Viral Panic

This week I discovered that “TB Baby”, 18 months old and severely malnourished with no weight gain in many months, is unable to sit independently, unable to crawl, unable to weight bear on her legs and unable to walk.  We don’t think help will be forthcoming.

Perhaps, after all, it never was TB?  It is now almost nine months since the treating doctor suddenly ceased her TB treatment midway through the course, despite her only weight gain in many months coinciding with this treatment.  He suddenly and unilaterally decided “it’s not TB” with no explanation.  Had he noted or thought to mention her lack of gross motor development, perhaps we could have taken another course for her in the days when services were operational, pre-Covid?  It continues to dumbfound me that in a country with almost no Coronavirus (as of today, 141 cases with 0 deaths), already-inadequate services are shut down due to pandemic-related fear and redirection of funds.

Over a year ago when her mother told me that her older sister “got TB and then stopped walking”, maybe “got TB” to an impoverished and illiterate homeless woman actually just meant “got sick”?  These are complicated and tough but important lessons to learn.  We are supporting the family with iron rich foods and very basic infant feeding lessons but so far it’s having little impact.  As my colleague said the other day, “Mum is broken”.

The young man whose photograph I shared here on June 23 is about to die.  One of his only hopes was a human rights organisation but their funding has been cut drastically and they are not responding to requests for assistance to ensure appropriate treatment.

Jacquelin Magnay wrote this great article in The Australian today, 11 July 2020.

Viral panic just as dangerous as we confront COVID-19 second wave
Jacquelin Magnay
Follow @jacquelinmagnay

Australia is at the point where Britain stood three months ago. COVID-19 is transmitting through the community.

Australia’s leaders, with their quick border closures in January, gave themselves a short window to watch the rest of the world and pivot a pandemic response accordingly. Yet what has happened? Military deployed, heavy fines, interstate border closures, regional lockdowns, panic and fear, inflammatory language by state politicians: a reaction seemingly disproportionate to the viral threat. In Britain, the decision-making has been no less hysterical and wholly unpredictable. Borders stayed wide open until last month, only to shut when the virus was in rapid decline; schools are closed for most pupils until September, but pubs reopened last weekend.

These are the lessons Australia can learn from the overseas experience.

Check the latest science

Coronavirus is nasty for a very small proportion of people, but it is not Ebola. It badly affects the over-80s with comorbidities, including obesity, yet even of that highest risk group more than nine out of 10 survive. There are no details about the comorbidities of those who have died in Australia. In Britain, 89 per cent of deaths have been those aged 65 and older and 91 per cent of these had at least one underlying condition.

Significantly, the latest (yet to be peer-reviewed) studies show people — as many as 80 per cent — have natural immunity to the virus because of the body’s T-cells.

The Karolinska Institute in Sweden found public immunity is significantly higher than antibody testing by at least 30 per cent.

German researchers found that in 81 per cent of cases, people’s exposure to four other common colds promoted T-cell immune reactions against COVID-19.

That could explain why as few as 15 per cent to 20 per cent of partners in the same household, despite being in close contact, get coronavirus. The cruise ship statistics show a similar rate, and the locked-down Petri dish of the Melbourne tower blocks may yet show similar numbers.

British cancer doctor Karol Sikora has long suggested T-cells are the key to the immune response. “This is significant (research),” says Sikora. “It could mean that lots of people have some immunity. More work to do, but very promising.’’

Do not follow the UK

“If Australia is now copying the UK, it is bad for Australia, since we haven’t made a good job of it,’’ John Lee, a former professor of pathology and National Health Service consultant pathologist, tells Inquirer. “Our (British) government jumped in with drastic curtailment of freedoms without giving any thought at all to the risks to health, to the economy, or to other knock-on effects.

“Lockdowns and social distancing are not proven to be effective for the virus, and they clearly cause many other harms; so really, the response to this infection has been a total fiasco.’’

Along with nearly every other scientist, he believes despite the best efforts, no one can stop the virus and Australia should revisit what its endgame is. “This is an airborne virus … governments should think very carefully about what they are doing before they leap in,” Lee says. “Sometimes it is logical, scientific and least harmful to do nothing while waiting to better understand the truth of a situation.

“Countries have been copying China in a sort of political control-fest. But really there is no scientific justification for dealing with epidemics by following the approach of totalitarian states and locking us up.’’ Countries without lockdowns have similar transmission patterns, and most countries, including Britain, locked down well after peak transmission.

The reopening up of Britain, Italy, Spain and France has not led to any spike in deaths. Even in the US, as cases rise, the death rate is well below the peak.

As in Melbourne, the more tests, the more positive cases will be found, but most are mild or asymptomatic cases of younger people not requiring hospitalisation.

The latest immunological and serological studies show coronavirus is indeed like a very bad flu season. It is easy to look overseas and see horrendous figures, but cases are not deaths, and comparisons should be made with previous years in each country.

