Though the Kingdom has made progress since the health-related development goals were adopted, officials must now combat emergent trends as well as problems that persist
An HIV-positive woman lies in her wooden house in central Phnom Penh. Despite impressive progress in reducing HIV rates in Cambodia, the Kingdom may still not meet its Millennium Development Goals for health.
WHEN Mony Pen discovered five years ago that she was HIV-positive, the list of things she did not know about the disease included how she got it, how she could treat it and how long she could live with it.
"People told me I was probably going to die very soon," said the 28-year-old Phnom Penh native, who learned of her status only when her husband, a policeman, died of full-blown Aids two years after they married.
These days, Mony Pen, now an adviser to the Cambodian Community of Women Living with HIV/Aids (CCW), knows all about transmission and treatment, and can discuss in detail everything from antiretroviral drugs to the threats posed by opportunistic infection.
She also knows this expertise sets her apart from the majority of Cambodian women, particularly those outside Phnom Penh. The 2005 Cambodia Demographic and Health Survey (CDHS) found, for example, that 67 percent of women in Mondulkiri and Ratanakkiri provinces believed HIV/Aids could be transmitted by a mosquito bite and 56 percent believed it could be spread "by supernatural means".
Mony Pen said she believes this lack of knowledge could fuel a resurgence of the disease that might erase the much-touted gains made against it in recent years.
This concern is not hers alone. UNAIDS Country Director Tony Lisle told the Post this week that several trends - in particular, the rise in so-called indirect sex work performed in beer halls and karaoke bars - could trigger an increase in new infections that might even "set the scene for a second-wave epidemic".
In this regard, Cambodia's fight against HIV/Aids resembles its broader effort to meet targets under the three health-related Millennium Development Goals (MDGs).
With some exceptions, notably in the area of maternal health, available data shows that Cambodia met or exceeded targets for 2005 and is likely to do the same in 2010 and 2015. But certain recent trends have muddied the picture, reinforcing the fact that progress is not inevitable.
Speaking in reference to HIV/Aids, Lisle captured a widely held view of the general health picture in the Kingdom, one articulated in recent interviews by doctors, NGO workers and government officials: "Yes, Cambodia, you've done a fabulous job," he said. "But it's not over."
An HIV-positive three-year-old child plays at home in Phnom Penh after receiving treatment at a Phnom Penh hospital.
A FOUR-PART LOOK AT CAMBODIA'S MDGS
Last year marked the midway point for achieving the Millennium Development Goals, benchmarks for developing countries established in 2000 that cover everything from poverty to environmental sustainability. Last year also marked the five-year anniversary of the adoption of Cambodia's Millennium Development Goals, the localised versions of the global goals. In a four-part series, the Post looks at the progress made and the challenges that remain in achieving targets set for 2010 and 2015, drawing on government data as well as interviews with officials, NGO workers and Cambodians who stand to benefit from the effort. Part Two looks at the goals for child mortality, maternal health and diseases such as HIV/Aids.
A recent survey assessing the impact of rising food prices on child health underscored the tenuous nature of progress made in pursuit of MDG No 4: to reduce child mortality.
The Cambodian Anthropometric Survey, findings of which were made public last week, found that the percentage of children classified as acutely malnourished - the number of which had fallen by half between 2000 and 2005 - increased from 8.4 percent in 2005 to 8.9 percent in 2008.
The strong link between child malnutrition and child mortality - noted, among other places, in the 2005 assessment of MDG targets published by the Ministry of Planning - suggests that, in light of the survey results, Cambodia might have trouble meeting its 2015 target mortality rate for children younger than five: 65 deaths per 1,000 live births.
The survey results run counter to Cambodia's recent performance in the area of child health. Between 1998 and 2005, the under-five child
mortality rate fell from 124 per 1,000 live births to 82, far surpassing the target of 105.
Viorica Berdaga, chief of child survival at Unicef, said via email that this decline could be attributed to factors including better access to safe water and the promotion of breastfeeding, which provides children with disease-fighting antibodies.
But Berdaga also noted that the mortality decline was in part due to a lowered fertility rate, which calls into question Cambodia's ability to reduce child mortality even further.
In its 2005 assessment, the Ministry of Planning noted that fertility declines have had a similar effect on child mortality in other developing countries but that, in most cases, "the initial positive impact" was "not enough to sustain continued improvement in child mortality due to underlying causal factors". Berdaga said this assessment could be applied to Cambodia as well.
Asked to predict whether Cambodia would meet the 2015 child mortality target, Berdaga could say only that the Kingdom "has a chance".
If current trends continue, several experts said, Cambodia has little, if any, chance of achieving targets set under the fifth MDG: to improve maternal health.
The most recent reliable data shows that the maternal health situation has worsened as of late. The Cambodia Demographic and Health Survey (CDHS) found that the maternal mortality rate per 100,000 live births had increased from 437 in 1997 to 472 in 2005. The interim target for that year was 343.
In a recent email interview, however, Pen Sophanara, a communications associate for the United Nations Population Fund, emphasised the "promising signs" she said could potentially reverse the trend, including higher rates of deliberate birth- spacing.
She echoed the conclusion presented in the 2005 Ministry of Planning assessment that officials could significantly lower the maternal mortality rate by providing more family planning resources, which allow women to allot sufficient time between pregnancies. Longer gaps between pregnancies tend to result in smoother pregnancies and healthier infants.
On top of limited family planning, Pen Sophanara said efforts to improve maternal health continued to be hindered by a shortage of midwives and skilled birth attendants.
She said the Ministry of Health was aiming to have one midwife stationed at each of the Kingdom's health centres by the end of the year. In addition to bolstering recruitment, she said, officials will need to distribute resources to rural health centres to ensure midwives can be effective.
Kek Galabru, president of the rights group Licadho, said midwives should be able to take blood samples, conduct ultrasounds and screen for potential delivery complications.
She also stressed that midwives should be adequately paid so they do not collect informal fees, a practice that prevents very poor women from accessing health services.
Pen Sophanara said midwife recruitment and other efforts in place could potentially yield a drop in the maternal mortality rate, pushing it closer to the goal of 140 deaths per 100,000 live births by 2015.
"Nobody wants to see women die giving lives," she said. "If these figures continue to be positive, maternal death will be lowered."
The HIV/Aids fight
Mony Pen, whose late husband gave her HIV, works to give women access to HIV/Aids information.
One target already surpassed is that pertaining to HIV/Aids infection, a leading indicator of progress made in achieving the sixth MDG: to combat HIV/Aids, malaria and other diseases.
Meeting the target resulted in part because of a statistical error that caused the rate of infection in the late-1990s - which was used as a base in establishing benchmarks through 2015 - to be artificially inflated when the MDGs were adopted. Because of the adjustment that occurred when better data became available, current rates of infection are already lower than the targets.
For example, the estimated prevalence among Cambodian adults in 2006 was 0.9 percent, lower than the 2005 target (2.3 percent), the 2010 target (2 percent) and even the 2015 target (1.8 percent).
According to a 2008 UNAIDS report, however, Cambodia's prevalence rate is the second-highest among all countries in South and Southeast Asia (only Thailand's is higher). And, while acknowledging progress, Lisle and other experts cited a range of persistent problems.
Mony Pen said she has concluded from her own observations that discrimination against those infected with the disease remains high.
Sou Sina, 29, who is from Sihanoukville and now works at CCW in Phnom Penh, said she encountered this very obstacle when she tested positive at the age of 20.
"At the time, my family took care of me, but they were afraid," she said. "They didn't understand the disease. And that broke my heart."
Like Mony Pen, Sou Sina learned of her status only when her husband died. She also found out then that her son had been infected through mother-to-child transmission, but she did not know how to obtain treatment for him. He died two years later - at the age of four - of tuberculosis.
Lisle said it is common for women to become infected by their husbands unwittingly. In addition, he pointed to data suggesting that programs designed to prevent mother-to-child transmission have been ineffective.
Data from 2008 indicated a mother-to-child transmission rate for HIV-positive pregnant women of 35 percent.
Lisle said Cambodia has traditionally "led the region" in the fight against HIV/Aids, adding that he has every reason to believe this will continue. But a failure to respond to these emergent trends, he said, could quickly render the Kingdom's recent progress aberrational.
In Cambodia, Lisle cautioned, there exists the threat of "a second epidemic waiting right around the corner".
ADDITIONAL REPORTING BY MOM KUNTHEAR AND CHEANG SOKHA