“Let’s us rise up and be thankful , for if we didn’t learn a lot today, at least we learned a little, and if we didn’t learn a little, at least we didn’t get sick, and if we got sick, at least we didn’t die; so, let us all be thankful.” Buddha.
I have often heard it said that Khmer people are among the happiest in the world. Every Khmer person I have met is quick to smile, nodding enthusiastically as we have random conversations that neither of us could understand. They are universally friendly, approachable, warm and genuine.
Today I visited a hospital in near to Kep, in the South of Cambodia, called the Sonya Kill Memorial Hospital. Run as an NGO supported by HOPE Worldwide, this hospital was established by a German family in the name of their daughter, who died in an accident. The aim of the hospital was initially to provide affordable care to the Cambodian people – particularly mothers and children. Since then it has expanded its’ remit and now has an A&E department, cardiology and various other embryonic services. Payment is via a sliding scale, with those unable to afford payment being able to receive some healthcare. As I wait to meet the Chief Medical Officer, I sit in the main waiting area of the Accident & Emergency Department – a bright, sunlit courtyard, flanked with wooden benches and filled with banana trees. A woman in a wheelchair sends a text. A girl sleeps, curled up on a bench, her mother stroking her head. There is an abiding sense of calm and peace, despite the nature of this courtyard. L, the CMO< tells me that he has plans to expand services to train Cambodian doctors to be family practitioners. Unlike General Practitioners in the UK, their role would be based within a hospital clinic. Their remit would be to provide “whole family care” – and they would have the entire family on their caseload. Currently there is no facility for cancer care, and no capacity for imaging other than a basic X-Ray machine. People suspected of having cancer must travel to Phnom Penh for radiography services, around a 4 hour journey.
80% of the population live in rural areas, many down tracks such as those in the image on the right above. During the rainy season these can rapidly turn to deep mud and become inaccessible (the image shows my friendly moto driver, apologising after the bike got stuck in the mud and we had to walk four miles in bare feet…!).
I ask the doctor about domiciliary care for those too unwell to get to hospital, or who cannot afford the journey. The doctor shrugs. “Here in the South, there is none. If you are unwell, you come to hospital or you stay at home to be cared for at home.” I ask him what happens if a person is too unwell to come to hospital, and he tells me that their relatives may come in their place to tell the story. As in the other hospitals I have visited, intravenous morphine is available while in the hospital, but once a person goes home they are given tramadol, diclofenac, paracetamol. There is no oral morphine available for patients living outside the reach of NGOs such as DSF.
He also tells me that he is also concerned to extend and expand mental health services. He sees a lot of unmet need. Mental health problems are largely unaddressed with the health systems here. Anybody born in Cambodia over the age of forty will have lived through the years of the Khmer Rouge regime. Mental health problems are rife; a 2012 study by the Royal University of Phnom Penh revealed that 27% of 2,600 Khmer people experienced symptoms of acute anxiety, 16.7% suffered from depression and 2.7% exhibited symptoms of post-traumatic stress disorder (PTSD) – prevalence of the latter being seven times higher than the worldwide average. An earlier study of 2000 Khmer Rouge survivors by the Berlin Centre for the Treatment of Torture Victims identified a prevalence of PTSD at 11.4%, while 30% of participants suffered from depression and 36.8% from anxiety. Cambodia has only one mental health facility, at the Khmer Soviet hospital, and the lack of availability of psychiatrists (after Khmer Rouge, there were only 10% of the number of doctors compared with before 1975) means that often the staff resort to binding patients to beds to keep them safe. It is rare to see people with severe mental health problems on the streets, although visibly disabled people – landmine amputees, those with horrific scars – are common around the markets where they beg for food or money.
In an essay entitled “The Difficulty of Imagining Other People”, Scarry writes about the connection between our ability to empathise and our ability to permit pain and suffering – hence the importance for those who inflict pain to have undergone a process of distancing from the victim, often removing any reminders of their personhood and individuality in the process. Of course, the notion of being someone able to inflict torture is an extreme example, but in a sense there is an important lesson here. We usually think about person-centred care and dignity as being important for the person we are caring for – but maintaining the human inside the person is also essential in order to access empathic insight into their worlds.
Elaine Scarry suggests that physical pain causes the “unmaking” of the human world – a loss of identity and dignity that strips us of our personhood. Assessment and management of pain in life-limiting illnesses continue to challenge us. We try to gain peoples’ own words -“burning? stabbing? aching?” – in an effort to narrow down our differential diagnoses – neuropathic? visceral? somatic? breakthrough?”. Yet it is difficult whilst directly in the grip of severe pain to find the words. Even more challenging is the need to make this interpretation across cultural and linguistic boundaries. Scarry also points out that it is virtually impossible to write reliably about pain in order to convey this adequately to another person, as while a person is experiencing the pain directly, it is often impossible to find words to describe it because of the immediacy of the adversive experience. She suggests the it is only possible to find words for it once a certain distance has been acquired between oneself and the pain. Suffering (with its’ connotations of emotional, social and spiritual dis-ease) is different. Compared to physical pain, it is easy to find literature that describes suffering. Indeed, in Thomas Mann’s 1924 novel “The Magic Mountain”, the fictional character Settembrini sets about creating an encyclopaedia of literature that relates to suffering. He is obliged to abandon this idea when he discovers that there is no literature that is not about suffering.
If one cannot imagine pain, one is less likely to be motivated to seek to alleviate it. Pain is what a person says it is. Yet, if a person cannot speak, or cannot describe their pain, it is incumbent upon us to first, recreate the human that is experiencing the suffering, and next, use ones’ creativity and imagination to develop an understanding of what that pain might mean. Only then can it be successfully approached.
Frankl famously wrote that man is not destroyed by suffering, he is destroyed by suffering without meaning. His book – “Man’s Search for Meaning” – was based upon his experiences of internment in a concentration camp during the Holocaust. He noted that some prisoners demonstrated an ability, in the face of extreme adversity, to maintain positive outlooks and hope regarding a future world that is free from suffering. At the core of his theory is the role of love and compassion. Many of the people Frankl met talked often of their loved ones, and how they drew strength from the connectedness that they felt. Also significant, was the extent to which prisoners could envisage a future for themselves and their loved ones. Frankl believed strongly that love and compassion enables humans to exist and even to thrive in adversity – and that this love can be in the heart even if the object of that love is physically absent, as was usually the case in the Holocaust – “Love goes very far beyond the physical person of the beloved. It finds its deepest meaning in his spiritual being, his inner self. Whether or not he is actually present, whether or not he is still alive at all, ceases somehow to be of importance.”
It did seem to me, despite the picture painted by many of the professionals I have met, that the majority of older people I have met, including those with visible physical disabilities, have been warm, friendly and happy. I wonder whether this is because those with less resilience are perhaps less visible in the busy streets, whether they remain out of sight. Resilience is dynamic process in which there is positive adaptation despite significant adversity. The literature on resilience is fascinating and the debates are heated. Some believe that exposure to trauma enables resilience and activates self-protective efforts. Others argue that resilience is an innate trait. Another perspective is that resilience constitutes an invulnerability to difficult life events, but this challenged by those who believe that resilience can only arise as a consequence of challenges. When I tried to put the key into the ignition of the wrong motorbike outside the market today, an old woman nearby started laughing, a surprisingly loud belly laugh for an apparently diminutive woman. She found it even more hilarious when I asked if I could take her picture, rocking back and forth on her crossed legs.
It is said in Buddhism that the path to happiness is to understand the root causes of suffering. One of the primary sources of suffering is attachment, particularly to ones’ ego. I have been reflecting a lot on the deep involvement of families in the care of dying people here. It is not just that extended families tend to live, eat and work together. There is more to the story than this. I believe it relates to the fact that the Khmer value highly the family structure – indeed, it is said that the bond between a parent and child is far more important than the marriage bond. As such, all decisions are taken as a family, all suffering is experienced as a family, all happiness is experienced collectively. And in this collective, relational way of being, there is less of a place for ego. To me, it seems that many people here are genuinely grateful to be alive.