blogCambodia Elective Report
Cambodia is a South East Asian country of roughly 15 million people. It is a country that has a legacy of human suffering and devastation. During the 3yr rule of the Khmer Rouge 30% of the population was slaughtered in a horrific ‘auto-genocide’ and many more died in the following years due to disease and malnutrition. Once an Asian centre for Medicine, after the Khmer Rouge regime the numbers of doctors fell to less than 50. Cambodia has since made much progress - they have achieved peace and had a sustained economic growth. The percentage of the population living below the national poverty line has fallen to 35%. However, in a setting of poverty, sex work, overcrowding, lack of infrastructure and lack of health funding, Cambodia’s health situation is poor. Communicable diseases, especially TB, HIV, STIs and malaria, dominate all age groups accounting for 83 per cent of all disease burden. About 11% of the population is below the minimum level of dietary energy consumption. Nearly half of all Cambodian children are malnourished, and one in eight dies before their fifth birthday, largely due to preventable causes.
Spending our time in the city of Phnom Penh we weren’t made as aware of these statistics however we did see a lot of patients suffering from the consequences of TB, HIV, malaria and leprosy infections. Hopefully this will begin to change as the healthcare for Cambodian people becomes a priority on a national and international stage.
One thing that struck Courtney and I was the huge number of hospitals and medical and public health clinics both in Phnom Penh and in rural areas. While their condition and service availability might be less than adequate and, granted, the clinics never looked to be open, signs of healthcare are certainly always visible. There are also plenty of billboards explaining normal paediatric milestones, promoting safe sex and raising awareness about malaria and bird flu.
We spent our first two weeks at Kien Khleang Rehabilitation Centre Ophthalmology Clinic which is in the north of the city. It is assisted by Rose Charities New Zealand. There is only one ophthalmologist on staff, Dr Hang Vra, and every morning he sees approximately forty patients. He is assisted by a very capable team of people including several local medical students who spend their weekdays working there and then go to university on weekends. We spent mornings in clinic with Dr Vra who constantly tried hard to include us. The hospital/clinic is small, especially to contain the huge numbers of patients, but comfortable. Patients seem to come enmasse, maintain some system of order and struggle through a series of steps that take them inside and outside seeing different people. They start on the verandah where their visual acuity is tested and written on a small square of paper. Next they wait to see Dr Vra. Generally the door to the clinic was full of people trying to see what was going on inside. After that they have their intraocular pressure checked on the other side of the room, wait outside for their dilating eyedrops to work, push their way back in for another check with Dr Vra and then see the pharmacist to get their medications. At times there were several people fighting for the one chair, but generally they seemed to have an understanding of some kind of order. We saw a good range of eye diseases and Dr Vra would let us use the slit lamp and the ophthalmoscope. The main condition by far was cataracts, but there were also many cases of corneal scarring, glaucoma, fungal and bacterial conjunctivitis, pterygiums and retinal diseases such as retinitis pigmentosa in quite young adults. Many patients would include us in their consultation, turning to us and launching into a lengthy story in Khmer, to which we’d just smile nicely and nod. Dr Vra’s most commonly used phrase was “they’ve come too late, that eye is gone already”. Most patients seemed to accept blindness as part of their life. For many however Dr Vra had the joy of being able to restore their sight or prevent its further loss. In a noisy, stressful and often tedious environment he seemed to take constant satisfaction from this. He often remarked that the other eye clinic just next door didn’t do good quality surgery and quite a few people turned up to see him with an eye that couldn’t be saved due to botched surgery. We found it sad that this can become so widely known, even by word of mouth in the general public, and yet the place is still allowed to run.
Lunch consisted of us going to a small local place with the Optometrist and one of the med students or struggling through interesting food shopping experiences with the small shop owners who spoke no English and didn’t seem to have the ability to get their message across any other way.
After lunch we would join Dr Vra in surgery. While we weren’t able to get involved we could look through the microscope and watch the surgery or watch the anaesthetist prepare the next patient. We became quite knowledgeable of the procedures involved in a cataract operation or a trabeculectomy for glaucoma. Probably the most exciting surgery we saw was an evisceration of an eye which involved cutting out the iris and then scooping out the lens, vitreous humour, retina and choroid. We became used to those little unique differences in surgery such as wearing thongs and washing gloves with saline between patients instead of changing them.
The rest of our time was spent at Chey Chumneas General Hospital in Takhmao which is about 20mins to the south of the city. The hospital consisted of several buildings spread out over quite a large site. The grounds were dusty and quiet and it often seemed like nothing was happening. The general surgery block was always crowded of a morning with the patients and their extended families. Our main contact there was Dr Nous Sarom who is a maxillofacial/reconstructive surgeon and works for FIRST - Rose Charities Canada. He was very friendly and helped us organise a simple timetable for our stay before introducing us in each section. This made things much easier since they all knew to expect us. He also gave us keys to his office which was a nice spot to keep our valuables and go for a cup of coffee. FIRST have their own building and operating theatre and you could definitely see the benefit the international funding has had. We saw some really interesting post-reconstructive surgery patients of Dr Sarom’s on the first day there but after that he had no surgery scheduled. It was harvest time in Cambodia so families don’t book in for elective surgery. We were looking forward to seeing cleft palate surgery so it was a bit disappointing and if you were choosing this as a surgical elective then this definitely isn’t the time of year to go. Instead we divided our time between the Children’s Mental Health Centre, the Children’s HIV clinic and General Surgery.
The Children’s Mental Health Centre was a really well run service and consisted of a very friendly, multidisciplinary team of people who all spoke very good English. We were able to sit in on the early development assessment clinics and assess and play with babies and small children who had a variety of neurodevelopmental delays. Most of these children had a past history of tuberculous meningitis. Every Tuesday they have an educational day for special needs children since there are no schools that offer this and we joined in on one of these. It was interesting to see that it was these children who accepted us more openly and naturally than at any other people during our trip. On Thursdays villagers from a rural province are brought in for their children to see the doctors. We were able to sit in on the consultations with the children and their parents. The children had a range of disorders but most common were epilepsy, mental retardation and personality disorders. In some cases we were shocked by how many difficulties of various kinds the mothers or grandmothers live with every day.
The paediatric HIV clinic was another good experience. The mothers were all very keen for us to play with their children and quite often a woman would lead her children to us so we could talk and play with them. This was harder than it sounds since we didn’t speak their language but the children seemed to like us. Almost all the children there were infected with HIV from their mothers during birth. We found it strange that the children all presented with varying degrees of skin infections, respiratory infections and malnutrition while their mothers all looked perfectly healthy. Generally the children were happy and relatively well despite having TH4 counts of around 1%. Most were there for a checkup and review of their antiviral medications. Occasionally a child would look quite skinny and unwell and we found it quite sad to see this. The life expectancy of most of the children would be approximately 18yrs. One little girl had been an inpatient for a month due to severe diarrhoea and malnutrition and she was still the skinniest, tiniest 4yr old I’ve ever seen. Several doctors working at the clinic spoke good English and were really keen to tell us everything despite it slowing them down so much that they’d only get through 2-3 patients in a morning!
It was quite a trip each day from Phnom Penh to Takhmao so for 1 week we stayed at the comfortable guesthouse across the road. On most days there wasn’t much to do after about 2pm so it was good to have our room so close. However it is a part of town where tourists aren’t common and we found the stares, limited restaurant options and lack of spoken English quite difficult. We would recommend staying in town and travelling out each day.
In all we had a great time. The medicine wasn’t very hands on and I suppose you could say that the learning opportunities for serious medicine were limited however we definitely gained an insight into the lives of the Cambodian people and got to see a little of the hardships they face in accessing and financing adequate healthcare. As to the standard of healthcare, because all our time was spent in charity assisted clinics we found it to be excellent. I suppose in the government hospitals and clinics it may be a little more sub-standard. We also overlapped with some other med students from NZ and enjoyed spending some time with them. I would never knock back an opportunity like this, to spend a month getting to know and understand a complex city like Phnom Penh.
Some points for future students:
* Don’t expect it to be a completely surgical elective if you go Jan-Feb
* Take your own scrubs
* Short sleeves are good because it’s oppressively hot but dress modestly.
* Mosquitoes aren’t as much of a problem as guidebooks say they are (at least not at this time of the year)
* Even as 2 females, we felt safer than we usually do in Sydney. We never had a problem.
* Contrary to some info, there are now ATMs in Phnom Penh. They dispense USD and are very reliable. Bring money in small denominations ($1, $5) and expect to deal in a mixture of riel and USD.
* The food is really nice, there are countless little family-run restaurants to eat at and they’re safe and cheap.
* Tuktuks are great transport for 2 ppl, just agree on a price first. Drivers will often arrange to come back for you in the afternoon.
* Get the 3 day pass for the Angkor temples, start early and take your time
* Visit Capitol Guesthouse for ideas for weekends
* Eat, stay or both at the Boddhi Tree opp Tuol Sleng Museum for a week, it’s really lovely.
* Internet is very available and cheap.
* All guesthouses supply linen and towels.
* Learn some Khmer - I found numbers and ‘no thankyou’ to be the most useful
* Remember to bargain, it becomes a lot easier once you get used to what things should cost.
* Have a chat to some of the kids that are selling things - they can be annoying but they’re still kids and some love an interesting talk and their English is almost the best you’ll find.
* Phnom Penh grows on you, it really does!!! There’s something really nice about it, just give it some time.
