Metal doors squeak. The wind stirs clothes, assorted rubbish, water bottles, plastic chairs. Life has disappeared from Malakal, a key town in the oil-rich Upper Nile state of South Sudan. The clashes between government and opposition forces have turned Malakal, a square grid bordering the river Nile, into a ghost town. But some people didn’t manage to escape – they were forced to witness the horror.

Ronyo Adwok is one of these people. When the most recent clashes erupted in Malakal on 18 February, the 59-year-old history teacher’s house was attacked. In the attack, one of his legs was injured, so Ronyo went to Malakal Teaching Hospital for treatment. He thought the hospital would be a safe place to be. He was wrong.

“Every day, 10 to 15 men entered the hospital with guns,” says Ronyo. “They’d ask for cellphones and money. If you didn’t give anything to them, they would shoot you. In my ward many people were shot. They even took some women away.”

It is not the first time that medical care has come under fire in the world’s youngest nation since the crisis erupted in mid-December. In Leer, Unity state, an MSF team returned to the hospital to find it had been thoroughly looted, vandalised and then burned. MSF’s compound in Bentiu, also in Unity state, was looted, too. These attacks took place amid a wave of violence that saw hospitals targeted, as well as markets, public spaces and sometimes entire towns.

When running away is not an option

What happens when a civilian cannot escape this landscape of violence? Ronyo Adwok is among the patients who were physically unable to run away from Malakal Teaching Hospital when it was attacked. The rest, including some patients with tuberculosis and kala azar, were able to flee. The MSF team was forced to temporarily suspend its activities on 17 February due to the violence.When they were able to return to the hospital five days later, they found a horrifying scene.

“There were 11 dead bodies in the hospital – patients murdered in their beds,” says Carlos Francisco, MSF field coordinator in Malakal. “We found three more bodies near one of the hospital gates. The feeding centre had been burned down and the supplies had been looted. It was unrecognisable as a hospital – everything was a mess.” There were corpses lying on the beds, and medicines, clothes and suitcases scattered on the floor – a sign of the terror experienced by those who fled. “The first day we came, we even found a patient hiding on the roof,” says MSF nurse Siobhan O’Malley.

Fifty-three patients had been stranded in the hospital for several days with no medical assistance. The MSF team immediately organised for the patients to be transferred to the UN compound in Malakal, which hosts around 21,000 displaced people. Together with the International Committee of the Red Cross (ICRC), MSF set up a tented hospital to provide them with emergency care. Only six kilometres stand between Malakal and the UN compound – an arid area which was the scene of some of the fiercest clashes. “Look”, says Francisco from the car, just 100 metres from the UN compound. “It’s the body of a civilian. He was killed trying to enter the UN camp.”

The situation inside the compound is dire. “More than 20,000 people are crammed into an overcrowded camp in terrible conditions,” says Francisco. The displaced people are desperately short of space and clean drinking water, and sanitary conditions are poor. The camp is in an area that often floods, and the upcoming rainy season is a major concern – both for the people sheltering there and for the humanitarian organisations trying to help them. The overcrowding brings a risk of epidemics, as well as exacerbating tensions between those sheltering there. In February, dozens of people were wounded in the camp when fighting broke out between different groups, mirroring the armed clashes in town. In total, MSF and ICRC treated 152 people injured in the violence, 32 of them with gunshot wounds.

Over 1 million people displaced in 100 days

In the space of just 100 days, 803,000 people have been displaced from their homes within South Sudan. About 254,000 people have sought refuge in neighbouring countries, according to the UN. The figures are a grim reminder of the scale of the conflict, which started within the army and has gone on to engulf large parts of Unity, Jonglei and Upper Nile states. The three main communities of South Sudan – the Dinkas, Nuers and Shilluks – have all been caught up in the crisis, with tens of thousands of people now sheltering in overcrowded camps dotted across the country.

“The sad truth is that we are not able to reach all the people who need assistance,” says Llanos Ortiz, MSF emergency coordinator for South Sudan. “Violence is preventing us from accessing areas with large numbers of displaced people. We fear that epidemics may spread and malnutrition may strike, especially with the onset of the rainy season.”

In Malakal, medical teams are seeing large numbers of people with diarrhoea, and there are fears that malaria and malnutrition may increase in the coming months if conditions in the camp do not improve. Patients are being admitted to the new MSF facility, and there are still those who survived the armed assault on the teaching hospital. Many have wounds, some have undergone amputations,others have serious burns. Most are suffering psychological trauma. One man was shot in both arms and both legs by someone who clearly intended to leave him permanently disabled but still alive. A Sudanese trader who was shot in the jaw was unable to chew and died on 12 March.

“During this war, everybody got separated,” says Yay Jack Abuor, a former student from Upper Nile University. “I was shot in my hand. We ran away towards the Nile and we were chased. I hid for several days between two boats – I just came out to drink water and urinate. Then I was taken to a church, and MSF and ICRC brought me here.” Yay lost one of his fingers, but otherwise is likely to make a full recovery.

The stories told by those who survived the attack on Malakal have one thing in common: all describe sudden and brutal attacks that tore families apart, split communities in two, and forced everyone to run for their lives.

“When the war started in Malakal, everyone ran away in different directions,” says Yay. “I don’t know where my people are.” It is the same for Ronyo Adwok; “I don’t know where my family is,” he says.

Fleeing down the Nile

Two hundred kilometres downriver is another side of the story. This was the direction taken by many of those who fled Malakal and the surrounding area. In Melut county, more than 18,000 people have settled in three camps. Little humanitarian aid has reached them. The area, though sparsely populated, is strategic because of its proximity to oil fields. Some 3,500 people arrived in Melut at the end of January, and since then more have kept coming by truck, boat and on foot. MSF has set up a clinic in the largest of the three camps; its teams are providing 100 medical consultations each day and have vaccinated 4,500 children under five years old against polio and measles.

Most of the displaced people in Melut come from Malakal or from Baliet county, to the south – the scene of heavy fighting since the conflict between government and opposition forces started. There are lots of children, women and elderly people, but very few men. Most of the men were killed in the fighting, are still at the frontline, or just stayed behind, according to the camps’ residents.

Surrounded by other women, 45-year-old Ajith Athor describes the journey that brought them all to this camp. She fled with her husband from Baliet to Malakal. “In both Baliet and Malakal, houses were burned and buildings were destroyed,” she says. When clashes broke out in the town, she escaped towards the north, on foot, but lost track of her husband. “I don’t know whether my husband is dead or alive,” she says.

“When we got here, we were afraid,” says Ajith. “Even now we are afraid, because if the clashes reach here, we will die.”

Ajith is living with more than 30 women and children in a big tent, waiting for humanitarian aid to arrive. They have no news about the horror that they left behind or the situation in Malakal, which is now empty of people. All those who fled northwards along the Nile can only guess what happened to their loved ones.

“We wait for five days in the camp,” says Ajith. “If our people don’t come, we assume they are dead.”