Cambodia's Curse: The Modern History of a Troubled Land

by Joel Brinkley

  Chhay Sareth, the provincial council chief, said he never heard about this case. “I think the authorities have covered it up. But if you commit a crime like this, you are like Pol Pot.”

  Teng Soeun, director of Kossamak Hospital, was a troll-like fellow, short and round. But his manner was concerned, soothing, and seemingly sincere. “As the director I feel sick that a man died without any treatment,” he said. “It is against the ethics. I have to tell you that any patient who comes here, they have to get treatment. We have this hospital to help the poor even if they cannot pay for treatment.” He said all that with a straight-eyed stare and an unwavering manner of conviction.

  “I was on duty that day,” said Ek Sonsatthya, a nurse. She and several others who had been involved in Leang Saroeun’s care were sitting on a sofa in the director’s large office. (Missing, of course, was the doctor who had asked for the bribe.) On the floor was an inexpensive oriental rug. “He got a prescription injection on 20 June and an IV,” she said, consulting the dead man’s case file. “His wife stayed with him. He had burns on 80 percent of his body. It was so bad that it was hard to find a vein to make an injection.”

  “His condition was very serious,” said So Saphy, chief of the hospital’s intensive care unit. “I told the patient’s mother.”

  “According to our rules,” the director interjected, “we have to treat the patient to the last breath. And if a patient dies here, we give them a free coffin. We cannot force them to leave, and we usually advise them carefully. But if he dies,” he said again, “we give him a free coffin.”

  But what about the demand for $150?

  “There have been cases in the past,” the director allowed. “I agree in past times there was corruption. But now no more. We will try to clean up all this mess. We try to implement the regulations. Our hospital is one of the honest hospitals.” Of course, any other hospital director would say the same, he acknowledged, chuckling.

  When the discussion ended, So Saphy offered a tour of the intensive care unit, downstairs. Fourteen patents lay on battered old metal beds with straw mats they’d brought from home, laid on bare wood frames. The ICU had two respirators, three oxygen saturation machines, and no other medical equipment. In the adjoining medication pantry, So Saphy pointed to a glass cabinet that held two dozen IV bottles, neatly arranged. “This is the serum for patients who pay,” she said without expression. Then she pointed to a low cabinet on the other side of the room and slid open a metal cabinet door. The cabinet was full of rags and other debris, but she reached toward the back and pulled out two IV bottles. “This is the serum for patients who can’t pay.” She held up one bottle. The expiration date, in bold blue letters, was five months earlier. She allowed me to look at the drugs in the medicine cabinet, assorted bottles and jars, nearly all with expiration dates long past—six months, a year, two years. Looking at one dated the previous year, So Saphy just pursed her lips and shook her head.

  Asked about that later, the health minister, Dr. Mam Bunheng, a gynecologist, offered scant reassurance. “That is not allowed,” he insisted. “We have a monitoring system. We check every year.” But that may have been among the least of his problems.

  Mith Ran, forty-nine, had a well-worn artificial leg and a doleful expression affixed to his face. He had served in the Khmer Rouge army and lost his right leg to a land mine. Decades later he lived in Pailin, still home to many Khmer Rouge veterans. Mith Ran’s wife was recently deceased, another unfortunate death, and as a result four of his seven children, the youngest of them, were in an orphanage because, he said, he could not care for them alone. The others, pulled from school, were at work in a cornfield.

  One evening, he sat on the front steps of his little home just like all the others: one room, small, dark, and bare. An empty bag of corn lay on the ground beneath him. Chicks pecked at the few remaining kernels as he told of his wife’s death. She was pregnant; this was her eighth baby. One night the previous month, when she said she was ready, he rushed her to the hospital in Pailin at about ten o’clock. The medical staff wheeled her to the maternity ward, “and thirty minutes later a doctor looked at her and said she was not ready. I said, ‘Please help my wife. This is her eighth baby.’” He told the story as if he had related it more than once before, which he had. Human-rights workers had come to see him and promised to take his case to court.

  She went into labor at 3:00 a.m., he said, and “asked me to wake up the nursing staff. I knocked on the door several times, but the nurses were asleep. I pounded on the door. They would not come out. At 3:30 one of them finally did come out, a girl with slightly crossed eyes, and she brought in the doctor. I asked him please to take her to the delivery room. The doctor said, ‘Do you have any money with you?’ I asked how much. He said 100,000 riel,” or $25. For Mith Ran the sum might as well have been $25 million, given how unapproachable the doctor’s bribe request was.

  “I said no. He asked where I lived. I told him.”

  “Do you have relatives there who can lend you the money?”

  “No.” Then, like the doctor at Kossamak Hospital, this one “pulled off his gloves and walked away.”

  Later, his wife’s water broke, and “I called the medical staff. I banged on the door. They would not come out for a long time. I pleaded with the medical staff, ‘Please, please, help my wife. I am poor. Please!’”

  He sat on his false leg; a battered black wing-tip shoe covered the artificial foot. He looked at the ground and shifted from his story into a litany of woes. “I own no land. I am just a worker on other people’s land. I did own land, but I had to sell it to get treatment for my leg. I stepped on a land mine in 1993. The bone was infected, so it was expensive. I am a former Khmer Rouge soldier in Battambang. I cannot read and write. I didn’t go to school. I joined the Khmer Rouge when I was thirteen. My parents were killed, beaten to death by a plantation owner.” Then he broke free of his dark reverie. “Help my wife,” he said again, looking up. “I asked the nurses, ‘Please, help my wife!’” A few hours later his wife and their baby died.

  At the Pailin hospital maternity ward the next afternoon, two women lay with their newborn babies on wooden-slat beds covered with straw mats the patients had brought from home. Fluid from an IV bottle dripped slowly down a tube into one of the women. The clear plastic bag hung from a crooked bamboo pole tied to the side of the bed with white string.

  If the ward had a nursing staff, the nurses were out of sight. But then a blue door was closed—the same door Mith Ran had pounded on over and over again. A sign on the wall above, in Khmer, declared “Duty Room.” Now, once again, repeated knocks on the door brought no reaction. Not a sound. So I opened the door. A nurse, in bed, asleep under a blanket at three in the afternoon, woke up with a start, rubbed her eyes, and slowly got out of bed. Minutes later she came out. Sun Thida was her name, and she said she was the duty nurse. She was thirty years old and wore a red shirt festooned with panda cartoons. Her eyes were slightly crossed.

  “I wasn’t here” when Mith Ran’s wife died, she averred. “That wasn’t my shift. But I heard about it. That was a complicated case. But I was not on duty.” Sun Thida said she had been a nurse “for five or six years. I had twelve years of school and a short course in nursing once I got here. A seminar, three days.”

  Dr. Sou Vichet, the hospital’s new director, had a nervous tic. He simultaneously blinked and squinted when he was nervous. Now he was blinking away at a pace so rapid that he could barely see. “That night I was not here; I didn’t have this job yet,” he said. “But I’ve investigated. At that time there were two or three nurses and two or three medics on duty” in the entire hospital. “The doctors were gone. Some were at a seminar to improve their education. The director of the hospital was not here, either. I can’t say if they were violating regulations.”

  He sat at a battered old gray metal desk in the hospital’s administrative office. He’d been on the job only a few weeks, but now, he said, doctors were requi
red to be on duty around the clock. As for sleeping during the duty shift, “I don’t blame her. She probably had a late shift,” but then, blinking away, he insisted, “It is not routine that medical staff sleep during their duty shift like that.”

  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 famil
y 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.