Over the last three years, the oil rich state of the Upper Nile in South Sudan has seen continuous conflict between government and opposition forces. This has forced many families to make a drastic decision – stay and risk being killed, or leave and maybe have their property stolen.  

Across the border to the north lies Sudan's more peaceful White Nile State, where many South Sudanese have decided to flee to in order to escape the violence. Currently, six refugee camps host 83,000 people and many more live outside these designated zones.

Earlier in 2016, the rainy season brought a brief lull to the fighting in the south, but now it is over and there is a return of hostilities between the warring sides. Families have resumed their migration to find safety across the border.

MSF currently runs a 40-bed hospital in White Nile State. It is based just outside Al Kashafa camp where over 17,000 refugees have been allowed to settle. A wide range of services are provided in the inpatient and outpatient departments, where the most common concerns relate to reproductive health issues, throat infections and malnutrition.

Mary, a refugee from Kaka in South Sudan's Upper Nile state, explained, "When the armed men came to our village they showed no mercy. Neither the young nor the old were spared. As soon as we heard that the killing had started we didn't stop to think, we just ran from the village taking what we could carry."

"To pass through some of the military checkpoints we had to lie about the tribe we belonged to, otherwise we would have been stopped and the worst would have happened. We feel very lucky, as miraculously nobody was hurt."

While some arrive worn out from their ordeal, suffering from malnutrition and malaria, the majority endure the journey well enough, walking up to eight days to get to the camps.

Mary's four-year-old daughter is a patient at the MSF hospital because she arrived malnourished. "She fell sick on the journey and stopped eating, had severe diarrhoea and started coughing," explains Mary. "When we got here the doctor told me that she needed help and put her on the special nutrition programme run by MSF. I hope that this will make her strong again."

Water and sanitation in the refugee camps

"By far our biggest cause for concern is the sanitation and hygiene in the camp. People live so closely together and there aren't enough toilets and latrines. They are openly defecating near their shelters and those of their neighbours," says Mohamed Jibril, the MSF project coordinator for the hospital.

"There is a huge risk of acute watery diarrhoea spreading throughout the community, and the hospital is always ready to deal with an outbreak despite our limited capacity. Young children are particularly at risk as they play in these unsanitary conditions with their friends."

MSF is contributing to the upgrading of the sanitation standards with the construction of latrines in two camps (Al Kashafa and Joury). Community health promotion activities are also part of the package offered by MSF, with the aim of increasing the awareness on health behaviour.

MSF’s hospital in Al Kashafa camp

MSF's hospital also functions as a referral point for other camps, and it has the only nutritional stabilisation centre in the area. The most serious medical cases are referred to Kosti hospital which is 80 kilometres away on a sandy and difficult road.

The medical facility is not just being used by the new arrivals. Nearly half of all consultations are for local people living around Al Kashafa camp, which includes the host Sudanese community and refugees from the other five camps.

Before MSF arrived, the local community had very few alternatives when it came to medical care and the MSF hospital has become a point of reference for the local population as well.

"For weeks I was suffering from a very bad headache and a sore throat. My family wanted me to try some traditional medicine. It's all they could suggest, but I knew it wouldn't work. So I came to the MSF hospital where the treatment is free and the doctors know what they are doing," explains Elizabeth, from the nearby village of Alseror,

Looking to the future

Many of the people living in the refugee camps have family in Sudan, understand the culture and speak Arabic so they may choose to move on to one of the larger towns in White Nile State. Those with money and family connections might even travel as far as Khartoum to start a new life.

Others will stay in the camps, hoping the situation will improve. While international NGOs are providing basic education for children, there is little for the adults to do. Some try to eke out a small living by selling fish or trading in the local market. Others find work labouring on local farms. This enables their families to supplement their food rations and maybe save a little for a better life.

If things improve in South Sudan and the fighting abates then many may decide to go home. For now though, this is only wishful thinking.