HEALTH AND WELFARE

The government made a great effort to train new medical personnel, especially nurses and midwives, following independence in 1953. By the late 1950s, however, infant mortality reportedly was as high as 50 percent. Dysentery, malaria, yaws, tuberculosis, trachoma, various skin diseases, and parasitic diseases were common. Inadequate nutrition, poor sanitary conditions, poor hygiene practices, and a general lack of adequate medical treatment combined to give the average Cambodian a life expectancy of about forty-six years by the late 1960s. This figure represented a significant increase from the thirty-year life expectancy reported a decade earlier. The catastrophic effects of the war and Khmer Rouge rule reversed this positive trend. During the unrest, many Western-trained physicians were killed or fled the country. Modern medicines were in short supply, and traditional herbal remedies were used.

Public Health

According to traditional Cambodian beliefs, disease may be caused by some underlying spiritual cause. Evil spirits or "bad air" are believed to cause many diseases and can be expelled from the body of a sick person by trained practitioners, who may be traditional healers--bonzes, former bonzes, herbalists, folk healers--or Western-trained doctors and nurses. Aside from a wide variety of herbal remedies, traditional healing practices include scraping the skin with a coin, ring, or other small object; sprinkling or spraying water on the sick person; and prayer. The use of cupping glasses (in French, ventouse) continued in widespread use in the late 1980s.
Sanitation practices in rural Cambodia are often primitive. The water supply is the main problem; rivers and streams are common sources of drinking water and of water for cooking. These water sources are often the same ones used for bathing, washing clothes, and disposing of waste products. Adequate sewage disposal is nonexistent in most rural and suburban areas. Sanitary conditions in the largest urban areas--Phnom Penh, Batdambang city, and Kampong Cham city--were much improved over the conditions in the rural areas, however. By the early 1970s, Phnom Penh had three water purification plants, which were adequate for the peacetime population but could not provide safe water when the city's population increased significantly in the mid-1970s. The city had regular garbage collection, and sewage was usually disposed of in septic tanks.
The medical situation in Cambodia faced its first crisis at the time of independence in 1953. Many French medical personnel departed, and few trained Cambodians were left to replace them. In addition to a lack of personnel, a shortage of medical supplies and facilities threatened health care. To correct the first problem, in 1953 the government established a school of medicine and a school of nursing, the Royal Faculty of Medicine of Cambodia (which became the Faculty of Medicine, Pharmacy, and Paramedical Science in 1972, and probably the Faculty of Medicine and Pharmacy which reopened in 1980). The first class of candidates for the degree of doctor of medicine was enrolled in 1958. In 1962 this school became part of the University of Phnom Penh, and in 1967 it expanded its teaching program to include training for dentists and for medical specialists. By the late 1960s, trained Cambodian instructors began replacing foreign personnel at the Faculty of Medicine, and by 1971 thirty-three Cambodian medical instructors represented in sixteen specialized branches of medical study.
A school for training nurses and midwives was operating before 1970. This institution also trained sanitation agents, who received four years of medical training with emphasis on sanitation and on preventive medicine. These agents provided medical services for areas where there were no doctors or clinics. The number of nurses trained almost quintupled between 1955 and 1970. In Cambodia, nursing careers had been primarily reserved for men, but the number of women entering the field greatly increased after 1955. Midwives delivered almost half of the babies in the early 1970s. In March 1970, eighty-one pharmacists practiced in government-controlled areas. By 1971 the number had dropped to sixty three.
Cambodia never has had an adequate number of hospitals or clinics. In 1930 there was only a single 450-bed hospital serving Phnom Penh. By 1953 however, 122 public medical establishments operated in Cambodia, and, between 1955 and 1970, many improvements were made by the royal government. Old hospital buildings were replaced or repaired, and new ones were constructed. In 1962 provincial hospitals, along with many infirmaries, operated in all but three provincial capitals. By March 1970, 29 hospitals, with a total of 6,186 beds, were in operation; by September 1971, however, only 13 still functioned.
Phnom Penh had greater hospital resources than other parts of the country. In the late 1960s, hospitals served inhabitants in the surrounding area as well as residents of the city. At that time, seven hospitals (including five teaching institutions), several private clinics, twenty-two public dispensaries or infirmaries, and six military infirmaries operated as well. The major hospitals in Phnom Penh were the Preah Ket Mealea Hospital, the largest in the country with 1,000 beds, which was built in 1893; the 500-bed Soviet-Khmer Friendship Hospital, built in 1960; the Preah Monivong military hospital complexes; the French-operated Calmette Hospital; a Buddhist monks' hospital; and a Chinese hospital. Eight of the eighteen operating theaters in Cambodia in the late 1960s were in Phnom Penh.
A leprosarium in Kampong Cham Province provided care for about 2,000 patients, and the Sonn Mann Mental Hospital at Ta Khmau provided care for 300 patients. In 1971 Sonn Mann had about 1,100 patients and a staff of six doctors, twenty-two nurses, one midwife, fifty-four administrative employees, and eighty-nine guards.
Modern medical practices and pharmaceuticals have been scarce in Cambodia since the early 1970s. The situation deteriorated so badly between 1975 and 1979 that the population had to resort to traditional remedies. A Cambodian refugee described a hospital in Batdambang Province in the early days of the Khmer Rouge regime: "...the sick were thrown into a big room baptized `Angkar Hospital,' where conditions were miserable. Phnom Srok had one, where there were 300 to 600 sick people `nursed' by Red Khmer, who used traditional medicines produced from all sorts of tree rooths [sic]. Only few stayed alive. The Red Khmer explained to us that the healing methods of our ancestors must be used and that nothing should be taken from the Western medicine." International aid produced more medicine after 1979, and there was a flourishing black market in medicines, especially antibiotics, at exorbitant prices. Three small pharmaceutical factories in Phnom Penh in 1983 produced about ten tons of pharmaceuticals. Tetracycline and ampicillin were being produced in limited amounts in Phnom Penh, according to 1985 reports. The PRK government emphasized traditional medicine to cover the gap in its knowledge of modern medical technologies. Each health center on the province, district, and subdistrict level had a kru (teacher), specializing in traditional herbal remedies, attached to it. An inventory of medicinal plants was being conducted in each province in the late 1980s.
In 1979 according to observer Andrea Panaritis, of the more than 500 physicians practicing in Cambodia before 1975, only 45 remained. In the same year, 728 students returned to the Faculty of Medicine. The faculty, with practically no trained Cambodian instructors available, relied heavily on teachers, advisers, and material aid from Vietnam. Classes were being conducted in both Khmer and French; sophisticated Western techniques and surgical methods were taught alongside traditional Khmer healing methods. After some early resistance, the medical faculty and students seemed to have accepted the importance of preventive medicine and public health. The improvement in health care under the PRK was illustrated by a Soviet report about the hospital in Kampong Spoe. In 1979 it had a staff of three nurses and no doctor. By 1985 the hospital had a thirty-three-member professional staff that included a physician from Vietnam and two doctors and three nurses from Hungary. The Soviet-Khmer Friendship Hospital reopened with sixty beds in mid-1982. By 1983 six adequate civilian hospitals in Phnom Penh and nineteen dispensaries scattered around the capital provided increasing numbers of medical services. Well-organized provincial hospitals also were reported in Batdambang, Takev, Kampong Thum, and Kandal provinces. Panaritis reports that rudimentary family planning existed in the PRK in the mid-1980s, and that obstetrics stressed prenatal and nutritional care. The government did not actively promote birth control, but requests for abortions and tubal ligations have been noted in some reports. Condoms and birth control pills were available, although the pills had to be brought in from Bangkok or Singapore.
As of late 1987, the government in Phnom Penh had disseminated no information on the spread of the Acquired Immuno-Deficiency Syndrome (AIDS or HIV virus) in Cambodia. In addition, the list of common illnesses in Cambodia, as reported by international organizations, does not mention Karposi's sarcoma and pneumo-cystic pneumonia (PCP), the most common complications resulting from infection by the HIV virus. The risk to the Cambodian population of contamination by carriers of the HIV virus carriers comes from two sources. The more likely of the two consists of infected, illegal border-crossers, including insurgents, from Thailand, where authorities identified a hundred cases of AIDS in 1987 (triple the number in 1986). Less likely is the risk of infection from legal travelers. Cambodia remains a closed country, and access by foreigners (except for Vietnamese, Soviet, and East European visitors) is limited to a few scholars and to members of international and private aid organizations.

