On a sweltering day this past July, Dr. Stanley Schrier, of Stanford University School of Medicine, found himself almost 8,000 miles from his home in San Francisco and surrounded by children with malaria, dengue fever, infantile diarrhea, severe forms of thalassemia, and iron deficiency anemia — not his normal caseload. The children were patients at the Angkor Hospital for Children (AHC) in Siem Reap, Cambodia, one of the hematology programs offered through Health Volunteers Overseas (HVO). In partnership with ASH, HVO sends volunteers to teach and train local health-care professionals in some aspect of hematology, with the goal of empowering them to become self-sufficient.
HVO programs are developed by the medical personnel at the site. In 2007, Dr. Peter Smith, a member of ASH, made an initial site assessment, building on his experiences as a prior HVO pediatrics volunteer. As chair of the HVO Hematology Steering Committee, Dr. Schrier traveled to AHC in July 2008 to build on Dr. Smith’s initial site assessment to learn what type of volunteers would make the program most successful. Dr. Schrier met with Dr. Sing Heng, who manages pediatric hematology and oncology cases at AHC.
With between 350 to 400 outpatients a day, AHC is the primary pediatric care facility in the region. During the busy season, which includes the annual dengue epidemic, the outpatient caseload can increase to more than 500 patients a day. Access to care is not dependent on one’s ability to pay; the vast majority cannot. About 450 patients are admitted each month — over half of these to the IPD and 55 to the ICU.
Currently, anemia resulting from malaria is the most common diagnosis. Asymptomatic children may present with anemia with pallor and hepatosplenomegaly, as well as clinical and laboratory evidence of thalassemia. Patients do not receive blood transfusions unless they display symptoms of thalassemia major. Dr. Heng performs hemograms as part of the work-up database for patients on the wards, but he cannot perform them for outpatients. Because of the lack of testing, many moderate and severe cases of white blood cell disorders and thrombocytopenias go undetected. Dr. Heng believes that there are a surprisingly large number of cases of aplastic anemia that go undetected, partly because of a lack of facilities for bone marrow aspiration and analysis. The incidence likely increases in the endemic dengue season, when monsoons sweep over the country for several months.
"AHC needs clinical lab support," said Dr. Schrier. "They can provide red blood cells for transfusion, but they need marrow aspirate, staining and interpretation, and component preparation, particularly platelet preparation." The first volunteer at the site, Dr. Dorothy Barnard, spent the month of October working with Dr. Heng to assess what it would take to build a successful hematology laboratory.
In an effort to further build its hematology capacity, AHC will hold an extensive pediatric hematology/oncology course for fellows, students, and residents in May 2009. The course will be the only one of its kind in Cambodia outside of the capital, Phnom Penh, about half a day’s drive from AHC. Dr. Heng hopes that HVO faculty will be the key to making the curriculum successful in training a new generation of health-care professionals who focus on hematology.
HVO hematology volunteers can be ASH members from anywhere in the world. Volunteers are currently being recruited for sites in Kampala, Uganda, and Siem Reap, Cambodia. Additional sites in Latin America are anticipated in 2009.
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