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Moat Klas VISIT 22/9/09 and 29/9/09

I am a UK Medical Practitioner, and in the past I have also worked in New Zealand for nine years and have both UK and NZ qualifications. I have been involved in student teaching in both New Zealand and the UK, and in GP training in the UK. I worked with Jon Morgan at Angkor Hospital for Children for four months in 2006 and was very keen to return to undertake further work, hopefully working with Jon again. This is my fourth visit to Cambodia and Siem Reap and I am honoured to have been able to go out on two trips this month to the lake clinics and to work at the TLC office in Siem Reap.

We were travelling to Moat Klas, a floating village of about two hundred and fifty families about 3 hours by boat from Kampong Khleang and the first stop on our three day visit. The day started very early with a torrential downpour at 4.15 am and we thought the trip would have to be canceled as the lake can become very rough in bad weather and the TLC-1 is light and flat bottomed. However the rain stopped after about one and a half hours and we were able to remain fairly dry leaving the apartment at and getting in to the Landcruiser. By the time we arrived at the boat station at about 7.30 am the weather was fair. There was some difficulty starting the engine but once fired up it worked well and we traveled slowly out on to the main lake down a channel passing through the trees, the tops of which were visible popping out of the water. We arrived at Moat Klas towards the end of the morning, and while Aly and Kim cooked some lunch the rest of us unloaded the tables, chairs, medical equipment, medication and dressings.

At this time of year, towards the end of the rainy season, the lake is nearing its fullest. It has risen massively so that the outer edges have moved several kilometres inland, covering and concealing trees, scrub and vegetation. At the same time the depth of the lake has increased by several metres. The floating villages that we were heading for are completely water bound which has obvious dietary implications and there is a significant lack of available fruit and vegetables.

The fact that the lake rises in this way is due to a unique phenomenon. During the rainy season the Mekong river, which arises in Tibet and flows through China, Laos Cambodia and Vietnam, carries so much water that the delta in South Vietnam cannot absorb it. As a result the water back flows up the Tonle Sap river from Pnomh Penh and up in to the lake causing it to increase in size and bringing with it an influx of fish, nutrients and clear and clean water. When the rain stops, the flow down the Mekong reduces and the Tonle Sap river reverses direction thus emptying and effectively flushing out the lake. The lake is a critically important source of nutrition for Cambodia and, apart from sustaining wet season fishing and the livelihood of those who live on and around it, also enriches the soil around it allowing an improved rice crop.

The team consisted of Dr Sombun, Nurse Savann, Midwife Kim, Aly, ship's captain and cook, myself and my wife Jenny. We also took on two Village Health Volunteers (VHVs) at Moat Klas who accompanied us for the rest of the trip. We started the clinic after lunch and continued for a bit over three hours. I saw exclusively children. Most of them were not in fact that ill and the predominant problems were gastroenteritis, upper respiratory infections, and non specific viral illnesses. Three children had pneumonia with clear and well localised chest signs but again were not, at this stage, particularly ill. But this is the kind of situation where our intervention hopefully prevented a more serious illness.

Dr. Michael and Dr. Sambun consult.

In the evening at the end of the clinic, one of the girls from the village took us on a long thin wooden boat propelled by an outboard motor with the propeller 6 feet from the engine on a long pole. This propeller can be lifted out of the water by the person driving and it is often necessary to do this if there is debris or floating vegetation in the way. We went to see a "graveyard". The bodies are put in coffins (when it can be afforded) and covered by plastic sheeting/shrouding and put in the treetops above the water line. This is because they cannot be buried as there is no dry land. For the same reason they cannot be cremated either. When the lake is high in the rainy season as now, the village is completely water bound. In the dry season huge areas that were under several metres of water become dry. All the houses and other buildings, such as a school, float on various pontoons, usually bamboo, and the village moves according to the water level. The houses are towed by small boats to different locations.

Pek Chikrey

We started this clinic on the second afternoon. This village houses 70-80 families. In the morning we had done a long and full clinic at Moat Klas, where we had spent the night, lasting about five hours. On the way to Pek Chikrey we went out in to the lake and stopped for a marvellous swim moored to a tree top. It was also an opportunity for Savann to catch up with his administrative duties.

