Picking in Provence

Picking grapes?
Picking lavender?
Picking olives?
No!
Picking whether or not to be here.
Talk about a First World Problem!

There are castles on hilltops at every turn and churchbells ring out on the half hour from medieval spires reaching into blue skies.  Ancient Roman cities recently discovered under layers of soil sit on display in sunken parks beside current day market places.  Stone houses rise out of cliff faces, their walls thick with green vines shaped around doorways and shuttered windows furnished with blossoming flower boxes.  The scent of lavender fades in and out as you walk through the cobbled streets which seem almost haunted by the likes of Cinderella and Rapunzel.  It is a whimsical place.

New York “Karen #1” is doing a cooking class here.  She planned this trip two years ago, and her two bedroom / two bathroom apartment is in the centre of a medieval village north of Avignon, considered the capital of Provence.  Karen very generously invited me to join her, on condition that I understood she would be buying cheese, critiquing olive oils, tasting wine, cooking and eating with her tutor and about 10 classmates, for up to ten hours each day.  So by day I hang out in “our” village, or cycle to neighbouring villages to compare hilltop castle ruins and terrace garden cafes.  It is sheer bliss.  By night I have company to sip wine and eat strawberries and cheese with, on a balcony overlooking the local castle.

IMG_4960

Two days ago cooking class went to the village’s weekly market to choose fish fillets, vegetables and various other ingredients.  I was invited to join them.  It was interesting, a lot of fun, and demonstrating my interest in cooking, I came away with two new tops, two new pairs of trousers and a number of Provençal laughs.  Karen came away with about 300g of goat’s cheese for the princely sum of €22.  This was fairly and squarely my fault as I stopped to taste morsels being held out to me on a wooden board, embroiling us in a situation with a French guy in a chef hat and red and white checked apron.

French people are nothing like the stereotypes which have made me reticent about visiting their country in the past.  They are lively, friendly, funny, open and polite, with what seems to me like a very strong sense of community spirit.  Life is centred around big open, treelined shady squares, very much like the plazas in Spain.  Adults sit in cafes on the edge of the square watching children play around the trees and fountains in the centre.

Yesterday I hired a bicycle, repeating the words of the rental guy in my head as I pedalled up some steep hills: “if you don’t climb the hill you will not see the view”.  How right he was!  Cycling on French roads, you are treated like royalty by the cars sharing your space – they slow down for you, queue behind you until there’s somewhere to pass, give way to you at roundabouts and other intersections.  There is no sense of being in anyone’s way.  A number of times I passed groups of cyclists going the opposite way, two-and-three-abreast on the road, with cars queued behind them waiting patiently for a place to pass.

Farewelling Karen on Saturday I’ll be in Provence for at least another week, possibly longer because it is going to be a pull getting me out of here.  As yet I have no onward plans.  Having seen so much in the past three months, I want to savour what I’ve seen of Europe and not rush off to see/do any more.  You cannot see or do everything, even if you spent your whole life traveling, and the best way to travel is to stop and spend time getting to know the place, people, language, culture and lifestyle.  For now I can’t think beyond staying still for a while in Provence and just being in this very magical moment.  Perhaps this will be my final European destination before returning to Cambodia.

Reiterating the extreme good fortune I am always so aware I live with, I type this with BBC World News on mute in front of me and livestreaming MSF’s International General Assembly in Barcelona on my laptop.  BBC continue to cover the migrants in Calais trying to jump into trucks crossing to the UK.  A few days ago I was in Calais again, for a flash of a moment as the Eurostar emerged from the Channel Tunnel and hurtled towards Paris, where I took a subway across the city to the TGV station en route to Avignon.  Joanne Liu, MSF’s International President, is speaking in Barcelona on the many complex challenges facing MSF, from Ebola in West Africa to the new sea search and rescue missions being undertaken in the Mediterranean, to mass population displacement in Syria and the spread of Drug Resistant TB across the poor world.

This brings my thoughts to Paula, the 25 year old DRTB patient who was told she had abdominal cancer when in fact it was Drug Resistant, abdominal TB.  As I type, as the migrants race to jump into the back of trucks at Calais, as Dr Liu speaks, I can see Paula sitting on her wooden bed beside the barred window in her elevated shack beside the Mekong, across the narrow track from her village mosque.  Her abdominal wounds ooze faeces, she struggles to gain weight beyond the 30kg she has achieved since a year ago when I met her, at 20.8kg and tearful that she had a terminal cancer she did not have.  Her 15yo brother and their father have moved to Malaysia to work on fishing boats in order to keep the family fed.  They will not return for three years.  She sits on that bed with a copy of the Koran as her constant companion.  She has sat there for months, wishing and hoping to recover from this debilitating disease.  So far, there is no indication this will happen for her.  Our simultaneous lives are so disparate that if I hadn’t experienced them both in person, I would not believe it possible.

