Impressions of Cambodia
- Tom Morley – medical student from Sydney Medical School, won the Carl Jackson Scholarship in 2012, and undertook an Elective from January – March 2012
- Louise Greenup – medical student from Sydney Medical School, won the Carl Jackson Scholarship in 2012, and undertook an Elective from January – March 2012
- Andrew Emanuel – medical student from Sydney Medical School, undertook an elective at the Children’s Surgical Centre, Phnom Penh, Cambodia – Jan/Feb 2011
- Alana Lessi – medical student from Sydney Medical School, undertook an elective at the National Paediatrics Hospital in Cambodia in 201011
- Costa Boyages – medical student from Sydney Medical School, undertook an ILA at the National Paediatric Hospital in Cambodia in 201011
- Katherine Miller – medical student from Sydney Medical School, undertook an elective at the National Paediatric Hospital in Cambodia in 20089
- Adrian Lo – medical student from Sydney Medical School, undertook an ILA in the National Paediatric Hospital in Cambodia in 20089
Tom Morley – medical student from Sydney Medical School, won the Carl Jackson Scholarship in 2012, and undertook an Elective from January–March 2012
As a fortunate recipient of the Dr Carl Richard Jackson Memorial Scholarship, I completed my medical elective term in Cambodia over the summer of 2011–2012. Conveniently, I had previously been involved with two Australian non-governmental organizations (NGO) operating in remote and rural areas of Cambodia. Although my elective was completed as two separate placements over a total of 12 weeks, I’ve chosen to reflect in depth upon the broad experience of the working in the health services in Cambodia. Describing and reflecting upon the two experiences with such radical word limitations would do no justice to the experience of what I have witnessed and had the privilege to be involved in.
Kampong Speu is one of the 24 provinces in Cambodia, situated to the west of the well-known urban epicenter of Cambodia, Phnom Penh. Famous for its production of palm sugar and palm wine, the province is rapidly developing to house some of the country’s many expanding industrial and manufacturing facilities. It was in a humble village within this economically booming province that the first of my placements was completed under the guidance of the Australian NGO LifeOptions. This organization identifies itself primarily as one concerned with health education, committed to responding to the requests and requirements of local community health workers. By working with a Khmer partner NGO, LifeOptions aims to collaborate with the workers’ understanding of the health related issues affecting their own communities.
In stark contrast to Kampong Speu province, the second of my engagements took place in the tropical villages surrounding Battambang city, located in Battambang province in the north west of Cambodia. Known by many as the rice bowl of Cambodia, Battambang is the main region of the country that remains to be affected by landmines. The city is home to uncountable NGOs concerned with safe disarmament of the area, such as the Mines Advisory Group (MAG), as well as many providing relief to land-mine victims, for example the Italian Emergency hospital. Facilitated by the Australian NGO Hope for Cambodian Children Foundation (HfCCF), this placement saw me visiting varied settings from the ill resourced Battambang referral hospital, district hospitals and health centers to the exorbitantly priced private clinics.
There were very few aspects of my clinical experience that left me feeling disappointed. As I had attempted to prepare for, there were numerous clinical and non-clinical events that left me cringing, just as there were many that left me in awe. An example of the latter is the resilience of health workers to often function with inadequate training, inadequate support and inadequate resources. Attempting to perform in the conditions under which these staff work led me to appreciate that the practice of western medicine, with the privilege of almost unlimited resources, is of very little preparation for the practice of medicine in developing countries. The ability to consult, diagnose and treat with either no laboratory investigations, or limited options that were prohibitively expensive and delayed, was astounding. Having trained in a western system that places immense emphasis on evidence based medicine and defensive practice, the game of trial and error with patient health was a one that I was uncomfortable playing. The rules of this game seemed to be very much up to interpretation by the caregiver, with grave consequence for a poor performance.
When considering the time that I spent working in the health services in Cambodia, there is a unbelievable number of events that have had a profound impact not only on my understanding of the practice of medicine, but also on my understanding and appreciation of the vital importance of public health. Of the many realizations I had throughout my time working in what I can only describe as challenging conditions, by far one of the most significant was a newfound appreciation of the incredibly intertwined nature of clinical health services, public health practices and socio-economic development. Although not an easy task, extrapolating and adapting the theoretical study of international public health and development from both university curriculum and independent study has been one of the most enriching experiences of my education to date. Moving from theory to practice is a challenge in clinical medical education and is in no way different for public health. I feel that no extent of preparation through theory can compare to the firsthand experiencing of these critical situations.
Louise Greenup – medical student from Sydney Medical School, won the Carl Jackson Scholarship in 2012, and undertook an Elective from January–March 2012
Thank you very much to the Jackson Family for the opportunity to undertake my elective in Cambodia over the Summer of 2011/2012. I spent time both at the Children’s Surgical Center (CSC), Phnom Penh and the Helen Bonner Health Clinic, Siem Reap. This experience will hopefully prove to be the beginning of an enduring relationship of myself with a fascinating nation; plagued by decades of unthinkable torture yet strong, optimistic and determined to regain its footing on the world stage.
I was first based at the Children’s Surgical Center, Phnom Penh, a hospital which provides free rehabilitation to disabled and very poor Cambodia children and adults. Clinical specialties at the Children’s Surgical Center include ophthalmology, orthopaedics, plastic and reconstructive surgery and maxillofacial surgery and I was fortunate to be spend time in each of these areas. A key aim of mine was to gain surgical experience and I was able to assist with surgeries for repair of congenital malformations, e.g. cleft lip/palate, club foot, release of constriction bands; reconstructive orthopaedic surgery; hip replacements; vesico-vaginal fistula repairs; flexion contracture releases and tumour excisions.
Between surgeries, I thoroughly enjoyed time in the wards with the children. The children were delighted with the paper, pens and stickers I had taken with me to entertain them during their hospital stay. Even the adults were keen to get involved and we found many budding artists amongst the patients.
During my time in Phnom Penh, I also visited several clinics attached to the Children’s Surgical Center, for example the Cambodian Acid Survivors Charity which was established to rehabilitate survivors of acid burns through physical and occupational rehabilitation, pressure garment manufacture and psychological counselling services.
In addition to an eye-opening and inspiring clinical experience, my time in Phnom Penh afforded me a fantastic social life and times of relaxation. Most of all, I enjoyed getting to know the people of Cambodia. I became friends with many locals and had the unique opportunity of learning from many of them how the Pol Pot regime affected their lives.
My second placement was at the Helen Bonner Health Clinic, Siem Reap, a part of the Non Government Organisation, New Hope. In addition to the health clinic, New Hope consists of a school, training restaurant, farm and outreach centre. In the four years since New Hope’s inception, the health of villagers has vastly improved in this time though many challenges remain.
My placement coincided with the volunteering of several Australian doctors which was fortunate for me as I was able to benefit from their supervision and teaching. The clinic was a great opportunity for me to develop history and examine skills. We were fortunate to have interpreters to make the language barrier less of a challenge. One of the most valuable aspects of my placement was being part of the medical response unit team. This team consisted of a social worker, a doctor, a translator and a driver and was called out to attend emergencies in the surrounding villages and market places and to undertake outreach services. The emergencies not only provided me with practice of primary and secondary surveys in a community setting with limited resources but also demonstrated rather significant problems with the health system in Cambodia, including corruption and lack of resources.
Thank you again to the Jackson family for their generous scholarship to help medical students complete a placement in Cambodia. The value of this scholarship in nurturing a genuine interest in the health of Cambodia should not be overlooked and its potential role in aiding the long term provision of medical services to this great nation should be congratulated.
I spent six weeks at a non-governmental organisation (NGO) hospital in Phnom Penh known as the Children’s Surgical Centre (CSC) which provides free surgery to disabled Cambodian children and adults.
It almost goes without saying that an elective at CSC is suited to students who are interested in surgery as it is a small hospital that focuses on orthopaedics, plastic surgery and ophthalmology. In fact the hospital is mainly just four rooms – the operating theatre with 3 tables next to each other, the small recovery room, the ward and the consulting room. I was expected to scrub for almost every operation and most of the time I found myself much more actively involved in the surgery than I would be back home. The main conditions we operated on were fractures and associated complications, acid burn contractures and cleft palates. From an anaesthetics point of view, I learnt how to perform intubation as well as epidural and spinal anaesthesia. There were also some visiting anaesthetists from the USA and the UK who came for a few weeks each to teach the local staff and I learnt quite a lot from both of them. One of them even organised for myself and 2 other medical students to run a teaching session on advanced paediatric life support for the medical and nursing staff.
Overall, my time at CSC was a mixture of emotions - at times it was sad and frustrating and at others it was enjoyable and satisfying. For example, it was immensely satisfying to watch cleft palate repairs yet really sad when young patients with bone tumours had no access to chemotherapy because they couldn’t afford it. Seeing patients with acid burns is always shocking no matter how many different cases you see, yet it was nice to see the patients smile after the plastic surgeons performed skin grafts to improve their function and appearance. It was frustrating seeing patients with relatively simple problems that were presenting at more serious and advanced stages because they had tried Khmer traditional medicine or couldn’t afford the trip to hospital. We saw countless patients with complications such as Volkmann’s ischaemic contracture that resulted from inadequate treatment of simple fractures. Despite such frustrations, the positives certainly outweighed the negatives and every Cambodian patient I met was very appreciative of the free high quality surgical care they received at CSC.
