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
'catastrophe".
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.
I
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
late.
Fourteen thousand children would have died without the facilities
in our hospital. Early outpatient treatment could have saved thousands more from
hospitalization.
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
too.
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?:
- 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.
- 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
tuberculosis.
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.
But
these medicines are cheap. In serious medical care the efficiency of antibiotics
has to be proven in an expensive bacteriological laboratory.
For
severe cases the WHO recommends chloramphenicol. In doing so they make three
mistakes:
- Chloramphenicol has a resistance of 100 percent. It is nonsense to use it in
Cambodia.
- Sixty-five percent of children with severe respiratory infections suffer
from tuberculosis. Chloramphenicol does not treat tuberculosis.
- 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
countries.
Only a bureaucrat adopts a medical care program to the
resources and budget of a country: the bureaucrat decides, the poor children
die!
Without working facilities, however expensive, doctors miss
diagnoses; without doing diagnosis a doctor should stop medical
care.
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.