Over my months in Europe I have sent regular emails and photographs to the children at Phter Koma, some of who have replied, practising their English on me.  We’ve also Skyped.  I hear from Chom regularly via Facebook as well as a number of my old colleagues.  Happy news from Cambodia is that the baby of my colleague, who was dying in hospital, intubated and having to be manually ventilated by family members, made an amazing recovery!  He still has severe cerebral palsy so life will remain challenging and he is very vulnerable to further illness.  It has not been possible to have contact with many others who I miss a lot.  Paula is one.  The young family with the crippled father on the outskirts of Dara’s village, Dara and his family, the blind widow and her elderly parents and young daughters, the landmine victim in Siem Reap.  It is starting to feel like time to return.  If I can only find the momentum I’ll need to jump out of this fairytale.

Nelson Mandela

Advertisements

You Know You’re Back in Cambodia When…

Needing a bus ticket to Kampong Cham, I asked the hotel receptionist in Phnom Penh to organise one for me.  Soon enough, via an agency, my ticket arrived by motorbike courier.  Phnom Penh to Kampong Cham, 2-15pm, Seat 15.  With no record of which bus company, I asked “Is this Capitol Bus?” and she replied hesitantly.  My lack of Khmer combined with her uncertain English, I called Win who rang the ticket agency for me before calling back.
They said your ticket is for Battambang.
It can’t be, it says Kampong Cham on the ticket?
They said the 2-15pm bus is for Battambang, the Kampong Cham bus goes at 2pm.
Okay, I’m pretty sure that they simply wrote the wrong time on my ticket so I’ll turn up at Capitol in time for 2pm.
A few minutes later he called again.
The bus company rang me.  You are booked at 2pm for Kampong Cham, in Seat 19.
Okay, wrong time and wrong seat number is more reassuring than wrong bus!

On arrival at the chaotic bus station, the first “Tuk tuk madame?” guy (I’m disembarking a tuk-tuk, what do you think?!), pointed me in the direction of the Kampong Cham bus.  I walked in that direction and approached the counter, reaching over freight boxes piled high across the floor to present my ticket.
Oh you have to go that way, to Capitol Restaurant.
Wheeling one big case beside me and a smaller one behind, laptop leaning on one case, plastic bag filled with toiletries precariously atop the other, a pack on my back and ticket between my fingers, I clattered across the potholed pavement, squeezing around people and produce, to the corner restaurant.
Tuk tuk madame?
No, bus to Kampong Cham.
It’s that way!, pointing whence I’d just come.
No, I have to go this way.
No that bus is Kampong Cham!
But they told me to come this way, I insisted, going against his equally insistent advice.
At the restaurant counter they transferred my agency ticket to a Capitol ticket and sent me back towards the Kampong Cham bus.  As I walked past Mister Tuk Tuk Madame he called out to me:
I told you that way but you went this way!  You should listen to me!  I have good advice for you!
But I had to get my ticket changed!
Ah!  Okay!  Followed by big smiles.

The bus trip quickly removed all remnants of the Western World from my consciousness.  Months into the Dry Season, everything is caked in a layer of brown dust.  Leaves on trees, waterlogged green lotus pods, rooftops, even the white hides of oxen all give the impression of being cinammon coloured.  For most of the trip the air was a thick cloud of brown and upon arrival in Kampong Cham I looked like a huge walking cinnamon stick!  Greeted excitedly by Chom and his small son who I’d been texting along the way to keep them informed of my estimated arrival time, my cases were barely recognisable as they were dragged out from the hold looking as though they’d rusted along the way.  There was no time to shower so I turned up at my old workpace in the state I was in, for the New Year party which happened to be in progress.  My dirt-soaked appearance didn’t seem to perturb anyone as a can of beer and three plates of food were presented to me amidst hugs and enthusiastic chatter.

Just over an hour later, which was enough time to see and catch up briefly with most people, I realised that I couldn’t remain upright any longer and had to bow out.  One of the nurses offered to act as chauffeur.  In the front yard of the office, with my old boss watching on, I broke the golden MSF expat rule “no riding on motorbikes”, climbed aboard, and pillion passengered my way through the streets, wind evaporating my many sweats, feeling very “rebel without a cause” and of course, far more Cambodian than I’ve been allowed to act until now!

Win met me for breakfast this morning, joined briefly by Chom.  Filled on rice and chicken, I swung a leg over yet another moto and cruised pillion across to Shackville with Win as my chauffeur-translator.  In ten weeks noone has seen any sign of Dara but this morning his parents both appeared, Mum in tears, saying Dara is with her parents but he will want to come to town when he learns I am back.  I explained that in NZ I received money from family and friends who wanted to help them get a toilet for their village.  They want to build it immediately so the plan is to help them purchase all materials this Friday.  Following Chom’s advice to keep a tight reign on this money, which is a huge lump sum to poor Cambodians and could easily be redirected to other causes, I’m remaining involved and will take photographs of the project in progress.  It should prove an interesting observation for my First World brain!

