As for the bribe demand, Phab Sou Vichet said he had no knowledge of that. “Patients are not required to pay.” The doctor in question had not been penalized; the hospital seemed to accept his argument that all of the problems were the woman’s fault. He was still on staff, just like the doctor at Kossamak Hospital in Phnom Penh who refused to treat Leang Saroeun.
Dr. Meng Huot, the hospital’s deputy director, interrupted the conversation to say, “A reporter came to us and said he would not print a story about that case if we paid him $100 to $250. I don’t know his name. He wanted me to send the money someplace. I didn’t pay him,” perhaps because the
Phnom Penh Post
printed a story about the woman’s death a day or two later. (These blackmail attempts were not
uncommon; the “reporters” wrote for small papers and, in these cases, published stories under pseudonyms.)
Meng Huot spoke with an omnipresent sneering grin but took on a more serious tone when he volunteered that “in this area, the education of the medical staff is quite limited. If people are educated, they don’t want to come here to Pailin. If they come, they don’t want to stay. So the only people we have to take care of these poor people are not the best in their profession.”
“If the doctor had given her a normal delivery, on time,” said her husband, Mith Ran, rocking slightly as he lamented, “she would have survived. If she’d had a C-section, she probably would have survived. But she died.”
Mith Ran probably hadn’t known it, but if he had asked the doctor for a C-section, he might have gotten the physician’s attention. In maternity wards around the country, C-sections were all the rage. Normally, “between 5 and 15 percent of births require a C-section,” said Dr. Paul Weelen of the World Health Organization office in Cambodia. But nationwide, a far larger number of women giving birth (no one was counting) were subjected to surgery instead of being allowed to give the child a natural birth. The reason for this was simple. “The fee structure for maternity is as follows,” said Dr. Sin Somuny, executive director of Medicam, which represents all the donors involved in health-care issues. “A midwife costs $15; $20 for a regular delivery—and $150 for a C-section.”
In a maternity ward at Battambang Hospital, one of the nation’s major health-care facilities, two women lay in bed with their new babies. Both said they had been given C-sections. Yoeun Chantho was still in pain; dark bloodstains spotted the front of her blouse. “This is my second baby and my second C-section,” she said. Her oldest son, nine years old, held her IV for her, dangling from the end of a bamboo pole. It looked like he was holding a fishing rod. “The last time they said I had high blood pressure; this time they said the baby was in the wrong position.”
In an adjoining room Hop Thoeum looked to be near tears. Her mother sat on a mat on the floor beside her. They had no baby. “The doctors told us the baby was about to die, so they gave her a C-section,” said the mother, Run Hon, fifty-six. “But the baby died. They said he drowned. They didn’t ask for money this time. In this case whether we paid or not wouldn’t have helped. It was not about money; it was related to capability.”
In fact, at Battambang Hospital and a growing number of health facilities nationwide, money was becoming less of an issue because, as several patients said, “the NGOs paid for it.” In a small office at the hospital’s entrance, several workers sat at computers emblazoned with big, bold USAID stickers. The workers were employees of health-care donor organizations. Their job here was to certify patients as truly poor, under a new government program.
Until 2009 a poor person who fell ill had been required to visit the communal government office and get a document certifying that he or she was indeed poor. The problem was, a really sick person did not have the time or capability to travel there, wait for the offices to be open (usually just two or three hours a day), and bribe the responsible officer.
Under the new program, the government was distributing identity cards to poor people, which meant that they would not have to pay for their health care. In the Battambang Hospital office, a stack of these cards sat on the desk of one worker. “We help them fill it out,” he explained. “Most of these people can’t read or write. Most of the interviews for these cards are done in the villages, but if they show up here we do the interview here.” Outside a naked baby boy, by himself, toddled past the door.
This new program was an important change, pushed by the donor community and accepted by the government. However, across the country the administrators were employees of donor organizations. The government had agreed to implement the program only so long as it did not have to administer it. As it was, the Battambang Hospital’s
administrative staff, about a dozen people sitting at desks with a television on a shelf above them, spent that afternoon watching WWF wrestling.
With the new card in hand, patients were entitled to free care. That did not necessarily prevent doctors from demanding bribes, but they might have been less likely to exploit people who were certified to be poor.
Perhaps the greater problem, as the dead baby’s grandmother had said, was the quality of care. How many Cambodian doctors had been accepted to medical school with a score of 25 percent on the entrance exam? How many of them had bribed their way through their medical education and training? How many had access only to expired medications and primitive or nonexistent equipment? For example, not one Cambodian hospital had a bacteriological lab, used to test for infections.
Cambodian women faced a high risk of death when they got pregnant. In 2009 the United Nations reported that 1 out of every 185 pregnant women died during childbirth. (In Vietnam the number was 1 of every 666 women. In the United States it was 1 in every 4,800.) But the UN said the larger problem was that Cambodia’s miserable statistic had not improved in decades.
In response, Hun Sen called for the recruitment and training of more midwives—while proposing no new program or funding to accomplish such a goal. Michael O’Leary, head of the World Health Organization office in Cambodia, shook his head. “Midwives are one part of the solution,” he said, “but that alone will not bring the rate down. It’s a multifactoral problem. You need emergency obstetric care.”
Even if that were available, most people lived too far from a health clinic to reach one in time. And in fact, most clinics were open just two or three hours a day. Like teachers, the government paid doctors, nurses, and paramedics so little that they could not afford to work at the clinics all day. They had to find other jobs. Doctors opened private
clinics. In their hospital jobs they earned fifty to eighty dollars a month, the health minister said. Oftentimes they worked in the hospital for only a few hours a day. That was the probable reason no doctors were on staff when Mith Ran’s wife died at Pailin’s hospital. “What you are getting now is more and more doctors working in private clinics—when they are supposed to be at the hospital,” said Sin Somuny of Medicam. “So they end up working in the hospital just to promote their names, and then they poach the patients. This is leading to a collapse of the public health system.”
With or without doctors, a patient could not survive in a Cambodian hospital without the help of a family member or friend. Many services are inaccessible to anyone who is seriously ill.
Battambang Hospital provided lunch and dinner. A woman rolled a wheeled lunch wagon around the campus and waited for patients to come out to get the food. One afternoon a woman with an apron and a gray chef’s cap parked her wagon outside the maternity ward. Patients or their relatives came out with plastic bowls they had brought from home; the “chef” doled rice and beans in prodigious portions out of large plastic buckets sitting in her cart. Behind her, across the street, was the six-grill “kitchen”—just concrete pits with three-post pot stands. Patients had to bring wood for fire, pots, pans, and food for any patient or family member who wanted to make their own meals. When doctors told patients they needed ice, they had to trudge over to the hospital icehouse, pay seventy-five cents, and carry the ice back to their rooms.
The emergency-room duty nurses’ station, a large open room, was empty. But a green door was cracked. Three women were inside, sitting on beds, eating bananas and rice cakes. One of them spotted me looking through the crack of the door. She jumped up in a rush and pulled on her white coat. “Just a minute,” she said, obviously embarrassed. The other two nurses were bumping into each other as they scrambled to put on their coats and nurses’ caps, shove the bananas
under the bed, and come out of the room. Two of them scurried down the hall.
I asked the third nurse how many people had been admitted that day. “Ten new inpatients,” she said, distracted, embarrassed. “They are being treated for high blood pressure, encephalitis, dengue fever, and malaria.” All the windows in the emergency room were open to the outside. No screen, no glass, nothing to keep malarial mosquitoes out of the ward. The nurse’s name, on her name tag, was Meas Sudhan, R.N. “Another patient was bitten by a poisonous snake,” she added. Then she, too, hurried out of the room—all of a sudden attentive to her patients.
Just then a woman came in the front door, barely able to walk, leaning heavily on her husband. Her breathing was heavy; sweat rolled down her forehead. Trailing behind her, three family members carried large bags of food and gear. A doctor led her to a bed—just a steel frame with wooden slats. He stood still with the woman, whose legs seemed ready to collapse beneath her, while family members dug hurriedly through their bags until they found a straw mat, woven with green and yellow flowers, and laid it across the bed frame. One of them, who looked like the sick woman’s sister, pulled a pillow from another bag and laid it on the bed. Only then did the doctor help the patient onto the bed, take out his stethoscope, and begin to examine her.
At Battambang Hospital and every other health-care facility across the nation, patients arrived with illnesses, often fatal, that were almost never seen in other nations, including Vietnam and Thailand. A large part of the problem was hygiene. Ninety-eight percent of Thai had access to clean drinking water; 95 percent of them had a toilet in their homes. In Cambodia about 14 percent of the population had access to clean water. Just 22 percent had a toilet, and in rural areas the number was 16 percent.
At the end of 2008 UNICEF and Cambodian government statistics estimated that 9.7 million people were treated for diarrhea and other
sanitation-related illnesses each year, most often from dirty water. That was 72 percent of the population. Each year nearly 10,000 people died. “It’s routine to have diarrhea here,” said Loch Pheach, vice chief in the village of Sangkum. “It happens a lot.”
Chea Sophara, the minister of rural development, did not dispute the World Bank’s numbers. They had barely improved in decades. So he offered one of the government’s facile promises: “We want all rural people to have clean and safe water to avoid diseases. By year 2015, we believe 50 percent of rural people will have access to clean water, and by 2025, everyone in the country will have clean water.” Opposition lawmakers, as usual, noted that the government was dedicating no money toward the goal; officials seemed to be waiting for donors to step up and take on this problem.
But then when the World Bank gave the government $11.9 million for seven major rural sanitation projects, in short order the bank found that the money was being squandered in a typically Cambodian festival of corruption. This included “solicitation and acceptance of bribes as a condition for allowing companies to participate in bidding, rigging of bids for construction contracts and manipulation of procurement, fraudulent bid securities, price fixing and collusion to manipulate tenders, inflated bid prices, fixed outcomes of competitive procurement procedures, and submission of fraudulent bids by unqualified bidders who misrepresented both their financial statements and prior experience,” the bank said.
Furious, bank officials demanded their money back. Hun Sen hemmed, hawed, and stalled until finally he found a fall guy. Mour Kimsan, former deputy director general at the Rural Development Ministry who now was working as a consultant there, was charged with embezzling $880,000 of the bank’s money. The bank canceled its sanitation project.
In Bon Skol, near the Vietnam border, village chief Mou Neam was among the more prosperous people in town. He had an outhouse beside
his house, a little shed with a seat over a deep pit he had dug. When the pit filled up, he could dig a new one and move the shed. As it happened, just ten yards away he had also dug a well with a pump. There he could draw water from the same aquifer into which his septic pit drained.
Mou Neam’s situation was not at all unusual. It was the norm. Viey Savet, a twelve year old from the village of Chong Kneas near Siem Reap, told the Red Cross as part of a study on sanitation problems, “I wake up and wash my face and brush my teeth using water from the lake. I go to the toilet. Our latrine goes straight into the lake. My parents both bathe in the lake. To make dinner, my parents boil water from the lake to use for cooking. I bathe three times in the lake each day with soap.” So, “the passive genocide continues,” as Dr. Beat Richner put it.
Richner, a Swiss physician, was an irascible fellow, contemptuous of people he considered to be fools and scoundrels. In Cambodia he believed he saw one every time he turned around. Richner operated a pediatric hospital in Siem Reap, and the difference between his facility and Battambang’s public hospital could not have been more striking. Kantha Bopha Hospital was large, clean, modern—and free. Patients were not charged for their care; doctors and staff were paid a living wage and did not ask for bribes. Kantha Bopha and Battambang Hospital shared one common feature: the patients.
Standing at the entrance to one ward, where twenty children rested in real beds, Richner waved his hand across the room as he looked at a chart. “They have malaria, dengue fever, encephalitis, hepatitis, meningitis, pneumonia, diarrhea.” Then he launched one of his rants. “We have thousands of typhus cases. We had forty-two cases of dengue in the hospital and ninety-five new ones this morning. Eighteen meningitis cases. If in Switzerland you had three cases of meningitis in the whole country, it would be all over the newspapers. Here if you go to a health clinic, they charge you sixty dollars. But which child has sixty dollars? We do tuberculosis research. It was not known before that TB
can cause encephalitis. We are going to publish in November. Twenty-five percent of Cambodians have hepatitis B or C, and 63 percent of them are infected with tuberculosis.”