Nutrition

Malnutrition has increased. Undernutrition in children is not due to lack of calories but rather lack of proper nutrition. Overcrowded, unsanitary living conditions foster parasites, which are a major contributing factor to malnutrition in young children. Out of a total of 97 cases of nutritional deficiency treated in 1990, 73 were in Chuuk, 19 in Pohnpei, 5 in Yap and 1 in Kosrae. In the following year, more than twice as many cases of undernutrition (189) were reported.

Vitamin A deficiency in children is prevalent, particularly in Chuuk and Pohnpei, and its incidence is among the highest in the world. It is associated with night blindness, can cause complete blindness, and is believed to contribute to otitis media (middle ear inflammation) in children. It is estimated that the incidence of Vitamin A deficiency has increased from 6.4 percent in 1989 to 17.6 percent in 1991. Contributing to malnutrition in infants is the replacement of breastfeeding with infant formulas. Infants being breastfed are also being weaned at earlier ages. (SPEHIS, 1994; Scheder, 1989; Schoeffel, 1993).

Overnutrition in adults leading to obesity is due to improper diet and sedentary lifestyle, adding to the risk of developing heart disease and diabetes. Medical researchers suggest that a "thrifty gene syndrome" may be operating among indigenous Pacific Islanders. In the past these people relied upon food that was seasonally scarce, and periodic famines often occurred after storms and other natural disasters. Consequently, islanders genetically adapted to famine by developing an ability to store body fat rapidly. While this may have served them well in earlier times, it can predispose them to obesity as they shift to consistently available, processed, high caloric foods (Schoeffel, 1993).

Dental caries among children three to five years old were found to be three times that of the US mainland. Imported foods high in sugar and inadequate oral hygiene can be blamed for the high incidence of dental disease among people of all ages (UH School of Public Health, 1989).

Infectious Diseases

Urbanization has increased the probability of infections becoming epidemic due to crowded conditions, improper food storage, contaminated water supplies and poor hygiene. Reported deaths from pneumonia doubled from 1986 through 1989. Children and the elderly are especially at high risk for pneumonia, tuberculosis, and influenza which were less communicable when island populations were more scattered and isolated. Conjunctivitis ("pink eye") is a common affliction and is easily spread (UH School of Public Health, 1989; Abraham, 1992). Waterborne diseases are a leading cause of illness in FSM. Fecal coliform contamination is common due to the lack of safe drinking water in most areas (World Bank, 1993). Cholera epidemics occurred in Chuuk in 1982 and 1983, made worse by inadequate public sanitation and drought conditions.

Tuberculosis is making a comeback worldwide. TB is widespread in FSM but as yet no preventive immunization program exists. While tuberculosis incidence has been decreasing, its prevalence continues to be much higher than in the US. (Haberkorn, 1995; Abraham, 1992).

Hansen's Disease incidence is low in FSM, but consistent monitoring is necessary to prevent an increase. Prevalence of Hansen's Disease (leprosy) in Chuuk increased by 200 percent between 1978 and 1982 (Scheder, 1989).

While only two confirmed cases of HIV/AIDS in FSM were reported in 1994, both cases contracted their disease while overseas. As people migrate in and out of FSM, and as tourism continues to grow as an industry, the probability of increased exposure to this deadly virus grows.

Behavioral Risks and Mental Health

Modernization has brought other health and social problems. Unhealthy behaviors put people more at risk for disabilities and diseases and put their families and communities more at risk socially and economically.

Mental health problems are thought to be increasing as people cope (or fail to cope) with the dramatic cultural and social changes occurring, but the prevalence estimates are unreliable due to inadequate reporting procedures, lack of qualified professionals to diagnose mental illness, and the tendency to keep the mentally ill close to their home villages and under the care of relatives. Males show symptoms of serious mental illness four times more frequently than females (Hezel, 1988).

Micronesians have been able to legally drink alcoholic beverages in modern times for slightly over 30 years. In that comparatively short time, the social problems associated with alcohol abuse have developed. Micronesian men are drinking more than the women. Problems with domestic violence, fighting and general public disruption, crimes committed while drunk, disabilities and injuries resulting from drunk driving, and loss of productivity on the job and in the family have serious social and economic consequences. Chronic heavy drinking and binge drinking can result in disease or premature death as many NCDs are known to be associated with excessive alcohol consumption. These diseases include heart disease, hypertension, stroke, cancer, liver diseases, and non-insulin dependent diabetes mellitus (Marshall, 1993).

