Dog Bite - Happy Canada Day!
It happened during lunch, and fortunately, it wasn't me. My fellow volunteers, Kathleen and Allison, and I were eating lunch at our regular Khmer place, when we stood up to return to the guesthouse, and it happened. The restaurant's dog was sleeping under the table, and Kathleen accidentally stood up right on its back. The dog squirmed loudly and bit her in the heel. Not a big bite. If you didn't see it happen, you would have mistaken it for a scratch. But we were nervous, knowing that bites from rabid dogs are deadly. The virus spreading through and attacking the body's nervous system.
There is a pre-immunization for rabies, which consists of three shots over a few weeks. It's called a pre-immunization though because even with it, you are not immune to rabies. What it does is it buys you time. Without the pre-immunization you only have 24 hours to get to a cheap cialis and have the first vaccination dose, one of 5 vaccinations you must receive over a period of 28 days, including immunoglobin, which apparently many hospitals in developing countries do not carry. Before coming to Cambodia, our supervisor warned us that if we got bitten by a dog, there was a high chance you would have to be emergency evacuated to Bangkok, in Thailand in order to find the vaccine.
Unfortunately, Kathleen did not receive the pre-immunization. It is a gamble, and usually doctors will not pressure their patients into getting it because it is expensive (about US$300), and the chances of being bitten are not extremely high. And if you receive the pre-immunization, you still have to be shipped to a hospital to receive the post-vaccinations.
So, when Kathleen was bitten, we immediately notified everyone in the program, we called Kunthy, our Kep program manager who was a qualified nurse, midwife, and accountant, and Buntheon who was our Phom Penh program manager and driver. We also notified our supervisor in Canada, as well as the one in Kep, who was replacing her for this week only. There was a hospital in Kampot (about 30 minutes away), and Kunthy was sure that she saw a private clinic that carried the vaccine. but after seeing the hospitals and health centres in Kep province, Kathleen was a little nervous about the cleanliness and sterility of their medical equipment. The other and more reliable option was to go straight to Phnom Penh (about 3 hours away) to the International SOS hospital, that was open 24/7.
While Allison rushed to look up information about the vaccination process post-bite, I hurried to e-mail our supervisor in Canada, and Danielle, a second year medical student that had just arrived from Phnom Penh, helped to reassure Kathleen that she had some time (24 hours), all we had to do was take her somewhere to get a vaccination. Danielle also insisted that she come with Kathleen to get the vaccination, to accompany her, help ask the doctors the right questions, and notify the travel insurance company about the incident. They arranged for the taxi who had just dropped the two girls off from Phnom Penh to wait for them while they packed their things to go to the hospital. Stephanie, who was good friends with Kathleen, also made sure to remind Kathleen about what she should bring (passport, insurance policy, money, clothing, etc.) and comforted her as well. Buntheon and I were dispatched to the Khmer place where Kathleen had been bitten to inquire about the dog, his age, normal temperament, and whether or not people knew if the dog had bitten anyone else before.
Within an hour of the bite, Kathleen was on her way to Phnom Penh with Danielle to accompany her.
Luckily, the hospital did have the vaccine, and Kathleen received the first dose in 5-8 shots from shoulder to foot. She arrived back in Kep within 24 hours vaccinated, and much calmer. The travel insurance company even promised to cover the entire cost of the vaccine. She will have to return to Phnom Penh to receive the remaining 4 doses in 3, 7, 14, and 28 days from Canada Day the day she got bitten. What a way to celebrate!
When I think back on this incident, I admire the way in which our entire team of volunteers and staff helped to make sure that Kathleen was ok. It is amazing to think that within 24 hours, she went to the hospital in Phnom Penh and back and received the right vaccination. It seems like such an amazing feat when I think about the dozens of families that I personally interviewed that I knew would very likely die from rabies, if they were bitten by a rabid dog. If you are living on less than 25 cents per day, there is no way you are going to be able to search the internet for vaccination procedures, or have access to people who have nursing or even medical knowledge, or health insurance. The whole trip to Phnom Penh for Kathleen would have cost a maximum of perhaps US$71 (US$45 taxi, $6 for hotel, $5 get to the hospital and back to the hotel, $5 to come back to Kep on the bus, $10 for food) and then another couple hundred for the vaccine, which she will get re-imbursed. You could also count the opportunity cost of having 2 of our volunteers away from work for 1 day.
As a villager among the most vulnerable families in kep, the situation would probably have run more like this. Most people know that when you get bitten by a dog, you have the potential of dying from rabies. If the family happened to have a neighbour or relative who had gone to the health centre before, then the neighbour or relative may or may not say very positive things about it. As recently as 2001, full-time health centre and hospital health staff were being paid as low as US$15/month. This extremely meager salary contributed to very low staff motivation to deliver quality health care. Often times there would be NO health staff even present, because they would be busy operating from their own private practices, or doing another job. The health centres are often not well equipped, and at best, they would have chlorinated water, and some drugs, but no electricity (which didn't arrive in Kep until 2007). Because of the lack of staff motivation, you probably wouldn't be referred to the hospital.
If by chance you WERE successfully referred to the hospital, in order to pay the admission fee and transportation and food to get there, you would need to either sell your assets (at worst your productive assets/land), or get a loan, for which interest rates are 10-20%. If you are even near-poor (not extremely poor, but poor) you will likely fall into deeper poverty through this process, which is exactly what has happened to a lot of families in Cambodia.
On the other hand, if none of your neighbours or relatives had been admitted to hospital (which is very likely, b/c the cost of getting admitted is on average about US$54 per admission, including treatment - which is WAY above what any of the families on the Most Vulnerable Families List can afford - they have US$0.25 or less to spend per person per day), you would end up consulting a traditional healer or private practitioner, who would A, not have the vaccine, and B, charge you anyway for a different drug because they want to make a profit. And remember if you don't get vaccinated within 24 hours...the virus will spread through your body, and as the doctor at the International SOS hospital explained "you will experience symptoms after a couple of weeks, and you will die."
Luckily with the Most Vulnerable Families List and with the Health Equity Funds (HEFs) being implemented in two thirds of the country, many poor families are able to access more timely heathcare at a reduced cost (all HEFs cover healthcare costs, and some even cover transportation, food, and lodging costs - none cover opportunity costs yet). For the time being, much of the Health Equity Funding are coming from internatinoal Aid agencies, but more research is needed to figure out how on earth we can fundraise sustainably. One province, Takeo, currently has a local NGO, called Buddhism for Health, that is trying to do just that, but collecting donations from the community itself for the Health Equity Fund.
Anyways, I thought I would take the opportunity of the dog bite to explain the issues that I've been reading about and experiencing in Cambodia. Moral of the story: always check that there are no rabid sleeping dogs under your table, and appreciate the public health care system in your country!
---
I have uploaded some pictures here about our recent visit to some nuns in Kep.
Preview:
There is a pre-immunization for rabies, which consists of three shots over a few weeks. It's called a pre-immunization though because even with it, you are not immune to rabies. What it does is it buys you time. Without the pre-immunization you only have 24 hours to get to a cheap cialis and have the first vaccination dose, one of 5 vaccinations you must receive over a period of 28 days, including immunoglobin, which apparently many hospitals in developing countries do not carry. Before coming to Cambodia, our supervisor warned us that if we got bitten by a dog, there was a high chance you would have to be emergency evacuated to Bangkok, in Thailand in order to find the vaccine.
Unfortunately, Kathleen did not receive the pre-immunization. It is a gamble, and usually doctors will not pressure their patients into getting it because it is expensive (about US$300), and the chances of being bitten are not extremely high. And if you receive the pre-immunization, you still have to be shipped to a hospital to receive the post-vaccinations.
So, when Kathleen was bitten, we immediately notified everyone in the program, we called Kunthy, our Kep program manager who was a qualified nurse, midwife, and accountant, and Buntheon who was our Phom Penh program manager and driver. We also notified our supervisor in Canada, as well as the one in Kep, who was replacing her for this week only. There was a hospital in Kampot (about 30 minutes away), and Kunthy was sure that she saw a private clinic that carried the vaccine. but after seeing the hospitals and health centres in Kep province, Kathleen was a little nervous about the cleanliness and sterility of their medical equipment. The other and more reliable option was to go straight to Phnom Penh (about 3 hours away) to the International SOS hospital, that was open 24/7.
While Allison rushed to look up information about the vaccination process post-bite, I hurried to e-mail our supervisor in Canada, and Danielle, a second year medical student that had just arrived from Phnom Penh, helped to reassure Kathleen that she had some time (24 hours), all we had to do was take her somewhere to get a vaccination. Danielle also insisted that she come with Kathleen to get the vaccination, to accompany her, help ask the doctors the right questions, and notify the travel insurance company about the incident. They arranged for the taxi who had just dropped the two girls off from Phnom Penh to wait for them while they packed their things to go to the hospital. Stephanie, who was good friends with Kathleen, also made sure to remind Kathleen about what she should bring (passport, insurance policy, money, clothing, etc.) and comforted her as well. Buntheon and I were dispatched to the Khmer place where Kathleen had been bitten to inquire about the dog, his age, normal temperament, and whether or not people knew if the dog had bitten anyone else before.
Within an hour of the bite, Kathleen was on her way to Phnom Penh with Danielle to accompany her.
Luckily, the hospital did have the vaccine, and Kathleen received the first dose in 5-8 shots from shoulder to foot. She arrived back in Kep within 24 hours vaccinated, and much calmer. The travel insurance company even promised to cover the entire cost of the vaccine. She will have to return to Phnom Penh to receive the remaining 4 doses in 3, 7, 14, and 28 days from Canada Day the day she got bitten. What a way to celebrate!
When I think back on this incident, I admire the way in which our entire team of volunteers and staff helped to make sure that Kathleen was ok. It is amazing to think that within 24 hours, she went to the hospital in Phnom Penh and back and received the right vaccination. It seems like such an amazing feat when I think about the dozens of families that I personally interviewed that I knew would very likely die from rabies, if they were bitten by a rabid dog. If you are living on less than 25 cents per day, there is no way you are going to be able to search the internet for vaccination procedures, or have access to people who have nursing or even medical knowledge, or health insurance. The whole trip to Phnom Penh for Kathleen would have cost a maximum of perhaps US$71 (US$45 taxi, $6 for hotel, $5 get to the hospital and back to the hotel, $5 to come back to Kep on the bus, $10 for food) and then another couple hundred for the vaccine, which she will get re-imbursed. You could also count the opportunity cost of having 2 of our volunteers away from work for 1 day.
As a villager among the most vulnerable families in kep, the situation would probably have run more like this. Most people know that when you get bitten by a dog, you have the potential of dying from rabies. If the family happened to have a neighbour or relative who had gone to the health centre before, then the neighbour or relative may or may not say very positive things about it. As recently as 2001, full-time health centre and hospital health staff were being paid as low as US$15/month. This extremely meager salary contributed to very low staff motivation to deliver quality health care. Often times there would be NO health staff even present, because they would be busy operating from their own private practices, or doing another job. The health centres are often not well equipped, and at best, they would have chlorinated water, and some drugs, but no electricity (which didn't arrive in Kep until 2007). Because of the lack of staff motivation, you probably wouldn't be referred to the hospital.
If by chance you WERE successfully referred to the hospital, in order to pay the admission fee and transportation and food to get there, you would need to either sell your assets (at worst your productive assets/land), or get a loan, for which interest rates are 10-20%. If you are even near-poor (not extremely poor, but poor) you will likely fall into deeper poverty through this process, which is exactly what has happened to a lot of families in Cambodia.
On the other hand, if none of your neighbours or relatives had been admitted to hospital (which is very likely, b/c the cost of getting admitted is on average about US$54 per admission, including treatment - which is WAY above what any of the families on the Most Vulnerable Families List can afford - they have US$0.25 or less to spend per person per day), you would end up consulting a traditional healer or private practitioner, who would A, not have the vaccine, and B, charge you anyway for a different drug because they want to make a profit. And remember if you don't get vaccinated within 24 hours...the virus will spread through your body, and as the doctor at the International SOS hospital explained "you will experience symptoms after a couple of weeks, and you will die."
Luckily with the Most Vulnerable Families List and with the Health Equity Funds (HEFs) being implemented in two thirds of the country, many poor families are able to access more timely heathcare at a reduced cost (all HEFs cover healthcare costs, and some even cover transportation, food, and lodging costs - none cover opportunity costs yet). For the time being, much of the Health Equity Funding are coming from internatinoal Aid agencies, but more research is needed to figure out how on earth we can fundraise sustainably. One province, Takeo, currently has a local NGO, called Buddhism for Health, that is trying to do just that, but collecting donations from the community itself for the Health Equity Fund.
Anyways, I thought I would take the opportunity of the dog bite to explain the issues that I've been reading about and experiencing in Cambodia. Moral of the story: always check that there are no rabid sleeping dogs under your table, and appreciate the public health care system in your country!
---
I have uploaded some pictures here about our recent visit to some nuns in Kep.
Preview: