On Friday I taught a “First Aid” workshop at my new job. Let me just say that teaching first aid skills in a developing country is a bit different than teaching it at home – not that I've actually taught ”first aid” at home, but I once was a certified CPR instructor many years ago, for what that’s worth.
In fact, we didn’t learn CPR at all on Friday. For one, I know of no CPR dummies available here, and it’s the kind of thing you really want to do some hands-on practice with. But even if there were any, I would still be reluctant to think that teaching CPR is the best use of time. Last I knew, when I was still getting re-certified every year, CPR doesn’t often work so well, and when it does, it’s because the EMTs with the defibrillator arrive within minutes – after all, the first thing you do is call 911. But here, there is no 911 to call. There is no number of any kind to call, because there aren’t any EMTs or real ambulances or defibrillators or well-equipped hospital ERs to resuscitate those whose hearts have stopped for whatever reason. There are lots of people who live miles and miles and miles from any healthcare facility of any kind, and the small government clinics they might be able to access after a long bumpy motobike ride (assuming they have access to a motorbike and the roads aren’t flooded) are little more than dispensaries for paracetomol (Tylenol) and amoxicillin. (Interestingly, the standard protocol at the village clinics for paracetomol seems to be to take twice the recommended dose only half as often. Not really so useful.)
It seemed to be a more productive use of time to talk about the real health problems that people are likely to have here that we can potentially have some impact on. So while we skipped CPR, we did learn and practice the Heimlich Manuever. We also talked a lot about cuts and bleeding and burns – and we talked a LOT about fainting. People in Cambodia report a lot of “fainting.” Everyone has a story about having fainted, or someone in their family having fainted, or a stranger on the road fainting. I can’t begin to tell you why it’s so common, though I suspect that general poor health and nutrition, un-diagnosed diabetes, chronic dehydration, and stress/anxiety/hyperventilation often play a role. Recently there have been mass faintings at garment factories in Cambodia, and while poor ventilation or chemical fumes have been blamed, no has been able to pinpoint the cause for sure. And considering that in one report, even the security guards outside the factory ended up fainting as well, I suspect that there is at least in small part a bit of mass hysteria that played a part in 300+ people keeling over at a time in different locations on different days. I hope that doesn’t sound insensitive – I don’t mean to imply that people were faking, just that people here have a lot worries and misunderstandings about their health, which leads to a lot of anxiety, and one or two people fainting could easily scare many others into a fit of hyperventilation.
One of the Khmer staff had a story to share about how he has helped people in the past who have fainted. Twice he has been able to “revive” someone by biting them. On the heel. He swears that it worked, and they woke up. While commending him for caring enough to take action, I suggested that he could probably skip the heel-biting in the future.
Everyone around the table had stories to share, which made for lively conversation and all kinds of new learning opportunities for me. When talking about dealing with cuts and bleeding, I learned that people use both spider webs and cigarette ashes in wounds to help stop bleeding. Headaches are often cured by applying burning incense to the scalp and pulling the hair. Children’s stomach troubles may be treated by applying hot coals to their belly. Some of those methods are a bit concerning, and I tried to address them in culturally respectful ways. Other traditional healing methods are widespread but relatively safe, and I wouldn’t begin to tell someone that getting coined (rubbed repeatedly with the edge of a coin until bruises appear) is not useful. People believe that it releases “bad wind” from the body, and it used as a cure for everything from fever to fatigue to body aches – and if you believe something will help, it probably will, either because of the placebo effect or because the pain of being coined causes endorphin release so that you actually feel better for a while. (Or because the pain of being coined takes your mind off the original problem.) In any case, it is amazingly common, and I’m not going to get anywhere telling people that it doesn’t work. If people in the west want to use crystals or feng shui or chicken soup and claim to feel better, I’m not going to argue with them either. I’ll only draw the line at burning children with hot coals...
Many of the staff had good questions, such as “If you live with someone who has diabetes, can you get it too?” When we talked about burns and why cool water is better than ice to apply to a burn, I ended up talking about the damage that ice can do by explaining what frostbite is – no one had ever heard of such a thing, and now I think they assume I come from a very dangerous country if my toes can potentially freeze off in the winter.
While we talked about lots of things to do in response to injuries or illness, I talked even more about prevention. In a world littered with plastic bags, where children use sharp implements from a very early age, where gasoline is sold in soda bottles, where child-proof caps are completely unheard of, and where “the kitchen” is an open fire on the ground outside your house, there are unlimited possibilities for poisoning, burns, and injuries. In a place where few people ever get a tetanus vaccine and even fewer dogs get a rabies vaccine, the potential for serious consequences of otherwise relatively minor problems is huge. And in a world where many people have no clean water or soap, even simple advice like keeping a wound clean is far more complicated than you might imagine.
The clean water thing is huge. In my first weeks on this job, I came to realize that many of the families we visit have no clean water. They may be drinking what they scoop from the river, and often don’t even boil it. When you ask if they know that boiling the water makes it safer, they often say that they know, but they’re “too lazy” to do it. They tell us, “No one in this village boils the water.” Lazy sounds harsh; I suppose that when you’re living hand-to-mouth, possibly malnourished and probably depressed, boiling all your water does seem like a daunting task. And there is no obvious immediate effect from not boiling the water – sure, people get sick, but it’s not always clear that the filthy water is the culprit. Maybe they can’t spare the fuel for the fire to boil all the water they would need. Maybe they don’t have a big enough pot. Maybe there are the factors in play that I know nothing about. In any case, it has become part of my mission as the person responsible for health concerns for these families to address the water issue, and the director is on board after our email discussions. She’s working on raising the money to provide the ceramic and plastic water filters to all of our 47 families. This will present its own set of logistical challenges – while the filters only cost about $15, they are big and difficult to carry on a moto to deliver to all these far-flung families. They will require some washing and maintenance in order to remain effective. And lots of evidence shows that people are far less likely to be invested in using and caring for it properly when they have been given the filter for free rather than having to pay even a small amount. So figuring out how to deliver all these filters, train people to use them well, and monitor their use will be one more thing for the staff to take on. I’ll let you know how it goes.
The best resource I’ve got here when doing any sort of health teaching is the book “Where There Is No Doctor.” It’s an amazing resource that I may have mentioned before. The English version can be downloaded completely free, and it was recently translated into Khmer by friends of ours who have lived here for a few years. It’s full of good advice appropriate for developing countries and places with limited resources, and I photocopy the Khmer pages back to back with the English pages so everyone can look at particular sections in their first language and have the same information. Given the limited literacy of many rural Khmer people, it’s not so useful for them (and also a BIG book, so sometimes a bit daunting to find what you’re looking for) but it’s great to use for staff trainings. I will be forever grateful to those who took on the task of getting it translated, and to the Hesperian Foundation, which makes English versions of all their many useful resources available for free download.
So my job as a “visiting nurse” in Cambodia is in some ways not so different than my job was at home – focused on education and prevention wherever possible. The next big task is to arrange for some of the kids I visit to be seen at the local children’s hospital and get some actual diagnoses and treatment, if possible, for the varying and vague symptoms that some of them have. “Seizures” abound among these kids, but the histories and descriptions are so vague and confusing that nothing is clear. I saw a girl last week whose grandmother’s chief worry was the girl has a “hot body” all the time. “Hot body” may or may not mean fever, and no one has a thermometer anyway. She looked pretty fine the day I saw her, other than the infected toe from stepping on a thorn and then probably running through the cow dung in the yard. I am quite sure she will not be happy to see me again after we dealt with that on my first visit.
So, the next time you cut yourself, be thankful for the soap and clean water and Bandaids and Neosporin you have available any time you need them. No need to look for a spider web or cigarette ashes to apply – just stay out of the cow dung. And if you’d care to contribute to the water filter fund, let me know and I’ll send you the link. In the meantime, I’ll be here NOT boiling my water (because I can afford to buy it) but doing other stupid shit that I know isn’t necessarily good for me.
To avoid posting a text-only blog entry, here are some photos that demonstrate the current status of water in the town of Siem Reap. The river has overflowed its banks and getting around town is interesting:
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To avoid posting a text-only blog entry, here are some photos that demonstrate the current status of water in the town of Siem Reap. The river has overflowed its banks and getting around town is interesting:
