If I had to pick a pivotal milestone during my daily experiences in Cambodia, I would probably pinpoint the boat trip with Mum and Ruth in January 2014. It was my first holiday, three months into my assignment with Medecins sans Frontieres. Since landing in Phnom Penh I’d been bombarded by sights which did not immediately make sense to my rich world brain. Adorable tiny babies who could walk and talk initially captivated me. The genesis of their adorability however, is acute-on-chronic malnutrition caused by severe deprivation. Astonishing sights on the roads, of vehicles loaded beyond imagination, were highly amusing. Until my thoughts processed that these dangers are the result of people doing everything within their power to earn enough to feed their families. At the hospital many people literally died of starvation before my eyes. Children out of school, the elderly, blind, amputees and those with deformities and disabilities seemed very visible and behaved in ways which were unfamiliar to me. Walking the streets with a sense of determined purpose, foraging for something to eat, or for something to sell in order to eat. Many sleep rough in the city’s streets.
Perhaps it was the fact that everything was happening on water rather than land, that the sights along the Sangker River and across the huge Tonle Sap lake between the cities of Battambang and Siem Reap, seemed so striking to us? We spent eight hours traveling on an open air boat through riverside and floating villages, dismayed by the scenes of poverty and simultaneously fascinated by the bustling activities all happening on this endless body of water.
Our journey set sail on the outskirts of Battambang city. Less than a year later Roka village, a short distance west of the city, with a population of around 800 people, made international headlines. In November 2014 a 74yo TB patient from Roka tested positive to HIV, a routine test in any TB diagnosis. With no risk factors for HIV he became concerned and his family also sought testing. His son-in-law and grandaughter also tested HIV positive. The family alleged that injections from a local unlicensed practitioner were to blame and encouraged others who had visited this medic to get tested. 30 new HIV notifications from within or close to Roka were reported in December 2014, compared with four new notifications for the whole year preceding this.
Experts from a Phnom Penh university and the National Centre for HIV/AIDS, Dermatology and STIs (NCHADS) immediately formed the Roka Cluster Investigation Team and traveled to the village. Over 8,000 residents living in the area around Roka were tested and by February 2015, 242 new cases of HIV had been diagnosed. Analysis of the blood samples confirmed that most infections were recent and that a single HIV strain was responsible for the outbreak, meaning they all originated from the same source. Many had no risk factors at all, including young children born to HIV negative mothers and 4yo twins, only one of whom was HIV+ on testing. There was a significant association with the administration of intravenous fluids or injections in those who tested positive.
A significant number of victims also tested positive for Hepatitis C virus, which is also associated with unsafe injecting practices. Until very recently Hepatitis C, which ultimately leads to cirrhosis and liver cancer, has been extremely difficult to treat. This year the Australian government approved the use of brand new treatments which can cure the virus with few if any side effects. Australians infected with Hepatitis C can now access these drugs free of charge on the Pharmaceutical Benefits Scheme. Each short course of treatment costs in the vicinity of $80,000, meaning the drugs are inaccessible to most people in the world. Obviously villagers in Roka have no way of receiving such treatment although Medecins sans Frontieres are working at implementing a program to make the drugs freely available to a cohort of Hepatitis C patients in Cambodia.
The self-proclaimed “doctor” at the heart of the Roka outbreak was 55yo Yem Chroeum who has since been sentenced to 25 years imprisonment on charges including murder and knowingly infecting people with HIV. He is accused of reusing needles and syringes on multiple patients. Chroeum received informal training by a foreign doctor in a Thai refugee camp during the 1970s/1980s. He returned to a distressed country decimated by genocide and civil war with 25 surviving qualified doctors, most of whom could or would no longer practice medicine.
Immediately after World War II ended the USA shipped billions of tonnes of food to Western Europe and Japan before implementing more long term economic supports to rebuild both regions which were considered paramount in preventing the spread of communism from Russia and China. Both regions became powerful economic forces despite their war time devastation. Cambodia on the other hand, “liberated” by the communist Vietnamese in 1979, has suffered an entirely different fate. The entire Western world enforced economic sanctions and blocked almost all foreign aid to the country, effectively debilitating the nation until the Paris Peace agreement was signed in 1991. Their opportunities to rebuild and prosper have been severely hampered.
Chroeum settled in Roka in 1995 and was allegedly a popular medic among villagers, reputedly skilled at treating fevers. He maintains his innocence but has admitted to reusing equipment. However, according to Centers for Disease Control, 99.7% of needlestick injuries involving HIV-infected blood do not result in transmission, so reuse of infected equipment alone does not seem to account for the outbreak? Since his arrest Chroeum’s family have suffered social isolation and financial hardship. Without their father’s income and as many villagers now refuse to buy from the family shop they struggle to pay for his prison meals which are not provided by the state.
Intravenous infusions are a highly popular treatment for all ailments in Cambodia. Bags of fluid suspended from bamboo poles traveling through the streets are a regular sight as patients cruise on the backs of motorbikes while they wait for their infusion, delivered by the many local private clinics, to finish. Some Cambodians have told me that if a clinician does not offer intravenous infusion as part of the treatment for any ailment, they are not considered authentic. In a country so poverty-stricken, under-resourced and under-trained it is amazing, with so many intravenous lines being inserted, that more service-acquired bloodborne virus transmission does not occur. In fact, Cambodia have been highly successful at reducing their HIV prevalence rate which peaked at 2% in the mid-1990s and is now down to around 0.4% of the population.
Almost 300 people linked to the Roka outbreak have been diagnosed as HIV+ and at least 16 have died, mostly infants or the elderly, who are less able to contain the infection and/or unable to tolerate the side effects of anti-retroviral treatment (ART). ART medications are provided free of charge via the Global Fund but all other health interventions cost money and many have had to sell land, livestock and other assets in order to pay for medical expenses. Many have fallen victim to theft as illness has made their homes and livestock vulnerable to opportunistic crime; many are also too sick or too weak from medication side effects to work, intensifying their financial hardship. Stigma and discrimination, travel companions of HIV and other bloodborne viruses in the most privileged and educated of societies, have stamped their mark, with many first hand reports of ostracism within and beyond Roka which also severely affects peoples’ livelihoods.
In response to the outbreak, the government cracked down on unlicensed health care providers. Cambodia has a total of 3,000 qualified doctors for a population of 15 million. This is comparable to the proportion of doctors in Afghanistan and contrasts with Australia where we have 70,000 qualified doctors for 20 million people. With such inadequate services, 70% of Cambodians seek health care from unlicensed providers and many have never seen a qualified doctor in their life. The official health system is so fraught with problems that it cannot guarantee a better quality of care anyway.
These are the realities of what it means to be impoverished. Lack of individual money is only one aspect to a widespread societal issue relating to options and opportunities which are tangled up in historical considerations, education, economics and politics.
As the experience in Roka demonstrates so acutely, poverty is an expense that society cannot afford.