Field doctor in Southern China.
I am an online graduate student in public health. I choose not to disclose my university’s name, but I’ll just say that I really love it because of the flexibility it offers me. I’m in my early 60s. I’m in the middle of my degree and I decided to study public health in Cambodia. Moving with confidence and a sense of adventure, I nevertheless in the back of my mind imagined I would get some sort of stomach bug within my first month, experience some diarrhea and possibly vomiting, and recover in a week. I was in Phnom Penh, the capital after all. It would give me the opportunity (not that I wanted to get sick, of course) to see how the public health system works and what I, coming from a Western university background, could contribute through my observations. I was more naive than I thought.
I did get sick- a lot sicker than I thought I would (bacterial dysentery). And when I did get sick, I was bewildered by the tangled mess of the hospital system here and the surprisingly high costs, which were on par with hospitals in developed nations. Foreign patients at hospitals are treated differently for various reasons, but the consultations I found were rigorous and amounted to several hundred dollars for a diagnosis before actual treatment. I immediately wondered how the average or worse, marginalized Cambodian could possibly afford that
There are not many clinics in Phnom Penh, there is a sort of ‘in-between’ land of small hospitals and independent pharmacies. Amid those, doctors may sometimes work with patients at their homes and offer consultations. The public health system is often portrayed as a few, expensive hospitals for more serious conditions, while pharmacies make up the bulk of everyday healthcare needs. But that’s not entirely accurate-as there are two kinds of pharmacies, the lower end, loosely regulated being small drug stores, allowed to dilpense drugs that would require prescriptions in most of the world. The first are professional establishments, often attached to hospitals and staffed by bonafide pharmacists who earned a pharmacology degree at a university and are licensed. The second type, by far the majority, are small shops run by two or three staff members. They are too many to count and on every street. By and large, the staff are well-meaning but ill-trained. Very few professionals who work at the small pharmacies are actually pharmacists, though over years time they do gain experience and expertise. Newer staff may know very little about medicine and make poor prescription choices. Even among staff with years of experience, the medicine business is more akin to a goods shop such as health foods or homeopathic medicines, with the disturbing exception that, while technically regulated, small pharmacies can and do sell many drugs, especially antibiotics, without a prescription. When in doubt, throw antibiotics at the problem has become a go to in Cambodian drug stores with a burgeoning growth of antibiotic resistance. Typically, a patient goes to a small drug store, explains their symptoms, and the pharmacist dispels medication. After that, if the patient suffers side effects (which is very like to happen during a proper course of antibiotics) the patient is likely to come back and accuse the pharmacist of harming them. Even if the pharmacist knows that they were following the recommended course, they soon become reluctant to give a full course of antibiotics for fear of being harassed. and For the same reason, they may give placebos such as galangal root. While generally patients go to pharmacists out of trust and follow their advice, there are patients too who self-diagnose and tell the pharmacists what drugs and in what quantity they want. If that sounds dangerous, it is. Nevertheless, pharmacists tend to oblige the patient, assuming that either they must know what they are doing or if they don’t it’s out of their hands.
I know this first hand because I blundered and wrecked my gastrointestinal health by self-diagnosing in Cambodia. To be fair, the environment was bewildering and I had no idea where to go for treatment. I got a ‘belly bug’ (Shigella) a month into my stay in Cambodia which did not surprise me but I saw the urgency to get it taken care of. As a graduate student in public health, I was a little too cocky and found that Giardia ticked all of the diagnostic boxes, plus it is extremely common. I researched the course of Metronidazole I should take, went to a pharmacy and simply bought the antibiotics. I thought I had found my cure! But I didn’t. And that was because I didn’t have Giardia. Two hellish weeks later after a constant low-grade fever and anorexia which made me lose over 2 kg., I found a clinic run by a British doctor who specializes in tropical diseases and had been in practice for three decades. Within a minute of the consultation he definitively ruled out Giardia and said he was nearly certain I had Shigella. He put me on Ciprofloxacin, and despite some side effects (I found out later Cipro can have very serious side effects), I’m getting better. Without going into the all of the details of the consultation, physical exam, and treatment, suffice it to say that a population of people without access to good doctors will no doubt suffer. Here in Cambodia there is one system that works for the rich and a system that works for the poor, and it is not that the poor are at the mercy of the pharmacy. It’s that pharmacies are ill-equipped and in a sense intimidated by a non-compliant public that keeps coming back when they don’t improve immediately and do not understand their treatment. It’s that the wealthy feel that they can go to the best hospitals and trust their doctors, even if treatment isn’t always comfortable. They talk with their doctors and understand their prognosis. It’s not that the poor are submissive by any means. It’s that they don’t understand biology, illness, and disease, and the pharmacist is a modern day shaman. They are prone to superstisions and rather than looking for a physical explanation for an illness, may blame the room as the cause and feel confident that if the ill person changes locale, they will get better. That describes the health care wealth gap in Cambodia, and until the pharmacological regulations are enforced and sanctions meted out for non-compliance, 70% of the country will be deprived of doctors and good treatment, while 30% will be treated on the hospital on top of the hill run by professional medical teams and licensed pharmacists..
