This week I met a new patient who was unable to control quiet tears every time any of the staff walked into her isolation room. That’s not especially surprising, being diagnosed with two stigmatising diseases (HIV and DRTB) in a country where the majority are already consumed by poverty-related stress. I knew that as the team asked her what was wrong. What I didn’t really get at that time, even though it is self-evident, was the tiny amounts of money which can cause extreme financial stress to people living in hardship in the third world. This particular patient, widowed and with a seven year old son relying on her, took out a loan with a micro-finance company and needed to work to make the repayments. But her disease diagnosis ripped her from her small job and planted her in hospital, unable to earn and therefore unable to make the repayments. The burden was weighing so heavily that her tears flowed.
As the doctor questioned her in the hope that we could understand her stress, she explained these details. Then he questioned her some more and she said that the repayments were 10,000 riel per month. That equals US$2.50 per month. He then asked how much the total debt was. I don’t know what I was expecting to hear, but certainly not the answer she gave.
One hundred dollars.
Were my ears deceiving me? The doctor repeated the amount and said that he understood now, why she was so tearful. My brain malfunctioned, readjusted and recovered over the next few moments. This small, malnourished, tearful woman was living in constant anxiety with years of repayments ahead of her, because of $100. This seemed like such an intolerable situation that when I had time to speak with my translator I said that I felt I should help her. Without hesitation he replied “yes, I think so”. So with the generous donation from a friend in England on my side, I met with the micro-finance company her loan was held with and we removed the debt from her life. Where there were once tears, there are now smiles. I liked to think that was the end of it. To the contrary, it was ironically only the beginning,
This morning our team met to discuss an older woman with a supportive husband, recently diagnosed with Drug Resistant TB (DRTB). From a community known for it’s high prevalence of tuberculosis, she was diagnosed with TB ten years ago and received three months of the recommended standard six month regime. At that time it was apparently not uncommon for patients in Cambodia to be charged for their TB medications and after three months she defaulted treatment as she could not sustain the cost. Some months ago she re-presented with TB again. It is quite possible that for the past ten years she has relapsed and recovered any number of times. She was commenced on Category II treatment, in which Streptomycin injections are added to the medication regime in order to address any possible resistance to the standard Category I drugs. This is a common problem for patients who have previously defaulted treatment (or who present with particularly severe disease).
Recently her sputum cultures, which can take up to 8 weeks to grow, returned a result of drug resistance, meaning that the medication regime has to be altered to combat the bacteria’s ability to produce enzymes which fight the standard Category I and Category II drugs. So today a meeting was held to discuss her case and determine whether she is prepared to commence the long treatment regime. This preparation includes medical / clinical condition as well as psycho-social preparedness for a long course of potentially toxic medications. This psycho-social preparedness includes a good understanding of the disease and treatment, possible side effects, preventive measures to be taken against infecting others, treatment adherence, follow up and social issues such as family support and financial concerns related to the loss of employment which inevitably accompanies a DRTB diagnosis.
The medical team started the meeting with her medical history and clinical presentation. The nursing team then discussed their insights. The previous treatment default was a concern as it means she has a higher risk of defaulting again, but this was explained by the fact that she had previously been required to pay for the treatment. The situation has improved markedly in Cambodia in the past ten years and patients are far less likely to come up against illegal charges for TB treatment which is supplied without cost. Without this barrier, the risk of her defaulting now is minimal. Time had been spent explaining the treatment regime with her and she was encouraged to speak to two other patients who have been on the same medication regime as is being recommended for her. After meeting with these people she felt reassured that she would be able to tolerate the treatment. The nursing team’s conclusion was that she was appropriately informed and prepared.
The social work team were then asked for their input. The first statement made about her was “This patient is in financial crisis”. Who isn’t, I thought to myself. She borrowed money to start her own business, cooking noodles and selling them from her home. She needs to continue working in order to meet the monthly repayments. She expressed concern that the treatment may not cure her disease, and reassurance was given that TB is a curable disease, and that with good adherence and recommended follow up, the aim of treatment is cure, but it would be months before we could tell her with any certainty, whether this was achieved. The conclusion from the social workers was that she was ready to commence treatment but that she is keen to go home as soon as possible in order to continue working so that she can meet her debt repayments. She is required to make monthly repayments of 18,000 riel per month (US $4.50) and the total debt is US$100. Her loan is to a neighbour, not to an organisation. Again I found my brain readjusting to the idea of $100 causing someone long term financial stress.
Cambodia has changed my perceptions and understanding of the world in very many ways. But this has to be the most significant yet. How can an amount that many people from my world earn in a single hour, be so catastrophic to people in this parallel universe? How did I never know this to be the case before now? As I got up to leave one of my colleagues stopped me to explain that in Cambodia there are a small group of powerful people who have far too much wealth, which they keep in banks in “Sweden? Switzerland? No, it’s Sweden”. They spend $20 every single day on their dogs, drive big cars and lavish various other extravagances on themselves, but they do not care at all about the people, and most of the people are extremely poor like this patient. As he criticised this small group of Cambodians, I pondered on the position that we in the western world hold in this scenario. Third World plights are a global issue, not separate national issues. Cambodian people are exactly like me and if my own country’s history was anything like Cambodia’s, then I too would be surviving this fate. Civilisations rise and fall and the West would be very wrong to assume our futures or those of our descendants will never face such struggles just because we have a comfortable existence today. Meanwhile, being able to occasionally help someone in some small way is far more fulfilling for me than it could ever be for the recipient. The experience for me has little to do with providing financial relief and everything to do with helping someone with an extremely inferior position in the world, to feel valued.
Meanwhile other discussions with patients have included a 58yo man whose grandchildren aged 7yo and 10yo are staying at home alone while he is hospitalised with his wife as his carer. The children are on school holidays and they have noone to cook for them while his wife stays with him, so she spends a few days in hospital and a few days at home with their dependent grandchildren. The children do not have a mother and their father lives at the other end of the country where he works on a rice farm, visiting his children for a couple of days each month. I said that I would take some colouring-in books to the children when I visit them and their grandfather did not know what colouring-in books were. Win tried to describe them to him but he had never seen such a thing and he looked blankly at us, unsure what we were talking about.
Another patient is a man in his 30s, father to two young children and employed as a teacher at his village school. Next week he is sitting his own high school exams. This indicates the current level of education in Cambodia. In the 1960s Cambodia had one of the highest literacy rates and most progressive education systems in South-East Asia. The University of Phnom Penh attracted foreign students and thousands of young Cambodians attended universities abroad, including Saloth Sar who attended a technical school in Paris for four years. He then returned to Cambodia, where he became known as Pol Pot and led the Khmer Rouge on their communist revolution, during which 80% of the country’s academics were murdered. By the end of the Khmer Rouge reign of terror in 1979 Cambodia had less than 50 doctors and their pool of 25,000 teachers had been reduced to 5,000. It is hardly surprising then, that today there is a discrepant situation with high value being placed on education, but too few human resources available to meet the demand.
This situation has also resulted in the high demand placed on Barang (western foreigners) who come to Cambodia and is the reason I find myself recruited to all kinds of endeavours which I would never have considered applicable before my time here. It seems another absurdity that those least in need of opportunity are those with the most opportunities available. I guess it is no different to the First World, where the wealthier you are, the more educated you are likely to be and the more likely you are to know people who can help you reach your goals. In Cambodia it is a very exaggerated scenario, which is the case with so many facets to life here.