Sometimes The Battle …

Wealth like ignorance

Sometimes whilst blogging I go searching for the right quote to fit my reflections.  This quote seemed perfect for today’s story relating to the small Islamic community I am currently working with.  I had never heard of Ali ibn Abi Talib, who according to Wikipedia “…. was the cousin and son-in-law of Muhammad, the last prophet of Islam. He ruled as the fourth caliph from 656 to 661, but is regarded as the rightful immediate successor to Muhammad as an Imam by Shia Muslims”.

Innocent misinformation stemming from poverty continues to throw regular blows at me from left field with scenarios such as today’s encounter seeming inconceivable and taking my slow first world brain some time to process.

In my March 12 blog I first mentioned, under the heading of Infant Feeding, the baby I met early in February when she was just 18 days old, whose mother had been supplied a free can of artificial infant formula by the maternity clinic.  Mum’s ability to breastfeed had already been disrupted when we met.  Mum is illiterate and was struggling to feed the baby using bottles.  Since then my colleague and I have put in a great deal of effort including some community level education to promote breastfeeding, but also teaching this mother 1:1 what to do around how to make the milk; volumes and frequency of feeds; cleaning equipment; monitoring baby’s faltering growth; and preparing for changes in feeding instructions as baby gets older.  We have also devised, with the support of a nutritionist colleague in Australia, a poster with pictorial instructions to reinforce what we are teaching.   Soon I will leave Cambodia for a few months and my untrained colleague is going to have to pick up the responsibility of monitoring and supporting this mother, and probably many others, so the teaching material will serve a dual purpose.  Some of our lessons have included:

  • Powder to water ratios.  These are specific depending on manufacturer instructions which require a level of literacy and numeracy that Mum does not have;
  • Requirement to add the correct volume of water first, followed by the correct number of scoops of powder.  This ensures accuracy of the required ratio, which is usually 30ml water to one scoop or 60ml water to one scoop, depending on the written instructions on the can.
  • Reassurance around the confusion that the ratio instructions can cause.  For example, if baby needs 150ml volume of milk, but powder to water ratio is 1 scoop to 60ml, then 180ml water should be measured out then 3 scoops of powder, being the nearest correct measurement to ensure an adequate feed is made.  This not only leads to some wastage, but the three scoops of powder also increase the volume of liquid in the bottle to more than the initial 180ml.  All of this can be quite confusing to the untrained mind.
  • Discard remaining milk which baby will inevitably not drink if the volume is too much, in an environment where there is no refrigeration.  This is a difficult instruction for a mother with extreme financial constraints, but necessary to avoid the opportunity for, and dangers of, bacterial growth.
    [21 March: I’ve since realised that she likely does not discard anything and it could be why baby got diarrhoea, if she is saving leftover formula in the heat.  So on advice from my mother I am going to suggest that she take any leftover out of the bottle at the end of a feed and give it to her 5yo, perhaps added to rice].
  • Proper cleaning of bottles and teats.
  • Recommended volume and number of feeds per 24 hours, which changes (at times rapidly) with age.

This mother could have breastfed her child freely and safely if she lived in an environment where breastfeeding is supported, rather than an environment where artificial infant formulas (aka “breastmilk substitutes”) are ruthlessly marketed.  We have since invested many hours informing her appropriately so that she can protect her child from all manner of risks associated with bottle feeding in an impoverished environment.  Everyday that I work on this activity, I wonder at the thousands and probably millions of other mothers around the world who have fallen prey to the marketing of breastmilk substitutes.

It is impossible to reflect on the victims of this global horror without simultaneously wondering at its beneficiaries.  In May 2016 World Health Organisation published a document Guidance on Ending the Inappropriate Promotion of Foods for Infant and Young Children.  WHO predicted in 2016 that by 2019, the market value of breastmilk substitutes would reach US$70.6 billion.  That’s some extreme wealth being accumulated somewhere.  Certainly not anywhere on the shores of the Mekong River where I tread, and where the chances of living safely let alone in comfort, are asphyxiated by all manner of adversity.  WHO also stated that women and children have the right “to be free from inappropriate marketing of baby formula and related products”, which are “not in the best interests of maternal and child health”.

It still astonishes me that the “Baby Killer” scandal of the 1970s never really ended; that I ever believed, after reading of the global response to this scandal during my studies almost 20 years ago, that it had been resolved; and that in 2019 I now find myself working so closely with its ongoing ramifications.

