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end of August, beginning of September 09

a travel blog by katja-horsch



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end of August, beginning of September 09

Phnom Penh, Cambodia


27.08.09
Now, Channa has Malaria. He complained about neck-stiffness and fever. When I found out I sent him immediately to the doctor and he has not only malaria but also typhoid fever. He is a tough cookie, he had injections yesterday and today and wanted to come back to work tomorrow. I refused to have him back for the rest of the week.


Yesterday I started to give the teachers in the RTC lessons for the first time. I do that now every day from 16:30 – 17:30. We have two groups, one group for Baby-English, one for advanced English. So far so good. It’s really fun. I really like it very much. The groups are not big and that is nice, so it is very participatory.
I like to prepare the lessons and when I develop a photocopy, I put a picture of England or Germany on it.

On Thursdays and Fridays, I also teach my neighbours girls English from 18:30 –19:30. I really like that and I have the feeling, I give something to individuals who benefit from it hopefully at some point.

Otherwise my days are a little bit dull. Getting up early in the morning, sitting in the RTC from 7:30 – 11:30, then going home for lunch, shower, nap, back to work at 14:15 –17:30, then usually home, shower, dinner, DVD, shower, bed, reading, lights out at 22:00. Because I’m on my own it is just uneventful. I never thought it would be like that, but it is. Well, we have nearly September and in October, my ICT starts and I’ll meet more new volunteers and that will hopefully give me new energy.
I think, that live is so much more worth if I can share moments and experiences with somebody else.

On the other side it is good to spend so much time in the RTC. I have the feeling to be on top of things and also that I’m doing what I can at the moment.

09.09.2009
Well, generally I am over my low point now, I think.

On Saturday, I usually have my 3 student nurses at home around lunchtime. One weekend I cooked my very famous Thai curry and the other weekend, they said they will bring something around. So they did. And we had a feast of Khmei soup and we had a small party and invited Delia as well. It was fun. Then after lunch we usually watch a DVD on my laptop, of course action film, and then they have to go to study.


So the last time they came around they told me that they never’ve been to Phnom Penh. I couldn’t believe that. Because they are Cambodians.
But because of money shortness they could never afford it. They really wanted to go though one day, so I said, why don’t we go together? I will help out with the tickets and we hopefully find a cheap place to stay.
They were so exited! But me too. I am really looking forward to that trip, so we’ll go on the 18th – 21st of September. That will be also a nice break for me, finally.

On one Sunday I asked Chantra, to show me the place where you can spot Dolphins here in ST. So he took me at 8am in the morning to a place, in fact a school, where he taught in the past. It was a beautiful morning, lush green forest apparently with monkeys until a few years ago, and so we waited at that little beach at the Mekong river for them.


But no Dolphin appeared. Third time unlucky.
Will I ever see them?

Afterwards we went to a place where people made traditional wooden sculptures, which was interesting.
Then Chantra showed me his little farm where he raises fish and grows vegetables to sell them at the market. There I had my first taste of wild freighted frog because one of the farmers cooked them for lunch. It just smelled really delicious, so I tried and there were really tasty. Like chicken. Would eat them again probably.
On the way back through the wood we saw 2 big snakes, gosh that was scary and lots of pineapple plantages.

Otherwise the rainy season has fully started now. It rains nearly all day at the moment and that is inconvenient with white trousers, cycling to the RTC. Fortunately I got those ‘Crocks’ like shoes before I left and they are worth gold now. The water for washing clothes and flushing toilet I actually save in buckets at the moment. So less to pay water bill.

What else?
I spent a lot of money on a few shopping trips over the past weekends in Stung Treng market. I bought 4 blouses there

, and also I went to a tailor to make a “Sompot” for me. That is a traditional long skirt, made from silk like material and you can get it in different colours. Mine is lila-pink and has a golden pattern at the end. Cambodians wear it for special occasions, and I bought mine for my first placement meeting with Daniel and the director from the RTC.
That will take place on the 10th of September, tomorrow and I have to make a presentation about my achievements and failures so far, and we have a Annual Work Plan to update and discuss, which then need to be followed for the next 12 month. So I prepared a lot of things for that and it kept me busy.

The other thing I am really happy about is that Vanny, Delias cleaning lady is a very good tailor too. So she adjusted a few clothes for me which were too big for me after having lost some weight since being here. Delia gives her own clothes to her and Vanny copies them with nice looking material.
I should do that too. It is so cheap and quite good quality.

