Valuing health workers

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.

Cambodian exceptionalism

Visiting a friend in Washington a few years ago now I was first introduced to the concept of American exceptionalism. What I didn't realise is that this same concept can be applied to any country - including Cambodia.

What makes someone or a whole nation feel that they are exceptional? Imperialism, insecurity, positive affirmations, ignorance?

As previously blogged about before "This is Cambodia!" is a common response to any suggestion of deviation from the status quo.

The best example of this that I can think of is the time I was training a group of nurses about sepsis & what was considered an abnormal temperature. One of the parameters that can define Sepsis is a temperature above 38 ˚C or below 36˚C - the whole room shook their head in disagreement. They didn't consider these the normal parameters - Barangs I was told have a lower body temperature because they live an a cooler climate. I tried to explain the concept of homeostasis & homeotherms but Cambodians are different & have a higher temperature than other nationalities.

Another favourite is midwives will also tell you that Cambodian women's perineum is tougher & thicker than other nationalities so they all require episiotomy at all deliveries.

Cambodian doctors can't spend any time taking a history - it takes too long.

Cambodian nurses can't be expected to perform basic hygiene for patients - they are too busy.

etc. etc. etc........

The list of exceptions is a long one, after all - This is Cambodia!

A well needed break

I'd say this is the 2013 WPC shortlist but after another year of not even a special commendation for my entry, my hopes are not high.

Myanmar was beautiful though & below is a little taster of my well needed break......

Yangon - Shwedagon sunset

Irrawady view 

Irrawady Sunset

Bagon Temple

Restoration at Bagon Temple

Bagon sunset

Monk teacher at Golden Palace

Monks enjoying the view from Mandalay Hill

Amarapura teak bridge

Amarapura Boats

Amarapura agriculture 

Amarapura ploughing 

Monk at Amarapura Monastery 

Inle Lake 

Bamboo shed

Inle lake

WPW - part 3

M is 17 year old girl that lives in a village one hour away from Battambang. Her family, like 70% of Cambodians, is poor & lives a rural existence. Her father can no longer work after an injury sustained working in a factory. He now, with her mother, farms their small piece of land. Her older sister works in a garment factory in Phnom Penh. M was working illegally in Thailand in construction when she developed her tachy-arrhythmia that I have written about previously ('WPW - what patients want'& 'The best thank you'). Her family could not afford the medication she needs for one week let alone her life time.

F had told me about a Cambodian cardiologist - Dr C - that could do an ablation which would prevent the same life threatening arrhythmia happening again. I emailed him & he told me the procedure would cost $1000 but I anticipated there would be many hidden costs. Rather than organise it over email or phone I arranged to meet him face to face where he is based, the next time I was in Phnom Penh.

Of course when I arrived at the specified date & time at the hospital he wasn't expecting me but looked at her ECG & told me to bring the girl to him immediately & he would do. I tried to explain to him that she was very poor & still at home. I needed to have an idea of cost as I would have to fund raise that amount. He told me I could just pay for it afterwards & he was happy to defer payment to do it as soon as possible - he said it was urgent. I could tell that as I was barang he thought that I could easily cover the cost (currently I can barely afford to cover my mortgage in the UK!) and he didn't even acknowledge that I was a doctor, drawing a child-like diagram of the heart & talking in condescending tones. Even when he asked me what I did & I explained I was an emergency medicine specialist the tone remained. Perhaps it was my gender or/& my volunteer status. Maybe it was just him.

Either way I set about arranging for M to come down to Phnom Penh the next day for pre-op work up & to have the procedure the following day. The day after that I was flying to Myanmar for a well needed (if not deserved) holiday. Thanks to D (URC office BTB) & lovely L (my VA) after numerous phone calls they had booked M & her Mother on the first bus to Phnom Penh the following morning. Daneth paid for the tickets (I still need to pay her back) & we had to negotiate only one family member accompanying her. Initially they couldn't get the early bus as the family doesn't own a moto and have to rely on a neighbour to take them into the bus station. After some to-ing & fro-ing we worked out that she lives on the route to Phnom Penh but as they had never used a bus (too expensive) they didn't realise the bus could stop & pick them up on the way. She needed to get down to Phnom Penh in order to see Dr C in the afternoon.

I spoke with URC's health equity fund (HEF - health insurance for poor patients) about covering transport & food costs - they arranged for someone to meet me at the hospital to help organise payment. For user fee & treatment costs this was not covered as the hospital does not have an agreement with the HEF, I managed to secure donations (I am really not a natural fundraiser) from a friend of mine from medical school, my old friend's sister, J's oldest friend & a few others that wish to remain anonymous.

A very BIG thank you to Ruth, Hannah, Elaine (and anon +) - you really have restored my faith in human nature & your generosity astounds me.

The following day there was an anxious wait & a few more phone calls to ensure that the bus driver stopped & they were on the bus. I thought this would be the biggest hurdle - I was very wrong.

L & I had to leave our VSO workshop to meet them off the bus & take them to the hospital. They wanted lunch but I just wanted to get them there first to make sure Dr C's promise was good. Dr C was there but seemed only interested in showing me a powerpoint presentation of all the ablations & research he has done. He didn't even look at M or say hello to her & her mother - well she is poor after all!

Whilst she had an ECG & bloods taken I went with L to get water & some food for their predicted 2 day stay. I also gave them a little bit of money for buying more food but I planned to come again tomorrow as I didn't want them to have too much money on them. If they didn't have money then they couldn't pay the bribes.

A person from the health equity fund came to meet me so we could discuss payment with administration. The admin people were rude & arrogant - this is a mild description of their behaviour & attitude. They refused to allow deferred payment at first despite me insisting that this is what Dr C had agreed. Eventually after emptying my cambodian bank account so I could pay the user fee - initially quoted as double what it actually should be until I bartered it down - I left with the understanding that treatment, investigation & other costs could be deferred 48 hours until I had sufficient funds to pay on Saturday morning. After the 40 minutes of negotiation I was given a pack for M of toothbrush, soap, comb & flannel - I hoped it would be worth it.

I felt really uneasy about leaving her & her mother alone there - my instinct was accurate.

The following day L called M who said they wouldn't do the procedure as the staff were waiting for me to come in to pay first. I rang Dr C & he assured me that he would do the ablation at 10 am & I needed to arrange with admin deferred payment. I explained I had already paid the user fee & arranged deferred payment with admin so surely it was all systems go.....errr no actually.  At 9 50 am Dr C called me saying "you come here now & pay $1000 or I will not do at 10 am and she will lose her slot. I will keep her in hospital for a very long time which will mean you will have to pay a  much bigger bill at the end". I calmly pointed out that this was slightly different to the promise a day earlier that he would do without payment & was happy to defer or the arrangement I had already made with admin.

This is Cambodia. No money, no life.

I asked L later - In Cambodia do you go to a restaurant & pay for the fried rice then eat it after?!

I called Jn, from URC, who arranged for health equity to go & pay as admin were now requesting - they paid for the user fee again plus treatment. By this time however she had missed her slot but after further phone calls it was established she would have the 1 pm, which didn't actually fit with the earlier threat from Dr C. Funny how money talks & what it says, here in Cambodia. This makes me sick - quite literally - I get palpitations & chest pain still thinking about this whole incident - I'll be the one needing an ablation next!

At 4 pm Liong told me that M's mum had called and "She has not had it done yet!" - I went ballistic. As we were in the middle of the VSO workshop I took  outside to get further details. Translation error - I had to explain to L that "She has not had it done yet" is not the same meaning as "She isn't out of surgery yet"! We both anxiously waited to here how it had gone.

After the workshop L & I hurried over to be greeted by an anxious mother - 5 hours & still no sign of her daughter. This could mean one of two things; 1) the procedure was technically too difficult for Dr C to do or 2) there had been a complication (as a doctor I am including death as a complication). I was being increasingly aware that the more time I spent at the hospital the higher the final bill would be. I texted Dr C who I presumed was busy in theatre with M. We waited with M's Mum - I tried to be reassuring. I rang J & ranted down the phone at her about the Cambodian health service until my credit ran out.

I received a text from Dr C - he could not successfully do the procedure it had turned out to be too difficult but he assured me that in February an American cardiologist was visiting and would do it then for free - but there is no such thing as free health care in Cambodia I have learned.

Before going to the airport the following morning I went early to the hospital to visit M & check on her well being, also I wanted to make sure they had enough money for food & transport home. The first thing I was presented with was a bill for investigations that I thought had been paid the day before, a little bit like the user fee. I was beginning to feel like a walking $ bill. No one had spoken to her about the result of the procedure, future treatment plans or asked her how she was feeling, so I did that too. Regarding payment they had been previously told by the HEF that they should not 'bother me'. Regarding payment I suggested they called HEF & just to be sure got L to do it before I left for the airport. I also called Dr C who said she needed to stay another day as she had pressure bandages on both femoral arteries - ker-ching!

I met a friend at the airport, who the evening before had been visiting the same hospital & had mentioned to a member of staff there that she knew me - "Oh! Is that the doctor from England that pays for treatment out of her own money?!" had been their response. Neither true or what I really want people to think about me.

