MID the fanfare of the opening of the Kantha Bopha II hospital, it was no surprise
that founder Beat Richner had a few words to say about people who advocate "poor
medicine for the poor people in poor countries."
"It is a false and hypocritical idea to want to adapt medicine to the conditions
of poor countries," he said in his opening speech before King Norodom Sihanouk,
Swiss President Jean-Pascal Delamuraz and assembled dignitaries Oct 12.
It was a familiar line from the Swiss pediatrician who is as famous for his attacks
on international health organizations as for his vision of providing the highest-quality
medical care to Cambodia's poorest children. Or, given that, as famous as he is a
For a man who has publicly accused the World Health Organization (WHO) of effectively
sanctioning murder in its policies, Richner is not a man to mince words or shy away
As he opened his second hospital - upon land personally donated by the King - there
were likely more than a few other health professionals in Phnom Penh cringing at
the limelight granted him.
At the heart of the controversy surrounding Richner is a debate over the philosophies
of health care for poor countries, and of sustainable development.
No-one doubts Richner's commitment to offering high-quality medical care to Cambodians
and of his seemingly inexhaustible ability to raise money for it.
But in his attempt to provide "Rolls-Royce" care, as a WHO official once
said in response to Richner, he is criticized for creating an oasis of high-quality
medicine outside the national health policy.
To Richner, his theory is simple - providing good medical care free of charge to
as many people as possible. Money, he believes, should be no barrier; there is no
excuse why Cambodians should have to accept anything less than what is provided in
Richner's odyssey in Cambodia started in 1974 when he came to work in the Kantha
Bopha pediatric hospital built by the King and named after his daughter who died
from leukemia. The Khmer Rouge forced both his departure in 1975 and the closure
of the hospital. The regime's collapse in 1979 saw it reopened as part of Phnom Penh's
Richner, running a pediatric practice in Switzerland, returned to Cambodia for a
visit in late 1991 and was asked by the government to oversee the revival of the
former pediatric hospital.
"I thought this would be the task of the Swiss government. As the government
did not agree to fund the project, I decided to."
Richner turned to one of his great loves - the cello - to help him raise funds. Well-known
back home under his stage name Beatocello, he was able to put his fame to good use.
Within a year, Kantha Bopha I was open for the first time in 17 years. Equipped with
modern laboratories and surgical wards, its reputation soon spread. Today, people
come from all around Cambodia to take their sick children to the hospital.
Each morning, they queue at the entrance up to two hours before the gates are open.
Guards give each family a ticket and they await the calling of their number for a
The patient numbers are astounding - 1,000 to 1,200 children a day is common, and
even as many as 1,800.
"Twice we have reached 1,800 patients," says Dr Peter Studer, vice-president
of Richner's foundation which supports the hospital. "At this point, we cannot
accept any more."
Everything is free: consultations, medicine and, if needed, hospitalization.
Kantha Bopha I has 210 beds, and at times as many as 300 children require them. Beds
are set up in the corridors to cope when necessary.
When demand for consultations or beds is too high, families spill over to the National
Pediatric Hospital, which is supported by the NGO World Vision and is separate from
Kantha Bopha II, due to open Nov 4, will add up to 200 more beds. It will be for
hospitalization only; all initial consultations and surgery will be made at the first
Richner secured a single private donation to build Kantha Bopha II, and the gift
of land next to the Royal Palace from the King. He aims to match the same high standards
- the hospital will boast the first neurological scanner in Cambodia.
In the future, Richner hopes to expand into the provinces, at first working with
the provincial hospital of Kompong Cham and ultimately building more Kantha Bophas.
"With five centers like Kantha Bopha we could solve the problem of children's
health in Cambodia," he declares.
"Not true," replies a foreign doctor who has worked with an NGO for five
years. "What Dr Richner is doing is very good, but we need to develop something
that is complementary."
Critics advocate a better primary health care system, with a referral system to hospitals
They also suggest that the quality of diagnosis is inevitably jeopardized by a workload
as high as that of Kantha Bopha I.
"A Kantha Bopha cut off from the world causes a saturation of the hospital...
the doctors do not have enough time to spend with each patient and to develop contact
with families," says the NGO doctor, who does not want to be named.
The Post was told of three cases of misdiagnosis or inadequate treatment, including
a child who, suffering a broken collar bone, had his lower arm plastered.
"Mistakes can happen," says Richner, though other health professionals
acknowledge that Kantha Bopha's quality is undoubtedly higher than most other hospitals.
