Eye Is For Ice

This week I lost my housemate and friend to Bangladesh, where she will work with the Rohingya refugees escaping indescribable violence in Rakhine State across the border in Myanmar.  We spoke a lot about them and about Cambodia before she left.  It always looped back to ourselves, our appreciation for our extreme luck of birth and our drive to make the most of our good fortune.  I’ll miss the thought provoking conversations.

Rakhine State

For now I live alone.  Right now I am typing a blog overlooking the skyline of Phnom Penh from my balcony.  Five floors above the streets where people are doing whatever they can to simply survive, it is a “bubble” up here.  Outside people are searching for ways to have enough food for the day while I live in protected luxury, with the comforts that have always constituted my charmed life.

As a first year student nurse in England the first essay I ever wrote was 5,000 words on Inequalities of Health.  I still have that essay somewhere, with it’s featured photograph from The Independent newspaper in 1991, of a homeless man lying in a sleeping bag in the snow in a London park.  The wealth-poor divide is highly visible in Phnom Penh, as it is in any location where travelers from the Rich World live alongside locals who never have the opportunity to leave the small patch of territory where they toil day after groundhog day.

Last week The Eyes came to Phnom Penh so that 7yo could have her surgical appointment with visiting overseas ophthalmologists via SEE International .  Her behaviour suggests more than just eye problems.  So do some of her facial features.  She is odd looking and oddly behaved, does not learn well at school, has no friends in school, and generally a highly unfortunate little girl.  A child like this in Australia would be known to various specialist support services.  In Cambodia she lives in a little village in the dust with a blind widowed mother and widowed grandmother whose most recent distress came from the theft of their chickens.  I received a call from Dan about a month ago, the chickens have been stolen and they needed them to sell at market and now they have no food to eat.  As well as sorting out some food for the month we put our heads together with the village builder and organised a new chicken coop.  I’m always entertained by these unlikely agricultural interventions I find myself engaged in!

Chicken coop 02

Hoping to avoid further chicken thefts

The day that Boat Baby was born we were taking supplies to The Eyes, who live in the same village but across the vast corn field which was under water on that visit.  These peoples’ only experience of water is shown in this photograph of Little Sister greeting me as our wooden boat arrived in the brown slush of the Mekong Delta outside their house.  Last week those little girls had their first and only taste of water as I grew up knowing water.  Oneday at the hospital we were sharing lunch together with noone to translate so I was forced to practice my Khmer.  I picked up a chunk of ice and announced it’s Khmer name.  They smiled and agreed, before asking me it’s English name.  “Ice”.  “Eye”.  “Ice”.  “Eye”.  S never comes at the end of words here, so I agreed they had it right, laughing privately at The Eyes repeating the word Eye to me!

Three out of five members of The Eyes family have vision problems which were not addressed due to their inability to access health care, until I met them three years ago.  It has possibly cost me in the vicinity of US$500 to engage them with SEE International over the past three years.  We have lived through three operations, four sets of glasses, a number of trips to Phnom Penh for pre- and post-operative appointments, severe travel sickness on buses and mini vans leading to tuk tuk rides of >5 hours each way and all kinds of other issues.  The eye surgery is offered free of charge but villagers with no income have no way of affording the transport, accommodation and other associated costs such as post-operative medications.

This is only one family of the millions worldwide who cannot and therefore do not access necessary health care.  Their story includes grandad Joe, who I wrote about many times, a probable victim of Polio whose death a year ago this month was likely due to Post-Polio Syndrome.  All he could tell me when I asked, was “during Pol Pot I got a fever and then I couldn’t walk properly”.  For years he survived without the wheelchair he needed, which I was able to organise almost immediately thanks to my financial ability to bring him to town and engage him with the relevant organisation.  Their story also includes the girls’ father who drowned in the Mekong, with no clear story of what happened.  As a friend of mine said at the time “it could be murder, but she is a blind woman and very poor, so she has no power to talk to the police”.  It could also have been suicide.  We will never know although people seem to think it was not an accident.  He and his motorbike were dragged out of the Mekong three years ago.

I always assumed a genetic cause for The Eyes vision problems.  Last month when I visited Boat Baby I learned that his mother also has vision problems.  Could this be mere coincidence?  Reading up on Agent Orange, I have learned that 173,000 acres in Kampong Cham were sprayed with Agent Orange between April 18 and May 2, 1969.  The spraying took place at night with evidence that it was carried out by the CIA.  Villagers allege in fact, that similar spraying continued frequently into the 1970s.  There are no official records of most of these sprayings which defoliated vast areas, intending to expose enemy troops to the bombers flying above.  I am unable to find a map showing exactly where the spraying occurred.  The area was also heavily bombed and many of my friends and colleagues here have vivid memories of bombs exploding on their villages and homes, killing family members and leading to the digging of rudimentary underground bunkers covered with layers of bamboo.

Vietnam War veterans in New Zealand, Australia and America have long held strong opinions that exposure to Agent Orange has caused high rates of developmental, immunological and neurological problems in their children and now, their grandchildren.  Governments have been reluctant to accept the argument, but compensation is provided in various ways to children born to Vietnam War veterans with certain disabilities.

The issue can be summed up briefly with these two statements:

The US military denies any link between the defoliants and the illnesses and deformities found in Vietnamese children who have become the world’s most recognizable symbol of the effects of Agent Orange. Among scientists the debate over the (alleged) adverse effects of Agent Orange remain a contentious issue.
Cambodia Daily March 2004

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….The scale of the damage wrought by use of the chemical in Cambodia is still unclear as there has been little research into the victims. Local doctors have called for an official survey on the effects.
Star News article 2008



A child at the Ba Vi orphanage, part of the third generation of Vietnamese victims of Agent Orange and other chemicals used by the U.S. military a half-century ago.   Ahkoblitz Blog   Visiting The Eyes at hospital last week I saw a child with a similar affliction to this.


