Africa, Asia and Australia in a Day

Back in familiar surroundings, my days are going to be less blog-worthy for a while, but I’ll write when something of interest happens.  Yesterday was blog-worthy so here I am!

As a well resourced country Australia has the facility to respond in an influential way to emergencies of international importance.  A current example is the West African Ebola outbreak.  Disappointingly our government have taken a very parochial approach rather than offering leadership and increased capacity at the source of the outbreak, where the biggest impact at halting the epidemic can be ensured.  This has brought the government under severe criticism from public health experts including Medecins sans Frontieres (MSF) who have been the leading aid organisation treating Ebola patients across West Africa since the outbreak began.

About a year ago a group of alumni from Australian National University’s Master of Applied Epidemiology recognised the gap in Australia’s ability to coordinate a national or international response to infectious disease emergencies.  To address this gap, they formed a group named Australian Response Masters Network (Arm Network) and tapped into their professional networks to increase membership.  Supported by University of NSW, Australian National University and the Burnet Institute, Arm Network exists to provide standby for emergencies in Australia or requests from bodies such as World Health Organisation, for assistance in international infectious disease emergencies.

Yesterday ARM Network ran a one day Ebola Infection Control training workshop at University of NSW’s School of Public Health.  I was one of approximately fifty attendees from various walks of life including GPs, epidemiologists, virologists, paediatricians, infectious disease physicians, infection control nurses, public health nurses, aid organisation administrators and many others.  Some of the group attended because of their involvement in implementing Australia’s domestic response in the event of Ebola cases being diagnosed here and others like myself were there because of plans to work with overseas aid organisations in affected areas.

The training included information on microbiology and clinical features of the virus, epidemiology, modes of transmission, principles of infection control, MSF’s response to the current outbreak, specimen collection and handling, experimental drugs, vaccine development, socio-cultural issues, health systems and much more.  A range of presenters came, we had practical demonstrations of handwashing and how to “don” and “doff” the Personal Protective Equipment (also known as PPE, this refers to the paraphernalia such as hoods, masks, aprons, boots etc worn by Health Care Workers in known infectious areas of treatment centres or hospitals) and a panel discussion led by a group of Epidemiology students from West Africa.

One of the most interesting points, from a thoroughly interesting day, related to the issue around transmission of Ebola virus.  It is thought that the virus originates from bush meat which is hunted, preserved, cooked and eaten throughout this area and includes such things as bats, antelope and monkeys.  A certain type of fruit bat is the most likely reservoir.  Once the virus enters a human host, a series of processes occur which not only lead to illness in the host, but also allow the sick host to transmit the virus to others.  Since the virus was first identified in 1976, direct contact between humans has been considered the main transmission source of Ebola outbreaks in human populations.  However yesterday we heard about the clinical complexity of infectious diseases which rarely have a unimodal transmission, meaning that there is usually a main route of transmission (eg direct contact, as with Ebola), but it’s always possible that other transmission routes may occasionally occur in certain, perhaps unusual, circumstances.  An example might be respiratory transmission if a virus normally only transmissible by direct contact is aerosolised.  For instance if Ebola-infected fluids were sprayed with a full force hose, this could potentially suspend virus particles in the air and give them the opportunity to be inhaled.  Currently this is only a theory and it is not a known transmission route of Ebola virus.  However, it has been the basis of some recent controversial debates in public health circles.  It should also be noted that in a scenario such as this, virus particles would be diluted, therefore also reducing the possibility of transmission, which is a good case-in-point regarding the complexity of pathogen transmission.

Health care acquired infections are a significant cause of illness and death worldwide.  Every year approximately 75,000 Americans die from infections acquired in hospital.  This number must be much higher in third world countries where standards are lower, resources much more scarce and surveillance systems are non existent, such that WHO do not provide any estimate of numbers that I can find.  The number of infections leading to illness and morbidity without death are even higher. Some of these infections occur in Health Care Workers who are at high risk due to the nature of the work they do, being exposed daily to patients with various illnesses.  It is therefore amazing that in all of the Ebola outbreaks in Africa until this year, only a very small number of Health Care Workers contracted the disease despite their exposure to unwell patients.  This has been thought to be a reflection of how difficult it is to contract the virus, which is mainly transmitted by direct contact with infected body fluids and requires an entry point such as mucous membranes or broken skin.  A common statement heard in the media is that “unless a patient who is sick with Ebola bleeds or vomits on you, it is very difficult to contract the disease”.  This statement is not untrue but it does omit the issue of “clinical complexity” in disease transmission, where on occasion other routes of transmission may occur.

The current Ebola outbreak has been exceptional in many ways.  More people have contracted the virus in this outbreak (over 8,000 with exponential rises predicted), than in all previous known outbreaks put together.  The case fatality rate is approximately 50%, largely due to the inability of health systems to respond appropriately.  It is the largest and longest Ebola outbreak in history.  It is the first time Ebola has occurred in more than one country simultaneously (with a case recently diagnosed in Mali, there are now six African countries which have been affected, as well as a number of western countries).  It is the first time Ebola has affected urban areas and capital cities.  It is also the first time that person-to-person transmission has occurred outside of Africa.  As such, if we do not have selfless reasons to feel concerned about the inappropriate international response, we should surely develop selfish cause for concern?

