That one patient…

When I meet patients who are undergoing treatment for TB, I am usually optimistic for them. Though they are going through a tedious recovery, it is a recovery nonetheless. The therapies that they are receiving are life saving, and without them, the patients would inevitably die. Each time, I hope that the tuberculosis was caught early enough that they can return to a productive life when they are out of treatment.

But then I met this one patient…

She was thin, like most of our other patients. But this woman, the counselor informed me, had an HIV/TB co-infection. Tuberculosis is a common opportunistic infection for those who are infected with HIV, as their immune system becomes compromised. But HIV, unlike TB, isn’t curable. There are anti-retrovirals (ARVs) which can alleviate symptoms and prolong life, but they are not a cure.

Along with symptoms of TB, the woman also had blisters on her skin which reminded me of pictures that I have seen of Kaposi’s sarcoma, a cancer that develops commonly as a result of HIV. Of course, I don’t actually know what the blisters were… She also complained of arthritis in her joints and something resembling diabetes manifesting in her foot. I wish I was a doctor so I could figure out exactly what it was..

I asked her if I could take pictures and she said yes, but was too embarrassed to show her face.

After sitting with her for a little, she began to loosen up. She showed me pictures from before she was diagnosed. The first thing that struck me was how much weight she had lost. Before, she was normal, maybe even on the pudgy side. Now, she looked like she was barely 80 pounds.

Even if her TB is cured, with a concurrent HIV infection, there is nothing to stop it from coming back. And if it’s not TB, it’ll be something else.

I felt so useless sitting there with her in her house. How do you tell someone that everything is going to be okay, when you can see so plainly that it’s not?

Pictures from the Field.

Note: I asked permission from the patients involved (or their parents) when taking photographs.

You can click on the pictures to enlarge them.

This is the home of one of our patients. It is literally a hole in the wall. No door. Just a mat on the ground, and everything she and her husband own exposed to the world.

The same patient whose home I described receiving treatment

Children playing on dirt. The child in the brown t-shirt is one of our patients. Kids who develop TB are at greater risk for developing extra-pulmonary TB (EP-TB), TB that infects a part of the body other than the lungs.

A mother crushing her son’s pills before he takes them.

A child with EP TB taking his medicine.

Swollen lymph nodes (visible on this child’s neck) are a sign of EP TB.

Another child with EP TB.

Language Barriers, Fair&Lovely, and OpASHA Cambodia Staff

I wrote this post a while ago but never published it. It’s a little late in the scheme of things, but I thought I’d share anyway:

I read a Nelson Mandela quote recently that has resonated with me:

“If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.”

I’ve never experienced such a vast language barrier before, since the majority of my global health experience has been in Peru, Costa Rica, and the United States. Because my work was previously focused in Latin America, and I’ve always been mildly cognizant of the fact that I may end up practicing medicine in Los Angeles, I chose to major in Spanish. Khmer is completely foreign to me and the language barrier has made me more uncomfortable than I could have ever fathomed before. The inability to efficiently articulate myself makes me feel frustrated and vulnerable. Most significantly, it hinders my ability to connect with patients in the way that I desire during field visits, which are my favorite part of this internship.

Despite my inability to directly speak with patients, I have been fortunate enough to do my field visits with counselors who can speak an intermediate level of English, and they are able to translate most of what is going on for me.

My favorite counselor is Srey Leak (pronounced Srey Lee-uh). She takes me on most of my field visits. All the counselors are lovely, but she is my favorite because I’ve spent the most time with her and because I can communicate with her. I guess this gives her an unfair edge over the rest of them. 

Srey Leak more often looks like this when we ride out.

Many Cambodians (like lots Pakistani’s and Indian’s I know) are deathly afraid of getting dark. It’s so hilarious since I am the complete opposite. They have their own brands comparable to Fair and Lovely and will wear full-on jackets, masks, gloves, and socks when in the sun–no matter how hot it is–just so they don’t get a tan.

Rina, another OpASHA employee, also takes me out with the counselors and translates for me. She is wearing her jacket here (not to try and be modest, as my Muslim family will attempt to convince me when they reprimand me for wearing a sleeve-less shirt) so her arms stay white.

Notice her trying to sneak on her fuzzy gloves to cover her hands before we start driving in the furnace-like weather.

