Unconnected Connections

Fundraising for the 20yo woman with (probable?) Rheumatic Heart Disease needing urgent heart surgery continues.  A friend asked me to prepare a Powerpoint presentation for a fundraiser she is organising and I thought I would share it here as it summarises some of the stories I’ve spoken about disjointedly.

Story One: An Inconceivable Connection

In May 2014 I met a 25 year old Islamic woman from a rural village in Cambodia who had been told she had terminal cancer.  Surgeons in Cambodia operated twice to remove the “cancer” from her abdomen, first forming a colostomy as they removed some bowel.  The diagnosis came purely from the doctors opening her abdomen to investigate the pain she had been experiencing since pregnancy with her now-8yo son.  They based their diagnosis on what they could see – inflamed lymph nodes in her abdomen.  There were no resources to take a biopsy or other investigations which would give a proper diagnosis.

Surgical practices are basic at best and often dangerous without good equipment.  When her pain persisted, they performed a second operation which damaged her bowel, causing a second opening on her abdominal wall to form (a fistula).  She now oozed faeces from two sites on her abdomen.  This caused acidic burning of her skin and she was unable to absorb food so she became severely malnourished.  Doctors finally told her she should go home to die.  A short time later she developed a chronic cough and was diagnosed with lung TB.

Although it was thought she was dying, her TB needed to be treated for public health reasons.  Constant abdominal pain, oozing faeces which burned her skin and severe malnutrition were her main physical problems when she was admitted to the MSF program I was working on, with drug resistant TB.  We were unable to find any muscle mass to inject the second-line TB drugs when she was admitted to us, and she was unable to stand up without assistance.  She weighed 20kg.

After a few weeks on the right TB medications her cough eased and her abdominal pains ceased and I was sure that she had abdominal TB rather than cancer but there was no way of confirming this.  She continued to ask us if we thought she was going to die and we had no way of knowing the medical answer to this question.  She stayed in hospital for two months before we discharged her home.

My nurse team visited her at least once a month and I visited her either with them or at weekends, multiple times but I was at a loss to help in any meaningful way.  She needed colostomy bags and protective dressings but they were unavailable in Cambodia.  When I came home to NZ and Australia  I tried to source them but they were expensive and I was not able to supply more than a few weeks’ worth, so I did not supply them.  She had to wipe the openings with tissue or gauze many times during the day and night.  All I could really offer was a little financial help to the family for food, school fees and gauze, and some emotional support.

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Waiting to die from surgical complications related to undiagnosed mesenteric tuberculosis (2015), photograph courtesy El Pais newspaper who visited the MSF TB project

Her other problem was the debt her family had accrued trying to find a diagnosis and treatment for her.  They sold their house.  Her father had moved to Malaysia where he could earn a slightly better income selling food at a street stall.  Her grandfather had taken a loan out with his house as collateral.  Her younger brother, a very eager student, had been told once he turned 15yo that he would have to leave school and was thinking of moving to Thailand to work on unregulated fishing boats.  They were financially desperate.  Her mother stayed at home to nurse her daughter’s wounds and care for her 4yo son.  They were living in an extended family home in crowded conditions.  Laundry is done in the nearby Mekong and I was constantly astounded that the open, oozing wounds, had not become infected.  This was testament to the family’s extreme care.

In June 2015, a year after I met “Paula”, I was on holiday with an American friend in Provence in the south of France.  She invited me to a lunch at a beautiful medieval homestead with some wealthy Americans at an exclusive cooking class.  During conversation some of the Americans were very interested in Cambodia and asked me to explain what I meant when I used the word “poverty”.  I tried to explain Paula’s situation and the health care system.  I described her sitting on her death bed in a wooden hut beside the Mekong as we sat at this lush table with so much more than we needed.

Three American women sitting opposite me were on holiday together.  They were especially interested and one of them cried as I told Paula’s story.  Another asked me so many questions that I thought she must be a doctor or a nurse.  But she eventually told me that her husband is one of America’s leading gastro-intestinal surgeons and he would be fascinated by Paula’s story and would want to treat her himself!  When I explained that this was a nice idea but completely impossible, she assured me that it was perfectly possible.  She and her husband sat on the hospital board and could influence them to agree to a charity case for free surgery.  Someone else at the table was so inspired that she offered to pay for all other costs if the medical costs could be covered.

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A very memorable lunch

I returned to Cambodia almost immediately, cutting my European holiday short to organise a million details including passports, American visas, air travel for a critically unwell passenger.  She fainted at the photograph store when we took her for her passport photographs; fainted between the tuk tuk and hotel a number of times; fainted twice inside the American Embassy in Phnom Penh during her visa interview.  My life from July 2015 until early October 2015 was filled with taking this dying woman to various appointments and helping her fall to the floor as we challenged her to travel and walk distances she was not in any position to tolerate.

In October 2015 I travelled with her, her mother and a Cambodian nurse who acted as our translator, from Phnom Penh to Seattle.  A local Imam met us at the airport and drove us directly to the hospital.  En route, with the skyline of Seattle ahead of us in the distance, I heard her speaking Arabic to him from the front passenger seat.  Some time later he informed me that she had said to him “I can die now, because look at the experience I have had”!  She was admitted to the surgical ward and immediately began receiving the type of health care that we in New Zealand take for granted.  Within days her nutrition had improved and within two weeks she was deemed nourished enough to undergo surgery.

During our first 24 hours I found myself responsible, as the only native English speaker, for finding Halal food for her and her mother, which was quite a feat in a wealthy inner city area of one of America’s most prosperous cities.  After some time searching the streets I found a Vietnamese restaurant and ordered takeaway.  When I arrived back at our hospital room, a group of Islamic people were visiting.  They approached me eagerly to ask “are you the Australian doctor who brought her here for surgery?”.  Errr… no?  “Yes you are, it’s you who did this for our sister!”.  From that moment for the following two week stay, I was overwhelmed with attention from dozens if not more than 100 Cham people, mostly refugees from Pol Pot’s Cambodia in the 1970s, who have a strong community.  I never went looking for food again, as we were inundated with home cooking multiple times per day.  I was invited to stay at a family’s home where dozens of Cham Cambodians came for dinner to meet us.  The next morning the teenage son of our host family found a shoe box, cut a hole in the lid, taped the lid to the box and said he was taking it to mosque to raise money for Paula’s family.  He returned a few hours later with US$3,000.  The money was given to me and I was told “you must tell them what to do with it”.  I carried it back to Cambodia and gave it to grandad, who took it on the back of Paula’s sister’s motorbike, straight to the debtor, at my request and with me following in Chom’s tuk tuk!

Within two weeks of our arrival in USA an eight hour operation rejoined Paula’s bowel and closed her wounds.  She remained in America for five months to recover and to cut a very long story short, this is a photograph of her at home in Cambodia taken last week <not shared online to protect her privacy>.  She remains impoverished but she can care for her son and she works, selling homemade rice cakes from outside her house.

Story Two: A Fishy Connection

In February 2017 after more than a year away I returned to Cambodia and am now working on a project with Medecins Sans Frontieres, based in Phnom Penh.  The rich-poor divide in the city is visible and extreme.  The poor have few options and I can probably count the list of their choices for income on ten fingers.  One of them is to run a mobile “restaurant” from a trolley on a bicycle, cycling the streets hoping to find someone who will buy your fried banana.

Inequality in a pic

Searching the streets for recyclable tin, plastic, paper and cardboard is another common income generator and you see very young children and very elderly people pulling trolleys through the streets, as well as parents with children in the trolley with their collection of rubbish.

Phnom Penh Scenes 01

Last year when I came home to visit I landed in Christchurch at midnight with no way of making my way home to Mum until my uncle insisted on driving the almost three hours one-way to collect me and taxi me home in the middle of the night.  This uncle fishes off the shores of New Zealand’s picturesque South Island almost daily.  He took me out in his boat to pull up some craypots, and we swam in the open ocean in wet suits.  He dons goggles and swims with a long spear, catching butterfish.  He has regular close encounters with fur seals and dolphins and has even been up close and personal with Orca.  He refused to accept anything from me in thanks and so I promised that I would fix a fishing boat in Cambodia on his behalf.

Across Cambodia and in a particular location near Phnom Penh there are many landless communities of Islamic Cham people who live on boats or, when the river water is low enough, build makeshift shacks with any material they can find, on the riverbank.  A friend of mine volunteers with an organisation who work with one such community of about 500 people, ensuring the children have birth certificates, pay the school fees for families who fit their criteria (agree to keep their children in school and not make them work on the boats), work with families in need of health care etc.

For at least part of the year the community live on their boats as the riverbank disappears underneath the rising waters during Wet Season.  In April this year a particularly strong storm swept through Phnom Penh.  Even from my fifth floor apartment with it’s double glazed windows I could hear the torrential rain and winds.  That night one family’s boat sank to the bottom of the Mekong leaving them without their only source of income – access to fish which both feeds their family and gives them something to sell.   When I told the organisation a few weeks after this storm, that I had a donation to use on repairing a boat, this was the family they identified.

The family bought a new boat and when I visited about eight weeks later, it was upside down on the riverbank being waterproofed.  They told me via a translator that “we do not know how to thank you, there is no way to tell you how much thanks we have for your help”.  I also learned on that visit that they could not live on their boat as they had no roof for it.  The parents and two youngest children were sleeping in a tiny shack, two other children with a neighbour on their boat, and two children in a land based shack with another neighbour.  The wrong (cheaper) roof could potentially pull the boat over in strong winds and they could not afford a better roof.  When I asked how much a decent roof would cost they showed me a roof that was for sale at a boat nearby, for $60.  We funded this roof for them immediately.

046 Cham Visit

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The $60 (unaffordable) roof for sale, in front of the neighbour’s boat.  The neighbour has a newer roof (on the boat behind), hence the older roof for sale.  This “quality” roof can last for about ten years.  The family are able to live together again on their little boat.

Story Three: The Rheumatic Connection

Or so I think.  It could be another disease, but it’s most likely Rheumatic Heart Disease, a condition of poverty which occurs at very high rates in impoverished populations, including Central Australia’s indigenous communities.

Last month a friend told me about Sokum, a 20 year old woman dying from heart failure.  She could live if she could access the cardiac surgery that would treat her condition, but cannot afford the $6,000 needed.

Her family have no way of raising the funds to pay for her surgery and an American student working with Sokum’s husband started a fundraiser to help them.  So far we have raised just over US$3,000 but donations are drying up.

The family went into debt to organise a cardiologist review some months ago, and were told that she will be too unwell for surgery if they wait too long but without the money for hospitalisation costs, they have no choice but to watch her fade away.  Without access to her cardiologist I can only guess that her most likely diagnosis is Rheumatic Heart Disease, which is common in populations living in poverty.

When I asked her husband to say something for fundraising purposes in New Zealand here’s what he wrote:

My wife’s name Sokum and 20 Years old.

Before her parents take her go to meet traditional doctor but she is not better and then my parents continue to take her go to public district health hospital a doctor said that lung failure. The doctor provided a lot of medicine but feel not well more serious ill so, my parents continue to take her go to referral provincial the doctor said that can not treatment here need to send Phnom Penh city. In the Calemet health hospital doctor asked her about situation and check with x’ray so the doctor tell her truth about heart problem.  need to make surgery very soon.

Before we don’t know but when we were to Calemet hospital and know about her heart problem 1 year.

Now she doesn’t work because too sick of her. She stay at home right now can’t do hard work and can’t eat with salt food.

Before she is works at factory worker 3 years and during work with factory she working hard to find money to support the family.

Thank you helen
If you have more question please feel free let me know.

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I should be in a position to provide an update on this fundraiser in a week or two.  Things are moving slowly but surely and Sokum had a cardiologist appointment in Phnom Penh today.  Some incredibly generous gestures have been made on her behalf which I look forward to speaking about once everything falls into place.  All donations continue to be warmly welcomed, either through Go Fund Me or by contacting me directly.

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This Thing We Could Do

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Study after study by psychologists has shown that there is no correlation between wealth and happiness. The only exception is in cases of real poverty, when extra income does relieve suffering and brings security. But once our basic material needs are satisfied, our level of income makes little difference to our level of happiness. Research has shown, for example, that extremely rich people such as billionaires are not significantly happier than people with an average income, and suffer from higher levels of depression.

Madness of Materialism

This is just one short paragraph from one single link, in the plethora of knowledge about the causes and ills of materialism.  I like it because it implies the difference that those of us with disposable income can make if we were to replace the all-too-common act of “retail therapy” with “philanthropic therapy”.  So many of us are suspicious of others’ need for help, believe that we can’t make a difference or think that by offering help we could make ourselves vulnerable to charlatans.  Our suspicions are – in the main – completely wrong.  Katharine Hepburn, in the quote below, speaks for me in this regard.

Atheist Katharine Hepburn

This week alone I have been involved with five different families suffering from an inability due purely to lack of finance, to access the health care that their children, elderly or vulnerable need.  This is not a small problem that people recover from, but a profound and overwhelming problem which leaves families indebted and reveals itself in the premature life expectancy rates of an entire nation’s population.  Functioning health systems rely on good governance, reliable information, adequate financing and other elements which are either absent or inadequate in countries fraught with poverty, political instability, lawlessness and systemic disarray.  Sadly these descriptions reflect the current day Cambodian experience despite so many good people doing what they can to improve matters, which continue to progress in small steps.

I know a vibrant young Cambodian woman who is waiting to die from the manifestations of Rheumatic Heart Disease.  One of the obvious “diseases of poverty”, Rheumatic Fever was a leading cause of death in America, Australia and Europe until less than 100 years ago.  Improved living conditions reduced our risk of exposure to the bacteria Streptococcus pyogenes which can cause an autoimmune response leading to various symptoms, the most serious being scarring of heart valves which results in heart failure and ultimately death. At the same time, Penicillin was discovered and we learned that it could treat Rheumatic Fever to effectively prevent the heart damage before it manifests.  As such, rates of Rheumatic Fever and Rheumatic Heart Disease plummeted in the wealthy world.  Our health systems also improved dramatically with significant advances in surgery and medicine meaning that cardiac surgeons can now cure Rheumatic Heart Disease when it occurs by repairing or replacing damaged heart valves.

Today the highest recorded rates of Rheumatic Heart Disease in the world occur in Central Australia’s indigenous population.  Just one of the many diseases of poverty our indigenous people live with and die from, this is a travesty.  Yet we have a health system which can count and record the diseases prevalent in our population, who do have access to Penicillin and cardiology services.  Places like Cambodia on the other hand, likely have even higher rates of these diseases, but without the resources or systems in place, people suffer and die silently and invisibly, often without any explanation of the cause of death.

With no cardiac surgery services available in Cambodia’s public health sector, the only option available to this young woman is to find the funds needed for surgery at a private hospital.  Her desperate husband and family have started a GoFundMe page (link below).  As poor rural villagers, they don’t know people who can contribute in any significant way, as you’ll see by the contributions made.  My hope is that some reading this will think about our ability to engage in retail therapy at whim and take a chance at substituting a trip to the shops with offering something towards helping to save a young life.  Even if we don’t make it to our goal, small contributions will show her that she is cared about.  If only 600 people donate $10 each, our goal will be reached.  Be one of those 600!

Sophors’ Family Surgery Fund

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People From The Sky

Good enough

It’s okay to be imperfect.  On the other hand, we should not allow perceived success or praise for perceived success affect our ego.  Someone cycling Road X is no better or worse than someone walking Road Z.

In the field of humanitarian work it’s easy to find people willing to shower you with praise.  This sits uneasily with me as I’m well aware that I am living the life I want to live, because it suits me.  I don’t believe there is a humanitarian anywhere with entirely selfless motivations.  Living as a nurse in a place like Cambodia is really not so different to living as a nurse in Australia.  The challenges are different and there are difficulties that don’t exist in the wealthy world, but ultimately I’m using the same skill set to do similar work, only for a different population and with different resources.

Yet it could be easy to believe the praise.  Which I guess is why it is not so difficult to find people working in the so-called humanitarian world, who are driven by ego and power.  Thankfully my current assignment has no such characters among the expatriate team.  My first assignment was a mixed bag, as I made firm friends but I also struggled enormously with one or two conceited narcissists.  Some of my Khmer friends with a long history working in international NGOs such as MSF confirm that it can be extremely difficult to work with “the people from the sky” (they fly in, dominate with an air of aggrandized importance then fly out again).

