Wheels

One of the things I have learned about the world since coming to Cambodia, is that there must be millions of people whose lives could be transformed by something as simple as a wheelchair, but who instead are confined to a tiny space by their inability to walk.  I have met a surprising number of people trapped in this way, usually without a diagnosis or access to any meaningful care.  The fact that an NGO might exist who can supply a free wheelchair is not necessarily of any benefit in many parts of the poor world.  In a place like Cambodia for example, services are not easily publicised; people’s capacity to access transportation to attend services is limited by their poverty; and they are often very hesitant to attend services where they have to deal with educated, confident and often intimidating professionals.

Today I had the privilege of arriving at a client’s home with the wheelchair he had been waiting on for a month since we sourced it for him, but which he has needed for almost two years when he first became house-bound due to his paralysis of unknown cause.  He was sitting in the doorway of his tiny rental room eating a small plate of plain rice when we arrived.  He only noticed me when I spoke “Salam Alaikum”.  He looked up and replied “Alaikum Salam”, before averting his eyes to the tuk tuk driver behind me who was pushing his new wheelchair.  His face transformed to a bright smile!  We assisted him into the chair and he disappeared down the alleyway at lightning speed.  Some days are really worth getting out of bed for, and today was one of them.

KF 22 Mar Wheelchair (2)

The concept of “transportation” took on new meaning for me in 2013 when I first came to Cambodia.  Firstly, the scenes of people traveling on the roads were mind boggling.  Secondly our program included a client assessment with social workers to determine whether transportation support was indicated.  This involved offering less than $5 to those who otherwise could not afford to attend their appointments.  Who could not afford $5 in a single month?, was my thought when I heard this discussed for the first time.  As it turns out, many millions cannot!

Yesterday as we visited our various clients around this particular slum area, my colleague informed the poorest of them, who often have no food, that “a foreigner” has been seen at a particular Phnom Penh market, choosing 6 people per day and offering them a meal.  If they go to this particular market, they could get chosen and receive a meal.  One older lady with missing front teeth and visible malnutrition replied that she didn’t know this market?  She then said “I have lived in Phnom Penh my whole life but I don’t know where anything is.  I heard that the riverside is a really nice area to visit but I have no ability to go there”.  The area she refers to is literally 1km (as the crow flies) across the river from where we were standing.  But she would have to travel about 5km to reach it, as it’s across the shore.  Similarly, most Cambodians dream of visiting Angkor Wat, the legacy their ancestors built which is a cause of much pride.  Yet most Cambodians have never been there.  A young French man turned up for dinner with some friends recently and they asked him, what did you see at Angkor Wat?  He replied “a lot of stone”, to the bemusement of the Khmer people at the table.  I have learned about Angkor Wat, that it is visited en masse by people from afar with plenty of money, for whom it has little meaning except tourism value; while those who live nearby, for whom it holds great significance, can only dream to visit it.

The capacity to travel matters far more than those of us who never have to think about it, realise.  There is a reason that in Cambodia you see people traveling in all manner of dangerous forms.  A few weeks ago this particular mini van caught my attention from my seat on a large bus as they were leaving a roadside stop and driving out onto a busy highway.  If I was paying $4.75 for my safe seat, what were these passengers paying and what was their income, that $4.75 was not an option?  These are questions that I continue to spend hours wondering about everyday.

KC005 (2)

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Cool Fires

Cambodia is in the throes of “the Hot season”, better known in tropical Australia as “the Build-Up”.  It is hot and extremely humid, with clouds building up in the sky but very little rain, so that the humidity just builds and builds.  Even the locals are suffering.  Tonight, leaving my apartment, our security guard was shirtless and wiping sweat from his brow with his t-shirt.  Earlier today during a home visit, a 12yo girl was covered in pearls of sweat.  I always say that you know it’s truly hot when even the locals are feeling it.

A nationwide energy crisis is being blamed on the long Dry season which has depleted the hydropower dams supplying much of the country’s electricity.  Phnom Penh began experiencing daily power outages about a week ago, just as I was leaving for a weekend away.  It’s a real killer when your electric fan turns off in this weather.  Thankfully I live in an apartment block with a generator that kicks in with every power cut.  If I am home I often don’t know if the power is out or not.  On Monday morning, oblivious to the power cuts that had been happening like clockwork all weekend, I walked down the street to the beauty salon to get my nails done.  The girl turned me away saying “Sorry, can  you come back, because we have no fire?”.  No fire?  “Yes, do you know, no fire?”.  I could not imagine why she needed a fire to do my nails but I told myself “because Cambodia” and walked back home in blissful ignorance.  Relaying my confusion to a friend later in the day, I learned that the direct translation of “electricity” in Khmer, is the same word as “fire”.  So the reason we’re all suffering in the heat around here, is because we don’t have enough fire.