Last year more than 800 people, medium age 86, died in Australia from flu, with 310,011 laboratory-confirmed flu notifications. This year 106 people have died, attributed to COVID-19, with another eight now in intensive care and more expected as the virus permeates the population.

Stanford biophysicist and Nobel laureate Michael Levitt released a new mathematical study last week, saying: “We are going to see that although coronavirus is a different disease, the net impact of death is going to be very similar to severe flu and it’s going to be that way without lockdown.’’

If there is an increase, the weather, or perhaps airconditioning, may have more to do with infection rates than any distancing or lockdown, some scientists believe, for the virus thrives in cooler, moist conditions.

Look after the elderly and vulnerable

British officials made a big mistake in clearing out hospitals in a panic after epidemiologists had so wrongly predicted half a million deaths.

“Please don’t shut down other parts of the medical system,’’ says Angus Dalgleish, a cancer specialist who developed a treatment for HIV-AIDS and is working on a coronavirus vaccine.

He says doctors now know the virus affects a T-cell response and have adjusted their treatment so at the earliest sign of a severe infection patients are treated with high-dose vitamin D and anti-inflammatories. As well, the damaging use of invasive mechanical ventilation has declined.

But back in March, the British transferred tens of thousands of elderly patients back into care homes without testing for coronavirus, and these infected patients quickly passed on the disease to the most vulnerable.

The numbers of British COVID-19 deaths is approaching 45,000 and half as many again from the lonely elderly “giving up’’ — heart attacks, strokes and suicides brought on by the stressful and depressing shutdown of society. About 500,000 people die in Britain each year in normal times.

This year has followed similar patterns to bad flu seasons in 2018 and 1962. In England and Wales 307,000 people have died this year of all causes, 52,500 more than the five-year average. In 2017-18 there were 49,000 excess deaths caused from the flu. Another bad flu year, 1962, had 89,000 excess deaths.

The Office of National Statistics believes COVID-19 “brought forward’’ deaths of some elderly only by several months and will result in lower death rates than the five-year average for the rest of the year. Translated, that means some died of coronavirus in March and April before they’d have died of something else in coming months.

Beware meatworkers, hospital staff, cabbies

This week the British government shut down Leicester because of a spate of cases mainly involving meat-production factories and sweatshops. Abattoirs are believed to spread the virus because of the cold conditions, the heavy work promoting deep breathing and, like sweatshops, the close living quarters of the workers in camps.

In Britain, worker deaths have been highest in sedentary occupations such as taxi drivers, chauffeurs and bus drivers, and medical personnel — including the cleaners, administration staff and trolley persons moving throughout the hospital.

Consider the big picture

About 120 days ago — and remember the virus back then was still a frighteningly unknown beast — the Boris Johnson government briefly went for a herd-immunity response before clamping down hard with a total lockdown. (Studies show peak infections were on March 17, five days before this decision.)

Everything bar supermarkets and emergency departments of hospitals was shuttered. Now the societal damage of virtual house arrest is emerging. Even parking the 25 per cent drop in gross domestic product in two months — with more bad news to come — the impact of diverting every medical resource to coronavirus, when the medical system was never overrun at any point, has been devastating. Treatment for people who may have many years to live, such as young mothers with myeloma, was brutally cast aside to focus on the virus that targets the elderly, most already suffering significant heart problems, obesity and diabetes.

The economic carnage is just beginning, with scores of companies announcing tens of thousands of lay-offs. Nine million people are on government furlough (similar to Australia’s JobKeeper) and unemployment will soar when the scheme ends in October.

This week Chancellor of the Exchequer Rishi Sunak announced new economic stimulus measures worth £30bn ($55bn): cuts to stamp duty, discount restaurant meals, paying six months’ wages of apprentices, on top of nearly £200bn already promised to try to resuscitate the country.

If Australia persists with a hard-lockdown policy it has to weigh up, and cost, the overall consequences.

Be ready for no vaccine

Australia has closed its borders until a vaccine is in place and this may mean a very long and expensive international isolation as the rest of the world reopens from the pandemic. Only two companies, Moderna and Sinovac, are in stage-two trials; five other companies are in stage-one trials while scores of others, including the University of Queensland project with GlaxoKlineSmith, are in preclinical phase.

To date there is no vaccine for other coronaviruses, such as the common cold, and one doctor who was instrumental in discovering a treatment for HIV-AIDS tells a cautionary tale.

Dalgleish tells Inquirer many of the COVID-19 trials have focused on antibody responses in the body, and not on the important T-cells.

By way of disclosure he has teamed with a Norwegian firm to develop a virus vaccine called Biovacc-19 to attack just a small part of the coronavirus, using the same principles that developed Vacc-4x, a T-cell treatment that kills HIV-infected cells.