Pimp My Tuk Tuk

may you always do for others

Many hours of many days during my first 2 years in Cambodia were spent adventuring with my good friend, a tuk tuk driver who I blog-named Chom.  He is currently living in Japan to earn $60 per day as a farm worker (10 hours per day, 7 days per week).  This is big money to him and should ensure that his family will be more comfortable than they ever would have been had he stayed in Cambodia for the three years that he plans to be away.  His children were 6yo and 1yo when he left at the end of last year.  He often told me that tuk tuk drivers are considered lowly on the social spectrum here.  Nevertheless only this year did I comprehend the fact that tuk tuk drivers are often very poor.  They usually don’t have enough education to be competitive in the private, government or NGO employment market (where salaries reflect a local “middle class” of US$300+ per month depending on the role and qualifications required).

Under Medecins Sans Frontieres local regulations which state we should not travel by motorbike, I’m reliant on tuk tuks to get around.  I hate negotiating prices and so I tend to find a regular driver and stick with him.  This means I get to know and usually befriend my drivers.  In Cambodia everyone’s story is so far flung from anything we are accustomed to in Australia and the wealthy world, that all of “my” drivers have something foreign and interesting to share.  My housemate, colleague and good friend Theresa, who started a few short weeks after me earlier this year, is a kindred spirit and we have many discussions about the tuk tuk drivers we encounter.  Yesterday none of our regulars were around and very unusually, we had to walk towards the corner of our street to hail a tuk tuk.  We didn’t make it to the corner.

A few metres out of our gate, a driver passing on the crossroad spotted us, making a quick half-u-turn into our street to approach us hopefully.  In our rudimentary Khmer we negotiated a price and hopped on.  It’s become an impulse for me to assess the state of the tuk tuk I am in.  This tuk tuk had old, worn out upholstery.  One of the arm rests was completely missing so that the only thing separating the loose seat cushion and the road below, was thin air.  The carriage’s suspension was distorted so that I seemed to be sitting on a slant.  We got about halfway to our destination when his moto stopped at an intersection and no matter how many kick starts he gave, it refused to restart.  He called out to a passing driver and swapped us into another tuk tuk.  As we drove away I looked back to see him pushing the vehicle into a driveway and turning it around.  With any luck the downhill slope helped his bike to un-flood.  It can’t be a fun work day when that’s your lot.

Two years ago I was stranded in Skun en route to Kampong Cham.  Pushing my case along the main road, voices from a passing tuk tuk shouted “hello” before pulling over.  Full of people and luggage, they were amazingly traveling from Phnom Penh to Kampong Cham to visit their grandmother and offered to take me.  They squeezed me in Khmer-style and saved my skin.  I promised that I would always use Dad (the tuk tuk driver who I’ll call Sam,) whenever I was in Phnom Penh, and so Sam has become my regular guy in the city.  A quiet and unassuming guy with better English comprehension than we realise because he only uses it when we give him no choice, we recently went halves in the cost of replacing his torn tuk tuk upholstery.  Since then, with our regular custom, he has pimped his own tuk tuk somewhat, adding a plastic wire guard to reduce the chances of bag-snatchers and we now travel with Cambodian flags flying from the back seat.  Our conversations with Sam are always fun, particularly by telephone when we recite what we have to say before calling, always hopeful that his reply will be a simple “yes” or “no” because the minute any detailed information has to be shared, we’re lost!  He knows our regular routines – the family I visit on the outskirts of town every few weeks; the other family Theresa and I visit together near our office; Theresa’s weekly swim lessons; our occasional social hot spots; our various strange little ways.  It’s so much easier having someone who knows where we want to go and who we don’t have to negotiate with.

Around the same time that I was befriending Chom in Kampong Cham over three years ago now, I met Rav in Siem Reap who I have also become very fond of, along with his friend Seth and their wives and young families.  He impressed me when Kim and I were in need of assistance to communicate together the day I bought Kim’s wife a sewing machine.  Rav not only translated for us, but he drove us to the market, negotiated a decent price for the machine we wanted, guided me over the busy street, and was generally very kind and helpful.

Theresa and I currently have a Rav-Seth project underway with a group of Khmer graphic designers building a website to promote their tuk tuk services.  Siem Reap is a very touristic place with a focus on the temples of Angkor Wat stealing from the other attractions of the province.  Hundreds of tuk tuks vie against each other and low season means many days are spent with no income.  We are working on promoting attractions off-the-beaten-track for tourists interested in a more authentic experience of Siem Reap.  Plans are still underway but may include overnight stays in Seth’s floating village, where he grew up on a small boat which he says “sometimes had a roof but sometimes the roof would break and we didn’t always have enough money to make a new roof.  I like sleeping under the stars but it is too hot under the sun and so bad under the rain”.  Rav is from an equally impoverished background and we have been discussing the fact that sometimes tourists don’t want to see the temples and stay in fancy hotels; the chance to interact with locals, experience local knowledge and connections can be marketable assets which are as yet, untapped.  We hope that a website can increase their access to customers in what is an extremely challenging market.  If this website is successful then we plan to replicate the project for another tuk tuk in another resort town who we know and have been trying to help.

Meanwhile you could say that, as with anything, poverty is always relative.  It’s impossible to help everyone and important to remember this when you live in a place such as Cambodia where at every turn you see another level of poverty.  Waiting at the intersection yesterday, in the ricketty tuk tuk which wouldn’t kick start, an elderly man rested on his decrepit cyclo which Theresa suggested for emphasis, “was built by the Russians”.  A few hours later, waiting for friends near the corner I wondered at the story of the many small children working the busy streets to collect recyclable rubbish or sell fruit from plates atop their little heads.

Rav’s family often say to me that they feel lucky to know me, because of the little things I’ve been able to do at no sacrifice to myself, for them.  A conversation with his sister yesterday went along these lines: “you help us so much”, no I only help you a very little “no, it is little for you but it is big for us”.  Rav recently said “there are 15 million people in Cambodia, so it is amazing that I could be the one who met you”.  I reminded him that he met me because he was helping Kim, so any gratitude he has for his so-called good fortune ought to be for his own willingness to help someone in need.

Do good and good will come


Standing On The Outside, Looking In

It is much more difficult in Phnom Penh, to find the impetus to write.  My accommodation is a fifth floor apartment overlooking rooftops for as far as the eye can see.  This removes me from community life somewhat although I’m slowly starting to recognise the neighbours beyond our apartment block.  We recently relocated our office to be near the clinic, in another part of town.  Now we drive to and from work in tuk tuks.  This puts us on the bustling city streets for half an hour each morning and evening, with many fascinating sights and sounds.  In work hours I find myself walking the short distance between office and clinic a number of times each day, again putting me on the always-intriguing streets.  Still, a significant amount of my spare time is spent suspended in the sky, disconnected from the community I live in.  This is not a complaint – I love the apartment and am enjoying my expatriate colleagues / housemates.  We arrive home before 6pm, I go for a swim, share a drink and meal, then hit the sack in time for another work day.  Our location and routine diminish the inclination to write.  Perhaps once I get a weekend routine going this might change.

According to The World Bank four million people were lifted out of poverty between 2005 and 2015 due to positive developments in the Cambodian agriculture sector.  Most of these people remain poor and vulnerable with a loss of US70c per day being enough to drag poor families back into poverty.  Defining and measuring these categories is a complicated discipline which I am not equipped to explain here.  My observations on poverty are that it is not always, or solely, about individual income.  Rather, there are many factors at play.  Someone with a home and secure and livable income who lives in a place where access to education or health care is limited, is still affected by poverty.  Nowhere is this more obvious, than in many of Australia’s remote indigenous communities where public facilities such as education and health care are often insufficient and people experience social and economic challenges which affect their well being and contribute to the indigenous health crisis.

An extremely common Cambodian story is that of families separated due to work commitments.  Twice a year the nation celebrates important national holidays which routinely see economic activity grind to a halt much like Christmas or Easter in western nations.  My tuk tuk friend in Siem Reap, who I call Rav here, had not seen his mother for three years despite living a mere 320km away.  His sons are now 5yo and 6yo, significantly different to the tiny boys their grandmother last saw.  Rav is probably “poor”, rather than impoverished.  He pays $40 a month for a small rented room (literally a room with a bathroom and a kitchen bench with running water on one wall).  Driving tourists to the temples makes this rent and the family’s other short term expenses do-able if he is careful, except in low season when the lack of customers turn an already competitive market into a very tight squeeze.  His income doesn’t stretch to taking time off or to the cost of tickets to travel away.  When I saw him in Siem Reap in February Rav was very low, feeling trapped by his economic circumstances and worried about his mother’s ill health.  I have regular donations from a number of friends and family and so I told him that I had some donor money I could contribute to get the family to Phnom Penh to visit his family.  At first he was reluctant but as Khmer New Year drew near, he agreed to my offer and brought his wife and sons to Phnom Penh for a three day visit.

The family met me for lunch oneday.  Rav said that his mother could no longer walk and they did not know what to do for her.  He did not know if her feet were swollen, but both feet were causing a problem.  My suspicion was liver or heart failure, which lead to fluid retention and immobility; or uncontrolled diabetes, which can lead to loss of feeling in the feet due to a build up of sugar in the bloodstream.  I suggested that she should go to hospital but they were reluctant due to hospital fees.  70% of Cambodia’s health care costs are paid for out of pocket by patients, with many thousands of already-poor people going into debt or selling assets to cover the cost of medical needs.  A large portion of the country’s population are considered vulnerable to these “health shocks”.  Paula’s family, who sold their house during her illness and whose father now lives permanently in Malaysia in order to earn enough money to continue paying off their health care debts, are an example of this cycle of poverty connected to medical care.

With their hesitance about hospital I suggested to Rav that I visit his mother.  That night at dusk, after a half hour tuk tuk drive to the edge of town, I arrived at her tiny rented room.  Rav’s two sisters with their partners and children, his mother, and he with his brood were all apparently occupying this tiny space.  Perhaps another reason that Rav doesn’t make regular visits to the family?  Lying on a bamboo mat on the floor, his mother sat up while I found a space to sit beside her.  With Rav’s translation she proceeded to give a very clear description of sciatic pain radiating from her right buttock into her groin and down the back of her right leg, with some lesser pain in the left leg.  Astoundingly I had just been discussing sciatica with a family member who had been given a low dose of Amitryptilline which alleviated their pain almost immediately.  With the assistance of a physician friend I was able to recommend the medication.  Darkness enveloped us and Rav suggested that I needed to go, as though he was concerned about my safety in his overcrowded little laneway.  The assumption of people like Rav, is that they have nothing to offer when in fact, their small acts of caring and of sharing their lives have a big impact.  It is amazing to me, to be so warmly welcomed into the homes and lives of people living so differently from me.

With many thank yous and goodbyes, the tuk tuk wended down the dirt lane and out onto the main boulevards towards home.  Phnom Penh’s outer suburbs at night are an experience unlike the Phnom Penh expat night life where well lit pavements are lively and fun but removed from the grime, congestion and poverty which most expats, despite living in this city, are far removed from.  Elsewhere in the same city, public squares are unlit and dirt-floored, chickens saunter through crowds as their cousins rotate on spits, open fires grill all sorts of meat, you inhale a fluctuating mix of barbecue smoke and exhaust fumes, markets heave with people, motos and the beat of popular music and traffic regularly grinds to a halt.

