Common illnesses in tropical Asia and significance of medical volunteering

2.1 Overview of Cambodia

Cambodia is a country located in the southern part of the Indochina Peninsula in Southeast Asia. It is 181,035 square kilometers in area and has a population of 15,957,223. Cambodia won independence from France in 1953. From 1975 to 1979, when the Khmer Rouge held power, almost 2 million civilians were killed, including significant numbers of health-care providers [14, 15].

Cambodia remains one of the poorest countries in Asia, although it achieved dramatic economic growth in recent decades; the gross domestic product per capita was $608 in 1993, increased to $2,454 in 2012. It also struggles with severe income inequality, poor job prospects, and endemic corruption. The lack of basic infrastructure in rural areas, where 80% of the population lives, is another serious problem [14, 16].

From a health perspective, Cambodians’ life expectancy at birth is 72 years as of 2012 [11]. The physician density rate is 0.17 per 1000 people, which puts Cambodia in the lowest quartile of the world’s countries [9]. Health care is provided by both public and private practitioners. Trust in the health-care system is still recovering after most of the doctors were killed by the Khmer Rouge about 40 years ago [17].

2.2 Details of volunteering activities

Our volunteer team has been conducting medical volunteering missions on an annual basis since 2012: the first two times in the Cham Lak area in Kampong Cham province, and the next three times in the Khsoem area in Kratie province. All missions lasted for seven days. The Cham Lak area is 122 kilometers northeast of Phnom Penh (Cambodia’s capital and largest city) and consists of six villages, each with 120 to 150 families. The Khsoem area is about 240 kilometers northeast of Phnom Penh. It consists of four villages with 150 households, 200 households, 300 households, and 400 households, respectively. Both areas have agriculture as their main industry, and they do not benefit from basic infrastructure such as electricity, water, and gas.

Our team ran only a medical clinic during the first two missions; starting with the third mission, we also performed various community-friendly activities. Our non-medical volunteers (NMV) were recruited for those activities, and they painted mural paintings at local kindergartens during the third and fourth missions. On the fifth mission, they taught children in local kindergartens and educated local teachers. Our NMVs consisted of experts for each activity and young volunteers to assist them. For interpreting and medical consultation, Cambodian doctors and college students studying medicine or midwifery were hired. Table 1 summarizes the composition of our team during the five missions.

Our list of medications is organized in collaboration with Korean doctors, including dermatologist, specialists in internal medicine, pediatrician, and radiation oncologist, and a Cambodian doctor. A medicines list used in our fifth mission is shown in Supplement Table 1; this can serve as an example for preparation of a medical volunteering mission.

Ethics approval. This study was approved from the Institutional Review Board (IRB) of Ansan Hospital, Korea University Medical Center, Gyeonggi-Do, Korea (IRB No: 2017AS0087). Patients’ consent was waived with consideration because there was no potential risk to the patient, no information that could be personally identifiable was used, and owing to language barriers and lack of contact methods (e-mail, telephone, etc.). All volunteers (including medical and non-medical volunteers) who participated in this study agreed to the academic publication of this study. Otherwise, we recognized and adhered the World Medical Association Declaration of Helsinki.

2.3 Data collection and statistical analysis

Since both of our destination areas had no electricity, all the procedures, including prescribing and checking the quantity of medicines, medical treatment, and charting, were done by hand. We used a self-designed medical chart, based on our experiences in the first mission. This chart is designed to ask about symptoms related to the five most common illnesses we encountered in our first service, which are upper respiratory infections, gastroenteritis, vaginitis and/or cystitis, work-related symptoms, and dermatitis. The chart also included questions about the need for parasite prevention, mainly to prescribe anthelmintic drugs to children. The clinical data from the first, third, and fourth missions were provided to the local public health department, and the data from the second mission in the Cham Lak area and the fifth mission in the Khsoem area were used for this study.