“We don’t want a repeat of the HIV fiasco, which delayed the development of an effective treatment for decades because the technology for such vaccines was fundamentally flawed,’’ Dalgleish says.

As British Prime Minister Johnson said in May, “I must be frank that a vaccine might not come to fruition.”

Jacquelin Magnay, Foreign Correspondent

The link to this article is here: Viral panic just as dangerous as we confront Covid-19 second wave

This is an interesting interview with Dr Soo Aleman, researcher at the Karolinska Institute in Stockholm, talking about her research into Covid immunity.

This interview with Dr Scott Atlas, from the Hoover Institute at Stanford University, discussing the unintended consequences of pandemic response and a sensible way forward, is insightful and intelligent.

When God Syndrome Gets in the Way

Mary, as I have been calling her, has remained severely malnourished now for four months of her almost seven months of life.

Her five year old sister has a neurological disability caused by TB Meningitis, which happens to children when their TB disease goes unchecked for too long.

Noone has ever identified the adult who must have infected the sister three years ago, meaning Mary could easily have been infected by the same person.

Mary’s mother was given intensive training on how to feed Mary as soon as it became apparent that she was being bottle fed inappropriately.  Money for artificial milk has been supplied for Mary for a year via our organisation, who supply the cans of powder to her mother once weekly.  She has consistently reported following our instructions.  Unless she is lying about that, which is unlikely given that her older children did not starve to death, then feeding cannot be the reason that Mary has remained persistently malnourished since her first reported respiratory illness.

According to the World Health Organisation, 36% of all TB cases are estimated to be undiagnosed and/or untreated.

Approximately 250,000 children die from TB every year, which may be a very conservative estimate given how difficult it is to diagnose TB in children.  Not to mention the invisible way that so many who are poor, suffer and die.

80% of TB deaths in children occur in those under the age of five.  One of the main reasons is that children only need a tiny number of bacteria to make them sick, making TB very hard to detect in children.  The tests that assist in diagnosing TB in older children and adults are almost always negative in tiny children, particularly if malnourished or unwell.  Children are also less likely to present with the classic symptoms of TB such as clear signs on chest x-ray.  Persistent malnutrition with or without intermittent chest infections is often one of the only signs that a child has active TB.

After many weeks of intense effort, making  her mother present to and queue for many hours at various services, none of whom provided any consistent or even necessarily correct messages to her mother, who seems to have become very untrusting as a result, two weeks ago our organisation managed to convince a doctor to treat Mary presumptively for TB.  The clues being her persistent malnutrition, the  possible epidemiological link with an unknown infectious source, and her repeat presentations with respiratory symptoms that come and go.  Even in Australia where TB is a rare disease, a child presenting in this way, with no other diagnosis, would be offered presumptive TB treatment and observed for clinical improvement.  In a country with high rates of TB it seems like a no-brainer!

After less than two weeks of a required six to nine month treatment course, she presented once more to a busy hospital where a doctor saw the negative results which we had convinced the treating doctor to ignore, and announced categorically “she doesn’t have TB”.  This incredibly confident announcement was enough to make the treating doctor doubt his decision and her TB treatment has been ceased.  Her treating doctor has announced that he knows how to feed her and she will be cured by food.

It feels like watching manslaughter in slow motion, caused by an uncoordinated and ill informed system filled with people brave to make categorical announcements whilst simultaneously doing what it takes to ensure she doesn’t receive a cure.

If she is cured by food then I will be thrilled but I wont take any of my words back because there is no way any of these people can justify sweeping claims that she does not have TB.  For months now, presumptive TB treatment might have seen her condition improve.  With no other diagnosis, treating her for TB was the possibility of a fair chance at survival.

The uncoordinated and expensive “care” this little baby has received is a sign of what people in poor countries experience when they need to access health services.  Nothing short of chaos and debt.  Her mother could never have afforded to present to the different hospitals and clinics that our organisation has supported her to.  Perhaps that would have been a better outcome in the end given that her prognosis remains the same despite multiple outpatient appointments.

Health systems in rich countries can be difficult to navigate, confusing and fear-inducing, and of course the big egos that medical and other health profession training seems to create are always there.  But the experience of Mary and her mother, in their slow festering misery, has been nothing short of a horror story.

A friend suggested “It has the makings of a movie, let’s contact Angelina Jolie”.  Sadly, the best I have to get the story into the world, is this blog.

Dismay and Disarray

It’s a month since I wrote about Mary, aka “TB Baby”.  Sadly there is still no reprieve for this deteriorating almost-6-month-old.  She remains untreated and dangerously unwell at home.  Her weight is perilously stagnant, with no weight gain for over 3 months.  She is now developing other symptoms related to her suppressed immune system caused by severe malnutrition, such as diarrhoea caused by inflamed intestines and skin abscesses caused by her body’s inability to fight exposure to skin bacteria.  The only reason that she is being left in this appalling condition without treatment, is that she is poor.  If a wealthy baby, or even a baby in a wealthy country with low TB prevalence and a functional health system, presented so severely malnourished with respiratory symptoms unresponsive to standard antibiotics, appropriate TB treatment would have been made immediately available.  Especially when a four year old sister, suffering lifelong neurological consequences from TB Meningitis provides evidence of recent family exposure to TB.

