Life is a series of disappointments

I have upset my brother-in-law & best friend by telling their offspring my perceived words of wisdom - life is a series of disappointments. This wisdom has been cemented by living for over a year in Cambodia & working as a volunteer. It really does help prepare you for disappointment & failure, something as simple as ordering an iced coffee can be fraught with unexpected results & ultimate disappointment. Richard & Penny think that I am being negative & pessimistic as well as a bad influence (well at least I think this is their objection) but it is actually for me a very positive & realistic outlook to have. I have become much more accepting of my fate & realize now that very rarely will things ever work out the way one hopes or plans.

So this philosophy has stood me in good stead for the week that I have just had - or as my Khmer teacher would say (thanks to Geordie & not me, I hasten to add) - I have had a shit week.

It started off bad (see A Reflective Writing Practice Blog) and continued to descend into a series of professional & personal disappointments - thank heavens for low expectations.

The low point would have to be this Thursday when I made the big mistake of going to the Paediatric ward to cheer myself up, only to find a 2 year old girl gravely ill in the emergency ward. She had been admitted at 8 am that morning (it was now 11 am). Her notes were blank & there was no doctor on the ward - they were at a wedding party. When V & I arrived there was no nurse with her. I spoke with the family who told me she had been sick for 3 days & had been diagnosed with typhoid at their local health centre but whatever the source of infection now she had overwhelming sepsis. Despite no history, examination or management plan being documented in her notes (the irony of this being that frequently the notes will have observations for the next day in them) she had been recieved antibiotics, steriods, fluid & a nebuliser. She was in severe respiratory distress & with help from V we sat her up & administered oxygen which seemed to help her work of breathing but then she started to show signs of pulmonary oedema. With no facility to invasively monitor her or intubate her I reached a dead end of what else I could do for her. However we did endeavour to get the head doctor to come & review her.

As we left the ward V asked me "When would you intervene & take over rather than just advise?" - that made me feel particularly great. The truth is that in medicine no one ever works alone, as part of a team there is not one person who 'saves a life'. Without basic nursing care, continuing medical management & resources the outlook was grim.

We returned an hour later to find the all to familiar & sickening sight of an empty bed, V like my old VA failed to understand the significance (x-ref comment at the end of Curve Ball Blog) & when he asked was upset when the nurses just laughed and told him the little girl had died.

We went to our office, I showed him the Curve Ball Blog, he took photos of me wearing J's glasses which he then posted on K's facebook wall with the message below;

"She is trying to cheer herself up after hearing that one child died without any attention from too busy nurses and doctors(busy or lazy?) I also want to show my upset face but no one took picture for me. If people think about one rule" treat other as we want to be treated" it refers to that if we want life. Other also needs life. Help other people as we want to be helped. Human must be full of mercy and compassion. Please not be too selfish. We have virtue, our image is as god's."

I went to speak with my deputy director - I was already frustrated because all week I had been trying & failing to get the ICU ward to treat a severe asthma patient correctly. ON was great (as always), he asked me if I was depressed - a legitimate question for him as he is one of Cambodia's few specialist psychiatrists. He said that Buddhism says that you should not let your mood go up & down and that I should just concentrate on delivering the message & not focus on whether there is a positive or negative result. He declined my semi-joking request for medication or hospitalization but offered me talking therapy. The subtext of our conversation was - Esther, life is a series of disappointments!

Then Friday evening came & it was the Khmer New Year Hospital Party, there was karaoke, beer & dancing. I dragged ON on the dance floor & we danced most of the night, ON dragged the Hospital director to dance with me for one dance. Even PPF (punch provoking face - as V calls him) danced with me. People were friendly & teaching J & I how to dance properly, we had fun. 

So you see life may be a series of disappointments but it is often punctuated with hope, you just have to manage expectations.

ON & me rocking on down to some classic khmer tunes

A Reflective Writing Practice

As I've learnt that my lovely VA can say things much more eloquently than I ever could I am blogging another reflective practice piece. This time there is my VAs piece first & then mine, reflecting on the same incident at the start of this week.

Its been a tough week & monday morning heralded how the week would turn out. As the week went on V & I struggled to find ways to keep our chins up & our spirits elevated. You'll see that my conclusion & action plan is less than serious, however I have started action plan 2) in earnest with White Mischief Vodka that Suzi bought me as a thank you present & that which entirely lived up to its name.

Reflective Practice

1.     Description

It was in the morning at ICU medicine ward that I thought that it was not a good day at all. I saw a lot of serious patients lying on the bed and some relatives standing beside with worried faces. I took a look outside and I saw one patient surrounded by nurses, student nurses and some patient’s relatives crying and saying “Please help.” I knew that one patient was dying. His wife cried without releasing any sound because she was too depressed. Sooner or later, her husband died. Some nurses came and took back some equipment that was used before the patient died. I heard one student nurse’s voice. It seemed she was crying. I listened seriously and I could understand that she was laughing.

