Sweet Temptations

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The look in takaiti tamaroa's eyes is best not dwelled upon. Not if one wants to stay composed-and remain a little longer in the surgical ward at Tungaru Central hospital in Tarawa, the capital of Kiribati. Supine in bed and devoid of energy, Tamaroa, 54, is sweating through her first full day since the big toe of her left foot was amputated as a result of sepsis, a severe blood infection that is a complication of her diabetes. Her bandaged leg is red and puffy, and illness and misery surround her. But nothing in the ward is quite so unsettling as Tamaroa's dark eyes, because in them is only despair.

Yet in a sense she is lucky. She has lost only a toe and should learn to walk again unaided. Afraid of hospitals, some I-Kiribati with sepsis wait so long before seeing a doctor that they eventually lose a leg, or both legs, or die from rampant infection. Others are struck down by one or more of diabetes' other complications-blindness, kidney failure, heart disease-afflictions that not long ago were all but unheard of in Kiribati.

Not all the victims are elderly. Among the sick are young adults, men and women in their 20s and 30s with smooth skin and small children. "What aids was in the last 20 years of the 20th century, diabetes is going to be in the first 20 years of this century," predicts Paul Zimmet, director of the International Diabetes Institute in Melbourne. "It is wiping out Nauru, the Marshall Islands, Tonga. Name any island, and diabetes is its main health threat."

A republic of 33 atolls and some 92,000 people, Kiribati was probably the last place in its region to succumb to the juggernaut that is causing the epidemic: the rapid Westernization of traditional cultures. Even today, type 2-or maturity-onset-diabetes (an obesity-triggered disorder in which the body is unable to process sugars from food) is rare on most of Kiribati's 20 inhabited islands, where the main threats to life remain the communicable maladies-respiratory infections, gastrointestinal diseases-so common in the developing world. On these strips, the natives live as they have for centuries, climbing trees for coconuts, paddling canoes out to sea to fish, and munching on breadfruit, pandanus and taro. Many have the sinewy bodies of athletes.

But what Zimmet calls "Coca-colonization" has transformed South Tarawa, the nation's commercial hub, where most workers sit at desks all day and cars and buses zoom up and down the sole asphalt road. In the dingy grocery stores it is easy to buy cigarettes and processed food-there are shelves of cream biscuits, chocolate bars, snack foods, soft drinks, canned meats and baked beans, imported mainly from Australia. Fruit and vegetables are much harder to find. There is the odd fruit stall outside, but it is rare to see someone fork out for a bunch of overripe bananas that has baked for hours in the equatorial sun. More common is the sight of an I-Kiribati strolling along the roadside with a 20-liter bottle of cooking fat in each fleshy hand. The junk food not only tastes better, it is often cheaper -a key point on an island where hundreds of people respond to advertisements for the most menial jobs, and most workers are paid less than $5,000 a year.

The price of this calorie-rich diet is thousands of diabetics like amputee Tamaroa, who was told she would have to take medication for the rest of her life when her illness was diagnosed 10 years ago. "But I stopped taking it when I felt better," she says, "and I kept eating sweet things." Dr. Baua Tebau, Kiribati's acting director of health services, says it is not unusual for three-quarters of the beds in the surgical ward to be filled by diabetes patients.

Each year, an average of 25 I-Kiribati become amputees. Many are referred to Dutch volunteer physiotherapist Marie-Jose Bergs, who says their problems are just beginning when they lose a body part. Crutches and wheelchairs are scarce in Kiribati; prosthetics are virtually non-existent. As a result, she says, "many amputees lie about at home feeling depressed, and their diabetes gets worse." The desperate shortage of crutches angers Tebau. "Nobody thinks that these are part of treatment for the patients," he says. "The decision makers sometimes do not know the need, since they are not the ones in need."

Tebau must repress his sympathy, however, for those patients whose kidneys fail: "To them, we say, 'Sorry, but there is nothing we can do.' " There are no dialysis machines in Kiribati, nor the means or expertise to perform transplants. Scattered across Tebau's chaotic desk are letters from I-Kiribati pleading to be sent overseas for treatment. "But we cannot afford to set a precedent," he says. "Sometimes the family will say, •But this patient is a very important man.' It doesn't matter." Exceptions are made only for those youngsters, Tebau says, "who may grow up to be our surgeons."

When it comes to disclosing their state of health, poor countries tend to fall into two categories: those which exaggerate their problems to gain international attention and help, and those which, out of pride, play down their troubles. Kiribati, according to local health workers, is in the second category. The International Diabetes Institute determines a country's rate of diabetes by calculating the percentage of its citizens aged 25 and over who have been diagnosed as diabetic. Australia's rate is 7.5%. China's is 2%. According to Kiribati government figures, the rate in South Tarawa is just under 9%. This is an underestimate: the government has used 15, not 25, as the minimum age. Kiribati admits that the number of diagnosed cases of diabetes in South Tarawa has quadrupled in the last four years. Zimmet, who since the mid-'70s has conducted on-the-ground research through the Pacific, estimates that the rate of diabetes in Betio, the most populous district of South Tarawa, is 20-25%.

