Malaria in Cambodia: You Disrespect the Lord of the Land

When I started writing my term paper about malaria for Global Health class, the first thing that came to my mind was how Cambodian’s belief shaped the perception of this disease. I recalled a story about a man who visited Pailin and found himself very sick a few weeks after he arrived. Pailin is located in western Cambodia and is known for its rich natural resources stemming from extensive gem deposits and precious timbers. Some people call it a gem town hidden in the tropical forest and mountain ranges. Despite its rich and beautiful landscapes, it is a generous atmosphere for malaria’s prevalence.

The Story of Mr. T

The man, I will call him Mr. T, went to Pailin hoping to explore the tropical rainforest and seek a job as a gem miner. He spent nights sleeping in a hammock outside his friend’s house that was surrounded by bushes and shrubs. One morning, he got up and prepared for his journey into the forest. But right before the journey started, Mr. T began to sweat. He felt that his muscles had gotten weak and his body shivering. His friends suggested that they take off tomorrow instead to give him some time to rest. The journey never started because Mr. T’s condition got worse. After his initial symptoms, his friends practiced the common treatment in Cambodia which was coining with Tiger balm to detoxify his body. Later, they gave him unprescribed paracetamol’s acetaminophen to reduce his body temperature and relieve body pains. None of these treatments worked. They finally brought him to a local traditional healer when everything came into a conclusion that he was “ចាញ់ម្ចាស់ទឹកម្ចាស់ដី/janh m’jas tek m’jas dei/”. This term came from a belief that an outsider came into a town and disrespected the Lord of the Land of the town and therefore were defeated by the power of the Lord. The direct translation would be “He lost to the Lord of the Land”.

Instead of sending Mr. T to the hospital, they organized a praying and healing ceremony for him. They prepared food, incense, flowers and drinks; and devoted this ceremony to the Lord in order to seek forgiveness. They burnt incense, prayed and apologized for the unintended mistakes and reckless behavior of Mr. T that might insult the Lord. The ceremony lasted a few hours and later that day Mr. T felt a bit better. Everyone was reassured that Mr. T was forgiven. But it was just the beginning of a critical stage of Malaria’s symptoms. The next day, Mr. T became fatigue that he was not even able to get out of his bed. With severe headache and high body temperature, he vomited and later had a seizure. Forgiveness had never been granted to Mr. T. As his condition became worse, his family and friends sent him to a local clinic where they were told by the doctor that Mr. T was most likely diagnosed with malaria. After an examination, he was denied a clinic entry and treatment. Wherever he was sent to rejected him. Hopeless, his family decided to bring him home and to continue using traditional medicine and herbs to treat him. Later that week, Mr. T passed away. Mr. T’s clinic rejections were due to two major reasons:

1- His condition was too critical and too late to be treated.

2- His family didn’t have money to pay for his treatment.

Mr. T’s case was not the only case. There were thousands of victims who died from this treatable and curable disease and who shared similar story to Mr. T’s. These stories were always connected to the belief that these victims were defeated by the Lord of the Land.

Lower Socioeconomic Status and Malaria Infection

Malaria is the most prevalent parasitic endemic disease, which is preventable, treatable and curable. It is caused by the Plasmodium parasite. The parasite can be spread to humans through the bites of infected mosquitoes. Africa and many parts of Asia with tropical rainforest are most exposed to this disease. In Cambodia, 21 out of 25 provinces are found to have malaria’s present. The epidemic are most prevalent during hot and rainy season between July and November. This season is an excellent time for infected mosquitoes to lay eggs in small ponds, wet grass and shrubs, and therefore increase its population. People in rural Cambodia are the easiest victims of these infected mosquitoes and are at the highest risks of malaria infection because of the forestry environment that surround them. The Lord of the Land is not the one to blame for thousands of death from Malaria. It is in fact a low socioeconomic status that prevents people from maintaining a good preventive behavior. I found some empirical studies that suggested a correlation between the two variables. For instance, a study of Childer and Chiou in 2015 found that communicable diseases such tuberculosis and malaria are widespread among lower SES group.

In my semester study of socioeconomic status (SES) and preventive behavior in Malawi, I used two sub-variables, level of education and wealth, to measure SES and two sub-variables, ownership and usage of insecticide-treated bed nets (ITNs), as a form of preventive behavior. Later in this study, I used an econometric model and methodologies of Ordinary Least Squared and Maximum Likelihood to measure the gradient. The model is simply outlined as follow:

Null Hypothesis: Eci > 0 indicates that a change in SES by a constant c on individual i has a positive effect (E) on preventive behavior.

And L:Pr(Pi=1)i = βo + βeEi + βwWi + εi which was a regression model used to measure the correlation. (Please contact me if you wish to read my paper which will explain in more details about this regression model)

Outcomes of my study are relatively consistent with majority of empirical studies. I justified that more highly educated and wealthier people have a much higher chance of owning and using insecticide-treated nets. People in this group have a much better understanding of malaria and the consequences of the disease. Therefore, they tend to seek preventive solutions and take immediate actions if they suspect any symptoms. In addition, wealthier people who own a television or a radio have a better access to information about malaria and malaria preventions.

In this article, I cannot relate the case of Malawi to the one of Cambodia without any data to back it up. But presumably, the case in Cambodia is not any different. According the World Health Organization, the risk of malaria infection is highest in forest and forest fringe in the north-eastern part of the country. Majority of the population in these areas are poor, less educated and vulnerable to this disease. Without sufficient and accurate information about malaria and how to prevent it, the Lord of the Land became a big role in the death and the prevalence of the epidemic.

World Health Organization and Cambodia have launched aggressive programs to eliminate malaria since 2005. An intervention was started to educate people about malaria, and to improve practices and the supply of quality-assured drugs and the Rapid Diagnostic Test to the private health sector. In the past 10 years, the number of reported malaria cases had drastically declined by almost 58 percents. According to WHO, the surveillance system recorded only a single malaria death in 2016, compared to 46 in 2012.

The reported decline of malaria cases from 2001 to 2016. Image courtesy of WHO

Lessons from Mr. T’s Story

One thing that we absolutely learned from Mr. T’s story is that the Lord of the Land has almost nothing to do with the widespread of malaria epidemic. Education is the most crucial factor for people to acknowledge the existence of malaria and to understand prevention methods. The government must ensure that information about malaria is delivered to all parts of the country and provide all kinds of support to educate its people. Although the education part seems to be greatly successful, there is a problem that still remains, the country’s healthcare system.

Similar as many developing countries, Cambodia is still adopting an out-of-pocket healthcare system. Majority of people are not insured, that means when they get sick they will have to pay with cash in order to be treated. Mr. T was denied hospital entry and treatment because he was not able pay the fees. Although Cambodia has become more developed, healthcare system still remains underdeveloped. Private healthcare market still has not earned people’s trust due to many cases that insurance buyers are not fairly insured when they get sick. Even if the trust is earned, it is most likely that private insurance will not reach the poorest and most vulnerable groups as their premium, considered a low income in Cambodia, is relatively too high. Public healthcare system such as the National Health Insurance model as seen in Canada and South Korea with the government as a single-sole payer might do a good job. But there are also other models that provide universal coverage to the people that might help. It is about time Cambodia studies the reform of its healthcare system and adopts the one that fits best so that people like Mr. T can survive from a treatable and curable disease. But the reform is not an easy task, especially when it is not the government’s priority.

In the next article, we will discuss the most appropriate healthcare system for Cambodia and what it can learn from its neighbor country, Thailand, about the healthcare system.

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