They are late and still building momentum but the Monsoons have arrived in South East Asia. With a bit of fluctuation, the Mekong River is rising steadily. Slowly surging out into the delta, rising waters are transforming the lowest level green fields into massive brown lakes. Soon many villages will become submerged in a combination of rain and swollen river waters for up to three months. For now the rains turn everything to slush which, in the hot dry intervals between showers, quickly evaporates to dust. Muddy puddles make great paddling pools for raucous children who haven’t developed my obsessive-compulsive-disorder about tropical diseases. The other day I watched some children I know well, splashing around in roadside puddles before one of them ran over to me and leaned in for a hug. Before my brain switched on in time to prevent it, I was theoretically smothered in a textbook of parasite species. Consciously dissuading myself from OCD-induced panic, I took an unscheduled shower and determined to remember that course of Albendazole when I get home to Australia!
His krama wrapped turban-like around his head and otherwise clothed in just a pair of undies, Joe was sitting in his boat repairing the floor as we pulled up outside their bamboo gate last week. The shoreline is currently about 1km away but soon enough this heavy wooden canoe will be their only transport from the top steps at the front door. On our way out of town Chom and I packed the tuk tuk with eggs and stocks of long life food such as soy sauce, fish sauce, sugar and garlic: hopefully enough to last the family until they can reach town again in a few months’ time. At home on smooth bitumen roads I inevitably break eggs between the supermarket and my front door. In Cambodia they bounce around on unsealed tracks in a ricketty tuk tuk without so much as a hint of a crack. Even eggs seem to have an other-worldly tenacity for survival against the odds! After about an hour with the family I said my first farewells for the year as the roads will become impassable soon and I won’t be able to visit them again until my return sometime next year.
Speaking of tenacity, Paula has metamorphosed from a smiling and persevering bag of bones, to a laughing and animated bag of bones! We also visited her last week to get some paperwork signed for the upcoming journey to USA. Between us, including Chom’s invaluable and comical consultation, we decided that due to the language barrier, it was best to send “Samantha”, who coordinated Paula’s nursing care under my management and beyond, as their escort. She knows the family well and has good English skills, meaning she can translate for Paula and her mother on the journey, which I could not do if I travelled alone with them. Samantha has also never travelled before and so while it will be challenging for her to navigate airports and border control etc, she is perfectly capable and will be well prepped. She is equally excited about the opportunity to visit another country. The two young women speak daily now, for up to two hours at a time, about their upcoming, life-changing (especially for Paula) adventure. I love being a bystander to their excitement.
Meanwhile in the US there is talk of a television network covering Paula’s story! This would be deserved recognition, albeit only available to one of so many families in similarly miserable predicaments. Paula and her family are a prime example of the human realities behind various analyses of global poverty and near-poverty. In 2014 Cambodia ranked 136 of 187 in the United Nations Human Development Program’s (UNHDP) Human Development Index (HDI). This puts Cambodia 51 countries ahead of the world’s most impoverished nation, Niger. In comparison, Australia ranked second after Norway with USA at 5 and UK at 14. The indicators used to calculate the HDI include, but are not limited to, life expectancy at birth, mean years of schooling and gross national income. This is not a perfect tool because, for example, years of schooling does not measure the quality of education, which in Cambodia seems to be variable and lacking. This is hardly surprising given that a mere generation ago all of the nation’s teachers and other educated professionals were exterminated. The HDI is complicated and can be read in full at this link: http://hdr.undp.org/sites/default/files/hdr14-report-en-1.pdf
Despite the serious effects of the Global Financial Crisis of 2008, the news is not all doom and gloom. For example the World Bank reported that Cambodia’s poverty rate had decreased from 53.2% in 2004, to 20.5% in 2011. However, we should never look at this with blinkered “first world eyes”. The same report states that the impact of losing US30 cents ($0.30) income per person per day would double the poverty rate to 40%. The “near poor” status which many have transitioned to is not a safe nor comfortable circumstance. Many Cambodians are food-insecure, with almost 40% of all children under the age of 5 having chronic malnutrition.
