Kampuchea Crossings

Bump to baby on the beaten expat track

Omigod-I’m-in-Cambodia

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…continuing the catalogue of follies…

We have this month in the office two interns, one from Hungary who has never been to a developing country (…?) and the other is from Germany. Our deputy director took them out to lunch at one of his favorite spots, a curry noodle shop. The steaming bowls came out and everyone dug in. The girls ate in silence. Before long one of them turned to the other with a small whisper, “Are you eating the ants too?”

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One of the problems in this field is the cut-and-paste methods of some foreign inputs. Of course, if a template exists for say, a patient consent form for surgery, then it is within reason to do this. Documents are translated to Khmer, then inadvertently the original is discarded. When a barang (foreigner) comes along during the course of the project, the document then needs to be translated back to English. The English, translated from Khmer after being translated from English, of an informed consent form:

Knowing that the doctor has done his best but does not know how to do the surgery, I consent to the procedure and agree not to seek recourse.

It’s meant to contain the following elements: The nature of this condition and the present treatment course, the alternate treatment options, possible side effects, and risks have all been explained to me… I understand that no assurance as to the results obtained has been given… With the information I have of my condition and the proposed course of treatment, I authorize the performance of ___ procedure.

the US Agriculture Policy

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CARE Turns Down Federal Funds for Food Aid

An interesting development, and CARE risks much with it. They traditionally employed monetised food aid but have been debating the damage such a system facilitates to the markets (people) which they are specifically trying to help. Essentially, subsidised US farm products (already controversial by its own right) are shipped from the US on American lines, sold by NGOs, the profits of which are used to fund their aid operations. Because aid organisations are not commodities experts, that profit margin is also impacted.

This event is interesting on many levels. It highlights the incredible role of food aid in politics, as leverage, as a weapon, to control the markets. Aid is no longer tied as a matter of official procedure but in practice it’s a different story.

Additionally, phasing this scheme out of CARE operations sends a clear message about the US agricultural policy. You Are What You Grow is an interesting look at the farm bill on a personal level. Why is there a growing obesity epidemic, and why is it largely among the poor? The grocery store, we all know, is a sophisticatedly designed space, the result of extensive market studies and specialised consumer research. Nutrient-poor products are clustered in the centre of the store; junk food and sodas are cheaper because they’re the processed outputs of farm subsidies. Globally, the farm bill impacts public health, the environment, immigration, poverty in the developing world and it fuels damaging agribusiness practices.

The farm bill is renewed every five years. It is now in Congress being reviewed and revised, and it goes to the floor in September 2007.

Aid frustrations: A Doctor’s View Into Humanitarian Aid

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Guest Poster: J Chan. She captures quite nicely the frustrations of development work:

I’m back in Mozambique again, now in the 2nd largest city in the country- Beira. It’s nice to be back in Mozambique and the 30hr plane rides are getting more monotonous. I hope to spend a little bit more time checking out the towns along the way while I’m working.

I’m here for the 2nd phase of another project. We were able to get the lay of the land of the flood situation back in May and now we are back to perform a more rigorous assessment of the water and sanitation activities in the resettlement camps (like refugee camps in some ways) by the Zambezi River. We will try to link this information with the risk for cholera outbreaks to help the project guide their future programming in the region.

Consulting for a large international NGO such xxx has been rewarding this year, but also a bit frustrating because it has provided the window to much of the disorganization in the humanitarian world. The interplay between government interests, NGOs strapped by funders as well as their own disorganization and at times lack of skills, create a challenging atmosphere for providing services to communities such as those affected by the floods in Mozambique. Services are being provided to some degree, but not often in a timely manner and often without the greatest leadership.

This work is so different from working in the ER in Boston, where flow, efficiency, and quick, accurate decision-making are the keys to making a shift work well. Accountability is also another element of providing medical care in the ED (as with most of medicine in the US), but now being an attending physician I feel that and see that in a whole new light.

