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Saturday, March 14, 2009

Curing Cambodia’s children with music

By Ben Bland


In a concert hall not far from Cambodia’s majestic Angkor temples, a Swiss paediatrician is playing the cello. Beat Richner squeezes his eyes shut and breathes audibly, a picture of concentration. He has chosen one of Bach’s complicated cello suites, and the sound of his unaccompanied instrument is both intimate and haunting. The audience of 200 is transfixed, apart from one girl wrapping herself in her mother’s shawl to keep warm; the air-conditioning in the auditorium is on full blast – this must be the coldest place in Cambodia.

As Richner finishes the piece the audience, mostly composed of middle-aged European tourists visiting the Angkor temples, applauds warmly. With his cello resting against his burgeoning waist, Richner reaches for a microphone and, after a polite greeting and a quip about Barack Obama, shatters the atmosphere of pleasant indulgence. “Without our hospitals, 90,000 children a year would die in a passive genocide,” he announces. “The creed of the World Health Organisation and Unicef is that medical treatment must correspond to the economic reality of each country – but the economic reality of most Cambodians is zero.”

Richner, aged 61, has built five hospitals that meet international standards for cleanliness and quality and that provide free care to 85 per cent of Cambodia’s children. Now, sitting at the cello, he points his finger in accusation. “If we followed the advice of the international community” – by which he means the intergovernmental organisations he has just cited – “which travels the world telling people what to do, we could not save one single child infected with dengue fever or tuberculosis.”

Richner also built this concert hall, a simple construction of brick and bamboo nestled around several elegant ponds. It is part of the Jayavarman VII hospital in Siem Reap – a rapidly growing city of 140,000 people in the north of Cambodia. Richner’s foundation, Kantha Bopha, completed the hospital in 1999. Tonight’s concert is one of two Richner performs weekly; the money he raises by playing helps generate the $25m a year he needs to run the foundation.

He intersperses Bach cello suites with further lecturing and hectoring: “We only had 7,000 cases of dengue this year compared to last year’s epidemic, when we had 22,000. But we still need blood to treat them.” Sweat beads on his balding pate as he becomes more animated. “I ask the younger guests for blood, especially type B and O. I ask the older guests for money. So, blood or money: that is the question.”

One in three Cambodians lives on less than a dollar a day, and even in a country riven by war, corruption and political infighting, medical expenses remain one of the biggest causes of poverty. Richner first came to Cambodia in 1974 as a young Red Cross doctor. He worked at the Kantha Bopha hospital in the capital, Phnom Penh, which had been set up by King Norodom Sihanouk. But in April 1975, Richner was forced to flee ahead of the murderous Khmer Rouge entering the city. Most of the doctors he worked with then were killed – only 50 out of 950 survived as Pol Pot’s regime closed hospitals as well as banks and schools and targeted anyone with an education as an enemy of the state.

Richner compares this experience with that of a concentration camp survivor: he feels guilty for making it out alive. It’s that guilt, coupled with his humanitarian convictions, that brought him back to Cambodia. After a chance meeting in Paris in 1991, Sihanouk asked him to rebuild the ruined hospital he’d fled almost two decades earlier. (The king was in the French capital for the negotiations that would eventually bring peace to Cambodia; Richner was there to see a friend star in an opera.) He accepted the invitation and, though he initially planned to stay only for a year or two, he has been here ever since.

On the night of the concert Richner was worn down, suffering from a fever. He has locked himself into a seemingly endless struggle to find money, and this has taken its toll on a man who was once best known in Switzerland as an entertainer, singing comical songs in his stage guise as “Beatocello”, part musician, part clown. At the end of his performance, however, the entertainer is nowhere in sight: after a few cursory bows before a standing ovation, Richner flees to his office.

Half an hour later he appears in the lobby to greet lingering supporters, donors and medical students. But he appears awkward. “Sometimes it’s difficult for me to talk with my audience,” he admits later. “They are from a different world. But it’s my mistake. I’m alone here and all I do is work. I go to Switzerland two or three times a year for concerts but I’ve had no holiday in 17 years and never really have a day off.”

. . .