It’s very true, that you find all sorts in all places.  It’s also true that there are different motivations towards pursuits which are seen generally as altruistic.  The best example I have is a French doctor some years ago who, in criticising MSF for not approving an extra day off, declared “They should be grateful to have me!  I don’t have to be here!  I am not a local staff who has no choice!  I am a Ewe-Manit-Eerian!  So are you!  We are both ewe-manit-eerians, ‘Elen!”.  Never had I wanted the ground to swallow me up so badly!  Being ewe-manit-eerian is a running joke within my current team who appreciate the farce of over-inflated ego.

The definition of what makes a humanitarian is also an interesting question.  MSF focuses on emergency relief so that many of our expatriates have experienced war zones, famines, disease outbreaks and natural disasters.  Some of these field workers, after multiple assignments, move into the ranks of management based in first world cities such as Paris, Tokyo and New York.  One recent such visitor from London suggested that “you should not stay too long in one place, because it becomes something other than a humanitarian action if you end up staying for your own reasons”.

With a deep love of Cambodia, I’ve ruminated on this statement greatly.  It is dangerous to be poor in this world – you will be forced to live in varying degrees of peril.  If you are incapacitated there will be almost no assistance outside of your own unqualified and un-resourced family or village.  If you die prematurely, it will likely be as an invisible non-statistic who was never counted anyway.  The billions of dollars going towards medical research in first world institutions across the globe generally don’t benefit anyone but those living in the wealthy world, so that preventable illness, injury and death is a common theme in the poor world.  I have loved realising the experience of making small differences to lives which ultimately, to the powers that be in their own higher society and levels of government but also to most of us in the world, hold little to no value.  Stay or go, like all of us with a choice, I’ll choose what suits me most.  Whether here or elsewhere, my main hope is to avoid becoming one of the “People from the Sky”.

Meanwhile, The Excruciating Fundraiser has surpassed it’s goal and our friend can have surgery with a safe and more comfortable recovery than would otherwise have been possible.  We took the family swimming today at a local resort with a small water park.  It was their first time at a swimming pool and a very happy day was had.  On the way home we crossed a bridge over the mud brown river, where a bunch of children were playing on a black tyre in the muddy water lapping at the doors and floors of their little wood and tin shacks. The contrast with where we were coming from was stark.

This 4 minute video, which I think I’ve shared before, explains why this stark contrast exists.

The Richest 300 People

Making Sense of Another World

A first impression of Phnom Penh for any newcomer will likely relate to the traffic.  Sitting at intersections beside trailers piled disproportionately high, their loads towering ludicrously into the sky, you may have fleeting images of death-by-crushing.  Ladders stand tall on seats of motos between the back of the driver and the front of the first passenger, who often has a paint pot hanging from the crook of an elbow and a third passenger behind.  Other ladders balance horizontally along the length of their moto.  Motos and moto-pulled trailers carry long rods of steel protruding into the surrounding traffic space, causing images of death-by-impalement.  None of these near-death visions are helped by the way that everyone weaves around each other, edging into crossroads slowly but persistently so that you are eventually in the middle of an intersection with traffic purring towards you from all directions.  It takes some experience to learn that it’s probably going to be okay and you’re probably going to make it across the intersection without incident.  At major junctions children, elderly women and disabled men wait at the centre barrier for lights to turn red before venturing out into the crowded vehicles to beg for a morsel, knocking on car windows or waiting hesitantly at tuk tuk steps.  Often they have chains of jasmine for sale or dusters made from chicken feathers fixed to a stick of wood, offering to dust car windows.  Many have nothing to sell, only mumbled words of begging.  Blind people busk along congested sidewalks, amputees sit at the same corners where naked and malnourished children play with loose bricks or dirt while scavenging parents rest beside their parked, hand-pulled wooden barrows on what must be a long, hot and dirty work day.

It’s all very interesting.  At the same time there is a harshness and injustice to it which many of us might only fleetingly consider before making our way again towards our comfortable lives.

Local elections are imminent and both major parties have been parading through the streets with megaphones blaring from tuk tuk roofs, crowds piled into trucks, pick ups, tuk tuks and trailers, party flags flying jubilantly.  According to Cambodia Daily, Prime Minister Hun Sen, who makes regular televised monologues of many hours long in parliament, said two days ago he was willing to “eliminate 100 or 200 people” to prevent his overthrow.  Smashing teeth, slitting throats, burning homes, references to war (far from trivial in a place still traumatised by years of violent war), imprisoning journalists and bloggers, are all a part of the rhetoric being reported, little of which appears to make news beyond Cambodia’s borders.

Yesterday I had a particularly grueling lesson in my ever-emerging comprehension of the “lot” of tuk tuk drivers.  During my 2015 year-long holiday I met a tuk tuk driver who I will call “TTM” (Tuk Tuk Madame), in a seaside resort town who showed me some sights and transported me around for a few days. During this interaction I learned that until recently TTM had worked at a shoe factory in Phnom Penh where he had to rent a room and buy food-for-one as well as budgeting to feed his wife and family separately.  The micro-salary was essential to his family’s survival but it came at some cost including the sacrifice which so many Cambodians make, of living away from a young family.  Sometime before I met him, he had resigned from the factory job and bought a tuk tuk and moto to generate income from home.  Reliant solely on paying customers, I knew even in 2015 that it was a hard gig.

Caz and I visited his town in March for a few days and since then we have had more contact, as I’ve returned again for a long weekend and he occasionally says hello on Messenger.  Last night it came as no surprise when he said hello out of the blue, until he shared a crying emoji.  I asked why he was sad and he slowly but determinedly told me in very broken, misspelled, almost indecipherable written English.  Slightly horrified and slightly cautious, I rang Samantha who agreed to call him and find out the detail for me.  A number of conversations later, by Messenger with him and telephone with Samantha, I had the full story, my caution demolished and my horror bolstered.

The purchase of his moto and tuk tuk had been made via a loan from a well-known, prevalent micro-finance company.  This particular company feature in my mind because when we were looking for ATMs in Siem Reap recently I was moved by Seth’s reference to them as “the PLC Bank”, highlighting the minimal cause he has had to ever notice financial institutions.  The ubiquity of such inexperience is highlighted by TTM’s need to use a micro-finance company, with extremely high interest rates, over a bank, because without a bank account there is no choice.  It is not viable if you earn a tiny amount of money, to have a bank account, as the fees can exceed your income.  In 2013 the World Bank reported that less than 4% of the Cambodian population had a bank account.  This makes people immediately susceptible to exploitation.

According to Investopedia the intention of micro-finance is to give low income people an opportunity for self sufficiency, most often associated with low-interest lending but some offer additional services such as bank accounts and information to increase financial literacy.  As with so many well-intentioned activities in unregulated nations such as Cambodia, micro-financing has been corrupted into an exploitative enterprise, offering loans to the very poor who have no other available options, at excessively high interest rates.

TTM took a loan of $2,000 to purchase his moto and tuk tuk, thinking that by being close to home (with less expenses), and in a resort town (with the chance of paying customers), he could pay the loan off over the contracted 20 months and be in a better financial situation than he was, working at a shoe factory.  With Samantha’s final phone call this morning I learned that he has been committed to $100 in principal repayments and $35 in interest repayments, every month since his venture began (ie 35% interest rate).  In a place where the monthly average income is about $90, this is a massive commitment which he has struggled to maintain.  He took an extra $500 loan last year to help relieve the repayment stress, but he remains $800 in debt.  When Samantha called me to explain she said “last month and this month is wet season and not so many tourist, and also is election season, so he cannot find customer so he cannot find money to pay back the loan”.  I asked her what election season had to do with it?  She replied “because when it is close for election Cambodian people are afraid of the war again, and we will not go anywhere and we will not spend any money because we might need it if the war happen.  If you ask all Cambodian people, maybe 80% of us think like this”.

With no customers, TTM has had no way of repaying the lending institution, who sent him a letter informing him that the tuk tuk would be repossessed in two weeks unless his repayments were honoured.  He photographed the letter and his repayment information and sent them to me this morning.  I forwarded them to Samantha for translation and she confirmed the loan, remaining balance, principal and interest amounts.  With the threat of losing the family’s only income-generating asset, TTM was desperate and I was his only connection to anything resembling possible assistance.  I did assist him a little and he has some time now, to try and earn enough to pay the rest of the loan.

Recently Caz and Rav both informed me that the hotels who have their own tuk tuk drivers, often in some sort of hotel uniform or numbered tuk tuk, charge these drivers a commission in order to be connected to their hotel.  Fees differ per hotel, but are usually between $400 and $1000 as a one-off payment.  Keen to earn a regular income, drivers will take loans to pay this fee in order to have a guaranteed income with exclusive access to a niche customer market.  Once connected, drivers are guaranteed a small daily stipend (smaller than most fares), regardless of whether they transport customers or not.  If you book into a hotel advertising a “free tuk tuk”, your driver is the one paying the price for your saving.

I hope that anyone thinking of visiting Cambodia who comes across this blog, can know one thing.  The fun and smiling, or humble and quiet character who calls “tuk tuk Madame” or “tuk tuk Sir” at you, is one of this country’s poor.  He probably has no education and he may well be struggling with debt.  His tuk tuk might be rented, reducing his revenue further.  Look at his moto, the upholstery of the seat you’re sitting on, the condition of the roof and floor of the carriage you’re riding in.  Ask him about his life.  While you need to pay a fair market price for the sake of the micro-economy you have entered, you also should not negotiate him down to an unlivable tariff and if there’s anything you can do to help him, maybe you would both benefit from the experience.  When you touch a tuk tuk in Cambodia, you are touching the essence of this nation’s austerity.

The Frangipinis Above Me: Part 1

A friend was telling me the other day about her experience on a medical mission in Haiti.  In 2010 a catastrophic earthquake killed at least 100,000 people, maimed many more and destroyed existing infrastructure and services.  Many countries responded with humanitarian aid.  By the time my friend’s mission began, some years later, she witnessed examples of what unsustainable humanitarian aid can leave behind.  Lives can be saved at the expense of abandoning people with chronic needs when well resourced, short term services withdraw.  My friend saw people with conditions which would be treatable with appropriate ongoing medical intervention but which, in a place so destroyed, left victims behind to exist with harrowing illnesses and deformities and no treatment or assistance.  She wondered aloud at the ethics of providing assistance which is not sustainable.  In turn, it made me wonder at the ethics of the appeal that acute disasters seem to hold (at least from media attention and donor interest angles), over chronic adversity which is no less damaging to it’s victims.

When Caz was in Cambodia she claimed that “Helen adopts tuk tuk drivers”.  It is beginning to feel as though she was right!  I hate negotiating prices and I like having some sort of rapport with the person driving me around, so I tend to find someone I like and stick with them.  This inevitably results in my having “a tuk tuk in every port”, so to speak.  I have bonded with drivers in a number of different places, been introduced to families, eaten at peoples’ homes and referred to as “bong srey” (older sister) and “mak” (mother) many times.

The thing that bonded me to “Rav”, my guy in Siem Reap, was his willingness to help when Kim asked him to translate for us.  He was kind, enthusiastic and humble, giving nothing away about himself such that I figured he was probably living a comfortable life.  It was only after we’d spent some significant time together, that I slowly learned he was just as poor as Kim, who he was helping so earnestly.  It was one of my Cambodian unraveling experiences, where I began to comprehend that poverty does not have a face, and that the people who are most helping the poor, are the poor themselves.

