Chronic Diseases Matter

A Proposal for the U.S. to Address Chronic Disease in Developing Countries

I locked eyes with a Cambodian girl sitting outside the temple of Angkor Wat and offered her a handful of jolly ranchers from my backpack. She took them, albeit hesitantly. “Don’t feed the children,” said my friend Rob, referencing the Visitor Code of Conduct on the back of his temple ticket. “It encourages kids to beg instead of attend school, and if they learn to trust strangers like you, they are more likely to be pulled into human trafficking.”

Ticket to Angkor Wat advises against giving candy to children
Ticket to Angkor Wat advises against giving candy to children

The next day we travelled south to Phnom Penh and watched workers erect a portrait of Chinese President Xi Jinping alongside the portrait of Cambodian King Norodom Sihamoni in front of the Royal Palace. Xi was scheduled to visit Phnom Penh the following week (13-15 October) to sign agreements forgiving Cambodia’s massive debt and gifting the country 100 million yuan. Rob sighed, “Cambodia accepts China’s money like the girl took your jolly ranchers.”

Chinese President Xi Jinping alongside Cambodian King Norodom Sihamoni in Phnom Penh
Chinese President Xi Jinping alongside Cambodian King Norodom Sihamoni in Phnom Penh


A Chinese idiom 禮尚往來 translates to “courtesy demands reciprocity.” Xi said in 2015 that wealthy nations should “step up their support for developing countries with no political strings attached,” but China’s aid packages are tightly bound.

This summer – just months before Xi arrived in Phnom Penh with the aforementioned red packet – Cambodia supported China by blocking a strongly worded ASEAN statement on the South China Sea . It is remarkable how close the two have grown since Cambodian Prime Minister Hun Sen called China the “root of all that is evil in Cambodia.” Alas, China appears to be exchanging blank checks for political support with countries throughout Southeast Asia, from Cambodia, to Laos, the Philippines, and Thailand.

Some argue that while China’s cold hard cash is tied to political favors, China’s overseas infrastructure projects are designed to strengthen developing nations. But even though these projects are blanketed under the long-term One Belt One Road initiative, individually they are just Band-Aids. China does not promise to fund ongoing maintenance costs, which can be more expensive than initial construction, and the structures will be useless after they fall apart, as was the case with the 87 million yuan Aquatic Centre that China built in Samoa. Like the candy that tourists give children in Siem Reap, China’s infrastructure projects make developing countries more dependent on handouts and ultimately weaker.


It is in the interest of the United States for diplomatically and strategically important countries like Cambodia to be too strong for big economies like China to push around.

The strength of a nation rests on several pillars, such as education, security, and health (please note that democracy is not one of them). Alarmingly, the pillar of health in many countries is missing key supports. Developing countries receive assistance fighting infectious diseases like HIV/AIDS, tuberculosis, and malaria, but non-communicable diseases are often neglected. Infectious diseases that are only a plane ride away from international donors hog the spotlight, and meanwhile non-communicable, chronic diseases like cardiovascular disease, cancer, diabetes, and asthma claim two-thirds of deaths worldwide each year. The global economic burden of chronic disease amounts to hundreds of billions of dollars each year, including the direct medical costs associated with chronic illnesses, and the cost in terms of the depleted quality and quantity of labor units.


The U.S. should fully support public health in developing countries and address not only infectious diseases, but also chronic diseases.

Sun Tzu in The Art of War wrote that “the supreme art of war is to subdue the enemy without fighting.” Likewise, the U.S. should focus on preventive, not reactive, medicine to address chronic disease in diplomatically or strategically important countries like Cambodia. The old adage, “an ounce of prevention is worth a pound of cure,” applies when dealing with chronic illness, as preventive medicine is both cheaper and more effective than reactionary care. The U.S. should focus on motivating positive changes to diet and lifestyle; screening for cancer; and testing for blood glucose, blood pressure, and cholesterol (among other preventive strategies), instead of nursing mature chronic illnesses.

Second, efforts to prevent chronic disease must be tailored to each country, as each nation has unique problems, social perceptions of disease, and control methods. An effective plan would be less like the Washington Consensus with a uniform blanket solution and more akin to the Beijing Consensus with elements customized to local conditions. For example, the best platform for a prevention program in the U.S. might be public schools, but the best vehicle for a similar program in Africa might be community-level religious organizations that hold more clout. Lung cancer might need the most attention in countries where smoking is still on the rise, but Cambodia might require special assistance with type 2 diabetes. Recent studies suggest the increasing incidence of diabetes in Cambodia may be attributed to the widespread starvation under the Khmer Rouge in the 70s. And the issue will not disappear with time – genetic changes caused by famine are passed from generation to generation, effecting the survivors of the genocide as well as their offspring.

Blood still stains the floors of this Khmer Rouge torture facility in Phnom Penh. Only a recent memory, the genocide that vic
Blood still stains the floors of this Khmer Rouge torture facility in Phnom Penh. Only a recent memory, the genocide that victimized millions still psychologically and physically effects Cambodians.


Money – often the biggest obstacle to U.S. government programs – is not a significant limiting factor to this proposal. A full range of chronic disease prevention methods are “very cheap on any scale,” according to the World Health Organization.

The biggest obstacle is time. Whereas China can sign deals in a matter of weeks, it would take the U.S. months and years to develop and implement a strategy to prevent chronic disease in developing countries. Budgetary regulations, changes in presidential administration, and the focus of elections on contemporary issues make it difficult for the U.S. to focus on long-term efforts like the one proposed. In the past, these constraints have created a default policy of crises reaction instead of forward-looking crises prevention.

The already staggering death toll of chronic disease around the world is projected to increase by 17% over the next decade. Will the U.S. continue to be limited by traditional policy constraints? As the Chinese proverb goes, “The best time to plant a tree was 20 years ago. The second best time is now.”


The views expressed here are my own and do not reflect the official position of the Department of Defense.

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