Neang Keo was at work in her job as a cleaner at a casino in the Cambodian coastal town of Sihanoukville when she got an alarming phone call — her husband was vomiting blood.
Her husband, Ngoem Phea, was at their home province of Takeo more than 200 kilometres away and had been drinking rice wine with friends at one of their homes.
"I was so panicked and crying," Ms Neang said.
"I went home about two or three hours later, but he died before I arrived."
The rice wine had been contaminated with deadly methanol.
Mr Ngoem, 53, and two of his friends died, while another three were hospitalised.
Three months after Mr Ngoem's death, the mass methanol poisoning in Laos, which claimed the lives of Australian teenagers Bianca Jones and Holly Bowles along with four others, has put a spotlight on the issue of tainted alcohol in the region.
Hundreds of people die from methanol poisoning every year, with the vast majority of recorded incidents in Asia.
In some cases, methanol is added to drinking alcohol in the misguided belief that it is a cheap way to boost alcoholic content.
In others, poor distilling processes can produce alcohol tainted with methanol, although the amount is typically very small.
As little as two teaspoons can cause blindness, and 30 millilitres can be fatal.
Medecins San Frontieres (MSF, also known as Doctors Without Borders) reports that if not treated, fatality rates can be between 20 per cent to 40 per cent.
It's a global problem with a profound personal impact.
"I miss him so much," Ms Neang said, through tears.
"Especially when it rains, when I am sick. He would give me a massage, or would go get medicine for me. He was a very caring person.
"He didn't really drink often. He only drank occasionally with his relatives and friends while visiting home in Takeo."
The numbers behind a 'forgotten crisis'
Methanol poisoning has a devastating impact on local communities, although cases like Mr Ngoem's rarely make a ripple in the international press.
"There are many tourists in these regions, but the locals are much more often the ones suffering — however far less of these cases make it to the headlines," said Dr Knut Erik Hovda, an expert in global methanol outbreaks from Oslo University Hospital.
"This is why we call it a forgotten crisis, most commonly affecting the poorest of the poor; yet — as we have just seen — no one is spared."
The Methanol Poisoning Initiative — a joint venture between Dr Hovda's university and MSF — tracks global outbreaks based on local news reports.
According to its database, there have been 58 incidents of methanol poisoning worldwide in the past 12 months, affecting more than 1,200 people and resulting in more than 400 deaths.
But Dr Hovda said the true scale of the problem is unknown.
"We're afraid that we're only seeing the tip of the iceberg," he said.
According to the data, over the past five years, there have been almost 400 incidents, poisoning some 11,800 people and killing 4,500.
One of the most severe incidents was in Iran in early 2020, which was one of the worst-hit countries by COVID-19 at the time.
Many Iranians turned to bootleg alcohol in the false belief it could stave off the virus.
As a result, more than 500 people died from drinking the toxic methanol, more than 5,000 were poisoned and 90 suffered eye damage, including blindness.
There were two major outbreaks in India in June and October this year, where dozens were killed after drinking illegally brewed alcohol tainted with methanol — known locally as "hooch" .
Indonesia has the most methanol poisoning cases worldwide
According to the MSF database, Indonesia is the country with the most methanol poisonings each year.
Although much of the country’s Muslim majority do not drink alcohol, certain cultural groups in the archipelago use alcohol as a facet of their traditions.
In Indonesia, methanol poisoning is mostly caused by the widespread production of bootleg liquor called "arak" — a locally brewed concoction made from the fermented sap of coconut flower, rice and sugarcane.
Ady Wirawan is a public health and travel health expert from Udayana University who has conducted research on methanol poisoning as a danger for tourists in Bali.
He said not all local alcohol production processes are standardised, so some end up producing methanol instead of ethanol — which is safe alcohol for consumption.
"Weak regulation and minimal oversight of the production and distribution of illegal alcohol allow this practice to continue," he said.
"The high price of legal alcohol encourages consumers to look for cheaper alternatives, despite the risks."
Dr Wirawan added that many consumers were unaware that home-made liquor could contain the dangerous substance — but added that stigma was also an issue.
"In some areas, alcohol consumption is considered taboo, so victims are reluctant to seek medical help or report their cases," he said.
Dr Elvine Gunawan, a psychiatrist from Mental Hub Indonesia, has seen the psychological fallout of methanol poisonings.
One of her patients was the only survivor in a case of methanol poisoning that claimed the lives of four others.
"They feel guilty for not being able to save the friend who died right in front of their eyes," she said.
The patient, who is now blind as a result, was "shamed and abused by the community".
She said there was an attitude that the patient got what they deserved or should have died with their peers, and her patient has stopped seeking mental health care.
Stigma of alcohol consumption
Dr Gunawan said stigma remains a barrier in seeking treatment for methanol poisoning.
"Ideally we would have immediate treatment for observation but instead they cover it up because they're ashamed," she said.
Ironically, one of the early intervention treatments for methanol poisoning is to administer ethanol — safe drinking alcohol — according to Dr David Ranson, a professor of forensic medicine at Monash University.
He said methanol becomes a problem when the body metabolises it.
It breaks down into harmful chemicals — formaldehyde, used in embalming, as well as formic acid and formate, which "basically kills cells".
"It's a direct cell poison — it interferes with the energy production of the cells, and so the cells die."
He said because the body prioritises processing ethanol, introducing more ethanol in the system can help keep the methanol at bay and stop it being broken down before it's passed out of the body.
Other treatments include the antidote fomepizole, which is more expensive and unavailable in some parts of the world, and dialysis — a process in which a machine filters the blood.
Although a religious ruling from the Indonesian Ulema Council in 2018 said medical practitioners could use ethanol in life-or-death situations such as methanol poisoning, it often comes down to an individual doctor's beliefs.
"Since it's not for sinful use and instead to save lives, it is permissible. But again, it goes back to the doctor's ethical values," Dr Gunawan said.
The ABC has contacted the Indonesian Health Ministry for comment.
Families left reeling as poisonings persist
The hidden dangers of methanol remain an ongoing problem in countries like Cambodia, where home-brewed rice wine is a part of traditional gatherings like weddings, funerals and spiritual holidays.
After a spate of fatal cases in 2021, Cambodian authorities said they were taking steps to combat the problem, by arresting illegal brewers and shutting down dodgy distilleries, as well as temporary bans on the production and sale of herbal and rice wines in certain areas.
But for Ms Neang, mourning her husband, there has been little resolution.
Although police arrested the rice wine producers, she said she signed a letter to "let them stay out of prison".
The local deputy police chief Nget Phatt said the rice wine producers were detained for about 48 hours before the case was transferred to the authority of the courts, and he understood that the case had been dropped.
"I don't want anything. I just want them to help cover the cost of the funeral," she said.
"But so far, I haven't received a cent. I am struggling."
She said her 20-year-old son was now a security guard like his father, but Mr Ngoem had been the main breadwinner.
"He worked so hard to earn and save every cent so that we can build a nice house for the three of us," she said.
"We can hardly get by."
The ABC has contacted the Cambodian Health Ministry and the Commerce Ministry's Consumer Protection, Competition, and Fraud Repression Directorate-General for comment.
Dr Hovda said the Methanol Posioning Initiative was created to raise awareness about "the great imitator", as symptoms could be easily mistaken for inebriation or other conditions.
"We need simple diagnostics and effective treatment available on the ground: then almost all cases can be saved," he said.
"The recent incident has been a tragic incident for many families around the globe, reminding us how vulnerable we all are to even small amounts of toxic substances.
"But while this has caught the eyes of the international press, I wish I could say the same about the constantly ongoing silent killer of those who nobody sees."
