Fourteen years ago, the Cambodian Health Committee (CHC) began its work in the tuberculosis (TB) wards of three district hospitals in Svay Rieng Province, a poorly accessible and impoverished area of Cambodia bordering Vietnam. Svay Rieng was devastated during the Vietnam War, and when CHC arrived in 1994, the province had the poorest rice harvest in the country, and one of the highest TB rates in the world.
Among the poverty and neglect, the CHC staff discovered strong communities and tight-knit extended families, and moved quickly to incorporate these assets into a novel treatment program. Training patient supporters, community health workers, food assistance and a village loan program based on the Grameen Bank, linked to TB care and AIDS prevention, CHC built a first-of-its-kind model of community based TB care and treatment. The model proved highly successful at tackling both illness, and its root cause, poverty. But its notable achievement has been in the scale up of these activities to impact TB and later AIDS care in the country in general.
Since 1994, the CHC's efforts have enabled the cure of more than 13,000 people from TB in Svay Rieng and in another war-impacted province, Kompot, where the Khmer Rouge were actively fighting until 1997, shortly before CHC began work there. Thousands of villagers have received education about TB and HIV/AIDS and have participated in microloan programs to increase their income. CHC worked from the beginning to train national staff in TB and The Cambodian National TB program adopted the CHC's model throughout the country.
Building upon the success of the TB program, the CHC applied its novel approach to treat AIDS. Today, the CHC cares for over 3,000 people in provincial AIDS treatment programs in Svay Rieng and Kompot. CHC has created Centers of Excellence for TB and AIDS care for adults and children in Phnom Penh, and together with the National AIDS Program is pioneering new ways to care for people with AIDS in hard-to-access rural areas.
Our TB and AIDS treatment programs and our advocacy work continue to promote innovative approaches to treating infectious diseases in partnership with families and communities. Our research has revealed answers to many scientific questions about TB and HIV infection.
The roots of the CHC go back nearly 30 years, to the original efforts of a handful of dedicated health care workers who came together in the war-torn refugee camps on the Thai-Cambodia border. This is our history.
| 1979-1980 | 1980's | 1990's | 2000-present |
| 1979 | Vietnamese troops occupy war-torn Cambodia, a country that has been in the grips of the genocidal Khmer Rouge regime, which has already killed 1 million Cambodians. When the regime falls, another 1 million starving people flee west to refugee camps on the Thai border. American Refugee Committee is founded in Minneapolis and Chicago to aid Indochina Refugees, and begins a program of health worker training in Cambodian camps. |
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| 1980 | ARC recognizes tuberculosis as a leading health problem in camps. While curable, the disease is notoriously hard to treat, requiring a year-long regimen of multiple drugs. Because drug resistance threatens to emerge whenever treatment is interrupted, the international health community opposes a TB treatment program in the camps, fearing there is no way for dispossessed refugees to complete the arduous treatment. | |
| 1981 | Steven Miles, MD and Bob Maat of ARC argue that TB can and must be treated . Working from thatch-roof buildings with no electricity, they start a program in the Nong Samet refugee camp. Using a new antibiotic regimen that shortens the treatment time from one year to six months, they enlist family members as patient supporters and provide food along with the medicines. Their program marks the first use of the new DOTS (daily observed therapy, short course) method in an active war zone. | |
| 1983 | Refugee Sok Thim arrives in Nong Samet with his family. He begins nursing training in the ARC school. ARC volunteer Anne Goldfeld, MD, a resident training in Internal Medicine at Massachusetts General Hospital (MGH) and Harvard Medical School, arrives in Nong Samet for the first time. |
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| 1984 | Miles and Maat publish their landmark article on DOTS treatment in Nong Samet. Their results show nearly 100 percent adherence to medicine and many cures, despite the difficult conditions in the camps. Sok Thim moves from nursing to ARC's medic training course and eventually becomes Maat's assistant. He becomes head of the TB treatment program in Site II, a new camp built after Nong Samet comes under attack by Vietnam-based Cambodian troops on Christmas Day. During the immediate evacuation of refugees all TB patients regrouped at the evacuation site and none missed a dose of TB medicines. |
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| 1988 | Goldfeld continues her work on behalf of refugees, and is the lead author on the first peer- reviewed scientific article on the medical effects of torture, which appears in JAMA (the Journal of the American Medical Association), which for the first time shows that rape is a common form of torture that women undergo in situations of war. | |
