Tuberculosis can lay dormant for years. In the developed world 1 or 2 percent of the population has it even in dormant form. Illness, age, or malnutrition can trigger active tuberculosis, and Richner said he could gauge the state of the nation by watching the prevalence of the active disease among children. “Now it is up,” he said. A spike in TB cases indicated that malnutrition was increasing. “Eighty percent of our malnutrition cases also present TB.”
In 2008 high food prices nearly doubled the rate of severe malnutrition, to 16 percent of all children, the government reported. The next year, even after food prices had declined, the figures showed no improvement. “TB is a bellwether for malnutrition,” said Mam Bunheng, the health minister. “And, yes, it is rising.”
Richner moved without pause to another complaint. “Corruption is a killer,” he said as he hurried down a hall between wards, always a few steps ahead of his guests. “It takes thousands of lives. If you show up and you can’t pay, no one will help you. Here the nurses’ station is in the ward.” He pointed to a large rectangular table in one ward, where nurses sat at computers and worked with charts. “They are not in the back, hiding.”
Richner, a pediatrician, was a portly sixty-two year old who first found himself in Cambodia in the early 1970s, working for the Swiss Red Cross. Like most westerners, he left as the Khmer Rouge approached Phnom Penh. “At that time Cambodia had 943 doctors. Only about 50 of them survived. I do have a conscience. Leaving in 1975, leaving behind all those doctors who did not survive, I still feel a little guilty.”
After the war, King Sihanouk “asked me to come back to fix Kantha Bopha Hospital in Phnom Penh. So I said, ‘Oh, okay, I will do it.’ I thought I would at least try but was not sure I could do anything. I was aware of the problem of corruption.”
In fact, Cambodia captured him. Driven by anger, guilt, contempt, and, yes, compassion, Richner raised tens of millions of dollars and opened his first hospital in 1993. Now he operates five of them. All of them provide free care to any child who comes in. “The first year we had 5,367 patients; last year, 1.3 million.” He liked to say he treated 85 percent of the nation’s children, a figure that was easy to believe but difficult to prove. Every morning starting at four o’clock hundreds of mothers with children in tow poured into the Siem Reap hospital’s lobby and sat cross-legged on mats, waiting for treatment. By seven they were sent to triage doctors who determined whether the children were likely inpatients, generally about 10 percent of the new patients, or could be treated and released. “We have 640 new patients so far today,” Richner said with a boastful tone, just after seven o’clock. Already a large sweat stain permeated the back of his shirt. Already the cries of wailing babies came from every direction, muted in each ward by the sound of forty-two ceiling fans, whirring at full speed. “Yesterday the number was 1,200.”
The hospital was as well equipped as most any in the West. It had CAT scan and MRI machines and a bacteriological lab. Expectant mothers were given ultrasound exams. The hospital had 800 staff physicians, 400 nurses, and 590 regular patient beds, 100 in the delivery ward. No other hospital in Cambodia came close—except Richner’s other facilities. But all of it depended on donations, and he needed $26 million a year, more if he wanted to expand or buy new equipment. His detractors—and his abrasive manner ensured that he had many—said his model was not sustainable. Who can raise $26 million each and every year? “Hun Sen gave us $3 million,” Richner said, “directly to us, not through the ministry so they could take some.” He had several other more reliable donors. Richner was also a cellist, and every Saturday night he gave a concert for tourists who were in town to see Angkor Wat.
Before taking their donations, he liked to tell them of his war with Dr. O’Leary at the World Health Organization in Phnom Penh. He
offered a synopsis of his weekly speech: “The creed of WHO is that treatment should correspond to the economic reality of the country,” he said with fresh anger and resentment, even though he had made that remark hundreds of times. “But the economic reality of Cambodia is zero. They also expect Cambodians to pay. But they are all farmers. How can they pay? The WHO’s view of ‘appropriate care’ for this country is a Maoist idea. Poor people deserve poor care. That is their idea of justice.” Allowed to, Richner would have prattled on into the afternoon, listing the woes of the Cambodian people and the uncaring venality of the nation’s health-care establishment.
