Sick Children, Why The Cambodian Genocide Toll Is Still Rising

Decades after the Khmer Rouge, the legacy of their brutal regime claims a new generation of victims.

A Cambodian child in Phnom Penh
A Cambodian child in Phnom Penh
Hanno Charisius

SIEM REAP Ros Mom wears socks even on hot days. No one is supposed to see her feet while she is sitting on the bed in her Quonset hut in a small village near Siem Reap, in northwestern Cambodia. Ros Mom lives not far from the ruins of Angkor Wat. But the money brought by 2 million tourists every year has little impact on the economy in the surrounding jungle. The streets around the temple are paved. But the path leading up to Ros Mom's hut is just dirt and sand.

A couple of months ago the mother of four developed an open sore on her left foot because she didn't have enough money to buy insulin to treat her Type-2 diabetes. The monthly prescription of the vital drug costs $25, Ros Mom explains as a squeaky old ventilator churns up the hot air under the corrugated iron of her hut. Only when the ulcer developed did she return to the clinic of the Cambodian Diabetes Society (CDA) to visit her doctor, Lim Keuky.

The clinic is situated on a muddy alleyway of Siem Reap, the capital of Siem Reap province. From here the 80-year-old endocrinologist leads his fight against obesity, diabetes, and the burden of the past.

The Khmer Rouge regime was short, but long enough to cause damage across generations

Approximately 6% of Cambodia's 16.6 million people suffer from diabetes, according to the World Health Organization (WHO). Of those, the vast majority (90%) have the Type-2 variety. More troubling still is that the numbers are rising, particularly among young patients. Compared to other countries, the overall diabetes rate isn't all that high in Cambodia. But it's rising, particularly among young people, says Lim Keuky.

Elsewhere in the world, the typical Type-2 diabetic is old, obese, and is not active enough. But at the CDA clinic on the edge of Siem Reap, Lim Keuky has had to treat more and more patients in their 30s and 40s, many of whom, he notes, who were born when the Khmer Rouge ruled Cambodia and starved, tortured, and massacred millions. A lot of these patients are of normal weight but are unable, nevertheless, to regulate their blood sugar levels.

"The Khmer Rouge regime was short but long enough to cause damage across generations," the doctor says.

Genetic scars

Lim Keuky isn't the only person who connects the horrible experiences under the Pol Pot regime to the suffering his patients experience all these years later. Biochemists in the new field of epigenetics have considered how the environment can influence a person's molecular biology. Hunger, stress, and violence appear to alter how cells interpret a gene's DNA code and thus leave traces behind in the genotype.

The Munich-based doctor and neuroscientist Elisabeth Binder, today the director of the Max Planck Institute for Psychiatry, was able to show several years ago that people who experienced trauma in early childhood also carry this trauma later in life. The damage caused can be like a scars on the genome in the victim, she demonstrated. Not only that, but these epigenetic alterations are also likely to pass on to the next generation.

In Siem Reap, Lim Keuky usually greets people with a handshake rather than putting his palms together in front of his torso as is customary here. It's one of the western mannerisms he picked up while studying in United States and France. After discussing the daily schedule with his coworkers, he sits down, gazes in the distance and says, "I'm here to save lives."

He and his two colleagues handle 1,200 diabetic patients at the clinic they founded in Siem Reap in 2010. That's the most they can do. Their workspace consists of a big room, where the office and the treatment areas are separated by shelves and curtains. Only the bathroom and the cold storage room containing the medication have a door.

Right now it's 9 a.m., and the first 20 patients are already back on their way to work. Most of patients come with relatives, and the room fills up quickly. Everyone stands shoulder-to-shoulder.

Death camps

Cambodia has still not recovered from the atrocities committed by the Khmer Rouge, the guerilla movement that seized power on April 17, 1975, when it captured the capital city, Phnom Penh. The movement wanted to bring communism to Cambodia.

Two days later, its soldiers began to deport urban residents to the countryside, where they were forced to grow rice. The capital was nearly emptied in 24 hours. Many were arrested without a reason. For the soldiers, the orderly arrest of a person sufficed as proof of guilt. For "brother number 1" — Pol Pot — the willpower of the people alone sufficed.

Stress and hunger very often influence the disease risk, as they influence how the cells read the DNA code of the genes.

Lim Keuky had the chance to leave his country before the mass murders began. When he returned, 42 members of his family were dead. The Pol Pot regime raged for just three years, eight months and 20 days. And yet, in that relatively short time, between 1.4 and 2.2 million Cambodians died. There are no exact numbers, despite the fact that the Khmer Rouge held registers of the people exterminated in their death camps. The people who died in the fields or starved remain uncounted.

