Some Implications of President Clinton’s Visit to Cambodia

January 14, 2007 at 8:05 am (Lee's Posts, Uncategorized)

President Clinton visited Phnom Penh, Cambodia, on December 4, 2006. It was a momentous and significant occasion—it was the first time that any American president (current or former) had ever visited the country. Before that, the most famous American to have ever visited Cambodia was Angelina Jolie. Some still consider her to be #1. Jacqueline Kennedy visited in 1965 to commemorate the completion of a USAID-built road between Phnom Penh and Sihanoukville (which was later destroyed by the Khmer Rouge and recently restored by private corporations—it’s a toll road now). But in my mind, President Clinton easily wins the title for “most important American to visit Cambodia.”

Anyway, President Clinton’s visit was a true success on five fronts:

1) It brought worldwide attention to the Cambodian government’s successful HIV/AIDS treatment program. Back in 1997, Cambodia had the highest HIV prevalence rate in Asia, and it was expected to keep growing quickly. But through successful and targeted prevention and treatment campaigns in a multisectoral response to the epidemic, the government health sector, together with the hard work of many local and international NGOs and international organizations, curbed the prevalence rate to 1.9% in 2003. It is thought to be at 1.6% today. Furthermore, the treatment program and national laboratory system have been streamlined (through large technical and financial contributions by the Clinton Foundation and others) and now boasts over 18,000 people on treatment, including more than 1500 HIV+ children. Cambodia has the highest percentage of people living with HIV/AIDS (PLHAs) who are able to access treatment of any country in Asia, and has the third or fourth most total number of PLHAs on treatment of any country in the world.

All of this had remained relatively unknown to much of the international community, but the President’s visit highlighted the accomplishments of the National Center for HIV/AIDS (NCHADS), a success story within what is usually considered an ineffective and corrupt government.

2) The positive attention and recognition described above, as well as the symbolic importance of a visit from a well-regarded former US President, was an incredibly positive step for Cambodian diplomacy and Cambodian self-confidence. Putting Cambodia on center stage in such a positive light will help to shed some of the massive cultural baggage and self-deprecation that has carried over from the Khmer Rouge. This self-understanding, an almost depressed nationalism, is ubiquitous in the population and can be sensed just below the surface.

3) The Presidential visit highlighted one of the Clinton Foundation HIV/AIDS Initiative’s (CHAI) most successful programs. The partnership between CHAI and NCHADS is seen as a model of seamless and productive collaboration that other programs seek to emulate. CHAI’s accomplishments in assisting NCHADS with massive reductions in the prices of antiretroviral (ARV) drugs, as well as increasing the availability of ARVs within the country, are impressive. CHAI has also helped to restructure NCHADS’ national laboratory system for HIV testing and its logistics management system, thereby improving efficiency in the government’s procurement, storage, and distribution of ARV medicines, lab reagents, and other consumables.

4) President Clinton and Cambodian Prime Minister Hun Sen signed a Memorandum of Understanding (MOU) that allows Cambodia to access UNITAID donations. UNITAID is a newly established drug procurement and donation mechanism, housed within the UN and funded principally by France, Norway, Brazil, and a few other countries. CHAI was asked to and accepted the role of organizer and distributor of these donations.

The signing of the MOU allows the Cambodian government to access large amounts of donations of pediatric ARVs, lab reagents, and therapeutic food supplements (or RUTFs, for severe malnutrition) in 2007 (with ability to renew and increase procurement in 2008). Importantly, it will donate some pediatric fixed dose combinations (FDCs–in this case, 3 drugs in one) and offer further purchases of these ARVs at greatly reduced prices, so that Cambodia will have the means to procure pediatric FDCs for the first time.

The significance of FDCs: adherence to a drug regimen, especially for impoverished people living far from a hospital or health clinic, is one of the most difficult issues facing HIV/AIDS treatment. These drugs are only effective when taken regularly, and FDCs have been shown to improve adherence by creating a simple regimen consisting of taking only one pill, twice a day. With increased access to these pediatric ARVs, NCHADS and CHAI can push forward together towards their goal of a pediatric scale-up involving 1500 new children on ARV treatment in 2007 (doubling the current number of HIV+ children receiving treatment in Cambodia, for a total goal of 3000 by the end of 2007).

