For the first two months of her life, Mary James slept with no blanket on a steel bedframe inside a small,
damp shelter in the middle of an overcrowded displaced persons camp. Now, she’s sleeping in an MSF
hospital bed, fighting for her life.

Each time the three-month-old exhales, it makes a rasping sound as her breath forces its way through
her tiny, infected lungs. When the infant cries, her body contorts with the effort of breathing. Until
recently, she’s been connected to an oxygen machine to support her breathing.

Mary lives in the United Nations Protection of Civilians Camp (PoC) in Malakal, South Sudan. As the cold
season sets in, children like Mary suffering from pneumonia and other respiratory tract infections make
up over half of the admissions to the pediatric ward in the MSF hospital, which is the main provider of
inpatient secondary healthcare in the camp. Recently, a malaria outbreak filled the hospital with
convulsing children. As beds filled up, many patients slept on mattresses on the floor.

“The root cause of these illnesses is overcrowding and sub-standard living conditions,” says MSF medical
doctor Yasser Sharaf as he makes the morning rounds. Outside the hospital gate, nearly 50,000 people
are sheltering in thousands of tents and shelters packed so tightly together that residents walk sideways
through some of the narrowest passages.

The families living in the worst areas arrived three months ago, when 16,000 people fled an upsurge of
conflict, violence and malnutrition. Most of them travelled at night in small canoes from nearby Wau
Shilluk, on the opposite side of the White Nile River, where humanitarian assistance had been cut off for
months. They arrived to the camp with almost nothing.

Forty-year-old Nya Gaw was among them. Formerly a midwife with a career and middle-class home, she
is now almost completely reliant on humanitarian assistance. In the PoC, she lives with 55 other people
in a dirt-floored communal tent. Sitting in her tiny living space, she removes the stems from a pile of
leafy greens known as Lum. It’s a food-of-last-resort foraged from outside the camp to supplement her
meager monthly food rations.

Nya arrived with two sons but her family has grown bigger since she came here. In spite of her difficult
circumstances, Nya has taken in four other children who were separated from their parents during the
conflict. Nobody knows where they are. Together, Nya’s expanded family shares a single cot and a
couple plastic mats on the floor for sleeping. Their living space is the size of a single bedroom.
At night, it is getting increasingly damp and chilly, and the air buzzes with mosquitos. The narrow ditches
and alleys that separate Nya’s tent from the others around it are filled with mud and stagnant water.
There are barely more than four square meters of space per person in this area of the camp – less than
one seventh the minimum space required by international humanitarian standards.

Put simply, Nya’s living conditions are a recipe for disease. She says that two children living in her tent
have been admitted to the MSF hospital recently, gesturing to their families’ equally-cramped living
areas.

“At night, everyone is coughing and sickness is spreading,” says Nya, a comment echoed by many
mothers in the camp. “We need more space.”

Only about half of a square kilometer has been allocated by the United Nations for families like Nya’s
sheltering in the camp to actually live in. More room is urgently needed. Presently, there is not enough
space to expand life-sustaining services like water points, bathing areas and latrines – never mind
adequate schools, recreational spaces or markets.

About 200 meters from Nya’s tent, a set of taps is surrounded by winding lines of jerry cans. The taps
are connected to a bladder which is filled with water twice a day, but never stays full. A group of women
ha