Rina friend-requested me on Facebook. Thinking nothing of it, I accepted. Throughout one night she proceeded to dig back into my facebook and “like” pictures from years ago. This type of shameless “Facebook stalking” is semi-socially unacceptable phenomenon in the US, but I found it hilarious and flattering and it made me love her even more.

Mr. Hing, the Program Coordinator, speaks English, but most of the time I can’t take him seriously because he makes faces like this.

He is quite possibly the kindest, most considerate, and funniest individual I’ve ever met. Here is the email he sent me before I arrived in Phnom Penh.

Dear Iman,

I got your information relates to your flight.

I think, it will be better if you send me your currently face picture. I want to try to guest you first through your picture (surprising you) and if not possible I show the sign of your name ” Iman “. Or you will call to me by 012 910 931 immediately if you feel lost. But I am expecting that it will not happening because the airport in Cambodia is small if compare to other countries.

Thanks,

Hing

LOL it sounds creepy, but it was sent with the purest and best of intention. Other funny things he has told me include…”You remind me of my niece. But my niece, she is fat.” And “You look like you could be Cambodian, but your nose is very nice. Not squished.”

Below is Charlie. He is the Program Director (small chance that I am mixing up his and Hing’s titles).

He is extremely nice and caring as well. He called me when I was sick in my hotel one day and said “Don’t worry, I take care of you!” He offered to bring me medicine, and I immediately felt looked after and less alone. One interesting thing is that Charlie is not embarrassed to speak in great detail when it comes to medical issues. He asked me to describe exactly what my vomit and diarrhea looked like (too much info for Americans, right?!) and explained to the staff in full the medical complications of his wife’s pregnancy from the details of the cesarean section to infection in her amniotic fluid. But, when we were having a conversation about HIV and he was explaining to me the risk factors for acquiring AIDS, he had to whisper that one of them was men who have sex with men (MSM). I know he didn’t mean anything derogatory by it, I guess I am just hyper-sensitive to “gay comments” coming from a pretty liberal women’s college.

Side note: I’ve heard quite a few gay jokes and homophobic comments in Cambodia…it’s a little disheartening. 

Charlie and his wife just had a baby. I was invited to a party at his home 30 days after his daughter was born. This is a Cambodian tradition. Most of the staff and counselors were there–it was great fun.

Aman, my supervisor/boss, is the Country Director of OpASHA Cambodia. He is from India, assigned to OpASHA as an iCATS Fellow through LGT Venture Philanthropy. Won’t say any more about him…he’ll probably be reading this post at some point. HI AMAN!

Last, here is a picture of many of the counselors. All of the counselor’s in the Western Operational District gather like sardines in our small little office every Saturday for the Weekly Meeting. 

Pokaoey Sreymom – Bati Team Supervisor

Pokaoey Sreymom, 28, started working as an Operation ASHA counselor in Phnom Penh, Cambodia, in July 2011. Born in Phnom Penh, Sreymom attended school until grade 9, upon which time she started working in order to contribute to her family’s income. Before joining the OpASHA team, she worked in Siem Reap, the home of Cambodia’s largest tourist attraction, Angkor Wat. There, she made a modest living styling and cutting hair in a local beauty salon, until her mother asked her to move back to Phnom Penh to take care of her. Sreymom found that she could not establish herself as a hair stylist in Phnom Penh—the pay was too little, and the market overcrowded.  She applied for a job opening with OpASHA.

Sreymom decided to work with OpASHA because she saw the difference that tuberculosis treatment was making in the lives of patients in her area. At first, Sreymom’s friends and relatives were extremely uneasy about her new employment. They did not feel that she would be able to enroll enough TB patients to make a decent salary. But Sreymom did not have the same reservations. She says that many TB sufferers do not openly admit to their symptoms because they are afraid of the stigma and unemployment that can accompany the disease. But as a woman, Sreymom feels that she is able to communicate closely with village residents, and exhibit much more patience than men when convincing them to undergo treatment. She tries to gain the trust of TB suspects because she knows that she can help cure them. She admits that she is much more willing to endure the harsh conditions and long work days than many other counselors, and she motivates herself to work hard because she wants to serve TB patients and give back to her community. Her family and friends are now incredibly proud and supportive of the work that Sreymom does with Operation ASHA.