When I was last in Siem Reap there were four of us with occasional competing interests meaning that we needed two tuk tuks.  My friends were at the temples with Rav when I arrived so he arranged his good friend “Seth” to meet me at the bus station and bring me to the hotel.  Soon enough I had another tuk tuk adoptee.  A young father of four, he lives with his parents at his brother in law’s home “in a very small space”.  Rav had obviously told him about me, as he already knew about the school sponsorship of Rav’s sons, the crowdfund I did for Rav’s motorbike and the help I’d given Kim until recently.

Last week Seth sent me a distraught message with a photograph of his son in a hospital bed, saying “the dogs in my street have better life than my sons”.  I couldn’t understand much of it and he apologised that he could not explain “because my English so bad”.  Win was nearby so I asked him to call and the story came back that his 6yo son had been attacked by a swarm of wasps.  The hospital treated his son without charge so I still did not really understand how I could be of help, only that he seemed to think that in some way, I could be.

With the Kings Birthday weekend upon us, I had things to do in Kampong Cham.  Siem Reap is always a relaxing place to visit thanks to my favourite hotel in Cambodia being here.  So I said I might come to Siem Reap at the weekend, from Kampong Cham.  Such snap decisions are just another example of the freedoms in my life.

Last Christmas some extended family in Australia pooled their present money together and sent it to me instead of buying each other presents.  I’ve mentioned this before, and my plan to buy a cow with the gift, for John (remote villager with a probably-Polio-deformed leg) and his wife Sarah.  On Saturday I arrived in Kampong Cham in time for lunch before Dan picked me up for some jaunts through the countryside.  We started with a visit to the “house that Caz built”, where the family are very happy and have asked for a framed photograph of me to put on their wall!  Not a project I am feeling terribly inspired by!  For the first time in their lives they have a toilet and electricity; and after years of living on the edge, Simona (blind widowed mother of two young daughters) can safely move around without threat of her house structure breaking underneath her.

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Dan, Project Manager, standing on the steps of the finished product. New toilet just visible to the right and back of the home.

We then made our way back into town and via the bus station for my ticket to Siem Reap, then continued out towards Dara’s village.  Passing the Little House in Rice Fields, Dan called out to the excited children that we would stop in on our way back from Dara’s home, a short way further along.  At Dara’s home I was met with a bunch of about 15 wide-eyed village children looking dumb struck at me.  Luckily I’d thought to bring a bunch of 3D bookmarks from Australia which have been sitting in wait of just such a moment and even luckier, there appeared to be enough for everyone.  Much excitement was generated when the children realised that by moving the bookmark slightly, they could make the kangaroos in the photograph jump!  Dara’s mother said that he was having problems getting to school, about 1km away, as his friends don’t always want to take him on the carrier of their bike.  I agreed to donating a bicycle to him and the next morning before catching the bus, Dan and I made our way to a second hand bicycle dealer.  Before I’d left Kampong Cham, Dara and his parents had arrived in town to pick up his new wheels.

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Two wheels going home on two wheels with three humans, a pretty ordinary sight really!

Leaving Dara’s home, we made our way back down the dusty track, past many little houses in soaking rice fields, towards John and Sarah’s home, as I studied every cow we passed.  Once more, Sarah was not home.  She is employed as a construction worker now, in Kampong Cham.  She leaves home before 7am and returns to the family after 6pm, with no days off.  It is hard to imagine this tiny pretty woman working on a construction site, but it’s a common phenomenon across Cambodia.  His disability precludes John from being able to make such a contribution to the family’s income so he stays home with the children.  I came with colouring books and a set of pencils, whose approval rating soared immediately.

I also came with cow money.  We discussed our business deal with Dan as translator and everyone understands that Collins, named after the family who donated the money, is my cow, but her progeny will belong to John and Sarah, whose idea this novel business plan came from.  Once Collins has had a baby, John and Sarah will identify someone in or near their village who is as needy as them, who can take over the care of Collins and earn ownership of her next baby.  I’m unsure how many times I can expect Collins to procreate on this plan, perhaps twice might be the limit, we will have to see.  The following day Dan forwarded me photographs of Collins and her transport home.  The seller wanted US$740 for her, but agreed to negotiate down to $700 including transport, in Dan’s exact words, “to help the poor family”.  The photograph of the seller, standing on a dusty track in her wrap around skirt and matching blouse, didn’t exactly suggest signs of a non-poor-family, but she did have US$700 in her hand, more than most around here have ever touched.

On the way home we stopped in to visit the Phter Koma children at their new digs.  I guess we sat for maybe an hour, under a tree as the sun drew slowly towards the horizon.  The children are doing well in school, settled with their new abode and carers, and all very keen that I take them “skiing” (skating) or swimming next time, so we’ll arrange that.  They always understand when all I can offer is a quick visit and never seem anything but happy to see me.  Some of them are approaching adulthood, at 17 and 18 years old; the younger ones are changing before my eyes, having growth spurts and their little faces transforming out of the cherubic stage.

The final colouring books and pencils caused a stir with the children of the cleaner at my hotel, who live next door to the hotel and who I have known for about three years now.  Their father is in prison as a subject of the infamous “government crackdown” on drugs, I don’t know the story behind that.  Their mother, as a consequence, is working two jobs; cleaning by day and waiting on restaurant tables until 10pm each night.  Her 12yo daughter plays second mother to the four younger children.  I spent an evening being asked whose colouring was “good or not?” as little heads concentrated on doing the best job possible.  It seems they go to bed hungry so when I was ready for some Me Time, I ordered three takeaway fried rices which were scooped up hastily with pencils and all small people suddenly vanished from my exhausting but very happy day.