Today I did some home visits to a number of clients with my colleague.  We followed up on two high risk babies who are both doing well; visited our paralysed client who continues to wait for his wheelchair; and searched unsuccessfully again for “Face Man” who was out on the water, fishing.  A family I have met a few times who are dealing with a number of crises asked us to visit.  Two twenty-something brothers were released from prison a few days ago.  They were arrested for drug possession but proclaimed innocence with a credible story about the drugs being secreted over a small brick wall onto their property during a police raid in the slum where they live.  Their imprisonment placed the family under financial strain as their 19yo sister needed to travel to the prison every few days to supply them with food.  This meant she was not able to work as reliably as usual and so the family took a US$200 loan to deal with rent and other expenses.  The moneylender takes $40 in interest each month, keeping them in constant debt.

The brothers came home a few days ago and their sister asked us for a clinical review.  Both have Chicken Pox-like rashes which have become infected.  One of them only on his lower legs, but the other reported having a very high fever with coryzal symptoms at the beginning, and the rash is all over his torso and legs, with extremely swollen lower legs, ankles and feet, probably due to the sores becoming infected.  I reassured them it was nothing to panic about and referred them for review by our MD.  I then explained that infections are easy to pass around in prisons where it can be crowded, and enquired if it was crowded where they were?  Their cell was 8m x 8m and housed anywhere between 110 to 120 people!  When I asked how this was possible, they said that they had to sleep lying on their side and had a rotation for lying down / standing up.  There was no “fire” so I am left imagining how it’s possible to survive in such torrid conditions, with no air movement except the heat of each other’s breath and, as my friend Chom calls it, “body gas”.  If all they came home with was infected Chicken Pox, I guess they’re pretty lucky and I have a new understanding now of just why diseases like Tuberculosis run rampant through prison populations.

A few different people send, or have sent, money to me for Cambodia and entrust me with deciding where to channel it.  I’m not sure if any of them imagined, or would approve, of paying off a family debt caused by two young men’s imprisonment.  But that’s exactly where some of the money is going.  The potential of impoverished youth all over the world is destroyed by the perils of poverty.  In the wake of New Zealand’s terror attack last week, the phrase coined by PM Jacinda Ardern seems appropriate to so many violations against humanity:

They Are us

Sometimes The Battle …

Wealth like ignorance

Sometimes whilst blogging I go searching for the right quote to fit my reflections.  This quote seemed perfect for today’s story relating to the small Islamic community I am currently working with.  I had never heard of Ali ibn Abi Talib, who according to Wikipedia “…. was the cousin and son-in-law of Muhammad, the last prophet of Islam. He ruled as the fourth caliph from 656 to 661, but is regarded as the rightful immediate successor to Muhammad as an Imam by Shia Muslims”.

Innocent misinformation stemming from poverty continues to throw regular blows at me from left field with scenarios such as today’s encounter seeming inconceivable and taking my slow first world brain some time to process.

In my March 12 blog I first mentioned, under the heading of Infant Feeding, the baby I met early in February when she was just 18 days old, whose mother had been supplied a free can of artificial infant formula by the maternity clinic.  Mum’s ability to breastfeed had already been disrupted when we met.  Mum is illiterate and was struggling to feed the baby using bottles.  Since then my colleague and I have put in a great deal of effort including some community level education to promote breastfeeding, but also teaching this mother 1:1 what to do around how to make the milk; volumes and frequency of feeds; cleaning equipment; monitoring baby’s faltering growth; and preparing for changes in feeding instructions as baby gets older.  We have also devised, with the support of a nutritionist colleague in Australia, a poster with pictorial instructions to reinforce what we are teaching.   Soon I will leave Cambodia for a few months and my untrained colleague is going to have to pick up the responsibility of monitoring and supporting this mother, and probably many others, so the teaching material will serve a dual purpose.  Some of our lessons have included:

  • Powder to water ratios.  These are specific depending on manufacturer instructions which require a level of literacy and numeracy that Mum does not have;
  • Requirement to add the correct volume of water first, followed by the correct number of scoops of powder.  This ensures accuracy of the required ratio, which is usually 30ml water to one scoop or 60ml water to one scoop, depending on the written instructions on the can.
  • Reassurance around the confusion that the ratio instructions can cause.  For example, if baby needs 150ml volume of milk, but powder to water ratio is 1 scoop to 60ml, then 180ml water should be measured out then 3 scoops of powder, being the nearest correct measurement to ensure an adequate feed is made.  This not only leads to some wastage, but the three scoops of powder also increase the volume of liquid in the bottle to more than the initial 180ml.  All of this can be quite confusing to the untrained mind.
  • Discard remaining milk which baby will inevitably not drink if the volume is too much, in an environment where there is no refrigeration.  This is a difficult instruction for a mother with extreme financial constraints, but necessary to avoid the opportunity for, and dangers of, bacterial growth.
    [21 March: I’ve since realised that she likely does not discard anything and it could be why baby got diarrhoea, if she is saving leftover formula in the heat.  So on advice from my mother I am going to suggest that she take any leftover out of the bottle at the end of a feed and give it to her 5yo, perhaps added to rice].
  • Proper cleaning of bottles and teats.
  • Recommended volume and number of feeds per 24 hours, which changes (at times rapidly) with age.

This mother could have breastfed her child freely and safely if she lived in an environment where breastfeeding is supported, rather than an environment where artificial infant formulas (aka “breastmilk substitutes”) are ruthlessly marketed.  We have since invested many hours informing her appropriately so that she can protect her child from all manner of risks associated with bottle feeding in an impoverished environment.  Everyday that I work on this activity, I wonder at the thousands and probably millions of other mothers around the world who have fallen prey to the marketing of breastmilk substitutes.

It is impossible to reflect on the victims of this global horror without simultaneously wondering at its beneficiaries.  In May 2016 World Health Organisation published a document Guidance on Ending the Inappropriate Promotion of Foods for Infant and Young Children.  WHO predicted in 2016 that by 2019, the market value of breastmilk substitutes would reach US$70.6 billion.  That’s some extreme wealth being accumulated somewhere.  Certainly not anywhere on the shores of the Mekong River where I tread, and where the chances of living safely let alone in comfort, are asphyxiated by all manner of adversity.  WHO also stated that women and children have the right “to be free from inappropriate marketing of baby formula and related products”, which are “not in the best interests of maternal and child health”.

It still astonishes me that the “Baby Killer” scandal of the 1970s never really ended; that I ever believed, after reading of the global response to this scandal during my studies almost 20 years ago, that it had been resolved; and that in 2019 I now find myself working so closely with its ongoing ramifications.

Today when we met this mother and weighed her baby, the promise of her growth pattern improving had vanished and this week her weight has plummeted.  As I pondered on what might be wrong given our intense efforts, Mum spoke at length in Khmer with my colleague.  I then received a translation that – again – left me in a state of shock.

On Sunday, some weeks after Mum began following our instructions for bottle feeding, baby developed a distended abdomen and some diarrhoea.  Mum took her to hospital.  In hospital she was told that the reason her baby got sick, was that she was not making the bottles correctly, and was given a completely different (and incorrect) set of instructions as follows:KF 20 Mar 001 (3)

If you plan to give your baby 60ml of formula, fill the bottle to the number 2 with powder, and then add water until it reaches the number 60.  If you plan to give your baby 90ml of formula, fill the bottle to the number 3 with powder, and then add water until it reaches the number 90“.  And so forth.  Thankfully the relationship my colleague has with this family means she was able to encourage Mum to follow our instructions and ignore the hospital staff’s unfathomable advice.  Not before 3 days of incorrect feeding on top of a bout of diarrhoea had worsened her previously-improving malnutrition.  During our conversation Mum also asked, “why is she vomiting a lot now?”.  How long has she been vomiting?  “Since two days ago”.  It was useful information to help convince her that the hospital’s instructions were obviously incorrect and had upset baby.

As an aside, but keeping with the theme of the power of marketing, Cambodia’s Ministry of Health announced recently that cases of the mosquito-borne virus Dengue Fever are expected to rise markedly this year.  Media reports have stated that in 2018 approximately 25,000 people fell ill with Dengue Fever in Cambodia, 23 of whom died.  Today with my colleague translating, we delivered a community education session to five women and 18 children, on Mosquito Prevention.  One of my messages, relating to female mosquitoes relying on blood to nourish their eggs, was around the fact that male mosquitoes feed on flower pollen whilst female mosquitoes feed on human blood.  The presentation on my computer screen included the following two slides:

At the end of our session we held a quiz with some prizes to those with the fastest correct responses.  When we shared the cartoon captioned “Only female mosquitoes bite” we asked, what is the boy mosquito drinking?  A crowd of children shot their arms into the air and my colleague translated (unnecessarily), “they think he is drinking Coca Cola”!

