Baby Business

Herman Melville Quote

The other day here in Australia, I was with a friend in town when her daughter called her, panic-stricken after being bitten by a snake at their home 10km from town.  As I sat on the phone with Emergency Services, who answered on the first ring, replying to their orderly and systematised questions, my surprisingly calm friend drove us home.  We followed organised traffic past well posted speed signs on sealed roads.  Within minutes of our arrival a distinctly marked emergency car with one paramedic led a fitted-out ambulance with two more paramedics into the driveway, sirens blazing.  They calmly entered the home wheeling a shining stainless steel, adjustable stretcher with a fitted mattress and carrying custom-made bags organised with various first aid equipment.  Their assessments and treatment were methodical, calm and professional.  Moments later the local snake handler arrived, photographed the bite site to help identify the species of snake he should look for, and took his snake hook outside hoping to capture the culprit (alas, to no avail).

Once stable the patient was rolled onto a sheet, the stretcher was lowered smoothly to floor level and she was lifted onto it.  A clip of a switch lifted it to normal height and she was wheeled out to the ambulance, where the stretcher clicked onto a hydraulic system and manoeuvred into the ambulance cab with minimal manual effort.  The vehicle was equipped wall-to-wall with state-of-the-art emergency apparatus and appropriate seatbelts to ensure the comfort and safety of the patient and other passengers.  In the Emergency Department she had her own private, shining clean, spacious cubicle with two doctors and two nurses hooking her up to monitors and inserting intravenous lines, all following well-established and evidence-based protocols.  After a few unsuccessful attempts at intravenous cannulation the doctor disappeared briefly, returning with a mobile ultrasound machine to help him locate a vein.  Mum and daughter were well informed about every procedure and every discussion between the team included them.

Not only are all of the bells and whistles available in our health services, but our health professionals have received first world, advanced training, with regular professional development to ensure practices remain up to date.  They work in teams so that no single person “owns” all of the information, nor all of the power in decisions made about patient care.  This does not mean that mistakes are not made, but all of these very first world aspects to health care reduce the chances of error significantly.  Every health professional we encounter earns a salary allowing them to feed their families, pay off mortgages or afford rent, furnish homes, take out loans on motor vehicles, go on regular holidays and various other first world “needs”.  Not one requires, nor works in a system which allows them to ask for or expect, cash payments from the patients in their care.

In comparison to this experience, images of the “Emergency” ward in Cambodia flashed in and out of my mind like waves crashing to shore.  Memories of a nurse at either end of a canvas fitted through two rusty poles, bearing half-shares of the patient’s weight as they ran their stretcher hurriedly across uneven gravel, past leaking sewerage pipes and stained, dirty concrete walls.  Passengers sitting unrestrained on the bare floor of a mini van with an almost comical siren squealing from it’s roof, a single red strip across the vehicle’s centre identifying it as some sort of ambulance.  Patients lying in rows of steel beds without mattresses, surrounded by others lying on hard concrete floors, with dust and dirt and grime in every nook.  An immobile elderly patient clambering out of bed onto a floor-level toilet pan in plain sight, sound and smell of at least 30 other people.  Stepping over crowds of sick bodies mingled with newborn babies.  The complete lack of anything remotely resembling a monitor.  Bags of fluid hooked onto the ends of bamboo sticks.  A malnourished elderly man, ribs sucking in and out with each breath, in desperate need of unavailable oxygen, his only relief a wet cloth patted on his forehead by a doting daughter.  Nurses dressed in white from the caps on their heads to the shoes on their feet, reminiscent of 1920s Australia.

Photographing my friend sitting in the ambulance with her daughter, she shouted out to me “You’re not in Cambodia now!”, explaining to the paramedics that I had “just come back from living in Cambodia”.  The snake handler turned to me and said “you have to try quite hard to die from snake bite in Australia but the opposite can be said for places like Cambodia”.  No truer words were spoken, and snake bite is only the tip of the deathly iceberg!