Today when we met this mother and weighed her baby, the promise of her growth pattern improving had vanished and this week her weight has plummeted.  As I pondered on what might be wrong given our intense efforts, Mum spoke at length in Khmer with my colleague.  I then received a translation that – again – left me in a state of shock.

On Sunday, some weeks after Mum began following our instructions for bottle feeding, baby developed a distended abdomen and some diarrhoea.  Mum took her to hospital.  In hospital she was told that the reason her baby got sick, was that she was not making the bottles correctly, and was given a completely different (and incorrect) set of instructions as follows:KF 20 Mar 001 (3)

If you plan to give your baby 60ml of formula, fill the bottle to the number 2 with powder, and then add water until it reaches the number 60.  If you plan to give your baby 90ml of formula, fill the bottle to the number 3 with powder, and then add water until it reaches the number 90“.  And so forth.  Thankfully the relationship my colleague has with this family means she was able to encourage Mum to follow our instructions and ignore the hospital staff’s unfathomable advice.  Not before 3 days of incorrect feeding on top of a bout of diarrhoea had worsened her previously-improving malnutrition.  During our conversation Mum also asked, “why is she vomiting a lot now?”.  How long has she been vomiting?  “Since two days ago”.  It was useful information to help convince her that the hospital’s instructions were obviously incorrect and had upset baby.

As an aside, but keeping with the theme of the power of marketing, Cambodia’s Ministry of Health announced recently that cases of the mosquito-borne virus Dengue Fever are expected to rise markedly this year.  Media reports have stated that in 2018 approximately 25,000 people fell ill with Dengue Fever in Cambodia, 23 of whom died.  Today with my colleague translating, we delivered a community education session to five women and 18 children, on Mosquito Prevention.  One of my messages, relating to female mosquitoes relying on blood to nourish their eggs, was around the fact that male mosquitoes feed on flower pollen whilst female mosquitoes feed on human blood.  The presentation on my computer screen included the following two slides:

At the end of our session we held a quiz with some prizes to those with the fastest correct responses.  When we shared the cartoon captioned “Only female mosquitoes bite” we asked, what is the boy mosquito drinking?  A crowd of children shot their arms into the air and my colleague translated (unnecessarily), “they think he is drinking Coca Cola”!

In the midst of it all Cambodia’s only three helicopters, which I talked about in my 15 February blog post, once more flew directly overhead, forcing a pause in our quiz game while we waited for their raucous chopping to pass.

I came home, lay on the couch and slept for two hours.  Because sometimes the battle…..

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Catastrophic Cycles

Corruption in Health

This cartoon derives from a 2015 article about an anti-corruption exhibition organised by Transparency International Bangladesh.  TIB arranges 10th Anti-Corruption Cartoon exhibition at Drik Gallery.  It illustrates the user-pays health care system prevailing across the poor world in which health professionals are enriched on the backs of an already impoverished general public.  “Without money you die” are words spoken by doctors and nurses as a matter of fact to patients on a daily basis here in Cambodia.  Their words reflect reality as people suffer and die in all manner of unimaginable ways due solely to a lack of money, many leaving their families behind with an inheritance of crushing debt.

Many of the doctors prospering from this system have received training in wealthy nations whose intention, I am sure, is to promote quality care in places with limited means.  I am equally sure that few involved in offering the various scholarships and other opportunities understand that they are often serving to further empower oppressive systems.  This could be regulated at least in part, by placing certain conditions on the beneficiaries of such training and by requiring some level of monitoring, as exists in countries where the public do have safeguards.

For many in Cambodia, the only option for health care comes in the form of NGOs, of which there are many yet there are not enough and for which there is little to no coordinated collaboration between services.  Brief and temporary services are also offered by various visiting organisations as a form of stopgap and often as a means to offer further training to local staff.  As someone trained in public health, familiar with health systems, experienced in sourcing services for clients, and with access to resources, I do not navigate the health systems in Cambodia easily because there is no centralised point of communication about what is available and where.  There is limited governance so that private businesses can impersonate NGOs with impunity and a black market offers all manner of medications and supplies, even anti-TB medicines which require strict regulation for protection against bacterial resistance.

