Out on the Lake

A Midwife's Tale

2012-01-16T15:43:00.008+07:00

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.

Through Jenny's Eyes II

2011-12-21T14:37:00.013+07:00

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

From the diary of Iris Ma

2010-05-20T10:37:00.017+07:00

©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.

TLC in HD Video

2010-02-04T14:37:00.010+07:00

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

Care that People Need

2010-01-14T06:00:00.007+07:00

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

Further Out on the Lake

2009-12-16T07:42:00.007+07:00

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

2009 through a lens

2009-12-07T11:19:00.038+07:00

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.

Through Jenny's eyes

2009-11-18T10:26:00.007+07:00

This is the TLC 1 Blog from Jenny Shepherd on the first of her two journeys with the crew in September and October.

I have been working as a TEFL teacher for many years and have made 3 previous visits to Cambodia. In 2006 I worked as a volunteer for four months with Mieko Morgan (Jon's wife) and Nhean Sakhem in the Capacity Building and Health Education Program alongside the Angkor Hospital for Children.

SEPTEMBER 22nd – 24th 2009
I awake to the sound of thunderously tipping water but I am not even out on the boat yet. It is 4.40am and a cool tropical rainstorm is battering its way onto the world around me. By 6.00am the rain has lessened and Sothot miraculously arrives to pick us up from our room. We arrive at the office where Sambon (Doc), Savann (Nurse) and Kim (Midwife) are waiting and we quickly load the plastic boxes of drugs and huge heavy blue diesel containers into the back of the land cruiser before setting off on a rainy road to Kampong Khleang.

TLC-1 looks a little different to how I remember her as she now has an extended top deck. This is going to make for more comfort and space for all on board. We unload and whilst I am deciding where to tidily dump my stuff, Aly starts up the engine which keeps misfiring. It takes a little time to put right. I am unaware at this stage that this is a common occurrence that is always eventually sorted out successfully – and with humour!

Aly is a very competent pilot and appears to know this part of the Lake well. She comes from the village where we are heading, Moat Klas (Mouth of the Tiger) which is 3 hours away and she knows the shortcuts to take when the weather is rough on the lake.
I am entranced by the vista around me, as we get further away from land. Rackemesque trees push their way up through the water and swathes of bright green plants float in untidy batches. This is where many of the wild birds breed and also where some of the lake snakes can be found. I feel like I have arrived in a lost world and I just want to keep looking and listening, drinking in the colours and smells; watching the shapes of branches, the silhouettes of small fishing canoes, the sudden swoop of a graceful two toned bird, and then I hear a voice saying lunch is ready! We are approaching Moat Klas where we will moor up alongside the Chief’s house.
Aly knows that I don’t eat meat and luckily she loves cooking fish in a variety of different ways. It is our first meal all together and she has cooked a delicious meal.
We are joined by two young VHV’s (Village Health Volunteers) who help Aly with the preparations and clearing up. My Khmer is hopeless and I am determined to learn more. Kim, who speaks little English, manages to tell me that my Khmer accent is very bad indeed and then bursts into merry laughter and I hoot along with her, knowing that my hearing was once much sharper and desperately watching her mouth as she speaks a Khmer word so I can imitate the sound better.

Srei Dai, the VHV who is acting Registrar moves fast after lunch to get everything that is needed off the boat and onto the large platform of the Chief’s house. He has the largest house in Moat Klas and it is certainly perfect for holding a clinic, though I am told that there has been an occasion when so many patients arrived that the house literally started tipping to one side and the Chief got rather cross and told those who had been treated to leave! Already many patients can be seen across the stretch of water heading towards us in their small boats, many clutching small babies who are wearing woolly hats. Women start arranging themselves on the floor once they have checked in with Srey Dai; there is little chatter amongst them though they watch curiously at everything going on around them.
photo one:
It is at this stage that I think I must get my camera, my books, pens, pencils, paper and paints and find a little space for myself, on the edge of the platform and gently see if I can entice any of the children to come and have a go at drawing, writing or learning some elementary English. The most immediately successful activity is the coloured chalk and black paper. Some want to show me how they can write one or two signs of the beautiful Khmer script, others want to show me that they can count 1,2, 3 in “Anglais” and then proceed to write the numbers. I notice a shy group of about 4 very stunning young teenagers who count very clearly to about 8 and can write 1 – 5 and they are certainly very keen to learn more.

Whilst the younger children are occupied with some cards, crayons and felt tips, I concentrate on these eager learners who copy, chant, repeat, write the words and numbers I am teaching them. There is so much fun and laughter that I don’t even notice till I try and stand up how very stiff my legs feel. I have managed to snap quite a few photos during the three hours; everyone seems happy about having their photo taken but I always ask just to make sure. The clinic is packing up and we leave most things carefully stacked up to one side, ready for our next morning’s work.
As I walk towards TLC 1, I notice the Chief’s daughter beckoning me to come and look at what is cooking in her tiny open plan kitchen. Small sardine like fish are smoking on a grill placed over the clay cooking pot that is full of glowing embers. On the floor is a large aluminium pot half full of a salty, stodgy whitish and very smelly mixture: of course it is prahok, the pungent Cambodian fish paste that is used as a seasoning on virtually everything. In fact, we eat some of this with our own evening meal at 6pm.

There is a wonderful tranquility. I love this time of day, especially after such a rewarding afternoon. Suddenly Srei Dai appears alongside TLC 1 in her blue painted canoe and beckons me, Mike and Sambon to get on board with her as she has something to show us. Good balance is necessary plus the right positioning for weight and with a cheerful grin and laugh from her, the propeller swings into action and we shoot down the lake towards what I am informed is the graveyard for those who die in the rainy season. It is a rather macabre sight: a wooden box wrapped in sheaths of shredding plastic which is roped to dividing branches near the top of a tree. When the water recedes, this sacred area becomes dry land and a proper burial can then take place. I think how difficult it must have been to have prepared and placed the coffin up there.
We speed back to our boat, chewing up clumps of the ubiquitous water hyacinths on the way, watching the sun begin its descent with a soft breeze on our faces.

