By Alex Consiglio and Hay Pisey
The Cambodia Daily
As the number of villagers testing positive for HIV continues to climb in Battambang province’s Roka commune, the Health Ministry is scrambling to rein in the illegal medical practices that may have led to the outbreak and are widespread throughout the country.
Two hundred and twenty-six villagers in Sangke district’s Roka commune have now tested positive for HIV since the commune health center began preliminary tests on December 8, deputy commune chief Soeum Chhom said Sunday.
Yem Chrin, an unlicensed doctor who often made house calls and treated his patients using injections, admitted to police that he reused syringes on multiple occasions, and was jailed on murder charges on December 22.
The cause of the outbreak remains unknown, but a government-led task force, which includes the U.S. Centers for Disease Control, is investigating possible sources of the epidemic and has sent blood samples abroad to determine whether the villagers’ infections share the same viral subtype, which can help narrow down the mode of transmission.
Medical experts say the reuse of syringes is unlikely to be the sole cause of the HIV outbreak, but that it is plausible a lone medical practitioner single-handedly spread the virus to hundreds of people if infection prevention protocols were not followed.
“This can happen anywhere,” said Ung Prahors, acting director of the Cambodian Health Committee, an NGO that provides assistance to villagers in poor communes suffering from AIDS and tuberculosis.
“We have seen through our work…that there are a lot of unlicensed health workers who go around injecting people,” Dr. Prahors said. “If they do not practice infection prevention control, they will also spread HIV in the villages.”
Last week, the Health Ministry issued a directive to provincial health department officials, as well as provincial police and prosecutors, urging them to stop unlicensed health care workers from operating in their jurisdictions.
“Please take the most serious measures against unlicensed health services that do not comply with the law…by filing cases of unlicensed health services to the court,” says the document, which is signed by Health Minister Mam Bunheng.
Oum Sopheap, the director of Khana, a local HIV prevention and support NGO that has been aiding Roka commune residents who have tested positive for the virus, said Mr. Chrin was able to operate in the commune for many years because health officials do not proactively seek out unlicensed health-care workers.
“It’s not until something like this happens that there is a response from the government,” he said. “It’s [Mr. Chrin’s] responsibility for using dirty needles—he needs to be held responsible—but it’s also the authorities’ responsibility. It seems he was able to operate a long time without any proper checks.”
Srun Sok, director of the Health Ministry’s hospital services department, which oversees the licensing of doctors and clinics, said in a recent interview that his ministry was unaware of Mr. Chrin’s practice.
“We didn’t know, because there were no reports on this person,” he said. “It must be the commune chief or chief of the commune health center that reports it to the district level,” which then informs the provincial health department.
However, By Beng Sor, who took over as director of the Roka health center about a year ago, said he was not aware that he was meant to be responsible for reporting on health-care workers operating without a license.
“I have never reported any,” said Mr. Beng Sor, noting that Mr. Chrin had been working in the commune for more than a decade. “If they had asked me to, I would have.”
Seth Savuth, the former director of the commune health center, claimed that in 2012 he reported at least two unlicensed health-care workers in Roka commune—including Mr. Chrin—to district health officials.
But the director of the Sangke operational district’s health department, Im Chetra, who oversees the Roka health center, said he never received any reports with Mr. Chrin’s name on them.
“I have not seen his name on the reports,” Mr. Chetra said, adding that while it is easy to crack down on unlicensed clinics, tracking down unlicensed doctors who make house calls is far more difficult.
According to the Health Ministry, the number of unlicensed clinics dropped from 87 in 2010 to zero in 2011, a figure maintained in 2012 and 2013.
The Health Ministry’s Mr. Sok stressed that these statistics only reflect unlicensed practices being run out of a building.
“Currently, we are worried about mobile health workers working illegally,” he said.
Spreading the Virus
Whenever Yuom Nary had a headache or fever, she would ask Mr. Chrin to visit her home and administer an injection or intravenous drip.
Ms. Nary, 25, said she cannot recall what the doctor injected her with, but that his treatments helped and were offered pro bono when she did not have enough money to pay for them.
“I usually had injections and IV drips from him when I had a headache and fever,” she said.
“I got injections not only from him, but also from other doctors who are in my village,” she added. “I had injections with other doctors when he was busy with other patients.”
Chris Grundmann, country director for the University Research Co., which implements programs funded by the U.S. Agency for International Development to improve health care services, said Cambodians often do not feel that they are getting treated properly unless an injection is administered.
“What most people want when they go to a village doctor is an injection of some sort or an IV drip,” he said. “A lot of times, it is a vitamin injection, which is not particularly useful, but [it] is what people want.”
Mr. Sok said Roka commune residents likely choose to be treated by private, unlicensed doctors because the commune health center only administers injections in emergency situations, or as part of a vaccination program.
“The people working at [commune] health centers do not have the knowledge,” he said. “We believe that their capacity, knowledge and skills are not sufficient to provide injections [on demand].”
Sten Vermund, an HIV expert at the Vanderbilt University School of Medicine in Nashville, Tennessee, whose research focuses on developing countries, said it would probably take a long period of time to infect hundreds of people with HIV simply by reusing syringes.
“I think it’s improbable that 200 people would get infected in a single episode of needle-syringe contamination because there is a diluting effect,” Dr. Vermund said. “But it might have been repetitive behavior on the part of the doctor.”
Roka commune residents who have tested positive for HIV include a 4-month-old and a man in his 80s, and migrant workers who had been out of the country for a year.
Considering the range of villagers testing positive for the virus, Dr. Vermund said other possible sources of the infection, via medical practices by so-called “injectionists,” could be the improper use of multi-dose vials.
He said that if Mr. Chrin had been using multi-dose vials—– common in developing countries because they are less expensive—he might have injected an HIV-positive patient and then dipped the needle back into the vials to draw up another dose.
“People can make that mistake, where they’ve inoculated the bottle of medicine so now the next nine doses coming out of that bottle are contaminated, even if they do use a new needle and syringe,” he said. “So you can make the mistake once, and everyone down the line pays the price, even if subsequent needles and syringes are sterile.”
Dr. Vermund added that if Mr. Chrin had been using a saline solution to prepare medications for injection, he might also have contaminated a large supply of the solution by double-dipping a contaminated needle.
“It has to be an absolutely strict protocol [for infection prevention],” he said. “You can’t make one mistake out of ten—you have to make zero mistakes.”
A foreign doctor working in Cambodia, speaking on the condition of anonymity in order not to jeopardize his frequent work with the Health Ministry, said the dangerous practices mentioned by Dr. Vermund were common in the country.
“These bad practices exist in Cambodia because there often isn’t the right supplies,” the doctor said. “In Cambodia, they don’t have single-dose vials for all medications; they often have multi-dose vials.”
Dr. Vermund said that if authorities have confiscated medical tools used by Mr. Chrin that have HIV on them, the virus could be compared to that in villagers’ blood.
“You can do a molecular evaluation to see whether the doctor’s needles have the same viral subtype,” he said. “That would increase the evidence immensely. If they want to definitively evaluate this, it can be done.”