Sudan and South Sudan: Subsistence Farming, Market Economies, Conflict, and Healthcare Inequality

Author(s): Scott Douglas Jacobsen

Publication (Outlet/Website): A Further Inquiry

Publication Date (yyyy/mm/dd): 2025/08/24

Part 2 of 2

Eddie Thomas, a researcher specializing in Sudan and South Sudan, discusses the transition from subsistence farming to market economies, the impact of conflict, and healthcare inequalities. In this 2-part interview, he examines how wars have disrupted traditional kinship networks, pushing people into market dependency. South Sudan’s caloric intake has dropped, leading to malnutrition. Sudan’s healthcare disparities stem from colonial-era spatial inequalities and privatization. Border conflicts like Kafia-Kingi influence economic dynamics, and kinship networks are under pressure. Thomas advocates for universal healthcare and decommodification as solutions to economic instability and conflict. He acknowledges Sudanese revolutionaries striving for systemic change.

Scott Douglas Jacobsen: What are the key drivers behind Sudan’s healthcare inequalities? Are these comparable to those of other countries, or are their causes and characteristics unique?

Eddie Thomas: Sudan’s inequalities are well known and have multiple dimensions. One of the most significant factors is spatial inequality. Some regions benefit from Sudan’s merchant and trade systems, where the wealthier populations reside and have access to services. Then, some regions generate wealth for these merchant systems—through agriculture, gold mining, oil extraction, and food production—yet remain significantly disadvantaged.

Most of this wealth-generating activity occurs far from the centers of trade. Historically, Sudan’s economic hub has been around Khartoum. At the same time, peripheral areas have suffered from lower life expectancy, higher child mortality rates, and other indicators of material disadvantage. These disparities were entrenched during the 19th century due to colonial aggression and the arbitrary drawing of colonial borders, which heavily favoured the central regions.

The healthcare system that emerged under these conditions had serious shortcomings. There was a strong bias toward providing better healthcare in wealthier regions, with greater access to medical personnel and facilities. In contrast, poorer regions suffered from stark disparities in mortality rates, particularly infant and child mortality.

Furthermore, Sudan’s healthcare system has historically been skewed towards curative rather than preventative care. Those living in the capital could access expensive medical procedures. At the same time, those in remote areas often lacked access to vaccines or basic preventative medicine. This structural imbalance has persisted, reinforcing the country’s deep-seated healthcare access and outcomes inequalities.

After the end of the colonial period, there was a global movement toward primary healthcare, aiming to expand medical services to poor and marginalized communities. The goal was to provide the best possible healthcare for all, leading to the development of some health facilities in underserved peripheral regions. There was also an effort to improve healthcare access for economically disadvantaged populations. Sudan had significant social inequalities, with rich and poor people living side by side in cities. This movement gained momentum in the 1970s and 1980s.

However, by the 1980s, a global financial crisis caused a significant shift in the financial landscape. One of the outcomes was a severe debt crisis across Africa. Many governments have been encouraged to take out loans to build productive infrastructure and social welfare services, including healthcare. Right-wing economic policies advocating for privatization gained prominence when the debt crisis struck. These policies argued that people should not expect free healthcare, leading to declining public health services.

During this period, Sudan initially experienced some growth in healthcare access, and free services were available in many places. When I first visited Sudan, one could walk into a healthcare facility and receive basic treatment, such as a bandage, without charge. However, this changed drastically in the 1990s when a new military government took over. Adopting hyper-privatization and austerity measures, they systematically cut back public health services.

A weak, developing healthcare system came under immense strain. Additionally, the government initiated conflicts in many regions where they imposed austerity, as such policies often required coercion and repression. This further eroded the health system. By the early 21st century, Sudan’s healthcare had become highly privatized and heavily concentrated in Khartoum, which retained the majority of medical personnel.

Most Sudanese doctors sought better opportunities abroad, particularly in Saudi Arabia or the UK. Those who remained in Sudan preferred working in private hospitals in major cities, where they could earn a livable wage, rather than in underfunded public hospitals in rural areas, where salaries ranged between $50 and $200 per month—insufficient for someone who had endured the rigorous training required for a medical career.

As a result, Sudan developed a highly centralized healthcare system focused on Khartoum, making access to medical services in other regions extremely difficult. When Khartoum fell in April 2023, this unequal system was effectively decapitated. Most specialist hospitals, clustered around the presidential palace where intense fighting occurred, were forced to shut down, leaving only a few operational facilities.

Healthcare provision then shifted into two main spheres. On one hand, private actors relocated their services outside of Khartoum. On the other hand, grassroots emergency response groups emerged during the 2018–2019 revolution and stepped in to provide urgent medical care. These mutual aid organizations had pioneered self-help models, running emergency rooms nationwide. However, they were ill-equipped to handle the massive healthcare crisis. Their resources were scarce, medical buildings were destroyed, and doctors were arrested and tortured.

Despite their efforts, these groups faced overwhelming challenges and became key targets of government repression during this turbulent period.

Jacobsen: How have cross-border conflicts and territorial disputes, such as the Kafia-Kingi enclave, shaped some of the political-economic dynamics of the region?

Thomas: I worked on Kafia-Kingi a few years ago but am unaware of recent developments except through friends and other contacts. However, Sudan and South Sudan have a relatively unique set of border conflicts because they are both recent and unresolved. Border disputes exist across Africa—there is a contested triangle on the Egypt-Sudan border and another between South Sudan and Kenya, where different interpretations exist regarding ownership.

Often, the more powerful state maintains control over disputed enclaves. This has been the case along much of the Sudan-South Sudan border, where Sudan, with its larger population, military, and financial resources, has retained its presence in key border areas.

Not all border disputes are resolved through war. Most are long-term disputes that gradually get negotiated. Sudan has maintained control over Kafia-Kingi, a mineral-rich enclave South of Darfur, which, by legal standards, should have been ceded to South Sudan in 2011. The rules established that areas administered by southern provinces in 1936 would remain part of South Sudan. However, Kafia-Kingi was the largest land area transferred from South Sudanese to North Sudanese provincial administration, an early post-independence decision.

There were several reasons for this transfer. Kafia-Kingi was sparsely populated, making it a difficult area to govern. Additionally, its mineral wealth made it highly valuable, prompting authorities in Khartoum to exercise greater control over the region.

When South Sudan gained independence, border enclaves became one of the many unresolved issues negotiators had to address. Other complex matters included national debt allocation, ownership of embassies such as the one in Nairobi, and South Sudanese citizens’ status in Sudan. These were sensitive topics requiring significant compromise.

As a result, negotiations on border enclaves were indefinitely postponed, and it is likely to take a long time before any resolution is reached.

Kafia-Kingi is particularly significant because it borders the Central African Republic and Chad. Despite being a remote and sparsely populated area, it has become a hotbed of activity due to arms trafficking, gold smuggling, and the presence of various outlaw groups.

It is now a highly contested zone, as one of the major gold mines fueling the war in Sudan is located within the enclave. The ongoing conflict between the Rapid Support Forces, the military, and their respective allies is partly driven by control over these gold resources.

Unfortunately, this beautiful and remote forested region has been brutally drawn into the turmoil of modern geopolitics, with its resources becoming central to an increasingly violent conflict.

Jacobsen: What are the major challenges foreign-funded healthcare initiatives face in Sudan? Supply chains, delivery, application, things of this nature.

Thomas: Foreign funding does not constitute a significant portion of Sudan’s healthcare economy. The most recent national health accounts, published about six years ago, estimated that foreign funding accounted for approximately 5% of the country’s total healthcare costs. Much of this funding came from global philanthro-capitalist organizations, such as the Gates Foundation and Gavi, which focused on vertical programs.

Vertical programs allocate funds for specific interventions—such as vaccines or malaria nets—rather than supporting comprehensive healthcare systems. While these programs can lead to progress on urgent public health challenges, they are limited in scope. Effective healthcare requires addressing multiple needs simultaneously, and vertical programs do not always integrate well with broader health initiatives. For example, malaria nets alone are insufficient in communities facing malnutrition, infectious diseases, and epidemic outbreaks.

Most foreign-funded healthcare in Sudan was channelled through the Ministry of Health, which managed the distribution of funds and resources. However, with the government’s collapse, these funds’ status remains uncertain. Efforts have been made to transition toward UN funding mechanisms. However, coordination with the Ministry of Health is still necessary at some level, as it maintains connections across the country.

The volume of foreign aid has likely contracted, given the logistical challenges of transferring funds, purchasing medical supplies, and distributing goods within Sudan. Though I do not have precise figures, I suspect foreign funding has not increased. An increasingly significant element of foreign-funded healthcare is diaspora remittances, which support emergency rooms providing critical care across Sudan.

Jacobsen: What about kinship networks in Sudan and South Sudan’s economies? Are these scaled in a way that helps at least some of the population and mitigates healthcare gaps?

Thomas: Kinship networks exist everywhere, don’t they? Powerful figures like Mr. Trump have kinship networks even in the United States. They are an integral part of social organization.

Economic and social life was historically structured around kinship-based production systems in many places. However, not all social orders were strictly kinship-based. Production was sometimes organized around alternative social networks, such as age groups. These networks were not necessarily based on family ties but on individuals coming of age together in a specific place—a pattern seen in many societies worldwide.

You see these types of networks everywhere—think of school reunions. People still attend them as useful networking events. For example, Harvard alums often connect with fellow graduates to secure job opportunities.

These networks have always existed, but previously, labour was not mobilized through markets. Instead, it was organized through reciprocal obligations that weren’t formally tracked or bartered. Let’s say, Scott, that you invite me for dinner tomorrow, then again the following week, and a couple of weeks later, a third time. I wouldn’t write you a check saying I owe you a dinner, but after the third invitation, I would likely feel an implicit obligation to return the favour. You, too, might expect that I reciprocate in some way.

That is a better way of understanding how these economies function than the concept of barter, which is largely an invention of right-wing economists who misunderstand social reciprocity. If you’ve invited me multiple times, I should contribute something. If you are significantly wealthier than me, I may not invite you back to my home out of embarrassment. Still, I will find another way to reciprocate—perhaps by helping you in some other manner.

These networks, however, are under immense pressure as people increasingly need money. Many are forced to relocate, live in refugee camps, or seek safety in displacement camps. In such environments, individuals must sell their labour and endure harsh conditions. The freedom to choose is greatly diminished, and they must adhere to external demands rather than act according to their social obligations.

Jacobsen: To move into a more constructive discussion, what policy recommendations could mitigate economic commodification and conflict in Sudan’s healthcare system or South Sudan?

Thomas: If you want a policy recommendation, why not aim for a global free healthcare system modelled after Canada or Cuba? If discussing real solutions, why not advocate for a universal healthcare system?

People are under tremendous pressure to access healthcare and education, enduring significant hardships to obtain these basic needs. Nearly everyone would prefer free healthcare and education. Suppose wealthy countries do not want people migrating across their borders. Why not invest in comprehensive social services in their home countries? By fully decommodifying healthcare and education, you incentivize people to remain in their communities rather than seek opportunities elsewhere.

That is a genuine policy recommendation. There are other policy approaches, but I often see them as non-solutions. For example, some propose micro-enterprise programs to empower women—yet these initiatives often result in marginal economic gains, with individuals earning just a few dollars a month. These approaches fail to address the root causes of economic disparity and healthcare inequity.

Those are the policy prescriptions of the aid industry, but they have been tried before.

Jacobsen: Do you have any comments on Omer Al-Bashir’s impact on healthcare access or medical services, particularly in rural areas?

Thomas: He was an arch-neoliberal, managing healthcare in rural areas accordingly.

Jacobsen: Who do you think is leading, organizationally or individually, a positive collective movement toward a better future for Sudan? Who is working towards reducing human rights abuses, improving healthcare, and ensuring people’s needs are met?

Thomas: Sudan has undergone a revolution. Brilliant revolutionaries have eloquently articulated Sudan’s crisis and proposed practical solutions. They have devised models of decommodified healthcare in a highly commodified healthcare environment. These individuals and movements are leading the way, and people should pay attention to what they have to say.

Jacobsen: Excellent. Eddie, I have no more questions. Thank you very much for your time today. It was nice to meet you.

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