Culture Shock
Unprepared for the hard realities of life in Cambodia, volunteer RNs
struggle to cope with challenges to save ailing children
By
Karen Coates
August 20, 2002
It's 3 p.m. Thursday. The rain has stopped. The air steams. Faces glisten with pearls of sweat. Fluorescent light shines on rows of beds; mosquito nets await hanging at dusk. A wave of workers in blue and green hospital scrubs moves from child to child, checking charts on daily rounds.
It's been six days since California nurse Matt Bording, RN, finished his year at Angkor Hospital for Children in Siem Reap, Cambodia. He volunteered for $350 a month plus room and board, experienced the expatriate life and gleaned a wealth of introspection. He lent his knowledge to a fledgling Khmer staff. He helped save hundreds of lives. And eventually, his time came due.
"Would I do it again? Yes, but differently," he said. "Of course, we can say that about anything in our lives. There were both personal and professional gains from this."
Although he leaves the hospital a better place, himself a changed person, the workload at the children's hospital never ends. Day after day, a steady stream of need flows through its doors.
In his last week, a newborn arrives. Dad drops off a tiny child, weighing less than 3 pounds, born at 30 weeks gestation. A tiny body with blue-gray skin and blistering lips, bundled in an incubator. The father leaves and never returns. This is not unusual, Bording said. He doubts the child will live. But six days later, during Thursday's rounds, the baby still sleeps soundly and the staff is hopeful.
In bed 10: a 13-year-old boy, fluid in the knee, gored by a water buffalo.
In bed 15: a malnourished girl. Her father holds her twin in his arms. "Are we feeding both children?" asked Eugene Tragus, MD, director of surgery and critical care. There's discussion in the crowd. "Please see that the mother has money so she can buy food so she can eat so she can have breast milk to feed the babies," Tragus said. The mother has eight children.
In the ICU, a girl with rheumatic heart failure sits in bed. She has a DNR order and a file that is inches thick. She came the day the hospital opened in 1999, and has returned many times. She will die soon, and although the staff has not told her this, she knows they can do nothing for her. If she lived in Malaysia or France or the United States, she could have an operation. But she doesn't. She lives in Cambodia, and there's simply no money or facilities to save her life.
"We've run out of money to send congenital heart patients to Malaysia-and they're going to die," Tragus said. That inability is the most difficult part of his job.
Cambodians see death everywhere. From 1975 to 1979, the Khmer Rouge tried to create an agrarian utopia. At least 1.7 million people died of disease, torture, starvation and execution. According to hospital records, all but 40 doctors fled Cambodia or were killed by 1979. The Khmer Rouge civil war lagged until 1998. Health care still is catching up.
According to a 2002 UNICEF report, the average Cambodian earns $260 a year. Nearly half the children are underweight and suffer stunted growth. Only 30 percent of the population has access to safe water, and even fewer to proper sanitation.
Japanese photographer Kenro Izu founded the nonprofit Friends Without a Border, through international donors and his photography sales, to build a children's hospital. Its doors opened in May 1999.
Such dire need draws people such as Bording. But living in Cambodia is a profoundly soul-searching experience, as well. "There was a lot of inner and outer learning," he said. "There was also a deep examination of not only my own values, but those of the United States."
The hospital sits in a Siem Reap town on a dirt road just a few miles from the world-renowned Angkor temples. It averages 135 patients a day. Its staff includes more than 60 nurses, 13 physicians and, until recently, 14 expatriate professionals. Khmer outpatients who can afford the price pay 25 cents for medical service.
Nursing director Mieko Morgan, RN, said the hospital's mission is twofold: Offering top-quality health care and "at the same time, we are training the next generation of professionals." The hospital is building a new medical education center, and eventually the staff will govern itself.
One day at a time
Each morning, hordes of parents and children crowd the wooden benches of an open-air waiting room, watching cartoons in Khmer, awaiting help. They come for every imaginable reason.
"My God, every day brought bizarre and unusual things," Bording said. "I saw a couple of kids die of rabies, severe malnutrition, heart failure from rheumatic fever, traumas from hand grenades, worms climbing out of colostomies ..."
And kids falling out of trees, Tragus added. "Up there getting coconuts or something."
