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Body and Mind |
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Survivors of the Mahantdorai, the Cambodian holocaust, are experiencing a
health crisis that is a direct result of their
extraordinary trauma. Overwhelming evidence shows that
Cambodians who remained in Cambodia from 1970-1980 had
between 8-16 major trauma experiences (Kinzie, 1984;
Meinhardt 1984; Mollica, 1986; Realmuto, 1992) that
include long periods without adequate food or water,
experiencing combat conditions, slave labor,
imprisonment, witnessing atrocities, torture both
physical and psychological, death of family members,
physical injury, sickness without access to health care,
the loss of home, property and country. These trauma
experiences correspond to the categories of experience
described in the literature of survivors of the Nazi
concentration camps and prisoners of war camps.
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Starvation was
identified as a major cause of post trauma health
problems in survivors of the Nazi Holocaust. (Eitinger,
1973; Thygesen et al, 1970 ) One of the most
comprehensive studies of the effects of starvation on the
human body and mind are found in the heroic research of
the physicians of the Warsaw Ghetto. While starving
themselves, they meticulously kept records of their own
conditions and that of their patients, describing in
detail the stages of starvation and their attempts to
understand and treat them. These documents were smuggled
out of the Ghetto and hidden until after the war.
(Winick,(ed) 1979). The dramatic changes in the body
during starvation, described in this study leave little
room for doubt that the body cannot spontaneously recover
from near death starvation. Autopsies in the Ghetto as
well as those done in Concentration Camps show hearts
that have shrunk to half their normal size, mitral valve
prolapse, change in the composition of bone and blood, as
well as changes in the brain.
Cambodian survivors account for four periods of food shortages or starvation
that occurred over a 10-16 year period . The first
shortage occurred between 1970-75 when as many as 3
million Cambodians were forced from their villages
because of the American bombing and the advancing Khmer
Rouge forces. As the fighting increased, the rice
planting and harvesting were disrupted and the only
consistent sources of food available was what was
airlifted into the country. The price of a kilo of pork
was about 30% of the monthly per capita income of the
average Cambodian in peace time. (Kuoch, 1984) Deaths
from starvation were common and malnutrition was almost
universal in the peasant population. The Khmer Rouge
period from 1975-79 brought unprecedented malnutrition
and prolonged periods of starvation in which the daily
calorie intake of non-Khmer Rouge Cambodians did not
exceed 500 calories.
Although there is no known study which examines the food intake during this
period in detail, refugee accounts prove to be very
consistent in describing rations of between 250-400 grams
of rice per day except during the harvest periods at
which time rice intake was more adequate.(Twinning, 1989
) . The invasion by the Vietnamese in 1979 brought the
destruction of the rice crop and produced famine in many
parts of Cambodia. (Shawcross, 1984) Refugees flooded the
Thailand border where the United Nations created a land
bridge specifically for the purpose of distributing food.
The fourth period of food shortage occurred in the
refugee camps where the quantity and quality of food was
erractic. Feeding programs in the camps prevented
starvation, but did not eradicate malnutrition. It is
reasonable to conclude that malnutrition and starvation
were part of life for all survivors who were resettled
after 1975.
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| Forced labor that
included long hours of work under harsh conditions with
inadequate food rations were almost universal experiences
in concentration camps and prisoner of war camps. During
the Pol Pot Regime, slave labor was the rule for everyone
including children who were separated from their families
as young as 8 years old and placed in special work
groups. Refugee accounts of this forced labor describe
10-16 hours of work that included activities normally
delegated to beasts of burden. Teenagers and young adults
were singled out for work on "mobile teams"
which had one of the highest mortality rates because of
exhaustion and exposure to injury. (Twinning,1989)
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Prior to 1975, all
areas of Cambodia were involved in armed conflict. The
American bombing of the countryside was approximately 3
times the intensity of the bombing of Japan throughout
the duration of World War II. (Etcheson,1984) Between
March 1969 and August 1973, 539,129 tons of bombs were
dropped on the countryside including heavily populated
areas. Estimates of death are as high as 600,000.
(Schanberg, 1974 ) Rocket attacks in cities occurred with
regularity usually in the market place, airports or
schools exposing all civilians to warfare. The Khmer
Rouge relied heavily on atrocities to terrorize the
civilian population into submission prior to 1975 and
early in their reign.
The evacuation of Phnom Penh and Battambang City are events which defy
description, as over 3 million people were force marched
out of the cities over a three day period. The death toll
was high, children were separated from their parents and
people were totally unprepared for what they were
experiencing, creating a surreal atmosphere which
continues to defy belief even today. (Ponchaud, 1978).
Between 1975-79, the Khmer Rouge used atrocities selectively to control the
population. Apparently aware that over exposure to
atrocities creates a numbed indifference, Khmer Rouge
leaders terrorized people by threatening to " call
them for a meeting" a euphemism for sending someone
to be killed. Survivors describe hearing people beaten to
death, seeing bloody clothing, hearing cadres brag about
killing and smelling dead bodies, but they saw people
killed on those occasions planned by Khmer leaders or if
they secretly followed the KR to the killing fields.
People more often witnessed atrocities with senses other
than their eyes, a factor which has a profound relevance
on survivors sense of reality as well as the content of
their flashbacks.
Refugees told of a plan to exterminate all witnesses of the Khmer Rouge
atrocities before the Vietnamese army could take control.
During this chaotic period, people often found loved ones
who had been separate for years, only to see them killed
in the violence of that period. The Cambodian Genocide
Project, a U.S. funded program to gather information
about this time period has made the statement that "
After mapping the graves of seven of Cambodia's 22
provinces, using Australian satellites, the investigators
estimate the number to be between 10,000 and 20,000. They
are reckoned to have held an average of 100-250 people
the biggest may contain several thousand victims."
(Econonmist, 1996) Many of these killing fields were in
use throughout the Pol Pot period, and many were dug by
the victims of the Khmer Rouge during the last days of
the regime.
Refugees began pushing across the Thailand border in large numbers in the spring
of 1979. They were starving and looking for a safe haven.
The Thai military rounded up thousands of these survivors
and took them by bus to the mountains where they were
pushed at gun point over the cliffs. They had no food and
all sources of water were surrounded by landmines.
Mothers,despairing of their own survival, gave their
babies away to Thai villagers. Old people had to be
abandoned on the mountainside in yet another forced march
which rivaled the cruelty of the Khmer Rouge period. At
least 10,000 died during what has become known as
"the pushbacks".
Combat and atrocities did not stop when refugees entered the UN controlled
camps inside Cambodia. In fact, many refugees died trying
to enter these camps and many had to pay in gold to get
in. There are accounts of women and children being
kidnapped and sold into prostitution. Thousands of people
who did not have food cards had to hide in tunnels dug
under the camp. Task force 80, a group of Thai rangers
who guarded the camps were notorious for their cruelty
and abuse and eventually outraged the world community
enough to cause them to be replaced. Bandits using
rockets and hand grenades regularly attacked the camps.
Many of the border camps were the head-quarters for the
Cambodian resistance armies which meant that they were
subject to mortar attacks on a fairly regular basis.
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There is no question
that starvation and slave labor were a part of the
torture plan of the Khmer Rouge. It is possible to
control large numbers of people when they are exhausted
and hungry. Brainwashing or indoctrination always
occurred after a long day of work when people were
exhausted and most vulnerable to suggestion. Slogans and
speeches included the concepts that people had no value,
they are always being watched and the Khmer Rouge can
destroy them at any time.(Criddle,1987; Marston,1990)
These are concepts which have a profound effect on
survivors even today.
During the Pol Pot Regime, many people were singled out for additional
torture based on their past involvement with the
military, the government or even a university. Sometimes,
just the fact that someone wore eye glasses was reason
enough to make them a target. The torture techniques were
as cruel and as varied as the torturers themselves.
Isolation, mock executions, beatings, burning, cutting
off fingers, pulling off nails were among the techniques
commonly used. The purpose for the torture was usually
defined as an attempt to obtain a confession of crimes
against the state.
The interrogation of all adults occurred regularly throughout the Pol Pot era.
People "gave their stories" early in 1975 and
these stories were checked for discrepancies at later
times. Changes could be the basis for being "called
to a meeting." If torture is defined as the
infliction of pain for the purpose of taking control,
then there was no greater torture for Cambodians than
being separated from their families and forced to watch
them suffer. Survivor stories are full of descriptions of
how parents and children or siblings tried to find their
loved ones and save them from pain. Khmer Rouge often
forced people to watched their family members be killed
or raped and forbid the survivors to show emotion. This
was perhaps the most cruel torture of all.
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During the civil war and American bombing, people in the countryside lost
access to health care that included both traditional and
Western resources. Malaria which had almost been
eradicated prior to 1970 became a major health problems
as soldiers moved into mosquito infested areas. By the
time the Khmer Rouge took control, sanitation systems
were totally disrupted. The return to a completely
agrarian system which the Khmer Rouge called the
"year zero" had no regard for the lessons of
modern hygiene. People were often ordered to pick up
human and animal feces without the benefit of a tool or
basket. Soap, shampoo, toothpaste were non existent.
Clothing was washed only by the rain and hours of
standing in the fields flooded for the rice crop.
While famine is known to prevent infection and disease, there is no question
that many people suffered from malaria and had
infections. This may be due to the period of time during
rice harvesting when food rations were increased to a
near normal state. Essentially little is known about the
health status of Cambodians during the Pol Pot years.
Cambodians often describe the "Mussulmans"
state in family or friends who died. This is the stage
generally prior to death in which the victims of
starvation looks like skeletons and become indifferent to
their environment. Memories of family members who died in
this state have a disturbing effect on survivors,
especially children who remember the indifference of
their loved one and their own inability to save them.
What sets the Khmer Rouge apart from their Nazi counterparts is that they
immediately and very systematically murdered all known
doctors, scientists or intellectuals who might keep an
account of their atrocities. Hospitals during the Khmer
Rouge era were places where people went to die. There are
even stories of how watery rations of rice soup were
served in the same bowls that were used as bedpans.
(Kuoch,1984) Intravenous solutions were infused using
contaminated solutions that were part of a bizarre
attempt to feign medical care. The few physicians who
survived the Pol Pot Regime, such as Dr. Haing Ngor,
managed to do so by carefully hiding their identity. They
did not dare to treat patients or keep records.
Cambodian survivors have offered stories that suggest the Khmer Rouge used
their victims for medical experiments. An elderly
Cambodian woman described being part of a large group of
starving people who were lined up and had pieces of
bamboo inserted into the tissue on their back. Whether or
not the bamboo contained medication or herbs is unknown,
as is the outcome of the procedure. In other stories,
survivors described being transfused with coconut water.
There is no documented evidence that medical experiments
were sanctioned by the higher authorities within the
Khmer Rouge nor is there any record of the findings, if
there were experiments, according to Ben Kiernan of the
Cambodian Genocide Project at Yale. Likewise, while KR
issued directives for prolonging the life of victims
during the torture process, they are not known to have
kept records of their victims medical conditions.
(however,recent discoveries of documentation of
extermination practices may possibly include these
descriptions) When refugees entered border camps in 1979,
they had access to food that they had not seen in years.
The refeeding period was not under the control of medical
staff which may have contributed to a high rate of
thiamine deficiencies in refugees as well as an increase
in infections. Diseases such as malria, tuberculosis,
hepatitis, as well as typhus, cholera and dengue were
common diagnoses.
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Conditions and
experiences of Cambodians fall into the same extreme
trauma categories experienced by Concentration Camp
Survivors and Prisoners of War and make it reasonable to
rely on the long term research of these groups in
projecting the long term needs of Cambodian survivors. Concentration
Camp Syndrome, a syndrome first observed in
survivors of the Holocaust under Nazi Germany and in
POW's (Prisoners of War).includes the symptoms of
premature aging, reduced resistance to disease, headache,
fatigue, gastrointestinal disorders, depression, social
adjustment problems, and posttraumatic stress disorder.
This syndrome, as described in the medical literature,
persists for decades and causes poor health, emotional
suffering, and early death. The key contributors to
Concentration Camp Syndrome are believed to be long
term starvation, overuse of muscles and bones, exposure
to the elements and exposure to disease. In addition,
exposure to death and atrocities as well as terrorization
and brainwashing are compounded by a loss of a sense of
order in a world where there is no recognizable pattern
of the cause of death or suffering. Clearly ,survivors of
the Mahantdorai fit every aspect of the cri-teria for
what is known as Concentration Camp Syndrome, KZ
Syndrome or Famine Disease
The study of Concentration Camp Survivors and Prisoners of War (POW's)
which began during internment and continued after World
War II offer a 50 year view of the course of disability
in survivors. Leo Eitinger a world renowned expert on Concentration
Camp Syndrome initially described the syndrome as
being organic in nature, but over time, he developed a
integrated understanding of the relationship of the
psychological and physiological aspects of the disorder.
He describes the psychic symptoms of Concentration Camp
Syndrome: increased lassitude, failing memory and
inabil-ity to concentrate, dysphoric moodiness, emotional
labi- lity, sleeplessness, sense of insufficiency, lack
of initiative, nervousness or irritability, vertigo,
vegetative lability, and headaches. Eitinger found that
85 of 100 concentration camp survivors had 5 or more of
these symptoms. Eitinger concludes that these psychic
symptoms are the result of starvation induced organic
brain changes.(Eitinger, 1961) Grovnik and Lunnum found
that 92 of 100 survivors had neurological signs such as
altered reflexes, coordination problems, diminished
sensation, and speech disturbance as well as specific
abnormalities on neurological tests such as a
pneumoencephalogram. These findings confirm Eitinger's
suspicion of organic changes. Eitinger and Strom, in a
different studies, found that survivors had almost three
times the incidence of neurotic symptoms as the general
population; the reported incidence in various investigations
ranges from 24% to over 90%, depending on the method of
diagnosis. How have concentration camp conditions
effected the health of Cambodian survivors? The following
is a description of studies of Cambodian survivors and a
comparison of the studies of survivors of Nazi
Concentration Camps and Prisoners of War.
