CAMBODIAN REFUGEE CAMP, NOVEMBER, 1979 © Keith Dahlberg
A Bit of History first: In late 1978, Communist Viet Nam invaded Communist Cambodia; the war reached full intensity in 1979. Viet Nam's army was much better equipped, and soon had control of much of Cambodia's territory. At the beginning of the rainy season (about May, 1979) the remnants of Cambodia's Khmer Rouge forces were mostly bottled up in the sparsely populated, forested hills of southwestern Cambodia, across from the Thailand border. Each side had destroyed rice fields in attempt to deny food supplies to the other, and the million or so refugees in the hills had little to eat but leaves from the trees during the five-month stalemate of the rainy season. That was also the time of year when malarial mosquitoes were most numerous out in these forests.
When the rains ended in October, Viet Nam's tanks could advance again, and hundreds of thousands of sick and starving Cambodians flooded over into Thailand. The world's newspapers were full of pictures of nearly-dead Cambodians, too weak to move their match-stick limbs. T hai military forces mobilized, and set up make-shift refugee camps away from the border in case the Vietnamese crossed over in hot pursuit. World response would eventually be massive, but took a couple of weeks to organize and arrive.
Our Hospital at Mae Sariang was an early responder
Fall harvest time was never very busy at our hospital in northwest Thailand, some 600 miles from the Cambodian border. Patients don't want to leave their fields unless they are very ill, so our staff had some time on our hands. Seeing the horror stories in the press, we offered the Mission Refugee Committee some time if they needed us. A telegram quickly came back asking for as many of us as possible to come right away to work on the Cambodian border.
Half the hospital staff wanted to go. Nurses said they would farm out their children; one even offered to wean her baby immediately. But of course the hospital had to be kept running too. Five finally went: Lois, Rosa, and Mala, all nurses, and Weena, one of our best nurse aides, and I as doctor. The telegram came October 25th, and we were on the bus to Chiangmai next morning to catch the overnight train to Bangkok. Pat and Bob Coats, former neighbors in Mae Sariang who now worked at mission headquarters, had us all to breakfast, thoughtfully inviting our daughter, Nancy, a boarding student at Bangkok's International High School.
We were to be on loan to CAMA Services, Inc., the service arm of the Christian and Missionary Alliance mission, which had long worked with Cambodians. At their office later that morning, we met our future coworkers and learned that the Thai Military had just opened a large new refugee center at Sa Kaew, about sixty kilometers from the Cambodian border. The Red Cross had set up a hospital there with several medical teams; CAMA had a permanent medical team coming from the Netherlands, but it would not arrive for two weeks. Several CAMA workers had helped in the search for refugee groups along the border near Aranyaprathet, and reported thousands scattered here and there in the bush, many dying or too weak to walk. These were mostly people pressed into service by the Khmer Rouge, whose army remnants were backed up against the border. There were probably ill soldiers among the refugees, too, but those capable of fighting were still inside Cambodia.
Sa Kaew Refugee Camp I.
It' a three-hour minibus trip from Bangkok to Sa Kaew, good highway through farming country where the vinegar smell of drying tapioca overlies everything. (Thailand is known for its rice production but tapioca is also an export, to Europe for cattle food.) Our guide said we might as well stop at the camp before going on to our living quarters in Sa Kaew town, ten miles farther on, so the minibus pulled off on to a dirt road where armed guards checked all traffic.
Our first impression was barbed wire and mud. The camp was only in its fourth day of operation, and appeared to be a bulldozed area in the middle of swampy rice fields, where black-clad people stood behind a fence. We had to step from grass hummock to tree root to get around. At one point, Lois had to put her arm elbow-deep in mud to retrieve a shoe.
The hospital area was on slightly higher ground, but was otherwise in chaos. We were introduced to someone who said, "Fine, go to work in that tent over there." That wasn't at all what we had had in mind; we'd been up since five a.m., some of the women needed a bathroom, and we weren't even sure where we were supposed to live. But the word was, "Work a little now, so you'll know the problems by tomorrow."
I transposed the next scene into my novel "Flame Tree" but it was real in 1979:
So I went into the tent indicated, where a harried-looking doctor was carrying a large cardboard box. Motionless patients were lying every which way on bamboo mats on the mud floor. We had to stoop to avoid the bamboo cross-pieces of the tent frame. His box contained a jumble of paper cups of pills, syringes, bottles of liquids, bags of intravenous fluid, 6 x 8-inch file cards, and a lot of other stuff. The first thing that happened was, the bottom of the box dropped out and everything slid among the patients. I went to find another box, finally dumping some bottles out of a carton I found in a supply tent. A patient needed a shot. I borrowed one from the more organized tent next door. The doctor I was assisting had only started work that morning. Two Red Cross doctors had already quit, he said, after working only two days. He looked at another patient. "The A on his arm means he's getting ampicillin. We'll give him another shot of it now."
"That's an every-six-hour drug," I said, "Who gives it at night when we're gone?"
Most of my three hours that first afternoon was spent trying to find things. The doctors in the far tent spoke French. The British lady presiding over a card table full of medicines in Tent. No. 1 was having trouble supplying her own patients, so I hunted among the unattended supply tents. I began to get dizzy every time I stood up; the heat was oppressive, and I was wet with sweat. The other members of our team were presumably off with other doctors. Several dead bodies, rolled up in the mats on which they had lain, were in a row between tents. No one paid them much attention. It began to rain lightly.
At dusk, our guide found us and told us to round up and move on. I found Lois away over in the orphans' tents, following a doctor with no more idea than I where to find the medicines he was ordering. Then the word went through the hospital, "They're unloading another convoy, come and help!" On the road outside the camp, we stood by a line of army trucks, helping down emaciated new arrivals who couldn't have weighed more than sixty pounds apiece. Most needed help to walk, and clasped bundles or cooking pots. Several husky young volunteers scrambled up into the truck to hand down a half dozen who made no effort to move. Some felt very hot to the touch. I found myself trying to hoist the mid-section of a large unconscious man onto a piece of cardboard. Four of us struggled through the mud to the fence and pushed apart two strands of barbed wire to hand him through to volunteers inside.
We were all bone-tired on the ten-mile ride into town. I admired the two Red Cross doctors who managed to last two whole days. We ate at a Chinese restaurant, and finally arrived at the house rented for us by CAMA. A lady introduced herself as Winnie, and said there was plenty of hot water and clean beds ready, dormitory style. It was Winnie and her husband, and Aree the cook, who made life possible for us those next two weeks. Other teams told us about their scrungy hotel rooms and worse food, and coming home too tired to fix any supper, but after our second day, we always had a hot meal waiting.
Up next morning at sunrise. Our CAMA team leader, Bob Jono, a twenty-something young man, told us we had our own newly-established tent to work in today.
Remembering the disorganization yesterday, we stopped in town to buy a couple of folding tables, plastic baskets, cups, tea kettles to carry water in, and five-gallon jerry cans to fetch it from the camp water tanks. We looked like we were on safari, moving through the hospital area gate. On subsequent mornings, we also carried cases of pop and big containers of crushed ice, to combat the heat exhaustion that had bothered us that first day.
The dead bodies were still there or, more probably, new ones. The most noticeable thing about entering the hospital was the lack of conversational background noise among the patients. No children cried, just a constant quiet undercurrent of coughing.
Our new tent, Ward 8 (someone later altered the numeral to depict a snowman-type figure gripping his belly), was ninety feet long by twenty wide. It held 150 sick human beings, and about 15 more had built little lean-to shelters outside the far end. Everyone was crowded in at random, lying on mats on the ground. Some had tags with notes about treatment they had received at the border; others had letters inked on their arms, standing for various medicines. Q must be for quinine; F for Fansidar (another antimalarial drug, and we had no idea what some of the other letters meant. We had no translator for the first two or three days, and the patients spoke only Khmer. Anyone with education was not about to let the Khmer Rouge among them know it. It is said that Pol Pot's government summarily shot those wearing eyeglasses, because they presumably had education. The Khmer Rouge brave new world had no use for any schooling other than their own indoctrination. Those first few days, no refugee wanted to call attention to himself by being the first to do anything. Even the clothing was uniform black shirt and pants, with a checkered violet and white head cloth.
Lois and I, with a clipboard and basket of medicines, started on the nearest patient. We marked a number 1 on her arm, listened to her chest, felt her abdomen, gave her antimalaria treatment, vitamin B complex and iron, and moved on. Patient number 4 had diarrhea. There were no bedpans. Those strong enough to crawl went to the little ditch at the edge of the tent. Weaker ones lay where they were. There were no clean clothes to change to; that first day, there wasn't even a rag to wash her with. We found some old newspapers to put under her, gave her paregoric and an antibiotic, and started a bottle of intravenous fluid, hanging it from the tent frame with a piece of bent wire.
We moved slowly down the tent . Some had massive swelling of their bellies and legs from protein deficiency. Many were burning with fever, most probably malaria or pneumonia. Some were dead white (inner eyelids, tongues, and nails) from severe anemia. Many had beriberi (vitamin B-1 deficiency) and were too weak to stand up. Several had deep ulcers - bedsores from lying for days in one position out in the jungle. Children lay listlessly, or had a futile try at their mother's dried-up breasts. Some had arms and legs about as big around as my thumb.
I felt a dull bitterness inside me toward leaders who make war and let other people pay the price. But mostly there was only time for squatting down again to listen to another chest, feel another spleen, start another intravenous bottle. Muscles ached from the constant squatting, kneeling, and bending. In later days, we ate all the lunch that Aree and Winnie packed for us, but that first day the scene was still too new; we weren't hungry. Somewhere in that day, an American Embassy doctor pitched in and helped, but when it was time to go, at sunset, we still hadn't seen everybody.
Bob Jono and I had to stay after dark to attend the nightly staff meeting, where the days problems were ironed out. At that point, I couldn't have been less interested. When I learned that each group had to provide a doctor and a nurse every five nights to cover the whole 1,200-bed hospital from 6 p.m. to 8 a.m., I thought, "I'm finally getting too old to take it anymore!" (I was 50.) We got back to town about 7:30, ate supper and fell into deep sleep.
But as we weathered the first few days, things began to get better. We got a small tent in which to keep our medicines and eat lunch. We built up our medicine supply, and what we didn't have we knew where we could trade. Bob found us a Khmer who spoke fluent Thai and a little English, and we began communicating with our patients. Weena mass-produced milk and protein gruel and passed it around all day long by the bucket-full to supplement the rice and soup that came from the camp kitchen twice a day. We got so we could finish morning rounds by three p.m., and one afternoon we cleaned out the dirtiest mats and had the patients lie in three rows with space to walk between. We discharged enough patients back to the main camp (population about 25,000, one of many camps) to bring our tent's count down to one hundred, and moved all the outside patients in under the tent. We shared medicines and nurses with Tent 9A next door, where a couple of American doctors on loan from some research group were getting reacquainted with clinical medicine. And the tent grew noisier. People had strength enough to talk now, sometimes even smile. One little girl with diarrhea and pneumonia, with no one to look after her at night, whom we left each evening not expecting to see her in the morning, sat up one day and began crying something. Tann, the interpreter, grinned and explained, "She's saying she doesn't want that old soup, she wants a fish!" We not only found her a fish, but a banana too.
Excitement broke out at the far end of the tent one afternoon. Another little girl, who had been separated from her family a year ago, suddenly spotted her father and sister walking by outside.
There were discouraging things too. People who couldn't be persuaded to eat, comatose patients who sank lower and lower and finally died quietly, a few days after reaching this sanctuary. (Miserable as camp conditions were at first, camp was a big step up from starving in the hills.) Death came so quietly sometimes that the first sign was dozens of body lice deserting the body. I suppose they sensed the dropping body temperature. We had about one death a day in our ward. The record for the whole camp was 42 deaths in one day, but usually it was around 15 or 20.
We got to know many of our patients, after a fashion. (Asking about personal history was taboo. There were still Khmer Rouge agents around.) There was the mother with three kids, who hated shots worse than they did; the cripple on crutches who led his blind friend with a stick; the young man with TB. The pretty young girl with cerebral malaria who developed a bed sore overnight when she was comatose and there was no one to turn her. And the old man with the gradually healing sores on his legs.
Our long-time friends, Marnie and Dick Gregory came out from Bangkok one day to bring us food. (Marnie was always concerned that her friends got enough to eat.) As I saw some of the patients gazing admiringly at Marnie's large figure looming outside the tent, I reflected that it must have been years since the Khmers had seen an obese person. I told one of them that this was what three months of our medicines could do for them, but I think it got lost in translation.
After we had been there a week, a team of Israelis took over the tent next door from the departing American researchers. The new team resembled the cast of Fidler on the Roof, if you can imagine that cast dressed in green surgical scrubs emblazoned with a red Star of David. They were very competent army medics and soon had a receiving ward that accepted hospital admissions and stabilized them before distributing them to the rest of the wards. The camp outpatient tent saw several thousand patients daily (and I use the word "saw" advisedly.) The outpatient team had only one or two doctors and nine nurses, so the new screening ward was a real help. The Israelis were a friendly lot. Unfortunately, the first day, they came to camp without lunch and we had only ham sandwiches to share.
The hospital as a whole, now down to only a thousand patients, was under the joint direction of the Thai and International Red Cross, but there were six groups more or less working independently, each with one or two tents. Besides the Red Cross, there was the French Medicine Without Borders, World Vision, CAMA (us) and the Israelis. A group of Catholic sisters staffed the hospital kitchen and took care of about four hundred orphans. A nearby Buddhist monastery volunteered to bury the dead. A German doctor had a special nutrition unit, and a lab tech from somewhere opened up a blood bank that I'm sure saved many lives. He drew blood from visitors to the camp; no one would talk to news media unless the reporter could show a receipt for blood donated. Each pint was split into two half-units. But when your blood hemoglobin level is around 2 grams (normal is 12 to 18) even a half-pint can be significant. The French had a labor and delivery room in their ward. Full-term babies born at camp mostly weighed only 3 or 4 pounds.
And everywhere there were volunteers who came in from Bangkok on a day-to-day basis. The American Embassy sent a daily bus; others drove their cars. Our daughter Nancy and some of her high school friends came out on Saturdays, and donated their annual "sneak" day to the camp. Some took over the job of cleaning diarrhea patients. (there was new clothing and blankets available by then.) Others spoon-fed the weak. Some ran errands, or helped discharged patients get settled out in the main camp, or passed out food. One afternoon I found each patient in the tent holding a hard-boiled egg (which not all stomachs were up to handling); another day each had an orange, or a loaf of French bread. One elderly European, with whom I could communicate only in Thai, simply stayed in the tent next to ours all night, watching over an especially sick Khmer he had sort of adopted.
A few came only to sight-see. Politicians arrived in helicopters that blew dust in our faces. The French ward got some people one day who wanted to feed the patients lunch. The doctor explained that they had already had their lunch, but that some were badly in need of a bath. The visitors said they didn't come to do that kind of work; they just wanted to feed people. We had a couple of Thai students who mostly just drank our pop. But another Thai girl student stuck with an old lady who was too listless to eat, and kept spooning gruel into her. "She's not going to die, is she?" the student kept asking nervously, "I don't want to see anyone die!" Yet three or four days later when another patient died, it was the student who rounded up stretcher bearers and saw the body to the morgue tent. The Khmer refugees themselves had teams of women (Khmer Rouge medics, we were told) who helped in bathing and feeding. Like the Bangkok volunteers, some were very good, others not so useful.
As time went on, CAMA had other doctors and nurses arrive. One doctor-nurse couple from Brazil, two doctors from the U.S., a missionary couple from Paris who could speak Khmer. Another young Khmer girl came from her home in New Zealand, terrified that the Khmer Rouge would try to murder her. We always had 2 doctors in our tent now, and sometimes three. Our tent received maybe ten new patients a day (refugees were still arriving from the border), but others were getting well enough for discharge so that they no longer had to lie shoulder-to-shoulder.
The World Discovers Sa Kaew
Sa Kaew was among the first camps, at the most dramatic time, and had been operating almost two weeks. There were now so many cameras and reporters around that we became quite blasé. A man with a microphone squatted beside me as I worked with an unconscious boy and asked me to describe the case. That night I was on Voice of America, I am told. Another night an NBC television crew taped our team with a little girl who was too weak to walk. I was introduced as a "malnutrition expert" (for which read, "the only doctor available who had been in Asia awhile and who had an American accent.) I described the refugees by likening the situation to being stranded in a blizzard; when the firewood pile is all gone, you break up the furniture to keep warm, and finally even burn parts of the house itself.
I remember I kept my feet tucked under me while on camera so no one back home would see how swollen my legs had become. The up side was, the broadcast was repeated several times in America and Europe, making it the only time in my life I ever sent a message to perhaps a hundred million people.
Not everyone back home realized that Lois was also on TV, her back to the camera. when Rosalynn Carter walked through our tent and paused to ask her a couple of questions about the patients. Lois's most memorable phrase that morning, however, was addressed to the retinue, where reporters were three deep at the side of the tent, shouting "Get down! Get down!" so they could get a clear shot of Mrs. Carter. Lois remarked, to no one in particular, "If the reporters would move back a little, they wouldn't be standing in the patients' latrine ditch." A lady near Mrs. Carter said ,"Oh dear! I wish I had known that a little sooner." And a Secret Service man grinned to Lois, "Say it louder. We're being recorded."
I missed the Carter tour; being back in town that morning to lecture an incoming group of Southern Baptist doctors on tropical medicine and what to expect in the new camp to which they were going. ("Two weeks ago I couldn't even spel ekspert and now I are one!") I had my own excitement of a lesser sort that night, when the sound of gunfire woke me. A passing policeman had surprised some men who were stealing the medical supplies stored under the CAMA house. The thieves got away with one case of I.V. fluids.
That second week we were still dog-tired, but felt like we could make it, even with hour-long staff meetings making me late for supper. Some of us even took a turn at night duty. Rosa Crespo was managing the pharmacy and supply tent, by this time, and Ruth Jones, whose husband was mission treasurer, came out from Bangkok as an extra nurse for the ward with Lois, Mala and Weena. Lois and Ruth and the interpreter and I did the fourteen-hour night shift one night, watching over the whole hospital. (The Thai army maintained a security curfew over the camp during these hours, but allowed one medical team to stay.)
There isn't much you can do for one thousand unfamiliar patients. Most of the ward aides were sound asleep. That's not unusual in Asian hospitals; family members are expected to maintain watch, but most patients here had no family. We toured all the wards every three hours, re-started a few I.V.s, and carried out two dead bodies (whose beds were shared by other patients.)
I gossiped with the Israeli medic (who was allowed to staff the 24-hour receiving ward) as we took a breather, about midnight, watching the all-night drilling crew working on the deep-water well, and the linemen installing lighting atop some very tall poles. In a conversational pause I said, looking up at the linemen, "Haman built a gallows, fifty cubits high . . ." The startled Israeli exclaimed, "How did you know what I was thinking! How did you come to know that story?"
"Hey," I said, "the story of Esther is in our Scriptures too."
We watched a couple of labor cases in the French tent (and were glad they waited until after 8 a.m. to deliver.) We cleaned up one teen-age boy who was bloody diarrhea from the waist down. Four wards had moved out of their tents into semi-permanent buildings by then, with bamboo walls and gravel floors. For some reason, though, the contractor had omitted sanitary facilities, and the gravel floor was getting pretty brown in places. Anyone sick enough to be in the hospital was too sick to make it out to the open pits along the perimeter fence.
Our Relief Arrives
We left Ward 8 in the hands of a lady named Eva Hartog, a TV personality from Holland, who brought out a team of eight Dutch nurses to work with the three American doctors who inherited our tent. The nurses had spent the last two years in Bible school, and were a little uncertain about giving an injection, but we heard later that they were doing fine. The whole hospital soon moved into the new type buildings, and a letter some days later remarked about the first day where there wasn't a single death in the whole camp. New waves of refugees continued to come in, some with war wounds, and the Sa Kaew camp hospital opened a small surgical unit. The day we left, epidemic meningitis threatened the camp, but few cases developed.
On our last day, we remembered to take some photos of the entire camp with its sea of blue plastic "tents" supported by sticks, now swollen to some 35,000 people. Now the patients visited back and forth; kids were playing games or standing in line for milk, wearing their tin bowls on their heads. Some refugees had overcome their fear of the Khmer Rouge and had accepted new clothing in many colors. The little girl featured on NBC's program because she was too weak to walk, squealed in mock terror and ran when her sister told her I was coming to give her a shot. It's good to know that we made a difference, but I don't mind admitting that all of us were glad to get away and rest.
Maesariang Christian Hospital's other doctor, Bina Sawyer, with Rosa Crespo and a couple other nurses spent a month or two at a newer refugee camp. Rosa was amused to note that some of the camp staff always parked their cars facing west, in case the Vietnamese tanks came roaring over the border. Someone advised not to worry about it, Bangkok traffic jams will stop even a tank column.