Here's what a non-communicable disease crisis looks like: It's midday on a Wednesday in tiny, tropical Palau, an island in the western Pacific with a population of 20,000. The forecast is balmy. Then the sirens start up again. A diabetic grandmother sits up on her veranda, looks out at the road, and settles back down. "Another ambulance," she murmurs. Its destination: Palau National Hospital, the unlikely epicenter of one of the world's worst diabetes crises.
"Unlikely" because in most respects, Palau is every bit the tropical fantasia that tourists expect when they see pictures of its world-class diving sites and emerald Rock Islands. Fair tourism laws have given Palau the highest GDP per capita of Pacific Island countries; in turn, locals are generous with their time and money, and eager to share their natural inheritance. Stay here for longer than a week, and odds are you'll be invited along to camp on a private beach, or hike to hidden waterfalls.
But no matter how discreet the diabetes epidemic might be, those sirens—and the statistics—don't lie. According to the World Bank, 20.9 percent of adult Palauans have diabetes. That's the fourth-highest rate in the world. The vast majority of Palauans have the Type II variant of disease. This form of insulin resistance typically shows up after childhood, and is accompanied by excess weight, high blood pressure and cardiovascular disease. Without proper treatment, diabetes can lead to kidney failure, loss of limbs and early death.
All are far too common in Palau. "The nickname for the hospital is 'the morgue,'" says Kris Kitalong, a pharmaceutical botanist and local health campaigner. A hyperbaric chamber at the hospital—first installed to treat scuba divers with the bends—has been requisitioned to treat diabetics in danger of losing their limbs to amputation. (Lacking enough insulin to break down excess glucose, it's hard for diabetics' blood to reach extremities). The hospital's outpatient unit hosts early-onset patients as young as 15. And its surgical wards see far more patients with diabetes complications than with emergency trauma, doctors say.
Ester*, 63, sits in a surgical recovery room with three other patients. When asked if she has diabetes, she says, "Yes, of course." High blood pressure? "Yes, of course." She's been in the hospital for three days to heal an infected foot. Like many diabetic patients with weakened limbs, she didn't notice the original cut to her heel. Days later, it festered and swelled. Now she's being treated with surgery and antibiotic IV drips.
The causes for diabetes are complex, but the surest bet to avoid it is exercise and a healthy diet. Ester grew up in rural Palau consuming local food: "Breadfruit, oranges, taro, fish," she recalls. As a young woman, she moved to Koror, the country's main town. She began to eat imported dishes like canned corned beef and soda; sometime in the years since, her metabolism failed her. Ester father's side of the family followed the same path to diabetes. Now, she says, many of them are dead.
Non-communicable diseases like diabetes and high blood pressure are often called "lifestyle diseases." And indeed, it might be tempting to place the blame for Palau's plight squarely on its so-called lifestyle choices. But doing so is kind of like shaming a canary for choking in a coal mine. Palau's failure to control diabetes is very much the entire world's failure.
We may have gotten better at treating some aspects of diabetes thanks to insulin injection therapies developed in the last century. But as the world's diet gets richer, and its population becomes more inactive, so many people have developed diabetes—422 million in 2014, up from 108 million in 1980—that according to the New England Journal of Medicine, "we are arguably worse off now" than we were in the 1800s.
If you ask, Palauans will tell you their particular story of how development and diabetes spread hand in hand—but first, they need you to understand how genetics affects their outcomes. Studies have suggested that Palauans—along with other Pacific Islanders—have so-called "thrifty genes" that make them put on weight rapidly. That may have helped them survive starvation on long sea voyages, and on land in times of scarcity. "Now, in a time of plenty, we're just exploding," says Stevenson Kuartei, a physician and senator in Palau's Congress. "That's why I have a problem with the term 'lifestyle-related diseases' when it comes to this traditional population. Indirectly, it says that for some reason as a race we're unable to control our lifestyle."