When the education system started from scratch in 1979, 75% of all teachers and 95% of all tertiary students had been killed in the Khmer Rouge genocide.  Forty years on, through decades of political and economic turmoil, the education system is still re-establishing.  Teachers in public schools, many of whom are based in dusty rural villages with few to no resources, earn a low income and have unclear levels of training.  Teacher salaries are so low that students are required to pay a small daily cash fee to ensure a livable income.  In many families cash is often unavailable, affecting school attendance rates as much as the bare, dusty and overcrowded classrooms must.  Insufficient family income further encourages the mass exodus of  children from school before their literacy has been established as children are needed to help support the family.

Ignoring the multitude of other complex factors at play in Cambodian society, this alone offers explanation of the low levels of literacy and numeracy and high levels of hardship seen in rural villages and urban slums here.  Children pulling wooden carts looking for recyclable materials to sell; parents labouring for low casual wages far away from their young families; and perhaps more worryingly, young people vulnerable to persuasion by all manner of dubious employment offers, all stem at least in part, from the need created by an inadequate education system.

The population survive (and perish) in a micro-economy where even the literate and educated face challenges that are unheard of in the wealthy world.  The fact that accomplished, qualified and experienced doctors, engineers and architects can face high rates of unemployment is perhaps the most remarkable example.

This background of necessity leads to any number of inventive and creative enterprises.  Profiteering from health care services delivered with inadequate regulation to a population with deficient health literacy is probably the biggest and best example among many, of this inventiveness.

Alongside the perpetual need endured here, is a chronic state of systemic corruption.  As a colleague said to me some years ago “I feel upset when foreigners accuse me that I am from a country of corruption.  They feel okay to challenge me but then they show big respect to the high ranks who ARE corrupt.  I am not corruption.  I am the victim of corruption”.  It is important to understand this because those of us from countries where corruption (which is never non-existent) exists at lower levels, or in a more hidden form, can be quick to judge local people without understanding the situation.  In fact, individual corruption, although it also exists, is not the real problem, but rather systemic corruption which is established from the top and filters down through the various institutions.

After 2.5 years living in Cambodia I still have a very basic understanding of the way that deficient systems provide an ideal environment for corruption to become institutionalised and normalised.  Talk of purchasing black market medications to treat a patient for example, sounds shocking until you understand that the doctor speaking to you wants to cure his patient, and understands that his patient cannot afford to (and therefore will not) attend the established health facility who could provide regulated medicines.

Example 1: Infant Feeding

I provided the above background in an attempt to explain why it is necessary to recognise that not everyone employed inside corrupt institutions or engaging with corrupt systems, is corrupt themselves.  Often at an individual level there is no other option.  Not everyone involved in corrupt systems is aware of the role they are playing, or has alternative choices, or is even necessarily doing the wrong thing by others, at least not consciously.  Many are as much the casualties of their nation’s established need and chaos, as anyone else.

Last month I encountered an eighteen day old baby lying asleep on the bamboo strip floor of a little hut.  I was busy assessing her mother’s four year old in the dirt on the Mekong shore, who appears to have some form of polio-like condition.  Only after I finished “playing” with this little girl, did her mother announce “I also have a new baby”.  Big brother moved further inside the open walled hut and reappeared with his tiny sleeping sister.  Enquiring about her health, Mum presented me with a blue tin of artificial infant milk powder and stated “I don’t have enough breastmilk”.  Over the years I have learned that this is a common phrase used in maternity clinics here to promote the sale of artificial infant milk.  Even educated doctors have told me “I am mix-feeding because I don’t have enough breastmilk”.

Training mothers that they “don’t have enough breastmilk” commences on Day 1.  My guess is that health professionals who probably know otherwise, use misinformation to train uneducated staff to undertake this work, as a way of boosting artificial milk sales.  It all happens at a highly emotional time for new mothers, before breastmilk production and a feeding pattern can be properly established, and before weight gain or urine output can be monitored as ways to gauge whether the baby’s intake is adequate.  There is a wealth of understanding today among health professionals, of the health benefits of breastfeeding for both mother and child.  Equally, we also understand the strong influence that artificial infant milk promotion has on breastfeeding rates even in countries where this promotion is strictly regulated, and where the population have sound health literacy with access to reliable information and support systems.  As this infographic illustrating the stomach size of a newborn baby shows, the statement that a new mother “doesn’t have enough breastmilk” is probably almost always false.