2.     Feeling

 I was really unhappy with his death and I felt so frightened because I haven’t seen people dying much. I imagined that if I were in that situation or if I were his son, what I would be like. However, I tried to convince myself that it was human life, dying is inevitable and it was so common at the hospital. What I really didn’t understand was that why the student nurse laughed while others were crying. I was so upset with this misbehaving.

3.     Evaluation

I did think that what the student did was not very polite. Even there was something that very funny, she shouldn’t have laughed while the patient was dying and the relatives were crying. It is not acceptable for me and other people

4.     Analysis

In my own inference is that the student was not paying much attention on working but on other thing else. If she really had paid close attention, she wouldn’t have laughed in front of patient. She would have felt like me if she had put herself in the situation as I did. I don’t know if there are any principles for doctors and nurses or not. What the nurse must do and what the nurse mustn’t. For example, doctors and nurses mustn’t behave in any ways that can make patients feel insecure or embarrassed.

5.     Conclusion

The student nurse’s mistake was laughing in front people crying. When people see someone laughing when there is another person dying, they will think that the laugher doesn’t give any value to life. He or she might think that life is not important. The student shouldn’t have laughed but should have shown that she also felt sorry for the death through facial expression or direct talking to the patient’s relatives.

6.     Action plan

I  know that this mistake or even more mistakes will be made next time, hence  if nothing can be done it would result more badly. I am just assistant who doesn’t have much power to effluence people in the hospital but my boss does, not entirely. It is a good idea to tell her about what I have seen and not so appreciate. I can tell her to tell to the nurse, not a form of blaming, but just giving some explanation of what nurse must not do.

Reflective piece

Description of the event

V & I went to ICU medicine on Monday morning and found a man on a trolley on the veranda in the sun. There were 3 student nurses taking his observations but it was clear to me that he was cheyne stoking & about to die. V said to me “it is not a good time to be here”, and I replied, “this is the best time to be here”. I asked V to try & find out what the story was. His wife told us he had been hit with a stick in the abdomen 10 days ago. There was no doctor seeing to the patient but Mr S came out & gave him some oxygen & brought out the suction machine. V translated to me that one of the nurses had told the family to tell the tuk tuk to stay as it could take the body away once he died. I knew that there was little I could do to save this patient & so instead afterwards I engaged in a conversation with the staff about triage & having a designated resus room for patients such as this patient. This was met with hostility & aggression. One nurse who had not moved from her seat in 15 minutes – just sat doing nothing - told me they were “too busy” to have triage & a resus room. Eventually Dr L arrived & we had a conversation, which was not aggressive or hostile but ultimately did not alter the outcome for the patient or how the ward is run.

Feelings & thoughts

Situations like this occur everyday for me here; I am left feeling impotent & useless. Firstly I am restricted, especially in an emergency situation where time is limited by inadequate communication & slow communication through a translator, also the staff will often not do what I ask or reverse my actions such as speeding up IV fluids. I feel helpless & inadequate; even though I know that this patient was past saving I feel I have let him down. It upsets me that a dying man only had 3 student nurses doing his observation with no trained staff coming until V & I appeared. The staff, it seems to me, just doesn’t care about patients & are happy to let them die without dignity, then pile them back on the tuk tuk that brought them. They never talk kindly to the family, show compassion or any evidence that they care. I find it hard to capacity build staff that bear little resemblance to my own ethics. I struggle with the balance of showing the staff respect in their workplace & wanting patients to get better care. When V told me “it is not a good time to be here.” I felt angry as I misunderstood what he meant & thought he was telling me that as the staff were busy we should leave them alone. I get very angry when the staff say they are busy because even at their busiest they do not work as hard as staff in the NHS on an average day. They say they are busy when they are sat watching karaoke on TV & doing no clinical work – this drives me mad. I know that they earn very little but my sympathy is with the patients & not them. This event leaves me feeling like a failure because although I tried to use it as an example of the importance of triage & resus I feel I failed to have ay impact on the patient’s outcome or future improvement of clinical care.

Evaluation & Analysis

I think that it was good that we stayed & tried to make something positive out of the patient’s lack of treatment & death. I am learning to ask V what he means as often things are lost in translation. I feel I could have been more proactive to try & get a doctor to come or move the patient to at least inside the ward instead of dying out on the veranda in public display.

Situations like this make me feel so impotent because in my role In the UK I would be leading the resus & staff would be listening to me & acting on my requests. Here I can’t even get an adequate history from the patient – in actual fact Dr L told me after that the patient had liver cirrhosis & ascites.

