I'm currently helping to develop a Severe acute malnutrition (SAM) training package - my session is on the stabilisation phase, steps 1-6 - and so found myself in the paediatric ward asking if I could take some photos of the medication they have for SAM patients. One of the nurses always brings her 4 year old daughter to work & after 2 years she's become bold with me. Chatting away to me in english & khmer. "Hello" she says, "Sok-saa-bai?" I ask "Fine thank you" she replies, "Nyam bai howee?" I ask and the khmer conversation circle has been completed. She has stopped asking me where I come from after 18 months & she doesn't seem so interested as to where I might be going.
On this occasion she was sat on the table in the staff room stuffing oranges into her mouth & looking the picture of a well nourished & healthy Cambodian child. Her mother lazily got up, on one of the paediatric all star's request, to unlock the room for me where all the malnutrition medication is kept. F-75 & F-100 a special formula, ReSomal for dehydration & BP-100 a special food supplement bar.
Whilst I was taking photos of the packets of medications - because that is what they are, special medication for children who have severe malnutrition - the nurses daughter came in & started pulling at a box on the floor. Her mother went to the box & got out a vacuum packed packet of BP-100, I smiled & said politely "Do the children with malnutrition like to eat this?" just as the nurse started to open the seal. Before I had the chance to construct a sentence in khmer saying I didn't need it opened she wordlessly gave the bar to her 4 year old child who started shoving it into her mouth, like a child who had been asking for the bars that she always gets when ever she is in work with her mother.
Sadly I was not that shocked or surprised, after all this is the same nurse I've seen sat watching TV, eating snacks, laughing, whilst children die without medical intervention only 5 metres away. It doesn't surprise me at all that she may see nothing wrong in quite literally stealing food from the mouths of children who are starving to death. All in a days work.
What upset me was my response & the conversations I had afterwards about this incident.
Walking for a well needed iced coffee break afterwards with L, I asked if she thought it was wrong to take BP-100 & give it to well children? - yes. And had I done the right thing? - yes. As my translator she has a vested interest in me not upsetting people as it is, after all, her that gets it in the neck.
I then spoke with the Cambodian NGO worker I share an office with when I got back there. He laughed - this is normal for Cambodia. Was it wrong? - yes, but it was still normal for Cambodia. What would he have done? nothing or maybe made a joke.
I spoke with R - he shrugged, this is Cambodia, I do not understand why this is upsetting you. He told me to put it into perspective. With all the huge corrupt practices & the money skimmed off at ministry level why was I so concerned about a single bar of BP-100.
From little things big things grow.
I went for my khmer lesson, S & I had a long conversation about this. Apparently I am in Cambodia - I require reminding of this fact at least 4 times a day. She told me a great proverb which although involving a lake & country side basically means the same as 'when in Rome, do as the Romans do'. What do you think I did? I asked her. You must say nothing & keep silent she implored me - like any one who lived through the khmer rouge would tell you this is the only survival strategy here. Slowly & calmly in khmer I asked her - I do not want to know what you think I SHOULD have done, I want to know what you think I ACTUALLY did? She smiled at me knowingly & said - you stayed silent.
She was right. I knew that saying something in that time, that place, was just pointless.
When in a lake do as the country people do!
I was feeling pretty depressed by this. Have I lost my fight? Is it time for me to leave?
I discussed with R, S & L again about the morality of what happened. I gave them 2 scenarios. The first is a health worker who has a headache or fever whilst at work so takes paracetamol from the drug cupboard so they can then carry on with their shift. The second story, some what emotively, involved stealing medicine from the mouths of starving babies.
What's the same about these stories? Well they are both stealing so therefore morally wrong.
So why is story 1 more palatable, more acceptable?
They all answered the same, and I also agree, which is that although in story 1 the health worker is stealing, they are self medicating & staying at work to do their job & care for patients. They could go home, they could leave work to buy medication or they could stay & be ill & not as effective in their work. What they choose is not the worst option for the patients. Their motivation & intent is not completely morally wrong.
Thankfully they all agreed that Story 2 was wrong & felt more wrong as the child is eating a medication for malnourished children when she is in fact perfectly well nourished. Also they all know that often the hospital runs out of medication & this is the reason is why. S is a retired teacher & she knows this is the case - its common knowledge.
I know this happens everyday. I know it is a normal part of Cambodian culture. I know that it is wrong.
What I don't know is why I didn't think it was right say something at the time or why all the people I work with don't seem as upset & disturbed by it as I am when their job is the same as mine - to cspscity build & improve health care.
The following day I was waiting to speak to the head nurse about it - knowing full well he would never act on my complaint - when I had a call from Jn my future boss.
She wanted to ask about cellulitis but the conversation quickly came around to malnutrition & the nurse. I told her how useless I felt, I said I was actually sat writing my final report for VSO when she rang & it was making me realise I have achieved nothing & I am a waste of space.