| 1989-90 | Sok Thim takes over management of the ARC TB treatment program from Maat and eventually becomes the head of all camps for the United Nations Border Relief Organization, an international effort to aid Cambodians and others affected by years of warfare along the Thai-Cambodian border. Goldfeld, who has completed her training in internal medicine and infectious disease, makes her first visit inside war-ravaged Cambodia, which is still under an international trade and aid embargo. She works briefly as a medical advisor to the Mennonite Central Committee there, then assumes the position of medical coordinator for ARC at Site II where she meets Sok Thim. Goldfeld and Thim begin to compile the case histories of all the TB patients treated in the camps, and pool their expertise to write a manual to treating the disease among refugees in war zones and in developing countries. At Site II, Goldfeld also initiates the land mine injury prevention program, in response to her experience caring for impoverished refugees who were injured by landmines while scavenging for food outside the camps. She makes the first call for a ban on landmines in 1991, in Congressional testimony before the US House Foreign Affairs Committee. Goldfeld becomes a leading voice in the fight against land mines, publishing articles and photos in outlets including the New York Times, Washington Post, Boston Globe and The Nation, making the link between poverty and victimization by landmines. She founds the US Campaign to Ban Landmines with Holly Myers in 1994, and serves as an advisor to the International Campaign to Ban Landmines, which goes on to win the Nobel Peace Prize in 1997. |
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| 1992 |
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| 1993 | Sok Thim travels to Boston to finish the TB treatment manual with Goldfeld, and together they make plans to start a TB program in Cambodia. The first case of AIDS is diagnosed in Cambodia. |
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| 1994 | The CHC is officially founded in Svay Rieng, Cambodia, by Sok Thim, Goldfeld and Brian Heidel, Cambodian Country Director for the ARC, with a mission to deliver tuberculosis treatment to rural residents. In founding CHC they overcome international skepticism that community based care for TB could be successful in Cambodia or elsewhere. With a private donations, a TB program is started in the spring of 1994 using some approaches from the successful ARC camp program, but modified to meet the needs of impoverished and isolated residents in one of Cambodia's poorest provinces. Working out of three district hospitals in collaboration with the National TB Program, CHC rapidly expands to include free medicine, food assistance (in partnership with the World Food Program), patient supporters and community health workers and a novel village bank/microloan program. Beginning with a cadre of health workers trained by ARC in the border camps, CHC focused on the development of community health workers and joined forces early on with Ministry of Health doctors and the Cambodian National TB program providing training and support to them. This alliance ensures that the CHC's work will be sustainable and not just a boutique health delivery program. In partnership with OxFAM America and later with Catholic Relief Services, CHC initiates the first microfinance program linked to a TB treatment program, based on the Grameen bank model. The CHC Village Bank program goes on to make approximately 20,000 loans, and uses its profits to train village health workers. TB patients whose families participate in the village bank program have close to 100% adherence with TB medicines and similar cure rates. The dozens of village health workers trained with interest from the loans turn out to be key players in spreading information about the new epidemic of AIDS that is gripping Cambodia. CHC continues to refine its system of training community health workers, enlisting relatives as patient supporters and drafting treatment contracts, which eventually becomes the standard for outpatient TB treatment throughout Cambodia. The technique is also used as the base for other models of TB and AIDS care globally. Goldfeld testifies before the United States Congressional Hunger Caucus on Tuberculosis and Poverty in Cambodia. |
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| 1995 | Research program on TB begins, in partnership with Goldfeld's laboratory at Harvard Medical School and later at the IDI Institute for Biomedical Research in Boston, Massachusetts. Goldfeld sees the opportunity to collaborate with the Cambodian patients and health workers to make significant progress into understanding the immune response to TB, and to develop new therapies linking delivery of care with basic scientific discovery. | |
| 1997 | With additional private funding, the CHC expands its TB treatment program to Kompot, another poor and war-affected province in southern Cambodia, that had been a Khmer Rouge stronghold up until a few months before. CHC begins HIV/AIDS prevention programs in Svay Rieng and Kompot, providing education about the disease to high-risk groups and teens using peer group counseling and its extensive community and village bank networks. |
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| 1998 | Goldfeld's research with Cambodian patients uncovers the first susceptibility gene for TB, which helps explain why some people become sick with the infection, and others do not (hear a Boston Public Radio interview of Goldfeld describing the discovery and its follow up from 2006). | |
| 1999 | Home DOTS program begins: Mobile health teams fan out from district hospitals to deliver TB medications to villagers in remote locations daily. Health workers use village bank networks to seek out TB infected villagers for treatment. | |
| 2000 | Sok Thim and Goldfeld publish Curing Tuberculosis: A Manual for Developing Communities. Goldfeld and team discover a unique immune reaction in patients that helps the TB bacterium evade host defenses. It is later found that this mechanism is a general mechanism by which the host immune system is regulated in many infectious diseases. Goldfeld begins a long-term research project in the Peruvian highlands around Cusco. The study of Quechua people will help to understand the genetic causes for differences in the immune response to TB. |
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| 2001 | CHC begins treating hard-to-cure cases of drug-resistant TB in Svay Rieng. The program treats people in their homes using community health workers, patient supporters and individually tailored regimens of drugs (DOTSPlus). Goldfeld and Sok Thim spread the CHC model by traveling to Pakistan and Afghanistan with the American Refugee Committee to establish AIDS and TB treatment programs in refugee camps there. CHC-USA incorporated as a tax-exempt 501(3)b charity. |
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| 2002 | CHC receives planning grant from the United States National Institutes of Health under the Comprehensive International Program of Research on AIDS (CIPRA) to establish a TB and AIDS clinical and research network throughout Cambodia. This leads to an extensive planning process engaging the French Agence Nationale Recherches sur le Sida and Cambodian governmental health agencies to achieve this goal. Goldfeld and Sok Thim return to Afg hanistan and Pakistan refugee camps (hear Chicago Public Radio interview). ARC subsequently establishes the largest health care program for Afghan refugees in the Quetta area and begins AIDS prevention activities in the camps. Goldfeld writes and speaks about the devastating TB problem in Afghanistan and its heavy toll on women. |
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| 2003 | As an outcome of the CIPRA planning process, the CHC develops a proposal to carry out the CAMbodian Early vs. Late Introduction of Antiretrovirals (CAMELIA) trial, which will establish the best timing of medication regimens for patients with both TB and AIDS. The study, the first of its kind, receives funding from the French ANRS and will be done in collaboration with the US NIH funded CIPRA. To raise global awareness of AIDS and TB, Goldfeld initiates a project with photojournalist James Nachtwey to document the twin epidemics in Cambodia. His photoessay, TB in Cambodia, is part of a portfolio that garners the Magazine Photographer of the Year award from the National Press Photographers Association. With support from the Jeanne and Joseph Sullivan Foundation CHC is able to buy AIDS drugs for 100 patients for one year. Dr Didier Laureillard, the medical coordinator of MSF France's pioneering AIDS treatment program in Phnom Penh serves as an advisor to CHC. |
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| 2004 | The NIH/CIPRA expands the planning grant to a five year, $2.5 million grant to build a clinical and research network for TB and AIDS and to support the CAMELIA trial. With support from US NIH and the Japanese embassy, CHC begins to renovate and upgrade the TB care facilities in the pulmonary ward of the largest hospital in Phnom Penh (KSFH, the Khmer-Soviet Friendship Hospital), which serves the poorest and sickest Cambodians dying from both diseases. With the support of the Sullivan Foundation and the American Foundation for AIDS Research TREAT Asia initiative, the CHC starts a pioneering at-home AIDS treatment program for AIDS patients built upon its TB treatment model. The program is based on the successful CHC TB model, using community health workers, patient supporter, education, treatment contracts, and food. It allows patients to receive care near their homes so they do not have to seek care in Phnom Penh where cut off from social supports they often end up homeless, sick and dying. CHC opens an AIDS clinic and inpatient ward at the Svay Rieng Provincial Hospital, the first rural Cambodian managed AIDS project. Thim and Goldfeld publish results of community-based TB treatment in JAMA. Their work ensconces the practice of combining microloans with food aid and home DOTS in TB and global health care. |
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| 2005 | The CHC opens an AIDS treatment clinic at Kompong Trach District Hospital in Kompot Province, making it the most rural area to have access to AIDS treatment. Didier Laureillard leaves MSF France and becomes the first CHC medical coordinator, a position he will hold for two years, helping to launch the CAMELIA trial. CHC works with Japan International Cooperation Agency to expand TB treatment and Community DOTS to all of Svay Rieng province. Svay Rieng village bank microloan program, started by CHC in 1994, becomes an independent Cambodian Microfinance Institution dedicated to alleviating poverty. Sok Thim named a Hero of Global Health by TIME Magazine, which profiles him, Goldfeld and the CHC in its focus issue on global health. |
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| 2006 | CHC opens Maddox Chivan Children's Center (MCCC) in Phnom Penh, with the support of Angelina Jolie, providing a new model of integrated medical care, education, and social support to children infected or affected by AIDS. Marie-Pierre Fernandez leads this effort as its director. Cambodian National TB Program officially adopts CHC treatment model country-wide. First Cambodian patients begin CAMELIA trial. CHC is featured in three People Magazine issues sponsored by the Jolie-Pitt foundation, with photos by James Nachtwey. |
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| 2007 | James Nachtwey's photo exhibit at the United Nations, "A World Free of TB," spotlights the efforts of the CHC. To provide universal access to drugs for MDR TB, CHC develops a countrywide treatment plan at the request of the National TB Program, and receives Green Light Status from the World Health Organization to obtain low-cost drugs for the program. CHC convenes the first MDR Working Group Conference to develop the Cambodian national guidelines for treatment and prevention of MDR TB. The CAMELIA trial recruits its 382nd patient. |