Medical evidence of human rights violations against non-Arabic-speaking civilians in Darfur: a cross-sectional study.
ABSTRACT Ongoing conflict in the Darfur region of Sudan has resulted in a severe humanitarian crisis. We sought to characterize the nature and geographic scope of allegations of human rights violations perpetrated against civilians in Darfur and to evaluate their consistency with medical examinations documented in patients' medical records.
This was a retrospective review and analysis of medical records from all 325 patients seen for treatment from September 28, 2004, through December 31, 2006, at the Nyala-based Amel Centre for Treatment and Rehabilitation of Victims of Torture, the only dedicated local provider of free clinical and legal services to civilian victims of torture and other human rights violations in Darfur during this time period. Among 325 medical records identified and examined, 292 (89.8%) patients from 12 different non-Arabic-speaking tribes disclosed in the medical notes that they had been attacked by Government of Sudan (GoS) and/or Janjaweed forces. Attacks were reported in 23 different rural council areas throughout Darfur. Nearly all attacks (321 [98.8%]) were described as having occurred in the absence of active armed conflict between Janjaweed/GoS forces and rebel groups. The most common alleged abuses were beatings (161 [49.5%]), gunshot wounds (140 [43.1%]), destruction or theft of property (121 [37.2%]), involuntary detainment (97 [29.9%]), and being bound (64 [19.7%]). Approximately one-half (36 [49.3%]) of all women disclosed that they had been sexually assaulted, and one-half of sexual assaults were described as having occurred in close proximity to a camp for internally displaced persons. Among the 198 (60.9%) medical records that contained sufficient detail to enable the forensic medical reviewers to render an informed judgment, the signs and symptoms in all of the medical records were assessed to be consistent with, highly consistent with, or virtually diagnostic of the alleged abuses.
Allegations of widespread and sustained torture and other human rights violations by GoS and/or Janjaweed forces against non-Arabic-speaking civilians were corroborated by medical forensic review of medical records of patients seen at a local non-governmental provider of free clinical and legal services in Darfur. Limitations of this study were that patients seen in this clinic may not have been a representative sample of persons alleging abuse by Janjaweed/GoS forces, and that most delayed presenting for care. The quality of documentation was similar to that available in other conflict/post-conflict, resource-limited settings.
- SourceAvailable from: Emily Banks[Show abstract] [Hide abstract]
ABSTRACT: Armed conflict has broad-ranging impacts on the mental health and wellbeing of children and adolescents. Mental health needs greatly exceed service provision in conflict settings, particularly for these age groups. The provision and targeting of appropriate services requires better understanding of the characteristics and requirements of children and adolescents exposed to armed conflict. Routine patient and programme monitoring data were analysed for patients <20 years of age attending mental health services provided by Médecins Sans Frontières (MSF) in three countries affected by armed conflict: the Democratic Republic of Congo (DRC), Iraq and the occupied Palestinian territory (oPt). The demographic characteristics, presenting mental health complaint, attributed precipitating event, services provided and short-term outcomes for mental health services users in each country are described. Between 2009 and 2012, 3025 individuals <20 years of age presented for care in DRC and Iraq, and in 2012 in oPt, constituting 14%, 17·5% and 51%, respectively, of all presentations to MSF mental health services in those three countries. The most common precipitating event was sexual violence in DRC (36·5%), domestic violence in Iraq (17·8%) and incarceration or detention in oPt (33%). Armed conflict-related precipitants were reported by 25·9%, 55·0% and 76·4% of youths in DRC, Iraq and oPt, respectively. The most common presenting complaints in children and adolescents were anxiety-related, followed by mood-related, behaviour-related and somatisation problems; these varied according to country and precipitating event. Although a high proportion (45·7%) left programmes early, 97% of those who completed care self-reported improvement in their presenting complaint. Brief trauma-focused therapy, the current MSF mental health therapeutic intervention, appears to be effective in reducing symptoms arising from the experience of trauma. Although inferences on outcomes are limited by high default rates, this provides a feasible tool for addressing the mental health needs of children exposed to armed conflict. Priorities for future research include understanding why children and adolescents constitute a small proportion of patients in some programmes, why many leave care early and how to address these issues, but this research must occur within the context of efforts to provide access to mental health services for children.Paediatrics and international child health. 11/2013; 33(4):259-72.
- [Show abstract] [Hide abstract]
ABSTRACT: Following the declaration that President Mwai Kibaki was the winner of the Kenyan presidential election held on December 27, 2007, a period of post-election violence (PEV) took place. In this study, we aimed to identify whether the period of PEV in Kenya was associated with systematic changes in sexual assault case characteristics.PLoS ONE 08/2014; 9(8):e106443. · 3.53 Impact Factor
Medical Evidence of Human Rights Violations against Non-
Arabic-Speaking Civilians in Darfur: A Cross-Sectional Study
Alexander C. Tsai1,2.*, Mohammed A. Eisa3,4., Sondra S. Crosby3,5,6, Susannah Sirkin3,
Michele Heisler3,7,8,9, Jennifer Leaning10, Vincent Iacopino3,11,12
1Robert Wood Johnson Health and Society Scholars Program, Harvard University, Cambridge, Massachusetts, United States of America, 2Center for Global Health,
Massachusetts General Hospital, Boston, Massachusetts, United States of America, 3Physicians for Human Rights, Cambridge, Massachusetts, United States of America,
4Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts, United States of America, 5Department of Medicine, Boston University School of Medicine,
Boston, Massachusetts, United States of America, 6Department of Health Law, Bioethics, and Human Rights, Boston University School of Public Health, Boston,
Massachusetts, United States of America, 7Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan,
United States of America, 8Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States of America, 9Department of Health
Behavior and Health Education, School of Public Health,University of Michigan, Ann Arbor, Michigan, United States of America, 10Francois-XavierBagnoud Center for Health
and Human Rights, Harvard School of Public Health, Boston, Massachusetts, United States of America, 11Department of Medicine, University of Minnesota Medical School,
Minneapolis, Minnesota, United States of America, 12Human Rights Center, University of California at Berkeley, Berkeley, California, United States of America
Background: Ongoing conflict in the Darfur region of Sudan has resulted in a severe humanitarian crisis. We sought to
characterize the nature and geographic scope of allegations of human rights violations perpetrated against civilians in
Darfur and to evaluate their consistency with medical examinations documented in patients’ medical records.
Methods and Findings: This was a retrospective review and analysis of medical records from all 325 patients seen for
treatment from September 28, 2004, through December 31, 2006, at the Nyala-based Amel Centre for Treatment and
Rehabilitation of Victims of Torture, the only dedicated local provider of free clinical and legal services to civilian victims of
torture and other human rights violations in Darfur during this time period. Among 325 medical records identified and
examined, 292 (89.8%) patients from 12 different non-Arabic-speaking tribes disclosed in the medical notes that they had
been attacked by Government of Sudan (GoS) and/or Janjaweed forces. Attacks were reported in 23 different rural council
areas throughout Darfur. Nearly all attacks (321 [98.8%]) were described as having occurred in the absence of active armed
conflict between Janjaweed/GoS forces and rebel groups. The most common alleged abuses were beatings (161 [49.5%]),
gunshot wounds (140 [43.1%]), destruction or theft of property (121 [37.2%]), involuntary detainment (97 [29.9%]), and
being bound (64 [19.7%]). Approximately one-half (36 [49.3%]) of all women disclosed that they had been sexually
assaulted, and one-half of sexual assaults were described as having occurred in close proximity to a camp for internally
displaced persons. Among the 198 (60.9%) medical records that contained sufficient detail to enable the forensic medical
reviewers to render an informed judgment, the signs and symptoms in all of the medical records were assessed to be
consistent with, highly consistent with, or virtually diagnostic of the alleged abuses.
Conclusions: Allegations of widespread and sustained torture and other human rights violations by GoS and/or Janjaweed forces
against non-Arabic-speaking civilians were corroborated by medical forensic review of medical records of patients seen at a local
for care. The quality of documentation was similar to that available in other conflict/post-conflict, resource-limited settings.
Please see later in the article for the Editors’ Summary.
Citation: Tsai AC, Eisa MA, Crosby SS, Sirkin S, Heisler M, et al. (2012) Medical Evidence of Human Rights Violations against Non-Arabic-Speaking Civiliansin Darfur: A
Cross-Sectional Study. PLoS Med 9(4): e1001198. doi:10.1371/journal.pmed.1001198
Academic Editor: Egbert Sondorp, London School of Hygiene and Tropical Medicine, United Kingdom
Received July 15, 2011; Accepted February 16, 2012; Published April 3, 2012
Copyright: ? 2012 Tsai et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study was funded by Physicians for Human Rights with support from the Open Society Foundations and the Sudan Aid Fund of the Community
Foundation of Western Massachusetts. ACT received salary support through the Robert Wood Johnson Health & Society Scholars Program. MAE received salary
support through Physicians for Human Rights, the Open Society Foundations, the Sudan Aid Fund of the Community Foundation of Western Massachusetts, the
Scholar Rescue Fund of the Institute for International Education, and the Robert F. Kennedy Center for Justice and Human Rights, as well as in-kind support from
the Harvard Humanitarian Initiative. No funding bodies had any role in the study design, data collection and analysis, decision to publish, or preparation of the
Competing Interests: Six of the study authors are currently affiliated with organizations that advocate for the prevention of mass atrocities, protection of
internationally guaranteed rights, and/or prosecution of those who violate human rights: the Amel Centre for Treatment and Rehabilitation of Victims of Torture
(MAE), Physicians for Human Rights (MAE, SC, SS, MH, VI), the Harvard Humanitarian Initiative (MAE), the Francois-Xavier Bagnoud Center for Health and Human
Rights at the Harvard School of Public Health (JL), and the Human Rights Center at the University of California at Berkeley (VI). From 2004 to 2009, one of the study
authors (MAE) served as medical director of the clinic from which the data were obtained. All authors have declared that no financial conflicts of interest exist.
Abbreviations: ICC, International Criminal Court; IDP, internally displaced person; GoS, Government of Sudan
* E-mail: firstname.lastname@example.org
. These authors contributed equally to this work.
PLoS Medicine | www.plosmedicine.org1April 2012 | Volume 9 | Issue 4 | e1001198
In the Darfur region of western Sudan, ongoing conflict
between Arabic-speaking and non-Arabic-speaking tribes [1,2]
has reached crisis proportions since the Government of Sudan
(GoS) first initiated its military response to organized armed
groups opposing the GoS . In addition to targeting armed rebel
forces in its response, however, the GoS has also been accused of
targeting non-Arabic-speaking civilians, namely members of the
Fur, Masalit, and Zaghawa tribes [3,4]. By the end of 2007, more
than 2.4 million refugees from the violence, or nearly one-third of
the population , had fled to camps for internally displaced
persons (IDPs) within Darfur or to similar refugee camps in
neighboring Chad , thus creating a severe humanitarian
Prior research has focused on generating accurate mortality
estimates to inform policy and programming [7–13], with recent
studies estimating 200,000–300,000 deaths directly and indirectly
attributable to the conflict in 2003–2005 alone [14,15]. The
reported systematic, repeated, targeted assaults on non-Arabic-
speaking civilians, large-scale disruption of rural livelihoods, and
deliberate consignment to conditions conducive to death have
prompted observations that these could constitute acts of genocide
[4,5,16–19]. Following a United Nations–appointed Commission
of Inquiry and an International Criminal Court (ICC) investiga-
tion, the Pre-Trial Chamber I of the ICC issued arrest warrants for
allegedly responsible authorities, including two arrest warrants for
Sudanese President Omar Hassan Ahmad Al Bashir (‘‘Al Bashir’’)
on the grounds of crimes against humanity (March 4, 2009)
[20,21] and genocide (July 12, 2010) .