In this post emergency phase in Mozambique I wonder who is responsible and even accountable for the fact that many people still are living without homes, little sustainable water and from what we know so far still living in high risk areas of poor sanitation. Is it the NGOs who are in the field, some of whom lack leadership to make decisions and provide water sources, or is it the local government who lack human capacity and support that they themselves don’t provide services either… But in the end the communities who live by the Zambezi river are returning to their lives with or without the help of govt and aid workers–as they do this every few years when the Zambezi rivers flood…. It the resilience of these communities and the savvy coping mechanisms they create to withstand these multiple shocks that are most powerful in my mind..

Its a great balance to have both types of work (ER and Humanitarian work) fill my days, and I can’t complain at all for these opportunities.

Dysfunctional Programme Management

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Calling in overwhelmed today … these are generally about the software industry, but applies to any field where you have to work in a team!

Asshole Driven development (ADD) – Any team where the biggest jerk makes all the big decisions is asshole driven development. All wisdom, logic or process goes out the window when Mr. Asshole is in the room, doing whatever idiotic, selfish thing he thinks is best. There may rules and processes, but Mr. A breaks them and people follow anyway.

Cognitive Dissonance development (CDD) – In any organization where there are two or more divergent beliefs on how software should be made. The tension between those beliefs, as it’s fought out in various meetings and individual decisions by players on both sides, defines the project more than any individual belief itself.

Cover Your Ass Engineering (CYAE) – The driving force behind most individual efforts is to make sure than when the shit hits the fan, they are not to blame.

Development By Denial (DBD) – Everybody pretends there is a method for what’s being done, and that things are going ok, when in reality, things are a mess and the process is on the floor. The worse things get, the more people depend on their denial of what’s really happening, or their isolation in their own small part of the project, to survive.

Get Me Promoted Methodology (GMPM) – People write code and design things to increase their visibility, satisfy their boss’s whims, and accelerate their path to a raise or the corner office no matter how far outside of stated goals their efforts go. This includes allowing disasters to happen so people can be heroes, writing hacks that look great in the short term but crumble after the individual has moved on, and focusing more on the surface of work than its value.

Source: Asshole-driven development

Tuki gecko

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Tuki geckos can get as long as ~30cm, but they’re skittish compared to their ubiquitous smaller gecko cousins so it’s hard to spot them.


ReeaAAARRRRRRRRR!!! Tuki and the Cat!!!
[photo courtesy of Chakra House, Phnom Penh]

Instead of taking my own photos here are some great shots. Keith’s trigger happy with that Cannon. Check out the “On the road” section!

Health Care for Expatriates in Cambodia

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Published in AsiaLIFE Phnom Penh April 2007

A thriving health industry in Phnom Penh no longer warrants an urgent plane ticket out of the country for routine care. To boot, medical care is easy on the pocket. But while most practitioners aspire to the western model of care, the system is far from user-friendly and choosing a practitioner is not a simple task. On top of the usual precautions are considerations to a developing country’s medical environment. This is a brief guide to navigating the (western medicine) landscape in Cambodia, with tips for routine and emergency care, and a short look at medical insurance.

Where to find a good doctor?
• Go public or private? The public sector is much maligned, for good reason (though to give them credit if alternatives aren’t available, such as in the provinces, their capacity has much improved for simple procedures). The national hospitals and programmes (HIV/AIDS, TB, malaria, immunisation) receives dedicated funding and so has better services than in the rest of the sector. In response to market demand given the weak public health infrastructure, the private sector is booming, offering much better care.

• Go local or foreign? With medical (and other) degrees an easy purchase in Cambodia, the natural reaction is to avoid all Khmer facilities. But this is a dangerous yardstick. There are many excellent Khmer clinicians, charging significantly less than foreign colleagues for equal or even better quality care. Likewise are some Western practitioners causing more harm than good. A foreign doctor / foreign-run facility is not assurance of quality care.

• Seek endorsements from friends and check for medical certificates during the visit. The accreditation system is at infancy; enforcement capacity of the Ministry of Health (MOH) is inadequate, with cases of illegal practices simply referred to the police (–uhm, well, uhm….). In absence of a functioning regulatory mechanism, patients need to conduct their own quality survey. With views on health care vast and varied don’t stop at one person’s professed experiences. And keep in mind that information from embassies and government websites may be biased in favor of that country’s interests over the patients’. Listed below are personal recommendations based on positive outcomes after consultations.

• Obtain referrals to competent technicians and labs from a reliable practitioner. Having sophisticated equipment is not a guarantee that it is operated properly or that results are accurately interpreted. Patients have left consultations where technicians did not catch broken bones! The same holds true for laboratories.

• Medicines should be purchased at facilities known to dispense legitimate drugs procured from reliable suppliers. On the national level is the problem of quality control. With the increasingly sophisticated counterfeit industry small measures such as checking for proper storage, expiration dates and packaging (don’t buy drugs in unmarked plastic bags!) only go so far. Even holograms can be counterfeited— and testing is only done at laboratories through the MOH. At the pharmacy level, be aware that even in licensed facilities bearing the green cross, it is not necessarily a trained pharmacist at the counter. This is not the place to seek medication advice!

• See the specialist and not the temp. In some clinics the higher the qualifications the higher the fees. Similarly, higher consultation fees are charged to see Westerners and foreign-trained doctors.

• Fee structures should be disclosed before beginning any consultation to avoid surprises.

• Language presents a challenge and patients should be able to communicate with the practitioner. Multi-lingual skills is good, but technical jargon is another level of competency altogether. (French is the language of the medical profession here.)

Tips for medical emergencies
As far as accidents go, technically victims are taken to one of the national hospitals specialising in trauma care, such as Calmette or Kossamak hospitals. But as a matter of practicality it’s anyone’s guess what the emergency response will be. Some private clinics make arrangements with the police so that ambulances take accident victims to that facility, where treatment is of low quality and expensive. One Khmer insurance agent’s advice is to stay conscious long enough to ensure being taken to the facility of choice, to prevent theft of personal effects, and to summon a friend or colleague. While this certainly is not reassuring, there’s a lesson to be had: prepare for the possibility of an accident.

• Identify in-country healthcare resources in advance of a medical emergency. Having these numbers handy will shave precious time in seeking advice and referral during a crisis.

• Exchange contacts lists with a trusted circle of friends familiar with each other’s routines and schedule. This list should contain your general practitioner and preferred hospital for emergencies, special medical conditions, insurance information and the Embassy/Consulate numbers. (speaking of emergencies, is there an internationally agreed system for labeling priority contacts on mobile phones??)

• Carry this list on a small card in Khmer in your wallet/pocketbook.

• Identify potential donors with compatible blood types in case of emergency. The blood bank has procedures in place to keep the blood supply safe, but it being in perpetual short supply it is not fail-safe. Without a local medical advocate minding your care, foreigners are better off at the following four facilities with regard to blood supply.

• Emergency medicine options are narrowed to the national hospitals specializing in trauma (ie. semi-private Calmette and government-run Kossamak) and foreign-run clinics (ie. French/Khmer-run Naga Clinic and American-run SOS). An adequate comparison is beyond scope of this article—even those in health and medicine have conflicting views. Recent assessments of the national hospitals by expert evaluators report that Calmette and Kossamak both receive intensive foreign technical assistance and mentoring, and are both equipped with excellent trauma surgeons and equipment. Their capacity to administer appropriate care has significantly improved in the past decade.

Options for medical coverage
Given the low cost of medical care, many don’t find health insurance necessary. For those seeking peace of mind given that emergency evacuation and hospitalization can run into the tens or even hundred thousand dollars, the Cambodian market has several private brokers such as Asia Insurance, Forte Insurance and Infinity Financial Solutions.

