Yesterday four of us (2 Australian, 1 French and 1 Slovakian) cycled a 70km journey through the Cambodian countryside. We had two aims. First, to experience the fairytale scenic villages along the shores of Kampong Cham, including a visit to a beautiful temple complex. Second, to visit a young patient who was sent home from hospital last week, in very bad physical condition, to very dire living conditions, but with a caring and attentive family who may possibly be her saving grace.
Where I come from this patient would receive intensive medical and nursing care and have an excellent prognosis. Unfortunately due to her birth fate, she probably won’t see her 26th birthday. After a prolonged hospitalisation, we have developed a relationship with her and some of her large extended family. We wanted to visit her for a clinical review but mostly to provide her with some hope. She teeters between dying (the assumption our remote advisers have made about her fate) and some hope for survival (our admittedly biased sentiment for her). She regularly asks is there hope and we have truthfully told her that there is. She also regularly darts between crying uncontrollably and making comments such as that she is no longer afraid and other references to the death that seems imminent. Despite having a good appetite, due to her clinical condition she weighs 23kg.
It was my fourth visit to her home, approximately 30km from town in a picturesque but very poor rural riverside village. The first three visits were work related and I attended in order to follow the case through from hospital to home, in a purely supervisory role with the nurse employed to undertake this work. The first visit was to identify and recruit a Home Based Care (HBC) Nurse to provide her Direct Observed Treatment (DOT). We located a trustworthy and respected Village Health Volunteer (VHV). Each village in Cambodia has two VHVs whose job is to identify TB suspects and refer them for diagnosis; to follow up TB patients; and to provide regular health education in the village about TB. The purpose of this work is to optimise early diagnosis and treatment, one of the most important interventions in reducing the spread of TB. We then returned to train him about MDRTB (which remains rare enough that the VHVs are not usually involved with this). We then discharged the patient on Wednesday and traveled to her home early Thursday morning to meet the VHV at her home and supervise / advise on the first home DOT, as well as to ensure that she had all the materials needed to care for her wounds, etc.
The materials for her wounds are the most basic, just gauze and tape with some trials of other available dressings which will eventually deplete. Her wound nurse is her mother, who has an excellent clean technique and is far more attentive than any nurse she could have asked for. This week some discussion around dressing materials included a suggestion that items might be provided which could be washed and re-used but after attending her home on the riverbank where her mother does laundry in the muddy brown water of the Mekong, this idea was immediately quashed. Having only ever nursed in Australia and England it is impossible for me not to make comparisons against the places I am familiar with, where wound care specialists, cutting-edge dressings and other life saving interventions are available, ensuring a recovery back to full health.
In all of my experiences here, this case has most starkly highlighted the difference in value of life based on where you happen to be born. From the safety of the First World, despite feeling concern for people, I always felt a detachment from the little I knew of Third World plights. I’m not detached from this beautiful, intelligent, humble and grief-stricken young woman or her caring, attentive and grieving family. Yet I am removed enough from their situation that it is difficult to imagine the oppressive poverty that forms the basis of their existence. These thoughts play havoc with my imagination as I observe the pea-soup-coloured mud around the base of their elevated wooden shack, envisaging it turn to a large muddy lake once the rains arrive in full force. How will the children ever leave the house without drowning? At best they must be exposed to all kinds of bacteria and parasites living in the mud, not to mention the ideal breeding ground it makes for mosquitoes. How will I be able to visit her – the house where she lies on wooden floorboards in the middle room under the tin roof will seemingly be inaccessible? Are the holes in the tin roof too small for raindrops to fit through, or is she going to be rained on from above? What about when the rain sheets in at an angle as it inevitably will during tropical storms – will the gaps in the wooden walls expose her to the rain?
Questions galore for this first world brain as it sits on one of the borrowed red plastic chairs supplied for our visit just before lunchtime. We are surrounded by at least twenty family members seated on the floor before us, watching and listening as I speak on the phone with my translator, then pass the phone to the patient lying on the floorboards smiling up at us, or her mother. We pass the phone back and forth, smiling and each attempting a few words in the other’s language as we wait for a full translation. Children stare at us, adults too except that their eyes flit away quickly before we catch them. Many smiles are exchanged and bamboo-encased Khmer cake of sticky rice with beans is brought to us with bottles of cold water. Halfway through our Khmer cake we realise that noone else is eating and then we remember that it is Ramadan and they are all fasting! We stop eating and wonder if we’ve committed a faux pas, or if it’s okay to eat if it’s known that you are not observing Ramadan? It is too late to worry now, and we continue to receive many smiles so we must not have done anything too offensive, but we stop eating and utter “Somtoh” (sorry), which is accepted with gentle nods.
Between assessing the wounds, watching Mum re-dress them, the doctor performing a medical assessment, and a few other work-related issues, we also exchange some social conversation. Via telephone translation the patient tells us that she would like to thank us very much for visiting her, that she was very excited to see us and that last night she couldn’t sleep for the anticipation of our visit! As I pose for a photograph with her mother, she leans in and knocks her head against mine and my colleagues sigh in hilarious unison. We assure everyone that she seems much better than she did in hospital, she tells us how happy she is to be home again, we admire the many children surrounding us, they ask us did we really cycle all the way here and are we sure we didn’t park our car up the road and cycle only a short distance, they laugh at the many sweats we are oozing, and we leave feeling as though the visit was well worthwhile for everyone’s sake (not least our own).
Back out onto the bumpy, hole-ridden road which switches regularly between bitumen, sand and mud, we cycle back to Kampong Cham. A journey which began with conversations about how fantastic a cycling holiday through Cambodia would be, ends with sore thighs and bums and far less enthusiasm about mounting our bicycles ever again! We land at Destiny for a late and well deserved lunch, where the sight of our soaked and dusty bodies and the noise of our gregarious, adrenaline-driven laughter about how ridiculous we look and how hungry and sore we feel, immediately lowers the tone of the establishment. Thankfully noone seems to mind and an hour later, stomachs filled, muscles rested and recollections of a great day rehashed enough for now, we head home for showers and solitude before we spend the evening sipping wine on the balcony together, rehashing the thrill of a great day some more while rain lightly falls on the intact roof above us.
Cycling in the Countryside: Photographs from our day out