A selfish post

Greetings, dear blog readers;

     I write to you today, as usual, from Siem Reap, where the sun is shining and the water is just starting to recede a bit from the third (or is the fourth?) flood of the season. We're off on a little adventure to Phnom Penh this weekend to attend TEDx Phnom Penh, which should be interesting. We're all busy with work and school and sweeping and trying to keep our feet dry, and life is generally very good.

     I feel a little awkward about posting this particular entry, but I am motivated by the fact that from time to time, people ask if they can send us something to help out in our various endeavors. Steve knows a few former volunteers from Australia who have generously sent items for his classroom. Last year, in time for Christmas, our friend Miriam and her family sent a box of medical supplies. Our friend Alison and her kids came in February and fulfilled all kinds of wishes from our list at the time. You can't imagine the joy of receiving a box of stuff here - it's better than Christmas ever was, even as a kid! Since our friend Miriam is coming for a long-overdue visit sometime (probably) in December, and has reported that she will have room to bring things in her suitcase, I thought I would put the word out.

     If you have ever thought about wanting to contribute something, but haven't been sure what to send or how to send it, I have created a solution. I spent some time on the Amazon.com website and made a "Wish List of things I can't get in Cambodia." (It totally reminded me of the hours I would spend as a kid pouring over the Miles Kimball catalog, making lists of items I lusted after.) If you want to spend $3 or $10 or $25 or anything at all, you may find something on that list that fits.

     I have no expectations whatsoever here. I don't want anyone to feel any pressure or obligation or anything else unpleasant. This is really meant as an opportunity for those who have expressed interest in "doing something" and nothing more than that.

     There are a number of medical and health-related items on the list, which are my top priorities. These can be used in both of my jobs and also in my "freelance" nursing role here in town. Most prescription drugs are available here cheaply over the counter, but other things are impossible to find or enormously expensive.

I love doctors with "skills."
I once saw a sign for a doctor
who advertised "Using real otoscope."
My best advice: Don't get sick here.

     There are also arts & crafts items on the list that can be used by the girls at the shelter. I don't write about the girls that often, in part out of respect for their privacy, but at any given time there are between 5-20 girls age 5-17 years old who are studying and recovering and getting counselling and preparing for the next stage of their lives, and nothing makes them happier than creating something - and I think it's therapeutic as well.

They make the most amazing things with just colored paper,
but imagine what they could make with other stuff...!

     (I must confess that there are a few selfish items on the list. Feel free to ignore them, but I couldn't resist the urge to include a couple of things we could use around the house. They are lowest on the priority list for sure.)

Sometimes, you just want a little familiar tea for your sore throat.

     So if you're interested in "doing something," take a look at the list at this link. You will be able to see my comments and priorities on the right side of the page. You can sort by price or by priority. You can have the items sent directly to my friend Miriam's address, avoiding any troublesome logistics. Many of the items listed are just examples of things needed and you can easily substitute something else bought locally - or better yet, if you happen to have something already lying around the house unused, send that. I guess that idea works better for some things than others - a used blood glucose monitor is a fine idea, but maybe used rubber gloves are not...

     Have questions? Ask me. Have something else in mind that you want to send along? Just ask me to make sure it's a good use of Miriam's suitcase space - you can never predict what is and isn't available here, and some things are dirt cheap. And if there's something you'd like from Cambodia, I bet Miriam will have suitcase space on the way back too. Just ask me!

     I'm sorry I can't offer you a tax deduction for any contribution you make, but I promise that anything sent will go to the best possible use and I'll be able to tell you all about how amazingly helpful it is.

     In the meantime, I am missing my friends and family and Vermont foliage, but feel honored to be able to be here trying to do my small part in the world. Perhaps our next trip home to Vermont will be for yet another wedding, as Skyler has just proposed to his wonderful girlfriend Jenny and there is another wedding in this family's future!

With heartfelt gratitude and warmest regards,
Jess

 

The weather, and other topics

The past few weeks have been full of things to write about, and yet my general sense of inertia has prevented me from sharing it here. Today I will make an effort to catch up a bit, though as one experience after another leaves an impression in my mind, I fear that the older impressions get fuzzier and fuzzier...

Despite its reputation as a meaningless topic of conversation, the weather has been pretty remarkable here lately. Though we are getting closer to the end of rainy season, it shows no sign of  letting up, and there have been tremendous floods all over, including right here in Siem Reap town.  The Siem Reap River, which normally ambles through town as a slow-moving ribbon of brown water (they try to trap all the garbage in a big net just before the river hits the touristy part of town) rose dramatically to the edge of its grassy green banks, and then quickly spilled over into the streets. Our house was not affected, for which we were very grateful, but the main streets were hip-deep in some places, and lots of people had to vacate their homes when the water came inside or the roads became impassable. Getting from one place to another became a huge wet adventure. I learned that as long as my muffler didn’t end up underwater, I could drive my motorbike through the flooded streets, but the problem was that sometimes the water was only shin-deep in one spot, and then quickly became much deeper, leaving little opportunity to turn around and go back. The roads themselves weren’t visible through the filthy water, and it became impossible to see the pot holes and broken pavement. As cars and truck ands tuktuks made the same valiant attempts to move around town, they created wakes and currents and shoulder-high splashes, which meant that going anywhere, even when it wasn’t raining, resulted in getting soaked. People were kayaking down Pub Street, the main drag of restaurants where all the tourists usually for dinner. 

Driving on dirt roads was even more of a challenge than driving on paved streets – the roads were washing away bit by bit, exposing unseen boulders, or the mud was ankle-deep slippery clay, providing a fish-tailing experience similar to driving on an icy Vermont road in January. The roads to both my office and the shelter were flooded, and the shelter itself ended up partly underwater. One day, I saw fish swimming in the driveway as the poor barefoot security guard slogged through the water to open the gate. Kids swam in the streets and jumped off the bridges into the fast-moving river. Stories abounded about crocodiles that had escaped from the crocodile farm right here in town and were swimming in the streets – making me worry a bit about those kids dog-paddling down Sivatha Boulevard!

Allegedly an escapee from the crocodile farm

The first time the river overflowed, it was pretty impressive and the whole thing was a bit of a fun adventure. When it receded after a few days, everyone breathed a sigh of relief and set about drying out their belongings and mopping up the mess. When the rains started again a few days later and the river came up faster and deeper than the first time, it wasn’t nearly as amusing. Even more Cambodian villages were flooded, a group of tourists had to be air-lifted by helicopter out of one of the temples when the water came up suddenly, and the news was filled with photos of people clinging to trees and roofs and escaping their homes by boat. Many people couldn’t get home for the big Pchum Ben holidays. The last figures I heard say that more than 150 people have died in flooding in Cambodia, with hundreds of homes, businesses, pagodas, schools, roads, and hospitals damaged or destroyed, not to mention vast areas of ruined rice crops. While we whined about the inconvenience, that’s all it was for us, but for many people here this is devastating, and of course there is no safety net.

Many events around town were cancelled, lots of expats took the opportunity to get out of town and go to Bangkok for a few days, and our shopping and eating expeditions were limited to places closer to home than usual. As of two days ago, the water has receded yet again – though just as it was starting to go down, we received emergency emails and text messages from the US Embassy warning of us of impending floods in the next few days. Either they’re a little late getting their warnings out, or there is more to come. Time will tell.

In the meantime, I sneak looks at people’s Facebook photos of Vermont foliage and feel quite homesick. I'm sure I will feel differently when I start seeing people post about freezing temperatures and snowstorms, but for now, I truly do miss the crisp fall air and the blaze of color and freshly-picked apples. I would love to be sitting in front of our fireplace with a glass of red wine, smelling a pot roast simmering in the oven, and hanging out with my friends and family. I’m not sure why we feel this so strongly right now (Steve and I are on the same page at the moment); maybe there’s something about having been gone for a full year and missing things for the second time around that make it more difficult. Rest assured, Vermonters – we miss you!

In other odd tidbits, there have been the usual moments of serendipity and surprise. A couple of weeks ago, I got an email from an American woman who had just arrived in town and confessed to being a blog reader. She was kind enough to have looked at our “wish list” on the blog and generously brought me two boxes of my favorite cereal. I have savored every mouthful of Frosted Mini Wheats and Cracklin’ Oat Bran. Ah, the kindness and generosity of strangers!

While we can’t enjoy those freshly-picked Vermont MacIntosh apples, we do continue to enjoy the huge variety of fruit available here. There is always a lot to choose from, but as things come into season, they get ever more delicious and cheaper. I paid 75 cents per kilo for rambutan the other day (about 35 cents/lb) and shuddered to think about the time back home in Vermont that I splurged and bought some past-their-prime rambutan at the Asian market for $8/lb. (My advice is don't bother.) Having found lox in the freezer section of the local supermarket, I have finally learned to make bagels since none of the bagel options in town measure up. Steve made the most excellent pasta sauce last week and we ate that for two nights in a row with no complaints because it was so delicious. Sovann has just started his full-time studies at Ecole Paul Dubrule, the Cambodian equivalent of New England Culinary Institute, and I assume that his repertoire in the kitchen will soon expand and we’ll enjoy the benefits here at home.

    

We celebrated Steve’s 60^th birthday this past weekend in grand style. He and I spent Friday night at the big fancy hotel where he has a tennis membership, since his membership fee included a free night’s stay. I so rarely venture into these big hotels that I forget how foreign they can seem. We had a beautiful room overlooking the free-form pool and lush gardens, and it felt like we could have been in Orlando for all we knew. We had a real bathtub (a true luxury here), took advantage of the breakfast buffet and even had a complimentary massage that was vastly better than what one can get at the $6/hour places around downtown. It felt quite decadent. 

After coming home on Saturday, we got ready for Steve’s birthday party. Having invited all our local friends to stop by any time over the afternoon or evening to have a drink, we weren't sure how many to expect, but they showed up in large numbers! As usual, it was an lively mix of Cambodians and Westerners, and it was a lot of fun. I finally met some of Steve’s tennis partners , one of our Cambodian friends brought his extended family, and our driveway was packed with tuktuks, motos, and cars. (We know people here who have cars!!!) It was interesting to see how our varied our social circles are here; a few expats met each other for the first time. Leave it to Steve to know how to put together a good mix of guests, as always, and if the number of empty beer cans waiting to be cleaned up in the morning were any indication, it seems that everyone had a good time.

In between all the flooding and parties and day-to-day details of life, I had a bit of an adventure in Battambang province with Sovann’s family, which I think I will save for another entry. I only hope I can do the experience justice, because there is a story to be told if I can find the right words. 

An ounce of prevention (or would that be a gram?)

     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:

365 days; 4,637 questions

     Back in December, soon after I left my first job at the clinic, I posted a blog entry that included the following quote:

"...I beg you... to have patience with everything unresolved in your heart and to try to love the questions themselves as if they were locked rooms or books written in a very foreign language. Don't search for the answers, which could not be given to you now, because you would not be able to live them. And the point is to live everything. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer."
                                                                                          Rainer Maria Rilke, 1903
                                                                                          in Letters to a Young Poet

     Today marks one year since we arrived in Siem Reap. I am living the questions, as hard as I can, and there are more questions than ever.

     I had every intention of writing an entertaining retrospective of the last twelve months, but this just isn't one of those days; all feeble attempts to write have been quickly deleted. Steve and I thought that perhaps we should treat ourselves to a nice dinner out to celebrate, and then we were invited to a party to celebrate two birthdays and a farewell, so instead we'll go hang out with an interesting bunch of young expats and we'll toast to birthdays and farewells and anniversaries.

     And I'll keep trying to live the questions, which come fast and furious. There are plenty of new questions since this time last year, and some of the same old ones continue to provide fodder for endless mulling and theorizing. Now I understand why Cambodia advertises itself as the "Kingdom of Wonder" - it leaves me wondering about so many things every day.

      So, lacking profound things to say about our first year in Cambodia, I will instead leave you with a peek at my notebook collection. Some of you who know me well may remember that I love notebooks: the symbol of a fresh start, of learning something new and promising myself I will only write neatly this time, a repository for lists and random thoughts and notes from dinner parties. One of the good things about Siem Reap is that there are a number of shops that sell notebooks, and I've amassed a nice little collection, each chosen for their interesting cover art or captions.

"Whispers of love
Love is good for your heart
My love for you will never end"
"HEART TO HEART ENVELOPE SET
Love and friendship"
"Enjoy your writing with MengFeiEr products"

"WOOO is super ecological building material"
"WORK SHOP"

"I lost you.

This is in the world,  each persons have the person who wants

look for, once missed will not come back."

"very good"
"so love"
"pain past is pleasure"
"of all...papo terie r"

"notebook"

"best"

"story"

"beanfield"

"No. 1
STRONG
Good quality worthy of trust
Be the best oneself"

"FLOWER
Happy time
together we spend
exciting every day"

"That's incredible!"
"Sim Sim!"
"happy"

"What's up in your Fashion?
Precious things are very few
That must be why there's just one for you"

"Lattice emotion
Because earlier results in the past (the first due to consequences)
is one of the characteristics of the causal link, but the causes and consequences
must be contact with the inevitable, that the relationship between
...pace...home...step up...nest...cell...shack...
...cage....bleach...coop...fossa...
the two is the relationship between
cause and be caused"

"I promise that I'll be able to recover all my memories of you
she said all of a sudden as we were walking along...
We've se enten so together. Ever nery In rla I would fee your traces. Newborn babies.
the pntt on the plate that you can see under a paper-thin slice of sashimi:
fireworks of one summer. The moon hidden by clouds over the scene at nig...
When I'm sitting down inadvertently stei on toes nnd have to apol
when someone I've dropped..."

"Eternal Forever Hot Thailand Summer Chili"

"Silent is a silent movie

only images of early film, film itself is silent, only the background music. 

Dramatis personae through the movements, facial expressions

so the that audience understand the plot, a bit like a pantomime. When necessary,

would be to insert some subtitles to help viewers

understand what people say."

(The even smaller writing in the upper right makes even less sense.)

This one is valued for the caption printed on every page:

"Take up your pen and open your note book right now. Note down what you thought,

what you felt. Return to the writing age. After many years,

when you open the notebooks, you will find something

different about yourself. You will feel that everything is on its way to somewhere."

   
     As a matter of fact, I do feel like everything is on its way to somewhere...

Nothing is ever as simple as it seems

The idea: Provide vitamins to poorly nourished children in a developing country. (Who can argue with that?)

The plan: Ask people in the US to donate vitamins, have someone bring them to Cambodia, and deposit them in the office of a small NGO focused on children with disabilities so they can be distributed.

The result: 5,470 doses of vitamins ready to be distributed! Fantastic!

Vitamins - they're good for you
(unless you overdose)

The challenges:

• The  vitamin collection includes various types and brands of vitamins. Some have iron and some do not. Some are about to expire or already have, and some are good until 2014 or beyond.

• We cannot give the vitamins in their original containers because they have mostly arrived in large bottles of 150-300 vitamins per bottle, and there aren’t enough bottles to distribute one to each family. Even if we had enough bottles, people here are unfamiliar with child-proof caps and tend to either not be able to open them easily even after instruction, or so frustrated that once they wrestle it open they prefer to just leave the cover off so they don’t have to struggle with it again and again. This would mean the vitamins would likely go bad due to moisture, or would be eaten all at once by the children because they look and taste like candy.

• We can repackage the vitamins in small ziploc medicine bags that even come with pre-printed no-literacy-required cues about how often to take them, but these are not child-proof, and keeping medicine out of reach of children is either impossible or not a priority. (Impossible, you ask? How can that be? Well, where can they put it if they live in a palm-leaf hut with no furniture? It’s not like they have a medicine cabinet, or even a drawer or cupboard. Even if they hang it on a nail high up on the wall, children here are have very little supervision and are excellent climbers. And it’s a foreign concept to keep children away from medicine – when we gave out meds at the clinic, the parents would often hand the little bags to their toddlers to carry home.)

• Iron-containing vitamins can be toxic – even potentially fatal – if you take too many. But how many do you have to take? A good bit of internet research reveals a good bit of info, and the most conservative estimates say that 10-20 mg/kg of iron is nontoxic. This means that for a 10 kg. (22 lb.) child, 100 mg of iron is probably the upper limit of safe. So giving out any more than 100 mg of iron at one time means taking the risk that as soon as we’ve left the family’s house, some kid is going to eat the whole bag of vitamins and get sick.

• As I mentioned above, the assortment of vitamins on hand vary in their iron content. Some are iron-free, some have 5 mg iron (a low dose, which means we could give up to 20 vitamins in one bag without potentially poisoning anyone), some have 9 mg, and some have 18 mg (which means anything more than 5-6 vitamins could be potentially toxic to a 10 kg child.)

• So now the vitamin bottles are all labeled in big fat Sharpie with their expiration date, their iron content, and most importantly, how many we can safely give out at one time. 5-6 vitamins isn’t much, especially since we see some families only once or twice a month, and there may be several children in one family who will share what we bring, but what else can we do? I’ve discussed this forever with the local project manager about how important it is to provide education to the families about giving all medicine properly, and we will give the vitamins out to parents in medicine bags rather than as loose “candy” in the bottom of a goodie bag that is handed to children, but he is not at all confident that parents will pay attention and heed our warnings. So we cannot give more than could cause damage, which means that in many cases we will be giving far less than anyone really needs.

     This is a classic example of the challenges we face here every day. Something that seems simple rarely is. You have to contend with more than just sourcing the thing you need, you have to figure out how to distribute it sanely.

      Anyone have any brilliant suggestions? All ideas are welcome. 

Doing what I can, as soon as I figure out what that is.

     It’s been an incredibly busy week, in some of the best possible ways. I’m not even sure quite where to begin, but let’s start with my new job.

     I am now employed part time by Safe Haven, which is a partner of Community First Initiatives. For those who don’t want to take the time to check out those links, here is a brief explanation: Safe Haven is a small organization started by an American woman whose connection to Cambodia started years ago when she came to make a documentary film about children living in the garbage dump. (Sorry, one more link: Small Voices.) The mission is to one day build a school for children with disabilities, who otherwise have no opportunity for education in Cambodia. Until the school can be built, Safe Haven has an Outreach program that serves up to 50 children in a handful of villages outside of Siem Reap. These children all have one or more disabilities, including things like CP, seizure disorders, Down syndrome, orthopedic problems, or mystery conditions which haven’t yet been diagnosed. Along with the Khmer Project Manager and physiotherapist, my job is to visit these children at home and facilitate their medical care. This means trying to figure out where (if anywhere) they’ve been getting their medical care, what kind of medications they’re taking or should be taking, and will also include accompanying some of them to Phnom Penh in the coming months when they are scheduled for orthopedic surgery, and then following up at home to make sure their recovery goes smoothly. In other words, I’m a visiting nurse again, and I’m very happy about that.

This beautiful girl is the primary caretaker for her younger brother,
and she does an amazing job.

     Despite whatever neat little explanation I can try to offer about what the job entails, I’m still really trying to figure it out, and as expected, there will be challenges. I have been very lucky in these first two weeks on the job to be able to accompany a visiting team of speech language pathologists from Columbia University who have come to evaluate a number of the children. I always learn something useful when working with professionals from other disciplines, and this has been no exception. It’s been great to tag along on their visits to begin to get the lay of the land and start thinking about how I will gather the information I need from families and what I can then do with that information. As has always been the case in my experience here, getting a history from parents about their child’s health issues is confusing and difficult. So often, what they report doesn’t make any sense based on my Western medical knowledge, and asking the same question in slightly different ways or several different times often gets completely different answers. Again, I cannot tell whether it is a language/translation issue (though the Project Manager seems to be a very good translator) or a lack of understanding on the part of the parents about the facts of the situation. Possibly, it is just because if I ask the same questions more than once, they assume they didn’t yet give me the “right” answer, so they try something different the next time I ask– I have no idea. But this is consistent with all my experiences here, and with those of other professionals, so at least I know it’s not just me.

This is what happens when the Safe Haven crew makes a home visit:
lots of people gather around to see what's up.

     Here’s an example of the type of challenges that come up. I went with the speech team to visit a five-year-old girl.  If she has any particular diagnosis, no one knows what it is. This may be because there just isn’t one, or because the family doesn’t know what it is. She’s been seen at one of the two children’s hospitals in town – unfortunately, at the one that doesn’t allow Westerners inside and never shares any information with anyone, including the other children’s hospital. (The man who runs this place is a master at fund-raising and publicity, but no one knows why he won’t allow any sharing of information, which fuels all sorts of rumors about what really goes on behind those closed doors. Experimental treatments? Pharmaceutical testing? Who knows.) In any case, this lovely little girl presents with gross developmental delays, little recognizable speech, and “severe headaches.” 

     In trying to get information from her grandmother, who appears to be her primary caretaker, I asked lots of questions about her history, which is always a slow process when done through a translator. This is the picture I got: She was born very small and stayed in the hospital for two weeks because of a “problem with her navel being cut” and being weak. She has been back to the hospital twice since birth for “strong fevers.”  Her problem now is that “she gets headaches”  a few times a month, but when trying to pin down how they know an essentially nonverbal child has headaches, all I could get was that “first she gets a fever, then she wants to have a seizure, then she has a headache.” When she has an episode, they give her paracetomol (Tylenol) and then “she is fine after 3-4 minutes.” Doesn’t add up. First of all, both “fevers” and “seizures” seem to have a different definition here than we have at home. People often report a fever when they have none, and no one even has a thermometer, so a fever seems to be more of a global “I don’t feel so well” sort of thing. How they can tell that she “wants to have a seizure” is a mystery, and no one can seem to explain whether she has ever actually had a seizure. (Another nonverbal child’s parents reported that they knew when his skin condition was painful because his “lips get very red .” And after that, of course, “he gets a fever.”) The only intervention I’ve been able to make for this kid was to teach them about the correct dose of paracetomol – they were giving this little 12 kg girl a large adult dose of a brand that includes a hefty dose of caffeine. A week after teaching them how to give the dose properly (correct dose at correct intervals), they told me that she was much better and her latest headache didn’t last nearly as long. Who the hell knows? Sometimes I think that the best I can possibly hope for in some of these situations is to at least prevent people from giving toxic doses of medications, which I suppose is worth something.

     Another child we saw had an episode of (possibly?) TB meningitis at the age of eight months or so, and has been severely delayed in his development since then. He has been taking a liquid antihistamine twice a day for years, which his mother explained is for his “fevers.” She clarified that which type of medicine she gives him depends on what the local health clinic has in stock at the time, so brand and amount are not consistent. She also had empty bottles of amoxicillin (the cure-all for everything in Cambodia) which she gives him for a few days every time his cough gets bad (which explains the rampant amoxicillin resistance here. His lungs sounded lousy and his overall muscle tone is very floppy, but near the end of the visit, when I asked the mother what she was most worried about related to his health, it turned out to be an itchy skin rash and his severe and chronic constipation. Luckily, I had some good skin cream to offer at the time of that initial visit, which will likely help the rash. I also have some knowledge about treating constipation in children and some expert  professionals back home to consult with via email, so with the limited options available here, I hope we’ll be able to tackle the constipation as well over the next few weeks. His respiratory issue is probably the thing I worry about most immediately, but I’m guessing his lungs have sounded lousy for years, and if there’s one thing I know, it’s that identifying what the family is concerned about and trying to address that issue is what works best to begin to build trust and rapport. I shall let you know if that strategy is as useful here as it is at home.

     As I said earlier, working with the speech language team has been great. The professor and supervisors are crackerjack at their jobs, and they have seven graduate students with them who are all eager to learn and put their knowledge to some use. I have tried to soak up what they can teach me while they’re here, and I have certainly been soaking up the camaraderie and opportunity to share experiences and ideas. I will miss them all terribly when they’re gone, but I expect to keep in touch and am thrilled to have their expertise only an email away.

     The children I have seen so far live about 20-30 minutes away from Siem Reap by motorbike, which provides me with a fantastic opportunity to get out of the traffic and into the countryside. It's particularly beautiful this time of year - green and lush, sometimes wet and muddy, and the fields are dotted with farmers transplanting rice and herding their cows to the next grazing spot. One community served by Safe Haven, Sen Sok, lies about 90 minutes outside of town in an area which can only be reached by big 250 cc motorbikes, and we’ve made two attempts to get to those villages which have so far resulted in a score of Cambodia: 2, Safe Haven: 0.

Rice ready for transplanting

     Our first attempt to get to Sen Sok was a week ago. The speech team hired big motorbikes and drivers and we set off in a convoy of three. Within 20 minutes or so, one of the bikes had problems, which turned out to be seized rear brakes, aborting the whole mission. An hour and a half after first setting out, we were back in town where we started, so we installed ourselves in a local restaurant and ordered drinks. It made for a wonderful day of hanging out with wonderful people, but we weren’t exactly doing what we had set out to do, so Plan B was made to try again the following week.

This is a monster-sized bike around here.

     Last Friday, we set out again, this time in a convoy of five. After about 45 minutes of riding on the main road, just where we were turning off to hit the dirt, one of the bikes got a flat tire. In general, a flat tire in Cambodia is no big deal because there are mechanics and air pumps everywhere you look, but tubes and tires for the big bikes are not so easily available. Eventually someone was dispatched to go back toward Siem Reap and get what was needed, and after an hour of sitting in the shade and chatting while we waited, all was well again and we set off. We roared along, all of us female passengers hanging on and trying to avoid getting our asses pinched by the seat bouncing against the frame of the bike as we flew over potholes. These bikes are not really designed for two people, especially when one of them is a “sturdy” foreigner, otherwise known as a fat barang. Luckily, the scenery provided lots of distraction, and as the rice fields and palm trees and buffalo and naked children whizzed past, I could only grin at the thought that at that moment, this was my commute to work.

     Another 30 minutes or so into the ride, the same bike had a flat again. Now we were nowhere near any source for parts, and there was clearly an underlying problem that wasn’t going to be fixed by yet another innertube, so it was time to find a shady spot again and sort out the options. While the drivers and local staff conferred with village men about our predicament, the rest of us found a roadside shop with the ubiquitous orange cooler and had a beer. Another 45 minutes or so passed – we had started out at 8:30 in the morning and it was now somewhere around noon, and we hadn’t yet seen even one of the four children we hoped to visit.

Yup, flat again.

     It became clear that the only option for the broken bike was to have it trucked back to Siem Reap. Most of the homes in the villages where we were going were still too far off or inaccessible for the rest of us to continue the journey given how much of the day had already disappeared, and now everyone was worrying about whether the remaining bikes were going to hold up under the weight of the passengers. The best we could do was to go and see one child who lived not too far away from where we sat, and then all return to town with the broken bike and pick-up truck that was on the way to collect it. So off we went, to see the child who we were all the most anxious to see, a five-year-old with severe CP who was badly malnourished because of his feeding difficulties.

     Like some kind of crazy barang circus parade, we all arrived at this child’s home. Three big bikes and four big white people took up most of the space in front of the little stilted palm-leaf house, and the Khmer project manager went to greet the family. Even from afar, I could see by his reaction that something was wrong, and I immediately assumed that after all our efforts to get there, the family probably wasn’t even home. Unfortunately, the news was much worse than that. The child had died a week earlier.

     This situation brought many things to my awareness. For one, I’m not completely sure about the culturally appropriate response to this kind of news. I don’t even do well at home knowing what to say to someone who has lost a loved one, and I don’t understand Cambodian beliefs and practices around death nearly well enough. I had to wonder if the death of this severely disabled child was in part a relief for this family. For a family of subsistence farmers, a child who not only can’t contribute to the good of the family but also requires a lot of time and energy to care for is an enormous burden. The situation also made clear the fact that Safe Haven hasn’t yet had to decide how best to respond to a family under these circumstances or what to tell them about future involvement with the organization. In true Cambodian fashion, the mother was smiling and greeting everyone, and someone went to get mats and spread them out in the shade so we could all sit down and talk.

     It is impossible to know why this child died. The family described what happened by saying “he had a seizure for 24 hours and then he died.” Did he truly have a seizure? Did he die of complications from his malnutrition? Did he have other underlying medical problems? Did he get a run-of-the-mill illness that his fragile body couldn’t overcome? We have no idea. We don’t much about this child at all – he was only just discovered by Safe Haven staff a short time ago, and as usual, his history was mysterious.

Kids in the village checking out the foreigners.

     Children – and adults – die here all the time. They die of things that we never have to think about at home, despite our messed up healthcare system – things like TB and diarrhea and pneumonia. People die of things that we have every expectation can be cured or managed: diabetes, hypertension, appendicitis, bleeding ulcers, cancer. They often die without a diagnosis or any medical attention at all. And even when they can get to a hospital, that doesn’t mean that diagnosis or treatment will be available. I spent a morning at the government Provincial Hospital last week, where I was invited to witness a surgery (actually, I was invited to ASSIST in a surgery!) and the scrub sink outside the operating room had no running water. We had to scoop standing water out of an open plastic bucket to wet and rinse our hands. That’s the state of medical care in Cambodia, in a nutshell. (That hospital experience deserves a blog post all its own, but I’m not sure I have the fortitude to write about it.)

     So that’s how I spent some of my time so far trying to get a grip on what my new job will be. I think it will be wonderful and awful and beautiful and painful. I will be dealing with everything from constipation to death. I will spend hours trying but not getting to where I need to be. I will collect black and blue marks on my ass from riding on motorbikes over red dirt roads. I will try to forge relationships with my Khmer co-workers and the families I will visit. I will pass out paracetomol and condolences. I think I will sometimes wonder who the hell I think I am that I expect to be able to do something genuinely helpful, and I hope that sometimes I will have moments of clarity about the fact that I have something, however small, to offer. I will take it all in, and try to figure it out, and hope that I can give back even a tiny percentage of what I gain from this experience. Wish me luck.

I wonder where this road will take me?

Cambodia: the adventure continues

     I am motivated to write by the realization that if someone looks at my blog for the first time, the entry that greets them is the one that's full of my whining and complaining. Not a very good first impression.

     It's also no longer an accurate reflection of how I'm feeling, fortunately. As we all know, those moods come and go, and thankfully, that one has gone. Life is back to feeling like a more balanced mix of charming amusements and mild frustrations, interesting opportunities and predictable routines, with an occasional bit of novelty thrown in now and then.

     I took my motorbike in for service and an oil change last week. There's a Suzuki dealer just around the corner from our house, so I stopped in to see what would happen if I tried to explain the funny noise and odd hesitation I was noticing. I was shown to a plastic chair and my bike was put up on a lift a few feet in front of me while two men in spiffy uniforms went to work dismantling practically the whole thing. Bit by bit, they showed me pieces they removed that needed replacing. Some I could recognize: the chain, the sprocket, the brakes, the wheel bearings. Some I couldn't recognize at all. Each part was presented to me with a sad and apologetic look and the receptionist translated for the mechanic. "Sorry, Madame. This one, need new also." I would ask how much, and would be told, "Sorry, this one three dollars." (Or two dollars, or - OMG - nine dollars!) Much like when I would take my car in for service to an unfamiliar mechanic back home, I would wonder whether this particular part truly needed replacing, but would put myself at their mercy for lack of a better option. In the end, it took 25 minutes to replace everything with new parts right out of the boxes, and cost $36. And I must say that the bike both goes and stops much better than before. (Sovann was quick to tell me that I paid too much and should have gone to one of the roadside mechanics who set up shop under a tarp, but in the end I felt like I got my money's worth, both in terms of service and confidence in the experience.)

After all that repair work, I took the bike for a wash.
For about 60 cents it got all cleaned up while I was given a chair and the opportunity to
read Khmer newspapers or watch Tom & Jerry cartoons on TV.

One of the more popular models: the Suzuki Smash.
Why not just call it the Suzuki "Accident?"

