Phnom Penh is a city of wide boulevards crossing narrow litter-filled lanes. The crowded streets are swarming with motorbikes ducking and weaving between trucks, mini buses and cars, all diligently transporting a surprising variety of people and goods. The traffic rules are loose, if not completely absent. Whole families travel on mopeds in various configurations, none of which look safe, with helmets an optional rarity. Children stand in front of the driver grasping the handlebars, sit or lie between the driver and pillion passenger or hold on from the back. One young boy was fast asleep on the back of a bike with his arms straddled around Dad’s waist.
Clusters of live poultry headed for market hang upside down on the back of many vehicles, occasionally lifting their heads up to get a view from their precarious and likely frightening position surrounded by noise and commotion. Trucks loaded with mountains of produce – bicycles imported second-hand from Japan in their thousands stacked neatly on top of one another, fresh harvested crops and processed sacks of supplies all piled meters above the rim of the truck, some tied securely and many apparently not secured at all. Every moving mountain of cargo has at least one but often multiple people perched on top, looking down on the world moving below them. Run-down French heritage buildings reminiscent of history that has long passed are now dilapidated apartment blocks. The streets are teeming with rusty old stalls, marketplaces, produce and people.
The MSF compound in Phnom Penh is an aged but grand old sprawling French colonial with offices on the ground and middle levels, and guesthouse accommodation on the middle and upper levels. Wide marble staircases, polished mahogany doors and furniture, decorative cast iron external doors and staircases, and a number of large verandah areas furnished with lounges and tropical plants. The home is set in gardens behind a high dirty white rendered wall with cast iron spikes and a cast iron gate, where watchmen have a sheltered outdoor office area from which they allow visitors in and open the gate for those cars allowed into the garden, who honk from the street for access.
After some short briefings with the French headquarter staff, and a lot of sleep under my mosquito netted bed, on Tuesday I piled my overloaded cases into the MSF troupee. With the driver, the French Project Coordinator (my direct supervisor and one of my new housemates) and the Cambodian Pharmacy Coordinator (visiting our project for a few days), we headed to Kampong Cham, three hours north east along the Mekong.
Recently 168 people lost their lives, 40% of them children, and 100,000 people were left homeless, when the Mekong broke it’s banks earlier this month and 20 of the country’s 24 provinces were flooded. The highway travels through rice paddy fields, where it was impossible to tell where the river ended and the still-flooded fields began. Occasionally we saw scattered herds of water buffalo standing waist deep in brown soupy fields or along the edge of the road. One small herd were even walking across the highway, as though they knew exactly where they were going and why. All the way along the highway we passed busy agricultural activity. About two hours into the journey we stopped at one of the roadside bamboo huts to get a coconut, which the seller hacked with a machete on one side to make a flat bottom, and on the opposite side to make an opening through which she put a straw. The driver also bought some freshly grilled bite-sized bananas and shared them amongst us – the heat forms a crust, encompassing warm sweet fruit.
My first impression of Kampong Cham City (the capital of Kampong Cham Province) was of a rather unglamorous small town with very wide streets and almost no traffic. The streets come alive at night though, and the quietness allows for a laid back lifestyle which I have already embraced. Not to mention the ability to cycle around safely with a fairly casual observation of any road rules.
The Kampong Cham house is another big old French colonial behind compound gates manned continuously by watchmen. Not as sprawling or spectacular as the Phnom Penh home, but beautiful nevertheless, filled with wonky character and situated on the shores of the flowing muddy Mekong, where we can watch fishermen from our balcony sitting in canoes with their nets cast into the flows.
View from our balcony on a muggy day, over the road to the Mekong and the bridge to Tboung Khmoum District of Kampong Cham
My first night in Kampong Cham I was given Bicycle 10, with it’s yellow tassled handlebars, and we cycled in procession through the dark streets to my predecessor Steffen’s farewell. He arranged and paid for a local restaurant to feed around 50 of our colleagues, with the arrangement that everyone donate $2.50 to a local orphanage in return for their meal. It was a highly entertaining night with good food, free-flowing beer, Karaoke singing and disco dancing on an elevated verandah under a thatched roof. The first thing I learned about my Cambodian colleagues is that they like to drink beer, sing Karaoke, dance and have fun. I sat next to the logistician, a very humble, engaging man who talked to me about his memories from the Khmer Rouge era. His family escaped to Thailand, but were ejected back across the border in an area where many landmines were planted. Some people ran back into Thailand to escape the landmines, only to be shot at the border.
I am employed by MSF as Nurse Manager of the Tuberculosis Department at Kampong Cham Provincial Referral Hospital, which serves the people of Kampong Cham Province, 80% of whom are sustenance farmers living in rural areas outside the city.
The patients have very basic accommodation in the TB Department, which is divided into three separate patient areas. Beds with wooden slats are provided with no mattresses or bedding. The traditional style for sleeping here is on a bamboo mat on a hard surface, so patients either bring their own mat, or they are provided with one, which is rolled out onto the wooden slats. The bathrooms are a hole-in-the-ground latrine with a small bath sized concrete box filled with cold water and a scoop to wash from.
My role with MSF includes certain responsibilities for all three areas. The first is a newly implemented (one year ago) “Screening Area” where patients with unconfirmed diagnosis await their sputum results / clinical decision about diagnosis. Those for whom TB diagnosis is excluded are discharged or transferred to another area of the hospital, and those for whom TB is confirmed are transferred to the TB Inpatient area. The Screening Area has been established in an old hospital building a few metres from the newer TB Department areas which are in a series of white stone buildings interconnected by wide verandah walkways.
The Outpatient Area
The Inpatient Area
Patients outside the Screening Area
The Screening Area’s birthday cake, celebrating one year since inception.
Across a gravelly patch of ground from the Screening Area is the Outpatient Area for new presentations with possible TB and follow up of patients on TB treatment. Those presenting to the Outpatient Area for the first time are sent from an initial screening area at the main hospital when they are assessed as having possible signs or symptoms indicative of Tuberculosis. They are given a mask and directed to our Outpatient Area. Upon presentation at the Reception window they are registered, then join a queue for the vital signs table where clinical observations (temperature, nutritional status, heart rate etc) are undertaken. From here they queue for a clinical assessment with one of the doctors in a clinic room. There is a blood taking room for baseline tests and an outside sputum collection area where patients can provide a sample without risk of infection to others .
Via the verandah walkways on the other side of the Outpatient Area, is the Inpatient Area for patients with confirmed TB requiring hospitalisation. This area is divided into a series of individual rooms for those with Drug Resistant TB near the back of the grounds. A separate Prison area of three barred cells behind a white stone wall ventilated with slanting gaps to allow air flow whilst obstructing the view into and out of the cells. Policemen / jail guards lie on hammocks outside this area, keeping watch. Then two separate areas divided by patients’ status as either “BK negative” or “BK positive”. In brief, BK is a French abbreviation for Bacille de Koch, meaning the bacillus of Koch, the microbiologist who, among other achievements, discovered the Tuberculosis bacillus. Patients who are BK+ have Acid Fast Bacilli (AFB – the abbreviation used in English instead of BK) visible on sputum microscopy, meaning that the bacteria can be seen under the microscope before being cultured. This suggests a high bacterial load, and these patients are considered infectious. Patients who are BK negative do not have AFB seen on microscopy, and are not considered so infectious, even if the bacteria cultures at a later stage, confirming the diagnosis of Tuberculosis.
Other rooms and areas include a room for sputum induction (a process of nebulising high sodium concentrations to patients suspected of having TB who are unable to produce sputum, to induce sputum production), a pharmacy room, counselling rooms, reception and data collection room, medical records rooms.
For my first three days I received handover from Steffen, met various colleagues and became familiar with the department and some of the processes. There are many Cambodian colleagues who have very similar names beginning with “So” – Soldea, Sotheara, Sopheak, Soty, Sodina, Sokhon, Solidem, and the list goes on. I guess I will learn to distinguish them all!
Each morning we leave the house and cycle through the sleepy boulevards to the hospital, where my day begins with attendance at the first of two handovers. The first handover occurs at the Screening Area. The nurses in this area are a team of four young men and a young woman, all in their 20s, who work alone on a rotational roster. All are employed by MSF. The morning shift nurse provides a brief handover to the Nurse Manager (myself) and the medical team about the patients. This is done in English when possible. However, myself and the expatriate MSF doctor both have our own translator, who accompanies us throughout our day to ensure good communication. My translator is a lovely man with perfect English, who I know I am going to enjoy working with. English language is a desirable requisite for nurses here, but is not essential, and so varying levels of English are spoken throughout the hospital. With so many expatriates from around the globe rotating in and out on Missions with MSF, Khmer is rarely (if ever) spoken by the expatriates, although I hope to at least get a basic grasp so that I can communicate a little easier whilst I am here.
After the Screening Area handover I have time to assess the area for any issues or concerns, talk with staff and undertake some of my official duties such as collecting data required for financial and HR reasons. I then attend a second handover at the Inpatient Area, which is a much larger area with more nurses on duty, employed by the Ministry of Health. My responsibilities in this area are of a more technical than supervisory nature. After this handover I meet with various colleagues and ensure things are running smoothly throughout both the Inpatient and Outpatient areas.
Once everything appears to be running smoothly at the hospital, I cycle a few short blocks away to the office, where many of my duties are carried out at a computer desk. At this stage my role appears to consist of training and supervision of staff at the hospital, ensuring good nursing care, processes and working equipment, plus organising rosters, ensuring good quality data and various other management tasks. These are all responsibilities I have had before, and so I am not (currently) daunted by any of it, and in fact looking forward to the experience.
My week in Kampong Cham has been one of sensory and work overload. There are many new people to get to know, new processes to learn and understand, new routines in and outside of my work environment, and a whole new life to lead for the next nine months. Yesterday I began Khmer language lessons with Chanthy on the balcony at home. She overloaded me with phrases and words to learn for the week, before my second lesson next Saturday. From there five of the seven housemates cycled to a local small roadside stall for a delicious $1 lunch of rice flour crepes with lettuce, cucumber, herbs and sweet chilli sauce. We cycled along the Mekong, past the ornate golden temple-like Buddhist University, and into a side street where expatriates are obviously a unique sight. As we sat at the small plastic stools perched at a makeshift wooden table in front of our cook with her various pots, pans, jars and other paraphernalia, various people came out from behind gates and inside shopfronts to watch us, while others pulled up on their mopeds to order lunch or came past with their pastries to offer dessert from a basket on the back of a bike.
Many of the new experiences are so unfamiliar to me, as to be highly entertaining. One of the most entertaining parts of my week has been the experience of working for a French organisation in a Khmer speaking setting, with expatriates from around the world, all working in English. It makes for some very funny translations. German speaking Steffen wanted to order a “Do not urinate here” sign to go on an external wall of the TB Department. It is a visual sign with a red cross marked across a cartoon figure of a male urinating. Steffen wrote on the order form “Do not pie”, before asking me how to correctly spell “piss”. When I informed him that this was a bad word, and he should use “urinate” instead, he and our Khmer translator fell about laughing with me – he has been saying “piss” for almost a year without being corrected!
Working with impoverished people also provides many different experiences, for example the cleaner who this week proudly announced (via our translator), that she had learned to write her name (in Khmer) so that she could sign the newly implemented sign-off sheets to indicate a room has been cleaned. Our next job is to teach her how to sign against the correct date on the sheet!
The orphanage in town, Phter Koma, is apparently a place worth getting to know, which some of my Khmer colleagues are very involved in. I look forward to joining them sometime soon!
Working in another culture is also a privilege filled with new and sometimes not-well-understood experiences. At Inpatient Area handover one morning Steffen and I sat down behind the nurses. Some conversation occurred in Khmer, and then handover began in English. Everyone in the room was Khmer except Steffen and I. A few moments later one of the translators, who had both been delayed, whisked himself onto a chair. Everyone immediately clapped the nurse who had held his own in English, and handover switched to Khmer with translations. The English handover had occurred especially for our benefit.
This weekend we have no internet at the guesthouse, so I have come to a riverside restaurant to use the free wi-fi. This restaurant exists to train young local people in hospitality, who would otherwise have limited opportunities for training and employment.
My name in Khmer! (“For Helen”)
One of the staff prayed for a Lottery win. The other day she won the equivalent of US$70, and fulfilled her promise to thank the god(s) by offering a glass of water, a chicken and some burning incense!