Welfare Programs

Steinberg cites twelfth-century King Jayavarman VII as having begun a public welfare system in Cambodia. Jayavarman built public rest houses along the roads, distributed rice to the needy, and banned tax collectors from places where the sick were cared for.
Beginning in 1936, the French colonial authorities passed legislation affecting the hours of work, the wages, and the worker's compensation for foreign employees. Later, Cambodians were covered. A system of family allotments was instituted in 1955. Under this system, employers were required to contribute a monthly sum for the welfare of the worker's family.
A few welfare organizations were established in Cambodia under the Sihanouk regime. In 1949 the National Mutual Help Association was founded to provide money, food, and clothing to the needy. In 1951 the Cambodian Red Cross was organized to provide aid to disaster victims, especially those suffering from floods. The Women's Mutual Health Association was formed in 1953. It was associated with the Preah Ket Mealea Hospital in Phnom Penh, where it provided prenatal and child care. During the 1950s, the Association of Vietnamese in Cambodia opened a dispensary in Phnom Penh. The most ubiquitous source of assistance for the average Cambodian, however, was the network of Buddhist wats that extended down to the grass roots level. Also, relatives and, in the case of the Chinese, extended families and business associations provided assistance to needy members.
In the PRK under the government's gradual evolution toward Marxist-Leninist socialism, the ability of the wat to extend charitable aid was seriously impaired because these institutions existed in conditions of near penury, following their active suppression under the Khmer Rouge, and they were barely tolerated by the PRK regime. Instead, fragmentary evidence suggests that public welfare was decentralized and, because of the paucity of resources, received only small amounts in funds from the central government. According to available literature, the care of needy persons was entrusted to local party and government committees and, at the lowest echelon, to krom samaki (solidarity groups). Leaders at these grass-roots levels thus were able to evaluate true need and to extend aid varying from in-kind assistance to informal job placement. Such decentralization avoided the bureaucratization of welfare but, at the same time, it carried its own potential for abuse because aid could be apportioned on the basis of fidelity to regime and to party, or even to enforce loyalty to local leaders. The extension to the local level of such social services, however, indicated that the PRK was slowly extending its presence in the countryside, thus reinforcing its claim of nationhood, and its control over its territory and over Cambodian society at large.