Cambodia Health & Beauty 2009

2 Phnom Penh Post

Health & Beauty Supplement

29 May, 2009

Iodised salt push for public health Written by Mom Kunthear

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 Relief from Nuclear fallout

D

uring the Cold War people took iodine

pills at times when there was a threat of a nuclear attack. Why? Because an exploding nuclear bomb forms radioactive iodine. Those who eat, drink or inhale this isotope can develop thyroid damage or cancer. By taking an iodine pill, potential victims saturate the thyroid gland with iodine thus preventing it from absorbing the radioactive iodine.

I

odine deficiency disorders can seriously

Photo by: HENG CHIVOAN A worker sifts salt at a salt plant on the outskirts of Phnom Penh.

damage your health. In addition to stunting growth and causing deafness, dumbness and goitre, iodine deficiency can significantly lower the average national IQ in areas where it is widespread.

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.

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Health & Beauty Supplement

29 May, 2009

Cambodia has historically been highly susceptible to various micronutrient deficiencies, and a nationwide survey conducted in 1997 revealed a total goitre rate (TGR) of 12 percent among schoolchildren of 8-12 years of age - rising to as high as 45 percent in some areas. According to UNICEF Cambodia, "any country with a TGR of 10 percent or more is likely to suffer a population-wide lowering of intellectual capacity from 10 to 15 IQ points," thereby shaving incalculable potential off a nation's development. To address the problem, in 1997 a National Subcommittee for the Control of Iodine Deficiency Disorders in Cambodia was established within the National Nutrition Council. The country began salt iodisation in 1998, and domestic production of iodised salt began exceeding annual national requirements by 2004. A nation-wide school-based survey in 2008 revealed that 62 percent of households use adequately iodised salt. This is encouraging. However, UNICEF Cambodia highlighted unresolved issues related to low use of iodised salt in salt-producing provinces including Kampot and Kep, and provinces bordering Vietnam, such as Svay Rieng. "The quality of iodised salt remained relatively low and quality control systems on production levels need improvement," a UNICEF report said.

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.

Skin safety is made in the shade Written by Nora Lindstrom

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

A

void, avoid, avoid, avoid is the best advice when it comes to

preventing sun damage to the skin. Unless you live above the polar circle during the winter months, it is a near impossible dogma to follow. In a tropical climate where the sun is constant and intense, precautions are essential. Through repeated and excessive exposure to the sun you can seriously damage your skin and even develop cancer. Dr Christoph Bendick, Senior Lecturer for Dermatology and Sexually Transmitted Diseases at the Faculty of Medicine at the University of Health Sciences in Phnom Penh says the sun can be quite harmful, particularly to those from other countries living in tropical climates. "Many of us have skin types which are not adjusted to the amount of sunlight we are getting here," Bendick says. "It's not without reason that Cambodians who are born here usually have darker skin.

Photo by: MARK ROY Relaxing on a sun lounge in Sihanoukville is a pleasant way to wile away the hours, but the effects of the sun on unprotected skin include wrinkles, age spots, loss of elasticity and cancers.

The science

"The darker the skin is the more protected it is against the harmful effects of sunlight. The whiter it is, the more it is prone to damage." Fair-skinned Caucasians are prime targets for sun damage, while the skin cancer rate among those with darker skin is significantly lower.

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Health & Beauty Supplement

29 May, 2009

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. Prevention, however, is key. "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.

Follow these easy steps There is no need to go to extreme measures to avoid direct sunlight. Small measures and a bit of forethought is all it takes to keep on the safe side of pink skin. Bendick highlights the following:



Avoid the sun, especially during the most intense hours of 10am-2pm

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Don't expose yourself unnecessarily - seek shade

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Cover up with clothes and hats

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Wear sunscreen every day, whether it is cloudy or sunny

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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.

We asked some westerners 'Do you take precautions against the sun?'

