Phnom Penh Journal II

Friday 23 March, 2012


Phnom Penh Journal II

I have taken the morning off to write a lecture and to write this. I am back at Brown, the coffee shop a short walk from my guesthouse. At 10 on a Friday morning it is not a quarter full—a few school boys stopping by for coffee but not staying; a woman writing a novel or a thesis, I cannot tell which—last Friday I thought it was a novel, but there are too many technical-looking notebooks today. We are partners in solitude; she speaks to no one and works for hours without looking up.

At the other tables a Facebook checker, someone making PowerPoint slides, another person reading something on a Kindle. Half of us are not Cambodian. There are no couples yet in the overstuffed chairs in the front; they will start turning up this afternoon seeking refuge from the 99o heat and something like privacy in the cool white rooms.

The cappuccino here is wet and very good.

By yesterday afternoon I felt worn out from writing and giving eight lectures, making rounds, and seeing a patients in the emergency rooms and clinics. I wake without an alarm at 4 to write my morning whiteboard talk, leave for the hospital at 7. The talk is informal and I do what I can without images. At 8:15, I start writing the afternoon talk, and we round from 9 to 11. From then on I scramble to have the afternoon talk finished and respond to requests to see patients in the emergency rooms and clinics. Except for the office in which I write, there is no air conditioning. I have to remember to drink water.

At the end of the day I told Kruy I needed this morning to write; of course, since I am a volunteer, it was okay. Kruy works six days a week, gets calls all night, manages all the personnel issues and politics and requests—desperate requests—to admit a patient or find money for a CT scan.

I cannot tell if my talks and precepting are useful to the staff and residents. I wonder if I am failing.

* * *

There are two clinics and two emergency rooms, separated by a broken, narrow road full of food carts and motorbikes and tuk tuks waiting for patients needing transportation. There is no parking lot at the hospital because few patients own a car; most of the staff and doctors arrive by motorbike taxi. I walk between the two buildings to see who might have a patient to discuss—the patients who can pay are in a nicer building. There is air-conditioning; patients without money are in the older hospital, where they sit outside waiting to be seen.

The clinic for patients with the ability to pay is just a year old. Because of the worldwide financial crisis, by the spring of 2010, money to operate the hospital had sharply diminished as donor countries and businesses cut back their funding and charitable organizations experienced lower levels of contributions and increased requests for help from many other similarly distressed countries. Because Japan does not contribute military support as foreign aid, the government, corporations, and universities have been active in what they call international cooperation, particularly in countries they occupied during their domination of southeast Asia from the 1930’s to 1945. When the tsunami and nuclear evacuation hit Japan a large part of the remaining funding collapsed. Sihanouk Hospital had to close their emergency room and inpatient beds for a year. The staff was cut dramatically: I think I heard the only six of 15 doctors could stay. To reopen the hospital, over the past year Hope has moved toward care of paying patients attracted by the hospital’s good reputation as a strategy to earn enough to support part the unpaid care.

Gradually the old hospital for the poor has reopened medical and surgery beds; recently the emergency room has been open twelve hours each weekday. Hope has also opened a few clinics in more affluent areas near the tourist hotels and embassies to expand their profit-making capacity. Opinion among the staff and volunteers who have been here for years is mixed: some feel that the purity of the mission to care exclusively for the poor has been compromised; others see the entrepreneurial shift as not just resuscitation, but as the path to the future. I spend little time seeing the patients who can pay.

Yesterday I saw a 40 year old woman with breast cancer; for two weeks she has been vomiting and unable able to move the right side of her body. She has been to half a dozen clinics. In each something was done but she did not know what. She had a thick packet of xrays documenting her extensive disease, but no other records. We put her films on a view box: her bones and liver are full of cancer. When I examined her, she clasped my hand with her left hand and held it, looking at me with the one eye that she could open. She was not pleading, just connecting, since we could speak only through the resident. Like most of our patients, she was resigned. She could drink nothing without vomiting. We give her IV fluids. I asked Kruy if we could admit a patient who probably has metastases in her brain. Kruy said we could not—there was nothing we could do. The woman had never married; her aunt takes care of her. I explained that the weakness and vomiting may continue until she dies.

In two weeks they have found no place for her. In Phnom Penh patients without money are not hospitalized to die, there are no hospices, no nursing homes—just her aunt’s single room. Tomorrow she will probably go to yet another clinic.

* * *

On our rounds I watch the patients’ family members providing all of their care. If the bag attached to a foley catheter or a bedside commode is full, a family member empties it. Chest physical therapy is done by 8–year-old grandchildren and elderly friends. Half of our patients have high temperatures—they are continuously cooled with wet clothes. If a patient becomes delirious, the family holds them down. Family members spend the night curled up on two wooden chairs or beside the bed on the floor.