The picture becomes further complicated, Kuartei says, by a colonial history that forced unhealthy food into Palauan stores. Palau was "discovered" by a shipwrecked English crew in 1783. But the archipelago's isolated location and razor-sharp outer reef kept foreign interference at a minimum—and traditional life intact—for the next century and a half. That meant a diet of plants and seafood, and "survival of the fittest—literally, only the fit would survive," says Emais Robert, Palau's minister of health.
Japan controlled Palau after World War I, and the US took it over as a "trust territory" after WWII. Along with tanks and quonset huts, the Yanks brought the shelf-stable staples of the US military diet: corned beef and Spam, soda and chocolate. Most Palauans couldn't afford such luxuries, but their brief encounters with the stuff during special occasions, or as part of military rations distributed after storms, got them hooked.
By the 1980s, Palau was on its way to independence, and locals were benefitting from tourism and trade. "We got infected by tobacco, corned beef and candy after the War. Then, by the '80s, we could finally afford them," Kitalong says. During that same decade, Palauans began to resettle in the central town of Koror to take jobs in tourism and the new national government. Physical activity declined.
"And that's when we started developing diabetes," Robert says. "Once people started working 9 to 5, they're driving their cars, they're not doing much farming and fishing, and it really developed into what we have today." According to the ministry of health, diabetes reached the point of no return a few years later, in the early 2000s.
Fighting a non-communicable disease like diabetes—in Palau, in the US, anywhere—is mostly a preventative battle. In Palau, the walls of the national hospital's outpatient diabetes clinic are lined with posters depicting "stop" and "go" foods. "Go" foods include breadfruit, taro, carrots, sea cucumber, brown rice, and fish. "Stop" encompasses Spam, corned beef, sausages, candy, cookies, beer, and other assorted vices.
It all looks simple. The reality check, however, comes just a few hundred feet away. The hospital convenience store is called "West Mantekang"; Mantekang, it turns out, means "lard" in Palauan. Inside are all the STOP foods: Ramen, hot dogs, Japanese and American chocolate bars, Vienna sausages, Fritos, Spam (Garlic, Bacon, Original Recipe). The GO foods are represented by tapioca plus a few desultory apples and oranges. As in the US, eating healthier in Palau is easier said than done, especially on the go.
The government knows this, and is doing a lot of the expected things to combat diabetes and obesity. It's jacked up tobacco taxes to pay for healthy eating initiatives and strollable sidewalks. It screens students for health problems and recently banned hot dogs in public schools. It runs radio ads around the clock urging citizens to eat less and exercise more, and has opened gyms around the country. This is all good, but not good enough.
Consider childhood obesity, which is a risk factor for early-onset diabetes and many other health complications; it affects a third of all young Palauans. "My generation didn't start with a 33 percent obesity rate," says Kuaratei, the doctor and congressman. "We were very skinny. And by the time we got to adulthood, almost 65 percent of us are obese, and many of us are diabetic. Young people, though, they're starting with 33 percent obesity. We're beginning to see Type II diabetes in youth—15-year-olds with sugars and cholesterols that are way off."
Kuartei and Robert are both in their first year of government service. They want to see Palau take more drastic measures. They envision a community-based system that sends doctors, nurses, and health counselors out of the hospital and onto the streets. Health professionals would go door-to-door in villages and in town checking vitals, answering questions, and coaching their neighbors on how to live healthier lives. If any country could pull off such a system, the doctors argue, it's a small, close-knit microstate like Palau.
Robert says he's attended far too many funerals, and performed too many amputations on diabetic patients. And although others in the government are already fretting about costs, Robert argues that a community program will save lives and money in the long run. "We need someone in the community who comes out every day," says Robert. "At first it's going to be irritating. Today you see somebody coming to your house dressed up like a nurse, and you close up your doors and windows like it's the Jehovah's Witnesses. But it'll become part of the routine."
*Source preferred to use a pseudonym.
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