Health and Development: Seeking the Best of Both Worlds
Anecdotal accounts of the health of Pacific Islanders at the time of early contact with Europeans tell of their physical strength and healthy appearance, their "strong white teeth" and "smooth skins." Remember, however, that these observations refer to adult survivors; health conditions were not ideal, and young children were probably frequently the victims of malaria or other diseases. In some areas natural disasters caused temporary food shortages that affected the entire community, children and adults alike.
Disease introduced by European contact transformed what was a balanced, if somewhat precarious, existence into a situation of dramatic population decline. A single measles epidemic in 1866 killed thousands in Vanuatu, and one in 1875 is estimated to have reduced the population of Fiji by one-third. During the twentieth century, public health measures served to reverse population decline, and high fertility leading to rapid population growth now brings its own threat to the region. But today the legacy of morbidity and mortality from introduced diseases remains.
Early traders, whalers, and missionaries in the Pacific brought with them other, apparently more benign, elements of their civilizations: ship's biscuits, flour, salt and sugar, corned beef, and alcohol. What was once just a trickle of these commodities has become a flood since World War II. The decades since the war have been characterized by sweeping social change in virtually every aspect of life. And, once again, new diseases have begun to take hold - this time the diseases of modernization.
Today in Melanesia the wide range of disease patterns, their underlying causes, and the attempts to solve the region's health problems make a fascinating case study of the health challenges of both the "underdeveloped" and "developed" worlds in a single geographic region.
Diseases of Poverty, Diseases of Affluence
"Diseases of poverty" are those associated with adverse environmental and sanitary conditions, undernutrition, high fertility, and lack of basic health education and services. The high mortality rates in some parts of Melanesia are indicative of such conditions; in Papua New Guinea, for example, 60 to 70 out of every 1,000 newborns die before reaching their first birthdays, and maternal mortality is among the highest in the world.
Infectious and parasitic diseases are a particular risk for infants and young children, and include those brought by the first Europeans as well as others, like malaria, which existed prior to contact. In Vanuatu and Solomon Islands, at least one-fifth of deaths are caused by these diseases, many of them immunizable or amenable to simple interventions. Malaria, now including the more virulent strain of cerebral malaria, is responsible for a high proportion of illness and death in large parts of Melanesia. Mosquito-borne dengue fever is also a health threat, and is endemic in Fiji and New Caledonia where malaria is not a problem. As is common in Third World countries, acute respiratory infections (ARI), including pneumonia, are a major cause of death at all ages, and the main cause of child deaths: in one Papua New Guinea study ARI accounted for one-third of deaths to children under five. Undernutrition is a major contributing factor in deaths from ARI and other infectious diseases. Tuberculosis is widespread throughout Melanesia, and diarrheal disease is a threat where sanitation and nutrition are poor. Hepatitis B is endemic in some areas, and leprosy is still found. High levels of anemia have been recorded; contributing factors to anemia include malaria, parasite infection, poor nutrition, and frequent pregnancy.
To the continuing toll taken by these diseases are now added the so-called "diseases of affluence." The underlying causes of this constellation of disorders are well known: poor dietary balance, lack of physical exercise, tobacco use, abuse of alcohol and other drugs, and stress. Poor dietary balance is perhaps the most striking of these factors in the Pacific, where there is an ongoing transition from a high-fiber, low-animal-fat diet based on root crops, fresh fish, green leaves, and coconut to one based on white flour or rice, tinned meat and fish, and large quantities of sugar and salt. In Fiji the proportion of total energy derived from imported food has been steadily increasing; in 1977 it was already 43 percent nationwide, and by 1981 it had risen to 63 percent.
