Reducing child and maternal mortality?

What do you know about the Millennium Development Goals?

To my shame I knew next to nothing until a few weeks ago, despite them being one of the most important agreements in the world.

Basically all countries have signed up to 8 targets to be achieved by 2015. These range from an end to poverty and hunger, and promotion of universal education and gender equality, through to HIV/AIDS prevention, environmental sustainability, and global partnership.

Noble aims – but quite a challenge!

My work in Cambodia is linked with two particular goals – number 4, to reduce the mortality rate for children under five, and number 5, to improve maternal health.

In July, all the VSO health workers in Cambodia and our volunteer assistants gathered in Phnom Penh to share our learning and refocus on why we are here. This year we looked specifically at these goals - reducing child and maternal mortality and morbidity in Cambodia – and what difference we can make as volunteers.

Where we are going seems to be well defined – starting from 1990, the aim is to reduce child mortality by two thirds and maternal mortality by three quarters by 2015. Only five years left then!

So where are we now? Agreeing on figures was surprisingly difficult. For example, according to the Central Asia Health Review, from 1990 the maternal mortality rate (the number of mothers who die as a result of childbirth, per 100,000 live births) fell from 900, to 590 in 1995 and 450 in 2000. But then the rate not only stopped falling, but had actually risen to 540 by 2005.
Does this mean that things are getting worse?

Not necessarily! In discussion it seemed that the increased rate may have more to do with better reporting than worse outcomes. Either way, it will be really difficult to meet the three-quarters reduction, which would be a rate of 225 in just five years time.

It’s worth pausing to take in what these numbers actually mean. Right now, for every 100,000 live births in Cambodia, 500 women die due to childbirth every year. If this doesn’t shock you, note that in neighbouring Vietnam the figure is less than a third of this, at 150 a year.

And in rich nations such as the Netherlands the rate is only 6.

This is because most maternal mortality is entirely preventable, a result of severe bleeding or haemorrhage and bacterial infections, pregnancy-induced hypertension (pre-eclampsia) and obstructed labour, along with unsafe abortions. These are often associated with other issues such as malaria, HIV/AIDS, complicated pregnancy and cardiovascular disease - and by the distance and cost of travelling to the nearest clinic.

This is truly a global scandal – women are still dying of completely preventable conditions in poor countries like Cambodia.

So what are we doing about it?

Encouragingly, we heard many examples of work VSO colleagues are doing to help prevent women dying unnecessarily.

Our guest speakers came from a small project called M’day Reak Reay, Kone Reak Reay (‘happy mother, happy baby’) who promote cooperation between midwives and traditional birth attendants. They gave us fascinating insights into how to work through the social hierarchy, getting permissions from every conceivable level, and how traditional birth attendants can actually play a useful role in identifying early complications and encourage women to go to hospital – which could literally save their lives.

We also had a great session on ‘behaviour change’ – if we are to make any lasting contribution then we need to work with women, families, communities and healthcare colleagues to change some of the factors which lead to maternal death. We reflected on what might influence us to change what we do (say washing our hands or wearing a moto helmet), and soon recognised that our own belief in a benefit or the support of those we trust can be far more powerful than lectures or threats from well meaning outsiders or ‘the authorities’.

Even our lunch break was a chance to learn: VSO recruits a number of nutrition advisors, who cooked us a traditional lunch whilst helping us to understand the importance of good nutrition in reducing mortality and morbidity. They demonstrated simple techniques such as putting tofu into soup and carrots or green leaves into the traditional bor-bor (rice porridge) - it was actually very tasty!

Our final session, bringing together all this background, challenged us to come up with practical ways in which we can make a difference to these goals as VSO volunteers. These included practical suggestions such as sharing our information, resources and skills, learning to work within the cultural hierarchies, role-modelling good practice, and getting the best from our volunteer assistants – and remembering that many improvements don’t need money. We also identified that we can be most effective when we ourselves are healthy and motivated – so I vowed to go off to nibble carrots and learn the 33 Khmer consonants.

To round things off, the Phnom Penh 5 O’Clock Blues Band (formed just a few hours earlier) brought some light relief to the evening, showing what the accompanying partners are up to whilst we are saving the world. My highlight was undoubtedly ‘The Development Blues’: “I godda big white four by four… Yeah I godda big white four by four… Need a four by four… to he-elp the poor”. Cutting!

A fascinating, , exhausting and inspiring 2 days – hopefully it will help us to make a difference.

Enemies of the People

He looks like a decent man: a kind, soft face, deep brown eyes, avuncular wrinkles. In fact to me he looks like a maths teacher – which is what he was.

Not the sort of guy, then, who would direct horrific torture and mass murder at Phnom Penh’s notorious ‘S21’ Tuol Sleng prison / death camp.

But that’s exactly what happened. The Extraordinary Chambers in the Courts of Cambodia have finally, 11 years after they were established, convicted the first member of the Khmer Rouge for crimes against humanity.

Comrade Duch’s story is remarkable for many reasons – the horrors committed by a seemingly ordinary man, his mysterious disappearance after the fall of the Khmer Rouge, and his bizarre chance discovery twenty years later by a British journalist.

