When the War Was Over

If that was a week in Sihanoukville, then I guess I’ve had it!  Today I start the journey home in time for work on Monday afternoon. Partly to have some down time and partly to avoid the seediness and desperation in the tourist areas, we chose to stay near the private beach of our basic but lovely accommodation for much of this week.  The experience of sleeping in a charming wooden, thatched hut to the sound of the ocean’s steady thunder was amazing.  I started writing this post around sunset, sitting under the huge umbrella shade of a frangipani tree on the beach as waves crashed and rolled towards me, on an incoming tide.  A man dressed in khaki uniform with a badge and walkie-talkie appeared under the tree, stood over me with a toothless grin staring for an uncomfortably long time, then produced a smartphone which he pointed in my direction and photographed me!

I had hoped at 4pm that my laundry would be ready for collection but the cranky local laundress scornfully informed me, without checking, that I had to come back at 5pm as per her scrawl on the ticket from a few hours earlier.  So I sat down at a bar, ordered a wine and watched the world go by some more.  The seedy, depressing world of Sihanoukville.  Testosterone oozing western men hang around in groups together, or with young (often young enough to be their daughters or granddaughters) Cambodian women.  Children wander the streets selling bracelets and sunglasses, trying to charm the westerners into paying them some attention.  Women walk along with trays of food balanced on their heads.  Every evening a young man parks his sidecar moto, then walks up and down the street knocking a stick against a plank of wood to announce that his takeaway noodle soup has arrived.  Tuk tuk drivers laze in the back of their vehicles keeping a keen eye open for any tourist who dares to wander in their general direction.  Restaurants and bars do a roaring trade to mostly young backpackers, and the wealthy westerners mingle confidently among the struggling locals.  Advertisements on the back of tuk tuks range from the Sihanoukville special of mildly veiled sleaze, to nationally-implemented Child Safe messages.

It was good to see Sihanoukville but despite it’s natural beauty I am not particularly enamoured as I am with other parts of Cambodia.  This feeling is exaggerated by the depressed hotelier who wants to talk to me at every opportunity, to either point out the wealth he’s observing (“the party boat is coming in from the island now”, as he gazes sadly out to sea) or, more likely, tell me about his hardships.  A divorce, two children, an elderly father, a dependent sister, tiny salary, no opportunities, unhappy with the boss, need for a telephone, would I like to visit his home in the countryside this afternoon?  I feel as though I am being head hunted as a potential benefactor and regardless of how genuine the need may be, I can’t bring myself to do it.  I thank him but I have other things to do today, perhaps another time?  The injustice is not lost on me.

Our beautiful private beach space

Our beautiful private beach space

A gorgeous photograph ruined by humidity before a rainstorm!

A gorgeous photograph ruined by humidity before a rainstorm!

Some of my holiday time has been spent reading and yesterday I started When the War Was Over by Elizabeth Becker.  I am not very far in but it’s going to be an informative 519 pages.  The book is best known for introducing the world to a young Cambodian woman, Hout Bophana.  In her years of research the author spent time at Tuol Sleng, a Phnom Penh high school converted by Khmer Rouge into a prison and torture chambers known as Security Prison 21 (S21).  The biggest of many schools converted in this way during the Khmer Rouge regime, close to 20,000 people lost their lives here during staged confessions about alleged misdemeanours.  The victims were buried in mass graves on the grounds.  Upon liberation (such as it was) in 1979, only seven survivors were found.  Tuol Sleng is now Cambodia’s Genocide Museum.  At least one of the survivors now sells books outside the museum, alongside beggars with missing limbs, burned faces and various other shocking deformities, in his continued struggle to exist in what appears to be a life of infinite suffering.

The Khmer Rouge kept meticulous written records on all of their prisoners and in 1981 Becker, ploughing through these records at Tuol Sleng for her book, found the file of Hout Bophana, murdered at the age of 25.  Becker converted the file, filled with love letters written to her also-tortured-to-death husband, into a biographical account of this young woman’s experience.  A Khmer language film based on the story was produced in 1994 Bophana: A Cambodian Tragedy by Rithy Panh.  As an aside, this year Panh’s latest film The Missing Picture was nominated at the Oscars for Best Foreign Language Film.  Bophana won a number of international awards in the 1990s and the Bophana Audio-Visual Resource Center in Phnom Penh, where Khmer films, photographs and sound records are collected, screened and preserved, garnered it’s name from her legacy.

Despite dying without knowing the fame her letters would oneday gain, Becker reports that Bophana “promised her husband she would stay with him to the end and then return to Cambodia as a ghost and ”win total revenge.”  She has more than fulfilled that promise.”  (http://www.nytimes.com/2005/08/28/books/review/28BECKERL.html?pagewanted=all)  I consider this as evidence of the fact that life is full of unimaginable and unpredictable twists and turns, which should never be far from any of our minds.  In suffering, the knowledge of this fact gives us hope while in prosperity, it keeps us grounded.  Without it we are all at risk – of hopelessness at one end of the spectrum and of grotesque arrogance at the other.  As I cycle alongside my translator discussing the differences between our third world and first world existences, a daily occurrence in my current work routine, abstract thoughts of the impossible twists and turns in life are ever-present.  These thoughts are what give me hope for his country and simultaneously keep me reflective about my own comforts.

From Comfort Zone to Coconut Mission

After spending more than ten years in the same job – which I loved very much – I was well and truly ready for a change.  But being slightly older, settled and happy made for a very cozy comfort zone.  One friend jogged me into action.  Prompted by regular ambiguous references to my imminent Long Service Leave, she sat me down with a prepared list of negative and positive options for me to review, edit and consider.  It was only a matter of weeks from this round table discussion, to my moving out of home and beginning the journey I am currently on.  Who knows what I would have done otherwise, it was far too difficult to get my head around actually making a move until this spur, and I will always be grateful for her persuasion.  Also for the support and encouragement of many others, from the friends looking after my mail, to those who housed and fed me when I was homeless in the lead-up to leaving town, those who donated parcels and money to Cambodia, those who have visited me here, and those who have maintained contact and friendships across the miles.

Yesterday I finished reading “Bandaid For a Broken Leg”, Australian doctor Damien Brown’s account of some MSF missions he did in Africa in the mid-to-late-2000s.  His experiences living in mud huts in compounds with tight security restrictions, in isolated and inaccessible remote locations with gunshots blasting nearby, attending to rival armed guerillas and various other incredibly stressful situations highlighted to me just how much of a “Coconut Mission” I’m on.  We live in a huge house, each with our own bedroom and ensuite, with all modern conveniences, in a town with decent western restaurants along a tourist-targeted riverside with houseboat cruises coming and going, sightseeing attractions, shops selling wine and cheese, all a few hours very safe bus ride away from the capital city.  There are few if any security concerns, which allows me to lead a very normal life and to publish this blog, albeit with some personal limitations related to patient and staff confidentiality.

