A staff member counts out tablets in the dispensary at the Khmer-Soviet Hospital's psychiatric clinic in Phnom Penh (Photo by Robert Carmichael)
In April, the governor of Cambodia’s southeastern province of Takeo raised eyebrows when he ordered that people believed to be suffering from mental health issues should be rounded up and taken to pagodas.
Once there, he said, monks would help them using meditation, among other techniques.
While the governor’s concern about an issue the World Health Organization’s (WHO) Cambodia office last year described as “critically neglected” may be admirable, his proposed solution is misguided, say experts: people with suspected mental illness first need assessment and medication — not meditation.
The problem, though, is that Cambodia’s mental health facilities are at best limited and oftentimes unavailable. Rural areas, where most people live, are particularly poorly served, as 54-year-old Iev Lek discovered three years ago when her daughter fell ill.
“When she started getting sick, at first she didn’t say anything. Then, while I was sitting one day, she ran up to me and told me: ‘Mother, I am so scared. Somebody cut my stomach open,’” Lek tells ucanews.com. “After that she couldn’t sleep — she’d dream of bad things happening to her.”
Lek initially took her daughter, who is in her twenties, to a traditional doctor — a village healer whose remedies for ailments typically include herbal concoctions and potions. But his ‘cures’ were useless.
Then, on the advice of a doctor in the province, Lek took her to a private clinic in Phnom Penh.
“But it didn’t help at all,” says Lek of the results of a further year’s worth of treatment that cost her nearly US$500, a fortune for a rural rice-farming family like hers.
It was only after villagers told her about the psychiatric clinic at the government-run Khmer-Soviet Hospital in Phnom Penh that Lek took her daughter there.
“The doctor there was nice,” says Lek, though she dearly wishes her daughter could get treatment closer to home. “We’ve a public hospital nearby, but the doctors there don’t work on mental health issues.”
The lack of services in rural areas explains why, each weekday morning, the long corridor leading to the waiting room at the Khmer-Soviet Hospital’s psychiatric department is packed with people. Among their numbers each month is Lek’s son, who makes the trip from Prey Veng to fetch his sister’s medicines.
The clinic is run by Dr Yem Sobotra. When he started working here 15 years ago, it handled between 75 and 150 patients each day. Now that number averages nearly 400. Yet with just 10 psychiatrists and 10 nurses, there is only so much they can do.
The sheer number of patients coming to Dr Yem’s clinic, about 10 percent of whom are new arrivals, leaves little more than a few minutes with each. It’s not enough, he says.
“We [have] not much time to give good service for them — especially for psychotherapy,” he says. “Only some short counseling, short psychotherapy for the patient.”
Despite the lack of resources, those who make it to the Khmer-Soviet Hospital are the fortunate ones.
A 2012 report by the Leitner Center at the Fordham Law School in New York noted that Cambodia had just 35 psychiatrists and 45 psychiatric nurses providing mental health services. And while half of the 84 referral hospitals nationwide offer “some form of mental health services”, fewer than 20 of nearly 1,000 health clinics “have staff with some mental health training”.
Dr Yem Sobotra runs the psychiatric clinic at Phnom Penh's Khmer-Soviet Hospital (Photo by Robert Carmichael)
High demand, limited supply
That shortfall, particularly in rural areas, is pressing, says Dr Chhim Sotheara, one of the country’s most respected psychiatrists and the head of the Transcultural Psychosocial Organization Cambodia (TPO-Cambodia), the country’s leading mental health charity.
“There are a lot of needs,” he says, “But there are [few] resources in response to the needs.”
And that in a country with a more acute need than most — Cambodia has worse mental health statistics than almost any other, largely due to the 1975-79 rule of the Khmer Rouge when Pol Pot’s movement enslaved the population. By early 1979 two million people had died from execution, disease, starvation and overwork, and most of the six million survivors had experienced appalling cruelties.
“And I think the problem will accumulate [because] those who have been taking care of the people with mental health problems will suffer from mental health problems themselves,” says Dr Chhim.
Couple the consequences of that period with the ongoing challenges of poverty, domestic violence and other social ills, and the inescapable conclusion is that much more money is needed. And while the government has allocated more funds to the Health Ministry, with a near doubling projected to $450 million between 2014 and 2018, the sums available for mental health are insufficient.
What is available has come off a very low base — only a few years ago the total budget for mental health was $30,000 for the year. And it’s not clear what that number is now; the government’s newly formed Department for Mental Health and Substance Abuse said only that it gets less than one percent of the Health Ministry’s budget — perhaps $1 million currently.
That lack of resources plays out on the ground. The clinic at the Khmer-Soviet Hospital is not only understaffed; on occasion it runs out of medicines, which are supplied by the Health Ministry. And when it comes to medicines, says Dr Yem, those it receives are not as advanced as the drugs available in Vietnam or Thailand, and are unsuitable for patients with ailments such as heart conditions.
When it comes to solutions there is little reason to expect an influx of more psychiatrists: nationwide just six students are studying psychiatry at degree level, says a senior academic at the University of Health Sciences’ psychiatric department. He blames the low salaries on offer and the fact that psychiatry is a tough course.
It is a near-perfect storm of insufficiencies. Given that, says TPO’s Dr Chhim, the government ought to implement the WHO’s recommendation that it ensure medical staff in referral hospitals and health clinics are trained in basic mental health skills: “Transferring skills from highly trained to lower-qualified people.”
That is something TPO has done, though on an admittedly small scale: instructing village health support groups, including monks and nuns, so they can help mentally ill patients before they are seen by doctors or psychiatrists. Dr Chhim describes it as “first aid for mental health issues”.
“Training these people to be able to identify problems, manage [them] and, if they cannot manage, then refer,” he says of the WHO recommendations. “That would be a good step to decentralize the mental health service to rural areas.”
At the Ministry of Health’s Department of Mental Health and Substance Abuse, Deputy Director Dr Muny Sothara says the ministry has started training doctors in basic mental health skills, but admits much more is required.
“We need to improve the quality of the existing trained staff instead, and also additionally mobilize new general practitioners and nurses in order to operate more mental health units in other [lower] sectors,” he says, explaining that the goal is to ensure basic mental health treatment at commune-level health centers.
Yet it’s hard to know how much progress is being made: department head Dr Chhit Sophal did not respond to numerous requests for statistics about how many doctors and nurses have received training in basic mental health.
Small steps
Despite a litany of failings, there have been some improvements. For a start, says Dr Yem at the Khmer-Soviet Hospital, fewer people in rural areas believe mental health problems are caused by evil spirits. That makes families more likely to bring the afflicted to hospital for assessment and treatment.
Yet abuses remain common: in some places, families unable to cope with mentally ill relatives simply shackle them to a post under their homes, leaving them untreated for years. TPO’s Dr Chhim knows of at least 15 people who have been chained up, some for up to seven years, adding that the true number is certainly higher. There are, he says, many reasons why families might resort to chaining a relative.
“Either [the family is] very desperate about helping these people — they are very aggressive, they beat family members, they kill, they may pose a danger to the family member or themselves,” says Dr Chhim as he shows ucanews.com photographs on his smartphone of a middle-aged man chained under a home in a village.
Other families might have tried and failed to get help; or they might be so impoverished that they cannot afford to take their relative to a hospital. And, Cambodia’s weak health system means few staff have the resources or the willingness to conduct home visits.
“So the family has no choice but to lock them up otherwise they cannot go to work,” says Dr Chhim.
In response, TPO is launching a program called Operation Unchained. Mental health experts from the NGO will go to each home where they know a mentally ill person has been shackled, and take them to a facility for treatment.
In the meantime the battle being waged by rural families like Iev Lek’s continues: her daughter is fine while she takes her medicine, she says, but the symptoms return when she runs out. Then she talks to herself, moves her head a lot and stares off into space.
“Sometimes she sees one plate as though it is three plates — and then later asks people who took the other two plates away,” Lek says. “Some villagers have stopped talking to her because she is ill; others insult her saying: ‘You’ve been sick for so long, and more than other people — why don’t you just die?’”
Others are compassionate, but after three years even Lek wonders whether her daughter has been cursed.
“Can you find someone to help her?” she asks. “I want an NGO that can find a good doctor who can cure my daughter.”