Mos Dangerous DAy

Financial Times reporters on three continents follow the fates of three women and their babies in this report on childbirth in poor nations at Three Births

Last year when Chom’s wife was having their second child, and again this year as Samantha approached the birth of her second child, I found myself increasingly exasperated by both couples’ apparent ill-informed and irrational medicalised approach to childbirth.  Chom’s wife had miscarried previously and Samantha’s first child is her now-2.5yo son who continues to exist with a severely debilitating, ultimately terminal, genetic condition for which the only care he receives is from his impoverished family.  Even so, the apparent obsession both couples expressed about medical interventions seemed bewildering to my first world brain, which knows that excessive medical interventions are more likely to be harmful than helpful in normal pregnancies.  The talk from both couples included innumerable ultrasound scans for no apparent reason and excessive talk about caesarean sections, all of which are costly and unnecessary interventions.  Given my descriptions herein of the public hospital experience it was no real surprise that both sought obstetric care in a private clinic, but the lead up to both births left me flummoxed at how medical it all seemed, for no credible reason.

Visiting Chom’s newborn at the private clinic, some of my puzzlement fell into place.  A beautiful building in comparison with any public clinic or hospital, although equally as crowded with newborn babies and their families squeezed into every space in foyers and along open corridors.  Chom paid extra for a private room which was furnished elaborately with a private bathroom, air conditioning and a television.  Superficially, everything looked superior to the alternative and I understood why private clinic was considered the best choice.  However, these clinics are run as profit making enterprises by the doctors who own them.  Medical interventions paid for by the client are highly profitable, including ultrasound scanning and caesarean section, so I came to understand why such interventions are promoted as “best care” when in fact, they are quite the opposite.

Cambodia’s health literacy is led by private-clinic-owning doctors, in a population crippled by poverty whose young adults of today are a single generation away from the complete destruction of the country’s education system.  The promotion of unnecessary and often risky interventions to paying clientele, in a country with no malpractice liability and low health literacy, is hardly surprising.  With a lack of access to alternative reliable information, it is also unsurprising that their clientele believe what they are told by wealthy and successful doctors working out of superior health facilities.  Even so, most Cambodians cannot afford to attend these clinics, and childbirth usually takes place either at home or in public facilities.  This is likely the only reason that the caesarean section birth rates are as low as they are, at just 3%.

Caesarean section is major surgery with many associated short and long term adverse effects, from wound infection and infertility in the mother, to feeding difficulties and lung problems in the baby.  The World Health Organisation recommends caesarean sections only be performed when medically necessary, and has stated that there is no justification for C-section rates to be any higher than 10 to 15% of all births in any given region.  The outcomes for both mother and baby are generally much better when childbirth occurs naturally, except for those rare cases where C-section is indicated for medical reasons.  Despite this, there has been a profound upward trend of caesarean births in wealthy nations.  When first measured in 1965, the national C-section rate in USA was 4.5%.  In 1991 Australia’s national C-section rate was 18%.  Today both countries record C-section birth rates of around 32%.  The rate in Australia’s private clinics rises to 43%.

It is difficult to pinpoint exactly what leads the upward trend towards caesarean sections and doctors appear to give different reasons than midwives, for the pattern.    Two medical reasons given, which are not relevant in poor nations such as Cambodia, include the increase in age of mothers and the increase in obesity, both of which are more likely to be associated with an indication for C-section.  Many doctors also claim that women are increasingly asking for C-section while midwives have claimed that women are subtly coerced by obstetricians, whose training is almost entirely related to abnormal pregnancy and surgical intervention, to consider C-section as a preferable alternative.  Midwives also argue that most women who deliver by C-section do so despite not wanting to.  While there are no direct financial incentives in Australia for performing C-section, scheduled elective surgery does allow doctors to take on more clients, so there is a definite indirect financial benefit to the doctor when women choose C-section.  Another determinant in a country like Cambodia, is likely the observation from afar, of the rising popularity of this intervention in wealthy countries.  We are, after all, shining examples of health care, to be emulated wherever possible!

