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Friday, May 15, 2009

Cambodia: a patient waiting

The response in Cambodia to the emergence of the H1N1 virus is a singular example of how a predominantly rural country is preparting for the threat of an epidemic without borders, says Michel Thieren.

May the tevoda grant us good health and prosperity, freeing us from suffering and fear. [...]
I am finishing my call, o nineteen pralung, come back all together now.

There is no more suffering, no more fear, no more misfortune.

O my dears, your relatives are gathered together in great number."

- Hau Pralung, Treatise for Calling the Souls of the Sick

"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity"

- the World Health Organisation, constitution

The emergence of a new threat to people's health is always refracted through the immediate and local circumstances of their lives. The worldwide reaction to the Influenza A (H1N1) virus is an example. Cambodia, where I work and live, offers a singular portrait of how a society - rural and poor, with its own unique cultural and ethnographic character - responds to and copes with an epidemic without borders .

The cost of ignorance

The World Health Organisation (WHO) reported that as of 06:00 GMT on 15 May 2009, there were had officially 7,520 cases of Influenza A (H1N1) infection in thirty-four countries; there had to that point been sixty-five deaths. The world has since 4 May been on level five (on a scale of six) of "pandemic alert".

This category, to health professionals, indicates a sustained community transmission of the virus in at least two countries within the same region (continent); a situation that in turn augurs the imminence of a global pandemic (active transmission in two continents). When it occurs, the emergency committee of the International Health Regulations (IHR) - an international legal instrument binding 194 countries to help the international community prevent and respond to acute public-health risks - can activate plans and preventive measures, publish daily updates, and make available knowledge about the evolving situation.

This mechanical precision is indispensable, but it also comes up against the limits of current understanding: for as yet, science knows very little about A/H1N1, and this opens the door to all sorts of allegations and interpretations of what is actually happening.

On 12 May 2009, for example, a leading online political magazine in the United States had as its main headline: "The List: Five Disease Outbreaks that are Worse than Swine Flu". There, A/H1N1 was retrospectively minimised by comparing it (already!) to five serial-killers: cholera, meningitis, HIV/Aids, Ebola, and dengue fever. By thus comparing numbers which should not be compared - because they denote different events, risks, patterns - the result is to remove readers and citizens from the core realities, instead of bringing them closer.

In any event, it will be a long time before the data on A/H1N1 will allow general inference for a long time, and therefore cannot now be subjected to (abusive) "analysis". The issue around A/H1N1 is not whether it spreads less or spares more lives than many other ongoing threats: it is that 7 billion humans are at equal risk of being infected by an entirely new virus against which no one is immune and whose epidemic and killing path cannot be predicted. This is what makes A/H1N1 different from any other disease - regardless of their respective morbidity and mortality totals.

The gaps in scientific knowledge are too easily filled by rumour, myth, hyperbole and attention-seeking media dramas. Many public-health practitioners have come to realise that fighting these requires much more work than solving a real problem.

In science's name

The WHO director-general Margaret Chan made her first official communication on A/H1N1 on 29 April 2009. She warned the world that "new diseases are, by definition, poorly understood and influenza viruses are notorious for their rapid mutation and unpredictable behaviour". The implicit message was that science - both virology and epidemiology - would restrict itself to support evidence-based communication on the new phenomenon. The tone was set that the WHO's messages with regard to A/H1N1 would for the foreseeable future operate with a degree of approximation and conditionality, all in the name of scientific exactitude.

However, when scientific evidence remains largely unsettled, the communication interface can be problematic. A messenger is scientifically accountable and needs to stand on the true ground of current knowledge; yet the recipient of the message requires a simplified and unambiguous formulation in order to take appropriate action. When an international health agency speaks within the strict limits of health and biomedical science, it may compromise its duty to preserve the collateral consequences on its auditors of the possible ambiguities these limits contain.
Yet if the same organisation presented user-friendly categorical statements without proper acknowledgment of doubt, it would to some degree sacrifice its commitment to scientific excellence. How to reconcile theory with practice? Only by stratifying messages through different audiences, from lay individuals to scientific experts, progressively loading them with technically complex and interpretable content.

