A Legacy of Imperialism: Health Disparities in the Pacific

BY ERICA KOCHER

The Pacific Islands, sometimes known as Oceania, include the regions of Melanesia, Micronesia, and Polynesia. These three regions encompass tens of thousands of islands, each of which has a distinct culture. Although Oceania covers approximately 15% of the Earth’s surface area and is home to millions of Pacific Islanders, the unique issues and health concerns its population faces are rarely discussed.¹ As a result, the specific health concerns of Pacific

Islanders, including the rising burden of non-communicable diseases (NCDs) and continued prevalence of communicable diseases, remain largely ignored and unaddressed, both within the context of the Pacific and among migrant communities around the world. It is particularly important to understand the health disparities among Pacific Islanders because the issues that exist today are, at least in part, the result of imperialist action by the United States and other Western powers.

The Pacific Islands are known and discussed internationally today for two reasons: tourism and military battles and bases. The Pacific is often viewed as open and untouched—a beautiful, natural space for vacation and fantasy. Tourism on islands like Hawai’i began after their seizure and annexation by Western powers like the United States to counter Japanese power in the region at the end of the 19th century.² The annexation of Hawai’i began with the overthrow of the Hawaiian kingdom by white plantation owners backed by the U.S. military. This was the first in a process of events forcing Native Hawaiians out of their homes and traditional ways of life, replacing staple crops such as taro and sweet potatoes with sugar cane and constructing luxury resorts and military bases over sacred burial grounds.^3,4 In other parts of the Pacific, imperial military control has had even more destructive results, as nuclear weapons testing poisoned native peoples and their homes for generations in the Marshall Islands and French Polynesia.⁵ In spite of and perhaps because of this legacy of Western involvement, Pacific Islanders are largely unknown to much of the world. This obscurity is fueled by the perceived isolation of the islands, which are often excluded from world maps. In addition, the Asian American and Pacific Islander (AAPI) label remains widely used within the U.S., despite having since been replaced on the census with Native Hawaiian and Other Pacific Islander (NHOPI), which further obscures the distinct concerns of Pacific Islanders.⁶ Without data about these specific concerns and experiences, the health issues Pacific Islanders face cannot be widely understood or represented.

The Pacific Islands face the double burden of growing non-communicable diseases and continued communicable diseases. In general, the burden of disease, which is a measure of the causes of ill health in a population, is broken down into three broad categories: Group 1, which includes communicable, maternal, neonatal, and nutritional diseases; Group 2, which includes most other non-communicable diseases; and Group 3, accidents and injuries. In 2015, NCDs represented the largest share of the burden of disease in Oceana, accounting for 58.4% of disability-adjusted life years (DALYs) and 68.4% of total deaths.⁷ In contrast, “Group 1” conditions caused 30.7% of DALYs and injuries accounted for only 10.9%.⁷ Throughout the

Pacific, ischemic heart disease is the leading cause of deaths annually, followed by diabetes and cerebrovascular disease, all of which are NCDs.⁷ As a result of these conditions, 70-75% of deaths in the Pacific are considered premature, occurring before the age of 60.⁸ Even these statistics specific to the Pacific, however, obscure disparities and differences between the countries and territories. For example, in the Federated States of Micronesia, NCDs account for 73.9% of DALYs, but NCDs make up only 54.06% of DALYs in Papua New Guinea.⁷ Similarly, while, in the Northern Mariana Islands, injuries make up 13.75% of DALYs, in Samoa, they account for 9.74%.⁷ Though each island has its own unique balance of health concerns, the growing burden of NCDs is relevant throughout the Pacific and is often not discussed.

One of the foremost health concerns among Pacific Islanders is obesity and the associated NCDs. In American Samoa, 95% of the population is considered overweight or obese.⁹ Similarly, 57% of people in Tonga are obese, compared to 35.7% of Americans.^10,11 The high BMI and dietary risk factors associated with obesity are the top two leading causes of NCD-related death and disability in Oceania.⁷ Ischemic heart disease and diabetes, for which obesity is a risk factor, are among the top three causes of deaths in the Pacific. In the case of diabetes, prevalence among adults aged 20-79 ranges from 6.33% in Papua New Guinea to 37.06% in the Marshall Islands, compared to 9.3% among Americans.^12,13 Because diabetes is a major risk factor for renal failure, chronic kidney disease is the fourth leading cause of death in American Samoa, Micronesia, Fiji, and the Marshall Islands.⁷ Understanding these serious conditions and their causes is central to providing effective treatment to improve the health of Pacific Islanders.

The factors contributing to the rising burden of disease in the Pacific include genetics, the nutritional transition associated with urbanization, changing access to foods, and the continued importance of cultural traditions. A study published in 2016 found that approximately 25%

Samoans have a gene mutation that predisposes them to obesity, a potential genetic mechanism to explain the high prevalence of obesity and overweight in these populations.¹⁴ The introduction and rise of obesity as an epidemic in the Pacific, however, is also closely associated with Western contact and imperialism. Through the Westernization of many Pacific islands, traditional sustenance farming lifestyles were replaced with more sedentary ones that involved office work and a reliance on cars for transportation. This process shifted Pacific cultures from their traditional labor-intensive agricultural lifestyles towards increased consumption of processed foods and inactive leisure time, which contributed to the rise of obesity.¹⁵

The rise in consumption of processed foods was the result of increasing reliance on imported foods that arrived by cargo ship. A 2013 study found that in Guam, 59% of food products were produced in the United States, with only 6 out of 2105 products produced in Guam itself.¹⁶ Fiji and New Caledonia also imported the majority of their food products.¹⁶ Foods that can be transported by cargo ship are often processed, high in sodium, or packed in oil. These less nutritious foods, such as turkey tails and mutton flaps, have come to dominate local food culture as signs of status and are even considered delicacies in places like Samoa and Tonga. The Pacific Islands have become a dumping ground for these products that cannot be sold elsewhere due to restrictions on fatty foods in the West. The adoption of liberal trade policies by the Pacific Islands allows manufacturers in high income countries to offload their cheap, low quality, and otherwise unsellable cuts of meat on these low-income countries.¹⁷ These products often then take the place of traditional staple foods in ceremonial feasts and cuisine, further contributing to rising obesity.^16,17

While traditional practices like ceremonial community feasts may play a role in the NCD epidemic, the root causes of obesity were introduced with Western contact. It is not the traditional culture, but the way in which Westernization has interacted with these traditional values, that has led to a rise in NCDs. A study comparing the rural and urban regions of Western

Samoa found that the prevalence of NCDs was significantly lower in rural regions.¹⁸ In these regions, Samoans maintain a more traditional, active lifestyle, growing and consuming staple foods and working on plantations, while in urban Apia, people tend to work sedentary jobs and eat a diet more supplemented with the imported, processed foods.¹⁸ The study was published in 1981, making the statistics out of date today, but it reported a prevalence of diabetes three times higher in urban populations than in rural ones, suggesting that it was Western modernization, and not cultural values alone, that helped shape the rise of NCDs and obesity in the Pacific.¹⁸

In addition to the obesity-related NCDs facing Pacific Islanders, cancer resulting from nuclear testing is also a significant issue that must be addressed. As of 1980, the United Nations estimated that more than 200 nuclear bombs had been detonated in the Pacific by British, French, and American scientists and military personnel.⁵ The United States tested its first atomic bombs in the Marshall Islands, including many at Bikini Atoll, because they were largely isolated and had a small enough population to be easily relocated.⁵ Although Bikini Atoll was declared safe for inhabitants to return in 1968, the 23 nuclear tests conducted there had left the island poisoned with radiation and those who returned developed cancers and birth defects.⁵ A 2003 study in the Marshall Islands found a higher prevalence of thyroid cancer among both those exposed to the nuclear testing and those born after testing but who lived in affected area.¹⁹ Similar problems have been documented in French Polynesia, the site of French nuclear testing, as well as food poisoning resulting from the associated environmental destruction.²⁰ Cancers make up only 6.05% of DALYs in the Marshall Islands, compared to 15.34% in the United States. However, imperial powers who conducted the testing are still denying responsibility, thereby preventing access to resources necessary to fully diagnose and address the problem.⁷

While NCDs dominate the discussion of health in the Pacific Islands, Group 1 conditions remain important to address, especially in Pacific countries with lower GDP per capita. Although most discussion of nutrition in the Pacific focuses on obesity, iron deficiency anemia is the third largest Group 1 cause of DALYs for the region, demonstrating the dual burden of both under and over-nutrition.⁷ Infectious diseases are also a concern for the Pacific. Lower respiratory infections cause 8.27% of total DALYs in Papua New Guinea, and are the leading Group 1 cause of DALYs throughout Oceania.⁷ While malaria is a concern primarily for Papua New Guinea, the Solomon Islands, and Vanuatu, tuberculosis is most pressing in Kiribati, the Solomon

Islands, and Vanuatu and remains more prevalent than malaria in the rest of the Pacific.⁷ Finally, neonatal preterm birth and other birth complications represent 3.77% of total DALYs for the region.⁷ In the United States, these conditions represent 1.45% of total DALYs, which suggests that they are preventable with stronger health systems.⁷ As they undergo modernization, the

Pacific Islands continue to face this double burden of communicable and non-communicable disease. Despite the need for addressing the rising burden of NCDs, it is also important to recognize that communicable diseases are still a concern and that these issues occur in different combinations in each community throughout the Pacific, and in diaspora.

Understanding the health concerns facing Pacific Islanders is crucial to more adequately addressing them both in the Pacific and among immigrant communities. Migration to and from the United States, Australia, New Zealand, and throughout the Pacific is common.²¹ It is estimated that at least 16,000 Pacific Islanders leave home each year, often young migrants looking for better education or work and sending remittance back to their families.²² As of 2010, 1.2 million people in the United States self-identified as Native Hawaiian and Other Pacific Islander.²³ New Zealand has the second-largest population, at nearly 300,000 Pacific Islanders, not including the indigenous Maori population.²⁴ The health issues observed among populations in the Pacific are also found among these immigrant populations in diaspora. 33.13% of NHOPI report having hypertension, compared to 25.05% of white Americans, and 36.44% of NHOPI are obese, compared to 27.2% of white Americans.¹⁰ Similarly in New Zealand, 67% of adults and 30% of children who identify as Pacific Islanders are obese, compared to 32% of adults and 11% of children in the broader New Zealand population.^25,26 These statistics demonstrate the importance of understanding and addressing the health issues specific to Pacific Islander cultures and contexts, even outside the Islands themselves.

Although there are millions of Pacific Islanders living within and outside of Oceania, their health concerns are largely unknown and under-studied. Similar to the obscuring effect that the “AAPI” label has had in inappropriately grouping Pacific Islanders with dissimilar groups, the use of Native Hawaiians and Polynesians to represent the entire Pacific obscures the interests of people from Melanesia and Micronesia. While Pacific Islanders have many common interests and shared health concerns, they remain an amalgamation of thousands of unique peoples. To appropriately understand and address their unique concerns, increased awareness and study of the region is crucial. More data needs to be collected about the burden and causes of disease and disability within individual regions of the Pacific, instead of using only a few cultures, usually those of Polynesia, to represent the interests of all Pacific Islanders. Finally, it is crucial that these efforts involve Pacific Islanders in studying their own health issues, because they are best prepared to understand how best to intervene to the benefit of their own people.

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