HEALTH AND HEALTH CARE IN CAMBODIA

HEALTH IN CAMBODIA

Life expectancy: female—65 years; male—57years in 2009 (Compared to 82—female and 76—male in Japan and 47-female and 42-male in Guinea). "Life expectancy" is an abstract and complicated concept a complex formula that attempts to predict the lifespan of children born today by subjecting a hypothetical child born today to the current risk of dying in each bracket he or she mature through until, in effect, the accumulated risk of death is 100 percent. In the 1990s, Cambodia was one of the few countries in world with a disability-adjusted life expectancy lower than 45.

Cambodia’s infant mortality rate, despite improvements in recent years, still places it in the bottom 10 percent worldwide, according to the most recent U.N. figures — 158th out of 194 nations. Probability of dying under five (per 1 000 live births): 43. Probability of dying between 15 and 60 years m/f (per 1 000 population) 350/190. In the 1990s, the average Cambodian died before the age of 50 and almost 20 percent of all children died before the age of five—12 percent before the age of one. [Source: World Health Organization, Contact information WHO Representative in Cambodia: van Maaren, Dr Pieter J.M., PO Box 1217 Phnom Penh, Cambodia. Tel. +855 23 216942, fax: +855 23 216211. E-mail: postmaster.cam@wpro.who.int ]

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. [Source: Library of Congress, December 1987 *]

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. *

In the 1990s, malnutrition was worse and more widespread in Cambodia than in North Korea. The average calorie intake in Cambodia at that time was 1,890 compared to 2,390 calories in North Korea in the famine years. According to a United Nations study, half the children under five in Cambodia's poorest rural areas had their growth stunted by malnutrition and 20 percent suffered from acute malnutrition. Among upper-income children under five, 36 percent were moderately underweight and 21 percent were stunted. Breast feeding immediately after birth is considered taboo, and infants are therefore deprived f highly nutritious colostrum or first milk.

Health Care

Health expenditures per capita: $121 in 2010. Total expenditure on health as percent of GDP (2010) 5.6.

Traditionally half the budget has been spent on security while virtual nothing went to education and health.

The health care system is inadequate. In he 1990s some hospitals had no running water and Health officials used elephants outfit with loudspeakers to announce polio vaccination campaigns.

History of Health Care in Cambodia

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 still as high as 50 percent.

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.[Source: Library of Congress, December 1987 *]

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. [Source: Library of Congress, December 1987] 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. *

Health and Health Care Under the Khmer Rouge

Health facilities in the years 1975 to 1978 were abysmally poor. Many physicians either were executed or were prohibited from practicing. It appears that the party and the armed forces elite had access to Western medicine and to a system of hospitals that offered reasonable treatment but ordinary people, especially "new people," were expected to use traditional plant and herbal remedies that usually were ineffective. Some bartered their rice rations and personal possessions to obtain aspirin and other simple drugs.

Clinics and hospitals had no medicine and no doctors—they had all been shot. Some people were able to treat themselves with medicinal plants they gathered in the forest. Patients were treated by acupuncturists with three days of training. Francios Bizot wrote in The Gate , “I saw an acute era infection treated by pushing a needle several centimeters inside a prisoner’s ear. Anyone who was ill was nevertheless bound to consult them, as evidence of his unshakable trust in the revolution.”

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. [Source: Library of Congress, December 1987]

Getting Sick and Dying in the Khmer Rouge Years

The survivor Sok Sunday reported: “Most distressingly, a few days after the death of my younger sibling, the village chief summoned my father and other new people of about the same age to make biographies. My father told the village chief the truth that he was a former naval captain at Chroy Chanva. Other people also told him exactly about their former occupations. Three months later, my grandfather began to get sick. At first it was minor, but this barbarous regime did not have medical care. He later died. The village chief told us to bury him. We had no coffin to put him in, we had only sleeping mat to wrap his body. In just three months, three people in my family had perished.[Source: from petition was forwarded from the UN’s Cambodian Office of the High Commissioner for Human Rights, Documentation Center of Cambodia, d.dccam.org/Survivors/38 # ]

