Académique Documents
Professionnel Documents
Culture Documents
Cambodia’s health ministry is advertising the benefits of iodised salt in a campaign aimed at overcoming
diseases and slow development from a shortage of the essential micronutrient
In April, the Ministry of Health revived a campaign raising awareness of the importance of a sufficient iodised salt intake,
especially among children and pregnant women.
The campaign includes educational television and radio broadcasts, as well as school visits by specially trained health
instructors, according to Dr Ou Kevanna, manager of the National Nutrition Council, which was established in 1998 by the
health ministry.
"Many Cambodian people believe that their children are not brave or clever because of race or other problems, but they actually
lack iodine in their bodies," he said.
"Children who lack iodine cannot learn or remember as well as those with sufficient levels. They are also more inactive."
Short supply
Iodine is a micronutrient naturally present in the food supplies of many regions. However, in countries like Cambodia, where
natural levels of iodine in the soil are low, and it is therefore not absorbed easily by vegetables, iodine added to salt provides the
small but essential amount needed by humans.
Public health experts say putting iodine in salt may be the simplest and most cost-effective health measure in the world. Salt is
an effective vehicle for distributing iodine to the public because it does not spoil and is generally consumed by the population in
fairly predictable amounts.
Table salt can be mixed with a minute amount of potassium iodide, sodium iodide or iodate. According to the New York Times,
two ounces of potassium iodate, costing about $1.15, are needed to iodise a tonne of salt.
Deficiency of this vital iodine trace element causes sufferers to feel tired, depressed, cold, weak, and they may eventually develop
thyroid gland problems, specifically endemic goitre, the most visible symptom of which is an often gross swelling of the neck. On
a medical mission in 2001, Canadian endocrinologist Keith McDonald was "impressed" by the high frequency of enlarged
thyroids he found, particularly among women.
Children who lack iodine cannot learn or remember as well as those with sufficient
levels.
A lack of iodine can also cause serious developmental delays. In 2007 the World Health Organisation identified iodine deficiency
as "the single greatest preventable cause of mental retardation" worldwide.
3 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
Reaching out
Doctor Ou Kevanna said it was important people received a daily intake of at least 20 to 50 micrograms of iodine to prevent
health problems. The recently revived public awareness campaign reached Neang Sopanhna, 32, a housewife who said: "I use
iodised salt every day, but I didn't realise its importance until I watched the Ministry of Health's television broadcast."
Her 12-year-old son, Chiv Sokhour, however, said he didn't believe eating iodised salt made him smarter or a better student.
"I will be a good student because I try to study hard and I listen to my teacher's explanations," he said.
Pen Saroeun, director of the School Health Department at the Ministry of Education Youth and Sport, said that the ministry was
cooperating with the National Subcommittee for the Control of Iodine Deficiency Disorders and the Ministry of Rural
Development to train instructors in four provinces - Prey Veng, Svay Reang, Kamport and Kep province - to spread knowledge
about the importance of iodised salt.
The burnt, pink skin of foreigners is often a source of hilarity among Cambodians – but if precautions are
not taken, the long-term effects of sun damage are anything but amusing
The sun emits three kinds of ultraviolet radiation: UVA, UVB and UVC.
Of these, the effects of UVC are negligible, while UVA is most harmful for the ageing of the skin, and UVB is what mainly causes
DNA damage which in turn can cause skin cancer.
The sun can also temporarily weaken the immune system and give rise to viruses such as herpes of the mouth. Furthermore,
existing skin diseases can be aggravated through sun exposure.
The skin doesn't forget any damage we have inflicted upon it.
It's not all bad news though, as sunlight can have a positive effect on mood and promotes important vitamin D production.
Nevertheless, skin aging - complete with wrinkles, age spots and loss of elasticity - is undesirable, and the risk of skin cancer
should be enough for everyone to slap on some sunscreen and keep in the shade.
Alas, many don't. Bendick says that during his 15 years in Cambodia, he has seen skin cancers "very frequently" mainly among
the expat population, many of whom don't take the necessary precautions.
Skin cancer also comes in three main types: basal cell carcinoma, squamous cell carcinoma and melanoma.
Of these, melanoma is the least frequent, but also the most dangerous. Left untreated, it leads inevitably to death.
"What we know today is that it is particularly the sunburns in childhood which make us more susceptible to the development of
malignant melanoma," Bendick says.
"The other skin cancers are more produced through the cumulative effect of lifelong daily sun exposure."
He is quick to remind parents of their responsibility to keep their children protected from the sun.
"The skin doesn't forget any damage we have inflicted upon it, so every sunburn is stored in the cumulative memory of the skin,"
he says.
Be safe
Though it is difficult for a layman to diagnose skin cancer, certain observable changes in the skin may mean a visit to a qualified
dermatologist is in order. "You should consult a dermatologist whenever you have a new lesion that you cannot easily attribute
to an insect bite, scratch or pimple," Bendick says, "especially if this lesion doesn't heal after a suitable time."
In addition, should you notice a new (or existing) mole that is particularly black, bleeding, itchy, irregular or growing, it is
recommended you have it checked with a professional.
