I am happy but scared...I don’t know how we are going to eat when he is gone Phal Sao, Lorn Sao’s wife
Placing a Band-Aid
on a tumor Koh Kong Province, Cambodia
Lorn Sao is instructed to open his mouth in order to have his tumor inspected by an American doctor from the visiting CHPAA medical mission. At 44, Lorn’s tumor has been growing since the age of 19.
"If they cannot remove it...then I will die," said Lorn Sao while he waited for the Cambodian-American doctors’ decision on what measures they would be willing to take. Sao was among the thousands that traveled to Koh Kong to be seen by American doctors. By Laura Barron-Lopez Flashes of pain and discomfort shoot across his disfigured face as the doctors prod and poke the benign tumor encompassing more than half of his mouth. Lorn Sao’s tumor has been growing since he was 19. The growth has pushed Sao’s tongue completely to the right side of his face. Doctors debate over possible treatment but they express little hope on what they are capable of doing. He is now 44 and the tumor extends close to his left side, creating a massive lump roughly larger than a golf ball. The doctors do agree that he must undergo surgical removal of the tumor, an operation that costs $300 – a fortune in Cambodia where per capita income is just $2,300 – and requires a trip to Phnom Penh, the capital. Sao must return to the clinic tomorrow, today the doctors have no answers. “If they cannot remove it I will remain like this,” Sao said. “And if I cannot eat then I will die.” Sao’s condition illustrates what ails Cambodia’s health care system
Photographs by William Camargo
today. There are only .227 physicians and .1 hospital beds for every 1,000 persons compared to 3 physicians and 3 hospital beds per every 1,000 persons in the United States. Not surprisingly, this Southeast Asian country is 177th on the world’s ranking of life expectancy. And that is why the Cambodian Professional Health Association of America, a non-profit led by Cambodian-American refugees organized a mission to aid their impoverished homeland, a homeland still plagued with troubles from economic instability, disease, and even land mine injuries left behind by the Khmer Rouge of the 1970s. The Khmer Rouge, a communist guerilla movement, controlled Cambodia from 1975 to 1979 and is responsible for the killings of roughly 2 million Cambodians. Still, in the aftermath of genocide, CHPAA returns to a nation of approximately 15 million inhabitants, the majority of whom have never seen a doctor with the hope that somehow they will instill change. CHPAA raised roughly $60,000 in funds for this mission and has the government of Cambodia on their side. Despite these monetary advantages it’s not clear if the mission made a significant difference in the province of Koh Kong and if it will leave the Cambodians better off than before.
“I believe we made a small temporary impact in terms of health outcome, a longer lasting impact on dental outcome,” said family Dr. Daniel Chan of Los Alamitos. “But overall, it’s still a very small impact because we were there only a week and treated only a few thousand patients. So I felt very inadequate coming back home but the few thousands that we did help were the reason that I felt so good.” Dr. Chan admitted that the task was monumental, that aiding a country of 15 million is something beyond the scope of CHPAA’s mission. Instead, they aim to help one province at a time. CHPAA’s strong tie to the government, which is currently under rule by the Cambodian People’s Party, makes CHPAA unlike any mission currently aiding the public. Their connection with the Cambodian government springs from a basis of friendships. Dr. Song Tan a Long Beach pediatrician and the president of CHPAA went to college with the Minister of Health of Cambodia, Mam Bunheng, they have been friends ever since. “They compliment our activity and we select for them to see rural areas,” Buheng said. “Dr. Tan and I were classmates at the University in Phnom Penh.” Bunheng attended CHPAA’s welcome reception in Phnom Penh and
Top Left: Sao is asked the history and symptoms of his tumor by a Cambodian doctor after being seen by American doctors who took samples of his tumor. Only simple questions about symptoms and the history of his tumor were asked by the doctor. Top Right: Sao gets injected with antibiotics—the reason still unknown. There was little talk between Sao and the Cambodian doctor. Bottom Left: Sao and his family wait in the hot Cambodian heat as a result of not being able to afford the trip back home. He and his family were forced to stay at a friend’s house. Bottom Right: The bed Sao rested on in the hospital’s ward lays empty. He was referred to the hospital in Phnom Penh and was transported there on the fifth day of the clinic. His family would not have been able to afford the journey on their own. The status of his recovery is unknown.
spoke on the collaboration between the government of Cambodia and the medical mission. “That is the beauty of this. The Minister of Health helped us. He is very supportive of the mission because they are trying to bridge the gap of needs,” Dr. Tan said. “He just gave a phone call to Department of Health in this province and they gave us full fledged support.” CHPAA held its clinic at the Provincial Hospital of Koh Kong, facilities that were provided free of charge by the Department of Health. With 90 doctors and volunteers CHPAA traveled thousands of miles to aid the people of this Third World country, Sao being one of them. When Sao returned the next day, Dr. Daniel Chan, of Los Alamitos sat down with Dr. Tan, who would decide what measures could be taken. “No. We don’t have the money to pay for anything but we can refer.” Dr. Tan explained. “We are going to see a lot of patients like this. The question is do we pay for transportation.” To that Dr. Chan countered, “That’s my next question then. What kind of precedence, if we don’t do anything, are we creating for the future.” That is why they treat each case separately, Dr. Tan explained. Dr. Hay Layson, the deputy director of Koh Kong’s provincial hospital, walked into the conversation. The rest of the conversation transpired in Khmer till Dr. Tan turned to Dr. Chan and asked, “Did you hear that?” Koh Kong Provincial Hospital has government funding that they petition for every five years. The funding for Sao would come from the Reproductive Health Association of Cambodia, Dr. Layson said. There is a process to everything and Sao would need to complete a series of questions and paperwork. Essentially, Sao needed to be poor enough, to receive money for care, transportation to Phnom Penh, and the surgery. As a fisherman, Sao lives on $1 to $2 a day, working seven days a week. Husband to 33-year-old Phal Sao, together they have three children. Two meals a day is all they get. The pain in Sao’s mouth has worsened today from the prodding and swallowing large amounts of saliva. The agony can be seen on his face. He is lying on a bed with no linens, in a room with no light surrounded by a suffocating stench of decay. A doctor just admitted him to the Koh Kong hospital, he will no longer be treated by CHPAA. Now Cambodian doctors working at the provincial hospital will take care of the rest and determine his needs for funding. Without speaking a single word the doctor injects an antibiotic into Sao’s lower back. Unlike the American doctors who interact with their patients and attempt to explain what they are doing, the Cambodian
doctor remains quiet, with a disgruntled look on his face. He leaves Sao in silence to wait. Sao said the doctor didn’t tell him what the antibiotic was or why he gave it to him. Hours passed and no one came to speak with Sao. Outside Sao’s room the medical mission continued, busy as ever. In six days, thousands poured in. In six days, the mission took over an underused hospital and saw more patients than the facilities would normally hold. Dr. Tan noted that the hospital lacked doctors and equipment and to contribute CHPAA was leaving left over medical supplies there It was not a surgical mission; it was mainly a general one that provided check-ups to Cambodians, many of whom had never seen a doctor in their lives. Multiple doctors admitted the difficulty in treating chronic illnesses. The best that can be done is provide temporary relief with pills and some education. Angeline Barnes an anesthesiologist out of Long Beach touched on this concern. “I hope it’s not treating them for a month and then leaving,” Barnes said. “I guess I do this because selfishly it’s satisfying for yourself.” The mission had different stations set up to assist the patients. The nursing station took the patients’ basic vitals next depending on what was found the patients saw a general doctor or were referred to pediatrics, genecology, respiratory, family or dentistry. “Another team went to Tai Kei province and will be performing surgeries, mostly OB-GYN surgeries,” Dr. Tan said. “Family doctors, anesthesiologists and pharmacists are going.” Dr. Tan explained why the mission didn’t have as many surgeries and the hope that their next mission would include numerous ones. “We tried to have surgeries here but there were no elective cases,” he said. “The hospital was underused and not enough required surgery. So we don’t have enough patients.” In Dr. Tan’s opinion surgeries are more productive, take care of the problem and serve immediate needs. However he defended the acute care the mission provided for wounds, colds, skin care and medication.
“Next year there will be more surgeries like ophthalmology, plastic surgery and maybe some general surgery,” Dr. Tan said. Aside from the surgical and acute illness needs lies a far more serious problem with the health care system of Cambodia. The nation allocates only 5.8 percent of their gross domestic product to health expenditures, the CIA reported as of 2009. By comparison, the U.S. falls second in the world with 16.2 percent GDP on health expenditures. To explain where CHPAA stands in all of this, Dr. Chan referenced the saying, “If you give a man a fish, he’ll eat for a day. If you teach him to fish, he’ll eat for a lifetime.” “I would say that so far we’ve been giving fish,” he said. “But I’m glad to tell you we are gearing up to create educational activities in which we can provide effective health teachings to the poor people and educational lectures to the medical students.” These developments Chan hopes will lead to more involvement with the government. “I hope we can raise awareness among the authorities there to somehow pay more attention to the unhealthy conditions that people live in,” Dr. Chan said. “This is something that I hope is coming down the pipeline, although we have not discussed it at our meetings yet.” Sao’s predicament typifies the problems of this nation whose history haunts it to this day and is the cause for the country’s average age, 23. He came to CHPAA’s mission hoping that these American doctors would be the ones removing his benign tumor. However, that wasn’t the case. It was not known how long the operation and recovery time would take. Sao’s family would be traveling with him to their nation’s capital with only $20 in their pocket. They would have to make it last. Phal stood by her husband on his final day at the hospital with their three girls. Their son, the eldest of the children would not be going with them to Phnom Penh. “I am happy but scared,” Phal said as tears streamed down her face, their baby in one arm and her hand tightly intertwined with the hand of one of their daughters. “I don’t know how we are going to eat when he is gone.”
No. We don’t have the money to pay anything but we can refer. We are going to see a lot of patients like this. The question is do we pay for transportation. Song Tan, Long Beach pediatrician and president of CHPAA
Photographs by William Camargo