Despite investigations into the violence in Darfur, little research
to date has been able to make use of Sudanese documents to
substantiate victims’ or observers’ claims of violence amounting to
war crimes, crimes against humanity, or genocide. GoS forces
were implicated in the Atrocities Documentation Survey [5,23–
25]. Arab Janjaweed (‘‘men with guns on horses or camels’’)
militias, which originated as Libyan proxy militias in the Chadian
civil war and have been suspected of collaborating with GoS forces
, have been implicated in reports of sexual violence described
by Darfuri women now living in IDP camps . The systematic
destruction of livelihoods, which under certain circumstances can
be considered an act of genocide [17,27,28], has also been
described. However, a critical limitation of prior studies is their
reliance on self-report data gathered from victims living in refugee
camps outside of Sudan. One team of investigators attempted to
conduct interviews at IDP camps within Darfur but was refused
access by the GoS [17,27]. With unique access to medical records
of clinical encounters in Darfur, we undertook this study to
characterize the nature and geographic scope of alleged abuses
against civilians in Darfur and to substantiate the allegations with
forensic review and analysis of the medical evidence.
As this was a retrospective analysis of de-identified medical
records, informed consent was not obtained. All study procedures
were approved by the Harvard School of Public Health Office of
Human Research Administration as well as an independent ethics
review board convened for this research project by Physicians for
Human Rights. Given that the medical records used in the analysis
were de-identified, this research project was assessed to represent
minimal risk to Amel Centre patients. The ethics review board was
guided by the relevant process provisions of Title 45 of the US
Code of Federal Regulation and the Declaration of Helsinki as
revised in 2000  and was composed of individuals with
expertise in forensic medicine, public health, bioethics, and
international health and human rights research.
Study Population and Setting
Data for this study consisted of 325 de-identified medical
records of all initial visits (i.e., excluding follow-up visits) of patients
seen for treatment at the Amel Centre for Treatment and
Rehabilitation of Victims of Torture, in Nyala, South Darfur, from
its opening on September 28, 2004, through December 31, 2006.
Records for 2007–2009 could not be retrieved because of ongoing
security concerns (as described in more detail below). With funding
from the European Commission, the United Nations High
Commissioner for Refugees, the US Agency for International
Development, and the United Nations Development Programme,
the Amel Centre was the only dedicated local non-governmental
provider of free clinical and legal services to any civilian victim of
torture or other human rights violations. The Amel Centre
received referrals from volunteers placed in three large IDP camps
near Nyala (Dreig, Otash, and Kalma) but accepted civilian clients
from all over Darfur. Aside from the free services, and
transportation to and from the IDP camps, patients were not
given additional incentives or benefits.
The Amel Centre’s initial staff in the Nyala office consisted of
one general medicine doctor (M. A. E.), one junior doctor, one
psychosocial worker, and two lawyers. Their training on the
treatment of victims of torture and sexual violence was facilitated
by the Sudan Organisation Against Torture and was consistent
with the Manual on Effective Investigation and Documentation of Torture
and Other Cruel, Inhuman or Degrading Treatment or Punishment
(‘‘Istanbul Protocol’’) [30–32]. The paper-based record-keeping
system was similar to other prototypical clinics operating in
conflict zones. Although examining clinicians typically conversed
with patients in the patients’ language of choice (typically Fur,
Zaghawa, or Dago), notes documenting the encounters were
written in English. A standardized medical record form was used,
but few fields specified closed-ended responses (e.g., ‘‘name,’’
‘‘date of birth,’’ ‘‘date of detention’’). The content of the clinical
encounter, and therefore the bulk of the medical record
documentation, was driven by patients’ concerns. A network of
volunteer physicians and social workers provided specialty care,
and all women who disclosed that they had been sexually assaulted
were referred to a gynecologist for evaluation. The laboratories
associated with the network were able to implement all necessary
blood, urine, stool, serological, and pregnancy tests but did not
have the capacity for deoxyribonucleic acid analysis. After the
initial visit, follow-up visits were provided to assess symptomatic
improvement and provide longer term physiotherapy where
indicated. The care provided and coordinated by the Amel
Centre was delivered under difficult and often dangerous field
conditions. After the ICC issued the first arrest warrant for Al
Bashir , the Sudanese Ministry of Humanitarian Affairs
ordered the Amel Centre, along with two other local and 13
foreign aid groups, to cease operations . The three clinicians
formerly on staff are now living abroad. Prior to fleeing the
country, they preserved hard copies of the medical records for
2004–2006 and sent them out of the country.
Amel Centre clinicians generated the medical records for the
purposes of clinical care and internal record-keeping. We sought
Human Rights Violations in Darfur
PLoS Medicine | www.plosmedicine.org2April 2012 | Volume 9 | Issue 4 | e1001198
to abstract the data both accurately and in such a way as to
capture the main themes identified in the records. Guided by prior
research [34–41], we created a list of different types of abuses that
may be considered evidence of torture and/or other human rights
violations, as well as symptoms potentially reported by patients
and signs potentially documented by examining clinicians. Then
we developed a medical record abstraction tool that included lists
of standardized names (e.g., tribes and rural council areas) and
response options to guide efficient abstraction of data (Text S1).