"The wheel can't be turned backwards so it's best to avoid damage from the very beginning," Bendick says. He cites shade,
sunscreen and protective clothing as suitable precautions against harmful sunlight.
Many people complain wearing sun screen is uncomfortable and cosmetically undesirable.
However, a cursory glance through the better pharmacies in Phnom Penh reveals a wide variety of lotions, gels and sprays to suit
every need and wallet. Though quality brands may provide enhanced protection, any sunscreen with both UVA and UVB
protection is better than nothing.
It is advisable to avoid oily lotions, as these can clog the pores in your skin and stop sweat evaporating.
"I know that in our culture, it is preferential to be tanned," Bendick says, while noting many Cambodians aspire to the exact
opposite.
Yet while a bit of colour may have a positive effect on one's self-esteem, red peeling skin after a week's holiday on Sihanoukville's
beaches is surely redundant.
Avoid the sun, especially during the most intense hours of 10am-2pm
Choose a high SPF factor and sun-screen that protects you against both UVA and UVB light
Apply sun screen 30 minutes or more before exposure, and reapply after swimming or sweating.
Its reputation for dodgy doctors may still be intact, but Cambodia is re-creating itself as the perfect
destination for those looking for a new face, fuller breasts or a flatter stomach
With its burgeoning middle-class and relatively underdeveloped health care system, Cambodia has been fertile ground for
internationally trained professionals.
Dr Theung Chanseiha, a surgeon at the Cambodia-Russia Friendship Hospital and a manager at the Sok Hok clinic, trained in
cosmetic surgery in France and Italy and has also witnessed this local development.
"Now plastic surgery is really popular in Cambodia, even with good-looking people," he says. "Sometimes people might just be
unhappy with their nose, and now they can operate to make it smaller and prettier."
6 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
Happier at home
With no certified cosmetic-surgery training available in either
Cambodia or neighbouring Vietnam, wealthier Khmers would
previously have travelled to Singapore or Thailand to receive
treatment of an international standard.
"It can be a scary thing to have done, but I think people feel safer
with Western doctors," he said. "Patients would tell their friends
what they had done, and the Cambodian girls started pouring in."
However, it is not only among women that the trend is catching on,
and Sheftall suggests that his male clientele base has grown to
Dr Reid Sheftall in his surgery. IMAGE SUPPLIED around 10 percent of patients in the past six months.
"There's been a real shift with more men wanting liposuction and treatment for baldness," he said. "Guys are more vain than you
think."
And with cosmetic treatment in Cambodia a fraction of the cost of Western surgery, the image-conscious from around the world
are being drawn to the country in a new wave of medical tourism.
People can fly over from the States, have surgery with the same Western standard of
care and a two-week holiday here, and still save about $5,000.
A tummy tuck can be purchased from the AMC for around $4,000 and a "boob-job" for around $2,500, compared to in excess of
$10,000 in the US. "People can fly over from the States, have surgery with the same Western standard of care and a two-week
holiday here, and still save about $5,000," Sheftall said.
Kimberley, a 49-year-old Khmer-American who asked for her surname to not be publicised, underwent tummy-tuck surgery
with the American surgeon last week. She is among those now able to afford the luxury of a holiday-cum-makeover.
"I couldn't afford surgery in San Francisco, and I have my own business so it's hard to take time off," she explained. "But I could
come here to visit relatives and have time to recover from the operation."
She said she would be quick to recommend that others in the US follow her lead. "Dr Reid explained everything he was doing, so
I was clear about the procedure and the care has been really good," she said.
Dangers lurk
However, as more local clinics cotton on to the cosmetic surgery demand and begin advertising bargain procedures for as little
as $200 from murky premises, the new-found status of the local cosmetic surgery scene is coming under threat.
With no government regulation of services in Cambodia, and some outlets claiming their doctors are taught in countries like
Vietnam, which also has no certified training institutions, many of these practices are cause for serious concern.
"Plastic surgery is very new to Cambodia, and there are few skills among surgeons here," Theung Chanseiha said. "Cosmetic
surgery can have a serious impact on patients if the doctors don't have proper skills."
Although plastic surgeons in Cambodia are required to register with the country's Ministry of Health, Sann Sary, head of the
ministry's department of hospitals, told a Thai newspaper last month that many operated in illegal premises.
Despite this recent allegation, Sann Sary was this week unwilling to discuss the problem. However, doctors such as Sheftall have
witnessed first-hand the not-so-pretty face of Cambodian plastic surgery.
"You would be horrified by some of the things women who come to see me have had done to them," he said. "Often clinics use
suction cups to supposedly augment the breasts and make them fuller, but it only tears the ligaments away from the body,
causing serious damage."
Sheftall sees these painful outcomes as a symptom of a cultural pre-occupation with Western archetypes. "Every culture has own
norms of beauty, but because Cambodians see a lot of Western girls in the media, they develop an idea of that kind of beauty and
start wanting big breasts and a high nose," he said. "Personally, I really want Khmers to appreciate the beauty from their own
culture."
Unlike many other local practitioners, Sheftall, who also runs a charity to treat acid-burn victims, does not advertise his
cosmetic services and frequently turns women away if he considers a procedure inappropriate.
"I'm not into the whole Pamela Anderson thing at all, especially on naturally petite Khmer girls," he said. "Often I just tell
women not to even think about surgery, that they're pretty the way they are. I'm not here to make money; if I wanted to, I would
be in Florida."
7 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
As a breeding ground for malaria strains immune to the latest drugs, Cambodia is hosting an
‘unprecedented’ containment strategy designed to completely eradicate the killer bug
But with funding from the Bill and Melinda Gates Foundation,
Cambodia and its partners are racing to contain the increasingly drug
resistant parasite with an "unprecedented" containment strategy.
"Migrants go from here to Burma, from there to India, and then on to Africa," Dr Habib said, saying that this is what happened
to chloroquine, an anti-malarial that is largely ineffective in Cambodia.
Dr Ros Seyha from the WHO added: "Everyone agrees that if it were to spread to Africa it would be a disaster."
In 2006, the year with the latest available data, Africa accounted for more than 90 percent of the world's malaria cases with
about 801,000 deaths, according to the WHO. Malaria killed 207 people last year in Cambodia.
Philanthropic funds
The WHO received a two-year grant from the Bill and Melinda Gates Foundation for more than $22 million to fight malaria,
with Cambodia's NCM receiving a substantial chunk of that money.
In order to prevent an international disaster where malaria spreads unchecked, the WHO and the NCM have developed an
expensive, multi-pronged attack to all but eliminate the disease by 2015.
The main aspect of Cambodia's prevention strategy is the distribution of hundreds of thousands of long-lasting, treated bed nets,
according to Duong Socheat.
8 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
The NCM has divided the area into two zones - one zone that includes much of Pailin province and has been designated a high-
risk area, and a second zone at moderate risk.
Zone one has a population of just under 500,000, and zone two has a population of nearly 2 million, according to Duong
Socheat.
Despite receiving the Gates Foundation funds in February, the NCM has only been able to distribute about 200,000 treated bed
nets. It is hoping to hand out between 100,000 and 200,000 more.
"That is not enough," Duong Socheat said. "We have more than two million in the population; 200,000 is still very few."
In order to reach the remote areas of the region, the NCM and WHO have developed a network of about 2,000 village health
volunteers who distribute both information about malaria and treated bed nets.
Cambodia has also set up a network of about 600 village malaria workers who are trained to diagnose and treat the disease. They
are primarily located in high risk areas, far from public health clinics.
Shortcuts on care
But many Cambodians still seek treatment from private providers who may not prescribe a full treatment or supply counterfeit
drugs.
"Among the poor, the majority buy their drugs from private health providers," Habib said.
The NCM, with the help of the WHO, has been educating private pharmacists about the importance of a full course of treatment,
Duong Socheat said, but it was an uphill battles without affordable medicine. "People buy according to their pocketbook, not
according to the dose," he said.
The danger is that suboptimal doses will not clear out the parasite completely, leaving only the most resistant parasites.
Fortunately, Cambodia is eligible for Global Fund support to make a full course of medicines more affordable, Ros Seyha said.
Along with its prevention and education strategies, the WHO and NCM have started a pilot mass screening effort in the high risk
zone one.
Duong Socheat said the program aims to screen up to 200,000 people in zone one, testing blood samples of every person in
selected villages.
If a person tests positive in one of these screenings, the person will not receive the normal artemisinin combination therapy but
will instead receive Malarone, a treatment that is normally prohibitively expensive for poor countries.
"We don't want to put more pressure on the parasite to become drug resistant," Najib said.
Duong Socheat explained that avoiding artemisinin as part of a combination therapy was only temporary. "It's a special case and
will only be for two years. Because one component of Malarone is that the parasite develops resistance to it very quickly."
He added that every malaria case would be followed and that other therapies would be prescribed if the Malarone treatment was
ineffective.
Moving fast
In addition to the mass screenings, when a case of particularly resistant malaria is found, the WHO will target the entire village
where the person is from, in hopes of nipping the spread of the malaria strain early, Duong Socheat said.
Eliminating malaria will not be easy, but Dong Socheat was optimistic that Cambodia could all but rid itself of the disease by
2015 with adequate funding. "If we have enough money and motivation, we can contain the parasite by 2015," he said.
According to February's Malaria Journal article, the last remaining parasites will be the most resistant, meaning if the WHO and
NCM fail to contain the parasite, there would be a far more resistant population than before.
"We cannot stop midway," Duong Socheat said.
The conventional advice around town is that you should not drink the tap water, with rumours abounding
that it may contain anything from harmful bacteria to arsenic – but how much of this is urban myth, and
how much is based on hard fact?
9 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
Your average glass of tap water from the capital may contain
unhealthy doses of hyper-vigilance, ambiguity and
misinformation - but what else is in there?
Where does this stuff come from, and who puts what in it?
And is it really safe to drink?
Doctor's orders
"Don't even think about it," says ex-pat general practitioner and tropical diseases specialist, Dr Gavin Scott, of the Traveller's
Medical Clinic.
"I certainly do not drink the water here and would advise others not to," he says.
"With bottled water so cheap, there's just no need to risk it."
According the Scott, who has lived in Phnom Penh for 17 years, around 30 percent of the patients who come to his clinic are
suffering from travellers' diarrhoea - the proverbial "runs".
Diarrhoea can be triggered by ingesting ecoli bacteria or gastro-intestinal parasites such as worms, amoeba or giardia as a result
of faecal contaminants in the food or water supply. And while some residents may build up temporary resistance to the
nefarious ecoli, there is no immunity against parasites and worms or other more serious water-borne diseases such as
rotaviruses, Hepatitis A and B and typhoid, all of which occur through faecal contamination.
With the myriad dubious hygienic practices potentially occurring out the back of your favourite restaurant or below the surface
of the hotel swimming pool, it may be difficult to avoid, or even identify, sources of contamination.
If you can smell the chlorine, I means that there is no bacteria and the water is
absolutely safe to drink.
But like other medics, Scott insists that drinking, washing food and brushing your teeth with bottled water is one way of limiting
your exposure.
"There's never any guarantee of complete protection - it's all about reducing risk," he says.
"I have no confidence in the plumbing system here, and if the water supply doesn't already have bacteria in it, it definitely could
by the time it comes out of the faucet."
Photo by: TRACEY SHELTON Ek Sonn Chan's 12-year innovation made him the
With small bottles of water costing up to $3 in some nightclubs, object of assassination rumours, but it also saw him
awarded the Asian Development Bank's 2004 Water
drinking tap water is an option for those wanting to rehydrate after
Prize to become a ‘water champion'.
a long night of dancing.
10 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
Hin Dan, 25, Kampong Speu province Duy Sreyroat, 24, Takeo province
5 years in Phnom Penh 5 years in Phnom Penh
“I think the tap water is not so clean, but I use it "At home I used to use water from the well and
for everyday things like drinking and cooking. It’s rainwater, so it’s a bit strange for me to have to
not good for our health because sometimes it use tap water for the first time in Phnom Penh. It’s
smells bad and it’s murky and even if I boil it I easier than before, but I don’t think the water is
can’t kill 100 percent of the bacteria. But it is good to drink because it comes from the river and
better than water in rural areas. When it smells is just cleaned with a machine. It has a lot of
bad I use tea to reduce that smell. I’m afraid that diseases that we can’t see even though it looks
using the tap water will have long-term effects on clear. I use tap water for cooking and cleaning
our health, but I have no other choice. I want to clothes but boil it before I drink it.”
use pure drinking water, but can’t afford it.”
11 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
Ahti Westphal, 29, United States Thong Yort, 25, Prey Veng province
5 months in Phnom Penh 4 years in Phnom Penh
“I don’t knowingly drink tap water. I drink water "I think the tap water is cleaned up for us a bit,
that is served at most establishments with a and is okay to use, but its smell is not so good. It
certain amount of faith that it won’t kill me. I seems like they've put chemicals in it. I don't think
haven’t yet been so bold as to draw a nice tall we can drink it directly from the tap, and before I
glass from the kitchen faucet and drink it down. drink it I store it in an ceramic filtration barrel for a
I’m pretty sure if I did, it would be OK though. I day or two. I think it might have an impact on my
figure that if there is bacteria or toxins in it, you’re health one day, but I don't know how much and
going to be exposed to them anyway – through ice, how long it will take to appear."
eating out, washing your hands, et cetera.”
According the director, PPWSA now provides 90 percent of Phnom Penh's residents with safe, treated and disease-free water
from the city's own Tonle Sap river.
Unlike groundwater supplies in rural areas, the Tonle Sap is not subject to arsenic contamination, nor does it have toxic
pesticide residues, a fact confirmed by the most recent World Health Organisation (WHO) survey, which described the river as a
good quality source requiring only basic disinfection treatment.
However, Ek Sonn Chann is aware that many residents, mainly the more affluent classes, remain unconvinced.
"Most poor people drink tap water, but the rich people don't trust our workings," he explains.
"I'm always promoting the safety of tap water, yet they think it is unclean, and insist on drinking purified water."
But convincing wealthy Cambodians of the quality of PPWSA's product is not Ek Sonn Chann's primary concern.
"I'm not going to force these people to drink our water," he says. "The main problem we face today is supplying safe water to
everybody, not just 90 percent of the city."
Leading by example
Jan Rosenboom, Country Team Leader of the World Bank's Water and Sanitation program since 2003, is quick to affirm the
quality of PPWSA's supply.
"It's a fantastic authority," he says. "There's been an enormous amount of renovation of the pipe and distribution system, and
now it's a world-class facility."
Rosenboom's team has collaborated with organisations including the Ministry of Health and WHO to develop the current
interim Cambodian Drinking Water Quality Standards (CDWQS), to bring the water supply in line with international standards.
And unlike medical authorities, Rosenboom encourages residents to follow his lead and do away with the personal and
environmental expense of bottled water.
"The water quality here is great and the supply to the whole centre of town is fine to drink," he says. "I would suggest that
medical advice saying otherwise is very outdated."
While pipe systems connected directly to the street are guaranteed to receive PPWSA's treated supply, Rosenboom explains that
the old, open brick storage tanks used in some residences may pollute the supply with algae or other toxins.
However, it is not the possibility of biological contamination from outdated storage units which deters most residents from
drinking tap water, but the chemicals added by the PPWSA to combat bacterial contamination.
"The funny thing," Ronsenboom says, "is that both in and outside of Phnom Penh, many people aren't aware of chlorine and
don't like the taste or smell, so they're suspicious and won't drink the water. But if you can smell the chlorine, it means that there
is no bacteria and the water is absolutely safe to drink."
"Too little chlorine and it doesn't kill the bacteria, too much and you'll get chlorine by-products," Shantz says.
Shantz also explained the cloudiness that may appear in a glass of tap water left standing overnight. "This is usually the result of
iron reacting with oxygen, and is not a health risk," he said.
While RDIC endorses PPWSA's regulation of bacteria and chlorination, they also suggest that it is not the water source but its
distribution which can be cause for concern.
"The water comes from the Tonle Sap, which is good chemically," says Deputy Director, Marc Hall. "They pull drinking water
from the north of town, whereas the effluent is flowing to the south. The problem tends to be in the distribution system, which is
variable," he explains.
"It's not the government's fault," he says, "but it's just an old city, and they didn't have access to new materials like PVC, so can't
guarantee clean delivery without digging up the whole place."
In light of the idiosyncracies of Phnom Penh's plumbing system, RDIC makes no broad recommendations to residents about the
safety of drinking tap water.
Their laboratory can analyse individual water samples and provide scientific advice accordingly. RDIC also provides low-cost,
ceramic water filters, and distributes these to villages in the provinces. More information on their silver-impregnated,
12 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
The water sample was sent to RDIC for testing for biological and chemical contaminants, along with two samples of filtered
water from commercial bottled water suppliers.
Surprisingly, the results suggested that the biggest difference between the bottled water and the tap water was the price.
All samples were free of arsenic, E coli and other chemical contaminants tested for by the laboratory. And while the chlorine
levels in each sample fell below the optimum CDWQS range, RDIC explained that this would only be of concern if bacteria were
also present.
The verdict?
"The water from the BKK1 sample would be absolutely fine to drink," says Shantz.
In the absence of home-testing kits, filters, or the patience for boiling, these ambiguities may well raise the perennial question:
"to drink or not to drink"?
Let's put it in perspective. Between the beef lak lak you just ate for dinner and post-monsoon gutter you just waded through to
get home, a few draughts of PPWSA's highly esteemed water supply may be the least of the murky of waters you have to contend
with.
While it is impractical and unnecessary to test for all possible contaminants in water, the most likely cause of problems in
Phnom Penh is bacteria, although metals and pesticides may also be of concern.
However a recent WHO study found Phnom Penh's water source to be free from pesticides.
For the Phnom Penh Post's tests, a sample of tap water was taken from a house in BKK1 and tested alongside two samples of
bottled water at an independent laboratory for the following:
Iron: an indicator of rusted pipes, iron increases the "hardness" of water and can stain plumbing fixtures and laundry.
Arsenic: an odourless and tasteless semi-metal, arsenic has serious health effects. It is not usually present in surface
water, but can find its way into groundwater.
Turbidity: a measure of the cloudiness of water, turbidity may be caused by mud, silt, sand, pieces of dead plants,
bacteria, aquatic organisms, algae and chemical precipitates. It is a measure the effectiveness of water filtration.
Conductivity: a measure of the water's ability to conduct electrical current, conductivity indicates the amount of
dissolved minerals, or electrolytes, in the water, but does not indicate which minerals or metals are present.
pH: a measure of the alkalinity or acidity of water. A pH of 7 is neutral, while lower pH is acid and higher is alkaline.
Total coliforms: Coliform bacteria are present in surface water, and may indicate harmful bacteria such as klebsiella,
cryptosporidium, giardia, or salmonella.
E Coli: Escherichia coli is a type of faecal coli that indicates septic contamination.
Chlorine: a disinfectant. When added to water, some chlorine reacts with organic materials and metals and is not
available for disinfection. The remaining chlorine is the total chlorine, which is divided in turn into combined chlorine, the
amount that has reacted with nitrates, and the free chlorine which is available to kill disease-causing organisms. A free chlorine
level of 0.5mg/L will maintain the quality of water through a distribution network, but is unlikely to maintain the quality of
water stored in a bucket for 24 hours.
13 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
None of the parameters tested exceeded the limits recommended by the Cambodian Drinking Water Quality Standards.
The tap water was higher in iron than the bottled water, with three to five times higher turbidity. It also contained electolytes,
whereas the bottled water contained none. ADDITIONAL REPORTING BY MARK ROY
Cambodia may be a stress-free place to live for many, but it remains essential to take proper care of your
health – and your insurance policies – for peace of mind for you and your loved ones
ADVICE
By David Carter
P EOPLE are attracted to Cambodia by the warm weather, friendly atmosphere and the chance to make a good living. Many
end up in Phnom Penh, where there are many opportunities but with them many risks.
It's easy as a new resident to be complacent about things that were a "must do" back home, such as proper management of your
health. Contrary to some beliefs, Phnom Penh has excellent health and dental care available; however, these services do come at
a cost.
The question all foreign residents must ask themselves is: Do you have a health care plan? If so,
will it respond adequately in an emergency?
The options for expatriate medical insurance are many, ranging from the cheapest policy that provides basic inpatient medical
cover and evacuation to the nearest countries, to the broadest in- and outpatient cover and evacuation to the place of your
choice.
The premium charged ranges according to the level of cover and the amount you choose to pay as a policy excess. The variations
of cover are many so it is also very easy to get confused.The best way to arrive at the right cover for your circumstances is to ask
yourself some basic questions such as:
What lifestyle stage am I at, for example single, married with children, or retired with no dependents
How financially secure am I and what can I afford to pay for the insurance each year
14 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
Answer these questions and contrast these against your current policy or, if uninsured, against the options available. This way
you stand to get the best fit for your needs.
Ultimately the choice is yours, but everyone living away from home needs to remember that accidents and illness do happen
and, when they do, you will have to deal with them straight away.
It is an unfortunate but true fact that most medical service providers require surety of payment before treating patients. Buying
the right cover from a reputable insurer means a major part of the "what if"question disappears.
Ultimately the premium outlay when measured against an uninsured medical expense for an emergency can be a tiny
percentage, especially when it involves your most important assets - you and your loved ones.
_______________________________________________
David Carter is the CEO of Infinity Insurance,
a member of the Royal Group. He can be contacted at david@infinity.com.kh
High costs relative to income put many off treatment for toothache, while poor dental education makes
decay a serious problem.
According to dentist Chum Mony, most patients only visit his clinic
when the pain becomes agonising. "Cambodian patients procrastinate
until they cannot deal with their work.
They will only visit a doctor when they get seriously ill," he said, adding
that financial constraints and people's ignorance of dental problems
create the misconception that having dental examinations every six
months is a waste of time.
Sor Chandara, an English teacher who complains about the high price of dental services, still does not have his teeth checked -
even though he knows that doing so regularly would keep his teeth healthy.
"I have to spend money on food every day, so how can I afford $15 to $20 per check up?" he asked.
Education needed
Meanwhile, 21-year-old medical student Hor Lat Soriya always takes proper care of her teeth. She thinks that most Cambodians
lack knowledge and understanding of dental problems, and that this is a big social concern.
"Oral hygiene is crucial since we must communicate every day," she said. "We don't know exactly how many people suffer from
dental problems, but I believe many Cambodians have this problem."
Brushing your teeth is not enough. Using a mouthwash and floss helps clean them sufficiently, as well as reduces bacteria in the
mouth. If left, this bacteria turns into acid and speeds tooth decay.
Chum Mony, dentist at Pachem Dental Clinic, suggests that people eat more fruit and vegetables, while those with sensitive teeth
should avoid drinking freezing cold or boiling hot liquids.
15 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
Phnom Penh’s spas have not been immune to the effects of the economic crunch, but owners are
confident the thriving sector will survive the downturn
The study highlighted a booming national industry Photo by: TRACEY SHELTON
which in 2007 generated about $6 million in
A patron enjoys one of Aziadee’s ever-popular back and shoulder
revenues, through around 200,000 customers,
massages.
serviced by 400 staff.
SPA GUIDE
Aziadee
#16AB, Rue 282, 023 996 921
This French-owned facility, operating from a tranquil and cinnamon-fragrant renovated villa, offers massage therapies including
Thai, Indian and Egyptian techniques, as well as a range of Jacuzzi and scrub treatments. The Back and Shoulder massage and
Aziadee facial, which uses a freshly made, all-natural mask of eggs and chickpea flour, are favourites.
Bliss Spa
#29, Street 240. 023 215 754
This tranquil, two-storey, Moroccon-inspired villa, houses a jacuzzi, steam-room and courtyard plunge pool, and offers a range
of massage, facial and scrub treatments. The therapists speak fluent English and use 100 percent natural products, including the
Australian Jurlique range. Special services include luxurious private spa and dinner evenings for small groups.
In-Style Spa
#63, Street 242, 023 214 621
Phnom Penh’s oldest stand-alone spa is situated in a lush, tropical garden with an outdoor massage and Jacuzzi area. It offers
numerous body treatments and international massage therapies, but the house special, a combination of Indonesian and Hong
Kong massage techniques, remains a popular favourite of expats.
Although no demographic research has been published, it is estimated that around 90 percent of patrons are expats and foreign
tourists, the majority from European backgrounds. With around half of all spa providers located in Phnom Penh, where a
number of outlets have opened since the report's publication, the capital is well-equipped to cater to their needs.
Cassandra McMillan, owner of the well-known Bliss Spa and Boutique, was among the first to identify this latent demand when
she arrived in Phnom Penh 15 years ago.
"I really felt there was an element missing," she said. "There was a real need for a place where people could go to escape from the
hustle and bustle and all the dust and noise; somewhere that was not complicated, to cleanse the mind and body."
At that time, the main personal treatment therapies were massage parlours, many of which operated under the dubious premise
of offering "that bit extra", she said.
I’ve tried to keep our standards consistent and our products natural.”
16 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
The Australian fashion designer therefore decided to open an adjunct spa business in 2003, bringing in professional trainers
from Brazil, Thailand and Australia to help create her longed-for "little oasis".
Intelligent Spas' managing director Julie Garrow said "each country, city and business applies their own unique spin on what
they consider a spa", but explained that it should include elements of water, relaxation and healing, whether through modern or
traditional practices.
Many spa entrepreneurs in Southeast Asia combine treatments from both East and West in a regional take on the concept - like
the renowned Amrita Spa, a subsidiary of regional conglomerate Raffles Hotels and Resorts. "All of our therapists are Khmer,"
explains spa supervisor Prom Puth.
"But they are trained in traditional Thai, Swedish and Khmer massage, as well as reflexology, aromatherapy and facial
treatments."
Established in 1997, Amrita is the city's oldest spa. "At first we weren't so busy because people didn't really know what a spa
did," Prom Puth said. "But now that there's been more promotion of spas, we have more customers and a lot more business."
Garrow identified this increase as part of a global trend of spa development as massage parlours and beauty salons expanded
their services. However, while the quantity of spas in Cambodia has grown exponentially over the past decade, the quality
remains unclear.
"I think many spas opened because people think that it will be easy money," said Celine Jacobelli, owner of the popular Aziadee
and recently opened Amrette establishments.
"Often people aren't really interested in spas, so the quality of the training is not very good and the products are all synthetic.
"I've tried to keep our standards consistent and our products as natural as possible. I think that's kept people coming back."
Rising costs
Although the increased competition has posed little threat to institutions with a faithful following, the rising cost of materials
and recent economic downturn means that opening a spa in Phnom Penh in 2009 may not be a path to quick riches.
"In February we really noticed a drop in business," Jacobelli said. "We've lost about 20 percent of our clientele this year, mostly
tourists. But we're still doing OK."
Consistent with these estimates, Intelligent Spas recently found that, globally, spa operators received 13 percent less business in
2008 than predicted, and the company has lowered its initial forecasts for worldwide 2009 revenue by almost 10 percent.
However, they have given a more positive global and regional forecast for 2010, predicting a rise in average revenue and
patronage.
McMillan is similarly optimistic about the future of Bliss spa. "We have seen a small drop", she said.
"People who maybe came for a weekly treatment are now coming once a fortnight instead, but I'm not panicking about it. We
have a solid base of regular clientele, so we just have to ride it out."
With the days now growing hotter and wetter, and residents still bustling to their regular providers to cool down or scrub up, it
seem that, come rain or shine, spa treatments are a luxury that Phnom Penh residents will strive to afford.
Cambodia’s reputation for a hardworking, intense lifestyle means women have to take particular care with
their health
17 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
Watson says many of her wealthier clients don't trust the OK pill and condom because it is so cheap.
But the pills and condoms are heavily subsidised and quality-controlled by Population Services International, a global health
NGO, who target the OK brand at poor women.
According to Watson the OK pill is the same as a very popular pill called Microgynan, currently prescribed to 70 percent of
women in the UK.
It is also popular in the US, Australia and other developed nations because it is well-tolerated by most women.
Watson says many Cambodian clients misuse condoms and the pill, so family planning counselling and clear instructions are a
priority.
Cambodians and expatriates clients are also regularly concerned about weight gain and loss when taking the pill, but Watson
assures users that this fear is not founded in scientific fact.
"There is some evidence that the pill stimulates appetite, but there are absolutely no findings that it makes you fat," she said.
Never taking a holiday, not looking after yourself properly, drinking too much, smoking
too much – this kind of burnout behaviour we see a lot of.
OK condoms retail for 500 riels for a packet of three while the OK pill is just $2 for a year's supply.
Regular check-ups
Pap smears and breast examinations are available in Cambodia, and Watson
advises regular breast self-examination and Pap smears for all women aged
over 25, or three years after initial sexual intercourse.
Women who have never had sex or are over 65 do not need to have a Pap
smear.
Watson advises having a Pap smear every two to three years, although there is
debate over this, with different countries offering alternative advice.
Older women need to think about dealing with menopause, vigilant breast
examination and keeping their bones healthy.
Pregnancy
Along with contraception use and regular breast self-examination, Watson's
strongest advice for women living in Cambodia is not to have children too late.
"Fertility is a big issue for women here. There are a lot of career women in
Cambodia and they get over 35 but haven't found the right time or the right
partner and always assumed they can have families," she said.
"I see a lot of women having fertility problems, and I think it's very difficult for
Dr Laura Watson. PHOTO SUPPLIED the individual and the relationship to go through fertility treatments."
Watson says she counsels a lot of women who have trouble meeting the right partner in Cambodia, after focusing on their
careers and moving around a lot, and the anecdotal "man drought" in Cambodia is a big concern for many women.
"I think there's never a right time to have a child and if you've found someone you want to have a baby with - go for it," she said.
18 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
Watson also says if you can afford it to have your baby overseas, the closest options for modern health care being Singapore or
Bangkok.
She says there are no international standard neo-natal intensive care facilities in Cambodia, and while most women are low-risk,
if there is an emergency during the birth, such as respiratory problems, there are no adequate facilities in Cambodia.
Mental health
Watson says she wonders whether a lot of "Type A" personalities are drawn to Cambodia, loosely meaning highly ambitious,
workaholic, competitive people.
"A lot of people who have struggled to fit in at home are attracted to Cambodia because there are a lot of people who are
different here. And there are also a lot of people who are running away from problems and end up in Cambodia - people with
drug problems, alcohol problems and mental health problems," she said.
"It's the kind of intensive living that people often do here. Working seven days a week, never taking a holiday, not looking after
yourself properly, drinking too much, smoking too much - this kind of burnout behaviour we see a lot of."
Watson says generally women are more accepting of mental health issues than men, and the idea that physical symptoms may
the product of mental stress.
She says a lot of her work involves talking to people about structuring their coping mechanisms and discussing holistic lifestyle
changes that may help deal with the problem.
Phnom Penh’s massage parlours seldom employ professionally qualified staff, but they can nevertheless
provide some much-needed relaxation for the capital city’s urbanites
The contention is echoed by Andrew Marriott, an Australian-certified massage therapist also practising in the capital. "If one is
looking for relaxation, then any massage which comes in contact with the skin is very helpful for the skin, because the skin is the
largest organ," he said.
It can be quite relaxing ... but they don’t know what they are doing or why.
However, Marriott also noted that for purposes of actual treatment of muscular pain, going to a professional is highly advisable.
He said that though an amateur massage may provide some relief in the short run, it is always prudent to visit a specialist to
prevent initial problems developing into bigger ones.
Though not advocating against high street massages, Dhuez is wary of the so-called traditional Khmer massage. He explained
that most traditional massage styles, from Chinese, through Japanese to ayurvedic, are based on a set of protocols, and
practitioners usually go through rigorous training before starting work at a practice. "They know what they're doing and they're
treating people," he said.
In contrast, according to Dhuez, there is currently no established discipline behind "traditional" Khmer massages. Instead, the
techniques are handed down through generations by being taught from one person to another. "They have learned a recipe and
they are applying it," he said.
19 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
"It can be quite relaxing because they are pressing the muscles, but they don't know what they are doing or why," he continued.
This is precisely what many massage aficionados, who are constantly on the lookout for that seemingly elusive perfect massage,
say.
Dhuez laments many spa owners' unwillingness to invest in staff training. Many prospective spa owners come to him for advice,
he said, but back down when they learn the cost of professional training.
Yet unprofessional massages, especially traditional Khmer ones, can potentially be harmful.
"Sure, it can do damage. Because in addition to pressing the muscles, you also twist the body and that can be dangerous if the
masseur doesn't know how to do it," Dhuez said.
He cites problems such as misaligned vertebra, twisted pelvises and pulled muscles as possible complications. "It can create a
problem where there wasn't a problem before. It doesn't happen that often, but it's something you should take into account," he
said.
The bottom line, thus, seems to be that if you suffer from a recurrent, chronic problem, or experience severe or acute pain,
consult either a physician, physiotherapist or qualified massage therapist.
Even then, however, as both Marriott and Dhuez pointed out, there are generally no quick fixes. Twenty years of back pain won't
go away in a session, but the sooner you go, the better.
On the other hand, if you're generally healthy and simply looking for an hour away from your blackberry, that five-dollar-
massage-parlour around the corner might just do the trick.
Lead on quality
In targeting that middle class, Pharmalink has decided to ensure
it provides quality service by demanding that customers present
prescriptions before buying certain drugs, Forsinetti said.
"Health care is very specific. You need to deliver quality and you
Photo by: Sovann Philong
have responsibilities," he said.
DeVenco Vice President Christophe Forsinetti.
"If you sell something to a person and you're not supposed to, and that person has a problem or dies because of that
prescription, then you're in trouble - and we cannot bear that responsibility."
20 Phnom Penh Post Health & Beauty Supplement 29 May, 2009
He acknowledged that many people would rather save themselves the effort of obtaining a prescription by buying
pharmaceuticals from any of the thousands of other pharmacies in Phnom Penh.
This may be true, but it doesn't make the practice any less dangerous.
And, as Forsinetti states, health care ought to be much more regulated.
"It's our role to take the lead and try to put some industry standards in place," he said.
Asian people are really concerned about their image, their health, the small products
that you can use.
Keeping it real
Another pertinent issue that Pharmalink must deal with is the counterfeiting of drugs. Pharmaceuticals may have
misappropriated brand labels, or may not even have the chemicals they purport to contain.
"I would say this is much more common with very small pharmacies," explained Forsinetti.
"They will try to pull the prices as low as possible, so they are likely to buy from people importing drugs illegally from Vietnam
and Thailand."
He explained that Pharmalink aims to buy their products exclusively from reputed laboratories and distributors.
However, counterfeit drugs remain a reality for all Cambodian pharmaceutical businesses. "It's never 100 percent bullet-proof,"
Forsinetti admits.