Dealing with DRTB

As my project with Medecins Sans Frontieres draws to a close, reflections about the year laid out behind me prevail.  I am only leaving Cambodia briefly but my departure and the end of my work commitment here have me feeling very philosophical about this beautiful and catastrophic nation and the incredible experiences I’ve had here.

When my predecessor left in October last year I was present for his farewell speech during the weekly all-staff meeting in the foyer, when around fifty of our almost-100-strong team stand around for a briefing of anything important that needs to be shared.  What struck me most about his parting words was the cherished memories he would forever hold dear, of working with Cambodian people.  I hoped then that I might have a similar experience but I had no idea how powerful an effect the people of Cambodia would have on me.  The gentle, humble, unassuming and fun loving nature of my colleagues, the national members of the orphanage board I am now part of, the children, the patients and their families, is really something that western culture could learn from.  I hope that I have learned from it and I suppose the challenge will be retaining my sense of “calm amidst calamity” upon landing back in the ego-centric culture that I come from and belong to.

That’s not to say that Cambodia is without problems.  You only need to read a little about the Khmer Rouge and their contradictory gentle yet murderous nature, to know that gentleness is not necessarily all that it appears.  Cambodia’s military and police forces are corrupt, dictatorial and can be extremely violent, as the front pages of national newspapers here illustrate almost daily.   Yesterday I cycled to work on a high after my encounters with Dara and his Shackville community.  As I approached the boomgate, the young man operating it who is usually friendly seemed reluctant to let me through and was looking across the driveway at something I had not noticed yet.  He let me through and I was immediately confronted by a very stern soldier with a rifle slung over his torso who ordered me off my bicycle and motioned me with attitude to keep away from a formal ceremony which was taking place in the driveway.  I was knocked off my high very quickly!  The use of military force to protect dignitaries here is a visible and common sight, with said dignitaries usually living very wealthy lifestyles beyond that which most Australians can imagine.

Almost twenty years ago a friend instructed me that I absolutely “must” watch the Quentin Tarantino film Pulp Fiction.  I rented it one afternoon, watched it alone and felt very disturbed by my own laughter.  In fact what I was laughing at was cold blooded violence and I was conflicted between laughter and wanting to press the Stop button.  I’ve since discovered that Tarantino’s skill lies in causing internal conflict in his audience.  A similar but far less concerning disturbance occurs here on a daily basis.  One of the most significant features of my year has been the realisation of my naivety as a monolingual English speaker.  The exposure I’ve had to Khmer and European people speaking and working in English has been a surprisingly profound lesson.  I am constantly entertained by the hilarious invented modifications of English, but it disturbs me at the same time because I have absolutely no right to find humour in someone else’s multi-lingual talents.  I try very hard not to appear amused, but as a native speaker it really is comical to hear your language mangled, especially when the mangling is perfectly comprehensible despite being so wrong.

Working alongside a translator with an academic interest in English and language in general, has been a new and novel experience.  I’ve learned so much, not just about the English language but also it’s global domination and the power it possesses.  Win calls Generation Y “The English Generation” and often nudges me if we are in a remote place and a young person suddenly speaks to me in English, proving his point.  When we have attended schools and universities for health promotion sessions, he always says to the crowd when introducing himself as my translator, that anyone who wishes to practise their English on me should do so instead of relying on him for translation.  Most young people have spoken to the crowd in Khmer but we always drew a small private audience afterwards, wanting to speak and ask questions in English with me.  This always seems like an extension of the daily bike ride ritual of being pursued by young people on bikes or motos wanting to practise with me, or children shouting out excitedly “Hello!  What is your name?!” or “Hello!  How are you today?!”, usually laughing uproariously when I shout a response back to them!

There are two young volunteers working at the orphanage for the next few months, who have given me a respite from the English teaching.  The timing was perfect as I am busy with my final weeks at work and the lessons have been time consuming.  The “extra” students who travel to the orphanage with us are not benefiting from these volunteers though so I am unsure whether to continue a small class with them or wait until my return, when my sole occupation will be teaching English.  I continue to be approached almost daily by parents and children wanting me to teach them English so it’s a high-need occupation.

In ten years working with Tuberculosis in Australia I encountered one patient with DRTB.  Here however, I have encountered dozens in a single year.  It is a complicated disease with many facets to it, not least of all the social problems faced by patients who are almost always impoverished.  This week alone we became aware of a problem with a young 20-something woman with DRTB whose mother is, like so many other Cambodians, crippled by an un-payable debt connected to health care costs (not related to her daughter’s TB as TB care is free).  This young woman has been under constant pressure from her mother to get a job and help with the debt repayments.  The first time I heard this story we were at her home, a small elevated hut on the edge of a dusty main road with bamboo strips for a floor which I was afraid to walk on in case they broke under my weight.  Looking around her hut which contained a hammock, a bed mat and not much else, this was one of the first exposures I had to what it means to be actually, genuinely “poor”.  Since then this level of poor has permeated my reality as I visit patients’ homes regularly and lifestyles like this are the norm for most rural Cambodians.

This particular young woman has raised concerns within our team as she has given conflicting accounts of how she is now spending her days.  She should ideally not be working at all, as she remains potentially infectious and could spread her drug resistant TB to colleagues.  However, as she has expressed her lack of choice in the matter, it was agreed that she look for work based outside so that good ventilation would reduce the risk to others.  She has given conflicting reports though, and asked questions which have raised our suspicions.  She claimed to her community volunteer that she was selling in an outdoor market but upon quizzing by our social work team it was suggested she was actually working in a factory.  We interviewed her community volunteer last week and I quizzed him extensively, recruited to do so because of the influence I hold as a Barang.  Along with my nurse, we felt he was being truthful, in that he continues to treat her as he is contracted to do and that he is not complicit in her work activities.  In past cases, the volunteers can agree to leave medication with the patient so that they are not observed taking their medication, which goes against the principle of Direct Observed Treatment which is recommended for DRTB patients in order to ensure all medication is taken correctly as prescribed.  We are still in the throes of investigating her situation in order to try and protect the public as much as possible but in such a low resource setting it is a difficult task.  The next intervention we plan is to attend on a “surprise visit” to see her unexpectedly – we often find out a lot of information during surprise visits.  In Australia a patient like this would be isolated in a hospital room with many resources in place to ensure adequate treatment adherence.  The possibilities here are so much more limited, and tend to require very creative interventions which has been a steep learning curve for me.

This week another patient went home after months in town because his rural location meant there was noone able to provide him with his daily injection.  The injections have ceased and he could finally return home.  One of my nurses attended his home the next day to meet and obesrve the practice of his community volunteer.  He returned and told me “I am very pity for this patient because he is so poor.  The house is made from leaf and everything will come through the roof – the sun comes and he gets very hot and the rain comes and he gets very wet”.  This patient hopes to find work in a nearby rice field, and if that happens he can feed himself instead of relying on his neighbours to feed him, as is currently the case.

I’ve written all of that from the air conditioned comfort of a local restaurant where I’ve sipped diet coke, munched on rice paper rolls and watched my beloved construction workers out there in the 34C (“real feel 42C”) , 60% humid weather.  The chef went out and returned with an orange gas tank strapped to the back of his moto which he then lugged through the restaurant out to the kitchen.  A moto-drawn trailer pulled up at the front with empty sacks covering a pile of produce packed into sacks on the trailer.  The driver lifted a full sack of what looked like potatoes off the trailer, heaved it onto one shoulder and carted it through the restaurant to the kitchen.  A woman covered in the traditional checked sunhat with matching face covering cycled by with a plastic basket hanging from each handlebar and a large cane basket on the back carrier, all filled with produce for sale.  A man wheeled his bicycle drawn carriage loaded with green coconuts past.  The construction workers pulled their archaic barrow filled with sacks of concrete powder past.  An untold number of sidecar shops attached to the side of motos slowly puttered by.  Teenagers, some even questionably that old, drove past on their motos with three to four pillion passengers lined up behind the driver.  A bicycle rider held onto the side of a truck, speeding along without any effort.  Children on bikes, pillions sitting on the handlebars or standing on the edges of the back wheels.  A father on a moto with two children holding on behind him – the c.2 year old sandwiched between Dad and big brother of about 5yo who had his arms around little brother, clutching onto Dad’s shirt.  Utility trucks with passengers crowded onto the tray back drove by.  A large old wooden boat meandered past on the Mekong with jeans and shirts hanging from the outside walls of the wooden deck shelter.  A woman with a large round flat tray balanced on her head, selling breads and nuts calling out a catch phrase to attract customers sauntered by.

To finish, if you want to know how DRTB is dealt with in Australia, take a look at this very entertaining article.  Even TB can be funny when the right person is inflicted with it!

One thought on “Dealing with DRTB

  1. The power of English. I can see why parents go out of their way to try to find English lessons for their children.

    Great scenes filtered through my mind as I read this post.


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