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International Child Health Section: Articles
Siem Reap, Cambodia, November 12- December 4, 2007
Submitted by Kayla Feldman
Some things are universal – a smile, “hello” – and in a country where almost everything is foreign – the language, the food, the culture – these simple gestures can provide some common ground between strangers.
I recently had the privilege to volunteer at the Angkor Hospital for Children (AHC), located in Siem Reap, in the northwestern part of Cambodia. AHC is a paediatric teaching hospital funded by the non-governmental organization, Friends Without a Border. The hospital is staffed mainly by Cambodian people, with expatriates serving largely a volunteer role.
AHC provides paediatric care to children living in Siem Reap and neighbouring provinces as well as medical education programs to Cambodian health care workers and community outreach. Services provided by the hospital include outpatient, in-patient, acute, emergency, surgical, dental and ophthalmologic care. The outpatient department sees 300+ children each day and the hospital maintains 50 in-patient beds. The most common diagnoses for patients admitted to the in-patient unit are pneumonia, sepsis +/- meningitis, dehydration secondary to diarrheal illness, severe malnutrition, HIV/AIDS, dengue fever, malaria, tuberculosis, intestinal parasites, and renal disease (e.g. nephrotic syndrome, acute glomerulonephritis).
Prior to my experience at AHC, I had never participated in an international health elective. However, I have had a long-standing interest in traveling and in gaining exposure to different cultures, people, and landscapes. Given my current status as a senior paediatric resident, I felt that I might be able to offer some useful medical skills.
The main thing that struck me about AHC upon my arrival was the high level of care that the hospital provides to Cambodian children despite limitations in resources. I was quite surprised to find that it runs a four-bed ICU and has the ability to provide CPAP and mechanical ventilation. While some children still die of illnesses that may be preventable here, many severely ill patients are able to receive life-saving treatment.
I was also impressed by the breadth of care that is provided at AHC. While the hospital currently does not staff any formally-trained paediatric subspecialists, each of the senior Cambodian paediatricians have taken an interest in various subspecialty areas, and several have received grants to pursue more in-depth training in order to provide more focused care to children. In addition, volunteer specialists (medical and surgical) donate their time and expertise to provide care for AHC’s patients. During my elective at AHC, a visiting plastic surgeon performed numerous cleft lip and palate repairs and volunteer dentists and trainees ran a very busy dental clinic.
The hospital also provides a large number of additional services. It has a dedicated homecare team, consisting of six nurses who provide home-based care for children with chronic illness, including severe malnutrition, HIV and neurological disabilities. In addition, there is a multidisciplinary HIV team that provides extensive counseling, education, support, and treatment to parents and children living with HIV. While not all ancillary services are available, the hospital employs one full-time Khmer physiotherapist, and a play specialist works with children in the outpatient and in-patient departments. AHC also offers a two-year training program in paediatrics for junior Cambodian doctors, consisting of both clinical and theoretical teaching. A physician is available on-site 24 hours per day. The level of dedication of staff working in all areas of the hospital is remarkable. Despite suboptimal numbers and long working hours, they work tirelessly to provide quality health care to large numbers of patients each day.
Many of the challenges that I expected to encounter during my elective were, in fact, experienced. Lack of money and resources always come to mind when considering health care in developing countries, and despite the high level of care that is provided at AHC, there are still limitations. For example, I followed an adolescent girl with severe lupus nephritis, which was not controlled with corticosteroids. In the Western world, this girl would have had a renal biopsy prior to being started on further immunosuppressive therapy. However, renal biopsy is not available at AHC; therefore, we had to make a decision about starting this patient on potentially toxic therapy without pathological confirmation of her underlying renal disease. Although volunteer cardiac surgery teams perform PDA ligations on children at AHC, open-heart procedures are not feasible. Therefore, children with other relatively ‘simple’ congenital cardiac lesions, such as ventricular septal defects, are unable to undergo repair.
The majority of patients at AHC are from impoverished rural rice-farming communities, which can be a significant distance away. Although health care centres exist in these communities, the availability of staff, as well as the quality of care, is extremely variable. Many people living in these rural areas also turn to traditional healing methods, such as “coining” and herbal concoctions, as their first line of therapy. Both of these factors often lead to a delay in receiving appropriate care, and by the time some children are brought to AHC, their illness has often progressed substantially.
Other factors that compound the severity of a child’s illness include malnutrition and HIV positive status. Of a population of 13 million, nearly half are under the age of 15*. The average family size in a rural area seemed to be at least 6-8 children (personal observation). Approximately 34% of Cambodians survive on less than $1 US per day*. Fifty-one percent of Cambodian children are malnourished*. An estimated 12,000 Cambodian children are living with HIV/AIDS*. Due to the fact that most births still take place at home, the incidence of vertical transmission of HIV remains high. Many children have lost parents to AIDS. I remember the disbelief that I felt when I was told that the primary caregiver for a 6-year-old HIV positive patient was his 14-year-old uncle.
One of the reasons I chose to volunteer at AHC is that the operating language in the hospital is English. This certainly made it easier for me to communicate with nurses, physicians, and other health care workers; however, a significant barrier to communication with patients and families remained. Despite the fact that nurses were able to act as interpreters for me, I found it difficult not being able to provide explanations and answer questions directly. Although I felt that the care that I was providing was appreciated, my ability to establish a therapeutic relationship with patients and families was certainly limited by my inability to speak with them in their language.
Overall, I feel fortunate for the time that I was able to spend at AHC and in Cambodia. My elective exposed me not only to health care in a developing country but also to a culture and environment that is very different from ours. I really enjoyed living in one place for several weeks and becoming familiar with the food, the people, and the way of life in and around Siem Reap. My experience was definitely eye-opening, and there are many aspects from my stay that have left a long-lasting impression in my mind. Perhaps the most positive memory that I will take away with me is the enthusiasm with which children waved hello when they saw a foreign face passing by and the excitement and smiles that they displayed upon receiving greetings in return. How rewarding it is when such a simple gesture can evoke such extreme happiness!
I am grateful to the Don and Elizabeth Hillman International Health Grant and the Canadian Paediatric Society for their support towards this elective.
* Refer to the AHC website, http://angkorhospital.org
Posted: January 2008
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