Coin Rubbing Part 1: Introduction

Known in Khmer as កោស​ ខ្យល់ (koah kshal - scraping the wind), in Vietnamese as Coa Gio (catch the wind), in Chinese as Gua Sha (scraping away fever), and in Indonesian as Kerokan (scraping technique), coin rubbing is a healing technique practiced in most of southeast Asia as well as some prominent east Asian countries. In Cambodia it is practiced by virtually everybody. The people I have talked to about the practice have never met another Cambodian who didn’t “believe” in coin rubbing. It is practiced both in families and professionally. Going down most roads in Phnom Penh you should eventually run into signs that advertise for 5000r massages.

While the practice and its explanation differ according to region, there are some important commonalities. The procedure always involves a type of oil or ointment and a hard circular disk, usually a coin. My experience has been almost exclusively with tiger balm but any oil containing combinations of camphor, methanol, winter green oil, eucalyptus oil, peppermint oil or cinnamon oil (taken from here citing Sullivan, 2005). My wife claims that before the magical introduction of tiger balm her family used machine oil. The oil is applied and a coin is rubbed until red marks, blood under the skin, becomes visible. In my experience, the lines are rubbed on either side of the spine (or directly down the middle) and then in horizontal lines down the back. If pain is serious enough it can also be done on the whole body (head, neck, chest, arm, legs). Sometimes it is only done in the local area of the pain or soreness. It is supposed to be able to cure insomnia, migraines, headaches, cramps, muscle soreness, respiratory problems, chronic pain, chronic cough, carpal tunnel, joint problems, whiplash, diarrhea, other stomach related problems, fevers, urinary disorders and probably a whole range of other symptoms.

Different hues and boldness of color can often be used as a diagnostic tool. I have heard different interpretations but my wife’s family generally follows a simple pattern. If the red of the blood is light, it is a light illness. As the red increases in intensity, so does the illness. Some people’s skin however, don’t show these fluctuations.

The lay explanations I have heard justifying the procedure generally rely on the idea of bad wind or miasma being the root of illness. The rubbing and breaking of blood vessels allows this miasma to leave from the body. Sometimes this is framed as an imbalance. As the practice probably comes from China some have linked it to yin and yang. Balance is an important part of all medical systems, and was even was the dominant paradigm of the western medical system before the 1900’s. It is an explanation that is intuitive and can be understood quite easily. Other explanations involve increasing blood circulation and breaking down toxic blood clots.

In the United States, Southeast Asian communities still practice coin rubbing but have run into problems with schools and medical professionals mistaking the marks for abuse. Proponents claim that it causes no long term harmful effects and is an attempt to heal a child from a loving parent. There is currently increased awareness of the cultural practice and the instances of these accusations have decreased. Despite this awareness however there is no actual acceptance of the practice as a legitimate healing method among western health professionals. In Cambodia the dissonance between what educated professionals are taught and what their families and patients practice is ignored but I can see it developing into a problem in the future. The scientific community cannot accept coin rubbing as legitimate practice for two reasons. The first is that it’s premise, that illness is caused by miasmas, has not been proven in a repeatable way in a laboratory. The second reason is that there are no studies showing that it effects pathways in the western physiological model of the body.       

I have heard a variety of lay explanations of how coin rubbing may be able to fit into a western model of medicine. They include the distraction of pain, a release of endorphin, muscle relaxation, bringing blood to the surface to cool down fevers, increasing white blood cells counts and, of course, the placebo effect. I'm not a huge fan of the placebo effect as a blanket explanation for anything and I may write more about the later. I think it is used too often to explain away results that we do not fully understand. Some or all of these may have an effect but unless someone forms a quality repeatable experiment it will all be guesswork. Coin rubbing may not have any real physiological benefit or it may use pathways that we have not yet begun to understand. Personally I think that there is a lot to learn from traditional medicine and that until it is fully understood, it needs to be taken with a degree of seriousness. I am also aware that popular use does not necessarily mean it is a positive procedure, as blood letting was at one point quite popular and has since been shown to be a negative experience.

For my next two posts I want to explore recent literature which may or may not show physiological benefits and physiological damage cause by the practice.

As always, feel free to comment with your own experiences and thoughts about coin rubbing.

Blood Donation News Update: Police Donation

In recent news 60 police officers donated blood to the National Blood Transfusion Center (source). I cannot find much more information than that. While I doubt that this was an entirely voluntary operation (they are all still in uniform and I have a feeling there was a little outside pressure) I think it is overwhelmingly positive. The more events like this get in the news the better, especially with those in positions of authority. Now all we need is a picture of the Prime Minister giving blood.

The same site also mentions that Hun Sen recently 

"gave a recommendation to the Ministry of Health, asking the institution to set a specific date for blood donation to prevent the damage from unexpected things" (source).

I do not know what "unexpected things" means but instituting regular national blood donation days doesn't seem like a bad idea. 

Blood Donation Part 3: Blood Tourism

While researching blood donations in Cambodia one of the strangest things I came upon was the amount of advertising advocating blood donations from tourists. Just a quick google search renders the following:

Jayavarman VII Hospital
Angkor Hospital for Children (AHC) in Siem Reap
Kantha Bopha Children's Hospital

These are also recommended by both TripAdvisor and Lonely Planet. 

I have never given blood in Cambodia and now greatly regret it. I remember the last time I was there with my family my brother expressed interest but everyone decided that it was probably a risky decision. I now firmly believe that that trepidation was unwarranted, and is similar to the reason there is a shortage in the country in the first place. Not donating blood in Cambodia, because of fear of lack of sterilization, is much akin to the native aversion due to “lack of energy.” It does much more good than many other forms of volunteerism in the country. Donating blood goes directly to saving an individual's life. Many other tourist volunteer programs, such as visiting orphanages, are somewhat less substantial and can often do more harm than good (recent studies have shown that the turnover of volunteers at orphanages in developing countries is traumatic for the children).

The blood contribution of a single individual does little to fix the widespread problem but certainly has much more impact in Cambodia than it would have in a developed country.

Accounts I have found online of foreigners who donated blood are generally positive. Here are two samples from individual bloggers.

Sample 1:

"When I came to the gate I said I wanted to donate blood and I was walked to the blood bank. There was no one else there and after filling out a form I had a needle in my arm and they were draining blood. Maybe I looked pale or something but there were three of the nurses and doctors standing around asking me if I was feeling fine. But donating blood here was not a problem – I only had to donate 300 ml compared to the 500 ml that is donated in Norway. I guess it is because Cambodians have a smaller body than your average westerner and that is why they drain less blood here. Anyway, I got a Coke while I was donating blood and I even got a t-shirt."

Sample 2:

"In Cambodia donating blood is not very common, as there is a fear that you could get sick. One of the tuk tuk drivers told me it has something to do with the thought that the old and new blood mixing together will cause illness. First we would check the place out to make sure we were all comfortable with the set up. Two of the girls from Belgium actually draw blood back home so they knew what to look for, and I have donated enough times to also know what to look for.The hospital was not even close to anything I've seen in the US. There did not appear to be an official waiting room as there were a lot of people just waiting around outside the various buildings. We headed to the blood bank which was housed in it's own building. It was a bit small so we quickly filled up the place.There were 2 ladies working in the clinic that really only spoke Khmer, but we had one of the Khmer teachers with us to help with the translation. We asked to see the equipment that would be used, with the needles being our main concern. We checked everything out and felt comfortable with the set up, they seemed to have no problems with all our questions.We started with a questionnare which asked many of the same questions that are on the paperwork in the US. Somehow I ended up going first and so they checked my pulse, my blood pressure, and my iron levels (this is normally the point where I fail), and everything was at acceptable levels. Last thing they did was weigh me, which just looking at me it's clear I'm nowhere near being underweight, but they were just following procedures. Then they cleaned my arm, found a good vein and put in the clean disposable sterile needed. My blood is a little slow, but once I was done they put the bag (350ml) next to me so that I could have a photo taken (I'm sure not part of the standard procedure). They had me lay there for a bit and once I sat up they had a nice cold Coke waiting for me (they also had these for us as we filled out the paperwork). They could only do one person at a time so we sat around talking, drinking Cokes and eating the cookies I brought. I'm sure the ladies worked well past their normal time, but never indicated this was an issue. They even gave each of us a t-shirt, and started a blood donation card for the Cambodian blood blank."

If you are still feeling uncomfortable about donation safety. Here are two videos of how the process works for foreigners in Siem Reap.

Foreign donation has two positive effects and I highly encourage it. The first is that it is a reliable source supplying a very small portion of the needed blood. The donations are entirely altruistic and therefore will generally be screened effectively. The second is that sufficient reporting of international participation should both instill confidence and a sense of national guilt/obligation. This second benefit is by far more important and will hopefully lead to an overall increase in blood bank supply.

Blood Donation Part 2: Blood Money

In the simplest terms, the shortage of blood is a result of perceived high risk of donation, very low incentive for donation and increasing demand for blood.

Not only are people afraid of possible serious health ramifications (whether they are real or not) but the cost of travel and time is significant. I know diabetes patients who don’t go to pick up free medication because it is too expensive to get to the hospital. Interestingly enough they are also afraid of getting in accidents and dying on the way but that may just be a result of age and illness.

Cambodia currently does not pay for blood, unlike countries like China. They follow the same model that the US FDA advocates which requires that all blood used in hospitals needs to be obtained purely by donation. There is one overriding reason for this. Studies and common sense have shown that when money is offered for blood people are more willing to lie during screening (one example). While most diseases can easily be screened, some cannot, and many countries are not following correct screening procedures in the first place (source). Additionally, screening blood that ultimately cannot be used is costly. I can certainly see this being a problem in Cambodia and understand completely why they rely on donations.

There are problems however. Many people are also suspicious that doctors and hospitals are profiting off of their charity because blood needs to be paid for by patients. These costs are mostly due to the price of screening but accepting that requires trust in the medical system which does exist (and perhaps isn’t warranted). Furthermore, the shortage is so acute that when blood is not available for a patient, and family members are unwilling to supply blood themselves, the common recourse is to petition, and pay, anyone who is willing to fill the need. Doctors are left with no option but to request that their patients follow these measures. Ultimately all of the problems that you avoid by taking only donations are still in play, if not more so.

A quote from a recent article:

“Older street children...are selling blood sometimes, including drug users...They mostly hang around the hospitals, and if people need blood, they'll buy from them.” - Man Phally

I have heard quite a few suggestions of measures that could be used to incentivize blood donations without increasing the frequency of risky donations. To do this effectively you would have to do two things. First, you would need to create an incentive that is not particularly attractive to at risk populations. I would not know where to begin to profile the type of donor that you want in Cambodia. Certainly you want to exclude drug using homeless children but beyond that many of these diseases are not necessarily demographic specific. Its possible that someone could argue further that more wealthy populations are more educated and therefore understand more clearly the implications of falsifying medical data but I don’t buy it. Not only is wealth not necessarily tied to education its also not particularly tied to morality. Suggestions such as tax exemptions or gym memberships that have been popular solutions in the United States do not seem entirely plausible. I do think that it may be worthwhile to create a partnership with the flurry of exercising groups that have overtaken almost every public park in Phnom Penh. These are health conscious people organized into neat social groups. Is there a more opportune population to target? Another possibility could be providing free physicals to blood donors. It is a clear incentive, but receiving a physical and lying about health information at the same time is somewhat counter productive. Not foolproof, but a possible solution.

Second, you would need to find a way to tie said incentive to the individual giving blood. This would be necessary to avoid creating tertiary markets which would negate any effect of the first requirement. In Cambodia in particular this would be difficult. National IDs could be used but they are not beyond forgery. Fingerprints or palmprints (hospitals in NYC have begun using technology that identifies individual vein patterns in palms) may be effective but the country may not have the infrastructure/man power to handle the data and unless some very complicated measures were put in place it could be a very serious breach of privacy.

Without financial incentive, the only real benefit to blood donation is the warm fuzzy feeling that comes from fulfilling moral or national obligations. This works for quite a few countries, including the US which currently has a surplus. Indeed, the book Freakonomics quotes a study which shows that paying for blood donation decreases the altruistic incentive and decreases blood donations. Unfortunately this hasn’t been working for Cambodia. I am preferential to the idea of only receiving donated blood but am forced to wonder if offering hard cash incentives under a more controlled environment would be a better option than allowing families to pay street children. Soft incentives (T-Shirts, buttons, cups, hats, physicals, subsidizing exercise, etc...)  need to be explored but if they fail to produce results it may be necessary to take the lesser of the two evils.