Traveling through these bustling, dimly lit neighbourhoods I pondered, as always, on the difference between my privileged and egocentric experience of the world, which comes with it’s own set of complicated disadvantages, and the world as it is experienced by most humans.  The more I see my birth entitlements, the more I see that others are no less deserving than me and that my so-called successes were really more a matter-of-course related to my privilege, than indications of real success.

Success in Life 02

Wheelbarrows and Debts

Yesterday I watched in awe as a group of men and women covered from head to toe with traditional checked khromars wrapped around their heads for sun protection and dressed in pyjamas (women) or shirts and jeans (men), worked with a heavy wheelbarrow, carting wet concrete from the mixer about fifty metres away, to a track being cemented into a single lane roadway.  With a “driver” leading the way, pulling the barrow handles from behind and four people pushing the back of the barrow, they built into a run from the mixer up the slight incline, over a pathway of planks laid for the journey.  Upon reaching the section being cemented, the team repositioned to push the barrow over, pouring the cement out.  A man using a long stick of wood then smoothed the concrete while the barrow team returned to the mixer for the next barrow load.  As we watched from our office doorway, a local colleague told me that they would probably earn around $2 each for the day but that many labourers earn only food, not cash.  It would be interesting to know how many calories their bodies burned – no doubt a much bigger benefit than the paltry financial gain being earned, but probably also at risk of long term complications which are likely the reason I see so many older people bent over themselves with bone and spine deformities.

Concrete SA 20 May 012 b

My colleagues talk about their involvement a few years ago in a response to a Cholera outbreak which occurred here.  According to media reports, in 2010 at least 60 Cambodians died of Cholera during an outbreak which spread across 20 of the country’s 24 provinces.  One of the reasons for the outbreak is cited as being that people do not have access to clean water and, especially in the Dry Season, will drink whatever water is available.  I guess this is the reason that bottled water is heavily marketed here, selling to locals for around 500 Riel (US12c) per 500ml bottle, which seems cheap but is nevertheless unaffordable if you have no money.

It’s easy to imagine, watching these teams of thin bodies push themselves in the hot sunshine, how vulnerable people are to infections.  When the environment is conducive to bacteria, viruses and parasites anyway, bodies with no reserve will surrender so much easier to infection.  The level of chronic malnutrition in Cambodia is a reason that TB has such a strong hold over the population, but TB is not the only organism able to thrive here.  Dengue and Japanese Encephalitis viruses and Malaria parasites are the most common mosquito borne diseases; diarrhoeal diseases including Giardia and Cryptosporidium (parasites), Rotavirus (especially in children under 2yo) and bacteria such as Salmonella and Campylobacter contribute significantly to the issue of childhood malnutrition, which cycles well with diarrhoea, making the host more susceptible to illness, which in turn exacerbates malnutrition.  Other respiratory diseases such as Streptococcus pneumoniae and Haemophilus influenzae are also very common causes of morbidity and mortality.

Throughout more than 20 years of nursing I have been trained about the risks of germs spreading in hospital settings, which are productive germ factories as people congregate in a single location with whatever ails them, searching for a cure.  Infection Control is big business in the First World, where degrees and doctorates are earned by nurses and doctors who make specialised careers out of the subject.  In contrast, the Third World have very few resources for the purposes of Infection Control, which is a large part of my role in the hospital setting here but on a very basic scale as hospital acquired infections are not monitored, let alone identified and acted upon as they would be in the Western World.  I am on a very steep learning curve, coming from a country with many resources and having spent many years away from the hospital setting.

Toys in a paediatric setting are very important for the psychological well being of patients, but have to be carefully managed to ensure they don’t contribute to the spread of hospital acquired infections.  As they are much easier to clean, hard toys are the only acceptable option in hospital settings where Infection Control is a primary concern, particularly in difficult circumstances such as the Third World where water supply, sewerage maintenance, hygiene standards and living conditions are all a constant struggle.  Almost daily I am confronted with blocked toilets, leaking pipes, shortage of cleaning or waste disposal products and various other challenges to our attempts to maintain good Infection Control practices.

A good summary of the problems relating to soft toys and the spread of infection in health care settings can be found here:


In case the link doesn’t work, the text from this article is pasted below.

After mentioning on Facebook that certain specific toys would be of great value here, I had an astoundingly generous response with untold parcels received from as far away as Australia, NZ, UK and America, all of which I have not yet been able to distribute due to the sheer volume.  It was on the whole a very fun and happy exchange with many thoughtful friends.  I received a volume of parcels almost daily for a period of time, all of which required payment to the postal service upon receipt which involved some organisation as colleagues in Phnom Penh were paying out of their own pockets on my behalf.  I managed to offend a tiny minority of donors by stating that some parcels were directed away from the hospital, which was done for practical reasons as described herein.  Unrealistic and impractical stipulations were attached to two or three parcels which were not expressed until it was too late and which I could not have complied with even if I had known.  It was a lesson for me that not everyone gives without strings attached or with reasonable scrutiny and expectation.

Today I visited some patients and Home Based Care Nurses in their communities.  At one location we sat on a bamboo day bed underneath a small wooden stilt house in the countryside, surrounded entirely by newly planted rice fields with just a narrow dirt lane leading through the rice fields to the house.  An elderly man joined us, thin and wasted by Tuberculosis, while his son lay in a hammock nearby and his wife joined us to talk about the side effects of the treatment her husband is receiving for Drug Resistant TB.  In a nutshell, her husband is experiencing some psychiatric problems related to one of the TB medications, as well as headaches, joint pain, back pain and decreased appetite.  She has hypertension treated with medication she has to pay for, her son has pre-existing psychiatric problems, one daughter collapsed in a factory where she works recently and was unconscious for three days, leaving them with a hospital bill which they cannot afford and another daughter works on a construction site in Phnom Penh.

