Part of VSO's global strategy for health is valuing health workers. Recent research carried out by VSO in Cambodia found that health workers here say what most health workers around the world would probably say about their job.
It found that Cambodian health care workers go into health because they want to help people, someone was sick in their family & they thought if they were a doctor or a nurse they could have cured them, they want to be respected in society, they want high status & a secure income.
They complain that they don't get paid enough, they work too hard & have long antisocial hours, the patients & relatives are demanding & don't respect them. No one appreciates the good work they do.
If this study was from the UK, I could relate to the interviewees & agree with their complaints but here in Cambodia I find it very hard to match the findings of this survey with the reality of my observations at the hospital I volunteer in. The small hospital on the border I go to once a month perhaps does mirror this research but in my main placement - where I have spent the last 20 months, I can't make that correlation.
Discussing this research with the VSO volunteer who is writing the report resulted in a major epiphany for me - of course valuing health workers is important, in fact you could say if you don't value somebody how can you capacity build them. And I'm afraid I just don't value the health workers I work with.
A wise Cambodian NGO doctor once told me - If you want to change someone you must first change yourself. I think I have a lot of changing to do.
But before I try to work out how I can change for the last 4 months of my placement I think its only fair for me to give an example of why I find it so hard to value health workers in the first place.
S was born at 32 weeks gestation weighing only 1.7kg. It is most probable that because staff told his parents that he wouldn't survive he was abandoned at the hospital on day 3 by his parents. J saw him in an incubator on the Friday (day 2) & asked why he wasn't being NG fed, this request was repeated by me on the following Monday & Tuesday. Although the official line the staff gave was that the baby could suck, I'm pretty sure that they have all had training by more than one NGO about nutrition in premature babies & knew he needed NG feeding. The reluctance to NG feed was much more likely due to laziness. Nurses in Cambodia don't nurse patients - that is what relatives are for. J also asked the staff if there was an NGO that could support this baby in the absence of his birth parents and was categorically told there were no NGOs that would take a baby so small.
S was losing weight, drowsy & dehydrated.
On Wednesday two paediatric nurses from New Zealand were being shown around the hospital by J when they noticed one of the twin babies next to S had stopped breathing. Trying to get anyone - trained nurse, student nurse or doctor - engaged in this twins care was near damn impossible. The kiwi nurses bagged & suctioned for over one hour. When I questioned the twins mother she told me that her baby had been having apnoeas (intermittently stops breathing) for 36 hours but the nursing staff had told her with twins one always dies & so they had neglected to treat him. He was septic & just needed oxygen, IV fluids & IV antibiotics - all available at this hospital. The reason we couldn't generate enthusiasm for his resuscitation was because the staff had already decided he was going to die.
I tried to explain that both the twin & S were curable - they both needed very simple interventions which the hospital was more than capable of providing. I'm always told that the reason care is poor is because of lack of resources but this was just another good example of the staff's attitude quite literally killing patients. I asked once more for an NG tube & feeding for S & if they could transfer the twin to an NGO hospital.
The twin was transferred later that day.
S remained hungry but did have an IV for fluid. Still no NG tube.
Thursday I tried to ask the duty staff why the baby didn't have a NG tube & I was told he didn't need it as he could suck. I asked to see his feeding chart & daily weights - proof of his ability to suck & adequate intake. The medical assistant shouted at me the baby could suck & said they had done daily weights but as they were normal they hadn't recorded them. To call this medical assistant a liar is too mild but lets try to keep it polite.
I was fuming, I don't mind the staff not caring or being lazy or ignorant but being lied to makes me angry.
The head of service got an earful & said he would speak to his staff.
Friday J asked if the baby could be transferred to an NGO hospital, the hospital director refused to talk to her (he could see her on Monday!) & the paeds ward staff refused to do so without his permission. J bought clothes, a mattress, bottles & a mosquito net for S and was told the staff would buy some formula from a whip round they had. Maybe things were improving after all. The staff even admitted to having never weighed the baby & when it was done found he had lost 200g. They put down an NG tube. They said he pulled it out - a baby too weak to suck had pulled out his NG feeding tube - forgive me for being cynical. It was never replaced.
