Initial thoughts on Phnom Penh

Alright, so it’s taken me 5 weeks to write a “personal post” about life in Phnom Penh…that’s half of my internship. I think there are a few reasons for that. First, writing is not my favorite exercise, but also, I don’t think I can properly describe what life is like here.

For a SoCal (recently converted into East Coast), American girl, life here is surreal.

A few thoughts:

1) Culture Shock. Hey, I’ve travelled before. And to a lot of different places. I never thought it would happen to me, but looking back, I’m pretty sure I was in culture shock for at least 1 full week. Jet-lag aside, I basically hid in my room and didn’t come out. I didn’t speak the language, I knew a total of one person in Phnom Penh, and I had no idea where to go or what to do with myself. Over it now, but it’s interesting that it happened.

2) None of the locals here can accept that I am American. “Where are you from?” ….”America…”….”No, where are you REALLY from?”….”America”….”originally!”….”um…my parents are from Pakistan”….*lightbulb* “OH! You are from Pakistan! You look Indian!” Americans come from all types of ethnic, racial, and religious backgrounds. Most of us look completely different from each other. Many times, people abroad expect all Americans to have white skin, blonde hair, and blue eyes. I’ve been asked if I am Indian, Peruvian, Brazilian (flattered), and now even Cambodian. Nope, I am American. Even ask Pakistanis and Indians. It’s the way I talk, the way I was raised, my mannerisms, and so much more that makes me completely American. But this isn’t supposed to be a Jhumpa Lahiri style post about my daughter-of-immigrants identity crisis. So I will continue…

3) I had never ridden a motorcycle before coming to Cambodia. Now, I have ridden a motorcycle (or better known here as a “moto-bike”) more times than I can count. I hop onto the moto taxis quite regularly as they are the cheapest form of transportation. I’ve even ridden one sitting sideways because I was wearing a dress. Every time I choose to get on a motorcycle I think to myself, “Please let this end safely otherwise my dad will kill me for a) riding a motorcycle and b) not wearing a helmet.” I guess the only consolation is that there is so much traffic in Phnom Penh, the moto-bike basically cannot accelerate to more than 20 kph.

This is actually a pretty tame scene driving around in Phnom Penh. I’ll have to get a better picture depicting how crazy it can usually be..

4) There is a HUGE expat culture here which I absolutely did not expect. I have met countless Americans, British, and Australians. Most expats living here either work for an NGO or some version of a multilateral or bilateral agency (WHO, USAID, etc). Though I can’t say I’ve made many permanent friends, I will say that people here are incredibly nice, and it’s easy to talk to other expats at cafes, pubs, restaurants, and other sorts of gatherings.

5) I’ve had lots of visitors! It’s been fun to take them around the city and to see so many familiar faces from home.

Johnny and Nicola via Burma and Bangkok. Our visit to the National Museum.

Nafeesa (to my left) and Sara (right) on their backpacking trip through Southeast Asia.

RUQS (my mother) fresh off the plane from her trip to Vietnam!

Tuberculosis, an Imminent Global Concern Pt. 2

As I mentioned in my previous post, YES, Tuberculosis has a cure. But, it is a slow and painstaking recovery. It takes an antibiotic regiment of at least 6 months to eradicate the disease from a patient’s body.

Have you ever been on an antibiotic regiment that caused you to feel side effects like nausea? Imagine 6 months of that—amplified.

Many patients experience harsh, uncomfortable side effects to the antibiotics that can result in abandonment of treatment. Also common are patients who abandon treatment when they start feeling better, before their course of antibiotics is complete. Unfortunately, these types of patients are not cured of TB and symptoms usually re-emerge, which are harder to treat the second time around. Abandoning, or improper treatment, are a few ways of developing multi-drug resistant strains of TB (MDR-TB), which are much more dangerous and difficult to treat than regular TB.

In attempt to circumvent some of these problems, the World Health Organization’s standard for TB treatment is DOTS (Directly Observed Therapy, Short Course). As per DOTS guidelines, a health professional, or more commonly, a community health worker, must physically watch a patient take his/her dose of antibiotics daily, and counsel him/her through the side effects and tribulations of treatment. However, due to the time and human capital that this treatment model entails, many countries, especially those with poor health systems, little public health infrastructure, and small budgets allocated to healthcare, struggle to provide DOTS and curb the TB epidemic in their own backyards. As stated before, the people affected by this disease live in poor conditions, and can certainly not afford to see private physicians and pay for their treatment. They also cannot afford to forgo wages and responsibilities in order to travel long distances to health clinics to retrieve their medicines.

Operation ASHA in India—an Urban Model

In India, Operation ASHA operates in urban cities and slums (with high population densities). OpASHA sets up clinics to accommodate its patients by making sure that they are no more than 10 minutes walking distance from the nearest clinic. OpASHA even uses biometrics technology to ensure precision and efficiency. They employ a system called eCompliance at every clinic. The system is equipped with a small laptop computer, a fingerprint scanner, and an SMS modem. Patients visit the clinics regularly to see counselors and to take their meds—upon each visit, each patient checks in by scanning his/her finger print. At the end of each day, the system sends an SMS message central database which records and analyzes the data. An additional SMS is sent out to the counselors, informing them if one of their patients has missed a dose. A counselor then follows up with the patient and aims to complete the treatment. This model ensures that patients do not miss doses, and are receiving the proper counseling and support needed to complete treatment. The model is sustainable and cost-effective: it employs local community health workers and many times uses local shops and businesses as clinics, thereby providing employment and education. Though the NGO is not a complete solution for a lack of accessible and affordable healthcare, it is effective in curbing the debilitating incidence of TB rampant in India (see graphic below).

Operation ASHA in Cambodia—A Rural Model

Outside Phnom Penh, the capital of Cambodia, most areas are rural, and less densely populated. Consequently, an urban clinic model like the one in India is not the most efficient way to reach patients. Lack of access and long distances to health facilities are common problems in many rural areas. To address this problem, OpASHA has modified their model in Cambodia—counselors operate “mobile clinics,” and travel on motorbikes from village to village providing DOTS to their patients. Each counselor is assigned to a population served by one health center.  Each day, the counselor treats enrolled patients and spends a considerable amount of time searching for new patients. Sample sputum is taken from each new “suspect patient” to be tested in the referral hospital (the health centers are not equipped with enough technology to make this diagnosis. The counselors all meet the “sputum collector” at a pre-assigned time and location; the sputum collector is the one who takes all the samples to the referral hospital lab. At the end of each day, each counselor sends an SMS to headquarters, reporting on his/her patients’ progress and any new cases detected. This way, OpASHA brings meds to the doorsteps of its patients, who otherwise would not have the time or resources to seek treatment. This type of mobile health (mHealth) model is increasingly popular in areas like Asia and Africa where mobile technology is becoming almost universal. It is the next “big thing” in global health, and is changing the way that public health is tackled in resource-poor settings

eCompliance has not yet been introduced to Cambodia, but the entire team here is eager to pilot it and incorporate it into the program. Minor adjustments may need to be made, as the apparatus would need to be mobile instead of placed inside a stationary clinic. However, it will be interesting to see if this technology could become a universally applicable model, and change the way TB is treated worldwide.

Tuberculosis, an Imminent Global Concern

“Excellence without equity looms as the chief human rights dilemma of health care in the twenty-first century.” Paul Farmer

Unlike the recently emerging HIV/AIDS epidemic, tuberculosis (TB) is an infectious disease that has plagued human kind since as early as 5000 BC. Manifestations of spinal deformities consistent with TB have been found in mummies from both Egypt and Peru. The ancient Greeks, Romans, and Indians all coined their own names for the disease, but perhaps its most widely recognized synonym comes from England—Consumption, or Wasting Illness, is estimated to have killed more people in the history of the world (~2 billion) than any other infectious disease.[1] TB prevalence in Europe spiked during the 17^th-19^th centuries as cities rapidly urbanized and industrialized. In the 19^th century, TB accounted for nearly ¼ of all deaths in the crowded, urban cities of Europe.[2] European colonialism spread tuberculosis, among other diseases, to Africa and Asia, the effects of which are being felt globally till this date.

So what is tuberculosis and what makes it so infectious? Tuberculosis is an airborne bacterial disease caused by Mycobacterium tuberculosis. Infection may occur upon inhalation of bacterial particles omitted when an infected person coughs, sneezes, talks, or spits. Its most distinct clinical manifestation is pulmonary TB, but the bacteria can infect other parts of the body resulting in extra-pulmonary TB. “Respiratory symptomatic” patients, that is, patients symptomatic of pulmonary TB, often exhibit excessive coughing of phlegm or blood for two weeks or longer. Other symptoms include weight, energy, and appetite loss, and chest pain accompanied by difficulty breathing. In the modern, globalized world, tuberculosis, though concentrated in the developing world, is a source of concern for all—the highly infectious and airborne nature of the disease allows it to jump borders easily through waves of travel and immigration, and develop drug resistant forms when treated improperly.

At the turn of the 21’st century, tuberculosis remains a major threat to global health. Worldwide, there were an estimated 8.8 million new cases of TB in 2005, with greatestburden of the epidemic encumbering the developing world.[3]

Fact—TB, unlike HIV/AIDS and many other infectious diseases, is curable by commonly available antibiotics. But, those who are most affected by the disease are (not coincidentally) the least able to afford a cure. From a political-economy perspective, the rate and prevalence of the disease are telling indicators of a country’s level of wealth and inequity.[4] Cambodia appears on the World Health Organization’s list of 22 countries with highest TB burden, but not every citizen in Cambodia experiences a uniform risk—TB is unequivocally a disease of the poor. It is most contagious to those living in small, crowded areas such as squatter settlements and slums, in close proximity to those who have acquired the mycobacterium. Whereas a healthy individual’s immune system may successfully kill the bacillus, those who have a compromised immune system due to malnutrition or HIV/AIDS are particularly susceptible to developing symptoms.

Why are people still sick from a disease that has a well-known cure? Why haven’t antibiotics been widely distributed? And most importantly, who will advocate for TB patients when the very governing bodies that are responsible for the health and productive livelihoods of their populations fail to address the problem?

Look out for another blog post about the complications of TB treatment, and Operation ASHA’s model for treatment in India and Cambodia, which addresses some of these questions.

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[1] Anne-Emmanuelle Birn, et al., Textbook of International Health (New York: Oxford University Press, 2009), 283.

[2] Birn, International Health, 283.

[3] Birn, International Health, 284.

[4] Birn, International Health, 285.

Greetings from Phnom Penh

First off, I want to start off by saying that I recognize that starting a blog can be perceived as somewhat “douchey” and egocentric as my good friend Molly Teodo pointed out before I left for Cambodia. I don’t consider myself a particularly good writer or photographer, and this blog is by no means an avenue through which I intend to showcase those talents (or lack thereof).  However, since I deleted my facebook account (temporarily?) and people have expressed discontent over the fact that they cannot “stalk” me quite as comprehensively as before, I decided to blog during my time in Cambodia. This way, friends and family can have some idea of what I am up to, and I won’t have to copy/paste quite so many emails.

A brief description of what I am up to–

I received a Global Engagement Grant from Wellesley College to intern with Operation ASHA for ten weeks this summer in Phnom Penh, the capital of Cambodia. OpASHA deploys mobile clinics to rural areas of Cambodia through which counselors provide Directly Observed Therapy Short Course (DOTS) treatment to tuberculosis patients.

Look out for more posts about Operation ASHA and what I’m doing during my internship!

Meanwhile, here are some pictures documenting my first few days here since my arrival on Friday June 1st. I’d love to hear your feedback and comments!

Best,

Iman

First sighting of land from the airplane from Taipei to Phnom Penh. This actually could be Vietnam.

View from the airplane.

Mr. Hing, the Program Coordinator at Operation ASHA Cambodia, picked me up from the airport.

View out of the “tuktuk”…Cambodia’s version of a rickshaw.

The “Referral Hospital” in Phnom Penh.

A counselor on the job.

A slum of Phnom Penh.

Operation ASHA’s stationary clinic in a slum of Phnom Penh.

The owner of the shop where OpASHA set up one of its clinics.

An OpASHA counselor.

An OpASHA counselor.

The OpASHA clinic / convenience store.

A few children buying snacks at the store/clinic.