living for the weekend

I am going to resist the temptation to blog about the 'training' Kristy & I attempted to do this week or my 3 month review meeting with the hospital or any other clinical stories with invariable unhappy endings and instead concentrate on the weekends. A routine of sorts is developing for my weekends in the 'bang and it makes it almost feel like home - after 4 months that's not bad going.

Last weekend Katie & I were up bright & early on Saturday morning to get to the market in search of Tofu - an necessary early purchase food item. Then it was back to mine for a banana milkshake made from possibly the biggest bunch of bananas I have ever seen, homegrown by my landlady & presented to me at 6am the other morning. I have got into the habit of wondering my house in various states of undress and luckily for her on this occasion I was wearing a T-shirt when she popped up at my screen front door.

Katie had made the grave mistake of buying sweet bread in the market (I normally make a big show of saying "ot payem" repeatedly and 'prai, prai" until they get the message) so before we could move on to the second course of breakfast - egg roll - we had to venture out to purchase a more traditional bread product. This inevitably resulted in further purchases - Katie - radio & blender, me - cake. Tea and cake has now become a saturday institution.

Then there is the obligatory de-dusting/cobweb-ing/dead insect-ing and general sweat inducing cleaning of the house which is a constant battle and the fauna of my house are winning. This is then followed by the new introduction of khmer lesson on weekend afternoons. This however deserves a whole blog to itself - suffice to say anyone who was around for me learning to read and write english will know I don't really have the temperament for learning complexed and intensive study-requiring skills. But it gives my weekend structure and I am not complaining - really though all the 33 consonants and 25 vowels sound quite similar. The monks banging their drums at 4 am every morning for 3 months leading up to Pchum Ben is helping me to develop patience and tolerance or perhaps it is just the sleep deprivation is sapping my will to fight back.

C, Gary and my VA, is off to Malaysia tomorrow to teach English & Khmer for 6 months leaving us in search of our 3rd VA since I started. C's in-laws live 18km outside of the 'bang and last Sunday morning C invited us to have lunch with his family. 

We were reassured by C that it is quite normal in Cambodian Culture for all of his extended family not to come over to us and it would take several visits to get even a smile. It is a strange dynamic to be invited to someone's house and then to be completely ignored by them for your entire stay.

There was sitting (huge pass time in Cambodian), eating (also popular - especially snacking on buses) and drinking of beer. The women of the family - C's wife, sister-in-law and mother-in-law - remained  in the kitchen creating a feast of noodles and soup curry with salad, fish and rice, chicken curry, beautifully sculpted home grown pineapples. The father-in-law remained sat on his day bed in the lean-to next to the kitchen with a very serious face silently watching the proceedings. The children played at a safe distance away from the barangs and resisted all my attempts to engage them in conversation. Limited to "Ayu-ponman?" and "Chemuh-ay?" - how old are you? What your name?
C reliably informed me I should just speak english because my khmer is so bad - I shan't miss his unfailing support, encouragement or opinion!

C before starting with us 2 months ago had worked as an English teacher and Malaysia is a huge opportunity for him but it means leaving his wife and family for 6 months as the visa is just for him. His first baby is due in January so hopefully he will get back just in time for the delivery.
He had invited students from his old class to come to the 'party' as well. You would have got the impression that he taught at a female only university but he reassured us he teaches males as well but for some reason only the 19 year old girls came - odd! The students - like the children - were resistant to speaking in khmer or their C taught english but there were plenty of photo opportunities.

Then it started to rain so the walk around the family farm was cancelled and in a gap in the rain we headed back home, but we got caught on the outskirts by the second heavy rain. I got home in time for my lesson soaking wet, full of delicious home cooked food & home grown coconut milk and slightly intoxicated by a midday angkor beer. It did impact on my performance which if you believe C is already pretty terrible.

We had our final farewell meal for C on friday with his wife at a restaurant in town. The farewell between C and Gary was emotional - a big hug - bromance is strong here in Cambodia. I however had limited physical contact and had to be satisfied with mild arm touching. I did however hug his wife - same gender physical contact is allowed - and made her promise to contact me if she needed anything (medical or not) whilst C is away. I know the medical care available here and when I make friends with Cambodians I feel that a 24 hour health help line is the least I can do. The barang community are already averaging 3 calls a week.