WHO states that previously Health Care Workers became infected with Ebola before the disease was identified and that the numbers of workers falling ill fell dramatically once appropriate protective measures were implemented.  They also say that the chains of transmission in previous outbreaks were far easier to break than in the current outbreak.  This year to date more than 400 Health Care Workers have contracted Ebola virus and approximately half of these have died, including the leading viral haemorrhagic fever expert in Sierra Leone, Dr Sheikh Hummar Khan, whose death is a huge loss to the battle against Ebola.  Infected Health Care Workers have mostly been local staff, but it also includes a handful of expatriates returning to their country of origin before becoming unwell, as well as two American nurses and a Spanish nurse who contracted the virus whilst nursing returned expatriate patients.  Yesterday New York announced their first case of Ebola, in an MSF doctor returning home to Manhattan after spending time in Guinea.  Thankfully for this tiny minority of victims, the chances of survival for someone being treated in a first world hospital are much higher than those being treated in Africa where health systems have effectively already collapsed.  Contact tracing, the only effective way to break the chain of transmission, is also likely to be much more thorough in countries which are well resourced.  This excellent seven minute video piece from the New York Times shows the state of health care in Monrovia, Liberia, where one epidemiological study has predicted up to 70,000 or more people may die of the disease by mid December.  Clearly these circumstances are vastly different to the circumstances that patients in western countries find themselves in.  http://www.youtube.com/watch?v=ZBbsnyqlihs  (This video is less than 8 minutes long).

The number of Health Care Workers becoming infected in the current outbreak has been particularly contentious as assumptions have been made that PPE protocols must have been breached by the staff infected, for this to occur.  However, the possibility that current guidelines are inadequate, or that the virus in these cases was transmitted outside of the person’s workplace are valid suggestions which were demonstrated yesterday in a very entertaining but somewhat disturbing timeline of events.

This leads me to the debate that has been raging about transmission of Ebola, how easy it is or is not to contract, what PPE should be recommended and whether assuming a breach in protocols without any evidence to suggest this, is an appropriate response.  It’s perfectly understandable that the Director of the American Centers for Disease Control would want to call for calm in the escalating media storm but he has come under a lot of scrutiny and criticism, which is best demonstrated by the below footage of Tom Frieden being interviewed by Megyn Kelly.  Kelly is not without her own hysterical leanings, such as her recent criticisms of the New York doctor who in fact did quarantine himself as soon as he knew he was unwell, and her calls for a travel ban from West Africa.  Such measures are not only pretty much impossible to implement, but they are also known through experience (eg public reactions during the H1N1 pandemic in 2009) to have an opposite effect than intended – encouraging people to behave dishonestly and making the disease even harder to identify, which in turn increases transmission rates.  I also disagree that Tom Frieden was lying because following the MSF protocols required of him at a Treatment Centre in Liberia does not mean he was dishonest about what he would feel safe doing.  However, the way it played out on Fox News was more than a little unfortunate!  It does also highlight the need for consistency where PPE recommendations are concerned and for an alteration of protocols when they appear to be failing.

http://www.youtube.com/watch?v=zKYwjXTN5nA  (This video is less than one minute long).

The longer interview between Kelly and Frieden can be seen here, and is worth watching too.  http://www.youtube.com/watch?v=Lz1I2UAlI8I  (This video is less than 10 minutes long).

It’s a long and fascinating subject, but if I don’t stop now I can’t move onto my next topic, so I am stopping.  Not before I share one more video though, for entertainment purposes, showing the difference between USA and UK media outlets in their coverage of the Ebola outbreak.  http://www.youtube.com/watch?v=lAz-F1QnyCk  (This video is less than 4 minutes long).

After my fascinating day in the classroom, I dashed home, got changed into my best evening dress and jumped in a cab to a big converted warehouse on the waterfront at Pyrmont, where Cambodian Children’s Fund were holding their 10th Anniversary Gala Dinner.  Due to a combination of expense and other commitments I was unable to find anyone to go with me and so I put on my Brave Hat and turned up alone, encouraged by reassurances over the phone by the conference organiser.  At a beautiful venue with views of the Harbour Bridge and the cityscape, I mingled with some lovely people with varying connections to CCF.  I met teachers who have raised money through their small community, volunteers who have worked with CCF, not-for-profit workers involved in administration of funds, some family members of CCF’s founder Scott Neeson, and even some of the CCF children who attended the event to tell their stories.  Lisa Wilkinson was MC for the night, items were raffled, charity packages sold, various people presented, drinks and gourmet food were served, the John Field Band played popular jazz music between presentations and a good time was generally had by all.

Overriding all of that, was the amazing experience of hearing first-hand from some of the children whose lives have been transformed by CCF.  Video footage was screened of Scott Neeson at the Steung Meanchay garbage dump in Phnom Penh, approaching children scavenging for a living amongst the city’s waste and asking them if they would like to study at CCF.  Two of the films were recorded nine years ago and each showed a young child ploughing through infinite piles of wet, smelly, dirty garbage, navigating around unloading garbage trucks, searching for anything worth recycling.  The children, covered in dirt and dressed in rags, spoke to the camera in Khmer about their lives and experiences, describing deprivation of such magnitude that it is difficult to imagine.  One young boy told of how he stopped to bury the bodies of babies when he encountered them amongst the rubbish.  It was nothing short of horrific, and the footage of Neeson approaching them was brief, showing none of the ensuing events when clearly parents and families were approached and processes put into place to allow the child to put down their sack and enter a classroom for the first time in their life.

At the end of each of these heart-rending films, each child – now a young adult – stood in front of an audience of over 200 Australian adults in an environment nothing less than deluxe and spoke in fluent English, describing what had happened to them since this video footage was filmed.  Dressed in smart clothes, well educated with ambitions and hopes for their futures which eclipse the filmed comments such as “I am destined to be poor”, they spoke of wanting to become a video editor, a doctor and a fashion designer.  The fashion designer hopeful has already been offered a lucrative contract but has put her plans on hold while she works at CCF, providing social support to her elders and teaching English to children in her neighbourhood.  Her desire to help her community reflects the community spirit, leadership and compassion that the children at CCF are also growing up with.  Listening to her and the other young people speak, I doubt that there was a dry eye in the room.