Dara’s amputated bone has apparently grown quite long and he is no longer able to wear his prosthesis but they have no money to take him to the hospital because “our money is all used for food”.  Win explained to them that I can help with this as well, which is also thanks to various peoples’ generosity while I was home.  The family bicycle which I had repaired for them at the grand total of $10 continues to go well, used to transport Dara and his sisters to school as well as for daily market trips by grandparents and others.  I asked where is the blind lady with two infant daughters, whose husband works with you?  Her husband drowned in the river “over there” (metres away) and she has returned to her village to grow rice.  I could hardly believe my ears!  Where is her village?  A long way away, we don’t know where.  I’m so shocked and saddened by this.  Those beautiful little girls have lost their father; his earning capacity of $4 per day has plummeted to a family income of enough rice to eat (if the harvest yields for them); and I am likely never going to see them again.  On our way to dinner on New Years Eve, Karen and I went out of our way to purchase a My Little Pony for each of them at a specific corner store in Greenwich Village.  Some other small girls will no doubt appear and score these sooner or later.

From there we cruised over to the hospital where Drug Resistant TB “outpatient day” is in progress and I was able to see a number of our most complicated cases who I had been very involved with.  It all flooded back to me as I greeted at least ten of my previous patients who remain under the TB Program’s care.  A few examples who I am sure I’ve spoken about before:

  • severe treatment side effects have led to an 80yo man stopping his treatment and he has gone home to die.  TB is a curable disease but there are times when this fact becomes a fiction;
  • the HIV-co-infected widow separated from her 10yo son while his mother remains infectious with DRTB was there.  She smiled happily at me from underneath her mask as I promised to cycle out to her home sometime soon to visit;
  • just out of her clinic appointment, the malnourished 25yo mother with two open abdominal wounds walked slowly out to the waiting area and waved out to me.  Despite her malabsorption which makes gaining weight almost impossible and compromises the efficacy of her anti-TB drugs, threatening her chances of a cure, she appears to be improving.  She is now 8kg heavier than when I met her seven months ago – a whopping 28.5kg from her initial 20.8kg!  Efforts are being made to consider surgical intervention which could see her return to a normal quality of life.  She has to gain another 10kg+ before this becomes an option, assuming the surgeons think there is anything they can do.  Her sister and brother-in-law left for Thailand last week “because we have to spend 10,000 riel ($2.50) everyday on gauze for my wounds and they need to earn money”.  When will they come home again?  “We are not sure, maybe in a few years”;
  • the malnourished 57yo woman who we sent home assuming she would die pulled up on a moto, sitting upright between the driver and her husband.  She climbed unassisted off the moto and with minimal assistance walked up the ramp to the waiting area!  Her abdominal wound, caused by TB disease, is apparently much improved but remains an open wound affecting her absorption meaning weight gain remains a slow and challenging issue;
  • the elderly man living with his wife and their psychiatrically unwell son still has gynaecomastia (breast growth) due to one of the drugs he is on and remains incapacitated by drug-induced arthralgia.  Nevertheless he remains compliant and is progressing through his two years of treatment.

A quick visit to the office to deliver gifts.  Jewelery for the women and pens for the men, all from New York which might as well be on another planet after the re-introduction I just had to the way so many people exist.  Toys or NY-logo clothes for various children.  My case was 3/4 full before I even started to put anything of my own into it!  But somehow it all arrived safely and I now have a 3/4 empty suitcase at my disposal, albeit saturated in dust!  Win dropped me off and I ordered a chicken salad for lunch which was followed by the appearance of a coconut milkshake from the waitress asking me “please can you try this and let us know if it is good?”.  Of course!

With fundraising money and medicines to distribute yet, an English lesson schedule and lesson plans to prepare, charity status application to make via Global Development Group in Australia, staff meeting to chair on the weekend, a website page to edit, toilet construction to fund, patient homes to visit and of course, part-time food tasting, my “holiday” has a purpose attached to it now, for the ensuing few months.  I wouldn’t have it any other way!

Dealing with DRTB

As my project with Medecins Sans Frontieres draws to a close, reflections about the year laid out behind me prevail.  I am only leaving Cambodia briefly but my departure and the end of my work commitment here have me feeling very philosophical about this beautiful and catastrophic nation and the incredible experiences I’ve had here.

When my predecessor left in October last year I was present for his farewell speech during the weekly all-staff meeting in the foyer, when around fifty of our almost-100-strong team stand around for a briefing of anything important that needs to be shared.  What struck me most about his parting words was the cherished memories he would forever hold dear, of working with Cambodian people.  I hoped then that I might have a similar experience but I had no idea how powerful an effect the people of Cambodia would have on me.  The gentle, humble, unassuming and fun loving nature of my colleagues, the national members of the orphanage board I am now part of, the children, the patients and their families, is really something that western culture could learn from.  I hope that I have learned from it and I suppose the challenge will be retaining my sense of “calm amidst calamity” upon landing back in the ego-centric culture that I come from and belong to.

