Fieldset
Cambodia: The Gift of Simplicity
It's estimated that up to 750,000 people in Cambodia are infected with hepatitis C, a virus which can cause potentially life-threatening damage to the liver. Theresa sends an update from the MSF clinic in Phnom Penh...
 
It's estimated that up to 750,000 people in Cambodia are infected with hepatitis C, a virus which can cause potentially life-threatening damage to the liver. Theresa sends an update from the MSF clinic in Phnom Penh...
 
When I'm not seeing patients in the hepatitis C clinic, I'm writing a set of standard operating procedures (SOPs) for the project. These SOPs will ultimately become the basis for the MSF guidelines to treating hepatitis C in Cambodia. 
 
The goal of writing these SOPs is to keep them as simple as possible. The medical infrastructure in Cambodia has been rebuilding slowly since the Khmer Rouge regime and the Vietnamese occupation ended in 1991. Although Phnom Penh, where we are currently based, has most diagnostic options available, the rural provinces where MSF hopes to decentralize its work on hepatitis C will have only the most basic laboratory and radiology studies on hand. So the need to provide a simple set of instructions based upon the easiest-to-use techniques will be an essential part of our work here.

40% of our patients travel hours from the provinces to keep their appointments

So far MSF has introduced rapid diagnostic tests (RDTs) to perform the initial screening on patients suspected to have hepatitis C. These tests look for antibodies to hepatitis C in the patient's bloodstream and can be performed on fingerstick samples, which greatly simplifies the screening process. Soon MSF looks forward to streamlining the next stage of screening, which requires a second blood test to look for actual copies of the virus. This stage may also be accomplished using an RDT.
 
Furthermore, as we are getting more experience with treating patients with direct-acting anti-viral (DAA) medicines, we are finding that few, if any, suffer from serious side-effects, so MSF has decided to cut back on the number of required visits the patients make to our clinic. Given that 40% of our patients travel hours from the provinces to keep these appointments, this will make it easier for them to be treated. I always ask patients how far from Phnom Penh they live. "I'm from Battambang," they'll say, or Kampong Thom, or Kampot--all at least three hours drive from the capital. One woman told me that she'd come from Ratanakiri, a remote northeastern province. "I'm sorry I'm a day late for my appointment, but our cow got away, and by the time I found him I'd missed the bus!" For many of our patients, the $7-10 they must pay in bus fare may represent a week's wages. Simplifying the experience for them is an important part of our service.
A cow walks into a shot of the beautiful green fields of Cambodia

The derelict cow? Photo: Theresa Chan / MSF

Even as we streamline the process for being treated for hepatitis C, some aspects of both the disease and the treatment inevitably add complexity. For example, patients with other medical illnesses need to have these taken into consideration before we start DAAs. In some cases their daily medicines need to be changed, and in others we need to think about the potential impact of DAAs on kidney function. There is no way to eliminate these complexities entirely, because no one comes into treatment as a blank slate. Everybody brings with them an entire personal history, medical and social, which turns a one-size-fits-all protocol into an impossible dream, and introduces so many interesting stories into the work we do.
 
 
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