Recent research has shown that a much higher proportion of Pacific Islanders smoke tobacco than persons in developed countries and many other developing countries. One study in 1978 found cigarette smoking almost universal in Ifaluk and Ulithi (Yap State outer islands) with an average consumption of a pack a day. Tobacco smoking is associated with heart disease and serious respiratory illnesses such as lung cancer, chronic bronchitis and emphysema. Respiratory diseases are a major killer in Micronesia. Tobacco use can also combine with alcohol use to raise the risks that the person will develop heart disease or suffer a stroke. Few Micronesians smoked manufactured cigarettes before the 1960s. Now that people have had 20-25 years of chronic cigarette use, smoking-related morbidity and mortality will probably begin to show up in health statistics (Marshall, 1993).

A Generation of Smokers

Notable among adults on Pohnpei who are in their early to mid-50s, is the high number of cigarette smokers. This is particularly true among those with high school educations. Why is that?

When these individuals were attending (and many boarding at) the intermediate school on Pohnpei, in the late 1950s to early '60s, the US government provided surplus military rations to the school as part of an aid package. According to former students, these military rations comprised their principle diet. In those days, military rations contained a small quantity of cigarettes which proved to be a curious, fascinating novelty to the young, adolescent students. Starting as something to do "for fun," it did not take long for addiction to set in, often resulting in a lifelong habit that no doubt has lead to serious health consequences.

Limited studies have been done on marijuana and other illegal drug use in Micronesia. It appears that marijuana use has been growing since the 1960s and '70s, particularly among young people. Marijuana smoke contains about 50 percent more cancer-causing hydrocarbons than does tobacco smoke, and recent research shows that marijuana produces a net four times greater burden on the respiratory system. Structural changes to the smoker's lungs, made worse with tobacco smoking, can increase the risk of developing lung cancer and chronic obstructive lung disease (Marshall, 1993).

There are suspected health risks in betel nut chewing that will require further study to confirm. The combination of lime and/or tobacco with betel nut chewing may pose a risk to developing certain oral/throat cancers (Scheder, 1989).

Shown in statistics as "external causes" of death are accidents, suicides, and deaths primarily associated with alcohol and substance abuse. External causes were responsible for 16 percent of all deaths in FSM in 1980. Young adult males are more represented than women in this category. Motor vehicle accidents (often associated with drunk driving) are a major cause of death among young men. The suicide rate in Chuuk was found to be ten times the US rate, increasing 6 times since 1960 (Scheder, 1989). Affecting primarily young adult males, the male suicide rate was found to be 11 times greater than the female rate. Alcohol was typically involved with suicide. In Micronesia, "Young people drink in order to die as well as die because they drink." (Hezel, 1984).

The costs to society of excessive alcohol and tobacco use are indeed great. Not only is it a strain on the health care system to take care of people who have developed lifestyle diseases such as emphysema, cancer, diabetes and heart disease, there are increased costs to police, judicial, and social service systems, and severe hardships for the families involved. Long-term disabilities and death can result from drunk driving, and too often the injuries are to the innocent victims and their families.

Diseases of Modernization are Preventable

What needs to be emphasized is the fact that lifestyle diseases and high-risk behaviors are preventable and controllable. The drinking water supply must be made safe. In order to accomplish that, sewage and trash disposal systems must be improved. Public sanitation needs priority attention. Public education is essential to raise people's awareness of how they can take better care of themselves. As educational, environmental and public health programs result in actual behavior changes, the health of the nation will improve. A health care system that focuses more of its resources on preventive primary health care services can benefit more people than the same amount of resources spent on curative care for a few.

Health Indicators

Respiratory diseases appear to be the top cause of illness among people of all ages, and waterborne diseases are a leading cause of illness in FSM. The list of leading health problems treated is given in Table 7.2.

Table 7.3 lists the main causes of death in the FSM for 1989. Circulatory system disease, including hypertension and heart attacks, was the leading cause of death in FSM. The second leading cause of death was respiratory system disease which includes pneumonia, influenza, bronchitis, emphysema and asthma. Diabetes is included in the endocrine/metabolic/nutrition category.

The infant mortality rate is defined as the number of infant deaths per 1,000 live births in a year. It is considered a good indicator of the quality of health care in a nation, because mortality is high during the first months of life and small improvements in this indice can be measured. 1994 FSM Census data reveal a high infant mortality rate in FSM that should be of great concern to FSM's policy makers and health system. The FSM infant mortality rate of 46 was higher than the average (33) among neighboring Pacific Island nations.

