Rural Cambodian Health Care – Part 1: Initial Impressions

Dear Grampa,

One of my favorite Khmer health care terms sounds like peanut chah chah which literally translates as “check-up old old.” This is what we call the weekly health screenings for the elderly villagers. Sometimes they are hosted at one of the many stunning local pagodas.

I first learned about these check-ups in the same way I’ve learned about most Cambodian gatherings – by being stuck on a moto with coworkers and whisked away to a new village with little explanation, followed by a lot of fumbling observation/aggressive grinning while the key players set-up and run the show. I was thrilled once I understood what was going on. The elders would have their blood pressure, urinary glucose, and other ailments lamented about before snagging some appropriate medication and having their grandsons aid their laborious strolls home. I started watching like a hawk for the right moment to swoop in and drop some health education with those meds – Less salt, more water, buy soap, BOOM. – but I was stopped short that day.

A few things became evident about these group check-ups, things which would prove to be common elements about all group activities conducted by my health care team. First of all, several key steps of both technical operation and interpersonal communication were being completely mismanaged. There were small things like staff members declining to leave the test-strips submerged in their urine samples for the full prescribed minute or failing to give proper instructions about medications. Some things felt like greater trespasses, such as dumping the urine samples on the floor amongst everyone’s feet or guessing people’s weight and blood pressure.

And second, patients were made to wait until a crowd of them amassed and then shuffled into a tableaux for photo-taking with the chief and any commune officials who may be present. In fact, since I arrived, not a single collective activity at the health center has come to pass that has not been commemorated on Facebook, whether it be a community check-up sanctioned by the Ministry of Health or simply moving dirt about. I have learned that it’s most desirable to feature in these photos the ubiquitous Cambodian People’s Party placards and/or likenesses of Hun Sen that decorate the roads through the countryside as well as the home of many a village-chief.

If I had to condense my initial impressions of rural Cambodian health-care into a single, succinct perception I would stress the importance of appearances. Patients want treatment that they can lay their eyes on – pills, injections, numbers – and they want it from the health care staff, who allot patients mountains of ibuprofen and amoxicillin everyday under the auspice of extreme prestige that comes from donning at least half a pair of scrubs. Most patients come first thing in the morning. They want their rightful handful of meds and they want to scoot back home as soon as possible. This leaves little room for health education. Grandmothers can’t understand why they should believe in hand-washing (yet another task) or germs (invisible) when they could just give their grandkids cotrime (tangible pills) for their recurring diarrhea. Indeed, our pharmacy counter is the proverbial WebMD of rural Cambodian life. Patients impress me every day with emphatic descriptions and theatrical pantomimes of their various ailments as if we will only yield the meds if satisfied with the performance. My older uncle coworker who mans the registration desk has perfected the art of waiting quietly for their conclusion before calmly asking, “Anything else?”

All of this hype for prompt and palpable treatment results in a very busy work life for one very dear coworker – the serene, the organized, the enduring Uncle Vuth the Vaccinator.
You may remember him from such great hits as his self-staged photo-shoot with some corn in this post or from his skeptical satisfaction with my odd pumpkin pie in the account of Thanksgiving. Our commune loves vaccines. At least once, usually twice per day, a parent will arrive with a tiny kid proclaiming that it’s been a few months since their last stick. Vuth is always the one to either the recognize the child or consult his detailed, immaculate records and shoo the pair away. Rarely is the child actually due for any type of vaccine. Other times, folks will show up feeling weak. We give them an IV of saline. Between Vuth’s organization and cooperation between the village and commune officials, periodic vaccine delivery throughout the area has eradicated measles, mumps, rubella, tetanus, diphtheria, and Hep A-Z. The flood of eager mothers makes each vaccine runs a madhouse.

Given the patchwork nature of our health-center, plastered with materials from a dozen and a half NGOs from all over the world over years of brief, uncoordinated visits and trainings, I can’t blame my coworkers or staff for being inundated and impassive.So ubiquitous is the climate of international aid that I embarassed myself the other day when I asked, “Who donated the paint and building supplies?” as we began sprucing up the center when a coworker plainly said, “We actually bought them.”

I have begun to weasel my way into the pharmacy and accompany Vuth on vaccine outreach with the hope of discovering an avenue for more education. The staff have expressed interest in active/complementary feeding education for young mothers and hand-washing for recurring diarrhea patients. We shall see. Certain things already run so smoothly here. Breastfeeding is widely accepted and encouraged. As mentioned, vaccinations are on point. Pregnant women take their iron-pills regularly and come for frequent antenatal care. We consistently harangue the elderly into coming for wellness check-ups. And  finally, my personal favorite, local mothers cook up an enormous batch of rice porridge with veggies and meat three days per week for the local kiddos. Naturally, I coerce them into playing germ-related games.

Students: Germs, what time is it?

Germs: It is time!

Me: Don’t let the germs touch you!

Somedays all I do at work is rock the nurses’ babies to sleep while their mom’s get real work done or help the midwives flirt with English-speaking suitors online. It takes an effort on my part to relax into this and play the long-game, hoping that these relationships will pave the way for projects down the line. I’m just fine with playing doctor for a little longer. Grampa, have you been to the doctor lately? Last I checked you were the prize of the practice, fit as a fiddle, strong as an ox. I wish your trip to the doc could be a stroll as easy and breezy as my morning commute so that you could go in and impress them more often.

Be well. Love,

Kels