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The Shifting Burden of Illness

By Francis X. Hezel, S.J.

Health

Micronesia can have a variety of different meanings, often referring to the islands in the Western Pacific just north of the equator. In this presentation, however, we will be using the term to refer principally to the Caroline Islands (comprising what is now the Republic of Palau and the Federated States of Micronesia), and the Marshall Islands. All these islands have a history of political association with the US that dates back at least to the end of the Second World War. The influence of Western society on these islands extends much deeper into the past–to the mid-nineteenth century, at least, when American whaleships began making regular stopovers for rest and refreshment and when American missionaries first brought their Christian message.

The Era of the Epidemic

Just as the Guam and the Marianas underwent a period of disease and depopulation resulting largely from foreign ship traffic in the late 17th and early 18th centuries, so most of the remainder of Micronesia faced the same scourge a century or so later. As Western sailing ships reached the islands ever more frequently during the nineteenth century and contact between Micronesians and Westerners became more intensive, notable depopulation occurred owing to the diseases introduced from abroad. There are numerous examples of this. When the American whaleship Delta came to anchor off Pohnpei in 1854, it put ashore two of its crew members who had contracted smallpox during the voyage and buried another. Pohnpeians promptly stripped the diseased men of their clothes and, according to one version of the tale, dug up the body of the other. The result was a severe outbreak of the disease, which raged through the island for several months, despite the efforts of an American missionary and physician to control the epidemic. Eventually the disease claimed about 4,000 lives, or about 40 percent of the island's population.

The missionary letters from Pohnpei are punctuated with constant references to contagious disease throughout the last half of the century. Albert Sturges, one of the missionaries, refers to "consumption," or tuberculosis, as "one of the most common and fatal diseases." Missionary letters report outbreaks of one disease or another every few years: influenza was rampant in 1856, 1863, 1866, 1871,1874 and 1879; while measles outbreaks occurred in 1861 and 1894. As a result, Pohnpei's population at the end of the century was estimated at about 5,000, half of what it had been in 1840 before foreign disease had exacted such a heavy toll on the island.

Just about the same time, a terrible influenza epidemic broke out on the neighboring island of Kosrae killing 300 people. This, as it turned out, was just the beginning of Kosrae's health problems, since one epidemic followed another throughout the mid-1800s with devastating consequences. By the end of the century, Kosrae's population had dropped from 3,000 to a mere 300, so that the island suffered a 90 percent loss of population in just 40 years. This rapid depopulation on Kosrae paralleled the precipitous population decline in the Marianas two centuries earlier, when the number of Chamorros plummeted from 40,000 to 4,000 in an equally short period. Reports from this period chronicle in some detail the yearly outbreak of what came to be called the "disease of the ships," the epidemic of influenza or some other communicable disease that inevitably broke out after the arrival of the annual Spanish galleon.

Meanwhile, in the Marshalls similar disasters were beginning to occur. In 1859, the year in which the first resident foreign traders were landed in the Marshalls, an outbreak of influenza took so many lives that the Marshallese didn't know what to do with all the bodies. Missionary accounts tell of people wrapping the bodies in mats and affixing small sails to them before pushing them out to sea to be carried off by the wind. A measles epidemic struck two years later, just as the influenza was recurring, and in 1863 a virulent attack of typhoid fever broke out. Within four years, three epidemics had taken a couple hundred lives on only one or two islands of the Marshalls.

The physical deformities of some of the adults, especially on Pohnpei and Kosrae, the two islands that absorbed most of the whaleship traffic from 1840 to 1860, attracted the attention of foreign visitors. One Pohnpeian woman had lost her eyes and half her face, while another man had lost his nose–both victims of what was in those days called "the pox." Missionaries offered vivid descriptions of the disfigurement that they found nearly everywhere and which they attributed to the prostitution that was rampant on these islands during the heyday of foreign ship layovers.

Even if the symptoms ascribed to "the pox" were manifestations of yaws rather than syphilis, as early writers often supposed, there is clear evidence that sexually transmitted disease was having a considerable impact on the islands. An abrupt drop in births was noted in many places during those years. "There are next to no infants on the island," a missionary wrote of Kosrae in 1855. Pohnpei was little better off: in a letter of 1854, Sturges bemoaned the fact that there were only seven births in the last two years. In Palau infertility was not as rampant, but still it was cause for concern. One visitor to that island in 1875 wrote: "Not two in five women bear children, and two or three children are considered a large family."