That’s not to say that Cambodia is without problems.  You only need to read a little about the Khmer Rouge and their contradictory gentle yet murderous nature, to know that gentleness is not necessarily all that it appears.  Cambodia’s military and police forces are corrupt, dictatorial and can be extremely violent, as the front pages of national newspapers here illustrate almost daily.   Yesterday I cycled to work on a high after my encounters with Dara and his Shackville community.  As I approached the boomgate, the young man operating it who is usually friendly seemed reluctant to let me through and was looking across the driveway at something I had not noticed yet.  He let me through and I was immediately confronted by a very stern soldier with a rifle slung over his torso who ordered me off my bicycle and motioned me with attitude to keep away from a formal ceremony which was taking place in the driveway.  I was knocked off my high very quickly!  The use of military force to protect dignitaries here is a visible and common sight, with said dignitaries usually living very wealthy lifestyles beyond that which most Australians can imagine.

Almost twenty years ago a friend instructed me that I absolutely “must” watch the Quentin Tarantino film Pulp Fiction.  I rented it one afternoon, watched it alone and felt very disturbed by my own laughter.  In fact what I was laughing at was cold blooded violence and I was conflicted between laughter and wanting to press the Stop button.  I’ve since discovered that Tarantino’s skill lies in causing internal conflict in his audience.  A similar but far less concerning disturbance occurs here on a daily basis.  One of the most significant features of my year has been the realisation of my naivety as a monolingual English speaker.  The exposure I’ve had to Khmer and European people speaking and working in English has been a surprisingly profound lesson.  I am constantly entertained by the hilarious invented modifications of English, but it disturbs me at the same time because I have absolutely no right to find humour in someone else’s multi-lingual talents.  I try very hard not to appear amused, but as a native speaker it really is comical to hear your language mangled, especially when the mangling is perfectly comprehensible despite being so wrong.

Working alongside a translator with an academic interest in English and language in general, has been a new and novel experience.  I’ve learned so much, not just about the English language but also it’s global domination and the power it possesses.  Win calls Generation Y “The English Generation” and often nudges me if we are in a remote place and a young person suddenly speaks to me in English, proving his point.  When we have attended schools and universities for health promotion sessions, he always says to the crowd when introducing himself as my translator, that anyone who wishes to practise their English on me should do so instead of relying on him for translation.  Most young people have spoken to the crowd in Khmer but we always drew a small private audience afterwards, wanting to speak and ask questions in English with me.  This always seems like an extension of the daily bike ride ritual of being pursued by young people on bikes or motos wanting to practise with me, or children shouting out excitedly “Hello!  What is your name?!” or “Hello!  How are you today?!”, usually laughing uproariously when I shout a response back to them!

There are two young volunteers working at the orphanage for the next few months, who have given me a respite from the English teaching.  The timing was perfect as I am busy with my final weeks at work and the lessons have been time consuming.  The “extra” students who travel to the orphanage with us are not benefiting from these volunteers though so I am unsure whether to continue a small class with them or wait until my return, when my sole occupation will be teaching English.  I continue to be approached almost daily by parents and children wanting me to teach them English so it’s a high-need occupation.

In ten years working with Tuberculosis in Australia I encountered one patient with DRTB.  Here however, I have encountered dozens in a single year.  It is a complicated disease with many facets to it, not least of all the social problems faced by patients who are almost always impoverished.  This week alone we became aware of a problem with a young 20-something woman with DRTB whose mother is, like so many other Cambodians, crippled by an un-payable debt connected to health care costs (not related to her daughter’s TB as TB care is free).  This young woman has been under constant pressure from her mother to get a job and help with the debt repayments.  The first time I heard this story we were at her home, a small elevated hut on the edge of a dusty main road with bamboo strips for a floor which I was afraid to walk on in case they broke under my weight.  Looking around her hut which contained a hammock, a bed mat and not much else, this was one of the first exposures I had to what it means to be actually, genuinely “poor”.  Since then this level of poor has permeated my reality as I visit patients’ homes regularly and lifestyles like this are the norm for most rural Cambodians.

This particular young woman has raised concerns within our team as she has given conflicting accounts of how she is now spending her days.  She should ideally not be working at all, as she remains potentially infectious and could spread her drug resistant TB to colleagues.  However, as she has expressed her lack of choice in the matter, it was agreed that she look for work based outside so that good ventilation would reduce the risk to others.  She has given conflicting reports though, and asked questions which have raised our suspicions.  She claimed to her community volunteer that she was selling in an outdoor market but upon quizzing by our social work team it was suggested she was actually working in a factory.  We interviewed her community volunteer last week and I quizzed him extensively, recruited to do so because of the influence I hold as a Barang.  Along with my nurse, we felt he was being truthful, in that he continues to treat her as he is contracted to do and that he is not complicit in her work activities.  In past cases, the volunteers can agree to leave medication with the patient so that they are not observed taking their medication, which goes against the principle of Direct Observed Treatment which is recommended for DRTB patients in order to ensure all medication is taken correctly as prescribed.  We are still in the throes of investigating her situation in order to try and protect the public as much as possible but in such a low resource setting it is a difficult task.  The next intervention we plan is to attend on a “surprise visit” to see her unexpectedly – we often find out a lot of information during surprise visits.  In Australia a patient like this would be isolated in a hospital room with many resources in place to ensure adequate treatment adherence.  The possibilities here are so much more limited, and tend to require very creative interventions which has been a steep learning curve for me.