The world’s garbage dumps, slums and ghettos must surely be filled with young potential such as this, who could never imagine the possibilities CCF has extended to these Cambodian children.  They are living proof that a little coordinated humanity towards even the most destitute in our world can reconstruct futures and revolutionise societies.  Work like this could have a momentous influence on communities across the globe and I doubt I am the only one who hopes that it does.

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Worlds Colliding

It’s nice to be home!

With Sydney’s 55km Spring Cycle Challenge behind me (Sunday was a beautiful day for it and despite cycling amongst the hoardes, it was relaxed and without accident), I now have many other commitments ahead of me.  Visiting various friends and family, attending a day of Ebola training, the Sydney to Woollongong cycle and various other obligations are planned.  Being on paid leave I now cannot work for a salary but MSF seem to think they can get around this issue by putting me on a “zero contract”.  As such I have given them the end of March as my next availability, this time only on a short mission of maximum three months.  I hope to get some experience on a vaccination or outbreak response next.  It would be very interesting to work with Ebola, but hopefully by March the current outbreak will have been reined in.

Upon return to Sydney I was obliged to attend a debriefing at the office which was about two hours long and involved seeing Human Resources, Communications, the placement officer and then talking by telephone with the Tokyo office about my experience and providing them feedback on the program which I just left and if/how I view my future plans with MSF.  It was an effective way to feel some closure to my experience.  I can also sense a shift in approach, moving from my status as a “first missioner” to someone with a year of MSF experience behind me.  Previously I wasn’t given much choice as to the type of mission I would like to do but now they are talking to me about my preferences, further training needs, etc.  This leaves me in a bit of a quandary as I consider whether I want to stay in my currently-on-hold position in Alice Springs, where I have friends, a home, stability and familiarity; or if I want to make a career/life move towards permanent humanitarian work in the third world.  Luckily I have another year to think about this.

Today I have spent a chunk of time on the telephone trying to work through the complications of how we might put the orphanage in Cambodia onto an Australian-friendly system so that Australians who are interested might make donations.  The orphanage is a registered charity in Cambodia and France, where we have bank accounts.  Australians wishing to donate currently have to make international transfers which have significant bank fees attached to them.  I have spoken with the Australian Charities and Not-for-profit Commission and also the Australian Tax Office.

In short, more for my own records than because readers would find this particularly interesting, to open an Australian bank account linked to the orphanage, we would need an Australian Business Number (ABN).  This is a complicated process requiring applications through the Department of Foreign Affairs and would take at least, probably longer than, a year, with no guarantee that it would be approved.  If approved, then once we have an ABN we would then need an Australian Board of Directors to administer funds because foreign nationals do not meet the criteria for administering funds raised in Australia.  The current Board of Directors consists of Cambodians, French, an American and myself.  It is not possible to open a bank account in the orphanage’s name without an ABN, so it’s a catch-22.  The alternative is to find an Australian-registered charity who would be willing to act as our agent in receiving and distributing the funds.

While I understand the need for rules and regulations it seems that these things could potentially be made much easier if there was coordination between first world nations relating to third world charities, where funds are so desperately needed?  Meanwhile children in a very high needs country sit precariously in wait of an unknown outcome for their future.  While it was so easy for me to raise money for an Australian fundraising event (the Sydney to Woollongong cycle which raises money for Multiple Sclerosis sufferers in Australia), it’s astounding that raising money for vulnerable children in a poor country is so much more complicated and difficult to achieve?  I have approached four large Australian charities asking for assistance in this regard.  With any luck we may find someone willing and able to receive funds in Australia on our behalf.

While that is going on, after a year of advertisement-free living I’ve been surprised by the amount of “native advertising” which takes place on our news programs.  Yesterday there was a multiple-car pile up in northern Sydney after a truck’s brakes failed (noone was killed and injuries reported were minor, miraculously).  A reporter speaking from a helicopter above the scene transitioned from events occurring below him on the motorway, to how you can purchase a new Mazda motorcar, as though the Mazda was somehow connected to the accident below – which surely wasn’t a good association!  To ears not used to this form of advertising, it is quite disconcerting to see our news, which is already so melodramatic, dumbed-down and entertainment-based, infiltrated by such blatant commercialism.  On the other hand I got to see Judge Judy for the first time in over a year (just to show that I am not 100% against commercialism)!

In 2.5 months I will be back in Cambodia.  Meanwhile, I don’t think it’s really going to take me so long to step back into my First World existence.  The only thing I can say about that, is how incredibly lucky I am to have such a choice.

Special Farewells

A quick message from Phnom Penh Airport.

Last night I received a message from one of the Alice Springs town camp kids I have known since she was five years old.  She is a real stand-out and now at 16, attending boarding school with a focus on her education which if you knew where she comes from, is no mean feat.  I was so chuffed to get this message from her:

Hey Helen how are you going ?  Um I was just wandering what’s the job that you are doing called?, because I’m thinking about doing something like what your doing when I leave school

If that wasn’t uplifting enough, as I checked my emails at the airport, twelve separate emails arrived in my inbox from the orphans who are learning to use email and obviously continuing with their English studies.  Each email is a little different but here are a couple to give you the general gist:

hello helen
how are you?
i love you
i like banana, i like apple, i like coconut,
i like orange,i like tomato,i like to swim,
i like skate,i am happy,thank you helen
i am fine thank you
i like to go to skate with you
i want to study English
i love you helen thank you

And another:

hello helen
how are you?
i love helen.
i like basketball
i will be a guide
i will skate
i like study english
i am happy.
i like study computer.
good bye

Win rang me at 4pm.  He knew that was check-in time and wanted to ensure I didn’t need anything.

