Case Report - (2015) Volume 3, Issue 2
In Cambodia, anthropology is ignored by most of total population and governmental employees and officers, except historians who can take care of cultural anthropology. Medical anthropology is also ignored by health professional and is not integrated in medical curriculum. There is no national document, text book or article written by Khmer people or medical doctor on medical anthropology as referent comprehensive document on medical anthropology. But it is said among population.
This article is a personal collection of all information and experiences of practice in health issues that the authors have been provided from different ethnic minorities and other sources across the country through decades from 1970 till current date we start to write.
Among general population, the knowledge of modern medicine is just grown in recent decades. The majority of population are not enough educated and their knowledge related to health issue is very limited. They perceive health problems based on traditional concepts that health is composed by earth, water, fire and air. When they become sick it means there is imbalance between these four components of health.
The head is part of the body that everybody could touch. The head represents the site of individual spirits. In addition everyone is protected by spirits protector which is living on the head. It is called masters’ spirits or “kru bathyeay”. Touching gently the head by hand is allowed to older people especially in the family like parents, grandparents, uncles, aunts, rarely older siblings. It is prohibited to touch the head with foot, elbow, or with objects. Touching the head violently or inappropriately, different from cited above site it might cause trouble to the spirits. It might lead to poor intelligence or mental retardation, poor memory, seizures, fever, headache, low school performance, etc.
Khmer people used to believe that “the smaller cannot win the bigger” in Khmer word we say “a toch min chhneas a thum”. It means microbes are smaller than human being could not cause sickness. This idea spreads out among general population and they become careless in regards to infections.
In the remote area, traditional medicine is the first choice or the first line medical care. Around the house, there are diverse medicinal plants, including fruit trees. When anyone in the family get sick such as diarrhea, fever, pain, they pick some leaves, fruits or flowers of those plants to prepare remedy, in general it is effective. Once we pick the leaves from the tree we have to hold our breath until we finish doing it. When these remedies could not heal, they send patient to traditional healers who are monks in the village, and kru. Those traditional healers in general combine superstition with medicinal plants to treat those patients. When those traditional healers cannot cure them, the family bring the patients to see doctors in public or/and private clinics.
Vis a vis an epidemic outbreak; hill tribes and ethnic minorities chose to abandon their living area to set up at new area that they have to build new living facilities because they believe that their previous village becomes very dangerous to them, they can’t no more live in it. As they have very low education and poor practical knowledge they can only apply very poor hygiene in their daily life. In old time they consume fresh water from the sources without boiling it. Now still some of them remain doing the same. For special occasion they perform ceremony or ritual in the village to fight against evil spirits and to build protection of the village where they are living.
When there is an epidemic outbreak happens, villagers are very scared and panicky, they believe that there might be some bad spirits arriving in the village to cause trouble and kill someone in each family. These bad spirits might go from one village to other villages. From what they experience such as they see people in the village and their family members are killed day to day, they dare not say the name of any epidemic because they feel too much afraid that once the word is said it might make the epidemic more serious and kill more people, a life threatening phenomenon. To prevent the aggravation, expansion of this epidemic, villagers make puppets with straw covered by old clothes. These puppets are place at the front gate or in front of their house; sometimes they put a wooden weapon with it to make the puppet more powerful than that bad spirits of epidemic. This is a way to reinforce the fighting against the bad spirits, to extinguish the epidemic outbreak in the hosting village and to prevent the invasion of this bad spirit in to neighboring villages as well. In some area at night time, villagers use bamboo trunk to fire to make sound as canon explosion; this is the way to threaten the bad spirits which are believed to cause epidemic outbreak, such as cholera, measles, hemorrhagic dengue fever, scarlet fever, etc. to go far away from their homeland. They use also some collars made by cotton threat put on the neck with a pendent make by piece of coconut, dry gourd skin and old bronze coin. Beside that parents invite monks or kru to come to perform ritual at home to protect and heal the sick child or children. Some parents try to move for a while with their child or children to other places far away from their homeland or to give their child to siblings or relatives who live outside.
