Khmer Rouges Visits Australia

Sar Kheng has been the Minister of the Interior for Cambodia, and the Deputy Prime Minister, since his communist Cambodian People’s Party (CPP) lost the election in 1993.  You did not mis-read that.  I did say “lost”.  At a cost of $2 billion to the international community via a heavy United Nations presence during 1992 and 1993, this election failed magnificently as intimidation, murder and disappearance replaced the idea of “free elections”.  The country remained in a state of civil war until the year 2000.  It is not at all uncommon for journaists and other opposition to disappear or be anonymously assassinated in Cambodia to this day.  The leader of the main opposition party, Sam Rainsey, who has actually won at least two elections but never held his rightful position as Prime Minister, has survived a number of assassination attempts and for some years lived in exile outside Cambodia.

As with many others in the CPP, including the Prime Minister Hun Sen, Sar Kheng was a Khmer Rouge cadre during the genocidal years from 1974, until he escaped to Vietnam in 1978.  While other ex-Khmer Rouge who did not have the foresight or opportunity to escape across the Vietnamese border face trial for their crimes, the powerful CPP members undertake their roles as leaders of the country.  This week part of Sar Kheng’s role is to play guest of Tony Abbott’s government in Canberra.

Allegedly visiting to sign a new immigration and border protection agreement with his Australian friends, Sar Kheng claimed as he left Phnom Penh two days ago, that the refugee deal is not on the agenda for his delegation’s Australian visit.  He doesn’t want to “campaign for tourists”, and says that if the refugees don’t want to come to Cambodia then “it doesn’t matter”.  With $35 million of taxpayer money already on the table from Australia, I am sure it truly does not matter.  Meanwhile in Nauru, there are apparently 25 refugees willing to “hear what he has to say”, but despite being told Cambodian officials will hold meetings with them this week, this appears not to be the Cambodians’ intention at all.  Knowing what I know about Cambodia’s treatment of minorities, I can only say that this has to be a good thing.  Not that the Abbott government’s treatment of minorities is any different.

While this extravagant and despicable folly plays out in the shining and well-fed halls of Canberra, Bunong tribal people in remote Cambodia are being coerced and intimidated by authorities to submit their thumbprints onto papers which they cannot read, in the midst of a land dispute.  By the end of this month, if they do not provide their thumbprints, “further measures will be taken”.

The Montegnard minority of Vietnam’s central highlands are also facing persecution in their homelands.  Many have escaped into Cambodia and been repatriated home almost immediately without due process.

The Australian government are closing down indigenous communities in remote Australia which sit on land which appears to be of mining interest.

Similarities between the communisit ideologies in Cambodia and right wing ideologies in Australia are clearly very close indeed.  The thought of being a pawn in the games of these amoral and powerful players does not bear imagining.

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El Pais on Tuberculosis in Cambodia

In the past year two different Spanish journalists passed through the TB Department in Kampong Cham, reporting in El Pais, one of Spain’s leading daily newspapers, about Medecins Sans Frontiere’s work.  The earlier report dated 22 October 2014, “Cambodia Advances in the Fight Against Tuberculosis” by Ana Salva, is longer and more difficult to copy / translate, but the link for those interested is http://elpais.com/elpais/2014/10/21/planeta_futuro/1413906960_427611.html.

The most recent article includes this fantastic series of photographs and accompanying commentary by Manu Mart, who visited last month.  These appeared in El Pais last week.  I put the Spanish commentary through Google Translate so it may not be precise.  The direct link to the Spanish article is below.

The Multiresistant Cambodia

El Pais 001

The Image of the Sick

El Pais 002

Lung x-ray of a healthy person (right) versus a patient with pulmonary TB (left).  Cambodia rank second in the world in terms of TB prevalence of the disease, with 800 people per 100,000 having active TB.  60,000 people develop TB each year.  The existing health system only identifies 25,000 to 30,000 of these cases, which is a huge gap in the detection of the disease.

The Bacteria

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Tuberculosis spreads from person to person through the air and is caused by bacteria which mainly affects the lungs.  When a person with active pulmonary TB coughs, sneezes or spits, the bacilli are expelled into the air.  A person only need inhale a few of these bacilli to become infected.  When the disease becomes active symptoms include cough, fever, weight loss, night sweats and more, which can be mild for many months.  As a result patients are slow to seek medical attention, while passing the bacteria to others.  Over the course of one year an infectious patient can infect 10 to 15 others who he/she maintains close contact with.

The Waiting Room

El Pais 004

Patients wait their turn to be seen at Kampong Cham Hospital, a town 130km from the capital Phnom Penh, where Medecins Sans Frontieres has a diagnostic and treatment unit where it has worked for 20 years.  Before patients receive a comprehensive survey, staff take their blood pressure and check their temperature.  This assists in determining if the patient may or may not be infected.  Staff and patients wear masks due to the high risk of contracting the disease.

Four Tenths

 El Pais 005

A few degrees of fever can be key in identifying the presence of disease in a patient, in this case a girl.  Many cases occur in rural areas and patients do not go to the hospital until their disease is well advanced.  Last year, MSF launched it’s program Active Case Finding (ACF), a small mobile van with which they can access remote areas, home to about 80% of the Cambodian population, to identify and refer TB patients.

Chan Lammaq

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Chan Lammaq, 30yo, is infected with Multidrug Resistant TB (MDRTB), a variant of the disease requiring more lengthy and costly treatment with greater side effects.  Since 22 December 2014 Lammaq, a mother of three, has been in hospital.  Two of her children now stay with their grandmother and do not visit because they think they may have HIV.  This causes an immune suppression which makes their risks associated with exposure to TB worse.  Social stigma attached to the disease is one of the problems patients face and is another reason people present to health services late, as they try to hide their illness.

Sey Seang Mey

El Pais 007

Sey Seang Mey, 20 years old, went to the hospital because during the last year she experienced two of the clearest symptoms of TB: cough and fever.  X-rays showed a lot of fuid in her lungs.  In the photo, a medical team is preparing to perform a puncture to remove this fluid so that she can breathe normally.  A sample of this fluid will be sent to the laboratory for examination and to confirm whether or not she has the disease.