Women experienced high rates of morbidity and mortality as a result of teenage pregnancies, high parity, poor birth spacing, child-bearing complications, malnutrition, and poor or non-existent prenatal care. Of the women attending prenatal clinics only 11 percent of all women made their first visit during the first three months of their pregnancy and nearly 60 percent did not attend the clinics until the last three months (Abraham, 1992).

Teen pregnancy is reported to be a major problem, but in some states more than others. The rates of birth to single teenage mothers varies from a high of 18 percent on Pohnpei to a low of only 4 percent in

Chuuk, as Table 7.5 indicates. The problem appears to be diminishing, however. Five percent of all teenage women in FSM bore a child in 1994, in comparison to the 7 percent in 1980 and the 9 percent in 1973 who had borne children in those years (FSM OPS 1996a).

Teen pregnancy is reported to be a major problem, but in some states more than others. The rates of birth to single teenage mothers varies from a high of 18 percent on Pohnpei to a low of only 4 percent in

Chuuk, as Table 7.5 indicates. The problem appears to be diminishing, however. Five percent of all teenage women in FSM bore a child in 1994, in comparison to the 7 percent in 1980 and the 9 percent in 1973 who had borne children in those years (FSM OPS 1996a).

Problems with Health Services

There appears to be extensive agreement on what the major health care problems are:

Reliance upon curative care through a hospital (centralized system) is more costly than a decentralized, preventive health care system. It is felt that significant savings and improved health outcomes would result from a shift away from reliance on hospitals for health care.

Overseas referrals for just a few people are consuming an inordinate share of FSM's health budget, averaging about 25 percent or more of state budgets during 1985-1989. These referrals are paid by government even for well-to-do, powerful families. Referrals are sometimes ill-advised, as in the case of a terminally ill patient, and not always made by a qualified doctor. Referrals can be made by politicians who are not basing their referrals on medical considerations.

Many don't participate in medical insurance. There appears to be little incentive to buy into insurance as long as government heavily subsidizes medical care. The cost of an average outpatient visit is about $3 for people without insurance. Government's current policy not to deny health care due to inability to pay, while admirable, is not helping the health care system to maintain or improve its services. The policy may also be a disincentive for people to take better care of themselves in order to minimize their own health care costs.

Hospitals and many dispensaries are suffering from deteriorating facilities, shortages and delays in essential supplies and drugs, overstocking and understocking of certain drugs due to ineffective tracking systems, and insufficient funds for health facility equipment and maintenance. While this report was being written, in October 1996, Pohnpei hospital's nurses and doctors had not been paid for 2 weeks of work.

The FSM economy cannot continue supporting the health system at its present level. For example, the First Pohnpei Economic Summit in 1995 reported that an average of 5 clients per year receive hemodialysis services in Pohnpei at an average cost of over $150,000 annually. Only $50,000 a year is appropriated by Pohnpei State's legislature for this need. This presents a tremendous burden on Pohnpei's Health Services. Yap State has made the decision that funds for overseas referrals will come from Compact money which steps down to zero by the year 2001. It is a way of putting the pressure on all people to buy into health insurance that covers overseas referrals. This assumes that an affordable health insurance plan can be set-up that will sufficiently cover large overseas expenses. As it is, the National Government Employees' Health Insurance plan which is open only to national and state employees and private businesses covers a maximum of $50,000 for medical referrals

Reducing the Costs of Diabetes

As FSM modernizes, Type II diabetes mellitus (adult onset, generally non-insulin dependent) is becoming more common. Heart disease contributes to 75% - 80 percent of deaths in people with diabetes. Diabetes is often not mentioned on death certificates as a cause of death, although it may be the underlying cause of deaths due to kidney failure, heart disease or stroke.

More likely to develop in people who are overweight and physically inactive, some people have a genetic predisposition to developing this disease. Diabetes can be prevented and controlled. Effective control through diet, exercise and weight management can prevent life-threatening complications.

In a primary health care approach, resources are focused on educating diabetics and their caretakers in how to better manage the disease. People are taught how to monitor their blood sugar levels, given dietary counseling, shown how to respond to their bodies' cues when they are experiencing excessively high or low blood sugar levels, learn the importance of monitoring their cholesterol levels and blood pressure, learn preventive foot care, and encouraged to get regular check-ups. Services might be provided through a combination of homevisits, regular doctor check-ups, and educational support groups.