Cambodia’s Ministry of Planning coordinates an “ID Poor Card” scheme which is supposed to identify the most destitute families in each community, who upon receipt of this card become eligible for free health care at the local Health Centre and exemption from teacher payments at school.  Village Chiefs are responsible for distributing these cards in their community and my colleagues all say that in reality, the families of Village Chiefs are the primary beneficiaries of ID Poor Cards, which is just another example of the pervasive corruption in  Cambodian society.  Despite being eligible for an ID Poor Card, this family do not have one.  They have debts related to their ill health and no way of paying them.  When I asked what amount the debt was, assuming it to be many hundreds of dollars to be causing such stress, the answer was 300,000 Riel, which converts to US$75.  I returned to the car and got as much money as I had with me, and brought it to her, having my colleague translate for me that this was from me personally and not from our employer, to go towards paying their debt.  Having received cash from other friends who did not want to send parcels I explained that this was a gift from overseas friends who wanted to contribute to Cambodia and that I felt their plight was deserving.  As I passed the money (which did not cover the full debt) to her she began to cry, repeating “Oor kun jirian” (thank you very much) over and over, with her hands in sampiah gesture against her forehead.  She then hugged me, followed us up the laneway to our car, thanking me tearfully all the way and hugging me again.  To have such extreme stress by such a small amount of money truly astonishes me.  But debt caused by hospital bills seems to be a crippling experience of many Cambodians.  It was gratifying to be able to help one family in a small way.

To end on a slightly lighter note, the other night we were out for dinner and parked our bicycles up outside the restaurant, then took our seats at an outdoor table overlooking the river.  We ordered drinks and after a few moments, the waiter approached us and said “Excuse me, please can we ride your bicycle?”.  Excuse me?  “Please can we ride your bicycle?”.  Yes sure, you can take that one, it’s closest.  The waitress came out and boarded an MSF bicycle and cycled off into the night skies.  A few moments later she returned with the basket filled with a huge bag of ice, and our chilled drinks were served a few moments later.  How can anywhere match the character of this place?!  Now, the next time I’m told that they are out of wine or gin, I hope the offer of a bicycle loan may offer a practical solution, as the nearest liquor store is around the corner and there was an occasion some time back when we could not order wine for about three weeks!

Evidence-Based Practice: Examining the Risk of Toys in the Microenvironment of Infants in the Neonatal Intensive Care Unit

Review of the literature on toys included both clinical inpatient and outpatient settings (see Table 4 ). Two studies were identified that compared hard and soft toys in the waiting rooms of general practitioners. The first, a descriptive study from Edinburgh, reported cultures from 50 toys shared by children in the waiting and consultation rooms of a busy, inner-city practice.[42] Investigators found organisms on 60% of the hard toys and 100% of soft toys. Organisms judged as “potentially pathogenic” were found more frequently on soft toys (30%) than on hard toys (5%) (odds ratio, 8.14; 95% confidence range, ). The authors cite a 1 in 10 chance of exposure to a pathogen from communal toys as an unacceptable risk. The study was limited by differences in culture techniques; swabs were used to culture hard toys, whereas direct cultures were obtained from the soft toys.

The second study described contamination of hard versus soft toys. Twenty-two hard toys and 10 soft toys were gathered from 6 general practice offices in New Zealand.[43] The toys were soaked in a broth media, which was then cultured for coliforms and total bacteria. Ninety percent of soft toys showed coliform contamination compared to 13.5% of hard toys (P < 0.001). Soft toys were more often contaminated (100% v 91%) and were more likely to have moderate to high bacterial counts (90%) when compared to hard toys (27%; P = 0.002). Although useful information is provided about the ineffectiveness of decontaminating toys (particularly soft toys) by soaking, machine washing, or autoclaving, data are not provided to support these conclusions.

Together, these 2 studies provide consistent and moderate (level IV) evidence that toys in the waiting rooms of general practitioners are quickly colonized with bacteria. Soft toys colonize at higher rates and present the greatest risk of contamination. Procedures for cleaning are generally more effective for hard toys.

A number of case reports in hospital settings describe toys as probable reservoirs for pathogenic organisms. A report from an ICU in the United Kingdom describes a 79-year-old woman who was given a cuddly toy dog by her family.[44] Knowing the patient previously had MRSA, a culture of the toy was obtained and promptly grew MRSA. In this case, it appears the patient contaminated the toy. The toy was removed from the ICU at the advice of the infection control team. The clinicians advocate a ban on cuddly toys.

An outbreak (8 cases) of rotavirus was reported in a 42-bed cancer center.[45] After weeks of aggressive infection control measures with no decrease in incidence, a pediatric epidemiology investigation revealed that toys in the playroom had not been cleaned according to the weekly protocol. Cleaning procedures were enforced; although no further clinical cases occurred, this finding may be related to seasonal patterns of this infection. The toys were not tested for rotavirus. Investigators hypothesized that shared toys were likely serving as fomites transmitting rotavirus.

One practitioner reports a case of a toddler from his neighborhood who presented with diarrhea caused by a Giardia infection after having swallowed several gulps of water from a toy left in a stagnant pool of water.[46] Although no evidence of cause is presented, the author warns clinicians not to overlook water toys as a source of infection.

These cases individually provide low levels of evidence (level V) linking toys and infection. When reviewed together, however, they reflect reports in the more general fomite literature and offer stronger and more consistent evidence. Use of molecular technologies to link organisms at a highly discriminate level will provide stronger evidence in case reports as the following study demonstrates.

