HEALING UNEQUAL ACCESS TO CARE

Tuberculosis can be cured in the wealthiest countries of the world and also in the poorest countries. However, when CHC set out to attack TB in rural Cambodia in 1994, it faced a succession of barriers to treatment. It was not thought that poor rural peasants could successfully complete an 6 month, or as was required in the country at the time an 8 month course of treatment. The ongoing war that had destroyed the country’s medical capabilities and the poverty and lack of access to health care in Camdodia in 1994 all conspired to make Cambodia a hot spot of TB and later AIDS. The impediments to health were numerous, but this new kind of program that was delivered by CHC created from the grass roots in Cambodia, surmounted them all.

The Challenges to be Overcome to Treat TB in Cambodia in 1994

When CHC initiated community-based TB care in Svay Rieng Province in 1994, the Cambodian medical infrastructure had been decimated by 3 decades of war. While TB infection was rampant at the time, only 30% of patients who managed to access treatment, finished the 8 month treatment course that was being used in the country at the time. This resulted in continued sickness and spread of TB. To improve this situation, the emerging Cambodian National TB Program was advised by the WHO and the French Red Cross to institute a policy of forced hospitalization for the first 2 months of TB treatment for all TB patients. However, this approach resulted in another very big problem. Most of teh patients were extremely poor, particularly in a province such as Svay Rieng, where most of the patients were impoverished rice farmers who could not leave their fields or jobs for 2 months, or even for days in most cases, without their families going hungry, or risking economic collapse. This led sick people to not seek TB treatment until they were very sick and could not work. Another hurdle was that even if patients agreed to the 2 month hospitalization, showing up monthly to pick up medicines over the following 6 months meant the expense and time away from work traveling to the provincial hospital to make that trip.

Solutions

Building on the back of the ARC Refugee Camp TB Program

CHC co-founders Sok Thim and Anne Goldfeld met at the Site II refugee camp on the Thai-Cambodian border where Anne was the American Refugee Committee (ARC)’s Medical Coordinator and Sok Thim was the TB Coordinator. Thim had been trained in treatment of tuberculosis (TB) by Bob Maat PA, the expatriate Tuberculosis (TB) Coordinator in the radical TB program that he and Dr. Steve Miles had launched in 1981 and Bob developed over the next decade. Using novel approaches conceptualized by Bob and Steve, which included patient supporters who accompanied the patient through treatment, education about TB disease for the patient and supporter before treatment, and the signing of treatment contracts between the patient, health worker and patient supporters that outlined their commitment to cure. The results of this pathbreaking program overcame the many objections voiced against treating TB in Cambodian refugees in an active war zone refugee camp. And, it went on to demonstrate outstanding adherence, completion of therapy, and numbers of patients cured. Strikingly, it was the first program to successful treatment of TB in a refugee camp. It also was an early demonstration of the success of short course (6 month) treatment of TB as reported (hyperlink to bolded sentence before for articles). The ARC program and its expansion throughout the Thai-Cambodian border camps went on to treat 10,000+ people for TB until the camps were closed. Without treatment at least 50% of these people would have died.

CHC set out to use the approaches of the ARC TB Border Treatment Program and to apply it to rural Cambodia. Between 1994-1999, CHC used patient-centered approaches developed in the refugee camps such as treatment contracts and patient supporters, and worked to make the hospitalization and outpatient phases of TB treatment a success developing new community-based strategies to meet the needs on the ground in rural Cambodia. The belief, which underscores all of CHC’s work from then until now, is that anyone, no matter their economic or educational level, can honor a commitment to be well and to cure their families and communities of tuberculosis with the right support from a program.

New ideas: food, surprise home visits, poverty reduction, home TB care, and ‘clean the dish’:

In spring 1994, CHC initiated TB work in three district hospitals in Svay Rieng Province, which shares a border with Vietnam, Svay Rieng had been severely bombed during the Vietnam war, had poor soil quality, and one of the highest prevalences of TB in the world at the time. From those first days CHC worked in partnership with the National TB Program, an approach that CHC continues until this day.

CHC began a collaboration with the World Food Program (WFP) to supply food during TB hospitalizations and to deliver a monthly food package as an incentive for all patients to pick up their monthly supply of medicines during the 6 month outpatient phase, consisting of 15 kg of rice, 700mL of cooking oil, and 2 cans of fish. This became a nationwide component of the Cambodian National TB Program and standard in TB programs worldwide. As well, patient supporters were also tasked with helping the patient to take their TB drugs in the outpatient phase. CHC’s and ARC’s patients supporters that accompany patients through their therapy would become a part of many TB programs around the globe.

CHC also launched an outpatient team that checked up on each patient monthly and examined other household members for TB. They also conducted surprise home visits to count pills and to check on medication consumption and if there was an interruption of therapy to strategize with the patient and the supporter about any issues interfering with their TB treatment and how to overcome these. 2780 patients with TB were treated in the CHC program with 2 months of forced hospitalization during the period 1994-1999, per the national protocol, followed by 6 months of outpatient therapy with monthly drug pick-up at the health center with mean cure rates of 94%.

Another very successful strategy we began in 1994 was linking a ‘poverty reduction’ village bank microfinance strategy focused on benefiting TB patients. Among 590 families with TB patients who participated in the village bank program, there was 100% Loan repayment and TB cure rates approached 100% among these families. Interest charged on funds provided through village banks established a Village HealthFund and enabled the training of 96 Village Health Agents, who conducted community education and assisted in patient detection and follow-up, who were mobilized to provide education about HIV/AIDS.

From 1999 to 2001, a separate Home DOTS protocol used mobile health teams to actively detect patients in 2 districts not served by a hospital or health center to provide TB therapy to patients in their homes. Mobile CHC teams screened clusters of villages, going house-to-house, to find people who may be suffering from TB. In this way, TB can be diagnosed and treated earlier, before the infection has had an irreversible impact on patients’ lungs and health and before it infects additional people and “clean the dish”. The mobile team visited each patient in their home 5 days a week and then the patient supporter supervised the therapy on the weekends during the initial two-month intensive phase of TB therapy. Among the 219 patients in TB Home DOTS, TB cure rate was 99%. The results of the CHC Program described above were published in the Journal of the American Medical Association in 2004 (add hyperlink to bolded in previous sentence).

Origins of Community DOTS and Countrywide Scale-up:

In an effort to increase accessibility for vulnerable rural populations, based on the success described above, in 2002 the CHC developed a Community Treatment Model program for Cambodia, which trains community volunteers, sometimes former TB patients, to assist with distribution of TB medications as patient/or DOT supporters, which CHC piloted in Svay Rieng and Kompot provinces with the support of JICA (Japanese International Cooperation Agency). Outstanding rates of TB case detection and a TB treatment outcome of 95% in 2006 was achieved. This program expanded the reach of treatment beyond the area of mobile health teams, by training community members to help patients adhere to their medication regimen during the entire course of treatment. The CHC mobile staff provides guidance to the patient and their supporter, during all phases of treatment. The CHC Community DOTS initiative was able to further increase detection, education and cure rates, as well as engage the community in controlling the spread of TB.

Based on CHC’s successful demonstration of Community DOTS (or c-DOTS), a decision was made to scale it up throughout the country by the National TB Program with funding from the Global Fund for TB, Malaria, and AIDS. It has been credited by the World Health Organization (WHO) for the dramatic reduction of TB disease in Cambodia.

2025

As of 2025, CHC provides direct TB care through Community DOTS to 13 out of the 25 Cambodian provinces (Svay Rieng, Prey Veng, Kampong Cham, Tbong Khmum, Mondul Kiri, Kratie, Stung Streng, Kandal, Prah Vihea, Oddar Meanchey, Banteay Meanchey, Battambang, and Pailin), covering a catchment area of nearly 7 million people..

IMPACT

Over the past 31 years, CHC has provided high quality direct community-based TB care to over 110,000 persons throughout Cambodia with extremely high adherence and cure rates in partnership with the Cambodian National TB program. In 2024 for example, treating XXXXX people with TB and curing XXXX of them.

CHC has brought innovative and effective strategies and lessons to the global community to treat TB in high TB-burdened countries such as Cambodia to improve treatment compliance, case detection, and cure including: Community DOTS, patient supporters, treatment contracts, food supplementation, stategies to mitigate poverty and to lessen the economic burdens of hospitalization and travel to health centers/hospitals

HEALING THE WORLD ONE LIFE AT A TIME