One of the most dramatic and well-documented changes in disease pattern has been the increase in diabetes, primarily in Polynesia and Micronesia, but also in Fiji, where 20 percent of hospital beds are occupied by people suffering from diabetes-related illness. Rates of diabetes are particularly high among the Indo-Fijian population. Although it is thought that heredity factors play a part, changes in diet, reductions in physical activity, and rising stress levels have allowed the disorder to increase manifold in recent decades. Cardiovascular disease - including high blood pressure and heart disease - accounts for more than one-third of deaths in Fiji and is the second-highest cause of death in New Caledonia. Although cancer increases are most dramatic in Fiji and New Caledonia, there is evidence of increasing rates in Vanuatu (where nearly 40 percent are cancers of the reproductive tract) and Solomon Islands, where mouth and liver cancers are most common, perhaps related to betel nut chewing and the prevalence of hepatitis B. Cancer has probably always been part of the Pacific disease pattern, but with modernization additional causal agents are being introduced. Another health problem prevalent prior to development, anemia, may have increased with the shift to modern diets containing lower iron and vitamin content. Dental caries have risen dramatically, paralleling the rapid rise in sucrose consumption. Concern has been expressed about the growing practice of infant bottle feeding, which can lead to poor nutrition, gastroenteritis, and lowered resistance to infection.
Chronic alcoholism is significant in New Caledonia; elsewhere in Melanesia, the health effects of alcohol are related to the accidents and violence associated with drinking, with indirect effects through its impact on the family economy. The full effects of tobacco-related illness will not become apparent for some time due to the lag between the onset of heavy use and appearance of lung and cardiovascular disorders; however, massive cigarette advertising campaigns are already spreading through the region, and tobacco is grown commercially in Papua New Guinea and Fiji. A recent survey reported that 88 percent of rural Melanesian Fijian men were smokers (Tuomilehto et al. 1986). The rate of sexually-transmitted diseases is high and on the increase, related to increasing mobility of youth, circular migration, prostitution, and tourism. Such a pattern is conducive to the spread of AIDS; cases of both HIV-positive individuals and those with full-blown AIDS symptoms have already been documented. Although much has been written about violence in warfare during pre-contact times, violence is also a marked feature of contemporary Melanesian society: a national survey by the Law Reform Commission of Papua New Guinea found that two-thirds of all married women, both rural and urban, reported they were physically assaulted by their husbands several times a year (APWRCN 1989:167).
Health Services: Access, Effectiveness... and Expropriation
Duality in disease patterns is accompanied by an imbalance in health services. Some Melanesian communities suffer from scarce, poor-quality services; in Papua New Guinea, for example, one-third of all children are not within even an hour's walk of a maternal-child health clinic. Immunization coverage in many areas is low by international standards, and family planning services are very limited except in Fiji. Although there are some growth-monitoring programs of infants, health workers are often trained more in the "ritual" of weighing infants and less in the crucial component of nutrition and other forms of health education. This is a symptom of a wider preoccupation with providing curative rather than preventive services. It has been argued (Thomas (1989) that in contrast to Polynesia, where village women's groups formed the original core of broad-based health programs, Melanesian systems tended to depend on the knowledge of male medical orderlies with a strong curative bias.
The public health system in contemporary Melanesia suffers from shortages of trained personnel and operating funds. But more than that, despite supportive rhetoric about grassroots public health care, the largest share of available government funds is allocated to urban-based hospital and curative services. In the case of Solomon Islands and Vanuatu, half the health budget goes to the hospital sector; in Fiji the figure is 70 percent.
This "overmedicalization" of the health system parallels what has happened in the West: the trend toward expropriation of health care by specialists, and declining community and individual responsibility for health. In the Pacific this has meant the loss of some valuable traditional forms of prevention and cure; for example, early colonial health workers quickly eradicated the custom of mothers chewing food before giving it to their infants, yet premasticated fresh foods, given immediately to the infant, are in fact preferable to some of the inappropriate weaning foods that today are leading to infant malnutrition.
More fundamental than changed specific health practices, however, is the effect of medicalization in eroding the principle of self-sufficiency in both health and wellness, from childbirth to care of the aged. Where once women had strong support groups to share knowledge of infant feeding, they now increasingly turn to the medical establishment for advice. Such advice has not always been beneficial; sometimes, for example, it has led to the substitution of infant formula for breastfeeding. The increased dependence on imported goods and technologies, both regionally and nationally, is thus mirrored in increasing health dependence at the community and individual levels.