Yet it has not been an easy experience.  I’ve had to learn to live and work alongside thankfully rare arrogant petulance which in a normal life I simply would not have encountered, let alone been forced to spend time with.  That is probably the biggest challenge I’ve had, and one which will direct future decisions about whether ongoing MSF missions are something I could do.  This experience is dwarfed by the strong friendships formed and great experiences shared with most expats, but may not have been so easily dwarfed had I been living in a tent or mud hut arrangement.

The work conditions are also difficult, not because of my colleagues who have been truly inspiring, but because of the physical environment.

With inadequate resources, waste management is crude at best.  Sewerage overflows settle in puddles right at the doorway of where nurses are expected to execute good infection control practices and where patients are expected to recuperate.  General waste rots and is then burned at the edge of a TB Department where patients with respiratory illness are exposed to the toxic odours and smoke.  Well fed rats and snakes live alongside us, with staff claiming that the rats are very educated because they are impossible to trap.  During one conversation about how to deal with the rats, my suggestion of poison was rejected because the corpse can be difficult to locate.  A trap was suggested, but then discussion ensued about the type of trap.  I asked if they had traps which break the animal’s neck and the translator looked surprised, replying no they get a trap with a door which traps the rat inside.  When I asked what then happens to the trapped, live rat, I was informed they are taken somewhere and freed!  An American friend and I frequently ask each other “What would Buddha do?” (shortened to WWBD), intended to chill and make us laugh during times of stress.  During this rat trap conversation my impression was that Buddha would not unnecessarily kill an animal who could instead be relocated?!

The human conditions of Cambodian people are also challenging to a protected western observer.  Homelessness is common, staff are provided trees from which to sling their hammocks, or live in the morgue with their small children who play amongst patients, visitors and beggars on the rubble-filled hospital grounds, because the salary they rely on is not enough to afford rent.  Patients regularly die from preventable illness which ravages their system before they receive a proper diagnosis or treatment.  With no back-up system in place and unable to afford the cost of health care when illness occurs, people work through their afflictions in order to continue feeding and supporting dependents who range from young children to the elderly and disabled.  When the affliction is TB, they stay in the rice fields or factories working while their disease progresses over months, only presenting to health centers or hospital once they have collapsed in severe condition.

Once they do make it to hospital, supplies are limited.  The common need for oxygen, which flows through pipes in the walls with an outlet at every bed of every other hospital I’ve ever worked in, requires heavy lifting of large tanks which arrive by truck at regular intervals, but sometimes run out requiring the use of back-up oxygen concentrators.  These machines push the ambient air through a system which filters other gases out, amassing oxygen which is passed through tubing to the patient.  Their efficacy is basic and relies on a number of machine-related aspects.  They regularly break down and have to be sent for repair by the logistics team who perform an enormous range of duties related to ensuring the program continues to function.

When patients are too sick to remain under our care they must be transferred to the “reanimation” ward, where a national policy requires all patients be sent when they are critical, so that staff with adequate resuscitation skills (but next to no equipment) are available to perform any life saving interventions.  I knew this happened but it was months before I saw how and I will never forget my shock as I looked up oneday to see a transfer taking place.  The transfer stretcher is a strip of canvas with poles sewn along both edges forming handles at both ends.  With a nurse on one end and a family member on the other, the patient was suspended in mid air and being “run” in a very bouncey fashion across the rubble with a third person running alongside, holding a bag of intravenous fluids above the patient.

Despite the very basic conditions in the TB Department, where patients lie on wooden slats of bed frames in a stark, high ceilinged, open air building, the building is nonetheless new with a modern and functional design and was not a shock to my first world system when I first saw it, despite being far more basic than anywhere I’d worked previously with the single exception of East Timor.  The same cannot be said about visits to other wards at the hospital where patients lie either recovering or dying, on crowded floors in foyers and corridors.  There is no equipment such that intravenous fluids are suspended on bamboo poles, and conditions are reminiscent of scenes from the Crimean War in Florence Nightingale’s time.  Hospital supplied food is cooked in an open space behind some buildings with massive wood piles leaned up against crooked shacks making a playground for naked children who run about in the smouldering smoke.  Huge pots are delivered by moto to each ward from this “kitchen”.

Fundamental supplies such as dressing materials, cleaning products and medicines are also supplied within a system of finite resources on a very low budget.  Things which were assumed as “the basics” in my former life are unavailable or restricted and I hear myself having conversations, even arguing for the need, relating to rubbish bags and hand washing products as I wonder where these things came from in my former job, where such thoughts had never entered my mind – things we needed were simply “there”.  An interesting manifestation to this situation is the creative, solution-seeking abilities of Cambodian people in general and of my national colleagues in particular.  It has impacted me in that for my first few months here, I saw many problems.  Now I only see things that require a solution and I usually have full confidence that if one is possible, then in admirable collaborative fashion my team of colleagues will find it!

Just as I finished writing that, Angelina Jolie appeared on my television screen in the 2003 movie Beyond Borders, co-starring Clive Owen as a doctor working for a humanitarian aid agency in various war-ravaged countries!  What an extraordinary coincidence!  Jolie put Cambodia on the map at the beginning of her involvement here in the early 2000s.  She adopted Maddox, her eldest child, after staying here during the filming of Tomb Raider.  She has since visited as part of a UNHCR convoy and she established the Maddox Jolie-Pitt Foundation, another NGO dedicated to trying to improve life in Cambodia.  http://www.mjpasia.org/about.html

Jolie has also come under fire for her involvement in Cambodia.  Following the adoption of Maddox, other westerners flocked here to take advantage of the adoption process, which led to allegations of child trafficking and resulted in changes to the rules about expatriate adoptions.  http://www.voanews.com/content/cambodia-says-international-adoptions-will-resume-in-2014/1804051.html  There are also accusations that she brokered a property purchase with a former Khmer Rouge official.  http://www.theinvestigativefund.org/investigations/international/1568/angelina_jolie%27s_legacy_in_cambodia/

This leads me to the issue of criticisms.  I’ve long since realised that there will always be critics.  No matter what you do or don’t do, you’re likely to encounter people who judge, criticise and accuse, often with the smallest if any detail.  There will always be imperfections to our actions, things can always be done another way, we will make mistakes and there are always opposing viewpoints.  But fear of criticism should never rule our actions and others don’t have to understand our journey, as they are not walking our path.  Writing a blog is also very exposing.  I previously tried to write about my experiences in another forum after a friend encouraged me to share my email writings, but I was accused of “running a sheltered workshop”, condemned and attacked by people based worlds away, driven by their own motives.  It took a lot of learning to realise that these detractions were never actually any of my business.  The encouragement and feedback that I receive from friends and family has kept me writing, but I promise that once my holiday is over, I’ll stop making daily blog posts!

