The man leading Cambodia’s seemingly Sisyphean attempt to combat dengue fever can be found most days in a weakly lit office inside the Communicable Disease Control Department, which is stacked wall to wall with drooping folders and medical texts.
For more than 10 years, the soft-spoken Dr Chantha Ngan – director of the Ministry of Health’s anti-dengue program – has been fighting a thankless battle for funding and attention over a virus colloquially known as “break-bone fever”.
“Our job is difficult, but I don’t want to complain about our small resources,” Ngan said, diplomatically. “All we can do is do the best we can with what we are given.”
What they are given is generally a fraction of that dedicated to fighting malaria.
But, while malaria deaths have dropped 25 per cent in the Kingdom since 2000, dengue cases more than doubled between 2000 and 2010.
According to the latest figures from the World Health Organization, 12,943 cases and 40 deaths have been reported this year thus far.
Closed off from the seeming funding bonanza that is malaria, those fighting dengue – a far less fatal disease – have learned to make do with less.
The Global Fund contributed more than $89 million to battle malaria in Cambodia in 2012 and $98 million in 2013.
The entirety of dengue funds from all sources, meanwhile, stands at less than $2 million a year.
As a cost-cutting measure, and with the aim of reaching far greater numbers of Cambodians, the program has been decentralised, with the provincial and district levels relying on low-paid staff to properly implement national procedures.
Underpaid volunteers are tasked with the time consuming and tedious job of spooning insecticides into water containers and spraying a dot of paint on it to mark treatment, day after day.
The day rate doesn’t cut it, according to Hai Ra, head of dengue control in Kampong Cham, which has allocated two workers per village and 15 tonnes of insecticide twice a year.
Hired larvacide applicators “receive only $2 per day for water and transportation. Most of them travel back to their homes in the villages because [the stipend] is not enough to pay for food,” he added.
Sao Vuthy has been working as one of the volunteers responsible for disbursing Abate – a common larvacide – in the water of villagers in Kampong Cham’s Koh Sotin district since 2005.
“It is not enough for spending on food and water. For example, 4,000 riel for breakfast means we only have $1 [left] for other food,” he said, adding that he often asks local villagers for water or brings it from home.
Volunteers are paid less per day than construction workers, but Vuthy says he keeps volunteering because his knowledge of dengue prevention is invaluable to his community.
“I think all volunteers should get $5 per day because this work is difficult and can be risky because of rain and dog bites,” noting that several volunteers had confided they spent their daily stipend on injections after sustaining dog bites while working.
Health officials representing the provincial health department accompany the larvacide applicators but are paid $5 more to provide “technical skill” and monitor the larvacide’s administration, according to Ra.
Volunteers “should receive $10 per day, because everything is very expensive. We used to request more for them, but we did not get it, because [funding allocation is determined by] government policy,” Ra said.
Despite the low-grade pay, data reveals a 50 per cent decrease in both cases and deaths in the first eight months of this year compared with the same time period in 2012, according to Ra.
But the numbers remain sobering.
In Kampong Cham, “three people died and more than 1,600 people were sick between January and August”, Ra said.
Dr Bov Savin, provincial supervisor of dengue in Siem Reap province, confirmed that volunteers administering larvacide were paid a rate set by national policy.
Students with extra time are trained before being sent out in the villages and given $2 for food and water.
“We often requested more for volunteers, but couldn’t get it, because it’s the national policy that sets the rate,” Savin said, adding that dengue rates were on the rise in his province.
Ideally, 90 per cent of homes should be treated with larvacide, and treatment should be accompanied by a village-wide public-awareness campaign educating local villagers about removing or covering sitting water.
One official unauthorised to speak to the press said he had encountered reports of just 50 to 60 per cent of households receiving treatment in multiple provinces.
Where is the money?
The bad news first: Dengue is being transmitted at low levels year-round in every province thanks to the indoor breeding of Aedes mosquitoes, a population that swells during the rainy season, when outdoor containers fill with rainwater.
For the past 50 years, the rates have increased worldwide in every country the mosquito, most commonly the Aedes aegypti mosquito, has found a host worth harvesting on.
