Tackling the double burden of disease in the Pacific will require new thinking on integrating healthcare services and stronger health systems.
The islands of the Pacific conjure up images of a healthy, carefree lifestyle. But the reality is a little different from the dream, and many islanders are suffering from diseases that could be prevented. Here, the policy and practical challenges of managing communicable and non-communicable diseases are difficult to surmount; add in over-stretched health services and the problem becomes even more complex.
Some of Australia’s closest neighbours are engaged in a battle to combat this double burden. Non-communicable diseases such as heart disease, stroke, cancers and diabetes are major killers in the Pacific Islands region, where an estimated 70 per cent of all deaths in the 22 islands are due to non-communicable diseases.
Many of these deaths are thought to be preventable as some of the risk factors for non-communicable diseases are modifiable. These risk factors include obesity, high blood pressure, high cholesterol levels, a lack of physical activity and cigarette smoking.
Pacific Island ministers of health and governments are at the forefront of major efforts to prevent and control non-communicable diseases. These efforts have been articulated in the recent meeting of Pacific health ministers in Fiji earlier this year. Historically, in the Pacific, as in many other countries, the prevention and management of such diseases has been managed differently and sometimes separately to communicable diseases.
Non-communicable diseases often have a slow onset, require a health promotion and prevention approach and have not been a priority for surveillance in the Pacific, as is the case for many countries globally. Evidence on how to best prevent non-communicable diseases has also been lacking, which is particularly evident in the Pacific context. Conversely, communicable diseases, which require a rapid response for the most part due to their communicability, have been under surveillance for many years and have vaccination programs, infection control and contact tracing, among others, as core control strategies. In recent years the convergence of communicable and non-communicable diseases has come into focus, especially in the Pacific Islands where some countries experience a high burden of both.
Diabetes is just one example where a non-communicable disease intersects with communicable diseases. Each year, the International Diabetes Federation release a Diabetes Atlas which provides national estimates of the prevalence of diabetes. Of the 10 countries with the highest prevalence of diabetes globally, seven are in the Pacific: Tokelau, Federated States of Micronesia, Marshall Islands, Kiribati, Cook Islands, Vanuatu and Nauru.
Here, between one-quarter and one-third of adults have diabetes. These are staggering figures, with long-term ramifications both for individuals, who suffer the damaging clinical effects of diabetes including blindness and amputations, and for governments, who struggle to fund the services needed to adequately prevent diabetes and treat people.
In many of the Pacific Island countries rates of communicable diseases such as tuberculosis (TB) are also high. These countries face a dual burden of disease, the magnitude of which is becoming clearer as new information comes to hand. The TB-diabetes combination in particular is extremely relevant in the Pacific Islands. Not only is the prevalence of diabetes among adults the highest in the world, but stubbornly high rates of TB persist in many countries such as Kiribati, Papua New Guinea and the Republic of the Marshall Islands.
The unhealthy partnership between TB and diabetes was recently brought to global attention by an influential paper, written by public health academics from Harvard University. In their systematic review published in 2008, the Harvard researchers found that people with diabetes have three times the risk of developing TB, regardless of the setting or the type of study that was assessed. Additional research determined that screening TB patients for diabetes and vice versa leads to detection of undiagnosed TB and diabetes with varying yields (two to 37 per cent), depending on the setting.
In addition, new research recently published in the journal of Tropical Medicine and International Health by an international research team (including an Australian researcher) examined the relationship between TB and diabetes in the Pacific Island nation of Kiribati.
They identified that just over one-third of TB patients in Kiribati also have diabetes; and many patients did not know about their diabetes diagnosis. Research in neighbouring Micronesian countries has reinforced these findings, with almost half of TB patients having diabetes in the Republic of the Marshall Islands and three per cent of people with diabetes being diagnosed with active TB in Federated States of Micronesia.
This situation highlights the need for health services to collaborate on prevention, screening and treatment. Integrated care is paramount. In many countries in the Pacific, this service collaboration is starting to happen. For example, in Kiribati all adult TB patients now receive a test for diabetes at the TB clinic. These findings also highlight the need for patients to be treated holistically; there are often two (or more) diseases but one patient, who requires integrated and well-co-ordinated care for a range of conditions. Prevention efforts should be a key component of this care.
This research also highlights the challenges of health care provision in the Pacific islands. Ministries of health continue to battle against high rates of communicable and neglected tropical diseases such as leprosy, dengue and chikungunya. At the same time they provide prevention and care services for people with lifelong chronic conditions, such as diabetes.
This double burden of disease will continue to challenge health service providers, governments and clinicians in the Pacific Islands. To effectively combat it, new and innovative ways of integrating health care services are needed, alongside efforts to strengthen the foundational elements of the health care system.