Baby steps

Being back in Cambodia again was almost like coming home – the sights, the smells, the sounds – they were all familiar. I was happy to be back.

Little had changed in Siem Reap since we had last been here two months ago – the constant barrage of “Lady, lady, you want to buy something?”, “Sir! Tuk tuk? You want to see Angkor Wat?  Floating village?” – even that annoyingly charming young woman in front of Khmer View restaurant who I will forever know as the “Beer.. free popcorn.. fried rice.. fruit salad..” lady. They were all here, and yet this time around, things were different. My work at Angkor Hospital for Children was showing me a side of Cambodia that I had never expected to know.

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I’ve only been working at AHC for 2 weeks now, and I’ve somehow found myself sitting outside a family’s home in the middle of rural Cambodia. I’m sitting across from Sen, a 7-year old boy with beautiful round, brown eyes, wearing a dirty red linen shirt with lace trim around the collar. He’s shy – so shy that he doesn’t say one word in the 45 minutes that Sakan (an AHC nurse) and I spend with him. While Sen’s brothers dart from bush to bush “shooting” me with their fingers and dying laughing anytime I catch their inquisitive stares, Sen doesn’t budge from under his grandmother’s arm. He won’t even open his mouth as part of the physical exam, and we end up leaving that part blank.

We’re here for Sen’s bi-weekly home-care visit from AHC. Sen is HIV positive, and Sakan is here to deliver Sen’s monthly allotment of anti-retroviral pills that keep him alive.

Sakan spends the first 30 minutes of our visit counting out at least 3 different types of pills with Sen’s grandmother, who is his primary caregiver. She helps divide the pills into their correct slots in the weekly-reminder pill box, and there is a lengthy scuffle about how to best divide an oval pill into thirds…

Because Sen must take his pills at the same time every day, Sakan asks to see how the grandmother keeps track of the time. She pulls out a bulky wind-up blue clock from the plastic bag where she keeps Sen’s supplies and proudly holds it up for us; it’s an hour and a half off, and, apparently, she doesn’t know how to read it.

During the social assessment of Sen’s family life, Sakan notes that the pill cutter is dirty and jots it down in his notebook. But the pill cutter is really just the beginning. Behind us, outside the home, sits a single home-made wooden table that serves as the kitchen, which has nothing more than a few plates, a couple mismatched plastic glasses, and a pot, which they put over a fire to boil rice each day. Repeatedly, chickens from the village hop up onto the table and run across the plates, jumping off the other side. The grandmother and the uncle, who has been casually watching the home visit from his squatted perch in their home, both laugh as the chickens scurry across their dinner plates. I just want to scream; just last week, a 2 year old being treated at AHC died from H5N1 flu (transmitted by chickens in the village), and, with Sen’s immunocompromised state, I just know that he can’t afford to get sick any more than he must.

I notice that Sen’s fingernails and clothes are also unwashed, and I ask Sakan if he has reminded the grandmother about the importance of making Sen wash his hands before meals. He simply responds, “I have tried, but this family’s hygiene is not very good.”

“Would it be helpful to go over the importance of it with them again?” I kindly persist. Whether he thinks it will help or not, he stresses its importance again to Sen’s grandmother, and I feel like I’ve made some minuscule difference.

The grandma looks at me and says something that I don’t understand. I ask Sakan to translate, and he points down to 3 wooden mouse traps that have been sitting at my feet the whole time. She says they are for catching rats and mice, which is the family’s only source of meat. She goes on to explain that they rarely have enough food to eat, and they don’t have enough water to drink during the dry season, and I find myself realizing why Sakan’s hands rarely get washed.

Their home consists of nothing more than a raised wooden platform supporting two woven rattan walls and a rattan roof. There’s no furniture in the house, just a few bags of rice siting on the floor and some colorful woven sleeping mats. An old wooden wagon wheel rests against the side of the house, covered in tattered clothes that have been hung out to dry. Noticing my gaze, the grandma directs my attention to the huge 200 kilogram sack of rice sitting in the home, which she says they will try to sell for only $50 at the market – their entire income for the month. I ask Sakan how the family pays for Sen’s life-saving anti-retrovirals that he receives from AHC each month – he tells me they’re given to him by AHC for free, a service that will continue until he’s 18 years old.

After Sakan finishes Sen’s physical assessment (as much as Sen will allow), Sakan pulls out some hand sanitizer for himself and for me, which I just feel awkward using at this point. (Shouldn’t he be giving it to Sen, instead?) We all hike back through the twisting dirt-path village to the donated AHC jeep, where Sakan hands the grandma two full paper sacks of free corn, mangoes, coconut milk, salt, cooking oil, toothpaste, and 4 toothbrushes. Amazing. She turns to thank me, and I embarrassingly shake my head and point to Sakan.

It’s little miracles like these that make Angkor Hospital so great. These home-visits are just one part of its mission to extend its reach beyond the hospital and into the homes of children living with chronic diseases or into homes where families cannot afford to make the often long journey to AHC.