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Eighteen years after
the first refugees came out of Cambodia there is
surprisingly little available information on survivors
state of health. There is no known longitudinal study of
the health of Cambodian survivors. The information that
is available about the state of health immediately after
the Khmer Rouge Regime can be found in the documents of
the United Nations High Commission for Refugees which
oversaw all the medical programs in the refugee camps.
However, access to these documents is difficult to
obtain, and the raw data would require extensive work to
be given any meaning. Unlike European Concentration Camp
Survivors and Prisoners of War, there was no program to
follow a group of Cambodian survivors over a long period
of time. The movement of refugees through the camps with
some refugee having been in as many as 5 UN monitored
camps, as well as the politics of the camps make it
impossible to replicate the European studies. Likewise,
the lack of legal action against the perpetrators of
crimes aganist humanity have negated the medical studies
that are usually a part of compensation programs for
victims.
However, like European Concentration Camp Survivors, Cambodians died in large
numbers from communicable disease immediately after their
departure from concentration camp conditions under the
Khmer Rouge and like European Survivors, Cambodians
experienced a honeymoon period for several years after
their resettlement in which they had few complaints of
physical or psychological symptoms. By the mid-1980's
Cambodians were subjectively describing themselves to be
in fair to poor health ( Meinhardt 1984; GongGuy, 1987).
Headache, fatigue, muscle and bone pain, palpitations,
dizziness, sweating and "fever" are symptoms
associated with starvation in Concentration Camp
Survivors and are symptoms frequently complained of by
Cambodian survivors.
A treatment outcome study done at the Indochinese Psychiatric Clinic (IPC) in
Boston in 1985 indicated that 40% of Cambodian patients
in that clinic had diagnosed medical disorders in
addition to psychiatric disorders. (Mollica et al, 1985)
The most comprehensive study of Cambodian survivors to
date is found in the report published by the Harvard
Program in Refugee Trauma and the World Federation for
Mental Health titled, Repatriation and Dis-ability: A
Community Study of Health , Mental Health and Social
Functioning of the Khmer Residents of Site Two. This
ramdom sample of 993 Cambodian adults and 182 children,
was completed in June 1990 in the largest Dis-placed
Persons Camp for Cambodians in Thailand. Of the adult
sample 87% of the survivors identified themselves as
being in fair to poor health . Twenty percent described
being in moderate to severe pain. Sixty percent of
children were reported to be in fair to poor health.
Although this study was done on Cambodians overseas who
experienced 5-10 years of additional trauma in the
refugee camps, the data confirms the concentration camp
experience and the range of disabilities that are the
sequelae.
A more recent survey conducted by the Indochinese Psychiatric Clinic (IPC) in
Boston of 168 Cambodians who had lived in Cambodia from
1975-79 and are presently living in Lynn, Massachusetts
was conducted over a 14 month per- iod in 1993-94. Like
survivors of Concentration Camps, Cambodians in this
study had a very high incidence of headache (73.8%),
dizziness ( 69.6%) and weakness(69%). as well as
communicable disease and psychiatric disorders. (Mollica
et al. 1994)
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Starvation and torture
involve extreme stress to the heart and vascular system.
Eitinger and Strom found clear evidence of excess
mortality from coronary heart disease among Holocaust
survivors,and of excessively severe morbidity from
cardiovascular diseases with a high rate of recidivism,
especially coronary heart disease and hypertension.
Inbona describes that his survivor patients in France had
nearly universal tachycardia and other heartbeat
problems. Their hearts turn senile typically twenty years
earlier than normal. He also found frequent circulation
problems in the legs that make it difficult to stand for
long periods of time.
In the Proceedings of International Conference on the Later Effects of
Imprisonment and Deportation. The Hague: World
Veterans Foundation. November, 1961, M.Dvorjectski, M.D.
a physician who was a survivor of the Vilna ghetto
described monitoring the heart rate of other inhabitants
of the ghetto during the course of their famine. He noted
that as the starvation progressed, people developed
bradycardia at rest and tachycardia with even minor
exertion. He also quotes research carried out by Jewish
doctors at the Warsaw Ghetto on cardiac path-ology.
Autopsies on 492 people who died from starvation showed a
correlation between degree of starvation and the size of
the heart muscle. One victim had a heart that weighed
100grams, the usual weight of a heart is approximately
250 grams.
While there are no known studies of the cardiovascular state of Cambodian
survivors, there are several studies which suggest that
they are at risk for cardiovascular disease due to a
change in diet and lifestyle. The State of California is
one of the few states in the nation that maintains health
statistics broken down into ethnic subgroups for Asians.
In Analysis of Health Indicators for California's
Minority Populations , Cambodians had half as many
deaths from coronary heart disease as the white
population of California, but they had four times the
death rate from stroke. The UNBRO Medical Statistics
Annual Report for Border Camps in1987 listed heart
disease and cerebralvascular disease among the three
leading causes of death in adults over the age of 45 and
heart disease as the leading cause of death in adult
women under 45.
Dr. Lawrence Brass a researcher at Yale conducted a study of Prisoners of War
which showed them to have a rate of stroke much higher
(9.3%)than WWII veterans(1.2%) although there was no
difference in the prevalence of hypertension. While the
evidence is not conclusive, it is widely believed that
the Sudden Death Syndrome may be caused by cardiac
arrhymias. This syndrome which occurred more commonly in
the early to mid-1980s among Southeast Asian refugees is
well known in refugee communities because of the dramatic
manner in which victims die. Victims wake from a
terrifying dream complaining of chest pain or holding
their chest and are dead within minutes. In the refugee
camps several deaths would occur within a short time
period generally among young healthy males. During the Asian
Sudden Unexplained Death Syndrome Research Conference Dr.
Michael Brodsky described three female Southeast Asian
women who experienced black outs due to ventricular
tachycardia. " Symptoms included palpitations,
atypical chest pain, sleep dis- orders and psychological
difficulties. Heart rate were measured at 250 beats per
minute. "Their ventricular tachycardia was not
reproducible in an electrophysiologic study. but with the
use of the adrenalinelike medication isoproterenol, the
tachycardia started after stimulation."
Changes in cardiac functioning is a leading cause of death in anorexia
nervousa usually associated with electrolyte imbalance.
However, long term studies of patients who are in remission
show cardiac changes including prolapsed mitral valves
thought to be due to self starvation. To date, studies of
adult Cambodians have shown them to have normal to below
normal blood pressures when monitored at rest.(Chen,
1994; Tanji,J. et al 1994) . In a study completed in
Utah, Burke found that only 3% of her sam-ple of
Cambodian adults had elevated blood pressures. (Burke,
1986 ) A study of children in the Minnesota area however,
showed Cambodian girls to have an above average blood
pressure which might be indicative of future
hypertension.(Munger et al, 1991) Khmer Health Advocates
monitors patients blood pressure routinely and has seen a
definite rise in hypertension over the past several
years. However, hypotension is also a problem which
interferes with the use of some medications.
