"Our island was beautiful. We had farms and many cattle," recalls 60-year-old Nyanuot Giel Tor from Nyaling community in Payiat Boma, Fangak County.
"But when the water came, everything was destroyed. Our crops and cattle died. The water eventually reached our houses and overnight there was water everywhere. Our island is now completely submerged and we had to move to higher land."
Since 2019, communities across Fangak County in Jonglei State, South Sudan, have faced a cycle of flooding, displacement, and insecurity. Recurrent floods have submerged homes, farmland, and grazing areas, forcing families to abandon their villages and seek safety on scattered islands and patches of higher ground across the vast Sudd wetlands. As communities become increasingly dispersed, accessing basic services, including healthcare, becomes more difficult, with many people living hours away from the nearest functioning health facility.
For Nyanuot and her family, displacement has reshaped nearly every aspect of daily life. The land they once cultivated remains underwater, while the cattle that sustained their livelihoods have long been lost. Like many others in Fangak, the family now relies largely on fishing and collecting water lilies from the river as a source of food.
The challenges facing communities in Fangak extend beyond flooding. Since late April 2025, tensions between government forces and opposition groups escalated repeatedly forcing community movements across the county, pushing many people even further from healthcare. In May 2025, MSF's hospital in Old Fangak, which served more than 110,000 people, was bombed by the Government forces of South Sudan during an aerial attack that killed seven people and injured 27 others, including patients and MSF staff. The destruction of the hospital removed one of the county's most important healthcare facilities and further disrupted access to medical care in an area already struggling with the consequences of displacement.
Today, more than one million people living in opposition-controlled areas of Jonglei State rely on just two functioning hospitals, both of which are operated by MSF. The impact of these overlapping crises is visible in the communities where MSF teams work today as the impact of flooding and conflict has fundamentally changed where people live and how they access healthcare.
"We found many people huddled together living on islands that are higher because of the floods and because of the fighting, especially after the bombing of the hospital in Old Fangak," says Dieu Top, MSF Outreach Nursing Team Supervisor in Fangak. "Most of these people escaped to hard-to-reach places looking for safety and shelter."
For many families, healthcare becomes difficult to access once they have settled in these remote locations. Safety often takes precedence over proximity to services, leaving communities isolated from routine medical care.
"The most important thing for people here is to find where they can feel safe," says Top. "They find it safer living in areas that are very difficult to access. In doing so, they move away from healthcare services and miss essential services they should receive."
Transportation presents another major challenge. Across much of Fangak County, canoes are often the only means of travel between communities. They are used to access markets, fishing grounds, schools, and healthcare facilities. However, years of flooding have submerged large areas of woodland traditionally used to make canoes, making them increasingly difficult and expensive to obtain.
"Our only means of transport is a canoe and getting a canoe is very difficult," says Nyayiek Gai from Dhornor Boma. "We sometimes have to wait for days to get a canoe when someone is sick to take them to the health center."
The challenges facing communities have been compounded by significant reductions in overall humanitarian funding in South Sudan. As a result, several organizations operating in Fangak have scaled down activities in recent years, placing additional pressure on an already fragile health system and increasing the burden on MSF, one of the few remaining health actors in the area.
In February 2026, MSF introduced the Community Paramedicine Initiative in Fangak county with the objective to decentralize healthcare and bring essential medical services closer to people living beyond the reach of conventional facilities. The programme serves an estimated 25,146 people across the islands of Dhornor, Kuerbuay, Kuerdeng and Payiat.
Patients are no longer required to travel long distances by canoe, and healthcare workers travel to their communities to deliver care. Through regular visits, teams provide outpatient consultations, maternal healthcare, follow-up care, and boat referrals for patients requiring more advanced treatment. The initiative also works closely with community-based drug dispensers, who help ensure young children living on smaller and more isolated islands can access timely treatment closer to home.
"After the bombing of Old Fangak, this community was one of the places people fled to in search of safety," says Ghan Paul Hoth, an MSF paramedical clinical officer in Dhornor. "We see more than 100 patients every week, and there are many cases of diarrhea because people here do not have access to safe drinking water."
Back in Payiat, Nyanuot sits with her 4-year-old grandson while he receives treatment from the MSF paramedical nurse. He has been coughing for the past two days, and she brought him to the paramedical site to be reviewed by the nurse. Life on the island remains challenging, and the fear of conflict and flooding has not disappeared. Yet the presence of healthcare within the community has eased one of the many burdens families face.
"Knowing that we now have free medication close by is the one good thing we have," says Nyanuot.
Across Fangak County, flooding, conflict, and displacement have repeatedly pushed communities further away from healthcare. Through the Community Paramedicine Initiative, MSF is adapting to that reality by bringing care directly to people living in some of the county's most isolated locations, ensuring that access to healthcare does not depend on a family's ability to find a canoe or travel long distances in search of treatment.