The Challenge: Building Appropriate Programs
The primary health care approach offers the potential of building on many of the strengths in Melanesian society to help solve the health problems of both the "underdeveloped" and "developed" worlds. The essential components of this approach are a focus on prevention, community participation, and integration of health with broader social and economic policies and programs.
Most people associate primary health care with Third World programs such as immunization campaigns and child weighing, using minimally trained village-level workers. But the basic approach is just as applicable to health promotion programs aimed at combating health problems such as diabetes and heart disease. Industrialized countries, concerned by the escalating costs of high-technology treatment for diseases such as cancer and cardiovascular disorders, are trying to emphasize health promotion programs and other forms of prevention - in effect, primary health care in an overmedicalized setting, motivated by economic necessity. In Melanesia, where the diseases of modernization have not yet taken as firm a hold as in industrialized countries, the challenge is to actively launch programs that will help to avert the trend toward an increase not only in these health problems, but in the expensive curative approach to solving them.
Preventive primary health care programs can attack simultaneously diseases of underdevelopment and diseases of development. Prevention, whether it be child immunization to avoid infectious disease or changed diet and increased exercise to avoid diabetes, is based on belief in the value of the practice. Traditionally in Melanesia preventive rituals were taught as part of socialization; today the value of preventive practices needs to be taught through channels such as school, youth clubs, the media - all of which shape attitudes in contemporary society. Some steps have already been taken to develop culture-specific materials in nutrition and other areas of health; the South Pacific Commission and groups such as the Diabetes Resource Centre in Fiji have played important roles.
Efforts in specific disease control would also benefit by being incorporated into more broadly based preventive primary health care programs; for example, malaria will not be controlled by spraying alone, but also through education about personal protection and community efforts for effective vector control.
One of the basic tenets of primary health care, community involvement, is essential to the development of appropriate materials and approaches that can change health behaviors. But community participation means more than community consultation; women and men in the community, including traditional health practitioners, need to have a say in decision making from the earliest planning stages. The attempt to foster self-reliance in health will need to take different approaches, depending on local situations and priorities for change. Village women are often a key to successful programs.
Many of the answers to the region's health problems lie beyond the portfolios of health departments. The reasons for the striking dietary change in the Pacific, for example, relate not only to nutrition education but to food import policies; limited incentives for subsistence agriculture; inefficient mechanisms for local transport and marketing which can make indigenous food actually more expensive than imported food in cities; and media promotion, which gives imported foods high status. Innovative approaches are needed - say, improved methods of processing indigenous food to make it more competitive with imported "convenience" foods. Perhaps it is too late to recapture the ritual and symbolic value of some indigenous foods, but campaigns could stress other qualities of these foods to increase their popularity.
Physical Health, Cultural Health
Many components of so-called development in Melanesia - increased dependence on imported foods the expropriation of health care by specialists, and, more generally, the far-reaching transformation of lifestyle - have already make incalculable changes to both physical and cultural health in the region. As in all societies, the health of individuals and the health of their culture are closely interrelated. The most promising efforts to improve conditions lie in not only recognizing this relationship, but in building upon it to create health programs strongly grounded in local culture.
A common phrase repeated in the Pacific is that the region's people will take only what is good from other cultures, while retaining what is good in their own. Many good public health and curative measures have been adopted, but few would say that the balance in health is right. Is it too late to seek the best of both worlds?
APWRCN (Asian and Pacific Women's Resource Collection Network)
1980 Asian and Pacific Women's Resource and Action Series: Health. Kuala Lumpur: Asian and Pacific Development Centre.
1987 Health and Nutrition Problems and Policy Issues in the Pacific. In D. Throsby, ed. Human Resource Development in the South Pacific. Canberra: National Centre for Development Studies.
Coyne, T. with J. Badcock and R. Taylor, eds.
