The Roots of the Cambodian Health Crisis

Survivors of the Mahantdorai, the Cambodian holocaust, are experiencing a health crisis that is a direct result of their extraordinary trauma. Overwhelming evidence shows that Cambodians who remained in Cambodia from 1970-1980 had between 8-16 major trauma experiences (Kinzie, 1984; Meinhardt 1984; Mollica, 1986; Realmuto, 1992) that include long periods without adequate food or water, experiencing combat conditions, slave labor, imprisonment, witnessing atrocities, torture both physical and psychological, death of family members, physical injury, sickness without access to health care, the loss of home, property and country. These trauma experiences correspond to the categories of experience described in the literature of survivors of the Nazi concentration camps and prisoners of war camps.

Starvation and Malnutrition

Starvation was identified as a major cause of post trauma health problems in survivors of the Nazi Holocaust. (Eitinger, 1973; Thygesen et al, 1970 ) One of the most comprehensive studies of the effects of starvation on the human body and mind are found in the heroic research of the physicians of the Warsaw Ghetto. While starving themselves, they meticulously kept records of their own conditions and that of their patients, describing in detail the stages of starvation and their attempts to understand and treat them. These documents were smuggled out of the Ghetto and hidden until after the war. (Winick,(ed) 1979). The dramatic changes in the body during starvation, described in this study leave little room for doubt that the body cannot spontaneously recover from near death starvation. Autopsies in the Ghetto as well as those done in Concentration Camps show hearts that have shrunk to half their normal size, mitral valve prolapse, change in the composition of bone and blood, as well as changes in the brain.

Cambodian survivors account for four periods of food shortages or starvation that occurred over a 10-16 year period . The first shortage occurred between 1970-75 when as many as 3 million Cambodians were forced from their villages because of the American bombing and the advancing Khmer Rouge forces. As the fighting increased, the rice planting and harvesting were disrupted and the only consistent sources of food available was what was airlifted into the country. The price of a kilo of pork was about 30% of the monthly per capita income of the average Cambodian in peace time. (Kuoch, 1984) Deaths from starvation were common and malnutrition was almost universal in the peasant population. The Khmer Rouge period from 1975-79 brought unprecedented malnutrition and prolonged periods of starvation in which the daily calorie intake of non-Khmer Rouge Cambodians did not exceed 500 calories.

Although there is no known study which examines the food intake during this period in detail, refugee accounts prove to be very consistent in describing rations of between 250-400 grams of rice per day except during the harvest periods at which time rice intake was more adequate.(Twinning, 1989 ) . The invasion by the Vietnamese in 1979 brought the destruction of the rice crop and produced famine in many parts of Cambodia. (Shawcross, 1984) Refugees flooded the Thailand border where the United Nations created a land bridge specifically for the purpose of distributing food. The fourth period of food shortage occurred in the refugee camps where the quantity and quality of food was erractic. Feeding programs in the camps prevented starvation, but did not eradicate malnutrition. It is reasonable to conclude that malnutrition and starvation were part of life for all survivors who were resettled after 1975.

Slave Labor

Forced labor that included long hours of work under harsh conditions with inadequate food rations were almost universal experiences in concentration camps and prisoner of war camps. During the Pol Pot Regime, slave labor was the rule for everyone including children who were separated from their families as young as 8 years old and placed in special work groups. Refugee accounts of this forced labor describe 10-16 hours of work that included activities normally delegated to beasts of burden. Teenagers and young adults were singled out for work on "mobile teams" which had one of the highest mortality rates because of exhaustion and exposure to injury. (Twinning,1989)

Combat and Atrocities

Prior to 1975, all areas of Cambodia were involved in armed conflict. The American bombing of the countryside was approximately 3 times the intensity of the bombing of Japan throughout the duration of World War II. (Etcheson,1984) Between March 1969 and August 1973, 539,129 tons of bombs were dropped on the countryside including heavily populated areas. Estimates of death are as high as 600,000. (Schanberg, 1974 ) Rocket attacks in cities occurred with regularity usually in the market place, airports or schools exposing all civilians to warfare. The Khmer Rouge relied heavily on atrocities to terrorize the civilian population into submission prior to 1975 and early in their reign.

The evacuation of Phnom Penh and Battambang City are events which defy description, as over 3 million people were force marched out of the cities over a three day period. The death toll was high, children were separated from their parents and people were totally unprepared for what they were experiencing, creating a surreal atmosphere which continues to defy belief even today. (Ponchaud, 1978).

Between 1975-79, the Khmer Rouge used atrocities selectively to control the population. Apparently aware that over exposure to atrocities creates a numbed indifference, Khmer Rouge leaders terrorized people by threatening to " call them for a meeting" a euphemism for sending someone to be killed. Survivors describe hearing people beaten to death, seeing bloody clothing, hearing cadres brag about killing and smelling dead bodies, but they saw people killed on those occasions planned by Khmer leaders or if they secretly followed the KR to the killing fields. People more often witnessed atrocities with senses other than their eyes, a factor which has a profound relevance on survivors sense of reality as well as the content of their flashbacks.

Refugees told of a plan to exterminate all witnesses of the Khmer Rouge atrocities before the Vietnamese army could take control. During this chaotic period, people often found loved ones who had been separate for years, only to see them killed in the violence of that period. The Cambodian Genocide Project, a U.S. funded program to gather information about this time period has made the statement that " After mapping the graves of seven of Cambodia's 22 provinces, using Australian satellites, the investigators estimate the number to be between 10,000 and 20,000. They are reckoned to have held an average of 100-250 people the biggest may contain several thousand victims." (Econonmist, 1996) Many of these killing fields were in use throughout the Pol Pot period, and many were dug by the victims of the Khmer Rouge during the last days of the regime.

Refugees began pushing across the Thailand border in large numbers in the spring of 1979. They were starving and looking for a safe haven. The Thai military rounded up thousands of these survivors and took them by bus to the mountains where they were pushed at gun point over the cliffs. They had no food and all sources of water were surrounded by landmines. Mothers,despairing of their own survival, gave their babies away to Thai villagers. Old people had to be abandoned on the mountainside in yet another forced march which rivaled the cruelty of the Khmer Rouge period. At least 10,000 died during what has become known as "the pushbacks".

Combat and atrocities did not stop when refugees entered the UN controlled camps inside Cambodia. In fact, many refugees died trying to enter these camps and many had to pay in gold to get in. There are accounts of women and children being kidnapped and sold into prostitution. Thousands of people who did not have food cards had to hide in tunnels dug under the camp. Task force 80, a group of Thai rangers who guarded the camps were notorious for their cruelty and abuse and eventually outraged the world community enough to cause them to be replaced. Bandits using rockets and hand grenades regularly attacked the camps. Many of the border camps were the head-quarters for the Cambodian resistance armies which meant that they were subject to mortar attacks on a fairly regular basis.

Torture

There is no question that starvation and slave labor were a part of the torture plan of the Khmer Rouge. It is possible to control large numbers of people when they are exhausted and hungry. Brainwashing or indoctrination always occurred after a long day of work when people were exhausted and most vulnerable to suggestion. Slogans and speeches included the concepts that people had no value, they are always being watched and the Khmer Rouge can destroy them at any time.(Criddle,1987; Marston,1990) These are concepts which have a profound effect on survivors even today.

During the Pol Pot Regime, many people were singled out for additional torture based on their past involvement with the military, the government or even a university. Sometimes, just the fact that someone wore eye glasses was reason enough to make them a target. The torture techniques were as cruel and as varied as the torturers themselves. Isolation, mock executions, beatings, burning, cutting off fingers, pulling off nails were among the techniques commonly used. The purpose for the torture was usually defined as an attempt to obtain a confession of crimes against the state.

The interrogation of all adults occurred regularly throughout the Pol Pot era. People "gave their stories" early in 1975 and these stories were checked for discrepancies at later times. Changes could be the basis for being "called to a meeting." If torture is defined as the infliction of pain for the purpose of taking control, then there was no greater torture for Cambodians than being separated from their families and forced to watch them suffer. Survivor stories are full of descriptions of how parents and children or siblings tried to find their loved ones and save them from pain. Khmer Rouge often forced people to watched their family members be killed or raped and forbid the survivors to show emotion. This was perhaps the most cruel torture of all.

