The new clinic comes in addition to MSF project sites in Leer, Lankien and Nasir as well as health centres run by other charities in Ayod and Old Fangak that all report an unusually large number of kala azar patients seeking medical care. Some patients travelled for days to get treatment. Many clinics report dozens of new admissions each week.

"Based on our experience last year, we expected an increase of patients from early September, but the number of cases turning up at the various health centres in the region indicate that it will be even worse than the previous years," said Chris Lockyear, MSF’s head of mission in South Sudan. If left untreated the disease, transmitted through the bite of the sand fly, is fatal. Treatment includes not only providing kala-azar drugs, but also intensive treatment of associated infections such as pneumonia, diarrhoea and anaemia as well as focusing on malnutrition.

"The fact that we see these high numbers so early, in the traditional low season of the disease, indicate that we are on the brink of a massive outbreak later in the year", says Koert Ritmeijer, MSF’s health advisor and kala azar specialist.

The explanation for this early outbreak of the tropical disease is complex. "The last big outbreak of the disease was eight years ago", says Koert Ritmeijer. "And as a result there is a whole new generation that has not built up immunity against the disease."

According to him, other influencing factors are climatic conditions which favour the sand fly, allowing it to thrive and transmit the disease. High levels of malnutrition this year in various regions of South Sudan because of insecurity and failed harvests compound the problem as it makes people more susceptible to kala azar.

To relieve the pressure on the existing health centres MSF decided to set up this extra base in Pagil. It is a remote village with only one solid building that serves as a clinic with the MSF team members living in tents and treating most of the patients under canvas. Within the first two days the team confirmed 16 cases of kala azar. It is expected that this number will rise once the word spreads in the communities that treatment is available in Pagil. The team, consisting of on average six international and national staff members, are facing some difficult logistical challenges.

"We aim to resupply the team every seven to 10 days", says Chris Lockyear, "but that’s entirely dependent on the weather and the condition of the small airstrip, which is just black cotton soil that turns into sticky mud as soon as it rains. So we have to carefully select the drugs and medical supplies and not overload the small plane."

The team will assess the need to open other sites in the vicinity of Pagil depending on the trends of patients reporting themselves to the various MSF clinics. As a result the Pagil base will remain open well into 2011.