Twelve hours earlier, at seven o’clock on Friday morning, all 650 seats in the concert hall are full, but with doctors, nurses and cleaners at the hospital’s main daily conference. Richner sits at a table in front of the stage, flanked by his two key lieutenants in Siem Reap, Yay Chantana, the hospital’s 41-year-old medical director, and Keo Sokha, the 39-year-old head of surgery. As the staff shift about in their seats – wearing flip-flops and sandals, they find the intense cold even more uncomfortable than the tourists will – the heads of department update Richner on the previous day’s events. “Were there any deaths overnight?” asks Richner. Luckily not, Chantana responds. After a brief teaching session, Chantana calls the meeting to an end and escorts his boss out of the hall.

Richner strides into the intensive care ward, followed by Chantana and a gaggle of junior doctors. As he walks up to the first patient, an 11-year-old girl suffering from severe pain in her right hip, the other physicians manoeuvre to get out of his way – no easy task in the cramped ward. Richner refuses to turn away sick children, so when the beds run out, patients are treated on mats on the floor.

Chantana explains that the girl has advanced tuberculosis, which has already destroyed much of her hip. Her family lives more than 100 miles away, and like many other Cambodians who cannot afford time away from work, they put off coming to the hospital. “She walked with a wooden stick for five months before coming here,” says Chantana. “Because of the late presentation, she needs surgery to save her hip. It’s a two-hour operation and she will have to remain in hospital for eight weeks afterwards.” Using an MRI scanner that is part of the new $12m wing opened by the Cambodian king in December, the doctors have been able to ascertain exactly how much of her hip has been destroyed, allowing them to save the rest.

Watching Richner stomp around the wards, you wouldn’t guess it, but his donor-reliant model, which aims for excellence over affordability, and his stance on Cambodia’s medical priorities have put him on a collision course with the international health establishment. One development consultant who works for the WHO in Cambodia, but asked not to be named, explains: “My main concern is the sustainability of his operation. Richner is nothing if not an excellent fundraiser – he’s got a lot of charisma – but what happens when he dies? Who will raise the money then?”

Richner’s critics also accuse him of failing to provide value for money by not making enough use of cheaper, generic drugs and by relying on the most expensive medical supplies. “It’s wonderful that he uses such sophisticated equipment but even in his own country, much of this stuff would only be available in private hospitals,” says a doctor who recently toured one of Richner’s hospitals but also asked not to be named. People within Cambodia’s NGO community are reluctant to speak publicly against Richner, for fear of escalating the clash. They are also eager not to generate adverse publicity at a time when Cambodia’s Prime Minister, Hun Sen, is pushing ahead with a new NGO law that some feel is designed to restrict their ability to operate in the country. Some NGOs are also concerned that Richner’s focus on child medicine could be diverting money, doctors and attention from other severe health challenges, such as the high rate of maternal mortality and the growing HIV epidemic.

The received wisdom among international public health experts is that development aid is best spent on education and the provision of basic rural clinics. But Richner argues that all people have the same fundamental right to good healthcare. He characterises the other approach as “poor medicine for poor people”. “When I got my first CT machine in Cambodia 10 years ago, there was an outcry from the WHO and Unicef,” he says. “They said it was stupid to spend so much money on this machine. But you need a CT scan to diagnose and treat TB.”

He is fond of recounting anecdotes that demonstrate the idiocy and hypocrisy – as he sees it – of his critics. “Princess Anne came here a few years ago as president of Save the Children,” he says. “I showed her our laboratory and she said that we must not have such hi-tech machines in such a poor country. ‘You must work on the base and Cambodian people must learn how to wash their hands first,’ she said. “Then, when I showed her our new maternity ward, she told me it’s better to offer birth control than maternity care – but this was stupid. There was a genocide here so there’s no problem with overpopulation.”

This open antagonism to the mainstream NGO community is extremely unhelpful, his critics argue. “He’s merely building up a host of enemies so the fact that no one wants to work with him becomes a self-fulfilling prophecy,” says the WHO consultant. “But there’s always a tension between innovators doing good things on a small scale and the more sluggish public health systems.” The clashes between competing humanitarian organisations can be as bitter as corporate rivalries. Richner’s insistence that Kantha Bopha remain independent of the public health system and his refusal to bow to the prevailing corruption in Cambodia has put many noses out of joint, and even led to his receiving death threats. And in 1995, the health ministry tried to close the first Kantha Bopha hospital because health officials and their international advisers believed it was undermining attempts to build a national health system. Only the personal intervention of the king saved it. In 2002, Richner threatened to close the foundation himself unless the health minister stopped criticising his work.

The king eventually brought about another truce and although relations with the health ministry have improved since then, the small amount of funding that Richner receives from the Cambodian government is still paid directly to his foundation, bypassing the ministry.

. . .

No one disagrees about one fact: that many of the children in intensive care at Richner’s hospitals would die without the treatment they receive there. As Chantana and Sokha observe an operation to remove a nine-year-old girl’s appendix, they talk about what her options would be without Richner. Sokha explains that this girl would not have been able to obtain proper treatment anywhere else in Cambodia, let alone in a state-of-the-art operating theatre. “In a government hospital,” he says, “you have to pay under the table to see the doctor, you have to pay for an X-ray, you have to pay for the surgeon and the anaesthetist and then you have to find a doctor to look after the follow-up. Altogether, it would probably cost $400 and there’s no way her family could afford this.”

In a private hospital, the situation would be even worse. “If you complain of abdominal pain, they’ll just remove your appendix for the money without properly diagnosing the problem, and the patient will still suffer from the same untreated pain.”

When Richner stepped on to one of the last US flights out of Cambodia in 1975, it was with the expectation that he would be back in three weeks. He was doing important work in extremely difficult circumstances: half of the children treated at the Kantha Bopha hospital did not survive. In the spring of that year, a tired-looking 28-year-old Richner told a British TV journalist: “Last week, I cannot say how many children were dying as they didn’t come to the hospital because rockets were falling down all around. At the moment, it’s very dangerous to bring the children here and it can only get worse. Worse and worse.”

Within days it became obvious that Phnom Penh would fall to Pol Pot’s Khmer Rouge fighters and the hospital was abandoned. And yet no one at that stage envisaged the terror and suffering that was about to be unleashed as Pol Pot proclaimed “Year Zero” and launched a brutal, all-encompassing Maoist revolution. It would lead to the deaths of as many as two million Cambodians.

Given the destruction that was wrought, the scale of what Richner has built is impressive. Since 1991, the Kantha Bopha foundation has raised and spent more than $370m, with the vast majority of his funding coming from private donors, many of whom live in Switzerland. All five hospitals constantly operate at capacity, with around 300 admissions of seriously ill children every day, 60 operations, 3,000 outpatients, 1,500 vaccinations and 50 deliveries at the maternity unit in Siem Reap. Meanwhile, Richner’s drive to cut the rate of transmission between HIV-infected mothers and their newborn children has met with huge success: the normal mother-to-child HIV transmission rate in Cambodia is 40 per cent, but at Jayavarman VII they have reduced it to less than 5 per cent by performing caesarean sections, treating the mother and child with anti-retroviral drugs and insisting that they stop breast-feeding.

Victories like these make a case for the argument that one committed person can achieve more than scores of bureaucracy-laden NGOs. Richner employs 2,100 people but spends just 5 per cent of his annual budget on administration (his 180 doctors take a central role in running the hospitals; they earn about $1,000 a month compared with the $40 they would get from a state hospital). Richner imports all his drugs and medical supplies directly from Thailand to avoid the counterfeit pharmaceutical products flooding Cambodia. The head nurses personally distribute the medicines every day, to ensure no thefts. This vigilance goes for the patients as well as the staff. Chantana points out a young girl who is being treated for TB with a nine-month course of drugs. Like every other patient, she has returned to the hospital for her check-up carrying the empty blister packets to prove that she has taken her medication rather than sold it to a back-street pharmacist.

The problem, then, is not the medicine but the money. Richner only has five months’ funding left in the kitty and, unlike many charitable foundations, he has no endowments other than a commitment from the Swiss and Cambodian governments to cover 8 per cent of his annual budget each. He spends everything he gets on new buildings, machinery and drugs, as well as day-to-day expenses. In the past three years he has spent $34m on new construction projects. “The hospitals are working well and everything can continue without me, but the ongoing nightmare is the money,” he discloses as he puffs on a Davidoff mini cigarillo, well away from the main hospital buildings. “I can only start to think of my [succession] plan when I get the money – this $200m I need to save Kantha Bopha for 20 years. Then I will be a free man.”

It is this attitude that disturbs Richner’s critics at the WHO and other international health organisations in Cambodia. They have seen countless maverick humanitarians fall by the wayside when the funding for their donor-heavy projects ran out. “I can think of at least three or four other great individual initiatives in Cambodia that have atrophied when donor funding has dropped off,” says one long-standing NGO worker in Phnom Penh. “It would be nice to think that someone else would come in to the fill the gap if funding drops off, but you can’t just assume that.”

. . .

As he’s showing me the hospital, Chantana at one point confides: “We don’t have to look for God as we consider Dr Richner a god.” Richner was named “Swiss of the Year” in 2003 but his work remains little known outside his homeland – where his name often comes cloaked in controversy. Last year, he was criticised in a number of newspapers for turning down a $91,000 donation because it had been raised from the sale of the infamous nude portrait of Carla Bruni, the French first lady, by the Swiss photographer Michel Comte. Although he needed the money, Richner said that nudity offended Cambodian sensibilities and he dismissed the offer as a publicity stunt.

This incident and a number of more serious clashes with the media have left their mark on Richner. In 1997, he was accused of breaking his Hippocratic oath by failing to treat some of the more than 150 people injured in a lethal grenade attack on an opposition political rally – a charge he dismisses. He has since been the subject of highly critical documentaries in Switzerland. He very rarely grants interviews these days.

Last year, about $7m of the foundation’s annual budget came from concert donations, with one anonymous Californian couple giving $1m after seeing Richner perform in Siem Reap. But his love of music has withered in recent years. “I don’t have the mood to sing songs now,” Richner explains as he taps away at the keyboard in his small office. On top of all his medical, administrative and fundraising duties, he is busy writing another book (his first, Kantha Bopha: A Children’s Doctor in Cambodia, outlined his philosophy of medicine and his early clashes with the health establishment). Richner’s two large desks are overflowing with papers, books, DVDs and videos. Gifts, many of them still unopened, are piled on the floor: statues of Buddhas still in their boxes, bottles of champagne and chocolates. The obligatory kitsch painting of Angkor Wat fills almost the entire length of one wall.

Richner’s 200-year-old Italian cello rests on the floor in its blue soft case. As he talks, he gets up to close the door, anxious to ensure that the air-conditioned room stays cool and dry so that “his wife”, as he calls it (Richner is single and lives alone), does not deteriorate in the sticky climate. “The cello has a very human voice, like the saxophone,” he says. “You can express better what’s going on with the cello than by talking. It’s not aggressive or accusatory, like me.”

Although his protracted struggles have darkened his character, he remains determined to continue. “When I’m frustrated and angry with the government and the evolution of health policy in the poor world, I visit the wards with my colleagues and then I don’t doubt that what I’m doing makes sense.”

While the future of Kantha Bopha in Cambodia is far from secure, Richner still hopes to take his model to other damaged nations, such as the Democratic Republic of Congo and Burma. He is launching a new academy to train young paediatricians from Asia and Africa in his methods, so they can recreate what he has achieved in their own countries. “I want to show people that it’s possible to do this elsewhere,” he says. “After Cyclone Nargis, I went to Burma and got a visa even though the NGOs did not. The hospitals are very poor, they have no equipment and a lot of dengue fever, but we could do the same there that we did here.”

He is not put off by the rampant corruption in Burma or the malign influence of the military junta. “It was difficult here, too, but it would be possible in Burma,” he says. “The only condition is that Bill Gates, Bill Clinton or Barack Obama gives me $200m, because if I leave Cambodia, it will be harder to keep raising money.”

Ben Bland is a freelance journalist based in Singapore

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Lost in the ruin of Cambodia

Kim Echlin's masterful novel of meetings, partings and cross-cultural love

By Kim Echlin


'Tell others," commands the epigraph to Kim Echlin's third novel. Concise and eloquent, the words, belonging to Cambodian genocide survivor Vann Nath, are a fitting portal into the precise, expressive story set to unfold.

Anne Greaves is a precocious 16-year-old. It is 1979 in Montreal, and she is at a club with friends listening to Buddy Guy play the blues. A man joins their table, his eyes on her. She asks where he comes from and he names the Asian nation of Cambodia, then at the mercy of the Khmer Rouge. "Things are unimaginably free here," he says of Canada.

He is 21, a musician, now in his sixth year in exile in the West. The attraction is immediate. For her, it is "that animal feeling, the smell of your leather jacket, the quiver in my stomach, Buddy Guy's voice and your breath on my ear." For him, it is, in part, the dare, "an Asian guy with a white girl," and "all of us pretending nothing was forbidden." They are soon lovers.

The affair is reckless and Anne's father, her only parent, is disapproving. But the two are magnetized, the pull at once erotic and spiritual. "I love you with or without a name," he tells her on their first night. She mentions his name, Serey, one of the few instances in The Disappeared when he is so identified. Another night, she dreams that she calls for him but he cannot hear. "Do not worry, oan samlanh," he says, mixing Khmer with English, "I will always be here."

Her premonition, it turns out, is well founded. Montreal, the title of the novel's opening section, ends in the wake of Serey's return to Cambodia after the fall of the Pol Pot regime. Its buoyancy, capturing the lightness and charge of first love, gives way to the weighted adult textures of the dominant middle part, Phnom Penh. Echlin's storytelling, shifting continents and years in a paragraph, gathers much of its pace and grace equally from her lyrical prose.

A decade has passed. Anne, who has not heard from her lover in all that time, has likewise never ceased being in love. She appears in the Cambodian capital on the eve of contentious elections, with the government brutalizing the opposition. The ragged city, still in shock - like the entire nation - from its recent waking nightmare, is finely rendered: "Phnom Penh. The leisurely put-put sway to the traffic, rickshaws drawn by skinny barefoot men who run or pedal bicycles, four-wheeled remorques drawn by motorcycles, white UN vans, Red Cross trucks, military jeeps and buses, an elephant carrying lumber, the streets wrinkling up from the waterfront ..."

In the city, she meets first a driver named Mau, with "a scar across his left cheek," and then a fellow Montrealer who is in Cambodia helping chronicle the genocide. Forensic worker Will Maracle is actually from Kahnawake, the Mohawk reserve south of the city. "I like the intuition it takes to get bones together," he explains, "to make sense of the scene."

In Phnom Penh, Anne Greaves does finally locate her own "disappeared." The reunion of lovers is human and sad, a meeting of adults now separated by experiences and fates more than cultures or proprieties. In the book's final section, titled Ang Tasom, after a village outside the capital where Anne, Mau and Will Maracle travel, events turn harrowing - bone stripped of all flesh.

Emerging from those final pages is an act of love, and an image of horror, that elevates The Disappeared to a level of tragic intensity that it had been bound for from its opening sentences. To describe the act apart from its setting as the climax of a powerfully vivid narrative would be ruin its extreme beauty.

Readers of Kim Echlin's earlier books, Elephant Winter and Dagmar's Daughter, will be familiar with the tension in her fiction between a literary anthropologist's interest in archetypes and a poet's rendering of the sensory world. By the close of her luminous new novel, it becomes apparent that for her the two perspectives, or truths, are in harmony.

For all its brevity, The Disappeared still attends to the skulls and bones and slaughterhouses of Cambodia's agony. Anne's defiant visit to Tuol Sleng, the school-turned-prison where 14,000 men, women and children were killed - and from which Vann Nath, who provided that two-word entreaty to "tell others," emerged, one of just seven survivors - is about witness and record: "In Tuol Sleng," she writes, "a person is asked to stare."

But for the penultimate scene, the truth is definitely poetic. It may also be dramatic. The book, which can be read in a single sitting, builds toward a complex expression of annihilating loss and eternal love that is best experienced, in a sense, like the final act of a tragic play: as something inevitable and beyond the calculations of reason. The final line certainly speaks to that variety of wild human truth. "Come and I will whisper your name to you one more time."


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