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LIFE ON THE LAKE

The Tonle Sap is big, really big!

It’s not only the largest lake in SE Asia, but home to some of Cambodia’s poorest and most isolated families. They live by fishing, and their livelihoods and floating homes move several times each year, according to the water. By the end of the monsoons the lake will cover 8 times the area that it covers in the dry season – vast bodies of water become vegetable gardens, navigable boat routes become tiny streams, and access becomes increasingly difficult.

All of this makes life and work a challenge for the health care teams who work on The Lake Clinic boat, a floating health care service for thousands of families for whom there are few other services available – no electricity, no clean water supply, no sewerage, no public transport, and no food supplies other than those harvested from the lake. Floating school rooms, and sometimes even floating health clinics, are present in many villages, but rarely do teachers or health care staff from the land stay to work in these inhospitable locations.


The Lake Clinic boat, TLC 1, with its teams of Khmer doctors, nurses, midwives and support staff, visits each village on its route every 4 – 6 weeks. People paddle in small wooden boats, motor in fishing boats, or get lifts with friends and neighbors to gather at the clinic reception. Children are often malnourished, old people have untreated chronic illnesses, fishermen may have injuries, and pregnant women come for ante natal care. People needing more intensive treatment are advised to go to hospital in the towns, women are encouraged to go to hospital for delivery of their babies, but often they don’t have the resources to make these trips. Babies born in the floating villages suffer one of the highest neonatal mortality rates in the world.


I worked as a volunteer nurse and midwife on TLC 1 during the wet season, when we had access to many villages. This entailed a 5 – 7 hour trip across the lake from a port near Siem Reap, carrying all supplies and equipment needed – easy in fine weather, but treacherous in heavy rain and strong winds. Over 100 patients are seen on many days, and float home with medications, or bandages, maybe new glasses, and always with reassurance. This service is provided without charge, and the caring connection between patients and staff is a joy to see.

The service could be improved. Days of travel time to and from these isolated villages means that only 2 clinics are held each week – a faster boat would mean less time commuting and more time seeing patients. Access to many villages is difficult or impossible in the dry season due to low water levels – a large boat with a shallow draught would accommodate staff and adequate supplies year round. In an emergency such as acute illness, accident or equipment failure, a rapid response boat for support would be very much appreciated.*
Lorel Adams; midwife and author (L)
However, the TLC 1 visits continue, and families living on the lake are healthier and happier because of this support.

*TLC Note: Not just one, but funding for two new boats has been secured and will be constructed this year.

I’m back! It’s been too long since my last outing on TLC 1 and I am so excited at this opportunity to get back on the lake.
My newly acquired, second hand, mobile trills out its 5.30 wake up call and as the bags are packed up already, it takes little time to wash, dress and jump into a tuk-tuk to take us to the office.

I am introduced to the new team: Rida, a beautiful young Khmer doctor who has recently finished her medical training in Russia; Mom, a serene and lovely young midwife/nurse; and Sy Sathya, a very attractive mother of three who has taken Aly's place as cook. No one is wearing a glint of eye make-up or lipstick: they just look naturally fabulous. I won’t have competition for the one, small mirror then, when putting on my mascara.

Sombun, greets me warmly, for we have travelled on quite a few trips together by now, and he and Mike, my husband, work harmoniously together. But there are still three more to say hi to: another doctor, Andrew, who has already done a week’s work with Team A, and a well dressed young guy called Phou Kong, who is now working as the registrar. He greets me with a wide grin. I am intrigued that he has a large mask, quietly at rest on his chin; later, when doing the clinic, he wears it firmly in place over his mouth and nose. Actually, I have already been surprised at how popular these masks are in Siem Reap; I don’t remember seeing any, 18 months ago.
That leaves just the singing boatman: Thun Chantrea: lithe, forever smiling and known for bursting into musical solos whilst maneuvering TLC through trees, water hyacinths and around the villages. He is full of such good humour that his presence rebounds long after leaving the boat. It's almost enough to help forget Aly's absence from her post at the wheel.

Sothat, is driving us all to the boat in the large van, donated by IMPACT-UK, which is a bonus, as there is room for the 9 of us, plus medical equipment, food and our own personal belongings to be snugly piled up in the back. There is even some air-con, unnecessary for a cool November morning, but I know the day will heat up mercilessly soon enough. The road to Chong K'neas, where TLC is now moored, has turned into a Grade Z road. It must be because of the recent floods, but I spy drainage pipes due for installation and huge bulldozers ripping up what surface is left, and I am vaguely puzzled about which came first! We follow a long track of bumpy riding with most vehicles tending to steer down the middle of the road, which makes for some swift steering changes when oncoming traffic appears.

I am visually inhaling roadside village life waking up, noticing how the uniformed children handle their bikes that bounce over potholes and boulders or swerve around trucks and motos. I notice a small shack where a man is threading up his sewing machine prior to his morning’s work and see the cockle sellers in demand and then I realize, suddenly, that I am rather hungry too and find myself looking longingly at some of the food vendors. When we finally arrive where TLC is moored, the luggage is most efficiently carried onto the boat and as I admire the elongated proportions of TLC, I realize that we are moving away from our mooring and our voyage has begun.

It is a long journey to Pov Voey, the village where we are heading this day. As I seat myself comfortably on the top deck, leaning against the back seat, I think of all the people whose lives have been enhanced by the work that comes from the sturdy team who make up The Lake Clinic. In the 18 months since I was here last, not only has the Team doubled but also the number of villages visited has expanded to 8. A new floating health clinic is already being built and more are planned. Sakhem is imminently taking charge of a small, shallow, speedy boat, TLC-2, which he will use to do day trips to certain villages to follow up on the VHV programme. In leaps and bounds, in small ways and vital ways, many of the fishing families are beginning to reap the benefits of having a mobile health team reach into their furthest communities.

Coffee appears in steaming plastic mugs and then we are called downstairs for noodle breakfast. Gosh, it sort of feels as if it should be lunch, but I am secretly glad that this means there are still two meals to go. The day begins and ends early on the Lake and we are governed by the hours of daylight, as there is no electricity in these villages; whatever electricity there is, comes from car batteries.

The sun is penetrating its way onto the side of the boat where I am sitting, so I move along a bit and promptly hear something giving way. A square wooden board appears to be loose and I vow not to go near it, or put any of my books on this space. However, the sun keeps its focus firmly on my body and I find myself inching towards the forbidden area and end up jumping up and standing near the front of the boat. I heard it said that no women should sit at the front of the boat as this is purported to bring bad luck, so I ensure that I remain on deck, regardless of the eventual lack of shade.

I start writing in my notebook until I feel my skin beginning to burn and then I decide that I will just have to join the others inside the bunks downstairs. All is very quiet. There is absolutely no room to join them in the cabin and I look gently at the girls and Kong at rest, before I dart into the memorably diminutive toilet-cum-shower.

Just before we stop for lunch, Sy Sathya takes over the driving to give Chantrea a break. However, there is a bit of a drama when the boat lurches over a series of waves and I look up to see we are about to hit a mangrove tree. Andrew swiftly ducks as a chunk of branches thrust their way onto the deck. Seconds later, Sathya reverses and to our horror, we see there is another tree behind us! Chantrea is up in seconds, grabbing the steering wheel and telling his friend to go back to prepare lunch! Shortly, we tie up to a lone mangrove tree and we all tuck into a delicious spread of rice, chicken and fried fish that Sathya has somehow managed to put together. I spy my favourite fresh chilli, garlic and fish sauce which I pour rather liberally over my meal! There is silence then laughter and Khmer chatter and I wish once again that I had done my language homework so I could understand and even participate!

I doze and then move to whatever is left of the shade on the top deck. This amounts to a halo’s worth and, fortunately, that is surrounding Chantrea. I decide to point my camera into the horizon, hoping to capture wild, exotic birds alighting and departing from the frail greenery in the distance. It is then that I notice a large, solid looking building in the distance that looks vaguely like some sort of temple.


As we draw closer and edge round some vegetation and boat houses, it almost takes my breath away to see an ancient temple sitting in the middle of a large square completely surrounded by water. I watch as young, orange swathed, young boys walk slowly through the square, or lean over the balustrade outside their living quarters, which flank either side of the ‘island’. There is a tall palm tree beside steps half submerged in water. This is where we tie up TLC 1. It is around 4.30pm and we need to take all the plastic medicine chests into a covered area behind the temple. A very excited group of mischievous looking boys bound around us and with squeals of delight show they want to carry the boxes for us! They move like quicksilver! They are full of curiosity but it’s not long before they are amusing themselves near us with rough and tumble games. All the meanwhile, the young novices come to watch us too, but from a measured distance and they stand silently in doorways or at their windows or by the railings outside their living quarters.

The light is stunning; the setting is mystical and there is an air of tranquility and peacefulness. This is a very special moment. The young monks are beginning to gather in the ancient temple for prayers and soon the air will be full of their chanting. As I lean back against the tall palm, Rida joins me and asks if I would like to visit the women’s temple with her, which is situated on the far left of the square. We walk inside and look at paintings depicting the story of Buddha and then I notice three older women stirring pots in an anteroom and four small children squatting with some food beside them. We smile and nod and then I walk back to the open window and peer out to see a thriving patch of herbs and vegetables growing and two boats paddling by on their way to the village “shop”. Rida tells me there is something else she wants to show me and we walk to a little altar behind the temple where there is a sacred rock which has, according to legend, the Buddha’s hand imprint on it. It is quite difficult to see it clearly but we kneel and honour it together.

Walking back towards the boat, we pass some novices walking down to the water to bathe and enjoy the coolness of the lake. But for us, it is supper time and Sathya and Chantrea have laid up our feast on the flat length of the back of the boat: rice, meat with vegetables, boiled fish and chilies, followed by fresh watermelon. Quite delicious! As we eat, dusk drops silently around us. Suddenly, an array of small lights shines out over the temple and above the steps. We feel rather delighted: this must be in our honour! It is also rather good to be able to see what we are eating. However, these lights turn out to have nothing to do with our arrival at all: a long boat is approaching the jetty with several monks inside it and one woman. They clamber out with some difficulty and step onto the stone, to be greeted by several of the novices. We discover that three local monks have brought with them a visiting monk from another monastery who has come with a donation!

I have been so caught up in watching the scenario unfold, that I have failed to notice that everyone else is busy putting up the mosquito nets, going to have a shower, clearing up supper or putting up beds outside the novices’ dormitory. Mike and I have got the top of TLC as our double bed, minus a mattress but with a thin matting and sheet. It all looks unbelievably romantic when the netting is in place and even though it is only 6.30 pm, we’ll be happy to snuggle in there. But the shower (which is working, much to everyone’s relief) has to be tackled first! I manage to get everything wet in sight, including my sarong, as my awkward arms spray the shower too strongly in the wrong direction. I’m still trying to rinse myself from the soapy shower gel, and I haven’t gone near my hair as that is altogether too challenging. Finally, after I am sure the pump has sucked out all the water off the floor and I have dabbed around the place with my clothes to dry everything off, I emerge trying to look fresh and clean, even though I am wearing a soaking sarong and clutching very damp clothes. I lean over the boat with my toothbrush and toothpaste and a bottle of water for rinsing and then climb the steps to our hideaway. The monks and novices are chanting in the Temple and I have to pinch myself that this is for real. Before disappearing under the net, I turn to look across the lake and marvel at the twinkling lights and the vast open starlit sky above.

I wake to hear movement and realize that it’s 5.30 and time to get up and prepare for our long day ahead. Everything is stacked away neatly, our bed folds down; other bedding is stowed away alongside ours and then it is time for strong Khmer coffee and a breakfast of rice and meat, and thoughtfully, some fish for me. Already, we are aware of small boats arriving loaded with locals, who make their way to the back of the ‘island’. Four tables are in place and the boxes of medicines are set up on one. I get out the measuring tape and with Sambon’s help, we stick it to a concrete pole. This is where I will measure and then weigh each of the children. Mike and Sambon work at a table together and Rida and Andrew are at another. The backdrop is like an enchanting stage set.
It is while I am liaising between Mom and Kong and the patients’ notes that I become aware of a still figure observing me. It is the monk of honour who arrived last night. I give him a smile and then, when there is a lapse in the queue, we start talking. He tells me his name and that he is currently living in Adelaide but is originally from a small village in Ratanakiri. He has been a monk for a long time but never known about this monastery until recently and was very pleased to be able to come in person to hand over the donation raised for it. He pauses and then asks me solemnly if I would be so kind and spend some time teaching the Buddhist novices this morning. I think this to be an honour and accept happily. Within five minutes he has summoned about 20 adolescents who greet me with winning smiles. I already recognize quite a few who have been gazing down at us from their balcony.

I start my lesson. From time to time the group is joined by a few more, who are encouraged by their peers to practice new words and phrases. They seem to be quick learners, and Lee, who remains as a keen overseer, translates from time to time, which is most beneficial. At one point, my enthusiasm carries me away and I come far too close to them, so that they all simultaneously draw back from me. Lee laughs and explains that it is forbidden for them to get in close contact with females. Nor, I discover, are they allowed to jump and run, as I had some teaching material involving this, so I have to change my plans accordingly. There is lots of laughter with the new language and I am sorry when it is time for them to head off to their lunch. They all thank me with great sincerity.


I slide back to the large day bed to find a host of young children drawing me some wonderful pictures.
I take some photos of them and the others at work. I am getting hungry and realize that 4 hours have gone by. The last person is being seen and I tidy up the day bed when I see one of the novices carrying two plates of food and he is bringing them to me! Lee appears and says that he knows we are about to have our lunch but would I like to accept the plate of small bananas and a plate of freshly fried bananas in batter, which happen to be my favourite thing (how did he know this?) I thank him gracefully and pass them around the team. We go back to the boat for lunch and then have a rest until 2pm when the afternoon clinic begins again.

There are plenty more people rolling up to attend the clinic and we get to work rapidly. Already, I notice word has spread that there is a stack of drawing materials and some animal figures for the children and I find the day bed rather crowded with small boys with such eager enthusiasm for showing me what they can do. Once the measuring is all out of the way, I sit down with them and we have such fun together drawing animals and boats and teaching each other words for our drawings. I produce some scissors and we cut out and hang some fish on a tree. Several of the novices who have been watching from the temple window, suddenly appear to my right, watching me most intently. I offer them paper and crayons. Three of them nod and with wide smiles walk off with their bounty. About an hour later they return with three beautiful drawings which they have clearly spent all this time creating: one is of a handsome Buddha, one a fishing scene, and the third has the young Buddha astride a magnificently drawn elephant. I am impressed.

The heat of the day is finally ebbing. We have had to move our position several times around the huge day bed and I have been taking photos and observing the action around me. Two elderly ladies with shaved heads, have been squatting for over an hour waiting to be seen. They sit silently and contentedly along with others in the queue that seems to have formed beside the day bed. All the time though, everyone is watching everything!

When patients need to lie down to be examined, they go into the ‘women’s temple’ with the Doc, or just lie down on a stone bench near the day bed. It is very much a whole village spectacle going to the doctor’s and there is no such thing as a private consultation as, frequently, small children, and adults, constantly hang around watching or listening in fascination. Everyone wants to be a part of the action, in whatever capacity! We, in turn, are a most novel event, but most importantly, this village now knows that once a month, they have the opportunity to see a well qualified medical team and soon there will be a network of Village Health Volunteers, trained up by Sakhem, and chosen by the villagers themselves, who can advise on hygiene, diarrhoea prevention, and, check out that those, who need a visit to the next clinic, do turn up. Moreover, the new floating clinic will allow for much needed privacy in the near future.

The last patients have been seen, Mom has administered the last lot of medicine, Kong has packed up his table and we all clear up around us. The boxes all need to be loaded onto the boat, but where are our helpers? I spy some little boys eating with the shaven headed women; the others must have just nipped into boats and disappeared to their homes. It is very quiet. There is just time before supper to pay a visit to the main temple. Rida and I go together. We slip off our shoes and walk inside on the cool tiled floor. There is a large Buddha surrounded by smaller statues and colourful offerings and there are lovely wall paintings, some of which are in need of restoration. Here it is timeless, quiet as the earth hiding its history, a sanctuary for those who enter. We sit, we stay awhile, lost in thought.

Supper is being laid out again on TLC as we clamber aboard. A lone novice comes down the steps to collect water in a bucket while others are bathing.

The sun is setting, flooding the sky with vermillion and crimson hues. As we sip a drink in silence, the staggering scenery slowly blacks out before our eyes. Dusk drops like a stage curtain.
The few lights from some of the boathouses across the water flicker and glow and there is the faint noise of a shallow boat being raced, to which the two local dogs howl in response.
Above us, the heavens are pierced with diamonds. I eat my rice, pondering on these last two days and the enormous influence they have had on me. I will remember the magic on stepping onto this spot and the joy on the children’s faces; the ancient serenity seeping from the open temple; the throng of patients waiting to be attended to medically; the mixture of novice monks and visiting village life; the teaching to a group whom I will probably never meet again and yet I won’t forget their warmth and smiles; and, the great team of people who make up TLC.


Jenny Shepherd
December 2011

©2010 Iris Ma, MD

3/29:
I arrived in Cambodia ~midnight on Sunday, March 28 to be picked up by Sothat, a fluent English-speaker and self-described Cambodian "farmboy" who lives with his "[god]Dad," the famous Jon Morgan, an American and fearless leader of The Lake Clinic.

At the airport, Sothat was quite confused by my appearance as he clearly expected a fair-skinned Caucasian as opposed to a fast-talking Asian-American. All this was made somewhat more entertaining by the fact that my plane came from Seoul and was composed of mainly South Korean tourists.

My first impression of Siem Reap is that it is a bustling, touristy, well-outfitted city with a lot of dogs. These dogs are generally medium sized, but thin and generally non-aggressive but highly alarming. It's no wonder that rabies is a problem and this knowledge, combined with my general discomfort around canines makes me somewhat skittish on the streets.

Otherwise, I am happy to walk around taking in the sites and food. Everything is skinny here: skinny people, skinny dogs, skinny chickens, skinny cows. I wonder how a Cambodian would react to a day in Dallas, Texas.

©2010 Iris Ma, MD

4/1
I left for the lake on 3/29 with Dr. Sambun, Savann (nurse and team leader), Ally (excellent boatwoman, cook and former resident of Moat Klas, the largest of the floating villages) and the Chantriya (boatdriver). We traveled 1 hour by car to Kampong Khleang to board what the team jokingly calls "TLC Zero".

The lake is particularly low this dry season, measuring less than 1 meter in several areas and impeding travel significantly. The chocolate milk complexion of the water is alarming, especially knowing that is where all the people and animals defecate, urinate, bathe and drink.

Unfortunately, TLC One is too heavy to travel with the lake’s low water levels, so this week a small boat has been rented to make the journey through the narrow channels.

Like the Little Engine That Could, TLC Zero made it to Moat Klas (Tiger’s mouth) in a little over 5 hours, about twice as long as it usually takes, and continued for 6 hours until we reached Don Sdeung. There were several problems with the engine and getting stuck in the shallows.

©2010 Iris Ma, MD

Our intrepid boatdriver would frequently hop into the lake to push the boat. It was disheartening to see that at times he was only up to his knees or thighs. We made it to only two villages this week and were forced to cut out a clinic half-day due to long travel times.

