As Cambodia moves closer to maternal and neonatal tetanus elimination validation*, the message is clear: It’s working.
Story by Amy Wiser
Photos by Curtis Billue and Amy Wiser
*Editor’s note: In October 2015, just four months after this article was published in Kiwanis magazine, Cambodia was validated by the World Health Organization as an MNT-free nation.
Over the glittering Tonle Sap River. Beyond the hustling noise, dazzle and construction rebirth of capital city Phnom Penh. Past rice fields, faded sentinel temples and the schoolyards where row after neat row of bicycles lean in anticipation of their owners. Across roadways that mesh patches of sleek highway with rut-pocked red-dirt paths. This is the way to Cambodia’s future.
Six hours deep into the drive, Phnom Penh has disappeared into vague memory. Gritty towns give way to verdant pepper, coffee, cashew and rubber farms. Farms fade to a dustier savannah-like scrub-and-shrub landscape, long stripped of its timber. This is the way to Cambodia’s Mondulkiri Province, one of the nation’s last hold-outs for validation against maternal and neonatal tetanus (MNT).
This is the way to the village where Phalla Srey Lin and her sparkle-eyed daughter Nget Snet live.
Nget Snet is just shy of two years old. She clutches a yellow balloon as she snuggles into her mother’s protecting arms. Phalla Srey Lin is 18 years old. She and her husband farm rice and cassava, scratching out their living on a small patch of land. They are part of Poutert village where, as far back as she knows, they and their extended family have always lived.
Steeped in the global hope of mothers everywhere, Phalla Srey Lin has big dreams for her daughter. She wants Nget Snet to become a doctor.
“I want her to study, graduate and become a doctor,” the young mother says without hesitation. It’s clearly not the first time she’s thought about her daughter’s future—or that of her community. “Being a doctor could have a lot of advantage in our village. We have a health center, but we still have a lot of people who need help.”
Nget Snet could grow up to be that help. She could grow up to be the person who creates a new cycle of health and hope in her village. In Cambodia. In the world.
That’s what happens when people invest in human potential. And it’s already happening in countries like Cambodia because of Kiwanis and The Eliminate Project. For Nget Snet, the investment began when her mother received her series of tetanus toxoid vaccine, protecting Nget Snet and any future brothers or sisters from tetanus.
On the brink of being validated for MNT elimination by the World Health Organization, Cambodia is an example of how funding is put to work on the ground by UNICEF. It is also a study in the intricacies of communication and health strategy in a poor nation’s most remote reaches—and how tetanus vaccination has opened doors for other vital health initiatives.
According to UNICEF Cambodia, as of 2010 about 85 percent of pregnant women were vaccinated against tetanus—up from 69 percent in 2005. The most recent validation work shows the bulk of the nation to be MNT-free. Yet there are pockets—remote areas, like Mondulkiri Province—that cannot yet make that claim. Mondulkiri has a high ethnic minority population; creating linguistic and cultural barriers to immunization and health education. The population is spread thin over a vast, tough-to-navigate geography. High migration rates make it difficult to reach new, sometimes transient residents. Despite these challenges, UNICEF, Cambodia’s health ministry and a network of health volunteers has put on the full-court press to change “almost” to “done.”
“It’s about working at the local level to ensure women are going to health centers, that they’re attending their antenatal visits, that all the community members are aware of how to avoid tetanus and that all the community members are demanding that they’re vaccinated and protected from tetanus,” says Rana Flowers, the UNICEF Representative in Cambodia.
In Pourchrei Commune in Mondulkiri Province, 52-year-old Ya Tharin has seen babies die of tetanus. Among them, those of his own mother and sister.
“The child would be shaking,” he recalls. “It wouldn’t want milk. But we didn’t know it was tetanus. I was scared when I saw this. I didn’t understand it.”
What Ya Tharin and others now know was MNT was then attributed to the belief that the baby’s “original mother” had come to reclaim her child. When a newborn no longer wanted to nurse and took on a far-away look—as though looking beyond everyone—villagers believed a “previous,” unearthly mother had come for her baby.
That was, however, 30 years ago, says Ya Tharin. Now, MNT is becoming rare. He’s seen many improvements in antenatal care in the village, including introduction and regular distribution of the tetanus toxoid vaccine, umbilical cord care education, increased use of the health clinic and, critical to the whole operation, a growing network of volunteers from the community to promote it all.
“When I realized (tetanus) was preventable, I wanted to spread the word quickly,” he says. “I’m happy to spread the message and make sure women are informed.”
Ya Tharin is part of an education and messaging strategy. He is a health volunteer within a network of volunteers.
“Volunteers are used to communicate with the women, because the healthcare workers simply can’t talk to every pregnant woman,” explains UNICEF Cambodia health officer Chum Aun.
“The value of the health volunteers and the way they combine with the (local) health centers in terms of communication is a crucial element,” Flowers adds.
The provincial-level maternal and neonatal child health (MNCH) ministry recruits one man and one woman from each village. Like Ya Tharin. The health ministry has guidelines for who is best to serve a village as a health volunteer.
“The volunteers are nominated during a recruitment process, and they receive respect from the other villagers,” Aun explains. It’s set up as a part-time volunteer position, as both men and women often work on their farms together. The volunteers receive a small stipend to attend regular training.
“We’re seeing an increase in antenatal care, and more people are receiving their tetanus toxoid vaccine. Before, only five to six women a year would come to the health center for antenatal care. Now, it’s more than 100.”
Once a month, the volunteers and village leaders—including the village chief—gather with other villages’ volunteer network teams to learn new antenatal care information, refresh their knowledge of best practices—including the importance of tetanus vaccination—and set goals. Representatives from the provincial-level MNCH ministry lead the sessions. Then, the information goes back to the villages where the volunteers convene women once a month to teach them, as well.
