Sunday, February 20, 2011

A man for all seasons?

During a stay in Tokyo I was proudly informed by my hosts that Japan is the only country with four proper, well-defined seasons.

I was skeptical, but every country I’ve been to since has seemed a little confused about its seasonal distinctions. Cambodia is a good example - can someone please tell me what season I’m meant to be in just now?

It’s certainly not rainy anymore - autumn was never exactly mists and mellow fruitfulness here, and the rains ended late last year leaving the worst flooding in living memory with their final throw. You wouldn’t know it now, with our once overflowing lake now withering rapidly in the heat. So I guess that makes it dry season? But it’ll be dry for the next 6 months, so that’s not much use as a definition. Our Khmer teacher Dara called it windy season, and the afternoon breeze is certainly a welcome change.

My vote is for dusty season - as opposed to the muddy season before. My local newspaper, fascinated that there may be life beyond northern England, asked me what was on my CD player (vinyl is being slowly phased out in Oldham). ‘A thick layer of red dust’ I answered bitterly. It now seems perfectly normal to tenderly tuck a sheet over my beloved computer in the evening to protect if from clogging with dirt. This is opposed to the impending hot season, when in temperatures of over 40 degrees many computers just stop working unless you get them their own special fan.

My Cambodian friends just call this Winter. Certainly not the snowy wonderlands I long for, but it’s logical. (Which hemisphere do you think Cambodia is in? We sure get tropical heat, but we’re actually well north of the equator here). Until a few weeks ago discontented hospital patients took to sporting socks, gloves, even balaclavas. Staff wore thick Parka jackets over their uniforms as temperatures plummeted below 30. Even I took to sleeping under a thin sheet.

Traditionally, the end of the rains also heralds the dreaded wedding season. Here this translates as open season for the excruciating noise, excessive drinking and revolting food which bring such joy to happy couples here. I though I'd escaped lightly this time, but I hadn’t reckoned on Chinese New Year - every morning the tormenting loudspeakers woke me at 4am for special sino-torture including kung-fu movies, fire-crackers and plinky-plonk ‘music’ (it sure wasn’t Vivaldi). After a couple of hours, when thoroughly past any chance of sleep, it promptly stopped - just when I had to get up.

To everything there is a season, and sadly now seems to be a time for war on the Thai-Cambodian border. I live just 15km from Thailand, and there’s plenty of cross-border commerce. Every so often shots are traded too, usually further east near the disputed temple at Preah Vihear. It’s probably just an annual show to keep nationalist voters happy, and no doubt the generals will smooth it out over a rice wine or two. But I confess to being a little disconcerted at reports of tanks trundling through my nearest town. And I wouldn’t like to try explaining the logic of seasonal scuffles to the wife of the Cambodian solider or dependents of the Thai villager who were both shot dead the other night.

Happily, life continues as normal in my village. Now the rains have gone, it also seems to be building season. Tents have sprung up outside many homes as families renovate (read knock down and rebuild) their homes. And I’m delighted to say that this is also the case at the hospital - our new surgical ward is taking shape at blistering speed, so much so that we might not have any staff trained in time for its opening!

Of course the real test comes in the next month or so, when it gets even hotter. I’m sure I’ll find a few choice adjectives to describe that season - temperatures are already pushing into the 40s and high humidity will mean I’ll do little else but try to keep cool. Let’s see how I get on - only time will tell if I can really claim to be a man for all seasons.

Tuesday, February 15, 2011

Infection Control Drive!

Just why are we doing this again?

A perfectly normal question once you’re past the initial, enthusiastic stage of any project.

On this occasion I was talking to myself – muttering probably – though I did aim the question later at both my colleague Alison and my long-suffering meant-to-be-on-holiday parents.

We were helping to clean the wards at Thmar Puok hospital, part of our infection control drive.

So the answer’s clear, right? I mean, you don’t really need to ask why you’d want to control infections. It’s blindingly obvious - nobody wants to be contaminated, least of all weaker, more vulnerable people in hospital - so limiting bugs is what us managerial bullshit speakers term a no-brainer, no?

