negotiating the layers of healthcare

We (Nimol and I) decide to head over to the pedeatric hospital in the morning, before 9:30am, so that we can catch the doctors while they are on rounds. Hopefully their rounds will be in the morning. Hopefully they will not finish before before 9:30. The last two times we went we were unable to find a doctor to speak to you about Chan's daughter's condition. I want to help, but it's difficult to consider treatment options when the diagnosis is unclear. Ít's difficult to do anything when no one can answer your questions. She has been in the hospital for two weeks, taking medications, but the diagnosis is unclear and there has been no change in her condition. I'm a bit confused by this. I wish I could do more. Looking at scribbles and pill packets, my gut tells me this cannot be the beginning or end of the medical care. Walking up the stairs, a statue of Jesus Christ looking down on us, the nauseating smell of vomit and diarhea hits us again. This time Nimol doesn't really respond to it. This time, it's not as harsh as the first. I realize we are quickly adapting to it.

We are in luck. All of the doctors and the interns are milling around. I think my presence makes them mill around more. Sometimes this is good, sometimes this is bad. I am learning how to use the symbolism or meaning of my presence (that being a foreigner) to advocate for those I can help. Sometimes that means I have to leave because I become a barrier. That's fine too...as long as they get what they need in appopriate way.

We sit and chat with Chan and her daughter. I play with the baby. She is gorgeous with a head of crazy soft black hair. Her name is Ka - which means beautiful girl. Indeed! The doctors begin their rounds - looking at x-rays, physical exams, checking the charts and going back to looking at x-rays and physical exams. From a distance, through my inexperienced eyes, it all looks ok. Nimol has that smile on her face. That smile I have learned to know - something is going on and her eyes are catching the discreptancy. I ask her "What is it?" She says: "I have never seen doctors spend so much time with each patient before!!! I think you should come here every morning and play with Chan's baby!". Right. Well, at least today.
Then finally it is our turn.
The doctor looks over the chart: the lab tests and the medications perscibed so far. Last night she did not sleep due to abdominal pain, and her blood pressure was very high again. She looks more swollen today - the edema on her face and legs is palpable. Chan did not sleep either. She is concerned. The doctor doesn't change anything, just writes down the symptoms the mother reports. Nimol says, "Now you can ask you questions to the doctor. He speaks English!". I look at him and ask : "Do you speak English". He laughs, shakes his head "No", he says in english. Back to you Nimol. I want to know what is the diagnosis. Alot is said in Khmer. The english translation : "he is not sure". OK. second question: "the treatment they give so far - does it work ? Have the levels of protein in the urine changed?" Again, alot is said in Khmer, but the english translation: "not sure". OK. third question: "the lab tests indicating the protein levels what do they say - he was looking at them". the answer: "there is no change". The doctor then explains that they need to do blood tests to determine the diagnosis, but the patient needs to pay for these test. Nimol begins to speak quickly with a tone of voice that I know - she is becoming inpatient and pointing the obvious to the doctor: "how can she pay when she is in room for poor people and everything here is for free because they are poor?!" The doctor doesn't seem to discuss anything else except that nothing else can be done (or discussed, or considered) until the patient pays for the necessary blood work. Nimol presists (this is why I like her!): "but they took blood yesterday!"and points to the small bruise on Srey Po's left cubital foassa. The doctor doesn't seem to know and does not know where the blood has been taken to. This is becoming ridiculous. A second doctor walks in. Nimol nods her head: "he is good...I work with him at another clinic. I will ask him". She walks over and beings the dialogue. I feel ridiculous sitting there just looking over shoulders and eaves dropping on conversations I cannot participate in. My role has become to press Nimol for more clarification. I know she doesn't feel comfortable...it's a slippery slope: push too hard and they shut you out, don't push hard enough and you are shut out and ignored. The doctor reviews the chart. Explains the two possibilities. Explains there are blood test results - he points them out...the very page the other doctor looked at at least 3 times!!...so there are blood test results...it takes me a couple of seconds before the blood rushes out of my head and I can concentrate once again on what he says. I can't believe that someone would take advantage. Well, yes I can. I hits like a wave though. How do you inspire change in such an attitude that takes advantage of the poorest? I suppose I must return to the writings of the great few who had the patience, the understanding. I am but a student in the back row somewhere.

We leave the hopstial. Nothing has really changed except that we ruffled a few feathers and that I going to looking around for another opinion about what can be done for Srey Po. I have 5 days left. LEt's see what I can do...

An hour after, I get a phone call that a foreigner patient needs x-rays and an operation. 5 Cambodian staff and myself spend 4 hours transporting this patient for x-rays and to a hospital for an operation. I wonder if a Cambodian in the same situation would have been afford the same time? I imagine they would show up on a moto holding their own leg...

I arrive back at PT House at 4:40pm...Exercise class started at 4:30pm. I promised I would come today to at least come to do the hoky-poky dance with them. This silly little dance inpsires laughter and good spirits for hours afterwards. It seems ridiculous to be travelling across town to do a 5 minute exercise. But I keep my word; I show up and we dance and sing together. I realize this is building trust...an important element. But more important, the sight of their smiling faces, their laughter and ability to move limbs covered in scars and bandages to this silly song makes it all so worthwhile.

Arrival- August 19

Arriving into the Cambodian heat felt good. Familiar. Familiar is the general feeling that is at the forefront as I leave the airport and become acustomed to new faces, palms, the orange colour of the dirt, the numerous land cruisers and squatting moto drivers. The soft Khmer language hits my ears. At first it feels a bit distant and then I settle myself back into its familar sounds. My hellos quickly transform into hands in a praying position and a small bow. I do not do it as gracefully as the Cambodians though...there is a softness to how their hands meet in this gesture.
Driving through the bizarre traffic, I become aware that people are driving faster, there are more cars, more traffic. The cloud of exhaust smoke is much thicker. A flashing thought of my lungs inhaling this stuff for the next month makes me enjoy the current car drive. A hummer drives by us. It looks obnoxious set against the rickety store fronts and naked, dirty children.
The familar layer of sweet quickly forms on my forehead. Goldie, the dog, is in the back fully enjoying the wind, tounge hanging out. Dr. Jim is catching me up on what has been going on and introducing me to Pang, as he negotiates the stop and go flow of the traffic. We fall into an easy and light conversation. Welcome back...

I take a nap. I shower. I unpack a little bit. Read a little bit of the Cambodian Daily and guzzle water. We leave for the Australian compound for dinner in the late afternoon and have a lovely dinner with fascinating characters. One woman has worked extensively in the "HIV/AIDS world" of Asia. Another woman works at Hagar shelter (the one where Chan stays). Another man is currently living in Sierre Leone and in Cambodia on vacation to visit friends. He has warm and penetrating eyes and a striking scar on his forehead; I keep biting my tounge so as not to blurt out a question about it. We are all relatively new to one another but fall in and out of numerous fascinating conversations. I find myself at a constant intersection of colliding cultural interrpretations and misinterrpretations in a profound effort to understand and do some small piece of something in needy lands. I am inspired by their courage and fascinated by what drives them to undertake the lives they lead and do the work that they do...

Finally the jet lag over takes me. I am exhausted. Two days of travelling and 23 hours in a plane has left me dehydrated and longing to lie horizontally. I fall into a deep sleep and wake up refreshed, ready to head out into Cambodia...

This morning...

It was about 11:30 am. We had finished the morning treatments and while Thary (the PT) was preparing lunch, I was finishing the exercise posters we had put together for the patients. As I traced out elegant and curvy Khmer alphabet outlining basic instructions, I heard a beautiful sound. It was singing. The melody had various undulations and patterns. It was sweet like mango juice. I stopped what I was doing and began to follow it...outside, three of the patients were sitting on one of swing sets in the front yard. One woman, who lives in permenant darkness for the scars have sealed her eyes shut and continue to ooze puss, was singing in the most beautiful voice. The other patient, also a woman who's burns resulted from a gasoline explosion fire, was lying on the other bench, also humming along. The blind singer was holding and caressing the hand and shoulder of one of the male patients. He is the most quite of all the patients; keeps to himself and doesn't say very much. I usually find him quietly lying in his bed and when I ask why he is not out with the others, his sads eyes look up and he just says "pain". Here he is - outside and smiling.
I brought the posters outside, set myself up on the front stoop, the house dog lying on my lap and floated with their songs...