In the end, however, there must be a consistent thread that links the two ends of the discourse, and in a way that the recipient at each point along the way can make sense of it for their own purposes: the virologist researcher who typified the A/H1N1 virus or decoded its ADN sequence; the epizootic expert who implements the food-standard guidelines, the Codex Alimentarius; the epidemiologist who estimates the lethal risk and the contagion of the virus (and who establishes the principles of the IHR); the economist who estimates the macro- or micro-economic consequences of a pandemic on a household's purchasing-power; all the way to the pig-farmer in the Argentinean pampa or among the Cambodian ricefields, whose only income depends on the readiness of people to eat pork.

The fact that there is very little in common in the knowledge, beliefs and daily lives of the people who exist along the communication "thread" makes it vulnerable to conflicting or overlapping messages. Often, experts speak from their respective scientific locus with no concern that different locuses may conflict with each other. Even as individual statements are pronounced in the name of scientific excellence, the "excellence" of an influenza epidemiologist may collide with the one of a public-health

veterinarian or an economist. When science leaves interpretation on pork-safety open with regard to A/H1N1, the consumer may start to see the threat coming from the food rather than from the person coughing and spluttering in the vicinity.

Cambodia in the world

Cambodia, like its immediate neighbours in southeast Asia - Vietnam, Laos, Thailand - has at the time of writing experienced no case of A/H1N1, and the situation has remained in preparedness mode. In the three weeks since (on 24 April 2009) the World Health Organisation released its first report of an "Influenza-like illness in the United States and Mexico", Cambodians have been waiting for their "public enemy". Many predicted that it would kill in massive numbers - something not so hard to conceive in a country which in 1975-78 experienced genocide at the hands of the Khmer Rouge.

It is indeed often the case that contingency planning is - rightly - planning for the worst scenario, even if it is rarely the worst scenario that ultimately prevails. So, in Cambodia, "pandemic contingency plans" were discussed, updated and activated at all levels. The international organisations operating in Cambodia reviewed their procedures on how to protect their personnel and maintain business continuity. Cambodian health authorities refreshed their plans too with the support of international-aid agencies; they received up-to-the-minute messages from Mexico, Atlanta, Ottawa, Geneva; and they took the necessary actions to broadcast basic prevention measures to the Cambodian population.

For example (albeit a weak example, as the measure generates a very low transmission-limiting dividend), a thermal scanner was installed at Phnom Penh and Siem Reap international airports to monitor returning travellers over possible contamination with the virus. This was complemented with quarantine and medical evacuation of screened suspected cases at Calmette general public hospital - perhaps not necessarily the one that people who can afford international travel would select, but the one where effective mass patient management could be organised.

A stoic response

The Cambodian media has done a good job in relaying what the country's 13.4 million people needed to know about the new disease without either distortion or panic. In most parts of the country, it quickly became clear that this was an enemy to be watched but from afar rather than an immediate danger; and that this new disease was a human-to-human problem and not about animals - a piece of information Cambodians can't but be very receptive to.

The common sense of the rural population has been strikingly evident. There is no sign that the pork-based economy in provinces like Kompong Thom is in any way affected. Cambodian farmers continue to raise and sell pork to smoking factories, and people continued to consume pork without further questioning.

But discreet signals of fear have been visible in the cities - mostly among the higher economic end of the Cambodian population and the expatriate community. Pork-meat and pork-based products were left in piles on the shelves of main supermarkets. In Phnom Penh, there was a roaming undercurrent of worry - of a new flu virus that would spread fast and kill in numbers (the memory of "severe acute respiratory syndrome" [Sars] in 2003 was ever-present here). The louder fears expressed by leading global voices and media outlets were softly replicated. The fact that Vietnam and Hong Kong had been epicentres of recent flu outbreaks added to the concern.

In short, Cambodians' relatively stoic attitude has not reflected a lack of public concern. The signs are that the country's government - doubtless aware of the political gains and losses associated with good and bad pandemic management - is truly committed to protect the health of its people. The response to A/H1N1 in Cambodia has been free of what have been regarded as democratic malpractices.

A fragile balance

This balance of communication and precaution was somewhat jeopardised by a report in the leading newspaper the Cambodian Daily on 7 May 2009 on the sensitive subject of meat-consumption. The approach was precisely to pick some dissonances from among leading voices on the pandemic, each one speaking from its own specialised interpretation of partial evidence. An expert warned that "meat from sick pigs or pigs found dead should not be consumed under any circumstances"; another attested that "all pork products are safe for consumption"; a further said that "this new strain of influenza virus does not contaminate humans easily and has a very low pathogenicity for both humans and pigs, unlike the avian flu which killed millions of poultry".

The appearance of scientific cacophony makes the consensual and reassuring message of the WHO director-general even more essential, in reaffirming that "influenza viruses are not known to be transmissible to people through eating processed pork or other food products derived from pigs". The relatively low intensity of the new disease abroad and its absence in Cambodia have played a role in holding rumours at bay. The consumption of pork is safe because there is no case of A/H1N1 in Cambodia, not because the virus is primarily associated with human-to-human transmission. But if any proof of A/H1N1 transmission appears in the country, the mixed messages in the 7 May report could revive and eclipse the WHO's efforts to achieve coherence in communication.

The result could then be stories about the power of A/H1N1 to attack humans and animals, followed by people ceasing to eat pork and the sudden imperiling of an entire vernacular economy of subsistence. In an instant, tens of thousands of people in Cambodia would move from daily subsistence to daily survival; and in a country where five mothers still die every day in childbirth, and where 127 children in every 1,000 born to the poorest families already die before reaching the age of 5, the fragile health gains that have been made may be wiped out. In short, to overestimate the food-borne risk of A/H1N1 in the name of (incomplete) science and consequent difficulty to estimate and aggregate risks could lead to underestimating the one of sudden poverty-induced illness. The media too has a crucial role in matters of life and death.

Thinking in Cambodia

Even those international public-health doctors who now mostly sit in research laboratories or other institutions once sat at the bedside of a patient. It is important for all of us to maintain the doctor's ethos at the heart of our work, and preserve direct contact with the realities and lives of the population we serve. In Cambodia and for Cambodians, good public-health practice must begin by integrating two basic features of Khmer culture: how illness is represented, and how the language accommodates semantic nuances.

Cambodia is predominantly a rural country; the Cambodian farmer is the socio-cultural nexus, at the core of the country's identity and heritage. The Cambodian farmer - and by extension every Cambodian - carries some sense of a direct line of descent from the ancestors of the ricefield; it is routine to be at the same time loaded with animist convictions while riveted to an unequivocal pragmatism.

All Cambodians - including public-health officials - can accept and understand that the "early signs of Influenza A (H1N1) are flu-like, including fever, cough, headache, muscle and joint pain, sore throat and runny nose, and sometimes vomiting or diarrhoea". They also know that "when a person is gravely ill, on the verge of losing consciousness, it is understood that the person's pralung (independent soul-entities) are no longer in his or her body"; thus, traditionally, to call the pralung to return to their residence within the patient's body requires a ritual to be performed. Moreover, the pralung are "also found in certain objects, plants and animals, whose integrity at particular moments is likewise essential to the integrity of the community". The way illness is conceived in this profound and affectively rich context presents singular challenges to the communication of scientific argument that disaggregates animal-to-human and human-to-human transmission of new viruses.

The Khmer language does not formally mark the distinction between different conditionals, nor easily accommodate assumptions, understatements, or subordinate and multifaceted assertions. The semantic nuances of "could be", "should be", "can be" and "will be" are easily lost in translation; in most cases they would end up by converging on the last one. The development of WHO-style consensual messaging using multivariate conditionality to incorporate initially dissenting opinions is not easy in this context.

The outcome of a situation where being scientifically right can generate conceptual or semantic ambiguities is, where A/H1N1 is concerned, yet to be fully tested in Cambodia. So far, its people are continuing to handle everything the world can throw at them with characteristic yet extraordinary grace and fortitude. The global is everywhere local. In the end people will, within their own cultural and social reality, find ways to manage a threat and protect themselves against it.

Read more!

