Those seeking to improve health care in Cambodia face daunting challenges on every front, but there have been successes: Some health status indicators have gotten better, and more indigenous professionals are being trained. At the same time, Cambodians living in the United States are benefiting from creative, culturally sensitive health care programs. In both cases, what has been accomplished is often the result of heroic efforts on the part of dedicated individuals. There are many lessons here for health care reform.

This is the second article in a two-part series on health care for Cambodians in that country and in the United States. The first article, "Starting from Scratch: Rebuilding a Health Care System," was published in H&HN Weekly on June 2 of this year. I hope that you will read that article first, if you have not done so, as I will not be repeating material from it here.

The facts cannot be denied. Of all Southeast Asian countries for which reliable statistics are available, Cambodia's health status indicators are the worst. From infant and maternal mortality to diabetes to tobacco use, Cambodia lags behind its neighbors. Given its recent history, this is hardly a shock; what is more surprising is the amount of effort to improve the situation.

A Commitment to Improvement

During my four visits to Cambodia, if I have seen anything consistent in its health care sector (and consistency is not a hallmark of Cambodian society), it has been the passionate desire on the part of so many people to create a more functional system that provides higher-quality care to more folks. Although this is also a goal of U.S. health care, we have far more tools with which to do it, if we ever get around to it. In Cambodia, public health officials, leaders of nonprofit organizations and many of those working in for-profit settings seem committed to improving what was a health care disaster 20 years ago. They are aided by donors from around the world.

Everyone has a different agenda, of course, but a major blueprint is the Ministry of Health's Strategic Plan, 2008-2015, issued last year. Its stated vision is "to enhance sustainable development of the health sector for better health and well-being of all Cambodians, especially of the poor, women and children, thereby contributing to poverty alleviation and socioeconomic development."

Its guiding principles are:

• social health protection, especially for the poor and vulnerable groups;
• a client-focused approach to health service delivery;
• an integrated approach to high-quality health service delivery and public health interventions;
• human resources management as the cornerstone for the health system; and
• good governance and accountability.

This is a tall order for a system that is coming back from nothing. And we have all seen master-plan documents that have landed with a loud thud and were never implemented. Still, this is a start; at least the ministry has defined its priorities, which is more than has happened historically with U.S. efforts

Lessons for Reform

I believe that the health care experiences of Cambodians and the people who care for them, both here and in Cambodia, have much to teach those who are seeking to reshape American health care. Here are a few of those lessons.

A solid health care infrastructure is necessary, especially a public health infrastructure. One of Cambodia's greatest problems is that a basic public health infrastructure simply does not exist. Although that is true of only a few locations in the United States, the fact is that public health agencies have been fiscally starved here for decades. Now, with the H1N1 virus looming, the federal government is madly trying to fund development of a vaccine, but seems to have overlooked the fact that in many areas, the public health infrastructure may not be there to provide the vaccinations — and many private providers don't do it for free.

Frankly, I have grown exceedingly tired of policymakers and pundits yammering about prevention and public health while they continue to shovel money toward the back end of illness — emergency departments and such — and scrupulously ignore or underfund proven interventions that can prevent disease in the first place.

All the pretty buildings in the world don't matter if you don't have qualified personnel. Cambodia lacks a sufficient supply of skilled clinicians, but that's hardly unique. There are not enough primary care physicians in the United States, not to mention some other specialists, and don't get me started on dentists. And if you are uninsured or have Medicaid (or, in some cases, Medicare), good luck getting in to see any kind of practitioner — sometimes even in to federally qualified community health centers.

The dentistry situation is complex and has much to do with a paucity of dental insurance. The primary care situation is more easily explained: Organized medicine, medical education and third-party payers have consistently shown the backs of their hands to primary care practitioners and those who seek to join them. These physicians are underpaid, underappreciated, denied research and association opportunities, and overworked. No wonder nurse practitioners are flooding into the field; it's wide-open.

Cambodia also teaches us that health care workers should be paid decently, treated decently and have access to continuing education. That standards for competence should be reasonable and should be enforced. That indifference to patients is not acceptable. And that those who toil in the challenging vineyards of difficult patients, intractable chronic disease, isolated rural settings and unappreciative organizations should be celebrated, not treated as stepchildren.

If all else fails, try planning. In his searing memoir of the KR years, Dr. Haing S. Ngor provided an important insight. Writing about yet another KR blunder — pulling prisoners out of the rice fields before the crop could be harvested — he observed, "It didn't surprise me that they were doing it. To me, the only question was whether they were doing it to kill us intentionally, or whether they were doing it by mistake. For if there was one thing sure about the Khmer Rouge, it was that they knew nothing about planning. They were always starting projects but not finishing them, then going on to the next."

Gee, that sounds familiar. The United States took a stab (some would use that term literally) at health planning in 1972, with, shall we say delicately, varying results. Some planning agencies took their jobs seriously; others were little more than a joke. Most institutional providers hated the planning agencies and certificate-of-need laws, and were generally successful in beating them into submission. What was supposed to be a planning statute morphed into a cost-containment campaign. Just about everyone except diehard planners were probably relieved when the thing was allowed to die less than a decade later.

But the fact remains that when no one is overseeing a health care system, unfortunate things happen. There are too many specialty cardiology and orthopedic hospitals in too many places. There are too many "medically underserved" areas. As I have written previously, the town of Gilbert, Ariz., has far too many hospitals while Gary, Ind., which has the same population, has only one — and it wants to move. The 1970s planning experiment did not work, but the Wild West approach we have taken since isn't any better. At least the Cambodian Ministry of Health has a master plan and has set priorities, daunting as it will be to see it all through.

Success requires innovation and an understanding of risk. All the rhetoric aside, most U.S. health care folk are perfectly happy to think and work inside the box — sometimes a very small, comfy box. Cambodian health care providers and those who serve Cambodian-Americans don't have that option. You can't apply the usual techniques to a 60-year-old whose entire family was massacred before her eyes. You can't railroad people into mental health services when they deny that anything is wrong. New techniques, new approaches, new thinking must be used — and the entire system must be flexible. Stuff happens. Influenza. AIDS. (Does anyone remember the original rigid, inflexible reaction to the HIV epidemic in the early days, and the eventual development of compassionate, flexible and effective responses?)

Really good health care systems are innovative, responsive and flexible. Nothing can be set in stone in this sector. But the corollary is that not everything will work. There have been disastrous experiments in the past, and there will continue to be. That is the price of innovation. Those who wish to move the system forward must have, in the words of transplant surgeon Denton Cooley, "the courage to fail."

Social factors are as important to good health as clinical care. Bacteria, viruses, cancers and injuries are not the only enemies. Poverty, malnutrition and poor diet, unsafe water and food, lack of sanitation, substandard housing, overwork, racism, and other factors can ruin health just as thoroughly as HIV. Inspecting the home of an older person living alone for possible sources of injury such as electrical wires that can trip her is far more cost-effective than replacing the hip that was shattered because the home was not checked out. Somehow, social risks and clinical risks must be addressed in a harmonious and mutually nonthreatening way.

Access must be a reality, not a concept. Several key questions about access to care should be at the forefront of policymakers' discussions. The first, and most obvious, is: Access to what? Which services should be readily available, and for whom? And who should decide?

Second, theoretical access and real access are two different things, both in Cambodia and in the United States. Many hospitals claim to have open doors, but those doors have real good locks on them for some patients. Many physicians follow suit.

Third, the Cambodian experience reinforces the fact that there are always tiers of care. They are inevitable. All I ask is that care in the bottom tier be of sufficient quality, and that access to that lowest tier not be compromised by financial barriers. A corollary is that privatization of public providers should preserve access for vulnerable populations, which has not happened in either Cambodia or the United States. If we wish to declare as policy that there is no right to health care and that if you don't have the money, you can die in the street, then let us do so, rather than continuing the bitter farce of privatizing public facilities and expecting them to behave as they did when they were in the public sector.

Fourth, allocation of resources to various health care entities should follow need, not desire or presumption, and should be at least vaguely fair. Neither Cambodia nor the United States has distinguished itself in this regard.

Health education of the population is essential. Many people in Cambodia and in the United States who are HIV-positive or diabetic don't have a clue that they are ill. In Cambodia, illiteracy and ignorance, as well as a fear of "bad news," explains much of this, along with poverty, a poor communications infrastructure and the lack of public health outreach. In the United States, we hardly have such excuses, yet the same problems persist. But the exemplary efforts of the Cambodian-American programs I have described here (and there are equally laudatory programs for most minority groups in this country, from Somalis to gays) demonstrate that successful outreach is possible.

Yes, it takes hard work. It must be culturally sensitive. It should be driven by epidemiology and not the desire of a pharmaceutical firm to push a given medication. And it must employ a variety of approaches; in Cambodia, 20 percent of the men and 40 percent of the women are illiterate. As bioethicist Judith Swazey recently told me, "The oral interaction is always more important than the written interaction." Information must be conveyed in any way that works. At the Social Health Clinic in Phnom Penh, one AIDS awareness approach uses an embroidered quilt, quite in keeping with Khmer tradition. Doing this right, however, takes time, and that means that physicians, nurses and health educators must be paid for taking that time to teach patients.

Meaningful oversight is crucial. In an earlier episode of the television show Law & Order, Assistant District Attorney Jack McCoy (yes, he's the DA this season, but he wasn't in that episode), asserts that "Man has only those rights he can defend." In health care, someone must defend the rights of patients, providers and the population at large, and that duty cannot be assigned to lay people under the guise of "consumer-directed health care." If we have learned anything from the ruinous legacy of a do-nothing Securities and Exchange Commission and greedy corporate boards and executives, it is that corruption, incompetence and indifference are not victimless crimes.

One of the best ways to keep track of what is going on is collection and evaluation of data — and acting on what is learned. It is definitely worth the investment; otherwise, how will we know that what we sought to achieve actually happened? And how the program can be modified to perform better?

In Cambodia, many proposals and plans have been put forward that have not yet seen fruition. In the United States, it is not very different; we love to pass laws and enact regulations, but we rarely go back to find out if they were effective. Let us hope that we do not repeat this sad experience with health care reform.

Many decisions have a long tail. The U.S. bombing of Cambodia that began in 1969 is still having repercussions in that country. Similarly, as reform advocates in Congress and the Obama administration promote the model of medical group practice and integrated health care systems, the American Medical Association's decades-long fight against that model, and against prepaid capitated health insurance, lingers as a palpable ghost. In many places, the infrastructure isn't there and will have to be created.

Health policy decisions made decades ago — the creation of Medicaid and Medicare, the choice to rely on market forces, the preference of most physicians for self-employment in small settings, the way providers are reimbursed — continue to influence how just about everything in health care goes. These are not one-time incidents; they are precipitating events whose legacy echoes down the years.

Hiding or ignoring history only allows us to repeat the mistakes of the past. The story of the Cambodian horror (and that of Jews and Gypsies at the hands of the Nazis, and of Armenians at the hands of the Turks, and the people of Nanjing at the hands of the Japanese in World War II, and the Bosnians, and the Rwandans, and those in Darfur, and all the others) should not be forgotten. Yet these stories could slip through the cracks of history.

With most of the population of Cambodia so young and unschooled in what happened, the lessons could be lost. In a New York Times story published earlier this year, Seth Mydans tells of "widespread ignorance" of the holocaust. Indeed, some analysts fear that a KR-type dictatorship and genocide could happen again. (Cambodia and Thailand have been involved lately in some border skirmishes over contested real estate, and former KR soldiers have volunteered to go to the border to fight. I watched a Cambodian friend read about this — a man who survived the KR, although several of his family members did not — and although he is a quiet, disciplined and self-contained person, I know fear when I see it. The idea of rearming the KR terrifies many Cambodians.)

Yet most of the young are unaware even of the war crimes trials of a few KR leaders taking place in Phnom Penh — and many who know don't care. It is ancient history to a teenager. And the country's prime minister, Hun Sen, a former KR officer, has publicly opposed the trials and has suggested that Cambodia "dig a hole and bury the past." At the same time, children in rural areas who discover the bones of victims of the KR — which are still turning up, even after 30 years — call them "the skulls of ghosts." People still leave offerings for them.

Are we so different? Historian Arthur Schlesinger Jr. described the United States as "an essentially historyless nation" — and we are. Those who founded this country did not want to be victims of oppressive tradition or prisoners of the past. The price we have paid for that, however, is that we do not learn from what went before, and we repeat our mistakes. A hundred years of health reform efforts have failed. That is not only due to powerful special interests or the messy processes of democracy; it is also the result of our refusal to heed the lessons of the past.

Heroes and Hope

The last lesson is about heroes. In its groundbreaking 1999 report on failures in health care quality, the Institute of Medicine made an enormous point of stating that it is systems, and not individuals, that fail. Efforts to improve quality and patient safety, the IOM urged, must be rooted in systemic change. Given what I have witnessed in both Cambodian and U.S. health care, I could not agree more.

But that is not the whole equation. While we tinker with our systems and try to enact meaningful change in the face of conflicting agendas, ingrained resistance and fear of the unknown, there are heroes among us who go about changing the health care world in small ways, day by day, person by person.

In Cambodia, they are people like Dr. Yos Phanita and Dr. Mean Chhivun, working within a difficult bureaucracy to improve quality of care and access to services. They are also people like William and Lori Housworth, both physicians with master's degrees in public health, who, like many of us who have been there, fell in love with Cambodia and its people and eventually packed up their three kids and moved to Siem Reap. She provides clinic services to the poor, although soon she will be supervising the new clinic in Dam Daek; he runs the premier children's hospital in the country. Their housing is substandard, their days are long, their challenges constant. Their view? "When you give yourself away, you really do get so much back. You have so much joy," Lori told the Louisville Courier-Journal in June. I have spent a good bit of time with Bill Housworth, and I have to tell you, he is a fulfilled guy. And he and Lori are emblematic of all those health care folk, Cambodian and foreign alike, who strive to save the lives and health of people in one of the poorest countries on earth, which has suffered far more than its share of hardship.

Elizabeth McLellan is a nurse administrator at a major Maine hospital. She has traveled extensively, and one day she came to Cambodia. Of all the places where she was troubled by obviously inadequate health care, this was the worst. "Oh, my God, it was really amazing," she told the Maine Sunday Telegram in June. "They had HIV everywhere, tuberculosis everywhere, and nothing, no supplies whatsoever. And it was filthy dirty." She subsequently founded Partners for World Health, through which medical supplies that have not been used or even opened but have been disqualified for use in the United States because they were taken into a patient's room, are distributed in the Third World. When she travels, she takes as many as 20 duffel bags filled with supplies; most airlines allow her to check them for free. "We nurses hate what we throw out," she told the newspaper. "And we know we can use this somewhere in our world. There is no reason why the people of Ethiopia shouldn't have the right to a sterile syringe." The leaders and staff of the hospital support her every way they can.

These heroes are everywhere, from a former monk in Chicago who tries to cajole traumatized Cambodian refugees to seek help, to all those in both countries who do the extra thing, work the extra hour, extend the helping hand. They don't have to do this. Heroes aren't required to be who they are. They are the gifts among us. And wherever they go and whatever they do, they bring hope to us all.

And so, while we try to figure out how to shift our systems and create new ones and improve quality and engineer access for everyone and how to pay for it, as we dream our big dreams and craft our proposals, I have a simple request: While we are busy with all that, could we support and protect those heroes who are moving health care forward while the debates go on and on in the halls of power? Can we not recognize and enhance the work of people who got tired of waiting for the world to change and decided to do it themselves? Can we remove ourselves from our own egos and our own preoccupations long enough to understand that in health care, whether here or along the Tonle Sap River half a world away, success is always measured in persons as well as statistics? And that health care, no matter where it is offered, is always about persons?

In the meeting room of the Social Health Clinic in Phnom Penh, I noticed a couple of jigsaw puzzles on a side table. Given that the room is used by support groups of patients with infectious diseases, this was hardly surprising. But there were a few pieces missing from both puzzles.

There are also pieces missing from the health care systems of both Cambodia and the United States. Let us hope that we can find those pieces and put them in the right places, so that our puzzles will at last be solved.

Acknowledgments: Again, my thanks to the people who shared their expertise, opinions and time with me, both in Cambodia and in the United States. My thanks, too, to all those who reviewed these articles, especially Marty Arizumi and Maria Friedman.

Copyright ©2009 by Emily Friedman. All rights reserved.

Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Weekly. Contact Promenade Speakers Bureau, LLC to book her to keynote your next event.