Analysis: What ails Cambodia's mental health system?

Skulls on display at Tuol Sleng Genocide Museum, where more than 12,000 prisoners were interrogated, tortured and killed (Photo: David Longstreath/IRIN)

PHNOM PENH, 12 March 2012 (IRIN) - In Cambodia, the psychological fallout from one of the world's heaviest bombing campaigns, genocide and two decades of conflict, coupled with chronic poverty, have left a heavy mental health burden that medical services are ill-equipped to handle, say experts.

Lack of funding, human resources, national vision and leadership, as well as poor coordination of groups working in mental health, are among the biggest challenges.

Sareth Mon, 58, takes anti-anxiety medication regularly, obtained from the public hospital Preah Kossomak in the capital, Phnom Penh.

Soon after the Khmer Rouge took power in 1975, Sareth's one-month-old baby died in her arms as she was no longer able to breastfeed. Her three-year-old daughter died from illness. "There was just no medicine available then," she told IRIN. "I brought them into this world, but could not protect them long enough to keep them alive."

But it is not only the genocide - which killed at least two million people, or one-third of the population then - that haunts survivors, but also the violence that preceded it, said Chhim Sotheara, a psychiatrist and head of one of the main local NGOs working in mental health, Transcultural Psychosocial Organization (TPO).

"We have all been touched by trauma. Our psychological courage has been broken," he said, in a rough translation of the local Khmer concept known as "baksabat".

Cambodia is the most heavily bombed country in the world - and more so than previously thought, according to 2006 research by the Canada-based human security scholar, Taylor Owen, based on declassified US government records.

Rather than the oft-quoted half a million tons, Cambodia was bombarded from 1965-1973 with 2.7 million tons, dropped on about 100,000 sites, at times less than 1km from villages, Owen learned by mapping the US Air Force data.

Just over 10 percent of the bombing was indiscriminate, with some 3,500 sites listed as having "unknown" targets and another 8,200 sites listing no target.

Budget

And while the government has declared mental health a priority, adopting a 2011-2015 mental health and substance-abuse plan, the 2012 mental health budget accounts for a mere 0.01 percent of the nation's yet-to-be-approved US$2.6 billion budget, or $300,000.

This is a more than four-fold increase over last year's budget of $70,000 and $13,000 in 2010, but still only a fraction of the 20 US cents per person other low-income countries spent on average in 2011.

The budget amounts to 2 cents per person in a country where the national legacy of violence is a "heavy burden of trauma mental health", as noted in Cambodia's Hidden Scars, a 2011 publication on trauma psychology by the local Documentation Centre of Cambodia (DC-CAM).

And most of the budget goes to methadone "maintenance", used to treat the growing number of injecting drug users, Chhit Sophal, deputy director of the National Programme on Mental Health, told IRIN.

Daily doses of methadone, a pain reliever, have been shown to help wean off injecting drug users by blocking drug-induced euphoria and blunting their withdrawal symptoms.

Meanwhile, most mental health disorders, including trauma, are still overlooked and under-treated. "Right now, we are providing basic services... giving pills and sending patients home," said Chhit.

Legacy of the country's status as one of the most heavily bombed nations worldwide (Photo: David Longstreath/IRIN)

Among patients seeking care, their diagnoses range from anxiety (39 percent), depression (29 percent), psychosis (18.5 percent), epilepsy (5 percent) and substance abuse (3 percent), according to the National Programme on Mental Health.

Services

While mental health treatment is available in hospitals, most staff and NGOs trained in providing such services are in the capital, where two million of the total 14 million population live.

As of 2010, 50 out of 84 referral hospitals and 18 out of 967 health centres nationwide (about 2 percent) offered mental-health services. There are two psychiatric in-patient units in the capital with 14 beds to treat the toughest cases.

General health staff provide most services; mental health specialists work in only 10 sites located in eight provinces.

There are no health services in northern provinces, including Preah Vihear, said Chhit, because "we don't have the human resources to send people up north".