Visitors to Cambodia dip as global economic crisis continues

The number of foreign tourists visiting Cambodia dropped in the first quarter of 2009 as the global economic crisis cuts the number of people travelling.

Visitors from South Korea and Japan are down sharply.

Presenter: Robert Carmichael
Speakers: Ell Lavy, Siem Reap tuk tuk driver; Dr Thong Khon, Cambodian Minister for Tourism

CARMICHAEL: Leave the famous jungle temple - known as Ta Phrom - outside Cambodia's tourism capital of Siem Reap and - as you can hear - you are surrounded by vendors selling cold drinks, musical instruments and postcards. Cambodia has relied for a decade on the expanding tourist trade as one of its pillars for economic growth. A record 2.1 million people visited the country last year.

So the news that tourism numbers have dropped in the first quarter of 2009 from the same period last year is not good. Overall the number is down just three and a half percent to 622,000 which is better than the government had feared. But the headline figure tells only one part of the story. Tourists from richer countries such as Japan and South Korea have dropped by a third, with short-term visitors from neighbouring Vietnam making up the numbers.

And that is why tourism worker Ell Lavy - a 25-year-old driver of a motorised rickshaw around the temples of Angkor Wat - has seen his monthly earnings drop from one hundred US dollars to just seventy. Previously he would get two or three tourists a week - now he is lucky to have one.

LAVY: You know last year when I recommend them to another place they say no problem for them. But this year when I invite them to somewhere they say they that no - they have no money to pay everything. [CARMICHAEL: So you have noticed they are spending less money, and there are less tourists?] Yes, less tourists also.

CARMICHAEL: Government figures show the number of visitors from South Korea and Japan, which last year provided the largest and third-largest number of foreign visitors respectively, dropped by one-third to around 100,000 in the first quarter of this year.

Gregory Anderson is the general manager of the upmarket Le Meridien Angkor hotel in Siem Reap. He has noticed there are fewer Japanese tourists in town, and says occupancy rates are down 20 percent for Siem Reap's upmarket hotels. He blames the global economic situation, as well as political volatility in Thailand and an ongoing border dispute between Cambodia and Thailand.

So in the face of lower spending on travel and tourism in the current global downturn, what can Cambodia do to boost visitor numbers? Tourism Minister Dr Thong Khon says he is targeting countries that are less affected by the global slump. And he is optimistic that 2009 could yet prove better than last year. But he says Cambodia is not helped by problems in Thailand.

KHON: Because you know Thailand is a main gate to Cambodia. Thirty three percent of total arrivals to Cambodia come from Thailand by air, by water, by land. When Thailand is affected, so it affects Cambodia too.

CARMICHAEL: To minimize that problem, the ministry is trying to boost short-haul flights from within the ten-member ASEAN nation and China, Japan and South Korea. Cambodia has already scrapped visa requirements for nationals within a number of ASEAN states. And he says the private sector must work to make the country more attractive - including using discounts for hotels and restaurants.

But making Cambodia more attractive isn't helped by the trickle of reported crimes against foreign tourists, some of them serious. The most high-profile was that a friend of Britain's Princess Eugenie had her handbag stolen in Phnom Penh recently. What does he think of the incident?

KHON: In Cambodia the whole country is completely safe and secure. But the thing that happened is not everywhere. Sometimes like this or like that. But the case of the princess - we checked with the police, we checked everywhere - they have no information. If the case really happened, why did they not report it to the police?

CARMICHAEL: Dr Thong Khon says the global crisis has seen Cambodia downgrade its estimate of tourist arrivals for 2015 by around one-fifth to 4 million visitors. So what message will he take to the region to try and boost visitor numbers?

KHON: Many tourists come to stay in home-stay, in the countryside, on some islands, for one month, for two weeks with the family. From Scandinavia, from Australia. They come from everywhere. No problem. Come. Come to stay in Cambodia.
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Area students discover Cambodia


Two young alumnae of Defiance College on Thursday shared their experiences in Cambodia with a group of area high school students and Rotarians.

"Despite their poverty, the people of Cambodia were so gracious. I never felt threatened at all," said Renee Chaffee, a 2007 DC graduate. "They just wanted to tell their stories."

"They have the same emotions as we do," added Jennifer Creighton of Evansport, who graduated last weekend. "They still love and care for each other. They were some of the nicest people I've ever met."

Their poignant remarks were made as co-keynote speakers at the grand banquet for the 23rd annual World Community Workshop, which runs through Saturday at Defiance College.

The workshop is sponsored by Defiance Rotary Club, Rotary District 6600 and the McMaster School for Advancing Humanity. It provides young people with an opportunity to learn about history, customs and economic and political issues of a selected area of the world.

Chaffee and Creighton reflected on their experiences in Cambodia as part of the McMaster School for Advancing Humanity program. Chaffee worked at the Cambodian Women's Crisis Center, where she addressed domestic violence as it relates to women and children to assess whether they were receiving adequate services.

"I interviewed women one-on-one," said Chaffee, who will receive her master's of social work degree next week from Case Western Reserve University. "That was the part of my life when I knew I wanted to work with women and children who had been victimized."

Chaffee also discussed "the Killing Fields," a number of sites in Cambodia where large numbers of people were killed and buried by the totalitarian communist Khmer Rouge regime from 1975-79. These locations were the subject of a 1984 movie of the same name.

"It was very surreal being there," she said. "It's scary to know this happened in my lifetime."

Creighton's project involved the natural forms of birth control, since Cambodia's past unrest has made the use of and methods of obtaining medicinal forms of birth control difficult.

Her research took her to CycleBeads, developed by the Institute for Reproductive Health at Georgetown University.

"I wrote training materials about how to use the beads," said Creighton. "They have a 95 percent effectiveness with correct use and 88 percent effectiveness with typical use."

She said she observed a wide disparity of wealth and poverty in Cambodia, often right next to each other.

"On the streets you would see people pulling carts and others driving Land Rovers. The middle class were the people that had huts with shutters."

The workshop resumes today, when students will break into small groups and develop a presentation covering a certain aspect of Cambodian history, customs, economics and politics.

All presentations will be held Saturday morning.

"Rotary is in many countries and our mission is world peace and understanding," Rotary 6600 district governor David Daugherty told the students.

"I'm glad you are here. Make the most of it."

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China, Australia to Build Final Leg of Asian Railway

Man drives homemade wooden cart on railroad in Kampong Chhnang province some 50 kilometers north of Phnom Penh (2008 file photo)

By Luke Hunt, Phnom Penh

Chinese and Australian engineers are gearing up to build the final stretch of track in the Trans-Asian Railway, which will link Singapore, Malaysia and Thailand with Vietnam and China through Cambodia. The Cambodian government has divided the country's railway system in two. Australia's Toll Holdings takes control of old French-built lines in the east, which run from the capital to the Thai border and south to Sihanoukville, home to one of the largest ports in the Gulf of Siam.

The China Railway Group has the contract to carry out a feasibility study that will link Phnom Penh with Snoul near this country's western border with Vietnam.

This 255-kilometer stretch will complete the Singapore-to-Kunming line, a railway connecting southeast Asia to the heart of China.

Paul Power is an advisor to the Cambodian government and team leader for the Asian Development Bank's involvement in the reconstruction of Cambodia's railways. He says the railway's economic benefit for the region and Cambodia will be enormous.

"It makes Cambodia the hub of transportation between China and Singapore and you would have a port link, you would have a link to Thailand, you'll have a link through to Vietnam," Power said, "and the implications for that, for Cambodia in the region, are that Cambodia becomes the hub."

He says freight will provide the greatest economic benefits, particularly for shipping bulk goods like rice. The railway will be a cheaper alternative to ships and trucks.

However, the contractors first must deal with the thorny issue of resettling people living along the route. In Cambodia, poor landholders often are pushed out with little compensation to make way for commercial developments, causing considerable public anger.

Power says the companies working on the railway are aware of the problems that have afflicted other construction projects and thinks they can avoid similar difficulties.

If the resettlement issues are resolved quickly then authorities hope the first passengers from Singapore to China and beyond as far as London, will start boarding within the next two years.
Read more!