Insight World Aid Cambodia Mission

CHPAA Medical Mission to Cambodia—February/March, 2013

By Christine Bitonti

It is 6:30 in the morning.  Already it is warm, the air heavy around us as we walk from our guesthouse to the Takeo (pronounced “Ta-kow”) Referral Hospital in southern Cambodia to begin the first day of clinic.  I am in a group of six or seven members of the Insight World Aid contingent of this mission.  There are 26 of us in all and more than 150 total on this mission, including over 40 Cambodian medical students who are to be our interpreters.  There are medical, dental, vision, and surgical teams included.

Beneath our feet, the ground is uneven with rocks and loose bricks and tree roots presenting obstacles along the way.  At street intersections, motorbikes laden with riders (sometimes as many as four) whiz past, heedless of pedestrians—even foreigners wearing identical blue medical scrubs.

Everyone in this town knows who we are—the Americans who have come to offer free health care.  We see the line of potential patients stretching along the wall that encloses the hospital, and then we catch sight of the swarm of people clambering for entrance at the main gate.  They are kept in some order by monks in their colorful orange robes using bullhorns to contain the crowd.  The moment is surreal, and I ask silently, “What have I gotten myself into?”

The sea of people parts to allow our passage.  Inside the wall, chaos reigns.  Staff from CHPAA (called “Chapa,” which stands for Cambodian Health Providers Association of America) are setting out rows and rows of red and blue plastic chairs to create a makeshift waiting room and various treatment stations under large, colorful tents erected for this occasion.

The tables that were promised to our group have not yet arrived, so there are no surfaces on which the doctors and nurses can place their equipment and supplies.  Some people—also in blue scrubs—whom we don’t know yet (but, will soon come to know) are racing around, pointing and shouting instructions to one another and huddling together in impromptu strategy sessions.  We are transfixed by the scene.

We make our way over to a two-story building designated as the briefing room, cafeteria, and rest area during our six-day stay in Takeo.  A smaller room upstairs, filled with rows of tables and chairs for eating, has the only air conditioning on the site (except for three operating rooms provided to our surgical team).

Large foil trays and pots of food are stretched out on a table outside the eating area.  We soon discover that breakfast is nearly the same every day—bowls of rice porridge, fruit, thin egg omelets and French bread.  I am grateful for the protein option.  Although repetitive, the omelet gets me through each morning.  We will eat three meals a day at this site (except when too tired to return to the hospital from the guesthouse after a full day of work).

The 26 of us from IWA have not been given assignments.  We wait patiently for this to happen, but it never does.  In an hour or two it becomes clear that we are on our own to find a spot, a role, a purpose—some way to be useful.  It is easier for the medical providers to accomplish this task.  Once tables arrive (which happens, thankfully, that first morning), they can claim the corner of a table, place a few chairs around, locate a supply box, and begin seeing patients in the open-air venues.  It is less clear how the rest of us can be useful.

Somehow, miraculously, order is carved out of the chaos.  By noon, there are hundreds of local people inside the hospital gate—children, their parents, grandparents, and siblings, pregnant women, monks—all sitting on chairs, waiting for their vital signs to be taken and subsequently to be escorted to one of many patient treatment areas established under the main tent or on one of the covered porches adjacent to the hospital buildings.

By mid-morning on that first day, many patients have been triaged and are ready to be seen by a provider.  A few of our doctors have set up shop at tables in the main adult treatment area.  Not yet knowing how I can be helpful, I follow two IWA providers (Jeff, an ER doctor from Sacramento and Nancy, a nurse-midwife from San Francisco) up a ramp to an area designated as “Pediatrics.”  They want doctors in that area who can see adults, as well, so that those accompanying the children will not have to wait in line a second time.  Nancy specializes in Women’s Health and ends up receiving referrals from doctors throughout the complex.  Luckily, there are six small examination rooms that open on to the porch, one of them set up for gynecology.

Several of us begin to arrange chairs along the wall of the porch to create a rational flow of patients through the waiting area.  We also begin to serve as escorts, guiding patients who have been referred to “Pharmacy,” “Dental,” “Vision,” “Mental Health,” and “X-Ray” (the latter provided to us by the hospital).

What I observe right away is the appreciation of the Khmer people.  They bow and said, “Aw kohn” (thank you) over and over to all of us as we welcome them to our “clinic,” offer a chair, or guide them to another service area.

The Pediatrics/Women’s Health portico becomes my home for the week, except for a brief stint in the Mental Health area.  I enjoy talking with people (mostly about ways to lessen their anxiety), but there are not enough interpreters to support all the mental health professionals, so I return to my original post.  Later in the week, I was asked to pass out reading glasses, but I made a mess of that assignment.  There were thousands of glasses of various levels of magnification in supply room boxes.  I began giving them to anyone who came up to me (not just those with slips from a doctor).  The hospital staff (not a part of our mission) got wind of my generosity and began to swarm the table, which irritated CHPAA staff, since the glasses were meant for patients.  I wasn’t very good at keeping order (especially without an interpreter), so I returned to the Pediatrics unit for the rest of the mission where I managed to stay out of trouble.

Prior to beginning this trip, I had set two main intentions:  1) to be of service any way I could and 2) to accept with equanimity whatever conditions I encountered.  The first was not difficult to achieve since there was so much to do.  The second formed the basis of my practice for the week.  To say that our conditions of living and working were not ideal would be an understatement.  But, the experience provided opportunities moment to moment to be mindful.  I can’t imagine doing this trip (as others did) without the support of a community of mindfulness practitioners.

To be fair, our guesthouse in Takeo was relatively new and had western toilets and (most importantly) in-room air conditioning.  There was no A/C in the lobby where we meditated daily.  The shower water was not even lukewarm, and water did not drain properly in the bathroom (shower and toilet were in one space), so the floor was almost always wet.  The beds were hard. Geckos scampered along the walls and mosquitoes buzzed our heads now and then.  But, all in all, it was a very nice place.

The real challenge for me was fairly constant back pain.  I began each day feeling rested and ready to work.  After a quarter-mile walk to the hospital, I remained on my feet for hours, helping to manage the waiting area or escorting patients around the grounds.  Eventually, my back just felt like it was ready to give out, and I’d have to find a chair to sit on.  It wouldn’t be long before I’d be up on my feet again, assisting patients or keeping the waiting room line moving.  I decided early on that I wouldn’t leave my shift early and that I would not complain.  Luckily, I had absolutely no pain or stiffness in my new knee!  That was amazing.

By noon each day, most of us were damp from the heat and humidity.  Personally, I wasn’t as affected by the heat as I had expected to be.  I considered it a minor inconvenience, although I’m sure it contributed some to how bedraggled I must have looked at the end of the day.  People kept asking if I felt OK, so I must have looked awful.  I did have trouble walking by 4:00PM, so I generally hailed a tuk-tuk (pronounced “tuke,” not “tuck”) to take me back to the guesthouse.  These conveyances are covered carriages (like a large rickshaw) pulled by motorbikes—a wonderful mode of transportation for just a couple of dollars per trip.  I gladly paid the asking price (sometimes $3.00 or $5.00 when there were more people transported), although I was repeatedly told by others that I had paid too much.

Actually, I was often told I had paid too much for everything (for goods, services, tips, etc.).  I offered the amount that these things were worth to me, not what I thought I could get away with spending.  People work really hard to scratch out a living in Cambodia.  I used my bargaining skills sparingly there, and if I made someone’s day with a generous tip, I was glad to do it!

Case in point.  My collapsible cane became jammed at one point (in a position too short for me to use it any more).  So, I gave it to one of the CHPAA staff working the main waiting area.  He found an elderly man who was quite hunched over and offered it to him.  The staff member later found me to say that the gentleman wanted him to thank me personally as he was delighted with the cane.  Later, however, I was in desperate need of back support while touring the Angkor Wat area.  We came across a group of men cutting branches from a Sycamore tree.  One of the branches looked just like a cane (only too long) with a bent end.  I motioned to one of the men and pantomimed using a cane.  He cut it shorter with his machete, and I gave him $5.00 (which, apparently, caused quite a stir among his peers).  Someone told me that I had probably given him the equivalent of several days’ pay.  Well, that makeshift cane allowed me to continue sight-seeing through the temples.  It was well worth $5.00!

