3rd Quarter, October through December 2016
	Adult Men	Adult Women	Children Under 14	TOTAL
Pediatric Care	0	0	1045	1045
General Medicine	400	1160	0	1560
Ante Natal Care	0	139	0	139
Dental	19	29	565	613
Eye Care	5	18	2	25
Referral	1	1	3	5
Immunizations	15	157	581	753
Birth Spacing	1	71	0	72
Health Promotion/Education	345	1101	904	2350
Home care visit	0	5	9	14
Visual Acuity Exams /school children	0	9	537	546
TOTAL	786	2690	3646	7122

	4th Quarter, January through March 2017
	Adult Men	Adult Women	Children Under 14	TOTAL
Pediatric Care	0	0	1802	1802
General Medicine	957	2797	0	3754
Ante Natal Care	0	187	0	187
Dental	34	78	146	258
Eye Care	14	31	6	51
Referral	2	5	11	18
Immunizations	2	163	540	705
Birth Spacing	3	136	0	139
Health Promotion/Education	431	1495	1085	3011
Home care visit	0	7	6	13
Visual Acuity Exams /school children	0	0	46	46
TOTAL	1443	4899	3642	9984

The Environment

The year 2016 will be remembered as “the year of no rain”. This was the high water level this year.

El Nino came to Cambodia and was merciless in its intensity and duration. On land there were villages throughout the country to which water needed to be trucked in by the military. On the Tonle Sap Lake lower water levels meant that less of the forest would be flooded, lessening the size of the “nursery” for the migrating fish which will lead to smaller fish yield is 2017.

Of course, for TLC the work always continues in spite of what Nature brings our way. It is certainly less comfortable, and without a doubt more physically challenging. But this is TLC’s 9^th year of operations, and our staff has learned to accept such conditions as “a part of the job”.

The demand does not go away.

There are still villages where TLC cannot place a floating clinic, and services are being provided wherever there is enough dry space to set up.

TLC knows how to make the best of things even in difficult working environments.

A doctor’s story.

Dr. Carola Webster

Looking to incorporate some “off the beaten path physical activity” into our three week adventure through Laos, Vietnam and Cambodia my husband and I enjoyed a guided kayak excursion of Tonle Sap. We kayaked through the colorful maze of stilted homes in the community of Kompong Khleang. We watched and waved at boats full of children who floated by us on their way to school. We marveled at the ingenuity of the Bahn Mi salesman who outfitted his boat with the same unique fixtures as to the moto cum food truck. We mused at the boats tied up to the stilted variety store with five foot high ceilings selling gasoline in used “coca” (cola) bottles with the sweet treats next to balls of twine and baskets of mangoes. The further we paddled the more the bright colors and the spectacle of this unique way of life fell into the background allowing us to focus on the people and their homes. We saw one-room homes that were assembled with found materials, hardly weather proof. It was difficult to imagine how these structures might hold up in the heavy rain sand winds that occur here seasonally. We saw women cooking over wood fired stoves inside their homes. Fishermen chopped their catch and washed-up with brown lake water. Children bathed and played in the water. It became very obvious to us that there is no running water and no sewage containment. To the people who live here, the lake is everything. It is a source for drinking water, food, washing and all the other important matters of life. There are few places in the world where people live in such impoverished conditions. It was unforgettable. My husband Dan snapped a picture of “The Lake Clinic” boat next to a stilted house.

A year later, as we prepared dinner at home in Canada, our computer screensaver rotates pictures of our travels. The photo of the TLC clinic popped up and Dan wondered out loud “do you think they need any help”? And so it began.

The TLC clinic, I was told has a role for western trained physicians who can provide bedside teaching and clinical updates for Cambodian trained TLC physicians. Cambodia’s medical community is developing, like the rest of the country. However the courses and conferences that western physicians rely on to refresh their training are not yet a reality for Cambodia. Jon Morgan, founder and director of the The Lake Clinic welcomed my offer to come and work with the TLC doctors for 1 month.

