Rocks and Hard Places

If I had to pick a pivotal milestone during my daily experiences in Cambodia, I would probably pinpoint the boat trip with Mum and Ruth in January 2014.  It was my first holiday, three months into my assignment with Medecins sans Frontieres.  Since landing in Phnom Penh I’d been bombarded by sights which did not immediately make sense to my rich world brain.  Adorable tiny babies who could walk and talk initially captivated me.  The genesis of their adorability however, is acute-on-chronic malnutrition caused by severe deprivation.  Astonishing sights on the roads, of vehicles loaded beyond imagination, were highly amusing.  Until my thoughts processed that these dangers are the result of people doing everything within their power to earn enough to feed their families.  At the hospital many people literally died of starvation before my eyes.  Children out of school, the elderly, blind, amputees and those with deformities and disabilities seemed very visible and behaved in ways which were unfamiliar to me.  Walking the streets with a sense of determined purpose, foraging for something to eat, or for something to sell in order to eat.  Many sleep rough in the city’s streets.

Perhaps it was the fact that everything was happening on water rather than land, that the sights along the Sangker River and across the huge Tonle Sap lake between the cities of Battambang and Siem Reap, seemed so striking to us?  We spent eight hours traveling on an open air boat through riverside and floating villages, dismayed by the scenes of poverty and simultaneously fascinated by the bustling activities all happening on this endless body of water.

Shopping on the waterways of Sangker River, January 2014

Shopping on the waterways of Sangker River, January 2014

Our journey set sail on the outskirts of Battambang city.  Less than a year later Roka village, a short distance west of the city, with a population of around 800 people, made international headlines.  In November 2014 a 74yo TB patient from Roka tested positive to HIV, a routine test in any TB diagnosis.  With no risk factors for HIV he became concerned and his family also sought testing.  His son-in-law and grandaughter also tested HIV positive.  The family alleged that injections from a local unlicensed practitioner were to blame and encouraged others who had visited this medic to get tested.  30 new HIV notifications from within or close to Roka were reported in December 2014, compared with four new notifications for the whole year preceding this.

Experts from a Phnom Penh university and the National Centre for HIV/AIDS, Dermatology and STIs (NCHADS) immediately formed the Roka Cluster Investigation Team and traveled to the village.  Over 8,000 residents living in the area around Roka were tested and by February 2015, 242 new cases of HIV had been diagnosed.  Analysis of the blood samples confirmed that most infections were recent and that a single HIV strain was responsible for the outbreak, meaning they all originated from the same source.  Many had no risk factors at all, including young children born to HIV negative mothers and 4yo twins, only one of whom was HIV+ on testing.  There was a significant association with the administration of intravenous fluids or injections in those who tested positive.

A significant number of victims also tested positive for Hepatitis C virus, which is also associated with unsafe injecting practices.  Until very recently Hepatitis C, which ultimately leads to cirrhosis and liver cancer, has been extremely difficult to treat.  This year the Australian government approved the use of brand new treatments which can cure the virus with few if any side effects.  Australians infected with Hepatitis C can now access these drugs free of charge on the Pharmaceutical Benefits Scheme.  Each short course of treatment costs in the vicinity of $80,000, meaning the drugs are inaccessible to most people in the world.  Obviously villagers in Roka have no way of receiving such treatment although Medecins sans Frontieres are working at implementing a program to make the drugs freely available to a cohort of Hepatitis C patients in Cambodia.

The self-proclaimed “doctor” at the heart of the Roka outbreak was 55yo Yem Chroeum who has since been sentenced to 25 years imprisonment on charges including murder and knowingly infecting people with HIV.  He is accused of reusing needles and syringes on multiple patients.  Chroeum received informal training by a foreign doctor in a Thai refugee camp during the 1970s/1980s.  He returned to a distressed country decimated by genocide and civil war with 25 surviving qualified doctors, most of whom could or would no longer practice medicine.

Immediately after World War II ended the USA shipped billions of tonnes of food to Western Europe and Japan before implementing more long term economic supports to rebuild both regions which were considered paramount in preventing the spread of communism from Russia and China.  Both regions became powerful economic forces despite their war time devastation.  Cambodia on the other hand, “liberated” by the communist Vietnamese in 1979, has suffered an entirely different fate.  The entire Western world enforced economic sanctions and blocked almost all foreign aid to the country, effectively debilitating the nation until the Paris Peace agreement was signed in 1991.  Their opportunities to rebuild and prosper have been severely hampered.

Chroeum settled in Roka in 1995 and was allegedly a popular medic among villagers, reputedly skilled at treating fevers.  He maintains his innocence but has admitted to reusing equipment.  However, according to Centers for Disease Control, 99.7% of needlestick injuries involving HIV-infected blood do not result in transmission, so reuse of infected equipment alone does not seem to account for the outbreak?  Since his arrest Chroeum’s family have suffered social isolation and financial hardship.  Without their father’s income and as many villagers now refuse to buy from the family shop they struggle to pay for his prison meals which are not provided by the state.

