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/

Baby Business

Herman Melville Quote

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

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

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

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

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

Mos Dangerous DAy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cycling in the Countryside

Yesterday four of us (2 Australian, 1 French and 1 Slovakian) cycled a 70km journey through the Cambodian countryside. We had two aims. First, to experience the fairytale scenic villages along the shores of Kampong Cham, including a visit to a beautiful temple complex. Second, to visit a young patient who was sent home from hospital last week, in very bad physical condition, to very dire living conditions, but with a caring and attentive family who may possibly be her saving grace.

Where I come from this patient would receive intensive medical and nursing care and have an excellent prognosis. Unfortunately due to her birth fate, she probably won’t see her 26th birthday. After a prolonged hospitalisation, we have developed a relationship with her and some of her large extended family. We wanted to visit her for a clinical review but mostly to provide her with some hope. She teeters between dying (the assumption our remote advisers have made about her fate) and some hope for survival (our admittedly biased sentiment for her). She regularly asks is there hope and we have truthfully told her that there is. She also regularly darts between crying uncontrollably and making comments such as that she is no longer afraid and other references to the death that seems imminent. Despite having a good appetite, due to her clinical condition she weighs 23kg.

It was my fourth visit to her home, approximately 30km from town in a picturesque but very poor rural riverside village.   The first three visits were work related and I attended in order to follow the case through from hospital to home, in a purely supervisory role with the nurse employed to undertake this work.  The first visit was to identify and recruit a Home Based Care (HBC) Nurse to provide her Direct Observed Treatment (DOT). We located a trustworthy and respected Village Health Volunteer (VHV). Each village in Cambodia has two VHVs whose job is to identify TB suspects and refer them for diagnosis; to follow up TB patients; and to provide regular health education in the village about TB. The purpose of this work is to optimise early diagnosis and treatment, one of the most important interventions in reducing the spread of TB. We then returned to train him about MDRTB (which remains rare enough that the VHVs are not usually involved with this). We then discharged the patient on Wednesday and traveled to her home early Thursday morning to meet the VHV at her home and supervise / advise on the first home DOT, as well as to ensure that she had all the materials needed to care for her wounds, etc.

The materials for her wounds are the most basic, just gauze and tape with some trials of other available dressings which will eventually deplete. Her wound nurse is her mother, who has an excellent clean technique and is far more attentive than any nurse she could have asked for. This week some discussion around dressing materials included a suggestion that items might be provided which could be washed and re-used but after attending her home on the riverbank where her mother does laundry in the muddy brown water of the Mekong, this idea was immediately quashed. Having only ever nursed in Australia and England it is impossible for me not to make comparisons against the places I am familiar with, where wound care specialists, cutting-edge dressings and other life saving interventions are available, ensuring a recovery back to full health.

In all of my experiences here, this case has most starkly highlighted the difference in value of life based on where you happen to be born. From the safety of the First World, despite feeling concern for people, I always felt a detachment from the little I knew of Third World plights. I’m not detached from this beautiful, intelligent, humble and grief-stricken young woman or her caring, attentive and grieving family. Yet I am removed enough from their situation that it is difficult to imagine the oppressive poverty that forms the basis of their existence.  These thoughts play havoc with my imagination as I observe the pea-soup-coloured mud around the base of their elevated wooden shack, envisaging it turn to a large muddy lake once the rains arrive in full force.  How will the children ever leave the house without drowning?  At best they must be exposed to all kinds of bacteria and parasites living in the mud, not to mention the ideal breeding ground it makes for mosquitoes.  How will I be able to visit her – the house where she lies on wooden floorboards in the middle room under the tin roof will seemingly be inaccessible?  Are the holes in the tin roof too small for raindrops to fit through, or is she going to be rained on from above?  What about when the rain sheets in at an angle as it inevitably will during tropical storms – will the gaps in the wooden walls expose her to the rain?

Questions galore for this first world brain as it sits on one of the borrowed red plastic chairs supplied for our visit just before lunchtime.  We are surrounded by at least twenty family members seated on the floor before us, watching and listening as I speak on the phone with my translator, then pass the phone to the patient lying on the floorboards smiling up at us, or her mother.  We pass the phone back and forth, smiling and each attempting a few words in the other’s language as we wait for a full translation.  Children stare at us, adults too except that their eyes flit away quickly before we catch them.  Many smiles are exchanged and bamboo-encased Khmer cake of sticky rice with beans is brought to us with bottles of cold water.  Halfway through our Khmer cake we realise that noone else is eating and then we remember that it is Ramadan and they are all fasting!  We stop eating and wonder if we’ve committed a faux pas, or if it’s okay to eat if it’s known that you are not observing Ramadan?  It is too late to worry now, and we continue to receive many smiles so we must not have done anything too offensive, but we stop eating and utter “Somtoh” (sorry), which is accepted with gentle nods.

Between assessing the wounds, watching Mum re-dress them, the doctor performing a medical assessment, and a few other work-related issues, we also exchange some social conversation.  Via telephone translation the patient tells us that she would like to thank us very much for visiting her, that she was very excited to see us and that last night she couldn’t sleep for the anticipation of our visit!  As I pose for a photograph with her mother, she leans in and knocks her head against mine and my colleagues sigh in hilarious unison.  We assure everyone that she seems much better than she did in hospital, she tells us how happy she is to be home again, we admire the many children surrounding us, they ask us did we really cycle all the way here and are we sure we didn’t park our car up the road and cycle only a short distance, they laugh at the many sweats we are oozing, and we leave feeling as though the visit was well worthwhile for everyone’s sake (not least our own).

Back out onto the bumpy, hole-ridden road which switches regularly between bitumen, sand and mud, we cycle back to Kampong Cham.  A journey which began with conversations about how fantastic a cycling holiday through Cambodia would be, ends with sore thighs and bums and far less enthusiasm about mounting our bicycles ever again!  We land at Destiny for a late and well deserved lunch, where the sight of our soaked and dusty bodies and the noise of our gregarious, adrenaline-driven laughter about how ridiculous we look and how hungry and sore we feel, immediately lowers the tone of the establishment.  Thankfully noone seems to mind and an hour later, stomachs filled, muscles rested and recollections of a great day rehashed enough for now, we head home for showers and solitude before we spend the evening sipping wine on the balcony together, rehashing the thrill of a great day some more while rain lightly falls on the intact roof above us.

Cycling in the Countryside: Photographs from our day out

???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????