The populations of the Pacific are few in number, and yet they are dispersed over an area covering almost a quarter of the surface of the earth (see Figure 1). The cultures of the Pacific divide into three distinct groups. The Polynesians, including the Hawaiians, Samoans, Tongans, Maori, and Tahitians, make up the best known and largest populations in the Pacific. The other two groups are the peoples of Micronesia (little islands) and Melanesia (dark skins).
The locations of the three cultural groups are geographically distinct. With the exception of the residents of the State of Hawaii, Micronesians are in the north, Melanesians are in the south, and Polynesians are in the middle. Studies of the cultures of Micronesia and Melanesia have filled books. However, information on the public health of these peoples is much less common.
As with many indigenous cultures around the world, the concept of the human organism in these cultures is holistic—the person is seen as the amalgam of body, mind, and spirit. As such, traditional systems of healing tended to follow this concept. When the Spanish explorers of the early sixteenth century arrived in these islands, they found that spiritualists, masseuses, herbalists, and vaporists provided the basis of the healing systems.
However, the details of the nature of the health systems of both Micronesia and Melanesia have remained locked in the colonial systems of power that have dominated the region for the past four hundred years. For many of these populations, the pathway of the Spanish, followed by the Germans and then the Japanese, yielded to the Americans, Australians, French, and English after World War II. The systems of care clearly reflect this history, and the problems associated with these care systems continue to plague these young nations struggling for independence and sustainable economies.
THE AREA, THE PEOPLE, AND THEIR HEALTH
The populations of the Pacific nations, Hawaii and Papua New Guinea included, represent a small fraction of the world's people. In the area known as Micronesia, the largest centers of population are Guam (154,623), Kiribati (91,985), the Commonwealth of the Northern Mariana Islands (71,912), and the Federated States of Micronesia (133,134). Somewhat smaller are the Republic of the Marshall Islands (68,126), the Republic of Palau (18,766), and Nauru (11,845). Melanesia has somewhat larger nations, including Papua New Guinea (4,926,984), Fiji (832,494), the Solomon Islands (466,194), New Caledonia (201,816), and Vanuatu (189,618).
In general, within the region, birth and death data are somewhat unreliable. However, from the data available, the population is growing more rapidly than most other places in the world. From the high of the Republic of Marshall Islands (RMI)
Table 1
Birth and Death Data 1996-1998*
Country
Births*
Total Fertility**
Infant Mortality***
Deaths*
* per 1000 population
** the sum of the age-specific fertility rates over the whole range of reproductive ages (15-49) for a particular period (1 year) In essence, this represents the number of children per woman of child bearing age
*** deaths of infants (< 1 year) per 1000 live births
total fertility rate (TFR) of 6.6 children per woman to the low of the Commonwealth of the Northern Mariana Islands' (CNMI), rate of 1.7 children per woman, the consistency of the growth of the region is clear. Most areas have a TFR above 3.2. The infant mortality rate (IMR) also has wild variation across the region, with Vanuatu at 62.5 and the CNMI at 5.8 deaths per 1,000 live births (see Table 1).
For the most part, the economies of this region are dependent on fishing, external government grants-in-aid, and a small tourism industry. Exceptions to this occur in Guam, which has a strong U.S. military presence, and the Commonwealth of the Northern Mariana Islands, which has a number of off-shore textile manufacturers.
The region faces an almost impossible task as it attempts to deal with the major infectious diseases of cholera, dengue, and tuberculosis at the same time that it faces an ever-increasing burden from chronic diseases, particularly diabetes and various cancers. The systems of care in place are ill-equipped to manage either of these disease patterns. As new diseases emerge in the area, including HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency disease) in Papau New Guinea and crystal methamphetamine addiction in the Mariana Islands, the systems of care have neither the skilled providers nor the facilities and materials needed to cope with these problems.
THE PUBLIC HEALTH SYSTEMS
Throughout the colonial eras of the Spanish, the Germans, and the Japanese, the systems of public health in both Micronesia and the Melanesia were designed to assure a healthy workforce. Early records describe the "primitive" ways in which the people practiced even the most basic hygiene with water supplies contaminated by feces from animals as well as humans. Minimal available food made malnutrition a given among the population, and traditional healers practicing their trade as bone setters, herbalists, masseuses, and spiritualists, as in most indigenous populations. The establishment of the early German trading posts meant the need for local labor capable of loading and unloading ships. Thus, plantation-type medical care was made available, often from ship doctors and others with minimal training. With the movement of the Japanese into the area following World War I, the colonization of the region became more ordered, with settlers coming from Japan and local people receiving some basic education to improve the productivity of the copra (a coconut by-product) and other crops. The Japanese had physicians in all colonial outposts to address the immediate needs of the workers. Water and sewerage systems were established in the larger villages, and, in general, the public health of the population, while not excellent, was at least able to reduce the death rates from the many diseases brought to the islands over the preceding thirty years.
With World War II and the military mobilization of the Japanese colonists, the plantations became less important and the need to maintain a viable workforce was reduced. The public health system remained, as did the dispensaries and hospitals; however, as the war in the Pacific expanded, the infrastructure was destroyed.
At the end of World War II, there was no health or public health system throughout the Japanese-occupied areas. The American, Australian, and New Zealand troops dispatched to secure the various outposts brought their own medicines and providers with them and, as part of their efforts to win over the people, provided medicines
Figure 1
and care to those in need. In the U.S. Pacific, an assessment of the needs of the islanders in their protection (by international mandate) was made by the USS Whidbey in the early 1950s. The findings were shocking, in that the people suffered from many diseases that were thought to no longer be a problem to the world. Recommendations to the U.S. government at the end of the military era established the Trust Territory of the Pacific Islands (TTPI), with headquarters in Saipan and responsibility for all aspects of life in the "American Pacific" which, with the exception of Kiribati and Nauru, encompassed all of Micronesia.
Farther south, the abundance of the U.S. treasury was not available. The Australian and New Zealand governments assisted the Melanesians (including the people from Kiribati and Nauru) in their sphere of influence and brought public health and medical care to the southern Pacific, with the exception of New Caledonia, which remained a protectorate of France.
The modern public health and medical care systems of these two distinct regions of the Pacific have their basis in the postwar era. In the north, the U.S. government, through the TTPI, established a system of hospitals as the central points of care in all of the ten jurisdictions for which the TTPI had responsibility. In 1985 (1999 for Palau) the three areas now known as the Republic of the Marshall Islands, the Federated States of Micronesia, and Palau established a formal relationship with the U.S. government known as the Compact of Free Association. Under that compact the newly
Table 2
Leading Causes of Death, 1996-1998*
Country
Cause 1
Cause 2
Cause 3
Cause 4
Cause 5
* data are expressed as rate per 100,000 population
created nations were to be systematically transformed from dependencies to independent nations over a fifteen-year period. The responsibility for health services transferred to the island governments, and with it the determination of health priorities and expenditures. The period since 1985 has been spent revitalizing the public health and general health care systems. Newly trained indigenous health providers have staffed the health departments of these three nations, and reorganization of the strategies for health has come through much consultation with the World Health Organization (WHO) and the Asian Development Bank (ADB). These systems are attempting to establish primary health care centers throughout each nation, with the intent to reduce the dependence on expensive hospital-based care. However, budgets are small, needs are great, and the systems are weak.
In the southern Pacific, the transition from the post-war military care system to one operated by the national governments accompanied the independence of the various nations. The systems of care that the national governments inherited were already targeted on primary health care, and they already had a considerable investment in the use of dispensaries as a major source of care. However, the budgets have been very small in these nations as well, and the retention of trained local practitioners has been a major problem. Facilities have been built through bilateral arrangements sponsored by several foreign governments, and the basic public health infrastructure has begun to take shape through various ADB loans and other arrangements. The WHO has been very active in the southern Pacific, as has been the South Pacific Commission (now Secretariat for Pacific Communities) which has been instrumental in developing the health education focus of the region as well as the improvement of health data and general health department capacity.
In a short fifty years, the people of Micronesia and Melanesia re-created their public health systems. The water supplies are nearly all safe and sewerage is mostly disposed of in an appropriate manner. The food supply is inspected and safer, as is the supply of medicines used by the dispensaries and the hospitals. The prevalence of parasitic disease among children is remarkably reduced, as is the number of deaths from malnutrition and other nutritional deficiencies (see Table 2). However, the epidemiological transition is not over for the people of the Pacific. The future is dotted with many diseases of modernization—diabetes, substance abuse, severe mental illness, cancers, heart disease, and environmental diseases. The systems of care are not yet mature, and the need for continued support from major developed nations is obvious to any who have traveled the area.
