When a patient is diagnosed with Drug Resistant Tuberculosis (DRTB), measures are put in place in an attempt to cure the patient as well as to hamper the bacteria’s transmission to other people, particularly close family and household contacts. In a third world setting DRTB mainly travels amongst the poor, who already have impaired health and restricted opportunities. The bacteria often wastes their bodies before they find themselves placed into enforced isolation in hospital while their families are left to deal with the repercussions of their absence, which is an enormous strain if the patient is a main breadwinner or carer. Treatment side effects can often be extreme, exacerbating the patient’s fragility so that they are left to endure physical illness combined with social and financial stress.
Many people I encounter in Cambodia are earning in the vicinity of US$1.25 per day, often in exchange for heavy physical labour. Today I traveled to a remote village in the north of our province with a nurse and two social workers to meet with family of a hospitalised DRTB patient and discuss plans for discharge. This included identifying a villager who is able to provide the daily Direct Observed Treatment (DOT). This volunteer will receive basic training within our program about storage and administration of the drugs, including injection techniques and how to monitor side effects, in return for less than US$1 per day – which could and often does double the family’s income.
Including our very entertaining driver, five of us drove north out of the city, over the Mekong River and towards Vietnam. The main road was busy with agricultural workers transporting hay, fruit, vegetables and other produce, almost all overloading the vehicle so that every motorbike, wooden trailer, truck and tuk tuk appears to be straining under the weight it carries. Hay hangs out doubling the width of motorbikes or rises to the sky from the base of trailers, sacks of carrots ooze out of the back and over the top of trucks, ox-drawn carts lug rice as the oxen clip-clop along the busy highway apparently oblivious to the traffic weaving around them. My eyes bulge at the evolving scenes before me while my Cambodian colleagues disregard it all in favour of chatting and laughing with each other.
About an hour up the road we turned off the highway and drove through a busy marketplace before entering a rural village scene with elevated wooden houses and thatched roof huts, chickens pecking along the side of the road, dogs trotting amongst them, children playing in the dust and adults sitting at the top of the wooden ladders leading to their front doorways or lazing in hammocks slung between tree trunks. We turned onto a dirt track shaded by banana fronds interspersed with towering coconut palms and after some directions offered by a villager dressed in a short checked sarong wrapped around his waist, found the family we were looking for. The driver parked in the middle of the dirt track and occasionally children playing on a bicycle or villagers on mopeds drove around us while we stood in the middle of the track talking to the family group. They were expecting us and about six adults with a few children were congregated in the dusty front yard. A hen had dug a dirt nest and was trying to keep her tiny chickens in check under her feathers, while roosters and chooks pecked about under the house and through the yard.
The social workers sat on the laddered steps to the front door with some women while the father crossed the road with the nurse and I to his own yard opposite to speak separately with us. His house was very basic but very charming, made from vertical strips of wood elevated about six feet high on wooden pylons held on small concrete blocks in the dust by the weight of the house. The front door was made from flat vertical bamboo strips secured by about three horizontally placed bamboo strips. Underneath the house a hammock was slung between two of the pylons, a bamboo bed base in one corner and many more pecking chooks and roosters roaming around in the dust. He explained that his son had received a scholarship to attend a local high school. This included a bicycle for his son to travel to and from school and some chickens for the family to raise in order to have enough food. The social workers obtained an assessment of the family and house, to determine how many contacts the patient has, where the patient would live and sleep upon discharge home and what supports may need to be put in place to ensure the family can continue to earn and survive. The family also identified a local villager who could be approached and asked to provide DOT.
We then drove up the shady dirt track, past neighbouring village houses and stopped near the next corner. Myself and the nurse walked through the dusty yards of about five houses, exchanging chum reap suors with various neighbours, to the back section where the village DOT volunteer was waiting for us on a bamboo bed base under a thatched shelter in the yard with her husband and family. The volunteer and two men sat on the bamboo base, offering us a plastic chair each, and the conversation about community DOT, or c-DOT, took place in this beautiful tropical jungle location. Two dogs slept lazily in the dust nearby, chooks roamed and pecked, a massive pink pig oinked from a wooden pen on the other side of a thatched roof bough shelter and family members slowly climbed down the stairs from the house and came to sit nearby and listen in. Under the bough beside us a young woman sat on a tree stump in front of a table made from another tree stump, chopping something green very finely with a machete.
The nurse and the c-DOT had a lengthy conversation about her experiences volunteering with TB patients, her availability to attend the next training, what her role will entail and the stipend she will receive in exchange for providing c-DOT to the patient. A young couple sat smiling politely at us for a while before going over to a tall tree nearby with a very long piece of wood which they used to knock three large green coloured fruits down from the tree. A plastic bag appeared and the fruits (oversized grapefruits called “goroetlong”) were placed into the bag which was tied and put on the bed with a smiling gesture towards me. When we left, the bag of fruit was given to us as we all exchanged chum-reap-lears (the farewell version of chum reap suor).