The Cambodian code of physical contact between people of different genders has however not been read by some of the doctors at the hospital and this week there has been numerous arm slapping and grasping and a prolonged hand holding episode. When seeking advice about what this means from 'local experts' I am unhelpfully told it is not Cambodian. It feels to me like a thawing of attitudes but I know all to well that here in Cambodia nothing is as it seems.

However when I received an invite to a presentation by the head surgeon from the hospital this weekend at a hotel - drug company sponsored and all, I knew my prior arrangements would have to go on hold. I have been here 4 months and this is the first time I have been invited to anything. People working in smaller hospitals in villages will probably have been to 20 weddings by now, know all the hospital staff and surrounding community but here in Battambang it is a tough room and being accepted is probably an impossibility I am beginning to learn.

My attendance caused much hilarity with the hospital staff as I rocked up on time with Katie as my 'guest'. The drug reps - in khmer - asked me where I was from so in my (very poor) khmer I explained I was from england and I worked with VSO at the hospital. After several more questions in khmer they finally asked if I spoke English -" errr yes I am from england" - much relief and further communications in perfect english.

A discreet entrance into the room was impossible and Katie received lots of attention as a new face. Mr S (head nurse) warmly welcomed me then asked where was Gary - this is a common occurrence and reinforces my belief that if I was male they might actually listen to a word I say.

So we arrived at 6pm for a 6pm presentation and as I predicted from previous experience of hospital meetings the presentation kicked off at 6 50pm. The highlights for me were after Katie and I agreeing that no-one would sit next to us, S, top medical ICU nurse came right to the back corner where we we hiding and sat down next to me. He has no english, I have (as confirmed by my ex-VA) terrible khmer but we never let that stop us attempting communication. If all else fails I find that a smile gets you a long way. Dr O - who until this week wouldn't look at me let alone smile my way - walked into the room (late of course), sat down, turned around and smiled and waved at me.

The talk was on hip surgery and with the help of french power point presentation, medical context and understanding every 10th spoken word in khmer I was able to understand it. During the subsequent drug rep sales pitch Katie & I played hangman.

Post talk there was free food and drink provided so the room emptied quicker than if we had been in a burning building. Like leaving a wedding after the first dance I thought now was a good time to make our exit. I thanked the head surgeon for inviting me, we talked about trauma management as we walked down the stairs, Katie was given a firm un-Cambodian handshake and we left the hospital staff to their meal and went in search of a strong G&T and cheese wontons.

Although nothing is as it seems here, I can't help hoping that what I am seeing are the first signs of a thaw - that would be good, because it has been a long hard metaphorical winter. I will however not be holding my breath.