Infant Stomach CapacityClearly the Baby Killer scandal of the 1970s continues unabated today in parts of the world where necessity and chaos reign supreme.  Since meeting 18 day old, who is now seven weeks old, I have learned a lot.  When we met her again at 5 weeks old the blue tin of artificial milk powder had been replaced with a green tin.  My translator informed me “The maternity clinic donated the blue tin to her, but when she went to buy it, it was too expensive so she bought this one because it is cheaper”.  Mum, who cannot read or write, was still following the instructions from the maternity clinic about how to make the milk and how much to give.  These instructions are appropriate to newborn needs which change rapidly over the first few months, requiring some level of health literacy and ability to read instructions, to implement.  This explained her very unsettled and hungry baby’s advancing malnutrition.  Working with her to address the problem, I contacted a nutritionist colleague in Australia who further investigated, finding that this particular company offer “infant milk” formulas up to the age of six years old, when normal cow’s milk can be safely introduced from 12 months old.  The market for artificial infant milk – very likely still responsible for many infant deaths – is clearly a very lucrative one.

We continue to work with this mother, and monitor baby whose growth pattern has started to improve with a little education and support.  We are also working to encourage establishing breastfeeding as the accepted norm in her small community, including strategies for women to respond when placed under pressure to use artificial infant milk.

Example 2: Curative Potions

A few years ago I spoke about Joe, who died slowly from probable post-Polio syndrome, lying on the hammock inside his falling-down banana leaf-walled, bamboo-floored hut in a remote village.  Just after Joe died, I learned that his family had sold their cows to purchase a medicine from a visiting salesman who promised his remedy (which sounded from the unreliable translation, like a human colostrum formulation) could be curative.  The same day that I heard this story, the guard at my hotel told me he had a day job as well as his night job, selling something for a “medicine company”.  Earning US$100 per month offering security services in the evening during the hotel’s busiest hours, he slept on the restaurant couch at the locked front door of the hotel by night.  He was pleased to have found a second job as a salesman to supplement his main, barely-livable income.  He spoke about it openly and even with some pride that a medicine company would employ him.

It is almost five years since I met Paula, age 25 and weight 20.8kg in May 2014.  Her story has been covered in various blog posts since that time as she had such a profound affect on me.  As did the incredible serendipity of encountering an American surgeon with the skills to cure her hospital-acquired injuries, in the company of some people with the capacity to cover the cost of getting her to America.

The first time I met Paula’s father was in May 2014 when he appeared before my eyes carrying an unrecognisable bundle towards me on the hospital verandah.  The shock I felt when I realised it was a human in his arms, is embedded in my brain.  The last time I saw him was at Phnom Penh Airport when Paula was lying on a stretcher waiting to enter the departures lobby for our flight to the surgeon in Seattle.  Since then her father has been living in Malaysia, selling food at a street stall in order to pay off the family debt incurred by the various and injurious treatments that Paula received prior to arriving at our service and learning her condition was not cancer, but rather drug resistant mesenteric TB.

A few weeks ago an email from the Seattle surgeon’s wife included the words “I hope she is giving back in some way“.  My internal, unspoken response was “if she had an education and some opportunity she could“.  A few days later I received a message from Paula’s family that her father had returned from Malaysia and could I plan to visit him?  I took a weekend trip to Kampong Cham and traveled out to their village to meet him.

Paula, now in full health, was away but her parents informed me proudly that she has a job.  My tuk tuk translator said “she sells something for a medicine company.  Something to drink.  If she sells enough she can get high salary but if she does not sell enough, only a low salary”.  An uneducated and impoverished villager selling medicine for commission?  I slowly registered that rather than “giving back” in any way, she is unwittingly engaged in the damaging private business of defrauding illiterate and desperate villagers!  My Khmer friend who was in Seattle with us responded with disappointment that “rich people often get benefits from poor people”.  She has promised to contact her today to “talk about this”.  It is highly likely that she has received some form of training via her employer that whatever it is she is selling, has curative properties.  There would be little reason for her to understand otherwise given her own lack of education and every reason for her to want to believe it, as her way of earning an income.  Despite her extraordinary life-saving American experience she remains a casualty of the chaos and necessity that Cambodia’s population are immersed in, living inside the cycle of catastrophe that poverty guarantees.

Necessity is the mother of Invention;
Chaos is the mother of Corruption.