An analysis of the savings that can be realized through preventive care of diabetes on the US mainland showed that:

1. Diabetic kidney disease requiring dialysis could be reduced by 50 percent through preventive efforts.
2. 90 percent of diabetes-related blindness could be prevented if annual retinal examinations were the standard of care for all diabetics.
3. Blood pressure control was critical, as hypertensive diabetics had a 2 - 3.5 times greater risk of cardiovascular mortality than diabetics with normal blood pressure.
4. Major amputations could be reduced by 50 percent among diabetics who were taught (and practiced) preventive foot care.
5. Hospitalization rates could be reduced by 73 percent among persons with diabetes as a result of primary care, outpatient programs.

Source: Claresa Levetan, MD, and Robert Ratner, MD, "The Economic Bottom Line on Preventive Diabetes Care," Practical Diabetology

Ideas for Improvement

FSM's health care system could be made more cost-effective and accessible by shifting from its current emphasis on centralized, curative care delivered out of hospitals (which is very costly), to an improved, preventive, primary health care system that is delivered out of decentralized, community-run dispensaries. This way health care can be made more accessible to outer islanders and rural residents. Decentralization will require collaboration between national and state governments in implementing major changes. It involves decentralizing decision-making procedures, including the local community in determining what services are most needed, strengthening of middle management, and decentralizing budgetary control. Privatization of security, ambulance, janitorial, kitchen and pharmaceutical services has been suggested as a cost-saving measure.

People would receive most outpatient care at the dispensaries and any hospital visits would require a prior referral through the dispensaries. Direct services staff would need to put more time into outreach activities. Outreach has been identified as a way to improve mental health service delivery. Home visits are often the most effective way to reach those people who are not yet coming in to the established dispensaries or health centers. Health consumer groups could be formed as a means of educating people on specific health topics and helping them to take a more active role in community-based health services. Efforts have been made to initiate early intervention and prevention programs, and although these programs, such as child immunization, have demonstrated their effectiveness, they have received relatively little of the available funding, as illustrated in Table 7.3.

People need to pay more for health services. As it is, money that is collected from patients amount to no more than 10 percent of the total health costs. People appear willing and able to pay more for health care, judging from the willingness of some to go as far as Palau to obtain quality care. One could look at the money people are willing to spend "on ways to destroy themselves" (eg, alcohol and tobacco) and reason that surely they can manage to pay a small monthly premium for health insurance and a larger share of the costs of medical services (Micronesian Seminar, 1994). By paying more for their own health care, people will be more motivated to take care of themselves and not take medical services for granted.

FSM national government now offers a medical insurance plan for national and state government workers and recently opened this plan to small private businesses. Medical insurance can be helpful in reducing and controlling the financial burden of overseas medical referrals, which is a major liability. In selecting an insurance plan, exclusions and benefit limits are important considerations. For example, the National Government Employees' Health Insurance plan has a number of exclusions, such as "hemodialysis for renal failure secondary to diabetes mellitus..." and "diagnostic and treatment services for congenital deformities and abnormalities." The AFLAC private health insurance plan is available for a small monthly premium to any individual and family. It provides limited coverage and might be helpful should a need for overseas referral arise. There will always be uninsured, underinsured and indigent people whose emergency medical needs will challenge (and burden) the system. More control over overseas referrals by requiring the decision to be made by qualified medical personnel and utilizing Philippine medical centers would be cost-saving.

FSM government needs to resist the temptation to rely on taxes, import duties and licensing fees from alcohol and tobacco as a way to generate more income. This has been a common practice in developing countries, to the detriment of the health of their people. Countries relying on revenues from alcohol and tobacco sales have a vested interest in increasing those sales so as to increase revenues. The costs to society of encouraging alcohol and tobacco consumption by far outweigh the financial gains (Marshall, 1993).

Participation in family planning programs and prenatal clinics needs to be strengthened, as does public education to increase the people's awareness of population issues and the impact overpopulation can have on the quality of life. Concern has been expressed over what appears to be an increase in teen pregnancy. Teenage mothers are more likely to drop out of high school and give birth to infants with low birth weight. Unmarried teenagers may be too embarassed to be seen waiting outside of a family planning clinic at a public hospital. It has been suggested that family planning services might reach more women through better community-based health centers that are staffed by women health workers and open to women who have not yet had at least one child (Schoeffel, 1993).

As long as drinking water is unsafe and unsanitary conditions are widespread due to inadequate solid waste and sewage disposal and management, the people in FSM will be vulnerable to waterborne diseases that can be life-threatening.

Maintaining a healthy environment and healthy personal lifestyles and habits will do more for raising the health status of the nation than pouring more money into the medical service system. The health of a community is the responsibility of the people who live in that community, not just the few health care workers working in that community. People ultimately are responsible for their own health care. These are the essential messages that need to be conveyed as FSM's health care system shifts its emphasis to primary health care.