After a brief orientation to Siem Reap and The Lake Clinic’s modest headquarters I set off on my first outing. The journey started at 6AM when the group worked together to stock the weathered mini-van with boxes of equipment and supplies. Everyone piles in for the three plus hour drive/boat ride to the river clinic, one of five locations served by TLC. I am curious and excited to go even further into the river than our kayak excursion years before. I appreciate the beauty of the landscape while at the same seeing homes that become ever more meager the further we travel from the port. As we approach the TLC clinic I see a barge with a simple structure of 4 walls and a roof approximately 20 X30 feet. My western eyes see something akin to a large gardening shed. I know the Khmer villagers see it differently. This structure will function as the waiting room, clinic, kitchen, dining hall and sleeping quarters for the next 3 days. The team members get to work by sweeping up the remnants left behind by the critter-inhabitants who invade when there is less activity. All the boxes are unpacked, the kitchen and bathroom are made serviceable while the patients start to arrive.

Soon, twenty or so patients congregate in the waiting area sheltered from the sun by a tarp. Each patient is registered. Individual medical charts are retrieved from storage. A record is made of the patient’s height, weight and blood pressure. The group is offered an informal talk about public health topics such as basic hygiene and nutrition while they wait for their turn to visit with the doctor or midwife. Then one by one, accompanied by a locally trained doctor, I meet the patients. Many of the problems are similar to the illnesses I treat in my own clinic in rural Ontario, Canada. Problems like ear infections and sore throats. But then there is more…. severe malnutrition, severe dental carries, and new presentations of advanced diseases. There are traumas and lacerations from accidents with knives or boat propellers. There is Type 2 Diabetes and hypertension in people much younger and thinner than the western world, a consequence of malnutrition in their younger years. With each new encounter I am amazed at the care and attention that is provided by TLC staff. For instance, there is gentle teaching of lifestyle factors that can be adjusted to help their conditions. Is it possible to reduce the salt that is used in cooking one patient is asked? The answer is that sometimes it is possible, but salt is a much-needed preservative for fish so that it can stored for later consumption. Is it possible to eat more vegetables? Maybe, the next patient says, the only source of vegetable here is what grows naturally in the lake. Medications are provided free of charge. Patients are invited to follow up on the plan of care in the weeks to come when the clinic staff return to this location. Women are encouraged to engage in birth spacing and are offered the education and support to achieve this. Birth control pills or IUDs are offered free of charge. Trained midwives offer antenatal counseling and care. The patients are offered the same kind of care I give my own patients at home. Because of TLC it is absolutely free of charge, without judgment, without expectation, all with a good measure of respect. The day wraps up with a wonderful khmer meal served on the same tables that served as desks minutes before. The team members sit together and talk over the events of the day. They share updates and stories about their life at home. They are connecting with their work-family. Then its time to set up the cots and mosquito nets and settle in for the night, before it gets too dark and insects flood toward the solar powered lights.

Once day breaks the clamor of boats and patients arriving coincides (thankfully) with the smell of coffee and the line up for the single bathroom. There is time for a quick breakfast before this room is turned into a clinic once again. This morning I am asked to accompany the TLC doctor on a house call. House calls, I wonder, aren’t they a thing of the past? This morning a very tiny one-year old child, suffering of severe malnutrition receives a follow up visit. His elderly grand parents are the primary caregivers while mom and dad are away at work in a neighboring country. He is provided with calorie dense food supplements as he is not yet gaining enough weight to be healthy. The grand parents are counseled about proper hygiene and care of their little charge. Later, another house call for a woman who is unable to walk because of a spinal cord problem. She has several chronic diseases but her life is being made better by the treatment she is receiving from TLC. This family is so grateful for the care we receive a freshly caught snake as a gift. I am impressed by the sensitivity that is given to the patient’s circumstances, and the flexibility that is inherent in this organization’s culture. Each patient’s needs are met in the best possible way.

I am in for yet another surprise when I join the Lake Team on the second week with TLC. I am invited to join the doctor and dentist for a school visit. I was so pleased to see a classroom full of students eager for our visit. Each student has a medical chart. From this I can see that TLC visits every 6 months. It’s an opportunity to measure height and weight, as these are indications of nutritional status. Those students who are not keeping pace are given nutritional supports and close follow up care. An eye test is completed, and the children who received their free glasses are reassessed. Each child has a dental and medical check up. There is time at the end to teach the enthusiastic group about dental care in a fun, lighthearted way. Every child receives free deworming pills and tooth brushes. The kids crowd around me the foreign doctor for some laughs as we take group selfies making funny faces.

As Sovann, Nurse, and clinical leader of TLC says, “when you work at TLC you bring your heart to work with you”.

