Link to Affluence Hides Extent of Diabetes Problem

A poor, developing such as Cambodia is expected to have its share of health issues: malaria, malnutrition and HIV/AIDS come to mind. But diabetes, an illness that many incorrectly associate with more affluent nations, is in fact a serious problem in Cambodia, and a disease that is as ignored as it is devastating.

Even by the most conservative estimates, there are at least four times as many diabetics in Cambodia as people living with HIV/AIDS. It could even be 10 times more: few studies have been conducted, but the figure most commonly cited is 255,000 diabetics in the country in 2005. And as Cambodians start feeling the effects of the world financial crisis, the threat of the disease will only grow for the urban poor. The World Health Organization predicts a doubling of the number of diabetics in the world by 2030.

“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 Cambodians and 1 in 20 rural ones are diabetic, according to joint studies from the Ministry of Health, Cambodian Diabetes Association, the European Center for Diabetes Studies and the French drug company Servier.

“They have the rates of developed countries…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 of limbs, and eventually death.

There are three factors that account for Cambodia’s high diabetes rate, Dicquemarre explained.

Many Cambodians have abandoned farming to live in towns and cities. Urbanization leads to unhealthy lifestyles, which leads to people being 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 sugary soda, according to a list compiled by University of Sydney 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. And that’s where diabetes ceases to be a rich person’s disease.

As the country faces new economic hardships, low-income Cambodians are likely to increase the amount of rice-a cheaper food-in their diet, and their blood sugar levels are likely to increase too, Dicquemarre said.

“When eaten alone, [white rice] is almost like getting sugar in an IV,” Dicquemarre said.

But, argued Dr Jean-Claude Garel of the Naga Clinic in Phnom Penh, a longtime physician here, rice has always been a part of the local diet and diabetes is a more recent phenomenon.

“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 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-reduction of which is one of the Millennium 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 remain undiagnosed and untreated, 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 difference between whether you’re going to have money to eat or not,” he said.

“It is possible for many Cambodians to pay for their own medicine because the medicine for diabetes can be really cheap,” he added.

Yel Daravuth argued that 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 Mission Care’s diabetes program at Preah Kossamak hospital, only one in 15 patients has had diabetes for more than a decade, Dicquemarre said. Most Cambodians simply can’t survive 10 years into 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 won’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 just focused on medical expenditures. It is also 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.”

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