When their children are affected by measles and similar infections, parents appear very afraid because they believe such infection might be very fatal, causing death or leaving sequella. During the active phase of the infection parents try to give shower as much as they can, in order to facilitate skin eruption and to treat fever. When there is a lot of skin eruption they believe that the illness comes out of the body. It is sign for good prognosis. If there is not enough or just very few eruption on the skin they believe that the illness keeps living in the body, and it is a sign of complication and severity of the illness and it makes parents worry a lot about the future of their child or children. To prevent complication, when there is no more fever parents used to give a lot of kind of foods to the ill child or children, as much as they can, that they believe it is the way to sensitize the body to majority of foods to become safe once the patients get recovered. They believe that once recovered those children might have intolerance with those foods if they could not have chance to consume during that phase. At the beginning of the eruption phase a lady having menstruation are not allowed to touch the patient even to be present with the patients. Her presence might block skin eruption and cause aggravation of prognosis.
Anyone suffering from chronic illness such as anemia, headache, depression, endocrine disorders, etc. is believed to suffer from spiritual problems. It could be related anger from ancestor spirits, abuse of code of conduct and other spiritual context. The family used to bring them to the kru to identify what kind of spiritual problem could happen and to explore the way to heal. The kru use to explain the cause and to recommend the parents or family to perform different type ritual according to type of belief and according to their formula. The kru might suggest performing several rituals at home or at pagoda or in front of ancestor ashes or site. Sometimes the patients should perform ritual every holly day. In addition some kru provide amulet to be put around the hips.
There is one medical terminology called in Khmer word as “Khyal chab”, which has meaning by translating word by word as “air catch”. This is a syndrome characterized by mixed aspects such pain, dizziness, GI discomfort, loss of energy, fever, malaise, sometimes with diarrhea, vomiting etc. It is believed by most of Cambodian that it is caused by loss of equilibrium of air distribution, inside the body. It could be that the air is stuck somewhere in the body leading distribution disorder. Sometime it is caused by the excess of the air in the body. The treatment is intend to scratch the air or catch the air, which is call in Khmer word as “kaus khyal”. It consists in scratching the skin with a piece of coin after lubricating a bit with oil. The coining direction should follow some rule. The coining should go from central area to distal area of the body, like a dispersing movement of the air in the body. This technique is very well known not only for Cambodian, but also for Vietnamese, Cham, and Lao people. This represents a very useful technique that Cambodians people practice for adults, elderly, children, both sexes. It costs nothing. “Khyal chab” is a preliminary diagnosis of many disorders characterized by loss of energy, pains, dizziness, fever, dyspepsia, GI discomfort, etc. and it is confirmed when red marks appear on the skin and especially when symptoms disappear, once coining is performed. When somebody suffers from any health problem, the family, friends or neighbors used to start treatment with “kaus khyal” as first aid act. It is a very popular and simple technique which can be performed anytime and anywhere. It can surprisingly cure many health problems such as headache, vomiting, fever, tiredness, diarrhea, pains, and many other common health problems. In each Cambodian family there are at least 2-3 coins to be used for skin scratching. Everyone in Cambodia, especially women knows well how to do coining.
Malaria is perceived as incompatibility between a person and an environment. In general malaria happens when someone from the village go to the jungle or mountain. Human being adapts his body and health to physical and spiritual conditions of his living environment that is called Khmer word “chanh tuk chanh dey” which means “incompatibility to water” and “incompatibility to soil or land”. It could also be “chanh neak ta” or “incompatibility to spirit protector”. When he or she goes to a jungle or mountain, where it is believed that the physical and spiritual conditions are different, it might cause incompatibility. Once someone has committed some error in adapting to this new environment he/she might contract malaria. Very often it was believed that then soil, the water, the air, the climate of the new environment could cause malaria if the body of human being cannot adapt to. To prevent against malaria everyone should drink boiled water, and to eat hot, not to say bad word when living in that area. In addition we have respect the spirits of that area; we should make some small offering like fruit and food. Now, still people practice this way when they go to jungle, or to mountain or some to superstitious area.
In Khmer culture there are some famous traditional orthopedists. But all Khmer traditional healers cannot perform orthopedic intervention. Some skillful kru can do it very well. They can cure many cases of non-complicated fractures only. They used support or prosthesis made by small bamboo sticks that they make a net, by assembling them with strings, to immobilize the fracture once it is fixed by manual pressure and traction. Some herbal medicines are used to cover the swollen and painful area of the fracture in order to reduce pain and edema. In general they keep this remedy and immobilization for three weeks, then they take it away and the patient can move his/her arm with highest precaution and not to move more when it remains painful. Three months after the immobilization the patient can do daily life activities as before, except some pain which will not last longer. But these procedures cannot heal complicated fractures. In general when it fails, the patients used to go to orthopedists at late state or with complications such as infection, gangrene, sepsis, which requires amputation. That is the reason that general population used to accuse surgeon and orthopedists the one who always recommend amputation.
When a mother is delivering a baby we call in Khmer as “chhlong tonle” which means crossing a river. It is a concept believed by Cambodian that during the time of delivering the mother might encounter very dangerous conditions such as terrible pain, hemorrhage, death of baby, death of mother, etc. It could happen as while we are crossing the river we might encounter storm, shrinking, and other fatal situations. That is the reason why Cambodian people call delivering as crossing the river. During the phase of delivery, everyone is very scared and many family members are called to stay in the house or next to the delivery room. Some might pray god or ancestors’ spirits to help. Until the baby gets out and cries everyone almost never says word. Once the delivery finishes safely, everyone gets happy as just survive from disaster. The mother remains laying on the bed with some fire under it. This is a method to warm up the body of the mother which gets cold after losing blood. The warming process lasts 3-4 days. As soon as possible the mother feeds her baby with her breasts. The one, who delivers at maternity service, stays in the ward for 3-5 days before returning back home. The baby is protected from the evil spirits by putting a pair of scissors under his/her pillow. In the countryside, mothers seek for traditional birth attendant to help during delivery at home. In general people in the countryside trust traditional birth attendants, because they are about 40-50 years old, and they know some superstitious ritual during delivery. Traditional birth attendants can help only normal cases. Complicated cases are referred to hospital, with late decision.
Culture and religion represent a barrier for medical progress in the country. Post mortum autopsy is not allowed in Cambodia. Post mortum diagnosis could not be performed, because in Buddhism once someone died, his/her body should be cut. People believe that everyone could be reincarnated. If the body is cut after death when he/she will be reincarnated, he/she will be born with malformation. In addition the human corpse is considered as sacred.
When someone in the family gets sick, the family members get panicky. They lose mind. Many members in the family tend to send the patient too many kinds of healers, according to their perception on the illness. Some intend to send the patient to the monk; others plan to send the patient to a general practitioner, and the rest wants to send to a specialist. Such situation makes confusion. They cannot make clear decision. Finally they contact someone in family who is stronger and knows more about health care to make decision, and they follow his idea. Some members consult a general practitioner whom they trust well, to get advice before sending to appropriate specialist or service. If there no help from a strong family member or from a general practitioner they remain confused and the patient could not get appropriate care. Sometime they decide to have combined care by traditional healers and doctors. Such situation used to happen in case of chronic illness, and mental health disorder. In these cases the doctor should take care of the whole family rather than the patient alone.
Zoster is treated with crashed green bean which is applied on the affected skin. Mumps are treated with red seal and a caricature of tiger drawn on the skin which cover the affected glands.
Hot stone or bag was to cure abdominal pain and other pains. Abdominal massage was to help constipation, dyspepsia, and abdominal pain. Body massage was used to heal muscle pain, stiffness, join pain and improve body circulation. Some hot herbal bags are to heal join pain. Massage on the shoulder could heal headache, tiredness, and neck or shoulder pains. Massage on the lower back and hips could heal back pain, sciatica and pelvic pain. Pinching the skin of forefront could heal dizziness, nausea. Coining the front side of the chest could heal chest tightness.