I am truly amazed at how much TLC staff are able to accomplish with the limited compliment of resources. Much of what is accomplished is driven by a desire to offer the best possible care, with the most loving, respectful, flexible approach possible. This is a small but very mighty organization. I am so happy to have been a small part of it all for one short month. I leave with a heart full of inspiration and gratitude for the experience.

Is this a portent of things to come?

The Tonlé Sap Lake has always presented us with challenges. The dynamic change in water levels each year has demanded that we maintain a small fleet of boats in order to reach the villages. High water coincides with monsoonal rains and strong winds. Low water means that the staff must very often get out of the boats and push them over the sandbars that form at the mouth of every waterway feeding the Tonlé Sap.

This year we are seeing the impact of both an El Niño weather event and the damming of the Mekong River. Drought conditions began in the spring of 2015, and it is forecasted that the drought will continue through 2016. We have never seen the water level as low as it is now, and it has become essential to bring extra props to each mission in case the boats get stuck in the mud. As a result of both of these natural, and also not so natural, events, we have sadly not been able to use The Taxi (TLC-4) so far this year, and we are currently using smaller boats to reach the clinics.

As the water level falls, the concentration of water hyacinths increases to narrow and block the waterways that connect villages to other villages. Now, some villages are completely cut off, such as Baloth and Komping Traleich, and unfortunately we expect to lose contact with others within the next few weeks.

The photo below shows our clinic in Ksacrchearos village along the Stung Sen River (see map on page 4). For the time being, it is still floating. However, we cannot say for sure how much longer we can expect it to be afloat, as the water level in many areas along the river are as low as 30 cm.  It is almost like walking on water.

For more information about the drought and the dams, please see these links:

Al Jazeera – ‘Cambodia’s ‘beating heart’ and climate change disaster’
Open Development Cambodia – various articles here and here
SEA Globe – ‘Cambodia Faces Severe and Prolonged Drought’

A STORY FROM THE RIVER

Thankfully, here at TLC, our staff is positively adapting to the challenging circumstances that they face at their watery (and now, quite muddy) workplace. They keep on doing a wonderful job. We have also been lucky to have some great volunteers come and work with us during these first few months of the year.

There are numerous stories that can be told from these isolated and remote areas. When working so closely with the villagers, we truly get to see, and take part in, both the good times and the bad. We are present and witness their personal and physical developments. Just like elsewhere, there are the stories of the sick who will not seek medical care, of those who will refrain from going to a hospital when they are advised to, those who will find their own ways of dealing with their illnesses. However, we are pleased to see that with our presence on the lake, there is a growing change of mindset, and thus also behavior, moving in a positive direction. Indeed, there are many stories, and some of them are highly worthy of being shared. This is the story of a baby boy who lives in the village connected to the clinic on the photo above.

In late December, a desperate mother, Heang, came to our clinic in Ksacrchearos village along the Stung Sen River (see map below).

Her tiny baby of no more than 7 days suffered from fever and pneumonia, and was c
ritically ill. Our volunteer doctors at the time, Dr. Emily Whitaker and Dr. Bill Duke, and our own Dr. Kuch Kamsan, concluded that the baby would need to be taken to a hospital in order to survive. Despite their best efforts to convince the mother that this was the right thing to do, the mother refused. The only thing we could do at the time was to give paracetamol for the baby, and try to convince the family that he needed to be treated in a hospital. Heang and her husband live six kilometers downstream in the opposite
direction of the provincial hospital. We hoped that they would take their baby there.

When we returned to the River Clinic the next week, the mother didn’t bring the baby back to us for a follow-up visit, as we had requested. TLC’s doctors, including a volunteer, Dr. Jameel (neonatologist), went to the family’s house in the evening. As they arrived, Heang admitted that they had not gone to the hospital. Even more concerning was the fact that the baby’s condition had worsened, albeit he was still alive.

The presence of all these visitors to
an otherwise remote
homestead did not go unnoticed by other villagers.  Soon there was a crowd gathered listening to the pleas of TLC’s staff and to the excuses of the mother and father. Sometimes, peer pressure can be a good thing. They finally agreed to go to the hospital. However, upon arrival, the hospital staff in Kompong Thom told them there was no hope for the baby as it was too small and sick. It appeared to have stopped breathing. Heang and her husband travelled back to the village with what they believed to be their dead baby boy.

