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Web-only Exclusives November 30, 2000 From Our Correspondent: Hirohito and the War A conversation with biographer Herbert Bix From Our Correspondent: A Rough Road Ahead Bad news for the Philippines - and some others From Our Correspondent: Making Enemies Indonesia needs friends. So why is it picking fights? |
SEPTEMBER 17, 1999 VOL. 25 NO. 37
Hope in a Land of Despair
Cambodia's health service is like many of the country's other institutions - penniless, ramshackle and corrupt. But the efforts of a determined Swiss doctor are making a difference for thousands of children
By CARLA SOMMERS Phnom Penh
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In bed 35, a 13-year-old shares her mattress with her baby brother. Her leg has been amputated because of a cancer--and now she has been diagnosed with tuberculosis. Outside, a 23-year-old mother from the eastern province of Kampong Cham is waiting nervously in the admissions hall. She says she has already spent $3 on ineffectual drugs for her baby's cough. With very little money left, she has journeyed two and a half hours by road to Kantha Bopha. "I'm here because it's free and because the care is good," she says. "I can't pay for medicines anymore."
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"The health system--like the education system--is at zero," says Guido Cornale, program coordinator at UNICEF. "Everything has to be redesigned from scratch. There has been an exodus of doctors from the profession, leaving very few qualified staff." The health threat looming over the survivors of the Cambodian holocaust reflects the fact that the government spends just a little over a dollar per person on medical care in a year.
Even with extensive help from overseas medical aid agencies such as UNICEF, the government cannot save over 70,000 Cambodian children from dying each year from disease and malnutrition. It was a situation that Beat Richner could not ignore. The 53-year-old Swiss pediatrician works between the three institutions that he has founded since 1992--two hospitals in Phnom Penh and a third, opened in March this year in the northern provincial town of Siem Reap. All three offer world-class diagnosis and treatments, all are equipped with the latest technology and are staffed by highly competent Cambodians. Each offers its services free of charge and is funded by private donations.
Richner is adamant that Cambodian people should not be denied access to the highest standards of treatment simply because their country is poor. He attacks the large aid organizations as slow-moving and bureaucratic, complaining that too much money goes into fat salaries for officials and too little toward healing the sick. His confrontational stance has not earned him many friends in bastions such as the U.N. agencies or the International Committee of the Red Cross.
In his highly personal book, Kantha Bopha--A Children's Doctor in Cambodia, Richner attacks a WHO official in Geneva who argued that "Rolls-Royce" medical treatment was inappropriate in Third World countries. "How can we say expensive medicine is too good for Cambodia? How can we?" Richner explodes with indignation. "Every child should have a right to the best possible treatment. Instead, [international bodies] promote a policy of poor medicine for poor people in poor countries."
The pediatrician says his experiments have indicated that typhus bacteria are resistant to several international drugs commonly administered in Cambodia. "Rocephin is more effective and causes less damage to the liver, but it is expensive," he says. "So they use drugs that are useless." He throws his arms up in disgust. "We should not treat poor people like this. It is just like the Titanic, where they blocked the exits of the third-class passengers so that the first-class passengers could save themselves."
Richner was in his 20s when he first arrived in Cambodia in 1974 to work as a doctor in the original Kantha Bopha Hospital. Like many, he had to leave the next year when Phnom Penh fell to the Khmer Rouge. On a return trip to Cambodia in 1991, he revisited what was left of the hospital. He was so distressed he pledged to come back and help reconstruct it. "If you had told me back then how hard it would be to do all this, I probably would have thought about it a bit longer," he acknowledges with a wry smile.
After great effort, scrounging and countless failed appeals to governments for funding, Kantha Bopha re-opened its doors in 1992 at a cost of $15 million. The hospital--named after one of Cambodian King Sihanouk's daughters who died of leukemia--offers the best medical services in the country. Richner has insisted on his own blood banks, a highly advanced operating theater and a microbiology laboratory. Operating costs for his three hospitals total about $9 million a year.
A dengue epidemic last year nearly put Richner out of business. Some 7,500 sufferers of the life-threatening fever sought help at Kantha Bopha. Many required emergency blood transfusions, and each one had to undergo blood tests--at $50 each. At the end of 1998, Richner was left with a $2 million budgetary shortfall. What to do? A talented cellist and a celebrated comic musician in Switzerland, Richner returned there to make media appeals and to play in charity concerts. The short trip generated enough cash to save the hospital. Richner takes a number of fundraising tours each year, but cannot be away too long. "They need me here, but if I have no money, what will I do?"
It is evident his presence boosts morale and helps maintain rocksteady discipline. Kantha Bopha is run with Swiss-style precision. In admissions, where at any time a few hundred people wait patiently on the floor, everyone must queue, rich or poor. Richner insists no one gets preferential treatment, except for medical reasons. His staff constantly scan arrivals to check for emergency cases. Each patient receives a color-coded line-up card and a dossier separating new patients from repeat cases, or those arriving for inoculations. The weight and height of sick children are noted. Today a premature baby arrives in the arms of its guardian. The size of a small loaf of bread, the child, at three weeks, weighs just 1.5 kg. The infant receives priority treatment.
In the next wing, inoculations are given against common killers such as tuberculosis and Japanese Encephalitis (JE). Richner says international organizations are doing too little to halt the spread of killer diseases. A major vaccination campaign is needed, he insists. In a report known as the Black Document, published in 1998, Richner said JE vaccines were charged at around $60 each at a Phnom Penh clinic. While foreigners can afford this, locals cannot. His vaccines are directly imported from Japan for $4 a shot.
Drug supplies are scrupulously monitored. In a country where pharmaceuticals are scarce and offer a high resale price on the street, drugs are given out in doses for two to three days only. This also prevents over-medication. As an extra control, the empty vials must be returned, to preclude their being resold to pharmacies for profit. Kantha Bopha claims to have stamped out the corruption that is rife in Cambodia's public health system. Richner says this is due to professional ethics and fair salaries--his staff are paid up to 10 or 15 times more than those in other health institutions. Cleaning workers receive $150 per month, compared with a national average income of $300 a year. "Of course we should pay them highly," says Richner. "Their work is just as important as the doctors' and nurses'. If they don't do a good job, the hospital cannot function." Kantha Bopha employs 600 people, of whom six--two doctors, three nurses and a microbiologist--are Western.
Each day, on average, there are five life-saving operations. Today, 14 patients need surgery. In the pre-operation room, staff attend to a case of severe peritonitis in a four-year-old. He must wait. Before him on the operating table is a day-old baby with a rare congenital deformation of the anus. Upstairs in the post-surgery ward, a nine-year-old burn victim lies bandaged from the waist down, another victim of low-level fires used for cooking. Marked in French are areas on the child's body from where the skin grafts have been taken. At a non-Richner hospital, this operation would have cost her family upward of $800.
Richner may have made enemies, but few can fault his determination to help a crippled and impoverished country. He has won the support of King Sihanouk and the Ministry of Health. Dr. Lo Veasna Kiry, deputy director in the ministry's planning unit, is grateful for the Swiss doctor's contribution, but worries about what may follow. "There is no doubt he is saving lives, no doubt at all," he says. "But we are concerned that one day he may not be here. What then? How can the state find the funds to run these hospitals?" This is not so much a criticism as a genuine concern for the future. Over the past decades, Cambodia has had many hospitals co-run or supported by foreign organizations--only to be left to fend for themselves.
Many agree that the ultimate answer to Cambodia's health crisis lies not with international donors but with the government. It has to raise its commitment to its own people, including introducing long-promised civil-service reforms, including wage structures that would foster a new generation of medical professionals. Kiry says he is optimistic these changes will take place. For his part, Richner asserts he will keep his hospitals going, come what may. Asked by Kiry what happens when he is no longer around, he replies: "Dr. Richner never dies."
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