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Where Love and Hate Collide

Joe died in his home three weeks ago, unknown to any health service.  His family do not know why he died.  Joe also did not know why his legs became weak/deformed as a young child.  All he could tell me when we met, was that he got a fever and then stopped walking “during Pol Pot”.  The story fits with Polio.  His death fits with Post-Polio Syndrome.  The Mayo Clinic’s website states that “up to almost half the people who had polio at a young age may experience certain effects of the disease many years later — post-polio syndrome“.  They talk in detail about the syndrome at Mayo Clinic Post-Polio Syndrome.

When I saw Joe in November, lying in a hammock tied to the supporting poles of the family’s thatched bamboo/banana leaf hut, he was anxious.  His legs had become progressively weaker and painful, he had trouble swallowing, seemed even thinner than usual and was constantly exhausted.  He was no longer able to get around in the wheelchair we had sourced for him about 13 months earlier.  I was only on a fleeting visit and so I asked if, when I returned in February, he would like to go to a doctor or clinic with me?  He was extremely keen on the idea.  I am sad that he died before this could happen, but I am also sure that there would likely have been little anyone could do for him.  I left a very large supply of Acetaminophen, Tramadol and some other painkillers for him, which was probably as much as he could hope for in this environment.  Certainly physiotherapy or other such treatments were not a realistic option.

Previously I have referred to Joe’s daughters as Simona (blind widow with two small daughters) and Sophia (single with a bad strabismus).  There is a third daughter who is married and lives with her husband in his family’s village.  Dan drove me to Joe’s village on Monday morning.  We arrived as Simona, whose vision impairment improved slightly after the operation in Phnom Penh in September 2015, was pulling into the driveway with Maia, her youngest daughter, on the carrier of her bicycle.  She has enough distance vision that she can transport the children to school on a bike with the girls acting as her eyes on the finer details.  There was much excitement to see me, which always makes me very uncomfortable as it illustrates just how desperate these young women feel.  When I visited in November, Sophia was living in a different town, working as a cleaner but she returned home when it became apparent that her father was about to die.  As Simona was busy telling me through Dan, that she “can no longer live here, it is too terrible now, since Sophia got married and brought her husband here”, Sophia slammed into me from behind, holding me in a gridlock and squeezing me such that I thought we would both topple backwards.  We all admonished her until she stopped, then Dan told them “you should not fight, you have to live in peace together”.  Sophia looked tearful and walked away.  Weeks from their father’s death, emotions are obviously running very high.

The dynamic between the sisters is fractious and complicated as Simona relies on Sophia as the breadwinner for herself and her daughters since her husband drowned in the Mekong in January 2015.  We went inside the little house together and sat talking.  Joe’s hammock has disappeared and his absence was sad.  I explained that I believe I know why he died, and that even in a rich country, he would probably have died.  Sophia has married a man who looks at least ten years older than her.  He was quiet and pleasant but he has quickly replaced Joe as the man of the house and the second breadwinner in the family.  He has also brought his own stock of cows to the family home, which must add to his financial power in the situation.

There are two houses on the family land, both thatched huts.  The smaller, younger hut is in bad disrepair.  Simona lived in this hut when she married her (now deceased) husband.  She has returned there now, but has to vacate during rain or strong winds.  She can’t move far from the family as she is not able to cook / fend for herself without assistance.

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The family’s bigger, better home

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Simona’ current residence

When I asked if the family had food Dan said that they are living on dried fish and rice.  We climbed down from the house and with Simona holding my shoulder, walked across a dirt track, around a corner to the village store.  I told her to buy what she needed and was dented $7 for a week’s worth of meat and vegaetables.  As I stood in the verandah shade of the wooden hut shop, a lady looked down at me from the doorway of the house next door, grinning from ear to ear and calling out.  Before I could even pay, Simona took my hand and led me to the bottom of the ladder.  Dan took his shoes off and I asked “are we going inside?”.  Yes!  At the top of the ladder I was introduced to Joe’s sister and her husband, and instructed to sit down under the fan.  They talked at length with Dan about losing Joe, how they knew of me and thanking me for my help, and that they were so happy when Joe got his wheelchair but he no longer needs it and I should return it.  “Okay, we can do that, but do you know anyone else who might use it?”.  A double amputee in a neighbouring village had been waiting for a long time for a wheelchair and they didn’t want to put me out, but if I wanted to, they could not possibly thank me enough.

On return home with the groceries, Sophia had already lined the wheelchair up alongside the tuk tuk.  Dan somehow managed to jam it into the back seat space before Sophia, Simona, 5yo Maia and myself squeezed in with it!  About 5km of dust road later, we pulled up to the sight of a wheelchair sitting underneath this man’s home.  Foiled!  En route home again Simona pointed to my shoes and preceded her otherwise unknown words with “som” (please).  She wanted some shoes.  So we stopped at a local shoe store and 3 pairs of shoes / $6 later, for her and both of her daughters, we were back on the road.  Just near the village temple Dan pulled over and turned off his engine.  “Helen, I think that maybe we should give this wheelchair to the monks because maybe they know someone who can use it?”.  So we detoured through the Wat grounds, where we were liberated from a very congested tuk tuk!

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Yesterday during poolside cocktails in our very plush Siem Reap hotel, Caz and Kelly came up with a cunning plan that the US$3,500 Dan suggested it would take to replace Simona’s little shack with something more solid and safe (using the same materials), should not be such a difficult feat?  It would inject a little into the village economy if we can use locals to do the building, which I think will be possible.  The house is Simona’s most pressing problem, it would remove her somewhat from the power disparity she faces with her sister.  Her lack of income generation is going to be much more difficult to find a solution for in her circumstances.  So once more I find myself engaged in my most un-favourite activity, raising money for a good cause.  It’s funny how I can be so passionate about good causes, yet so repelled by the activity which makes my good causes come to fruition!  Anyone reading this who wants to donate, or even run some sort of a fundraiser (Caz suggests entrance-fee “high tea” at your home is a good option), towards this cause, please contact me!  The GoFundMe page is still open, but as they take a 3% fee, if you’re in Australia, NZ or UK, then putting it directly into my bank account would be a better option.

Throwing The Baby Out With The Bathwater

Almost a week ago I returned to Cambodia for another extended stay.  In a few weeks I begin my second assignment with Medecins Sans Frontieres, this time in Phnom Penh.  Meanwhile a holiday with friends, tripping around the country, is underway.

Two nights at Wat Opot Children’s Community was as boisterous as one might expect of a place where 50 children who have lost their parents/carers to AIDS reside.  It is difficult to find words for the beauty of Wat Opot.  Their website might do it more justice than I could – Wat Opot.  We arrived on the same day as a new resident, a 12yo girl who might pass for 7yo, with severe malnutrition, spinal scoliosis (I have a high suspicion that this may be caused by spinal Tuberculosis), struggling to walk on tiny pin legs, and all alone in a sea of new children.  Another new resident, 2yo and a shockingly tiny 6kg, has recently started her lifelong course of anti-retroviral treatment.  Her misery is likely a combination of medication side effects, which should subside and her new and overwhelming environment.  Otherwise, every other child plus “Number 51”, as we labelled our 8yo Australian travel companion, was robust, active and thriving in this world of organised, joyous chaos.

I learned of Wat Opot through my friend and about-to-be-colleague-again, Dr Theo, when he identified it as a refuge for three brothers orphaned by AIDS/Tuberculosis in the final months of the MSF project here in Kampong Cham.  It was amazing to meet these brothers again, and after one year since we last met, be able to converse in English with them!  While most of the children were in school, we walked to and climbed beautiful Phnom Chisor (“Chisor Mountain”), where we explored the hilltop temple grounds.  Lunch inside the ancient walls consisted of sitting in an unwalled bamboo hut within sight of our cook who promoted her fried chicken with lemon grass option.  Said chicken made a noisy but swift departure from this world, thankfully from behind the open fire so that we didn’t quite witness it, about twenty minutes before being presented to us on a plastic plate, infused and tasty, with a pot of boiled rice.

Anyone looking for a worthwhile cause, whether for fundraising, donating or volunteering, would be hard-pressed to find better than Wat Opot with it’s impelling history of quite literally “rising from the ashes”.  Yet there is a growing movement against orphanages, most famously perhaps, the arguments put forward by JK Rowling of Harry Potter fame.  Rowling founded Lumos, an organisation dedicated to closing all childrens’ homes, arguing that “No child should be denied a family life because they are poor, disabled or from an ethnic minority. Lumos works to support the 8 million children in institutions worldwide to regain their right to a family life and to end the institutionalisation of children.

Voluntourism and Orphanage Tourism are phrases coined from the arguments raised – rightly – against the exploitation of children living in institutions.  The issue is especially pertinent in countries such as Cambodia where corruption can permeate through absent and/or poorly governed regulations.  I have written on this topic before, for example at An Infinite Learning Curve in August 2014.  There certainly are children who should not be living away from their families and there certainly are institutions which exist for the wrong reasons and/or exploit the children in their care, often in shocking ways.

Yet there is another side to the coin.  There are institutions which exist for the right reasons, who are doing the right thing for the children in their care.  There are children who, without those institutions, are either dead, or abandoned to their own devices.  It is not uncommon to see “street children” in Cambodia, existing in dire circumstances and without care and support.  Wat Opot in Takeo Province or the residence where the children from Phter Koma now reside in Kampong Cham, have strong and valid reasons to exist.  The twelve year old girl newly resident at Wat Opot is a visible example of what can happen to stigmatised and rejected HIV+ orphans when they lose their parents in communities which are already struggling to survive impoverished circumstances.  Without Wat Opot, she and so many of her fellow Wat Opotians would die.  The same can be said for the children of Phter Koma.

Today I visited the Phter Koma children who, along with their Khmer carers, have moved to another establishment after Phter Koma, as was always their aim, transitioned to a local organisation.  The children are focussed on their studies, accept their routines including continuing English classes and twice yearly visits where possible, to extended family in their home towns. Each of them appears thriving and happy.  Much like an aunt from another place, they know and trust me yet also understand that I am not a primary carer, connecting me instead to speaking English and having occasional treats.  When will we go swimming next, when will we eat at Night Market next, can I advocate for them to have improved internet access so that they can send emails to myself and the French founder.

Wat Opot and Phter Koma are two excellent examples of institutions serving a valuable purpose in the community.  Both employ local staff who dedicate time and skill to identifying family, assessing the ability of family to receive the child back into their care, if not permanently then at least for visits, and maintaining a safe and nurturing environment for those children who cannot return home.  The children at both of these institutions are engaged in school with opportunities to advance through trade school or university which are inaccessible to so many of their peers.  Volunteers are or have been an integral part of both institutions, for the purposes of offering exposure to new languages and skills.  The children have uninterrupted relationships with long term carers and do not suffer from separation anxiety around short term volunteers.

Far from exploitation, the children at these two examples of valid residential institutions, are protected, cared for and flourishing despite histories of extreme loss, illness and suffering.  They have only benefited from the input of overseas volunteers who are vetted and work within set boundaries relating to the needs of the children rather than the needs of the volunteers.