1984 The Effect of Urbanisation and Western Diet on the Health of Pacific Island Populations. Technical Paper No. 186. Noumea: South Pacific Commission.
1985 Health in the Pacific Islands. Honolulu: Pacific Islands Development Program, East-West Center.
1989 A Short History of Women's Involvement in Primary Health Care in the Pacific, 1923-1988. In J. Browett, ed. Women's Health: Women's Development. Adelaide: Flinders University Centre for Development Studies.
Tuomilehto, J., P. Zimmet, R. Taylor, P. Bennet, E. Wolf, and J. Kankaanpaa
1986 Smoking Rates in Pacific Islands. Bulletin of the World Health Organization 64(3):447-456.
THE NUTRITION FACTOR
Some years ago in Fiji, the first meal we had with a family in a small village deep in the interior of the main island consisted of the starchy root crop taro (dalo in Fijian), freshwater crayfish we helped to catch, greens from the house garden, papaya, and water from the local spring. Our farewell meal months later, provided by young Fijian friends living in Suva, consisted of beer, fried potatoes, tinned corned beef, sweet biscuits, and kava (yagona), the latter "spiked" with gin in what was then a local fad. The two meals that framed our stay in Fiji form the two ends of a continuum of dietary practice (from T. and V. Hull, fieldnotes).
In a comprehensive South Pacific Commission study (Coyne et al. 1984:18), dietary changes occurring in islands such as Papua New Guinea and Fiji were characterized by the following trends:
Calorie intake increases
Protein intake increases
Carbohydrate intake decreases
Fat intake increases
Sucrose intake increases
Salt intake increases
A primary health care program utilizing women from remote villages in the East Sepik Province was recently initiated in Papua New Guinea. The program, named Marasin Meri ("medicine woman" in Pidgin), was the product of collaboration between the Maprik Women's Association and the Maprik Hospital in response to villagers' need for better access to common medicine.
Women selected from the villages complete a one-week training course at the hospital. Upon completing the course, the women receive a supply of medicine to take back to their villages, where they are responsible for administering treatment, referring seriously ill patients to the hospital, and promoting general health and sanitary education. The women selected are strong traditional leaders in their community.
The overall goal of the Marasin Meri Program is to improve the health care of the villagers so that they can lead a more productive life. Objectives of the program are to make medicine for simple diseases readily available; reduce the incidence of scabies, ringworm, sores, and enlarged spleens in the villages by educating the people in treatment and prevention; and promote the building the village toilets and the use of safe, clean water in the villages.
From "Medicine Women Trained." South Pacific Commission Women's Newsletter 3(2-3) (April/July 1988), Noumea, South Pacific Commission. Reproduced in APWRCN 1989:31.
"THINGS GO BETTER WITH COCONUTS"
A Micronesian Model for Melanesia?
A nutrition survey on the island of Yap found that it was not unusual for the average Yapese adult to consume several soft drinks daily, and as much as a half pound of sugar mixed with coffee, tea, milk, or plain water.
A two-year nutrition education program focused on the increased use of indigenous foods, discouraging the use of expensive and nonessential imported foods. The program emphasized practical methods of changing nutrition practices and attitudes.
In one component of the project, promotion materials showed the relative nutritive value of soft drinks and coconut juice, and demonstrated that the sale of coconuts was advantageous to the local economy. A large grocery store was enlisted to sell drinking coconuts and display posters. The local newspaper carried a photo of coconuts with the caption, "It's the Real Thing," while a well-known soft drink was captioned, "It's the Artificial Thing."
As a result of the campaign, most stores began to keep cold drinking coconuts in their refrigerators, selling for about half the price of imported soft drinks. Coconuts are served in local restaurants, movie theaters, and as refreshments at the majority of official functions.
Tax receipt data on imports of soft drinks indicated a marked decline in the year following the campaign.
Summary of Nancy Rody (1978). "Things Go Better with Coconuts - Program Strategies in Micronesia." Journal of Nutrition Education 10(1):20-23.
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