Fieldset
Learning to count in Nuer: Teaching basic healthcare in remote South Sudan

In depths of the Sudd - a vast South Sudanese swampland - access to healthcare can be extremely limited. Nigerian nurse Stephen shares his story of reaching cut-off communities with a grassroots approach to saving lives.

MSF staff registering patients ready for consultations in the village of Kuemdoum

I first went to Old Fangak in September 2018, and I recently finished my third assignment there as MSF's outreach manager.

Old Fangak is a town in a vast wetland called the Sudd.

This area historically has been a refuge for people fleeing conflict. So, when the civil war broke out in December 2013, people again returned to Old Fangak and the relative safety provided by the wetland. 

Life in Old Fangak

There are no roads, no cars, no motorbikes and no bicycles. People walk for hours or even days to go anywhere.

Many people keep cattle and move according to the season. In the dry season, they move closer to the rivers to get water, grass for livestock and fish.

Many outlying areas have no access to healthcare beyond what we provide

Old people and young children stay in remote villages. Villages of a few thousand people are spread out over wide areas, with families living in their tukuls – a kind of mud hut – several hundred meters apart from each other.

Mobile clinics

MSF works in a small hospital in Old Fangak, but many outlying areas have no access to healthcare beyond what we provide through our outreach work.

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An MSF mobile clinic team travels down the Phow River from Old Fangak
An MSF mobile clinic team travels down the Phow River from Old Fangak

Every week, our mobile clinic teams travel over 150 kilometers (93 miles) north or south by boat, doing mobile clinics in villages. We arrive according to a schedule, and people know when and where to find us, walking several hours if necessary.

Mainly we treat patients with respiratory tract infections, diarrhea or malaria, while we take patients with more severe conditions to the hospital in Old Fangak. These include occasional cases of gunshot wounds, severe malaria, obstetrical emergencies, tuberculosis or suspected HIV.

Managing care in the community

Even with the hospital and mobile clinics, it is a challenge to meet the health needs in an area this large, where the population is so dispersed.

So, in March 2019 we started training people to diagnose and treat two common pediatric conditions in their communities: simple malaria and diarrhea. This is known as “Integrated Community Case Management”, or ICCM.

When we started, it was the first time in years that many of these villages had seen a health worker.

We had to adapt our approach because of the low level of formal education in the area. After many years of civil war, most people have never been to school and cannot read or write. This is especially true for the women.

When we asked communities to identify a trusted local person to diagnose and treat malaria and diarrhea, we realized we needed to teach basic numeracy as well, so that they could read thermometers.

Drug distributors

There are now 20 women and men serving as “community-based drug distributors” in our program, spread around 12 remote villages.

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MSF supports 20 women and men to serve as community-based drug distributors in remote areas around Old Fangak
MSF supports 20 women and men to serve as community-based drug distributors in remote areas around Old Fangak

When a child is sick, one of their parents takes them to the house of the community-based drug distributor, who takes their temperature.

If the child has a fever, they administer a rapid diagnostic test for malaria and give malaria medication if it is positive. If the child has had more than three loose stools per day, they treat diarrhea with oral rehydration solution.

Other cases are referred to our mobile clinic.

It is a very basic health system, but it works. From March to November 2019, our community-based drug distributors have been able to treat more than 4,000 children in their communities, about 14 percent for malaria and about 86 percent for diarrhea.

Tall grass and crocodiles

Our outreach activities and our community-based approach are necessary because of the geographical challenges and the people's seasonal movement to cattle and fishing camps.

It makes me feel like everything is possible

The absence of roads and infrastructure, and the swampy nature of the terrain, leave boats as the only practical means of transportation for our teams. So, every week, we spend many hours navigating the river—sometimes slowed down by tall patches of grass or meeting the occasional crocodile—to make sure that the people living in this remote area of South Sudan have access to medical services.

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The Sudd is a vast swamp, with rivers often the only way to travel
The Sudd is a vast swamp, with rivers often the only way to travel

I was glad that I learned to know these communities over the course of my three MSF assignments. Before I left, I was speaking the local Nuer language, I could count from 1 to 100 and carry on conversations with local leaders.

Personally, it makes me feel like everything is possible.

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