Data were abstracted by one of the authors (A. C. T.) from the
demographic, incident, and clinical care components of the Amel
Centre’s general medical records. Although the general medical
records may have noted the presence of diagnostic or laboratory
testing, or specialty medical records, access to these raw data
elements unfiltered by the examining clinicians (e.g., diagnostic
imaging or laboratory reports) were not available for our analysis.
We collected data on patient socio-demographic characteristics,
alleged abuses, and the harms reportedly resulting from the
abuses. To assess the reliability of the data abstraction tool for
coding the key variables on alleged abuses, we randomly selected
20 medical records for independent coding by two other study
authors (M. A. E. and S. S. C.) as well as for wider discussion by
the research team. Inter-rater agreement exceeded 0.70 on the
coding of most of these variables. The abstraction tool was further
refined through an iterative process to ensure that the variables
were clearly defined and could be applied consistently to the data.
With regards to content validity, the 20 records were carefully
reviewed to ensure that all potential categories were represented.
Data from the remaining 305 medical records were then
abstracted by a single author (A. C. T.).
Medical Opinions on Alleged Abuses
Two study authors with extensive medical experience in the
evaluation and treatment of survivors of torture and other forms of
physical and psychological abuse (S. S. C. and V. I.) independently
reviewed each medical record, blinded to each other’s assessments.
First, they determined whether the medical record contained
sufficient detail to enable an informed opinion about the
consistency of the documented signs and symptoms with the
record of alleged abuses in the medical notes. Second, among the
cases that did contain sufficient detail, they assessed the extent to
which the recorded signs and symptoms were consistent with the
alleged abuses described in the medical record. Consistency was
scored using a five-point Likert-type scale: ‘‘not related to alleged
abuse,’’ ‘‘not consistent with,’’ ‘‘consistent with,’’ ‘‘highly consis-
tent with,’’ and ‘‘virtually diagnostic of.’’ These evaluations were
based on the Istanbul Protocol [30–32] and other conventions for
the evaluation of survivors of torture and other human rights
Data were entered into Excel (version 12.0, Microsoft) and then
exported to Stata (version 11.0, StataCorp) for analysis. We
characterized socio-demographic, incident, and clinical variables
with medians and inter-quartile ranges. Inter-rater agreement was
assessed using the kappa statistic . The locations of alleged
attacks were mapped to the longitude and latitude [47–49] of the
administrative center, principal town, or largest secondary town of
the rural council area where they were reported to have taken
place. ArcGIS (version 9.2, Esri) was used to generate a
continuously variable proportional circle map, with circle sizes
classified into seven categories using the Fisher-Jenks algorithm
Characteristics of Amel Centre Patients
We obtained medical records for all 325 patients presenting for
care at the Amel Centre from September 28, 2004, to December
31, 2006. Summary statistics are presented in Table 1. Most
patients were brought in by friends or relatives (54.2%) or by staff
or volunteers (28.0%). Median age was 35 y, with a range of 4–
82 y. Thirty patients (9.2%) were under the age of 18 y. Men
comprised the majority of patients (252 [77.5%]). Approximately
one-half (49.5%) of the men and boys were younger than 36 y of
age. Most patients were married (76.3%). All self-identified as
Muslim. The sample included patients from 14 different non-
Arabic-speaking tribes, and members of the Fur, Zaghawa, and
Dago tribes accounted for nearly 90% of patients. Only two (0.6%)
patients were from Arab tribes. Most (84.9%) lived in South
Darfur, where the Amel Centre was located.
Patterns and Geographic Scope of Alleged Abuses
The attacks documented in the patients’ records occurred
between 2002 and 2006, with a peak frequency in March 2005.
Characteristics of these incidents are displayed in Table 2.
Between the date of the incident and the date of presentation at
the Amel Centre, a median of 101 d had elapsed (inter-quartile
range, 22–365 d). Approximately one-third (36.6%) of patients
presented to the Amel Centre within 6 wk of the alleged
Alleged attacks on individuals and villages recorded in the
patients’ records took place in 23 rural council areas (out of 65
total) throughout Darfur (Figure 1). Of the total, 281 (86.5%)
occurred in South Darfur, 35 (10.8%) occurred in West Darfur,
and eight (2.5%) occurred in North Darfur. Approximately one-
third (35.1%) of the attacks disclosed by patients were also
described by at least one other Amel Centre patient. Many villages
were repeatedly attacked, with five villages reportedly attacked a
total of 41 times during the study period: Marla was attacked 13
times during a 12-mo period from December 2004 to December
2005; Adwa, ten times (October 2003–November 2005); Labado,
seven times (March 2004–December 2005); Bendisi, six times
(August 2003–Dececember 2004); and Mukjar, five times (August
2003–August 2004). In addition, 46 (14.2%) patients disclosed that
they had been attacked in the vicinity of an IDP camp: 16 (34.8%)
of these attacks occurred inside the camp, 15 (32.6%) occurred a
median of 3 km outside the camp, six (13.0%) occurred an
unspecified distance outside the camp, and nine (19.6%) occurred
within the general vicinity of a camp but the exact location was
Two hundred ninety-three (90.1%) patients described their
perpetrators as GoS and/or Janjaweed forces; of these, 48 (16.4%)
stated that GoS and Janjaweed forces attacked in concert (Table 3).
Thirty-two (9.9%) patients disclosed that they had been attacked
by rebel soldiers, bandits, community authorities, or other
community members. Among those attacked by GoS and/or
Janjaweed, 292 (99.7%) patients were from 12 different non-
Arabic-speaking tribes, and only one (0.3%) was from an Arab
tribe. Thirty-two (9.9%) patients disclosed to the examining
clinician that a military commander was present during the attack.
