Iknew very little about Cambodia before I landed at the airport in Phnom Penh. I imagined luminous green rice paddy fields, smiling brown faces, and the perfect antidote to my disillusionment with medicine after only 2 years working in the Australian public health system. My medical resident jobs had seemed to require more secretarial ability than clinical skills, and hours were lost begging for an urgent investigation or trying to secure an outpatient appointment within the next 6 months. I wanted to witness the power of basic medical treatment — to save lives with a course of penicillin, to save sight with a few doses of vitamin A.

I had teamed up with a small Australian non-government organisation called Awareness Cambodia and agreed to take on the task of establishing an outpatient medical clinic in the rural province of Kampong Speu. I had 5 months in which to do it.

The van ride into Phnom Penh from the airport was enough to trigger a surge of panic as I tried to digest a series of confronting images. A mother clutching her very young baby with one hand and, with the other, manoeuvring her motorbike through a sea of traffic; a barefoot boy with a swollen belly, his naked younger brother in tow, begging at a busy intersection; pre-pubescent girls in make-up and pyjamas loitering outside ramshackle wooden brothels. The brutal realities of living in a developing country hit me hard in the face.

The next few weeks were spent doing the necessary groundwork around Phnom Penh and Kampong Speu, visiting the local hospitals and established clinics. From what I could see, a bed in a public hospital was no more than a bed in a cheap guesthouse. Only the intensive care unit had any equipment — a few oxygen tanks and perhaps one functioning cardiac monitor. To my horror, I discovered that it was not uncommon to use blocks of ice for postoperative analgesia (applied, for example, directly over a patient’s midline abdominal wound), and that, because of sheer lack of staff, the patient’s families performed almost all of the nursing duties. Hospitals run by foreign non-government organisations were so overloaded that patients would literally have to win a lottery to receive care in these hospitals.

In the clinics I attended it was rare to see a doctor listen to a patient’s chest before prescribing three antibiotics for a chest infection, and intravenous (IV) drips were consistently the favourite therapy among Cambodians, who believed that they could cure anything from a headache to a sore toe. It was not unusual to see an IV pole protruding through the window of a passing car, or held up by a devoted parent as the family rode home on their trusty motorbike. In a corner of Phnom Penh, I discovered a network of pharmacies stocked wall-to-wall with the latest broad-spectrum antibiotics and a never-ending stream of patients buying them, without prescription.

In the countryside, Western doctors had to compete with village doctors, some of whose remedies were like something out of a bad fairytale. A colleague told me that she asked why a child in one village had a glass eye and was told that the eye had been used in a concoction to cure the child’s mother of a serious illness. I personally remember a woman with scabies who was non-compliant with the standard topical permethrin treatment, opting instead to pour hydrochloric acid on her wounds to take away the itch.

I faced different problems in my interactions with the government health centre that we planned to work with. The centre appeared to have all the fittings required for a clinic, including a wealth of power outlets, light fittings and taps, but there was no electricity or running water. Instead of being glad that we were providing doctors and free medicine, our initial proposal for a fortnightly outpatient medical clinic for the villagers in Kampong Speu province was met with hesitation because of fears that it would increase the workload of the health centre staff. As they only earned US$18 per month, out of necessity, they ran their own private clinics in the afternoon. We ended up having to supplement the government workers’ salaries before we were allowed to provide our free service to the villagers.

To save myself from jumping on the next plane back to Australia I had to focus on small goals and achievements. I began to take pride in our clinic and the fact that when we examined patients we spent a good 10 minutes with them, instead of the usual 2 minutes. We checked people for anaemia with simple laboratory tests, and we gave them vitamin supplements and treated them empirically for worms — but it was a far cry from what I had imagined.

The sickest patients, who needed our help the most, were the hardest to treat. A 21-year-old man with pancytopenia readily comes to mind. We referred him to the local hospital because he could not stand up and was bleeding from his gums. But his family could not afford the blood transfusions he needed, let alone the hospital costs and the further investigations required. He ended up relying on herbal remedies and died six weeks later.

It was not uncommon to find families falling deep into debt trying to save their loved-ones, often to no avail. Other families would put their sick relatives in a hut on the outskirts of the village and leave them there to fend for themselves — out of sight, out of mind.

Nothing was easy. If we decided to refer a patient to the local hospital or to Phnom Penh, we needed to spend the next few hours working out the logistics of finance for transport, meals, compensation for lost income, and a carer for the six or seven children left behind.

Ethical dilemmas emerged on a daily basis. An elderly woman presented with fatigue and occasional per rectal bleeding and, on examination, was slightly pale. In Australia she would have been on the next colonoscopy list. In Cambodia this would mean a long trip to Phnom Penh to the only public hospital that performed colon-oscopies. But who was going to pay for the colonoscopy? And, more pertinently, what would we do if we found something? Was it ethical to submit an otherwise well 70-year-old woman to an abdominoperineal resection or partial colectomy when she might not survive the operation? Was it worth sending her family deep into debt? Or was it more ethical to treat her anaemia with iron tablets and improve her quality of life? Working in Australia was beginning to seem like a dream.

But having said all this, I will never forget one woman’s smile as we helped to secure an operation for her granddaughter’s cleft palate, and I still treasure the bowed thanks from the villagers for making them feel better, if only by turning up every week, listening to their problems and giving them our time.

My 5 months in Cambodia may not have unfolded as I expected, but I do not regret it. I learnt that I am lucky to live in a country where I, and my patients, have access to free health care and where I can practise medicine with the knowledge that there are good referral systems in place.

I thought I would go to Cambodia and change people’s lives, but instead when I went there it changed mine. The experience gave me perspective, not only in my medical practice but in all aspects of my life. My time in Cambodia has helped me see an abundance of resources and opportunities that I couldn’t see before.