Jn told me something that pulled me out of my nose dive. She said this "Esther you have had conversations with people about the morality of stealing. If you weren't here they would not even think about whether the nurse taking the BP-100 was right or wrong. They would just accept that this is the way that things are here in Cambodia. Every day you challenge & question them. Even if you don't change their attitude or behaviour you have introduced them to another point of view. That is what capacity building is. That's what I want to see written in your final report!"
It really is exhausting constantly challenging others received wisdom, constantly doubting your own morality or motivation or reason. But that's my job, my choice.
Today I will discuss this case with Mr S, the head nurse. Today I will be a Roman even though I am in actual fact living in Cambodia.
Whilst I was taking photos of the packets of medications - because that is what they are, special medication for children who have severe malnutrition - the nurses daughter came in & started pulling at a box on the floor. Her mother went to the box & got out a vacuum packed packet of BP-100, I smiled & said politely "Do the children with malnutrition like to eat this?" just as the nurse started to open the seal. Before I had the chance to construct a sentence in khmer saying I didn't need it opened she wordlessly gave the bar to her 4 year old child who started shoving it into her mouth, like a child who had been asking for the bars that she always gets when ever she is in work with her mother.
Sadly I was not that shocked or surprised, after all this is the same nurse I've seen sat watching TV, eating snacks, laughing, whilst children die without medical intervention only 5 metres away. It doesn't surprise me at all that she may see nothing wrong in quite literally stealing food from the mouths of children who are starving to death. All in a days work.
What upset me was my response & the conversations I had afterwards about this incident.
Walking for a well needed iced coffee break afterwards with L, I asked if she thought it was wrong to take BP-100 & give it to well children? - yes. And had I done the right thing? - yes. As my translator she has a vested interest in me not upsetting people as it is, after all, her that gets it in the neck.
I then spoke with the Cambodian NGO worker I share an office with when I got back there. He laughed - this is normal for Cambodia. Was it wrong? - yes, but it was still normal for Cambodia. What would he have done? nothing or maybe made a joke.
I spoke with R - he shrugged, this is Cambodia, I do not understand why this is upsetting you. He told me to put it into perspective. With all the huge corrupt practices & the money skimmed off at ministry level why was I so concerned about a single bar of BP-100.
From little things big things grow.
I went for my khmer lesson, S & I had a long conversation about this. Apparently I am in Cambodia - I require reminding of this fact at least 4 times a day. She told me a great proverb which although involving a lake & country side basically means the same as 'when in Rome, do as the Romans do'. What do you think I did? I asked her. You must say nothing & keep silent she implored me - like any one who lived through the khmer rouge would tell you this is the only survival strategy here. Slowly & calmly in khmer I asked her - I do not want to know what you think I SHOULD have done, I want to know what you think I ACTUALLY did? She smiled at me knowingly & said - you stayed silent.
She was right. I knew that saying something in that time, that place, was just pointless.
When in a lake do as the country people do!
I was feeling pretty depressed by this. Have I lost my fight? Is it time for me to leave?
I discussed with R, S & L again about the morality of what happened. I gave them 2 scenarios. The first is a health worker who has a headache or fever whilst at work so takes paracetamol from the drug cupboard so they can then carry on with their shift. The second story, some what emotively, involved stealing medicine from the mouths of starving babies.
What's the same about these stories? Well they are both stealing so therefore morally wrong.
So why is story 1 more palatable, more acceptable?
They all answered the same, and I also agree, which is that although in story 1 the health worker is stealing, they are self medicating & staying at work to do their job & care for patients. They could go home, they could leave work to buy medication or they could stay & be ill & not as effective in their work. What they choose is not the worst option for the patients. Their motivation & intent is not completely morally wrong.
Thankfully they all agreed that Story 2 was wrong & felt more wrong as the child is eating a medication for malnourished children when she is in fact perfectly well nourished. Also they all know that often the hospital runs out of medication & this is the reason is why. S is a retired teacher & she knows this is the case - its common knowledge.
I know this happens everyday. I know it is a normal part of Cambodian culture. I know that it is wrong.
What I don't know is why I didn't think it was right say something at the time or why all the people I work with don't seem as upset & disturbed by it as I am when their job is the same as mine - to cspscity build & improve health care.
The following day I was waiting to speak to the head nurse about it - knowing full well he would never act on my complaint - when I had a call from Jn my future boss.
She wanted to ask about cellulitis but the conversation quickly came around to malnutrition & the nurse. I told her how useless I felt, I said I was actually sat writing my final report for VSO when she rang & it was making me realise I have achieved nothing & I am a waste of space.
Jn told me something that pulled me out of my nose dive. She said this "Esther you have had conversations with people about the morality of stealing. If you weren't here they would not even think about whether the nurse taking the BP-100 was right or wrong. They would just accept that this is the way that things are here in Cambodia. Every day you challenge & question them. Even if you don't change their attitude or behaviour you have introduced them to another point of view. That is what capacity building is. That's what I want to see written in your final report!"
It really is exhausting constantly challenging others received wisdom, constantly doubting your own morality or motivation or reason. But that's my job, my choice.
Today I will discuss this case with Mr S, the head nurse. Today I will be a Roman even though I am in actual fact living in Cambodia.
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