Sadly though, when you are poor, you have to jump through a million hoops if you want to access even the most basic health care.

I will write about it properly soon, when I can collect my thoughts on the entire horrific situation and hopefully when we’ve come up with some sort of solution before it’s too late.  This post is just a brief update.

KF Kunthak Bopha 004

This photograph, taken on one of many difficult days, shows a tiny portion of the queue at 4am outside one of Cambodia’s only “free” hospitals for children, known as Kunthak Bopha.  People travel from across the country to attend this hospital with their sick children in order to access care without incurring the crippling debt that most Cambodian patients end up with.  Mary and her mother arrived at 4am in order to get a place in the queue which reportedly stretches many blocks everyday.  They were able to enter the triage area eight hours later, and were seen almost 11 hours after arrival.  At which time she had a five minute consult, was given another course of standard antibiotics and sent home.  Her TB-affected sister was present for the appointment.  When her TB history was explained to the doctor, her mother was berated with “you should have brought her to see us before she ended up in this condition”!  Whilst simultaneously sending her obviously-TB-affected baby sister away!

Another, earlier instance, was the day Mary and her mother attended Kunthak Bopha Hospital for perhaps her first presentation with respiratory symptoms.  With assistance of an Australian Nutritionist advising from afar, myself and my Cambodian colleague had spent hours training Mum in how to make the baby’s bottles, which can be complicated without training and even more so when you are not literate.  The correct amount of water should be added to the bottle first, then the corresponding number of scoops of formula powder based on instructions on the can.  Due to her illiteracy we prepared diagrammatic instructions based on the correct information from the specific formula can, with amounts per bottle and numbers of bottles per day confirmed by the Nutritionist, which she was following.  She came home from hospital having been told “the reason your baby is sick is that you are not making the bottles properly”.  Then a set of instructions so wrong that I could barely believe what I was hearing.

empty baby bottles

After telling her that following our instructions was the reason her baby was sick, she was instructed to fill the bottle to the number on the right (eg 50) with formula powder, then top it up to the corresponding number on the left (eg 2), with water.  Fearing further rebuke and confused by the contradictory information, Mum followed these instructions until she could meet with us a few days after discharge.   At that time she informed us what she’d been told to do – and was therefore currently doing – and asked “why is she vomiting a lot?”.  Luckily the trusting relationship she has with my colleague meant that further reassurance and reinforcement from us was enough to convince her to revert to our instructions.

These are examples of the levels of “care” that poor patients can expect to receive, the contradictory information they constantly have to navigate and the multiple presentations that they have to make to health services under challenging circumstances.

My colleague in Cambodia, yesterday, during discussions about our repeated attempts to obtain TB medications for a baby who is in effect, dying of TB, described the lives of the world’s most impoverished as:

Ordinary people living under extraordinary circumstances and pressures that we cannot begin to imagine

When we have some sort of resolution to Mary’s illness I will try to post a full article about the experience and outcome.

A Parable From Paradise

The roads leading out of Phnom Penh are chaotic with many traffic sights.  Traveling south on the bus I had my camera ready and snapped many pictures, occasionally noticed by subjects who happened to realise what I was up to through the bus window and who without fail responded with an amused smile from their various interesting perches.  On the outskirts of the city urban sights began to intersperse with rural paddocks, engines became rarer while hoofed transport increased and loads of boxed and/or processed goods gave way to loads of fresh agricultural produce.  Soon the landscape became rice fields with enormous factories scattered amongst them.

The garment industry that I know of in theory is real and busy on this southern highway, and we passed through just as workers were finishing for the day.  Remorks, mini buses and trucks were lined up in the hundreds at the gates of many colossal factory complexes, waiting for thousands of passengers to make their way out of these manufacturing plants, where people spend up to 12 hours a day sitting behind machines in order to take home US$70 per month.  I’m fascinated in a macabre way, and the grisly impression is exacerbated by the thousands of people standing on crowded trucks, reminiscent of scenes from 1940s Europe.

Thousands of workers milling out of one single factory at home time
Thousands of workers milling out of one single factory at home time
Loading onto one of dozens of trucks outside a garment factory at home time
Loading onto one of dozens of trucks outside a garment factory at home time

I hope and plan to always check where my clothes come from in future, but with this many people employed in Cambodia alone in the mass production of cheap clothing, how could you ever be sure that you’re buying from an ethical company?  It’s a subject I’d had a vague interest in before seeing these workers in-the-flesh being transported home en-masse in crowded vehicles, or hearing stories from national colleagues about wives and sisters who move away from families in order to earn such small amounts just to assist in the family’s survival.  I still know very little, but the deaths of factory workers in Bangladesh in recent times highlighted the exploitation of low paid workers in the third world providing cheap clothes to the first world.  This was followed earlier this year by extreme police brutality in Phnom Penh against garment workers protesting for a rise in their salaries which are, even on a Cambodian scale, shamelessly meager.