In the lead-up to the birth of Samantha’s second child, she was given multiple reasons for the recommendation of caesarean section birth, none of which held up well to proper scrutiny.  She has always claimed that her first child was born after a difficult and lengthy labour.  However, upon questioning it appears that in fact, she had not progressed to labour yet, when an emergency C-section was determined necessary.  She blamed her son’s neurological condition on this “difficult labour” for many months.  When we were in Seattle together with Paula my very kind friend arranged a consultation with a paediatrician who determined that his condition is in fact genetic and nothing to do with anything that happened during pregnancy or childbirth.  Nevertheless, she was understandably anxious about the second birth, this time of a girl who will not be afflicted by the same genetic syndrome.

She underwent multiple ultrasound scans during pregnancy and from a very early time began speaking of caesarean section.  The reasons given at differing times included: previous C-section as an indication for future C-section (this is incorrect, and trial of labour is normally recommended for women who have had one previous C-section); breech presentation on scan at 34 weeks pregnant, when a large proportion of babies have not yet turned (and when scan is not indicated); nuchal cord (umbilicus around the neck) on another scan at about 38 weeks, which is an extremely common presentation and not considered to be associated with adverse events during normal vaginal birth.  Each of these reasons suggested that she was either looking for a reason to have caesarean section, or being coerced by her private doctor to believe it was the best option.  She said things to me such as “I must do the right thing for my baby, so I should have a C-section”.

Each time she returned from her (many) medical appointments, she presented a new reason for C-section birth.  When I and my midwife friends explained away each pseudo reason, she would present after her next appointment with a new medical “reason”.  Finally a midwifery lecturer friend and I met with her by video conference to speak at length about the reasons that normal vaginal birth would likely have better outcomes for both baby and mother.  In no small way did one of these reasons include a financial saving of many hundreds of dollars.  She appeared convinced and we felt we’d done a very good deed for a young family.

On the due date she presented to hospital with pre-labour pains and was informed that she had appendicitis and needed an appendicectomy!  As they must operate anyway, they would deliver the baby by C-section at the same time!  With so much persistent talk about C-section over so many months, and an absence of any symptoms of appendicitis except abdominal pains, this reeks to me of fabrication and her family will be paying their surgical debt for months if not years to come.  With the severe damage done to Paula’s gastro-intestinal system by over-zealous and obviously unqualified surgeons, the thought of agreeing to abdominal surgery in Cambodia fills me with horror and I was glad that I only learned of Samantha’s fate after the event.  She is now home and apparently recovering.

Associated with this topic, is the issue of breastfeeding versus artificial feeding.  In the 1970s the World Health Organisation introduced an international code of marketing for infant milk substitutes.  This followed the scandal of formula companies, most famously Nestle, unscrupulously promoting their products to impoverished mothers.  Hundreds of thousands of babies died unnecessarily in third world countries, and many more suffered malnutrition, disease and permanent stunting. because of this rampant corporate exploitation.  The scandal was first publicised in Mike Muller’s 1974 report, The Baby Killer.  It is one of the most infamous public health scandals of the 20th century and led to Australia’s very strict rules around baby formula and all baby products, which cannot be sold or advertised in the vicinity of facilities providing care to pregnant or post-partum women.  I studied this scandal in detail, understanding exactly why, as Nurse Manager of a Paediatric Ward some years ago, I had to be vigilant to the presence of anything that could appear to be marketing any kind of baby products whatsoever in our hospital, down to health promotion materials even mentioning the name of certain corporations.

Last September when I walked into the maternity clinic to visit Chom and his new baby, I was stopped dead in my tracks inside the main door, by the sight of baby formula and bottled water stockpiled from floor to ceiling!  Across the foyer was a second shop, stashing every imaginable baby product from powders and soaps to strollers and cots.  Chom’s new son had arrived by normal vaginal birth without complication.  Immediate skin-to-skin contact with Mum is recommended to promote breastfeeding and he explained that this had happened but after five minutes, baby was whisked out of the room and handed to Dad and grandma “because they had to make sure <mum> was okay”.  Mum was perfectly fine and there was no other reason given for her to be separated from her baby, making me wonder at why, in a maternity clinic blatantly promoting baby formula, this separation appeared to be normal practice?  The baby screamed incessantly for a prolonged period and because he was so hungry his grandmother finally sent Chom downstairs to purchase water and milk powder so that he could be fed.  How calculated and convenient it all seemed!  The scandal which was so widely publicised in the 1980s, appears to me, to be proceeding unabated in countries where people are ill-informed and powerless, and where practices are poorly monitored, if at all.

On my arrival at the clinic I asked Chom’s wife if I could please photograph the bottled water and formula to send to my friends in Australia “because they would be so shocked”.  Chom said “this is normal in Cambodia, it is okay”, looking slightly dumbfounded at my reply which went something like “it is absolutely not okay, it is babies in poor countries who suffer because of formula feeding”.  That day he and his wife decided to discard the formula, despite having paid for it and planned not to let it go to waste.  As far as I know, his baby was then exclusively breastfed, although I know that they introduced solids much earlier than recommended, relying as so many do, on their own ideas about what to do, in the absence of any proper information.  WHO describe breastfeeding as “the normal way of providing young infants with the nutrients they need for healthy growth and development. Virtually all mothers can breastfeed, provided they have accurate information, and the support of their family, the health care system and society at large….  Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond“.

It disappointed me this week, after relaxing when I heard that her baby was breastfeeding well, to hear Samantha say “because I don’t have enough milk, I get formula for her too and she will have both”.  This is contrary to the well established evidence that breastfeeding stimulates milk production and adding formula feeds ensures the failure of breastfeeding for many known physiological and psychological reasons.  Again, my first world brain was horrified and I gave a strongly worded response, asking if the clinic sold formula.  Possibly afraid of giving the wrong answer, Samantha did not reply to this question.  The answer is surely yes!

It is astounding to see this promotion of artificial feeding for no reason other than what appears to be profiteering, in a population who can ill afford the extra unnecessary expense.  This is even more shocking when malnutrition, infectious diseases and ill health already dominate peoples’ lives, all of which can be prevented in the first months of life by exclusive breastfeeding.

The dangers associated with childbirth in developing countries appear to have opened up a market of unethical practices, such as promoting surgical intervention and artificial feeding as the best choice for mothers and babies, all because these have a much more profitable result for the facilities providing care.  The general population are in a vicious cycle, aware through close hand experience, of the perils of childbirth, therefore wanting the best.  “The best” appears to be available from private enterprises who prosper from implementing bad practices, ultimately resulting in worse long term outcomes for mothers and babies?  The debt of a mother who dies in childbirth will not be forgiven, and widowed fathers and extended families can spend years trying to repay money owed to clinics responsible for their loved one’s death or disability.  There was no better example of this, than Paula, whose repeated surgeries were not pregnancy-related.  Her intestines were quite literally hacked to pieces and she was sent home to die, her family left in severe debt to the people responsible.  Their search for a “cure” resulted in severe disability leading to a slow and painful death, and a debilitating family debt.

Some of the indicators in reports by UNICEF and WHO, for positive maternal and neonatal outcomes, include such things as the number of facilities offering peri-natal care, per head of population.  With what I have learned about the private facilities and their focus on profits, I wonder if this necessarily equates to positive outcomes?  As most pregnancies are normal and healthy physiological processes, could it be that poor villagers who have no choice but to give birth at home, might in fact be ultimately better off than people who have the capacity to take out loans for private health care?  The examples of Chom and Samantha alone, would suggest so.  When I told Win some days after my visit to Chom’s family at the maternity clinic, that I had stood on the stairs and photographed the clinic shops, he replied “that is why they do not like foreigners to go to their clinics, because you know too much and it can cause problems for them”.

When I feel exasperated by some of the behaviours of my friends, particularly around health care, I have to remind myself consciously of the comparison between our experiences and perspectives.  As someone from the rich and privileged world, I know what is best from my educated and unexploited place in the world.  That does not mean however, that I am in a position to judge the behaviours of those who only know adversity that I have never even had to imagine.  Figuratively speaking, it is all too easy to condemn the behaviour of those floundering in bare feet on jagged stones as we amble comfortably along soft terrain at lofty heights with an unlimited choice of footwear.  It is also, as Herman Melville said, preposterous of us to do so.


Magnifying the Magic

The world is full of magic things, patiently waiting for our senses to grow sharper ~ WB Yeats

The day I met Paula and her family 16 months ago, they were resigned to a diagnosis of terminal cancer.  Tears were common at that time and I remember not believing our initial reassurances to her, that there was still hope she could be cured despite what she had been told.  You might wonder why doctors and nurses would give a patient false hope.  Without any first world resources of even the most basic capacity, her diagnosis was made purely on the basis of medical guesswork.  She had since been diagnosed with a second illness (Tuberculosis), which potentially explained her “terminal cancer” of the lining around the intestine, called the mesentery.  I have seen mesenteric TB before, in a young man in Australia, who was also diagnosed initially and incorrectly as having terminal, intestinal cancer.  In Australia’s robust health system, diagnostic tests eventually gave an accurate diagnosis without any unnecessary interventions and he was treated successfully with anti-TB drugs.  Not before he too, had grieved his imminent death for a few weeks until the conclusive test results brought good news.  There has been no confirmed good news for Paula, just an evolution of realisation that she appears, despite her chronic state of ill health, not to have terminal cancer.  It was memory of the Australian man’s experience which urged me, despite not knowing, to give her as much hope as I could muster from my ambiguous thoughts.

There are tears now too, but today’s tears come from a different place altogether and now they flow as far away as America, where a dozen or more people who have never met Paula are already involved in getting her into the hands of those with the skill to cure her.  Until today I’d managed to remain stoic in the face of all Paula-related tears, be it last year’s mourning or this year’s rejoicing.  Today however, Paula’s grandfather ambushed me with some dignified and humbling words.  A group of her siblings and other extended family were with me in a semi-circle facing Paula on her camp bed.  Another translator friend (not Chom, whose long-overdue son finally entered the world late last night) was sitting with us.  Tall, quiet and elegant, her grandfather entered the room of their elevated wooden home and sat beside me on a mat on the bamboo slat floor.  He lives over the road from Paula, beside the big colourful community mosque, and obviously saw us arrive.  After sitting for a few moments he spoke to me serenely as he allowed an occasional tear to swell before blinking it away.  He waited for translation at the end of each sentence before continuing on and his words included the following.  We have nothing to give you to say thank you.  But we give you our hearts.  You are not from our country and we do not have the same religion but you help us anyway.  We don’t know why you do this for us and we never met anyone like this before.  My reply to this was that I have a lucky life and I want to share it with others who don’t have my luck.  Nodding recognition of this, he continued.  Everyday I go to the mosque five times and five times everyday I talk about you and I ask Allah to give you a long life, good health and good luck.  You should have everything you wish for because you are taking my grandaughter to America.  The only dry eyes in the room belonged to raucous children.  So I finally capitulated to the infectious Paula tears!

After time with The Eye Sisters on Monday, I made a mad overnight dash to Phnom Penh on Tuesday to farewell friends holidaying from Australia.  Wednesday was a return mad dash home, on a bus that broke down about halfway up the highway.  Hanging around on the roadside, passengers chatted and formed friendships.  A young guy who I’d noticed in his seat diagonally across from mine, hoisted himself off the bus with a walking crutch.  His left foot hangs loosely at around knee level on a shortened, deformed leg.  He works for a company, traveling the country to repair machinery.  Keen to speak English with me, we had a friendly chat and swapped numbers so that “when I have spare time I can call you”.  Looking for shade, I then joined a mother with her three small daughters under a tree and we had a conversation of sorts, in Khmer.  In desperate need of the toilet, I then walked to a nearby restaurant where a lot of fellow passengers were hanging out.  Asking in Khmer for the toilet, the server instructed her small daughter to escort me.  She led me across a large dust bowl behind the restaurant and into the yard of an elevated wooden house.  Near the stairs leading up to the front door, a crowd of men appeared to be playing cards together.  They turned in unison to look at me, we chum-reap-suored each other and I was led behind them to the toilet.  A typical brick outhouse with squat platform and makeshift bathtub filled with mud-brown river water for “flushing” things away with a plastic pot floating in the water.  On my way out, the owner stopped playing cards and escorted me back to his restaurant, speaking in English to ask where I was from, where I was going, apologise for the mud-brown flushwater, etc.

