Get your ears checked!

Since I've been working on a report of the Health Equity Fund in Kep Province, my routine here is pretty boring. I'm in the work eat sleep cycle that strongly resembles my final year of college, so any chance that I get to go out into the field is an adventure for me! This week, I followed Kunthy on two health education trips. On the first day, we visited Phnom Leuv village in Pong Teuk commune. It is about a 30 min tuktuk ride away from the Seaside guesthouse (where I am living). The topic was "healthy ears." All Ears is an NGO that conducts ear clinics around the country, they have visited Kep 3 times before, and they are back again (after 3 months) to find new patients and follow-up with more complicated cases.

The second time, we went to Okrasa village in Okrasa commune, but it was rainy and windy like no other. We rode ther on the back of a motorcycle, our ponchos flapping noisily in the wind, and rain hitting my face like pellets. When we got there, the roads were too muddy to ride through, so we had to get off and walk. To my surprise-in this horrid horrid weather where my sandals were getting stuck in the mud, I was slipping and sliding on the dirt path, dodging cow dung every couple of meters, and trying to ignore the sandy slippery feeling on the soles of my feet and thinking about all the bacteria and parasites that I now had lodged in my footwear and on the bottoms of my now drenched pants-there were people out, happily and calmly planting their rice seedlings. They seemed so happy and many of them were not wearing ponchos. You would have thought that it was like any other day.

The old woman who had offered her home up for the health education gathering this morning even stopped her rice planting, and walked the several hundred meters bare foot in the slippery sliding madness to lead us to her house. When we got there however, we realized that nobody had bothered to show up. Number 1 it is difficult to get villagers to gather together during the rainy season, because this is when they do a lot of their rice planting, and many people often only have enough land to secure enough rice for half of the year or less. Number 2 it was raining and very windy - 'nough said.

On our way back, to get the mud off of my shoes, I approached a relatively "clear" looking puddle and washed my sandals in them. As I was doing so, an image of a little boy that I had seen the other day, peeing right next to our favourite restaurant on the cement floor popped into my head. In this rainy environment it is impossible to tell what is urine and what is not...I told Kunthy before I mounted her moto "Somebody has probably peed in that water, but I just had to get that mud off of my feet." To which she replied, "Pee is probably not the only thing in that water..."

Picture Album (Coming Soon!)
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Water Filter Distribution Photos

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Photos Day 1, Day 2 courtesy of Diana Wu.

Water Filter Distribution to Most Vulnerable Families in Kep.

The last two days, we distributed 250 filters to most vulnerable families in two communes of Kep province, Okrosa (of DomnakchangAeuk district) and Prey Thom (of Kep district). The cool thing was many of the families had been interviewed by Centre for International health (CIH) volunteers in June.

We held two water filter distribution "ceremonies," because one of the district governors refused to go to another district governor's ceremony. (The pagoda's where we held the ceremonies were less than 20 minutes apart...I thought it was a pretty lame excuse.) While Kunthy, our CIH program manager and organizer of the water filter distribution ceremony, rode her motorbike to the pagoda, the 6 of us volunteers took a tuktuk. In about 15 minutes we arrived at a beautifully carved stone arch, that lead us to a large open sandy area, where the pagoda was located. The pagodas in Cambodia are very open, with colourfully painted balconies (red, yellow, blue, pink...) beautiful frescos detailing the life of Buddha lining the top of the walls, and lines hanging from one end to the other, criss-crossing each other, with cute little shapes (flowers and triangles) cut from patterned shirt fabrics of all the colours you can imagine hanging from them in series. Some of them also have a wall where they record major donations and contributions from the community.

We were met with curious stares, and when we walked up the steps to the pagoda, and removed our shoes, a little boy with a buzzcut grabbed some straw mattresses, placed them on the ground and motioned us to sit on them. All of the villagers had arrived already, and were sitting patiently on the tiled floor. At first they look like a sea of darkened faces from the rice planting and the hot Cambodian sun, amid a multicoloured palette of dusty pink, purple, yellow, and grey blouses. Most of them were women, most middle aged or older, and some men. Slowly though, we began to recognize faces. In Prey Thom, we realized that two of them were our dessert ladies, others had charmed us with their hospitality and kindness when we interviewed them regarding safe drinking water in June. Suddenly the faces seemed friendlier, I even noticed one of my interviewees falling asleep during the district governor's talk (they are known to be long-winded...we asked them to speak for 15 minutes, but neither were able to stick to their time limits. They say it may be a Cambodian habit, of zoning out when you are being lectured at, because that is what they used to do during the Khmer Rouge regime.)

After the district governor and commune chief made their speeches, Allison and I with Kuthy's help, made a small presentation on the importance of drinking clean water (you can avoid getting stomach ache, diarrhea, and malnutrition if you remove the bacteria and worms from your water), and how to prepare, use, and maintain the filter in their homes. I was impressed with Kunthy's ability to connect with the audience. While we were up there, I noticed that every single face was turned towards us - not only was the material more interesting, and not only were we standing up and being more animated, I think Kunthy was doing a good job of using real life examples and cracking jokes here and there (e.g. the ceramic pot that filters your water is not a flower pot like you have at home, though it may look like it). She got the audience to participate, and she got them to ask questions when they were confused. From what I had been told by villagers during water filter interviews, it sounded like a lot of villagers missed a lot of information (particularly the woman that went back to drinking dirty pond water after her water filter broke!), and I thought that it was perhaps because of the boringness of the health education meetings. But now that I'd seen what Kunthy does, I think it has more to do with the fact that many of these villagers are illiterate.

In Canada, say if you wanted to know more about diabetes, you can ask your friends, family, relatives for answers. Ultimately though you will end up relying and trusting what you will have read, because you either look online for information, or ask your doctor because you have easy access to him/her. If you don't though, you end up relying on word of mouth for all of your information. You can imagine how confused you can get at the end of the day.

After the education about the water filters, we went to our stations to distribute them. That was another headache all together. Each volunteer was paired up with either a village chief ("mey poom") or village volunteer (each of them are paid $2 for helping out). They did not speak English, so Kunthy quickly taught us a few Khmer words "Ot Mow" for absent, "niak poom" for villager, and the relevant respectful titles. It seemed as though they were not well briefed on the distribution procedures because everyone seemed to be doing it differently. We were to collect 2,000 riel (US$0.50) for each filter (each filter costs US$10, but we ask for a small contribution from each villager to encourage them to value it, take care of it, and not sell it), and make sure that all of them are accounted for (somebody was caught stealing 8 filters last summer.)

Some of the village volunteers though were rushing through the process, calling villagers' names and handing out filters without marking things down, other volunteers were collecting money and stuffing it into their pockets without counting the money, still others collected money from everyone before the ceremony started without noting down who had paid what, and still others did not even ask for the villagers' Most Vulnerable Families List (MVFL) cards before they handed out the filters. It was a reflection of what both groups of volunteers were used to (doing things by memory and trusting villagers rather than keeping detailed records to avoid liability). In the end, out of all of the villagers in category 2 ("very poor" who lived on US$0.25 per member of the family per day), almost all of them were able to pay. For category 1 ("extremely poor" who lived on US$0.13 per member of the family per day) a little more than half were able to pay (sometimes they would give what they had, maybe about a fourth or 2/3 the asking price).

Since many of the villagers who had come to pick up the filter were old, we worried about them having to bring the filters back home. After all it was a pretty fragile and heavy giant ceramic pot inside a sturdy but still breakable plastic bucket and cover. Some villagers carried them home on their bikes, others had their 5 year old daughter carry them home with them, but for many of the elderly, their only option was to carry it themselves. And we're not talking about a simple 5 minute walk around the block, we're talking 30-40 minutes in the blazing hot sun of early afternoon in tropical, having to walk across very narrow rice field paths, over bushes, sometimes between trees, avoiding cow poop and trying not to fall into the ponds. It is HARD, and I have no idea how to describe it in words, or with pictures. You just have to come to Cambodia and try it yourself.

Anyways, that's all the time I have right now to blog, so I will be back with pictures. Stay tuned.

Dog Bite - Happy Canada Day!

It happened during lunch, and fortunately, it wasn't me. My fellow volunteers, Kathleen and Allison, and I were eating lunch at our regular Khmer place, when we stood up to return to the guesthouse, and it happened. The restaurant's dog was sleeping under the table, and Kathleen accidentally stood up right on its back. The dog squirmed loudly and bit her in the heel. Not a big bite. If you didn't see it happen, you would have mistaken it for a scratch. But we were nervous, knowing that bites from rabid dogs are deadly. The virus spreading through and attacking the body's nervous system.

There is a pre-immunization for rabies, which consists of three shots over a few weeks. It's called a pre-immunization though because even with it, you are not immune to rabies. What it does is it buys you time. Without the pre-immunization you only have 24 hours to get to a hospital and have the first vaccination dose, one of 5 vaccinations you must receive over a period of 28 days, including immunoglobin, which apparently many hospitals in developing countries do not carry. Before coming to Cambodia, our supervisor warned us that if we got bitten by a dog, there was a high chance you would have to be emergency evacuated to Bangkok, in Thailand in order to find the vaccine.

Unfortunately, Kathleen did not receive the pre-immunization. It is a gamble, and usually doctors will not pressure their patients into getting it because it is expensive (about US$300), and the chances of being bitten are not extremely high. And if you receive the pre-immunization, you still have to be shipped to a hospital to receive the post-vaccinations.

So, when Kathleen was bitten, we immediately notified everyone in the program, we called Kunthy, our Kep program manager who was a qualified nurse, midwife, and accountant, and Buntheon who was our Phom Penh program manager and driver. We also notified our supervisor in Canada, as well as the one in Kep, who was replacing her for this week only. There was a hospital in Kampot (about 30 minutes away), and Kunthy was sure that she saw a private clinic that carried the vaccine. but after seeing the hospitals and health centres in Kep province, Kathleen was a little nervous about the cleanliness and sterility of their medical equipment. The other and more reliable option was to go straight to Phnom Penh (about 3 hours away) to the International SOS hospital, that was open 24/7.

While Allison rushed to look up information about the vaccination process post-bite, I hurried to e-mail our supervisor in Canada, and Danielle, a second year medical student that had just arrived from Phnom Penh, helped to reassure Kathleen that she had some time (24 hours), all we had to do was take her somewhere to get a vaccination. Danielle also insisted that she come with Kathleen to get the vaccination, to accompany her, help ask the doctors the right questions, and notify the travel insurance company about the incident. They arranged for the taxi who had just dropped the two girls off from Phnom Penh to wait for them while they packed their things to go to the hospital. Stephanie, who was good friends with Kathleen, also made sure to remind Kathleen about what she should bring (passport, insurance policy, money, clothing, etc.) and comforted her as well. Buntheon and I were dispatched to the Khmer place where Kathleen had been bitten to inquire about the dog, his age, normal temperament, and whether or not people knew if the dog had bitten anyone else before.

Within an hour of the bite, Kathleen was on her way to Phnom Penh with Danielle to accompany her.

Luckily, the hospital did have the vaccine, and Kathleen received the first dose in 5-8 shots from shoulder to foot. She arrived back in Kep within 24 hours vaccinated, and much calmer. The travel insurance company even promised to cover the entire cost of the vaccine. She will have to return to Phnom Penh to receive the remaining 4 doses in 3, 7, 14, and 28 days from Canada Day the day she got bitten. What a way to celebrate!

When I think back on this incident, I admire the way in which our entire team of volunteers and staff helped to make sure that Kathleen was ok. It is amazing to think that within 24 hours, she went to the hospital in Phnom Penh and back and received the right vaccination. It seems like such an amazing feat when I think about the dozens of families that I personally interviewed that I knew would very likely die from rabies, if they were bitten by a rabid dog. If you are living on less than 25 cents per day, there is no way you are going to be able to search the internet for vaccination procedures, or have access to people who have nursing or even medical knowledge, or health insurance. The whole trip to Phnom Penh for Kathleen would have cost a maximum of perhaps US$71 (US$45 taxi, $6 for hotel, $5 get to the hospital and back to the hotel, $5 to come back to Kep on the bus, $10 for food) and then another couple hundred for the vaccine, which she will get re-imbursed. You could also count the opportunity cost of having 2 of our volunteers away from work for 1 day.

As a villager among the most vulnerable families in kep, the situation would probably have run more like this. Most people know that when you get bitten by a dog, you have the potential of dying from rabies. If the family happened to have a neighbour or relative who had gone to the health centre before, then the neighbour or relative may or may not say very positive things about it. As recently as 2001, full-time health centre and hospital health staff were being paid as low as US$15/month. This extremely meager salary contributed to very low staff motivation to deliver quality health care. Often times there would be NO health staff even present, because they would be busy operating from their own private practices, or doing another job. The health centres are often not well equipped, and at best, they would have chlorinated water, and some drugs, but no electricity (which didn't arrive in Kep until 2007). Because of the lack of staff motivation, you probably wouldn't be referred to the hospital.

If by chance you WERE successfully referred to the hospital, in order to pay the admission fee and transportation and food to get there, you would need to either sell your assets (at worst your productive assets/land), or get a loan, for which interest rates are 10-20%. If you are even near-poor (not extremely poor, but poor) you will likely fall into deeper poverty through this process, which is exactly what has happened to a lot of families in Cambodia.

On the other hand, if none of your neighbours or relatives had been admitted to hospital (which is very likely, b/c the cost of getting admitted is on average about US$54 per admission, including treatment - which is WAY above what any of the families on the Most Vulnerable Families List can afford - they have US$0.25 or less to spend per person per day), you would end up consulting a traditional healer or private practitioner, who would A, not have the vaccine, and B, charge you anyway for a different drug because they want to make a profit. And remember if you don't get vaccinated within 24 hours...the virus will spread through your body, and as the doctor at the International SOS hospital explained "you will experience symptoms after a couple of weeks, and you will die."

Luckily with the Most Vulnerable Families List and with the Health Equity Funds (HEFs) being implemented in two thirds of the country, many poor families are able to access more timely heathcare at a reduced cost (all HEFs cover healthcare costs, and some even cover transportation, food, and lodging costs - none cover opportunity costs yet). For the time being, much of the Health Equity Funding are coming from internatinoal Aid agencies, but more research is needed to figure out how on earth we can fundraise sustainably. One province, Takeo, currently has a local NGO, called Buddhism for Health, that is trying to do just that, but collecting donations from the community itself for the Health Equity Fund.

Anyways, I thought I would take the opportunity of the dog bite to explain the issues that I've been reading about and experiencing in Cambodia. Moral of the story: always check that there are no rabid sleeping dogs under your table, and appreciate the public health care system in your country!

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I have uploaded some pictures here about our recent visit to some nuns in Kep.
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