In the midst of it all Cambodia’s only three helicopters, which I talked about in my 15 February blog post, once more flew directly overhead, forcing a pause in our quiz game while we waited for their raucous chopping to pass.

I came home, lay on the couch and slept for two hours.  Because sometimes the battle…..

Catastrophic Cycles

Corruption in Health

This cartoon derives from a 2015 article about an anti-corruption exhibition organised by Transparency International Bangladesh.  TIB arranges 10th Anti-Corruption Cartoon exhibition at Drik Gallery.  It illustrates the user-pays health care system prevailing across the poor world in which health professionals are enriched on the backs of an already impoverished general public.  “Without money you die” are words spoken by doctors and nurses as a matter of fact to patients on a daily basis here in Cambodia.  Their words reflect reality as people suffer and die in all manner of unimaginable ways due solely to a lack of money, many leaving their families behind with an inheritance of crushing debt.

Many of the doctors prospering from this system have received training in wealthy nations whose intention, I am sure, is to promote quality care in places with limited means.  I am equally sure that few involved in offering the various scholarships and other opportunities understand that they are often serving to further empower oppressive systems.  This could be regulated at least in part, by placing certain conditions on the beneficiaries of such training and by requiring some level of monitoring, as exists in countries where the public do have safeguards.

For many in Cambodia, the only option for health care comes in the form of NGOs, of which there are many yet there are not enough and for which there is little to no coordinated collaboration between services.  Brief and temporary services are also offered by various visiting organisations as a form of stopgap and often as a means to offer further training to local staff.  As someone trained in public health, familiar with health systems, experienced in sourcing services for clients, and with access to resources, I do not navigate the health systems in Cambodia easily because there is no centralised point of communication about what is available and where.  There is limited governance so that private businesses can impersonate NGOs with impunity and a black market offers all manner of medications and supplies, even anti-TB medicines which require strict regulation for protection against bacterial resistance.

When the education system started from scratch in 1979, 75% of all teachers and 95% of all tertiary students had been killed in the Khmer Rouge genocide.  Forty years on, through decades of political and economic turmoil, the education system is still re-establishing.  Teachers in public schools, many of whom are based in dusty rural villages with few to no resources, earn a low income and have unclear levels of training.  Teacher salaries are so low that students are required to pay a small daily cash fee to ensure a livable income.  In many families cash is often unavailable, affecting school attendance rates as much as the bare, dusty and overcrowded classrooms must.  Insufficient family income further encourages the mass exodus of  children from school before their literacy has been established as children are needed to help support the family.

Ignoring the multitude of other complex factors at play in Cambodian society, this alone offers explanation of the low levels of literacy and numeracy and high levels of hardship seen in rural villages and urban slums here.  Children pulling wooden carts looking for recyclable materials to sell; parents labouring for low casual wages far away from their young families; and perhaps more worryingly, young people vulnerable to persuasion by all manner of dubious employment offers, all stem at least in part, from the need created by an inadequate education system.

The population survive (and perish) in a micro-economy where even the literate and educated face challenges that are unheard of in the wealthy world.  The fact that accomplished, qualified and experienced doctors, engineers and architects can face high rates of unemployment is perhaps the most remarkable example.

This background of necessity leads to any number of inventive and creative enterprises.  Profiteering from health care services delivered with inadequate regulation to a population with deficient health literacy is probably the biggest and best example among many, of this inventiveness.

Alongside the perpetual need endured here, is a chronic state of systemic corruption.  As a colleague said to me some years ago “I feel upset when foreigners accuse me that I am from a country of corruption.  They feel okay to challenge me but then they show big respect to the high ranks who ARE corrupt.  I am not corruption.  I am the victim of corruption”.  It is important to understand this because those of us from countries where corruption (which is never non-existent) exists at lower levels, or in a more hidden form, can be quick to judge local people without understanding the situation.  In fact, individual corruption, although it also exists, is not the real problem, but rather systemic corruption which is established from the top and filters down through the various institutions.

After 2.5 years living in Cambodia I still have a very basic understanding of the way that deficient systems provide an ideal environment for corruption to become institutionalised and normalised.  Talk of purchasing black market medications to treat a patient for example, sounds shocking until you understand that the doctor speaking to you wants to cure his patient, and understands that his patient cannot afford to (and therefore will not) attend the established health facility who could provide regulated medicines.