Trash To Treasure

She lives in a tin hut in a back alley filled with makeshift shacks stacked beside and atop of each other.  Roosters crow, ducks, chooks and skinny kittens peck around for morsels in the same muddy piles of trash, dogs laze in shaded patches, and pigeons coo from a cage.  A neighbour is crouched over a bucket of soapy water, scrubbing clothes.  Suds spill over into the dirt as we step over the rivulet of foam trickling downhill and seeping slowly into the damp soil.  She broke her wrist about two months ago.  I ask did she see a doctor?  “No, she has no money for that”.  Does she have any painkillers?  “No, she has no money for that”.  How long ago did it happen?  “Maybe two months”.  How old is she?  “Eighty eight”.  At the nearest pharmacy I purchase a 75c sheet of Paracetamol and we give it to her for the pain.  Her friend is hunched over awkwardly and when it comes time to tell her story, she lifts her shirt, showing a spine crumbled into a hunched back which she explains happened after she started treatment for TB three years ago.  I tell her this was caused by her disease and not the medicine.  When I return the following day with the organisation’s doctor I see her walking, her torso at a right angle to her hips.  These are just two of the people our small and under-funded organisation are assisting.   Recently their biggest donor died, slashing the monthly budget in half.  After salaries for a doctor, a program manager, a social worker and a driver, remaining funds are used by prioritising competing needs, which includes obtaining necessary medicines, supplying food to the hungry, paying school fees.  I hear my colleague explain a number of times to different clients, that “we can no longer offer the same support as before, because our biggest donor died”.

For some years now I have dreamed to volunteer my time and skills in a local community and finally I’m able to do so, albeit temporarily.  My national colleagues are some of the world’s heroes.  In one area known as “Ghost Village” because the men can earn money by preparing dead bodies for cremation, I’m told that during the Wet Season the shacks can only be accessed by walking in waist-deep water.  When I state that “I won’t  be able to visit here when it is like that”, she says without so much as a sideways glance at my prima donna comment, “It’s okay you can stand on that high part there and I will walk in to check the people”.  She then says to me “Even I am poor but sometimes I know I am not as poor as these people and I give my own money because it is so difficult if we don’t help”.  Learning that due to lack of funds this month’s food parcels have been delayed, I offer to cover this cost.  As she receives the money from me she says “I really hope you can continue to support us”.  I reply that I will try and I will tell as many others as possible about the need.

We meet an HIV+ woman looking after her neighbours’ children while their parents are looking for recyclables in the city streets.  Another woman with Multi Drug Resistant Tuberculosis gets in the tuk tuk when my colleague stops to talk with her.  She wants to tell us about her uterine prolapse and in passing her TB diagnosis is mentioned.  Our doctor is not there so I work out from the vague details shared in broken English by people with limited health literacy, that she has MDRTB and is not receiving the required treatment because she cannot tolerate the side effects of the medications.  I explain that she must take the medicine or the TB will kill her and that meanwhile she is spreading it to others.  She replies “I am not so worried by coughing blood, my biggest worry is that I don’t know how I can eat tonight if I don’t find any money and my prolapse is very uncomfortable but I cannot afford the treatment”.  This is what those books and articles mean when they say that “TB is a disease of poverty“.  She is in fact, sick with poverty, and TB is just one of the symptoms, albeit the symptom most likely to kill her.  Perhaps the person with limited health literacy is in fact, me?

We go into a tin shed where a 60yo man and his wife are caring for their 2yo grandson who is swinging in a hammock slung between two posts at grandad’s bed.  Grandad’s feet are badly burned, the wounds open and festering.  His story is that he needs to take this medicine (he pulls a packet of Gliclazide which treats Diabetes from a plastic bag hanging from the window above his head).  This medicine makes him feel better, but he cannot always afford to buy it.  Recently he was worrying a lot about his family’s finances because the shed costs $40 per month to rent, so he found a construction job that paid $5 per day.  He only had a pair of rubber thongs to wear so he went to work in them and during the day the hot concrete burned his feet (which are numb from having too much sugar in his bloodstream, caused by his Diabetes).  Without our MD’s help he would be at very high risk of losing his legs due to these injuries, or dying from blood poisoning caused by the infected wounds.  But our doctor can treat his Diabetes, his hypertension and his wounds because he has been identified as a high priority case.

On the shore of the Mekong River we meet an elderly woman who my colleague identifies as one of the ten neediest community members who we try to provide monthly food parcels to.  Previously she could earn $1 per day by cutting fish for sale at market.  Now she is old, sitting down for long periods is not possible so she can no longer do this job.  She searches the ground for cans and plastics to recycle, but the area she lives in has few recyclables, so she only earns about 25c per day in a place where the cheapest meal costs 75c.  She lifts the scarf on her head above her ears, revealing a cheap pair of gold plated earrings in her pierced ears, stating “I feel very worried about food but when I get hungry enough I have these earrings and I will be able to sell them for a meal”.  Leaving Australia last month I packed a small silk bag with my unused, unwanted jewelry, thinking “someone in Cambodia will be able to make use of this trash”.  On day one volunteering I met that someone.

It’s easy in the “rich world” to think that if you don’t have a spare $50, you therefore don’t have anything to offer to charity.  But amounts as small as $10 can make huge differences to people who have nothing.  Part of the problem from rich countries is knowing who / where / how to donate.  This seems to drive most people to donate to large organisations while small NGOs employing locals are often capable of offering much more accessible services with better impact but for their lack of funds.

 

Every Time I Go On A Plane

Kung Future is a tiny NGO working in Phnom Penh off the smell of an oily rag, with landless Cham people who live on their boats at the conflux of the Mekong and Tonle Sap rivers.  This week Kung Future reported the death of a two year old boy who fell off the boat he was living on and disappeared, despite the efforts of many who tried to find him by diving into the muddy waters.  His body was found some days later.  Kung Future do a lot of work in this community including organising birth certificates for children who would otherwise officially not exist; enrolling children whose parents cannot pay the fees, to school; some health care support when possible.  They also provide upkeep for boats in disrepair, which often leaves families with no choice but to try and fill holes with whatever they can find, even rolled up paper!  The community’s needs are high and the resources to meet their needs are extremely limited.

Cham fisherman painting his newly repaired boat, courtesy Kung Future

Meanwhile back in Australia, I feel a world away from all that.  The Project is a current affairs entertainment show airing here on weekday evenings.  One night recently, musing on a news item related to our national airline Qantas, one of the commentators said “every time I go on a plane…” as if it was the most ordinary statement, along the lines of “every time I eat breakfast…”.  As ordinary as they may have seemed to most Australians, these words revealed the extreme privilege that simply being born in Australia bestows upon us.  Our privilege is so normalised to us that we don’t see it.  Not every Australian can speak so casually about plane travel, but every Australian can hear it with a feeling of mundanity.  In contrast, I have lost count of how many seemingly worldly Cambodians have asked me with genuine fascination, about flying on an aeroplane, or how many countries I have visited.

Almost daily someone currently asks me if I find it difficult to settle back in at home.  The biggest impression I have on my return is our normalised privilege.  I don’t struggle with it at all; I am merely returning to my own normal life.  However I do have a very heightened awareness of it after moving rapidly (in the space of a 10+ hour flight), from a place where survival and limiting hunger are the focus for a large proportion of the population, to a place where liberty and comfort are central to our reality.  My friends and family here are securely employed, living in homes with solid roofs, paying off affordable and regulated mortgages, driving safely maintained cars, with opportunities to travel and the right to hold political opinions without fear.  My friends in Cambodia have between none and a few of those things, on a much smaller scale and in a suffocating economy where poverty is a highly visible feature of everyday life.

Something else many people ask me is why I would choose to follow my plans to return to Cambodia rather than stay in Australia.  A Cambodian friend suggested that maybe I don’t really love myself, that I would choose to live there rather than be among the comforts of my first world existence.  Friends in Australia frequently suggest I need to focus on settling down / building a nest egg for the future.  To the contrary, these quotes speak the most to me:

~ Jim Carrey

In The powerful way that normalisation shapes our world, Jessica Brown comments that “our grasp of normal is an entanglement of objective and subjective, moral and social judgements, prone to changing for the better and for the worse“.  She highlights the complex nature of normalisation, in that it can easily change (eg the normalisation of various previously unacceptable behaviours during the era of Trump) but can also be very fixed (eg ideas on female beauty).  It is an intricate phenomenon that most of us probably never really think about.  The reason I think about it is because what seems normal when I am living in Cambodia, is very different to what seems normal when I am living in Australia and these differences are particularly heightened for me now, as I settle back into a six month stay in Australia.