After lunch we began the clinic, and saw about 40-50 patients. The clinic was held in a school house although the lack of a teacher meant that it was not currently being used. Again I saw exclusively children with a preponderance of gastroenteritis and respiratory problems. Savann continued to translate for me and we sat at desks in the schoolroom on a teak floor supported by floating bamboo pontoons. Whilst we were doing this full clinic Aly was starting to prepare dinner for later, cooking on the barbecue which she had installed on the wooden walkway beside the schoolroom. When all was finished, the desks, chairs, equipment and patient notes were loaded back in to the boat and we cast off, heading for Steung Chrov through the trees and water hyacinths.

Seykim (midwife) and Aly (pilot, mechanic, registrar and cook) prepare the next meal.

About two thirds of the way to Steung Chrov the engine started misfiring and sputtering and our speed gradually reduced until everything ground to a halt. By dusk we were drifting in a channel surrounded by water hyacinths and tree tops, listening to the water lapping at the boat after repeated unsuccessful attempts to restart the engine. It was calm and peaceful and the darkness gathered quickly as the sun set and we sat in tranquillity on the front of the boat. The problem was eventually traced by Aly and Sombun to the spark plugs but also to the petrol filter which was found to have water in it. The spark plugs needed changing and the filter needed to be removed, cleaned out and flushed through and then replaced and primed, but before doing this Aly produced a very good meal which we ate in the cabin surrounded by insects and the dark outside. She then returned to the engine, in the dark and with minimal light, and I was truly impressed by her complete unflappability, good humour and ability to multitask!

We finally started moving again and after a short journey arrived to a very quiet Steung Chrov where everyone appeared to be asleep even though it was actually not that late. We tied up behind the local school house, again unused, and unloaded all the equipment again prior to the clinic the following morning.

Steung Chrov 70-100 families

We woke early, around 5.30am, as the village started to come to life at daybreak. The TLC-1 was moored to the school house, which is a substantial building with a separate "office" and an imposing desk for the patients to be checked in.

It floats on bamboo pontoons and around us were large areas of water hyacinths floating and moving in the water in the light wind, and large fish jumping in the clear water nearby. A slightly precarious plank walk away was a pontoon, with a fish cage underneath and a chicken shack on top with about six chickens. Next to it was a small floating fish market with a considerable amount of commerce and activity: there was a further soft cage full of extremely active fish about eighteen inches long which were being traded and pulled out into plastic laundry baskets and then loaded on to small long boats. There was a small boat tied up loaded with sardine sized fish which were destined, not for the villagers, but to feed the larger fish in the "tanks". In Siem Reap they are available at twice the price for cooking and eating.

Savann and the never-ending paperwork

The clinic on this occasion was fairly quiet and the reason for this I was told was that the villagers go out fishing early in the day at this time of year to make the most of this rainy season and the fullness and richness of the lake. The clinics are generally much busier in the dry season. After a gentle morning?s work we loaded up the TLC-1 again and headed for Moat Klas where we dropped off the two VHVs and had lunch. We then set off for home travelling back out to the main lake and then along the edge trees where we saw numerous birds.

The idea and vision of creating the Lake Clinic with the aim of bringing health care to isolated villages is impressive enough, but it is only when you actually get on the boat and go to the villages yourself that you realise the enormity of the task and what a huge amount has been done to get to this point. The average daily income on the lake is less than one US dollar The floating villages are very isolated and extremely deprived and impoverished and the process of delivering health care and the boat's weekly visit all had to be negotiated with the chief of each one and this involved multiple visits and uncertainties. Even the creation of a regular voluntary non profit making visit is not straightforward when it is being arranged, and sensibilities have to be acknowledged. There are now ongoing negotiations to include (from next month) a further three villages in Kampong Thom province which have had no previous health care delivery at all.
There are the weekly logistics of provisioning and refuelling the boat and also restocking all the medical equipment and medication. There is the uncertainly of whether the weather will permit the trip at all and this may not be known until the end of a one hour drive to Kampong Khleang from Siem Reap. From Kampong Khleang it is a three hour boat ride to Moat Klas and a further hour on to Pek Chikrey and the following a day a further hour through the trees and lilies to Steung Chroy. The usual medical team of a doctor nurse and midwife (and two volunteer health visitors who join the boat at Moat Klas) has had to be carefully thought out within the limited space of the boat. There are also regular volunteer dentists and occasional volunteer doctors. The mix of skills is designed to meet the objectives of the Lake Clinic which revolve around the three principles of prevention by medical intervention (immunisations, antenatal care, cure of morbidity inducing illnesses, and health promotion by nutritional and dietary education, hygiene and sanitation awareness, and the promotion of breast feeding.

End of Part I.
To be continued.

Michael Shepherd, MD
October, 2009