As fighters from the Rapid Support Forces paramilitary closed in on government positions in the besieged Sudanese city of al-Fashir in October, a skeleton crew from the city’s last functioning hospital treated a surge of wounded in a makeshift emergency room.

Shells pounded the area around Saudi Hospital, hitting civilians and combatants. It felt like “doomsday,” said one nurse. Her scrubs became soaked with blood as patients streamed in. Staff wrapped wounds and broken limbs in mosquito netting, having run out of gauze and tourniquets.

“We had to jump over the dead bodies to get to the patients,” the nurse said. “We couldn’t bury them because the drones were overhead.”

The next day October 26 shelling continued and RSF fighters entered the hospital, a witness said.On October 27, RSF fighters brought in Abdallah Yousif, a trader they had abducted on the road. Yousif told Reuters he saw bodies scattered throughout the compound children, women, elderly people and patients who had been too sick to flee. He said he watched RSF fighters taking people from the hospital. Some were held for ransom, others killed.

“They took the young men and killed them in the road,” Yousif said.

The World Health Organization reported that shelling of the Saudi Hospital killed one nurse and injured three other health workers on October 26. In a separate attack, on October 28, the WHO said, more than 460 patients and their companions were shot and killed there. Reuters was unable to confirm the date or death toll.

Satellite imagery from October 28 reveals signs of mass killings at Saudi Hospital. The images show clusters of human-sized objects, according to an analysis by the Yale Humanitarian Research Lab. Later images show what appears to be bodies being burned — a violation of Islamic burial customs — with white oblong objects “visibly charred with black smoke emitting,” according to Yale researchers.

The October attacks on Saudi Hospital were a stark example of what doctors viewed as a systematic campaign by the RSF to dismantle al-Fashir’s healthcare system, part of a broader effort to drive civilians away and take over the besieged capital of Sudan’s North Darfur state.

The RSF did not respond to requests for comment.

In an October statement issued before the takeover of al-Fashir, the RSF said that hospitals in the city had been used by its enemies as barracks and to launch attacks. Medics from al-Fashir disputed this, saying the facilities were used solely for medical purposes to treat both civilians and wounded soldiers. Under international humanitarian law, combatants who are incapacitated by sickness or injury are protected from attack, as are hospitals treating fighters.

Violence against healthcare facilities and workers is an increasingly reported tactic in modern warfare. Worldwide, at least 12,944 incidents of conflict-related violence and obstruction affecting healthcare were recorded from early 2021 through late October 2025, according to Insecurity Insight, which collects data for a group of international non-governmental organizations called the Safeguarding Health in Conflict Coalition.

Reported incidents peaked at 3,891 in 2024, up from 3,217 in 2023, 2,315 in 2022 and 1,602 in 2021. Conflicts in Gaza, Myanmar, Sudan and Ukraine were among the main drivers. Insecurity Insight bases its tallies on news reports, accounts from nonprofit organizations and other publicly available information. It does not have complete details on every incident, and the quality of reporting varies from country to country.

The data and interviews with more than a dozen doctors, aid workers and residents reveal a steady destruction and dismantling of healthcare capability in al-Fashir, the North Darfur capital, from the spring of 2024 and intensifying through the RSF takeover in October.

Since war erupted in Sudan in April 2023, combatants have attacked, damaged or obstructed healthcare in North Darfur at least 130 times, the Insecurity Insight data show. The data list RSF as responsible for at least 71% of the incidents; the Sudanese Armed Forces 3%. Most remaining cases involved unknown actors or RSF-SAF fighting. At least 40 health workers have been killed, according to the data.

In response to questions from Reuters a senior Sudanese army source said reports it attacked medical facilities are false. “The army was defending al-Fashir’s citizens before the RSF entered, and this is the army’s duty anywhere in Sudan,” the source said.

Attacks on healthcare intensified after the RSF besieged al-Fashir in April 2024. They ranged from looting and blocking of hospital supplies to shootings inside hospitals and artillery and drone strikes that forced facilities to close.

One by one, the city lost its hospitals. On May 11, 2024, an SAF airstrike landed about 50 meters from Babiker Nahar Children’s Hospital, collapsing the ICU roof and killing two children and a caregiver, according to the data and a report by the medical nonprofit Médecins Sans Frontières, which provided supplies and staff there. The hospital closed.

In June 2024, surgeon Ezzeldin Asow was in the middle of a procedure at Southern Hospital when RSF artillery tore through the operating theater, he told Reuters. The next day, he said, RSF soldiers raided the hospital and beat him. The hospital closed permanently, forcing his team to decamp to Saudi Hospital.

RSF advances pushed the city’s residents from one shattered clinic to the next, residents told Reuters.

“If the hospital gets hit, what will civilians do if they are injured?” Dr. Asow said. “Those who can, leave.”

Three doctors told Reuters the Saudi Hospital came under intensified attack after the facility became the last one standing more than a year ago. Incidents escalated from artillery strikes to drone attacks and, in recent months, near-daily bombardments.

Health workers were chased by drones, seven medics and three other sources told Reuters. Driven into hiding, doctors performed surgeries in foxholes and homes. Medical staff resorted to treating people in makeshift networks — triaging in one building, operating in another, sending patients to recover in a third. Ambulances were destroyed, so people hauled the wounded by wheelbarrow or donkey cart, only to have drones follow them and bomb the clinics upon arrival, the seven medics told Reuters.

“They bring the injured, and then the drone finishes them off at the door,” Dr. Asow said.

International laws of war forbid targeting civilians or civilian facilities and extend heightened legal protection to hospitals and medical units. The attacks on healthcare in al-Fashir, given their repeated and frequent nature, are clear violations, said Tom Dannenbaum, a Stanford Law School professor. “It’s unambiguous that this requires war crimes investigations,” he said.

Israa Mukhtar said RSF fighters cited the lack of adequate healthcare during an April attack that sent hundreds of thousands of civilians fleeing Zamzam, the displaced persons camp where she lived in North Darfur. Mukhtar and other women were collecting water at a pump near the camp’s main health center, run by aid group Relief International. RSF vehicles arrived and fighters spilled out.

“Why are you still here?” she recalled one fighter asking. “If you get injured, what will you do?” After someone replied that the health center was still open, the fighters drove toward the clinic. Minutes later, Mukhtar heard gunfire and screams.

Around 11 a.m. that day, RSF soldiers arrived at the clinic, said a nurse who worked there. The soldiers forced five men from the clinic’s staff to lie on their backs, pointed guns at them and shot them, the nurse said. When Mahmoud Babiker, a doctor, tried to leave the trench where he and the nurse were hiding, RSF soldiers shot him. He collapsed onto the nurse. The fighters then moved to another trench where three more of her male colleagues were hiding. The nurse heard gunshots. When she looked, all three were dead.

“They were like my brothers, all these men who died,” the nurse said. A total of nine staff were killed, including Babiker.

RSF fighters looted rooms, taking phones, laptops, medicine, therapeutic biscuits for malnourished children and milk, the nurse said. After killing her colleagues, one fighter called the nurse and a female coworker “falangayat,” a derogatory term used by the RSF for people who work with the Sudanese Armed Forces.

“Then we thought we would also die,” the nurse said. But one fighter told her and the female coworker to leave. She walked out with her hands raised, her dress covered in blood.

Former colleagues of the nurse and two other witnesses corroborated her account of the attack.

Among the dead at the Relief International health center were Mubarak Farid’s son Muhanad and his nephew and adopted son, Mohamed. Both worked as drivers for Relief International.

Farid, who supplied vehicles to Relief International, said he learned of the killings that evening. At the scene, he said, he saw that Muhanad had a gash in his leg that exposed bone. One victim was shot in the mouth. Dr. Babiker’s skull was shattered. Farid and three other men buried the dead in a single grave as missiles fell.

“These doctors had nothing to do with war,” Farid said. “And my sons had nothing to do with it. They never carried a gun in their lives.”