Overall, the intermittent epidemics brought on by contact with foreign ships–mostly influenza, measles, and possibly tuberculosis–were causing an enormous spike in death rates, while the infertility stemming from gonorrhea was depressing the birth rates. Under such conditions rapid depopulation was inevitable. In Kosrae the depopulation was massive; the island population dropped away from 3000 to 300 in half a century. Meanwhile, Pohnpei lost about half its population, falling from 10,000 to 5,000 in about the same period. The Marshall Islands dropped from about 13,000 to slightly more than 9000 in less than 30 years. Palau's population plunged from 8,000 to just over 3,700 by the early 1900's. If Chuuk and Yap escaped the worst of the depopulation during this time, it was only because these places were not the desirable ports for foreign ships that other islands in the area were.

During the nineteenth century the population drop in Micronesia could be estimated at between 30 and 40 percent overall. It was hardly a surprise that Westerners, like the German trader Alfred Tetens, were ready to shovel soil on the grave of these island cultures. "The weak, deteriorating natives will not be able to resist the advances of civilization. Before long the last Micronesian will have disappeared," he prophesied.

Figure 1: Micronesian Population (1800-1900)

The Arrival of Western Medicine

The annexation of the islands by foreign powers in 1885-1886 initiated a century of colonial rule. Intermittent but frequent contact with Westerners during the nineteenth century yielded to regular contact with administrators, teachers, and agents of foreign business firms. When the German flag replaced that of Spain in 1899, the first organized attempt to provide health services for islanders was begun. The German administration brought in Western medicine, opened the first hospitals in the islands, and stationed doctors on Pohnpei and Chuuk.

From the outset, German authorities recognized the importance of taking measures to prevent the spread of infectious diseases carried by foreign ship crews and passengers. They implemented quarantine measures, first on Yap and then in other island groups as well. The Germans also introduced regular vaccination to the islands, especially to protect against smallpox. By 1906, they could report with little exaggeration that all the Western Carolines had been immunized against smallpox and a good start had been made in the islands to the east.

A further contribution made at this time was in the diagnosis of the nature of the problems that were afflicting island people. Robert Koch, an eminent medical researcher who paid a visit to Micronesia during this period, discovered that yaws (then known as frambesia) was the cause of the disfiguration and bodily lesions that had long been attributed to syphilis. German medical reports showed that respiratory diseases, ranging from whooping cough to tuberculosis, had become a common health problem throughout the region. These were regarded as more serious than yaws, ringworm, intestinal parasites, and the host of minor diseases that were to be found nearly everywhere. As a result of these efforts, the German administration was able to arrest the population decline everywhere but in Yap, where the fall off continued for another 50 years.

Japan, which took over the German island possessions in 1914, made further improvements in health services by expanding the hospitals, assigning a permanent medical staff to each major island group, and offering services to the outer atolls on regular field trip visits. The administration also established leper colonies to deal with the growing number of cases of Hansen's Disease. The epidemics that periodically coursed through the islands taking scores of lives even as late as the early 1900s were gradually being brought under control. They still came and went–an outbreak of whooping cough that struck Yap in 1925 and another epidemic that took 207 lives in Chuuk the year before–but they were increasingly rare. The normal case load for the hospitals and dispensaries of this period was intestinal parasites, respiratory disorders and skin diseases. The major causes of death throughout these years were almost equally divided into three general types: infectious diseases, respiratory diseases and what were called disorders in the digestive tract. Despite Japanese advances in health service, no real growth in the local population was registered during the 30 years of Japanese rule.

World War II, which ended the period of Japanese administration in the islands, resulted in surprisingly few deaths from military action, everything considered. Ironically, the lasting effects of the wartime privation on the general health of the Micronesian population were far less severe than were the effects of the times of plenty that followed. When the US Navy conducted a health survey of the islands after the war, it found intestinal parasites, yaws, tuberculosis and skin diseases widespread. This was not surprising in view of the contaminated water and unsanitary conditions that prevailed. Cases of yaws were easily treated with penicillin, the "wonder drug" developed during the war, while intestinal parasites could be handled by oral medication. Within a few years of the end of the war, yaws, long an endemic problem in the islands, was virtually wiped out. Overall, their survey "presented a summary picture of excellent health."

The survey team also noted the almost complete absence of malnutrition or obesity-an observation confirmed by the photos taken of islanders, nearly all of whom could be described as well-proportioned and physically fit. The survey found no indication of diabetes. A blood pressure study conducted on Pohnpei during late 1940s showed almost no hypertension, and it was suspected that the same was true of other islands in the area. An independent survey done in 1947 on Pohnpei revealed that only 9.5% of those tested were hypertensive and that the average blood pressure for all those tested was 111/76.

All things considered, the prospects for long-range population growth after years of stagnancy appeared very bright. Already by 1948 the birth rate for the territory had risen to 33 per thousand, while the death rate had dropped to 17. Hence, a population increase of 1.6% yearly could be anticipated over the short term, and the figure would greatly increase over the course of the next three decades. Life expectancy was estimated at 50-55 years for both males and females.

Throughout the next 20 years of slow growth in the US-administered Trust Territory, the health conditions in the islands were largely unchanged. In the early 1960s, when I first arrived in Chuuk, most of the patients at the hospital were being treated for so-called traditional diseases: gastro-intestinal conditions, parasites, respiratory diseases and infections. The Chuuk hospital, like the hospitals in other places, had both a TB ward and a leprosy ward, reflecting two of the major health problems in those days. There were still occasional epidemics, some of them quite serious, like the polio outbreak in the Marshalls in 1962 that left 190 persons crippled, and the measles epidemic in Chuuk a year later that took several lives. Still, it seemed that infectious disease was gradually being brought under control and that at long last the era of the scourge of epidemics was all but over.

The New Scourge of Affluence

The rapid socio-economic changes dating from the Kennedy Administration in the early 1960s changed all that, as we would soon learn. The annual US subsidy to the islands, a lean $6 million in 1962, was doubled and redoubled again throughout the remainder of the decade. From $60 million in 1970, it escalated still higher during the next several years. With the increase in US subsidy came an expansion in the number of salaried employees–from 3,000 in 1962 to 18,000 fifteen years later. Meanwhile, the salaries grew even more rapidly, with per capita Micronesian income rising from $60 to $400 during the same period. (See Figure 2)

Figure 2: Micronesia Per Capita Income 1950-1977 (in adjusted 1950 dollars)

The huge influx of money introduced significant changes in lifestyle, of course. Ships from abroad arrived with increasing frequency, as they had a century before; now, however, they carried not infectious diseases, but cargoes of imported food–food that was once prohibitively expensive but was now affordable to many Micronesians for the first time. These ships also carried pickup trucks and outboard engines, conveniences that made it possible for people to dispense with much of the bodily exercise that had always been such an integral part of island life.

Meanwhile, the birth rate had been rapidly increasing since the end of the war, reaching 40 per thousand by 1966. Even Yap, which had been in a long population decline up to World War II, recovered and began to show an increase in the 1967 census. Consequently, population growth rose to well over 3% yearly, reaching as high as 4% in the Marshalls by 1980. Population was growing rapidly, and health planners were soon as concerned about keeping it under control as they were about the handling the normal burden of disease they faced.

Figure 3: Micronesian Population (1800-2000)

Yet, a new set of health problems were just beginning to surface. The records for treatment in hospitals and dispensaries, however incomplete they might be, give a clear indication of the direction in which the burden of disease was headed throughout the remainder of the Trust Territory years and afterwards. The annual report for 1956 recorded just 8 cases of diabetes treated throughout the territory. By 1976 the number had expanded to 522.

Figure 4: Treatment in TT Hospitals and Dispensaries for Diabetes and Heart and Circulatory Disease, 1956-1976

  Diabetes Heart Disease
1956 8 192
1966 280 1,082
1976 522 1,4

[Note: Data taken from TT Annual Reports for 1956, 1966, and 1976]

The problems under the category labeled as "heart and circulatory problems"-which would include hypertension and heart disease–grew even faster. In 1956, as the table shows, there were 192 visits to the hospitals and dispensaries for treatment of these problems. By 1976 the visits had increased to 1,494. By contrast, the number of patients seen for treatment for chicken pox, measles, and gonorrhea held steady or declined during the same twenty-year period. The health department records may not have been complete enough to yield robust figures on morbidity, but they certainly were indicative of trends during those years.

