Berkley Center

Background: Cambodia’s health system has changed dramatically since the destruction wrought by the Khmer Rouge era (1975-79); in the early 1980s, only ten Cambodian doctors were practicing in the country. Non-governmental organizations (NGOs), many with religious affiliations, played vital roles in serving people as the country was rebuilt. They are still significant today, though in the very different climate of a fast-growing economy with a government rapidly rebuilding its capacity to serve the population. Among the NGOs is the medical center and trauma center operated by The Handa Foundation, where Dr. Simon Stock oversees training and surgery operations as a volunteer. He also visits rural communities regularly with a mobile clinic. During a visit to Battambang, Katherine Marshall met with Dr. Stock and discussed his motivations for serving in Cambodia, the challenges he faces, and his appreciation for the changing demands and future prospects of NGO work and health care in Cambodia.

How did you come to be working in Cambodia?

My wife and I and our whole family moved here [to Battambang] in 2012. Why is a long story. We're Christians, and my son became a Christian in 2010, through a very dramatic experience. He'd been studying at university and had been back and forth to Cambodia in his gap year. He then kept going back for all the wrong reasons: girls, parties, drugs, everything else. We'd been out to Cambodia as well, before then. And my wife came to Poipet in 2006 to support a friend visiting an NGO that was working with people living on a rubbish dump. So, she'd had some exposure to Cambodia. But neither of us had any inkling that we would ever work here.

When you say your son became a Christian, what did that involve? Did he join a specific denomination?

He was born again. We were at a Baptist church, but that's not important. I was brought up in the Church of England, but in a very low Anglican church. My wife became a Christian when she was in her early 20s, and we've been through various communities. We're not bothered by denominations, particularly. We always felt we should worship at a church near our home. Sometimes it is Methodist, sometimes it's Baptist, sometimes it's Anglican, whatever.

My son felt very strongly that God was calling him to come out to Cambodia to work, and he moved to Poipet just about two weeks after his conversion All sorts of things fell into place around that. Six months earlier he'd sent an email to someone at a Cambodian-run orphanage, inquiring about doing some voluntary work, but heard nothing until the pastor contacted him the very night after he became a Christian. He had found the email just checking through his spam and sent a message saying "Come out, there's lots you can do." My son worked there for a while then turned to learning the language on his own; he’s very gifted with language skills. Then he started to work with YWAM (Youth With A Mission). They have a big base in Battambang. He he did the DTS (Discipleship Training School) in Phnom Penh, and then he went to the School of Biblical Studies, a nine-month program that goes more in depth into biblical studies. Then, he began to teach in the same course. He met a Khmer lady and they married. His plans were to stay in Cambodia.

We visited him in Battambang a couple of times during this period, just as family. But my wife felt that God had begun to call us to come back to Cambodia to work. At first, she brushed this aside as it did not seem at all the right thing. Many things were preventing us from moving: mortgages, a daughter who was heavily involved in equestrian events professionally, all the usual family stuff. I had a permanent job. We also thought the last thing Jonathan, our son, would want, was for him to move halfway around the world and have his family follow him out there.

But the feeling became stronger and stronger, and my wife and I thought about it, prayed about it, and felt that this was a genuine call. And gradually, one by one, all these issues got resolved. One of them was obviously our son, because he didn't know at this stage, that we were thinking along these lines. He phoned up one day and said quite out of the blue, "You know, it'd be amazing if you and Dad could come out here. There's so much you can do." That put another tick in the box. A whole series of events like that came about.

What were you doing before that?

I was working as a surgeon in the Isle of Man, a little island between England and Ireland. I had a full-time job there, and I wasn't retirement age. In the end, I took an early retirement to come to Cambodia. Basically, we sold up everything and moved out here. We didn't know even a few weeks before what we would do when we got here. We just knew here was where we should be.