This week another patient went home after months in town because his rural location meant there was noone able to provide him with his daily injection.  The injections have ceased and he could finally return home.  One of my nurses attended his home the next day to meet and obesrve the practice of his community volunteer.  He returned and told me “I am very pity for this patient because he is so poor.  The house is made from leaf and everything will come through the roof – the sun comes and he gets very hot and the rain comes and he gets very wet”.  This patient hopes to find work in a nearby rice field, and if that happens he can feed himself instead of relying on his neighbours to feed him, as is currently the case.

I’ve written all of that from the air conditioned comfort of a local restaurant where I’ve sipped diet coke, munched on rice paper rolls and watched my beloved construction workers out there in the 34C (“real feel 42C”) , 60% humid weather.  The chef went out and returned with an orange gas tank strapped to the back of his moto which he then lugged through the restaurant out to the kitchen.  A moto-drawn trailer pulled up at the front with empty sacks covering a pile of produce packed into sacks on the trailer.  The driver lifted a full sack of what looked like potatoes off the trailer, heaved it onto one shoulder and carted it through the restaurant to the kitchen.  A woman covered in the traditional checked sunhat with matching face covering cycled by with a plastic basket hanging from each handlebar and a large cane basket on the back carrier, all filled with produce for sale.  A man wheeled his bicycle drawn carriage loaded with green coconuts past.  The construction workers pulled their archaic barrow filled with sacks of concrete powder past.  An untold number of sidecar shops attached to the side of motos slowly puttered by.  Teenagers, some even questionably that old, drove past on their motos with three to four pillion passengers lined up behind the driver.  A bicycle rider held onto the side of a truck, speeding along without any effort.  Children on bikes, pillions sitting on the handlebars or standing on the edges of the back wheels.  A father on a moto with two children holding on behind him – the c.2 year old sandwiched between Dad and big brother of about 5yo who had his arms around little brother, clutching onto Dad’s shirt.  Utility trucks with passengers crowded onto the tray back drove by.  A large old wooden boat meandered past on the Mekong with jeans and shirts hanging from the outside walls of the wooden deck shelter.  A woman with a large round flat tray balanced on her head, selling breads and nuts calling out a catch phrase to attract customers sauntered by.

To finish, if you want to know how DRTB is dealt with in Australia, take a look at this very entertaining article.  Even TB can be funny when the right person is inflicted with it!

http://www.abc.net.au/news/2014-09-01/bondi-hipsters-fully-sick-rapper-christiaan-van-vuuren/5707750

Unequal Exaggerations

This week I met a new patient who was unable to control quiet tears every time any of the staff walked into her isolation room.  That’s not especially surprising, being diagnosed with two stigmatising diseases (HIV and DRTB) in a country where the majority are already consumed by poverty-related stress.  I knew that as the team asked her what was wrong.  What I didn’t really get at that time, even though it is self-evident, was the tiny amounts of money which can cause extreme financial stress to people living in hardship in the third world.  This particular patient, widowed and with a seven year old son relying on her, took out a loan with a micro-finance company and needed to work to make the repayments.  But her disease diagnosis ripped her from her small job and planted her in hospital, unable to earn and therefore unable to make the repayments.  The burden was weighing so heavily that her tears flowed.

As the doctor questioned her in the hope that we could understand her stress, she explained these details.  Then he questioned her some more and she said that the repayments were 10,000 riel per month.  That equals US$2.50 per month.  He then asked how much the total debt was.  I don’t know what I was expecting to hear, but certainly not the answer she gave.

One hundred dollars.

Were my ears deceiving me?  The doctor repeated the amount and said that he understood now, why she was so tearful.  My brain malfunctioned, readjusted and recovered over the next few moments.  This small, malnourished, tearful woman was living in constant anxiety with years of repayments ahead of her, because of $100.  This seemed like such an intolerable situation that when I had time to speak with my translator I said that I felt I should help her.  Without hesitation he replied “yes, I think so”.  So with the generous donation from a friend in England on my side, I met with the micro-finance company her loan was held with and we removed the debt from her life.  Where there were once tears, there are now smiles.  I liked to think that was the end of it.  To the contrary, it was ironically only the beginning,

This morning our team met to discuss an older woman with a supportive husband, recently diagnosed with Drug Resistant TB (DRTB).  From a community known for it’s high prevalence of tuberculosis, she was diagnosed with TB ten years ago and received three months of the recommended standard six month regime.  At that time it was apparently not uncommon for patients in Cambodia to be charged for their TB medications and after three months she defaulted treatment as she could not sustain the cost.  Some months ago she re-presented with TB again.  It is quite possible that for the past ten years she has relapsed and recovered any number of times.  She was commenced on Category II treatment, in which Streptomycin injections are added to the medication regime in order to address any possible resistance to the standard Category I drugs.  This is a common problem for patients who have previously defaulted treatment (or who present with particularly severe disease).

