Maryknoll in Cambodia
Seedling of Hope Project
Seeding of Hope
The situation in Cambodia regarding HIV and AIDS is increasingly serious. The first case of AIDS was diagnosed in 1993. Since that time there have been an estimated 24,963 individuals infected and 21,619 AIDS cases. This year (2000), about 50,000 new cases of HIV infection and 13, 243 of AIDS will be reported. In 1998 about four percent of all sexually active adults (15-49) tested positively for the virus. The new rate, estimated to be much higher, is not yet available. Sentinel surveillance conducted by the Ministry of Health in 1998 documented the highest prevalence rates in the southeast, central provinces, and along the Thai border. The predominant mode of transmission remains heterosexual sexual contact though little information is available on homosexual/bisexual transmission. (UNAIDS, Country Profile, 2000).
The national response is necessarily limited by the destruction of the health system under Pol Pot and its under-funding since that time. Consequently, fiscal and human resource constraints in the health sector remain severe. The reach of public and private health facilities is small both because of quality and cost. Cambodia has one of the lowest rates of the utilization of health services in the world with only an average .35 contacts per person per year (UNAIDS, Country Profile, 2000).
In 1999, the National AIDS Authority replaced the National AIDS Committee and Secretariat. The purpose of the NAA is to coordinate the national response. Secretaries of State from selected ministries comprise a policy board in order to facilitate intra-governmental communication and coordination. The national response itself continues to focus prevention, regulation, and monitoring. Home care experiments remain small and suffer from limited resources.
National and local government rely heavily on NGOs to help with awareness building but particularly with the care and case management of individuals with HIV/AIDS.
Cambodia has one of the highest sero-prevalence rates for HIV in the world and, with its dramatic scarcity of human and financial resources, is one of the countries least equipped to address the multiple problems of people living with AIDS. High rates of poverty and migration, political instability, and the socially accepted use of commercial sex workers have compounded the problem.
Since 1993 there have been an estimated 240,000 cases of HIV/AIDS. About 4 percent of all sexually active adults (15-49) test positively for the virus. This year an estimated 50,000 new cases are expected. It is these realities which The Seedling of Hope hopes to address in a small way directly and in a larger way indirectly by providing a workable model/s for what the Government calls other "willing hearts and hands".
The Seedling of Hope opened its doors in 1996 to provide education awareness services to high risk populations and clinic and home care to poor people living with AIDS. Four years of work with the poor and wrestling with the related issues in evaluation processes have profoundly deepened our understanding of our clients' needs and how best to address them. With financial support from Maryknoll, The Seedling of Hope is operating an expanded set of services. The proposed three-year project incorporates these efforts to ease the suffering of our clients.
In summary, the proposed project has four objectives
Maryknoll's response to HIV/AIDS in Cambodia is carried out in harmony with the National AIDS Program Office plans and in cooperation with NGOs with related interests. Wherever possible, existing resources and materials are used. Coordinating with other organizations operating HIV/AIDS programs, as well as groups involved in psycho-social work will remain a priority. Due to the careful planning, coordinating, and networking done to date, Maryknoll project staff are contacted routinely by other agencies for information, advice, and assistance.
The Maryknoll Project has well-defined target groups. First, Chakangre Krom is a poor, densely populated urban area with many factories. To date the commune has had no HIV/AIDS program services. The area is mixed ethnic with Khmer and Vietnamese and abounds in factory workers who are typically female, young, lonely, and poor and often live away from the families that they support with their wages.
Secondly, The Seedling of Hope reaches out to destitute and frequently despised Vietnamese in 16 fishing villages along the Bassac and Mekong Rivers. Because they are both poor and shunned, the Vietnamese have almost no access to services, including medical services. Maryknoll has a longstanding relationship with these communities.
Finally, Seedling through a wide network of NGOs serving HIV/AIDS Seedling reaches out to the truly abandoned throughout the city.
Through The Seedling of Hope's multi-dimensional approach, the project will increase knowledge and awareness of sexually transmitted diseases, including HIV/AIDS. Our experience has shown us that it is the combination of our formal education awareness sessions and our presence in the neighborhood, at our center, in the hospital and doing home care that ultimately breaks down prejudice against and fear of people living with AIDS.
This in turn makes it more likely that with some assistance poor families can look after their own, and that the children of AIDS parents are accepted by their relatives. While maximizing familial and friends' support, however, it will always be true that for some--maybe because they are the last alive--total care will be needed. Without some hospice and group home facilities, people will deteriorate rapidly and just die where they lie, on the streets. The medicines we provide help address physical complaints; our accompaniment addresses quality of life and, in the end, quality of death.
In sum, the proposed project will continue strengthening the capacity of Cambodians to respond to the AIDS crisis through education and awareness activities and through the modeling of teaching awareness, case management and home care and residential services.
The Maryknoll HIV/AIDS project will be staffed by at least two Maryknoll expatriates, ad hoc volunteers (currently two foreign doctors, 1 Jesuit, and 1 Providence Sister volunteer), and 12 to 15 Cambodian staff. The staff, many of whom participated in the last project period receive continual training.
The exact nature of the training depends on the opportunities that present themselves. For example, five of our staff just participated in the field worker training offered by Quaker Service Australia. Obviously we look for opportunities for training in field work, case management, hospice care, awareness training, etc. In addition to external opportunities for training, staff receive on-going training in hands-on patient care, good hygiene, and hospice waste disposal. Much of this training is done by one of our expatriate doctors and an expatriate nurse.
Staff, who so desire, also take language lessons. These are important for communication with other international NGOs, and international doctors and health personnel within the project and at the hospitals we use. Members of our staff are fluent in one or more of the following languages: Khmer, Vietnamese, French, and English.
The First Project (1997-1999). In June 1996, Maryknoll, supported by CARITAS Switzerland, Catholic Fund for Overseas Development (CAFOD), and Catholic Relief Services (CRS) and, at the urging of the local Catholic community, opened The Seedling of Hope. The Seedling of Hope was designed to respond in a special way to the growing HIV/AIDS crisis in Cambodia. The response combined raising awareness with hands-on health services thus linking preventive efforts with active support for poor individuals with HIV/AIDS and their families.
These support services have included AIDS counseling, referrals to other services, free medical consultation and regular visits to home and hospital clients. The clients and their families are provided, in their homes, in the hospital, or at The Seedling of Hope Center, with encouragement, assistance in addressing physical care and family welfare issues, basic medicines, and a small amount of monetary support for food, medicine, and transportation.
Between June 1996 and January 2000, The Seedling of Hope:
The project evaluations in January and then December 1999 reported that The Seedling of Hope had exceeded its own goals and objectives, at times dramatically surpassing indicators of service. At the same time, the staff was struggling with ways to address the needs of increasing numbers of poor without family, friends, and often shelter.
Typically, individuals or families who once had been able to support themselves became too weak to continue to do so. The extended families of some were financially unable to assist, others unwilling to bear the economic or social burdens related to AIDS. The net result in both cases was/is abandonment. The Seedling of Hope responded to such individuals by increasing food allowances, renting housing, providing care-givers for the hospitalized or referrals to the hospice of the Missionaries of Charity. As time went on, it became increasingly clear that the response was inadequate both in terms of the clients' realities and as a teaching model.
Both reflection about needs of the abandoned poor during the evaluation exercises and the Government's own new initiatives, played an important role in project re-design. By mid- 1999, The Royal Government of Cambodia and the Ministry of Health had developed a national plan for STD/HIV/AIDS Prevention and Care in Cambodia.
The major focus of this plan is prevention and, while the Government acknowledges the importance of care for people with AIDS, capacity and resource issues act as major constraints to involvement other than through guidelines and regulations. Nonetheless, a collaborative World Health Organization and the Ministry of Health effort has resulted in the establishment of eight pilot home care offices around the city within existing Government health centers. Two of the participating NGOs were willing to take over The Seedling of Hope Home Care assigned area. Adequate lead time and hard work ultimately made a smooth transition possible at the end of the first project's three year period.
The Pilot Project (2000-2001). As the new century dawned, Maryknoll agreed to support a pilot project to address the needs of the poorest of the poor among the HIV/AIDS communities; thus permitting The Seedling of Hope to build on its strengths while experimenting with alternative ways to meet the needs of poor people living with AIDS and their families. The National AIDS office and Government officials were pleased with The Seedling of Hope's new direction. The necessary arrangements were made so that the first project terminated December 31, 1999 and the Pilot Project began January 1, 2000.
The Seedling of Hope is now located in Chakangre Krom, which edges the city along the Bassac River. It is a densely populated area dotted by factories but as yet almost devoid of social services. Like many communities near the river, Chakangre Krom is home to both ethnic Khmer and ethnic Vietnamese. This location provides the opportunity to serve the poor of both ethnicities and in so doing build bridges, at least among their sick, between them. The Seedling of Hope cooperates closely with the only other NGO in the area with related interests, the Servants of the Urban Poor, as well as with a wider network of AIDS projects throughout the city.
The HIV/AIDS awareness activities, home and hospital visits, food and rent subsidies, and clinic services have been continued. Many of the old staff have been re-hired and the project benefits from the volunteer services of two expatriate doctors. In addition to its traditional services, The Seedling of Hope has opened a 12-bed hospice for clients without friends or family who are no longer capable of taking care of themselves. The hospice is generally full and the clients are well know to us or to the Servants of the Urban Poor, or the Missioners of Charity, or other NGOs working with AIDS. Prior worries about criteria for selection of patients, particularly, economic status and existence of family have proved unfounded.
In May 2000, The Seedling of Hope opened its first group home for the poor clients with AIDS and no family but who are still strong enough to care for themselves with minimal assistance. Shelter and reasonable nutrition remain the most practical methods of extending a reasonable quality of life. Another alternative being explored is the placement of AIDS clients who still can care for themselves in foster families in the community.
New ideas for the multi-purpose The Seedling of Hope Center are also being trialed. Not only does the Center host our clinic, our administrative services, our one hour daily staff meetings, but it also serves as a "workplace" and social support center for our clients. Maryknoll has donated a number of sewing machines for those of our clients who are still strong enough to sew. The international community and the working poor who run the local sewing shops, have donated materials.
Some of our clients collaboratively make bed covers and as the covers are sold each of the sewers will have a little money for their families. Others crochet cloths used in the hospice. While the objective here is not long-term income generation, the intent is to build self esteem, promote peer support, and facilitate self-support when clients feel strong enough to work. Longer-term objectives are not feasible since most of our regular clients already have full-blown AIDS.
Education for awareness about sexually transmitted diseases, including HIV/AIDS, remains an important priority. Twice a week, staff provide training in the neighborhood and to factory workers. The young girls in the garment factories are a special concern. They leave their homes in the provinces with little schooling. They become the family wage earner and send most of their money home. Those without family in the city live at the margin. Ignorance, poverty, and loneliness place them at high risk for HIV/AIDS.
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