Cambodia HIV Outbreak: Thorough Investigation or Pakistani Style Cover-Up?

There has been a lot of wringing of hands and gnashing of teeth among the global health community about how the recent ebola epidemics in Guinea, Liberia and Sierra Leone may have been contained if only there had been universal healthcare (UHC) in place. Amartya Sen even makes a similar point in his excellent article on UHC in the English Guardian.

But this public angst seems to imply that around 20 earlier outbreaks of ebola were contained because health systems in the countries involved, Nigeria, Uganda, Sudan and the Democratic Republic of the Congo, were adequate. In fact, the opposite was the case in some instances, with several outbreaks dying out once the local healthcare facilities were overwhelmed and forced to close down.

Perhaps UHC, however vital, is not enough on its own? For the seven countries listed above, can anyone say that health services, while weak, are safe? An article just published on knowledge and practice of universal precautions among healthcare workers in Nigeria concludes that "the practice of universal precaution is not given much attention in [Primary Health Care] and this may constitute health risk to the nurses and the patients in the study setting".

Nigeria is not alone; the Don't Get Stuck With HIV site's 'Cases of HIV from Blood Risks' section lists 17 African countries where healthcare related outbreaks have occurred, along with nine non-African countries. Cambodia will soon be added to the latter collection.

The number of people found to have been infected with HIV in Roka Commune, Battambang Province, probably through unsafe healthcare, possibly administered by an unlicensed practitioner, is now well over 230. But that number is already several days old.

More importantly, the inquiry appeared to go beyond the village where the first cases were found, as more turned up from other villages. Will the inquiry also look for outbreaks elsewhere around the country? Surely there are other unlicensed practitioners, other practices where safety is not the priority it should be?

In addition, there may be licensed practitioners and practices where risks are being taken. Perhaps few people have been infected as a result, perhaps none; but if unsafe practices are to be found anywhere in the country there is a risk that there will be other outbreaks in the future.

There have been no serious investigations of healthcare associated HIV outbreaks in African countries, where all the worst epidemics are to be found. The countries where there have been investigations are mostly ones where the global health community does not have a lot of influence, such as China, Kazakhstan, Uzbekistan and Kyrgyzstan.

An investigation carried out in 2008 in Pakistan after a very large number of people tested positive in this low prevalence country was too superficial to identify any additional infections, although the outbreak was clearly a result of unsafe healthcare. Here too, the finger was pointed at a few unlicensed practitioners, leaving licensed healthcare out of the picture altogether.

None of the media reports from Cambodia suggest that journalists are making any attempt to go beyond what they are fed in the form of press releases. They could quite easily ask people in any village in the country, or even in the cities, about unlicenced practitioners and practices. But the implications of this outbreak seems to be entirely lost on them.

The Australian media, in particular, has had little to add to the subject, although Cambodia is dominated by Australian NGOs, NGO workers, expats of various kinds, business people, tourists and the like. Australians are less likely to visit unlicensed practitioners or practices, but levels of safety in licensed healthcare are unknown.

The UN and its employees are not in any danger, of course, because they are all issued with advice, even injecting and other equipment when they visit certain areas. They have their own UN-approved health facilities and would rarely any serious healthcare risks.

The press may continue to wait for the scraps that will eventually be thrown to them, or they could carry out their own investigation into healthcare safety in the light of the outbreak of healthcare associated HIV in Battambang Province. But they may end up missing a cover-up on the same scale as the one that appears to have gone unnoticed by the press in Pakistan a few years ago.