     We splurged and bought an oven a few weeks ago. It's more like an over-sized toaster oven, but it does have temperature control and is big enough to hold a loaf of bread, so that's mostly what I've been making. It's amazing how much pleasure can be had from a loaf of warm oatmeal bread or a pan of brownies. Before we got the oven, the only food I ever made here is hummus and burritos, but now I find myself occasionally interested in cooking. Perhaps I'll expand my repertoire even further.

     I'm planning to go to a combination yoga and cooking class in a couple of weeks. I've been saying I should try yoga for years and never have - now seems as good a time as any. I'm a little late on the yoga bandwagon, but it's time to give it a whirl.

     Work at the World Hope Assessment Center feels more and more comfortable as time goes on. As with any job, the first few weeks or months are fraught with moments of confusion and the accompanying lack of self-confidence that comes with either not being sure of the best way to handle something, or being quite sure that I have no idea how to handle something. But I learn, and I do some research, and I ask questions. Sometimes I try something and find that my basic instincts were spot on, and sometimes I find that I've misread a situation entirely. The language barrier is a part of my daily existence, and even with people who speak relatively good English, we have moments of mis-communication. But I feel more and more comfortable in my role, which is always a good feeling.

     Another part-time job opportunity has presented itself, which I will explore further this week. This one involves working with a relatively new organization that serves children with disabilities and would include coordinating their medical care as well as doing home visits. In some ways, it's the perfect fit for my skills, except for the part about not having a lot of experience with children with disabilities, but I can learn. More news about this when I know more.

Random photo for your amusement:
a condom ad at the local corner store, funded in part by USAID.
I really need to ask someone to translate the words for me.

      Steve continues to play tennis like a maniac as often as he can. In a good week, he can play 3-4 times, sometimes early in the morning before the heat becomes too oppressive, but he's been known to play in the worst heat of the day when the opportunity presents itself. He's enjoying his new morning job, where he's finding that his skills are appreciated and his ideas are valued. Such a refreshing change. And in the category of trying new things, Steve was one of six speakers for the inaugural Nerd Nite Siem Reap. This is an event in which people have the opportunity to speak to an audience about something they're passionate about, and they can show 20 slides for 20 seconds each in order to do it. Can you guess his topic? Food, of course.

Steve and his fellow Nerd Nite presenters.

      Jaz is about to finish a full-time online semester at CCV and is already enrolled in her classes for the fall. She's teaching a few private students and plans to start a morning teaching job at another international school in a few weeks, after she and Sovann come back from a real vacation in Thailand in mid-August. She hasn't left Cambodia in over a year, and has really only left Siem Reap to go visit Sovann's family, so she's long overdue. And Sovann, who has struggled the past few months with no tuktuk work at all, has just passed the entrance exam to a very good culinary school here in Siem Reap and will begin his full-time studies in September. I look forward to sampling all of his homework - he's already a good cook, but I hope we'll be able to taste all the things he's learning over the next 10 months.

      Speaking of vacation, Steve and I are talking about taking a long weekend to get out of town. All the long-time expats offer the same advice: get out of town on a regular basis! We haven't listened to that advice well enough, and several of them who read the last blog entry pointed out that my mood might be greatly improved by a brief change of scenery. So maybe we'll head to Bangkok or the Thai beaches in the next few weeks for a mini-vacation. It doesn't have to be too expensive, though it still feels decadent when you think about the fact that most Cambodians work harder than we do and never have such a thing as a vacation. Add that to the list of things to feel ambivalent and/or guilty about...

      While folks back home in Vermont were having a heat wave, we had a bit of a cool spell. The rains, which had ceased for a couple of weeks, returned and brought much cooler weather for a few days. While that brings its own challenges (driving in the mud can be as challenging as driving in ice and snow, and a hard rain while you're driving a motorbike can feel more like hail as it pelts down on you), it was nice to have a break from being sweaty every minute of the day. Of course, after a few days the rain stopped again and the heat returned full-force. It usually cools down a bit after the sun sets, but the other evening it was still more than 90 degrees at 8pm, which I find a bit too much.

     There are social events and dinner parties and new restaurants around town, and thanks to a very active Siem Reap Expats Facebook page, we hear about new things all the time. A great new falafel place just opened: $3 for falafel, fries and a beer. We're looking forward to trying the new Texas BBQ restaurant someday soon. There are art openings and more live music than ever before - life in Siem Reap isn't all about sweating and trying to keep the ants out of the cereal box. All these youngsters in town know how to party, and if we pace ourselves carefully, we can keep up now and then.

     So there's our latest news. More details will be coming soon about the new job, and I have some other ideas percolating that I've been meaning to write about for a long time, so stay tuned.