In March 2012, Sreymom was promoted to be a Team Supervisor in the Bati Operational District of the Takeo Province, OpASHA’s newest area of expansion. Her superior performance and unwavering dedication to OpASHA’s programs made her the perfect candidate to mentor and lead a new team of counselors. At the start of every week, Sreymom commutes approximately one hour on her moto-bike from Phnom Penh to Bati. She resides in Bati on workdays, but spends Sundays with her family back in Phnom Penh. Along with gaining practical knowledge of tuberculosis counseling and treatment, Operation ASHA has allowed Sreymom the opportunity to gain experience in the field of computers and technology. Sreymom is now proficient at using her email account and MS Excel to report her team’s enrollment data to the Operation ASHA upper-management. She did not have access to a computer before joining OpASHA.

Sreymom is delighted to continue working with Operation ASHA. When asked about her goals for the future, she stated honestly that she plans to work with OpASHA for as long as she can. She is excited to see OpASHA help eradicate TB from Cambodia and India, and expand its programs to countries such as Vietnam.

 

Pheng Sedavotey, OpASHA Counselor

Votey, 19, was born in Phnom Penh, Cambodia, where she is now an Operation ASHA counselor in the Western Operational District of the capitol city. She has finished high school, and is now completing her degree at Pannasastra University while simultaneously working for OpASHA. Votey has a rigorous schedule providing DOTS treatment to her patients in the mornings, finding new TB patients in the afternoons, and attending her university classes for three hours every evening. Though her schedule is exhausting at times, she chooses to challenge herself because she feels lucky to work with OpASHA. Working at OpASHA allows her to help her people and also provides her with valuable experience before embarking on her long-standing goal of becoming a nurse. Additionally, for the first time, Votey can contribute to her family’s income, as money is always tight.

Votey has three siblings: one older sister, a younger sister, and a younger brother. She is happy to know that she is a good role model for her siblings. Her siblings, family, and friends all express to her that she makes them proud. Her father, especially, encourages her to continue working for OpASHA, even when Votey seems overwhelmed by the demands of her hectic schedule. She laughs and says she can now confidently fight off any dog that tries to bite her, or man who tries to hassle her. Sometimes her motorcycle breaks down, and she has to call her patients in the area for help. But to her, it all becomes worth it because the community members in her catchment area call her “teacher” and present her with fruits in great appreciation for her counseling.

Votey has developed a close relationship with her both her patients and the medical staff at the health centers and Referral Hospital. She feels lucky to be able to direct her questions about tuberculosis to the OpASHA and health center staffs. Her relationships with everyone she works with embody mutual respect, and a sincere desire to rid Cambodia of tuberculosis. It pains her to see her patients coughing and experiencing side effects to TB therapies. She loves to see the smiles on her patients’ faces when they finally begin to recover from their disease. She says that it is the greatest feeling of relief and happiness when they are finally cured of tuberculosis, and can continue about their daily lives as before.

Phum Srey Leak, OpASHA Counselor

 Before Srey Leak, 31, joined the OpASHA team, she had to carry out many different jobs in Phnom Penh to support herself. Her previous employments included stitching in a garment factory, selling clothes at the local mall, waitressing at a restaurant, and working for Care International. Every month, Srey Leak needs to make enough money not just for herself, but also to send back to her family in the Candal Province of Cambodia. She says her parents have become old, and cannot farm and raise cattle like they used to. That is why she was sent to Phnom Penh from Candal when she was 10 years old—to live with a family-friend, attend school, and find work so that she could contribute to her family’s earnings. It is difficult, she says, to make money in the rural areas of Phnom Penh. The primary life style is farming. She now lives with her sister, and helps cook, clean, and take care of their apartment when she is not working. She began employment with OpASHA in August 2011, when a friend of hers, another counselor, told her about the job opening.

She was excited to join OpASHA’s program in Cambodia. She wants to help treat and prevent the spread of tuberculosis in her country. She says she works hard every day, but she is happy to do so. She must start visiting patients at 6:30 AM every morning, since some of her patients have to start work in a garment factory at 7 AM. She must make sure that she reaches them before they leave their houses, because she knows it is important that they do not miss any doses. Every day, she provides DOTS counseling until 10:30 or 11 AM. Then, she proceeds to the Referral Hospital to ask questions and discuss cases with the doctors. They give her advice for her patients when they are experiencing side effects. In the afternoon, she does active case finding, travelling from village to village searching for TB suspects who are presenting symptoms. She says it is not too difficult to find suspects. She is able to build contacts in the villages and they often tell her if they know anyone with symptoms.

