Building, Breaking, and Beyond: Lessons from Sudan’s National Mass Casualty Preparedness Program

The global disaster risk landscape has undergone a profound, century-long transformation, yielding increasingly complex and ubiquitous hazards impacting all nations. This pervasive evolution, evidenced by frequent, widespread disasters, unequivocally demonstrates that no nation is impervious to the extensive public health and societal ramifications.[1,2] Consequently, in light of these escalating complexities, governments and international organizations have increasingly foregrounded community resilience and robust disaster risk reduction frameworks.[3] Central to these endeavors is the imperative for health systems to adeptly anticipate, absorb, and respond to disaster-induced health sequelae. Attaining this requires specialized acumen, rigorous evidence-based methodologies, and seamless multisectoral orchestration for efficacious, prompt intervention.[4] This necessitates the integration of domain-specific knowledge, the deployment of empirically validated strategies, and the synchronized execution of multisectoral actions to ameliorate adverse impacts on population health and societal infrastructure.[5] Program overview: Aims and Scope Mass casualty incidents (MCIs) defined as events that rapidly overwhelm local healthcare systems, resulting in casualty numbers that surpass available resources and capabilities. Such events necessitate the mobilization of additional resources and coordinated multi-agency responses to ensure the effective care and management of affected populations.[6] This broad definition encompasses diverse traditional disasters as earthquakes, floods, and transportation accidents in addition to nontraditional emergencies as chemical spills and radiological incidents. In 2007, Sudan’s Federal Ministry of Health (FMoH) initiated a national program aimed at enhancing disaster preparedness and response within both pre-hospital and hospital contexts. The primary goal was to strengthen the health system and its affiliates through the acquisition of essential competencies, operational frameworks, and resources for effective MCI management, thereby aligning international best practices with local needs.[3] This initiative reflects a robust commitment to enhancing Sudan’s capacity in mitigating the health impacts of catastrophic events and reinforcing overall health system resilience. Program phases: A Staged Implementation Approach The program implementation unfolded through systematically structured phases that commenced with the establishment of a dedicated mass casualty unit (MCU) within the FMoH as the central coordinating body. A multidisciplinary technical committee, comprising experts in disaster management, emergency medicine, and public health, was assembled and trained to steer program development. A significant output was the formulation of a comprehensive national guideline for disaster preparedness and response, anchored in an evidence-based framework tailored to national needs, thereby enhancing coordinated actions across all strata of the health system.[3] The implementation phase employed a robust multifaceted capacity-building strategy, encompassing extensive training to bolster the competencies of both healthcare and non-healthcare personnel in disaster risk management [Figure 1]. This phase cumulatively produced extensive national and sub-national plans for preparedness, resilience, response, and recovery, stipulating comprehensive all-hazards, multi-agency protocols for various disaster scenarios.Figure 1: Moulage of multiple casualties during a disaster management training exercise at a medical instituteA validation phase followed, which evaluated operational readiness through extensive simulation exercises, including full-scale field drills simulating casualties, facilitated by Sudanese Red Crescent Society volunteers. These exercises assessed system functionality and inter-agency coordination under simulated emergency conditions [Figure 2].Figure 2: Pre-exercise orientation for out-of-hospital disaster management trainingConcurrently, proficient trauma and disaster rapid response teams were established for fast deployment to crisis areas. To ensure long-term sustainability, the initiative established a framework that includes regular forums on disaster preparedness and the development of community-based disaster response teams [Figure 3]. Program evaluation focused on stakeholder engagement throughout pre-implementation, implementation, and post-implementation phases, utilizing standardized forms completed by at least two independent observers. Findings were discussed in the MCU meetings and incorporated into final reports, while regular stakeholder assessment reports facilitated continuous program evaluation and refinement, fostering a deeply ingrained culture of preparedness and resilience across all societal levels.Figure 3: Moulage for training in-hospital triage of severe trauma in medical disaster scenariosProgram outcomes: Assessment and Attainment A diverse array of public, private, and military healthcare institutions engaged in a systematic initiative across all 18 Sudanese states, yielding three primary outcomes: the training of 30%–40% of health and related non-health personnel per state, the formulation of comprehensive hospital-specific MCI management plans, and the validation of these plans through mock victim simulation exercises. In the capital, implementation encompassed over 10 hospitals, including military and police facilities, along with ambulance services, supplemented by biannual reevaluation simulations in select states. These efforts culminated in the establishment of localized trauma and MCI management protocols, thereby enhancing overall preparedness through the strategic allocation of specialized personnel. Notwithstanding various operational challenges, including a lack of political will, ineffective engagement from political officials and the public, inadequate infrastructural support, particularly in communication systems, and poor funding resources, the program has nonetheless achieved significant progress in improving national MCI readiness, notably through the widespread adoption of a standardized framework facilitated by the MCU. However, this progress was severely compromised by the onset of the armed conflict, which rendered many participating health institutions actively participating in the program non-operational within the first week of the conflict, also targeted trained personnel, impeding their access to service areas.[7-9] Post-conflict status: Challenges and Pathways to Recovery The recent catastrophic conflict in Sudan has severely undermined the healthcare system, resulting in extensive facility destruction, operational disruptions, and a considerable outflow of health professionals.[7,9] A centralized disaster management body risks inefficacy amid systemic collapse; thus, post-conflict health system reconstruction necessitates a decentralized strategy involving state and local entities, supported by robust legislation to incorporate internationally adapted, locally relevant guidelines. The focus must shift to establishing multi-focal mass casualty units across urban centers, integrated within a comprehensive national disaster management plan informed by international best practices. Furthermore, mandatory disaster management training should encompass all demographics including public, students, and government officials beyond healthcare professionals, as these groups may become critical resources during MCIs.[10] Such measures are essential for cultivating resilience and augmenting the healthcare system’s efficacy in disaster aftermath. Conclusion The comprehensive national disaster program significantly enhanced Sudan’s MCI preparedness through systematic planning, extensive training, and simulation exercises, fostering a culture of resilience. However, recent armed conflicts severely disrupted these advancements, highlighting the critical need for decentralized MCUs, evidence-based strategic plans, and mandatory, widespread disaster management training to rebuild and strengthen the national healthcare system’s resilience against future catastrophic events. Financial support and sponsorship Nil. Conflicts of interest There are no conflcits of interests.