Another “first” I’m having here is living under the thatched roof of a wooden seaside hut on a secluded white sandy beach with coconut palms blowing wildly and waves crashing loudly outside the window.  It epitomises Coconut Mission to an almost comical degree, on the last holiday I’ll have before ending my time here.  My biggest problem?  The large rat scurrying about on the ceiling above.  I’m not afraid of him particularly, but he is destroying the oceanic peace!  Is that a First World Problem (FWP)?  I’m not sure, but it’s another “first”, and it’s spoiling my Coconut Mission Experience (CME)!

Choose to Create

Templed Out

The other night we went to Sandan Restaurant in Sihanoukville for dinner. Very young apprentice waiters and waitresses, many quite hesitant and nervous, served us under the watchful eye of a slightly older, more confident and experienced young supervisor.  Occasionally the apprentices would approach us independently and occasionally the supervisor would accompany them to our table.  It became obvious that English phrases were being rehearsed in the corner before they approached to serve us.  One young teenager pointed to an empty plate on our table, asking “can I get you something else?” before taking the plate away.  He was immediately followed by an equally young colleague who asked “can I take your plate away?” while offering us the menu.  They seemingly realised their mistake as they stood off to the side watching us with apprehensive smiles as we tried to stifle our charmed amusement.

Throughout the meal we became increasingly enchanted by these shy, anxious, inexperienced and clearly very brave young people who despite all that, provided an excellent service with delicious food.  Unlike young staff in other establishments, it was immediately obvious that they were not accustomed to either speaking English, nor serving or communicating with Barang.  Approaching us even for such simple things as taking away an empty plate appeared to be a big deal, but a lot of mutual support was in play as they merged together after each table approach, watching the customers while engaging in quiet conversation together.  The team work between them all seemed to include encouragement in the lead-up to a table approach; debriefing after a table approach and observing their Barang customers with quiet fascination.  It reminded me of my own early forays into working life, when communicating with a boss, serving a customer, even speaking to someone on the phone, was a very stressful experience.  The many differences though, include the decent education behind me, access to opportunities, my good health and access to quality health care, secure home life and complete ignorance of the ugly or seedy side to life.

Sandan is one of a series of training restaurants associated with Tree Alliance, an NGO training street youth and marginalised young people.  According to their website http://www.tree-alliance.org/index.asp there are five restaurants, two based in Phnom Penh, one in Siem Reap, one in Sihanoukville and one in the Laotian capital Vientiane.  In Sihanoukville the local NGO M’Lop Tapang coordinates the recruitment and training of these youth who are all at least 15yo.  http://www.mloptapang.org/index.php?id=34

Our fascination with these young hospitality apprentices, where they must come from and what they must have endured in their brief lives monopolised our dinner conversation and we sensed that we were equally fascinating to them as a whole lot of reciprocal gawking prevailed throughout the night!  According to M’Lop Tapang’s website, they have worked with the street children of Sihanoukville since 2003, beginning with a plan to feed and offer safety to six homeless children who slept under a tapang tree on the beach.  As with other NGOs such as the Cambodian Children’s Fund in Phnom Penh https://www.cambodianchildrensfund.org/, this small yet important creation stemming from the heart of caring individuals amplified into a large foundation serving many families and children, reflecting the need that exists in Cambodia.

Equally interesting is the history of Medecins sans Frontieres (MSF) which was established in a similar way when a small group of doctors and journalists recognised a need for an independent organisation able to deliver impartial and effective medical aid.  The first MSF mission was to Nicaragua in 1972, following an earthquake which razed the city of Managua, killing many thousands of people.  Since then MSF has developed into a massive humanitarian medical NGO working in almost 70 countries around the world (www.msf.org.au).  In Kampong Cham where I have been living for almost a year while working for MSF, Buddhism for Social Development Action (BSDA) http://www.bsda-cambodia.org/ is a local NGO which was started in 2003 by seven Buddhist monks motivated by a vision to support and empower marginalised people through health, education and social programs.  Destiny Rescue http://www.destinyrescue.org/us/ who work to rescue children from human trafficking and sexual exploitation are a Christian organisation working in Cambodia, Thailand, Laos, Myanmar and India.  With a base in Kampong Cham, Destiny was started by an Australian man after determining that he wanted to help the poor and vulnerable, particularly children being exploited for prostitution.  Other worthwhile organisations seeking the support of Australians include Care Australia, Plan Australia, Mahboba’s Promise and Watoto, all of whom have information available on their websites about the work they do in the developing world.  Global Volunteer Network and the Bill & Melinda Gates Foundation are also worth a mention.

I admit to being skeptical in the past of charitable organisations.  At the age of 18 I sponsored a child for a short time through a well known global organisation.  Some time after I began my sponsorship, they held a conference in my home town in which a christian evangelist conducted spiritual healings.  In protest I withdrew my sponsorship and became very cynical about the “good” such organisations purported to do.  However, I have developed a broader understanding of the work that various organisations undertake for the greater good and my previous strongly held anti-religion views have become much more inclusive, whilst I still don’t support the “colonisation” approach of religions trying to convert their beneficiaries.  Personally, I feel well represented by the words of Thomas Paine, an English-American activist and author who lived over 200 years ago.

Thomas Paine

As I say goodbye to another overseas visitor heading off to the temples of Angkor Wat before flying home to Australia, the arrival of an email from a previous visitor who spent three weeks here earlier in the year surprised me.  Part of this email reads Met somebody last week who had been to Cambodia earlier this year, her comment was “We were templed out”.  Don’t think she saw much of Cambodia.  Seeing the temples of Cambodia is only one small part of the travel experience here.  If this blog does nothing else, I hope it provides information to potential travelers about the people of one of the world’s poorest countries.  When you visit a place where one third of the people have no access to clean water, two thirds have no access to clean toilets, and one third live on less than $1 per day, where NGOs are working hard to improve these conditions, look for things to do and people to meet where your presence in the country can make a small improvement to someone’s life.  You will benefit too – because there is absolutely no reason to ever be “templed out” in Cambodia.

A Parable From Paradise

The roads leading out of Phnom Penh are chaotic with many traffic sights.  Traveling south on the bus I had my camera ready and snapped many pictures, occasionally noticed by subjects who happened to realise what I was up to through the bus window and who without fail responded with an amused smile from their various interesting perches.  On the outskirts of the city urban sights began to intersperse with rural paddocks, engines became rarer while hoofed transport increased and loads of boxed and/or processed goods gave way to loads of fresh agricultural produce.  Soon the landscape became rice fields with enormous factories scattered amongst them.

The garment industry that I know of in theory is real and busy on this southern highway, and we passed through just as workers were finishing for the day.  Remorks, mini buses and trucks were lined up in the hundreds at the gates of many colossal factory complexes, waiting for thousands of passengers to make their way out of these manufacturing plants, where people spend up to 12 hours a day sitting behind machines in order to take home US$70 per month.  I’m fascinated in a macabre way, and the grisly impression is exacerbated by the thousands of people standing on crowded trucks, reminiscent of scenes from 1940s Europe.