 Ngin Yim

El Pais 008

In the picture, Ngin Yim undergoes a blood test.  Among the elderly in Cambodia, like her, the prevalence of TB is three times higher than among the general population, so MSF have developed a screening among those over 55 years to identify those infected and thus prevent transmission of the disease.

Keo Phalli

El Pais 009

Keo Phalli, 25 years old, is infected with Multidrug Resistant TB (MDRTB).  She must take a combination of up to four different types of drugs.  For Phalli the disease is especially serious as two intestinal operations have left her bedridden for four years.  She weighed 22 kilos and her life was endangered.  In recent months she has gained some weight and some improvement in her condition is evident.

 Hoon Honc Sring

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Hoon Honc Sring, 45 years, was sick with MDRTB until 2014, when she completed 20 months of treatment and was completely cured.  In her case, she had family support and recovered at home, which encouraged  her to continue treatment.  She is still weak, but gradually making a normal life and has returned to doing odd jobs at the school where she taught before contracting the disease.

Cambodia’s Time

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Cambodia has still not reached their UN Millenium Development Goal targets, but TB prevalence, incidence and mortality have improved over the last ten years.  Later this year MSF will leave it’s program in Cambodia as they expect the government to invest more resources against the disease.  Since 2014 it spent only about 4% of it’s national program budget (about $30 million).  The country’s health system has improved since the devastating civil war which affected the country into the late 1990s, but Dr San is not too optimistic.  “The quality of care we have undertaken will be hard to match in our still-weak health system.  There is a strong awareness in the country, of the seriousness of Tuberculosis in Cambodia”.

Copied as directly as possible from
Manu Mart
La Multiresistente Camboya
El Pais newspaper
18 March 2015
http://elpais.com/elpais/2015/03/18/fotorrelato/1426695583_539489.html#1426695583_539489_1426697742

Worlds With, Worlds Without, Worlds Apart

Despite having worked with Tuberculosis for many years now, my world is very largely without Tuberculosis courtesy of the luck which I was born into.  TB exists in Australia at an annual rate of between 5 and 6 cases for every 100,000 people.  In 2013 Australia, with a population over 23,000, notified 1,256 cases of Tuberculosis.  Many, though not all, of these occur in immigrants from high prevalence countries.

For over a year now, I’ve been living and working in Cambodia which is mostly a country of “withouts”.  In reference to TB, the tables turn and it becomes a country of “withs”.  The annual rate per 100,000 people is 715, which translated in 2013 to over 39,000 cases for a population of slightly more than 15 million people.

Before leaving Kampong Cham one recent Sunday, Bea, one of the doctors and I were out on a bike ride through the rural villages.  En route home we visited the young girl whose father had reported his concerns to me over his daughter’s regular migraines which have not resolved after some years.  During the informal clinical assessment he presented us with her health documents, which included a TB treatment card showing she was diagnosed and treated last year via her local village health centre.  Finding someone in Australia who was ever treated for TB, let alone in such recent times, whilst out and about on other matters, would be an incredibly rare find indeed.  Here, it is par for the course.  This is a practical example of the difference between TB rates in the two very different countries.

Today, 24 March 2015, is the 20th anniversary of World TB Day which was initiated in 1995 by World Health Organisation and has been recognised annually ever since.  Needless to say, Cambodia and countless other places have been alive with TB health promotion activities.  Teams were in market places and on the streets, delivering messages related to this year’s theme, of reaching the estimated 3 million people thought to contract TB disease each year without ever being diagnosed or treated.  This theme was started last year, and continued this year to promote it’s significance.

My old team have apparently had a fun day, out and about at various locations spreading the message about TB.  I was highly amused to find a photograph on Facebook of Chom, my tuk tuk friend, standing in this year’s green t-shirt alongside a dozen or more of my old team, at my old office!  His services were recruited to hang one of the canvas banners from his tuk tuk, with a loudspeaker attached to his roof, playing messages about TB as he putted his way through town all day.  That’s a solid day’s work for someone usually reliant on the rather unreliable tourist population, in competition with any number of other tuk tuk drivers.  About three years ago his father in law, Microphone’s grandfather, died of TB.  Another example of the fact that in Cambodia you don’t have to look far, to find connections with TB.

TB Day 2015

Cheung Prey TB Day pic

Cheung Prey World TB Day

In 1993 the United Nations instigated the first annual World Water Day, which is now held on 22 March every year.  On Sunday organisations throughout the world promoted messages about water and sustainability.  Thankfully I had already left Kampong Cham when their water supply shut down, which occurred sometime last week, continued over the weekend including throughout World Water Day, and remains in progress as I type.  Some areas are now into their second week of having no water at all.  None of MSF’s staff have access to running water, all are bathing by hurling pots of water over themselves from remaining tank water which is also running dangerously low.  Apparently it is a very uncomfortable state of affairs.  I left town at the exact right time!

MSF is currently supplying the hospital with two truckloads of water each day to keep things operational until the town supply is recitified.  This will probably be done by pumping river water directly into the town wells as a temporary measure.  A combination of no rain for months and high temperatures causing rapid evaporation has caused the town’s well water to dry up.  Locals report spending $2.50 per day on bottled water just to survive.  This is unaffordable to many if not most and no doubt contributing to the overburden of illness which already exists.  Many, such as Dara and the others in Shackville, are unaffected because they already live without proper access to water.  Shackville’s water supply is a homemade pipe system made by Dara’s father and colleagues, which extends from the Mekong, up the bank, over the road, and down into the concrete tubs sitting outside their tin shacks.  Every evening during the sunset traffic cruise which brings Kampong Cham alive, thousands of bicycles and motos drive over these pipes, which are protected by strips of wood placed parallel against the hoses as they pass over the bitumen.  Vehicles make contact with the wood sitting alongside the hoses, rather than the hoses, keeping them from traffic damage.

