Diabetes needs community ‘ownership’
A non-communicable disease (NCD) epidemic — with diabetes at its epicentre — is raging in urban centres throughout the Pacific, causing much more damage than debilitating health problems alone — though these, including cataracts, kidney failure and amputations, are bad enough.
The economic impact is significant and growing. In nine of 12 Pacific nations, reported the World Bank in a 2012 study on the economic costs of NCDs, these diseases account for 70 percent of deaths. In the Marshall Islands, for example, 90 percent of all hospital inpatient visits are related to NCDs, principally diabetes. Ministries of Health are today shelling out large dollar amounts to pay to treat patients suffering from NCDs. Then there is the harsh economic reality that thousands of adults are being hit with symptoms of diabetes and other NCDs in their 30s and 40s, preventing them from working. Just when people should be in a productive period in their lives, NCDs attack and the symptoms or side effects of the medications people take result in countless hours lost on the job — or worse. Finally, once people get into the end stage of diabetes, it becomes a huge burden — physically, mentally and financially — on their families who must care for increasingly disabled members of their family.
The statistics for Pacific islands are sobering. The Pacific region tops the world obesity and diabetes charts. For example, 75 percent of people in American Samoa, Nauru, and Tokelau are obese by World Health Organization standards. Other islands also show large percentages of their populations obese, a risk factor for diabetes: Kiribati (51 percent); Marshall Islands (45 percent) Islands; Pohnpei, Federated States of Micronesia (43 percent); Solomon Islands (33 percent); and Fiji (30 percent). Diabetes rates are shockingly high, ranging from 14 percent in the Solomon Islands to 47 percent in American Samoa. For perspective, diabetes affects three-to-six percent of Australians.
The Secretariat for the Pacific Community (SPC) put together a remarkable document with the bland title, ‘NCD Statistics for the Pacific Island Countries and Territories,’ that contains charts titled ‘Low Physical Activity,’ ‘Hypertension,’ ‘Obesity,’ and ‘Low Fruit and Vegetable Consumption.’ The information contained in the SPC report should scare national planners in any island nation. In the ‘High Risk of NCDs’ graph, only three countries — Papua New Guinea, Samoa and the Solomon Islands — are under 50 percent, no doubt at least in part because large numbers of their populations still live in villages where urban inactivity and a diet heavy in imported processed foods has not yet taken over. The majority of islands surveyed by the SPC show 60 to 80 percent of their populations at risk for NCDs.
The extent of the problem motivated the World Bank, in 2012, to issue a report on the economic impact of the growing NCD crisis. In reporting the ‘large health, financial and economic costs on countries,’ the World Bank made the point that financial burden on island nations is putting huge financial pressure on governments that already fund largely socialised health systems. ‘Risk factors in the Pacific are feeding a pipeline of potentially expensive-to-treat NCDs, but governments are already fiscally constrained in how much more they can provide to the health system,’ the World Bank report commented.
This report, like many on the issue, observed that ‘many of the NCDs are avoidable — or their health and financial costs can at least be postponed — through good primary and secondary prevention. This will require a more coherent approach to health system financing, and health system operations more generally.’
Which gets us to the point: How can Pacific islanders counteract the debilitating scourge of NCDs? To do so means changing behaviour, always a difficult undertaking. Health departments everywhere tend to engage in ‘health education’ that advises readers or listeners to eat a healthier diet and to get exercise. In most urban centres, however, there is little room for gardens to improve fresh food availability — or, as poverty worsens, neighbours steal garden produce as it ripens, a big disincentive to making the effort to plant and raise crops. Economic hardship is an obvious driver of diabetes, since an increasing number of urban dwellers can’t afford to buy the fruits and vegetables they are urged by health educators to eat.
But equally problematic is exercise. If you’re a student or in your early 20s, there are usually — depending on the island — organised volleyball, basketball, rugby or soccer leagues that offer good opportunities for fitness. For people in their 30s and older, what sports programs are organised on an ongoing basis? Not many, which mean individuals have to motivate themselves to walk or jog or find a gym where they can work out. The statistics tell us that few do. For one thing, if you want to walk or jog, in many urban centres in the region, you must be armed with rocks or sticks to ward off attacking dogs, and you have to beware of drunk drivers. This is not an environment conducive to encouraging people who are new to the exercise routine to get out and do something (as a person who has been a life-long jogger and is motivated for exercise, I know how hard it is to get out on the road to exercise in Majuro).
What I see is an obvious disconnect between government policy (combat NCDs through diet and exercise) and government action. In the Marshall Islands, for example, for the past several years a plan for a new hospital has been a priority, with a couple of million dollars invested in architectural designs for what could be a US$50-70 million facility. The last thing Majuro needs is an expensive facility that it will not have the money to maintain. Despite the declaration by government of a national health emergency for NCDs in late 2012, there have been no new sports facilities developed in Majuro by the national government. A question is, why not take some of the money that is designated for a new hospital and use it to create recreation areas with walking tracks and some sports courts such as basketball or tennis in high-population communities in the capital? This would be a first step to making it possible for people to follow the advice of the health promotion department. Indeed, in overcrowded urban atoll environments, the government will need to commit funding for landfill to create space for recreation facilities in high-population zones.
A community group on the overcrowded island of Ebeye has broken new ground in efforts to curb the level of NCDs, particularly diabetes. Known as the Kwajalein Diabetes Coalition, the group conducted a community survey to find out what people knew about preventing NCDs. They learned that people in their small island were concerned there was no safe and accessible area for exercising, that the high cost of imported fruits and vegetables prevented people from eating a healthy diet, about a negative stigma associated with having diabetes, such that some don’t want to acknowledge they have the disease, and had a general lack of understanding about the causes of the illness.
These are not eye-opening discoveries, but they gave the Coalition a starting point. They’ve engaged with the Taiwan Technical Mission to provide assistance in gardening techniques and seedlings for establishing a nursery that they hope will be one step to improving availability of nutritious foods.
What the Coalition is doing to address the exercise problem is innovative. They have rented a conference room at the main hotel on Ebeye, and turned it into an exercise room with a variety of exercise equipment that is open to the public. A longer-term plan to build a walking path is moving ahead through a partnership with the power and telephone utility companies. They have teamed up to all contribute to building a seawall, which will protect the utility companies’ property, and making a lighted walkway on top of it. The walkway is expected to be completed in 2014.
‘Our Diak Plan sets the framework for Kwajalein Diabetes Coalition to lead a community-wide effort that aims to systematically reduce the burden of diabetes on our island community,’ says Romeo Alfred, who heads the group. ‘Diak requires the involvement of everyone onboard a sailing canoe. Our community’s involvement in this evolving process gives hope that this whole effort will create a notable change in the quality of life for people suffering from diabetes and their families within the Kwajalein Atoll community.’
Without government and donor investment in recreation and sports infrastructure, few people in the 30-60 age group living in urban areas of the Pacific will get out to exercise. A great example of this is Palau, where the government spent around a million dollars to construct a six-lane, all-weather track field for the 1998 Micronesian Games. In the 16 years since, the facility has been used day and night by hundreds of runners and walkers in the main city of Koror.
Like the Kwajalein Diabetes Coalition collaborating with local utility companies to produce funding to create a walking track, we need to develop creative community partnerships, get governments to invest in recreation areas that encourage urban residents to exercise, and focus on the details needed to afford urbanites an improved quality of life. In the long-run, this will provide opportunities to reduce the financial burden on government health services to treat the symptoms of these modern diseases.
CAPTION: Changing diets and lifestyles as Pacific islanders migrate to urban
centres has caused an epidemic of non-communicable diseases, with
diabetes at its epicentre.