A report of 9 cases of multiresistant P. aeruginosa in a pediatric oncology unit compared isolates from infected immunocompromised patients to environmental cultures taken from wet surfaces.[47] Using molecular DNA analysis, researchers found that isolates from 8 infected cases had identical banding patterns that matched isolates from 3 bath toys and a box for water toys. A case-control study compared the 8 infection cases to controls that matched the disease. It showed a significant association between infection and use of bath toys (P = 0.004), use of bubble bath (P = 0.014), duration of stay (P = 0.007), and previous antibiotic exposure (P = 0.026). The authors caution against the use of water-retaining toys with immunosuppressed patients. This study provides good evidence (level III) linking toys to infection by using molecular technologies and case-control risk analysis.

In a descriptive study, random selection and culture of an unspecified number of toys from a pediatric ward communal playroom were undertaken.[48] Sterile swabs were used on hard toys and contact plates were used on soft toys to culture organisms. The results showed no growth from the contact plates taken from the soft toys. Swabs on agar plates from the hard toys grew Staphylococcus albus and Bacillus species. The author suggests that although only environmental organisms were found, these pose a risk for immunocompromised children and those with invasive devices. Lack of data to support findings, an unknown sample size, and varied sampling techniques are limitations of this study. The evidence (level IV) presented shows weak support for the presence of organisms on hard toys.

A prospective study in a hematology/oncology unit showed positive cultures of 39 stuffed animals.[49] The “T. Bears,” sponsored by the Department of Health and Human Services (HHS), were a mascot to promote handwashing and were given to hospitalized children ages 9 months to 15 years. All of the toys were colonized with at least 1 organism within the patient’s first week of admission to the hospital. The organisms represented human skin flora, although not necessarily flora from the cohort patient. Five of the 39 patients became bacteremic 1 to 30 days after receiving the T. Bear. The toys could neither be implicated nor excluded as the source of infection. No effect was noted on monthly NI rates. Of clinical significance were the rapid colonization rate of the T. Bears and the presence of organisms known to cause severe infections in the study hospital. The authors concluded that the colonized toys could provide an unnecessary means of nosocomial transfer and spread of organisms. This study provides some evidence (level IV) of the presence of pathogens on soft toys; however, the effect on NI rate or bacteremia is not demonstrated.

Further information is provided by a small prospective study that examined nonsterilized stuffed toy animals placed in the incubators of 12 NICU infants.[50] The infants had a mean age of 30.6 weeks (±3.4) and a mean weight of 1419 grams (±743). Aerobic cultures of the toys, incubators, and infants’ skin were taken at 0 and 72 hours. The cultures (sites not specified) predominately revealed CONS. The authors concluded that the results “failed to implicate the stuffed animals as harboring pathogens.” This study was reported in a brief letter that provided no specific data. Other limitations of the study include the use of only aerobic cultures, cultures for no longer than 72 hours, and the small sample size. The presence of CONS, the most common cause of late-onset NI in the NICU,[12,54,55] is evidence contrary to the authors’ conclusions. The presence of these known potential pathogens may represent a risk for this population. The conclusion, that the practice of placing stuffed toys in incubators “may be safe and reassuring for both parents and neonates,” is an overstatement of the type, size, and scope of the study and, further, is inconsistent with the evidence (level IV) presented.

The trigger study that led to this evidence-based clinical project is a cross-sectional, longitudinal survey of the toys in the beds of NICU infants.[10] The authors investigated the bacteria and fungi contaminating toys in a 20-bed, level III NICU in Melbourne, Australia. Infants’ mean age was 28.2 weeks (range, 23 to 41) and mean weight was 1114 grams (range, 480 to 2710). Toys resided in infants’ beds and were cultured weekly over a 4-week period. A total of 86 cultures from 34 toys of 19 infants were collected. Bacteria grew in 98% of cultures. The most common organisms were CONS (98%), Micrococcus species (58%), Bacillus species (24%), MRSA (15%), and diptheroids (14%). Colonization rate did not change with bed type, presence of humidity, toy size, toy fiber, or toy fluffiness. Eight (42%) of the infants had a positive blood culture, and 5 of those isolates (63%) were the same type as the corresponding toy. Unfortunately, molecular techniques were not used in this study. The authors concluded that toys might be reservoirs for potential nosocomial sepsis. This prospective, well-designed study provides good evidence (level III) of bacterial and pathogen colonization of toys and highlights the potential for fomite transmission to a neonatal population.

In summary, the evidence demonstrates that toys are reservoirs for infectious organisms in a variety of settings. This is supported by the breadth and depth of literature related to organisms present on fomites[20,22,23,25-41] and, more specifically, on toys.[10,42-46,49] Two studies (level IV) demonstrated higher colonization rates on soft toys.[42,43] Caution was raised (level III and V evidence) regarding colonization of water toys with pathogens.[46,47] Although randomized controlled studies are lacking, these level III, IV, and V studies show generally consistent findings. Colonization of the microenvironment with potential pathogens has clearly been established.

The evidence to link the colonization of toys to increased risk for NI is plausible but not proven. An association between NI and organisms on toys was evidenced by both well-designed studies (level III)[10,47] and a case report.[44] The use of resistant organisms and DNA molecular technologies show discriminate evidence linking the organisms of sick infants to those on toys.[47] Weaker evidence of linkage was provided by comparing organism species in the sick infant to those on toys.[10,49]

No prospective randomized controlled trials were identified with sufficient power to support the safety and efficacy of toys in the microenvironment nor, conversely, to demonstrate a cause and effect relationship between colonized toys and increased NIs. In the absence of randomized trials and clear causality, an attempt was made to determine if evidence about causing harm is valid.[56,57]

The scientific principles of fomite transmission and literature review support plausibility:

–  Toys are potential reservoirs for pathogens and other organisms;

–  The hands of health care workers and families transmit organisms between toys and infants;

–   Infants exposed to pathogens and other organisms are at high risk for NIs and associated morbidities and mortalities

–  Drug resistance patterns and DNA technologies have linked organisms in hospitalised patients to those on their toys

–  A common theme throughout the literature suggests that NI outbreaks reliably declined when fomites were removed from patient contact.

 From Advances in Neonatal Care, 2004; 4(4)

The Anguish of AIDS

Last time I gave a pseudonym to a young patient so I could refer to him easily, he died, making me reluctant to name my young friend.  But she is the same 14yo with HIV and TB that I refer to in my previous entry “Observations of Poverty”.  She has been with us for the past two weeks, but yesterday when her condition deteriorated, she was transferred to another ward where the care is better in that a doctor is based there.  Otherwise nothing changes – she is still on a bamboo mat atop the wooden slats of a bed, with limited medications and no health technology.  Some liquid glucose is fed into her veins through a plastic tube by force of gravity from an IV stand attached to the head of her bed.

She has been on TB treatment for approximately two weeks and today she began the Anti-Retroviral Treatment (ART) for HIV.  Her acute malnutrition, the biggest and most immediate threat to her life, has worsened thanks to continuous diarrhoea and vomiting.  The bloody diarrhoea is probably due to some sort of bacteria or parasite that would make most of us slightly unwell, but which can overwhelm HIV patients with low CD4 count.  CD4 are “helper” white blood cells which help protect us from infections.  HIV infects these cells and slowly obliterates them, making the person vulnerable to many infections, including TB.  Her vomiting could be due to the same infection, or perhaps a side effect of the many medications she is now taking.

This afternoon I went with my translator to the ward to visit her.  She was lying flat on her back with her eyes rolling to the back of her head, underneath a thin blanket which camouflaged her so well that you could easily have missed the fact that there was any shape above the flat bamboo mat she lay on.  Her mouth was slightly ajar but she was not in any apparent respiratory distress.  A wet towel on her forehead had slipped down over her eyebrows.  When she realised we were there she opened her eyes and adjusted the towel with her pale, swollen hands.

Her adoptive father was sitting in a doorway at the end of her bed, looking out to the hospital kitchen which is a series of ramshackle wooden huts where open fires billow smoke into the atmosphere, polluting the lungs of tiny children running around while their parents cut fish caught from the nearby Mekong to cook with rice on the open fires for patients, or collect rubbish from the hospital grounds into wooden makeshift wheelbarrows to cart to the open waste disposal area where more open fires regularly burn.  Small children dressed in rags often enter the hospital grounds with big sacks over their shoulders, looking for aluminium cans or plastic bottles to sell at recycling dispensaries in the hope of feeding themselves and likely their siblings and other family.  Occasionally I’ve seen children, some quite young, walking the streets with plastic bags of glue sealed to their faces.  I asked a local recently what makes the children sniff glue.  Apparently the sensation of being high on glue masks the sensation of hunger.  Unfortunately it also causes brain damage and can provoke psychological disturbance including violent behaviour.

As always, her father was bright eyed and smiling at us from the ground as we stood above him asking for information about her condition and treatment since the ward transfer.  He said that yesterday he had decided to take her home, but then changed his mind.  He did not say why but I assume due to despondence at their situation.  If he takes her home now she is guaranteed a quick death, while there is still currently hope of recovery despite her fragile state.  I encouraged him to keep her in hospital despite how hopeless it seems right now.  This morning he heard her cheyne-stoking and thought she was dying.  As he uttered these words, her eyes widened again from their drowsy state suggesting she had heard the comment.  With any luck the ART and TB medications will begin to improve her condition slowly, the gastrointestinal infection will be diagnosed and treated so that she can begin to eat and drink again, and she may gain strength.  In a First World country she would have a very high chance of survival.  But here?  In these conditions……?

We had a conversation with her father about his children (3 daughters plus this girl who he adopted when his “in laws” both died of AIDS).  I asked if there was anything that he needs for himself (as opposed to our patient) and he suggested that a bicycle-style wheelchair, I imagine much like the picture below (courtesy Google), would be very helpful.  Hopefully another NGO, “Handicap International”, may be able to assist in our quest for one.

I then bent down to the low-set bed where this c.20kg teenager was doing her best to stay awake in our company and put my hand on hers.  Through my translator I said to her that it is very good that she is taking the medicine and not vomiting it, and that she will eventually get better now that she is on all of the right medicine.  She squeezed my hand.  Then she did not let it go.  I rubbed her arm and said some more reassuring words, and she squeezed my hand even tighter – proving that there is still some energy in her emaciated little body.  As we held onto each other I grasped that she was letting me know how afraid she feels.  Some strands of hair were stuck across her knife-sharp cheekbone.  As I stroked the hair behind her ear, despite the visibly sharp bones of her face, it was still a shock to feel the bones against my fingers.  I asked if there was anything that she needs.  The answer in Khmer was quite long, perhaps because there is no one word for it, or perhaps because she was explaining why.  The answer in English was “nappies”, to contain the diarrhoea.  Given that this diarrhoea could kill her, I promised her we would find some and bring them this afternoon, because if this is as dignified as her death can be, then she at least deserves such a tiny request to be met.  Thanks to MSF she is now supplied with some proper incontinence pads to contain the ongoing diarrhoea and hopefully she will rest much easier tonight.

Tomorrow we will visit again.  Meanwhile, debriefing with colleagues, a game of badminton after work, fried rice from the Night Market, upbeat songs on the iPod and a few laughs online with friends in far-flung prosperous places have all failed to quell the sorrow that connection with a dying 14yo, suffering the consequences of catastrophic poverty, provokes.

Poverty is the worst form of violence ~ Mahatma Ghandi

If you have a spare hour, this 1979 award-winning documentary from Australia’s John Pilger gives some historical background into Cambodia’s current plight.
The empty bed you see about half an hour into this documentary is identical to the empty bed Tom left behind in November.  And the one which is currently occupied by a 14yo girl on the brink of a death not unlike those featured in the documentary.

