Diabetes in Samoa

In the last ten years, the Pacific Islands’ reputation as a honeymoon destination has been somewhat superseded by a newer and more worrisome title: the region with the highest rate of diabetes in the world. According to the World Diabetes Foundation, more than half of all Pacific Islanders are obese and one in every four lives with diabetes.

For this reason, it was important for us to include at least one Pacific Island on our itinerary. Finances and logistics ultimately determined which one: Samoa. Samoa’s diabetes epidemic is not as severe when compared to some of the other Pacific Islands but their struggle against this disease is representative of the crisis affecting the region.

Firstly, size is noticeable. Samoans are larger than life, in their smiles and in their body mass, and it is not immediately clear how much of this is genetic and how much has been brought on by lifestyle changes. During our stay, we observed two very distinct Samoans, however. The Samoan of Savai’i – the island that still maintains the traditional lifestyle – cuts a leaner, more muscular figure. While men and women are still big, they appear to be built this way – big-boned, perhaps, but not necessarily obese.

In comparison, the more modern island of Upolu shows a “more modern” Samoan, with greater access to processed food and job opportunities. With more purchasing power, people often choose to buy Western food instead of growing their own. It means less work in the fields under a hot sun and it’s generally seen as trendy.

People are able to use cars and buses to move around and they may have jobs that are more sedentary than in the past. As a consequence, extra body mass can be seen almost everywhere.

However, diabetes can manifest itself in many ways, not just through obesity, and we wanted to understand the full picture.

Samoa is the first country that we have visited on our journey that is not considered First World, and consequently, our conversations about diabetes were markedly different. There are no diabetes clinics or support groups in Samoa and we didn’t have much luck interviewing individuals because of the fear of stigmatization and misinformation. However, with a bit of asking around, we were directed to the Apia Diabetic Foot Clinic at the local hospital and the National Kidney Foundation of Samoa. We were also able to deliver two successful diabetes workshops to our hotels, Le Manumea in Apia and Vacation Beach Fales in Manase.

We learned from the National Kidney Foundation of Samoa (NKFS) that kidney failure, a major consequence of untreated diabetes, has been on the rise.

“Before we would see diabetes and dialysis at ages 60, 70, or 80,” Cristina, the manager of renal services, states. “But now the norm is changing. We are seeing dialysis patients at age 25 or 30. When we started in 2005, we had 5 patients. Now we’re up to full capacity, 88 patients, and they’re still coming.”

There are two dialysis clinics run by the NKFS on the islands, one on Upolu and the other on Savai’i. 75% of their patients are diabetic, usually type 2, and most show up at the clinic with end stage renal failure, rather than stage one.

“Samoans are complicated people,” Cristina explains. “There are a lot of factors influencing decisions: family, village, church. Not everyone comes for help when they should. But I think we are finally starting to become more open about diabetes and accept that it is a problem.”

There used to be a diabetes clinic in the capital of Apia, but the rumor (we could not get an official confirmation) is that it was shut down on grounds of corruption. “This was a serious detriment to the community,” Cristina says, ”Because going to a diabetes clinic is a lot less intimidating than going to the hospital for your health problems.”

The Diabetic Foot Clinic at the Tupua Tamasese Meaole Hospital in Apia is doing its best to fill the void left by the diabetes clinic, but it’s difficult. They’re understaffed, overworked, and they’re connecting with their patients very late in the game. From 9 to 5pm on Mondays and Thursdays, diabetics can come to the hospital for foot and wound care. The staff, which includes a few nurses and one podiatrist for the whole island, tries to use this time to give proper diabetes education as well.

However, their primary job is to address foot complications related to untreated or advanced diabetes.  They must explain the importance of getting a toe or foot amputation in order to avoid necrosis or sepsis and possible death. Unfortunately, this conversation is one that they are having daily with their patients, because the conversation about what to eat and how to manage diabetes either arrives too late or its importance is diluted by the many nuances of Samoan culture.

Along with the Samoans complicated relationships to family, village, and church, they must also face poverty, apathy, isolation, and misinformation. In general, the Samoans who come to the clinic, if they come at all, know very little about their condition and don’t always trust or follow what “Western medicine” recommends.

Here are just a few examples of what they are up against:

FOOD

The arrival of cheap, processed food and Western fast food chains like McDonald’s to Samoan shores have drastically changed eating habits. In supermarkets, we could see wall-to-wall processed food and a very limited produce section. Processed food was also considerably cheaper than any kind of fresh produce. In every village store, we observed that the only items for sale were instant ramen noodles, cookies, and Coca Cola products.  Furthermore, eating this kind of food is often considered a status symbol while eating local food or “living off the land” is viewed as a sign of poverty.

Unfortunately, even many of the mainstays of the traditional diet are no longer ideal for fighting diabetes because Samoans are not maintaining the same active lifestyle of the past. Starchy vegetables like taro, breadfruit, and yams are quite high in carbohydrates and can be seen at every mealtime. If you’re not burning those calories off in the field every day, these food choices can become detrimental to your health.

ACCESS TO CARE

Traditional healing still forms a very big part of Samoan culture and many people will visit a traditional healer before seeing a doctor about an illness. There is also an element of distrust towards the doctor.

“Everyone has a story about an auntie who went to the hospital for a sore foot and died,” one nurse at the Diabetic Foot Clinic retells. “Samoans still believe in a little bit of black magic as well. So that plays a part.”

“I had someone with an eye infection once,” a med student shares. “The traditional healing solution was to flick a piece of glass into the eye. I don’t understand what they were thinking…but these things happen.”

It’s clear that the government needs to play a stronger role in preventing this kind of harmful misinformation by healers, but regulation is complicated, because it would go against the traditional way of the people, and Samoans hold their culture very close.

At present, the government has limited itself to working on a cookbook to provide ideas for more healthy eating options in the home. We also saw some nutritional propaganda posted around the islands, but we felt that overall, the level of response to the issue hardly fulfills the need. It’s worth repeating that there is no diabetes clinic in a country where 1 in 14 adults have diabetes. (International Diabetes Federation). The Diabetic Foot Clinic in Apia is open only two days a week and there is usually a two-hour wait. At best, the staff can see about seven patients a day.

Diabetics also must pay for their supplies, but they do get a discount. They buy their glucose meter, but they pay only five tala for all medication related to diabetes. They must also pay for their test strips when they run out.

“The prices are accessible for most Samoans, I would say, but sometimes they just don’t buy it,” the podiatrist explains. “Sometimes they prefer to buy a new cell phone or maybe they really do have a more pressing need, many people are poor, but the general impression is that they don’t seem to be prioritizing their health.”

CULTURE

To make matters worse, Samoans have a culture of feasting. It is tradition to have to’ona’i every Sunday after church; a lunch so big that it puts everyone to sleep. And since Samoa is a highly religious Christian country, you can be sure that everyone in the community is there to enjoy the meal and socialize with friends after mass.

Thus, diabetics and pre-diabetics find it more difficult to change their eating habits when everyone else around them is guzzling sugary sodas and feasting on a sumptuous array of food every Sunday. In fact, a refusal of food may come across as offensive. With so little communal support for this difficult but necessary lifestyle change, it’s easy to see why Samoans are often labeled as “lazy” or “indifferent” about their disease. Or perhaps, with everyone making the same bad choices, a kind of “we’re all going down together” mentality emerges. To get a clearer picture of what exactly Samoans are thinking, we recommend you check out the feature Obesity in Paradise,  done by the UK TV program Unreported World. The Diabetic Foot Clinic in Apia is featured as well.

If diabetes education and prevention is to become commonplace in Samoa, they will need to find a way to address the ritual of feasting without compromising its cultural importance. If this seems like the right challenge for a diabetes clinic, we agree. It’s clear that to improve the situation in Samoa, re-establishing a diabetes clinic must be first on the agenda.

When we talked to hotel owners at Le Manumea Hotel and Resort in Apia and Vacation Beach Fales in Manase, they were both eager to know more about diabetes – for their guests and for their employees. (We even had a situation where three family members came to learn more about diabetes for their recently diagnosed grandfather. The grandfather had not wanted to come to the meeting, but later he stopped by our table where we were having dinner and quietly asked for an informational flyer.)

We are particularly grateful to Luna and her staff at Le Manumea Resort in Apia as they allowed us to store some of our insulin in the hotel fridge while we traveled to Savai’i for a few days. Luna also treated us to one complimentary night at the lovely resort as a gesture of support for our cause.

“I think it’s wonderful what you are doing,” she said. “It’s no different from spreading the word of God. You are going out there and telling people important information, information that can really help them. We know in Samoa that diabetes is serious and we need to taking better care of ourselves.”

Our time in Samoa made us realize even more just how much every conversation counts. We left with a better understanding of just how complicated diabetes care can be and with a hopeful petition for the health of Samoa. We hope they resist the creeping Westernization of their culture and that they are able to develop new healthy lifestyle practices while still preserving the best parts of the beautiful Samoan Way.

an example of traditional Samoan cooking – the umu

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