Dr. Matthias Hrubey is a general practitioner who runs the Médecins Sans Frontières (MSF) primary health clinic in Kass, South Darfur, a town with a population less than 30,000 that has swelled to an estimated 77,000 with the influx of approximately 48,000 people displaced by violence in the region. The MSF clinic opened in mid July and Dr. Hrubey and a Sudanese doctor see 120 to 200 patients per day. MSF also runs a therapeutic and supplementary feeding program for malnourished children in Kass.

In this first episode, Dr Hrobey describes the conditions where he is working and the establishment of the first MSF health facility in the town.

"I am a country doctor in Germany. This is my second mission with Médecins Sans Frontières (MSF). My first was in a post-emergency project in Sierra Leone from 2002 to 2003.

"When I first learned that I might go to Darfur, I thought it could be very interesting to work in an emergency project and I knew there were great needs. I was well prepared to find real chaos and difficult security and living conditions, and certainly a high amount of suffering.

"I was to be in charge of setting up a clinic in Kass because the health system was very limited and unable to deal with the huge numbers of displaced people who had arrived in the town over the past year. MSF already had a therapeutic and supplementary feeding program set up, but there was a real need for a primary health clinic.

"When I first arrived in Kass, I was quite impressed by the set up of the town. The displaced people here are not living in big camps like they are in some parts of Darfur, but are all mixed up with the residents. They are crowded together in small camps and others are living among host families. There are close to 80,000 people living here, but it still looks like a town of 20,000 because people are all crowded together.

"Many people are living in small shelters built out of nothing more than sticks and plastic sheeting. When I arrived there were some camps where people had shelters covered with plastic sheeting, and some people had nothing more for shelter than a one-meter square of plastic sheeting. Whole families of seven, eight, or nine were living in the space of a tent that would hold one or two people in Europe. The living conditions are still very basic.

"My first impression was that people were very afraid and concerned about their future and what was going to happen. Everyone seemed to have a story of how they had been forced to flee their home village.

"Most of the displaced spoke of how one day or night their village had been attacked, their homes destroyed, women raped, and many men and others killed. People were forced to flee with more or less nothing. They talked about how they had found safe haven in Kass, but were still very worried about how long they would be able to stay here, whether they might be attacked here in town, and how they could manage to get enough food and the few things they needed to survive. People from the same village tried to stick together as they fled and now the camps in Kass are named for the villages that the people living in them came from. It gives them some sense of security to stay together in the semblance of a social structure that they know.

"We had a very difficult time controlling the crowd because everyone was so desperate for medical treatment. It took us quite some days to come up with a system for the crowd and organizing the flow of patients into the clinic. We even had to close for a half day because the crowd was so big that people were beginning to step on each other."

"Getting the clinic set up was a challenge. We started preparations as soon as I got here by identifying a site for it and then designing and building a structure with local materials. We ordered the medicines and supplies we would need and began hiring staff in preparation for opening. The biggest difficulty was not building the clinic, but trying to find the qualified medical staff and translators we would need to run it. We decided to start small by building just one local-style stick and straw structure called a "rakuba". We opened with this one building, some tables, benches, and mats, and a small pharmacy.

"People were so desperate for health care. Everybody was asking for us to open a clinic as soon as possible. They had watched us building the clinic and everyone in town knew that we would be providing medical treatment, so on the first morning that we opened in mid-July there were about 400 to 500 people waiting outside the door. We had a very difficult time controlling the crowd because everyone was so desperate for medical treatment. It took us quite some days to come up with a system for the crowd and organizing the flow of patients into the clinic. We even had to close for a half day because the crowd was so big that people were beginning to step on each other.

"We opened the clinic for everyone. Internally displaced people, residents of Kass. We treat anyone who comes in. After a bit of time, the message began to get around and we started to see people coming in from as far as thirty kilometers for treatment and more and more people from the host population.

"After working for a few days, we realized that we didn't have enough space, so we constructed more rakuba and reorganized the clinic to make the flow of patients more efficient. We're still constantly working on improving our services and every day there is something more to do."

"In the first weeks, we saw up to 200 or 250 people in a single day. There was just a local doctor and myself at the time. We worked ourselves to the limit each day, but still we have been forced to send as many as 200 people home at the end of the day. At least if you work your hardest, you know you have done the best you can, even if you still have to send people away. It is not a good feeling, when you have so many people waiting, that it is even difficult to be able to pick out the sickest. You always know that among those you are sending away are some really sick people who may have waited two or three days just to see a doctor. We've had people lining up at two or three in the morning just to be in front of the queue when the clinic opens at eight in the morning.

"After working for a few days, we realized that we didn't have enough space, so we constructed more rakuba and reorganized the clinic to make the flow of patients more efficient. We're still constantly working on improving our services and every day there is something more to do.

"It was clear very early on that we needed an observation area for patients to stay in during the day so that we could give them injections and intravenous drips and keep an eye on them. At first they were just lying on the floor between the consultation rooms, but now we have an observation "rakuba" with nine beds, as well as areas for doing dressings and administering oral rehydration salts.

"We've also set up two rooms for use by a new midwife who has arrived to set up an antenatal program as we have seen many pregnant women with problems, but were previously not able to offer them many services. Now we will be able to.

"...we have no choice but to send patients home at the end of the day - even if they are very sick - without any supervision, and hope that they come back the next day. Unfortunately, they don't always come back and it is terrible not knowing what has happened to them."

"The biggest challenge at the moment is that we don't have any overnight facility and have to send patients home at the end of the day. There is a ten o'clock curfew in all of Kass and the security situation still makes it too dangerous for us to stay in the clinic overnight and our staff is still too limited. So, we have no choice but to send patients home at the end of the day - even if they are very sick - without any supervision, and hope that they come back the next day. Unfortunately, they don't always come back and it is terrible not knowing what has happened to them. Sometimes we hear later that they have died or they didn't have the money to pay for a donkey cart to bring them back to the clinic.

"For example, we had a 16 year-old boy who was very ill with cerebral malaria who arrived at the clinic in a comatose state at 3:30 in the afternoon. All we could do was to give him injections and send him home not knowing what might happen to him. His family was not from the town and they had to stay with friends who had some shelter. It was a great relief to see him in the clinic the next morning sitting up. Three days later he could walk and eat again. That was a very positive outcome, but it is not always like that.

"We also had the case of a one-and-a-half year-old child who had severe pneumonia and had stayed the whole day in the clinic in a very critical state. Still we hoped that he would make it overnight. But the next day when he didn't show up, we started to suspect that something might have gone wrong.

You have to deal with all the problems that come your way. You have to improvise all the time. You don't always have the drugs or equipment you need, but you still have to treat every patient that comes to see you the best that you can."

"The next day his mother came and asked me for a death certificate. The child had gone into convulsions and died at two in the morning. Because of the curfew, she was unable to call anyone or go anywhere. You never know, but if we had been able to keep the child overnight and give him a glucose drip, he might have made it. I am almost sure that he would have. Unfortunately, this is not the only example I have like this.

"In Germany, I work as a general practitioner in a country village. I think it has prepared me well for the work I am doing here with MSF in Darfur. Even in a village at home, you have to have a broad medical knowledge and be able to do everything, diagnosing mild to severe problems and even doing small surgeries.

"The big difference is that, at home, there is always the possibility of referring a patient to a hospital or a specialist when you don't know what to do anymore. That is something that you just can't do here. You have to deal with all the problems that come your way. You have to improvise all the time. You don't always have the drugs or equipment you need, but you still have to treat every patient that comes to see you the best that you can."