Putting a face to the health system

This is a message that I sent out to all of our project staff in November, I thought that others might appreciate it.

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Almost by the definition of what public health means, we who work to improve health systems tend to be somewhat removed from the immediacy of patient care. We know, or hope, that we are saving lives through our work, but we rarely see the people whose lives are saved or lost in relationship to our efforts.

On Tuesday I was in a situation that unavoidably put a face on the Better Health Services Project and the Cambodian health system as a whole. While visiting Sisophone Hospital we came across an 11 year old patient, semi-comatose, being tended to by his mother. He had arrived that morning and was deathly ill. He was HIV+ and according to records his mother brought had been on ART for 5 months. Looking at him this was hard to believe. He was as emaciated as a concentration camp victim. He had a severely swollen belly (ascites, or fluid in the peritoneal cavity) and marked edema of his hands, feet, and face (to the point that his eyes were swollen almost shut). Every other part of his body revealed no subcutaneous fat and almost no tissue. He was panting in an effort to get enough air into his lungs and the only treatment offered by the hospital was the administration of oxygen through a cannula. I have attached a picture of him so that you can all see how ill he was.

A brief physical examination revealed that his left lung space was completely filled with fluid (empyema) which made breathing difficult. His stomach was so distended that it was difficult to feel the organs underneath, but he appeared to have a significantly enlarged liver. The mother (also HIV+ and on ART) initially reported that he had been active until 3 days previously (given the level of malnutrition it is difficult to imagine that he could have been very active) which would have suggested (perhaps) Pneumocystis pneumonia - PCP), it later came out that he had been getting sicker over the past 3 or 4 weeks, and the underlying cause was TB.

In any case, he was a severely ill child on the brink of death, and he was lying in a hospital ward that was incapable of giving him the treatment he needed. We urged the Director of the hospital to transfer him to Angkor Hospital for Children, he resisted and instead wanted to keep him overnight and then, possibly, transfer him to Mongul Borey. After some discussions and assurances via telephone from our HEF team in Phnom Penh that the ambulance transfer would be paid for by the HEF operator, he was transferred to AHC.

There he received a chest drain, but the pus was so thick that it didn’t flow well so the pleural cavity did not clear. His breathing became worse and he had to be intubated and put on a mechanical ventilator (i.e. a machine was breathing for him because he lacked the strength to breathe for himself). The pus from his chest cavity came back highly positive for TB. An ultrasound showed that portions of his lungs had died due to the TB infection. He was too weak to undergo an operation, so they could not clean up his pleural cavity surgically. His infection overwhelmed him, and 27 hours after admission to Angkor, and about 30 hours after we had first seem him, he died.

It is easy to say that this child was very sick (true) and that it is not surprising, and not a system failure, that he died. But this child can be seen in a different light. More than two thirds of untreated HIV+ children die before the age of 2. Those that survive are considered “hardy”, they have unusually strong immune systems that can fight off the HIV virus in a way that most people cannot. But they can’t do it forever. The child had fought all by himself as hard as he could against a very serious disease, and now he needed help that he didn’t get.

Now children die every day in every country in the world. But this child was particularly poorly served by the health system and I think it is instructive for us, as a health systems project, to reflect on how each of our technical units has some stake in the death of this child. I’ll go in alphabetical order since it is impossible to quantify the importance of the various parts of the system in contributing to the overall system failure represented by this child.

Clinical Services: CS comes first alphabetically, and it is perhaps the easiest failure to see since, until he arrived at AHC, the child received very poor care. There is no doubt that the project has enormous work to do to increase the competence of Cambodian clinicians. However, it should be noted that the child did not arrive in Sisophone Hospital until Tuesday morning at which point even the best care in the world probably wouldn’t have saved him. There may have been failures in clinical care in other health facilities, but we would need to conduct an investigation to confirm this. There were many points in this child’s life where he would have been well-served by good clinical care, but he didn’t die on Wednesday because of poor care received over the previous days.

Health Financing: The family was a Health Equity Fund beneficiary family. There were some problems around the understanding of what the HEF would or wouldn’t pay for in terms of referrals (also seen in BTB Hospital earlier on the trip), and it is likely that he would not have been transferred absent out intervention, and he certainly would not have been transferred to AHC. But more importantly, it seems likely that the lack of money played some role in the mother waiting so long to bring her child to the hospital. Perhaps she had been forced to pay under the table payments, maybe she didn’t think that services would actually be free or transport reimbursed, but whatever he thinking she waited far too long to bring her child in and the costs involved almost certainly played a part in her decisions.

Health Information Systems: The mother was carrying a number of patient records (notably the ART booklet and the child health card), so at one level we were able to identify when ART had been started and what drugs the child received (the mother had also brought all of the pill bottles). However, the HIS had also completely lost track of this child, newly started on ART. An ART patient is supposed to be checked on regularly in the first months of care, and then followed up by a home-based care system. Neither appears to have happened here, instead the child was counted as a “success”, another pediatric ART patient, and then ignored to the brink of death. The HIS should have been able to pick this up, but it didn’t.

Health Systems Management: Somehow a child, who was desperately ill in a manner that was clearly visible even to an untrained eye, fell through the cracks of the system. Then, after admission to the hospital, was incorrectly managed. There was little to no communication between the hospital management and the HEF management. Neither was willing to take “the risk” of transferring the patient, more worried about unallowable costs than a patient’s life. The different parts of the health system (hospital, OD, health center, and HBC) could not have been communicating or the child would not have ended up this sick.