But, says UNICEF officer-in-charge Andrew Morris, "the problem is more complex
than just building five hospitals.
"People do not have [medical] knowledge, they have no money for transport to
Parents, he says, don't have enough information to know when their sick children
could be looked after at home, when it is necessary to take them to a nurse, and
when hospitalization is required.
"It is OK to build hospitals but it is not enough," agrees Dr Georg Petersen
of WHO. "What we need is primary health centers. We need to put the health care
where the people live.
"In Cambodia there are only 13,000 doctors for 10 million people. Most people
go and see a nurse rather than going to a doctor. We have to train the nurses and
make them understand when to send a patient to hospital."
Petersen compares it to the practice in western countries where people go to a general
practitioner before, if needed, being referred to a specialist.
"Most common diseases contributing to children's deaths can be prevented or
treated at an early stage without sophisticated medical supplies or experts,"
says Jaisankar Sarma, country director of World Vision.
"For example, diarrhea can easily be treated with oral rehydration solution
to prevent death from dehydration. Parents can be taught to recognize danger signs
of dengue haemorrhagic fever so that they can come for early treatment..."
NGOs advocate working with the government to produce a national health policy of
several layers of health care. They urge medical centers in communes and districts,
with a referral system to a provincial hospital, and greater education of parents,
nurses and doctors.
Petersen says Kantha Bopha, which he agrees is "of the best standard",
could fit into the top rung of such a national policy. "My wish would be that
Kantha Bopha be integrated in the national structure as a specialized hospital. In
all countries there is a university pediatric hospital."
Adds an NGO doctor: "If Kantha Bopha stays as a bubble in the air, it is just
a drop of water. It is a good opportunity for young doctors to work in normal conditions.
It should be integrated in the system to upgrade all of the system."
Richner says that Kantha Bopha already has 60 young doctors, and some anesthetists,
As for a focus on primary health care, Kantha Bopha runs a preventative education
center and an outpatient service.
But, Richner warns, "nothing is simple in terms of child health." For instance,
"diarrhea is not simple and needs to be properly diagnostic through a test with
Ionogramme, which we are the only one to use."
He says primary health care centers must offer the same quality as a proper hospital;
for instance anywhere minor surgery is performed must be 100 percent sterile, and
all blood products properly screened.
Richner says that working within the government system comes with its own problems
such as corruption.
"With corruption nothing can work properly. Everything is going to be lost."
Underpaid doctors, he says, are tempted to sell medical equipment or drugs or charge
for services, which can deter patients from seeking treatment. To maintain high standards,
Kantha Bopha I doctors are paid $500 a month - compared to about $20 in the public
"We are jealous of his success. He is good because he has the capacity to raise
money," admits a doctor from an international organization. "But what will
happen after him? He has to foresee what will happen when the money is not there
Putting it more bluntly, he adds: "I'm not sure that it is a good idea to give
privilege to one hospital among all the shit. Maybe it is better to upgrade all the
Dr Dy Narong Rith, Secretary of State for Health, says Kantha Bopha - whose yearly
budget equals about a fifth of the national health budget - is like a pilot hospital.
It is high-quality and a good example of what could be done if the ministry could
afford similar hospitals in the future, he says.
"We have to enjoy the experience as long as the funding is there. Afterward,
the equipment will remain and we will have to prevent all of it returning to ruins."
Richner acknowledges that it is becoming more difficult to raise money, but remains
confident that he can keep doing so.
Kantha Bopha I has a yearly budget of $4 million. More than $3 million of that goes
to operating costs including equipment, medicine and salaries of Khmer staff. Another
$800,000 is spent on the hospital's 12 expatriate staff.
Small donations flood in to Richner's foundations in Switzerland, says Studer. "We
are receiving about 200 donations every day. It is between $3 and $4 million a year."
Richner remains optimistic. "I hope the Swiss government will increase its participation
in the funding. They are already giving $1 million a year. I hope they will increase
their participation to $2 million in the next year."
And the long term future? "During the next ten years the funding will have to
come from outside. But little by little as the middle class gets better, we could
ask some patients to pay and the government would have to tax the richest."
In the meantime, "I am going in Switzerland three times a year and raising the
money by playing cello."
Will he ever tire of relying on his music abilities to raise funds? Richner replies:
"Did you see the cello on the gates of Kantha Bopha II? It means Beatocello
does not want to die."