Thousands of workers milling out of one single factory at home time

Thousands of workers milling out of one single factory at home time

Loading onto one of dozens of trucks outside a garment factory at home time

Loading onto one of dozens of trucks outside a garment factory at home time

I hope and plan to always check where my clothes come from in future, but with this many people employed in Cambodia alone in the mass production of cheap clothing, how could you ever be sure that you’re buying from an ethical company?  It’s a subject I’d had a vague interest in before seeing these workers in-the-flesh being transported home en-masse in crowded vehicles, or hearing stories from national colleagues about wives and sisters who move away from families in order to earn such small amounts just to assist in the family’s survival.  I still know very little, but the deaths of factory workers in Bangladesh in recent times highlighted the exploitation of low paid workers in the third world providing cheap clothes to the first world.  This was followed earlier this year by extreme police brutality in Phnom Penh against garment workers protesting for a rise in their salaries which are, even on a Cambodian scale, shamelessly meager.

Meanwhile on the bus, across the aisle from me, gazing out of the opposite window, sat a good friend from Sydney.  Her first job on arrival in Kampong Cham was to deliver my requests from Australia.  Some of this delivery, she had retrieved from cases waiting for me in the loft of my cousin’s Sydney home, and some she’d shopped for me, not least of all the new pair of decent sunglasses to replace my broken $6 imitations.  On her first night in town we had a busy time catching up on each other’s news.  The following day I was making a home visit to some patients, one of whom has a particularly woeful story.  Upon hearing about this patient my friend boldly and generously announced that instead of repaying her for the consignment she’d just delivered, I should give the money to this needy case.

The next day my colleagues and I sat on the clean and tidy packed earth beneath the wooden floorboards of the patient’s elevated home, as he humbly accepted the envelope from me with my explanation that a friend from Sydney wanted to ease his difficulties and had asked me to deliver this envelope to him.  With no way of earning any income, he and three elderly family members rely on the monthly food basket provided by MSF while he is on treatment for DRTB.  Treatment is due to cease in a few short months and his main concern is how, in his newly-incapacitated state, he might earn income when the food baskets cease.  I know that my friend’s generous donation will make a significant difference to their lives, at least in the short-to-medium term.  We then visited a local organisation whose role is to assist the very poorest of Cambodia’s poor in finding ways to generate income.  Hopefully measures will be put in place for this gentle and unassuming young man who has been permanently maimed by Tuberculosis.

Scapulae of a TB patient in Cambodia, highlighting the level of malnutrition which occurs

Scapulae of a TB patient in Cambodia, highlighting the level of malnutrition which occurs

Back on the bus to Sihanoukville, we drove through rainforests, rice fields and villages for many hours as the landscape became increasingly tropical with wide brown rivers, waterfalls and jungle-covered mountains all passing us by.  Arrival in Sihanoukville after dark was marred by tuk tuk drivers quoting us treble the real cost of a trip to our accommodation.  Combined with my tired and indignant response this caused a bit of a stir among the many drivers who milled around vying for our custom.  While the combination of desperation and “normalised” corruption alongside naiive and wealthy foreign custom make this an understandable gig in the tourist areas, being targeted unscrupulously is still highly irritating!   The quiet, humble and amused older man sitting off to the side eventually won our custom and we made it to our beachside bungalow.  The bungalows are halfway up a rubbled, pothole-ridden hillside driveway which the driver stopped at the base of, and said “walk”!  Laughing at the instructive English, we dragged our cases up the hill, miraculously making it in the dark without injury.

The ongoing issue of brazen tuk tuk drivers in a quiet off-season in the tourist areas (thankfully not in Kampong Cham!) is an interesting experience.  In Phnom Penh a few weeks ago I was sitting in a tuk tuk, about to disembark at the bus station when another driver called to me, did I need a tuk tuk?  Do I look like I need a tuk tuk I said silently as I tried to ignore him before realsing he required a reply or it would not stop!  In Sihanoukville the situation is equally dire.  Yesterday as we disembarked from and paid one driver, another driver approached suggesting his tuk tuk services.  Walking along the street another driver asked how we were and when we replied in kind, he shouted jovially, his feet hanging over the side of the back seat “not good!  No customer!”.  His good humour won him our custom but we weren’t ready yet so he quietly kept an eye on us as we window shopped down the hill to the beach, then back up the hill again, occasionally driving by and beaming us a happy smile.  Once we were ready we found him and as we were about to board, another driver who neither of us recognised approached, insisting HE had spoken to us first!  We insisted we would only go with the man we knew, which elicited a mouthful of Khmer attitude as he walked away in disgust that his bullying had not worked on us.

Child Safe sign outside a Sihanoukville shop

Child Safe sign outside a Sihanoukville shop

A bright and sunny day led us to the beach underneath our bungalows where a private strip of white sand and blue ocean kept us content for most of our first day in Sihanoukville, followed by the quick visit into town before cocktails at a bar recommended for it’s sunset views.  Most of our conversation throughout the day was dominated by the topic of human interplays when wealth (tourists) meets poverty (locals).  Our observations included overbearing and cantankerous tuk tuk drivers, timid and reverent waiters, elderly white men with child-like Asian women, jovial sellers, hotel staff keen to practise their English and tell us their stories of hardship, backpackers and touring westerners of all varieties.  This town, where the children don’t seem to notice us, is extremely different to the agriculture-dominated lifestyle of Kampong Cham where westerners are rare enough that the children shout English phrases from afar when they see us, but it is also incredibly beautiful here.

View from tourist-hotspot, Serendipity Beach

View from tourist-hotspot, Serendipity Beach

Daybed at our private stretch of white-sand

Daybed at our private stretch of white-sand

In contrast to yesterday, today is wet and overcast so we have come to The Starfish Project for a late breakfast, and will head to Central Market for a look before probably spending a chunk of time inside a bar or the cinema.  Sihanoukville, like other tourist attractions in Cambodia, has many non-government organisations involved in trying to pull marginalised and uneducated people out of their poverty traps.  The Starfish Project is one such local organisation, where I am writing this from a lounge chair at their cafe, filled to the brim with a homemade sandwich.  They provide employment opportunities for young disabled Cambodians.  Their philosophy and name come from a beautiful parable, italicised below, which is very relevant to anyone traveling to a third world country who struggles with the issues that I constantly refer to and struggle with.

A Buddhist monk was on the beach with his apprentice the day after a fierce storm. Thousands of starfish had been washed up and stranded on the shore. Stooping down, the monk carefully lifted a single creature and returned it to the sea. His young apprentice wondered aloud why his master bothered to do this when it made little difference to the mass of helpless creatures. As they walked along, the monk picked up another single starfish and replied, “It makes a difference to just this one.”

http://www.starfishcambodia.org/

Cycling in the Countryside

Yesterday four of us (2 Australian, 1 French and 1 Slovakian) cycled a 70km journey through the Cambodian countryside. We had two aims. First, to experience the fairytale scenic villages along the shores of Kampong Cham, including a visit to a beautiful temple complex. Second, to visit a young patient who was sent home from hospital last week, in very bad physical condition, to very dire living conditions, but with a caring and attentive family who may possibly be her saving grace.

