Dr. Lim Tung (left) and Dr. William Housworth at the
Sotnikum Referral Hospital, Dam Daek.
Photo © Emily Friedman, 2009; all rights reserved.
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First published in Hospitals & Health Networks OnLine, August 4, 2009
After years of war, Cambodia is struggling to re-create a health care system. Its experiences offer pointers for those trying to reform health care in the United States. (Second of two parts.)
Emily Friedman
Those seeking to improve health care in Cambodia face daunting challenges on every front, but there have been successes: Some health status indicators have gotten better, and more indigenous professionals are being trained. At the same time, Cambodians living in the United States are benefiting from creative, culturally sensitive health care programs. In both cases, what has been accomplished is often the result of heroic efforts on the part of dedicated individuals. There are many lessons here for health care reform.
This is the second article in a two-part series on health care for Cambodians in that country and in the United States. The first article, "Starting from Scratch: Rebuilding a Health Care System," was published in H&HN Weekly on June 2 of this year. I hope that you will read that article first, if you have not done so, as I will not be repeating material from it here.
This article, like its companion piece, is dedicated, with great respect, to the memory of Dr. Haing S. Ngor and to all those who work to improve the health of Cambodian people, wherever and whomever they may be.
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Hope is the thing with feathers That perches in the soul, And sings the tune-without the words And never stops at all, And sweetest in the gale is heard; And sore must be the storm That could abash the little bird That kept so many warm. I've heard it in the chillest land, And on the strangest sea; Yet, never, in extremity, It asked a crumb of me. |
| — Emily Dickinson, "Hope" |
The facts cannot be denied. Of all Southeast Asian countries for which reliable statistics are available, Cambodia's health status indicators are the worst. From infant and maternal mortality to diabetes to tobacco use, Cambodia lags behind its neighbors. Given its recent history, this is hardly a shock; what is more surprising is the amount of effort to improve the situation.
During my four visits to Cambodia, if I have seen anything consistent in its health care sector (and consistency is not a hallmark of Cambodian society), it has been the passionate desire on the part of so many people to create a more functional system that provides higher-quality care to more folks. Although this is also a goal of U.S. health care, we have far more tools with which to do it, if we ever get around to it. In Cambodia, public health officials, leaders of nonprofit organizations and many of those working in for-profit settings seem committed to improving what was a health care disaster 20 years ago. They are aided by donors from around the world.
Everyone has a different agenda, of course, but a major blueprint is the Ministry of Health's Strategic Plan, 2008-2015, issued last year. Its stated vision is "to enhance sustainable development of the health sector for better health and well-being of all Cambodians, especially of the poor, women and children, thereby contributing to poverty alleviation and socioeconomic development."
Its guiding principles are:
This is a tall order for a system that is coming back from nothing. And we have all seen master-plan documents that have landed with a loud thud and were never implemented. Still, this is a start; at least the ministry has defined its priorities, which is more than has happened historically with U.S. efforts.
The plan's citing of human resources management as the cornerstone of the system is not misplaced. As I described in the first article, the shortage of skilled, properly trained health care professionals is the key problem, especially in rural areas. It is a profoundly difficult issue to address, given that after the fall of the Khmer Rouge (KR) in 1979, most surviving physicians, nurses and other professionals (and there weren't many left) fled the country.
Yet medical and nursing education has improved enormously. The nonprofit Sihanouk Hospital Center of Hope in Phnom Penh has devoted itself to training both Cambodian and international physicians, as well as nurses, laboratory technicians and pharmacists. The hospital boasts approximately 50 physicians, 100 nurses and 12 pharmacists, and the vast majority of them were trained there. It also offers education to visiting clinical professionals from all over Cambodia and the world in a variety of topics, from HIV/AIDS to tropical diseases.
At the Angkor Hospital for Children in Siem Riep, training of clinicians is a similar priority. William Housworth, M.D., M.P.H., the executive director, reports that the training is designed "to help achieve sustainability of health care in Cambodia." The principles of evidence-based medicine are emphasized. All but one member of the medical staff are Cambodian, and most were trained at the hospital. Nurses from all five Cambodian nursing schools train there. Dr. Housworth adds, "Part of our goal is to take things that are unknown in Cambodia and make them known, from something as simple as multidrug-resistant pneumonia to things as complex as multiple causes of mortality."
It takes time. Dr. Housworth tells of a nurse who came to the hospital with minimal training in the early 1990s. She worked extremely hard to learn more, including studying English and taking classes in Thailand. She is now the hospital's lead nurse educator, supervising the training of more than 800 nurses and nursing students annually. But it took her 10 years to get this far. "That's what it takes to rebuild a health care system," Dr. Housworth says. His main goal? "To turn health care over to the Cambodians. They want that. And if there is going to be a success here, it will have to be a Cambodian success."
At the Sotnikum Referral Hospital in Dam Daek, about an hour's drive from Siem Reap (and where the Angkor Hospital for Children is building a satellite clinic, which will also be a training site), hospital director Lim Tung, M.D., is hopeful. His first desire is for better-trained staff, and a sufficient number of them. He also wants to motivate his staff so that they are enthusiastic about their work, which is difficult when they are paid so little. In some places, health care workers are paid less than what is required for bare subsistence.
Dr. Lim Tung (left) and Dr. William Housworth at the
Sotnikum Referral Hospital, Dam Daek.
Photo © Emily Friedman, 2009; all rights reserved.
But all this raises the question of whether Cambodian physicians and nurses, once trained, will remain — especially in the public and nonprofit sectors. They can make much more money in the for-profit sector or overseas. One nonprofit hospital administrator told me, "We have a core of senior staff who are very, very committed to our mission and to what we are doing. But we also try to pay people as well as we can, to offer education and other opportunities, to have a good work environment, and to keep morale high. It's an ongoing effort."
Part of that effort involves weaning health care professionals from the unfortunate practices of charging patients "informal fees" (which most of us in the United States would consider bribes), drug diversion and a private practice on the side. Key to that is sufficient pay. After a site visit on which Dr. Housworth graciously hosted me, I asked how much I should tip the driver. He replied that I was not to do so, because the driver was paid well enough and because the Angkor Hospital for Children forbids solicitation of any type of private "fees."
There are many other training programs, not the least of which is the health care component of the Girls Be Ambitious effort, funded by American Assistance for Cambodia, based in Tokyo. Cambodian women are more likely than men to be illiterate and to lack opportunities for education; this program trains young rural women in basic life sciences and public health, other health care skills, and women's health care rights. Those who complete the program become community health workers, who are sorely needed in rural areas.
Another challenge is that the quality of care in many settings is often substandard and can be pretty awful. A number of efforts have been initiated. One UNICEF-funded program (in which other nongovernmental organizations [NGOs] are involved, as well as the Ministry of Health) establishes "health equity funds," which serve two purposes: They pay for the care of low-income patients in public hospitals, and they supplement the base pay of health care workers, thus encouraging them not to solicit hidden fees or engage in private practice when they are supposed to be caring for public hospital patients. One result of this program has been greater use of public hospitals and clinics by low-income patients (use by paying patients remained stable). Although quality problems persisted, some were ameliorated.
There are also telemedicine programs. The U.S.-based Markle Foundation partnered with American Assistance for Cambodia and Partners HealthCare System in Boston to offer telemedicine to rural clinicians. "One neat thing that has come out of this is that telemedicine has been a learning experience both for the doctors who are located out in the rural provinces and for the ones who are working with them in the United States," reports Lygeia Riccardi, former director of the Markle Foundation's health program, now a consultant. "The doctors and nurses who are out in the rural areas [in Cambodia] strengthen their education and understanding of what is going on, and at the same time, the doctors based in the United States find it is a really good experience to learn about tropical diseases that they're not exposed to in Boston."
Another program (originally funded by the Asian Development Bank in 1998) created contract management arrangements between NGOs and public clinics, either through outsourcing care to NGO sites or by bringing NGO leadership into existing public sites. Through more efficient processes, more independent administration, subsidy of care for low-income patients and higher pay for health care workers, the program has improved both utilization and health status, as well as employee morale and performance.
But the role of NGOs in Cambodia is complex. There are many of these organizations operating in the country, within and outside health care, and not all of them, in my opinion, adhere to the highest ethical standards, although most do. In addition, Cambodia spent much of its last 200 years threatened or controlled by this or that foreign power, and there is a nascent desire for self-governance in many areas of society. As Dr. Housworth says, "Nongovernmental organizations should be working to establish an independent Cambodian health care system and should not become self-perpetuating." However, as we all know, an NGO presence can last forever.
Another issue is that most NGOs are dependent on donors, who call the tune. And donors tend to be drawn to quick fixes, as opposed to less sexy long-term solutions. As a 2007 World Health Organization report on health care in Cambodia noted, donors' priorities were poorly aligned with realities on the ground. Donors focused on sexually transmitted diseases, especially HIV/AIDS; infectious disease; and health policy and management. The country's self-identified needs were access to primary care, expansion of health equity funds, and care in remote areas. Not exactly a match made in heaven. Furthermore, chronic disease is on the rise in Cambodia, and it gets just about as much attention as it does in the United States, which is to say, hardly any. Mental illness is also almost completely ignored.
As Maurits Van Pelt, director of the NGO Mopotsyo, has observed, "Diabetes [in Cambodia] is a public health and poverty disaster that needs to be addressed, and it gets zero attention." According to Mopotsyo, 60 percent of donations to health care activities in Cambodia are targeted to communicable disease, especially HIV/AIDS; 1 percent goes to noncommunicable disease. One health care executive told me, "The donor interest is in specific diseases or maternal and child health, but not in general public health."
This is probably why, despite his intense gratitude for the donations his hospital receives from around the world, Dr. Housworth says, "I would love to see a day when this entire health care system can be weaned from external donor assistance." That day is not likely to come soon.
Although preventive care has a long way to go, one success has been the Ministry of Health's campaign to reduce the rate of new HIV infections. The plague that is crippling so many African and Asian societies threatened to do the same in Cambodia, but fervent efforts have avoided that. According to Mean Chhivun, M.D., director of the National Center for HIV/AIDS, Dermatology, and STDs within the ministry, 67,000 Cambodians are living with HIV, and 32,000, including 3,000 children, receive antiretroviral treatment. The government has established 50 treatment sites, including the excellent Social Health Clinic in Phnom Penh, and 217 testing sites. The rate of mother-to-child transmission during birth has dropped to nearly zero.
Dr. Mean Chhivun credits several factors, chiefly the centralization of these efforts, which allows for "a common mission, a common strategy, a common policy and common monitoring." He also cites "having a good partnership with the international community and civil society [NGOs], team approaches to the effort, integration of all services, and real involvement of people at all levels." In addition, he says, "a consistent model" leads to better communication, replication and results. However, he adds, in some ways he almost regrets their accomplishments: "Some donors say that Cambodia has been so successful that it doesn't need any more money. We are punished for our success."
Médecins Sans Frontières (Doctors Without Borders) has also operated a very successful program of HIV testing and treatment, which I understand will be turned over to the Cambodian government by the end of this year. Some observers have expressed concern about this because of the possibility of inadequate funding and portions of the program being eliminated.
These programs and others have contributed to a remarkable change in public attitudes toward HIV/AIDS: Dr. Mean Chhivun reports that in the early years of the epidemic, infected persons were often shunned by their communities and even by their families. A few years after the epidemic surfaced, hoping to find sanctuary for very sick patients, the ministry established a hospice at a pagoda (Buddhist temple), where the resident monks would care for them. It was a flop; attitudes had shifted enough that families wished to care for their dying relatives at home.
Other successes include a sharp drop in the incidence of Hansen's disease (leprosy), which carries a stigma in Cambodia, as is true in much of the world. Although there are approximately 500 people with the disease and new cases do appear, this is less than a third of the incidence 20 years ago. Equally important, strenuous efforts to teach rural Cambodians about the disease appear to be lessening the stigma. Some patients have benefited from micro-loans from the Swiss NGO CIOMAL, which allows them to develop small businesses. CIOMAL and the Cambodian government have cooperated on projects for Hansen's disease patients since 1983.
There has also been a decline in the incidence of malaria. Jean-Claude Garen, M.D., a French physician who operates clinics in Phnom Penh and Siem Reap, reports that this is in part due to the fact that medication is available very inexpensively, and sometimes at no cost. The main problem areas are rural. On the other hand, several sources told me independently that the main reason for the decrease in malaria is that there has been so much illegal logging and destruction of mosquito habitat that there are fewer mosquitoes to bite people. This might be the only positive result of what has been a largely unnoticed ecological disaster.
Another hopeful sign is the stated commitment of the current minister of health, Mam Bun Heng, to maternal and child health. Although some Cambodian health status indicators have improved, maternal mortality is believed not to have decreased in recent years. Furthermore, according to Medicam (the umbrella organization for health care NGOs in Cambodia) and other sources, women's health care issues take a backseat to those of men. For example, Medicam reports that 18 percent of women suffer moderate to severe post-partum depression and 25 percent experience moderate to severe anxiety. Yet a Medicam report concludes, "The mental health of mothers is given low priority among policymakers and stakeholders." Perhaps the minister's public stance will improve this situation.
It also must be noted, as Dr. Yos Phanita observed in my previous article, that health care does not stand alone. Cambodians, especially those in rural areas, face everyday threats to their well-being that range from lousy sanitation and unsafe drinking water to good old garden-variety malnutrition. Yet, as in the United States, these are often not perceived as health care issues.
It may be that nonclinical initiatives can do as much to enhance health status as traditional approaches. One program, among many, that is improving the health of some Cambodian kids has little to do with clinical care. (In the interest of full disclosure: I donate to this program, as I do to the Angkor Hospital for Children. But I don't have enough money to give me any clout, I assure you.)
A New Day Cambodia was founded by renowned Chicago sports photographer Bill Smith, who was appalled to see toddlers spending their little lives searching the Phnom Penh city dump for anything they could sell to support their families. A New Day provides some of these children, who often do not live to the age of 10 if they continue to work at the dump, with safe housing, schooling, extra education in English and as much health care as can be wangled.
I have visited its homes in Phnom Penh, which shelter 100 kids. And I have asked myself whether it is better to provide a safe home and education and clothes and showers, or to offer care to those who are sick or injured because they do not have such protection. This was brought home to me when I was told the story of a little girl, a sister of a New Day resident, who died after being horribly injured by a forklift at the dump, despite the best efforts of health care providers. A family has to survive, somehow.
It isn't an either-or situation; all urgent needs should be met. But one must ask, in a country such as Cambodia, what the top priorities should be.
I should add that the health care improvements that have been achieved are very fragile. Money flows in strange ways in Cambodia, and it doesn't always get to where it is supposed to go. Inflation is intense, and the collapse of tourism thanks to the world economic crisis and political turmoil in Thailand has led to the loss of many jobs and diminution in income of people who were just hanging on by their fingernails. Long-term stability in any aspect of Cambodian life is a common hope, but it is rarely a reality.
Needless to say, Cambodia is hardly out of the woods in terms of health care. There are many unresolved issues and challenges.
The lack of a public health infrastructure ranks right up there. The majority of rural residents live (and die) with unsafe water, unreliable (if any) sewage and sanitation, and often a diet that combines the best of malnutrition and glucose overload, which is to say: rice, rice, rice. As Sin Somuny, M.D., executive director of Medicam, observes, "Improving health requires actions beyond the health system. We have nice hospitals for care of diarrhea [a common condition of which children still die], but when they go home, they still do not have a safe water supply."
Other nonclinical factors are important determinants of health status in Cambodia, as elsewhere. One example is tobacco use. Reportedly, 54 percent of men smoke — a time bomb that will explode in an already overburdened health care system. There are efforts under way to change this, but if the U.S. experience is any guide, it will be a long, hard slog.
Another challenge is that the relationship of top levels of government with the rest of the health care system is convoluted and sometimes dysfunctional. Alleged corruption undoubtedly plays a role, but there are also problems of incompetence, misplaced priorities and lack of oversight. The administrator of one public hospital offered me an almost pathetic "wish list": enough properly trained staff to take care of his patients; any kind of administrative assistance, of which he has none; and a decent supply chain that would provide a sufficient quantity of what he needs on a timely basis. The next time an American hospital CEO is thinking about increasing his or her administrative staff, he or she should have a thought for this poor guy.
And the quality of care continues to be all over the place. The public hospitals are trying, the NGOs are trying, and so are the for-profits. Dr. Garen of the Naga Clinic in Phnom Penh hopes that the for-profit sector "has increased the standard of care," but its services are not available to everyone.
Also, the information technologies that are revolutionizing health care in the United States and elsewhere are often only a fantasy in a country that doesn't even have a functional postal system. Indeed, many Cambodians who could afford it have skipped landline phones and regular mail and have gone directly to cell phones and the Internet. Unfortunately, much of the emerging health care system has been unable to make the same leap.
Beyond all this, often the horse has no interest in drinking the water. Even if people trusted the health care system, which they generally don't, and even if they could afford care, which they often can't, traditional beliefs interfere with seeking clinical care, even if the situation is life-threatening. To quote a friend who has lived in Cambodia for many years, "One thing I have observed among my own friends and employees is that some people have a reluctance to seek medical help for fear of receiving 'bad news.' There are those who would go so far as to die 'ignorant' rather than know of a serious problem, even if it is treatable. In recent years, several of our neighbors have died relatively young from long, painful illnesses of an unknown nature; none ever sought care beyond a local clinic where the consultation was something along the lines of 'the patient complains of pain' and the doctor responds with painkillers, vitamins and, likely, an IV drip." On more than one occasion, this friend has had to force an employee to seek care for an obviously life-threatening condition.
Finally, Cambodia has a bedrock problem that is hardly unique. At least 50 million people died during World War II; afterward, most European women of child-bearing age had one more child than usual, and within 10 years the population was just about where it would have been if there had never been a war. In Cambodia, which experienced the worst genocide of the post-World War II period (by percentage of lost population), the pattern has been the same. It could not support its population of 7 million or 8 million before the catastrophe, and it now has a population of at least 14 million. With the world economy in meltdown, the chances of a better life for most of them are slim to none.
Nevertheless, what has impressed me most about Cambodia is its people's capacity for hope. Part of it I can understand; if you lived through a time when your parents, your wife, your husband or your children disappeared or were murdered or starved to death in front of you, just being poor would be a godsend. But most Cambodians are younger than 30, and, given that the history of the KR period is not taught in most schools, young Cambodians are largely unaware of it (unless they might inquire about their lack of grandparents). Their ability to hope cannot be attributed to an understanding that things are better now than they were during the horror.
I believe that due to some cosmic combination of experience, religion, entrepreneurialism, faith in family and belief in the future, Cambodians are intrinsically given to hope. Not because there is any reason for it, not because there is any rational basis for it, and not because it is justified; but rather because hope is the thing with feathers, and it rests lightly on the shoulders of these gentle people, no matter what has happened to them, or what might.
During and particularly after the four-year Khmer Rouge slaughterhouse, Cambodians made their way to U.S. shores, in most cases traumatized, desperate and without resources. Originally, they settled all over, thanks to the generosity of many communities, but folks will go where folks will go, and they often go where folks like them are. The largest single Cambodian community is in Long Beach, Calif.; the second-largest is in Lowell, Mass.
The 2000 census recorded approximately 200,000 Cambodian-Americans. Given their high birth rate, the general guess is that the population today is between 300,000 and 400,000.
Their overall health status is not great. Rates of heart disease and stroke far exceed those of whites. Liver, mouth and cervical cancer are more common than in other populations. The hepatitis rate is three times that of the overall population. Rates of gestational and Type 2 diabetes and maternal mortality are also disproportionately high. Behavioral risks are also present; tobacco use, especially among men, is much higher than for the overall Asian-American population or the U.S. population as a whole. Domestic violence against women is reported to afflict at least half of all families.
In addition, many Cambodian-Americans suffer from mental illness. Among those who lived through the 20 years of American bombing and invasion, civil war, the KR period and the Vietnamese occupation, headaches, dizziness, physical weakness, nightmares, depression and post-traumatic stress disorder (PTSD) are common. That's bad enough, but other factors make treatment difficult. Many people are reluctant to seek care, even if they have suffered for years. Kompha Seth, executive director of the Cambodian Association of Illinois (CAI), told me that even after someone complains repeatedly about headaches or nightmares and he suggests that the person seek help, the response is almost always, "I'm fine; I'm OK." This goes beyond the common reluctance of people to admit that they are troubled; it is symptomatic of a visceral need to repress horrifying memories, which is characteristic of people who have been severely traumatized. However, when a crisis occurs, the terrible memories tend to come flooding back.
Furthermore, many U.S. physicians are not used to treating victims of torture and atrocities, and therefore may not ask about past traumatic experience or PTSD symptoms. Finally, although the younger generation knows more about Western medicine, older people, especially immigrants, may prefer to use the traditional therapies with which they are familiar.
It was for these reasons that the Metta Health Center was established in Lowell, Mass., in 2000. Part of the Lowell Community Health Center, the Metta Center was established to serve the large Cambodian and Laotian populations in that city. It also treats many other Southeast Asian patients. The word metta means "love, kindness, and compassion" in Buddhist Sanskrit, and the center seeks to provide kind, effective and culturally appropriate services.
Most staff are Cambodian, some of them survivors of the violence and refugee camps, which helps them relate to patients still suffering from trauma. Most are also bilingual in English and Khmer. They use a team approach, combining Western and traditional Khmer therapeutic approaches. A consulting Buddhist monk provides guidance, traditional healers participate in care, and services such as acupuncture and meditation are offered. A meditation room is available to patients, as well as instruction in meditation techniques. The center emphasizes prevention and provides services that range from flu shots to a cookbook, A New Day Cambodia, which offers alternatives to what is often a rice-, sugar-, salt- and fat-laden diet.
The meditation room at the Metta Health Center, Lowell, Mass.
Photo © Emily Friedman, 2009; all rights reserved.
The physical surroundings are designed to be sensitive to patients: A television in the busy waiting room shows Cambodian videos, entryways and decorations are culturally appropriate, and all signs are in English, Khmer and Laotian. Patient privacy is a major priority, and areas where mental health care is provided are discreetly not labeled.
In 2008, the Metta Health Center had about 10,000 visits (its method of counting patient encounters changed late in the year, so an exact number was not available when I was there). In 2007, it treated 5,407 unique patients; the number for 2008 will likely come in somewhat higher.
Sonith Peou, program director of the center, has been able to recruit Cambodian practitioners to Metta, but he also says they are "very, very careful" about whom they hire. Staff must be able to deal with both Eastern and Western approaches, a variety of sometimes-exotic conditions and therapies and a broad range of sensitivities. Nurse practitioner Chhan Touch, R.N., a survivor of the KR period and a historian of the horrors, told the Boston Globe in 2006, "I've never seen anybody so sick as this group — the hypertension, the diabetes. They just stop caring for themselves, and they fall apart." Fortunately for them, the Metta Health Center is there to help.
In 2006, the center was a finalist for the prestigious Premier Cares Award and won a $28,000 grant from Premier Inc.
Although most Cambodian-Americans do not have access to clinics specifically designed for them, there are other worthwhile programs. In Long Beach, Calif., home to the largest Cambodian community in this country, the Older Southeast Asian Health Project, based at St. Mary Medical Center, has focused on the specific needs of aging refugees, virtually all of whom suffer the health consequences of trauma. In Hartford, Conn., the Khmer Health Advocates organization coordinates the National Cambodian American Diabetes Project, which works in five sites across the country to raise diabetes awareness and teach patients how to live with the disease and avoid complications. The National Cambodian American Health Initiative has produced a plan for health improvements and a stronger communications network among providers, and is a crucial part of the national diabetes initiative.
And there is also creativity in communities that cannot sustain a full range of targeted services. The CAI serves a Cambodian population of some 2,600 in the Chicago area and elsewhere in the state. Its four founding principles are "love, compassion, appreciation and equanimity," according to Kompha Seth. Although the CAI does not operate a clinic, it has established a relationship with Chicago Health Outreach, a nearby community health center, for care of uninsured Cambodian-Americans. The CAI also engages in its own outreach, especially for mental health and hepatitis B screening, as well as offering aid to families in need, linking them with social services and providing case management; it serves 400 to 500 clients at any one time.
It can be a tough go, especially when it comes to mental health. Kompha Seth says, "The main problem is denial." Furthermore, with the recession, many families have financial problems, which tends to exacerbate underlying troubles.
Kompha Seth was a Buddhist monk in Cambodia for 23 years before coming to the United States in 1975 — he is one of relatively few monks to survive the KR. He is keenly aware of the central role of religion in the lives of Cambodians, especially older ones, and of the healing power of a cultural continuum in the face of violent disruption. In 2004, the CAI opened the Cambodian-American Heritage Museum and Killing Fields Memorial in Chicago. The museum highlights various aspects of Cambodian life, as well as displaying beautiful artifacts. The CAI also offers instruction in the Khmer language and in traditional Khmer dance. It has aided development of a "genocide curriculum" for educators.
But the centerpiece of the museum is the memorial. Reminiscent of Maya Lin's Vietnam War Memorial in Washington, D.C., it features an altar and a candelabra with seven candles, each representing a day of the week when someone died or was murdered. Behind it, on a carved stone column, a lotus blossom floats above the words, "We continue our journey with compassion, understanding and wisdom." On either side of the column are glass panels on which are inscribed the names of some of the 2 million who died. Kompha Seth reports that people come from all over the world to view it; some weep, some smile and some report a kind of closure, if there can be such a thing in these circumstances. "The memorial is very important in healing," he says. "It tells us that yes, we have suffered, but we must move on."
The Killing Fields Memorial, Chicago.
Photo © Emily Friedman, 2009; all rights reserved.
Life goes on.
I believe that the health care experiences of Cambodians and the people who care for them, both here and in Cambodia, have much to teach those who are seeking to reshape American health care. Here are a few of those lessons.
A solid health care infrastructure is necessary, especially a public health infrastructure. One of Cambodia's greatest problems is that a basic public health infrastructure simply does not exist. Although that is true of only a few locations in the United States, the fact is that public health agencies have been fiscally starved here for decades. Now, with the H1N1 virus looming, the federal government is madly trying to fund development of a vaccine, but seems to have overlooked the fact that in many areas, the public health infrastructure may not be there to provide the vaccinations — and many private providers don't do it for free.
Frankly, I have grown exceedingly tired of policymakers and pundits yammering about prevention and public health while they continue to shovel money toward the back end of illness — emergency departments and such — and scrupulously ignore or underfund proven interventions that can prevent disease in the first place.
All the pretty buildings in the world don't matter if you don't have qualified personnel. Cambodia lacks a sufficient supply of skilled clinicians, but that's hardly unique. There are not enough primary care physicians in the United States, not to mention some other specialists, and don't get me started on dentists. And if you are uninsured or have Medicaid (or, in some cases, Medicare), good luck getting in to see any kind of practitioner — sometimes even in to federally qualified community health centers.
The dentistry situation is complex and has much to do with a paucity of dental insurance. The primary care situation is more easily explained: Organized medicine, medical education and third-party payers have consistently shown the backs of their hands to primary care practitioners and those who seek to join them. These physicians are underpaid, underappreciated, denied research and association opportunities, and overworked. No wonder nurse practitioners are flooding into the field; it's wide-open.
Cambodia also teaches us that health care workers should be paid decently, treated decently and have access to continuing education. That standards for competence should be reasonable and should be enforced. That indifference to patients is not acceptable. And that those who toil in the challenging vineyards of difficult patients, intractable chronic disease, isolated rural settings and unappreciative organizations should be celebrated, not treated as stepchildren.
If all else fails, try planning. In his searing memoir of the KR years, Dr. Haing S. Ngor provided an important insight. Writing about yet another KR blunder — pulling prisoners out of the rice fields before the crop could be harvested — he observed, "It didn't surprise me that they were doing it. To me, the only question was whether they were doing it to kill us intentionally, or whether they were doing it by mistake. For if there was one thing sure about the Khmer Rouge, it was that they knew nothing about planning. They were always starting projects but not finishing them, then going on to the next."
Gee, that sounds familiar. The United States took a stab (some would use that term literally) at health planning in 1972, with, shall we say delicately, varying results. Some planning agencies took their jobs seriously; others were little more than a joke. Most institutional providers hated the planning agencies and certificate-of-need laws, and were generally successful in beating them into submission. What was supposed to be a planning statute morphed into a cost-containment campaign. Just about everyone except diehard planners were probably relieved when the thing was allowed to die less than a decade later.
But the fact remains that when no one is overseeing a health care system, unfortunate things happen. There are too many specialty cardiology and orthopedic hospitals in too many places. There are too many "medically underserved" areas. As I have written previously, the town of Gilbert, Ariz., has far too many hospitals while Gary, Ind., which has the same population, has only one — and it wants to move. The 1970s planning experiment did not work, but the Wild West approach we have taken since isn't any better. At least the Cambodian Ministry of Health has a master plan and has set priorities, daunting as it will be to see it all through.
Success requires innovation and an understanding of risk. All the rhetoric aside, most U.S. health care folk are perfectly happy to think and work inside the box — sometimes a very small, comfy box. Cambodian health care providers and those who serve Cambodian-Americans don't have that option. You can't apply the usual techniques to a 60-year-old whose entire family was massacred before her eyes. You can't railroad people into mental health services when they deny that anything is wrong. New techniques, new approaches, new thinking must be used — and the entire system must be flexible. Stuff happens. Influenza. AIDS. (Does anyone remember the original rigid, inflexible reaction to the HIV epidemic in the early days, and the eventual development of compassionate, flexible and effective responses?)
Really good health care systems are innovative, responsive and flexible. Nothing can be set in stone in this sector. But the corollary is that not everything will work. There have been disastrous experiments in the past, and there will continue to be. That is the price of innovation. Those who wish to move the system forward must have, in the words of transplant surgeon Denton Cooley, "the courage to fail."
Social factors are as important to good health as clinical care. Bacteria, viruses, cancers and injuries are not the only enemies. Poverty, malnutrition and poor diet, unsafe water and food, lack of sanitation, substandard housing, overwork, racism, and other factors can ruin health just as thoroughly as HIV. Inspecting the home of an older person living alone for possible sources of injury such as electrical wires that can trip her is far more cost-effective than replacing the hip that was shattered because the home was not checked out. Somehow, social risks and clinical risks must be addressed in a harmonious and mutually nonthreatening way.
Access must be a reality, not a concept. Several key questions about access to care should be at the forefront of policymakers' discussions. The first, and most obvious, is: Access to what? Which services should be readily available, and for whom? And who should decide?
Second, theoretical access and real access are two different things, both in Cambodia and in the United States. Many hospitals claim to have open doors, but those doors have real good locks on them for some patients. Many physicians follow suit.
Third, the Cambodian experience reinforces the fact that there are always tiers of care. They are inevitable. All I ask is that care in the bottom tier be of sufficient quality, and that access to that lowest tier not be compromised by financial barriers. A corollary is that privatization of public providers should preserve access for vulnerable populations, which has not happened in either Cambodia or the United States. If we wish to declare as policy that there is no right to health care and that if you don't have the money, you can die in the street, then let us do so, rather than continuing the bitter farce of privatizing public facilities and expecting them to behave as they did when they were in the public sector.
Fourth, allocation of resources to various health care entities should follow need, not desire or presumption, and should be at least vaguely fair. Neither Cambodia nor the United States has distinguished itself in this regard.
Health education of the population is essential. Many people in Cambodia and in the United States who are HIV-positive or diabetic don't have a clue that they are ill. In Cambodia, illiteracy and ignorance, as well as a fear of "bad news," explains much of this, along with poverty, a poor communications infrastructure and the lack of public health outreach. In the United States, we hardly have such excuses, yet the same problems persist. But the exemplary efforts of the Cambodian-American programs I have described here (and there are equally laudatory programs for most minority groups in this country, from Somalis to gays) demonstrate that successful outreach is possible.
Yes, it takes hard work. It must be culturally sensitive. It should be driven by epidemiology and not the desire of a pharmaceutical firm to push a given medication. And it must employ a variety of approaches; in Cambodia, 20 percent of the men and 40 percent of the women are illiterate. As bioethicist Judith Swazey recently told me, "The oral interaction is always more important than the written interaction." Information must be conveyed in any way that works. At the Social Health Clinic in Phnom Penh, one AIDS awareness approach uses an embroidered quilt, quite in keeping with Khmer tradition. Doing this right, however, takes time, and that means that physicians, nurses and health educators must be paid for taking that time to teach patients.
Meaningful oversight is crucial. In an earlier episode of the television show Law & Order, Assistant District Attorney Jack McCoy (yes, he's the DA this season, but he wasn't in that episode), asserts that "Man has only those rights he can defend." In health care, someone must defend the rights of patients, providers and the population at large, and that duty cannot be assigned to lay people under the guise of "consumer-directed health care." If we have learned anything from the ruinous legacy of a do-nothing Securities and Exchange Commission and greedy corporate boards and executives, it is that corruption, incompetence and indifference are not victimless crimes.
One of the best ways to keep track of what is going on is collection and evaluation of data — and acting on what is learned. It is definitely worth the investment; otherwise, how will we know that what we sought to achieve actually happened? And how the program can be modified to perform better?
In Cambodia, many proposals and plans have been put forward that have not yet seen fruition. In the United States, it is not very different; we love to pass laws and enact regulations, but we rarely go back to find out if they were effective. Let us hope that we do not repeat this sad experience with health care reform.
Many decisions have a long tail. The U.S. bombing of Cambodia that began in 1969 is still having repercussions in that country. Similarly, as reform advocates in Congress and the Obama administration promote the model of medical group practice and integrated health care systems, the American Medical Association's decades-long fight against that model, and against prepaid capitated health insurance, lingers as a palpable ghost. In many places, the infrastructure isn't there and will have to be created.
Health policy decisions made decades ago — the creation of Medicaid and Medicare, the choice to rely on market forces, the preference of most physicians for self-employment in small settings, the way providers are reimbursed — continue to influence how just about everything in health care goes. These are not one-time incidents; they are precipitating events whose legacy echoes down the years.
Hiding or ignoring history only allows us to repeat the mistakes of the past. The story of the Cambodian horror (and that of Jews and Gypsies at the hands of the Nazis, and of Armenians at the hands of the Turks, and the people of Nanjing at the hands of the Japanese in World War II, and the Bosnians, and the Rwandans, and those in Darfur, and all the others) should not be forgotten. Yet these stories could slip through the cracks of history.
With most of the population of Cambodia so young and unschooled in what happened, the lessons could be lost. In a New York Times story published earlier this year, Seth Mydans tells of "widespread ignorance" of the holocaust. Indeed, some analysts fear that a KR-type dictatorship and genocide could happen again. (Cambodia and Thailand have been involved lately in some border skirmishes over contested real estate, and former KR soldiers have volunteered to go to the border to fight. I watched a Cambodian friend read about this — a man who survived the KR, although several of his family members did not — and although he is a quiet, disciplined and self-contained person, I know fear when I see it. The idea of rearming the KR terrifies many Cambodians.)
Yet most of the young are unaware even of the war crimes trials of a few KR leaders taking place in Phnom Penh — and many who know don't care. It is ancient history to a teenager. And the country's prime minister, Hun Sen, a former KR officer, has publicly opposed the trials and has suggested that Cambodia "dig a hole and bury the past." At the same time, children in rural areas who discover the bones of victims of the KR — which are still turning up, even after 30 years — call them "the skulls of ghosts." People still leave offerings for them.
Are we so different? Historian Arthur Schlesinger Jr. described the United States as "an essentially historyless nation" — and we are. Those who founded this country did not want to be victims of oppressive tradition or prisoners of the past. The price we have paid for that, however, is that we do not learn from what went before, and we repeat our mistakes. A hundred years of health reform efforts have failed. That is not only due to powerful special interests or the messy processes of democracy; it is also the result of our refusal to heed the lessons of the past.
The last lesson is about heroes. In its groundbreaking 1999 report on failures in health care quality, the Institute of Medicine made an enormous point of stating that it is systems, and not individuals, that fail. Efforts to improve quality and patient safety, the IOM urged, must be rooted in systemic change. Given what I have witnessed in both Cambodian and U.S. health care, I could not agree more.
But that is not the whole equation. While we tinker with our systems and try to enact meaningful change in the face of conflicting agendas, ingrained resistance and fear of the unknown, there are heroes among us who go about changing the health care world in small ways, day by day, person by person.
In Cambodia, they are people like Dr. Yos Phanita and Dr. Mean Chhivun, working within a difficult bureaucracy to improve quality of care and access to services. They are also people like William and Lori Housworth, both physicians with master's degrees in public health, who, like many of us who have been there, fell in love with Cambodia and its people and eventually packed up their three kids and moved to Siem Reap. She provides clinic services to the poor, although soon she will be supervising the new clinic in Dam Daek; he runs the premier children's hospital in the country. Their housing is substandard, their days are long, their challenges constant. Their view? "When you give yourself away, you really do get so much back. You have so much joy," Lori told the Louisville Courier-Journal in June. I have spent a good bit of time with Bill Housworth, and I have to tell you, he is a fulfilled guy. And he and Lori are emblematic of all those health care folk, Cambodian and foreign alike, who strive to save the lives and health of people in one of the poorest countries on earth, which has suffered far more than its share of hardship.
Elizabeth McLellan is a nurse administrator at a major Maine hospital. She has traveled extensively, and one day she came to Cambodia. Of all the places where she was troubled by obviously inadequate health care, this was the worst. "Oh, my God, it was really amazing," she told the Maine Sunday Telegram in June. "They had HIV everywhere, tuberculosis everywhere, and nothing, no supplies whatsoever. And it was filthy dirty." She subsequently founded Partners for World Health, through which medical supplies that have not been used or even opened but have been disqualified for use in the United States because they were taken into a patient's room, are distributed in the Third World. When she travels, she takes as many as 20 duffel bags filled with supplies; most airlines allow her to check them for free. "We nurses hate what we throw out," she told the newspaper. "And we know we can use this somewhere in our world. There is no reason why the people of Ethiopia shouldn't have the right to a sterile syringe." The leaders and staff of the hospital support her every way they can.
These heroes are everywhere, from a former monk in Chicago who tries to cajole traumatized Cambodian refugees to seek help, to all those in both countries who do the extra thing, work the extra hour, extend the helping hand. They don't have to do this. Heroes aren't required to be who they are. They are the gifts among us. And wherever they go and whatever they do, they bring hope to us all.
And so, while we try to figure out how to shift our systems and create new ones and improve quality and engineer access for everyone and how to pay for it, as we dream our big dreams and craft our proposals, I have a simple request: While we are busy with all that, could we support and protect those heroes who are moving health care forward while the debates go on and on in the halls of power? Can we not recognize and enhance the work of people who got tired of waiting for the world to change and decided to do it themselves? Can we remove ourselves from our own egos and our own preoccupations long enough to understand that in health care, whether here or along the Tonle Sap River half a world away, success is always measured in persons as well as statistics? And that health care, no matter where it is offered, is always about persons?
In the meeting room of the Social Health Clinic in Phnom Penh, I noticed a couple of jigsaw puzzles on a side table. Given that the room is used by support groups of patients with infectious diseases, this was hardly surprising. But there were a few pieces missing from both puzzles.
There are also pieces missing from the health care systems of both Cambodia and the United States. Let us hope that we can find those pieces and put them in the right places, so that our puzzles will at last be solved.
Acknowledgments: Again, my thanks to the people who shared their expertise, opinions and time with me, both in Cambodia and in the United States. My thanks, too, to all those who reviewed these articles, especially Marty Arizumi and Maria Friedman.
Copyright ©2009 by Emily Friedman. All rights reserved.
Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Weekly and a member of the Center for Healthcare Governance's Speakers Express service.
More photos of health care activities in Cambodia as well as of its temples and other sites
First published in Hospitals & Health Networks OnLine, August 4, 2009
The first part of this article, "Starting from Scratch: Rebuilding a Health Care System," was published in Hospitals & Health Networks OnLine on June 2, 1009
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