Meanwhile on the bus, across the aisle from me, gazing out of the opposite window, sat a good friend from Sydney.  Her first job on arrival in Kampong Cham was to deliver my requests from Australia.  Some of this delivery, she had retrieved from cases waiting for me in the loft of my cousin’s Sydney home, and some she’d shopped for me, not least of all the new pair of decent sunglasses to replace my broken $6 imitations.  On her first night in town we had a busy time catching up on each other’s news.  The following day I was making a home visit to some patients, one of whom has a particularly woeful story.  Upon hearing about this patient my friend boldly and generously announced that instead of repaying her for the consignment she’d just delivered, I should give the money to this needy case.

The next day my colleagues and I sat on the clean and tidy packed earth beneath the wooden floorboards of the patient’s elevated home, as he humbly accepted the envelope from me with my explanation that a friend from Sydney wanted to ease his difficulties and had asked me to deliver this envelope to him.  With no way of earning any income, he and three elderly family members rely on the monthly food basket provided by MSF while he is on treatment for DRTB.  Treatment is due to cease in a few short months and his main concern is how, in his newly-incapacitated state, he might earn income when the food baskets cease.  I know that my friend’s generous donation will make a significant difference to their lives, at least in the short-to-medium term.  We then visited a local organisation whose role is to assist the very poorest of Cambodia’s poor in finding ways to generate income.  Hopefully measures will be put in place for this gentle and unassuming young man who has been permanently maimed by Tuberculosis.

Scapulae of a TB patient in Cambodia, highlighting the level of malnutrition which occurs
Scapulae of a TB patient in Cambodia, highlighting the level of malnutrition which occurs

Back on the bus to Sihanoukville, we drove through rainforests, rice fields and villages for many hours as the landscape became increasingly tropical with wide brown rivers, waterfalls and jungle-covered mountains all passing us by.  Arrival in Sihanoukville after dark was marred by tuk tuk drivers quoting us treble the real cost of a trip to our accommodation.  Combined with my tired and indignant response this caused a bit of a stir among the many drivers who milled around vying for our custom.  While the combination of desperation and “normalised” corruption alongside naiive and wealthy foreign custom make this an understandable gig in the tourist areas, being targeted unscrupulously is still highly irritating!   The quiet, humble and amused older man sitting off to the side eventually won our custom and we made it to our beachside bungalow.  The bungalows are halfway up a rubbled, pothole-ridden hillside driveway which the driver stopped at the base of, and said “walk”!  Laughing at the instructive English, we dragged our cases up the hill, miraculously making it in the dark without injury.

The ongoing issue of brazen tuk tuk drivers in a quiet off-season in the tourist areas (thankfully not in Kampong Cham!) is an interesting experience.  In Phnom Penh a few weeks ago I was sitting in a tuk tuk, about to disembark at the bus station when another driver called to me, did I need a tuk tuk?  Do I look like I need a tuk tuk I said silently as I tried to ignore him before realsing he required a reply or it would not stop!  In Sihanoukville the situation is equally dire.  Yesterday as we disembarked from and paid one driver, another driver approached suggesting his tuk tuk services.  Walking along the street another driver asked how we were and when we replied in kind, he shouted jovially, his feet hanging over the side of the back seat “not good!  No customer!”.  His good humour won him our custom but we weren’t ready yet so he quietly kept an eye on us as we window shopped down the hill to the beach, then back up the hill again, occasionally driving by and beaming us a happy smile.  Once we were ready we found him and as we were about to board, another driver who neither of us recognised approached, insisting HE had spoken to us first!  We insisted we would only go with the man we knew, which elicited a mouthful of Khmer attitude as he walked away in disgust that his bullying had not worked on us.

Child Safe sign outside a Sihanoukville shop
Child Safe sign outside a Sihanoukville shop

A bright and sunny day led us to the beach underneath our bungalows where a private strip of white sand and blue ocean kept us content for most of our first day in Sihanoukville, followed by the quick visit into town before cocktails at a bar recommended for it’s sunset views.  Most of our conversation throughout the day was dominated by the topic of human interplays when wealth (tourists) meets poverty (locals).  Our observations included overbearing and cantankerous tuk tuk drivers, timid and reverent waiters, elderly white men with child-like Asian women, jovial sellers, hotel staff keen to practise their English and tell us their stories of hardship, backpackers and touring westerners of all varieties.  This town, where the children don’t seem to notice us, is extremely different to the agriculture-dominated lifestyle of Kampong Cham where westerners are rare enough that the children shout English phrases from afar when they see us, but it is also incredibly beautiful here.