Recently her sputum cultures, which can take up to 8 weeks to grow, returned a result of drug resistance, meaning that the medication regime has to be altered to combat the bacteria’s ability to produce enzymes which fight the standard Category I and Category II drugs.  So today a meeting was held to discuss her case and determine whether she is prepared to commence the long treatment regime.  This preparation includes medical / clinical condition as well as psycho-social preparedness for a long course of potentially toxic medications.  This psycho-social preparedness includes a good understanding of the disease and treatment, possible side effects, preventive measures to be taken against infecting others, treatment adherence, follow up and social issues such as family support and financial concerns related to the loss of employment which inevitably accompanies a DRTB diagnosis.

The medical team started the meeting with her medical history and clinical presentation.  The nursing team then discussed their insights.  The previous treatment default was a concern as it means she has a higher risk of defaulting again, but this was explained by the fact that she had previously been required to pay for the treatment.  The situation has improved markedly in Cambodia in the past ten years and patients are far less likely to come up against illegal charges for TB treatment which is supplied without cost.  Without this barrier, the risk of her defaulting now is minimal.  Time had been spent explaining the treatment regime with her and she was encouraged to speak to two other patients who have been on the same medication regime as is being recommended for her.  After meeting with these people she felt reassured that she would be able to tolerate the treatment.  The nursing team’s conclusion was that she was appropriately informed and prepared.

The social work team were then asked for their input.  The first statement made about her was “This patient is in financial crisis”.  Who isn’t, I thought to myself.  She borrowed money to start her own business, cooking noodles and selling them from her home.  She needs to continue working in order to meet the monthly repayments.  She expressed concern that the treatment may not cure her disease, and reassurance was given that TB is a curable disease, and that with good adherence and recommended follow up, the aim of treatment is cure, but it would be months before we could tell her with any certainty, whether this was achieved.  The conclusion from the social workers was that she was ready to commence treatment but that she is keen to go home as soon as possible in order to continue working so that she can meet her debt repayments.  She is required to make monthly repayments of 18,000 riel per month (US $4.50) and the total debt is US$100.  Her loan is to a neighbour, not to an organisation.  Again I found my brain readjusting to the idea of $100 causing someone long term financial stress.

Cambodia has changed my perceptions and understanding of the world in very many ways.  But this has to be the most significant yet.  How can an amount that many people from my world earn in a single hour, be so catastrophic to people in this parallel universe?  How did I never know this to be the case before now?  As I got up to leave one of my colleagues stopped me to explain that in Cambodia there are a small group of powerful people who have far too much wealth, which they keep in banks in “Sweden?  Switzerland?  No, it’s Sweden”.   They spend $20 every single day on their dogs, drive big cars and lavish various other extravagances on themselves, but they do not care at all about the people, and most of the people are extremely poor like this patient.  As he criticised this small group of Cambodians, I pondered on the position that we in the western world hold in this scenario.  Third World plights are a global issue, not separate national issues.  Cambodian people are exactly like me and if my own country’s history was anything like Cambodia’s, then I too would be surviving this fate.  Civilisations rise and fall and the West would be very wrong to assume our futures or those of our descendants will never face such struggles just because we have a comfortable existence today.  Meanwhile, being able to occasionally help someone in some small way is far more fulfilling for me than it could ever be for the recipient.  The experience for me has little to do with providing financial relief and everything to do with helping someone with an extremely inferior position in the world, to feel valued.

Meanwhile other discussions with patients have included a 58yo man whose grandchildren aged 7yo and 10yo are staying at home alone while he is hospitalised with his wife as his carer.  The children are on school holidays and they have noone to cook for them while his wife stays with him, so she spends a few days in hospital and a few days at home with their dependent grandchildren.  The children do not have a mother and their father lives at the other end of the country where he works on a rice farm, visiting his children for a couple of days each month.  I said that I would take some colouring-in books to the children when I visit them and their grandfather did not know what colouring-in books were.  Win tried to describe them to him but he had never seen such a thing and he looked blankly at us, unsure what we were talking about.

Another patient is a man in his 30s, father to two young children and employed as a teacher at his village school.  Next week he is sitting his own high school exams.  This indicates the current level of education in Cambodia.  In the 1960s Cambodia had one of the highest literacy rates and most progressive education systems in South-East Asia.  The University of Phnom Penh attracted foreign students and thousands of young Cambodians attended universities abroad, including Saloth Sar who attended a technical school in Paris for four years.  He then returned to Cambodia, where he became known as Pol Pot and led the Khmer Rouge on their communist revolution, during which 80% of the country’s academics were murdered.  By the end of the Khmer Rouge reign of terror in 1979 Cambodia had less than 50 doctors and their pool of 25,000 teachers had been reduced to 5,000.  It is hardly surprising then, that today there is a discrepant situation with high value being placed on education, but too few human resources available to meet the demand.

This situation has also resulted in the high demand placed on Barang (western foreigners) who come to Cambodia and is the reason I find myself recruited to all kinds of endeavours which I would never have considered applicable before my time here.  It seems another absurdity that those least in need of opportunity are those with the most opportunities available.  I guess it is no different to the First World, where the wealthier you are, the more educated you are likely to be and the more likely you are to know people who can help you reach your goals.  In Cambodia it is a very exaggerated scenario, which is the case with so many facets to life here.

