Starting from Scratch: Rebuilding a Health Care System

by Emily Friedman

First published in Hospitals & Health Networks OnLine, June 2, 2009

After 20 years of war, genocide and occupation, there was hardly anything left of health care in Cambodia. The story of how this tiny, largely impoverished nation is trying to rebuild — indeed, re-create — its system of care has lessons for those who seek reform in the United States and elsewhere. (First of two parts.)

Emily Friedman

On March 18 of this year, we marked the 40th anniversary of the beginning of the organized American bombing campaign in Cambodia. On April 17, we marked the 34th anniversary of the fall of Phnom Penh, the Cambodian capital, to the murderous Khmer Rouge. Few people in the United States seemed to notice (or perhaps they just didn't want to be reminded). But whether we remember or not, the consequences of these traumatic events still reverberate.

Loyal readers of this column (you know who you are — all 12 of you) will recall that I wrote an earlier piece about Cambodia entitled "Other People's Health Care," which was published in what was then Hospitals & Health Networks OnLine on April 3, 2007. But it was a cursory look, something of a glancing blow; I had taken my first trip to Cambodia and observed some things that distressed me, so I wrote about them. It was, I now realize, a somewhat uninformed effort. Nonetheless, I am repeating (or updating) some information here that was in that piece, for the benefit of those who did not read it then.

I have been back to Cambodia three times since that first visit, and have spent a good part of my time there learning more about the efforts to rebuild its shattered system of health care — although the word system, which barely applies to the U.S. health care sector, is even more inappropriate when used in the context of Cambodia. I have learned much about this unique situation, and, given current enthusiasm for substantive change in the U.S. "system," I thought that there are lessons from the Cambodian experience that might help inform our efforts here.

I want to emphasize, however, that this is not a scholarly study; there are plenty of those, conducted by people who are far more deeply involved in, and have a far more intimate knowledge of, health care in Cambodia. What I report here comes from my own observations, interviews, site visits and research, and as such reflects my own highly subjective views. All opinions voiced here, unless attributed to a specific individual, are my own.

A few technical notes are in order. First, traditionally, Cambodian names are written surname first, followed by given name. However, many Cambodians are adopting the Western practice of given name first, followed by surname. This can lead to confusion on the part of Westerners like me, who cannot always recognize a Cambodian surname as being such upon hearing or seeing it. As a result, in order not to insult those people who were kind enough to speak with me during my visits, I am using their full names.

Also, in some cases, I do not use my source's name but rather report the information anonymously. This is simply to protect people from any negative consequences arising from our discussion of sensitive or delicate issues.

Last, health care statistics for Cambodia are wobbly on their best days; I report some data here that conflict with each other and that are somewhat suspect. That's just how it is.

Finally, for the most part, if Americans are even aware of Cambodia, they think of it as a country where millions of people died in an insane auto-genocide some time back, a story told in the award-winning 1984 film The Killing Fields. Cambodia is usually thought of as tragic, a place filled with death and suffering. That was true from 1975 to 1979, and to a lesser but still significant degree, during the entire period from 1969 to 1989 life there was exceedingly difficult, and death was commonplace. For many people, that is still the case.

But that is not the whole story, by a long shot. To one degree or another, life has improved for much of the population. And Cambodia is a beautiful land with lovely rivers; a huge freshwater lake with a large bird reserve; verdant national parks; an extraordinary region of ancient temples that includes Angkor Wat, the largest extant religious structure on this planet, and the mysterious and haunting ruined temple of Ta Prohm; many impressive pagodas and temples; the amazing buildings and grounds of the Royal Palace, including the breathtaking gold-filled Throne Hall and the legendary Silver Pagoda; and a national museum that contains one of the largest and finest collections of ancient Buddha statues in the world.

Cambodia has superb urban hotels, excellent restaurants, exquisite handicrafts and extensive shopping opportunities. Its cuisine is wonderful, influenced by its French colonial heritage, its neighbors Thailand and Vietnam, and its own ancient culinary traditions; I think Cambodian rice is the best in the world (and I'm a rice junkie).

In four visits there, I unfailingly have been treated with civility, gentleness and respect. People who did not know me have done me huge favors — I mean, huge favors. I have been invited to private homes, had lovely meals cooked for me, and have been hosted at dinners, picnics and barbecues. I even got to participate in a traditional wedding celebration. (You should have seen me marching in a parade carrying a ceremonial tower of betel nuts! On second thought, maybe not.) I have come to love Cambodia, and if its health care system is not what it might be, well, neither is ours, although we are in a much better position to improve it. I intend to return, and I hope you will visit there as well. I say all this because nothing that I write here is intended, in any way, to diminish the wonders of this magical country.

This article, and the one that will follow, are dedicated to the memory of Dr. Haing S. Ngor, a physician who survived unimaginable cruelty and loss at the hands of the Khmer Rouge. He went on to tell his country's story as a lead figure in The Killing Fields film, won an Academy Award for best supporting actor, and was murdered in 1996 near his home in Los Angeles, allegedly in a random attack by street gang members, although many of us have our doubts about that. It is further dedicated to all those health care folk, Cambodians and others alike, who struggle to improve the health of the Cambodian people, in their country and ours, despite all the obstacles they face on a daily basis.

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All changed, changed utterly:
A terrible beauty is born.

William Butler Yeats
"Easter, 1916"

Cambodia, as one writer put it, has always been a victim of its location. With the exception of a bit of seacoast, it is totally surrounded by Thailand on the west and north, Laos on the north, and Vietnam on the east and south. A thousand or more years ago, it was the boss of Southeast Asia; the Khmer Empire ("Khmer" is the name of the largest ethnic group in Cambodia, as well as the official language) once encompassed present-day Cambodia as well as much of present-day Thailand, Vietnam, Laos, Myanmar (Burma) and Malaysia, and a hunk of China. But the empire fell apart, as empires do, and eventually Cambodia shrank into the smallest nation in Southeast Asia.

In the early 1800s, Thailand (then Siam) and Vietnam agreed to divide what was left of Cambodia between them; it might well have disappeared entirely if the French had not agreed to save it by making it a protectorate — in effect, a colony — in 1863, a situation from which Cambodia extricated itself (peacefully) in 1953. Since then, it has all too often been a plaything for its neighbors and other countries; and that culminated, beginning in 1969, with disaster.

There are myriad books and articles about what happened (I offer some references at the end of this piece). I will focus on what happened to health care, and in a horrible way, it is simple enough.

In 1969, Cambodia was a neutral nation, and its wily head of state, Prince (formerly King) Norodom Sihanouk, who had managed to disentangle Cambodia from the French, had also managed to avoid getting it entangled in the Vietnam War next door. Unfortunately, no one told the North Vietnamese military, who, in order to escape American bombing, illegally crossed over into Cambodia and set up enclaves. The United States, in violation of international (and American) law, began bombing inside Cambodia along the border. The Vietnamese, who weren't stupid, simply moved farther into the country. Prince Sihanouk, clever as he was, didn't have much of an army and could not prevent these incursions, so he tacitly allowed them; soon, that would not matter.

For many reasons, some involving domestic Cambodian politics and some (rumor has it) involving the American CIA, Prince Sihanouk was overthrown in 1970 and replaced by Lon Nol, a delusional army general who proceeded to preside over a complete calamity. Prince Sihanouk, although corrupt and strange, had tried to keep Cambodia together; what Lon Nol wanted was a mystery, and he was just as corrupt and strange, if not more so.

In any event, the United States and the South Vietnamese, having failed to drive out the North Vietnamese by intense bombing, invaded Cambodia in 1970 in order to achieve their goal. They failed (by most estimations) and withdrew in 1971, although the United States continued its bombing campaign, soon engaging in carpet-bombing (saturation bombing) of virtually all of Cambodia, which ended only in 1973, by congressional mandate.

This is not a polemic against the United States alone, although its actions were illegal. There is blood on our hands, but also on those of the Vietnamese (North and South, not that it matters now), the Thais, the North Koreans, the Chinese and the (former) Soviets, plus a world community that looked the other way, as it has done so often before.

Civil war ensued. A small communist outfit that Prince Sihanouk had dubbed the Khmer Rouge ("Red" or "Communist" Khmers, whom I will hereafter refer to as the "KR," as everyone in Cambodia does) held itself out as the only faction willing to protect Cambodian integrity. It built its strength with the support of China and North Vietnam. In the face of the bombing, rampant corruption and intense KR recruiting, thousands of young Cambodians flocked to its banner, not all of them voluntarily. Meanwhile, Lon Nol's military was helping itself out by selling armaments to enemy forces, claiming that there were more soldiers on the payroll than there were and pocketing the difference, and generally fighting an incompetent war.

And the bombs kept falling; it is estimated that in a nation of 7 million or 8 million people, between 250,000 and 500,000 Cambodians died from the bombing (estimates run up to 1 million), and that the same number died in the civil war. Who knows? Soon, no one would be keeping statistics.

It was a multifaceted civil war, but the KR won in 1975. Their leader, Saloth Sar (known to the world as Pol Pot), was an intelligent, French-educated Maoist revolutionary who had a vision: a one-class agrarian paradise of peasants working on blissful communal farms, with no intellectuals, no upper class, no Buddhist monks, no corrupt politicians or generals. Others have had that vision, but Pol Pot had a twist: He figured the easiest way to establish his Nirvana was simply to kill off or "convert" everyone who wasn't a peasant. It was much easier to get killed than to be converted — if anyone was.

Death of a Health Care System (Such as It Was)

The Khmer Rouge began by emptying the cities, and, for some reason, they started with the hospitals. In his gut-wrenching memoir, Dr. Haing Ngor told of being in surgery, tending to an injured soldier, when a KR fighter burst into the operating room and ordered all the staff out — not just out of the hospital, but out of Phnom Penh. The soldier was lying there, under anesthesia, with a long open incision. Dr. Haing Ngor was forced to leave him to die. "All my illusions were gone," he wrote. "They had broken into the sanctuary of the operating room." I believe that he never got over that, although there was much worse to come.

It is important to understand that Cambodia didn't have the world's best health care system to begin with. The poor often died of whatever they contracted; they died in childbirth, of malaria, of Dengue fever, of infections of every sort, and from many other conditions. There were hospitals and clinics — Dr. Haing Ngor had a clinic and hospital privileges in Phnom Penh — but the French had never really allowed an educated middle class of any size to emerge.

So at the beginning of the civil war in 1970 (keeping in mind that all Cambodian health statistics are soft), there were probably only 500 physicians for 7 million or so people, and most Cambodians had no access to their services. There was a largely primitive system of clinics and hospitals, but generally, as most people lived in rural areas, they used traditional healers and midwives or just coped as best they could. "Western" health care was for the urban and well-to-do.

By the time the KR seized power in 1975, Cambodian health care was already in shambles. Although the United States did not mean to bomb hospitals or clinics, carpet-bombing is carpet-bombing, and when a bomber is given a set of coordinates, it tries to hit every square inch of the area. Most rural health care facilities were destroyed, not that they were anything to write home about. Civil wars are not exactly protective of health care facilities or practitioners, either. Phnom Penh, soon swollen to a population of perhaps 2 million as refugees flooded in, was spared, as were the priceless antiquities of Angkor. Not much of anything else made it through intact.

And the KR planned to do away with what was left, structural and human. If you are seeking to establish a Khmer peasant paradise, nothing "Western" (or Vietnamese, or Thai, or anything else, as it turned out) is acceptable. The KR made short work of whatever had survived, and that especially meant trained health care professionals.

In his memoir, Dr. Haing Ngor describes, in horrifying detail, what the KR did to him after he was captured and interned in order to force him to admit he was a physician, despite his claim that he had been a cab driver in Phnom Penh. He survived sadistic torture and illness; few other physicians or nurses did.

"We Don't Need Doctors Anymore"

Life in the camps was horrific; people died of direct murder, overwork, starvation (the most common cause of death), disease, torture and heartbreak (often in the form of suicide). Although a few clinics and hospitals were still operating here and there, they were not available to the camp prisoners, unless a bribe might be successful. (Bribery and corruption have long been features of Cambodian society, unfortunately, extending back to French colonial days; indeed, a common slang term for a bribe was bonjour, or "good morning" in French.)

Despite the vestigial survival of formal health care in a few spots, the official mantra was that traditional Khmer medicine was the only acceptable treatment. This was not followed scrupulously, and indeed, many Khmer Rouge cadre were aware of the usefulness of pharmaceuticals and medical devices; they just didn't have access to them most of the time.

When they did, sometimes they combined Western and traditional approaches with limited knowledge — and fatal results. Dr. Haing Ngor watched an uneducated KR "healer" kill an infant by injecting the child with a dose of Vitamin B1 hundreds of times greater than what was safe (probably with a dirty needle, to boot). Another alleged health worker told him that if a patient needed medicine, they would put coconut milk into an IV — again, in septic conditions.

At one political indoctrination session, a KR leader announced, "We don't need doctors anymore. If someone needs to have their intestines removed, I will do it. It is easy. There is no need to learn how to do it by going to school."

One ironic blessing is that there were relatively few pregnancies among the prisoners, simply because starvation tends to make women infertile. It has since been learned, however, according to Cornelia Häner, M.D., M.Sc.P.H., chief clinical officer at the nonprofit Sihanouk Hospital Center of Hope in Phnom Penh, that the children of women who starve during pregnancy tend to have very narrow and underdeveloped blood vessels. Even today, finding a vein in which to insert a needle or an IV in many adult Cambodians can be a difficult task.

But many imprisoned women did not survive childbirth. Dr. Haing Ngor was a noted obstetrician, but while a prisoner, he watched his beloved wife and their fetus die as she tried to give birth; she needed a cesarean section, but there was nothing with which to perform one — and to betray his technical knowledge would have meant instant death for all of them, including the nurses who tried to help.

Not surprisingly, Dr. Haing Ngor would suffer from periodic clinical depression for the rest of his life, long after he made it to Thailand and on to the United States. So would tens of thousands of other Cambodians who survived the horror. Typical of his thoughts during the KR period were, as he wrote, "If only I had time to fish and to gather foods openly, if only they didn't kill us, if only men like me had time to make love to our wives and raise our families with dignity and take care of our old parents [his mother had committed suicide and his father had been murdered by then] — if, if, if — I would have accepted my fate, and become a rice farmer with all my heart and soul." He was not even allowed that.

The Remains

The KR were barbaric, but they were also guilty of poor planning (which led to failures of rice crops and famine) and some really terrible decision-making; one of the worst examples of the latter stemmed from their lust to kill the Vietnamese. (Ironically, Lon Nol, who had usurped power from Prince Sihanouk, shared this hatred and engaged in genocide against Vietnamese people living in Cambodia during the civil war.)

Not content with trying to wipe out any Vietnamese still living in Cambodia (along with members of the Muslim Cham minority and other groups), the KR began crossing into Vietnam to kill people. Not a good idea; as the Americans and the French before them had learned, and as most people in Southeast Asia already knew, messing with the Vietnamese is not likely to meet with a good end. At that time, Vietnam had the most skilled and experienced military force in the region.

In 1978, fed up with cross-border incursions, the Vietnamese invaded Cambodia (again) with tens of thousands of battle-hardened troops. It did not take long to push the KR into isolated rural areas (although the KR took thousands of "war slaves" with them and continued to be a plague on the Cambodian people until well into the 1990s). The story of what happened with the KR is long and complex and continues to this day, as, more than 30 years after the fact, some of its surviving leaders are on trial in Phnom Penh for crimes against humanity.

The problem was not that the Vietnamese invaded Cambodia and freed most of it from the KR; as a Cambodian friend of mine says, "Anything would have been better than the Khmer Rouge!" (Indeed, there is a singularly beautiful memorial park in Siem Reap dedicated to the Vietnamese who died fighting in Cambodia.) The problem was that the Vietnamese wouldn't leave, and stayed as an occupying force for 10 long years until they began to tire of it and the United Nations coaxed them into departing and took over for a few years.

And, as historian William Shawcross has observed, although the Vietnamese weren't quite as brutal as the KR, they did impose a hard-line dictatorship of which torture and political murders were sometimes features. Another writer observed, "The Vietnamese occupation of Cambodia was benign only by Khmer Rouge standards."

If it weren't for bad luck, Cambodia would not have had any luck at all.

Once the KR were on the run, there was a huge rush to get out of Cambodia into Thailand (traditionally, the Cambodians have felt closer to the Thais than to the Vietnamese, in part because of a shared form of Buddhism that the Vietnamese do not generally practice). Many remaining educated Cambodians joined the flight, including a significant number of nurses, physicians and other health care professionals. It was a nightmarish transit that some did not survive. Border areas in Cambodia were — and are — riddled with millions of unmarked land mines, which to this day continue to kill and maim innocent civilians. In addition, bandits, KR stragglers and unsympathetic Thai soldiers lay in wait and killed many refugees. But some survivors, including Dr. Haing Ngor, made it through.

But that was only after Dr. Haing Ngor saw what had happened to his country. He wrote, "Cambodia did not exist any more. Atomic bombs could not have destroyed more of it than civil war and communism. Everything that had been wrecked by the civil war ... was unrepaired and further eroded — the flattened villages, the blown-up bridges, the roads cut with trenches, the washouts caused by the rains.... There were no telephones or telegraphs, no postal services. In Phnom Penh itself there was little or no water and electricity and little functioning machinery of any kind. No typewriters. Not even pens and paper. There had been deaths in almost every family in the country. Widows and orphans wandered about the countryside, dazed, too hurt to cry." And nearly 2 million Cambodians were dead.

Furthermore, he reported, "Of 50,000 monks, less than 3,000 survived and returned to their former temples [Buddhist temples, or pagodas, had been the center of Cambodian life]. Of 527 graduates of the medical school in Phnom Penh, about 40 survived.... Of the 41 people in my immediate family, only 9 survived."

After the KR defeat, pressured to remain and work in Cambodia by a former colleague and by government officials, Dr. Haing Ngor agreed to visit what was left of the provincial hospital in Battambang, a city in the northwest part of the country. He was appalled by what he encountered: "For a short while around 1977 a distinguished Western-trained doctor... had been allowed to practice there, but then the Khmer Rouge killed him and let the hospital slide into ruin. The laboratory wasn't functioning. There was hardly any medicine or surgical equipment. The patients flowed into the hospital endlessly, a river of the malnourished and ill.

"We walked into the delivery room and saw a woman in her seventh month of pregnancy in labor. She had broken her water many hours before, but the labor was making no progress.... Though the doctors and nurses were doing their best, there was nothing they could do. They didn't have the equipment." Suddenly besieged by crippling memories of his wife's death, Dr. Haing Ngor ran from the room.

He worked at the hospital for a while, and then fled to Thailand.

In 1979, it is estimated, there were between 10 and 45 physicians left alive in Cambodia, and few nurses.

Coming Back Slowly

To their credit, the Vietnamese did try to rebuild the health care system, in a way. They built clinics and hospitals and re-instituted health professions education. Unfortunately, the shortage of physicians and other professionals was so critical that short cuts were taken. As Yos Phanita, M.D., deputy director general of health in the Ministry of Health, told me, "They really shrank the curriculum." The medical school was re-established in 1981, he says, but students graduated after two years as "medical assistants," not fully trained physicians. He adds that throughout the 1980s, training improved, and a six-year medical school curriculum was instituted, although "medical assistants" were still being graduated.

From everything I have been able to learn, the shortage of properly (and continually) trained professionals is the worst health care heritage of the Cambodian disaster. As Dan Liu, executive director of the Sihanouk Hospital Center of Hope, says, this is "the bottleneck in health care in this country."

To paraphrase the clich� from the film Field of Dreams, if you build it and none of them are left, they won't come.

Dr. Yos Phanita is optimistic that within 20 years, Cambodia will have a sufficient supply of native physicians. But, he says, a maldistribution has already emerged, with most physicians practicing in urban areas while the rural areas remain underserved. Sound like any place you know?

Even today, there are only an estimated 30 physicians per 100,000 people, and they are concentrated in the cities.

Mean Chhivun, M.D., director of the National Center for HIV/AIDS, Dermatology, and STDs within the Ministry of Health, agrees that in the early days after the KR, many health care professionals were insufficiently trained. Although much progress has been made, he says, "The first issue is quality. The second issue is quantity. And the third issue is maldistribution of clinicians."

Training has improved greatly; the medical school continues to raise its standards, and there are several nursing schools. However, more than one observer told me that training of lower-level health care practitioners still lags, especially in rural areas. Some hospitals are involved in outreach programs to remedy this situation, but it is a significant problem.

A Multi-Tiered Arrangement

The institutional "system" that has emerged has striking similarities to that in the United States — and some equally striking differences. There are, basically (and it is much more complicated than this), five major sectors: traditional healers (khruu khmer), outpatient and primary care clinics, public hospitals, nonprofit private hospitals, and for-profit private hospitals and clinics.

Traditional healers. The khruu khmer are found most often in rural areas. They deliver many of the babies, dispense herbal medicines and traditional therapies and, because their services cost less than those of formal health care institutions, are widely used — sometimes to patients' misfortune. Their approaches can be successful, useless or dangerous. In addition to these practitioners, there are many flat-out frauds who hawk patent medicines, phony pharmaceuticals and outright poisons in the markets and elsewhere. In many parts of Cambodia, however, this is all that people can afford — and this is what they are familiar with.

Outpatient and primary care clinics. The clinics (some known as health centers) come in all varieties: government-run, private nonprofits, and physician- or corporate-run for-profits. The quality of care ranges from excellent to horrible. Part of the reason is that although clinics are licensed, there is little government oversight. Most of them can get away with anything.

One troubling aspect of some clinic and informal healer activity is that, for reasons unknown to me, many Cambodians believe that in order to be cured, one must receive an injection or an intravenous infusion. I have seen, in Phnom Penh, young men riding on the backs of motorbikes (the most common mode of urban transportation) with IVs attached to their arms. Jean-Claude Garen, M.D., a French-born physician who runs the highly-regarded Naga Clinic in Phnom Penh, told me that IVs are grossly overused, often in septic conditions, but that patients believe that intravenous therapies are the most effective. Many clinics employ them, whether they are needed or not, and without follow-up.

Public hospitals. Public hospitals are organized into tiers, starting with district hospitals and clinics throughout the country, then provincial hospitals that receive patients from the district facilities, then referral hospitals, which treat more serious cases, and then the national hospitals, which are the tertiary centers, all of which are located in Phnom Penh. (As with all things Cambodian, the actualities are much more complex than what I report here.)

The public hospitals also range in quality from good to awful; their general reputation is that they should be avoided, which may not be fair. The public Calmette Hospital in Phnom Penh was the first facility to take part in a semi-privatization experiment through which it would still receive government funds but would be self-governing and raise additional funds from patients who could pay. Anyone who can't guess what happened, raise your hand. Fees were imposed, quality of care did improve, and, as one observer noted bitterly, "They will happily let you die on their doorstep if you lack the needed funds for your treatment." This hospital is not alone; understaffing, underfunding, corruption and what might be kindly described as low morale (some would call it indifference) have led to many other patients being left to die in public facilities.

Then there are the "informal" fees for even basic care, and the chronic lack of supplies that leads patients' families to run from pillar to post to obtain drugs, blood and other necessaries from outside sources, only to face demands from health care personnel for bribes. There are even "tiers" within some public hospitals, wherein patients who can pay more receive much better care.

Four more hospitals, including the Soviet-Khmer Friendship Hospital in Phnom Penh — the largest facility in the country and a tertiary center — are scheduled to be cut loose under the same program this year. This has produced widespread anxiety. It is not that this approach cannot work; it is more that so far, the results at Calmette have not been encouraging in terms of care for the poor.

Furthermore, the medical, nursing and other professional staff members at most of these facilities are not paid even a living wage — they often earn only one-quarter or one-third of what is considered bare subsistence income. Given the shortage of skilled professionals, it is not surprising that many physicians, nurses and others also have private practices — often 10 times as lucrative as public employment — and that they split their time between the two. Their "other" practice takes place in private hospitals and clinics, many of them owned by the practitioners themselves.

And who can blame them? As one physician who worked in Cambodia observed, "Many physicians will work in a [public] hospital in the a.m. with an average monthly salary of $50, and then conduct a private clinic in the afternoon with an average monthly salary of around $500." One almost wants to congratulate them for giving their time in the morning.

A number of my sources expressed sympathy for those who opt for this split-time life, emphasizing that one cannot support a family — indeed, barely oneself — on what the public hospitals pay.

Unfortunately, the end result is that clinical care is usually available in the morning, skimpy in the afternoon, and nonexistent at night. (I recall a bitter joke that I once heard from an American nursing home administrator that an LPN is a registered nurse after 6 p.m.)

And, as everywhere, it is the poorest who suffer.

The women's ward,
Sotnikum Provincial Hospital, Dam Daek
Photo by Emily Friedman.
Copyright � 2009 Emily Friedman

Even when patients can get in, most of these hospitals have plain iron beds with no linens (and sometimes not even that; when I told a friend about one of the hospitals I visited, he exclaimed, "They have beds?"). In some hospitals, patients lie on the floor, attended by their families. Where there are beds, patients use mats they bring themselves to protect their bodies from the cold (or hot, depending on the season) iron. Because there is no air conditioning, rooms are open to the air and allow both severe heat and cold (by Cambodian standards) to enter. Mosquitoes can bite as they please, bringing malaria and Dengue fever. These open-air rooms and wards probably don't do much for prevention of cross-infection or sepsis, either.

Nonprofit providers. Happily, Cambodia benefits from the work of nonprofit nongovernmental organizations (NGOs, as they are universally known), funded by both the government and outside sources, which in many ways offer the best hope for the future of Cambodian health care. (I would prefer to say this about the public providers, but unfortunately, that is not the case.)

Indeed, the nonprofit sector is graced with physicians, nurses, other clinicians, administrators and others who not only often provide excellent health care, but also are committed to training Cambodian health care professionals. Some are well-known, such as the Jayavarman VII pediatric hospital in Siem Reap, which is part of the Kantha Bopha hospital group run by the enigmatic Swiss physician and cellist Beat Richner (who did not respond to my request for an interview). Others, such as the Sihanouk Hospital Center of Hope in Phnom Penh and the superb Angkor Hospital for Children in Siem Reap, are less well-known, but quietly go about their business of trying to save lives and teaching others how to do the same.

To say that they have a difficult time is to understate the situation drastically; resources are profoundly scarce and need is endless. Indeed, the Sihanouk Hospital Center of Hope offers training to physicians from around the world in — to use Dan Liu's delicate phrase — "providing health care in low-resource situations." (It also offers training in the treatment of drug-resistant HIV and tuberculosis, tropical diseases and other plagues.)

Waiting to be evaluated at the
Sihanouk Hospital Center of Hope, Phnom Penh
Photo by Emily Friedman.
Copyright � 2009 Emily Friedman

Indeed, until fairly recently, so many patients came to the Sihanouk Hospital Center of Hope, seeking care, that a lottery was instituted for non-critical patients, so that a few could be treated each day. That was phased out in 2007, and now admissions are based strictly on clinical criteria and capacity restraints.

There is simply never enough to go around for the NGOs, despite the generosity of donors around the world. Sin Somuny, M.D., M.P.H., executive director of Medicam, the umbrella organization for most of the NGOs, estimates that per capita, his member organizations have perhaps 1/25th of the resources that have been devoted to health improvement campaigns in other countries.

And although none of my sources would speak about it, I am convinced that a great deal of government funding that is supposed to go to providers — public and NGO alike — disappears along the way, appropriated in an environment of underpayment, indifference and bonjour.

Private for-profit providers. These are often the providers of choice, if you have the money. They include clinics, some of which are wired to Thai-owned Bangkok Dusit Medical Services, a publicly owned firm listed on the Thai stock exchange that owns hospitals in Thailand, Cambodia, Myanmar (Burma) and Bangladesh. They own a facility in Siem Reap and another in Phonm Penh and are building a luxury tertiary facility in Phnom Penh that will open later this year.

Ironically, care in most Cambodian hospitals is so suspect that the general advice has been that if you think something is seriously wrong, you should fly to Bangkok. Why is that ironic? Because one of the owners of Bangkok Dusit Medical Services also owns Bangkok Airways, a major carrier between Bangkok and Cambodia, so it's all in the family.

Once the fancy new hospital in Phnom Penh is open, however, its lucky patients won't have to fly anywhere for first-class care. And the money will go to the same place.

Royal Angkor International
Hospital in Siem Reap.
Note the credit card icons.
Photo by Emily Friedman.
Copyright � 2009 Emily Friedman

I visited the Bangkok Dusit-owned Royal Angkor International Hospital in Siem Reap, which is one of the poorest provinces in Cambodia, despite its being home to some of the greatest antiquities in the world (the admission fees go elsewhere; bonjour ). I was treated with great civility by its representative. And I was struck by two things. First, a sign outside the hospital lists which credit cards it accepts. Second, it had very few patients. I was puzzled. Nurses in starched uniforms at state-of-the-art computers, a beautiful atrium design, air conditioning (which I did not encounter in any other hospital in Cambodia), lovely patient rooms with mattresses and clean linens, the whole nine yards. Later, a friend explained that the hospital doesn't need many patients, given what it charges.

I asked the hospital representative whom they treated. She was not shy in her reply: Wealthy tourists, expatriates and locals. I asked if the hospital admitted poor local people. "They can go to the public hospitals," she said. At least she was honest, which is more than I can say about admitting practices in many American hospitals.

Perhaps I should not complain about luxury health care services being available to the lucky few in the Third World; it happens everywhere else, so why not here? (Although I do wonder about the quality of care, given what we know about the relationship between patient volume and mortality.) The problem is that not only do these hospitals skim high-paying patients from the rest of the system; they also have a habit of recruiting many of the precious few properly trained health care professionals from other facilities that cannot compete in terms of salary.

Again, the parallels to U.S. health care are obvious and disturbing.

And, as has been observed many times, people vote with their feet. In 2005, according to the World Health Organization, of all people in Cambodia who had suffered illness or injury in the past 30 days, 8.5 percent did not seek care, 21.6 percent sought care in the public sector, 48.2 percent sought care in the private sector (including both NGOs and nonprofits) and 20.8 percent sought care in the "nonmedical sector," which I presume is largely traditional healers and quacks.

A Medicam report for 2008 found much the same thing. "The informal private sector and the use of all kinds of medicines from pharmacies and drug stalls is the most dangerous issue," the report concluded.

There are so many dangers that it's hard to know which is the greatest.

In 2004, the average Cambodian spent $33 a year on health care, while the government spent $2 per capita. That might not sound like much out of pocket until one realizes that the average annual Cambodian income was at best $600 before the onset of ruinous inflation and the world economic collapse in 2008. As for health insurance, there have been some efforts to create nonprofit "social health insurance" plans, but they cover only 35,000 people and are not a significant factor. For the most part, it's cash on the barrelhead.

A Long Way to Go

And so, given all this, how is the health status of the Cambodian people? The good news is that it is improving; the bad news is that it is the worst in Southeast Asia, so far as we know (data on Laos and Myanmar are scarce and unreliable, for the most part).

Part of the problem is that there are underlying factors that impair health without being identified as such. As Dr. Yos Phanita says, "Health status does not exist on a stand-alone basis."

The country is poor to a degree that most Americans cannot even fathom. Poverty is rampant; 34 percent of Cambodians live on $1 a day at most, when $3 to $4 is considered to be bare subsistence income. The poverty rate is at least 30 percent; by the United Nations Human Poverty Index, Cambodia ranked 73rd out of 78 developing countries in 2000, although things have improved somewhat since then. (On the other hand, the world recession and political turmoil in Thailand have seriously depressed tourism, a major part of the Cambodian economy.)

Furthermore, 80 percent of the population lives in rural areas, which means less access to health services across the board. And 20 percent of men and 40 percent of women are illiterate.

These social factors affect health status, as we all know. Not a surprise, then, that life expectancy, at last measure, was about 50 to 55.

Yet despite the enormous challenges, things are getting better. In 2000, infant mortality was 9.5 per 1,000 live births; in 2005, it was down to 6.6 (by the way, that same year, African-American infant mortality was 13.6 per 1,000 live births, so I wouldn't get too haughty). In 2000, the death rate for children under five was 124 per 1,000; by 2005, it was 83 per 1,000.

William Housworth, M.D., M.P.H., executive director of the Angkor Hospital for Children in Siem Reap, says that although a few years ago, by his figures, one in five children were dead by the age of five, now it is only one in 15. "That is still unacceptable," he concedes, "but there's been a lot of improvement. Yet we have a long way to go."

Why do so many children die? Too many do not survive birth. Probably 70 percent of women have children at home with the assistance of traditional midwifery, and it doesn't always work out: Maternal mortality in 2005 was 472 per 100,000 live births, and often the child dies, too. A middle-class employee of a friend of mine died in childbirth last year. I did not understand why until I spoke with Dr. Housworth at the Angkor Hospital for Children. He explained that because of poor diet and other factors, many Cambodian women are anemic, but they still choose to give birth at home. When they run into trouble, they hemorrhage easily, and by the time they are taken for formal care, it is often too late.

I learned last year that a Cambodian friend was pregnant. On my next trip, I brought half a suitcase of vitamins and folic acid. She delivered a healthy baby girl in April.

Beyond the birth issues, 51 percent of children are malnourished, as are many adults. And 8.9 percent of kids are severely malnourished. Another friend of mine who works with an NGO told me that she saw a documentary about Phnom Penh in the 1960s, before the catastrophe. She said, "It was so odd; they actually had meat on their bones. They weren't terribly thin, as they are now."

One of the great ironies regarding the chronically underweight Cambodian population is the spread of diabetes. What? Diabetes in such thin people? You bet. Dr. Haner and Dan Liu at the Sihanouk Hospital Center of Hope told me that the diabetes rate is already 5 percent in rural areas and 11 percent in urban areas. There are 300,000 diabetic Cambodians and 700,000 more who are glucose-intolerant, so there could be 1 million diabetics within a few years. Why? Because in very slender people, even a few extra pounds can put an intolerable load on the pancreas. You don't even have to be overweight; you could just attain a normal weight. That can be enough. This risk is exacerbated by high levels of rice consumption, as rice is a high-sugar food.

I would add that, in my personal experience, even light-eating Cambodians seem to have a sweet tooth, and glucose intake is probably far more than it should be.

And, of course, as is happening around the world, burgers and fried chicken and similar foods are making inroads, and obesity is an issue — in a nation where, 30 years ago, most people considered a bit of yam a luxury.

As for diabetes treatment, in the urban areas, it is possible and available. In rural areas, there are rather fundamental problems. As Dr. Housworth observes, it's hard to keep insulin cold when you don't have a refrigerator. And it isn't just rural areas; friends of mine in major urban centers do not have refrigerators, either.

Other major challenges include HIV/AIDS and other STDs (sexually transmitted diseases). In 2004, a physician at Calmette Hospital found that 20 percent of his patients had AIDS and 10 percent had tuberculosis, a potentially deadly combination. Dr. Mean Chhivun reports that in 1998, 2 percent of the population was HIV-positive; due to determined efforts on the part of many, the rate is now 0.9 percent, and the government hopes to get that down to 0.6 percent by 2012. Most of those infected, Dr. Mean Chhivun says, are young adults aged 15 to 49. The reasons for this are many, including a clandestine but widespread sex trade, a tragic child sex industry, and a tendency among many Cambodian men to have mistresses or to use prostitutes and then infect their wives.

The list of common illnesses goes on and on: acute respiratory infections, cholera, Dengue fever, diarrhea, Hansen's disease, malaria and others, some preventable, most treatable. But people still die of them. Three conditions merit special attention. The first is cancer. In 2005, 11,000 Cambodians died of the disease, 9,000 of them under the age of 70. The illness has more or less flown under the radar as authorities focused on HIV/AIDS and malaria. But its occurrence is increasing. At the Soviet-Khmer Friendship Hospital in Phnom Pemh, of all cancer cases, 25 percent are cervical cancer, 19 percent are breast cancer, and 16 percent are head and neck cancers associated with male drinking and smoking. (Apparently tobacco use is a growing plague in Cambodia, about which I am ignorant; none of my friends or acquaintances smokes.) Unfortunately, despite the existence of a vaccine against human papillomavirus (HPV), the most common cause of cervical cancer, it is apparently not used very much — not good in a country where the men tend to stray.

The second condition is maiming by land mines. Some of you may remember that the late Princess Diana of Great Britain embraced this cause, and that American activist Jody Williams won the 1997 Nobel Peace Prize for her efforts to rid the world, and especially Cambodia, of this scourge. Nonetheless, despite remarkable efforts to find and remove these deaths-waiting-to-happen, 962 Cambodians were killed by land mines between 2000 and 2005. Fortunately, the number dropped to 173 in 2006-08. However, 1 in 250 Cambodians is an amputee as a result of encountering a land mine, and many cannot obtain prostheses, let alone work.

The third condition, and perhaps the most deadly because of lack of attention and cultural taboos, is clinical depression. Virtually all of my friends in Cambodia lost someone they loved during the horror — fathers, mothers, siblings, aunts, uncles, children. Although most of my friends are much younger than I am, and thus did not experience the holocaust as adults, I can still see the pall spread over their faces when I ask about whom they lost. For family is everything in Cambodia. Blood isn't thicker than water; it is water, the elixir of life.

In addition, Cambodians are conditioned not to speak about what they and their families endured. I believe it was Nick Ray, author of the Lonely Planet Guide to Cambodia, who wrote that the Cambodians "had sustained a grievous wound to the national psyche from which they have never been allowed to recover." That is a paraphrase, but the thought is absolutely correct. Once the immediate terror had ended, they got 10 years of foreign occupation as a door prize. And they won't, or can't, talk about it.

Should any of us be surprised that depression — unmentioned, undiagnosed and untreated — is common? Dr. Haing Ngor wrote about finding many people suicidally depressed in the Thai refugee camps; those who treat refugee Cambodians in this country report the same, decades after the holocaust ended. It may be that depression is one of the worst epidemics in Cambodia, and the one to which the least attention is being paid.

None of this should seem strange to us; the United States faces many of the same issues: poor people without access to decent health care, providers gouging patients, profiteering, untreated disease, rampant depression, and an inability to get things organized and funded. As Dr. Housworth of the Angkor Hospital for Children says, "A lot of the challenges we face here are similar to challenges in the United States; it's just that the degree is more extreme."

Acknowledgments

I wish to thank all those who participated in my interviews and site visits, taking precious time out of very long, busy days. I am also grateful for interpretive services provided by Mr. Vuthy and Ms. Salin Prak. I also wish to thank Marty Arizumi and Maria Friedman for their reviews.