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Cambodia Exploratory Trip 2008

Exploratory trip to Cambodia
Program in Speech-Language Pathology
Teachers College, Columbia University
 

Karen Froud and Cate Crowley visited Cambodia in July and August 2008. We wish to gratefully acknowledge the support of the TC Provost's Office and the Department of Biobehavioral Sciences in providing funding for this trip. We also wish to acknowledge the amazing work of the organizations we visited while in Cambodia:

Karen Froud is an assistant professor in the Speech-Language Pathology and Neuroscience & Education programs at Teachers College, Columbia University, and director of the Neurocognition of Language Lab. A former speech-language therapist in the UK, she moved into research and now specializes in brain imaging studies of how language is neurally represented in typical and damaged brains, as well as those of individuals with developmental disorders. Karen teaches graduate level classes on language acquisition, language disorders, and neuroscience of communication disorders, and she also serves on the faculty of the Bilingual Extension Institute at TC. Cate Crowley, distinguished lecturer and coordinator of the Bilingual Extension Institute, as well as the bilingual/bicultural program focus in TC's speech-language pathology program, has already established a 4-week annual program to Bolivia, whereby graduate students in the department participate in work, study and humanitarian outreach activities in this resource-poor region. The Bolivia Project has enhanced students' experiences of the essence of multiculturalism, and has brought much-needed services in intervention, diagnosis and training to Bolivian children with disabilities, their families, and the professionals who work with them.

Karen has a long-standing association with Cambodia in the person of Karl Balch, an old family friend who now serves as the British Consul Warden in Siem Reap province. Having visited the country several times, Karen was already aware of the levels of need for educational and health services, and the country's unique situation following the genocide years under the Khmer Rouge in the 1970s. A generation of educated professionals was wiped out, along with all the country's educational and healthcare infrastructure. Despite the long history of the Khmer people as artisans, priests, teachers -- a history vividly embodied in the gigantic remains of the city-state centered on the huge temple of Angkor Wat -- Cambodia today is a country struggling back to its feet after many years of social and educational deprivation. Karen raised the possibility of an exploratory mission to Cambodia with Cate as a result of Cate's amazing experiences in Bolivia and Ghana, in the hopes that some service provision for and by TC graduate students could be established in Cambodia.

Karen and Cate were accompanied on the trip by Sam Froud, Karen's 9-year-old son, who became the designated trip photographer -- a role he carried out with patience and finesse.

 
SIEM REAP
Temples

After long journeys via (for Karen and Sam) Tokyo, (for Cate) Hong Kong, and (for all of us) Bangkok, we took a couple of days to acclimatize and explore the temples around Siem Reap. Angkor Wat (above) of course must be seen to be believed. In scale alone Angkor Wat beggars the imagination, and though every year more tourists visit, it's still possible to find a quiet corner, which permits a more direct experience of the temple's brooding grandeur. The temples were originally Hindu, but became centers for Buddhist devotion and pilgrimage under the rule of Cambodia's King Jayavaraman VII in the 12th century. We also visited Angkor Thom (left), and Ta Prohm (right), the overgrown ruins which were made famous by Angelina Jolie in the Tomb Raider movies. At the Bayon, a huge ruin which is best known for the monolithic carvings of the king's head facing north, south, east and west on each of its many pinnacles, we encountered Cambodian Temple Dancers (below), looking like figures come to life from the stone carvings on the walls.

On leaving the Bayon, we stopped in at a couple of the large Buddhist roadside temples which are currently active in the area. The official religion of Cambodia is Buddhism, and most people in the country will spend some time in their lives living and working as part of a Buddhist temple community. At the second of these village shrines, our visit coincided with the arrival of an important Rinpoche (senior monk), who graciously gave us his blessing and stopped for a few words with us. Despite the language barrier, we did feel truly blessed by his shining presence -- it seemed a very good omen for the rest of our trip.

 
 
Angkor Hospital for Children (AHC)

AHC was the first of the organizations we'd scheduled to meet. The hospital is supported by Friends Without A Border, an NGO operating out of New York City. The first sight that greeted us as we entered the hospital was a crowd of people waiting for access to the outpatient clinic. With around 500 visitors per day, and only 60 inpatient beds, the AHC nevertheless provides free medical care to anyone who needs it. This works primarily by a very efficient triage service; nurses and healthcare professionals work with all visitors, providing information and care for issues within their purview, and referring those in need for medical attention. Families come all together from the provinces around Siem Reap, and stay in the hospital grounds for the duration of treatment for their affected family member; there were hammocks, cooking fires, large tables and piles of food, and many children everywhere we looked. The Executive Director of AHC, Dr William Housworth, had many questions for us about the nature of our program and our plans for addressing critical issues like sustainability of service, and the language barrier. Despite a couple of lessons, Cate and Karen between them had mastered only a few phrases of Khmer; for Sam picking up the language was much easier, of course! Luckily, we had opportunities to show that it's possible to provide some helpful interventions in SLP, very quickly and without needing detailed language-based communication, by providing modeling and reinforcement.


Dr Housworth explained that the hospital each year receives many volunteers, and surgical missions, and that there's a difficult balance to be maintained in terms of deriving the greatest benefits for the people served by the hospital while minimizing the inevitable drains on hospital human resources incurred by training and supervising volunteers. Bill invited us back to AHC to meet with the Medical Director, Dr Ngoun Chanpheaktra, and one of the senior pediatricians, Dr Varun Kumar. On this second visit, Varun was kind enough to provide a whirlwind tour of the AHC facility, which includes state-of-the-art operating rooms and intensive care units, as well as a nutrition program, a model farm where visiting families are taught how to raise beneficial crops for their families, a dental clinic, and the services of a play/art therapist.

Varun and Pheaktra discussed with Cate and Karen the possibility of piloting a visit from a small group of TC students, with supervision to be provided by Cate, Karen and other clinical supervisors, and we're in the process of working out details of when this can happen, and what form such a program could take. The pilot visit would provide us with even more concrete information about the best and most beneficial (for students and for the local community) ways to structure a clinical experience in this environment. One identified need was for AHC professionals to receive training in SLP-related issues so that the work could continue even when the students and professors from TC are not around; we also discussed possibilities for tele-practice as an additional means of addressing the sustainability question.

Handicap International (HI)

Dr Housworth at AHC had mentioned HI as an organization we should try to connect with, and we were very glad we followed his advice. The offices at HI are a mix of administrative, workshop, accommodation, education and rehabilitation facilities. The organization was initially established to provide prostheses and rehab services for people who have lost limbs in landmine-related incidents, but the work has extended to provide remediation of "clubfoot", provision of special seating and mobility aids for physically handicapped individuals, and physiotherapy and other support for those with cerebral palsy. We met with Mr. Sok Sophorn, the manager of the Siem Reap outpost of HI, and his very able assistant manager. Karen and Cate told them about the plans for SLP provision and training, and were pleasantly surprised to discover that a recent survey commissioned by Handicap International out of Singapore, had designated speech-language pathology as an area of need in Cambodia which Handicap International were keen to address. HI were therefore very willing to consider ways to work with us.

A large part of HI's work in Siem Reap involves bringing children with cerebral palsy, and their families, to the center for a week at a time, and providing a kind of "workshop" approach to alleviate physical and cognitive difficulties. Currently their interventions are limited to some wheelchair and seating provision, with some physiotherapy and sometimes the services of a play therapist. During one of our visits to HI, we met a 2-year-old boy with CP accompanied by his mother. Due to hypotonicity affecting his trunk, the little boy sat hunched over, with his gaze permanently fixed on the floor. By showing the mother to hold his head, and change his posture, and by providing some stimulating materials (an Elmo book!), we were very quickly able to engage the little boy's attention -- within a few minutes he was reaching out to turn the pages by himself. The mother and phsyiotherapist we worked with were delighted, as were we, to see just how quickly some simple-to-demonstrate intervention techniques can make a real difference. We're hoping that we can participate as service providers and trainers in one of HI's cerebral palsy workshops.

 
 

PHNOM PENH

We traveled by boat to Cambodia's capital city, Phnom Penh. The five-hour boat journey down the Tonle Sap river to its confluence with the Mekong affords some amazing sights -- there are whole villages on the Tonle Sap, floating homes occupied by fishermen and market people, their extended families and pets. We saw tiny children handling big boats with great ease, families relaxing in front of the TV in their floating living rooms, youths playing pool on a raft. Coming into Phnom Penh, the river becomes lined with huge Buddhist temples and pagodas, and then abruptly we're at the dock, with people competing to help us with our bags and to provide us with tuktuk transportation to any hotel or guesthouse.


Family Care Cambodia

Our work in Phnom Penh began with a visit to the Cambodian Center for the Protection of Children's Rights (CCPCR), just one of the projects undertaken by Family Care Cambodia. The extraordinary people running FCC's projects are Ann and Alex Soldner, and they became our surrogate family for a few days, along with their two youngest children (of 8!) -- Leah and James, aged 15 and 14. Sam and James got on famously well, and Leah was incredibly helpful, providing insights and recommendations for everything from the best places to go shopping to aspects of traditional Cambodian life -- especially the role of dancing in social situations (we tried to learn some dance moves, but were hopelessly outclassed by Leah).

The CCPCR is a residential and vocational center for girls and young women who have been removed from abusive or dangerous situations at home. We arrived on a morning when the road outside the center was being dug up for new drainage ditches, so we had a hilarious journey through mud and puddles to get to the front gate. Once we arrived, we were led upstairs to see the morning dance class; the girls were dancing beautifully in traditional Cambodian style (above). After dance class we had an art class, led by Ann, and Karen and Cate joined in so that each of us worked with two or three girls. The task set by Ann was to make an abstract design using three fish shapes, three circles and three triangles; we used the opportunity to get help with counting in Khmer, and made the girls laugh at our efforts. At first it was difficult for the girls to get started, because they were concerned to try and make exact copies of the original design shown as an example. But once we got going, they all managed to come up with a unique fishy design. Ann helped everyone write their names on the designs, in English and Khmer, and one of Karen's new friends added the words "I love you" and insisted on making us a gift of her design. Cate led an "English lesson" based on Eric Carle's book "I can do it!" -- and in true Cate style soon had everyone on their feet pretending to be elephants and crocodiles, and giggling together. Then we all met the puppies that were recently born at the Center - everyone got a turn at holding them. 

Some of the young women at CCPCR are talented artists, and they make beautiful paper mosaics - see some work in progress below. One way you can support the Center is buying these mosaics - please email us if you'd like more information.

It's a real testament to the strength of these young women, and to the importance of the amazing work undertaken by Ann and Alex, that despite the terrible experiences they've been through, we all felt so uplifted by spending this brief time with them. Family Care Cambodia runs several projects, all immensely important to the local communities, and seemingly without any consistent funding. We don't know how they do it, but we're so glad they do. Take a look at their website, please, and consider supporting their projects.


Phnom Penh Pediatric Hospital

Ann Soldner had arranged for us to visit Dr Chour y Meng, the medical director at Phnom Penh Pediatric Hospital. Dr Meng is an extraordinary force, and has built the hospital up from one or two rundown buildings to a complex of modern facilities, within a few short years. We were honored that Dr Meng, on hearing about our program and our plans, unhesitatingly gave us his hearty endorsement and welcomed us to be part of the work at his hospital.

We were accompanied on a tour of the facility by Dr Long Vanna, a talented surgeon who showed us some of his work in the person of a young boy whose severe cleft lip and palate had recently been beautifully repaired. Many new patients were still awaiting their surgery dates. Dr Vanna candidly explained that he was confident in his ability to intervene surgically in cases of severe cleft, but that he found surgery for children with simple cleft lips even more challenging, because the standard for that repair is perfection -- which is always hard to achieve. In the face of such concrete evidence of the excellence of his work, this comment gave us insight into Dr Vanna's modesty and his unwavering commitment to providing these children with the highest level of care.

Cate's expertise in SLP intervention with cleft lip and palate post-repair came in very useful, as we were able to talk with parents and extended family members of children with recent repairs. We met Farid and his family -- Farid was due to have his repair the day after our visit, and was a very engaged (and engaging) baby who was delighted to try to imitate Cate's bilabial "noises". Farid's mother and aunt were with us, and quickly picked up on this activity for Farid; with the help of Dr Vanna's medical social worker, we were able to explain that this simple activity after his surgery would help Farid to start making those "front" sounds which can be very difficult for children who are born with craniofacial abnormalities. Cate and Karen will be providing some non-verbal information (pictures, cartoons) for Dr Vanna's patients to take home with them after surgery, in the hopes that a few such simple activities could help to minimize later speech disturbances.

While we expected to find children needing speech and language services, we found one thing that was completely unexpected - a very lonesome EEG machine! Dr Vanna also showed us the operating facilities at the hospital, and then took us to the emergency room, where Karen was delighted to find a 36-channel EEG setup for monitoring brain activity. The system had been generously donated from Korea, but the one person on staff who knew how to use it had left -- so Karen will be providing the doctors with some EEG training when we return to Phnom Penh.


Operation Smile

Dr Mok Theavy of Operation Smile works out of the Khmer-Soviet Friendship Hospital in Phnom Penh, and was kind enough to squeeze in a meeting with us between his surgeries and his outpatient clinic. The photo at left is from Operation Smile's mission in Phnom Penh last year. Like Dr Vanna, Dr Theavy was very much aware of the limitations of intervening in a purely surgical way in cases of cleft lip and palate, and was very open to including speech-language therapy provision as part of his services. Dr Theavy discussed with us the hope that he could identify someone on his team who would be able to participate in any training we might set up, and then disseminate and put into practice the relevant information. It was at this point that Karen and Cate both started to realize the desperate desire in Cambodia for information, training, education -- Cambodian people don't want our help, they want to be able to help themselves. As in Bolivia, it's a priority that any program we set up in Cambodia provides information and training for people who live and work in the local communities.


Krousar Thmey ("New Family") School for the Deaf

Krousar Thmey, like Family Care Cambodia, has many projects currently underway in Cambodia and we were only able to visit one of their sites in Phnom Penh. Every year Krousar Thmey's school for the deaf, situated just outside the city, holds training for its teachers while the children take a vacation from classes (many of the children at the school also live there, so they are still around during the summer). The training for the past four years has included visits (and some residencies) from speech-language pathologists from France, and we were able to meet with the three amazing women who were this year's trainers: Sylvie Clavier from Rouen, Marie-Noelle Bergues from the Paris suburbs, and Isabelle Roy from Purville-sur-la-Mer. We also met two of the people who have repeatedly been recipients of the training, and who are coming to levels of expertise in speech-language pathology -- especially in the context of working with the deaf and hard of hearing -- not previously attained by people from Cambodia. These "Khmer speech pathologists in training" were Dos Phallin and Sok Sereyvutiny -- Mr. Phallin and Mr. Vutiny -- and they also expressed a keen interest and enthusiasm for any training and educational opportunities we might be able to provide. A very striking thing about the school was the great energy and enthusiasm of the teachers, coupled with a severe lack of resources. The photo to the right shows the entire stock of toys available for the school's kindergarten classes, and we've committed to try and send them some more appropriate materials over the next few weeks -- please email us if you have donations.




Where do we go from here?

We left Cambodia uplifted by our experiences, and full of ideas. We were moved by the work we saw that is already being done by the people we met in Cambodia. In many of our meetings we heard about an already identified need for the knowledge and skills that we speech-language pathologists have. We were greatly encouraged by this. Our timing seems quite good, too, as Cambodia seems to have begun its own rehabilitation as it recovers from decades of conflict.

There is much that we can do and many children who need our services. Most of the places we visited have a number of children with a variety of communication disorders that we could help. We also have identified particular disabilities that we could target, such as children with repaired cleft palates after they have recovered from their initial surgery to close the palate, and children with cerebral palsy who lack effective communication systems. All of the places we visited seemed like fertile ground for providing quality clinical training for our graduate students.

Perhaps what we found most remarkable about many of the Cambodians we met is their thirst for our expertise. As we played with the children post-cleft repair in Phnom Penh, we could see their mothers' eyes, and the eyes of many others in the waiting room, widen as we joyously worked with their children whom others had shunned. Our thoughts about training Cambodian peopleto work as SLPs were met with great enthusiasm, and we intend to incorporate a strong training component into whatever work we do in Cambodia. That training will include parents, outreach workers, medical professionals, and teachers. In addition, we hope to identify and fund a group of Khmer peoplewho can work side-by-side with us as our interpreters and at the same time acquire the knowledge and skills of a speech-language therapist, both while we are working with them and through the internet when we are away. Little-by-little we hope to collaborate with these Cambodians to develop the first group of Khmer-speaking speech-language pathologists. These are our dreams that we intend to turn into reality.

 
 

We'll use this webpage to publicize our ideas and plans for a speech-language pathology training experience in Cambodia, as we begin to work out details and decide what specific form our program could take. Please check back often, and email us with your comments, ideas and questions.


Thanks Sam for the photos. Sam is available to hire for photojournalism assignments of all kinds, in all locations around the world; please contact his mother for details..

Karen Froud: