This cartoon derives from a 2015 article about an anti-corruption exhibition organised by Transparency International Bangladesh. TIB arranges 10th Anti-Corruption Cartoon exhibition at Drik Gallery. It illustrates the user-pays health care system prevailing across the poor world in which health professionals are enriched on the backs of an already impoverished general public. “Without money you die” are words spoken by doctors and nurses as a matter of fact to patients on a daily basis here in Cambodia. Their words reflect reality as people suffer and die in all manner of unimaginable ways due solely to a lack of money, many leaving their families behind with an inheritance of crushing debt.
Many of the doctors prospering from this system have received training in wealthy nations whose intention, I am sure, is to promote quality care in places with limited means. I am equally sure that few involved in offering the various scholarships and other opportunities understand that they are often serving to further empower oppressive systems. This could be regulated at least in part, by placing certain conditions on the beneficiaries of such training and by requiring some level of monitoring, as exists in countries where the public do have safeguards.
For many in Cambodia, the only option for health care comes in the form of NGOs, of which there are many yet there are not enough and for which there is little to no coordinated collaboration between services. Brief and temporary services are also offered by various visiting organisations as a form of stopgap and often as a means to offer further training to local staff. As someone trained in public health, familiar with health systems, experienced in sourcing services for clients, and with access to resources, I do not navigate the health systems in Cambodia easily because there is no centralised point of communication about what is available and where. There is limited governance so that private businesses can impersonate NGOs with impunity and a black market offers all manner of medications and supplies, even anti-TB medicines which require strict regulation for protection against bacterial resistance.
When the education system started from scratch in 1979, 75% of all teachers and 95% of all tertiary students had been killed in the Khmer Rouge genocide. Forty years on, through decades of political and economic turmoil, the education system is still re-establishing. Teachers in public schools, many of whom are based in dusty rural villages with few to no resources, earn a low income and have unclear levels of training. Teacher salaries are so low that students are required to pay a small daily cash fee to ensure a livable income. In many families cash is often unavailable, affecting school attendance rates as much as the bare, dusty and overcrowded classrooms must. Insufficient family income further encourages the mass exodus of children from school before their literacy has been established as children are needed to help support the family.
Ignoring the multitude of other complex factors at play in Cambodian society, this alone offers explanation of the low levels of literacy and numeracy and high levels of hardship seen in rural villages and urban slums here. Children pulling wooden carts looking for recyclable materials to sell; parents labouring for low casual wages far away from their young families; and perhaps more worryingly, young people vulnerable to persuasion by all manner of dubious employment offers, all stem at least in part, from the need created by an inadequate education system.
The population survive (and perish) in a micro-economy where even the literate and educated face challenges that are unheard of in the wealthy world. The fact that accomplished, qualified and experienced doctors, engineers and architects can face high rates of unemployment is perhaps the most remarkable example.
This background of necessity leads to any number of inventive and creative enterprises. Profiteering from health care services delivered with inadequate regulation to a population with deficient health literacy is probably the biggest and best example among many, of this inventiveness.
Alongside the perpetual need endured here, is a chronic state of systemic corruption. As a colleague said to me some years ago “I feel upset when foreigners accuse me that I am from a country of corruption. They feel okay to challenge me but then they show big respect to the high ranks who ARE corrupt. I am not corruption. I am the victim of corruption”. It is important to understand this because those of us from countries where corruption (which is never non-existent) exists at lower levels, or in a more hidden form, can be quick to judge local people without understanding the situation. In fact, individual corruption, although it also exists, is not the real problem, but rather systemic corruption which is established from the top and filters down through the various institutions.
After 2.5 years living in Cambodia I still have a very basic understanding of the way that deficient systems provide an ideal environment for corruption to become institutionalised and normalised. Talk of purchasing black market medications to treat a patient for example, sounds shocking until you understand that the doctor speaking to you wants to cure his patient, and understands that his patient cannot afford to (and therefore will not) attend the established health facility who could provide regulated medicines.
Example 1: Infant Feeding
I provided the above background in an attempt to explain why it is necessary to recognise that not everyone employed inside corrupt institutions or engaging with corrupt systems, is corrupt themselves. Often at an individual level there is no other option. Not everyone involved in corrupt systems is aware of the role they are playing, or has alternative choices, or is even necessarily doing the wrong thing by others, at least not consciously. Many are as much the casualties of their nation’s established need and chaos, as anyone else.
Last month I encountered an eighteen day old baby lying asleep on the bamboo strip floor of a little hut. I was busy assessing her mother’s four year old in the dirt on the Mekong shore, who appears to have some form of polio-like condition. Only after I finished “playing” with this little girl, did her mother announce “I also have a new baby”. Big brother moved further inside the open walled hut and reappeared with his tiny sleeping sister. Enquiring about her health, Mum presented me with a blue tin of artificial infant milk powder and stated “I don’t have enough breastmilk”. Over the years I have learned that this is a common phrase used in maternity clinics here to promote the sale of artificial infant milk. Even educated doctors have told me “I am mix-feeding because I don’t have enough breastmilk”.