I leave Cambodia feeling very loved and the feeling is returned!  Thanks and Goodbye, Cambodia!!

Here in Subcity

There’s something quite exotic about the streets of Phnom Penh, especially at night when I regularly get a sense of being inside a historical South East Asian novel, which I don’t ever recall reading.  The closest I can think of is the film The Best Exotic Marigold Hotel which is set in 21st century India.  The main streets are busy, crossed frequently with quiet laneways where people sit outside their houses in the dark alongside smelly canals lined with the city’s waste and various rubble, watching the world go by.  Motos and tuk tuks putter past, dogs bark, children play and sellers continue to offer their various produce from sidecars, traybacks and wheelbarrows moving slowly through the streets.  Just driving through the darkened streets on a rumbling old tuk tuk makes me wish I were a novelist.  Alas that is not what I am!

Yesterday my colleague arrived at the house and carried my oversized case down the stairs on his shoulders, wrapped it in a big tarpaulin on the trayback of the work ute and drove me out of town, south-west towards Phnom Penh.  My year-long mission is over and I have begun my journey home.  My manager was returning from Phnom Penh so we did the regular halfway meet, swapping cars and drivers.  Texts, emails, Facebook messages and phone calls have arrived steadily from people I am already missing, particularly little Dara who my housemate sent some previoulsy-unseen photographs of.

The driver from Kampong Cham is a guy I came to know well over the past year as we have driven hundreds of miles together, visiting patients, families, health centres and home based care nurses across the province.  A little younger than me, he was born during the Pol Pot regime.  His story has always touched me, probably because we were growing up simultaneously in parallel worlds.  While I was riding bicycles, jumping on trampolines, going to swimming club, Brownies, birthday parties and decent schools, he was surrounded by Khmer Rouge soldiers and then labouring in the fields to ensure the family’s food security which was always a temporary guarantee.  He is now married with a child and lives 4 hours drive from his young family.  His wife spends the busy season at home in the rice fields and during the quiet season she leaves their infant at home with her parents and moves to Phnom Penh to work in a garment factory, earning $70 per month for her sacrifice.  With MSF talking of closing their Cambodian program he is preparing to return to the family farm as the chances of re-employment are so low.  The advantage of this probability is that he will get to spend time with his daughter who he currently only sees one weekend per month.  His wife is talking about going to work in Malaysia as a factory worker, where she can earn more than is possible in Cambodia.  He is a quietly spoken, smiley, fun and gentle guy who tells his story matter-of-factly with the odd comment such as “yes it is very difficult”.  We said goodbye just outside of Skun on the red dusty highway, hugging in the shadow of a truck loaded sky-high with sacks tied metres above the cab, which threw dust at us as it chugged by at an arm’s length from us.

The Phnom Penh driver who took me the rest of the way to the city is a man I also know reasonably well.  In his 50s, dressed in smartly ironed suits and spectacles and speaking excellent English, he gives an impression of being middle class.  Spending most of my time in provincial Cambodia, only visiting Phnom Penh occasionally, it has also been easy to assume that Phnom Penh inhabitants are more urban and prosperous, which is certainly true of some individuals.  Last time I was in a car with this driver, he stopped along the road to visit his sister in law briefly, who was not well.  On that particular day we waited in the car during his five minute interlude.  Yesterday I asked after her and he said she was still not well, unable to walk on her leg and not able to move the arm on the same side.  Thinking it sounded like a stroke I asked what her doctor had said and he replied she had not seen the doctor because she had no money.  As we were driving near her home I offered to stop in and visit her in case there was something I might be able to do to advise.  He agreed.

We pulled into the side of the highway, along a parallel side road with a row of the usual elevated wooden houses where he told me his family all live as neighbours.  His sister in law was sitting alone on her raised verandah with two bowls of food on the floor beside her.  We kicked off our shoes and climbed the stairs to her.  Blind and clearly suffering with acute arthritis in a number of joints, he explained to me that she had been blind since birth and had never married.  Within a few moments a younger man climbed the stairs to join us, accompanied by a young boy of about 12yo.  My colleague introduced them as a nephew and his son.  This man and his older brother, also living in this row of houses, are also blind.  Noone knows why certain members of the family have hereditary blindness.  I asked how they obtain food and was told that the blind men are able to work in the rice fields!!  The woman, immobilised now by her arthritis, stays at home alone and the children of the family – I met five of them, the eldest being the 12yo boy – keep an eye on her from the neighbouring houses while the adults are working.  I wrote the names of some medicines that might help her if she can access them and gave a little money to assist her in affording them for a brief time.  Their gratitude was as strong as my horror at their circumstances.

Across Cambodia these are the ordinary and everyday stories of people.  Every time I see a trailer piled a storey high with cardboard or a motorbike framed in it’s entirety by bunches of bananas driving down the motorway, I realise that the amusement I am experiencing also has a story of persistent adversity behind it.  Not one of the hundred or more people I have worked with and come to know in the past year is separated from this ubiquitous poverty.  As a foreigner visiting the country, it is easy for the destitution and hunger surrounding us to be invisible to our first world eyes.  We are not only regularly entertained by the staggering creativity so commonplace on the streets of Third World countries, but we also expect poverty to have a certain “look” which it doesn’t have.  It has many faces and in my Cambodian experience it hides well behind handsome, well dressed young people in a country where half of the population are under 20 years old.

Writing my last blog from Cambodia for a couple of months (unless something extraordinary happens tomorrow), I sat on the mezzanine floor of a coffee shop sipping red wine, looking down a spiral staircase at the wealthy and mainly-Khmer customers on the marble floor below, their busy chatter echoing up to the chandeliers hanging parallel to my head over a decorative banister.  I wish this level of prosperity for all Cambodians, that they may all sit at plush tables with their iPhones and iPads, sipping iced coffee and wine with their friends and family.  Thanks to Tracy Chapman for entertaining me while I wrote – my current favourite croon from her is very appropriate to the topic, as Cambodia is the epitome of her Subcity.