For those who can afford the trip, treatment at AHC is almost completely free from the moment the child arrives. AHC charges a one-time registration fee of only 25 cents to its patients (and even that can be waived if necessary). After that payment, any treatments, medications, lab work, even surgeries, cost nothing. And because few families that travel to AHC can afford to stay in hotels or buy food in restaurants once they’ve arrived, AHC allows the families to sleep inside the gates of the hospitals, where they are provided with bedding and mosquito nets, and the hospital also provides them with free meals throughout their stay. Intertwined with their mission of promoting affordable holistic health to children in Siem Reap province, AHC also teaches families about nutritional requirements and how to maintain a proper garden. When the families leave, AHC provides them with vegetable seeds to start their own garden at home.

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But AHC is not only offering free care; it’s offering good care. Care that can change a child’s life in the most unexpected ways –

At AHC, I do no nothing more than work in the hospital’s laboratory. Except for the home visit with Sakan, I never interact with patients or directly see the children that we, the lab workers, are helping to diagnose. We receive samples from the nurse, such as urine, stool, spinal fluid, pus, blood, which we then process using a variety of microbiological methods until we have identified the precise species that is infecting the patient. We also determine which antibiotics the bacteria are sensitive to, providing the doctor with the appropriate knowledge of how best to treat the patient. I don’t think I ever realized the impact that this aspect of patient care could have until one day last week.

We had just received a genital swab taken from a two year old girl, which we began to process just like we would any other sample. My co-worker began streaking out the sample onto the appropriate Petri dishes, while I began staining the sample to examine it under the microscope. One look under the scope, and my heart just broke. I could tell immediately that this baby had a sexually transmitted disease, and I was possibly the only other person on the planet to know what had happened to this little girl except for her perpetrator. I told my co-workers what I saw, and we followed up the tentative findings with a more expensive confirmatory test – unfortunately, our suspicions were confirmed. She had gonorrhea.

We alerted the patient’s nurses and doctors, who I assumed would initiate an investigation involving the police. When I directly asked her doctor what the next steps would be, he was.. unsure at best. He said he would ask the parents what they knew about the abuse and then inform them of how she must have been infected. And that was it… It seemed that there wasn’t much of a plan in place to handle these cases, and not wanting to be too critical of their system, I was forced to let it go.

Yesterday, we received a similar sample from a similar patient – another 2 year old toddler with similar symptoms. And again, the same result.  I did not expect this. I did not expect this. 

My sadness and confusion for the first case was now turning into anger and frustration. Again, I asked the staff what would happen, and again, no one really knew.

Every Friday, I attend the free lunchtime seminars that are given to AHC staff on a range of topics. Last week, the seminar was given by Chang, 1 of 3 social workers at AHC, who started AHC’s first social work program less than 2 months ago. What I found to be a pretty routine lecture, in terms of what social work is and why it’s important, was met by a flurry of questions and eager hands from the nurses and doctors in attendance – they had never heard of social work before. Social work is, apparently, an entirely new concept to Cambodia, with AHC being the pioneer. I was shocked. More so, I knew that this man was the person I needed to speak to about what would be done about the STD cases that we had just diagnosed.

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One day as I was heading to my daily Cambodian language classes, I noticed Chang making copies in the administrative office. I put my papers down in the classroom and went back to explain who I was and why I knew about the two STD cases. I expressed my concern and explained that I was interested in knowing how the cases would be pursued.

Chang did not know either. He reiterated much of what I had heard from his lecture about social work being a new field here and that he had talked to the children’s parents (apparently “they didn’t know anything about it”, even though a background check on one father showed that he also had gonorrhea). He did say that the case was passed on to a local NGO working in Cambodia, and that did seem like a great first step.

Chang spent the next 15 minutes getting my opinion on whether there was any way that this type of infection, at that site in the body, could be anything other than abuse. I went over the entire background and lifestyle of the causative organism, and assured him that it is very, very unlikely that it could have been contracted any other way (by clothing, for example). He asked if I would come present a lecture to the social workers on the disease, but unfortunately there was not enough time before I would be leaving AHC.

“Will the police perform a proper investigation?” I persisted.

“Unfortunately, in Cambodia, there is no law that makes this illegal…” he answered. So that was it. All of the hand-slapping and “discussions” with the parents that I had been told about were all that anyone legally could do. There would be no investigation, no arrests.

He continued, “You know that there were 2 different cases of gonorrhea one week apart, yes? Well, the two girls came from the same village.”  I was stunned. Yet more evidence of wrong-doing that would unfortunately go unused by the legal system here.

It’s clear that many of Cambodia’s social and governmental problems are being met with vastly inadequate solutions. But cases like these are not a waste. At the very least, the villagers will talk, and other children from the village might now be spared a similar fate. These two precious little girls might be kept under more vigilant watch by their mothers and sisters in the future. Had they been taken to any other hospital in the country, they would have been given a general antibiotic to clear their infections and would be sent back into potentially a lifetime of abuse. These last few weeks at AHC taught me the importance of proper diagnosis. It doesn’t just save lives. It can make lives worth living.

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