“Sah aht”

Many words could be used to describe Cambodia, but this week nothing is more appropriate than “beautiful”, or in Khmer, “sah aht”.

Apparently I arrived here for the wedding season, just as the tropical rains end and young couples lavishly celebrate their planned futures with family, friends and colleagues.  During a month in Kampong Cham I have cycled past many wedding receptions and even been woken in the very early hours of the morning when a neighbourhood wedding apparently began at 3am!

The receptions are held at hotels or restaurants whose frontages are temporarily decorated with candy coloured canvas trimmings, or pastel pavilions erected in the street and all day people can be observed arriving and leaving.  The men dress very smartly and many of them are ridiculously handsome.  But the women steal the show, dressed in traditional long and tight wrap skirts with matching fitted bodices, in bright materials sprinkled with glimmering jewels.  They almost always wear their straight black hair long, and for the occasion have it styled at the hairdressers with make up that transforms them beyond recognition.

This week I attended the evening wedding reception of a Cambodian colleague.  Except for seeing and hearing a number of weddings as a bystander cycling past, I had no idea what to expect and turned up with my housemates and quite a bit of trepidation.  I wore the best dress I had, which seemed fairly glamorous before I was confronted with the radiance of twinkling colour illuminating the room.

We walked through the gates of the hotel into what must usually be a carpark, which was transformed into a glitzy entrance pavilion with a canvas roof high above us and red carpet underfoot.  A grand golden framed photograph of the couple dressed in traditional costume not unlike the stolen photograph below was displayed on a golden easel.  A table next to it was manned by people receiving gifts.  Waiters dapper in black wearing bluetooth earpieces greeted and escorted us into the reception room.  We entered an enormous indoor space furnished with at least ten large round tables seating ten per table and set with rotating turnstyles, a large dance floor, a stage with a live band singing Cambodian pop, rock and traditional music and a large cinema screen on the front wall beside the stage, showing video footage of the stage, dancefloor and tables as well as wedding photographs.

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The table we sat at glimmered with beautiful women in shining jewels.  I felt as though these stunning women who were smiling at me knowingly were somehow familiar, but at first could not place them.  It took me about five minutes to identify each and every one of them as my colleagues who I have been seeing daily for the past month!  I don’t even know how to describe how exquisite they looked.  Two were in similarly coloured bright sparkling green, one in purple, one in a flowing white, one in apricot.  I don’t believe I had ever been dazzled before sitting at that table!

Waiters wandered the room with cane baskets adorned with pink ribbons, delivering beer, water and soft drink on demand.  Plates of food were served constantly onto the turnstyle and we dished our own servings of chicken, noodles, fried prawns, soup and other, sometimes unknown ingredients (some of which I admit to being unwilling to try!), into little white bowls with chopsticks.  At least three cameramen were positioned around the room, taking footage being displayed onto the cinema screen.  Dotted about the room were people I knew, and after a bite to eat and some beer for Dutch courage, I accepted someone’s suggestion that we hit the dance floor.

Just when it seemed that the opulent costumes couldn’t be topped, some hilarious dance floor shenanigans revealed the true highlight of my night.  Dancing merged with hilarity to make for a very lively and entertaining evening.  Occasionally the rock and pop was switched with slow traditional ballad music.  The insanity would stop while everyone faced the same direction and moved together in a slow graceful rhythm of four steps forward, four small steps back, so that the throng slowly danced in unison around the centre table which was adorned with flowers and fruits.  These foot moves were combined with graceful hand motions that are a little like the Hawaiian hula, only slower and more methodical.  Video cameras focussed in on individuals and eventually someone would win as the best traditional dancer, at which time flower petals showered the crowd and tropical fruit prizes were presented to the winner as the wild music fired up again.

A number of my colleagues ascended the stage at various times of the night and took control of the microphone, there were solo acts, duets and group acts, all of them tuneful, some of them very funny and all of them highly entertaining.  The only other country I’ve visited that could closely match this level of impromptu musical revelry, is Ireland.  So I have dobbed Cambodia as the “Ireland of Asia”.