View from tourist-hotspot, Serendipity Beach
View from tourist-hotspot, Serendipity Beach
Daybed at our private stretch of white-sand
Daybed at our private stretch of white-sand

In contrast to yesterday, today is wet and overcast so we have come to The Starfish Project for a late breakfast, and will head to Central Market for a look before probably spending a chunk of time inside a bar or the cinema.  Sihanoukville, like other tourist attractions in Cambodia, has many non-government organisations involved in trying to pull marginalised and uneducated people out of their poverty traps.  The Starfish Project is one such local organisation, where I am writing this from a lounge chair at their cafe, filled to the brim with a homemade sandwich.  They provide employment opportunities for young disabled Cambodians.  Their philosophy and name come from a beautiful parable, italicised below, which is very relevant to anyone traveling to a third world country who struggles with the issues that I constantly refer to and struggle with.

A Buddhist monk was on the beach with his apprentice the day after a fierce storm. Thousands of starfish had been washed up and stranded on the shore. Stooping down, the monk carefully lifted a single creature and returned it to the sea. His young apprentice wondered aloud why his master bothered to do this when it made little difference to the mass of helpless creatures. As they walked along, the monk picked up another single starfish and replied, “It makes a difference to just this one.”

http://www.starfishcambodia.org/

Hammocks on the Mekong

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A handsome couple who happily posed for a photograph today on the banks of the Mekong in Kampong Cham

In Cambodia alone there are thousands of hammocks slung between trees on the shores of the Mekong.  I see them all the time, many positioned in fairytale-worthy locations.  But there’s always poverty.  I am sure it gets boring hearing this from the First World where I am well aware how difficult it is to envisage the scale or impact of such things because we just don’t see or experience it.  The last thing I want to be is boring.  But I feel confronted everyday by the levels of hardship experienced here.  Perhaps no more so than the malnourished 14 month old dying of AIDS who we met yesterday.  Fading in and out of consciousness, the size of a wasted-away two month old, bones protruding through skin at every joint, lying on a wooden bed base beside a very healthy looking older sibling who stared at us in fascination while the elderly grandmother sat quietly touching her grandbaby lightly, her face lined with age, worry and sadness.  We spoke to her very briefly and she said that the children’s parents had both died.  We were there to visit one of our students, an HIV positive orphan hospitalised with an acute lung infection.  One of her fellow pre-adolescent orphan “sisters” was with her, sitting serenely surrounded by sick children.  Aware of their diagnosis by now, I wonder what goes through their mind when they see these unwell, dying children, all victims of the same virus that has them in it’s grip.

Yet despite the often-overwhelming despondency there are always plenty of laughs and positive or cheerful moments to be had.  My translator has encouraged me to take photographs whenever I want because “usually Cambodian people don’t mind.  Because your people have a good reputation.  We don’t think you would use photographs in a bad way and we think that you are generous and you want to help”.  He’s proven to be more than just a translator, he’s a wealth of knowledge and understanding, about both his own nation and culture as well as the many western cultures he has worked with over the years.  More of a cultural consultant, than a mere translator.  Recently a friend returned to Cambodia from Australia, carrying with her a book of Australian slang for him because he is always throwing unexpected Australianisms at me, eg just before a meeting we had to attend recently “wait here for me, I just have to go to the dunny!”  Then a pause while I process what I just heard, followed by a round of laughter, then a check with me “that’s correct, isn’t it, dunny?”  Yes!  But where on earth did you get it from?!  And he laughs his way to the loo while I explain to the room-full of English-speaking but confused Khmer colleagues what just went on.

One of my favourite western restaurants in Kampong Cham is Destiny, who serve gourmet sandwich / pub style food.  This morning after 3 hours cruising on bicycles through rural lanes with my Australian and Slovakian housemate-colleagues, we landed sweaty and hungry at Destiny for a late breakfast.  The manager was there and happened to mention that this cafe belongs to Destiny Rescue, which I had not heard of, training victims of human trafficking.  I knew the staff came from disadvantage but hadn’t realised the magnitude.  So I spent a little time browsing their website this afternoon.  It is interesting and informative, and they are clearly another organisation worthy of support.
http://www.destinyrescue.org/aus/who-we-are/about-us  There are an estimated 27 million slaves in the world today. Destiny Rescue is committed to liberating those enslaved and restoring those that have been abused. Already serving in five nations, Destiny Rescue will keep expanding to reach even more children.
The manager sat near us at breakfast and we chatted with him intermittently in between talking amongst ourselves.  Later in the day I returned alone to use the wi-fi and he approached me for more information on how to contact us because he was speaking about us to a doctor working with Destiny who would like to meet us!  Things like this happen all the time here – expats seek other expats out, or NGO involved people network with others doing similar things.  I’ve been offered the chance to volunteer with three other NGOs once my MSF mission here ends and hope to coordinate all three somehow in order to return and spend more time here.