Whatever the exact figures, Kiribati's diabetes crisis pales by comparison with that of its nearest neighbor, Nauru, which became so rich from phosphate exports last century that it was sometimes called "the Kuwait of the South Pacific." Nauru (pop. 12,000) imported delicacies such as gristly turkey tails and mutton flaps, and sugary treats like icecream and candy, and Nauruans devoured them all in large quantities. Mining, meanwhile, was reducing all but the coastal fringe of the island to a moonscape on which crops may never grow again.

One day in May, 1975, Zimmet was part of a team which randomly tested 100 adult Nauruans. To his astonishment, 33 had diabetes. That rate, confirmed by more testing over the next few days, placed Nauruans alongside the American Pima Indians of Phoenix, Arizona, as the most diabetes-ridden people in the world.

Things have only got worse. Today, according to Zimmet, the diabetes rate in Nauru is 40-45%. "It's a disaster," he says. "Type 2 diabetes used to be something we saw mainly in people over 55. Now children are getting it. In Nauru and other Pacific islands, we're seeing 10-year-olds with type 2 diabetes-kids who by the time they hit their 20s may have developed any of the complications, including heart disease."

Nauru, at least, has been better able than Kiribati to look after its sick. Its hospital has a world-class dialysis unit with seven machines, and until recently, all patients it could not care for properly were sent to Australia for treatment, all expenses paid. As a result, though diabetes and heart disease are more prevalent in Nauru than in Kiribati, life expectancy in both countries is about the same: mid-50s for men, early 60s for women.

Zimmet, who is Nauru's health adviser, estimates that as recently as five years ago, more than 100 sick Nauruans would have flown to Australia each year. These days, with Nauru all but mined out and much of its money squandered in failed investments, the influx has become a trickle. (For the high-flying Nauruan, a trip to Australia can be a bad career move: while having a toe amputated in Melbourne last March, Bernard Dowiyogo lost the Presidency to Rene Harris in a no-confidence vote.)

Most Pacific Islanders have a lousy diet, but why so many of them develop diabetes used to puzzle researchers. After all, if a group of young Caucasians moved permanently to Nauru and adopted local eating habits, it's unlikely that anywhere near one-third of them would develop diabetes. Epidemiologists are convinced there is a genetic factor at work. The widely accepted theory-proposed in 1962 by American geneticist James Neel-is that Nauruans and other Micronesians have a "thrifty gene" that enables them to store even small amounts of surplus sugars as fat, a propensity that enabled their ancestors to survive periods of famine, but which predisposes today's islanders to life-threatening illnesses such as diabetes, heart disease and stroke, known collectively as New World syndrome.

Part of the answer is an overhaul of diet and lifestyle, but on Tarawa, this message is not getting through. Says Scott Stinson, an Australian doctor doing a two-year stint at Tungaru hospital: "The people here are not silly. They are as interested as Westerners in the good health of themselves and their families. But there is simply not the media-generated barrage of health information that people elsewhere take for granted." Indeed, there is very little local media-just two thin weekly newspapers and one radio station.

Many I-Kiribati are ignoring the early warning signs of diabetes-like unquenchable thirst and increased urination-and, once diagnosed, are not persisting with treatment. Says Zimmet: "Pacific Islanders look at diabetes as they would a chest infection: take a tablet for five days and it will go away." Among some I-Kiribati, he adds, there is still a preference for "natural healers" over Western-trained doctors. There is also a belief that physical bulk signifies prosperity and prestige.

Exercise, another key to controlling diabetes, isn't exactly the rage on Tarawa, where the sapping year-round heat can make crossing the street an act of endurance. Some locals jog at night, though they risk attack from the scores of starving dogs that roam the island. Aside from those deterrents, says physiotherapist Bergs, most I-Kiribati regard exercise as "a silly pursuit of the imatang [white people]."

Years ago, Zimmet recommended to the Nauruan government that it build a public leisure center, replete with swimming pool, tennis and basketball courts and coffee shop. Nothing happened. "If I was AusAID," he adds, "instead of letting Australia send all this rubbishy food, I'd be sending sports equipment and instigating programs that would encourage kids on the islands to want to be Olympic champions."

But the eventual solution, Zimmet fears, will be poverty. "Diabetes is virtually wiping out some Pacific countries' economies," he says. "The way they're headed, they may soon not be able to afford to import these junk foods. I see some regression of the disease process when that occurs." At that point, life on Tarawa may wind back-for better and worse-to a time when outsiders observed a happy people living simply, instead of the despairing eyes of women like Tamaroa, tempted and poisoned by the sweet fruits of a foreign culture.