Sense of smell

Sometimes the cultural differences here can still catch me off guard, even after more than 2 years. Recently I was helping my Cambodian work colleague with his English homework. He had to write a piece on the sense of smell & it's connection to memory, he wanted me to give him an example first before he wrote his piece for homework.

I spent 2 years of my childhood in South Africa so proceeded to recall how the smell of wood smoke always transports me back to a place on the very periphery of my conscious memory - I can feel the sun's heat, see the red earth & taste the fresh orange segment, so that even on a cold winters day in the UK the smell of wood smoke will always evoke a long, almost forgotten memory from my childhood in Africa.

R recorded me on his mobile & listened to my recounting. Then the following day he asked if he could tell me his own memory connected with smell which he would write about. We were sat eating Bor Bor as he told  me but he omitted to begin with exactly what smell he would be talking about.

His story went something like this - when he first qualified as a nurse he had a job in Bantay Meanchay province in a small rural hospital. One day he was asked to go with the ambulance driver to attend the scene of a mine explosion. When they got there they found four people who had been fishing when a mine had detonated injuring them. They had various limbs missing & were exsanguinating from their wounds. The area was covered in their blood & body parts. R's punch line was that the smell of blood always made him think back to that scene of carnage & devastation & how the limbs were like meat being sold at the market.

Like I said before, sometimes the cultural differences still catch me unawares. 

At the blunt end of development work

As I come to the end of my placement, my last day in the hospital was today, I've spent quite a bit of time reflecting on the last 26 months spent with VSO & volunteering in Cambodia.

Recently I was talking with a friend of a friend who works for a large international NGO & I asked her how other NGOs view VSO. VSO is regarded, I was told, like a cultural holiday for middle class people or Raleigh for the middle aged. It was not considered 'proper' development work by many.

So has the last 26 months just been a glorified cultural holiday for me? Is volunteering with VSO not proper international development or humanitarian work? Where do I go from here?

I can't contest that this is the view that other agencies or people have about VSO, after all everybody is entitled to their own opinion, but I can argue against the assumption that VSO is a holiday or that capacity building does not represent effective development.

If VSO is a holiday I think I need my money back.

It has been a great experience living in another country, learning a new language, making Cambodian friends & learning about a new culture. The Cambodian food put pay to the Cambodian weight loss plan. But working with MoH health workers in MoH facilities & watching people needlessly die each day hasn't felt like much of a holiday to me. Especially as the purpose of my stay here was to capacity build the health service & improve health care here - to see healthcare failing (& by extrapolation me failing to improve it) so spectacularly is hardly compensated by the nice weather or the cheap cocktails.

Well when I say nice weather, if I was an NGO worker on an enormous (relative to local living costs) salary, who could afford AC & all the other ex-pat luxuries, then I'm sure temperatures of 40+˚C and >90% humidity would be lovely. Or if I lived in a house with a roof that didn't leak directly over my bed, maybe the rainy season - all 6 months of it - would be a bit nicer.

The cocktails really are cheap here but then again so is life.

VSO gives volunteers a living wage comparable with local salaries. This means that you need savings if you want to live anything other than a local lifestyle especially if you have financial commitments at home - mortgage, professional memberships, insurance etc. it is wise to have savings. My little 'holiday' in Cambodia has cost me a 5 figure sum - this has been despite considerable support from my family & mainly due to expenses in the UK rather than any extravagances in South East Asia. I budgeted for this as part of the cost of volunteering (along with my sanity) & if I had wanted a cultural holiday I could have easily have chosen instead to spend this amount on an around the world ticket or travelled around Asia on a shoe string for the same amount of time.

I chose VSO because I believe in their approach to development. Of course there is a place for international aid, humanitarian work & big budget development work but studies have shown that in health, I can't comment on other sectors, capacity building although expensive & time consuming leads to effective & sustainable change. But rather like a glacier or glass creep, progress is almost imperceptible & no one individual can claim to have seen any major impacts resulting from their work. It just takes time to change peoples behaviour & attitudes. You have to look hard for the changes & they sometimes appear in the most unexpected places.

