Beyond AIDS: Health crises plague developing countries

Ask any foreign medical officer what has been accomplished here in the past few years, and he most likely will say: We defeated HIV/AIDS in Cambodia.

Prodded and funded by foreign governments and private groups, Cambodia has reduced the prevalence of HIV/AIDS in the general population from more than 3 percent to just under 1 percent - a major public-health victory.

But that accomplishment masks a darker truth that afflicts poor populations in Cambodia and most of the developing world. Health policy in this country is determined by the priority or caprice of officials in Geneva, Washington or Berlin - not Phnom Penh. That has given this country a health policy that appears patently absurd.

"Everybody talks about AIDS," complained Dr. Sin Somuny, executive director of Medicam, which represents 117 health care providers in Cambodia. "It affects .09 percent of the population. Well, diabetes now affects 10 percent of the population. But no one talks about that. Funding for diabetes is 25 to 30 times less."

That makes no sense. How can it be?

International donors "want to give money to the big thing of the moment," acknowledged Dr. Michael O'Leary, director of the World Health Organization office in Phnom Penh. "Right now, it's influenza," better known as swine or bird flu.

Beat Richner, a Swiss doctor who runs five children's hospitals across the country, puts a positively uncharitable spin on that analysis.

"They care about bird flu because a bird may fly to California," he told me. "But a mosquito flies only 120 meters." Hence the dearth of funding in Cambodia for malaria or dengue fever, two mosquito-borne illnesses.

"Infectious diseases, infectious diseases," Somuny said, shaking his head. "If you care about the lives of the people, it should not just be infectious diseases."

"You know, beggars can't be choosers," said Dr. Paul Weelen, another WHO official in Cambodia. "Donors set the agenda for what is done in these countries."

Cambodia spends almost $200 million a year on health care services for its 13.4 million citizens. Foreign donors and charities provide about 40 percent of that, giving them outsize influence over health policy. (Per capita, most Western states spend almost 1,000 times more.)

A few years ago, Cambodia's Health Ministry told international donors that it had an urgent priority: to establish a primary health care system - doctors, hospitals and health clinics - to serve citizens nationwide. The Khmer Rouge killed all the doctors and destroyed the health care facilities during its reign 30 years ago.

The donors were largely unresponsive. So, largely with its own money, Cambodia built dozens of hospitals and health clinics. I visited several. Signs and stickers show that international aid groups did provide some equipment and infrastructure. But these are Cambodian operations, as they should be. Still, the hospitals are so underfunded that it's a wonder they can do anything at all. Nurses are poorly trained, underpaid, overworked - and, as a result, often indolent. Doctors might earn $200 a month, so they sometimes demand under-the-table payments before they will treat patients.

In Battambang hospital one day this month, patients lay on straw mats they had brought from home, placed on top of wood slats in rusty white-enamel bed frames. Ten miserable patients lay unattended in the emergency room. The nurses' station was empty, but a green door at one end was cracked open. Inside, three women lounged on beds, snacking on bananas and rice cakes. I knocked.

"Just a minute!" one of them shouted as she jumped out of the bed and frantically pulled on her white nurse's coat.

In private hospitals, adequately paid and supervised, Cambodian doctors and nurses provide superb care.

No one expects the international community to pick up responsibility for funding Cambodia's hospitals. But if the foreign donors at work in Cambodia and in dozens of other poor nations made an effort to direct their money to the nations' priorities, they might save millions of lives.