TB? Or Not TB?

TB Baby

This is a World Health Organisation growth chart for a child from birth to six months old.  The Y axis follows weight in kilograms, while the X axis follows the age in weeks to 12 weeks, then in months to six months.  The coloured curves traveling from the left to the right of the chart are percentiles.  They predict, based on worldwide population studies, how a baby’s growth should travel based on their weight at birth.  Baby Mary, who belongs to this particular growth chart, was born just above the middle green line, called the 50th percentile (which basically means that about half of all babies will be on or above this line, and half of all babies will be on or below this line).  As you can see from the weights we have recorded, her actual weight is severely faltering.  She has crossed all of the percentiles and her weight is “flatlined” well below what any baby of almost five months old should weigh.

We don’t know why.

The things we do know are:

She lives in a landless community who assemble tiny huts on the riverbank in the dry season, and in the wet season they disassemble their huts and live on their boats.  Her parents are fishers, relying on a daily catch for daily income.  There are only specific times of the year when fish supplies are reliable enough to guarantee catching enough for the family as well as some to sell for cash at market.  Hunger is a common experience as is ill health and premature death.  Her four year old sister has a neurological disability that looks like Polio, but is apparently a permanent sequelae from Tuberculous Meningitis as a toddler.

KF 7 March (2)

KF 007 (2)

The second thing we know is that she was born in a maternity clinic who supplied her mother with a free can of artificial milk powder, a small baby bottle with the capacity for only 40ml of liquid, one teat and no education on how to feed the baby.  Mary was 19 days old when I first met her and bottle feeding from an artificial teat was well established.  Sadly I didn’t have the skills or resources to teach or encourage her mother about re-lactation, which might likely have been the best option.  The second best option would have been trying to access donor human milk but I am unsure if that would be possible in this environment.  Artificial milk is an inferior alternative for many reasons and particularly in such impoverished settings.  It also feeds a highly lucrative corporate market, as I have discussed before.

When I asked her mother how she afforded to buy the milk powder she replied “when we can afford it, we buy it.  If we cannot afford it we have to go without”.  Feeding babies “rice milk” (the white liquid leftover from boiled rice) is not an uncommon practice and I  have seen malnourished babies who were living on this.  When I told an Australian friend Mary’s story she transferred enough money for six months of milk powder to my account the next day.  Although solids should be commenced around six months of age, babies rely on milk until 12 months of age for their nutrition, and should not commence cows milk until 12 months old.  In hope of keeping her nourished, when I left Cambodia in April I left enough for the second six months of formula.

As her growth chart clearly shows, she is in a dangerous state of malnutrition.  For months we have been monitoring her and trying to work out what could be wrong.  She was unwell about six weeks ago and Mum took her to hospital, who gave her “medicine” and arranged a follow up appointment at the end of June.  Was she sick now?  Apparently not.  Was Mum making the bottles correctly?  Apparently.  It really seemed a mystery and various questions entered my head from afar, such as, were staff weighing her incorrectly, was Mum selling the cans of formula and feeding her inappropriately?  Apparently not, to all of my imagined scenarios.

Finally our part time doctor, who spends his own money on patient treatments regularly despite being on a low salary, was able to review her.  He can hear noises in her lungs and wants her to return to the hospital appointment with the weight chart, for review of probable Tuberculosis.

With TB diagnosed in the family a mere two years ago and this baby infected within the past five months, it is highly likely that the same person who unwittingly infected her sister, has this year also infected the baby.  My colleagues went to great lengths to assist the family to an outpatient department for review in hope of identifying the source.  So far her parents and siblings have all been cleared.  Somewhere close, a grandparent, aunt, uncle or neighbour must be coughing TB.  Assuming they have not sought medical attention, they very likely feel reasonably okay and have become accustomed to a chronic cough.  I would love to be there with my Tuberculosis Investigator hat on, but I hope that by the time I do return, the source will have been identified and treated.

In a place where health services are not well coordinated, with all sorts of reasons that turning up unannounced and well (on face value) may not work, we have to wait now, for next week’s appointment, and hope that Mary comes home with anti-TB medications.  She is the second baby in this community in a mere six months since I began working with them, that I know of, who has been or will be, commenced on anti-TB medications.  According to World Health Organisation, in 2017, an estimated 1 million children became ill with TB and 230 000 children died of TB.  With any luck little Mary will come out of this insidious situation, alive.

TB or not TB?
That is congestion.
Con-sumption be done about it?
Of cough!  Of cough!
But it’ll take a lung, lung time…

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Baby Bears and Coffee Creamers

Before leaving Cambodia I did some training with my local colleague on how to correctly weigh babies.  She has since trained one of our village volunteers.  Last night they sent me some weights from the past few weeks to interpret and advise on.  Before I even analyse the results properly, I can see a range of malnutrition issues that are difficult to resolve with our tiny budget and the absence of services.  Still it was great to see my butcher scales being put to good use without me and to remain included in their activities from afar.

KF002

Babies who are breastfed fare better in infancy, but also throughout life, for many reasons connected to the health-giving benefits of breast milk, especially when the baby receives nothing else in their first six months of life.  A midwife friend is always talking about the need to “normalise breastfeeding”, because it is up against some serious interference.  Many in Australia, for example, consider breastfeeding in public to be improper, with all kinds of cultural constraints placed on young mothers.  Bigger than this however, are the various strategies used by corporations to promote breast milk substitutes inside a product market worth billions of dollars and growing steadily.  These profits come at a far greater human cost, presenting as infant illness and death in the poorest parts of the world due to multitudes of factors including maternal illiteracy, lack of access to clean water, and substandard or absent health care to teach and support mothers.

In 1981 the World Health Organisation introduced the International Code of Marketing of Breastmilk Substitutes (known as “The Code”), as a policy to protect and promote breastfeeding.  The Code consists of a list of recommendations aimed at halting the impact that marketing of breastmilk substitutes is known to have on maternal and child health outcomes, and ultimately on overall public health.  When I learned about The Code 20 years ago I, like many others, believed its implementation had resolved the problem.  Only my time in Cambodia over the past five years has revealed that in fact The Code is openly violated in a variety of ways, in places with the weakest systems, where population health outcomes are negatively impacted the most.

Infant Formula Market

Breastfeeding economic
After learning about these issues years ago during my public health studies, it is only recently that I encountered the reality of them, when I offered a voluntary child health service in a small community in Cambodia.  Almost daily I faced situations which led to surprised thoughts such as “I read about this in 1999!”, or “So that’s how a mother who cannot read and write, exposed to milk formula advertising, interprets what she should be doing for her baby”.  When I recommended to one young mother of a newborn to “breastfeed your baby until he is six months old, and don’t give him anything else”, she replied “I have no choice because I don’t have money to buy formula”.  I applauded her poverty as being a great protection for her baby, causing her to look at me quizzically.  The following day during  a health education session, a group of mothers announced in unison “we don’t have the money to buy baby milk so we have no choice but to breastfeed”, and again when I greeted their announcement with approval, they seemed taken aback.

There are no lactation services so another young mother described her experience of worrying that she didn’t have enough milk, watching her baby lose weight and having no choice but to persevere under highly stressful circumstances, with no way of seeking advice or support.  Her outcome was a success story, no thanks to her poverty preventing her from accessing appropriate support, but simultaneously thanks to her poverty giving her no choice but to “stick it out” with breastfeeding.

The number of mothers in Australia who seek breastfeeding advice and support and the services available here show how important such services are and highlight why, in the absence of services, mothers resort to all sorts of alternative ideas.  These alternative ideas may come from ill informed or outdated grandmothers or neighbours, or by paying for services who are being compensated by milk formula companies.  Returning this week to Child Health work in Australia, where regulations are in place to protect breastfeeding as the healthiest option and a range of coordinated public health services are available to back this up, the difference in our educated and well-serviced population dazzles me.  Feeding breastmilk substitutes in the Australian context comes with far less risk as we have easy access to clean water, a mostly-literate population, health promotion notices on our television screens and high quality health services.

Why would mothers in poor countries where breastfeeding has been the cultural norm be so convinced that breastfeeding is not best for their children?  Years of health research tells us a part of the answer to this question, well summarised in this article by Hubert Barennes et al as “Breastfeeding is being endangered by the increased marketing of formula and non-formula milk…. The advertising, though attractive, highly convincing and sometimes subtle, is thoroughly misleading. Funds dedicated to promoting breastfeeding are negligible compared to what is available for the advertising campaigns of companies manufacturing <formula and non-formula milk>“.  Ellen Piwoz and Sandra Huffman described the impact of this in their 2015 article in which they state “Suboptimal breastfeeding results in 800 000 child deaths annually.  There are multiple causes of suboptimal breastfeeding, including marketing of breast-milk substitutes“.

In 1974 an organisation called War on Want published a report titled “The Baby Killer”.  This report is not a long read, but four decades on it remains a worthwhile and relevant read.  Part of that relevance is the ongoing issue of infant formula and food product companies expanding their markets into communities who are more susceptible to marketing pressures, less protected due to substandard services and absent or poorly enforced regulations, and more vulnerable to the health and economic impacts associated with using breastmilk substitutes.

Stories from The Baby Killer report included trained and untrained staff wearing crisp white nurse uniforms to represent their milk substitute companies and claims from their companies that the role of said staff was “health education”.  Yet investigations showed that this education promoted the idea that breastfeeding needed to be supplemented.  A lot of scandal revolved around the practice of providing free samples to uninformed mothers who did not know that by the time the free can of milk powder was empty, the option to breastfeed would be severely jeopardised.  Free samples essentially “lock in” mothers to many months of purchasing canned milk which they often cannot afford.  This encourages them to seek alternatives and make the powder last by diluting it beyond recommendations, placing their children at risk of a multitude of health risks such as malnutrition and kidney disease.  The most common problem associated with bottle feeding in poor communities is the much higher risk of infection, especially diarrhoea, due to low quality water and sanitation.

A current university assignment requires me to formulate a research project.  When I submitted this topic as a possibility the lecturer was surprised to learn that these marketing strategies are still practiced. When I contacted an Australian midwife for advice after meeting the bottle feeding mother who had been given a free sample of infant formula at the clinic where she birthed her newborn, I got the same surprised reaction.  Yet the more I read, the more I learn that these tactics remain widespread in parts of the world where systems to protect breastfeeding are deficient and health services are profit making businesses.

A 2008 British Medical Journal research article described the impact of a “Bear Brand” coffee creamer sold in Laos by Nestle, the company at the centre of The Baby Killer scandal in 1974.  Research found that the logo of this coffee creamer led to many illiterate mothers believing this product was a breastmilk substitute.  Sold in many rural roadside shops it contains 3.6% protein and 27.3% fat (compared with recommended content for infant formulas at 7-12% protein and 40-54% fat), as well as listing sugar as an ingredient.  Nestle used the same logo on sterilised cow’s milk and infant formula products.  The authors encountered children admitted to hospital with malnutrition who had been exclusively fed this product, prompting their research.  Their findings showed that large proportions of the Laotian population believed this brand to be a breast milk substitute, demonstrating the strength of a cute logo over any written warnings not to use it for bottle feeding.  Some years later the researchers described Nestle’s delayed response to warnings about this product logo, and a number of humanitarian organisations have boycotted Nestle for their marketing strategies which continue to jeopardise infant health.

Nestle are only one such company however, and others employ similar strategies to expand their markets to poorer parts of the world where profits can be made.  For this reason, during my health education sessions in Cambodia I included the political aspect of infant feeding.  I showed pictures of commercial products and infographics of the massive profits being made courtesy of young parents being duped into believing that breastmilk substitutes are superior to breastfeeding and that commercial food in packets or jars are superior to fresh food.

The bottle fed baby who we supply one can of formula per week to, seems to be continuing her pattern of low level malnutrition.  Could it be that Mum is making that one can last a whole week because she has no cash to purchase the extra needed?  Meanwhile in Australia this week my first baby was a bottle fed two month old showing hints of excessive weight gain.  Life involves bouncing between advising on under nutrition in one location, to advising on over nutrition in another.  And now I’ve blogged through hours of procrastination, it’s time to rewrite my latest failed assignment on the topic!

Pre-Departure Refurbishments

Sadly I’m returning to Australia after four very fast months in Cambodia.  The last few days have been busy tidying up loose ends.  Yesterday I had a final child health meeting in a Phnom Penh neighbourhood of busy alleyways encircling a very large pagoda.  Tuk tuk rooftop scraped past truck walls, moto handlebars knocked my arm rest, pedestrians stepped into doorways as we mounted the crowded sidewalk to make way in the single-vehicle-width alley for a third vehicle to squeeze by.  How we ever got in and back out of there without at least running over a set of toes, claws or paws eludes me, but we did.

Post-meeting, Job Number 2 was to get the hole in the back leg of my trousers mended.  Tuk tuk understood and two corners away he spotted a shopfront sewing machine, pulled over and directed me out of the tuk tuk with wave of the hand.  A very effeminate young man with a beautiful smile looked at my trousers, laughed nervously and said “Sorry Madame, I think I don’t know how”.  That seems to be code for “You might not like my work so I won’t risk it”.  Tuk tuk laughed as I returned, trousers in hand, shaking my head.

Slow surveillance of the hundreds of street-side businesses as we traveled to our destination soon found another sewing machine, this time at a home business offering street food on plastic stools at a tin table on the sidewalk while you watch your tailoring in motion.  A serious man sat at a very old foot-pedaled machine behind a glass cabinet displaying meatballs and salad.  I squeezed between the table, cabinet and a couple of motos to reach him.  As he realised I was headed his way he looked progressively more startled.  Sometimes launching into Khmer is unnecessary.  Standing before a tailor holding a pair of trousers with a hole in them is one such time, so as his stress levels increased my own dwindled.  He took the trousers, prodded the hole, turned the leg inside out to investigate further, then made a zig-zag motion with his finger over the hole, to ask my permission for a rough-shod job.  I nodded enthusiastically.

He re-threaded his machine with dark cotton, as I looked around the front room of his house.  Three women were perched on stools behind the meatball cabinet, chatting and laughing.  Three small children were splayed across the tiled floor, also chatting and laughing.  The mandatory hammock was slung in a corner of the room as the only furniture except a television against one wall.  The whole house front was open to the street courtesy of heavy metal security doors slid all the way open.  What would be a sidewalk in Australia was restaurant and motorbike park.  With the cotton organised he looked around the floor of the room, spotted a remnant of an old hem among the cuttings strewn on the tiles that seemed about the right colour, grabbed it, cut it to size, and sewed it across the hole in my trousers.  It took all of 60 seconds from start to finish.  Fifty cents later, my trousers and I were ready for the next stop: my final visit to the beautician for one last refurbishment.

It’s been a wistful few days saying not-goodbye and not-farewell, but see-you-soon to people. But at 39C in 70% humidity with hours of power cuts everyday (which courtesy of staying in an area where some powerful names also live exempts me from the experience), I am ready for an Australian winter re-boot.  There are many worthwhile stories that I haven’t yet told, and cannot do justice to right now.  Tomorrow the wife of the disabled man who works washing dishes at night for $2.50 an event will find out that she can buy the motorbike she needs to get to work and home again, safely.

On Monday the small girl whose hands are bent in place at the middle knuckle as a sequelae of TB meningitis will receive some small balls to roll around in her hands to work her hand and arm muscles.

Last time I saw her one year old neighbour whose mother is in jail and father ran away after selling someone else’s moto to pay a debt, we weighed her at a busy child health clinic.  Amidst the chaos after she was weighed, I was shocked to see her being put back into a “dress” made of patches of cloth loosely pieced together with large hand stitches of what looked like string, reminiscent of something out of Dickensian London.  Her carer, an unrelated elderly woman living on a wall-less bamboo platform approximately 2m x 2m on the riverbank, spent her days begging in the community to get enough food for her small charge.  We managed to find an organisation able to support the child’s nutrition but I couldn’t let her continue getting around in that rag dress, so on Monday she will receive two new little outfits.

I would be lying if I denied thinking about the hundreds of millions of dollars pledged to reconstruct the burned bricks and mortar of Notre Dame de Paris in one of the world’s wealthiest cities.  If only human life, human potential and human dignity held the same sway.

A Collision of Two Lives

Both of these young women are Cambodian.  One is 23yo from current day peasant roots and the other, now a generation or two removed from her peasant roots, 17yo from an established ruling class family.  Juxtaposed, these photographs demonstrate my point that poverty is not necessarily a visible thing.  So often I have encountered elegant young people holding themselves confidently only to learn that they live in a shack in an urban slum or remote village.  My first revelation of this phenomenon came during a home visit to a TB client in Kampong Cham five years ago.  As we sat on a wooden slat platform at the front door of the patient’s little bamboo hut her brother appeared in only a pair of black shorts and made his way to the large concrete tub of water at the front corner of the house.  With a plastic handled pot he doused himself in water, shook it off and went back inside.  Moments later he reappeared in a pair of black trousers, a crisp white shirt and shining black shoes, boarded a moto and drove out onto the busy highway.  He would not have looked a step out of place on Threadneedle St in London or on Wall Street in Manhattan.

Ruling class connections in the post-Khmer Rouge system are steeped in corruption, intimidation and serious human rights violations.  Many of the ruling class started their careers in the Khmer Rouge.  They have rights above and beyond those of everyday Cambodians and are considered superior simply because of the power they wield.  Criminal Cambodians from the ruling class are often dual citizens in another, wealthy country.  Whilst none of my Cambodian friends, regardless of qualifications, experience, character or ability, have the capacity to obtain a visa to visit or live in Australia, the case is completely different for anyone with money.

Drug dealers, people connected to events of violent intimidation and who have gone unpunished for crimes including killings, live in comfort in Australia whilst maintaining their Cambodian connections, where their income is generated and their power in the top echelons is maintained.  That is not to say that any Cambodian living in Australia is from such a background, which is in fact unlikely to be the case when you analyse the numbers.  With 80% of the population living in abject poverty, there’s 20% of 15 million people who do not.  A small percentage of those are truly wealthy and only a small but powerful minority within the wealthy subgroup belong to the ruling class.  There are wealthy Cambodians who have “struck it lucky” by owning land in the right location, or who have family who escaped to a wealthy country during the genocide or subsequent civil unrest, and various other possible scenarios.

A very common feature of life in Phnom Penh is the lack of traffic rules and plethora of traffic violations.  Another common feature is the sense of superiority and entitlement that many with money and/or perceived power have and the very commonly reported tactics of intimidation used when control needs to be exerted in the absence of any real legal protections.

One example is when a friend once asked a colleague discretely not to spit in the clinical area, and that night received a phone call from her husband suggesting “if you want to feel safe in this town you won’t speak with my wife about that again”!  The combination of class-based superiority and lawlessness is the likely reason that drivers of expensive cars exert the most rights on the streets.  It’s only a couple of months since the nephew of a friend was killed when his moto was hit by a car traveling at high speed, which drove away into oblivion.  Last night as I was writing this blog a friend messaged me to say our colleague’s 18yo brother was killed in a traffic accident.  The biggest killer in Cambodia is traffic accidents, many of which involve scenes of appalling carnage.

Another example is the recent killing of a young man accused of stealing a car.  In fact he bought the car and had made a $3,000 down payment.  But the seller had a better offer and rented the car out.  The buyer located the car and took it back.  With connections to the police, the wealthy seller reported the car as stolen.  Police, on nothing but instruction from a powerful ruling class, located the man and shot him dead with ten bullets.  Again, it’s not written about in any mainstream newspaper but a link to the story is here: Police Officer Held Over Prey Veng Shooting.

Due to her outstanding academic results the young peasant woman in the picture on the left won a scholarship to a prestigious international university.  By day she studied and by night she apparently worked to send money home to her mother.  In the face of this challenging schedule and despite sharing her studies with privileged kids whose parents afford the school fee and don’t need their children to do anything but focus on their studies, she was first in her class four years in a row.  She was due to graduate in three months.

The young woman on the right is the daughter of a governor who wields significant power.  She was apparently born in Australia.

Two days ago the lives of these two women collided.  Literally.  One, allegedly upset with her boyfriend, drove her Range Rover through the streets at speed described as “like she was on a race car track”.  She rammed into the other’s motorbike, thrusting her against a wall and killing her outright.  She drove on without stopping.  There are few CCTV cameras in Cambodia and this is one reason that dangerous driving and hit and run accidents almost always go unpunished.  The driver could safely assume that she was going to get away with it.  She and two friends allegedly abandoned the car after fleeing the accident scene.  It was reportedly found in a garage.

Unbeknownst to her at the time, a very rare, recently installed CCTV camera caught the whole scene on video in explicit detail.  The video soon made its way to social media and quickly went viral.  The license plate number was magnified for all to read.

A chief of police is quoted as saying “We conducted an investigation into this case after the story went viral. After identifying the driver of the car, police will question that person and send the case to court.”  After it became obvious that her identity could not be kept secret, her father confessed that his daughter was driving the car, but one report claimed this confession came some hours into a police interview.  Another report states he only turned himself in after the Prime Minister ordered the driver to come forward.  Such orders are rare in the multiple stories of other hit and runs which are barely acknowledged and appear to have little to no police attention.

By way of reparation to her grieving family the driver’s father offered US$5,000.  Five thousand dollars for the violent death of a promising young life.  Five thousand dollars from the pocket of a multi-millionaire with a young daughter of his own, driving a Range Rover at age 17**.  The victim’s mother has rejected the offer, asking instead, following Buddhist tradition, for the killer to “bow down and say sorry to her corpse”.  A ruling class bowing down to a peasant?  Unlikely!  My guess is that she will be charged, money will pass hands between her family and justice officials and she will make her way back to Australia for a life of relative anonymity, in freedom and comfort.  It’s just a repeat of others who have gone before her.  Given the Australian government’s complicity with the Cambodian government, I don’t see any repercussions at all for her coming from that angle.

**As at 29 March the case has finally made its way to some English news sites.  The family representative is now saying that the $5,000 was purely to cover funeral costs.

The story does not appear so far in any mainstream media.  Protection of the ruling class is well established but for the emerging revolutionary power of social media which is giving Cambodia’s youth a voice.  You only need to see how other Communist countries have addressed this issue to know where that’s probably headed.

The expression in the eyes of young mothers as we review their children’s chronic malnutrition and they tell me that they understand vegetables and meat are important but they have no money, is a new image ingrained into my memory.  There is a foreigner currently in Phnom Penh who is trying to feed as many people as he can.  My friend encountered him at a specific market in the city and she recently introduced herself, offering to show him some of Phnom Penh’s community life.  The other day he went with her to a specific community where she quotes him as saying “Oh my god, how the people can live like this?” before arranging with her to make an en-masse food pack delivery to multiple families.  The excitement as she described to me, her ability to help her fellow Cambodians thanks to meeting someone with the resources she doesn’t have, was heartwarming.

