What Starts Here Changes The World

Basket shop on it's way home after a busy day at Central Market, Kampong Cham
Basket shop on it’s way home after a busy day at Central Market, Kampong Cham

These guys changed my world just by being there!

University of Texas (UT) graduate, Admiral William H McRaven of the US Navy Seals, gave an inspirational commencement address to 8,000 Class of 2014 UT graduates on 17 May this year.  You can watch the speech at this link, which went viral after it was uploaded to YouTube.


He says that the average American will meet 10,000 people in their lifetime.  I’m guessing that is similar for most of us living similarly to Americans, in the Western World.  If each of us changed the lives of just ten of the people we meet, and each of those changed the lives of ten people, and another ten, then in five generations – 125 years – the class of 8,000 graduates he was speaking to, would have changed the lives of 800 million people.

He further argues that it is not difficult to change the lives of ten people and describes some military experiences in this regard, of one person making one decision, in a single instant, which lead to lives being saved and the impact this had on so many other lives.

He states that regardless of who we are, where we come from, our gender, social status, religion or ethnicity, our struggles in this world are similar and that the lessons to overcome our struggles and move forward, to change ourselves and the world around us, apply equally to all.

It’s a resonant message for me at this time as I encounter the struggles experienced by many if not most Cambodians.  Everyday I face reminders of the incredible stroke of luck afforded me at birth.  While I played with siblings, cousins and friends on bicycles, trampolines and in swimming pools around receiving a decent education, oblivious to the possibility of any other type of childhood, my counterparts in Cambodia were living in constant fear of a barbaric regime, facing starvation, unimaginable brutality and deprivation.  This could sound melodramatic except the history books confirm what various colleagues tell me they lived through and many continue to be tormented by.  The younger generation who did not experience this continue to reap the consequences of a country that was torn to shreds and whose civil war only came to an end less than 15 years ago, with autocracy and corruption now dominating, often with violent force.  I regularly pinch myself that I am the one hearing about these things from the safety of a privileged background and existence.  Only recently did I come to realise that on a global scale, I belong to a charmed minority.

I grew up in a home where helping others was considered the right thing to do and thanks to the direction of  a mother, grandmother, some aunts and uncles and various other influences, this is a guiding principle in my life, which is not only the right way for me to live but also makes my life happy and fulfilled.  During my childhood we occasionally had a sickly, neglected and abused boy spend weekends at our home; an elderly man being nursed in his home by Mum spent Christmas Days with us and I often went on the “District Run” with Mum when she visited patients in their homes as the local nurse, which were some of the most interesting times of my most formative years.  Mum’s sister and her husband who we regularly stayed with also often had “strays” at their home and to this day all of them have an open door policy for visitors.  It’s a rewarding existence for them and they are young spirits because of it.  I credit them with my journey into public health and all of the experiences I have had which ultimately led me to this year in Cambodia.

Prior to 1943 there were no known anti-TB medications and TB patients received supportive therapy only.  This included such things as being nursed in high altitude locations where the clean dry air was considered curative; being nursed in TB sanitoria on open verandahs (for ventilation) in direct sunlight (which kills the bacteria) and various outdated medical procedures such as collapsing the lungs.  In 1943 a drug named Streptomycin, derived from a species of bacteria called Actinomycetes was discovered to kill Tuberculosis bacteria in doses that were reasonably safe to the human host.  The first human to receive Streptomycin, 21yo “Patricia T”, had a severe case of Tuberculosis and had been a sanatorium inpatient for over a year when her doctors approached her in late 1944 with the offer to trial this new drug.  In the first experimental treatment trial she received three hourly doses of the drug which proved very difficult due to side effects and she eventually ceased the treatment with little improvement.  The second trial with an improved formulation and dosing schedule cured her TB and saved her life.  The scientists credited with discovering Streptomycin went on to receive awards and royalties under circumstances which led to a very public rift between them.

Despite the breakthrough that Streptomycin provided in treating Tuberculosis, it was a short-lived success due to the bacteria’s ability to produce enzymes to combat the antibiotic, which led quickly to Streptomycin resistant forms of TB which could no longer be cured.  Hot on the tails of Streptomycin other anti-TB drugs were thankfully discovered and the use of multiple drugs at the same time was found to combat this resistance, providing a long standing cure for the disease.  Despite it’s ability to treat TB, the use of Streptomycin was ceased as a standard first-choice treatment, which I understand is because of the need to administer it as an intramuscular injection (the other first line drugs are oral) and the many possible side effects of Streptomycin which can be severe, the most significant example being ototoxicity, leading to possible deafness.  It is still used as part of treatment regimes where resistance to other drugs is suspected or known.