In Cambodia, like in other poorer countries, cases are likely underreported because tracking hinges on the number of patients recorded by local hospitals. Anyone too weak to travel or unable to pay out of pocket medical fees won’t make the final count.
But if misdiagnosed, or if treatment is delayed, dengue can prove fatal when it develops into haemorrhagic dengue fever (HDF), also known as “severe dengue”, potentially leading to “plasma leaking, fluid accumulation, respiratory distress, severe bleeding, or organ impairment”, according to the WHO.
Previous years point to outbreaks beginning in April through May, peaking from August and September and typically diminishing in correlation with the rainy season, a pattern that unhelpfully varies in severity by province.
There are four serotypes, or versions of “dengue”, each immunologically different (Den-1, Den-2, Den-3, Den-4), meaning you could easily contract the four different types of dengue in your life.
After most people have contracted whatever strain is prevalent in a particular area, recovery from one serotype gives lifelong immunity to that particular serotype; once a community builds “herd immunity”, one serotype dies out and the next one begins circulating, mostly in newborns with no immunity.
“Den-1 peaked last year in Cambodia but is still everywhere. In 2010, Den-2 and Den-1 overlapped; before that, Den-2 dominated in 2008-2009,” Chantha said. By next year, a new serotype will likely be prevalent.
Because of the way immunity develops, children are especially prone to contracting the disease. In the two Kantha Bopha Children’s Hospitals, 1,752 children were hospitalised with HDF in August alone, according to spokesman Dr Denis Laurent.
“I cried a lot when I realised my daughter and son had dengue fever. It is so lucky that they got to the hospital in time,” said Ngoy Pouy Keang, 35, a mother of three living in Phnom Penh, who rushed her children to Kantha Bopha as soon as their temperatures started rising.
Initial warning signs of HDF occur three to seven days after the first symptoms, and once the temperature has risen above 38°C/100°F, getting to the hospital becomes crucial.
Proper diagnosis requires eyes trained to connect a high fever to anything from throbbing joints, blistering migraines, rashes, nausea and aching behind the eyes.
Administering fluid intravenously to maintain blood volume is why fatality rates have dropped to one per cent in Cambodia, highlighting the importance of early treatment.
For severe dengue, medical care by experienced doctors and nurses familiar with proper treatment are consistently saving lives, decreasing mortality rates from more than 20 per cent to less than one per cent.
The good news?
“You can prevent death, which is the great success story of dengue in the past 20, 30 years thanks to proliferating knowledge that you can bypass the crisis period by carefully monitoring fluid management,” said Steven Bjorge, team leader of the WHO’s Malaria-Vectorborne-Parisitic Diseases program based in Phnom Penh.
Early detection and proper access to medical care lowers fatality rates to below one per cent.
And therein lies the crux of Cambodia’s dengue problem: If the virus is treatable and preventable, why are Cambodians still dying from dengue?
Show me the money
“I have never been careless with my children’s health,” Ngoy Pouy, the mother living in the capital, told the Post last week.
“I spray mosquito pesticide every day and sanitise my house to avoid mosquitoes,” she said, unconsciously revealing exactly why the national program is in desperate need of a media campaign to bolster awareness around preventative dengue control.
While maintaining sanitary conditions is key to combating the spread of vector mosquitoes, covering and emptying domestic water storage containers on a weekly basis is as crucial.
When asked if he had enough funding to adequately address and prevent epidemics throughout the provinces, Chantha said he was thankful for existing funding efforts.
About $1.8 million a year is doled out by the government, Asian Development Bank and the World Bank, the two primary donors to the dengue program.
But if that scant funding can’t be sustained, Cambodia’s rates may well rise.
In the meantime, Dr Chantha Ngan’s team is expected to “perfectly control dengue, mosquitoes using techniques that only work imperfectly, with entirely inadequate resources”, Borge said.
Throw in rising temperatures caused by climate change and pair it with low infrastructural capacity to deal with epidemics and the Kingdom is facing a potentially dire scenario down the line.
“This is Cambodia,” said Po Vannara, 27, a resident of Phnom Penh who burst into laughter when asked if she had ever contracted dengue. “Everyone has dengue.”