“Five days passed, my younger (three-year-old) sibling drank unclean water, which caused vomiting and diarrhea. My parents brought my sibling to the sub-district hospital, but as the hospital had no medicine, my younger sibling died soon after being brought back home. Later they evacuated my family to Battambang province by boat. After staying in Ponhea Leu pagoda for two or three days along the way, a few trucks arrived to take evacuees waiting in the pagoda to a train station to Battambang. Because my uncle had paralyzed legs, they said that the journey required some walking after the train journey and no one would be able to carry him a long way. They told us to unload our belongings and stay. We waited many more days for a boat to bring us back to the village we left. In the pagoda, they let us stay in an abandoned, unwalled coffin storehouse with no bed. We slept on the ground and as we looked up we saw scary coffins stored on the attic. #

“Days passed and we were running out of food. We collected plants to make salted rice soup. When the boat arrived, we were all sick, unable to get up, except my grandmother, who at the village took thin rice soup from the cooperative kitchen for us. My crippled uncle and grandmother’s older sister were unable to recover and had serious diarrhea without medicine. They died soon afterward. Before we gained full recovery, unit chiefs called my mother and two uncles to dig a water channel and fetch water for the workers at the work site. The water source was 7 kilometers from the village and we did that everyday. #

“In mid-1978, my two uncles fell ill with knee injuries. The Khmer Rouge accused them of pretending to be sick to avoid working, so they took them, along with other four or five patients, to be killed at Prey Sva pagoda. This pagoda was a large killing field where people of all age groups, male and female, were brought from other provinces and ruthlessly executed. Execution tools consisted of a long knife, a hoe, and a bamboo pole. There were 30 to 40 mass graves containing 20 to 30 bodies each. In around September 1978, as the pagoda was flooded, the bodies swelled, pushing up from under the shallow graves. Dogs tore and ate the rotten flesh. #

Medical Treatment Under the Khmer Rouge

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." [Source: Library of Congress, December 1987 ]

The survivor Sok Sunday reported: “One day the cows became agitated and pulled the rope through my palm. The rope cut through the corner of my thumb and the wound bled heavily and I cried. I was all alone and had no medicine. I urinated on the cut to prevent it from getting infected. Then I tied the ropes around my wrists and walked back to the village.[Source: from petition was forwarded from the UN’s Cambodian Office of the High Commissioner for Human Rights, Documentation Center of Cambodia, d.dccam.org/Survivors/38 # ]

“When we arrived at the cooperative kitchen, the chief’s son called out two women to Kaos Khchal me [a.k.a. dermabrasion - a traditional Khmer way of curing fever and faintness by scraping one’s skin with a coin until the skin becomes red]. One woman kept me from moving, while the other scraped my back like a butcher scrapes fur from the skin of a pig. My body became red [as if whipped]. Afterwards, the chief asked, “Are you hungry?” I said yes. Then he took out a bowl of rice with salt. As I ate, he rested one leg on my chair and asked, “How is rice with salt?” I told him it was delicious and sweet. Later he let me tend only two cows. I brought my cows to higher ground and no longer fed them on farm dikes, nor did I let go of the rope. #

Health Care After the Khmer Rouge

The public health service was functioning again in the mid-1980s, and modern medical services were available although trained medical personnel and some medicines continued to be in short supply. The shortage of medical personnel was partially filled by foreign doctors and technicians.

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. [Source: Library of Congress, December 1987 *]

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. *

NGOs Transforming Health Care in Countryside

Celia Dugger wrote in the New York Times, “In Cambodia, the NGOs- all of them international- are instilling discipline and clarity of purpose in a health care system enfeebled by corruption, absenteeism and decades of war. They have introduced incentives to draw Cambodia’s doctors and nurses back into the system. Patients, especially the poorest, have followed in droves. Today, international donors provide about two-thirds of public spending on health and over the years have financed the construction of hundreds of hospitals and clinics. But money and buildings alone were not enough to overcome a bureaucratic culture afflicted by favoritism and lackadaisical accountability. [Source: Celia Dugger, New York Times, January 9, 2006 **]

“The Health Ministry began testing the use of contractions in 1999. Then, the main hospital in the Pea Reang district was a crumbling shell. Six years after it was turned over to Health Net International, based in the Netherlands, Pea Reang’s hospitals and clinics now see thousands of patients a week. In just the first nine months of 2005, more than half the district’s 200,000 people sought care. **

“The five NGOs running parts of the health system, Health Net and Save the Children Australia among them, are paid based on their performance in improving services. With additional support from the British and the World Bank, the government recently expanded the approach to cover one in 10 Cambodians. Districts managed by the NGOs have been much more successful in improving health services than districts run by the government, a World Bank study found, though both have made progress. **

“The Health Ministry began testing the use of contractions in 1999. Then, the main hospital in the Pea Reang district was a crumbling shell. Six years after it was turned over to Health Net International, based in the Netherlands, Pea Reang’s hospitals and clinics now see thousands of patients a week. In just the first nine months of 2005, more than half the district’s 200,000 people sought care. **

Setting Up an NGO Hospital in Cambodia

Celia Dugger wrote in the New York Times, “ changes took time. For years, Dr Fred Griffiths, the 54-year-old Pakistani who runs the Pea Reang district for Health Net, said he saw most of this operating budget from the government skimmed off as it made its way through layers of bureaucracy. ” At least 10 percent of the budget just disappears, ” said Sao Chhorn, who then monitored the contracted districts for the Health Ministry, and now works for a consulting firm. ” and this is the best situation. In the worst situation, almost all of it disappears.” [Source: Celia Dugger, New York Times, January 9, 2006 **]

“Dr Griffiths found himself in the worst of situations, and the did not take it quietly. “We screamed at workshop and conferences, wherever there was a forum, ” he said. I as year, to his relief, the government began transferring the funds directly from the national treasury to the contractors. But his toughest job was motivating the staff. The government paid just $20 a month to a doctor, and $15 to a nurse. The staff pocketed the paltry government salaries and spent almost all their time operating private practices. **

“Not surprisingly, there were almost no patients at the district hospital in Snay Pol, a three-hour driver from Phnom Penh. Sokong Lim, 34, then a paramedic, said he saw only two patients come for treatment in the two years before Health Net arrived. But he also admitted that he was usually working at this own clinic. “Nobody was willing to work at that time, ” he said. ” Even the chief of the hospital had his own business.” **

“The hospital itself was like a stolen car stripped of its parts. Dr Griffiths said the equipment had simply disappeared, probably into staff members’ private practices. Dr Griffiths decided to use part of his contracting budget to supplement his staffs’ pay. Pea Reang also introduced small fees, charging $0.25 to see a doctor and $0.75 for a day’s stay at the hospital.Health Net used the revenues to bolster staff income, paying incentives for punctuality and reaching child immunization targets, and generally instilling a culture of accountability. Despite grumbling, most staff gave up their side jobs to work full time. Nurses now earn $60 to $200 a month depending on qualifications and performance, while doctors make $200 to $250. **

“The hospital under Health Net’s management has gradually won people’s trust. Not least, the district’s newfound credibility, as well as the 24-hour availability of qualified midwives and doctors, has transformed childbirth habits. As far back as anyone can remembers, the women in Reab village have depended only on traditional birth attendants- village women with no formal medical training- to deliver babies. But now more than half the women in the district give birth in a health center, compared with less than 10 percent in Cambodia overall.” **

Health Care Provided by an NGO Hospital

Reporting from Reab Village, Pea Reang district, Prey Veng province, Celia Dugger wrote in the New York Times, “ Sovan Sna had been in labor all night long. By the 16th hour of contractions, she was in trouble. The baby, her first, was not coming out. And she was so exhausted and in such pain she could barely speak. Her mind churned with fear. In Khmer, this most treacherous passage in a woman’s life-child-birth-is called crossing the river. Her aunt had died giving birth to a first child who perished in the womb. Sovan Sna wondered if she and her baby, too, would drown before reaching the other shore. [Source: Celia Dugger, New York Times, January 9, 2006 **]

“Not long ago, Sovan Sna would have had little choice but to give birth at home, like her aunt, and risk both her life and her baby’s. But on this morning, her terrified husband hired a pony cart and was able to take his wife to a small, no-frills public hospital. If childbirth is a miracle of nature, then the thriving, honestly run network of clinics and hospitals here is a human marvel, man-aged not by the government but by one of the nonprofit groups it has hired to run entire public health districts. **

“All our parents delivered at home, ” said Sovan Sna’s husband, Veasna Van, ” Now, nobody does. We believe the health care center can save lives if there is a problem.” Sovan Sna’s birth attendant, Min Heng, 50, agreed. Health Net turned women like Min Heng into some of its best recruiters. It pays the clinic an extra $20 for every woman who gives birth there. The clinic, in turn, pays the attendants a bonus of $1.25 for each woman in labor they bring in. **

“With Min Heng assisting at the clinic, the midwife began to worry that Sovan Sna’s labor had reached a standstill and decided she should be taken to the hospital in Snay Pol, where surgeons and better equipment were available. A half hour later, they arrived at the hospital. Dr Sorny Kong hustled into the birthing room. She started Sovan Sna on a sugar drip to give her a bit of a lift, got out the vacuum extractor and attached the suction cup to the crown of the baby’s head. A half hour later, a healthy boy emerged into the world. **

Health Customs in Cambodia

Keo Mony wrote in “General Etiquette in Cambodian Society,” a guide for health care providers in the U.S.: “Cambodians are considered shy, especially women. It is advisable that healthcare providers consider this when trying to have a frank and open discussion with their patients. Same sex providers are preferred. Preventive medicine is uncommon to Cambodians. Healthcare remains a luxury to many Cambodians who cannot afford it. A long-held belief “if nothing broke, don't fix” also plays a part in Cambodians not utilizing preventive care. [Source: Keo Mony, General Etiquette in Cambodian Society, Sensitive Care Provider Issues, January 21, 2004 /\]

“Cambodians have experiences inconceivable suffering and violence during thirty years of brutal wars. Chronic mental illness has affected many Cambodians. But, culturally, Cambodians are unaccustomed to opening up and discussing their feelings, especially the men, as they think it would make them look weak. They also equate mental illness to craziness. The stigma from being branded as crazy is enormous. Thus, Cambodians are often reluctant to talk about their experiences and their related illnesses./\

“Modern medicines are available and easy to obtain in Cambodia. In fact, no prescriptions are needed in order to purchase them. However, they are too expensive for many people. Counseling is an alien notion to Cambodians whether related to marriage or health, especially counseling offered by a trained or licensed counselor. When advice is needed, it is often sought from a monk, traditional healer/herbalist or the abbot.

Traditional Medicine in Cambodia

Local people often insist that disease is caused by evil spirts. Rather than seek hospital care or see a doctor they hang sacrificed chickens and pigs on forest paths, rub blood and rice wine into their homes, and make straw effigies of swords and rocket launchers to guard their villages and huts. When disease eventually stops villagers often credit that to a big ceremony in which many villagers were present and ate meat and blood and wine and then retreated to their home to their homes for 24 hours to allow the spirts to imbibe. Breast feeding immediately after birth is considered taboo, and infants are therefore deprived f highly nutritious colostrum or first milk.

Keo Mony wrote in “General Etiquette in Cambodian Society,” a guide for health care providers in the U.S.: “Traditional healers or herbalists (known as “kru-Khmer”) and laymen who arrange religious healing ceremonies (people known as “aa-jaar”) have the respect of the community. They are considered leaders in the community. Many Cambodians still depend heavily on traditional healers and traditional or herbal medicines for treatments of all kinds of illnesses. Traditional medicines are made out of roots, barks and animal bones. They are believed to cure a wide variety of illnesses, even AIDS. No regulations govern traditional medicines. In the U.S., many Cambodians still use the traditional medicines with which they are familiar. They are available in many grocer stores or sent over from Cambodia. [Source: Keo Mony, General Etiquette in Cambodian Society, Sensitive Care Provider Issues, January 21, 2004 /\]

Many Cambodians blame disease on supernatural spirits or emotional problems. Many Cambodians seek treatment from kru faither healers for physical and psychological problems. Treatment include folk medicines and Chinese procedures such as moxibustion conducted by kru healers. Tea brewed from the lotus seed is used to reduce fever. Boiled and dried lotus flowers is said to help induce labor in pregnant women. Bat meat is considered a delicacy and blood is used to cure cough.

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. [Source: Library of Congress, December 1987]

Mirrors Ease Cambodian Amputees' Phantom Pain

Reporting from Kampong Chhnang, Michelle Fitzpatrick of AFP wrote: “Pov Sopheak lost his left leg in a landmine blast in 1990. Yet some nights the pain in his "left foot" is so bad he cannot sleep. Like many amputees, he suffers from phantom pain. Now, after two decades of agony, the Cambodian is embracing an innovative technique that promises relief simply by using a mirror to trick the brain into "moving" the missing limb, allowing the pain to subside. Sitting in a chair and holding a full-length mirror against his leg, Sopheak, 50, smiles self-consciously as some two dozen physical therapists gather around him. [Source: Michelle Fitzpatrick, AFP, February 27, 2012]

It is their first mirror therapy training session at the Cambodia Trust, a rehabilitation charity for amputees in the central province of Kampong Chhnang.But Sopheak visibly relaxes as he follows the instructions of visiting Canadian trainer Stephen Sumner to wriggle his right toes and keep his eyes on his foot's reflected image, super-imposed on the missing one."It's a new sensation. It's strange but in a good way," the former soldier, who now works as a security guard, told AFP. "I see my leg in the mirror and I feel happy, like my mind is at ease."

Sumner explains that the reflection of the intact limb can fool the brain into "seeing" two healthy legs, allowing it to once again send command signals to the phantom leg -- signals that would previously come back distressed because the limb was missing. "Looking in the mirror, the brain suddenly enables you to move your phantom foot and do everything the real foot is doing," said Sumner, 51, who lost his left leg in a hit-and-run motorbike accident eight years ago. "The brain just wants to be tricked. It's dying for release."

The theory, which also works to ease phantom arms out of painful or cramped positions, was developed in 1995 by neuroscientist Vilayanur S. Ramachandran from the University of California, San Diego, named as one of the world's most influential people by Time magazine in 2011. The neurological trickery also reached a wider audience after it featured in a 2009 episode of "House", a popular US medical drama. But it is still largely unknown in Cambodia, a small country with tens of thousands of amputees as a result of traffic accidents, disease and, in most cases, landmines left over from decades of civil war.

Phantom pain is thought to affect around 80 percent of all amputees and there are no drugs that can cure it, but Sumner stressed that the mirror method was not a quick fix. Sumner, who says his own bouts of phantom pain felt like "lightning bolts through my foot", is determined to spread the message. Backed by the Canadian non-profit End The Pain Project, he is training dozens of physicians and amputees across Cambodia and, crucially in this impoverished nation, handing out free mirrors -- full-length ones for legs, half-length ones for arms. "Mirror therapy won't cure you immediately. You have to keep at it for at least four weeks," he told the Cambodia Trust therapists, recommending two 10-minute sessions a day of flexing one's hand or foot. It could even help double amputees. "Even a simple prosthesis on one limb can work in the mirror. Even that's enough. The brain wants to be healed so much," Sumner said.

Sopheak said he hoped to keep up the routine and finally ease his suffering, which he said "feels like my leg is shaking" followed by a sharp pain in his phantom little toe and big toe. Until now, he has tried to deal with his pain with diversions such as drumming or singing, by massaging his stump or by taking the occasional pain killer, to little effect.

While experts say mirror therapy can be a useful tool for many amputees, Altschuler, an associate professor of physical medicine and rehabilitation at the New Jersey Medical School, said it was important not to give "false hope". "Nothing works for everybody," he said."The mirror is very helpful for movement-type problems like spasms or a clenched fist. It does not work for burning pain, for instance."Still, Altschuler, who has just returned from training physical therapists in Haiti, said he was pleased the technique had reached Cambodia. "It has the potential to have tremendous utility," he said. "Mirror therapy is inexpensive and easy. Patients can do it by themselves, allowing them to take control of their own health. Any mirror will do."

Image Sources:

Text Sources: New York Times, Washington Post, Los Angeles Times, Times of London, Lonely Planet Guides, Library of Congress, Tourism of Cambodia, Compton’s Encyclopedia, The Guardian, National Geographic, Smithsonian magazine, The New Yorker, Time, Newsweek, Reuters, AP, AFP, Wall Street Journal, The Atlantic Monthly, The Economist, Global Viewpoint (Christian Science Monitor), Foreign Policy, Wikipedia, BBC, CNN, NBC News, Fox News and various books and other publications.

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© 2008 Jeffrey Hays

Last updated May 2014

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