Women gather for a free tetanus vaccination in Kuajok, South Sudan. Photography by Christina Reynolds.

I met Ajok Madut where much of South Sudanese life takes place—in the shade of a big, broad, drought-resistant neem tree. On this day, she was one of dozens of women and schoolgirls who walked to this hot, dusty site on the outskirts of Kuajok, the capital of the state of Warrap, near the country’s northern border, to receive a free tetanus vaccine.

Wearing a traditional lawo wrap and plastic sandals, she was toting her nine-month-old son, Ayi, while her three-year-old daughter, Acol, trailed behind. Madut, who looks about 30 but doesn’t know her own age, came here because she heard that this immunization would help protect her future babies. She had already given birth to seven children—all by herself, at home in a mud-and-grass hut—but three of her babies died soon after birth. “At labour time, there was no time to go to the hospital,” Madut tells me, speaking Dinka, through a translator. “Traditional birth attendants won’t help because they are scared that if there is a problem and someone dies, they will be blamed.” So, using a UNICEF-provided “mama kit”(which includes a plastic sheet, soap and a sterile razor blade to cut the umbilical cord, among other items), she gave birth alone each time. “I felt the pain,” she says. “But I couldn’t let myself become too scared, because there was no one to help me. Being scared wouldn’t be good for the baby.”


South Sudan, which seceded from Sudan to become the world’s newest country on July 9, 2011, has one of the world’s highest maternal-mortality rates—2,054 per 100,000 births. (That is compared to 7.8 per 100,000 births in Canada.) More than 60 percent of the population have no access to clean drinking water, and over 50 percent live below the poverty line.

“It’s a country starting from scratch. There is no health system in place,” says Paula Nuer, a health specialist with UNICEF who is overseeing the regional maternal and neonatal tetanus (MNT) vaccination campaign. That is not an overstatement. For a country with a population of eight million, there are just 120 doctors, 100 registered nurses and 10 midwives, according to estimates. There are few health-care facilities, and those that do exist are extremely primitive—even the largest primary-health facility I visited in the region, which had 50 beds, was a crumbling cement structure. Hundreds of patients were waiting outside in the blistering heat. The health challenges in the region are numerous, from malnutrition and anemia to malaria and tetanus.

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Women wait their turn to be immunized. Photography by Adriane Ohanesian.

Because 80 percent of South Sudanese women give birth at home and because of poor record keeping, when a woman and/or baby dies, it is hard to know the cause of death. “Often, death comes because of infected and open wounds, like an umbilical-cord cut,” says Nuer. “And in cases like that, the cause is often tetanus, which is an extremely painful way to die and has a fatality rate of 95 percent without treatment.”

Yet tetanus is totally preventable. A vaccine has been available for more than 80 years, and—except in 30 countries, including South Sudan, Haiti and Nigeria—the disease has been eliminated around the world. To complete the job, UNICEF and Kiwanis have partnered on a five-year $110-million global effort to eliminate MNT by 2015. A series of three tetanus vaccines—costing only $1.80—can provide almost 100-percent protection for a mother and her future children. In South Sudan, the vaccination campaign is part of a broader UNICEF strategy to reduce maternal-mortality ratios by three-quarters by 2015. “The tetanus vaccinations will not be enough if we don’t have hygienic deliveries and more trained midwives,” says Nuer, who grew up in southern Sudan before her family fled north to Khartoum during the war. She then completed her master’s in public health in the United Kingdom before returning home. “We’re moving in the right direction, but it’s very slow because of a lack of services. It takes three years to properly train a midwife.”

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Back beneath the neem tree, three local volunteers run the modest vaccination efforts. They have set up just outside of a county health facility—a two-room yellow cement building—in a part of Kuajok called Block 14, one of the areas designated for more than 147,000 displaced people who have been steadily returning to the state since 2007. There’s a blue banner with drawings depicting a vaccination (the images are vital—just 16 percent of South Sudanese women can read and write), a worn plastic table, a few mismatched plastic chairs and a long wooden bench. Mary Michael, the “vaccinator,” mans a portable cooler with ice packs that are keeping the vaccine vials cold, as well as a bottle of rubbing alcohol and little piles of needles and cotton swabs. Joseph Wol, the “recorder,” is documenting names in a notebook and handing out a yellow record slip to each woman. Emmanuel Bol, the “social mobilizer,” can be heard periodically calling out “You women, come to the hospital to be vaccinated. It is very important for you,” in English and Arabic over a megaphone as he circles the nearby mud-and-grass huts on his bike.

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"Social mobilizer" Emmanuel Bol spreads the word about the vaccination campaign. Photography by Adriane Ohanesian.

The previous day, the group vaccinated 175 women. “I’m upset about our community,” 25-yearold Wol, a first-year law student, tells me during a short lull in vaccinations. “This is a good way to help make the country better.” Over the next few days, 267 like-minded trios of volunteers will fan out across Warrap to set up similar immunization hubs in an effort to reach 316,000 women of childbearing age. This is the first of three rounds of vaccinations. It will be repeated later this year and again in 2014.

At the same site, I meet 17-year-old Monica Adjok, who has come to get vaccinated during a break from studying for her primary-school exams. She recently returned from Khartoum with her family because her parents “wanted to be part of the new nation,” she tells me in English, which she is learning in school. (It’s the new country’s official language.) “South Sudan is a good place,” she says. “I want, God willing, to become minister of health—to help my family, to help all people of South Sudan.”

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Minister of health is a tough job—especially since South Sudan shut off oil production in January 2012 due to a dispute over payments with Sudan. The oil accounted for 98 percent of government revenues. As such, there is not even enough funding for government salaries, let alone health care. (In March, the two governments signed an agreement to resume oil production, but there is no guarantee that the agreement will last. There is also no assurance that the revenues will trickle down to those most in need, which has been a problem in the past.)

