Les activités du Centre Clinique et Chirurgical Takeo Bambino Gesù de pédiatrie clinique et chirurgicale au Cambodge ont commencé en mai 2006 après la signature d'un accord formel entre le Gouvernement Royal du Cambodge et l'hôpital. Actuellement le centre pédiatrique est composé d'un service pour les patients en régime ambulatoire habilité à l'activité diagnostique avec ultrasons, d'un service d'obstétrique et de gynécologie, 3 salles de consultation, 20 lits pour les activités cliniques, 13 lits pour la chirurgie, 7 lits pour les soins intensifs des patients pédiatriques, 2 pour les pansements, une section pour les patients en régime ambulatoire (stérilisation), 1 bibliothèque pour la consultation hors ligne et en ligne, une salle de jeux et une laverie et, enfin, un bureau d'administration. Pendant les cinq années de son existence, l'activité du Centre n'a jamais cessé d'incrémenter, et la population locale commence à se pencher sur le Centre comme un hôpital local et régional de référence à grande échelle. A partir des 190 cas traités en 2006, le Centre est passé à 669 interventions chirurgicales en 2010 et à 341 dans les quatre premiers mois de 2011, et il existe de bonnes perspectives de dépasser le seuil de mille opérations avant la fin de l'année 2012. Le Centre Takeo a également projeté un petit hôpital mobile pour aider directement les enfants dans les zones rurales dépourvues d'équipements de santé. Aujourd'hui, le Centre est une nouvelle réalité dans le système sanitaire cambodgien.

Nonetheless, Cambodia still faces major challenges in several areas in order to achieve the CMDGs. These include the urgent need to reduce the high maternal mortality rate of 461 deaths per 100,000 live births and is among the highest in the region. Moreover, findings from the Cambodia Anthropometric Survey 2008 reveal that the percentage of children classified as acutely malnourished ("wasted") and underweight has remained largely unchanged since 2005. The survey also found that wasting among underprivileged urban children increased from 9.6% in 2005 to 15.9% in 2008. Cambodia remains one of the 33 "alarming or extremely alarming" countries in terms of hunger and undernutrition. Nutritional programmes targeting pregnant/nursing women and young children will need to be strengthened if the gains made since the late 1990s are to be maintained. Significant inequities also persist between rural and urban areas, across provinces and between people with different educational levels and economic status. Living condition differences are large between urban and rural areas. The standard of living is better in urban areas, especially in Phnom Penh. There is also a need to strengthen national capacities for health stewardship, in particular human resources management, service delivery, financing, and governance. According to the Cambodia Socio-Economic Survey 2004, about 18% of the population experience monthly some illnesses, injuries, or other healthrelated symptoms. Illness rates are highest among children under age 5 (25%) and are lowest among teenagers. From age 20 the rates rise steadily to over 40% among the oldest (age 65+), rates being slightly higher for women. Among children under 5 years of age 20% develop symptoms of acute respiratory tract infection, the primary cause of morbidity and mortality, and 19% have diarrhoea and dengue fever. In recent years several dengue fever epidemics have been reported in Cambodia.¹ Dengue fever, unless it is haemorrhagic (0.8%), rarely causes death. There is no vaccine or specific drug treatment for this disease; intravenous fluids are administered to maintain adequate homeostasis.

The purpose of this paper is to overview the activities from August 2006 to April 2011 of the Bambino Gesù Paediatric Clinical and Surgical Centre Takeo, now recognized as a leading best-practice example serving a rural Cambodian province and to illustrate its current and future projects.

Initially, repeated missions from the main hospital in Italy (BGPH) were undertaken to upgrade existing infra - structures in Takeo Province (including the Paediatric Ward in Takeo Referral Hospital). The missions provided all the necessary medical equipment, medicines, linen, furniture, and medical supplies needed for the inception of the clinical and surgical practice. All technologies required in the paediatric sub-intensive care unit (PICU), the operating theatre, and the consulting rooms were also provided.

Since expanding its capacity, the paediatric centre has consisted is currently composed of an out-patients department with diagnostic ultrasound and an obstetrics and gynaecology service, 3 consultation rooms, 20 beds for clinical activities, 13 beds for surgery, 7 beds for the PICU, 2 dressing rooms, 1 operating block (1 operating theatre, sterilization), 1 library for off- and on-line consultation, a playroom, laundry facilities, and an administration office.

The financial resources allocated and actually spent between 2006 and April 2011 amounted to $US 1,867,534.29, between medical equipment ($US 723,498.40), running costs ($US 271,208.22), renovations and maintenance costs ($US 253,028.70), clinical and surgical costs for indigent patients ($US 207,837.44), expenses of visiting doctors from Italy ($US 81,901.69), staff training ($US 8,806.94), and communication and visibility ($US 4,154.00) (Table II).

Since the construction of the operating room in August 2006, 2164 surgical operations have been performed in our Centre with an average of 500 operations per year (Table IV). Over the years, an increasing number of operations have been performed by orthopaedic surgeons and ophthalmologists in the centre, accumulatively amounting to 16% of the overall number. Ear, nose and throat surgery is also a substantial part of the BGPH'S commitment to treating disadvantaged children. In addition there has beener commitment in providing specialized surgery, including urology surgery that accounted for about 2% of the total.

Table IV and Fig. 1 indicate that 45% of the total interventions were general surgical procedures, compared with 32% in reconstructive surgery. The total interventions were often of moderate complexity, while surgical interventions aimed at improving anatomical and functional improvement were often complex and time-consuming (Fig. 2).

Reconstructive surgery was for the head and neck (congenital malformations such as cleft lip and palate, burns, release of severe contractures), urological malformations (hypospadias, urinary bladder reflux, and other urinary tract malformations), hand surgery (syndactyly, camptodactyly, burn contractures), and trauma surgery (Fig. 3).

Burns remain one of the most important causes of injury in this country. Free flame, gas stoves, oil lamps, and the high number of still remaining land mines are frequent causes of children's burns. Acid attacks on women and young men are very common for reasons of jealousy or revenge.

There is no specialized burns centre in the territory and burns sequelae are often dramatic as a result of inadequate care and the general tendency of the population to develop keloids.

A study³ published in 2004 by one of the present authors considered the question of whole person impairment, which rates five classes of skin damage, ranging from 0 to 95% impairment. This scale sets up five classes of increasingly severe skin disorders and disabilities in everyday life due to the scars, which are described here. We also considered the aetiology and the general parameters of the patients' injuries.

In Cambodia some 20,000 burn injuries occur every year, almost two-thirds of them involving children under 10 years of age (accurate epidemiological data on burns are not available in this country).

One hundred and sixteen children with significant burns sequelae have been treated at the Takeo Centre, with scars mainly affecting the limbs and the neck, with involvement also of the axilla, hands, elbow, and knee. We also assisted a large number of young women with serious facial in the face due to the criminal use of acid for sentimental reasons.

The surgeons' wide experience use of the most effective technique in each case, e.g. Z-plasties, skin expansion, skin grafting, and local or distant pedicled cutaneous or myocutaneous flaps. However, owing to Cambodia's lack of technology, simple but most effective techniques were preferably used.

In our practice we laid great stress on post-operative care with physiotherapy, elastic compression, and massages to improve the final results.

Sometimes children with severe burn scar contractures of the limbs, with bone deformities particularly of the radius and hands, needed to be operated on and, in these few cases, alteration of the growing bones was observed. Physiotherapy played a leading role in post-operative care.

Since most burns in rural areas are accidental and occur in the home setting and are therefore preventable, an effective paediatric burn prevention campaign is currently being considered.

Together with surgical activities, the BGPH's commitment to treating pathological cases has been constant, and performed with increasing efficiency and effectiveness year by year.

Finally, as a result of the successful implementation of the Pilot Project for a Mobile Clinic (Fig. 4), BGPH is expanding its coverage and area of intervention and has now committed itself to a broader set of complementary health-related activities including:

In one year (2010-2011) over 5,500 children received free clinical and surgical consultation, 350 were admitted to the Centre for medical and surgical assistance, and 60 rural communities had training and seminars in basic health.

702 patients were treated free of charge by the Mobile Clinic Project:

The positive feedback laid the foundations for the creation in 2006, thanks mainly to the support from the Ospedale Pediatrico Bambino Gesù of Rome, of the Pediatric Clinical and Surgical Centre, recognized now as a leading of the best-practice example serving Takeo Province.

The work of all the staff at the Centre has always sought inspiration from a patient-centred approach and made humanitarian medicine a crucial aspect its actions.

One of the main goals has clearly always been to encourage improvement of the skills and expertise of the local staffin order to create a structure that can function autonomously and ensure long-erm sustainability and ownership.

The highest costs that our Hospital has to face are those of the visiting staff involved in the programmme such as travel and accommodation expenses, plus logistic expenses.

The importance of humanitarian action is not only centred in the health sector but contributes to the beneficiary country's social and-economic development. Many thousands of patients will thus be enabled to live their lives well accepted by the society around them without malformations and able to work and to grow and raise a family.