterranean. We have been guided by his guidance throughout our research. lastly, we thank everyone who supported us in bringing this work to fruition.

Conflict of Interest

The authors declare no conflicts of interest related to this study. This research was conducted independently, without any financial, institutional, or personal affiliations that could influence the findings. The results presented are based solely on data analysis and objective interpretation, ensuring scientific integrity and neutrality.

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