Aly has prepared a feast for us all. There is much laughter around the table and Khmer joking. I am becoming deeply attached to rice and fish soup with lime and chilli. After supper we don’t go out on deck again because of the mosquitos but Savann has a meeting organized back in the Chief’s house with the 8 Village Health Volunteers. It is important to have this regular contact with them as Savann can monitor their work and teach them more about health education.

Wednesday 23rd September

At 5.45am we are up. It is another beautiful day. Kim hasn’t slept well and is like a cocoon under her mosquito net. Aly is already boiling water for the coffee and Sambon and Savann are up and dressed! They are expecting between 100-120 patients today so are tucking into a hearty breakfast of condensed milk sandwiches followed by packet noodles and the sweetest concoction of coffee. We skip the sandwiches but are delighted to have noodles. Kim is now up and showered and applying various creams to her face. I give her my new mascara and ten minutes later she looks gorgeously turned out and ready to start her work. Today, I place my gear beside the large rolled up fishing net and before I have even taken out the paper and pencils, a whole group of mothers with their children come and sit in front of me. An elderly lady whom I remember from yesterday’s clinic places herself firmly to my left. She remains there all morning watching with great interest and nodding frequently but does not want to be further involved.
Lots of children come and go, some clutching their small plastic packs of pills and accompanying card. The place is buzzing with activity: small children are sniffing, some crying, some quiet as they wait their turn to see Doctor or Nurse. Luckily, they are all rather happy when they get to me and they use the coloured pencils, felt tips and card with gusto. They sit around me screeching with laughter, (my Khmer pronunciation again!) as they learn their numbers and other useful words in “Anglais”.

We practise some writing and then they want to do some drawing. The morning passes quickly and with much enjoyment. I notice that Sambon, Mike and Savann have had a steady stream of patients to tend to. I have taken many photos, when I’ve been able to squeeze myself away from my spot and it’s good to see how happy the crowd seems by the medical care and attention.

There is a commotion by the moored up canoes and the three dogs are barking. The lunch boat is arriving, steered in by a Vietnamese lady. Huge pots of thick soup like mixtures are on offer today- probably everyday, as I know that there is not much variety in the diet here on the Lake.

We start packing up and re-loading onto TLC 1. Aly has food all prepared on the table and we are all very hungry; her cooking is once more a triumph. The VHV’s clear away whilst Aly starts the engine and we depart for Pecha Kraiy. This is about an hour away but there is talk of us stopping in deep water to have a swim. It is so hot and the lake looks incredibly inviting that by the time we have moored up to a half drowned tree I am ready to jump in. However, Sambon and Savann beat us to it and wearing red life jackets, they land in the water with enormous splashes having jumped from the top deck. The water is silky warm and exhilarating. We are squealing and laughing with the delight of it all and it is exactly what is needed after the hard work that Sambon, Savann and Mike have put in. I never think for a moment about the water snakes!
Thoroughly refreshed we are once more on deck, showered and dressed for the next clinic. This is a much smaller floating village with around 70-80 families and as we pull in to the now redundant school house, there are already quite a few men, women and children arriving around the edge of the small building.

The VHV’s are amazingly efficient and the clinic is set up in the tiny room where a sad array of unused, stacked up desks are rusting in the corner. It is stiflingly hot inside and I quickly search for a convenient spot where children can sit around me. Whilst I am getting myself organized, the medical consultations are already in action and Aly is grilling pork on a small barbeque just outside the room. A shy and charming little boy of about 10 comes to sit on my left and he wants to try everything. There are a few male teenagers who cannot quite manage to join me but observe every detail of what is being said, written, drawn or made. I get out my fabulous fast dye paints and paintbrushes and off we go. The young fellow is thrilled and the paints are clearly new to him. It is wonderful to watch him so totally absorbed in creating a beautifully coloured flower in a pot – so unlike the usual uniform way of drawing a flower that I am used to seeing drawn here. As more children come and go and the clinic is nearing an end, I notice an elderly looking man hovering and I gently gesture to him to come and sit with me. He laughs and then sits down and eagerly takes some coloured pencils (not the paints I notice), and very carefully he draws a flower. His wife stands beaming. When he seems happy with the finished drawing he looks at me and with a warm smile hands me his picture. I thank him abundantly and give him in return a large wodge of paper and some pencils. He is the village Chief.
Back on our faithful boat we are once more ready to leave for our next destination where we will moor up for the night.
It is that beautiful time of early evening and we sit out on the bow of the boat keenly looking out for birds. All is peaceful. We chat to Sambon and Savann until a rather ominous sound tells us that all is not well with the engine. Several new spark plugs later, together with a clearing of the filter, and we are able to reach our new mooring position at Steng Chroy.

We seem to be completely immersed in succulence! The thick glossy green leaves of the water hyacinth are laid out like a carpet around us. We are tucked away from the main part of the village, moored to a turquoise painted floating school house that is not in use any more. This village and Pcha Kraiy once had a teacher who taught up to third grade but the conditions of living on the lake, together with the isolation and low salary quickly put an end to a future career for teacher and children. It is obvious from the keenness and ability that the children have shown, that this is a need that deserves to be fulfilled. Some children from the wealthier families in Moat Klas are lucky enough to stay with relatives on land and attend the local school but for the majority, especially in these smaller and more inaccessible floating villages, this is not a viable option and without a resident teacher, even for a part of the year, their learning is greatly curtailed, though happily not their yearning to learn! The children here grow up learning other things though, like how to work the nets on the Lake. Like generations before them, these children become skilled at an early age at handling the small fishing boats or canoes and gain a knowledge, probably unparalleled, about the catch, the monsoon and the seasonal flow of the river.

Thursday September 24th
We sleep well once more under our colourful mosquito net, rocked by the gentle movement of the water. I slide out carefully from our bunk so as not to disturb Kim who is finally sleeping deeply. I head towards the shower and happily spray cold water all over myself trying to keep it off the closed loo seat. I have worked out a method for placing my dry sarong in the fold of the curtain but knowing where to put my towel is a different matter but I get more proficient each time I do this! Clean, cold water is a great way to start the day and I feel refreshed when I emerge and definitely ready for the steaming mug of coffee that Aly has already prepared. Kim is now stirring and I lay out a different cream for her to try. She is more interested in her own white cream for her face but happily takes my lavender oil and lavishly applies it to herself. I offer Aly some cream for her face but she shakes her head and giggles. I have been learning some Vietnamese words with her and she tells me my accent is excellent so this is greatly encouraging and I think I will learn some more! No doubt I will get fearfully muddled as I try and say “delicious food” to her in Vietnamese and then Khmer, especially as I will fail with my Khmer pronunciation.
I am enjoying my breakfast noodles when Kim suddenly calls me over to her and asks me to take some photos of her on her own and also with me. Certainly, I reply and get my camera to the ready. We chuckle away as I have to get Mike to help out here! Soon she is tucking into her condensed milk sandwich and looking happy. She will be with her family by the end of the day and she tells me she misses her children, and her husband.
Steng Chraiy, which means Deep River, is another small village of roughly 80 families. It is a very poor village and quite remote. There are a few floating houses alongside the old school house and I notice that on the pontoon nearby, there are several women pounding fish and generally chatting amongst themselves whilst something steams away in a large pot. Under the platform adjacent to us is the fish farm. They are fed on tiny fish caught in the nets and they snap angrily and competitively when anything is chucked into their contained area. Apparently they grow quite enormous and are then sold for a good profit. The VHV, Srey Dai, tells me that of course the wild fish from the Lake taste much better and I whole-heartedly agree with her.
I notice in the house adjacent to the kitchen, a mother sitting beside her disabled child. Kim goes over to see them. I know that there is not much that can be done to stimulate these children with disabilities and I ponder on the impact that this must incur when all the resources are geared towards maximum fishing productivity.
The old school house is fortunately slightly larger than that in Pchai Kraiy as it has two rooms. Sambon is afforded more privacy with his patients (mainly adults) as he sets up his table in the smaller of the rooms. Mike and Savann are positioned in one corner and so I place myself near the door where I can see who is arriving.

Today, the Clinic is not busy. We believe that this is due to the fact that the villagers are out making the most of the morning’s fishing, which is vitally important to them. In fact fishing is very much a family affair with no-one left behind as everyone has some part to play.
For this family, however, there is a need for some medical attention. Lee, the 11 year old girl in the picture, spends some time with me. She has never seen paints in her life before and I have to show her how she can use the paintbrush and the different vibrant colours in various places on the paper and not just on top of each other! She shows me first how she can write some words in Khmer and then to my delight asks to write her name in “Anglais”. I teach her new words, which she then insists on writing down in both Khmer and English. She writes beautifully. She wants to draw me a picture. I am astonished at the difference between her writing and drawing skills but am also humbled by her desire to give me her work of art once finished.

It is the end of the Clinic. We pack up and Aly has prepared another delicious meal for us. My favourite green mango, chilli and lime salad is on the table and I place quantities of it on my plate together with the steamed rice and a slice of the fresh large fish that is the speciality of the day. How lucky we have been to be a part of these three days. My head is spinning with all the sensations that I have incurred and I feel an addiction coming on to TLC 1.
I have enjoyed talking to everyone: somehow, even with the paltry amount of Khmer that I can muster, there has been hugely enthusiastic and humorous communication amongst us all and a great deal of fun and laughter around the table at meal times and in between times. Sambon and Savann speak good English and so this is easy for us, but Kim and Aly are still learning but know more English than we know Khmer!
I can’t even remember now if the engine faltered once more on our journey back as I am just infused with the memories of those Clinics, the grace and charm of the patients and their families, the hospitality of the Chiefs of the Villages and the abundance of dedication and hard work given by the staff on TLC 1. The amount of hard work cannot be under-estimated, nor the vision of setting this whole project up and putting it so competently into action. There are some of us who have good ideas and some of us who are good at putting ideas into action but very few people have the ability to know what is needed and act on that knowledge, and are prepared to slog for months fundraising, persuading the right authorities of the need of proper medical aid for its people in these far removed floating fishing communities, and actually finally achieve what they had hoped for. This is how TLC 1 was born and now, a year into its life it is remarkable to see the benefits that have been incurred for all.
I simply cannot wait to head out again on TLC 1 with its crew next week. Thank you for having me.

Jenny, October 2009

Changes

2009-11-05T10:03:00.011+07:00

Pictures do say a lot.

The Spirit House of Moat Klas Village in March '09.

That same Spirit House in October of 2009

Some words:

The surface area of Lake Tonle Sap varies greatly by season. Data sources report surface areas of from 2,569.9 km2 to 30,000 km2. Furthermore, as the main Mekong flood level heightens each year during the southwest monsoon every June or July, the direction of flow of the Tonle Sap River reverses, creating the exceptional and unique hydro-dynamics with huge changes in the lake water level (from about 1m up to 10 meters) and water volume (from about 2,500 km2 to approximate 11,000 km2) between seasons.

Dr. Michael Shepherd, 2

2009-10-24T09:23:00.007+07:00

Second trip 29 September, 2009

The weather was very different and although the first day started well, albeit with deeply overcast skies, the weather changed dramatically in the evening after the first Moat Klas clinic and supper.
We went to bed early as usual around 7.45 pm but I was woken around 11pm by water around my feet and legs and discovered the bunk and sheet were soaked . It had started to rain heavily with a high wind and this, we discovered afterwards, was the tail end of the tropical cyclone Ketsana that had just battered the Philippines. The hatch above the bunk open had been propped open with an insecticide aerosol to achieve some much needed ventilation and when the rain had started the water had come in to the cabin fuelled by the increasing wind! A quick dry out, the removal of the sheet and replacement with a damp but adequate towel solved the problem (although a persistent ?dampness? remained) but the weather worsened rapidly and we woke to torrential rain and very high winds at 5 am. There was no visibility at all and the TLC-1 was moving around a lot, banging against a pontoon away from the chief?s house to which we had been moved during the night.

The forecast was for continuing severe storms and rain over the next two days so the only option was for us to stay moored at Moat Klas and ride it out and wait. Luckily I had two books, which I had not expected to read, and this laptop. We also used the time for some clinical discussions about the management of hypertension CCF Diabetes and stroke secondary prevention ( there is a woman with a hemiplegia at Moat Klas and a very high blood pressure around 170/120).

The chief said that 7-8 people died during the night in the storm and apparently ended up in the water when their house broke up. They have not yet been found and may not appear again for several months, if at all. Some of the houses are fragile and unstable and would be expected to come apart in winds of this magnitude. A further 20 people suffered injuries overnight including fractures which have not been treated and they could not get across here to be seen due to the wind. Another house was completely turned over in the wind. No one was injured in that case but they lost all their possessions and their home. The village chief advised everyone to stay home and for some to move their houses, if they could, to more sheltered locations.
During the clinic the day before I saw a one month old baby who was failing to thrive and sick. His birth weight had been 3 kg, he had had a fit at about 10 days of age, although getting a clear history was not easy. It made me realise the limitations of an outreach clinic but also the benefit because we were able to tell his mother to take him to hospital - previously the parents would have done nothing except wait and he would probably have died. He still may but his mother was willing to take him to hospital in Siem Reap although unfortunately not that afternoon as it was too late to get there through the waterways. These are the logistics of remote health care which we do not need to consider when working in the West.
The following day we woke to light rain and a reducing wind and we were able to do a further morning clinic at Moat Kla for about three hours. We saw no injuries in fact and it mainly consisted of children.

We set off again after lunch and had a fairly uneventful trip back to Kampong Klang but we saw some wonderful birds including Pelicans.
On the way back in the Land cruiser we began to see some of the effects of the storm. A small village had been 70% destroyed by the wind with broken houses and even a concrete wall. They were already beginning to try to repair this. As we approached Siem Reap we began to see evidence of significant flooding. The Siem Reap river had burst its banks for the first time in nearly twenty years and the roads were littered with broken down cars and tuk-tuks. In the picture below the river is to the left behind the trees and the road ahead is completely covered in water.
We drove through this, boat-like, in the Land cruiser scattering water in all directions to the TLC headquarters where we unloaded prior to bicycling back to our apartment via the Angkor Market. We managed to avoid the water until we arrived at Raffles Grand Hotel where the water began. We crossed the river on the bridge and proceeded to Wat Bo road where we hit the water which continued to our apartment (fortunately on the first floor) with a depth varying between 6 inches and a couple of feet. So we got pretty wet but it was a unique experience and gave us a whole new take on Siem Reap.

Dr. Michael Shepherd
September 2009

Dr. Michael Shepherd, 1

2009-10-05T11:14:00.009+07:00

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

Why we do it

2009-07-28T08:37:00.014+07:00

Two and half year old Nuon Lek was brought to see the TLC team because she had a runny nose caused by nothing more serious than a common cold.

click on photo to enlarge

Here in Cambodia she is described as having an "elephant face". It is a facial meningocele and is caused by a failure of the bones in the skull to fully close. Mom had no idea that anything could be done to help her baby. Everyone she talked to in the village thought she just had "bad luck".

Lek's a charmer, and like many youngsters she is in love with the sound of her own voice. Her laughter can and does fill the available space around her. It's regrettable that there are no pictures of her smiling, but coming from Pek Chikrey she has never seen a white face before and the sight of me (as well as my size) is just too scary.

When we returned to the office after that first meeting a few months ago, I contacted Dr. Jim Gallogly at the Children's Surgical Center in Phnom Penh. Dr. Jim immediately set a future date for Lek to come to the center to be evaluated by a team of visiting surgeons, and we made plans to bring Lek and her mom from Pek Chikrey first to Siem Reap and then to Phnom Penh.

On the 18th of June mother and daughter made the five hour boat trip from Pek Chikrey to Kompong Khleang, and then for a first-time-in-their-lives automobile trip from Kompong Khleang to their lodging in Siem Reap where they stayed the night. The next morning they were escorted to Phnom Penh by Dr. Sambun who brought them by bus--another 5 hour ride--to the Children's Surgical Center and met with the doctors there.

The operation took place on June 23rd. This is not "routine surgery" at all and requires a highly skilled team from different specialties. This surgery is offered free of charge.

Ten days later I went to Phnom Penh and stopped by to see Lek and her mom. Lek was not happy to see me at all. I had planned to try and bring her and her mom to one of the larger restaurants overlooking the Mekong for lunch, but Lek's fear of me was overwhelming even to the other patients and families in the ward. I know when to retreat.

By July 9th Lek and mom were on their way back to Pek Chikrey aboard the TLC-1, and their arrival back in the village was The Event with just about everyone wanting to come to see how (and if) Lek had been helped.

The time for her follow up came last week, and we brought Lek and her mom back with us again from Pek Chikrey to Siem Reap on the 23rd of July. Lek was....ok around me, as long as I didn't make eye-contact with her. The next day we travelled together to Phnom Penh in TLC's 17 year old Landcruiser, as I continued to avoid looking directly at Lek.

It was a long ride. Mom thought that if she spoke Khmer LOUD enough then I would be better able to understand her village dialect. Lek was car sick much of the way and didn't always let mom know when she needed a pee break. I was exhausted from three mostly sleepless days out on the lake; worrying about budgets, and the number of suicidally-intent water buffaloes stepping out in front of the 100 kph Landcruiser seemed larger than ever and kept my mood rather tense, perhaps a bit irritable. You could say that I was cranky.

I fell into a rather sullen silence half-way to Phnom Penh.

Then I heard something that changed everything, and like putting on a new pair of glasses my outlook changed. Lek was laughing. Giggling and talking to herself in that way children have of doing when they feel safe and loved. I caught a glimpse of mom and Lek sitting together in the back and I thought...this is why we're doing what we're doing. It's that simple.

High and dry

2009-05-18T09:00:00.003+07:00

While the Tonle Sap Lake awaits its seasonal flooding and the TLC-1 remains in port on the river in Kompong Khleang, TLC's clinical staff continues to make weekly trips to "our" villages.

While some may say that "getting there is half the fun", I'm sure that such sentiment would be open to debate here.

Dr. Sambon helping to unload the Landcruiser.

The journey to our first village, Moat Klas, begins at the office of TLC in Siem Reap with the staff meeting here at 0630. From here it is more than an hour's drive to the village of Kompong Khleang where we have rented a water-taxi for our weekly missions. The Landcruiser is crowded with staff and supplies and everyone must pitch in to help offload the vehicle and then load the boat.

Where the Landcruiser is parked will be under 3-4 meters of water and the village will be cut off from access to roads and land travel.

Savann heads down the slippery slope.

Unless you've been here, it may be hard to imagine that in just another two months the waters of the Tonle Sap Lake will have risen to within inches of these houses.

From the slippery slopes of the river to the water-taxi is another balancing exercise. My 100kg body is too much for the planks to bear (embarassment) and all I can do is watch as our staff makes trip after trip with all of our necessary materials and equipment.

I couldn't help but think of how people in other countries tune into their television sets at night to watch "reality tv", and would pay good money to have an opportunity to fall off such a bridge in front of millions of viewers.

Lunch is prepared enroute by Aly (TLC pilot, registrar and cook) and Kim (TLC midwife) amongst the clutter of our supplies and the noise of a Chinese built diesel engine--sans muffler.

The village of Moat Klas, now choking with water hyacinths, is a vastly different place than six months ago.
Many of the floating homes have moved further out and are on the lake proper. Some are sitting on dry (muddy) land, and some--like the village chief's house below-- are pretty much where they were when we last saw them.

The chief's house at Moat Klas.

Life in the shallows.

While in Moat Klas Dr. Sambon and Savann made a housecall to deliver a mattress to an elderly woman. Katrin Thieme, a physio-therapist with Angkors-Kinder and a previous volunteer with TLC, purchased the mattress for her. We'll be making weekly visits to this home and are confident that this mattress will help to prevent the formation bed-sores, something that could quickly become a fatal infection in this environment.

another day brought our team to Peak Chikrey and the process of unloading and setting up began all over again.

Whether the water is low or high, the practice of health care looks the same.

But getting to that care can still be a bit of a challenge.
And more of a challenge to some, than to others.

And at the end of the day.
Among seafarers there is a common bit of knowledge, "The cook is the most important person on the ship." Having something to look forward to at the end of the day makes the work a bit easier, even if dining is after dark and on the bow of a water-taxi.

Jon
18 May, 2009

Village Health Volunteers

2009-03-26T04:19:00.003+07:00

March 2009

Thanks to a donation from the ROTARY Club in Greentown Malaysia we have been able to begin the development of a network of Village Health Volunteers (VHVs) to help us in a number of ways. After undergoing a period of training, each VHV will be assigned to monitor the health and health needs of 30 to 35 families. They will also be trained in providing basic health education to these families as well as acting as our eyes and ears within the community.

Our aim is to address what we know to be a root cause of disease--ignorance--and to be sure that those who need our care know that we are there for them.

16 March, 2009

The first group of VHVs is to be organized in the village of Moat Klas. With the TLC-1 in dry dock, the staff took a more common means of river and lake transport with TLC's Rem at the helm.

Photo: Uk Savan

Lower water levels in the Tonle Sap Lake means that many migrant families can set up temporary homes and farm what will be mostly dry land for 2-3 months.

Photo: Uk Savan

It also means that the floating homes are crowding together more near the mouth of the river.

Photo: Uk Savan

45 potential volunteers (and on-lookers) were on hand for the first of three sessions that would ultimately see 140 men and women participating in a selection process that would involve an election of the VHVs by their village peers.

Photo: Uk Savan

Simple, but obviously fun games were played to break the ice and to elicit participation from otherwise (politely) shy people.

Photo: Uk Savan

And with some encouragement from Aly and Sakhem.

Photo: Uk Savan

Sakhem explains the work and the place of the VHVs in the overall mission of both TLC and the Ministry of Health.

Photo: Uk Savan

At the end of the second day, there were 8 young women selected--two Vietnamese speakers--to become VHVs for TLC. When their training is complete they will be responsible for providing a broad range of health teachings that will include: the importance of immunizations for children; tetnus prevention for expectant mothers; family planning/birth spacing; danger signs of serious illness; household hygiene and more.

Photo: Uk Savan

They are young, from 18 to 24 years old, and though in many other areas of Cambodia (and the world) the "typical VHV" is an older woman, that model doesn't hold in these floating villages where the consensus is that older woman and mothers must fully participate in fishing everyday.
If one considers their life experience, and understands the true nature of their day to day life, you will understand that though chronologically young, they are more deeply involved and aware of the realities that face them than are their counterparts in other lands.

Photo: Uk Savan

Thank you.

Dr. Bob Nassau

2009-02-28T07:20:00.011+07:00

This blog is a bit out of chronological order; written in early February about a trip taken in mid-December. This blog is also without pictures because the thumb drive holding those files has been...misplaced.

For those who know Bob, those photos may not be necessary. For those who do not...just know that he is a very handsome fellow with a countenance that inspires confidence in patients, families and colleagues alike. Jon F. Morgan, 28 February 2009.

I have known Jon Morgan since 2001, seeing him each year on my volunteer trips to the Angkor Hospital for Children. I had heard a lot about the TLC project and was anxious to see how the project delivered health care to the remote floating villages on the Tonle Sap. I was the pediatrician on the December 16-18, 2008 trip.

I had met with the staff and Drs. Mette and Stein several times for briefings before the trip and went over the medical supplies that would be available on the boat. It was with great excitement that I met Jon at 6AM at the Blue Pumpkin for coffee and last minute instructions. The crew assembled at the TLC office, loaded the supplies to the van and drove about 1.5 hrs to get to the boat dock.

The boat was actually larger than I had imagined from photographs and had a spacious cabin below deck, complete with cooking area, a sand filter for clean water, berths and toilet/shower. Solar panels for electricity were on the upper deck.

Any anxiety I had about the trip, fell away as I got to know the medical crew on the boat, learned more about what types of patients we would see and realized how supportive the crew would be to me. This was also the first trip for Dr. Somboun, a Cambodian physician who would see the adults while I saw the children. Savann, a nurse I remembered from AHC would be my nurse, translator and I would rely on him to tell me how various medical problems were handled on the TLC.

We made a brief stop at Moat Klas to check in with the village chief, then continued on to Peck Chikrey for our afternoon clinic. This was a restful, lovely 4 hour trip on the glorious Tonle Sap Lake, which included lunch enroute cooked by our ship’s mate, Aly.

We saw about 30 patients that afternoon, most of them children. Some were there for their first ever visit to a doctor. Many had respiratory problems and various forms of mild gastrointestinal disease. Several patients stand out in my memory.

I saw a 3 month old with significant pneumonia. He had mild respiratory distress, and difficulty breathing. We were able to ease his breathing somewhat, start him on antibiotics and he will return for follow-up at the next clinic.

An 8 year old boy had a very large abscess on his buttock. This obviously needed to be drained. Savann and Dr. Somboun and I took him to a separate area, away from all the waiting patients, the dogs and general village activity of cleaning fish and mending nets that was also going on in our clinic space. We explained the procedure to him and I was pleased to see that everything I asked for, Savann quickly pulled out of his “surgical” kit. I did the incision and drainage, inserted a drain (a finger of a sterile glove) in the wound and dressed it. The child was given antibiotics and would be seen the next week.

There was a 3 year old boy with an extensive 2nd and 3rd degree burn on his torso from boiling water that had happened 3 weeks ago. This was the first time he was being seen. I debrided the area as best I could. But felt it would have healed better and with less scarring if he had been seen sooner.

After Clinic, we had a 1 hour ride back to Moat Klas, enjoying the sunset on the lake. Following a great dinner of rice, chicken, vegetables, fish soup, a little socializing with crew and village chief, it was time for lights out about 8PM. I slept pretty well in my berth, with my mosquito net, bug spray and the help of a sleeping pill. It had been a great day. I felt we had made a real difference to some of the patients we saw, did some important screening exams and were a part of bringing a modicum of health care to people who have had no access to care.

I was up at 6AM, swam in the lake, did yoga with Savann on the upper deck, ate breakfast and then we started clinic about 8AM. This was a busy day with over 90 patients seen. They included another 2 month old with pneumonia, several children with draining ears, one who had had a seizure and another burn patient.

The clinic was on the village chief’s float, which was a large space and functioned as the village center. This was a major social event for the village. People came to be seen by us and also just to see what was going on. Food sellers constantly pulled their boats up and sold noodles, rice and candy to the villagers. Fish sorting, net repair and other parts of village life went on a few feet from where I was seeing patients.

We watched the sunset as we took a boat ride around the village, saw fish traps, how people lived in their tiny floating bamboo shacks and returned to our boat for a dinner of fish, rice, vegetables and soup. I went to sleep around 8PM as the Karaoke across the lake was closing down.

The next day, I watched children going to school by boat. Some paddling, some in motor boats of various sizes. After breakfast, we had another clinic and by the time we left, we had seen a total of about 140 patients.

I thoroughly enjoyed my time on the TLC-1. The Program offers a much needed service to the people living on the Tonle Sap, by providing health care and health education. I look forward to another trip when I return to Cambodia next year.

Robert Nassau, MD
7 February, 2009

January 2009

2009-02-05T09:42:00.016+07:00

TLC-1's first six months of operation are behind us. We've entered a new year, and we too look forward to a change, and will be doing what we can to make this corner of the world a better place.

These six months have seen the staff of TLC come together as a team; operating independently aboard the TLC-1 on their weekly missions. This month's blog is really a photo essay devoted to them and their work. The photos were taken by Uk Savann, our nurse and Team Leader aboard the TLC-1.

Our "Ship's Mate", Aly, registers each patient prior to their examination.

Dr. Sombun examines a child.

This clinic was held in the village of Moat Klas, where the TLC-1 ties up to the floating home of the village chief and sets up for a day's work.

When not caring for pregnant women or new mothers, TLC's midwife "Kim", also serves as the clinic's pharmacy technician.

Everyone working...it's a boss's delight!

TLC-1's pilot, Rem, works on the engine by day.

And by night.

Sometimes two hands just aren't enough.

Physio-therapist, Katrin Thieme (Angkors-Kinder), provides self-help advice to a woman who had a CVA ("stroke") last year with assistance from TLC's Uber-accountant and Office Manager, Ouk Sopheap, who went along to serve as interpreter.

On loan from The Angkor Hospital for Children, Channy--Medical Assistant/Eye Nurse, treats an infection in Steuong Chrove Village. Channy identified 15 individuals who will have eye surgery in February of this year at the Siem Reap Provincial Hospital.

Sometimes house-calls are necessary.

In medical-speak, "comfort measures only".
Aging is difficult everywhere, but even more so in some places.

Beauty is found everywhere too.

Jon Morgan
January, 2009

Doctors on Stage

2008-11-27T11:41:00.005+07:00

Having passed the midway point in our two month mission to the floating villages of Tonle Sap, it is time for a first, brief summary and some reflection.

Being G.P.’s from a city-doctor-practice-in a well-developed country like Norway, we were well aware of the fact that not everything would be exactly like back home. Furthermore, we had been given valuable briefing and information by Jon and other informants prior to our first mission. The talks had been about the already existing health care system in Cambodia, which is not absent, but to the remote villages of Tonle Sap it is not easily accessible - it had been about a medical culture and thinking that is very different from the one in Norway, about illiteracy and ignorance, about TLC’s aims and goals and about our own expectations.

We thought we were to some extent prepared for the first mission.

Well, we were not really.

By the time we at lunch-time, reached the first village, Moat Klas, after a three hour ride in the village chief’s taxi boat, starting to unload our stuff, we already found ourselves surrounded by some fifty-odd villagers/patients wanting to see us. Within a few minutes we were having the first consultations, mediated by the young translator, Sothat. The patient waiting room was about 20 cm away, 50 pairs of eyes following every word and move we made, while discussing themselves in between in Khmer. Add to this a huge machine for fish-chopping in full action about 4 meters away, and an on-going boat race on the river lake, producing a cacophony of sound rising to unbelievable peaks. We found ourselves in the middle of an absurd theater, playing the main parts.

With the help of our crew, we slowly got better organized, and we were able to communicate, understand or not understand, consider and give medication, and even to distinguish a few really sick patients whom without our presence would have been worse off.

Exhausted, excited, happy, overwhelmed and inspired we closed down the Lake Clinic at sunset the first day. An excellent Khmer dinner cooked by our midwife, Kim, finished the day, and by eight thirty, the batteries, and consequently the light (except for a spare battery serving the chief’s TV set transmitting a Cambodian Karaoke show!) went out, everybody turning to their hammock or mattress with mosquito-net, and with the help of modern pharmacy, we had a few hours’ well deserved sleep.

At this time we have completed 3 missions, whereof the last 2 on the restored TLC-1. You can imagine that the comfort is a little closer to our usual standards on the TLC-1 than on the chief’s fleet – and I have deliberately omitted the most private part of it – the TLC1 offers possibility for a cool shower and even a toilet.

Following the Hippocratic motto: Sometimes cure, often relieve, and always comfort, we realize that there is a long way to go for The Lake Clinic. But everything has a beginning, and as we learn more about what is possible to obtain and what is not, as we learn better to understand and interpret the villager’s expression of health problems, and as doctors learn to live side by side with the ghosts, spirits and ancestors, we will slowly get better both in the here-and now situation, and hopefully also in contributing to basic health needs such as better nutrition, better hygiene, birth control, etcetera et cetera, the list is long.

We both feel privileged to have this unique opportunity to participate as pioneers from the very beginning in this ambitious project, - SERVING THE UNDERSERVED.

Drs. Stein and Mette

Mette and Stein

2008-10-30T11:22:00.006+07:00

The Lake Clinic is fortunate to have two medical volunteers from Norway with us from mid-October through mid-December.

Drs. Mette Horgen and Stein Wiel underway aboard the TLC-1 to the village of Stung Chrov

Though we usually conduct our clinical mission Tuesdays through Thursday, this past week we postponed until the weekend (24 to 26 October) to take advantage of a Singaporean holiday that would allow our favorite dentist, Dr. Hal Kussick, to join us.

Hal

The village of Stung Chrov ("Deep River") is about 10 kilometers south and east of Moat Klas. It's a four hour journey from our port in Kompong Khleang.

Dr. Stein conducts a history taking with translation assistance from Savann, a nurse volunteer.

The village of Stung Chrov has a houseboat used periodically as an education center by the Ministry of Environment and the Department of Fisheries. TLC is able to set up and conduct our clinic here in relative roominess, and shelter from the rains.

Dr. Mette and Dr. Hal set up their respective areas while dental nurse, Phaly, provides oral health education to the early crowd.

Hal described his experience as "dental aerobics".

The village of Stung Chrov has only about 90 families living there with the average family having about 5 children. Their household income is approximately $2.00/day and is derived almost entirely from fishing.

As night falls and the light fails, Dr. Mette continues by the light of her otoscope.
(the TLC camera insisted on using its flash)

In the village of Moat Klas our Mette and Stein work with Sothat, translator, on a floating platform belonging to the village chief. While performing medical consultations the platform is also used concurrently to weigh and buy fish catches.

As I write this, Drs. Stein and Mette along with photographer Daniel Rothenberg are seeking shelter from a lake storm in Moat Klas and may be extending this weeks journey by a day awaiting calmer waters.

30 October, 2008

22 August, 2008

2008-08-22T12:39:00.002+07:00

Sakhem was right. "The TLC-1 is like the bride in an arranged marriage." (Sorry for the male-centric point of view). Awkward and shy in the beginning, but over time we learn about each other and a beautiful dance begins. She handles differently from all the other boats that I’ve been aboard. The way the stern swings to the left or right throughout a turn no longer seems wrong. It’s graceful.

Designed to navigate shallow water, the TLC-1 does just that without complaint.

We’ve made two journeys out now. The first to Moat Khla (“Tiger’s Mouth” and sometimes spelled “Klas”) providing both dental and prenatal care with some minor treatments for burns and cuts. We also recruited two local residents as volunteers. (See Hal's posting below) These two received a one day training session from Sakhem on how to conduct our demographic and health survey. The second trip found us stopping briefly in Moat Khla in order to follow-up on our earlier visit and to meet with the volunteers to pick up the survey forms.

Click on image for larger view.

From Moat Khla we travelled another 12 kilometers to the village of Steung Chrov (“Deep River”). There we met with the village chief and the community council; introducing ourselves and the TLC project. The next day we found two more volunteers and provided the same training for conducting our survey.

Both villages are more than 30 kilometers from the nearest health care facility. I did not see many old people—something our research might explain. These villages are “mobile” in that during the rainy season they spread out and move into the flooded forested areas to seek a bit more shelter from the wind and the waves that accompany these monsoon storms. During the dry season they move in closer together to share a common waterway.

It’s easy to be taken in—maybe “seduced” is a better word—by the natural beauty of the environment and the smiles of the people.

It is beautiful.

The smiles are real.

But seduction is often a matter of wish-fulfillment, and who among us has not longed for a simpler, more pastoral life? The other side of the picture is much harsher. The other side of the smile is much sadder. There is a desperation here that is palpable.

Please continue to read (below) about Dr. Hal Kussick's first trip aboard the TLC-1.

Jon Morgan

Snapshots by Jon

Dr. Hal's First TLC Trip

2008-08-18T14:10:00.006+07:00

The Lake Clinic is up and running..The TLC Flag flying proud...before Jon took a short cut home.

This past week was a big one for The Lake Clinic-Cambodia. After a bit more than a year of planning, fundraising and building TLC, Jon Morgan’s vision of a floating, all purpose primary health care facility to bring healthcare to some of this country’s poorest became a reality and went to work.

The poorest live among the poor.

Our inaugural trip out on the Tonle Sap Lake was to the floating village of Moat Klas. This is a completely floating village of more than 1,000 people whose subsistence is based solely on fishing. Most have never experienced running water, electricity, or real healthcare. The lake and its waterways serve as both the source of drinking water and as their toilet.

The Gateway to Moat Klas (Tiger's mouth)

After a three hour, 32 kilometer cruise we set up shop on the covered deck of the village chief’s house; a 6 meter by 20 meter floating platform. By far this was the largest in the community where the vast majority of floating homes—constructed of bamboo and thatch—are no more than 12 meters square. While we worked some villagers continued to socialize, cook, ate, traded fish and slept in that same space.

Business as usual.

Our ambitions where modest.

· To provide emergency dental treatment and oral health education.

· Prenatal care.

· To begin a detailed survey of the community to assess health care needs for future planning.

Working

Samphaut teaching a lesson in good oral hygiene.

We totaled seven on this trip. Rather cramped for the TLC-1, but some of the local staff decided to sleep in mosquito net covered hammocks on the village chief’s deck. (Regardless of where one slept, the mosquitoes were INCREDIBLE—the size of a sparrow, at least!)

On board we had:

Jon—Captain, skipper, TLC director and sterile supply technician.

Me, Hal Kussick—Dentist

Sakhem—Managing Director of TLC

Kim—Midwife

Samphaut—Dental Nurse/Dental School Student.

Daniel Rothenberg—photographer

Ly—Pilot in training and registrar.

A rare photo of Daniel C. Rothenberg leaving to document Sakhem conducting the village survey.

Ly, the former police chief of Kompong Khleang, home port of the TLC-1, and pilot intraining working as registrar.

In the end we saw 90+ dental patients; 8 expectant mothers, and trained two villagers in how to conduct our survey. They were beginning that survey when we left, and the TLC crew will pick up the results next week when they visit again.

Sakhem instructing (from left to right) local residents Pov and Aly, along with TLC midwife, Kim, in proper survey techniques.

The trip, we felt, was a great success. The TLC-1 proved herself up to the task. We learned a lot that will improve our operations in the future, and despite Jon’s “shortcut” back to Kompong Khleang, we survived and I’m planning my next volunteer stint for October.

Not working.

Hal Kussick, DDS

15 August, 2008

Snapshots by: Hal, Sakhem, Jon

Jon's shortcut.

2 March, 2008

2008-03-13T08:28:00.034+07:00

We (Hal Kussick, Tim Matsui, Sakhem, my wife Mieko and even our daughter Riki) have just returned from another visit to Moat Klas, the same village we visited last month.

Moat Klas is one of the more isolated villages on the Tonle Sap, and we have a keen interest in learning about the local culture as well as the unique challenges. We were all very sorry that Rick and Adrienne, who sponsored this trip, could not come along with us.

This time, we began our journey in Kompong Khleang. From the photo above, you can see just how dramatic the rise and fall of the Tonle Sap is. During the rainy season the water reaches to within less than a meter of the houses.

Sakhem and I have been discussing whether or not to make Kompong Khleang the home port for our boat, as there is a strong sense of "community" here that has been lost at the port closest to the city of Siem Reap, Chong Kneas.

With that feeling of community comes security. Chong Kneas, just south of Siem Reap, is now very much oriented towards tourists and is now inhabited in large part by people from elsewhere in Cambodia. Though Kompong Khleang is almost an hour's drive from Siem Reap, we may feel less anxious knowing that our boat is there.

This bridge is entirely underwater during the high-water season; marked only by the "flags" to indicate the channel.

As with past trips to this area, a great deal of time is spent simply riding across open water:

Mieko and Hal have the time to catch a nap.

Morgan Reaksmey, aka "Riki",enjoys the view from the bow.

Sakhem! Master of the Tonle Sap.

We finally arrived almost 3 hours after leaving Kompong Khleang.

Sakhem and the village chief of Moat Klas discuss the community, its problems and the village's history of involvement with other organizations...

...while Mieko takes samples of water from three different kinds of water filters to take back to her laboratory.

Sunset brings a beauty of its own to the surroundings.

A night filled with swarms of insects trying to invade our mosquito nets gave way to a beautiful morning. Breakfast delivery arrived shortly after sunrise...

...as did the butcher.

Many thanks to Tim Matsui for his time and his photographs.

1 February, 2008

2008-02-13T05:30:00.030+07:00

This was literally "the end of the road", if indeed you could call it a road. Once you were off the main track, Route 6 between Siem Reap and Phnom Penh, the road became a sandy, cratered path. I, of course, very much enjoyed driving that road.

Rick, Sakhem, Dr. Bill and I left Siem Reap for Chikreng District early in the morning. Sakhem and I wanted to give Rick and Bill a better understanding of who TLC is trying to reach. Today's trip will be to a village called Moat Klas (Tiger's Mouth) that's about 30 kilometers from here.

This place serves as both a market and a boat landing for a variety of people. Because of the ever changing water levels in the Tonle Sap this village is "portable" as the shopkeepers must move their shelters and their wares numerous times throughout the year.

From that landing it was a 10 kilometer trip downstream to the lake itself.

I'll let the photos speak for themselves.

Scenes from Moat Klas

Downtown Moat Klas. This village moves itself 6 times per year as 98% of its residents are full time fisher-folk.

Home delivery.

Boat repairs.

Sakhem, sitting on the bench, interviewing the village chief while your's truly and Rick Lennert (in foreground) try to keep up with the conversation.

Dr. William Duke, MD

Rick Lennert, Shipwright

Contact

2008-01-01T16:50:00.000+07:00

If you would like to know more about Lake Clinic Cambodia, The Lakeship TLC and our work on the Tonle Sap lake, please email us at:

info@lakeclinic.org

Or you can call us in Cambodia on: +855 12 815 460

Donations

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If you would like to support our work out on the Tonle Sap lake, you may do so as follows:

U.S. residents: please click here

U.K. residents: please click here

German residents: please click here

Anyone may donate by credit card, via Facebook Causes: please click here

...and we'll add your name to our Donor Hall of Fame - (unless you prefer to remain anonymous).

Thank you.

Jon Morgan