Text and photos by Fridtjof Morten Jonassen
Fifteen years ago, Norwegian psychiatry professor Edvard Hauff went on a home visit in a rural area of the traumatized Cambodia where the son was possessed by an evil spirit. Inside the hut, Edvard Hauff found a teenage boy with ball and chain around his legs. The boy had been acting strange over a long period of time; he was constantly exhilarated, saw bizarre things and played the guitar and sang songs without breaks. The mother was on the ground crying and the boy’s sisters had left ashamed of the brother’s behavior. They were all convinced that the boy was possessed by evil spirits and, therefore, considered to commit collective suicide. In a culture where it’s all about presenting a blameless appearance, this was truly a disaster.
Hauff recognized the boy’s behavior as a manic psychosis and gave him some psycho pharmaceuticals. Only months after Hauff’s visit, the young man was fit as ever and had even opened his own stall in the village.
“It is experiences like that, which makes it meaningful and fulfilling to work with psychiatry in this country,” says Hauff.
But how did a psychiatry professor from Ulleval in Norway find his way to the rural areas of Asia’s backyard?
I meet Edward Hauff at the medical faculty in Phnom Penh, where he is invited to be an external examiner for the senior students, who for the last three years have specialized in psychiatry. Apparently Hauff is a star within the field of psychiatry in Cambodia.
“My good friend Edvard is the father of psychiatry here in Cambodia,” explains professor and Dean Ka Sunbaunat, and continues:
“Our traumatized people had until a few years ago no chance of receiving psychiatric treatment. Thanks to Edvard, modern treatment has become available throughout the entire country.”
The stress level for the already nervous students isn’t exactly reduced when they are told that the professor from “the North Pole” is going to be their examiner. Not only is he half a meter taller than most people in Cambodia, last year he failed several students.
“What did your patient experience during the period of the Khmer Rouge?” Hauff asks the last of the students to be axamined that day.
Mak Raveang humiliatingly admits that she had forgotten to ask that particular question. On the other hand, she satisfactorily accounts for potential diagnoses and possible treatments, and, thus, passes.
“Congratulations! You are now Cambodia’s 38th specialist in psychiatry,” Hauff says.
“But remember to ask your elderly patients this. Some were inflicted great physical and psychological traumas during Pol Pot,” adds Hauff.
Not until the middle of the 90’s did doctors of Cambodia get the opportunity to specialize within the field of psychiatry. Edvard Hauff has been instrumental in providing this education. Cambodia now has 38 psychiatrists spread across the country’s poly clinics.
Dr. Sunbaunat, who was among the first group of educated psychiatrists, makes it clear that without the effort of Edvard, things wouldn’t have been so successful.
Initially, the program was financed by Norway. Today, the national health department has taken over the responsibilities. But at the faculty in Phnom Penh, they believe that it is still very important that external professionals contribute in raising the standard.
Professor Ka Sunbaunat is one of the victims of the Khmer Rouge. He lost most of his family during the horrible years from 1975 to 1979 but luckily he survived. One of his brothers was tortured to death simply because he had eaten fallen fruit, which he had found on the ground. Like many others Sunbaunat was sent to the countryside in order to work in the rice fields under inhuman conditions.
After Cambodia was freed by Vietnam, Sunbaunat’s first thought was that revenge wouldn’t heal him. Instead he decided to become a psychiatrist in order to help other people.
He has no problems treating former Khmer Rouge supporters. During the trial against those guilty of the atrocities, Sunbaunat was responsible for the psychiatric observation of the main suspect “Duch” of the Toul Sleng prison. But personally he has no faith in the ongoing process:
“The trial won’t cure the distress of the people nor hinder that something like it will ever happen again. At worst, it will have a negative effect if people won’t find the conviction to be righteous,” Sunbaunat says.
Ball and Chain and Bamboo cages
Previously there was a great risk that mentally ill patients would be put in bamboo cages or put in ball and chain. Especially psychotic patients were mistreated.
“Only 13 years ago, I heard about a schizophrenic man, who was trampled to death by a monk who was trying to exorcize evil spirits,” Sunbaunat tells.
Traditional healers hit patients or inflicted facial bruises with hot steam. Today, the offer of modern treatment is well-known in all of Cambodia, which means that families bring their sick family members to the poly clinics. The biggest poly clinic in the country is in Phnom Penh, which daily receives about 300 patients. The hospital was once built with support from the Soviet Union.
Patients and their families are waiting in cool corridors with palm leaves poking through holes in the walls where there should have been windows. A psychotic and anxious young man is held tightly by a fellow patient. Monks and pregnant women are first in line.
“Although we’re short of time and everything happens a bit fast, the accuracy of the diagnoses and treatments are good enough,” Hauff says.
The amount of cases of depression, schizophrenia, and bipolar disorder is about the same as in the West. Common issues are young psychotic men from small villages in the rural areas and depressed middle aged women from the city.
A consultation is 2 US dollars while the medicine is free. The drugs that are used have long been on the market such as lithium, which is used when a patient needs to be treated for bipolar disorder and Haldol, which is used to treat psychotic illnesses.
Psychiatry in a culture of Buddhism
Hauff believes that important symptoms are the same regardless of one’s culture. However, the way symptoms are construed and descriptions of such vary. Delusions can be interpreted differently and in the Buddhism culture you are most likely to believe that atrocities in a previous life are the reason you have problems in your current life; because of a violent past it is a continued post traumatic disorder.
“We find plenty of useful references from Buddhism, which we use in psychiatric knowledge acquisition and therapy. We focus on the messages of the religion; about true understanding, the right way of thinking, and about what can cause such disorders. On the other hand the idea of Buddhism, of karma, can seem passive if you believe that most of your life is already decided by faith.”
Laos is next
The training and educational program has become internationally acclaimed. The World Health Organization and the national health department in Laos currently wish to establish something like the success of Cambodia in its even poorer neighboring country of Laos. Colleagues Hauff and Sunbaunat have already started planning.