“The oil shut-off has stopped development,” says Aguek Deng, director general of the ministry of health for Warrap. “Everyone is waiting for the oil to come back on.” Last year, he left his clinical work as a doctor to take on this job, but he is facing many challenges. “The logistics are not easy,” he says. “The distance between counties is great, and the roads are not good. For vaccinations, we need more solar refrigerators. Fuel is expensive for the generators needed to maintain the vaccine cold chain.” UNICEF provides and transports the vaccines to government cold rooms and is coordinating the logistics of the vaccination campaign. But that’s no easy task in a region with extremely poor roads, an unreliable power grid, no postal service and very limited communications— most people are lucky to have access to a radio.

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Volunteer "vaccinator" Mary Michael administers a vaccine as "recorder" Joseph Wol completes the paperwork. Photography by Adriane Ohanesian.

To give you an example, this was my journey to Kuajok: From Toronto, it took two commercial flights and 17 hours in the air to reach Juba, South Sudan’s new capital in the south. Then there was a two-hour UN World Food Programme flight—on a different day and to a different city from what was originally planned—with one refuelling stop along the way. Cap that off with a jarring five-hour pothole- ridden drive along 160 kilometres of unmarked red-dirt roads dotted with goats, cattle and brokendown trucks—and a narrowly avoided baboon. When I finally reached Kuajok, it was hard to believe I had arrived in a capital city. Among all the mudand- grass and tattered-tarp huts, it’s difficult to spot a two-storey building. One of the two traffic roundabouts leading to the main business street consists of a waist-high wood stump (with an empty red food can perched on one of its branches). The nicest building I visited was the year-old ministry of health headquarters. But throughout my meeting with the health minister and the ministry’s director general, my eyes kept wandering up to a sad-looking air-conditioning unit that was balanced precariously in a chipped-out hole in the cement wall several feet above the minister’s head. At my hotel, one of just a few in town, I locked my room’s corrugated-steel door with a padlock and was lucky to have power—thanks to a generator—for a couple of hours each evening. If it’s this hard for a person to reach, and stay, in Kuajok—in the best of circumstances—you can just imagine the difficult journey that a temperature- sensitive vaccine must take.

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Despite all the efforts to get the vaccines to those in need, not all the immunization sites I visit are well attended. When we arrive at one, beneath yet another neem tree, it’s virtually empty. Nuer jumps out of our UNICEF Land Rover to see what’s up. The social mobilizer is sitting at a table. She returns to the truck, a bit exasperated, and quickly makes a cellphone call to try to get things moving. “They have to step up the social mobilization. This is day two. You have to be following up and checking with them,” she instructs another UNICEF staffer kindly but firmly. “The mobilizer just isn’t going out.”

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Mary Athieny Makot (centre) socializes at a vaccination site. Photography by Adriane Ohanesian.

Still, those who do come for vaccines remain hopeful. I meet Mary Athieny Makot at another vaccination spot just outside the region’s 50-bed primary-healthcare centre. She greets me with a big smile and a warm “I am Mary; what is your name?” in heavily accented English. At 27, she has been married for four years, and, despite living 10 minutes away from the hospital and having given birth to three babies there, this is her first tetanus shot. While her husband is away studying at university—she is the second of his three wives— Makot is living in Kuajok at her childhood home with her mother, her brother and other relatives. “My greatest challenge is that there is not enough money for daily needs like food,” she says, in Arabic, through a translator as she fiddles with a green plastic bead on one of her silver earrings. “There is nothing left for school fees.” Her children are still too young for school—the fees she is referring to are for her to attend school and learn English. She does odd jobs, when she can, and helps her family raise cattle. “We need jobs,” she tells me as we stand between her family’s two modest huts surrounded by a grass fence. “I’m happy you’ve come. When I see people coming to visit, it gives me hope.”


Makot is lucky to have been able to wait until her 20s to wed. According to Human Rights Watch, child marriages are a continuing problem in South Sudan. According to government statistics, in 2010, 38 percent of girls married before 18—and it goes up to 54 percent for those from the poorest households. Early marriage usually leads to early pregnancy, which can be deadly. A United Nations Population Fund study found that in Africa, girls aged 15 to 20 are twice as likely to die in childbirth as those in their 20s, and girls younger than 15 are five times more likely to die. One reason is that younger women are more prone to obstructed labour because they have smaller pelvises, which can give rise to complications like an obstetric fistula, a condition in which a hole develops in the rectum and/or vagina, causing leakage. Without surgery, the condition often leads to social ostracism. It is estimated that 5,000 girls and women suffer from fistulas each year in South Sudan.

But there is some good news. Women make up 34 percent of the country’s newly elected legislature, and more people like Nuer are returning to help. “It was a bit hard to come back here from London and face these challenges,” says Nuer. “But this is a place where you can make a real difference.”

Canadian Efforts

Julia Levine knows a lot about tetanus: For the past two years, she has spent countless hours giving speeches about it. “It is said to be one of the most excruciating ways to die, and wherever there is dirt, there is tetanus,” says the retired elementary schoolteacher from Owen Sound, Ont. Levine is a regional volunteer spokesperson for Kiwanis’ global Eliminate Project partnership with UNICEF. Kiwanis Canada is aiming to raise $4.8 million as part of the $110- million global effort to help end MNT by 2015. “It costs so little to protect a mother—as well as her unborn children,” says Levine.

UNICEF’s Mother and Baby Tetanus Pack Survival Gift costs $15 and pays for 250 tetanus vaccines— and each purchase will be matched by Kiwanis Canada (survivalgifts.ca).

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