Subjectively, KHA patients are greatly distressed by
changes in their heart rate. One patient recently stated
she was not concerned when her "heart begins to
race, but when it beats too slowly, I feel like I am
going to die".
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The interaction
between the mind and the body are most dramatically
played out in the survivor of Concentration camp
experiences. Trauma causes stress and stress can cause
arrhythmias. Trauma also causes mental health disorders
which take a high toll on the body of the survivors.
Concentration camp survivor studies originating in the
United States focused on the psychic nature of symptoms
especially PTSD, Post Traumatic Stress Disorder. The
Vietnam Veterans studies of the late 1970's and early
'80's brought greater attention to the phenomenon of long
term psychic sequel-ae. Follow up studies of
concentration camp survivors and prisoners of war showed
that survivors not only had symptoms such as sleep
disorder, flashbacks and nightmare some 40 years after
their trauma experiences, but also that these symptoms
increased as the survivors aged and became physically
more disabled.(Van Kammen,1986)
In the early studies done in the United States of Cambodian survivors, Kinzie
and Mollica were readily able to identify PTSD symptoms
in their patients. Kinzie used the term Concentration
Camp Syndrome in describing the symptoms of
Cambodians in his early studies, and has gone on to do
ground breaking work in the use of beta blockers to
alleviate some of the somatic symptoms associated with
this Syndrome. (Kinzie, 1991) Post Traumatic stress
disorder is one specific set of symptoms often found in
survivors of life threatening traumatic experiences. Its
3 major features are the reexperiencing of the trauma,
symptoms of increased arousal of the nervous system, and
a numbing of responsiveness along with avoidance of
stimuli associated with the traumata. Using a
questionnaire survey of 590 Khmers, the California State
Department of Mental Health found that 16% met the
criteria for PTSD. In a series of more detailed studies
of 69 teenagers, Kinzie and Sack, et. al., found that 40
to 50% of Khmer teenagers who lived through the
Mahantdorai had PTSD, as diagnosed in clinical
interviews.
In a Harvard School of Public Health study of the Site Two refugee camp in
Thailand, Mollica, et al found a 15% incidence of PTSD
among 993 adults, but more than 60% experienced some
symptoms associated with PTSD. Khmer Health Advocates
identifies some PTSD symptoms in almost all patients and
reports an increase in PTSD as a presenting problem in
recent years. Patients describe more pronounced intrusive
symptoms especially auditory flashback that are often
reported as "hearing noise" but upon
questioning are clearly sounds from the past. These are
often misdiagnosed as auditory hallucinations in patients
who are agitated by the sounds and unable to communicate
their history.
Most of the epidemiological studies of de-pression among Cambodians
in the medical literature indicate that clinical
depression is also very common among survivors of the
Mahantdorai. In a Harvard School of Public Health study
of the Site Two refugee camp in Thailand, Mollica, et al
found a 55% incidence of clinical depression among 993
adults, using culturally appropriate diagnostic
techniques. In the United States, Kinzie and Sack, et al
found 53% incidence of clinical depression among 69 Khmer
teen agers. The California State Department of Mental
Health found 36% incidence among Khmers using a
population level survey. Using a nonclinical definition
of depression, Rumbaut found 32% incidence among Khmers.
Among survivors of Nazi concentration camps, Thygesen et al found 59%
incidence of clinical depression, along with many of the
symptoms now recognized as posttraumatic stress disorder.
Fatigue which is described as a central symptom in
Concentration Camp Syndrome is also a central symptom of
depression and it is often dismissed as a somatic display
of a psychological problems. Eitinger believes that
fatigue is an organic symptom that is directly related to
long term starvation. Other experts in the field,
attribute it to neurasthenia, or to depression. In the
UNBRO annual report for 1987, fatigue was the most common
noninfectious condition to be treated in the Out Patient
Department of all of the border camps. Approximately 7%
of the camps population sought treatment for this
problem.
Khmer Health Advocates
see fatigue coupled with numbness of the extremities,
symptoms that are extremely common in the patient population.
Watching Cambodians pound on their arms and legs during a
conversation is a common occurrence and a behavior that
rarely draws attention or comment from other Cambodians.
A Recent random survey of Cambodians in the Greater
Boston area conducted by the Harvard Refugee Trauma
Program suggests that numbness is more frequent in the
patient population than in the general Cambodian
population and the level of distress experienced by
patients suggests that it may be a symptom that causes
survivors to seek treatment. Carlson and Roesser have
found that 84% of a random sample of Cambodians
experience dissociative symptoms. With this in mind it is
difficult to determine if numbness of the extremities is
due to dissociation or cardiovascular problems. Khmer
Health Advocates has seen numbness improve dramatically
in some patients with a low dose of Prozac, while other
patients continue to complain of numbness long after
symptoms of anxiety and depression has been alleviated.
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Evidence of dissociation in KHA's patients is most dramatic in
adolescents who were born during the Pol Pot Regime.
During one family session a rebellious,
"Americanized" teenaged girl who had no memory
of Cambodia turned into a drooling, stuporous child as
her mother described the death of her brother during the
Pol Pot Regime. A major conflict developed between
parents and the child protection workers who saw the girl
as being a victim of her parents inability to
acculturate. An evaluation done by a child psychiatrist
did not include any mention of dissociation and
identified the girl as having an adjustment problem. The
report also did not include a trauma history. In a
variation of this same theme, a heavy set Cambodian boy
terrorized his teachers and then turned into a clinging,
frightened child when he was with his parents. He was
able to function well in a structured environment but
became belligerent and hyperactive in a mainstream
classroom.
Another boy in this age group was suspended from school after sexually
assaulting another student. His rationale for the attack
was that a friend ,"told me to do it." This boy
scored a 4 on the HIP (Hypnosis Induction Profile) The
lack of memory of the child's own trauma experiences has
led many to believe that the trauma is inconsequential to
the development of behavior problems. Short attention
spans have been reported by many teachers of children who
were born during the Khmer Rouge or in refugee camps.
Attempts to have these problems evaluated have proven
troublesome, as the children were either considered
uncooperative or the testing was not considered valid
based on culture.
In a survey of Southeast Asian adolescents in Rhode Island, Diane
Brouusseau Pizzi questioned high school and middle school
girls about their memories of war in Southeast Asia.
While 100% of the Cambodian high school girls thought
about the war, only 33% thought that others Cambodian
adolescents thought about it too. These same children
identified their parents as talking about the war only
once in a- while. As with other survivor groups, there is
the unspoken suggestion that no one is to speak of this
subject which plays such a major role in the lives of
survivors. Khmer Health Advocates frequently encounters
families in which the children have no idea of the
circumstances of their resettlement in the United States.
One young man who is from an ethnic Lao family from
Cambodia had no idea that he came from Cambodia or that
his twin brother had died during the Khmer Rouge. He
always thought that the reason his mother never came out
of her bedroom was because he made so much trouble for
the family.
