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Physiotherapist Deum Sokha performs an exercise with a colleague. Eliah Lillis

Stigma and misunderstanding barriers for Cambodia’s physios

Social stigma, lack of understanding and high costs are creating a shortage of physiotherapists just as demand for such therapy is expected to rise.

It was while she stirred a pot over a hot fire, bending to taste ingredients, that she first felt the twinge in her lower back.

Kim Hor, a chef, then felt a shooting pain down her leg, which made it difficult for her to walk.

She went to the hospital and was handed painkillers, but the pain kept coming back.

It was then that she turned to physiotherapy – a treatment she knew next to nothing about.

“I heard that it was a kind of massage, but it is totally different to massage,” she says.

Hor said the assessments, stretches and exercises helped ease the source of her pain, unlike the medication, which washed away the stabbing pangs only for short amounts of time.

While lower-back pain like Hor’s is not the reason physiotherapy initially came to Cambodia, it is indicative of the coming demand for the profession.

In the wake of the civil war, and the horrific impact of leftover unexploded ordnance, NGO Handicap International helped establish the first physiotherapy department in Cambodia – at the University of Health Sciences’ Technical School for Medical Care – as a form of emergency aid to rehabilitate those who had lost limbs.

But as the need to help amputees from the remnants of war thankfully wanes – there were 83 casualties in the Kingdom last year, compared to an annual average of 4,000 during the 1990s – physiotherapy is turning to new fields: treating pain and strain on labourers’ bodies, helping stroke victims regain the use of their arms, and aiding children with cerebral palsy to move freely, and even to play.

Non-communicable diseases are another major development for the physiotherapy field, including diabetes, which is on the rise in the region thanks largely to the proliferation of junk food and sugary drinks.

And yet, despite a growing need for physical therapists in these new areas, the number of new students enrolling in the three-year associate degree at the government’s University of Health Sciences in Phnom Penh has dipped to dangerously low levels in recent years.

Dr Khoy Vuthly, head of the physiotherapy department, says 17 students were enrolled in the course back in 2010 and 2013, but that figure dropped to just five students in 2014, and nine in 2015.

For Vuthly, as well as several practising physiotherapists, the drop was attributable to two things: firstly, the cost of the course at $1,000 a year. And secondly, a fundamental misunderstanding about what physiotherapy – which is often referred to interchangeably as physical therapy in the Kingdom – actually is.

A social stigma
Oeum Sokha, 25, is dressed in deep blue scrubs at the private practice where she works in Phnom Penh.

She has a concentrated energy as she demonstrates how a patient should arch their back, tilt their pelvis, and turn their torso to stretch and strengthen their bodies.

“Before, people were working with amputees, but right now and in the future, we treat all kinds of different things,” she said, naming breathing problems as an example.

Sokha’s colleague, Eth Mey Mey, points to vertebrae on a model spine as she remembers beginning her studies without knowing much about physical therapy.

“My sister’s friend told me the skill is one that not many are interested in, but a good skill for the future,” she says.

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Physiotherapist Deum Sokha at the Alpha Clinic. Eliah Lillis

“People are confused about this kind of skill,” Sokha agrees. While her family was immediately accepting of her chosen study there are other physiotherapists in her family some friends and other people called her a “massage girl”.

This is a traditional misconception, says Cambodian Physical Therapy Association (CPTA) president Song Sit. With “massage” being loaded with connotations of sex work in Cambodia, it could deter girls from enrolling, he says.

Sit feared that the low enrollments could prompt the university to shut it down.

Sit and the CPTA have been working closely with the International Committee of the Red Cross (ICRC) to promote the benefits of physiotherapy. Vuthly attributed this effort, as well as five scholarships offered by the ICRC, as the reason for a sudden spike in enrollments last year – from nine to 19.

According to Chap Sarun, head of the physiotherapy unit of Kien Khleang Physical Rehabilitation Centre, between 25 and 30 patients are treated each day at the centre, for everything from spinal cord injuries to club foot.

Sit says Cambodia currently has one physiotherapist for every 10,000 people, but in countries like Singapore or Japan, that rate is one per 1,000.

At the university, Vuthly hopes a new chapter will begin for the practice with yesterday’s launch of a one-year bridging course – which lifts the three-year associate degree to the level of a bachelor.

Additionally, he’d like to see the government reduce or waive the cost of the course for students.

Ministry of Health spokesman Ly Sovann responded that “if there is a request, the ministry will consider it”. While Sovann was unaware of the new bridging course, he said the practice shouldn’t be underestimated.

“Because of accidents, because of high blood pressure and stroke, and because we have so many non-communicable diseases, it is necessary that we have more and more physiotherapists to cure our patients to go back to normal functioning,” he says.

Sit says the new course will bring Cambodia in line with other qualifications on offer in Southeast Asia – and there are hopes higher education, like masters programs, will be available in the future – but he stressed more still needs to be done in the workplace.

“The awareness of physiotherapy within the health system is not strong . . . Many medical doctors don’t understand well about the advantages of physiotherapy to provide some benefit to pathology, so they don’t recommend it,” he says. “For those in the provincial hospitals, they don’t play a role as a physical therapy professional.” Instead, they are frequently relegated to nursing roles or administration tasks.

For Phok Khemara, who owns Alpha Clinic where Sokha and Mey Mey work, this rang all too true. He says when he and others interned at hospitals as part of their study, the role of physiotherapists was drastically limited.

“Students are afraid to enroll, because they don’t know what they can do after this,” he says. “The hospital never recognises the role of their skills, so people are afraid there is little or no market.”

He says that situation is improving as more Cambodians come to value the practice, though the desire for a quick fix was still strong in the Kingdom.

“The culture is, if it’s sore, take medication,” he says. “But physical therapy can improve motion by curing naturally.”

Sit adds that the slow-burn effect of physical therapy has longer term benefits than popping a pill, and the impact was not just individual, but societal.

Despite the obstacles, he is hopeful for the future of the profession. As a practitioner himself, he knows the art of strengthening a system takes work and practice over time.

“Physiotherapy is not like being a doctor or nurse – when a patient has pain, they just provide a tablet of medication, and the pain goes away,” he said. “But with physiotherapy, we need time to prove the effectiveness of our intervention.”

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