About two hours later I finally arrived home and Paula was already here, lying on her hotel bed, with Mum, 5yo son and 15yo brother.  Too embarrassed to be seen in public and too incapacitated to walk far unassisted, she did not leave her room for 48 hours.  But she was thrilled to be here.  The family had already eaten lunch and announced that the western hotel food was delicious, much to my surprise!  Mum did ask if there was any dried fish, which there is not, so the next morning I headed early to Central Market and got the Islamic restaurant to make up five takeaway breakfasts of rice and dried fish which I shared with the family in their room.  But they were keen to revert to the hotel food thereafter, much to my amusement, including a hamburger order!  We managed to apply online to the US Embassy – a massive rigmarole which took up about ten hours of my time including time with a translator going through a myriad questions relating to intent of travel, then paying the fees and organising all relevant documents, making the appointment, then requesting an expedited appointment for medical emergency, all via required and exacting processes.  We took 5yo son for a couple of tuk tuk rides, to organise the fee payments at the bank and get his grandmother’s visa photograph taken, which helped keep a bored child semi-happy, assisted by the acquisition of a new truck at Central Market.


Forty eight hours later it was time to drop them at the morning minivan for the journey home.  Paula never eats prior to travel, in order to avoid digestion problems during the journey.  This causes her blood sugar to plummet and she becomes very faint.  We went by tuk tuk via the photograph shop to have her visa photograph taken.  On an empty stomach and weighing 30kg, her mother half-carried her into the shop, a distance of around 15 metres.  She sat down, suddenly looked very pale and then glided gracefully to the floor with Mum’s very calm assistance, unconscious.  About 20 seconds later she woke in Mum’s arms beaming a smile, eliciting guffaws from everyone looking down anxiously at her!  She soon sat up for her photograph and we dropped them at the minivan under assurances she would be fine.  My heart sank later in the day when a new website page instructed me that the passport sized visa photograph had to show the ears of the person – both women had their hijabs in place and ears out of sight.  This week we have to go through the process again, although this time I’ll arrange it at a time when she has been able to eat.

Two of Paula’s brothers are reportedly very clever and through my time with the family I’ve learned that English school costs $4 per month which the family cannot afford.  This week I agreed to sponsor the two to attend private English classes and today’s trip to the community was in order to put this in place for them.  Chom was insistent I pay the fees directly so that I can see the school and know the fees have not been redirected.  We arrived at their home this morning and the boys changed out of their Islamic long dresses and headgear, into shorts and shirts.  We then drove the 8km to the nearest town and found the private English school.  Five months of fees for two set me back US$40.  What a worthwhile expense, especially for 16yo who keenly speaks to me in single words to show me his enthusiasm to learn my language.  Each afternoon 11yo brother will go on the carrier of his older brother’s bike and they will travel the 8km to school for an hour, then make the return trip home.  It might require a second bicycle but I will wait til Chom is free to advise me on this.  Such small amounts of western money can make such big differences in the lives of people in the poor world.  My experience here over the past two years has taught me that sharing the magic magnifies the magic, for myself as much as anyone else.  All of us from the wealthy world can enrich our own lives by sharing some of our magic with those less fortunate than ourselves.

A 16km round-trip each day will bring Paula's two brothers to this private English class, under the teacher's elevated home.

A 16km round-trip by bicycle, six days per week, will bring Paula’s two brothers to this private English class, under the teacher’s elevated home.

Paula's mother's market vegetable stall. While in America, Paula's sister will keep the stall going in order to keep an income in the family.

Paula’s mother’s market vegetable stall. While in America, Paula’s sister will keep the stall going in order to keep the family income flowing. They earn between $0 to $3 per day at this stall and her father is in Malaysia, earning $70 per month.

