Georgia Physician Magazine

One by One
Georgia physician Richard Kauffman gives an account of his visit to a third-world country being blind-sided by AIDS.

I left for Cambodia on Aug. 31, 2004, not knowing what I was getting into. I had responded to an e-mail request for physician mentors to go to a third-world country to help stem the devastating tide of HIV/AIDS. I could not resist the strong urge inside me to volunteer, so I went.

Along with two nurses and another physician from Brazil, we launched the first team of volunteer mentors to Cambodia. Dr. Marcio Fonseca and Brianne Fitzgerald, R.N., went to the southern province of Koh Kong, while Jennett Baker, R.N., and I went north to Bantay Meanchey Province (BMC). There are two hospitals in Bantay Meanchey, one in Sisaphon and one in Monkol Borei. I was charged with teaching everything I knew about HIV in only three months to eight physicians who hardly spoke English, and I certainly spoke no Khmer.

Having been accustomed to the wonderful hospitals of Atlanta, the hospitals of BMC were shocking. The wards were all open to whatever wanted to come in: flies, mosquitoes, roaches, geckos, dogs, cats and other unwanteds. Just outside in the courtyard, cows and goats were grazing. I had to dodge cow piles on many occasions going from one ward to another. Immediately adjacent to the HIV ward, a swamp provided a breeding ground for mosquitoes, and the windows had no screens to keep out the many insects.

The stench of human waste was ubiquitous. The hospitals took no responsibility to provide food, gowns and bed linens. The beds were without mattresses, and patients brought their own mats to cover the wooden slats that comprised their beds. Nurses were strictly medication givers and did not provide traditional nursing care. They took no responsibility to bathe patients, change dressings or clean bedpans. These duties were left up to patientsÕ family members. Nurses were paid a paltry $17 per month to provide this care. The doctors, paid $30 per month by the Cambodian government, were swamped with patients who were near death.

Dying families
Husbands who contract AIDS in a brothel bring the dreaded disease home. The practice of visiting brothels is widespread in Southeast Asia, where sexual activity is not limited by marriage vows. Wives, subsequently, are infected and give birth to children already infected. These unfortunate children are usually orphaned by the time they reach ages 5 or 6. The unsuspecting parents come down with tuberculosis and other opportunistic infections. As the breadwinner of the household repeatedly gets other infections, he rapidly loses the ability to support his family. First, the cattle are sold to pay for traditional therapies that cannot stave off the encroaching illness. Then, the land is sold parcel by parcel until nothing is left, and death finally makes its house call.

Left behind are orphaned children spawning street kids, school dropouts and prostitution. The responsibility to care for these children is thrust upon grandparents and other family members who are ill-prepared to care for them. Far too often, these children are forced to fend for themselves in the streets with no place to call home. This certainly leads to destitution, hunger and desperation. Epidemics usually target the very young and the aged rather than those who are in their prime, such as mothers and fathers, teachers, bookkeepers and farm workers.

The victims
Em Tear was a 7-year-old orphan, also infected with HIV and totally alone in this world. He had accompanied his father to the hospital in Mongkol Borei to help care for him while he lay dying in the HIV ward. Tear had already lost his mother to the disease. Eventually his dad died, leaving him all alone in this world. When I first met Tear, his arms and legs were covered with draining sores. As if this were not enough, he also had a high fever and pneumonia. Tear was admitted to the hospital, and we treated his multiple infections. I took a keen interest in Tear and became his Òpapa.Ó I found an orphanage that was run by the Marynoll Catholics in Phnom Penh that had a program, Little Sprouts, devoted to caring for children with HIV. At the end of my stay in Cambodia, I took Tear to the capitol to become a Little Sprout so that his needs for nutrition, medication and education were met.

Chung Phally was a father of three children, all younger than age 10. He had tuberculosis and HIV wasting syndrome. His wife and children were HIV positive. Chung has been a patient in the hospital since long before I arrived. When I first saw him, I told the doctors there was nothing we could do for him and that he was likely to die any day. He, however, clung doggedly to life and actually gained a kilogram during my three-month stay. Chung was a patient in the tuberculosis ward, which meant his wife and small children had the run of the ward as well. The children, with their naked little bodies, also had the run of the rest of the hospital, spreading germs from their fatherÕs ward at will.

Ham Sok Hak was 29 years old with severe anemia and fevers. His wife left him when he became too ill to support her and their 2-year-old son. Ham wasted away in front of our eyes. His anemia was so severe that he would black out when he tried to sit up. Although the laboratory results, ultrasound and x-rays were negative for tuberculosis, we decided to treat him for it anyway. His fevers abated, and he began to gain weight. His mother now takes care of him in the hospital that has become his permanent home.

The reality
Across BMC, AIDS has taken out a generation that should be in the fields harvesting rice and tending to the normal duties of living, instead of filling hospital wards and crematories. The sound of funeral music fills the air several times daily as this plague takes its toll.

During my visit, I was taken aback by the severity of the situation in this remote part of Cambodia. It reminded me of the early days of the epidemic here in the United States, only much worse. I made rounds with these war-weary local physicians every morning. On my first day, Dr. Var Sopul, who was in charge of the HIV ward, confided to me that he was tired of seeing so many patients suffering with tuberculosis and cryptococcal meningitis, or going blind from cytomegalovirus retinitis, only to eventually die.

Physicians in Cambodia typically try to keep from touching their patients, for they, too, are afraid of ÒcatchingÓ the disease. Every patient we saw in our rounds was an opportunity for me to teach something of value about the HIV treatment. I also seized the opportunity to show them hands-on physical examinations. Most of all, I wanted to show the doctors how to care for their patients in a compassionate manner.

Every afternoon, we assembled for a didactic session with the doctors. My lectures initially were about the opportunistic infections and how to use appropriate prophylaxis against theses diseases. The latter half of my stay was devoted to training them on the use of ARVs and the hazards they will encounter once these drugs arrive in BMC. The Cambodian government had scheduled Dec. 1, 2004, for the arrival of these much-needed drugs. Fifty doses were scheduled initially, but the number was increased to 350 by the end of January 2005. The goal is for 750 patients in BMC to be on therapy by the end of 2005. This is just a start for the thousands of people who need the medications desperately.

Cambodia is a country of 13 million people. There are about 200,000 people living with HIV/AIDS. Every year, about 20,000 people die of HIV/AIDS. Most of these deaths are parents in the primes of their lives. This leaves an incredible number of orphans having to survive alone.

A large number of these orphans also are infected with the HIV virus and will create a huge burden for the government in the future.

Unless we in the developed world step up to the plate and do more than throw money at the problem, third-world countries, like Cambodia and the countries of Southeast Asia and Africa, will become a nightmare for the rest of the world. We need to send more mentors Ð clinicians who are willing to sacrifice a little of their time Ð to help teach the caregivers in those countries how to best deal with the coming onslaught. It is already an obscenity that we have allowed so many young mothers and fathers to die, leaving so many children who, unlike my little Tear, will have to deal with staving off starvation, illnesses and destitution.