In such a vulnerable population, one would hope for a basic level of health care to be available. No such thing exists although attempts are being made to implement a health insurance program to provide poor families with free access to health care. The situation is complex. World Health Organisation, in their 2014 “Country Cooperation Strategy – At A Glance” brief (http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_khm_en.pdf), identify poor regulation of services, high levels of out of pocket payments and poor quality of care, as significant challenges to the national health system. 70% of health care expenditure in Cambodia is paid “out of pocket” by the individual patient. In a population stricken by poverty and near-poverty, this manifests in high levels of debt and asset sales which can become a catastrophic cycle of financial obligation and destitution. Families sell property and borrow money, often at high interest rates, to cover the costs of health care intervention. Friends have told me that even basic interventions such as replacing an intravenous fluid bag or administering analgesia, can require a cash payment made to the provider before the work will be carried out and so officially reported costs could be severely underestimated.
I have known all of this for the best part of my two years in Cambodia. I have also encountered many patients in stress due to debt caused by health care costs. So why was I shocked when Samantha told me yesterday, about Paula’s family’s economic plight? The only explanation is because I was looking at them with my blinkered first world eyes. I knew that Paula has had multiple hospital admissions, surgeries and investigations for her unexplained and undiagnosed abdominal pain. I also knew that she has not contributed to the family’s income generation since her illness incapacitated her. The cumulative financial cost of her ordeal did not occur to me, despite evidence staring me in the face. Samantha had to spell it out to me.
Paula developed abdominal pain during her pregnancy almost five years ago. Over time she attended her local clinic, graduating to the regional referral hospital, and then a big city hospital in Phnom Penh. With little in the way of diagnostic resources, she was operated on a number of times. Prior to her diagnosis of Drug Resistant Pulmonary TB (DRTB of the lungs) in May last year, she had been told that she had incurable intestinal cancer. She was tearful, believing that her illness was terminal. This is not unlike a case of mesenteric TB I encountered in Australia, of a young man with abdominal symptoms which doctors mistakenly diagnosed as abdominal cancer. Obviously misdiagnosis is not the exclusive domain of under-resourced third world health services. We don’t know what her abdominal illness was, but upon commencing TB treatment the symptoms subsided. By then she had already undergone various surgeries resulting in a number of post-operative complications including gaping, non-healing abdominal wounds which ooze faeces and burn her skin, and malabsorption leading to severe malnutrition.
The economic cost of her five year ordeal has been sale of the family home plus a comparatively large and crippling debt, which sent her father and young brother, who should be in school, to Malaysia where they can earn more in a labouring job than is possible in Cambodia. As her main carer, her mother works early mornings selling vegetables from the back of an old moto around the nearby villages, before returning home to cook for Paula and tend to her wound dressings.
As is becoming a pattern with me, the main reason for my astonishment at the revelation of the family’s financial crisis, was my own ignorance of their plight. This is partly due to the lack of shared language, but also the yawning cultural chasm between my first world perspective, and the perspective of people for whom struggles like this are a commonplace reality. The mismatched underlying assumptions between those telling me something and me “getting” what this means continually throws my world view out of alignment. For example “we don’t live in our own home anymore” (I haven’t lived in my own home for two years either) and “Dad and bro have left to work in Malaysia” (I have also been working overseas) have very different connotations in their reality, than they have in mine. Coming from such divergent world views, it takes the likes of Samantha to translate for my first world brain.
As I talk to Samantha, Paula and her mother about what they can expect to see, hear and experience when they travel to big-city-America, where she will receive state-of-the-art first world treatment at no cost, I keep this chasm between us in mind. It will be interesting to learn how well I did in my pre-journey cultural preparations once they return. I fully expect there to be some assumption mis-matches which despite all attempts, I will not have been able to anticipate on their behalf.