Thursday, August 16, 2007

An Israeli view on health

Perhaps too often we only hear about the major players in the western world giving a helping hand to Cambodia, such as the US or the UK and her European allies. Here's a view of Cambodia and its health-care challenges from an Israeli point of view.

A land of beauty and illness by Alex Levac,

We are sitting in a pickup truck, squashed in the back seat. The truck bounces along the bumpy road, a heavy monsoon rain falls outside, and the air conditioning is too cold. We are four people in a very cramped space: Prof. Dan Sherman, the director of the Assaf Harofeh Hospital's high risk pregnancy unit; Yael Rubinstein, the Israeli ambassador to Thailand and Cambodia; Dr. Tcha Marie of the Cambodian Ministry of Health; and myself, there to document the trip. Sherman is there to help the Cambodian Ministry of Health solve improve the country's pre- and postnatal care. Later on, we learn of other - no less important - motives for the professor's trip. First we meet with the Cambodian minister of health in his Phnom Penh office. This is the second attempt to establish medical cooperation between the two countries. Around six months ago, Dr. Yitzhak Ramon, a burn expert at Rambam Medical Center, went to help the victims of domestic violence, which for some reason is expressed in the cruel form of pouring acid on the woman's face, destroying it. At the time, the minister pleaded for assistance in the area of prenatal care, which he called his country's real problem. Cambodia's childbirth mortality rate for mothers is 0.5 percent, compared to 0.06 percent in Israel. Infant mortality is around 9 percent, compared to 0.9 percent in Israel. The Cambodian health minister was very excited by Dr. Sherman and the Foreign Ministry's willingness to help. His office provided us with a car, a driver and two local physicians who presented us their country with all its beauty and illness.

We turn onto a dirt road. If the uneven asphalt had tossed us about, now we feel like we are inside a washing machine. As we pass an ox-drawn cart with huge wooden wheels, crawling along, I understand that these roads are the heart of the Cambodian transportation network; they dictate the pace of life. Can you imagine, says Sherman, what happens when an expectant mother must urgently get to a hospital? The view is intoxicating. Children swim in a muddy, brown river, someone stands in waist-high water, pulling in a net full of fish. A motorcycle, hitched to a long cart, tows dozens of schoolchildren in blue and white uniforms. Even the miserable huts built on stilts seem picturesque. There are hammocks beneath mango and banana trees. The endless green of the lush vegetation, the chickens and cows - everything seems so tranquil, safe and protected. I remember the cruel regime that tortured, jailed and killed more than 2 million of the 7 million Cambodians. But from the window of the air-conditioned vehicle, Cambodia is a beautiful, tropical country. There are endless rows of rice paddies, and herds of buffalo wallow in the mud, grazing, or stand hitched to wooden plows. Stunning shores are freckled with coconut palms against a backdrop of heavy clouds, lightning and thunder, which pierce the sky as the monsoon season begins. With the rain forests, broad brown rivers, intense heat and high humidity, and the smiling people, it all seems like paradise straight out of National Geographic.

We reach the home of an 18-year-old mother who recently died in childbirth, along with her child. Sherman wants to understand why it happened. The family congregates next to the house. Someone sets out a pitcher of water and metal benches. We were warned not to drink anything but mineral water, but for the sake of being polite, I drink and immediately imagine thousands of bacteria feasting on my pristine stomach. A bald elderly woman, whose head resembles a perfect egg, presents a large photo, framed in gold, of a young, serious woman, who perhaps foresaw her future. Her hair is tied back and adorned with a red flower. This photo holds the power to preserve the presence of the deceased. Unfortunately, I have photographed such pictures many times: a relative holding a picture of a deceased beloved. At the entrance to the hospital in the village of Kampong Speu hangs a large color poster of a person who looks like he survived Hiroshima. A poisonous snake is coiled around his neck, his is face twisted, his body leprous and his limbs missing. The Ministry of Health issued this poster to caution against smoking cigarettes. Most men I meet in Cambodia smoke. This poster is about as effective as the frightful Israeli radio spots designed to combat road accidents. Over 10 days we visited 17 health centers and hospitals across Cambodia, all of them outside the capital of Phnom Penh. The neglect is visible at the hospital in Kampong Speu. The walls are in urgent need of painting. The doors to the hospitalization rooms are open to provide some relief from the intense tropical heat. In one room, the washed floor is covered with a mat where feverish babies lie with shut eyes, receiving infusions. Another baby swings in a hammock, along with the infusion holder. Mothers bend over their babies and shoo away the flies.

Desperate situation
Cambodia is a poor country, writes Prof. Sherman in his report on the state of medicine there. "The situation is very desperate, and anyone looking to help will have a hard time deciding where to start. The distances are far, the roads are bad, there are no means of transportation, there is no medical insurance or basic government health services, and medical treatment is expensive. Lack of awareness is a big problem; the public often does not seek medical services due to ignorance, poor education and lack of information. The health centers and hospitals suffer from a lack of means, both in equipment and manpower (there is a severe shortage of trained staff)." Prenatal, neonatal and postnatal care in Cambodia makes almost no use of labs, fetal monitors, ultrasounds, drugs or Caesarean sections (1 percent of all births are by Caesarean, as compared to around 20 percent in Israel). At the end of a long and depressing day, we sprawl on lounge chairs on the beach in Sihanoukville, gaze at another kaleidoscopic, tropical sunset, sip Cambodian Angkor beer and eat grilled fish that young women pull out of wicker trays atop their heads.

"What really brought me here," says Sherman, "is that a year and a half ago I concluded that I must return to what guided me when I chose to study medicine 40 years ago. Medicine in Israel is becoming increasingly technical, closed and limited by protocols and standards of treatment. The importance of the patient is gradually declining, and physician's challenge is to remain human, to guide and to counsel. The patient's rights law demands of us, the physicians, that we present all the treatment options and let the patient choose which is appropriate for him. But we overload the patient and his family with so much data and information that he cannot digest it and make a decision. Not only is that inhumane, it is also frustrating, because sometimes we do not succeed in showing the patient what is important. "In the past, I enjoyed coming to see an expectant mother, placing a hand on her belly and telling her, 'Trust me, do this and this, it will be okay,' and it was okay. I felt I gave something of myself, of my experience and my personality. Now I am forbidden to do so. The courts and the rulings against doctors in medical malpractice suits are gaining control over the nature of medicine in Israel. Some try to instill fear and anxiety, and send people for expensive and meaningless tests in order to turn a profit. We, the physicians, are wallowing in the muck of defensive medicine, motivated by the fear of legal suits, which does not always regard the patient's welfare. "So I spend more time documenting and recording the details of my consultation than actually talking to and consulting with the patient. I started looking for a place where the lack is so great that they still need real, old-fashioned medicine. A place where you don't need form 17, where you can focus on actual medical care. A place where anything you do will lead to a big, significant change in people's lives."

The Cambodian people need help to improve the medical services available under the current limitations. Among other things, Sherman suggests setting up a team of local doctors and midwives to review cases where women die before, during and after childbirth, and setting up mobile baby care clinics (Ambassador Yael Rubinstein has already found donors for this project). Israel also can help by offering supplementary training and guidance, enrichment courses and practical exercises in the field of prenatal care. Sherman escorts me to the airport in Siam Reap. From there I am to fly to Bangkok, Amman and finally Tel Aviv. The check-in clerk asks where I am heading after Bangkok and I say Amman, Jordan. At the last second, as my suitcase moves down the conveyor belt toward the airplane, I see the tag says Jordan, U.S.A. Wait. I grab the suitcase, and explain to the clerk that Jordan is not in the United States. I try to explain that it is a country next to the state of Israel. She has never heard of either of these countries, and tells me, "This is what the computer is giving me." I hope we finally have found a place where they will hear about us only in the context of medical cooperation and humane outreach for the needy.

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