Miraculously enough, when they came back to the village, the baby started breathing. Immediately, they came to the River Clinic. The antibiotics that the baby had been given by Dr. Jameel were working, and the tiny boy was beginning to look more comfortable. He was severely malnourished, dehydrated, and needed support that could only be provided in a hospital. This time, the family readily agreed to our suggestions. Ultimately, we took the mother and her baby to the Angkor Hospital for Children in Siem Reap, where they would spend three days.

Ever since, this little baby boy, has been one of the top priorities of the River Team. Every week, his height and weight is measured, and we give him a full medical check-up. Heang has struggled to breastfeed him, and they could not afford infant formula. TLC has therefore been supplying formula, and has also been educating the family about preparing the milk and cleaning the baby bottles hygienically, in order to support his first few months. Moreover, we brought the family clothing which had been kindly donated to us.

For each time the River Team sees him, he looks healthier and happier. This is noticeably reflected in his mother. The photo above was taken on April 6^th, and the change from December is quite remarkable. Needless to say, we are very proud that this little boy has survived and is now doing so well. That is what keeps us going!

KEY STATISTICS JANUARY – MARCH – INFOGRAPHICS

 

STATISTICS JANUARY – MARCH 2016 – TABLE

	Adult Men	Adult Women	Children < 14 y	TOTAL
Pediatric			1242	1242
General Medicine	397	1343		1740
Antenatal Care		102		102
Dental Treatment	8	22	48	78
Eye Care	7	13	7	27
Referral	1	1	8	10
Immunizations	36	90	135	261
Birth Spacing	8	67		75
Health Promotion and Education	318	958	725	2001
Home Care Visit		8	4	12
Visual Acuity and School Check-up			164	164
TOTAL	775	2604	2353	5732

By Vanessa Kellenberger, Volunteer from Switzerland

For TLC it’s all about identifying problems early and preventing serious illness. One of the best ways to do this is to engage people in looking after their own health. That’s why every six months we visit floating schools in each of our villages and spend time teaching children about simple things like hand washing and dental hygiene. We also carry out comprehensive school health checks for each student and refer children to our clinics if we pick up any problems. What do we see the most? Unfortunately the most common problems are easily preventable – parasite infections, decayed teeth and poor nutrition.  

Our school health check

Carrying out the school health check is quite a logistical challenge and involves lots of different team members. We set up stations for measuring height & weight, for a dental check up, a medical check up and an eye check. On average there are 30 kids in each class and it usually takes about 2 hours for them to rotate through the different stations. Like most school students the prospect of a diversion from lessons gets the class quite excited!

First: Measuring height and weight

The first step for all students is to have their height and weight measured and recorded on their school health check card. This helps us to keep track of whether the kids are growing as much as they should, and it helps us to identify any children who are malnourished. As we’ve mentioned in other blog posts, chronic malnutrition is a huge problem for communities on the Tonlé Sap. Most people can only afford to eat two meals per day and their diets are limited to rice and a little fish with hardly any fruit and vegetables. Many families also drink water directly from the lake which often leads to diarrhoea and parasite infections that prevent children from gaining weight and growing properly.

Second: General health check

Next the children see one of TLC’s doctors. They get a full check up and we pay particular attention to checking for common problems like ear infections and scabies. Because parasite infections are almost universal due to dirty water and unhygienic living conditions, we give all children anti-parasite medicine. Each child is also given a Vitamin A supplement as this important nutrient is lacking from most diets.

Third: Eye check

Although we don’t have an eye specialist in our team, we do a basic eye test using a letter chart to identify any children with poor vision. These children can then be referred to get glasses made when an eye specialist or optometrist visit TLC.

Fourth: Dental check

Our dental nurse Molika sees the children next. She checks every child’s teeth and counts the number of caries (decayed teeth). On average the primary school children we see have at least 4 caries! However, the few kids who brush their teeth regularly are doing a very good job. If there are any loose teeth, gum infections or other issues that needs further treatments then the child is asked to come to the clinic.

Fifth: Health education

Once every child has been seen by every member of the team, we dedicate some time to talking to the class about their health. One of the simplest ways to prevent illnesses is to wash your hands before cooking or eating and after using the toilet. Our team demonstrate how to wash your hands properly using soap and clean water and the children compete to see who can get the cleanest hands. Looking after your teeth by brushing them at least twice per day can prevent painful caries but also stop gum infections that can have more serious consequences. We use a model to demonstrate the best brushing technique and each child is given a shiny new toothbrush. We ask them to bring the old toothbrush back at the next school health check and trade it in for a new one. 

What we do with the results of the school health check

After every school check we give the kids a copy of their record card and ask them to discuss it with their parents. If they need any further treatment we ask them to come to our clinic with a parent or older sibling. Unfortunately, sometimes a family feels that medical treatment is not necessary but we continue visiting the schools regularly and try to convince them gradually. Our mission is to improve health on the Tonlé Sap Lake by providing medical care and health education step by step.

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By Vanessa Kellenberger, Volunteer from Switzerland

Since we last wrote about the tiny baby, TLC’s river team has been making weekly home visits to follow his progress. We have been very anxious about our little patient but this week we have good news: The baby is thriving!

Home visit

As you probably remember, this baby was in a critical condition when we first saw him and we feared that he was too small and too sick to survive. It took a lot of time and effort to persuade his mother that he needed urgent hospital treatment, but eventually he got the treatment he needed and was sucessfully discharged home. Since then our team have been doing home visits every week to keep a close eye on him medically and to support the family in caring for him. This Tuesday we went there with our team leader Dr. Sopheak, a volunteer paediatrican Dr. Hasan, our midwife Sreyneth and our family planning specialist Kolyan. As we arrived, the baby was sleeping peacefully in a hammock.

Thriving

Every week we measure the length and weight of the baby and give him a full medical check up. We discuss how he is doing with his mother and grandmother and give any advice needed. Unfortunately his mother has struggled to breastfeed and infant formula is much too expensive for a poor family. Normally in this situation, the family would feed the baby rice porridge and water which does not give adequate nutrition for an infant and carries a risk of infection from dirty water. TLC has therefore been supplying formula and educating the family about preparing the milk and cleaning the baby bottles hygienically, in order to support his first few months.

This week the little boy has gained weight again and is looking much healthier. The mother who was also unwell during pregnancy with very high blood pressure and sickness is feeling better too. We also brought the family some clothes for the baby and the four older children which were kindly donated to us and the family was so happy to get these gifts. TLC is very proud that this little boy has survived and is now doing so well. That is what keeps us all going!

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By Vanessa Kellenberger, Volunteer from Switzerland

Recently a desperate mother visited TLC at the River Clinic. The tiny seven-day old baby she carried with her suffered from fever and pneumonia. The baby was clearly critically ill and Dr. Emily, Dr. Bill and Dr. Kimsan concluded that a hospital would be the only chance to save the baby’s life. Despite their best efforts to convince the mother that this was the right thing to do, the mother refused. But there is a happy ending.

What the TLC doctors diagnosed

The mother, Heang, had delivered her son a few days before, after what she said was a normal pregnancy. The baby looked extremely small, and only weighed 4lbs. It seemed more likely that it had been born prematurely. Being born early in one of these villages is bad enough, but it was clear that this baby was also very sick. The tiny boy had a serious respiratory infection and was working very hard to breathe. He was so tired from all of this effort that he barely responded to the doctors assessments. The mother didn’t look much healthier herself. She complained of a terrible headache and her blood pressure was very high. She likely had pre-eclampsia, which could have killed her. 

What we did

The only thing we could do at the moment was to give paracetamol for the tiny baby, and try to convince the family that it needed to be treated in a hospital. Normally, a visit to the  hospital is unaffordable for the people who live on the lake or river. Making things worse, hospitals that provide free health care are very far away, requiring private transportation, often a boat or a motorbike. In these situations TLC will pay the journey for the families in need. Heang and her husband live six kilometers downstream in the opposite direction of the provincial hospital. We all crossed our fingers and hoped that they would take the baby there.

What happened after the visit at TLC River Clinic?

When we returned to the River Clinic one week later, the mother didn’t bring the baby back to us for a follow-up visit, as requested. TLC’s doctors, including Dr. Jameel (a neonatologist from the USA) were very concerned and went to the family’s house in the evening. As they arrived, they realized that Heang had not gone to the hospital. Even more concerning, the baby’s condition had worsened, but against the odds, he was still alive. So TLC once again discussed the importance of further treatment.

The presence of all these visitors to an otherwise remote homestead did not go unnoticed by other villagers.  Soon there was a crowd gathered listening to the pleas of TLC’s staff and to the excuses of the mother and father. Sometimes, peer pressure can be a good thing. The family finally agreed and left for the hospital, but not before Dr. Jameel started the baby on an antibiotic.  The family arrived there and hospital staff in Kompong Thom told them there will be no hope as the baby was too small and too sick. It appeared to have stopped breathing. So Heang and her husband took the bumpy road back to their village, bringing home what they believed to be a dead baby.

The Happy End

When they arrived back home they realized that the baby was, in fact, breathing! As soon as they noticed, they came to the River Clinic. It was early in the morning when they reached us. We were so happy to see the baby alive, but it still was not out of danger. The antibiotics were working, and the tiny boy was beginning to look more comfortable. He was severely malnourished, dehydrated, and needed support that could only be provided in a hospital. This time, the family readily agreed to our suggestions. We ultimately the mother and her baby to the Angkor Hospital for Children in Siem Reap. He stayed there for 3 days and received the treatments he needed before being discharged home looking much better. What a strong baby!

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By Vanessa Kellenberger, Volunteer from Switzerland

Recently we received a very generous donation. A Japanese dental team travelled to Siem Reap and gave us 7000 toothbrushes for children! Why do we need so many? Because they are not available on the Tonlé Sap Lake.

A great gift

Two weeks ago a Japanese dental team arrived in Siem Reap with a donation of kids toothbrushes by Okina. Our public relation specialist from Japan, Toyomi Maehara, welcomed them with gratitude and an invitation for dinner. The dentists also work for the Cambodia Kakehashi Project that provides free dental health care in different clinics in the countryside.

Why toothbrushes?

Most of the people who live in the floating villages on Tonlé Sap Lake don’t know the importance of dental hygiene and oral health, and the majority never brush their teeth. Although there are some toothbrushes available on the lake for little money, unfortunately the ones with a smaller head for children aren’t widespread in Cambodia. However, that is not the major difficulty for our patients. The main reasons for not using toothbrushes are related to local culture, traditional behaviour patterns and families’ priorities. The communities living on the lake rely on fishing for their income and most live on just one dollar per person per day. Toothbrushes are not essential for survival so they are not a priority for scarce resources.

Impact of poor dental hygiene

As toothbrushes are not viewed as crucial for this population, it is up to TLC to try to educate families on the importance of dental hygiene and good oral health. We frequently see patients with black, decayed teeth. Children are most afflicted by this problem as sweets and fizzy drinks become more available in this area. This also means that children are at high risk of suffering caries in secondary teeth. Furthermore, poor dental hygiene often causes periodontal disease and bacterial infections that lead to the loss of teeth in adults and children when untreated. In addition, gum infections produce bacteria that end up in the bloodstream and are linked to several other health problems.

How we try to educate children

Apart from individual education in our clinics, our dentist Molika regularly visit schools to provide oral checks and lessons about dental care. Children love our educational picture books! At the moment, we serve six villages with about 100 school kids each. Fortunately, the donation from the Japanese dentists will allow us to distribute toothbrushes to these children every three months. This is a great improvement as previously we were able to supply toothbrushes once per year at most! To make sure that our toothbrushes will be used, we ask children to bring back their old toothbrush for Molika to check before giving them a new one when necessary. We recommend using salt and water instead of toothpaste during the education sessions, as this alternative is preferred by our patients and is always available in people’s homes so they have no reason to stop brushing their teeth.

Why do we target children?

There are several reasons why we are targetting children’s dental care and not adults. As mentioned previously while adults toothbrushes can easily found, children’s toothbrushes are not widely available in Cambodia. In addition, attempting to establish healthy behaviour in children is much easier than trying to change behaviour in adults who are often reluctant to adopt new habits. Of course, we hope that the children will also teach their parents and show them all the advantages of brushing their teeth too!

Would you like to donate kids toothbrushes? Every donation will be gratefully received! Please contact us for more details.

By Hasan Merali, MD

Since 2011, the best part of each year has been volunteering with the staff at TLC in Cambodia. TLC has come a long way in just these 4 years from the slow and steady “Charming Duckling” boat and sleeping outdoors in the villages, to the sleek and quick TLC-4 boat and the relatively luxurious floating clinics with showers and electricity!

TLC’s Ky Kolyan–midwife and VHV Coordinator shares a lighter moment with Dr. Hasan Merali of Toronto Sick Children’s Hospital.

As a pediatrician, the statistic that strikes me the most in rural Cambodia is the neonatal mortality rate which is unacceptably high. One of the main reasons that so many infants die in the first few minutes of life is that they are born outside of health centers and do not receive adequate resuscitation when they need it the most. Along with the staff at TLC, we are trying to change that.

Long term TLC volunteer, Dr. Emily Whitaker (top left), looks on as Ky Kolyan teaches a group of Village Health Volunteers.

To start, I first qualified as a Helping Babies Breathe (HBB) Master Trainer. The HBB program provides neonatal resuscitation skills to rural healthcare workers. In 2013, Jon and I applied for, and were awarded, a three year International Community Access to Child Health grant from the American Academy of Pediatrics for our project: Implementing Helping Babies Breathe in Remote Floating Villages. This grant will provide us enough funds to purchase the required teaching materials and resuscitation equipment for all of the village health volunteers in the region who we plan to train.

Ky Kolyan explaining the basics of childbirth.

The first year of the grant was last year and during my trip I was able to train all of the TLC staff and get ideas on how to tailor the program to rural health providers in Cambodia. Earlier this year, I returned to Cambodia to implement the program in the floating villages. Kolyan, one of TLC’s midwives, has a gift for teaching and is now the team leader for the project. Together we were able to co-teach training sessions in Peam Bang and Pech Chakrey.

Sreyneth (on the right), TLC midwife, learns by doing alongside Kolyan.

Kolyan, Sreyneth (midwife) and several other staff are now teaching the course and delivering the equipment to other villages that TLC serves. Our goal over the coming year is to provide equipment and training to all of the midwives and village health volunteers involved in deliveries, especially to those providers involved in home births. The equipment is completely reusable and we hope that with this project, we will be able to make a significant impact on neonatal mortality in the region.

By Kathy Brook

Some of the TLC team at the river clinic. Dr. Kathy is 4th from the left.

I spent the peak season this year working with the dedicated team at The Lake Clinic, Cambodia. I have taken time away for my GP training in Southwest England to volunteer with TLC.

The months I spent living and working with TLC were a privilege in many ways. Consulting with patients in partnership with the Cambodian doctors and allied health professionals was a great opportunity to share knowledge and experience. Travelling to the lake villages and spending days living and working there was great fun. I loved being part of the TLC team and taking part in the daily routine of sleeping, eating, socialising and working all in the same floating clinic room.

Transport on the lake takes many ingenious forms!

The clinical work was varied and interesting. Much of the chronic diseases and childhood infections were not dissimilar to cases I would see in general practice at home, in contrast to the occasional snake bite or very advanced presentation.

Young girl having her temperature and weight/height measured.

Without the opportunity to arrange diagnostic tests and without the safety net to see patients the next day/week, the consultation is both more challenging and more straight forward.

Highlights of my time with TLC include stopping for sticky rice with the team on the way back from the lake clinics…

…and of course sitting down altogether at the end of the day for a feast lovely prepared by Channy or Satya!

The challenge for me was in hearing the patients’ narratives – poverty and difficult social situations with no hope of improvement. The stoicism I encountered and the warmth from so many of the villagers I met will stay with me. I feel lucky to have worked here and hope to return in the coming years.

 

 

 

 

1 January through 31 March 2015

Patient Statistics:

			1 January through 31 March
		SERVICES	Adult Men	Adult Women	Children Under 14	TOTAL
		Pediatric Care	0	0	1198	1198
Number of villages worked in:	9	General Medicine	376	1451	0	1827
Number of clinics held:	114	Ante Natal Care	0	121	0	121
		Dental	11	32	240	283
		Eye Care	10	20	10	40
		Referral	1	1	5	7
		Immunisations	1	117	277	395
		Birth Spacing	0	0	0	0
		Heatlh Promotion/Education	196	728	717	1641
		Home care visit	1	12	1	14
		Visual Acuity Exams /sch children	0	0	453	453
		TOTAL	596	2482	2901	5979

 

Environment:

The first three months of 2015 were gentle months. Warm, not hot days and cool nights were the rule. The Lake’s waters began to disappear rapidly towards the end of February, and by mid-March the TLC-4 was taken out of service at the water levels dropped below 40cm.

We are anticipating a lower than usual level of water this dry season as rainfall and snowfall throughout the Mekong region has been below “normal”.

 

Program:

Clinical care continues to be the core activity for both the Lake and River Teams but our own findings through surveys and mass examinations have shifted much of our intellectual energy into a parallel effort.

“It’s all about nutrition.”