I have found ego to be a huge factor in development. There is an innate human need it seems to get recognition & plaudits for work done. To work without acknowledgment, praise or thanks is not easy. To never see the fruits of your labour can severely impact on your own motivation & self belief.

I am/was an emergency physician so I have for a long time been used to seeing the response to my interventions & the effect of my work. I thrived on this. These last 2 years have been a constant struggle to keep positive & focused on what I am doing & assessing whether it is the correct approach or not.

Reflection is good practice, too much reflection will tear you apart.

I've worked weekends, evenings, public holidays here, Easter & Christmas. I have lost sleep worrying about the work I do. I have lost years off my life because of the frustration & anger generated by my role.

Have I convinced you yet that VSO is not a holiday?

So is the work VSO does any less effective than other NGOs?

I have had the advantage of volunteering with VSO whilst also working closely with a USAID, big budget NGO. I have seen first hand what is good about VSO's style of development work compared to the 'shiny white 4x4-AC-per diem-visit once in a while & tell you what to do' approach.

There is power in staying in a place, day in - day out. There is a beauty in role modelling best practice over months & months. There is a connection that is made with people that transcends snacks & donations of equipment. There is a respect, slow growing, that develops when you stand along side the people you want to change.

And the truth is - you are the one that changes. Because as I was once wisely told, to change other people you must first change yourself. The process of capacity building is a subtle, almost subconscious symbiosis.

I have written a report recording all that I have done, I think I know what I may have achieved, I am doubtful about the sustainability of any of it, but what is there that I don't know about the impact I have had here? What still remains unseen by me? How can any NGO truly know what its long term impact is even though they will write reports about the perceived impact in the very short term?

But capacity building can occur beyond what you can see or planned. Sat with my VA writing her final review she told me this, "I feel that now I can talk freely about things that before I didn’t think I could share my ideas. This gives me confidence. I can be more open in the future." 

In pre-departure training there was a lot of talk about 'empowerment'. I quickly became quite cynical about the over use of this word in the development circle. But after 26 months here I had an epiphany - I have actually empowered my VA. I wasn't trying to empower her - I was interested in her, wanted to learn from her, wanted to share ideas & to support her as she always supports me. And what do you know - by complete accident - I only went & empowered her. Not sure her father will be too pleased about it!

A visiting Anaesthetist to theatres at BTB recently was impressed that one of the Surgeons wanted to know more about fluid balance. Now I am not taking full credit for this but like a dripping tap, mine & many others effort's over the years must have increased awareness & attitudes towards fluid management in surgical patients - maybe soon the sink will be full!

Who knows what other unseen outcomes my crazy Barang behaviour may result in. I may never really know, which makes writing final reports & fund raising bids a little difficult. It also makes it harder to convince people of the effectiveness of capacity building when people would prefer to see a goat or a long drop toilet as a solid or concrete outcome to their donated money, rather than an intelligent female living in an unequal society feeling more confident to express herself with in her own context or doctors thinking sightly differently about fluids for their patients - a bit harder to make a fridge magnet out of that - hey?

VSO may not be at the cutting edge of development work but sometimes a sharp knife is not the required tool for the job.

Where next? - well Lewis Carroll put it best with this following extract from Alice in Wonderland -

'Would you tell me, please, which way I ought to go from here?'
'That depends a good deal on where you want to get to,' said the Cat.
'I don't much care where,' said Alice.
'Then it doesn't matter which way you go,' said the Cat.

I'm actually heading in the direction of that big shiny USAID 4x4 vehicle with AC & per diem but my consultancy fee is significantly reduced & I will keep working with the same health care workers I've got to know over the last 26 months, who I am sure will continue to change me whilst simultaneously driving me completely crazy. 

No doubt the blogs & the litany of despair will continue.....

Point of Reference

My deputy director has written my reference.

"Level of professional/technical competence - Excellent

Ability to work on own initiative - Good

Ability to work as a team & to motivate others - Good "hospital really need skilful Dr like her."

Ability to communicate effectively - Average "should be better"

Reliability - Excellent

"Strong point: active, initiative idea, being honest, commitment, skilful, encourage staffs to do what they have never done, helping to develop internal protocol, revise national protocol, provide our staffs very important skill like reading ECG, fluid balance, trauma care, burning protocol that we have not enough skill before.
Weak point: relationship may according to culture sometime""

And from all this the only thing I have picked up on is that I am an average communicator - AVERAGE!?

Sat having a my daily valium/iced coffee afterwards one of the surgeons came to join the table where I was sat & told me that I should stay here at the hospital to work in the ER when it opens, "forever"!

I guess if I did that then I would have to work on my communication skills......

Epiphany - better late than never!

My VA was telling me how she "hated all men". She had good reason to feel negative but I was gently trying to explain to her that it probably wasn't ALL men that she hated. She assured me it was ALL Cambodian men - she has had a rough 48 hours. I told her if that was the case then really what she hated wasn't men but the culture of a place or society that allows all men to behave in a way she hates so much.

As the words came out my mouth I realised that I can't possibly be angry at all Cambodian health workers for their hateful actions. Of course it is the system that is failing & I should probably take my own advice & acknowledge that it is the organisational culture that allows a whole work force to behave in a way that I find so reprehensible.

With 5 working days as a volunteer left this kind of realisation although late is better than not at all

Capacity building water

Today I was discussing with my VA that I think my final report for VSO would be best expressed by the poem below - in particular in reference to verse 3. Although I was talking about impact or sustainable chsnges rather than being missed. I may not leave a hole but I do have a very wet hand......

"There Is No Indispensable Man"
by Saxon N. White Kessinger

Sometime when you're feeling important;
Sometime when your ego's in bloom
Sometime when you take it for granted
You're the best qualified in the room,

Sometime when you feel that your going
Would leave an unfillable hole,
Just follow these simple instructions
And see how they humble your soul;

Take a bucket and fill it with water,
Put your hand in it up to the wrist,
Pull it out and the hole that's remaining
Is a measure of how you will be missed.

You can splash all you wish when you enter,
You may stir up the water galore,
But stop and you'll find that in no time
It looks quite the same as before.

The moral of this quaint example
Is do just the best that you can,
Be proud of yourself but remember,
There's no indispensable man.


You can probably tell I have water supply on the mind currently!

Water Aid

Every month for years I have donated money to the charity Wateraid - it was originally an option my water company gave me when setting up an account with them, the feel-good factor.

I support Water Aid for several reasons; as an expedition medic I have carried a days supply of water on my back all day trekking, I had carried 25 litre jerry cans of water from the hand pump to our camp, I had experienced having no water when the village pump broke - no water for construction of floors in schools (our main purpose for being in the remote bushman village), no water for washing, limited water for drinking & cooking. I had learnt very quickly two universal truths 1) Water is fecking heavy 2) No water - no life.

When I did my diploma of tropical medicine & hygiene at Liverpool some years after being an expedition medic I learnt about wells, water pumps, sewers & long drops. It is staggering the numbers of people that die each day just for the want of some clean running water. During this time of study I switched my banking to Co-operative bank, set up a direct debit to Water Aid & became an insufferable bleeding heart champagne socialist.

Cambodia is referred to as VSO-lite by many in the know because has relatively advanced infrastructure compared to the other countries VSO works in & a well established ex-pat community & NGO network. In my house I have running water & electricity with a gas bottle for cooking. Battambang has a public swimming pool, you can buy western food & there is AC in some buildings. I have never claimed to be slumming it.

When I say my house 'has running water' what I mean is it used to have running water. Because of the generally reliable supply it was built without a reservoir water tank in the bathroom. A sort of mini swimming pool that can be used to flush toilets & take bucket shower in the absence of running water but can be filled up when there is water. My fellow VSO volunteers in the villages & smaller town have these. I went to do some training at Anlong Veng last year & will never forget the scream of my fellow VSO-er as she bucket showered a frog (previously living quite happily in her tank) over her head.

3 weeks ago the water supply from the tap became intermittent. Last weekend I had no water all day but as I could see a big hole in the road in front of my house & new pipes being placed, I felt reassured it was only a temporary glitch. Last week I went away to SLN & on returning I found out that I still have no water, neither does it seem does the rest of Battambang town.

Now Cambodians have been through quite a lot in recent years so no running water doesn't even register on their radar as a problem, most of them do not have mains water anyway. My VA & good friend pump water from river/well. Despite lacking tap water they both always look immaculately turned out whilst I persistently look as if I have been dragged through a hedge backwards despite litres of piped water at the turn of my hand. My khmer teacher laughed at my concern about how I would manage with out water - as a 61 year old woman, she has lived with a lot worse.

My landlady filled my one small bucket with rain water from the big jars found outside every Cambodian home. The thing is that last rain season wasn't so rainy, the river is almost dry & talk is that the reason there is no tap water is because water reserves are so low. I prefer the post office man's theory that the pump at the water plant is broken. Hope for the best, fear he worst!

After one bucket of water had bucket washed me, cleaned my dishes & flushed the toilet, I decided that no water in the hot season (42˚C & 90% humidity) wasn't very pleasant. I then developed a fever & started vomiting. Being sick in the hot season with out any water is even less pleasant.

At the weekend I went to meet my friend who was visiting at her hotel & the manager - a friend - who seeing me immediately offered me a room. It is not very VSO but them as I have a week left who cares? Tomorrow there is a planned electricity cut for the whole day. The Bambu has a generator & its own water tank - I may never leave! I once gave the manager some dressings for a moto accident injury so I figure this is more than a fair exchange.

I wait patiently for normal service to be resumed. When I started volunteering with VSO I stopped my Wateraid & CAF direct debits. Today I am restarting my Wateraid donation & I would implore you all to do the same.

Scabby Dog - an Allegorical tale

In our pre-daparture training, 27 months ago in a wintery Birmingham, a VSO nurse told us to NEVER touch animals whilst on our placement & warned against Rabies & vicious dog attacks. She never warned us about not being able to bare the way that animals are treated in our host countries or that we may fall in love with an animal & want it as our pet.

I've lived in the same house for 2 years now. The compound has 3 dogs that belong to my landlady & whose sole purpose is to keep away the ghosts. The 8 foot razor wired topped fence & locked gates deals with any potential human intruders. Yappy dog was disposed of after my neighbours complained about his barking. Snappy dog, true to his name, has bitten me & several visitors but no one seems to want to dispose of him & last but not least Tony - the landlady's deceased husband's big, ugly, white dog - who is a psychopath dog, I hate him. Even after 2 years he still barks & growls at me, not just when I enter or leave the compound but often even when I am INSIDE my house & he is stood on the other side of the closed door on my veranda or one storey below my window.

Kind, helpful people, who don't realise that I grew up with dogs, have repeatedly told me I should feed Tony then he will respect me as a pack leader. As Cesar the dog whisperer would say, Tony is the worst kind of dog to rehabilitate - he is an insecure, anxious dog. He barks & growls & snarls at me but when I go to feed him he runs away - still barking. I've tried everything but Tony is a dog that only deserves to be kidnappped & eaten at Pchum Ben, unfortunately due to the whole deceased husband situation this is very unlikely.

Up until recently the VSO nurse's advice to avoid all dogs wasn't that difficult to follow.

Scabby dog crept into the compound & the hearts of mine & the Landlady's daughters a few months ago. She just appeared one day - this hairless, scabby, emaciated, smelly, wretch - covered in encrusted dirt, mange & sores. But she had that quality for which I like dogs for, even in her weakened wretched state she would wag her tail when ever she saw me & say "LOVE ME, I LOVE YOU, PLEASE LOVE ME" with her a big, brown & the only part of her body that wasn't diseased, eyes.

She made me want to help her. I discussed her with R - often reviled & ridiculed by his own family for being kind to animals. He saved a puppy with one gammy eye & nursed him back to health. Tony - his dog, much nicer than my psycho Tony - is a barang dog. He is loved, fed & watered & understands english commands. R had some of Tony's medicine left over & reluctantly - I think he gets fed up with all the ridiculing from Cambodians - he agreed to help me treat scabby dog.

The first injection we gave, I held her down & he administered - she whimpered a little but after licking her injection site she then started following me about even more adoringly. I believed she could sense I was trying to help her & I spent silly money, for a volunteer, on dog treats & started feeding her every day.

2 weeks later she was a little less scabby & tufts of hair were growing back. She was still pretty smelly but also equally very loving. She could always be found laying on my welcome mat on my veranda & making the whole place smell disgusting. Encouraged by the improvement we gave her a second shot - much to the amusement of my landlady & her family.

Snappy dog started bullying her, adding bite marks to her mangy skin. I began to really hate the other dogs & became very protective of scabby dog - who because of her very sweet nature never fought back.

One day I came home from work & scabby dog rushed out the gate to greet me - she then saw a male american tourist walking into the hotel next door & went to him instead. I felt a little put out by her behaviour but my Australian friend pointed out that scabby dog was only doing what most people did - getting what she could from who ever would give it to her. I felt cheated & used, after all I was the one who fed her & gave her medicine. I had to keep reminding myself she was a dog.

I went away for 3 weeks & when I returned there was a startling transformation - scabby dog was plump & healthy looking. She had a full coat of fur, was happy & playing with snappy dog & Tony. I got the best welcome home greeting ever, in direct contravention of the VSO nurse's rules about touching dogs. She even would tell Tony to shut up when he started barking at me.

R thought she needed a third injection & also suggested given her a depot injection to prevent unwanted puppies. One day soon after this conversation I needed to get something from me home - dressings for a hotel receptionist's leg, another blog - so R gave me a lift from work on his moto. On arrival scabby dog was locked in doggy sex with the dog that lives across the street, it would appear that we were a little late in giving her depot contraception. She tried to wag & greet me but with a shaggy dog attached to her it was less easy for her to be welcoming.

R thought it was hilarious especially because of my reaction. I was disappointed, having spent the last few months nurturing her back to health, feeding her, gaining her trust & confidence so that in return she was going to get herself knocked up by first dog that came along. Who would look after the puppies hey? I'm sure the neighbourhood stud had promised to respect her & take responsibility for any puppies but he looked like just another dirty dog misogynist from where I was standing.

R got an english lesson in conditional & unconditional love.

I seemed to be taking it all very personally.

R used his buddhist card when I asked about performing a doggy abortion.

The stud followed scabby dog around for 3 days - she didn't look like it was completely unsolicited attention but equally she was looking a bit bored by his relentless attention. They would sleep on my steps or veranda & whenever I came or went scabby dog would wag her tail & stud would growl at me. I started throwing water over stud & calling him a dirty dog misogynist twat. I appeared to be harbouring a lot of unresolved rage.

I oddly felt as if scabby dog was throwing all my help & care back in my face - rather than her in actual fact only doing what all dogs do. R had a theory that I was jealous of scabby dog. R is a Cambodian male so you should take his theory from his cultural perspective & with a pinch of MSG. R also thinks that all women are lazy, stupid & weak as well as jealous.

The stud has now left the compound - good riddance, so I have to find a new object to channel my rage at. Scabby dog is getting even plumper.

After a week in SLN I came back to find that scabby dog is scabby again, she has open, bleeding sores and is loosing weight & as well as hair.

For the last 4 months I have tried to help her but she needs constant support & supervision that I can only give her for the time I am here. She is currently dependent on the kindness of the landladies daughters & R's medicine. I don't want her to be dependent on me but don't like to think of someone else looking after her either. My intervention changed her life but it wasn't sustainable & now she needs more. In return for my efforts I just get a waggy greeting every day & a smelly veranda.

Tony continues to growls & bark at me.

I'm sure there is a lesson in here somewhere.......