That’s my thong buried deep in Mekong Delta mud. My foot was down there too, a moment before I took this photograph, at which time I was doubled over laughing. It was a strange combination of hilarity and panic. The idea of parasites burrowing through my skin into my capillaries and worming their way to whichever organ they are most suited to destroying, contributed to my uncontrollable cackles. Chom’s comedic commentary played no small part either.
The experience of being on the receiving end of the health care system in Cambodia has been predictably interesting. First with the birth of Chom’s son two weeks ago at a private, fee-for-service maternity clinic and secondly this week with The Eyes. I am always reminded, when I attend health services with patients, how vulnerable we are to the behaviour of those employed to serve us. Nowhere is this vulnerabililty more profound than in places where people are already incapacitated by poverty, illiteracy, ill health and the crushing consequences of corrupt systems.
In the 1970s an international scandal erupted, exposing certain formula milk companies who were aggressively marketing their products in the Third World. It was estimated by US Agency for International Development, that a million babies were dying each year from malnutrition and diarrhoea, directly due to marketing strategies employed by companies to encourage mothers to abandon breastfeeding in favour of formula. Free samples were supplied to new mothers amid zealous and dishonest promotion of the benefits of these products. This assisted in reducing mothers’ breastmilk supplies, which are generated by suckling, quickly causing mothers to become reliant on formula to feed their babies. Once free samples ran out, many were then unable to afford the formula they needed. Lack of access to safe water, temptation to dilute milk in order to make it last, and inability to read product instructions, all contributed to the carnage.
This all happened over forty years ago now. Since then Australia’s “Baby Friendly Initiative”, ensuring that babies and parents are protected against company marketing strategies, has been in place for years. This prohibits companies from promoting baby products, particularly formula milk powders, anywhere near maternity services. While the baby formula scandal is infamous to this day, in my rich world perception, it is historical. As such it was, but should not have been, surprising to learn that in Cambodia no such protections exist against formula and baby product marketing.
Visiting Chom’s new baby at a maternity clinic two weeks ago, I observed in quick succession: a mountain of motorbikes at the front entrance, followed by a mountain of shoes outside the door. I kicked my own shoes off into the jumble, but upstairs Chom said he’d already lost two pairs of shoes from there, so he ran downstairs and rescued them for me. Inside the bustling foyer I was curious at a mountain of tiny eggs piled on a plate at the seated knees of a sole seller. Two shops on either side of this foyer inside the clinic, are stacked high with baby products including floor-to-ceiling baby formula next to equally mountainous supplies of bottled water! Abandoning my usual self control, I grabbed the camera and snapped a couple of photographs to share with the midwives back home, before heading upstairs to meet Microphone’s baby brother. I ducked and weaved my way through crowds of mothers, neonates and visiting family members in and around beds on the open plan mezzanine floor, towards the expensively furnished double room where Chom and his cute little family were relaxing in privacy.
The story of his birth reinforced my assumptions after seeing the marketing of products at the clinic entrance. Dad, not allowed in the delivery room, sat at the doorway in the corridor. Upon delivery, as research recommends, baby was immediately placed on Mum’s chest to start feeding. A short while later however, Mum needed “to be checked”. Baby was removed from her and given to Dad. Soon enough hunger set in and his persistent cries while Mum remained “unavailable” in the delivery room, eventually became distressing enough that grandma made an executive decision to purchase formula milk at the shop downstairs, plus the required bottle and teat. It was a natural birth and there was no apparent medical or other reason for the baby to be kept away from his mother at all, let alone for so long.
My visit became a mission to educate the family on the benefits of breastfeeding and the tricks employed by formula milk companies to make money. Yesterday, almost two weeks later, I was relieved to hear Chom say “we already threw away the milk”. The same can no doubt not be said for the many dozens of babies born at this one clinic of many likely practising in similar ways. Talking to Win at breakfast the next day about this, he said “this is why they generally don’t like white skinned people like you to come to their clinics”. Which is not a reference to my white skin so much as my level of awareness about issues such as formula milk!
This week’s trip to Phnom Penh dragged out for four days, full of health practitioner and health system revelations and frustrations. Advertised as “free of charge to the patients” on an Australian NGO sign above the registration window, I soon parted with around US$200 before the experience ended, without including transport, food and accommodation. Cataract operations are free, courtesy of this NGO, but all other procedures and all medications are charged for. For patients who have no idea why their vision is impaired, many of whom have to go into debt to afford the medications even if their surgical procedure is free, this surely seems like false advertising.
Thanks to a few family members who recently donated money to “Cause Cambodia”, when the doctor explained that there were no donors for strabismus correction, I replied “okay so I can be the donor”. Selena was horrified to see me hand over $100, until I explained that my family had heard how sad she was about her eyes and had contributed the money, prompting a low bow of gratitude. I also became the donor for Mary-Lu’s thick-lensed glasses which allow her to see properly for the first time in her short life. Simona’s cataract removal surgery was free, apart from the post-op medications, but unfortunately she remains severely vision-impaired.
After an afternoon review by a very personable Khmer doctor on Monday, we returned at 0830am Tuesday morning as instructed. A disorganised crowd were congregated around the registration window. I soon learned that if I didn’t stand my ground I would spend the entire morning being shoved aside by some monumental “pushing in”. With size on my side, after the first few pushers got in front of me, I simply stood my ground, keeping some sort of informal place in the mayhem until I finally reached the reception window.
The registration nurse, who I later observed assisting with minor procedures, had the worst attitude of any Khmer person I have ever met, apparently unable to mask her distaste for the lowly humans on the receiving end of her rude and dismissive conduct. Refusing to speak to me in either Khmer or English, I called upon Tuk Tuk to communicate on my behalf and we were told to “wait”, with zero explanation. With no other choice, we waited. For two hours. The following day I was instructed that both Selena and Simona needed protective sunglasses. Walking up the driveway connecting the main road with the hospital grounds, I found a pharmacy selling sunglasses but Arrogant Nurse was the shopkeeper! Clearly making an income selling sunglasses and medications to the patients she victimises at Reception, I refused to hand my money to her. Tuk Tuk very patiently drove me out onto the highway to locate a sunglass shop nearby, where I parted with $2 for two pairs of Ray-Bans! That, and putting her photograph on the internet, makes me feel avenged of her contemptuous treatment of us and others unfortunate enough to end up on the receiving end of her substandard “care”.
The post-op medications alone came to US$35, which would be prohibitive to most Cambodians, including Selena and Simona. With no explanation as to what the eyedrops and pills being bagged up without proper labeling were actually for, I was shocked at the price and spent an evening at the hotel researching the medications and expected prices. All were sold to us at first world prices, but dispensed in third world fashion, unlabelled and with no explanation except when to take what, written in marker pen on the packets, eg 1 x 3 (1 tablet three times a day). My research showed that some were recommended post-surgery and some were less necessary and more precautionary. In my shock at being charged yet more money as I stood underneath the “at no charge to patients” sign, I took a risk and only agreed to purchase the eyedrops for Selena, forcing the nurse to remove multiple packets of tablets from the equation. I then explained to the sisters that they could share Simona’s Paracetamol and Zinc tablets, amid protestations from a nearby patient who (quite rightly) knew not to tablet share. Reinforcing that vitamins and Paracetamol are over the counter drugs which can be shared, Tuk Tuk translated this to my growing audience with apparent success. Slightly anxious that Selena will now get an infection or other complication because of my frugality, we rang today and learned that both are feeling well. So far so good!
After two nights in hospital, the family were discharged yesterday and we made our way with Tuk Tuk to the nearby market which minivans use as their pick-up station. Hawkers at these locations often run out into the road, shouting and competing for custom when they see potential passengers approaching. Tuk Tuk nodded at the first hawker and we were immediately surrounded – jumping onto the steps of the tuk tuk, running behind or alongside us, the wheeling and dealing shouted around me was completely beyond my grasp but a moment later bags were whipped off the tuk tuk and into a yellow van. I stood at the door watching the women and two girls climb in and over the seats to the back of the van, wondering how their travel sick selves were going to cope back there. The seat directly behind the front passenger seat was saved for me, so I sat three rows in front of The Eyes, and spent the journey reasonably unaware of how they were getting on. Occasionally I would look behind to see Selena’s head leaning out of the back window.
From my comfortable front seat, only slightly squeezed in for only some of the way, it was a surprisingly uneventful journey. As well as stopping at routine points along the way, the driver honked at people standing on the roadside, stopping for those waving him down. We dropped off and picked up the whole way home. At routine stops, beggars and sellers leaned in every window trying to sell their wares or hoping for a donation into their begging bowls. In Skun fried bugs and spiders were the predictable order of the day but the wide eyed baby on her beggar mother’s hip was the biggest mutual attraction. When she realised her baby was staring in fascination at me, the mother stopped begging to appreciate the hilarious experience of what may have been the first time her daughter had ever seen such pale skin or blue eyes.
Disembarking in Kampong Cham, I learned a very unwell Selena had vomited the whole way. “Oh my god! You should have given her a bag” came Chom’s belated advice. “I did!”. But she vomited too much, and the bag was too small! Clambering over the seats to retrieve my bag from under their seat, vomit rubbed against my arm from the side of the case. I passed it out through the back window to Chom who, sickened by the smell of his own newborn baby’s pooh, immediately began dry retching! Tipping the driver apologetically as he wiped the floor with someone’s t-shirt, we squeezed onto Chom’s tuk tuk with all our gear and “they want to go straight home”, headed straight to their village 30km upstream.
After a brief interlude with Joe and his wife, very happy and thankful to see their little family safely home again, we headed back to town on the muddy roads. Making a shortcut turn just outside their village, Chom hesitated at a muddy patch across the track and asked what I thought. “It’ll be fine, go!” was my reply. A moment later we were bogged. “Oh my god, why did you say to go!”. Jumping out to help push, the rest is explained in the opening photograph. In mud up to my ankles, I helped us out with some serious pushing and on we went as the mud dried itself into a layer of cake tightening it’s hold on my skin.
Coping with some serious parasite OCD the rest of the way home, we encountered another puddle on another shortcut turn, and risked it again, unbelievably becoming bogged again! This time the tuk tuk was immersed in a big brown puddle, angled sharply ro it’s right over the muddy water. Remembering the last time this tuk tuk turned onto it’s side, I stood on the skyward-facing step and Chom shouted at me to jump off and push. Hesitating as I looked down into the water, which was up to Chom’s knees, I remained on board as he stood beside his moto and revved, sending the tuk tuk onto an even sharper angle. “Oh my god! Why are you still there! I thought you already got off!”, he shouted when he realised I hadn’t moved and wasn’t helping. Just as I was hysterically about to force myself into the puddle, with my foot hovering over the water like a child afraid to get into a cold swimming pool, a man and two young boys appeared out of thin air and Chom translated “they will push, they said you can stay there!”. Feeling like a queen in her chariot, the four males powered us out of the bog, sending the tuk tuk back into an upright position. We chugged off with shouts of thank you and good luck at the rescuers shrinking out of sight behind us. Chom’s final words on the matter were “see how the poor people, they have nothing but they still give everything that they can?”.
On the way home I fantasised about the long body scrub I was about to have and pondered on how my stressful hospital experience in Phnom Penh was completely washed away (admittedly with muddy parasite-ridden water), as soon as Chom re-entered my life. Life’s about to get a whole lot more boring.