In a study of startle respones of Cambodians traumatized as children, female
survivors demonstrated an unusual lack of physiologic
response to a startle paradigm. (Wright et al. 1994) This
brings into question the accepted understanding of the
adaptation process in trauma victims and validates the
complexity of evaluating the traumatized Cambodian child.
Dr. Robert Krell, a child psychiatrist and expert on
Concentration Camp Survivors has pointed out that most
children who survived concentration camps have remained
silent about their experiences. "Their memories,
rather than fading with time, have intensified
....Parents and even psychiatrists do not credit child
survivors with their ability to remember. As a result,
child survivors have difficulty verifying their memories
and have spoken very little about them." Many years
after their trauma experiences, child survivors are
having breakdowns and instrusive memories. (Krell et al.
1990).
Parents and teachers describe personality changes in young adults that leaves
them baffled and uncertain how to deal with them. While
the extreme trauma experienced by many children, early in
their development years, would lend itself to multiple
personality disorder, there are no published studies of
this condition in Cambodian children. However, Dr.
William Sack and his associates have clearly identified
PTSD in a longitudinal study of Cambodian adolescents and
have verified the cross-cultural appropriateness of this
diagnosis. In a chapter of a bilingual book called, Harvard
Guide to Khmer Mental Health, Richard Mollica
writes, "Cambodian leaders who have worked with
Khmer refugee children have observed that children who
have the greatest stress express it by an inability to
concentrate or sit still. This has been affirmed by lay
workers and border officials in the camps. All felt that
the most disturbed children had the following symptoms:
poor concentration, distractibility, inability to focus
on learning, nervousness, constant movement and
anxiety." These observation were made while children
were in a continuing traumatic environment. How are these
symptoms interpreted when the child is far away from
their trauma experience? How many of these symptoms are
due to organic changes similar to those of adults.
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The availability of sophisticated diagnostic tools have again shifted the
focus of survivor studies back to organic origins of
symptoms. Recent studies of combat veterans and
Concentration Camp Survivors have shown what are believed
to be trauma related changes in the hippochampus that are
associated with problems of concentration and short term
memory in survivors. (Bremmer, 1995) The Indochinese
Psychiatric Clinic is presently completing a indepth
evaluation of fifty Cambodian Survivors who were given a
complete neurological exam including an MRI, SPECT scan
and EEG. "Preliminary results indicate that a
history of torture is associated with hidden or
undiagnosed traumatic brain injury which may be
interfering with postive response to psychiatric
treatment."(Mathias, 1995) Combat veterans have been
the focus of many studies since the Vietnam Veteran
Project began in the late 1970's and early 1980's.
Neuropathy was found in Prisoners of War which is
believed to be due to nutritional deficiencies.
(Hong,1986) Neuropathy including optic atrophy and
sensorineural deafness is associated with the starvation
conditions of the Prisoner of War experience.(Gill, G et
al., 1981) The magnitude of the health problems of
survivors of Concentration Camp experiences makes the
further exploration of the co-existence of physical
illness overwhelming. Again, the interaction of the body
and mind must be respected to fully comprehend the
struggle of the survivor.
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Upon their release from Concentration camps, up to 18% of survivors had
active tuberculosis, report Eitinger & Strøm; many
more died from it before release from refugee camps in
1949. Years later, Strøm (reported in Thygesen et al)
found that 14.5% of survivors still had active
tuberculosis cases. There are severe longterm effects of
tuberculosis that persist even after recovery. Cambodian
refugees entering the United States were required to
complete treatment for active TB prior to their arrival.
In 5 studies completed between 1980 and 1984, Cambodians
with a postive TB skin test numbered between 39-57% of
those screened. (Erickson, 1980;Cantazaro, 1982;
Sutherland et a, 1983; Barry et al) Infectious hepatitis
is prevalent in ap-proximately 14% of Cambodian refugees
and Cambodians have a carrier rate 3times that of the
general population.(Cantezaro 1982; Judson, 1984) While
statistics are rare that include the ethnic subdivisions,
the California tumor registry showed a high proportional
incidence ratio of liver cancer in Cambodian men. While
this does not necessarily indicate a higher incidence
rate, it does indicate cancer sites that should be
targeted for intervention in the Cambodian population.
Hepatitis was a major cause of illness in POW's who were
interned in the Japanese camps. Evidence of hepatitis B
was found in 20% of these POW's. It is estimated that
approximately 10% of those with hepatitis B have gone on
to have severe problems with their liver. (Venn, 1991)
Many investigators have reported on the high incidence of ulcers and
diarrhea among survivors of the Nazi concentration camps.
Eitinger & Strøm reported that 20% of exprisoners
had ulcers or other peptic disorders compared with 8.6%
in the matched control sample, and with much greater
severity. They find similar results with regard to other
digestive diseases. Thygesen et al, in a study of 373
former prison-ers, find ulcers with incidence of 25% and
periodic diarrhea with incidence of more than 50%.
Cirrhosis of the liverÑmore commonly associated with
alcohol abuseÑis also a sequel of starvation. Thygesen
et al list several studies that indicate cirrhosis of the
liver as a major cause of death among survivors.
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Gastrointestinal
disorders are seen extremely frequently in KHA's patient
population. Symptoms include bloating, heart burn,
constipation and diarrhea. These are among the most
difficult symptoms to alleviate and KHA knows of no
patient who has been symptom free following treatment. At
the same time, many patients experience an increase in
PTSD symptoms associated with an episode of GI
disturbance as well as an increase in memories of
starvation trauma . This combination of symptoms often
causes internists to dismiss the physical symptom and
attribute it to psychological factors.
The H.phylori bacteria, now known to be an important factor in the development
of ulcers and gastric inflammation is more prevalent in
unsanitary living conditions, a uni versal exper-ience
for survivors. Although cancer statistics often do not
include ethnic subcategories, it should be noted that
stomach cancer is part-icularly high in Asian women.
There is also an association between H. pylori infection
and a higher incidence of stomach cancer. In view of
recent information about ulcers, as well as studies that
show that such conditions as tropical sprue are found in
POWs and travellers as long after their exposure, it
would seem reasonable to suspect organic causes for
chronic gastrointestinal distress.
The high rate of
hepatitis B in Cambodian survivors also must be
considered when they complain of digestive problems.
Liver cancer and cirrhosis are becoming increasingly more
common which is consistent with findings about POW's and
Concentration Camp Survivors. While digestive problems
may be due to past starvation, it must be noted that
survivors are also found to have parasites more than 10
years after their resettlement. (Lurio et al, 1991)
Intestinal parasites commonly cause bloating and GI
distress. Prevalance rates of parasites in newly
resettled Cambodian refugees were extremely high with 67%
of a large study having one or more parasite. Hookworm is
the most common parasite in Cambodians and is a major
cause of anemia. In this same study, 48 % of Cambodians
screened had anemia.(Catazaro et al. 1982) In reviewing
medical records, KHA found a number of survivors who have
high eosinophil counts and who have had their GI symptoms
dismissed as being stress related.
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Malnutrition and starvation can lead to various disorders of the skeletal
system caused by decalcification, according to Deveen.
Rheumatism, osteoporosis, and other disorders are
reported with great frequency in the literature. These
disorders develop slowly, and are often confused with
natural aging. But epidemiological evidence shows that
concentration camp survivors experience much earlier
onset (premature aging) of these skeletal diseases.
Thygesen et al detail a number of studies that show early
onset and extreme severity of these diseases; Eitinger
& Strøm found 47.5% inci-dence of musculoskeletal
diseases, much greater than average severity. Eitinger
& Strøm pointed out that musculoskeletal diseases
can be very debilitating, and thus a major factor in many
survivors inability to maintain employment. Khmer Health
Advocates reports almost universal experience of body
pain in adolescent and adult survivors.
The most common pain is in the shoulders with periodic numbness in the hand
and arms. Leg cramps are also a problem that survivors
frequently do not mention as they consider them a simple
fact of life. In a study of 100 Concentration Camp
Survivors, "2/3 of the 100 patients have suffered
considerable discomfort from "radicular" pains
and paresthesia, pains in the neck and arms."
according to Grønvik. Chronic pain play a big role in
sleep problems and often gets overlooked in light of the
overwhelming symptoms of PTSD with the accompanying
nightmares and night terrors. The inefficiency of sleep
is noted in several studies of PTSD and undoubtedly plays
a major role in the experience of fatigue. In light of
liver problems, there is also a concern that Cambodians
rely heavily on acetominophen for pain and alcohol for
sleep, a potentially deadly combination.
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concentration camp survivors that associate thyroid
disorders with trauma have not been found. However, more
recently, abnormal thyroid studies have been associated
with trauma. KHA notes abnormal T3 and T4's, in patient
records and has had several patients with goiter. Large
numbers of female survivors were reported to have very
noticeable hair loss, including bald spots. This problem
is extremely demoralizing for women who feel that it is a
continuation of their de-grading existence during the
Khmer Rouge. Metabolic disorders were commonly found in
Concentration camp survivors as well as sur-vivors of
famine. Some correlation has been found between survivors
of famine and the development of diabetes. The only study
of the incidence of diabetes in Cambodian survivors is a
study of gestational diabetes which is ex-tremely high
among Cambodian women. KHA believes the rate of diabetes
to be high in Cambodian survivors and questions whether
changes in blood sugar can account for some of the high
incidence of headache, dizziness and fatigue.
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Chronic health problems as well as signs of premature aging greatly
diminish the quality of life for survivors. Vision
changes were prevalent in concentration camp survivors
with the early development of cataracts due to
nutritional deficiencies. Cataracts are extremely
prevalent in young and middle age Cambodians and while
the prevalence of cataracts is common in Asia, KHA
suspect that the incidence in Cambodian survivors is
higher than usual. The distress from these eye conditions
is often not mentioned until the survivor is unable to
work or take care of their chores. Among other vision
problems are the reports of psychosomatic blindness among
Cambodian women in California as reported by RozeeKoker.
This report identifies a significant number of women who
have no organic evidence of blindness, but nonetheless
are unable to see. KHA has many patients who complain of
vision problems and although they never describe
blindness, they commonly describe their vision as being
dim. In a review of medical records, KHA has found that
several of these patients have been diagnosed as having
psychosomatic blindness by ophthalmologists. The low
incidence of reported cases of psychosomatic blindness in
states other than California may be due to the priority
of symptoms for which survivors seek treatment.
Hearing problems are another chronic condition which have both a physical and
psychosomatic basis. Symptoms of "ringing in the
ears" or "hearing a buzzing noise" are
very common as well as an almost universal complaint of
vertigo, true dizziness rather than lightheartedness.
Hearing loss due to chronic infections are common and
noted in the literature of Cambodians survivors, however,
little is known about inner ear conditions. Studies of
Concentration Camp Survivors indicate that syncope and
Menieretype attacks were common. The majority of KHA
adult patients report "hearing sounds or noise"
that can be annoying or distressing. On questioning, some
patients will confide that they believe the sounds to be
the voices of ghosts and when asked for details, they are
able to identify the voices which are most often
associated with a trauma event. This leads to the
speculation that auditory flashbacks are a much more
common symptom than originally observed.
Likewise dental problems with loss of teeth and gum disease certainly
take a toll on the digestive system and must be
considered when evaluating digestive problems. The loss
of teeth are also associated with blows to the head from
assaults or injuries as well as a neglect of dental
hygiene during the Pol Pot Regime and afterwards due to
the prohibitive costs of dental care. The widespread use
of betel nut which is chewed like tobacco coats the teeth
with a red-black film which is believed to protect them
from decay. This practice is most common in middle age to
elderly women and has been associated with cancer of the
mouth.
Other mysterious symptoms include severe motion sickness that can prevent
survivors from seeking medical care or having a social
life as the trip to the doctors office or to the wed-ding
is so distressing that it is not worth the effort. The
complexity of Cambodian survivors health problems are
overwhelming. Even under the best of circumstances where
there are sensitive, trained translators and health care
providers familiar with severe trauma, treatment is
complicated and long term . As survivors of torture, it
is often terrifying for Cambodians to undergo having
blood drawn or CAT scans that enclose them in a small
space. Medications are unfamiliar and frightening to
people who hear rumors of addictions and complications of
using traditional and western medicine together.
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Psychosocial problems are as complex as medical problems, but again they mirror
the problems experienced by Concentration Camp survivors
and POW's and torture victims. The depression and
disability, often unrecognized by society, of
Concentration Camp Syndrome can push some to commit
suicide. Thygesen et al report a striking number of
suicides among Danish survivors, and Eitinger and Strøm
note that suicides were unusually common among Norwegian
survivors over 50 years old. We have no known statistics
of the suicide rates in Cambodians, but have knowledge of
deaths from suicide in Connecticut, Rhode Island and
Massachusetts as well as attempted suicides among Khmer
survivors, especially among unaccompanied minors.
Violence has long been a part of Cambodian life and survivors often have their
trauma experiences re-enacted in the home and on the
streets. In California, Cambodians have been rumored to
have the highest murder rate of all of the Asian groups.
Statistics from the Department of Corrections in
California show that 40% of the 64 Cambodians presently
serving sentences in prison are there for killing
some-one. Another 11% are there for assault Despair and
violence are most obvious in areas with large
concentrations of Cambodians such as Southern California
and Lowell, Massachusetts where incidence of murder are
often stunningly shocking in their brutality. A mother
shot through the heart while nursing her baby, three
children attacked and murdered with a machete by a
boyfriend who feared being rejected.
Domestic violence and child abuse are common in every state but access to the
numbers of families experiencing these problems is very
difficult to obtain. Arrest records do not indicate when
assault is committed at home. Statistics from state
agencies designated to protect children are more
difficult to obtain as they are not uniform in their
categorization of ethnic groups. Sam Chittapalo, the
Asian Affairs Liaison officer with the Long Beach Police
De-partment says that there are 2,762 cases of Cambodian
families currently involved with the Division of Children
and Families because of juvenile problems, domestic
violence and child abuse. Malis Oeur Chum in a chapter on
domestic violence in the Harvard Guide to Khmer Mental
Health describes the process in which families
experiencing domestic violence isolate themselves. She
speculates that the community does not interfere because
of a fear of retaliation. (OeurChum, 1996). Revenge for
all manner of slights, real or imagined, are a major
cause of assaults in the Cambodian community.
In Cambodia, domestic violence is considered to be at epidemic levels. A
research project funded by the Montreal based
International Devel-opment Research Center and carried
out by the Ministry of Women's Affairs and the Project
Against Domestic Violence found evidence of as many as a
quarter of a million women seriously injured by domestic
violence. Essentially one out of six women is a victim of
this problem Sima Wali reports that research conducted by
Refugee Women in Development finds that women who were
raped during their escape from their country are more
likely to be victims of domestic violence.(Wali, 1993)
Trauma victims need for control is cited as an important
aspect of domestic violence and loss of control is often
felt to be life threatening. Without question, dealing
with this issue is only the beginning of a long process
of unraveling the threads of violence which have plagued
Cambodian families for more than a quarter of a century.
The expression of violence is found in all age groups. Among Cambodians,
youth gangs are common and violent, perhaps replacing the
youth groups of older siblings. The gang problem is most
serious in Long Beach, California, where, according to
Detective Sorensen of the Long Beach Police Department,
there are about 30 homicides involving Cambodian gangs
each year, and continuous violence between the Cambodian
gangs and the Hispanic gangs. The gangs also target Khmer
businesses and families for robbery and extortion. The
gangs are beginning to spread beyond their birthplaces:
Detective Sorensen tells of gang members traveling across
the country to escape the police, who simply join gangs
again in their new home. Khmer Health Advocates is aware
of gang related assaults and deaths in New York, Rhode
Island, Massachusetts and Connecticut. Cambodian adult
survivors see gangs as a continuation of the Khmer Rouge
influence, stealing their children and turning them into
strangers, a problem compounded by the very real language
barriers between the generations.
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Alcohol abuse is commonly associated with depressive symptoms and nervous
problems. Eitinger & Strøm found that concentration
camp survivors were ten times more likely to be alcohol
abusers, based on hospitalization. Their study methods
revealed only the most severe cases, but still 17% of
their subjects were alcohol abusers in Norway, where laws
against alcohol are strict. Cambodians face many of the
same risk factors, and KHA can anecdotally confirm that
alcohol abuse is a problem among Khmers based on our own
observation of many cases. Among Cambodian survivors
there is evidence of a growing alcohol and drug problem.
One study identified a drinking problem among Cambodian
women in Massachusetts (D'avanzo et al, 1994 ) and a
MICAS needs assessment showed that drinking is considered
to be a major problem identified by survivors.
Khmer Health Advocates has no doubt of the severity of the alcohol problem but
without concrete data is unable to determine how much of
the alcohol abuse is an attempt to control symptoms of
PTSD. What proportion of alcohol abuse can be traced to
familial predisposition and what belongs to trauma? It is
interesting to note that in the UNBRO report for 1987,
intoxication was listed as one of the leading causes of
death in women. In considering the long term health of
survivors, it also must be noted that there is an
extremely heavy dependency on smoking in the Cambodian
population. While the largest number of smokers can be
found among males, wo men are also smoking in large
numbers. Smoking was used as a means of controlling
appetite during the Pol Pot Regime and its comforting
role makes it extremely pernicious as an addiction. In
light of a high incidence of asthma and TB, there is no
question that smoking will greatly diminish the quality
of life for survivors.
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Problems with access
to care have been a continuous problem for Cambodian
survivors and a costly problem for tax payers. Lack of
trained medical translators has caused health care
providers to depend on expensive and often mean-ingless
laboratory testing which frightens survivors and deepens
the barrier to communications. Likewise, test results are
often not communicated to the patient or are meaningless
to them within their cultural concept of illness. This
causes many survivors to avoid seeking Western treatment
or to be non-compliant with a plan for follow up care.
Many survivors rely on traditional medicine or
pseudo-traditional medicine to cure symptoms.
Traditional healers find it difficult to practice in the United States as
they do not have access to herbs or the ability to
support themselves while they practice their healing
rituals. The mental and spiritual preparation necessary
for being a traditional healer is difficult in the United
States. Experienced traditional healers have a clear
understanding of what symptoms they can cure and what
conditions need referral for Western treatment. The
emergence of "quacks" who claim to have
traditional medicine to cure survivors symptoms is
prevalent and costly to families who are living below the
poverty level. Nonetheless, KHA has seen families that
will spend $100 for a vial of medicine to cure stomach
distress or will spent $500 for a transfusion in New
York's Chinatown. Use of these methods often postpones
treatment for serious conditions or threatens the
compliance with Western medicines. It also potentially
puts Cambodians at risk for AIDS because of the
circumstances surrounding intravenous medication use.
Cambodians are often secretive about the use of these
methods as they feel that Western providers do not
understand "Cambodian" illness.
The United States is one of the few countries in the world that has not had
the experience of war within its borders in this century.
Health care providers have little experience with
conditions associated with war trauma and are able to
refer combat veterans to federal hospitals for treatment,
reducing the necessity for expertise in this area of
medicine. Conditions associated with starvation are also
rarely seen in general practices and few practitioners
think of nutritional disorders when they hear symptoms of
headache, dizziness or numbness or are evaluating
attention deficits and memory disorders.
Cambodian survivors often associate the telling of their trauma stories with
past exper-iences. Biographies were compiled during the
Khmer Rouge Regime for the purpose of finding
"enemies of the regime" and people who provided
inconsistent stories were often executed. During the
refugee camp experience, immigration officers were also
threatening or abusive to refugees whose stories were
told in an inconsistent manner, a pattern often seen in
severe trauma. Likewise in a health setting, survivors
often feel threatened as well as overwhelmed by the need
to provide complex details in a limited amount of time,
usually without a trained translator. They get little
comfort from a declaration that this is nothing wrong
with them based on a lab test. A review of medical
records of KHA patients reveal that few health care
provider elicit information about trauma experiences.
This may be due to a concern about stirring up painful
memories, but most likely, it is based on difficulty with
communications and the length of time it takes to
describe a complex health history.
While KHA has no statistics on the numbers of Cambodians without health
insurance, within the Cambodian community in Connecticut
only a handful of people are presently receiving public
assistance and medicaid. The vast majority are among the
working poor who work several low paying jobs many of
which may offer health insurance, but only for the worker
and not their family. KHA has also seen instances when
survivors were able to see a doctor, but could not afford
medication. In states with small refugee populations,
there are often no support persons to help people find
available resources. Studies of managed care in
relationship to immigrants and refugees suggest that this
system of health care has increased the barriers to
access for non-English speaking people.( Chicago
Institute on Urban Poverty, 1996)
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The disability rate of
Concentration Camp Survivors was at least 80% according
to most studies. (Eitinger, 1973) How many of these
disabilities could have been prevented with prompt
treatment and prevention of secondary health problems?
