On September 27th, 28th, and 29th, several of the English Teacher Peace Corps Volunteers (PCVs) from Takeo and Kampot provinces, and their Cambodian teacher counterparts, invited 50 high school aged boys for a three-day Camp BREW (Boys Respecting Empowered Women). It’s a camp focusing on topics related to health, career planning, gender issues, and community engagement. These are topics generally misunderstood or overlooked in the public schools. Camp BREW allows attendees to be exposed to and discuss these topics in a safe environment, while they gain knowledge and skills in areas needed to succeed after graduation. It also allows a rare opportunity for Cambodian students from different provinces to meet and exchange ideas on how to better their communities. There is a similar all girls event put on by PCVs called Camp GLOW (Girls Leading Our World).
I was invited to teach a health related section at the camp. One of my secondary projects here is working with several other health volunteers to create a series of curriculum toolkits containing lessons on health topics. This was a great opportunity for me to pilot several of these lessons.
I presented on substance abuse, in particular alcohol use, a topic I consider very important here in Cambodia, and completely overlooked in the schools. 54% of Cambodians report having used alcohol in the last 30 days and men are 10 times more likely than women to heavily use alcohol. Cambodia currently has no minimum drinking age, and although they do have a blood alcohol limit for driving, it is not enforced. Alcohol is uncontrolled and can be obtained any place and by any one regardless of age. The only barrier to obtaining alcohol in Cambodia is money. There is tremendous peer pressure to drink alcohol, especially amongst men, which usually manifests in the form of binge drinking. A common phrase in Cambodia is “Drink to get drunk, and if you are not getting drunk, then why drink?”
With the help of a wonderful teacher Sokhom Kourn as my translator, my presentation began with a quick basic anatomy and physiology lesson explaining how alcohol is processed and its effects on the body.
Then, I led a discussion on the consequences of intoxication. We explored the ways that alcohol can affect many aspects of our lives such as financially, our health through harm to our health through disease as well as through accidents and increased risk for sexually transmitted diseases, and socially through our relationships including increased domestic violence.
I had the students play a spoon game. In this game, they close their eyes and spin 10 or 20 times to get dizzy. Then I ask them to walk a straight line balancing an egg on a spoon. The idea is to illustrate how alcohol alters our consciousness and coordination preventing us from doing tasks we normally can do effortlessly. The boys loved this, and they easily made the connection on their own to driving drunk. Road accidents are the number one killer in Cambodia, and alcohol accounts for more than half of traffic fatalities.
My presentation concluded with having the boys write a list of all the things they think they are good at. Anything could be on their list. Then I divided the boys into smaller groups, and had them create lists of things that they could do better together as a group. After the groups presented their lists, I guided them to see that as individuals, they have many strengths, and as a group, they have even greater strength to accomplish things in their lives. The intent was to foster greater confidence and self esteem, two qualities important to combating peer pressure. We finished with a discussion of peer pressure and its role in the abuse of alcohol.
Other topics covered in sessions over the course of the camp were study skills, reproductive health and sexually transmitted diseases, domestic violence prevention and prostitution, what it means to be a man, playing sports, and how to plan for your future.
The camp culminated in a field trip to the southern Cambodian beach town Kep.
Here we purchased 30 Kilograms of fresh blue crabs and had them cooked up for us along with fresh fish squid, and shrimp for a seafood smorgasbord. Many of the students had never seen the ocean let alone eaten this kind of food. They were all thrilled.
So were the teachers.
After lunch, we played soccer on the beach and swam in the ocean.
… and of course took a nap.
In August, the US Marines were at my health center doing great work. On September 9th, 16 US Air Force airmen and 20 Royal Cambodian Armed Forces (RCAF) security personnel and engineers arrived and began work side by side at my health center. Operation Pacific Angel is a recurring joint/combined humanitarian assistance mission sponsored by US Pacific Command (USPACOM) designed to bring humanitarian civic assistance and civil-military operations to areas in need in the Pacific region, like Cambodia. The project builds medical and civil assistance capacity. I was made aware of this opportunity through the US Embassy. I spoke with my health center staff about it, and after identifying some relevant needs, I wrote a proposal to the US embassy. My health center was chosen along with two others to be a part of this Pacific Angel project.
One of the bigger goals of this operation is to visibly express the Unites States’ commitment to Cambodia and demonstrate their continuing resolve to support international disaster and humanitarian relief efforts in the Asian region. At the local level, however the impact to my community is enormous. It brought a $35,000 upgrade to the infrastructure of my health center, improving resources and capacity to the community far beyond anything that they or I could have done on our own.
On August 5th, members of the Pacific Angel Team toured my site to look at the proposed work. The scope of the work was large enough that and bids were collected to have some of the work done by a private Cambodian contractor.
On August 29th, the private Cambodian contract crew arrived and work began. As all this unfolded I felt a lot like a contractor. My years of construction experience came into play. I was constantly running around acting a liason between the health center, contractors, vendors, and military personnel.
Upgrades to the facility included refurbishing 4 bathrooms (above), pumping 10 septic tanks, building a new larger septic tank, replacing sewer lines, and installing new handwashing sinks in several of the buildings.
The electrical service to the facility, which previously was a maze of twisted spliced wires, was entirely replaced. New poles were set with new service wire to each building meaning if a slice or wire broke it now would no longer cut electricity to the whole facility beyond the break.. Tying all the buildings into the generator was now possible providing ensured power during the frequent black outs the community suffers.
All the buildings received attention form the electricians. Light fixtures, switches, and fans were repaired or replaced. Two old air conditioners that were installed by another foreign aid project, but never worked were repaired.
It was great to see the US and Cambodian forces working side by side learning from each other.
Airmen Lance Speed (above) worked with an interpreter to diagram and teach a Cambodian counterpart a more efficient way to wire light fixtures that uses less of the costly wire.
Lance’s Air National Guard unit from Idaho sponsors Cambodia, and this is his second operation in the country.
Even the local kids (left with lance) were learning and lending a hand to help out.
The patient rooms god a good cleaning when ceramic tile was added to the walls. The tile provides a much more sanitary environment that stays cleaner for the patients.
The kitchen shack was totally rebuilt providing a more sanitary place to prepare patient meals and storage.
My health center delivers about 30 babies a month. Disposal of the afterbirth is the responsibility of the family. Until now that meant they either took it home in a plastic bag or buried it behind the delivery building. This project brought the construction of a new bio-hazard incinerator where patients can now burn the afterbirth.
This is our new patient shower (right). This was another project started by an NGO that was never finished. Our inpatients typically have family stay with them for overnight stays. If they bathe while here, they have to bathe outside next to the well and drinking water (right below). Now they at least have the option to use an actual shower.
Honestly I am not sure how well this will go over as most of the patients have never seen or used a shower. But at least they now have the option.
Above is a new red roof awning that was built over the walkway connecting two of the buildings. I call area the IV garden because of the numerous patients who often rest at the picnic tables here with their IVs. This was something the staff particularly wanted built.
It provides shelter from the sun on the hot days and from the monsoon rains this time of year for the staff when transporting patients and supplies back and forth between the buildings. It also made a great place to stage the patients while their rooms were being tiled. (above before and after look at the IV Garden)
The oldest building received the most work. This building received a new roof, celing, windows, electrical, and was totally gutted reconfiguring the rooms.
A new infectious disease ward room for tuberculosis patients, staff rooms, and a cleaning supplies room were created. Before the health center occupied this building, it was a theater. So this remodel has not only updated the building, it has improved the efficiency of its use and patient flow dramatically.
Because the bulk of this Pacific Angels operation’s work was done at my health center, it was also chosen as the site for the final closing ceremony. The ceremony afforded an opportunity for the health center staff, and US and Cambodian forces to hang out a bit and enjoy a catered lunch togehter.
Speeches were made, certificates and gifts of appreciation were exchanged. Generals, Majors, community dignitaries, and the Cambodian and US press were on hand. You can read two of the stories written about this operation here on the Pacific Air Forces web site and here in the Cambodian Herald
Beyond the obvious physical upgrades to the facility, there is and indirect benefit to my community equally as important. The work done here has been very visible. The community is talking about it, and I think it has added a lot of credibility to the health center. I think it has increased confidence and trust in the government health care system, which is lacking generally, and will encourage people to seek care at the health center. It has also made the staff think a little bit more about their efficiency. With the reconfiguration of the one buildings in particular, the staff has improved the efficiency of the way they utilize space, and work with patients.
For me, this was a very rewarding project. I am happy I was able to facilitate it all happening. As with the Marines in August, I think I was valuable in making sure the needs of both the health center and the military personnel were met. Additionally, I think I was able to facilitate a greater cultural understanding on each side between the Americans and Cambodians.
No, I did not join the Royal Cambodian Armed Forces, but the Military Police whom I got to know over the weeks while they stayed guarding the health center really wanted to see me in their uniform. It could use a little letting out.
On August 12th, 13th, and 14th, thirteen members of the 3rd Medical Battalion, of the United States Marine Corps from Okinawa, Japan, spent time with me, and the staff of my health center. They came on a Medical Exchange (MEDEX) for a military to civilian Subject Matter Expert Exchange or SMEE as they like to call it. Since the Marine Corps do not actually have medical personnel, most of our guests are actually Sailors assigned to the Marines from the US Navy. It was a pleasant surprise for me to learn the US military does this kind of humanitarian work.
For the Marines, the purpose of their Cambodian MEDEX 13.2 is to improve interoperability, increase local medical capability and capacity, and foster goodwill while developing a medical needs assessment to plan for future exercises within this region. For my Health Center staff, it is an opportunity to share with them how the medical system works here in Cambodia, and to learn some new skills from the Marines. This opportunity came through the US Embassy who contacted all the Peace Corps Volunteers in my province. I responded with a proposal and after a site visit they selected my health center for the exercise.
Throughout the event, I acted as the liaison between the health center and the Marines. Although the Marines brought very good Khmer translators, I was often able to better clarify information flowing in both directions interpreting the cross cultural and medical perspectives needed for both the Marines, the Khmer translators, and Cambodian staff.
On the morning of day one, I made introductions and gave a tour of or facility to the Marines. During the tour, I told the marines about the services we offer, and they observed the staff work, while learning about the resources my health center has, and does not have. I think the most telling comment came from one of the corpsmen who said to me, “wow, and I thought we had to work with a minimum of equipment under hard conditions”.
Critical Care Nurse Angela visits with a new born baby born just a few hours earlier.
After the tour, with the help of the two excellent translators the Marines brought, I facilitated a meeting with the Marine officers and my HC Director, Dr. Sera. We identified areas of medical knowledge both wanted to share and learn about. Prior to their arrival, I had spent a fair amount of time working with Lt. LaBarbera, the Company Commander coordinating and formulating a schedule, but after an on the ground look at the health center and a chance to meet with the staff, we chose to make some adjustments. Throughout this whole event, I was very impressed with the Marines willingness and flexibility to adjust the schedule.
After Lunch, Dr. Grant the dentist gave a presentation on dental assessment. In my community, there is absolutely no dental care. This means there is very limited and incorrect basic knowledge, and no preventative check-ups. If you have a problem here, unless you can afford to go the provincial capital or Phnom Penh, you just suffer until your teeth fall out.
The staff showed real interest in this presentation and asked a lot of questions. It also became clear that simple things, like how to properly brush your teeth, are things they did not know. When Dr. Grant was finished, I suggested if time permitted, he should speak again tomorrow and give a proper brushing demonstration.
The second presentation of the day was from Critical Care Nurse Dougherty on teamwork. For the Cambodian staff this is a brand new concept. It was a shortened presentation as the staff honestly seemed a bit bewildered and confused by the concepts. Structured teamwork with predefined roles in a crisis is just not common here, and I think the presented concepts were too abstract and un-relatable.
Dr. Decker, an Emergency Room Physician presented next on trauma assessment. This subject is particularly valuable for the staff to learn. As a former medic, I am acutely aware through observation of the lack of knowledge the staff here has about even the basics of treating traumatic injuries. I asked Dr. Lawrence to keep to the basics, which he did presenting the introductory course they give to the Marines for field trauma assessment, stabilization, and transport. The HC staff really seemed interested, and it gave me the idea to follow this up later as a practical session.