Curve Ball

It has come to my attention that nothing is really as it seems in Cambodia, so every-time I think I have finally got something sussed karma will throw a curve ball right back at me. Sometimes this can be unbearably frustrating and morale breaking yet other times it is quite simply perfect - in a bitter sweet way.
The monks changing the 5 am plinky plonky music and chanting from a weekly event to a 4 am drum banging session that will be nightly for the next 3 months, culminating in a 14 day festival, all day chanting and music starting at 3 am, is definitely a turn for the worse - I live RIGHT next door to a pagoda.
The ants, extra protein, in my breakfast smoothies are however just a fact of life now, nothing curvy or ball-like about it.
But for example when I had finally accepted that all other road users were basically out to kill me, a moto driver actually stopped & gave way to me today. Generally they prefer to overtake you just as you are clearly turning left. A great example of this was last Friday, I sat waiting on the balcony of the Gecko Cafe for Louise and as I gazed down expectantly at the 'rush hour' traffic of the 'Bang' I noticed a pre-pubescent boy and a woman picking up Lou from a muddy puddle on street 3. The boy had decided to overtake Lou as she turned left (why not?) and had knocked her off her bike with such force that the pocket of her jeans is an imprinted bruise on her arse.
Lou had spent the previous 5 days, working 12 hour days, painting the Paediatric ward at her hospital - URC staff comments on her efforts included "you should have more animals - birds - children like birds Louise, and bears" and "There should be paintings of children playing". She had a particularly infuriating conversation about the khmer alphabet which involved a URC staff member telling her it was his idea to have it painted on the wall and Lou trying to explain to him it was already painted by the sink and then the URC staff saying "Yes that is my idea - you should paint the khmer alphabet on the wall" and so the conversation continued to insanity and beyond.
Katie went to a meeting without her VA last Friday and not only understood the gist of the conversation but spoke to the director afterwards about some of the points in khmer. She was also was expected to give an impromptu speech in khmer. Her feedback was how funny it was that she couldn't survive without her VA and her khmer was not good. When her VA told me he thought Katie wasn't so happy about the meeting, I explained the concept of positive feedback and encouragement and how perhaps in future he could say some nice stuff as well as criticism, but he declared "her khmer is not good but that does not mean that it is bad!". Later that day when Katie came around for tea she was looking rather bemused and puzzled. Her VA had told her that afternoon that "he loved it when she spoke khmer", when I confessed to my little 'chat' with him she looked relieved - positive comments from a Cambodian about speaking in khmer - a curve ball too far.
In work today I was sat on a bench outside the surgical ward talking with Mr S, the head nurse, about the same subject of positive and negative feedback. So it came to pass that I found myself getting the talk I'd given Katie's VA being given straight back to me - what goes around, comes around. Mr S thought I was improving ie less critical (probably because the medical culture shock is abating) and then suggested a team building away day every 6-12 months. Two months ago I would have probably cut in and explained I didn't have money to take the whole ward to the beach. But today I sat listening and then said "I think that is a really good idea, lets see if we can get some funding for that" - I'm taking mine and Mr S's advice and focusing on the positives.
On ITU today a regular attender with heart failure had a cardiac arrest and I calmly watched as an 'attempt' to resuscitate her commenced. No defib or monitor, no emergency trolley, a bag valve mask but no oxygen tubing, no intubation kit, poor cardiac compression with loooooong gaps - no chance of survival. She remained dead and I took my VA and myself for a walk and some reflection time.
I did go back later and not only did the staff all agree that basic and advanced life support training was necessary (they didn't even mention kit for a change, ironically it was me that said they did need more resources) but they also said this week was too busy but perhaps I could teach them next week. This resulted in me having to suggest that maybe this was a case when ward based teaching (what I have been advocating until I'm blue in the face) wasn't the best forum and perhaps it needed a more formal 2 day course (with snacks and per diems). How the mighty have fallen, I'm a heartbeat away from running a 'workshop'.
Then the ward threw me a complete curve ball - ok-  says I - as the life support course will take a little time to organise, is there anything I can do for you sooner? I've been asking this question since I got here and the answer is always the same a) silence, or b) money. But this morning Mr So, chief of ward, looked me in the eye and said "well we could do with a session on blood transfusion, indications, what checks to do, what to monitor, what to do after, things like that". I swear I nearly fell off my stool, apart from the fabulous training suggestion I wasn't aware his English was so good.
But the best curve ball this week happened whilst I was getting my paeds fix and reflecting on the worst resuscitation I have ever seen that morning on ITU medicine. I have a few favourites on the paeds ward that I like to visit daily- these include a little boy with dengue who has the best smile, a baby with the worst bowel obstruction I have ever seen whose mother has been very tolerant of all the photos I have taken of him, the apnoeic neonatal sepsis baby who I just like to make sure made it through the night, and then of course there is Dr CP and Dr M who are the all star paediatricians.
This morning however it was a relative that threw me the curve ball. She warmly grabbed my hand and started imploring me to come with her. My VA finally made sense of what she was saying and it turned out that she was the mother of a past ITU medicine patient and she had something to show me. The patient was the young girl who had the moto accident and had been flown to Vietnam with her head injury and ended up with an infected VP shunt. The last time I had seen her she was being sent home to die as a hopeless case. It really upset me at the time as I felt that the patient had been stuck in the middle of a battle of wits between me & Dr L, who had wanted me to intubate her which I had refused to do (its all in an earlier blog). Well it turns out the neighbour who was a midwife had recruited another doctor to treat the patient privately - she had got the antibiotics denied her at the hospital and although by no means well she was miraculously still alive. Some what more miraculously was what I had assumed was a full bladder was in fact a uterus with a 6 month fetus in it! No-one else had picked up on this fact either until she had delivered at 30 weeks gestation at home unexpectedly.
The mother (now grandmother) was full of joy about the new addition to her family, it was such a stunning contrast to the distraught woman I had wordlessly comforted last month. I was able to tell her via my VA how sorry I was about her daughter and how deeply it had effected me. She thanked me and hugged me. Then we all stood around the cot marveling the little dot of her grandson.
While since I'm in the ball park of americanisms I guess thats what they call closure!