Issues of liability often send research money into the
areas of identification of disorders and their cause and
little money into preventing the secondary conditions
associated with extreme trauma. There are several areas
of prevention which could in fact prevent many health
problems and save survivors and their families needless
pain. Without question, programs that addresses substance
abuse in the survivor population could pay for themselves
100 times over in what it would save in treatment and
family dysfunction.
At the present time, the HIV/AIDS prevalence rate in Cambodians is so low that
it is almost impossible to get funding for prevention
programs that target Khmer speakers. This is despite the
fact that the country of Cambodia has one of the highest
rate of growth of new cases of HIV/AIDS in the world
today. The WHO puts the numbers of HIV infected people at
150,000. The Southeat Asian Health Project identified 48%
of prostitutes being HIV positive. Cambodians from the
United States are travelling back to Cambodia in large
numbers and are at great risk for contracting strains of
HIV/AIDS that are presently rare in the United States. A
needs assessment done in Connecticut in 1995 showed that
65% of the 30 Cambodians who were interviewed believed
that they had little or no chance of getting AIDS despite
the fact that more than 90% believed that it was
moderately common to very common for men to have sex
outside of marriage. ( Dyton, 1996)
Prevention of child abuse and domestic violence should be a priority in
communities with histories of trauma. The cost of family
investigations, foster care, court cost and incarceration
cost in relation to domestic violence and child abuse are
known to be extremely high, but there is no known study
of the prevalence and cost in the Cambodian community.
Prevention of mental health problems is not an area that
receives funding in this population despite the high
incidence of mental health problems. One of the few Khmer
language videos available about mental health problems
was produced by Amos Deinard of the University of
Minnesota and addresses depression and PTSD using
survivors who tell their stories and describe their
symptoms. This video has been extremely valuable in
dispelling the idea that people are alone in their
suffering, but unfortunately, too few resources of this
nature are avail able.
Prevention of communicable disease, cancer, hypertension or stroke is
funded at a minimal level or is nonexistent in some
states, even though prevention would probably save many
lives and certainly prevent costly disabilities. Without
skilled Khmer speaking outreach workers, it is highly
unlikely that TB or hepatitis prophylaxis is possible in
a culture that does not conceptualize the existence of
disease without symptoms. Refugee camps had a high suc-
cess rate in completing prophylaxis as they operated
direct observation treatment and saw their patients on a
daily basis. The need for research on cardiovascular disease
is extremely urgent to identify why Cambodians have such
a high stroke rate. Is it due to cardiac arrhymias,
stress or head injury? Would taking an aspirin a day help
to prevent stroke in the survivor population? It would be
tragic if a lack of research prevented relatively simple
interventions which could prevent costly long term
illness.
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Over the past decade,
the dramatic increase in applications for SSI by
Cambodian survivors has prompted a concern that
Cambodians were feigning illness in an attempt to receive
benefits. The Government Accounting Office pub-lished a
report published in 1994 that was a response to the
dramatic increase in applications for SSI from the
refugee communities across the country. This report
identified a problem with "middlemen" who
charged survivors larges amounts of money to help them
apply for SSI. These middlemen often gave false
information in order to assure that the person qualified
for benefits. While the report was able to identify Khmer
speaking conmen who fraudulently made money at the
expense of refugees, they clearly laid the blame for this
fraud on a lack of professionally trained translators.
The report found no evidence of fraud on the part of the
Cambodian survivor applying for benefits. Nevertheless,
the issue of refugee fraud was the focus of several
television news stories that were both inflammatory and
misleading.
Without question there are always some people who will attempt to beat the
system. However, KHA believes that the level of
disability is considerably higher than that represented
in SSI statistics. KHA has had numerous experiences with
survivors being rejected for SSI based on evaluations
that were made without the use of translators at all. One
elderly man who had a stroke was declare fit to work
because his blood pressure was under control. The
neurologist who examined him failed to determine that
this man had no idea of where he was, who he was living
with or what year it was. In several other cases,
Cambodians were declared cured of psychiatric disorders
because they were taking medication and despite
documented evidence that the person was still
symptomatic. If these Cambodians did not have the support
necessary to demand a hearing and if they did not have
extensive documentation to present to the evaluator, they
would have been rejected. In most cases, applicants
simply give up after they receive a rejection letter. Two
KHA patients received letters that stated, "your
doctor says that you have depression but have been
successfully treated for this disorder." referring
to KHA when in fact, KHA documents said exactly the
opposite.
On an even more dramatic note, KHA has seen evidence of medical neglect
and malpractice in two cases in which people died because
of a lack of medical translators. Medical records
indicated that the treating physicians did not perceive
themselves as having the responsibility to obtain a
medical history prior to treating critically ill patients
because the patient did not speak English. In fact in one
record, the only reference to a concern about a
communication problems was the documented irritation of
the doctor when no one in the refugee's home could speak
English.
To date, KHA knows of no recent comprehensive health needs assessment that has
been completed in the survivor population. Problems
presented by patients suggest that many families have
members who are housebound and unable to seek medical
assistance at all. Likewise, patients who have the most
disabling symptoms are also those who are too disorganized
to consistently return for follow up care. Alcohol abuse,
gambling, promiscuity, domestic violence and child abuse
are social prob lems which are often precipitated by
Concentration Camp Syndrome but quickly stigmatize the
patient as being untreatable. Without adequate outreach
services, these patients are difficult to follow and
usually become involved with the legal system. Because of
language and culture, those survivors who are disabled
are often shut out of rehabilitation services. The
"either or" nature of the disability status
also makes it impossible for disabled individuals to
function at their maximum level. There are no provision
in the SSI status which allows for partial disabilities
or disabilities which are chronic but not necessarily
constant. Cambodian survivors today are sick and injured
and struggling to stay alive. Social Security
Supplemental Income is not compensation, it offers the
average Cambodian about $450 a month and limited access
to health care, hardly an excessive contribution to the
lives of "those who have suffered so much and so
much."
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| Sixteen years after
one of the greatest tragedies in modern history,
Cambodian survivors are fading into obscurity. As this
report is being written, textbooks in Cambodia are being
rewritten and reference to the bloody reign of the Khmer
Rouge is being removed. Only three short months ago, the
United States Congress denied the reality of the
Cambodian experience by simply changing their status from
refugee to alien and declaring them ineligible for Social
Security Supplemental income and Medicare. Survivors
themselves live in fear of retaliation if they speak of
their experience and identify their persecutors. It is
within this context of denial and fear that Cambodian
community workers and health care providers face the
overwhelming tasks of addressing complex problems with
diminishing resources. Those who care for suvivors of massive
trauma must now take on the role of witness and advocate
in order to alleviate pain and improve the quality of
life for people who most certainly have earned
entitlement to care.
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Body & Mind