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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/default.php
Posted:
January 2008
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