After a glance at the patient's past, Lim Keuky creates a file for each of them. He wants to know how their grandparents lived, what their parents had to endure during the Khmer regime, if they starved, if they were tortured. The fate of the patient's ancestors tells the doctor about his risks of being diabetic. Stress and hunger very often influence the disease risk, as they influence how the cells read the DNA code of the genes. Embryos and fetuses are particularly sensitive to these signals, which they experience in the womb.

To grow from a single cell to a being constituted of multiple organs, a human being's chemical labels on the DNA activate or deactivate the necessary genes, depending on the organs that are formed. The cells don't actually use all the genes stored in their genome. A nerve cell develops differently from a skin cell. The same mechanism also allows biochemical communication between different generations. Parents, through their own life experiences, can therefore influence the health of their children via molecular biology.

Impoverished patients

A lot of Lim Keuky's patients had never heard of type-2 diabetes before they were diagnosed. And the public health system is not yet focused on this "sugar disease." In recent decades, the government successfully decreased the overall mortality rate among children and has fought infectious diseases like HIV. But diabetes was largely overlooked until 2007, when a WHO study revealed the magnitude of the problem.

Distrust in governmental institutions is commonplace in Cambodia, another legacy of the Khmer regime.

It was at that time that Ros Mom discovered her condition. She didn't trust the public health centers, so she drove 300 kilometers to Phnom Penh to have the diagnosis confirmed by another clinic. Distrust in governmental institutions is commonplace in Cambodia, another legacy, perhaps, of the Khmer regime.

Ros Mom couldn't afford regular appointments at a private clinic, and so an acquaintance recommended she contact Lim Keuky. At the diabetes center in Siem Reap, patients pay what they can. "When they can't afford to give us anything, that's OK," Lim Keuky says. But the patients do still have to pay for their medication.

In public institutions, Cambodians with a card specially issued for the poor can access the medication free of charge. But there are still more patients coming to the center than the endocrinologist and his colleagues can handle. So far, Lim Keuky hasn't been able to convince other doctors to come work in Siem Reap. "Working here is a sacrifice. You barely have a private life," he says.

Short lives

Given all her pains and problems, Ros Mom's medical story is a actually success, though one that could change course if she can't afford medication anymore. According to the Cambodian NGO Mopotsyo, most diabetics in Cambodia live short lives. Out of a group of 500 polled diabetic individuals, the average life expectancy after the illness had been diagnosed was of only four years. Only one in 10 survives more than 10 years.

The high death rate also comes from the fact that for many, the illness goes undiagnosed. Either that, or it's discovered too late. Lim Keuky says that patients usually ignore the first symptoms: thirst, hunger, tiredness or a numbing in their hands and feet. "Without the right treatment at the right time, they die," he explains mater of factly.

Even if the epigenetic program from at least one generation of Cambodians has been mixed up, most diseases can be prevented. The most vulnerable individuals just need to be careful, as Lim Keuky always explains to his patients. Once of the tools he uses is a school textbook in which medial recommendations are presented as comic strips. He has several thousand copies.

"Exercise more, eat less. Listen to the doctor," the last piece of advice reads. Sometimes, it's that easy.

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Queen Elizabeth II with UK PM Boris Johnson at a reception at Windsor Castle yesterday

Anne-Sophie Goninet, Jane Herbelin and Bertrand Hauger

👋 Hej!*

Welcome to Wednesday, where chaos hits Syria, Brazilian president Jair Bolsonaro is accused of crimes against humanity and a social media giant plans to rebrand itself. For Spanish daily La Razon, reporter Paco Rodríguez takes us to the devastated town of Belchite, where visitors are reporting paranormal phenomenons.



• Syrian violence erupts: Army shelling on residential areas of the rebel-held region of northwestern Syria killed 13 people, with school children among the victims. The attack occurred shortly after a bombing killed at least 14 military personnel in Damascus. In central Syria, a blast inside an ammunition depot kills five soldiers.

• Renewed Ethiopia air raids on capital of embattled Tigray region: Ethiopian federal government forces have launched its second air strike this week on the capital of the northern Tigray. The air raids mark a sharp escalation in the near-year-old conflict between the government forces and the Tigrayan People's Liberation Front (TPLF) that killed thousands and displaced over 2 million people.

• Bolsonaro accused of crimes against humanity: A leaked draft government report concludes that Brazilian President Jair Bolsonaro should be charged with crimes against humanity, forging documents and incitement to crime, following his handling of the country's COVID-19 pandemic. The report blames Bolsonaro's administration for more than half of Brazil's 600,000 coronavirus deaths.

• Kidnappers in Haiti demand $17 million to free a missionary group: A Haitian gang that kidnapped 17 members of a Christian aid group, including five children, demanded $1million ransom per person. Most of those being held are Americans; one is Canadian.

• Putin bows out of COP26 in Glasgow: Russian President Vladimir Putin will not fly to Glasgow to attend the COP26 climate summit. A setback for host Britain's hopes of getting support from major powers for a more radical plan to tackle climate change.

• Queen Elizabeth II cancels trip over health concerns: The 95-year-old British monarch has cancelled a visit to Northern Ireland after she was advised by her doctors to rest for the next few days. Buckingham Palace assured the queen, who attended public events yesterday, was "in good spirits."

• A new name for Facebook? According to a report by The Verge website, Mark Zuckerberg's social media giant is planning on changing the company's name next week, to reflect its focus on building the "metaverse," a virtual reality version of the internet.


"Oil price rise causes earthquake," titles Portuguese daily Jornal I as surging demand coupled with supply shortage have driven oil prices to seven-year highs at more than $80 per barrel.



For the first time women judges have been appointed to Egypt's State Council, one of the country's main judicial bodies. The council's chief judge, Mohammed Hossam el-Din, welcomed the 98 new judges in a celebratory event in Cairo. Since its inception in 1946, the State Council has been exclusively male and until now actively rejected female applicants.


Spanish civil war town now a paranormal attraction

Ghosts from Spain's murderous 1930s civil war are said to roam the ruins of Belchite outside Zaragoza. Tourists are intrigued and can book a special visit to the town, reports Paco Rodríguez in Madrid-based daily La Razon.

🏚️ Between August 24 and September 6, 1937, during the Spanish Civil War, more than 5,000 people died in 14 days of intense fighting in Belchite in north-eastern Spain, and the town was flattened. The fighting began on the outskirts and ended in house-to-house fighting. Almost half the town's 3,100 residents died in the struggle. The war annihilated centuries of village history. The town was never rebuilt, though a Pueblo Nuevo (or new town) was built by the old one.

😱 Belchite became an open-air museum of the horror of the civil war of 1936-39, which left 300,000 dead and wounds that have yet to heal or, for some today, mustn't. For many locals, the battle of Belchite has yet to end, judging by reports of paranormal incidents. Some insist they have heard the screams of falling soldiers, while others say the Count of Belchite wanders the streets, unable to find a resting place after his corpse was exhumed.

🎟️ Ordinary visitors have encountered unusual situations. Currently, you can only visit Belchite at set times every day, with prior booking. More daring visitors can also visit at 10 p.m. on weekends. Your ticket does not include a guaranteed paranormal experience, but many visitors insist strange things have happened to them. These include sudden changes of temperature or the strange feeling of being observed from a street corner or a window. Furthermore, such phenomena increase as evening falls, as if night brought the devastated town to life.

➡️


We still cling to the past because back then we had security, which is the main thing that's missing in Libya today.

— Fethi al-Ahmar, an engineer living in the Libyan desert town Bani Walid, told AFP, as the country today marks the 10-year anniversary of the death of dictator Muammar Gaddafi. The leader who had reigned for 42 years over Libya was toppled in a revolt inspired by the Arab Spring uprisings and later killed by rebels. Some hope the presidential elections set in December can help the country turn the page on a decade of chaos and instability.


Iran to offer Master's and PhD in morality enforcement

Iran will create new "master's and doctorate" programs to train state morality agents checking on people's public conduct and attire, according to several Persian-language news sources.

Mehran Samadi, a senior official of the Headquarters to Enjoin Virtues and Proscribe Vices (Amr-e be ma'ruf va nahy az monkar) said "anyone who wants to enjoin virtues must have the knowledge," the London-based broadcaster Iran International reported, citing reports from Iran.

The morality patrols, in force since the 1979 revolution, tend to focus mostly on young people and women, particularly the public appearance for the latter. Loose headscarves will send women straight to a police station, often in humiliating conditions. Five years ago, the regime announced a new force of some 7,000 additional agents checking on women's hijabs and other standards of dress and behavior.

Last week, for example, Tehran police revealed that they had "disciplined" agents who had been filmed forcefully shoving a girl into a van. Such incidents may increase under the new, conservative president, Ibrahim Raisi.

Speaking about the new academic discipline, Samadi said morals go "much further than headscarves and modesty," and those earning graduate degrees would teach agents "what the priorities are."

Iran's Islamic regime, under the guidance of Shia jurists, continuously fine tunes notions of "proper" conduct — and calibrates its own, interventionist authority. More recently the traffic police chief said women were not allowed to ride motorbikes, and "would be stopped," Prague-based Radio Farda reported.

Days before, a cleric in the holy city of Qom in central Iran insisted that people must be vaccinated by a medic of the same sex "as often as possible," and if not, there should be no pictures of mixed-sex vaccinations.

✍️ Newsletter by Anne-Sophie Goninet, Jane Herbelin and Bertrand Hauger

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