Self-Medication and the Pharmaceutical System in Cambodia

ABSTRACT

Based on an ethnographic study of the Cambodian pharmaceutical system conducted in an urban and a rural setting between January 2015 and June 2016, we report on the complex dynamics surrounding the issue of self-medication in that country. We describe the history of the circulation of pharmaceuticals in Cambodia, and we discuss the contemporary relationship individuals have with these medicines and with those who distribute them. We illustrate the specific dynamics of the pharmaceuticalization of Cambodian society, where private drug vendors are playing a key role.

KEYWORDS:

• Cambodia
• autonomy
• pharmaceutical system
• self-medication

Acknowledgments

The project was approved by the National Ethics Committee for Research in Health of Cambodia (466, NECHR). We thank all those interviewed during this research project for the time they generously gave us. We also thank Maurice Cassier who led us to the conceptualization of “depharmaceuticalisation” for the situation of Cambodia during discussions at an internal Globalmed project meeting in September 2016, held in Paris.

Notes

1. For further information see http://globalmed.ird.fr/la-recherche/contexte-et-objectifs.

2. Although we focus on pharmaceuticals in this article, in the study we examined the range of health practices people use: traditional medicine (Khmer medicine founded in the scholarly tradition transmitted through texts, primarily based on using medicinal plants and officially recognized by the Ministry of Health); popular medicine, meaning syncretic home remedies based on a combination of lay knowledge, knowledge of Khmer medicine and/or biomedicine; and “neo-traditional medicine,” which uses products, often phytotherapy, from a variety of therapeutic traditions, with standardized, specific contents and packaging.

3. Semi-wholesalers purchase their supplies from “pharmaceutical companies,” sell wholesale or retail, and have a pharmacy license. They are not authorized to import, yet our interviews indicate they do so illegally, mostly from neighboring countries such as Vietnam and Thailand. Sometimes these semi-wholesalers run an import company alongside their pharmacy.

4. In local use, the term “pharmaceutical company” refers both to local medicine manufacturing firms and medicine import-export and distribution companies. They have a special license from the Ministry of Health to import and export medicines.

5. The drug market is related to health but is also a lucrative market. Different actors along the biomedical medicine circulation chain use them as a resource to enhance their personal income. Biomedical standards are not always respected, and actors try to keep their practices secret so that ordinary citizens are unable to discern that they are evading the law.

6. This concept, analyzed by Egrot and Desclaux (2015), refers to the increase in the volume of pharmaceuticals in circulation and their increasingly predominant place in society.

7. Pharmaceutical practices outside of frameworks are defined by the state and the country’s health officials.

8. This category is subjective and is not strictly related to the source of medicines. Drugs considered to be in this category by both clients and vendors may come from France but also from Korea or Germany. Generally, these are expensive drugs, similar to the category “French drugs” or “pharmacy drugs” described for Benin (Baxerres 2013).

9. In private pharmacies and depots, most drug vendors called consumers neak ting (buyers) or client pniou. In this article we use the term “client” to refer to the consumers of these private outlets. In hospitals and health centers, health professionals called them neak tchum ngeu (patient).

10. Generally, one of the vendors in these retail places has completed three months of training, organized by the Provincial or Municipal Health Department of the Ministry of Health, but this does not replace the training received by health professionals authorized to distribute medicines.

11. There is no universally recognized phonetic transcription system in Cambodia; in this article, we used a liberal transcription system to facilitate the pronunciation of Khmer words for an English speaker.

12. To protect the subjects’ privacy and confidentiality, pseudonyms are used throughout.

13. As explained by a member of DDF (Phnom Penh, August 2018), the Ministry of Health is in the process of solving this problem.

14. Pdassaï refers to a “nosologic popular entity” (Jaffré and Olivier de Sardan 1999) generally translated as “flu” and “common cold;” Cambodians use the word pdassaï for different disorders such as runny nose, headache, sore throat, cough, fever and sneezing.

15. According to several local sources, the color green did not exist for a long time. One health professional remarked that “traditionally, we say that the rice fields or the trees’ leaves are blue” (Interview, Phnom Penh, March 2015).

16. Although the word thnam is commonly translated by “medicine,” it is a generic term that covers a vast lexical field. “Hair dyes,” “nail polish,” “wax,” “tobacco,” “pesticides,” “paint” and “poison,” for example, are also referred to as thnam. According to Michel Antelme and Gerard Diffloth (linguists specializing in Mon-Khmer languages), the word thnam is derived from the Khmer word dam, from the verb “to boil.” This term refers to a combination of various products that have been processed using various methods (boiling, drying, cooking, crushing and grinding) to produce a final product that may not only be used to heal or embellish, but also to kill or destroy.

Additional information

Funding

This project received funding from the European Research Council under the European Union’s Seventh Framework Programme (FP7/2007-2013)/ERC [grant agreement no. 337372].

Notes on contributors

Eve Bureau-Point

Eve Bureau-Point is an anthropologist at the French National Center for Scientific Research (CNRS) in Marseille. She undertook her PhD and two periods as a post-doctoral research fellow in Cambodia on the circulation and appropriation of medical knowledge and technologies. Address correspondence to: Eve Bureau-Point, UMR 8562 Center Norbert Elias, 2 rue de la charité 13002 Marseille, France. E-Mail: [email protected]

Carine Baxerres

Carine Baxerres is an anthropologist at the French National Research Institute for Sustainable Development (IRD), and a research fellow at MERIT, IRD, Université de Paris Descartes, Laboratoire Population Environnement Développement, Marseille. Since 2001, she has studied access to healthcare and global and local pharmaceutical markets, including the circulation, distribution, regulation and uses of pharmaceuticals in West Africa. E-Mail: [email protected]

Sena Chheang

Sena Chheang is a pharmacist, Professor and Dean of Faculty of Pharmacy at the University of Health Sciences in Cambodia. He undertook a Diploma of Research in France (DUR), René Descartes Paris 5, from 2000 to 2002. He was head of the Drug and Food Authority of Kampong Cham Province, was responsible for the drug management inspector’s team 1995-2014, and was a member of the Pharmacovigilance Committee of the Ministry of Health. E-Mail: [email protected]