Last night, in fear of rainfall all evening, we took 16 children to the Night Market for a meal/treat.  Two homeless girls, two siblings staying in hospital while their father is very ill, one son of a staff member and 11  of the 12 orphans (because one is sick and had to miss out).  Eight of us piled onto four bicycles in true Cambodian style, and doubled our way to the market, with children laughing excitedly all the way.  The orphans, also doubling each other, met us soon after.  Combinations of fried rice, ice cream, fruit soaked in sweetened condensed milk and cans of soft drink were ordered, all outside of our comprehension of what was being said to the server, amidst chatters of excitement and interspersed with brief shouts in English of “thank you!”, “delicious!” and “happy!”  It was clearly a treat, confirmed by the Orphanage Director who said that this morning the children were full of talk about their trip out.  In my wildest dreams I could not have imagined this block of rat-infested broken pavement housing grubby outdoor stalls, selling $1 meals, cheap clothes (which a local told me I should not buy because they are over-priced!) and with a few rusty looking childrens’ rides and some trampolines, would be considered a “treat”.  But last night I learned that it is!

Meanwhile Tuberculosis continues to teach me daily lessons that in my wildest dreams I could not have imagined possible.  Many TB patients are memorable for different reasons.  In ten years of working with TB in Australia I remember every one of my patients well and with fondness.  Some of them are alive today and far too many of them have died prematurely (thankfully, unlike my Cambodian patients, never from TB).  A few years ago we had a patient from a TB-endemic country who had been told by Australian doctors that he probably had abdominal cancer, which appeared as tiny nodules which had riddled the mesenteric lining of his abdominal cavity.  Biopsies were taken but the doctors, from a first world country where TB is rarely considered high on the list of probable diagnosis (except when doctors have experience in TB-endemic countries), were fairly convinced of an aggressive and late stage cancer diagnosis which was also supported by the clinical presentation of severe weight loss among other symptoms.

Having only recently married, he and his wife returned to their home country to spend his last days with his parents and family.  However, when the test results for TB returned positive eight weeks later (the time it can take for TB bacteria to culture), his diagnosis was altered.  He suddenly had a curable disease.  When he returned to Australia and met me for his first TB treatment appointment, he had been through a terrible ordeal, facing imminent death, and could not believe his stroke of luck that the doctors had gotten things so wrong.  He was also a very interesting case having commenced his TB treatment overseas, in a poor country where health care is fully privatised.  His TB drugs had been free via WHO but his doctor had also recommended various additional treatments which he had to pay for.  He produced a brown paper bag filled with both anti-TB medications and various extra vitamins and supplements, telling me in detail why he was on the various extra medications and very reluctant at first to consider ceasing these added drugs because his doctor had so convincingly recommended them (something his new doctor successfully addressed).  Most surprising of all to me was the way he pointed to each drug and told me exactly how much each individual pill had cost him!

This was my first exposure to the Fixed Drug Combinations (FDCs) used via World Health Organisation, where all of the anti-TB molecules are combined into a single pill.  The purpose of this is to reduce the number of pills patients are required to swallow.  For example, the standard TB regime begins with four different anti-TB molecules, which when administered as four separate pills can amount to 15 or more pills (depending on the patient’s weight).  When an FDC is used, this number reduces to 3 or 4 tablets per dose.  This simple measure increases patient adherence to treatment.  In Australia we have the resources to increase adherence in other ways and we have not moved towards using FDCs that I am aware of, but in the developing world where resources are so scarce, simple measures such as this are important.  I have since seen FDCs in both East Timor and Cambodia, and according to a TB Alliance report, 20 of today’s 22 highest burden TB countries (of which Cambodia is currently listed as number 22) now use FDCs.  When I presented an education session on TB recently I showed a photograph of an outstretched hand with single molecule TB medications sitting on it.  One of  my very experienced nursing staff said to the group “these are the old fashioned medicines we used to use, but now we have FDC so many of you will not recognise these tablets”.  I countered with the information that in Australia we still use these single-molecule tablets, to which they all chattered excitedly in Khmer before one of them said to me in English “Australia is supposed to be a developed country!”, clearly fascinated that in this single matter, Australia is not as up to date as Cambodia!