Training mothers that they “don’t have enough breastmilk” commences on Day 1. My guess is that health professionals who probably know otherwise, use misinformation to train uneducated staff to undertake this work, as a way of boosting artificial milk sales. It all happens at a highly emotional time for new mothers, before breastmilk production and a feeding pattern can be properly established, and before weight gain or urine output can be monitored as ways to gauge whether the baby’s intake is adequate. There is a wealth of understanding today among health professionals, of the health benefits of breastfeeding for both mother and child. Equally, we also understand the strong influence that artificial infant milk promotion has on breastfeeding rates even in countries where this promotion is strictly regulated, and where the population have sound health literacy with access to reliable information and support systems. As this infographic illustrating the stomach size of a newborn baby shows, the statement that a new mother “doesn’t have enough breastmilk” is probably almost always false.
Clearly the Baby Killer scandal of the 1970s continues unabated today in parts of the world where necessity and chaos reign supreme. Since meeting 18 day old, who is now seven weeks old, I have learned a lot. When we met her again at 5 weeks old the blue tin of artificial milk powder had been replaced with a green tin. My translator informed me “The maternity clinic donated the blue tin to her, but when she went to buy it, it was too expensive so she bought this one because it is cheaper”. Mum, who cannot read or write, was still following the instructions from the maternity clinic about how to make the milk and how much to give. These instructions are appropriate to newborn needs which change rapidly over the first few months, requiring some level of health literacy and ability to read instructions, to implement. This explained her very unsettled and hungry baby’s advancing malnutrition. Working with her to address the problem, I contacted a nutritionist colleague in Australia who further investigated, finding that this particular company offer “infant milk” formulas up to the age of six years old, when normal cow’s milk can be safely introduced from 12 months old. The market for artificial infant milk – very likely still responsible for many infant deaths – is clearly a very lucrative one.
We continue to work with this mother, and monitor baby whose growth pattern has started to improve with a little education and support. We are also working to encourage establishing breastfeeding as the accepted norm in her small community, including strategies for women to respond when placed under pressure to use artificial infant milk.
Example 2: Curative Potions
A few years ago I spoke about Joe, who died slowly from probable post-Polio syndrome, lying on the hammock inside his falling-down banana leaf-walled, bamboo-floored hut in a remote village. Just after Joe died, I learned that his family had sold their cows to purchase a medicine from a visiting salesman who promised his remedy (which sounded from the unreliable translation, like a human colostrum formulation) could be curative. The same day that I heard this story, the guard at my hotel told me he had a day job as well as his night job, selling something for a “medicine company”. Earning US$100 per month offering security services in the evening during the hotel’s busiest hours, he slept on the restaurant couch at the locked front door of the hotel by night. He was pleased to have found a second job as a salesman to supplement his main, barely-livable income. He spoke about it openly and even with some pride that a medicine company would employ him.
It is almost five years since I met Paula, age 25 and weight 20.8kg in May 2014. Her story has been covered in various blog posts since that time as she had such a profound affect on me. As did the incredible serendipity of encountering an American surgeon with the skills to cure her hospital-acquired injuries, in the company of some people with the capacity to cover the cost of getting her to America.
The first time I met Paula’s father was in May 2014 when he appeared before my eyes carrying an unrecognisable bundle towards me on the hospital verandah. The shock I felt when I realised it was a human in his arms, is embedded in my brain. The last time I saw him was at Phnom Penh Airport when Paula was lying on a stretcher waiting to enter the departures lobby for our flight to the surgeon in Seattle. Since then her father has been living in Malaysia, selling food at a street stall in order to pay off the family debt incurred by the various and injurious treatments that Paula received prior to arriving at our service and learning her condition was not cancer, but rather drug resistant mesenteric TB.
A few weeks ago an email from the Seattle surgeon’s wife included the words “I hope she is giving back in some way“. My internal, unspoken response was “if she had an education and some opportunity she could“. A few days later I received a message from Paula’s family that her father had returned from Malaysia and could I plan to visit him? I took a weekend trip to Kampong Cham and traveled out to their village to meet him.
Paula, now in full health, was away but her parents informed me proudly that she has a job. My tuk tuk translator said “she sells something for a medicine company. Something to drink. If she sells enough she can get high salary but if she does not sell enough, only a low salary”. An uneducated and impoverished villager selling medicine for commission? I slowly registered that rather than “giving back” in any way, she is unwittingly engaged in the damaging private business of defrauding illiterate and desperate villagers! My Khmer friend who was in Seattle with us responded with disappointment that “rich people often get benefits from poor people”. She has promised to contact her today to “talk about this”. It is highly likely that she has received some form of training via her employer that whatever it is she is selling, has curative properties. There would be little reason for her to understand otherwise given her own lack of education and every reason for her to want to believe it, as her way of earning an income. Despite her extraordinary life-saving American experience she remains a casualty of the chaos and necessity that Cambodia’s population are immersed in, living inside the cycle of catastrophe that poverty guarantees.
Necessity is the mother of Invention;
Chaos is the mother of Corruption.