Cambodia's Lost Generation
Radiologists trace the collapse of Cambodia's health care system and the road to recovery.
In December 2010, Morlie L. Wang, MD, sat on a flight to Phnom Penh, Cambodia, reading a Lonely Planet travel book. Busy with preparation, it was the first time she had been able to read about Cambodia's history, despite her plans to spend a month in the small Asian country on a Goldberg-Reeder travel grant.
Wang, passionate about traveling and working with the underserved, first learned about radiology in Cambodia from an ACR volunteer profile of radiologist Michael R. Paling, MD. Wang contacted Paling and he put her in touch with a Cambodian radiologist in Phnom Penh. Soon after, she was boarding the plane to Cambodia, where she would train medical students and assist radiologists in interpreting studies on the area's first CT scanner. As she sat, reading passages describing the brutality of the Khmer Rouge, however, she recalls, "I started reading the history and thought, 'Oh my gosh. Where am I going?'"
On April 17, 1975, the Khmer Rouge took control of Phnom Penh, the capital city, and declared "Year Zero" in Cambodia, signifying the dawn of a new and classless society based on communist agrarian reform. The rebel group forced villagers at gunpoint into what are now called "the killing fields" to work long hours with little rest and next to no provisions.
Cambodian radiologist Vannarith Chea, MD, the same radiologist with whom Wang spoke before traveling to Phnom Penh, was just 13 years old when his family was forced from their village. Forty years later, he recalls the events. "We were slaves," says Chea. "We worked hard, more than 15 hours a day, but received only two bowls of rice soup a day."
While the Cambodian people planted and reaped the harvest, the Khmer Rouge sowed terror throughout the country. The group targeted those who deemed most likely to resist the cause: the wealthy and educated. "It was said that wearing eyeglasses was a sign of being an intellectual," says now-retired Paling, who volunteered in Cambodia from 2008 to 2014 and now volunteers at Hospitalito Atitlan in Guatemala. "You were shot straight away."
An estimated 1.7 to 2.2 million people were killed between 1975 and 1979 in Cambodia, nearly a quarter of the population at the time. Under the Khmer Rouge, the health care and education systems also collapsed. By 1979, only 45 physicians survived, many of whom left the country after the Khmer Rouge was expelled that year. Though the Khmer Rouge was gone, Cambodia was desperate for physicians, medical supplies, teachers, and basic health care.
Despite an interrupted high school education and years spent working in construction and picking cotton under the Khmer Rouge, Chea entered nursing school in 1980. Three years later, he graduated as part of the first class of nursing students since the Khmer Rouge collapsed.
While working as a nurse, Chea stumbled into radiology. Even though the health care system was being reestablished, the specialty was nearly nonexistent. "Most people in the radiology department at the time were from fields like cleaning or security. It was rare for people who had medical backgrounds to work in radiology," Chea says.
In 1987, Chea entered medical school at the Faculty of Medicine in Phnom Penh. Though Chea became fascinated with radiology, there was little time to learn and very few teachers. "I took a little time at lunch to stay with my radiology professor, but it was not enough," he says. With no access to formal radiology training and no radiology textbooks in Khmer, the Cambodian native language, there is little opportunity for Cambodian students to study the specialty.
In 1996, after almost two years of correspondence with a Cambodian radiologist in Canada, Chhem Keith Rethy, MD, PhD, Chea secured a fellowship to study radiology for 18 months at Montreal General Hospital and Montreal Hôtel Dieu Hospital. "There, I started to understand what modern radiology includes," says Chea, who is now the head of radiology at Preah Angduong Hospital in Phnom Penh. "I was very impressed with MRI and CT. In my country, we didn't have these modalities."
The majority of Cambodian people live in rural areas without access to modern medical care. An estimated 40 to 50 percent of the population relies on traditional medicine, mostly due to lack of financial resources.
"Patients come in with problems that are unimaginable to those of us who mainly practice in developed countries," says Paling. Cancer, for example, remains mostly untreated in Cambodia. Though Sihanouk Hospital Center of HOPE received the country's first CT scanner in 2010, resources are still minimal for treatment. "If you are diagnosed with cancer, your choices are limited here," says Paling. There is one radiation therapy machine, which is currently broken, and few can afford chemotherapy. According to Chea, the typical cancer diagnosis accompanies a three-year life expectancy at best.
"The Khmer Rouge wiped out a whole generation of doctors, and that affected the next generation and the generation after," says Wang, who now works for Northwester Medicine Central DuPage Hospital in Winfield, Ill. Though the number of medical students in Cambodia has increased exponentially, the system still struggles to find its footing and lacks experienced attendings to train current medical students.
Each year, Cambodia receives volunteers from around the world who work in hospitals and clinics. However, Paling, Wang, and Chea agree that the best way to help Cambodia is for physicians to share their knowledge. "We need more experience and skill," says Chea. "We need support from developed countries." When Paling returns to Cambodia, he spends a large amount of time lecturing and working with junior doctors one on one. "If you see an opportunity to start teaching, seize it," he says.
Though Wang has not returned to Cambodia since 2010, she continues to offer online one-hour radiology lectures to Chea and his students once a week using Skype. When lecturing, Wang insists, "You have to find innovative ways to approach things. Instead of saying, 'Make sure you check the biopsy clip placement,' I have to say, 'Do you have biopsy clips?'"
Wang encourages radiologists to consider ways to share their expertise, even if they can't travel abroad. "People are starving for knowledge," she says. "Here, we take it for granted that we can just ask people. The knowledge you can give is priceless."
By Chelsea Krieg, freelance writer for the ACR Bulletin