Expatriates routinely see cases they only learned about in school and rarely encounter at home-landmine injuries, typhoid, tuberculosis, malaria, dengue fever and hemorrhagic shock. Bording himself contracted dengue-"not recommended"-and suffered its fatigue for several weeks. The mosquitoborne viral illness in August 2001 filled the hospital beyond capacity.
"There was almost always at least one case of meningitis in the hospital, including TB meningitis, which I had only heard of," Bording said. Until then, he had never seen children with empyema, a pneumonia complication of pus surrounding the lung.
Bording said most of his American critical care knowledge "simply didn't apply, as there wasn't much in the way of technology. In the ICU, there were some newer heart monitors and an ECG machine, but that's about it, so it was clear that reinforcing good, basic nursing care was a priority."
Consequently, many diagnoses are made through a process of elimination rather than expensive tests. "We're a very poor hospital financially," Tragus said. "It would be nice if we could afford an X-ray. A lot of the time we just can't afford it." He's also trying to secure funding for a ventilator. Without one, "the nurse sits there and bags the child" as long as necessary.
Such funding woes also make for tough decisions. "Many of our long-term ICU patients in the U.S. have hospital bills higher than the AHC's annual budget," Bording said. "Using maximum resources to try-often unsuccessfully-to save a few people, while others are dying of easily treatable conditions is just not part of my value system."
Still, he was not accustomed to so much death among children, and he couldn't fathom some of the parents' reactions. "Usually they would appear somewhat grim," he said, "but often they showed little emotion, and when we would tell them their baby was dead, they'd just say, "OK" and walk off. Many of the rural people had huge families, and it was almost expected they'd lose one or two."
Culture and history play into this. "A country such as this, where one's mortality is in their face all the time," Bording said, "possibly lessens the fear of death. It's not some sanitized and faraway thing like it is for us in the West."
Cambodia also is a country where 80 percent of the population lives in rural villages, often hours from paved roads and city doctors. Many Khmers have never been to a hospital. Health care is dramatically underfunded.
Prak Manila, a nurse at the children's hospital, worked at a government hospital three years ago and took home $10 a month. "We cannot provide good nursing care like that," she said. But as the AHC nursing education coordinator, she makes $200 a month.
The nurses are patient. They treat emotional as well as physical health. And they learn on the job. "This hospital is very special in Cambodia," she said. "Nurses in this hospital get education every day. Education in this hospital is the main job."
The Khmer staff has graduated from Cambodian medical and nursing schools. However, expatriates agree that education was rudimentary.
Lesson plan
Bording liked the opportunity to teach. "Teaching classes was something we did several times a week, which meant I had the chance to do reading and research," he said. "I prepared many handouts. If there was an interesting case, sometimes I would go read up on it, and prepare a quick informal lecture, which they loved."
But there were cultural barriers, particularly with attitudes toward pain. "Pain was grossly undertreated, and this required a lot of education," he said. "Sometimes it was mortifying to see. Through hammering away at this on many levels, I'm happy to say pain control is much better."
Language was another obstacle. "They learned their curriculum in French," he said. "I taught about heart failure, and no one understood the word 'pump' so I'd have to think of ways to describe the action of the heart, in simple terms. It was usually a matter of finding the right analogies."
Furthermore, most Cambodian students are too poor to buy textbooks, "so the teacher just lectures, and the students just listen and take notes," he said.
Morgan said Khmer nurses also refrain from questioning authority or admitting to things they don't know. "Nurses are just doctors' extra hands and legs-that's all. But AHC encourages them to speak up or say they don't understand something. That's the safest thing for the patient."
Bording agreed. "A lot of work was put into getting them to think for themselves and possibly make suggestions, with only a little success," he said. "Since I'm from a system where communication between all staff is essential, I did what I could to encourage the nurses to ask questions, making sure I backed them up if the doctor became petulant and hissy."
He sometimes contradicted doctors himself. "After a while, it was still difficult to tell when to be appalled at what was happening but just let it go, and when to dive in and try and change things," he said. "Certain aspects of nursing-and medical-care were substandard, but not really dangerous, and everyone was comfortable with doing something a certain way, so changing it would be difficult. But if I saw a procedure being done improperly, say without pain management, I would stop the doctor or nurse and insist they take care of it."