Awareness on mental health and mental disorders among Cambodian people has just been developed since 1994. Traditional perception on mental health still remains as a huge taboo still now. Western psychology is rarely aware by Cambodians. When somebody presents an acute onset of mental disorders, it is believed as cases of possession, or caused by spirits. It could be spelt spirits or spirits protectors, or spirits of ancestors or evil spirits from somewhere. Immediately the family seeks for help from traditional healers including monks, kru, sorcerer, magicians. Traditional healers used to heal psychotic patients with blessing water and rituals. They rarely give remedy. There remedy is just water that they blow by mouth with chanting prayer. Some kru treat psychotic cases by beating on the body with incent sticks. This is to make the spirit inside the body suffer then to go out of the body of patient. In the old time there is an aggressive practice but sometime effective to heal psychotic patient. It consists in putting the patient at one place, and someone shoots close his ear. Another method consists in showing a puppet make by banana tree in front of the patient, and someone cut it with a swart. New and very strong stimuli remove the attention of the patient from his world of delusion and hallucination to the real world. Then it is believed that this way could chase the spirits from the body of the patient.
Anxiety disorders, somatoform disorders, PTSD, depression are perceived as chronic conditions known is Khmer language as “toas”. “Toas” means disorder, intolerance, incompatibility. These conditions happen only on women at active age who have delivered baby, not on single women or girls, not on women after menopause. There are many kinds of “toas”, including “toas tum”, “toas ring rey”, “toas min doeng muk”, “toas bek sraka”, “toas sasay”, “toas damnek”, “toas chamney”. “Toas ring rey” is a condition which lasts long time with cachexia. “Toas tum” means a condition with symptoms of severity. “Toas min doeng muk” is a condition without reasonable cause. “Toas bek sraka” is a condition with chronic symptoms associated with scale like skin. “Toas sasay” is a chronic condition caused by early start of daily activities after delivery. “Toas damnek” is a chronic condition caused by early start of sexual intercourse after delivery. “Toas chamney” is in general chronic condition associated with chronic or acute diarrhea after taking some foods or fruits that are not supposed to be consumed after women deliver baby. Many women have postpartum infections or anemia could be classified as “toas” too. “Toas bek sraka” “toas ring rey” “toas min doing muk” and “toas tum” could have psychological and physical causes. Toas are treated by traditional remedies such as medicinal plants, herbs. Sometimes the ones who suffer from “toas” used to get coining to release acute symptoms when it happens as panic attack, flashback, distress, exhaustion, malaise, pains, dizziness, chest distress, etc.
Some foods are prepared for ill people. When someone gets sick, we used to consider his body becomes weak and he might need some foods that we believe as light foods or healing foods. Light foods or healing foods are simple foods easy to prepare and easy for digestion. Light foods are very acceptable by sick people. In general rice porridge is the main food for sick persons. It consists in cooking rice with a lot of water. When it starts to boil we keep it for about 4-5 minutes, then it is done. Porridge is consumed with salty fishes, salty vegetables, sauces, etc. We have to eat porridge when it still remains hot. After eating hot porridge, the ill person get a lot sweating then he might feel released from pain, fever, tiredness, distress, abdominal discomfort. Beside porridge, hot drinks are also ideal drinks for ill people. These are healing drinks. The aims of consuming hot drinks are to supply energy, heat, and to get released from pains, distress, fever, exhaustion, tiredness, etc. Hot ginger drink, is prepared with some pieces of ginger put in a cup of hot water as ginger tea. Some sugar could be added. It is served hot to get released from exhaustion, GI discomfort, constipation, headache, flue, etc. One concept is using heat to treat fever. The reason is when we have fever we feel cold, so we have to provide heat to treat feeling cold. In practice it does work well; several minutes after taking hot foods or hot drinks, we start to sweat a lot later we feel normal, no more fever. Spicy foods are not allowed. These healing foods and healing drinks could not heal fever caused by bacterial infection.
Seizures on neonates and babies are called “skon mday doeum”, it means former mother’s seizures. It is believed that neonates and babies are controlled by their former mother. Once they are born, neonates and babies are still under care of their mother in the past life. When the neonates and babies smile or cry during sleep it means that they see their former mother. When they have seizures it means that the seizures are induced by the former mother. The former mother is represented by her spirit. In this case we pray the spirits of former mother.
To treat fever on baby and small child we use gel that we make by ourselves with plants. Leaves and flowers of hibiscus are mixed with water to make gel. The trunk of kapok tree or cotton tree is pounded with water to make gel. We apply gel on the body of the baby or child in case of fever. We renew it until the fever is gone. But when the baby or child has chills we cover the body with blanket.
Before the Khmer Rouge regime, as modern medicine was not yet well developed to remote areas only people living at urban areas had opportunity to access to health care system. At rural areas, majority of population used traditional medicines, medicinal plants, herbs. Traditional healers, kru, monks, sorcerer, magicians, were still very important healers. In the territories occupied by government, people had more chance to use modern medicines. Still traditional medicine played complementary role. In the territories occupied by Khmer Rouges, there was no access to modern medicine. People living there rarely could use modern medicines which were smuggled from governmental. Resistance troops of the Khmer Rouges, during the war against governmental army used also medicinal plants, herbal remedies combining with some modern medicines.
In Khmer rouge regime, as there were no modern medicines, we used to treat ourselves with medicinal plants. Superstition did not exist. The Khmer Rouge traditional healer never chanted prayer neither used superstitious methods to treat patients. As there was easy access to those health care systems, we tried our best to heal ourselves and friends who were in the same mobile team. We learnt from friends who learnt from mouth to ear. Some of those young leaves and small fruits of guava were used to treat diarrhea. Ginger is used in case of dyspepsia. A stained nail was immerged in the palm vine to make a remedy against anemia. Sulfur got from a ceramic cable fixator was pounded into powder and mixed with coconut juice to be taken against itching, skin allergy, skin rashes. Flower of chrysanthemum was used against coughing and pertussis. Resin of several trees was used to treat dysentery very effectively. One kind of plant that we believe containing belladonna is used to make cigarette against asthma. Chicken liver was used to cure nyctalopia or hemeralopia. Boiled water with sour leaves was used to heal wounds. A personal observation found a very wonderful remedy could heal snake bite within three minutes. It was a piece of horn of one kind of wild buffalo called in Khmer word “khting voar or snake wild buffalo” which is believed eating snake. A thumb like piece of its horn was place on the wound of snake bite after disinfection with drinking alcohol. Two to three minutes later the terrible pain was gone, and the victim slept deeply. A fresh fish scale has been used by author to stop hemorrhage cause by leech bite. Leek mouth has anticoagulant enzyme. Once it bites us it delivers its enzyme in our skin which causes sustained hemorrhage. A fish scale big enough to cover the wound can stick to the skin and obstruct the wound until the coagulation process starts. Tobacco was also used to stop hemorrhage.
After the fall of Khmer Rouge regime, there was shortage of modern medicines, we still used traditional medicines to heal patients. Everyone used technique whatever they can to take care of their family as we have been doing in Khmer Rouge regime. In the Thai border camps people used traditional remedies with to modern medicines supplied by NGOs. In the country when their traditional practice failed they sought for modern medical care services, far from their house. As the country has been developed, little by little modern medicine expanded from urban areas to rural areas and health care services expended gradually to countryside. Since then there are more and more utilization of modern health care systems. Currently Cambodian people still used traditional medicine in addition to modern one. Crocodile eggs and meat are used to heal asthma. The roots of grenade fruit are used against teniasis. Shops of medicinal plants work very well in Phnom Penh city and serve a lot of clients who can formulate the ingredients. The sellers just provide what and how much the need. Kru, monks, magicians, etc. still continue their activities in cities as well as in rural areas. They still trust superstition. Superstition finds its place more in mental health, especially with acute cases with loss of association, strange behavior, seizures, hallucination, aggression, behavioral change in children and unexplained symptoms and recurrent infections.