Tonight she died

Tonight my mother arrived in Phnom Penh from New Zealand, and my good friend’s mother arrived with her from France.  They met up in Singapore, arriving in Phnom Penh on the same flight.

We were sitting poolside sipping wine at our boutique hotel when a call came through from one of the nurses.  14yo’s father wanted to let me know that tonight she passed away.

That is the reality of the world.  The well-off luxuriate, while the anguish of  poverty kills others.  All in the same moment in time.

RIP, beautiful girl.
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The Anguish of AIDS

Last time I gave a pseudonym to a young patient so I could refer to him easily, he died, making me reluctant to name my young friend.  But she is the same 14yo with HIV and TB that I refer to in my previous entry “Observations of Poverty”.  She has been with us for the past two weeks, but yesterday when her condition deteriorated, she was transferred to another ward where the care is better in that a doctor is based there.  Otherwise nothing changes – she is still on a bamboo mat atop the wooden slats of a bed, with limited medications and no health technology.  Some liquid glucose is fed into her veins through a plastic tube by force of gravity from an IV stand attached to the head of her bed.

She has been on TB treatment for approximately two weeks and today she began the Anti-Retroviral Treatment (ART) for HIV.  Her acute malnutrition, the biggest and most immediate threat to her life, has worsened thanks to continuous diarrhoea and vomiting.  The bloody diarrhoea is probably due to some sort of bacteria or parasite that would make most of us slightly unwell, but which can overwhelm HIV patients with low CD4 count.  CD4 are “helper” white blood cells which help protect us from infections.  HIV infects these cells and slowly obliterates them, making the person vulnerable to many infections, including TB.  Her vomiting could be due to the same infection, or perhaps a side effect of the many medications she is now taking.

This afternoon I went with my translator to the ward to visit her.  She was lying flat on her back with her eyes rolling to the back of her head, underneath a thin blanket which camouflaged her so well that you could easily have missed the fact that there was any shape above the flat bamboo mat she lay on.  Her mouth was slightly ajar but she was not in any apparent respiratory distress.  A wet towel on her forehead had slipped down over her eyebrows.  When she realised we were there she opened her eyes and adjusted the towel with her pale, swollen hands.

Her adoptive father was sitting in a doorway at the end of her bed, looking out to the hospital kitchen which is a series of ramshackle wooden huts where open fires billow smoke into the atmosphere, polluting the lungs of tiny children running around while their parents cut fish caught from the nearby Mekong to cook with rice on the open fires for patients, or collect rubbish from the hospital grounds into wooden makeshift wheelbarrows to cart to the open waste disposal area where more open fires regularly burn.  Small children dressed in rags often enter the hospital grounds with big sacks over their shoulders, looking for aluminium cans or plastic bottles to sell at recycling dispensaries in the hope of feeding themselves and likely their siblings and other family.  Occasionally I’ve seen children, some quite young, walking the streets with plastic bags of glue sealed to their faces.  I asked a local recently what makes the children sniff glue.  Apparently the sensation of being high on glue masks the sensation of hunger.  Unfortunately it also causes brain damage and can provoke psychological disturbance including violent behaviour.

As always, her father was bright eyed and smiling at us from the ground as we stood above him asking for information about her condition and treatment since the ward transfer.  He said that yesterday he had decided to take her home, but then changed his mind.  He did not say why but I assume due to despondence at their situation.  If he takes her home now she is guaranteed a quick death, while there is still currently hope of recovery despite her fragile state.  I encouraged him to keep her in hospital despite how hopeless it seems right now.  This morning he heard her cheyne-stoking and thought she was dying.  As he uttered these words, her eyes widened again from their drowsy state suggesting she had heard the comment.  With any luck the ART and TB medications will begin to improve her condition slowly, the gastrointestinal infection will be diagnosed and treated so that she can begin to eat and drink again, and she may gain strength.  In a First World country she would have a very high chance of survival.  But here?  In these conditions……?

We had a conversation with her father about his children (3 daughters plus this girl who he adopted when his “in laws” both died of AIDS).  I asked if there was anything that he needs for himself (as opposed to our patient) and he suggested that a bicycle-style wheelchair, I imagine much like the picture below (courtesy Google), would be very helpful.  Hopefully another NGO, “Handicap International”, may be able to assist in our quest for one.
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I then bent down to the low-set bed where this c.20kg teenager was doing her best to stay awake in our company and put my hand on hers.  Through my translator I said to her that it is very good that she is taking the medicine and not vomiting it, and that she will eventually get better now that she is on all of the right medicine.  She squeezed my hand.  Then she did not let it go.  I rubbed her arm and said some more reassuring words, and she squeezed my hand even tighter – proving that there is still some energy in her emaciated little body.  As we held onto each other I grasped that she was letting me know how afraid she feels.  Some strands of hair were stuck across her knife-sharp cheekbone.  As I stroked the hair behind her ear, despite the visibly sharp bones of her face, it was still a shock to feel the bones against my fingers.  I asked if there was anything that she needs.  The answer in Khmer was quite long, perhaps because there is no one word for it, or perhaps because she was explaining why.  The answer in English was “nappies”, to contain the diarrhoea.  Given that this diarrhoea could kill her, I promised her we would find some and bring them this afternoon, because if this is as dignified as her death can be, then she at least deserves such a tiny request to be met.  Thanks to MSF she is now supplied with some proper incontinence pads to contain the ongoing diarrhoea and hopefully she will rest much easier tonight.

Tomorrow we will visit again.  Meanwhile, debriefing with colleagues, a game of badminton after work, fried rice from the Night Market, upbeat songs on the iPod and a few laughs online with friends in far-flung prosperous places have all failed to quell the sorrow that connection with a dying 14yo, suffering the consequences of catastrophic poverty, provokes.

Poverty is the worst form of violence ~ Mahatma Ghandi

If you have a spare hour, this 1979 award-winning documentary from Australia’s John Pilger gives some historical background into Cambodia’s current plight.
http://johnpilger.com/videos/year-zero-the-silent-death-of-cambodia
The empty bed you see about half an hour into this documentary is identical to the empty bed Tom left behind in November.  And the one which is currently occupied by a 14yo girl on the brink of a death not unlike those featured in the documentary.

Observations of Poverty

For much of my time here I feel harrowed by the situations I see people existing in.  I regularly have to talk myself out of the tears which threaten to surface as I realise the significance of the poverty I’m witnessing.  But the smiles on the faces of those who own these situations usually manage to knock me out of my precious state of mind.

Today I met a man with some sort of crippling condition in his legs.  He sits on his buttocks with his knees up at his chest, and walks with his hands lifting him up and forward.  He is agile and fast.  His fresh face smiled at us openly as his malnourished teenage daughter lay wasting away in a hospital bed with HIV and Tuberculosis, so thin that her pale skin is pasted to her skeleton and her face is sharp with bones.  As the doctors spoke to them both, asking questions, assessing her clinically, ordering tests, and discussing what they consider to be her biggest issues, all I could think was that poverty is the only real issue at play here.

Her father’s kind and intelligent face radiates gentility and he smiled at me from the concrete floor and communicated with me via my translator.  It was a humbling experience to meet and spend time with him, and I agonised for hours during the rest of the day over what I could do to alleviate their destitution.  They have no access to a bank account and live in a remote area which would be difficult for me to visit.  The fact that he is so nimble and strong tells me that he works in some sort of physical job, probably in the rice fields.  Unlike the First World, here if you don’t work, you don’t eat, so disability is not an impediment to hard physical labour and aids such as wheelchairs are a luxury that most live without.

His daughter will remain with us for some time to come, so maybe over the next few weeks I will come up with a way of assisting them somehow?  But their story is not unique and any help I offer is a drop in the ocean.  In the ward with her at the same time are a 12yo boy who is stunted from malnutrition with suspected TB lymphadenopathy, a 13yo girl suspected of having spinal TB which was finally diagnosed as spinal degeneration due to the heavy work she does in the rice fields and three infants all with varying degrees of malnutrition.  This is the harsh reality of Cambodian health statistics which are not easy to comprehend until you meet them in the flesh.  45% of Cambodian children have moderate to severe stunting caused by chronic malnutrition.  In other words, they are short statured because their bodies have never received the nutrition required for adequate growth.  Hunger is a daily experience for many.  As a colleague said to me the other day “when Cambodian people have no food, we die”.  In his quiet and unassuming way he just informed me that he has witnessed starvation.  I probably have too, as the death of Tom in November comes to mind.  Everyday I see old people hunched over with such severe back deformities that their upper body is almost at right angles to their lower limbs, after years of hard physical labour in the fields.  I guess this is exacerbated by malnutrition which leaves bones brittle.

Thirty five years ago tomorrow, Cambodia was liberated from the Pol Pot regime by Vietnamese forces backing the current government who have been in power ever since.  It is celebrated as a national holiday known as “Victory Over Genocide”.  Celebrations occurred en masse very early this morning.  By the time I made my way to work the ceremony was over but truckloads of people dressed uniformly in blue and white were being driven through the streets as legions of army and police patrols blocked intersections.

Our office is across a park from a government building which has been heavily guarded for weeks now, due to the garment factory demonstrations.  This park disappeared this morning under a lavish arrangement of canvas pavilions decorated with pot plants and truckloads of plastic chairs in neat rows under the canvas shelters.  By the time I saw it, the ceremony was already over and everything was being dismantled onto trucks and taken away again.  Apparently the truckloads of uniformly dressed civilians were conscripted from surrounding villages under government order.  Even the most basic freedoms I take for granted are a perilous thing for Cambodians when it comes to showing support for the ruling administration.  When I mentioned the celebrations to a colleague as we watched from our office doorway and suggested that he must not have been alive when the Victory Over Genocide occurred, he replied that he was not, but that even many people who remember the genocide do not support “this”, as his arm motioned towards the pavilions being dismantled.

Contrary to thinking that everything happened 35 years ago, which is not such a long time anyway, the Paris Peace Treaty was signed in 1991.  The first election was held in 1993 and the Khmer Rouge led insurgencies and continued their terror from the safety of strategically landmined jungle areas until after Pol Pot died in a jungle village in 1998.  Yesterday I was informed “Cambodia was still at war until 2000”.  Tribunals continue today against some of the Khmer Rouge leaders who are all elderly but still defiant.

After work tonight I spent some time at the reopened bamboo bridge (“p’dar”), watching the evening crowds come to life as dusk turned the muddy Mekong waters purple.  Sitting on a park bench above the embankment leading down to the water’s edge I watched a girl of about 6 and her younger brother, dressed in rags, drag sacks bigger than themselves as they climbed the embankment looking for plastic bottles to be recycled for a small payment.  An hour or so later I ate dinner at the Night Market with a housemate and we were approached by two young boys of about 8yo dressed in rags and asking for money.

Today’s news included the headline “After Clashes, Garment Workers Flee Veng Sreng Street.  The few remaining residents of Phnom Penh’s garment factory-lined Veng Sreng Street, where government forces armed with assault rifles shot dead five striking workers on Friday, said Sunday that most workers had since fled in fear for their lives”.
http://www.cambodiadaily.com/news/after-deadly-clashes-garment-workers-flee-veng-sreng-street-50134/
Another article interviews some of the wounded, a number of whom were not protesting, but cooking in the kitchen or walking home when struck by the indiscriminate bullets flying through the street.  Someone else said to me today that the death of one westerner makes a much bigger problem for Cambodia than the death of many Cambodians.  Given that the garment workers’ situation appears to be accepted by most of the international community (activist organisations excepted), this appears to be an accurate conclusion.

It’s hard to find a cheerful note to end on some days.  But tonight’s dinner conversation revolved around the calm dignity of Cambodian culture and the privilege we feel working with such gracious people as our colleagues and our patients.

Lights of Kampong Cham's P'Dar (Bamboo Bridge) at dusk.

Lights of Kampong Cham’s P’Dar (Bamboo Bridge) at dusk.

Attacked by a chicken

About half a million of Cambodia’s 15 million population are employed in the garment factory industry.  These workers make around $80 per month.  Export from this industry earns the Cambodian economy around $5 billion per year.  In recent times garment workers have been lobbying for a pay rise to $160 per month.  Today at least five Cambodians lost their lives over the issue.

Demonstrations have been occurring around the country for some weeks now.  Here in Kampong Cham military police have been heavily present outside a government building very near our office and while I haven’t seen any demonstrators, I have heard their chanting from a distance.

The Prime Minister of Cambodia, Hun Sen, is from Kampong Cham and the town despite it’s visible poverty also has a small amount of extreme and conspicuous wealth.  Hun Sen was a commander in the Khmer Rouge but he fled to Vietnam in 1977 during some internal regime strife.  In Vietnam a rebel army was formed in which he became one of the leaders.  This army was sponsored by the Vietnamese government who liberated Cambodia in 1979 and installed the new government, of which Hun Sen was initially Deputy Prime Minister.  Since this time he has maintained leadership in the country under a number of different titles, but for almost 30 years as Prime Minister.  This has been a hotly challenged position with accusations of ballot corruption as recently as last year following the July election.  Demonstrations are a frequent event across Cambodia, but particularly in the capital of Phnom Penh.

It was with apprehension that I read in yesterday’s newspaper that the government warned of “consequences” if garment workers continued their demonstrations.  Yesterday’s apprehension was followed today by great sadness at the news that military police opened fire on striking garment workers in Phnom Penh, with at least five dead and an unknown number wounded.

While this was happening in the city I was having a very peaceful and interesting day visiting patients in the countryside of Kampong Cham.  Patients with Drug Resistant TB are required to take their medication by DOTS (the acronym for Direct Observed Treatment, Short Course).  When a patient is diagnosed with DRTB, our DRTB nurses travel to their home and identify someone willing and able to take on the role of directly observing every dose of medication.  Usually this also involves administering at least one medication by intramuscular injection.  On a regular basis the team travels out to perform “surprise visits” on both the patient and their Home Based Care Nurse (HBC Nurse), to ensure that everything is happening as it should with no complications or problems.  The medications cause many side effects and require a reasonably strict regime, which if not followed well can result in poor outcomes for the patient as well as placing their household and close contacts at risk.

We arrived at the office early and piled into the car.  A driver, a social worker, a nurse and myself.  We left the city and headed south on the main road, as always past many sights including ox-drawn carriages piled high with hay, trucks almost doubled in height by their produce, with sometimes dozens of workers seated atop the produce at dizzying heights.  Long wooden carriages being towed by motorbikes or bare tractor engines carry groups of women to the garment factories for a day’s labour.  Tuk tuks and mini vans overloaded with people or produce, motorbikes carting whole vegetable stalls with produce held between the knees of the driver, piled up against the drivers’ back and stretched across the back of the bike in cane baskets.  None of these things are of interest or concern to the locals I travel with but all continue to make me wide-eyed and agog.

Recently the most common sight in front yards has been rice drying on canvas tarpaulins in many front  yards, but this morning rice had been replaced with the white chopped roots of cassava much like the photograph below, stolen via Google.

cassava

A moderate distance out of town we pulled into a small concrete roadside home.  Reminiscent of a quaint old colonial cottage, with widely spaced metal bars behind wooden shutters in the window space; an adjoining thatched lean-to, dirt floors throughout and the tin roof reinforced with dried palm leaves.  Next door a family were sitting on the grass in a circle, I guess eating something together.  Chickens pottered about, puppies played, and a fence of bamboo was suspended across a space of about two metres with grass sheaves crossed over the fence, drying for an unknown but no doubt productive purpose.  The closest image I can find of this scene is these sheaves of wheat.

Sheaves of wheat

With hammocks slung between anything vertical that is strong enough and bamboo-based day beds always situated in outdoor undercover spaces, the family appeared and perched in various locations to join us as we spoke with the young patient about her medication regime, side effects, concerns about not yet being allowed back to her job at the factory, etc.  Without a translator I rely on snippets of information from my colleagues, who very kindly always include me in the conversation whenever possible.  A lively and jolly conversation transpired while a young man approached a large ceramic tub, collected water from it with a handled plastic pot, transferred a trickle of water into a smaller tub and washed himself before disappearing into the house, reappearing in a smart shirt and trousers, and driving off on his motorbike.

From this house we visited four more locations including a home I had visited previously, where I was welcomed with greetings of familiarity and many smiles.  It was here that I was motioned to sit on a plastic chair which was brought downstairs from the house, to the breezey dirt floor space underneath the house.  Children appeared from all angles and stared at me, laughing whenever I made eye contact with them and otherwise smiling gently as they observed my every move.  As I watched the pet chickens pottering around I suddenly found myself in the path of a retreating chook as she hurried to escape from an attacking rooster and landed noisily almost in my lap, creating a brief din of shock and hilarity as my colleague shouted “sorry!” at me and brushed some wayward feathers off my t-shirt!

At another elevated bamboo home I was invited upstairs and inside.  At the top of the stairs I hesitated as I looked down and through the gaps in the bamboo to the ground about 3 metres below and wondered if this precarious looking floor was going to hold my weight.  My two colleagues and the two residents were already inside sitting down and all encouraged me in with assurances.  We sat on a floor mat near a mosquito net covering another mat used for a bed, in a setting very similar to this image stolen from the internet.

Bamboo floor home

Everywhere I have been, people have very little materially but much to give in the form of welcoming smiles, reassuring gestures and inclusiveness towards the obvious foreigner who doesn’t even know how to walk on the floor of your home.

After our last home visit we drove back to the town of Skun which is best known in the travel books as the place where tarantula spiders are deep fried and served as a snack.  I’ve been through Skun a number of times now but had not seen the spiders.  Today we stopped at the side of the street market in Skun to drop someone off.  Immediately the car was surrounded by vendors offering us various dishes being held up to the windows.  As I looked up at some chunks of pineapple and tried to absorb the scene before me, a big plate of fried tarantulas appeared at my window with a pair of hopeful eyes trying to tempt me!  Needless to say she received a categorical shake of the head in response before we drove off to escape the hopeful masses.

Fried tarantula in Skun (courtesy Google)

Fried tarantula in Skun (courtesy Google)

We pulled into a local outdoor restaurant for a Khmer lunch and I got to know my colleagues a little more.  Khmer food is delicious but nothing goes to waste, so eggs are eaten complete with shell, chunks of meat are interspersed with chunks of offal, the rice is bottomless, and chunks of tropical fruit come on large wooden sticks for dessert.  Many of my colleagues are not from Kampong Cham and spend days or weeks at a time away from their family in order to support them with the small but reliable wage that MSF can offer.  Stories are commonplace, of fathers who live away from home except for one or two weekends per month, mothers who work seasonally in the rice fields (hard physical labour) near their children, but after harvest season travel to the city, leaving the children in the care of elderly grandparents for prolonged periods so that $80 per month can be earned in the garment factories.

Back at the hospital I attended an education session with my translator.  Everyone in the room except me was Khmer.  The presenter asked was he to present in Khmer or English?  The room remained silent.  I suggested it should be in Khmer as I was the only non-Khmer person there.  He replied in Khmer, that he would present in Khmer but that it was important for everyone to practise their English and learn to understand and speak it well because “when you use English you will understand the world much better and have many more opportunities”.

That is no doubt a true statement.  But Cambodia and Khmer speakers are opening my eyes to the real world, too.