Second in a series: This is the continuation of our Q&A with Dr. Frank Underwood, who currently serves as the Marshall Islands’ director of public health, a position he began during the initial stages of the Covid-19 pandemic in 2020 based on his experience in communicable disease controls after serving in a national advisory position in Fiji on TB control.
Pacific Island Times: What are the most concerning public health challenges for our country and the region?
Dr. Frank Underwood: Public health-wise, the biggest threat to the northern Pacific is diabetes or NCDs, including heart disease, hypertension, and obesity and their complications. Right now, in the Marshall Islands, 73 percent of all deaths are attributed to NCDs. In Fiji, it's about 76 percent, and for most island nations in the Pacific, it’s in that range of 65 percent to 80 percent.
So predominantly, we've got up to three generations of our people “lost at sea” in terms of having diabetes, which is not well controlled, then developing complications and having –potentially– a loss of many years of life compared to RMI's current life expectancy of about 71 years for males and 72 for females.
In my opinion, the solutions for the northern Pacific are harder to come by and solve than in most countries of the world because –and I keep stressing this to WHO and CDC officials who visit us here in the RMI– you must look at these disease burdens in the context of where we are. We live on atolls. We cannot grow our own sustainable food supply, so healthy options are expensive and usually imported. We have the impacts of climate change, and that compounds the complications of NCDs more than is typical in other countries.
PIT: How does climate change impact NCDs?
Dr. Underwood: Traditionally, when we think of climate change and health, we think of climate-sensitive vector-borne diseases such as dengue fever and not the non-communicable diseases. But people have been internally displaced. The urban centers are crowded, poverty is exacerbated, and purchasing power for healthy foods is much less. We don't have space for a lot of exercise. All of this worsens our NCD burden.
PIT: In response to these challenges, do you believe that government needs to take a more holistic approach?
Dr. Underwood: People are expected to make the best decisions for their families based on the information that's given to them, so the Ministry of Health or MOH can provide that. There's a lot of information on what “healthy living” is. But government has a responsibility to regulate the market and ensure there are conducive spaces for the agriculture sector and for physical activity. Smoking and alcohol are an issue. We've got to ensure that policies are in place so that our people have the best odds of succeeding and having a healthier life.
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PIT: What are some of the more practical solutions?
Dr. Underwood: The hybrid survey in 2018 for NCDs showed that about 50 percent of adults who had an NCD did not even know they had it. So an aggressive system for screening needs to be put in place. Secondly, the study showed that even for those who did know they had NCD issues, 80 percent of them did not have adequate control over their health issues, especially diabetes, and that hasn't changed much.
There are some obstacles to buying the medications, even though it's only $5 per visit. So there are still barriers to accessing medications because of cost, and this is from surveys that we've done recently that show that half of the individuals who need to come to clinics don't because of the cost of taxiing and paying for the visit.
PIT: So how do we address this at MOH?
Dr. Underwood: There’s a house-to-house outreach program that has been initiated, which has become part of our nursing zoning system. That's the future. And then even at home, we're coming across individuals with NCDs who are not taking their medications.
Prevention is the best solution for our younger generations before they have risk factors. But they're getting those risk factors early by not getting enough physical activity and because of poor diets high in fat and carbohydrates.
PIT: How important is it to find less costly alternatives and not more expensive ones for dietary solutions such as drinking water or a coconut instead of a cola?
Dr. Underwood: The dream, the idea of paradise, is having more traditional meals with local foods. Currently, typical meals here consist of rice, chicken and cola. So that has to change before you see changes in health outcomes for our society. A lot of work needs to be done, but it's not the Ministry of Health alone, it will take the whole of government and society. Churches play a big role here in the Marshall Islands and should be used as positive influencers. We have a long way to go.
PIT: What about preventable cancers as a public health issue?
Dr. Underwood: There are two types of cancers. There are cancers caused by infectious diseases. HPV (human papillomavirus) as a virus causing cervical cancer is one. We have among the highest rates of HPV in the world. The most effective public health solution is vaccination. The HPV vaccine is safe and it's protective up to 70 percent to 80 percent for reducing the chance of a woman developing cervical cancer, and those are excellent odds and a safe vaccine. But our uptake of the HPV vaccine has been low here. The primary reason for this is misinformation, but we need to change that because too many of our women are dying unnecessarily.
The second infectious disease cancer is hepatitis B. We now have treatment for hepatitis B that can slow down damage to the liver and prevent the development of what we call hepatitis cellular carcinoma or cirrhosis and its complications.
A large proportion of our younger kids have been vaccinated since the HPV vaccines were introduced. But middle age to older generations are the cause of a lot of the carriage of hepatitis B, so that's one area we're trying to address.
All other cancers are mostly NCD risk-related: obesity, alcohol, smoking and not eating a balanced diet tend to cause these cancers in the bowels, breasts or lungs. All are very common here. Besides prevention, early detection is important. We need to change the culture in terms of health-seeking behavior. People need to come in to get screened for disease on an annual basis.
PIT: So the idea of creating an efficient way to get an executive or an annual checkup, like what they provide in the Philippines or Taiwan, becomes a potential solution?
Dr. Underwood: We must reorientate our health programs to offer this kind of service to the public at least once a year.
You would get a full NCD screening and cardiac respiratory evaluation. Plus, you could get your cancer checks and then be informed of the preventative strategies that go with it. You would get a flu shot, an HPV vaccine for younger females, and any other vaccines you may need. Early detection also reduces healthcare costs in the long run.
Jack Niedenthal is the former secretary of Health Services for the Marshall Islands, where he has lived and worked for 42 years. He is the author of “For the Good of Mankind, An Oral History of the People of Bikini,” and president of Microwave Films, which has produced six award-winning feature films in the Marshallese language. Send feedback to jackniedenthal@gmail.com
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