Rebuilding a country, step by step

In November, James Cook, a registered nurse from Sydney arrived in north-west Cambodia to begin an 18-month stint. He tells of his experiences providing much needed care and training to the local community.

I work in a busy emergency department in one of Cambodia’s major referral hospitals. Serving a population of 1 million people, Siem Reap Provincial Hospital is in one of the largest provinces in Cambodia but there is no electronic equipment and a chronic shortage of basic supplies.

Most patients that arrive are critically sick and the treatment offered is limited by the severe lack of resources. The hospital laboratory can do basic blood tests only. More advanced blood tests such as measuring lactate levels, creatine kinase, or cardiac enzymes are not possible.

Microbiology is also extremely limited, for example the laboratory is unable to do blood culture or CSF culture. There is no blood gas analysis. Diagnostic imaging is restricted to X-ray and ultrasound and there is no CT scanner.

There is a blood bank, however, supply is low and therefore the relatives of the patient receiving the transfusion are required to donate their blood to replace the supply.

The hospital wards are always full, far beyond capacity. The capacity of the hospital is 230 patients, but it actually has about 330 at any given time. These crowds of extra patients are crammed into the corridors or cared for on the floor.

Based in the emergency department at the hospital, I see a range of injuries and critically ill patients. As well as the usual presentations that any ED would see (abdominal pains, cerebral strokes, orthopaedic fractures, etc). There is a high proportion of tropical and infectious diseases and also a high incidence of cerebral malaria, meningitis and typhoid fever. Haemorrhagic dengue fever is a major cause of mortality here during the wet season.

We see a lot of complications arising from TB and HIV because of the high prevalence of these diseases among the population. Other chronic diseases such as diabetes and hypertension are mostly misunderstood, and the patient generally only takes the daily medication when feeling unwell. The concept of asymptomatic disease is generally not accepted. This of course leads to complications being all too common, due to years of unmanaged chronic disease.

The rural areas of Cambodia are home to some dangerous snakes. These can inject poisonous venom, causing either a fatal coagulopathy or paralysis leading to respiratory failure. The hospital stocks lifesaving antivenom, although this is only effective if the patient presents early enough, before envenomation develops.

Another condition requiring immediate delivery of an antidote is organophosphate poisoning. Most of the population here earn their livelihood through farming, and so they and their family have access to large qualities of insecticides. It is not unusual to have someone brought in with organophosphate poisoning as a suicide attempt. Unfortunately, these patients are often brought in too late for treatment to be effective.

Road accidents are extremely common here, due to the lack of adherence to traffic rules. The roads are of poor quality and the situation is made worse by the fact that most motorbike passengers don’t wear helmets. These factors make motorbike trauma a leading cause of mortality.

Due to there being no neurosurgical capabilities in Siem Reap, any serious head injury would need to be driven to the capital, Phnom Penh, some six hours away. This of course is a significant delay for any intracranial haemorrhage. For the majority, however, it is not even an option, as they would not be able to afford the transfer fee and treatment costs.

Severe sepsis is also a common presentation. For many it is because they have delayed treatment for their infections, and so by the time they present to the hospital they are in a critical condition. There may be a delay because the family did not feel that they could afford the treatment or because they physically live so far away. Some patients I have met have had to travel at least 200 kilometres to get to the hospital, a journey made somewhat longer by the poorly maintained roads.

Without a national emergency telephone number, or a collaborative ambulance service, most patients are bought in to the ED by a family member on the back of a motorbike, a farm trailer or in one of the commonly used tuk-tuks (motorised rickshaw).

In the hospital grounds there is an emergency department, medical wards, surgical wards, and two operating theatres. Other wards include orthopaedic, ENT, ophthalmology, tuberculosis, gynaecology and a maternity unit.

Part of my role is nurse educator to the staff. This involves both bedside coaching as well as more formal classroom teaching. The nurses are very skilled at what they do, and are very efficient at following the orders of the doctor. However, they have limited background knowledge, and lack the theory behind their practice. They are not familiar with assessing the patient and evaluating the patient’s condition by themselves.

I have a translator working with me most of the time which enables me to offer bedside coaching, and to train the nurses as issues arise. I also deliver teaching sessions a few times a week, in a more formal classroom style of teaching.

The other part of my role is nurse adviser. Some of the areas that I have been advising on are triage, nursing documentation and infection control. I will also be involved with various grant applications and proposal writing.

One specific objective I have during my 18 months here is to develop the resuscitation room. The room at present has no electric equipment in it. I hope to facilitate equipping it with a cardiac monitor, a defibrillator, and a couple of electric fluid pumps. This is equipment that would be seen as essential in Australia, but is too expensive for the hospital to purchase.

Cambodian history

The country has a population of 14.8 million people. Located in South-Eastern Asia, it boarders Thailand to the north-west, Laos to the north, and Vietnam to the east.

In terms of human development, it ranks 139th out of 187 countries. According to the UN Development Program, its national economic performance is ranked well below other south-east Asian countries.

Cambodia has achieved remarkable progress over the past decade in a number of areas important to human development, such as childhood and maternal mortality rates. However, it has to be remembered that these improved figures are actually being compared to a shockingly high baseline, and even though improvement can be seen, the figures remain unacceptably high.

Up until a few years ago, Cambodia had the highest infant and under-five mortality rates in south-east Asia. It also had one of the highest maternal mortality rates in the region. These health indicators are improving but nevertheless women in rural areas continue to die in large numbers during childbirth, and child mortality still remains incredibly high. Cambodia is ranked lowest among eight countries in ASEAN in terms of infant mortality as well as life expectancy and education.