“It’s a slow process but it moves, and it makes a change,” says Bin Rattana, MNCH chief for the provincial health ministry in Mondulkiri. She leads the once-a-month training sessions for the volunteers and village leaders. “We’re seeing an increase in antenatal care, and more people are receiving their tetanus toxoid vaccine. Before, only five to six women a year would come to the health center for antenatal care. Now, it’s more than 100.”
She says that with more volunteers in villages to carry the message, she believes Mondulkiri Province also will declare MNT elimination. It works, she says, because everyone is hearing the same message about tetanus, umbilical cord care and antenatal care—and the message is being reinforced by “top down” messaging from the village chief, as well as peer-to-peer from other health volunteers.
That’s how Phalla Sey Lin learned about the tetanus vaccine, the health center and other antenatal care services.
“And I went, because I wanted to be healthy as a mother,” she says.
On a shaded porch, women with young children nestled in their laps and at their feet, sit on the floor in a circle. Volunteers Phally Heap and Trouy Veth lead the monthly discussion. The topic is antenatal care and umbilical cord care.
The shade and a gentle breeze make for a comfortable afternoon on the porch. As the volunteers finish their presentation, many of the women remain to continue talking with one another, laughing and corralling children while they enjoy sweets the volunteer leaders distribute. It could be the end of a parent-teacher-association meeting or neighborhood coffee klatsch. The sessions are as much social gathering as they are educational—and this is important in drawing the women.
“If this activity continues, there will be more women who understand,” says Phally Heap, a 26-year-old mother of one. “What makes me happy about being a volunteer is that when they come here, they learn and follow (what we tell them). It makes me feel satisfied. But I also feel discouraged that not everyone comes.”
“We just keep trying, keep telling them all the time,” adds Trouy Veth, 43 and mother to six.
And it’s important that they continue to come. One of the women participating in the day’s session explains that she is not vaccinated against tetanus. She was working in the field when vaccinations were offered. She understands now how critical the vaccine is and has made plans to get her vaccinations.
It’s working. As Kiwanians around the world rally to raise US$110 million by December 31, 2015 for The Eliminate Project to help eliminate MNT, Cambodia is an example of how funding provided to UNICEF is already making its mark against the horrific disease. And more. It’s not only providing the tetanus toxoid vaccines themselves, but also education in antenatal care and other health services, safe delivery practices and cord care. It’s building networks like the one that connects Cambodia, UNICEF and local volunteers to make sure the message breaks into even the hardest-to-reach regions.
And because of the successful in-roads made through Cambodia’s MNT-elimination program, the door is open for UNICEF and Cambodia to address other critical health concerns, such as nutrition, clean water and sanitation, as well as child protection and education.
“We’re looking at integrating our approach so that when we are doing the outreach, we’re combining other really important interventions,” says UNICEF Cambodia’s Rana Flowers. “So we combine with the vaccination for tetanus an approach to nutrition and information on other health issues and really promoting those to come together so that the whole health management starts to really protect the communities in a more efficient and effective way.”
As the people of Cambodia have become aware of the dangers of tetanus and the need to have the vaccine, Flowers notes, that success has seeded trust and the opportunity to infuse other health initiatives into the mix and into health volunteer messaging.
“When women go for their vaccines, they should also be asking for other services while they’re there,” she says. “It’s about ensuring wives, mothers and daughters get the right antenatal care and also that they follow up with their newborn babies to protect them.”
That’s the way to Cambodia’s future as a nation that invests in the human potential of children.
“Having a partnership that is focused and that is supporting an important element in the program—a life-saving element of the program—is absolutely vital,” Flowers says. “We can’t do this unless we have the support of Kiwanis.”
The support is an investment in the potential of children like Nget Snet and all the possibilities that lie ahead for her and the legacy she will leave.
“A service like this helps people understand,” says mother Phalla Srey Lin. “I would just like to say thank you.”
Changing Ways
Educating families about safe umbilical cord care is vital in Cambodia’s MNT-elimination efforts. Through practices passed down generations, some believe that placing substances—such as cow dung, wasps’ nests, spider webbing and ash—on a newborn’s umbilical cord, will protect the child. In fact, those substances can transmit tetanus, among other diseases. Proper cord care is a strong educational message that’s getting through, and women are demanding it. One mother of three noted that after she learned about proper cord care, she informed her husband that she would not put wasps’ nest on the baby’s cord—though he was insistent. She prevailed, and one more family is informed and protected.
Elimination
Globally, The Eliminate Project is raising US$110 million to help eliminate MNT in the 38 nations where the disease remained a public health threat. Each year, more than 49,000 newborns die from tetanus—134 deaths each day or about one every 11 minutes. The disease is caused by bacteria found everywhere in soil and animal excreta. Tetanus infection in a newborn baby causes severe spasms and an excruciatingly painful death. Any physical contact exacerbates the baby’s pain, so a mother’s touch hurts, leaving the baby to writhe in agony—unheld—for days until he or she dies. It costs about US$1.80 to immunize a woman against tetanus with a series of three doses, which provides an immunity she passes along to her future babies during childbirth.
Funding through The Eliminate Project supports UNICEF and its partners who have already eliminated MNT in 35 countries. With Kiwanis’ global volunteer network, along with UNICEF’s field staff and technical expertise, The Eliminate Project serves those who live in some of the most underserved areas where healthcare is limited. As of this past April, The Eliminate Project had raised more than US $75 million in cash and pledges to support UNICEF’s MNT elimination program.
This story originally appeared in the August, 2014 issue of Kiwanis Magazine.