This has been the message that the staff of TLC has been hearing since the beginning of 2014, and that they continue to hear even louder in this first quarter of 2015. Its echo is reaching to the Village Health Volunteers who conduct both large and small group sessions.

TLC staff supervise while a new Village Health Volunteer takes advantage of the clinic’s waiting area to engage in a teaching/learning session about nutrition. (The artificially red colored sugar water was later discarded, but not without tears.)

As the low-water season is upon us, and the ability to create “proper” floating gardens will not return for several more months, the TLC team has taken once again to the schools to encourage school children to lead the way with a different strategy.

TLC’s Ky Kolyan leads this teaching session.

The school children in the village of Pek Chikrey were taught the basics of nutrition by describing food at either “body building food”, “body maintenance food” and “body energy food”. When asked to prioritize their food tastes between fish, meat, vegetables and rice the children ranked vegetables the highest—they learn quickly!—with fish at the bottom. They are obviously quite bored with a diet of mostly just fish and rice.

To bring these lessons home, TLC started a “bottle garden” project with the school children modeled on our Stung Sen River Clinic’s own bottle garden. This methodology was started by one of TLC’s cooks, Si Sathya, who is an avid home gardener, and wanted to have the freshest herbs and spices for the dishes she prepared for TLC’s staff. From just a couple of bottles filled with local soil she expanded the idea from just basil and chilli, to the local spinach and green onions along with mint and even tomatoes.

 TLC’s River Team can always enjoy the freshest of ingredients.

As absolutely nothing succeeds like success, this method of home gardening has spread along the river. Perhaps everyone isn’t as ambitious as Sathya, but the idea has taken on momentum as Sathya teaches both proper nutrition and how to cook.

School children learn how to create their own hanging bottle gardens using discarded PET bottles and local soil that is now available during the low-water season.

For this first step green onions were chosen for their ease of care and resilience to the inevitable forgetfulness of some of the children. TLC plans to add more vegetables to the menu one by one over the next months.

Other:

In the past few years HomeCare has become a regular activity for TLC’s clinical teams. The aged population on the Tonle Sap Lake is increasing and a number of frail elderly and other handicapped handicapped people in our villages are not able to get to our clinics.

TLC staff and volunteers hike along the dry Stung Sen riverbed in Kompong Thom Province on their way to visit a house-bound patient.

Drs. Sopheak and Kamsan examine an elderly woman in her home as family members anxiously look on.

Photos by: Bryan Watt (as noted) and Toyomi Maehara

By Doctor Suzanne Montemuro

 

In February 2015 I joined The Lake Clinic Cambodia and spent 3 days per week working with their teams at various floating clinics on Tonle Sap Lake and Steung Sen River.

 

 

 

TLC has built 4 floating clinics. These simple structures are where the team sees patients, eats and sleeps (all in the same room) and are complete with all manner of creepy crawlies. Getting to these remote clinics takes about 3-4 hours by van and boat.

Week 1&2 were spent at the Steung Sen River clinic with a doctor, 1-2 nurses, a registrar and a cook (all Cambodian). Patients seen included: a child with severe congenital heart disease, a woman with end stage TB, a man with severe kyphoscoliosis, a new born with respiratory difficulties, multiple children with upper and lower respiratory infections, parasites and adults with gastritis, HTN (hypertension) and diabetes. Most surprising was a home visit to a woman 102 years old, living in a small wooden shack on stilts!

 

 

 

 

 

 

 

 

 

Weeks 3&4 were spent with the Tonle Sap Lake team. The villages on Tonle Sap Lake, consist of very basic shacks sitting in a brown soupy mix of garbage, excrement, and fish guts.

The clinics were very busy and noisy. Imagine: 2-3 docs, nurse/midwives, a dentist, and registration, all in one room with constant motor boat traffic outside!

What we saw: a child with acute renal failure, a baby with severe developmental delay, a young girl with purpura (bruising), a school room where every child had head lice, a young man with bradycardia and syncope, children with burns (open fires in small grass shacks)…and lots of GI complaints and respiratory infections.

What I enjoyed the most: working with a dedicated team of Cambodians in difficult conditions, supporting each other, providing medical care to Tonle Sap Lake and Stung Sen River communities. Volunteering with this group was an unforgettable experience.

What was difficult: the bugs, mosquitoes and other things that crawl, the tragic conditions people live in.

Would I go back: you bet!