We analyzed the distribution of illnesses by categorizing the cases that our team most commonly encountered into the six groups, as we mentioned above: upper respiratory infection, gastroenteritis, vaginitis and/or cystitis, dermatitis, work-related pain and parasite prevention. Work-related pain is defined as the pain of a knee, a waist, or a shoulder that typically worsens with farming labor is relieved when resting. Differences in disease distribution in the two villages were analyzed using chi-square tests. All analyses were performed using SPSS version 23.0 (SAS Institute Inc., Cary, NC, USA).

4.1 Summary and analysis of experience

Our research provides information on common illnesses that could be encountered in medical missions in the rural areas of tropical Asia. Although the two regions where we conducted the missions are not so far apart and have similar climates, the distribution of common illnesses was different. It was unexpected to find this, because we thought the main illnesses in these areas would be caused by a lack of infrastructure such as water supply or sanitation facilities, and there was no big difference between the two areas in that regard.

After consulting with the Cambodian doctor, we suggested a hypothesis for the cause of this difference. In the Cham Lak area, where we conducted the first two missions, people use the nearby lake as their main water supply. They use lake’s water for laundry, bathing, and sanitation. For drinking purposes, they use small wells belonging to the village. For the people of the Khsoem area, where we performed the third, fourth, and fifth missions, their main water supply is water pumps (which drain ground water from much deeper than village wells do). People of the Khsoem region also buy water for drinking purposes. Additionally, people living in the Cham Lak area are engaged mainly in rice farming, while those living in the Khsoem area mainly farm a crop called kawa, which must be dig out including roots from the ground and whose harvest can thus cause musculoskeletal pain. The differences between the two villages in terms of water supply and farming style seem to have caused the difference in illnesses.

There are few health literature reports on the rural areas in Eastern Cambodia where we have conducted volunteer work. Thus, we carefully discussed our volunteering experiences with recent health studies targeting Kratie and Kampong Cham provinces regionally, where our destinations are located. Some researchers have reported that helminth infection, such as Opisthorchis viverrini or Schistosoma mekongi, is not uncommon in this area [18, 19]. These might reflect the need of parasite medication, such as albendazole, in our services. It is also reported that water and food in this area contain heavy metals such as mercury and arsenic, as well as harmful chemicals such as phthalate esters [20,21,22]. The relatively high incidence of gastrointestinal disorders in our missions might be related with an absence of systemic management for food and water, and that refrigerators are not commonized. Moreover, people in this area, who live in houses made with thin, hand-made wooden boards and engaged in farming, are difficult to protect themselves from insects including mosquitoes, and the occurrence of dengue fever is not uncommon [23]. This is difficult to be differentiated from upper respiratory infection only by clinical symptoms, especially when a language barrier existed.

Physicians in developed countries tend not to be aware of the ways in which situations in the rural areas of low-income countries can differ. Even when different rural areas have similar climates and levels of infrastructure, teams planning medical missions might need to take into consideration their specific circumstances.

4.2 Common critiques of short medical volunteering

The duration of medical missions varies, but more than 70% of missions have been short-term (less than four weeks) [10]. These short medical volunteering missions have been criticized for their possible negative impact and lack of sustainability [24,25,26]. “First do no harm” is the primary principle, which we agree, in preparing a short medical volunteering mission [25]. If supporting facilities are insufficient and continuous follow-up is impossible, extensive procedures or invasive treatments should be avoided. It is also essential to educate participants about the lifestyle of community, its medical problems, and effectiveness and safety of intervention for both practitioners and the patients [27].

Cost-effectiveness is important for significance and sustainability of the medical volunteering [10, 28, 29]. Maki et al. reported that the average expenditure of medical missions performed by 543 organizations was $50,000 per mission [8]. Abdullah noted skeptically that on one mission, a 10-person medical team spent $30,000 on travel and hotel costs in a country where a 30-bed hospital could be built for $60,000 [5]. Our medical volunteering has been performed with small finance, and we knew the cost-effectiveness was very important for sustainability. On our fifth mission, our team including 17 participants spent approximately $10,000 in all. This budget was possible because we were staying in a local house belonging to a church and living with local people and interpreters. Staying with the locals helps to promote cooperation as well as financial savings.

Volunteer physicians in developed countries often lack in-depth understanding of poverty and local social and economic contexts [7, 30, 31]. Since low-income countries often have an unfortunate history and might be sensitive about their environment in poverty, volunteers should be careful with and respectful to locals.

4.3 Travel information for volunteering in rural areas of Eastern Cambodia

Volunteering mission should be accompanied by a cooperative local director, and a leading physician who is well experienced with medical volunteering. Potential team members should be told about the standards for accommodations, food, and drink before they commit to participating.

Herein, we share our advice based on experience because there is very limited literature regarding information related to travel in rural areas other than those around Cambodia’s major cities (Phnom Penh, Siem Reap). In rural areas of Eastern Cambodia, there is no public electricity and tap water available. In order to use electric medical devices, it is necessary to use a rechargeable device or a portable generator. Internet is usually unavailable even with use of local universal subscriber identity module (USIM) card. It is difficult to maintain the freshness of the food because the weather is consistently hot through the year and the refrigerator is unavailable. As mentioned in the above section, water or food might not be free from heavy metals, harmful chemicals [20,21,22], or other contaminants. One should follow the local coordinators’ instructions for food, however, if no such help is present from the trustable local coordinators, it is safer to prepare food from the neighboring town. Drinking water is recommended to be prepared in advance at a nearby town; one can drink canned beverage sold in local stores in rural areas. Insects and worms are prevalent during rainy seasons, usually from June to November. Insect repellent and allergy medicine should be prepared for susceptible people. The best period for volunteering is between November and February, during which time the weather is not overly hot, and rain is infrequent. The average daily temperature in Cambodia is over 30 degrees Celsius through the entire year [32]. However, since houses in rural areas are mostly built of thin, hand-made woods, blankets or extra garments might be necessary to keep body temperature at night.

Figure 1

Medical station in volunteering

4.4 Benefit of short medical volunteering

If we consider the medical impact of a single medical mission, it is easier to criticize than to find the benefits. Therefore, the benefit of the medical volunteering should be considered from a longer-term perspective.

We visited Cambodia on an annual basis and have performed symptom-based treatment, as well as prescribing medications and conducting health education in cooperation with interpreters. Definitely, annual mission is not enough to manage the diseases caused by a lack of infrastructure, poor hygiene, and working conditions. Management of chronic disease represents another difficult concern. As our visit was only once a year, we did not prescribe hypertension or diabetes medication, because prescribing drugs for long-term use can lead to overuse and misuse.

However, we consider our previous five missions as the beginning of the journey. Through our experience with past missions, we have trusting relationships with the Cambodian branch of the Korean Mission Society, which is in charge of local co-ordination, and with Cambodian doctors and college students who participated in interpretation and medical consultation. After assisting with one mission, the Cambodian participants want to help with the next, whenever they are able to. Some of them have been participating in our missions without receiving fees, and want to be colleagues of our team. Our NMVs have played a leading role in harmonizing and building relationships with local people. Based on this trust and cooperation, we are able to plan medical activities that can provide more sustained and practical help in the future.

Volunteer missions are beneficial for health-care professionals in developed countries to find their role of caring humans, who might suffer poverty and nescience, in crucial needs of medical help. Also, it provides solidarity and confidence to local people [5, 12, 33]. All the participants in our missions clearly felt gratitude for their assignments and became more dedicated to their role. At the end of the second mission, the teacher in charge of the church kindergarten told us: “It was a great pleasure to have you with us, eating meals together, talking and laughing, and playing with our children; those moments were more than happy, and it really improved our confidence.” These words summarize the significance of our mission and will motivate us to prepare for the future.

4.5 Limitations and conclusion

We conducted five medical volunteering missions for five years, but only used data sets of two missions, because we provided data sets of other three missions to the local health department for the supplement of the health data in Cambodia. In addition, detailed diagnosis was not possible and the diagnosis was made mainly according to physicians’ impression, because the tools available for diagnosis were very limited.

Supplement materials