Wheelbarrows and Debts

Yesterday I watched in awe as a group of men and women covered from head to toe with traditional checked khromars wrapped around their heads for sun protection and dressed in pyjamas (women) or shirts and jeans (men), worked with a heavy wheelbarrow, carting wet concrete from the mixer about fifty metres away, to a track being cemented into a single lane roadway.  With a “driver” leading the way, pulling the barrow handles from behind and four people pushing the back of the barrow, they built into a run from the mixer up the slight incline, over a pathway of planks laid for the journey.  Upon reaching the section being cemented, the team repositioned to push the barrow over, pouring the cement out.  A man using a long stick of wood then smoothed the concrete while the barrow team returned to the mixer for the next barrow load.  As we watched from our office doorway, a local colleague told me that they would probably earn around $2 each for the day but that many labourers earn only food, not cash.  It would be interesting to know how many calories their bodies burned – no doubt a much bigger benefit than the paltry financial gain being earned, but probably also at risk of long term complications which are likely the reason I see so many older people bent over themselves with bone and spine deformities.

Concrete SA 20 May 012 b

My colleagues talk about their involvement a few years ago in a response to a Cholera outbreak which occurred here.  According to media reports, in 2010 at least 60 Cambodians died of Cholera during an outbreak which spread across 20 of the country’s 24 provinces.  One of the reasons for the outbreak is cited as being that people do not have access to clean water and, especially in the Dry Season, will drink whatever water is available.  I guess this is the reason that bottled water is heavily marketed here, selling to locals for around 500 Riel (US12c) per 500ml bottle, which seems cheap but is nevertheless unaffordable if you have no money.

It’s easy to imagine, watching these teams of thin bodies push themselves in the hot sunshine, how vulnerable people are to infections.  When the environment is conducive to bacteria, viruses and parasites anyway, bodies with no reserve will surrender so much easier to infection.  The level of chronic malnutrition in Cambodia is a reason that TB has such a strong hold over the population, but TB is not the only organism able to thrive here.  Dengue and Japanese Encephalitis viruses and Malaria parasites are the most common mosquito borne diseases; diarrhoeal diseases including Giardia and Cryptosporidium (parasites), Rotavirus (especially in children under 2yo) and bacteria such as Salmonella and Campylobacter contribute significantly to the issue of childhood malnutrition, which cycles well with diarrhoea, making the host more susceptible to illness, which in turn exacerbates malnutrition.  Other respiratory diseases such as Streptococcus pneumoniae and Haemophilus influenzae are also very common causes of morbidity and mortality.

Throughout more than 20 years of nursing I have been trained about the risks of germs spreading in hospital settings, which are productive germ factories as people congregate in a single location with whatever ails them, searching for a cure.  Infection Control is big business in the First World, where degrees and doctorates are earned by nurses and doctors who make specialised careers out of the subject.  In contrast, the Third World have very few resources for the purposes of Infection Control, which is a large part of my role in the hospital setting here but on a very basic scale as hospital acquired infections are not monitored, let alone identified and acted upon as they would be in the Western World.  I am on a very steep learning curve, coming from a country with many resources and having spent many years away from the hospital setting.

Toys in a paediatric setting are very important for the psychological well being of patients, but have to be carefully managed to ensure they don’t contribute to the spread of hospital acquired infections.  As they are much easier to clean, hard toys are the only acceptable option in hospital settings where Infection Control is a primary concern, particularly in difficult circumstances such as the Third World where water supply, sewerage maintenance, hygiene standards and living conditions are all a constant struggle.  Almost daily I am confronted with blocked toilets, leaking pipes, shortage of cleaning or waste disposal products and various other challenges to our attempts to maintain good Infection Control practices.

A good summary of the problems relating to soft toys and the spread of infection in health care settings can be found here:

http://www.medscape.com/viewarticle/489955_6

In case the link doesn’t work, the text from this article is pasted below.

After mentioning on Facebook that certain specific toys would be of great value here, I had an astoundingly generous response with untold parcels received from as far away as Australia, NZ, UK and America, all of which I have not yet been able to distribute due to the sheer volume.  It was on the whole a very fun and happy exchange with many thoughtful friends.  I received a volume of parcels almost daily for a period of time, all of which required payment to the postal service upon receipt which involved some organisation as colleagues in Phnom Penh were paying out of their own pockets on my behalf.  I managed to offend a tiny minority of donors by stating that some parcels were directed away from the hospital, which was done for practical reasons as described herein.  Unrealistic and impractical stipulations were attached to two or three parcels which were not expressed until it was too late and which I could not have complied with even if I had known.  It was a lesson for me that not everyone gives without strings attached or with reasonable scrutiny and expectation.

Today I visited some patients and Home Based Care Nurses in their communities.  At one location we sat on a bamboo day bed underneath a small wooden stilt house in the countryside, surrounded entirely by newly planted rice fields with just a narrow dirt lane leading through the rice fields to the house.  An elderly man joined us, thin and wasted by Tuberculosis, while his son lay in a hammock nearby and his wife joined us to talk about the side effects of the treatment her husband is receiving for Drug Resistant TB.  In a nutshell, her husband is experiencing some psychiatric problems related to one of the TB medications, as well as headaches, joint pain, back pain and decreased appetite.  She has hypertension treated with medication she has to pay for, her son has pre-existing psychiatric problems, one daughter collapsed in a factory where she works recently and was unconscious for three days, leaving them with a hospital bill which they cannot afford and another daughter works on a construction site in Phnom Penh.

Cambodia’s Ministry of Planning coordinates an “ID Poor Card” scheme which is supposed to identify the most destitute families in each community, who upon receipt of this card become eligible for free health care at the local Health Centre and exemption from teacher payments at school.  Village Chiefs are responsible for distributing these cards in their community and my colleagues all say that in reality, the families of Village Chiefs are the primary beneficiaries of ID Poor Cards, which is just another example of the pervasive corruption in  Cambodian society.  Despite being eligible for an ID Poor Card, this family do not have one.  They have debts related to their ill health and no way of paying them.  When I asked what amount the debt was, assuming it to be many hundreds of dollars to be causing such stress, the answer was 300,000 Riel, which converts to US$75.  I returned to the car and got as much money as I had with me, and brought it to her, having my colleague translate for me that this was from me personally and not from our employer, to go towards paying their debt.  Having received cash from other friends who did not want to send parcels I explained that this was a gift from overseas friends who wanted to contribute to Cambodia and that I felt their plight was deserving.  As I passed the money (which did not cover the full debt) to her she began to cry, repeating “Oor kun jirian” (thank you very much) over and over, with her hands in sampiah gesture against her forehead.  She then hugged me, followed us up the laneway to our car, thanking me tearfully all the way and hugging me again.  To have such extreme stress by such a small amount of money truly astonishes me.  But debt caused by hospital bills seems to be a crippling experience of many Cambodians.  It was gratifying to be able to help one family in a small way.

To end on a slightly lighter note, the other night we were out for dinner and parked our bicycles up outside the restaurant, then took our seats at an outdoor table overlooking the river.  We ordered drinks and after a few moments, the waiter approached us and said “Excuse me, please can we ride your bicycle?”.  Excuse me?  “Please can we ride your bicycle?”.  Yes sure, you can take that one, it’s closest.  The waitress came out and boarded an MSF bicycle and cycled off into the night skies.  A few moments later she returned with the basket filled with a huge bag of ice, and our chilled drinks were served a few moments later.  How can anywhere match the character of this place?!  Now, the next time I’m told that they are out of wine or gin, I hope the offer of a bicycle loan may offer a practical solution, as the nearest liquor store is around the corner and there was an occasion some time back when we could not order wine for about three weeks!

Evidence-Based Practice: Examining the Risk of Toys in the Microenvironment of Infants in the Neonatal Intensive Care Unit

Review of the literature on toys included both clinical inpatient and outpatient settings (see Table 4 ). Two studies were identified that compared hard and soft toys in the waiting rooms of general practitioners. The first, a descriptive study from Edinburgh, reported cultures from 50 toys shared by children in the waiting and consultation rooms of a busy, inner-city practice.[42] Investigators found organisms on 60% of the hard toys and 100% of soft toys. Organisms judged as “potentially pathogenic” were found more frequently on soft toys (30%) than on hard toys (5%) (odds ratio, 8.14; 95% confidence range, ). The authors cite a 1 in 10 chance of exposure to a pathogen from communal toys as an unacceptable risk. The study was limited by differences in culture techniques; swabs were used to culture hard toys, whereas direct cultures were obtained from the soft toys.

The second study described contamination of hard versus soft toys. Twenty-two hard toys and 10 soft toys were gathered from 6 general practice offices in New Zealand.[43] The toys were soaked in a broth media, which was then cultured for coliforms and total bacteria. Ninety percent of soft toys showed coliform contamination compared to 13.5% of hard toys (P < 0.001). Soft toys were more often contaminated (100% v 91%) and were more likely to have moderate to high bacterial counts (90%) when compared to hard toys (27%; P = 0.002). Although useful information is provided about the ineffectiveness of decontaminating toys (particularly soft toys) by soaking, machine washing, or autoclaving, data are not provided to support these conclusions.

Together, these 2 studies provide consistent and moderate (level IV) evidence that toys in the waiting rooms of general practitioners are quickly colonized with bacteria. Soft toys colonize at higher rates and present the greatest risk of contamination. Procedures for cleaning are generally more effective for hard toys.

A number of case reports in hospital settings describe toys as probable reservoirs for pathogenic organisms. A report from an ICU in the United Kingdom describes a 79-year-old woman who was given a cuddly toy dog by her family.[44] Knowing the patient previously had MRSA, a culture of the toy was obtained and promptly grew MRSA. In this case, it appears the patient contaminated the toy. The toy was removed from the ICU at the advice of the infection control team. The clinicians advocate a ban on cuddly toys.

An outbreak (8 cases) of rotavirus was reported in a 42-bed cancer center.[45] After weeks of aggressive infection control measures with no decrease in incidence, a pediatric epidemiology investigation revealed that toys in the playroom had not been cleaned according to the weekly protocol. Cleaning procedures were enforced; although no further clinical cases occurred, this finding may be related to seasonal patterns of this infection. The toys were not tested for rotavirus. Investigators hypothesized that shared toys were likely serving as fomites transmitting rotavirus.

One practitioner reports a case of a toddler from his neighborhood who presented with diarrhea caused by a Giardia infection after having swallowed several gulps of water from a toy left in a stagnant pool of water.[46] Although no evidence of cause is presented, the author warns clinicians not to overlook water toys as a source of infection.

These cases individually provide low levels of evidence (level V) linking toys and infection. When reviewed together, however, they reflect reports in the more general fomite literature and offer stronger and more consistent evidence. Use of molecular technologies to link organisms at a highly discriminate level will provide stronger evidence in case reports as the following study demonstrates.

A report of 9 cases of multiresistant P. aeruginosa in a pediatric oncology unit compared isolates from infected immunocompromised patients to environmental cultures taken from wet surfaces.[47] Using molecular DNA analysis, researchers found that isolates from 8 infected cases had identical banding patterns that matched isolates from 3 bath toys and a box for water toys. A case-control study compared the 8 infection cases to controls that matched the disease. It showed a significant association between infection and use of bath toys (P = 0.004), use of bubble bath (P = 0.014), duration of stay (P = 0.007), and previous antibiotic exposure (P = 0.026). The authors caution against the use of water-retaining toys with immunosuppressed patients. This study provides good evidence (level III) linking toys to infection by using molecular technologies and case-control risk analysis.

In a descriptive study, random selection and culture of an unspecified number of toys from a pediatric ward communal playroom were undertaken.[48] Sterile swabs were used on hard toys and contact plates were used on soft toys to culture organisms. The results showed no growth from the contact plates taken from the soft toys. Swabs on agar plates from the hard toys grew Staphylococcus albus and Bacillus species. The author suggests that although only environmental organisms were found, these pose a risk for immunocompromised children and those with invasive devices. Lack of data to support findings, an unknown sample size, and varied sampling techniques are limitations of this study. The evidence (level IV) presented shows weak support for the presence of organisms on hard toys.

A prospective study in a hematology/oncology unit showed positive cultures of 39 stuffed animals.[49] The “T. Bears,” sponsored by the Department of Health and Human Services (HHS), were a mascot to promote handwashing and were given to hospitalized children ages 9 months to 15 years. All of the toys were colonized with at least 1 organism within the patient’s first week of admission to the hospital. The organisms represented human skin flora, although not necessarily flora from the cohort patient. Five of the 39 patients became bacteremic 1 to 30 days after receiving the T. Bear. The toys could neither be implicated nor excluded as the source of infection. No effect was noted on monthly NI rates. Of clinical significance were the rapid colonization rate of the T. Bears and the presence of organisms known to cause severe infections in the study hospital. The authors concluded that the colonized toys could provide an unnecessary means of nosocomial transfer and spread of organisms. This study provides some evidence (level IV) of the presence of pathogens on soft toys; however, the effect on NI rate or bacteremia is not demonstrated.

Further information is provided by a small prospective study that examined nonsterilized stuffed toy animals placed in the incubators of 12 NICU infants.[50] The infants had a mean age of 30.6 weeks (±3.4) and a mean weight of 1419 grams (±743). Aerobic cultures of the toys, incubators, and infants’ skin were taken at 0 and 72 hours. The cultures (sites not specified) predominately revealed CONS. The authors concluded that the results “failed to implicate the stuffed animals as harboring pathogens.” This study was reported in a brief letter that provided no specific data. Other limitations of the study include the use of only aerobic cultures, cultures for no longer than 72 hours, and the small sample size. The presence of CONS, the most common cause of late-onset NI in the NICU,[12,54,55] is evidence contrary to the authors’ conclusions. The presence of these known potential pathogens may represent a risk for this population. The conclusion, that the practice of placing stuffed toys in incubators “may be safe and reassuring for both parents and neonates,” is an overstatement of the type, size, and scope of the study and, further, is inconsistent with the evidence (level IV) presented.

The trigger study that led to this evidence-based clinical project is a cross-sectional, longitudinal survey of the toys in the beds of NICU infants.[10] The authors investigated the bacteria and fungi contaminating toys in a 20-bed, level III NICU in Melbourne, Australia. Infants’ mean age was 28.2 weeks (range, 23 to 41) and mean weight was 1114 grams (range, 480 to 2710). Toys resided in infants’ beds and were cultured weekly over a 4-week period. A total of 86 cultures from 34 toys of 19 infants were collected. Bacteria grew in 98% of cultures. The most common organisms were CONS (98%), Micrococcus species (58%), Bacillus species (24%), MRSA (15%), and diptheroids (14%). Colonization rate did not change with bed type, presence of humidity, toy size, toy fiber, or toy fluffiness. Eight (42%) of the infants had a positive blood culture, and 5 of those isolates (63%) were the same type as the corresponding toy. Unfortunately, molecular techniques were not used in this study. The authors concluded that toys might be reservoirs for potential nosocomial sepsis. This prospective, well-designed study provides good evidence (level III) of bacterial and pathogen colonization of toys and highlights the potential for fomite transmission to a neonatal population.

In summary, the evidence demonstrates that toys are reservoirs for infectious organisms in a variety of settings. This is supported by the breadth and depth of literature related to organisms present on fomites[20,22,23,25-41] and, more specifically, on toys.[10,42-46,49] Two studies (level IV) demonstrated higher colonization rates on soft toys.[42,43] Caution was raised (level III and V evidence) regarding colonization of water toys with pathogens.[46,47] Although randomized controlled studies are lacking, these level III, IV, and V studies show generally consistent findings. Colonization of the microenvironment with potential pathogens has clearly been established.

The evidence to link the colonization of toys to increased risk for NI is plausible but not proven. An association between NI and organisms on toys was evidenced by both well-designed studies (level III)[10,47] and a case report.[44] The use of resistant organisms and DNA molecular technologies show discriminate evidence linking the organisms of sick infants to those on toys.[47] Weaker evidence of linkage was provided by comparing organism species in the sick infant to those on toys.[10,49]

No prospective randomized controlled trials were identified with sufficient power to support the safety and efficacy of toys in the microenvironment nor, conversely, to demonstrate a cause and effect relationship between colonized toys and increased NIs. In the absence of randomized trials and clear causality, an attempt was made to determine if evidence about causing harm is valid.[56,57]

The scientific principles of fomite transmission and literature review support plausibility:

–  Toys are potential reservoirs for pathogens and other organisms;

–  The hands of health care workers and families transmit organisms between toys and infants;

–   Infants exposed to pathogens and other organisms are at high risk for NIs and associated morbidities and mortalities

–  Drug resistance patterns and DNA technologies have linked organisms in hospitalised patients to those on their toys

–  A common theme throughout the literature suggests that NI outbreaks reliably declined when fomites were removed from patient contact.

 From Advances in Neonatal Care, 2004; 4(4)

Paradoxical Phnom Penh

There is a seedy side to Cambodia which thankfully, as a woman living provincially, I have not really been exposed to. Nearing the end of a weekend in Phnom Penh, this morning Bee and I found ourselves sitting at an al-fresco pub on the riverfront for a few hours. After a while we began to notice with some unease, a lot of western men of varying ages but at least half of them in their 50s to 70s, moving in pairs and groups. I’d been to this area before and was aware that the streets leading inland from the riverfront are some sort of Red Light district. But today it became apparent that the area attracts groups of western males looking very much like the stereotypical sex tourist. In various combinations of over-tanned, ageing, toned, obese, shirtless and tattooed, posing larger than life in tuk-tuks or strutting the streets like proud peacocks, we became increasingly aware that we were surrounded by sleaze.  We are mindful that many men, some of whom we know personally, happen to be here for innocent and decent reasons but fit the stereotype and find themselves judged unfairly. But even if our judgement was only 10% accurate then dozens of people in our vicinity were here to exploit vulnerable people. At this specific pub we suspected the older western owner could well be involved in attracting sex tourists to the area as mobs of men filled the undercover tables lining the footpaths, as if loyal customers to his establishment. Lavish amounts were spent on beer and western food at comfortable breezy tables as beggars roamed the edges of the roadside in the scorching sun before us, hoping for a little compassion from the affluent, overly-confident and indifferent all-male crowds.

Having said all of that, despite the imbalance of power in such situations, many Cambodian women consider the chance of a relationship with a western man offers more financial stability and less risk of intimate partner violence. Cambodian men are involved in prostitution and human trafficking on a much larger scale than westerners, who represent a small percentage of the overall sex trade and also perpetrate less rape and violence than the local male population.  It is also not unusual to hear of mothers pressuring their daughters to sell themselves for financial gain.  This is no more an indictment on all Cambodians than our observations at the riverside were an indictment on all westerners.

Perhaps the time we spent with another friend this weekend influenced our uncomfortable realisation of the probable ugliness surrounding us. Yesterday morning we attended a riverside slum community with a local Non-Governmental Organisation involved in trying to protect people exposed to risks that I had never considered before. The fisher families resident in this location are exploited by a local, corrupt police force who profiteer from their tenuous incomes.  Children are unable to attend school due to the small but unaffordable daily payments required by poorly-paid teachers. Child prostitution and human trafficking are constant and very real risks in which the United Nations suggest government officials are complicit.

Many children living in these impoverished places are not registered at birth, something I had never considered previously, but which places them at risk of abuse and disappearance, leaving little impetus for authorities to investigate because in legal terms, these victims do not exist. The NGO undertake family assessments to obtain census information on the population living on this shorefront slum which disappears underwater when the river rises during the Wet Season, scattering the landless fisher families to other areas until the land reappears once the river abates again, some months later. They are also involved with local schools, covering attendance payments, as well as offering activities outside of school hours to help the children build confidence and life skills despite living transiently in ramshackle huts on a muddy shore.

One of the children we had hoped to meet was described as a teenager with a disability of unknown cause, who cannot sit or stand independently and lies on the ground all day, unable to speak or communicate. However, when we got to the small hut where he lives with his grandmother, father and siblings, he was not there. His father had loaded him into the canoe-shaped wooden fishing boat and taken him on the water, as there was noone else able to care for him and Dad needed to fish in order to feed the family. We met his elderly grandmother and heard that he seemed to be doing okay this week, so they arranged to meet with him next week instead. Another teenager appeared and signed some papers which were needed to move him to private school as he is achieving well and the NGO had found some funds to send him and a small group of his peers to a private school where it is hoped he will receive a more intensive education. Standing beside the canvas-roofed wooden shelter under which I was sitting he looked at me with a proud but shy smile as the worker explained to me that he was a star student. I smiled back in wonder as I considered the destitute surroundings and tried to imagine where he would study at night with no power, no furniture, no shelter from the rain, no access to guaranteed meals from one day to the next, no protection from the potential risks I was hearing about?

During discussions over a very educational weekend with my friend who is connected to this NGO, we were introduced to the magnitude and complexity of the human trafficking problem in Cambodia. I don’t feel particularly informed yet, but my interest has been piqued and I plan to educate myself on the subject.  The most telling quote I’ve seen in my readings so far, which summarises many of my friend’s stories of vulnerability, risk factors and uninvestigated disappearances, is from here:
http://www.no-trafficking.org/reports_docs/estimates/uniap_cb_estimates_report.pdf
The history of any country affects its present, both through the individual and collective memories of its people and through the cultural artifacts that serve as reminders of earlier periods. The single most important historical period during the past century in shaping the Cambodia of today is that of the Khmer Rouge from 1975 to 1979. As a result of the chaos during and following this period the current sex industry arose in an uncontrolled fashion in the 1980s and 1990s that allowed trafficking to flourish

We left this slum and returned by tuk-tuk to a local coffee shop to enjoy some air conditioned comfort and debrief about the slum residents doing it tough on such an unfathomable scale, a very brief distance away.  The rest of our weekend was spent experiencing the oriental pizzazz of a wealthy Phnom Penh – shopping centres, negotiating dollars with tuk-tuk drivers, sunset rooftop cocktails with 360° views over the city, a sushi restaurant for dinner and American ice cream overlooking the Mekong for lunch.

My friends in Phnom Penh are shameless humanitarians without being religious or even particularly altruistic, just empathetic souls who have found a balance between helping others on professional as well as personal levels, and living their own life.  Perhaps more than anything else, having inspirational friends and supportive family is the biggest privilege of all?

Cutting Cambodian Corners

There are many bicycles in Kampong Cham, even moreso in Cambodia, which carry large sacks shaped around frames positioned over the back carrier and suspended beside the back wheels, used for collecting recyclable cans and plastic bottles which generate a small income.  This morning on my way to work, an old woman dressed in rags with the traditional red-checked scarf called a Khromar wrapped around the top of her head, had parked her recycle-bike and was crouched down at a pile of black rubbish bags in the street, searching for cans and bottles.  I pulled over with two Diet Coke cans to give her and pointed at them in my bicycle basket.  She smiled widely showing her two remaining teeth and pointed to the sacks.  I made my contribution and cycled off into the slow but busy traffic, musing as I so often do these days about the entitlements that are mine simply due to when and where I happened to be born, compared to the misfortune surrounding me which cripples so many into a slavery-like existence.

The other day on my bicycle I waited at a red light on a busy intersection until the light turned green in my favour.  Checking that the traffic on the opposite light was stopped I started up a slight hill across the busy main road.  As I reached the centre of the junction a black Landcruiser with tinted windows sped through the red light, around a parked truck which had obscured it’s approach from my vision.  I swerved to a halt in the middle of the road, avoiding a serious collision between bicycle and Landcruiser.  They (dubbed “20178” for the licence plate number I tried to memorise) continued on their merry way, leaving me incensed and shaken.

On telling my colleagues about my near-miss that night, we came to the conclusion that 20178 was highly likely a military vehicle because they are the only ones who tend to drive so aggressively here, with most road users driving slowly, albeit with limited skill from a western perspective.  The military are also usually immune to any punishment in road traffic accidents and part of my briefing to Cambodia was that if I find myself in any sort of situation on the road with such vehicles, to never argue or disagree.

The road rules here are random, with most traffic appearing to rely on civility towards one another combined with slow speeds.  Little else is reliable or predictable and you have to keep a close eye at all times on what is going on around you.  It is unusual when coming around a corner, to look behind for oncoming traffic.  The traffic behind is responsible for moving out of the way or announcing their presence by a honk on the horn.  Cutting corners is normal, taking the shortest distance possible from your right lane on one road, across the left lane into the left lane of the road you are turning into, and then across into the right lane where you belong.  Often on my bike, when cycling straight over intersections I will be cut off by a moto passing me and then turning in front of me.  This also happens with motos and bicycles coming from the opposite direction, who will cut into you head-first to get around the corner.  At first this was shocking to me and also highly irritating but I have since come to accept all broken rules as normal.  In fact, when I first started cycling the streets of Kampong Cham I had a lot of suppressed road rage, but soon realised that the rules are at best casual, that anything goes, and that courtesy prevails no matter what.

At intersections unless there are traffic lights, the right of way is given according to vehicle size with trucks and cars, who usually honk as they approach the intersection, having right of way.  Horn honking is common and always intended as a courteous warning.  Motos and bikes hold similar sway on the lower end of the spectrum, so it depends a lot on non-verbal communication as you debate with those crossing your path by eye contact and somehow this seems to work well.  The other thing that works well is understanding that when you’re crossing through traffic lanes occupied by two-wheeled vehicles, you can all swerve around each other without anyone needing to stop!

Yesterday evening Bee and I took the first of this week’s three English lessons at the orphanage.  As arranged with the two homeless girls I have mentioned, we picked them up from their tree at the arranged time.  As we left, grandad drove his moto out of the area at the same time.  At first I assumed he had something to do, but when we reached the meeting point to wait for our tuk-tuk driver he pulled over and waited and it became apparent that he was following us.  It also became apparent that quite a community of bystanders were vigilant that these small girls were in our care, as grandad apparently explained to a number of different people that it was okay.   Soon enough Chom, our tuk-tuk driver, arrived and introductions were made before we climbed aboard and he navigated through the streets with my instructions, grandad following closely behind and pulling up alongside us at the traffic lights.

On arrival at the orphanage grandad came inside the gate to look.  I showed him the outdoor classroom area, motioned that the folded desks would be assembled and the girls would sit on stools with the other children who were slowly making their way outside to join us.  He said something to the girls who nodded shyly, and we communicated that I would return the girls to him in an hour.  At first the girls were extremely shy, but the orphans created space for them and they sat wide-eyed at first, but by the end of class were participating softly as we included them in brief and simple activities.

After a very subdued tuk-tuk drive to the orphanage, when we boarded outside the gate after class, they both chatted animatedly to us in Khmer all the way home, reciting “Hello” to us and listening with huge smiles as we coaxed them (unsuccessfully) to say some other brief English phrases.  As we arrived back at the area near their tree, the same crowd of bystanders were there, making comments to the girls who grinned from ear to ear all the way to grandad, who was waiting and watching for their arrival.

Bee said it best when she expressed her heartfelt surprise that these girls, despite having nothing, not even a home, clearly belong to a community of people who protect and care for them.  It’s so easy to dehumanise the existence of people who have nothing, to assume that they have nothing because they are not as deserving or that something is lacking in them as a  person or a population.  But from necessity, it seems to me that the less people have, the more “real” they often are, building structures of community rather than possession, to protect and support each other.

The Power of English

This morning for the first time since arriving in Cambodia I braved the sweltering morning heat just after dawn and headed out into the streets for a 2km jog with Bee, who strode ahead of me and managed 4km in not much more time than my 2km took.  The Mekong has had over six months of Dry Season to dwindle to levels as shallow and still as it probably ever gets, making the surface highly reflective.  Wooden boats float on brightly glimmering expanses of water and the river reflects mirrored images of bridge supports, tree-lined shore, floating houses and boats, bringing the water to colourful life.  It is difficult to believe that in a few short months, once the pending monsoons have had time to take effect on the river, it will be flowing fast and high again, with many of the current low-lying landmarks disappearing under volumes of raging water.

Demand for my English skills is snowballing and I now spend seven hours per week in language lessons.  As well as the four hours per weekend in reciprocal English-Khmer lessons with a small group of men, this week I added an hour three evenings per week teaching a group of 12 orphans aged from 6yo to 15yo.  Previously my housemate was volunteering in this role but as is the case with MSF missions, he was only here temporarily and left over a month ago, so a new teacher was sought.  These lessons have since grown to include two homeless children I have come to know via daily contact at work, aged 6 and 11, who will come with me in a tuk-tuk each evening and I will deliver them to their hammock under a tree after the hour-long session.

The lessons occur at the orphanage, on the ground floor undercover area of the high-set stilted house.  Teaching children is a very different enterprise to teaching adults.  I realised the night prior to starting these lessons that the experience of turning up to 12 expectant young pairs of eyes was going to mean I needed to be organised in some way which has not been necessary with the adults, so I spent a number of hours on Google and YouTube getting ideas for a lesson plan.  This was all I needed for the first three evening classes to run smoothly, as I came prepared with a number of different interactive exercises to keep the children entertained and motivated.  Although they seem to be motivated anyway, with even the six year old sitting quietly facing the board and writing out his letters with great concentration when it is time to copy our recited words from the board.

Not only is it a steep learning curve, to suddenly find myself being called “Teacher”, and being responsible for the entertainment and leadership of a tribe of kids for three hours per week, it’s also a huge amount of fun despite the significant language barrier.  One of the songs they already knew, “Head, Shoulders, Knees and Toes” is a great hit and they sing it repeatedly, starting over enthusiastically when it comes to an end, watching me studiously as we get to the “Eyes, Ears, Mouth and Nose” part of the song to try and grasp which word belongs to which facial feature and laughing uproariously when we speed up the tempo.

Thankfully a Khmer colleague comes with me whenever he is available which makes a big difference as he is able to translate instructions, the meaning of new words, etc.  He enjoys the kids as much as I do and we come away feeling exhilarated with lots of cute and funny memories, feeling like we’ve made a small contribution to the community.  His words to me when we spoke of this were “I want to help the Cambodian children because I pity them so much and if they can learn English it is so important to their life”.

Equally exhilarating, but in a completely different way, are the reciprocal English-Khmer lessons with four young men who learn English at night school and attend class with me at weekends because of the perceived benefits of having contact with a native English speaker.  At this morning’s lesson there were two Khmer guys with Bee and myself, both Australian.  We spent an hour at the table teaching each other various things, before it was suggested that if we were in the market we could practise our Khmer in a real-life situation and it would have more impact.

With myself and Bee on our bicycles and the men tandem on a single moto, we rode abreast through the streets to the Central Market where we had a few small purchases to make.  With our Khmer instructors there to tutor and support us, we asked for items and prices, translated the Khmer replies of stall holders into English for ourselves, bargained for cheaper prices, asked for our things to be packed and put into practise various other phrases we have been learning from the safety of a private space.  We came away with a new hand-held fan each, a bamboo mat to use in games with the young English students, two books and two pens for each of the new students joining me at the orphanage this week.  Nearby stall holders in the narrow undercover lanes of the market gathered near us to observe as our Khmer bargaining took place at different stalls and there was much sign language and laughter as we all attempted to communicate in Khmer together.  Our tutors corrected our grammar, asked us to “please say it in Khmer” when we gravitated back to English and encouraged us to bargain the price down, a usual and expected custom.

Meanwhile, this week the six year old homeless girl who I see daily was devastated by something on Monday morning.  She sat on the pavement sobbing for an inordinate amount of time and could not be consoled.  Later in the day with my translator I was able to have a conversation with her grandparents from their “home” under a tree. The last time she had seen her mother she was about 4yo. Her mother works in Thailand at an air conditioning factory and only comes home when there is a break between contracts.

Last week the girls’ mother visited her daughters for the first time in 2.5 years.  On Monday she returned to Thailand and she will not return home to Cambodia until her next contract ends in three years’ time.  Searching the internet for information on air conditioning factories in Thailand, it is difficult to find anything specific.  However the general employment conditions of migrant workers in Thailand appear to be rife with human rights abuses.  I can only imagine the conditions she works in, in a country where the minimum wage is $280 per month but appears not to be easily or readily enforced.  Yet, it is clearly considered a worthwhile sacrifice for a young mother to make, leaving the children with caring but homeless grandparents who earn a grand total of US$70 per month in a country which does not have a minimum wage nor reliable salary payments to lower level workers.  The following two websites give a little insight into worker conditions in Thailand.
http://goodelectronics.org/news-en/labour-issues-in-the-thai-electronics-industry
http://investvine.com/thailand-wage-hike-comes-into-effect/

Yet my observations are that these committed grandparents ensure the children get to school each day and despite the impoverished living conditions, keep the children clean and fed.  Many Cambodian children do not have the advantage of regular, or for many, even any school attendance.  Teachers in Cambodia earn a tiny wage and rely on payments from students to make their income livable.  I am told that children have to take 500 riel (equivalent of US12c) to school each day, to pay the teacher.  Children who attend without this payment are apparently sent home.  For many Cambodian families with unreliable income, earning tiny amounts for hard physical labour and employed as daily workers, meaning from one day to the next their ability to earn anything is unpredictable, this is not an affordable amount, particularly when there is more than one child to educate.  Schools also seem to hold morning and afternoon classes, with most primary students only attending for two to three hours per day, either the morning or the afternoon class depending on the school’s organisation of grades.

This family’s story seems shocking to my first world brain but such unimaginable sacrifice is not at all an uncommon scenario. Many of my own colleagues do not see their children for weeks, sometimes months at a time, as they have been able to find work in Kampong Cham, many miles from home and for some at the other end of the country from where their often young children, partners and extended family live.  This sacrifice is made for wages that are in the US$200 to US$500 range per month.  A colleague recently explained to me that living apart from family but remaining in Cambodia pays less than they could earn in Vietnam or Thailand, but they choose this lesser sacrifice to remain closer to their families than travelling to another country would allow.

Today I informed my Khmer classmates that I had started teaching English to some children and one of them expressed that he wished he had known me when he was a child because learning English as a child would be so much easier and learning English from a native speaker considered far superior than learning from someone who knows English as a foreign language.  The fact that I, a very unlikely teacher, was head hunted for this role by two quite different groups of people; the studious attention that my adult and child students pay to learning English from an untrained and less than average teacher; the comments I have heard about the importance and value of English proficiency; the outsider observations I have made of the difference in income, small as this difference is to a westerner, between those in English-speaking jobs and those whose jobs do not require English; are all factors which have revealed to me a surprising insight into the power that the English language possesses in Cambodia and many other places in the developing world.

As if to confirm my point, the article from People Magazine in December 2012 below, was posted to my Facebook page tonight.  The last line in the article is a quote from a girl who spent her first decade of life scavenging in Phnom Penh’s Steung Meanchey rubbish dump before being rescued by Scott Neeson, founder of the renowned Cambodian Childrens’ Fund: “Now my life has changed.  I can speak English with you.  I have the opportunity to go to school.  Everything is different”.

https://www.cambodianchildrensfund.org/images/stories/ccf_media/magazine/PEOPLE_Magazine_USA_December_2012.pdf

Language Lessons in a Sauna

Teaching English is not a pastime I had ever considered. But a colleague’s husband is at English night school and they saw in me, a native English speaker wanting to learn Khmer, an opportunity which we’ve both seized upon. Now I spend four hours per weekend in reciprocal English-Khmer lessons with a number of English language students.  Another Australian colleague/housemate has recently joined us. The Khmer being taught is very basic, while the English is advanced and more conversational.

We are learning as much about our own language and it’s nuances, as we are learning new Khmer. When you use a language daily from birth it becomes less conscious and more instinctual. So teaching someone the various subtleties and ambiguities in a language that is such an integral part of who you are can be quite a challenge.  For example, the various uses of the word take – take in, take on, take out, take down, take away, take a bath, take over, take part, take into account. Unfortunately teaching is not something I am either trained in or natural at, so they are receiving amateur coaching at best. But my English proficiency is in high demand despite my teaching incompetence. Moreover, we are having an enjoyable shared experience which I for one, am relishing.

When these classes began we held them at an outdoor table in the grounds of a Wat – the walled Buddhist community centre which every community has. Wats consist of large spacious grounds almost always at the end of a long dusty laneway, through a grand high-walled entrance decorated with statues. These wats always house beautiful golden high-roofed temples, ornate tombs known as stupas, communal dormitories for resident monks, classrooms and tree-lined shady paths and gardens, with thoroughfares between the walled entrance-ways for community access. The general public transit through the grounds, use them to rendezvous for various reasons, and of course they are a place for spiritual observance, counseling and ceremonies. However the heat of the pre-Wet season inspired a change in location and now the fan-furnished dining room of our MSF home acts as our classroom each Saturday morning and Sunday afternoon.

A typical golden wat roof (Wat Nokor, Kamong Cham)

A typical golden wat roof (Wat Nokor, Kampong Cham)

This week I was invited to a ceremony at a colleague’s home on Thursday evening. After the death of a loved one, the funeral and cremation are followed by a seven-day ceremony, then three years later another ceremony of remembrance and offering. From an outsider’s observations these ceremonies can be easily mistaken for weddings as large decorative pavilions are erected in the street, with catered meals serving hundreds of people at round tables seating eight per table. However, unlike the colourful weddings, dress for these ceremonies is dark trousers or skirts with white shirts or blouses. The music is much more sombre and the tents which are decorated less lavishly always fly a flag depicting a crocodile, which signifies the loss of a loved one.

My translator Win was also invited to this ceremony and as I do not survive well in an all-Khmer environment, we arranged to attend together. I cycled to his home, where some time was spent with his mother, his wife and their 3yo, before we left them behind and headed out into the busy evening streets. Win took his motorbike and I cycled alongside him on my bicycle. One of the most Cambodian experiences is to socialise from behind the handlebars of your moving two-wheeler, particularly in the evening between about 4pm and 7pm. In these cooler hours the streets come alive with young people on bicycles and motorbikes, riding up to three abreast, with up to four on a bike so that three-abreast can be a crowd of 12 friends, chatting animatedly in the evening breeze as they slowly cruise the streets, ducking and weaving around the hundreds of others sharing this social street time. The purr of small engines and effusive chatter of young voices on-the-move dominates these twilight hours.

We made our way at bicycle speed through the streets, around the busy round-about at the foot of Kizuna Bridge, up residential streets laden with potholes, past a trio of white oxen harnessed to each other being shepherded up the riverbank and out onto the road, where they loped along calmly beside the humming traffic, past clip-clopping horse-drawn carriages, wedding tents blaring music across neighbourhoods, a riverside Wat compound, night market place and riverside food stalls.

Parking our bikes in an allocated vacant lot, we were greeted by our host at the tent entrance in the middle of the street and made our way past the host family who formed two lines on either side of the doorway, exchanging the usual sampiah gesture of respectful greeting as we progressed into the tent. We found a table, thankfully near a large industrial fan, and sat with a group of Khmer-speaking strangers. Platters of rice and various dishes were delivered to the turnstyle in the centre of the table and we served ourselves a delicious meal of chicken, vegetables, fish and noodles. Smiles and polite nods were exchanged with the other guests sharing our table and Win taught me a little about the meaning of the ceremony, the stupas (tombs) which are usually inside the Wat grounds but occasionally seen in peoples’ yards, housing their departed loved ones and also the small golden shrines seen in every yard in Cambodia, believed to provide protection to the household and also often housing the ashes of recently departed family.

From our meal we made our way through the tent, down into the front yard of the home, which was similarly crowded with round catering tables, towards the edge of the yard where a series of square tables along the fenceline were staffed by men accepting offerings of money from queuing guests into a large round bowl, acknowledged with a chanted prayer delivered by a layman sitting on one of the tables. We signed our offering into a book before the lid of the bowl was lifted for our money to be dropped into. From here we returned back out into the street where we farewelled our host, still holding fort at the tent entrance, before making our way abreast of each other, talking all the way, back through the suburban streets.

Thankfully on that particular night we had no rain, but the monsoons are slowly evolving into a nightly ritual with alarming blasts of overhead thunder, brilliant lightning flashes igniting the night sky and cloudbursts of torrential rain tumbling to earth at heavy and high speed, turning the streets into rivers within minutes. These storms provide a brief respite from the stifling humidity until it builds up again over a few hours. They also present new and novel portraits of Cambodia which, when wet, is entirely different to the Cambodia I thought I had become familiar with. Young people frolicking barefoot in deluged streets; a shirtless motorbike driver with one hand on the handlebar, the other holding a yellow umbrella over his orange-robed passenger; an open-engined truck overloaded with cane baskets cranking through the streets, covered meticulously with a huge blue canvas as though wearing it’s own custom-made raincoat. Cycling through knee-deep water, bicycle tyres surging through ripples of white water. Arriving to destinations soaked to the bone but refreshed and cool instead of soaked in salty sweat.

Frolicking in flooded streets, Kampong Cham 28 April 2014

Frolicking in flooded streets, Kampong Cham 28 April 2014

Soon enough brown fields will be shimmering green again, dust will turn to mud, mosquitoes and the diseases they carry will make their annual reappearance, the low-lying calm Mekong waters will rage again and the yearly threat of floods which killed almost 200 people last year will threaten livelihoods and lives.  All the while, the 1.6 million Cambodian families estimated to face food shortages for up to six months every year will continue to be threatened with starvation as volatile weather conditions determine their crop outcomes.

Ploughing rice fields in Prey Veng Province, April 2014. Photograph by Sok Limseng

Ploughing rice fields, Prey Veng Province April 2014 Photograph by Sok Limseng