At first sight, Kebkabyia in North Darfur appears to be a thriving desert town. In the bustling market place, or 'souk', stall-holders sell tea and tomatoes, beans and batteries; young men wheel round on shiny Chinese bicycles; small donkeys bray raucously and groups of kneeling camels blink and yawn in the dazzling Saharan sun.

Yet in fact, Kebkabyia is a town full of people who did not use to live there. The population is largely made up of displaced people, who fled the surrounding villages and towns after violent attacks during the past year and who now cannot return home because of continuing severe insecurity. Once home to about 16,000 people, there are now probably more than 70,000 living in Kebkabyia, although with more displaced families arriving weekly in the town, nobody really knows for sure.

Since the Darfur conflict started over a year ago, the town health facilities - already desperately run down, ill equipped and manned mainly by staff lacking even the most basic training - have been completely unable to handle the rising tide of health problems suffered by the swelling population. The funding system made it impossible for the hospital to provide free health care to the increasing number of vulnerable people; both the displaced and the resident population suffered from this.

"When I arrived as part of the first MSF team in Kebkabyia five weeks ago, the general hygiene in the hospital was very bad," says Ann Ottosson, emergency field coordinator for MSF.

"When our doctor, Anders (Anders Krondhal, MD,), saw an operation being performed for the first time he was schocked by the conditions in which the surgery took place. The operation table was stained with blood and looked like it had not been cleaned in a long time.

"Some of the nurses did not know how to take a patient's temperature. There was no water supply to the hospital since the water-pump was broken, and the sanitation and waste management situation was terrible. There were needles lying on the floor, empty vials of drugs were not taken care off, people were even using the patient showers as toilets."

Over the past five weeks, much has changed. The MSF team set priorities: make free access to care and medicines possible, clean the place, organise waste management as well as water supply and sanitation, train hospital staff in the basic medical procedures.

"Even though the hospital was 'functioning' to a limited degree before we arrived, we had to start from scratch," explains Ann. "We spent several days just cleaning and disinfecting the wards and surgical theatre and collecting medical waste from the hospital compound to be burned.

As well as setting up a sterilisation room and training nurses in disinfection and sterilisation procedures, MSF has introduced out-patient health-cards, organised a clean water supply, brought in new stocks of drugs and dressings and completely overhauled the pharmacy."

Since MSF started working on the June 12, there have been about 1,500 consultations given each week, both in the hospital and in a separate out-patient clinic in the east of the town. The team also had to set up a system for selecting who needs medical care most urgently, as the staff capacity remains limited.

Some of the patients have extremely old injuries, which they sustained during the peak of the fighting in the region more than a year ago.

"One man had been injured by a bullet in his leg 13 months ago." says Dr Anders Krondhal, who has been working in the hospital for the last month. "The wound became infected and he had just been lying in his house, unable to move. He also has a bullet lodged in his left thorax. When he was admitted to the hospital he weighed only 32 kilos. The wound is now cleaned and dressed every day, he is on antibiotics and we are working on increasing his weight."

With firearms a common sight on the streets, there are also patients arriving with recent gunshot wounds. "One young girl - Arafat - was brought to us last week with a very serious gun wound - the bullet had ripped across her jaw and only just missed her carotid artery. She's now doing well, but she's extremely lucky to be alive. She's only about 14 years old. Yesterday we performed surgery on a man who had been shot in the stomach during a fight, apparently with his brother. He survived but the other man died."

The example illustrates the difficult choices MSF has to make in a situation where the needs are much larger than the resources.

In the hospital compound, relatives of patients sit in groups on the sand, women dressed in vibrant colours under one tree, men serenely wrapped in white under another, all of them waiting for news of a daughter or father or aunt.

Some of the patients have conditions which have become serious simply because the lack of free health care in the past made it impossible for them to get treatment previously.

In the paediatric ward is a cheerful boy, Mohammed, who cannot walk. When Dr Krondal lifts him up and supports him, he hops along, dragging his left foot behind his right. The foot is twisted and his legs are painfully thin. In fact, Dr Krondhal believes that Mohammed will be able to walk fine after some simple physiotherapy and daily leg exercises.

"I think that what probably happened is that the boy was left lying down for a long time when he had severe malaria," he explains. "Because he was just lying in one position, some nerves in his leg were and he was left unable to move his foot. I have shown the mother the leg exercises she should help him with each day, and we should soon see an improvement in the mobility of his foot."

Despite the striking progress in the hospital, there is a huge amount still to be done. All the nurses are now going through an intensive three-week training program, organised by MSF in collaboration with three Ministry of Health (MoH) nursing schoolteachers from the MoH. It will begin with the absolute basics such as how to recognise vital signs, how to take blood pressure, how to dress a wound and how to give injections.

The water and sanitation team are busy digging a five metre deep trenches for eight new patient latrines. They are finishing work on a waste management area with an incinerator for the safe disposal of medical waste, a pit for 'sharps' such as needles and a pit for organic waste such as placentas.

In addition, the team have just finished constructing an entirely new
outpatient clinic in the north side of the town, where many of the displaced people are sheltering. When it opened recently there were more than 150 people waiting outside, with problems ranging from children with severe malnutrition to suspected malaria to respiratory tract infections. Many have problems that typically result from crowded, cramped living conditions in which diseases can spread easily, such as diarrhoea or skin and eye infections.

"We built the new clinic right in the heart of the area where the displaced people are living because we believe that many of them are very vulnerable and we wanted to make sure they had easy access to health care," explains Ann Ottosson.

"Having fled their homes with nothing, they have suffered terribly and are now entirely dependent on aid organisations to provide them with everything: food, clean water and medical care. They cannot leave Kebkabyia to collect firewood for cooking or cultivate land because it is extremely dangerous - they risk being killed or raped.

"You can see frail old women walking around, picking up tiny bits of stick, trying to gather enough to build a fire in order to cook food. The food
situation for the future is very worrying. Because people have no access to land and have no seeds, they will be completely reliant on food distributions for the foreseeable future. Keeping these people alive is going to take a long-term commitment from the aid community and a real, determined effort from the authorities to make sure that civilians are protected from suffering yet more violence."