Asked about Richner, O’Leary, the director of WHO, wouldn’t take the bait. “Good things get done,” he said without apparent emotion. “It’s parallel work. Our jobs are different. Our job is to support the government and by extension the people.” But people in his office, talking not for attribution, disparaged Richner’s combative attitude and his refusal to coordinate his work with the donor community—a charge Richner heatedly denied.
Richner was a prodigious fund-raiser, but he walked a tightrope—pushing, struggling to raise tens of millions of dollars every year. So what would happen when he retired or died? “A successor has been chosen,” he said. “He can run this.” But what about raising all that money? “Well, that is a concern. We are now looking for permanent sources. But this is an obligation we will fight for. It is a war.”
Beat Richner ran the largest and most expensive health-care operation in Cambodia. James and Cara Garcia had more modest plans. He was an emergency medical technician, she a registered nurse. They lived in South Carolina and knew nothing of Cambodia’s tortured history and byzantine present. But in 2008 they found themselves on vacation in Cambodia, indulging Cara’s new interest in Theravadist Buddhism.
Moving around the state, they saw what every visitor sees: a seemingly gentle people living in abject poverty. “Children playing with
broken flip-flops—or a frog tied to a tree,” Garcia said. Infants left to walk around naked because their parents could not afford diapers. Families eating fried grasshoppers for dinner.
But the Garcias also looked at the Cambodians through the eyes of health-care professionals and saw a host of debilitating medical conditions that were being left untreated. Suddenly Cara was seized with the idea of uprooting their lives, moving to Cambodia, and opening a health clinic for the poor. Her husband eventually agreed; this would solve some problems in their lives, and they would live an adventure!
Without realizing it, they had stepped into a drama that proved Ambassador Joseph Mussomeli’s prophetic warning about the state. As he had always told visitors, “Be careful because Cambodia is the most dangerous place you will ever visit. You will fall in love with it, and eventually it will break your heart.”
The Garcias sold almost everything they owned, netting about $40,000, and managed to raise another $16,000 in donations. With that, they set off for Phnom Penh, hoping to open a clinic and begin treating patients right away.
Altruism is a rare commodity. While Garcia was telling the truth when he said, “We were just trying to do a good thing,” the couple did have other motivations. Cara had a mental disorder. She was bipolar and considered disabled. What’s more, six years earlier, she was caught, twice, stealing prescription drugs from the pharmacy in a hospital where she worked. The South Carolina State Board of Nursing censured her. Needless to say, all of that made it virtually impossible to get a job. The new venture might give her a fresh start.
They met with Mam Bunheng, the health minister. He’d run the Health Ministry since 1983 and had become a master of ingratiation. Donors large and small streamed in and out of his office day after day, and he offered each of them a smiling blizzard of words about his goals and how far the nation had come since the Khmer Rouge killed all the doctors. He soothed and flattered the donors. “We develop policy together,” he liked to say. “Ownership. Every donor has ownership.
The health sector is one of the most effective at using international funds.” When the inevitable difficult questions popped up, Mam Bunheng was a master at deflecting them. Bribe payments to doctors? “You heard about this because they know they have the right to talk. This is a free society. That’s good.”
So it was with the Garcias. He gave them permission to open a health clinic in Kampong Thom Province that would be an official part of the state’s health-care system, Garcia said. The Health Ministry would provide the clinic with the supplies it needed. So, using their own money, they began seeing patients, hundreds of them—more than nine hundred every month. But when they asked the local Health Ministry office for supplies, the drugs and medications they needed, the local representative said the warehouse was bare. “We put in request after request but were always told they had no medications,” Garcia said. Then one evening the Garcias happened by the ministry’s local warehouse when the doors were open. They saw that it was fully stocked with all the medications they had been requesting. Garcia asked why his requests were turned down but said the warehouse manager told him simply, “‘None of this is for you.’”
