Serm Chom, an HIV-positive rice farmer and commune councillor from Roka village, sits outside his house in Battambang province (Photo by Robert Carmichael)
Drive through Roka village and life would appear to be going on much as it does elsewhere in this rural part of western Cambodia: newly-harvested rice drying on plastic tarpaulins, white cattle roaming the stubbled paddies, and schoolchildren pedaling down shaded dirt roads.
But over the past six weeks, the lives of more than 170 residents of Roka village — and more than two dozen other people in two nearby villages — have been upended after they tested positive for HIV. Those infected are the young and the old, male and female, rice farmers and Buddhist monks.
To date, 174 of Roka’s residents have learned they are HIV-positive out of 1,436 who have been tested. That is a rate of 12 percent, 20 times the national average. Testing for HIV in Cambodia is voluntary (and free), and the remaining 1,000 or so residents have chosen not to find out.
Among those who contracted HIV is 72-year-old rice farmer Serm Chom, as did a dozen of his relatives ranging in age from babies to a widow in her 70s. People are falling ill, he says, villagers are angry and they need more help.
“First, we have lost our children to this,” says Chom, who is also a member of the commune council. “Second, we don’t have the energy to earn a living and feed our families. Third, I want to know the real reasons behind this. Also I want to see that doctor jailed.”
The doctor in question is an unlicensed medical practitioner called Yem Chrem, whom Cambodian authorities have arrested on suspicion of being behind the outbreak. Chrem, who reportedly admitted reusing needles on patients, practiced here for two decades after picking up some medical skills in refugee camps on the Thai border in the 1980s.
The outbreak in Roka has surprised health experts not least because Cambodia’s much-vaunted HIV policy has been so successful, making the country a leader in global efforts to counter the virus. Since 1998, the national infection rate has dropped from two percent to 0.6 percent.
While it’s too early to say what is behind each of the 212 infections in Roka commune — the administrative area into which Roka village falls — work done by the government and health partners such as the WHO, UNAIDS, USAID and others indicates a “statistically significant” link to needles.
“The study showed that the percentage of people that reported receiving an injection or intravenous infusion as part of their health treatment was significantly higher among the people who tested positive for HIV than the people who were HIV-negative,” the Ministry of Health said in a statement on January 9.
Other possible routes such as engaging in unprotected sex or transmission from mother-to-child, by comparison, showed no significant impact.
The outbreak in Roka raises questions of potentially nationwide import in Cambodia, a corrupt country with a weak healthcare system, too few trained medical professionals (who are generally underpaid), and a penchant for intravenous drips or infusions for even minor ailments — which are far easier to contract in rural areas like Roka that have limited or no sanitation.
Roka has shown that dirty needles and fake doctors are a time bomb. And while Cambodia has protocols governing the use of needles and years-old legislation barring quacks from working, it’s clear that the authorities in Battambang failed to enforce the latter until it was far too late.
The Ministry of Health is now stepping up efforts to ensure adherence to the needle-use policy, and will also work harder to stop unlicensed medical practitioners from working. But the latter could prove tricky given that no one knows how many fake medics are out there.
Speaking by phone, Minister of Health Mam Bunheng says local authorities are undertaking a nationwide recount of the number of people practicing as health professionals.
“We should make a precise inventory … as quickly as possible,” he says, “because we need to look at this and ban all the unlicensed practitioners.”
Less clear, though, is whether action will be taken against individuals in the provincial or district bodies who failed to act against Chrem, and so contributed to this outbreak.
That, the minister says somewhat vaguely, will “depend on the law”. In the meantime, he says, the government and its health partners are providing villagers with assistance, including anti-retroviral drugs for the worst affected.
An HIV-positive patient in Roka village holds anti-retroviral tablets (Photo by Robert Carmichael)
The obvious question is whether what happened in Roka is happening elsewhere too.
Marie-Odile Emond, the country coordinator for UNAIDS, reckons the national surveillance system for HIV would have picked up any large-scale outbreak. But Roka’s cluster “is definitely a concern” when considering the national picture.
“We don’t know the magnitude of the problem because we don’t know how many [unlicensed] practitioners there are,” she says. “[But] it also of course depends very much on the practice — [with those using] safe needles and syringes there’s obviously less risk.”
Although some unlicensed practitioners are likely providing key services to people at no risk, she says, Roka has highlighted the need to do better not just in terms of minimizing the risk of HIV transmission but of the spread of other diseases too.
Although Emond describes Roka as “a wake-up call”, she does not believe it will alter the country’s to-date successful focus on high-risk groups such as entertainment workers, men who have sex with men, and intravenous drug users.
“All the estimates are that the [national] epidemic is mostly concentrated in some key affected populations, and that’s been consistent with the surveillance system, with all the estimates in many different studies,” she says.
But more work is needed in Roka, she adds, “to see where there’s other risk, whether there is a need for further investigations to prevent any such incident happening in any other places in the country.”
That investigative work will soon start, albeit only in the area around Roka, says Dr Mean Chhivun, who heads the National Center for HIV/AIDS, Dermatology and STDs and who has led Cambodia’s HIV effort for two decades. Step one is to study HIV prevalence in every village in Roka commune and several villages outside it.
“We have to have clear evidence,” he says. “So the reason why the near-future plan is to conduct the HIV prevalence study [is] so that we can say, OK, no problem: the outbreak has only occurred in this commune. [But] until now, [it is] still unclear. So when we get a clear result from this study, we can say.”
Back in Roka commune, authorities have provided free anti-retroviral drugs to more than 70 villagers whose white blood cell count has dropped below 500. And NGOs such as Buddhism for Development are pitching in to counsel villagers and further educate them about the risks of transmission.
But for more than 200 villagers, much of this is too little, too late.
The Venerable Mom Heng, the 82-year-old chief monk at Roka pagoda, regularly called on Chrem for treatment. It wasn’t until several of his relatives told him they had contracted HIV that he considered getting checked.
“They said that I should get tested for HIV,” he says. “And I told them: it’s not possible. I have been a monk for a long time.”
To his shock, his result came back positive. The elderly monk doesn’t know when or how it happened: he always watched carefully to make sure the needles and syringes were taken from sealed packaging, and that the ampoules for treatment were new and were fully drained.
“All the villagers felt very fearful [when the results began to come back positive], especially for those children who have now contracted HIV,” he says. “As for me, I am old. But for the youngsters I feel great pity.”