The middle-aged brain and how to make it better

Interesting NYT article "How to Train the Aging Brain". So prejudiced employers listen up - you're just doing yourselves a disservice by not hiring those above 40.

- "Recently, researchers have found even more positive news. The brain, as it traverses middle age, gets better at recognizing the central idea, the big picture. If kept in good shape, the brain can continue to build pathways that help its owner recognize patterns and, as a consequence, see significance and even solutions much faster than a young person can." (See, young friends, I'm not cynical - I'm just old.)

- “There’s a place for information,” Dr. Taylor says. “We need to know stuff. But we need to move beyond that and challenge our perception of the world. If you always hang around with those you agree with and read things that agree with what you already know, you’re not going to wrestle with your established brain connections.” (Go on, go out and start arguments at the pub - most people are too polite but I'm going to challenge old people - after all, it's for their (and my) own good! LOL)

Such stretching is exactly what scientists say best keeps a brain in tune: get out of the comfort zone to push and nourish your brain. Do anything from learning a foreign language to taking a different route to work. (I'm going to try to learn French in 2010)"

(By the way, the diagram is NOT from the venerable NYT. Pic of the young brain (haha) from pagetutor.com/jokebreak/images/male_brain.gif)

Siem Reap clinic vs hospital

Yesterday was a stressful day, but I finally got to experience Siem Reap's notorious Royal Angkor International Hospital. I have heard so many stories from travellers and expats about outrageous fees (you can read one customer's experience here). One expat told me, for instance, the hospital often recommends patients do an MRI scan, whether necessary or not. The impression many Siem Reap expats have of this hospital is that it is out to make as much money as possible from insurance companies. And, after yesterday's experience, I have to say, I left feeling the same.

This was what happened.

A Malaysian man working in Singapore had come to Siem Reap for a four day holiday with his Thai girlfriend. He wrote to me about hiring Phoen the tuktuk driver. On the first evening they went to see the sunset at Angkor and then ate at one of the restaurants at the Old Market itself after trying to get a table at Khmer Kitchen. The next day, W messaged me at 9am to say he had stomach pains and could I let Phoen know to pick them up a bit later. He felt better and they went to see the temples.

At 2pm the pains were back and I told Phoen to take him to Ly Srey Vina, a clinic I'd been to. I assumed he had eaten something bad.

W called to tell me it was his appendix and to fix it would cost US$1200. I still had no idea how serious it was until Phoen came to my house because he wanted me to see W. I left on his tuktuk for the clinic. It was about 5pm.

W seemed ok and was able to sit up, but the doctor told me his appendix had ruptured and they recommend immediate surgery. It was highlighted in blue on the medical report that they consider this an emergency.

One problem was the clinic does not have credit card facilities and W wanted to pay with his card. Seriously, how many people carry around US$1200 with them on a short holiday?

As W has travel insurance, I suggested we try the Royal Angkor International Hospital for two reasons. Firstly, because I stupidly believed it's a proper hospital and would have better facilities and secondly, I thought, it's a good idea to get a second opinion. (A lesson I learned from this experience is sometimes you just have to trust your Cambodian doctor - some of them really do know their stuff).

We took the Ly Srey Vina car to the hospital which is just before the Siem Reap airport. The drive down National Road #6 was just 5 minutes. The driver called the hospital to tell them to get ready for an emergency and we alighted at the hospital's emergency entrance.

At the hospital, a young man in a white coat started asking W the same questions: did you have diarrhoea, when did the pains start, do you have any drug allergies. By now, W was in serious pain. I got annoyed and said we brought along the medical report from the clinic, which we had given to the nurse. Why don't you read that. He then said, "Yes, ok, the doctor will be down in a minute." I thought I heard him say "I am only an M.O (medical officer)."

Ten minutes later, the doctor came down from the third floor. He read the report and said "We can operate but we have no anaesthesiologist."

You've got to be kidding. What kind of hospital advertises "24-Hour Accident & Emergency service" with no anaesthesiologist on hand? How is it a small clinic down the road can have an anaesthesiologist and not an "international" hospital?

I asked if he could get an anaesthesiologist from another clinic to assist him, since this was an emergency, but he said "Cannot. Not qualified."

The doctor, who is Thai, then said, "We go to Phnom Penh for the operation". I asked how? Are you flying him? Amazingly, they had planned to drive there. Phnom Penh is 315km from Siem Reap so even if we sped at 100km/hr, it will still take us over 3 hours. Three hours on the road for an emergency. Seeing how worried I was, the doctor told me "You don't worry, I go with him, I do the operation."

(Later, W's Thai girlfriend told me the Thai doctor had said to her, while they were conversing in Thai, that he is a "nose doctor" and would not be able to work on W. I thought I had heard wrongly and clarified with her: she repeated he was a plastic surgeon. I suppose the hospital has a plastic surgeon on hand for accident cases (smashed face, anyone?) - but even then, what good is that without an anesthesiologist?)

I asked about flights and they said we can book a flight with Cambodian Angkor Air but they were not sure of the flight times. It was about 6pm by this time.

I asked about Bangkok and he said medivac (medical evacuation) to Bangkok will cost US$15,000.

Finally we decided to return to Ly Srey Vina and I told the Thai doctor so. W was in much pain by now (he had already been given one morphine jab at the clinic but clearly it was not enough). W decided to take the hospital's ambulance back to the clinic as the pain was unbearable. We were informed the cost was US$50 which we had to pay in advance. Ly Srey Vina charged half that. I had already told the couple to expect huge fees, so none of us said anything.

The nurse volunteered (I guess she is used to trying to justify the cost): in addition to a driver, we would have a hospital staff member would sit with us in the ambulance. (I wondered how much the drive to Phnom Penh would have been - a thousand dollars?) I went to the counter to help the couple settle the bill as they prepared to board the ambulance and we left.

Later, W's girlfriend told me she was given a form saying consultation was US$120 (so, up 20% from a year ago, according to what this customer said ). The girlfriend was upset, saying "We pay US$120 for nothing."

She had assumed I had paid the consultation fee in addition to the ambulance fee, but I told her I was only charged for the ambulance. We wondered if the hospital waived its fee because they did nothing of use, or in the drama, simply forgot to charge us. Frankly, I think it was the latter.

Five minutes later, we were back at Ly Srey Vina, where Dr Vuthy, a former war surgeon, would operate on W. Dr Vuthy arrived at the clinic about 10-15 minutes later, by which time, the girlfriend was in tears. She said W had turned very pale - but where was the doctor?

Dr Vuthy had removed a small lesion from Alan previously and he did a good job so I felt confident. He explained he would have to clean the abdomen of pus as the appendix had already ruptured. The surgery would take an hour.

I got us coffee from the Caltex down the road and sat waiting for Dr Vuthy to give us news. An hour and a half later, he emerged to say it went well and our friend would be ok, but W would have to stay in the clinic for a few days for observation and to ensure there was no serious infection.

Later, another doctor at the clinic told me if W had waited another hour, it would have been very serious indeed - and later reading on the Internet about appendicitis, I was so thankful we chose to return to the clinic for the op.

About appendicitis:

"The classic symptoms of appendicitis are abdominal pain and loss of appetite. Abdominal pain usually begins in the center of the abdomen, around the area of the navel. Later, the pain may move downward and to the right, to an area called McBurney's point, which roughly corresponds to the location of the appendix....

There is no specific incubation period (the time it takes for symptoms to develop) for appendicitis. Once the appendicitis symptoms appear, it can take as little as 48 to 72 hours for the infected appendix to rupture. If the appendix ruptures, the infection will likely spread to other areas of the abdomen, increasing the risk of serious complications and making treatment more difficult."

I am so glad W is fine. It's a terrible thing to be ill on holiday, and worse if you have a major sickness in a third world country. Thank goodness W and I had been in contact. I doubt if tourists know where to go in case of an emergency. No doubt they would be taken to the Royal Angkor International Hospital if they ask their hotel or tuk tuk driver, simply because most people in Siem Reap know of this hospital because of its advertising efforts.

This is why I am writing this blog post. There are alternatives to the Royal Angkor International Hospital and in case you need an anesthesiologist at 6pm on a weekday, the hospital may not be your best bet.

The Thai girlfriend said in Bangkok if you are sick, doctors and nurses would be rushing to help you, but here, everyone moves so slowly. I have to say I agree - people and processes in Cambodia move much more slowly than what I am used to in Singapore, but I am just thankful for the Cambodian doctors who helped W. It's made me more confident about healthcare options here.

Singapore healthcare

I've been back in Singapore since mid-Oct for a health thing. (If you are interested, I wrote about my trip to a good Cambodian clinic in Siem Reap which led to this trip home).

Singapore has one of the best healthcare systems in the world and it's again in the spotlight at a time when the US is debating healthcare reform.

I was happy with my experience at the Toa Payoh government polyclinic. I took a number and within 20 minutes saw the doctor. I was done just over an hour, including waiting time for the medication. The clinic also called up a hospital for me to see a specialist. For the consultation, I paid - wait for it - SGD8.80 (USD6.30)! The medication, Serratiopeptidase (for inflammation) cost SGD4 for 40 pills. Incredible. I could not believe how cheap it was. The only complaint is that I did feel that the doctor was in a rush and was not interested in going the extra mile to find out what was wrong with me, basically taking me at my word. It all felt very perfunctory. (A friend said "What do you expect? It's conveyor-belt heathcare!")

One possible downside is you don't get to choose the specialist at the hospital if you go through the government-subsidised route, which is what I chose to do. You also have to wait some time for your appointment. In my case it was just over 2 weeks which I thought was fine. But for these small inconveniences, I will pay SGD25 for the consultation with the hospital doctor, compared with SGD83 should I choose to bypass the government system and go directly to the hospital.

A few years ago, in his book "The Undercover Economist", Tim Harford praised the health care policies of Singapore, which have resulted in the lowest infant mortality rate in the world, out of 224 countries: 2.31 deaths per 1000, versus the US's 6.26. Out of interest, Cuba's infant mortality rate is 5.82 and Cambodia's is a whopping 57.79.

(Still, you have to question these figures. Singapore is a small country and the time taken to send a sick baby to the hospital, thereby increasing the chances of his survival, is much shorter than say the US, a geographically large country. A better comparison would be say between Singapore and Manhattan - what is the difference in mortality rate for the two cities?)

Life expectancy at birth in the U.S. is 78 years; in Singapore, it's 82 years. (Cuba's is 77 and Cambodia's 62) Source for all these figures: CIA world factbook 2009 estimates.

This is even though the U.S. has 2.6 physicians per 1,000 people, compared with 1.4 physicians in Singapore. The United States has 9.4 nurses per 1,000 people; Singapore, just 4.2. And while the U.S. spends almost 16 percent of its GDP on health care, Singapore spends a mere 3.7 percent. Figures quoted from Niko Karvounis' excellent essay "Health Care in Singapore: What's the Secret?".

So how does Singapore do it? If you know anything about Singapore, you would know that while the ruling People's Action Party has consistently rejected the notion of being socialist, professing to run Singapore as a free-market economy, it has many socialist policies. Public housing, where 80 per cent of Singaporeans live is one, as are the government-linked companies (GLCs) that account for more than 60% (I think 60% only if GLC is very broadly defined) of the country's GDP (source: nationsencyclopedia.com). You would be hard-pressed to get the ruling party/government to admit to this. There should be a difference between "the ruling party" and "the government" but there isn't in Singapore, a one-party state.

This "state capitalism" has done well for the country, ranked the top 5 richest country in the world GDP (PPP) per capita for 2008. (Another blog post on the culture of business and resulting materialism of the country beckons. I feel like an alien in Singapore having lived in Cambodia for over 3 years now).

Back to Singapore's healthcare system.

In the 1980s, the Singapore government rejected the British-styled National Health Service and instead came up with the “3M” system — Medisave (1984), Medishield (1990) and Medifund (1993).

Medisave is a national health savings account and people contribute to this fund through their CPF (Central Provident Fund) deductions. For every dollar you earn, you and your employer have to contribute a percentage into your CPF account. This forced savings is supposed to form the retirement money for Singaporeans who are able to withdraw the money only after a certain age (55, but the government plans to increase this, to correlate to a higher retirement age). Medisave, a subset of a Singapore's CPF account was supposed to help with healthcare costs.

Medisave proved insufficient. Read Niko Karvounis' above mentioned article "Health Care in Singapore: What's the Secret?". It is the best explanation of Singapore's healthcare system I have read and I highly recommend it.

He notes that according to William Hsiao, a Professor of Economics at the Harvard School of Public Health, Medisave has failed to contain health care costs in Singapore: since Medisave was introduced in 1984, the rate of health care spending per capita increased from 11 percent to 13 percent a year after the program’s introduction.

By 1993, Singapore’s government started Medifund, an endowment fund to help poor patients pay their medical bills. According to Singapore’s Ministry of Health, the Medifund endowment was SGD1.6 billion this year and 98 percent of patients who apply for Medifund aid are approved.

But the real changes made in 1993 represented a paradigm shift: from regulating the demand for healthcare (what patients would pay) to regulating the supply of healthcare (what resources are available). Today, hospitals have to clearly list the costs of their service and there is a price cap on public hospital services, not only for surgeries but for hospitalisation. In 2009, means testing was introduced, which ensures only patients who truly cannot afford to pay qualify for the high hospital bill subsidies (up to 80%).

There is a lot more to the system and for further reading check out Niko Karvounis' essay.

Of course the system is not perfect and it is hard to replicate elsewhere, especially in the US, where people are paranoid about government regulation or intervention, except of course when it suits them.

Countries with Universal Healthcare

LEGEND
Red - Iraq and Afghanistan universal health coverage provided by US war funding
Grey - Countries with no universal health coverage
Dark Green - Countries with some kind of universal health coverage
Light Green -Countries attempting universal health coverage

"Keep in mind: this is a simple list of countries that have some sort of publicly sponsored health care system. For instance, Sri Lanka may be far from having a true, working universal health care system like France, but prescription drugs are provided by a government-owned drug manufacturer. This qualifies as "some sort of publicly sponsored, universal health care system."

Source: Gadling.com.

Universal healthcare is simply health care coverage for all eligible residents of a political region where costs are borne in the majority by government-funded programs. I am not sure why Singapore is not coloured dark green though.

To the doctor's

I went to see a doctor yesterday for some, shall we say, female problems. I am saying this up front for the sake of queasy male readers who may wish to stop reading. But I am going to write about it because women readers may find it useful.

The clinic I visited here in Siem Reap was recommended to me by an English woman friend. It is called Ly Srey Vina 2 and is located on National Road number #6, just before the junction that turns into Salina Hotel. The clinic is an associate of Singapore's Raffles Hospital.

I was very lucky to have been able to see Dr Ly (pronounced Lee) herself since she is usually in Phnom Penh. Initially, I was asked to wait 15 mins for a male doctor, but Dr Chubby didn't exactly inspire confidence and looked kind of pompous, the kind of doctor who expects nothing less than deference from his patients. No doubt I am just finicky since there were Khmer women there who saw Dr Chubbs. Because I am a troublesome "jon jiat" (literally "nationality" but is another Khmer term for "foreigner") I asked for a female doctor, and the receptionist called Dr Ly who came over in 15mins.

Dr Ly was extremely friendly and greeted everyone the moment she stepped into her clinic, unlike the other doctor who did not even glance at us patients. Dr Ly was very nice and patient and spent so much time with me. Alan, who accompanied me to the clinic, remarked how we would never get so much time with a doctor back in Singapore. Ten minutes, tops. Or you pay through the nose.

At 37, I am apparently at the age where "hormones are strong" (I think she means out of whack?), and Dr Ly suggested I do a full body check up, including blood, urine and stool tests to assess my problem. It was USD62 which I found very reasonable. I did the Essentially Hers package when I was in Singapore in April this year and it cost me about SGD220 (USD152). The package included a pap smear but not an ultrasound because, the doctor explained, government polyclinics do not have the ultrasound machine, which I found shameful in wealthy Singapore.

So I did an ultrasound here in Cambodia, which cost only USD15. The machine is a Honda (they make everything!) and looked ancient (it had that yellowish plastic shell you see in very old 486 PCs). But it worked which was all I cared about.

Another doctor operating the ultrasound machine (they call it an "echo" here in Cambodia) put some gel on my stomach and moved the probe around my stomach. Lo and behold they see something. It is a fibroid in my uterus. I was not surprised because the women in my family have the same problem.

According to the US Department of Health and Human Services, "about 20 percent to 80 percent (what a strange statistic - do they mean "up to 80 percent"?) of women develop fibroids by the time they reach age 50". It seems fewer than 50 percent of women who have fibroids develop symptoms, so many don't even know they have it. I have a very minor symptom but a symptom nonetheless which is why I took action.

(I guess the male equivalent would be the enlarged prostate, where there is a 50 percent prevalence after 50. "By the time you get to men in their 80s, nearly 80 percent or more have some degree of BPH (benign prostatic hyperplasia)", CNN reports. Like the fibroid, you only do something about BPH if it causes you problems.)

One problem is fertility. Dr Ly said with the fibroid it will be difficult to conceive, although I read this pamphlet (PDF) which says it is rare for fibroids to inhibit pregnancy. Dr Ly was amused at my happy exclamation, "Really?", upon hearing this. "Why you don't want children?" she asked. "You still can."

It's not something I think about, I said. I'm not alone. In my country, I told her, the government has resorted to offering us cash to have kids. It was recently reported the Baby Bonus programme hasn't worked despite a record SGD230 million (USD159.6 million) given out last year, up from USD55 million just five years earlier.

Dr Ly who was last in Singapore in August 2008 to attend a medical conference told me she knows about the country's low birth rate. Dr Ly has five (!) children herself and told me although kids can be a handful at times, they make her " see the world in pink colour". I guess the English version would be looking at the world with rose-tinted glasses. Dr Ly spoke to me in perfect English so I had to ask Thyda afterwards what the Khmer expression is. She said Khmers say when you have children, "jivert sroh tlah" ("everything in life is fresh, beautiful").

Chhun Hy tells me Khmers like children because there will be people to pray for you and celebrate festivals like Pchum Ben (the festival to honour the dead). By the same token, they feel sorry for people who have no kids because no one will be there to pray for and honour you when you are dead.

I am sure it will change though. I am sure as the country develops and women have financial independence and higher education, they will have fewer children. (Of course just because you are educated and well-off doesn't mean you won't want kids. Dr Ly is a perfect example. What I mean is that these things give you options.) Already some of my Khmer women friends are saying they don't want any. This is the story with my family: grandma 11 kids; mom 3; me and younger sister, zero--each. Haha. (My parents do have one grandchild - my Greek sister-in-law gave birth to a supercute baby girl).

Anyway, Dr Lyna called in the very evening of my tests to give me the results. So efficient! It takes two working days in Singapore. I am in the pink of health! Except for the fibroid of course.

Dr Ly suggested I go back to Singapore at my earliest convenience to get the fibroid removed. The male doctor who ran the ultrasound mentioned a hysterectomy which I thought was a bit severe. Dr Ly says full hysterectomy is easy and can be performed in Cambodia. Partial hysterectomy, which she thinks is more appropriate for my case, is more difficult and not many doctors in Cambodia are skilled in this, so she suggested I go home to Singapore. I guess because I indicated I did not want kids, a hysterectomy was proposed.

Because my fibroid is only 30mm or 3cm, I was thinking keyhole surgery could be the answer.

But then I get an email from an American friend, a registered nurse with decades of experience and who herself had a fibroid. She told me hormones can sometimes shrink the fibroid. Since I am still in my reproductive years, I could also consider a D & C or a Dilation and Curettage, to remove just the fibroid.

I am going to do a bit more research since there is no urgency. My concern now is insurance. I am covered for accidents and "critical illnesses" and I'm guessing my fibroid is neither.

In that case, I will check out hospitals in Malaysia's Penang or Thailand's Bangkok, places that are trying to promote medical tourism.

Flu and germs in Cambodia

(H1N1 virus photo from US CDC, linked below.)

I was sick with the flu for a week. It was funny how many people told me maybe it was swine flu, since there have been four reported cases of swine flu infections in Cambodia. Cambodian Health Minister Mam Bun Heng told reporters all four cases were students who arrived from Texas on June 19. They ranged in age from 16 to 20.

I wasn't particularly worried even if it was swine flu, since for most people, it's mild. If you are interested to learn more about swine flu, the US Centers for Disease Control and Prevention is a good site. You may also like to read how H1N1 was traced to US factory farms.

Many people over-react to swine flu, as Newsweek's Fareed Zakaria writes in "The Sky Is not Falling". I loved this comment from a poster: "90 people get the Swine Flu and everybody wants to wear a mask. A million people have AIDS and no one wants to wear a condom." Hahahaha! This is so true in Cambodia, where so many people wear face masks to avoid air pollution but are lackadaisical when it comes to using the condom.

Now that I think about it, in the three years I have lived in Cambodia, I've hardly been sick. A Singaporean friend joked at a party back home how I probably have the strongest immune system among the Singaporean friends present, because I'm exposed to more bugs.

I've become much, much less anal about hygiene since living here. Singaporeans are typically paranoid about hygiene, and I say paranoid, because I think you can be too uptight about these things. For instance, Singaporeans will not place food directly on a table, but on a buffer, such as a piece on tissue paper. I was like that too. I was amazed and appalled when an Australian, a champion triathlete I knew in Singapore, would make his sandwiches directly on the kitchen counter, a place we are told is teeming with bacteria. Is Andrew the worse for it? Not if you ask his doctors. Singapore doctors were routinely blown away by his heartbeats -- so slow, they indicated a super-strong, super-human heart.

On my last visit home to Singapore, I joined a picnic at Pasir Ris Park with a group from the Singapore Vegetarian Society and the Singapore Kite Association. It was great fun, flying kites and eating veggie burgers. Anyway, what I remember was how the only person who was like me, leaving our burgers on an exposed surface, with no tissue or paper napkin, was a Singaporean lorry driver and part-time kitemaker. He reminded me of Cambodians in his casual way of handling food. (I have to write about this lorry driver some time. I really respect the guy, bringing up four children delivering goods by lorry to Malaysia and back. To supplement his income, he makes kites from recycled umbrellas and plastic).

I'm not at all advocating abandoning hygienic practices, only that there should be some sort of balance. I know paranoid young Singaporean parents who do not allow their children to go to the playground or let a dog lick them for fear their precious children will catch something. Exposure to germs can be good for you as Scientific American notes in "Strange but True: Antibacterial Products May Do More Harm Than Good": "What doesn't kill you makes you stronger" is the governing maxim here, as antibacterial chemicals select for bacteria that endure their presence."

I did fall sick often when I first relocated to Cambodia. I had flu-like illnesses once a month for the first three months. I remember because I wrote to a friend about it and she was worried. But it looks like my body was just getting used to new bugs.

(The last time I fell sick was in Oct 2006 when I contracted dengue in Phnom Penh. I was put on a drip for a couple of hours and was fine after that. I did write about that dengue experience and the funny trip to the doctor.)

Many Khmers asked me: "Why are you sick now? Usually people have stuffed nose (p'da sai) during the cold season (November to February)". They have a point. There is such a thing as Seasonal Flu, which is most prevalent from December to March according to about.com.

Khmers believe it is the change of the weather, from hot to cold, that bring on the sickness. Many do not understand the flu is caused by a virus and not from the weather. Khmers will cover up, bathe in hot water, and stop drinking cold drinks when they get a cold because they think the cold weather is the cause, so they must somehow keep warm to fight the disease.

None of these things will make a virus go away. There is simply no cure for influenza. You can take medication but these only alleviate the symptoms. Tamiflu is one such medication.

In fact, because the virus is passed from person to person, one of the simplest ways Cambodians can avoid spreading the flu is to stop sharing food. I always, always tell the Bloom team to use a serving spoon instead of everyone dipping their spoon into the common dishes, but old habits die hard.

Because I know there is no cure for the flu, I did not bother seeing a doctor. Which is the other thing Khmers do - they all asked me if I had seen the doctor because they believe medication will cure it. Our housekeeper offered to make me the Cambodian concoction of some boiled herbs but I did not try.

Anyway I'm listing Flu symptoms below. They are only symptoms and people should know that many illnesses share the same symptoms, so if you are not convinced you have the flu, but something else, go see a doctor.

1. Loss of appetite
2. Fever. Childhood flu fevers are often more severe, but it's not at all uncommon for any adult to run a fever in the 100's when they have the flu. Often a low fever - and the weakness and chills it causes - are your first hint that the flu is about to hit you in full force.
3. Congestion that turns to a runny nose.
4. Sore throat.
5. Cough that turns productive.
6. Exhaustion and weakness.
7. Muscle aches and pains.

To get over the flu, it is recommended you:
1. Drink plenty of fluids - water and sports drinks
2. Take over the counter medications to relieve symptoms
3. Sleep as much as possible
4. Eat when you feel like it, but don't worry about it as long as you are drinking plenty of water
5. Avoid alcohol and tobacco use

That was how I got over my flu. Just sleep and sleep and drink water. I was well after a week.

(Flu information from About.com who says its Health's Disease and Condition content is reviewed by its Medical Review Board).

The World Diabetes Foundation replied!

I love, love the Internet.

Ok, so we can get proper help for Chhun Hy's father, finally. After my email to the Foundation's Communications Director, I received an email from the Hospital Director at Kampong Thom.

Dear Diana Saw,
I got your message forwarded from Dr. Varoeun, Chief of Diabetes program in Cambodia asking the contact number and address for Kampong Thom Diabetes clinic. The Diabetes clinic in Kampong Thom is located in the compound of Kampong Thom Provincial hospital along the Stung Sen riverside in the midle of Kampong Thom town. The chief of the clinic is Dr. Nget Bochum. His contact number is [...]. You can directly contact with him or write a message to me via my e-mail address [...] . Don't worry about the cost of treatment it is cheap. But one thing I have to tel you that if the condition of the patient is not serious, he or she can just take medicines home if not they have to be admitted in the hospital for intencive care.