Whilst we had breakfast together & caught up - concluding that our destiny was to grow old, remaining single & childless, meeting to discuss international health in unlikely places all around the world - I received a call from HEF saying that I needed to come to the hospital & pay another $1000. By this time I was very close to the edge of my patience with the whole rotten, corrupt, crappy situation but managed to defer him to Jn, who had calmly reassured me earlier she would sort out any further payment issues & we could settle later after I was back from my fortnights holiday & was a little less stressed!

I think L has developed a stomach ulcer during the whole debacle, I had to give her the last of my Omeprazole as I feel responsible for her work stress related illness!

M was actually kept in for a further 2 days, for what medical reason I am still not clear. She has been told to go back for a 'check-up' soon. Not sure how they expect a family that lives on $2 a day to afford the journey down & back for a clinic check-up appointment. If it is for a repeat ECG & medication then obviously as a female volunteer I am clearly totally incapable of reading an ECG or reviewing her medications.

Luckily I have enough donations now to cover the 3 months of medication she requires until the repeat surgery in February. The $1000 treatment cost ended up being $1500 & with no positive result or cure, one can only guess what the 'free' treatment will end up costing next February.

I really tried to do what I thought was the best for M but as is so common here it just came back to bite me, turning out not to be the best thing to do at all. What is left now is the hope that she will make it to February in good health & that the corrupt, flagging health care system won't fail her then.

Anyone who dares to complain to me about the NHS at the moment will have ignited the blue touch paper & should just stand well clear!

You know you need a holiday when....

Last time I came down to Phnom Penh it took me 9 & half hours by bus. This was because there was an ASEAN meeting & a certain re-elected north american president & "leader of the free world" was in town so they had shut ALL roads.

The journey hadn't started well with the discovery that my headphones were broken (the fifth set to die here) & I was therefore unable to drown out the karaoke & violent chinese films. Cambodia has not been kind to my electronic equipment, as well as the headphones I have been through 3 iPods, 2 cameras, one phone, one kindle, and had the whole bottom part of my laptop (bar the hard drive) replaced.  I am feeling slightly more buddhist about material possessions - especially electronics.

I was sat next to a man - who was actually sat in my window sit but I didn't have the energy to challenge him - who must have extraordinary enormous testicles as he was sitting with his legs so far apart he was occupying both his (really mine) & my (really his) seat. He also seemed quite insecure about his testicles too, as he had to keep checking they were still there. On the other side of the aisle was a man who was coughing, hawking & spitting into a bag for the whole 9 & a half hour journey. I think he may have TB - after this journey I suspect I may have TB too.

When R called me to say that he had left one &a  half hours before me but was now stuck at the edge of Phnom Penh because all the roads were shut for security I knew skipping lunch & not weeing at the last bus stop were both grave errors.

Apparently the knowledge that Mr President was flying in to town & that all the roads were closed had been received but not processed by the transport companies - hundreds of vehicles ground to a halt on the perimeter of Phnom Penh, there was no plan B.

R wanted to know if our gridlocked buses were close to each other so perhaps we would share a tuk tuk but there was a lot of traffic in between 10 30 am when he left & my midday departure. My mobile phone battery died. I switched to my UK mobile.

Moto drivers were asking for $10 to take passengers the last 5 km into the city, my well endowed neighbour muttered in khmer that for that price you could get the bus from Battambang to Phnom Penh AND back again. Supply & demand - the laws of capitalism.

Every hour or so we would move to a different place at which to remain stationary. I would say this  was in order to change the scenery except that it was pitch black by this point. It was during this long 3 hours that J let me know that the room I had booked at the guest house was not available & I had no room to stay in. I wasn't too concerned as it looked like we would all be sleeping on the bus at this rate.

Then an extraordinary thing happened - the bus driver had an idea. It was a good one but would have been an even better one if he had it 3 hours earlier & shared it with the hundreds of other buses also waiting for miles along the main roads into PNH. The idea was as the best ideas usually are very simple - lets go the other way around!

So we did just that which made 3 and half hours of unnecessary waiting even more annoying. My UK mobile died. This meant not only was I unable to share R's annoyance at his fellow countrymen's incompetence but I was also unable to broadcast my annoyance to various friends scattered around the planet.

I arrived at my guest house & J kindly shared her room & bed with me. The following morning we flapped around trying to find the lost room key, which J eventually found hanging from the key hole on the outside of the door. It would appear that I wasn't the only one in need of a holiday.