In the capital, seven health facilities are medicating some 250,000 out-patients.

About 120 trained mental health workers serve 500,000 patients nationwide as of February 2012. "The budget my department receives is not an issue," said Chhit. "Even if I had $1 million, I wouldn't be able to use the money because I can't find skilled professionals."

Training

To date, 300 doctors and almost as many nurses have undergone basic mental healthcare training. The first group of 15 counselling students graduated from the Royal University of Phnom Penh (RUPP) in 2011.

There is little or no counselling in public health centres. "Our mental health programme is still [in its infancy]," said Chhit.

Chhit Sophal (Photo: Botumroath Lebun/ IRIN)

Among the estimated 50 doctors (out of 1,000 practising before 1975) who survived the genocide, none was a mental health professional. Since 1994, almost 300 students have completed RUPP's undergraduate psychology programme.

Few work in clinical settings, with most opting for NGOs or non-clinical jobs.

Lack of coordination

According to a 2010-2011 unpublished evaluation of mental health in Cambodia by the International Organization for Migration (IOM), committed mental health professionals are at risk of burnout due to how "rising demand (increased awareness and treatment seeking) and low supply (minimal services, human resources) of mental health treatment have created a high potential for work overload and burnout, subsequent decrease in quality of care with higher volume of patients and less time for continuing education or supervision opportunities".

One of the country's first trained psychiatrists after the genocide who is a practising clinician in the capital told IRIN the national mental health programme exists in name only, but lacks structure and a clear vision.

"I worked with the national programme, but became increasingly uncertain about the roles of different agencies. There is insufficient coordination among the top leaders. Who is responsible for what? It [mental health services management] is not well-organized and [getting what you need] all depends on whom you know. Where can staff turn to for professional growth? As a result, the motivation for mental health system development is stifled."

Chhit acknowledged the need for structure and highlighted lack of coordination with NGOs as a problem.

Respondents to IOM's evaluation cited "the need for a strong, charismatic leader" to unite different actors. Suggestions included using the World Health Organization to broker communication between the two sides.

How to fix?

Other suggestions from almost 40 local mental health professionals responding to two recent independent surveys of how to improve the mental health system included greater NGO involvement in mental health policy; more regular interagency coordination meetings, which have lapsed; increased collaboration between oft-segregated mental health disciplines; moves away from over-medicating mental illness; mental health mobile teams to expand services to underserved, mostly rural areas; more training; and involving more government ministries that can hold sway in the healing process, such as religious affairs and education.

Hong Sarath, pictured outside Tuol Sleng prison (Photo: Alan M.Thornton for TPO Cambodia)

Others suggested pushing for mental healthcare as reparations through the ongoing Khmer Rouge war crimes trial, formally known as the Extraordinary Chamber of the Courts in Cambodia (ECCC).

But the Supreme Court closed off this option in a 3 February ruling, saying the court could not force the government to pay for health services.

For Hong Savath, 47, thoughts of suicide still arise intermittently.

"I saw my parents tied and sitting on the ground in front of the hole [in 1979]. I could see bodies all around them and in the hole. They killed my mother first with a bayonet and then my father," she told TPO in 2010.

Raped at age 14 by the same guards who killed her parents, she has since married and had a second child at age 46 - but still seeks answers to decades-old questions.

Days before a life sentence verdict was handed down for Kaing Guek Eav, the former chairman known as Duch of the Tuol Sleng security prison-turned-torture chamber, she told IRIN: "If I could address Duch, I would ask, 'Who ordered this?' I saw my family killed with my own eyes. I want to know who is responsible. I would get over my sadness if I knew who did this. And why?"

Muny Sothara, a psychiatrist in Preah Kossomak hospital, said the weight of such questions can make healing difficult. "Meaning can help heal. A survivor of a tsunami has a scientific explanation of death and destruction. A genocide survivor - many survivors - seek the same."