Example 1: Infant Feeding

I provided the above background in an attempt to explain why it is necessary to recognise that not everyone employed inside corrupt institutions or engaging with corrupt systems, is corrupt themselves.  Often at an individual level there is no other option.  Not everyone involved in corrupt systems is aware of the role they are playing, or has alternative choices, or is even necessarily doing the wrong thing by others, at least not consciously.  Many are as much the casualties of their nation’s established need and chaos, as anyone else.

Last month I encountered an eighteen day old baby lying asleep on the bamboo strip floor of a little hut.  I was busy assessing her mother’s four year old in the dirt on the Mekong shore, who appears to have some form of polio-like condition.  Only after I finished “playing” with this little girl, did her mother announce “I also have a new baby”.  Big brother moved further inside the open walled hut and reappeared with his tiny sleeping sister.  Enquiring about her health, Mum presented me with a blue tin of artificial infant milk powder and stated “I don’t have enough breastmilk”.  Over the years I have learned that this is a common phrase used in maternity clinics here to promote the sale of artificial infant milk.  Even educated doctors have told me “I am mix-feeding because I don’t have enough breastmilk”.

Training mothers that they “don’t have enough breastmilk” commences on Day 1.  My guess is that health professionals who probably know otherwise, use misinformation to train uneducated staff to undertake this work, as a way of boosting artificial milk sales.  It all happens at a highly emotional time for new mothers, before breastmilk production and a feeding pattern can be properly established, and before weight gain or urine output can be monitored as ways to gauge whether the baby’s intake is adequate.  There is a wealth of understanding today among health professionals, of the health benefits of breastfeeding for both mother and child.  Equally, we also understand the strong influence that artificial infant milk promotion has on breastfeeding rates even in countries where this promotion is strictly regulated, and where the population have sound health literacy with access to reliable information and support systems.  As this infographic illustrating the stomach size of a newborn baby shows, the statement that a new mother “doesn’t have enough breastmilk” is probably almost always false.

Infant Stomach CapacityClearly the Baby Killer scandal of the 1970s continues unabated today in parts of the world where necessity and chaos reign supreme.  Since meeting 18 day old, who is now seven weeks old, I have learned a lot.  When we met her again at 5 weeks old the blue tin of artificial milk powder had been replaced with a green tin.  My translator informed me “The maternity clinic donated the blue tin to her, but when she went to buy it, it was too expensive so she bought this one because it is cheaper”.  Mum, who cannot read or write, was still following the instructions from the maternity clinic about how to make the milk and how much to give.  These instructions are appropriate to newborn needs which change rapidly over the first few months, requiring some level of health literacy and ability to read instructions, to implement.  This explained her very unsettled and hungry baby’s advancing malnutrition.  Working with her to address the problem, I contacted a nutritionist colleague in Australia who further investigated, finding that this particular company offer “infant milk” formulas up to the age of six years old, when normal cow’s milk can be safely introduced from 12 months old.  The market for artificial infant milk – very likely still responsible for many infant deaths – is clearly a very lucrative one.

We continue to work with this mother, and monitor baby whose growth pattern has started to improve with a little education and support.  We are also working to encourage establishing breastfeeding as the accepted norm in her small community, including strategies for women to respond when placed under pressure to use artificial infant milk.

Example 2: Curative Potions

A few years ago I spoke about Joe, who died slowly from probable post-Polio syndrome, lying on the hammock inside his falling-down banana leaf-walled, bamboo-floored hut in a remote village.  Just after Joe died, I learned that his family had sold their cows to purchase a medicine from a visiting salesman who promised his remedy (which sounded from the unreliable translation, like a human colostrum formulation) could be curative.  The same day that I heard this story, the guard at my hotel told me he had a day job as well as his night job, selling something for a “medicine company”.  Earning US$100 per month offering security services in the evening during the hotel’s busiest hours, he slept on the restaurant couch at the locked front door of the hotel by night.  He was pleased to have found a second job as a salesman to supplement his main, barely-livable income.  He spoke about it openly and even with some pride that a medicine company would employ him.

It is almost five years since I met Paula, age 25 and weight 20.8kg in May 2014.  Her story has been covered in various blog posts since that time as she had such a profound affect on me.  As did the incredible serendipity of encountering an American surgeon with the skills to cure her hospital-acquired injuries, in the company of some people with the capacity to cover the cost of getting her to America.

The first time I met Paula’s father was in May 2014 when he appeared before my eyes carrying an unrecognisable bundle towards me on the hospital verandah.  The shock I felt when I realised it was a human in his arms, is embedded in my brain.  The last time I saw him was at Phnom Penh Airport when Paula was lying on a stretcher waiting to enter the departures lobby for our flight to the surgeon in Seattle.  Since then her father has been living in Malaysia, selling food at a street stall in order to pay off the family debt incurred by the various and injurious treatments that Paula received prior to arriving at our service and learning her condition was not cancer, but rather drug resistant mesenteric TB.