5) With photographs of President Clinton hugging, laughing with, and admiring the song-and-dance performances of healthy, active HIV+ children at Maryknoll orphanage, his visit has generated a visual understanding of what it means to have a successful pediatric AIDS treatment program. Hopefully, these images will galvanize support, both technical and financial, in order to scale-up pediatric AIDS treatment programs across the globe. The goal will be to have as many HIV+ children accessing and adhering to an ARV regimen as possible, so that all can appear as active and healthy as the Cambodian children at Maryknoll. I recognize that this statement is simplified and to some extent naïve, and does not account for many issues such as dependence on foreign aid or the additional needs of HIV+ children such as education, nutrition, and psychosocial support (among a whole host of issues). However, as a broad goal it will do.

For more info on the visit, please see my Cambodia blog–there is a link to it on the right-hand side of this page.


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October 31, 2006 at 7:59 am (Lee's Posts)

My job has been quite interesting, challenging and filled with opportunities for learning. There is quite a steep learning curve due to all the policies and acronyms and government bodies that we work with. Unfortunately, I have yet to go for a site visit to the rural provinces to see HIV+ adults and children who are benefiting from the work we’re doing in trying to get them ARV medicines cheaply. But feeling fulfilled by my work is too much to expect in 3 weeks anyway.


Oh, yeah, the basics. I am working for the Clinton Foundation HIV/AIDS Initiative, whose Cambodia office consists of my boss Alex and me. We work inside of the National Center for HIV/AIDS, Dermatology, and STIs (NCHADS) in Phnom Penh. NCHADS is a body of the Ministry of Health (MoH)—really, a whole lot of acronyms. My title is “Cambodia Country Analyst” and I just got business cards made—my first ever! I work in a small room near my boss’ front room; that’s where there was a free desk. Sharing the office with me is Sonyouth, a fun 26-year-old Cambodian who works on Data Management (he majored in Computer Science) and is studying for his MBA. Also in the office about half the time is Nicole Seguy, a middle-aged French woman from the WHO who (haha) is assisting NCHADS with scaling-up treatment and establishing a more efficient data management system.


My first project was to create a poster to visually demonstrate the linkages that need to be made in the Cambodian health system between the Prevention of Mother-to-Child Transmission (PMTCT), pediatric AIDS care, and early diagnostic services like the co-treatment of opportunistic infections (OIs). My first draft of it was apparently too complicated, though graphically easy to follow. The director of NCHADS, Dr. Mean-Chhi Vun, told me to keep it simple (stupid!) and include cartoons, because Cambodians love cartoons.


Essentially, there was an initial crevasse in our communication—I had thought the poster was to train doctors and nurses, but Dr. Vun had wanted it to be accessible mostly to community health workers and the general public (it will be translated into Khmer and available in both languages). He told me that Drs and nurses can read about the exact procedures in a government policy, but that community health workers who only had a minute to glance and learn about the system of referrals needed something bold and simple, something that grabbed them. The project was a great learning experience, both in terms of integrating policy into visual substance, and in terms of better understanding my audience and the needs and structure of the Cambodian health system.

Here’s the complicated poster:


Complicated Poster



And the simple one:





My most challenging project so far has been to write, almost single-handedly, Standard Operating Procedures (SOP) for a government-based coordinating mechanism to implement social care for orphans and vulnerable children (OVC—again with the acronyms). Essentially, I had 2.5 days to draft national policy about something I knew nothing about at the beginning of that first day. We had an initial meeting with members of NGOs working on social care with OVC, namely, Save the Children Australia, UNICEF, New Hope for Cambodian Children (a local NGO run by an American) and members of NCHADS’ AIDS Care unit who specialize in Pediatric AIDS Care. After the meeting, and an initial meeting with the director of NCHADS, Dr. Vun, I set off to read about 300 pages of policy and reports given to me by the meeting attendees. I had one day to read all this, take notes, and then I began writing the next day.


I received a lot of positive feedback from all stakeholders in the draft process—we had two more consultations with the NGOs listed above and I met with Dr. Vun, who told me what needed to be added and changed according to his vision of NCHADS role in providing the mechanism for social care (rather than implementing it themselves).


So the content of the SOP—NCHADS does not have the funds to provide nutritional support, transport subsidies for medical purposes, and educational subsidies (mainly for supplies, because education is supposed to be free impoverished children) for all HIV+ children, much less all OVC in the country. However, Dr. Vun understood that there was a lack of coordination among NGOs operating in the same provinces and districts, and that as a result many funds were wasted and many OVC were not identified (because of the great fear of many NGO funders who require that grants to demonstrate how a project is original and does not overlap with anything currently being implemented).