Intravenous infusions are a highly popular treatment for all ailments in Cambodia.  Bags of fluid suspended from bamboo poles traveling through the streets are a regular sight as patients cruise on the backs of motorbikes while they wait for their infusion, delivered by the many local private clinics, to finish.  Some Cambodians have told me that if a clinician does not offer intravenous infusion as part of the treatment for any ailment, they are not considered authentic.  In a country so poverty-stricken, under-resourced and under-trained it is amazing, with so many intravenous lines being inserted, that more service-acquired bloodborne virus transmission does not occur.  In fact, Cambodia have been highly successful at reducing their HIV prevalence rate which peaked at 2% in the mid-1990s and is now down to around 0.4% of the population.

Almost 300 people linked to the Roka outbreak have been diagnosed as HIV+ and at least 16 have died, mostly infants or the elderly, who are less able to contain the infection and/or unable to tolerate the side effects of anti-retroviral treatment (ART).  ART medications are provided free of charge via the Global Fund but all other health interventions cost money and many have had to sell land, livestock and other assets in order to pay for medical expenses.  Many have fallen victim to theft as illness has made their homes and livestock vulnerable to opportunistic crime; many are also too sick or too weak from medication side effects to work, intensifying their financial hardship.  Stigma and discrimination, travel companions of HIV and other bloodborne viruses in the most privileged and educated of societies, have stamped their mark, with many first hand reports of ostracism within and beyond Roka which also severely affects peoples’ livelihoods.

In response to the outbreak, the government cracked down on unlicensed health care providers.  Cambodia has a total of 3,000 qualified doctors for a population of 15 million.  This is comparable to the proportion of doctors in Afghanistan and contrasts with Australia where we have 70,000 qualified doctors for 20 million people.  With such inadequate services, 70% of Cambodians seek health care from unlicensed providers and many have never seen a qualified doctor in their life.  The official health system is so fraught with problems that it cannot guarantee a better quality of care anyway.

These are the realities of what it means to be impoverished.  Lack of individual money is only one aspect to a widespread societal issue relating to options and opportunities which are tangled up in historical considerations, education, economics and politics.

As the experience in Roka demonstrates so acutely, poverty is an expense that society cannot afford.



A Tale of Two Cities

Best of Times
In 1843 a survey was conducted in London which found that only 26 of the city’s 2,400 hospitalised patients were children.  Yet in the same year, of 51,000 deaths recorded in London, 21,000 were children under the age of ten and one third of London’s children died before their first birthday.  Clearly there was a need for paediatric inpatient care, but children were generally kept at home even when seriously unwell.  In 1848 Dr Charles West published Lectures on the diseases of infancy and childhood which remained an authoritative medical reference for the next fifty years.  A powerful orator and renowned physician, he fundraised the money to establish ten hospital beds dedicated solely to the inpatient care of children, opening in 1852 at 49 Great Ormond St in Bloomsbury.

London teemed with the poverty, inequality and injustice chronicled so potently by Charles Dickens, who was publishing novels such as Bleak House and Hard Times at the same time as Dr West was treating the poor.  Almost all of Great Ormond St Hospital’s patients came from the surrounding slums of Clerkenwell, Holborn and St Pancras.  Charles Dickens was a staunch supporter and benefactor of Great Ormond St Hospital, acknowledging that it was the only public institution dedicated to saving the appalling waste of human life suffered by London’s children.  His public reading of A Christmas Carol at a festival dinner in 1858 raised enough money to purchase the house next door, allowing the hospital to increase it’s capacity to 75 beds.

Since that time, Great Ormond St Hospital (GOSH) has grown exponentially, opening it’s own School of Nursing in 1878 and a Medical School ten years later.  Many pioneering medical researchers and practitioners lived their careers out at GOSH.  JM Barrie, author of Peter Pan, donated the rights of his famous book to the hospital in 1929, claiming Peter Pan had been an inpatient there and “it was he who put me up to the little thing I did for the hospital”.  Princess Mary, the only daughter of King George V and Queen Mary, completed her nurse training at GOSH, as did Princess Tsahai, daughter of Haille Selassie, after fleeing Ethiopia when Mussolini invaded in 1935.  Princess Mary became the President of GOSH some years later.  Princess Tsahai returned home in hope of using her skills to develop child health services, but died from meningitis at the age of 24.  Britain’s founding child psychiatrist, Mildred Creak became GOSH’s first female medical consultant in 1940.  Many firsts have happened at GOSH since that time, including the UK’s first Paediatric Neurosciences Unit in 1959, the UK’s first Leukaemia Research Unit in 1961, the world’s first heart and lung bypass machine for children in 1962, the world’s first successful bone marrow transplant on a child in 1979 and numerous other pioneering interventions.

Princess Diana became President of the hospital in 1989 until her death in 1997.  I traveled to London for an interview at the GOSH School of Nursing in August 1997.  During my two week visit Diana was killed in Paris.  My interview and pre-admission exams were some time before the funeral.  We were taken on a tour of the hospital which included the hospital chapel where an arrangement of lilies with a message from Prince Charles, William and Harry to staff and patients sat poignantly near the altar.  After being accepted into the year-long Registered Sick Children’s Nurse course at GOSH, I learned some months later that visa entitlements meant I could not undergo the training as planned.  This was devastating at the time, but I likely would have followed a very different career path and perhaps never experienced Timor and Cambodia, which have been so dramatically life changing.

Today GOSH is infamous as a leading world paediatric treatment and research centre.  The GOSH Facebook page is filled with features on sick children, often with rare conditions, receiving world class care and attention.  In mid July when video footage of this sculpture hooked to a crane, flying in the London skies and landing on the roof of a new state-of-the-art facility at the GOSH site, appeared in my news feed, I felt at once heartened – for those able to receive the care they deserve; and saddened – for those who will never experience such care.

GOS swan

Today a beautiful swan sculpture created by artist Chris Brammall ‘flew’ into place on top of the Premier Inn Clinical Building, part of the Mittal Children’s Medical Centre at GOSH. The 4m long steel sculpture is the first artwork to be installed in the building and will be visible from patient bedrooms when the building opens next year. The sculpture is dedicated to children and families affected by Syndromes Without a Name, commonly referred to as SWAN, and echoes the building’s natural world design features.

In particular, I thought of Samantha’s almost 3yo son in Phnom Penh.  He probably has a known genetic syndrome, but because there is no way of diagnosing him in Cambodia, it remains unknown, putting him into the same classification as a child affected by SWAN.  Rather than receiving state-of-the-art care, at times he has been turned away from receiving any care at all, in an underfunded and resource-starved system which allows discrimination and neglect, relying on the individual standards of health professionals who receive varying degrees of training and supervision.  Deprived of the most fundamental resources needed to provide a basic level of care, people’s energy is spent resolving a multitude of complex structural problems.  In my own experience, when in a single day at work there is no running water, no way to fix sewerage leaking out of the ground near your patients, and no oxygen supply for patients with respiratory disease, your ability to care for patients is reduced and you develop a level of powerlessness.  Contending with a barrage of such problems on a daily basis can erode your spirit, although it offers the opportunity to develop keen problem solving skills which are redundant in the comfort of first world health care settings.

This week’s news from Cambodia included a broken hearted email from a Khmer doctor involved in an advocacy capacity with HIV+ children who I know and have worked with.  The adults caring for these children are not medically trained and have naturally put their trust in the medical staff dealing with their HIV treatment.  The children are being taught to be independent in their daily medications and so it took some time for an adult to notice that the tablets in one of the children’s bottles were broken roughly into halves, quarters and crumbs!  This caused the carer to look closely at the other children’s medications, finding another child has been taking already-expired tablets.  Thankfully, with a doctor advocating for them, the carers are empowered to speak with the treating doctors and ask for rectification.  But how many children in impoverished places are not in the care of literate adults who would notice a problem in the first place, let alone feel confident to question or challenge health professionals who sit in positions of power at clinics and hospitals?  It would be easy to think that this somehow reflects the character of Cambodian health professionals but I disagree.  Over the years I have worked with hundreds of nurses and doctors and it is only the well resourced standardisation of our system with it’s protections and quality processes, which shields any of us from the same flaws which exist in any group of individuals.

Had Charles West and Charles Dickens been alive in today’s globalised society, the unequal status quo of the world’s children would have been unacceptable to them.  The poorest of the world’s poor may no longer be London-based, but they are still afflicted by appalling suffering and loss of life, which ultimately hurts us all.  In this age of cutting edge innovation and prosperity for those of us living in the best of times, those experiencing the worst of times are no less deserving.  Former US President Ronald Reagan advocated for international aid as a way of promoting economic growth and democracy.  The aid America provided to Germany and Japan after World War II stands as an excellent example of two potentially unstable nations becoming important allies and trading partners, whose prosperity has in turn benefited the rest of the world.  International growth and development, particularly the small investments needed to make significant change in the poor world, serves us all.

My observations of local life in Cambodia have regularly evoked comparisons with what I know of Dickensian London and it’s disparities between a powerful minority and the vulnerable teeming masses.  The difference today is that the wealthy minority is just as likely to be foreign onlookers of poor nations (in person or via the media), as it is to be that nation’s local elite class.  We – including those who consider ourselves common battlers – are today’s “high society”, purely thanks to the systems that work in our favour to ensure we  have shelter, food, education, opportunity and services.

Doctor Charles West, in his everyday approach to other people, showed us how we can capitalise on our privilege for the benefit of everyone.  Small sacrifices at both national and individual levels can make the biggest difference to those in need.  The alternative seems to be, to take on the role of Ebeneezer Scrooge, Dickens’ cold-hearted moneylender who despised the poor and approved of their suffering.  Even Scrooge eventually realised the selfish benefits of generosity and changed his ways.

In commemorating the 200th birthday of Charles West on 9 August 2016, GOSH said:
Today we’re celebrating the bicentenary of our founder Dr Charles West. Dr West was driven to found a specialist children’s hospital in the 1850s after being appalled by the extent of sickness among children of the poor in London. Dr West was loved by the patients he treated – he never prescribed a foul tasting medicine, always ensured his instruments were warm before using them, and had a drawer full of toys in his consulting room that was ‘accidentally’ left open. Happy birthday Dr West!

Giving to end poverty

Not Out Of The Woods Yet

But it seems that the remaining project now, is to cram my belongings into a case and meet my travel companions

~  Famous Last Words By Me
A Couple of Hours Ago

Proof reading the final version of my last blog post less than two hours ago, this happened.

Finding the words for a blog requires silence, peaceful frame of mind, a little comfort and few interruptions.  There’s a cafe nearby with air conditioning and today is particularly hot so I was hiding away in the cool, writing.  Unexpectedly a Khmer friend opened the door and began waving in an elderly woman who I often see around town with a sack on her back, searching for cans and bottles to sell.  An American couple had given my friend some cash for her and he had come looking for them to show them she had received their donation.  They were not here but I was.  I’ve often watched her and wondered.  Why are her legs deformed?  Why does she scavenge, surely she has children who could look after her?  He encouraged her in and asked me to photograph her with the money, as evidence to the Americans.  She removed her krama which sits curled around her head as she wanders the streets and smiled for a couple of photographs.  I offered her a drink and she asked for Coca Cola!  A seventy two year old Cambodian woman sitting across from me drinking Coca Cola – that’s another “first”!

As she sipped her Coke, my friend translated for me.  Her husband died during Khmer Rouge.  They had three children.  Her sons were called to military training in the 1980s and were both killed by landmines at that time.  Eight years ago a motorbike crashed into her while she was out scavenging.  Three bones in her legs were broken and she was hospitalised.

Her daughter had just given birth to a fourth child.  Worried about her mother, she walked with the baby to visit her mother in hospital.  With assurances that she was fine, her mother sent her home to care for the four children.  She walked the 3+km home again.  The next day she was dead, I guess from a post-natal haemorrhage exacerbated by the long walk?

With no way of feeding the baby, she soon became unwell.  They took her to a doctor who offered to adopt her.  She has not been seen since.  The children’s father left to marry another woman, leaving his remaining three children in the care of their grandmother.  He has since also died.  To feed her three grandchildren aged 6yo, 10yo and 12yo, she walks the streets scavenging.  She is indebted to a villager who provides her with rice.  She takes the sacks of bottles and cans to this villager as repayment.

We went in the tuk tuk together, picked up her two bulging sacks of recyclables, and drove her home.  I will repay the debt for her and bought her a 50kg bag of rice, which will last the family a month.  I asked for her expenses which come to $85 per month.  Sending each child to English classes would be an extra $12 per month at $4 per child.  We left with the promise that I will try to find people in Australia willing to sponsor her so that she doesn’t have to walk the streets scavenging anymore.

If you are interested in helping this family, it would only take four people to donate US$30 per month (to cover bank and GoFundMe fees) allowing this tiny beautiful woman some security and dignity in her final years.  When I am not in Cambodia this can be reliably entrusted to one of my loyal Khmer contacts, with regular updates.

The same crowdfund page will work for this:
Help a Cambodian Family

It may not work but given the achievements we’ve had so far with so many projects, it’s worth giving this a go!  I promise that my final project is now definitely just to pack and leave.

Meanwhile, correspondence with a friend in Australia is also worth sharing:

I reckon we can do better than this. I’m reflecting that cuts to Australia’s aid budget are implicated in sad stories like this… my own offer to volunteer in Cambodia through Red Cross was turned down because Australia couldn’t afford to let me volunteer through Australian Volunteers in International Development (AVID – AusAID funded).

Most Australians don’t realise how little we spend on foreign aid, and how much it can achieve. Personal stories like this might help not just your poor lady but thousands of others.

Interestingly we donate much more personally than we do as a country, yet a co-ordinated aid program sounds so much more valuable than each of us forking out a little bit for this lady who had the good fortune to meet you.

How about an open letter to (politicians).

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