(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: A fire set voluntarily to clear forest on the Bolaven Plateau in Laos. 8 March 2009. By Isabelle Roughol.)

By Isabelle Roughol

Environmental activist Dr Francis Glémet arrived in Cambodia about three weeks ago with no contacts and no introductions. Since then, he’s been knocking on doors, burrowing his way through Phnom Penh’s media and academic circles and calling up government officials.

The retired pharmacist who speaks too fast in the joyful accent of southeastern France and likes having dessert in the middle of the afternoon is an unlikely prophet with a simple gospel: no government, not even a poor one, can afford to ignore pollution and global warming any longer.

Jumping from one topic to the next, his conviction evident, he spewed in a recent interview a litany of pollution-related ailments: asthma, cardio-vascular disease, obesity, Alzheimer’s, heavy metal poisoning, all sorts of cancers, and the latest, diabetes, recently found to be facilitated by air pollution. Not to mention the decreased fertility that, in the very long run, could mean the slow extinction of humanity, he added.

He spewed solutions, too: incinerating trash at least, if not recycling it; prohibiting a dangerous chemical in plastics; reducing packaging; requiring particle filters on new and diesel cars; setting up public transportation in the capital, and so on.

“It’s true, this discourse is out of this world [in Cambodia.] But I believe that today, whatever the contingencies of a country are, we all live on the same Earth. The global problem will catch up with us sooner or later,” he said.

Glémet is the president of France’s National Medical Coalition for Health and Environment, or CNMSE, a 1-year-old alliance of 3,500 health professionals who want people to live green, if for nothing else, to preserve their lives. All volunteers, the members reach out to government officials and media wherever they travel in the hope of influencing policy and creating an environmental consciousness.

Dr Claude Thuan, a French endocrinologist who traveled with Glémet, is his sobering voice.

“We must go step by step,” Thuan said. “What Dr Francis Glémet talks about is an ideal, but the ideal doesn’t exist [in reality].”

Cambodia has many other issues to address, Glémet conceded, and he is not optimistic about the results of this month-long visit.

“It is by repeating things, it is by having loudspeakers,” that you get results, he said. “It’s certain that this first mission may end on just being listened to. If we are listened to, somewhere we’ve opened a door.”

Glémet met with Heng Nareth, director of pollution control at the Ministry of Environment.

“I explained him the situation in our country: water pollution, air pollution, waste management,” Heng Nareth said Monday.

“I don’t know what he’s going to do. He’s just only an NGO. We really appreciate his NGO’s contact with the ministry, but he did not say any promise,” he added, before hanging up the telephone when asked about the government’s anti-pollution measures.

That is a typical reaction: governments are interested in the message but want him to bring ready-to-go projects with funding, even though the CNMSE has no budget, Glémet said. Meetings in Cambodia went well, but funding is always the issue, he added.

“We don’t have financial means, we only have our knowledge and our good will,” he said.

“Our mission is first and foremost to sound the alarm,” he added.

And alarm there must be, explained Minh Cuong Le Quan, manager of the climate change unit at the environmental NGO, Geres. Cambodian farmers are the first to feel the effect of global warming, when swarms of brown grasshoppers and recent droughts followed by unusually strong rains destroy their crops.

“The interest that people have in protecting the environment is not ideological; it’s existential,” he said.

However, the link between pollution, climate change and health problems is still something few Cambodians understand and need to be more educated about, Le Quan said.

For instance, when trash is burnt in heaps on the side of the road, including plastic waste from the textile industry, dioxins are released and eventually find their way into the food chain, he explained. When chickens were found to contain dioxins in 1999 in Belgium, it created a scandal all over Europe.

“No scandal comes out in Cambodia because people are not aware and we’re used to living in a very contaminated environment,” he added.

The government is conscious of environmental issues, but because of Cambodia’s usual governance issues, not enough is done, he said. For now, it would be more effective to appeal to economic interests, by advertising the business opportunities in waste management and other green industries, he added.

There is also a need for more studies that would give an accurate picture of Cambodian pollution on which the government could base its policies, he said, a view echoed by Glémet.

One rare study, led by researchers from Japan’s Kanazawa University with help from Cambodian officials, showed hydrocarbon particles concentration in Phnom Penh to be more than seven times that of Bangkok, based on samples taken in 2005.

The stake is to not see in Cambodia the vertiginous rise in cancers other diseases seen in the West in the past two decades, said Glémet, who goes back to France on Thursday and plans to return to Cambodia for another ‘mission.’

“To walk around at 5 pm, and to have red eyes, to have a pressing coughing fit and to practically lose your voice, as happened to me yesterday [Feb 1], it means something,” he said. “It’s true that when you live in this country, you get immunized, but for how long?”

(Photo: Françoise Barré-Sinoussi at the French Embassy in Phnom Penh on the day she received the Nobel Prize of medicine. 7 October 2008. By Isabelle Roughol)

By Isabelle Roughol

Françoise Barre-Sinoussi, a French researcher, was in Phnom Penh on Monday when she learned she was to receive the Nobel Prize in Medicine for her discovery in 1985 of the human immuno-deficiency virus that causes AIDS.

“It’s a moving moment for me, all the more moving that I received the news in Cambodia,” Barre-Sinoussi said at a reception in her honor at the French Embassy.

“Despite this prize, I will always be here to work in cooperation with this country, which is dear to me,” she added.

Barre-Sinoussi, who has long worked in cooperation projects between France and Cambodia and makes frequent trips here, shares the Nobel prize with her French co-researcher Luc Montagnier and German researcher Harald Zur Hausen for his work on cervical cancer.

Speaking of current AIDS research, Barre-Sinoussi, who directs a research laboratory at the Pasteur Institute in Paris, said much still needs to be done.

“There is still an enormous, enormous amount of research to do, even extremely basic research,” she said. “Is a vaccine possible, yes or no? I cannot answer that question today.”

Barre-Sinoussi said that she was attending on Monday the bi-annual Cambodge Sante conference at the University of Health Sciences in Phnom Penh when she was inadvertently informed of her prize by a journalist who telephoned from France asking for comment.

“It proves that French cooperation in Cambodia seeks to offer the best and that in fact, we do not have a discounted cooperation; we do the best cooperation possible,” French Ambassador Jean-François Desmazières said.

“We don’t send students; we send the masters,” he said.

By Isabelle Roughol
Santa Cruz Sentinel correspondent

WATSONVILLE, Calif. — Hanging on the wall in Jack’s Cigar Store is a 1970s photo of the shop’s founder, Jack Novcich, standing in the doorway of his store’s original location.

Back then, the smoking room was the only thing standing between the Democratic and Republican headquarters on Main Street.

Today, Jack’s Cigar Store still has a Main Street address: 446A Main St. But that A makes all the difference: the store now occupies what used to be its garage.

“Big businesses start in a garage and grow big,” said current owner Zarko Radich. “Mine ended up in one.”

Like other tobacconists across the nation, Radich suffers from tobacco having fallen out of the public’s favor. Rising awareness of the health dangers of tobacco means fewer people push the door of the nearly centennial store, and the business is dying its slow death.

“When I came [to the United States], you had to whisper for condoms and could yell for cigarettes,” Radich said. “Now you have to whisper for cigarettes.”

Radich has no estimates of how much business he’s lost, just a general feeling of changing times. “I used to call companies every morning and beg them for cigars,” he said. “Now they call me.”

Novcich moved to the United States from Serbia in 1906 and opened his tobacco store in Watsonville in 1914. He worked there from the early days of World War I to the collapse of the former Soviet Union. Radich married Novcich’s niece and became a partner in the store when he moved to Watsonville, from Serbia too, in 1980.

Radich, 59, agreed that “there’s nothing good to say about smoking,” as a customer walked into the store with an oxygen tank strapped around his waist, as though to stress his point.

“Even when I was a heavy smoker, I never was pro-smoking. I’d never recommend it to anyone,” Radich said. “If you really want to smoke, I’ll recommend a better cigar and less poison.”

So Radich isn’t particularly bitter that none of his three sons, the last one recently out of college, will take over the business. Radich said he is bitter, however, that tobacconists seem to be the sole targets of the public’s discontent. He often jokes that he really works as a tax collector for the state of California.

In California, each pack of cigarettes is taxed 87 cents, and other tobacco products are taxed at 46.76 percent.

Since the late 1990s, a trend of tobacco tax increases, in California and nationwide, and smoking bans in many public areas have decreased the use of cigarettes, said Charles Ganigan, president of the California Association of Retail Tobacconists. But the sales of other products such as premium cigars, small cigars, hookahs and smokeless tobacco have increased modestly, he said.

“It is a challenging business for the future, and it’s one that requires the most adept business acumen in order to survive,” Ganigan said.

Tobacconists also must deal with the competition of online stores, which many consumers turn to to evade California taxes. Retailers that survive, Ganigan said, are those who can adapt the products they carry to the demands of more educated consumers.

Jack’s Cigar Store still has customers of two kinds, Radich said. There are those who want to buy cheaper tobacco, and those who, like Bob Steinberg of Aptos, say that “you don’t smoke a cigar, you have a relationship with it,” and shop in Radich’s wall-to-wall collection of Arturo Fuente, Cohiba or Avo cigars.

Radich also has modified the original business plan and makes up the losses in tobacco sales by selling sandwiches and drinks. He said he hopes to keep the store open until its centennial, in 2014, but said he doubts anyone will want to buy it when he retires.

“This little by little becomes the wrong business.”