Chasing Buffalo and Other Cambodian Pursuits

A few weeks ago Paint, the disabled carpenter I’ve talked of, called my number while my translator was on holiday.  Conversation was not possible and so upon Win’s return we called him back.  A short conversation ensued before a pause for translation.  Poker-faced, Win stated “Paint is not home at the moment because he has gone out to collect grass for the buffalo.  He will not be home until this evening”.  Given the grass-collecting I see everyday, it was inevitable for this line to be thrown at me eventually I suppose.  Such a foreign activity spoken so matter-of-factly, and about a man who walks on his hands, floored me initially before the absurdity made me laugh.   Buffalo care is a perfectly ordinary pursuit to the average Cambodian, even one as educated and western-seeming as Win.  In fact, buffalo ownership suggests a certain level of wealth as they are valuable animals.

Oneday recently a driver, nurse, social worker and myself were driving through a very remote area when a man wearing only a traditional checked kramar wrapped around his waist like a skirt, appeared across a field, chasing a buffalo calf which was threatening to run into his rice field and trample it.  As we drove by I couldn’t get my camera quick enough (see the first photo below) and my colleagues were far more amused at my alarm as I grappled for the camera with my eyes glued to the scene, than at this amazing sight.  Once an admittedly less-than-ordinary photograph had been obtained they explained that buffalo have to be kept out of the rice fields which is why we see so many people collecting grass at this time of year.  Once rice planting begins the animals are moved from fields into yards and under houses.  This is only one example of the daily fascinations I experience in Cambodia while my local colleagues, many of whom have worked in the fields, take absolutely no notice.

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Collecting grass to take across the river

Collecting grass to take across the river

Buffalo have many uses

Buffalo have many uses

Collecting Grass, Cambodian-style

Collecting Grass, Cambodian-style

Working for almost a year now with Tuberculosis in a Third World country, you would think that the situations I am constantly exposed to would no longer surprise me, yet they continue to do so.  My most heart wrenching patient at the moment has developed permanent hearing loss and permanent disfigurement in her twisted-up hands, caused by the medications being used to kill her drug-resistant TB.  Weighing just 34kg, she has onset of severe nausea as soon as the drugs are delivered to her bedside each morning (who wouldn’t?!).  Patients dying from cancer without pain relief, their diagnosis nothing more than an educated guess once other diagnoses (including TB) are excluded.  Children with spinal damage caused by hard physical labour in the rice fields.  Old people permanently bent at right angles due to decades of stooping in the fields.  Unrelenting hunger and the malnutrition that trails it like a shadow.  Babies who weigh a third of their recommended weight.  This week as I cooed and cuddled one such “TB Baby” her father asked me “If we were to offer her to you, would you accept?”.  Having never known such hardship, I cannot attempt to comprehend the kind of suffering that would lead someone to consider this question – even if it were rhetorical – of his clearly very-loved youngest child.  How Win translates these things to me so straight faced I don’t know but he is as affected as I am by the desperation, which prompts many interesting conversations between us.

I doubt that adversity comes any more magnified than for a homeless widow co-infected with Hepatitis C virus, HIV and Drug Resistant TB.  Looking tearfully in my direction she told me that she doesn’t know where she can live because her only housed relatives are 84yo and 87yo and “very poor”, so if she moved to live with them she would not have any food.  She also told one of my nurses that if we commenced her on the drugs for DRTB and she experienced side effects, then she would immediately stop the treatment.  She prefers to die than to endure an ounce more suffering.  But the treatment for DRTB is guaranteed to increase her suffering, as nausea, dizziness, joint pain, vision, hearing and psychological disturbances are all common enough that she is unlikely to avoid at least some of them.  This is without mentioning any of the interactions between HIV medications and TB medications or the various symptoms of all three diseases.  These factors combined make our medical and social management of her disease very complicated.

The little guy at Shackville remains immobile due to the bone of his lower leg growing through his amputation stump, causing pain and making his prosthesis unwearable.  Last week the stump became infected and he was hospitalised for five days.  Ironically, given my previous ruminations, with his mother’s permission I photographed the stump and emailed a brief paragraph with photos to a friend in Sydney with orthopaedic contacts.  The next day this reply arrived: “I showed to our ortho guys who didn’t think this was an emergency but said it should be revised mostly as he isn’t walking or using his prosthesis. They said it could be revised with a fat pad“.   I answered: “Thank you SO much.  This gives me something to work with – I will encourage Mum to come with me to Handicap International and see if I can advocate for him to get a “fat pad” for the prosthesis.  If they say no, then it sounds like something I might be able to create myself using sponges or something similar.  I will let you know what happens.” A very short time later I received this response: “Bless you but the fat pad means an operation!  Sorry I wasn’t very clear!  The orthopaedic guys would need to shorten the bone then make a flap to come under the end with lots of fat in it“.   That’ll teach me to assume I know what someone is taking about!  This is advice his Mum was told around the time I met her, before being informed more recently that they will not act “until the bone stops growing”, which is another 15+ years of pain and immobility!  This cannot be right and I plan on advocating for them somehow, but am nervous about the kind of advocate I make, going by current evidence!

This week some European friends were in town and I hooked them up with Chom, my tuk tuk friend who acts as our driver-translator in the English classes at the orphanage.  Oneday I invited them to visit my workplace as they were very interested in some of my anecdotes.  As arranged, Chom’s tuk tuk appeared laden with Spaniards.  Fluent in English, Chom has been hurling Spanish phrases at me ever since!  After announcing to some stunned Spanish faces that most Cambodians have encountered TB in their lives, I interrupted Chom to ask as an example if he ever knew anyone with Tuberculosis?  “Tuberculosis?  I don’t know this word, what is it?”.  Maybe you know it as TB?  “No”.  I guided him to the Departmental sign which is written in English and Khmer and he suddenly understood “Oh!  Yes!  My father in law died of this disease two years ago.  He came here all the time to get his medicine but it was in his body, like everywhere and the medicine could not cure him.  He died in 2012 when he was only 43 years old”.   There could surely be no better illustration of the proximity Cambodian people have to TB than that single random sample!

While the Spaniards were in town we ate three evenings this week at my favourite riverside restaurant which doubled as their hotel on my recommendation.  One evening as we were preparing to order, the young waitress who I’ve known for almost a year now, approached our table and interrupted with “Hello Helen?  My boss needs me to speak with you”.  The smiling boss was standing behind her, holding a pink paper gift bag with a teddy bear face pasted on it.  “She wants me to say thank you very much because you always come here, you bring your friends, you are such a good customer, and she wants you to have this gift”.  The pink paper bag was ceremoniously presented to me with sampiah gestures and more words of gratitude.  I was speechless to find the most beautiful carved wooden statue inside!  The boss then spoke to me at length in Khmer, with her waitress translating many words of appreciation, many sampiah gestures exchanged between us and just a very unexpected, cheerful interlude between four Spaniards, two Cambodians and an Australian!  All because I happen to like their menu and free wi-fi!

Another thrill this week was receiving the below photograph of myself with some of my English students who are homeless and stay in hammocks under trees (during the dry season) or a shanty shelter (during the wet season) with their grandparents who earn US$40 per month as cleaners while the children’s parents live and work in Thailand to send money home.  These children belong to quite a community of homeless domestic staff and variously connected children.  Three times per week six of these children come with me to the orphanage for English lessons and I am regularly approached by new children and parents wanting to enrol their children into the classes.  This is not possible at this stage as we are already teaching 18 children, six of whom travel with us by tuk tuk, squeezing in with sometimes three adults!  The only reason our overcrowded tuk tuk draws attention is because of the Barang traveling with Khmer children – the overcrowding factor is neither interesting nor unusual!  The children have started speaking basic English since classes began three months ago.

Now that they are on school holidays these kids plus some visiting children are around every day and have taken to following me around when I’m at this particular work site.  I regularly hear my name shouted in unison by six or more little voices who often run at me, chase or jump onto the back of my bicycle, peek through open barred windows while I’m in meetings, hide behind trees or around corners to jump out at me, falling about in hilarity when I get a fright, and generally just make my work days so much more fun than they would otherwise be.  On this particular day they were pushing a 3yo who has learned to shout at me in exact imitation of the older children, on a little tricycle, when I passed by and stopped to say hello.  A colleague was watching from a nearby building and took this photograph of our encounter.  Despite the many and daily laughs and tears during my time here, I expect the stolen moments with these children to be the most poignant memory and one of the biggest privileges of my Cambodian MSF experience.

Me and Kids cropped

Ambiguous Expectations

An American friend who worked in Hollywood for years tells some incredible stories about the perils of celebrity.  Fame and money can play havoc with the human spirit as much as neglect and destitution can.  We all develop behaviours matching what we have learned to believe about ourselves.  In destitution, behaviours relate to excessively low expectations, while in celebrity they relate to excessively high expectations.  Which is not to say that every destitute person has low self esteem, or that every famous or rich person is arrogant.  But that these are risks associated with people who find themselves living an extreme existence.

En route to our English lesson the other day we had an interesting discussion about the criticisms of volunteering with children in third world countries.  The concerns and opinions which I’ve shared on previous blog entries are many, real and valid, but some of them are not clear cut.  For example, to volunteer with orphaned babies in institutions where they are lined up in rows of cots, receiving minimal attention or care.  Devoting a period of time in your life to feed and care for these babies seems a wholesome endeavour, offering human interaction and stimulation which they otherwise do not receive.  Such neglect in infancy can have drastic consequences reverberating throughout a person’s life, explained so well in Dr Bruce Perry’s book The Boy Who Was Raised As A Dog: And Other Stories From A Child Psychiatrist’s Notebook. In his book Dr Perry shares some phenomenal experiences and insights into the behaviour of people who are traumatised at critical times in their childhood and it is a fascinating read.   However volunteering in this way also means you are bonding with a child and then abandoning them, which can likewise contribute to known and predictable psychological disturbances.  Similar arguments can be made about volunteering as an untrained English teacher.  For example, would you want your children being taught by someone without adequate training?  It would seem indisputable at first glance.  But what if your only other option was no English lessons at all?  And what of the high value that is placed in many parts of the non-English-speaking world, of exposure to native English speakers?

These are some of the questions I grapple with during my various Cambodian endeavours.  No single undertaking is without debate around it’s impact.  The contribution Medecins Sans Frontieres makes is a good example.  We enter a country with the intent of making a difference and there is no doubt that significant and positive differences are made.  But there are pitfalls.  For example we adhere to local labour laws, which often exist only on paper and are not implemented either at all, or well, in struggling local systems.  We apply national-standard minimum wages and employment conditions which are often markedly different to those of local government employees.  This establishes a two-tier system which may in turn create a dynamic between, for example, MSF and Ministry Of Health (MOH) staff who work alongside each other.  Staff with identical roles and responsibilities may have quite inequitable conditions.  Then, once our intended goals are completed we implement an exit strategy and depart, usually leaving behind many suddenly-unemployed ex-staff in a struggling economy which cannot sustain it’s workforce.  In my recent experience, once the exit strategy enters the agenda, local staff become anxious and stressed about their imminent future.  The repercussions can be much more far-reaching, affecting patient confidence in the system, service quality as staff leave, and many other related issues.

The other night during a visit with the little boy at Shackville, I asked his mother if I could photograph him.  She agreed and instructed him to put his infected stump up so that it was in the photograph!  Taken aback, I got a great shot of his handsome little face, managing to avoid any unnecessary pictorial evidence of the amputation site.  I showed her the photograph and will give her a copy, so she knows I did not photograph his stump.  Perhaps she believed I wanted a photograph of his injury in order to show others who may be able to help their plight, although I could not be sure.  When I have offered assistance to those in dire need, I have credited it to an overseas friend, often because I have received a donation from generous family and friends wanting to help, but also in order to demonstrate that I have limitations, relying as I do on others to help.  This seems effective in ensuring I am not seen as some sort of “boundless benefactor”.  A logical reaction to this might be attempts to connect through me, to distant and unknown people?

Suffering in Cambodia is conspicuous and beggars are prevalent in comparison to the first world where some level of security is in place for vulnerable people.  Although many beggars are disabled in some way, it is rare here (although not altogether absent, especially in the tourist areas) to see disabilities used brazenly for the purposes of begging.  This is in comparison with other places which I have not visited, where I understand disabilities have a worth attached to them based on the sympathy and donations they can garner from strangers, making the disabled vulnerable to all kinds of shocking abuse.  So while I want to contribute to the life of this little boy, the last thing I want is to influence him or his family to perceive his disability as some sort of cash cow.  Yet if I had not noticed his disability, I would never have approached his mother to ask about him.  So have I already turned his disability into a meal ticket of sorts?

Despite the risks of negative consequences, I firmly believe in engaging with people in need and helping when possible.  Unwanted repercussions can be minimised by being informed and reflecting on our actions and their consequences.  During a recent meeting with the Board of Directors at the orphanage some thought-provoking debates played out between members who feel very strongly about not teaching the children to have high expectations which, once they are living as independent adults, they will not be able to sustain; and other members who feel equally strongly that it is healthy and positive to give the children the confidence and insight to pursue higher dreams.  We were not debating highly unrealistic goals, but rather what prospects should be considered attainable for children from impoverished circumstances, living with a stigmatising chronic disease who are clearly going to face many harsh challenges in life.  I don’t know where I stand on the “Expectations Spectrum”, but it was an absorbing and contemplative debate which I felt privileged to be part of.

Contact between “us” in the wealthy world and “them” in the developing world is no longer a distant and unlikely thing, thanks to the internet.  As the most popular social networking site with almost 100 million users, Facebook is an excellent example.  I follow various Facebook pages, including a number of charities who regularly post messages and photographs to promote the work they do.  This is great publicity for an organisation who rely on donations in order to continue operating.  But it also serves a more important purpose, connecting human beings.  People from far-away places can watch and comment and I regularly read people wanting to reach out and help – asking how to volunteer, how to donate, or sending messages of hope, support and encouragement to individuals whose stories and circumstances touch them.  This is a doorway which, without the internet, would never have been open to so many of us (or to the people who benefit from these organisations).

One of my favourite Facebook pages is Humans of New York (HONY), a photography page started by a young guy called Brandon after he lost his well paid job in Chicago.  He bought a camera and embarked on a tour of America, taking portrait photographs of people he encountered in the street and posting the photographs to a Facebook page.  He asked his friends to like the Facebook page and slowly acquired a small online audience.   When he landed in New York the venture took on a life of it’s own, as to be expected in New York!  He began recording conversations he had with the people he photographed and adding short quotes as a caption to each portrait.  This connected his audience to the subjects of his photographs and the popularity of his page snowballed.  He now has almost 10 million Facebook followers.

Brandon is currently on a United Nations-sponsored “world tour” to ten countries.  With four or five days in each country, he started in Kurdistan about two weeks ago and has since been to other parts of Iraq, as well as Jordan, Democratic Republic of Congo and Kenya, where his most recent photographs were posted from.  He will circumnavigate the globe, touching down to meet and photograph people in various impoverished locations as far apart as Ukraine to Haiti.  The aim of this trip is to promote the United Nations Millenium Development Goals.  There are eight MDGs,  attempting to end poverty and improve life for the world’s most impoverished people.  Read more about them here: http://www.un.org/millenniumgoals/.

Following the HONY theme, Brandon’s captioned photographs on this global endeavour connects us to people who we would not otherwise encounter.  Brandon’s own words about this project are “Those are the places that have the most extreme headlines coming out… Those are the places most skewed in people’s heads. The work has a very humanizing effect in places that are misunderstood or feared.”  Like thousands of others I enjoy following his journey, “meeting” some of his subjects and learning a little of their lives.  Thanks to Brandon and the UN I’ve met children crowded together on the back of a parked utility truck, waving, hugging and posing excitedly like many scenes I’ve seen in both Central Australia and Cambodia, only these faces are Caucasian instead of Black or Asian; a legless man sitting on the ground in Nairobi describing the impact his disability had on his (non) education; men and women in war torn countries pursuing higher educations in order to contribute to the growth and development of their nations; and so many others who are just people like you and me but born into difficulties that we have never had the misfortune of experiencing.

Perhaps a year ago Brandon posted a picture from Washington Square Park in the affluent Greenwich Village suburb of Manhattan, of a little boy sitting with his mother on a path I recognised as adjacent to an apartment block where Eleanor Roosevelt once resided and surrounded by apartments now inhabited by New York University academics and professors.  A mat was stretched in front of them with “cowboy supplies” displayed for sale.  The little boy wanted to raise money to buy himself a horse and by the end of that day he had earned US$1 towards his goal.  Living in a small city apartment with no extra money meant this was an impossible ambition, but despite this his mother was supporting her son to pursue his dream.  Brandon posted the photograph and caption to Facebook.  An amazing thing then happened – his followers banded together and raised enough money for the boy to go on a horse riding holiday!

The generosity of his readers continues today, with connections being sought from his audience to his subjects daily.  As one of very many examples, this morning a young Kenyan woman’s portrait caption reads: I’d been studying German for a few years, and I met this woman who gave me the opportunity to go to Germany for a full year. The brochure looked very nice. The program included hikes, volunteer work, singing in church. It was very expensive, but my family thought it would be a great experience for me, so all my relatives chipped in to pay the program fee. I was so excited for months. On the day that I was supposed to leave, I went to the airport, and waited in line to check my baggage. When I got to the front of the line, they told me that my ticket was a forgery. When I tried to call the woman’s phone, it had been disconnected.”  A frenzy of overtures has arrived from HONY.  Offers to buy her a plane ticket, to represent her legally, to host her in Germany and all sorts of other contributions are being hurled at poor Brandon!

He doesn’t acknowledge publicly whether he can follow up on these offers.  I suspect that he cannot because the intention of his work is actually not to alleviate the suffering of random individuals he happens across, but to raise awareness of a global situation.  The enthusiasm shown by his readers wanting to support underprivileged people wherever they are, is an inspiring testimony of the natural tendency humans have towards compassion and philanthropy.  Translating these qualities into acts that actually benefit the most people in the most meaningful way seems to be where the challenge lies, as our need to connect is so firmly entwined with our desire to contribute.

With all of the atrocities that the internet has received notoriety for, it seems to me that social networking also provides us with the possibility of meaningful connections which could literally revolutionise the world?  That’s my hopeful expectation for today’s information superhighway, anyway.

Angkor Athletes and Apsara Angels

Angkor Wat is the biggest of many historic Khmer temples situated near the tourist resort town of Siem Reap in Cambodia.  It is the largest religious monument in the world and has been ranked as one of the Seven man made Wonders of the World.  Khmer civilisation came into it’s own and thrived here for centuries through the Middle Ages.  Yesterday the inaugural International Angkor Empire Marathon was held, with a starting point at the entrance gate into Angkor Wat Temple and a course encircling the World Heritage listed site, including through the ancient walled city of Angkor Thom and past many other temples.  It was an exciting event and registration fees will be divided between a number of local hospitals and charities.

There are currently eight expatriates living and working together with MSF-France in Kampong Cham, a diverse but well-matched group of people from all over the world who socialise and work as a happy (and incredibly lucky) team.  We hired a driver and mini van for the weekend and on Friday afternoon headed off with stocks of wine and snacks for the five hour journey to Siem Reap, for a weekend together.

Despite a fun journey along rural roads with many interesting sights, luxurious boutique hotel accommodation and decent tourist-friendly shopping and restaurants in Siem Reap, where I now know people who I enjoy catching up with, the highlight of my weekend was definitely the 0430am start four of us made yesterday morning. We reached Angkor Wat in time to watch the sun slowly rise behind the famous ancient temple spires before cheering on the race starters for the 21km half marathon at 6am, followed by the 10km competitors at 0610am, then lining up for my own 3km fun run take off at 0620am.

On previous trips to Siem Reap I’ve mentioned Rav, the affable young tuk-tuk driver who translates for me with the landmine victim whose family I support.  We visited them on Saturday for our usual encounter at their little single room accommodation sleeping a family of four and serving as Mum’s workplace with the sewing machine set up in one corner.  Yesterday at 0500am Rav was waiting as arranged and runners were already on the unlit road outside our hotel, 5km into the 42km full marathon which had started half an hour prior in the dark, their silhouettes silently pounding the road as policemen lined the streets to mark their route.  We packed into the tuk-tuk, the two serious competitors who were about to run 21km and 10km respectively, full of nerves and excitement.  The tuk-tuk made it’s way out into the road, crossing in front of runners in the usual Cambodian style of casual but polite rule-free road-sharing which I have become awkwardly familiar with and which makes me worry for my return to Australia where road rules and road rage will be unfamiliar and alarming!

Sunrise at the temple was a spectacular array of slowly-evolving colours, with a DJ on stage spurring the crowds, calling for competitors to make their way to the start line, appealing for cheers according to the nationalities he was naming randomly, playing loud beat music and rousing applause for the competitors at each take-off.  Our Slovakian colleague left first in the half marathon, full of nerves but no doubt stimulated by the adrenaline rush the crowd and atmosphere generated.  Ten minutes later our Australian colleague took off in a similar rush of excitement for the 10km race, followed ten minutes later by myself and our American colleague for the 3km fun run.  Unlike my American friend who planned a stroll, I was determined to run the distance despite my similarly inappropriate attire and utter lack of athletic desires or talents.  I started at a slow pace which I correctly thought I could maintain for the duration.  Surrounded by a mixed and happy crowd of joggers and walkers, and inspired by the beautiful tree-lined route in such a magical site, I mused about the historic events preceding my own footprints on this patch of land over many centuries as I ran to the beat of the tunes on my newly-created “Angkor Marathon” playlist.  Plenty of interested local people lined the route going about their usual daily business of selling to or cleaning up after tourists, with lots of staring, waving and smiling as I plodded past, helping me to maintain my pace so that within 20 minutes I had shuffled my way back to the finish line, feeling quite accomplished.  After all, I can now say that “I ran in the inaugural Angkor Empire Marathon” – with the subtle distinction of adding the word “in” to my sentence making all the difference to the truth of my statement!

Just as I was reaching the finish line a very fast and fit male runner strode past me, giving me the extremely false impression of competing in a serious race – the difference being that I shuffled across a white chalk line in one direction as he veered the bend and bounced energetically underneath the red banners of the serious finish line.  Rav found me a few moments later and we stood along the edges cheering in the approaching serious competitors.  Green cardboard squares attached to plastic ice cream sticks were being handed out and we waved these at ourselves to cool down in between using them to cheer on the athletes.  Our walking MSFer was next over the line, strolling casually along in her thongs!  About twenty minutes later Bea appeared, crossing the 10km finish line in good time with a beaming smile.  About an hour later our Slovakian 21kmer strode in looking like she’d just taken a walk in the park!  The serious runners received a medal while the 3kmers received a certificate with space on it to complete our names and finish times.  Along with the green cardboard fans and after taking some photos for evidence that we did get a finishing certificate, Rav’s children inherited these.

After cooling off, rehydrating and soaking up some of the race atmosphere Rav pulled in alongside Angkor Wat’s moat and we piled in again for the return journey to the hotel for breakfast, a shower and a much-deserved rest.  Rav parked himself across the road from the hotel and waited, the standard pastime of thousands of tuk-tuk drivers throughout Asia!  A few hours later we gave him some more custom, heading into town and then to visit the two year old I spent time with in April whose tracheostomy has been removed and is healing well, before returning to town for lunch while Rav sat patiently once more in the back of his own tuk-tuk.  After lunch I needed to stop at the bank so we parked and I jumped out and ran into the ATM.   Stuffing my money into my purse I turned around to the sight of my three housemates madly fanning themselves in unison in the back of a parked tuk-tuk with three green cardboard fans which Rav had obviously retrieved from under the seat amidst complaints of “many sweats” in the still and steamy air.  It was a quintessentially Asian-hilarious sight.

This morning I arrived at work and negotiated the discharge of a 64yo patient who is ready to return home where she has her own business which she created with $100 borrowed from a neighbour.  She has been hospitalised for a month now and her business and the repayments have all been on hold.  When I told a friend in Australia her story, which involves existing as subsistence farmers in a home made out of bamboo and banana leaves, with malnourished children in the house including a 7 month old who weighs 4kg, they sent me $100 to pay off the loan.  Today with my translator back at work after two weeks away, I was able to communicate this news and give her the money to pay off her debt.  She listened to my translator explain my possession of $100 intended for her, and nodded quietly before announcing that she was very excited to finally be going home.  We returned a few moments later with the money in an envelope.  She appeared from the bathroom with a krama wrapped sarong-like around her chest.  She slowly and demurely changed in front of us, into a white laced pyjama-like top before calling her husband in from the undercover pathway outside where he had been chatting with some other patients.  He then changed into a pair of black pyjamas and sat next to her.  I held the envelope as Win explained that they should be discreet about it as it was not possible to do this for the other patients.  They agreed quietly to this and I placed the envelope on her wooden bed base.  Via Win I then asked for a photograph to send to the donor and they agreed.  The envelope sat on the bed untouched, and so I sat down on top of it to have my photograph taken with them.  Without any verbal recognition of the money, the patient placed her hands on my arm and stroked it repeatedly, saying I had beautiful skin, and that I looked healthy.  I looked at Win, suspicious that he had substituted “healthy” for “fat”.  Reading my mind he said “she means that you are very healthy, it is a very positive thing in Cambodia”!  Against her 40kg frame which knows both hunger and tuberculosis intimately I do look gigantic, so I can accept this “compliment” without too much torment!  We did argue back and forth a bit as she said she wished she had my “health” and I replied in jest that I wished I had her slim figure, eliciting a more forceful “but I really wish I was healthy like you”.  I let her win the battle, realising that my luck at birth means I already won the war.

Making the most of my translator we then cycled to Shackville (as I have dubbed it) to visit the mother of the 6yo amputee boy.  I met her this morning on my way to work and we conversed as we always do – with much laughter and little understanding of what each other is saying, so I told her I would return “with Khmer” (the only way I know how to say “with my translator”).  Her son came to the Night Market with us a few Sundays ago, when we took the orphans to a Childrens’ Fair event.  I had managed to communicate to her earlier that day, my request that he join us at the Fair and she had conveyed her understanding and consent.  When I returned that afternoon to collect him as arranged, he very slowly put his prosthesis on, looking nervous and slightly confused the whole time.  With his growing bone protruding through the skin of his stump, the prosthesis is uncomfortable and he is only wearing it at the moment for aesthetic reasons.  I carried him to my bike and put him on the carrier, cycling away with a very anxious boy watching his mother disappear into the distance behind us.

When we arrived at the Fair his nerves slowly dissipated as he played with the other 6yo in our group, hopping along behind the other children or asking the older ones to carry him.  Apsara dancers and children juggling featured at the fundraising event and we bought the children an ice cream and some fried noodles to share.  After two hours he announced that he was ready to go home (via the Cambodian Orphanage Director who was with us).  So I picked him up and carried him home as he nodded off in my arms.  When we arrived at Shackville he opened his eyes and suddenly became very animated, shouting out to his mother, pointing towards the Night Market excitedly and talking at high speed.  His gut busting enthusiasm told me without understanding a word, that he had enjoyed the excursion.

Today thanks to Win, his mother was finally able to relay his version of events.  He told her that he ate a lot of different foods and he “even saw many angels”!  It took me a while to process what he could possibly be speaking about.  The “lot of different foods” were an ice cream and a small plate of fried noodles divided as a snack between three children.  The angels were Apsara performers!  He is staying with his grandparents at their village seven kilometres from here because Mum has to work and she doesn’t have enough money to feed him, which is why he was crying the last time I saw him.  I cycled by and waved out, aware that he was in Mum’s arms crying but because I was late for work, didn’t stop.   Mum speaks to him everyday on the telephone and in every conversation he asks “did My Barang come to look for me today?” and tells her “Mum, please don’t abandon me”, as his way of pleading to return to Shackville!  The kid is a heart breaker!

These are his angels performing for him!
Childrens Fair Night Market 9 Aug 036a

Imperfect Souls

African-proverb-sleep-with-mosquitoMosquito killer

When I was about ten years old I used to visit a young mother because I liked playing with her baby.  I don’t remember how I came to know her but she lived in a house on a street between my house and St Josephs Primary and I remember stopping in to visit them on my way home from school.  It was quite a surprise to me when Mum told me oneday that this woman really appreciated my visits and that they always cheered her up.  Looking back now, I realise that she was an impoverished single mother who probably had little to no support, so an older child taking the little kids off her hands occasionally made a difference.

Ten years later as a student nurse in England, I nursed a frail, elderly woman who lived at home with her equally-elderly sister and would come to hospital for respite care once every six weeks.  Her sister had long-ago retired from a senior nurse position at the same hospital and I loved to hear her stories about working in our hospital during the war years, when the hospital was bombed and regularly dealt with war wounded citizens and also soldiers who were transported from battles across the English Channel.  When the frail sister was admitted into a nursing home her respite care to hospital ended, but I stayed in touch with them occasionally.  Oneday I phoned to say hello and the healthy sister was very upset because she was not well and could not visit for her nightly routine tending to her sister at the nursing home.  I offered to go in her place and for about a week I visited the nursing home, put her sister’s slippers on for her and fed her dinner.  I was also able to pass messages between them both so they did not fret for each other until they got back to their normal routine once the second sister was well again.  It was around the corner from my home and took me less than an hour, so it was no effort and in fact an enjoyable interlude for me.  But again, something so small in my mind surprised me when it transpired that it had made a difference to both their lives, to the extent that when the last sister died a decade later, she left me an inheritance.