Nearly all (98.8%) attacks occurred in the absence of active armed
conflict between GoS/Janjaweed forces and rebel groups. The
examining clinician noted when patients speculated as to reasons
for the attack: 60 (18.5%) patients stated that they were targeted
because the attackers suspected them of being rebels, and 58
(17.9%) stated that they were targeted because of their racial or
Human Rights Violations in Darfur
PLoS Medicine | www.plosmedicine.org3 April 2012 | Volume 9 | Issue 4 | e1001198
Patients’ medical records described a wide range of alleged
abuses, including beatings (161 [49.5%]), gunshot wounds (140
[43.1%]), destruction or theft of private property (121 [37.2%]),
involuntary detainment (97 [29.9%]), and being bound with rope,
chains, or other material (64 [19.7%]) (Table 4). GoS forces were
described as accounting for more than one-half of custody-related
incidents (61 [59.8%]), whereas Janjaweed forces were alleged to
have accounted for most incidents involving physical assault (148
[50.7%]), sexual assault (28 [62.2%]), and destruction or theft of
private property (77 [63.6%]). In addition to the abuses patients
personally experienced, the medical records for this group of
Table 1. Characteristics of patients presenting for care at the
Amel Centre for Treatment and Rehabilitation of Victims of
Torture in Nyala, South Darfur.
Variable NameNumber (Percent)
Brought to center by friend/relative176 (54.2%)
Brought to center by staff/volunteer91 (28.0%)
Referred by friend/relative 13 (4.0%)
2004 47 (14.5%)
2006 45 (13.9%)
Male 252 (77.5%)
,26 y 96 (29.5%)
26–35 y 85 (26.2%)
36–45 y 68 (20.9%)
46–55 y 43 (13.2%)
.55 y32 (9.9%)
Farmer 199 (61.2%)
State of residence
South Darfur 276 (84.9%)
West Darfur37 (11.4%)
North Darfur 5 (1.5%)
Table 2. Characteristics of incidents that led to injuries.
or Median (IQR)
2006 26 (8.0%)
Days elapsed between incident
and presentation to Amel Centre
Days elapsed # #42 d
Yes 119 (36.6%)
No 204 (62.8%)
Could not be calculated2 (0.6%)
Same incident also reported
by another Amel Centre patient
Rural council area where incident took place
Abu Agura34 (10.5%)
Other locations throughout North,
South, and West Darfur
IDP camp where incident took place, if noted
Otash 15 (32.6%)
Kalma 14 (30.4%)
Distance from IDP camp
Outside camp 21 (45.7%)
Inside camp16 (34.8%)
In the general vicinity (but exact distance
Distance outside IDP camp (kilometers)a
aFrom the 15 records in which the patient provided an estimated distance to
the examining clinician.
IQR, inter-quartile range.
Human Rights Violations in Darfur
PLoS Medicine | www.plosmedicine.org4 April 2012 | Volume 9 | Issue 4 | e1001198
patients also collectively describe that they witnessed the killing of
948 other persons.
Consistency between Allegations of Abuse and the Signs
and Symptoms Described in the Medical Records
The signs and symptoms most frequently documented in the
medical records were chronic pain (194 [59.7%]), wounds or scars
(167 [51.4%]), functional disabilities (e.g., contractures causing
restricted grasp) (65 [20.0%]), and bone fractures (55 [16.9%])
(Table 5). There was 96.3% agreement (k=0.92) between the
medical reviewers on whether the medical records contained
sufficient detail to enable an informed opinion about the
consistency of the recorded signs and symptoms with the
allegations documented in the medical record. More than one-
third (127 [39.1%]) of the medical records were assessed by at least
one reviewer to lack sufficient detail (i.e., documentation was
incomplete) to enable him or her to render an informed judgment
about consistency. Of the 198 (60.9%) records that were
considered sufficiently detailed by both reviewers, the medical
reviewers agreed that the recorded signs and symptoms were
either consistent with (101 [51.0%]), highly consistent with (81
[40.9%]), or virtually diagnostic of (5 [2.5%]) the alleged abuses.
There were no cases in which the reports of medical examinations
were considered not consistent with, or unrelated to, the recorded
allegations. In only 11 (3.4%) cases did the medical reviewers
disagree in their consistency scorings, for an excellent inter-rater
agreement overall (k=0.89).
Approximately one-half (36 [49.3%]) of all women presenting to
the Amel Centre disclosed that they had been sexually assaulted.
One-half of sexual assaults on women were recorded as having
occurred in close proximity to an IDP camp, with nine (25.0%)
recorded as having occurred in the general vicinity of the camp
and nine (25.0%) having occurred within 3 km of the camp. The
majority (31 [86.1%]) of sexual assaults on women involved rape
or gang rape. Among these, five (16.1%) women disclosed they
had become pregnant as a result of the alleged rape; no follow-up
information was available on the remainder. Nine men also
disclosed that they had been sexually assaulted, including one who
had been raped. Twenty-five (55.6%) medical records of sexual
assault victims were considered by the medical reviewers to be
sufficiently detailed in recorded signs and symptoms to enable him
or her to render an informed judgment about consistency. Of
these, the medical reviewers agreed that the medical evidence was
consistent with (14 [56.0%]), highly consistent with (9 [36.0%]), or
virtually diagnostic of (1 [4.0%]) the alleged sexual assault. There
were no cases in which the medical findings were considered not
consistent with, or unrelated to, the alleged sexual assault. The
reviewers disagreed about the scoring for one (4.0%) case, for an
excellent inter-rater agreement on sexual assault findings overall
Figure 1. Geographic pattern of attacks reported by patients, 2002–2006. The largest circle corresponds to the town of Nyala, where the
Amel Centre was located. The base map for this figure was obtained from ArcGIS (version 9.2, Esri) Online World StreetMap, accessed on February 22,
2011. Sources: Esri, DeLorme, NAVTEQ, TomTom, US Geological Survey, Intermap, Increment P Corporation, Natural Resources Canada, Esri Japan, and
the Japanese Ministry of Economy, Trade and Industry.