As one of many examples, I am staying with friends at the moment, who due to some veterinary visits, have spent more on their pet dogs in the last two weeks than most Cambodians can spend on themselves in a year.  These friends are living well, but they are not wealthy by Australian standards.  Yet to my adjusting brain, sharing their lifestyle for this short time highlights how extremely privileged we in Australia are, with very little recognition of the fact because it is merely normal to us.  It gives me some context to refer to, when trying to understand the complex nature of my relationship with impoverished villagers in Cambodia, who see me as infinitely wealthy.  My existence is beyond their normality, for the sole reason that I have enough money to appear in, and disappear from their lives, seemingly at whim.  Most of these are people who have never traveled away from their own village.

Before leaving Cambodia I wanted to visit Boat Baby, who I “caught” when he was born on the small wooden boat over the Mekong Delta in August.  About six weeks ago now, I spent a weekend in Kampong Cham, visiting various people with Dan (tuk tuk driver), to say farewell.  Boat Baby lives in the village next to the blind family who I have often talked about, so we added him to our itinerary in that direction and picked up an extra bag of rice for his family.  Five months old, he was swinging in a hammock inside the family’s elevated bamboo shack as we arrived.  He appeared to be asleep and I tried to stop grandma from waking him, as she bent to pick him up.  As she did so, I realised he was awake, but with semi-closed eyes.  A short conversation with Dan ensued, who then turned to me and with a tone of surprise said “Helen he is blind”.

Yet another vision impaired person in the same village?  Can this really be just coincidence?  My thoughts keep reverting to the knowledge that this area was heavily sprayed with Agent Orange in the 1960s.  We will never know because this is not a place where researchers will spend money or time investigating, and even the American veterans exposed to Agent Orange, still reporting high rates of disability in their offspring, have had limited recognition.  There is almost nothing written about it, but according to this article from 2008:,

Kampong Cham, Cambodia | The proportion of babies born with disabilities in eastern Cambodia is more than 50 times higher than in other parts of the country, according to local doctors.
While the reason for the higher rate has not officially been confirmed, it is generally believed to result from the use of Agent Orange, a dioxin-containing defoliant, by U.S. forces during the Vietnam War.

I was predictably horrified at the news and wanted to help.  His grandmother was forced into the jungle in this area during the Vietnam War and remembers living as a soldier alongside the country’s Prime Minister, who also comes from this region.  When I asked via Dan, does she know if they sprayed Agent Orange in the area, I understood her swift answer immediately – a very normalised “yes”.

The family had returned days prior from Phnom Penh, where doctors had already advised them to go to the paediatric hospital in Siem Reap where surgery may help.  Having just traveled to Phnom Penh, they did not have any money for this and would have to wait.  I gave them US$200 for the purpose of having him seen immediately but they could not leave now due to harvest commitments.  Last week they finally took him to the hospital, a day-long bus trip, and were given a planned appointment for the end of this month.

My communications with Dan following this trip to Siem Reap not only saddened me but also highlighted the complexities of relationships such as mine with this family.  A return bus trip and 1 or 2 days’ stay in Siem Reap would have cost a tiny portion of the $200 I had given them.  So I was confused by their request via Dan, for more money to attend the next appointment.  Dan never says anything bad about anyone, yet his reply to me when I asked why they needed more money already, implied that they had spent the money on other things assuming my money was free flowing, and that “everything not good” (ie he is unhappy with them).

Obviously I won’t continue to support the family in these circumstances.  Which means the baby will either not receive any treatment for his congenital blindness, or his family will have to go into debt for the purpose.  Health care debt is a normality in Cambodia where all health care works on a user-pays system.  Poor families may receive discounted or waivers if they can produce a “Poor ID” card, however these cards are notoriously provided by village leaders to their own family, leaving the poorest in communities with no evidence that they need support.

In my world, people do the wrong thing all the time but they don’t have to pay for it with their health, the health of their children, or as is so often the case in Cambodia and other poor places, their lives.  I feel very disheartened by this little boy’s circumstances and his family’s inability to understand the risk they took by making assumptions about my perceived wealth and perhaps my perceived obligation to him.  Finding a balance in this situation is going to take some time, patience and soul searching.