Sometimes I think the apathy of the staff is contagious & I am slow or reticent to act as I feel the same sense of hopelessness they have. After many times of trying to engage the staff & direct them towards better care & failing one becomes less inclined to try. Also it is hard to capacity build absent doctors.

It is my tendency to take on the failings & inadequacies of others – this is not good. I should only consider & take responsibility for my actions & behaviours.

I talked to the family.

I tried to engage with the staff around the patient’s bed.

It was too late for me to intervene to save the patient & there is no post resus care available here if I had successfully resuscitated him.

I spoke with the head of service after and tried to put forward positive changes rather than criticize the lack of treatment.

Conclusion & Action Plan

I think I can conclude that working in health in Cambodia is very challenging; staff do not care or do not want to listen to me. The patients keep dying despite me being here & the changes (if any) are so small & slow that I can not detect them.

My options are;

1)   Carry on calmly, trying to intervene in patient care & capacity building by role modeling despite the wall of hostility, resistance & active ignorance from the majority of the staff.

2)   Develop a drinking habit to help me through the working day.

3)   Go to a different hospital or work with other organizations some of the time so I am in the environment of the referral hospital less.

4)   Leave – go back to a well-paid job in the UK or Australia & leave the capacity building to the grown ups.

I am leaning towards a combination of 1), 2) & 3)!!!

Dear Esther & Kristy

I spend quite a lot of time on this blog describing the difference between mine & Cambodian culture in a less than non-judgmental way. There is a book that is given as part of a VSO volunteers welcome pack which was written by an ex-volunteer (Jenny Pearson) & her Cambodian colleague at her NGO (Leng Chhay). It is called 'Working in Cambodia' & gives both Cambodian & Expatriates perspectives on living & working together.
My VA V (my third & hopefully last although there is a threat of a forth on the horizon) has started doing reflective practice writing to help his written english & to help both of us make sense of our experience at the hospital.
This week I was away doing health facility reviews & training whilst V had a wisdom tooth removed. I suggested to him he could write a piece on what it is like working with Kristy (an australian volunteer with VIDA, she is a lab scientist & has been here the same length as time as me, we share V part time) and me.
Below is the result - its not 'Working in Cambodia' but it made me smile, laugh & shed a tear. His english you will see requires little correction & I'm sure the sentiment is more than a little coloured by his tooth extraction without adequate anaesthesia. I think he feels the same way about the hospital staff as Kristy & I do but he has a special ability to convey all that in few words  e.g 'I work for her but she works for nobody'.
If someone can explain why it is 'both my bosses' but 'my two bosses' in grammatical rules & terms that would be really helpful.
Enjoy.

Dear Esther and Kristy

I do understand that my both lovely bosses  really look forward to seeing my piece. I am so sorry for delaying in writing it because of time barrier or perhaps they would say because I am lack of commitment. I have found that working with them is very good and enjoyable. First, I want to express something that makes me happy. Esther often goes away to have trainings and meetings. So I have some more days off. I can stay home, read some books, wash my clothes and sleep. Both of them always motivate me that make me feel more confident and warmer in working with them and I feel like I am having a new family. Every day, I can practice speaking English with them. Before I found that listening to the foreigners was very hard, especially my lovely boss Esther, but now I find listening to Cambodians, who speak English, is harder to understand because of their pronunciation and fluency. I have learned a lot about slangs they have taught me and  from two books that they bought for me. I am very happy for being loved and paid attention. On the other hand, I also think that I understand nothing about what they are saying. When they meet to each other, they talk too fast and use most slang language and I just smile and try to catch their words. They ask me “Do you understand V?” I usually say that I don’t understand even I understand some parts. When Esther talks accompanied with gesture, I always follow her. It becomes my habit. One day I thought that it was very funny for myself. I wanted to laugh but I tried to control it. One Cambodian man was making conversation with Esther he also was scratching his bottom. After he finished speaking, I started translating what he said. I didn’t know why I unintentionally scratched my bottom. I really wanted to laugh but I couldn’t. Another example, while the blood transfusion lesson was being  taught, one nurse started to ask a question. While she was asking her hands were playing with her purse. After she finished questioning, it was my turn to translate. I immediately took her purse and I realized that it was money. I suddenly put it down. Now I want to tell about working with Kristy. I  don’t think I work much in verbal translation but written the most. In the beginning I found it was very difficult. I usually asked for help from her and other Cambodian staff. But now I feel it is quite easy and I know a lot about laboratory terminologies. I usually try to cheer her up because I do understand that the working environment in the lab is very boring. I think that I work for her but she works for nobody. I am really sensitive to my both bosses’ mind. They really try to make improvement but they usually don’t get much support and good collaboration. To tell the truth since the beginning of my work, I have treated both of them as my second family. They are so good to me. I do love them equally.

However, when god lets people know each other and stay together, he usually separates finally. Kristy is going to leave so soon. I am so unhappy about her leaving, but I am happy that I can know her and work for her. She and Esther  always encourage and forgive me. Today is Monday when I had tooth operation. I need to finish writing this piece because I can’t do other things. I am resting at home. I don’t know when I can go to work for them.

Finally, I am so grateful to them for my tooth operation payment, for your compassion and for good consideration. I will try my best to work for them and support them in any forms I can. I want to say sorry in advance if I have made any mistakes in this writing.

Love You,

V

Blind them with logic

To say I am having some difficulties being respected or my medical skills & expertise acknowledged by the hospital staff would be a gross understatement. It's not enough to calmly discuss with staff evidence based practice or use logic & reason. Like with a stroppy, hormonal teenager rationality doesn't appear to work here.

There have been only two occasions in the last year where I have momentarily silenced the torrent of defensive abuse & excuses from the staff & seen the look of recognition of a sound logical argument & almost heard the penny drop. This of course is short lived and is followed by rebound excuses and hostility.

The first occasion was just a few weeks ago when I presented a CPG (clinical practice guideline - the existing MoH guidelines are dated from 1999 so are currently being updated) on organophosphate poisoning (OP), a common overdose & method of suicide here. In the CPG it describes the cholinergic syndrome that occurs with OP - another great mnemonic opportunity SLUDGE (salivation, lacrimation, urination, defeacation, GI upset, Emesis). The CPG clearly states that Atropine - the antidote - should only be given if a patient has signs of a cholinergic syndrome AND NOT just pupil constriction.

This revelation started Dr L on a pompous rant about how ridiculous this protocol was because at least 90% of the patients they see with OP in ICU never develop signs or symptoms of cholinergic syndrome yet they will all still receive Atropine.

The current situation is that any patient who claims to have ingested organophosphates receives large doses of Atropine, the side effects of which include agitation & hallucinations. The end result is the patients being physically restrained for at least 5 days.

Calmly I proposed to him that perhaps another way of looking at this would be that the 90% of patients with OP that don't develop symptoms & signs of cholinergic syndrome DON'T need Atropine therapy.

There was a full beat of silence, then a full moment of quiet contemplation by the whole room. Finally Dr L countered - but what harm is there in giving every patient (regardless of indication) Atropine for 5-7 days?

My response - Atropine has very unpleasant side effects & results in hospital staff tying patients to their beds in direct violation of their human rights - that one got a laugh. Nothing funnier than a direct violation of human rights.

The second occasion was this week when I was in negotiation with HS regarding a 33 year old woman who was dying a slow, painful & undignified death on his surgical ward. I was gently trying to explore issues around palliative care - this woman had no analgesia or sedation prescribed, she was unable to eat or drink & had poor mouth care. Invariably however one tries to discuss patient care - mitigating for a saving face culture & fragile egos - there is always a defensive response.

Again calmly (this is a great strain for me with my usual highly excitable state) I asked him not to get angry and we were just discussing the best care for a dying patient. After hostility usually follows a hopelessness/helplessness response - "I can't do anything, its beyond my capacity, we don't have the resources....etc.etc."

An idea is commonly floated by the hospital doctors that I should just write in the notes & stop talking to them. It has been pointed out that as I would be writing in english none of the nurses & few of the doctors would be able to understand what I had written. Of course there are more fundamental reasons why I object to this suggestion which I carefully & calmly explained to HS.

If I write in english in the notes - nobody reads, nobody understands, everyone ignores. If I see patients WITH a clinician & then have a conversation where ideas are explored & challenged then perhaps I will change their attitude, better still maybe when faced with a similar clinical situation in the future they will change their behaviour.

HS looked at me long & hard as he processed what I had just said, then with a look of resignation - blinded by logic - he took the patents notes from me and prescribed analgesia, sedation, IV fluids & basic nursing care.

The woman died later that same day.

Ants & Epipens

From time to time my medical skills get called upon, generally this does not happen in my role as a VSO medical advisor but more often than not as an ad hoc GP to other expats.

Last weekend I was overcome by an overwhelming lassitude that only later I identified as a fever in the tropics. But as my medical skills are so rarely called on or respected I just thought I was a little tired so took the opportunity to sweat quietly on my sofa & watch Bridesmaids for the umpteenth time & skype my friend who is practically a neighbour now in Singapore.

I missed a call from L whilst skyping so called her back - she was ringing to tell me that her husband A had been bitten by ants. Not enormous fire ants or monster ants just little black nondescript ants, but he has had a previous reaction to them & this time it was a lot worse. He didn't have any antihistamine in the house & L was in Phnom Penh. I said I would go & check up on him with some antihistamine tablets. Being a true doctor I then rang J - a nurse - who lives just around the corner from A & has a moto, I live a 20 minute cycle ride away & do not own a moto - asking her if she could go and administer for me.

J was (like a true Cambodian nurse) having her nails done & previously had missed a call from L & had ruined her nail polish trying to find her ringing phone in her bag, so was having a touch up when I called. She agreed that once her nails were dry she would moto around with some medications.

L called me back to tell me to go quickly as A was feeling worse. I called J to tell her that her nursing skills would not be effected by tacky nail varnish and although I was now going perhaps she would be faster than me. I text K 'duty calls' and cancelled our previously arranged coke & cake date (we live it up wild here in the 'Bang).

I called A - he answered & told me he didn't feel too well. This was useful as I could ascertain that he had an airway, was breathing, had no stridor or wheeze and had enough circulation to perfuse his brain & hold a phone - my medical skills came flooding back to me.

I peddled away in haste in the hot season sun & was half way to A's house when I received a call from J to say although A was having a severe allergic reaction he was still alive & she had administered an antihistamine tablet.

I stopped off at a pharmacy to try & acquire an epipen as I was anticipating an anaphylactic reaction - can't believe I was kicked out of the girl guides - always prepared. I wrote ADRENALINE on a piece of paper. The girl typed it into her computer - it is a rather swanky pharmacy which is new & replaced a rather lovely iced coffee place opposite the hospital. Even though the computer said 'yes' - the girl said 'no' or rather gazed blankly at me with her mouth half open not comprehending. This went on for several minutes.

I cut my losses & headed on to A.

I arrived to find A looking rather flushed & covered head to toes in urticaria with a pulse that felt better when we sat him down, when he stood up he kept telling us he felt rather strange.

J looked rather flushed also & was openly relieved to see me despite me having nothing to offer - its good to know I can still generate an false atmosphere of calm reassurance.

Within 15 minutes A was back to his normal colour & felt much better, J's nails were dry & I had stopped sweating. A refused further observations & said he would call us. J went to have a khmer lesson & I went in search of adrenaline as it occurred to me this might still be a good thing to have - ants are every where here (x-ref 'resilience - study'). After several pharmacy visits by me in Battambang & L in Phnom Penh we concluded that Epipens do not exist here in Cambodia. Plan B is insulin syringes & 1:1000 Adrenaline which comes to the great sum of $2 for 10 sets.

I fear that my pre-occupation with the lack of epipens may be masking the slightly bigger problems of the Cambodian health service.

A lives on.

A snake in the grass

I relayed this story to my VSO neighbours, they live in the same compound, the other day;

Whilst my family were visiting me for my birthday we went to J & G's house for pre-circus tea/G&Ts and cake at their house. D my favourite tuk tuk driver arrived to take us on to the circus & whilst he waited for us to gather ourselves together he stood admiring J's newly washed Honda Dream moto, he then spotted the snake. Very calmly he informed us all that there was a snake on the moto. Unfortunately there were 2 motos - G's was parked inside the gate & J's outside on the road. So we all instinctively moved towards D & J's moto - avec green tree viper i.e highly venomous.

D desperately tried to communicate with us to go back towards G's moto but it was all lost in translation & fear. Hence we all ended up within a 2 metre striking distance of said snake.

D went in search of a big stick, J picked up the toddler neighbour who was stood right underneath where the snake was coiled around J's moto's right wing mirror, G went to get salad tongs - the heroes in this story were identified.

D used the big stick to knock the worryingly camouflaged snake onto the ground where he pinned it down paralyzed by his buddhist principles which meant that he was highly reluctant to kill the snake. The local children starting to gather to see what was all the fuss the barangs were making. G returned with his salad tongs & was instantly advised by D that what he really needed was a 'very big stick'!

With all the children about & a positive ID of a potentially lethal snake plus J & my certain knowledge of the lack of any meaningful medical care or anti-venom within a 300km radius, the snake's fate was sealed.

D was unsettled by bad karma, I was more concerned about the fact that I had naively believed that these things only ever happened in the phoom (village) & like malaria, Japanese encephalitis & a life without 24 hour electricity - snakes were purely a rural experience.

'My' I told Scott & Sonia on my recounting of this story, 'it certainly has made me slightly nervous around foliage!'

And quite right it should, as I then discovered.

They proceeded to tell me that another one of our neighbours this week got onto his moto outside my house ,putting his rucksack on his back, when he felt something around his neck - yep that's right, a BLOODY venomous snake had slithered out of his ruck sack!

He wasn't bitten & (as a fellow volunteer calls it) he did the 'spider dance' so that both human & snake escaped unscathed.

