Off For Cambodia
How did this happen?
I first learned of the needs of Cambodia from a local Denver surgical team that frequently makes trips to Phnom
Penh to perform surgery at the Calmette Hospital. After one of these trips in 2006, they decided to see what
pathology work was being done at the hospital. They found that all specimens were being sent out for histologic
processing and pathologic diagnosis. On their next trip the Denver team decided to see what could be done to
change this. They asked a pathologist from here in Denver to help on this fact finding trip. It happened to be a
pathologist whom I knew very well. She had never participated in missionary-type work and asked for my help.
With the goal of assessing what was available within the country with respect to a histology lab setup, I helped
develop a check-list of supplies to look for and questions to ask. We were shocked at our findings. Confirming the
findings of the visiting surgeons, neither histology preparatory work nor pathologic interpretation was being done
on-site. Likewise, while cytology laboratory facilities were present, interpretation was carried out in France, despite
Calmette Hospital being one of the major hospitals in Cambodia. That is when I decided to apply for the Lee Luna
Scholarship with the primary objective of helping to develop an in-house pathology laboratory.
At the National Society for Histotechnology Fall meeting in Pittsburgh I was fortunate enough to receive the
scholarship. At the time our laboratory was in the process of moving into a new hospital a few miles away so my
trip had to be postponed for a few months. However, on the 26th of November (Thanksgiving Day), 2009, I was
off for my three week visit to Cambodia. After almost 24 hours of travel time and loss of a day in time zone
changes I arrived in Phnom Penh. Fortunately I arrived early on a Saturday giving me two days to adjust to the new
time zone and get my bearings. Luckily I had made some good contacts at the Calmette Hospital and was picked
up at the airport by Dr. Kouch who was in charge of the Cytology Laboratory. He was really a big help in finding
me a hotel close to the Hospital and helping to orient me to the layout of the city. In retrospect, the 14 hour time
zone change was the hardest thing for me to get adjusted to. It took a good three or four days to readjust my
internal clock before I became comfortable with my new work schedule.
The next morning was Sunday. I hired a Tuk-Tuk Taxi for $15 US and spent the day
sight seeing and getting comfortable with what was to be my home for the next 3
weeks (Phnom Penh). The Tuk-Tuk was well worth the $15. My driver could even
speak a little English. He showed me the local markets, the Royal Palace, some local
Pagodas, and the "killing fields" from the Khmer Rouge years (1975 -1979) replete
with museum-type collections of skulls, uniforms, and historical perspective. Before I
summarize the lab-based component of my trip, I think it would be of interest to share
a little about Cambodia, its history, and its people, so you might better understand
some of the problems that exist there and some of the
obstacles I encountered. Some of the obstacles are
similar to what I have found in other parts of the
World. However, each location presents its own
unique challenges, and I have found through my
previous travels, that adjusting to the cultural
differences remains one of the primary obstacles.
Cambodia:
The Kingdom of Cambodia has had many names over the years. It has been called Khmer Republic, Democratic
Kampuchea, Peoples Republic of Kampuchea, and the State of Cambodia. It is located in Southeast Asia with
Thailand to the west, Viet Nam to the East, Laos to the North, and the Gulf of
Thailand to the South. The country of Cambodia is around 14 million in
population with its land size being approximately the same size as Oklahoma.
The Capital of Cambodia is Phnom Penh. It has a population of around 2.5
million people and is located on the Tonle Sap and the Mekong Rivers in
central Cambodia. Cambodia has a tropical monsoon climate with clearly
defined wet and dry seasons. The official language of Cambodia is Khmer
(95% speak this), with English and French widely spoken in the major cities
and among the business and educated parts of the population. 95% of
Cambodians are Buddhists. The average income of the common worker is less
than $2 dollars US per day. Cambodia has two classes of people, the rich which constitutes less than 5%, and the
"poor" which constitutes 95+% of the population. They do seem to be starting to develop a middle class, but it is
slow to come. More than 25% of the country is illiterate. Cambodia has a mandatory military service for males
between the ages of 18 and 30 for a period of 18 mos. The Cambodian Riel is the official currency trading at 4,000
to the US dollar. However, the US dollar is as widely used as the Riel; I was quoted prices in dollars for most
transactions. I assume this was mostly because merchants knew I was not Cambodian and suspected I would have
trouble with the conversion; they were right in assuming so. Cambodia is still primarily an agricultural country that
depends on farming and fishing for their livelihood. Cambodia is perhaps best known for (1) its ancient temple
complex of Angkor Wat (900 to 1300 AD), the largest religious monument in the World, and (2) for the brutal
Khmer Rouge regime of Pol Pot.
