The history of how CHC healed access to TB care in Cambodia

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 either a 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 the 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.

Finding Sustainable Solutions in Partnership with the National TB Program

Building CHC: standing on the shoulders of the ARC TB Program on the Thai-Cambodian border

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, the expatriate Tuberculosis (TB) Coordinator in the radical TB program that he and Steve Miles launched in 1981 and that Bob then developed and innovated over the next decade with the refugee medics with whom he worked. This program conceptualized and actualized patient supporters who accompanied the patient through treatment and through the TB education that every patient went through. The program provided supplemental food, and formalized the commitment of the patient and health worker with the signing or thumb printing of a treatment contract. formalizing the commitment to complete the 6 month therapy between patient, health worker, and patient supporter. The results of this pathbreaking program overcame the many voices that raised objections against treating TB in Cambodian refugees in an active war zone refugee camp. Strikingly, the ARC TB Program went on to demonstrate outstanding adherence, completion of therapy, and numbers of patients cured. It also was an early demonstration of the success of short course (6 months) TB treatment as they reported (HYPERLINK to be added). 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 it is estimated that at least 50% of these people would have died.

With a small grant from Holly Myers and Kirk Neely and the Blue Oak Foundation in 1994, CHC set out to treat TB in Cambodia using the patient-centered approaches developed in the refugee camps such as treatment contracts and patient supporters, supplemental food, and treatment contracts and worked to make the hospitalization and outpatient phases of TB treatment a success in the extremely impoverished environment of Cambodia post decades of ward. CHC complemented this with 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 everyone that everyone deserves the right to access treatment for a treatable disease such as TB. And, no matter their economic or educational level, everyone can honor a commitment to be well and to cure themselves, 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. The Ho Chi Minh trail passed through Svay Rieng and it was heavily bombed during the Vietnam war. The province had poor soil quality comported to other areas of the country with diminished rice harvests, and it had one of the highest prevalences of TB in the world at the time approximately 900 TB cases/100,000 people. Furthermore, only 30% of patient who started TB treatment completed the TB treatment leading to poor outcomes, death, and spreading the TB disease. From those first days CHC worked in partnership with the National TB Program, an approach that underpins all of CHC’s (and GHC’s) work over the past 31 years.

Food is essential to TB cure, and also serves as a powerful addition to motivate patients to stay with the 6 moths long treatment that is necessary. CHC began a collaboration with the World Food Program (WFP) in 1994 to supply extra food during TB hospitalizations and to help CHC 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 of TB treatment. This package, consisting of 15 kg of rice, 700mL of cooking oil, and 2 cans of fish, ultimately 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 monitor the patient taking their TB drugs in the outpatient phase. The concept and reality of patient supporters in CHC’s and the Border Refugee Camp’s programs then provided a powerful new approach showing that accompanying patients through their therapy is extremely affection and it 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. The outpatient team also conducted surprise home visits to count pills and to check on medication consumption and if there was an interruption of therapy in order to strategize with the patient and the supporter about any issues interfering with their TB treatment and how to overcome these. During the period between 1994-1999, 2780 patients with TB were treated in the CHC program with 2 months of forced hospitalization as per the national protocol, followed by 6 months of outpatient therapy of monthly drug pick-up at the health center. They mean cure rate of 94% a stunning improvement over the 30% of patients who completed treatment prior to the CHC Program being instituted

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 (HYPERLINK to be added).

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 Daily Observed Therapy (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. CHC’s community DOTS has been credited by the World Health Organization (WHO) for the dramatic reduction of TB disease in Cambodia.

Through the years, in addition to critical funding for this program was provided by The Blue Oak Foundation, the Pittsfield Anti-TB Foundation, Mark Peters, and Jeanne and Joe Sullivan.

CHC’s Impact in 2024/2025

As of 2025, CHC has provided TB care to 110,000+ persons and currently, provides direct TB care through Community DOTS to 13 out of the 25 Cambodian provinces covering a catchment area of nearly 7 million people (Svay Rieng, Prey Veng, Kampong Cham, Tbong Khmum, Mondul Kiri, Kratie, Stung Streng, Kandal, Prah Vihea, Oddar Meanchey, Banteay Meanchey, Battambang, and Pailin).

In 2024, CHC treated 11,361 people with TB with a cure rate of 97%.

Healing the world one person at a time