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Health & Beauty Supplement

Laura Mitchell Almost 1 year in Cambodia “I think I’ve used sunscreen maybe twice in the last month. My excuse is my olive complexion. But I know I should because I worry about aging. When I first came to Cambodia, I did use sunscreen, but you sweat so much it’s useless. I do, however, seek shade when I’m out and I don’t go sun tanning.”

29 May, 2009

Bruno Maltoni 5 years in Cambodia “No, I don’t. I don’t use sunscreen – I’m Italian so we’re used to the sun. I don’t go tanning though. I don’t worry about skin cancer or any other harmful effects of the sun.”

Jean-Luc Marliere 2 weeks in Cambodia “I was born in Rwanda and lived there for 8 years and got too much sun then, so I have to be careful now. Usually, I use sunscreen on my face, arms and legs when I’m in a hot climate. I also seek shade and wear a hat when I work in the sun. I go to the dermatologist for checkups regularly.”

Cambodian holidaymakers stay abreast of trends in makeovers Written by Zoe Holman

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

W

orld-CLASS health care is not usually one of

Cambodia's international selling points, but in recent years, a number of medical centres in Phnom Penh have seen an influx of affluent patients from around the country and globe. However, rather than life-threatening illnesses, it is hairlines, waistlines and panty-lines that foreigners, expats and middle-class Khmers are so eager to ameliorate. Dr Reid Sheftall, a registered general and plastic surgeon from the American Medical Centre (AMC), has been at the receiving end of a cosmetic surgery boom that has seen unprecedented numbers demanding his services. "Between 2008 and 2009 I think business has increased about 10 times," said the American professional, who began practising as a general and cosmetic surgeon in Phnom Penh nine years ago after extended periods volunteering and working in the region. This 26-year-old Khmer women recently had her breasts augmented at the hands of Dr Reid Sheftall. PHOTO SUPPLIED

"I would go home for a few months and come back again and there would be 20 people on my waiting list, so I decided just to move over here," he said.

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."

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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. However, Sheftall explains, "there are no Western surgeons practising in Thailand, and people have come to regard American medical treatment as the elite". Sheftall estimates that around 75 percent of his patients are middleclass Khmers, most of them women seeking breast augmentation, tummy-tucks or rhinoplasty. "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."

Dr Reid Sheftall in his surgery. IMAGE SUPPLIED

However, it is not only among women that the trend is catching on, and Sheftall suggests that his male clientele base has grown to 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

Malaria disaster looming as drug resistance develops in northwest Written by CHRISTOPHER SHAY

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

F

AKE drugs, improper treatments and mobile populations along

the Thai-Cambodian border threaten to unleash a rogue strain of malaria that can resist even the most powerful medicines. "When the parasite is fully resistant, it will be a disaster," said Dr Duong Socheat, the director of the National Centre for Malaria (NCM). 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. "We're doing things as fast as possible," said Dr Najibullah Habib, the World Health Organisation's (WHO) Malaria Containment Project Manager. "This is a unique and unprecedented project, because we're going for 100 percent elimination." Artemisinin, a drug first isolated from Chinese wormwood in 1965 but only recently adopted internationally, is the front line defence against malaria. In Cambodia, it is the only viable drug against the most lethal malaria strain, Plasmodium falciparum. But in recent years along the Thai-Cambodian border, artemisinin is taking longer to clear the parasite, signaling an increased resistance. According to an article published in the Malaria Journal in February by a team of international scientists, the only way to contain the artemisinin-resistant malaria is to eliminate it completely from western Cambodia. If there is no intervention, the researchers say, "by 2030, ... the prevalence of malaria will have doubled compared to 2008 and resistance to the artemisinins will be approaching 100 percent". But the resistant strain does not just threaten people along the ThaiCambodian border. In the past, drug resistant strains have spread across the world.

Photo by: Sovann Pilong A young girl is taught how to apply mosquito repellent. In the high risk northwest, mosquito nets are the repellant of choice.

Everyone agrees that if it were to spread to Africa it would be a disaster. "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.

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The NCM has divided the area into two zones - one zone that includes much of Pailin province and has been designated a highrisk 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.

There's something in the water – or is there? Written by Zoe Holman and Mom Kunthear

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?

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Health & Beauty Supplement

29 May, 2009

I

t seems the slogan "think before you drink"might provide

sage counsel to many of Phnom Penh's inhabitants. But while vigilant residents and tourists alike imbibe gallons of bottled water each day, demurring from what they perceive to be an ‘unclean' local supply, data from authorities suggests that this advice might be more aptly applied at the local bar than at the kitchen sink. 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? Consumers associate bottled water with healthy living. But bottled water is not guaranteed to be any healthier than tap water. BLOOMBERG

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."

The authority from the Authority By contrast, Ek Sonn Chan, director of Phnom Penh Water Supply Authority (PPWSA), is brimming with confidence. "All citizens in the capital can drink the water straight from the tap - without even boiling it," he says. Ek Sonn Chan is so confident in the capital's tap water that in 2007 he said he would pay compensation to anyone who got a stomach ache after drinking it. But then some degree of faith would be warranted, given he's risked his life for it. After joining the war-torn PPWSA in 1993, Ek Sonn Chan implemented a dramatic overhaul of the organisation, rectifying leaks, illegal pipe connections and contamination, and increasing the utility's distribution network from 40 to 80 percent of the city. Photo by: TRACEY SHELTON With small bottles of water costing up to $3 in some nightclubs, drinking tap water is an option for those wanting to rehydrate after a long night of dancing.

Ek Sonn Chan's 12-year innovation made him the object of assassination rumours, but it also saw him awarded the Asian Development Bank's 2004 Water Prize to become a ‘water champion'.

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What our city folk think about whether to drink

Jolynna Sinanan, 26, Australia 8 months in Phnom Penh “I definitely don’t drink the tap water in Phnom Penh. I don’t trust it – I mean, have you seen the river? I could get any number of things. But I do brush my teeth with it, because I figure I will consume far less of the stuff than by drinking litres of it directly from the tap.”

Warren Jameson, 40, United Kingdom 2 months in Phnom Penh "No, I don’t drink it unless it’s boiled, like in tea, or filtered. We have a filter tank at home so it’s easy just to use that. I don’t think the water here is treated correctly and the source certainly does not seem particularly clean. I do brush my teeth with it though and I’ve never had any problems with that.”

Hin Dan, 25, Kampong Speu province 5 years in Phnom Penh “I think the tap water is not so clean, but I use it for everyday things like drinking and cooking. It’s not good for our health because sometimes it smells bad and it’s murky and even if I boil it I can’t kill 100 percent of the bacteria. But it is better than water in rural areas. When it smells bad I use tea to reduce that smell. I’m afraid that using the tap water will have long-term effects on our health, but I have no other choice. I want to use pure drinking water, but can’t afford it.”

Duy Sreyroat, 24, Takeo province 5 years in Phnom Penh "At home I used to use water from the well and rainwater, so it’s a bit strange for me to have to use tap water for the first time in Phnom Penh. It’s easier than before, but I don’t think the water is good to drink because it comes from the river and is just cleaned with a machine. It has a lot of diseases that we can’t see even though it looks clear. I use tap water for cooking and cleaning clothes but boil it before I drink it.”

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Ahti Westphal, 29, United States 5 months in Phnom Penh “I don’t knowingly drink tap water. I drink water that is served at most establishments with a certain amount of faith that it won’t kill me. I haven’t yet been so bold as to draw a nice tall glass from the kitchen faucet and drink it down. I’m pretty sure if I did, it would be OK though. I figure that if there is bacteria or toxins in it, you’re going to be exposed to them anyway – through ice, eating out, washing your hands, et cetera.”