Human Rights Violations in Darfur
PLoS Medicine | www.plosmedicine.org5April 2012 | Volume 9 | Issue 4 | e1001198
We analyzed the medical records of 325 consecutive patients
who were seen for care at the Amel Centre in Nyala, Darfur,
between September 28, 2004, and December 31, 2006, with the
aim of assessing the consistency between the recorded allegations
of abuse and the signs and symptoms noted in the medical record.
Our findings show that in all of the medical records that contained
sufficient detail, the medical evidence was considered to be at least
consistent with (if not highly consistent with or virtually diagnostic
of) the human rights violations disclosed by the patients. There
were no cases in which the reports of medical examinations were
considered not consistent with, or unrelated to, the recorded
allegations. Most of the abuses described in the medical records—
which included beatings, killings, sexual assault, torture, and
involuntary detainment—were allegedly perpetrated by GoS and
Janjaweed forces and were described as having occurred
throughout Darfur, with five villages attacked a total of 41 times
during the study period. The spatial distribution of reported
incident locations in our data suggests, at a minimum, that the
attacks were widespread. However, our lack of a representative
population-based sample makes it difficult for us to generalize
about the full extent or population incidence of attacks. Many
patients reported attacks by GoS and Janjaweed forces acting in
concert. In some cases, patients disclosed to the examining
clinician the names of specific victims, perpetrators, or military
commanders, and this information was noted in the medical
record. Fewer than 1% of patients reported observing the
perpetrators to be in active armed conflict with rebel or other
groups. Although the medical reviewers had no way to
corroborate the identities of the perpetrators, these findings are
consistent with prior research implicating GoS forces in the
perpetration of human rights violations upon non-Arabic-speaking
civilians in Darfur [24,25].
Nearly one-half of women presenting for care disclosed that
they had been sexually assaulted. The use of sexual violence in
armed conflict has been recognized as a means of not only
demoralizing individual victims but also destabilizing their families
and terrorizing communities [51–56]. Rape and other forms of
sexual violence have been recognized as war crimes and crimes
against humanity , as well as instruments of genocide [55,58].
Moreover, one-half of these assaults were described as having
occurred in close proximity to an IDP camp. These data are
consistent with prior reports of rapes occurring near IDP camps
[26,55,59], as well as previous work documenting that violence
was responsible for a substantial proportion of deaths among
persons settled (i.e., not in the villages or in flight) in IDP camps in
West Darfur . Collectively, these data raise questions about the
security provided to persons living in IDP camps, notably women,
who must frequently venture outside the camp to gather firewood
for fuel . The Inter-Agency Standing Committee has issued
guidelines that suggest several minimum prevention and response
interventions that could be implemented with regards to security
mechanisms instituted in areas of close proximity to IDP camps.
In contrast to prior studies’ reliance on self-report of refugees
living outside of Darfur [17,24,25,27,28], our data are based on
unusual access to medical records of clinical encounters in Darfur
maintained by local clinicians directly responsible for treatment
and record-keeping. Medical forensic experts reviewed and
analyzed the signs and symptoms described in the medical records
and evaluated their consistency with the alleged abuses docu-
mented in the medical notes. Less than two-thirds of the records
were detailed enough for the forensic reviewers to substantiate the
patients’ claims of abuse, a finding that is not surprising given that
the Amel Centre medical records were not intended for research
purposes. In a similar study in which third-party experts assessed
the official medical evaluations of forensic experts working for the
Mexican Procuradurı ´a General de la Repu ´blica (Office of the
Attorney General), in 18 of 39 cases (46%) their assessments were
indeterminate because of insufficient documentation to corrobo-
rate alleged torture and ill treatment . Their findings are
consistent with ours and highlight the potential value of using
clinical information to corroborate allegations of abuse. In our
study, among the medical records that contained sufficient detail,
all were assessed to be at least consistent with (if not highly
consistent with or virtually diagnostic of) the allegations. These
data substantially enhance the credibility of the patients’ claims of
abuse. Importantly, however, the medical records provided the
forensic reviewers with no data that could be used to corroborate
either claims of assailant identities or claims of genocidal intent.
Interpretation of our findings is subject to a number of
limitations. First, we used a discrete, comprehensive sample of
patients, but it was not systematic. During this time period, the
Sudanese Criminal Procedure Act required all injury or trauma
victims to file a report with the police in order to obtain a medical
evidence form (‘‘Form 8’’), without which they were legally not
permitted to receive treatment from an authorized medical officer
[55,61–63]. In practice the police were known to deny the Form 8
Table 3. Characteristics of alleged perpetrators.
Affiliation of alleged direct perpetrator(s)
Janjaweed 166 (51.1%)
Both GoS and Janjaweed48 (14.8%)
Military commander present
Number of alleged perpetrators
Single perpetrator7 (2.2%)
More than one but exact number unspecified 207 (63.7%)
2–5 perpetrators 55 (16.9%)
6–10 perpetrators21 (6.5%)
More than ten perpetrators 35 (10.8%)
Number of alleged perpetrators, if noted5 (2–20)
Reason for incident as perceived by patienta
Suspected of being a rebel60 (18.5%)
Targeted because of racial or tribal identity 58 (17.9%)
Suspected of supporting rebels24 (7.4%)
Suspected of theft, or was defending self against theft11 (3.4%)
Suspected of political activity5 (1.5%)
Suspected of working against rebels4 (1.2%)
aResponses in this category were not mutually exclusive, so percentages do not
add up to 100.
IQR, inter-quartile range.