Infectious Diseases: The child died of the effect of 2 infectious diseases, HIV and TB. The first receives about half of all of the money spent on the public health care system in Cambodia, the second receives another big chunk of funding. The child lived in an area where both diseases are known to be prevalent, but the hospital was unable to clinically manage the case. And the condition of the child upon admission demonstrates that he wasn’t being managed correctly in the 5 months previously either. This is a failure of the two biggest “vertical” programs in the country.

MNCHN: Of our technical units MNCHN is perhaps the least involved with this specific case since the child was 11 years old and outside of the normal range of child health interventions. However, a well-functioning well-baby system would likely have prepared the mother better to take care of a sick child, no matter what the age. Attention to growth monitoring in early life might have prepared both the mother and the caregivers who saw the child during the months where he was wasting away to realize that severe weight loss is a clear (though non-specific) indicator an underlying health problem.

So all of us on this project have a role to play in saving the lives of children like this one. We can’t succeed all of the time, but we need to look at the cases where we fail honestly and we need to learn from them, so that we can serve future patients better. I don’t really know why this particular child has affected me so much (an American doctor at AHC said that, after 4 years of seeing kids die, he rarely cries anymore, but that he did after this case), but I, and we, need to learn from this experience and we need to use it to remember why we do what we do. We work to try and save people’s lives, or to ease their suffering. Remember that when you’re asked to put in extra hours over the weekend or you receive a particularly annoying request to do something that you think is not necessary (whether it be from BHS management, USAID, or the MOH J )

The key lesson: The health system is not an end in itself; it is a means to better health outcomes.

Following up on that completely different note

I have now seen the video from which the picture below was grabbed. On the video it does not seem as if Obama was checking out the girl, who is apparently the daughter of the Brazilian President, instead he is turning back to help Michele down the step.

However, in the video Sarkozy practically bends over backwards to follow the girl's path. It is truly comical, obviously the French have absolutely no shame about being caught checking out someone. If Obama had done what Sarkozy did he would probably be in the middle of getting impeached, I wonder if the story even ran in France?

On a completely different note

Isn't the look on Sarkozy's face hilarious? Given the positioning of the various bodies he was no doubt checking out the same girl and then his eyes come across Obama, and he gets a perfect Gallic "aha" look on his face. I can just hear the conversation tonight around the Sarkozy-Bruni dining room table, "See, Carla, he is not perfect, he is human, just like all of us (imperfect men)."

That last part in brackets would only be implied, it is so understood that it never has to said out loud :-)

Anthony's and Sidonie's Marriage Day

The reason we all went to Abidjan was for the wedding of my friend and colleague Anthony Tanoh to Sidonie, his partner of 10 years. The concept of Ivoirian weddings are a bit different that the American theory. Most couples in Côte d’Ivoire don't go through any marriage process at all, and for most people this lasts for the entirety of their time together (which would become common law marruage in the States, but apparently there is no equivalent in Côte d’Ivoire). The decision to get married in Côte d’Ivoire comes after couples have been together for quite a while, and they usually have children. Getting married symbolises that the couple intends to stay together forever, separating is no longer on the table. While in theory this is also the idea of marriage in the States the fact that roughly 1/2 of marriages end in divorce tends to obviate the theory.

My favorite quotation about life in general (this is probably related to the work I have chosen to do in life) is attributed to Albert Einstein: "In theory, theory and practice are the same. In practice, they are not." American marriage is theory, Ivoirian marriage is practice.

So our family went to Côte d’Ivoire to witness Anthony and Sidonie announce to society that they were going to stay together through thick and thin. Anthony and Sidonie had named their third child "Christophe," which we initially took to be more of less the equivalent of being named a godfather in American terms (an honor with few obligations), but which we learned is far more symbolic in Ivoirian culture. In essence the formal naming of a child after a friend in Côte d’Ivoire bonds the two families together for life. This became clear a few years ago when Christophe was born and, in both formal and non-formal settings, we began to meet more and more members of Anthony's extended family. In the picture below Anthony and Sidonie are getting ready to pose for wedding pictures, their 3 children (in descending age), Henri- known as "Junior", Yann, and Christophe are to Anthony's right (the flower girls in green dresses are all relatives, but not the children of Anthony and Sidonie).


The wedding day had 3 main components: a civil service overseen by the mayor of Cocody, Abidjan; a religious ceremony at an Episcopalian Church (Anthony's family are Protestants, Sidonie's family is Roman Catholic, the Protestant's won out); and a dinner reception for about 500 people on the grounds of the National Library. I will put together a brief movie of all of this for a future post, these pictures were taken off of the video footage. The above picture was taken on the banks of the Abidjan lagoon between the civil service and the religious service, the picture below of Stefan below was taken at the same time, he is doing his best Leo DeCaprio impersonation (I just watched a $1.50 bootleg copy of "Body of Lies" last night, I'm not kidding, check it out, he just needs a Brazilian Supermodel girlfriend). Brooks Brother suit compliments of a doting mother...


From here we went to the church, which thankfully had many ceiling fans, as spending a full day outdoors in Abidjan in a tie and suit was an idea that had never previously crossed my mind as something one might consider reasonable. Luckily, it was abnormally cool the week we were there. Here is a picture of Anthony and Sidonie at the front of the church during the middle of the ceremony.


From the Church we went to the dinner. Kathy and I had been the witnesses to the Civil Ceremony, two other friends were witnesses to the religious service, interestingly, each pair of witnesses got premier seating at the dinner. The two people we would consider "Best Man" and "Maid of Honor" sat out of sight behind the dais, their roles were much more support than honor. Below is a picture of our two boys at dinner, we were finally allowed to jettison our jackets, though I am proud to say that they sucked it up until I went first (I'm obviously a bit biased in my picture choices...).

I'm not sure that I've exactly covered the day, but I'm running out of gas and it is past dinnertime, so this is what you're getting for today. Best to all.

Back in Phnom Penh

The Krasovec Grundmann clan is now back to being spread out all over the world again after having spent last week together in Abidjan for the marriage of our friends Anthony and Sidonie Tanoh. This holiday weekend (it never feels much like Independence Day outside of the States) finds Kathy in Bamenda, Cameroon doing some work for EGPAF and the Cameroon Baptist Convention Health Board; Nico slumming around Bangkok at the start of his 7 week S.E. Asian adventure with his friend Max; Stefan in Washington, D.C. starting work at FINCA (a micro-finance organization); and me sweating lightly under a fan here in PP.

I have mentioned before that Cambodia is quite hot, but that we've seemingly adapted to it faster than I would have expected. This was reinforced during out trip to Abidjan. I've been to Cote d'Ivoire a couple of dozen times and not once did I ever think that it was anything but hot. On this trip it seemed almost cool. Admittedly, it rained almost every day, but it does here in PP as well. Unless it was a freakishly cool period in Ivoirian climate history (which nobody alluded to) the only conclusion can be is that it is really, really hot in Cambodia...

Our trip to Cote d'Ivoire was also interesting for a completely different reason. For the whole time I worked in CI Americans did not need visas. So we assumed Americans still didn't need visas. Bad assumption. Kathy, Nico and I all arrived in Abidjan on the same flight and were met at the gate by a friend of Anthony's. As we approached Immigration we were joined by another friend of Anthony's, who turned out to be the head of the Airport Police Division. He asked for our passports to jump the lines waiting for their passports to be stamped (VIP service, in other words). He casually mentioned that we must have visas. After 3 minutes of discussion where we made clear that we did not have visas, he made a snap decision and walked us right by all of the immigration officials, waving them off and telling them that "we'd be back". Which, of course, was not true. So we ended up in CI for a week illegally without visas.

The problem was that Stefan was arriving 24 hours later and would face the same problem. So we called him and caught him in the Atlanta airport between the first and second of the 3 flights that he was taking to get to Abidjan. We told him that he would be met at the plane and whisked through immigration. Both the friend and the policeman said that they would meet Stefan the next night. But for some reason I had a bad feeling...

So, 30 hours later we were waiting for Stefan at the airport as the Air France flight came through immigration and customs. No Stefan. Then a policeman arrived and asked us what Stefan looked like, which didn't seem like a very good sign. Turns out that the Police Chief had taken ill, and that the friend had decided to watch the Cote d'Ivoire-Burkina Faso soccer game rather than go to the airport. Stefan had found himself at immigration without a visa, had turned to the closest policeman for help when the Immigration Officer started shouting at him in French, and soon found himself being marched over to the departure wing to be put right back on the Air France flight out of CI. He had the presence of mind to argue enough with the policemen that his parents were awaiting for him and they let him come out front to see us (otherwise he would have just been whisked around in back and we would never have known what was happening).

Anthony arrived on the run and, 3 hours and a whole bunch of phone calls later, we all left the airport together. The sick Police Chief had ordered him off of the plane (over the phone from his sick bed), but the police who had ordered him on the plane refused to officially reverse their decision, so we had to wait for a shift change before he got the paperwork that let him into the country. The irony was that in the end Stefan was the only one who got a visa, and Nico, Kathy and I had to be escorted back through departure Immigration by the police chief to get out of the country. So we went all week without visas, which was a little stressful because there is always a small risk of getting pulled over at a police stop.

In the end we got some stress and Stefan got a story for life.

Texting

Seems more common in Asia, though given that the NYT just said that the average Anmerican 18 year old makes 2,000 texts a month maybe I'm just out of it, let us just say I text here more than I did in the States.

On that note, from McSweeneys:

GOD TEXTS THE TEN COMMANDMENTS.
1. no1 b4 me. srsly.
2. dnt wrshp pix/idols
3. no omg's
4. no wrk on w/end (sat 4 now; sun l8r)
5. pos ok - ur m&d r cool
6. dnt kill ppl
7. :-X only w/ m8
8. dnt steal
9. dnt lie re: bf
10. dnt ogle ur bf's m8. or ox. or dnkey. myob.

M, pls rite on tabs & giv 2 ppl.

ttyl, JHWH.

ps. wwjd?

History in Statistics

I was at a meeting in the Battambang Provincial Heath Office yesterday and the following graph was on the wall I was facing over the heads of the government counterparts with whom we were having a discussion.


This is a "population pyramid", a common way of presenting a country's population by age (you can double click on the graph to make it bigger). The Y axis is composed of 5 year age tranches, Zero through 4, 5 through 9, etc. The red are males, the green are females. The numbers at the end of each bar represent the percentage that tranche represents of the population. So female 5-9 year olds represent 7.9% of the total population.

The interesting thing here is that 20-24 age tranche which is significantly smaller than would be expected (normally these pyramids are completely smooth, the only part that changes is the "steepness" (everyday language for "slope" in statistics) of the sides, developed countries have steeper sides because the population lives longer and has fewer children.

