HEALTH: A country in love with injections and drips

Mom Hing is chewing as he talks. The abbot of a Buddhist temple, he is sitting on the floor in his orange robes. He's been receiving gifts of food, drink and some money from worshippers in the village of Roka. In exchange, he gives them a blessing.

But this 82-year-old monk is HIV-positive, and he's certain how that came about. "Since I came to this village in 1994, I've been having injections from a medical doctor who was trained in a refugee camp. And I got HIV-Aids from him - I only got injections from him."

 

The man he's talking about was the village "doctor" for two-and-a-half decades - an unqualified, unlicensed doctor. Earlier this month he was given a 25-year prison sentence for manslaughter, accused of reusing needles and syringes.

Yet Mom Hing bears no malice. "Let it be - life and death are normal things," he says. "I'm not worried about myself at all. I'm getting older. What I'm concerned about is the young."

Tragically, more than 270 people in and around Roka - a population that numbers in the hundreds rather than thousands - have tested positive for HIV. Ten are reported to have already died from Aids.

Lap Hoy, a 51-year-old grandmother, says she went to the village doctor when she had a cold and a fever. She is now HIV-positive and so are four other members of her family, who were also given injections by the doctor.

"My grandchild got infected, her mother got infected and I, her grandmother, also got infected," she says.

Lap Hoy says she doesn't want the doctor to ever to return. Her son-in-law, lying in a hammock, is more forthright. "If he ever came back, he wouldn't have any chance of survival," he says.

 

The mass outbreak shocked a country which, with substantial help from foreign donors and NGOs, has made good progress over the last decade in reducing HIV levels. It also prompted the Cambodian government to announce a clampdown on unlicensed health workers.

But are the unlicensed doctors, midwives and pharmacies really the problem?

A Westerner, who has worked in Cambodia's health sector for many years says there is a general lack of knowledge about infection control throughout the country's healthcare system.

"I would say there are many more Rokas in Cambodia," she says.

The practices are so poor that it's inevitable. I don't think there's a difference between licensed and unlicensed doctors. I think what we saw in this case was a breach of infection control practices [and] doctors working in the government sector get very little training - if any - in infection control."

Part of the problem is the fascination many Cambodians have with injections and intravenous drips. Driving from the capital Phnom Penh, towards Roka, in the west of the country, I regularly saw people on IV drips - and not just on IV drips but also on motorbikes. These were mobile IV drips.

I stopped one motorbike, which had three people on it. The passenger at the back was holding up a stick, at the end of which, covered in a black plastic bag, was a bottle of IV fluid. 

 

The mass outbreak shocked a country which, with substantial help from foreign donors and NGOs, has made good progress over the last decade in reducing HIV levels. It also prompted the Cambodian government to announce a clampdown on unlicensed health workers.

But are the unlicensed doctors, midwives and pharmacies really the problem?

A Westerner, who has worked in Cambodia's health sector for many years says there is a general lack of knowledge about infection control throughout the country's healthcare system.

"I would say there are many more Rokas in Cambodia," she says.

The practices are so poor that it's inevitable. I don't think there's a difference between licensed and unlicensed doctors. I think what we saw in this case was a breach of infection control practices [and] doctors working in the government sector get very little training - if any - in infection control."

Part of the problem is the fascination many Cambodians have with injections and intravenous drips. Driving from the capital Phnom Penh, towards Roka, in the west of the country, I regularly saw people on IV drips - and not just on IV drips but also on motorbikes. These were mobile IV drips.

I stopped one motorbike, which had three people on it. The passenger at the back was holding up a stick, at the end of which, covered in a black plastic bag, was a bottle of IV fluid. 

I spent about half a day with Chin. Despite his assurances that he never reuses needles, I wasn't wholly convinced by his infection control practices. He didn't wash his hands, or wear surgical gloves. I had my suspicions about a loose needle he kept in a silver metal box, which he used to fill the syringe with medicine from a bottle, before returning it to the box. And I had doubts about how sterile his cotton swabs were.

I took my concerns to the Western doctor who quickly pointed out that no needle should ever be reused, whether it's to inject directly into a patient or to draw up the medicine.

"Of course, things are only problems if you recognise them as problems," the doctor warned.

"Many Khmer do not see these problems - for example antibiotic resistance [and] infection control breaches.

"People blame this HIV outbreak [in Roka] on an unlicensed practitioner. But it could be many practitioners, licensed or unlicensed, working for the government or not, who have bad practices which can end up with Hepatitis B, or Hep C, or HIV. If you aren't aware of the problems then it's harder to fix them."

By John Murphy