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PLoS Medicine | www.plosmedicine.org6April 2012 | Volume 9 | Issue 4 | e1001198
to members of non-Arabic-speaking tribes, so this legal require-
ment represented a substantial hurdle, and in many cases a
complete barrier, to accessing health care services. Consistent with
this, patients in our sample presented for care a median of 101 d
after the abuses leading to their need for treatment. Furthermore,
the majority of patients seen were men, highlighting the issue of
women’s lack of adequate access to care and their overall limited
public mobility in this setting. These barriers are of particular
salience with regards to cases of sexual violence , where
victims may fear reprisals, blame, and other psychosocial
consequences of disclosure [5,26,59,64–68]. A second limitation
relates to the delay in presentation for care. Although physical and
psychological sequelae may persist for years and even for the
duration of a victim’s lifetime, some symptoms and disabilities may
resolve or diminish over time [42–45,69]. Despite their training
and experience, Amel Centre staff could have under-detected and
therefore under-documented some symptoms, especially those
concerning sensitive topics (e.g., sexual violence, psychological
distress) that might not be spontaneously disclosed. More
generally, the medical chart review literature is characterized by
under-documentation of signs and symptoms [70–73], so we
Table 4. Types of abuses disclosed by patients.
Type of Abuse
Affiliation of Alleged Perpetrator(s)
GoS and/or Janjaweed (n=293)Other/Unknown (n=32)
Attacks involving heavy weapons33 (11.3%) 2 (6.3%)
Ground explosives (bombing, grenades) 2 (0.7%)
Attack by aircraft or helicopter18 (6.1%) 1 (3.1%)
Attack by land cruiser 24 (8.2%)1 (3.1%)
Physical assault 264 (90.1%) 28 (87.5%)
Blunt trauma (beating, whipping) 145 (49.5%)16 (50.0%)
Gunshot wound 125 (42.7%)15 (46.9%)
Burns or electric shocks 21 (7.2%)
Stretch injury (hanging, suspension) 19 (6.5%)
Genital trauma10 (3.4%)
Sexual assault39 (13.3%)6 (18.8%)
Forced undressing 12 (4.1%)1 (3.1%)
Insertion of foreign object into anus/vagina3 (1.0%)
Attempted rape5 (1.7%)
Rape15 (5.1%) 1 (3.1%)
Rape by more than a single perpetrator12 (4.1%)4 (12.5%)
Humiliation or psychological manipulation 70 (23.9%)3 (9.4%)
Verbal abuse 32 (10.9%)1 (3.1%)
Verbal abuse involving racial slurs 6 (2.1%)
Forced performance of humiliating/taboo acts7 (2.4%)
Verbalized threats of death43 (14.7%)2 (6.3%)
Custody-related violations 95 (32.4%)7 (21.9%)
Involuntary detainment90 (30.7%)7 (21.9%)
Bound with rope or other apparatus60 (20.5%)4 (12.5%)
Crowded, unhygienic conditions 43 (14.7%)
Deprived of food/water or medical care32 (10.9%)1 (3.1%)
Sensory deprivation25 (8.5%)
Destruction or theft of private property 115 (39.3%)6 (18.8%)
Data are number (percent).
Table 5. Common symptoms and signs documented in
patient medical records.
Type of Symptom or SignNumber (Percent)
Pain (non-pelvic)194 (59.7%)
Wounds or scars167 (51.4%)
Functional disability65 (20.0%)
Broken or fractured bones55 (16.9%)
Pelvic pain 34 (10.5%)
Insomnia 32 (9.9%)
Swelling 18 (5.5%)
Headache 14 (4.3%)
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would expect this limitation to generically apply in any setting.
Third, because these data were not collected in a research setting,
in most if not all cases, the same individual documented both the
allegations of abuse and the results of the medical examination.
The examining clinician’s prior knowledge of the nature of the
allegations could have biased the completeness of the documen-
tation with regards to signs and symptoms observed. Fourth, few
rape cases were scored by our medical forensic experts as virtually
diagnostic of the alleged assault. Amel Centre protocol directed all
female rape victims to a gynecologist for evaluation .
However, these records were unavailable for analysis because
they could not be secured and sent out of the country prior to the
clinicians’ fleeing the country (as described above). Fifth, we were
unable to include information on victims who were killed, so it
may be more appropriate to regard our data as underestimating
the true severity of atrocities inflicted upon non-Arabic-speaking
civilians living in this region. Sixth, Amel Centre staff were
routinely subject to surveillance, detainment, and interrogation by
GoS forces [75,76]. With increasing frequency in 2009, Amel
Centre staff were detained, interrogated, tortured, and accused of
collaborating with the ICC. Upon Al Bashir’s indictment, they
were advised to flee the country. Because of ongoing security
concerns, we could not obtain the records for 2007–2009 to
analyze for this study. This limitation underscores that the Amel
Centre clinicians provided medical and legal services under
dangerous working conditions. Health care workers in other
settings have faced similar challenges , further emphasizing the
need for international support for the protection of health
professionals working under similar circumstances.
In summary, despite these unavoidable limitations, our study of
non-Arabic-speaking civilian patients who visited the Amel Centre
in Nyala, Darfur, between 2004 and 2006 found that in all of the
medical records that contained sufficient detail, the recorded
medical evidence was considered at least consistent with the
alleged incidents of torture and other human rights violations.
There were no cases in which the reports of medical examinations
were considered not consistent with, or unrelated to, the recorded
allegations. The widespread, organized, and sustained pattern of
attacks documented in our study indicates that the actions of
Janjaweed and GoS forces may constitute war crimes, crimes
against humanity, and/or possibly acts of genocide.
and response options, used to guide abstraction of data
from the medical records (version of December 7, 2010).
