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First published in Hospitals & Health Networks OnLine, April 3, 2007
A visit to Cambodia and a glimpse of its health care services, still recovering after decades of war and repression as well as ongoing poverty, raises questions about the ironies of history and the nature of social responsibility.
I spent a week or so in Cambodia at the end of 2006. I went to see the temples and other antiquities in the Angkor area around the provincial capital of Siem Reap. That part of the trip was wonderful. But I also was interested in the health care system (or the lack thereof), and that led to an equally profound experience.
First, a bit of history is necessary, even if it is only a gloss of a very complex situation. Between 1969 and 1979 (and, to a lesser degree, until 1998), largely as an offshoot of the war in Vietnam, the neutral nation of Cambodia suffered at the hands of China, North Vietnam, South Vietnam, the Soviet Union, Thailand, the United States and, at times, its own government. It was carpet-bombed and invaded; parts of it were occupied; and its longtime leader, Prince Norodom Sihanouk, was overthrown by an unpopular military coup in 1970.
The resultant destabilization led to the takeover of the country in 1975 by a Marxist-Leninist Cambodian group known as the Khmer Rouge, which was led by a shadowy figure who used the name Pol Pot. He and other Khmer Rouge leaders had a nightmare vision of a totally egalitarian, one-class, agrarian society where everyone worked in the fields. They emptied the cities, murdered educated Cambodians wherever they found them, and were responsible for the deaths of an estimated 2 million people. The slaughter finally stopped when Vietnam invaded Cambodia (not for the first time) in 1978. The Khmer Rouge were driven back to isolated parts of the country, but intermittent fighting went on until the late 1990s. Cambodia is now a titular democracy.
The Khmer Rouge closed Cambodia to virtually all outsiders, but information about what was happening still leaked out (although it was largely ignored by the international community). Part of that information was that Cambodia's health care system, which had been rather threadbare to begin with, was being destroyed.
This didn't make much sense; it would seem that even if you were hell-bent on murdering anyone who had an education, who could read, who spoke a foreign language, even those who wore glasses, you still had soldiers and civilian cadres who would need health care. But Pol Pot's lunatic vision included a deep-seated hatred of anything considered "Western," including health care, so he ordered that only traditional healing practices and materials be used.
In his history of the Cambodian holocaust, Sideshow (Touchstone, 1987), William Shawcross describes what happened in Phnom Penh, Cambodia's largest city, when the Khmer Rouge marched in on April 17, 1975: "Toward the end of the morning a platoon of the young victors marched into the grounds of the Preah Ket Melea Hospital. Most of the doctors had already fled, and here, as in most other hospitals, patients lay untended in filth and agony . . .
"The soldiers marched through the wards, and then they ordered all those patients who could walk to get off their beds and push out through the doors those who could not move. And so, in the heat of the day, a most dreadful parade began.
"From hospitals all over the city crawled and hobbled the casualties of the war, the first victims of the 'peace.' Men with no legs bumped down stairs, and levered themselves on skinny arms along the street; blind boys laid their hands on the shoulders of crippled guides, soldiers with one foot and no crutches dragged themselves away, parents carried their wounded children in plastic bags that oozed blood. Beds were pushed slowly, jolting along, the blood and plasma bottles breaking." Virtually none of the patients survived.
Those who had provided care fared no better. One of the few observers, Andrea Panaritis (now executive director of the Christopher Reynolds Foundation in New York City), reported that more than 500 physicians were practicing in Cambodia at the time of the Khmer Rouge takeover; by 1979, there were only 45 left. Another report found fewer than 10. A 1995 article in the British Medical Journal reported that at the time of Pol Pot's fall, only 25 physicians and three staff members at the Ministry of Health were still alive. Hospitals that had not been flattened by years of U.S. bombing were destroyed intentionally. Most clinics suffered the same fate. A large proportion of the 2 million who died were killed by untreated disease or injury, including the effects of 13 million land mines planted by the various combatants over the years.
In his second book about Cambodia's fate, The Quality of Mercy (Simon and Schuster, 1984), Shawcross relates how greetings among friends changed over time. When Sihanouk was in power (he was deposed by General Lon Nol in 1970), the greeting was, "How many children have you?" During the Lon Nol years (1970-1975), a friend would be asked, "Are you in good health?" Under the Khmer Rouge, the whispered question was, "How much food do you get in your cooperative?" After the Khmer Rouge were overthrown, friends would ask each other, "How many of your family are still alive?"
It was a question I asked the Cambodians whom I met and who befriended me. Everyone had lost family members. My guide said, quite matter-of-factly, "You couldn't avoid that."
The road back for Cambodia's health care system has been slow and difficult. Once peace was restored, the rushed, substandard training of the first health care workers produced only marginally competent personnel. Wages in public hospitals and clinics were so low that many caregivers spent most of their time in more lucrative, if technically illegal, private practice. Many Cambodians feared formal health care settings.
With poverty rampant and formal care prohibitively expensive, traditional healers, sellers of dubious patent medicines and untrained local caregivers were often the only alternative. A 2004 study found that out-of-pocket payments for "Western" health care could exceed a family's annual income, often forcing the sale of land, cattle or other essential belongings and driving families deeper into poverty. (In 2004, according to the World Health Organization [WHO], government funds accounted for 15 percent of health care expenditures, out-of-pocket funds 72 percent and other private sources 13 percent.)
Furthermore, corruption was rampant, with a great deal of money--much of it donated from abroad--skimmed off before it reached hospitals or clinics. Some observers reported that physicians and nurses demanded bribes before providing critically needed treatment.
To its credit, the Ministry of Health has worked diligently to change this dismal situation. Non-governmental charitable organizations (NGOs) were contracted to run many clinics, with impressive results; in an interesting echo of American "pay-for-performance" experiments, the NGOs are paid on the basis of improved outcomes such as higher inoculation rates and lower infant mortality.
A large number of international organizations, including Health Net International (Netherlands), Médécins Sans Frontières (France and other nations), UNICEF, WHO and Save the Children (Australia and elsewhere), have participated in efforts to upgrade the health care infrastructure, aided by funding from the Asian Development Bank. Indeed, over a hundred Cambodian and international NGOs are active in the health care sector.
There are signs of hope in many places. The Jayavarman VII Hospital for Children in Siem Reap provides free care for children ages 1 to 5. The Sihanouk Hospital Center of Hope in Phnom Penh is as state-of-the-art as one might find; unfortunately, it cannot begin to care for all the non-emergency patients who seek care, so the patients came up with the idea of a daily lottery. About 10 patients per day win the right to receive care--out of dozens. Both public and NGO-directed clinics are showing better outcomes.
I was starting to feel better about how things were going when I saw the sign outside the children's hospital in Siem Reap: ACUTE OUTBREAK OF HEMORRHAGIC DENGUE FEVER; PLEASE GIVE BLOOD. Just in case I might forget I was in a country whose health care system and health status are still hanging by a thread.
Cambodia's infant mortality rate is 95 per 1,000 live births; its maternal mortality rate is 590 per 100,000 live births. Life expectancy for men is 55; for women, 59--still, a great improvement over 30 years ago. Common causes of death include tuberculosis, smallpox, malaria, diphtheria, typhoid, dengue fever, cholera and AIDS, although that last disease is cloaked in a veil of denial and lack of reporting.
One cannot help but be moved by the international outpouring of assistance for rebuilding health care in Cambodia. The Siem Reap children's hospital was donated by the Swiss; foreign donations fund the Sihanouk Center of Hope. One sees plaques or acknowledgments of help from Canada, France, Germany, Japan, the European Union and many other sources, including several U.S. NGOs.
What one does not see is evidence of assistance from the governments of the countries whose actions led to the destruction of much of Cambodia's infrastructure. I saw no signs of official help from China, Russia, Thailand, the United States or Vietnam, although I was told that Vietnam has done some good, which is appropriate, given that it invaded and essentially occupied Cambodia for years.
In trying to understand why the desire to destroy seems to have been stronger than the desire to rebuild, I asked a friend about the disparity. She replied, "Cambodia doesn't have anything the United States wants."
Maybe so. But Cambodia never did anything to the United States, and it seems a pity that we are unwilling to try to repair some of the human damage we did, especially bombing the country's hospitals and laying land mines that we did not go back to retrieve. Nations that were not involved in the Cambodian tragedy have been willing to help in reconstructing its health care system; it is those that had a hand in its destruction that are distressingly absent.
It can be argued that some of these countries have health care infrastructure problems of their own, and it is a valid argument. But we have no such defense. The Cambodian clinics that are saving countless lives are doing so for $4 per person per year--as one reporter noted, "what a couple of aspirin tablets would cost in many American hospitals." We spent $2.1 trillion on health care last year. When health care is allowed to become a commodity, the collateral damage can be felt halfway around the world.
On the path to the temple of Ta Prohm in the Angkor district, I heard beautiful music playing. It was being performed by a group of musicians who had all lost limbs to land mines; they did not have prostheses, which are expensive and out of the financial reach of most Cambodians. I made a donation and bought their CD, but that would not restore their arms or legs or get them prostheses.
On the airport road in Siem Reap, a beautiful new hospital is being built. It is a joint for-profit project of a Thai investment group and Bangkok Airways (which led one Siem Reap resident to quip that if patients need to be evacuated, the airline can call the flights the Distress Express). One of my Cambodian friends told me the hospital would take only cash, not even health insurance, which means nothing to the locals, who have little of the former and none of the latter.
In New Orleans, Charity Hospital of Louisiana, one of the two oldest public hospitals in the United States, was so badly damaged by Hurricane Katrina and subsequent flooding that it will not reopen. A bitter political fight has broken out over what should replace it. Meanwhile, those hospitals that are open struggle to care for the massive number of uninsured residents of a city that is also trying to rebuild its health care system.
We all have our priorities, I guess.
First published in Hospitals & Health Networks OnLine, April 3, 2007
© Emily Friedman 2007
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