As the local diet changed, new nutritional problems surfaced. Infant malnutrition seemed to be a more common occurrence, perhaps partly owing to the growing popularity of bottle-feeding infants. Parents or care-givers unfamiliar with the nutritional needs of small children were cutting the formula for powdered milk to save money or substituting punch or Kool-Aid for milk. Others were replacing the healthy local foods once fed to children with white rice or junk food. Vitamin A deficiency was found to be a common condition in children, especially in Chuuk and Pohnpei. Doctors everywhere were soon recording abnormally low weights of infants.

Infants might have been smaller, but adults were becoming larger than ever, thanks to the shift toward a high-sodium, high-fat diet bulked up by less nutritious carbohydrates like white rice. In the years following the rescinding of the ban on alcohol in 1960, after-work and weekend drinking became a popular recreation for many islanders. This, of course, only added to the new disease burden consisting of those noncommunicable diseases that would become an ever larger health threat as the years passed. Nutritional imbalances, at birth and in adulthood, were making islander people a target for disease at both ends of the life cycle: malnutrition in its various forms early on, and non-communicable diseases later in life.

The Chronic Disease Survey done in three of the FSM states in 1994 revealed how large a percentage of the population in these three places were suffering from diabetes and/or hypertension. (See Figure 5) According to the survey, hypertension rates among Micronesians of these three island groups in the 45-55 age group run to about 45%, well above the 29% that is recorded for Americans.

Diabetes has become an even larger health problem in the islands, at least when compared with the United States. The FSM diabetes rate of about 20% for the age group 45-55 is more than double the US rate of 8% for the same group. Rates are even higher in certain island groups: the Kosrae rate for the 55-65 age cohort is over 30%, and in the Marshalls 30% of all those over the age of 15 show signs of the disease. Two of the consequences of the disease have been apparent lately; death due to renal failure has been on the rise, as have limb amputations. There is no doubt that the "sugar sickness," as islanders call it, is one of the major health problems in the islands.

Table 5: Chronic Disease Survey, FSM 1994

  Overweight (% of population) Diabetes (% of population) Hypertention (% of pop)
  Kosr Chk Pohn USA Kosr Chk Pohn USA Kosr Chk Pohn USA
35-44 yrs 78 80 84 36 7 9 14 -- 24 34 24 16
45-54 yrs 84 79 84 39 21 22 19 8 40 48 45 29
55-64 yrs 79 68 71 44 33 18 21 13 51 57 55 47
65-74 yrs 59 53 67 41 9 9 21 19 50 65 71 58

[Note: Data based on S. B. Auerbach's survey of 1500 people in Chuuk, 600 adults on Kosrae, and 600 adults in Sokehs, Pohnpei. "Overweight"= BMI>27.8 (males), BMI>27.3 (females). "Diabetes"= OGTT>200. "Hypertension"= BP(sys)>140BP(dis)>90. Joseph Flear, Summary of the Health Priority Seminars, 1998]

It would appear that changing lifestyle patterns during this age of affluence have been largely responsible for the increase in those non-communicable diseases that might be termed the "Big Three:" diabetes, heart problems and stroke. All three are linked with obesity, which has become a serious concern in the islands today. About 80% of the FSM citizens aged 35-54 screened in the survey tested as overweight. This is more than double the rate of 38% overweight found in this age cohort of the US, a country that is itself vexed with the problem of obesity. Life expectancy for Micronesians, after all, is close to 65 years–a full ten years lower than in the US.

The toll that diabetes, hypertension and stroke are taking on the Micronesian population may be gauged by referring to Figure 6, which shows the percentage of all recorded deaths due to NCD's during the six-year period (1991-1996). Overall, the three life-style diseases--diabetes, hypertension and stroke–accounted for 46% of all adult (ie, 5 years or older) deaths during this period. Cancer deaths represented another 17% of the total. Non-communicable diseases, then, were responsible for nearly two-thirds of the deaths during those years, while heart disease, stroke and diabetes caused nearly half of all adult deaths.