A brief summary of the Cambodian History:
Records indicate that Cambodia has been inhabited since approximately 4,000 BC. The zenith of power was the
Angkor Empire between the 10th and the 13th centuries. Over the next 500 to 600 years Cambodia’s neighbors
Thailand and Viet Nam had nearly continuous wars with the Cambodians which, little by little, ate away at the size
of the country. Finally, in 1863 the King of Cambodia placed the country under French protection. Cambodia
became part of French Indochina in 1887. In 1953 Cambodia became independent from France. The next few
years they had civil war after civil war until, in 1975, the Khmer Rouge under Pol Pot came to power. Pol Pot
attempted to make the country a completely agrarian state, dependent completely on agricultural activities for all its
needs; as such, he and his followers drove people from the large, commercial cities. Pol Pot did away with the
banking system, the school systems, and the medical systems. The Khmer Rouge devastated the country by
torturing and killing the educated and anyone who went against the party. The population of Cambodia in 1975
was approximately 7 million. The Khmer Rouge killed between 1.7 and 2.2 million. In 1979 Viet Nam helped
drive out the Khmer Rouge. The Khmer Rouge left only 10 - 40 medical doctors and no organized hospitals in the
country. After 1979 Cambodia went though a few additional years of civil war. Finally, in 2002, communist
control was dismantled and free elections were held. Cambodia is now a democracy with a Prime Minister and a
King. The King is only a figure head who has steered clear of politics but is well respected by all. He does have
some weight at court but does not have supreme power over the country.
Health Situation:
Cambodia’s long road to recovery after years of brutal genocide in the 1970’s continues today. The health
situation in Cambodia is in a critical state. More than 30% of the population live in extreme poverty without
modern sanitation or health care facilities. Major illnesses include bacterial and protozoal diarrhea, cholera,
typhoid fever, dengue fever, Hepatitis A, B, C, and E, malaria, Japanese Encephalitis, polio, yellow fever,
HIV/AIDS, rabies, tuberculosis, and H5N1 (bird flu). They also have a great problem with malnutrition. So, you
can see why I selected November and December (the dry season) for my visit so I could avoid at least some of
these risks. The Cambodian government does spend a great deal on the healthcare (12% of their GDP). However,
due to bureaucracy and corruption only a small proportion of this allotment actually reaches the healthcare system.
This lack of funding has left many public institutions unable to provide even the most basic of treatments and they
have to turn many patients away. The infant mortality rate is at 95 per 1000 live births. At the Calmette Hospital
there are two distinct patient populations and two separate entrances. One entrance is for those who can pay the full
amount to see a doctor ($30 plus medicine charges); the other, in the back of the hospital, is for those who can only
pay a part of the charges and for the indigent. Often the back door patients do not get taken care of. Many people
die from curable and preventable diseases at least in part because of this limited access to appropriate care and
medicines.
My Experience at the Histology Lab of the Calmette Hospital, Phnom Penh, Cambodia
When I first started to plan my trip to the Calmette Hospital they had no Histology or Pathology (2006 -2007).
Since that time a histology laboratory had been established using some of the young medical doctors within the
hospital. They have acquired some old equipment from the Louis Pasteur Medical Center in Phnom Penh which
had decided to discontinue its histology laboratory because of finances. Calmette did get some training for the two
doctors who are presently performing histology from the former technologist at the Pasteur Clinic. However, they
still lacked a basic understanding about how and why things are done in the modern histology laboratory.
I was able to acquire and take with me a Leica 1512 microtome. It was a challenge
carting the microtome on my trip, but I was glad I did. The second microtome
provided backup equipment and allowed the laboratory staff to accomplish their
work in a timely manner. It also allowed for more time for training. Presently, the
Calmette hospital is still doing things on a limited scale. They average around 10
to 15 blocks per day. Once a week, histology personnel packages the slides and
sends them to pathologists in Paris for diagnosis. In Paris it takes an average of 2
weeks to get the slides read and returned to Cambodia for transcription to be done
at Calmette. However, if any advance IHC or special stains are required the Paris
Pathologists will request the block to be sent with that week’s delivery of slides.
This adds an additional 2 to 3 weeks for the turn-around of a diagnosis. In
summary, turn-around time is approximately 3 or 4 weeks for a simple case and up
to 6 to 8 weeks for any complicated diagnosis. This is clearly not ideal, but the
best they have at the present time.
My first week was more of a fact-finding period to see how I might best help them.
My next 2 weeks involved daily work with staff and I presented formal didactic
and practical classes on tissue processing, embedding, microtomy, and special
staining. We discussed and established variable processing schedules that could be followed for different sizes and
types of tissues. I had to stress the importance of a proper volume of fixative to the size of tissue and the need to
open large specimens so that optimal fixation was achieved Processing was very similar to what we are currently
doing with respect to standard processing in the United States. I did help them reduce the duration of some
processing steps to avoid the drying out of the tissues. Embedding skills were adequate. I did show them how to
properly orient tissue when they had multiple pieces and taught them about inking when grossing for orientation.
When it came to placing tissue on slides I had some learning to do to understand
their methods. Histology initially makes a ribbon of tissue and lays it on a paper
towel. Next, they use a blade to cut off one section from the ribbon and place it on
a pre-labeled uncoated slide that has a large amount of an albumin solution on it.
The dry microtome section is placed on top of the albumin on the slide. The
albumin solution is made by adding 3 drops of albumin into a 5 ml dispenser
of water and mixing well. They then place the slide with the albumin and the
tissue on top of the albumin on a 50 degree C hot plate. At this time a tech will
take two razor blades to pull out the wrinkles from the section of tissue on the
slide. When the tissue appears flat with no wrinkles, a gentle wiping is
performed around the tissue with tissue paper to remove any excess Albumin
solution. The slide is then placed back on the hot plate to dry for 30 mins.
After the 30 mins on the hot plate the slide is moved to the microwave oven to
complete the drying procedure. Now the slide is ready for are an H&E stain.
The initial stain done on all tissues is a little different as well. They do use
Hematoxylin (Mayers), but do not use Eosin. The French pathologists have the
staff using Saffron & Phloxine in their staining procedure. After staining and
overnight drying the stained slides and one blank each are saved and at the end
of the week sent to Paris for diagnosis. They send the week's work to Paris
every Saturday. I was not able to touch this staining procedure but I did inform
them that we routinely use H&E stain in the USA. I did take over a used water
bath but I question wether it will ever get any use. After some of my classes I
was able to make some headway with lowering their processing times,
embedding procedures, and with the maintenance of the microtomes. I told
them that oil was a friend of the microtome. Language was a bit of a problem
but a bigger problem was that they only worked from 9 AM to 1 or 2 PM. I
was glad to have the 3 weeks with them. They do not get paid much for their
work and must work a second job to make ends meet.
Below are some of the wages paid at the Calmette hospital and in Cambodia.
With respect to expenses and transportation, automobiles cost about the same
as in the United States and gasoline costs over $4 per gallon. Hence,
motorcycles and bicycles are the principle means of transportation for many.
Field Worker
Market worker
Secretary at Hospital
Executive Secretary.
Nurse
Doctor - Technologist
Doctor - Consultant
Doctor - Surgeon
$1.5 / day
$2 / day
$200 – $300 / mo.
$300 - $400 / mo.
$300 -$400 / mo.
$300 -$400 / mo.
$500 - $700 / mo.
$600 - $1,000 / mo.
My normal day was to get up an take a tuk-tuk taxi or motorcycle to have
breakfast around 8 AM. I would walk from my restaurant where I had breakfast,
to the Calmette hospital, and arrive 9 AM. From 9 to 11 AM I would work with
the technologists in the lab. At 11 AM I would get the computer set up and give
a didactic lecture for the next hour and then head back to the lab to finish the day
at around 2 PM. Often, I would stay until 4 or 5 PM to print out procedures and
prepare for the next day. The first week afternoons were spent trying to find my
way around town and finding places to eat. I did try some fruits I had never seen
before but I did not try most of the local insects. I just did not think they looked
tasty. They have a number of infectious disease problems like cholera or typhoid
that I really wanted to stay clear of. I have been back in Denver for a week now
and, other than having problems with the time zones, I am still healthy.
In Conclusion:
I think I was able to introduce some new methods and allow them to make minor changes without total overhaul of
their laboratory procedures. I was careful not to go into another person’s kitchen and tell them how to cook. Some
things I could not touch. You can show them different ways but they have to make the decision to change
themselves. This was one of my most rewarding overseas trips. I hope my friends at the Calmette hospital feel it
was of value to them too. I would like to thank Dr. Reasey Mao the director or the medical labs for Calmette, Dr.
Kouch, Dr. Vannarith, and Dr. Puntuna for all the help they gave me and for their hospitality while I was in
Cambodia. They were all fantastic hosts and I would welcome the opportunity to go back and help them anytime.
All of my hosts were eager to learn and always very professional.
Why Volunteer?
I think you can see why one can justify giving time, money, and talent to this cause. You can say you are only one
person and you most likely will make no impact. However, if a number of people help and share resources and
talents we can make a difference and it is a good investment for us all. I learn each time I go out and help. Each
place I go is always different and with different problems and challenges. However, each trip has been rewarding
personally and professionally.
David Davis, NSH Member
2008 Recipient, Lee G. Luna Foreign Travel Scholarship