"To Catch a Bug"

A report from Cambodia

Imagine working as a doctor without laboratory facilities to confirm a diagnosis. Now imagine working in a tropical country riddled with various strains of parasitic and other infectious disease, where diseases are resistant and where drugs and budgets are limited. Welcome to Cambodia.

Twenty years ago, over 2.5 million people were killed in the Cambodian genocide. All educated people, including doctors, were targets. Today, despite political and economic instability, roads riddled with mines, poor communications and low levels of education, Medecine Sans Frontier (MSF) is working with the Ministry of Health to improve standards of care through training and support to the provinces.

TB, malaria and dysentery are widespread and HIV infection is spreading faster than in any other country in South East Asia. Yet the average annual spending on health per citizen is just US$19, the average doctor's monthly salary is US$15 and there is little or no laboratory support to hospitals and health centres.

Doctors have to diagnose 80% of diseases using clinical signs and symptoms alone. In many cases, this means treating three diseases at the same time, at three times the cost in the hope that at least one treatment will be effective.

To improve health care in the provinces and to reduce such prescription costs MSF, working alongside the Ministry of Health and National Laboratory School, launched a programme to improve laboratory support.

When the programme began eight years ago, lab technician training lasted three years and relied completely on theory. Louis Goubert, who has been running the programme for the past three years, described just how basic the immediate problems were:

"There were no microscopes and practical training was non-existent. The first thing we did was to provide microscopes and include the professors as well as the students in the practical training as many had never seen or worked with a microscope before. We also carried out an assessment in the provinces and adapted the curriculum to meet local needs."

To begin with, ex-patriate MSF staff taught all practical classes using simultaneous translation from French or English into Khmer and it was through these early classes that the Cambodian teachers themselves learned the practical techniques of isolating and identifying germs under a lens.

The language barrier, however, was not the only problem. Given the low level of training, many of the students needed to learn the basics of biology, chemistry and mathematics. Also, due to the lack of funding and facilities, the MSF teams had to teach adapted sustainable lab techniques which have been obsolete in Europe since the 1950's, usually involving test tubes and comparative chemical tests, colouring the blood and viewing it under the microscope.

To provide relevant samples for students to test, MSF teams organised a system with the provincial hospitals to send in regular stool and blood samples. Three years ago, this `low tech' lab identified the first positive sample of the rare `Schistosomiasis mekongi' parasite epidemic, before it was confirmed by the Pasteur Institute.

The lab course itself is now focused on the relevant pathologies of South East Asia and the length reduced to two years. The selection procedure for students has been tightened to target higher level recruitment from the provinces and the first official Cambodian practical reference manual has been written and distributed nationwide.

MSF estimates that a minimum of 361 qualified technicians are needed nationwide. Since 1990, an average of 28 technicians, 20% of them women, have completed the course each year. As Louis Goubert explained: "When these technicians go back to their provinces, many are better trained than the doctors. The hope is that they will widen the doctors' understanding of existing and new parasites and that together they can provide better and cheaper care for all their patients".

Reproduced from and with acknowledgement to Dispatches the newsletter of Medecine Sans Frontier (Issue No 12, Winter 97/98)