The 20-24 year olds in this graph represent those kids that would have been born a year or so into the Khmer Rouge years until a year or so after the Vietnamese invaded and overthrew the Khmer Rouge. There were undoubtedly two aspects to this, fewer women were getting pregnant, and more infants were dying. The result, a lot fewer surviving children, and now a lot fewer adults in that age group (this data was collected in 2001 or 2002, so the age tranche today would be adults somewhere around the ages of 28-33.

War doesn't only affect the present, it affects the future as well.

I'm becoming Cambodian...

I drove the Vespa to the office today and it wasn't until I got here and reached up to take off my helmet that I realized I'd forgotten to put it on.

Luckily, it is only a 3 block drive. So no cops to pull me over and get their $1.50 "fine".

Driving in Phnom Penh

Within the first minutes of arriving in Phnom Penh one is struck dumb by the driving habits. There are the outward signs of a traffic law-abiding society: traffic lights (that helpfully count down the time until they change); signage with the dos and don'ts (one way street, no left turn, etc.). But this is all completely superseded by the basic two rules of Cambodia driving: 1) you can do anything you want as long as you do it slowly; and, 2) it is very bad form to have to completely stop.

Up to a certain level of traffic flow this actually works fairly well. To give one example, if you are driving down a busy street and you want to turn left under the quaint notion of traffic law, you need to go up to the point where the 2 streets intersect, stop, and wait for a sufficient break in the oncoming traffic to make the left turn. The way Cambodians see it, if there is a break in the traffic (more on their definition of a break later) anytime you are within a few hundred yards of where you want to turn left it makes much more sense to cross over there, from where you slowly drive against traffic, pinned up against the left curb of the street (that would be the wrong curb for those of you having trouble picturing this move) until you arrive at the street where you wanted to go left, at which point you turn left.

The most amazing part of this is that it will engender absolutely no negative reactions from anybody, including any policeman whom happens to be standing by eying traffic to see who he can cite (pronounced "bribe") for a helmet violation. No horns honking, no raised middle fingers, no looks of exasperation, nothing, just traffic as usual.

Thinking this logic through you can see the favored way of turning left on to a boulevard if you come up on to it from a smaller side street. No stopping to wait for a break in traffic, which would break the cardinal rule of Cambodia driving (no stopping). Instead, you immediately turn left going into oncoming traffic, and drive slowly until the opportunity comes to tack over to the proper side of the road. This has a sort of elegance when you are driving a motorbike, as you don't disturb the oncoming traffic that much and it only has to adjust slightly to flow around you. But people in Land Cruisers do this. Imagine that you were driving down Rockville Pike (or El Camino, of whatever serves as a busy 4 lane street in your neck of the woods), in the slow lane, minding your own business, and then, magically, coming out of a small side street, a full-size 4x4 was all of a sudden driving right at you (albeit slowly). Remember, you are not allowed to honk your horn.

Up to a certain point of traffic density this has a certain Buddhist balletic quality to it. Go with the flow, adjust to the flow, and make a new flow. It reminds me of nothing more than watching water currents go around boulders and fallen logs. You see someone a head of you wants to do something, and you adjust to allow him to do it. Pedestrian street crossings take particular faith in this ability to adjust, as you are essentially putting your life in the faith that the oncoming Lexus 470 will slow down, move over the center line to go around you, and not run you down.

But this balletic quality can, and frequently does, come to a complete stop, when too many car and motos try to share the same piece of road. Since the first thing that anybody does when there way is blocked is to drive around it, even if that takes you across the center line, and the second thing that happens is that all the space behind you will fill up with people doing the same thing, it is easy to see what happens when everybody acts like this and there is literally no room to move. Everything stops, completely and absolutely. Face to face, usually on a diagonal tangent across the road (you'll have to sketch this to see how it works, it is like a problem in thermodynamics). Motos get through for a little while, like water leaking at a faucet, but eventually even they get boxed in, and then everybody moves into disengagement mode, which translates essentially to every small vehicle doing whatever it can to get out (driving up walkways, sidewalks, etc.) and every car trying to turn around is a series of microscopic movement 3 point turns which take a good 10 minutes to execute.

And eventually traffic moves again, for a little while.

On the Vespa I try and stay on the side streets, you have to be more careful at every intersection, but there are fewer blockages.

Raining Now

April was supposed to be the hot and dry month, with the rains coming in the later part of May. As in any agricultural society, the timing and content of the rains are closely watched and much discussed, even by people who haven't farmed in their lives. The rains came early this year, the first downpours coming in mid-April, a month or so early. So now everybody is convinced that they started too early and thus will end early and the crops will be meager. It is tough to be a farmer, God (from whatever provenance) is rarely supportive.

But when it rains here, it really rains.

We live near the Royal Palace, which lies in a low-lying area of Phnom Penh. So we have learned that the streets around us flood with some regularity. We were battered last week by a ferocious thunderstorm that must have dumped three or four inches of rain over the course of couple of hours in the late afternoon. I had a perfect view of all of this out of the windows of my 4th floor office, and I could watch the street in front of the office slowly fill up with water. Half a block down to the right where the street hits the Royal Palace wall, the water was at least 18 inches deep. Cars pushed small waves in front of them and one in ten died. Motos did no better, and faced the double hazard of running into small potholes unseen below the water, sending the rider a tumble.

Norodom Blvd, the big street between the office and our house, was not underwater but was essentially a parking lot; filled with frustrated drivers driven off of the smaller, sodden side streets. At dusk, not wanting to navigate in the dark, I mounted the Vespa to drive the 3 blocks home (walking would have meant unavoidably wading through a foot or so of water). I did fine at first, edging up the left side of the normally two-way street now turned one-way by the all consuming desire for higher ground, water up to the foot platform of the Vespa, held off from coming over my feet by the bow wave formed by moving forward. I was within 10 yards (maybe meters) of dry road (heading up to Norodom) when I was brutally cut off by a frustrated car and I had to stop and put my foot down in a foot of water. After that I cut through the stopped cars, drove through two bank parking lots, and traversed the flooded street in front of our house (water lapping at the gate) and got home.

All in all, quite a bit of fun.

Status Update

Another few weeks have passed in a blur of activity hard to decode after the fact. One thing is for sure, the day to day mechanics of running a large project (reviewing and signing travel authorizations and bank reconciliations, signing checks, logging on and sending electronic payments, dealing with personnel issues, ad nauseum) take a lot of time, and when you add in the task of trying to lead the somewhat cumbersome project technically, and to change its structure and outputs in a pretty significant way, the days just flow by. Or, "the days are just packed", to quote Calvin.

We still do not have our car or our belongings, now sitting in Sianhoukville Port for the past 6 weeks. From what we can decipher post mortem, the company hired by the American shipper to clear the container here in Cambodia was simply incompetent. As in they had no idea what they were doing. So we have hired another, we'll see. As such we are only using a few rooms of the house. Our bedroom is pretty well furnished other than a few dressers we'll add when the shipment finally arrives. We have bought a teak patio set that now sits at the base of the stairs and is where we take our meals. The living room has one teak and rattan lounge chair, which will also eventually end up outside on the porch, where one person can read under the fan.

Considering how much furniture we shipped over, the change that will occur upon delivery of the container will be marked.

Khmer New Year

It is Wednesday morning, the middle day of the 3-day Khmer New Year, and Kathy and I are in my office taking advantage of the internet (our home internet is acting particularly weird), and I thought I'd mention a word or two about the Khmer New Year. Or in this case, copy from a site called ethnomed.org:

Usually, Khmer New Year is celebrated for three days:

The first day of New Year is called as Moha Sangkran, and it can be described simply as the inauguration of the New Angels who come to take care the world for a one-year period. This year is the year of Snake (Msanh), and Moha Sangkran of the New Year will begin on April 13th at 11: 36 PM. The leader of Angels is named KimiteaTevi. People need to clean and decorate the house and also prepare fruits and drinks for the New Year inauguration and to welcome the New Angels at every single home. Elderly people like to meditate or pray the Dharma at that time because they believe that any angel who comes to their houses at that time will stay with them and take care of their family for the whole year. Actually, in the morning at the first day of New Year, most Khmer people prepare food to offer the monks at Khmer temple to get blessed. It is a great time for boys and girls to play traditional games together at the temple or any field or playground in their village because it is only at the New Year time that boys and girls are allowed to play or to get together. Also it is a wonderful time for single people to search for the special partner to get married in the future. In the past 30 years, "Dating" did not exist in Cambodia.

The second day of New Year is called as Wanabot, which means day of offering gifts to the parents, grandparents and elders. Usually, Khmer People like to share gifts or presents to employees and also donate money or clothes to poor people. In the evening, people go to temple to build a mountain of sand and ask the monks to give them a blessing of happiness and peace.

The third day is called as day of "Leung Sakk;" that means the year starts to be counted up from this day, for example it is when the year of 2000 would change and begin to be 2001. Traditionally, in the morning, we used to go to the temple to perform the ceremony of the mountain of sand to get blessed. In the evening, to complete the New Year festival, our Khmer people need to perform the last ceremony, called as "Pithi Srang Preah", which means giving a special bath or a special shower to Buddha statues, the monks, elders, parents, grand parents to apologize for any mistake we have done to them and to gratify them. Every one must have a wonderful time during this ceremony because it is a great opportunity for every one, young and old, man and woman to have much fun by spreading out water to each other.

You can also read more at :
http://en.wikipedia.org/wiki/Cambodian_New_Year


The most striking thing so far is that Phnom Penh almost completely clears out. I mean, completely. It makes August in Paris look overrun with Frenchmen. I'd say traffic is down by 90%. Apparently everyone who does stay in Phnom Penh (those who were born here and have family here, presumably) goes to Wat Phnom in the evening, so we ran into a little traffic jam there yesterday evening, but otherwise you can just sail around on the boulevards, where traffic normally averages maybe 15 mph.

The Outside of Our House (and a Vespa to boot)

In the last post you saw what the inside of our house looked like, now you can see the outside. Put briefly, we live in a classic "Indochine" colonial house. For reasons I don't know, these houses and buildings were painted in a mustard yellow. They had wooden shutters of slightly brighter mustard yellow. There are relatively few of these houses left in Cambodia, mostly because the Khmer Rouge burned most of them down during their reign from 1975-1979 on the theory that anybody who lived in one was bourgeois. I'm guessing here, but there are probably less than 20-30 houses like ours left in Phnom Penh.

The KR were probably correct about the bourgeois elements living in such houses. The underlying question was whether society was better off without any bourgeois elements. As a fairly representative member of the bourgeoisie (the international bourgeoisie at that), my vote is no. My dimly-remembered 22 year old Marxist-infused self has trouble believing that I just wrote that, but there you go.

On a strange historical note, for some reason te French Colonial Administration in Vietnam taxed houses on the width of their property. Not surprisingly, this led to a lot of very deep, but not wide, houses. Many Vietnamese Colonial era houses have a courtyard in between two separate buildings, built front and back on a very slim plot to minimize taxes. The French Colonial Administration in Cambodia followed a different taxation policy, and thus Cambodia has relatively "normal" looking houses (absent Khmer Fouge destruction).

This first photo is looking at the back of our house up the garden side of the house (the other side is all driveway).

It isn't completely clear from this picture, but the house has the height of a 3 story house, but is only two stories high due to the 14 foot ceilings. The grass is watered during the dry season by a sprinkler system (the first that I have ever had). I am looking at this piece of land as the future site of a "plunge" pool, which is to say a simple small swimming pool into which one can immerse oneself at the end of a long hot day to unwind. We'll see.

This next photo is taken catty-corner from the last looking from the front of the house towards the back, on the driveway side of the house. One of my favorite parts of the house is the alcove jutting out from the main body of the house, this is where the dining area seen in the previous post is situated. You can also see the building off the back of the house, this houses both the kitchen (to the right), and 2 bedrooms and a bathroom (to the left). We'll probably use the bedrooms for our exercise equipment (the main house already has 3 bedrooms), but we'll see after all of our stuff gets delivered.

This next picture is taken from the other front corner, and shows the porch that comes off of the main living/dining room. The table that we are now using inside will move out to this porch, and I imagine that we will take many meals sitting outside-- assuming we come up with a way of providing air circulation. Come visit, and you, too, could be eating good French croissants on this porch as Phnom Penh comes to life on one morning....

This last photo is not of our house, it is of my Vespa, a mid-60s "150 Super". Cambodia is not the old Vespa nirvana that Vietnam is, but there are still some around, almost all owned by sappy expatriates (a Honda Super Cub, which also dates back to the 50s, is much more fuel efficient and almost never breaks down, so defending the decision to drive a Vespa invariably returns to non-rational roots). In my case these non-rational roots come from my ownership of two different Vespas during mu college years, one of which (I kid you not) had its rear wheel come fully off when I was driving down Junipero Serra Blvd. at 45 mph at 3:00 AM one morning after my nightly bartending shift at the Dutch Goose. Yet, I continue to have a soft spot for Vespas. So we'll see. Given that You Tube has videos of people throwing Super Cubs off of 3 story buildings, and then going down to start them and drive off, and a Vespa will stop working if you look at it sideways, this may be a passing fancy, a midlife crisis, if you will, but I think we would all have to agree, if the extent of my midlife crisis is to buy an old Vespa,we're all in good shape. Let us all pray the same for the Vespa (Which is about 10 years younger than me, and they say 50 is the new 30...).

A Happy Khmer New Year to All.

The Inside of Our House

We are living in a great old French Colonial house in Phnom Penh -- or maybe camping out is a better term in that our household furniture remains in the grip of the Cambodian Customs Service (absent the "Diplomatic Note" that will free our car from customs), the problem is that our car is in the same shipping container as our furniture, ergo, no furniture (and no car).

So we have bought enough furniture locally to get by. This first photo is our bedroom. In it you can see our truly amazing Cambodian bed, which is estimated to be somewhere between 75-125 years old. While it is hard to tell from this photo it is composed of two mahogany planks, each 30 inches wide and about 1.5 inches thick, laid across two mahogany feet. To truly appreciate this I would have you go down to your local lumber dealer and ask him for a piece of immaculate mahogany 7 feet long, 30" wide, and 1 1/2 inches thick. After they stop laughing you'll begin to appreciate this bed.

The bed is tastefully accented by the steel garment racks covered in raw canvas purchased at the D.C. Wisconsin Avenue Container Store. I'm not sure how long we will continue to use these (they came over in our air shipment) but they have been nice in the short run. To put the next paragraph in visual context, the garment racks are over 6' tall.

You can see the 14 foot ceilings of a pre-air conditioned house, ceiling fan in place (sadly not one of the pre-war art deco French versions that look like something Daisy Buchanan would have used to make sure she never perspired). Not in this picture, but just off to the left, is the air conditioner outlet that lets us sleep in comfort.

5

Living in tropical climates you learn a lot about thermodynamics. The first days I was sleeping in this room (Kathy was in Kenya visiting Stefan) I put on the air conditioner and the fan. And the temperature in the room never dropped below 84 degrees Fahrenheit. Then one day I forgot to turn on the fan while I was downstairs having dinner, and when I walked into the room it was 76 degrees. It turns out (duh!) that cold air stays in the bottom of the room and hot air rises, and by putting on the fan I was mixing them, and raising the overall temperature significantly.

All of this makes me look amazingly anal retentive unless you realize that, by chance, the travel alarm clock I use has a thermometer on it. Also, 84 degrees with the breeze from the fan and 76 degrees without the breeze feel about the same. Not sure where that leaves me.

This next photo is looking towards the bottom of the stairs (the bedroom is upstairs). We bought a patio table which will soon move move outside to the patio, but in the meantime is serving as our dining room table. This section of the house has no air conditioning, the window to the right is wide open (screened) to the elements. There is both an overhead fan for normal days and a large circular fan (bottom right of the picture) for hot days to keep us cool while we eat.

This next photo is of our main downstairs room, which will eventually (see customs clearance above) have the formal dining table and our living room furniture. It runs the whole length of the house and opens out on to a small, raised front patio. I may be odd but when I stand in it I just feel like I need to have a gin and tonic in my hand to complete the picture. You can see that we have bought one rattan lounger, which I thought would eventually end up outside on the patio, but which Kathy has decided will be our television watching seating (our television to be is in our shipment caught up in customs). It doesn't take a genius to figure out that if this last vision is true we will need a second rattan lounge chair, and it won't surprise those of you who know us well that a second is on order from the Indonesian furniture store that sold us the first lounge.

This last photo is a close up of our tiled floor. As you can see it is pretty ornate. I tried to explain this to Kathy when we were back in Luray packing up to come here, but nonetheless we have 9 Persian and Moroccan rugs on their way here. It is going to be interesting to see how many are actually used, Kathy seems pretty insistent that we put some down, I am having trouble picturing the clashing patterns. We'll keep you, dearest readers, posted.

Next, the outside of the house.

What Can I Say?

I'm a bad blogger. Good bloggers manage to post 3 or more posts a week, no matter what. That way beloved blog readers keep checking in to read the posts. I, on the other hand, go months at a time without posting anything. Leading beloved readers to wander off to whatever corners of the internet keeps them interested.

In my defense I could say that I have been busy. Even very busy. That I spend an unbelievable amount of my time going to meetings in which I have no desire to participate. But that as a distinguished, senior public health professional I have to go to such meetings, or risk embarrassment to all that I hold dear (that is, more or less, the way it has been explained to me).

Maybe I have to figure out a way to write blog posts while I am being bored out of my mind at said meetings.

Anyway, it is Sunday afternoon in the week leading up to the Khmer New Year (Tuesday-Thursday), which has about the same effect on Cambodian life that Christmas week does on American life, so no more meetings for a little while, and time to post, so after the drought...

the monsoon....

See, that was a S.E. Asian reference, no monsoons to be had in Virginia or Maryland. Maybe there is a reason for you all to check in to this website every once in a while. Or maybe sign up for the RSS feed, that way the intertubes will tell you when I have managed to post something and you won't waste your time checking in.

P.S. As another free hint, if you double click on the photos they get bigger, showing you more detail of the documentation of our exotic lives. No photos in this post, but more coming at you soon.

Squeezing in February Posts

Saturday night finds me alone in a hotel room while Kathy is off celebrating Stefan's 21rst birthday with him in the Masai Mara (Kenya) looking at lions and giraffes and who knows what else. Which is good news for avid followers of the blog since here I am belatedly posting (that avid part would be 3-4 of you from what I can tell) instead of out living up the Phnom Penh nightlife with my lovely wife.

I should have had a lot of pictures to post from my trip this week to the western border of Cambodia (that would be the Thai border for those of you a little shaky on your S.E Asian geography), but inexplicably the camera battery that I very carefully recharged before heading off proved to have no charge whatsoever when I pulled out the camera, I swear...and the dog ate my homework too. I should note that if the battery had worked you would have seen photos of working elephants, not is some namby-pamby game preserve like in Kenya, but being used as beasts of burden. Elephants seem to be sort of the Caterpillar equipment of Cambodia, if you need something big moved, you turn to elephants. Only they don't paint them yellow so you have to keep an eye out to see them. Anyway, you get no photos, only narrative.

Which is more work for me, if you really think about it. So that dog story may have some validity.

Cambodia doesn't look very big on a map, but it turns out it takes a while to drive around in it. The roads were actually pretty good, a huge upgrade from years past (I'm told), but they are only one lane in each direction and there is a lot of traffic that varies in speed from oxen to Land Cruisers, and the slower speeds tend to trump horsepower (this would not be a country where you would get much use out of a Porsche).

So I took a 3 day trip out to the Western border town of Poipet, which turns out to be a really, really low rent version of Las Vegas. Seems that neither Thailand or Vietnam permit gambling and Cambodia does, so Cambodia is the Nevada of S.E. Asia. Poipet, smack on the Thai border, is filled with Thai-owned casinos sitting on Cambodia territory. The funniest part is that the casinos are actually located between the Thai customs checkpoint and the Cambodian checkpoint, instead of a no-man's land like between most border offices it is a free-gambling zone. The Cambodians are clearly not too worried about smuggling because if you are in a car with Cambodian plates you are not even stopped as you drive into the no-man's land (we spent the night in one of the casinos, there wasn't any other choice). And coming out we just sort of indicated that we had spent the night at the hotel (one of about a half-dozen) and they waved us on back into Cambodia. I don't know how you could make money smuggling stuff from Thailand to Cambodia, but if I stumble across it I'll know how to do it.

I do know how you can make money smuggling stuff into Thailand. There was an article in the Phnom Penh English-language newspaper that described an argument between the new customs director of Poipet and a group of handicapped vendors. Apparently for years these handicapped vendors have collected grasshoppers and grubs on the Cambodian side of the border and then wheeled across to the Thai side where they can sell these delicacies for far more than they can in Cambodia. I can't explain why insects and grubs are more highly valued in Thailand than in Cambodia (though it is going to make me examine my food a bit more closely the next time I am in Thailand) but the profusion of handicapped vendors comes from (sadly) all of the landmines and other unexploded ordinance that the U.S. left after the Vietnam War. One of the weird lessons of the Vietnam War is that is was a lot better to be on the other side of a declared war against the United States (i.e. Vietnam) than to be on the other side of an undeclared war (i.e. Laos and Cambodia). Turns out the rules of engagement (don't plant land mines indiscriminately, don't bomb schoolhouses or churches, etc.) only apply to countries on whom we have officially declared war, in undeclared war anything goes.

So, hooray for Obama setting a time line for pulling out of Iraq.

Anyway, to get back to my story the new Director of Cambodian customs at the Poipet border crossing is apparently allowing his staff to hit up the handicapped insect vendors for about 20 cents a kilo which seriously cuts into their profit margin. Apparently insects and grubs are not on the official list of things to which a tariff applies, so the handicapped vendors have the law on their side (not to mention public opinion). We'll see how it plays out.

Anyway, I have more to post on other things I saw, but this post is already pretty long, so bye for now.

Sunrise over the Tonle Sap

Here is a video taken out of our hotel room window looking out over the Tonle Sap River (this side of the point of land) where it merges with the Mekong River (the other side of the point of land and the dredge). I apologize for the jerkiness, I'm just getting the hang of this Flip camcorder.

Stefan's Blog

While the idea of thisblog was that the whole Grundmann/Krasovec clan would post to it you can see that to date it has mainly been me (Christophe) posting. Stefan is in Kenya volunteering at an orphanage and is posting to his own blog along with his friend Frost. If you want to keep up with his life you can read his blog at http://dartmouthinkenya.wordpress.com

Phnom Penh for real

Kathy and I have now been in Phnom Penh slightly short of a week, we're staying in the same hotel I stayed in last time for the month of February, in March we'll move into our new house, an updated French Colonial a mere 3 minute walk from my office. The view from our one-bedroom suite in the Himawari Hotel (think of it as a slightly fancier Residence Inn) is an upgrade from my last posting, we now look out over the Tonle Sap and Mekong rivers, I'll try and post a short video I took from our bedroom window of fisherman seining for small fish early this morning.

The time change seems to have caught up to me this weekend, after a pretty busy week at work which I handled fairly well considering we'd just arrived Monday evening, I find myself dragging around this weekend. Kathy is out with a friend getting a massage, manicure and pedicure which is what recharges her batteries, I'm just up from a 2 hour nap which seemed more likely to recharge mine (that may not have been the right call since I'm still a bit logy).

We have a work plan due to USAID for our whole project, which is creating quite a bit of work for me since to work with our team to come up with a work plan I first have to understand what the project has been doing and we seem to have done (and want to continue to do) a lot of different things. One of my jobs is to put a coherent strategy around those various pieces. On top of which Cambodia is undergoing a lot of changes in their health sector, which seem to be progressing at varying speeds with varying success, to try and understand it all is going to take some time. In the mean time I'm reading a lot of documents. one thing you can always count on development agencies to produce.

First post from Phnom Penh

What can I say, I 'm a pretty lousy blogger. In my defense, I'm a better blogger than any of the other 3 people on the masthead (that would be one Krasovec and two boys for those slow on the uptake). I still have a lot of stuff from Kathy's and my trip to S.E. Asia and China to post, including some truly cool pictures from the Olympics (Usain Bolt is fast even in tourist photos), but for now you get my first posting from Phnom Penh, my current location and our future home.

To bring you all up to speed, I have left my job with the Elizabeth Glaser Pediatric AIDS Foundation and gone to work for a non-governmental organization called University Research Company, LLC. Which is to say a consulting firm, or a beltway bandit, depending on your take. They clearly are a discriminating and intelligent organization, they hired me, after all. I am starting a job as the Chief of Party (United States Agency of International Development talk for boss) of the Health Systems Strengthening Project - Cambodia 2 Project (HSSC 2). I am actively working to come up with a new name - I don't do sequels.

The project works to support the health system in Cambodia, primarily by focusing on the quality of care and the support structure for peripheral service delivery for the government health system. We also work a bit with other NGOs and private providers. I have a projected staff of 60 (which seems a bit much), 40 of whom currently work on the current project.

From my first week here this seems like it is going to be a nice place to live. I am here for two weeks (one week down, one to go), after which I'll return to the (currently freezing) Shenandoah Valley to pack up, after which Kathy and I will move out here for the next 5 years. Phnom Penh is a much more vibrant place than our previous overseas postings. It is full of restaurants, lots of night life, and there are a lot of interesting places to visit in the immediate vicinity.

I have taken some photos (I can't say that I have strayed far on my photojournalism, other than the first photo, these all come from the grounds of my hotel). This first photo is taken from the window of my current office. It shows life in downtown Phnom Penh. However, we are about to move offices. And, luckily for me, it is an upgrade. My new office will look out over the royal palace. But in the meantime, this is what I see. As you can see, not too many high rises.

This next picture is taken from the back of the hotel where I am staying now and we will be staying until we find a house. Just to the left of the photo the Mekong and Tonle Sap rivers merge, this is the picture of the now larger Mekong as it works its way down to Vietnam and the South China Sea. The Tonle Sap is one of the few rivers in the world where the current changes direction. Most of the year is flows into the Mekong. However, when the Mekong floods during the peak rainy season, the Tonle Sap reverses direction and it fills the Tonle Sap Lake (which is huge, on the banks of which sit Siem Riep and Angkor Wat). During the rest of the year the lake slowly discharges into the Mekong.

This next photo shows Phnom Penh from my hotel room window (opposite the river view of the previous photo).

Another view from my window, showing three Wats (Buddhist temples) in the foreground and the distance. They take Buddhism seriously in this part of the world).

All for now, more later.