Rice and Resistance

When it’s time to plant and grow the rice, it’s time for Barang to take a lot of photographs ~ Me, July 2014

Rice planting in Tboung Khmum Privince, July 2014
Rice planting in Tboung Khmum Province, July 2014

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Our current pre-language-class routine happens at the end of three work days per week.  One, two or three of us meet three of our young students at the office, wander past another location to meet the next two (temporary) students, then wait at our usual pick-up point for Chom to arrive in his tuk-tuk.  This area is always busy with moto-dups (motorbike taxis) and tuk-tuks who initially waved or called to us for custom but have come to know we have an arrangement in place so instead they now banter with us, mostly in Khmer so we have no idea what’s being said but it appears to be quite amusing with lots of smiles and laughter exchanged.  When Chom arrives the children pile in while the adults cycle alongside or in bouts of energy race his tuk tuk, to the hilarious squeals and shouts of excited children.

For the past few weeks murmurs of more students have become a part of this experience.  It started with one of the homeless girls talking to me at length in Khmer, which I knew due to the nervousness of her behaviour related to a request of some sort.  When I returned with my translator she said in the presence of an agitated grandmother who was clearly concerned about the subject, that some other children want to learn English with us.  I asked her to find out how many and said we would discuss it once I knew.  When she didn’t broach the subject again I promptly forgot about it.  But it has been approached another way since then, with children turning up at the meeting point hoping to get a seat in the already overcrowded tuk tuk.  Last week we agreed to take on two temporary extras who are in town due to an ill father.  But they are by far not the only interested extras and as we approached the meeting point last night, a mother with her young daughter was waiting for us.  It was obvious what she wanted but not so easy to explain to her why I was turning her away.  Among the crowds a woman with very limited English tried to act as translator but combined with my limited Khmer we were not in sync at all.  When Chom arrived he explained that the girl is eight years old and has never learned English before, but her parents would like her to and she is only one more student, the mother says she can fit on the tuk tuk.  The little girl looked shyly at the ground as I explained via Chom that we could not bring her but that I will speak to her mother with my translator tomorrow.  Who knows what arrangement we’ll put in place, but I sense a monster growing!

More surprising than the extreme desire for English lessons is the number of people around me who are homeless.  It’s not possible to pick them the way you can in a western country.  They’re clean and well presented with no visible clues as to their desperate circumstances.  But the circumstances are usually shocking, at least to me.  Even more so is the vulnerability this creates, which I’ve talked about previously.  Last night the newly formed Child Protection Unit announced the launch of their website (https://www.cambodianchildrensfund.org/cpu/) amidst reports of a sting operation in which an English school founder was arrested for allowing paedophiles access to his students.  http://www.phnompenhpost.com/national/school-boss-arrested-sting  This is an extreme example of the Orphanage Tourism issue I’ve mentioned before.

Meanwhile the English lessons continue to go well, with all of our students in various states of enthusiasm beginning to speak small amounts of English with us.  We mix the lessons up and have a combination of chaotic game-playing mayhem, to quiet reading, spelling, listening and speaking.  It’s very interesting to find yourself reading an English story book to 17 children, ranging from 6yo to 16yo, listening intently to you as though they know what you’re saying when you know they actually don’t.  Thankfully we have some decent short and rhythmic stories with great illustrations, which Bea brought back from Australia on a recent trip home.  Perhaps the pictures or the rhythmic repetition is what mesmerises them so?  Teaching directions the other day, Bea had 17 children lined up behind her, imitating both words and actions as she shouted “left” and threw her left arm out, then “right” and threw her right arm out.  This was imitated by 17 young followers, including a six year old who was eagerly throwing both arms up simultaneously as he shouted at the top of his voice, causing much hilarity among the crowd until I stood behind him and took control of his little arms to show him the meaning of the activity.

Since I began my job here nine months ago our program has diagnosed at least 18 patients with Multi Drug Resistant Tuberculosis (MDRTB), which is a complicated and very difficult disease.  Each month the team, including doctors, nurses and social workers, meet to discuss the ever-changing list of MDRTB patients under our outpatient and inpatient care.  These meetings are  intriguing, partly because of the clinical issues but mainly (for me) because of the social situations discussed, which are so normal to Cambodia and so abnormal and horrifying to me.

The first thing diagnosis of MDRTB does to a person’s life, apart from the often-severe physical ailments, is render them home (or hospital) bound.  This restricts (at best) or eliminates employment opportunities which, in a country where 20% of the population earn less than $1.25 per day, threatens food security and associated issues such as shelter and basic family concerns related to money, for example paying school fees or repaying debt which is such a common feature of Cambodian life.  These things are an ever-present concern for those able to earn money let alone those rendered unemployable for prolonged periods of time in a country where there is no back-up system.  It is therefore very common for MDRTB patients to have very stressful home situations with parents, children and others pressuring them or having to leave to find work as the usual breadwinner can no longer provide.  Separation and divorce are also common in this group.  This in turn leaves patients who are in need of care, alone or in very challenging situations, sometimes caring for others when they are in need of care themselves.

One of our patients is a man in his 40s with Rheumatoid Arthritis which has deformed many of his joints.  Combined with MDRTB, this degenerative condition which is also very painful has resulted in the patient being unable to earn any income.  His only pain relief is Paracetamol.  His back is bent, his hands and legs are deformed, with further deformity over the coming years a medical guarantee.  Every month we discuss his circumstances which entail a sick wife who has left to live with extended family so that she is not a burden on her unwell husband, who she is unable to care for.  Every month his main concerns are the illness and absence of his wife, the worry of being so poor with no way of earning income.  Every month ideas are spouted about who may be able to provide a little support to him.  Every month nothing changes in his situation.  For the moment his TB diagnosis means that he receives a monthly food basket, so he is able to eat.  I have no idea what will happen once he is cured, which is thankfully six months away yet.

Another patient regularly discussed is a young woman who presented to hospital unconscious with a large mass in her abdomen.  Investigations found disseminated tuberculosis – meaning the bacteria had spread throughout her body.  It was in the lining around her brain, in her bones, her joints, her intestines, the lining around her lungs and in her lungs.  The meningitis rendering her unconscious led to permanent deafness.  Once she commenced treatment her condition improved but she is on long term treatment for DRTB which causes joint pain, nausea and vomiting and she often wants to stop the treatment, meaning our team have to work hard to provide support and encouragement to her and also to the Home Based Care Nurse, a village volunteer responsible for administering her daily medications.

A middle aged man who lives at home with his wife and a son who suffers from psychiatric illness experiences general body pain, dizziness, poor sleep, hearing loss, hallucinations and gynacomastia (growth of breast tissue) due to the severe medications he is required to take to kill the DRTB in his body.

A young woman has fever, shortness of breath, loss of appetite and conflict with her mother who has a lot of debt and was relying on her daughter as the breadwinner.

An HIV positive middle aged woman diagnosed recently with DRTB refuses to attend for treatment because she has young children.  She has to be in the rice fields everyday or her family will not eat.  So we discuss ways to support her so that she will agree to receive treatment.

A middle aged man has had to stop his teaching job for at least a year, but thanks to an official letter from our doctors to his employer, he continues to receive his base salary until he can return to work which is one positive light in the sea of darkness.  When he first presented to us, he was a bright vivacious person but since commencing Cycloserine, one of the drugs used for DRTB, which is often dubbed Psychoserine due to the well known psychiatric disturbances it causes, he has become serene and quiet, reporting regular nightmares.

When I learned about the severe side effects of DRTB from books and articles in Australia where DRTB is a very rare occurrence, I never imagined the associated social ramifications this causes on populations already challenged by poverty, low literacy and limited protections against extreme privation.  With my first world brain I see the patients as having “many problems”.  But “problem” is not a word I ever hear my Cambodian colleagues utter.  They use phrases such as “we will need to try and find a solution”, always looking towards a fix and never focussed on the obstacle itself.  When I told a colleague yesterday that this has been an observation in my time here, he replied “yes, because we always have to think about how to fix things, because Cambodian people have a lot of experience with finding solutions to many things and I think in your country, you have less experience like this”.  A very insightful reply!

Information about MDRTB can be found here: http://www.tballiance.org/why/mdr-xdr.php

Direct Observed Treatment in a patient's home: MSF Nurse, Village Health Volunteer and a family member discuss the medications
Direct Observed Treatment (DOT) in a patient’s home: MSF Nurse, Village Health Volunteer and a family member discuss the medications to be administered daily to the home based patient.
TB patients await their doctor's appointment, Kampong Cham Hospital July 2014
TB patients await their doctor’s appointment, Kampong Cham Hospital July 2014

Below are some photographs of typical Cambodian homes.

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