As with my observations in East Timor last year, the average Cambodian adult weighs in the vicinity of 45 to 50kg. When ravaged by Tuberculosis, as so many here are, this average can plummet and it’s not so unusual to see adults weighing as little as, or even less than, 30kg. In East Timor I met a 20-something year old woman who weighed 25kg. Dr Dan was reviewing her one morning and he turned to me suddenly and asked “When was the last time you weighed 25kg?”. The question flummoxed me at the time but the answer is probably when I was about eight years old.
There’s something truly alarming about a grown body so ravaged by malnutrition that every vein, bone and ligament is transparent through a fine layer of skin. When I first heard of Tuberculosis many years ago, I learned that it was once referred to as “Consumption” because it would consume the patient’s whole body, which would waste away. In places such as Cambodia, where many sit on the brink of malnutrition anyway, there is no past tense involved – TB still consumes.
Perhaps it’s not so ironic that a personal goal for my time in Cambodia is to lose weight. It has not been difficult implementing this goal so far, thanks to factors such as heat, healthy and delicious food, a very good cook at the house, super cheap restaurants and exercise, which are all a part of my daily routine here. But there is also the ethical dilemma of being plump in a place where plump is rare and seems almost pompous. I can’t help the fortune I was born into, but I don’t have to flaunt it so ungraciously!
Today I spent an afternoon traveling to some villages in a distant location where we plan to send two patients with multi-drug-resistant-TB (MDR-TB) home once they are well enough. MDR-TB causes the same clinical illness as TB that is sensitive to standard treatment. However it is much more difficult to treat, as the standard drugs do not work and the alternative drugs tend to be far less effective with many more serious side effects, combined with a very extended treatment duration. Drug-sensitive TB usually only requires six months of treatment, whereas MDR-TB can require up to two years of treatment which is often difficult to tolerate and can have dubious outcomes even with good adherence.
These patients will commence their treatment tomorrow and wait in hospital for about two weeks to ensure they are tolerating the medications’ side effects, before being discharged home to continue treatment via health workers in their villages. Part of today’s trip was to identify and meet with these workers. Their job is imperative because TB should always be treated using Direct Observed Treatment (known as “DOT”), involving a support person who watches the patient take their medication. Without DOT adherence may be sub-optimal, giving the bacteria an opportunity to develop resistance or, in the case of MDR-TB, further drug resistance.
Many TB patients are poor with limited health literacy and limited access to quality health care. Our TB Program, as with many others around the world, aims to support MDR-TB patients through their treatment. This helps to ensure good treatment adherence, improving each patient’s likelihood of a cure and simultaneously limiting the spread of this deadly disease. We have dedicated staff who work to ensure adequate support in the patients’ family and community. They travel regularly to outlying villages where patients are from, spending time with the family and networking with community members such as village chiefs and local health centre workers. The purpose of this work is to investigate issues which MSF’s TB Control Program may be able to address in order to ease an already poverty-stricken existence which now has the added stress of a long and complicated treatment regime.
This week’s newest MDR-TB patients face a number of issues which to date I had only read about. One young woman is from a family with other members who have previously been treated for TB. She expressed concern that her family have been ostracised by some of the community as “The TB Family”. This is the stigma that TB carries with it and communal living inevitably results in the disease spreading among family members. This young woman is also the only breadwinner in her family, holding a job at a local factory. Her colleagues have been calling her regularly to ask why she is having so much time off sick and she is trying to avoid telling them the reason. Meanwhile her family, reliant on her wage, are experiencing hardship while she is unable to work. My colleagues are familiar with stories such as this and discussed some very feasible solutions which include offering education within her village about TB and supporting the family with food supplies. The team also offer skills training to patients and their families in occupations which may lead to extra income, such as handcrafting.
The second patient we were engaging with is from another area in Cambodia where he was unable to find work. Some years ago he moved to Kampong Cham Province where he works in a mango orchard. The local people built him a home near the orchard so that he could stay and he owes money in the village for this home. Now that he is unable to work he is troubled by this debt and his family are at risk of hunger. One of his five children is a young man with mental health issues who travels to town once a month to receive anti-psychotic medication.
We attended this man’s home to meet with his wife and daughter to get to know them and learn about any issues which may affect his treatment adherence once he returns home. The house was almost identical to the one below, stolen from the internet. We walked through a neighbour’s yard to a back section from the road, past ducks, chickens, roosters, pigs and dogs. We were welcomed into the ground floor shelter under the house, where a pot steamed atop hot coals on a stone table. I sat on a large square platform made of bamboo strips alongside the family and the social worker sat on the wooden bed frame across the mud floor from us. I did not understand the conversation, but I understood from the smiling Chum Reap Suors that I was welcome to their humble abode and the social worker translated some of the conversation to me about the family’s situation.
An ordinary day for my colleagues, but another extraordinary experience for me.