On a Sunday evening in May, 27-year-old Tang Keo Ratanah was driving his moto home from a friend’s house in the outskirts of Phnom Penh’s Steung Meanchey district.
It was two weeks since environmental activist Chutt Wutty had been killed and the day before, Ratanah, a radio reporter, had been in Koh Kong covering the story.
The events had got him thinking about what he wanted to do with his life. ‘When I get back,’ he thought, ‘I’ll study English.’
Neurosurgeon Dr Nay Taranith at Calmette hospital. Photograph: Alexander Crook/7Days
He doesn’t remember much after that, other than fragments of the accident he didn’t see coming as he turned left, off a dark road near Monireth Blvd.
There were two moto drivers, talking to each other, he thought, speeding towards him in the opposite lane.
“I crossed the way to the left side but one of the other motos was coming first – it drove slowly – when I beeped him, he sped up,” he said. “After that I crashed and my head hit the road. I woke up for a moment and fainted. I can’t remember after that.”
What happened next was a life or death race to save his seriously battered body, and most crucially his brain, from permanent damage.
Unconscious, he missed almost all the nightmares of the next few hours: the frantic phone call to his work colleague from strangers who watched as the culprit sped away, the inability to pay for an ambulance, the nearby clinic that couldn’t provide emergency care or treatment for his rapidly swelling brain.
For his frightened family, however, and those of the forty others seriously injured on Cambodia’s roads that day, they are a reality in a spiralling road toll.
Last year an average of five people a day died as a result of road crashes; those left with serious injuries numbered more than 15,000 in total, of which the medical costs have been estimated at nearly $16 million.
Overall, the financial cost of the Kingdom’s road crashes has been put at more than $310 million, according to the Road Crash and Victim Information System.
The toll has risen to such an extent that now more are killed on the roads than from malaria, dengue and landmines.
As a reporter, Ratanah had covered road safety for his radio station and before his Steung Meanchey crash, he had already been in “four or five” minor crashes, the most recent of which saw him chase down the other moto driver and hand him over to the police.
Statistically, his collision was not an anomaly. He is a male aged between 25-29, the second highest risk age group and on a moto, on which 66 per cent of accidents occur. It was 6pm in Phnom Penh, the most dangerous time and city to be a road user, and the driver that clipped him, despite coming off so lightly as to be able to flee the scene, allegedly did so from human error rather than obvious impairment.
Although it broke in two as it hit the ground, Ratanah’s helmet certainly saved his head some damage – but by the time he reached hospital it was still too hard to tell.
To neurosurgeon Dr Nay Tararith, who treated Ratanah at Phnom Penh’s public Calmette Hospital, his case was nothing new. He can’t give an exact number, but says “a lot” of the patients he meets on the operating table are road trauma victims and as his latest moto casualty, Ratanah’s prospects did not look good.
“If we didn’t do head surgery he would have died,” he told me from his office at Calmette’s teeming neurosurgery ward. “I (later) thought he would live but have a little bit of a mental problem.”
Time is critical when it comes to operating on brain injuries and on occasions Dr Tararith is forced to plead with the families of insured patients, to not send them overseas for surgery and risk more damage.
Most shockingly, is when he has to make the decision not to operate on patients at all.
“Before operating I do an evaluation of the patient. If I think the patient will be good after operating, I do,” he explains. “But if I know the future of one patient will not be good, I don’t operate. Sometimes the family of the patient tells me to do the operating. If I think the patient will (be left mentally disabled) I don’t operate.”
How does it feel to make such decisions?
“Sometimes my feeling is not good but I have no choice,” he said.
“Sometimes I do the operation on the patient (even if) I think they will have the mental problem. But if this person has a lot of family around them I know they will be taken care of. But some family – if the mother and father is very old and they have no other family around him – if he has a mental problem, it’s very different. But a big family will support him.”
In France, where he studied, surgeons can afford to operate on the odds of survival of any kind. There is a health and a welfare system to help the person, no matter what condition they are left with, to lead a decent life.
“But Cambodia is not the same,” he said sadly. Those who might live but will be left with severe brain injuries, the kind requiring constant care, won’t get it.
According to the RCVIS, one per cent of discharged road accident patients are left with permanent disabilities, but this figure is misleading, says Socheata Sann, Handicap International’s road safety program manager.
“(The data) might only see it in terms of physical disabilities (or) they might only consider long term disabilities but don’t consider people missing months of work. This is one of the reasons we will conduct a disability study,” she said.
The study will see Handicap International team up with US John Hopkin’s University for a two-year follow-up with road accident victims from six main hospitals.
“This will help us to see the impact on the victims and the assistance that they receive.
I think that is one of the big gaps in Cambodia. We focus on the prevention side but for the rehabilitation and post-crash side, we tend to forget,” Socheata said.
After waking from emergency surgery at Calmette, Ratanah was asked an endless string of testing questions.
“They asked me who I am, where you’re from, what’s your father’s name, mother’s name; where did I work? Relationships? I could remember everything. My memory was good. The doctor said, ‘you are okay’. It was his first case where a patient remembered everything.”
While he was lying in the small dim ward at Calmette, he overheard a doctor talking to a group of medical students.
“They told the medical students, ‘we don’t have to send him to Thailand, Singapore or Vietnam,’” he said. He knew he would be OK.
The surgery Dr Tararith had performed involved removing a piece of Ratanah’s skull to stem the swelling on his bleeding brain.
To keep the small piece of skull bone insulated, it was sewn into his abdomen and put back in his head after another two or more months. The procedure is not uncommon in neurosurgery, I was told and Dr Tararith introduced me to another moto accident victim, a similar age as Ratanah, who was recovering from the same operation in the private patient ward of the hospital’s neurosurgery building.
The doctor picked up my hand and pressed it against the man’s stomach, where I could feel the solid piece of skull through his skin. The patient, calm and apparently recovered after a life threatening ordeal, said he didn’t mind.
The death toll of road accidents has doubled in the last seven years, while the number of registered vehicles has skyrocketed by 231 per cent – 84 per cent of them motos.
With the government’s Road Safety Action Plan focusing on overall safety management such as road rules enforcement and behaviour change, Socheata Sann believes the social justice measures – such as a compensation rate for those without insurance – also need to be addressed .
For the very poor, a national health equity scheme covers hospital treatment and nobody is denied treatment by public hospitals like Colmette.
However, the long-term costs for those left with injuries and the uninsured, has not been fully gauged.
“When we compare road safety to UXOs and HIV – why is the difference in funding so huge? HIV has reduced because off the high investment from stakeholders.
Road accidents are increasing and one of the reasons is the investment and concern is still very limited,” Socheata said.
“It’s hard to tackle,” she says emphatically, “But it has to be tackled.”
Covered by private insurance, Ratanah was able to pay the $10,000 costs of his treatment but he shudders to think what would have happened had he not.
Despite his lucky escape from death and brain injury, two months after coming home, he was back on the saddle of a new moto - at least until he can afford a car.
He needed to get to work, he explained, and when he feels a lingering pain in his head, he simply pulls over and takes off his helmet until it goes away.
“I feel I am very lucky because I am still alive, without losing my memory (but) I’m still scared when I’m driving on the roads.”
To contact the reporter on this story: Rosa Ellen at firstname.lastname@example.org