Banana fronds and Bamboo huts

When a patient is diagnosed with Drug Resistant Tuberculosis (DRTB), measures are put in place in an attempt to cure the patient as well as to hamper the bacteria’s transmission to other people, particularly close family and household contacts.  In a third world setting DRTB mainly travels amongst the poor, who already have impaired health and restricted opportunities.  The bacteria often wastes their bodies before they find themselves placed into enforced isolation in hospital while their families are left to deal with the repercussions of their absence, which is an enormous strain if the patient is a main breadwinner or carer.  Treatment side effects can often be extreme, exacerbating the patient’s fragility so that they are left to endure physical illness combined with social and financial stress.

Many people I encounter in Cambodia are earning in the vicinity of US$1.25 per day, often in exchange for heavy physical labour.  Today I traveled to a remote village in the north of our province with a nurse and two social workers to meet with family of a hospitalised DRTB patient and discuss plans for discharge.  This included identifying a villager who is able to provide the daily Direct Observed Treatment (DOT).  This volunteer will receive basic training within our program about storage and administration of the drugs, including injection techniques and how to monitor side effects, in return for less than US$1 per day – which could and often does double the family’s income.

Including our very entertaining driver, five of us drove north out of the city, over the Mekong River and towards Vietnam.  The main road was busy with agricultural workers transporting hay, fruit, vegetables and other produce, almost all overloading the vehicle so that every motorbike, wooden trailer, truck and tuk tuk appears to be straining under the weight it carries.  Hay hangs out doubling the width of motorbikes or rises to the sky from the base of trailers, sacks of carrots ooze out of the back and over the top of trucks, ox-drawn carts lug rice as the oxen clip-clop along the busy highway apparently oblivious to the traffic weaving around them.  My eyes bulge at the evolving scenes before me while my Cambodian colleagues disregard it all in favour of chatting and laughing with each other.

Image

Kitchenwares for sale in Kampong Cham.
An example of what I mean when I say “overloaded”!

About an hour up the road we turned off the highway and drove through a busy marketplace before entering a rural village scene with elevated wooden houses and thatched roof huts, chickens pecking along the side of the road, dogs trotting amongst them, children playing in the dust and adults sitting at the top of the wooden ladders leading to their front doorways or lazing in hammocks slung between tree trunks.  We turned onto a dirt track shaded by banana fronds interspersed with towering coconut palms and after some directions offered by a villager dressed in a short checked sarong wrapped around his waist, found the family we were looking for.  The driver parked in the middle of the dirt track and occasionally children playing on a bicycle or villagers on mopeds drove around us while we stood in the middle of the track talking to the family group.  They were expecting us and about six adults with a few children were congregated in the dusty front yard.  A hen had dug a dirt nest and was trying to keep her tiny chickens in check under her feathers, while roosters and chooks pecked about under the house and through the yard.

The social workers sat on the laddered steps to the front door with some women while the father crossed the road with the nurse and I to his own yard opposite to speak separately with us.  His house was very basic but very charming, made from vertical strips of wood elevated about six feet high on wooden pylons held on small concrete blocks in the dust by the weight of the house.  The front door was made from flat vertical bamboo strips secured by about three horizontally placed bamboo strips.  Underneath the house a hammock was slung between two of the pylons, a bamboo bed base in one corner and many more pecking chooks and roosters roaming around in the dust.  He explained that his son had received a scholarship to attend a local high school.  This included a bicycle for his son to travel to and from school and some chickens for the family to raise in order to have enough food.  The social workers obtained an assessment of the family and house, to determine how many contacts the patient has, where the patient would live and sleep upon discharge home and what supports may need to be put in place to ensure the family can continue to earn and survive.  The family also identified a local villager who could be approached and asked to provide DOT.

We then drove up the shady dirt track, past neighbouring village houses and stopped near the next corner.  Myself and the nurse walked through the dusty yards of about five houses, exchanging chum reap suors with various neighbours, to the back section where the village DOT volunteer was waiting for us on a bamboo bed base under a thatched shelter in the yard with her husband and family.  The volunteer and two men sat on the bamboo base, offering us a plastic chair each, and the conversation about community DOT, or c-DOT, took place in this beautiful tropical jungle location.  Two dogs slept lazily in the dust nearby, chooks roamed and pecked, a massive pink pig oinked from a wooden pen on the other side of a thatched roof bough shelter and family members slowly climbed down the stairs from the house and came to sit nearby and listen in.  Under the bough beside us a young woman sat on a tree stump in front of a table made from another tree stump, chopping something green very finely with a machete.

The nurse and the c-DOT had a lengthy conversation about her experiences volunteering with TB patients, her availability to attend the next training, what her role will entail and the stipend she will receive in exchange for providing c-DOT to the patient.  A young couple sat smiling politely at us for a while before going over to a tall tree nearby with a very long piece of wood which they used to knock three large green coloured fruits down from the tree.  A plastic bag appeared and the fruits (oversized grapefruits called “goroetlong”) were placed into the bag which was tied and put on the bed with a smiling gesture towards me.  When we left, the bag of fruit was given to us as we all exchanged chum-reap-lears (the farewell version of chum reap suor).