A few weeks ago an email from the Seattle surgeon’s wife included the words “I hope she is giving back in some way“.  My internal, unspoken response was “if she had an education and some opportunity she could“.  A few days later I received a message from Paula’s family that her father had returned from Malaysia and could I plan to visit him?  I took a weekend trip to Kampong Cham and traveled out to their village to meet him.

Paula, now in full health, was away but her parents informed me proudly that she has a job.  My tuk tuk translator said “she sells something for a medicine company.  Something to drink.  If she sells enough she can get high salary but if she does not sell enough, only a low salary”.  An uneducated and impoverished villager selling medicine for commission?  I slowly registered that rather than “giving back” in any way, she is unwittingly engaged in the damaging private business of defrauding illiterate and desperate villagers!  My Khmer friend who was in Seattle with us responded with disappointment that “rich people often get benefits from poor people”.  She has promised to contact her today to “talk about this”.  It is highly likely that she has received some form of training via her employer that whatever it is she is selling, has curative properties.  There would be little reason for her to understand otherwise given her own lack of education and every reason for her to want to believe it, as her way of earning an income.  Despite her extraordinary life-saving American experience she remains a casualty of the chaos and necessity that Cambodia’s population are immersed in, living inside the cycle of catastrophe that poverty guarantees.

Necessity is the mother of Invention;
Chaos is the mother of Corruption.

Ladles and Jellyspoons

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.

Treating Treasures as Trash

powerbygandalf

Burnt to a crisp, parts of his clothes fused to his charred skin, his face black and locked in an expression of pain and horror, the patient had been doused in petrol and set alight by an angry boss.  Shuttled from health center to provincial hospital and finally making it at impossible expense to the city, he lay in a so-called “Intensive Care” bed where staff gave him IV fluids and an injection, then walked away.  “Several hours later, a doctor came in.  He told us the burn was very serious and he needed to clean the wounds.  But we would have to pay him $100.  He told this to my grandmother.  She is old and she had just lost a leg to a land mine.  Through the evening, the price increased to $150.  I was crying.  I told the doctor I didn’t have $150.  The doctor said “Well, I guess we don’t need to clean the wounds”.  He took off his gloves and walked away”.  That was the last they saw of him.  Transported all the way home again with no pain control or treatment, a few days later, he died.  No charges laid, not even, it would seem, a wrap on the knuckles.

Cambodia’s Curse, The Modern History of a Troubled Land
Joel Brinkley, 2011
Summarised and quoted from Chapters 12 and 13

This week I met a range of people with a range of health complaints. Each and every one of them has a story worth being shared. There are too many to share them all so the three most significant ones are summarised briefly here.