Tracy Chapman – Subcity

Crying for Cambodia

As a young teenager in the mid 1980s Mum sent me off to boarding school and suffered severe consequences for her sins.  Noone is capable of shedding such sorrowful and persistent tears as the teenage me was.  Then in 1989 I traveled to London and spent the following six years living, working and studying in England.  Despite the amazing experience this turned out to be, I was still capable of regular tearful calls home to Mum.

On my first night in Kampong Cham almost exactly a year ago I went to my predecessor’s farewell party where a lot of dancing and frivolity went on around me.  I sat next to a quietly spoken Cambodian colleague only a few years older than me, who told me that he had lived through the Khmer Rouge and experienced some terrible things before his family decided to escape across the border to Thailand after the so-called “liberation” in 1979.  Thai authorities ordered them home through landmine-ridden jungle dotted with corpses, shot at them and they almost died from starvation.  When I got home that night, I remember thinking “wow… I just met someone who survived the Khmer Rouge”, as though it was symbolic of the year I was about to have.  I was right, it was symbolic and many of my colleagues have memories and scars from that era.

After working with and developing a very high regard for this particular colleague over the past year, last night at my final work function I found myself sitting next to him once more.  He was already speaking with one of the other expats when I joined in on the conversation and he was talking about the American bombs which fell on his province when he was a small boy.  The Khmer Rouge used villagers as human shields, forcing hundreds of people into their military headquarters while they inhabited the villages in order to survive the bombing of military targets.  He told us about the shrapnel damage his father suffered from the bombs and how incredibe it was that none of them were killed, and returning to their village where every house had been razed by the Khmer Rouge, including his pigs which had burned alive.  He had a young friend who attended a Khmer Rouge assassination in his village and returned telling a gruesome story about a man sliced open alive and having his liver ripped out.  This friend was “marched away” by Khmer Rouge soldiers some time later and my colleague regularly wakes in the night even now, worrying about what went through this friend’s mind as he was marched to his death, or the manner in which he might have died, knowing the atrocities they were capable of.

The same day that the Khmer Rouge captured Phnom Penh in April 1975, my colleague’s 2yo brother died of Measles.  “My brother was a very lovely little boy.  To lose him like that was terrible.  For one year I did not smile”.  His family tried to move north towards the most peaceful area of the country, piling seven into a car with all of their belongings and traveling through hundreds of road blocks, each of which was manned by guards demanding bribes to allow them through.  But the Khmer Rouge infiltrated the whole country and they spent the next four years separated into communes which were moved regularly, so he spent periods of time living near his mother, father or siblings, and periods apart from them, depending on where he was ordered to live at any time.

They lived on rice water.  Rice was boiled and fed to the Khmer Rouge soldiers who controlled everyone.  The citizens “ate” the water that this rice was boiled in.  On one occasion it was raining very heavily and the rain was falling into his rice soup,  In order to stop any further dilution of his only calories he tipped some of the rain water from his bowl and a Khmer Rouge soldier who saw him doing so accused him of being a capitalist who was used to eating well.  This was a very dangerous accusation and could have seen him marched to his death.  He remembers this soldier well and says “I last saw him riding a horse cart sometime after the war ended.  To this day I would recognise him and I feel that I would be entitled to do absolutely anything to him for what he put me through.  I would even follow him to Hell to ensure he got there”.  His life from 1975 until 1979 was spent focused on survival from starvation and threats of death by the soldiers controlling his every move.  “In the 1980s we saw pictures on television of Ethiopia and then Somalia during famine and I looked at these pictures of children and I recognised them because they looked like I had looked.  I knew what they were experiencing.  When you are so hungry that it is impossible to sleep and your belly swells and there is nothing between your skin and your bone”.

When Cambodia was liberated from the Khmer Rouge by the Vietnamese he was in a commune with his younger sister, but in the excitement and fear of events, she fled.  He waited for her for a day before deciding he had to return to his family.  “I walked back to my parents.  It took me many hours to reach them and when I arrived I said to them, my sister is gone.  We had to assume she had been killed and we were so sorrowful and then, after two days, my sister returned.  It was unbelievable”.  The family (parents and five remaining children) then decided that rather than remain in the Communist regime which had “liberated” them, they would escape to Thailand for a chance at freedom.  They spent many days walking along a track which had been de-mined, so they knew it was safe to walk to the border.  Along the way they had to look for food and water.  At the Thai border, they entered a village and were held at gunpoint and robbed of all belongings.

They were then allowed to continue but upon reaching the border authorities told them they could not stay in Thailand.  The border guards had also set up a search hut near the refugee camp in order to strip search people as they crossed the border but journalists arrived with cameras to report on the situation and this plan was abandoned (the power of scrutiny!).  Almost immediately they were made to board a bus which drove all day.  The driver and conductor were very kind men who looked sad the whole journey and like their passengers, did not eat all day.  He now realises that they knew where they were taking their passengers.  They were disembarked in an area, given food and water rations, and told to walk in a particular direction back into Cambodia.  The area was heavily mined and there were corpses and injured people “one woman was trying to walk but her leg had been blown off and there was noone to help her.  I don’t know how far she got but she fell and died”.  They ran out of food and water and his father told them to wait while he went to a known stream to collect more water.  While he was gone a mine detonated in the distance and they assumed their father had been blown up.  They were mourning for him when he reappeared with the water he had gone for.  It took them a day to walk not even 200 metres as they tried to make their way through the landmines.

Somehow they all survived but his sister died “from a disease, I think it was probably Tuberculosis” in 1986.  His father died in the 1990s and his mother in 2008.  His other siblings are still alive.  Through all of these harrowing stories which I have rehashed via my memory of only a few of the things he talked about last night, he did not show any emotion, although he talked of his emotions, sadness and fear.  But when he talked of his mother’s death the tears streamed out of his eyes as he continued speaking, explaining the tears as “I try not to talk too much about her and what she went through because when I do the tears just fall out of my eyes like this and I have no control of them”.  Our eyes were streaming too and the thought went through my mind that “this is one time I am crying for a worthy cause” as I thought about where I was and what I was doing, and not to mention what I was probably crying about in my privileged world, as he was surviving his living hell.

As late as 1989, when I was probably roaming the cobbled streets of Covent Garden or seeing a West End show, he was in the mountains with his brother searching for gems, when they heard soldiers nearby who demanded they show themselves.  They stayed still in the thick vegetation and a soldier commanded his team to shoot into the jungle at them.  “This is the most afraid I have ever been.  But then they did not shoot and they eventually left the area without finding us”.  On other occasions he has been accused of being Chinese and of being Vietnamese, both accusations which at certain times, in certain places, have been life threatening.  His family changed their name in order to escape the persecution of being Chinese, although they mistakenly changed from one Chinese surname to another!  The Cambodian war actually only ended in 2000.

Now in his mid-50s he has four children, the youngest eight years old, who live in his home province in the north of Cambodia while he lives and works away from them, like so many other Cambodian men and women who I work with.  Land ownership is a tenuous thing, so families are forced to stay with their land while the breadwinner goes to wherever they are able to find work.  Women have three months of maternity leave and return to work many hours away from their tiny babies who are inevitably cared for by grandparents.  This is a very common theme which I have seen many times in the past year, and the same goes for fathers who work away from young families who they see one weekend per month, finances permitting.  These are the privileged Cambodians who can speak English or have other skills which make them attractive to employers, almost all of whom are Non-Government Organisations.  Their c.$500 monthly salaries make this sacrifice worthwhile.  Their situations are far more tolerable than the 80% of the population who work as subsistence farmers.

I like to think that things will only improve for Cambodia but there is reason to have doubt.  The government, headed by an ex-Khmer Rouge who defected and returned in 1979 with the Vietnamese to “liberate” Cambodia, are all-powerful and very wealthy.  The population are kept on their knees by systems which ensure survival remains the main focus – a survival which not everyone manages to win.  Visiting the paediatric ward at the hospital is the most extreme example of the depravity around me.  Dara’s mother is there with his big sister at the moment and I stopped to say hello yesterday just as a baby was passed to her from another mother in the bare concrete surroundings.  This little floppy baby lay in her arms looking sadly into my eyes, his hand limp when I put my finger into it hoping to feel a grip.  He just stared, silently expressing far more wisdom than any infant should ever have.  I was told things about him which I could not understand but it was obvious that the other mothers in the room had a lot of concerns for him.  A stark example of the lack of justice in Cambodia.

True peace is not merely the absence of violence, but the presence of justice ~ Martin Luther King

Millions of Monks

Cambodia has an impressive total of 28 national holidays per year.  That’s another 5+ working weeks of days off added to the annual leave people can take.  Not that most people are entitled to annual leave given that less than 20% work in occupations which follow the labour laws.  Most people work seven days per week, 52 weeks per year, just to feed themselves, many managing this in a less than adequate way.

Yesterday was not a public holiday but provincial towns including Kampong Cham held a big annual event of dragon boat racing.  Between 40 and 50 rowers per massive canoe raced on the river outside of our house during the day.  This was a lead-up event to the famous Water Festival which has it’s main celebration in Phnom Penh in November.  Unfortunately I only saw a very brief glimpse of the racing en route to work.  Over my year here I have seen many of these beautifully decorated boats sitting under shelters as we’ve cycled through their owner villages.  The purpose of yesterday’s event was to put the boats and rowers from these villages onto the water in preparation for the bigger event in Phnom Penh, where they will all travel downstream in about a month’s time.  It was quite a sight, with dozens of oars on one boat moving in chorus, propelling the boat at some speed over the current of the Mekong.

In the evening small homemade boats decorated with food and candles were floated onto the river, apparently in order to send the ancestors back to their other-world after they visit as ghosts during the observance of the two week Pchum Benh festival.  It was a big and busy day for Kampong Cham, followed by a big and busy evening.

I went out in the evening to check things out, starting at a riverside restaurant where the young wait staff were busy decorating their paper and banana leaf boats and preparing to join the procession to the riverbank.  Variously adorned skiffs appeared from behind the bar amidst a lot of excited commotion.  At one point a young waiter appeared with a ceramic dinner plate bedecked with a bunch of bananas and a candle in the centre, which sent his workmates into spasms of laughter.

Processions began to make their way along the promenade, including one large ornamental boat carried on the shoulders of a crowd of men who chanted as they marched along.  Most others were small and humble, but there were swarms of people everywhere, both on foot and oozing out of vehicles which purred along the crowded esplanade at snail pace.  I found a place on the walled embankment to sit and watch the full moon rise as these symbols were released onto the water, enjoying the sight of two big boats cruising nearby, one of them a new riverboat with fairy lights and light music playing to a subdued crowd who I imagined probably had champagne flutes in their hands; the other a big old wooden barge with a crowd concentrated on the bow, clanging steel on steel in rhythm and shouting out boisterously.  As the symbolic boats were released some people were jumping into the muddy water to swim them out into the current; other groups were on small fishing boats, collecting the rafts wafting on the shores and transporting them into the middle of the river to release them again.

