Legacy of Atrocities: Diabetes in Cambodia

Hidden scars of the savage Khmer Rouge regime can still be seen today, especially in the diabetes clinic in Siem Reap. According to the World Health Organization (WHO), 5.9 percent of the 16 million Cambodians have diabetes – around 90 percent of the patients are type 2 diabetes cases. Unfortunately, the number of people living with this disease is expected to increase and most of the cases will remain undiagnosed. While previously, type 2 diabetes used to affect only middle-aged and overweight individuals, the patients nowadays treated by the endocrinologist Lim Keuky are in their early 30s and of normal weight. Nowadays, Cambodians are eating more than before and, at the same time, becoming less active. However, this development as well as the fact that type 2 diabetes has multiple causes cannot sufficiently explain why Cambodia’s diabetes clinics are filled to overflowing. The reason for Cambodia’s increasing cases of diabetes must be another one.

Lim Keuky, president of the Cambodian Diabetes Association (CDA), sees a correlation between the famine during the Khmer Rouge regime and the epigenetic of the Cambodians conceived and born during that period. He believes that the famine Cambodian people experienced during the regime’s ruling period from 1975 to 1979 may have affected the health of their children and grandchildren. “The Khmer Rouge regime ruled for a relatively short period of time - but long enough to set up generational damage”, Keuky said. People who experienced the regime are significantly more likely vulnerable to cardiovascular diseases and diabetes. 

Not only the 80-year-old endocrinologist Lim Keuky is convinced that terrible experiences are related to the suffering of his patients. Biochemists have been discussing how the environment can influence the molecular biology of a human being regarding the epigenetic inheritance, which is reversible in contrast to DNA. Starvation, stress and violence seem to change how cells interpret the DNA-code of the genes and thus leave traces on the genome. It has been proven by neuroscientists that people who were traumatized in their early childhood carry this severe trauma in their cells even later in life. Presumably, some of these epigenetic changes are passed on to the next generation.

In the CDA clinic, which was founded in 2010, about 1200 patients are treated by Lim Keuky and his colleagues. The clinic’s main purpose is the early diagnosis of individuals living with diabetes and the screening of communities to identify adults affected by type 2 diabetes. Considering Cambodia’s past, the family history can help identify those most at risk for diabetes. Hence, Lim Keuky makes a family tree for every patient. He wants to know under which conditions the grandparents lived, what the parents had to endure under the Khmer Rouge, and whether they had starved or were tortured. Malnutrition and starvation during pregnancy can have irreversible health damage to the unborn child. As a fetus, the unborn child learns to deal with shortages of food. After the childbirth, the baby will be particularly sparing with dietary energy. As time passes and the child can eat as much as it wants, due to overnutrition the body gets so much additional energy that heart disease, high blood pressure and diabetes are potential consequences. This process, known as epigenetics, is considered the link between environmental influences and genes: It determines the circumstances under which the gene is switched on and off because no cell actually uses all the genes stored in its genome.

In recent decades, the child mortality and infectious diseases such as HIV have decreased significantly. Nevertheless, Cambodia still has a major public health issue due to chronic diseases. A WHO study from 2007 revealed the state of the diabetes problem, but the public health system has not been adjusted to diabetes yet. Several of Lim Keuky’s patients had never heard of type 2 diabetes before their diagnosis. Frequently, many of diabetes cases go undiagnosed because Cambodians do not go to health centers, either because they do not recognize the symptoms of diabetes, or because many of them have a great mistrust towards official institutions. At the same time, some of the diagnosed patients decide not to follow the medication therapy vital for their survival, as they cannot afford it. 

Obviously the Cambodian people still suffer from the trauma of the Khmer Rouge regime in many ways. Lim Keuky was lucky to leave the country before the Khmer Rouge started the mass atrocities. But when he returned after the war 42 of his family members had been killed.

This article is an unofficial summary of the German text that was published in Suddeutsche Zeitung on 30th June 2017. The original German text can be found here: http://www.sueddeutsche.de/gesundheit/spuren-der-gewalt-die-kranken-kinder-des-genozids-1.3567664
Translated and summarized by Bianca Rancea