Ezibon Charles Ruben and his two colleagues have been cycling for miles.
For the last two hours they’ve been struggling along the bumpy track through the dense green bush, their journey made harder by lumpy backpacks, crammed with medicines, medical supplies and patient forms.
Though it’s the rainy season, the temperature is still high and Ezibon briefly admits to himself that he’s tired before casting the thought out of his mind and focusing on why he’s travelling.
A stream comes into view, swollen by the recent rains. The three-strip down to their underwear and wade into the water. It’s lucky they’re tall as the water comes right up to their necks.
Carrying their backpacks above their heads they cross to the other side, placing the medicines on the bank. Back and forth they go, transporting their clothes and bicycles to the other side.
Finally, they pull themselves out of the water, get dressed – making sure to look presentable as they’ll soon be seeing patients – and get back on their bicycles to head on their way.
Ezibon is a nursing care provider (NCP) who works as part of Doctors Without Borders (MSF’s) Integrated Community Case Management (ICCM) programme in Mundri, in the Equatoria region of South Sudan.
ICCM is an adapted way to bring healthcare as close as possible to people in their communities. By foot or bicycle, the nursing staff travel from one community to another, bringing healthcare to people living in remote locations.
Healthcare out of reach
The Equatoria region of South Sudan is very fertile and incredibly green. Outside the town of Mundri, there are small, isolated communities accessible only by tracks cut through the bush.
As you travel, it can feel like the thick, vibrant vegetation is closing in and swallowing the tracks. Sometimes the elements overwhelm and the tracks become impassable due to flooding or fallen trees.
The area once had some of the country’s strongest health structures but that all changed when the conflict intensified in the region in 2016.
A peace agreement signed in September 2018 has seen fighting significantly reduce in the area but many of the healthcare structures are damaged or rarely open, disused relics of the time before the worst of the conflict.
There is a Ministry of Health Primary Healthcare Centre in the town of Mundri but this is difficult to access for the people who live in the small, remote communities outside the town.
The most common diseases and the biggest killers among children, in South Sudan are malaria, acute watery diarrhoea and pneumonia, three deadly illnesses that can be easily treated if caught early but early treatment is hard to find when healthcare is so hard to reach.
People often wait and see how symptoms progress before seeking medical care, but the wait is fraught with risk as all three diseases can quickly turn deadly if left untreated.
As these illnesses progress, more advanced treatment is required, but this is beyond the scope of the few health centres that are dotted around the area, with suitable care only available at the Ministry of Health’s Mundri and Kediba Primary Healthcare Centres.
These facilities are far away from remote communities and a person’s condition may drastically deteriorate on their delayed journey to seek care.
As Ezibon explains, “In some areas, there is a lot of suffering. It can take a long time for us to reach these areas and we can get very tired riding our bikes, but for the sake of our people we cannot stop, because we have seen the suffering of our community, especially vulnerable groups like children and pregnant mothers. I’m really very proud because I’m saving my community.”
Leaving before sunrise
At another ICCM site a mother arrives with a boy and a girl, neither older than ten and her baby daughter that she clutches close wrapped in an animal fur. The elder girl looks clearly unwell: withdrawn and uncomfortable.
She has walked for four hours to get here, leaving before sunrise.
William, another nursing care provider, begins his consultation for the baby by speaking to the mother to understand the symptoms. The baby is coughing but not crying and the mother explains her child has had diarrhoea.
William glances at his watch and stares intensely at the baby’s chest, counting the breaths she takes in a minute.
77, higher than it should be. William then takes the baby’s temperature, which is also high, and finally performs a malaria test, after drawing a small drop of blood from the baby’s toe. Next, William repeats his consultation with the elder girl.
Both patients have malaria and the baby also has pneumonia and diarrhoea. William gives the mother medication for the children’s malaria and fever and explains how and when it should be taken.
For the baby’s diarrhoea, William takes some oral rehydration salts which he dissolves into the water before passing the cup to the mother. Gently and with a warm comforting smile he holds the baby’s head as the mother pours the oral rehydration solution into the child’s mouth.
Thanks to William’s treatment, both children should recover. Their mother smiles and thanks to William before beginning her long journey home.
“Saving the future generations”
In the first six months of 2019, MSF’s 22 nurse care providers treated over 16,000 patients, over a quarter of whom were children under five.
The nursing staff also screen children under five for malnutrition and can make referrals to the Ministry of Health or MSF facilities, arranging for a motorbike to take patients with severe symptoms for emergency treatment.
Part of their job also involves providing health promotion lessons on topics such as sanitation, personal hygiene and disease prevention to inform communities how to stay healthy.
In June alone they provided 100 health promotion sessions with over 3,000 people in attendance.
They also lead conversations about the health implications of sexual and gender-based violence and how people can access confidential medical treatment at MSF’s facilities in Kediba and Mundri.
MSF teams go to great efforts to ensure regular supervision, training and observation of patient consultations.
Several times each week an MSF team led by Man Hin Chio (Hebe), a nursing activity manager from Hong Kong, and Rose Dawa Booms, a South Sudanese outreach nurse and MSF’s ICCM supervisor, meet the nursing staff for training and supervision to ensure that patients are provided with a high standard of care.
The supervision team travel either southwards or eastwards from Mundri, driving hours through an endless sea of green broken only by the rusty, bumpy dirt track.
Beyond the swathes of vegetation, there are few signs of life. Small collections of tukuls – small mud huts with thatched roofs – can be spotted amongst the trees as the land cruisers crawl onwards.
Sometimes you see vegetation smouldering, set alight in preparation for the planting of crops, or abandoned areas for grazing cattle where the sky-high green grasses make way for dark and empty fields.
The supervisors arrange in advance where to meet the nursing staff, making do with whatever venue is available. In some locations there are Ministry of Health structures, in others, benches sat in the shade of mango trees or a tent in the corner of a field must suffice.
It’s only possible to meet each nursing team once a week, so Rose and Hebe make the most of their time. The days are extremely busy, crammed with information for the nursing staff.
As ever, the nursing staff often travel some distance to reach the supervision venue, but they are engaged and attentive throughout, eager to learn as much as possible to help people in their communities.
Rose explains what ICCM means for local people: “If MSF was not doing ICCM, more people would be dying. Before MSF introduced ICCM children were dying.
Children under five are the victims, they are the ones who die very fast from malaria, acute watery diarrhoea and pneumonia, these three killer diseases. That’s why MSF came here – we are saving our children, the future generations.”
Read about MSF's activities in South Sudan