Well yes… but somehow out here it’s not as simple as that. The staff claimed to know all about the importance of infection control and how to do it. In fact, when we tried to do a quick refresher on the basics, eyes were rolled and we were grumblingly accused of ‘trying to teach crocodiles to swim’ (Cambodia grandmas don’t go in for egg-sucking).

Yet even a cursory tour of the wards showed a yawning chasm between theory and practice. Dirty doesn’t get near. I tour the wards every day, and was ashamed I’d put up with the filth for so long. Shit stuck to beds was probably the worst, but other lowlights included needles tossed aside, decomposing food stuffed into note trays and decades worth of accumulated grime, blood and worse under every bed, behind every cupboard and inside every drawer.

So however self-evident the need, the wards hadn’t had a proper clean for ages. So why were we doing this… now?

One answer is that we, the outside volunteers who like ‘nice clean western wards’, had asked to (albeit a rather insistent, toddler-after-a-lollipop request) – and our hosts were too polite to refuse. In fairness we planned the event together with the hospital’s head nurse, and timed it for the dry, quiet run up to Khmer new year, which also happens to be a traditional time for ‘spring cleaning’.

But we did have another, stronger reason – the Ministry of Health had laid down numerous standards, including levels of cleanliness, and were coming to assess how we matched up. The following week.

Somehow bigwigs from the capital focused minds in a way that even the whiff of festering wards hadn’t. And so we were permitted to start a clean of the whole hospital that morning, starting with the Medicine ward.

Breakfast was a nervous affair. What’s the worst that could happen? asked Alison. Well, for a start they’ll find some reason why today isn’t a good day to clean, and it’ll likely go downhill from there, I replied. I’m not really a morning person.

The doctor in charge of Medicine greeted us warmly. Just one thing - today’s not really a great day to clean because… So far, so predictable. I wasn’t in a mood for negotiating, and risked a bullish approach of ‘We’ve got to do it now. And your boss agrees’. He gave way with remarkable good grace. Maybe he knew what was under the dressing trolley.

So we started dragging beds outside, which had an amazing effect - suddenly the huddled nurses were all too happy to carry them outside. And then the main toy came out: the hose! Never has so much fun been had outside of a karaoke bar - the boys were positively wrestling it out of each others hands.

To our shame we rather forgot the patients in all this. Admittedly those who could walk had seen the inevitable and retreated to the relative safety of the cooking area. But two poor souls remained: a man bent double with abdominal pain, and a wafer-thin lady in the terminal stages of AIDS-related illness. The doctor wisely transferred the man, and it fell to Alison, my visiting mum, me and a passing relative to carry her to safety, each holding a corner of her wicker mat - the nurses were still having far too much fun with the hosepipe!

But in fairness the staff - particularly the cleaners - were doing a great job at scrubbing the floors, walls and even ceiling. Strangely though, there was much less enthusiasm for cleaning beds. And when I asked them to help me to paint, they point-blank refused. To this day I don’t know why: there must be something in the hierarchy which makes it ok to brush floors, but beyond the pale to brush paint. Some things I guess I’ll just never understand. Fortunately a placatory call to the hospital director broke the deadlock, with an agreement to pay a labourer to paint beds if we cleaned them and provided paint. Good deal!

In fact the painting was key. Some volunteers back away from helping to decorate their hospitals, feeling that it literally ‘paints over the cracks’ and gives a false impression of cleanliness which leads to apathy. I take the point, but disagree. In practical terms dirt shows up much more easily on white walls, and is easier to clean from freshly sanded and painted surfaces. And boy does a row of beautifully painted beds lift a place! The Medical ward in particular was completely transformed - to my eyes at least, by the end of the day it really looked quite beautiful.

A week later, the men from the ministry are in full swing, and the hospital is looking spick and span. One of my favourite moments of my whole year here happened this morning. The once recalcitrant medicine doctor skipped past announcing that he was on the way to collect some health education posters to decorate his newly cleaned walls. Wow!

Sustainability, of course, is the goal, and it remains to be seen whether the staff actively keep their wards clean, or passively allow the dust, dirt and other unmentionables to return. I’m an optimist, and really believe that now we have helped them see things can be better, they will improve even further.

