Humility in Service

Cambodian Health Professionals Association of America (CHPAA) are about to embark on their tenth mission from USA to Cambodia where they are setting up shop for a week, offering free medical, surgical and dental treatment to people who otherwise cannot access care.

Earlier this year I wrote about my experience traveling to a province outside Phnom Penh with a rabble of about twelve impoverished sick people piled onto the back of a pick-up truck.  The biggest success of that trip was the 32yo mother living on a canoe-sized boat with her husband and children, one of whom had drowned some months before I met her.  The day I met her, one of my first volunteering with a small local organisation, I was on the riverbank with our doctor and social worker.  The boat-dwelling residents heard we were there and many of them climbed the bank to meet us on the footpath.  Various complaints were expressed, the most significant being this young woman who presented me with an ultrasound report written in French.  I could vaguely make out that she must have gallstones.  As my colleague translated to me that she was having severe bouts of acute pain and had been quoted $1000 for surgery, the woman pierced me with watchful eyes.  We didn’t need to speak the same language for me to understand that she desperately hoped I could help.

That night I discovered that CHPAA were due to arrive in Cambodia for their ninth mission a few short weeks later.  On the back of our crowded pick-up truck one hot February morning came this woman, her husband and their 2yo daughter.  A few days later we returned home post-surgery and she was able to resume normal, if you could call it that, life again.

KF 003 (2a)

This short video has footage from the 2019 CHPAA mission, which I was a very small part of: CHPAA Ninth Mission to Baray Santuk

This Facebook video explains CHPAA a little more and shows the spirit underlying the honour of being able to make a small difference in places that the privileged among us can never truly perceive: The impact of Cambodia on CHPAA volunteers.  The emotion and humility from volunteers touched by their experiences helping the unseen and unheard is heartening.

CHPAA undertake their tenth mission in a couple of weeks.  I am not there sadly, but this year a family in Alice Springs Australia, instead of buying each other Christmas presents, donated money to me for Cambodia.  Alongside some other donations offered by family and friends, I’m sending it today to my colleague who has a group of sick clients she can gather together and transport, courtesy this donation.  She tells me “one man the same like <gallstone lady>” so he’s about to be cured!  I look forward to hearing some more success stories of health care being made available to people who otherwise suffer and die, silent and invisible.

Oops and Stupid Deaths

Dr Paul Farmer, co-founder of Partners In Health, talks about “oops” health care leading to “stupid deaths”.  I have often referred to the destitution seen in Cambodia, caused by people needing to pay from their pockets for all health care costs – that’s “Out Of Pocket Spending”, or “oops”.  Health care in Cambodia, and across the poor world, is both expensive and generally poor quality, leading to high rates of preventable suffering (including healthcare-induced destitution) and death, aka “stupid deaths”.  Farmer refers to “oops” elements in the US health system, comparing care available in affluent parts of America with the lack of care in impoverished areas of higher need, in this excellent article on global health inequalities.  Farmer’s narrations of this tragedy playing out across our globe, including this priceless quote, speak volumes:

I was tempted to record the cause of death as “weak health system for poor people,” “uninsured,” “fell through gaping hole in safety net,” or “too poor to survive catastrophic illness.”

It is easy from the rich world to believe that these problems occur due to low knowledge or inexperience, but in fact my Cambodian colleagues have vast experience, knowledge and skill.  The issue lies, as described so succinctly by Dr Farmer, with the quality of systems in place.  Without established systems, processes and regulations, then up to date, evidence based and consistent care cannot be maintained.  For example in Australia, I must show that I have undertaken at least 20 hours of formal professional development annually, in order to maintain my professional registration which is reviewed and renewed each year.  I am required to undertake and maintain regular extra training before I can perform some specific tasks or procedures; to follow certain guidelines and processes; and to document my work in specific ways.  When I make an error in practice I am required to report it via a risk management system that considers human error an expected deviation to be addressed through quality improvement reviews.  These regulated requirements are constantly reviewed and improved in order to ensure that the systems, established to ensure quality care is provided, have intended impact.  This ongoing process is what makes the care I provide consistent against the care someone else in a similar job would also provide, which gives service users an appropriate level of trust in the care that they receive.  Intuition develops with experience and enhances competence but the same knowledge and experience freely gliding along solo with only individual intuition as a guide would (and does) result in very inconsistent care, and inferior outcomes for those receiving health care.

Sadly it seems that baby Mary, now 10 months old, is on an oops-like trajectory towards a stupid death.  She received three months, or about half, of a course of anti-TB medication, sourced from the black market and administered with only vague adherence to the public health recommendations for treatment of tuberculosis.  Her response to treatment was slow at best and she continues to present with repeated respiratory infections and ongoing, although slowly improving, malnutrition.  A month ago she developed another respiratory infection and the sole doctor treating her responded by ceasing TB medication altogether, based on his persisting intuition that she does not have TB.

This is an astounding response to a baby who is malnourished with respiratory symptoms – the main ingredients of tuberculous disease.  Particularly in a place with high prevalence of TB and when her older sibling is permanently disabled from tuberculous meningitis, demonstrating the presence of infectious TB within the vicinity of this family.  If she does have TB then partial treatment is both useless for cure as well as placing her at risk of the bacteria developing resistance to the standard treatments, which is why partial treatment for TB is contra-indicated in all of the literature and guidelines.  It was probably an inevitable result in this case, as just another link in the chain of care to be expected from a fragmented, disorganised system with inadequate regulation and no requirement for collaboration or structured public health approaches which are the benchmarks of health systems in countries like Australia, New Zealand and the United Kingdom.

Mary was turned away by the National TB Program when they were not able to “tick every box” required by the Global Fund who supply the anti-TB drugs, before the drugs can be dispensed.  This is no doubt required as a way to prevent corruption, by ensuring that only people with clear TB diagnoses receive the drugs, which can end up on the black market where they can be used inappropriately (case in point: Mary).  It is an example of a system that needs to be reviewed and amended when those needing treatment cannot access anti-TB drugs.  World Health Organisation state that “Ensuring all TB patients have access to free-of-charge life-saving treatment is fundamental to minimizing disease and deaths due to TB“, yet this clearly does not happen particularly for the world’s poorest, who are also those at highest risk of TB disease.

Clear TB diagnosis is not always possible as tuberculosis disease often camouflages itself.  Patients sick with TB or whose immunity is suppressed by their illness often test negative to the diagnostic tests.  Childhood TB very often presents in atypical ways, making diagnosis difficult or impossible.  70% of TB disease occurs in the lungs but 30% occurs in other body organs.  It can affect any organ – I have seen skin TB, ovarian TB, abdominal TB and renal TB, to name a few.  Patients with unusual TB presentations often present as if they have cancer and in places where consideration of TB is not well programmed (which is usually places where TB is more prevalent, due to the lack of proper systems), it is not unusual for people to be told they have terminal cancer, which is often an incorrectly assumed cause of death.  Or, as I continue to learn, that they have a mysterious illness without the world’s leading infectious killer being considered a possibility.  A very stupid death indeed, but the fault of systems rather than individuals.

The STOP TB Partnership recently released 2018 statistics per country for TB, at stoptb.org.  Below are some comparisons between Australia and Cambodia created from this source.  The differences relate specifically to multiple types of poverty, including poverty of living conditions, poverty of health care systems, poverty of population health literacy and poverty of human rights.  Less poverty in Australia results in far fewer instances of TB, much less undiagnosed TB when it does occur, and far fewer TB deaths.  The estimated TB deaths in Cambodia total almost 10 people per day, most of which occur at the end of an “oops” journey through health services despite claims that TB treatment is free, and all of them “stupid deaths”.

2018 TB Stats Table

Strike a Chord

“Humanitarian work isn’t criminal, nor is it heroic. Helping others should be normal. The real people who are suffering and dying are those already fleeing persecution.” Seán Binder

There’s not a lot to blog about right now as I remain in Australia working but these words really struck a chord with me.

You can read about Sean Binder, a young Irish man who spent 100 days in a Greek prison for the “crime” of rescuing refugees in distress at sea, at the link below.  You can also sign the petition challenging the Greek government on their policy of criminalising the saving of lives.

Demand the charges against Sarah and Sean are dropped

Scales and Skills

I’ve been in Australia since April.  Since then I’ve been helping Cambodia out a little from afar, but mainly focused on studies and work here, saving for the next jaunt to Cambodia early next year.  That’s why there’s been a paucity of blog posts.

Earlier this year I obtained a set of butcher scales and organised to have a sling made to hang from them in order to weigh children.  The scales are very versatile, and we’ve hung them mainly from ceiling rafters, but tree branches also work.  These babies rarely get weighed and it’s been such a joy teaching their mothers a little bit about how to keep their children healthy.

TB baby (“Mary”) remains malnourished but slowly improving, I hear very little except a weekly report on current weight as my colleague continues to make good use of her new skills and scales.  And usually a weekly gallery of photographs and videos of the children and families I know, with updates of various struggles such as boats sinking, houses blowing away, school uniforms and resources being distributed.  I pine to be there but soon enough I will be again.

The premise: Every human life is of equal value

What suburb someone lives in.  How much they earn.  How big or beautiful their house is.  The university they went to.  The degree(s) they earned at that university.  How they look.  What clothes they wear.  What car(s) they drive.   Where they go or what they do on holiday.

When these are the standards set to measure success it becomes easy for the idea that every human life is of equal value to become distorted.  Some of the biggest distorters of this premise are, in my experience, those who refer to themselves as “humanitarian”.

When I first went away with Medecins Sans Frontieres I had an excessively emotional and at times distressing ordeal.  Not from seeing poverty on a scale beyond anything I’d ever perceived was possible.  Not from seeing children, young and old people dying from completely preventable and unnecessary causes, with hunger often the underlying culprit leading to their disease.  Not from stepping over newborn babies, postnatal mothers, medical, surgical, paediatric and infectious patients all huddled as one on dirty hospital floors in foyers and corridors.  Not from the many disabled people I met without the wheelchairs, prostheses or other basic assistance that they needed.  Not from the parents asking me if I would please take care of their child so that she might survive.

My excessive emotions came directly from fellow expatriates sharing this environment with me.  A European doctor who, in explaining to me how angry she was that she hadn’t been authorised the extra day off she wanted, announced in front of our local colleague who could hear and understand her, that “I am not just some local staff with no choice!  I am ‘ere because I am a ‘ewe-manit-eeeeerian!  WE, ‘Elen, WE are ‘ewe-manit-eeeeerians”!  I looked out of the window away from her, recoiling at the idea that I was in any way connected to humanitarianism if this level of open arrogance was what it meant.  That was my first insight into the idea that not everyone traveling away under the guise of offering their services for humanitarian causes, shared my premise that all lives are equal.  My experiences in this regard, in hindsight, ran riot in that first twelve months, when I spent interminable hours trying to understand the viscerally disturbing anger welling up inside of me towards some of my colleagues.

That is not to say that every expatriate was excessively arrogant.  They were not and I made some lovely, lasting and respectful friendships.  But I struggled continuously with many enormous egos who didn’t understand that the cute baby they were taking a selfie with and posting on Facebook, was actually cute because she was so badly malnourished and that her parents had no way of preventing you from plastering her photograph on a public and international forum.  Or that the elderly, toothless lady whose face abruptly met the lens of your camera had no idea about Facebook, or that her image was about to be sent out across cyberspace without her knowledge, let alone her permission.  Oneday I had to literally fight with a European doctor who wanted to visit the home of a dying patient in an Islamic village, directly over the street from the village mosque, dressed in buttock-exposing shorts and spaghetti straps tank top.  This same doctor was later sent to another country with enormous poverty and disease, and her main impression was relayed to us as not being allowed to wear her bikini on the beach.

Expatriates from France, where Christmas and Easter are such commanding traditions, complaining about Khmer celebrations because “I cannot understand why this is so important to anyone”, seem to have no insight into their egocentrism.  They have no misgivings whatsoever, in sending local staff away from home on the cheapest bus fare, to stay in the cheapest accommodation, and joking that the staff must be trying to cheat them by taking the policy-driven per diem (<$10/day) to cover away-from-home costs; then in the next week sending their highly paid European counterparts to the same location in a private car, booking VIP hotel rooms and checking that they are not in any way out-of-pocket.

When a local doctor oneday informed our staff meeting that a specific patient was severely ill and would need palliative care, the newly arrived French nurse manager with no experience in the medical condition being discussed, instructed the team “No!  I saw that patient yesterday!  He is not so sick and we will not pay for transfer to palliative care”.  The next day the patient died.  Would she dare be so imperious to European doctors?  No she would not.

My own experiences are crumbs compared with those that local staff tolerate from expatriates who arrive from their comfortable homes, into positions of power over locals whose strong knowledge, years of experience, and contextual understanding are not recognised or appreciated.  At an annual work dinner recently, the restaurant was contacted and requested to reserve one table as “VIP”.  Every expatriate joined this table, not one of them questioning their self-nominated status against their local colleagues.  Some expatriates assume the local staff are all corrupt and cannot be trusted; others think that recent graduation from a rich-country university places them above experienced locals and use the opportunity to teach people to suck eggs without any attempt at assessing the situation first.  This lack of humility leads to some very embarrassing situations, but when you consider yourself superior you can brush humiliation off with ease.

Local people in poor countries have limited options in life which leaves them unprotected and vulnerable, emboldening perceptions of supremacy in visitors from privileged backgrounds.  The only time I’ve heard any public mention of the known abuses that occur in environments with excessive power differentials, such as the humanitarian world, has been when the abuse reached sensational levels.  Headlines in 2017 of sexual harassment, exploitation and abuse in some international NGOs don’t describe transgressions occurring in isolation of otherwise virtuous behaviour.  They sit at the pinnacle of a largely invisible, unreported and demeaning iceberg of imported egoism and self-appointed prestige.

Returning to my first paragraph:
What suburb someone lives in.  How much they earn.  How big or beautiful their house is.  The university they went to.  The degree(s) they earned at that university.  How they look.  What clothes they wear.  What car(s) they drive.   Where they go or what they do on holiday.
Expatriate humanitarians from wealthy countries beat local staff in poor countries at most of these superficial measures, as do a small privileged number of locals.  Yet, after years of observing the dynamic between people sharing a workplace but with a massive gap in power levels and privilege, the likes of which is not experienced in wealthy countries, I have measured true success in humility, generosity, humour and dignity, often in the face of discrimination and injustice.