On Wednesday I went on a field visit to a remote village with some colleagues to meet with a patient who is not complying with his TB treatment.  Known as “retreatment”, the drug regimen he is on includes daily injections of Streptomycin for the first two months of an eight month course.  This is because the patient was already treated for TB once and his TB recurred, suggesting a possibility of some level of resistance to the standard drugs used during his first treatment course.  Streptomycin is added in the retreatment of such patients to strengthen the chances of a cure.  However use of Streptomycin comes with some complications.  Because it must be administered by intramuscular injection, the system in place here requires patients to remain in hospital for their first two months of treatment in order to receive the Streptomycin by trained staff.  Due to the high number of TB patients and the various supports put in place to assist them through treatment in an environment where very few supports are available, whilst seeming to First World eyes to be an unnecessary strain on the patient as well as the hospital system, this arrangement is considered the most practical to ensure good adherence.

Should retreatment patients not wish to remain in hospital, they can go home and have the Streptomycin administered by a Home Based Care Nurse who their local Health Centre will nominate.  However these nurses require financial assistance to carry out the work, to cover the cost of petrol getting to their patient each day and by way of acknowledging their time.  It costs between 3,000 (75c) and 5,000 ($1.25) Riel per visit, ie per day – money which many Cambodians cannot afford.

The patient in question is 42 years old and has an amputated leg which I have not asked about but it would be safe to assume he is one of Cambodia’s many landmine victims.  He decided to return home and have his Streptomycin injections via a Home Based Care Nurse.  However, within about a week he realised he could not afford the injections and while he continues the oral medication reliably, he ceased the Streptomycin.  This places him at high risk of developing Multi Drug Resistant TB (MDRTB).  So my team were deployed to locate him, discuss the matter and convince him to return to hospital to continue the Streptomycin free of charge.

It was about an hour’s drive out of Kampong Cham through some very rural areas, to the patient’s home.

Village Wat in rural Kampong Cham
Village Wat in rural Kampong Cham
Visiting a rural patient
Visiting a rural patient

He cannot afford to pay the HBC Nurse and he also needs to be at home to care for a young child while his wife works in a labouring job on the rural land where they live while she is employed here, to pay off a debt that is weighing them down.  We sat with the patient, his wife and two of their children for over an hour, hearing why he doesn’t feel able to stay in hospital but also cannot pay a HBC Nurse for the injections.  The nurse and social worker spent considerable time and energy explaining the risk he was putting his own health and that of his family at, by taking this approach.  My nurse gave an excellent analogy to them, of mixing cement and sand together but not using any water and expecting to make concrete, comparing this with treating his TB with the oral medications but ignoring the injectable.  After an hour or more of discussion he seemed unconvinced that he would follow our advice.  Unlike Australia and other western societies where there are laws in place to force non-adherent patients to follow advice when public health is considered at risk, there are no such protections in place here.  It was suggested that I say something and so I talked about recognising him from his recent stay in hospital, but that now I know his story I would be able to support him more than I did last time (I did not actually meet him last time).  That the burden of debt seemed foremost in his mind right now, but that when his health deteriorates this debt will seem insignificant.  That we work as a team with our patient as a part of that team and that we would support him and he can talk to us about his problems and we can try to find solutions together so that he can recover his health.  That two months is a short period of time, is going to prove negligible in the overall time it will take to repay their debt and that once he is well he will be able to contribute more than simply staying at home with the baby.  He listened but we left not knowing if he will follow our advice or not.

It was quite an experience, sitting under a hole-riddled rusty tin roof on an elevated bamboo floor in this wall-less hut, trying to convince someone from a world so far from mine, that I could remotely understand his predicament.  A young woman bathed her toddlers by pouring pots of cold water collected from a nearby well over their tiny brown bodies as they jumped and skipped to one side of us and some young teenagers walked past and stopped to stare intently at me for a moment or two.  The patient stated matter-of-factly that the debtor had told him that if he died his wife would be cleared of the debt.  My staff talked further about the possibility of a healthy future but I wonder at how much influence it had.  As we left I said that I would be very happy to see him oneday soon at the hospital.  He smiled back.  We drove home through fields of workers harvesting cucumber, school children cycling home along dusty tracks in their blue and white uniforms and crazy overladen vehicles transporting all manner of agricultural produce.