Poverty remains unacceptably high and according to the World Bank, a third of the population lives on less than 58 cents a day.

Poverty compels Cambodian children to be removed from primary school at an early age. Fewer than half enrolled children complete primary school. Reasons for this may be the inability to afford school books and materials, possible long or difficult travel, and the requirement to enter the labour market to earn money for the family. This leads to a highly uneducated future labour force, and an ongoing cycle of poverty.

Poverty leaves many children in Cambodia malnourished. According to the latest UN Human Development Report, in 2007, 79 per cent of children were either moderately or severely stunted, and 8.9 per cent of children were suffering from wasting. Nutrition is a key determinant in health, and widespread malnutrition has profound implications for the physical and mental development of Cambodia’s next generation.

The Cambodian population is vulnerable to many tropical and infectious diseases. When compared with other countries of south-east Asia, Cambodia has a particularly high incidence of malaria, tuberculosis and HIV/AIDS. It also has high numbers of dengue haemorrhagic fever.

The majority of Cambodians live in rural areas, some 85 per cent of the population, with only 15 per cent living in urban dwellings. Nearly all who live rurally get their livelihood from agriculture, and most of the land is not irrigated. Without irrigation systems, most farmers are only able to have one crop a year, and they do not have the luxury of being able to experiment with alternative crops and methods, as failure could lead to severe food shortages for their family.

Having only one harvest each year, and the lack of crop diversification, restricts their ability to earn and pull themselves out of poverty. In addition, without irrigation systems, the farmers are reliant on good rainfall, which means some years the quantity and quality of the crop can be inadequate. What’s more, they are very vulnerable to natural disasters, such as floods and droughts, which can turn the poor farmer into one that’s destitute.

Those that live rurally, mostly live more or less like their ancestors did centuries ago. Conditions remain primitive, with over 80 per cent of rural households having no electricity. Access to sanitation is also extremely low, with 57 per cent of households having no toilet facility. Sanitation systems and sewage treatment facilities are non-existent in most places. More than 50 per cent of rural people do not have access to improved drinking water, such as new wells or rebuilt urban piping.

Villages often only have a single water source for drinking which can easily be contaminated and spread water borne diseases, such as hepatitis A and typhoid. Many have no choice but to drink directly from unsafe water sources, such as rivers, lakes, and unprotected wells. Water borne diseases are rampant, and are one of the major preventable causes of death for children.

These are some disturbing figures, and that’s not even mentioning the landmines, human trafficking, child labour, street children and child sex abuse that, distressingly, are quite common. What are the causes for such tragic statistics? I believe some of the answers lie in its very traumatic and recent history.

Cambodians have endured decades of violent political upheaval since they gained independence from the French in 1953. The Vietnam War caused much political instability across all of Asia in the 1960s. In 1969 America conducted bombing raids over Cambodia. This no doubt increased the public’s turn of support, away from Prince Norodom Sihanouk, the head of state, to the Khmer Rouge, a fanatical communist faction which was fast gaining momentum.

Civil war broke out in 1970, which eventually lead to the Khmer Rouge taking power. On April 17, 1975, the Khmer Rouge declared “year zero” and took control of the capital, Phnom Penh. They evacuated the residents at gunpoint, into the countryside to work as forced labour. They attempted to create an agrarian communist society.

The brutal regime ruled the country between 1975 and 1979. To ensure no future threats to their power, they targeted the educated or wealthy. They hunted down lawyers, judges, doctors, businessman, students, teachers, civil servants, intellectuals, monks, and anyone that could be a potential threat. They were ruthlessly executed. It was genocide.

Education was abolished. The country’s infrastructure was destroyed. Money became worthless. Severe food shortages lead to starvation. The health of the population deteriorated, and disease was rife.

During the four years of Khmer Rouge control, it is estimated that between 1.7 million and 2.2 million people or about 25 per cent of the population died, through starvation, disease, exhaustion and execution.

Under the Khmer Rouge, the healthcare systems collapsed. Most of the country’s doctors were killed. The lasting impact of this is still obvious in the state of the present day national health care system.

The regime was overthrown in 1979 by their Vietnamese neighbours. The country remained occupied by the Vietnamese for the next decade. Khmer rouge remnants hung on, and guerrilla war continued throughout the 1980s, which greatly impeded development. The Vietnamese pulled their troops out in 1989. Armed conflict continued, and the UN then occupied the country with their peacekeeping operation, and oversaw the elections in 1993. The elected government was then toppled during bloody clashes in 1997.

Years of brutal conflict have hindered development, leaving a weak economy, inadequate infrastructure, and an inadequate health service. Decades of civil war and political instability have made Cambodia one of Asia’s least developed countries.

Like most hospitals in the country, Siem Reap Provincial Hospital suffers from a chronic and severe lack of basic supplies, medicines and equipment. This, combined with the fact that the patients are often so critically ill, creates many challenges on a daily basis.

I chose to come to Cambodia for several reasons. However, I feel extremely privileged to be here, and honoured to be welcomed into this hospital. I am excited about what can be achieved. It is important not to get overwhelmed by the national statistics and instead look to what can be done. And there is a lot that can be done in the hospital here.

James Cook is a registered nurse in Sydney. He previously worked in the emergency department at St Vincent’s Hospital. For more information or to help, visit www.medicalcambodia.com

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