Cambodia!

Dear friends,

I apologize for the long delay in publishing a blog about my trip to Cambodia. I really have no good excuse except for the fact that I am really enjoying my time here!

Many of you supported my efforts to reduce preventable blindness in Ghana, and I thought that perhaps you would find the continuation of my journey in global health of interest. I will be here for 8 more weeks, and hope to update my blog weekly.

I have now been in Cambodia for over three weeks now. I spent the first half of it in Phnom Penh, the capital, where we did a lot of sight-seeing, and the rest of it on the Southern Coast of Cambodia, which includes Kep City, the small rural town where my global health activities are based, Kampot, a slightly bigger town just 45 minutes West of Kep, and Sihanoukville, an ex-French vacation spot and popular beach area also on the Southern Coast of Cambodia.

Kep City is a small seaside town 5hrs South West of Phnom Penh. The shore is populated with inexpensive guesthouses ($8/night 2-bed room - $4/night if you share) and up-scale hotels that charge up to $150/night. The cost of living in Cambodia is going exponentially up because the tourism industry is developing quickly and realizing that foreigners are often willing and able to pay a lot more than the asking price. Further inland, there are acres and acres of bright and neatly organized rice fields, spotted with horse-sized white cows, and separated with red dirt roads, and thin snake-like walking paths. With 50% of Cambodia’s population under the age of 18, you see mostly younger people tilling the fields, harvesting the rice, and herding the cows.

FIRST IMPRESSIONS – A city where things are not as they seem.

Many things in Cambodia reminded me of Ghana, the smells, the odours, the stares, the dust, and the daily language lessons. I have never been in a country with such lavish national monuments amidst such abject poverty, and such reverence for a head of state. At every major roundabout in Phnom Penh, there is a gigantic photograph of the King, the head of state of Cambodia, in gold framing. Near the Royal Palace, where I was staying at the Okay Guesthouse, were several very beautiful boulevards with traffic going in opposite directions on either side of a very long, grassy, and tiled park. Nearly every roundabout and boulevard has a large monument or statue. This is what people use to give directions (To get to Kampot, make a left at the white horse...) even though there are street names. It’s similar to Hong Kong, where people know where they are based on landmarks, rather than street intersections, as in North America. The imposing pictures of the King however, mask the person who has the real power in the country, and that is Prime Minister Hun Sen. The ex-Khmer Rouge, pro-Vietnam leader has been in control since the 1980s, and it is because of him that there is no free press or speech in Cambodia. In fact, even though year after year, during “democratic elections,” Cambodians don’t vote for him, he still wins.

Even though Cambodia has many flashy and comprehensive laws (They legalized abortion in 1997 and made child labour illegal in the last decade, and also have made helmet-wearing for bicycle and motorcycle riders mandatory) it is rarely reinforced, and the police who dot the cities and towns will stop you, but easily let you go for a bribe. The best example of this is the traffic. I’ve never seen a place with such chaotic traffic. There are jeeps, cars, motorcycles, tuktuks (carriage-like things attached to the back of motorcycles), bicycle-powered carriages, and bicycles. At most intersections people simply slow down, inch slowly forward in the opposite flow of traffic , and then make the turn. I compare it to what would happen if the road was a pedestrian side walk. There are loose guidelines (like drive on the “right” side of the road), but people don’t really follow it at all. They just do whatever will get them to their destination fastest and safest.

One thing I noticed here was that there were a lot of tourists, backpackers, as well as a lot of NGO workers. Every corner you turn in Phnom Penh there are NGO offices, or organizations that run restaurants that support community organizations like the street kids, or the blind. In fact there are about 1,000 int’l NGOs providing vital services that the government fails to provide. The wealth of NGOs however has given way to neo-colonialism. With so many foreigners making big bucks and living in a country where much of the population is making less than 1USD a day makes for a very well-established expatriate community, who live a very colonial lifestyle here, a life that is often very separate or hypocritical of the job that they hold here in this country. I can see how leading a high-class lifestyle is tempting because many of these workers are making developed world incomes and paying developing world prices for goods and services. On the one hand, you could argue that it creates employment and supports the local economy, but on the other hand, one can’t help but feel that something unethical is going on here. Recently a group of children from an international school in Phnom Penh came to Kep Seaside for a week of vacation and sight-seeing. On Janice’s last day of volunteering with CIH, we walked next door to the “Sailing Club” which is the hotel that charges $150/room/night, where we thought we’d treat ourselves to a special fancy dinner. When we arrived at the entrance, I see three tuktuks drive up to the hotel filled with the international school children and their chaperones. Upon seeing them, we attempted to race to the “Please wait to be seated” area to secure a table, but the kids simply strolled into the restaurant’s main dining room and sat down to what appeared to be a regular meal. Meanwhile, the waiter motioned us to go sit outside on the patio, which was still nice, but not as well-lit. Not only do these kids eat a place where the average meal is at least 3x more expensive, but they take a tuktuk to get to a place literally next door.

Another paradox is that Cambodia actually has a lot of very exciting and culturally and historically important tourist attractions, like the Choeung Ek Killing Fields. The sad thing is that many of them have been sold to Japanese, Vietnamese, or Chinese buyers and investors – which means that every dollar you spend on admissions often goes into another country’s hands and not into the country you are visiting. Choeung Ek, the place where thousands of Cambodians were executed and slaughtered during the Khmer Rouge is Japanese owned. The problem is money talks in Cambodia. Money talks like NO OTHER, and for a country as poor as Cambodia – it is very hard to say no.

Enough Negativity – what do I love most about Cambodia?

The people. Although I am miles away from home, Cambodia has made me feel at home. From the tuktuk driver I met in Phnom Penh, to the staff at Kep Seaside Guesthouse, and the deaf students from Epic Arts in Kampot. I have met some of the most warm-hearted individuals in this country. Never have I met so many people so eager to learn and to share their culture. Everyday, I am aware of the cultural and language exchange, and it is such a wonderful experience to be able to understand the way someone else sees and experiences the world. I have been having language exchange lessons with some of the staff at the Kep Seaside Guesthouse, and they have been some of the most memorable moments I have spent here. My time at Epic Arts was also unforgettable, of all the places I have seen in Southern Cambodia, I saw the most energy and happiness among the deaf students of Epic Arts. They were just exploding with enthusiasm and a desire for interaction!

I have also fallen in love with Cambodian cuisine. The food is tasty, full of spices and herbs, and yet, very little is actually spicy – which suits me perfectly! One of my favourite dishes so far is Amok, which is like curry, mixed with cooked vegetables, and egg, served with rice. We also had some small fried fish. Very delicious, and only 1.50 USD. They serve every kind of tropical fruit (pineapple, dragon fruit, longan, rambutan, fan fruit, coconut, mango, apples, bananas, and asian pears! Mmm...)

Cambodian street-food is also one of the best I’ve tasted in the world. There are sweet fried bananas and fried sweet potatoes. There is “jiahooey” grass jelly, with crushed ice, carnation milk, and sugar syrup, there is “Nem Grouak” which is rice flour balls with green onions, shrimps, yummy sauce and chilly, there are waffles and coconut cakes, the list goes on, and on, and on. I LOVE CAMBODIAN FOOD!

SIGHT-SEEING

In the first two days, Janice, a neuroscience undergrad student at U of T and I explored the tourist spots in Phnom Penh, including the Choeung Ek Killing Fields, the Tuol Sleng Museum (aka S-21, the “security centre,” aka prison), the Phnom Tamao Wildlife Centre, foot massage on the riverfront, and meeting with one of my friend Samantha’s friends who was on a mission trip for almost a year in Phnom Penh.

In Kampot, Janice and I followed some deaf students at the Epic Arts Cafe to see their school and the Epic Arts studio.

In Sihanoukville, the volunteers and I explored the coral reefs at a nearby island by snorkling, and had some delicious Japanese food. I think the pictures here can explain more than I can in words. Please visit my picasaweb album:

Phnom Penh

Kep City

Epic Arts - Kampot

GLOBAL HEALTH PROJECT

As some of you may know, what I will actually be doing there has been sort of been a mystery to everyone including myself. The Centre for International Health definitely encourages initiative-taking and independence by providing relatively little support, compared with Unite for Sight.

The Centre for International Health at U of T is a small office that provides administrative support to students wishing to do some course or degree-related research in global health. Students range from Masters’ students to medical residents, to undergraduate students, or in-between students hungry for global health experience, like myself. Rebecca Draisey, is the director of the Cambodia Program at the Centre for International Health, and spends 6 months out of the year in Cambodia, overseeing the program and negotiating with local officials so that we can carry out our research activities.

It has several programs that have come out the participants’ interests. Students generally conduct their own independent research, but last summer, they collaborated to apply for funding from Earthtones, which is a fundraising concert put on by the U of T Medical School. As a result, Rebecca, the director, is left with a ton of money that can be spent on water sanitation (which includes distributing water filters to villagers, doing safe water education, and establishing a clean water system at the Kep Referral Hospital). My job as a volunteer is to help out with this side project, while focusing on the Most Vulnerable Families List.

The Most Vulnerable Families List can be understood in the context of health care insurance in Cambodia. Currently, the government has 1 referral hospital in each province, and a few health centres for each referral hospital. Whereas in Canada the government collects taxes which go towards supporting a variety of initiatives including paying for the health system, the government in Cambodia collects no taxes, yet pays the staff at the hospitals and health centres. The result is poorly paid health workers – which a few years ago translated into dismal health care. In order to make enough to sustain their families, almost all government health workers and teachers have two jobs. In the past few years the government started implementing a user fee system. So, patients would pay for the care they received at health centres and that money was used to improve the quality of care at the health centre/hospital. The change to a user fee system vastly improved the quality of health care at health centres, but also created a different problem – that of equitable access.

For obvious reasons, the poor were excluded from this system because of their inability to pay. You would show up at a hospital with someone who was about to die and they would simply turn you away because as a health worker in a user-fee system, you get paid more to help people who have money to pay you. So, the government decided to implement a “health equity fund” which would compensate health workers for treating poor patients. The problem was that this process of deciding whether or not somebody was poor was up to the discretion of the person at the door, receiving the poor patient. In Kampot, a neighbouring province, a German NGO called GTZ was called upon by the government to create a system to rectify this problem, but only in Kampot. What they did was they utilized the already existing pagoda community networks (since about 90% of Cambodians are Buddhist, most people belong to a pagoda, aka Buddhist temple) and elected representatives from each village to help administer a questionnaire to figure out who the poorest in that village.

GTZ divided the poorest into two categories: extremely poor, and very poor. The process of determining who is considered extremely poor and very poor is actually a very transparent process, whereby local power-holders or typical decision makers mainly serve as facilitators rather than actual participants, and lists are made available to the village and open for negotiation and taken back for revision a few times before it is made official. The list of extremely poor and very poor families is called the Most Vulnerable Families List, and is used to make ID cards for each of the families on that list. When poor families show up at the doorstep of health centres, heath centre staff can now immediately recognize who they should offer discounted or free services, and know that they will be reimbursed by the government.

This has opened up a lot of other opportunities in Kampot, where a pilot project was run a few years ago, and students belong to families on the MVFL are offered scholarships for school, for example. (Education from primary to high school is free in Cambodia, but uniform, school supplies, and printing costs are not covered).

The problem with this MVFL is that it is only being implemented in certain provinces in Cambodia. The program requires some “seed funding” from int’l NGOs, because the government simply does not have enough or want to cover it. And the problem is that Int’l NGOs won’t come and help unless they see some evidence of local capacity to carry out and sustain the program. NGOs are not looking for need, they are looking for ability. CIH’s job therefore in this MVFL project is to help show that Kep Province has the capacity to carry out such a program. Kep has shown its ability by already completing the identification part of the most vulnerable families and even the card distribution using the pagoda community networks. My job will be to document all the knowledge we have about Kep Province, and what has already been achieved in terms of identifying the Most vulnerable families to encourage the government to find an external funder to implement health equity funding in Kep, and to encourage governmental sectors and other NGOs to utilize the list as a way of targeting their programs and services to accomplish the nation’s goal of reducing poverty.

So far, last week, I followed Kunthy, who is qualified to do nursing, finance, and midwifery and works as the program director in Kep City. She brought us to see some of the families who needed to be interviewed in order confirm eligibility to be on the Most Vulnerable Families List. After reviewing several criteria that included how much land the family owned, how many working members were there in the family, how many children they had, monthly income, etc. We would take a photo of them along with their number (which identified the province, district, commune, and village they belonged to) with their entire family, and create a card that was about half the size of an A4 sized page. This was the card that would need to be reviewed and stamped by the village working group and officials. I was surprised to see that I just could not identify by eye who might be eligible and who was not, and I could tell that Kunthy, too, could not just by eyeballing someone, so this process is very important and identifies immense need.

The next day, we delivered a wheelchair, that I helped transport from Canada to Cambodia, to an 62-year-old lady who lived in small one room brick house in a village about 40km away from Kep city, in Bon Teuk commune, tucked away amidst a display of shimmering rice paddies. Because of sudden high blood pressure, she had fallen down and lost the use of her legs including the ability to speak. She has been bedridden since then, and that was three years ago. She lives with her husband (who was a volunteer in the village working group, and who helped determine who was eligible to be put on the Most Vulnerable Families List), and grandson. I was surprised to find out that even this family did not belong on the MVF list. They’re home was very simply a one room brick house with dusty wooden panels for beds, no other personal belongings in the room to speak of except for a stack of rice bags in the corner of the room, one cow and a cow shed.

Besides, that we spent a whole morning and afternoon cleaning out the CIH office at the Kep Seaside Guesthouse. The place was ridden with dead bugs, dust, mold, and rust that had developed over the 6 months when Rebecca was away. We also sorted through and took inventory of the medical supply donations that we had brought with us from the CIH office. They were to be delivered to the health centres and hospital in the province.

The next week, while some of us did some field research for the water project, which consisted of finding out what happened to the hundred or so ceramic water filters that were distributed last year, Marlene, Kunthy, and I worked on a grant proposal for Earthtones to create an emergency medical transport fund for children and expectant mothers of the most vulnerable families in Kep province. Currently, I am helping to do data entry with the surveys the girls have completed in the field regarding water filters, and will be begin writing the first chapter of the MVFL documentation I hope to complete for CIH over the summer.

Ok, gotta go to bed now, on to my fourth week!