One of the people I didn’t mention in my previous blog is a 32yo woman residing on a little wooden canoe on the muddy water with her husband and three children. I would have said four children only last year her three year old fell off the boat and disappeared. The community men spent days diving into the waters with no resources and no rescue service, yet only meters from a tourist strip where wealth flourishes, first in a bid to save him and then to retrieve his body. He washed up downstream about three days later. His death, like so many other Cambodian children who drown at an official rate of five per day, is uncounted.
Weeks ago when we ran an impromptu clinic on a patch of grass under a tree at the riverside I met this young mother. Along with a crowd of others she came up from the boat community below and joined the circle of people with varying complaints. She had an ultrasound result written in French but appearing to state either gallstones or kidney stones. Experiencing severe intermittent pains she had been quoted US$1,000 for surgery to remove the stones. Subsistence fishers with only a little wooden canoe to their name, this was beyond her family’s capacity. She wore a deeply concerned expression and I felt helpless to offer any kind of solution.
That same day I met a 34yo man taking anti-retroviral medications for HIV whose mobility has slowly disappeared on him over the past 18 months. Starting with numb feet, climbing into his legs which have lost their muscle mass and now, where he could previously lift himself up with his arms, he is losing upper body strength. Sitting on the unfurnished floor of the small rental room he has not left for months, which he shares with his 10yo son and a brother who is out all day earning enough money for rent and food, he moves forward on his bottom by pushing one leg out with his hands, then the other, then lifting himself forward before repeating the exercise. An HIV clinic supply three months of treatment at a time but noone has offered any ideas relating to his neurological condition.
Days later, climbing around on the muddy embankment with my colleague on a community visit, a man appeared uphill from us before turning away quickly and disappearing between the shacks. About twenty meters away, I exclaimed “that man has a big growth on his face!”, which was only visible from afar due to the size and distortion. We made our way through the shacks to locate him, hiding in the dark shade of a curved tin sheet bent over a little bamboo platform beside the water. He usually hides away when we visit the community but his growth has become infected and so he agreed to speak with us. From his pocket he pulled out a foil strip of Ciprofloxacin, an antibiotic. Trying to self-treat, as so often happens in a place where qualified health care comes at an impossible cost, a neighbour recommended this for his pain. He doesn’t always have enough money to buy it so he takes it sparingly, only when the pain is very bad. This is another public health concern affecting the future of us all, as it is the ideal environment for bacterial antibiotic resistance to develop. Barely able to see him from the shade he was guarding himself with, I could see that the massive disfigurement that is his face had a small patch of open infected wound. I explained that this medicine is not a painkiller and that it would not help the infection if he did not take it correctly, and it may not even be the right medicine to help the infection, so would he agree to see our doctor? Yes.
As we were having this discussion a loud motorised noise devoured the air. Initially assuming a loud boat, I looked to the water but there was nothing beyond the usual array of fisher canoes, ferries and tour boats. Lifting my eyes to the sky, three helicopters came across the river and directly overhead, drowning out our conversation until they had moved upstream. A black chopper centre of two military choppers, my colleague stated “it’s the Prime Minister, he is the only person in the country with a helicopter and it’s how he travels. He must be visiting somewhere distant”. My favourite childhood poem came to mind. With a tiny edit the nonsense becomes garishly real!
Ladles and Jellyspoons,
I come before you, to fly above you
And teach you something I know nothing about.
Next Friday, the day before Thursday
There will be a ladies’ meeting for men only.
Wear your best clothes, if you haven’t any
And if you can come, please stay at home.
Admission is free, but you’ll pay at the door.
We’ll give you a seat, then you’ll sit on the floor.
It doesn’t matter where you sit,
The man above you is sure to spit.
Meanwhile a friend visiting from Australia took a day trip to Wat Opot, where she coincidentally happened across Doctor Rick. We’ve met Rick before, as he visits Cambodia once per year from America for a one week medical mission with Cambodian Health Professionals Association of America, and always spends a bit of time at Wat Opot along the way. My friend returned to Phnom Penh announcing that Rick was here, CHPAA were setting up their clinic next week, he says they can definitely help out some of my clients, it’s all free except they need to get there. Due to Rick’s unfamiliarity with place names, many of which sound very similar, it took a few days to work out where this year’s medical mission was to be based. Meanwhile we approached our unwell clients to inform them about CHPAA and offer our support including all transportation, food and accommodation costs should they wish to attend.
It was a long and messy week for my colleague who spent hours recruiting, convincing and reassuring clients who know all too well that “free care” is never free and even when it is, the cost of a bus ticket or a hotel room are impossible expenses. Experiences with the health service here are fraught for the poor and their fears are well founded. We couldn’t convince “Face Man”, my conclusion on him being that he has spent his life believing his case is hopeless. In a local sense it is because maxillo-facial services do not exist here and if they did, the cost would be prohibitive to a landless fisher. Prolapse lady wanted to come with her husband but on the day of departure they finally declined, worried about leaving their only asset – a little wooden canoe – unattended on the shore. In fact, the list of reasons she probably refused was provided by a Khmer friend as follows:
1- She feels hopeless
2- She does not trust the service
3- Concerned no one will help her post-surgery
4- Worried about money
5- Confused the activities belong to a religion who want to convert her
6- She feels too unwell
7- She is afraid to have surgery.
