Wednesday, September 14, 2011

A new life?

Between us, Katja and I volunteered for over 4 years in Cambodia.  We wanted to do something, however modest, to help people less fortunate than ourselves to have new, better lives.

Fine words, but not always easy in practice! 

In my remote village of Thmar Puok, the director asked me to help breathe new life into his hospital, which had gently drifted since it was cobbled together in the aftermath of the Khmer Rouge nearly 30 years ago.  

I offered to help them to improve the care they offered to patients by using a quality improvement system in their ward or department.  Happily, the tool we used was not imposed by well-meaning outsiders, but was developed by Cambodians themselves and agreed by their own Ministry of Health.  And it wasn’t me doing the assessing – rather, I helped ward chiefs to score their own area against a detailed list of good practice. 

Another benefit of this approach is that - unusually for hospitals - we could actually measure improvements.  We agreed the present situation for equipment, documentation, hygiene, and patients’ views of their care.  These scores could be compared over time, or at one point between wards (healthy competition!).  Where scores were high we gave praise, and where not we focused on improving things - a manager’s dream!

It wasn’t perfect:  some of the scoring was strange, like getting hygiene points simply for toilets being unlocked, or for having a ward free of motorbikes.  And some staff ‘played the system’ - from giving their ward a rare clean just before the inspectors arrived, to making up documentation such as vital signs and medical notes in retrospect (it’s called fraud where I come from).

But if staff were playing, so were we - it was a ‘percentage game’, with at least some of the improvements made in advance of the assessment continuing afterwards.  Some things just dropped back to their original level - even basics like turning up for work, wearing uniform and washing hands.  Yet my heart leaps when I still hear doctors explaining diagnoses and proposed treatments.  And many of the issues which affect patients most - hygiene, nutrition, medication, finances - continue to be discussed in wonderful staff-led carer education sessions, which continue every Tuesday morning.

I would have preferred that staff enhanced care through a sense of empathy or professional pride.  But if in fact they made things better because they liked to get points, look good or avoid getting into trouble – well, so be it.  The fact is, things still improved for patients.

Appropriately for our planned renaissance, the best progress was in obstetrics. The midwives were the most receptive of all staff, and this year they agreed to be assessed against tougher (‘level 2’) standards.  They did really well – despite having a shabby old ward they kept it clean, maintained decent records, and gave a good quality of care to mothers and their newborn babies.

This was particularly pleasing as maternal health is (in theory at least) the key focus for all VSO health volunteers in Cambodia.  And it is richly symbolic:  if the whole aim was to give new hope and new life to the poorest people in a poor country, what better way than helping to bring babies into the world with more chance of a better life than their mum?

So, after two years, our thoughts also turned towards new lives, this time our own.  Katja returned first to the UK, to continue the theme of re-birth by starting two years further training to be a midwife herself.  The main reason she gives for taking on this tough extra study is not just that she loves babies, but also that she feels this is the best way she can help poor people in the future.  Now you can see why I admire her so much!

And for me too a new life was beckoning:  the prospect of discovering Oxford, possibly changing job or even career.  Importantly, I also hoped I would have a novel perspective on things – a better work-life balance, a calmer outlook, a clearer focus on what is important.  And, of course, I would be setting up home with the new love of my life - a wonderful, totally unexpected bonus of volunteering!

And so to my punchline.  At this point I had planned to make a happy announcement – of one more new life. 

Around a month before she returned to start studying, Katja and I found that she was pregnant.  We were so happy and excited – this really did mean that a new life would await us back in the UK. 

I couldn’t believe it:  “I’m going to be a daddy!” I chanted.  The thrill of the return home was enhanced by debating when and how to make the announcement, where to live, what marque of superbuggy to covet.  Most difficult of all was names.  Oliver was firmly at number one in the UK baby charts: what good taste parents have.  And these days there is also the issue of the surname, which presented a unique challenge for us – would we really risk condemning our offspring to a life of ridicule by imposing the easily mispronounced ‘Horsch-Shipp’?

But it wasn’t to be.  Sadly, after three months Katja rang me distraught to say she’d had a heavy bleed.  After dashing to the emergency obsterics unit and a further scan it was confirmed she had suffered a miscarriage. 

As suddenly as it had started, our dream was over.  Of course I rushed home, and am writing this in the day unit at Oxford’s John Radcliffe hospital, waiting for Katja to return from her operation, a coldly clinical ‘evacuation of retained products of conception’.  The physical evidence will soon be gone, and all that will remain are our dreams of what might have been.

It would always have taken us time for us to adjust to our return in the UK.  Now, with this wretched, unexpected twist, it may take even longer.  But I honestly feel that if we can survive two years in the most rural corners of a developing country, then we will have the strength to recover and move on. 

Just as we tried to give help and hope of a better future to others in Cambodia, I believe that we too will enjoy and embrace our new life.

Thursday, September 8, 2011

The Road

Just before I came to Cambodia my friend and football teammate Jules gave me a book called The Road.  It’s about the struggle for survival in a barren, post-apocolyptic wasteland.  It was a nice thought, but I decided to wait until I returned from rural, post-conflict Cambodia before reading it!

But perhaps that was a mistake:  the thing I talk about, whinge about, dream about more than anything else here is my goddammed godforsaken road.

The 50km route from the provincial town of Sisophon to my village is officially National Road 59 - the equivalent of an ‘A’ road in the UK.

But as you leave town the tarmac abruptly becomes a derisory dirt track. A large, faded sign mockingly pronounces that a new highway has been funded by the Asia Development Bank, work to start in 2006 and finish 2008.

In fact, the running joke here is that the new road will be completed “in just two years”.  A rolling two years, that is, from whenever you ask the question.  It was two years when I arrived here, two years ago, and if it’s even started in two years time I’ll be happy.

So what’s the big deal?

Well, clearly the main reason to improve the road is for my personal comfort!  This is particularly the case since the surface got so bad that even the once-a-day bus service stopped last year, apparently as the vehicles could no longer cope with the journey.  What about me?

There are other, even more convincing arguments.  Watching poor local people struggling through the waterlogged clay it’s clear a new surface would deeply improve their lives.  Everyone works the land, even those with other jobs.  If they are lucky enough to have excess rice then they need to transport it to market.  Equally, a decent road would open up their villages to new goods and services which have never made it up the terrible old one.  Watching children struggle through the mud or market women cover their faces from the dust makes me feel wretched for what they haven’t got.

Our focus here is on maternal health, and if an expectant mother is diagnosed with a condition such as pre-eclampsia (basically pregnancy-induced high blood pressure) then it’s vital this is recognized and treated quickly.  Here, this can mean helping to prevent seizure, such as by giving magnesium sulphate injections and avoiding stimulation.  But the only cure is to have the baby.  As this is likely to be by caesarian, mothers need to be transferred to a larger hospital for this major operation.  And how to get there (still avoiding stimulation of course)?  The only way is in the back of our ancient ambulance, feeling every bump and rut in the hellish 50km route.  It must be an agony for a poor woman in such a condition - another compelling reason for the road to be improved.

Sadly, some of those who are meant to be helping the poor also seem to be a little shy of the present travel conditions.  Whereas nearby Siem Reap is heaving with well-meaning charities, very few indeed can be persuaded to help the real poor people in my area.  Is it coincidence that they work where there are already great new roads which join the fancy hotels to the amazing temples?  I understand why of course - the most important thing for any NGO is to ensure their shiny white four-by-fours don’t get muddy.

So much for the poor then.  But surely the rich dollar-earning tourists have more influence? 

You see, my road is also a key link for anyone wanting to visit the pre-Angkorian temples at Banteay Chhmar.  The site is being restored by the UN Heritage Fund, and there are impressive plans for a ‘’community-based’’ approach to tourism there (no hotels, but rather staying with local people and getting an insight into how they live, eat and even travel – courtesy of an ox-cart ride!). 

But for now, few tourists brave a 100+ kilometre round trip on bone bashing boulders when the alternative is the smooth, straight tarmac direct to Angkor.  Surely the tourist income will help persuade the authorities to build a new road?

There is one other factor:  the N59 runs parallel to the Thai border, from the south up towards the area of disputed temples.  With a new government taking power in Thailand it is hoped that the will be no more fighting – but the military’s desire for a good transport link for troops and equipment must make it of some strategic importance.

So why then does this road – my road – remain the only unpaved national road in the whole country?

Money is bound to be an issue – over 50kms of road doesn’t come cheap, and funding is scarce in the present economic climate.  Apparently the original plan was bankrolled by Thailand, who pulled the plug when the recent fighting broke out.

But I have another theory. The people up here are close-knit, independent and proud.  The government in Phnom Penh closely oversees roadbuilding, knowing the political value of being seen to bring new infrastructure to a region (Prime Minister Hun Sen is said to insist on personally opening every new bridge and highway in the country).  So it’s simple – there’ll be a new road just as soon as the unruly folk of my area start voting the right way!

There’s an upside to all this:  a new road would certainly help development, but it would cause problems too.  Evidence suggests that better roads actually lead to worse traffic problems – more people will drive cars and lorries, they will go even faster, and they will maim and kill even more people.  They will also cause more noise and pollution whilst contributing nothing to the communities they zoom past.

So as I slither along the mud track to my village backwater I know in my head that a new road will on balance be good for the people here.  But in my heart I’m very glad that, at least for my time here, I will enjoy the peace and safety of a car-free existence. 