An example

I thought you might appreciate an example of a typical conversation in my work place.

To set the scene, me and an australian lab scientist, Kristy, are collaborating to develop a training package on laboratory requesting and how to interpret results. In our discussions it came up that doctors often only ask for a white blood count but the haematology machine does a complete blood count on every sample sent. However if the doctor has not requested a Haemaglobin, haematocrit & platelets the lab staff will not write this information on the result sheet - even if they are abnormal & significant to patient management.

We concluded that I could inform the doctors about the machine & advised them to request a full blood count as it is being done anyway and the information is often diagnostically helpful.

Location of conversation - sat around table in staff room of ICU medicine ward.

Participants of conversation - me, Dr L, Dr O, my VA

Focus of conversation - 28 year old man with an alcohol problem, has frequents fits and is now complaining of headache, no neck stiffness, low grade fever, has just had a very traumatic lumbar puncture and now needs blood tests doing.

Me: "What blood tests are you going to do on the patient with the headache?"

Dr O via my VA; "White blood count, malaria screen, calcium, glucose"

Me: "Did you know that the machine in the lab does an Hb, haematocrit & platelet count on every sample anyway? So you may as well ask for of all them!"

Dr O via my VA (who is growing increasing bored & disinterested - I think he thought there would be more saving lives & less sitting); "Why would I need a Hb or platelet count?"

Me; "Well you have malaria as a differential diagnosis and the patient comes from Pailin" (home of Pol Pot & falciparum - two killers)

Dr O (not even waiting now for my VAs translation); "IT IS NOT MALARIA - the man has meningitis!"

Me; "But you have requested a malaria smear, surely knowing a Hb and what his platelets are would be a useful thing & the test is being done anyway in the lab. The test is run as a complete blood count not just white cells."

Dr L (in english & with his best condescending tone); "The patient has meningitis, he does not have malaria, there is no need to demand an Hb."

Me; "But if is being done anyway why not? The machine in the lab runs a full blood count" to my VA "Do they understand what I am saying? Could you translate it for me?"

My VA *silence*

Dr L (in english and increasingly withering); "There is no machine in the lab, there is NO MACHINE & no reagent"

Me; "There is no machine that works for electrolytes and no reagent for that at the moment it is being fixed BUT there is a haematology machine, I spoke to the lab about it today"

Dr L (his back to me - talking now to my VA in english) "Tell her there is no machine, there has never been a machine"

Me (to my VA) "But there is a machine, we saw the machine this morning, we spoke to the lab scientist about it and we are going to do training, could you perhaps translate that?"

My VA *silence* (he doesn't like disagreeing with doctors unless they are female and foreign)

Me; "Well OK then, I'll leave you in peace & I'll come back later to see what the results of the LP & bloods are - Lea Hai!"

I had to go back to the lab to check with Kristy that I wasn't imagining a machine, like an oasis mirage in a resource poor setting. When faced with such fervent belief that there is NO MACHINE the high levels of self doubt kick in. Kristy reassured me that there was and even made me take a photo of it on my phone so if I ever doubted its existence again I had proof.

Five hours later I went back to the lab as the results weren't in the notes, they were in the pigeon hole waiting to be collected my a ward nurse, they will be waiting a while as the nurses were all at a wedding. The white count was normal as were calcium & glucose and the malaria screen was negative. As for the Hb & platelets we will never know as the lab staff didn't write the result down because the doctor hadn't ticked the box.

The LP was grossly abnormal - I questioned it with Kristy as it made no sense to me. Kristy re-did microscopy. The 750 reported lymphocytes were in fact 750 red blood cells - small cells with no nucleus as opposed to larger cells with a big nucleus AKA lymphocytes, capacity building the lab staff is her problem not mine!

My conclusion was this patient does not have meningitis  (gram stain negative, glucose high normal, protein normal) but if I said the sky was blue the doctors would say it was green, so I told the family (who had no communication with any staff & just wanted to know what was going on with their relative) that he was being treated for infection & I'd ask the staff for some paracetamol for his headache.

I hope his headache wasn't too bad though, I'm pretty sure that my request on his behalf for analgesia  meant the staff would do the complete opposite. (They did argue the toss over the dose of paracetamol - I swear they can't help themselves)

The mythical haematology machine

And so not inexplicably but still very irritatingly, all day I have been singing these lyrics -

"Just as I thought it was going alright
I find out I'm wrong, when I thought I was right
s'always the same, it's just a shame, that's all
I could say day, and you'd say night
tell me it's black when I know that it's white
always the same, it's just a shame, that's all

I could leave but I won't go
though my heart might tell me so
I can't feel a thing from my head down to my toes
but why does it always seem to be
me looking at you, you looking at me
it's always the same, it's just a shame, that's all"



GENESIS AND PHIL COLLINS GET OUT OF MY HEAD!

Looking for the silver lining

Its been another great week in the world of capacity building and health. (please read with heavy sarcasm)

But I did promise that the next blog would be positive and up-beat - so here goes!

Well I think we have established that no-body at the hospital - including my VA - has the slightest clue what I am doing here. This came to a head last friday when ITU medicine ward decided enough was a enough & I should stop advising and see some bloody patients. Before I could explain that as an advisor, with the capacity building NGO VSO, service provision wasn't my main focus, I had MSF thrown at me. Hmmm I thought to myself, yes MSF - get your hands dirty, do proper clinical work, bear witness & get paid better - that might well be in the next 5 year job plan. Whilst the male nurses got really hostile & started shouting at me I retreated to the safety of my shabby VSO office .

Later that morning in conversation with the deputy director who barely knows who VSO are, less about capacity building, he told me I must not talk to nurses. So bizarre was this request that I asked for clarification before being quite sure that I was only allowed to talk to Doctors & must not talk with nurses. I had two responses to that one - 1) I am a health care professional, communication is essential with other health care professionals and nurses are health care professionals - WATER TIGHT LOGIC - can't argue with that. 2) If I can't talk to nurses how come they can shout and be hostile & aggressive towards me - honestly I think I had him more stumped on the latter point.

There is however a silver lining to all this. Free from the constraints of a ward that want a MSF doctor & lots of resources but not me, I found myself being requested by J to see a breathless baby that she was concerned about. I have mentioned before that the paediatric ward has & continues to have a whole load of capacity building support and it really does show. Positive point - change can happen but it is slow & bloody hard work.

The 6 week old baby looked to me as if he had bronchiolitis, respiratory rate was 80/min and he was recessing like a recessing thing on a very recessing day. Basically he was working very hard to breath and had been for the last 2 days, I was told. J quite rightly was concerned that the baby was going to get completely exhausted and have a respiratory arrest. Whilst I stood talking to the young mum & examined the baby he stopped breathing, so I gently stimulated him to remind him he needed to breath then explained to the mum to do the same if it happened again.

I then found the duty paediatrician & asked what he thought was going on with the baby. We talked around bronchiolitis & the viruses that cause it, what observations the child had, how I was concerned about his breathing and what their management plan was. Then very gently, after being shouted off a ward for asking where in the medical notes it said the 33 year old woman with 24 hours of untreated fast AF now had a dense hemiplegia, I asked the doctor if he thought CPAP may help the baby. I was expecting dismissive, condescending, patronizing, refusal of my opinion being worth anything (as is the norm here) but instead his brow creased & he said "do you think so?". Now my self doubt is at an all time low so I really gave it some thought before tentatively replying "Yes, I do think so."

What followed was a thing of beauty, out came the CPAP machine, 30 minutes of the staff trying to work out how to use it (so rarely it is used). This involved the oxygen connector flying off the cylinder at high pressure and nearly hitting the baby in the head hence negating any good that the CPAP could have achieved by delivering a fatal head injury to the child. But after some suction of copious snot and the mother now obsessively stimulating her poor exhausted baby even when it had remembered to breath - CPAP was commenced. Later that day I went back to see a much happier baby - still recessing but not an impending respiratory arrest. Every day I have been in to see the progress & I have been told by the head doctor all about how they are weaning him off CPAP & oxygen, almost like we are two doctors discussing a patients care. Today when I dropped by to see him he is now on nasal spec oxygen and breast feeding - see its not all bad. Not gold yet but a good solid silver lining....

The ravings of a capacity building fundamentalist

Last week every suggestion Gary & I made (well all two of them, allocated patients & weekly ward training sessions/meetings) at the ITU medicine ward meeting were declared “impossible” by a militant & united mass of nurses and doctors. But today in the hospital morning meeting, the chief of surgery, an orthopaedic surgeon with a killer smile, flashed me that smile then winked at me (swoon). Then the gynaecologist to my left implored me to speak up more in these meetings, he wanted my support. The ups & downs in this volunteering lark are giving me motion sickness.

The morning meeting was discussing the case of an 82 year old man who had fallen out of bed and died (not an unfamiliar scenario in an NHS hospital) but no-one would speak up to suggest that perhaps the hospital was responsible for looking after patients when they are in its care. The Gynaecologist - a Cambodian doctor who has spent 3 years in France training – wouldn’t speak up with his opinion because he said they would all just get angry with him & then say he thought he was better than them. I countered this with my tested truth that if I said something I would also get anger & then be told that this is Cambodia and I am NOT Cambodian.

Sometimes I feel that certain members of the hospital staff do want me there (not just because they are winking at me), they are just not sure what to do with me. Often they just want me to be their voice – I have Barang immunity – to say the difficult stuff that they all know but are trapped in silence by Cambodian cultural norms. They also say that they want my expertise but when I question their practice or suggest even small changes the heels dig in & the “this is Cambodia” speech is trawled out.

The ITU medicine ward’s agenda currently is for Gary & I to support them to have ventilated patients on the ward & show them how to use the new shiny defibrillators that a French doctor donated. Gary & my agenda differs slightly – we would like to implement ward management, improve basic nursing care & improve doctors’ clinical reasoning skills & management of patients. Basically using child development milestones, we want them to sit unsupported, they want to hop, skip & jump.

This weekend I went to Siem Reap with Katie & her brother, who was out visiting. We found ourselves tricked into going to a free ‘concert’ which was in fact a fund raising event for one of the NGO hospitals there.

Whenever I try to promote continuing medical education (CME) & regular training & supervision sessions with the hospital staff, the second most common response is “we are not an NGO hospital, that won’t work here” (the first is the “this is Cambodia” chestnut). It frustrates me but after sitting through the pseudo-concert I found myself beginning to understand the thinking of my Cambodian counter parts – astonished that cleaners at the NGO hospital earn $250 a month whilst a Government Hospital doctor earns $100, nurses $70. If the doctors & nurses aren’t on the wards you will find them in their private clinics or working their 2^nd & 3^rd jobs to earn a living wage.

I’m not suggesting that NGO hospitals aren’t doing a fantastic job and providing essential care to the sickest and poorest, its just they are not always helping to improve the government health system in the process. In fact they may well be making matters worse because despite what the cello playing Swiss doctor tells all the tourists so ready to part with their US$ for a good cause – it is not sustainable to run a hospital where 90% of its running relies on private donations. There is nothing sustainable about creating inequalities in workers salaries & training and care provided to patients. It is an admirable life’s work & has filled a huge short fall in health care services in a post war Cambodia – but surely what Cambodia needs now is to work towards providing good healthcare to all Cambodians and stop being so reliant on outsiders’ money & skills.