Sidecars and Pyjamas

The only sidecar I ever encountered until I came here was on our television screen in the 1970s.  George & Mildred was an English comedy series which I loved as a child.  The opening sequence featured Mildred in her old fashioned helmet looking decidedly unimpressed from the low-set sidecar attached to her husband George’s old motorbike.  The scene kicked off half an hour of cheap laughs each week.  Many of the sidecars here, serving as taxis, mobile shops or freighting all manner of produce, often so heavily laden that they can only travel at very slow speed, look like they travelled directly out of George and Mildred’s 1975 garage.

On more than one occasion in life I’ve been the subject of amused derision when my not-so-well-hidden pyjamas were identified as I tried to sneak down to the shop under a winter coat, or opened the door to unexpected visitors wearing a red polka dot ensemble.  So to finally find a place where pyjamas are accepted daytime attire, is a very lucky break.

Because I hope to maintain contact with him, I will give the 12yo boy who is effectively the first patient I met in Cambodia, mentioned previously, the alias of “Tom”.  As I will also no doubt be talking frequently about my translator, I will also give him an alias – Win.

Over the weekend Tom was moved out of the Tuberculosis Department and into the General Paediatric Department.  When our morning duties were complete this morning, Win and I went to Paediatrics to visit Tom and his mother.  We navigated our way over the dozens of shoes left at the doorway, through the room furnished solely with bed bases and the occasional metal stand holding a bag of fluids.  As we stepped around shoes and people towards his bed, other parents stopped in their tracks and watched us curiously.  He is still attached to oxygen with some mild improvement to his breathing, but still struggling for air and spiking fevers.  With his mother sitting beside him in her yellow floral pyjamas and smiling affably, Tom was sitting upright on the wooden slats of a bed base looking exhausted.  He appears no better and it seems the cause of his chest infection remains unknown and probably untreated (he is on a broad spectrum intravenous antibiotic).

With Win’s assistance I learned from his mother that Tom would be much more comfortable with a proper pillow to sit up against.  His family have no disposable income and are reliant on another NGO to provide money for food whilst they are hospitalised, so I offered to purchase a pillow, to which his mother agreed.  Many “chum reap suors” were expressed as we made our way out of the congested room.

At lunchtime my Australian colleague/housemate Sarah and I cycled through town looking for a shop that sells pillows.  We headed in the general direction of the Chinese Shop because that street is a jumbled mix of wares and services.  At the other end of the street we’d had no luck so I suggested we turn the corner, into which we entered “the wild west”.  A long narrow, crooked lane crammed with food vendors along crowded footpaths, motorbikes and bicycles weaving around one another in the busy single lane running through the centre of the marketplace.  Vendors at makeshift wooden stalls laden with woks and dishes were selling birds cooked with their beaks and claws intact, baked fish crushed between long thin wooden tongs, boiled eggs and plastic bags filled with boiled rice.  In amongst these busy makeshift stalls were permanent shopfronts, one of which I spotted had a mattress sitting on top of a wardrobe at the doorway.  We stopped to look and the merchant came out and greeted us with “Hello”.  His five year old daughter sitting on the footpath in her blue and white school uniform called out “Hello!  How are you?!”, eliciting a surprised reply.

Back out on the street a few moments later I wedged my new thick pillow into the basket of my bike, commenting on how local I felt with an oversized item bulging from my designated set of wheels.  We cycled back onto the main boulevards, and towards the hospital where I veered off into the Paediatric Department to deliver Tom’s new pillow.  At the time of delivery, Tom was sitting across the corner of his bed and the window it is adjacent to, his thin protruding shoulder blades resting directly against the window’s iron bars, and his mother was curled up asleep on the wooden slats of the bed.  I hope the addition of a pillow means that he and his mother both get to sleep a bit more comfortably tonight.

This week Médecins Sans Frontières have representatives at the International Union Against TB and Lung Disease (IUATLD) World Conference on Lung Health in Paris, where they have advocated for the desperate need to improve approaches to treatment for Drug Resistant Tuberculosis (DRTB).  An insidious infectious disease when it is susceptible to treatment, Tuberculosis that has learned mechanisms to resist the few effective drugs we have to fight it, is a genuine threat to the human race.  It is something that we should all care about if we care about the future of generations to come and none of us should assume immunity just because we live where TB is currently not prevalent.  Drug resistant TB has and will continue to gain a foothold on populations everywhere.

For this reason, today I signed MSF’s TB Manifesto, alerting the global community to the urgent need for improved diagnostic methods, treatments and preventive measures against DRTB.  Currently the treatments available for DRTB are a complicated mix of ineffective and expensive, with side effects so severe that many people prefer to die than endure two years of treatment.

Please learn more about DRTB and join the 1,002 people who signed the manifesto today.
http://www.msfaccess.org/TBmanifesto