* * *

The 34 year old woman, Srey, had gotten better earlier this week, although there is little hope she will recover from her multiple lung abscesses. For two days she was sitting up and she had begun to smile when I passed. Then for two days she again coughed up blood. And now for two days her bloody coughing is less.

Yesterday, with the help of her intern, I talked with her, sitting beside her bed. I asked her the usual questions about appetite, sleeping, pain—the questions that keep a doctor at a proper professional distance, focusing on what can be made better. But I cannot stay at that distance any more, either here or at home.

I asked about her trip home, if it ever occurs. She lives about 100 miles away. I asked about her children—the little one is with her grandmother.

The other? Is she in school? How old is she?

Not in school, there is no money. She is working for a westerner who has a farm, picking vegetables. She is 14.

How long since she has seen her daughters?

A month.

Will she see her daughters when she returns home?

No. No money, and the 14 year old will lose her job if she doesn’t keep working.

Are you worried?

Her answer is to ask me, will I be cured?

I am silent for a little while. What good would it do to be honest? It will take a long time, I say.

When I leave her bedside she presses her hands together with her finger tips at the level of her chin and bows her head slightly, the Cambodian gesture of greeting, of thanks, of respect, of farewell. She smiles faintly.

I do the same. When I examined her there was nothing between her bones and her skin. She weighs about 55 pounds. If she leaves, Kruy will give her about $40 out of her own pocket to pay for the trip home, I’ll give her $10 more—she and her husband have no money left.

The intern tells me, her husband is a good boy, he cares for her all the time. He has been the sole person at her bedside for two weeks.

* * *

The Department of Medicine office is one person, Neary. Neary manages the volunteers and everything having to do with the education program. She is bright and quick and at 37kg and 5 feet she manages me like a big sister of an overgrown five-year-old boy. She is indignant when I give her too much information about which talk to download—she already knows. She is incredulous about snow and doesn’t understand hibernation. She has two children—only the two-year old lives with her. Neary drops her off at some kind of childcare on her trip to the hospital. The older daughter lives with her grandmother during the week and lives at home on weekends. A picture of the two girls is Neary’s screensaver.

The ward secretary Kallyan is about the same age, and when she and Neary arrive at the hospital after separate 40-minute motorbike taxi rides, they go off together to a coffeeshop holding hands. I see this kind of casual affection between women everywhere. Kallyan sits in the middle of where the residents write in charts and I quickly discover that she understands every disease, knows the meanings of all the tests, she is three steps ahead of the residents in knowing what to do. I tease her that she should go to medical school. She is shyly pleased. She graduated with a bachelor’s degree in banking and finance. She tells me her husband is a doctor. I make an inspired guess—he was a resident at the hospital. Yes. And he fell in love with her. Yes. And now? He works in another hospital. She has a young child who stays with a grandmother during the day. In 10 minutes Neary knows I have teased Kim about becoming a doctor. Together they descend on me and want to know if women become doctors in the United States. They are amazed that half our students are women. At Sihanouk Hospital there are few “lady doctors”; in Cambodia, women with children are expected to quit work and stay at home to raise the children. In the presence of their female colleagues some of the “gentlemen doctors” are outspokenly skeptical about women going to medical school: women have babies and quit.

That revolution has not yet gathered momentum in Cambodia.

* * *

Last Sunday Daroth asked me to go see her brother. He lives with her mother beyond the Phnom Penh airport. For an hour we travelled by tuk tuk in heavy Sunday traffic. The edges of Phnom Penh are packed with shops all selling what hundreds of other shops are also selling: motorbikes, tires, locally-made furniture, giant pastel stuffed animals, gasoline, clothes, barbequed meat, shoes, cell phone, cases of Angkor beer, full-sized yard-ornament plaster elephants. There are ten thousand green coconuts on a hundred carts on every kilometer of road, a man or woman slumped over them, torpid in the blazing heat.

When cars enter the road needing to make a left turn, if there is too much traffic for them to cross, they simply head right into the oncoming traffic until they gradually work their way to the edge of the proper lane. No one honks a horn—or slows down. The air was heavy with smoke and dust. At the rare stoplights most of the bike drivers turn off their engines.

Beyond the airport, the farms have the dried, chewed down stalks of last year’s rice; new planting will occur when the rains start in a few weeks. Now the fields are full of lean goats and cows that wander without fences or respect for right of way. There is no money in the few areas where there are houses—tuk tuks do not come here, transportation is foot or a motorbike. The roads are unpaved. Children play in the dirt without toys. The mothers sit and watch.

Daroth’s family has been trying to build a house in this desolate land for three years. Their house and hundreds of others were conscripted by the government so that a foreign corporation could set up a factory. An article yesterday in the English language newspaper said that the government has also taken about 13% of “government land” in the last year and turned it over to international agribusinesses. Villages are bulldozed. Without their small farm, most of the evicted have no work.

The new house is stuck half built, the neighbor having asked for $10,000 because one wall is 8 inches over the property line. The rooms have a few bare wooden beds and a TV set. Daroth’s mother and brother live in it from time to time and bed with friends or family the rest of the time. Daroth’s mother often spends the night at Saffron, sleeping in a single room with Daroth and three other young women who work there. Sometimes the mother cooks when the chef is gone.

Daroth’s brother is about 25, the second child. In school the brother knew everything, studied English and computers. At about 20 he left for a construction job in Thailand. He was there for about a year. At one point he spent two months in a jail because of a visa problem. It is hard to find jobs in Cambodia, and many Cambodian men illegally cross the borders to work in factories or at construction jobs in booming Thailand and Vietnam. Their bosses give them amphetamines so they will work hard for 12, 14, 16 hours a day. When their addiction takes them over they come back to Cambodia ruined.

Daroth’s brother returned unable to think clearly. He talked constantly, had fantasies about working as an executive. For two years he has tormented his family, stealing everything to sell for the cigarettes he chain smokes. He runs away and returns home with no clothes—he has sold them. He begs for money when Daroth visits.

I talked with him a little—his English is still pretty good. My guess is that he has brain and heart damage from cocaine and IV amphetamines. There will be no work for him in Cambodia, and there are no social agencies.

Daroth’s little sister Daney is living at a Catholic girls boarding school a dozen kilometers away. Living at home with the brother “made her crazy” (that phrase is now universal). Daney is 11 and has been away from home for the past 4 years.

Daroth's middle sister Pich works part-time at Saffron, and her younger brother is a policeman with a family. They both earn $50 a month. Her father lives away in another province and sends a little money home. Her mother sometimes earns a few dollars. Daroth and Pich and sometimes their mother have meals and a place to sleep, but there is no other income.

* * *

Saturday, 24 March

Last night Kruy and two of the senior staff took me to dinner. We drove through the French Colonial section of Phnom Penh—it is huge and I had no idea it existed—my explorations have been limited to places I can walk to. This section has most of the five star hotels, many built in the late 19th century. The American embassy with a high, heavy fence is a few blocks from the historic site of Phnom Penh’s founding, Wat Phomn. The old French administration buildings have been turned into headquarters for government agencies. There is a large medical school and an even larger university, both founded by the French, and a half dozen private hospitals. There are lawns and gardens here, and suddenly western tourists strolling the wide, clean streets.

From the 7th Century, for a thousand years the Cambodians ruled a vast empire surrounding the Mekong River from Angkor Wat. The Angkorian empire had begun to decline by the 10th century and after the decision to abandon Angkor as the capital of Cambodia around 1600, Cambodia was a weak country, its most important assets controlled by the Thais, Vietnamese, and the internal Chinese community. It was the French, seeking to bolster a resurgence of Cambodian patriotism to better push back the aggressive Thais, that encouraged the creation of Phnom Pehn’s greatest tourist attractions--the Royal Palace, the Silver Pagoda, the national museum, the central market, and the Independence monument.

Our drive took us across the Tonle Sap River to a restaurant at the top of a 17-story apartment house owned by a wealthy doctor (you can buy a condo here for $80,000). Any city is beautiful at night when viewed from a height. As we waited for dinner, a black storm swept in over the sparkling streets in a blaze of lightening and gusts of horizontal rain. The more timid groups fled to the inside restaurant where a cooing vocalist fronted a small band. We held on and in half an hour the air had cooled and freshened for the first time.

The men had asked if I ate everything, and I said I did. They said in Cambodia that meant a person ate snakes, spiders, ants. I backed away from “everything” and said that when I eat meat, it is mostly fish. So among the many dishes they ordered, the prize was Mekong River fish baked with lethal amounts of chilies and bristling with bones. Aware of neither, at the first bite I was outmatched. Politely ignoring whatever distress I was showing, they asked how I liked the fish. Tears were streaming down my face, sweat dripped off my ear lobes, I had fingers in my mouth trying to remove a dozen barbed bones. I could think of no answer that was at the same time polite and honest. I was glad that at least I had been clear about the tarantulas.

* * *

Yesterday afternoon Srey, the woman with lung abscesses, was discharged to home. Her husband gently assisted her into a wheelchair. A few plastic bags of clothes and medications were placed on her lap. There were four or five more plastic bags remaining beside her bed. I carried a few; a patient’s daughter carried the others. Srey rolled down a ramp and into the parking lot at the head of a small, poignant parade of nurses and a few family members of other patients. None of us broke away until an automobile-taxi drove her away to the bus station.

I was late to start my lecture.

When my lecture was over Neary told me that all the doctors like my lectures. I think she knew I needed a boost. As always, I resisted reassurance.