A friend often tells me “I don’t like to hear foreigners say that they love Cambodia, if they love it they don’t know the reality”.  I get this point but the other side of the coin is that amongst the visible inequality, injustice and suffering, you find good facing evil, courage facing power, and principles facing corruption.

Crash Moto

The victim’s moto at the scene

 

Wheels

One of the things I have learned about the world since coming to Cambodia, is that there must be millions of people whose lives could be transformed by something as simple as a wheelchair, but who instead are confined to a tiny space by their inability to walk.  I have met a surprising number of people trapped in this way, usually without a diagnosis or access to any meaningful care.  The fact that an NGO might exist who can supply a free wheelchair is not necessarily of any benefit in many parts of the poor world.  In a place like Cambodia for example, services are not easily publicised; people’s capacity to access transportation to attend services is limited by their poverty; and they are often very hesitant to attend services where they have to deal with educated, confident and often intimidating professionals.

Today I had the privilege of arriving at a client’s home with the wheelchair he had been waiting on for a month since we sourced it for him, but which he has needed for almost two years when he first became house-bound due to his paralysis of unknown cause.  He was sitting in the doorway of his tiny rental room eating a small plate of plain rice when we arrived.  He only noticed me when I spoke “Salam Alaikum”.  He looked up and replied “Alaikum Salam”, before averting his eyes to the tuk tuk driver behind me who was pushing his new wheelchair.  His face transformed to a bright smile!  We assisted him into the chair and he disappeared down the alleyway at lightning speed.  Some days are really worth getting out of bed for, and today was one of them.

KF 22 Mar Wheelchair (2)

The concept of “transportation” took on new meaning for me in 2013 when I first came to Cambodia.  Firstly, the scenes of people traveling on the roads were mind boggling.  Secondly our program included a client assessment with social workers to determine whether transportation support was indicated.  This involved offering less than $5 to those who otherwise could not afford to attend their appointments.  Who could not afford $5 in a single month?, was my thought when I heard this discussed for the first time.  As it turns out, many millions cannot!

Yesterday as we visited our various clients around this particular slum area, my colleague informed the poorest of them, who often have no food, that “a foreigner” has been seen at a particular Phnom Penh market, choosing 6 people per day and offering them a meal.  If they go to this particular market, they could get chosen and receive a meal.  One older lady with missing front teeth and visible malnutrition replied that she didn’t know this market?  She then said “I have lived in Phnom Penh my whole life but I don’t know where anything is.  I heard that the riverside is a really nice area to visit but I have no ability to go there”.  The area she refers to is literally 1km (as the crow flies) across the river from where we were standing.  But she would have to travel about 5km to reach it, as it’s across the shore.  Similarly, most Cambodians dream of visiting Angkor Wat, the legacy their ancestors built which is a cause of much pride.  Yet most Cambodians have never been there.  A young French man turned up for dinner with some friends recently and they asked him, what did you see at Angkor Wat?  He replied “a lot of stone”, to the bemusement of the Khmer people at the table.  I have learned about Angkor Wat, that it is visited en masse by people from afar with plenty of money, for whom it has little meaning except tourism value; while those who live nearby, for whom it holds great significance, can only dream to visit it.

The capacity to travel matters far more than those of us who never have to think about it, realise.  There is a reason that in Cambodia you see people traveling in all manner of dangerous forms.  A few weeks ago this particular mini van caught my attention from my seat on a large bus as they were leaving a roadside stop and driving out onto a busy highway.  If I was paying $4.75 for my safe seat, what were these passengers paying and what was their income, that $4.75 was not an option?  These are questions that I continue to spend hours wondering about everyday.

KC005 (2)

Cool Fires

Cambodia is in the throes of “the Hot season”, better known in tropical Australia as “the Build-Up”.  It is hot and extremely humid, with clouds building up in the sky but very little rain, so that the humidity just builds and builds.  Even the locals are suffering.  Tonight, leaving my apartment, our security guard was shirtless and wiping sweat from his brow with his t-shirt.  Earlier today during a home visit, a 12yo girl was covered in pearls of sweat.  I always say that you know it’s truly hot when even the locals are feeling it.

A nationwide energy crisis is being blamed on the long Dry season which has depleted the hydropower dams supplying much of the country’s electricity.  Phnom Penh began experiencing daily power outages about a week ago, just as I was leaving for a weekend away.  It’s a real killer when your electric fan turns off in this weather.  Thankfully I live in an apartment block with a generator that kicks in with every power cut.  If I am home I often don’t know if the power is out or not.  On Monday morning, oblivious to the power cuts that had been happening like clockwork all weekend, I walked down the street to the beauty salon to get my nails done.  The girl turned me away saying “Sorry, can  you come back, because we have no fire?”.  No fire?  “Yes, do you know, no fire?”.  I could not imagine why she needed a fire to do my nails but I told myself “because Cambodia” and walked back home in blissful ignorance.  Relaying my confusion to a friend later in the day, I learned that the direct translation of “electricity” in Khmer, is the same word as “fire”.  So the reason we’re all suffering in the heat around here, is because we don’t have enough fire.

Today I did some home visits to a number of clients with my colleague.  We followed up on two high risk babies who are both doing well; visited our paralysed client who continues to wait for his wheelchair; and searched unsuccessfully again for “Face Man” who was out on the water, fishing.  A family I have met a few times who are dealing with a number of crises asked us to visit.  Two twenty-something brothers were released from prison a few days ago.  They were arrested for drug possession but proclaimed innocence with a credible story about the drugs being secreted over a small brick wall onto their property during a police raid in the slum where they live.  Their imprisonment placed the family under financial strain as their 19yo sister needed to travel to the prison every few days to supply them with food.  This meant she was not able to work as reliably as usual and so the family took a US$200 loan to deal with rent and other expenses.  The moneylender takes $40 in interest each month, keeping them in constant debt.

The brothers came home a few days ago and their sister asked us for a clinical review.  Both have Chicken Pox-like rashes which have become infected.  One of them only on his lower legs, but the other reported having a very high fever with coryzal symptoms at the beginning, and the rash is all over his torso and legs, with extremely swollen lower legs, ankles and feet, probably due to the sores becoming infected.  I reassured them it was nothing to panic about and referred them for review by our MD.  I then explained that infections are easy to pass around in prisons where it can be crowded, and enquired if it was crowded where they were?  Their cell was 8m x 8m and housed anywhere between 110 to 120 people!  When I asked how this was possible, they said that they had to sleep lying on their side and had a rotation for lying down / standing up.  There was no “fire” so I am left imagining how it’s possible to survive in such torrid conditions, with no air movement except the heat of each other’s breath and, as my friend Chom calls it, “body gas”.  If all they came home with was infected Chicken Pox, I guess they’re pretty lucky and I have a new understanding now of just why diseases like Tuberculosis run rampant through prison populations.

A few different people send, or have sent, money to me for Cambodia and entrust me with deciding where to channel it.  I’m not sure if any of them imagined, or would approve, of paying off a family debt caused by two young men’s imprisonment.  But that’s exactly where some of the money is going.  The potential of impoverished youth all over the world is destroyed by the perils of poverty.  In the wake of New Zealand’s terror attack last week, the phrase coined by PM Jacinda Ardern seems appropriate to so many violations against humanity:

They Are us

Sometimes The Battle …

Wealth like ignorance

Sometimes whilst blogging I go searching for the right quote to fit my reflections.  This quote seemed perfect for today’s story relating to the small Islamic community I am currently working with.  I had never heard of Ali ibn Abi Talib, who according to Wikipedia “…. was the cousin and son-in-law of Muhammad, the last prophet of Islam. He ruled as the fourth caliph from 656 to 661, but is regarded as the rightful immediate successor to Muhammad as an Imam by Shia Muslims”.

Innocent misinformation stemming from poverty continues to throw regular blows at me from left field with scenarios such as today’s encounter seeming inconceivable and taking my slow first world brain some time to process.

In my March 12 blog I first mentioned, under the heading of Infant Feeding, the baby I met early in February when she was just 18 days old, whose mother had been supplied a free can of artificial infant formula by the maternity clinic.  Mum’s ability to breastfeed had already been disrupted when we met.  Mum is illiterate and was struggling to feed the baby using bottles.  Since then my colleague and I have put in a great deal of effort including some community level education to promote breastfeeding, but also teaching this mother 1:1 what to do around how to make the milk; volumes and frequency of feeds; cleaning equipment; monitoring baby’s faltering growth; and preparing for changes in feeding instructions as baby gets older.  We have also devised, with the support of a nutritionist colleague in Australia, a poster with pictorial instructions to reinforce what we are teaching.   Soon I will leave Cambodia for a few months and my untrained colleague is going to have to pick up the responsibility of monitoring and supporting this mother, and probably many others, so the teaching material will serve a dual purpose.  Some of our lessons have included:

  • Powder to water ratios.  These are specific depending on manufacturer instructions which require a level of literacy and numeracy that Mum does not have;
  • Requirement to add the correct volume of water first, followed by the correct number of scoops of powder.  This ensures accuracy of the required ratio, which is usually 30ml water to one scoop or 60ml water to one scoop, depending on the written instructions on the can.
  • Reassurance around the confusion that the ratio instructions can cause.  For example, if baby needs 150ml volume of milk, but powder to water ratio is 1 scoop to 60ml, then 180ml water should be measured out then 3 scoops of powder, being the nearest correct measurement to ensure an adequate feed is made.  This not only leads to some wastage, but the three scoops of powder also increase the volume of liquid in the bottle to more than the initial 180ml.  All of this can be quite confusing to the untrained mind.
  • Discard remaining milk which baby will inevitably not drink if the volume is too much, in an environment where there is no refrigeration.  This is a difficult instruction for a mother with extreme financial constraints, but necessary to avoid the opportunity for, and dangers of, bacterial growth.
    [21 March: I’ve since realised that she likely does not discard anything and it could be why baby got diarrhoea, if she is saving leftover formula in the heat.  So on advice from my mother I am going to suggest that she take any leftover out of the bottle at the end of a feed and give it to her 5yo, perhaps added to rice].
  • Proper cleaning of bottles and teats.
  • Recommended volume and number of feeds per 24 hours, which changes (at times rapidly) with age.

This mother could have breastfed her child freely and safely if she lived in an environment where breastfeeding is supported, rather than an environment where artificial infant formulas (aka “breastmilk substitutes”) are ruthlessly marketed.  We have since invested many hours informing her appropriately so that she can protect her child from all manner of risks associated with bottle feeding in an impoverished environment.  Everyday that I work on this activity, I wonder at the thousands and probably millions of other mothers around the world who have fallen prey to the marketing of breastmilk substitutes.

It is impossible to reflect on the victims of this global horror without simultaneously wondering at its beneficiaries.  In May 2016 World Health Organisation published a document Guidance on Ending the Inappropriate Promotion of Foods for Infant and Young Children.  WHO predicted in 2016 that by 2019, the market value of breastmilk substitutes would reach US$70.6 billion.  That’s some extreme wealth being accumulated somewhere.  Certainly not anywhere on the shores of the Mekong River where I tread, and where the chances of living safely let alone in comfort, are asphyxiated by all manner of adversity.  WHO also stated that women and children have the right “to be free from inappropriate marketing of baby formula and related products”, which are “not in the best interests of maternal and child health”.

It still astonishes me that the “Baby Killer” scandal of the 1970s never really ended; that I ever believed, after reading of the global response to this scandal during my studies almost 20 years ago, that it had been resolved; and that in 2019 I now find myself working so closely with its ongoing ramifications.

Today when we met this mother and weighed her baby, the promise of her growth pattern improving had vanished and this week her weight has plummeted.  As I pondered on what might be wrong given our intense efforts, Mum spoke at length in Khmer with my colleague.  I then received a translation that – again – left me in a state of shock.

On Sunday, some weeks after Mum began following our instructions for bottle feeding, baby developed a distended abdomen and some diarrhoea.  Mum took her to hospital.  In hospital she was told that the reason her baby got sick, was that she was not making the bottles correctly, and was given a completely different (and incorrect) set of instructions as follows:KF 20 Mar 001 (3)

If you plan to give your baby 60ml of formula, fill the bottle to the number 2 with powder, and then add water until it reaches the number 60.  If you plan to give your baby 90ml of formula, fill the bottle to the number 3 with powder, and then add water until it reaches the number 90“.  And so forth.  Thankfully the relationship my colleague has with this family means she was able to encourage Mum to follow our instructions and ignore the hospital staff’s unfathomable advice.  Not before 3 days of incorrect feeding on top of a bout of diarrhoea had worsened her previously-improving malnutrition.  During our conversation Mum also asked, “why is she vomiting a lot now?”.  How long has she been vomiting?  “Since two days ago”.  It was useful information to help convince her that the hospital’s instructions were obviously incorrect and had upset baby.

As an aside, but keeping with the theme of the power of marketing, Cambodia’s Ministry of Health announced recently that cases of the mosquito-borne virus Dengue Fever are expected to rise markedly this year.  Media reports have stated that in 2018 approximately 25,000 people fell ill with Dengue Fever in Cambodia, 23 of whom died.  Today with my colleague translating, we delivered a community education session to five women and 18 children, on Mosquito Prevention.  One of my messages, relating to female mosquitoes relying on blood to nourish their eggs, was around the fact that male mosquitoes feed on flower pollen whilst female mosquitoes feed on human blood.  The presentation on my computer screen included the following two slides:

At the end of our session we held a quiz with some prizes to those with the fastest correct responses.  When we shared the cartoon captioned “Only female mosquitoes bite” we asked, what is the boy mosquito drinking?  A crowd of children shot their arms into the air and my colleague translated (unnecessarily), “they think he is drinking Coca Cola”!

In the midst of it all Cambodia’s only three helicopters, which I talked about in my 15 February blog post, once more flew directly overhead, forcing a pause in our quiz game while we waited for their raucous chopping to pass.

I came home, lay on the couch and slept for two hours.  Because sometimes the battle…..