خدمات بهداشت روانی در کامبوج، چالش ها و فرصت در یک محیط بعد از جنگ

Cambodia had suffered enormously due to war and internecine conflict during the latter half of the twentieth century, more so during the Vietnam War. Total collapse of education and health systems during the Pol Pot era continues to be a challenge for developing the necessary infrastructure and human resources to provide basic minimum mental health care which is compounded by the prevailing cultural belief and stigma over mental, neurological and substance abuse disorders (MNSDs). The mental health research and services in Cambodia had been predominantly ‘trauma focused’, a legacy of war, and there is a need to move toward epidemiologically sound public health oriented mental health policy and service development. Integrating mental health program with primary health care services with specifically stated minimum package of activities at primary level and complementary package of activities at secondary level is an opportunity to meet the needs and rights of persons with mental, neurological and substance abuse disorders (PWMNSDs) in Cambodia, provided there is mental health leadership, government commitment and political will.

The Khmer empire extended as far as Thailand, Malaysia, Vietnam and Laos during the eighth to twelfth centuries, a golden period that is enshrined in the magnificent temples of Angkor, a world heritage monument in Cambodia. Cambodia has been a land of perennial conflict since Angkorean times. Following the independence from French colonial rule, the country deteriorated to become the poorest in the region, a ‘victim of its geography and political underdevelopment’ (Shawcross, 1994). The spillover of Vietnam War and the social engineering and pogrom of Pol Pot regime in the 1970s resulted in collective trauma of the entire population. A million and a half died due to starvation and sickness, half a million were eliminated in the name of agrarian revolution and about two million people were internally displaced between 1975 and 1978. Studies in the refugee-sites along the Thai border revealed the impact of war and internecine conflict on the mental health of the Cambodian population (Mollica et al., 1997). The end of the Cold War and the Paris Peace Agreement of 1991, followed by UNTAC-intervention (United Nations Transitional Authority in Cambodia) brought an uneasy peace and stability but the country continues to suffer from political instability and the impact of chronic conflict (Deth, 2009). The people of Cambodia are in the process of reconciling with the trauma of war and conflict of the past whereas lack of institutional structures remains to be a challenge for the growth and development of the nation, particularly health services (Bockers et al., 2011). Deva et al. (2009) outlined the development of mental health services in Cambodia and the challenges ahead in the backdrop of sparse human resource and meager allocation of national health budget to the mental health program. Research and development of mental health services in post-conflict countries such as Cambodia, had been trauma focused and there is a need to move beyond post-traumatic stress disorder (PTSD)-paradigm to address the range of common mental and neurological disorders (de Jong et al., 2003 and Murthy and Lakshminarayana, 2006). This article, a follow-up to the update on the mental health situation of Cambodia by Deva et al. (2009), underscores the importance of epidemiologically sound, public health model of mental health service delivery, with an emphasis on integration of mental health services with the primary, secondary and tertiary health care systems in Cambodia.