Canadian university students in Cambodia (AM)

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Preamble: "Going There"

  • We still believe it's important to be exposed to other surroundings and cultures vastly different form our own, definitely for our education. Whether we can be effective in making a positive change in such surrounding is debatable.
  • How we conduct ourselves, the personal comforts we seek, the technology and symbols of wealth that we take with us, our attitudes & self knowledge, all influence how we see ourselves, how we are perceived and what kinds of impact we have.

I went to Cambodia through a U of T Centre for International Health project. The Centre had signed an agreement with the Cambodian government 5 years ago to implement a primary care system in one of the poorest regions.

Students were to go for summer projects gathering epidemiological, needs assessment and program evaluation data. Several of these student reports touched on the very high maternal mortality rate in the area, which had remained unchanged despite the programs implemented by the centre and the building of local health centres set-up and operated by the government. My goal was to figure out why the available services were not being used despite the apparently high need.

When I got there I solved "the mystery" in one day: The services I had been led to believe were "under-utilized" did not in fact exist, and had never really existed in the form reported on. And the person who had suggested I go there, one of my role models during medical school, knew that.

  • No patient care services had been provided by the centre in the five years aside from a few sporadic "outreach camps"
  • Other services & organizations had been diverted from area because of the perception that it was being served by CIH
  • The small local hospital & health centres still had no electricity, no clean water, no ability to manage complications of labour.
  • The cost of labour and delivery amounted to over 2 weeks of income for the average farmer living on ~25-50 cents per person, per day, with no increased safety and significant transport problems between most villages and the health centres.
  • None of the reports were translated into the Khmer or French. Most had no Ethics approval.
  • Most were by students with little experience, minimal faculty supervision; Most of the data is essentially unusable.
  • ~7 of the reports present high quality & novel data. No recommendations have been implemented.
  • Other organizations associated with group have dissociated themselves.
  • Local officials were threatening to dismiss the organization.

Impacts

  • Deep distrust of outsiders; The general (and evidence-based) attitude that most foreigners came, asked lots of questions, filled surveys, sat on the beach, ate seafood, left, and were never seen again.
  • Development of a reaction system in the community ... selecting for some of the most unscrupulous (and relatively well-off) individuals in the community to set-up operations to counter-exploit foreigners within their range of activities. Some of these gains occasionally benefit the community.

Notes


I abandoned this project and started looking at other opportunities and began to get a broader picture of the aid scene in Cambodia and I became interested in looking at the side-effects of these processes and whether there was any systematic cost-benefit analysis out there.

  • In Cambodia the presence of such a large number of foreign aid workers has caused significant inflation, in particular effecting land and food prices (as much as 10-fold increase in land prices in 3-years). Various other factors contributed to this inflation as well, but the consumption rate and purchasing power of aid workers made many things inaccessible to the local population.
  • Landlessness is a particularly striking example. It is the predominant determinant of poverty and hence health for subsistence farmers.
  • Slums evacuated in Phnom Penh to make apartments which will be mostly occupied by aid workers.
  • After 15 years of being one of the top 2 per-capita aid recipients in the world most people in the country still do not have access to clean water and sanitation. Child mortality, according to the WB's own data has actually gone up since the civil war ended.

This is where my questioning started.

We each have a responsibility to ask these questions of our experience. We need to consider the impacts of our action as broadly as possible. We'll have different experiences but these questions will still apply.


Analysis

Why was I here? What did I think I was doing?

  • Well there were a lot of reasons I could list but in the end they came down to two: First I wanted to Help, to do good, because I felt responsible, or altruistic, or guilty about my privilege or whatever else. The second I was curious, I wanted to learn, I wanted an adventure, values that my culture prizes. I'll start with curiosity.


Curiosity...

  • As you are well aware Curiosity Killed the Cat. Until recently I had always interpreted that curiosity as being the Cat's curiosity. The cat was curios, went in to the street and so on... But then I realized that far more often things die not because they are curious but because someone or something else is curious about them. Someone else's curiosity about the cat may have killed it. We live in a culture that assigns a very high moral value to curiosity and desire for learning. It has been essential to the material achievements of our civilization. Despite the realization the curiosity can be dangerous and destructive (hence Research Ethics Boards) deep in our psyches we still seem to see the love of learning as something pure, beyond all evil. I am certainly guilty of this, even now.


Help...: How do I picture "helping"?

  • I am doing something, I need help, I call you over, tell you what I need, if you can and you want to then you grant my request.
  • Or I see someone on the ground, I ask if they need help, they say yes, then...
  • Or they are unresponsive in which case I assume that they do not have the capacity to accept/refuse and I make the decision by myself.

Most of the "help" situations I found myself in fit uncomfortably into the above schemes

  • People asked me for money, I was repeated told not to start giving money
  • I was not asked for any of the "help" that I actually did provide
  • Most of the individual recipients, and communities were alert and oriented x 3 and fully capable of asking for help. But I had no way of really having a meaningful conversation with them about their needs either by myself or through my cultural intermediaries.


What was I "helping" them to do or get? I was "helping" them to "develop" to be more like me ... YIKES What does "Development" mean? "Developing country"?

  • Seeing our way of life, our way of defining health and illness, as the ultimate objective and all alternatives not as different but as inferior.
  • We live in a time of massive loss of cultural diversity. Some 90% of languages that were spoken in the 1960's will be lost by the end of this century.


What is the impact? The only book I have found to date that is actually written by someone who was on the receiving end of this help in Cambodia is Towards Restoring Life in Cambodian Villages by Meas Nee

"And so it was that I could be so easily degraded by foreign aid workers. They came with humanitarian assistance and would sometimes give me the responsibility I wanted - the chance to work for our people. This was like putting an oxygen mask over my mouth and nose. I needed this to live. But they could so quickly criticize and blame me for no reason that I could understand. It was as if they kept their hand over the tube coming from the oxygen cylinder and could squeeze that tube whenever they wished." (page 28-29)


Where am I getting my feedback from?

  • People here telling me I am a saint
  • Positive ego feedback when I give a presentation like this
  • People I worked with, some with more experience (but with careers and lives dependant on this)
  • Talking to the "Locals" I worked with ... But
    • racism of this notion of "locals"
    • how "local" where they?
    • What interests did they really represent?
  • Did I have any way to know whether the people I was "helping" really wanted or benefited from this kind of help?
  • I became more and more aware of the Distance that separated my world and that of the people I was supposed to be helping, and how it was so easy to think that I knew what they wanted when I really had no idea. So back to Meas Nee
"[The] message that we were less than human was repeated over and over. I recall that from time to time Site 2 [the Refugee Camp housing 180 000 refugees] was shelled and all foreigners working there were taken out to safety. We were left inside. We would often say that the foreigners were like the angels who could fly from danger; greater than ordinary human beings. We on the other hand were less than human, more like the spirits in hell." (p30)


Then a friend sent me a lecture by Ivan Illich titled To Hell with Good Intentions. Given that Illich was a Catholic priest, I took those words rather seriously.

"If you insist on working with the poor, if this is your vocation, then at least work among the poor who can tell you to go to hell. It is incredibly unfair for you to impose yourselves on a village where you are so linguistically deaf and dumb that you don't even understand what you are doing, or what people think of you. And it is profoundly damaging to yourselves when you define something that you want to do as "good," a "sacrifice" and "help."


Why wasn't I working in homeless health or aboriginal health?

  • because I had a better visceral sense in the distance between my own experience and that of a homeless person here, or someone living in a remote aboriginal reservation. In those cases I could see the vastness of the distance I would have to traverse to be relevant, to be taken seriously. Here I had somehow been lead to believe that "Just being there" and "meaning well" and "caring" and "bearing witness" would mean so much to "these people"
  • Sure it changed my life, and I learned lots, but at whose expense? What right did I have to make that decision unilaterally (I had the power but did I have the right given that the cost was borne by others?)
  • After coming back for a while I thought that I should have spent more time living in a village, and less time in the city with so many other foreigners. I still think that would have been great for education, but I realized only while working on this presentation, that I never asked myself what right I had to just show up in a village and essentially impose myself as a guest on a community that had never invited me and couldn't really tell me to get lost because I was too linguistically and culturally ignorant to understand them. I would have just seen their smiles and interpreted that as approval.

What rights do I grant myself? Should I voluntarily give up doing some of the things I have the power (and even social encouragement) to do?

  • When I am "working there" I am not just working there. I am also being there. I live there, I interact with other people, rich and poor, I interact with animals, the plants, the land, the imported products. Even if I don't think about it, like breathing, it still happens. And the people who see me, who I interact with, will perceive me in terms of their own perspective, will assign meaning and be effected by that meaning of my actions, even if to me the action was entirely "without intent." I had no idea that this little bundle of medicine on my belt would be a constant reminder for you that your life was worth less than mine.
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