There were many other opportunities for generosity on this mission, and our group of 26 people—many of them experienced Buddhist practitioners—found novel ways to share with the Khmer people whose smiles and graciousness were payment enough!

I think the medical providers experienced the most stress during the week because of the importance of their roles and the primitive conditions under which they were practicing.  They had to make clinical judgments on the basis of very brief medical histories and minimal physical exams without benefit of laboratory tests or sophisticated imaging.  And, they had only a limited formulary of donated medications.  Some expressed worry that they might have done more harm than good in certain cases.

But, there can be no doubt that miracles occurred and, in several cases, lives were saved.  For example, one woman in her ninth month of pregnancy with twins had extremely high blood pressure and would likely have died if our team had not performed an emergency C-section.  She and her babies were subsequently admitted to the hospital (which might not have occurred without our intervention).  Cambodians are often turned away from medical facilities for lack of funds—even in life-threatening situations.

In another case, one of our mobile teams working in a very rural area of the province treated a 14 year-old girl who had attempted suicide by swallowing rat poison.  They were able to get her transported to the Takeo Hospital where members of our Mental Health team looked in on her for a few days.  As I write this story, a little boy is in a Phnom Penh children’s hospital, awaiting a critical surgery to save his life, because one of our physicians recognized the severity of his condition and advocated for him to get the resources he needed.

Many people showed up at our clinic with severe dehydration and a few with delirium from sepsis.  The latter were admitted to the hospital, probably because to refuse them would risk bad publicity for the institution.  I know that this sounds cynical, but it is more likely than not the truth.  That is why 10,000 people were seen in our clinics over the course of six days and more had to be turned away when we reached capacity.  The poor of this country have little, if any, access to medical care.

One of the bright spots for all of us were the 40 or so Cambodian medical students who served as our interpreters.  There is no way this mission could have been conducted without them.  But, they also boosted morale with their smiles, energy, and enthusiasm.  They gave us hope that with each new generation, things will change in the Cambodian Medical system.

The mission ends as it began, with an elaborate banquet at what I’m guessing is a typical wedding venue (spacious room with a dance floor and mega speakers, little thatched huts on either side of the room, dozens of round tables for eight, etc.).  There are dignitaries (CHPAA leaders, US Embassy staff) making speeches and awarding certificates to the medical students for their participation.  We had pooled money to provide several scholarships to them, as well.

After six days of eating rice at every meal, accompanied by some slight variation on the same culinary theme (cooked veggies and/or pieces of meat or chicken in a sauce), it is wonderful to behold the magnificent array of Khmer dishes and raw vegetables at the extensive salad bar.  I gravitate toward the odor of barbeque, which appears to be chicken.  Foregoing the rice and noodles, I opt for the chicken and a beautiful garden salad of my own creation.  Using a pair of tongs, I pluck a couple of pieces off the grill.  The first is a wing, which is delicious.  But, when I turn the second piece over, I am horrified.  There, staring up at me, is a fully-formed bird—beak and all!  Later, I learn that it was a songbird—very popular in Cambodia, but left untouched on my plate (except for the wing, of course).

Almost every day, our team meditates in the lobby of the guesthouse or in a lounge or conference room in the hotels at Phnom Penh and Siem Reap.  It was wonderful to be traveling with a group of people practicing mindfulness even while working and touring.  It becomes very evident to me that as the days wear on (especially on the mission) nerves are beginning to fray among many of the volunteers.  I catch myself being irritated on several occasions and (mostly) curb my impulse to say something unskillful.  On one occasion, after our small team of waiting room attendants had spent the morning designing the best system of patient flow we could, one of the doctors stands up and, in a less than gracious tone of voice, shouts, “Where’s my next patient?  This is the most disorganized place I’ve seen!”  His criticism feels very dismissive to us, but we shake it off and get to work figuring out how to move people from the waiting area to the treatment area faster.  I want to say (but don’t), “For gosh sakes, this is a developing country, not your private practice!  And, we’re volunteers, too!”