As yet I have no insight into the actual wedding ceremonies here, but I know weddings regularly last for up to three days, and include time in a Buddhist temple.  Apparently monks determine the date(s) for individual weddings, which they administer.

Cambodian beauty is not just seen in the splendid fashion, landscapes, villages, gentility and kindness I see all around me, but also in the peoples’ ability to merge modern with traditional festivities and really rock the room.

Riverside Ramblings

Motorbikes ruin photography here.  You get a great shot lined up just in time to photograph the handlebars of a moped, or a chain of blurred bodies moving across the scene you’d intended which saunters out of sight before you can re-focus your lens.  Some dedicated photography sessions will be needed to get a few half-decent shots during my time here.  Orange-wrapped Buddhist monks under yellow umbrellas.  A wooden trailer stacked with a mountain of hay driving through the streets, secured by bodies sitting high on top.  Babies perched at the handlebars of motorbikes, cocooned in Dad’s arms with Mum and two or three siblings lined up behind (some of them standing to see over the grip on Mum or Dad’s shoulders).  Women in bright baggy pyjamas or tightly wrapped sarongs riding side-saddle.  Houseboat lights glistening on the river at dusk.  These are some of the scenes I tried to memorise today when for various reasons the camera couldn’t capture them.

Pyjama scene almost ruined by a moped

Mekong pyjama scene almost ruined by a moped

At last I captured a sidecar shop

At last I captured a sidecar shop

Houseboat approaching the Kizuna Bridge, with the old French Tower across the shore from Kampong Cham

Houseboat approaching Kizuna Bridge. The French Tower on the opposite shore from Kampong Cham is in the background.

In the past few weeks I have presented a few times to groups of colleagues about life and work in Australia.  The interest I have in Cambodia is returned many times over by keen eyes and ears at the photographs and information I have shared via my equally interested translator, followed by many questions about our work conditions and Australia in general.   The discussions stemming from these presentations have highlighted to me that much of what humans everywhere want has been contorted in the First World into a superficial need that we could do without quite comfortably.  An extreme example being the surprised laughter that ensued as I told a group of nurses that ill patients in Australia would never accept a hospital bed without a mattress, pillows and linen on it.

The information I am happy to share about my experiences from a First World life has had to be balanced with an articulated distinction between the things we do or have because they are vital to good nursing practice, with what we happen to do or have simply because we are unnecessarily indulged.  Another example that springs to mind is the array of handwashing soaps, hand rubs and moisturisers that are supplied at handbasins in Australian hospitals, where one simple type of soap with some running water, as we have here, is all that is needed for good hand hygiene.

Another difficulty lies in convincing people who are so resource-deficient that they are providing a good standard of health care and that they possess skilled expertise.  There is a natural human tendency to assume inadequacy when you lack many of “the basics” that you know exist elsewhere.  Yet there are very good reasons that a Tuberculosis Department in Cambodia will have experience and skills that are rare and hard to come by in Australia, where the prevalence and range of clinical disease is rare.

Consideration and care is given here to people’s social circumstances in a systematic way that is not so forthright in most First World settings I have experienced.  Supports and measures are implemented here to promote healthy behaviours and treatment adherence as well as to reduce stigma and marginalisation of people struggling with social challenges such as alcoholism, homelessness and ostracism from families or communities.  One of our local doctors talks openly about the adversity of his patients from a very personal perspective, remembering the hunger, illness and death he witnessed as a child when many of his friends fell ill and either returned to school eventually, or died.

My impression is that in a place such as Cambodia the destruction of poverty occurs on a pervasive and visible scale which is not limited to racial or cultural minorities or in isolated slums.  This connects everyone to the deprivation, perhaps making a socio-medical approach seem more of an obvious requirement than it seems from a position of privilege in the First World, where we might not realise the struggles of our patients simply because they are not so palpable?  A point I have made to my colleagues here is that poverty exists in Australia despite our overall wealth.  Yet most Central Australians for example, despite being surrounded by it, are unaware of or protected from the hardship and poverty that exists in many of our indigenous communities.

How Many Cambodians Does It Take to Ride a Motorbike?

The evenings in Kampong Cham come alive with young people on motorbikes.  Three riding abreast equals at least six teenagers socialising as they cruise through the streets.  Five is the most bodies I’ve sighted on a single moped to date.  Helmets are an optional rarity.

Another regular sight is these wooden wheelbarrows which have many purposes.  They can carry anything, from human to vegetable, fruit, cardboard, piles of plastic goods or woven cane baskets and anything else that might possibly be sold or exchanged.  They may be drawn by motorbikes, horses or oxes,  pushed or pulled by humans.

Horse and Tray

Horse and Tray

Today the Stop TB Partnership made an announcement.  Each year three million people with TB are missed by health systems.  The theme for World TB Day 2014 has been decided – “Reach the three million : A TB test, treatment and cure for all”.  In their announcement they state “To reach the three million and move towards zero TB deaths, infections, suffering and stigma, we must aggressively scale up TB programmes, especially for the most vulnerable groups and in hotspots, while investing in research and development for the new tools that we urgently need“.  World TB Day happens each year on 24 March and aims to build public awareness of the ongoing epidemic which kills almost 1.5 million people every year, or 3 people every minute of every day in the year.  The date commemorates the day in 1882 when Dr Robert Koch astounded the scientific community by announcing that he had discovered the cause of tuberculosis, the TB bacillus. At the time of Koch’s announcement in Berlin, TB was raging through Europe and the Americas, causing the death of one out of every seven people. Koch’s discovery opened the way towards diagnosing and curing TB.  (http://www.stoptb.org/events/world_tb_day/)

Meanwhile today in my little corner of the world I saw two extraordinary chest x-rays.  Both show a whole lung whited out by pleural effusion.  This is a rare sight in the First World and would result in each patient being admitted to a high-technology Intensive Care Unit with supported ventilation.  Here it is a much more common finding with oxygen administered by nasal prongs the only support available.

Chest x-ray 001

Chest x-ray 001

This x-ray shows the left lung almost completely “whited out”, filled with fluid probably caused by an infection (but possibly another cause, eg cancer).

Chest x-ray 002

Chest x-ray 002

Similarly, the left lung here is also completely whited out.  The trachea is severely deviated to the right because of the pressure in the left lung and the right lung is much smaller than it should be, as pressure from the left pushes into it, effectively squeezing it.

Both of these men presented today with extreme breathlessness and very poor respiratory clinical findings.  Both are at risk of death if the cause is not diagnosed and treated.

Poverty causes men like these to present very late for medical intervention.  As agricultural workers with families who rely on them for their day-to-day existence, they cannot afford to spend a day traveling to town for such self indulgent reasons.  Lung disease such as this tends to progress in a slow and chronic way so that patients may not notice how unwell they are becoming at first.  But a day off work means the family may not eat and so once the illness is severe, they delay presentation until they are unable to physically work.  Sometimes it is only when someone has collapsed in the field that they are brought to hospital.  By then it may be too late.

When I cycle the dirt lanes of the local villages on my days off, stories like this must surround me as I exchange smiles and chum reap suors with my impoverished neighbours.

Village scene Mekong shore Kampong Cham

Village scene Mekong shore
Kampong Cham

Potholes to Phnom Penh

This morning our Ugandan housemate and I walked to the bus station through the Central Market (aka “the wild west”), giving way about as often as we were given way to by the hustling traffic.  A throng of waiting passengers were already at the bus station.  As we arrived our bedraggled looking bus pulled up so we boarded almost immediately.  We took a seat directly behind the driver and watched the world go by under the silky blue curtain with it’s silver tassles dangling across the top of the front window.  For 120km we bumped along the pothole-ridden road, arriving more than three hours later.  Various sized craters, some of which have been neatly filled with rocks  and stones to soften the blow to everyone’s tyres, dominate the road all the way.  When you’re not zigzagging around them, you’re jolting over them, at low speed the entire journey.  When the potholes are fewer on the other side of the road, that’s where you drive, so very often I found myself looking head-on at vehicles coming towards us.  But someone – not necessarily the person on the wrong side of the road – seems to always give way in time.

The entire journey is bustling with people busy with their particular enterprise.  Pigs and cows in wooden cages on the back of motorbikes driving alongside people walking with cane baskets upon their heads overflowing with various greenery from the fields.  Graders widening the road almost all of the way, miles of rock piles in rows waiting to be laid as highway, workmen with checked headscarves wrapped around their heads like balaclavas labouring with shovels and picks.  There were so many things to see that it was hard to absorb any single sight properly.

Singing about another city altogether, Art Garfunkel crooned through my earphones “to that tall skyline I come” just as Phnom Penh’s five or six skyscrapers came into view on the edge of the city.  Near the city the roads became even more chaotic, with trayback cars loaded high above the height of the cab with produce, a steel frame securing the produce into place and upwards of 20 people sitting on top of the frame.  It’s also common to see a single body sitting cross legged on the roof of a mini bus, or three cross-legged bodies across the width of vehicle rooftops.  The back doors of minibuses are held ajar by bicycles, motorbikes, filled sacks or passengers using the doorway for space.  A man saddled the seat of one motorbike as it hung out of the back end of a minibus, so that he was suspended perilously over the highway behind the vehicle carting him.

It was a successful day in Phnom Penh, with the purchase of a much-awaited camera and a much-needed hair cut and colour.  Before I bought my camera I used my iPhone to capture this banana-ised motorbike:

Phnom Penh 001

As always the poverty is disturbing and being a large city, Phnom Penh has it’s share of beggars.  A tiny thin woman with a baby pouched into a sarong tied diagonally around her shoulder and waist approached me as I was boarding a tuk-tuk to go home.  Arms outstretched and pointing to the sleeping baby, I initially shook my head but when she persisted I took $1000 Riel (25c) from my purse and gave it to her.  This prompted other beggars to the edge of my carriage and I had to wave them off.  Who am I to wave needy people away from me as I carry plastic bags filled with luxuries to my palatial accommodation?

Sitting in the middle of my own tuk-tuk carriage along the streets home, I passed other tuk-tuks overflowing with Cambodian passengers sharing the cost and questioned my existence and privilege.

The Human Element: Melinda Gates and Paul Farmer on Designing Global Health

Last year a friend in East Timor recommended a book to me which totally transformed my previously defeatist view of the Third World.  After reading the biography Mountains Beyond Mountains by Tracy Kidder, my view of what can and is being done in the Third World was transformed.  Paul Farmer has been working in Third World settings, alongside his role as professor at Harvard University, since he was in Medical School.  And supporting radical change.  The book is a fascinating read for anyone interested in the lives of the world’s most poverty-stricken, and how those lives do not have to be written-off as too hard to alter.

This brief interview in Wired Magazine with Dr Farmer and Melinda Gates is full of uplifting news from places which many assume to be beyond assistance.  Positive change can and will happen, and the privileged few of us should stop claiming it’s all too hard because it’s not.  We can all contribute to this revolution.

http://www.wired.com/wiredscience/2013/11/2112gatefarmers/?mbid=synd_bmgf
By Caitlin Roper

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Paul Farmer and Melinda Gates have a lot in common. They’re both Duke University alums, and they’re both devoted to improving health around the world, especially in places with few resources. As cochair of the Bill & Melinda Gates Foundation, Gates is particularly dedicated to empowering women and girls, which in turn benefits the health and prosperity of entire communities. Farmer splits his time between Boston (where he runs the Department of Global Health and Social Medicine at Harvard Medical School), Haiti, and Rwanda. He’s founding director of Partners in Health, an international nonprofit that delivers health services to the rural and urban poor in a dozen countries. Gates and Farmer don’t often work together, but their work certainly unites them. In New York City for UN meetings, the two friends talked to wired about the best ways to improve health all over the world.

WIRED: What innovation do you think is changing the most lives in the developing world?

MELINDA GATES: Human-centered design. Meeting people where they are and really taking their needs and feedback into account. When you let people participate in the design process, you find that they often have ingenious ideas about what would really help them. And it’s not a onetime thing; it’s an iterative process.

How does that work in practice?

PAUL FARMER: In Haiti I would see people sleeping outside the hospital with their donkey saddle under their neck — they’d been waiting there for days. And no one was asking them, “What are you eating while you’re waiting? What is your family eating while you’re gone?” We have to design a health delivery system by actually talking to people and asking, “What would make this service better for you?” As soon as you start asking, you get a flood of answers.

GATES: The first time I went to Haiti and saw Paul in 2003, he said, “How can we expect them to take these pills if they have nothing to eat?” He decided that they needed health care workers who could follow patients, and that they had to be people from the community.

FARMER: In Rwanda we worked with the ministry of health when it decided to vaccinate all 13-year-old girls against HPV. And we said, “OK, but what about the girls in school? How would they get the second dose? What about the third? And what about the girls not in school — how do we find them?” With community health workers. And when we studied this new system, we saw that it wasn’t just improving the outcomes a little, but a lot: Rates of HPV vaccination in Rwanda are twice what they are in the US.

GATES: Transportation is a huge issue in health. I was in Malawi, and in one village they were mapping things out on a piece of butcher paper, trying to figure out why they don’t transport women to facilities to give birth. Well, they realized that they didn’t have a bridge to get across a stream that becomes a river during the rainy season. They realized they needed resources to build a bridge — and to buy motorcycles.

Do you see ways for communications technology to help further these efforts?

GATES: I think cell phones are a huge opportunity. I saw it firsthand when I was in India earlier this year. I met with a network of community health workers who had been given cell phones by the government. Each day via cell, the local health authority sends these workers, mostly young women from villages, a list of patients they need to visit. The workers also have training modules they can call into from their phones, and they get free airtime so they can make personal calls to their families once they’ve listened to their modules. Every week they meet with someone further up in the system who can answer questions. But also, if they go into a patient’s home and the person doesn’t trust their advice, the worker can call a more highly trained health worker and give the phone to the patient so they can be reassured. What this means is more people are getting better health care in a really efficient way. That’s the power of a simple cell phone.

FARMER: The cell phones are also a way to develop human capital. Say you have a 22-year-old woman who becomes a community health worker. Using the example Melinda gave, that person can obtain some continuing education through technology that just 10 years ago wasn’t even available.

So in India, do community health workers sign up so they can get a phone?

GATES: Yes. That’s part of how they are paid. And they love being more knowledgeable! All of a sudden they have so much more cachet. People say, oh, they really do know what they’re talking about. And when I talk about contraceptives, I see that young women are starting to stand up to their husbands, because they’re empowered by what they learn from the health workers.

What about established medical professionals?

FARMER: Partners in Health built a teaching hospital in Haiti, and not too long ago I stopped by the emergency room. There had been a road accident with 12 critically injured people, but there were also more than a dozen doctors and nurses, and there was a functioning CAT scanner. Not a single person died. I had never seen that before. I watched a doctor who had always seemed so dispirited. But that night at the new hospital, he looked excited — you can see people come alive if you just give them a chance to learn and to provide better care.

Weighing in on Cambodia

As with my observations in East Timor last year, the average Cambodian adult weighs in the vicinity of 45 to 50kg.  When ravaged by Tuberculosis, as so many here are, this average can plummet and it’s not so unusual to see adults weighing as little as, or even less than, 30kg.  In East Timor I met a 20-something year old woman who weighed 25kg.  Dr Dan was reviewing her one morning and he turned to me suddenly and asked “When was the last time you weighed 25kg?”.  The question flummoxed me at the time but the answer is probably when I was about eight years old.

There’s something truly alarming about a grown body so ravaged by malnutrition that every vein, bone and ligament is transparent through a fine layer of skin.  When I first heard of Tuberculosis many years ago, I learned that it was once referred to as “Consumption” because it would consume the patient’s whole body, which would waste away.  In places such as Cambodia, where many sit on the brink of malnutrition anyway, there is no past tense involved – TB still consumes.

Perhaps it’s not so ironic that a personal goal for my time in Cambodia is to lose weight.  It has not been difficult implementing this goal so far, thanks to factors such as heat, healthy and delicious food, a very good cook at the house, super cheap restaurants and exercise, which are all a part of my daily routine here.  But there is also the ethical dilemma of being plump in a place where plump is rare and seems almost pompous.  I can’t help the fortune I was born into, but I don’t have to flaunt it so ungraciously!

Today I spent an afternoon traveling to some villages in a distant location where we plan to send two patients with multi-drug-resistant-TB (MDR-TB) home once they are well enough.  MDR-TB causes the same clinical illness as TB that is sensitive to standard treatment.  However it is much more difficult to treat, as the standard drugs do not work and the alternative drugs tend to be far less effective with many more serious side effects, combined with a very extended treatment duration.  Drug-sensitive TB usually only requires six months of treatment, whereas MDR-TB can require up to two years of treatment which is often difficult to tolerate and can have dubious outcomes even with good adherence.

These patients will commence their treatment tomorrow and wait in hospital for about two weeks to ensure they are tolerating the medications’ side effects, before being discharged home to continue treatment via health workers in their villages.  Part of today’s trip was to identify and meet with these workers.  Their job is imperative because TB should always be treated using Direct Observed Treatment (known as “DOT”), involving a support person who watches the patient take their medication.  Without DOT adherence may be sub-optimal, giving the bacteria an opportunity to develop resistance or, in the case of MDR-TB, further drug resistance.

Many TB patients are poor with limited health literacy and limited access to quality health care.  Our TB Program, as with many others around the world, aims to support MDR-TB patients through their treatment.  This helps to ensure good treatment adherence, improving each patient’s likelihood of a cure and simultaneously limiting the spread of this deadly disease.  We have dedicated staff who work to ensure adequate support in the patients’ family and community.  They travel regularly to  outlying villages where patients are from, spending time with the family and networking with community members such as village chiefs and local health centre workers.  The purpose of this work is to investigate issues which MSF’s TB Control Program may be able to address in order to ease an already poverty-stricken existence which now has the added stress of a long and complicated treatment regime.

This week’s newest MDR-TB patients face a number of issues which to date I had only read about.  One young woman is from a family with other members who have previously been treated for TB.  She expressed concern that her family have been ostracised by some of the community as “The TB Family”.  This is the stigma that TB carries with it and communal living inevitably results in the disease spreading among family members.  This young woman is also the only breadwinner in her family, holding a job at a local factory.  Her colleagues have been calling her regularly to ask why she is having so much time off sick and she is trying to avoid telling them the reason.  Meanwhile her family, reliant on her wage, are experiencing hardship while she is unable to work.  My colleagues are familiar with stories such as this and discussed some very feasible solutions which include offering education within her village about TB and supporting the family with food supplies.  The team also offer skills training to patients and their families in occupations which may lead to extra income, such as handcrafting.

The second patient we were engaging with is from another area in Cambodia where he was unable to find work.  Some years ago he moved to Kampong Cham Province where he works in a mango orchard.  The local people built him a home near the orchard so that he could stay and he owes money in the village for this home.  Now that he is unable to work he is troubled by this debt and his family are at risk of hunger.  One of his five children is a young man with mental health issues who travels to town once a month to receive anti-psychotic medication.

We attended this man’s home to meet with his wife and daughter to get to know them and learn about any issues which may affect his treatment adherence once he returns home.  The house was almost identical to the one below, stolen from the internet.  We walked through a neighbour’s yard to a back section from the road, past ducks, chickens, roosters, pigs and dogs.  We were welcomed into the ground floor shelter under the house, where a pot steamed atop hot coals on a stone table.  I sat on a large square platform made of bamboo strips alongside the family and the social worker sat on the wooden bed frame across the mud floor from us.  I did not understand the conversation, but I understood from the smiling Chum Reap Suors that I was welcome to their humble abode and the social worker translated some of the conversation to me about the family’s situation.

Cambodian Home

An ordinary day for my colleagues, but another extraordinary experience for me.

Tuberculosis in the Tropics

Living in the Tropics comes with its own set of challenges, especially when you are working around the Tuberculosis bacterium.  Because it is such a potentially dangerous disease and transmitted through the air, infection control measures against Tuberculosis, known as “airborne precautions”, are an important protection.

Airborne precautions in a health care setting require well people coming into contact with patients who have (or are being investigated for) infectious Tuberculosis, to wear a special high filtration mask.  Also known as a respirator, these masks are strapped to your face, snugly fitting over your nose and mouth so that all of the air you breathe passes through the filters in the mask.  These filters are so small that the TB bacterium cannot pass through them.  As you suck air in through the mask, it caves in towards  your face and as you exhale, the mask expands with your warm breath.

High filtration masks Courtesy ABC News

High filtration masks
Courtesy abcnews.go.com

In a climate where the temperature is 33C and humidity upwards of 60%, donning a high filtration mask feels much like walking into a steam sauna and putting on a woollen balaclava.  The sweat pours out of my scalp in an ooze of warm salty water, frizzes my normally straight hair and leaves me dripping.  Ultimately I am not involved in direct patient care and everyday I remove the mask to spend a fair proportion of my time in a ventilated office.  The same cannot be said about the nurses providing direct patient care, who spend up to eight hours everyday wearing a mask.

This afternoon I had the privilege of listening to one of our local doctors present on TB-HIV co-infection.  Globally one third of the world are infected with Tuberculosis.  Contrary to having the disease, this simply means that one third of us have been exposed to TB bacteria.  90% of those infected, in whom a healthy immune system usually contains the infection, known as Latent TB Infection (LTBI), do not know they have been infected, will not have any signs or symptoms, and are not able to transmit the infection to others.  However in populations where HIV is prevalent, TB can have devastating consequences.  A suppressed immune system (such as in someone with HIV) is far less able to contain TB infection, allowing active TB disease to emerge.  As such, HIV and TB are dangerous partners in crime.

In Cambodia 64% of the population is estimated to have been infected with TB.  This is a sign of the high rates of active TB disease, which transmits from infectious carriers to their close contacts such as family and friends.  The Cambodian population have active TB disease at a rate of 764 / 100,000 (see reference 1 below) – that is, 764 people in every 100,000 people per year will be sick with TB.  This is in stark contrast to Australia’s TB prevalence rate of 8.8 / 100,000 (see reference 2 below).  Recent figures show that around 11-12% of TB patients in our area of Cambodia are co-infected with HIV, and the mortality rate in these patients is between 15-18%.

This morning as I cycled into the hospital grounds fighting thoughts of the pending mask, a motorbike towing a long flat wooden trailer pulled into the main entrance just ahead of me.  There was some commotion, then an orange floral sarong covering a bony figure was swept off the back of the trailer and carried through the main doors.  Given the urgency of the action I guess she was still alive.  The way to the TB Department passes by an entrance into the main building where many patients congregate to watch the world go by.  As I passed this entrance one afternoon last week, a gaunt corpse covered in a thin blue cloth was carried in the arms of a man into a rusty old blue van with only front windows, which I assumed was a hearse of some sort.  Death in Cambodia is younger, more skeletal and much more likely to be from an infectious cause such as TB, compared with death in my home country of Australia.

Meanwhile I had a delightful Sunday morning cycling through the nearby countryside with another Australian nurse and a German doctor who has spent the past year exploring the surrounding area by bicycle on his days off.  It was surprising to see how rural our immediate vicinity is and how productive everyone is on a Sunday.  We pedalled our way through a busy agricultural marketplace with many fruits, vegetables and meats on sale from cane baskets or ricketty old wooden tables under frayed cloth shelters.  Then traversed fields of bright green rice on dirt tracks shared with all sorts of other travellers.  The most novel sight to my eyes was the pigs travelling to market in cane baskets on the back of motorbikes.  In every village we were greeted with giggling children running towards us and shouting “Hello” excitedly.

Colours of Kampong Cham

Colours of Kampong Cham

My bicycle

My bicycle

Reference 1: https://extranet.who.int/sree/Reports?op=Replet&name=/WHO_HQ_Reports/G2/PROD/EXT/TBCountryProfile&ISO2=KH&outtype=html
Reference 2: https://extranet.who.int/sree/Reports?op=Replet&name=/WHO_HQ_Reports/G2/PROD/EXT/TBCountryProfile&ISO2=AU&outtype=html