Disease

During the civil war and American bombing, people in the countryside lost access to health care that included both traditional and Western resources. Malaria which had almost been eradicated prior to 1970 became a major health problems as soldiers moved into mosquito infested areas. By the time the Khmer Rouge took control, sanitation systems were totally disrupted. The return to a completely agrarian system which the Khmer Rouge called the "year zero" had no regard for the lessons of modern hygiene. People were often ordered to pick up human and animal feces without the benefit of a tool or basket. Soap, shampoo, toothpaste were non existent. Clothing was washed only by the rain and hours of standing in the fields flooded for the rice crop.

While famine is known to prevent infection and disease, there is no question that many people suffered from malaria and had infections. This may be due to the period of time during rice harvesting when food rations were increased to a near normal state. Essentially little is known about the health status of Cambodians during the Pol Pot years. Cambodians often describe the "Mussulmans" state in family or friends who died. This is the stage generally prior to death in which the victims of starvation looks like skeletons and become indifferent to their environment. Memories of family members who died in this state have a disturbing effect on survivors, especially children who remember the indifference of their loved one and their own inability to save them.

What sets the Khmer Rouge apart from their Nazi counterparts is that they immediately and very systematically murdered all known doctors, scientists or intellectuals who might keep an account of their atrocities. Hospitals during the Khmer Rouge era were places where people went to die. There are even stories of how watery rations of rice soup were served in the same bowls that were used as bedpans. (Kuoch,1984) Intravenous solutions were infused using contaminated solutions that were part of a bizarre attempt to feign medical care. The few physicians who survived the Pol Pot Regime, such as Dr. Haing Ngor, managed to do so by carefully hiding their identity. They did not dare to treat patients or keep records.

Cambodian survivors have offered stories that suggest the Khmer Rouge used their victims for medical experiments. An elderly Cambodian woman described being part of a large group of starving people who were lined up and had pieces of bamboo inserted into the tissue on their back. Whether or not the bamboo contained medication or herbs is unknown, as is the outcome of the procedure. In other stories, survivors described being transfused with coconut water. There is no documented evidence that medical experiments were sanctioned by the higher authorities within the Khmer Rouge nor is there any record of the findings, if there were experiments, according to Ben Kiernan of the Cambodian Genocide Project at Yale. Likewise, while KR issued directives for prolonging the life of victims during the torture process, they are not known to have kept records of their victims medical conditions. (however,recent discoveries of documentation of extermination practices may possibly include these descriptions) When refugees entered border camps in 1979, they had access to food that they had not seen in years. The refeeding period was not under the control of medical staff which may have contributed to a high rate of thiamine deficiencies in refugees as well as an increase in infections. Diseases such as malria, tuberculosis, hepatitis, as well as typhus, cholera and dengue were common diagnoses.

Studies of Victims of Massive Trauma

Conditions and experiences of Cambodians fall into the same extreme trauma categories experienced by Concentration Camp Survivors and Prisoners of War and make it reasonable to rely on the long term research of these groups in projecting the long term needs of Cambodian survivors. Concentration Camp Syndrome, a syndrome first observed in survivors of the Holocaust under Nazi Germany and in POW's (Prisoners of War).includes the symptoms of premature aging, reduced resistance to disease, headache, fatigue, gastrointestinal disorders, depression, social adjustment problems, and posttraumatic stress disorder. This syndrome, as described in the medical literature, persists for decades and causes poor health, emotional suffering, and early death. The key contributors to Concentration Camp Syndrome are believed to be long term starvation, overuse of muscles and bones, exposure to the elements and exposure to disease. In addition, exposure to death and atrocities as well as terrorization and brainwashing are compounded by a loss of a sense of order in a world where there is no recognizable pattern of the cause of death or suffering. Clearly ,survivors of the Mahantdorai fit every aspect of the cri-teria for what is known as Concentration Camp Syndrome, KZ Syndrome or Famine Disease

The study of Concentration Camp Survivors and Prisoners of War (POW's) which began during internment and continued after World War II offer a 50 year view of the course of disability in survivors. Leo Eitinger a world renowned expert on Concentration Camp Syndrome initially described the syndrome as being organic in nature, but over time, he developed a integrated understanding of the relationship of the psychological and physiological aspects of the disorder. He describes the psychic symptoms of Concentration Camp Syndrome: increased lassitude, failing memory and inabil-ity to concentrate, dysphoric moodiness, emotional labi- lity, sleeplessness, sense of insufficiency, lack of initiative, nervousness or irritability, vertigo, vegetative lability, and headaches. Eitinger found that 85 of 100 concentration camp survivors had 5 or more of these symptoms. Eitinger concludes that these psychic symptoms are the result of starvation induced organic brain changes.(Eitinger, 1961) Grovnik and Lunnum found that 92 of 100 survivors had neurological signs such as altered reflexes, coordination problems, diminished sensation, and speech disturbance as well as specific abnormalities on neurological tests such as a pneumoencephalogram. These findings confirm Eitinger's suspicion of organic changes. Eitinger and Strom, in a different studies, found that survivors had almost three times the incidence of neurotic symptoms as the general population; the reported incidence in various investigations ranges from 24% to over 90%, depending on the method of diagnosis. How have concentration camp conditions effected the health of Cambodian survivors? The following is a description of studies of Cambodian survivors and a comparison of the studies of survivors of Nazi Concentration Camps and Prisoners of War.

General Health Status

Eighteen years after the first refugees came out of Cambodia there is surprisingly little available information on survivors state of health. There is no known longitudinal study of the health of Cambodian survivors. The information that is available about the state of health immediately after the Khmer Rouge Regime can be found in the documents of the United Nations High Commission for Refugees which oversaw all the medical programs in the refugee camps. However, access to these documents is difficult to obtain, and the raw data would require extensive work to be given any meaning. Unlike European Concentration Camp Survivors and Prisoners of War, there was no program to follow a group of Cambodian survivors over a long period of time. The movement of refugees through the camps with some refugee having been in as many as 5 UN monitored camps, as well as the politics of the camps make it impossible to replicate the European studies. Likewise, the lack of legal action against the perpetrators of crimes aganist humanity have negated the medical studies that are usually a part of compensation programs for victims.

However, like European Concentration Camp Survivors, Cambodians died in large numbers from communicable disease immediately after their departure from concentration camp conditions under the Khmer Rouge and like European Survivors, Cambodians experienced a honeymoon period for several years after their resettlement in which they had few complaints of physical or psychological symptoms. By the mid-1980's Cambodians were subjectively describing themselves to be in fair to poor health ( Meinhardt 1984; GongGuy, 1987). Headache, fatigue, muscle and bone pain, palpitations, dizziness, sweating and "fever" are symptoms associated with starvation in Concentration Camp Survivors and are symptoms frequently complained of by Cambodian survivors.

A treatment outcome study done at the Indochinese Psychiatric Clinic (IPC) in Boston in 1985 indicated that 40% of Cambodian patients in that clinic had diagnosed medical disorders in addition to psychiatric disorders. (Mollica et al, 1985) The most comprehensive study of Cambodian survivors to date is found in the report published by the Harvard Program in Refugee Trauma and the World Federation for Mental Health titled, Repatriation and Dis-ability: A Community Study of Health , Mental Health and Social Functioning of the Khmer Residents of Site Two. This ramdom sample of 993 Cambodian adults and 182 children, was completed in June 1990 in the largest Dis-placed Persons Camp for Cambodians in Thailand. Of the adult sample 87% of the survivors identified themselves as being in fair to poor health . Twenty percent described being in moderate to severe pain. Sixty percent of children were reported to be in fair to poor health. Although this study was done on Cambodians overseas who experienced 5-10 years of additional trauma in the refugee camps, the data confirms the concentration camp experience and the range of disabilities that are the sequelae.

A more recent survey conducted by the Indochinese Psychiatric Clinic (IPC) in Boston of 168 Cambodians who had lived in Cambodia from 1975-79 and are presently living in Lynn, Massachusetts was conducted over a 14 month per- iod in 1993-94. Like survivors of Concentration Camps, Cambodians in this study had a very high incidence of headache (73.8%), dizziness ( 69.6%) and weakness(69%). as well as communicable disease and psychiatric disorders. (Mollica et al. 1994)

The Cardiovascular System

Starvation and torture involve extreme stress to the heart and vascular system. Eitinger and Strom found clear evidence of excess mortality from coronary heart disease among Holocaust survivors,and of excessively severe morbidity from cardiovascular diseases with a high rate of recidivism, especially coronary heart disease and hypertension. Inbona describes that his survivor patients in France had nearly universal tachycardia and other heartbeat problems. Their hearts turn senile typically twenty years earlier than normal. He also found frequent circulation problems in the legs that make it difficult to stand for long periods of time.

In the Proceedings of International Conference on the Later Effects of Imprisonment and Deportation. The Hague: World Veterans Foundation. November, 1961, M.Dvorjectski, M.D. a physician who was a survivor of the Vilna ghetto described monitoring the heart rate of other inhabitants of the ghetto during the course of their famine. He noted that as the starvation progressed, people developed bradycardia at rest and tachycardia with even minor exertion. He also quotes research carried out by Jewish doctors at the Warsaw Ghetto on cardiac path-ology. Autopsies on 492 people who died from starvation showed a correlation between degree of starvation and the size of the heart muscle. One victim had a heart that weighed 100grams, the usual weight of a heart is approximately 250 grams.

While there are no known studies of the cardiovascular state of Cambodian survivors, there are several studies which suggest that they are at risk for cardiovascular disease due to a change in diet and lifestyle. The State of California is one of the few states in the nation that maintains health statistics broken down into ethnic subgroups for Asians. In Analysis of Health Indicators for California's Minority Populations , Cambodians had half as many deaths from coronary heart disease as the white population of California, but they had four times the death rate from stroke. The UNBRO Medical Statistics Annual Report for Border Camps in1987 listed heart disease and cerebralvascular disease among the three leading causes of death in adults over the age of 45 and heart disease as the leading cause of death in adult women under 45.

Dr. Lawrence Brass a researcher at Yale conducted a study of Prisoners of War which showed them to have a rate of stroke much higher (9.3%)than WWII veterans(1.2%) although there was no difference in the prevalence of hypertension. While the evidence is not conclusive, it is widely believed that the Sudden Death Syndrome may be caused by cardiac arrhymias. This syndrome which occurred more commonly in the early to mid-1980s among Southeast Asian refugees is well known in refugee communities because of the dramatic manner in which victims die. Victims wake from a terrifying dream complaining of chest pain or holding their chest and are dead within minutes. In the refugee camps several deaths would occur within a short time period generally among young healthy males. During the Asian Sudden Unexplained Death Syndrome Research Conference Dr. Michael Brodsky described three female Southeast Asian women who experienced black outs due to ventricular tachycardia. " Symptoms included palpitations, atypical chest pain, sleep dis- orders and psychological difficulties. Heart rate were measured at 250 beats per minute. "Their ventricular tachycardia was not reproducible in an electrophysiologic study. but with the use of the adrenalinelike medication isoproterenol, the tachycardia started after stimulation."

Changes in cardiac functioning is a leading cause of death in anorexia nervousa usually associated with electrolyte imbalance. However, long term studies of patients who are in remission show cardiac changes including prolapsed mitral valves thought to be due to self starvation. To date, studies of adult Cambodians have shown them to have normal to below normal blood pressures when monitored at rest.(Chen, 1994; Tanji,J. et al 1994) . In a study completed in Utah, Burke found that only 3% of her sam-ple of Cambodian adults had elevated blood pressures. (Burke, 1986 ) A study of children in the Minnesota area however, showed Cambodian girls to have an above average blood pressure which might be indicative of future hypertension.(Munger et al, 1991) Khmer Health Advocates monitors patients blood pressure routinely and has seen a definite rise in hypertension over the past several years. However, hypotension is also a problem which interferes with the use of some medications. Subjectively, KHA patients are greatly distressed by changes in their heart rate. One patient recently stated she was not concerned when her "heart begins to race, but when it beats too slowly, I feel like I am going to die".

Mind and Body

The interaction between the mind and the body are most dramatically played out in the survivor of Concentration camp experiences. Trauma causes stress and stress can cause arrhythmias. Trauma also causes mental health disorders which take a high toll on the body of the survivors. Concentration camp survivor studies originating in the United States focused on the psychic nature of symptoms especially PTSD, Post Traumatic Stress Disorder. The Vietnam Veterans studies of the late 1970's and early '80's brought greater attention to the phenomenon of long term psychic sequel-ae. Follow up studies of concentration camp survivors and prisoners of war showed that survivors not only had symptoms such as sleep disorder, flashbacks and nightmare some 40 years after their trauma experiences, but also that these symptoms increased as the survivors aged and became physically more disabled.(Van Kammen,1986)

In the early studies done in the United States of Cambodian survivors, Kinzie and Mollica were readily able to identify PTSD symptoms in their patients. Kinzie used the term Concentration Camp Syndrome in describing the symptoms of Cambodians in his early studies, and has gone on to do ground breaking work in the use of beta blockers to alleviate some of the somatic symptoms associated with this Syndrome. (Kinzie, 1991) Post Traumatic stress disorder is one specific set of symptoms often found in survivors of life threatening traumatic experiences. Its 3 major features are the reexperiencing of the trauma, symptoms of increased arousal of the nervous system, and a numbing of responsiveness along with avoidance of stimuli associated with the traumata. Using a questionnaire survey of 590 Khmers, the California State Department of Mental Health found that 16% met the criteria for PTSD. In a series of more detailed studies of 69 teenagers, Kinzie and Sack, et. al., found that 40 to 50% of Khmer teenagers who lived through the Mahantdorai had PTSD, as diagnosed in clinical interviews.

In a Harvard School of Public Health study of the Site Two refugee camp in Thailand, Mollica, et al found a 15% incidence of PTSD among 993 adults, but more than 60% experienced some symptoms associated with PTSD. Khmer Health Advocates identifies some PTSD symptoms in almost all patients and reports an increase in PTSD as a presenting problem in recent years. Patients describe more pronounced intrusive symptoms especially auditory flashback that are often reported as "hearing noise" but upon questioning are clearly sounds from the past. These are often misdiagnosed as auditory hallucinations in patients who are agitated by the sounds and unable to communicate their history.

Most of the epidemiological studies of de-pression among Cambodians in the medical literature indicate that clinical depression is also very common among survivors of the Mahantdorai. In a Harvard School of Public Health study of the Site Two refugee camp in Thailand, Mollica, et al found a 55% incidence of clinical depression among 993 adults, using culturally appropriate diagnostic techniques. In the United States, Kinzie and Sack, et al found 53% incidence of clinical depression among 69 Khmer teen agers. The California State Department of Mental Health found 36% incidence among Khmers using a population level survey. Using a nonclinical definition of depression, Rumbaut found 32% incidence among Khmers.

Among survivors of Nazi concentration camps, Thygesen et al found 59% incidence of clinical depression, along with many of the symptoms now recognized as posttraumatic stress disorder. Fatigue which is described as a central symptom in Concentration Camp Syndrome is also a central symptom of depression and it is often dismissed as a somatic display of a psychological problems. Eitinger believes that fatigue is an organic symptom that is directly related to long term starvation. Other experts in the field, attribute it to neurasthenia, or to depression. In the UNBRO annual report for 1987, fatigue was the most common noninfectious condition to be treated in the Out Patient Department of all of the border camps. Approximately 7% of the camps population sought treatment for this problem.

Khmer Health Advocates see fatigue coupled with numbness of the extremities, symptoms that are extremely common in the patient population. Watching Cambodians pound on their arms and legs during a conversation is a common occurrence and a behavior that rarely draws attention or comment from other Cambodians. A Recent random survey of Cambodians in the Greater Boston area conducted by the Harvard Refugee Trauma Program suggests that numbness is more frequent in the patient population than in the general Cambodian population and the level of distress experienced by patients suggests that it may be a symptom that causes survivors to seek treatment. Carlson and Roesser have found that 84% of a random sample of Cambodians experience dissociative symptoms. With this in mind it is difficult to determine if numbness of the extremities is due to dissociation or cardiovascular problems. Khmer Health Advocates has seen numbness improve dramatically in some patients with a low dose of Prozac, while other patients continue to complain of numbness long after symptoms of anxiety and depression has been alleviated.