Because Cambodia's population density is quite variable - some provinces are isolated and mountainous (Ratanakiri), and some are populated and fertile (Battambang) - the country's health care needs and services vary greatly. Cambodia's population is approximately 15 million, with about 2,000,000 people living in the capital, Phnom Penh.

Under Prince Norodom Sihanouk and the French, a basic but rudimentary health care system was in place. During the Sihanouk and Lon Nol regimes in the 1960s and up until 1975, bombing and guerrilla warfare raged in the countryside, especially near the Cambodian-Vietnamese border. Population shifts occurred from east to west, and from rural to urban areas. During this period, the population of Phnom Penh swelled from about 25,000 to more than one million.

From 1975 to 1978, the Khmer Rouge attempted to return Cambodian to a model agrarian society. There were widespread and continuous population shifts from urban areas throughout the country. The entire health care system was destroyed: equipment, supplies, and personnel, along with major infrastructure: transportation, power, water, sanitation, and irrigation. One of the greates losses was people: of a population of about 7 million, 1 to 3 million are estimated to have died under Khmer Rouge rule. Many of those who perished were people with higher levels of education. Only 45 medical doctors survived, and of those, 20 left the country. Only 26 pharmacists, 28 dentists, and 728 medical students remained in Cambodia in 1979.

Lack of adequate water, sanitation, education, transportation, and communication have caused huge problems in the development of the health system. The most common diseases in Cambodia today are related to problems with water and sanitation. In 1999, many people who came from the countryside to Phnom Penh were unused to urban living. Efforts are still being made to educate the population about health and hygiene.

People in remote villages in the provinces have difficulty obtaining health care. Besides geographical and physical barriers, trained health personnel from Phnom Penh are reluctant to be isolated in distant locations. Many provinces lack antibiotics and other medicines; many do not have cold storage facilities, so vaccine distribution, already difficult due to transportation problems, is next to impossible.

During the last decade, continuing warfare has caused further population movements. Thailand now shelters 325,000 refugees from Cambodia. Other Cambodians travel temporarily to the Thai-Cambodian border area to trade or to look for gems in Pailin. The PRK's K5 (border defense) program created temporary population movements to the border area, which have affected the spread of diseases such as malaria and tuberculosis.

Since millions of people died under the Khmer Rouge, many families have been trying to replace those lost, resulting in a very high birth rate. There was not a family planning program in place as of mid-1989. There are many more women than men due to the large number of men killed during the Khmer Rouge years - not mention continuing war casualties.

The lack of accurate statistics and surveys makes planning for the development of the health care system difficult. There has not been a census since 1962, and the system is plagued by a lack of trained personnel, lack of knowledge of public health and epidemiology, security problems related to the continuing war, and severe infrastructure problems from the war years.

Over the last 20 years, landmines have been planted in many regions of Cambodia, as they are still today, leaving a trail of injuries, deaths, and mine-infested lands. A 1989 United Nations Development Programme (UNDP) Kampuchea Needs Assessment Study recommends that measures be taken to educate local populations on how to locate areas affected by landmines and to develop measures to deal with them.

Health care is in theory free for all citizens, but in fact there are many charges for services, and when supplies are unavailable in hospitals the patient must purchase them on the open market. Each province has a separate budget, and provinces receive different amounts of humanitarian aid.

Major Health Problems

According to Dr. My Samedy, the dean of the faculty of Medicine, the most important health problems are malnutrition, malaria, tuberculosis, and diarrheal diseases. Dr. Samedy estimates that 2 million Cambodians have malaria and 200,000 have tuberculosis. Agencies working in Cambodia identify major health problems somewhat differently, focusing on diarrheal diseases, acute respiratory infection, malaria and dengue fever, and childhood illnesses. War injuries, dysentery, typhoid, hepatitis, venereal diseases, yaws, and intestinal worms are common as well.

The Department of Epidemiology in Phnom Penh states that "prevention is better than treatment." However, the health care system is essentially based on curative medicine, with minimal emphasis on primary health care. As the health system has gradually strengthened, changes are being made. The Department of Epidemiology has been working with UNICEF on primary health care, and distributes preventative health educational materials via radio, television, newspaper, posters, seminars with flip charts, and audio-visual displays, often in coordination with labor unions and women's associations NGOs incorporate principles of primary health care into their programs: "clean water, clean food, clean living."

Maternal and Child Health Care

Between 40 and 50 percent of Cambodia's population is under 15 years of age. With an infant mortality rate of 120 per 1,000 births up to age one, and 200 per 1,000 births for children from one to five years old, Cambodia has one of the highest rates in the world. NGO health personnel report that the major causes of child death are diarrhea, dengue hemorrhagic fever, malaria, respiratory infections, and malnutrition.

The PMI (the Department of maternal and Infant Protection), working with assistance from several of the NGOs and UNICEF, has trying to improve prenatal and infant and child health through education and direct care. The PMI has trained staff in all provinces, in provinces more than others. Training has been inconsistent, but the structure appears to be in place.

In 1985 a system was designed for children under the age of five who were suffering from acute malnutrition, diarrhea, and dehydration. Centers were established for rehydration, immunization, nutrition, and education (RINE Centers). In 1989 there were ten centers in Phnom Penh, and nine in all the provinces. There is also a system of day care centers, or "creches," which increased from one in 1981 to eightyone centers in 1987.

Immunizing children has been one of the Ministry of Health's priorities, with vaccination coverage in Phnom Penh reaching 80 percent. Coverage in the provinces is much less, ranging from 30 to 60 percent. Children are vaccinated against pertussis, diphtheria, polio, measles, tetanus, and tuberculosis. Some infant mortality still is attributed to tetanus and measles, and other preventable diseases.

Hospitals in Phnom Penh

Phnom Penh has nine central and four district hospitals. Hospitals are assigned specialties; the April 17th Hospital, for example, is for surgical cases, especially trauma and orthopedics. With 400 bed, it is the largest surgical center in Cambodia. An average of 10 surgeries are performed each day in its three operating rooms. A medical team from East Germany has been assisting the Cambodian staff. Power and electricity failures occur frequently, but there are several generators that supply electricity to the operating rooms. In the intensive-care wards only very basic services are available, such as oxygen and intravenous medications. The National Blood Bank provides the hospital with one liter of blood per day, but in 1979 the stated need was four liters per day.

Another hospital specializes in eye, ear, nose, and throat problems. It does not have its own set of surgical instruments, so each day its staff must borrow equipment from another hospital. The hospital has only thick suture materials, which are inappropriate for eye surgery.

Especially problematic for health is Phnom Penh's water supply. Due to lack of maintenance and destruction of the water system, sewer water and clean water mix, risking outbreaks of major epidemics.

Most direct patient care in hospitals is given by family members rather than nursing staff. The role of the nurse in Cambodia is to administer medications. Families might also cook food for patients and donate blood.

National Tuberculosis Institute

The National Tuberculosis Institute, just one of several institutes under the Ministry of Health, is a well-organized treatment program for the entire country. Considering the difficulties with roads and telephones, there is good communication between the institute in Phnom Penh and the provincial health department. Cambodian doctors and other health care workers receive assistance from the French Red Cross. Since compliance with treatment is of utmost importance, careful monitoring is supplemented with a network of village level workers. Education is an important part of the treatment, and the success of the program is evidenced by the fact that patients hold scarves to cover their mouths when visitors tour the institute.

Pharmaceuticals and Traditional Medicines

The pharmaceutical factories produce 22 percent of Cambodian's medication needs. Other factories produce gauze, plaster, leather (used for artificial limbs), soap, alcohol, and traditional medicine. Intravenous serum is made in a factory, as well as in small production units in most hospitals. In all, 143 kinds of medicines are produced. Cambodians often prefer imported drugs, though the drugs manufactured in Cambodia are reported to be adequate quality. Most drugs are distributed in bulk, due to a lack of packaging materials and techniques.

Medicinal herbs and acupuncture are two of the treatments studied in the field of traditional medicine. A Traditional Medicine Research Center was opened in 1982, and in 1983 production of selected medicines began. Thus far 514 plants have been identified and published in two books. But security problems have made sample collection difficult. Cambodia's 400 specialists in traditional medicine have been brought to the Faculty of Medicine for conferences. One of the faculty's goals is to introduce traditional medicine in all curricula at primary, secondary, and university levels.

Mental Health

Experience in the Cambodian refugee camps in Thailand, and with Cambodian refugees in the United States, indicates that many Cambodians suffer from post-traumatic stress. The Ministry of Health has expressed interest in learning more about Western approaches to mental health, but it has done little so far. The nursing or medical schools do not seem to offer instruction in mental health, and many hospital administrators in Phnom Penh deny admission to those suffering from mental health disorders. Since psychological problems are often handled within the community through traditional medicine or religious practices, discovering their nature is difficult for a Western observer.

Physical Rehabilitation Services

Although many provinces have statistics on the number of persons with physical disabilities, it is difficult to obtain and integrate these records. The percentage of the population with physical disabilities is certainly high, due to war injuries and to land mines. Many provincial hospitals perform at least 10 amputations per month; with the recent increase in fighting, these numbers have been growing. Other problems requiring physical rehabilitation include arthritis, back problems, hemiplegia, paraplegia, leprosy, polio, meningitis, and bone and brain tuberculosis. The National Rehabilitation Center in Phnom Penh treats such problems; in addition to physical therapy services, it provides appropriate technology artificial limbs and adaptive equipment. The 1987 School of Nursing curriculum included a formal training program for physical therapists.

Provincial Health Care System

There are 29 provincial hospitals, 157 district hospitals, and 1,725 town infirmaries in Cambodia. There is a shortage of trained health personnel in the provinces, and those assigned are often away for training or other duties. Electricity in the provinces is even less consistent than in Phnom Penh; many hospitals have power for only a few hours in the late afternoon or early evening. In many provinces, the major problems are malaria and war injuries, mainly amputations. Some provinces have separate wards for tuberculosis patients.

Health Care Training

In 1979, none of the 19 professors from the medical school in Phnom Penh remained there; there are few with experience in planning and management. A 1989 Ministry of Health report on the restoration of the medical faculty emphasizes training in science and technology rather than administration and management.

The health care training system has been restored from the top down. The first priority was medical doctors in Phnom Penh; later, doctors and nurses were sent to the provinces. Efforts are now being made to recruit students from the provinces so that after training they will return to homes in distant locations. Primary health care and training of village health workers has been a stated goal, but training is still insufficient.

Because education has been one of Cambodia's priorities in the last 10 years, the output of health professionals has been high. However, the training has focused on quantity rather than quality, and on rote learning: students take notes, memorize, and are tested on facts. Integration, problem solving, and supervised clinical experience are minimal. Education is based on a curative model, with training based in hospitals rather than in the community. Much of the health training comes from a French model from the 1960s and does not take into account Cambodia's current problems.

As is true throughout Cambodia, very few books are available, and only a few are in Khmer. The nursing and medical textbooks consist of mimeographed notes that students must purchase from the school. The languages of instruction in the Faculty of Medicine have been French and Khmer, but program is being developed for Khmer-only instruction. Nursing schools teach in Khmer, but due to the great number of technical terms in French, many of the written materials are in French. French is included in coursework in the School of Nursing, and both French and Russian are offered as courses at the Faculty of Medicine.

Some individuals who have received training overseas also have foreign-language skills. Thus they are in administrative or public relations positions rather than in teaching or hands-on care, where they could utilize their medical training.

Faculty of Medicine

This faculty was, and remains, the only medical school in Cambodia. The Faculty of Medicine, Pharmacy, and Dentistry was created in 1953. Under the French, prior to 1953, higher medical education could only be obtained up to the level of health officer (now called medical assistant). Between 1953 and 1975, it had graduated approximately 500 medical doctors, 120 pharmacists, 80 medical assistants, and 90 dentists. Between 1980 and 1989, it graduated 494 doctors, 230 pharmacists, 34 dentists, and 1,019 medical assistants.

Dr. Samedy, who is also secretary-general of the Red Cross and president of the Olympic Committee, is one of the few doctors to have survived the years of Khmer Rouge rule. After 1979, he began the slow task to rebuilding the demolished medical school and health care system, with help from doctors from Vietnam and some NGO assistance.

Dr. Samedy outlines the destruction of the medical school: everything, including desks, blackboards, books, and laboratory equipment, was destroyed. In 1979, resources were minimal. Surviving doctors were appointed as professors and administrators; medical students were enlisted from the ranks of those students who had begun their studies prior to 1975.

Other Schools

The "Ecole Centrale des Cadres Sanitaires," or School of Nursing, is one of three nursing schools in Cambodia. The training is three years for nurses, midwives, and laboratory technicians. Provincial training schools for assistant nurses and midwives (nine months) have been in place since 1984. In 1989 a training center for health care workers was established. In addition, village-level health workers are trained by the PMI, the Kampuchean Red Cross, the women's associations, and the provincial public health committees. These auxiliary health care workers have varying amounts of training, and systems sometimes overlap. The health care worker's duties can include giving vaccinations, promoting public health education, and assisting with patient transfers from district-to province-level centers.

Problems in the Health Care System

Humanitarian assistance has been limited in Cambodia. Agencies that normally work on smaller-scale projects are helping the government with major infrastructure projects, such as restoring the water system, training hospital personnel, and rebuilding schools and hospitals. Because the current Cambodian government is not recognized at the United Nations, bilateral aid from Western countries and multilateral development aid (other than emergency aid) have not been available in Cambodia. Humanitarian assistance is also impeded by limited access to the countryside due to security problems and restrictions on the number of visas available to foreign aid workers. The humanitarian aid agencies working in Cambodia are helping the government develop plans to absorb increased aid after a political settlement.

Salaries for government employees are very low, $3-$5 per month. Health care workers, as employees of the state, must take on additional work to survive. Since private medical practice was legalized in 1989, health care personnel might be less motivated to work for the state.

Medications are expensive. Some Cambodians living in the United States send medicines to their relatives in Cambodia, which in turn are sold on the black market. Unfortunately, there is little regulation for medications, and they are often taken in the wrong way (i.e., by injection instead of ingestion) or in the wrong doses.

Since the government has limited means of producing income, assistance by aid agencies is used as a sort of currency. This often becomes necessary in order for departments and the individuals in departments to survive. Unfortunately, this system does not encourage communication among ministries, departments, or individuals.

Many of the health problems facing Cambodia are exacerbated by the country's isolation from the Western world. A political settlement, and other steps to reintegrate Cambodia into the international community, are essential for the rebuilding of this shattered country. The Cambodian people have demonstrated amazing perseverance in the face of near impossible odds.