Exposing the intersections of health, society, and economics during a pandemic – perspectives from Cambodia

There has never been such a defining time in recent history to launch a new journal. If 2020 signalled that the world was about to change in ways we could not have imagined; 2021 confirmed that any hopes for a speedy resolution to the COVID-19 pandemic were looking less likely. The effects of COVID-19 have and will result in profound changes, including changes to many people’s social and economic security together with long-term effects to their physical and mental health that are yet to be fully appreciated.

If 2020 signalled that the world was about to change in ways we could not have imagined; 2021 confirmed that any hopes for a speedy resolution to the COVID-19 pandemic were looking less likely. The effects of COVID-19 have and will result in profound changes, including changes to many people's social and economic security together with long-term effects to their physical and mental health that are yet to be fully appreciated.
In January 2020, as the world began closing borders, but before the World Health Organization (WHO) declared a global pandemic, Cambodia exemplified its early global health diplomacy when passengers on the Westerdam cruise ship were able to disembark in Sihanoukville, after weeks of being turned away from other countries . In the year that followed, Cambodia, a country with limited resources, protected its citizens exceptionally well from COVID-19. At the end of January 2021, there were less than 500 reported cases and no reported deaths.
However, on the 8th of February 2021, the Khmer Times reported four recently arrived foreigners, who were required to complete a Government-imposed, mandatory 2-week quarantine period, bribed their way out of their assigned hotel. When they returned to the hotel on the 18th of February for their second PCR test, the foreigners tested positive to . Although the outbreak of community transmission cannot be linked to just this one source, nevertheless, for the people of Cambodia it represented a pivotal event for understanding the changing landscape of COVID-19 in Cambodia. In March 2021, the Government declared a lockdown of Phnom Penh and zoned the city using different colours depending on transmission rates. Those zoned 'red' (with the highest rates of COVID-19) were unable to leave their homes, and many have faced serious issues of economic security because of being unable to work, and food security challenges because of tight restrictions on any movement outside the home.
This resulted in different actors from the Government Ministries, the United Nations and various Non-Government Organizations (NGOs) discussing and recommending policy responses. These included provision of direct access to food by handing out food packages, and unconditional cash transfers for the middle social layer of families who had not been identified as eligible for the previously issued cash handouts linked to the Identified Poor register. Cash transfers (CT) can protect living standards during periods of economic downturn, so that people do not need to sell assets or take on debt. They also as act as a mechanism for building human capital and wealth promotion (de Groot et al., 2015). It is argued that provision of CTs can reduce transitory poverty due to the economic impacts of adverse events, such as the COVID-19 pandemic and that, in the longer term, they can help people escape chronic intergenerational poverty (Black et al, 2013). Projections by the Government are that the lockdown in Phnom Penh prevented an estimated average of 1,650 new cases per day at the peak of the community transmission. However, although lockdowns are critically important to slowing the transmission of COVID-19, they nevertheless are a serious burden to affected communities and individuals, especially for those with limited resources and/or who rely on earning a daily wage.
Globally, although COVID-19 has affected both rich and poor nations, it has not been the great equalizer. It has disproportionately impacted on those who are less-educated and in lower-income jobs, and whose work cannot be done from home. The widespread closure of business, and the lockdowns which required people to stay at home meant that many people, particularly those working in the informal sector/economy, lost their jobs and livelihoods (ILO, 2020). Poverty, overcrowded housing, poor nutrition, lack of access to water and sanitation, and poor access to health care, has revealed the multiple burden of disease, where people's lower socioeconomic status has not only increased their risks of exposure to the disease, but also their ability to combat it, from both an economic and health perspective (Patel, et al., 2020). This will continue to be exacerbated as increasing numbers of people are pushed into poverty with the associated health, social and economic risks. A recent UN policy brief argued that a lack of income and social protection systems for those most vulnerable to economic shocks will reverse decades of poverty reduction, with the connected cost to human potential (United Nations (UN), 2020). This is important, as disasters not only impact on an individual's health, economic and social outcomes in the short termbut will also affect individual, family, and community social, economic and health status across generations. There are pressing questions in regard to those who have been disproportionately affected, and their double burden of poverty and disease. These are areas of concern, not only for health professionals, but for economists, social scientists, policy makers, teachers, and researchers.
The ease with which COVID-19 has traversed arbitrary national boundaries has also reinforced the important interrelationships of public, animal, and environmental health.
This has focused attention on the reality that when dealing with current and future disease outbreaks, new approaches, such as a One Health approach, are urgently needed. Chhem, Chhem and Vento (2020) argue that increasing globalisation, rapid urbanisation, collapsed geographical boundaries, along with the high frequency of global travel and increased human consumption of wildlife have contributed to the rise in infectious/zoonotic diseases. A One Health approach is underpinned by an ecological approach that promotes interdisciplinary collaboration amongst researchers and practitioners working in health, veterinary and environmental science, together with policy makers and government organisations, to promote public health alongside environmental and economic protection. It is argued that this holistic approach to research can offer a way to mitigate and provide solutions to responding to the COVID-19 pandemic and, importantly, to future disease outbreaks. In the future, working collaboratively across sectors and disciplines will be more important than ever.
Education is another sector that has been seriously impacted by COVID-19. This is particularly true in Cambodia where the technological leap into online learning presented both major challenges and significant opportunities. In March 2020, with the arrival of COVID-19 in Cambodia, directives by the Cambodian Ministry of Youth, Education and Sport (MOYES) physically closed education facilities, including schools and universities, which remained physically closed for over 6 months. Higher JOURNAL OF CAMBODIAN HEALTH VOL 1 2021 4 Education Institutions (HEIs) had to rapidly respond by delivering education online, or risk permanent closure. This presented huge challenges for HEIs in preparing staff and students many of whom had little or no prior digital exposure or experience, to use online platforms, (Sin, Kheing, Leng & Water, 2021). However, it has been suggested that although COVID-19 has disrupted education systems in Cambodia, it also offered an opportunity for HEIs to leapfrog ahead by nearly a decade to implement new ways of learning and teaching and join in the global digital transformation of education delivery (Findlay, Chhem & Chhem, 2020).
As the front-line workers in treating patients with COVID-19, health professionals such as doctors, nurses and paramedics have experienced both the personal and professional devastating consequences of COVID-19 on patients and colleagues. By September 2020, it was estimated that, globally, 7000 health professionals had died from COVID-19 (Amnesty International, 2020). Many more health professionals are experiencing Post Traumatic Stress Disorder (PTSD), with many deciding to leave their respective professions (Benfante, et al., 2020). This response to the experience of trying to care for COVID-19 patients has created a new crisis where many countries now have a shortage of existing qualified health professionals with the impact on students enrolling in health professional programs still to be seen (International Council of Nurses (ICN), 2021). This will pose future serious challenges for health care organisations/service delivery as well as for educational institutions that train health professionals.
A medical anthropological lens reveals how the now-ubiquitous Personal Protection Equipment (PPE) mobilised in the protection of populations, has also become a symbol of risk, rights, responsibility, and leadership. In some countries (predominantly in the Global North), the use of the face masks has become politicized by some vested interests as a symbol of assault on individual rights, rather than an effective support for good public health. While some sections of the population have insisted on their 'individual rights', this stands in stark contrast to the collective burden this assertion places on more vulnerable populations around them, and on health care systems and the health professionals who work within them. Arguably in some countries, this has also contributed to increasing reservoirs of COVID in the community, creating a perfect storm for mutations of the virus. In South East Asia and countries such as Cambodia, initial low rates of community transmission were linked to cultural early adoption of wearing masks and a sense of collectivism. In many countries in South East Asia, wearing a mask was already a normal practice if a person was unwell, and viewed as good social etiquette. Public health in any country is therefore reliant not only on good science, but also conditional on the social beliefs, culture, and values of a community/country. From a medical anthropological stance, masks have come to represent the face of the epidemic literally and figuratively. Alongside this, it has been argued that some countries have witnessed the moral failure of leadership where power and politics has been seen as more important than upholding public health and protecting citizens. In this context, public health has been politicized, with some world leaders choosing to ignore science in favour of rhetoric and personal gain.
Other countries have followed health advice to varying degrees, and some, notably Sweden, have adopted alternate approaches that attempt a longer-term approach of protecting their economies and long-term health by targeting protection and care to vulnerable groups. Only hindsight, and analysis of long-term excess death rates across countries adopting the various strategies will tell which approach has been more effective.
This raises pertinent questions about what to measure and how to represent nations' populations, for example, as numbers weighed against their economic recoveries.
Collecting epidemiological data on COVID-19 has entailed collecting real-time statistics on prevalence, incidence, mortality, and morbidity. However, statistics are also a social and political issue in regard to how they configure the relationship between sovereign states, subjects, and citizens (Isin, & Ruppert, 2020). Hacking (2015 describes this as an avalanche of numbers and links this to Foucault's notions of bio-politics and the regulation of public health. Fassin (2009) makes the argument that life is not just a biological status where human beings are reduced to populations to be governed or managed through public health measures; but rather life that is also lived. Therefore, public health and politics (economic arguments) are not just about governing but also about what is at stake (Fassin, 2009 what is implicitly or explicitly exposed in the choices of 'making live' but equally important how 'to live'? In the future, decisions that were made about how to respond to the pandemic will reflect not only political and financial economies, but also moral economies and a politics of life. For most countries, vaccination now represents the best opportunity to control transmission of COVID-19. Although elimination of the virus would be the best outcome, inequitable access to vaccines means there are countries, in particular the Global South, which will not be able to afford this level of protection for their citizens for some time to come (Chhem, Gilberg & Chhem, 2020). The Royal Government of Cambodia has recognised the importance of vaccination in protecting both its citizens and economy and is second in the region, just behind Singapore, to vaccinate its population. To date (May 2021) 2 million Cambodians and foreigners of an estimated 17 million inhabitants in Cambodia have been vaccinated, with plans to vaccinate at least 10 million of the population by the end of the year.
COVID-19 has more than ever exposed the intersection of social, economic and health outcomes that is difficult to detangle into discrete verticals. It has also highlighted the need for collaborative intersectoral approaches from health, environment, and veterinary health professionals to protect and improve the resilience to future disease outbreaks. It is hoped that this journal will provide a place for such a multi-sectoral approach to the many issues that face us all today.
In this first edition of the Journal of Cambodian Health, authors highlight the importance of health professional education, and ensuring organizations work within best-practice frameworks to ensure positive outcomes for vulnerable populations. A key finding of their study is that students felt safe to make mistakes. This is important for any health-care profession as mistakes are also learning opportunities (whilst balancing patient safety) for taking initiative and reflection. Good lines of communication between students, mentors, clinical teachers, and academic lectures, meant a safe environment for student learning was supported. How the mistakes are responded to and addressed by the faculty or clinical area can either be positive or traumatic for the student, and lead to ongoing patterns of practice where reflective learning and practice development (rather than stagnation) can be encouraged or discouraged (Zieber & Williams, 2015). The study points to the importance of supportive education environments in promoting current and future learning. in an environment where efforts to improve health and social outcomes are often hampered by multiple actors with differing agenda. Cambodia is ranked as having one of the highest number of NGOs in the world, with approximately 3000 NGOs in-country in 2020. This can lead to siloed and fragmented approaches to care and service provision, as well as an overdependence on external aid. In many instances, funding for service provision is based on the number of clients enrolled in programs and the units of services delivered. In this context, there is little incentive to exit people from a service, and a lack of focus on sustainability to ensure that people have the support and skills to take up their own lives at some point. Evaluating the impact of implementing a Case-Management pathway into a local Khmer NGO highlighted the benefits of focusing on case closure at the very beginning of enrolling children and families into the program, and on interventions that increased client's autonomy rather than service dependency.

Ryan
The Journal of Cambodian Health (JCH) is a peer-reviewed journal committed to supporting and expanding health research and scholarship in Cambodia and the ASEAN region. The Journal takes a broad approach to contemporary health issues and welcomes submissions on broad health topics which may include Sustainable Development Goals, health professional education, public health, health policy, community health, environmental health, clinical issues, case-studies, evidencebased practice/medicine approaches and decision making, advocacy and human health security, and history and anthropology of health.
The JCH invites discipline-specific and interdisciplinary submissions including original research, reviews, policy briefs and commentaries on health and health-related social issues, as well as submissions from students enrolled in health or policy programs.
Acknowledgments: JCH would like to acknowledge the support and willingness of others', to share previous experience, knowledge, and pearls of wisdom in setting up an Open-Source Journal (OSJ). Thank you to Luqman Hayes from the Auckland University of Technology in New Zealand who has a passion for promoting scholarship through OSJ and pioneered the Tuwhera project in New Zealand. His insights were invaluable. When we hit a major roadblock in Cambodia, Luqman was generous in support, and practical in his solution, by offering to co-host JCH via the AUT library server. This also solved our ISSN challenges and meant each article would have a DOI. Thankyou also to Donna Coventry from AUT for her incredible knowledge on OSJ publishing and her willingness to share this. Thank you to our colleagues in the Nursing Department at AUT, and Professor Stephen Neville. Big thanks go to Kham Sokheng in Cambodia and Takeo Echizenya in New Zealand for their unfailing support and solutions to all the IT infrastructure needed. Thank you to Lyn Bayly for the final copy editinga pen is indeed much more powerful than a sword! And finally, thank you to Eng Muynigm, a committed health researcher in Cambodia, for her unfailing energy, enthusiasm, and contribution to making the journal a reality.