The point of recognition days such as World Water Day and World TB Day is to raise public awareness of their respective issues.  For those of us from the wealthy world it is extremely easy to incorrectly think that neither of these subjects pose a risk to us.  As an example, a very commonly held myth in Australia and New Zealand is that “TB was eradicated”.  For those in the poor world, promotion of accurate messages about both issues is a difficult and complicated thing to achieve.  Low literacy, stressful living conditions, mixed messages and priorities related to immediate survival make the delivery and processing of messages convoluted and difficult.  This is hardly surprising given the low levels of informed opinion which exist in the developed world.

On Thursday I’m leaving Phnom Penh for some time to visit friends and travel in Europe.  My excitement is tinged with flashes of the young blind woman in her remote village, who has fallen out of two elevated houses already.  When I return later in the year, the Mekong will be flooded and there will be no way of visiting her.  During recent visits to Dara in hospital I’ve met a number of other patients including a 12yo boy who is currently hospitalised with a deformed arm, which he broke falling out of his house.  This seems to be a common phenomenon in a country which requires houses to be elevated for the flood season.  It is connected to another common phenomenon – drowning.  Last year at a work conference held at a resort I had a really fun time swimming with my Khmer colleagues.  Young and fit, none of them swam as fast as me, which was clearly related to the fact that I received training as a child and have a proper swim stroke.  One of my colleagues asked me if I had taken swim lessons as a child and when I replied affirmatively he said “we don’t have swim clubs in Cambodia.  In Cambodia, if we don’t swim we drown”.

Yesterday I picked up Dara and his mother in a tuk tuk I negotiated for the day and we traveled to the city, spending about seven hours sightseeing together.  Mum, who cannot recharge her mobile phone because it requires reading numbers and instructions, had her phone in her hand all day and took more photographs than me!  She pointed to Phnom Penh’s tallest skyscraper (there are only two) and explained that she had been a construction worker on this site some years before Dara was born.  I took some photographs of her with this building in the background.  Below is a photograph of the same skyscraper, taken from a friend’s apartment a couple of weeks ago, with a construction worker on another site, in the foreground of this city landmark.  Clearly being a sightseer instead of a worker in the city, was a remarkable and new experience for her and it was special to share this time with her.  Inside the Royal Palace grounds I joked that I was staying in one of the fancy apartments across the manicured gardens from the Silver Pagoda.  She believed me!  Which is very similar to the perceptions that my Central Australian indigenous friends have of “whitefellas”, who they seem to imagine have no limits either financially, nor regarding possible high-falluting connections.

As we walked through the Royal Palace yesterday, Dara hopped along on his crutches with his one leg and I pondered about Tuberculosis, drowning, unsafe water, falling, traffic accidents, landmines, disease and all the other “withs” which accompany Cambodian life.  While I flit off to the other side of the world at great expense, the only “withs” in my life being privilege and advantage, what delights will Dara and so many others I know and love, face during (but regardless of) my absence?  Why do I get so much while others get so little?  As an MSF colleague who is currently in Sierra Leone on an Ebola assignment says, we have to make the most of our privilege whilst at the same time helping those who weren’t born into our extremely fortunate circumstances.  The problem for me is finding a balance between decadence in my favour and basic assistance in others’ favour.  I want to enjoy the decadence my lifestyle affords me but forevermore it will be tinged with flashes of Dara, the blind lady, Kim in Siem Reap and his extreme struggles, and so many others who cannot even imagine the “withs” in my life and their opposite connotations to the “withs” in a world that is “without”.  Life is certainly not black and white and I hope that upon return to Australia I can retain the insight I have developed of my infinite advantages in life.

Phnom Penh Construction Worker

Construction in the foreground of what are currently Phnom Penh’s only two skyscrapers.

 

Fifty Ways to Leave Your Lover

The problem is all inside your head, she said to me
The answer is easy, if you take it logically
I’d like to help you in your struggle to be free
There must be 50 ways to leave your lover

~  Paul Simon

The market town of Skun in Kampong Cham province, Cambodia, is one of my all-time favourite places in the world.  It has absolutely nothing going for it.  Unless you like busy, overcrowded third world markets filled with unfamiliar smells and fresh produce, including fish still wriggling in a struggle for life.  Or eating at open air restaurants where pots sit atop flames contained by circular stones and meals cost 75c per person.  Or watching mini vans packed so full that the frame sinks precariously close to the ground, with people on the roof and fare spilling out of the roped-open back door.  Or you like to marvel at plates overbrimming with fried tarantula, fried cricket, fried red ant, fried water beetle, fried cockroach and various other fried-exotic-insect-species, sometimes carried on the head of their vendor.  Or maybe to walk through puddles of brown sludge which sit stagnant for weeks on end after the slightest rain.  Or to see fluorescent green rice paddies dotted with tall coconut trees and white oxen.  Or breathe more dust in a day than you cumulatively breathed before in your life.  With so much character, I guess it’s not surprising that this is the place where some of my most fun, hilarious and adventurous experiences seem to have taken place.

Leaving Kampong Cham was one of the hardest things to do, made easier by the fact that I will return later in the year and by the drawcard of another dance party in the red dirt of Skun, which was my first overnight stop.  MSF will leave Skun soon and a few nights ago held their program-closing party.  As expected, the Khmer team floated like angels around the dedicated pot plant placed centrally in the dirt area of the front yard nominated as the night’s dance floor.  While their arms gracefully flowed in rhythm with their buoyant bodies, we clumsy expats followed in our dust-soaked thongs, “freestyling” in pursuit of the impossibly graceful and synchronised moves of our national colleagues.   We also drank beer poured around huge blocks of ice which allowed one can to be shared amongst many plastic cups, laughed, gossiped, eyed off the gorgeous 20-something dude coordinating the sound system, and ate a delicious buffet Khmer meal of spicy salads, soups and noodles.  The neighbours seemed to know when the formalities were over, appearing in their floral pyjamas and party moods carrying plates of fried duck and pork, cans of Angkor beer and plastic bags filled with ice.  The “duck killer” and “pig killer” were identified amidst shocked laughter.