Day two started with the Marines doing a more formal inventory of the hospitals resources. They took a closer look at equipment, procedures, and spoke with the staff in each department about what resources they have, is broken, or is lacking.
Dr. Grant presented on proper tooth brushing in the afternoon. I had a stash of toothbrushes I collected from the freebees given in hotel rooms, and we passed them out as Dr. Joe spoke and showed proper brushing technique. I encouraged Dr. Grant to emphasize the need to get the young children brushing. A common belief in Cambodia is that children do not need to brush because they have baby teeth, which just fall out any way. When I told this to Dr. Grant, he was shocked.
Nary Ly is a Cambodian who achieved her PHD in the US, and now works for the US Naval Medical Research Unit (NAMRU) here in Cambodia. She spoke on recognizing and proper treatment for two respiratory infectious diseases that have been a problems here, severe acute respiratory syndrome (SARS) and “bird flu” or A(H5N1) a subtype of the influenza A virus.
Dr. Decker finished the day with part one of a talk on non-surgical approaches to birth complications. Childbirth is one of my health centers primary services. Although we provide a higher level of care than many Cambodian health centers, they are not equipped or staffed to handle all problems, so this presentation was of great interest for them. Typically when a problematic delivery is recognized the patient is transferred in our ambulance to the referral hospital in Kirivong. This presentation focused on what to do when there is not time to send a patient on this 45-minute trip.
In the morning of day three, I joined the Marines on a tour of the Referral Hospital in Kirivong. They were interested in learning what the next higher level of care here in Cambodia is like, and what services and equipment they provide. In the afternoon, we heard part two of the non-surgical approaches to birth complications, and then it was my staff’s turn to present.
I did not want this event to be a one-way exchange of knowledge, so I arranged for our midwives to show the Marines how they handle a delivery. This was really fun. The Staff was reluctant at first. They told me they feel that the Americans know more than they do. However, in fact, this is not at all the case. As a field medical unit, delivering babies is not what these military doctors, nurses, and corpsmen do on a daily basis. The midwives at my health center however actually do. They deliver an average of 30 babies a month. So, we all piled into the delivery room, and the Midwives put on an excellent presentation. That’s my host family sister Theray a senior Midwife on the left above and playing patient below.
They did a role-play, and acted out how they handle a delivery complication known as eclampsia. Eclampsia is an acute and life-threatening complication of pregnancy in which the delivering mother has seizures. It was great to get everyone out of their seats, have a reverse flow of information, and see them all laughing together having fun.
This led into a second role-play in which Nurse Dougherty led the Cambodian staff through a role-play on neonatal resuscitation. The staff loved it when one of the male corpsmen was volunteered as the expecting mother. I was proud when it was obvious that most of the information presented, the midwives already new. The big take away for the staff was really how she had them working together as a team, understanding the need to prepare for the worst in advance, and the need to practice.
The teamwork. preparation, and practice concepts were carried forward in our last activity. I gathered everyone at the primary treatment area and asked Dr. Decker to run through a real time demonstration of the trauma assessment presentation he had made.
I then partnered our HC staff with the Marines, and had them do the drill shadowed by the Doctor and corpsmen. I wanted the staff to do this exercise and experience how important it is to have leadership, predefined roles, and see how drilling together bonds them into an efficient team in which everyone knows what to do in a crisis situation. This is exactly the approach to training I used for years as an EMT instructor.
Finally, the HC staff did the drill on their own several times. It was super fun for everyone. Like me, Cambodians generally seem to be better hands on learners, and I think that doing this really sold the concepts of teamwork that were so intangible in Nurse Dougherty’s presentation the day before. As a follow up, I asked the staff what their thoughts on doing this drill are. They said they liked it and it was not hard. Dr. Sera, the health center director told me that he wants me to do drills like this with the staff every week.
No event in Cambodia would be complete without a closing ceremony. Dr. Sera made a formal thank you, and the Marines presented him and the health center with a framed copy of the group photo you see at the top of this post. Staff members also each received a certificate for their participation.
The hope is for the Marines to return at some point in the future, further build capacity at this health center, and serve the community with a MEDEX treatment clinic. It would be great if it happens, but already I think the primary goals of increasing local medical capability and capacity, and fostering goodwill have been achieved. Additionally, I think this has been a great cooperative effort between two US agencies, the US armed forces, and the Peace Corpse.
The young women on staff getting their picture with the hansom Lt. Joe.
In an effort to promote good sanitation in my health center, I have been communicating messages on proper cleaning technique to my health center staff. For months now I have been promoting the use of a 10% bleach solution as a basic cleaning agent. This is a solution recommended by the US Center for Disease Control (CDC) and adopted by most health facilities in the US. Currently when cleaning occurs however, I only see moping of the floors, and it is done intermittently with only water, or water and laundry soap. I see no wiping down of surfaces before or between patients, and often see the floor, beds, and other surfaces covered with a multitude of bodily fluids.
I have had many conversations with Dr. Sera the Health Center Director about the need for more frequent cleaning and the need for using bleach. He recognizes this as a need, and expresses support for the idea, yet little has come of it. The idea of more frequent and thorough cleaning has been slow to catch on. I often hear from him (this is a paraphrase), “yes, I tell the cleaners, but they do not make much money, so what can I do?” This is a common truth in Cambodia, and it is a barrier to change. The two cleaners here, who are responsible for cleaning 6 buildings and maintaining the grounds make about eighty dollars a month.
A few weeks ago, I was helping a mother in the exam room and her baby urinated all over the bed. Children here rarely wear diapers. There was nothing to clean it up with, and no one even seemed to notice. The next patient just came in and sat on the wet bed. The next day I brought in a rag and spray bottle I filled with the 10% bleach solution I had been talking about. I started using it between each patient to wipe down the bed.
That afternoon the Consultation Nurse Saran (above) I often work with, who is also the Assistant Health Center Director, asked me if I could get more bottles so he could have one in every room. Of course I said. My take away from this experience is that people respond slowly to spoken ideas here, but when they see or can experience an idea, it is easier to absorb. I am actually very much the same way.
The next week after some slightly more aggressive prompting, I finally got the health center to buy some spray bottles and bleach. I held a small staff training workshop focusing efforts on how to mix and clean with the bleach solution. I focused the effort on the cleaning staff who have no medical training and little knowledge of disease and infection. Some of the key medical staff attended as well. We talked about why they need to use this solution, either from the spray bottle, or mixed in a bucket for mopping, whenever there is blood, urine, feces, or any other bodily fluid present. We talked a bit about infectious disease, its transmission, and the role proper cleaning with bleach plays in keeping the staff and patients healthy. I also stressed the importance of using Universal Precautions, such as gloves, masks, wearing their uniforms, and washing hands.
I still don’t see bleach is being used as often as it should, but it is getting used. It will clearly take time to create this new habit. I guess that is one good reason I will be here for another 13 months.
All of us volunteers were instructed to stay at home for our safety, which I did, but saw no problems in my village. I will not make any commentaries or speak at all about the politics surrounding this election. There is plenty to be read on the Internet if you are interested. However, I did want to share the above picture of my family members that proudly voted today, and have the fingers to prove it.
I have been eating mangoes with almost every lunch and dinner I have had with my new host family since January when I moved in with them. You may remember me writing that a mango orchard surrounds the house.
There are near to 100 trees I am told. I did not believe it, so I set out to count them myself. I stopped counting after 70.
I was never really a lover of Mangoes. But I have learned like them here. In Cambodia, mangoes are eaten in two forms, unripe, or green, and ripe. I don’t think I have ever seen green mangoes sold in stores back home, and I was surprised when I saw people eating them this way here. They are the consistency of a crisp apple and more than a little tart. Typically they are skinned, sliced, and dipped in a mixture of salt and chili powder, or powdered instant soup mix (like from a Ramen noodle package). My favorite is the chili and salt. One day I saw one of the guys at the health center dipping mango into Oral Rehydration Salts (ORS), an electrolytes solution used for treating diarrhea. It’s mostly sugar and salt, and it was actually quite good.
Of course, the ripe mango is what everyone waits for, and that is what I have been feasting on for most of this year. A 31 gram mango has approximately the same amount of sugar as a can of coke! Yes, living with this new family I have gained weight.
The week before I left for Poland, I walked around the orchard with the family and picked the last remaining mangoes from the trees. Mango season has ended! And yes, since the end of mango season however, I have lost 2 Kg.
Typically the mangoes are picked slightly green and ripened off the tree. Above Toum wraps green mangoes in banana tree leaves and packs them in a box to ripen.
I am eagerly anticipating the next Mango season. In the meantime, I have been keeping a close eye on our banana trees. If you have never seen bananas grow, they are fascinating and beautiful. Banana trees are perennials. The time between planting a banana plant and the harvest of the banana bunch is from 9 to 12 months.
This is a banana tree bloom. The flower appears in the sixth or seventh month after planting. Banas are available throughout the year as and do not have a specific growing season.
I took this photo of the tree blooming just outside our kitchen the week I left for Poland.
Today, it looks like this, and I am eagerly awaiting the day I can eat one.
Haystacks in the rainy countryside of southern Poland
Because I did not want my last post, image, and thoughts of Poland to be about war atrocities, I offer you these benign haystacks.
During the Second World War, Germany and the USSR partitioned Poland. When German forces entered Krakow in September 1939, many academics were arrested or killed. As mass arrests of Poles increased beyond the capacity of existing “local” prisons, concentration camps were established, including Auschwitz.
All over the world, Auschwitz has become a symbol of terror, genocide, and the Holocaust. In 1940, the Nazis established it in the suburbs of Oswiecim, a Polish city annexed to the Third Reich. Its name was changed to Auschwitz, which became the name of the camp, Konzentrationslager Auschwitz.
Auschwitz was part of a network of concentration and extermination camps built and operated by the Third Reich in Polish annexed areas. Beginning in 1942 however, in part because of its central location to the extermination effort, Auschwitz became the largest of the Nazi death camps growing to a complex with 3 main camps: Auschwitz I, Auschwitz II-Birkenau, and a work camp called Auschwitz III-Monowitz.
1.3 million people, around 90 percent of them Jewish died in Auschwitz. Others deported to Auschwitz included 150,000 Poles, 23,000 Roma and Sinti, 15,000 Soviet prisoners of war, some 400 Jehovah’s Witnesses, and tens of thousands of other diverse nationalities. Those not killed in the gas chambers died of starvation, forced labor, infectious diseases, individual executions, and medical experiments.
On January 27, 1945, Auschwitz was liberated by Soviet troops, a day commemorated around the world as International Holocaust Remembrance Day. In 1947, Poland founded a museum on the site of Auschwitz I and II – Birkenau.
Auschwitz made a less formidable impression on me than the other camps I have see. Both Majdanek, which we saw earlier on this trip, and Terezin, in the Czech Republic, which I saw in 2011, had greater emotional impact. They seemed more haunting. Perhapse because they both are less “museum”, and without the distracting crowds, I was able to be more emotionally in the experience.
Stairs worn by the many tourists 1,300,000 annually, that visit the Auschwitz – Birkenau Memorial MuseumWe were led through the Auschwitz – Birkenau complexes by a tour guide. As we pushed through the crowds of other larger tour groups, and rushed past each exhibit, she spoke to us with obligatory dramatic affect about the camps history.
Shoes and luggage were taken from the prisoners that were killed to be recycled into the war effort.
Cyclone B (below) was the cyanide-based pesticide that was dropped through pipes into the gas chambers and upon becoming wet produce the cyanide gas that killed prisoners.
She constantly pointed out “the evidence before us” and how it serves a reminder keeping such atrocities like this from ever happening again. I kept thinking, too bad it has not worked, as she seemed oblivious to the facts of more recent atrocities like I am currently surrounded by in Cambodia, and that are still happening in other parts of the world today.