I walked to the office that morning as all the main boulevards were intermittently shut for various motorcades related to the ASEAN meeting. At the intersection between street 214 (where the URC office is) & Norodom the road was closed for a motorcade. A convoy of police motorbikes & cars sped by followed by black limousines. The cambodian police - a vision in khaki with round, shiny, tin hats & the ASEAN volunteers - who looked like boy scouts with little red flags, indicated to the stopped traffic that they could go just as the second half of the motorcade sped towards the intersection.

I don't know whether it was the "NOOOOOOOOOOOOoooooooooooo........." of the police, the frantic whistle blowing & flag waving of the boy scouts, the high speed, 'forward-wind' quality to the swerving & weaving of the motos as they tried to continue to cross the intersection regardless or the astonished expression on the motorcade's european cargo but at this point I just completely lost it.

I was crying with laughter in the street, sobbing silently & struggling to breath with all my hysteria. The tuk tuk drivers who hang outside the office & only ever say "you want tuk tuk lady?"to me, even asked me if I was alright. Only a person in need of a holiday would find a near-miss multi-vehicle pandemonium that hysterical. I still have a little chuckle & smile to myself thinking about it now.

It was just so beautifully, incompetently, chaotically Cambodian.

Unfortunately the week got worse before I got my much needed break, but that's another blog....

Pchum Ben

Pchum Ben is a 15 day Buddhist festival for the ancestors, who simplistically all get the opportunity each year to leave purgatory through the gate's of hell and eat rice offered by their descendants. Cambodians go to the Pagodas where their ancestors will be to give offerings to the monks. It is preceded by a 3 month lent-type period which involves banging very loud drums at 4 am every morning, which intensifies for the 15 day festival with the added joy of chanting & plinky plonky music - I may have mentioned it before. This occurs after the full moon in September but I have been in a post-dengue fugue since that time.

I know a little bit more about this festival as there is a reading exercise about it at the very end of the grade 2 khmer text book. Soyeth - my khmer teacher - was rushing me through the last pages, finishing words off for me, ignoring my mistakes more than usual when I realised it was because she wanted me to finish grade 2 before Pchum Ben so I could learn all abut it in khmer. 

With all the fun & games I had read about at the Pagoda I thought maybe I should go and see it for myself. After all my local Pagoda has been a reliable early morning alarm for over 3 months - I should probably go to see what all the noise at the Wat is about. Soyeth was simply delighted when I asked her if I could go with her.

So one weekend after my khmer lesson I went to Soyeth's local Pagoda with her. We had to go to the market first to by a ready made 'offering' to the monks - including such delights as fish sauce & washing powder as well as flowers for offering to Buddha. 

I had been instructed to wear a white shirt & Sompot (khmer skirt) but had been let off the Sompot as I had to cycle across town to Soyeth's. Soyeth lent me a scarf which is meant to act as a sash across ones torso but caused logistical issues as my torso is the equivalent of 3 cambodian torsos.

The routine goes something like this;

• give flowers to Buddha & 'corrup' three times - place your palms together whilst sitting & then bow down & touch the floor with your palms
• light incense
• get multiple burns to your hands from the cheap incense
• take incense outside & leave in a big pot with a prayer to Buddha (another one - the big one in the big part of the Pagoda)
• go back in & offer gift to monk
• get a very nice 'thank you' in english from said monk
• put one spoonful of rice in a row of bowls for monks
• have problems keeping your scarf in place (see photo below)
• don't forget to save a bit of rice to place in the scraps bowl with your fingers - significance of this still unclear to me
• bump into your deputy director & get introduced to his entire family who are buying food for all the people at the Pagoda - a yearly tradition for the wealthier families in the community

The following month I received an email ominously entitled 'photo of you' - ON my deputy director had sneakily taken a photo on his iPad of me.

In between times I had spent Pchum Ben down in Sihanoukville, then fallen off my perch with Dengue Fever. At the time it felt like going to the Pagoda was a good thing to do, especially as I was worried about the health of the 17 year old girl with the tachyarrhythmia. Giving blood the same week felt like surely good karma would now come my way. 

As we left the Pagoda Soyeth was muttering something under her breath - when I paid attention I realised she was talking to Buddha. She was telling him about me, she was saying "she is kind, she is intelligent, she has a good heart" - I'm not sure Buddha believed her or perhaps the coming weeks were just to remind me that life is, after all, suffering.

Soyeth with my $3 offering for the Monks - I got a nice Thank you in english for them

My Deputy Director sent me this photo he took - Soyeth thinks she looks old & her face is too thin. I think it is quite worrying just how much concentration I clearly require to simply spoon rice into bowls!