Observations of Poverty

For much of my time here I feel harrowed by the situations I see people existing in.  I regularly have to talk myself out of the tears which threaten to surface as I realise the significance of the poverty I’m witnessing.  But the smiles on the faces of those who own these situations usually manage to knock me out of my precious state of mind.

Today I met a man with some sort of crippling condition in his legs.  He sits on his buttocks with his knees up at his chest, and walks with his hands lifting him up and forward.  He is agile and fast.  His fresh face smiled at us openly as his malnourished teenage daughter lay wasting away in a hospital bed with HIV and Tuberculosis, so thin that her pale skin is pasted to her skeleton and her face is sharp with bones.  As the doctors spoke to them both, asking questions, assessing her clinically, ordering tests, and discussing what they consider to be her biggest issues, all I could think was that poverty is the only real issue at play here.

Her father’s kind and intelligent face radiates gentility and he smiled at me from the concrete floor and communicated with me via my translator.  It was a humbling experience to meet and spend time with him, and I agonised for hours during the rest of the day over what I could do to alleviate their destitution.  They have no access to a bank account and live in a remote area which would be difficult for me to visit.  The fact that he is so nimble and strong tells me that he works in some sort of physical job, probably in the rice fields.  Unlike the First World, here if you don’t work, you don’t eat, so disability is not an impediment to hard physical labour and aids such as wheelchairs are a luxury that most live without.

His daughter will remain with us for some time to come, so maybe over the next few weeks I will come up with a way of assisting them somehow?  But their story is not unique and any help I offer is a drop in the ocean.  In the ward with her at the same time are a 12yo boy who is stunted from malnutrition with suspected TB lymphadenopathy, a 13yo girl suspected of having spinal TB which was finally diagnosed as spinal degeneration due to the heavy work she does in the rice fields and three infants all with varying degrees of malnutrition.  This is the harsh reality of Cambodian health statistics which are not easy to comprehend until you meet them in the flesh.  45% of Cambodian children have moderate to severe stunting caused by chronic malnutrition.  In other words, they are short statured because their bodies have never received the nutrition required for adequate growth.  Hunger is a daily experience for many.  As a colleague said to me the other day “when Cambodian people have no food, we die”.  In his quiet and unassuming way he just informed me that he has witnessed starvation.  I probably have too, as the death of Tom in November comes to mind.  Everyday I see old people hunched over with such severe back deformities that their upper body is almost at right angles to their lower limbs, after years of hard physical labour in the fields.  I guess this is exacerbated by malnutrition which leaves bones brittle.

Thirty five years ago tomorrow, Cambodia was liberated from the Pol Pot regime by Vietnamese forces backing the current government who have been in power ever since.  It is celebrated as a national holiday known as “Victory Over Genocide”.  Celebrations occurred en masse very early this morning.  By the time I made my way to work the ceremony was over but truckloads of people dressed uniformly in blue and white were being driven through the streets as legions of army and police patrols blocked intersections.

Our office is across a park from a government building which has been heavily guarded for weeks now, due to the garment factory demonstrations.  This park disappeared this morning under a lavish arrangement of canvas pavilions decorated with pot plants and truckloads of plastic chairs in neat rows under the canvas shelters.  By the time I saw it, the ceremony was already over and everything was being dismantled onto trucks and taken away again.  Apparently the truckloads of uniformly dressed civilians were conscripted from surrounding villages under government order.  Even the most basic freedoms I take for granted are a perilous thing for Cambodians when it comes to showing support for the ruling administration.  When I mentioned the celebrations to a colleague as we watched from our office doorway and suggested that he must not have been alive when the Victory Over Genocide occurred, he replied that he was not, but that even many people who remember the genocide do not support “this”, as his arm motioned towards the pavilions being dismantled.

Contrary to thinking that everything happened 35 years ago, which is not such a long time anyway, the Paris Peace Treaty was signed in 1991.  The first election was held in 1993 and the Khmer Rouge led insurgencies and continued their terror from the safety of strategically landmined jungle areas until after Pol Pot died in a jungle village in 1998.  Yesterday I was informed “Cambodia was still at war until 2000”.  Tribunals continue today against some of the Khmer Rouge leaders who are all elderly but still defiant.

After work tonight I spent some time at the reopened bamboo bridge (“p’dar”), watching the evening crowds come to life as dusk turned the muddy Mekong waters purple.  Sitting on a park bench above the embankment leading down to the water’s edge I watched a girl of about 6 and her younger brother, dressed in rags, drag sacks bigger than themselves as they climbed the embankment looking for plastic bottles to be recycled for a small payment.  An hour or so later I ate dinner at the Night Market with a housemate and we were approached by two young boys of about 8yo dressed in rags and asking for money.

Today’s news included the headline “After Clashes, Garment Workers Flee Veng Sreng Street.  The few remaining residents of Phnom Penh’s garment factory-lined Veng Sreng Street, where government forces armed with assault rifles shot dead five striking workers on Friday, said Sunday that most workers had since fled in fear for their lives”.
Another article interviews some of the wounded, a number of whom were not protesting, but cooking in the kitchen or walking home when struck by the indiscriminate bullets flying through the street.  Someone else said to me today that the death of one westerner makes a much bigger problem for Cambodia than the death of many Cambodians.  Given that the garment workers’ situation appears to be accepted by most of the international community (activist organisations excepted), this appears to be an accurate conclusion.

It’s hard to find a cheerful note to end on some days.  But tonight’s dinner conversation revolved around the calm dignity of Cambodian culture and the privilege we feel working with such gracious people as our colleagues and our patients.

Lights of Kampong Cham's P'Dar (Bamboo Bridge) at dusk.

Lights of Kampong Cham’s P’Dar (Bamboo Bridge) at dusk.