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Boat Baby at home with Mum and Grandma

World Wealth Distribution

From Pew Research Center http://www.pewresearch.org/fact-tank

Anyone interested in where they fit into this scale of global wealth can enter their basic information into the calculator at GivingWhatWeCan.org.  Despite my exposure to poverty which I think is probably more than most Australians, my hunch about my own wealth was completely wrong and I am far wealthier than I would have thought.  That’ll be normalisation playing games in my head!

Unconnected Connections

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

Story One: An Inconceivable Connection

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

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

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

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

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

El Pais 009

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

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

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

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

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A very memorable lunch

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

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

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

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

Story Two: A Fishy Connection

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

Inequality in a pic

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

Phnom Penh Scenes 01

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

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

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

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

046 Cham Visit

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

Story Three: The Rheumatic Connection

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

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

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

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

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

My wife’s name Sokum and 20 Years old.

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

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

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

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

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

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

The Excruciating Fundraiser

My heart sinks in Australia whenever I get a cold call at home, or accosted in the streets by charities looking for donations.  Ditto when friends write saying they have a cause and would I donate?  It is not possible to help everyone and the phenomenon of donor fatigue is something I experience on a regular basis, particularly from Australia, where I can quickly feel disconnected from the need that I see here in Cambodia.  From within Cambodia it is quite the opposite, you could almost say I’m plagued by donor impulse here!  But I identify well with donor fatigue and I understand what my friends are experiencing when they see yet another appeal coming from my general vicinity.  This is what makes me loathe what I call The Excruciating Fundraiser.

On that note, I hope anyone reading this understands that my sharing this story is not to make you feel obliged, pressured or judged in any way.  Read it as a story of interest.  And if you are inclined to donate, then do; if not, no problem.  If you are inclined to share it with others then do; if not, no problem.  It really is interesting to know this story though, and if you click on the link you can watch a very touching video that was filmed before the family received the help that has since seen some improvement in their situation.

This project involves a single mother of 4 who broke her ankle >2 years ago now.  I talked about her in Bongs and Tycoons.  She walked on the bone for over a year because she couldn’t afford to seek medical care. This obviously did further damage. She finally sought care at a South Korean charity hospital, but has to pay to get there and for any medicines and tests – it’s just the doctor’s consultation that is free.  The surgery is much cheaper than it otherwise would be, but has (and will) still cost her. These small things have put strain on her financially and at one point, for an extended period her 13yo son was out of school in order to walk the streets pushing a cart selling clams and banana fritters.  Since getting to know this family my perception of the many similar street vendors in Phnom Penh has changed.  Where once they were mysterious, appealing and sometimes funny, now they are all these things while I also contemplate on what led to them purchasing a steel cart to wander the streets through traffic as a way to earn money.  Even more so when the seller is elderly, very young or visibly disabled, which is often the case.  No doubt every one of them has a story worth sharing.

In May this year Mum was climbing the rickety ladder from the door of her elevated wooden shack to the ground (about 2 metres high) when she slipped through the gaps to the ground, breaking the steel fixer pin holding her bone together! So now she is walking around with a broken pin in her bone.  When I visit her, I physically tremble climbing up and down this ladder with it’s rotting rungs.

We got involved when a friend shared the video with me and asked if I could find her because a wealthy businesswoman wanted to offer her some money. I met her and took the family out for a meal (pizza – if you watch the video or read the earlier post you’ll know why). Then I met her again with the businesswoman’s daughter and nephew, who gave her an extremely generous donation which is going towards the expenses of her ongoing medical consultations. She has to have repeat surgery in September and meanwhile needs to travel to consultations weekly, pay for medicines, tests and transport etc.

The doctors have told her the only hope for a reasonable recovery is if she rests her leg.  With no back up welfare system here, she has no choice but to work – except for the fact that she has since had this help, meaning that at the moment she can rest (but she has a 2yo daughter, so can’t stay off her leg the whole time). So we are trying to help by raising enough money to get her into a ground level home that is not dangerous (her elevated shack is very dangerous, the ceiling leaks during rainfall, some of the ladder rungs are rotting, the floor slopes and feels soft underfoot in places), plus have a carer for the baby during school hours when her sons cannot help her, plus replace the income she cannot earn.

We will need a minimum of $4,000 to make this possible for her, for about six months post-surgery. So far we’re only a quarter of the way there.

See the link created by my MSF colleague / housemate and watch the video if you are interested in just one of the many stories that surround me, provoking my constant battle with Donor Impulse.

The Excruciating Fundraiser

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
https://australianaid.org/