With Delia I meet up usually on Saturday mornings for breakfast at the market and then we have our toenails painted at a special place where I get to know the people already slowly. I’d never thought of doing that in England, but here it is just something, people do. Women walk in their pyjamas in daylight on the markets and have their nails done. And it is a very good business. It’s supporting Cambodians and getting to know them and the other way around of course. Even very little children sit in the little stalls, have their toe and fingernails painted red.


Then I usually get some food for the week at the market. I usually buy cabbage, peppers, carrots, aubergines and green leafs for a veg stir fry and then I usually have a look for a ripe papaya and dragon fruit. I never tasted papaya before, but here I have learned to love it. Then, usually Sareth, Parim and Srey-mom come. They want to call me Bong, which means Sister. I like it. We have grown closer now. We talk honestly and they ask me serious questions. I also find out a lot about Cambodians that way.

In the RTC I am doing ongoing supervision with the teachers and they seem to be ok with it now. Lately, I observed one of my favourite teachers, Mr. Sokhouen, in class, demonstrating a practical skill, ‘Indwelling Catheter insertion’. The problem was, that although the RTC has dummies, they don’t have enough material like catheters or sterile gloves. So they have to improvise and that is sometimes tricky. After his demonstration, some students take the used gloves out of the bin, re-powder them for the next demonstration. They re-use every single thing until it’s completely not useable any more. Then they start to practise.
Afterwards I gave Mr. Sokhouen feedback about his performance and also suggestions, how he could improve his teaching.

The English lessons for the teachers are a success and even if there are only a few people, I think it is still worth it to teach them. And the ones who come are very enthusiastic and keen and they actually learn something.

11.09.2009
8 years after the New York Ground Zero.
Yesterday I finally had my 3 month review.

It was ok, when Daniel asked the present staff ( Clinical instructors) if they know what my role is and why I am there, they couldn’t answer it. Because they actually don’t know. I found that quite funny. Seeing them every day, building up a relationship and they don’t know what I am doing there! Well, I told them then and also about achievements and failures so far. We reviewed objectives from last year and set new ones.
One thing I am particularly exited about is, I had the idea of producing a film for equal learning outcome. Basically I want to film each procedure ( most likely with my camera, a low budget film production : )) , a student needs to learn here in Cambodia to pass the exam. And there are around 24 different clinical skills/ procedures, a nursing student learns in 3 years training. That will be easier to support the teachers, who will get a good teaching material and also some confusion about how to do things hopefully will be erased.
So that is one activity related to one objective, we discussed in that meeting.
But before we can start this really exiting project, we have to go through a rather dry one. Because another activity will be to re-translate the nursing curriculum to find mistakes in the translation to prevent more wrong teaching. And that will take it’s time…
Altogether we set 6 objectives, for me to work on in order to support the RTC. I don’t want to bore you with details, it might be also too dry. Anyway, this work plan with the objectives lasts for one year and will be reviewed next year and updated.

13.09.09
Having had severe hair loss and maybe worms, I am still alive.
Talking about health, I would like to share some information with you:

The 2008 population of Cambodia is approx. 13.3 million, about 80% of whom live in rural areas. Although still very much a least developed country, economic growth over the 1994-2004 period averaged 7% per annum and the proportion of people living below the poverty line declined from 47% to 35%. As a result of a massive ‘baby boom’ from the 1980 through the mid 1990’s, the country has an extremely young demographic structure, with almost two thirds of the population under the age of 30. The first wave of ‘baby boomers’ are now in their early 20’s and generation a second, smaller ‘boom’ as they marry and start families. Consequently, despite a steadily decreasing total fertility rate, the crude birth rate is a high 25.6 per 1.000.


Most of the population is engaged in subsistence agriculture ( rice farming) but this is already starting to change with more non-agricultural employment seen among those under the age of 30 then in the older age groups. The reach of mass media- television and radio, in that order- is substantial; more than two thirds of all Cambodians watch TV at least once a week; among youth aged 15-24 years, half watch TV daily.

Although the level of education is low by international standards, it is significantly higher than in the recent past. 57.8% of 15-19 year olds have completed primary school, a more than 20%age point increase over the age group immediately ahead of them, and a huge difference when compared to less than 10 percent of persons aged 40 and over.
Equally important, this gain is basic education has been equitable and a formerly pronounced gender gap is rapidly closing. For the age group 20 to 24 years the female: male ratio for completion of primary school is 0.68, whereas for the age group 15-19years it has risen to .92. These trends seem certain to continue; the net attendance ratio for primary school is at an all-time high and the gender parity index for primary school attendance is now 1.02. Although males still outnumber females with respect to secondary schooling, that gap has significantly narrowed in recent years as well.


The average age of marriage is 20 for women and 22 for men and has remained virtually unchanged over the past decade. There has also been little change in the median age at first birth, which remains about 21-22 years. However, while having a child immediately after getting married was once taken for granted, there are signs that young couples are starting to plan the onset of child-bearing in addition to overall family since, as indicated by the percentage of young married women with no children who say they want to wait 2 or more years before becoming pregnant: less than 10% in 1998, 14.5% in 2000 and 18.3% in 2005.

Fertility and infant and child mortality decreased significantly in Cambodia between 2000 and 2005, along with a noticeable improvement in intermediate indicators as child immunization and contraceptive prevalence. However, at 84/ 1.000 live births, the under 5 death rate is still one of the highest in Southeast Asia, and maternal mortality has shown no improvement at a very high 472 deaths per 100.000 live births. Progress has been made in curtailing new transmission of HIV but the epidemic is far from over and transmission from mother to child remains a neglected area in terms of prevention.
Tuberculosis remains hyper-endemic, affecting approx. 225 per 100.000 of the population.
Dengue fever is endemic with major outbreaks occurring every 2-3 years.
Malaria is endemic in the more remote, forested parts of the country. The population remains vulnerable to unpredictable out-breaks of other infectious diseases such as SARS, avian influenza ( AI) and other respiratory infections.

Public Health System

The Ministry of Health (MOH) administers health services through 24 Provincial health Departments (PHD) and 76 Operational Districts ( OD). Within each OD is a network of Health Centres ( HCs) designed to provide primary preventive and curative health services known as the ‘Minimum Package of Activities’( MPA). Although the HC’s each cover a catchment area of only about 10-15.000 people, roads are poor and distances can be considerable. Consequently, immunization and other key preventive services are provided on an outreach basis, which is supposed to occur monthly. HC’s vary in how reliably they follow this schedule and tend to perform best in areas with technical/logistical support from NGO’s or other external agencies.

Supporting the HC’s is a ‘Referral Hospital’ (RH) which provides inpatient care and an expanded set of services known as the ‘Complementary Package of Activities’ (CPA). Development of the RHs to their officially designated CPA status is still a work in progress; many RHs lack surgical and blood-banking capacities and, by extension, the ability to handle obstetrical emergencies.

Weaknesses in the public sector service delivery
system include:

- inadequate financing and erratic provision of essential drugs and equipment
- Health provider incentives do not reward quality service delivery and performance; the health systems suffers from overlapping, counterproductive payment and incentive schemes and low public sector salaries leas to simultaneous practice in the private sector..
- Inadequate (numbers and skill-level) human resources at the service delivery level and inappropriate allocation of available human resources, especially midwives
- A general lack of accountability and transparency, and an organizational culture which is not merit-based or performance-oriented
- De facto autonomy of multiple vertical national programs; while this has, in some cases, been helpful in ensuring rapid action in response to specific public health needs (eg the HIV epidemic), it creates a considerable obstacle for needs that cut across administrative program lines, eg PMTCT and diagnosis/ treatment of HIV/ TB cross infection

Overall Government Hospitals perform poorly, especially in rural areas. Both service statistics and the CDHS indicate very low levels of utilization. While the previously described limited range of services available in many of the hospitals, as well as poor quality of care ( both technical and interpersonal) undoubtedly plays a role, there is data to support the common belief that financial barriers are paramount. The median health expenditure for treatment in a government hospital is $26.63 for an illness of moderate to serious severity, slightly higher than the median expense found in private hospitals. Most importantly, all but the highest socio-economic quintile experience problems in meeting this expense, as indicated by the percentage who report having taken a loan or sol an asset to finance it.

-Cambodia, Secondary analysis of the 2005 CDHS, unpublished-

I miss you all very much, take good care and keep in touch.

Yours Katja



permalink written by  katja-horsch on September 13, 2009 from Phnom Penh, Cambodia
from the travel blog: end of August, beginning of September 09
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