This is a message to all venomous snakes living in South East Asia - you stay outside, I'll stay inside and we can both just respect each others personal body space.

Thinking about these stories still gives me goose bumps even in 40˚C heat.

I would be lying & equally not proud if I told you that no snakes were killed in the  making of this blog

Bicycle repair man

There is a bicycle repair man next to the hospital who due the general state of dis-repair of my VSO bicycle is often visited by me. He has mended punctures, replaced leaking valves, tightened brakes, loosened brakes, put chains back on, tightened chains and of course pumped up my tyres (in a constant state of deflation) - he even has an adapter for the front tyre valve something a lot of the other roadside bicycle & moto repair stops don't offer.
I think of him as my granddad but in reality he is probably younger than my own father. He speaks no english & barely understands my 'unclear' khmer.
He started off charging me barang prices for repairs but recently he has been giving me freebie tyre inflations which has made me feel uncomfortable. In reality I'm talking about R200 which is 5 cents or 2p but he is doing a job & I feel I should pay.
This week I noticed my bike had started making a new interesting noise & on closer inspection I discovered I had lost a pretty essential nut and my bike stand, then back mud guard and then finally back wheel was migrating west from the bike frame. This also explained why my chain had been slipping.
I went to my bicycle repair man who was asleep & was woken from his siesta especially on my account. He proceeded to secured my wheel back into its proper position, then the mud guard & finally the stand, replaced the nut and secured it tightly for me. When I asked him how much he shooed me away.
Then I did something culturally inappropriate - I made him take some money.
I knew it was wrong but my discomfort of not paying yet again for his services was higher than the discomfort I felt for doing the wrong thing culturally. I gave him a dollar. He was deeply offended but I felt better.
When I told this story to Dr H he chastised me & told me I had been wrong (but this is a position I am very familiar with) - he told me that the people with the least are often the most generous - ain't that the truth.
I'm left struggling with accepting the kindness of Cambodians & seem to repeatedly fail to adequately reciprocate others generosity.

Mind the culture gap

Warning this blog contains strong feminist sentiments & mild rage

One of my favourite people here in Cambodia told me yesterday that I should stay in Cambodia forever & that he would find me a husband. When I gave my standard response (it's not such a rare conversation for me to have here) that I am too old & all Cambodian men within a 10 year radius are married, I was told, in all seriousness, that he knew plenty of MBAs - 'married but available'. Once again (at least a daily experience here) I heard that familiar voice - it's an automated recorded public address system in my head - that tells me "please mind the culture gap".

I've been told by someone I respect greatly that there are no gender issues here in Cambodia & to him & every other older, white male that thinks the same, I say politely & respectfully - you are all very wrong. I love a good culture gap but when it effects women & children and prevents me being effective in my work then I begin to struggle to revel in human diversity.

I'm not sure where to begin listing all the ways that the gender culture gap impacts directly on me daily without turning this blog into a feminist rant but I will give a go.

Because I am lacking a 'y' chromosome nothing I say has any worth. Maybe this was also the case in the UK but it's only now that it has become apparent to me. Often a person with a 'y' chromosome will repeat what I have just said but without any training or experience and will be listened to because he is the 'right' gender. (This is a common experience among female NGO workers in the hospital & not my own paranoia honest!)

I was put in my placement because I am an emergency specialist to help develop a new ER. I graduated from medical school in 1996 & I got my fellowship from the college of emergency medicine in 2008 yet one of the staff from the NGO I work closely with wants to send trainee emergency doctors to my hospital (residents/SHOs/ST3 call them what you will) because they think it would be better then me to train the staff on emergency care - guess their gender (NGO worker & residents!)?

I have been at my hospital almost a year & still don't get invited to hospital management meetings as "what could you possibly know?" - another previous VSO volunteer was invited to every meeting right from the start of their placement - guess their gender?

A first year student nurse told me I didn't know anything about prescribing charts & blood transfusion during a training session. When I told them I had been qualified for 16 years & worked in 4 different continents so had seen prescribing & blood transfusions from a few different angles rather than his extensive 6 months training in one hospital - that didn't seem to cut it. Guess what gender?

My ex-VA told me they didn't consider me their manager but did consider the male volunteer I shared them with their manager. This, I was told, was because women weren't 'bosses' in Cambodia & my VA didn't like working for a woman as it made them uncomfortable & it wasn't right. This unsurprisingly impacted on my work. Guess the gender?

You get the point (I hope!)? I could go on but I'm boring even myself now. My irritation with some sexism in the workplace is not the issue however, what really enrages me is how Cambodian women are treated.

There are only 3 female doctors & 3 female medical assistants out of the 38 Doctors at my hospital but at the morning meetings they sit on plastic chairs around the periphery with all the female nurses, whilst the men (nurses, doctors, managers) sit around the table in chairs made from the decimated hard wood forests of east Cambodia. It reminds me of being back at primary school, pushed to the edges of the playground at break time whilst the boys dominated the space with football or british bulldog.

Globally male children tend to be given preferential access to education & health.

My ex-VA proudly wrote in an essay that Cambodia had the lowest rate of domestic violence in Asia. I was proof reading his work & had to point out to him that it was the lowest "recorded" rate of domestic violence but perhaps other Asian countries had more reliable systems to record it or that violence & abuse of women was not culturally or socially acceptable in those countries.

And then, this is where this rant has been heading from the start, we come to the sex trade. Never have I been to a place where the exploitation of women is so ingrained into the culture & acceptable, although it could be argued I am very poorly travelled.

Of course married men have girlfriends, of course all men go to karaoke (I'm talking 'beer girls', not innocent, bad singing), and naturally most men use prostitutes. I have had many an interesting conversation with cambodian men who simply can't understand what my problem is with this.

In their defense they tell me that they married their wives young & they weren't love matches. Often they tell me their wives aren't even educated past mid-primary school level therefore they are 'stupid'. 'Really?' I ask, or are they just lacking in opportunity & never had the chance to realize their own potential.

I knew from the start I was living in a patriarchal culture here but it took me a year to settle on the word that captures it better - 'misogynistic'.

Today I was given a Sampot for international women's day from the hospital. At the same time a colleague was told that perhaps because it was women's day she could put on a skirt & wear some makeup!

Next year a better present would be to know that globally all female children are educated to secondary school level, that money is spent on their health equal to their male siblings or they are allowed to be born without being terminated for being the wrong gender, that they are not forced into marriage, that they are not exploited & trafficked in the sex trade & that men realize that this goal is not detrimental or a threat to them. One of the biggest interventions to international child health is educating girls to grade 11 - their children (male & female) have significantly better health outcomes as a result.

I know some strong inspirational Cambodian women who are doing their best in a very difficult environment, may many more join them.

There is a book which I strongly recommend everyone to read - "Half the Sky"- Nicholas D Kristof & Sheryl Wudunn have explored all these issues with more knowledge, research & definitely a lot more eloquently than I ever could.

Meanwhile back to my marriage proposal - I told Dr H if he could find me a Cambodian man who wasn't threatened by an intelligent, independent women and who would not have multiple affairs, go to karaoke & use prostitutes. If he could find me a man who didn't exploit or disrespect women and was single, then I would marry them.

There was a pregnant pause.

Then laughing he told me "But Esther that's impossible - in Cambodia that man does not exist"

I rest my case.

I'm off to start reading Wangari Maathai autobiography - 'Unbowed - One Woman's Story' - Thanks Ingrid.

A khmer wedding

Like visiting Angkor Wat my first invitation to a Khmer wedding came late. Ratha works as a local expert for GIZ at the Hospital and got married last weekend in Kampot, he was the first (& probably last!) Cambodian to invite me to their wedding. I leapt at the opportunity because although I have sworn against ever going to a wedding again on philosophical & ethical grounds, an overseas wedding falls under section 3.2 of the special circumstances amendment.

So the first thing to say is that my only experience of Khmer weddings to date has been the noise pollution & road obstructions - they are generally located in a makeshift tent construction blocking major thoroughfares and are really quite noisy, like dust, sweat & heat exhaustion they tend to only happen in the dry season (at any auspicious time of the day). They are bling affairs & I was very concerned about the dress code, in case you haven't noticed I am not a size zero (as most Cambodian women are) and when I wear makeup I look like a drag queen, so the sequins and frills of traditional Cambodian wedding dress-code filled me with dread.

Thankfully N (x-ref 'The kindness of Cambodians' blog) was J's & my cultural ambassador for the weekend & she said western dress, moderate makeup and comfortable shoes was allowed. However Janice hadn't opted for the comfortable shoes and Kampot appeared to suffer a severe shortage of Tuk Tuks on the evening of the wedding hence we arrived from our guest house with one of our party limping barefoot through the foliage to the side of the entrance rather than the more traditional red carpet route.

In the photos below (a combination of mine & E's) I have failed to convey the vast array of outfits modeled by bride & groom. Also impossible to convey is the stifling (unseasonal) heat or the wall of sound. 

In my limited knowledge & experience a khmer wedding (reception) goes something like this;

• Guests arrive - start time flexible & not necessarily kept to, they find their way by following the palpable vibrating bass & when closer deafening music of wedding band & mega-amp
• Bride & Groom with there families sit outside under a huge heart shaped arch with a massive photo-shopped picture of the happy couple, greeting all guests - this appears to go on for most of the night with outfit changes for the happy couple being the only release from reception duty
• Barangs are treated like royalty
• Tables with 8 seats fill up and then are served when a full complement has been achieved food is served - I had been warned about intestines and other such delicacies with associated  gastrointestinal badness but the food was absolutely delicious. (and anyway noodle soup with intestine, liver, lung and guess the anatomical part has become my favoured breakfast)
• Beer is drunk diluted to homeopathic concentration with ice
• Dogs wonder around foraging through the increasing pile of food debris on the floor
• Everyone gives their envelopes of money as a present to the 'accountancy' table or groom
• Street kids beg used cans and left over food - soft hearted NGO workers give them full cans (of Fanta not beer, although alcohol is probably a lot better for them than the e-numbers in the fluorescent green Fanta) and bags of food until one of the waiter shouts at us and hits the children with a big stick
• Some guests eat and drink their fill & just leave
• Most guest stay to watch the "Cutting the fruit" ceremony - like cutting our cake our cultural ambassador informs us
• Bride & Groom in their umpteenth but last outfit walk around some fruit on a table
• Barangs are dragged to stand (pride of place) close to the parents
• Petals are thrown
• Party string-spray is sprayed
• Fruit is fed to the parents
• Champagne is shared by the couple
• An apple is eaten (x-ref Lady & the Tramp spaghetti scene)
• First dance AKA humiliate the Barangs (unfortunately no photos exist of this and even if they did I certainly wouldn't blog them. Drunken friend of Ratha gets up on the stage and thanks the foreigners for coming and says to bless the wedding we must dance. Dazed and confused initially J & I slow dance with each other next to the bride & groom until two unwilling drunken males are dragged by mother of bride - quite literally - on to the dance floor AKA main road to Kep and are forced against their will to dance with us. J - now quite crippled by her 'Beautiful' but not comfortable shoes - proceeds to repeatedly step on her young suitors winkle-pickers, whilst my reluctant dance partner crushes me with his two left feet holding me at arms length by my elbows. Anyone who knows me will know that dancing at weddings is something I only ever do with enough alcohol in my system to induce amnesia requiring photographic evidence as proof/reminder or pike-jumping off a stage to Fame when I am 9 years old. Drunken friend of Ratha was thrilled and there were plenty of thumbs up in our direction. J by this stage has bleeding feet & is distracted by the pain. My pain is more psychological so I do what any Wilson family member would do & tried to strike up a conversation with my dance partner. Despite attempts in khmer, english & sign language I was unsuccessful. It was a very long song the band sung that first dance. After an age it finally came to an end & in perfect english my dance partner thanked me for the dance & then he & his friend ran off the dance floor giggling like girls or in these parts like Cambodian men.
• Traditional Cambodian dancing in an anti-clockwise fashion around a table with a pile of fruit on it - if only the Barangs could have escaped as quickly as their reluctant dance partners but our humiliation was not quite over and we had to endure more dancing whilst sober. I can't bloody do it either, it looks easy but walking around a table whilst doing stuff with your hands that represents an opening lotus flower is a lot harder than it looks. Meanwhile E looks on with her boss, she  suggested to him that  they should join us & share the pain. A direct order from her boss kept her seated!
• As the dancing kicks off & J's feet gently weep we decide to make our exit - leaving the wedding to the increasing drunken men and their long suffering wives
• Ratha's brother bundles us into his car for a lift home just as the drunken friend of Ratha gets back on stage with the microphone declaring that "the foreigners need to come back immediately & dance some more! If it wasn't culturally completely inappropriate I would have given Ratha a big hug at this point.

The following morning at the start of our 11 hour bus trip home we drove past (or technically over) the location of the wedding party & waved to a tired looking Ratha & his bride with family stacking chairs & tables and at the start of their hopefully long journey together.

N, me & J - an island of underdressed-under made-up-ness

This fails to capture the heart-shaped arch entrance but after N shouted at the camera man to switch off the lamp it is at least not back-lit 

J's dress complimenting with the bride & grooms outfit of the moment

The kids prior to the stick hitting incident

Our table buddies - the one of the right never cracked a smile for the entire meal. They left after eating hence missing J's & my dancing humiliation - surely that would have brought a Mona Lisa smile to her face!

Moments before the shouting and big stick

This photo was taken to demonstrate the rubbish but on closer inspection it also demonstrates the Cambodian males habit of not only using all the ground as a bin but also their urinal - this also drives me crazy but I'm sure Freud would've just said I had penis envy

Walking around a table with fruit

Location - half of main road from Kampot to Kep

My foot after two left feet had been all over them for what must have surely been a 15 minute slow song

One Picture can say a thousand words...

Plasters purchased from a Cambodian Pharmacy