It’s now 4 ˝ months that we’ve been in Sisophon, and we’re on the brink of
deciding whether or not to stay on past December 31 and if so for how long.
The rainy season is now behind us; that was a tough one. We didn’t notice
when we rented our house that the house lies at a lower level than the road,
and that the floor of our first floor is actually below the level of the
ground around us, so our kitchen and bathroom seem to be the absolute low
point, elevation-wise, in our neighborhood. Hence, we had ten floods.
flood brought to our house a strange visitor—one time a frog, another time a
crab; the last time strange fish-like creatures—-I fear they were
leeches—-swam out of the pipe in the shower room as I was bailing out the
remaining flood water. The rainy season also brought us rats, which are
upsetting to anyone but which set off a primal fear in Lynn from which there
was no escape. Our landlady, Lumpke, set out poison, which took out the
most audacious rat, the one that walked right past us as we ate our dinner,
but the problem is not easily controlled, as rats simply live around here
and prefer the comforts of a home to the out of doors.
So what is there to decide? Under these conditions what would possess us to
stay? I have to say I have been in a wrestling match with my work, but in
the end find it compelling. More about this in a moment. Lynn has written
to many of you about her work at the local prison teaching English to 20
inmates between the ages of 13 and 35, to whom she gives far more than
language lessons. She offers them laughter, respect, fun, relationship.
Early on she had them learning the names of parts of the body by having the
whole lot of them doing the hokey pokey! She’s also teaching English to a
few of the local housekeepers, who work for ex-pats. She said the other day
how glad she is she didn’t give this up as she they have so much fun
As for my work, today though not exactly typical, gives a sense of what this
is about. This morning I completed my chart review of patient care at the
Sisophon Clinic. This has been the clinic that I’ve been most proud of,
that has essentially been functioning on its own the last few months while
I’ve given my attention to the other 3 sites where AIDS care is less
The results were disconcerting; while the clinic has enrolled
over 500 patients and has started 230 on ARVs, there are many patients who
have been coming to the clinic for months, have very low CD4 counts, and are
still not on the ARV drugs. There have also been too many patients who have
come just once and not returned.
When the clinic opened, I worked closely
with the two doctors who were providing the care, but since then two
additional doctors have been added. One spent 6 months in an AIDS training
program at Center of HOPE Hospital in Phnom Penh; the other has had no
formal training but has been under the supervision of the clinic chief, who
is the most skilled clinician in the province. Most of the problems in care
that I noted from reviewing records had to do with the patients of these two
newer doctors. Therefore, this afternoon I sat with Dr. Ouk (not his real name), the
doctor who spent 6 months at Center of HOPE.
First patient, #389, one of the patients whose record I had reviewed:
CD4-47 (very low) in early August; quite stable, no current complaints. Dr.
Ouk paged through the chart, noting that the patient’s weight is
stable, and that she’s had no real complaints for some time. “What do you
think?” he asked me. “What do you think, Dr. Ouk?”
turned to the patient in drill mode: “What are the complications of ARVs?”
The patient looked uncomfortable, but answered, “Numbness and tingling in
the fingers and toes.” “What else?” “Abnormal liver enzymes.” “What
else?” Dr. Ouk wasn’t about to let up. She hesitated, unable to come
up with other side effects. “How are you to keep these medicines?” Dr.
Ouk continued the interrogation. “If I leave home on a trip, I will
keep them on my body at all times.” “When you’re at home, where will you
keep them?” She didn’t know what he meant; she couldn’t answer. “Out of
the reach of your children,” he responded with the correct answer. She
bowed her head in defeat. “I am going to send you back to the counselor
until you know the right answers.”
He turned to me, “Do you agree?” “Dr.
Ouk, I have to say that I am quite impressed with what she knows. It’s
most unusual for someone without a medical background to even know the term,
‘liver enzymes.’ Surely, she knows that her children can’t take these
medicines and will keep them out of their reach; she just didn’t know that’s
the answer you were looking for. This woman has been fortunate not to get
sick in the 3 months since you checked her CD4 count. She seems very
motivated to me, having missed no appointments here. I’d go ahead and
prescribe the medication.”
Dr. Ouk paused long enough to weigh what I
had said against his previous judgment. “All right.” He took out his
ledger, and proudly marked off the 16th tick—“This is how many I’ve started
on ARVs,” he said with some pride. I thought to myself, “Dr. Ouk,
you’ve worked here twice a week for 4 months and this is the 16th patient
you’ve started on ARVs??? That is what you’re here to do!” I felt terrible
that despite in-services I have given here, my words and his training at
Center of HOPE had not led him to act more swiftly to treat his patients.
Though I’ve sat with him before, it’s probably been 3 months since I did so
because usually on Mondays and Wednesdays, when he has his clinics, I have been
at the newer clinic in Mongkol Borey. I felt negligent, but hopeful that
this little mini-lesson would help him understand that while patients must
learn the lesson that they must take every dose of their medicine every day,
and while it is good for them to have some understanding of the possible
side effects they may encounter, they do not have to have a doctor’s fund of
knowledge about these drugs; and to improve their lives, it is crucial that
the drugs be prescribed.