Despite the disappointment of these refusals we were able to transport a motley crew to Kampong Thom province for some free first world medical care. A tuk tuk friend with good English drove me around Phnom Penh days before departure looking for an open air vehicle which we needed for infection control purposes due to the assumption that Prolapse Lady (with probable untreated TB) was coming. We finally found a pickup driver who agreed he could take us but I learned later that he was the middle man in our contract and our actual driver, in a different pickup, was traveling through Phnom Penh from a southern province to the country’s north. Due to his distant start place and unfamiliarity with the streets of Phnom Penh he was over an hour late to pick me up. While I stood outside my apartment waiting, my colleague filled a tuk tuk to overflow with clients + 1 family escort each, on the other side of town.
When the pick up finally arrived to collect me, my already on-edge heart sank at the sight of the driver’s wife and child in the cab and the trayback piled with their luggage. I asked my apartment security guard who had been giving telephone instructions of our location to the lost driver, to explain that there were as many as 13 more passengers yet and the reply came back “It’s okay, he will be able to make room for everyone”. Crawling through Phnom Penh’s peak hour traffic in what already felt like a full car to my Australian brain, I spoke to myself that this was Khmer style and I should remain calm. We arrived at the tuk tuk and sure enough, a whole lot of shuffling and activity including men carrying our immobile client and passing him between each other from ground to trayback, tying luggage to the opened tailgate, people negotiating their own space on either the floor or edge of the trayback, saw a single car loaded successfully with fifteen people. Thankfully I scored the front seat complete with functioning seatbelt. Luxury!
About three hours later the spacious rural grounds of a hospital came into view with tents erected on the lawns, under which rows upon rows of people sat in orderly rank on plastic chairs. Following Dr Rick’s instructions I made my way to the triage area to announce our arrival while the pickup unloaded, some young American “runners” sourced a wheelchair for our immobile man and we congregated at triage. I spent a full day waiting in the shade as clients saw triage nurses, then first-contact doctors who made referrals as appropriate to the various second-contact doctors in rooms along the sides of the undercover area they were working from. Allied health staff were also available including dentists, opticians, acupuncturists, phlebotomists with rapid test laboratory resources, occupational therapists and prosthetic technicians. Those Americans who did not speak Khmer were accompanied by translators identifiable by their yellow t-shirts. The nature of the one-week clinic was such that apart from some discussion of potential diagnoses and treatment advice, our chronic clients had limited success.
However our gallstone lady was offered free surgery to which she fearfully agreed. This meant that she, her husband and their adorable 18 month old needed to stay behind while at the end of a busy day, everyone else was set to return home. We broke into two groups; the homebound crew who waited for a mini van traveling south from Siem Reap; and me with “gallstone family”. We checked into a dusty guesthouse in the nearby town, and I only stopped feeling dust-ridden after my first home-based shower four days later. Everything we did during our time in Kampong Thom was dusty, from eating fish at a tin table on a busy village corner, to walking through marketplaces, to sitting around the hospital grounds, to sleeping in dusty hotel rooms. The following morning we arrived at the hospital and after a wait, they transferred us by mini van to another hospital 40km north, which was set up and staffed to perform a range of operations under general anaesthetic. As she was assessed pre-operatively word came that an emergency was en route and her surgery had to be delayed for a day. We had a day together in this small, hot and dusty rural town, getting to know each other thanks to frivolity and laughter which transcends all language barriers.
Finally on Wednesday morning her gallbladder was removed thanks to a team of American surgeons, anaesthetists, nurses, medical students, translators and “runners”. While we waited for word of her successful operation hubby, baby and I wandered over the road to a <dusty!> little streetside restaurant fronting a family home for a late breakfast. Of course, being Cambodia, as I finished breakfast I turned my head to learn that the man reclining in the chair behind me, overlooking the referral hospital from his seat, was in fact severely unwell. He lifted his shirt to reveal a rock hard, balloon sized abdomen and pulled down his lower eyelid to show me how anaemic he is! Gallstone Husband suggested to me that I could ask the American doctors to assess him? When we returned over the road I approached an American medical student who willingly agreed. Finally Rock Abdo Man was transported via CHPAA minivan to the initial assessment hospital 40km south, where Doctor Rick assessed him. Here’s what he told me in an email exchange:
Funny that you mentioned the man with the big belly. I saw him at the Mission. I am pretty sure he has myelofibrosis a disease I routinely treat in the US. The rock hard mass you noted is his spleen. We typically treat this with bone marrow transplantation but that is not done in Cambodia and would have had to be done years ago. There is not much that can be done other than blood transfusions at this point. Some day I’ll have to tell you about a patient with leukemia I met on one of these missions. Sometimes I feel like a bit of a voyeur with these situations and it is just insane that you may live or die solely by where you are born. I guess that is not very surprising but it is just so present here and brought out so vividly. I do enjoy working with the medical students who will hopefully not accept things the way they are.
There are good people everywhere, including in Cambodia where the help that most can offer is small and often inadequate. Those of us living in wealthy nations can offer more and adequate assistance, as CHPAA demonstrated so skillfully this week, changing the lives of many merely by showing that they cared enough to go to the trouble of employing their skills and resources. It was an inspirational experience to play bystander and who knows, perhaps I may have something of my own to offer at next year’s mission.
Just as inspirational for very different reasons, was the experience of delivering Gallstone Family back to their little wooden canoe on the shoreline. After inviting me with a shy smile to join them for a meal on their boat sometime, Dad ran down the riverbed, waded into the water and jumped on the boat first, “unlocking” their home by removing the wooden ladder balanced against canvases covering the opening of their tin roof. He then moved the boat up onto the mud so that Mum could climb on without getting wet. I passed the baby over to him and we waved goodbye, promising to see each other next week.