Coding sheet, with lists of standardized names
We thank the patients, for coming forward to seek care and share their
experiences with the Amel Centre staff; the Amel Centre staff, for their
courage and commitment to the health and well-being of the people of
Darfur despite extreme conditions and great personal risk; Holly Atkinson,
M.D., Adrienne Fricke, J.D., M.A., Frank Davidoff, M.D., and Mark
Russell, M.A., for critically reading a draft of the manuscript and providing
helpful comments; and Jeff Blossom, M.A., of the Center for Geographic
Analysis at Harvard University, for his assistance in mapping the attacks to
specified geographic locations.
Conceived and designed the experiments: ACT MAE SSC SS MH JL VI.
Analyzed the data: ACT. Wrote the first draft of the manuscript: ACT.
Contributed to the writing of the manuscript: ACT MAE SSC VI. ICMJE
criteria for authorship read and met: ACT MAE SSC SS MH JL VI. Agree
with manuscript results and conclusions: ACT MAE SSC SS MH JL VI.
Obtained funding for the study: MAE SS JL. Acquired the data: ACT
MAE SS VI. Contributed to interpretation of the data: ACT MAE SSC SS
MH JL VI.
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Background. Conflict in the Darfur region of Sudan
between Arabic- and non-Arabic-speaking tribes over the
past decade has resulted in a severe humanitarian crisis.
According to the United Nations, more than 2.7 million
people have fled from their homes to camps for internally
displaced persons (IDPs) or to refugee camps in neighboring
Chad, and up to 300,000 people have died from war, hunger,
and disease since the conflict started. The origins of this
conflict go back many years, but in 2003, organized rebel
forces began attacking government targets, accusing the
Government of Sudan (GoS) of oppressing black Africans in
favor of Arabs. In response, the GoS attacked the rebel
forces, but some observers allege it also targeted non-
Arabic-speaking civilians, in contravention of international
laws of war. Observers have also accused the GoS of having
links with the Janjaweed militias, nomadic Arabs who attack
settled black farmers, although the GoS denies any such
links. Indeed, reports of systematic, targeted assaults on non-
Arabic-speaking civilians, of large-scale disruption of rural
livelihoods,and of deliberate
conditions likely to cause death have prompted some
observers to accuse the GoS of genocide (violent crimes
committed against a national, ethnical, racial, or religious
group with the intention of destroying that group) and the
International Criminal Court to issue arrest warrants for the
allegedly responsible authorities.
Why Was This Study Done? Most investigations of claims
of violence against civilians in Darfur have relied on self-
reported data gathered from people living in refugee camps
outside Sudan. Because these data could be biased, in this
cross-sectional study (a study that characterizes a population
at a single point in time), the researchers investigate the
nature and geographic scope of alleged abuses against
civilians in Darfur and endeavor to substantiate these
allegations by analyzing the medical records of patients
attending the Amel Centre for Treatment and Rehabilitation
of Victims of Torture in Nyala, South Darfur. Opened in 2004,
this center provided free clinical and legal services to civilians
affected by human rights violations. Its staff fled in 2009
because of increasingly dangerous working conditions; the
medical records used in this study were sent out of Sudan
before the staff fled.
What Did the Researchers Do and Find? Between
September 28, 2004, and December 31, 2006, 325 patients
were seen at the Amel Centre. According to their medical
records, 292 patients from 12 different non-Arabic-speaking
tribes alleged that they had been attacked by GoS or
Janjaweed forces in rural areas across Darfur. Nearly all the
patients reported that they had been attacked in the
absence of active armed conflict between GoS/Janjaweed
forces and rebel groups. Half of them claimed that they had
been beaten, two-fifths reported gunshot wounds, a third
reported destruction or theft of property, and nearly a third
reported involuntary detainment. Half of the 73 women seen
at the center disclosed that they had been sexually assaulted,
often near IDP camps. Only 198 medical records contained
sufficient detail to enable the researchers to determine
whether the documented medical evidence was consistent
with the alleged abuses. However, in all these cases, the
researchers judged that the medical evidence was consistent
with, highly consistent with, or virtually diagnostic of the
What Do These Findings Mean? These findings provide
credible medical evidence that is consistent with torture and
other human rights violations being inflicted on non-Arabic-
speaking civilians in Darfur from 2004 to 2006. These findings
cannot be used to estimate the population incidence of
attacks on civilians or to corroborate claims of assailants’
identities or of genocidal intent. Moreover, their accuracy
may be affected by several limitations of this study. For
example, during the study period, only patients who
obtained a medical evidence form from the police were
permitted to receive treatment from an authorized medical
considerable hurdle to accessing health care services.
Nevertheless, the widespread, organized, and sustained
pattern of attacks documented in this study is consistent
with the possibility that the actions of Janjaweed and GoS
forces during the conflict in Darfur may constitute war
crimes, crimes against humanity, and/or acts of genocide.
Importantly, these findings also highlight the need to
working in countries affected by internal conflicts.
Additional Information. Please access these web sites via
the online version of this summary at http://dx.doi.org/10.
N The African Union–United Nations Mission in Darfur
(UNAMID) provides background information and up-to-
date news about the ongoing conflict in Darfur Amnesty
International, which campaigns for human rights, provides
background information and news about the current
situation in Darfur
N The Save Dafur Coalition also provides detailed informa-
tion about the situation in Darfur Physicians for Human
Rights, a non-profit organization that mobilizes health
professionals to advance health, dignity, and justice, is
calling for security in Darfur and compensation and
restitution for survivors of the conflict
N Wikipedia has pages on Darfur and on genocide (note that
Wikipedia is a free online encyclopedia that anyone can
edit; available in several languages)
N Details on warrants of arrest issued by the International
Criminal Court in response to the situation in Dafur are
Human Rights Violations in Darfur
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