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Diabetes and its discontents

6 Blood check

A rubbish strewn and flooded dirt path leads to a small concrete house where a number of people are dutifully gathered, patiently waiting for  neighbours to prick their fingers.

Though they will feel a sharp pain, the circle of crimson blood that results will indicate the state of their health and, crucially, whether they have kept certain promises.

Content image - Phnom Penh Post
A peer educator records blood sugar and blood pressure readings of diabetic community members at Srah Chak. Photograph: Scott Howes/Phnom Penh Post

These diabetes sufferers are captive to their weekly blood sugar readings – which are branded on their palms in black ink, as well as in the bright blue record books they all carry.

However, here in Phnom Penh’s Srah Chak slum community, treatment and monitoring is carried out with a sense of fun.

Geriatric men squat on standing scales, laughing and shouting, as their peers squint to read their weight.

A group of middle-aged women argue about exercise routines nearby, while another sits at their feet, quietly studying a colour-coded healthy diet pyramid poster.

“They don’t feel scared here . . . it’s better than going to the doctor. They can come here and talk to each other, and share knowledge and learn from me too,” says Meach Lina, 44, the home’s owner and a peer educator with chronic disease NGO MoPoTsyo.

The organisation has trained more than 100 diabetes patients like Lina around the country to provide counselling and blood sugar checks in their own homes for those who suffer from the disease.

According to MoPoTsyo’s director Maurits Van Pelt, the casual format allows patients to monitor their progress in a social atmosphere, and to take treatment into their own hands.

“It’s more informal. You can see that people here, if they don’t believe something, they will challenge it and they will speak back. And then all of the other people will also give their opinion,” he said.

“People can change their minds and actually understand something . . .  [whereas] when those messages are given in a clinical setting they just evaporate immediately.”

A hidden scourge

According to the International Diabetes Federation, there were an estimated 212,000 diabetes sufferers in Cambodia in 2012, with almost another 134,000 estimated to be undiagnosed.

The disease was responsible for more than 5,000 deaths last year and is one of four non-communicable diseases (NCDs) that, according to the World Health Organisation, account for 46 per cent of all deaths in Cambodia.

But historically, Van Pelt said, NCDs have received just one per cent of donor contributions in Cambodia, with communicable diseases such as HIV/AIDS receiving the bulk of funds.

“These four diseases [cardiovascular, respiratory, cancer and diabetes] kill Cambodian people at their most productive age,” Dr Sam Ath Khim, technical officer at the WHO for NCDs, told the Post.

Apart from key lifestyle risk factors such as insufficient exercise, smoking or unhealthy diets, there are also “root causes” of NCDs that stem from Cambodia’s rapid development, he said.

“We have to look at the causation pathways . . . which are related to globalisation, urbanisation, ageing and other social determinants.”

To wit: between 2003 and 2008 imports of soft-drinks and sweets into Cambodia rose by 5,041 per cent and 24,334 per cent respectively.

“[With] . . . economic growth, a lot of processed food has been imported. Five or 10 years ago you would hardly see fast food . . . but now there is a lot . . . people have started to change their lifestyle,” said Sam Ath.

The idea that NCDs are so-called “rich-man’s diseases” related to affluence, however, is a complete misconception with developing nations actually suffering most from the disease burden, he added.

Many MoPoTsyo patients, like 68-year-old Saing Savoeurn, who has had diabetes for 18 years and only spends $5 a month on subsidised medications, are poor.

“I prefer coming here than to a private clinic as I used to spend a lot of money on treatment. Here, the counselor gives me advice . . . and it costs less.”

The Cambodian diet, which involves adding plenty of sodium-rich ingredients such as fish sauce, MSG and soy sauce to food, has also contributed to the impact of NCDs, Sam Ath said.

Van Pelt identifies machine-polished white rice as the biggest change in the diet of Cambodians in recent decades.

“Nothing [else] can explain to me [why] suddenly so many of these middle-aged people in the countryside who are farmers are getting diabetes,” he said.

A study carried out earlier this year in Phnom Penh found that Cambodians were consuming an average of eight grams of salt per capita, well above the recommended dietary intake of five grams per day.

Approximately 34 per cent of Cambodians smoke tobacco daily, 26.7 per cent of urban Cambodians are overweight or obese, and 45.1 per cent of males drink heavily on a regular basis, according to a 2010 national health survey by the WHO.

The same survey found that 32.5 per cent of urban dwellers had high cholesterol, while 84.3 per cent of Cambodians had a low consumption of fruit and vegetables.

A heavy burden

The effects of NCDs on economic growth have been called “staggering” by the WHO, which estimates that losses to low and middle-income countries are equivalent to approximately four per cent of annual output.

A country like Cambodia loses about $25 to $50 per person per year to NCDs, with a 2011 WHO report recommending several “best-buy” intervention strategies and measures to reduce risk factors that would cost less than two dollars per person.

“In health terms, the return on this investment will be many millions of avoided premature deaths. In economic terms, the return will be many billions of dollars of additional output,” the report says.

The government does appear to be taking notice of the problem, with the Second National Health Strategic Plan for 2008-2015 including NCDs as a strategic priority for the first time.

A second national plan specifically targeting NCDs, for 2013-2020, is also in the approval process.

Meanwhile, a best-buy strategy that is beginning to be implemented is cervical cancer screening using visual inspection with acetic acid (VIA) with on-the-spot cryotherapy treatment, Sam Ath said.

The plan targets at least 80 per cent of women aged 30 to 49 being screened for the disease – the country’s most common cancer – by 2020, with several programs currently in pilot stage.

A funding pool supported by various international donors to assist the Ministry of Health is also increasing its annual allocation towards NCD prevention and control to 15 per cent, according to the World Bank.

Despite this, Sam Ath said, awareness about the largely preventable diseases remains low, with most of the government yet to seriously recognise an issue that requires multi-sector coordination.

Cost-effective solutions, like MoPoTsyo’s peer educator program, could thus serve as a tested model for the future.

Patients like 71-year-old Thorn Sameoeu, whose twisted, swollen feet and degraded toes show the consequences of unmanaged diabetes, have greatly benefited from the approach.

“My leg is better now and almost cured since I started coming here and got my blood sugar down. The numbness has gone and I can feel my feet . . . I can finally walk again.”

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