Second patient, #345, also amongst the patients I had reviewed: CD4 101 in
July; now in month 4 of treatment for extra-pulmonary tuberculosis, still
not on ARVs despite monthly visits since July—same situation as the last
patient with the additional problem of TB. Many AIDS patients with TB die
of TB despite being on drugs that should cure them of TB. There is mounting
evidence that this risk is reduced if patients are on ARVs.
Again the drill
began. The patient froze. He couldn’t name a single side effect of ARVs.
He had no idea what Dr. Ouk was getting at when asked where he’s to
keep his medication. Bunchhieng, my interpreter, asked if I wanted a piece
of gum. I brushed him aside completely absorbed in the unfolding drama.
This time my argument that some people can’t learn these things as
abstractions, that if you actually prescribe the medicines and tell him
yourself what side effects he’s likely to encounter, he will likely
remember, fell on deaf ears. I could not convince him.
I was tempted to
say, “Dr. Ouk, you have prescribed ARVs to 16 people; I have prescribed
them to hundreds. Please listen to me and do as I say.” But I didn’t. The
patient was sent back to the adherence counselors for more lessons. He
asked the patient to return in a month; I interrupted, unable to contain
myself. No, he should come back in 2 weeks. I addressed the patient: “Dr.
Ouk is rightly concerned that if he prescribes the ARVs, they can do
more harm than good if you don’t take them properly. I know you can take
them properly. The things you need to know are not difficult to learn.
Please do not be nervous when you see the counselor. In two weeks I know
you will be able to get the medicines….”
The patient departed; between patients I told Dr. Ouk that his concerns
must be weighed against the fact that in general Cambodians have been
extremely careful to take these medications exactly as prescribed, and that
we are jeopardizing the patient’s survival by delaying treatment.
Dr. Ouk was upset by my remarks because as the next patient entered the
room, his countenance became severe and he shooed the man away, telling him
he was Dr. Heng’s patient. I was shocked by Dr. Ouk’s handling of
the patient and sought details. Dr. Ouk is tired of having to see
other doctors’ patients on his clinic day. It turns out that Dr. Heng
had mistakenly scheduled this patient for tomorrow, a Tuesday, which is Dr.
Heng’s usual clinic day.
But this Tuesday is Water Festival, and the
patient knew the clinic would be closed. He came today instead so that he
wouldn’t run out of his ARVs. I told Dr. Ouk he can’t take out his
frustrations on the patients. Why not just tell the patient that you will
gladly see him but you need to see your scheduled patients first so please
wait —what if this patient leaves in anger and doesn’t get his ARVs?—then
he’ll run out of his drugs and will be facing the possibility of developing
The patient actually acted responsibly, doing what was
necessary to maintain strict adherence to his medication regimen. As it
turned out, the patient did leave in anger coming from long distance at
great expense. Only because I was there to make a fuss about it was he
reached when he could still easily return to the clinic, and the problem was
Wow, so much about the art of relationship that is critical to this work.
Dr. Ouk must learn not to complain in front of patients about all the
patients he is asked to see. He must not make the patients feel like they
are a bother. In the middle of one patient encounter, he interrupted his
questioning of the patient to tell me that today there is a big
international boxing match between the Cambodian champion and the champion
of Korea. It took great effort not to drop my mouth in disbelief at his
disregard for the circumstance of the patient in front of him.
understand how patients might see him once and never come back even knowing
that in not returning they lose the opportunity for life saving drugs. Up
until now I have felt that with the Sisophon staff I have had the right
blend of genuine respect and insistence on good patient care. I have felt
skillful in improving the care they are providing. Today I was uncertain.
At the end of the session, I asked to have a few minutes to debrief with Dr.
Ouk. He indicated he was in a hurry to go, but acquiesced when I asked
for just 5 minutes. I went over my major concerns. He thanked me for
helping him improve his care and accepted my offer to sit with him every
Monday for the next 6 or 8 weeks. I told him that I had done this with Dr.
Heng and Dr. Khieu when the clinic first opened, and that I think I can
help him to enjoy this work more. He agreed, but Bunchhieng thought from
his deferential answers that he was very upset with what had happened today.
We’ll see how this unfolds.
It was 4:45. I had promised to return to the inpatient unit to monitor the
status of a patient in horrible condition. The patient in Bed 8 had been
there for months. He was originally hospitalized with a severe allergic
reaction to TB medication consisting of severe ulcers in his mouth and
breakdown of skin all over his body.
Nothing that was done improved this
condition, and his skin became secondarily infected with extremely foul
smelling infection. His mouth and throat were so ulcerated that he could
not eat and lost a large amount of weight. Several weeks ago I had been
asked to see him, saw the probable hopelessness of the situation but
recommended an antibiotic change and asked the nurses to turn the patient
frequently so that he would not be lying on the foulest smelling infected
area on his back.