One of the most concerning patients I have encountered yet, is a 25 year old woman who weighs 21kg.  It is difficult to describe what this looks like.  Many online BMI calculators are unable to calculate her BMI because her weight and height are such an improbable combination.  Everyone is aware, not least of all the stunningly beautiful and  highly intelligent young patient, that she is teetering on the edge.  She had a tumour removed from her abdomen a few years ago, and without being too technical, developed a number of different complications which led to her requiring further surgery.  She now has a colostomy on one side of her abdomen and an irreparable wound on the other side which her mother dresses many times per day as it oozes faecal matter.  Despite eating very well she is absorbing about 50% of what she should be and so in front of our eyes, is fading away.  Since admission to hospital where we are watching her intake, providing nutritional supplements and can see she eats well, she lost 800g in a week.  We cannot say for sure that there is no hope because she may somehow beat the odds, especially if she starts to absorb some of the nutrients going into her emaciated body.  But it seems as though the inevitable outcome is also the unthinkable outcome.  She has a 3yo son who she asked one of our doctors to adopt one day and the following day told me she would like me to take care of him “so that he can learn the way that you have learned”.  This is the value placed on western education.

When I asked her if there was anything that she needed to make her stay in hospital more comfortable she said that she would like some English books to read.  I asked her in English “do you speak English?” and she replied in Khmer to my translator that she did learn English but she can no longer speak it because she has forgotten much of it, but she would like to practise with some books.  I provided some basic story books to her.  This morning when I visited her room, her mother became visibly emotional and said via my translator “when I see you coming it uplifts my heart”.

As she is Muslim there have been some issues regarding nutrition for her and she has eaten rice and eggs for over a week now which is not enough to turn the tides of malnutrition despite the added protein and vitamins supplied.  So today I went with her mother to a Halal restaurant to arrange meals she will eat.  Perhaps this will increase her chances of absorbing some protein and nutrients.  As we were leaving the restaurant, having put some arrangements in place to ensure that she will be nourished during her time in hospital, her mother repeatedly thanked me and then said that she had decided to take her daughter home to die until she met me, and that she is keeping her daughter in hospital now because she feels there is some hope with me involved.  She then stated she hoped that even if her daughter dies, that I might sponsor her family because she has five other children and a grandchild, their lives are a struggle and she would love to see them educated.

When I came home from English lessons with my small homeless charges the other night we were joined near their hammock by a small and grubby, almost Dickensian-looking homeless boy who knows the girls.  He was curious as to who I was and why she was with me.  The next day she approached me wanting to tell me something in Khmer.  Her grandmother seemed embarrassed by whatever it was and refused to engage with her about it.  I had an inkling that I knew exactly what it was.  We found an English speaking Khmer colleague who translated for me that there were some other children who wanted to come to English classes with me.  I could promise nothing because a) it will not be possible to bring anymore children than we already do, to the orphanage and b) this means committing to yet another English class!  But I did not say no either.  The son of my cleaner who has joined us for almost two weeks of classes now, had apparently asked his mother if he could do English classes which was not an option due to the cost involved.  So finding a free class with me was a solution (of sorts in my mind – apparently of epic proportion in theirs!).  There is a serious disparity between supply and demand in these parts!

There is a block of prison cells near where I work and recently complaints were received that the guards are causing a lot of noise at night.  One of them slung his hammock strings around one of the barred cell windows and broke the bars, so that now there is a gaping hole through which the prisoners may escape.  The guards apparently drink and play cards.  They also allegedly accept payments from women who wish to visit their imprisoned boyfriends or husbands, and when enough money exchanges hands, the women are allowed into the cells!  When I almost choked as this story unfolded, someone translated for me that the guards are government employees who make very meagre wages which they have to supplement to feed their families, that they are on the lowest rung of the ladder in a corrupt system and that it really is not a very shocking story if you understand how the system is.

It’s clearly not possible to change the whole world but that doesn’t mean you should not try to make a few small changes in your little corner of the ring.  Many now successful places such as New York and Sydney have dark and corrupt histories, which eventually unfolded into mainly-good places with prosperous economies.  The third world as it is now can also evolve successfully and there are many signs in many places, including Cambodia, that this is slowly happening.

Kindness random

4 thoughts on “What Starts Here Changes The World

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