Cambodia - 'It has always been my dream to nurse in a developing country...'

Caring for people with dengue fever, cobra bites and tuberculosis with few resources is all in a day’s work for James Cook.

It has always been my dream to nurse in a developing country, it is the reason I joined the profession. After completing my Bachelor of Nursing Degree in 2003, I worked in Bury Hospice, Manchester and then John Radcliffe Hospital, Oxford, before relocating to Sydney, Australia. After some years of working in a busy inner city accident and emergency department, I was lucky enough to be selected for a position as nursing advisor/educator for Siem Reap Provincial Hospital, Cambodia. I started it in November 2011 and the position is for 18 months.

Siem Reap Provincial Hospital is a major referral hospital for the whole Siem Reap province, one of the largest provinces in Cambodia. The referral hospital serves a population of 1 million people.

The hospital wards are always full, far beyond capacity. The hospital’s official capacity is 230 patients, but it actually has about 330 patients at any given time. These overflow patients are crammed into the corridors or cared for on the floor.

In the hospital grounds there is a busy emergency department, medical wards, surgical wards, and two operating theatres. Other wards include orthopaedic, ENT, ophthalmology, tuberculosis, gynaecology and a maternity unit.

The hospital laboratory can do basic blood tests only. It cannot measure lactate levels, creatine kinase or cardiac enzymes. There is no blood culture or CSF culture capabilities or blood gas analysis. Diagnostic imaging is restricted to x-ray and ultrasound, there is no CT scanner. The ECG machine is broken.

Blood transfusions are possible but supply is low, so usually the relatives of the patient receiving the transfusion are required to donate their blood to replace the supply.

I am based in the Accident and Emergency department.  As well as the usual presentations that any A&E would see (abdominal pains, cerebral strokes, orthopaedic fractures and so on), there are also a high proportion of tropical and infectious diseases, a high incidence of cerebral malaria, meningitis and typhoid fever. And haemorrhagic dengue fever is also a major cause of mortality here during the wet season. 

We see a lot of complications arising from TB and HIV because of the high prevalence of these diseases among the population. Other chronic diseases like diabetes and hypertension are mostly misunderstood, and the patient generally only takes the daily medication when they feel unwell. The concept of asymptomatic disease is generally not accepted, which leads to complications being all too common because of years of unmanaged chronic disease.

Then there is the environment to contend with. There are some dangerous snakes, such as cobras and vipers, in rural areas. These can inject poisonous venom, causing either a fatal coagulopathy, or paralysis leading to respiratory failure. The hospital stocks lifesaving antivenom, although this is only effective if the patient presents early enough, before envenomation develops.

Another condition requiring immediate delivery of an antidote is organophosphate poisoning. Most of the population here earn their livelihood through farming, and so they and their family have access to large quantities of insecticides. It is not unusual to have someone brought in with organophosphate poisoning as a suicide attempt. Unfortunately, these patients are often brought in too late for treatment to be effective.

Road accidents are extremely common here, due to the lack of adherence to traffic rules, the poor quality roads, made worse by the fact that most motorbike passengers don’t wear helmets. These factors make motorbike trauma a leading cause of mortality. Due to there being no neurosurgical capabilities in Siem Reap, any serious head injury would need to be driven to the capital, Phnom Penh, some six hours away. This of course is a significant delay for any intracranial haemorrhage. For the majority however, it is not even an option, as they would not be able to afford the transfer fee and treatment costs.

Severe sepsis is also a common presentation here. For many it is because they have delayed treatment for their infections, and so by the time they present to the hospital they are in a critical condition. There may be a delay in presentation because the family did not feel that they can afford the treatment, or the delay might be because they physically live so far away. Some have had to travel at least 200km to get to the hospital, a journey made somewhat longer by the poorly maintained roads.

Without a national emergency telephone number, or a collaborative ambulance service, most patients are bought in to the A&E by a family member on the back of a motorbike, or farm trailer, or in one of the commonly used tuk tuks. 

Part of my role is nurse educator to the staff. This involves both bedside coaching as well as more formal classroom teaching. The nurses are very skilled at what they do, and are very efficient at following the orders of the doctor. However they have limited background knowledge, and lack the theory behind their practice. They are not familiar with assessing the patient and evaluating the patient’s condition by themselves. 

I have a translator working with me most of the time. This enables me to offer bedside coaching, and train the nurses as issues arise. I also deliver education sessions a few times a week, in is a more formal classroom style of teaching.

The other part of my role is nurse advisor. Some of the areas that I have been advising on are triage, nursing documentation and infection control. I shall also be getting involved with various grant applications and writing proposals. In time I also want to assist with developing some policies and procedures for the department as currently there are not any.

One specific objective I have is to develop the resuscitation room. The room at present has no electric equipment in it. I hope to facilitate equipping it with a cardiac monitor, a defibrillator, and a couple of electric fluid pumps. Of which there are currently none of the above in the department. This is equipment that would be seen as essential in any A&E in England, but is too expensive for the hospital here to purchase. It would be done either through hospitals donating their old models (that could be brought over in someone’s luggage), or through financial donations to enable to purchase of new equipment from a local supplier here.

I chose to work in Cambodia for several reasons.

The country has a population of 14.8 million people (WHO 2012). Located in South-Eastern Asia, it boarders Thailand to the Northwest, Laos to the North, and Vietnam to the East. 

In terms of human development, it ranks 139th out of 187 countries (UNDP 2011b). The national economic performance is ranked well below other South-East Asian countries (UNDP 2011a).

Cambodia has achieved remarkable progress over the past decade in a number of areas important to human development, such as childhood and maternal mortality rates (UNDP 2007). However these improved figures are actually being compared to a shockingly high baseline, and even though improvement can be seen, the figures remain unacceptably high.

Up until a few years ago, Cambodia had the highest infant and under 5 mortality rates in South-East Asia. It also had one of the highest maternal mortality rates in the region. These health indicators are improving but nevertheless women in rural areas continue to die in large numbers during childbirth (UNDP 2007). And child mortality still remains incredibly high. Cambodia is ranked lowest among eight countries in the Association of Southeast Asian Nations (ASEAN) in terms of infant mortality as well as life expectancy and education (UNDP 2009).

Poverty remains unacceptably high. A third of the population lives on less than 61 US cents a day (World Bank 2009).

Poverty compels Cambodian children to be removed from primary school at an early age (UNDP 2007). Fewer than 50% of enrolled children complete primary school (UNDP 2007). Reasons for this may be the inability to afford school books and materials, possible long or difficult travel, and the requirement to enter the labour market to earn money for the family. This leads to a highly uneducated future labour force, and an ongoing cycle of poverty. 

Poverty leaves many children in Cambodia malnourished (UNDP 2007). In 2007, 79% of children were either moderately or severely stunted, and 8.9% of children were suffering from wasting (UNDP 2011a). Nutrition is a key determinant in health, and widespread malnutrition has profound implications for the physical and mental development of Cambodia’s next generation (UNDP 2011a).

As I mentioned earlier, the Cambodian population is vulnerable to many tropical and infectious diseases. When compared with other countries of South-East Asia, Cambodia has a particularly high incidence of malaria, tuberculosis and HIV/AIDS (UNDP 2011a). It also has high numbers of dengue haemorrhagic fever which reaches epidemic levels during the wet season. 

The majority of Cambodians, some 85% of the population live in rural areas, with only 15% living in urban dwellings (UNDP 2006). Nearly all of these who live rurally get their livelihood from agriculture. Mostly the land is not irrigated (UNDP 2007). Without irrigation systems, most farmers are only able to have one crop per year, and they do not have the luxury of being able to experiment with alternative crops and methods because failure could lead to severe food shortages for their family. Having only one harvest each year, and the lack of crop diversification, restricts their ability to earn and pull themselves out of poverty. In addition, without irrigation systems, the farmers are reliant on good rainfall, which means some years the quantity and quality of the crop can be inadequate. What’s more, they are very vulnerable to natural disasters, such as floods and droughts, which can turn the poor farmer into one that’s destitute.

Those that live rurally mostly live more or less like their ancestors did centuries ago. Conditions remain primitive, with over 80% of rural households having no electricity (National Institute of Statistics 2010). Access to sanitation is also extremely low, with 57% of households having no toilet facility (National Institute of Statistics 2010). Sanitation systems and sewerage treatment facilities are non-existent in most places. More than 50% of rural people do not have access to improved drinking water, such as new wells or rebuilt urban piping (National Institute of Statistics 2010). Villages often only have a single water source for drinking which can easily be contaminated and spread water borne diseases, such as hepatitis A and Typhoid. Many have no choice but to drink directly from unsafe water sources, such as rivers, lakes, and unprotected wells, (UNDP 2007). Waterborne diseases are rampant, and are one of the major preventable childhood causes of death in Cambodia.

These are some disturbing figures, and that’s not even mentioning the landmines, human trafficking, child labour, street children and child sex abuse that are also in distressingly high figures. What are the causes for such tragic statistics? I believe some of the answer lies in its very traumatic and recent history.

Cambodians have endured decades of violent political upheaval since they gained independence from the French in 1953. The Vietnam War caused much political instability across all of Asia in the 1960’s. In 1969 America conducted bombing raids over Cambodia. This no doubt increased the public’s turn of support, away from Prince Norodom Sihanouk, the head of state, to the Khmer Rouge, a fanatical communist faction, which was fast gaining momentum. 

Civil war broke out in 1970, which eventually lead to the Khmer Rouge taking power. On 17 April 1975, the Khmer Rouge declared “year zero” and took control of the capital, Phnom Penh. They evacuated the residents at gunpoint, into the countryside to work as forced labour. They attempted to create an agrarian based communist society. 

The brutal regime ruled the country between the years of 1975 and 1979. 

To ensure no future threats to their power, they targeted the educated or wealthy. They hunted down lawyers, judges, doctors, businessman, students, teachers, civil servants, intellectuals, monks, and anyone that could be a potential threat. They were ruthlessly executed. It was genocide.

Education was abolished. The country’s infrastructure was destroyed. Money became worthless. Severe food shortages lead to starvation. The health of the population deteriorated, and disease was rife.

During the four years of Khmer Rouge control, it is estimated that between 1.7 and 2.2 million Cambodians died, through starvation, disease, exhaustion and execution. That is approximately 25% of the population as it was then. 

Under the Khmer Rouge, the health care systems collapsed. Most of the country’s doctors were killed. The lasting impact of this is still obvious in the state of the present day national health care system. 

The regime was overthrown in 1979 by their Vietnamese neighbours. The country remained occupied by the Vietnamese for the next decade. Khmer rouge remnants hung on, and guerrilla war continued throughout the 1980s, which greatly impeded development. The Vietnamese pulled their troops out in 1989. Armed conflict continued, and the United Nations then occupied the country with their peacekeeping operation, and oversaw the elections in 1993. The elected government was then toppled during bloody clashes in 1997.

Years of brutal conflict have hindered development, leaving a weak economy, inadequate infrastructure, and an inadequate health service. Decades of civil war and political instability have made Cambodia one of Asia’s least developed countries. 

Like most hospitals in the country, Siem Reap Provincial Hospital suffers from a chronic and severe lack of basic supplies, medicines and equipment. This, combined with the fact that the patients are often so critically ill, creates many challenges on a daily basis. However, I feel so extremely privileged to be here, and I feel honoured to be welcomed into this hospital. I am excited about what can be achieved here. It is important not to get overwhelmed by the national statistics and instead look to what can be done. And there is a lot that can be done in the hospital here. If you would like information on how you can help, please visit my website medicalcambodia.com

Jenni Middleton

nursingtimes.net

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