  1. A woman with an unknown skin disease (? necrotising fasciitis) which seemed to eat the flesh from her skin.  When she presented to hospital the doctor asked “How can I treat you if you do not pay me?”.  Loans from neighbours combined with a loan from the bank, totalling $4,000 of debt later, she has had skin grafts and appears to be improving but without any of the physiotherapy or other services someone in her condition could expect to receive in the world where I come from.  Lying on the tiled floor of her tiny room at the top of some filthy concrete stairs in a crowded apartment block, she explained that her 17yo daughter left school and is working as a waitress for $120 per month while her mother cannot work.  Aware of her plight, the landlord reduces their monthly rent of $40 when he can afford to do so.  Loan repayments are a minimum of $200 per month and she suggested we might cover the family’s food expenses to assist?  Sadly this is beyond our organisation’s budget capacity.  We walked away as I wondered at the point of plummeting someone into a state of starvation while claiming to treat their health, with images of doctors driving Volvos and BMWs floating around amongst my thoughts.
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  2. Thinking I had seen and heard my shock for the day, we walked through a narrow alley, turned a corner into a wider path crowded with activity – freshly caught fish grilling on an open fire, naked children playing with stones, older children in school uniforms, a motodup driver loaded with groceries, neighbours socialising.  On a hard wooden platform outside a tin shack, a woman groaning in pain, her eyes shut, hand holding the edge of the platform she lay on, abdomen the size of a large exercise ball, skin a satin sheen from the swelling.  Her husband brought the clinical paperwork to show me and I deduced despite my French illiteracy, a diagnosis of cancer with metastases on private clinic letterhead.  As outlined by Joel Brinkley in Cambodia’s Curse, accepted practice here is employment on low wages in the public health system of medical staff who refer patients to their private clinics when the under-resourced public system has no capacity for diagnosis or treatment.  Sources cite the debt due to health care costs in Cambodia’s poorest (80% of the population) as being catastrophic.
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    Does she have any painkillers?  The doctors prescribed some but it depends if they have enough money to buy them, so her husband has to look after her in the day, then at night her children stay with her and her husband can work as a motodup driver.  If he earns enough then they can buy the medicine but they only buy a few days at a time as they can afford it.  So in effect, as I’ve learned happens to so many, she is dying of cancer without analgesia.  Luckily my contacts from previous projects were able to put me in touch immediately with an NGO called Douleurs Sans Frontieres (Pain Without Borders) who offer palliative analgesia to the poor for free.  A Khmer doctor and nurse working with DSF attended that afternoon, calling me later to confirm she was now in their care and asking me to refer any similar cases to them.  When I asked my colleague, are there any other clients suffering like this, she replied “Oh!  But last month, but she died already and oh my god, so terrible!”.
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  3. On 27 January I mentioned in my blog, a woman walking around with untreated Multi-Drug Resistant Tuberculosis (MDRTB), receiving no follow up and not wanting to take the medications due to severely unpleasant side effects and higher priorities such as finding food and a uterine prolapse causing much more discomfort than the blood she coughs up.  Yesterday I managed to get her to a hospital who claim to deliver “24 hour, high quality, free medical care for the poor and disadvantaged in Cambodia“.  Posters on the wall requested donations to assist in maintaining this “free care”.  Hours of my day were spent in a waiting room with the patient coughing, complaining of chest pain, expressing concern that she had no money to pay a hospital fee, and asking me to take her home because she felt normal.
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    At the end of a long and taxing wait, having dealt with many friendly, helpful staff all addressing me in English, two well-heeled TB doctors, noses in the air, tended to her, listening to her claims of no cough, no sputum, feeling fine, etc.  A normal response for a patient so impoverished and visibly unwell with a dangerous communicable disease which always requires a multi-disciplinary approach, would be to elicit any possible information from an escort.  Instead, my presence was not acknowledged except to ask her in Khmer who I was and why I was with her and ignoring my attempts to speak.  Knowing what I do about the treatment that patients receive from many in the higher ranks of the health system here, it became quickly apparent that her imminent death from TB was an unimportant detail in this company.  We left, required to pay a small invoice which would have been a larger amount except that the very decent receptionist negotiated the cost down after I, still reeling from the black hearts in the TB Department, pointed to the “free care” signs, and likely seemed as if I was threatening to make a fuss.
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    Next week we will try again to find a way to see this patient supported to receive the TB treatment that she needs.  Meanwhile, for months she has been transmitting a dangerous disease throughout her already-unwell community.  Obviously Tuberculosis continues to travel unabated throughout this country, with untold unnecessary misery and death, primarily among the poor whose demise are mostly invisible and uncounted.  Caught up in this pandemonium are reliable accounts of TB drugs, ostensibly regulated to reduce improper use, being available on a black market.  The global public health implications of this should cause all of us concern regardless of where we live.

This week’s news headlines – difficult to find in any Google search – have told of a wealthy landowner who requested military intervention to remove people living on land she had taken dubious ownership over.  One death and a number of injuries later, the landowner is said to have escaped the limelight, to her Australian home!
Phnom Penh Post : Families Vow to Fight On
Phnom Penh Post: Military Violence

I have often wondered at this quote by Nelson Mandela but in recent weeks I have started to understand what he meant and that poverty really is a man-made construction, built of corruption, greed, power imbalance and black hearts.

povertyismanmade

Trash To Treasure

She lives in a tin hut in a back alley filled with makeshift shacks stacked beside and atop of each other.  Roosters crow, ducks, chooks and skinny kittens peck around for morsels in the same muddy piles of trash, dogs laze in shaded patches, and pigeons coo from a cage.  A neighbour is crouched over a bucket of soapy water, scrubbing clothes.  Suds spill over into the dirt as we step over the rivulet of foam trickling downhill and seeping slowly into the damp soil.  She broke her wrist about two months ago.  I ask did she see a doctor?  “No, she has no money for that”.  Does she have any painkillers?  “No, she has no money for that”.  How long ago did it happen?  “Maybe two months”.  How old is she?  “Eighty eight”.  At the nearest pharmacy I purchase a 75c sheet of Paracetamol and we give it to her for the pain.  Her friend is hunched over awkwardly and when it comes time to tell her story, she lifts her shirt, showing a spine crumbled into a hunched back which she explains happened after she started treatment for TB three years ago.  I tell her this was caused by her disease and not the medicine.  When I return the following day with the organisation’s doctor I see her walking, her torso at a right angle to her hips.  These are just two of the people our small and under-funded organisation are assisting.   Recently their biggest donor died, slashing the monthly budget in half.  After salaries for a doctor, a program manager, a social worker and a driver, remaining funds are used by prioritising competing needs, which includes obtaining necessary medicines, supplying food to the hungry, paying school fees.  I hear my colleague explain a number of times to different clients, that “we can no longer offer the same support as before, because our biggest donor died”.