The nurse responded rudely to me that she had 40 patients
to take care of and she couldn’t possibly do this, that she herself makes
too little money and that the patient’s family should hire someone to do
those things. The patient’s wife, herself HIV infected but appearing
healthy, essentially had done all the nursing care for her husband for the
many weeks of his hospitalization and did her best to do as I suggested.
Since that visit I had checked in on the patient whenever I made rounds with
Dr. Heng, though I have to say the hopelessness of his situation led me
to maintain some distance, as I think was the case for the staff directly
caring for him.
My friend, Sartak, though, was visiting him every day. He
is not a doctor, but as part of his “practice” spends time on the ward just
sitting with patients. He speaks no Khmer but his presence I think brings
calm to difficult situations. He had become very close to the patient in
Bed 8 and the patient’s wife. Last Thursday he told me the patient was in
severe pain, and asked if there were something that could be done. I knew
that availability of morphine was very limited. A doctor in Mongkol Borey
has been approved to prescribe it, but no one in Sisophon had gone through
the special training I thought was necessary to prescribe it. I brought up
the problem to Dr. Heng, who said he was able to prescribe morphine.
Sunday (yesterday) it had not yet been prescribed so last evening I went
with Sartak to the hospital to arrange for its being administered. The day
nurse had left and the night nurse had not yet arrived. Dr. Khieu, who was
on call, came in and we discussed how to administer the drug through his
I.V. and that we should do whatever was needed to provide comfort.
returned to the ward this morning to find that the I.V. had infiltrated.
The patient was in a stupor, and I thought he could not survive more than 2
more days. I had the conversation with his wife that no one had yet had
with her—that her husband’s infections had not responded to the treatment
that had been provided, and that we could not save him. She had no sense
that this was the case; she had sold all her land, $5,000 worth, in an
effort to save him. Now she had nothing and she was going to lose him. She
held back her tears, containing her sorrow knowing it would take all her
strength to continue physically attending to her husband.
Now at 4:45 the situation had worsened. He had lost control of his bowels,
and had had a severe bout of diarrhea. His wife had changed him, but the
new clothes were already soiled. I left to try to buy adult diapers. I was
gone about 10 minutes; none of the three pharmacies near the hospital had
adult disposable diapers; I returned to the ward. The patient’s wife had
taken off the soiled pants and was so lovingly cleaning his bottom. I had
the sense of the patient resting in her comforting and knowing hands. She
had a clean kramah (Cambodian sarong) which she rapped him in; she turned
him from his side to his back, and in the next instant he died.
had just come in, and I was in mid sentence, telling her I thought that if
the patient appeared to be in pain, the morphine should be re-administered.
“Oh my goodness, he’s dead.” The nurse checked his pulse, confirmed that he
had died, and retreated to her room. A crowd had gathered, consisting
mainly of other AIDS patients but also the 6 year old daughter of one of the
cleaners and other hospital staff I did not recognize. I called Sartak, who
arrived soon thereafter with his wife Andy. To this gathered assembly all
of the sorrow that can be held in one woman’s heart poured forth.
From the perspective of my work I regretted that none of the Cambodian
doctors or nurses were present. The nurse on duty remained in her room
returning an hour later to ask the patient’s wife if she wished the body
brought to the pagoda (a free service) or to her home (for which she would
have to pay). She chose the pagoda; the nurse left, not to return.
it would be presumptuous of me to offer the staff lessons in the care of
dying patients, as the staff has witnessed all too many deaths and there are
certainly practices that are bound by culture that I don’t fully
understand, still I wished that the staff had shared in this profoundly sad
and moving experience. There is much that I obviously haven’t taught
regarding palliative care and the responsibility to prepare family when
death seems a certainty.
...So we have much to ponder. Stay or leave. Seeds have been sown, but so much more is needed. Two clinics are up and running. A third is about to open in Poipet under the auspices of Doctors Without Borders. If I stay, I
would hope to be able to help start a fourth clinic in Thmar Puok, an hour north of Sisophon, where there are hundreds more without access to ARVs. Meanwhile, across the 24 provinces of Cambodia clinics have been started and now more than 10,000 people (which I think includes the 4000 started by MSF (Doctors Without Borders)) have been started on ARVs, and, in fact, says my boss at NCHADS, we’re behind here in Banteay Meanchey compared to the
“progress” made in the rest of the country. We’ll see how this all turns out and keep you posted.
As we approach the week of Thanksgiving, I am reminded how often Americans returning from extended experiences abroad talk about how lucky we are to live in America. We certainly are. But having been here in Cambodia now for 1 ˝ years, I can’t help but feel uncomfortable with our privilege in the U.S.. The world is too small for the huge discrepancies between rich and poor nations to continue.
Some day perhaps historians will be able to look back and remind future generations of a past in which there were so called “under-developed” or “resource poor” countries, which co-existed on the planet with countries of astounding wealth. Hopefully, the day will come when the rights we consider “inalienable” are available to all.