The most serious emergency we had to deal with at Villa Maria was the lady who was brought in on the back of a bicycle, having ruptured her uterus during childbirth. We could feel the baby’s legs clearly under the abdominal wall. She needed an emergency laparotomy.  More usual procedures included lancing of breast abscesses, setting fractures, tooth extractions and treatment of gonococcal strictures.  The male ward was full of gonococcal strictures. When Dr Ivanovich, exiled from Yugoslavia for some dark reasons, marched into the ward, he would announce in his stentorian voice,  ‘Oomkoomkoomala  Booroongi?’ (Do you pass urine well?) whereupon all the patients would raise their sticks or whatever and call out, ‘Booroongi!’  The last thing they wanted was the hockey stick, a particularly nasty curved stainless steel bougie that was inserted into the urethra and forced into the bladder rupturing the strictures on the way!  What they really desired was a ‘Murphy’, a magic injection of coloured fluid that would make everything well.   

This was Uganda in 1967.  Medicine was a two tier system.  The shaman or local witch doctor looked after most illness with a combination of herbs, spells and hope.  The western doctor dealt with the rest; mainly surgical conditions. 

But much the same situation exists in Cambodia in 2010.  In Phnom Penh,  traditional medicine exists alongside conventional medicine. So when Trevor, an Australian ex-pat working for an NGO,  had a bad back he was given Clysters or cupping, where you heat the cups up, put them on the back so that the skin is sucked into the cups.  Clysters were abandoned in England by the middle of the nineteenth century.  Chinese herbs are used quite frequently. Acupuncture is used as well. But when a child fell down and started talking gibberish he was said to be suffering with the forest spirits and taken to an animist or shaman for healing.  Others would seek help from the pharmacy, some would might even go to a health clinic.     

Too many doctors in Phnom Penh  rely on tests and shiny equipment than on good clinical practice.  But equipment often breaks down, you cannot get the reagents or the parts, disposables are expensive.  Local substitutes and simple sterilisation techniques tend not to be used.  It’s  like being in a deep pit with a broken ladder, with no money to repair the ladder.

And then there are deeply entrenched prejudices to overcome.  Often a woman will not allow herself to be examined by a male doctor and will refuse Western treatment.  There is a terror of surgery.  Still too many people die because they refuse modern treatments or they can’t afford it. 

If the patient is admitted to hospital, nursing is done by the relatives who supply food, bring in the drugs, test the urine, administer  the bedpans and generally looked after the patients.  The nurses, as they are today, are  more like technicians.  This was what it was like in Villa Maria Hospital in 1967.  In Cambodia they felt that they weren’t being treated properly unless they got an intravenous infusion. 

It’s different  in the country.  Most people go to herbalists.  It’s much cheaper.  Herbalists understand the relationship between the illness, the person, the circumstance and the illness and select appropriate herbs and advice to treat them. 

In  rural Laos, patients prefer to keep their troubles to themselves, but if they fall sick, first the village elders are consulted, then the local healer or shaman.  Great faith is placed in the remedies handed down through generations.  And faith is a great healer!  Only if the disease does not respond to the shaman and time, might they think of contacting a doctor or nurse, but that takes money and a long journey into town.

There is just one doctor for every 9000 patients in rural Laos and most  want to be like western style specialists.  But there is at least one healer in every village and most women have a home spun knowledge or herbs, potions and illness.  Surely some kind of practical educational programme that recognises the best of both systems would be very valuable.  After all, the healers understand the patient and can put in the illness into a context where a combination of herb, home remedy and placebo may prove all that the patient needs, but if they also understood when the illness is not  just the result of circumstance but an infection, a cancer, a chronic inflammation that needs western medicine, then the skills of the western trained doctor can be focussed where they are most needed.             

When it comes down to it, a lot could be achieved by the application of good clinical medicine and simple bench testing,  combined with a working collaboration with local healers.