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'The real killers are poverty, ignorance, fear, and corruption. Disease just administers the coup de grace.'
HUM DOK PO, Cambodia -- The contractions were coming at shorter intervals on that steamy midday toward the end of rainy season. But despite the bursts of pain, Sath Yan, swollen with twins, felt contentment, even joy.
The 27-year-old's first pregnancy had come late by the standards of rural Cambodia. Now, as her time drew closer, she jokingly told her husband, En Reun, that her most fervent hope was that giving birth would end the relentless teasing by her younger sisters -- both of whom had babies -- and badgering from her mother-in-law.
"We felt so lucky at that moment," En recalled.
Then the bleeding started.
A pair of wizened great-aunts had already arrived at the family's house -- like all others in the village, a one-room hut of bamboo slats and palm thatch, raised on stilts above a cow manger -- to assist with delivery. The aunts had helped bring many infants into the world. But folk wisdom has its limits. As the rush of blood intensified, the old women clucked their tongues, applied rag bandages, and lit incense sticks to chase off the evil spirits that, they reasoned, must have entered the young woman's womb.
Instead, surmised a Western relief agency doctor who reviewed the case, Sath's bleeding probably came from a small rip in the birth tract exacerbated by iron deficiency anemia, lack of vitamin A, and other uncomplicated conditions that should not be killing women in the 21st century. Not in Cambodia, not anywhere.
Hemorrhaging can be stanched by even modestly skilled medical hands, but there were no doctors or nurses for miles around, not even a midwife. Like 79 percent of Cambodian women, Sath was giving birth without a trained attendant.
She needed a blood transfusion and other help, fast. But the district clinic was empty, as usual, because the poorly paid government doctor assigned to the post almost never bothered to show. Even in this impoverished land, $15 a month -- the average wage for public service physicians -- does not secure much in the way of professional dedication. Most doctors maintain side practices that occupy their time and energy, according to extensive interviews with Western and Cambodian health specialists.
This country's vicious civil war, made notorious by the 1974-79 "killing fields" genocide by Pol Pot's Khmer Rouge, sputtered to an end five years ago. Today, the great enemy of Cambodia is not guerrillas with guns but children with relentless coughs, family water jars swarming with mosquito larvae, umbilical cords severed by tetanus-tainted blades, endemic malnutrition among expectant mothers, and tuberculosis carriers coughing up gobs of infectious spittle in public places.
While neighboring Vietnam and Thailand have made astonishing economic and social progress over the past two decades, Cambodia -- so new to peace and desperately lacking medical infrastructure, trained personnel, and even decent roads that would allow the sick easier access to care -- remains among the poorest, most disease-racked nations on earth.
The capital, Phnom Penh, looks like a boom town with its honking traffic, hundreds of new shops, buzzing Internet cafes, and clatter of construction. But in the rural areas, where 80 percent of Cambodia's 12.7 million people still wrest a meager living from the rice paddies, fewer than 30 percent of families have access to clean drinking water, less than half the children receive basic immunizations, and tuberculosis infection rates are the highest in the world, according to the World Health Organization and other international health monitors.
Of every 1,000 children born, 124 die before attaining age 5 -- a rate nearly unchanged in 20 years despite massive efforts by Western relief agencies and tens of millions of dollars in emergency and development aid.
Put another way: 150 Cambodian children died yesterday, most succumbing needlessly to wholly curable diseases -- upper respiratory infections, dehydration caused by diarrhea, tetanus, and mosquito-borne dengue fever. Eight Cambodian women died yesterday during childbirth, deaths that would have been avoidable had the women received minimal medical treatment during pregnancy and been provided with a few basic nutritional and vitamin supplements. And dozens of Cambodians of both genders and all ages died yesterday of malaria and tuberculosis, diseases for which cheap, effective medical cures have been around for decades.
The ravages of disease are worsened by a medical system that is often corrupt and constantly overwhelmed. It is a system often lacking in basic technology, a system that regularly dispenses outdated medicines or spoiled vaccines, a system so widely despised and distrusted by ordinary folk that victims of serious illness routinely refuse to seek help until it is too late.
And those not frightened away by perceived medical incompetence are often deterred by cost: According to one recent study, the most common cause of land sales by peasants -- sales that can plunge self-sufficent clans into pauperism -- is to pay for treatment of preventable diseases, most commonly malaria, dengue fever, tuberculosis, and typhoid.
"In our country, the real killers are poverty, ignorance, fear, and corruption," said Ung Vibo, a physician at National Pediatric Hospital in Phnom Penh. "Disease just administers the coup de grace."
The story isn't all bleak. Measles and polio, which once took a savage toll, have been nearly eradicated. Small but ambitious antituberculosis programs, including one designed by a Harvard physician and her Cambodian colleague, have achieved local cure rates of 95 percent at little cost. And for all the failings of the system -- with its no-show doctors, bribe-seeking, and stunning lack of accountability at all levels -- there are daily acts of heroism by a small number of physicians, nurses, and other medical personnel.
"Tragically, Cambodia depends on a few courageous individuals working miracles here and there, not on a functional health system,"' said an Australian volunteer doctor who asked not to be quoted for fear of angering the Ministry of Health, which has final approval over Western health projects.
In Phum Dok Po village, where Sath Ran was slipping fast, there would be no miracles on this day, only the familiar specters of pathos, greed, and pain.
The closest public hospital lay in Kompong Speu, the provincial capital about 30 miles to the southeast, but there was no way to communicate with the facility from a hamlet that, like many in rural Cambodia, has neither phones nor two-way radios. So a relative of Sath's who owned a bicycle pedaled furiously to the nearest town, seeking a taxi. The driver, seeing opportunity in desperation, demanded 150,000 riels -- about $37 -- a huge sum for a subsistence rice farmer like En Reun, who earns $100 in a good year.
"The husband could only raise such a substantial amount by borrowing from richer farmers," said Men Hout, 71, a village elder. "He was afraid of ruin. But even more afraid of losing his wife and unborn children. Sath Yan's bleeding was worse."
Finally, the cash rounded up, Sath was bundled into the back seat for the jolting journey along the muddy, potholed track leading to Highway 44. It was past midnight when she reached the hospital, and it took precious time to rouse the attending doctor.
Sath's blood loss was terrible, her pulse a mere flutter. The first baby to emerge, a boy, never drew a breath. It's not clear whether Sath -- slipping from consciousness -- understood that her second child, at least, was a survivor. The young woman died as her new daughter was put to her breast.
"This is not an unusual story," said Men Hout. "This is just an everyday story for common people."
Over the past few years, Cambodia has become a hotbed for AIDS, a disease considered by many to be the medical scourge of modern times. But none of the dozens of Cambodian doctors and Western health professionals interviewed for this article cited the epidemic as the country's most dangerous health adversary.
"Foreigners who visit our project always ask about AIDS," said Dr. Long Viseth, who works for a Japanese-funded mobile clinic that provides care to rural districts. "AIDS is terrible but not as devastating as the everyday killer diseases that shouldn't be killing people at all."
The number of people in Asia, Africa, Latin America, and the Middle East who perish from maladies that no longer cast a shadow in the developed world -- respiratory infections, tuberculosis, malaria, measles, diarrheal illness, tetanus, typhoid, dengue fever, complications of childbirth, vitamin deficiencies -- is horrific: 8.8 million needless deaths a year, according to the World Health Organization.
Among health workers, that toll engenders as much rage as sorrow. "To die from a preventable or treatable disease is not just tragedy, it is terrible discrimination," said Anne Goldfeld, a specialist in infectious diseases at Harvard Medical School who works extensively in Cambodia. "It is injustice more fundamental than mere inequities of wealth. These lives are stolen."
In 1994 Goldfeld and a Cambodian colleague, Sok Thim, cofounded the Cambodian Health Committee, a program in remote Svay Rieng Province, where only 30 percent of tuberculosis victims received medical care at the time. "Untreated, half of TB patients die," Goldfeld said. "Treated, most live. It's that simple."
The committee's approach was to train family members or neighbors to assume responsibility for administering the full regimen of chemotherapy. Simple as it sounds, it was a radical departure from the centralized national health care system then favored by the government and World Health Organization.
"We showed that it's possible to leverage the social capital of family and community into a cure," Goldfeld said.
The Cambodian Health Committee has treated 2,998 tuberculosis patients in Svay Rieng over the past eight years, with a cure rate of better than 95 percent. Meanwhile, the program has begun researching the genetic components of the disease.
But for every success story, Cambodia has a hundred tales that end horribly.
In an open-air ward in Phnom Penh, Meas Rom, 36, hacked bloody froth from his tuberculosis-ravaged lungs. His mother, 55-year-old widow Chun Em, had exhausted her meager savings to bring her son from Koh Kong Province to the National Center for Tuberculosis. But their desperate journey came too late. Like so many Cambodians, Meas sought medical help only after his disease reached an advanced, lethal stage. "There are no government doctors in our home district," Chun said as she fanned her delirious son with a piece of cardboard. "And people believe, anyway, that the rural doctors are worse than the disease."
Now, penniless, Chun faced a monstrous choice: Stay beside her son during his final hours or flee in order to escape one final humiliation. Families of patients who die are required to pay $14 for Buddhist cremation. But Chun had spent her last riel on medicine.
Come nightfall, Meas lapsed into a coma. A sympathetic doctor told Chun there was no chance of reviving him. So the weeping mother stole away into the darkness rather than admit she lacked the wherewithal for a proper funeral.
Come morning, Meas's body was loaded into the back of a death truck and carried off to a pauper's cremation.
The scourge of poverty
"Far too many people still die who shouldn't die at all," said Lori Dostal of the Catholic Relief Service's health project in Battambang Province in western Cambodia. "The overall health system needs to improve. Immunization and antenatal care have to get much better. Access to clean water needs to be addressed. People also need food security, jobs, and education, or many will always be sick."
Many health workers such as Dostal argue that poverty and disease are inseparable, and that -- beyond the emergency interventions that save a life here or wipe out a source of infection there -- it is impossible to improve public health in Cambodia and other developing countries without improving the economy.
"People get sick because they are poor," said Dr. Nicole Seguy, medical coordinator in Cambodia for Doctors Without Borders. "And also they get poorer because they are sick."
At Takeo provincial hospital, 20-year-old Ky Ray writhed in agony on a metal cot spread with a straw mat. As is common in Cambodia, his family had taken up residence in the ward, responsible for procuring food for the patient, bathing his body, attending to his sanitary needs. Flies swarmed through the paneless windows. The close air in the dim ward -- crowded with eight patients and 30 relatives, from yowling babes to nodding grandmothers -- carried the coppery scent of blood, the sour tang of urine, and a whiff of marijuana, sometimes used as a poor man's painkiller. Pigs and cows belonging to medical staff foraged in the grassy compound outside the ward door.
Ky's diagnosis: typhoid fever, spread by sewage-tainted food or water. It is a disease that seldom occurs in the developed world, and when it does, it is quickly cured with antibiotics. But in the developing world, typhoid remains a relentless killer, infecting 17 million people a year and claiming 600,000 lives -- 1,643 per day, according to the World Health Organization.
"His case is hopeless," Dr. Mam Moni pronounced flatly. "He came too late."
Another doctor said that Ky was carried into the emergency ward only a day after the hospital had emptied its last bottle of ceftriaxone, the antibiotic often used against typhoid.
But Ky's family wasn't abandoning hope.
"We need this young man," said Meas Pal, an aunt. "We want him to live because we love him, of course, and because life is precious. But also because we need his labor for the family to survive."
Ky, his parents, and five sisters dwell on a 4.2-acre farm in the village of Tropeang Khha , subsisting on two annual crops of rice, eggs and meat from a small chicken flock, plus peppers, beans, and other vegetables from the garden. Drinking water comes from a small pond shared with six other peasant families. The water is cloudy with manure from surrounding fields and, according to the aunt, is sometimes fouled by human waste, especially in wet season, when sewage from latrines washes over the paddy dikes.
What cash the family earns -- about $120 a year -- comes from temporary manual labor jobs that Ky and his father find in Takeo city. Theirs is a simple life, but not lacking in dignity: Ownership of land confers a degree of security. Peasants sometimes go hungry, goes a Cambodian saying, but they seldom starve.
Now Ky's sickness was threatening to knock the family from its social rung. According to a study by the relief agency Oxfam, 45 percent of Cambodian peasants who become landless have been forced to sell their acreage because of illness, making disease far and away the largest single factor in the loss of agrarian livelihood. Moreover, in the words of the study, "The first four most frequently reported diseases of those who lost land -- malaria, dengue fever, TB, typhoid -- are preventable or curable diseases."
Ky's treatment was costing $9 a day, and by the third day the family's cash reserves were gone. On the fourth day, the family sold its hog, risking lean times ahead. That night, fearing destitution, they spirited Ky from the ward, borrowing money against their three cows to rent a motorcycle rigged with a wagon -- to carry him back to their village and the ministrations of a traditional herbal healer.
"Since he was not receiving proper medicine, we felt there was nothing to lose," said Kim Em, Ky's father.
When last seen, Ky appeared to be rallying under a regimen of pounded roots and bitter bark brew.
But Dr. Mam, back at the hospital, remained pessimistic. "The herbs give temporary release from pain and a temporary energy," he said. "So families believe, for a few days, they have found an inexpensive cure. But I don't think the young man can survive."
Whether Ky lives or dies, it will be months or even years before his father and other family members are able to pay off the debt incurred by the illness. And for that reason, their story has meaning beyond the travails of one clan.
"Bad health ensures that a country will not be able to break the shackles of poverty," said Jim Tulloch, country representative for the Geneva-based WHO. "Sickly children don't grow into productive workers. Money consumed fighting rearguard actions against disease is money that won't be spent on economic development. A country whose population is chronically ill is a country condemned to remain forever on the edge of the abyss."
Distrust of the system
A big part of the country's health crisis stems from an incompetent public health system so deeply distrusted -- even loathed -- by Cambodians that sick individuals refuse to seek care until they are too desperately ill to save.
"Availability of care is a critical issue; there are too few clinics with too few qualified doctors and nurses," said Richard Veerman of Doctors without Borders. "But confidence in the system is even more critical. Because people are mistrustful of the system, they will put off treatment that could save their lives. They don't go to the public hospital until they are at death's door."
A smell of raw sewage infiltrates the unlit halls of the Preah Ket Mealea hospital in Phnom Penh. Patients provide their own straw sleeping mats or hammocks and live with their extended families in packed wards droning with the hum of insects. Cooking fires are banked against the hospital walls.
Conditions at most hospitals in Cambodia are worse. Only a handful are better -- Phnom Penh's Sihanouk Hospital Center of Hope, managed and staffed by the charitable group Hope Worldwide, offers quality of care probably unmatched anywhere else in the country. But only dozens of the hundreds who clamour outside its doors each morning can be admitted. Doctors and nurses at Phnom Penh's National Pediatric Hospital and National Tuberculosis Center also treat patients with skill and dedication.
Still, patients are reluctant to trust even such "showplace" facilities.
Ly Chanthon, 26, looked like a living skeleton as she hobbled into the Tuberculosis Center, supported by her two sisters. A day later, she was unable to sit upright in bed. One sister, Ly Chantha, fed her tiny morsels of fruit, while the other, Ly Chanto, combed her lank hair. But force of love would not be enough to save her.
"It's frustrating," said her doctor, Prum Sayeun. "It is maddening. This woman should not be dying."
Ly's last words as she slipped into a coma were to her sisters: "Please do not be sad, beloved family, for I must go."
'Too used to death'
Saffron-robed monks murmured prayers as the white Toyota Land Cruiser pulled to a stop outside a Buddhist temple in the district of Srock Phnom Sroch. Dr. Long Viseth, along with a pharmacist and two helpers, hurriedly set up an examination table in the shade of the structure while a local elder -- using a battery-powered bullhorn -- urged the men, women, and children toiling in nearby paddies to attend the mobile clinic operated by the Association of Medical Doctors of Asia, a Japanese relief group.
Strangers seldom venture to the district. Mistrustful geese honked and snapped at the medical crew. Dogs snarled and children bawled. But for most inhabitants, this was an extraordinary event. Within minutes, more than 50 hopeful patients had gathered, with scores of others abandoning the fields just to gawk. "The nearest clinic is 42 kilometers," said Shiota Hirami, project coordinator. "For people with bare feet and no motor vehicles, that is an immense distance. Some will never travel so far in their lives."
Von Phenn's 3-year-old boy, Veth Vana, was wasted by diarrhea and fever. "I have given birth to five children and watched two die," she said. "Now I am frightened for this one."
Soy Soha, 12, was racked by coughing from a lung infection. Lath Ey, 58, shuddered with malaria. Rank pus oozed from the blind eyes of 40-year-old Yun Bo. "I was chopped on the side of my head by a Pol Pot soldier and have never seen the world since," she explained matter-of-factly.
The ailments were mostly simple. Dr. Long took temperatures, listened to heartbeats, and told patients -- most of whom had never undergone a medical examination before -- to stick out their tongues and say, "ahhhh" to uproarious laughter from bystanders. He wrote prescriptions, while the pharmacist dispensed free pills and potions, carefully explaining proper dosages.
Simple ailments, yes, but ailments that all too regularly kill.
"We have become too used to death in Cambodia," said Pol Vuthra, the village schoolteacher.
"Malaria and TB kill the men and women; dengue kills the boys and girls; diarrhea takes the infants," he said. "But this is such a joyful thing -- that a doctor would come to see poor people like ourselves. The hope he brings us is better even than the medicine. Maybe death won't always be sitting on our shoulder."
Colin Nickerson can be reached by email at firstname.lastname@example.org