It was a busy, interesting event to be amongst and as I was sitting enjoying the spectacle, Chom called me and shouted into the phone “I am at the front of your house!”.  I shouted my location back to him and he said he’d join me.  Moments later he appeared with his wife and son and we sat for about an hour watching the small and large boats, swimmers etc in the river under the moon’s reflection.

This morning a million monks weaved their way in single file through the busy streets of town, collecting alms from shopkeepers in a slow procession which stretched for many blocks.  The sight of monks collecting alms is not unusual but I have never seen them in such numbers before.  Apparently during the Wet Season (which has been disappointingly dry this year), monks stay at the pagodas and do not seek their regular donations from the general public.  This gives farmers and others reprieve to grow crops or save their produce without having to make regular donations from crops which are not yet ready to be harvested.  Today was the beginning of the new season in Buddhism and so the monks appeared in full force to begin their alms collecting again.

Monks collecting alms in Kampong Cham today

Monks collecting alms in Kampong Cham today

Yesterday while cycling through town to get Dara his daily treat I noticed a woman I have seen before in the same spot, sitting quietly with two naked children.  Clearly hungry, I bought them a fruit shake and took it to her.  Ineptly I asked if she had clothes for the children and she indicated no.  She then lifted her sleeve and showed me a badly infected, cellulitic arm.  Horrified, I asked if she had been to the hospital and was told no.  Payment of user fees in the health care setting here is an issue which keeps many Cambodians indebted and I understood why she was wary of my suggestion.  I said I would return in the afternoon but by then it was raining heavily and she was no longer there.  Meanwhile I recruited Win who provided me with some hand-me-down clothes from his son and I had these in my bag ready to clothe the babies.  Today at lunchtime I managed to locate her and she immediately clothed the children who were rapidly transformed – it’s amazing how good a clean pair of shorts can look on a little grubby, raggedy street-dwelling body.  I rang Chom who agreed to join us and while waiting for him, I cycled to the market and got some fried rice and coconuts for them.

As I arrived back at their tree Chom pulled up alongside us at the same time as a man on a bicycle who parked up and joined her on her park bench.  The ensuing conversation revealed this was her husband and they had four older children who were in the streets with sacks on their backs, scavenging for recyclables.  Chom explained that we knew somewhere she could go to have her arm seen to and when she initially declined, we explained that there would be no cost attached which immediately changed her mind.  She left the 3yo boy with his father and boarded Chom’s tuk-tuk with the baby.  We traveled in tandem, bicycle and tuk tuk, and made our way to a clinic where she was able to see a doctor who dressed the wound and provided her with antibiotics as well as de-worming tablets for herself, her husband and their six children as a precautionary measure due to their living conditions and the childrens’ malnutrition.

We all returned to the same park bench about an hour later and the older children appeared, two stunningly beautiful girls and two stunningly handsome boys aged 13yo down to 6yo, all dressed in filthy rags.  Dad immediately dispensed the de-worming tablets to each of his children and they dished out the two serves of fried rice between them.  Chom talked to me about his perceptions, which were much like mine, that this was an impoverished and uneducated village family eking out a form of a living by scavenging in the city.  As I am leaving next week there is little I can do for them and I am learning that there are very few NGOs here who can help in any meaningful way.  I am also learning that this is not an unusual situation for people to find themselves in, as I realise that there are hundreds of sack-bearing scavenging children on our streets.

Children scavenging along the embankment during a tropical downpour, yesterday.

Children scavenging along the embankment during a tropical downpour, yesterday.

Around 4pm this afternoon I was in a meeting when a text arrived from Chom “How are you?”.  I replied “Fine thanks and you”, to his “Me too, no customer and lonely”.  I suggested a 5pm drink together and we met at a riverside restaurant to catch up.  We spoke at length about some of the things we’ve done together, helping Dara and his family, the lady who sold her hair, and the family we saw today.  He said “I feel like my life is really changed now.  Before I thought so much about money and how I want the car and I want the nice things, but I don’t think about that anymore, I just think about my family and my friends and I really like having you as my friend and to help people with you”.  Doch knea – same here!  He then told me that his mother-in–law’s neighbour was widowed recently and has no way of feeding herself and “I told her that maybe you can help”.  To which I agreed and with a grand total of $10 we were able to ensure she has a stock of one month’s worth of rice, soy sauce and other extras including some eggs and fish for protein.  He rang her to tell her and there were tears and many thank yous.

I think about the charity Cambodian Childrens’ Fund a lot, as they are doing such remarkable work in Phnom Penh with families and individuals such as those I encounter here.  Interventions such as ensuring children attend school while giving their parents alternative choices, caring for the elderly and widowed, providing much-needed health care, etc.  How amazing it would be to come up with a plan to implement something similar for the people of Kampong Cham and other provincial towns, who have so little with no alternative but to live on the streets, begging and scavenging.

Meanwhile, these are all little things I am going to miss being involved with over the next few months while I catch up with family and friends and take a holiday back in the parallel universe that I call home.

Measuring a Year

Life-changing, terrible, amazing, love-drenched, enlightening, emotional, sickening, indescribable.  These are a few of the many adjectives deserving of a mention in my attempt at summarising the year I just spent living in Cambodia.

There are a million ways to measure my year.

The number of people able to fit on a single motorbike is a good place to start.  I had hoped to see seven, which I know is do-able, but so far I’ve maxed-out at a mere six.  I will never view a family car, nor the need for one, the same way again.

The peculiarities of traffic on Cambodian roads continues to flabbergast me.  I keep expecting it to become mundane but it never has.  The evaporation of all semblance of road rage no matter what is going on around me has accompanied a simultaneous evaporation of road sense as I came to know it at home.  The best evidence of my new road behaviour is a recent head-on collision with another cyclist because we just didn’t think to get out of each other’s way in time, picking ourselves off the bitumen, staring at each other in shock for a moment and then cycling off without so much as a hint of annoyance.  Trucks brimming to the skies with produce, all manner of animals traveling in all manner of ways amidst the humans, museum relics from my grandparents’ era driving on busy roads, and of course motorbikes.  Millions of motorbikes.

In my final weeks six year old amputee Dara and I developed a little routine together of boarding my bicycle and cycling to the market for a treat (fried rice; fresh fruit shake; new pair of shoes; fresh coconut with the top sliced and a straw inserted through the opening; etc).  On one of our first mornings doing this, we were cycling through the busy market area, navigating around unloading vehicles, fruit-and-vegetable-laden motorbikes, horse drawn carriages etc on the narrow crowded streets where the single road rule is “be polite about it”.  One of the local tuk tuk guys friendly with Chom drove past and waved, spotted Dara on the back of my bike, did a u-turn and escorted us to our corner shop, waving to traffic and obstructing oncoming vehicles so that we could cross the road.  On the same day I was cycling back to work at lunchtime as Chom drove towards me in the opposite direction.  We called out in unison and both immediately did a u-turn, swapping sides of the road, laughing hysterically with a couple of unknown bystanders who had witnessed our impromptu comedy act.

Cycling alongside friends on motorbikes or tuk tuks is a familiar activity which I will miss.  Teenagers here ride in groups up to five-wide, chatting animatedly as they cruise in the evening breeze and I think this is why I enjoy the experience – it makes me feel young and carefree.  I will miss half-expecting to be joined by a friendly face wanting to travel apace me and chat or practise their English, or even just stare and smile before passing me by.  Today the friendly face was a family of three on a moto who slowed down so that their son could have an English conversation of “Hello, how are you, I’m fine, what is your name, my name is…..” with the Barang on her bicycle.  Many times colleagues have caught up to me and slowed down to socialise as we made our way towards the office or hospital together.

Cyclists holding onto the edge of trucks or the shoulder of a moto-driving friend, for a pedal-free journey is also common, as is children driving motos, children riding on the backs of water buffalo, men standing on empty wooden horse drawn traybacks, or sitting between massive blocks of ice or atop bales of hay as examples of the things old wooden carriages transport around towns across the country.

Women wearing their pyjamas to market, often as they side-saddle behind husbands, usually on motos laden with market produce squeezed and balanced precariously around the human bodies concentrating on the job of keeping things in place.  One of my colleagues insisted that we wear our matching pyjamas to work one morning.  I reluctantly agreed, and thankfully left the house as light rain was falling so I covered my fashion statement with a raincoat.  But I cycled to my favourite breakfast haunt where I then had to remove the raincoat, revealing a pair of pale pink, floral baggy pyjamas.  Not a single soul so much as gave me a second glance!  Ditto at work – the only people remotely interested let alone amused by our attire, was us!

The loss of my translator who was transferred to another section weeks before my departure is a big one.  Today he and his wife gave me a beautiful farewell gift, trumped by the card which reads “It’s nice to have known you, a good hearted person.  I really enjoy working with you.  I miss our conversation and visits to Dara.  I never want you to go back at all.  I wish I could work with you.  I have not felt bored at all.”  As they say in Cambodia, doch knea – me too!  They know that when I return in a few months, the first place I will head is to their front door!

So many things at work have been heart wrenchingly desperate and terrible.  But I have loved the beautiful patients and the fun loving, funny, lovable staff.  The parties and weddings, the dancing and the buffoonery are a forever-memory impossible to describe with any justice.  Khmer traditional dancing is a graceful oscillation of bodies gliding around a dancefloor centrepiece (a table, a tree, a bucket – anything will do!), supple hands rhythmically contorting like ocean waves in harmony with all of the other hands floating above the dancefloor.  The clumsy Barang on the dancefloor always elicited attempts at dance lessons which inevitably collapsed into crazy hoopla as the futility of all endeavours became side-splittingly ridiculous.  “Oh wow” are words I’ll always associate with judgements of my Apsara inabilities!  My very first night in town was spent at my predecessor’s farewell.  I was tired, dripping with sweat and uncomfortable, surrounded by strangers speaking another language but even then I knew that “Cambodian people know how to party”.  A year later this fact has been reinforced in the most fun and happy ways as I take home new dance skills and many crazy laughter-filled memories.

Restaurant service.  Red wine and beer served with ice.  Waiters and waitresses relaxed to the point of making “service” a questionable description of their role.  Rice for every meal.  $3 meals of gourmet standard.  Many friendships with staff as we teach each other our respective languages and laugh at each other’s obvious quirks.

Teaching English – a surprising pursuit which I never imagined in my wildest dreams I’d ever find myself enjoying.  All that comes with this – the seemingly infinite accumulation of hopeful students, getting to know people well without sharing a common language with them and the crazy new endeavour of trying to teach when I don’t have a clue what I’m doing!  Value placed on the English language has been an unexpected epiphany.  Bonding with a beautiful group of children would have to be the highlight of all.

Babies swung to sleep in hammocks slung between trees or foundation poles underneath elevated thatched houses.  Boats mooring on the riverside and their owners bathing in the Mekong, pouring pots of mud-brown water over their sarong-covered bodies.  Dara’s family living out their days in full view of the world at Shackville, bathing fully clothed from the plastic rainwater drum on the roadside.  Lots of memories of Dara, his three sisters, the workers they live with and the other children and community members who have been my most interesting neighbours.  Talking with colleagues who survived the Khmer Rouge and other horrors of mass violence which Cambodia is still recoiling from, and trying to understand their world as opposed to mine of safety and comfort.

Cambodia.  In short, an immeasurable experience.