(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.”

(Photo: Phnom Penh’s main market, Phsar Thmey, being renovated with funds from the French Development Agency. 19 November 2008. By Isabelle Roughol)

By Isabelle Roughol

and Tim Sturrock

Despite continued complaints about the slow pace of reforms, international donors are pledging more than $900 million in aid to Cambodia for 2009, a substantial increase from previous years and from the government’s request of $500 million, a senior Finance Ministry official said Thursday.

Government officials and donor representatives met behind closed doors Thursday for the start of the Cambodia Development Cooperation Forum. Official aid figures will be released at the end of the conference today.

Asked if the pledge figure topped $900 million on Thursday, the Finance Ministry official confirmed that this was the case: “More than $900 million,” he said, speaking on condition of anonymity because he was not authorized to announce any aid totals until the end of the forum.

“I was surprised for the first time [at a donor meeting]-because of the global financial crisis,” the official said, adding that he saw the increased funding as a sign of approval of the government’s actions.

Despite opening their wallets, donors were more reserved in their praise of the government. They expressed satisfaction about the country’s impressive economic growth and advancements in health and education, but noted the continuation of slow progress on judicial and institutional reforms.

In his keynote address to the meeting, Prime Minister Hun Sen touted the country’s economic success, including double-digit growth in the past four years. He also reaffirmed support for judicial reforms and for the anti-corruption law, which has remained stuck in the drafting process for 14 years and is a constant demand of donors.

“[T]he Royal Government is strongly committed to ensure rapid conclusion and adoption of this law,” Hun Sen said.

The anti-corruption law was discussed at a Thursday session, but aid levels weren’t tied to its passage, UN Resident Coordinator Douglas Broderick said.

“There was no notion at all of boycotting…absolutely not,” Broderick said, adding that donors clearly wanted to see anti-corruption measures in place but that it would be a long process.

Rafael Dochao Moreno, chargé d’affaires of the European Commission, which has already committed in a multi-year plan to donate about $35 million next year, said the government told him the law would be passed next summer.

“We’re never happy 100 percent, in any country, even in our own European countries, but the fact that there is a reform, it’s already good news,” he said.

Eva Gibson Smedberg, resident representative of the Swedish International Development Cooperation Agency, expressed stronger criticism. She said the government was “lacking the real urge to go ahead” in passing the anti-corruption law and should also reform the courts and implement the Land Law.  Donors, too, should propose other solutions to fight graft instead of “making a statement and hoping something will happen,” she said.

Swedish aid, she said, is not a stamp of approval for the government.

“It’s more a show that there is a need, and we are there to help, not approval,” she said.

Other reasons can also push countries to increase their aid, said Volker Karl, director of the Phnom Penh office of KFW Bankengruppe, a German financial cooperation institution. Germany, for instance, has increased its aid worldwide to respect previous commitments to the G-8 summit, he said.

International Monetary Fund Resident Representative John Nelmes warned against attempts to increase military spending-which Hun Sen has previously announced he would like to do. Rather, the government should focus on infrastructure building, Nelmes said.

“When you put infrastructure in place, it creates the capacity for the economy to grow at a faster rate without creating inflation pressure,” he said.

Piper Campbell, chargé d’affaires at the US Embassy, said she was impressed by the frankness of Hun Sen’s speech and the range of issues he covered, adding it was a “good starting point.”

The US will not make a pledge during this conference because of the presidential transition in Washington and will announce figures later, Campbell said.

Once aid figures from the US and the Global Fund To Fight Aids, Tuberculosis and Malaria are announced, international aid to Cambodia for 2009 could surpass $1 billion, the Finance Ministry official said.

That figure, however, could be misleading.

For the second year running, China’s aid was included in the government figure, even though China does not participate in the donor meeting, according to the Finance Ministry official.

The government unveiled Wednesday a financial package of $215 million from China, only $7.3 million of which is aid and the rest loans that will need to be repaid.

Prime Minister Hun Sen has previously praised China for giving aid without the reform conditions imposed by other donors.

“It’s clear that for instance there are points of difference of opinion between the European Union and China. That means we advocate that the EU always has policies on democracy, on good governance and other countries don’t,” Dochao Moreno said.

China’s deep pockets and no-questions-asked attitude could be weighing on the donor conference.

“It’s true that emerging donors are making the environment different,” said Alain Goffeau, project implementation specialist at the Asian Development Bank, when asked if China’s position could be forcing donors to hold back in criticizing the government.

Chinese Embassy spokesman Qian Hai could not be reached for comment.

The political opposition held a news conference ahead of the donor meeting on Wednesday, wherein SRP President Sam Rainsy said that the government was “cheating” donors by not carrying out necessary reforms.

Mu Sochua, the SRP deputy secretary-general, said Thursday that she was disappointed the donors had decided to pledge more money than ever while also not being aggressive enough in seeking real change from the ruling party.

“It’s so much money when the reforms that have been promised have not been implemented,” she said, calling on donors to seek more oversight and set solid benchmarks for reform.

(Additional reporting by Yun Samean)

(Photo: Inauguration of a donated school in Prey Veng province, Cambodia. 26 December 2008. By Isabelle Roughol)

By Isabelle Roughol

Cambodia should in the next few years start relying less on international aid and more on private investors, European officials said Thursday.

The $7.855 billion given to Cambodia by foreign governments since 1992 was justified by the country’s huge reconstruction needs, but now that the economy is fast-growing, profit-making enterprises should take over, French Ambassador Jean-Francois Desmazieres said at a roundtable discussion on political and economic cooperation between the EU and Cambodia, which was organized by the Club of Cambodian Journalists.

“Cambodia remains one of the four least advanced countries in Asia, but it has progressed enormously. It is therefore important-and that is one of the themes we’ll approach with the government-that private investment, the investments of businesses, take over from [foreign] taxpayers’ money,” said Desmazieres, who also represents the EU during France’s presidency of the regional grouping.

“International aid should no longer be the sole engine of growth,” the ambassador said, adding that fighting corruption was key to attracting major foreign companies to Cambodia.

The government is scheduled to meet next Thursday and Friday with international aid donors to set their pledges for the next fiscal year and beyond.

Desmazieres declined to specify a figure or a trend for France’s aid ahead of the meeting, but he said that there would be no “dramatic change” and that the global financial crisis would not alter France’s commitment to Cambodia. In 2007, France had pledged $201 million, he said.

Rafael Dochao Moreno, chargé d’affaires of the European Commission, the top provider of aid to Cambodia, also echoed the ambassador’s wishes for more private investment over aid handouts.

“Cambodia is a country that has received non-refundable aid for a certain number of years. Now it must be a country that starts having other sources of funding, including foreign investment,” Dochao Moreno said.

Government officials responded cautiously.

Cambodia wants to be economically independent, but the country has only been stable 10 years and still needs help, Council of Minister spokesman Phay Siphan said.

“We are a small baby, and the challenge is huge,” he said, adding the country still needs funds for the many reforms engaged in education and government for instance.

The global financial crisis is another obstacle that could discourage private investors, making aid that much more needed, Phay Siphan added.

Cambodia has received about $690 million in foreign aid in 2008 and will request more than $500 million for 2009 at next week’s meeting, said CPP lawmaker Cheam Yeap, chairman of the National Assembly finance commission.

“I am optimistic that the international community will still provide aid to Cambodia, even if there is a global financial crisis, because they believe in Samdech [Prime Minister] Hun Sen,” Cheam Yeap said.

But the continuing corruption in the use of aid could push donors to reduce their pledges, even though aid is still needed, said SRP lawmaker Yim Sovann, citing the example of the recent accusations of systematic corruption in the distribution by local officials of emergency rice funded by the Asian Development Bank.

Also present at the forum, German Ambassador Frank Marcus Mann said good governance was a constant concern of the donor community and would be discussed with the government next week.

“As much as we talk about the progress and development, we have to address at the same time deficiencies and encourage the government to improve its record on certain topics, and corruption is one of them,” Mann said.

The US is still working on its own pledge and figures are not available because of the political transition in Washington, said John Johnson, spokesman of the US Embassy in Phnom Penh.

“I think it’s the ambition of all donors that the countries they’re giving aid and assistance to graduate. As far as Cambodia is concerned, it’s a multistage process and it’s difficult to pin down exactly where we’re at right now,” Johnson said.

(Additional reporting by Neou Vannarin)