That’s why we were doing it.

Monday, February 7, 2011

Pumpkins, Pagodas and Politics

“Pumpkin custard is off the menu”, the waiter at the smart restaurant in Siem Reap whispered confidentially. I settled for a trio of crèmes brulees - lime, ginger and lemongrass.

The Cambodia we experienced in two weeks in January was perhaps a trio of flavours - everyday life in the village, the highlife of towns and temples, and in the background the politics of a country so recently embroiled in catastrophic conflict.

Thmor Pouk is a large village with markets, schools, government offices, a hospital, health centre and pagoda. We had a dusty journey from the nearest town, Sisophon, an hour away on the main road (no tarmac yet).

Oly’s house is on the first floor of a traditional Khmer house, a little posher than most as his landlord is a village chief. The main feature is a tiled balcony, overlooking the street, from which we liked to watch Cambodian life pass by - children in their uniforms; women going to market; lorries collecting rice straw; numerous bicycles and scooters; and two stroke tractors, the universal utility vehicle of the countryside.

We went to the market where Oly buys his vegetables and fruit – pumpkin and little bananas are his favourite. He is the only barraing (foreigner) in the village, and has learned to speak good Khmer, especially for bargaining in the market and with tuk-tuk drivers in towns.

The village is dusty at this time of year, and smoky from cooking stoves, burning rubbish, and making charcoal - we saw many people wearing face masks. The rice paddies were brown and dry during our stay, but we did see green fields elsewhere in the country where irrigation was in place, and there are many banana and coconut palm trees in the village, so it is not short of greenery.

Cambodia is also noisy, and thankfully we were warned to bring ear plugs! Loud music woke us in the early morning, and there was karaoke in the evening, followed by dogs during the night and cocks the next morning! But we slept ok under our mosquito nets, which protected us from malaria – though dengue fever is more feared here, so we sprayed ourselves liberally with Modiguard during the day.

Although Oly is in a remote area he makes full use of modern communication - mobile phones are ubiquitous in Cambodia, as they are in most developing countries nowadays – and he even plans to bring the internet to his village, just as soon as he gets his dongle to work!

The hospital is a collection of single storey buildings with plenty of space. We saw the new children’s ward, financed by the US army, and a surgical ward being built. Oly and Alison, his nurse advisor colleague, were having an infection control drive during our stay, and we helped clean some rusty iron beds from the medical ward, which were then painted whilst the ward itself was washed down. We saw the new playground and flagpole, familiar to us from his YouTube videos! The site of the new vegetable garden looks fertile enough – getting it going will be another challenge!

Thmar Puok is in the north west of the country very near to Thailand. There were border problems while we were there, and Oly’s trip to the temple at Preah Vihear on the back of Sokpha’s moto had to be postponed. Sokpha, his Volunteer Assistant, is a charming man with three children, aged 40 he told us, so he was a boy during the Khmer Rouge years (1975-1979). Many died in the north west and there are several mass graves in the village. The area was also heavily mined during the 1980s by both the retreating Khmer Rouge and the advancing Vietnamese, and land mine removal is still ongoing.

The other aspect of rural life in Cambodia revolves around the water, and later in our stay we did an eight hour river trip from Battambang to Siem Reap, though villages dependent on the water. First there were houses on stilts backing on to the river, very low at this time of year. Families had their boats moored below and clambered up the steep banks on ladders. Diesel pumps brought water up long pipes to the houses. Other families lived on houseboats moored on the river. Later we passed a floating village where houses and shops floated on pontoons. Some of the fishing was large scale with big nets on a cantilever construction of long bamboo poles. The children were very adept at life on the river, balancing their boats with ease and sculling them standing up.

The river led into the Tonle Sap lake – really a vast inland sea - and we had a clear run across open water to Siem Reap. The natural environment of the region is very precious and we saw many birds, including pied kingfishers, bee eaters, swallows, egrets, herons, terns, cormorants and a pelican. The river was overgrown with water hyacinth in places – but it is a useful plant and is harvested by the river dwellers.

The temples of Angkor are unmissable in a visit to Cambodia and we spent our first three days in Siem Reap walking round a few of these enormous and impressive structures, built between the years 800 to 1400.

We found it difficult to conceive of the skill and artistry that went into these carvings – made in situ and carved once the walls had been constructed. It was like a combination of building the pyramids followed by multiple unknown Michelangelos carving these intricate and lively scenes of battle and everyday life.

The setting for Ta Prohm was spectacular with the much photographed trees that have taken over some of the buildings – Oly treated us to a viewing of Tomb Raider one evening! Particularly special were our visits to Banteay Chhmar, another hour or so along the dirt road from Thmar Puok, where the temple is right in the jungle; and to the delicate carvings of Banteay Srei, and the carved riverbed at Kbal Spean.

We could get as close as we liked and in some of the temples we just scrambled over fallen blocks at will to see the carvings. The Apsara dancers are perhaps the best known carvings, and we were able to see a live performance of this traditional art Siem Reap. There we also visited the National Museum, a fine, modern collection that really helped to explain the temples, religions, and early Khmer history.

You have to work out the relationship between Hinduism and Buddhism to understand the history - the kings who built the temples switched between these religions and in some ways merged them, and became god-kings themselves. The temples are religious buildings, but the wonderful bas-reliefs commemorate earthly struggles as well as the gods.

Buddhism remains the official religion in Cambodia. Every community has its pagoda and orange clad monks are a frequent sight. Young men are expected to spend time as monks. They are greatly respected and rely for their food on the community. Many households have a spirit house in their compound, surrounded with flowers. Chanting from local wats is another early morning sound we heard.

Whilst in Siem Reap we also gained some insight into Cambodia healthcare, with visits to Swiss cellist Dr Beat Richner’s fundraising concert for the Kantha Bopha hospitals, and the Japanese funded Angkor Children’s Hospital - and we enjoyed discussing how they fit (or don't) with the government healthcare system.

We also had two full days in Phnon Penh, enjoying the luxury of the Pavilion’s swimming pool and the tour-guiding skills of Katja. We enjoyed visiting the Royal Palace and the National Museum, an impressive 1920s terracotta building with a fine collection of Angkorian sculpture.

We saw the Mekong for the first time, sharing a sundown drink overlooking the river with Oly’s colleague Jerker, a Swedish professor of obstetrics. He is guardedly optimistic about the future of maternal and child health in Cambodia, the area that VSO volunteers in Cambodia focus on. We also met his wife Vathiny, a Cambodian doctor whose story is told in Red Lights and Green Lizards, an absorbing account of VSO health work in Cambodia in the early 1990s.

The next day Katja arranged for us to have four cyclos all day, one each, and we had a wonderful time being pedalled through the busy streets of Phnom Penh. But this sunny day included the darkest moment of our Cambodian visit when we went to Tuol Sleng museum, a former school was used by the Khmer Rouge from 1975-1978 as a ‘security prison’, where thousands were detained and tortured before being taken to the Cheong Ek Killing Fields to be brutally killed. The ranks of photographs of the prisoners, the cells in which they were held, and the instruments of torture are all there.

We read some English language newspapers in Phnom Penh which we thought were well written – some news from international sources – and were very informative about the ongoing War Crimes trials in Cambodia. One trial has been concluded so far. It is a lengthy but, we think, necessary process, and has taken over 30 years to bear fruit. A form of truth and reconciliation process is also needed, and we saw an engrossing film called Enemies of the People, made by a courageous Cambodian journalist, Thet Sambath, whose objective is just that - to tell people through real interviews exactly what happened. He was at the showing of the film at the German Cultural Institute, and answered questions, saying he is making a further film in which he would try to explain why these things happened. We found it difficult to match this recent history with the friendly and smiling Cambodian people we met during our visit.

But Cambodia has to move forward and still has political problems of corruption and nepotism – though this is not unique in the modern world. And it is very dependent on outside aid through NGOs and international organisations – we observed the imposing headquarters of the World Bank on Norodom Boulevard (interestingly just round the corner from the North Korean embassy).

So many memories as we said good bye to Oly and Katja at Siem Reap airport. It is a small, charming airport where you still walk out on the tarmac to catch your flight, and where the young man in Monument Books wished me a Happy Chinese New Year with a broad Cambodian smile, as he sold me my western ‘catch up’ newspapers - and a copy of the Phnom Penh Post.

Thursday, February 3, 2011

They lift you up your mum and dad

“We don’t get to choose our parents, but some of us do get extraordinarily lucky. I’m one of them”.

So says Dr Andrew Thomson at the end of his popular book subtitled ‘True Stories From A Warzone’, which starts in Cambodia and accompanied me in the last two weeks on my travels across the country with my own parents. I share his good fortune.

My mum and dad’s stay was great for all the best reasons. Any visit to my remote posting is special and uplifting, but with mum and dad we could also catch up on local and family gossip, agree that little changes back home, and enjoy tales of rotten weather and depressing government (or is it the other way round?).

It was a big moment too for Katja – ‘meet the parents time’! Strange that the girl who is so much part of my life had not yet met my family. Unless these days meeting by Skype counts, in which case they were already old friends. Either way I soon couldn’t get a word in edgeways, which I guess is a good sign?

It was also lovely to have time as a tourist in this wonderful country. My parents were incredibly generous in paying for hotels and restaurants way beyond my modest volunteer’s allowance, where I could gorge on bread and butter to my heart’s discontent. I’m very lucky that the bank of mum and dad stays open well into my thirties!

But their visit showed me I owe them much more than this.

For one, after over a year here it was great to once again see Cambodia through fresh eyes. The beautiful landscape (albeit browning rapidly), the smiling children, even just the peaceful simplicity of daily village life were all brought back to me afresh in their company.

Of course the temples of Angkor were unmissable, and mum and dad’s enthusiasm gave me a renewed interest in the ancient Khmer civilization. Their sedate pace helped me appreciate masterpieces such as Bayon’s ornate bas-relief carvings of daily life. They also persuaded me to visit Siem Reap’s national museum, a showy building with wordy captions, but redeemed by galleries such as the 1,000 buddhas which are simply breathtaking. Lucky mum and dad ignored the guidebook’s sniffy review or I’d never have gone.

I also learned a great deal from them about Cambodia’s more recent, less glorious history. We had enlightening debates about the impact of the American-Vietnamese war, the Khmer Rouge and the civil war (not the same thing, I now realise), the UN-backed elections of 1993, and how we arrived at today’s Hun Sen era.

Maybe parents never stop educating you? Another wealth of knowledge shared was about the natural environment. I love the beautiful flowers in the lakes, but thought they were lotus not lillies, and hadn't noticed how they open in the morning but close when it’s hot. I enjoy birdsong, but never really knew minors from sparrows, kingfishers from egrets. And do you know the difference between a moth and a butterfly?

But perhaps the biggest impact of their stay was in my little village of Thmar Puok. My friends and colleagues were fascinated that the respected elderly white visitors had made it to such a remote spot. My landlord even polished his trophy car and proudly drove us to the local temple – now that doesn’t happen every day!

Sadly I didn’t fully shake my workaholic tendencies, sneaking off to early morning hospital meetings whilst the oldies caught up on sleep. My colleague Alison and I were struggling to drum up enthusiasm for our infection control drive, and the poor parents had to put up with us complaining bitterly about the lack of progress on the first morning.

So what did they do? Rather than taking a well-earned rest, they came to the medicine ward in the afternoon and helped get things going. I was so proud of my mum and dad – 68 and 70, but still rolling up their sleeves in the heat of a foreign land, on their holiday no less, to help people less fortunate than themselves.

Happily, the next day staff jumped to the task of cleaning obstetrics, this time needing no encouragement or direction from us. I congratulated myself on having successfully shared skills in a sustainable way, the holy grail of volunteers. Only later did a colleague sheepishly admit that it wasn’t me so much as the sight of the elderly barraings scrubbing unmentionables off beds which shamed the staff into action. Good on you mum and dad!

This reminded me of yet another debt I owe my parents - in so many ways I wouldn’t be here without them. I like to think my wandering tendencies come from being conceived in Dar Es Sallam on the way home from their own development work in Zambia. Unless my gestation period was nearly a year it was more likely a council estate in Oldham, but I’m sticking with the more romantic, less likely version.