They represent the more popular insurance companies such as Bupa, Goodhealth, April, William Russell, Aviva. Plans range from coverage of only accident/trauma care to the gamut of long-term medical needs. Other sources of info are credit cards, professional societies, alumni associations and travel guide websites, who often partner with insurance companies to offer reduced rates to clients.

These sample quotes include hospitalization, emergency medical evacuation and repatriation services for a 33-year-old female. You aren’t limited to brokers in Cambodia. To avoid paying premiums higher than the official published rates, contact insurance companies directly for a quote and they will refer you to a local broker.

• Both Asia Ins. and Infinity represent Goodhealth. The range of plans start at $477 annually with no co-payment with Asia Ins., compared to $1,254 for the same package with Infinity.

• BUPA plans start at $821 annually ($1600 deductible annually) with Asia Ins., with comparatively higher rates for the same packages from Infinity.

• Forte’s Fig Tree Blue plans start at $448 per annum with no co-payment.

Another option are travel assistance packages with 24-hour access to full service coordination of legal, medical or billing issues related to emergencies. For an annual fee, services at affiliated clinics are also provided at the membership rate. American-based companies are listed below.

And for coverage of household staff, the community-based health insurance scheme at the Phnom Penh Municipal Referral Hospital, SKY (Health for Our Families), costs $4.50/person/month.

Everyday precautions
• Have an emergency plan: identify a physician and donor, keep contacts lists updated.

• Keep vaccinations up-to-date. Hepatitis B is a particular worry.

• Road accidents are increasing in Cambodia. It’s a good habit to use seatbelts in the car, or a helmet on the motorbike, both of which will soon be law. Many employers require it, and many insurance plans will be void if the accident victim is not in compliance. Be alert. A useful phrase is “Som, chee yeut yeut” (Please, drive slowly).

• Check for front brakes on motorbikes before using them (are there brake handles in front of the right handlebar, and a brake line down to the brake pads on the front wheel?).

• Using familiar and reliable drivers and motodops can also decrease the probability of accidents.

• Bear in mind that medicine is a business, dangerously more so in a climate lacking a regulatory infrastructure and patient protection mechanisms.

• Do not self-diagnose or self-medicate. The fact that a Cambodian medical office may not resemble those back home in no way makes you more competent than an MD.

And for those unwilling to traverse the medical landscape here, Thailand’s excellent facilities are just a day trip away. Bangkok and Thai Airways both occasionally launch specials in conjunction with the larger medical facilities.

Useful numbers in emergencies by no deliberate order:
Your Embassy: _________

Police hotline (from land line): 117
Foreigner Police: 023-366-841 or 023-720-235 or 012-942484

Fire service (from land line): 118
Fire: 023-722-555 or 012-786693

Ambulance 24 hours (from land line): 119
Ambulance 023-724891

Clinics in Phnom Penh:
Ly Srey Vyna Clinics 023 982 003 or 12-9090988
Liudmila Health Clinic 023-302868 or 012-813318
Somary Clinic 023 99 18 68 ext.8081, 023 99 11 66
Samphop Sophea 012 883 661
Visal Sok Clinic 012 817 794
Tropical and Travellers Medical Clinic 012 898 981
Naga Clinic emergency hotline: 011-811-175 or 023-211-300
SOS emergency hotline: 023-216-911

Laboratories:
Institut Pasteur du Cambodge 023 725 606
NIPH 023 88 29 41
Biomed Lab 023 88 48 89

Pharmacies:
Pharmacie de la Gare: 012-805-908
Naga Pharmacy: 023-212-324
U-Care 023-222399

Insurance brokers:
Asia Insurance Ravuth L. Phann 012 239 222
Forte Insurance Maak Vuthy
Infinity Financial Ouk Sameath 012 644 111
SKY Insurance 092 74 60 04

Travel medical and emergency assistance
International SOS: www.internationalsos.com.
MEDEX travel assistance services: www.medexassist.com
International Association for Medical Assistance to Travelers: www.iamat.org.