Its not just the rotten, corrupt, health system or the health workers in it that are a barrier to change & good health here, another big barrier is the general population's attitude to health & health care. There is a fatalism that extends beyond the frequently occurring scenario of a doctor sending home a potentially curable patient as "a hopeless case" to die. The people themselves also often display the same hopelessness & a learnt helplessness which surely comes from years of having such an ineffective health care system.
I have countless examples of patients just seemingly accepting their lot, which can often be more infuriating than the health workers attitudes. Patients are scared to ask for decent health care, they lack a sense of entitlement for it. This lack results from a complexed combination of history, resources, belief systems, heirachy, patronage, religion & of course culture.
M - the 17 year old girl with WPW syndrome - spent a week in an SVT of over 200/min waiting for me to get back from my holiday because she wouldn't go to the hospital if I wasn't there. She blindly hoped it would just get better by itself despite my advice that she should always go to seek help if she develops symptoms. This was frustrating when she finally came to hospital jaundiced & swollen from her multi-organ disfunction but not unsurprising considering how she had been treated on her first admission. Now I am left worrying about what she will do when the inevitable happens, her drugs run out or are lost before her next appointment & she has another run of SVT but no money to get to the NGO hospital. Will she just sit & wait patiently for karma to do its thing. Here the poor will often just shrug & think health care is too expensive for them. This is their fate, their karma from a previous life, their 'rice has run out', its their time to go. Small children die needlessly for the want of an antibiotic, immunisation or nutritious food and people shrug & say a spirit - the mother from a previous life - has taken the child back. Every one knows that only one twin will ever survive - that's just the way it is. One in twenty children not making it to their 5th Birthday is considered Karma.
My old VA contacted me about a health problem & I advised that he go to the local NGO clinic because it is both cheaper than any of the exorbitant private clinics here & inarguable provides a much better standard of medical care. Instead he chose to go to one of the many private clinics where they charged $450 for treatment which was most likely either inappropriate or completely unnecessary. Medicine is primarily about making money here & secondarily for curing patients. The fact that he, like every other Cambodian, refused to listen to my medical advice just meant that I felt significantly less obliged to pick up his over inflated medical bill.
Two of my friends have eye problems which I am worried about so want them to get checked out but both are resistant for similar reasons. They don't trust the eye doctor to know what is wrong with them & to do the right thing. They can't go back or ask for a second opinion without the doctor getting angry with them. They certainly can't ask for only a consultation because they will be 'forced' into purchasing unnecessary & expensive medication. One friend went & was operated on immediately without being given time to consider the options for her non-urgent eye complaint. If they ask any questions about their problem or the medications they have been given (all the labels will be removed so they can't buy them outside the clinic) the doctor will "shout & get angry". Why? I ask - because the Doctor is a very important person who knows everything & his patients are very low status & should not question him. I am inclined to believe from my experience with Cambodian doctors that the anger actually comes from ignorance - no one likes to be asked questions they don't, but should, know the answers to. I loitered outside the hospital eye ward for 20 minutes recently waiting for the doctor to leave so my friend & I could slip in & ask the nice nurse to use the slit lamp, me going along to a consultation with a doctor for either of them is absolutely out of the question. I think my friend would rather go blind than do that. That in itself is a damning indictment of the Cambodian health care system. The nurse however was extremely compassionate & kind - she should open her own clinic, maybe she already has.
There also seems to be a general ignorance when it comes to health in Cambodia, which surely must stem from the incredibly poor education & health systems, the poor governance hence minimal public health policies, plus of course genocide eradicating a whole generation of wisdom, knowledge & common sense. The median age in Cambodia now is 22.9 years old. This probably explains why the great Cambodian public think IV glucose is necessary for every condition & gives you 'energy', spitting in wounds is helpful not in fact an infection risk, massaging a fracture is healing rather than agonising, pulling a trauma victim around like a rag doll is spine friendly or rubbing someone repeatedly with a tiger balm lid until they are black & blue is a panacea for all ails. The general public's health ignorance results in my friend's family mocking his eye problem when in actual fact what he has is a common cause of blindness that their treatment of spitting, breast milk & steroid cream have all been shown to be wholly ineffective against.
I think it is probably fair to question the wisdom of a population that bruises, burns & puts inert poultices on the head's of their children yet doesn't know the dose of Paracetamol to give their child if they are in pain or have a fever. I often dream of producing a series of different dramas - the Cambodian equivalent to Casualty, Holby city, ER, Dr Martin etc. - which based on the philosophical foundation of public service broadcasting would inform, educate & entertain the masses. I would have to include one character; a pissed off English NGO doctor that no one ever listens to but who stubbornly stays regardless. I am sure Cambodians would enjoy watching her unravel whilst her closest Cambodian work colleagues learn to swear like dockers & become blind militant feminists. It has got to be better than the crap Korean soap operas we are currently subjected to here.
In the past the patient only paid the healer, whether that was monk, traditional or western doctor, at the end of a successful course of treatment, like in China, hence a doctor who was good at their job got paid more. Paying the doctor first removes this incentive & in a country where everything is about the money maybe this would be the best way to re-motivate doctors to do their job properly, keep up to date with & follow treatment guidelines. I suggested this to one hospital director & he laughed, agreeing with me. He then reflected that it was better when it was the 'old way', doctors had a better relationship with their patients. There was trust then, which currently is completely lacking.
Another huge issue & barrier is the levels of mental illness & psychological problems in the population that prevent access to healthcare but also affects the expression & presentation of illness. I was recently asked to see a relative of a staff member who was being treated for Hepatitis C with interferon. She was experiencing what sounded to me like anxiety attacks but they were tightly enmeshed with her hepatitis symptoms & the side effects of interferon. We had a long conversation about what her fears were & unlike her family who were looking for a physical cause & cure she too thought it was psychological. She was in her late 50s & lives in an area which had active violent civil war right up to the elections of 1993 & sees many consequences of the war to this day with mines & unexploded ordnance.
I talked about how people aren't just physical symptoms or purely expressions of their psychology. She has both physical & psychological elements to her - like we all do. She agreed with this but her Doctor relative also nodded sagely & told me - every patient that we see here in Cambodia we have to ask ourselves how much is a psychological manifestation & what is physical.
Although Cambodia has more than its fair share of mental health problems this country has very few psychologists or psychiatrists so any problems are mainly left untreated. Unless of course you can get to the Pagoda or traditional healer to exorcise the bad spirits.
Once my assistant asked me once to see a man who was withdrawing from alcohol because he believed he was possessed by evil spirits & wanted to show me - the skeptic - that spirits did really exist. Unfortunately having a translator who doesn't believe in alcohol withdrawal made it hard to convince the staff or relatives that the patient needed Diazepam. Luckily the patient himself needed less persuading to break his 48 hours abstinence from 2 litres of palm wine a day & promptly self discharged to self medicated.
And who can blame him? When I think about all the barriers to good health in Cambodia I find myself heading towards my emergency bottle of red wine too.
I have countless examples of patients just seemingly accepting their lot, which can often be more infuriating than the health workers attitudes. Patients are scared to ask for decent health care, they lack a sense of entitlement for it. This lack results from a complexed combination of history, resources, belief systems, heirachy, patronage, religion & of course culture.
M - the 17 year old girl with WPW syndrome - spent a week in an SVT of over 200/min waiting for me to get back from my holiday because she wouldn't go to the hospital if I wasn't there. She blindly hoped it would just get better by itself despite my advice that she should always go to seek help if she develops symptoms. This was frustrating when she finally came to hospital jaundiced & swollen from her multi-organ disfunction but not unsurprising considering how she had been treated on her first admission. Now I am left worrying about what she will do when the inevitable happens, her drugs run out or are lost before her next appointment & she has another run of SVT but no money to get to the NGO hospital. Will she just sit & wait patiently for karma to do its thing. Here the poor will often just shrug & think health care is too expensive for them. This is their fate, their karma from a previous life, their 'rice has run out', its their time to go. Small children die needlessly for the want of an antibiotic, immunisation or nutritious food and people shrug & say a spirit - the mother from a previous life - has taken the child back. Every one knows that only one twin will ever survive - that's just the way it is. One in twenty children not making it to their 5th Birthday is considered Karma.
My old VA contacted me about a health problem & I advised that he go to the local NGO clinic because it is both cheaper than any of the exorbitant private clinics here & inarguable provides a much better standard of medical care. Instead he chose to go to one of the many private clinics where they charged $450 for treatment which was most likely either inappropriate or completely unnecessary. Medicine is primarily about making money here & secondarily for curing patients. The fact that he, like every other Cambodian, refused to listen to my medical advice just meant that I felt significantly less obliged to pick up his over inflated medical bill.
Two of my friends have eye problems which I am worried about so want them to get checked out but both are resistant for similar reasons. They don't trust the eye doctor to know what is wrong with them & to do the right thing. They can't go back or ask for a second opinion without the doctor getting angry with them. They certainly can't ask for only a consultation because they will be 'forced' into purchasing unnecessary & expensive medication. One friend went & was operated on immediately without being given time to consider the options for her non-urgent eye complaint. If they ask any questions about their problem or the medications they have been given (all the labels will be removed so they can't buy them outside the clinic) the doctor will "shout & get angry". Why? I ask - because the Doctor is a very important person who knows everything & his patients are very low status & should not question him. I am inclined to believe from my experience with Cambodian doctors that the anger actually comes from ignorance - no one likes to be asked questions they don't, but should, know the answers to. I loitered outside the hospital eye ward for 20 minutes recently waiting for the doctor to leave so my friend & I could slip in & ask the nice nurse to use the slit lamp, me going along to a consultation with a doctor for either of them is absolutely out of the question. I think my friend would rather go blind than do that. That in itself is a damning indictment of the Cambodian health care system. The nurse however was extremely compassionate & kind - she should open her own clinic, maybe she already has.
There also seems to be a general ignorance when it comes to health in Cambodia, which surely must stem from the incredibly poor education & health systems, the poor governance hence minimal public health policies, plus of course genocide eradicating a whole generation of wisdom, knowledge & common sense. The median age in Cambodia now is 22.9 years old. This probably explains why the great Cambodian public think IV glucose is necessary for every condition & gives you 'energy', spitting in wounds is helpful not in fact an infection risk, massaging a fracture is healing rather than agonising, pulling a trauma victim around like a rag doll is spine friendly or rubbing someone repeatedly with a tiger balm lid until they are black & blue is a panacea for all ails. The general public's health ignorance results in my friend's family mocking his eye problem when in actual fact what he has is a common cause of blindness that their treatment of spitting, breast milk & steroid cream have all been shown to be wholly ineffective against.
I think it is probably fair to question the wisdom of a population that bruises, burns & puts inert poultices on the head's of their children yet doesn't know the dose of Paracetamol to give their child if they are in pain or have a fever. I often dream of producing a series of different dramas - the Cambodian equivalent to Casualty, Holby city, ER, Dr Martin etc. - which based on the philosophical foundation of public service broadcasting would inform, educate & entertain the masses. I would have to include one character; a pissed off English NGO doctor that no one ever listens to but who stubbornly stays regardless. I am sure Cambodians would enjoy watching her unravel whilst her closest Cambodian work colleagues learn to swear like dockers & become blind militant feminists. It has got to be better than the crap Korean soap operas we are currently subjected to here.
In the past the patient only paid the healer, whether that was monk, traditional or western doctor, at the end of a successful course of treatment, like in China, hence a doctor who was good at their job got paid more. Paying the doctor first removes this incentive & in a country where everything is about the money maybe this would be the best way to re-motivate doctors to do their job properly, keep up to date with & follow treatment guidelines. I suggested this to one hospital director & he laughed, agreeing with me. He then reflected that it was better when it was the 'old way', doctors had a better relationship with their patients. There was trust then, which currently is completely lacking.
Another huge issue & barrier is the levels of mental illness & psychological problems in the population that prevent access to healthcare but also affects the expression & presentation of illness. I was recently asked to see a relative of a staff member who was being treated for Hepatitis C with interferon. She was experiencing what sounded to me like anxiety attacks but they were tightly enmeshed with her hepatitis symptoms & the side effects of interferon. We had a long conversation about what her fears were & unlike her family who were looking for a physical cause & cure she too thought it was psychological. She was in her late 50s & lives in an area which had active violent civil war right up to the elections of 1993 & sees many consequences of the war to this day with mines & unexploded ordnance.
I talked about how people aren't just physical symptoms or purely expressions of their psychology. She has both physical & psychological elements to her - like we all do. She agreed with this but her Doctor relative also nodded sagely & told me - every patient that we see here in Cambodia we have to ask ourselves how much is a psychological manifestation & what is physical.
Although Cambodia has more than its fair share of mental health problems this country has very few psychologists or psychiatrists so any problems are mainly left untreated. Unless of course you can get to the Pagoda or traditional healer to exorcise the bad spirits.
Once my assistant asked me once to see a man who was withdrawing from alcohol because he believed he was possessed by evil spirits & wanted to show me - the skeptic - that spirits did really exist. Unfortunately having a translator who doesn't believe in alcohol withdrawal made it hard to convince the staff or relatives that the patient needed Diazepam. Luckily the patient himself needed less persuading to break his 48 hours abstinence from 2 litres of palm wine a day & promptly self discharged to self medicated.
And who can blame him? When I think about all the barriers to good health in Cambodia I find myself heading towards my emergency bottle of red wine too.
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