Around 90,000 displaced people live in the four camps surrounding Zalingei in western Darfur, Sudan. Photo © James Lorenz/MSF

It is early afternoon in the Ramadeqai camp for the displaced on the outskirts of the town of Zalingei in the troubled Darfur region of Sudan. The inhabitants, entering the last days of the Ramadan fast, are sweltering under the October sun. You can feel the lethargy that's descended.

Around 90, 000 displaced live in the four camps surrounding Zalingei. The makeshift shelters have been their homes since conflict broke out in Darfur early 2003. There have been no distributions of shelter materials for more than 18 months and their wood, earth and tarpaulin homes look bedraggled.

People fled to the camps looking for protection from the forces that had driven them from their villages. Instead, they found that those same forces encircled the camps, sowing fear and turning their refuge into a place of continuing terror.

Today, in conjunction with the ministry of health, Doctors Without Borders/Medecins Sans Frontieres (MSF) runs the 155-bed hospital in Zalingei, which is free and accessible in theory for both the residents of the town and the displaced in the camps. But even this is fraught with problems.

"Women are raped when they collect firewood, armed groups roam the camp at night spreading fear among the people and men are afraid of leaving the camp to walk 20 minutes to get medical care in the hospital in town." – MSF medical coordinator Severine Ramon

"The camp is like an outdoor prison," says MSF medical coordinator Severine Ramon. "Women are raped when they collect firewood, armed groups roam the camp at night spreading fear among the people and men are afraid of leaving the camp to walk 20 minutes to get medical care in the hospital in town."

Despite concern over access, the hospital carries out nearly 2,000 consultations per month, of which around 30 are for children with a combination of malnutrition linked to illness. Victims of sexual violence also get care, although the number of people treated is unlikely to represent the scale of the problem.

"In September we treated six rape victims," continues Severine Ramon, "but we fear that there may be many more who refuse to come forward because they are afraid to do so."

The difficulty that patients of all kinds have in getting medical care is partly the result of the problems aid agencies have in reaching out to them. Since the beginning of 2006, MSF teams have been the victims of more than 40 security incidents of varying severity, many of which have taken place on the roads supposedly under control of the Sudanese government.

The insecurity means that today, MSF is only able to use one road in the whole of Darfur, an area the size of France. All other transport is carried out by UN helicopter or plane. While MSF is still running major health care projects in 12 locations across the region, the result has been that many essential programs, such as mobile clinics outside towns, have been suspended.

Simple, but lifesaving, referrals have also become a near impossibility. For surgical cases for example, until recently MSF was able to refer patients the 60 kilometers (38 miles) from its health center in Niertiti to the hospital in Zalingei in an MSF vehicle. Following a serious security incident along this road in September, the referral service was discontinued and now patients have to rely on private transport.

"With MSF transport, this journey would take about an hour. With the trucks that serve as public transport, it can take up to ten. For a woman in urgent need of a cesarean this can have serious consequences," explains Severine Ramon.

Some programs such as Korma in north Darfur have had to be completely closed because of the insecurity, seriously reducing the access of people to health care. In September, a series of violent incidents forced MSF to withdraw from Kutrum in the Jebel Marra in the midst of a cholera outbreak after a series of incidents.

As MSF head of mission Jean-Sebastien Matte explains, "we have not had access to the rebel areas in the Jebel Marra for more than six weeks. We managed to care for about 500 cases of cholera before then, but there were certainly 300 to 400 more that we were unable to see. This means that these people may have died because a lack of medical care. Cholera can be rapidly treated but if there is no way to do so, then it kills you quickly. Today, we are not sure of the mortality rates, but we can only imagine that they are significant."

Since the western-backed Darfur Peace Agreement was signed in May 2006, the situation in the region has undoubtedly worsened. The number of groups involved in the fighting has multiplied and renewed fighting has begun between the government and groups opposed to the DPA. The resultant increase in insecurity means that across large swathes of Darfur, MSF is unable to even monitor the health situation.

The atmosphere in Darfur has been further polarized by the recent tensions over the illusion of an intervention from a UN peacekeeping force. Heated rhetoric from both sides of the debate has had consequences on the ground, with the Sudanese government stepping up its propaganda against what it terms as foreign meddling. Nongovernmental organizations have been among the first to face this wrath and false hopes have arisen among much of the population.

The tension has served to further tie the hands of independent and impartial aid work. "We have very limited access to the north of Darfur. So we don't even know what kind of state the people in some areas are in, whether they have access to water, health care, or food. Neither the government nor the different rebel groups give us the access we need; we are targeted from all corners. There is no question that we are unable to function as we would like," concludes Jean-Sebastien Matte.

The consequences for the people of Darfur, themselves faced with increased tension and violence, are worrying. Few in the area itself see any reason to believe that the situation is going to improve in the near future.