Moans and shrieks fill the corridors of the hospital in Ruhengeri, a town in north-western Rwanda. Doctors carry out impromptu operations on patients laid out on the floors.
These are the survivors of the latest massacre in Rwanda's worsening conflict between the minority Tutsi-led government and armed groups of Hutu militia. The rising brutality of the clashes has led to predictions that the country could be facing a calamity to match the genocide of 1994, when up to 800,000 Tutsis were killed in six weeks of bloodshed.
Guns and machetes were used to slaughter the victims of this latest atrocity. Hundreds of rebels descended on a refugee camp at Kinigi, in the countryside near Ruhengeri, on Tuesday night.
"There were many people, they were screaming. They carried machetes, some had guns. Some wore uniforms, but others did not," said Francois Munyakarambi, who is being treated for gunshot wounds. Two doctors and a surgeon work overtime. "We have 300 beds but over 350 patients. This violence is getting worse and worse every day," said Dr Karemera.
The deterioration coincides with the return of over one million Hutu refugees from Congo and Tanzania a year ago. Many of these were members of the defeated army and militias which were responsible for the genocide. The present government is dominated by Tutsis, which comprise only 15 per cent of the population.
The Kanigi camp housed ethnic Tutsis who were already in flight from the neighbouring Congo, where they were massacred in their thousands over a year ago. Now their persecutors have returned to haunt them. "I have moved three times already and still they come. Where can I go now?" asks Francois. Official estimates put the number of deaths in this attack at 30.
The situation begs comparisons with Algeria. As there, the rebels wage war with extreme brutality. Government forces in the Rwandan Patriotic Army (RPA) respond with excessive force, but seem unable to protect the civilian population. And innocent people have been caught in the middle, doomed to be tagged as traitors by one side or collaborators by the other.
The main difference is that while western observers are absent from Algeria's civil war, Rwanda is host to a massive array of human rights organisations. Yet the presence of the UN and nongovernmental bodies (NGOs) has made little impact on an increasingly bloody conflict.
The RPA is one of Africa's crack military forces. But it has been unable to quell the resurgence of the Hutu rebels, who were last active in the refugee camps that existed along the Rwanda-Zaire border until the end of 1996.
Tanks and rocket-launchers are of little use in the hilly, densely-cultivated terrain of this part of Rwanda. The army is pitted against a faceless guerrilla enemy that melts quickly into the forest or across the border with Congo. The rebels often wear RPA uniforms to confuse their opponents.
They have no clear political programme, and it isn't even clear if their actions are co-ordinated. But they enjoy widespread support among the population, many of whom are returned refugees from the Hutu camps in Zaire.
According to Konrad Huber, of the UN human rights field operation in Rwanda, security in the north-eastern provinces of Ruhengeri and Gisenyi has dramatically deteriorated. The rest of the country, though calmer, has been affected by individual killings and by growing human rights violations.
Westerners travel to Ruhengeri only by armed convoy during the daytime. By 3.30 p.m. the UN convoy can be seen speeding back on the heavily guarded road to the relative safety of the capital, Kigali. Gisenyi, where there has been shelling and aerial bombardment, can be reached only by plane.
As a result, no one knows how many people are dying. Only a fraction of killings are reported, and the army consistently plays down casualties. But last month's death toll alone illustrates the intensity of the conflict. The incidents documented include:
up to 40 brewery workers killed when their bus was attacked near Gisenyi town. Rebels stopped the bus, asked the people to divide into Hutu and Tutsi and, when they refused to separate, started killing them. Locals cheered on the rebels' efforts, and many who escaped from the bus were hacked down by the onlookers.
a similar incident in Rugerero sector in which 17 people died when they were attacked and their bus set on fire. Hundreds died in Nyamyumba commune when more than 1,000 infiltrators attacked their village during the night and burned it to the ground.
at a convent near Rwewere, rebels used machetes to kill at least nine sisters who were working at their clinic.
an estimated 500 people were killed in an army sweep in Kabilizi sector. Locals say they were unable to find a mass grave and the unburied bodies are being eaten by pigs.
The few aid workers remaining in Gisenyi province say the local population is resigned to the continuation of violence. One remarked: "People say they are more surprised to wake up alive than if they had been killed during the night".
In other areas the army has restored a fragile peace. In remote mountainous communes north of the main road to Ruhengeri, Concern has been building houses in a number of sites. At Nyamugali commune the 32 mud-bricked houses are completed but empty.
"They're afraid of being an easy target for attacks, because these houses are a few miles from the commune office," said a Concern field officer, Paul Comiskey. However, this area, so beautiful with its tea plantations in the valley and banana trees on the slopes, is becoming calmer, and Comiskey is told the families will move in shortly.
Other Concern developments are occupied, but there are requests for greater security. "Local officials were the ones who most wanted to live in a village, but now they are being targeted for assassination and are afraid to do so," said Comiskey.
The rains have been plentiful, and agriculture is making a recovery from the losses incurred during the genocide. But with farmers unable to work the land in large areas affected by war, there are fears of food shortages in this fertile land.