Srey Leak informs me that her family and friends “worship” her because she works at OpASHA. They tell her that her work is very good because she is helping those in need. Her mother and father beam with pride when they talk about her, and her sisters are also very supportive of her job. It lifts her self-esteem to know that so many people are proud of her. Her patients love her, too. For a while, she was contemplating leaving Cambodia and working in Korea so she could make more money to send back to her parents. Her patients pulled on her arm and told her, “Don’t go! Don’t go!” They wanted her to continue providing them with counseling; they didn’t want to receive treatment from someone else. She is delighted that her patients are so fond of her, and that they respect her abilities.

Srey Leak has learned a lot since she joined OpASHA, and has expanded on her future goals. She is well informed of the symptoms of TB, and it is very easy for her to spot a suspect case. She also knows her way around the confusing-Phnom Penh exceedingly well, which she did not know when she first moved here. She is now familiar with all the short cuts and alleyways in her part of the city. She is also acquainted with many people in the communities within which she works. In the future, along with eradicating TB from Cambodia, Srey Leak would like to open an orphanage. With her steadfast work ethic, and extraordinary passion for what she does, there is no reason that she cannot accomplish all that she sets her mind to.

Tong Pheak’s Story

“If you are healthy, you can achieve anything you want.” –Tong Pheak, 33, OpASHA patient.

I first met Tong Pheak when he started treatment about 2 months ago, near the beginning of my internship. I was asking the counselors to translate something from me to him, and I was completely taken aback when he answered me in perfect English.

Tong Pheak’s residence is one of many narrow, one-bedroom-one-bathroom spaces lining the flank of a housing structure in a crowded neighborhood of Phnom Penh, Cambodia. His inhabitance does not set him apart from his neighbors, or the majority of OpASHA’s patients, who live in modest to dismal homes. What does distinguish Tong Pheak, 31,from his neighbors is two things. First, Tong Pheak was diagnosed with pulmonary positive tuberculosis two months ago. And second, Tong Pheak speaks almost perfect English.

Tong Pheak informed me that he wanted to become a teacher ever since he was a child. At a young age, he developed a passion for learning and speaking English. He feels that if a person in Cambodia can learn to speak English, then he/she will have a better chance of finding a well-paying job and having a successful livelihood. He teaches English lessons at a nearby college, his students ranging from 10 year-olds to people older than he. Unfortunately, Tong Pheak’s selfless enthusiasm for teaching English and preparing the next generation of Khmer youth for successful careers in the globalized world was unexpectedly interrupted three months ago. At that time he began feeling constantly fatigued, experiencing difficulty breathing, and coughing up phlegm. He was referred to Calmette State Hospital, where several sputum tests later he was diagnosed with TB. Two months ago, the Teokthlar Health Center passed along Tong Pheak’s case, and the responsibility for administering his Directly Observed Therapy, to OpASHA.

When diagnosed, Tong Pheak felt immediately hopeless. He was afraid that he would be fired from his job and that he would no longer be able to provide for his household. After learning about how TB is transmitted, he feared that he would spread the disease to his seven-month-old son. He “always [thinks] about this.” He tells me, “I cannot kiss him.” When neighbors and others found out about his condition, they tried to stay away from him, and he always had to wear a mask. This made him feel dejected. He says, “I have to struggle with this illness.” Luckily, Tong Pheak’s manager lets him come into the office a few days a week to do administrative work to keep his spirits up, but he is no longer allowed to teach any classes. The desire to teach again, and spend time with his son, coupled with the support of his wife and counselor, Srey Leak, motivate Tong Pheak to observe his strict antibiotic regiment. He wants to recover so he can start living his life again.

But the road to recovery is not easy.  Even after he started taking his medicines, he continued to feel constantly fatigued. Often in the evenings he would experience a mild fever, and wake up mid-sleep from night sweats. He was informed by his counselor that these were normal side-effects to TB therapies, and that he should persevere regardless. Tong Pheak now understands that he must endure his treatment because “it is the only way to bring [his] health back.”

Two months into treatment, Tong Pheak is grateful to OpASHA because Srey Leak brings his medicine directly to him and offers him counseling whenever he is experiencing side-effects.  He is happy that he does not need to take time out of his daily activities to go to the health center; he simply waits at home. His symptoms have started to subside, and he only coughs once or twice a day. He still experiences chest pain, and cannot run, walk fast, or carry anything heavy, because it makes him tired. Nonetheless, he is optimistic about his recovery.

Tong Pheak hopes to continue teaching until he is old, upon which time he will open a small business to support his family. He wants his son to one day become a doctor, even though he knows he will have to spend a lot of money to send him to medical school. He is willing to do this because he wants his son to have a secure income, and to help the people of Cambodia. Tong Pheak’s experience with tuberculosis has made him realize that “health is a priority; if health is not good, you cannot do anything…you cannot achieve anything.”  He wants to send this message to everyone: that they must care about their health and take care of it. He did not realize this before. He hopes that OpASHA will continue to treat TB patients like him in Cambodia.

Tong Pheak today. He met us during a break from work, where he was doing administrative tasks.

Two pictures to make you smile

Two children holding hands at the Referral Hospital

Tuktuk advertising drawing from lolcatz memes.

Children and Guilt

Yesterday as my mother and I were sitting down for dinner at a Pakistani restaurant in Phnom Penh, a little girl came up to us. She looked about five years old, but could have been younger. She was holding a bouquet of roses, which it was clear she was supposed to sell. She stood next to us quietly with big, innocent eyes, and I immediately felt emotionally attached. She didn’t even ask us to buy her roses. She just stood there looking at us. Which made me feel worse.

I literally didn’t know what to do. I don’t like handing out money to beggars or street vendors, whether it is adults or children, because I have no way of knowing where the money is going (I’d rather give away my food, because everyone has to eat). You hear horror stories (mostly coming from places like Pakistan or India) about children being kidnapped and forced to beg on the streets. Sometimes, people even forcibly damage them in some way, inflicting blindness or another injury because crippled children probably make more money (Re Slumdog Millionaire). The money that they make that day ends up back in the pockets of their kidnappers. Therefore, even if they are given money, these children remain in poverty and have no way of escaping to a better life. But, if they come back empty handed, they could be beaten, raped, or otherwise punished. So what does one do?

I wanted to give that girl all the money in my bank account. An education. Love. Opportunity. Choices. A life outside of poverty.

Obviously no one deserves to live in poverty. But children, who have no control over the life that they are born into and the opportunities that they are given, deserve it the least.

Would it have really hurt for me buy a rose from her? Or to give her $5? Maybe she was working to support her family. Maybe it would have fed her and her siblings for a day. Maybe she could then go home for the night. It wouldn’t have been a long-term solution, but it could have alleviated her pain for just a little.

Instead, we gave her a piece of gum. She took it happily, chewed it, and walked away. But until this moment I can’t stop feeling guilty about not giving her any money. Especially when we easily spent $20 on our dinner, when we probably could have eaten for $2.

Undoubtably, if I went back to that restaurant tonight, I would see her again. Would I make the same choice? Giving her a little bit of money wouldn’t change her life, but it might clear my conscience. More realistically, it wouldn’t do either.

I’m afraid that once I am away from these situations, back in Los Angeles or Boston, it will be too easy for me to forget and move on. Out of sight, out of mind.

But these faces are hard to forget. 

  

Solving the problems stemming from inequitable distribution of wealth, healthcare, education, and economic opportunity shouldn’t be perceived as a matter of charity. It’s a matter of social justice.

Goals for this week

I’m hoping that publicizing them will guilt me into realizing them.

1. Get down some new blog posts and put up some pictures
2. Take more pictures
3. Get through more of Pathologies of Power by Paul Farmer. (Farmer’s writing [as opposed to Mountains Beyond Mountains] is kind of dense and at times difficult for me to get through after a day of work. I think it’s the kind of reading that can only be done after ingestion of caffeine.)
4. Do some real sightseeing in Phnom Penh. (I was told by my father recently that I “lack a sense of adventure.” I will pretend that I am only mildly offended).

My mother has been staying with me in Phnom Penh for a little over a week. She’s going back to the States on Thursday. I’ve been lucky enough to have her around to feed me and coax me into some adventures (visiting Hanoi, Vietnam and Siem Reap, Cambodia). After she leaves, I’m afraid it’s back to reality and back to work.

But now that I’m pretty much settled into life in Phnom Penh and there will be less distraction, there’s no excuse to not crank out that productivity. Maybe even crack open that MCAT book? (too soon…)