Monday, June 27, 2016

Cambodia - Cambodia's health care system struggles to cope with mentally ill patients

PHNOM PENH: As soon as the clock struck seven in the morning, a commotion broke out in front of an old, yellow building inside the Khmer-Soviet Friendship Hospital.

More than 40 people flocked to the main metal door separating them from the waiting area and consultation rooms. Some craned their neck to look for a sign of staff inside the building, while others searched for empty spots on the dusty ground to give their feet a rest.

Coming from various parts across Cambodia, they all shared one thing in common; everyone seemed stressed and weary, as they waited to enter the busiest psychiatric clinic in Phnom Penh.

“We’ll open at 9 o’clock today,” a member of the medical staff told the patients as she squeezed through the main entrance. “We have a meeting,” she quickly explained and continued on a dusty path linking the busy outpatient department with another building.

For mental health patients in Cambodia, long waits are far from uncommon at the state-run clinic. Although its outpatient department is the biggest in the country, the facility has 13 registered psychiatrists and 12 nurses to treat hundreds of patients per day. For those with serious conditions that require continual specialised care, there are ten beds available.

“One doctor treats about 50 patients each day,” said one of the psychiatrists at the clinic, Sou Sarifin. The limited resources mean that not every patient can be seen, consultations last minutes, and treatment is often limited to prescription drugs.

Mental health problems are widespread in Cambodia. Some patients are often locked up at home or chained to trees, as their family members do not know how to deal with the symptoms. Health care services exist but are hard to access, particularly in rural areas. And some patients are dropped off at the clinic with their hands and legs tied, Sarifin said.

Anxiety, depression, bipolar disorder and schizophrenia are the most common forms of mental illness diagnosed at the clinic. And a number of patients are survivors of the Khmer Rouge regime, whose legacy has left them with deep mental scars.

"They still have bad memories; some of their family members were killed during the Khmer Rouge regime," Sarifin added.

Under the Communist Party of Kampuchea (CPK), Cambodia was radically transformed into an agrarian society with no social classes. Its citizens were stripped of their basic rights and driven into forced labour in the countryside, while religions, education and financial system were abolished. Between 1975 and 1979, prisons and execution sites popped up across the country, as starvation, diseases, exhaustion and capital punishment killed nearly two million people.

And for those who have survived, many find it hard to deal with the psychological scars.


Some of the Khmer Rouge survivors with mental health problems are old people who still have fresh memories of the past.

One of them is Leang Korn. Her husband was killed in 1975, she said, 20 days before their baby was born. Both were accused of conspiring with the Central Intelligence Agency (CIA) against the Khmer Rouge.

“I couldn’t see my husband but heard his voice through the air. How scared and painful he was. We all couldn’t do anything but only whisper,” the 57-year-old widow said.

After giving birth to her child, Korn joined other Cambodians who were sent to work in the fields.

“One evening, several men came to me and said Angkar (the Khmer Rouge’s ruling body) wanted information about my work. There were about 10-12 men there. I fell unconscious when they started to rape me. They were like animals, not human beings,” Korn said.

Over the past 37 years, the old widow has been trying to live a normal life and forget her past. “But I can’t forget. My feeling is attached with something, something unclear, like a shadow.”

Mental health issues in Cambodia, however, affect more people besides Khmer Rouge survivors such as Korn. A number of mental health patients at the Khmer-Soviet Friendship Hospital have a long history of alcohol and drug use. Social factors such as poverty and gender-based violence also play a key role.

Of the over 15 million population, an estimated 40 per cent suffer from mental health and psychological problems, according to Transcultural Psychosocial Organization Cambodia (TPO) – a non-profit group that promotes mental well-being among Cambodians.

But despite high incidence of mental disorder, Cambodia's public health care is still lacking. It is estimated that only 0.02 per cent of the country's health budget goes to mental health, based on a report by the Leitner Center for International Law and Justice.

"Public mental health care in Cambodia is a little bit better now but there are still a lot of issues. Services provided are poor and to access them is difficult. There is only one hospital in Phnom Penh that provides mental health care," said Sek Sisokhom, Head of the Psychology Department at Royal University of Phnom Penh.

"People don't know about psychology because the concept is very new in Cambodia. When they encounter mental health problems, they often seek help from monks at the temple or spiritual healers," Sek added.


The mental health situation in Cambodia is "very challenging", according to Sek. The sector is only allocated a small amount of funds from the national budget and "there is no quota for recruitment of psychologists into the public sector," he said.

New graduates often face difficulties finding jobs in the mental health industry. In the entire nation, there are only a few state-run psychiatric clinics. One of them is located in the capital city and five more in Banteay Meanchey, Ratanakiri, Kampong Cham, Kampot and Battambang. "Mental health is not the government's first priority," Sek added.

Moreover, mentally ill patients at state-run facilities often receive bio-medical treatment rather than psychological or psychosocial treatment. "And this means the government services mainly lack counselling, psycho-education and community-based intervention that addresses the issue through a holistic approach," said Dr Sotheara Chhim, senior consultant psychiatrist and TPO executive director.

"There are huge needs for mental health care."

In a bid to improve mental well-being among Cambodians, many NGOs have set up their own mental health care facilities in response to the limited resources.

In 2015 alone, TPO’s treatment centre provided more than 6,500 consultations. But the group also aims to promote non-medical treatment through its several programmes targetting different groups of mentally ill patients, including the likes of Korn.

For several years, the Khmer Rouge survivor has been receiving mental health support from the NGO, which provides her with counselling every two months. Her conditions continue to improve over the years. Korn is now more open to discuss her past and fully aware of the problems she is facing.

Still, many mentally ill patients in Cambodia are struggling to live a normal life. “They’ve never received support from the government,” Sarifin said before rushing back into his office, as more patients streamed into the mental health clinic.

But soon, the door would be closed, and those who did not make it to the psychiatrists would have to come back again the following day.

Pichayada Promchertchoo

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