Unknown to the general public, the NGO Douleurs Sans Frontières (DSF) has nevertheless been working for more than 25 years in the service of underprivileged Cambodian populations. It is only recently that the fight against pain has really entered the field of medicine.
Trivialized for a long time by health professionals and civil society, it was not until 1995 that it appeared in a text of French law.
This late consideration is due in particular to the fact that pain is an individual experience. It is a feeling, which makes it particularly difficult to spot and assess. In countries with less established healthcare systems, pain is not always a priority. Its management remains a little-known medical specialty and the nursing staff is not or very little trained in relieving it.
Reducing pain in Cambodia is the mission of the NGO Pain without borders , in partnership with the Cambodian Ministry of Health. It implements a multi-disciplinary and cross-disciplinary approach bringing together various professions. In his team we meet doctors, nurses but also psychologists who help to recognize and take care of the emotional suffering of patients and also that of those who accompany them, very often close family members. Present in Cambodia since 1996, she has seen her field of expertise evolve, from the phantom pain of amputees (a frequent pathology after war) to end-of-life support and palliative care today. A French NGO little known to the French-speaking community in Cambodia, it treats around 1,000 patients a year.
Lepetitjournal.com met the brand new national director of DSF, Frederic Garcia, arrived a few weeks ago in Cambodia.
What is the reason for DSF’s presence in Cambodia?
DSF established its first program in Cambodia in 1996, in a country undergoing reconstruction following the Khmer Rouge tragedy. Founded by French doctors specializing in the management of pain, the first project aims to offer appropriate management of the pain of victims of anti-personnel mines. Over the years and in line with identified needs, DSF has developed its program towards other public health issues. In the 2000s, the program evolved to participate in the fight against the HIV epidemic. Then, while the epidemic is under control following the considerable efforts made by international and local actors, DSF turns to cancer patients, for whom the healthcare offer is insufficient, or even non-existent. With the support of DSF, the country is acquiring increasingly appropriate resources in the fight against cancer.
Today, the epidemiological transition taking place in Cambodia can no longer be ignored: non-communicable diseases represent 56% of deaths, and cancer alone accounts for 14% of recorded deaths. Faced with this observation, the health authorities must accentuate their strategy for the prevention and control of non-communicable diseases, while maintaining/improving the good results obtained in the fight against communicable diseases such as HIV, malaria and tuberculosis. . In this context, the Ministry of Health has defined palliative care as one of its priorities, as it is considered a cost-effective intervention in the fight against non-communicable diseases.
What are the criteria for defining that a patient is at the end of life?
According to the WHO, the end of life can be defined as the last moments of a seriously ill person, suffering from a serious and incurable disease, whose vital prognosis is engaged.
What are the specificities of pain management as a medical specialty?
In the management of pain, it is important to think about a quality assessment of the pain and a management and treatment adapted to each individual.
The concept of total pain – physical pain, psychological pain, social pain, and spiritual pain – is central to pain management and must be addressed.
It is a team work involving other health professionals or not such as doctors, nurses, pharmacists, social workers, a psychologist, a volunteer, a community (neighbors, religious personalities such as monks in Buddhism…) and more.
How are your patients referred to you?
Many of our patients come to us by word of mouth, they contact us directly. We also have a Facebook page in Khmer which is a vehicle for communicating our activities and for including new patients in our treatment program. In addition, we receive referrals from healthcare professionals from partner hospitals and organizations.
What services do you offer to your patients and their families?
Since 1996 in Cambodia, our desire to relieve suffering has been expressed in many ways: training of medical and paramedical professionals, community workers and family caregivers, public awareness, setting up support within the various structures local health centres, support for the creation of pain units, but also the setting up of intra-hospital mobile teams, palliative care teams at home as well as advocacy work on the availability of opioids.
Currently on the current program, we offer medical and psychological care for painful patients in palliative situations as well as their family carers in the 3 national hospitals in Phnom Penh and in our premises also in Phnom Penh. We have set up a home care service in 10 provinces of Cambodia with the addition of a teleconsultation service for patient follow-up. Our medical team prescribes and gives level 1 to 3 analgesic drugs (morphine) to pain patients in a palliative situation.
Indeed, the care offer for palliative care is centralized in the capital Phnom Penh and remains not easily accessible for the entire population.
Beyond the costs directly linked to the care, the ancillary expenses such as travel to the consultation or the purchase of medication constitute an additional obstacle, even are prohibitive for access to care. Because of their cultural and religious conceptions, the majority of patients do not wish to die in hospital and choose to return to their homes, surrounded by their loved ones for their last moments, hence the need for the establishment of home care by DSF.
What means do you have?
We have a multidisciplinary medico-psychological team made up of two doctors, two nurses, a psychologist and a pharmacist. This medical team is coordinated by a medical coordinator. Our premises are located south of the Russian Market in Phnom Penh.
What are your long-term goals?
Since its creation, DSF’s strategy has favored long-term actions through capacity building and support for institutional health actors and civil society.
Thus, the Cambodian mission maintains relations of trust with the local health authorities, which have enabled it to provide direct care for beneficiaries, but also to strengthen the capacities of local actors, particularly within hospital structures through various training programs. Until now, medical activities have been carried out mainly by DSF with the support of a few local partners. Over the course of our intervention in Cambodia, operational relations have thus gradually developed with other structures and the idea of combining the strengths of each of the structures and covering the entire Cambodian population in a complementary manner in coordination with Cambodia’s Ministry of Health is one of DSF’s objectives in Cambodia.
Your mission, where you only meet people in pain and at the end of life, doesn’t it end up weighing on the minds of your team?
Indeed, this is one of the difficulties expressed by our team. On a daily basis it can be difficult for them to work in this particular context, listening and support groups are set up for our teams.
Interview with Madame Mon Chhorvor
We were also able to speak with DSF’s medical coordinator in Cambodia.
Mrs. Mon Chhorvor is a doctor, graduated from the Faculty of Health Sciences in Phnom Penh in 2016. Aged 34, she holds the position of medical coordinator within the association. Francophone, she was kind enough to answer our questions.
In Cambodia, especially in rural areas, when someone is sick and/or suffering, he goes to the Krou. How do you articulate your action with them?
It is not a question of replacing the Krous Khmers, which would in any case be impossible given the sociological and medical context of rural Cambodia. We offer patients an additional service.
If we were to oppose traditional medicine, the majority of patients would continue to use it, hiding it from us. However, it is essential to know what were the prescriptions they received in order to know their effectiveness, their dangerousness and their compatibility with the treatments that we could be brought to give them.
What are the main problems you face?
We have to take a lot of time to explain our work. The main problem we face is the lack of information for patients and their families.
Often, patients expect an analgesic to take effect almost instantly, but it takes time. We need to explain to them what to do before they completely stop their treatment.
DSF will present its work during a photo exhibition within theFrench Institute of Cambodia in January 2023, by exhibiting the portraits of 4 end-of-life patients and by offering the public 2 films followed by debates in partnership with the French Embassy and with the financial support of the French Development Agency and Ethypharm Laboratories.
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