Bording also didn't find quite the collaboration he treasures in the States. "In the U.S., teamwork is not only highly valued, but absolutely necessary." That wasn't his experience at the Angkor Hospital for Children. He doesn't want to sound like he "has an ax to grind," and the differences he had were mostly personal, but "progress would have been [made] much faster if there had been collaboration."
But perhaps the biggest challenge was living there. "Even though I have seen a fair amount of poverty," he said, constantly seeing tattered clothing and malnutrition wore on him. "There is that balance between compassion and my own boundaries. Anyone who has been to Third World countries knows about this-it's like you want to help everyone, but the problem is so vast and complex, you would go broke and become overwhelmed, and still feel like you hadn't done anything."
But he has done a lot, and he'll continue. After traveling through the region for a few months, Bording will return to work at Good Samaritan Hospital in San Jose. He plans to further his education. And he said he would like to work in development health care again.
"My advice to other nurses is to do some kind of Third World travel; in fact, that's my advice to everyone," Bording said. "At this point I truly believe a factor in many of the world's problems is that Americans are completely clueless about the rest of the world, and when a scratch in their SUV becomes the most earth-shattering thing, I think we've seriously lost perspective.
"There are so many people I wish I could take to Cambodia for even one hour to show them how much of the world lives," he said. "Maybe then they'd be grateful for the things they do have, and not worry and stress so much over nonsense."
Eye opening experience
Was Matt Bording ready for the mental and physical rigors of nursing in Cambodia?
Bording is a veteran traveler to parts of Asia and other developing parts of the world. He had visited the hospital before starting. His colleague Eugene Tragus, MD, thinks he was ready. "Matt was prepared for it because he traveled sensibly," Tragus said. "Matt was an excellent nurse and a good teacher."
But Bording's answer is a little more complicated: "Was I prepared? Well, I thought so, until I was there only a short while," he said. "I have about 18 years of hospital experience, and I thought that especially with my critical care background, I could do anything. Ha ha."
He knew volunteers from developing countries had preceded him. "In my own American arrogance, I thought, "What could they possibly know that I don't?" Well, lots, it turns out. Once I grasped what had been done before me, I was definitely humbled.
"Doing development work like this, I could have gone back to school for a few years to prepare, but I would have missed the real experience," he said. "I had traveled to many countries in Asia before, and that definitely helped, but living in a place like Cambodia is much different than being a traveler where you can just pick up and go when you want."
It isn't easy finding expatriate nurses for the job, said nursing director Mieko Morgan, RN. "We have lots of mistakes we've learned from." Short-term volunteers often feel more like donors than employees. "The definition of volunteer commitment is individual." The hospital now looks for a minimum of one year.
Bording stressed the legwork needed before committing to anything. "If
someone wants to do this kind of work, researching the country, the organization
and knowing your own skills is essential; also knowing yourself as to
how much discomfort and inconvenience you can live with," he said.
"Clear direct communication is also crucial, knowing what will be
expected of you, and how to do any advance planning that might be required.
Having said that, I would highly encourage anyone to do something like
this, as they will grow in ways they can't imagine."
~Karen Coates
Cultural conundrum
Spin through a Cambodian market, and you'll find stacks of Alaska brand sweetened condensed milk, full of fat and flavor, but skinny on nutrition. The can's label sports a grinning, plump, light-skinned boy.
How can you tell a Khmer mother that such a diet will malnourish her baby? Why would she believe you, when her baby grows fatter with each can served?
It's a conundrum in a culture that prizes weight. "They're all malnourished and suppressed when they come in," said Eugene Tragus, MD, head of surgery and critical care at Angkor Hospital for Children. "So they all go home with vitamins. In fact, that's part of their routine."
According to hospital records, every year 64,000 children younger than 5 die of preventable diseases and injuries. Culture, superstition and traditional beliefs play huge roles in the way health care works.
Walk through that same market, and you'll find stall after stall selling barrel after barrel of white rice-but no brown. Brown rice would help eliminate vitamin deficiencies. But it has a bad connotation in Cambodia, where people were forced to eat it during the Khmer Rouge regime.
Tragus said "cultural thinking" is one of the most challenging aspects of work at the Angkor Hospital for Children.
~Karen Coates