Not long after, while Cara Garcia was out for a walk one night, she said she saw two SUVs pull up to the warehouse doors. Two men were filling the vehicles with medications and equipment. When the Garcias asked about this during a local donors meeting, they began to broach the second part of their Cambodian adventure, under Mussomeli’s gloomy formula. Most likely, they were told, the men were carting off the drugs, intending to sell them and keep the money. Across the province the Health Ministry operated nineteen clinics, more or less like the Garcias’, but most of them were closed, some boarded up permanently. Three or four were regularly open, though only for a few hours a week. The rest of the time, the nurses and paramedics were off working other jobs. With so many clinics shuttered, bureaucrats at the Health Ministry could pocket the salaries of ghost employees. Suddenly, in October, the Garcias’ good intentions ran full force into the ingrained customs of the nation they were trying to help.
Cara Garcia, particularly, did not like it. She raged at government officials, questioned their honesty, blamed them for the deaths of patients the Garcias could not properly treat. Cambodian corruption, she kept shouting, was killing little children. “You should be ashamed of yourself!” she told them, wagging her finger.
Her husband was used to her “severe mood swings,” as he put it. That was a feature of her illness. But Cambodians found her insulting in the extreme. To them she seemed to know nothing about the Asian need to save face. She also obviously had not read the
Chbab Srey
, that piece of folk literature that told women what their place in society should be. As those Swedish anthropologists had found in the 1990s, Cambodians were ill-equipped to deal with these direct affronts and often reacted with extreme violence.
A few nights later, the Garcias said, Cara was walking home from a meeting when several men jumped out of a car, dragged her into a rice paddy, beat and raped her for several hours, then left her for dead. She didn’t die, but she was broken.
The Garcias complained to the police in several locations. All of them were unresponsive. When asked about the attack later, they claimed that Cara Garcia had been running down the road, stark naked. Now the couple was radioactive. No one wanted to touch them. Finally, they gave up. They began packing up their belongings and settling accounts—only to discover, Garcia said, that their office assistant had been stealing from them for months. They had nothing left, “no home, no car, no possessions or belongings except what was in our suitcases,” Garcia lamented. They had no more money and had to solicit help to get home.
Back in the United States, Garcia reflected on their journey: “We gave all we had,” he recalled. But Cambodia “defeated our spirit”—and broke their hearts.
CHAPTER FOURTEEN
J
oseph Mussomeli had little knowledge of Cambodia before he became U.S. ambassador in 2005, though he had hung on to his anger over America’s perceived role in the nation’s destruction thirty years earlier. “In college I helped organize a demonstration against the U.S. invasion of Cambodia,” he recalled. “It has haunted me ever since. So, when I was presented with a list of Asian countries where I could serve as ambassador. I didn’t hesitate even five seconds. Cambodia.”
This was his first ambassadorship; most recently, he had served as deputy chief of mission in the Philippines. And a year or so after he arrived, when he invited several senior CPP officers to his house for dinner, “I was shocked,” he said, eyes wide. Referring to the United States, not necessarily the new ambassador, the Cambodians told him: “You never trusted us. You are always trying to embarrass and undermine us. You cut off direct aid in 1997. For so long, you have only supported our political opponents.”
All true. American relations with Cambodia were frozen in time. Almost ten years later the ban on direct aid, ordered after the so-called coup in 1997, remained firmly in place. Most American aid projects had to be funneled through NGOs or other private enterprises; almost
none could be given to the government. At the same time, many in the U.S. government still loathed Hun Sen and worked to promote Sam Rainsy. Hun Sen remained a persona non grata in Washington.
A few years earlier, when Kent Wiedemann was ambassador, angry officials in Washington had pulled back from any real involvement with the state, a result of the “coup.” “We don’t have any major national interests there,” Wiedemann had explained. “So we say, let’s make human rights the principal or perhaps the only foreign-policy objective.” This, of course, meant that the embassy was constantly battling Hun Sen and the CPP, the villains of human-rights advocates. That was the embassy Mussomeli inherited—even though the formative experience in his mind was the U.S. bombing and invasion of Cambodia during the Vietnam War.
By now all of the major State Department figures who had been players during those heady days of the UN occupation and the first elections in 1993 were retired or working in positions far removed from this issue. More than fifteen years had passed since Secretary of State James Baker had pushed Cambodia to the top of America’s foreign-policy agenda for a few months in 1990. The UN occupation in 1992 and 1993 was now a historical footnote—too far past to be part of the active political debate, too recent to be in history books.