Where I come from this patient would receive intensive medical and nursing care and have an excellent prognosis. Unfortunately due to her birth fate, she probably won’t see her 26th birthday. After a prolonged hospitalisation, we have developed a relationship with her and some of her large extended family. We wanted to visit her for a clinical review but mostly to provide her with some hope. She teeters between dying (the assumption our remote advisers have made about her fate) and some hope for survival (our admittedly biased sentiment for her). She regularly asks is there hope and we have truthfully told her that there is. She also regularly darts between crying uncontrollably and making comments such as that she is no longer afraid and other references to the death that seems imminent. Despite having a good appetite, due to her clinical condition she weighs 23kg.

It was my fourth visit to her home, approximately 30km from town in a picturesque but very poor rural riverside village.   The first three visits were work related and I attended in order to follow the case through from hospital to home, in a purely supervisory role with the nurse employed to undertake this work.  The first visit was to identify and recruit a Home Based Care (HBC) Nurse to provide her Direct Observed Treatment (DOT). We located a trustworthy and respected Village Health Volunteer (VHV). Each village in Cambodia has two VHVs whose job is to identify TB suspects and refer them for diagnosis; to follow up TB patients; and to provide regular health education in the village about TB. The purpose of this work is to optimise early diagnosis and treatment, one of the most important interventions in reducing the spread of TB. We then returned to train him about MDRTB (which remains rare enough that the VHVs are not usually involved with this). We then discharged the patient on Wednesday and traveled to her home early Thursday morning to meet the VHV at her home and supervise / advise on the first home DOT, as well as to ensure that she had all the materials needed to care for her wounds, etc.

The materials for her wounds are the most basic, just gauze and tape with some trials of other available dressings which will eventually deplete. Her wound nurse is her mother, who has an excellent clean technique and is far more attentive than any nurse she could have asked for. This week some discussion around dressing materials included a suggestion that items might be provided which could be washed and re-used but after attending her home on the riverbank where her mother does laundry in the muddy brown water of the Mekong, this idea was immediately quashed. Having only ever nursed in Australia and England it is impossible for me not to make comparisons against the places I am familiar with, where wound care specialists, cutting-edge dressings and other life saving interventions are available, ensuring a recovery back to full health.

In all of my experiences here, this case has most starkly highlighted the difference in value of life based on where you happen to be born. From the safety of the First World, despite feeling concern for people, I always felt a detachment from the little I knew of Third World plights. I’m not detached from this beautiful, intelligent, humble and grief-stricken young woman or her caring, attentive and grieving family. Yet I am removed enough from their situation that it is difficult to imagine the oppressive poverty that forms the basis of their existence.  These thoughts play havoc with my imagination as I observe the pea-soup-coloured mud around the base of their elevated wooden shack, envisaging it turn to a large muddy lake once the rains arrive in full force.  How will the children ever leave the house without drowning?  At best they must be exposed to all kinds of bacteria and parasites living in the mud, not to mention the ideal breeding ground it makes for mosquitoes.  How will I be able to visit her – the house where she lies on wooden floorboards in the middle room under the tin roof will seemingly be inaccessible?  Are the holes in the tin roof too small for raindrops to fit through, or is she going to be rained on from above?  What about when the rain sheets in at an angle as it inevitably will during tropical storms – will the gaps in the wooden walls expose her to the rain?

Questions galore for this first world brain as it sits on one of the borrowed red plastic chairs supplied for our visit just before lunchtime.  We are surrounded by at least twenty family members seated on the floor before us, watching and listening as I speak on the phone with my translator, then pass the phone to the patient lying on the floorboards smiling up at us, or her mother.  We pass the phone back and forth, smiling and each attempting a few words in the other’s language as we wait for a full translation.  Children stare at us, adults too except that their eyes flit away quickly before we catch them.  Many smiles are exchanged and bamboo-encased Khmer cake of sticky rice with beans is brought to us with bottles of cold water.  Halfway through our Khmer cake we realise that noone else is eating and then we remember that it is Ramadan and they are all fasting!  We stop eating and wonder if we’ve committed a faux pas, or if it’s okay to eat if it’s known that you are not observing Ramadan?  It is too late to worry now, and we continue to receive many smiles so we must not have done anything too offensive, but we stop eating and utter “Somtoh” (sorry), which is accepted with gentle nods.

Between assessing the wounds, watching Mum re-dress them, the doctor performing a medical assessment, and a few other work-related issues, we also exchange some social conversation.  Via telephone translation the patient tells us that she would like to thank us very much for visiting her, that she was very excited to see us and that last night she couldn’t sleep for the anticipation of our visit!  As I pose for a photograph with her mother, she leans in and knocks her head against mine and my colleagues sigh in hilarious unison.  We assure everyone that she seems much better than she did in hospital, she tells us how happy she is to be home again, we admire the many children surrounding us, they ask us did we really cycle all the way here and are we sure we didn’t park our car up the road and cycle only a short distance, they laugh at the many sweats we are oozing, and we leave feeling as though the visit was well worthwhile for everyone’s sake (not least our own).

Back out onto the bumpy, hole-ridden road which switches regularly between bitumen, sand and mud, we cycle back to Kampong Cham.  A journey which began with conversations about how fantastic a cycling holiday through Cambodia would be, ends with sore thighs and bums and far less enthusiasm about mounting our bicycles ever again!  We land at Destiny for a late and well deserved lunch, where the sight of our soaked and dusty bodies and the noise of our gregarious, adrenaline-driven laughter about how ridiculous we look and how hungry and sore we feel, immediately lowers the tone of the establishment.  Thankfully noone seems to mind and an hour later, stomachs filled, muscles rested and recollections of a great day rehashed enough for now, we head home for showers and solitude before we spend the evening sipping wine on the balcony together, rehashing the thrill of a great day some more while rain lightly falls on the intact roof above us.

Cycling in the Countryside: Photographs from our day out

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Rice and Resistance

When it’s time to plant and grow the rice, it’s time for Barang to take a lot of photographs ~ Me, July 2014

Rice planting in Tboung Khmum Privince, July 2014

Rice planting in Tboung Khmum Province, July 2014

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Our current pre-language-class routine happens at the end of three work days per week.  One, two or three of us meet three of our young students at the office, wander past another location to meet the next two (temporary) students, then wait at our usual pick-up point for Chom to arrive in his tuk-tuk.  This area is always busy with moto-dups (motorbike taxis) and tuk-tuks who initially waved or called to us for custom but have come to know we have an arrangement in place so instead they now banter with us, mostly in Khmer so we have no idea what’s being said but it appears to be quite amusing with lots of smiles and laughter exchanged.  When Chom arrives the children pile in while the adults cycle alongside or in bouts of energy race his tuk tuk, to the hilarious squeals and shouts of excited children.