And many of the characteristics they have passed to me - idealism, adventurousness, independence, even stubbornness - have stood me in good stead for my life as a volunteer. Given these gifts, perhaps it’s churlish to complain that they also passed me my big nose, hairy back and bald head…

So thank you mum and dad – for your visit, for showing me how extraordinarily lucky I am, and for reminding me why I love you so much.

Wednesday, February 2, 2011

Will more private healthcare help the poor?

VSO is great. It aims to make life better for the poorest people in the world. And an important part of a better life has to be better health.

I was proud to work for the UK’s National Health Service. Its founding principle was healthcare free at the point of use. Access to care depends only on clinical need, not on ability to pay. It isn’t perfect, but Britain's health system is a profoundly civilised arrangement.

In my new home, Cambodia, things are very different. Sadly, access to healthcare here depends almost entirely on ability to pay, and has little to do with clinical need.

Here’s how it works (prepare for a mini-lecture!):

A small number of rich people (including elite wealthy Cambodians and most foreigners - including me) can afford almost western standards of healthcare in expensive private facilities, either here or in Bangkok or Singapore.

Cambodians on modest incomes either buy health insurance where available, or pay the fees for public health centres and hospitals in provincial towns. They need money for travel, food and personal care, and must be able to afford not work whilst away. Some choose private clinics, pharmacies or traditional medicines as they don't trust public healthcare (with some justification).

The poorest Cambodians can’t afford to pay for public health facilities or health insurance. Only if they are lucky enough to live in an area which (apparently randomly) is covered by a ‘Health Equity Fund’, or if they can get to hospitals such as Angkor Hospital for Children or Kantha Bopha, might they get decent healthcare. Otherwise they simply suffer or die silently in their villages.

Doesn’t sound good does it?

So what is the international community doing in our name to help make sure the poorest and most needy get access the healthcare they need?

Well, the clever folks in organisations such as the United Nations Development Programme say the answer is to encourage more private sector provision.

Really? Sorry, but how exactly is encouraging more private provision of healthcare going to help those most in need? How will quality and access be improved for the poor?

For quality, private treatment is better for the rich, but is not better for the less wealthy. In fact, many private clinics are seriously dodgy, with regulation even more lax than in public hospitals. As for private pharmacies, get this: an estimated 80% of medicines sold in Cambodia are fakes, ranging from the expensive and useless to the highly dangerous. The private sector actively harms public healthcare: public hospitals routinely deal with late presentation by patients who have first been treated unsuccessfully in (unregulated) private clinics and pharmacies. Staff routinely abandon their patients in public hospitals during the day to work in their private clinics. Worse still, they often take the hospital’s drugs and equipment with them. It’s an absolute scandal, but it happens every day here. Do we really want to encourage even more of this?

For access, more private provision will lead to more inequalities. Only the rich people will be able to go - when did you last hear of a private hospital exempting poor patients from fees? Private providers are driven by the profit motive, so ‘cherry pick’ profitable sectors (imaging, cancer, cosmetic surgery), and will not offer services in areas where there’s little money to be made (including the areas where VSO Cambodia’s health programme focuses - reproductive and child health).

So will more private healthcare help the poor? Of course it bloody won't!

Well thankfully there are the good guys like VSO around. Right now in Cambodia the organisation is discussing its strategy for the coming years. My suggestion is that we must urgently challenge the move towards private health provision. There is a critical need for analysis of the impacts of such a move on the quality and access of healthcare for all Cambodians, and especially the poor and marginalised.

In fact, we should learn something from the UK’s health service, whilst it is still standing. If we truly want poor people to have better health, we must make sure healthcare is free at the point of use. Not only should we fight the slide towards more private care, we should reverse the privatisation of public hospitals, abolishing the existing payment systems which exclude the poor people from care. The funding arrangements will have to be made, but it's possible - the government and donors actually have plenty of money - it's just a matter of getting priorities right.

On behalf of the poorest people in this country, I for one would be proud to be part of such a campaign.