One patient come from border

 Recently, I reread Diamond Dust, the Akutagawa Prize–winning work by Keisi Nagi. The paperback edition contains three short stories written in the 1980s—“Adapting to Winter,” “The Long Shadow,” and “Fishing for Smelt”—all based on medical care for Cambodian refugees near the Thai-Cambodian border.

“One patient come from border.”

In the voice of a man speaking English with a Cambodian accent, those words sent the three of us toward the operating theater at Khao-I-Dang refugee camp, on the Thai-Cambodian border.

Through the dull green trees, our jeep raised clouds of reddish laterite dust. Patients were being brought in—some with legs blown apart by land mines. Every day, gunshot wounds and injuries caused by land mines were treated in the camp's operating theater.

Khao-I-Dang was one of the largest refugee camps along the Thai-Cambodian border. At its peak, more than 100,000 refugees lived there. The Khao-I-Dang holding center was administered by the Thai military, and at Task Force 80 along the road, everyone entering or leaving had to present an identification pass.

A Japanese medical team had a medical center in Sa Kaeo, on the Thai side, a short distance from the border. It had been built with Japanese assistance and included accommodation for medical personnel as well as inpatient facilities. We would leave there by minibus, pass through Aranyaprathet along the border, and after about an hour and a half arrive at Khao-I-Dang.

Once through the gate, the camp's Commander’s Office stood ahead. On either side of the road were the wards operated by medical teams from various countries. The Japanese team shared a building with the International Red Cross. Its walls were made of woven bamboo, with a corrugated metal roof above them. Large Red Cross symbols were painted on the roof so that the building could be identified from the air and spared from bombing.

There, we performed operations and treated hospitalized patients.

The first Japanese medical team was dispatched to assist Cambodian refugees in December 1979. Japanese teams continued to provide medical care in the border region for three years, until 1982. In total, 407 doctors, nurses, technicians, and other medical personnel took part. It was Japan's first large-scale humanitarian medical mission dealing with massive numbers of refugees in a setting completely different from medical practice at home.

In Japan, the principle seemed obvious: provide every patient with whatever treatment is necessary, and do everything possible to save each individual life.

But here, the circumstances were different.

Many of the patients suffered from land-mine injuries or gunshot wounds. When a leg had been destroyed below the knee, or an arm had been severely damaged, amputation was often necessary, but the patient's life could usually be saved.

Gunshot wounds to organs closer to the center of the body—such as the lungs, heart, or liver—were a different matter. Many patients died from massive bleeding before they could be saved. Even after reaching the hospital, patients with penetrating wounds of the abdomen or chest sometimes died on the operating table when transfusion and surgery could no longer control the bleeding.

When large numbers of critically injured patients require lifesaving treatment while medical resources are limited, an unavoidable question arises: who should be treated first, and what treatment should be given?

Triage becomes indispensable.

Yet at that time, the concept of triage—of determining the priority of treatment among patients according to their chances of survival—was not something that came naturally to us. In the medical culture of Japan at that time, it was taken for granted that every effort should be made to save every patient, regardless of the circumstances.

Meanwhile, the Vietnam War had become a quagmire, and the United States began bombing targets inside Cambodia. The bombing was not intended to strengthen the Khmer Rouge, but it contributed to growing anger and social disorder in the Cambodian countryside, which ultimately helped create conditions in which the Khmer Rouge could expand.

In 1970, Prince Norodom Sihanouk was overthrown, and the Lon Nol government came to power. Civil war in Cambodia subsequently intensified.

On April 17, 1975, before the fall of Saigon, the Lon Nol government collapsed. The Democratic Kampuchea regime was established under the Khmer Rouge, led by Pol Pot.

In a society shaped for centuries by Theravada Buddhism, a new ideology—communism—was introduced. It influenced members of the educated classes and gained support among some of them. Eventually, the Khmer Rouge seized power and began a political experiment fundamentally different from Western liberal democracy.

Pol Pot ruled through what was known as “Angkar,” while real power was concentrated in the Central Committee of the Communist Party of Kampuchea. A secret police apparatus exercised control over society.

During the years of the Pol Pot regime, approximately 1.7 million people died. Most of the victims, however, were Cambodians themselves. Intellectuals, urban residents, peasants, Buddhist monks, party members, and eventually even members of the Khmer Rouge itself were labeled “enemies.”

Pol Pot's radical ideology sought to create a “perfect” human being through revolution. Cities were abolished. Money, private property, and markets were abolished. Schools and religion were suppressed. The regime was also driven by an intense form of nationalism and hostility toward Vietnam.

Fueled by deep suspicion, the leadership gradually began to regard former supporters of the Lon Nol government, urban residents, intellectuals, religious figures, and eventually its own members as enemies who had to be eliminated.

When an ideal fails to become reality, those who are absolutely convinced of its correctness may begin to search for something that is obstructing it. An enemy is created, and the failure of the ideal is attributed to that enemy.

Then the purges begin.

At the end of December 1978, Vietnam launched a military intervention in Cambodia. On January 7, 1979, Phnom Penh fell, and a new government led by Heng Samrin was established.

As a result, increasing numbers of Cambodians fled the country. In October 1979, Vietnamese forces and the Heng Samrin government resumed military operations to consolidate their control over Cambodia. The fighting and political upheaval caused even more people to flee across the border into Thailand.

The world of Pol Pot seemed to resemble the “dark age” described in a nineteenth-century Buddhist prophetic text known as Put Thomniyay. The prophecy described a time when evil men would rule, cities would become empty, and starving people would chase dogs simply to find a single grain of rice stuck to their tails.

It foretold a time when the status of Buddhist monks would disappear, when wrong would be called right, black would be called white, and people would be made to believe that good was evil—the coming of a demonic king.

There was another Buddhist image associated with this dark age:

“Black crows scatter the seeds of the Rubea fruit across the land. The Rubea fruit is green and beautiful, shining on the surface, but inside it is filled with lice.”

The black crows could be understood as the Khmer Rouge.

The beautiful Rubea fruit represented the utopian promise of communist ideology.

And the lice hidden inside it represented the reality that emerged beneath that promise: killing, starvation, poverty, and suffering.

Why did such a catastrophe occur?

Was it an expression of something fundamental in human nature, as imagined in the Buddhist vision of the human world?

Was it the result of a misguided ideology carried to an extreme?

Or was Cambodia ultimately a victim of the political struggles and interventions of powerful neighboring countries?

The question remains open.