At the same time, NCHADS will ensure psychosocial support for OVC in the form of peer support groups that meet on the same day as the peer support groups they already set up for HIV+ adults. They will provide funding for these groups.


NCHADS wishes to create the coordinating mechanism for all operations pertaining to social and medical care for OVC, basically providing fora to discuss successful and unsuccessful procedures in order to implement the most effective models in each district. Essentially, the coordinating mechanism model seeks to create flexibility at the local level rather than dictating national policies that must be followed.


The SOP first lists the services that must be included in a Standard Minimum Basket of Social Care for OVC—psychosocial, nutritional, educational, and transport support (recognizing that other essential services like sustainable local socioeconomic projects, adequate shelter, etc are vital but could not be included in the SOP). The SOP creates the mechanisms for meeting at the district level (there are at least 3 districts in each of Cambodia’s 24 provinces) and delineating who should attend the meetings. Allowing for flexibility, these members include Directors of local hospitals, the Head HIV/AIDS officer of the district, the provincial officers from the ministry of education and the ministry of social affairs, reps of NGOs operating in the district, People Living with HIV/AIDS (PLHA), coordinators of peer support groups, and others.


The SOP describes a community-based model for identifying OVC and providing them with social care services. A model centered on pagodas has been very effective across Cambodia. Essentially, the NGOs we consulted with, as well as NCHADS, believe that, rather than create new institutions, the institution most ingrained and established in local Cambodian life—the pagoda—can and, where possible, should be utilized to help the surrounding community. Of course, this model misses certain sectors of the population, and the SOP describes a similar but secular model for performing these tasks.


The Pagoda-Based System:

· Monks, once trained as advocates, spend time visiting communities, identifying OVC—most of whom are in non-residential care settings such as family care, child-headed households, kinship care, community foster care, etc—and talking about HIV/AIDS treatment and prevention.

· Each monk working on the OVC support group shall oversee one neighboring village, depending on its size—monks can successfully conduct OVC identification and social care visits for 15-30 OVC.

· NGOs and donors shall facilitate training, and throughout the identification process, monks shall work with NGOs and donors to map each village under their jurisdiction.

· After establishing presence in the community, village chiefs often assist the reporting of additional OVC to monks.

· Each pagoda calls for practical and supportive responses to care for the children affected, as well as for the communities from which they come. The pagoda assesses separately the needs of individual children and their families.

· The pagoda works with NGOs and donors to provide material and emotional support to these children.


All in all, it’s an innovative and interesting approach to community-based support. There are still many problems, like the gap of trust that exists between HIV+ women and male monks. In this situation, the women often choose not to disclose their HIV+ status to monks, which may reduce the support they and their children receive. Resourceful strategies for building trust at the local level are still needed, and the hope is that the coordinating meetings between relevant stakeholders might generate some of these strategies.


Finally, the SOP delineates the exact procedure and chain-of-communication for connecting the identification of OVC with voluntary HIV testing for many different sectors engaged in work with OVC and HIV/AIDS (NGOs, orphanages, pagodas/faith-based organizations, schools, PMTCT centers, Home-Based Care (HBC) teams, adult peer support groups for PLHAs, and the child protection network). The need for this is obvious—while overall prevalence of HIV in the Cambodian population is estimated at 2%, the estimated level for orphans is 10%+. Basically, these children need to get tested to know their status, to receive immediate HIV education, to learn important preventative measures which have shown to have efficacy in Cambodia (95% of brothel-based sex workers now use condoms, and the overall rate of condom use has increased greatly), and, most importantly, to begin the process of accessing treatment.


The job is quite interesting, and I feel an immediacy to my work, that it might be useful to the people I am writing for/about. I think this is what has driven me to explore public health and global health in general. This immediacy is something that I definitely did not feel while writing my thesis last year in my carrel at Brown, even as I was writing about people I lived with and cared about.


The one thing that most bothered me, however, is that they assigned ME, of all people, to write the SOP. Clearly they value the quality of my writing, but to assign the person who has spent 1 week in the country and has never worked in a healthcare or policy setting to write the SOP—this just seemed ludicrous and irresponsible. I’m sure that if I had gotten off track, they would have told me, and the revisions suggested by Dr. Vun served that purpose.


On the upside, completing the project gave me the opportunity to read about many policies of NCHADS and to learn about a variety issues and multi-sectoral responses to social care, pediatric HIV/AIDS care, the overall status HIV/AIDS care in Cambodia, and the status of OVC here.

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