Yours Sincerely

Dr. Srey Sin, Hospital Director, Kampong Thom

Super. To all those who helped at the Foundation - thanks so much!

I removed the phone and email address cos I don't want the good doctor to be spammed, but if you need the information, please do email me.

Anyone know the phone number/add of diabetes clinic

in Kampong Cham? I just read this: "In addition, with funds more recently allocated by the World Diabetes Foundation, three provincial centers at Pursat, Kampong Cham and Prey Veng were established in 2007. The four clinics (Siemreap, Battambang, Pursat,and Kampong Thom) will provide the structureplanned by the Cambodian Diabetes Association(CDA) for its so-called “Great Lakes Project.” The two clinics at Prey Veng and Kampong Cham will cover the CDA’s “Mekong Project,” once a clinicat Kratie has been established. Together, these two projects will provide diabetes care for a population of almost 10 million people."

My email to the two most junior members on the World Diabetes Foundation contact list did not garner a response, so I emailed the communications manager who had visited Cambodia with the Managing Director in 2007. I hope he'll at least tell me the phone number of the clinic.

I also managed to find this doctor, "cochinjew" who wrote about "Doctoring in Kampong Cham": "It is amazing how little visited are the places outside Siem Reap and Phnom Penh are. I was invited to visit the local doctor in charge of Diabetes at the Kampong Cham Hospital. It had the lazy feeling of an erstwhile colonial town, the main streets are broad and there are very new buildings including the new hotel. The hospital buildings are from the colonial times and the new diabetes clinic is ready to be open. I plan to be back in Kampong Cham."

I sent Dr cochinjew a message too. It really should not be too hard to find the new clinic. If no one replies my emails, I have told Chhun Hy to go to the hospital in Kampong Cham. I am sure the local doctor in charge of diabetes there will be able to refer his father to the specialised clinic.

Diabetes and Cambodian witch doctors

Chhun Hy, the young man who works with me at the Bloom shop recently took a week off. His parent came all the way from Kampong Cham province, about a 4 hour bus ride, to see a witch doctor here. His father has diabetes and despite seeing doctors in Phnom Penh is not getting better.

Chhun Hy spent in total USD60 for this trip for his parents. They paid 30,000 riels per person for a return shared taxi from Kampong Cham to Siem Reap. Their guesthouse was USD6 a night and there were also meals. The actual witch doctor fee was only 5000 riels (USD1.25).

For the 5000 riels, Chhun Hy's father was burned in four places with an incense - 3 times in the back and one time on his leg. I have no idea what is going on in Chhun Hy's mind as we have told him enough about witch doctors and superstitions and he himself has agreed with us on some of these matters. In fact, I just showed him this article in today's Telegraph newspaper. In China, a woman boiled a man's head to cure her daughter's psychiatric problems. I told him this is what happens when you don't use your brain and just listen to rubbish.

But I am sure he was just being the filial son to desperate parents who heard about this witch doctor. The man is in his 70s and lives in a big house. Chhun Hy's father was told to return to see the witch doctor once a week--indefinitely, until he gets better. Chhun Hy says about 200 people see him everyday. I worked it out for Chhun Hy: 5000riels x 200 = 10,000,000. 10 million riels, or USD250, a day. Which works out to USD7,500 a month. Nice work if you can get it.

You can imagine how annoyed I am to learn about this. Chhun Hy keeps saying in Cambodia you need money to get better. He says the medicine given by the Phnom Penh doctor is not good because it is cheap. I told him that is not necessarily the case. It does not mean cheap medicine is rubbish and expensive medicine is good. "Tell me the name of the medication." But he does not know.

So I googled and found that in February 2007, the World Diabetes Foundation inaugurated two diabetes clinics in Cambodia. The site says this is because "a surprisingly high number of the adult population has diabetes although the Cambodians are not obese by international standards".

"The prevalence of diabetes in Cambodia is today surprisingly high and the factors ultimately leading to a diabetes epidemic are present. A recent epidemiological study published in The Lancet in 2005, estimates that a total of 255,000 people live with diabetes in Cambodia. About two-thirds of all cases of diabetes were undiagnosed before the survey."

"Economic restructuring, globalisation and the fast growing tourist industry leaves a trail of motorisation and changing food habits in the population as can be seen in Phnom Penh and Siem Reap. On top of the previous hunger and deprivation period ending in the 1980’s, this extreme change in lifestyle may play an important role in the development of an epidemic of chronic diseases, including diabetes."

The symptoms include: frequent trips to the toilet, unquenchable thirst, lose weight without trying, weakness and fatigue, tingling or numbness in your hands, legs or feet. This is what Chhun Hy reports his father has.

Anyway, the two centres are in Kampong Thom and Battambang. Kampong Thom is closer to Kampong Cham so that is the one I tried to find. I had to email the contacts listed to get the phone number and address as I could not find it online. I hope the representatives I emailed from the World Diabetes Foundation will respond, so we can get Chhun Hy's father proper treatment.

Chhun Hy seems pessimistic. He keeps saying you need money to be saved in this country. He told me about newspaper articles reporting how patients are routinely turned away by doctors because they have no money. One pregnant woman was turned away because she could not pay the USD10-USD20 medical fee to have her baby delivered. She died and her husband told his story to the papers.

Chhun Hy says, "My country very very bad. The doctors, the teachers- the same. If you have no money, the teachers will not teach you and the doctors will not help you."

I asked, "I thought Cambodians are Buddhist. Aren't you supposed to help people?" He replied, "Before, yes. Now they only want money."

Cambodians are so used to seeing people die, they have a different perspective. They are resigned at worse, sanguine at best. Chhun Hy says many of his neighbours in Kampong Cham have the same problem as his father and he thinks his father will be dead in 4-5 years, because that is how long his neighbours with the disease lasted. His father is only 45.

Get Fatter, Look Younger

From Ryan, an American blogger:

"I've been reading a bit about common cultural disconnects for Americans in Cambodia. I found several quite funny.

Imagine a total stranger telling you the following -

"You're really fat!" "You have a huge nose!" "You're really white!"

He goes on to say in Cambodia, being fat means you're rich, you can afford to eat, so it's a compliment. That was what I was told, too, that being called fat is a compliment in Cambodia. But while the older generation may think like that, the 20 somethings I've met all say it's not a compliment. They like their boyfriend/girlfriend slim and think it's not sexy to be fat. No doubt they, like youth everywhere, have bought into the images portrayed in their media.

Anyway, I was thinking about this after coming across this trueslant.com article. Maybe the Khmers are on to something: besides looking rich, fatter people also look young:

...more fat in your diet could mean a more youthful appearance (as long as you aren’t a pack-a-day smoker). A few more tidbits...:

-Deprivation of essential fatty acids and fat-soluble vitamins (A, D, K, E) has been linked to dry, scaly skin, skin wrinkling, and hair loss. Eat your avocado, and you’ll be more likely to have smooth skin and a full head of hair into your golden years.

-A 2009 study out of Britain compared 186 pairs of identical twins, and found that women over 40 who dropped a dress size “aged” by four years when compared to their fatter sibling. The same study found that overweight women under 40 looked older with weight gain, so so young ladies should hold off on the Twinkie-fests.

-Last year, researchers published a report on fat faces in Plastic & Reconstructive Surgery. They determined that more facial fat prevented skin sagging and hollowing as one ages. In fact, injections of fatty deposits into the face are becoming increasingly popular among pin-thin women who want to plump away their wrinkles.

How mad are you?

I'm watching this BBC documentary now. It's an interesting experiment.

Take ten volunteers, half have psychiatric disorders, the other half don't - but who is who? Three leading experts in mental health attempt to spot which volunteers have been diagnosed with a mental health condition. Can you guess who the ones with the disorders are?

The inspiration came from the Rosenhan experiment, conducted in 1972, when Dr David Rosenhan and 7 friends tried to gain admission to psychiatric hospitals. All were healthy, but everyone of them was diagnosed as mentally ill and some kept in hospital for 52 days. The results of the experiment shocked psychiatry to the core.

The study concluded, "It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals" and also illustrated the dangers of depersonalization and labeling in psychiatric institutions.

Floating toilets in the floating village

Photo credit: Channel News Asia.

Follow-up from a previous post World Toilet Day:

A Singapore charity is introducing floating toilets to residents living on the tonle sap.

"It is actually a simple system… We're going to use locally available buckets where they can collect the faeces. We are going to use some locally available agent to dry the faeces, that is, using ashes and other local material," said the CEO of Lien Aid, Sahari Ani.

To increase participation, local residents have to build their own toilets.

Hookworm in Cambodia

This is the Hookworm, so called because of its teeth, which hooks onto intestines, sucking out blood. Photo credit: Scienceblogs.com

Hookworms are endemic in Cambodia with a prevalence 20 -30%, according to this 2007 report.

On the BBC this morning, I watched a program on hookworms and how they infect farmers and children, who go around barefoot, in small villages in Brazil. The worms enter through the skin and stunts physical and mental growth. It can also cause anemia, and for the farmers in Brazil, infection means they feel tired and will not be able to work on their farms.

I am sure the situation is similar in Cambodia, where children routinely walk barefoot, even in the cities. I always used to tell Sipha's youngest daughter to put on her shoes when she joined us at the market. She never listened and her mother too, was not bothered. At that time, I did not even think of hookworms, just of infections, should she have a cut and pick up something nasty from the disgusting grounds of the wet markets, strewn with rotting vegetables and meat.

The poor farmers and people like Sipha probably would not even know what hit them, when they do get hookworms. The farmers in Brazil call the illness caused by hookworms, "Big Yellow", presumably because they turn pale and sallow from the blood loss.

While hookworm infection is rarely fatal, anemia can be significant. This is why in Cambodia, there is a focus on treating women. Almost half of Cambodian women of reproductive age (47%) and more than half of pregnant Cambodian women (57%) are anemic, according to the study linked above.

"The consequences of anemia in pregnancy are serious, reducing a woman’s ability to survive bleeding during and after delivery (postpartum hemorrhage). Anemia may result in premature or lowerbirth weight babies with a higher risk of death and cause weakness, fatigue and reduced physical ability to work. The amount of blood lost is directly proportional to the number of worms infecting the host. A moderate infection of hookworms approximately doubles the iron losses of a child or menstruating woman."

Even though the American Journal of Tropical Medicine and Hygiene reported a study on the low efficacy of Mebendazole against hookworms in Vietnam, in Cambodia, hookworm infection is treated, to some success, with Mebendazole:

"The prevalence of anemia decreased from 62% to 12% and from 57% to 26% in children 5 to 11 years of age in two rural primary schools in Kampot Province, Cambodia, after oral weekly supplementation with iron-folic acid tablets for 20 weeks and with vitamin A and mebendazole twice per year. In 12- to 15-year-old children, success was less marked. The prevalence of hookworm infestation did not change, but the number of eggs in the stool decreased drastically. The intervention had no significant influence on stunting and wasting. An integrated community approach including mass deworming, health education, and multi-micronutrient supplementation was very effective in reducing anemia in Cambodian schoolchildren and should be adopted on a larger scale." Abstract from here: Food Security and Nutrition Policy Support, German Technical Cooperation (GTZ)

One thing the authors failed to add was improved sanitation as part of the integrated approach to reducing anemia. As the BBC programme noted, doctors in Brazil are fighting an ongoing battle, so long as there are no proper toilets. Indeed, in the late 1800s and early 1900s, many people in Mississippi in the USA had hookworms because of the lack of proper sanitation facilities.

It should also be known that hookworms can also infect dogs, and while the canine variant rarely develop into adulthood in humans, you could get this from the lavae.

I was told by a healthcare person once that I should take de-worming tablets twice a year, so long as I am in Cambodia. Of course I forgot because worms aren't a big problem where I come from. But this morning, I popped two tablets of albendazole. I'm also going to buy the de-worming pills for the Bloom team and their children. I bought them some pills when I first arrived but they must need new ones now.

Today is World Toilet Day

A toilet-shaped house in Suweon, named "Haewoojae" which means in Korean “a place of sanctuary where one can solve one’s worries“. Photo from freshome.com.

The Phnom Penh Post reported on Monday that poor sanitation costs up to 10,000 lives a year in Cambodia.

"Economic Impacts of Sanitation in Cambodia 2008", said that in 2005, only 22 percent of Cambodians had access to a latrine, and there were still "more than 11 million Cambodians living with an unimproved latrine or with no latrine at all". The problem is most pronounced in rural Cambodia, where 84 percent of the population lives, but only 16 percent of those can access adequate sanitation.

Yesterday, a Time article "Toilet Tales: Inside the World of Waste" reviewed a fantastic book written by British journalist, Rose George, entitled The Big Necessity: The Unmentionable World of Human Waste and Why It Matters:

"Toilets are a privilege that nearly half the world lacks. At least 2.6 billion people around the planet have no access to a toilet...not a public toilet, not an outhouse, not even a bucket. They defecate in public, contaminating food and drinking water, and the disease toll due to unsanitized human waste is staggering. George notes that 80% of the world's illnesses are caused by fecal matter: A single gram of feces can contain 10 million viruses, 1 million bacteria, 1,000 parasitic cysts and 100 worm eggs. The consequence is often diarrhea, which is a mere irritation in the West, but in the developing world a lethal condition that kills 2.2 million people a year — more than AIDS, tuberculosis or malaria."

George argues for sanitation to be put at the top of the agenda for global development, because untreated sewage often ends up poisoning the clean water in developed countries. In India, "untouchables" (Indians from a low caste) like one woman named Champaben who can only find work cleaning the country's dry, filthy latrines, regularly contract dysentery, giardiasis and brain fever from her exposure to human waste.

There are things we can do with human waste. Biogas, energy created from the fermentation of human waste, can be used as fuel for electricity and cooking fires and Toto of Japan, the maker of the world's most advanced toilets, even uses human waste as a marker of health--their toilets can check your blood pressure at the same time!

And this is Singaporean Jack Sim, a retired entrepreneur and one man dynamo who founded the WTO (World Toilet Organization) in 2001.

I remember how people laughed at him when it was reported that Sim had a personal mission to ensure the cleanliness of Singapore’s public toilets when he started the Restroom Association of Singapore in 1998.

Today, the WTO is a network of 151 organizations in 53 countries. In 2005, Sim worked in association with Singapore Polytechnic to found the world’s first ever toilet college to train people in toilet design, maintenance, cleaning, and eco-friendly sanitation technologies.

WTO declared Nov 19--today--"World Toilet Day" to highlight the desperate need of the 2.6 billion people in the world who need access to latrines.

Massages and Money

More fascinating stuff about the Moral Molecule, also relevant to Cambodia--land of USD5 an hour massages. [Personally, I like Blue7 here in Siem Reap, where competition has driven the prices down to USD4 an hour. In Phnom Penh, Kerri and I go to Dai Prom Shop, near the Russian Market, for USD3 (!) an hour for a traditional Khmer massage where you get twisted like a pretzel).

Anyway, back to our story. Our neuroeconomist hero Paul J. Zak now wants to test if getting a massage makes people more likely to sacrifice money to help another person and if so, why?

Previous research by his team found that "monetary transfers denoting trust" caused the brain to release oxytocin. Zak's lab even showed "a positive relationship between the amount of oxytocin released and the amount people choose to return to the person who trusted them-even though they were under no obligation to do so."

With the massage, THOMAS (The Human Oxytocin Mediated Attachment System) was on steroids. "Those who were massaged and trusted sacrificed 243% more money to the person who trusted them compared to those who were trusted but not massaged. And the change in blood levels of oxytocin strongly predicted this behavior."

The experiment also found women to be more affected by touch: they had larger changes in oxytocin and sacrificed more money to those who trusted them.

So, if you are the owner of a massage centre in Cambodia, you may want to add a tip box or even a charity donation box (on second thoughts, scratch the latter, this being SCAMbodia!). And of course, you'd want to target the more susceptible women customers.

You can find details of Zak's fascinating experiments here.

Tubing in Laos and healthcare in Cambodia

This English lady came into the shop and told me she had hurt her foot while tubing in Vang Vieng, Laos. Tubing is where you sit on an inner tube (the inside of a tractor tire) and float down a river while stopping at bars along the way. I have never done it but plan to--it sounds like fun!

Except for a couple of caveats: don't get too drunk and drown and don't miss your last stop.

This customer told me if you miss your stop you may get lost, so you need to look out for the very last stop sign. She also said if you float too far from the river bank, don't worry because small Laotian children will dive in and haul you back.

You can read about tubing here www.travelpost.com.And watch a video of it on youtube.

Anyway, so this customer scraped her foot during the water ride. She did not see a doctor in Laos, only when she got to Siem Reap because by then her foot had become inflamed. She went to the Royal Angkor International Hospital.

She paid USD260 for the first visit to the doctor--USD100 for consultation alone. Thereafter she had to go back everyday to get her wound dressed and each visit was USD36. She went back twice before deciding it was not worth the money, since all the nurses do is clean the wound with saline and apply antibiotic cream. She figured she could do it herself since you can get these things cheap at pharmacies all over town.

Luckily this young woman has travel insurance. Imagine paying USD400 to fix a scrape! I asked if the international hospital employs Western doctors--is that why it is so expensive? She said only Asians tended to her, although she is not sure where they are from. So anyway expect these prices if you visit an international hospital in Siem Reap.

At the other end, Cambodians pay 5000 riels (USD1.25) for a consultation with a local doctor in a clinic. You wonder if the doctors are any good since corruption taints everything in this country.

However, I think Khmers themselves know when a doctor is good because you can tell from results. Khmer doctors also do not need to have a degree, in my opinion, because they learn from experience. And in this regard they are sometimes better than Western doctors, especially when it comes to local diseases. To give you an example, when we lived in Phnom Penh I used to take my dogs to a Khmer vet who has had no formal education. But because Parvo virus is common in Cambodia, he managed to save Austin simply because he has dealt with so many similar cases (Parvo survival rates for puppies, Rottweilers and Dobermans are 30-50%). A Western vet who has had little experience in Parvo, on the other hand, may not be as well-placed to care for the animal. Although I am sure Isabell, our German vet here in Siem Reap, would disagree!

Dengue Second Time around can be fatal

If you are like me and had dengue once, you should really cover up. Don't listen to people who know nothing about the disease telling you you would be immune cos you got it once. Dengue is unusual that way--it gets more serious the second time around. The reason is that there are 4 strains of dengue and if you contract any one of the 3 strains different from the one you got the first time round, your body will use all its resources to fight what it thinks is the first strain, leaving it defenceless against the new virus. You may then get Dengue Hemorrhagic Fever - which effectively destroys the platelets that cause blood to clot, meaning you can bleed to death.

It's rainy season now and I got dengue in Oct 2006 in Phnom Penh. Now, Chhun Hy, the young Cambodian man who lives with us here in Siem Reap has it. Which means if a mozzie bites him and then me, I will get it. Alan contracted dengue in Singapore, and the chances that he'll get a new variant here in Cambodia is higher for him. Very worrying.


You can read more about dengue here:

Scientists crack dengue fever puzzle

Experts may have solved the mystery of why dengue fever, unlike other infections, is usually more severe the second time around. Dengue is a debilitating, sometimes fatal illness endemic to much of the tropics. Caused by a virus, it is characterized by high fever, bone and muscle pain and -- in the most serious cases -- hemorrhage and fatal shock.
Dengue is also unusual in that //symptoms are more severe during a second or third infection compared to first-time infection. Experts estimate that over 50 million people are affected by dengue each year, with about five percent of patients dying of the illness.

The findings may complicate the search for a vaccine against the deadly mosquito-borne illness, according to British and Thai scientists. Now scientists believe they have solved the dengue paradox. The key to the puzzle, say researchers is the fact that the dengue virus falls into four distinct subtypes. Initial infection with one subtype causes the immune system to direct its response to that specific variant. But if an individual later contracts any of the three other variants, he or she is left virtually defenseless against the virus.

The scientists evaluated the immune cell response of 73 Thai children hospitalized with dengue fever and found that all but two had been infected at least once before.

What's more, these children had relatively low levels of infection-fighting T cells specific for the new virus. Normally infection with viruses such as hepatitis C or Epstein-Barr result in high levels of such T cells. The researchers think a second infection triggers the immune system to frantically hunt for the wrong subtype of the virus, causing painful inflammatory symptoms such as aching and fever.

However, this second immune response generates immune cells that only react weakly to the new virus. And the duration of the disease is also much longer because the body fails to clear the infection quickly.

http://www.bio-medicine.org/medicine-news/Scientists-crack-dengue-fever-puzzle-2063-1/

There is no vaccine for dengue, so you just have to use repellent and cover up.

Dengue is Me

Sat Oct 21, 2006

It finally happened. I contracted dengue. Barely four months into my third trip to Cambodia. It was quite an experience going to the hospital and I have to share it with readers who are planning to come here.

My symptoms started on a Wednesday evening, with pins and needles in my hands and ankles and feet. That night I came down with fever. The next day, my temperature was 38.6 degree celcius (101 degree farenheit), then went down to 35.9. Apart from the fever and chills, I did not have any other symptoms. The next day my temperature rose to 39.2 (102.5), which convinced me to see a doctor in Cambodia.

I called up someone who has been here for 11 years, Malaysian missionary Esther Ding, who is the founder of Khmer Life, and also, she says, Villageworks, the one that is now owned by the Singapore Girls’ Brigade (interesting story for another time). Esther told me to see Dr Lily of First Central Clinic on Monivorng Boulevard, just 10min walk from my house.

Dr Lily wasn’t in (I found out later she is from China and is the manager of the centre, which is Chinese run) and I was taken to see another Chinese lady doctor. A nurse approached me with a thermometer and I recoiled. “Is it clean?” I asked, thinking I had to put it in my mouth. Another nurse said don’t worry. In Cambodia, doctors always take temperature from the armpits. The temperature and blood pressure were normal.

The doctor did not speak English and I asked for a translator. It was a Khmer man who as it turned out, spoke worse Mandarin than me! So much for that plan.

The doctor then took out a wooden tongue press from a small metal box and stuck it in my mouth. It all happened so quickly that I did not have time to ask if it was sterilised. She kept asking me to say “ahhh…” and the Khmer man was translating, “doctor ask you to say ‘ah’, say ‘ah’!”, while I was just concentrating trying to push out the press! When I succeeded I immediately went to the sink to rinse my mouth and tongue. Very rude, I know. Meanwhile the doctor had put the press back into the box which contained some other stuff…

It was all very perfunctory, her questions, she only seemed keen for me to do a blood test. That was fine because I wouldn’t have trusted her diagnosis anyway. It turned out I had very low, 1900 (normal is 4000) white blood cells count, and low platelet count, 1850 (normal range is 1500-4000), which the doctor said would only continue to drop. Then I realised the name on the card was not mine! It was some other person called Wang Fuxing. I pointed this out and the doctor insisted it was my card, they just used the previous patient’s name! Anyway, it turned out it was my card, so they said anyway. The doctor decided I would have to stay the night at the hospital for observation. When I refused, we agreed for me to go on a drip, but only after I confirmed what I was getting. She claimed the first time it was antibacterial/virus drugs (fangjun yao), but the bags I saw were sodium chloride and dextrose. Salt and sugar. There might have been some drugs injected into the bags, but I did not see any on the preparation table.

It was fine with me because I had not been eating for the past 3 days, so I could do with the food. There is no treatment for dengue. In Singapore, the doctors give you potassium salt. You just need to have plenty of rest and drink lots of water.
It was traumatic though, because the first nurse, a Khmer woman, had tried to insert the needle and did it wrongly, causing me much pain. Then a Chinese nurse, who said she was more experienced, came along and wanted a go. *I* had a go at her: I’m paying money for this, why didn’t you come the first time round, why send an inexperienced nurse? Anyway, she too failed, muttering that my veins were too fine. Finally it occurred to them to change to a child’s size needle. Despite not being able to see my veins, they had insisted on using the standard adult sized needle. I was thinking how typical this inflexibilty in customer service is—in Singapore and in Cambodia. People just don’t use their brains, but follow SOP (standard operating procedure). The doctor herself finally got the needle in. So my advice is to get the doctor to do it for you the first time round.

It was hilarious being at the hospital, whose clients consisted only of Chinese and Koreans and me. There were no white people at all. When I told my English friend Myriam, she said, get a second opinion from a proper doctor! What was funny was the way people kept streaming in and getting put on drips like it was routine. The woman on the bed next to me had an inflamed throat and was given a drip! At 9pm, these two Chinese men strolled in, chitchatting with the clinic’s administrator, then comfortably settled on the beds, reading newspapers while being hooked up. You get the sense that for these people it’s just like going to the pub. “I’m not feeling too good today, I think I’ll pop down to the clinic (pub) for a drip (beer).” Alan and I were joking about infusing them with beer which is roughly the same colour as the dextrose. One Chinese guy asked the patient in the next bed whether there were any openings in his cardbox box manufacturing factory. Another one had asked for half a pack of dextrose, but fell asleep and when the nurse woke him up, he said, let me finish it and promptly went back to sleep. I wonder if it is the aircon that they like?

I had read in a book, I think it was the one written by a British doctor who had volunteered to work here in her 50s, that Khmers are big believers in drips. Whatever they’ve got, they insist on a drip. You often see people riding pillion on a motobike holding on to their drip bags. (There is also a country where the people like injections, although I forget where.)

In Singapore, it is antibiotics. Doctors insist on prescribing it to you for whatever illness. I am not sure if it is because they think that is what the patients expect, or whether it is their way of making more out of you. I dislike seeing doctors in Singapore for that reason. Taking antibiotics regularly is not without harm. You could get immune to the drug when you really need it, and worse, most antibiotics don’t work with pinpoint accuracy, which means they destroy good bacteria as well.

Anyway, it turns out, the consultation was only USD2 (what it was worth, probably!), blood test, USD7, and the 2 drips, USD25. No wonder they were so keen for me to take the drip—it’s more than 10times the consultation fee! Still, at USD34, it was fairly cheap. Myriam’s foreign doctor charges USD40 for consultation alone, about 6 times the price in Singapore.

The good news is I felt much better after the drips and could eat a bun that night. It’s the day after and I feel well enough to type this.