This week’s memorable patient encountered myself and a small team (driver, social worker and nurse) in her village this week.  We drove about an hour along dusty bumpy roads following the river south, sighting a group of tourists on race bikes in one remote location, but mostly seeing only Cambodian rural scenes of coconuts on sale from the back of shoddy wooden trailers attached to ancient motos, pyjama-clad women transporting produce on trays balanced atop their heads, horse and ox-drawn carriages filled with various agricultural produce, etc.  We went there to locate a Home Based Care (HBC) Nurse for a hospitalised MDRTB patient who is almost ready for discharge, once we find someone who can administer his Direct Observed Treatment at home.  At the patient’s home we sat and spoke at length with his sister about the treatment, plans for his return home and the need for a Home Based Care Nurse.  She had already nominated someone and confirmed to us in person that this woman would be competent and trustworthy to ensure all doses of the lengthy and difficult treatment were administered properly.  My nurse then called the nominated person who lives close by and she arrived moments later on her moto.  She sat with us as the team talked to her about the training she is required to attend with us and some of the difficulties she will face as the person responsible to administer 18 months of daily treatment which causes nasty side effects and guarantees bouts of depression and anxiety in the affected patient.  Despite not understanding (except for periodic translations given by the team when they were not involved in the conversation), I could see that we had found a good and honest HBC Nurse here.  She then offered to show us where she lives, as this is needed for the “surprise visits” we conduct as part of our way of monitoring treatment progress.

On arrival at her home we were offered seats and I looked around noticing pharmacy stock in glass cabinets, customers standing outside waiting for something, and very clean and shiny surroundings.  Then a very thin woman of about 40yo appeared in a beautiful pair of blue pyjamas, her hair in a bun and sat with us.  It transpired over the next quarter of an hour or so that the HBC Nurse runs a small private, legal clinic-pharmacy from her home, with her husband.  I say legal because some home based set-ups here sell drugs illegally – such as “black market” TB drugs which are supplied to the country via World Health Organisation and always available to TB patients for free, through a reasonably tight system.  Except that occasionally there are stories of patients purchasing these drugs which have found a loophole into the black market.  Such stories are always reported to the Public Health Department whose role it is to address such problems.

The blue-pyjama’d lady told us her story.  She is currently staying at the small clinic because she is not well and noone knows what is wrong.  When we asked her problem, she reported weight loss.  Before she weighed 42kg and now she weighs 36kg.  The implication was that this was her only problem.  Many things cause weight loss, so with TB in mind we asked some more questions and a lot more information was supplied.  Yes, she sometimes has night sweats.  Yes, she sometimes has fever, and also has “fever in her stomach”.  The HBC Nurse said “it can’t be TB because she does not have a cough”.  To which my nurse explained that extra-pulmonary TB patients do not cough (unless they concurrently have pulmonary TB).  Going back to her abdomen, we asked if she can feel any nodules in her abdomen?  “Mien!”.  (She has these).  I suggested that it sounds like it could be mesenteric TB, but that she needs to see a doctor for a proper diagnosis.  Only then did she mention that actually, she does occasionally have a cough because she has been unwell on and off for 18 years!  She has seen many doctors  and noone has ever diagnosed this chronic cough which comes and goes.

In Australia where health systems and social structures are functional, it would be almost impossible for someone to be unwell with symptoms, no matter how rare, and not receive some form of diagnosis via a referral system to specialists etc.  The chronicity of TB in Australia in my experience was perhaps up to six months at a push – usually much briefer though, before patients sought medical advice and received an accurate diagnosis.  I learned the theory around tuberculosis bacteria’s ability to endure in the patient’s suffering body for many years, during my studies in the 1990s.  Historically, prior to a good medical understanding of TB or the introduction of TB treatments as recently as the 1940s and 1950s, TB had three standard outcomes, being:

1.  The TB victim would become ill and die (usually infecting others during the illness);

2.  The TB victim’s immune system would manage to ward the disease off over time, or;

3.  The victim would spend years suffering the chronic effects of wasting away with a chronic cough, fever and other symptoms.
These chronic cases, during their infectiousness are considered to infect up to 15 other people for every year that they are unwell
with infectious TB.  (Not every case of TB is infectious, however).

When I learned this information it was presented as something which no longer happens because we now understand the disease, have (albeit imperfect) diagnostic methods which can confirm the bacteria’s presence, and treatments are available and free.  However, these outcomes do continue to plague many people, in places where health systems are weak, health literacy is minimal and resources are scarce.  I first encountered the enduring ability of TB in East Timor where I met a number of patients who had suffered undiagnosed symptoms for ten years or more before receiving an accurate diagnosis.  Despite knowing what I thought was a lot about TB, this experience astonished me.  And this week, in absolute amazement, I feel sure I have encountered it again, in my longest-suffering patient yet!  She agreed to travel to Kampong Cham this coming week, with the family of our hospitalised patient who will attend our clinic for contact tracing.  I fully expect she will be hospitalised for investigations and confidently predict that her 18 years of chronic ill health will suddenly dissipate thanks to a six month course of TB treatment!

**  Watch this space for an update! **

TB Patient goes for a stroll with his chest drain, Kampong Cham July 2014
TB Patient goes for a stroll with his chest drain, Kampong Cham July 2014