One young man half-danced-half-limped through the gate, seemingly already intoxicated until we learned he was lame from a moto accident, introducing himself to Bea as though he already knew her.  To my query about how she knew him she replied “I don’t”.  He sat down making a concerted effort to talk with her via translations from national staff sitting nearby.  He then limped away, returning a few moments later with a large watermelon which he presented to her with a short speech about how grateful he was to her for coming to his country to help his people and an apology that he had nothing else to give to her.  It seems he has watched her walking to and from the market, past his house, many times.  I suggested that after living for a year as the only foreigner in this remote town, she is probably known by many who she thinks she’s never seen before.

The following morning I turned up at the bus station, headed for Phnom Penh.  After my last visit to a bus station in Skun, I was wary and so I decided to go with another bus company.  A few days earlier Chom said he’d call and book a ticket for me.  He appeared to do so.  When he hung up from this call he told me that “if you know the place on the road where they can pick you up, that is good”.  I said I knew it and tried to describe the area.  He said that I should give him the name.  I didn’t know the name.  Then we had other things to talk about and changed the subject.  From Skun I called to ask if he’d booked my ticket?  “No because you didn’t know the name of the place to pick you up and they said you can get it at the restaurant in Skun”.  Okay, no problem.

A tuk tuk parked at the front door on what had been a packed dance floor a few short hours earlier.  My bags were piled into the cab, I climbed in beside them, and off we putted.  Pulling into the bus station I asked Tuk Tuk Madame to wait while I bought a ticket.  Well, that’s what I thought I was saying.  Apparently what I actually said was, can you come with me to buy a ticket.  The ticket seller, identified by the fat wad of tiny-value notes in his hand, turned as TTM spoke to him and pointed towards the road.  We followed his finger and watched as the bus drove right on by.  Amidst a blurry haze of dust, malnourished beggars and Khmer conversation with strangers, someone said “Phnom Penh?”.  Yes.  A finger pointed at a car parked in front of the tuk tuk and Khmer riel was translated to “five dollar” in English.  Done deal!

My bags were loaded off the tuk tuk and heaved into the back of this new-ish SUV.  Treading in foreign waters I watched the driver closely.  He leaned into his door to switch the ignition on.  An elderly man appeared from the restaurant and climbed into the front passenger seat.  The driver opened the back door and motioned me in.  I sat beside the window, smiled at the young man seated beside the opposite window, and reached for my seatbelt.  The driver, holding my door open, seemed to say that I shouldn’t use the seatbelt.  Soon enough I shuffled over to allow two more passengers in.  Four people across a seat built for three is very mild by Cambodian standards.  I texted Bea to let her know I was in a car with five other people.  A moment or two later I texted her again, correcting my mistake.  There were six of us.  My western brain was slow to recognise the extra passenger.  The driver’s head was positioned excessively central to the car and he was reaching in a twisted position for the steering wheel.  Wondering why, it took a few moments to notice the second head, belonging to a body positioned on his seat, between him and his door!

A two hour lumbering bus ride from Skun, we made it to Phnom Penh in just on an hour.  Approaching Central Market the usual array of moto drivers surrounded the moving car, peering in one window at the passengers, then manouevering through traffic around to the other side, peering in from another angle to select their preferred customer.  This seems to take place at all bus stops, with a coordinated tag system between moto drivers and tuk tuks.  When buses pull into the smaller market towns, moto drivers literally run to the door of the bus in an apparent race, with the first to touch the bus having first dibs on their choice of passenger.  At the bigger stations a more sophisticated “Hello Madame” approach is employed, with a line-up of offers from motos, tuk tuk drivers and placard-holding hotel reps.  It’s an experience we don’t face in wealthy countries, where we telephone taxis or approach them in their orderly queues, with meters calculating the fare.  In my culture, this passenger and fare bartering process is non existent which explains why until recenty, I found it so stressful and dreaded arriving anywhere.  I now see that it’s an informally well-coordinated system between people who have no other income source, no pension, no paid holidays and who rely on the cash in hand from this work to feed themselves and their families.  Perhaps the sense of desperation was the source of my stress because now that I am consciously aware of what’s going on, my stress levels have dissipated.

Saying goodbye to Kampong Cham the previous day was a mixed experience of excitement and sorrow.  Drama at Phter Koma with a misbehaving teenager stole my final morning from me, but proved an interesting problem-solving experience reminiscent of times with the misbehaving Mathew a few short years ago.  My boxes and bags disappeared from my room in a single convoy down the stairs and out the door, courtesy of the typical Khmer team approach.  The number of jobs in need of hands always equals the number of hands that seem to materialise from nowhere.  Chom’s tuk tuk was transformed from empty to piled high in the space of two minutes.  A row of young staff waved us off with promises to “wait for you”, referring to my planned return.

A few detours through town included a stop at the second hand bicycle shop where Chom chose a small bike for Microphone as my way of thanking him for his help over the months.  In the crowded aisle between hundreds of bikes, two young men worked simultaneously.  One removed training wheels from a nearby bike and attached them to the back wheel while another attached a basket to the handlebars.  The tyres were pumped and the bike was squeezed into the tuk tuk atop my gear.  We delivered everything to Chom’s house, farewelling a confused Microphone who woke to the image of Dad wheeling a bike towards him after months of discussion about why he can’t have a bike yet.  During more farewells, my bags were heaved between one MSF car and another amid discussions about how many staff were coming, requiring which vehicle.  Soon enough we piled into the troupee and made our way south to Skun.

Anticipations of the party and knowing that I will be back in about five months helped my departure out of town, but saying goodbye is never easy.  Now in Phnom Penh, Bea is joining me tonight for a final weekend before we both leave the country.  Other friends are or will be here and Dara, who I farewelled at Shackville on Monday as he boarded a moto with Mum to travel to the Children’s Surgical Centre at the National Rehabilitation Centre in Kien Khleang, is a tuk tuk ride away.  His amputated bone was surgically shortened two days ago and he should have a few years now, free of complications from the bone until it grows through the stump again.

Wooden slat beds are lined up in rooms housing adults and children together, all of whom have had some form of surgery in recent days.  Babies and young children in visible/audible pain, some with deformities, cry intermittently while bandaged adults lie quietly.  All are tended to by at least one family member, sharing the crowded beds under squeaking ceiling fans revolving at various speeds depending on their level of disrepair.  I did not see a nurse or any equipment during my hour-long visit yesterday.  The best on offer post-operatively for anyone in Cambodia is an intravenous line for fluids and some oral pain relief, unless you can afford to purchase the very rare supplies of parenteral analgesia, which most cannot.  Dara was unhappy but his “need” for a new balloon was satisfied by the loan of my iPhone to watch music videos, so he’s okay.  Mum appeared to explain that the money I’d given her to cover food and transport for the duration of this hospital stay was already spent, apparently during a single visit to the market!  I didn’t plan that assistance well – it’s a lot of money to give an illiterate rural villager visiting a city without anyone to guide and advise her.  Today I’m visiting again with a friend so will get more detail and try to ensure they can eat for the remainder of their time here.

All of this appears to be my final days in Cambodia for the next five months.  As yet I have no onward travel plans or bookings.  The Hot Season is upon us, my visa is about to expire and MSF have been unsuccessful in matching me to an assignment thanks to my limited availabiity.  This once-in-a-lifetime year-long holiday has been years in the making and resisting all temptation, I must not spend it’s entirety hanging out in Cambodia.  Many options are floating around in my head, amidst the hunger and need and all the small differences I could make if I wasn’t leaving.  Travel is not as interesting or exciting to me now, as the rewards I can reap by being in Cambodia.  But I will leave Cambodia because I feel I must, at least for a short time.  When, how and where to remains to be seen.

On Disability and Departure

Accurate statistics on disability in Cambodia are, as with most poor countries, unavailable.  However, United Nations have estimated that Cambodia has one of the highest rates of disability in the developing world.  Some reports suggest as many as 15% of the population have some form of disability.  Estimates include around 50,000 landmine victims; 60,000 Polio victims; 130,000 profoundly deaf; 144,000 blind; with no national statistics available for either mental health or intellectual disability.  Anecdotally I would hazard a guess that poor medical practices have also contributed to a considerable number of disabilities in the population, particularly “during Pol Pot”, a phrase I have become all-too-familiar with.  Given that Pol Pot’s regime annihilated the country’s skilled professionals, including doctors and nurses, this is hardly surprising.  In 1975 there were 450 doctors in Cambodia and 20,000 teachers.  At the end of Khmer Rouge rule not quite four years later, 45 doctors survived, 20 of whom left the country.  7,000 Teachers remained in a country where schools had been completely obliterated and all books burned.

Poverty is both a major cause of disability in Cambodia as well as one of it’s major consequences, affecting as it does, a person’s ability to make a living.  Despite the presence of NGOs such as Handicap International, there are few disability services and disabled people face stigma, social exclusion and isolation, and are highly vulnerable to neglect and abuse.  State support for disability services is almost non existent and open to significant corruption, as with most government departments.  If life for Cambodians is difficult, then life for disabled Cambodians is significantly worse.

Two days ago I received a call from Paint, the disabled carpenter whose adoptive daughter died of AIDS just over a year ago now.  I missed the call and before calling him back, summonsed Chom.  As I sat beside him feeling powerless in the face of untrained translation, I recognised what was happening.  Paint was being cross examined by my protector.  The message, after short and sharp questioning, was that he rang to say hello “so I said, is that all?”.  Paint said Helen promised to visit me when she came back “so I said, she is very busy”.  Paint said he just wanted to say hello “so I said are you sure that is all?”.  Paint then admitted that he wants to buy a pig “so I said, she doesn’t have very much money but she tries to help people but she can only help a little bit, how much will the pig cost?”.  Paint said $100.  What did you say to that?  “I said I would ask you and call him back”.  How I keep a straight face some days, is beyond me!

We called him back and arranged to visit the next day (yesterday).  As I am likely leaving the country fairly soon there are a few people I’d like to see, so we added the blind lady (Mini) to our visiting list for the day and at 8am Chom picked me up in his trusty tuk tuk.  Via the rice warehouse and picking up some soy sauce, fish sauce and eggs, which I had to hug on the bumpy roads, we headed first to visit Mini.  I am especially concerned for her as she has no back up system whatsoever, living with elderly parents, a crippled father and her one sister earning $95 per month which supports six people.  She, her two daughters and her parents were waiting in their best attire (which for Dad, is a red checkered kromar wrapped around his waist and a stick of bamboo as a walking stick).  Bottled water was presented to me and we sat inside the bamboo elevated home with a lot of animated and happy conversation between the family and Chom which I pretty much didn’t understand but enjoyed nevertheless.

Three adults and two children live in this overly-humble but typical Cambodian abode.  Upon return in August/September I probably won't be able to visit due to the high floodwaters.

Three adults and two children live in this overly-humble but typical Cambodian abode. Upon return in August/September I probably won’t be able to visit due to the high floodwaters.

From here we traveled the c.80km to Paint’s home.  Along very dusty, ungraded roads Chom lectured me with shouts from the front moto through his helmet “Helen!  Why do you know people who live a long way?!  You should only know people about 3 to 7 kilo from town!  Look at this road, it is crazy!”.  At one point, keeping us both entertained, he had his legs splayed out from the moto.  I was laughing happily when suddenly the tuk tuk toppled and my laughter turned into a scream.  This caused even more hilarity all the way home, and in the evening he texted me from home to say that the whole family were entertained by the image of Helen screaming!

At Paint’s house more animated conversation that seemed interesting and fun to my illiterate ears followed the agreement that I purchase shares in two baby pigs which can be fattened and sold for a profit.  The profit can be used for further pig purchases and further profits.  It sounds like an entrepreneurship worth investing in, to me!  We sat underneath the house on wooden bed frames, and Chom did his usual cross examination of Paint’s wife “why did you marry him when his legs don’t work properly” amid much laughter and the usual assurances from Chom that “for Cambodians talk like this is very funny”!  We traveled home along the same appalling roads and put our plans in place for the next day.

Yesterday morning Mini traveled to town to attend the Ophthalmology Unit on a promise from me that I would attend with her.  The story is that she has been blind since about 16yo when she was involved in a road traffic accident.  Her now-deceased husband wanted her to have an operation on her eyes which she agreed to two years ago.  Post-operatively the doctor “promised with her” to take the stitches out of her eye after a week, but her husband (who apparently had an alcohol problem) changed his mind and wouldn’t take her back to the hospital.  Now the stitches were scratching her eye and she wanted to know what I thought she should do.  She travelled to Shackville this morning and we picked her up to attend the hospital.  A few hours later, the ophthalmologist explained that there were no sutures in her eye and that the scratching sensation must be caused by dust or other irritants.  He understands she had a traffic accident but he can see that there is some eye disease present, unrelated to an injury.  Her 4yo daughter has an astigmatism and I hope that it is not related to any inherited form of eye disease.  Currently her sight is fine.  When I return later in the year I will help her to arrange correction of this.  Chom says that “in Cambodia we say that people with this are looking at the chilli but seeing the eggplant.  Girls like this, cannot find a husband”.

The visit to the Ophthalmology Unit at the hospital was interesting.  A lot of light hearted banter in the crowds waiting around the elevated outdoor tropical corridor around the edge of the building kept us entertained.  The patients from yesterday’s operations came out of the ward together and lined up to have their vision tests and consultations.  One woman was in a lot of pain, accompanied by a young adult son who attentively applied eye drops and ointment to her eye amid moans of pain beside me.  Various people sat in the broken plastic chair in one corner of the building while the nurse doing vision tests stood at a door at the other end, pointing to the Snellen Chart as patients motioned with their hands which way the three legs of the E were pointing.  One young woman stood up after her vision test and an elderly woman standing nearby said something which elicited laughter from the crowds.  Chom translated for me that “she asked her why you do like that?”, confused at the girl sitting in the chair and waving her arms in different directions.  Watching people try to navigate use of the “glasses” for their visual acuity test was equally funny and it was a really humourous couple of hours, tinged with sadness when the vision test on Mini showed that she could literally not see the hand being waved right before her face.

Visual acuity "glasses"

Visual acuity “glasses”

Visual acuity (Snellen) test used for those who don't read

Visual acuity (Snellen) test used for those who don’t read

AusAID funding of the Ophthalmology Unit in Kampong Cham.

AusAID funding of the Ophthalmology Unit in Kampong Cham.

It was rewarding spending time with her though, ensuring that the hospital fees ($1), transportation to town and a meal while she was in town, all enabled her to see the specialist without any stress.  We said goodbye and will see each other in a few months when I return.  In the meantime I would love to think of an occupation for her which she could undertake at home to generate a small income.  Options seem very limited in a remote village where few people have cash to spend.

Dara is going to Phnom Penh next week to have the bone (finally) shortened.  “The doctors” were meeting him at his village home this morning, which happened to be the time Chom and I had arranged to visit to say goodbye.  Again, we picked up some rice for the two families out that way and headed along the bumpy dust tracks, stopping first at the disabled man’s home about 2km from the village.  We delivered some rice and sat having a talk.  I cuddled the baby who landed some faeces on my thigh as a goodbye present and they talked about needing a toilet.  Chom said “they know you made the toilet for Dara, that is why they ask you”.  We explained that I am going away for five months and while I am away, I will try to raise funds for a toilet for them but that I cannot promise.  The father is very lame and it would be great to help him have a  proper toilet.  Despite his disability, he was out in the fields on his walking stick, working upon our arrival.

A wooden hut in the dust, rural Kampong Cham

A wooden hut in the dust, rural Kampong Cham

The dirt-floored interior.  Four months ago a baby was born in this room.

The dirt-floored interior. Four months ago a baby was born in this room.

We travelled on to Dara’s house where Handicap International were still visiting – the Director, a social worker, a photographer, a visitor from the French office and a driver.  The French visitor has worked with Handicap International for thirty years and knows the founding members who I wrote about three days ago, very well!  They are following Dara as a case study to publish in their next donor newsletter!  Dara, beside himself with so much attention, was hopping around on his crutches excitedly, showing us his various moves – forwards, backwards, sideways and a very agile fall-down-in-the-dust manouver.  As the Handicap International team left, we delivered 50kg of rice to grandma and entered the house to sit and chat for a while.  At one point I counted 28 children in the house with us.  “Helen, the whole village came to see you”!  We said our goodbyes and I promised to return in August/September.

From there I had a lunch date at Phter Koma, where I met the three new resident children who all knew about me and had all been versed to say “Excellent”, our trademark English class phrase.  It was nice to see the three new children happily ensconced in their new home, playing and spatting with the others as if they’ve never lived anywhere else.  Once again, I said more goodbyes and promised to return for English classes during the school holidays in August/September.

I appear to have farewelled everyone who needed to know about my pending departure, offloaded the remnants of last year’s boxes of toys, and all that remains is to pack my bag and go.  As yet there is no definite plan in place, but it appears I will likely go on a short assignment with MSF before heading to the European leg of my travels.  It is very hard to leave behind so much need, especially as I am about to embark upon an extravagant few months of self indulgence.  The contradiction between my lavish life as a “Have” and the lack of options available to so many “Have Nots” in such great need is not lost on me.  By far the most rewarding aspect to being a “Have”, over and above anything else my entitled life has given me, has been the privilege of interacting with and helping those living without.  Discovering this richness to life makes me even more privileged than I ever deserved to be.

On Difference

One of the leading practices of the Khmer Rouge regime between 1975 and 1979 was a program of racial “purification” which manifested as an assimilation policy with genocidal massacres.  They began with the Vietnamese ethnic minorities, none of whom appear to have survived within Cambodia, as they were either murdered or fled into Vietnam, where most had not lived for generations.  Since 1979 many have returned but today’s Vietnamese population is less than half of that in 1975.  Prior to the Khmer Rouge, Prime Minister Lon Nol had also led murderous pogroms against ethnic Vietnamese.  The relationship between Cambodia and Vietnam is complicated and filled with ill ease about land ownership particularly in the border areas.  I first learned this when I was talking to staff in 2013 about my experiences in East Timor.  They had never heard of East Timor and after I explained it’s history briefly, one of them commented very quick wittedly, “Did you know that there is also an East Cambodia?  It is called Vietnam!”.

The Vietnamese were not the only minority purged by Khmer Rouge.  City-dwellers became known under this regime as “new people” and were considered the enemy, taken as prisoners of war and forced out of the city into the countryside.  They were made to work harder and survive more extreme conditions than the country peasants, or “old people” who did not pose the same level of threat as the modern and educated urbanites.  Ethnic Chinese were automatically labelled “new people” because of their urban origins, and more than 50% of the pre-1975 Chinese population were killed during these five years.  Their deaths occurred at a much higher rate than other “new people”.  Exhibiting Chinese culture or speaking Chinese was punishable by death in some areas.  One of my local MSF friends is the son of a Chinese man whose family changed their name in 1975 to avoid detection of their Chinese origins as a means of survival.

In her book When The War Was Over, Elizabeth Beckett describes the near-extinction of the Muslim Cham community during Pol Pot’s rule, as “one of the sorriest tales of the revolution”.  Today these are a highly visible minority within the Cambodian population, thought to number as many as half a million.  They practice Islam, speak their own Cham language and have been present in Cambodia for many centuries.  But between 1975 and 1979 approximately half of them lost their lives.  After initially supporting the Khmer Rouge, as many others did in the hope of being liberated from the oppressive regime of Lon Nol, in 1973 the Cham lifestyle was declared “counter-revolutionary”.  They succumbed to a systematic attack during which their leaders were hunted down and murdered, mosques destroyed, forced to adopt Khmer names, shave their beards (men), cut their long hair (women) and banned from wearing Islamic attire.  They were also forced at gunpoint to eat pork, banned from speaking their own language, and families were separated to prevent children learning the culture they were born into.

Also supportive of the Khmer Rouge at first, were the Buddhist clergy who were actively recruited to the revolution and initially treated with respect.  Almost immediately upon victory however, monks were enticed to identify themselves to their superiors who forced them to reject their religious practices such as imposing arranged marriages on them and confiscating their orange robes.  Those who refused were executed.  The country’s nearly 1,000 pagodas were desecrated or destroyed.  Buddhism was banned completely and all religious texts were burned.

Everyone wore black pajamas, worked and lived in cooperatives, ate the same food and followed the same rules and routines.  The only exception was the higher ranking Khmer Rouge and their families, who hid away in Phnom Penh in relative comfort and safety.  For the rest of the population, the possibility of defining themselves as anything but worker-peasants was totally erased.  Behind this atrocious dominance over the population lay a philosophy of ensuring the survival of a “pure” Kampuchean race, resembling the racial superiority ideas of Nazi Germany.  As Cambodia’s ethnic history includes Negroid, Australoid, Malay, northern Mongoloid, Indian, European, Chinese and  Vietnamese heritage, this idea was complete science fiction.

The assimilation policy gave carte blanche permission for harrassment and murder of anyone deemed to be different.  This included a few very unlucky foreign travelers who were caught in waters off the coast – records at Tuol Sleng show that some Thai, Indian, Pakistani, American, English, Australian and New Zealand foreigners were tortured and murdered there!  All of this occurred without international witness as foreigners and journalists were extradited as soon as the Khmer Rouge marched into Phnom Penh on 17 April 1975.  The first foreign correspondents to return were Elizabeth Beckett, representing The Washington Post and Richard Dudman of St Louis Post Dispatch, who traveled to Cambodia on invitation from Phnom Penh.  They were joined by a third guest, Malcolm Caldwell, a scholar from the London School of Oriental and African Studies.  Caldwell was one of the few Western supporters of Pol Pot’s regime and it was repeatedly stated by their hosts that he was invited as a “friend”.

In December 1978 the trio traveled with high ranking Khmer Rouge cadre around the country on a very staged tour intended to show them the “success” of Cambodia’s as-yet hidden and mysterious communist state.  Despite the model communities and staged performances they were escorted to and past, Beckett could not help but realise the sinister nature of her hosts and the imposed regime.  This malevolence manifested when Caldwell was murdered in their guest house by an unidentified gunman who was probably recruited by Pol Pot himself for the job.  Some of the last forced confessions at Tuol Sleng related to the murder of Malcolm Caldwell, highlighting the truly psychotic nature of Pol Pot and his government.

Australian Prime Minister Tony Abbot’s latest claims that indigenous people living on ancestral lands and maintaining their own culture are “making a lifestyle choice”, seems to draw parallels with the philosophy underpinning the Khmer Rouge and other communist / assimilationist regimes.  His stamp of disapproval may not be as harsh as that of the Khmer Rouge but it shares similarities which ought to make him reconsider what he is promoting.  His claim is also disproved by the single example of the evolving outcome for Cambodia.  Pagodas and mosques have been rebuilt, providing a focal point for life in every village.  Schools and universities strain under the weight of young people searching for knowledge from an educational system which was so recently and entirely obliterated.  Buddhist and Islamic practices thrive once more.  Black pajamas have been firmly rejected in favour of bright florals.  Multi-lingualism thrives and people have firmly regained their cultural identities, despite continuing struggles for everyday basic needs such as food and clean water.  These are not “lifestyle choices” but human expressions of endurance and identity.  Something which in fact, we all practice, whether we recognise it or not.  That includes Mister Abbott in all of his privileged and powerful glory.

Cupcakes and Prosthetics

The bone on Dara’s amputated leg continues to grow, and will continue to grow into his early 20s.  It pushes through the stump, eventually causing pain and becoming infected.  Recently he has been in a  lot of pain from a recurring infection.  The repercussions of this include a lot of missed school, loss of appetite with accompanying weight loss and inability to wear his prosthesis due to the pain.

Bone growing through the below-knee amputation of a 6yo.

Bone growing through the below-knee amputation of a 6yo.

I can often have conversations with Mum and Dad via broken Khmer and various miming / sign language.  Sometimes I wonder if we think we understand each other whilst actually talking about entirely separate matters and we have a lot of laughs together.  The other day, talking to Mum, we didn’t understand each other so I pulled my phrase book out of my bag, found the word I needed, and pointed to it’s Khmer script.  She looked briefly, before explaining to me that she cannot read.  I called Win for a translation instead and he informed me that her 14yo daughter had gone to Phnom Penh “to work in a house as a servant”, for a salary of 300,000 riel (US$75) per month.  Later in the day I texted Win to thank him and said “I’m so sad for that daughter”.  His reply: “I think it is normal here for the poor.  Just try to help when possible”.  This morning we drove past one of Kampong Cham’s mansions and Mum pointed to it, explaining that at the age of 14 she worked in this house as a servant.

For a few weeks now, conversations with Mum and Dad have been about an operation on his leg.  Our language barrier makes it really hard to get a detailed picture of what is going on but yesterday I knew the appointment was today and that Mum was going to carry him on her hip, the c.2km to the appointment.  So Chom met me at Shackville last night to discuss the situation.  Chom agreed to transport them to the appointment and after some discussion Mum and Dad both expressed some anxiety about the cost of the operation.  If they travel to Phnom Penh they are away from work, losing $4 per day and have to pay for their transport costs, but the operation is free.  If the operation can be performed here, they have to pay the hospital costs which could be as much as $50, which they don’t have.  While I stress about which Spanish language school I can afford to attend in Spain, these people can’t afford basic health care!  Chom suggested that I attend today’s appointment with them, to get a better idea of what is being planned, so that I know exactly what help is needed.  So at 7am today he picked me up en route to Shackville, where Dara and Mum boarded the tuk tuk and off we chugged to the Handicap International Rehabilitation Centre.

Handicap International is an excellent NGO who are, according to their website, “an independent aid organisation who work in situations of poverty and exclusion, conflict and disaster.  We work alongside disabled and vulnerable people on 327 projects in over 60 countries worldwide”.  Two French doctors were working in 1982 at Khao I Dang (“KID”) Refugee Camp across the Thailand border where many thousands of Cambodians escaped to during Khmer Rouge rule and subsequently during the Vietnamese occupation and war.  Friends and colleagues have described their experiences of attempting to travel to, or spending time at, this camp.  One in particular tells of crossing landmine-ridden fields to reach the border, before being shot at by Thai border guards and having to run back into Cambodia, past the stench of dead bodies and hearing landmines explode around them.

These doctors began fitting thousands of injured Cambodian refugees, mostly landmine amputees, with prostheses.  The doctors trained local people, set up rehabilitation care for refugees in this and other camps, and Handicap International was born.  When refugees were repatriated home to Cambodia in 1993 Handicap International went with them to ensure their access to necessary services continued.  The organisation grew into a broad-ranging disability service across a number of provinces in Cambodia, and extending to other countries with similar humanitarian needs.

Today 1 in 5 of Handicap International’s clients in Kampong Cham are landmine victims (there are still thought to be up to 10 million unexploded landmines on over 700 square kilometres of Cambodian soil today).  Many other amputees, including Dara, are victims of road traffic accidents.  The organisation are still involved in mine clearance, as well as road safety programs, disability-related mother and child health, supporting local rehabilitation centres, integration of disabled children into schools and various other disability-specific projects.  Their work as a founding member of the International Campaign to Ban Landmines which led to the Mine Ban Treaty, saw them awarded with the Nobel Peace Prize in 1997.  As with so many humanitarian aid agencies, they rely on private donors to sustain their activities.  Their  most recent annual report can be found here: http://www.handicap-international.org.uk/Resources/Handicap%20International/PDF%20Documents/HI%20Associations/RA2013-FED-en.PDF

On arrival Dara was given a triage number before moving to the waiting area near the physiotherapy and prosthetic production area, up a long ramp.  At the triage area a young woman appeared and sought me out with “Good morning Madame!”.  Sometimes people just want to say hi, so I replied in kind.  She then asked me “Do you remember me?”.  I studied her face and realised it was the groom’s sister from the wedding outside Skun two weekends ago!  She was en route to work and recognised me so stopped to say hello.  A number of mothers and babies with no apparent physical disability were there, and also a number of other amputees with prosthetic legs and other disabilities.  A man in a white coat came out to talk with Dara, asking me if I was an Occupational Therapist.  I explained with Chom’s assistance that I was a family friend.  The man then attempted, unsuccessfully, to put Dara’s prosthesis on, before disappearing and returning with a set of crutches and lessons in how to use these began.  Dara was very excited, repeatedly calling to us to look at the frog hopping!

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Waiting for arrangements between doctors here and Phnom Penh may take all day so we decided to leave Mum and Dara there and Chom will pick them up later.  We went via a local restaurant to buy breakfast for Dara and a recharge card for Mum’s phone so that she can call Chom for pick-up.  Upon our return a vendor selling fruit and sweets from a round tray on the back carrier of her bicycle was parked on the path nearby.  Dara was eyeing off some coconut and sticky rice “cakes” in banana leaf cups.  For 25c I bought him two of these, one of which he devoured in the blink of an eye.  Chom passed the phone charge card to Mum, then received it back from her and punched the numbers into her phone “because she doesn’t know how to read the numbers”.  As we left Dara had a very big smile on his face, devouring cake and talking about the cars in the playroom a few metres away.  Entering the ramp on our way out, a complete stranger stopped me and placed a plastic bag steaming with six cobs of hot corn into my hand.  Chom translated that “In his village there are a lot of corn and he want you to eat it”.  Six cobs of corn!  Luckily it’s easy to find hungry beneficiaries around these parts, so they didn’t go to waste.

Coconot sticky rice cupcake in a banana leaf cup

Coconot sticky rice cupcake in a banana leaf cup