The day after the mission ends, we are bussed to the city of Siem Reap, where there is a lively night scene and lots of Asian, American, and European tourists.  It is fun to be able to take a a tuk-tuk with a small group to the night market and the restaurants on “Pub Street” (announced by a huge neon sign spanning the street).  This is really our first opportunity to explore independently and to shop.

For many of us, our American dollars are burning holes in our pockets.  Up to this point, I have only spent money on bottled water, local transportation, tips and a donation to the Wat Opat orphanage (really, a “children’s community”) where some of the IWA volunteers have spent the week volunteering.  The rest of our team are given the opportunity to visit there one evening while on mission.  Half of the 50+ children who live there are HIV-positive (and, fortunately, have access to medications).  They are a happy, lively group.  We are treated to the best food of the trip so far (in my opinion)—a homemade vegetarian Thai curry—and some disco dancing (yes, even I got on the dance floor, though I paid for my fun the next day).

Back to shopping in Siem Reap.  The night market is a colorful explosion of crafts and food items produced and packaged for tourists.  But, it is fun to stroll among the stalls and haggle (just a little) with the vendors, who are much less aggressive than their Chinese counterparts.

On this trip, we had some heartbreaking experiences along the way, visiting a killing field and the infamous S-21 prison where citizens were detained under the Khmer Rouge and tortured until they confessed to crimes they had never committed.  We met one of the last survivors of that prison (only seven made it out alive).  I bought a book he wrote about his life (Survivor:  The Triumph of an Ordinary Man in the Khmer Rouge Genocide by Chum Mey).

As horrifying as many of the aspects of Cambodian history are, some of the things we learned about and witnessed in the present day are disturbing in their own right.  Like the two little boys who came over to an abandoned restaurant table next to where a group of us sat dining and hungrily ate the food left behind on the plates.  I noticed that no one shooed them away.  Like the patients with incurable diseases (or conditions we simply hadn’t the means to treat) who left the clinic with nothing more than a bottle of vitamins.  Like toothless beggars on the street.  Like piles of garbage lining the highways in and out of Phnom Penh.  Like huge rats running along ceiling beams in an open-air restaurant near our guesthouse.  Like sewage being dumped into the river where people live (in floating homes) and fish.

Billions of dollars are poured into this country by governments and NGOs (non governmental organizations) every year.  It is common knowledge that only a fraction of this aid ever reaches the people for whom it is intended.  But, no one is willing to withdraw the aid in protest, fearing expulsion or worse yet, a takeover by the Chinese.

It is our last day in Cambodia.  About 20 members of the IWA group participate in a day-long retreat held at the lovely, spacious apartment of a friend of Jeff’s, a woman who works for CARE, a respected NGO.  Beth Goldring, who runs a Buddhist chaplaincy and social services program for people with AIDs also attends.  It is a wonderful day with meditation, silence, and mindful eating in the morning.  In the afternoon, Beth and our host (whose name I didn’t learn to spell), provide their perspectives on living and working in Cambodia.  We, in turn, share what we have learned.

I am touched by our leader, Jeff, who bore the considerable burden of logistics for our group and buffered much stress for all of us.  He bows to the group and apologizes for any of his words or deeds that might have caused harm along the way.  It is a truly humble, sincere gesture (though not necessary, in my view).  In all the days of shepherding us on and off busses (much like herding cats) and attending to our traveling needs, I only saw him slightly irritated with the group once.  Most of us would have been raving lunatics by the end of this trip in that kind of leadership role.  That’s the dharma in action!

Well, there is so much more I could describe about this trip (like the incredible thousand year-old temples we explored near Siem Reap).  But, as usual, I’ve droned on for long enough.  Hopefully, I’ve provided a glimpse of this wonderful experience.  I wouldn’t change a moment of it—good or bad, uplifting or heartbreaking.  This is a country whose history is important for all of us to know and understand and whose people are worth encountering and honoring for their grace and resilience.  I hope I can participate in future missions of this sort.

See more information and pictures at the Insight World Aid website: