In 2001 I visited a remote central Australian community about 800km from Alice Springs in my role as a public health nurse. I don’t remember the exact reason for my visit, but I spent some time wandering the community with a list of names and a cool box holding a small supply of vaccines, looking for people who had not been fully vaccinated. In fact, vaccination rates in indigenous communities are very high but there are pockets of high risk individuals not captured in certain areas at certain times.
Sitting in the dust with a group of young people, a very handsome teenager approached us with his nose poked inside a tin can suspended around his neck with a string of rope. After all the horrific stories I’d been told about petrol sniffers and the violence they perpetrate, I was initially afraid of him. I was also aware that he was at high risk of all kinds of illness and a premature death. He needed vaccination more than any of his non-sniffing peers. His name was on my list and he was eligible for three vaccines. I explained this to him with some trepidation and he told me to go for it. At no time during these three injections did he remove his nose from the can of petrol. The introduction of unleaded petrol throughout Central Australia has since seen petrol sniffing rates plummet to nothing.
Since then I have had all manner of interesting encounters with people doing all kinds of interesting things, both positive and negative. These experiences have played on my mind for years, as I try to understand from my perspective of comfort and privilege, how it must be to grow up and exist in poverty, surrounded by chaos. Perhaps my most significant observation is that the most attention is given to disordered behaviour. A teenager sniffing petrol is far more engrossing to observing eyes, than the mother locking herself in a room to sleep in one bed with many children in order to keep them safe, as must happen every single night in millions of locations around the world. I contend, despite all of the attention paid and praise crooned to those of us living as expatriates in “the poor world”, trying to have an impact, that in fact we are not the ones deserving accolades. It is the mothers, fathers, aunts, uncles, grandparents, neighbours and villagers, soldiering on with no spotlight or admiration and in fact, often denigrated in the blanket condemnation of the poor and marginalised, who in fact deserve any accolades on offer.
It is estimated that about 13,000 people in Cambodia use illicit drugs, with about 10% or 1,300 of these using injectable drugs. This week my new assignment took me to some drug “hot zones” in Phnom Penh. These field visits were reminiscent somewhat, of my time in Central Australian communities. We accompanied outreach workers visiting street-dwelling drug users who they clearly have trusting relationships with. The workers knew where to go and when we appeared at the top of stairwells in slums or on mounds of dirt in cesspits of refuse on otherwise-disused land, noone ran and noone tried to hide what they were doing. Exiting one building, someone on a corner called out to a woman all-in-white, who launched herself as if to flee. She looked behind me at the outreach workers, realised we weren’t the police and squatted back down. Tiny and visibly malnourished children played in rubble around sleeping parents.
Clean needles and syringes were retrieved from the workers’ backpacks, sometimes just in the nick of time. Workers squatted beside injecting or spaced out drug users to talk to them. Access to services such as HIV testing or information about who had most recently been arrested in the government’s drug crackdown, were topics of the day. One of the workers had a pair of long silver tongs which she used to flip rubbish searching for used needles. As she placed dozens of these in her plastic bottle for safe disposal, I understood why they had insisted I replace my thongs with a pair of black work boots, which I was clomping around in. As my French colleague described with sarcasm, it was “very sexy”!
All the while I was aware that surrounding us were human stories. For every drug user, who of course has their own story, there were any number of non-users trying to hold things together in this ferociously demeaning environment where human endurance prevails. The little boy carrying his bicycle up the grimey stairs on his way home from school, stopping for a quick rest on our landing before taking the next flight of stairs upwards; the old woman lugging her bag of vegetables home from market; the scavengers pulling their wooden barrows past us and the sugar cane juice seller with his bamboo bar perched across his shoulders, a wooden bucket of juice hanging from each end. They barely even looked in our direction as they made their way past us at various locations.
The Cambodian government declared a “war on drugs” late last year and to date in 2017 there have been over 4,000 drug-related arrests, mostly of drug users. Following a visit from the Phillippines’ President Rodrigo Duterte, Cambodia’s Prime Minister Hun Sen announced that there would be no bloodshed in Cambodia as there has been in the Phillippines. There have, however, been various other undesirable consequences. An almost 50% drop in access to needle exchange programs places users and the wider public at higher risk of transmission of diseases such as HIV and Hepatitis C. Users disengaging with medical services such as HIV treatment and Methadone Maintenance Programs due to fears of arrest, or actual arrest removing them from access to services, all have consequences to public health. Jails and courts have swelled to breaking point. Outreach workers are no longer able to locate their clients, or clients have become so transient in their evasion of authorities, that services are overlapping and therefore less efficient than they were previously able to be.
It is an interesting time to be working with Hepatitis C in Cambodia. New Direct-Acting-Antivirals (DAAs) mean that people infected with this virus, which leads to often-fatal liver damage, can be cured of their infection quickly and easily – a breakthrough in modern medicine which only occurred within the last two years. Curing enough people will see a reduction in transmission of the virus amongst the highest risk groups, of which IV drug users are the most at risk. This in turn will protect the general public. Yet there are very many obstacles in the way of ensuring appropriate treatment reaches those who need it most.