The floating village residents are essentially all fishermen/women and not considered so poor as there are a lot of fish. However, Cambodians, particularly educated Cambodians, have no interest in living in these distant fishing communities with their backwards ways and really difficult access to the rest of the world.

The UN has several programs in the area and I believe the UNDP even built a clinic facility in Don Sdeung, one of the villages I went to, but they were unable to recruit a doctor to work there.

As you can imagine, the underserved of Cambodia put the underserved of the US to shame.

Elana Rosenthal, MD empathizing with a small patient.
©2010 Iris Ma, MD


At Don Sdeung, we acted in an acute and primary care clinic capacity. Most of our problems were similar to those in the US as far as acute illnesses go with a lot of URIS, way more gastroenteritis and some acute otitis media. However, the chronic problems were fewer as there are not many older people and no obesity.

There was no hypertension (every BP I measured was 90-120/60-80)! Certainly, arthritis and vision problems abounded in the older patients, and we had one untreated diabetic with a horrible foot wound.

The pharmacy is impressive with a wide range of antibiotics including ciprofloxacin, trimethoprim-sulfamethoxazole, amoxicillin, ampicillin, metronidazole, clindamycin among others.

©2010 The Lake Clinic Cambodia

I had fun opening up a perirectal abscess in a 3yo boy. I'm sure it was horribly painful, but the amount of pus that came out was very, very impressive.

I suspect he would have died if not for this clinic as he was a small (~5kg) child with a very large, deep abscess. Mom and baby were crying during lidocaine injection and then later as I squeezed out about 1.5cups of pus and broke loculations. However, mom in the end was very satisfied and thanked us with a very large fish.

That night we continued on to Peam Bang, worked from 7:30 AM the next morning through a similar set of problems and left by 9:30 AM to make it home before dark.

We saw 66 patients on day one and 41 on day two.

4/2
I wish I could capture and send smells because Cambodia is a fragrant country. In the morning as I make my city rounds, usually around 6:30-7 as it becomes intolerably hot by 1030, the aroma from the food stalls/shanties wafts onto the street. A mix of garlic and fish sauce in a cloud of steam may sound unappealing, but is rather a delicious smell.

Continuing across the bridge over the Siem Reap River, I pass the Buddhist temples where monks light incense. The combination of incense and humidity is surprisingly potent. The smell is intense even at a distance, and suffocating within a 100-foot radius. Then there is the stench of the floating villages. It reminds me of the fish section of a Chinese supermarket served with a side of raw sewage. The villagers trade the cleanliness of isolation to live together.

4/4
I went to a real Khmer party! One of the doctors at Angkor Hospital for Children had a party - supposedly a birthday party for his 11-year-old-daughter, but there were about 5 children and about 80 adults. There were 5 courses of authentic Khmer food, a brief magic show, a cake and sparklers, some dancing, and a lot of Angkor beer.

Khmer dancing involved walking in a circle while waving one's hands gracefully and rhythmically (not so much in my case) in time to the music. For Apsara dancing (Khmer traditional dance), dancers are selected as children based on the elegance and flexibility of their hands.

Elana my closest friend and infectious disease expert-to-be arrived on Sunday. A brief bio: we were college roommates at Yale and she is soon to be an intern at Beth Israel Deaconess. Here in Cambodia, she's been going through the same transitions that I have - the 2am wakeups and adjusting to a slower pace. It’s great to have her here.

4/5
Back to the second week of The Lake Clinic. The main character this week is Sakhem, the dynamic leader of community development. He is 67 years old with completely white hair, completely buzzed except for a long tuft in the front - a stylish gentleman indeed.

In his earlier life, he was a parachuting captain and fought alongside the Americans against the Viet Cong. He continues to dress in military garb, but wears a dissonantly cheerful personality. His role with TLC is to supervise the Village Health Volunteers (VHVs).

Under Sakhem’s leadership, we made a dry season trip to recruit VHVs this week while the doctor and nurse/pharmacist/team leader are on vacation for the Khmer New Year. This was a bold decision as it is sweltering on the water this time of year even for the locals and the length of the journey twice as long as in the wet season.

4/8
So we went out on the boat again, this time to Pavoy and Moak La for Village Health Volunteer (VHV) selection and training. VHVs are elected representatives from the villages that TLC serves. They are responsible for helping with registration (getting people lined up and handing out numbers that determine the order in which people will be seen), disseminating basic medical information (antenatal care, birthing procedures, contraception, sanitation, diarrhea management), gathering feedback from the villagers to determine what TLC is doing well or needs to improve for future visits, and sometimes cooking for the TLC staff on the boat.

Sakhem and Ya, the kind midwife on our team, led elections in Pavoy. About 50 villagers appeared, including men, women, and children and 5 young, new VHVs joined the TLC team. Later in the year, they will travel to TLC headquarters in Siem Reap for more extensive training, and then they will be back to their village to improve health from the ground up. It is clear that VHVs are a critically important part of TLC. They increase the scope of TLC’s impact, place an appropriate emphasis on prevention, and provide invaluable feedback.

4/22
It was another struggle to travel to the villages, and we were forced to stay off the channels. We went to Pitchakray and Moak La, and saw over 150 patients. Again, we saw mainly viral infections interspersed with bacterial and fungal infections. We had a few chronic care patients, and a few emergencies.

There was a woman with a red, swollen hand with several areas of maceration and black streaking. Her hand had been caught in a boat propeller several weeks ago and her treatment had been antibiotics and bandages. Per our team, her hand looked notably improved from their previous visit. It must have looked awful before.

A 13-year-old boy was chopping wood and the axe glanced off the wood and lodged in his thigh. He was left with a fairly deep laceration, which I repaired in the chief’s house. It was a strange feeling to be operating on a wooden floor with an audience of young children. There were also unique distractions, for example, the chief’s grandson accidentally set fire to a napkin. All in all, our team worked as an efficient, effective unit and we were able to run smooth clinics.

4/24:
My time at The Lake Clinic is over, but I will keep with me many special memories and important lessons. It has been a privilege to work with the talented, generous TLC staff. They taught me so much, and always with a smile. And I will miss the floating villages, the excitement of the clinic as the boats pulled up to the rickety schoolbuilding coopted as medical building and the din of children and families eager for medical care.

The villagers deserve to have better - improved clinic facilities, hospital access, and a wider range of medications that includes diabetes meds and a few more key antibiotics. I feel proud to have been part of TLC. Thank you.

For viewing or for download.

Please use the link below.

A film by Todd Brown. Click on one of these links.

http://vimeo.com/9875870 (Full Version)

http://www.youtube.com/asiamedialab

~Jon

December 2009













Dr. Robert Nassau and a young patient.

As I planned my return volunteer trip to Cambodia, I was looking forward to making another opportunity to spend time on the TLC Boat. In December, 2009, I went out on the boat twice, once for three days and once for four days. Here are some of the thoughts and impressions that stand out most in my mind:

Jon Morgan has put together a great crew who work well as a team. Several of them, Savann, the nurse/translator, Dr. Sambun, and Aly--the pilot and chef--were on the trip I took in December, 2008 and have gone out on the boat almost weekly for over a year.

We were joined this year by Ya (right above), a midwife/pharmacist, and several village health volunteers from the floating villages who help with cooking and registering patients.


It's not easy to live, eat and sleep in such close quarters with 6-7 people week after week. However, the staff was always in good humor, joking, laughing, sometimes I?m sure at my expense, and clearly enjoyed working together. The meals were always exotic and delicious. Villagers gave us fresh and dried fish, Aly brought plenty of fruit and vegetables, and of course, there is no shortage of rice!




Villages are scattered along the lake, sometimes on rivers that flow into the lake. During some of the trip, we are on the huge open lake where there is often a very distant view of one shore and no sight of land in any other direction. The views are spectacular. At times we motored through very flat water, under a leaden sky making it hard to see where the sky meets the water in the far distance. The trip to some of the smaller villages involves following meandering narrow channels, choked with water hyacinths and half submerged trees.
Navigation can be tricky and Aly and Savann do it together using a GPS. Sunset, sunrise, and the myriad of nighttime stars, planets and satellites are a real visual treat.
TLC brings medical care to people who have no access to any medical care because of their isolation on the lake. The expense involved in getting to shore and from there to a medical facility is more than most of them can even contemplate. As a result, there are many children and adults with previously undiagnosed conditions.
TLC is able to provide screening exams for villagers, treatment for many acute illnesses, and medication and follow up for chronic problems such as hypertension. Midwife services and prenatal exams are also provided. Many patients have minor problems but for some the medical care provided by TLC is essential and long overdue.

On my two trips this year, I diagnosed significant problems in a number of new patients that will require further consultation and surgery. I saw two infants with congenital deformities of the penis who will need surgery, and two young women with congenital orthopedic problems that should have been addressed many years ago. They were a 15 year old who hopped around on one leg because she was unable to fully extend her other knee and put that foot on the ground and a 21 year old who had a non-functioning hand from birth because the four fingers were fused together to form a cup. Sadly, although they can both have corrective surgery now, it is difficult to know how much their function will improve. We also discovered a 5 year old girl with congenital heart disease who will require a workup and surgery.

After returning to Siem Reap, Savann and Jon made plans for the evaluation and treatment of these patients by the staff at Angkor Hospital for Children. TLC will bring them to shore for their appointments and has funds to provide them with a place to stay and money for food. When I asked Savann how will he get in touch with them again, he said: "No problem. I have their cell phone numbers!"
One man had a huge laceration on his hand from trying to start his balky outboard engine. The laceration had to be well cleaned and sutured using all my surgical skills! Savann had all the necessary supplies in his surgical kit. There was also a 2 year old who was rushed into one of our clinics. He had just swallowed some gasoline but seemed ok, probably had not aspirated and his lungs were clear. We told the family we would call them back in 4 hours for a progress report and make arrangements to pick him up if he was having breathing problems. When Savann called, he was doing fine.

Lastly, on our return we brought back a man with a severely gangrenous toe that required amputation in order to save the rest of his foot. TLC made all the necessary arrangements for him.

My few trips on the TLC have shown me how important this project is for the people on the Tonle Sap Lake. It is bringing basic and essential care to those who have had no access to care in the past. Importantly, TLC has a plan to provide consultations and sophisticated surgical and medical care for these people when indicated. There are funds that have been donated specifically for this purpose. I look forward to more trips on the boat and will to continue to support this program financially.

Dr. Robert "Bob" Nassau, MD
Putney, VT
December '09

In the last few weeks I completed 2 more trips out on the Tonle Sap Lake in Cambodia with The Lake Clinic. On these trips we provided medical, dental, midwife services, and vaccinations.


Since several of the villages we visited were new to us—we now serve a total of seven—there was quite a bit of work to be done.
Sambun, our Khmer physician was seeing up to 100 patients a day, Ya, our midwife was busy as well; and I had one morning where I extracted 30 teeth. Additionally, we had a government health worker along who provided vaccinations.
For much of the time, I was the only English speaker on the boat, and likely the only one within 75 miles of our location. Often on these trips, I’ll pause, and be in slight disbelief that I’m really in such a unique setting or situation, especially as an urbane westerner. It might be that I’ll be seeing patients with half of the village (their neighbors) watching you work; or lined up to see you next., while you’re soaking in sweat.
Other times it’s seeing a spectacular sunset over a deserted part of the lake from the TLC-1’s flying bridge. Sometimes it’s simply observing their unique lifestyle.
Every time out on the lake, I see something I hadn’t seen before. I also get to experience a pace of life, which seems to no longer be part of modern culture. Now if I could just get used to the taste of Cambodian fish sauce.

Hal Kussick, DDS
December 2009

The photos of
Daniel Rothenberg
Click on the image for a larger view.

















































































































































Photos: by Savann















































Thank you to everyone who has helped make '09 a success.