Regional inequality in surgical care in Cambodia from the perspective of an anesthesiologist in Japa

Author: Yurie Somekawa

Editors: Akihiko Ozaki M.D., Yuki Senoo

I have been working as an anesthesiologist for the past 5 years, and this year, I started to learn about public health at the school of public health for my master’s degree while I am working.

I started to work as a medical volunteer in Asian developing countries about 2 years ago, and my visit to Cambodia in August 2018 was my third.

I am interested in the field of global health, especially aiming to reduce the number of people in the world who cannot receive the necessary medical care.

People often ask me why I am engaged in global health. My first influence was probably books about the lives of people in developing countries and projects carried out by UNICEF, which I read during elementary school. It was when I was practicing Kendo, a Japanese style of fencing, in the garden that I randomly realized my personal ambition to work as a doctor in developing countries. This was when I was a junior in high school.

I am not good at thinking theoretically, and I often make intuitive decisions. For example, my final examination grades in a high school were at a level that called into question whether I could even enter medical university. All the people around me were, therefore, opposed to the idea of me taking a gap year to study for medical university, which was the idea I had intuitively come up with. Finally, I became obsessed with this idea and entered medical school.

However, I was not confident about the intuition to pursue becoming a doctor in developing countries. I had never been to developing countries because I did not have any connections to any of those countries. Additionally, I had the prejudiced idea that infectious diseases were prevalent there and that those countries were dangerous.

Two years ago was a turning point in my life. Because I had always dreamed of going to developing countries, I joined JAPAN HEART’s short-term medical volunteer program in Myanmar as an anesthesiologist after I learned the procedure of necessary medical treatment. Through this experience, I reconfirmed my idea to have a career related to international health, which was an idea I had when I was a junior in high school; it is not just a dream but something I really want to carry on throughout my life.

For that reason, I engaged myself in work overseas little by little to have a lot of opportunities to extend my experience.

For my research, I stayed in the Kratie province in Cambodia. The Kratie province is a 5- to 6-hour car drive northeast from the capital city of Phnom Penh. The Mekong River crosses this region, and the scenery is more tranquil compared to that of Phnom Penh.

According to the data of the Cambodia Demographic and Health Survey (CDHS 2014), the proportion of low-income families in Kratie province is over 35%. This makes the province the third worst in terms of impoverished families nationwide. As stated in the same survey, the under 5 mortality rate (U5MR) is 18 in urban areas, whereas it is 52 in rural areas (per 1,000 people). This indicates the severe regional inequality of medical care in the Kratie province. Furthermore, the Kratie province’s U5MR is the highest of all regions in Cambodia. I had the opportunity to go to rural areas in the Kratie province during my last visit. As you leave the towns, the roads change from concrete highways to unpaved roads. The bridges were made of crude-looking wood, which made me worry about whether we could cross with a 4 WD vehicle. People living in such rural areas seem to have no chance of going to Cambodia’s famous sightseeing spots such as Siem Reap and Phnom Penh due to the bad roads and poverty. In fact, some people have to travel over 2 hours to access the Health Center, which is the village’s only public health institution. Children in rural areas do not know the taste of pizza and hamburgers, which are the favorite foods of children in Japan.

This survey and research were a cooperative project of the Japanese NGO, International Development and Relief Foundation (FIDR). FIDR intervened with Kratie Provincial Referral Hospital (KPRH) about 2 years ago to improve the pediatric surgical field. KPRH is the largest public hospital in the Kratie province.

In developing countries, the propagation of safe surgical operations is a pressing need. About 60% of surgeries are conducted in economically prosperous areas, which account for only 15% of people in the whole world. Currently, 2 billion people worldwide do not have access to necessary surgeries, and it is estimated that 6-7% of deaths could be prevented by performing the essential operations.

Disease control priority 3 (DCP 3), published by World Bank et al., states the necessity to adjust a system to enable management of basic operations at first-level hospitals to propagate surgical operations. First-level hospitals are regional hospitals with 50 to 200 beds and have the facilities to perform necessary surgeries. A possible reason for this is that the capacity for surgical treatment does not meet the demand, particularly in rural areas.

Approximately 2,000 surgeries are performed annually at KPRH. In Japan, there are many elective operations, but in Cambodia, most operations are done in emergency settings. The higher the ratio of emergency surgery to scheduled surgery, the higher the burden on medical staff, especially surgeons. Medical professionals in these areas are under a tremendous amount of stress because it is difficult to predict when and what kind of emergency operations will take place at any time.

Among these 2,000 annual surgical procedures, the surgical operation rate for pediatrics accounts for only about 10%. This figure suggests that a lot of children may not receive surgeries considering the high demand for children’s surgery in developing countries in general. During my visit, I encountered a pediatric patient with a burn scar that seemed to have been left untreated for a long time. It caused severe dysfunction in his hand. If he were in Japan, surgery would have taken place before the malfunction occurred. This kind of situation is rarely seen in Japan.

The objective of our research was to improve access to pediatric surgical care at KPRH.

How could we achieve this goal? Problems are piled up. Among those problems, including the shortage of equipment and inadequate health care systems, I believe the lack of surgeons is the most critical. Currently, although this problem is also seen in the rest of the world, in developing countries, the situation is much worse. Due to the concentrated population of doctors in Cambodia’s capital, the rural areas suffer from a severe shortage of doctors. There were only five surgeons at KPRH, including one obstetrician. This puts considerable weight on their shoulders because they are required to handle more than 2,000 surgeries every year. I asked one of them if they were actually busy. This surgeon answered, “I am pretty busy with work other than surgery, such as ward management, communicating with the patients, and creating documents.”

Increasing the number of surgeons would be very difficult. It would require a lot of money and time. One possible solution to tackle the shortage of health care workers is a process called “task shifting,” which converts the tasks of medical doctors to non-doctor medical staff. This concept is said to be globally significant. Furthermore, in some countries, non-doctor medical teams perform simple operations, which works out sufficiently.

Moreover, the most important thing is the local people. What I felt particularly strongly during this trip was that foreigners can only do a small part of the help. After all, the central role is filled by the local people. Cambodian people are very nice. Everyone was kind and helpful to me whenever I was in trouble. In Cambodia, I also encountered many people who worked hard to make improvements in their home country and hometown.

As I talked with such people, one question emerged: Do I think about my country, Japan, or my hometown enough? The answer is “No.”

I have not thought about Japan in particular, and the same goes for my hometown. As I observed medical care in other countries, I realized how good our environment is and how protected Japanese people are. This safe environment is created and is maintained by someone. For the first time in my life, it came across to me very naturally that I should return the favor as one of the majorities who was raised in Japan and received the benefits. In my case, I think I have to spread the experience and knowledge I gained through my study of global health to medical care in Japan. At the same time, I want to grow as a person and extend my understanding of the phenomenon in the world as much as possible through my favorite work.

Finally, this trip and research were conducted with the cooperation of the following people. I want to say special thanks to Dr. Kuratani (Saitama prefectural childhood medical center), Dr. Yamamoto (Tokyo Metropolitan Tama Medical Center), Dr. Ishii (Kinki University Nara Hospital), Mr. Saeki (project manager of FIDR), and local staff in Cambodia. I am grateful to be in such a privileged environment in which I have a lot of opportunities to learn and sincerely appreciate all the people who are cooperating with me.