The staff at CSC speak English and they are all very friendly and welcoming. I forged many memorable friendships with the staff and my respect for them has grown after I began to understand the challenges involved in providing complex surgical care in Cambodia. I was very impressed with the efficiency of CSC as an organisation and the ability of its staff to get the job done despite its relatively limited resources. For example, I observed several complex scoliosis surgeries that were not only done on patients with particularly severe scoliosis but the surgeons had to use a mixture of older generation equipment because it’s all that was available. Another example was when I joined a weekend medical outreach clinic in Kratie - a rural province approximately 5 hours away from Phnom Penh. Whilst we were there we set up a temporary clinic in a school to provide primary care, eye care and women’s health services to people of all ages. Importantly, there were also areas devoted to health education and provision of basic health supplies and multivitamins. The trip was unexpected and it turned out to be one of the highlights of my elective. It was hard work, starting at 7am and in scorching heat with very few resources – just clinical acumen and a range of medications. I feel that these experiences of practicing medicine with fewer resources are valuable and indeed one of the benefits of doing an elective in a developing country.
My time in Cambodia turned out to be a fantastic grounding experience as the people are incredibly stoic and often very poor - many live off less than a dollar a day. At this level of poverty, many of the patients had poor access to so many things we take for granted including clean water and adequate food and shelter let alone the opportunity to travel to Phnom Penh to seek medical care. I certainly gained a new perspective on life and a new found appreciation for what hardship really means. Cambodia, and its smiling people, has found a place in my heart. I will return.
Andrew's placement was supported by a generous donation from the Jackson family in the form of the Dr Carl Richard Jackson Scholarship.
Alana Lessi – medical student from Sydney Medical School, undertook an elective at the National Paediatrics Hospital in Cambodia in 201011.
My first impression of the National Paediatric Hospital (NPH) was one of diversity. On my first day I began on the respiratory ward, where Dr Cheung was in the middle of conducting a teaching ward round in English, French and Khmer all at once! He was interactive and the students were clearly enjoying being pushed to come up with on-the-spot hypothesis for their patients’ states of disease.
Patients at the NPH ranged from financially comfortable locals of Phnom Penh to extremely poor families from distant provinces. I observed that these different socio-economic groups responded differently to disease and the help at hand. Local families were more likely to have sought medical help before presenting at hospital, and seemed more confident in the treatments offered at NPH. On the other hand, families from the provinces often presented as a last resort. Presentation had often been delayed because the family had been unable to identify the difference between an every-day injury or illness and a potentially life-threatening situation. In addition, the notion of illness as a form of punishment hindered such families from taking measures in disease prevention. The disparity in education, and the role of public education in population health became very apparent to me.
As more Sydney elective students arrived, we realised that the key to learning at NPH was finding a student or resident with good English. This obviously benefited my history taking, understanding clinical discussions etc, but it also allowed me to offer something in return. Thanks to my fellow-student translators, my knowledge of orthopaedics, tropical diseases and infectious diseases has vastly increased. In return we were able to provide them with an approach to learning about a clinical – and back it up with information-seeking from reliable sources.
Finally, any elective student visiting Phnom Penh should attend the annual Mekong Sante Conference, held in January. 2011 was the second Mekong Sante conference, and delegates included surgical, medical and public health consultants form all over Cambodia and several international presenters. Mekong Sante provides an insight into the current targets of local public health efforts and the difficulties of administering healthcare in a country where basic population data is only now becoming available.
I came away with a strong sense that in healthcare at least, international efforts are not in vain, and that progress is certainly being made. I would most sincerely like to thank the Jackson family for assisting me to undertake an elective in Cambodia – a place that I am already making plans to return to, contribute to and to learn from.
Alana's placement was supported by a generous donation from the Jackson family in the form of the Dr Carl Richard Jackson Scholarship.
Costa Boyages – medical student from Sydney Medical School, undertook an ILA at the National Paediatric Hospital in Cambodia in 2010-11
"Doing an ILA placement through the Office of Global Health at the National Paediatric Hospital in Cambodia was inspiring and humbling in equal measure. I was attached to the surgical team under the guidance of Dr Yuthy - an American trained surgeon who, unlike many doctors of his generation, had survived the Khmer purges of the professional class.
Cambodia is still achingly poor, riven inequity. This leaves little money for health in a state hospital like the NPH. The difference between medicine at the NPH and western hospitals is stark and largely a result of the discrepancy in resources: doctors at the NPH are more generalist, less reliant on expensive diagnostic techniques and mostly very young given the population explosion in Cambodia and policies in the 1970's which tried to turn Cambodia into a self-sufficient peasant agrarian society.
As first year medical students, we were conscious not to overstep our capabilities. We would observe procedures and consults. We were able to give back in small ways for example assisting young doctors (mostly trained in French) to write notes in English. Despite the learning environment being quite different, we all learned a great deal over the three weeks of our placement. Dr Yuthy and his team had an impressive range of clinical skills and would very generously take the time to translate and explain the presentation/pathology to us in English between consults.
Clinically, the cases were as varied as they were exotic including a gastroschisos surgery. Clubfoot, motorcycle accident trauma and scholiosis featured in the orthopaedic presentations very often. It was humbling to see the stoicism and cheer with which many Cambodians approach life. Equally, the resourcefulness, good humour and fighting spirit of Dr Yuthy and his team was impressive. "
"The doctors I worked alongside in Cambodia are the most inspiring I've ever met. In a system where there simply is no money for medicine, I watched as the surgeons joked with each as they made traction devices from cardboard and bandaging, as they used garden-shed pliers to remove pins, and wooden mallets to carve out bone and correct foot deformities. They never complained, quite the opposite, theatres were always filled with laughter and good humour, and they made me feel like part of the team. To me this felt like real medicine, using clinical experience and good judgement to treat patients, where resourcefulness is the greatest commodity you have. Many of these doctors had survived the Khmer Rouge, many of their patients were suffering the sequelae of a country torn apart and the massive loss of resources, especially health resources, that followed.
From the doctors I learned so much, the best way to perform a cleft palate repair, how to approach the diagnosis of congenital deformities, surgery from the bread and butter of hydrocele repair all the way up to treatment of Hirschprungs disease. I learned about diseases that I'd never heard of, and I saw the heartbreaking consequences of an ill-equipped ICU. I learned just how lucky we are in Australia to have our health system - Cambodia is still heavily reliant on NGOs to help a lot of their citizens. Best of all, I learned how to maintain good humour in any situation. With a lack of resources, extremely ill patients and burning heat, Khmer doctors, indeed Khmers in general, are always ready for a laugh, and are almost never without a smile. As a future doctor, the perspective this elective gave me, on medicine, and life, is something I will take with me forever. The good humour and resourcefulness of my mentors will make me a far better doctor than I would have been without this elective. They say that Cambodia changes you, and whoever they are, they are right.
I'd like to thank the Jackson family for the for the Dr Carl Richard Jackson Scholarship and for amazing opportunity they provided, and I highly recommend the National Paediatric Hospital to anyone considering an elective term."
"Coming into the Sydney Medical Program I set out to push myself beyond my comfort zone and experience as much as I could. I selected the Cambodia ILA because it was unlike anything I had undertaken in my first degree and it would enable me to experience healthcare in a developing world environment. To be honest at first I didn’t spend much time considering how I would be able to give back as much as I thought about what I could gain. That is what most first year medical students think about, also the opportunity to perform duties beyond our capabilities, because let’s face it, at this stage we all just want to cut, suture, inject or withdraw something from our patients. For my sake and the sake of my patients I was glad that the National Pediatric Hospital, Phnom Penh is a large teaching hospital. I certainly didn’t get to perform outside my capabilities but I did manage to learn an incredible amount in my 4 weeks.
I spent the whole time in the surgical department, watching mostly orthopaedic procedures on deformities we just don’t see in Australia. Things like osteotomies on children suffering Rickets, triple arthrodesis surgery for talipes equinovarus and hip surgery for children who had congenital hip dysplasia but weren’t picked up until well into their childhood. I grappled with the many reasons why such preventable deformities would still be happening, but after visiting cultural sites like Tuol Sleng (S21 prision camp) and Choeung Ek (the Killing Fields), I realized this small nation, including their medical system, is in the process of being dragged back into the 21st century after the Khmer Rouge regime sent it hurtling back to an agrarian society only 30 years ago.
My supervisor, Dr Vuthy is a man with such a passion for his work. I got to spend a weekend away with him and his family visiting the area he stayed in as a child during the Khmer Rouge regime. We even found the family which housed and protected him. It was such a moving experience. In my time at NPH I felt like I took a lot (the essence of being the dreaded ‘medical tourist’), but by chance my time coincided with a visiting American surgeon, Dr Gabriel. Dr Vuthy had saved up all of his ‘difficult cases’ for Dr Gabriel to consult and operate on. I had my Canon digital SLR camera with me at the hospital so Dr Vuthy asked if I could document, step by step the surgeries Dr Gabriel was performing for teaching purposes. I looked at this as my chance to leave a ‘positive footprint’, to give back in a way that will hopefully serve the future doctors of Cambodia for many years to come."
Adrian’s placement was supported by a generous donation from the Jackson family in the form of the Dr Carl Richard Jackson Scholarship.