Editor’s Note: This is the second in a series of three posts by Victoria Elliot, MSPH, a public health professional and medical student who accompanied HVO staff member April Pinner on a recent trip to Angkor Hospital for Children in Siem Reap, Cambodia. Victoria’s background in public health, coupled with the fact that she is in the midst of receiving her own medical training, enables her to bring a unique perspective to HVO’s long-standing and successful collaboration with AHC. We hope you enjoy this inside look from an outside perspective. View the first piece in the series, on HVO’s partnership with AHC, and stay tuned for the third and final piece, on transforming health worker trainees into teachers.
Controversy often exists around the effectiveness of international development work. At times it can be difficult to see a way through the many challenges that the international community faces along the path to having a positive and sustainable impact on the individuals, communities, and countries it aims to help. A vital component of overcoming these challenges, and being a part of positive and sustainable development, has been described by the well-known and probably over-used saying: “Give a man a fish, and you feed him for a day. Teach a man to fish, and you feed him for a lifetime.” HVO’s mission to “[improve] the availability and quality of health care through the education, training and professional development of the health workforce in resource-scarce countries” is a great example of how this can be done within the global health sector.
On a recent trip to Southeast Asia, I spent a week at one of HVO’s longstanding partner institutions, Angkor Hospital for Children (AHC), in Siem Reap, Cambodia. AHC is a pediatric hospital that provides high quality medical care to children free of charge. It was founded in 1999 by the non-profit Friends Without a Border. In 2013, AHC transitioned to become an independent non-profit organization. Today, 98 percent of the hospital staff is Cambodian. HVO has partnered with AHC since 2001, collaborating on a wide variety of projects, including nursing education, pediatrics, wound care, hematology and anesthesia. To support these projects, HVO sends highly qualified health care professionals who volunteer their time to provide training and continuing education to the health professionals at AHC.
During my time at AHC, I had the opportunity to meet with and observe the hospital’s hematology/oncology team. According to the recently certified AHC pediatric oncologist, Dr. Prom Vireak, the initial idea for this team came from Dr. Bruce Camitta, project director of HVO’s hematology training project at AHC, along with several other repeat volunteers. These dedicated individuals advocated for AHC to develop a strong multidisciplinary oncology team. HVO has continued to work with AHC to provide ongoing training to the five health workers that currently make up the team.
AHC’s oncology team is remarkable for numerous reasons, but I want to highlight two in particular. The first is the multidisciplinary nature of the team. In discussion with team members, I was told that it is the most multidisciplinary pediatric oncology team in Cambodia, and the first oncology team in the country to include a social worker and an ophthalmologist. Other team members include a junior pediatrician, a nurse, and a pharmacist. In meeting with the team, it was evident that one of the primary reasons for their success so far has been the mutual respect the team members have for one another. Not only do they trust each other, but they are also eager to learn from each other. The fact that AHC as a whole emphasizes the importance of teamwork and interdisciplinary collaboration has likely increased the cohesiveness of the team.
Another notable aspect of AHC’s oncology team is that it has made AHC the Cambodian referral center for children with retinoblastoma. This is facilitated by the fact that the hospital has an Eye Clinic, and that Dr. Khauv Phara, the ophthalmologist, is part of the oncology team. The team is able to diagnose retinoblastoma, which typically occurs in infants and very young children, and then works collaboratively to devise and carry out a treatment plan. The social worker, Ms. Dalen, is present when the patient and his or her family are informed of the diagnosis. Ms. Dalen continues to be involved throughout the treatment process as a source of social and emotional support for the patient and the patient’s family.
In cases where the cancer is very advanced, the eyeball with the tumor must be removed. Chemotherapy is also given when necessary. The team’s pharmacist, Mr. Leng Bunly, mixes the chemotherapy drugs for each case. AHC recently obtained a fume hood for this process, although it has yet to be connected via ventilation to the outdoors. Due to space limitations, patients receive chemotherapy within the hospital’s two general inpatient wards. However, the oncology team works with the Inpatient Department to ensure that, whenever possible, the isolation stalls within the two inpatient wards are reserved for patients undergoing chemotherapy treatment, to keep them in as sterile an environment as possible while their immune systems are compromised. The team’s nurse, Mr. Sath Saingnhan, and Dr. Vireak monitor the patients during chemotherapy.
Unfortunately, when patients are diagnosed with cancer in the early stages of the disease, before physical changes to the eyeball become visible, it can be hard for the family to understand and accept this diagnosis. I was told that it is not uncommon for families to remove their children from treatment at AHC against medical advice, coming back only when the tumor causes the eyeball to protrude. While the team still operates and provides the necessary treatment to care for the child, the outcomes of these cases are less successful, and palliative care is often the only remaining option.
The oncology team has received varying levels of training in hematology and oncology, much of which comes from HVO volunteers. Team members are eager to receive additional training, and many have pursued off-site professional development opportunities. Dr. Vireak, the pediatrician, has obtained the most extensive specialized training in oncology through multiple visits to the United States to train under Dr. Bruce Camitta. In 2015, Dr. Phara, the ophthalmologist, completed an International Visiting Program at Saint Jude Children’s Research Hospital in Memphis, Tennessee. Dr. Vireak also has biweekly online conferences with various HVO hematology volunteers to discuss unusually challenging cases and go over possible diagnoses and strategies for care. Mr. Saingnhan, the nurse, frequently joins Dr. Vireak for these conferences. I was lucky enough to observe one such conference, and was struck by the commitment of all participants to providing the best possible care to AHC patients, and to training AHC staff to become experts who will pass on their knowledge to the next generation of pediatric oncologists and health care professionals in Cambodia.
There are many challenges facing the AHC oncology team. The hospital has yet to acquire a CT scanner, so it must refer patients to a nearby hospital, which takes both time and money. AHC also has a limited selection of laboratory equipment. Many time-sensitive tests are delayed because samples must be sent elsewhere in Cambodia or even to labs in the United States for testing. Additionally, while AHC has acquired the technology and training to use cryotherapy, laser therapy, and chemotherapy, radiation is still unavailable. Despite these and many more challenges, the AHC oncology team provides hope to young children with retinoblastoma and their families.
At AHC, I encountered three retinoblastoma patients who had previously had an eyeball with a tumour removed and were now receiving chemotherapy treatment. The commitment exhibited by members of AHC’s oncology team to providing high quality, compassionate care to those who would otherwise face a very limited future was inspiring. With the assistance of HVO volunteers and the support and guidance of AHC management, the AHC oncology team has become an example of the way in which international collaboration can meet the challenge of having a positive and sustainable impact on health care in resource-scarce settings.