26 March 2009: A poor health infrastructure and little education leave many Cambodian diabetics ignorant of their disease and without the basic care that could save their lives.
(Photo: A rice seller at Phsar Thmey — Central Market — in Phnom Penh. One of the reasons for a high diabetes rate is poor Cambodians’ habit of filling their stomach with cheap, white rice. 30 August 2009. By Isabelle Roughol)
By Isabelle Roughol
A poor, tropical country such as Cambodia is expected to have its share of health issues: malaria, malnutrition and HIV/Aids come to mind, as well as a slew of exotic parasites. But diabetes, a disease many incorrectly associate with times of plenty, is in fact a much bigger threat to this poor country, as ignored as it is devastating.
Even by the most conservative estimates, there are four times as many diabetics in Cambodia as people living with HIV/Aids. It could be 10 times more: few studies have been conducted, but the figure most commonly cited is 255,000 diabetics in the country in 2005. As Cambodians start feeling the effects of the world financial crisis and recede into poverty, the threat of the disease will only grow for the urban poor.
“People always mistakenly think that it is the disease of rich people, and that’s far from true,” said Dr Jacqueline Dicquemarre, the president of Mission Care-Development Organization, an NGO with a diabetes program in Phnom Penh. “It isn’t at all the rich’s disease. It’s everyone’s disease.”
About 1 in 10 urban Cambodian and 1 in 20 rural ones are diabetic, according to joint studies from the Ministry of Health, Cambodian Diabetes Association, European Center for Diabetes Studies and French drug company Servier.
“They have the rates of developed countries where there already were a lot of [diabetics], such as the United States, Canada, Finland. At first, it is indeed really surprising,” Dicquemarre said.
Diabetes is a chronic disease that causes the body to either not produce enough insulin or not use it effectively. Insulin is a hormone that controls sugar levels in the blood stream. High blood sugar levels can over time damage many of the body’s systems, especially nerves and blood vessels. Uncontrolled diabetes can lead to heart disease, strokes, blindness, kidney failure, amputations, and eventually death. The World Health Organization predicts a doubling of the number of diabetics in the world by 2030.
Cambodia has drawn the short straw, combining three factors that account for the high diabetes rate, Dicquemarre explained. Urbanization leads to unhealthy lifestyles, which leads to overweight, a contributing factor in diabetes. Cambodians also might be genetically more prone to diabetes because the people who survived past famines and reproduced had metabolisms that better stored calories from food; others died of starvation. People with this capacity to “store” food are thus more genetically inclined to put on weight and develop diabetes when they can eat full meals.
“There would have been because of that difficult past…a sort of natural selection in these populations in favor of individuals who burn less calories than others, the ‘thrifty’ ones,” Dicquemarre explained. “And when they waste less, of course, they put on weight as soon as they have more food.”
The third factor is purely Cambodian, or at least regional: rice. A bowl of steamed Jasmine rice has a glycemic load of 46, three times that of a can of soda, according to a list compiled by Sidney University researchers. The glycemic load index compiles the quantity and quality of carbohydrates found in any food. The higher the number, the likelier the food is to raise blood sugar levels.
That’s where diabetes ceases to be a rich person’s disease. As the country faces new economic hardships, low-income Cambodians are increasing the part of rice—a cheaper food—in their diet, and their blood sugar shoots up, Dicquemarre said.
“When eaten alone, [white rice] is almost like getting sugar in an IV,” Dicquemarre said.
But, argued Dr Jean-Claude Garel of Naga Clinic, a longtime physician here, rice has always been a part of the local diet and diabetes is recent.
“I have seen the evolution in 15 years of my practice. Diabetes, 15 years ago, wasn’t a big problem locally,” but it is fast becoming one, he said. The issue is that people are quickly changing to an urban lifestyle without any education on what it might do to their health.
Prevention and lifestyle education is indeed necessary and would be much cheaper than treating the many complications of diabetes, said Dr Yel Daravuth, national professional officer for Tobacco-Free Initiatives and Health Promotion at the World Health Organization.