Cultural Chasms

They are late and still building momentum but the Monsoons have arrived in South East Asia.  With a bit of fluctuation, the Mekong River is rising steadily.  Slowly surging out into the delta, rising waters are transforming the lowest level green fields into massive brown lakes.  Soon many villages will become submerged in a combination of rain and swollen river waters for up to three months.  For now the rains turn everything to slush which, in the hot dry intervals between showers, quickly evaporates to dust.  Muddy puddles make great paddling pools for raucous children who haven’t developed my obsessive-compulsive-disorder about tropical diseases.  The other day I watched some children I know well, splashing around in roadside puddles before one of them ran over to me and leaned in for a hug.  Before my brain switched on in time to prevent it, I was theoretically smothered in a textbook of parasite species.  Consciously dissuading myself from OCD-induced panic, I took an unscheduled shower and determined to remember that course of Albendazole when I get home to Australia!

His krama wrapped turban-like around his head and otherwise clothed in just a pair of undies, Joe was sitting in his boat repairing the floor as we pulled up outside their bamboo gate last week.  The shoreline is currently about 1km away but soon enough this heavy wooden canoe will be their only transport from the top steps at the front door.  On our way out of town Chom and I packed the tuk tuk with eggs and stocks of long life food such as soy sauce, fish sauce, sugar and garlic: hopefully enough to last the family until they can reach town again in a few months’ time.  At home on smooth bitumen roads I inevitably break eggs between the supermarket and my front door.  In Cambodia they bounce around on unsealed tracks in a ricketty tuk tuk without so much as a hint of a crack.  Even eggs seem to have an other-worldly tenacity for survival against the odds!  After about an hour with the family I said my first farewells for the year as the roads will become impassable soon and I won’t be able to visit them again until my return sometime next year.

Helped by a push start, Joe demonstrates his new wheels

Helped by a push start, Joe demonstrates his new wheels

Joe and family at home before the monsoonal immersion

Joe and family at home before the monsoonal immersion

Speaking of tenacity, Paula has metamorphosed from a smiling and persevering bag of bones, to a laughing and animated bag of bones!  We also visited her last week to get some paperwork signed for the upcoming journey to USA.  Between us, including Chom’s invaluable and comical consultation, we decided that due to the language barrier, it was best to send “Samantha”, who coordinated Paula’s nursing care under my management and beyond, as their escort.  She knows the family well and has good English skills, meaning she can translate for Paula and her mother on the journey, which I could not do if I travelled alone with them.  Samantha has also never travelled before and so while it will be challenging for her to navigate airports and border control etc, she is perfectly capable and will be well prepped.  She is equally excited about the opportunity to visit another country.  The two young women speak daily now, for up to two hours at a time, about their upcoming, life-changing (especially for Paula) adventure.  I love being a bystander to their excitement.

Meanwhile in the US there is talk of a television network covering Paula’s story!  This would be deserved recognition, albeit only available to one of so many families in similarly miserable predicaments.  Paula and her family are a prime example of the human realities behind various analyses of global poverty and near-poverty.  In 2014 Cambodia ranked 136 of 187 in the United Nations Human Development Program’s (UNHDP) Human Development Index (HDI).  This puts Cambodia 51 countries ahead of the world’s most impoverished nation, Niger.  In comparison, Australia ranked second after Norway with USA at 5 and UK at 14.   The indicators used to calculate the HDI include, but are not limited to, life expectancy at birth, mean years of schooling and gross national income.  This is not a perfect tool because, for example, years of schooling does not measure the quality of education, which in Cambodia seems to be variable and lacking.  This is hardly surprising given that a mere generation ago all of the nation’s teachers and other educated professionals were exterminated.  The HDI is complicated and can be read in full at this link:

Despite the serious effects of the Global Financial Crisis of 2008, the news is not all doom and gloom.  For example the World Bank reported that Cambodia’s poverty rate had decreased from 53.2% in 2004, to 20.5% in 2011.  However, we should never look at this with blinkered “first world eyes”.  The same report states that the impact of losing US30 cents ($0.30) income per person per day would double the poverty rate to 40%.  The “near poor” status which many have transitioned to is not a safe nor comfortable circumstance.  Many Cambodians are food-insecure, with almost 40% of all children under the age of 5 having chronic malnutrition.