29 May, 2009

Thong Yort, 25, Prey Veng province 4 years in Phnom Penh "I think the tap water is cleaned up for us a bit, and is okay to use, but its smell is not so good. It seems like they've put chemicals in it. I don't think we can drink it directly from the tap, and before I drink it I store it in an ceramic filtration barrel for a day or two. I think it might have an impact on my health one day, but I don't know how much and how long it will take to appear."

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."

Meanwhile, back at the lab... According to Laboratory Manager at NGO Resource Development International Cambodia (RDIC), Andrew Shantz, water chlorination is a matter of fine lines. "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,

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antibacterial filters is available on their website at www.rdic.org.

The final analysis A random sample of Phnom Penh tap water was taken by the Post from a private residence in the city's Boeung Keng Kang 1 (BKK1) district. 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.

So what's the go with my H20? So where do these conflicting messages leave your average, thirsty Phnom Penh inhabitant arriving home after a big night, illequipped to rehydrate with a few litres of Evian? 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.

The facts: Phnom Penh’s water supply is put to the test

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:

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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.

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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

Staying under cover while living in a tropical paradise Written by David Carter

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

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International SOS's healthy living tips Have insurance but be prepared to pay and claim back, which can take up to six months. Set some money aside for health needs, keep receipts, etc. Have evacuation insurance that works in Cambodia and carry your card with emergency numbers at all times. Know how to activate your insurance in case of emergency. Choose a doctor and clinic before you need it! Go and visit, check out the facilities, meet the staff and check credentials, check operation times. Have both your clinic phone number and numbers you can call to get transport 24 hours a day at short notice in your phone. If you take regular medicines bring enough for 6 months to one year until you can establish a local source. If you have a chronic condition, go to see a doctor soon after you arrive with your medical records and medications and let them become familiar with you. Take measures to prevent accidents and illness. Seek medical help early if you are sick because organising an evacuation takes time (six to 24 hours).

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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 level of services are also limited if someone requires specialist or critical care. So when emergencies arise a typical response is to leave the country and go somwhere with more options, such as Bangkok or Singapore. 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?

Pick and choose In many cases a sponsoring employer will provide Medical and Evacuation Insurance to employees as part of their expatriate package. Where this is not the case, the employee must take out cover; and where the person is self employed, the decision is 100 percent up to the individual. 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:

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Am I healthy and not prone to sickness?

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What lifestyle stage am I at, for example single, married with children, or retired with no dependents

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How financially secure am I and what can I afford to pay for the insurance each year

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In an emergency, what do I want to happen and what are my plans?

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 [email protected]

Teething problems still afflict dental care development Written by Lim Seang Heng and Vandeth Dararoath

High costs relative to income put many off treatment for toothache, while poor dental education makes decay a serious problem.

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EARLY everyone experiences toothache at one time or another.

But dental problems occur more frequently in Cambodia, where many people live below the poverty line and education about oral hygiene is rare. Meas Raksmey, a 23-year-old student at the Royal University of Phnom Penh, suffers from toothache but says he tries to ignore the pain, hoping it will soon pass. But often it drags on. "If a toothache hurts like hell, I can't sleep or eat," he said. "And a week when my teeth are hurting seems to last a month. My face swells up like a balloon. I've had to skip classes because it grew too painful." 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. However, these kinds of problems would not be so serious, if only we started practicing preventative measures from a young age, Chum Mony said.

Brush your teeth. BLOOMBERG

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.

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What to do in your spa time Written by Zoe Holman

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

A

fter even the briefest ride on a moto in peak-

hour Phnom Penh traffic, or dash through your local fresh produce market, it's not hard to crave a few moments' reprieve from the filth and foul temper of urban conundrum. For residents of the capital, that reprieve lies mere moments away - in one of the city's day spas. According to the "Cambodia Spa Benchmark Report 2007-2010", produced almost a year ago by global industry surveyor Intelligent Spas, the country boasted 35 spas, 34 percent of them independent day spas and 66 percent destination spas offering accommodation. The study highlighted a booming national industry which in 2007 generated about $6 million in revenues, through around 200,000 customers, serviced by 400 staff.

Photo by: TRACEY SHELTON A patron enjoys one of Aziadee’s ever-popular back and shoulder massages.

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.

Amrita Spa. Raffles Hotel Le Royal, 92 Rukhak Vithei Daun Penh, 063 963 888 Located in the luxury hotel’s quiet grounds, the 5-room facility is the capital’s oldest and most expensive. It includes a steamroom, sauna, and Jacuzzi for up to four people. The English-speaking staff offer a range of massage, facial and body-scrub treatments, the most popular are the Signature and Invigoration Packages, which include access to the pool.

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.”

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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".

East meets West While elements of the modern spa have been practised in Asia for centuries in traditional therapies and natural springs, the term originated in Roman Europe in reference to the Belgian town, Spa, and came to mean "healing through water". 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.

Your guide to women’s health in Cambodia Written by Eleanor Ainge Roy

Cambodia’s reputation for a hardworking, intense lifestyle means women have to take particular care with their health

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octor Laura Watson is a general health

practitioner with a postgraduate degree in obstetrics and gynaecology. She is the resident women's health specialist at Phnom Penh's International SOS medical clinic, and what follows is some basic health advice for women living in Cambodia.

Family planning and contraception Condoms and the pill are the most common methods of contraception preferred by both expatriate and Cambodian clients at International SOS, and use of the ubiqtuous OK pill and condom, which is available at most pharmacies, is widespread. However more long-term methods such as IUDs, injectables and sterilisation are also available in Cambodia.

Photo by: RICK VALENZUELA A woman restocks a display of promotional condoms during last year’s Water Festival in Phnom Penh.

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. Dr Laura Watson. PHOTO SUPPLIED

"I see a lot of women having fertility problems, and I think it's very difficult for 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.

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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.

Amateur massage no quick fix Written by Nora Lindstrom

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

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OING for a massage is an affordable and common

pastime in Phnom Penh, particularly for expats. A general complaint, however, is that most masseurs simply go through the same set of moves every time, instead of focusing on those areas that need extra attention. Given the unregulated market and a general lack of professional training, can unprofessional massages do more harm than good? "Can it damage you? Yes and no," said Jean-Claude Dhuez, a French-trained physiotherapist who runs his own private clinic in Phnom Penh. "If you don't have any problems then, most of the time, no." According to Dhuez, most body and foot massages are safe and beneficial provided the client doesn't have any significant problems or injuries from before. He cites positive effects on the skin, the muscles, blood circulation and the mind, as well as general relaxation as benefits from almost any massage.

Photo by: Sovann Philong There is no established tradition behind “traditional” Khmer massage, a physiotherapist says.

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.

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"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.

Not all bad So why do so many of us keep going back to the same average service? Evidently, price is a factor; massages are more than affordable for most of us. Both Dhuez and Marriott also agree that they are likely to be relaxing; indeed, many heavy users keenly look forward to that hour or two of peace and quiet. 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-dollarmassage-parlour around the corner might just do the trick.

Pharmalink eyes swelling Cambodian health outlay Written by Bennett Murray

Pharmacy is concentrating on quality of care to capture a slice of the rapidly expanding health care sector in Cambodia

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harmalink, one of Cambodia's newest chains of pharmacies,

has opened three locations in Phnom Penh since its inception last year and plans to open 10 by the end of 2010. The chain was started by Phnom Penh-based investment consultants DeVenco. "Asian people are really concerned about their image, their health, the small products that you can use, especially women," explained DeVenco Vice President Christophe Forsinetti. "And that attitude is emerging in Cambodia, with the middle class that can now afford to buy more products." Forsinetti defines families who earn between $300 and $1,000 a month as middle class. "You have more and more of those people in Phnom Penh," he said. "They are the people starting to consume. They are the ones buying cars, motorcycles, or all the news services that you see in Phnom Penh."

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 have responsibilities," he said.

Photo by: Sovann Philong 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."

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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.