For the past few weeks murmurs of more students have become a part of this experience.  It started with one of the homeless girls talking to me at length in Khmer, which I knew due to the nervousness of her behaviour related to a request of some sort.  When I returned with my translator she said in the presence of an agitated grandmother who was clearly concerned about the subject, that some other children want to learn English with us.  I asked her to find out how many and said we would discuss it once I knew.  When she didn’t broach the subject again I promptly forgot about it.  But it has been approached another way since then, with children turning up at the meeting point hoping to get a seat in the already overcrowded tuk tuk.  Last week we agreed to take on two temporary extras who are in town due to an ill father.  But they are by far not the only interested extras and as we approached the meeting point last night, a mother with her young daughter was waiting for us.  It was obvious what she wanted but not so easy to explain to her why I was turning her away.  Among the crowds a woman with very limited English tried to act as translator but combined with my limited Khmer we were not in sync at all.  When Chom arrived he explained that the girl is eight years old and has never learned English before, but her parents would like her to and she is only one more student, the mother says she can fit on the tuk tuk.  The little girl looked shyly at the ground as I explained via Chom that we could not bring her but that I will speak to her mother with my translator tomorrow.  Who knows what arrangement we’ll put in place, but I sense a monster growing!

More surprising than the extreme desire for English lessons is the number of people around me who are homeless.  It’s not possible to pick them the way you can in a western country.  They’re clean and well presented with no visible clues as to their desperate circumstances.  But the circumstances are usually shocking, at least to me.  Even more so is the vulnerability this creates, which I’ve talked about previously.  Last night the newly formed Child Protection Unit announced the launch of their website (https://www.cambodianchildrensfund.org/cpu/) amidst reports of a sting operation in which an English school founder was arrested for allowing paedophiles access to his students.  http://www.phnompenhpost.com/national/school-boss-arrested-sting  This is an extreme example of the Orphanage Tourism issue I’ve mentioned before.

Meanwhile the English lessons continue to go well, with all of our students in various states of enthusiasm beginning to speak small amounts of English with us.  We mix the lessons up and have a combination of chaotic game-playing mayhem, to quiet reading, spelling, listening and speaking.  It’s very interesting to find yourself reading an English story book to 17 children, ranging from 6yo to 16yo, listening intently to you as though they know what you’re saying when you know they actually don’t.  Thankfully we have some decent short and rhythmic stories with great illustrations, which Bea brought back from Australia on a recent trip home.  Perhaps the pictures or the rhythmic repetition is what mesmerises them so?  Teaching directions the other day, Bea had 17 children lined up behind her, imitating both words and actions as she shouted “left” and threw her left arm out, then “right” and threw her right arm out.  This was imitated by 17 young followers, including a six year old who was eagerly throwing both arms up simultaneously as he shouted at the top of his voice, causing much hilarity among the crowd until I stood behind him and took control of his little arms to show him the meaning of the activity.

Since I began my job here nine months ago our program has diagnosed at least 18 patients with Multi Drug Resistant Tuberculosis (MDRTB), which is a complicated and very difficult disease.  Each month the team, including doctors, nurses and social workers, meet to discuss the ever-changing list of MDRTB patients under our outpatient and inpatient care.  These meetings are  intriguing, partly because of the clinical issues but mainly (for me) because of the social situations discussed, which are so normal to Cambodia and so abnormal and horrifying to me.

The first thing diagnosis of MDRTB does to a person’s life, apart from the often-severe physical ailments, is render them home (or hospital) bound.  This restricts (at best) or eliminates employment opportunities which, in a country where 20% of the population earn less than $1.25 per day, threatens food security and associated issues such as shelter and basic family concerns related to money, for example paying school fees or repaying debt which is such a common feature of Cambodian life.  These things are an ever-present concern for those able to earn money let alone those rendered unemployable for prolonged periods of time in a country where there is no back-up system.  It is therefore very common for MDRTB patients to have very stressful home situations with parents, children and others pressuring them or having to leave to find work as the usual breadwinner can no longer provide.  Separation and divorce are also common in this group.  This in turn leaves patients who are in need of care, alone or in very challenging situations, sometimes caring for others when they are in need of care themselves.

One of our patients is a man in his 40s with Rheumatoid Arthritis which has deformed many of his joints.  Combined with MDRTB, this degenerative condition which is also very painful has resulted in the patient being unable to earn any income.  His only pain relief is Paracetamol.  His back is bent, his hands and legs are deformed, with further deformity over the coming years a medical guarantee.  Every month we discuss his circumstances which entail a sick wife who has left to live with extended family so that she is not a burden on her unwell husband, who she is unable to care for.  Every month his main concerns are the illness and absence of his wife, the worry of being so poor with no way of earning income.  Every month ideas are spouted about who may be able to provide a little support to him.  Every month nothing changes in his situation.  For the moment his TB diagnosis means that he receives a monthly food basket, so he is able to eat.  I have no idea what will happen once he is cured, which is thankfully six months away yet.

Another patient regularly discussed is a young woman who presented to hospital unconscious with a large mass in her abdomen.  Investigations found disseminated tuberculosis – meaning the bacteria had spread throughout her body.  It was in the lining around her brain, in her bones, her joints, her intestines, the lining around her lungs and in her lungs.  The meningitis rendering her unconscious led to permanent deafness.  Once she commenced treatment her condition improved but she is on long term treatment for DRTB which causes joint pain, nausea and vomiting and she often wants to stop the treatment, meaning our team have to work hard to provide support and encouragement to her and also to the Home Based Care Nurse, a village volunteer responsible for administering her daily medications.

A middle aged man who lives at home with his wife and a son who suffers from psychiatric illness experiences general body pain, dizziness, poor sleep, hearing loss, hallucinations and gynacomastia (growth of breast tissue) due to the severe medications he is required to take to kill the DRTB in his body.

A young woman has fever, shortness of breath, loss of appetite and conflict with her mother who has a lot of debt and was relying on her daughter as the breadwinner.

An HIV positive middle aged woman diagnosed recently with DRTB refuses to attend for treatment because she has young children.  She has to be in the rice fields everyday or her family will not eat.  So we discuss ways to support her so that she will agree to receive treatment.

A middle aged man has had to stop his teaching job for at least a year, but thanks to an official letter from our doctors to his employer, he continues to receive his base salary until he can return to work which is one positive light in the sea of darkness.  When he first presented to us, he was a bright vivacious person but since commencing Cycloserine, one of the drugs used for DRTB, which is often dubbed Psychoserine due to the well known psychiatric disturbances it causes, he has become serene and quiet, reporting regular nightmares.

When I learned about the severe side effects of DRTB from books and articles in Australia where DRTB is a very rare occurrence, I never imagined the associated social ramifications this causes on populations already challenged by poverty, low literacy and limited protections against extreme privation.  With my first world brain I see the patients as having “many problems”.  But “problem” is not a word I ever hear my Cambodian colleagues utter.  They use phrases such as “we will need to try and find a solution”, always looking towards a fix and never focussed on the obstacle itself.  When I told a colleague yesterday that this has been an observation in my time here, he replied “yes, because we always have to think about how to fix things, because Cambodian people have a lot of experience with finding solutions to many things and I think in your country, you have less experience like this”.  A very insightful reply!

Information about MDRTB can be found here: http://www.tballiance.org/why/mdr-xdr.php

Direct Observed Treatment in a patient's home: MSF Nurse, Village Health Volunteer and a family member discuss the medications

Direct Observed Treatment (DOT) in a patient’s home: MSF Nurse, Village Health Volunteer and a family member discuss the medications to be administered daily to the home based patient.

TB patients await their doctor's appointment, Kampong Cham Hospital July 2014

TB patients await their doctor’s appointment, Kampong Cham Hospital July 2014

Below are some photographs of typical Cambodian homes.

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Hammocks on the Mekong

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A handsome couple who happily posed for a photograph today on the banks of the Mekong in Kampong Cham

In Cambodia alone there are thousands of hammocks slung between trees on the shores of the Mekong.  I see them all the time, many positioned in fairytale-worthy locations.  But there’s always poverty.  I am sure it gets boring hearing this from the First World where I am well aware how difficult it is to envisage the scale or impact of such things because we just don’t see or experience it.  The last thing I want to be is boring.  But I feel confronted everyday by the levels of hardship experienced here.  Perhaps no more so than the malnourished 14 month old dying of AIDS who we met yesterday.  Fading in and out of consciousness, the size of a wasted-away two month old, bones protruding through skin at every joint, lying on a wooden bed base beside a very healthy looking older sibling who stared at us in fascination while the elderly grandmother sat quietly touching her grandbaby lightly, her face lined with age, worry and sadness.  We spoke to her very briefly and she said that the children’s parents had both died.  We were there to visit one of our students, an HIV positive orphan hospitalised with an acute lung infection.  One of her fellow pre-adolescent orphan “sisters” was with her, sitting serenely surrounded by sick children.  Aware of their diagnosis by now, I wonder what goes through their mind when they see these unwell, dying children, all victims of the same virus that has them in it’s grip.

Yet despite the often-overwhelming despondency there are always plenty of laughs and positive or cheerful moments to be had.  My translator has encouraged me to take photographs whenever I want because “usually Cambodian people don’t mind.  Because your people have a good reputation.  We don’t think you would use photographs in a bad way and we think that you are generous and you want to help”.  He’s proven to be more than just a translator, he’s a wealth of knowledge and understanding, about both his own nation and culture as well as the many western cultures he has worked with over the years.  More of a cultural consultant, than a mere translator.  Recently a friend returned to Cambodia from Australia, carrying with her a book of Australian slang for him because he is always throwing unexpected Australianisms at me, eg just before a meeting we had to attend recently “wait here for me, I just have to go to the dunny!”  Then a pause while I process what I just heard, followed by a round of laughter, then a check with me “that’s correct, isn’t it, dunny?”  Yes!  But where on earth did you get it from?!  And he laughs his way to the loo while I explain to the room-full of English-speaking but confused Khmer colleagues what just went on.

One of my favourite western restaurants in Kampong Cham is Destiny, who serve gourmet sandwich / pub style food.  This morning after 3 hours cruising on bicycles through rural lanes with my Australian and Slovakian housemate-colleagues, we landed sweaty and hungry at Destiny for a late breakfast.  The manager was there and happened to mention that this cafe belongs to Destiny Rescue, which I had not heard of, training victims of human trafficking.  I knew the staff came from disadvantage but hadn’t realised the magnitude.  So I spent a little time browsing their website this afternoon.  It is interesting and informative, and they are clearly another organisation worthy of support.
http://www.destinyrescue.org/aus/who-we-are/about-us  There are an estimated 27 million slaves in the world today. Destiny Rescue is committed to liberating those enslaved and restoring those that have been abused. Already serving in five nations, Destiny Rescue will keep expanding to reach even more children.
The manager sat near us at breakfast and we chatted with him intermittently in between talking amongst ourselves.  Later in the day I returned alone to use the wi-fi and he approached me for more information on how to contact us because he was speaking about us to a doctor working with Destiny who would like to meet us!  Things like this happen all the time here – expats seek other expats out, or NGO involved people network with others doing similar things.  I’ve been offered the chance to volunteer with three other NGOs once my MSF mission here ends and hope to coordinate all three somehow in order to return and spend more time here.

Last night, in fear of rainfall all evening, we took 16 children to the Night Market for a meal/treat.  Two homeless girls, two siblings staying in hospital while their father is very ill, one son of a staff member and 11  of the 12 orphans (because one is sick and had to miss out).  Eight of us piled onto four bicycles in true Cambodian style, and doubled our way to the market, with children laughing excitedly all the way.  The orphans, also doubling each other, met us soon after.  Combinations of fried rice, ice cream, fruit soaked in sweetened condensed milk and cans of soft drink were ordered, all outside of our comprehension of what was being said to the server, amidst chatters of excitement and interspersed with brief shouts in English of “thank you!”, “delicious!” and “happy!”  It was clearly a treat, confirmed by the Orphanage Director who said that this morning the children were full of talk about their trip out.  In my wildest dreams I could not have imagined this block of rat-infested broken pavement housing grubby outdoor stalls, selling $1 meals, cheap clothes (which a local told me I should not buy because they are over-priced!) and with a few rusty looking childrens’ rides and some trampolines, would be considered a “treat”.  But last night I learned that it is!

Meanwhile Tuberculosis continues to teach me daily lessons that in my wildest dreams I could not have imagined possible.  Many TB patients are memorable for different reasons.  In ten years of working with TB in Australia I remember every one of my patients well and with fondness.  Some of them are alive today and far too many of them have died prematurely (thankfully, unlike my Cambodian patients, never from TB).  A few years ago we had a patient from a TB-endemic country who had been told by Australian doctors that he probably had abdominal cancer, which appeared as tiny nodules which had riddled the mesenteric lining of his abdominal cavity.  Biopsies were taken but the doctors, from a first world country where TB is rarely considered high on the list of probable diagnosis (except when doctors have experience in TB-endemic countries), were fairly convinced of an aggressive and late stage cancer diagnosis which was also supported by the clinical presentation of severe weight loss among other symptoms.

Having only recently married, he and his wife returned to their home country to spend his last days with his parents and family.  However, when the test results for TB returned positive eight weeks later (the time it can take for TB bacteria to culture), his diagnosis was altered.  He suddenly had a curable disease.  When he returned to Australia and met me for his first TB treatment appointment, he had been through a terrible ordeal, facing imminent death, and could not believe his stroke of luck that the doctors had gotten things so wrong.  He was also a very interesting case having commenced his TB treatment overseas, in a poor country where health care is fully privatised.  His TB drugs had been free via WHO but his doctor had also recommended various additional treatments which he had to pay for.  He produced a brown paper bag filled with both anti-TB medications and various extra vitamins and supplements, telling me in detail why he was on the various extra medications and very reluctant at first to consider ceasing these added drugs because his doctor had so convincingly recommended them (something his new doctor successfully addressed).  Most surprising of all to me was the way he pointed to each drug and told me exactly how much each individual pill had cost him!

This was my first exposure to the Fixed Drug Combinations (FDCs) used via World Health Organisation, where all of the anti-TB molecules are combined into a single pill.  The purpose of this is to reduce the number of pills patients are required to swallow.  For example, the standard TB regime begins with four different anti-TB molecules, which when administered as four separate pills can amount to 15 or more pills (depending on the patient’s weight).  When an FDC is used, this number reduces to 3 or 4 tablets per dose.  This simple measure increases patient adherence to treatment.  In Australia we have the resources to increase adherence in other ways and we have not moved towards using FDCs that I am aware of, but in the developing world where resources are so scarce, simple measures such as this are important.  I have since seen FDCs in both East Timor and Cambodia, and according to a TB Alliance report, 20 of today’s 22 highest burden TB countries (of which Cambodia is currently listed as number 22) now use FDCs.  When I presented an education session on TB recently I showed a photograph of an outstretched hand with single molecule TB medications sitting on it.  One of  my very experienced nursing staff said to the group “these are the old fashioned medicines we used to use, but now we have FDC so many of you will not recognise these tablets”.  I countered with the information that in Australia we still use these single-molecule tablets, to which they all chattered excitedly in Khmer before one of them said to me in English “Australia is supposed to be a developed country!”, clearly fascinated that in this single matter, Australia is not as up to date as Cambodia!

This week’s memorable patient encountered myself and a small team (driver, social worker and nurse) in her village this week.  We drove about an hour along dusty bumpy roads following the river south, sighting a group of tourists on race bikes in one remote location, but mostly seeing only Cambodian rural scenes of coconuts on sale from the back of shoddy wooden trailers attached to ancient motos, pyjama-clad women transporting produce on trays balanced atop their heads, horse and ox-drawn carriages filled with various agricultural produce, etc.  We went there to locate a Home Based Care (HBC) Nurse for a hospitalised MDRTB patient who is almost ready for discharge, once we find someone who can administer his Direct Observed Treatment at home.  At the patient’s home we sat and spoke at length with his sister about the treatment, plans for his return home and the need for a Home Based Care Nurse.  She had already nominated someone and confirmed to us in person that this woman would be competent and trustworthy to ensure all doses of the lengthy and difficult treatment were administered properly.  My nurse then called the nominated person who lives close by and she arrived moments later on her moto.  She sat with us as the team talked to her about the training she is required to attend with us and some of the difficulties she will face as the person responsible to administer 18 months of daily treatment which causes nasty side effects and guarantees bouts of depression and anxiety in the affected patient.  Despite not understanding (except for periodic translations given by the team when they were not involved in the conversation), I could see that we had found a good and honest HBC Nurse here.  She then offered to show us where she lives, as this is needed for the “surprise visits” we conduct as part of our way of monitoring treatment progress.

On arrival at her home we were offered seats and I looked around noticing pharmacy stock in glass cabinets, customers standing outside waiting for something, and very clean and shiny surroundings.  Then a very thin woman of about 40yo appeared in a beautiful pair of blue pyjamas, her hair in a bun and sat with us.  It transpired over the next quarter of an hour or so that the HBC Nurse runs a small private, legal clinic-pharmacy from her home, with her husband.  I say legal because some home based set-ups here sell drugs illegally – such as “black market” TB drugs which are supplied to the country via World Health Organisation and always available to TB patients for free, through a reasonably tight system.  Except that occasionally there are stories of patients purchasing these drugs which have found a loophole into the black market.  Such stories are always reported to the Public Health Department whose role it is to address such problems.

The blue-pyjama’d lady told us her story.  She is currently staying at the small clinic because she is not well and noone knows what is wrong.  When we asked her problem, she reported weight loss.  Before she weighed 42kg and now she weighs 36kg.  The implication was that this was her only problem.  Many things cause weight loss, so with TB in mind we asked some more questions and a lot more information was supplied.  Yes, she sometimes has night sweats.  Yes, she sometimes has fever, and also has “fever in her stomach”.  The HBC Nurse said “it can’t be TB because she does not have a cough”.  To which my nurse explained that extra-pulmonary TB patients do not cough (unless they concurrently have pulmonary TB).  Going back to her abdomen, we asked if she can feel any nodules in her abdomen?  “Mien!”.  (She has these).  I suggested that it sounds like it could be mesenteric TB, but that she needs to see a doctor for a proper diagnosis.  Only then did she mention that actually, she does occasionally have a cough because she has been unwell on and off for 18 years!  She has seen many doctors  and noone has ever diagnosed this chronic cough which comes and goes.

In Australia where health systems and social structures are functional, it would be almost impossible for someone to be unwell with symptoms, no matter how rare, and not receive some form of diagnosis via a referral system to specialists etc.  The chronicity of TB in Australia in my experience was perhaps up to six months at a push – usually much briefer though, before patients sought medical advice and received an accurate diagnosis.  I learned the theory around tuberculosis bacteria’s ability to endure in the patient’s suffering body for many years, during my studies in the 1990s.  Historically, prior to a good medical understanding of TB or the introduction of TB treatments as recently as the 1940s and 1950s, TB had three standard outcomes, being:

1.  The TB victim would become ill and die (usually infecting others during the illness);

2.  The TB victim’s immune system would manage to ward the disease off over time, or;

3.  The victim would spend years suffering the chronic effects of wasting away with a chronic cough, fever and other symptoms.
These chronic cases, during their infectiousness are considered to infect up to 15 other people for every year that they are unwell
with infectious TB.  (Not every case of TB is infectious, however).

When I learned this information it was presented as something which no longer happens because we now understand the disease, have (albeit imperfect) diagnostic methods which can confirm the bacteria’s presence, and treatments are available and free.  However, these outcomes do continue to plague many people, in places where health systems are weak, health literacy is minimal and resources are scarce.  I first encountered the enduring ability of TB in East Timor where I met a number of patients who had suffered undiagnosed symptoms for ten years or more before receiving an accurate diagnosis.  Despite knowing what I thought was a lot about TB, this experience astonished me.  And this week, in absolute amazement, I feel sure I have encountered it again, in my longest-suffering patient yet!  She agreed to travel to Kampong Cham this coming week, with the family of our hospitalised patient who will attend our clinic for contact tracing.  I fully expect she will be hospitalised for investigations and confidently predict that her 18 years of chronic ill health will suddenly dissipate thanks to a six month course of TB treatment!

**  Watch this space for an update! **

TB Patient goes for a stroll with his chest drain, Kampong Cham July 2014

TB Patient goes for a stroll with his chest drain, Kampong Cham July 2014