In such a vulnerable population, one would hope for a basic level of health care to be available.  No such thing exists although attempts are being made to implement a health insurance program to provide poor families with free access to health care.  The situation is complex.  World Health Organisation, in their 2014 “Country Cooperation Strategy – At A Glance” brief (, identify poor regulation of services, high levels of out of pocket payments and poor quality of care, as significant challenges to the national health system.  70% of health care expenditure in Cambodia is paid “out of pocket” by the individual patient.  In a population stricken by poverty and near-poverty, this manifests in high levels of debt and asset sales which can become a catastrophic cycle of financial obligation and destitution.  Families sell property and borrow money, often at high interest rates, to cover the costs of health care intervention.  Friends have told me that even basic interventions such as replacing an intravenous fluid bag or administering analgesia, can require a cash payment made to the provider before the work will be carried out and so officially reported costs could be severely underestimated.

I have known all of this for the best part of my two years in Cambodia.  I have also encountered many patients in stress due to debt caused by health care costs.  So why was I shocked when Samantha told me yesterday, about Paula’s family’s economic plight?  The only explanation is because I was looking at them with my blinkered first world eyes.  I knew that Paula has had multiple hospital admissions, surgeries and investigations for her unexplained and undiagnosed abdominal pain.  I also knew that she has not contributed to the family’s income generation since her illness incapacitated her.  The cumulative financial cost of her ordeal did not occur to me, despite evidence staring me in the face.  Samantha had to spell it out to me.

Paula developed abdominal pain during her pregnancy almost five years ago.  Over time she attended her local clinic, graduating to the regional referral hospital, and then a big city hospital in Phnom Penh.  With little in the way of diagnostic resources, she was operated on a number of times.  Prior to her diagnosis of Drug Resistant Pulmonary TB (DRTB of the lungs) in May last year, she had been told that she had incurable intestinal cancer.  She was tearful, believing that her illness was terminal.  This is not unlike a case of mesenteric TB I encountered in Australia, of a young man with abdominal symptoms which doctors mistakenly diagnosed as abdominal cancer.  Obviously misdiagnosis is not the exclusive domain of under-resourced third world health services.  We don’t know what her abdominal illness was, but upon commencing TB treatment the symptoms subsided.  By then she had already undergone various surgeries resulting in a number of post-operative complications including gaping, non-healing abdominal wounds which ooze faeces and burn her skin, and malabsorption leading to severe malnutrition.

The economic cost of her five year ordeal has been sale of the family home plus a comparatively large and crippling debt, which sent her father and young brother, who should be in school, to Malaysia where they can earn more in a labouring job than is possible in Cambodia.  As her main carer, her mother works early mornings selling vegetables from the back of an old moto around the nearby villages, before returning home to cook for Paula and tend to her wound dressings.

As is becoming a pattern with me, the main reason for my astonishment at the revelation of the family’s financial crisis, was my own ignorance of their plight.  This is partly due to the lack of shared language, but also the yawning cultural chasm between my first world perspective, and the perspective of people for whom struggles like this are a commonplace reality.  The mismatched underlying assumptions between those telling me something and me “getting” what this means continually throws my world view out of alignment.  For example “we don’t live in our own home anymore” (I haven’t lived in my own home for two years either) and “Dad and bro have left to work in Malaysia” (I have also been working overseas) have very different connotations in their reality, than they have in mine.  Coming from such divergent world views, it takes the likes of Samantha to translate for my first world brain.

As I talk to Samantha, Paula and her mother about what they can expect to see, hear and experience when they travel to big-city-America, where she will receive state-of-the-art first world treatment at no cost, I keep this chasm between us in mind.  It will be interesting to learn how well I did in my pre-journey cultural preparations once they return.  I fully expect there to be some assumption mis-matches which despite all attempts, I will not have been able to anticipate on their behalf.

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Paula as photographed by El Pais newspaper earlier this year

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Paula’s home as it begins to be immersed into the Mekong