HIV/Aids and diabetes have much in common: affected people can live for decades if the disease is managed through a rigorous treatment. Left uncontrolled, the diseases both lead to a slow and painful death, with the sick becoming disabled and an economic burden on their communities.
But while international donors have tackled HIV/Aids, which reduction is one of the Millenium Development Goals, diabetes remains ignored, said Maurits Van Pelt, director of Mopotsyo, an NGO with a peer education program for poor people with diabetes.
“The message is this is a public health and poverty disaster that needs to be addressed, and it gets zero attention from health policymakers,” Van Pelt said.
According to figures compiled by Mopotsyo, 60 percent of health sector donations to Cambodia go to communicable diseases, with HIV/Aids topping the list. Only 1 percent is devoted to non-communicable diseases. Lifestyle-related health issues, such as diabetes, obesity, tobacco and alcohol use, while deadly, get little attention, Yel Daravuth said, but added he could not confirm those figures.
“Not so many people die from bird flu, but a lot of money is put into it because people are concerned, people are scared of it,” he said.
The Ministry of Health identified the fight against non-communicable diseases as one of three goals in the government’s Health Strategic Plan 2008-2015, recognizing that lifestyle changes were likely to make NCD rates skyrocket in the next few years. Yel Daravuth said he hoped that would mean increased funding.
The government’s strategy is to reduce risk behaviors, improve access to treatment and better the public health sector. The plan says nothing of funding or precise methods, however. The plan’s objective is to lower, without a specific target, the diabetes prevalence rate in public hospital patients, reported at 2 percent in 2005. But since many diabetics are still undiagnosed, improving access to treatment could actually bring up the prevalence rate, at least on paper.
Cambodia could start addressing the issue without spending much money, Van Pelt argued. Low-cost peer education programs could teach diabetics to manage their disease, and government oversight of doctors and pharmaceutical companies could help keep the price tag low on essential drugs, he said. Without government control, drug companies lobby doctors to prescribe their most expensive drugs, and uninformed patients don’t know the difference, he said.
“If you have somebody living on $1 a day or $2 a day, it makes a very big difference what is on that prescription. If your medical bill is $40 a year or $300 a year, it’s going to be the different between whether you’re going to have money to eat or not,” he said.
“It is possibly for many Cambodians to pay for their own medicine because the medicine for diabetes can be really cheap,” he added.
Yel Daravuth argued drugs were expensive mostly because they must be imported.
In rich countries, more than half of diabetics are over 65 and have been controlling their disease for decades. They often die from something else, Dicquemarre said. Low- and middle-income countries account for 80 percent of diabetes deaths, according to the World Health Organization. There are no statistics for Cambodia, but in Micado’s diabetes program at Preah Kossamak hospital, only one in 15 patients has had diabetes for more than a decade, Dicquemarre said. Most simply can’t survive 10 years to their disease.
“For those who need treatment, since the patient must pay for the totality of the prescriptions here, the biggest difficulty is to have a regular treatment. It’s very dependent on economic conditions,” she said, explaining that poor patients only take their medication on days they can afford it.
For diabetics, blood sugar levels must be controlled all day, every day, for the rest of their life; otherwise, the treatment is useless, Dicquemarre said. If the economic crisis sends more people back into extreme poverty, it will be that many more people who don’t take their medicine, she said. She added that she was worried that a government policy to increase payment recovery in public hospitals would put one more barrier between the poor and the treatment they need.
The story of diabetes in Cambodia is like that of any disease. It is the story of the gap in health care access between rich and poor. In France, Dicquemarre explained, a quick laser operation can stop the bleeding of blood vessels in the eye, a common consequence of diabetes. Here, without money, trained specialists and equipment, people go blind.
Because the sick pay for treatment, not the state, the public cost of diabetes isn’t so much in the medical expenditures. It is an opportunity cost: hundreds of thousands of people who could be productive and instead wither away on a sick bed for years.
“No funding for diabetes and no policy attention is causing poverty and unnecessarily causing the disability of people,” Van Pelt said. “They could live 30 years, 40 years and die from something else.”