A peace I will enjoy on my balcony, watching people walk or cycle by, and reading a good book – anything other than The Road!

Friday, September 2, 2011

The Noble Art?

The evening of June 8th 1985 is clear in my mind for two reasons.

As we gathered excitedly round my granny’s telly, Barry McGuigan finally got his shot at a world title against Panama’s Eusebio Pedroza. It was so exhilarating that even my mild-mannered dad and brother were on their feet yelling ‘hit him, hit him, hit him!’.

But I also remember my mother’s entrance: carrying a tray of cocoa (it must have been one of those summers), she was clearly shocked by the atavistic blood-lust of her menfolk. “What a horrid sport!” was her typically polite criticism. She was right, but we told her to shut up anyway – it was just too exciting.

Twenty six years later, and I finally got round to watching another boxing match (in fact two in a matter of weeks). I'll remember these too, but I will also have the same mix of emotions about both of them.

At the most recent, we again huddled round the tv, but this time the drink was beer, the company soldiers, and grandparent’s house was Ta Mok’s.

Sounds like another cosy evening? Well, not if you’re from this country: Ta Mok’s name still strikes fear into the hearts of ordinary Cambodians. Widely known simply as ‘The Butcher’, he was possibly the most brutal of all Khmer Rouge leaders. He orchestrated appalling massacres in the southern zone from 1973, and led horrific ‘purges’ from 1975-1979.

His stronghold was the small northern town of Anlong Veng. I spent a week working at the (former military) hospital there, and had the dubious pleasure to visit his old home. Overlooking a lake, reflecting the Dangrek mountains, the setting could be beautiful – if it wasn’t that hundreds of slave labourers died cutting the trees and damming the river just to give him the lovely view.

The army commander who had taken up residence gently insisted we stay to watch some ‘pradal serey’ - khmer boxing. So we crowded round the battered old telly - it fact it could almost have been my granny’s old set from a quarter of a century earlier!

As for the boxing itself, I was struck by the shifting movements, and the use of elbows as well as feet: that’s got to hurt! And this particular bout was between two women - nice to see equality extends to the right to maul each other for public entertainment.

But I came away with very mixed feelings. It’s hard to relax in a mass murderer's lounge. Watching a boxing match in the home of a notorious killer is certainly one of the most unique memories I will take back with me from Cambodia.

My other recent experience of boxing, in the infamous Thai seaside resort of Pattaya, was also a memorable but ambiguous experience.
Having fulfilled the aim of our visit (Katja’s crazy bungee jump!), we celebrated with a night on the notorious Walking Street. In between the sleazy bars we found a ring, with two young boxers about to put on a show which we hoped wouldn’t stray below the belt.

This was the first time I’ve seen boxing in the flesh, and it was alarmingly vivid - they pounded each other with frightening power. It was impressive and repulsive in equal measure, and (probably like the clients of the neighbouring girly bars), I felt both excited and a little ashamed to be there.

Part of me is undeniably drawn to boxing. Whilst I’m not quite sure how Mohammad Ali could liken it to the pursuit of a beautiful women, I can almost see why it has been described as ‘the science of sweet bruising’. I can certainly understand how writer James Lawton concludes that “in its atavistic rages, its often beautiful skill and the implicit courage of the protagonists, boxing takes men and women into areas that are untouched in other areas of legal spectacle”.

As a cinephile, boxing combines the brutality of
Raging Bull, the passion of On The Waterfront, and the simple excitement of Rocky. As a health worker I note it is great for fitness (though not for brain injuries). And as a social activist I believe it offers a positive outlet for kids who would otherwise be punching dolphins or grannies.

I even had a go myself recently – no sparring of course, but I put on gloves and had a good go at my mate Pete’s punchbag. Throwing a punch is deceptively hard: there’s a whole art in placing the feet, positioning the legs, rotating the hips. It's almost like golf, in that it's much more about technique, balance and concentration than power. And landing a good blow gave the same exquisite feeling as hitting the sweet spot when striking a football or shuttlecock.

But the main attraction for me is simple. It is that boxing is the most basic of all sports - having a scrap.

Having said all this, another part of me - the larger, more rational part - really abhors boxing. The health arguments are compelling. And socially, there’s something not quite right about a couple of poor lads knocking lumps off each other for the amusement of sneering cigar-smoking bankers at the ringside.

In fact it doesn’t really need much debate: let’s face it, boxing is unpleasant, uncivilized and unsafe.

I guess it will eventually be banned - but not for a long time here in Cambodia. For one, nothing much gets stopped here, however bad it is. But also, it’s a national obsession, and it would take a brave fighter indeed to knock it on its head.

Perhaps the reason why it continues also reflects my mixed feelings about the whole thing. As Lawton concludes: “You can stop many things, for many reasons. But not included among them is a man's instinct to fight - and that equally compelling urge to watch”.