Even his trial was extraordinary, undertaken by a hybrid of a local court supported by international officials and money, with both local and international judges. Duch initially admitted his crimes and expressed remorse, but then dramatically sacked his defense team and called for an acquittal.

The trial was also profoundly significant in that it finally allowed victims of the regime in Cambodia to face up to one of the killers.

Pol Pot, however, will never face justice – he remained at large in the north of Cambodia, near where I live and work, long after his regime had fallen. Ironically, the western countries who are so instrumental in backing the international court were the ones who helped ‘Brother number 1’ evade justice, covertly arming him as a buffer against communist Vietnamese troops who overthrew his regime in 1979.

But his deputy, ‘Brother number 2’ Nuon Chea, is still alive and is due to face trial along with three others next year.

At the Cambodian premiere of a new film about him, Enemies of the People, Cambodian investigatory journalist Thet Sambath tracks down Nuon Chea and gains his trust to the extent that he admits his actions for the first time.

The film includes fascinating insights such as Nuon Chea interpreting footage of Saddam Hussain as showing a misunderstood patriot, his strange moral code in wanting to avoid ''embarrassment'' by reenacting how he slit the throats of victims, and all the killers' constant references to following the hierarchy of command as a reason for obeying orders to murder.

But ultimately the film – and the trial - left me more confused than ever: how on earth can a country kill up to two million of its own people?

More illuminating was the post-screening debate, with co-director Rob Lemkin pushed to turn over his footage to the courts. Lemkin argued that Sambath was only able to get unique admissions of guilt on film by promising that these were for historical not judicial purposes, and that the future of truth and reconciliation depends on honouring such agreements.

Perhaps both approaches have their place – Cambodians, prompted by the top-down work of the courts and the more grassroots discussion of the film, may finally be starting to come to terms with their terrible recent history.

Kep, naturally

Natural beauty is abundant in Cambodia, despite the history of destruction under the Khmer Rouge and the more recent ravages of ‘development’.

My village of Thmar Puok is in the far north of the country and has plenty in the way of trees and fields, with forests and hills in the distance lining the border with Thailand. What we don’t have is water – no mighty Mekong as in the east, no vast Tonle Sap lake as enjoyed by residents of the central plains – and certainly no sea.

So when Katja suggested we extend a trip to Phnom Penh include a trip south to the coast, I jumped at the chance. A mere 14 hours of bus journeys later and we were dipping our toes in the balmy waters of the Gulf of Thailand.

Cambodia’s main seaside resort is Sihanoukville (or Kampong Som as everyone calls it), but it sounds about as attractive as a crab curry. The quiet and understated town of Kep, popular with Cambodians as much as western visitors, is about 100 kms east and a world away. Naturally we headed there, and we didn’t regret it.

Kep sur Mer, as it was, became a popular seaside retreat for French rulers in the early 1900s looking for a natural break from the sound and fury of Phnom Pehn. It’s easy to see the attraction – colonial villas and lodges were constructed right on the unspoiled shoreline and up the steep green slopes of the hill offering sweeping views out to sea.

Sadly Kep suffered badly under the Khmer Rouge in the late 1970s. Not only were buildings directly destroyed, but what remained of the town was stripped bare by starving people made desperate by the regime’s disastrous attempts to create an ‘ideal’ peasant society. By the early 1980s the town lay in ruins.

Reconstruction has taken time, and on a walk around the hill we saw several buildings which were just shells occupied by poor farming families on an semi-permanent basis. But there is a buzz again about Kep, with several developments underway which at least appear to be sensitive to the local people and environment.

The 10km walk around the base of the hill was truly uplifting, for the sea views and also for the unusual efforts made to provide a sanctuary for wildlife and a pleasant environment for visitors. Not only did beautiful butterflies flutter overhead and giant millipedes crawl over my boots, but none of this was sullied by the piles of plastic bags and polystyrene food wrapping which blight much of Cambodia – truly a breath of fresh air.

Similarly inspiring was our stay on Rabbit Island, a short boat ride off the coast. I was initially concerned by my guidebook’s warning not to get the wrong boat – apparently if you stray into Vietnamese territorial waters you are less likely to be greeted with a lotus flower than a heavily armed gunship, as neighbourly relations remain strained. I hope I’m wrong, but I fear that the recent discovery of oil in the Gulf of Thailand may not be good news for these relationships, for the local people or indeed for preservation of the area’s natural beauty.

There are no rabbits on Rabbit island– the name comes from the shape of the island rather than its fauna – but there is a lovely sandy beach, a row of simple wooden beach huts, and lovely clean water. At night we dived off the pier into the warm, clear sea to watch the air bubbles on our skin shine bright with phosphoresence– it’s a wonderful natural phenomenon (and one which only happens in unpolluted water).

Back on the mainland, there was time to admire the great white statue which dominates this part of the coastline – gazing out to sea is a beautiful Khmer woman, dressed as if to swim (Cambodians like to splash around, though they are a little constrained by the fact that few have been taught to swim, and that their culture demands you must remain clothed to enter the water). The woman was hardly wearing a skimpy bikini, but apparently the statue was initially controversial, with conservative visitors even draping extra cloth to protect her natural modesty.

So here’s to Kep sur Mer – let’s hope it can be a model for how Cambodia can balance its need for development whilst protecting its stunning natural beauty.