Deaths attributed to diabetes were especially high in Kosrae (24%) and in the Marshalls (18%). Heart disease accounted for one-fourth of all the recorded deaths throughout the islands during this time period. Figures were especially high for Pohnpei (30%) and Chuuk (26%), however. Stroke was responsible for between 7% and 11% of the recorded deaths.

Figure 6: Major Causes of Death, 1991-1996 (As Percentage of All Adult Deaths)

  YAP Kosrae Chuuk Pohnpei Marshalls All Islands
Diabetes 6 24 9 7 18 13
Heart 12 20 26 30 14 24
Stroke 10 12 7 11 7 9
Cancer 23 16 15 13 16 17
Total 51 72 57 61 55 63
[Note: Figures for Yap include 1991-1995 only; figures for Marshalls include 1994-1997. No data for Palau available. Joseph Flear, Summary of the Health Priority Seminars, 1998]
 

Overall, the data for this period suggest that non-communicable diseases account for roughly half of the mortality throughout the islands today. This represents a striking reversal of early patterns of deadly disease in Micronesia, dating from the nineteenth century until after World War II, in which infectious diseases claimed the greatest death toll.

Summary

In our review of health and illness in Micronesia, we have witnessed two stages of disease burden corresponding to the classical division worldwide. The first stage, which began with foreign contact and continued through the years following World War II, could be called the First Generation. These older Micronesians, still rooted very much to the land and producing their own food for the most part, had the health problems of any traditional society: infectious diseases, respiratory illnesses, gastrointestinal disorders and the problems associated by poor sanitation. The post-war babies who were raised on Spam and rice comprised the Second Generation. This is the generation, rather well off when compared with their parents, that suffers from heart disease, stroke and diabetes.

If the change in lifestyle and diet brought on by the relative affluence of the post-1960s era constituted a serious health risk, many of the traditional island practices and attitudes only compounded the problem. To walk for exercise when one could ride by taxi or motorboat was looked on as silly. Even those who felt the need for regular exercise were inhibited by the local disdain for physical exertion. Micronesians would have agreed fully with Asians that only "mad dogs and Englishmen" (read "Americans" here) would venture out in the noonday sun, especially for something as ridiculous as exercise.

The traditional attitude to food stemmed from the "feast or famine" lifestyle of a society of hunters and gatherers. The genetic predisposition of islanders to diabetes may stem from the same source, at least if you embrace the "thrifty gene" theory. Certainly the cultural mindset–that is, eat it up today while it's here, for tomorrow there may be nothing to eat–did not encourage abstemious eating habits. Food, for the Micronesian, fell into two categories: starch and protein (mwongo and seeni, in Chuukese and related languages). Vegetables were not normally eaten as separate dish, but carbohydrates such as taro or sweet potatoes might be wrapped in taro leaves and cooked with greens. With the transfer to Western foods, lunch could consist in a can of corned beef or Spam and a large bowl of rice with soy sauce. This was, in local thinking, a balanced diet, even if no other food groups were represented.

As Micronesians put on more pounds, figures filled out, and bellies became rounder, there was initially no cry of dismay from oversized islanders as they looked at themselves in the mirror. Pacific Islanders, like Europeans of a former age, regarded corpulence as a symbol of prosperity. Chiefs, by virtue of their title, were supposed to eat well and engage in little physical labor (as their uncalloused hands might testify). Fleshiness was not just a symbol of prosperity, but a sign of beauty as well. The predilection of islanders everywhere in Micronesia did not seem to run toward spindly-legged women with anorexic figures, foreigners have noticed.

So it is that we find ourselves in our paradoxical situation today with regard to islander body size. On the one hand, many infants are showing abnormally low weights in early childhood. On the other hand, an increasing number of adults are overweight, with many plainly obese. Nutritional imbalances, at birth and in adulthood, are making islander people a target for disease at both ends of the life cycle: malnutrition in its various forms early on, and non-communicable diseases later in life.

What might we start in our attempts to address this problem? These are a few recommendations that might be considered.

1. Find out where we stand regarding NCDs. Provide updated survey samples of obesity, hold blood sugar, and hypertension. Use the same standards throughout the Pacific so that figures can be compared with one another. WHO might be asked to coordinate such a survey.

2. Undertake a public education campaign to inform the public of the dangers of the major NCDs: heart disease, diabetes and stroke. This campaign should draw on a variety of different types of educational materials: videos, posters, radio spots, print materials such as brochures in local language. Encouraging people to grow and eat local food is a good start, but the campaign should go much further than this. It should address the food question (moderate amounts; choice of low-salt , low-fat and low-sugar foods; and method of cooking), but also publicize the importance of moderate regular exercise, and explain the symptoms of the NCDs and their effects on the body.

3. UN and other regional agencies should compile a list of public education materials produced in and for the Pacific that might be shared for such a public education campaign. Each county need not each produce its own materials from scratch when many such materials exist that could be effectively used throughout the region.

4. It might help to mount a regional effort for such a public education campaign on NCDs and their impact on our populations. This could be coordinated out of an office in Fiji or Hawaii (much as Papa Ola Lokahi in Hawaii ran the Pacific Diabetes Awareness program for many years).

5. For the problem of infant malnutrition, we might begin with an easy to read brochure in English that describes the problem and tells people how to avoid it.


Notes

1. Two years later smallpox struck Guam and had an equally disastrous effect there. The Guam population, which before the epidemic was about as large as Pohnpei's, suffered about the same number of deaths that Pohnpei did.

2. Sturges to Anderson, 16 Aug 1866, ABCFM Letters and Papers, Micronesian Seminar, Pohnpei, FSM.

3. David Hanlon, Upon a Stone Altar (Honolulu: University of Hawaii Press, 1988), 204.Â

4. For population estimates of the island at different times during the 19th century, see Saul Riesenberg, The Native Polity of Ponape (Washington: Smithsonian Institution, 1968), 6.

5. Philip Ritter, "The Population of Kosrae at Contact," Micronesica 17 (1981): 22.

6. The depopulation in the Maraianas, because it coincided with a period of long guerrilla warfare between the colonizing Spaniards and the islanders, is erroneously attributed even today to guns and powder rather than to the burden of foreign-borne disease to which islanders had developed no bodily defenses. For a discussion of this, see Francis X. Hezel, "From Conversion to Conquest," Journal of Pacific History, 17 (1982): 115-137.

7. Francis X. Hezel, The First Taint of Civilization (Honolulu: University of Hawaii Press, 1983), 206.

8. Hezel 1983: 142, 146.

9. Snow to Anderson, 7 July 1855, ABCFM Letters and Papers.

10. Sturges to Anderson, 12 July 1854, ABCFM Letters and Papers.Â

11. Robertson, Russell, "The Caroline Islands," Transactions of the Asiatic Society of Japan, 5(1876):45.

12. Francis X. Hezel, Strangers in Their Own Land (Honolulu: University of Hawaii Press, 1995), 116, 125.

13. Tetens, Alfred, Among the Savages of the South Seas (Stanford: Stanford University Press, 1958), 4.

14. German Foreign Office, Denkschrift über die Entwickelung der deutschen Schutzgebiete in Afrika under in der Südsee, 1906-1907, p. 4123; German Foreign Office, Denkschrift 1907-1908, p. 7069.

15. Robert McKinney, Micronesia under German Administration, 1885-1914 (Master’s thesis, Stanford University, 1947), 90.

16. McKinney 1947: 75, 82.

17. Japanese Government, Annual Report for the Administration of the South Sea Islands under Japanese Mandate for 1926 (Japan 1926), 164.

18. Japanese Government, Annual Report for 1930, 193.

19. Dorothy Richard, US Naval Administration in the Trust Territory of the Pacific Islands (Washington: Chief of Naval Operations, 1957), III: 845-855.

20. Rupert Murrill, "A Blood Pressure Study of the Natives of Ponape Island,"Â Human Biology 21 (1949): 47-59.

21. US State Department, Annual Report on the Administration of the Trust Territory of the Pacific Islands for 1948 (Washington, Government Printing Office, 1949), 76.

22. A. Diaz, “The Health Crisis in the US-Associated Pacific Islands,†Pacific Health Dialog 4 (1997)1: 116-129.


Unpublished. 3 November 

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