Angkor Hospital for Children is another NGO hospital in Siem Reap - I've worked with some of their doctors because they collaborate with other NGOs in health, they run training programmes from their hospital, they accept referrals from government hospitals and their doctors work in government hospitals to improve child health in Cambodia.

Nothing would give me greater pleasure than to rearrange the ward to how Gary & I want to run it, to see my own patients, make clinical decisions & feel as if I was actively doing something to improve patients’ wellbeing & health. But (and it’s a big but) that is not why I am here, it is not why I chose to go away with VSO, its not what capacity building is about. So when Dr L tries to get me to do an LP when Dr R had failed to be successful  (mainly as he was attempting to do an LP through the sacrum by the look of the puncture mark position) I say no. However I encourage Dr L to perform it, film him for training purposes and then persuade Dr L to supervise Dr R for the next LP. Dr L is the LP king and I tell him that, it makes a nice change from my usual 3 year-old-like "why" constant questioning of him plus I don't want to humiliate myself in front of him, he does an LP in the time I will have injected the local anaesthetic. Although I do have emergency medic footage of me putting in a chest drain if he ever doubts my clinical skills!

Back to the pseudo-concert - I was also puzzled by the assertion from the speaker that poor people don’t die of poverty, his proof was that nearly all the children treated at his hospital survive & never get sick again (at this point I nearly walked out). Living on less than a dollar a day, no sanitation, no clean water, little nutrition, no money for schooling, no transport to access health care, lack of empowerment, corruption and poor governance do affect your health – I wanted to shout – but instead I chewed my hand off. I suffered the next day for that illicit nail chewing - all kinds of unsavory e.coli were hanging out there it would seem. However I was able to spend the 3 hours on the toilet reading a very good book - Half the Sky - a study on the struggle for equality for women within an international development context (check it out). I find myself growing more cynical by the day about international development so a few uplifting stories helps.

The other day in a particularly dull meeting with no translation I re-read an essay I’d written for my Child Health MSc, on international health policy. The naivety of my academic writing made me smile. Forgive me while I quote myself, the title was - What characterises the policy and organisational developments in those developing states that have achieved progress on public health?

“Conclusion

Although there is agreement that better public health policies improve population’s health, the evidence base for policy outcomes and cost-effectiveness is weak. Progress in achieving the Millennium Development Goals continues to be constrained by a lack of knowledge of how best to reform health systems. Further research is required as presently much of what is known to be effective is on a case study basis, the scope for transferable learning is great.

There is a tendency for cost-effectiveness of health care to dominate in policy making, as there is a constant political pressure to deliver immediate results. This has to be countered with capacity building of systems which can be time consuming and initially quite costly before long term gains are recognised. 

Context is essential when formulating policies and organisational developments that will be effective in improving public health. Generally speaking policies that are integrated into the macro-economic framework and health-in-all policies have a greater impact on public health. 

Reforming and financing health needs to be in line with the ideology of a population and failure to address this will impact on the progress in public health. A “bottom-up” approach with local community participation and clearer accountability has been shown to improve delivery of universal health-care and the equity of resource allocation. This however is dependent on a strong central government free from internal corruption or ‘bullying’ from international actors to instigate healthy policies that will be sustainable, empower the vulnerable groups within that society and result in better health for all.

“The Public health disasters of failed states provide ample evidence that a strengthened state is a necessary condition.” "

I’m not even sure I really understood the extent that corruption impacts on health or the complexities of NGOs and international health politics when I wrote this, but I had read a lot about it. Now I’m living it and could do with some practical solutions, I'm not sure there are any definitive answers.

But for the time being I'm going to corner the winking surgeon to see if he'd like to go on a primary trauma care course in Siem Reap to become an instructor, safe in the knowledge that I may not have a CT or MRI scanner but I do have a strong belief in capacity building even if it is costly & time consuming & I won't get to see any of the long term gains.

On the subject of definitive answers, I think we can conclude to the question "what is the appropriate foot wear when visiting Angkor Wat?" the definitive answer is "NOT flip flops". If only development work was as straight forward!