Kratie Province Cambodia 1994
I can still see it. The great clay green waters stretching like a slowly moving ocean. The tooth-like jagged rocks puncturing the surface as though some giant had scattered a pepper shaker of molten larva into the waters eons ago and the huge green islands basking in sun-warmed languor under the dusty sky of a Cambodian dry season day. Some time in the future there will be tourist hotels here and bars and swimming pools and stalls selling trinkets and handicrafts. But now there is just the rustle of the wind in the sugar-palm trees, the whack of small boy driving a water-buffalo to the river and the humming background chirp of a crickets.
And here in this small patch of dangerous paradise works a remarkable doctor. She is in her early 30's, dark haired and graceful in her step as she moves softly between the raised wooden houses of the small riverside village a small notebook in her hand. She wears around her waist the coloured kromma of the Khmer, and she speaks in their language to the people who come to greet her. Yet her skin is white and her dress of western style. Now and then she pauses to bend and put a comforting arm around a small child while the other lightly yet expertly assess the full curve of its protruding tummy. Then she rises to make a small note in her book while the children, unafraid stare at her with their big liquid eyes and smile.
To some of the children it is all part of a game, but Dr. Sophie Biays and the people of the river well know otherwise. For this is the land of the 'Fallen Turtle Disease' which swells children's stomachs and causes them to vomit blood until they can take no more. Old belief by some was that a turtle had fallen down inside the belly. Others considered the culprit was a bees nest. To Westerners it is known as Schistosomiasis.
For the people who live beside the Mekong it is their life. They drink its waters, use them as their source of refuge on in the relentlessly long afternoons of the hot season, wash in them, fish them, are carried by them in their small wooden boats and use them to transport the great jungle logs that they cut to be sold to eager traders from Thailand, Malaysia and Singapore.
Yet it is in these very waters that the fallen turtle disease lurks and is maintained by an unlikely creature; a tiny water snail, the largest of which are no bigger than a shirt button. The snails live on and under rocks and hence thrive in this area of the Mekong. Known as the 'Sambo Rapids', there are no real rapids in the normal sense of the word. Rather it is an area where for some primordial geological reason, the normal mud and earth bed of the river gives way to a structure predominantly of rocks and stones. As you run your eye across the glistening water great jagged icebergs of stone rise from the surface like dragons teeth and small swirls indicate boulders lying just below.
Until the French administration mapped out and marked a usable channel in the 1940's navigation through the area was a risky business. Now the large cement markers still stand, one of the very few remnants of the colonial era left untouched by the Cambodian holocaust of the 1970's.
The snails themselves are not the culprits, simply an inadvertent intermediate vehicle for one of the stages in the infection cycle of the miniscule blood 'fluke', a type of tiny short worm, which is responsible for the disease. After a gestation in the infected snail the organism is released as a tiny, torpedo shaped form known as a ceracria. The cercariae swim freely but will bore through any human or animal skin which has entered the water in their vicinity. Once inside the body, the organism changes shape and migrates to the veins around the liver and stomach. There the flukes mate and produce eggs. Of social interest in these days of increasing broken marriages it is interesting to note that the male and female schistosome mate for life. The longitudinally grooved male wraps his body around the cylindrical female to spend their days affectionately locked together as one egg producing unit.
It is not the adult flukes but the eggs which cause the long term damage. They excite inflammatory and immune reactions which block vessels and cause massive enlargement of the spleen and liver which will often lead to complications and death. Some eggs however will find their way through the intestinal wall and be excreted with the faeces. If the faeces are deposited near the river and are not treated the next rain storm will wash the eggs back into the river where they hatch into yet another form. And this form, the miricidium, penetrates the water snail to comple the cycle..
Dr Biays speaks with the soft accent of her native Brittany. She tells me modestly that the disease in Cambodia had been discovered years before and that her project was simply a continuation. The enormity of this understatement makes me smile. Although it was certainly recorded in the mid 1960's the almost umimaginable holocaust of the Marxist 'Khmer Rouge' overthro of the government ten years later resulted, along with the deaths of three million people, in the total destruction of almost every record of every fact in the country. The Khmer Rouge themselves appropriately referred to the start of their regime as 'year Zero', and set out to remould society comletely from a beginning wiped clean all local links with its past.
And within bloodshed and the destruction, the forced labour and the so called 're-education camps', later found to be basic extermination camps, the fallen turtle disease of the river and its sufferers were simply carried along in the juggernaut of horror. Their disease had been forgotten about and their lives hung like the others only on tiny threads of chance. For a smile or a tear at the wrong time was not permitted, a word or silence when it was not appropriate could mean a sentence of execution.
So when the UN men in the blue caps followed in the NGO workers so fifteen years later, they found a country almost totally devoid of any fabric of infrastructure or historical record. They found a people shattered, confused and shocked, and evrerywhre, the crumbling aftermath of mass distruction.
And into this vortex of disoriented confusion came Dr Biays, her job arranged through an NGO to assist the National Malariology Department in the capital, Phnom Penh to re-establish its role within the country. This meant regular field trips and one of these took her to the Sambo District of the Mekong.
'I was shown some "bad cases of malaria"' she said. 'Well, they do have malaria here and it does give enlargement of the spleen and liver.. but these cases seemed just too largd... I was suspicious ... I came back and took samples..'
So, far up the Cambodian Mekong Dr.Sophie Biays rediscovered Shistosomiasis. She realized immediately that there was a desperate problem. Medical services in traumaitzed rural Cambodia were in an almost totally non-functioning condition and even where help might be available, the disease was being wrongly diagnosed as Malaria, for which the treatment was entirely different. But she knew also that there was hope. Her training in Tropical Medicine had given her the knowledge that there was a cure and what was more, that it was close to 100% effective, could be given in just one dose - an enormously important point for treatment compliance. Developed originally for the lucrative vetinary world, the drug Praziquantel had to wait several more years before anyone was prepared to spent the money to carry out the necessary trials for human use. The sad fact is that the humnan pharmaceutical industry well knows there is little money to be made in developing countries where such diseases tend to lie. Eventually however the World Health Organization agreed to subsidize the trials, and a human wonder drug was borne.
But Praziquantel is relatively expensive and Dr Biays knew that if she were to start a treatment program, she would need help. And the help came from the Dutch/Belgian/Swiss branch of the NGO Organization Medicins Sans Frontieres, one of the most effective in the world. They not only agreed to sponsor Dr Biay's program but also to put her in charge and assist in building a small district hospital for the area. Early in 1984 Dr Biays bumped up the potholed hour and a half access road, moved into her small wooden house in Sambo Village and started work.
Few others would have. For in the dark brooding forests of Cambodia, the men of death, the Khmer Rouge guerillas, still lurk, moving silently into the villages at dusk or nightime to take food or money from the inhabitants. In the daytime they melt back into the forest but from their jungle bases manage the logging trade by taxing those who come to cut wood. Mainly without roads and largely ignored by their own governmment except by corrupt officials after the same lumber taxes, the villages of Sambo live in a semi- autonimous shaddow land of alleigance, bending theis way and that depending on who is making demands on them. No one, not even the villagers themselves, know when the Khemer Rouge will turn up, and neither does Dr. Biays. 'I have been lucky' she says. 'No problems so far, although there three full time Khmer Rouge villages we cant get to'
Yet there were problems, twice. In late 1994 when there was a flare up in fighting MSF had to pull Dr Biays and her team out for three weeks, and later, perhaps more seriously, she narrowly avoided being kidnapped at the time when the Khmer Rouge we looking for Western hostage. Dr.Biays had been held up by work-load in the small clinic that day and cancelled plans for a district visit. She later heard that on the road she had intended to travel, every passer by had been stopped by Khmer Rouge soldiers looking for Westerners. Of the seven that they did end up in taking in several episodes over those weeks, only one survived.
In the height of the dry season, the heat is intense. From middy to around 4pm it becomes almost unbearable as the land sweats and swelters under an apoplectic Cambodian sun. Only the tall sugar palms with their neat green haircuts seem to stand up to intensity. Yet on the doorstep of Sambo village runs the great river, its waters now low but softly calling a cool invitation to all those who are within earshot. And the buffalo and the children are the first to accept, the former wallowing happily their horned heads only visible like a cluster of Viking helmets thrown overboard by some ancient raiding party, while the latter in contrast jump and roister in a flurry of splashy antics which bring smiles to the fishermen and log cutters labouring on the sandy bank.
But it is in the dry season when schistosomiasis transmission is the highest. Then the water flow is slow and the low level brings the rocky habitats of the aquatic snail close to the surface. In their free time, the children are almost constantly in the water but to try and change this lifestyle of a thousand years or more would have been almost an impossibility.
systematically screened and treated the children of almost every village in the area. Like some tropical Florence Nightingale,
Everywhere we went we would be greeted by children and their grateful parents. Time and again she would point out to me a
child in the process of reverting to health under the effect of the drug or those who had ben completely cured. Amazingly she
seemed to know every one by name and I could see her overwhelming pleasure in their happiness. 'I love my work' she said,
and I believed her.
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