Pedalling Phnom Penh

I’ve left work behind for a few days of rest and recreation in the city, my main aim being to have the mop of discoloured shaggy hair on my head revived into something half-tolerable again.  Witnessing the suffering of our patients is often heart-wrenching and this week the severe chicken pox blistering of a patient had really taken it’s toll on my precious first world spirit.  Severely immuno-compromised, she had the misfortune of being visited by someone with a mild case of chicken pox a few weeks ago.  An otherwise healthy person would have the ability to remain healthy in the face of such exposure, perhaps experiencing a mild or even moderate case of chicken pox rash.  But with HIV already ravaging her immune system, even if she had some immunity from childhood, she was at risk of severe disease.  Initially appearing as a mild case, within days her entire skin surface, as well as the mucous membranes of her eyes, mouth, throat and intestines were blistered with large, fluid filled vesicles causing extreme pain and placing her at risk of many complications from diarrhoea (and resulting dehydration/exacerbated malnutrition) to blindness.  A very young woman, she has already faced the recent neonatal death of her first child, probably due to HIV which she was diagnosed with after the child’s death, and now multi-drug-resistant TB.  In my early adulthood I was travelling, working, studying, socialising and generally living a charmed life, unaware that in most parts of the world such seemingly normal activities could only be fantasised about, and that suffering such as this dominates the lives of many millions of people.

The streets of Phnom Penh bustle with an array of motorbikes, tuk-tuks, high-seated bicycle taxis, overloaded trailers, children and women pushing hand-driven wheelbarrows of shellfish, cardboard and other consumables which to a “first world brain” don’t seem saleable.  The air is so moist that you imagine the waters of the Mekong rising into invisible clouds which cloak the city in their wet heat.  An open bar with plastic tables and chairs is overflowing onto the footpath with local men shouting boisterously at the boxing match on the television.  Young women tend to wooden wheelbarrows on the street outside, babies sitting in cardboard boxes at their feet on the roadside.  Amputees hobble amongst the crowds with their caps outstretched hoping to find someone willing to help them obtain a meal.  Moto-taxis and tuk-tuks all vie for the foreigners’ custom, with calls of “Hello Madame” coming from all directions.  One tuk-tuk driver does not speak English and when I say the street number I want to go to in Khmer, he shrugs his shoulders with a kind smile, letting me know he doesn’t know how to get there (or perhaps more likely, that he doesn’t understand my Khmer).  So I walk on in the wet air, drops of sweat landing from the top of my head onto the top of my earlobes, giving the sensation of a fly walking on my ear.  Soon enough another tuk-tuk appears and negotiates the $2 fare with me, starting at $4, and when I say it usually costs $2, offers to meet me at $3.  I accept and am relieved to step into the shade of the curtained open cab as he winds and weaves through the traffic.

I find my hairdresser, a flamboyant young man who knows me now, at the salon.  He colours and cuts my hair while his sister wipes my brow with wet cotton wool and another assistant keeps my glass filled with ice and watches me closely to make sure there is nothing else I need.  Kim meets me and decides to have her hair done as well, so I wander around the corner to have a $2 manicure while I wait for her.  I come away feeling half-human again, with a neat hairstyle and pale pink nails, after months of self-neglect.

We walk to Central Market and organise our bus tickets home for tomorrow, then find a tuk-tuk driver to wind-and-weave us back to the guesthouse, enjoying the shady breeze as we soak in the novel sights, smells and sounds of the unfamiliar city.

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On Saturday night a crowd of our expatriate colleagues have arranged a barbecue at the house of a young French family.  Three of us climb onto the MSF-supplied bicycles and the watchman opens the compound gate for us.  We exit the high walls into our small alleyway, pedal past neighbours sitting on the rubbled roadside in the dark, hold our breath over the smelly canal lined with piles of domestic refuse, some of which has blown into the stagnant waters.  Making our way across busy intersections, we wait for a fleeting gap in traffic, take a deep breath, mumble a few expletives and pedal at full speed, laughing at each others’ reactions of relief as we reach safety on the other side.

As we arrive at our destination, over the road a small crowd of people are sitting on floor tiles inside a wide open doorway of a small house front, sharing a meal.  I wonder if it’s a tiny informal restaurant, or perhaps a private family gathering.  The watchman opens the gate and we enter a beautiful tropical garden of tall trees looming over a large wooden dining table.  Large opened French doors lead into an open plan living room / kitchen area which seems to be an extension of the shaded garden.  Cocktails, beer and wine are served, meat is barbecued, children run about at our feet, and the conversation flows.  At midnight we head back to the MSF Compound, feeling much safer courtesy of a little dutch courage and a lot less traffic.

On Sunday morning Kim and I meet at the top of the stairs and climb down to ground level, the watchman lets us out and we follow an orange robed monk under his yellow umbrella along the alleyway and around the corner to a local restaurant for brunch.  The wait staff look about eight years old, but when I ask one of them in broken Khmer, he thinks for a moment before replying that he is “Tdap param muey” (sixteen).  We surmise that the pause before replying was a recall of the age he’s been instructed to claim when asked.  He stands beside our table as we eat, serenading us with a Khmer tune that we’re not sure he’s even aware he’s singing!

From brunch of chicken and rice in front of a large circulating fan, we make our way back out onto the explosively hot street.  A tuk-tuk driver is lazing in the shade of his open cab on the corner over the road and as soon as he calls out “Hello Madame” we take him up on his offer.  We negotiate quickly (in his favour) before climbing into the shade and breathing sighs of relief.  He drives us a few blocks up to the busy Tuol Tom Pong (Russian Market).

Kim weekend Phnom Penh 042

Inside the steaming undercover alleyways of the market we wander past rows of clothes, shoes and materials, into the food hall.  Fresh chickens and other slabs of meat hang from hooks, fish sit in large steel crates making their last desperate attempts at finding oxygen as they stare up at us in shock, and colourful fruit and vegetables line the wooden tables staffed by sellers sitting cross-legged at the back of the tables.

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After a few worthwhile photographs we both realise that the heat is stifling and it’s time to go home and rest.  Another tuk-tuk driver wins the “uncomfortable tourist lottery” as we negotiate quickly and favourably with him to escape the sun’s rays.  An elderly and back-bent woman holding a plastic bowl comes up to the side of the tuk-tuk, hands outstretched to us and head bowed in reverence.  I guess her scarred blind eye is probably courtesy of the Khmer Rouge 40 years ago.  Random, brief and superficial encounters with such suffering are always perturbing.  We give her enough for a single meal and she smiles gratefully, waving and saying “bye bye” in English as we disappear through the crowded streets, never to see her again.  Where she goes, what she does, who she encounters, how they treat her, what happens to her for the rest of the day and the rest of her life are all questions which I will never have an answer to.  But her willing smile remains with me as a symbol of humanity’s ability to endure.

World Tuberculosis Day

Ploughing Cambodia's fields 2014

Ploughing Cambodia’s fields 2014

MSF speaks out on World TB Day, Cambodia, 24 March 2014

MSF speaks out on World TB Day, Cambodia, 24 March 2014

Disease incidence rates are defined as the number of new cases of a given disease in a given period of time, per population.  According to World Health Organisation (WHO), in 2012 Swaziland had the highest global incidence rate of Tuberculosis at an estimated 1349 people per 100,000 population.  South Africa came in second at 1003/100,000.  Rates plummet thereafter to country number 3, Sierra Leone, at 674/100,000.  Cambodia’s TB incidence rate in 2012 was 411/100,000.  To put these statistics into perspective, the equivalent rate in Australia is 6.5 per 100,000 and in America, 3.6 per 100,000.  http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317140584841

Another way TB is counted, is in absolute numbers and 22 of the world’s countries have been identified as containing 80% of all TB.  Cambodia currently holds place as 22nd of these 22 highest burden countries.

Since 1982 World TB Day has been a global event held on March 24 each year.  The significance of this date is that on March 24 1882,  German microbiologist Robert Koch announced his discovery of Mycobacterium tuberculosis, the organism responsible for TB.  Despite the bacteria’s relatively recent discovery in 1882, TB was known about since before Hippocrates, who in 460BC identified it as the most widespread disease of his time, almost always killing it’s victims.  Through the ages many famous people have suffered from TB, including the Bronte sisters, George Orwell, Frederic Chopin, Napoleon Bonaparte and many others.  It is recognised as the biggest killer of humankind throughout the ages, and today it is second only to HIV as the world’s biggest infectious killer.

World TB Day is used to promote awareness of the disease and spread messages about prevention, signs and symptoms, diagnosis and treatment, particularly to vulnerable populations such as the people of Cambodia.  This year in Cambodia I had the privilege of being a part of a group of teams who dispersed across Kampong Cham Province, to spread the word on World TB Day.

My team traveled to a market place near the border with Prey Veng Province, the poorest of Cambodia’s 24 provinces.  As 80% of Cambodia’s population are subsistence farmers, the agricultural market places scattered across the country in every town and city are packed with rural farmers, making them an ideal place to target the most vulnerable citizens who are graded by the World Bank as “poor” (living on <$2 per day) and “near poor” (living on <$2.30 per day).  http://www.worldbank.org/en/news/press-release/2014/02/20/poverty-has-fallen-yet-many-cambodians-are-still-at-risk-of-slipping-back-into-poverty

We drove for about an hour towards Prey Veng, arriving at the market around 8am just as things were livening up.  Horse drawn carriages and a variety of overloaded vehicles were flowing into the market getting ready for a day of sales.  The rented loudspeaker was waiting for us on an old motorbike driven by it’s owner who had a crippled arm.  When we located a place to situate ourselves he joined us, connecting the loudspeaker to two microphones and a radio to play music when we needed a break from speaking, and settled in to spend the day listening to us using his equipment.

We spent about an hour in one location near the entrance to the market, speaking into the microphone about tuberculosis and offering our time to anyone who wanted to interact with us.  Once we felt this location had served it’s purpose, we wandered to the nearby stalls and spent some time mingling with the sellers, who were all very happy to speak with us, many of them telling us about their personal experiences with Tuberculosis.  We had a lucky draw game in which anyone willing to answer three of our questions related to the basics of Tuberculosis could pick a piece of paper out of a box, with one of three possible prizes written on it (coloured pen, sweet or a World TB Day t-shirt).

From there we relocated to an intersection further into the market, where we hoped to reach a bigger audience.  Our whole day was spent taking turns (between four of us) with the microphone, speaking about Tuberculosis, wandering to and through the stalls speaking with people, and running our Lucky Draw via a quiz over the microphone with willing audience participants.  It was a very hot day, but we were furnished with a shady umbrella and the fun we had eclipsed any physical discomfort.

Some photographs from our day:

Hanging our World TB Day sign

Hanging our World TB Day sign

My World TB Day Team 2014

My World TB Day Team 2014

World TB Day team interacting with local market sellers

World TB Day team interacting with local market sellers

A few market scenes worth sharing:

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Monks on Motorbikes

Siem Reap is a bustling hive of tourism and wealth.  Unless you are not a tourist, or one of the privileged minority benefiting from the tourism, in which case it is a bustling hive of desperation and poverty.  Either way, it is a busy, vibrant place, situated 5km from the historic Angkorian temples made famous by Angkor Wat, the largest religious monument in the world.  Many other equally historic and spectacular Hindu-Buddhist temples are centred around Angkor Wat, built by different Khmer rulers between the 9th and 12th centuries.  For hundreds of years this was the centre of the Khmer Kingdom.  Today it is a UNESCO World Heritage listed site of 400km sq, attracting upwards of 2 million people annually from across Cambodia and around the world, for it’s historic, artistic, spiritual and cultural significance.

In one of the world’s poorest countries, the wealth of Siem Reap has attracted many Cambodian people to the city in hope of penetrating through the glass ceiling of ubiquitous poverty.  Even in the capital of Phnom Penh I have not seen such flagrant and palpable wealth surrounded on all sides by such flagrant and palpable hardship, although it certainly exists there too.  Designer clothes shops, market places filled with souvenirs and beautiful wares of silk and silver see tourists and beggars mingling together.  Some of the sellers and beggars have confronting disabilities such as traumatic blindness and missing body parts.  It is probably safe to assume that most of these are victims of the enduring presence of unexploded landmines, which continue to kill and maim over 200 people per year (mostly young boys).  Cambodia has the highest ratio of amputees in the world, courtesy of mines laid to defend or instil fear and carnage in areas affected by a complicated story of war and violence stretching across three decades from the 1970s, involving Vietnam, America and the infamous genocidal Khmer Rouge regime led by the psychopathic Pol Pot.

I first came to Siem Reap last month on holiday with family visiting from New Zealand and France.  Despite being all-too familiar with the poverty that pervades everyday life in Cambodia, I was confronted by the catastrophic suffering seen here, which exists in such concentration because of the equally visible wealth.  Blind men being led by small boys begging, maimed and mutilated men trying to sell trinkets or books, tiny women with thin babies strapped around their bodies.

To be blatantly affluent in a place like this was, for me, not a comfortable experience.  Pure luck of birth led me to being who I am, where I am, with what I have.  Nothing more and nothing less than pure luck that I was born in a country that happens to have flourished during and beyond my youth.  No country and no population is safe from the devastation that unexpected events such as war, famine and psychotic leadership can provoke.  Prior to the 1970s Cambodia was known as “The Pearl of Asia”, with a prosperous and educated population.  In 1975 the Khmer Rouge emptied Phnom Penh of it’s 2.5 million inhabitants, marching everyone into the countryside and killing anyone with an education (identified by such things as an ability to read, to speak English or French, or merely someone wearing reading glasses).  When Cambodia was liberated (a very generous term for what actually happened) in 1979, only around 300 Cambodians with a higher education remained alive.

One of the people we met in Siem Reap last month is a landmine victim who approached us with a basket of books and postcards hooked over his arm, hoping to sell us something.  We did not want any wares, but we gave him $1 which he exchanged for an A4 page with his story typed out in English.  It was a sad yet uplifting story of hardship and strength, and one which I felt affected by enough to want to engage with him.

We began communicating, first by email and subsequently by texts and telephone calls with my translator.  He has a small family who he struggles to support due to the loss of a lower leg, a lower arm and most of his other hand in a landmine explosion when he was 13 years old.  There is no social security back up in Cambodia, so if you don’t work, you don’t receive money.  As one of my colleagues said recently, “when Cambodian people don’t have food, we die”.  Money is perhaps less necessary in the countryside, where subsistence farming at least provides most with access to rice and other food.  In the cities this is not the case.

After a month or more of brief communications I decided to return to Siem Reap and meet “Kim” <not his real name>.  Part of his story is that in recent times he has been unwell and unable to sell in the streets, where he is often unsuccessful due to the reduced number of tourists in recent years, as well as the police presence which controls his movements near the more tourist-heavy areas.  It transpired during our communications that his wife can sew and has been offered the opportunity to work for someone, but needs her own sewing machine in order to work from home, which they do not have the means to obtain.  Helping them to purchase a sewing machine was an idea I thought I might be able to assist with.

He nominated a meeting place for us and I made my way there at the designated time.  As I was texting to let him know I had arrived, I heard a voice from over the road call out “Hello Madame!”, and turned to find him beaming, with his disfigured arms outstretched towards me.  A group of tuk tuk drivers were lazing on the corner undercover of one of their vehicles, in quiet conversation.  He approached them and after some discussion, returned with one of them, saying “he speak good English”.  I needed a translator and had been concerned about how this might play out, not wanting to breach confidentiality.  Telephone translation with my translator back in Kampong Cham was the solution that I had come up with, which Win had agreed happily to.  But Rav <not his real name>, chosen by Kim for the purpose, turned out to be the perfect solution.  A young and intelligent man who has befriended and helped Kim over the years that they have both been working around Pub Street with the tourists.  The communal spirit which exists in spades between my colleagues, is starting to emerge in my consciousness as a Cambodian spirit of mutual understanding between people who all share and understand the same struggles in life.  The workers around Pub Street clearly also share this strong and uplifting bond.

A very short ride out of the town centre, we pulled into a long driveway behind some local shops leading to a dusty yard in front of a small group of homes.  Kim, his wife and two young children, rent a downstairs room in one of these buildings.  They were expecting us and came out to greet me, welcoming me into their very small, very humble abode.  Outside the door sits the expected wooden bed base on one side and steps leading to the upstairs neighbour on the other, with another entrance door on the other side of the stairs, so three families in equally small spaces all just one wall or floor/ceiling away from each other.  Kim’s home for four people is about the size of my bedroom for one.  String is tacked to opposite walls and suspended across the centre of the room, with a strip of red satin material hanging from it, providing a curtain across the bottom of the bed which doubled as a face camouflage for his shy daughter in my presence.  A bed, a desk, a mattress upright against one wall and a small mobile gas hotplate on the floor was everything they had, plus some clothes hanging on hooks behind the door and two pots for cooking.  A door leads into a small bathroom space.  They purchase bottled water for cooking.

A plastic chair was presented for me to sit on and the others all sat on the floor.  We sat talking about life in general, my life in Australia, my experiences of Cambodia, where they come from, when they came to Siem Reap and why, their landlord who is a good person, where the children go to school, the business owner who wants Kim’s wife to sew for them if she is able to source a sewing machine.  The 12yo daughter showed me her English text book and they explained to me that she is learning to read and write English but cannot yet speak in English.  She goes to the government school in the morning, then a private school in the afternoon for English lessons, which costs money of course.

It was a relaxed and interesting hour or more.  When I suggested that I would like to help them with the purchase of a sewing machine some conversation ensued in Khmer, which Rav then translated to me.  Rather than take my money, they wanted to take me to the shop and choose a machine with me.  All in agreement, the children were left at home and we boarded Rav’s tuk tuk through the crowded streets to a local market across town.  Rav somehow managed to manoeuvre his tuk tuk through the gridlock of cars, bikes, trucks and pedestrians outside the huge market.  He instructed us out before moving into a tiny parking space and the four of us headed into the heaving covered market.  Through crowded rows of clothing, material, kitchenware, fruit, vegetables, fresh meat, jewellery, past sewing machinists who Rav obtained occasional directions from, we weaved in and out of the undercover alleyways, then back out onto a small laneway and over the road, under the protective leadership of Rav all the way, where we found the shop we were looking for.

Many big, old and clunky second hand sewing machines sit on shelves in this tiny shopfront and Kim’s wife identified two as possible contenders.  One was more expensive and made in Japan, the other cheaper but made in China.  I said I was happy to purchase the Japanese one, as I know they are better quality.  Rav then stepped in and while I did not understand the Khmer being spoken, I understood the body language and he was bartering for a better price, pointing to Kim’s disability for sympathy and suggesting they could do better than the discount offered.  Ten percent later a receipt was being written and the address recorded for delivery of the machine, which comes installed in it’s own table.

Back on the tuk tuk we headed out of the marketplace and back to Kim’s home where everyone including the children thanked me with genuine affection.  Mum then turned on the gas hotplate and fried some tiny finger sized fish which she first offered to me before serving the children with a large plate of rice, and they sat on the floor eating with their hands.  It was at this stage of the conversation that I also learned a little about Rav who was born in 1980, a year after the Khmer Rouge.  He is an obviously intelligent young man, who loved school but was only able to attend from 11yo until 15yo, after which he moved to Siem Reap hoping to make money.  He learned English and was good at it, in his school days, and after a short time working as a motorbike driver with locals he realised that he would make better money working with tourists as a tuk tuk driver, which he has done ever since.  A wife and two very young children at home, he has good days “when I take the tourists to the temples” and bad days “when I make no money”.  He has known Kim for a long time and has great sympathy for his plight.

Shortly after we drove back to Pub Street and said our farewells.  The saying that when you help others, the person you help the most is yourself, could not ring more true as I walked away from my new friends feeling like the world had just improved a little thanks to a very simple deed from me, in turn offering me such an interesting and inclusive experience of the real Cambodia.  I may not get to see the temples during this visit to Siem Reap, but I have experienced something at least as worthwhile.

Monks on motorbikes are a common sight in Cambodia

Monks on motorbikes are a common sight in Cambodia

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Orange clad monk with yellow umbrella, Siem Reap