Then, Lynnette was looking on the Internet and stumbled across The Handa Foundation website; they were advertising for a general surgeon. I emailed Kevin O’Brien (the executive director of The Handa Foundation), and it just happened that he was going to be in London the same three days I was doing a course there, with Christian Medical Fellowship, that was for people like me, who are going abroad to work in missions. It's a refresher on stuff that a surgeon doesn't normally do, like pediatrics, OB/GYN, tropical medicine, and so on. Kevin and I got talking; I had not known until then that he was a Christian. He urged me to come and have a look around when I got to Battambang, about five to six weeks later.

So, we moved out here. I went to the hospital, found out more about it, and the fit seemed perfect. I look back in some horror at my ignorance of global medicine. I had doubted what use a surgeon could be somewhere like Cambodia, but I very quickly realized that it was quite the opposite: there's a huge need for surgeons. We agreed that I would work half time at the hospital, because there were other things I wanted to do. I've been there ever since.

The other half of the week, we do community health work. It is very heavily supported by The Handa Foundation and the trauma hospital they manage. Nominally, that work is under the auspices of The Handa Foundation, though we have pretty free rein to organize it the way we wish. We get a lot of our medicines through the hospital pharmacy, and some of the staff sometimes come and help. We've built up a network of about seven or eight communities we go to on a rotating basis. We have been invited to go into each one. We've always looked for places that don't have an existing health care facility and where other organizations are not working.

The father of my daughter-in-law was in Battambang during the Khmer Rouge period. Basically, he survived by hiding in the jungle and moving from place to place. Many of the places where we work are the communities where he stayed during that era. He knew people and introduced us to them. We got to know some others in different ways; we work with a Khmer NGO in two of the villages. We met the executive director quite early on when we moved out here and were introduced by a person locally. They're involved in education, particularly for vulnerable children. We started working alongside them at the school, but then expanded into the community.

How do you see the work at the hospital fitting into the development of health care in Myanmar?

The question is always how to make such ventures sustainable. That's the most difficult challenge as far as the hospital is concerned. The long-term view is to try and integrate the hospital into the government health scheme somehow. One idea we have talked about is whether it could remain a fairly specialized trauma or orthopedic center, but run by government. There is a precedent with the children's hospitals in Phnom Penh and Siem Reap, founded by the Kantha Bopha Foundation. It was set up by a Swiss organization, and they've handed the hospital over now to the government to run. So, it can happen. However, it's quite tricky to preserve standards at the same time the facility is transferred.

There's still a huge gap between what you'd like and what you get, in terms of the government health system. The provincial health department knows what we're doing and is quite happy. We would like to try and integrate or involve the rural health facilities in due course. But, because we've deliberately chosen places that don't have easy access to health facilities at the moment, it's difficult for the people to get to the health centers. The further out you go, the less inclined, generally speaking, government is to be involved. They're understaffed, they're probably underfunded, and the motivation isn't always as good as it might be. There are notable exceptions: we have come across one health center where they already do outreach to villages around. It is just a rural health center, but they had a map of all the communities and visit them. It can be done, and that's what we would like to work toward.

But, at the moment, what we're doing is trying to educate the communities to take a bit more responsibility, to empower them to look after their own health. We've been quite involved in diabetes and hypertension; we do a lot of screening in cooperation with BASAID, a Swiss-supported organization linked to Novartis. We work to educate people in the communities, as health care workers, ultimately, or just as slightly more expert patients, so that they can begin to look after themselves and each other. Part of that is financial planning, so they put a bit of money aside to pay for medicine. At the moment, we subsidize what we provide: we don't charge for medicine. But that's obviously not sustainable in the long term. We've looked at revolving drug budgets, for example. You involve a local shop or pharmacy and do a deal, whereby they sell their medicines at a small profit in return for a guaranteed volume of patients. We agree to send all the patients to them for their medicines. We're looking at it as an option.

How do your clinics work?

We go out about every two months to each community and do a clinic. We serve whoever comes to the clinic. We have a truck and supplies, so it’s a mobile clinic. We have somewhere in each community where we meet, either in a school or even under a tree. One community is Muslim and there we meet in the school attached to the mosque. It depends on the community. They know we're coming, as we've been going for five or six years to most of them. So, they don't feel they've got to come and get as much as they possibly can, because they know we're going to go back. Which has been some help. At the start, people would just come and want as much medicine as they could possibly get. Several of the communities have had short-term visits in the past from NGOs. But we've always said it was going to be a long-term project. But we're still not in a position where we can withdraw, unfortunately. Obviously, that's our aim ultimately.

We have a Khmer doctor who comes out with us a lot of the time. He's very motivated, and he also works with me at the hospital in surgery. Another, unfortunately, kind of lost interest a bit. Other staff have expressed an interest in coming. So, we hope that we will be able to get some Khmer staff involved, which would then make the transition to the government system easier.

How many communities have you managed to reach this way? And how do you prioritize which communities to reach?

We're a very small organization, and we're just scratching the surface. There's a huge demand. And we don't go to the furthest flung communities because of time constraints. If you go up near the Thai border and into the forest, many communities have very, very little provision at all. There are certainly many other places where something needs to be done. But until the government shows a bit more willingness to spend the money on community development, it's very difficult to see how it's going to work.

In terms of priority, so far, we've really just worked in the countryside. As it is elsewhere, the divide between urban and rural communities is enormous. You go a few miles away from the city, and it's a whole different world. One of the arrangements we've got is that if I see someone in the community who needs surgery, I can admit them to the hospital and do their surgery free of charge. But some of them can't even afford the transport to the hospital. They are very, very poor. A lot of the people are just manual laborers in the rice fields and, often, they are paid only in rice and food. They have very little cash. That’s one reason we have to try to help them learn what to take for medicines, and so on. But it is a slow process.

I've noticed that, compared to some African countries, relatively few health providers in Cambodia have a religious link. Why is that?

No, there are not many. The French set up a quite modern health care system in the colonial days, pre-Pol Pot. I understand it was quite a reasonable health service, although it was a bit centrally driven. But then, of course, the vast majority of the doctors were wiped out during the genocide, so they had to start again from scratch. But I don't think there's been a huge input from the faith-based organizations. There is a Buddhist development organization, though I don't know much about it. I've just seen where their offices are, and so on. World Vision had quite a presence here, but a lot of what they do is not health care. Tearfund is involved, too. They have a partner in Poipet, and I think they do some work in Phnom Penh. But again, I think it's more children's work—vulnerable children rather than health care overall. So, there's very little faith-based activity, I think, in the healthcare sector.

What are the big challenges you're seeing?

Villages are now experiencing a rapid increase in non-communicable diseases. Hypertension is enormously common, largely because of the huge quantities of salt that people consume here. And diabetes is becoming a problem. It's not as common as in the West yet, but it's coming up. There are all sorts of interesting reasons why that is, but one of the big problems is white rice, which is now known to be very damaging as a dietary staple because it's got a very high glycemic index, which means it pushes your blood sugar up and stresses your pancreas.

Has the diet changed to white rice?

I don't know what people have eaten in the past, but they certainly eat rice three times a day and not very much else, because rice fills you up, and if you haven't got a lot of money, you can't afford to get meat or eggs or whatever. Diabetes here is caused by a combination of factors, and Asians in general are actually more susceptible to diabetes. Again, it goes back to Pol Pot. Intrauterine starvation damages your pancreas and predisposes you to diabetes. Based on their age range, the people developing late-onset diabetes now are very much those who would have been born at or about the Pol Pot period. So we think that is part of it. We've seen a similar effect after World War II among the children of concentration camp survivors. They have a higher risk of diabetes, same problem. So, it's not just a Cambodian thing. But of course it has affected so many people here, that it has had a bigger impact. That's one of the issues, and, of course, because you need long-term medication for diabetes, that becomes a problem with finance.

My son-in-law is involved in clean water provision, and that ties in with what we do. He works in the same communities and we have seen an improvement in terms of diarrhea and related illnesses from contaminated water. That's a bit less of a problem now than it used to be. There is some tuberculosis around, not like in India, but it's a significant undercurrent. Fortunately, HIV here is not a massive problem; the government's been quite successful in dealing with it, generally. There are a lot of musculoskeletal problems and joint problems because of the manual work. People are going out in their mid-70s to work in the fields, and they're wrecked, basically. There are a lot of digestive problems, stomach ulcers, and so on. The upside of that is, that you can, with relatively small interventions, make quite a difference to the working lives of people. And if you can keep them in work, they can continue to earn something. That is a benefit.

You said that a lot of people rely on wage labor. Who owns the land?

A lot of it is owned by Khmer people who own a lot of land, rice fields, and the rice mills; and they get very wealthy. I think it's probably been that way for a long time. But you do see people who have small plots of land and often end up selling them. If there's a health catastrophe, for example, they have to sell their source of income to pay for someone's health care. Sometimes, they just sell to buy stuff, which is very ill-advised. Or they'll take out a mortgage on their property, and they'll get into debt and lose their property. We see that quite a lot. A lot of microfinance institutions now try to help, giving small loans at not too bad interest rates, trying to stop people from getting into big problems with debt. I don't have details, but I read about these organizations from time to time.

The schools are also very important. We work with a Khmer organization called Children's Action for Development (CAD), that's been enormously successful. The Khmer guy who runs it, Racky, works with at-risk children there. A lot of parents go off to Thailand to work because there isn't really good work around locally. They'll leave the children with family or friends, and CAD tries to keep them in school and in the communities. So, there are schools in a lot of these communities. They are linked with the government now because they've incorporated, and they've got the government to provide extra money and extra teachers to come in. That has been very successful; they've reduced the truancy rate and improved literacy in the communities. There are islands of success.

Basically, however, few people want to work in the rural communities. They want to work in the cities. You don't get many working in the rural areas.

How might the Cambodian health system develop? Should it move toward greater governmental ownership of the health system or a mixed system with both public and private components?

No one goes to the government hospitals unless they can't afford to go somewhere else. If you train as a doctor here, you can set up your own clinic, really as soon as you're qualified, with a pitiful amount of experience. Thus, some of the smaller, private clinics are not very good either. They might have the modern equipment and buildings, but lack the skills to maximize them.

When I started serving at The Handa Foundation’s trauma hospital, an American internist had already worked here for a number of years. He had worked in Phnom Penh previously and taught at a university medical school. He saw an improvement in the standard. I also have noticed some improvement. But, having said that, there are still huge knowledge gaps in the doctors who are coming through. I really don't understand what they teach at medical school and what the curriculum is, because there are so many huge gaps in knowledge.

One problem is that much learning is by rote and people aren't taught critical thinking. It makes it difficult for them to adapt to different situations. But there's also, certainly in medicine, a very strong hierarchical system whereby, if you're older and senior, then you know it, and no one else can question what you say. Sadly, some of the more senior people are pretty ignorant and if they do know things, they don't share it with anybody else because they don't want to lose the advantage they've got. What they share may be wrong. My only real opportunity to draw comparisons is when we interview people for jobs at the hospital. We had to do a theoretical test because it was so abundantly clear that some people didn't have even the basic knowledge that you'd expect. We had to have some objective way of assessing it to see if there was hope of being able to build on the basis of some sort of foundation of knowledge. Interestingly, although most of our applicants are fairly new out of their medical school, we've had one or two more senior people apply. They're probably less knowledgeable than the new ones. If you gave our test to a newly qualified doctor in the United States or the United Kingdom, they'd be insulted by it, it’s so simple. People are doing better on that now.

It’s understandable why the senior doctors lack knowledge. All the teachers had been killed. Some people, a small minority, went overseas to train. And now there are scholarships. The French have done quite a lot with exchanges, and so on. There are some really good doctors in Cambodia. For a start, we've got an excellent orthopedic surgeon at our hospital who trained here, but worked a lot with international surgeons over the years at the hospital, so he got the extra experience and their teaching as a post-graduate. I've met some of the people in Phnom Penh, and at the Calmette Hospital, which is probably one of the best hospitals there. There are some very good doctors there, but most have had the opportunity to either go and work abroad for awhile or have other people come and work with them. It's broadened their horizons. If you haven't had any experience in anywhere outside your own country, you've got very limited horizons. Many people genuinely don't know what goes on in the outside world so they don't understand the difference in standards. It will probably take another generation before it filters through.

Are there medical missions in Cambodia sponsored by religious organizations?

We do see some. Partly through YWAM because they have a lot of teams, and although they aren't medical specifically, some of them have doctors with them come over for short-term trips. We have been involved with one or two. An NGO from the United Kingdom comes and works at Battambang Referral Hospital, the government hospital. They've been working with them on diabetes for a number of years. They come for two weeks at a time, maybe twice a year. Some dental teams come. I think they can make a bit more of an impact on a short-term basis.

We've become somewhat jaded with some of the short-term work. It depends on their attitude and their understanding. The more mature teams realize their limitations and realize that the best option is to come and work alongside what's already going on and benefit from it themselves, from having their horizons widened. The worst is when they go into community, do a clinic, and disappear again. What's the benefit of that? There's absolutely none, really. It's a one off, and you just leave people the same as they were before. You can level the same criticism with us at the moment because we've not fully got to the stage where we want to be with integration and making our work self-sustaining. But at least we're trying to keep the continuity going.

How do you see new technology offering new potential for treatment?

There's an NGO, Battambang Ophthalmic Center, which is Cambodian run, that does a lot of cataracts surgery. They have a screening facility for diabetics, and they go out to communities with their equipment in a mobile truck. They take them into Battambang to treat, but their mobile outreach facility seems to be very effective. And now you can use your Apple Watch, or whatever, to diagnose people's cardiac problems. The sky's the limit, really. I'm not at the high-tech end at all, but I certainly send x-ray pictures to colleagues back in the United Kingdom. A friend who's a dermatologist will look at difficult skin rashes for me. I just send him some pictures, and he'll send me his opinion back. Even at that level, it's a great help. It means you can achieve a lot more than you could just on your own.

A benefit here is that there's pretty extensive mobile phone coverage throughout the country, perhaps because it's so flat. The technology missed the fixed line altogether; they just jumped straight to the mobile. That means you can access the internet in the middle of nowhere to a fairly high degree. There is a lot more potential for that, I'm sure.

You started by talking about Christianity. How do you see the religious side of things as it affects your work now?

A number of Cambodian care coworkers are now Christians. People in communities will ask us questions like, "Why do you do this?" So, we will tell them, "It's because of our religious beliefs." And if they express an interest in finding out more, then our coworkers will talk to them about Jesus and do Bible studies with them, and so on. This is outside the clinics, but it's through the relationships we've built up. It's very much a relationship-based culture. It takes years to do that, but after five or six years, we begin to feel that we are accepted in the communities, and people trust us. And so these conversations go on. The medical work opens up avenues for other work because we're not doing the clinics all week, and our coworkers will go and visit people in the communities on other days, for Bible studies or just to get to know people better, and so on.

We have no religious angle to our mobile clinics. The classic example is the one Muslim community we visit. When we first started, some Muslim missionaries in the village from Malaysia were all over us, wanting to know what we were doing, and so on. We told them we were Christians, but they also knew that we were not there to try to convert the Muslims in the community. We go there because we love the people, not because we feel they've got to be Christians. So they've allowed us to continue. It’s quite a hardline Muslim community; they're learning Arabic in the schools and they read the Quran. There's a lot of Muslim missionary work going on in that community. We do the medical clinics, and that's all. We don't interfere in any other way. We wouldn't anyway, but we know that if we pushed anything Christian in the clinics, we would be told not to come back. We see it as two aspects of the same work, but separate.

There's a lot of religious freedom in Cambodia. It's a Buddhist country, though if you go back far enough, it was Hindu. But they don't prohibit anyone from sharing their faith. And that makes this work a lot easier. Go to Vietnam, and you'll be in big trouble for trying to do the same sort of thing because of the communist government. In Thailand too, the Buddhists are less welcoming.

Cambodia is unique in that respect. I think maybe it's because a lot of the NGOs and charities working in other roles have been faith-based. And I think the government, perhaps, realized the size of the contribution that they're making. So, they're happy to let that go, because it's benefiting the country. The contribution is substantial. I think the government is happy that the NGOs do stuff that saves them having to do it themselves, or from having to pay for it. So, they are willing to let it go on as it is. Maybe that will change, but there's not been really any sign of that at the moment.

Do you work with other religious NGOs in Battambang?

The Koreans are very active, and I’ve met a couple of Christian Korean doctors. The Seventh Day Adventists also have some Korean involvement. We have a link to YMAM through our son, and we help them out. We don't work for them, but we do work in one community with them. I serve as an unofficial doctor for the expats because there's a large expat community in the YWAM base. Teams visit, and inevitably people get sick. So, they asked to me help out with that. We cooperate with them unofficially. Overseas Missionary Fellowship has some workers, certainly in Phnom Penh, and up I think Mondulkiri and Ratanakiri, up in the Northeast, and in some more far-flung areas. We do some health care education for the staff of different NGOs if they express an interest. There's a group in Phnom Penh called Patient Care Ministries, just a very small organization, that's worked with us. And there's a group called PRIME (Physicians Responsible for International and Medical Education), which is certainly quite Christian-oriented. They travel around the world. We've been involved with them, doing some teaching in Phnom Penh. But most of our work is focused here in Battambang.

This region was more affected by the Khmer Rouge, and for longer, than many other parts of Cambodia. How do you see the effects?

Sadly the most graphic way you see it is with landmine injuries and the unexploded ordinance. That's what the trauma hospital originally opened up for, and we still do get those cases. Thankfully, way less than we used to. But that's a very real reminder of what it was like. This region was a stronghold for the Khmer Rouge in the latter days. A lot of people don't want to talk about it, and we're not really in a position to ask. But some of our coworkers sometimes find a bit out about what's been going on. We know a lot of the older people in the communities must've been involved—they must've worked for the Khmer Rouge. They're not all victims, or they wouldn't be there. Many of them survived by being in Khmer Rouge.

My daughter-in-law's mother worked as a cook for the Khmer Rouge. Because she was a good cook, she was allowed to continue that way. You had to have something to offer to be able to survive, or go into hiding. We met one lady who we know was very high in the Khmer Rouge—because she acknowledges that—who has actually become a Christian since. You meet some people who were involved in the atrocities. But most of the time, people don't want to talk about it, which is understandable. If you do talk to the families, they've all got relatives who were killed during that period.

No one has been untouched by the Khmer Rouge legacy. The history is largely tolerated in the community, though it's hard to get the feel for it without being sufficiently proficient with the language and understanding the culture of how these people coexist. Everybody in a community knows that some of the people have, in the past, been their enemies. And now, they're living alongside them. How that works, or whether it does, I don't know.

We also see a lot of post-traumatic stress. It is said that Cambodia is one of the few countries where it's actually been passed from one generation to the next. The people who suffered stress are now parents, and their behavior brings the same things into the next generation. Thus, post-traumatic stress is actually passed down to the next generation. Parenting is an area that potentially is a problem. We see some unfortunate behaviors and interactions between the older and younger members of the families—violence and domestic abuse. You might say, "You find that around the world." Which is true, but there is a lot of it here.

So where do you see yourself going in the future?

We're here for the foreseeable future. We've no plans to go back to the UK. We've got no real connections to the United Kingdom, except aging parents. We are very blessed because we have our family here. My son is in China now, getting a degree in Mandarin, but he plans to come back when he's finished to work in Battambang again. Our daughter and son-in-law live here. We've got three grandchildren, one who lives here and two in China. So, this is home.