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Experts urged to re-think child health strategy

Experts urged to re-think child health strategy

Kantha Bopha hospital director Dr Beat Richner argues that more money

must be invested into Cambodian children's health soon to prevent an even worse


THE Phnom Penh Post of July 14 1994 published my letter to

President John F. Kennedy (Dear JFK). In the meantime I got an answer by his

brother, re-elected Senator Edward M. Kennedy. From the World Health

Organization (WHO) I got a letter too, only less kind and encouraging.


wrote to them about their health strategy, calling it "poor medical care for

poor people in poor countries." Discussions were held in a friendly atmosphere,

but nothing has changed. The Phnom Penh Post of Jan 12 published an article

"Child health among world's worst". Indeed, the reality of child health in

Cambodia is a true catastrophe. In Kantha Bopha children's hospital we see this

all day long and all night long.

Since Nov 1992 til the end of 1994,

146,568 children were treated in our outpatient station. Some were seen several

times (362,784 consultations). Only the most severe cases were hospitalized:

17,100 children. These children were very sick. They belonged not only to the

one to five age group but also older - a bad sign for the general health

situation. Some come from far away, up to 300km; others arrive late - too


Fourteen thousand children would have died without the facilities

in our hospital. Early outpatient treatment could have saved thousands more from


Three years ago, when the Ministry of Health asked me to

restore and run Kantha Bopha hospital (where I worked in 1974/75), many experts

told me it would not be possible, it would not work. I had doubts


The project became more of a dream than a plan. But without having

dreams, what should you ever realize? Soon this dream came true. Kantha Bopha

works. Health experts and Health Ministry officials say it is good, but the next

moment criticize us as too expensive. Too expensive compared to what? Too

expensive for whom?

All the money we spent I looked for myself. The

money is still being donated by a huge crowd of anonymous private people, mostly

Swiss, because they know and trust me to ensure the money reaches sick children.

It is not spent on administration (we spent only three percent on

administration); nor on politics and propaganda.

The "catastrophe" of

Cambodia's child health could be stabilized and saved by four health centers

like Kantha Bipha spread over the country. The experts will say it is

impossible. Why can't the bigger dream come true? The experts will say it is too

expensive. This is an argument that paralyses all creative progress - and the

argument is wrong.

The cost of Kantha Bopha.

The talks

about the project started in Dec 1991; the contract was signed on Feb 5, 1992;

restoration and construction work began on April 22; it was inaugurated on Sept

22 and presided over by King Norodom Sihanouk, and the first patients accepted

on Nov 2. Until now we have spent $9.2 million.

What did we do with

this money?:

  1. A 200-bed hospital was built with a big outpatient station, a prevention

    center, two modern theaters with sterilization facilities, a blood bank, a

    hematological, chemical and bacteriological laboratory, two X-rays, a

    sonography, two water supplies, a laundry and a workshop.

  2. We have maintained and run it since Nov 2, 1992 including 146,568 outpatient

    treatments; 362,784 consultations (and no child has to pay for examinations or

    medicines); 17,100 inpatients; 2,000 surgical operations since Aug 93; all

    examinations (each laboratory has to do up to 150 analyses and take up to 70

    X-rays a day); pay salaries of the 350 Cambodian staff and the nine expat staff;

    buy electricity (the generators are working 24 hours the day) and pay other

    running costs.

For all this we spent $9.2 million. It is up to you look for a comparable

efficiency being less expensive.

The costs for 1995:

The running costs without further

investment will be $4 million. Without paying these a hospital cannot work. Its

efficiency will not only be weak but dangerous and irresponsible. We are going

to spend $1 million on salaries for the Cambodian staff. Without paying those

salaries corruption will arise and the hospital will become dirty. Both

corruption and dirt is incompatible with medical care - it would be better to

close the hospital immediately.

Ninety percent of children are too poor

to pay for hospital treatment. If the staff are not well paid they will be

forced to take money from patients under the table. Nine out of every ten needy

children could die; patients will not visit, and staff would be forced to steal

medicines - depriving the children and introducing incorrect medicines onto the

black market.

A hospital is a factory and a reservoir of dangerous

microbes. You have to clean a hospital three or four times a day or the

distribution of microbes will increase and the hospital close. The work of the

cleaner is as important as the work of the doctor. It has to be respected and

well paid. In Kantha Bopha there are 60 cleaners doing an excellent job. Without

them we would close today.

We will spend $2.5 million on medicines,

usually from Switzerland, and disposable materials.

The WHO does not

recommend expensive medicines or materials for sophisticated facilities - that

is not only inefficient but dangerous.

I call those recommendations "Poor

medical care for poor people in poor countries", but PMI (Prevention

maternal-infantile), WHO, UNICEF, World Vision, JICA and others go on teaching

this damn philosophy - most recently during a course last month for those

responsible for child health care in Phnom Penh.

They tell doctors that

patients should be divided up and treated by symptoms - diarrhea, malnutrition,

infections etc.

Few children arrive at our hospital suffering from one

disease alone. They have different diseases at the same time. Dividing them up

and treating their symptoms misses the diagnosis of the disease. We could find

that 65 percent of the undernourished are so because they suffer from

tuberculosis, and therefore unable to eat. You should treat the


The WHO recommends that infectious respiratory disease

should be treated by three antibiotics (penicillin, bactrim and ampicillin) -

antibiotics that have a resistance of up to 100 percent in Cambodia.


these medicines are cheap. In serious medical care the efficiency of antibiotics

has to be proven in an expensive bacteriological laboratory.


severe cases the WHO recommends chloramphenicol. In doing so they make three


  1. Chloramphenicol has a resistance of 100 percent. It is nonsense to use it in


  2. Sixty-five percent of children with severe respiratory infections suffer

    from tuberculosis. Chloramphenicol does not treat tuberculosis.

  3. Chloromycetin has not been used in Europe and the United States since 1970

    because of its side-effects: aplasia of the bone marrow. Here the children are

    so sick because they suffer at the same time from other diseases which causes

    anemias (malaria, typhus, dengue, tuberculosis) that they are too weak to

    recover even from the reversible aphasia. Being treated several times already by

    Chloramphenicol, they arrive at our hospital bleeding to death.

There is no excuse for this. For the continued recommendation that children

up to five be given intramuscular chloramphenicol, the WHO should be summoned to

the International Court in Den Haag.

There would not be any health

experts in the WHO, UNICEF, JICA or World Vision who would treat themselves with

chloromycetin. It is poor treatment for poor people in poor


Only a bureaucrat adopts a medical care program to the

resources and budget of a country: the bureaucrat decides, the poor children


Without working facilities, however expensive, doctors miss

diagnoses; without doing diagnosis a doctor should stop medical


There are still experts who think prevention is better and cheaper

than curative medical care. But for Cambodia's number one problem, tuberculosis,

there is no prevention. The epidemic can only be stopped by treating not only

the sick but also the infected. But first you need to make the diagnosis, and

for this one needs expensive facilities.

Kantha Bopha hospital now has

the biggest prevention and health education center in Camboda. Parents bring

their children for vaccinations and up to 1800 mothers a day listen to health

education waiting in front of the outpatient station. Prevention only works

effectively if the patients arrive. And they arrive because they trust a

hospital spending on the most important running costs.

By spending on

Kantha Bopha we have identified tuberculosis as the number one child health

problem in Cambodia, and can observe and document courses of cure not yet known

in Europe.

We discovered that tetanus could be treated successfully by

Rocephin, and document innovative treatments of polio, some nephritic syndromes,

and the liver's affection during the course of dengue. Some discoveries have

already been published in Switzerland.

Let me summarize: four more

centers like Kantha Bopha could save a bad situation. The medical professional

level should not be lowered. Its quality should be controlled by a university

children's hospital (in case of Kantha Bopha it is Zurich, Switzerland). There

are comparable universities in Oslo, Berlin, Amsterdam, Kroningen in Sweden,

Singapore and Boston. Those university's could do the same with their

government's as Kantha Bopha is doing with Switzerland's.

It is a dream.

If it does not come true, the Phnom Penh Post will soon be writing: Cambodia's

child health is the world's worst.


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