I’m no angel though, with plenty of faults and mistakes to my name.  With the recent headlines about Robin Williams’ suicide after years of torment, I wonder what failings haunted him so badly that he couldn’t forgive himself?  It would be so easy for hyper-sensitive and self-critical people to suffer terribly in the face of their own faults.  Tracy Chapman’s lyrics At This Point in my Life say it well – At this point in my life, I’ve done so many things wrong, I don’t know if I can do right…. I’ve been climbing stairs, but mostly stumbling down, I’ve been reaching high, but always losing ground, I’ve conquered hills but I’ve still got mountains to climb…. but right now, I’m doing the best I can.  She describes so well, the state of being human – the struggle of being an imperfect soul.  Noone in this life is faultless and it’s okay to work towards making small differences in the world, which will always be imperfect differences coming from an imperfect soul.

These are all reflections I made as I listened to Scott Neeson speak about how he transitioned from tycoon to philanthropist extraordinaire a decade ago.  His story is quite incredible and anyone interested in charity will really enjoy hearing him speak at this TEDx lecture delivered in Hong Kong in 2012.  I think his life story sums up the Anne Frank quote perfectly, that “Noone ever became poor by giving”.  Not that anyone, least of all Neeson, thinks we should all sacrifice everything and move to a third world garbage dump.  But pioneers like him are turning outdated negative attitudes towards giving to charity on their head and showing that individuals actually can make a difference in situations that seem hopeless.  And that being a “do-gooder” is not a one dimensional concept but is full of imperfect nuances implemented by imperfect souls.

https://www.youtube.com/watch?v=_tJK6R2y0bk

I follow Scott Neeson on Facebook and another reason to admire him, is that he never shows concern for others’ criticisms, he just gets on with doing what he does.  There are so many people who prefer to cast aspersions and yesterday a wise friend emailed me following some trouble she faced from detractors on a public website with over 20,000 members which she administers.  Her words about it were Some people are put on this earth purely to be destructive of anything built by someone else so why would I get upset by them?  Their words mean nothing to me.  Her wisdom is inspiring, and so on I shall blog!

Audrey Hepburn character

My Cambodian Week

Coming from a place where this is the normal standard of sharps care in hospitals…

Sharps waste, developed world

Sharps waste, developed world

….  it came as quite a shock to me when I first visited a health care facility in a third world country and encountered this.

Sharps waste, developing world

Sharps waste, developing world

Puncture-proof, well designed plastic containers with clear labeling are the basic standard in western hospitals, with many guidelines strictly adhered to around the disposal of sharps waste.  In comparison, waxed cardboard boxes are available in resource-poor settings, but stocks often run out, when they are replaced by ordinary boxes as seen here.  The scarcity of appropriate resources encourages lower standards, such as over-filling containers to the dangerous levels as seen in this photograph.  I have also caught children playing with potentially contaminated sharps left lying on hospital grounds.  Medical waste disposal is a very difficult challenge in an environment where there is no waste disposal or landfill centre for the town’s waste.

In my other life I have a very vague theoretical clue of what happens to waste after it leaves the clean, well lined bins in our well stocked health facilities.  Here I see the waste, smell the waste, breathe fumes from the burning waste, have discussions about the animals living amongst us because they are attracted to the waste, and have learned many things about the pros and cons of burying as opposed to incinerating waste depending on the type of waste and the risks each disposal method poses.  I have become quite intimate with hospital waste, in fact!

Standard Precautions is the current term used to describe Infection Control practices in health care settings.  Handwashing is the most basic Standard Precaution but also the single most important preventive measure against the spread of diseases.  Standard Precautions also relate to other hospital hygiene practices, from clinical waste and sharps disposal to staff health policies and procedures, use of Personal Protective Equipment (PPE) and many other measures.  Good implementation of Standard Precautions requires ongoing staff training as recommendations can change and Infection Control is an enormous topic in which academic degrees can be obtained.   So a few short paragraphs here cannot begin to touch on the topic.  Standard Precaution practices aim to reduce the transmission of pathogens between people and they successfully do so when properly implemented.

Knowing that one person has a particular disease does not preclude others from having the same disease.  Many people carry viruses or bacteria without knowing, and negative test results only represent the single point in time when the test was carried out.  This theory underpins the application of a minimum standard of Infection Control applied to everyone, which also serves to protect everyone from discriminatory practices.  The worst case of discrimination I heard about was in Bryce Courtenay’s book April Fools Day in which he writes about his son’s experiences with haemophilia and HIV in the 1980s.  He contracted HIV through a blood transfusion before the virus was identified or routinely screened for in blood donations.  Lying alone in a Sydney hospital isolation room in very poor condition with AIDS, one night two male nurses entered the room and beat him to a pulp!  Most discrimination is far more subtle than this and some of the most stigmatising diseases are Tuberculosis and HIV.   But the main aim of Standard Precautions is to ensure a good standard of practice based on current knowledge about pathogen transmission, with minimised discrimination a secondary outcome.

Upon seeing sharps containers overfilled regularly, one of the first tasks I set myself in Cambodia was to teach staff about minimum standards of sharps safety.  I have been consistently impressed at the dramatic improvement in practices in my time here and it has been months since I saw an overfilled sharps container.  So it came as quite a shock earlier this week when I lifted a cardboard sharps container and felt a needle penetrate into my finger.  The used needle had perforated through the wall of the waxed cardboard and was waiting for someone to stick.  That someone happened to be me.  Thankfully the only reason this occurred, was because of a fault with the box, which had been assembled properly and was not overfilled.

If a needlestick injury occurs with an infected needle (that is, a needle contaminated with virus-infected blood or body fluids, penetrates through the skin of another person), the estimated risk of transmission for the three main bloodborne viruses of concern is as follows:

  • Hepatitis B – up to 40% risk if the source is carrying the infectious “e-antigen”, but as low as between 1-6% if the source is not carrying this antigen
  • Hepatitis C – between 3 – 10%
  • HIV – between 0.2 – 0.5%

The only vaccine-preventable virus in this trilogy is Hepatitis B, for which I have good antibody levels following vaccination over 20 years ago.  The needle was situated approximately halfway down the box, which was approximately two thirds filled.  The needle had probably been disposed of some time ago, meaning any possible virus particles were unlikely to have survived.  No known HIV / Hepatitis B / Hepatitis C patients had been admitted for a week or more and so the chances of the needle having been used on an infected patient were very low.  Even if the needle was contaminated, the transmission risk is extremely low.

The HIV prevalence rate in Cambodia is 0.7% and Hepatitis B and C prevalence are generally both below 10%.  Post-Exposure Prophylaxis (PEP) guidelines, very briefly and applicable specifically to my situation, are:

  • When the source HIV status is unknown in a low prevalence setting, PEP is unnecessary.
  • There is no PEP available against Hepatitis C, so follow up serology to determine transmission is recommended.
  • Hepatitis B vaccine or immunoglobulin are not necessary as I have adequate protective antibodies.

So after following the advised first aid procedures at the time of the incident, followed by the advised reporting procedures and baseline blood tests, there is now little for me to do but follow the usual six month follow up of blood tests to confirm that an exposure did not occur.  I’ll update you in six months’ time!

Part of our project is based in the market town of Skun, on the highway between Phnom Penh and Kampong Cham.  Even more markedly than in Kampong Cham, the agricultural lifestyle infiltrates Skun’s urban streets.  Farm animals cart produce to market and everything from water buffalo to hay stacks travel from their rural origins, along dusty tracks through rice and corn crops, onto busy highways and into the busy market crowds.

The walk from our office in Skun to the local hospital took us along red dusty tracks, potholed by recent heavy rainfall.  We turned the corner at a home construction site where women covered with kramars on their heads, tracksuit jackets and pyjama pants protecting their skin from the sun worked alongside bare-chested men with brick-like torsos working in jeans and bare feet as they pick-axed and bricklayed with only the most basic tools.  Carrying loads on their heads and shoulders and digging into the ground with their manual tools, they slowed down or stopped to watch as four westerners walked by.  Mutually interested smiles were exchanged.  At the next corner two Buddhist monks were standing outside a house, alms bowls slung across their orange-swathed bodies like handbags, waiting for a donation from the home owner who was yet to materialise at the gate.  One of them turned to us with a shy smile before watching us walk around the corner.  Along this road we passed the local police station, a small brick building with a large verandah set behind an elaborate entranceway, where a man in plain clothes stood smoking a cigarette.  At the corner past a few tin-roofed wooden shacks with produce hanging from hooks under tin verandahs, we strolled around the edge of a busy market place with piles of fruit lined up on bamboo mats placed on the dusty edges of the partly-muddied red dirt road.  Vehicles were parked around the corner from here, which our local colleague explained were used to transport the produce to market – trailers with long wooden benches behind motos, beaten up mini buses and motos, all looking as though they had a reason to be waiting there as the drivers stood around chatting.

A short while later I did the return walk alone, and rather than shy stares and smiles, was greeted with friendly waves and shouts of “hello” from all directions.  One man saw me from a distance and drove his moto over, motioning that there was room on the back for a passenger, smiling happily as I waved him off with “Ot te” (no).  Halfway home a woman carrying a bunch of celery in her hand pulled up alongside me and spoke animatedly in Khmer.  When I said “Ot yul te” (I don’t understand), she motioned to the back seat of her moto and again, smiled happily as I turned her down before driving ahead slowly and turning back regularly to wave goodbye repeatedly.  Back past the construction site where more smiles and mutual gawking took place, a flooded water lily pond, noisy game of petanque happening on a square of dirt under a tin roof and fluorescent green rice fields in the distance, I made it back to the office feeling as though I’d just had a very “Skun experience”.

Back in Kampong Cham two days later I sat in a crowded room alongside my colleagues on wooden benches as our manager presented an update on MSF’s project plans.  Five of my nursing team were informed during this presentation that due to an evolution in the project’s operation, after two years of gainful employment caring for some of the sickest people in Cambodia, their contracts are about to be terminated as the work is transferred back to the Ministry of Health.  This was a very emotional announcement as the rest of the team are left to speculate on their own futures, which is a perpetual consideration for people living in a country with limited employment opportunities who are employed by NGOs with temporary, capacity-building objectives.  The excitement of securing a job with an international aid agency is always going to eventually lead to the disappointment of losing your job when the agency moves towards achieving their goals and acting on their exit strategy.  These young nurses have been a diligent, caring team to their patients as well as to each other and I am not sure if they believed our reassurances that this implementation does not reflect on them or their work.  I also worry, having come to know and care about them, where they will go and what they will do now their financial security via MSF has ceased.  It is very common for qualified professionals in Cambodia to spend months or years without work.  I know this because I have listened to staff talk about unemployed husbands, siblings and friends with decent qualifications and experience.  I have also fielded questions (which I don’t know the answers to) from staff, about how they might find and be sponsored to work in a “rich country”, where they believe they could spend a short amount of time saving huge (comparatively speaking) amounts of money which would allow them to return home financially secure.

This week the Mekong River reached flood levels with the esplanade in Kampong Cham submerged in shallow flowing muddy water, which of course I slipped on one evening, arriving home with one trouser leg soaked in mud.  Sandbags line the streets and crowds flock every evening to check the river’s level which rose almost 10 metres in less than a month.  At work doctors are speaking of the risk of a cholera outbreak when the river levels subside and I have been asked to ensure we have the latest Cholera Guidelines at hand.  With the Wet Season arriving late this year, rice planting began late and now the very young crops are flooded, meaning they may not cultivate well.  This places a large portion of the population at risk of famine as people rely on their own rice crops for sustenance as well as income.

The young woman whose home we cycled to recently as a team, attended hospital this week for an outpatient appointment and told us that her house is now above the Mekong, which has reached flood levels.  She traveled to us this week by boat and then tuk-tuk and has invited us to visit her again, saying that we can go by road to a certain point and her father will then meet us in his wooden boat and bring us the rest of the way!  So that is the next plot on our agenda – a boat ride with locals on the Mekong!  This patient has gained 1kg in the past month, so she is now 24kg.  Her condition is not significantly better but she is maintaining some level of stability and has started to walk again.  After believing she would die, it seems as though there is some real hope for her to return to a semi-normal existence, as long as she doesn’t succumb to any other infections, which is a very real risk.  She is an amazing example of the fact that in abject poverty, courage can triumph.

In a nutshell that has been the mixed bag that Cambodia threw at me this week, although I have not even mentioned the English lessons, the 6yo amputee boy living in a shack near our home who has befriended me, the visits from our Tokyo-based manager and Phnom Penh-based Head of Mission, dinner out with a lovely Canadian expat who found my blog and contacted me for a meet-up, or the Children’s Fair we are taking 18 children to this afternoon for some fun and frivolity.  All very enjoyable parts to the week but perhaps less peculiar than the details I’ve noted.

An Infinite Learning Curve

United Nations Children’s Fund (UNICEF) defines an orphan as a child who has lost one or both parents.  Using this definition, they estimate that there are 132 million orphans in the world, but of this number, children who have lost both parents (double orphans) total 13 million – still a staggering number.  HIV is named as the single most important factor affecting these numbers, but there are other reasons such as war which result in children losing their parents.  The UNICEF estimations do not include abandoned children or children who have been sold or trafficked.  While orphans are a worldwide phenomenon (there are obviously orphans in every country), the vast majority are living in the world’s poorest countries.

The first case of HIV in Cambodia was discovered in 1991, ten years after the epidemic was identified.  Cambodia’s first case of AIDS occurred in 1993 and the HIV prevalence rate by 1998 was 2.5% of the population.  Since then the rates have steadily declined, and in 2013 0.7% of people aged 15-49yo were estimated to be HIV positive.  This translates in total numbers to 71,347 people including 6,850 children.  On average three new HIV infections are contracted and six adults die from AIDS here each day.  Approximately 85% of people living with HIV in Cambodia are receiving appropriate anti-retroviral treatment (ART).  Another huge achievement is the much-reduced rate of HIV transmission from HIV-infected mother to child, to only 2%, thanks to the use of Prevention of Mother to Child Transmission (PMTCT) interventions.

In the past ten years the number of orphans in Cambodia has decreased (alongside the HIV epidemic).  Simultaneously there has been a 75% increase in the number of orphanages in the country.  This is directly linked to the concurrent explosion of tourism to Cambodia, with a 250% increase in foreign arrivals in the same ten years, with more than three million visitors entering Cambodia annually now.

Friends International list a number of dangers associated with Orphanage Tourism, as:

  1. 70-75% of children in Cambodian orphanages are not orphans and should be with their families.  They have been recruited from poor families with promises of educational opportunities which are otherwise unavailable.  Such recruitment is usually dishonest, with many orphans kept out of school entirely.
  2. International visitors have no child safe checks, allowing predators access to vulnerable children.
  3. Visiting an orphanage which allows you to come as a tourist or short term volunteer supports a business which is making money from the children.  This causes untold emotional damage to the children while the only real beneficiaries are the orphanage founders who gain financially from well meaning foreigners.

There is a lot of information available about the topic, and I’ve put some useful links below. Cambodia’s Orphans Business, a film by Juliana Ruhfus and Matt Haan, is 25 minutes of worthwhile viewing available at this link. http://topdocumentaryfilms.com/cambodias-orphan-business/

There are an estimated 10,000 children currently residing in approximately 500 orphanages in Cambodia.  A large number of these orphanages use volunteering or other means to attract foreign visitors (such as shows put on by the children) as a way to generate income.  Some keep the orphanage in poor condition, and even starve the children, in order to use it as evidence to visitors for the lack of funding.  Fabricated paperwork makes parents and families untraceable, meaning many children can never be reunited with their families.  Children are often kept out of school and forced to perform in front of visitors for cheap treats.  Supervision is often minimal or even non-existent.  These are just some of the issues arising in orphanages across the country.

Foreign NGOs are also involved in this scam, with an American organisation called Projects Abroad coming under the radar a number of times in the Cambodia’s Orphans Business documentary.  One volunteer reported that it cost her $3,000 to register with the NGO who sent her to Cambodia, while the local orphanage receive around $10 per week per volunteer.  The financial turnover in 2010 of Projects Abroad was US$24 million with a profit of over US$3 million, of which US$1 million was paid in dividends to their two directors.  Even more shocking, is the lack of criminal history checks on volunteers, making it easy for foreign sex offenders to enter Cambodia, hide their identity and carry out child abuse – some have even opened their own orphanages for this express purpose!

Until things in Cambodia improve, it is said that the country does benefit from the skills and qualifications that overseas visitors bring with them.  However, need will only be met with responsible volunteering alongside the implementation of in-country systems which can better protect the children.  Responsible volunteering is easy enough to explore via the internet.  Two decent and informative sites I’ve discovered, but no doubt there are many others, are http://www.thegreatprojects.com/responsible-volunteer-policy and http://www.gooverseas.com/blog/traits-of-responsible-volunteer-program .

With all that said, it is possible to volunteer responsibly and Cambodia also has many legitimate NGOs and orphanages, as I have mentioned previously.  I have also alluded previously to my involvement with an orphanage founded by a number of people including two of my national colleagues.  Prior to 2008 MSF-France worked on an HIV program and the doctors and social workers realised over time that many of their patients were dying and leaving behind children who were HIV positive, in need of adequate care, which was not being provided in their crisis-ridden home environments.  This motivated my colleagues to found an orphanage to take care of some of these children.  For the past three months, at the request of one of the founders who I work with, I have been attending the orphanage three times a week to teach English to the children, who have all suffered educational set backs due to their social and medical conditions.  It’s been a brand new endeavour for me, full of exhausting planning and preparations, classes which don’t go according to plan, and a failure on many days when craziness overtakes the structured plans in my mind!

More recently I have been recruited as the seventh member of the Board of Directors of this orphanage.  There are four local Khmer people and a French social worker, all of whom were involved in the founding of the orphanage, plus an American volunteer based in Phnom Penh and myself.  Yesterday I attended my first board meeting, where I spent four hours absorbed in discussions relating to the governance and functioning of the orphanage.  Issues ranging from the children’s education and health, exit strategies for each child when they reach adulthood, the possibility of admitting more children to the home, budget and staff salaries, donors, conditions relating to specific donations and transparency of financial and administrative aspects of the orphanage were all discussed.

Many of these points led to more general discussions.  How much money should a small, functional NGO should spend on overheads such as staff salaries (the short answer is 35% or less; the longer answer is much more complicated and far less clear-cut).  This thought-provoking 18 minute video is a lecture by American humanitarian / entrepreneur Dan Pallotta about the way we think about giving to charity.   http://video.ted.com/talk/podcast/2013/None/DanPallotta_2013-480p.mp4 His point that overhead contributes to the cause, rather than being an obstruction, turns the usual thinking about donor money on it’s head, and in my opinion, rightly so.  Which is certainly a controversial thing to say given the heated discussions I sat in on yesterday!

Our staff salary discussion in turn led to a more general discussion about Cambodian incomes.  Income and food prices work together in Cambodia to directly influence the population rates of malnutrition, which are very high.  According to the World Food Programme, rice supplies approximately 75% of daily caloric intake and fish is the main source of protein for the population.  Rice cultivation employs a significant proportion of the population.  There is a lucrative rice export industry but many families have their own rice fields, for self-sufficiency.  One of my colleagues recently took two weeks annual leave and upon her return I discovered that she had spent the time planting her rice field.  Not exactly my idea of a holiday, but she is guaranteed to be able to feed herself for nine months of the forthcoming year.

Depending on the arrival of reliable rains, rice planting season usually begins between June and July, and for a period while the rice grows, from August to December, rice and money often run out, making these the “hunger months” when people are much more likely to go hungry and malnutrition rates rise.  A new poverty line was reported in Cambodia last year, based on a combination of the costs of food items, purchasing clean water and non-food items, set at a nationwide daily limit of almost US$1 per day.  This rate differs between Phnom Penh, other urban areas and rural areas (refer http://countryoffice.unfpa.org/cambodia/drive/FinalPovertyinCambodia1May13.pdf).  As such, $1 per day per person is the very least amount required for basic survival.  This feeds my understanding around the fact that some colleagues and orphanage staff earn $100 per month and how $100 of debt can result in extreme stress.

The orphanage budget is very small and restricted and one of my roles as a board member will be to work out ways to try and increase donations as well as assisting with budget monitoring and transparency.  As I have never been involved in fundraising before, and am not a natural salesperson, this seems a daunting challenge, but one which I am prepared to have a go at.

I sat in a riverside restaurant writing most of this.  We are at the beginning of the final year examinations for Year 12 and the guest house here has many young Khmer girls who have traveled to town to sit their national exams.  As I sat here writing this a foreign man sat a few metres from me at the bar, leering shamelessly at the teenage girls coming and going as he bored the poor bar staff, a much less common occurrence in Kampong Cham than I’ve seen in places like Siem Reap and Sihanoukville.  There must be heavy rains to our north as the Mekong River is rising at a rate of knots and there is a lot of talk about it flowing over into the town.  The villages on the banks opposite us are already underwater, with boats taking the place of motos, tractors and animals.  Below are some photographs of the changing Wet Season land and waterscapes.

One of the many ways to transport rice seedlings

One of the many ways to transport rice seedlings

Rice seedlings arrive by bike and wait for planting

Rice seedlings arrive by bike and wait for planting

Planting underway

Planting underway

Cattle has to be kept away from the rice, so loads of grass are transported home each day

Cattle has to be kept away from the rice, so loads of grass are transported home each day

Boats which once traveled metres below us, out of sight, are now like an extra lane of traffic beside us

Boats which once traveled metres below us, out of sight, are now like an extra lane of traffic beside us

Responsible tourism www.aljazeera.com/peopleandpower

http://sisha.org/our-work/sisha-in-cambodia/

http://www.theguardian.com/world/2014/jan/02/cambodia-child-protection-workers-call-for-end-to-booming-orphanage-tourism

http://www.tripadvisor.com/Travel-g297390-c143217/Siem-Reap:Cambodia:Before.You.Volunteer.At.An.Orphanage.html

http://www.smh.com.au/travel/travel-planning/travel-news/orphanages-on-list-of-shame-20130406-2hdk7.html

http://www.aljazeera.com/programmes/peopleandpower/2012/05/201252243030438171.html

Unequal Exaggerations

This week I met a new patient who was unable to control quiet tears every time any of the staff walked into her isolation room.  That’s not especially surprising, being diagnosed with two stigmatising diseases (HIV and DRTB) in a country where the majority are already consumed by poverty-related stress.  I knew that as the team asked her what was wrong.  What I didn’t really get at that time, even though it is self-evident, was the tiny amounts of money which can cause extreme financial stress to people living in hardship in the third world.  This particular patient, widowed and with a seven year old son relying on her, took out a loan with a micro-finance company and needed to work to make the repayments.  But her disease diagnosis ripped her from her small job and planted her in hospital, unable to earn and therefore unable to make the repayments.  The burden was weighing so heavily that her tears flowed.

As the doctor questioned her in the hope that we could understand her stress, she explained these details.  Then he questioned her some more and she said that the repayments were 10,000 riel per month.  That equals US$2.50 per month.  He then asked how much the total debt was.  I don’t know what I was expecting to hear, but certainly not the answer she gave.

One hundred dollars.

Were my ears deceiving me?  The doctor repeated the amount and said that he understood now, why she was so tearful.  My brain malfunctioned, readjusted and recovered over the next few moments.  This small, malnourished, tearful woman was living in constant anxiety with years of repayments ahead of her, because of $100.  This seemed like such an intolerable situation that when I had time to speak with my translator I said that I felt I should help her.  Without hesitation he replied “yes, I think so”.  So with the generous donation from a friend in England on my side, I met with the micro-finance company her loan was held with and we removed the debt from her life.  Where there were once tears, there are now smiles.  I liked to think that was the end of it.  To the contrary, it was ironically only the beginning,

This morning our team met to discuss an older woman with a supportive husband, recently diagnosed with Drug Resistant TB (DRTB).  From a community known for it’s high prevalence of tuberculosis, she was diagnosed with TB ten years ago and received three months of the recommended standard six month regime.  At that time it was apparently not uncommon for patients in Cambodia to be charged for their TB medications and after three months she defaulted treatment as she could not sustain the cost.  Some months ago she re-presented with TB again.  It is quite possible that for the past ten years she has relapsed and recovered any number of times.  She was commenced on Category II treatment, in which Streptomycin injections are added to the medication regime in order to address any possible resistance to the standard Category I drugs.  This is a common problem for patients who have previously defaulted treatment (or who present with particularly severe disease).

Recently her sputum cultures, which can take up to 8 weeks to grow, returned a result of drug resistance, meaning that the medication regime has to be altered to combat the bacteria’s ability to produce enzymes which fight the standard Category I and Category II drugs.  So today a meeting was held to discuss her case and determine whether she is prepared to commence the long treatment regime.  This preparation includes medical / clinical condition as well as psycho-social preparedness for a long course of potentially toxic medications.  This psycho-social preparedness includes a good understanding of the disease and treatment, possible side effects, preventive measures to be taken against infecting others, treatment adherence, follow up and social issues such as family support and financial concerns related to the loss of employment which inevitably accompanies a DRTB diagnosis.

The medical team started the meeting with her medical history and clinical presentation.  The nursing team then discussed their insights.  The previous treatment default was a concern as it means she has a higher risk of defaulting again, but this was explained by the fact that she had previously been required to pay for the treatment.  The situation has improved markedly in Cambodia in the past ten years and patients are far less likely to come up against illegal charges for TB treatment which is supplied without cost.  Without this barrier, the risk of her defaulting now is minimal.  Time had been spent explaining the treatment regime with her and she was encouraged to speak to two other patients who have been on the same medication regime as is being recommended for her.  After meeting with these people she felt reassured that she would be able to tolerate the treatment.  The nursing team’s conclusion was that she was appropriately informed and prepared.

The social work team were then asked for their input.  The first statement made about her was “This patient is in financial crisis”.  Who isn’t, I thought to myself.  She borrowed money to start her own business, cooking noodles and selling them from her home.  She needs to continue working in order to meet the monthly repayments.  She expressed concern that the treatment may not cure her disease, and reassurance was given that TB is a curable disease, and that with good adherence and recommended follow up, the aim of treatment is cure, but it would be months before we could tell her with any certainty, whether this was achieved.  The conclusion from the social workers was that she was ready to commence treatment but that she is keen to go home as soon as possible in order to continue working so that she can meet her debt repayments.  She is required to make monthly repayments of 18,000 riel per month (US $4.50) and the total debt is US$100.  Her loan is to a neighbour, not to an organisation.  Again I found my brain readjusting to the idea of $100 causing someone long term financial stress.

Cambodia has changed my perceptions and understanding of the world in very many ways.  But this has to be the most significant yet.  How can an amount that many people from my world earn in a single hour, be so catastrophic to people in this parallel universe?  How did I never know this to be the case before now?  As I got up to leave one of my colleagues stopped me to explain that in Cambodia there are a small group of powerful people who have far too much wealth, which they keep in banks in “Sweden?  Switzerland?  No, it’s Sweden”.   They spend $20 every single day on their dogs, drive big cars and lavish various other extravagances on themselves, but they do not care at all about the people, and most of the people are extremely poor like this patient.  As he criticised this small group of Cambodians, I pondered on the position that we in the western world hold in this scenario.  Third World plights are a global issue, not separate national issues.  Cambodian people are exactly like me and if my own country’s history was anything like Cambodia’s, then I too would be surviving this fate.  Civilisations rise and fall and the West would be very wrong to assume our futures or those of our descendants will never face such struggles just because we have a comfortable existence today.  Meanwhile, being able to occasionally help someone in some small way is far more fulfilling for me than it could ever be for the recipient.  The experience for me has little to do with providing financial relief and everything to do with helping someone with an extremely inferior position in the world, to feel valued.

Meanwhile other discussions with patients have included a 58yo man whose grandchildren aged 7yo and 10yo are staying at home alone while he is hospitalised with his wife as his carer.  The children are on school holidays and they have noone to cook for them while his wife stays with him, so she spends a few days in hospital and a few days at home with their dependent grandchildren.  The children do not have a mother and their father lives at the other end of the country where he works on a rice farm, visiting his children for a couple of days each month.  I said that I would take some colouring-in books to the children when I visit them and their grandfather did not know what colouring-in books were.  Win tried to describe them to him but he had never seen such a thing and he looked blankly at us, unsure what we were talking about.

Another patient is a man in his 30s, father to two young children and employed as a teacher at his village school.  Next week he is sitting his own high school exams.  This indicates the current level of education in Cambodia.  In the 1960s Cambodia had one of the highest literacy rates and most progressive education systems in South-East Asia.  The University of Phnom Penh attracted foreign students and thousands of young Cambodians attended universities abroad, including Saloth Sar who attended a technical school in Paris for four years.  He then returned to Cambodia, where he became known as Pol Pot and led the Khmer Rouge on their communist revolution, during which 80% of the country’s academics were murdered.  By the end of the Khmer Rouge reign of terror in 1979 Cambodia had less than 50 doctors and their pool of 25,000 teachers had been reduced to 5,000.  It is hardly surprising then, that today there is a discrepant situation with high value being placed on education, but too few human resources available to meet the demand.

This situation has also resulted in the high demand placed on Barang (western foreigners) who come to Cambodia and is the reason I find myself recruited to all kinds of endeavours which I would never have considered applicable before my time here.  It seems another absurdity that those least in need of opportunity are those with the most opportunities available.  I guess it is no different to the First World, where the wealthier you are, the more educated you are likely to be and the more likely you are to know people who can help you reach your goals.  In Cambodia it is a very exaggerated scenario, which is the case with so many facets to life here.