“The very first requirement in a hospital is that it should do the sick no harm.”
― Florence Nightingale,
I have just left the office on foot before the rain begins. This is not like rain in England. When the first few drops appeared and I saw people don flimsy plastic capes, my immediate response was that they should try living in the Pennines. Then the real rain began – great splats of water that soon drenched me utterly. The sound is unlike any rain I have heard – the variety of building materials here mean that there are different tones made as the drops land – a percussive symphony of clangs and tings and slaps. The mud and rubbish on the streets mingle into large brown puddles – avoided by the moto drivers, splashed in delightedly by the children. Gritty mud oozes between my toes and I feel vaguely disconcerted by the simultaneous odour of human waste that emanates from the swollen ditch lining the alley. The monsoon season lasts from May until November. For the farming communities, the rain is literally the giver of life. In the city, rain provides a welcome respite from the intense heat of the day and the tuk-tuk drivers tack plastic sheets to the sides of their vehicles and continue to offer their services.
Today it was the palliative care clinic in the DSF office, located near to the Tuol Sleng Genocide Museum.
Before clinic began I visited the museum, and although I had known some of the facts about the Khmer Rouge regime I was unaware of the scale of the atrocities, and the exhibits were both unsettling and desperately sad. The events of 1975-1979 are still in living memory for many people in Cambodia, and people here are able to readily recount the members of their family who perished under the regime. Mortality is highly visible here. The buildings of S21 are in the centre of the city, its’ barbed wire perimeter runs alongside a road of homes, cafes and food stalls.
According to Terror Management Theory, the proximity of death catalyses powerful psychological defence mechanisms such as seeking to enhance ones’ self esteem, or engaging in activities that will secure symbolic immortality. Yet critics of TMT claim that it has never been studied in a cross-cultural context, and little qualitative work exists on the subject. A paper written in 2010 found that many Cambodian survivors of the regime experienced khyâl attacks, during which there was great fear that death might occur from bodily dysfunction. It has been suggested that Cambodian people are still experiencing a collective post-traumatic response. Perhaps this shared cultural memory is one reason that it is culturally much more acceptable for family members to be in charge of decisions and discussions about serious illness and its’ management. I am told that it is rare for conversations about death and dying to take place, and even more rare for these to include the patients. Commonly, if the family are able to afford it, treatment with curative intent will be continued until death. This surprises me in a predominantly Buddhist country and I wonder whether the legacy of Khmer Rouge has altered in some way the attitude of people here towards death. Death of a quarter of the countries population, accompanied by the systematic dehumanisation, displacement, torture and incarceration of those who remained, is not the kind of “death” one usually imagines when gently instructed by Buddhist scriptures to meditate on impermanence. So Buddhism has taken on its’ own form here, one in which lay people pay ever-increasing amounts of money to the monks on the streets in the hope that the next life might be easier , more comfortable and more peaceful than this one. Many offering and prayers are made for the sick person, by their family and friends. Every home, however small, has a shrine.
The wife and sister of a man recently diagnosed with liver cancer come to the clinic. They are here for the first time, after the patient was identified whilst in the hospital where he was diagnosed. They speak animatedly about him and I don’t need to speak Khmer to get the gist of the situation. They have brought his CT scans and the huge tumour is shockingly evident even for a radiology novice. They describe a catalogue of problems – he is anxious about the future, experiencing nausea and vomiting, has uncontrolled pain and cannot sleep. It has been this way for one week. They have brought his current medicines – two blister packets containing nutritional supplements. There are no medicines for pain. A plan to control the symptoms is formed and explained, and medicines counted out and dispensed. She will be able to come again next week for his care to be reviewed. It is unlikely that the team will be able to see the patient himself as he lives outside Phnom Penh and at present they have little capacity to provide domiciliary support beyond the city. They do, however, offer this clinic and telephone support which is highly valued. They are forging working partnerships with Cambodian Catholic Care, a hospice established for people with HIV/AIDS in Phnom Penh, whose two doctors alternate visiting the provincial areas of Kampot, Mondulkiri and Battambang. We will be visiting the hospice tomorrow.
The Cambodian doctor who sees them prescribes the medicines without seeing the patient. Running this clinic means the team can review patients by proxy, and it works well as many relatives prefer to keep discussion of the illness and its’ management out of earshot of the patient, who is often perceived to be to weak to be burdened with such things. Thus medicines are prescribed based on the reports of the relatives. Every person who attends the clinic has one thing in common: poverty. For the wealthy in Cambodia, treatments for cancer are often sought from more medically advanced countries nearby, particularly Singapore. As a consequence, there is little pressure from the upper echelons of society to improve healthcare systems here, and the population who live in predominantly rural farming communities, are often not empowered to speak out or ask questions about their disease. Hospital stays, though expensive, are rarely if ever challenged by patients who believe strongly in the authority of the doctors.
One of the doctors tells me that when she began work for DSF she felt frustrated a lot of the time, about all the people who could not be helped. But then she realised that there is something important about doing “enough”, and giving what you can give. This sometimes means accepting less than perfect situations or needing to be highly adaptable, but is the only way to sustain ones’ own emotional wellbeing in these challenging situations.
In “To Kill a Mockingbird”, Harper Lee observes that “you never really know a man until you understand things from his point of view, until you climb into his skin and walk around in it”. This is though to be the origin of the famous saying about walking a mile in another persons’ shoes, used in several papers written about communication skills and empathy. As I walk through the rain I think about my feet, aware of each cracked paving slab or pudde, the discarded chicken bones and green coconut shells crushed under my toes. It is easy to feel sympathy here, to join one patient’s husband in his anger and grief as he describes how the hospital has charged £700 for treatment that is not working and he no longer can afford to keep his wife there. It is also easy to try and seek out solutions which do not exist.
I reach the homestay and let myself in through the padlocked door. I wash the mud from my feet, and my toes reappear. The rain hammers on the metal roof and streams in brown rivulets through the courtyard below. Is it really ever possible to walk in another person’s shoes? And would one mile necessarily be the same as the next, given the ever-changing nature of experience? Or is empathy the experience of ones’ own emotions that respond to the other person, a kind of interdependence in which each person’s emotions belong to them alone, although they may be different or similar.