Over the weekend other mothers tried to feed S but he is small, premature & cold (they had taken him out of the incubator in Friday - day 9) so physically couldn't take in the volume of milk he required.
On Monday (day 12) I went to attempt to see if they would transfer him to an NGO hospital where he would receive proper care. There was a woman with S who said she wanted adopt him & had been looking after him over the weekend. She had fed him one fluid ounce at a time, as often as he would take it. He hadn't put on weight but he wasn't dehydrated either. His IV had tissued & he had a big, angry red lump on the back of his hand - in danger of becoming infected.
I tried to talk to the staff about who was going to adopt S so I could advise them to take him to the children's hospital in Siem Reap. The staff said that the woman who wanted to adopt was too poor & had too many children already - she had 2 children & a job. I tried to explain that maybe they were talking about another women to me but I just got shouted at. Why don't I take the baby I was told. At this point it was rapidly becoming plan B. Plan A was for the staff to actually do their job.
S continued to starve.
Some investigation from R who was getting really fed up about J & mine insistence to try to get this baby fed, found out the birth parents had signed the necessary papers for adoption & it was just a matter of the couple that had signed the adoption papers to come to the hospital & take him - this was not the woman who had been caring for him all over weekend that I had spoken to.
I suggested he wasn't medically fit for discharge & if he left now he would most likely die - the staff scoffed. As long as it got rid of me & J nagging them they didn't care what happened to him.
Tuesday - smaller, hungrier, lighter but S was hanging in there.
An upturned bottle full of formula milk was wedged between him & his sleeping form. R joked that not only could he suck but he would feed himself as well. Clever baby.
I got really upset by the whole situation & started seriously considering adopting him.
A young nurse took R to one side & gave him the phone number of an NGO that had agreed to take S a week ago but was waiting for him to get stronger. Of course the staff had probably lied to J when she asked if there was an organisation that could help. If they had told us it would have reduced their chances of getting money from us. Cynical but probably true. The young male nurse had taken pity on me & broken the code of silence. He probably will get into trouble for this.
I value one health worker in this story.
I rang the number & it turns out that the NGO, which usually provides homes for HIV positive children, had agreed to take him in. Of course they hadn't heard of VSO or URC being involved in S's care. They had named him, bought formula & were planning to take him when the doctors said they could.
I explained in no uncertain terms that the longer S stayed in this hospital the greater the chances of him dying of sepsis, malnutrition, dehydration & neglect. I said I thought he needed admission to a proper neonatal care unit, where he could be put back in to an incubator, NG fed & treated if he became septic.
That afternoon someone from the NGO came in to complete the paperwork & the next day he was taken to the NGO hospital in Siem Reap for a better chance of survival. They are hopeful that with just some very basic care he should survive.
I went back to the ward to ask why they hadn't told us before about the NGO adopting him, there were claims of ignorance all around. Then I started to try to broach the more general subject of feeding in premature babies. The head of service starting shouting at me - "if you cared so much then you should feed the baby yourself, that baby can suck, I SAY IT CAN. It is not my staff's responsibility to care for that baby. He is poor & has no parents. Who cares!?"
That's the head of Paediatrics at a CPA 3 hospital saying he doesn't care if a baby dies under his care because the baby's poor and confirming that he doesn't believe that caring & nursing a premature baby is his or his staff's responsibility.
One of the deputy directors talking to R about the situation explained that the staff in the hospital only treat patients with a good chance of survival & the rest are left to die, he didn't think this was ideal but then said he didn't care what happened with patients because he was retiring soon.
My Khmer teacher told me that in France & England she knows that we care for anyone regardless of their status, age or wealth. But in Cambodia one should only care for oneself & close family. She tells me it is just different - neither way is right or wrong. No money, no life. I've heard that before.
I thought all doctors took a hippocratic oath but it turns out obviously in Cambodia they don't. I can't bring myself to change my morality & ethics or to not view such blatant disregard for a new human life as wrong. Although I can do it intellectually, emotionally I still struggle to put these attitudes into the context of culture, recent history, poverty & corruption. This lack of care, this shocking neglect, this absence of any humanity, even after 20 months here, profoundly disturbs me.
And that is why currently I can't bring myself to value some health workers & why I must be failing to capacity build them too.
