“The traffic was bad but our driver managed to find his ways in the back alleys of Phnom Penh’s suburbs. The last kilometers were slow, and we bounced on the bad roads. When we finally arrived, we saw a hut made of recovered steel sheets, a hut with no window.
“Sopheak, a 24 year old woman with cervical cancer, DSF’s patient, came toward us and invited us inside where her sisters, aunts, cousins and neighbors were already gathered.
“She introduced us to her three year old son. Her husband was at work. She started to tell her story, how, when the sickness began, they had to sell their house and land to pay for treatments and medication.
“The young family had to move in with other relatives. Treatments couldn’t help her, and now everything is lost, she told us, weeping.
“I managed at least to reduce her pain. She asked me once again if she was going to heal. My answer remained the same. At the end of our visit, she gave us a coconut in thanks.”
Douleurs Sans Frontières
Douleurs Sans Frontières – Pain Without Borders – is a French international non-governmental organisation, whose main purpose is the management of pain, suffering and other symptoms associated with the end of life.
DSF started its work in Cambodia in 1996 and has since developed various programmes around palliative care and pain management. These include the management of pain from‘phantom limbs’ related to landmines, palliative care for people with HIV and AIDS, and palliative care for people with cancer.
Currently, DSF activities in Cambodia focus on people with cancer. Late diagnosis and the virtual absence of quality treatment make cancer the fourth cause of mortality in the country. By 2030, with over 25,000 deaths per year, cancer will be the second cause of death. DSF is the only structure throughout Cambodia to provide palliative care to those in need.
Waiting for death to come
Dr Vainio told another story, also of a young mother. “She was dying of breast cancer, unconscious for two days when we went to see her. In Phnom Penh’s poorest suburb, children played in the dust, between the houses.
“The room was full of people – family members, friends, neighbours. Our visit drew attention. The woman was lying on the bed, breathing peacefully. She seemed not to be suffering.
“Her husband was taking good care of her. The place was clean. I showed him how to hydrate his wife with just a piece of cloth.
“This woman would leave behind a beautiful young boy. He was nine. The family was worried that the cancer could have been passed on through breast milk. We reassured them. We went, leaving them waiting for death to come.”
The need for palliative care in Cambodia
Since 2011, DSF has been providing pain relief and palliative care for people with cancer in Cambodia. The organisation has developed a home-based care service, and every day DSF staff will visit the only two oncology departments in the country.
- 13,000 deaths were caused by cancer in 2015. This number is estimated to rise to more than 25,000 in 2030 (International Agency for Research on Cancer)
- there are 15,000 new cases each year (WHO NCD country profiles)
- there are only two oncology departments in the whole country, both in the capital, Phnom Penh
- 60% of people with cancer already require palliative care at the time of diagnosis (Phnom Penh Post).
Technical assistance and teh development of palliative care
DSF is the main partner for the development of palliative care within the National Strategic Plan for Non-Communicable Disease 2013-2020 of the Cambodian Ministry of Health.
The organisation provides technical assistance for cancer care in Cambodia’s hospitals. The staff give medical assistance upon request to doctors whose patients require palliative care and pain management.
The organisation gives about 70 hospital consultations to around 50 people needing palliative care each month.
DSF staff also provide palliative care to people after they have been discharged from hospital, with the aim of giving them comfort and relief at home, and a death with dignity.
These home visits constitute 150 consultations with around 40 patients each month.
Creating a home-based care service
Dr Faustine Colin, DSF Medical Coordinator for Cambodia, said: “Throughout our work, we have noticed that Cambodians want to die at home, amidst their family and loved ones. This is the main reason why we created specifically a home-based care service, and not a hospice building.”
Access to morphine is particularly challenging in Cambodia. Doctors are not used to working with and prescribing strong opioids,and many are afraid of these medications. At the same time, there is a lack of training and information on opioids from hospitals and training institutions.
In Cambodia, as in many places worldwide, non-communicable diseases have been left behind in terms of public health funding and practice. Communicable diseases (HIV, TB, malaria) remain the main recipient of funds mainly due to donors’ policies and preferences. This lack of funding, and even interest, has a huge impact for palliative care in Cambodia, which deals mainly with NCDs.
In terms of future work, DSF is currently reaching out to new partners to increase capacity to find patients in need of palliative care. At the same time, the organisation is planning to expand activities to include people at the end of life with other types of diseases (in Cambodia these include: rabies, organ failure, neurodegenerative diseases, HIV, TB and geriatric issues, among others).
DSF also plans to expand activities beyond urban centres to reach people with palliative care needs in the provinces.
Dr Colin said: “By 2020, we want to create a national network for palliative care, managed by a Khmer organization, regrouping home-based care teams working in each province.
“The palliative care services created should be accessible by everyone, no matter their diagnosis or financial capabilities, and it should be available everywhere. We are aiming for this palliative care network to be self-financed through a digressive participatory billing system.”
Read more about the work of Douleurs Sans Frontières online.