For some years now I have dreamed to volunteer my time and skills in a local community and finally I’m able to do so, albeit temporarily.  My national colleagues are some of the world’s heroes.  In one area known as “Ghost Village” because the men can earn money by preparing dead bodies for cremation, I’m told that during the Wet Season the shacks can only be accessed by walking in waist-deep water.  When I state that “I won’t  be able to visit here when it is like that”, she says without so much as a sideways glance at my prima donna comment, “It’s okay you can stand on that high part there and I will walk in to check the people”.  She then says to me “Even I am poor but sometimes I know I am not as poor as these people and I give my own money because it is so difficult if we don’t help”.  Learning that due to lack of funds this month’s food parcels have been delayed, I offer to cover this cost.  As she receives the money from me she says “I really hope you can continue to support us”.  I reply that I will try and I will tell as many others as possible about the need.

We meet an HIV+ woman looking after her neighbours’ children while their parents are looking for recyclables in the city streets.  Another woman with Multi Drug Resistant Tuberculosis gets in the tuk tuk when my colleague stops to talk with her.  She wants to tell us about her uterine prolapse and in passing her TB diagnosis is mentioned.  Our doctor is not there so I work out from the vague details shared in broken English by people with limited health literacy, that she has MDRTB and is not receiving the required treatment because she cannot tolerate the side effects of the medications.  I explain that she must take the medicine or the TB will kill her and that meanwhile she is spreading it to others.  She replies “I am not so worried by coughing blood, my biggest worry is that I don’t know how I can eat tonight if I don’t find any money and my prolapse is very uncomfortable but I cannot afford the treatment”.  This is what those books and articles mean when they say that “TB is a disease of poverty“.  She is in fact, sick with poverty, and TB is just one of the symptoms, albeit the symptom most likely to kill her.  Perhaps the person with limited health literacy is in fact, me?

We go into a tin shed where a 60yo man and his wife are caring for their 2yo grandson who is swinging in a hammock slung between two posts at grandad’s bed.  Grandad’s feet are badly burned, the wounds open and festering.  His story is that he needs to take this medicine (he pulls a packet of Gliclazide which treats Diabetes from a plastic bag hanging from the window above his head).  This medicine makes him feel better, but he cannot always afford to buy it.  Recently he was worrying a lot about his family’s finances because the shed costs $40 per month to rent, so he found a construction job that paid $5 per day.  He only had a pair of rubber thongs to wear so he went to work in them and during the day the hot concrete burned his feet (which are numb from having too much sugar in his bloodstream, caused by his Diabetes).  Without our MD’s help he would be at very high risk of losing his legs due to these injuries, or dying from blood poisoning caused by the infected wounds.  But our doctor can treat his Diabetes, his hypertension and his wounds because he has been identified as a high priority case.

On the shore of the Mekong River we meet an elderly woman who my colleague identifies as one of the ten neediest community members who we try to provide monthly food parcels to.  Previously she could earn $1 per day by cutting fish for sale at market.  Now she is old, sitting down for long periods is not possible so she can no longer do this job.  She searches the ground for cans and plastics to recycle, but the area she lives in has few recyclables, so she only earns about 25c per day in a place where the cheapest meal costs 75c.  She lifts the scarf on her head above her ears, revealing a cheap pair of gold plated earrings in her pierced ears, stating “I feel very worried about food but when I get hungry enough I have these earrings and I will be able to sell them for a meal”.  Leaving Australia last month I packed a small silk bag with my unused, unwanted jewelry, thinking “someone in Cambodia will be able to make use of this trash”.  On day one volunteering I met that someone.

It’s easy in the “rich world” to think that if you don’t have a spare $50, you therefore don’t have anything to offer to charity.  But amounts as small as $10 can make huge differences to people who have nothing.  Part of the problem from rich countries is knowing who / where / how to donate.  This seems to drive most people to donate to large organisations while small NGOs employing locals are often capable of offering much more accessible services with better impact but for their lack of funds.