Aid agencies working in northern South Sudan are worried about refugees from Sudan's war-torn Blue Nile State who are reaching under-resourced camps in increasingly poor health.
In recent weeks over 35,000 people have flocked to a site 50km from the border known as Kilometre 18 (KM18) by aid agencies - the distance to the nearest refugee camp (Jamam) holding over 30,000 people.
The war in Blue Nile between Sudan's government forces and rebels has raged since September 2011.
Several refugees from Bau County said they had joined an exodus of people fleeing recent shelling, bomber planes and soldiers attacking villages.
"We were running from the war," said 22-year-old Hawegu Oram Junjal, who arrived from Mugum village three days ago. "There was no one left in the village when we fled."
The UN Refugee Agency (UNHCR) last week said it expected up to 15,000 more people to cross from Blue Nile in the coming weeks to join over 100,000 refugees already in Maban County in South Sudan's Upper Nile State.
"I saw the army coming and the plane came and bombed so we ran away," said Anim Chapa, who, like many others, is now being treated at a Médecins Sans Frontières (MSF) clinic for dehydration at KM18.
After weeks and sometimes months of walking, aid agencies say refugees are arriving in places like KM18 (which have limited water and no sanitation) increasingly exhausted, malnourished, and in poor health.
KM18 under pressure
MSF doctor Erna Rijnierse said that last week, the clinic carried out 500 consultations, whereas half way through this week 900 people had already been seen.
Half of the consultations are for diarrhoea, with increasing cases of bloody diarrhoea from persistent dehydration and poor hygiene.
"There's not enough clean water, so people drink from pools of dirty water and get diarrhoea,” said an MSF worker as she handed out cup after cup of rehydrating fluid mostly to women, children and the elderly.
MSF said malnutrition was above emergency levels and particularly prevalent in children under five, for whom diarrhoea can prove fatal.
"Four out of eight children in the family have diarrhoea" from drinking dirty water, said Junjal.
"On the way, there was no food, no water", and some people died from bad water or a lack of it, claiming they could not walk any more, said Chapa.
"You are already vulnerable, you have very little to eat and you've been a refugee for four weeks, so if you suffer from diarrhoea, then it is quite easy to cross the line from being a normal kid to having severe malnutrition," said Rijnierse.
Aid agencies fear that if the lack of water, poor sanitation and rising diarrhoeal diseases cannot be solved, the possibility of disease outbreaks is very real. "You've got poor water, poor sanitation and poor hygiene… The risk of that turning into cholera is very high," said Pauline Ballaman, Oxfam's humanitarian coordinator in South Sudan.
MSF has vaccinated over half the child target group in KM18 for measles and hopes to achieve 90 percent coverage to avert an outbreak. It is also trying to deliver cholera kits and, in case of an outbreak, has earmarked sections of its tented hospital in Jamam.
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"When we came from there to here, we brought a little bit of sorghum with us, but when we crossed over, the food ran out, and we were just eating the leaves of trees," said Chapa.
The sight of small children in rags eating the whitish flesh from a tree stump is apparently not rare. "We've seen children eating bark at the side of the road," said Rijnierse.
"People need very basic things like shelter when it rains and they need proper food. There is food distribution going on but some people need something extra," she added.
MSF said it only had the capacity to treat the worst cases of malnutrition, and expects to have a much bigger caseload during the six-month rains, due to a lack of shelter and mosquito nets.
"The rainy season has started, and we are seeing the first cases of malaria and respiratory diseases," said Rijnierse.
Poor road access
It is a race against time before rains cut off access to transit points like KM18 and places like El Foj, just inside South Sudan, where refugees often rest before moving on.
UNHCR is trying to move 2,000 people per day to permanent camps using buses and trucks, but five days after the last rain, buses from Jamam to KM18 are getting stuck in the sticky clay.
“Normally it takes us about half an hour to get there [Jamam]. After one night of rain, it took about 4.5 hours,” Rijnierse said.
Water at KM18’s two `hafirs’ (man-made watering holes) is only expected to last another week, while rains could cut off aid agency access.
“The problem is that nothing is easy here. The roads are a nightmare. They turn into some kind of mud that sticks to everything,” said Rijnierse.
But even if refugees are moved in time, they will face similar water shortages in the camps that are already over their capacity.
“There is not enough space now in the camps. They are not ready and the rainy season is starting. It’s too late, we have to react right now,” warned MSF’s Maban County coordinator, Patrick Swartenbroek.
Maban County has an airstrip near Doro refugee camp, but the lack of other airstrips in the area has sparked concern among charities which believe Jamam, a new site called Yusuf Batil, and KM18 could be cut off.
On 16-17 June UNHCR gained access to government-and-oil-company-owned Paloich airport in Melut County 90km from Jamam and 150km from Doro.
"We needed a much swifter delivery system, as the number of refugees in Upper Nile rapidly surpassed our original planning assumptions," said UNHCR representative Mireille Girard. "Whereas we had planned for 75,000 refugees, we are already counting some 105,000 - with several thousand more reportedly about to cross the border from Blue Nile State."
Since 16 June, the agency has flown in thousands of plastic sheets, blankets, jerry cans, kitchen sets, mosquito nets, sleeping mats, in addition to more materials to construct wells, and piping. UNHCR said it is also planning to fly 5,000 tents from Nairobi to Paloich.
UNHCR recently appealed for an extra US$40 million to address the refugee crisis in Upper Nile and in neighbouring Unity State, where around 50,000 refugees have fled conflict in Sudan’s South Kordofan State since June.
Girard said only $34 million of UNHCR's initial appeal for $111 million had been secured, and that the agency had now exhausted its emergency reserves.
Meanwhile, Oxfam has been struggling to meet water and sanitation demands for months in an area with black-cotton soil and drill rigs which have dug boreholes that have simply collapsed.
In Jamam people are getting 5-7 litres of water a day, while the standard is 15 litres.
Oxfam's Ballaman said it had been impossible to get drill rigs big enough to match existing boreholes that are about 150m deep and were drilled by oil companies operating nearby. "It's an ongoing battle just to provide some of the basics… It's been a long time since we've had a positive borehole."
Oxfam hopes that some of the riverbeds they have found have water underneath, while MSF is setting up pipes to try and transport water from other 'hafirs' nearer Jamam.
"It's all terribly hit-or-miss, and there are no guarantees that this is going to be enough," said Ballaman.